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iyi^ai[@ 


Gift 
Dr. A. V*. fitting 


THE  DISEASES  OF 
THE  NERVOUS  SYSTEM 


A    TEXT-BOOK 
FOR  PHYSICIANS  AND  STUDENTS 


BV 

Dr.   LUDWIG   HIRT 

PROFESMIK   AT   THB   fMVEBSlT^  I)f    BKBSLAU 


TRANSLATED.  WITH    TERMISSION   OF   TIIIE   AL'TIIOR,    BV 

AUGUST   HOCH,   M.  D. 

tOUIKKLV    *ieiST*"T    rHYllCUH    in  rM»  JOHNS  HOriliH*  HtnriTAi. 
HOW  TU  TUB  HCLBAH    HOSPITAL,  WAVIRLV,  HAS. 

ASS15TEU    BV 

FRANK   R.  SMITH.  A.  M.   (Cantab.).  M.  D. 

utnucroit  IN  iisDicKO  in  n«  juhki  hofkihs  uhivusitv 

U'lTH  AM  INTRODVCT/0!V  BY 
WTLLIAM   OSLER,   M.  D..   F.  R.  C.  P..   F.  R.  S. 

rtO»ltS«olt  UP    bEPICIhP    IN  THI    JOHN^    HOPKINS  ITNIVHStTV,    KTC. 


WITH    ONE    HUNDRED    AND    EIGHTY-ONE    ILLUSTRATIONS 


NEW    YORK 

O.    APPLETON    AND    COMPANY 

1899 


'■. 


&^ai!t@ 


Gift 
Dr.A.Vi.uitting 


r.. 


INTRODUCTORY   NOTE. 


^ 


^ 


Thr  pleasure  cf  introducing  lo  the  profession  of  this  country 
a  transition  uf  a  standard  work  is  enhanced  by  the  opportu- 
nity it  affords  of  acknowledging  how  great  is  our  debt  to  those 
— translators  and  publishers — who  have  made  current  in  Eng. 
lish  the  works  of  Trousseau.  Niemeycr,  Virchow,  Cohnhcim, 
and  others.  All  recognize  the  necessity  ol  teachers  knowing 
tlie  classical  works  in  all  languages,  but  of  equal  importance  is 
it  that  the  practitioners  in  all  countries  should  have  easy  ac- 
cess by  means  of  translations  to  the  thoughts  nnd  experience, 
the  ways  and  methods,  of  the  masters  of  our  art  the  world  over. 
No  belter  corrective  exists  lo  the  vice  of  Philistinism — that  nar- 
row conceit  of  the  special  prominence  of  medicine  in  any  one 
country — than  a  wide  diffusion  in  all  of  the  best  works  of  each. 

Early  in  189O  ray  attention  was  called  by  Dr.  Weir  Mitchell 
to  the  first  part  of  Prof.  Hirt's  Handbuch  der  Ncrvcnkrank- 
lieiten,  which  he  chaniclerlzetf  as  an  exceptionally  well  ar- 
ranged  and  thorough  work  on  diseases  of  the  nervous  system. 
The  completed  work  seemed  in  many  respects  so  admirable  a 
tcxt.book  that  1  wrote  to  Prof.  Hirl  and  asked  his  permission 
to  have  it  Translated. 

The  arrangement  of  the  subjects  to  which  the  author  re- 
fers in  the  ]trelace.  though  somewhat  novel,  is  justifiable  and 
entirely  satisfactory ;  and  It  is  a  distinct  advance  in  classihca- 
tidn  lo  place  tabes  dorsalis  and  dementia  paralytica  among 
the  diseases  <if  the  general  nervous  system,  instead  of  in  the 
sections  on  diseases  of  the  cord  and  diseases  of  the  brain  re- 
spectively. 

The  fact  which  makes  the  work  of  value  to  the  teacher,  the 
hludeni,  and  the  practitioner  is  the  graphic  description  of  the 
anatomy  and  symptomatology  of  the  diScrent  diseases.  Where 
all  i»  so  good  it  is  invidious  to  select,  but  the  chapter  on  tabes 


vu 


vili  INTRODUCTORY  NOTE. 

is  an  illustration  of  our  author's  lucid  and,  at  the  same  time, 
thorough  treatment  of  his  subject  The  various  affections  are 
treated  of  also  from  an  advanced  modern  standpoint;  conflict- 
ing theories  and  passing  observations  are  submitted  to  a  wise 
criticism  through  which  the  author's  own  large  and  varied  ex- 
perience is  very  apparent. 

An  attractive  aspect  of  the  work  is  the  excellent  character 
of  the  illustrations,  which,  as  they  are  in  great  part  original, 
will  be  a  pleasing  relief  to  the  hackneyed  cuts  which  have  for 
so  long  passed  from  book  to  book  in  English  works. 

Pursuing  the  via  media  in  the  important  question  of  treat- 
ment, neither  displaying  the  pessimism  which  too  many  mala- 
dies of  the  nervous  system  would  seem  to  justify,  nor  an  opti- 
mism so  flagrant  as  to  savor  of  quackery,  Prof.  Hirt  is  a  safe 
guide  in  the  highways  and  byways  of  neurolherapeutics. 

And,  lastly,  I  think  the  author  has  been  fairly  handled  by 
his  translators,  who,  bearing  in  mind  the  admonition  of  Dryden, 
"  not  to  lackey  by  the  side  of  his  author,  but  to  mount  up  be- 
hind  him,"  have  given  a  clear  and  interesting  rendering  of  the 
original. 

William  Osler. 

Baltimore,  "January,  iSgj. 


CONTENTS. 


rAO 
Diseases  OF  the  Brain  and  its  MENiNCis,  including  those  or 

THE  Cranial  Nerves ".,,..  i 

PART  1. 

Diseases  of  tmk  Meninges  of  the  Bbain 3 

Chap.  I. — iDilamnialion  of  the  inner  surface  of  the  dura  mater,  pachy meningitis 

inlema  bE^morrhagica,  hxmaloma  dune  malris      ....  4 
II. — Inflammations  of  the  soft  membranes  of  the  brain,  leptomeningitis,  puni- 

lent  meaingilis 8 

PART    II. 

Diseases  of  the  Cranial  Nerves 24 

Chap.  I. — DiseaMS  of  the  olfactory  nerve 35 

II. — Diseases  of  the  oplic  nerve ag 

lit. — Diseases  of  the  nerves  supplying  the  ocular  muscles      ....  4a 

TV.— Diseases  of  the  Irigemina]  nerve 56 

V. — Diseases  of  the  facial  nerve 77 

VI. — Diseases  of  the  auditory  nerve qj 

VII. — I)i^cases  of  the  glosso-pharyiigeal  nerve 107 

VIII. — Disea.ses  of  the  vagus  (pneumogastric  nerve) IIO 

IX. — Diseases  of  the  accessory  nerve 136 

X. — Diseases  of  the  hypoglossal  nerve 140 

XI. — Simultaneous  affection  of  several  cranial  nerves — Multiple  paralysis  of 

the  cranial  nerves 147 

PART    III. 

IHSE.iSrS  OF  THE    BRAIN    PROPER l6l 

I.  The  study  of  cerebral  lesions  with  reference  lo  their  seat— Topical  diagnosis 

— Doctrine  of  localiiation 162 

Symptoms  referable  to  cortical  legions 164 

Symptoms  referable  to  lesions  of  the  white  matter  of  the  liemnpheres  and 

to  lesions  of  the  basal  ganglia 189 

II.  The  study  of  cerebral  lesions  with  reference  to  their  pathological  nature — 

Pathological  diagnosis 209 

Affections  of  the  brain  due  10  disease  of  the  blood-vessels  209 

A.  Diseases  of  the  cerebral  vessels  and  their  consequences  .         .        .  109 

ix 


X  CONTENTS. 

rAGB 

1.  Cerebral  bxTnorrhage 213 

a.  Embolism  and  thrombosU  of  the  cerebral  arteries — Encephalo- 

malacia    .         ,         ,          .         -         -         ^          -         -         ,          ,  244 

3.  EndartentU  (sj^hilitica) aja 

4.  DiUtacion  of  the  arteries  of  ihc  brain 953 

5.  The  neurosesof  the  arteriesof  the  brain  (aoaimiaandhyperxniia 

of  the  btain) 254 

B.  Diseases  of  the  cerebral  veins  and  sinuses 357 

Inflammatory  processes  of  the  brain  substance 360 

1.  Punilent  encephalitis — Brain  abscess 360 

2.  Nonsuppurative  encephalitis  and  its  consequences  ("athetosis")  366 

A.  In  adults 366 

B.  In  children — Cerebral  palsy  of  children — Hemiplegia  infantilis 

spastica — Polio-encephalitis 36S 

Brain  tumors 38} 

Appendix — Parasites  of  Ihc  Brain 305 

Congenital    diseases — Hydrocephalus —  Meningocele — Porencephaly — 

Absence  of  certain  ports  of  the  brain 30S 

Diseases  of  the  Spinal  Cord 314 

PART  I. 

Diseases  OF  THE  Spinal  Meninges 315 

Chap.  1. — Inflammations  of  Ihc  dura  mater — PaehymeningilU  spinalis                  .  316 
II. — Inflammations  of  the  soft  spinal  meninges — Leptomeningitis  spioalis  .  332 
III. — Hemorrhage  into  the  spinal  membranes — Meoingeai  apoplexy — Pachy- 
meningitis interna  hxmorrhagica 326 

PART   II. 

Diseases  of  the  Spinal  Nerves 330 

A.  Diiieases  of  Ihc  motor  and  sensory  nerves 333 

I.  Diseases  of  (he  cervical  nerves 333 

Chap.  I. — Lesions  of  the  cervical  pleius 336 

II. — Lesions  of  the  brachial  plexus 340 

II.   Diseases  of  the  dorsal  nerves 363 

III.  Diseases  of  the  lumbar  nerves 366 

IV.  Diseases  of  the  sacral  and  coccygeal  nerves 370 

V.  Neuritis  involving  several  spinal  nerves  at  the  same  time — Multiple 

neuritis 387 

B.  Diseases  of  the  Irophio  and  vaso-molor  nerves 397 

Appendix — Diseases  of  the  muscles — Primary  myopaihies      .        .        .  405 

PART   III. 

Diseases  of  the  Substance  of  the  Spinal  Cord 418 

I.  Consideration  of  spinal  diseases  with  reference  to  their  seat — Topical  diag- 

Do!.is 41S 

I.  Lesions  of  the  gray  matler — Poliomyelitis 42; 

Chap.  I. — Poliomyelitis  anterior  acuta — infantile  spinal  paralysis     .  426 
II. — Atrophia    muscularis    progressiva    spinalis — Progressive 

muscular  atrophy 434 


coy  TEXTS. 


XI 


racK 

II.  Lcdoat  of  the  while  matter  of  th«  tpinal  cord— L«<i«onir*lltt*     .         .  439 

A.  Prwuuy  leuonsi>(  ih«  white  culuMUii 440 

D.  ScconiUry  lc^■onl  of  ihc  whtle  calunmt 44S 

til.  I.aions  of  the  gny  iiul  white  mtlttt  of  ihc  spinal  cotd                          .  446 
II.  Sflul  Ictioni  Kgaideil  from  th«ir  iislhdoglcftl  akjiccl — Putholuglcil  dl^- 

kodt 4S0 

I.  ASeetioiK  of  lh«  hjiinal  CArd  tluc  to  diwate*  of  Ihc  blood-vcucU          .  458 

A.  IKieam  (d  the  atlerieK  of  the  t|ilnBl  cord  oiiil  ihcii  contcqwcncci  458 
1.  Spinal  fawmonhagc — llrnnorfliapo  (01  apoplckin)  mcdoUx 

tpioalis — HKRiaioinyclia 4S8 

1.  Embolbm  and  ihi«mlio«i»  of  Ihe  tpinnl  eiterici  and  mjrclo- 

taolacia 460 

3.  Endancritit  (lyphllllica) 461 

4.  Uilalalion  ol  th«  hplnal  aiterlet 4Ca 

%.  IC«uromorthe  tipinal  arteiict 46a 

O.  InSaiiunatorjr  proooses  in  the  tubiTniicc  of  the  »pinal  conl .         .        .  46s 

I.  PunilenI  mjrclilia — AbtccM  of  Ihe  tplnal  cord      .         .         ■         .  46$ 

9.  The  aon-puTulent  mreliiU 46$ 

A.  The  Kute  fiinn   .        .        , ifii 

B.  The  chxiiiic  fnnn 4^1 

'  tn.  Spinal  lumon ^fi^ 

Appendii— I'araalioi  of  the  tplnol  ootd 470 

ir.  Cangnillat  dbteaw*— llrdroiihachis— Spina  bifida                        .         •  47< 

U|»SA«BS   or  TIIK  GCKKKAI.   NKKVOUS  SYSTKU 476 


PART    I. 

UisaAhU  or  THE  GexutAL  NEkTotit  System  wituoit  ahv  RtcouNiUBUt 

Anatomical  Baiis—"  Functional  r»KuiioM:s"         ....  479 
firit  C'vttf. — Senru«*>  which  are  wont  to  ran  iheit  tourse  niihout  anjt  eisen- 

tlal  ira^iltcatioM  of  the  gencnl  o«|anitin 481 

A.  Alfectlont  ik  which  the  motorr  nerrc*  ace  chicily  impliMiled                .  481 
Chap.  l^C'horea— Choiea  Sancti  Viii— St.  Vitiw"  dance— Ball iimti»— Mel. 

aaeholia  ultaiu — Sydenham's  disease          .        .         .        ■         .  481 

II. — Tdaajr — Teianilla — Tetanui  intenniltciu 493 

Thoniaen't  diteate 496 

111.— Paialjrib  agltaiu — Shaking    paK; — I'arkiniou't  disease — Chon« 

jimcunlva JOO 

n.  Alfccilocii  111  which  the  tiuatirj  nerve*  arc  chicll}'  injilicaied    .        .  yaij 

Mtniknc— llemlcnnla -SO? 

C  AITecllonh  lii  which  the  trophic  nerve*  are  chirfljr  Impllcateil              •  Jia 

I.  AcTonieealy ,  51s 

9.  Oktcoanhiopathjr Jlfr 

Appeadii. 

t    OTai«a'disca»e — l)a»cJav*(  ditcatc — Eiaphthalmlc goitre .         .  J'^ 

II.  Myncrdeina ;>$ 

Smnd  Grvuf. — NcutiMeiin  which  the  entlte  organlun  U  more  ee  leu  Kvereljr 

tnpticaied S*9 

Cfca|i.  1. — Nearaithenia— NeiToiu  prottration jM) 

II.— Kyitcria SM 


xii  CONTENTS. 

PAGI 

III. — Epilepsy — Fallii^  sickDcss — Morbus  sacer — Morbus  coTnitialis     .     571 
IV. — H  ystero-epilcpsy — Major    hysteria — Hypnotism — Trcalment   by 

suggestioii 600 

PART   II. 

Diseases  op  the  General  Nekvous  System  with  Known  Anatomical 

Basis 616 

Chap.  I. — Multiple  sclerosis — Disseminated  sclerosis — Insular  sclerosis — Scl/rme 

atplaqMts — Sclerosis  cerebro-spinalis  dissemioHta  sive  multiplex     .     616 
II. — Tabes  dorsalis — Locomotor  ataxia — Posleiior  spinal  sclerosis — Leuco- 

myelilis  posterior  chronica. 629 

III. — Dementia  paralytica  progressiva — General  paralysis  of  ibe  insane — 

General  paresis — Softening  of  the  brain 688 

IV. — Syphilis  of  the  general  nervous  system 7CO 


LIST  OP   ILLUSTRATiONS. 


I 

I 


C<iw. 


4 
39 

31 

37 


37 
4" 

43 

44 
45 
S7 
S8 
74 
78 

84 


I.  Crau-xctiDD  throvgb  the  cerebral  cortex  Bn<l  iti  tnembranei 
a.  DiBgrxm  ibming  tbe  mune  ot  Ihe  optic  fibres  in  the  chUim 

3.  DiAgiam  ibowinj;  the  origin  of  Ilia  uplic  rierve  {alter  Wcrnidic)     . 

4.  Field  of  litioo  of  Tbe  left  and  right  tyv  (aflci  Kor^ter)    . 
i.  Fteld  of  vbioo  of  the  Ivfi  ami  riuht  vjr*  in  iGft-tiiled  hrmionopia  (aflcr 

et») 

6.  Crou-teclioa  Ibrongb  the  region  of  tlie  ant.  corpora  <|uadrigeinina 

7.  INagnnnMlk  longitadtnal  icclion  tlnvush  tho  poiu  with  the  nuclei  of  the 

oculu  nerra  (afiet  (^wen)  . 

9.  Cfou-tcclion  ttiroui-h  Ihe  region  of  (he  logmviitum  (after  Schwatbc) 
9.  Ctaa-Mttivm  ihroogh  the  poni  (after  .Schwnlbe)      .... 

10,  Nacleiof  the  trijccminal  riecve  Infier  Schwnlbe)      .... 

11.  Cnst-ieclion  ihtiwifli  the  mnlitlla  oblongata  (after  Schvalbef 
II.  IHitribvlioit  of  Ihe  teniory  cutaneou*  nervci  on  Ihe  be.nd 
I).  I>u{;nm  ihowinf  Ibecourie  of  the  facial  Bbm  in  ihe  pom  (al^er  Schwalbe) 
■^  Uiagram  ihiiB  i  ng  the  dcctutation  of  ihe  fibm  going  to  the  exttemitlo.  and 

lho«e  going  to  tbe  face,  in  the  pooi  and  medulla  oblonpu  . 

IJ.  Etb'i  dtactan  In*  facial  fiaral^ii B7 

lA.  Smm  of  lb«to-cBllc(l  "miilor  poiTil9''on  ihefaceand  neck  ....  9] 
■;.  Dli^raniMiiic  todion  ihtough  the  medulla  oblonpla  in  Ihe  rcpon  of  the 

(lower)  oIlvD 96 

ll.  CreM.wcllun  lhit>ilgh  itie  mcclulla  olilongaia  (after  Schwalbc)  iti 

t^  BUaieral  f^nipi*  of  the  rroirnnl  larytigeoL 117 

aa.  Keciirrcnl  Uryni^al  jMialyit* 117 

II.  1*8101x01  of  ibc  rMurrciit  Inryneeal  on  the  left  ^de 117 

31.  I'araljUb  of  botk  poletior  crico.antfnoidi 117 

3J.  Pualjrux  oJ  ihe  ri|^l  |x»l.  crlco-aiyicnoid 117 

a*   I'lnlyik  of  both  talemal  IhirTo-aiyMaoida 117 

■S.  ■'■nl]nb  of  both  inieraal  thyroarytenoid* 117 

A,  Cf«»-MCIian  ihnnigh  ibe  nrrical  oord 136 

IJ.  S«p«rfdal  origin  of  ihc  cranial  nervrt ,     141 

M.  CMtkalceairet  of  (he  left  henUphcTe  (after  Caweis) t4> 

tt,  HttnitlroptMlmgmit 14) 

to.  llvntialropliM  lingnic 144 

}t.  niaryngeal  and  Urpigol  electrode  ailh  anangtinenl  for  moliing  and  break- 

iMg  ihe  mnenl  (after  Erii) 149 

]1.  Facial  npteuiow  in  progrculve  bulbar  pataljiin  (l.eyden.  EichhonI)  .  .  I!4 
1).  Croia  iWiow  Ihroagk  ibc  upper  poiiionof  the  mc<Ui1lB  oblongata.  .  If6 
X-  Tha  poWerior  (dorial)  aipect  of  Ihc  incdulla  oblongata 157 

m 


xiv  LIST  OF  ILLUSTRATIONS, 

FIS.  fACa 

35.  Right  beniisphere  (after  Exner) 166 

36.  Left  bemi<>phere  (aller  Exner) 166 

37.  CoUToIulions  and  fissures  of  the  lateral  aspect  of  the  brain  (aflcr  Ecker)  167 

38.  Convolutions  and  fissures  at  the  base  of  the  bivin  (diHgrammatically,  after 

Kcter) 16S 

39-  DidgTun  illustrating  method  of  determining  the  location  of  the  fissure  of  I^o- 

londo 169 

40.  CoDTolulions  nnd  fissures  of  the  median  aspect  of  the  brain   ....  170 

41.  Convolutions  of  the  island  of  Reil  (J.  K.)  made  visible  by  removing  the  oper- 

culum         170 

4a.  Topographical  relations  between  the  exterior  of  the  skull  tuid  the  surface  of 

the  brain  (after  Ecker) 171 

43.  Wernicke's  schema  for  the  conical  mechanism  of  speech        ....  17J 

44,  45.  Lichlheim's  schema  illustrating  the  seven  different  forms  of  aphasia         .  179 
46.  Diagram  showing  the  direct  system  of  fibr«  (Plcchsig,  Mendel)    .  184 
47-  Course  of  the  libres  from  the  intemal  capsule  to  the  eras  cerebri  (diagram- 
matic, after  Wernicke  and  Edinger) IS9 

4B.  View  of  the  ventricles  on  horizontal  sec'.ion  (after  Edinger)  ....  190 
49.  Horizontal  section  through  the  brain,  about  a  finger's  brcadlb  below  that 

represented  in  Fig.  4S  (Edinger) igi 

50-53.  So-called."  frontal  sections"  through  the  brain  (after  Edinger)  .      19*,  193 

54.  Points  at  which  Ihe  Pitres-Nothnogel  sections  are  made          ....  194 

55-60.  Pities-Nothnagel  sections 195-197 

6t.  Diagrammatic  cross-section  through  the  anterior  corpora  quadrigemina  (after 

Edinger) aoo 

63.  Longitudinal  section  through  Ihe  region  of  the  corpora  quadrigemina  of  a 

human  fcetus  twenty-eight  weeks  old  (after  Edinger)      ....  201 

63.  Uii^rammatic  horiionlal  section  through  the  decussation  of  the  superior  pe- 

duncles of  the  cereoellum  (after  Edinger) 90l 

64.  Sagittal  section  through  puns  and  medulla  oblongata  (after  Mendel)               .  3o3 

65.  Cross-seclion  through  the  region  of  the  ant.  corpora  quadrigemina         ■  103 

66.  Diagram  showing  the  decussation  of  the  fibres  going  to  the  extremities,  and 

of  those  going  to  the  face,  in  the  pons  and  medulla  oblongata         .        .  £04 

67.  The  connections  of  the  cerebellum 307 

68.  Diigram  showing  the  circle  of  Willis no 

69.  The  cortical  distribution  of  the  middle  cerebral  artery  (after  Charcot)   .        .  211 

70.  Frontal  section  through  tbe  cerebral  hemispheres,  one  centimetre  behind  the 

chiasm 312 

71.  Cerebral  artery  from  an  apoplectic  focus  (after  Comit  and  Ranvier)                .  313 

73.  Miliary  aneurism  of  a  small  artery  of  the  lenticular  nucleus  (after  Marchand)  314 
73-  The  latge  head  electrode  (covered  with  sponge)  of  Erb 341 

74.  Porencephaly 367 

75.  Hemiatrophy  of  the  left  side  of  the  body,  front 374 

76.  Hemiatrophy  of  the  left  side  of  the  body,  back 275 

77.  Hemiatrophy  of  the  left  side  of  the  body  from  traumatism      ....  276 

78.  Hemiatrophy  of  the  left  side  of  the  body  from  traumatism      ....  277 

79.  Atrophy  of  (he  left  upper  and  lower  extremity 278 

Bo.  The  family  form  of  spastic  paraplegia  (after  Newmark) 379 

Bl.  Atrophy  of  paralyzed  side 38o 

83.  Atrophy  of  paralyzed  side  ;  contracture  of  wrist 2St 

83.  Atrophy  of  paralyzed  side  :  contracture  of  ankle     ...                 .         -  3S3 

84.  Atrophy  of  paralyzed  side  ;  contracture  of  ankle 263 


LIST  OF  ILLUSTRATIONS. 


sv 


rtc 

es 

S6. 
tt. 
9* 


P 


IIZ. 
»"S- 

Itfa. 

II  J. 

Ilk 


,1.9. 

!„,. 

m. 

in. 
itj. 
111. 
i»» 

M> 


CobvuIbvc  nuncntenti  of  lli«  cKtrcmUin aS] 

Cliotna  ltJaDgi«claliciiiD(ancr  ZicglcT) , 389 

rapUluy  tarcinooia  in  ihc  ihird  vrnirirlc  (after  Z)tcl«(>       ....  Vfi 

CTiiiMR-niracemonii  (after  MarchandJ Joj 

Ilyilrecephahu              309 

Cfoti-icclioa  ibrough  ihe  vertebral  column  and  the  i|Hnal  cord  (diagrun- 

iDitic«IH>^tc(  Eichhoni) 316 

Crau-MCiioa  ihrough  Ihe  miJdte  of  Ihe  lervicnl  mkr^emtnt  in  pachyiiwn- 

inptit  ccrvicalit  b)-peTlrophici  (after  Clinrcol) yVJ 

INyilioo  of  (ke  band  in  inchyincningilii  cflrvicalin  bypetlrupliica  (Chikrooll .  319 

Uia^rnBinalic  oaliino  of  Iho  ccrviml  and  l>rac]iial  I'lriiitei  lafler  Mlwaltif)  333 
CMe  uf  ri):bl-)i(l«d  wriBtus  paislytl*  In  a  mftii  Ihirlgr-fivc  ycais  uf  ago  (after 

EichhotHi) MI 

TI1D  Moc  ca>c  arith  the  amn  raiwd 3|) 

Position  of  ibe  head  in  tfusm  <A  iho  «pJcniu4  cajiliU  on  i])e  rtghi  »id«  .       .  343 

UuKiito^iral  jionljrus 3«4 

MMOf  jiutntt  of  ibe  n>iueulo>»|>lral  nerre  and  ihc  initsclM  Mtpplied  by  It      ,  347 
lOOi,  Tb«  dntrUiutkin  of  Uie  cuianeon*  nervci  of  the  um  and  hand  (aflct 

Ekhbora) yfi 

DlMrlbution  of  (he  teututy  ncivet  on  the  tiack  of  ihc  fingcn  (Kriuw) .        .  3*9 

Motor  pobiu  of  tbc  tnedfan  nerve  and  ilie  mutcin  tupplieil  by  it                  .  350 

Motor  poinu  of  the  olaar  nenv  and  the  muhclct  supplied  bj  It    .               .  350 

Motor  |MMn[»  'if  Ihe  ulnar  nerve Mi 

Claw-bandfiftTi  Duchenne) ygl 

Motor  polntt  cf  the  muteukKUtuiooiUi  nerve  and  Ihe  maKletnipplicdby  It  JJt 

Motor  {Nilntt  of  Ihe  brachial  pleim ;  Erb*«  raiwaclnviculu  poiiU  .                 .  3SS 
1 1 1.  Tbc  manner  in  nlilch  a  chilil  whote  ercctorci  tplnar  ate  panlyiod  got* 

up  from  tbc  ([loniuMaftcr  lioii*er%) 31M 

DbfraaamMie  onliinc  of  ihe  Kimbai  and  Mcral  picuwt       ....  367 
■  14.  Arcaaof  dittribulion  of  the  caianeous  nerve*  of  the  lower  extremity 

(4fier  lletile) 368 

MolDt  poiMc  for  the  ecrvct  and  mutelci  of  the  anterior  mrface  of  Ibe  leg    .  33> 

.Moloe  poiali  for  ihc  Kiaiic  nerve  anil  The  niutvle*  suji]ilied  by  it         .        .  3B3 
C«i«  of  peri|jlicnil  ncunlii  »f  ihe  tcloiic  ivcive,  with  ihorleuini;  and  atrophy 

of  llwaiSccird  cittemiiy 384 

Omk  of  peripheral  neuritis  of  the  fciailc  nerve.  «ilh  thortoninK  and  atrophy 

of  the  ^ITecird  extremity jSj 

tao.  LiKiinciute  in  ih«  iiuadratai  lumborum 386 

Atrophy  of  ihe  nuictei  of  the  rij^l  upper  arm  In  con>e<|uence  of  a  fracture 

of  ihe  Immcnii  levcn  yean  pieilouily 389 

I3J.  I^arthriiii  wiih  leoondity  muUii>1e  ncurlli*         ....     390^  391 

Hemiaitophia  facialis 404 

S»<all(d  JBveaile  muKulor  atrophy  (EA) 407 

Jurmile  iButcular  atrophy  iKib) 40C 

Jnrenitc  muuniUr  atrophy  (Krbi 409 

Jnienilr  mmcular  airophy  (P.rbl ,        .        .        .  410 

t'iDviciiivc  atrophic  myopaiby  (after  Marie  el  Guinnn)         .        .        '         .  411 
■"Mudo-hypenrophy  of  the  musclei  of  the  legi.  with  airophy  of  the  muKlet 

of  (be  back  laflei  Duchcnne) 413 

AlMnKT  of  the  finrcarmi 414 

Tha  nUikini  of  ihe  origin  of  Ihc  nenei  to  the  bodle*  of  the  Tenebnc  and 

tlie  ipinoeit  pniccwu  (after  Uowen) 519 


Xvi  USr  OF  ILLUSTRATIONS. 

no.  rAci 

133.  Scheme  of  the  conducling  paths  in  the  spbi!  cord  aE  the  level  of  fifth  dotsal 

nerve  (after  t'lechiig) 430 

134.  Cr[K&-&ectioii  through  the  spiaal  card  at  difTercnt  leve&  (after  Quain)  .        .  430 

135.  Reflex  arc 431 

136.  Transverse  section   from  the   cervical   portion  of  the  spinal   cord  (after 

Charcot) 436 

137.  Spinal  infantile  paralysis 437 

138.  139.  Progressive  muscular  atrophy  (after  Eichhorst) 435 

140,  141.  Progressive  inusculai  atrophy 436,  437 

141.  Friedreich')  disease  (ifler  Chauffard) ,     .  443 

143.  Ascendiog  and  descending  degeneration  in  the  spinal  cord  (after  Gowers)  .  446 

144.  Secondary  ascending  and  descending  degeneration  in  a  transverse  aflection 

of  the  upper  dorsal  cord  (after  StrlimpeU) 446 

145.  146.  Complete  interruption  of  conduction  of  the  spinal  cord  during  life  (after 

Eichhorit) 4J4 

147.  Schema  of  the  course  of  the  nerve  fibres  in  the  spinal  cord  (after  Brown- 

S^uard} 457 

14S,  149.  Thomsen's  disease  (after  Mills) 4g7,  498 

ISO,  151.  Specimens  of  handwriting  of  patient  with  paralysis  agitans  .        .     501,  iO^ 

152.  Position  of  hands  and  fingers  in  paralysis  agilans  (after  Eichhorst)       ,         ,  503 

153.  Position  of  the  body  in  paralysis  agitans S04 

154.  Entargemeni  of  jaw  in  acromegaly  (after  Marie) 511 

155.  Case  of  acromegaly  (after  Marie) 513 

156.  Case  of  acromegaly  (after  Buchwald) 514 

157.  Osteoarthropathy  (after  Rauzier) S'^ 

ijS.  Osteoarthropathy  (after  Spillmann  and  Haushaller) 517 

Ijg.  Graves' disease 519 

l6o.  Myxixdema  (after  Charcot) 526 

16[.  "  Idiotic  myioEdemaieuse  " 517 

163,  163.  Hysterical  muscular  atrophy 546,  547 

164.  Specimen  of  handwriting  in  a  case  of  multiple  sclerosis  ....  617 
l6;.  Specimen  of  handwriting  illustrating  alcoholic  tremor G32 

166.  Specimen  of  handwriting  illuslraling  tremor  senilis 633 

167.  Specimen  of  handwriting  of  a  patient  with  mercurial  tremor        .        .        .  634 

168.  Specimen  of  handwriting  illustrating  the  tremor  produced  hy  the  ccmbined 

action  of  alcohol  and  mercury 63g 

169.  Cross-section  through  the  cervical  enlargement  of  the  spinal  cord  in  a  case 

of  multiple  sclerosis  (after  Bramwell) 636 

170.  Hemiatrophy  of  the  longoc  in  an  otherwise  perfectly  healthy  child      ,        .  637 

171.  Specimen  of  handwriting  in  a  case  of  tremor  m  tabes 643 

172.  Two  cases  of  tabes  (after  Westphal) 649 

173.  A  case  of  Charcot's  joint  in  a  tabetic 654 

174.  Erosion  of  the  head  of  he  humerus  in  tahes  dorsalis  (after  Charcot)     .  656 

175.  Normal  humerus  (after  Charcot) 656 

176.  Skeleton  of  a  Ubetic  foot  (after  Charcot) 657 

177.  Plantar  fleiion  of  the  toes  in  the  course  of  tahes 661 

17B.  Section  through  the  cervical  coitl  in  a  case  of  commencing   tabes  (after 

Strtlmpell) 673 

179.  Section  through  the  lumbar  cord  in  tabes  (after  StrUmpell)  ....  973 
160.  Section  through  the  cervical  cord  in  a  case  of  advanced  tabes  (after  Slrilm- 

pell) 673 

181.  Suspension  apparatus  used  in  the  treatment  of  tabes 68$ 


DISEASES  OF  THK  BRAIN  AND  ITS  MENINGES, 
INCLUDING  THE  CRANIAL  NERVES. 


■  Hei 

m 

■ 

I 


study  oi  brain  diseases,  we  must  confess,  has  not  made 
the  strides  that  might  have  been  expected  alter  the  numerous 
and  varied  researches  ihat  the  last  decades  have  seen.  For 
this  our  present  very  imperfect  knowledge  of  the  anatomy,  and 
Mill  more  our  doubts  as  to  the  pbysioloji^cnl  functions  of  Ihc 
different  parts  of  the  brain  must  be  held  largely  responsible. 
The  »truc1urc  as  well  as  the  physintogical  functions  of  the 
human  brain  are,  up  to  the  present  titne,  so  little  understood 
that  we  are  far  from  having  any  sure  basis  upon  which  to  lay 
ihc  foundations  of  a  cerebral  pathology.  No  small  progress 
h:is  been  made  from  an  anatomical  standpoint  through  Stil- 
ling's  method  of  serial  sections,  a  method  which  Mcyncrt, 
Henic,  Wernicke,  and  others  have  not  been  slow  to  use.  (n 
r  admirable  researches,  to  which  important  additions  have 
11  made  by  the  embryological  studies  of  Flrchsig,  and  by 
the  method  of  "arresle*!  development  "  used  by  Gudden  and 
his  pupils  (atrophy  method:  Dfgfueralionsmdhoiif.  Schwalbe); 
btit  with  all  this  we  have  only  here  and  there  single  stones 
which  we  have  not  as  yet  been  able  to  combine  (or  the  con- 
struclion  of  a  harmonious  whole.  Brilliant  from  a  physiologi- 
cal stand|>nint  as  was  the  discovery  o(  Fritsch  and  f-Iilzig  (1870) 
of  the  cicclrical  irritability  ot  the  cortex,  and  of  the  existence 
of  motor  regions  therein,  unexpected  as  were  the  results  which 
the  experimental  method  of  Munk  brought  to  light,  extraordi- 
nary and  interesting  as  are  the  conclusions  based  upon  the  clini- 
cal and  post-mortem  observations  of  Charcot  and  his  S4;hi)ol — 
all  these,  wide-reaching  and  admirable  as  they  were,  arc  far 


3  DISEASES  OF  THE  BRAIN. 

from  having  given  us  a  full  understanding  of  the  functions  of 
the  different  parts  of  the  brain,  and  an  explanation  of  the  dis- 
turbances to  which  they  are  subject.  Constant  and  untiring 
work  is  still  needed,  and  the  best  results  are  promised  from  the 
intelligent  combination  of  clinical  observation  with  pathologi- 
cal research.  The  pathology  of  the  brain  can  not  be  better 
advanced  than  by  the  patient  clinical  observation  of  cases  dur- 
ing life  and  a  careful  autopsy  after  death.  In  institutions 
where  not  only  the  fullest  opportunities  are  afforded  for  clin- 
ical observation  and  for  the  systematic  conduct  of  post-mortem 
examinations  of  the  brain,  but  where  also  the  best  men  are 
found  to  supervise  the  work,  in  these  will  cerebral  pathology 
make  the  greatest  strides. 

We  shall  divide  our  description  of  cerebral  diseases  into 
three  parts.  In  the  first  we  shall  take  up  the  diseases  of  the  me- 
ninges, in  the  second  those  of  the  cranial  nerves,  while  the  third 
will  embrace  the  diseases  of  the  brain  in  the  stricter  sense,  i.  e., 
those  of  the  white  and  gray  matter  of  the  hemispheres  and  of 
the  central  ganglia. 


PART    I. 

DISEASES  OF  THE  MENINGES  OF  THE  BRAflT 


TllK  meninges  are  relatively  more  frequcnlly  affected  by 
disease  than  ihe  brain  subsiaiice  itself,  and  tjuitc  a  consider- 
able  number  al  the  cases  which  \vc  commonly  call  disc3M:s  of 
the  brain  are  really  to  be  classed  as  aReciions  ol  the  meninges. 
Since  these  diseases  can  develop  under  the  most  varied  con- 
ditiims,  and  can  be  primary  as  well  as  secondary,  they  are  of 
great  prnctical  importance,  and  we  must  try  to  disiinj^nisii 
most  carefully  between  the  differcnl  forms  which  they  assume. 

A  clear  understanding::  of  the  pathological  processes  in  these 
diseases  will  be  facilitated  by  some  remarks  upon  the  anatomy 
of  the  meninges. 

The  ouiermoftt,  tough,  Abru-tcndinons  membrane,  called  the  dura 
tn.iier,  fiKmi  ai  the  same  time  llic  inner  periosteum  of  the  cranial 
faoiies.  It  has  an  outer,  rou^h,  aiul  art  inner,  smooth  surface.  Tor 
the  nerves  as  they  cmcrue  from  the  skull  this  memhrane  supphe^ 
shcath-hke  coverings,  among  which  that  of  the  optic  nerve  (vagina 
optia)  i«  the  most  conspicuous.  The  blood-supply  of  the  tlura  is  de- 
rived from  branches  of  the  mening<.-al  arteries.  That  it  possesses  its 
own  ncrve»  jit  doubte<i  \>y  some  (among  them  I.uschka),  affirmed  by 
others  (Rticdinicer,  Alexander),  It  in  most  probable,  however,  that 
It  is  the  trigeminus  which  chielly  provideat  for  the  innervation  of  the 
durj, 

The  tccoQd  membrane,  the  arachnoid,  is  delicate  and  contains  no 
vcMeU.  Its  outer  surface  is  smooth  and  looks  toward  the  subdural 
»pa<rc.  while  the  inner  is  rough  .ind  turned  toward  the  pia  mnier. 
Tlie  !>o-catlcd  subarachnoid  *pacc  (I-'ig.  i).  which  in  situated  between 
the  arachnoid  and  pia,  contains  between  the  meshes  of  the  subarach- 
ni»id  li^Tiue  the  seroas  cerebfo-spinal  fluid. 

Tlie  third  menihrane,  the  innermost,  the  one  which  lies  directly 
on  the  surface  of  the  brain,  is  called  the  pia  mater.  It  dips  down 
into  the  depths  of  the  sulci,  forming  a  continuous  lining  of  thote 
parts  of  the  hrain-Mem  which  are  covered  by  the  cerebrum   and 

3 


4  D/S£ASES  OF  THE  MKA-liVGF.S  OF  rffH  BKAIN. 

cerebellum,  and  seems  to  penetrate  through  th«  so-called  fiisures 
into  the  interior  of  the  brain.  These  processes,  which  are  called 
telie    choroid  etc.    present    peculiar    villous    formations,    very    rich 

in  capillary  vc&s«ls, 
and  therefore  of 
a  deep  -  red  color 
(plexus  choroidei). 
The  covering  or 
ependyma  of  the 
ventricles  is  not  a 
part  of  the  pia  ma- 
ter, bul  is  simply  a 
layer  of  epithelial 
celK.  The  nerves 
of  the  pta  mater 
belonic  to  the  sym- 
pathetic. 

The  diseases 
of  llic  meninges 
of  the  brain  con- 
sist  mainly  of  in> 

flammatorv  processes  aflecling  cither  the  pia  or  the  dura  mater. 

We  shall  study  the  diseases  of  the  two  nieinbnines  separately. 


Flo.  I.— Ciiom  SeiiTiiiH  riiKot^uii  ritx  CtfttmuL  Curtcx 

ce.  Cor<« :  /,  pin  muer :  i.  a.  cuhorachTuild  ipocc :  >.  4,  iul>- 
dural  iTOce ;  4,  dun  nuiler ;  t.  p.  XiVxA  v«bc1i. 


CHAPTER   I. 


INrLAUUATION'  OV  TIIK  INNKK  SUBKACK  OF  THE  DHRA  MATCH, 
I'ACIIVMKMKCITIS  INTERNA  HiCMORKHAUlCA,  HEMATOMA  Dl'R.K 
HATRIS. 

The  origin  of  the  extravasations  of  blood  which  at  the 
autopsy  arc  often  found  on  the  inner  surface  of  the  dtim,  and 
which  can  be  easily  scraped  off  with  the  knife,  is  not  alto- 
gethcr  understood.  .Some  (Virchow,  1856)  hold  that  the  pri- 
mary affection  is  an  inflammation,  and  the  hemorrhage  takes 
place  secondarily  into  the  newly  formed,  highly  vascular  con- 
nective tissue,  while  others  look  upon  the  haemorrhage  as  pri- 
mary ;  and,  indeed,  recent  observations  (Sperling)  seem  to  be 
very  much  in  l.ivor  of  this  latter  view.  If  extensive  hxmor- 
rhugcs  occur,  after  spreading  over  more  or  less  of  the  inner 
surface  of  the  dura  (hey  become  encapsulated,  and  arc  then 


tACtlYMBNINCITlS  INTERNA  H^MORKHAGICA. 


s 


called  kamalomata  dura  matris.  Such  a  hacmatoroa  may  con- 
tain from  three  humlred  to  four  hundred  grammes  of  extrav^i- 
sated  blood,  may  attain  the  size  oi  a  raan*s  fist,  and  so  exert 
a  deleterious  pressure  upon  the  brain.  The  walls  are  some- 
limes  smooth,  sometimes  rough ;  the  contents  arc  not  always 
sanguineous,  but  may  be  serous  or  purulent.  They  are  most 
commonly  situated  at  the  vertex  near  the  (alx  cerebri,  some- 
times also  in  the  frontal  region,  very  rarely  at  the  haw;.  The 
arrangement  of  the  hematoma  in  layers,  which  is  seen  on  sec- 
tion, proves  that  the  whole  process  consists  of  extravasations 
which  have  occurred  at  different  limes.  In  the  least-marked 
cases  only  a  delicate  reddish  membrane  is  found,  presenting 
reddish  or  brownish  specks,  and  is  easily  stripped  off  from  the 
dura.  Only  gradually  the  different  layers  .ire  developed,  the 
ODC  nearest  to  the  brain,  of  course,  being  always  the  most 
recent,  the  one  lying  on  the  dura  the  oldest.  Ilctwccn  the 
layers  arc  the  hemorrhages.  If  it  happens  that  the  most  re- 
cent  layer  is  perforated  by  the  haemorrhage  there  occurs  free 
extravasation  of  blood  between  the  dura  and  the  arachnoid — 
that  is.  an  intermeningeal  hemorrhage. 

Etiology. — In  the  xtiology,  diseases  of  the  heart  and  kid- 
neys, but  especially  chronic  diseases  of  the  brain,  play  by  far 
the  most  important  part.  The  lesion  is  seen  in  almost  all  aflec< 
lions  which  lead  to  an  atrophy  of  the  brain  ;  further,  it  may  be 
met  with  in  infectious  diseases — for  instance,  in  typhoid  fever, 
scarlet  fever,  acute  rheumatism  :  also  in  conditions  of  what  we 
may  call  blood-dissolution,  as  in  the  gener.il  harmorrhagic  di- 
athesis. Frank  C.  Moyt,  of  New  York,  has  called  attention  in 
this  connection  to  a  lowering  or  complete  paralysis  of  the  vaso- 
motor tone,  which  according  to  him  is  associated  with  struc- 
tural changes  in  the  blood-vessels  (Medical  Record.  iRgj.  -ji). 
Among  the  exciting  causes  are  traumatism  of  the  cranial  bones 
and  inHaiiimntion  in  the  neighboring  parts— (or  instance,  in  llie 
petrous  portion  of  the  temporal  bone.  Of  predominating  wxu 
portancc,  as  an  {etiological  factor,  is  the  abuse  of  alcohol.  Al- 
most in  all  autopsies  on  old  drunkards  wc  find  a  more  or  less 
well  developed  pachymeningitis  interna,  which  has  recently 
also  been  experimentally  produced  in  dogs  by  continued  doses 
ol  alcohol  ([..eyden).  The  f.ict  that  statistics  have  established 
that  men.  and  more  especially  old  mm.  arc  by  preference 
affected  by  this  disease  also  seems  to  point  to  alcohol  as  the 
principal  cause. 


I>/S/iMSes  OF  THE  MES'IUGES  OF  THE  BR  A  Iff. 


i 


Symptoms  may  be  cnlircly  absent-  This  is  the  case  when 
ihe  hxmorrhage.  or  the  newly  formed  membranes  are  not  of 
sufficient  extent;  but  if  symptoms  are  present,  then  among  the 
most  important  we  fmd  heailnche.  which  may  persist  for  years, 
but  which  of  course  in  itself,  even  if  wc  have  a  history  point> 
ing  to  this  disease,  as.  for  instance,  the  abuse  of  alcohol,  is  never 
sufficient  to  justify  the  diagnosis.  With  a  sudden  rise  of  intra- 
cranial pressure  wc  always  have  agopleclifonn  attack^,  in 
which  consciousness  is  lost  (or  a  variable  time,  and  in  which 
ihe  patient  may  die  without  regaining  consciousness.  Vomit- 
inf.  slp>r  [lulsc.  and  a  very  conspicuous  narrowing  of  the  pupil 
are  not  wont  to  be  absent.  F<epealedly  peculiar  dreamy  con- 
ditions have  been  observed  alter  such  a  coma,  during  which 
the  patients  seem  completely  dazed  and  the  urine  and  l;eces 
are  passed  involuntarily.  I(  the  ha;matnma  lies  over  the  mo- 
tor area,  epileptiform  convulsions  and  hemiplegia  may  result, 
serious  motor  disturbances,  limited  to  one  side,  which  may  en- 
tirely disappear  in  a  short  while,  or  may  last  (nr  months.  Uni-J 
latenil  nystagmus  and  choked  disk  have  been  reported  by  some! 
{Fucrstncr).  The  further  course  depends  upon  the  absorption 
of  the  clot  or  the  occurrence  of  a  further  ha,'morrbage,  as  the 
case  may  be.  The  repeated  development  ol  severe  cercbrafl 
symptoms,  after  striking  and  rapid  improvement,  speaks  under 
certain  circumstances  (or  the  existence  o(  h?emaloma  of  the 
dura,  Ijccause  it  is  just  this  frequent  change  in  the  condition  of 
Ihe  patient  which  is  characteristic  of  the  course  of  the  disease. 
Months  and  even  years  may  thus  pass  without  a  fatal  result. 
and  much  more  rarely  than  nne  would  be  led  to  c)ipc*ci  is  it 
possible  to  make  a  positive  diagnosis  during  life,  because  all 
the  symptoms  which  we  have  mentioned  can  be  found  just 
as  well  in  other  cerebral  affections,  in  ha-morrhage,  embolism, 
new  growths,  etc..  and  the  only  thing  we  have  (o  fall  back  upon 
is  the  history,  if  this  be  nne  of  alcoholic  excesses.  The  parox- 
ysmal appearance  of  new  symptoms  is  not  to  be  overlooked, 
inasmuch  as  it  confirms  to  some  extent  the  diagnosis  of  pachy. 
meningitis.  However,  under  all  circumstances  the  task  is  a 
difficult  one.  The  cases  described  by  French  writers  (e.  g., 
Puech,  Progr^s  mWical,  1S89.  171  under  the  name  apofUxu prth 
gressivf  arc  instances  of  this  affection. 

Prognosis.— The  prognosis  for  recovery  is  of  course  ttbso* 
lutely  bad  if  thickening  has  reached  any  rlegree  worth  men- 
tioning :  and   when   wc  have  to  deal  with  a  large  hormatoma 


PACff  y,ve,vmG/r/s  interna  ha^morkhagica. 


I 


which  cncmachcs  considerably  upon  the  intracranial  space  llic 
prospect  for  life  is,  to  say  the  least,  not  hopelul.  On  various 
anatomical  grounds  death  can  occur  suddenly  and  iinexpGCl> 
ediy. 

Treatment  can  only  be  of  any  value  in  the  earlier  stages, 
ttut  unfurtunaiely  the  disease  is  usually  not  recognized  then. 
Interdiction,  or  at  least  restriction,  of  the  uiic  o(  alcohol,  if  this 
plays  a  part,  energetic  antiphlogistic  treatment  in  the  form  of 
local  bloodletting,  the  ice-cap  to  the  head,  countcr-irrilation  by 
inunctions  o(  mercurial  ointment,  and  active  purgation  (calo- 
mel) would  surely  give  us  good  results;  but,  as  we  have  said, 
these  means  are,  as  a  rule,  used  too  late,  and  as  a  matter  of 
fact  the  progress  of  the  disease  is  usually  not  altered  by  ^\\y 
therapeutic  measures. 

The  most  common  new  growths  of  the  dura  mater  arc 
sarcomata  (endothelioma,  fungus  durx  ntalris)  or  osteomata. 
Fibromata  and  lipomata  are  but  rarely  met  with.  They  are 
only  of  pathological  and  not  of  clinical  interest,  since  they  do 
not  give  rise  to  typical  symptoms. 

LITERATURE. 

Eulmtiutg.  A,     IxhrlHich  rfc*  Ncncnkrankhdlcn,     i.  Aufl,     Berlin.  1S78. 
ZirKtrr,     Ltlifbuch  der  allj-emcincn  uml  ^iprcicllcii  tMlholog.  Aoiitotnii!.     jenii. 

1S82. 
Wrniicli?.     l.chrlMich  der  Oehirnlcnnkhciten.     Bd.  iii.  pp.  483  H  ttq.     Berlin, 

Omrcn.     L^tlum  on  ilie  Ui.ifrncMifl  of  Dlscaaea  of  the  Brain,  delivered  it  Unl* 

venity  College  Hospital,  iStij^     Chiirchhitl :  iilvi  DUki^lon.  Phil  add  plua. 
UehcnMinicr     VoricMingrn  ;ibcrdie  Kmnkheilen  det  Ncn-en«y%lenis.     P.  306 

tt  ttq.     Leipzig:  Vogel.  i88fi. 
Eicbhurtl.    Handbuch  der  tpmicllrn  Paitinlogic  und  Thcrapic.     Bd.  iii,  pp,  439 

H  u^,     3.  Aufl.     Wien  und  l^piiK.  I'iH?, 
SceliKnioltcr,    Lchtbuch  der  Knnkheiien  d**  Kiickenmirks  un<i  Gehims.    Ahih 

II.  pp,  401  tt  u^.     l)riun«chwcii;.  18S7. 
llnfTrnvin.     Zur  I'nlhalogic  und  Thcrajiie  der  I'achyin,  ext.  putiil  ii.ich  Eni- 

nindUDgrti  des  Mitldolircs.    Deutsche  Zcitschnfi  fiir  ChiTurgic.  May  4. 

■ns,  vol.  xviii. 
ThlroluiK  et  du  I'utiuier.    Oasilkallon  de  U  dure  niJre  ;  inuft  pir  htmorrtio^e 

c<rrt)*ale.     Bull,  dc  U  Soc.  an.it .  Jan.  i,  1H91.  j  t^r„  vii. 
WtllelL     rihrama  rA  the  Dura  Mater  witlioui  Syniptonii.     F&lli.  Soc  Tranuc- 

lioiH,  1891.  xlitl.  p.  6. 


CHAPTER  II. 

INFLAMMATIONS    OF    THE    SOFT    MEMBRANES    OF    THE    BRAIN;    LEPTO- 
MENINGITIS;   PURULENT    MENINGITIS. 

A.  Pathological  Anatomy.    jEtiologv. 

Inflammations  of  the  soft  cerebral  meninges  occur  either 
at  the  base  or  at  the  convexity  of  the  brain,  according  as  they 
are  primary  or  secondary — (.  c,  associated  with  other  diseases- 
— and  one  can,  indeed,  with  a  few  exceptions  and  bearing  in 
mind  the  transition  forms,  put  it  down  as  a  rule  that  secondary, 
metastatic  meningitis  affects  the  convexity,  while  a  primary 
meningitis  is  usually  found  at  the  base. 

In  contradistinction  to  what  takes  place  in  the  dura,  where 
the  only  purulent  inflammations  that  we  find  are  such  as  have 
extended  by  contiguity  from  neighboring  parts,  here  we  have 
to  deal  with  purulent  inflammations  alone.  This  purulent  in- 
flammation of  the  soft  membranes  of  the  brain,  the  leptomenin- 
gitis cerebralis,  is  an  infectious  disease,  and  occurs  in  epidemics 
as  epidemic  cerebro-spinal  meningitis,  or  more  rarely  sporadi- 
cally, the  two  forms,  however,  being  JEtiologically  identical. 
Besides  these,  we  find  developing  in  the  course  of  tuberculosis, 
sometimes  very  early,  sometimes  late,  a  specific  form  of  menin- 
gitis, the  tubercular  meningitis. 

Pathological  Anatomy. — ^The  pathological  processes  can  be 
traced  in  the  pia  as  weli  as  in  the  substance  of  the  brain.  In 
the  meshes  of  the  former  we  find  a  purulent  exudate,  which  is 
in  rare  cases  limited  to  one  hemisphere  ;  if  it  is  copious,  the  pia 
can  easily  be  stripped  from  the  brain ;  if  it  is  scanty,  this  can 
not  be  done  without  loss  of  substance.  The  brain  substance  is 
oedematous  and  fills  up  the  skull  more  than  normally,  so  that 
the  convolutions  appear  flattened.  The  ventricles  are  filled 
with  an  unusual  amount  of  fluid  (hydrocephalus  internus).  The 
hsemorrhages  which  are  recognizable  in  the  brain  substance  do 
not  exceed  in  size  that  of  a  pin's  head,  and  are  either  isolated 
8 


l£P  TOMENINGITIS. 


or  are  seen  especially  near  the  ventricular  walls  in  greater 
numbers,  the  so^alled  capillary  apuplcxics.  Besides  these 
there  arc  other  small  punctiform  hxniorrhages,  or  rather  spots 
ol  red  softening,  and  minute  haimorrhagcs  closely  grouped  to- 
gether. All  these  focal  changes  arc  to  be  looked  upon  as  due 
to  the  influence  of  the  specific  virus.  1(  the  process  has  be- 
come  a  chronic  one.  then  the  characteristic  features  are  axltma 
of  the  pia,  wasting  of  the  brain  substance,  hydrocephalus  inter- 
nus.  and  thickening  of  the  ventricular  ependyma.  which  gives 
to  the  surface  a  %-elvcty  appearance  and  changes  the  shape  of 
the  ventricles  in  a  characlcristic  manner,  the  normally  sharp 
edges  becoming  rounded  off  ^chronic  meningitis). 

In  tubercular  meningitis  wc  find  not  only  signs  of  an  in- 
Raromatory  process,  but  ulsu  the  formation  of  tubercles  i  both. 
however,  do  not  pr<^rcss  park  pauu.  There  m;iy  be  a  very 
extensive  cntptiun  of  tubercles  and  a  relatively  slight  inOamma- 
tion,  or  xnct  versa,  but  always,  especially  in  children,  the  greater 
[}art  of  the  }elly-like  exudate  is  situated  at  the  base  (basilar 
meningitis),  between  the  pons  and  the  anterior  perforated 
space,  and  imbedded  in  it  arc  the  grayish-white  tubercles  which 
are  seen  as  nodules,  sometimes  as  large  as  millet-seeds,  and  are 
found  in  the  greatest  numbers  among  the  larger  vessels  of  the 
fissure  of  Sylvius,  on  the  chiasma.  pons,  etc-  The  vessels  are 
fuller  than  usual,  and  small  ha'inorrhages  can  occasionally  be 
seen  in  the  pia.  The  substance  of  the  brain  is  affecte<l  in  the 
manner  above  mentioned — hydrocephalic  effusions  into  the  vcn- 
triclcs  are  rarely  absent,  and  there  is  a  decided  fullness  of  Ihe 
choroid  pifsuscs.  Foci  of  softening  are  noted  chiefly  about  ihe 
btual  ganglia :  they  are  produced  sometimes  by  the  occlusion  of 
an  artery,  M>melimus  by  the  pressure  which  the  exudate  exerts 
on  the  vessel,  or,  again,  by  an  arteritis  obliterans.  Kegcncni- 
liuii  has  been  known  to  occur  even  in  tuberculous  meningitis. 
Dilaiatiiin  of  Ihe  ventricles  and  other  signs  of  .in  increased 
ininicraniul  pressure  may  continue,  and  collections  of  flui<l  in 
Ihe  pia  and  in  the  ventricles  m.iy  still  be  present,  but  tlie  fluid 
may  again  become  clear,  the  pia  moist  and  nonjidherenl  to  the 
cortex,  and  the  tubercles  present  no  infl.immation  around  them 
(Wernicke). 

A  chronic  form  of  Ixisal  meningitis,  in  which  the  pia  is  in 
places  either  thickened  and  indurated,  or  where  wc  have  a 
formation  of  brittle  crusts,  may  be  of  a  gummatous  nature 
<W«rnicke).     When  a  purulent   process  in  the   dura  extends 


lO  n/SF.ASES  OF   THE  MEAWXGES  OF   THE  BRAIN. 

into  the  sinuses  we  get  what  is  called  a  throm bo-phlebitis  or  a 
(marantic)  sinus  thrombosis  (see  Diseases  of  the  Cerebral  Veins). 

.^tiologfy. — As  has  been  stated,  cerebro-spinal  meningitis 
has  to  be  looked  upon  as  an  infectious,  sometimes  epidemic, 
disease,  the  parasitic  nature  of  which  was  demonstrated  by 
Leyden  in  1883,  He  found  in  the  tissues  of  the  pia  and  in 
the  turbid  cerebro-spinal  fluid  diplococci,  which  A.  Fraenkel 
(Deutsche  medicinische  Wochenschrilt,  1886,  13)  and  G.  Hauser 
(Miinchener  med.  Wochenschr.,  1888,  36)  recognized  as  identical 
with  the  pneumococcus.  Whether  or  not  these  cocci  gain 
access  to  the  meninges  through  the  nasal  cavities  and  the  fo- 
ramina of  the  ethmoidal  plate,  we  are  unable  to  say.  Children 
and  young  people  are  more  easily  affected  by  the  disease  than 
adults,  and  the  infection  can  be  carried  by  them  from  place  to 
place.  In  inclosed  and  crowded  localities,  e.  g.,  in  prisons  and 
barracks,  the  disease  may  become  endemic. 

But  even  when  there  is  no  epidemic,  the  disease  may  ap- 
pear sporadically  anywhere,  and  then  also  must  be  regarded  as 
being  just  as  much  of  a  parasitic  nature.  Whether  the  direct 
influence  of  the  sun's  rays  is  capable  of  producing  meningitis, 
or  at  least  of  favoring  its  development,  has  not  thus  far  been 
sufficiently  studied. 

A  tangible  cause  for  meningitis  we  find  in  traumatism  of 
the  cranial  bones,  causing  injury  to  the  soft  parts,  so  that  the 
pathogenic  organisms  can  penetrate  through  the  open  wounds. 
The  (septic  ?)  Streptococcus  pyogenes  (Eberth),  which  is  less  deli- 
cate and  more  resistant  than  the  above-mentioned  coccus,  has 
been  demonstrated  in  such  cases.  If,  however,  in  traumatism, 
the  air  remains  excluded,  as  happens  in  fractures  at  the  base, 
then  the  presence  of  a  purulent  meningitis  is  difficult  to  explain. 

The  diseases  of  the  bones  of  the  skull,  more  especially  those 
of  the  petrous  portion  of  the  temporal  bone  and  of  the  auditory 
apparatus,  play  an  important  part  in  the  aetiology  of  meningitis. 
From  an  otitis  media  may  be  developed  a  caries  of  the  petrous 
portion  of   the  temporal   bone  which  may  perforate  the  thin 
roof  of   the  tympanic  cavity.     The  infection  extends  in  such 
cases  along  the  auditory  nerve  (Kirchner,  Berliner  klin.  Wo- 
chenschr.,  1893.  33).     Another  extension  of  the  inflammation 
mav  come  from  the  mastoid  cells  if  an  embolus  passing  from 
the    veins  of  the   bone    lodges   in  one  of    the  venous  sinuses, 
which  then  becomes  the  seat  of  a  purulent  throm  bo-phlebitis. 
That  the  tuberculous  meningitis  has  its  origin  in  tubercu- 


LEP  TOM&NWGITIS. 


II 


lous  processes  In  other  organs  is  clenr,  and  tlie  xtiology  is 
therefore  identical  with  that  o(  tuberculosis  tn  general — i.  e., 
there  is  invariably  an  invasion  by  the  tubercle  bacillus.  It  is 
an  interesting  (act.  however,  that  though  the  primary  disease 
in  other  organs  need  not  necessarily  have  produced  any  or  at 
least  no  marked  disturbances,  we  can  still  have  secondary 
disease  of  the  pia  with  the  symptoms  peculiar  to  it,  which  we 
shall  describe.  Children  especially  are  not  rarely  attacked  by 
meningitis  the  tuberculous  nature  ol  which  is  only  recognized 
at  the  autopsy,  and  we  may  not  have  the  faintest  suspicion  of 
the  existence  of  a  previous  tuberculous  infection.  In  other 
cases,  however,  the  meningitis  only  appears  after  the  pulmonary 
tuberculosis  has  made  great  progress.  Caseous  bronchial  and 
meiienlenc  glands,  as  well  as  solitary  tubercles  in  the  brain, 
may  be  the  starling  point  of  the  meningeal  affection,  while  it  less 
commonly  follows  tuberculosis  of  the  joints  or  bones,  or  tuber. 
culous  affections  of  the  intestines  and  genito-urinary  apparatus. 

The  relation  of  meningitis  to  other  diseases — i.  c.,  its  simul* 
taneous  appearance  with  influemui,  pneumonia,  scarlet  fever, 
and  typhoid  lever,  ulcerative  endocarditis,  etc. — has  been  care- 
fully studied  by  Huguenin  (Correspondenzblatt  fUr  Schweizer 
Aerzle.  1S90,  23.  24).  but  the  question  whether  in  those  cases 
we  have  to  deal  with  a  double  infection,  or  whether  we  have 
a  single  noxious  agent  which  produces  both  the  meningitis 
and  the  affection  which  accompanies  it.  deserves  further  study, 
F.  Wolff  has  recently  discussed  the  possible  relation  of  the 
occurrence  of  cerebro-spinal  meningitis  to  meteorological  con- 
dilions — e.  g„  to  the  degree  of  humidity  in  the  atmosphere. 
The  fact  that  so  many  cases  occur  between  February  and  June 
is  perhaps  lo  be  regarded  as  a  consequence  of  the  greater 
humidity  which  commences  in  September  and  does  not  de- 
crease until  April :  scarcely  any  cases  occur  in  July  and 
August,  during  the  period  of  atmospheric  dryness  which  com- 
mences in  May  (Dcutsch.  med.  Wochenschr,.  1888.  38). 

It  is  well  established  that  children  and  young  people  are 
more  frequently  and  more  ,sevcrcly  attacked  by  meningitis  than 
older  persons,  and  it  seems  as  if  the  disease  is  never  found  in 
old  age.  Early  childhood,  the  period  between  two  and  three 
years  o(  age,  furnishes  relatively  the  greatest  number  of  vic- 
tims and  gives  the  most  unfavorable  outlook  (cf.  Kohts,  Uebcr 
Paralysen  und  Pscudoparalysen  im  Kindesallcr  nach  Influenza, 
Thenipcut.  Mc.naishefte,  i8go). 


I> 


1>/S£AS£S  Of  TUB  ME/ftA'GBS  OF  THE  BRAt.W 


B.    SVMPTOMS,   DiAGKOSIS,  AND   TREATMENT. 

Symptoms. — The  idiopathic,  purulent  meningitis  of    thcl 
aduk  usually  begins  alter  tnsigni^cant  prodromal  symptoms, 
such  as  digestive  disturbances,  hebetude,  etc.,  with  headache, 
which  soon  attracts  by  its  severity  and  it5  duration  the  atten-J 
tion  o(  the  physician.     Exceptionally  the  patient  has  hours  of' 
comparative  ease;  usually  the  headache  is  so  intense  that  he 
becomes  almost  frantic.     lie  tosses  about  in  bed  with  sighs 
and  groans,  and,  even  when  the  mind   has  become  dulled,  in- 
voluntarily again  and  again  puts  his  hand  to  his  bead.     Some- 
times  delirium  develops  early,  to  cease  again  and  sooner  or 
later  give  way  tu  a  dull  and  somnolent  cundilion,  which  in  its 
turn  passes  into  a  deep  coma,  the  immediate  forerunner  of  death. 

In  some  cas<rs  the  diagnosis  is  facilitated  by  characteristic 
symptoms,  such  as  rigidity  of  the  neck  and  marked  hyper- 
ar^thesia  of  the  skin  and  muscles.  The  former  is  especially 
well  recognizable  when  the  patient  is  asked  to  sit  up  in  bed, 
which  he  can  not  do  without  intense  pain :  the  latter  is  often 
detected  in  the  examination  of  the  patellar  reflexes,  which 
themselves  present  no  particular  abnormalities.  If  we  then 
find  besides  these  symptoms  in  the  beginning  of  the  disease 
occasional  (cerebral)  vomiting,  a  strikingly  stow  pulse,  which  Is 
in  remarkable  contrast  with  the  elevation  of  temperature  (io3* 
and  more),  and  if  we  carefully  examine  the  pupils,  we  can  not 
easily  make  a  mistake  in  the  diagnosis.  The  pupils  are  usually 
very  much  contracted,  but  may  show  alternate  contraction  and 
dilatation  when  illuminated  (or  any  length  of  time  (Ocstreichcr, 
Paradoxc  Fupillenreaction,  Berl.  klin.  Wochenschr..  1890,  6), 
Only  exceptionally,  however,  do  we  meet  with  a  combination 
so  favorable  for  the  task  of  the  diagnostician.  More  frequently, 
as  we  shall  explain  at  length,  he  has  to  encounter  considerable 
difficulties.  There  is  no  doubt  but  that  the  *-omiting  is  of 
cerebral  origin :  but  where  ihc  center  for  thu:  is  to  be  sought, 
whether  in  the  medulla  oblongata  or,  as  HIasko  claims  (Dor- 
pat,  Inaugural  Dissertation,  1887),  in  the  corpora  quadrigemina. 
still  remains  undecided,  as  also  does  the  question  whether  or 
not  we  arc  dealing  with  a  functional  stimulation  of  this  center. 
Choked  disk  and  transient  paralysis  of  the  ocular  muscles  are 
occasionally  observed.  The  former  is  not  easily  recognized 
when  the  patient  quickly  passes  into  sopor:  the  latter,  how- 
ever, is  recognized  without  difficulty  by  the  strabismus  which 


iJiP  TOM  EN  I  SGI  Tin. 


13 


it  causes  and  the  nystagmus-)ike  movements  ol  the  eyeballs. 
Symptoms  of  irritation,  partly  referable  to  the  cortex,  in  the 
form  of  general  or  unilatcnil  convulsions,  muscular  unrest,  or 
carphology,  partly  to  individual  cranial  nerves  {grinding  of 
the  teeth,  trismu!>,  facial  spasm),  have  been  repeatedly  noted. 
Tliey  seem,  however,  not  always  to  occur,  and  for  diagnosis 
must  be  considered  as  of  minor  importance. 

The  course  of  purulent  meningitis  in  the  adult  is  different 
in  different  cases.  As  a  general  rule,  however,  certain  symp- 
toms.  es|>ecially  headache  and  the  rigidity  of  the  neck,  some- 
times  hyperesthesia  of  targe  areas  of  the  skin,  persist  from  the 
onset  and  incre,ise.  while  others,  as.  for  instance,  the  vomiting 
and  the  cranial  nerve  symptoms,  arc  only  transient. 

The  duration  of  the  disease  can  be  two,  three,  four,  to  eight, 
more  rarely  ten  to  fourteen  days,  and  the  younger  the  patient 
the  more  dangerous  is  usually  the  disease.  The  patients  die, 
as  a  rule,  without  regaining  consciousness,  but  the  coma  may 
last  for  days. 

The  symploms  of  the  epidemic  contagious  (Kahlmann, 
Berliner  klin.  Wochenschr.,  188 j,  17)  cerebro-spinal  meningitis 
arc  on  the  whole  quite  similar  to  those  of  the  idiopathic  form. 
In  l>uih  the  headache  is  the  preduniinating  symptom,  and  the 
rigidity  of  the  neck  is  rarely  absent,  but  in  the  epidemic  more 
frequently  than  in  the  idiopathic  form  the  disease  begins  with 
a  chill.  The  course  of  the  fever  presents  nothing  character, 
istic.  It  is  sometimes  of  a  remittent,  sometimes  uf  an  inter, 
mittcnt  ty|>e.  the  temperature  sometimes  reaching  a  height  of 
104*"  lo  107*  F.  More  or  less  severe  disturbances  of  con. 
sciousncss  may  occur  c%-cn  without  a  marked  elevation  of  tem- 
perature. Atnong  the  cranial  nerve  symptoms,  the  disturb- 
ance fn  hearing  caused  by  the  auditory  nerve  taking  part  in 
Ihe  inflammniory  process  has  to  be  mentioned  (Schwabach. 
Zcilschr.  i.  klin.  .Med.,  1891.  xviii.  3.  4).  Visual  disturlwnccs 
■re  more  uncommon,  but  opiic  neuritis  has  been  repeatedly 
noted.  II  other  cerebral  symptoms— convulsions,  hemiplegia, 
aphasia — occur,  they  have  to  be  considered  as  C4)mplicaii(ins 
due  to  an  extension  of  the  inflammation  lo  certain  parts  of  the 
brain  substance. 

The  spinal  symptoms,  which  arc  superadded,  may  consist 
ol  a  distinct  lenderness  along  the  whole  vertebral  column,  of  a 
hypent^thcsia  of  the  legs  (which  is  of  diagnostic  importance), 
and  of  twitchings  of  the  extremities.     X  peculiar,  but.  as  it 


>4 


/y/S/iAS/CS  OF  THE  MEKI.VCES  OF   THE  BRAIX. 


appears,  extremely  uncommon  symptom  is  the  so-called  flexor 
contracture  of  Kcrnig:  tlie  patient  when  in  a  silting  posture 
is  unable  to  extend  his  knees,  because  a  contracture  in  the 
flexors  is  developed,  which  disappears  as  soon  as  the  thigh  is 
no  longer  flexed  at  the  hip-joint.  Bull  (cf.  lit.)  has  made  some 
communications  on  this  point.  The  mechanism  of  micturition 
is  only  influenced  when  the  patient  becomes  unconscious;  then 
the  urine  is  passed  involuniarily.  Besides  this  there  are  no 
important  bladder  syinptunis.  The  urine  sometimes  contains 
albumin  or  sugar,  also  some  tube-casts.  Sometimes  the  quan- 
tity voided  is  greatly  increased,  a  polyuria,  which  we  have  to 
consider  as  a  cerebral  symptom. 

Ol her  organs  rarely  take  part  in  the  disease.  The  circula- 
tory, respiratory,  and  digestive  apparatus  usually  remain  nor- 
mal,  and  serious  stomach  alTcctions,  endocarditis,  and  pneu- 
monia, of  which  we  have  already  made  mention  above,  are 
seen  only  rarely  as  complications.  Moderate  splenic  enlarge 
ment  often  occurs.  Among  the  skin  eruptions  which  some- 
times accompany  cerebro-spinal  meningitis,  besides  urticaria 
and  (much  more  rarely)  roseola,  we  have  a  herpes  labia  lis, 
which,  without  being  of  any  prognostic  value,  possesses  a  ccr- 
tain  diagnostic  significunce. 

The  course  of  epidemic  meningitis  is  still  more  uncertain 
and  variable  than  that  of  the  idiopathic  form.  It  may  be  rapid, 
and  end  fatally  within  a  day  or  a  day  and  a  half,  in  which  case 
convulsions  arc  followed  by  deep  and  persistent  coma.  It 
may,  however,  also  be  protracted,  and  with  remissions,  during 
which  the  patient  is  in  fairly  good  condition,  may  List  (or 
weeks.  In  the  beginning  of  the  epidemic  usually  grave  cases 
are  more  common,  while  the  longer  it  lasts  the  milder  they  be- 
come. It  seems  as  if  an  attenuation  in  the  virulence  of  the  mi- 
croorganism had  taken  place.  There  occur,  besides,  abortive 
cases,  in  which,  while  they  undoubtedly  must  be  classed  with 
llie  epidemic  disease,  only  a  small,  someiimes  quite  insignifi- 
cant, part  of  the  symptoms  arc  developed.  The  period  of  in- 
cubution  is  from  ihrtx  m  tivc  days.  Frequently  an  attack  of 
cerebro-spinal  meningitis  is  followed  by  certain  scquclx.  among 
the  most  common  of  which  are  headache,  pain  in  the  neck,  or 
neuralgias,  which  may  persist  for  a  long  time  after  cotivales* 
oenoe. 

The  sytnploms  of  tuberculous  meningitis  diScr  somewhat 
in  children  and  in  adults. 


LEr  TOMB/flNCI  T/S. 


15 


{a)  In  children  the  disease  runs  either  a  very  acute  or  a  more 
chronic  course.  In  the  lirst  case  only  a  few  days  may  elapse 
between  the  onset  and  the  fatal  issue :  in  the  Ltttcr,  weeks  and 
months  may  pass  before  amt^Huratiun  and  recovery,  ur  in  these 
cases  also  death  takes  place. 

The  acute  form  usually  begins  suddenly  with  epileptiform 
convulsions.  Apparently  healthy,  robust  children  fall  into  con- 
vulsions and  then  complain  of  severe  headache  and  nausea, 
which  is  often  followed  by  vomiting  ;  the  pulse  becomes  irrcg- 
ular,  and  its  variations  in  frequency  are  more  striking  than  in 
any  other  disease.  On  examination,  we  find  the  temperature 
only  moderately  elevated,  but  the  patient  is  very  restless, 
throwing  himself  about  in  bed  and  complaining  of  pain  in  the 
abdomen,  chest,  etc.  Strabismus,  trismus,  grinding  ol  the 
teeth,  are  often  noted,  and  on  mechanical  stimulation  of  the 
skin  striking  circumscrihed  red  spots.  Trousseau's  tathti  cfn'- 
braUs.  appear.  The  patients  sigh  deeply  when  examined,  or 
give  an  unexpected  loud,  sharp  cry,  the  cri  kydTdte^pkalique.  a 
very  unfavorable  symptom  which  is  of  far  greater  importance 
than  the  spots,  from  the  appearance  of  which  we  are  not  justi- 
fied in  drawing  either  favorable  or  unfavorable  conclusions. 
The  approach  of  death  is  announced  by  an  enormous  increase  j 
io  the  frequency  of  the  pulse,  by  renewed  convulsions,  and) 
deep  coma. 

The  chronic  form  begins  insidiously  and  gradually,  the  first 
thing  to  attract  our  attention  being  the  change  in  the  disposi- 
tion ol  the  child.  Previously  gay,  friendly,  playful,  and  com- 
panionable, he  becomes  peevish,  irritable,  unmanageable,  and 
willlul.  On  the  least  provocation  he  begins  to  cry  and  lo  be 
naughty,  so  that  the  parents  find  it  necessary  to  punish  him. 
It  is  not  until  the  sleep  begins  to  be  disturbed  and  the  child 
losses  about  all  nii^ht  and  groans  In  its  sleep,  wakes  up  in  the 
morning  without  being  rested,  and  complains  of  headache,  that 
the  parents  become  apprehensive,  and  the  loss  o(  appetite,  the 
occasional  vomiting,  the  obstinate  constipation,  and  the  pale, 
lickly  appearance  confirm  the  fear  that  a  serious  malady  is  on 
the  point  of  showing  itself.  The  symptoms  may  for  weeks 
remain  obscure ;  hit;h  temperature  may  alternate  with  low,  a 
frequent  with  a  slow  pulse,  without  it  being  possible  to  say 
anything  definite  about  the  case.  Only  when  one  day  an  epi- 
leptiform attack  occurs,  the  headache  increases  in  intensity,  the 
child  becomes  somnolent,  cries  out  during  sleep,  shrinks  on 


l6  DISEASES  OF  THE  MENINGES  OP  THE  BKAIN. 

being  touched  (hypcrscsthcsia  of  the  skin),  only  then  is  the 
condition  clearer,  and  finally  cnn  not  be  mistaken  when  such  a 
focal  symptom  as  paralysis  of  the  eye  muscles  appears.  Even 
then  remissions  may  occur,  and  decided  improvement  or  even 
complete  recovery  is  not  impossible.  The  outlook  is  always 
doubtful,  and  can,  even  when  the  prospects  appear  most  favor- 
able,  be  very  serious. 

(A)  In  adults  the  difference  between  the  chronic  and  acute 
form  is  less  marked  llian  in  children.  Patients  who  have  by 
no  means  presented  dehiiite  si|;n$of  tuberculosis  begin  to  com> 
plain  of  vague  headache,  general  prostration  and  malaia:  their 
sleep  becomes  disturbed  and  restless:  especially  in  the  morn- 
ing  they  fee!  tired  and  unstrung:  they  complain  of  loss  of  ap- 
petite, and  may  have  occasional  vomiting  spells.  In  some  cases 
the  psychical  symptoms  are  the  most  prominent,  and  i(  may 
happen  that  the  disease  begins  with  the  symptoms  of  a  deliri- 
um tremens,  especially  if  the  patient  be  a  drinker.  In  all  cases 
the  scnsorium  becomes  sooner  or  later  dull ;  the  patient  appeans 
dazed,  gives  confused  answers,  and  conveys  in  general  the  im- 
pression of  a  man  whose  mind  is  afTected,  Not  rarely  delirium 
comes  on :  in  it  the  excitement  and  exaltation  are  the  moM 
prominent  features.  But  with  all  these  symptoms  the  influence 
of  a  severe,  agonizing  headache  still  makes  itself  known,  and 
even  during  unconsciousness  the  patients  often  raise  the  hand 
toward  the  head,  throw  themselves  about  in  bed  restlessly 
with  gro:ins,  and  seem  sensitive  to  the  slightest  touch  or  tap  on 
the  head.  lipilcptiform  seizures  have  repeatedly  been  observed 
(Meloir,  fitude  sur  la  forme  6pilepiique  de  la  m^ningitetubcrc, 
Thisc  dc  I'aris.  rS88).  The  participation  of  certain  cranial 
nerves,  especially  the  ocuhj-molor  and  the  abducens,  is  evident 
from  the  transient  ptosis,  the  inequality  of  the  pupils,  and  the 
strabismus :  the  ophthalmoscopic  examination  not  uncommonly 
reveals  choked  disk.  II  in  looking  for  the  latter  wc  are  able 
to  find  tubercles  in  the  choroid,  this  is  of  course  of  the  highest 
importance  for  the  diagnosis.  The  facial  nerve,  which  often 
becomes  affected,  may  be  the  seat  of  spasm  or  o(  paresis.  If 
wc  remember  that  the  base  of  the  brain  is  the  chief  seat  of  the 
inflammation  we  can  easily  understand  why  these  cranial  nerves 
sliould  be  implicated.  If  motor  disturbances,  consisting  of  gen- 
eral or  unilateral  convulsions,  or  of  hemiplegia  or  paresis,  as 
well  as  speech  disturbances,  make  their  appearance,  wc  may 
assume  that  an  eruption  of  tubercles  has  occurred  in  the  brain 


LEP  TOMENINGI TIS. 


i; 


cortex,  an  assumption  which  is  to  a  certain  extent  supported 
by  the  occasional  appearance  of  trismus.  The  more  pronounced 
the*c  disturbances,  which  are  to  be  regarded  as  focal  symptoms, 
the  more  likely  is  it  that  circumtvcribcd  tuberculous  sollctiings 
exist  in  the  cortex.  Sometimes  also  a  peculiar  tonic  rigidity 
devcto[w  in  all  (our  cxtrcmilics  which  seems  to  be  of  reflex 
origin.  The  reflexes,  at  first  increased,  but  presenting  nothing 
chamctcristic,  usually  lose  in  intensity  as  Ihc  disease  goes  on, 
and  finally  dis:ippear  altogether.  With  regard  to  the  sensory 
changes,  it  should  he  remarked  that  hyperncsthesia  of  the  skin 
is  Dot  so  regular  a  symptom  in  this  as  in  the  6rst  described 
form  of  meningitis.  The  temperature,  as  a  rule,  is  somewhat 
above  the  normal,  yet  it  varies,  and  occasional  remissions  may 
be  followed  by  elevations,  or  it  may  remain  constantly  between 
toi"  and  tos*"  F..  or  thereabouts.  Nothing  certain,  however, 
can  be  said  about  it.  Strlimpelt  reports  a  temperature  of  SK" 
during  Ihc  agony.  Equally  variable  is  the  pulse,  which  as  a 
rule  is  slowed.  Wc  may  count  40  to  50  beats  a  minute,  while 
in  a  few  hours  it  may  rise  to  too  or  120. 

Other  organs  take  but  a  small  share  in  the  disease,  and  even 
the  lungs  show  signs  only  when  simultaneously  affected  with 
miliary  tuberculosis.  II  the  respiration  assumes  a  Cheync> 
Stokes  type  (alter  a  series  of  shallow  respiralions.  which  be- 
come deeper  and  deeper,  a  complete  pause),  this  is  usually  a 
bad  omen. 

To  say  anything  positive  about  the  course  of  tuberculous 
incningitis  in  the  adult  is  impossible.  It  is  not  constant,  but 
sometimes  acute,  sometimes  chronic,  sometimes  presenting  long 
tntermissions,  and  sometimes  steadily  progressive.  A  subdi- 
vision into  different  stages  may  look  very  well  on  paper,  but  to 
demonstrate  them  at  the  bedside  is  only  rarely  possible.  A 
period  o(  cerebral  irritation  has  been  distinguished  from  one  of 
increased  intracranial  pressure,  and  this  again  from  a  period  of 
paralysis.  The  first  has  been  thought  to  be  characterized  by 
headache,  vomiting,  and  delirium;  the  second,  by  slowing  of 
the  pulse  and  paralyses;  the  third,  finally,  by  increase  in  the 
frequency  ol  the  pulse,  elevation  of  temperature,  and  deep 
cocna.  But  such  a  division  entails  no  practical  benefit,  as  the 
8<M:&lleil  "stages"  arc  often  not  distinguishable  from  each 
otber.  but  pass  directly  one  into  the  other.  From  the  instruct* 
ive  treatise  of  Hirschbcrg  {c(.  lit.)  we  learn  that  evi-n  the  ni.in- 
ner  of  onset  may  vary  much,  and  that  it  may  be  dilTtcult  even 


I8  £>/SEASES   OF   THE  MENINGES  OF   THE  BSAIN. 

in  the  stage  of  focal  symptoms  to  make  a  diagnosis.  If  a  con- 
sumptive suddenly  develops  symptoms  of  motor  or  sensory 
paralysis  or  irritation,  this  should  always  make  us  suspect  the 
existence  of  a  tuberculous  process  in  the  brain. 

Diagnosis. — None  of  these  different  forms  of  meningitis  that 
we  have  described  is  easy  to  diagnosticate,  with  the  exception, 
perhaps,  of  the  epidemic  cerebro-spinal.  When  several  cases 
have  occurred  in  a  community  the  recognition  of  new  ones  pre- 
sents no  difficulty,  especially  if  we  keep  in  mind  the  frequency 
with  which  herpes  labialis  is  met  with  in  the  disease. 

A  serous  meningitis  may  be  not  infrequently  confounded 
with  the  purulent  form,  a  fact  to  which  Quincke  has  lately 
called  attention  in  his  excellent  paper  (Sammlung  klin.  Vortr., 
N.  F.,  Leipzig,  1893,  No.  67).  The  absence,  or  the  slight  de- 
gree, of  fever,  often  also  its  irregular  appearance,  together  with 
the  relative  mildness  of  the  manifestations  pointing  to  cortical 
involvement,  such  as  headache,  stiffness  of  the  neck,  and 
clouding  of  consciousness,  and  on  the  other  hand  the  relative 
frequency  of  choked  disk,  are  the  features  which  are  more 
characteristic  of  the  serous  form. 

Of  other  diseases,  typhoid  fever  is  perhaps  the  most  likely 
to  be  mistaken  for  meningitis.  There  is  no  doubt,  and  it  has 
been  shown  by  reliable  observers  (Curschmann),  that  there  are 
cases  in  which  meningitic  symptoms  are  very  well  marked,  but 
in  which  typhoid  bacilli  are  found  in  the  cord  at  the  autopsy 
to  be  the  infective  agent.  We  might  be  led  to  believe  that  at 
least  the  characteristic  temperature  curve,  the  splenic  enlarge- 
ment, the  condition  of  the  stools,  and  the  rose  spots  would  be 
sufficient  to  make  a  mistake  impossible,  but  this  is  by  no  means 
ii-miri  ihe  case:  there  are  instances  in  which  typhoid  fever 
ca^  ^A.  ■with  certainty  be  excluded,  and  then  the  differential 
&-^;^zi'jhi^  ii  dimply  impossible. 

i:  •j.-Kr=:ai  *nters  into  the  question  of  diagnosis,  the  exami- 
natiyii  v.  tbt  urine  Cfor  tube-casts,  etc.),  suppression  of  the  urine, 
a  it  sho'jid  i>t  present,  and  the  appearance  of  the  convulsions 
will  Jaciiilate  lie  recognition  of  the  true  condition. 

Whether  we  have  to  do  with  a  case  of  croupous  pneumonia 
or  with  meningitis  is.  in  the  majority  of  cases,  easy  enough  to 
decide.  Both  afieciions  may,  however,  occur  together,  and 
then  it  is  imporumt  to  remember  that  marked  hypersesthesia 
of  the  skin,  staggering  gait,  and  rigidity  of  the  neck  may  all  be 
present    with   pneumonia   alone,      if   this  be   complicated  by 


LEP  TOUH^'tAFCl  T/S. 


•9 


of  the  gloitig,  so  that  respiration  is  difficult,  the  patient 
will  fix  his  head  in  order  to  bring  into  play  the  auxiliary  mus- 
cles o(  respiration,  and  thus  in  the  rtcumbcnt  position  loo  the 
rigidity  of  the  neck  is  simulated  (Wernicke).  The  existence 
of  meningitis  is  only,  then,  to  be  assumed  if  pronounced  basal 
symptoms  arc  present,  and  especially  if  paralysis  of  the  eye 
muMrtet!  has  existed  (or  a  certain  period  o(  lime. 

More  fretpiently  delirium  tremens  is  associated  with  men- 
ingitis, and  we  are  not  always  able  to  decide  whether  the 
delirium,  (he  tremor,  and  the  epilepliform  convulsions  are 
referable  to  the  latter  or  to  the  former. 

It  is  well  to  remember  that  there  are  cases  in  which,  al- 
though the  symptoms  of  tuberculous  meningitis  seem  pro- 
nounced.  in  a  few  weeks  the  patient  completely  recovers,  in 
which  instances  the  assumption  that  there  is  a  pseudo-men- 
ingitis of  hysterical  origin  seems  necessary  (Carrier,  Lyon 
m^.,  October,  1892.  Ixxi).  Of  course,  the  previous  history  of 
the  patient,  the  family  history,  etc..  have  to  be  taken  into  con- 
sideration before  such  a  diagnosis,  which  wc  think  is  always 
very  risky,  can  be  even  thought  of.  Of  interest  are  the  ob- 
servations  of  Carl n  and  Iscovcsco  (La  France  mid..  136.  1888) 
upon  a  diagnosis  of  meningitis  in  cases  of  iodolorm  poisoning. 
The  occurrence  of  meningitic  symptoms  as  a  consequence 

I  ol  worm»,  which  l>cvaux  (cf.  lit.)  has  upheld,  is  certainly  ex> 
ceptional,  and  can  hardly,  for  any  length  of  time,  give  rise  to 

[an  error  in  diagnosis. 

With  sufficient  care  we  can  easily  avoid  confounding  men- 
ingitis with  eclampsia  infantum. 

Prognosis. — The  prognosis  in  every  case  of  meningitis  is 
very  serious;  we  are  never  in  a  position  to  predict  with  any 

I  certainly  the  outcome,  not  even  when  everything  seems  to  be 
going  on  very  favorably,  and  grave  symptoms  have  not  de> 
clared  themselves.  These  may  suddenly  develop  in  one  night, 
and  a  patient  whom  we  have  left  in  fairly  good  condition  in 
the  evening  may  the  following  morning  be  hopelessly  ill.  On 
the  other  hand,  we  should  not  give  up  our  patient  too  soon :  the 
gravest  symptoms  may  f.idc  away,  and  improvement  is  still 
posjtiblc  even  where  the  case  seems  desperate.  Undoubtedly, 
however,  meningitis  is  one  of  the  most  serious  diseases,  and 
one  in  which  recovery  is  rare,  the  epidemic  cerebro-spinal 
meningitis  being  the  only  form  which  sometimes  runs  a  more 
rorablc  course. 


20 


DISEASES  OP  THP.  MENINGES  OF  THE  BRAIN, 
t 


Partial  recoyeries  are  much  more  often  seen  than  absolute 
ones.  II,  for  example,  in  the  course  o(  meningitis,  a  hxmor< 
rhaf^tc  inflammarion  of  Ihe  inner  car  develops,  tins  gives  riSrC  lo 
pormuncnt  dcaincss.  which  in  younger  children,  as  a  rule,  leads 
to  dcaf-tiiurism  (Schulzc,  Taiibstummhcit  und  Meningitis, 
Virch,  Arch.,  1890,  cxix.  p.  1).  or  if  purulent  inflammation  of 
the  eyeball,  a  panophthalmitis  or  a  choroiditis  coexist  with  the 
meningitis,  this  may  entail  a  grave  disturbance  of  sight,  even 
phthisis  buibi,  and  complete  amaurosis.  In  cither  ol  these 
cases  the  meningitis  may  get  well,  but  leave  in  one  deafness,  ia 
the  other  impairment  or  loss  ol  sight,  and  in  Ihe  most  unfavor- 
able cases  both  remain  behind  without  the  development  ol  any 
mental  delects.  Blindness  may  also  be  a  consequence  of  an 
optic  neuritis,  which  does  not  get  well,  but  causes  shrinking  of 
the  opiic  nerve  and  atrophy  of  the  disk.  Cases  of  meningitis 
confined  to  the  convexity  sometimes  recover,  leaving  a  more 
or  less  marked  leeble-niindedness. 

Treatment. — The  treatment  is  first  to  be  directed  against 
the  inflanmiation,  and  later  endeavors  should  be  made  to  aid 
absorption  of  exudates  if  such  be  present.  For  this  purpose 
we  make  use  of  stvcalled  surgical  revulsives  {Erlcnmeyer, 
Deutsche  mcd.  Ztg-.  1893,  p.  Gi):  for  example,  local  bleeding 
and  the  application  of  cold  inunctions  of  mercurial  Dintmcnt, 
(our  to  eight  grammes  ( 3  j  t<i  3ij)  a  day  to  the  shaved  head, 
or  blisters  (Mr)sler,  Deutsche  med.  Wochenschrift,  18*8,  No. 
30.  p.  621).  In  some  cases  we  shall  succeed  with  such  me.is- 
urcs  in  lessening  the  severity  ol  the  symptoms,  but  often  little 
or  nothing  is  achieved  by  them.  Painting  the  shaved  head 
with  tincture  of  iodine  is  objectiDnable,  owing  to  the  disagree- 
able  and  painful  tension  which  it  produces,  and  which  is  but 
little  alleviated  by  ice.  That  free  purgation  with  large  doses 
of  calomel  .ictunliy  produces  an  antiphlogistic  effect  can  not  be 
proved,  but  there  is  no  reason  why  it  should  not  be  tried,  the 
drug  being  given  until  the  characteristic  stools  appear.  The 
absorption  of  exudates  is  attempted  by  large  doses  of  polas. 
slum  iodide,  four  to  six  grammes  (3j  to  3jss.)  a  day  in  hot 
milk,  a  medication  which  is  especially  indicated  in  the  gumma- 
tous form  of  meningitis. 

During  com:i  the  patient  may  be  put  into  a  tepid  bath 
{90"  to  93"  F.)  and  cold  water  (66'  to  60°  F.)  be  poured  over 
bis  head.  These  cold-water  allusions  may  be  continued  (or 
eight  or  ten  minutes,  with  the  frequent  result  of  actually  ruus- 


LEP  TOMBNlNGtTlS. 


21 


ing  the  patient  out  of  his  unconsciousness,  an  improvement, 
however,  which  generally  does  not  last  very  long.  The  repc. 
tition  of  this  procedure  several  times  a  day  is  therefore  neces- 
sary, notwithstanding  the  considerable  difficulties  with  which 
it  is  (at  least  in  private  practice)  attended. 

Symptomatica  I  ly  the  agonizing  headache  and  ihc  jactita* 
tions  may  lie  met  with  morphine.  The  same  drug  is  used 
against  the  obstinate  vomiting,  which  is  hard  to  treat,  and  in- 
deed  may  resist  all  efforts.  It  may  happen  thni  all  intcrnnl 
medicines,  cracked  ice,  champagne,  opium,  aromatic  tinctures, 
etc.,  as  well  as  .ill  applications  of  spiritus  sinapis,  etc..  remain 
without  eflcct ;  then  wc  arc  forced  to  resort  to  morphine,  the 
subcutaneous  ad miitist nation  of  which  generally  accomplishes 
more  than  all  remedies  previously  used.  The  regulation  of 
the  bowels  should  of  course  ne%*er  be  overlooked. 

We  can  only.  then,  with  reason  hope  for  success  from  our 
(hcrapcutic  eflorts  if  we  pay  careful  attention  to  the  nutrition 
of  the  patient.  As  soon  as  this  is  left  out  of  sighr  the  battle 
is  practically  lost  in  spite  ol  all  medicines  and  inunctions. 
More  than  in  any  other  disease  it  is  here  the  chief  task  of  the 
physician  to  see  that  the  strength  of  his  patient  is  kept  up.  so 
that  he  be  6t,  if  necessary,  to  stand  an  iltncss  of  weeks:  and 
more  than  in  aity  other  disease  is  here  the  prolonged  use  of 
wine  indicated,  and  is  much  more  important  than  all  drugs. 
Besides  wine,  a  Inblespoonlul  of  beef-tea  is  to  be  given  every 
hour.  This  is  prepared  by  gradually  heating  lean  beef  cut  into 
small  cubes,  afier  the  addition  of  a  little  sail,  in  a  lightly  closed 
glass  bottle  over  the  water-bath,  and  cooking  it  until  the  pieces 
arc  completely  disintegrated.  Two  pounds  of  meat  furnish 
about  a  cupful  of  beef-tea. 

In  very  cvccplional  cases  operative  measures  are  indicated, 
tiAmely,  where  we  have  sufficient  reason  to  suspect  the  exist- 
ence ol  an  exudate  in  (he  ventricles,  which  would  manifest 
itaclf  by  an  aggravatitm  of  the  symptoms  of  increased  intra- 
cranial pressure.  Trephining  and  lapping  of  the  ventricles 
(Keen.  Philadelphia)  may  then  be  resorted  to  if  the  circum- 
stances  arc  in  other  respects  favorable.  In  cases  ol  otitis  media 
the  tympanic  membrane  should  be  punctured  and  the  cavity 
syringed  out  with  antiseptic  solutions.  It  is  scarcely  lo  be 
expected  that  the  treatment  of  tubercular  meningitis  by  ]>;ira> 
centests  of  the  spinal  canal,  a  procedure  practiced  in  four  cases 


22  DISEASES  OF.  THE  MENINGES  OF   THE   BRAIN. 

by  W.  Essex  Wynter  (Lancet,  May  2,  1891),  will  meet  with 
general  acceptance. 

The  treatment  of  tuberculous  meningitis  in  children  has  to 
be  conducted  according  to  the*  plans  just  laid  down,  with  this 
difference,  that  the  inunctions  of  the  head  with  mercurial  oint- 
ment are  to  be  replaced  by  the  administration  of  calomel, 
three  to  five  centigrammes  (grs.  ss.  to  j)  every  two  hours. 
Besides,  the  inunctions  of  the  head  with  iodoform  ointment, 
lately  so  warmlj'  recommended,  should  be  tried  ;  but  here,  too, 
the  preservation  of  the  strength  must  be  our  chief  aim.  Milk, 
with  the  addition  of  a  little  Hungarian  wine  or  a  few  drops  of 
cognac,  should  always  be  kept  ready. 

LITERATURE. 

Bull.     Uebcr  die  Kemig'sche  Flexionscontractur  der  Kniegelenke  bei  Gehim- 

krankhdten.     Bert.  klin.  Wachenschr.,  47,  [885. 
Lcyden.     Bermerkungen  iiber  Cerebrospinal  me  ningilis  und  iiber  das  Erbrechen 

in  fieberharien  Krankheilen.     Zeitschr.  f.  klin.  Med.,  iX\,  4.  1887. 
Devaux.    Oxyures  et  symptdmes  pseud o-mfningitiques.     Progr.  m£d..  No.  46, 

1887. 
J.  Simon.     Diagnostic  diBErentiel  de  la  miningile  tuberculeuse.    Gai.  des  H<)p., 

No.  13a.     Nov..  1887. 
Woltr,  Felix.     Bemerkungen  iiber  das  Verhallen  der  Cerebraspin  at  meningitis  zu 

den   Infections  krankhdten.      Deutsche  med.   Wochenschr.,    50,  p.    1080, 

1887. 
Weichsclbaura.     Ueber  die  Aeiiologie  der  acuten  Mening.  cercbro-spin.     Fort- 

sclir.  d.  Med.,  i8,  ig,  1877.     (■'  Diplococcus  inlercellularis  meningitidis.") 
Hormann  v.     Ueber  die  acute  Meningitis  in  angeblich  ursachlichem  Zusammen- 

hange  mil   Misshandlungen   oder  leichten  Verleliungen.     Wiener  med. 

Woctienschr..  6.  1888. 
Pio  Foa  und  Guido  Bordoni-UfTreduizi.     Ueber  die  Aetiologie  der  Meningitis 

cerebrospinal  is  epidemica.     Zeilsclir.   f.   Hygiene,   1888,  iv,  No.   1,  pp.  67 

et  seq. 
Baaz.     Die  Cerebrospinalmeningitis,  ihr  Wesen  und  ihre  Behandlung.    Berlin- 

Neuwied,  Heuser,  1888. 
Freyhan.     Zur  Kenntniss  der  Typtiusmcningitis.     Deutsetie  med.  Woctienschr., 

1888.  No.  31.  p.  630. 
Wolff.  Felix.     Ueber  meningiiische  Erscheinungen  beim  Typhus  abdominalis. 

Ziemssen's  und  Zenker's  Archiv,  1888,  xliii.  Heft  2  u.  3,  p.  250. 
Stephan.     Des   Paralysies   pneumoniques.     Revue   de   mid.,    1889,  ix.  No.    I. 

("  Meningitis  as  a  Complication  of  Pneumonia.") 
Adenot.     Des  meningites  mikroliiennes.     Paris,  Bailliire,  1890. 
Fox.     Amer.  Journ.  of  the  Med.  Sciences,  June  6,  1890,  xcix. 
Oebeke.    Ueber  Meningitis  eerebrospinalis.     Berliner  klin.  Wochenschr.,  1891, 

No.  41- 
Hilt>ert.     Berliner  klin.  Wochenschr.,  1891,  No.  31, 


LEP  TOMENINGITIS. 


23 


Matthcs.      LinksBcitige    Hypoglossusiahmung    bd    tuberculiiser    Meningitis. 

MiinchencT  med.  Wochenschr,  1892,  No.  49. 
Trevelyan.     Cerebro-spinal  Meningitis.     Brain,  Spring  Number,  1892. 
Schwabach.     Ueber  Ciehiirstorungen  bei  Meningfitis  cerebrospinalis  und  ihre 

anatomischc  Begriindung.    Zeitschr.  f.  klin.  Med.,  1892,  xviii.  No.  3  u.  4,  pp. 

273-297. 
Mcrtz.     Deutsche  med.  Wochenschr.,  1891,  xix,  Na  2. 
AUya.     Three  Fatal  Cases  or  Cerebro-spinal  Meningitis,  with  Autopsies.     Med. 

News,  May  14,  1892. 
Maulwurf.     Wiener  med.  Wochenschr,  1892,  xlii.  No.  47. 
Mensie  Carbone.    Riroima  med..  1893.  ix.  No.  2. 
Zmkcndbrfer.      Zur  Bacteriotogie  der  Meningitis  suppurativa.      Prager  med. 

Wochenschr.,  1893,  No.  iS. 
Boix.     Revue  de  m^i.,  1893,  p.  413. 
Randolph.    Bull,  of  the  Johns  Hopkins  Hospital,  July  4.  1893  (forty  cases  of 

meningitis,  examined  clinically). 
Klemperer.     Ueber  die  Bedeutung  des  Herpies  labialis  bei  der  Cerebrospinal* 

meningitis.     Berliner  klin.  Wochenschr,  1893,  No.  29. 
Friis.     Ugeskr.    f.    Laegenidensk,    1893,  xxvi,  No.  27-29.     ("On  Meningitis 

cerebrospinalis  epidemica.") 


PART   II. 
DISEASES  OF   THE  CRANIAL   NERVES. 

If  we  once  have  a  clear  idea  that  in  the  cranial  nerves  we 
have  to  distinguish  the  origin,  which  in  aU  probability  is  found 
in  the  cortex  and  the  nuclear  region  o(  the  medulla  oblongata, 
from  the  partly  central  (intracerebral),  partly  peripheral  (ex- 
tracerebral) course,  it  is  self-evident  that  the  diseases  of  the 
cranial  nerves  are  divisible  into  those  which  aflect  the  nerve  at 
its  origin,  the  center,  and  those  which  aflect  it  in  its  course.  As 
we  shall  come  to  deal  in  the  next  part  of  our  book  with  the 
affections  of  the  brain  substance  proper,  it  necessarily  results 
that  in  the  following  chapters  we  must  either  touch  upon 
things  which  properly  belong  to  Part  III,  or  that  in  the  latter 
we  shall  not  be  able  to  avoid  some  repetition-  Neither  of  thSse 
courses  is  without  objections  ;  still,  from  a  practical  point  of 
view,  we  have  deemed  it  best  to  treat  of  the  diseases  of  the 
cranial  nerves  here  in  toto. 

The  central  lesions  of  the  cranial  nerves  olten  form  merely 
a  part  of  a  more  general  disease  of  the  nervous  system.  Those 
of  peripheral  origin  occur  also  independently — for  instance,  as 
the  result  of  exposure  to  cold,  traumatism,  etc.  In  very  many 
cases  we  are  not  able  to  determine  definitely  whether  the  dis- 
ease has  a  central  or  a  peripheral  origin.  For  a  clear  under- 
standing of  the  following  chapters,  a  knowledge  of  the  anatomy 
of  the  parts  naturally  can  not  be  dispensed  with.  Some  remarks 
bearing  on  this,  which,  of  course,  are  not  meant  to  take  the 
place  of  a  detailed  study,  have  therefore  been  inserted  at  the 
head  of  each  chapter  to  recall  to  the  reader's  mind  in  outline 
the  necessary  anatomical  relations. 
a4 


VISKASES  OF  TIIK  OLfACTORY  NERVE. 


25 


^ 


I 

p 

I 


CHAPTER   r. 

DISKASRS  nv    THE  OLPACTOHV    NERVR. 

olfactory  nerve  begins  in  a  small  pyramidal  [obule,  the  tu- 
ber ulfaclotium  (caruncula  mamillaris),  the  base  of  wbich  la  situated 
in  front  of  the  anterior  perforated  space.  Al  its  beginning,  the  nerve 
is  broa<l,  but  narrows  into  a  band  ^omcwliat  prismuidal  on  Metiun, 
which  is  called  the  olfactory  tract,  and  which  in  its  turn  ends  in  an 
oval  gray  swelling,  the  olfactory  bull).  From  the  tower  as]7ecl  of 
thi»  bulb,  which  lies  on  the  cribriform  plate  of  the  ethmoid  bone,  two 
groups  of  fibers  [»ass  through  the  Itlile  openinKs  of  the  bone  into  the 
nasal  cavity,  and  it  is  only  the  sum  of  these  filaments  (the  fila  olfac- 
toria)  which  can  be  looked  upon  as  the  nerve  of  smell  in  the  strict 
seiiKc  of  the  term.  The  olfactory  tract  and  bulb  arc  parts  of  a  cere- 
bral lobe,  the  so-called  olfactory  lobe. 

The  origin  and  the  course  of  the  roots  of  the  olfactory  nerve  (ttie 
X  Dlfaciorii,  Schwalbc)  are  not  known.  It  is,  howi-ver,  Kocrally 
:rced  ihat  there  are  three  roots,  The  outermost,  the  siningest,  i» 
said  to  be  traceable  into  the  island  of  Keil.  Schwalbe  supposed  the 
eaistencc  of  a  lateral  root  (radix  lateralis,  sen  longa,  sen  externa) 
originating  in  the  hippocampal  convolution,  and  of  a  median  (radix 
mcdialiK  mu  interna,  scu  brcvis),  coming  from  the  gyrus  fornicatus. 
Other*  have  looked  utK>n  the  anterior  commissure  and  the  corpus 
striatum  as  the  starting  points  of  the  olfactory  nerve,  but  nothinff 
positive  is  known.  An  olfactory  center  has  been  assumed  in  the 
gyrus  hippocampi  and  in  the  gyrus  uncinatus.  Lately  Zuckcrkandl 
(cf.  lit.)  has  claimed  Ihat  the  cornu  Ammonis  is  a  part  of  the  olfactory 
center  (cf.  also  (he  extensive  paper  by  Troland,  l>c  I'appareil  ncrveux 
central  de  Tolfaction,  Arch,  de  Neurol.,  1891,  Ix,  p.  335  ;  Uii,  p.  183: 
Ixiv,  p.  69;  l»v,  p.  103). 

Notwithstanding  the  fact  that  the  affections  ol  this  nerve 
are  not  of  very  great  practical  importance,  ihcy  afford  a  great 
deal  of  interest,  because  they  may  under  certain  circumstances 
(i.  c.,  il  a  careful  clinical  description  is  followed  by  an  exact 
and  accurate  post-mortem  account]  ^ive  us  some  information 
about  the  anatomical  and  physiological  questions  concerning 
the  course  and  ori^^in  of  the  nerve,  and  again  beciiuse  they  may 
attain  a  considerable  importance  and  value  in  the  diagnosU  of 
certain  cerebral  diseases. 

The  olfactory  nerve  may  be  diseased  in  its  central  or  in  its 
peripheral  portion.     In  the  former  case  it  may  be  the  olfactory 


26 


D/SKASJiS  Of  THE  CKANIAL  NERVS.S. 


center  which  is  afTected,  or  ihe  conduction  may  be  inlerfered 
with  somewhere  in  the  course  of  the  intracerebral  paths. 

Since,  as  we  have  stated,  the  situation  of  the  olfactory  cen- 
ter is  not  definitely  known,  wc  can  not  be  expected  to  know 
much  about  its  diseases.  It  would  appear,  however,  that  it  may 
be  affected  by  dcstriiclivc  as  well  as  by  irritative  lesions;  the 
latter  manifest  themselves  by  hallucinations,  the  former  by  lo!.s 
of  smell  (anosmia).  Among  the  diseases  in  which  hallucina- 
tions of  smell  occur  are  various  psychoses,  also  mjj^raine.  tic 
douloureux,  epitcpKy,  and  tabes.  Usually  the  smell  which  such 
patients  describe  is  bad,  disgusting — of  licces,  sometimes  of 
poisonous  plants,  putrid  substances,  etc.  (kakosmia) — and  it  is 
rare  for  them  to  imagine  that  they  smell  pleasant  substances. 
One  ol  my  cases,  who.  owing  to  an  ocular  paralysis,  was  treated 
with  the  galvanic  current  passed  through  his  head  from  one 
side  to  the  other,  declared  that  he  smellcd  oil  of  lavender  from 
the  moment  the  current  was  closed  until  it  w.is  again  broken. 
This  seems  to  point  to  the  possibility  that  by  the  galvanic  cur- 
rent the  olfactory  center  may  be  stimulated.  Central  anosmia 
is  sometimes  observed  in  cerebral  lesions  following  fracture  o( 
the  skull,  which  cause  hemiplegia  and  aphasia,  the  disturbance 
being  confined  to  the  nostril  on  the  same  side  as  the  lesion. 
Anosmia  is  also  known  to  occur  in  hysteria  and  in  old  age  ;  in 
the  latter  case  it  is  probably  to  be  attributed  to  atrophy  (senile 
anosmia).  Cases  have  been  repeatedly  noted  in  which  tumors 
of  the  anterior  fossa  of  the  skull,  exostoses,  meningitis  at  the 
base  of  the  frontal  lobe,  have  given  rise  to  anosmia.  The  fact 
that  several  odors  acting  on  the  olfactory  nerve  at  the  same 
time  suspend  each  other  is  probably  to  be  explained  on  physio- 
logical grounds,  as  is  also  the  fact  that  the  acutencss  of  olfac- 
tory  perception  is  diminished  if  at  the  same  time  another 
cranial  nerve— e.  g.,  the  optic  or  the  auditory — is  strongly 
stimulated. 

Interference  with  conduction  in  the  olfactory  nerve  may 
be  assumed  In  cases  where  there  is  a  history  of  traumatism — a 
fait  u|»(>n  the  head,  more  especially  upon  the  occipuL  Accord, 
ing  to  Carbonieri,  complete  loss  of  smell  suggests  strongly  dis- 
ease of  the  olfactory  tract  or  bulb. 

The  treatment  in  the  central  affections  of  the  olfactory 
nerve  must  of  course  be  directed  against  the  underlying 
disease. 

Of  greater  practical  interest  are  the  peripheral  affections  of 


D/SSASSS  Of  TUB  OLf ACTOR Y  NKRV^B. 


%1 


the  oUactory.  which  chiefly  consist  in  a  decrease  of  the  power 
of  smell.  Leaving  out  of  cunsidcration  the  common  cases  in 
which  an  acute  or  chronic  nasal  catarrh  causes  partial  or,  tem- 
porarily, even  complete  anosmia,  the  sense  uf  smell  may  be 
aflected  as  the  result  of  abnormal  dryness  of  the  nasal  cavity 
(diminution  in  the  secretion  of  tears  in  trigeminal  anasslhesia, 
diminished  How  of  tears  into  the  nasal  cavities  in  facial  paral- 
ysis). Not  rarely  certain  occupations  give  rise  to  anosmia, 
which  is  sometimes  associated  with  a  tolerance  of  disagreeable 
odors  which  at  first  were  highly  obnoxious  to  the  workers. 
Such  anosmias  are  to  be  found  in  soap-boilers,  catgut  spinners, 
tanners,  skinners,  and  butchers,  whose  sense  of  smell  is  often 
eonMclcrably  dulled  ;  again  it  may  be  due  to  disturbances  in 
nutrition,  to  the  action  of  caustic  substances,  or  injury  to  the 
peripheral  nerve  endings — effects  which  are  due  to  the  chemi- 
cal composition  of  the  inhaled  substances.  Thus  we  have  ob- 
$er\-ed  loss  of  the  sense  of  smell  in  those  working  in  chlorinated 
lime,  while  it  was  found  to  be  diminished  in  laborers  occupied 
with  the  pulvcrizaticm  of  chrome-ironstone.  Strieker  has  also 
known  it  to  occur  in  an  entomologist  in  consequence  of  the 
protracted  inhalation  of  ether. 

■I  have  observed  hyperesthesia  of  the  olfactory  nerve,  in 
hysterical  women  especially  during  pregnancy,  and  also  during 
galvanization  of  the  brain  (v.  s.). 

The  treatment  consists  in  turadiitation  (Beard  and  Rockwell) 
and  galvanization  (Fieber)  of  the  nasal  cavity,  or  painting  with 
a  one-pcr-ccnt  solution  of  strychnine  (in  olive  oil).  The  use  of 
irritative  snuff  powders  has  repeatedly  been  recommended  for 
ani]«mia  of  peripheral  origin,  but  has  frequently  been  used 
without  benefit.  Spontaneous  recovery  is  not  rare.  Finally, 
we  may  say  a  word  or  two  about  the  method  of  testing  the 
sense  of  smelt.  All  those  substances  which  irritate  the  trigem- 
inus should  be  avoided,  as.  for  instance,  acetic  acid,  smelling 
salts,  snuff,  tobacco;  the  patient  would  feel  what  he  can  not 
smell,  and  wc  might  be  thus  led  astray  in  our  conclusions. 
Cologne  water,  oil  of  rosemary,  musk,  catnphor,  anise,  oil  of 
turpentine,  asaf<£lid.l,  and  sulphurctcd  hydrogen,  arc  sufficient 
for  most  tests.  That  each  nasal  cavity  must  be  tested  se]>a- 
ratcly  goes  without  saying-  A  special  olfactometer  has  been 
devised  by  Zwaardemakcr  i  Birl.  klin.  Wochcnschr.,  1888,  No. 
47;  Fortschriltc  dcr  Med.,  18S9,  No.  19),  and  another  more 
recently  by  Savelicff  (Neurol.  Cenlralblatt.  1893.  No.  10). 


2i  DISEASES  OF   THE   CRANIAL  NEKVES. 


LITERATURE. 

Notta.    Rccherches  sur  la  perte  de  I'odorai.     Arch,  g^nfr.  de  xt\kA.,  April,  i  %^a. 
Ogle.     Anosmia,  or  Cases  illustrating  the  Physiology  and  Pathology  of  the  Sense 

of  Smell.     Med.-chir.  Transact.,  1870,  liii. 
Molliire.    Note  pour  servir  il'histoiredu  nerf  olfactif.    Lyon  mid.,  1871,  No.  30. 
Carbonieri.    Zur  Localisation  des  Centrum  olfactorium.     Riv.  clin.,  xniv,  9.  p, 

657.  September,  1885. 
Erben.     Wien.  meil.  Blatter,  1886,  No.  43,  44  (kakosmia  in  tabes). 
Moldenhauer.     Die  Krankheiten  der  Nasenhohlen  u.  s.  w.     Leipzig,  Vogel,  18S6. 
Cowers.     Lectures  on  the  Diagnosis  of  the  Diseases  of  the  Brain,  delivered  at 

University  College  Hospital,  London.     Churchill,  1885.     Also  Blakiston, 

Philadelphia.  1885. 
Thudichum.    On  ihe  Nature  and  Treatment  of  Hypertrophies  and  Tumors  of 

the  Nasal  and  Pharyngeal  Cavities.    The  Lancet,  August  27,  1887,  p.  401, 
Zuckerkandl.     Ueber  das  Riechcentrum.     Stullgarl.  Enke,  1887. 
Roth.    Die  Erkrankungen  der  Nasenschleimhaut.  ihre  Beziehungen  zum  tibrigen 

Organismus  und  Behandlung  derselben.     Centralbl.  fiir  d.  ges.  Thcrapie,  v. 

Heft  X,  October,  1887. 
Zwaardemaker.      Berliner  Klinik,      Reviewed   in  Wiener   med.  Presse,    1890, 

No.  39. 
Zwaardemaker.     Zur  Methodik  der  klin.  Olfactometrie,     Neurol.  Centralblatt, 

1893,  No.  21, 


CHAPTER   II. 


DISKA6R»  OP   TIIK   OfTtC    HIXVK. 


The  optic  nerves  derive  their  fibers  from  the  occipital  lobes,  the 
oplic  thalami,  lltc  outer  and  inner  geniculate  bodies,  the  anterior 
corpora  quadrigcmina,  and  the  cerebellum  (through  the  superior 
|K«liincle  of  the  cerebellum). 

What  arc  known  as  the  oi>ti<:  Irarls  bernn-  the  chiasm  is  reached, 
afcer  thisi  point  become  the  optic  ncrvo..  These  arc  niund  hard  cords, 
about  (our  millimetres  in  diameter,  which,  passing  in  a  iliverging 
direction  through  the  optic  foramina,  enter  the  orbits  and  reach  the 
eyeballs  after  iheir  pa&^gc  through  the  orbital  fdl.  Here  they  pass 
the  sclerotic  and   choroid  and  spread  themselves  over  the  fibrous 

layer  of  the  retina.     The  outer 
■"  covering  of  the  nerve,  which  is 

a  proccu  of  the  dura  mater,  is 
called  the  diiral  sheath;  the 
process  of  the  pia,  the  inner 
or  pial  sheath.  The  two  arc 
Bcparated  by  a  space  which  be- 
longs to  the  lymphatic  system, 
thn  so-c.illed  iniervaginal  or 
siibvaginal  space.  The  aiteria 
centralis  retina,  a  branch  of 
the  internal  carotid,  enters  the 
optic  nerve  atmiit  fifteen  or 
gp  twenty  iniHimctre»  from  the 
eyeball  and  runs  together  with 
the  vein  of  the  same  name  in 
the  substance  of  the  nerve  to  the  retina. 

The  chiasm,  which  is  formed  by  the  union  of  the  optic  traclBi  is  a 
fl«nen«d  four-sided  body,  in  which  the  croxMng  of  the  optic  fibers 
lakcft  place.  This  crosxing,  as  we  now  know  with  a  fair  amount 
of  certainty,  is.  however,  only  parttat,  a  semidecussation.  The  fibers 
from  (he  outer  half  of  the  retina  (represented  by  an  interrupted  line) 
pa«s  to  the  center  without  decussating,  while  those  of  the  inner  half 

«9 


•.     DtMMUM   SMOWDfO    THE    OuRn 
Tilt  Umc  FIBMICS  IM  lilt:  CuM^iM. 


30 


J>/S£AS£S  OF  THE  CRANIAL  NERVRS. 


cross  over  and  pass  to  the  centre  of  the  opposite  side  (cf.  Fig.  s). 
Each  occipiul  lobe,  therefore,  receives  fibres  coming  (rom  the  lein- 
poral  as  well  a&  (rum  the  iia&al  half  of  the  retina.  Thus,  for  in- 
Htance,  the  left  receives  fibres  from  the  outer  temporal  half  of  the 
left  and  from  the  inner  nasal  half  of  titc  right  retina.  In  dine.itcs  of 
this  lobe,  therefore,  images  falling  upon  the  left  half  of  the  retina, 
or,  in  other  words  thoM  which  tie  in  the  right  half  of  the  field  of 
vision,  arc  no  longer  perceived — right-sided  hemianopia. 

The  optic  tract,  the  superficial  fibres  of  which  can  be  traced  into 
the  white  covering  of  the  pulvinar  (the  bo-called  stratum  zonalc  ihal- 
ami),  originates  by  two  rootii — an  outer,  much  stouter,  the  end  ganglia 
of  which  are  the  anterior  corpus  (juadngcminum,  the  outer  genicu- 
late body,  and  the  pulvinar,  and  by  an  inner  root  which  can  be 
easily  followed  lo  ihc  inner  geniculate  body  (Wernicke).  These  end 
ganglia  of  the  optic  tracts  form  at  ihc  same  time  the  terminal  pointx 
of  certain  fibres  of  the  corona  r.-idiala,  which  run  in  a  sajtittal  direc- 
tion forward  from  the  «(r<:t])ital  lobe,  and  arc  connected  with  the 
pulvinar,  the  brachium  anterius  of  the  (juadrigeminal  body,  and  the 
outer  geniculate  body.  This  bundle  of  fibres  ih  the  sagittal  medul- 
lary tract  of  the  occipital  lobe,  or  what  is  called  the  optic  radiation, 
and  is  designated  in  the  diagram  by  i  {vide  Fig.  3). 

The  exact  localixalion  of  the  cortical  centre  of  vision  has  not  as 
yet  been  established.  According  lo  Ferrier,  it  is  in  the  angular 
gyru«;  according  to  Munk,  it  iit  in  the  convex  surface  of  the  occip- 
ital lobe. 

It  would  be  beyond  the  scope  of  the  present  work  lo  treat 
in  exUnio  of  those  diseases  of  the  optic  nerve  which  belong^ 
strictly  to  the  domain  of  ophtbalmoloffy ;  they  can  be  con- 
sidered here  only  so  far  as  ihey  are  connected  with  the  nervous 
system.  To  these  belong,  first  of  all,  certain  infl;nnmatory  con- 
ditions  which  act  upon  the  intraocular  end  of  the  nerve,  the 
papilla  (diski,  and  {five  rise  to  what  we  therefore  term  papU 
litis  (choked  disk).  The  name  optic  neuritis,  which  is  (re-1 
quently  used  as  a  synonym  for  papillitis,  is  inexact,  because  it 
may  imply  an  affection  of  the  whole  nerve  trunk. 

The  papillitis,  choked  disk  {SinHuugspapUU.  as  the  Germans 
call  it,  after  von  Graefe,  (859).  is  frequently,  although  not  al- 
ways, met  with  in  cases  of  intracranial  tumors,  and  is  (accords 
ing  to  von  Grade)  to  be  attributed  to  a  high  grade  of  venous 
engorgement,  produced  by  an  impediment  to  the  reflux  of  the 
venous  blood  into  the  skull  cavity.  Later,  when  Schwalbe  hadj 
discovered  that  there  was  a  communication  between  the  fluid 


DISEASES  OF  TUB  OPTIC  NF.RVS. 


3< 


contents  of  the  skull  and  the  intervaginul  space  of  the  optic 
nerve,  it  was  shown  that  the  subdural  space  was  distended 
with  a  serous  iiitlammaloiy  tluid,  and  that  the  uptic  nerve  at  its 
|)assage  through  the  lamina  crit>ro!>a  o(  the  sclerntic  becomes 
compressed  (iichmidl-RimpIer).    Finally,  Deulschmann  (cf,  lit.) 


FIC-  ]■— Dmokam  HHowiiro  the  Okmim  ov  THt  Orric  Setivc  (Arur  WcKHictu^> 
/,  cnatB  o(  1)m  ens  certtiri^  m.  nibMantui  nicn:  •'/•.  inim,  tgt.  nuur  c'i'culm 
bnlr :  r/.  bnch.  paM.  CDfp.  qnadr. ;  f«,  fancll.  UU.  <aq>.  qukd, ;  ^.  pulvinar  \  i,  uptle 
mtUioo. 

ha^  put  fonh  the  view  that  papillitis  is  not  caused  by  mechan- 
ical influences,  but  that  it  is  due  to  the  action  of  pathogenic 
organisms  which  euler  from  outside.  How  (ar  this  view  is 
correct  further  experience  will  show.  Besides  the  pure  papil- 
litis there  is  also  found  a  papillo-rettnitis.  the  nphthatmoscopic 
picture  of  which  diflcrs  from  that  of  the  lormcr  affection,  and 
which  is  to  be  referred  to  a  meningitis,  which  has  advanced 
ftiong  the  sheath  of  the  optic  nerve. 

A  pure  papillitis,  as  we  have  said,  is  chiefly  found  in  intra- 
cranial  tumors.  Patients  in  whom  a  brain  tumor  is  suspected 
ought  to  be  examined  for  choked  disk  even  if  they  do  not 
complain  of  any  subjecrive  symptoms  pointing  to  it,  because 
tight  may,  even  if  the  disk  \?-  markedly  swollen,  remain  nor- 
mal for  a  long  time.  Only  when  the  nerve  or  the  chiasm  is 
5tronglv  compressed  does  amblyopia  or  amaurosis  occur  in 
the  early  stages. 


32 


DtSEASRS  OP  THF.   CRANIAL  h'ERVES. 


The  scat  of  the  tumor  has  nothing  to  do  with  the  occur- 
rence of  papillitis.  Basal  neoplasms  can,  iTirough  direct  press- 
ure upon  the  optic  nervt.  cause  a  simple  atrophy  of  the  same. 
Nor  does  the  nature  ot  the  tumor  play  any  part  here.  Gum- 
mata,  tubercles,  cntozoa  (cyslicerci.  cchinococci),  carcinomata. 
gliomala — any  one  of  these  may  produce  a  papillitis,  which  is 
usually  bilateral  (in  ninety-three  per  ccut  of  the  cases,  Annuslcc 
and  Reich),  although  the  processes  need  not  necessarily  be 
equally  developed  in  both  eyes. 

Of  practical  importance  arc  the  sudden  spells  of  blindness 
which  occur  sometimes  in  the  course  of  a  papillitis,  termed  by 
H.  Jackson  epileptiform  amaurosis.  They  are  probably  due 
to  a  temporary  swelling  ol  certain  tumors  and  ihe  consequent 
compression  of  certain  areas  of  the  brain  or  the  vessels  (Leb«r) 
distributed  to  ihem.  These  attacks  may  last  for  hours  or  days, 
and  either  disappear  completely  or  leave  a  permanent  increase 
in  the  amblyopia  The  ophthalmoscopic  examination  docs  not 
teach  us  anything  about  this  periodical  blindness. 

A  papillitis  rarely  ever  gets  well;  in  by  far  the  greater 
number  of  cases  a  papillitic  atrophy  and  totnl  amaurosis  take 
place,  first  in  one  and  then  in  the  other  eye.  Cases  in  which 
one  eye  is  seriously  damaged  while  the  other  remains  per- 
fectly well  arc  extremely  rare.  I  have,  however,  bad  occasion 
to  observe  an  instance  of  this  with  Magnus.  More  Irequenlly 
both  eyes  become  diseased,  one  soon  after  the  other.  Dropsy 
of  the  ventricles  may  give  rise  to  a  simultaneous  amaurosis  of 
both  eyes. 

Fapillo-rctinitts  is  not  very  rare  in  tubercular  basilar  men- 
ingitis; in  epidemic  cerebro-spinal  meningitis  it  is  exceptional. 
Chronic  cerebral  affections  of  children  often  lead  to  it,  the 
amaurosis  in  these  instances  usually  developing  quickly,  while 
the  general  symptoms  become  intensified. 

Inflammations  of  the  optic-nerve  trunk  occurring  alone  may 
be  caused  by  cold,  febrile  diseases,  syphilis,  disturbances  in 
menstruation,  and  hereditary  influences.  On  ophthalmoscopic 
examinatiua  either  nothing  remarkable  or  only  a  slight  blurring 
ol  Ihe  disk  is  recognizable,  because  the  in  flam  mat  ion  ailccis 
more  espt-cially  that  part  of  the  nerve  which  is  bchiinl  the  eye- 
bull  (retrobulbar  neuritis  ot  von  Grade).  The  disturbance  of 
vision  usually  liegins  gradually,  and  is  confined  either  to  the 
periphery  of  the  field  of  vision  or  it  consists  of  a  central  am- 
blyopia or  a  circumscribed  central  amaurosis.     It  dues  not  ter-. 


D/S/-ASES  OF  THR  OPTIC  KERVE. 


M 


minale  in  complete  blindness  ;  frequently  only  marked  disturb- 
ance of  color  vi<iion  remain;*. 

To  the  neurologist  the  cases  o(  optic  neuritis  in  patients 
with  a  neuropathic  lamily  history  arc  of  extreme  inierest. 
Such  perS'His  usually  suffer  even  in  eiirly  youth  from  migraine, 
nervous  palpitation  of  the  heart,  vertigo,  somclimes  also  from 
epileptiform  attacks.  lietween  the  ages  of  twenty  and  thirty 
they  begin  to  complain  of  trouble  with  their  sifjhi,  either  of 
subjective  light  or  color  sensations  or  else  that  objects  appear 
lo  them  enveloped  in  a  dense  mist;  within  from  four  tu  six 
weeks  they  may  become  completely  blind,  but  their  blindness 
as  a  rule  docs  not  persist,  but  gives  place  to  a  central  ambly- 
opia with  normal  sight  at  the  periphery  of  the  field  Of  vision. 
The  prognosis  differs  markedly  in  different  families.  It  is  ol 
interest  to  note  that  as  a  rule  only  the  male  members  ol  the 
lamily  arc  wont  to  be  afTecIed  by  the  disease. 

In  Ihe  second  place  we  will  consider  atrophy  of  the  optic 
nerve.  It  consists  in  a  wasting  of  the  nerve  elements,  and  may 
be  cither  primary  (genuine)  or  inflammatory,  the  consequence 
of  a  previous  neuritis.  It  may  also  affect  the  trunk  of  Ihe 
nerve  as  well  as  the  intraocular  end  of  it.  If  the  nerve,  besides 
the  wasting  of  its  pulp,  also  undergoes  a  diminution  in  its 
volume,  so  that  it  appears  like  a  gelatinous  grayish-yellow  cord, 
the  atrophy  is  known  .is  gray  dcgcrncration. 

Tumors  and  inflariunatory  exudales,  as  well  as  splinters  of 
bone,  may  by  pressure,  by  shutting  ofl  the  blood  supply  (as, 
tor  tnsluncr,  in  embolism  of  the  arteria  centralis  retinee),  and 
through  ititerlercnce  with  the  nutrition  lead  to  atrophy. 

The  progressive  atrophy,  or,  as  it  ts  better  termed,  progress. 
Ive  gray  degeneration,  which  may  be  of  cerebral  or  spinal 
origin,  is  characterized  clinically  by  a  diininulion  in  the  acute- 
ness  of  the  central  vision,  a  contraction  of  the  whole  visual 
field,  and  disturbance  of  the  color  sense.  In  the  ophthalmo- 
scopic examinaiion  the  bluish-white  discoloration  o(  the  disk 
and  the  atrophic  escavation  of  the  nerve  {due  to  wasting  of  the 
sutrstance  ol  the  disk)  are  very  apparent.  The  acuteness  of 
vision,  grows  gradually  bui  progressively  less,  and  months  and 
years  may  pass  before  complete  amaurosis  is  developed.  Oa 
the  other  hand,  the  whole  process  may  run  its  course  in  two  or 
three  weeks.  The  contraction  of  the  field  of  vision  is  rarely 
concentric ;  usually  the  delects  are  in  one  direction  only,  and  are 
often  sectorial  (Leber).  Enormous  contraction  of  both  fields  ol 
J 


34 


iiiSEAS£S  OF  THE  CRASIAL  ^'BHVES. 


vision,  with  at  tlic  same  time  normal  acuteness  of  sight  in  the 
center,  which  was  eventually  (ollowcd  by  btinclncss.  has  been 
obscr\'c<l  by  Schwciggcr.  The  (listtirbaiicc  in  color  vision  is  at 
first  limited  to  the  perct-ptjon  u(  green,  which  is  confused  with 
white  or  gray,  the  perception  of  blue  and  yellow  being  rcla- 
lively  longest  retained.  The  atrophy  develops  bilaterally,  al- 
though one  eye  alone  may  at  first  be  affected,  and  the  other 
eye  remain  intact  for  years. 

Foci  of  softening  in  the  brain,  progressive  paralysis  of  the 
insane,  sometimes  also  epilepsy,  are  the  cerebnil  diseases  in 
which  the  affection  is  not  rarely  observed.  It  is  besides  alM> 
noted  in  multiple  sclerosis,  although  in  this  disease  ft  never 
leads  tototal  amaurosis,  a  fact  which  Charcot  was  in  the  habit 
of  emphasizing  in  his  lectures. 

More  important  is  the  fact  that  in  locomotor  ataxia  optic 
atrophy  is  comparatively  frequent.  Wharton  Jones  (British 
Medical  Journal,  July  24,  1869)  makes  the  sympathetic  re.spot)> 
sible  lor  this,  assuming  that  the  paralysis  of  the  vasomotor 
nerves,  producing  first  hypcrarmia,  leads  finally  to  atrophy  of 
the  optic  nerve.  This  explanation,  however,  is  at  once  over- 
thrown  by  the  tact  that  in  the  optic  atrophy  of  tabes  there  are 
at  no  time  any  traces  of  hypcnemia. 

Congenital  optic  atrophy  can  sometimes  be  traced  to  hered- 
itary influences,  or  lo  consanguinity  of  the  parents;  several 
cases  have  been  known  lo  occur  in  the  same  family  without 
apparent  cause  (Nicolai,  Ncderl,  Weekbl..  1890,  i.  5):  some- 
times it  is  due  to  hydrocephalus.  Injury  to  the  skull  in  conse- 
quence of  instrumental  interference  at  birth  very  i^rely  has 
anything  to  do  with  it. 

The  diseases  of  the  chiasm  and  optic  tract  may  be  consid- 
ered together,  since  they  possess  one  symptom  in  common 
which  is  of  special  interest  to  the  neurologist,  vix.,  hemianopia. 
It  is  the  only  form  of  visual  disturbance  where  one  can  with 
certainty  diagnosticate  a  central  affection  of  the  optic  nerve. 
It  is  likely  lo  be  of  cortical  origin  if  the  hemianopia  occurs  sud- 
denly as  the  only  symptom,  there  being  no  change  to  be  found 
on  ophthalmoscopic  examination  ;  whereas  if  other  symptoms 
accompany  it — aphasia,  hemiplegia,  etc, — this  idea  of  a  cortical 
lesion  must  be  given  up.  By  hemianopia  in  general  we  mean 
a  loss  of  one  half  (the  right  or  the  left)  of  the  field  o(  vision, 
so  that  patients  affected  with  right-sided  hemianopia  see  the 
objects  which  are  in  the  left  half  of  their  visual  field,  whereas 


4 


J>/SEAS/iS  Of  THE  OPTIV  XKRVE. 


35 


Ihosc  to  the  right  arc  not  perceived.  l(  ihe  disturbance  affects 
the  halves  on  the  same  side  of  both  eyes — that  is.  the  nasal  on 
the  one,  the  temporal  on  the  other — we  cnll  it  a  homonymous 
hemianopia.  If  in  both  fields  the  temporal  halves  arc  lost,  this 
constitutes  what  is  known  as  temporal  hemianopia.  which  is  of 
rarer  occurrence  ;  the  absence  of  both  nasal  halves  of  the  field 
of  vision  docs  not  sccra  to  occur,  and  the  superior  and  inferior 
hemianopia.  where  the  line  of  division  is  not  vertical  but  hori- 
zontal, seems  to  be  extremely  rare. 

The  explanation  of  the  hemianopia  in  lesions  of  the  cortical 
center  for  sight  is  quite  evident  if  we  accept,  as  is  now  gener- 
ally done,  the  existence  of  the  above-described  semidecussation 
of  the  fibres  in  the  chiasm.  The  path  from  the  optic  tract  to 
the  cortex  of  the  occipital  lobe  may  be  divided  into  the  follow- 
ing segments  (Wernicke):  The  first  includes  the  optic  radia- 
tion in  the  occipital  lobe,  the  lesions  of  which  give  rise  to 
homonymous  hemianopia  without  any  other  focal  symptoms, 
lesions  of  the  right  occipital  lobe  causing  left-sided,  ihose  of 
the  left  right-sided,  hemianopia  :  the  second  will  include  the 
place  where  the  fibres  of  the  optic  radiation  enter  the  internal 
capsule-.  aii<I  the  ganglia  of  origin  of  the  oplic  tract,  the  pul- 
vinar,  and  the  outer  geniculate  body — hemianopia  and  hcmian- 
aathesia  ;  the  third  will  include  the  optic  tract  in  its  course  at 
the  base  of  the  brain — hemianopia  with  hcmiplrgi.-j.  If  in  ihe 
region  of  the  visual  center  or  the  optic  radiation  a  bilateral 
focat  lesion  occurs,  then  we  may  have  complete  blindness  set- 
ling  In  with  an  apoplectiform  attack.  This  is  in  reality  a  bilat- 
eral hemianopia,  and  is  dcsign.ited  cortical  blindness.  The 
(uDclion  in  the  two  halves  of  both  eyes  need  not  be  totally 
lost ;  atrophy  of  the  optic  nerve  does  not  take  place-  Weir 
Mitchell  has  shown  ihat  a  lesion  of  the  chiasm  may  produce 
bilateral  hemianopia:  his  case  was  one  in  which  an  aneurism 
pressed  upon  the  chiasm  (Journal  of  Nervous  and  Mental  Dis- 
eases, January.  18S9). 

Of  diagnostic  value  in  these  cases  is  sometimes  the  so-called 
hemianopic  pupillary  reaction  (Hcddaeus.  Wernicke),  or  hemi- 
anopic  inactivity  of  the  pupil  (Leyden).  With  the  mirror  of 
the  ophthalmoscope  we  reflect  the  light  first  upon  the  left,  Ihen 
upon  the  right  half  of  the  retina,  and  observe  the  pupillary  re- 
action. If  the  reflex  occurs  normally,  the  optic  tract  must  be 
intiict.  and  the  disturbance  must  be  due  to  a  bilateral  lesion  of 
the  oplic  radiation  in  the  occipital  lobe,  or  in  the  cortical  ccn- 


36 


O/SSAS&S  OF  THE  CRANIAL  NEItyES. 


tcr.  \{  the  reflex  is  not  obtained,  we  must  assume  a  lesion  oE 
the  optic  tract  of  the  corresponding  side.  Light  perception 
and  pupillary  reflex  go  in  this  case  liand  in  hand.  In  a  recent 
article  lleddaeus  hitiiseU  expresses  the  opinion  that  for  the 
present  it  is  not  justifiable  to  base  the  differential  diagnosis  be- 
tween lesions  of  ihe  oplic  tract  and  lesions  of  the  fibres  in  their 
central  course  exclusively  upon  the  absence  or  presence  of  this 
symptom  (Deul&ch.  med.  Wochenschr.,  1893.  No.  3). 

In  diseases  of  the  chiasm  hemianopia  has  been  repeatedly 
met  wiili,  but  in  ihis  ease  we  have  not  a  homonymous  but  a 
bitemporal  hemianopia.  as  in  the  case  of  Oppenheim,  where 
gummatous  disease  of  the  chiasm  was  responsible  for  the  dis> 
turbancc  (cl.  Virch.  Arch.,  i885,  Bd.  civ,  2,  p.  306),  ()uite 
lately  the  same  author  has  described  an  "oscillating"  bltetn* 
poral  hemianopia  in  diseases  of  the  chiasm,  which  he  considers 
as  pathognomonic  of  basal  cerebral  syphilis  (cf.  lit,). 

If  the  tissue  injured  by  the  lesion  which  has  caused  the 
hemianopia  is  capable  of  regeneration,  as  may  be  the  case  where 
we  have  a  hasmorrhage  or  an  inllainmation.  the  defect  will  pass 
off  completely ;  whereas  it  this  is  not  the  case  the  trouble  re- 
mains stationary,  without,  however,  any  additional  disturbance 
of  sight.  Such  a  condition,  which  often  develops  as  Ihe  con- 
sequence of  an  apoplexy,  may  persist  for  years,  but  no  second 
attack,  by  which  the  centers  of  the  other  tract  also  may  be 
disturbed,  is  to  be  feared,  as  such  a  thing  has  never  been 
observed. 

The  examination  !n  a  case  of  hemianopia  may  (roughly)  be 
conducted  in  t  he  following  manner :  The  patient  is  to  be  placed 
at  a  distance  of  about  two  feet  from  the  examiner,  and,  if  the 
right  eye  is  to  be  examined,  asked  to  cover  his  left  eye  with  his 
hand,  while  with  the  right  eye  he  fixes  the  left  of  the  examiner 
who  covers  his  own  nght  eye.  The  examiner  then  holds  up 
his  finger  between  the  patient  and  himself,  and  moves  it  in  dif- 
ferent directions  as  far  as  the  border  of  his  own  field  of  vision, 
the  patient  at  the  same  time  being  asked  how  far  out  he  is  able 
to  see  the  finger.  The  examiner  is  thus  enabled  to  notice  every 
motion  of  the  patient's  eye  toward  the  object,  and,  judging 
from  his  answers,  can  compare  the  patient's  field  of  vision  with 
his  own.  Instead  of  the  finger,  a  small  piece  of  white  paper 
fa&tened  on  a  dark  penholder  may  be  used  in  a  similar  way. 
These  tests  should  be  made  in  a  good  light  (Donders,  Cow- 
ers). 


I 


J)/S£AS£S  OF  Tim  OF  TIC  NERVE. 


37 


The  more  extensive  defects  can  always  be  found  out  by 
this  method:  for  slight  uiie^  a  perimetric  examitialioii  t&  in- 
dispensable.    An  accurate  determination  of  the  field  of  vision 


rie,  «,— KtKjji  or  VtnoH  or  ihk  LKrr  ami  Kicht  lire.    (Afier  FnitirKa.) 

with  the  help  of  the  pcrimelcr  can  only  be  attained  by  prac* 
lice.      A  description  of  the  instrument  and   its  use  is   here 


Dc.  ^— FiiLU  or  VtoioH  or  thk  Lkpt  and  Rkiht  Evk  w  LurT-Hiin)  HKMiAxoru. 

(Aftn  GoWEHs. ) 


DO!  necessary.  Fins,  4  and  5  illustrate  0)  the  normal  fields 
ol  the  left  and  right  side;  (2)  the  hclds  in  a  case  of  left-sided 
bemianopia. 


38 


DtSEASF.S  or  THE  CKANtAL  NEFVES. 


I.ITKRATURE. 

Ojipenheiin,     [)ii;  oadllirenJe  Hciniupju  tHlemporalix  als  Kritcrium  dcr  bosakn 

Hiriis)]>hili§.    Ikriiner  Itlin.  WoclKnschr.  1887,  No.  jA. 
Fnrud.    L'clrer  H<:mi<>|>ic  im  fruhcsMn  KindcMillcr.    Wicnmncd.  WochcflschrH 

(«»«.  No.  31. 
Siles.    VoriibcTgrhcndc  Hcmiopie  nach  Ktuchhusien.     Bnljncr  Win.  Wochen- 

Kchr,  r88S.  No.  43. 
\ViII>innd.     liic  hem  iojwsc lien  (IriichisfelUfonnen  und  tla.t  opiwche  Wahrneh- 

mungsrcotnmi,     AiUs  hciiiiopi*chcr  nriccie,  Wiesbaden.  189a 
Ulhoff.     Deulsche  Meet.  Zij;..  i8r/>.  No.  10. 
WoHcnbcrjf.     Hfmio|)ie  aXs  Kolge  von  Tuinoren  in  dcT  hinteren  Schadelgrube. 

Arch.  f.  Psych,.  1890,  xxi,  No,  3. 
Lcyikn.     Ucticr  die  hcmiopiiclic   Pupil Ictiilarre  Wernicke's.    Dcuieche  mcd. 

Wochcnsclir.,  fSgi,  No.  1. 
Wilhnnd.     Ein   F.itl   von  Seeicnhlindhcit   und  H<rmioplc  mit  Seclloit»l>crund. 

UcutKhe  Zcilschr.  f,  Nervciilik..  tSyi,  ii,  No.  5  u,  6. 

The  so-called  flitting  scotoma  (amaurosis  partialis  tugax.  or 
temporary  hemianopia)  has  in  all  probability  also  to  be  regarded 
as  an  affection  ol  the  center  for  vision.  The  disturbance  comes 
on  in  paroxysms.  At  first  a  dark  spot  appears  in  the  field  of 
both  eyes,  which  increases  in  a  crescentic  or  horseshoe  form. 
It  begins  to  scintillate  and  becomes  bounded  by  a  bright  zig- 
xag  line  of  brilliant  colors.  If  this  has  alter  fifteen  or  twenty 
minutes  reached  the  border  of  the  5eld  of  vision,  it  disappears 
from  the  center  toward  the  periphery  and  the  field  clears  up 
again.  Most  probably  in  all  cases  the  affection  is  bilateral. 
The  attacks,  which  last  from  a  half  to  three  quarters  of  an 
hour,  occur  with  variable  frequency,  sometimes  only  once  dur- 
ing the  whole  life,  and  it  is  Jnleresling  to  note  that  thcv  arc 
almost  alwavs  associated  with  attacks  of 


migraine.     Of  the 

causes  nothing  is  known,  although  the  belief  that  hard  mental 
workers  are  especially  prone  to  il  is  not  without  foundation; 
but  there  arc  numerous  cases  in  which  we  arc  reduced  to  re- 
garding sexual  and  alcoholic  excesses,  cold,  etc.,  as  BCtiological 
(actors.  As  we  are  not  acquainted  with  any  remedies  for  the 
disease,  we  have  to  be  satisfied  with  prescribing  tonics  and 
strcnglhening  diet,  quinine,  and,  above  all.  mental  as  well  as 
bodily  rest.  The  so-called  night  terrors  of  children  are  prob- 
ably to  be  regarded  as  due  to  irritation  in  the  optic  center 
(Soltmann). 

The  nature  and  the  scat  of  those  forms  of  amblyopia  which 
develop  under  the  influence  of  hysteria  and  of  certain  toxic 
substances  are  still  obscure. 


DtSBASES  OF  TifE  OFT/C  A'SfifS. 


39 


I 
I 


I 


To  this  class  of  substances  belong  mure  especially  alcohol, 
tobacco,  and  lead. 

The  alcoholic  amblyopia  is  the  most  frequent  form.  In  the  . 
mildrst  cases  it  manilesis  itself  .-ts  a  simple  central  3iiibIyo|>ia 
without  distinct  scolumata,  without  disturbances  in  color  vision, 
and  without  contraction  of  the  visual  field  ;  whereas  in  the  most 
serious  forms,  which  may  occur  after  excessive  indulgence  in 
spirits,  especially  in  persons  of  previously  moderate  habits, 
there  may  be  an  acute,  almost  total  blindness.  Alter  the  recur- 
rence of  such  attacks  a  mure  severe  form  of  atrophic  disease  of 
the  opiic  nerve  may  develop,  with  which  is  associated  discol- 
oration of  the  whole  disk.  Central  colored  scotomata  and  sim- 
ple scotomata,  disturbances  in  color  sense  in  the  whole  visual 
field,  are  then  not  rare.  The  ophthalmoscopic  examination 
does  not  reveal  anything  very  characteristic.  Vision  rarely 
becomes  less  than  ^  to  ^,  and  complete  recovery  even  in  the 
most  marked  cases  is  possible.  The  few  examinations  of  the 
optic  nerve  which  have  been  made  after  death  seem  to  indicate 
that  alcohol  exerts  a  directly  injurious  action  upon  the  nerve 
itself.  The  latter  has  several  times  been  found  in  a  stale  of 
fatty  degeneration  with  or  without  compound  granular  cor- 
puscles and  thickening  of  the  interstitial  tissue  which  contains 
the  vessels  (Krismann.  Leber,  cf.  lit.).  Since  it  has  recently 
also  been  shown  that  alcohol  can  act  in  a  similar  way  upon  the 
peripheral  nerves  this  pathological  condition  is  more  easily 
Dndersitiod. 

Similar  in  its  development  and  in  its  course  is  the  so-called 
tobacco  amblyopia,  which,  caicris  paribus,  is,  however,  more 
rarely  met  with  than  the  alcoholic  form,  and  is  more  benign, 
inasmuch  as  it  usually  passes  off  after  the  cause  is  removed. 
The  diagnosis  is,  as  a  rule,  easy  enough,  as  other  signs  of 
chronic  nicotine  poisoninj;  (digestive  disturbances,  palpitation 
ol  the  heart,  insomnia)  arc  rarely  wanting.  The  disease  seems 
only  to  occur  among  those  who  use  tobacco  in  some  form  or 
other,  in  smokers  or  chcwers,  while  the  workers  in  tobacco, 
who  are  exposed  to  the  inhalations  of  the  tobacco  dust  and  of 
a  certain  amount  of  nicotine,  seem,  so  far  as  experience  goes, 
not  liable  to  the  compl.iint. 

The  one  form  of  amblyopia  which  has  been  more  carefully 
studied  than  any  other,  but  which  nevertheless  is  not  much 
better  known  or  understood  than  (he  affections  which  we  have 
just  treated  of,  is  lead  amblyopia  (amblyopia  saturnina),   in 


40 


mSf.ASF.S  O/--  TMH  CRANIAL  NERVKS. 


whici)  the  field  of  vision  may  remuin  normal  or  in  which  there 
may  have  developed  central  scotomata  or  contraction  of  the 
visual  field.  Pronounced  neuritis,  with  decided  swelling  of 
the  disk  and  with  peripapillary  hicmorrhagcs,  has  been  ob- 
served, and  the  termittaliun  in  complete  amaurosis  is  not  rare. 

Under  certain  still  (mlLiiown  conditions  a  sudden  bilateral 
blindness  may  develop  without  previous  decrease  ol  vision — 
amaurosis  saturnina.  It  is  commonly  preceded  by  lead  colic. 
The  aUcction.  which  bears  a  certain  resemblance  to  the  amau* 
rosis  of  urscraia,  may  sometimes  improve  with  remarkable 
readiness  after  the  removal  of  the  injurious  cause. 

In  a  gii'en  case  we  should,  for  the  sake  of  confirming^  our 
diagnosis,  never  fail  to  search  (or  other  cerebral  symptoms 
common  to  chronic  lead  poisoning,  such  as  epileptiform  attacks, 
hemiplegia,  speech  disturbanccii.  and  so  forth. 

About  the  relative  frequency  of  the  disease  no  definite 
statement  is  possible,  nor  do  we  know  which  particular  occu- 
pation  in  the  lead  industry  is  the  most  dangerous,  or  after  how 
long  an  exposure  eye  trouble  develops  in  lead  workers.  The 
rJ/c  which  the  su-c:illed  individual  predisposition  plays  in  this 
connection  seems  as  important  as  it  is  obscure. 

In  the  treatment  of  the  alcoholic  amblyopia,  local  bleeding 
with  Heurtetoup's  cups,  active  purgation,  diaphoretics,  and  Liter 
strychnine  injections  are  of  service.  In  tobacco  amblyopia  the 
lre.itment  is  the  same,  but  bleeding  may  be  dispensed  with. 
In  the  saturnine  form  purg.i(ivcs  arc  indicated,  also  opium  and 
subcutaneous  injections  of  morphine.  In  all  cases,  however, 
the  prompt  and  permanent  removal  of  the  injurious  agent  is  a 
sittf  qua  twtt ;  where  this  cannot  be  done  the  outlook  for  re- 
covery is  always  very  doubtful. 

Besides  the  substances  mentioned,  quinine,  bisulphide  of 
carbon  (Becker.  Ccntralblall  f.  prakt.  Augenhcilk..  1889.  p.  138), 
and  mercury  may  lead  to  disturbances  of  sight,  which  in  their 
course  resemble  those  just  described. 


LITEkATtlRE. 

Gracfe-Sacmbc}].     Handbuch  (l«r  gr^amniiEn  Augenheilkunrlr:..  Dd.  v.  Theil  v. 
LelKr.     Die  Krankhciicn  <l«t  Sehncrvrn,  p|>,  757  tl  it^.    Leipzig.  1877. 
FrtrUtT.     Betichungen  der  AUEcmFirileiden  u.  Orguiierkrankungcn  lu  Venln- 

deningcn  11,  Krankhriirn  <lf*  Schorg.ins     l.dpiig,  F.nKclmann.  1877. 
Plobin.    Des  troubles  ocuUiru  (Unn  In  m.-Lladics  de  IVnc£pli«lc.    1'«ri%.  RaiI- 

lUrc.  i8Sa 
_^MasiHi3.    Die  BUndheil,  ibrc  F.ntMehung  und  Vcrbiitung.    Unslau,  Kcm,  r883. 


DISEASES  OF   THE   OPTIC  NERVE.  ^x 

SchoelcT  und  Uthoff.     BdlrSge  lur  Palhologie  des  Sehnerven  und  der  Neti- 

haut  bei  AUgemeincriirankungen.     Berlin,  Peters,  1S84. 
Jacobean.    Beiiehungen  der  Venlndeningen  u.  Krankheilen  des  Sehorgans  lu 

Allgemeinleiden  u.  Organ-Erkrankungen.     Ldpzig,  Engelmann,  1885. 
Peltesohn.     Ursachen  u.  Verlauf  der  Sehnervenatrophie.    Cenlralbl.  f,  prakl. 

Augenheilk.,  pp.  45,  7$,  106.     1886. 
Bergmeisier.    Die  Intoxicationsamblyapien.     Wien,  1886. 
Nettleship.     Lancet,  July  16,  1887  (Quinine  Amblyopia), 
UihofT.     Untenuchungen  ijber  den   Einfluss  des  chronischen  Allcoholismus 

auf  das  menschl.  Sehorgan.     V.  Gracfe's  Arch..  Bd.  xxxiii.  Abthl.  1. 
Deulschmann.     Ueber  Neuritis  optica,  bes.  die  sogen.  Stauungspapille.    Jena. 

Fisclier,  1887. 
Siemerling.    Ein  FaUvongummdserErkrankungderHinibasismit  Betheiligung 

des  Chiasina.    Arch,  f.  Psych.,  nix,  3,  pp.  401  et  stq.     1888. 


CHAPTER    III. 


DI8RA8CS  OK  THK  KP.HVC.«  St.'l'PLVING  THE  OCULAR  MUSCLXN — I.  t... 
THK  THIRB  (uOTtlR  OCUl.l),  THE  FOURTH  (PATHETICUS),  AND 
THE  SIXTH    (aBDUUENs). 

The  (bird  ncn'c  emerges  from  ihc  brain  al  ihc  inner  margin  of 
the  cms  clo«e  to  \he  anterior  border  of  the  puns;  it  pa»se«  obltqudy 
forward  and  outward,  readies  the  outer  wall  of  the  cavernous  sinus, 
enters  it,  and  ikcn  divider  into  two  branchc§,  which,  passing  through 

the  sphenoidal  fissure, 
fu.a- — ■■    ^^ —     ^"-—^         ^        enter  the  orbit.     The 

upper  division,  which 
supplies  the  levator 
palpebrie  supcriorit 
and  the  rectus  supe- 
rior, is  the  smaller  of 
the  two.  Of  the  three 
branches  of  the  lower 
division,  the  one  sup- 
))lying  the  inferior  ob- 
ti<|ue  is  the  longest; 
the  two  others, one  of 
which  goes  to  the  in- 
ferior rectus,  the  oth- 
er to  the  internal  rec- 
tus, are  shorter.  The 
f%.  &-C»ow  Skttiooi  mKOfOH  tii«  Rwiioi.  or  the  ,  „   branch     that 

Am.  CoBTO«*  Qi;*p«i<iKMis.»-  longesi    urancn.    inai 

f«.a.ulerinrccq>ara<]UUlrigeiiilna  ;  f.e.  Krajr  mallrt  armiiwl  "'  '"^  inferior  OD- 
Ib*  aqueduct  <if  Sjlviui ;  ay.  aqueduct  of  Sylviu*:  ■///  lil|UC,  givcS  ofl  a 
nuckni  of  ihe  Ihlid  nem ;  lU.  posieriiH' lonciludinkl  bun-  <ihort  root  to  the  cili- 
dU:  r,  t.  »d  nucku.ftjrna.tum);  ».  »I-UMi.  ..ij^  '  ,;„„   n,^  fi,,. 

Qoou  Digcr)  1  /,  eocbral  Mdoode.  "  ?  h      ^ 

mcnis  of    which    are 

distributed  to  the  ciliary  muscle  (tensor  choroidea;)  and  to  the  COD- 
sirictoroftheiris(sphinclcrpupillK);  consequently  these  intrinsic  mus- 
cles of  the  eyes  also  arc  innervated  by  the  third  nerve,  while  the  di- 
lator pupilla;,  on  the  other  hand,  is  provided  for  by  the  sympathetic. 
4a 


/t/SAAUKS  OF   TUK  MOTOR   NI'.MVKS  OF   THK   F.YH. 


43 


» 


I 


The  nuclei  of  ihc  (hird  nerve,  a  column  of  multipolar  saiijEltontc 
cells,  lie  above  the  potiierior  longiludinal  bundle,  between  it  and  the 
aqueduct  of  Sylvius,  and  the  rout  librcti  coming  (rum  ilicm  divide 
into  scvetat  fuNciculi,  pierce  the  povlcrinr  Iniigiltidinal  bundle,  the 
tegmentum,  with  the  red  nucteuH  and  \\\<t  iiul>?.iunti.i  ni^ra.  and 
emerge  Iriim  the  brain  at  the  place  shown  above  (cl.  Fig.  6). 

Experimental  as  well  a^  clinical  ob!>crvatioiia  seem  tu  indicate 
ihjii  In  tile  coltectian  of  ganglionic  cells  of  this  nerve  nucleus  there 
exist  three  centres,  the  anlerior  of  which  is  the  centre  for  the  ciliary 
muscle  (accommodalton);  Ihc  next  the  centre  for  reflex  stimulation 
of  the  iris  b]r  light  \  the  third,  by  fur  the  largest,  the  centre  fur  the 
extrinsic  ocular  muscles  (Gowcns).  Observers,  however,  by  no 
means  agree  with  regard  to  the  number  and  puiiition  of  the  indi- 
vidual oculo-motor  nuclei  or  centres.  The  view  held  by  Guwer&  is 
diagrammatical ly  illustrated  in  Fig.  7. 

That  there  exists  a  cortical  centre  for  the  ocular  muscles  and  the 
levator  palpebrarum  is  beyond  question  ;  nuthing  certain  is,  however, 
known  about  its  situa- 
tion :  moitt  probably  it 
lies  in  the  upper  or  low- 
er parietal  lobe  (cf.  Ex- 
iicr,  Untcrsuchungcn 
Ubcr  die  l.ocalisation 
der  Funclionen  in  der 
(iriisshirnrindc  dcs 
Mcnschen.  Wien,  Brau- 
mQIIer,  1S81,  p.  41). 

The  fourth,  the 
trochlear  or  pathetic 
nerve,  is  the  smallest  of 
the  cranial  nerves,  but 

the   longcht   course   within   the   skull   c.ivlty.      It    leaves   the 

n  cloKc  behind  the  corpora  quadrigcmina  at  l^ie  upper  sur- 
face of  the  valve  of  Vieussens;  from  here  it  takes  a  lateral 
and  downward  course,  winds  around  the  outer  side  of  the  cms 
cerebri,  and  reaches  the  ba&e  of  the  brain.  Its  course  is  now  forward ; 
(Hercuig  the  dura  mater  behind  the  anterior  clinoid  proces:^,  it  reaches 
a  small  channel  of  the  cavernou'i  sinus,  and  runs  alongside  of  the 
third  to  the  sphenoidal  tissurc,  pierces  its  fibrous  membrane,  and 
finally  enters  the  superior  oblique  muscle. 

The  nucleus  of  the  fourth  lies  behind  the  collection  of  cells 
from  which  crtinnales  the  third  nerve  (Wernicke),  to  the  ventral  side 
of  the  aqueduct  of  Sylviuw,  on  the  (M)Slertor  longitudinal  bundle,  in 
the  Itrajr  matter  around  the  aqueduct.     From  this  nucleus  the  loot 


t^HE-  7.— nMOftJlMATIC  \ja»a\tVb\*M.  SeCTIOM  TIIIUIC«II 
THK  PWS  WITH  THK  NUCLEI  OP  THE  OcUljUl  BKKVU. 

(Aficr  GowKHK)  C.  0-  Coqiota qiudrtetmliM ;  at' tV 
and  I  c  npmcni  ihr  tenlrei  asd  tbc  >wrvc-nbn3 ;  a,  for 
•axmniDilaiion,  b,  («t  ihe  tHIo  iictlvliy  of  thi  irU,  t, 
fni  IliD  ntrlniic  nruUr  muicki :  all  dim  .irr  cimUiiud  in 
ibc  oculoniotorliu,     /t'.  palhctlc.      1'/.  kbtluceni. 


DISEASSS  OF  THE  CRANIAL  A'EfirSS. 

oriicinates,  which,  pa&ainc  (o  the  mc&ial  side  of  the  descending  root 
of  the  fifth  (Fig.  S,  Vd),  extends  as  a  round  bundle  (I  V)  to  the  pos- 
terior corpus  (|uadrig«minum ;  in  the  substance  of  the  valve  nf  Vieus- 
Bcns  it  is  cru)>»«d  by  the  nerve  of  the  opposite  side,  and  emerges 
finally  in  the  above -described  manner  on  the  Mde  opposite  to  that  in 
whkh  hs  nucleus  is  situated. 

The  sixth  nerve,  the  abduccns,  leaves  the  brain  at  the  pcisie* 
rior  margin  of  the  pons,  between  It  and  the  anterior  pyramid.     It 


Fig.  K^Cnoa^ttrTKis  THaounH  thr  S-toicik  or  meTtMUTirnnt.  (After  Sckwalkc.) 
tf.  palhflicuKTonlDC.  /I ,  I*alh«lu;uasl  iu  ciiL  /)''  ctom  iMttoftol  ikc  piMlwltai*  la 
iu  <niina  (o  Ih*  nudcuKi  K'-  daandine  rnM  of  the  iri|;Fmluta  (iiimi  ■iiilmi) :  nf, 
■qunduct.  f .  t,  cmlnl  eny  RutMUno  annind  the  aquodurt,  i./,  lubmoida  (emieip.  t, 
Mpk  pcdUDclr  of  onvUrlliiin  crunlac  '^<  '•  ''■  raphci  /-r.  lonaulo  reUcuUtU,  iJ,  pa»- 
Urlor  lODciludiiul  bundlr. 


takes  at  once  a  forward  course  and  passes  into  the  cavernous  iiaat, 
piercing  its  posterior  wall ;  it  then  runs,  surrounded  by  the  dtiral 
shcalh,  alongside  of  the  internal  carotid,  and,  emerging  through  the 
sphenoidal  fissure,  enters  the  external  rectus,  in  the  substance  of 
which  it  breaks  up  into  branches. 

The  nucleus  of  the  ahducens,  which  was  at  one  time  thought  to 
be  connected  with  the  rout  of  the  facial  nerve  (hence  the  facial- 
abduccns  nucleus  ol  Meynert  and  Stiilini;).  lies  m  the  fioor  of  the 
fourth  ventricle,  from  which  it  is  separated  by  the  cpendyma  The 
abducenit  root,  passing  through  the  peduncular  portion  of  the  pons 
to  the  outer  side  of  the  pyramids  into  the  tegmental  region  of  tt 
pons  to  the  median  side  of  the  upper  alive,  finally  enters  this  nucleuti 
(cf.  Fig,  9).  The  tegmentum  behind  the  lemniscus  is  divided  into 
three  parts  by  the  abducens  (and  facial)  root,  the  inner  two  of 
which  Meynert  has  called  the  motor  region  of  the  tegmentum. 


0/.1£ASSS  OP  THE  MOTOR  XERVLS  OF   THE  EYE. 


4S 


The  aflections  of  the  nerves  supplying  the  ocular  muscles 
belong,  strictly  speaking,  also  to  the  domuin  of  ophthalmology. 
Since,  however,  they  are  of  such  iinporlance  for  the  diagnosis 
and  the  prognosis  in  certain  nervous  diseases  (e.  g.,  labcs),  it  is 
necessary  to  devote  a  few  pages  at  least  to  the  description  of 
ihcir  symptoms  and  the  proper  methods  o(  examination. 

The  independent  diseases  o(  the  muscles  of  the  eyes  may 
be  of  a  paralytic  or  of  an  irritative  (spastic)  nature,  the  latter 


mVnr  Yu    I     Vila    rila 


na 


Flf.   ^  — CwiiA^BCTKM'  TtlNol-o»  THt  roNH      iMU-t  SCHWAi.nf..)     ■  I V.  abdiKVi)*  nq- 
dcMl      F/,  abdufcnf.     C>..V.,  Upprr  olive,     at',  ucendinE  "xil  «(  IricvTninut.     iC//, 
•Kleiuni  (>daL     nt'/lt,  vnitlarj  nuclcua  (uxalM  <tlvmal  nuclfui).      tV/.  VRiirEinK 
pMUon  n<  lacUl  nxA.    /->.  irinnrnt  libna  iif  tht  piiiu  which  are  dIvicM  intu  «up(rlidal 
I JW  Mid  dtcfi  ^.    fy,  fjnattisA  tract. 


class,  however,  l>cing  by  far  the  less  frequent  of  the  two.  Their 
seal  may  l>c  central  or  peripheral,  although  we  should  state 
that  an  undoubte<l  central  alTection  of  the  abducens  and  of  the 
paiheticus  has  never  been  observed.  Of  ncuhvmotor  paralysis, 
We  are  .icquainted  with  n  peripheral  and  a  central  form. 

A  peripheral  affection  may  have  its  seat  in  the  stem  or  En 
ttK  branches;  a  central,  in  the  nucleus  or  the  (supposed)  cortical 
center  of  ihc  nerve.  The  former  will  be  characterized  by  the 
absence  of  all  cerebral  symptoms,  which,  in  the  central  form, 
arc  nlni(»st  always  present.  It  can  be  brought  about  by  patho- 
logical changes  in  the  orbit,  in  which  case  the  eyeball  not 
infrc<iucnlly  protrudes  and  becomes  immobile.  Further,  it 
may  develop  as  a  rheumatic  paralysis  Irom  exposure  to  cold 


46 


tUSEASes  OF   THE   CKASIAL   NERVHS. 


{a  /rig»re);  also  in  constitiitiunal  syphilis,  in  diphtheria  and 
other  acute  infccltous  diseases,  in  meat  poisoning,  and  as  the 
result  of  alcoholic  excesses  ;  exceptionally  it  is  seen  alter  Irau- 
n)attsm.  In  one  oi  my  cases  a  man  was  kicked  by  a  cow  in 
his  right  eye ;  after  the  acute  symptoms  had  passed  oH,  a  pa- 
ralysis of  the  levator  palpebral  superioris  remained  for  months. 
Power  of  vision  was  not  interfered  with. 

The  central  paralysis  is  met  with  in  the  course  of  meningi- 
tis,  multiple  sclerosis,  progressive  bulbar  paralysis,  and.  above 
all.  locomotor  ataxia.  It  rarely  afTccis  all  the  ocular  mus- 
cles at  the  same  time,  but  cither  the  extrinsic  or  the  intrinsic 
alone  (cf.  Knies,  Ueber  die  cvntralcn  StUrungen  der  willkUr- 
lichen  Augcnmuskcln,  Arch.  fUr  Augenhk.,  1S91.  xxiii,  t,  p. 
19).  Although  the  diplopia  of  tabetics  is  neither  a  constant 
nor  a  pathognomonic  symptom  of  the  disease,  the  occurrence 
of  transient  double  virion  in  otherwise  apparently  healthy  per- 
sons ought  always  to  make  us  suspicious,  and  ought  to  induce 
us  to  subject  the  patient  to  a  more  careful  examination.  The 
nature  as  well  as  the  anatomical  seat  of  this  oculo-mntor  pa- 
ralysis occurring  in  tabes  is  entirely  obscure.  A  monocular  di^ 
plopia  may  occur  in  hysterical  patients  ;  owing  to  disorders  of 
accommodation  two  or  more  images  are  thrown  upon  the 
retina  ([Jouveret  ct  Chapctot,  Kcvue  de  m6d.,  10  Sept..  1892, 
p.  728;  and  Durct  ct  Dujardin.  Sur  la  diplopie  monoculairc 
comme  sympt6me  c^r^bral.  Journal  des  sciences  m^d.  de 
Lille,  1892). 

01  the  cortical  oculo-motor  paralysis  we  know  little  or 
nothing ;  the  only  well-established  fact  is  that  an  isolated 
paralysis  of  the  levator  palpebne  superioris  may  be  associated 
with  cerebral  afJeclions— for  instance,  with  a  cerebral  haimor- 
rhage,  but  the  location  of  the  center  is  not  known.  Grasset 
and  Landouzv  thought  it  to  be  in  the  second  temporal  convo- 
lution  (the  pli  ccurhf  of  the  French  writers),  but  Charcot  and 
Pitrcs  have  adduced  important  reasons  against  this  view. 
Lately  the  subject  has  again  been  taken  up  by  l^moine 
(Revue  de  m£d..  18S7.  vii.  ;).  This  "  blepharoplosis  ccrcbra- 
lis"  needs  much  further  investigation. 

Isolated  ptosis  may  be  unilateral  or  bilateral:  it  may  be  ac- 
quired or  congenital.  Of  the  latter  form  Siemcrling  has  pub- 
lished a  case,  with  autopsy,  in  which  he  found  degenerative 
changes  in  the  main  cell  group  of  the  ventral  as  well  as  the 
dorsal  oculo-motor  nucleus  (Arch.  f.  Psych.,  1892,  xxiii,  3,  p. 


0/SEAS£S  OF  THE  MOTOR  NERVES  OP  THE  EYE. 


47 


I 


764).  It  is  interesting  to  note  that  some  patients  with  ptosis 
are  able  to  open  their  eyes  if  they  put  into  activity  certain 
muM:Ics  supplied  by  the  trigeminus— for  example,  the  muscles 
of  mastication. 

Acquired  ptosis  is  not  always  due  to  an  aQection  of  the 
third  nerve,  but  may  be  the  result  of  a  primary  atrophy  of 
the  levator  palpcbrx  supcriorts.  Fuctis  has  reported  a  num- 
ber of  such  cases  (Arch.  f.  Ophthalm.,  1S90,  xxxvi^  1.  p.  234). 
Diitil  has  described  two  cases  of  ptosis  in  the  same  family. 
(Note  sur  unc  forme  de  ptosis  non  congenital  ct  h^riditairc. 
Progr^s  m&<\.,  1893,  2  S..  xvi.  46).  The  duration  of  the  dis- 
order varies.  1  have  notes  of  several  patients  in  whom  ptosis 
existed  for  years,  and  in  whom  no  other,  spinal  or  cerebral. 
symptoms  developed.  A  very  complete  paper  on  the  a;tioIogy 
and  the  aeliological  diagnosis  has  lately  been  published  by  Dali- 
chow  from  Senators  clinic  (Zcitschr.  f,  kUn.  mcd..  1S93.  xxii, 

4.  SV 

In  studying  the  symptoms  of  the  paralyses  of  the  ocular 
muscles  we  shall  tirst  consider  those  of  the  oculo-motor  pa- 
ralysis, more  especially  of  the  complete  form,  in  which  all 
branches  of  this  nerve  are  implicated. 

The  upper  eyelid  droops  completely,  and  the  eye  can  only 
be  opened  slightly  by  the  aid  of  the  frontalis ;  the  movements 
of  tlie  eyeball  arc  also  at  fault ;  the  eye.  deviated  outward  as 
it  is.  can  not  be  moved  toward  the  nose ;  similarly  any  up. 
ward  motion  is  impossible,  as  such  depends  upon  the  supe- 
rior rectus  and  the  inferior  oblique.  On  the  other  hand,  the 
outward  movements  arc  unhampered  (rectus  externus).  while 
the  downward  motion  is  performed  by  the  superior  oblique, 
the  pure  action  of  which  can  here  be  well  studied,  the  rectus 
iDferior,  which  otherwise  also  assists  in  the  downward  motion 
of  the  bulb,  bein^  now  inactive. 

From  the  different  directions  of  the  axes  of  the  two  eyes 
there  results  a  very  apparent  symptom,  namely,  strabismus, 
which  may  be  convergent  or  divergent,  acconiing  to  the  mus- 
cles affected.  This  strabismus,  due  to  piiralysis  of  the  ocular 
muscles  (paralytic),  diflers  from  that  caused  by  spasm  (spas- 
modic), inasmuch  as(i)  in  the  latter  the  deviation  exists  with 
■II  movements,  while  in  the  former  only  with  those  which  call 
into  action  the  paralyzed  muscle;  (3)  in  spasmodic  strabismus 
the  secondary  deviation  of  the  sound  eye,  of  which  wc  shall 
presently  speaic  (cf.  p.  51).  does  not  occur. 


48 


DiS£ASES  OF  THE  CRANIAL  NERVES. 


The  double  vision,  "diplopia."  which  is  associated  with 
strabismus,  is  especially  marked  at  the  beginning  of  the  dis- 
turbance, before  the  patient  has  learned  to  suppress  the  "  false 
image  "  seen  will)  the  aQected  eye.  and  only  to  pay  attention 
to  the  "true  image"  seen  with  the  healthy  one  (cf.  Amon. 
Ueber  Diplopie,  Mtiiichener  nicd.  Wochenschrilt.  1S90.  46). 
At  first  these  double  images  cause  him  much  annoyance,  until 
later  on  he  learns  to  close  the  affected  eye  by  contraction  of 
the  orbicularis,  or  to  put  the  head  into  a  position  in  which  the 
affected  muscle  is  not  called  into  play.  By  these  devices  he 
not  only  avoids  the  unpleasantness  of  the  double  images,  but 
also  the  consequences  which  the  erroneous  projection  of  the 
visual  field  entails,  namely,  a  peculiarly  disagreeable  feeling  of 
dizziness,  the  so.c;ill«d  ocular  or  visual  vertigo,  to  which  we 
shall  have  occasion  to  refer  again. 

Wilh  reference  to  the  pupillary  symptoms  we  must  keep  in 
mind  the  reactions  present  in  a  normal  eye:  the  pupil  reacts 
directly  to  changes  between  light  and  darkness,  contracting  if 
light  is  thrown  into  the  eye.  and  indirectly  in  that  the  pupil  of 
one  eye  dilates  if  the  other  is  covered;  it  also  reacts  on  •mti' 
tions  of  convergence  and  on  forced  accommodation,  contract- 
ing in  either  case.  All  these  reactions  are  lost  in  complete 
paralysis  of  the  third  nerve.  The  pupil  is  moderately  dilated 
and  gives  no  response  to  the  influence  of  light  or  accommoda- 
tion ;  if  the  paralysis  is  incomplete,  and  either  the  sphincter  of 
the  iris  or  the  ciliary  muscle,  or  both,  are  intact,  so  that  in  the 
latter  case  only  the  extrinsic  muscles  do  not  perform  their 
function,  the  size  of  the  pupil  can  vary  and  accommodation  be 
retained. 

The  reflex  immobility  of  the  pupil  (Erb),  also  called  the 
"Argyll-Robertson  pupil  "—that  is,  where  the  pupil  has  lost 
its  reaction  to  light  impressions  (reflex),  but  has  retained  its 
power  of  accommodation — is  very  frequently  observed  in 
tabetics.  Besides  this,  the  pupil  in  tabes  is  often  very  small, 
pin-head  pupil — spinal  myosis. 

Ineijualily  of  the  pupil,  anisocoria,  is  also  seen  in  the  course 
of  tabes,  in  general  •paralysis,  in  hemicrania,  optic  atrophy, 
separation  of  the  retina,  accommodation  paralysis,  etc.  Recke, 
in  the  ophthalmological  clinic  of  Magnus  in  Breslau.  has  lately 
pointed  out  that  this  symptom  need  by  no  means  have  the 
ominous  significance  which  has  formerly  been  attributed  to  it, 
but  that  not  infrequently  it  is  found  associated  with  asligma- 


DiSRASES  OF  THE  MOTOfl  X/SKrSS  Ot'  THE  EVE. 


49 


* 


tism,  myopia,  and  wiih  presbyopia,  especially  in  men,  wiihout 
the  existence  of  any  central  disease  (Oeiitsche  med.  Wochen- 
schrift,  1893.  '$)■ 

LITERATURE. 

Lecsrr.     Dir  PuplUaibewrgvng  in  physiologischcr  unit  p;itho1ogiBCI>(T  B«(eK- 

nag.     Wtethmilen.  Bi^rf;mann.  iSSz. 
HnblMait.     Die  I'upllUm'jiction  aii(  Lictil,  Jhre  Pnifung.  Mcflsuns  tincl  Uinlscbe 

Bcdcutiine.     WbwbiKlrn.  DcrgmAnn.  r886, 
Kmukiicui.    l1i)'Mok>g»e  und  Pailiologje  dcr  PupilUmeaciion.    Wiener  Klintk. 

ISBS,  Hcfl  4- 
flnliUcu't.     Rttlexcmjifirnllichkeil.  RcHenaubheit  und  rdleclorixche  Pupilleiw 

siarre.     Brrimi-r  kliru  Woclitnichr.,  18&8.  17,  18. 
Scg^L    Arch.  I.  Augcnlit:..  1893.  xxvi,  2.  jk  iji. 

Paralysis  of  the  ahdticcns,  unilateral  or  bilateral,  which  also 
comparaiivtrly  freqiieiiily  accompanies  locoinotnr  ataxia.  oElen 
constituting  here  the  nnty  initial  symptom  for  a  \ong  lime,  is  to 
be  recognJK'd  by  nulidiif;  that  the  eye.  which  is  slightly  turned 
inward,  can  not  be  moved  outward,  while  all  the  other  move- 
ments are  unimpeded.  In  exceptional  cases  this  is  found  asso- 
ciatcd  with  facial  and  trigeminal  paralysis.  The  condition  is 
ununlly  congenital.  Bernhardt  (cf.  lit.)  has  reported  cases  u( 
this  kind,  and  M(>bius  in  an  extensive  article  gives  a  careful 
study  of  the  inlanlile  nuclear  degeneration,  and  has  especially 
called  attention  to  the  fact  that  a  large  proportion  of  all  ocular 
paUics  are  congenital  or  acquired  in  early  life  (MUnchener 
med.  .\bhandl.,  1892.  6.  Rcihc.  Heft  4). 

Unilalcral  paralysis  uE  the  abducens  has  iihn  been  ob- 
served after  fracture  of  the  ba.<>c  of  the  skull  (KOhler,  Ber- 
liner Iclin.  Wochenschr.,  1891,  18). 

Unilatenil  paralysis  of  the  paihcticus,  which  supplies  the 
superior  oblique  muscle,  is  always  difficult  to  recog^nize  even 
when  the  muscular  system  of  the  other  eye  remains  perfect, 
and  can  only  be  di.ignosticated  after  an  examination  of  the  na- 
ture of  (he  double  images.  When  there  is  paralysis  of  the 
oculo-mniorins  in  the  othor  eve  a  diagnosis  is  impossible.  The 
examination  ought  to  be  made  by  an  ophthalmologist  in  order 
to  establish  the  absence  of  power  in  the  superior  oblique  (cf. 
Halm,  BcitrUgc  znr  TrochlcarislHhmung.  Tilbingen.  Moscr. 
18SS).  Extremely  rare  is  the  bilateral  pathciicus  paresis,  which 
has  been  noted  in  some  cases  of  ttiinor  of  the  pine.-il  gland. 
The  anatomical  conditions  directly  underlying  it  are  not 
known  (Rcmalc). 
4 


so 


n/SEASES  OF  THE  CHANIAl.  NERVES. 


A  paralysis  of  the  p»lheiicus.  superadded  to  a  paralysis 
the  ocuIo-nKilorius,  may  be  recognized  by  the  absence  o(  the 
cliaracteriitiic  rot.iliim  around  the  sagittal  axis,  wliich  would 
otherwise  occur  on  looking  down  (Wernicke). 

If  several  muscles  o(  one  eye  which  are  supplied  by  differ- 
ent nerves  arc  paralyzed,  or  if  there  exist  paralysis  of  the  mus- 
cles of  both  eyes,  we  speak  of  an  ophthalmoplegia  (Hirschbcrg, 
Mauthncr).  and  we  distinguish  an  external  ophthalmoplegia  if 
only  the  extriusic.  and  an  internal  ophthaltuuplegia  i(  only  the 
intrinsic,  muscles  of  the  eye  are  paralyzed  (sphincter,  dilator,  cil- 
iary muscle).  The  so-called  ophthalmoplegia  p;ogressiva  (%'on 
Gracfe)  will  be  described  in  the  eleventh  chaplcr  of  this  part 
under  the  name  of  pollencephalilis  Miperior  ( WcrnicfceV  Quite 
lately  attention  has  been  drawn  to  a  so-called  recurrent  pa- 
ralysis of  the  third  nerve,  of  which  Mauthner  has  analyzed  four- 
teen instances.  This  disease  is  characterized  by  the  fact  that 
only  one.  and  always  the  same,  oculo-motor  becomes  afFcclcd, 
and  that  the  paralysis  is  always  complete — that  is,  takes  in  all 
Ihc  branches.  Females,  especially  those  of  a  nervous  or  hys- 
lerical  temperament,  seem  more  predisposed  to  the  afTcction 
than  males.  The  duration  of  the  individual  attacks  varies 
from  one,  three,  four,  to  even  six  months.  They  may  recur 
after  an  interval  of  from  four  weeks  to  a  year.  Other  nervous 
symptoms— migraine,  vertigo — may  or  may  not  accompany 
them.  The  attacks  may  recur  during  the  whole  life  o(  the 
patient,  and  even  in  the  intervals  traces  of  paralysis  may  re- 
main ( Milbius.  Kcmak).  Whether  there  arc  instances  in  which 
the  disturbance  is  only  functional,  or  whether  in  all  cases  there 
exists  a  distinct  organic  basis,  we  arc  with  our  present  mate- 
rial unable  to  <li'ciiie  defuiilely,  and  wc  arc  equally  in  the  dark 
with  reference  to  Ihc  scat  of  the  affeciion.  as  td  whether  it  is 
of  peripheral  or  o(  central  origin.  That  there  are  instances 
where  the  former  is  true  is  proved  by  a  case  published  by 
Kichter  (cf.  lit.),  where  a  new  growth  in  the  nerve  itscK  was 
found. 

In  a  suspected  paralysis  of  the  ocular  muscles  wc  endeavor 
to  make  out  in  our  examination  any  defects  in  the  mobility  of 
the  eyeball.  For  this  purpose  Ihc  patient  is  asked  to  follow  with 
his  eyes  the  finger  of  the  examiner  indifferent  directions  without 
moving  his  head.  In  this  way  every  asymmetry  in  the  move- 
ments of  the  two  eyes  can  be  noted.  If  the  mobility  in  the  direc- 
tion of  the  action  of  the  affected  muscle  is  defective  ("primar)* 


DtSEASES  OF   THE  MOTOR   XERVES:  OF   THE   EVE. 


51 


deviAtioii "),  nystapfintis-like  Iwilching  is  sometimes  observed 
on  attempts  at  cxircmc  rotation  in  that  direction.  But  it 
may  happen  that  the  paresis  of  a  mtiscle  is  not  recognized  if  its 
innervation  is  particularly  strong ;  then  we  have  in  the  corrc- 
spondinor  muscle  o(  the  other  eye  so  abnormal  an  innervation 
that  in  the  latter  the  effect  is  excessive,  and  wc  get  a  so-called 
"secondary  deviation  "  of  the  sound  eye.  This  can  easily  be 
demonstrated  if  the  presumably  healthy  eye  is  first  covered 
with  the  hand  and  the  patient  endeavors  to  l\x  with  the  paretic 
eye  a  point  which  it  can  not  reach  at  all  or  only  with  the  ut- 
most  exertion.  II,  then,  the  fixing  eye  is  covered,  we  observe 
whelhrr  the  healthy  eye  be  in  a  proper  position  or  not.  and 
i^hall  find  that  the  latter  has  been  moved  too  far  in  the  desired 
direction.  If  this  method  docs  not  give  any  satisfactory  re* 
suits,  we  have  to  examine  into  the  nature  o(  the  double  images. 
One  eye  of  the  patient  having  been  covered  with  a  colored 
Iflass,  he  is  asked  to  follow  with  his  eyes  (of  cotirse,  again  with- 
out moving  his  head)  the  flame  of  a  candle  which  is  moved  to 
and  fro.  If  there  exists  paralysis  or  paresis  in  one  eye,  the 
patient  complains  o(  seeing,  on  the  side  toward  which  the 
affected  muscle  moves  the  eye.  two  flames,  which  become  the 
farther  apart  the  more  the  affected  muscle  is  exerted.  But  if 
now.  for  instance,  the  patient  looking  toward  the  left  complains 
n(  diplopia,  this  may  be  due  to  paralysis  of  the  left  external  or 
the  right  internal  rectus,  as  both  of  these  muscles  move  the  eye- 
ball to  the  left.  To  determine  which  ni  these  two  is  not  perform, 
ing  its  (unction  properly,  we  ninst  ascertain  from  the  patient 
whether  the  double  images  are  homonymous  or  crossed — that 
is,  whether  the  colored  picture  be  on  the  s:ime  or  on  the  oppo. 
site  side  to  the  eye  covered  with  the  colored  glass  (homony- 
m<M]sand  crossed  diplopia  respeclivelv).  In  the  former  case 
the  abiluocns  (rcct.  cxt.)  is  the  nerve  affected  :  in  the  latter  the 
ocul(»-mi)lorius(reci.  Intern.).  For  a  minute  study  of  the  double 
irnajes  the  reader  is  referred  to  the  plates  and  the  work  of 
L^indall,  of  Paris,  which  has  been  translated  into  German  by 
M.igniis 'Landoll-Magnus.  Brestati,  Kern,  tit!t7 ;  also  Landolt, 
Les  ch3tni>9  de  fixation  monoculairos,  le  champ  de  fixation 
binoculiiirc.  etc..  Arch.  d'Ophthatm..  1893,  No.  5). 

The  associated  lateral  movements  of  the  eye  to  the  right 
and  to  the  left  may  be  interfered  with  in  the  following  ways: 

I.  There  may  ciist  a  so-called  conjugate  devi-ition  of  the 
eyes — that  is.  a  permanent  fixation  of  both  eyeballs  t4>  one  side — 


52 


DISSAS£S  OF  TME  CRANIAL  NERVES, 


which  can  only  be  overcome,  and  then  but  temporarily,  by  the 
strongest  effort.  We  shall  refer  (o  this  symptom  again  in  our 
account  of  hemiplegia. 

2.  Motion  of  both  eyes  toward  one  side  may  be  permanent- 
ly lost.  In  this  case  wc  have  a  paralysis  of  the  abduccnsof  the 
one  and  paralysis  of  the  internal  rectus  of  the  other  side,  and 
the  cyfs  arc  turned  not  toward  (he  affected  but  toward  the  op- 
posite  side.  In  such  cases  the  lesion  is  situated  in  the  lateral 
portion  of  the  pons,  near  the  abductor  nucleus.  If  the  centres 
of  both  sides  which  lie  cKtsc  together  are  paralyzed,  ihc  eyes 
which  arc  fixed  in  the  middle  can  be  moved  neither  to  the 
right  nor  to  the  left,  but  only  upward  and  downward,  the  up- 
per eyelid  moving  normally  (Wernicke), 

3.  The  upward  and  downward  motion  of  the  eyes  may  be 
lost  and  only  the  Ltteral  motion  be  possible.  This  form  of  the 
a&sociated  ocular  palsy,  in  which  also  both  upper  lids  niuy  be 
paralyzed,  is  ciiuscd  by  a  lesion  of  the  centres  situated  in  the 
central  gray  matter  of  the  third  ventricle  and  the  aqueduct  of 
Sylvius — that  is,  in  the  region  of  the  oculo-motor  nucleus.  II 
this  be  accompanied  by  a  hemiplegia,  we  are  justified  in  diag- 
nosticating a  lesion  of  the  pyramidal  tract  at  the  level  of  the 
upper  corpus  quadrigeminum,  the  posterior  commissure,  and 
Ihc  adjoining  portion  of  the  optic  thalamus  (Wernicke), 

The  treatment  of  the  ocular  paralyses  is  very  problemat- 
ical, and  rarely  produces  unquestionable  results.  Ustinlly  a 
trial  is  made  with  iodide  of  potassium,  a  course  which  may 
be  justified  if  there  is  a  history  of  syphilis;  but  this  drug  is 
frequently  of  no  avail  whatever.  Electricity  is  used  either 
by  applying  one  electrode  over  the  closed  lid  of  the  diseased 
eye  and  the  other  over  the  base  of  the  neck,  so  as  to  pass  the 
current  through  the  whole  course  of  the  eye  muscles,  or  by 
allowing  the  current  to  pass  transversely  through  the  head 
from  one  mastoid  process  to  the  other.  Medium-sized  elec- 
trodes should  be  used  and  a  weak  current  be  applied  about 
four  times  a  week,  each  session  occupying  from  one  to  two 
minutes.  Now  and  ;ig.-iin  after  prolonged  galvanization  we  are 
really  fortunate  enough  to  perceive  an  improvement  in  the 
paralysis,  or  even  to  see  it  disappear.  That  much  of  this  is  to 
be  attributed  to  the  treatment  seems  doubtful,  if  we  remember 
that  it  is  utterly  impossible  to  stimulate  the  ocular  muscles 
with  the  current:  (or  the  same  reason  an  electrical  examina- 
tion in  ocular  palsies  is  impossible  (cf.  Hirt,  Lehrbuch  dcr 


J}/S£ASSS  OF  THE  MOTOR  NERVES  OF  TUE  EYE. 


53 


Electrodiagnostilc  und  RIectrolherapie.  Stuttgart,  Enkc,  1893. 

P-  75  0- 

Passing  over  the  different  spasms  of  tlic  eye  muscles  which 
occur  in  sornc  brain  diseases,  we  shall  p;iy  attention  here  only 
10  one  form  with  which  the  neurologist  ought  to  make  himself 
familiar,  viz.,  nystagmus.  This  consists  in  a  to>aiid-fro  motion 
o(  the  eyeballs  in  a  certain  plane,  usually  horizontal  {Hyitagmus 
oiciilatorms).  which  continues  on  voluntary  movements  o(  the 
eyes,  but  which  is  itself  not  under  the  control  of  the  will. 
These  movements  arc  usually  present  in  both  eyes,  and  vary 
quite  markedly  in  frequency  and  extent,  according  as  the  pa- 
tieni  is  made  to  fix  a  p{»int  or  to  change  the  direction  in  which 
he  is  looking.  The  c<indition  is  supposed  to  be  due  to  weak- 
ness of  sight  of  both  eyes,  dating  from  early  childhood — that 
is.  to  impairment  in  ihe  functions  of  the  retina  at  a  time  when 
these  have  an  important  regulating  influence  in  the  establisln. 
ment  o(  the  normal  fixation  of  the  eyes  (von  Graefe).  How- 
ever, there  are  undoubtedly  cases  which  do  not  belong  to  this 
zXaxf-.  for  it  is  a  wellknowii  fact  that  nystagmus  may  be  an  oc- 
cupation disease,  as  it  is  often  observed  in  miners  who  have 
to  use  their  eyes  in  the  dark  (Schroder,  Moorcn.  Nieden, 
Focrstcr,  Snell  [British  Med,  Jour.,  July  11,  1891J;  Priestley 
Smith  libid.,  Oct.  15.  1891],  and  others) :  and,  secondly,  it  ap- 
pears in  the  course  of  certain  nervous  diseases — perhaps  in 
connection  with  repeatedly  occurring  cerebral  anaemia  (Knoll, 
Ueber  die  nach  Verschluss  dcr  Hirnartcricn  atiftretenden 
Augenbcweguiigen — Sitzungsber.  d.  Akademic  d.  Wissen- 
schuften  in  Wien,  Abthcilung  III,  iSSfi).  In  both  these  classes 
of  cases  sight  is  often  not  diminished  at  all.  and  some  other 
than  Ihe  one  given  above  must  be  the  underlying  cause;  and, 
AS  a  matter  of  fact,  this  nystagmus  of  the  miners  is  simply  due 
to  overstrain  of  lf)C  eyes  in  an  insufficient  light,  while  the 
nystagmus  occurring  in  the  course  of  nervous  diseases,  more 
especially  of  multiple  sclerosis,  but  also  of  tabes  and  epilepsy, 
is  to  be  regarded  as  a  symptom  and  attributed  to  the  same  in- 
Ruenccs  as  the  main  disease.  That  nystagmus,  finally,  may 
also  be  a  symptom  of  hysteria,  and  may  persist  during  the 
whole  course  of  the  disease,  is  shown  by  a  case  published  by 
myself  {cf.  Deutsche  mcd.  Wochenschr.,  No,  30,  1887,  lit.). 
C.  S.  Freund  has  observed  nystagmus  in  a  case  of  Basedow's 
disease  (Deutsche  mcd.  Wochenschr.,  1891,  No.  3)1 


54  DtSEASES  OF  THE  CKASIAL  XEKVES. 

UTERATUBB. 
I.  tialaUd  Ocal^-JHot^  f»iulym. 

Richter.      Typiwh-KcidivireiMle    Ocukiniu(oriusbhniun);    mit   Scctrnixbcfund, 

Atch.  f,  Psyih.  II,  Ncricnlilf.,  1887,  nviii.  1. 
SucktiiiK-     ilrain.  18S;.  xxxviij.  p.  141  (attacks  of  migraine  (btlownl  by  iraitu- 

(orir  oculo-muior  p^ls)). 
Sen;itoi.     Ucbcr  p<-riO(lixche  OculomotoriutlKhmung.    Zdischr.  f.  klin.  Med.. 

1887.  xiii.  No.  3  u.  4. 
Jonchim.     Fall  vnn  periodischcr  OculonioloriusMruung.    Jahrb.  f.  KtiuWttik., 

188$,  xxriii,  I. 
Ucmhiirtlt.     Kecidtvirendi!  Oculoinoioriuslihinung.    Derliner  klin.  Wochenxlix., 

1889,  No.  47. 
Mai)'.    Die  rcci(livir«-n<k  OculomoioriuxIShitiung.    Berliner  klin,  WochmKhr.. 

1889.  XXII.  No,  34. 
Visscrini;.     L'eber  ciiien  Fall  von  rc('i<livin'ititcr  Uculomotonu&lUimung.    Mun* 

chcner  med.  Wtuhenschr,  18H9.  xxxvi.  No.  41. 
Muu.     UopiMlseitiijc  UculoTnoioriu^liniuiit;   bei  ccrvbraler  Kindeiliiliiriunt. 

Wiener  kli^,  Wochcnschr,.  1893,  v,  No.  41, 
Goldichniid.      Ein    Kull    von    IrAumatischer    tolaler    Oculomoloriuxiahitiung. 

Wiccier  med,  WVtheiisthr  .  1893.  xliii.  No.  7. 
Dalichow.     Actiologir  und  Ntlologi.sclie  IJi.-Lgoostik  def  Oculodnotonutjiaraljse 

^frotu  Senator's  clinic).    Zeitschr.  X.  klin.  Mnl..  189}.  xidL 

9.  PahUt  !•/  Ihi  Fyt  Afnutri  in  GrtHttl. 

Mauthii<-r.     Die    nicht    nuclcSrc    AugrnmutkdlShmung.      Wietbadeii,    Rcig- 

mann,  1886. 
Mauihncr.    Die  ntieleSrc  Augcni'ntiskclTStimung.    Wiesbaden,  tterj^nnn.  1886, 
MObius.     Ucbcr  die   Localisation  ilcr  Ophthalmoplegia  exterior.     CcnIralbL  f. 

NervenhL,  1886,  \x.  No.  17. 
Westphnl,     Arch.  f.  Psycli.  u.  N'ervcnhk..  1887,  xviil.  3.  p.  846. 
Landolt-. Magnus.      Uebcr^ichtliehc  Zuiuimii>en«tFllung  der  AuKenbewegungrn 

iin  j}h>sioloj{i>chen  und  patlioloj-iscticii  Zuitaivle.     Brcslai),  Kcm.  1887. 
Kemak.  K.     Doppebnilge  Trochlea risp.irr«e.     Neurol.  Centralbl.,  iSSS. 
Mautliner.     DilTcreniialitiagnosiik  der  Lihmung  tier  Krhebunt^muskcln  dct 

Auges.    Wiener  meil.  WoehenjictiT..  1888.  No.  J4. 
Landoli.    Unc  fonne  pariiculiirc  de  Paralyse  dcs  muxcleE  ocuUires.    Cleiinoni 

(Oisc).  1889. 
Boitigcr.     Arch.  f.  Pnch..  1889,  xxi.  1,  p.  517. 
Bcmlurdt.    Zor   Lehrr  Ton   der  nuclcSrcn   AuKenmuskelliShmunjt  und  ihrw 

Cumptlealionen.     Bnlinrr  klin.  Wochcnichr..  189ft  No.  4). 
Thomtien  (Bonn).    Zur  |iatholo)iisL-hcn  Anatomic  der  progrcMiven  Ophlhalmo- 

plejpe.    Fcsisehrifi.     Hamburg.  1891. 
Bafth.     Beitrag  nirchtonitchcn  progrcutven Ophlhalmoplegie.    Jahrb.d.Hani< 

burger  SL-uiit  Kmnkenimtduies  1893.  li.  p,  100. 
Schlciinger.     Augenmuskcliahmung  nach  Herpes  «Hter.    Wiener  in«i.  Pr«ae. 

1891.  xxxiii.  No,  43' 
Slower,     Ein  F^ill  von  iluppelseiiiser  Augenmutkclllihmung.    Munchcner  med. 

WochenKhr,,  189],  xixiv.  No.  48. 


« 
DISEASES  OF   THE   MO  TO  J!  NERVES  OF   THE  EYE.  55 

S<.hlesinger.    Zur  Diagnose derchronischen  nucleSren  Ophihalmoplegie.    Inaug.- 

Dissert..  Tubingen,  1S93. 
Cheneys,  Frederic.     Boston  Med.  and  Surg.  Journ.,  June  24,  1893,  exxviii. 
Bach.    Cenirall)!,  f.  Ncrvenhk.  u.  Psych.,  N.  F.,  1893.  iii,  p.  57. 
Koth.     Doppelbilder  bei  AugenmuskelUihmiing.     Berhn,  Hirschwald.  1893, 
Bar<ibasch<^w.     Wiener  klin.  Wochenschr.,  1893,  vi.  No.  17, 
Uraunstein.     Peiersburger  med.  Wochenschr,.  1893. 
Dalichow.     Die  Aetiolc^e  und  die  Sliologische  ]>iagnoEtik  der  Oculornoiorius- 

paralyse  mil  Beriicksichtigung  der  paihologischen  Analomie.     Inaug.-Uis- 

serl..  Tubingen,  1893. 
Hotz.     Arch.  f.  Augenhk.,  1893.  xxvi.  3,  4. 
Jackson,  Hughlings.     Lancet.  July  3,  1893,  ii. 

3.  Paralysis  of  the  Aidacent. 

Purtscher.     Traumalische  Abducenslahmung.    Arch.  f.  Augenhk.,  1888,  xviii,  4. 
Benneii  and  Savill.     lirain,  July,  1889,  xlv  u.  xlvi  (nuclear  paralysis  uf  the 

abduccns). 
Ulocq  ct  Guinon.     Sur  un  cas  de  paralysie  conjugic  de  la  sixi^me  paire.     Arch. 

de  nicd,  exp^rim.  et  d'anat.  path.,  i39t.  i. 
Bloch.     Hiatistisch-casuistischer  Bcitrag  zur  Lchre  von  den  Abducenslahmungen. 

I  naug.- Dissert.,  Berlin,  1S91  (43S  cases  oC  paralysis  of  the  abduccns). 


CHAPTER  IV. 

THE   DISEASES   OF   THE   TRIGEMINAL   NERVE. 

The  trigeminus,  the  stoutest  of  all  the  cranial  nerves,  leaves  the 
brain  by  two  separate  roots — an  anterior  small,  exclusively  motor, 
and  a  posterior  larger,  the  sensory  portion.  Its  point  of  exit  is 
situated  at  the  base  of  the  pons,  where  the  transverse  fibres  of  the 
latter  are  prolonged  into  the  middle  peduncle  of  the  cerebellum. 
Both  roots  lie  in  close  apposition,  and  pass  into  a  recess — the  cavum 
Meckelii — formed  by  the  dura  mater,  and  situated  over  the  inner 
end  of  the  superior  surface  of  the  petrous  portion  of  the  temporal 
bone.  Here  the  posterior  root  forms  a  somewhat  crescentic  swell- 
ing— the  Casserian  ganglion — from  which  pass  forward  the  three 
somewhat  flattened  divisions,  the  ophthalmic  and  the  superior  and 
inferior  maxillary  nerves,  the  last  being  joined  by  the  smaller  motor 
root.  These  three  branches  leave  the  interior  of  the  skull  by  the 
sphenoidal  fissure,  foramen  rotundum,  and  foramen  ovale,  respect- 
ively. 

The  trigeminal  nerve  possesses  two  nuclei — a  motor  and  a  sen- 
sory one.  The  first — the  smaller — is  situated  in  the  outer  part  of 
the  tegmentum,  and  its  ganglionic  cells  are  characterized  by  their 
relatively  large  size  {60  to  70  ft.  in  the  greatest  diameter).  The 
larger — sensory — nucleus  lies  external  to  the  motor ;  in  its  collection 
of  gray  matter  there  are  found  very  small  ganglionic  cells  {20  to  30  /* 
in  diameter). 

With  regard  to  the  origin  of  the  two  roots  there  exist  very 
different  views,  and  but  little  is  definitely  known  about  the  sub- 
ject. It  can  not  be  doubted  that  the  motor  root  springs  from  what 
has  been  decided  upon  as  the  motor  nucleus,  nor  that  there  exist  a 
number  of  small  bundles  of  fibres  which  arise  high  up  in  the  region 
of  the  anterior  quadrigeminal  body,  and  descend  outside  the  aque- 
duct to  the  level  of  the  exit  of  the  fifth  nerve,  where  they  help  to 
form  the  motor  root.  This  is  the  so-called  descending  anterior,  or, 
as  Henle  terms  it,  superior  root,  the  section  of  which,  a  crescentic, 
externally  convex,  internally  concave  figure,  at  once  strikes  the  eye 
in  frontal  sections  of  the  pons  (cf.  Fig.  8,  Vd).  That  the  sensory 
5& 


THE  DISEASES  OF  THE  THICEMIXAL  f,-ERVE. 


57 


root  arises  from  the  iibovc-tncntioncci  sensory  nucleus  \%  probable,  btit 
not  certain.  Oit  the  other  bund,  it  mn*\  be  remembcretl  that  as  low 
dnwa  as  the  neighborhood  of  the  second  cervical  iiervc  there  can  be 
demonMrated  in  the  caput  cornu  posteriori^  a  layer  of  longitudinal 
mcOulIatcd  fibres,  the  highly  characteristic  transverse  section  of 
which,  cre»centic  in  shape,  may  be  followed  upward,  as  it  gradually 
iacrcases  in  sise,  as  far  as  the  level  of  the  exit  of  the  trigeminus. 
Suitable  longitudinal  sectionit  pbiuty  thuw  that  this  longitudinal 
bundle  forms  a  large  )Kirt  of  the  sensory  root  of  the  nerve  This  is 
'  die  su-called  large  ascending  root  of  the  fifth,  the  position  of  vhich 


— ii,r». 


Vr 

nt  »— NOCLW  or  T1IK  Tmamisui.  Nwvk.    (Afwr  Scmwm  ob.)    a,  V.i..  nucleui  at 
tb«i— otj.    o.I'.ii.,  nackn  of  Uunratarooc    ^,  fibm  pOMini;  lo  the  raph*.     V.t., 


I 


m  transverse  section  is  represented  in  Fig,  ii.  The  cortical  area  of 
the  innemiiuis  is  not  dclinilcly  known  as  yet;  Mill,  from  c!(|>enmcnls 
un  animalft.  a»  also  from  the  few  clinical  observations  which  we  pott- 
tew^  there  \%  reason  lo  conclude  that,  at  least  so  far  as  (he  motor 
poriioa  of  the  nerve  is  concerned,  it  is  located  in  the  region  of  the 
antcriof  portion  of  the  fissure  of  Sylvius;  as  regards  the  sensory  por- 
tion we  know  nothing. 

We  shall  divide  the  affections  of  the  trigeminiis  into  ccn. 
\n\  and  jK-riphcraL  In  the  first  class  wc  recognize  cortical 
ontl  bulbar  diseases:  in  the  second  class  we  have  to  deal  with 
cither  intra,  or  extracranial  lesions.  The  trigeminus  being  a 
mixed  nerve,  containing  in  by  (ar  its  larger  portion  only  sen. 


58 


DISEASES  OF  THE  CHAStAL  ICEftVES. 


sory,  but  in  its  Ihird  branch  important  motor  fibers,  we  arc 
obliged,  as  there  may  exist  in  any  case  conditions  ot  irritation 

or  ol  paralysis,  to  distinguish 
clinically  between  hyperais- 
thcsia  (neuralgia,  neuritis)  and 
an:usthcsia  of  the  sensory  pari 
of  the  nerve,  and  between  hy- 
perkincsis  (sp.ism)  and  akinc- 
sis  fparalysis.  paresis)  of  the 
raolur  portion. 

I.  The  Central  AiTtcriONS 
OK  THK  Trigeminus. 

hi  dealing  with  the  corti- 
cal affections o(  the  trigeminus 
we  discriminate  between  irri- 
tative  and  destructive  lesions 
I         p  of  the  cortical  centre.     In  the 

■^  ^^  former  case  we  get  spasm,  in 

DutL*  0RUO1TO.T*.   (Aiw  scHWALBEi    ""^  '^"*^'^  i)arahsi!,oI  thc  mus. 
*.!'.  BMndine  mrt  tx  the  fifih.    n.xii,    clcs  of  mastication. 
l>adauD(lh*hnKvlr>»u*.    m.Xxnin.X'.  SpaSm    of    the    muSClcS   o( 

««r«.  A  N>m«y  tunicwiu.  ir»pi.,.ory    Hiastication  {trismus.  mastiea. 
fudcuiut).    /,  pyramidal  tract.   #,  oiivt    tory  facial  sp.ism — Romberg) 

Sa^rn-.'^-.'^ictrSr    --■■«    frequently   as   a    par. 

of  general  coiwnlsions  {St-na- 
lor,  Petrina,  Seligmiiller).  and  much  more  rarely  indepen- 
dently, unaccompanied  by  other  spasms  {Lupine,  von  Pfungcn. 
Langcr).  There  arc  two  forms:  atonic,  in  which  the  tcelh 
are  pressed  linnly  together  and  the  muscles  of  mastication, 
usually  of  both  sides,  are  hard  as  wood  to  thc  touch  :  and  a 
clonic,  in  which  the  lower  jaw  is  moved  to  and  (ro  horizon- 
tally or  vertically,  and  spasmodic  masticatory  movements  arc 
induced.  In  a  case  in  my  practice,  in  an  old  gentleman  who 
had  sulTcrcd  from  repeated  slight  apoplectic  attacks,  the  pa. 
lient  (or  scvend  hours  every  day  goes  through  well-marked 
chewing  movements  without  eating  anything,  which  at  times 
arc  so  vig<»rous  that  he  often  while  smoking  bites  throngh 
his  cigar  unintcnlionally.  The  origin  of  the  disease  is 
often  of  a  reflex  nature.  Toothache,  periostitis  of  the  inle- 
rior  maxilta.  or  face-ache  may  give  rise  to  il.  Sometimes,  it 
may  be.  a  cortical  aflection  lies  at  the   bottom  of  it,  but  for 


THE  DISEASES  OF  THE  TRIGEMINAL  NERVE. 


59 


I 


this  ihcre  is  at  present  no  evidence  furnislied  b>'  post-mortem 
examinations. 

ParalvMS  of  tlie  muscles  o(  mastic.ilion  \%  oil  the  whole,  less 
ircquciitly  observed  than  spasm.  Oarlow,  Oiitmoiit.  -ind  Kirch- 
hoff  report  cases  of  it,  recording  in  some  only  corlioil  lesions. 
Imt  in  others  changes  in  dccper-ljing  portions  o(  the  brain  as 
well.  All  the  C3SCS  had  this  one  anatomical  [(mature  in  common, 
vit.,  that  the  cortical  lesions  always  occurred  bilaterally,  thus  in 
every  case  invohinjj  both  centres.  The  first  instance  in  which 
a  unilateral  lesion  of  the  cortex  was  fmind  was  published  by 
myself  (cf.  lit.)-  It  contirms  the  supposition  that  the  cortical 
motor  area  of  the  trigeminus  includes  the  lower  third  of  the 
Ulterior  central  convolution  and  the  adjoining  portion  of  the 
second  and  third  frontal  convolutions,  and  demonstrates  that 
a  untblcral  lesion  of  the  cortex  (in  this  case  it  was  left-sirted)  is 
^uflicicnt  to  paralyze  the  muscles  of  mastication  on  both  »ides, 
The  legion  was  due  to  the  presence  of  a  psaiumoma  the  size  of 
a  fillwrt,  which  was  situated  upon  the  dura  and  cortex  at  the 
spot  indicated,  causing  a  depression  and  softening  of  the  tatter. 
The  paresis  of  the  muscles  of  mastication  had  reached  a  high 
degree,  and  was  the  more  interesting  from  the  fact  that  it  was 
accompanied  by  periodical  attacks  of  pain  in  the  face  and 
spasm  in  the  area  of  distribution  of  the  left  facial  nerve.  Pa- 
reus  and  paralysis  of  the  muscles  of  mastication  arc  occasion* 
ally  observed  among  the  symptoms  due  to  progressive  bulbar 
paralysis  and  to  pscudo-bulbar  paralysis.  The  idea  that  these 
may  develop  as  the  result  of  a  peripheral  affection  in  an  isolated 
dbease  of  the  motor  portion  of  the  third  part  of  the  tngeminiis 
oui  not  a  priori  be  considered  as  impossible,  but  there  have 
been  up  to  the  present  no  such  cases  observed.  The  dilTcren- 
tial  diagnosis  between  a  central  and  peripheral  affection  could 
be  made  only  by  means  of  an  electrical  examination.  The 
lesion  is  central  if  there  are  neither  qitanlitaiive  nor  qualitative 
changes  iti  the  reaction  to  the  faradic  and  the  galvanic  cur- 
rents. If  snth  changes,  however,  exist — for  instance,  if  there 
be  the  "  reaction  n(  degeneration  " — the  lesion  is  peripheral. 

Only  the  latter  form  of  the  disease  is  amenable  to  treatment 
(by  electricity),  and  then  with  but  slight  chance  of  success, 
Against  the  central  variety  we  arc  absolutely  powerless.  With 
regard  to  the  allectinn  of  the  nuclei  and  roots  of  the  fifth  nerve 
in  the  iions,  the  anatomical  relations  of  which  are.  as  wc  have 
seen,  not  as  yet  sufliciently  well  understood,  we  know  little 


6o 


D/SEAS£S  Of  THE  CXAX/AL  XERVES. 


or  nothing.  Whether  they  ever  occur  independently,  or,  as 
is  more  likely,  only  as  concomitants  of  diseases  of  other  bul* 
bar  nerve  centres,  has  not  bct-ii  determined,  However,  the 
supposition  seems  Justificfl  tliat  the  centres  in  question,  in  the 
course  o(  certain  general  diseascts  of  the  nervous  system — (or  in- 
stance, in  miilltple  sclerosis  and  particularly  in  tabes — are  a(< 
fectcd  relatively  early.  Thus  Erbcii  reports  (Wiener  nied. 
Blotter,  Nos.  43,  44,  ii!86)  that  he  has  obser\-ed  very  trouble- 
some paresthesias  of  the  sense  of  taste  in  tabetics  occurring  in 
paroxysms,  beginning  in  the  pharynx.  These  were  especially ' 
pronounced  at  the  anterior  edge  of  the  tongue,  and  were  ac- 
companied by  anxsthcsia  in  the  second  branch  of  the  fifth. 
This  condition  is  presumably  to  be  considered  a  disease  of  the 
nerve  of  taste,  being  analogous  to  the  so-called  gastric  crises 
which  are  attributed  to  an  affection  of  the  vagus  centre.  A  cen- 
tral anaesthesia  of  the  trigeminus  may  also  occur.  In  its  symp. 
toms  it  would  not  differ  from  the  peripheral  except  that  it  may 
be  bilateral.  The  central  nature  of  the  trouble  one  would  infer 
from  the  simultaneous  participation  of  other  nerves,  both  sensory 
and  motor  (Kombcrg).  The  interference  with  conduction  may 
take  place  at  the  base  of  the  brain. 

LITER  ATt;  RE. 

Romberg.     Lehrbuch  dcr  Norvcnkratikheiten  des  Mcnschoi.     3.  wrandcrte 

AuHai^.    Deriiti,  1S53.  p.  367  rf  seg, 
Senaior.    Berl,  klin.  Woe  lien  whr,,  4.  i879' 
Pttrina.     Prager  VieridJAhrschrifl.     Bd-  133. 
Sclijjmtillct.     Archiv  fOr  I'lychiaUie.     Bd.  vi.  p.  815. 
Crth.nrdl.     Fcitschnd  dcr  Wtlraburgcr  Universiiai.     Leipzig,  i88a. 
n.-irlow.     Brit.  Mrd.  Joiitn..  July  iS,  1877. 
Oulmont.     Revue  niciwuclk-,  1877. 
KinhholT,     Aceh,  (  Psyrhi.iiric.     Bd.  «i.  p.  133. 
Hin.    Zur  t.uc.iti^niion  d»  coriicdcti    KaurnuskclcfflinjiDs  bclm  Mmschen. 

Beri,  klin.  Wochcnsclir,.  No.  »?.  '887, 

11.    PeRIPHERAI.  APFKCTtOSS  OK  Tllli  TRIGKMINUS. 

In  its  pcriphera!  part  the  nerve  may  become  diseased  inside 
as  well  as  outside  of  the  cranium.  If  the  lesion  is  one  of  the 
stem,  and  extends  to  all  three  branches,  it  may  be  diflicuU,  in- 
deed impossible,  to  determine  its  exact  site,  because  we  do  not 
as  yet  possess  any  means  which  enable  us  to  definitely  decide 
whether  the  nen'e  is  diseased  centrally  from  the  Gasserian 
ganglion,  whether  the  ganglion  itself,  or,  finally,  whether  the 


THE  DISK  ASUS  OF  THK  TRICF.UtNAL  S'ERVE. 


6l 


Three  individual  branches  are  alt  uflected  at  ihdr  exit  from  the 
skull. 

An  affcclion  of  the  nerve  stem  lo  Ihe  central  side  of  the 
Casscriun  gjinglion  can  only  he  assumed  with  any  degree  of 
certainty  if  tlie  norve  is  diseased  in  its  whole  sensory  distri- 
bution and  if  extensive  trophic  disturbances  arc  also  pieseiit. 
The  aRcclions  of  the  Gasserian  ganglion  itself  (inflammation, 
ncitpliism,  softening)  have  as  yet  but  little  practical  importance. 
II  the  disease  does  not  take  in  the  stem,  but  only  the  terminal 
jHtrliuns  ul  the  individual  branches,  it  is  easy  to  determine  the 
Kat,  and  while  we  have  in  the  intracranial  diseases  to  consider 
those  of  the  finer  branches  of  the  nerve  in  the  dura,  in  the  ex- 
tncranial  we  have  (he  branches  distributed  to  the  face  and 
those  to  the  nasal  cavity. 


A,  Intracran'Ial  Diseases. 

Htaiiatht — Cephalalgia. 

Since  it  is  very  likely  that  there  are  only  exceptional  cases 
o(  idiofiathic  headaclic  in  which  the  fifth  or  its  terminal 
branches  in  the  dura  (cf.  page  3)  are  not  implicated,  it  seems 
advisable  to  speak  of  headache  here.  At  the  same  time  we 
must  expressly  state  thai  we  are  lorced  thus  to  take  up  differ- 
cnt  diseases  together,  which  are  etiological ly  as  well  as  patho- 
Ingically  to  be  strictly  separated  from  one  another. 

The  main  point  to  decide  in  a  given  case  will  always  be 
tthciher  the  headache  is  to  be  regarded  as  merely  a  symptom 
n(  another  disease  or  .is  an  affection  by  itself.  Nobody  ever 
would  assume  a  headache  which  occurs  at  the  onset  of  a  severe 
illness— (or  inslancc.  an  acnic  infectious  disease,  or  in  associa. 
linn  with  organic  brain  disease  (c.  g.,  tumor),  or  during  grave 
dtMrders  of  nnlrilion,  anxmia,  and  chlorosis — to  be  an  affcc- 
liiin  by  itscli  and  treat  it  .is  such.  I'hese  headaches  will 
■Iways  be  considered  as  a  mere  symptom  of  the  underlying 
disease ;  but  when  we  find  an  otherwise  healthy  person  suffer- 
ing from  protracted  or  paroxysmal  headache,  while  on  repeated 
careful  examination  we  are  unable  to  discover  any  other  dis- 
ease, then  we  are  forced  to  assume  an  independent  affeclion 
and  we  have  lo  endeavor  to  detcriuinc  the  following  points: 
(«}  The  scat  of  the  headache :  (p)  Its  peculiarities  and  its  course  \ 
(f)  its  srliologv  ;  iti\  ils  appropriate  treatment. 

(<t)  The  anatomical  situation  of  the  headache  can  hardly 


I 


DISEASES  O/--  THE  CRA.V/AI.  .VEXVBS. 

■  be  determined;  but  we  are  jusli6cd.  since  vie  < 
know  wliat  part  the  braiii  substance  takes  in  it.  in  bclievinf^ 
that  the  sensory  terminal  branches  of  the  trigeminus  in  the 
dura  (the  dura  receives  at  least  two  branches  from  the  tri- 
geminus) arc  always  implicated,  and  arc  thus  in  some  measure 
the  seat  of  the  headache.  L'nder  what  conditions  these  nerve 
endings  arc  thrown  into  a  state  of  irritation — a  state  upon  which 
the  headache  depends — is  not  well  understood,  and  all  we  know 
about  this  question  is  more  or  less  hypothetical.  The  most  prob- 
able  explanation  is  that  the  amount  of  blood  in  the  brain  or  its 
membranes  at  the  time  being  is  an  iinporlnnt  (actor  in  the  pro. 
duclion  of  the  morbid  condition,  whether  there  be  a  permanent 
increase  or  decrease  or  frequent,  perhaps  very  slight,  changes  in 
the  amount.  An  increase  constitutes  what  is  called  cerebral  hy- 
pcncmia.  a  decrease  cerebral  anarmia :  and  we  assume  the  former 
condition  if  (ull-blooded  individuals,  who  are  liable  to  rushes  of 
bliMxl  to  the  head, complain  of  paroxysmal  headache;  the  tatter, 
i(  it  occur  in  ]>ale,  anxmic  patients  who  are  subject  to  fainting 
spells.  However,  we  do  not  know  anything  positive,  and  we 
shall  have  occasion  to  deal  more  in  detail  with  this  in  another 
place.  Of  the  greatest  interest,  and  perhaps  ol  the  most  com- 
mon occurrence,  arc  the  fluctuations  in  the  intracranial  blood 
pressure,  which  possibly  are  the  cause  ol' the  irrit.ntion  of  the  ter- 
minal branches  of  the  trigeminus  in  the  dura  and  pia.  If  such 
fluctuations  appear  frequently,  so  as  to  give  rise  to  an  unequal 
distribution  ol  the  blood  in  the  two  halves  of  the  brain,  the 
irritability  of  the  sensory  endings  may  become  abnormally  in- 
creased, so  that  slight  causes  arc  sufficient  for  the  production 
of  the  pathological  condition.  The  clinical  observations  even 
go  to  show  that  wiihoiii  any  demonstrable  cause  from  time  to 
lime  there  may  develop  an  increased  irritability  of  these  tcr. 
miniil  branches  ol  the  fifth,  associated  with  simultaneous  Huct!ia- 
lions  in  the  blood  pressure.  If  'he  attack  ol  headiiche  tlius  pro-  ^^ 
duced  is  accompanied  by  vaso-moior  symptoms,  cither  of  a  para-^| 
lytic  or  of  an  irritative  nature,  it  is  designated  as  migraine  or  " 
hemicrania,  tlie  latter  name  being  given  to  those  not  very  cora-^^ 
mon  cases  in  which  the  patn  is  strictly  confined  lo  one  side  of  ^| 
the  head.  Ov\  ing  to  the  vaso-motor  disturbances  just  men- ^^ 
tioncd,  some  have  been  inclined  to  locate  the  seat  of  the  disease  ^j 
in  the  sympathetic  system,  without  being  able,  however,  toH 
show  that  the  symptoms  referable  lo  the  sympathetic  are  not  ^^ 
perhaps  only  a  secondary  result  of  the  pain,  and  therefore  reflex 


TUE  DtSKAS/CS  OF  THE   TK1CE.V/.VAL  XEXVE. 


63 


I 
I 


in  nature  (Mubius)  :  nnd  until  this  is  actually  demonstrated  not 
to  be  the  case  we  are  justified  in  looking  upon  migraine  as  be- 
longing to  the  affections  of  the  trigeminus.  In  some,  as  it 
seems  quile  exceptional  cases,  ihc  seat  ol  the  headache  is  to 
be  relerred  to  certain  muscles,  which  present  at  their  origin 
and  insertion  as  well  as  in  their  course  poinis  ol  tenderness. 
Among  these,  besides  the  frontal  occipilal  and  temporal  mus- 
cles, are  the  sterno-clcido-mastoid  and  the  upper  part  o(  the 
trapezius.  This  myalgia,  which  is  occisionally  produced  by  an 
unnatural  posilion  during  sleep,  and  which  is  easily  diagnos- 
ticated on  ciireful  examination,  is  said  under  certain  circum- 
stances fo  be  the  cause  of  headache. 

(A)  With  regard  to  (he  jH-culiLirilies  and  the  course  of  the 
headache  connected  with  the  aflcctions  of  the  trigeminus,  we 
know  that  in  its  character  as  well  as  in  its  situation  it  presents 
IK)  inconsiderable  number  nl  variations:  thus,  while  one  pnlient 
cnmplains  of  a  dull,  boring  ache,  anoiher  describes  his  pain  as 
xharfjand  burning:  while  in  the  one  it  is  worse  in  the  forehead, 
unotlier  refers  it  chiefly  to  the  occiput,  vertex,  or  temples,  etc. 
In  some  instances  the  patients  designate  sharply  circumscribed 
places  of  the  hairy  scalp  as  the  seat  ol  iheir  pain.  The  head- 
jchc  also  varies  much  in  degree— from  a  dull  sensation  of  pres- 
sure to  »  pain  which  allows  of  no  sleep.  In  some  cases  the 
mUering  is  increased  by  a  louch  or  a  tap  on  ihc  head,  while  in 
others  it  is  soothed  by  a  firm  bandage  around  the  temples. 
.Seldom  do  we  find  a  headache  lasting  for  days,  weeks,  or  even 
months  without  intcrrupiion  ;  usually  there  arc  times  when 
it  i»  less  severe  f>r  when  it  ceases  completely.  There  is  no 
regularity  i>r  uniformity  in  the  occurrenc-e  or  duration  of  the 
attacks.  Two  cases  are  scarcely  ever  alike,  and  almost  always 
eich  presents  certain  peculiarities  of  its  own  :  thus  in  the  one. 
slight  febrile  movements,  absent  in  another,  may  occur;  one 
patient  enjoys  a  splendid  appetite  during  the  most  viulcntpain, 
while  another  is  tm.-ible  to  eat  a  ihinf::.  etc. 

(r>  i-F.lio logically,  heredity  plays  a  certain  r6le,  though  this  is 
far  less  important  than  in  the  c:ise  of  migraine.  Frequently 
the  parents  of  the  patient,  especially  the  mother,  have  from 
their  ymiih  u[>  suffered  from  headache  without  atiathing  much 
miportance  to  it  or  consulting  a  physician  for  iL  Mentid  over- 
work in  young  people  is  somclimes  a  factor,  and  rapidly  grow- 
ing youths  n<it  infrequently  suffer  from  headache  (cephalxa 
udoleMrenrium).     In  anasmic  and  chtorotic  conditions,  in  chronic 


64 


D/SEA5SS  OF  THE  CKAS'lAI.  S'EKVES. 


dyspepsia,  after  acute  alcohol  intoicication.  headache  is  of  com- 
mon occurrence;  i(  may  also  be  caused  by  diseases  of  the 
pharynx  and  Ihc  middle  car  (I^gal).  The  etiological  impor- 
tance altribuiable  to  errors  in  accommodation  ur  refraction  has 
been  pointed  out  by  Bickcrton.  Certain  poisons,  if  introduced 
into  the  body  for  a  long  period  of  time,  lead  to  habitual  head- 
ache— c.  g.,  lead,  tobacco,  and  olhcm;  the  headache  iound  in 
lues  and  malaria  in  all  probability  also  belonj^s  under  this  cate- 
gory. The  reflex  origin  of  headache  due  to  affections  of  the 
nose  and  the  sexual  organs,  especially  the  uterus,  has  only  of 
late  years  been  sufficiently  appreciated.  It  is  most  important 
that  the  nose  should  be  carefully  examined  for  swellings  (Bres- 
gen.  Milnchcncr  mcd.  Wochenschr..  t893.  No.  5>. 

In  exceptional  cases  migraine-like  attacks  are  met  with  in 
cases  of  gout,  and  it  would  appear  as  if  ihey  were  also  in  some 
way  connected  with  the  excretion  of  uric  acid,  since  it  has  been 
found  that  before  the  attack  no  uric  acid  can  be  detected  in 
the  urine,  while  alter  it  the  amount  is  very  perceptibly  in- 
creased, and  later  on  (or  a  time  markedly  diminished.  The 
polyuria,  which  occurs  (requcntly  after  the  attack  and  lasts  (or 
several  hours,  with  an  acid  urine,  light  yellow,  almost  as  clear 
as  water,  of  a  very  low  specific  gravity  (1.005  *o  '-OO/).  has 
been  mentioned  before.  To  the  fact  (hat  migraine-Hke  attacks 
may  also  occur  in  the  initial  stage  of  tabes  and  may  be  of 
importance  for  the  diagnosis  and  prognosis,  we  shall  have  to 
refer  later. 

It  is  difficult,  indeed  at  times  impossible,  to  give  a  reliable 
prognosis  in  the  cases  now  under  consideration.  So  far  as  life 
is  concerned,  it  is  always  favorable,  if  the  case  is  of  a  purely 
functional  character — where  the  headache  exists  by  ilscll  as  an 
independent  affection,  and  where  it  is  not  to  be  regarded  as  a 
symptom  of  organic  diwasc.  The  patient  recovers  from  his 
severest  attacks  comparatively  readily,  and  even  after  IrcquenI 
repetitions  of  them  it  is  exceptional  that  the  digestive  disturb- 
ances and  the  loss  of  strength  which  these  entail  induce  a  really 
serious  condition. 

But  is  ihe  prognosis  lor  recovery  as  good  as  for  life  ?  To 
this  question  we  must  answer  without  reservation.  No.  One 
can  not  deny  that  the  outlook  (or  a  complete  recovery  is.  on 
the  whole,  very  bad,  and  that  the  chances,  ctetrrU  fiarilmi.  arc 
so  much  the  worse  the  longer  the  .iffcction  has  lasted,  and  the 
more  difficult  it  is  to  find  any  tunj^ible  cause  (or  iu  occurrence. 


TUB  DISEASES  Of  THE    TlilGBMIXAL  .VBRVE. 


65 


» 


The  worst  cases  arc  those  in  which  the  trouble  is  inherited  ;  in 
these  recovery  is  very  exceptional,  Al  any  rate,  the  prognosis 
in  all  cases  should  be  guarded,  and  little  should  be  promised. 
There  is  hardly  any  other  condition  which  is  so  liable  to  injure 
the  physician's  atithorily  and  the  patient's  faith  in  him  and  his 
medical  skill  as  migraine  and  hnbitiinl  headache.  On  the  other 
hand,  spontaneous  recoveries  arc  not  unheard  ol^a  fact  which 
we  ought  to  remember,  if  all  our  drugs  leave  us  in  the  lurch. 

(rf)  The  treatment  ol  habitual  headache  is  generally  very 
tedious,  and  puts  to  a  severe  test  the  perseverance  not  only  of 
the  patient  but  also  of  the  physician,  it  is  therefore  abso. 
lutely  neces»;iry.  before  undertaking  to  take  charge  of  a  patient 
ol  this  kind,  lo  lay  down,  after  a  most  careful  and  minute  ex- 
amination, a  definite  plan  of  treatment,  which  must  be  rigor- 
ously  adhered  to.  Il  is  not  sufficient  to  use  to-day  one  drug 
and  tomorrow  another,  of  which  we  have  possibly  read  in  the 
last  journal  as  being  effectual  against  headache,  and  with  which 
we  may  accidentally  obtain  a  transient  gi>od  result.  The  treat- 
ment  must  rather  be  sysleiuatic.  and  the  outcome  of  certain 
well-considered  conclusions,  which  we  shall  now  briefly  dis- 
cuss. In  the  first  place,  we  have  to  decide  whether  there  exists 
some  underlying  disease  which  causes  the  headache.  If,  as  is 
frequcully  the  case,  stomach  symptoms  are  present,  a  slay  at 
Carlsbad  or  Kissingen  may  do  much  good.  If  the  acidity  <)f 
the  gastric  juice  is  incrcised.  the  regular  ingestion  of  alkniiiie 
drinks  or  o(  lukewarm  water  is  indicated.  In  all  cases  much 
allcniion  is  to  he  paid  to  the  diet,  and  the  p.ntiei»t  should 
especially  be  warned  against  overloading  his  stomach  at  night. 
The  regulation  of  the  bowels  is  effected  by  massage  or  the  use 
ol  large  enemaia  ol  water,  or  of  small  injections  ol  pure  gly- 
cerin (5  to  6  cc. —  ni  Ixxx  10  c. — at  a  time),  or  by  vegetable  ape- 
rients,  such  as  rhubarb.  Any  degree  of  constipation  may  be 
attended  with  bad  consequences.  Diseases  of  the  middle  car 
Of  of  the  pharynx  should  be  treated  by  a  specialist.  If  the  pa- 
tient have  a  gouty  diathesis,  the  use  of  lithium  and  the  regula- 
tion ol  the  diet  should  constitute  the  main  treatment.  The 
eyes  should  be  examined  for  any  possible  errors  ol  accommo- 
dation or  refraction  that  may  exist,  and  these,  when  found, 
should  be  corrected  by  means  ol  proper  glasses.  Cases  which 
had  resisted  all  other  treatment  have  been  cured  in  this  man- 
ner (Blckcrton.  Hrailey,  Weir  Mitchell,  and  others). 

11  no  coexisting  disease  can  be  detected,  our  chief  efforts 
% 


66 


P/SP.ASES  OF    THE  CRA.VIAL   ifEXVES. 


must  be  directed  lu  buildinf:;  up  the  general  constitution. 
From  the  oold>watcr  treatment,  general  faradization  (according 
to  Deurd  and  Kockwelt),  franklinization  with  the  Holtz  ma- 
chine, systematic  gymnastic  exercise  at  home— from  any  <inc 
of  these  measures  we  may.  under  certain  circumstances,  obtain 
the  desired  result.  In  some  cases  lasting  advantage  has  hcen 
seen  from  a  change  of  cliniaie.  from  travel,  and  a  slay  in  the 
mountains  or  at  the  seaside.  With  regard  to  the  combating  or 
the  shortening  ol  the  attacks,  aniipyrine,  i.o  gm.  (15  grs.)  at  a 
dose,  or  3  to  4  gm.  (45  to  60  grs.)  a  day,  01'  phcnacctin,  0.25  gm. 
{4  grs.)  at  a  dose  to  1.25  gm.  (20  grs.)  a  day,  may  be  given. 
Tho  exhibition  of  these  drugs  is  frequently  followed  by  good 
results,  although  this  is  rarely  lasting.  If  vaso-motor  changes 
point  to  the  existence  of  a  pathological  contraction  or  dilata* 
tion  of  the  blood-vessels,  we  may  in  the  farmer  case — in  that 
of  contraction — resort  to  the  careful  administration  of  nitrite 
of  amyl.  three  to  live  drops  of  which  arc  put  on  a  handker. 
chief  and  given  the  patient  to  inhale  :  or  to  the  internal  tisc  of 
nitroglycerin  (one  drop  of  a  one-percent  alcoholic  solution 
three  times  a  day).  Great  care  has  to  be  exercised  in  the  ex- 
hibition of  the  latter  drug,  and,  if  the  pulse  indicate  it.  wc  ought 
to  begin  with  minitnum  duse^t.  Such  a  precaution  is  more 
especially  necessary  if  the  pulse  is  full  and  the  arterial  wall 
tense,  in  which  case  a  quarter  or  half  a  drop  is  sufficient  as  an 
initial  dose  (Trussewitsch).  It  is,  moreover,  not  advisable  to 
continue  its  administration  any  lunger  than  one  or  two  weeks, 
as  it  is  liable  to  give  rise  to  cerebral  symptoms  (buirxing  in  the 
bead,  vertigo).  In  the  second  case — that  of  vaso-dilatalton — 
ergot  is  indicated,  which  may  either  be  used  in  the  form  of 
hypodermic  injections  of  ergolin  [ergotini  dialysati,  1.0— grs. 
15;  aqua;  destill.,  4,0 — 3j.  Sig. :  Half  a  syrtngelul);  or  by 
the  mouth  (cxtr,  sccal.  corn,  (Denzel),  2.0 — ni  xxx  ;  aqua:  cin- 
namomi,  180,0 — 5").  Sig. :  A  tabtespoonful  every  two  hours). 
If  no  such  indications  arc  furnished  by  the  condition  of  the 
blood-vessels,  wc  have  to  try  which  medicine  will  do  the  most 
good,  and  may  begin  with  the  citrate  of  caffeine  (0.15 — about 
two  grains — three  times  a  day),  which  wc  have  found  to  be 
eRectual.  The  pasta  guarana,  2.0  grm.  (grs,  xxx)  twice  a  day, 
gives  similar  results,  but  often  interferes  with  digestion.  Sali- 
cylic acid  is  in  many  cases,  especially  at  the  onset,  followed  by 
surprising  results,  but  its  continued  use  is  disagreeable  to  the 
patient  on  account  of  its  bad  after-effects.    Application  to  the 


J 


THE  DfSF.ASBS  OF  TUP,    TKIGF.JUtXAL  NF.KVP.. 


67 


^ 


painful  spot  ol  an  alcoholic  solution  of  menthol  (three  10  twen> 
ty)  is  often  both  agreeable  and  refreshing  to  the  patient,  the 
migraine  pencils,  also  prepared  with  menthol,  having  a  similar 
cSecL  This,  according  to  Goidschcider.  gives  rise  to  a  hypcr- 
ieslhe«ia  to  cold  which  is  associated  or  followed  by  a  diminti- 
lion  in  the  excitability  of  the  sensory  ner\*es.  If  painful  points 
can  be  discovered  on  the  scalp  or  on  the  muscles  {vide  supra),  a 
slight  pressure  and  kneading  of  the  same,  later  a  more  energetic 
nuMge  to  the  head,  is  advisable. 

Electricity  may  be  used  (i)  in  the  form  of  a  constant  cur- 
rent passed  longitudinally  or  transversely  through  the  head  or 
by  applying  it  to  the  cervical  sympathetic,  and  {2)  in  the  form 
o(  the  laradic  current.  In  this  case  it  is  best  for  the  physician 
to  ftpply  his  own  hand,  previously  moistened,  to  the  forehead  of 
the  patient,  this  taking  the  place  of  one  electrode.  In  the  other 
h.ind  he  holds  one  of  the  electrodes,  the  other  being  placed  on 
the  back  of  the  patient's  head,  the  sternum,  or  some  other  in- 
diflerent  point.  With  this  mode  of  application,  whirh  Is  called 
the  ■'  laradic  hand,"  only  very  mild  currents  i^hould  be  used 
(cf.  Hirt,  {..chrbuch  dcr  Electrodiagnostik  und  Etectrotherapie, 
Stuttgart.  Enke.  1893). 

Numerous  as  are  the  means  at  our  disposal  for  combating 
the  diAe.isc,  quite  as  numerous  are  the  patients  who,  after  hun- 
dreds of  unsuccessful  trials,  give  up  all  medicines  and  all  physi- 
cians. They  retreat  at  the  beginning  of  the  attack  from  the 
world  and  from  their  families,  darken  their  rooms,  lie  down 
quietly,  and  take  simple  domestic  remedies,  among  which  Rus. 
Man  tea  with  lemon  juice  has  obtained  a  prominent  place.  Ab- 
solute rest  is  what  always  docs  most  good  to  all  these  patients. 
Finally,  wc  should  not  forget  to  dcprccile,  especially  here,  the 
use  of  all  hypnotics,  more  particularly  morphine,  as  they  never 
do  any  good,  and  arc  often  capable  of  producing  serious  harm. 


LITEKATURE, 

Kctlrr.     Dclaceplt.iUedcsadolrftcrnt^     Arch,  ite  tx-urol.,  16,  17,  1SS3. 
KvatMrh.    NrrrtMe  Cutmij-nsis  itls  cine  eigen«.  gcnnu  clMtakieriiirbarc  Foira 

(Icr  Drsprpue.     I>rut»ch<-s  Arch.  f.  klin.  Mrd.,  xxxv.  p.  38J.  1884. 
LqfL     tJelier  rine  dlierc  Unactic  drr  SchlJlfe-llitii^cl^niiptihopfM-limermi. 

tVtitsiito  ArdL  C  IcIiiL  M«d.  xt.  2.  188;:  lirri].ur/tl_/:(riijclir.,viii.  »,  1K8;. 
faoM.  W.     Antifchrin  gcgcn  KopruhnKn.     Deulsrht  rami.  WochcnKhT.,  No. 

16.  1887. 
BKlirrton.     On   llnKlMhe  due  (o  [Errors  of  the  Kcfntciivc  Media  of  ihr  Eye 

Luicn.  Aujfuit  \y  iSH?,  p.  yity 


68 


I>/S£AS£S  OF  THE  CRANIAL  S'EHVES. 


Truucwiisch.     Ucbcr  Anwcn<lunK  und  Dosirung  des  Nilroglycrnns  als  Atxnd- 

iiitttd.    I'cCenttwrxcr  med.  Wochen«chT..  No.  j.  18S7. 
Bibustte.     Deutsche  med.  Woehcnsthr,.  No.  37. 1888  (reeginmcinb  phenxetin). 
Day.     HcadachM,  Their  Nature,  eic.     London,  Churchill.  1888. 
Nosirom.    Ce|>h:LlaJgic  ci  masui^c.     I'uris.  iS^a 


B.    Extracranial  Lesions. 

The  extracranial  lesions  arc,  on  account  of  their  great  fre- 
quency, of  an  cminenll)'  prnciical  significattce  and  ot  scientific 
importance,  inasmuch  as  valuable  information  about  physiologi- 
cal questions — that  is,  the  course  of  the  trophic  and  the  gusta- 
tory fibres — may  be  gained  from  them  if  the  individual  cases 
are  carefully  observed  and  accurately  recorded.  We  shall  first 
treat  of  the  diseases  of  the  facial  branches  of  the  nerve,  and 
again  separate  in  our  consideration  the  paralytic  from  the  irri- 
tative affections. 

/.  Trigtmmal  Nturalgin — FothtrgiU's  Fatt-ackt  —  Tie  Doutourtux 

— Prosopalgia. 

Variable  in  its  degree  of  intensity,  beginning  with  a  moder- 
ate, dull,  boring,  but  always  distressing  and  uncomfortable  feel- 
ing of  pain,  and  sometimes  reaching  a  pitch  of  severity  experi- 
enced in  no  other  kind  of  neuralgia,  tic  douloureux  forms  one 
of  (he  most  common  affections  of  the  lifth  nerve.  I(  appears, 
its  a  rule,  unilaterally,  and  by  preference  fastens  upon  the  first 
and  second  branches.  The  sensory  division  of  the  third  branch 
seems,  at  least  by  itself,  rarely  to  be  the  seat  of  the  pain, 
whereas  it  is  not  uncommon  for  alt  three  divisions  to  be  simul- 
taneously attacked. 

Almost  every  patient  gives  a  difTercnt  description  of  his 
pain.  One  declares  that  it  feels  as  if  a  red-hot  wire  was  being 
driven  into  the  bone,  another  as  if  the  face  was  buried  in  a 
heap  of  stinging  nettles,  a  third  fancies  that  the  nerves  are  be- 
ing pierced  with  a  sharp  instrument,  etc.  Almost  every  case 
presents  its  own  peculiarities  as  regards  the  frequency  and 
duration  of  the  paroxysms,  between  which  there  are  often  inter- 
vals free  from  pain,  but  the  course  of  the  disease  follows  no 
hard  and  fast  rules.  The  tender  points  of  Vallcix  {poinCs  dou- 
lonrfux)  can  almost  invariably  be  demonstrated.  Almost  al- 
ways there  is  one  on  the  supra-  and  another  on  the  infra-orbital 
foramen,  a  third  over  the  exit  of  the  subcutaneous  mala.*,  a 
fourth  over  the  mental  foramen,  and  a  fifth  in  front  of  the  ear. 


THE  DISHASF.S  OF  TtfB    TKICEMINAL  NRKVK. 


69 


where  the  auriculo-lemporal  passes  over  the  zvgonialic  arch. 
The  so-called  palpebral  point  on  the  upper  eyelid,  the  parietal 
point  on  the  parietal  eminence,  the  liibiiil  point  on  the  upper 
lip,  and  many  others  arc  not  always  present.  Firm  pressure 
on  these  points  is  always,  even  in  the  intervals  between  the 
paroxysms,  disagreeable  to  the  patient  and  even  liable  to  pro- 
duce an  attack. 

The  neuralgia  of  the  first  division  of  the  tifih  nerve  is  nH»stly 
an  aflcclion  of  the  siipni-orbilal  nerve,  with  pain  in  the  fure- 
hcad,  the  nusc,  the  upper  eyelid,  and  the  eyeball  (ciliary 
Dcrves).  The  other  terminal  branches  are  hardly  ever  affected. 
The  neuralgia  of  the  second  division  attacks  the  cheek,  the 
lower  eyelid,  the  nose,  and  the  upper  lip.  often  also  the  upper 
row  of  (he  teeth  (n.  alveol.  sup.)  and  the  pulate  (spheno^palatine 
branch).  The  branch  most  commonly  affected,  sometimes  also 
by  itself,  is  the  inlra-orbital.  The  neunil^ia  of  the  third  division 
embraces  the  lower  jaw,  the  chin,  the  cheek,  sometimes  also 
the  auricle  and  the  external  meatus.  The  tongue  and  the  mu- 
cous membrane  of  the  mouth  may  be  affected  by  themselves 
(glossodynia).  and  this  may  give  rise  to  the  fear  on  the  part  of 
the  patient  that  he  has  cancer  or  ulceration  of  the  tongue  (Le(- 
fers.  imagin.  ling,  ulcerai.,  Med.  News,  i8t^8,  xi,  17;  cf.  also 
Bernhardt,  Neurol.  Centralbl..  1890,  No.  13).  Other  isolated 
affections  of  this  third  division  arc  compamlively  rare.  The 
ooly  exceptions  are  the  n.  buccinatoriits,  the  affection  of  which 
manifests  itself  by  pain  in  the  anterior  part  of  the  ear,  which 
radiates  to  the  check  (Tillaux).  and  the  inferior  alveolar  branch ; 
the  btier  is  not  nirely  attacked  separately,  and  the  consequent 
toothache  has  often  induced  patients  to  have  one  tooth  after 
ler  extracted — of  course,  however,  without  any  improve- 

11. 

That  the  vaso-motor  and  the  trophic  fibres  of  the  nerves  are 
also  at  times  implicated  is  evident  from  certain  symptoms,  viz., 
intense  flushing,  liyperidrosis.  strong  pulsation  of  the  temjKiral 
artery  on  the  diseased  side,  together  with  increased  secretion 
of  tears  and  saliva,  affections  of  the  hair,  which  has  a  tendency 
to  turn  gray  and  fall  out.  especially  over  the  most  painful 
places.  Such  symptoms  are  nut  uncommon.  Herpetic  erup- 
tions, especially  zoster  ophthalmicus  and  frontalis  of  the  af- 
(ectett  side,  have  been  repeatedly  described. 

Pathology.— 01  the  pathology  little  can  be  said  with  cer- 
latuly.     Ihe  iliickeniug  and  swelling  of  the  neurilcmm:i,  the 


;o 


DISEASES  OP   TtlK   CKAA'lAt.   .VA/tfU.I. 


(I^eneration  of  Ihe  Uasscrian  ganglion  and  o(  ilic  nerve  trunks, 
the  .small  inorganic  concretions  which  have  occasionally  been 
seen  on  Ihc  neurilemma — all  these  arc  changes  which  have  some- 
times been  observed,  but  whicli  quite  as  otlen  were  absent.  At 
all  events  no  particular  importance  can  be  attributed  to  them. 
Whether  cortical  lesions  and  aflections  ol  the  nuclei  and  the 
ro4}ts  arc  capable  of  bringing  on  the  disease  we  do  not  definitely 
know,  yet  such  possibilities  can  not  be  excluded  (cl.  the  cose 
published  by  myself  in  the  Hcrl.  klin.  Wochenschr.,  1SS7.  27). 

The  i>:ipcr  ol  Dana  (Journal  of  Nervous  and  Mental  Dis- 
eases, 1891.  xvi,  p.  $4).  in  which  he  claims  that  disorders  in  the 
blood-supply,  produced  by  arterio-sclcrosis,  are  often  the  cause 
o(  the  affection,  is  interesting ;  and  it  is  very  desirable  that  the 
vessels  should  be  carefully  examined  in  such  cases.  Thoma 
also  calls  attention  in  the  fact  that  he  has  lound  diffuse  arte- 
rio-scierosis.  which  was  more  marked  in  the  neuralgic  area 
[Dcutsches  Arch.  f.  klin.  Med.,  1888,  xliii,  4,  5). 

Course. — The  course  of  the  disease  is  on  the  whole  extreme- 
ly (odious,  and  attacks  which  harass  the  patient  to  the  end  ol 
his  days  are  to  be  observed  here  as  in  migraine,  the  only  differ- 
ence being  that  in  Ihc  disease  under  consideration  the  suffer- 
ings of  the  patient  are  still  more  unbearable.  The  disease 
throws  a  shadow  over  his  whole  existence  far  more  gloomy 
than  in  migraine,  and  so  wc  can  well  understand  why  again 
and  again  he  tries  all  sorts  of  remedies  and  frequently  even 
the  most  heroic  measures  to  relieve  his  pain  at  a  lime  when  a 
migraine  patient  would  have  given  up  all  medicine  and  all 
doctors. 

Treatment — Unfortunately,  here  also  therapeutics  is  often 
powerless,  as  has  already  been  indicated  by  the  remark  that  the 
disease  is  often  ol  life-long  duration.  Hope  of  recovery  is  only 
justifiable  in  cases  where  we  have  an  underlying  disease,  as,  for 
instance,  malaria,  in  which  case  the  neuralgia  is  to  be  regarded 
as  3  symptom,  or  where  local  causes  exist — for  instance,  bone 
diseases,  the  presence  of  foreign  bodies,  or  neoplasms  which 
can  be  removed,  etc.  Such  cases  will  repay  the  efforts  of  the 
physician,  and  a  cure  can  be  effected  by  proper  internal  medi- 
cation or  by  surgical  interference.  In  cases,  however,  where  a 
primary  cause,  which  would  furnish  us  with  data  (or  our  treat- 
ment.  can  not  be  discovered — where  wc.  therefore,  are  forced 
to  experiment  with  the  nervines  and  the  so-called  specifics — let 
us  beware  of  raising  our  expectations  too  high,  lor  too  often 


TUB  DISEASES  OF  THE    TklGEMlNAl.  ffEJit'E. 


;> 


all  our  efforts  will  be  in  vnin.  Arsenic,  sttiic.  quinine,  the  bro> 
midc  and  iodide  of  potassitim.  asafa'tida,  castorcum.  valerian, 
and  many  other  medicines  now  completely  obsolete  have  been 
tried,  and  still  to-day  sometimes  arc  tried  at  random.  The  one 
uses  this,  the  other  that  drug  ;  under  favorable  circumstances 
each  one  docs  good  once,  but  rarely  is  the  improvement  last- 
ing. Here  also  the  most  confidence  may  be  placed  in  :tniipy> 
fine  and  phcnacetine,  and,  if  chlorosis  be  present,  in  iron  (best 
administered  in  the  form  of  Bland's  pilts),  quinine,  arsenic,  and 
iodide  of  potassium:  if  these  leave  us  in  the  lurch  we  can  re- 
sort to  salicylate  of  sodium.  4.0-6.0  (3}- 3  jss)  a  day,  in  cap- 
sules, or  to  salul  or  gelsemium.  giving  the  latter  in  the  form  nl 
ihe  tincture,  and  pushing  il  perhaps  until  slight  symptoms  of 
intoxication  appear  (twenty  drops  every  two  hours).  I  have 
Uftcd  corrosive  sublimate.  0.05  (live-sixths  of  a  grain  a  day)  in 
pill  form,  several  limes  successfully.  Of  butyl  chloral  I  am  un- 
able to  say  anything  favorable  (bulyl  chloral  hydr..  7.5  (3}ss.- 
3i)>:  glycerin.,  20.O  (3.SS.);  aqua:,  130.0  (siv).  Sig.:  A  table- 
spoonful  every  ten  minutes).  In  all  my  cases  it  proved  very 
uosucccssdil ;  Ihc  same  holds  good  for  methylene  blue,  which 
was  administered  in  capsules  of  0.1-0.5  '"'^  '^^  P**"  ''i^  (2-7- 
12  ffrs.).  This  drug  has,  besides,  disagreeable  effects  upon  the 
urogenital  system,  giving  rise  to  strangury  and  pnin  tn  tlie 
glaoK  penis,  etc.  Other  anxslhetics,  chloroform  .ibovc  all.  do 
at  least  as  much  good,  and  the  narcotics  are  decidedly  better, 
as  Trousseau  has  already  upheld,  who  declared  large,  or  wc 
should  rather  say  huge,  dos<.-s  of  opium  or  morphine  to  be  the 
only  effectual  treatment.  Whatever  wc  may  think  about  mor- 
phine, in  aises  of  tic  douloureux,  especially  in  severe  instances. 
we  can  not  dispense  with  it.  The  combination  of  morphine 
with  atropine,  or  the  alternate  use  of  the  two  separately,  has 
been  recommended  (.Mthau-s) ;  chloral  hydrate  alone,  4.0-6.0 
(  j}-3j*s-)  "  day,  is  uncertain  in  its  action,  but  in  combination 
with  morphia  often  acts  very  well.  Cocaine  may  also  be  used 
externally  or  given  internally  (a  teaspoonful  of  a  one-half-per- 
cent solution  three  limes  a  day).  The  so-called  revulsives 
(daily  repeated  cold-water  enemata  (Gussenbaucr).  cold  or 
warm  poultices,  sinapisms,  superficial  cauterization,  the  elec- 
tric brush),  often  act  splendidly  where  we  want  to  produce 
temfwrary  amelioration  of  the  pain ;  but  unfortunately  this  Is 
only  transient.  The  same  is  true  of  electricity,  which  may  be 
uMd  according  to  the  polar  method  (steady  application  of  the 


72 


D/SF.ASES  OP  THE  CRANIAL  ffKMVSS. 


anode  over  the  painful  place,  cathode  at  some  indiflerent  place, 
weak  increasing  and  decreasing  currents  being  used),  or  ac- 
cording to  the  method  of  direction  of  the  current  (descending 
steady  current).  Zichl  (Berliner  klin.  Wochcnschr..  18S9,  t3) 
recommends  the  application  of  electricity  for  as  long  as  an 
hour  at  a  time.  Galvanism  to  the  neck  has  also  been  advised. 
The  constant  current  may  be  given  a  trial,  combined  vrith  the 
action  of  chlorolorm,  as  Adamkiewicz  has  proposed  in  his  pa- 
per on  cataphortsis.  I  have  several  times  used  the  "  diflusion 
electrode,"  which  he  recommends,  quite  successfully  (cf.  lit.). 
HofTmann  is  also  satisfied  with  the  results,  but  thinks  that  these 
arc  not  to  be  attributed  lo  the  electricity  (Neurol.  Ccntralbl., 
1888.  21).  The  faradic  brush,  the  unpleasant  action  of  which 
may  he  somewhat  mitigated  bv  putting  moist  blotting-paper 
on  the  skin,  is  often  very  satisfactory,  and  1  can  recommend 
the  strong  cutaneous  faradization  very  highly  even  during  the 
paroxysms.  Operative  interference  (neurectomy)  has  recently 
more  and  more,  and  justly  so,  fallen  into  disrepute.  The  re- 
sults are  often  entirely  negative,  and  where  some  success  has 
been  obtained  with  it  this  did  not  prove  lasting.  For  an  ac- 
count of  the  method  of  resection  the  reader  is  referred  to  the 
surgical  journals  :  the  nervus  buccinatorius  is  resected  accord- 
ing to  the  method  of  Zuckcrkandl  (Arch.  f.  klin.  Chirurgic, 
1888,  37.  2).  In  order  to  avoid  relapses  it  is  necessary  to  con- 
sider the  advisability  of  resecting  neighboring  nerves  (Oba- 
linsky,  Wiener  klin.  Wochcnsclir.,  1889,  41).  Repeatedly  the 
Gasserian  ganglion  has  been  successfully  extirpated  (Rose,  in 
London,  Lancet.  1893.  x,  32,  and  Krause.  IVulsche  mcd.  Woch- 
enschr.,  1893,  15).  The  same  is  true  of  the  resection  of  the  tri- 
gcminus  Irom  the  foramen  ()v.ile  {Sulzcr,  Arch.  f.  klin  Chir., 
1888,  37,  3>.  Baths,  especially  at  the  non-medicated  hot  springs, 
a  stay  at  the  seaside  or  in  the  mountains,  cold-water  treatment, 
and  vapor  baths  may  be  advised,  but  wc  are  unable  to  state 
definitely  which  of  these  modes  of  treatment  are  indicated  in 
any  particular  case. 

i^tiology. — About  the  reliology  we  know  little  worthy  of 
mention.  That  heredity  and  exposure  to  cold  have  something 
to  do  with  the  disease  we  must  .idmii :  hut  this  is  not  peculiar 
to  neuralgia  of  the  fifth.  However,  affections  of  the  pulp  of 
the  teeth,  which  arc  determined  by  an  examination  of  the  sen- 
sitiveness  to  temperature  changes  (Boennecken.  Berliner  klin. 
Wochenschr..  1893,41),  and  anatomical  changes  (exostoses,  nar* 


THE  O/SBASBS  OF  THE   THIGEMINAL  N£ki'E. 


73 


I 


rowing  of  bony  canals  due  to  syphilis,  etc.),  arc  here  frequently 
ol  moment.  Age.  sex,  and  occupnlion  do  nut  seem  to  exert 
any  particular  influence ;  slill.  the  disease  is  on  the  whole  very 
rare  in  ^niall  children,  and  i(  present  it  is  always  inherited. 

LITERATURE. 

Pcynwnet  de  LaronvMlfe.     De  la  neuralgic  ilu  trijuineuu  el  en  particulitr  At 

KM  inlteineni  par  les  initv^risalions  de  la  chlorure  <le  mflhyle.    Thi«c  de 

l*sri>,  1886. 
CuiAcnlMurr.     t/'eticr  Behandluri);  dcr  TrigetninuKnruralgic.    Prng.  mcil.  Woch- 

eitKhr..  nl.  31,  1&86. 
Schech.     Kkonidclte  Kr^mpre  dec  wcichen  Gaumrat  mil  objcctivem  OhrgcrSusch 

in  f  olge  von  lUMitcr  TrigcDMniUincunilgie.    Mimchcnet  mod.  Wochentchr., 

3).  18S& 

Ailunikicwici.    Die  DifTusionwU'krrodc.     Nfurol.  Centralbl-  No.  lO,  188& 

Hwi.     BredUuiT  SmI.  Zeiliclir.  No.  I!.  i886l 

Knrsrr.     Ctnirilbl.  i.  kliii.  Med..  44.  18S6.     (Anlifcbnne.) 

Sclfarrt.      Uelier  AntifebKn  al«  Ncn-inuHT.     Wirntt  med.  Wochcnschr,  35.  18S7. 

Von  Fnuikl-Hixliwatt.     Cenmlbl.  t  d.  rm.  Therapie,  1888.  \4.  9. 

ZtetiL     Bcrltncr  klin.  WochMisihr..  i8«9.  ij. 

Each.     EndrcsultAie  Axx  Nr«r«rio(nic  bd  Quiniuinruralpen.     Inaug.-Divicn., 

BctUii.  1889. 
M.  Itrnedict.     Ueber  Nmnilgle  und  ncuralgHuhc  AITcctloncn  und  drren  Bc- 

handluni;.     ^^'>cn.  ItintimilUer,  1891. 
Bin.     Lxlkrbuch  do   HlckumJiagiiMtik.  etc.     Stuilgan.  Enke.  1893.  p.  147 

3.  AmrstkftM  0/ the  TrigfmiiHS — Paralysis  0/ the  Trigrminns. 

Paralysis  of  the  sensory  branches  of  the  trigeminus  is  on 
the  whole  less  frequently  met  with  than  neuralgia  oi  the  face. 
Only  exceptionally  are  all  the  divisions  (the  motor  portion  of 
the  third  included)  affected  equally  :  but  most  observations  ji" 
to  shnw  th.1l,  as  a  rule,  oidy  individual  branches  suffer,  and 
these  not  in  their  whole  extent,  but  only  within  certain  areas. 
The  smaller  the  number  of  fibres  in  the  distrihulioti  of  which 
an.'Chihesia  obtains,  the  more  peripheral  is  t!ie  scat  of  the  cause 
(Romberg),  and  we  may  assume  an  affection  of  one  whole 
branch  to  entst  "  where  the  loss  of  sensation  is  found  not  only 
in  certain  areas  of  the  surface,  but  also  in  the  corresponding 
cavities  of  the  (ace  "  (Romberg).  Whether  the  branch  is  a0cct> 
ed  before  or  after  leaving  the  skull  we  have  no  means  of  de- 
ciding. 

A  lesion  of  the  first  division  also  causes  anxsthesia  of  the 
surface  uf  the  eyeball.  Since,  in  consequence  of  this,  influences 
from  outside  (.foreign  bodies,  dust,  tniumatism)  are  not  per- 


7A 


DlSEASeS  OP  TUF.   CRANIAL  NEKVES. 


ceivetl,  not  infrequently  a  keratitis,  which  begins  in  the  lower 
segment  of  the  cornea,  is  developed.  This  may  run  into  an 
jnflammatiun  of  the  whole  ball  nnd  bring  about  destruction  of 
the  eye  {pphtluilntta  paralylka).  That,  to  explain  this  condition 
we  must  not  assume  a  lesion  of  special  trophic  nerves  has  been 
shown  by  experiments  on  animals  (Scnttlcbcn).  An  affection 
of  the  second  division  deprives  the  nasal  branches  of  their 
function,  and  the  nose  becomes  not  only  insensible  to  external 
touch,   but  certain    pungent   smells — :is,   for  instance,   that  of 


Pie.  la— ninmiMinPN    '1   ^m  :^.      'bv  Citaxtwhs  TJkbv»  ox  twb  Hmu.    r,.  ^n 

(',.  |1»  ihrtv  bramlii  .  \  \'\.  l:  i.  .  i:iiiiiu,  •!/.  aurfcuki-ii'nipcml.  w,  Miinaoriiiut,  jf, 
tu|]ratruchlur.  il.  itiiuinKiilrAi.  /,  Isthryni*].  m.  eiciilitl.  4,  biKdnatOr.  *iK, 
aarbuUtl*  mkcniii.  j«.  lubmuncun  nuke,  cwid  mid  <9mj.  <>cclpt(ii]i«  pajor  and  minor. 
tt,  uipcrficlal  nmul. 

sniiff— are  no  longer  recognwed  on  (he  affected  side.  In  lesions 
of  ihe  third  division  the  corresponding  half  of  the  tongue,  but 
only  in  its  anterior  two  thirds.  loses  its  sensation,  and  the  pa- 
tient has  no  longer  any  sense  of  taste  in  this  area  (n,  lingualis); 
since,  however,  loss  of  taste  in  the  anterior  portion  of  the 
tongue  has  been  observed  in  some  cases  where  the  function  of 
the  third  division  of  the  fifth  was  found  to  be  perfect  (Heus- 
Dcr),  we  can  not  exclude  the  supposition  that  the  fibres  of  the 


^P  TttF.   DISEASES  OF  THE    7HtCEMINAL  NEKVR.  75 

chorda  tympani  {ur  at  least  a  considcrabk'  part  of  them)  }oin 
ihe  facial  from  ilie  second  division  of  the  iiltti.  Certain  it  is 
that  the  fibres  which  pass  to  the  chorda  return  again  to  (the 
second  and  third  branch  ot)  the  trigeminus  alter  having  proti- 
ably  run  with  the  facial  as  far  as  the  geniculate  ganglion. 
From  Fig.  \2  the  distribution  o(  nnsfsthcstn  over  the  skin  of 
the  lace  may  be  learned.  Vaso-motor  changes,  subjective  sen- 
sations of  hent  and  cold,  sensations  of  swelling,  and  disturb- 
ances in  the  movements  of  mastication  and  difficulty  in  open- 
ing the  mouth  (paresis  of  the  external  pterygoid  and  the  ante- 
rior belly  of  the  digastric),  are  sometimes  met  with  (M(lllcr). 

The  course  of  the  disease  depends  upon  the  seal  of  ihc 
lesion.  In  peripheral  aflcclinns  the  prospect  for  recovery  is 
usually  comparatively  favorable;  yet  this  Is  frequently  only 
{Kirtial.  and  several  of  the  qualities  of  scn<iation  remain  per* 
maitenlly  lost,  the  sensibility  in  general  is  dulled,  and  tactile 
[narxsthesias  persist — in  a  word,  recovery  is  imperfect. 

The  treatment  chiefly  consists  of  excitants,  among  which 
the  most  efficient  is  the  application  of  the  faradic  and  Ihc 
galvanic  brush  to  the  skin.  Transient  improvement  may  be 
ihus  obtained  after  a  short  while  in  the  peripheral  affections. 
The  electric  brush  is  the  best  excitant  lor  the  skin,  and  is  to 
be  preferred  to  all  liniments  and  the  Itlcc,  which  arc  supposed 
to  jict  in  much  the  same  w:iy.  Inlcrnal  treatment,  provided 
there  be  no  definite  underlying  disease,  is  absolutely  super- 
fluous. 

I.ITKRATURK. 

Multcr.    Zwri  FIlie  von  TngcminuiIHhmunK.    Anrh.  C  Psych,  u.  Nervcnkrankh., 

ilr,  3.  J,  tSSj.  • 

UlhofT.     Fiill  xsta  Nniritit  d««  rechlcn  Trif^Rimut  mit  AITcciJon  dct  Lacrynulis 

uiul  ctnsrltigetn  Aufbdren  iter  Thfaniriisecmion,     Deutsche  mcd.  Woclien- 

»chr..  xii.  19.  i88f>. 
Cwu.     A  Oueuf  Paralysniiftbc  Trijifeininui  (bllowrtl  by  Allernaic  llemiplq^ 

— Its  KcUliim  to  the  Nnvc  of  Tasic,     Jouni.  of  Mrnl.  nrtO  Ncrv.  Dim-jims, 

xiil.  J,  p.  A;.  1886. 
Ilmwirr.     Klnr  IleotMchtunt;  iihet  den  Verluif  der  GeschcMcksncrvcn.     Bcr- 

lm«  kiln.  Wochenschr,.  \t\:\.  44.  i88ti. 
('rrrlrr      IjimtM.  vol.  J.  No,  1,  iMlS. 
2Ktil.     Virch.  A(i:h„  1889.  cxvii.  Heft  ii  (Cas^  of  I'jiralysis  of  ihc  ThJrc)  llninch 

uf  xXve  Tri|{rtiitni»*l, 
ZMiL     KUi  neucr  Kail  von  isntinei  IJilintunK  ilu  (Jriilcn  Trigcnunuusin  mit 

((ncbnuekMiOruoi;.    VIrcli.  Arclt.,  1801,  cixi.  Hcfl  IIL 
Thutti^orti,  MraM.    A  Cist  of  Aiimihrfia  of  ihc  Trigcminu*.    Nord.  med.  Ark., 

1891.  new  w«)uence,  ii.  6.  Na  j8. 


76 


DiSSASES  OF  TUB  CRA.WIAL  ffEKVBS. 


J.    Trigtminal  Cough. 


Finally, 


call 


reflex  neurosis,  which 


alieiiLion  t< 
was  rtrst  described  by  Schadcwald,  and  then  studied  by  Willc. 
This  is  a  paroxysmal  cough  which,  occurring  in  individuals 
whysc  respiratory  organs  arc  perfectly  sound,  is  entirely  due 
to  an  irritation  of  the  trigeminal  fibres  distributed  to  the  nose. 
pharyns,  and  the  external  auditory  meatus.  These  two  wri- 
ters (lislitiguish  accot'djiigly  a  nasal,  a  pharyngeal,  and  an  au- 
ricular trigeminal  cough,  and  declare  the  Brst  (nasal)  to  be  the 
most  frequent  variety.  According  to  them  also,  this  neurosis 
is  by  no  means  rare,  and  the  possibility  of  its  existence  ought 
always  to  be  thought  of  where  we  have  to  treat  cases  of  an 
obstinate  paroxysmal  cough,  which  is  liable  to  be  produced  by 
the  aciion  of  pungent  odurs  and  by  changes  of  temperature, 
and  which  is  accompanied  by  hypersecretion  of  the  nasal 
mucous  membrane.  The  treatment  consists  in  the  use  of  the 
nasal  douche,  the  application  of  weak  induction  currents  di- 
rectly to  the  nasal  Givily.  and  the  administration  of  potassium 
iodide.  Further  observations  arc  still  needed  to  decide  whether 
we  actually  have  to  deal  in  these  cases  with  a  neurosis  ol  the 
trigeminus,  or  whether  the  vagus  has  not  something  to  do 
with  the  affection,  or  whether,  finally,  as  Hack  suggested,  the 
erectile  tissue  of  the  nose  is  responsible  for  it. 

Quite  lately  it  has  been  claimed  that  peripheral  irritation  of 
the  trigeminus  (by  inhalation  of  pungent  vapors,  new  growths, 
etc.)  may  reflexly  give  rise  to  sensations  of  dizziness  ("  ii.asal  ver- 
tigo-" Joa')-  Uitlil  more  confirmatory  evidence  is  brought  for- 
ward, it  would  be  well  to  suspend  judgment  on  this  question, 

LITKKATL'RE. 

HcrK)|t.     Dcr  acwXe.  und  clin>iL  Naicncitan-h  mil  brsondcrcr  Elcroeksiehli(pini; 

tits  ncrvosi'ti  Sdintipfcrii  (■■  Kliiniii*  vn-tomoloria ").     I.  Aufl..  (inu.  1SS6. 

Lcuschicr  &  l.uhrnski, 
WJIc     Iltr  TnitcrniniiihuMcn.     Dcvl^che  mcd.  WochcnKhr..  n,  16.  17.  iSBj. 
Jen).     Nasal  Vcriigo,     L.jinccl.  Kt-tiruarj*  1.  1887,  p.  31. 
BniKclmanii.     Ucticr  NascnKchwindcl  (a^trorcxia  nasalis).    Tbetapeul.  Monalt- 

hefte.  KcbniJity.  1889.  iii.  p.  5?. 
Baumgjnrn,  A.    nip  Ntun>vn  und  Rtflexncurosen  dw  K3searaclunnuui». 

VoIbtnann'sSammluiiK  Klin.  Vonr.,  1891,  N.  F.  4+ 


4 


CHAPTER   V. 


DtSKASM  OP   THK    FACIAL  NRRVK. 


I 

I 


I 


TiiR  facial  nerve  eroeigei  at  the  bane  of  the  brain  from  the 
Itilla  oblonj^ata  by  the  side  of  the  abducens  and  behind  the  tri> 
tinus  on  the  pnslerior  margin  of  the  middle  peduncle  of  the  cere- 
bellun.  The  auditory  nerve  is  situated  close  behind  it,  and  between 
the  two  a  separate  bundle  of  fibres  is  placed — namely,  a  Kccond  root 
oi  the  facial,  the  KO-called  nervus  intermedins  or  portio  inletmedia 
Wnsbergii.  With  the  auditory  nerve  the  (actal  then  pastes  for- 
oard  and  outward  into  the  internal  auditory  meatus,  at  the  bottom 
of  which  it  enters  through  a  small  opening  the  Fallopian  canal 
{cf.  ¥ig.  15),  tn  the  hiatus  of  this  canal  it  makes  an  almost  rccian- 
ttvlar  turn  (genu  nervi  facialis),  passes  backward  and  then  down- 
vard,  and  leaves  the  skull  through  the  stylo-mastoid  foramen  to 
divide  inside  of  the  parotid  gland  into  the  terminal  branches,  the 
temporo-facial  and  the  cervico- facial,  which  form  together  the  plexus 
iBscrinus  major.  At  the  so-called  genu  the  nerve  forms  a  gangli- 
forra  swelling — the  ganglion  geniculi — from  which  the  larger  sug>cr- 
licial  petrosal  nerve  is  given  off  (cf,  diagram.  Fig.  15).  These  are 
the  fibre-«  which  communicate  with  the  trigeminus  and  have  the 
(unction  of  gustatory  fibres  for  the  anterior  two  thirds  of  the  tongue 
(cf.  page  74). 

Tlie  nucleus  of  the  facial,  a  group  of  large  multipolar  ganglionic 
cells,  lies  four  millimetres  and  a  half  beneath  the  iloor  of  ilic  fourth 
*cntricle.  in  the  region  of  the  formatio  reticularis,  dorsal  to  the 
upper  olive  (cf.  Tig.  ij).  From  this  illustration  it  is  also  apparent 
that  the  ascending  root  of  the  trigeminus  has  the  emerging  portion 
of  the  facial  root  to  its  mesial  side,  while  the  anterior  root  of  the 
auditory  lies  external  to  it.  The  axis  cylinder  processes  of  the  gan- 
glionic cells  of  the  nucleus  are  united  in  a  larger  fasciculus,  forming 
the  fir»t  part  of  the  root  (Ursprungsschenkel  of  Kfau«).  which  at 
the  Hoor  iif  the  fourth  ventricle  becomes  a  compact  bundle,  the  in- 
termediate portion  (VII,  a).  At  the  anterior  end  of  the  emincntia 
teres  this  is  bent  at  right  angles  (genu  ccrebrale).  and  becomes  the 
etncrging   portion   (Austrittsschcnkcl)   of   the   facial    (VII),   which 

7J 


78 


J>/SEASP.S  OF  THE  CXAA'/AI.  NfiKyKS. 


reaches  its  point  of  exit,  before  mcntifincd,  through  the  transverse 
fibre*  i)f  the  pons. 

Quite  lately  experiments;  on  animals  by  Mendel  have  »h»vrn  that 


«.  rr     F//  » 


n.nrf  .- 


riu 


He.  ij.— DutOMAM  movriNO  tiik  Covnw  or  thi  I'a> 
ClALFlnncsittTiK  Potc9.  (Arur Schwa ldk.)  k.VU. 
(acbJ  oDcleu*.  C//A,  root-bundli  of  the  lodil  pudcua. 
f// «.  InlcniKdlMepnrtinn(cn>u->«cilon),  Vll.tramf 
iSK  fititlon  flf  (lin  fjiciil.  a.  I'/,  alxlufant  nudnu. 
*.  i'ltl.  nudeiu,  and  I'///,  rnni  o(  Ihr  Aiulitaiy  nervt. 
/.  fibrrs  eiimine  (ri::m  Ihr  ntpluj.  x.  fibmeoniine  from 
theabduani  nudtiu.  *.  i..  uppsi  ulive.  «.  r,asMnd- 
Inc  root  of  Uw  Irltemiaiu. 

panily^i^.     Wc  shuU  discuss  e;ich  clast; 


in  rabliits  and  i;uinea- 
\itgTi.  the  facial  branches 
to  the  eyes  take  their 
origin  in  the  oculo-mo- 
tor  nucleuH.  Whether 
this  is  the  cane  »r  not  in 
man  our  present  patho* 
logical  observations  do 
not  allow  tin  to  decide 
with  certainty. 

Just  as  in  the  case 
of  the  irigcniintis,  so 
in  the  ladal,  wc  must 
distinguish  between 
central  (conical  and 
biiU>ar)  and  peripheral 
(intra-  and  extra-cra- 
nial) lesions,  which, 
Dwinj;  to  the  purely 
mnlur  functinns  of  tlie 
facial,  may  give  iis, 
clinically,  spasm  or 
separately. 


I.  Facial  Spasm—"  MiMif  Faciat.  Si'asm  "— '•  Tic  Convulsif." 

l-esions  which  give  rise  to  facial  spasm  may  be  central  or 
peripheral  in  their  situation.  In  the  first  case  either  the  cor- 
tcx  or  the  nucleus  (or  ihc  root)  of  the  nerve  in  the  medulla 
obloiig:ita  is  concerned.  Accurdin};  to  otir  present  ideas  the 
cortical  area  for  the  facial  is  located  in  the  lower  half  of  Ihc 
anterior  and  the  lower  third  of  the  postfrior  central  convolu. 
lions,  and  il  is  also  supposed  that  the  posterior  halves  of  the 
two  lower  Irontal  and  the  anterior  part  <tl  the  supramar^inal 
convolutions  have  some,  although  a  less  important,  connection 
with  il  (Exner). 

It  is  not  known  whether  stimulation  of  these  centres  can 
produce  a  facial  spasm,  or,  in  other  words,  whether  there  exists 
a  real  conical  facial  spasm,  although  the  experiences  of  Cadiot, 


OrSP.ASSS  OF  THE  FACIAL  NRRVB. 


79 


^  alo 

lb- 


\ 


I 


to 


and  Roger  (Kevue  tie  m^d.,  Mny  lo,  1890,  No.  5) 
seem  to  leave  but  Utile  doubt  upon  this  point.  It  seems,  how- 
ever, well  cstahlished  that  the  disease  can  be  produced  by  rc- 
Rex  slimulaliun  of  the  (acial  niick-us  (,ci.  the  case  of  Ilcrger  and 
Hs  treatmenl)-  Undoubtedly,  disease  of  the  per)])heral  por 
tiona  of  the  nerve  is  the  most  common,  in  which,  just  as  in  Iri. 
geminal  allcclions,  either  the  whole  facial  area  or  only  indi- 
vidual branches  may  be  affected.  \Vc  distinguish  a  clonic  and 
a  Ionic  variety  of  spasm. 

A  patient  suflcring  from  clonic  diffuse  facial  spasm  has  lost 
itrol  over  his  facial  muscles,  either  on  one  or,  more  rarely, 
m  both  sides.  The  muscles  affected  are  in  irregular  motion, 
K)  that  against  his  will  the  patient  makes  the  oddest  faces, 
minklcs  his  forehead,  raises  the  ala:  nasi,  screws  his  eyes  up, 
ric.  When  the  attack  has  passed  )ie  has  a  temporary  respite, 
]ret  often  enough  the  pause  is  very  brief,  and  even  during  rc> 
missions  spasms  Hash  across  his  face,  so  that  his  features  are 
never  for  any  time  entirely  at  rest.  On  the  slightest  provoca- 
tion, by  speaking,  often  also  by  eating,  quite  violent  paroxysms 
uc  excited,  so  that  the  patient  would  lain  cover  up  his  dis- 
torted face. 

II  the  spasm  is  tonic,  the  allccted  side  of  the  face  is  singu- 
luly  rigid  and  takes  no  part  in  the  facial  movements,  but  is 
ftlorlcd.  The  muscles  arc  distinctly  hard  to  Ibc  touch,  the 
comer  of  the  mouth  is  pulled  toward  the  diseased  side,  the 
■Oulb  firmly  cluficd,  the  eyebrow  drawn  up — signs  suflicicntiv 
*ukcd  to  distinguish  it  from  facial  paralysis,  in  which  also  the 
»1cctcd  side  docs  not  take  part  in  the  movements  of  expres- 
•ion.    Vaso-motor  and  trophic  changes  are.  as  a  rule,  absent. 

Id  cases  where  the  sp.-ism  is  conlined  to  some  branches  of 
■ie  brial  only,  we  find  that  the  muscles  around  the  eyes  are 
ilniost  always  the  ones  affected.  The  eyelid  is  attacked  by  a 
oOBicor  tonic  sp.tsm,  and  conditions  arc  developed  which  go 
lUKJCT  the  names  ol  spasmus  nictitans  and  blepharospasm. 

Tlie  s/^ifnius  mclititHs  consists  of  spasmodic  blinking,  in 
*liicb  not  only  the  eyes  arc  rapidly  closed  and  opened,  but 
ibo  the  neighboring  muscles  (frontalis,  zygomatic!)  participate 
to  die  spasmodic  movements.  In  a  mild  form  this  spasm  is  seen 
in  many  people  where  it  is  only  to  be  regarded  as  a  bad  habit. 
BUpkaras/Msm  consists  of  a  paroxysmal  spastic  contraction 
of  the  orbicularis  palpebrarum,  lasting  a  few  seconds  or  min- 
utes, which  completely  clo:»cs  the  lids-    In  rare  cases  the  attacks 


So 


OfSCASBS  OF  THE  CRANIAL  NBHyP-S. 


I 


follow  each  other  so  quickly  and  are  so  prolonged  that  the 
patient  has  to  be  treated  as  a  blind  man ;  even  a  transient 
amaurosis  has  aclually  been  observed  (Silex,  Klin.  Monatsbl. 
f.  Augcnhcilk..  Marz.  i88S).  The  attacks  appear  unexpectedly 
and  quick  as  lightning.  They  are  often  precipitated  by  volurw  ■ 
lary  firm  closure  of  the  eyes,  eye-strain,  or  by  the  action  of 
light,  and  the  patient  is  utterly  unable  lu  raise  the  lid  until  the 
attack  has  passed.  The  physician,  however,  will  succeed  at 
times  in  cuttiii>;  short  the  paroxysm  if  he  be  able  to  discover 
any  oi  the  so-called  pressure  points,  which,  according  to  von 
Graefe,  who  lirsi  discovered  them,  arc  often  present.  More 
or  less  firm  pressure  exerted  at  these  points  is  capable  of  pro- 
ducing an  interruption  of  the  spasm  and  a  cessation  of  the 
attack.  Unfortunately,  however,  such  points  are  often  entirely 
absent,  and  when  ihcy  exist  their  position  is  so  uncertain  and 
changeable  that  they  may  only  be  accidentally  discovered. 
One  of  the  few  which  is  present  with  some  constancy  corre- 
sponds to  the  supra-orbital  foramen.  We  should,  however, 
look  for  them  over  the  whole  distribution  of  the  trigeminus, 
over  the  spinous  and  transverse  processes  of  the  cervical  vcrtc 
bne.  and  even  in  the  region  of  the  brachial  plexus.  It  is  our 
duty  to  make  a  frequent  and  untiring  search  tor  them,  as  we 
may  thus  be  able  to  afford  our  patients  very  great  relief. 

Course.  — The  course  of  the  disease,  be  it  in  the  form  of  a 
total  or  a  partial  spasm,  is  usually  very  tedious,  and  a  progno- 
sis for  recovery  must  be  very  guarded.  The  outlook  is  cspc. 
ctally  unfavorable  when  the  affection  is  complicated  with  other 
motor  disturbances,  as  I  have  observed,  for  instance,  in  two 
cases  where  the  facial  spasm  was  associated  with  writer's 
cramp.  Of  late  a  number  of  cases  have  been  observed  in 
which  various  motor  disturbances  were  associated  with  lie 
COiivulsif ;  these  conditions  have  been  described  as  a  new  dis- 
ease under  the  name  of  la  maladie  des  tics  convulsifs.  We 
shall  have  occasion  to  speak  of  them  in  our  chapter  oa 
hysteria. 

iEtiology.— We  know  little  about  the  a:tioIogy  of  blepharo- 
spasm. That  it  may  be  of  reflex  origin  can  not  be  doubted. 
The  most  varied  discises  of  the  eyes,  affections  of  the  nasal 
mucous  membrane,  or  of  the  trigeminus,  especially  tic  doulou- 
reux, carious  teeth,  intestinal  worms,  or  uterine  troubles,  may  ■ 
lie  at  the  bottom  of  it,  and  the  origin  of  the  disease  is  cleared 
up  only  if,  after  removal  of  some  primary  cause,  the  spasm 


I 
I 


DISEASES  OP  THE  FACIAL  NEKVE. 


8f 


^■tiddcnly  ccn<ic!>.     An  examination  of  (lie  ni>sc  shonid  never  be 

^neglected.     Il  has  repeatedly  been   noted  that  the  tic  disa)>- 

jicarcd  alter  swellings  or  tumors  ol  the  miicoii<i  membrane  o( 

Ilhc  nose  h;id  been  removed  (B.  Friinkcl.  Pcllewihn), 
I    saw  a  case  of   blepliarospasm,   which  hnd  persisted  (or 
fears  and  was  considered  hopeless,  cured  after  a  coexisting 
■exion  of  the  uterus  had  been  materially  improved.     Diseases 
n  the  blood-vessels  can.  furthermore,  produce  the  spasm,  as 
we  see  from  the  case  of  Uuss  ii:.\.  Hi.),  where  an  atheromatous 
i,»rtcry,  and  from  that  of  F.  Schultzc.  where  an  aneurism  of  the 
\\.  vertebral  artery  by  pressure  upon  ihe  facial  nerve  brought 
[tin  the  spasm.     Finally,  hystericil  conditions  can  lead  to  it.  as 
(h  shown  by  the  latest  communications  of  Charcot  o»  the  so- 
I  oiled  hemispasmus  glosso-labialis.  which  has  been  described 
by  Marie  (Progrfes  m£d.,  June  6.  1887). 

Treatment. — .All  these  points  we  must  keep  in  mind  in  de. 
dding  upon  a  line  of  treatment,  and  not  imagine  that  we  can 
ture  a  facial  spasm,  whether  it  be  total  or  partial,  clonic  or 
tD&ic,  with  indiscriminate  galvanization,  for  without  system  we 
shall  only  meet  with  success  in  rare  cases,  and  then  only  by 

kgnod  luck.  The  mosi  promi:4,iiig  plan  of  Ireatiiient  i«  the  appli- 
atiiinof  the  anode  to  pressure  points  if  such  be  present,  while 
Ihealhodcis  pl.iccd  on  some  indiderent  region,  the  back  of 
the  neck  or  the  sternum.  Weak  currents  applied  lor  one  or 
1*0  minutes,  with  careful  avoidance  of  make  and  break,  give 
the  best  results.  The  application  of  the  anode  to  the  back  ol 
flwhcacl.  keeping  it  at  the  same  point,  also  sometimes  meets 
•ilh  success  (Berber),  but  too  altcn  leaves  us  in  the  lurch; 
and  Ihit  will  hardly  surprise  us  if  we  remember  that  even  when 
tbt  mode  is  placed  on  the  back  of  the  neck  the  abnormally 
simulated  reflex  centre  in  the  medulla  is  by  no  means  always 
'Mclied  by  those  curves  of  the  current  which  really  do  pene- 
tote  deeply. 

Cures,  such  as  that  reported  by  Berger,  undoubtedly  de- 
Pnid  upon  a  happy  coincidence  of  circumstances.  The  me- 
^1  oblongata,  above  all,  where  in  such  an  astonishingly  small 
•pKca  number  of  the  most  important  nuclei  lie  close  together. 
*«»»  lo  be  the  most  unfavorable  place  for  local  electrization 
'fbckcnnc),  by  which  we  aim  at  affecting  individual  nerves  or 
■wtc  mots.  We  may  reach  all  or  none,  no  matter  whether  we 
UKimall  or  large  electrodes.  Still,  even  this  method  ought  to 
be  (tied,  since  we  have  no  positive  remedy.     Should  the  gaU 


S2  DISEASES  OP  THE  VKANiAL  .VEXfES.  ^ 

vanic  treatment  fail,  the  internal  treatment  is  still  mure  vague, 
and  it  is  well  to  inform  the  patient  of  the  uncertainty  of  this 
procedure.  Ol  course,  ttic  usual  nervines  and  antispasmodics 
are  to  be  given.  Hammond  has  seen  especially  favorable  re- 
sults from  the  use  of  coniin  and  alropin  (Med.  Record,  No.  41, 
September,  tSy;).  As  a  last  resort,  neurectomy  ol  the  supra- 
orbital or  stretching  of  the  facial  nerve  (Bernhardt,  cf.  lit.)  has 
to  be  considered,  yet  even  from  this  we  can  expect  no  lasting 
success. 

UTERATUKE. 

Bergtr.     NeuruloK-  Ccntralbl..  10,  1883. 

Bernhardt.     An:h.  f.  Psych,  und  Ncrvciiktankh..  xv,  j,  tSA^. 

Busa.     Neurol.  CenimlbL.  14.  1886, 

Hensclicn.    Keurtiatick  lie  convuUif  med  thnioeking  arnervj  rAci.-iliti  sum. 

ul.i  lilkareforcn.  Uirh.     1887,  xxiii,  3. 
Ctiilion.     Tic*  convulsifs  ct  hyrtfric     Revue  <!c  mill..  June,  1877. 
Cf.  bc^ci  the  Icxt-books  of  StriiinpcU,  Scciiginulter.  EichhorM.  Eulcnbutt^.  etc. 

2.  Facia],  Paralysis— Mimic  Facial  Paralysis— Hemi- 
pi.KGJA  Facialis — Prosopoplkcjia. 

Facial  paralysis  is  an  affection  the  relative  frequency  of 
which  makes  it  of  the  greatest  practical  importance.  In  this 
more  than  in  any  other  nervous  disease  any  Liyman  can  easily 
judge  just  how  much  the  art  of  the  physician  has  accomplished 
in  a  cfitain  time  in  a  given  case,  and  on  this  account  it  espe- 
cially behooves  us  at  our  first  examination  to  be  very  careful 
in  making  a  positive  statement  as  to  the  prospects  of  recovery 
or  the  probable  duration  of  the  disease.  Both  these  points  de- 
pend chiefly  on  the  seat  of  the  lesion,  which,  as  in  tic  convulsil. 
may  be  central  or  peripheral. 

A.   CKNTUAI.   KACIAI.   PARALYSIS. 

Symptoms  and  Diagnosis. — Central  facial  paralysis  may  be 
produced  either  by  a  cortical  lesion  (cortical  paralysis)  or  by  a 
lesion  of  the  facial  fibres  in  the  brain  between  the  cortex  and 
the  pons  (intracerebral  paruiy sis  /nir  rrceUfficf):  or.  finally,  it 
may  depend  upon  a  disease  of  the  nuclei  and  nerve  roots  in  the 
pons.  Corticil  facial  palsies  may  be  caused  by  tumors,  ab- 
scesses, or  chronic  inflammations  in  the  region  of  the  motor 
centres.  Those  ol  intnicerebral  origin  may  be  produced  by  I 
syphilitic  arterial  disease  or  by  rupture  of  a  vessel  in  the 
region  of  the  internal  capsule  and  the  crus  cerebri.     The  third 


DISEASES  OF   THE  FACIAL   NERVE. 


83 


i 


^ 


I 


form,  that  originating  in  the  pons,  is  found  in  Duchennc's 
paralysis  and,  more  rarely,  in  tabes.  There  exists  a  lorm  o( 
iacial  paralysis  the  pathology  and  the  seat  of  which  is  as  yet 
very  obscure,  and  we  can  only  say  that  prolxibiy  a  "  nervous 
predisposition  "  is  necessary  for  its  development.  It  may  oc- 
cur in  several  members  o(  the  same  family,  may  be  congenital, 
and  may  be  associated  with  paralysis  in  the  region  of  the  sixth 
nerve  and  of  the  trigeminus.  It  sets  in  without  any  appre- 
ciable cause,  is  wont  to  recur,  and  may  last  for  an  indt'fiiiite 
period  of  time:  probably  its  anatomical  scat  is  in  the  nucleus 
(•■  infantile  degeneration  of  the  nucleus,"  MObius),  but,  as  was 
said  above,  this  is  by  no  means  proved.  It  is  quite  possible 
thai  some  cases  may  have  a  peripheral  origin,  as  is  the  case  in 
the  recurrent  oculo-motor  paralysis  (of.  page  50). 

The  clinicil  picture  differs  but  little  in  these  three  forms, 
and  only  at  times  do  the  accompanying  symptoms  make  a  dif- 
ferential diagnosis  possible.  Thus,  for  instance,  the  intracere- 
bral  paralysis  often  appears  with  an  apoplectic  attack,  and  is 
iccompanied  by  hemiplegia  and  speech  disturbances,  while  if 
facial  paralysis  is  found  in  connection  with  spinal  disease  it  is 
Always  of  nuclear  origin. 

All  three  forms  oi  central  paralysis  have  usually,  however, 
two  features  in  common  which  can  almost  be  regarded  as 
pathognomonic  and  which  distinguish  them  from  the  periph- 
eral paralysis,  namely  :  1.  The  presence  of  a  normal  electrical 
excitability  in  the  nerves  and  muscles  to  both  currents.  2.  The 
escape  of  the  upper  facial  branch.  While  in  peripheral  paraly- 
Its  all  three  divisions  arc  equally  adccled.  we  lind  in  the  cen- 
tral form  the  upper  branch  usually  intact,  and  the  patient  can 
■rinkle  his  forehead  and  close  both  eyes. 

Wc  say  usually,  not  always,  because  there  are  undoubtedly 
exceptions,  where  wc  meet  with  a  central  paralysis  in  which  the 
upper  branch  has  not  been  spared.  It  is  quite  probable  that 
the  naso-labial  and  the  orbiculo-frontal  fibres  of  the  facial  have 
1  separate  cortical  origin,  and  we  can  well  imagine  that  if  the 
cause  of  the  paralysis — e.  g.,  a  small  focus  in  the  cerebrum — is 
iftiuted  above  the  union  of  those  two  branches,  one  remains 
intact  (in  the  large  majority  of  cases  the  upper),  whereas  if  it  is 
bdow  their  point  of  union  both  branches  are  affected. 

A  further  guide  to  localization  is  the  condition  of  the  move- 
ments of  expression  (Bechterew).  If  these  arc  lost  while  the 
Toluntary  innervation  ol  the  iacial  muscles  is  intact,  we  have  to 


84 


D/SKASfCS  Of   THK   CRAKIAL   NERVKS. 


assume  a  focus  in  ihe  opiic  thalamus,  the  centre  for  facial  ex- 
pressions, or  close  to  it  (Bcchtcrcw),  while  a  faoinl  paraly&is 
with  rcUiined  power  of  f:iciul  expression  allows  us  to  exclude  a 
lesion  in  the  thalamus  and  its  coronal  connection  with  the  hemi- 
spheres. In  the  case  of  Kosenbach  (Neurol.  Cenlralblatt,  n. 
lS86)therc  was  an  isolated  paralysis  o(  mimic  expression  in  the 
left  facial  and  right-sided  bilateritl  tiemiai)opia,  and  the  lesion 
was  taken  to  be  in  the  right  thalamus. 

In  differentia  ting  tR-lween  a  cortical  and  a  bulbar  facial  pa- 
ralx'sis  the  lollowing  points  must  be  taken  into  c<itisideraiion  : 
Thai  the  lesion  is  cortical  is  probable  if  Ihe  facial  alone  with- 
out the  corr<Mipondi»g  halt  of  the  body 
is  panilyzed  (monoplegia  facialis),  and 
if  Ihe  affection  is  confined  to  the  lower 
brandies  of  the  nerve,  while  the  nor- 
mal reaction  to  the  electrical  current 
remains  undisturbed.  It  is  easy  lo 
undcrsiatiri  that  the  hypoglossua  often 
takes  part  in  the  lesion  if  we  remember 
in  how  close  proximily  the  centres  of 
the  two  nerves  are  situated  in  the  cor. 
tex.  and  in  a  given  case  an  examination 
of  the  mobility  of  the  tongue  will  show 
whether  we  actually  have  to  deal  with 
a  so-called  monoplegia  facio-lingualis. 
Sometimes  a  disturbance  of  s|>cech 
points  at  once  to  this  combination.  In 
every  case  in  which  we  assume  a  cor- 
tical lesion,  the  sensation  in  the  distri- 
bution of  the  facial  and  the  hypoglossus 
ought  to  be  tested,  because  it  is  just  in 
these  cases  that  wc  find  not  infrequently 
sensory  changes — e.  g .  analgesias  and 
nnsesthcsi.is. 

We  shall  be  led  in  a  facial  paraly- 
.sis  to  think  ol  an  affection  of  the  pons 
when  not  only  the  nerve,  but  with  it 
one  whole   half  of  the   body   is  para- 
lyzed :  and  there  are  two  types  of  pon- 
tine facial  paralysis  according  as  the  lesion  is  situated  in  the 
upper  or  lower  part  of  the  pons,     In  the  first  case  (focus  a  in 
Fig.  14)  the   facial  and  the  same,  in  the  second  (focus  *)  the 


fif.    14.— OUORAM   miOWINO 

TiiK  OncvauTtOH  or  thi 
FiMiia    ootira    ttt  mx 

EXTHKMiriKII,  AKD  Of 
TIKm      OOIMC      TO      Tint 

Pack,  im  riiE  Pnvn  amd 

tlCblrLLAODLOXr.JtTA.    F, 

(«cial  iibm.  B.  fibm  p>- 
iiiK  (II  llic  ninmllic*.  P, 
piiiw,  O,  mtilulU  otilen- 
(lU.  fyx.  decuMMtna  o( 
Uie  prranildi)  tncU.  a,  ■ 
focun  In  the  upp*r.  i.  a 
(ocu*  ill  Uie  lonei.  put  ol 
tilt  poiu  (thi  bitcr  U  iltu- 
M«l  below  tlie  ibcuMMUon 
o(  Ihr  facial  fibmi. 


DJSEASEft  OF  Tl/B  FACIAL  XEKVB. 


ss 


I 


I 


facial  and  the  opposite  lialf  of  the  body  arc  uflcclcd  (hemiplegia 
altfrniins,  Gubler,  itt;9),  because  i)ie  facial  fibres  cross  in  the 
puns  ami  we  may  have  a  lesion  above  or  below  this  crossing, 
and  in  both  cases  thi^  will  be  siiiiated.  ol  course,  above  the 
crtwsing  of  the  fibres  going  to  the  extremities. 

The  facial  paralysis  caused  by  the  lesion  in  the  upper  pnrl 
of  the  pons,  and  that  found  in  connection  with  hemiplegia  after 
«  lesion  in  Ihe  internal  capsule,  arc  in  so  far  alike  as  they  arc 
boib  accompanied  by  paralysis  of  the  extremities  on  the  same 
side.  But  (here  is  one  point  of  difference  which  will  influence 
our  diagnosis,  namely,  that  after  pontine  lesions  the  facial  pa- 
ralysis, very  much  as  in  the  peripheral  form,  takes  in  all  three 
branches  of  the  nerve,  while  in  a  lesion  of  the  capsule  or  the 
basal  ganglia  only  (he  lower  branches  of  the  nerve  arc  affected : 
but  in  contradistinction  to  what  happens  tn  the  peripheral 
paralysis  the  electrical  condition  may,  ai  least  in  some  cases, 
rvmain  normal. 

The  mosi  striking  symptom  of  centra!  facial  paralysis  is  the 
relaxed  and  ex  press  ion  le-ss  appearance  o(  the  affected  side. 
The  rwso-labial  fold  is  more  or  less  distinctly  flaliened.  the  cor. 
Dcr  of  (he  mouth  is  slightly  open  and  hangs  down,  the  mouth 
leeins  to  be  drawn  to  the  well  side,  the  patient  is  unable  to 
rat»e  his  upper  lip  or  to  whistle.  On  inllating  the  cheeks  ihe 
air  escapes ;  drinking  and  speaking  are  difficult,  the  latter  espe- 
cially, because  the  labial  sounds  are  defectively  formed.  Dur- 
ing  eating  the  food  gets  in  between  the  cheek  and  the  teeth  on 
Ihe  allectcd  side,  and  the  patient  has  to  bring  it  lo  the  right 
place  again  with  the  lingers.  In  biting,  the  mucous  membrane 
of  Ihe  check  is  often  caught  between  the  teeth.  The  upper  p:irt 
oJ  the  face  is  in  by  far  the  greater  number  of  ciscs  normal ;  the 
forehead  can  be  wrinkled  well  in  its  whole  extent,  and  the  pa- 
tient can  frown  and  close  either  eye  perfectly. 

The  condition  of  the  velum  palati  and  the  uvula  varies,  and 
in,  therefore,  ol  no  value,  either  diagnosiically  orprognoslically. 
The  uvula  may  deviate  to  the  sound  or  to  the  affected  side. 
Of  mav  occupy  its  norm,*)!  position.  With  our  still  im;»erfccl 
btuwlcdge  of  the  innervation  of  the  muscles  concerned,  any 
attempt  to  explain  the  different  pc^silions  of  the  uvula  must 
t>cedh  be  hard,  but  we  sh.ill  be  less  surprised  at  our  difTiculty 
when  wc  consider  that  the  levator  pal.ili  is  supplied  not  only 
by  the  facial  through  the  large  superficial  petrosal,  but  very 
probably  also  by  the  vagus  accessory,  the  tensor  palati,  how- 


86 


DfSEASSS  OF  THK  CKANIAL  HEKVES. 


ever,  by  the  third  branch  of  the  fifth.  In  other  words,  at  least 
three  cranial  nerves  arc  concerned  in  the  motion  and  fixation 
of  the  uvula,  and  besides,  even  under  normal  condtllons,  the 
uvuta  is  occasionail)'  found  to  deviate  to  one  or  the  other  side. 
The  only  thing  of  which  wc  can,  perhaps,  be  sure  is  that  if 
during  phonaiion  paresis  of  the  velum  palali  and  deviation  to 
the  sound  side  becomes  apparent,  the  large  superficial  petrosal 
is  most  likely  affected  (paralysis  of  the  levator  palati  and  azygo? 
uvula;).  Of  greater  importance  lor  the  diagnosis  of  centra!  facial 
paralysis  is  the  persistence  of  the  reflexes,  which  in  peripheral 
paralysis  arc  often  diminished  or  sometimes  completely  lost. 

Furthermore,  the  disturbances  in  hearing,  the  alteralions  in 
taste  and  in  the  salivary  secretion,  so  frequently  observed  in  the 
latter,  are  almost  always  absent  in  central  affections. 

The  existence  of  a  bilateral  facial  paralysis — diplegia  facialis 
— points  as  a  rule  to  a  central  lesion,  and  more  especially  to  a 
bulbar  affection.  It  certainly  is  one  of  the  greatest  rarities  lo 
have  a  simultaneous  paralysis  of  both  as  the  result  of  a  periph- 
eral lesion. 

Prognosis — The  prognosis  depends  upon  the  anatomica} 
basis  of  the  disease,  lesions  of  the  cortex  and  the  pons  often 
bring  about  facial  paralyses  that  arc  incurable,  while  those  ob- 
served in  conjunction  with  cipsular  hemiplegias,  especially  in 
the  eartv  stages  of  the  latter,  frequently  present  a  decided  im- 
provement after  a  time.  .As  was  staled  above,  it  is  impossible 
in  the  cases  which  depend  upon  a  neuropathic  predisposition 
to  make  any  statement  either  with  reference  to  duration  or  with 
reference  lo  a  possible  recurrence  of  the  trouble. 

Treatment— The  question  of  treatment  arises  only  when 
the  primary  lesion  is  amenable  to  therapeutic  measures.  Since 
this,  however,  is  only  very  rarely  the  case,  it  is  best,  at  Icist  in 
the  central  facial  paralysis,  to  restrict  ourselves  lo  the  expecN 
ant  treatment.  The  measures  that  will  be  recommended  as  in- 
dicated in  the  peripheral  form  are  here  of  very  little  avail. 

n.   I'KKirilERAL  FACIAL   PARALYSIS. 

In  its  peripheral  course  the  facial  may  be  divided  into  two 
portions — an  intracranial  and  an  extracranial.  The  former  is 
lew  frequently  affected  than  the  latter,  which  is  more  ex- 
poted  to  atmospheric  influences,  especially  cold.  For  prac- 
tical reasons  %vc  prefer  to  consider  the  diseases  of  these  two 
•egtncntft  neparately. 


j>/seAsss  Of  TiiF.  facia!.  NRRX'K. 


87 


1.    Thf  iHlraeranial  lesion. 

This  form  is  dislinguislied  by  tlic  (act  that  besides  the  con< 
&tant  existence  ul  paralysis  of  all  the  facial  branches,  we  have 


xs—txtt*  DlwilUH  Fcni  FAi'tAt.  pAKALveis,  Ktrmsollni;  lh«  onuraf  of  ihp  fidal 
jtnak  fcom  tlw  bata  of  ih«  iliull  in  ih«  pc*  miutriDin.  ;V.  a.,  audiionr  nr«TT.  A'.  /., 
tol  »n*r.  A',  /.  1..  \iat:f  topFtficUl  pvlronl  nirrvt.  C  /..  E"iim<'>'  cangUoa. 
K.  t.  t.  f.  {.,  omoiunidtinc  bniiidi  tii  IjrmiMiiic  ptnu).  A',  tl..  ilupnliiu  iwrve. 
Ct.  /„  dla«da  Ipnpani,  G. /,.  i-tMUUnr  lilin*-  Sft,.  ■rcnui«T  iwrre  (o  nllmy 
(lia^    f,  tt.,  myto-mtiloU  formmrD.    X.t.f,,  poaurkit  audnilat  tnnt, 

odcn  certain  concotiiitnnt  symptoms,  which  can  only  be  fully 
understotxl  it  wc  picture  to  ourselves  the  exact  course  of  the 


88  DISEASES  OF   THE   CRANIAL  NERVES, 

nerve.  This  can  be  done  with  the  help  of  the  diagram  (taken 
from  Erb)  here  represented,  which  permits  an  accurate  locali- 
zation of  any  given  intracranial  lesion. 

{fi)  [f  the  lesion  be  between  the  exit  of  the  facial  stem  (from 
the  pons)  and  the  geniculate  ganglion,  we  shall  find  a  paralysis 
of  the  velum  palati,  abnormal  acuteness  of  hearing,  and  dimin- 
ished salivary  secretion. 

(*)  U  the  facial  be  affected  in  the  region  of  the  geniculate 
ganglion  itself,  then  we  find  in  addition  to  the  just-mentioned 
symptoms  alterations  in  the  sense  of  taste. 

((■)  A  lesion  between  the  geniculate  ganglion  and  the  stape- 
dius nerve  produces  the  symptoms  described  in  a  and  b,  but  no 
abnormality  of  the  velum  palati. 

((/)  A  lesion  between  the  origin  of  the  nerve  to  the  stape- 
dius muscle  and  the  giving  off  of  the  chorda  tympani  gives 
alterations  in  the  sense  of  taste  and  diminishes  salivary  secre- 
tion, but  no  abnormality  of  hearing  or  of  the  velum  palati. 

if)  If.  finally,  the  nerve  is  diseased  below  the  giving  off  of 
the  chorda,  in  the  Fallopian  canal,  we  only  find  paralysis  in  the 
distribution  of  the  posterior  auricular  branch  without  any 
trouble  with  taste,  hearing,  the  condition  ol  the  velum  palati, 
or  the  secretion  of  saliva.  We  should  state  again,  however, 
that  in  all  cases  from  a\Xi  e  all  the  facial  branches  take  part  in 
the  paralysis. 

Valuable  as  this  diagram  is,  undoubtedly,  regarded  from  a 
theoretical  stand-point,  yet  in  practice  we  but  rarely  meet  with 
opportunities  for  observing  cases  which  exactly  correspond  to 
it ;  nevertheless,  in  every  instance  we  should  not  fail  to  attempt 
to  Uxrate  the  lesion  with  as  much  accuracy  as  possible. 

A  physiological  explanation  for  the  appearance  of  the  above- 
mentioned  ciincomitant  symptoms  is  not  always  easy.  That 
alterations  in  the  sense  of  taste  are  due  to  lesions  ol  the  chorda 
tvmpani  can  not  be  doubted,  and  if  they  are  present  the  lesion 
is  situated  fjctween  the  geniculate  ganglion  and  the  giving  ofi 
of  the  chorda  :  if  thev  are  absent  the  lesion  must  be  sought 
below  this  region.  The  disturbance  in  the  sense  of  taste  is 
limited  to  the  anterior  two  thirds  ol  the  tongue,  and  exists,  of 
o>urse.  only  on  the  paralyzed  side.  Sensory  changes  \a  the 
tongue  are  not  necessarily  present.  Less  clear  is  the  cause  of 
the  diminished  salivary  secretion.  Its  occurrence  is  said  to 
p<.iint  to  a  lesii^n  above  the  geniculate  gaogHoa  (WacfasmuthV 
Mendel  has  obseni-ed  increased  salivary-  secretioii  in  an  instance 


D/SS4SES  OF  THE  FAVIAL  .VERVE. 


89 


in  which  it  was  also  diflfictilt  10  find  an  adequate  physiological 
explanaliun  (Neurot.  Ceiitralblftli,  11^90,  16). 

Amung  the  most  common  and  best  known  symptoms  arc  the 
dtsturbanccs  in  hearing,  which  consist  cither  in  an  abnormal 
Acutencss  of  hearing  (hypcractisis,  oxyacoia)  or  in  a  decrease 
in  the  power  of  hearing.  In  the  first  case,  where  we  have  a 
kind  of  hypeneslhcsia  for  alt  musical  tones,  the  alteration  is 
supposed  to  be  due  to  a  panilysis  of  the  stapedius  mu&cle  (which 
it  supplied  by  the  facial)  and  a  consequent  ovcractinn  of  the 
Icnsur  lympani  I.Luc;ic.  Ilitzig,  Rous).  The  latter — the  hard- 
ness of  hearing — can  be  due  10  several  causes.  We  may  either 
have  a  disease  of  the  middle  ear  and  the  adjoining  portion  ol 
ihc  temporal  bone,  which  has  aflcctcd  the  facial  nerve  by  con- 
ifguily,  or  a  simultiinei>us  aScction  of  the  auditory  nerve,  which, 
in  ihc  inrernal  auditory  meatus,  has  been  exposed  to  the  same 
delelerious  influence,  and  become  affected  by  the  same  disease 
as  the  facial.  Quite  lately  again  the  frequency  of  this  combina- 
tion of  facial  paralysis  with  a  slight  paralysis  of  the  auditory 
nerve  bait  been  pointed  out  by  U.  Koseiibach  (cf.  lit.). 

s,  Tkt  Exlrotramal  Lesion. 

The  peripheral  paralysis  of  the  facial  after  its  exit  from  the 
skull  is,  as  we  have  already  said,  the  most  common.  Ol  this 
class  ihc  so-called  rheumatic  form,  which  is  attributed  to  the 
influence  ol  cold  (  a jrigvri).  and  the  traumatic,  often  observed 
alter  operations,  gunshot  injuries,  etc.,  or  which  may  be  caused 
by  the  pressure  of  impacted  cerumen  in  (be  car  and  mastoid 
cells  (Dalbey,  New  York  Med.  Journal.  Iiv.  3.  l8ql).  arc  the 
two  chief  representatives.  When  any  one.  heated  as  he  is. 
passes  from  a  warm  room  into  a  cold  wintry  night,  or  is  ex- 
posed to  draughts  in  the  r.tilroad  cars,  and  hnds  himself  a  few 
hours  later  taken  with  a  paralysis  of  one  side  of  the  face,  this 
ill  ihc  ^o-callcd  rheumatic  form  which  has  attacked  Ihc  stem  of 
the  nerve  alter  its  exit  from  the  Fallopian  canal.  Dut  the  influ- 
ence of  cold  in  such  instances  must  be  regarded  only  as  the 
precipiuiting  cause  in  individuals  with  a  neuropathic  predis- 
position (Neumann.  Arch.  d.  Ncurolc^ie,  July.  1S8;.  xiv.  40). 

In  these  cases  all  three  facial  branches  arc  affected,  and  the 
appearance  ol  the  patient  is  changed  in  a  very  material  and 
linking  manner.  Rvcn  the  layman  notices  that  the  patient 
now  wrinkles  only  one  half  of  his  forehead,  and  that  the  folds 
aiid  furrows  generally  present  are  obliterated  on  one  side  :  that 


90 


D/SEASSS  OF  TflE  CkANIAL  NEKVES. 


be  can  shut  one  eye  only  while  the  other  remains  wide  open  and 
can  not  be  closed  despite  the  strongest  eflorts.  If  the  attempt 
is  made,  the  eyelids  remain  gaping,  the  eyeball  is  rolled  inward 
and  upward,  and  the  pupil  disappears  behind  the  upper  lid,  a 
position  which  is  also  maintained  during  sleep  (lagophthalmos). 
The  inability  to  shut  the  lids  prevents  the  tears  from  running 
into  the  tear  ducts  and  interferes  tvith  the  process  by  which 
foreign  bodies,  particles  of  dust  and  the  like,  arc  removed  from 
the  eye.  It  happens,  then,  that  the  tears  arc  always  running 
down  the  cheeks,  and  that  a  conjunctivitis,  even  an  ulceration 
of  the  cornea,  may  be  developed  through  the  mechanical  irri- 
tation caused  by  such  foreign  bodies.  The  appearance  of  the 
lower  part  of  the  face  has  already  been  described.  In  mild 
cases  the  tongue  does  not  deviate  at  ail :  in  grave  cases  it  is 
turned  toward  the  well  side  (Hitzig.  cf.  lit.)- 

It  is  interesting  to  note  that  in  the  first  stage  of  rheumatic 
facial  paralysis  the  patient  often  complains  of  pains  the  inten- 
sity o(  which  seems  to  be  proportional  to  the  degree  of  the 
paralysis.  These  arc  usually  localized  in  front  or  behind  the 
ear  and  radiate  toward  the  forehead,  the  temple,  and  the  cheek : 
sometimes  they  last  but  a  few  days,  in  other  cases  they  persist 
tor  weeks.  They  must  be  referred  to  an  affection  of  sensory 
branches  belonging  to  the  trigeminus. 

The  hyperidrosis  associated  with  facial  paralysis,  as  ob- 
served by  Windschcid  (Miinchencr  mod.  Wochcnschr.,  xxxvii. 
$o,  1890),  as  well  as  the  frequently  noted  puSine&s  and  the  porce- 
lain-like induration  of  the  aflecled  side  associated  with  vascular 
dilatation  and  elevation  of  temperature  (von  Friinki  Hochwan, 
Deutsch.  mcd.  Zig.,  1891,  35).  show  thai  vaso-motor  fibres  are 
also  implicated  in  facial  paralysis.  I  have  observed  the  appear- 
ance of  CL-dematous  swcllin<{  especially  in  the  recurrent  forms. 
The  implication  of  trophic  fibres  is  shown  by  the  not  rare  oc 
currcncc  of  herpes  zoster,  which  has  recently  been  described 
by  l-etullc,  Strllbing.  Voigt,  and  Perrin  (cf.  lit.).  Whether 
this  is  due  to  an  inflammation  of  the  peripheral  endings  of  ihe 
fifth,  which  is  transmitted  to  the  facial  (Strilbing).  or  whether 
the  stem  of  the  facial  contains  in  parts  fibres,  an  inflammatory 
irritttion  of  which  m-iy  produce  herpes  zoster  (Eulcnburg),  (s 
oot  clear. 

I  have  only  in  rare  instances  seen  this  complication,  and 
have  found  that  whenever  it  was  present  the  cases  pursued  an 
niuuiully  protracted  course. 


D/SHMSes  OF  THE  FACIAL  S'KRl'F.. 


9' 


^ 


N 


I 
\ 


Duration  and  Course.— The  duration  and  course  of  rheu- 
tnalic  facial  paruly5i<i  arc  extremely  variable,  and  it  is  of  great 
importance  for  the  physician  to  be  able  tu  give  nt  the  begin- 
HQg  an  approximately  accurate  opininn  a^  to  the  length  of  time 
ry  for  recovery.  This  we  can,  however,  only  do  il  we 
investigate  the  electrical  condition  of  the  paralyzed  muscles, 
ud  hence  it  follows  that  it  should  be  our  invariable  rule  to 
Bake  an  electrical  examination  before  venturing  upon  any 
<x]>ression  of  opinion.  The  following  are  the  chief  points  to 
piidc  us: 

I.  If  we  find  no  changes  either  in  faradic  or  in  galvanic  ex- 
cital>iliiy  the  prognosis  is  favorable  ;  recovery  in  from  seven  to 
twenty  days  (light  form). 

1.  If  we  f^nd  the  faradic  and  galvanic  excitability  of  the 
ncrre  diminished,  but  not  lost,  the  galvanic  excitability  of  the 
auKlcs,  however,  increased,  and  the  usual  formula  of  contrac- 
IMB  changed  {A.  C.  C.  >  C.  C.  C).  then  the  prognosis  is  rela- 
livcly  favorable  ;  recovery  in  from  four  to  six  weeks  (intcrme- 
diue  lorm  of  Erb). 

5.  If  the  reaction  of  degeneration  be  found — i.  e..  if  the  far- 
adiciitd  galvanic  excitability  of  the  nerve  and  the  faradic  ex- 
ciiabiliiy  ol  the  muscles  be  lost,  while  there  is  an  increase  in 
Ik  fralvanic  excitability  of  the  muscles  associated  with  quali- 
tative changes  and  changes  in  the  mechanical  excitability — then 
the  prognosis  is  relatively  unfavorable,  and  for  recovery  two, 
iMr,  six,  eight,  even  twelve  months,  may  be  required  (gnive 
V""'  These  arc  those  bad  cases  in  which  secondary  con- 
tectures  and  spasmodic  twitchings  of  the  muscles  also  appear, 
*hJch,  according  to  I  litzig's  opinion,  arc  to  be  referred  to  an 
objure  abniirmai  irritation  in  the  medulla  oblongata.  It  is 
*cll  ro  know  that,  as  convalescence  begins,  voluntary  motion 
lur  return  long  before  the  electrical  excitability,  so  that  often 
llic  patient  is  able  to  perform  some  slight  voluntary  movements 
Mure  laradic  stimulation  provokes  the  leai^t  contraction. 

The  palholtigical  changes  have  been  studied  by  Minkowski 
(Berliner  klin.  Wochenschrjfl.  iSyi.  27).  and  quite  recently  by 
Oarkschewilsch  and  Tichonow  (Neurol.  Cenlralblatt.  1893,  10). 
The  tatter  found  a  jKirenchymittous  neuritis  in  the  peripheral 
portion  ol  the  nerve,  and  in  the  central  portion  the  signs  of 
lecondary  degeneration,  with  many  perfectly  atrophied  libreg  \ 
the  nuclei  also  the  signs  ol  a  well-marked  atrophy  were 
nt. 


92  ■  /f/SSASes  Of  THE  CKAXIAL  NERl'BS.  ^H 

1 

Diagnosis. — With  regard  tu  the  diagnosis  there  is  even  (or| 
the  beginner  no  more  easily  recognizable  disease.  Slill,  therej 
arc  casts  whi-rc  it  is  difficult,  not  to  s-iy  whether  there  is  any; 
paralysis,  but,  strange  as  it  may  sound,  which  is  tnc  alTectedi 
side.  One  is  particularly  liable  to  mistakes  in  old  people,  iul 
whom  the  wrinkled,  inelastic  skin  has  produced  a  stereoty|»ed 
expression,  which,  even  when  the  facial  muscles  contract,  isi 
but  little  changed.  Suppose  now  the  muscles  to  have  lost  their' 
innervation,  the  paralyzed  side  lakes  on  ilic  soft  fcamrcs  of  an 
earlier  period  of  life,  aiid  this  may  go  so  far  thut  the  patient) 
believes  his  rigid,  wrinkled  side  to  be  the  paralyzed,  and  iho; 
affected  side  the  healthy  one  (Gowers).  \Vc  also  must  remcm<i 
bcr  that  the  non-paraly/cri  zyiromatici  pull  the  (ace  sharply] 
toward  the  well  side,  a  condition  which  easily  produces  in  the 
layman  the  impression  of  somclhing  nbtinrmal,  so  that  he  takcft 
the  side  thus  distorted  for  the  dist-ased  one.  In  general,  how» 
ever,  we  may  say  that  the  diagnosis  of  a  peripheral  facial  p»«, 
ralysis  is  one  <i(  the  easiest  imaginable  in  ncuro]>;ithology. 

Treatment. — In  the  treatment  we  m,iy  in  recent  cases  rec- 
ommend tor  trial  steam^baths  and  counter-irritation  to  the  skin  j 
but  never,  unless  there  is  a  special  indicalion.  should  iniernall 
remedies  be  advised,  because  in  a  non-com  plica  ted  rheumatic 
facial  paralysis  they  are  absolutely  superfluous.  In  more  pro* 
tracted  cases  the  methodical  use  of  electricity  is  strongly  indi^ 
caied,  (or  even  though  it  is  tnidoubtedly  true  that  the  disease^ 
if  the  prognosis  is  at  all  favorable,  gets  well  of  its  own  accord^^ 
and  really  requires  no  treatment  at  all,  there  can,  on  the  nihen 
hand,  be  no  doubt  but  that  the  electrical  treatment  hastens  the'; 
cure  in  n  marked  degree:  therefore,  electricity  should  be  used' 
under  all  circumstances.  Just  which  method  should  be  em." 
ployed  can  not  be  definitely  laid  down,  but  we  shnuld  keep  ini 
mind  that  not  only  the  galvanic  current  is  beneficial,  but  thatj 
the  faradic  brush  applied  to  the  stem  and  the  individualj 
branches  of  the  facial  gives  good  results,  and  the  ]>alienti 
should,  therefore,  be  persuaded  to  submit  to  this  sonicwhatl 
disagreeable  procedure.  The  places  from  which  the  most  im- 
portant facial  muscles  can  best  be  stimulated  are  seen  in  Fig, 
16.  At  these  points  the  molor-ncrve  branches  to  the  muscles 
concerned  lie  very  near  the  surface.  They  arc  called  "  motor 
points  "  (Xiemsscn).  In  galvanization  every  specialist  has  Ida 
pet  method  of  application  and  his  own  ideas  about  tlie  strcngtli 
and  direction  nf  the  current.     The  one  prefers  to  apply  the 


0/SEAS£S  Ofi  rtlE  FACIAL  NERVE. 


93 


electrode  over  the  mnstoid  proces».  placing  cither  the  anode  ur 
the  c:ilhf>de  on  (he  afTccted  side  of  the  face ;  another  treats  at 

he  same  time  the  sympathetic  in  the  iicck;  a  tliird.  again,  ap- 
plies the  anode  over  the  affected  nerve  and  the  cathode  lo  an 

ndiflerent  point,  and  so  forth.     Whichever  method  we  may 


Un>lmKko< 


Elcclono(th*MD- 


K«jiom  o(  the 
iipet<:li  centre. 

Upper  brinch  of 

F4ici'al  u«m. 

Middle  bruKh  ol  ttw  UciaL 


<K  amnorlui^ 


Supradarautar 

Kim    I  pla. 
■cli.t. 


f%.  tl— Sown  or  TKi  »<«i.LEi>  "UoTOK  Potvra"  oh  thk  Facs  ako  Nkck. 

pnltr.  the  main  thing,  after  all,  is  to  produce  by  repeated 
opcnitig  nml  closing  <if  llie  current  contractions  of  the  mus- 
<lnby  which  the  tonus  of  the  latlcr  will  soon  be  improved. 
Ith'xild  tike  to  mention,  loo,  that  t  have  seen  the  application 
"flbtfpilvanic  b^ush  and  the  use  of  the  combined  current  (de 
VCMIcwille)  repeatedly  atlendetl  with  satisfactory  results  (I  iirt, 
tefcrbuch,  etc..  toe.  at.,  p.  ro2  et  uq.). 


LrTKKATirKK. 

(WlUwit.      op.  iil .  pp.  Ji(>  ft  trq. 

IwiUt    Arelt  (k  I'hysiol.  !nic  »«r..  \\.  p.  66].  iSSj. 

ftitrtgrg.    Uebcr  Complicjllmven  von  pcr^phcrrr  Fnmliftlllhfnung  mil  ZoMer 
bdd    Centralhl  f  Nm-rnheillc.  ;.  iBSj. 


94 


D/SEASES  OF  THE  CHANIAL  JVEEI'ES. 


VoiKl.     reierehurger  med.  Wocheruchr..  ix.  4{.  iSSj. 

Kttnak.    Onluibl.  f.  Ncrrrnhdlk..  5.  1B85. 

Stnibttig.     Hcutsches  Arch.  f.  klin.  Med.,  ixxvii,  p.  513,  i88j. 

DarKuud.     De  I'h^niipljfjie  (acriale  iliins  lu  p^riode  Mcoodatre  de  b  sjrpbiic 

Thisedc  Paris.  1885,  No.  178. 
MUbitii.     Ccntralbl.  t  Ncrvcnhcilk..  ix.  7,  1885. 
Djuiuand  Wilkin.    Joum.  of  Mental  anJ  Nerv.  UiMaus.  Na  J.  1886. 
EJchhorst.     tiandbuch  drr  ftpccicllcn  Palliologie  und  Thcrapic,  Bd.  iii,  y    Aufl. 

WIen.  I  SB?. 
Ctiisolm.     Arch.  f.  Augeiihoilk..  xvii,  4.  p.  414.  1887.    (Congeniul  PnTalj-M*  of 

ihc  SixCh  nnd  Soenlh  Pair  q(  Cranial  Ncr\«,) 
Mendel.    Ueber  den  Kemutsprung  (le&  Augcnfacialis.     Neurol.  Ccniralbl,.  No. 

aj.  1887. 
Huet.     Hysterical   Facial    Paralyse.     Weckblsi)  v.  d.   Ncderl.  Tljdschr.  v. 

Ccneesk.,  2$.  1S87. 
Mi>biu«.      Ueber    die    angeborcne    doppclsdligt    Abducent- KacialiaUhmung. 

MOnchcnrt  mcd.  W<K:hen%chr..  188&,  86. 
Routland.     A  jirupoa  de  qut'lques  failx  <le  paralysie«  des  nouveau-njs.     Paris, 

Sieinheil,  1889. 
Foucher,     Dc  la  coniracturr  sccondaire  des  muscles  dc  b  face.     TUsc  de 

Pari^  1888. 
Slephan.     De  la  paral)-sie  bciale  des  nouvcau-nis.     Revue  de  mid..  1888.  7. 
Denioulin.     De  la  paralysie  fAciale  tardive  dam  les  fractures  tlu  tocher,     Gm. 

mii.  de  Paris.  July  14.  1888. 
VIziolL    On  Ihc  .^JUoiogy  of  Facial  Paralysis  a  frigart.     Riforma  med..  1888, 

pp.  a79-  180, 
nernlunli.      Ucber  .inKcborme  cinseiliKc  Trigeminus..  Abduccns-.  Facialit- 

lUhmurtK.     Neurol.  Ccniralbbit.  1890.  No.  14:  L'eber  Facial i^l&hmung  und 

Faciaiiskrainpr.     Berliner  klin.  Wochcnschr..  189;.  xxtx.  N'ol  51. 
Pcrrin.    Journ.  des  maUd.  cut.  ct  syjih.,  November,  1S91. 
Decomi.    De  la  p;iralysc  facUle  hysi^rlque.    Cajt.  de  Paris.  1891,  47. 
HUiig.     Die  Slellung  der  Zungc  bd  peripherer  Llitunung  des  Facblts.    Berliner 

klin.  Woctictnichr.,  iSgz.  Jo. 
Darkschewiticti  und  Tichonow.     Pathological  Alterations  in  Peripheral  Facbl 

Paralysis.     Med.  OboM,,  1893.  tS(Ru»suin). 
Stintfing.     Urber  Diplepa  facialis  (ProsopoOiplegia).     Munchcner  med.  Woch- 

sucht..  1893.  I. 


CHAPTER  VI. 


milRASI'.S   op   THK    AUDITOKY    Sf.KVW.. 


\ 


I 


I, 

I 


The  auditory  nrrvc  emerges  at  the  base  oi  the  brain,  alonji^ide 
o(  ilic  facial,  and  lakes  with  this  latter  a  forward  and  outward  course. 
After  having  entered  ilie  internal  auditory  meatus,  it  divides  before 
todiiRfE  the  cribriform  plate,  which  separateK  (he  internal  meatus 
(fob  the  internal  ear,  into  two  main  branches,  an  anterior  inferior 
and  a  posterior  superior.  These  nerves  pass  as  small  lilamenta 
thioagh  the  openings  in  the  plate,  to  be  distributed  respectively  to 
thccochlea  and  vestibule,  and  are  hence  called  ramus  cuchlearis  and 
nrnu  vestibularis. 

TV  cortical  centre  of  the  nerve  is  probably  to  be  sought  lor  in 
tW  Innporal  lobe;  the  fibres  are  .lald  to  run  through  the  laM  third 
o\  tk«  posterior  division  of  the  Internal  capsule,  through  the  middle 
inmlale  l>ody,  through  the  brachia  conjunctiva  posteriora.  the 
PMttnor  corpora  Quadrigcmina,  and  the  inferior  lillet  (v.  Monakow, 
Bifintky), 

About  tile  situation  of  the  nuclei  of  the  auditory  nerve  there 
Mtmt  still  to  exist  a  difference  of  opinion  among  the  anatombix. 
(''■utlly  two  nuclei  arc  distinguished,  an  inner  or  principal  nucleus 
■"■lu  outer  one  situated  laterally  from  the  first.  En  their  structure 
•''•«  present  material  differences.  While  the  former — the  inner 
"■Xtfu*— only  contains  scattered,  small,  slender,  giLnglionie  cells  (t5 
la  10)1  long),  the  tatter  contains  cell*  of  considerable  sixe  (60  to  100 
t  ituig  and  15  to  >i  fi  broad).  The  situation  of  the  two  nuclei  may 
^understood  from  the  accompanying  diagram 

Of  the  two  roots,  the  superficial  terminates  in  the  internal  audi- 
'07  nucleus,  while  the  deeper  one  passes  between  the  rcstifomi  body 
h4  the  ascending  root  of  the  fifth,  and  turns  towani  the  outer  one. 
Tht».  alMi,  the  diagram,  which  ts  taken  from  Wernicke,  and  which 
tfciiKrnsi rates  the  views  of  Mcyncrt,  illustrates. 

Although  the  diseases  of  the  auditory  nerve  are  not,  as  a. 
rule,  treated  of  in  neurological  text-books,  they  arc  found  .sotne- 
ttmcs  so  closely  conticcted  with  other  nervous  diseases,  and 


gg  DfSEASES  OF  THE  OfA.VlAl.  fifERySS. 

arc,  notwilhstanijiiig  their  coinparalivc  rarity,  of  such  decided 
practical  imporiancc,  that  we  feel  not  only  justified  but  com- 
pelled to  consider  them  here,  at  least  briefly. 

The  nerve.  :is  we  have  said,  nirely  ever  becomes  primarily 
diseased,  but  diseases  ol  the  middle  and  internal  ear— that  is. 
secondary  affections — arc  by  lar  Ihc  most  common  causes  o( 


Fif.  t;.— Dmcnakhatic  Stcnoji  Timoirdii  the  M»:r>i;i.i.«  Oki^noata  tx  niK  Rramt 
or  T»iE  (LowKM)  Uuvt.  The  ilelii  half  rrpmriiu  ■  1<iH*t  pbnr.  /,  pynmidi;  m, 
lower  ollv*  ;  /,  Icmnucui:  m/.  moUic  rcglmi  <i(  (lir  i>.|:inrni<im  -.  j.  atanAittti  roiX  ol  lb* 
flhti ;  ti.,  oiqi.  tmil,;  l^r.,  eilemBl,  H-i..  luwnikl  niKlruii  nl  Iht  uidilorr  :  tt..  rnnin. 
lens;  11,  nuclriu  and  ro-)!  al  (he  hrpagliiHUA;  lo,  roiit  -A  llir  vom* :  X.a.,  aMcttor, 
X.f.,  poMcrlot  v«K<"  Duclcui ;  X.f  .  combinaj  rmit  ui  tlir  "laUnl  mixed  qrMtfn  "  (e(. 
p.  loj)  ;*.(.,  iup«rAcUl.  »-/.,  <1<^  rool  of  thcauilltnrr  nrnw. 

diminution  op  loss  of  hearing.  We  may  distinguish  between 
condition!)  of  irritation  and  those  of  paralysi;^  so  that  on  the 
one  hand  we  shall  have  hypcrjcslhesias,  on  the  other  parescs 
or  paralyses. 


I.   Hvi'f.R/Hsthf:sias  of  the  Auihtorv  Nkrvk. 

We  speak  of  a  liypera-slliesia  of  the  audilr)ry  nvrsti  wher 
the  patient  experiences  a  painful  sensation  in  his  car  when  per- 
ceiving certain  sounds  or  noises.  For  instance,  in  excitable 
and  nervous  individuals  who  suffer  from  hcmicrania  or  tic 
douloureux,  such  .1  seiis.ition  tnay  be  produced  by  high  musical 


DISEASES  OP  THE  AVDITOKY  XERV&. 


97 


I 


whistling',  and  ilic  like.    Quite  a  (HfTcrcnt  aReclion  is  an 
irmnl  aculciicss  ol  hearing,  whicli  i.'i  extremely  r.irc,  the  &o- 

catlcd  ox^'iicutn  ol  which  we  have  spoken  in  the  chapter  on 

facial  par,-ilysi<i. 

Frcqueiiily  one  hears  nervous  patients  complaining  »(  sub. 

^ctivc  auditory  perceptions,  roaring,  buzzing,  hissing,  singing. 

httmining,  and  the  so-called  nervous  tinnitus  aurium,  which 

Buy  persist  during  the  whole  life  without  a  sign  of  any  other 
diuurbunces  of  function,  This  symptom  may  be  due  to  a 
|iurcly  functional  disorder  or  il  may  be  the  forerunner  of  n 
iii>Jdle-ear  sclerosis. 

Therapeutically,  we  may.  alter  the  removal  of  masses  of 
cerumen  or  epidermis  which  may  have  obstructed  the  outer 
laaal.  with  benefit  make  use  ol  blisters,  tittmulating  lotions  ap- 
plin!  to  the  mastoid  process,  subcutaneous  injections  of  mor- 
phiac,  the  bromides,  digitalis,  and  atropine.  If  abnormalities 
cri  tcnMtjn  in  the  sound-condurttn};  apparatus  and  coosequeni 
risciif  pressure  in  the  labyrinth  be  the  cause  of  ihe  disorder, 
llicnilie  inflation  of  the  middle  ear  and  the  rarcfacliuti  of  the 
win  the  outer  canal  is  to  be  reoom mended. 

II.  The  pAkESKs  and  Parai-vses  of  the  Auditorv  Nerve. 

Antilogous  to  the  rheumatic  facial  paralytus  wc  have  a  con- 
liilioii  in  the  auditory  nerve  which  manifests  itself  in  either  a 
ikcrosc  or  a  loss  of  the  (unction  of  hearing,  the  so-called  rhcu- 
ouiic  acusticiis  paralysis.  It  is  less  frequent  than  Ihe  former, 
itlhou^h  the  cause  of  both,  namely,  cold,  is  the  same.  Central 
P^fJiyses  are  always  connected  with  decrease  of  hearing  power 
O  One  side  only.  Absolute  unilateral  deafness,  as  a  conse. 
IWnre  of  a  focal  lesion  in  one  of  the  hemispheres,  has  up  till 
'"•*  liol  been  obser\'ed  (Wirnickc).  Whether  the  disturbances 
Rihtaring  observed  by  Baginsky  in  railway  spine  are  of  a  cen. 
'nl  nr  periphend  nature  remains  yet  to  be  studied  (cf.  lit.). 

Next  in  order  we  have  to  mention  in  ^his  connection  the 
Jnxjihcsia  and  paresis  of  the  auditory  ner\*e.  which  somelimes 
*;'|>e:ir  (]uitc  siiddridy  in  the  course  of  hysteria,  and  often  as 
*i«idciily  disippear  agaifi  after  a  longer  or  shorter  period  o( 
ifiM. 
(H  Interest  from  a  pathological  standpoint  is  the  nervous 

deafness  ix;curring  after  an  epidemic  cerebrospinal  meningitis. 

il  is  Itiia  lorm  which  has  been  so  thoroughly  studied  by  Moos. 


98 


D/SEASES  OF  TUB  CRANIAL  SERVES. 


There  is  liardl>-  any  doubt  but  th.it  it  is  caused  by  (he  passage 
of  purulent  mits&i'S  from  the  meninges  aluufj^  the  shciitli  of  the 
audilory  nerve  into  the  inner  car.  The  prognosis  is  unfavor- 
able. A  diminution  of  liearinfj,  probably  due  to  trnnsiiory  cir- 
culatory disturbances,  occurs  somclimes  after  epileptic  attacks. 
Although  nut  common,  this  alTeclioii  is  certainly  well  autheii* 
ticated. 

Ol  especial  interest  a'liologically  are  the  disorders  of  hear. 
ing  which  wc  find  in  cngint'crs  and  firemen  on  the  railroads  as 
ji  consequence  of  their  occiipiiliun.  This  must  priiuiipalty  be 
attributed  to  the  noise,  aided,  however,  to  some  extent  by  the 
abrupt  and  severe  changes  of  temijeralure  and  the  exposure  to 
all  kindsof  weather.  We  do  not  know  anything  positive  about 
the  relative  frequency  of  this  afTeclion,  which  consists  in  a  mure 
or  less  pronounced  decrease  of  hearing,  but  in  the  general  in- 
teres!  of  the  public  it  certainly  deserves  as  much  attention  on 
the  part  of  the  companies  as  the  color-blin<lness  which  h.-is  for 
years  been  carefully  looked  into.  Lucksmitlis,  blacksmiths. 
and  boilcr-makei's,  whose  audilory  nerves  are  also  being  c<m. 
stantly  uverslirnulated,  sulTer  from  similar  disorders.  In  rare 
and  exceptional  cnscs  it  has  been  observed  thai  mechanics  who 
are  "hard  of  hearing  "  hear  belter  during  the  usual  noise  con- 
nected with  their  work  than  when  everything  around  them  is 
quiet — paracusis  Willisii.  This  very  remarkable  phenomenon 
is  probably  due  to  a  decrease  in  the  vibratory  power  of  the 
auditory  ossicles,  owing  to  which  the  sound  is  conducted  with 
more  difficulty,  a  ccuidilion  which  is  obviated  by  a  more  forci- 
ble concussi<m  (Buerkner,  HoosiU.  We  would  not  leave  uf»- 
menlioned  the  fact  that  an  overtaxalton  of  the  audiKuy  nerves 
lusting  for  years  causes  great  nervousness,  and  may  even  pre- 
dispose to  mental  diseases. 

In  the  treatmLiil,  cndermic  inunctions  of  slryclmine  (o.l  to 
glycerin  10.0  |gr.  jss. ;  glycerin.  3  ijss.l — sig.,  ten  drops)  over 
the  mastoid  process,  and  funics  of  sulphuric  eiher  conducted  by 
a  catheter  into  the  tympanic  cavity  to  act  on  the  distnbi.ti<m  of 
the  acListicus.  deserve  recommendation.  A  beneficial  effect 
fiom  the  galvanic  current  can  he  expected  only  if  cxaminaiiim 
assures  us  that  the  current  has  a  modifying  influence  on  the 
subjective  noises  or  upon  the  power  of  hearing.  This  treat- 
ment necessitates  a  knowledge  of  the  investigations  of  Brenner 
on  the  galvanic  reactions  of  the  auditory  nerve  (c(.  Htrt,  Im. 
(it.,  p.  109). 


I 
I 
I 
I 
\ 


1>/S£.1S£S  OF  THE  AUDITORY  NERVE. 


99 


lIII.  MfiSifeHK's  Disease— M^NifeRE's  Vertioo — Vertico  ab 
AURE  L/i:sA — Vertigo  in  General. 

When  we  spenk  o(  M(Sni6re's  disease  we  mean  a  combinu- 
lian  of  symptoms  which  is  made  up  (i)  of  subjective  noises  in 
(W  car,  \z)  a  fcellnj:  of  dizziness,  uccumpuiiicd  with  vomiting, 
a  gradually  increasing  difficulty  of  hearing,  sometimes  end- 
deal  ne:^, 
'On  account  of  the  cx-ccptionally  practical  importance  which 
hu  10  be  attributed  to  the  so-called  vertigo  \le  verfigt,  Sckwm- 
itige/iikl),  we  may  be  allowed  to  make  some  general  remarks  on 
tbii  before  considering  the  special  form,  viz..  M£ni£re's  disease. 
By  vertigo  we  mean  a  subjective  feeling  of  motion  appearing 
or  gradually  without  any  loss  of  consciousness,  at- 
by  a  simultaneous  sensation  of  los^of  equilibrium.  The 
lubjcctivc  sense  of  motion  is  cither  referred  lo  the  body  or  parts 
u>  il.  or  to  surrounding  objects.  The  motion  is  in  dilTcrcnt 
directions,  sometimes  in  horizontal  or  vertical  circles,  revolving 
*ilh  their  crinvcxity  sometimes  forward,  sometimes  backward, 
ttd  tlic  older  obsen-ers  distinguish  accordingly  a  vertigo  litu- 
hns,  fluctuans,  etc..  from  the  nutatio— that  is.  subjective  iiiovc- 
■nus  in  a  straight  line.  As  concomitant  symptoms  we  note 
htadichc,  espcci.Tlly  in  the  iKick  of  the  head,  anxiety,  tremor, 
mU  sweat  on  the  face,  nausea,  vomiting:  in  grave  cases, 
tnnjtenl  clouding  of  consciousness,  as  in  the  prodromal  state  o( 
ua{ioplcct!c  attack.  If  consciousness  Is  completely  retained, 
uhappens  in  the  m.ijority  of  cases,  the  !>ubjeclivc  sensation  of 
miivetnenl  often  gives  rise  lo  objective  voluntary  movements, 
l"> bo  regarded  in  a  measure  as  instinctive  efforts  against  the 
t^itaicntng  danger  of  falling.  The  patient  plants  his  feet  firm> 
Ijr  (in  the  ground,  stretches  out  his  arms  into  the  air.  seizes 
lAh  hi*  hand  any  object  within  tiis  reach,  etc..  but,  in  spite  of 
lfl.lw  may,  notwithstanding  the  perfect  retention  of  cnnscioiis- 
Be»,  fall,  owing  to  the  feeling  of  disturbed  equilibrium — vcr> 
tifn  caducii. 

If  the  |iaticnt  is  unconscious— e.  g.,  asleep — then  he  cxperi. 
tnces  &  sensation  o(  falling  down  from  a  great  height,  down 
Urp\  or  out  of  the  winiiow :  he  imagines  himself  sinking  into 
■noprning  in  the  ground,  etc.  This  so-called  nocturnal  ver- 
ti^ {TruHmiclni'intifl)  usually  torments  those  who  sulTcr  frotn 
igo  when  awake.  Two  exquisite  examples  of  this  vertigo 
observed  in  Bright's  disease. 


[Ten 


have 


100 


D/SEjtSES  OF  THE  CRANIAL  /t'ERVES. 


By  far  most  atmmoiily  ihe  vcrligo  occurs  in  paroxysms 
which  appear  without  regularity  and  arc  of  vamlilc  duratiun. 
Between  Ihe  first  and  second  sometimes  hours  and  days,  more 
rarely  manlhs,  and  indeed  whole  years,  intervene,  and  only 
except iunally — e.  g.,  in  cerebellar  alfections — do  the  subjective 
sensations  of  movement  persist  uninterruptedly,  and  thus  render 
the  vertigo  couslniit. 

The  p<)sitian  r)f  the  body  has  rarely  any  influence  on  the 
vertifto,  for  althuiiKh  at  rimes  some  amelioration  is  (clt  on  sil- 
ting down,  there  arc  cases  in  which  the  vertiyo  continues  even 
when  the  patient  occupies-lhe  horizontal  position  in  bed.  The 
pathogenesis  of  the  trouble— that  is  to  say,  the  organic  changes 
in  the  brain  whitli  are  necessary  for  the  production  of  the  sen- 
sation — arc  but  little  understood.  It  is  generally  supposed 
that  changes  in  the  blood-pressure,  due,  perhaps,  to  stimulation 
or  paralysis  of  the  vaso-motor  nerves,  are  the  chief  cause  of 
s-ertigo,  just  as  a  lasting  decrease  or  increase  in  the  amount  of 
blood  in  the  brain  can  probably  give  rise  to  attacks  of  dizziness. 
Until  the  conditions  under  which  vertigo  can  ai)pear  in  other- 
wise healthy  people  arc  more  accurately  understood,  our 
knowledge  of  the  pathological  influences  at  work  can  be  only 
imperfect.  Of  great  interest  are  the  experiments  of  Purfcinje. 
undertaken  seventy  years  ago.  as  to  the  influence  of  swing- 
ing, and  especially  of  circular  movements,  in  the  production  oi 
vertigo.  These  were  published  in  Kust's  Magajtin  (Ur  die  ge- 
sammtc  1-Icilkundc,  part  i:.\iii,  1827,  and  have  been  reprinted  in 
Romberg's  Ncrvenkrankheiten  (/oc.  t//,,  p.  iiS)  with  this  addi- 
tion by  the  author :  "  From  all  these  experiments  we  see  that, 
taking  the  head  as  a  sphere,  around  the  axis  of  which  the  true 
motion  takes  place,  an  imaginary  plane  through  it  determines 
in  every  cuse  tlie  apparent  motion  of  the  objects  in  the  subse- 
()uen[  position  of  the  head  at  rest.  The  same  holds  good  in 
attacks  of  vertigo." 

Johannes  MlUler  also  h.is  made  experiments  on  vertigo,  and 
is  inclined  to  attribute  it  to  the  after-effects  of  visual  impres- 
sions on  the  retina.  That  this,  however,  is  not  always  the  case 
is  shown  by  the  fact  that  vertigo  may  appear  in  people  whose 
eyes  arc  closed,  and  even  in  the  blind. 

We  have  already  spoken  about  its  occurrence  in  the  paral- 
ysis of  the  ocular  muscles  (p.  4^!).  Here  let  us  add  that  this 
ocular  or  visual  vertigo  disappears  if  the  patient  closes  the 
aflected  eye  or  holds   his  head  in  such  a  position  that  the 


I 


DtSBASBS  Of  THE  AUDITOBY  NBRVB.  loi 

I  paralyzed  muscle  does  not  come  into  play  during  the  act  ol 

!  seeing. 

In  the  present  chapter  wc  shall  discuss  more  especially  hnw 
(jr  diseases  ol  the  internal  and  middle  car  are  connected  ivitti 
vertigo.  It  has  repeatedly  been  observed  that  affcclicins  o(  the 
nasal  mucous  metMbiane.  swellings  (if  rh«  creciile  tissue,  as  well 
as  ailcctions  of  the  mucous  membrane  of  the  larynx  associated 
with  violent  cough  (laryngeal  vertigo),  hnve  produced  it.  If, 
ihcn.  we  add  that  it  has  been  claimed  that  the  intestines  {in. 
teitinal  wuritis.  txnia.  ascaris)  and  (he  stomach  are  rcspunsihle 
for  feelings  of  dizziness,  which  Trousseau  calls  "vrrlign  a 
ttematko  Itts-o"  we  can  not  f.iil  to  be  impressed  with  the  com. 
jitcxity  and  the  lack  of  cleariiess  in  the  letiology  of  this  affec- 
tion. We  must,  however,  always  keep  in  mind,  no  matter  where 
the  remote  cause  lies,  be  it  in  the  faulty  movements  of  the 
ocular  n)U!«cU-s.  in  the  n(»se.  in  the  cars,  or  in  the  stomach,  etc. 
wc  must  keep  in  mind.  I  say.  that  ihr  influence  of  the  cerebrum 
ami  the  cerebellum  is  under  all  circumstances  quite  essential 
for  the  prtxluction  of  vertigo.  Whether  the  characteristics  cf 
the  vertigo  vary  or  not  with  the  different  organs  affected  is 
nut  yet  clearly  known. 

[The  dif.cAf'C  cle«crib«<l  by  (lerlicr  in  Ferncy,  which  shows  UscK  by 
y  prnmitinred  dizzy  feeling,  appearing  in  paroxyiini^ — the  so- 
called  "paralyiinc  vertigo" — is  accompanied  by  other  symptoms, 
ninicly,  a  we;ikness,  resembling  a  paralysis,  in  ihc  exircniJlies,  droop- 
ig  of  the  eyelid)^.  an<l  extraordinary  lassitude  wittioui  any  loss  of 
coasciousncss.  T))is  condition,  which  has  been  repeatedly  observed 
in  ibe  canton  of  Geneva,  where  it  occurs  epidemirally  among  labor- 
|.  crs  and  herdsmen,  ts  xltologicalty  mystennuK.  (lerlier  uttribiiten  it 
(ti  iiii.i^m:ilj  from  marshes  nod  stahles,  F.pcroii  (o  ilic  working  in  the 
«un  wliicli  produces  hyperemia  of  the  meninges  (Keviie.  mt'd.  de  la 
Suisse  ronufule,  18X9,  ix,  1) ;  but  neither  of  these  hypotheses  explains 
the  immunity  nf  the  female  sex.  For  this  new  and  as  yet  entirely 
(trange  neuri»*is  tJerlier  has  proponed  the  name  verligc  paralynant 
(Progr^M  miA ,  1K.S7,  36:  Lndame,  Revue  mM.  dc  la  Stiisse  romande, 
Janojirjr.  1887 ;  Deutsche  Med.  Zeitung,  18S7,  44,  1888,  14). 


Middle  life  and  moderately  advanced  age  (especially  in  the 

■  female  wx,  and  so  in  them  the  climacteric  period)  seem  to  pre. 
dispose  to  attacks  of  vertigo,  which  choosett  by  preference  Its 
victims  from  among  vigorous  and  fult-biooded  individuals.  Its 
ircqucnt  occurrence  in  advanced  old  age  will  not  surprise  us  if 


I02 


D/SBASES  OF  THE  CRANIAL  NBlfVES. 


we  remember  ihe  atheromatous  condition  of  the  arterial  walls 
and  the  consequent  irrcgiilaiirics  of  the  blood  supply  to  the 
brain  substance.  Amon^  the  excititif;  causes,  poisons— c.  g^., 
tobacco  (smokers"  vertigo)— unaccustomed  circular  rocking 
movements,  such  as  we  feci  on  board  ship,  play  an  important 
rHe ;  yet  it  is  by  no  means  clear  how  these  causes  act.  and 
every  attempt  to  explain,  for  instance,  the  nature  of  sea-sick- 
ncss.  or  to  prevent  and  cure  it,  has  thus  far  been  futile  (cf. 
Painpoukis,  Etude  pathog^niquc  et  expirimentalc  sur  Ic  vertige 
marin.  Arch,  dc  Neurol..  1888.  xv,  xvi).  The  di/zincss  ex. 
perienced  on  looking  down  front  a  height — the  "  height  dizzt' 
ncss" — which  has  erroneously  been  attributed  to  a  fear  of 
danger,  is  ]>robab]y  a  reflex  movement  evoked  by  a  wrong 
conception  of  our  position  in  space,  the  result  of  a  purely 
optical  illusion  ;  for  its  production  not  only  the  cerebrum  and 
ccrcbcltum,  but  also  the  action  n(  the  retina,  is  needed. 

The  prognosis  in  vertigo  depends  upon  the  nature  of  the 
primary  disease,  and  IJoerhaavc's  expression,  "  vertigo  est  om- 
nium morborura  capitis  levissimus  et  facillimc  curabilis,"  has 
to  be  taken  cum  granc  salis.  In  an  organic  lesion  of  Ihe  cere- 
bellum— or  more  especially  of  Ihe  vermis — wc  can  expect  no 
improvement  in  the  vertigo,  while  if  it  is  attiibutable  to  an 
anxmia  of  the  brain,  occurring  as  a  symptom  of  a  general 
anxmia.  the  outlook  is  decidedly  favorable. 

In  the  same  way  the  treatment  will  be  different  in  different 
cases  according  to  the  primary  disease,  which  always  has  to 
be  taken  into  consideration.  For  the  symptomatic  or  prophy. 
lactic  treatment,  the  repeated  administration  of  mild  laxatives, 
the  frequent  use  of  strong  stimuli  to  the  skin,  such  as  cold 
douches,  brushing  of  the  neck  and  the  back,  mustard  plasters, 
regular  bodily  exercise,  and  well-regulated  diet,  arc  to  be  rec. 
omiiiended.  while  any  overloading  of  the  stomach,  especially 
in  the  evening,  should  be  strenuously  avoided.  In  spile  of  the 
much-lauded  remedies  (cocaine,  etc.).  we  do  not  possess  any 
reliable  medicinal  treatment  for  sea-.iiickness  and  height  diz< 
ziness. 


After  this  digression  we  will  return  to  the  consideration  o( 
that  form  of  vertigo  which  is  especially  connected  with  aural 
disturbances.  Notwithstanding  the  fact  that  it  is  by  no  means 
settled  that  the  above-mentioned  combination  of  symptoms 
constituting  Meniere's  disease  can  be  produced  by  a  pure  ncu- 


DISEASF.S  OF  TtlE  AUDITOKV  NF.KVF.. 


103 


roMS  of  the  audiiary  nerve,  wc  will  take  it  up  here,  because 
under  all  circumstancctt  this  nerve  plays  a  prominent  part  in 
ihc  pathology  of  the  atTeclion. 

Since  Meniere  in  1861  first  Hescribcd  the  disease,  it  has  been 

repeatedly  observed  and  carefully  studied  by  German  physi. 

dans-     All  have,  however,  failed  as  yet  to  give  us  a  clear  un- 

I      ilerBtanding  of  its  pathology.     Mt-niftrc  himself  believed  that 

V  u  extravasation  of  blood  or  an  nculc  exudation  lakes  place 

V  into  the  Inbyrinth,  which   produces  the  $:ime  symptoms  as 
P  occur  in  animals  afier  injury  lo  the  semicircular  canals.     This 

vnm  is  in  so  far  incorrect  in  that  cerebral  alTeclions,  accumuln- 
tions  nl  cerumen,  and  diseases  of  the  middle  ear,  can  undoubt- 
edly produce  the  same  symptoms;  and  ihen  we  have  lo  re- 
member that  not  the  ha:morrh.ige  nor  the  exudation,  but  its 
Ktion  upon  certain  parts  of  the  membranous  labyrinth  is  ne- 
ceaary  before  the  symptoms  occur  (Politzcr).  It  can  easily  be 
I  iniS);iDed  thai,  whenever  the  extravasation  stimulates  the  nerves 
of  Ihcampulhe,  M^ni^re's  symptoms  are  produced,  while  they 
I        areaWnt  if  the  ha;morrhagc  does  not  directly  press  upon  the 

nervrt  of  the  antrum  or  the  ampulla;  (l*olitzer). 
^m  More  reccnlly  Brunner  (cf.  lit.)  has  put  forward  a  supposi. 
H  lion  Khich  we  think  is  u-urth  considering,  namely,  that  we  may 
bedcjlinji  "'''h  a  vawj-motor  neurosis  of  the  vessels  of  the  laby- 
rihlb.  According  to  him.  the  pressure  in  the  labyrinth  acts 
ba  Minilar  way  as  pre<isure  in  the  cranial  cavity,  where  con- 
>i(ienble  changes  are  borne  so  long  as  the  normal  expansion 
ollhe  subdural  and  subarachnoid  space  is  not  interfered  with. 
He  tbinks,  therefore,  that  narrowings  of  the  labyrinth  could 
produce  a  predisposition  to  Mt'-iiiire's  disease. 

This  hypothesis  is  extremely  plausible,  especially  as  the 

ipnptomsap{K-ar  paroxysmally.and  in  ihc  intervals  the  patient 

i»apparcMtly  in  jicrfcct  health.     In  this  way  also  the  favorable 

jaion  of  quinine  can  be  explained  if  wc  suppo.sc  that  it  dimin* 

itbes  the  hyperxmia  in  the  semicircular  canals,  just  as  Horner 

»bown  to  be  the  case  for  the  retinal  vessels.     He  observed 

large  doses  of  quinine  constantly  produced  considerable 

bchntnia  in  the  latter.    The  question  is,  however,  by  no  means 

fettled,  especially  since  cas«s  have  been  observed  where,  in 

ilc  of  the  absence  of  the  circular  canals  (Politzcr).  or  in  spite 

the  fact  that  they  were  filled  with  bloud-clots  (Lucae),  no 

disturbances  of  cquilibnum  were  noted  during  lilc.     Ilcnce  il 

nay  also  be  possible  ihat  vertigo  can  be  produced  by  pressure 


104 


DISEASES  OF  THE  CRANIAL  NERVES. 


changes  wtlliin  ihc  cranial  cavity  (Stcine-r,  Deutsche  mcd. 
Wochciischr..  1889,  47). 

The  view  expressed  by  fVugnicr  and  Fournier  (cf.  lit.)  that 
M^nit^re's  vertigu  is  n  cerebnti  altectiun,  nnd  is  only  tiiel  with 
in  individuals  who  arc  already  insane  or  who  will  later  stircly 
become  insane,  certainly  needs  hirlhcr  coiitirmalinii  and  does 
not  at  all  agree  with  our  experience. 

There  are  hardly  two  cases  in  which  the  sytnploms  are  ex- 
actly  the  s:imc.  and  the  course  is  so  iar  from  being  uniform 
that  we  can  not  be  surprised  if  often  great  uncertainty  about 
the  diagnosis  prevails.  The  onset  even  is  very  variable.  Now 
it  is  sadden,  with  loss  of  consciousness  and  apoplcciiform  symp> 
toms,  etc.;  again  it  is  gradual,  first,  subjective  noises  in  the 
ears  being  noticed,  sometimes  comparable  to  the  whistle  of  a 
locomotive,  sometimes  to  the  rustling  of  the  leaves  in  the  forest. 
Next  comes  a  feeling  of  dizziness,  at  times  only  moderate,  at 
limes  so  pronounced  that  the  patient  in  spite  of  all  his  efforts 
falls  to  the  ground.  Vomiting  may  be  present  or  absent. 
Finally,  a  decrease  in  the  power  of  hearing,  first  in  one,  then 
in  the  other  car.  becomes  noticeable.  Some  cases  show  a  de- 
cided progressive  tendency.  Alter  short  remissions  the  symp- 
toms always  reappear  with  increased  severity,  the  vertigo 
gains  so  much  in  intensity  that  now  the  patient  repc.Ttedly  falls 
with  great  violence,  vomiting  becomes  more  and  more  fre- 
quent, and  the  patient  becomes  at  first  incapable  of  following 
his  calling.  :md  tinalty  Is  reduced  to  the  si;ite  of  a  useless  mem- 
ber ol  sftciely.  In  rare  instances  periods  oi  marked  improve- 
ment, which  may  indeed  last  for  years,  occur.  In  these  even 
the  ditTiculty  in  hearing  may  be  gradually  diminished,  and  the 
prognosis  becomes  rcfalively  favorable.  Finally,  it  is  at  times 
observed  that  with  the  lull  development  of  (he  deafness  all  llie 
other  symptoms,  buzzing  in  the  ears,  vertigo,  and  vomiting, 
disappear.  In  other  words,  we  liave  wh.Tt  we  ciill  a  relative 
recovery  or  recovery  with  defect.  In  any  given  case  we  are 
never  in  a  position  to  predict  the  outcome,  and  have  always  to 
be  very  guarded  in  our  prognosis. 

Of  considerable  diagnostic  importance  i«.  the  fact  that  usu- 
ally the  examination  of  ihe  drum  and  the  (Eustachian  tube  does 
not  reveal  any  changes,  and  that  neither  cranial  nor  spinal 
nerves  present  any  disturbances  of  (unction.  Rinne's  test 
gives  variable  results  in  M^niire's  disease.  This  test  consists, 
as  is  well  known,  in  applying  a  vibrating  tuning-fork  with  mod- 


DISEASES  OF  THE  A  CD!  TOR  V  ^'EKVE. 


los 


I 


rratc  pressure  first  over  the  mastoid  process,  leaving  it  there 
milil  ihc  patient  no  longer  hears  the  sound,  and  then  as  quickly 
as  possible  brin^iiit;  it  immcdialely  in  front  of  the  external 
meatus,  avoiding  all  contact  with  the  head  or  car.  If  the  pa- 
tient then  is  able  to  hear  the  sound  of  (be  luuing.forlc  once 
mure,  this  is  a  sign  that,  as  \%  normally  the  case,  (he  conduction 
Ibrnugh  the  uir  is  belter  than  ihruu^h  the  bone.  If,  on  the 
iilher  hand,  he  does  not  hear  it.  the  conduction  through  the  air 
must  in  some  way  be  inierfcred  with.  In  the  diagnosis  these 
aic  points  to  be  considered. 

In  Ihc  treatment,  above  all.  the  action  of  large  doses  of 
quinine — 0.7-1.0  (gr.  x-xv) /»/-tf //»/~must  be  tried,  a  procedure 
warmly  recommend*^  by  Charcot,  and  later  used  with  gratify- 
ing results  by  Fir«5,  Moos,  and  others.  In  many  cases,  as  we 
h»vc  said,  the  cfiect  is  very  marked,  and  there  is  no  need  to 
>eek  further  lor  other  medication.  At  times,  however,  this  will 
liil,  and  then  we  are  forced  to  resort  to  a  two-per-cent  solution 
u(  pilocarpine  (nine  to  ten  drops  subcuianeously).  The  result 
it  oflcn  Surprising.  I  h.ivc  seen  grave  symptoms  completely 
uiltskle  after  three  or  lour  days'  use  of  this  medicine.  The  in- 
jections arc  to  be  continued  every  second  d.iy  for  three  or  lour 
weeks,  and.  as  a  rule,  after  the  fifteenth  dose  the  treatment  can 
be  discontinued,  at  any  rate  for  a  time.  We  need  not  add  that 
on  administering  this  drug  the  general  cnndilion  of  the  patient 
must  be  carefully  looked  .ifter,  and  any  symptoms  o(  colla]>se 
yarded  against  by  ihc  timely  exhibition  of  stimulants,  wine, 
and  the  like.  Whether  the  view  of  Field  {British  Med.  Jour- 
nal, 1890.  xvii,  ;)  that  the  action  of  pilocarpine  is  to  be  attrib- 
uted to  an  increased  secretion  of  cerumen  is  correct  or  not  is  as 
Crt  uncertain,  although  it  must  be  acknowledged  that  in  all 
cuKs  of  labyrinthiau  deafness  the  cerumen  is  absent. 


l.lTI-;RATtiRE. 

MoM.  ITclxr  Mcninglili  crrFttrospliinlii  epidetnica,  insiltnondcrre  lihrr  die  luch 
^H  ilrrtrlbrn  /urucl(l>k-lhrn(1cn  combintrtei)  (iehi)r»p  u.  Gltkhgcwichlsttdnin- 
W  em.     llriik'IbenE.  '»<■- 

Xluo«.     F.rknnl.un);(ii  tin  (ichoniiTifiinev  hei  t^ncoipotivfuhrrra  un<l  Hci/ern. 
^         ZcUKhr.  r.  Ohrmhfilk..  t.  4.  1881  ;  xl.  a.  188). 
^KColtMdn  u.  Knyscr     IlretUucr  Antl.  ZcilKchr,  ii>,  18,  i&Si. 
H^riincr.     Arch.  (.  Ohrcnhcilk..  xvii.  1,  i,  p.  8,  iliSi. 
^BHUty.     IN>t..  Kt\\.  4.  p.  ]^S.  1881. 

Rurckrurdi-Mrrian.    .Schnri/cr  CorrpspondmiM..  iriv.  t.  6,  1884. 
L     Zeiitchr.  f.  Ohrtnlwilk..  mii.  1,  3.  1884. 


I06  VISMASSS  OF   THE   CRANIAL   NERVES. 

Finkelstein.    Wratsch,  No.  I,  1886. 

Baginsky.     Ucher  Ohrerkrankungen    bei  Railway-spine.      Berliner  klin.  Wo- 

chenschr.,  3.  1888. 
Loeb.     Ueber  den  Antheil  des  Hbrnerven  an  den  nach  Gehimverletzungen 

auftretenden  Zwangsbewegungen,  Zwangslagen  und  associerten  Stellungs- 

Snderungen  der  Buibi  und  Extremiiilten.    Pfiiiger's  Arch..  1892. 1,  p.  66. 
Krcidl.     Beitriige  2ur  Physlologie  des  Ohrlabyrinihsauf  Grund  von  Versuchen 

an  Taubstummen.     Ibid.,  1892,  li,  p.  119. 

Miniin's    Disiase. 

Charcot     Klinische  Vortr^ge  iiber  Krankheiten  des  Nervcnsystems.    Deutsch 

von  Feiier,  Abthlg.  ii,  p.  343.     Stuttgart,  1878. 
Guye.    Arch.  f.  Ohrenheilk.,  xvi,  1,  3,  18813. 
FfirS  et  Damars.     Revue  de  mM,  i,  10,  1881. 

Woakes,  Edward.     Remarks  on  Verligo  and  the  Group  of  Symptoms  some- 
limes  called  "  Meniere's  Disease.''    Brit.  Med.  Joum.,  April  28,  1883,  p. 

801. 
Bechterew.     Neurol.  Cenlralbl,,  9,   r887  (anatomical  study  on  the  origin  of  the 

auditory  nen'e). 
Brunner.    Zum  Morbus  M^ni^re.     Zeitschr.  f.  Ohrenheilk.,  xvii,   1,  I,  p.  47, 

1887. 
Grasset.    Du  vcrlige  cardio-vasculaire  ou  vertige  des  artirio-scliraui.     Clin. 

m£d.  de  I'Hdp.  Saint-Eloi,  Paris,  1890. 
Buzzard.     Lancet,  1890,  i,  4.  p-  179- 
Peugnier  et  Foumier.     Vertige  de  Mfniire,  etc.     Revue  de  m*d.,  1890,  11: 

iSgr,  3,  3,  4. 
Mijller.     Ueber  Lahyrinthschwindel.    Deutsche  Med.  Ztg.,  1893,  No.  1,  p.  9, 


fAPTER 


I 


DISEASES  OF  THE  ULOSSO-PHAKYNCEAL  KKKVK. 

The  glosso-pharyngcal  nerve  leaver  the  brain  between  llie  root 
fibres  of  the  auditory  ;iti<l  thot^e  of  the  vagtm,  at  the  siJe  of  the 
DKiluUa  oblongata,  by  five  or  wx  ritaments;  these  soon  unite  to  form 
u  tnienor  (dinull)  anil  a  posterior  (tarccr)  bundle;  i hey  both  pass 
amnrd,  andrr  and  in  front  of  the  flocculus,  to  the  anterior  division 
of  the  jugular  foramen,  through  which  ihe  nerve  leaves  the  skull. 
Vhrther  the  so-called  jugular  ganglion  which  the  nerve  pre*ent» 
«ble  rtdi  inside  the  skull  has  to  be  looked  upon  as  a  special  gan- 
fknoronly  as  a  grnup  of  nerve-cells  which  have  separated  (hem- 
mIvcs  from  the  petrous  ganglion,  which  is  seen  on  the  nerve  immedi- 
UdT  after  Its  exit  from  the  skull,  remains  to  be  decided. 

The  gloMo-pharyngeal  ha»  nu  nucleux  of  it*  own,  but  originates 
biUrge  collctiion  uf  nerve  cells,  which  are  regarded  as  the  nucleus 
nmniin  tu  this  nerve,  the  vagus,  and  the  accessurius.  Hiis  nucleus 
Wuluaicd  midway  between  the  anterior  and  posterior  spinal  ro«i», 
la  (he  manner  in  which  its  root  fibres  originate  it  corresponds  partly 
lo (be  motor,  partly  to  the  sensory  type  (Wernicke).  It  is  thetcfore 
tei|[Uted  a»  the  mixed  lateral  yyittetii  ([)eiters),  and  it  is  supposed 
An  the  glo»so- pharyngeal  originates  in  the  upper,  the  vagus  in  the 
OHldlc,  and  the  accessory  in  the  inferior  portion  of  the  nucleus  (cf, 
•T  '?.  1>.  96)-  'I'hc  manner  in  which  this  common  nucleus  is  com- 
P»»til  is  not  yet  underKtood,  nor  do  we  know  how  many  modes  of 
ongin  tor  root  fibres  of  this  "  later.il  mixed  system  "  we  have  to  as- 
ttat.    Exact  data  inay  be  found  in  Wernicke's  text-book,  1,  p.  155 

The  glosso-pharyngcal,  which,  according  to  our  present 

Aw.  las  to  be  rcfiardod  as  the  only  genuine  nerve  of  taste,  is 

tbc  third  one  which  is  lo  be  taken  into  considcratiim  in  the 

'wmination  o(  llie  (unctions  of  taste.     The  trigeminus  (Ihc 

Hiird  branch  (lingual),  possibly  also  the  second  branch)  and  the 

^tal  (thortla  tympani)  we  have  treated  of,  and  it  remains, 

l^inHoix,  to  determine  whether  and  if  so  under  what  condi- 

■07 


io8 


DISKASES  OF  THE  CRANIAL  .VERVES. 


liuns  diseases  cunlincd  to  the  glosso-pliaryngcal  occur,  nnd  in 
what  manner  taste  is  aliercc)  by  them.  Since  it  only  supplies 
the  posterior  third  of  the  tongue  wilh  sensory  fihrcs  (rnintis 
tingualis  nervi  glosso-pliarynKfi),  it  is  not  to  be  wonderetl  at 
ttiat,  it)  detcrmitiing  vca  isolated  aHcclion  of  the  ner^-e,  we  not 
rarely  meet  with  considerable  difficulties. 

We  know  but  little  about  central  diseases  of  this  nerve.  It 
is  supposed,  however,  thai  there  exists  a  bulbar  afTeclion,  a 
gray  degeneration  of  the  nucleus  which  is  found  in  (.ibes  (Er- 
ben),  also  that  the  gustatory  paths  may  be  in  a  state  of  irritd- 
lion  which  gives  rise  to  alterations  in  t.istc-pcrccption  analogous 
to  the  panc^thesias  which  occur  with  irritation  of  the  p:iths  of 
tactile  sense  in  (he  posterior  columns  of  the  cord.  Conduction 
anasslbcsias  arc  also  said  to  occur,  although  it  is  impossible  to 
decide  whether  only  the  gtosso-piiaryngcal  or  whether  in  ad- 
dition the  trigeminal  and  the  facial  paths  arc  concerned  (cf. 
l-VUnkol.  Berl.  klin,  Wochcnschr.,  No.  3,  1875).  .\  centrAl 
imralysis  of  taste  manifesting  itself  solely  on  the  jjostcnar  third 
of  the  tongue  has  never  been  observed.  With  the  cortical 
centre  of  the  glosso-pharyngeal  we  arc  not  as  yet  acquainted. 

Peripheral  anicsthesia,  anxslheiiia  gustatoria,  ageusia  (a 
priv,.  7«crw,  sense  of  laste),  impairment  or  loss  of  tasic  pro- 
duced by  affections  of  the  peripheral  nerve  endings,  has  been 
met  with  in  diseases  of  the  mucous  membrane  of  the  (onguc, 
and  has  been  known  to  be  produced  by  the  action  of  low  tem- 
peratures (ice)  or  acrid  substances  (vinegar,  chewing  tobacco, 
r^  pepper).  In  testing  for  such  allcr-itions  the  patient  is  asked 
to  close  his  eyes,  open  his  mouth  widely,  and  protrude  his 
tongue  :  then  a  sinali  portion  o(  sugar  or  quinine,  etc.,  is  placed 
up<m  that  part  of  the  tongue  the  function  of  which  is  to  be 
tested,  and  the  patient  is  to  indicate  with  his  fmgcr  where  he 
perceives  the  taste  before  he  rctnicts  bis  tongue,  and  tell  us  by 
signs  what  he  has  tasted.  The  test  is  made  wilh  biiier,  sour. 
sweet,  and  salty  substances,  and  for  the  purpose  any  one,  as 
long  as  it  is  not  poisonous,  may  be  selected.  Further,  11  is  \vc>s~ 
Sible  (o  accunilely  determine  the  boundaries  of  the  area  with 
normal  and  that  with  disturbed  function  of  the  tongue  by  means 
of  the  galvanic  current.  As  we  know,  a  sour,  metallic,  the 
So-called  galvanic  taste  is  perceived  if  the  electrode  is  placed 
upon  the  tongue  and  the  current  is  closed ;  the  same  taste  is 
experienced  during  galvanization  of  the  throat,  the  neck,  or 
head,  and  is  probably  produced  by  the  current  acting  upon  the 


DfSEASES  OF  THE  ClOSSO-PflAXYXCEAL  NERVE, 


109 


lasle  nerves  in  their  peripheral  or  central  course.  The  use  oJ 
Ik  galvaoic  current  is  ais<>  10  Iw  recommended  in  ihe  treat- 
nicnt  of  the  alTeciions  uf  ihc  nerve.  The  siMintaneous  appcar- 
aace  of  a  sweet  or  sour  taste  in  the  mouth  (parageusia)  has 
■■(ten  been  observed  in  cases  of  diabetes,  though  we  are  igiio- 
niit  ol  the  cause  of  this  svmplom.  Therapeutically  the  leaves 
olGymnemasyUestrc.  or  the gymnemic  acid coiuiiineil  in  ihcin, 
lave  been  recommended  in  this  condition  (B  Acidi  gymnc- 
mici  (Merck),  0.1  (ijgr.):  spin  viii..g.5  {jijss);  iheae  nigr. 
I'l'koc,  4.0  (3i):  cxsicca  Iciii  calorc  ;  scattila  lignen.  D.  S. : 
One  10  [wo  wafers  to  be  talcen  into  the  moulli  repeatedly  dur. 
ini:  the  day  and  allowed  to  tncit  (Oefcle,  Aerzll.  Rundschau, 
iByj.  Nos.  37,  38). 

I.ITKRATUKE. 

RtoberX'     Of>.  cil ,  PI).  148  it  le^. 

Bfc    llandliuch  tier  Kf.inVheiicn  dcs  NeTvrn»>^1em».  \i\i.  219  rt  ti^.,  1876. 

HfutBcr.     Eine  tkolMclilung  ubcr  den  Verluuf  dct  Gctcliiniiclunervco.     BcT> 

iintr  kllli.  Woclirnsclir..  No.  44.  1886. 
^nrr,    Ktiniiclirr  Itcilnij;  ubcr  ilcn  Vcrl.-iiif  dcr  lieticliiiiackMierveii-     NeuniL 

Couralhl.  t888.  Nr  16. 
I'oiw.    TliromlMMis  of  vcricbril  artery  pTMiting  on  yla«K»-phar}'ngral  nerve; 

wiilaiml  Idm  ur  taMc  at  buckul'  lunijui:.     Utiliih  Med.  Jouni..  Nuvcmbcr 


CHAPTER   VIII. 

DISEASES   OF   THE   VAGUS   (PNEUMOGASTKIC    NERVe),    "VAGUS 
NEUROSES." 

iHUEDtATELY  behind  the  superficial  origin  of  the  glosso-pharyn- 
geal  on  the  post  ero- 1  ate  rat  aspect  of  the  medulla  oblongata,  the  vagus 
appears,  with  its  ten  to  fifteen  separate  bundles,  which  soon  unite  to 
form  one  trunk.  This  is  a  flat  band  which,  accompanied  by  a  process 
of  the  dura,  passes  outward  below  the  flocculus,  together  with  the 
accessorius,  to  the  anterior  division  of  the  jugular  foramen,  inside  of 
which  is  to  be  found  the  ganglion  of  the  root  of  the  vagus,  or,  as  it 
is  also  called,  the  jugular  ganglion.  After  its  exit  from  the  skull 
the  vagus  receives  a  part  of  the  accessorius,  and  forms  the  gangli- 
form  plexus  or  the  ganglion  of  the  trunk,  which,  however,  only  trans- 
mits a  part  of  its  fibres. 

About  the  difference  in  the  further  course  of  the  left  and  right 
vagus  we  shall  have  a  few  words  to  say  later. 

That  the  nucleus  of  the  vagus  is  only  a  part  of  the  nucleus  com- 
mon to  it.  the  glosso-pharyngeal,  and  the  accessorius,  has  already 
been  stated  in  the  preceding  chapter.  The  cells  of  the  part  belonging 
properly  to  the  vagus  are  spindle-shaped,  multipolar,  30  to  45  n  long 
and  12  to  15  /A  broad  (hence  much  smaller  than  the  cells  of  the  hypo- 
glossus  nucleus,  which  we  shall  describe  later).  As  another  impor- 
tant origin  of  the  root  fibres  of  the  vagus,  a  compact  round  nerve 
bundle  following  the  longitudinal  axis  of  the  medulla  oblongata  must 
be  mentioned.  It  has  been  described  by  Meynert  as  the  solitary  fas- 
ciculus, while  Krause  designates  it  as  the  respiratory  fasciculus,  be- 
cause it  connects  the  va(;us  with  the  origin  of  the  most  important 
respiratory  muscles  (cf.  Fig.  18).  The  so-called  nucleus  ambiguus  (in 
the  diagram  «.  am)  is  held  to  be  still  another  nucleus  of  the  vagus. 
This  is  a  oolleciion  of  peculiar  nerve  cells  situated  within  the  forma- 
tio  reticularis  to  the  mesial  side  of  the  nucleus  lateralis. 

Just  as  most  of  the  cranial  nerves,  the  vapus  may  be  d*' 
eased  in  its  centre  as  well  as  in  its  peripheral  course, 
first  class  of  cases  arc  usually  met  with  as  partial  ml 
110 


£>tS£Ali£S  OF  r/f£    yAGVS  {PNEUJiOCASTKii:  XE/tfKi.    ||| 


%T 


lions  of  other,  general,  diseases  (tabes,  liysteria).  The  latter 
are  distinct  affections  in  themselves,  which  may  occasionally 
be  due  to  |>i,-riphfr;il  causes,  such  as  indigestion,  catching  cold, 
or  reflex  influences,  diseases  oC  the  intestines  and  the  uterus. 
Very  frequently,  it  is  true,  the  seat  of  the  disease  remains  ante 
as  well  as  |x>st  mortem  obscure,  and  this  is  nut  to  be  won- 
dered at  if  we  remember  that 
we  know  little  or  nothing 
about  the  pathological  anato- 
my of  the  vat;us.  Aiiiuiig  the 
cases  hitherto  observed,  many 
were  not  fitted  to  throw  any 
light  on  the  symptoms  mani- 
fested during  life,  as  in  nu- 
merous instances  no  abnor- 
malily  at  all  was  found  in  the* 
nerve,  so  that  we  arc  led  to 
assume  that  the  disease  was 
purely  functional  (i.  e.,  a  dis- 
cisc  without  appreciable  an.v 
lomical  basis).  The  pathol- 
ogy of  the  vagus,  Iherelore. 
belongs  to  the  most  obscure  J"*-  '  nar 
chapters  in  the  pathology  of    Hg.  ■s.-C'.o«^«m''»T..»<woM  thk  hb- 

the  cranial  nerves,  and  the 
following  can  only  he  consid- 
ered to  be  an  imperfect  at- 
tempt at  giving  a  compre- 
hensive exposition  of  the  high- 
ly interesting  diseases  con- 
nected with  this  nerve. 

Since  the  symptoms  may  sometimes  be  the  same  whether 
the  disease  is  of  central  or  peripheral  origin,  we  shall,  so  as  to 
avoid  repetition,  deviate  from  our  usual  method  of  division,  and 
give  our  attention  chiefly  to  the  question  h()W  lesions  of  the 
vagus  may  influence  {a)  respiration,  \,li)  circulation,  {c)  digestion, 
(unctions  which,  as  is  well  known,  are  chiefly  under  the  con- 
trol of  ibis  nerve. 


DULL*  OnUISOAT.t, 
d.r.  uccndlne  root  of  Ihc  (iflh.  m.X/l, 
nuclnuof  the  tafpnt^owis.  n.X  ani  i.AT, 
nucleui  of  ibe  nfiitt.  X//,  hypi%\osal 
nerve,  /f,  KdlLuf  (unlculm  (ropliatary 
fucunilui).  p,  pfTimliat  imt.  »,  olive. 
>- A'. (i;rr>mldtl nucleiu.  /I. a.. anlprior lini> 
pludinal  litBun.  «.«•»,  nudmi  unbicum. 
«.  /, ,  Dudttiui  l>Ur>li*, 


113 


I>/SEAS£S  Of-'  TUB  CRANIAL  NERVES. 


A.    AnliCTIOKS    OF   THE    A I R- PASSAGES    DUE    TO    LESIONS  OK 

Tiiic  Vagus. 

t,  riic  larynx,  alio^'c  alt,  interests  us  in  this  connection.  Thla 
organ  it  innervated  liy  the  vagtis  and  Ihc  acccssorius,  though  it  is 
dttll  a  mailer  of  ili>iil>l  whelhcr  all  the  motor  fihres  originate  from 
the  laiter  or  only  tliose  iliat  innervate  llie  musclc«  uh>i]  in  the  pro- 
duction of  voice,  while  the  vagus  prcsitles  over  tlic  respiratory  move- 
ments of  tlic  vocal  cords;  the  sensory  fibres  of  the  larynx  certainly 
all  helonjr  to  the  vagus. 

'I'he  branthCK  of  the  vagu»,  wliicli  come  olT  in  ihe  cervical  portion 
of  the  nerve  and  innervate  the  laryngeal  muscles  arc  the  superior 
laryngeal  and  the  inferior  or  recurrent  laryngeal.  The  former  leaves 
the  vagus  at  the  lowtr  end  of  the  gangl'tform  plexus. and  divides  into 
a  motor  branch,  which  goes  to  the  crico-thyrnid  muscle,  and  into  a 
sensory  branch,  which  conlainH  the  librcs  for  the  mucous  membrane 
of  the  epiglottis  and  the  whole  laryngeal  mucous  membrane  abovii 
the  vocal  cords. 

The  rccorrent  laryngeal  is  shorter  on  the  right  side,  because,  with- 
out going  beyond  the  ii[ipcr  aperture  of  the  thorax,  it  curls  aroumi 
Ihc  subclavian  artery,  and  runs  hack  in  a  groove  between  the  trachea 
and  the  wsophagus  upward  to  the  larynx,  while  on  the  left  side  it  has 
to  make  the  lon^  course  around  the  arch  of  the  aorta.  It*  terminal 
branch  (K.  lerminalis)  dividt-s  into  two  twigs,  which  together  supply 
nil  the  muscles  of  the  larynx,  with  the  exception  of  the  above-men- 
tioned crico-thyroid,  with  motor  nerves,  and  the  mucous  membrane  of 
the  parts  below  the  vocal  cords  with  sensory  fibres. 

(.Jf  the  laryngeal  muscles,  the  jiosterior  crico-arytenoids  draw  the 
vocal  conls  apart — that  Is,  they  are  the  abductors  or  openers — while 
the  lateral  crico-arytenoids  in  conjunction  with  the  lateral  thyro- 
arytenoids draw  Ihcin  logcthcr,  and  arc  therefore  called  adductors  of 
closers.  Of  these  muscles,  on  each  side  (he  "abductor  "  arises  at  the 
posterior  surface  of  the  cricoid  cartilage  and  passes  upward  and  out- 
ward to  the  end  of  the  muscular  process  of  the  arytenoid  canilage, 
while  the  otlier.  the  "adductor,"  arisen  from  the  upper  margin  of 
the  cricoid  cartilage  and  is  inserted  at  the  outer  side  of  the  muscular 
process  of  the  arytenoid  cartilage.  It  moves  Ihe  muscular  proccsft 
forward,  being  thus  the  antagonist  of  the  abductor.  The  crico- 
thyroids provide  for  the  elongation  and  tension  of  the  vocal  cords; 
they  are  assisted  by  the  internal  thyro-arytenoids,  which  run  parallel 
with  the  vocal  cords. 


In  the  LTryngeal  muscles  paralysis  and,  thougli  compara- 
tively rarely,  spasms  have  been  observed. 


■       OtSEASKS  Of   THE   VAliVS  {.I'NKUMOGAHtltlC  .V/iftfKy     113 

^1  The  cliicf  lurms  uf  jiaralrsis,  which  we  shall  here  cunsidvr, 
^Hie  (I)  the  paralysis  i>f  the  recurrent  laryngeal,  in  which  case 
^nll  the  musclcii  supplied  by  this  iiervi-  are  pnraiyzfd  (or  weuk- 
^(mcdj ;  U)  the  so-called  abductor  paralysis — that  Is.  paralysis  t>l 
^■tbe  posterior  crioo-arytenoidti,  the  openers  of  the  glottis ;  (3) 
^kulysis  ol  the  internal  thyrn-arylcnoids. 
^^^Withoul  going  into  the  much-discussed  and  still  unsettled 
quejiion  as  to  the  mech;inism  of  these  paratysics,  wc  have  at- 

■  temiilcd  to  give  a  succinct  and  clear  summary  u(  the  clinical 
symptoms,  including  the  appearances  found  on  laryngttscupical 
examination  (cl.  tabic  on  page  1 1€). 

I  The  existence  o(  a  cerebral  centre  for  the  laryngeal  muscles 
is  ihown  by  the  fact  that  in  dificrent  cerebral  affections — c.  g., 
ptrudo-bulbar  paralysis  and  certain  brain  tumors — but  only  hi 
tare  instances  (Rougi,  Progris  mid..  1892.  36),  paresis  or  pa. 
nl|ug  o(  the  vocal  cords  has  been  observed.  In  chorea  addiic- 
iiir  paresis  has  been  noted.  A  most  curiously  perverted  action 
olthe  vocal  cords  has  been  observed  hy  Krause  in  the  course 
nl  hysteria ;  on  inspiration  they  were  apprwiched.  while  on  ex 
pinlion  the  glottis  tvas  wide  and  gaping. 

I  Another  form  of  central  paralysis  is  the  nuclear.  In  com- 
plete paralysis  of  one  vocal  cord  a  lesion  in  the  acccssorius 
nticlcus  of  the  corresponding  side  has  been  found  :  the  usunt 
CMiK  n(  this,  however,  seems  to  be  a  peripheral  affection  of  the 
trunk  uf  the  vagus,  or  of  the  recurrent  laryngeal  (by  pressure, 
cinilusion.  injuries,  surgical  operations,  tumors,  and  aneurisms). 
)d  wf  arc  not  often  in  a  position  to  speak  with  certainty  as  to 
the  seal  of  the  affection,  and  to  say  whether  this  is  central  or 
peripheral.  The  ruiturc  of  the  laryngeal  p;iratysi-s  which  occur 
in  general  neuroses  (hysteria,  epilepsy),  intoxications  (lead),  in- 
fectious diseases  (diphtheria,  dysentery,  cholera),  is  quite  i>b< 
»ci>Te.  The  easiest  to  understand  are  those  acquired  thnnigh 
Unining  of  the  voice  and  diseases  of  the  larynx  itself  (catarrh, 
(Ktidiondritis).    (B.  Frilnkcl  on  mogiphonia,  cf.  lit.) 

The  prognosis  ought  to  be  guided  by  the  consideration  of 
Ibe  nattiFc  of  the  primary  affection,  but  wc  should  also  take  into 
considenition  the  functions  of  the  affected  muscles,  and  not 
focitet  that,  for  instance,  in  abductor  paralysis,  danger  o(  sulTn- 
ouioQ  may  arise  at  any  moment.  It  is  always  unwise  to  prc> 
diet  the  exact  time  of  rcco>'%ry  ;  the  course  of  such  ]>aralyses 
i»  Qsually  very  protracted. 

be  treatment  of  most  of  the  cases  has  to  be  conducted  by 


114  D/SBASES  OF  THE  CRANIAL  NERVES. 

a  Specialist,  and  consists  in  touching  the  vocal  cords  with  the 
SDund  (Rossbach).  and  in  the  external  or  intralaryn^eal  use 
of  electricity.  Faradization  of  the  different  laryngeal  muscles 
necessitates  a  dexterity  which  can  only  be  attained  after  a  thor- 
ough acquaintance  with  the  laryngoscopical  technique.  The 
general  treatment  of  any  primary  affection  need  not  be  dis- 
cussed here. 

Spasms  of  the  laryngeal  muscles,  we  have  said  before,  are 
very  rare,  and  are  in  general,  with  the  exception  of  the  spasm 
of  the  glottis,  of  not  much  practical  importance.  Most  fre- 
quently the  spasm  affects  the  adductors,  and  the  condition  then 
resembles  very  much  that  of  abductor  paralysis,  with  this  excep- 
tion, that  the  spasm  is  generally  quite  transitory,  while  the  paral- 
ysis is  often  of  long  duration.  The  aphonia  spastica  described 
by  Schnitzler,  a  disturbance  of  co-ordination  of  the  muscles  of 
the  vocal  cords,  which,  on  an  attempt  at  phonation,  contract 
spasmodically,  is  found  occasionally  in  chorea  and  hysteria. 

The  spasm  of  the  adductors,  which  occurs  especially  in 
early  childhood,  is  called  spasm  of  the  glottis  (laryngismus 
stridulus,  laryngospasmus,  asthma  thymicum  sive  Millari).  Its 
paroxysms  usually  occur  unexpectedly  without  external  cause. 
They  consist  in  the  main  in  a  total  arrest  of  respiration  lasting 
from  several  seconds  to  a  minute  and  a  half,  and  are  ushered  in 
by  a  deep  inspiration  which  is  accompanied  by  signs  of  suffo- 
cation. Only  rarely  does  the  child  die  during  the  attack; 
usually  a  few  deep,  very  audible  respirations  indicate  the  cessa- 
tion of  the  spasm,  and  the  child  seems  completely  well  after  a 
comjiaratively  short  while.  No  definite  statement  can  be  made 
with  regard  to  the  number  and  intensity  of  the  individual  at- 
tacks, because  innumerable  variations  can  occur.  The  anatom- 
ical seat  of  the  disease  is  entirely  unknown  ;  yet  the  fact  that 
not  rarely  eclampsia  or  epilepsy  complicates  the  affection  rather 
speaks  for  the  possibility  of  a  temporary  irritation  of  the  corti- 
cal centre  for  the  laryngeal  muscles.  The  remarkably  frequent 
ucciirrcnce  of  it  in  conjunction  with  rachitis  has  led  to  the  idea 
(Ivlsiisscr)  that  we  are  dealing  with  a  rachitic  softening  of  the 
posterior  part  oi  the  skull,  which  has  rendered  possible  pressure 
upon  the  brain.  Nothing  definite  is  known  about  the  cause. 
In  the  treatment  early  hardening  of  the  child  and  rational 
nutrition  play  an  important  rSIe.  Robust,  well  -  nourished 
children  who  can  stand  changes  in  temperature  without  at 
yncc  catching  cold,  etc.,  are  hardly  ever  affected  with  laryngis- 


0rSSAS£S  OF  TUK    VAGVS  ^.PMEUMOGASTKIC  NHHVBY.     115 


P 


nns  stridulus;  only  delicate  children  with  a  convulsive  tcnd- 
raty,  who  have  been  fed  on  larinnccous  foods  and  oilier  inap- 
Iffuprbic  substilutcs  for  ihc  mother's  milk,  fall  a  prey  lo  (he 
disease.  There  is  no  medicinal  treatment  lor  the  affection. 
During;  the  attacks  we  have  to  avoid  the  danger  of  suffocation 
bf  carefully  watching  the  epiglottis,  sprinkling  the  body  with 
ic&water,  brushing  and  tickling  the  soles  of  the  feel.  After 
Ihc  attack  wc  may  give  nervines  (belladonna,  bromide)  and, 
pcrtia{>s  to  avoid  a  too  Irequcnt  repetition,  narcotics  (morphine, 
1 10  3  milligrammes — gr,  '/to-'/iu  subcutaneously).  The  treatment 
dthc  rachitis  should  never  be  omitted. 


Sensory  disturbances  ol  the  larynx  manifest  themselves 
tiiWr  in  anii-slhe^ias,  or,  what  is  less  common,  in  hypenesthc- 
tie  fit  the  mucous  membrane,  and  arc  especially  found  in  the 
'ii&tnl>ullnn  of  the  superior  laryngeal.  They  are  not  rarely 
rambined  with  motor  changes,  paralysis  or  paresis  of  the  pha- 
rngcal  muscles  (cf.  chapter  xi),  but  often  they  appear  alone. 
The  most  common  lorm  is  the  ana^thesia  attending  diphlhc- 
niic  |ii;iralysis:  it  is  characterized  by  the  absence  «1  the  rc- 
Att  tCiigging  and  cough  which  normally  follow  touching  the 
Ivyugeal  mucous  mcmbr:inc  with  the  sound,  the  finger,  or  the 
'''yiiKDscope.  In  such  cases  it  may  happen  that  liie  Inod  on 
(lq;hititiun  enters  the  larynx,  and,  through  faulty  closure  ol 
'fcf  glottis,  can  not  be  removed  by  coughing,  and  thus  gives 
w  lo  dangerous  attacks  of  choking,  and  even  to  aspiration 
Cnnitnonia,  The  latter  docs  not  seem  to  occur  in  cases  of 
purdy  hysterical  ana'sthesi;). 

Thchypcriesthcsia  is  found  in  ulcerative  processes,  or  in  bad, 

^■CDlc  catarrhs.  Although  it  seems  to  play  a  prominent  rdU  in 
^ntcrical  patients,  it  is  in  realily  not  present,  but  is  erroneously 
||d  lo  exist  by  patients  who  are  forever  worrying  ihemselves 
Handing  ntiw  ailnieuts,  or  is  produced  by  autusuggestiun. 
The  annrsthesia  calls  for  electrical  treatment,  galvanization 
<if(lic  larynx  and  the  palatal  muscles,  the  fanidic  brtish  to  the 
llirual,  etc.  To  meet  the  hyperarsthcsia,  narcotic  remedies  may 
be  of  service,  but  in  hysterical  patients  often  no  other  IreaU 
nnK  but  a  good  sensible  lecture  is  needed. 

ti-iri:k.\Ti;HK. 
WVgnwf.    I'cbcr  Krlilktififmuskcmihniung  jiU  }>ym|itoin  cl«r  Tal>e».     Inaug.- 
Ot«rn  .  IlrHlii,  r887. 
,  FitnkrL  IWmh,     Url>cr  dbe  DeschtriiitunKSSchwSchc  <Ier  Slimine.  Miitp phonic. 
Ucuurhc  met)  WoclimMhr..  1S8;. 


It6 


DISEASES  OF  THE  CRA.WIAL  NERVES. 


TABLE   OF   THE   MOST   COMMON    PARALYSES   OF   THE   LARVN- 
<;EAL   MUSCLES. 


KiDdof 

pAimlyib. 

Complete 

Occurrence. 

In  compression 

Symptom, 

OphthjilmoKopic  picture. 

Voice     not     clear. 

Vocal  cords  slightly  ab- 

recurrent 

paralyses   of   (he 

Patient    is   easily 

duc(ed,    (he    so-called 

laryngciil 

vagus  or  the   re- 

tired  on   talking. 

"cadaveric    position  " 

pOsy. 

current  laryngeal 

Coughing   impos. 

(Fig.  iq).     In  forcible 

(carcinoma    (Eso- 

sible. 

phonation  (he  healthy 

phagi),  often  uni- 

cord   reaches    beyond 

lateral    Qed).    as 

the  middle  line.    Over- 

initial  symptom  of 

Hding  of  the  arytenoid 

aortic     aneurism. 

cartilages  (Figs.  3o,  3i). 

In  tabes. 

Abductor 

In  diiieases  of  the 

If  bilateral:  extreme 

Glottis  appears  aa  a  nar- 

pBialysis 

nerve    itself,    the 

inspiratory    dysp- 

row  slit,  becoming  still 

< 

(paralysis  of 

causes   of   which 

ncea;  if  unilateral: 

narrower    on    inspira- 

the posterior 

are      often      un- 

inspiration   ham- 

tion   (Fig.    33).      In- 

> 

crico- 

known. 

pered,!  ong-drawn , 

ability   to  abduct   the 

1-1 

arytenoids). 

noisy.      Dyspnea 

paralyzed    vocal    cord 

on   the   least   ex- 

(Fig. 33). 

B 

ertion.        Speech 

M 

but  little  affected. 

Paralysis  of 

In  catarrhs  of  the 

Voice  hoarse;  speak- 

Glotds   does    not   close 

the  internal 

mucous      mem- 

ing an  effort. 

completely  on  phona- 

o 

thyro- 

brane of  the  lar- 

tion  (Fig.  34).     If  a( 

o 

arytenoids. 

ynx.     After  over. 

the  same  time  (he  aryt- 

a 

exertion    of    (he 

enoids   are   paralyied. 

I 

voice.       In    hys- 

the glottis  presents  an 

i3 

teria. 

hour-glass  outline  (Fig. 
25).     Neither  anterior 
nor  posterior  portion  is 
closed,   but   the   vocal 
processes  are  in   their 
normal  position. 

Adductor 

Rarely  isolated.    In 

Absolute  absence  of 

Nothing  characteristic 

paralysis 

hysteria. 

voice.     Power  of 

(paralysis  of 

coughing  retained. 

the  lateral 

"  Phonic     paraly- 

crico- 

sis'' (TUrck). 

arytenoids), 
Paraly!iiR  of 

Voice  rough  ;  high 

o  3 

After  diphtheria. 

Excavation  of  the  vocal 

gg 

tlic  crico- 

(ones impossible. 

cords.     Cords   do   not 

thyroid*. 

1 

vibrate  visibly. 

MSEAS/iX  OA   7J/£    fAUt/S  {PAUVMOOASrjf/f  A'tHVl^    117 


u*.     Oii«>TiillDe  u(  tb*  arytaioid  c*r> 


KiK  ». -fAHAiviii  or  iKyiM  PonvHQK 
CmcoAKyTRKiiiiHi  (In  liuplntlaa). 


fk  Ik— riULnttorTHRRioHTPMT. 
CBK-K-tRmMND  (ni  iMpiniUeai. 


riK.  >4.    PAULma  or  torn  IsmRHAL 

TirVM>^IIVTUN>IM  [•CIlH  iMTBfltlll. 


IT(,  as-—'*"*'*''-   "'    >■■  '  "   IM»:">"*1.  TltVTIi>*Hint»OIIM, 

■MHcMtd  Willi  puvm  ot  Uir  arytrnciid  mutcW. 
n^  •O'^S— Pully  atlm  STHt'MrViJ..  (d^iOy  Alter  KiniHOVm-. 


Il8 


ff/S£ASSS  OF  THE  VKANIAt  SERVRS. 


Ilolmn.  (lurdon     I'Mralysii  of  ihc  Abductors  of  (he  Vocal  Bands.    Lanni.  Ocio- 

twr  13.  1B87, 
Kidd.    DiUtirr.-il  I'aralyiis  of  ihe  Dilator  Mtisclei  of  ihc  filoilis,  with  Sub!tH|u«it 

I'jrcsiaurttK  Coiisinciors.     Lancet.  July  16,  rSS?.  |i.  108. 
Kuuncr.     Zur  Kcnntniw  clcr  VaguMj mpionii-  lici  tier  Tabc»  donal      Beflincr 

klin  WochenicliT.,  So.  ».  18S?, 
Zlems^rn,  V,     Ucbcr  diplithrritisdte  LtLhmung  und  dcrrn  llch-intllung.     Kiln. 

Vorrr,  Iv.  Lc>|Mig.  Vogcl.  i887. 
Newn^ann,    Olasgow  Med,  Joum..  September,  1S87  (\''iiKU!i  Sxinpiwrnx  in  Cajtc^ 

or  Aortic  AncuriMnl. 
Elscniohr.     Zur  Putliologic  cicr  ccniralcn  KrhlkopHHhniungcn.     Arch,  f,  Psych. 

u,  Ncrrctihli,.  1888,  %\x.  1.  314. 
Schech.      Vebcr  Kccurn;nsllthiiiun)[.      Munchencr  reed.   Woclieiuchr,,    1S88. 

x«xr.  51. 
Laitd^jraf.     Charlli  Annalm.    18S8.   xiii.   p,  150  (lj;ri-cidcd   Paialysin  or  the 

Vwal  Cords  in  Pericardii  in). 
Meymann.     Zwei  FSIIc  von   LSIiinung  d«  M.  crico-lhyreoideMs,     Ucutwhes 

Arch.  f.  klin  Med..  i8»9,  xUv.  r>. 
Itut|[cr.     Die  Frajrc  der  I'oslicuslShniung.     Volkniano'i  Samml.  klin.   Vorlr,, 

1891.  Ncuc  Folge,  57. 
Kalnnsttriii.     Ucber  die  Mcdianstclliing  dcs  .Stimmbande:!  bci  Kccunvndttli- 

itiunj;.    \'irchow'»  Archiv,  iSyj,  cxxviii.  Heft  i. 
L«hr.  M.     Deutsche  med.  Wochcnsehr,  i8<)3.  45. 

a.  The  lungs  receive  from  the  thoracic  portion  of  the  vagus  the 
pulmonary  or  bronchial  nerves,  the  so-called  anterior  branches  of 
which,  in  conjunction  with  filatnentsof  the  sympathetic,  form  a  plexus 
on  the  anterior  wul!  of  the  bronchus,  and  enter  with  the  latter  the 
tungs  wliilc  the  (luateriur  branches,  together  with  those  coming  from 
ihc  four  upper  thoracic  ganglia  of  the  sympathetic,  are  distrihuied 
in  the  same  way  m\  the  posterior  surface  of  the  bronchus.  They 
are  the  motor  nerves  for  the  unstriped  muscles  of  the  bronchial  tree. 

The  diseases  of  the  bronchial  nerves,  which  produce,  as 
it  seems,  a  (aully  innervation  of  the  circular  muscles  of  the 
bronchi,  give  rise  to  the  morbid  condition  which  has  lately 
been  the  subject  of  much  controversy,  and  is  describ«l  under 
the  name 

Brenthml  Aithma,  Asthma  Bronthiale  s.  Com'u/shvm  s.  AVrri*- 
w«i,  Sflasmus  BrvHchialis  {Rombfrg). 

Pathology. — Opinions  about  the  nature  of  bronchial  asthma 
ftre  slill  divided,  While  some  fSttjrk.  FrUntzel)  maininiii  lh;il 
it  is  due  to  an  acute  .swelling  of  the  bronchial  mucous  mem- 
brane, others  {Bamberger.  Winlrich)  consider  a  tonic  spasm  ol 
ihc  diaphragm  to  be  responsible  for  it ;  still  others  (Trousseau. 
Biermcr)  believe  it  to  be  a  vagus  neurosis,  supposing,  in  conse- 


WS£j4SeS  OF  run  vagus  {PKEUMOCASntlC  Xf.ttVK). 


"9 


I 


i 


quencc  of  a  disturbed  innervation  (va<;us),  .t  Ionic  spasm  to  take 
pbcc  io  the  circular  muscles  u!  the  mcdium-mcd  and  tine 
bronclu.   tlius    producing    an    acute   pulmonary    emphysrm.'i. 
M\cr  Berl  had  shown,  in  1870,  by  experiment  that  a  contrac- 
tian  of  (he  medium-sized  and  finer  bronchi  could  actually  be 
produced  by  irritating   (he  vagus,  later   Hicrmer  worked  out 
histheory  so  thorouglily.  and  has  defended  it  so  successfully, 
ihii,  ia  spite  of  the  objections  recently  raised  by  Schmidlborn 
fVolkmann's  Samml.  Idin.  Voriragc,  1889,  No.  328).  who  con- 
Milers  a  vascular  spasm  in  the  distribution  of  ihe  pulmonary 
attery  to  be  responsible,  we  arc  probably  justified  in  accepting 
it  as  correct,  especially  as  with  its  help  alt  the  characteristic 
t]riip1onts.  the  sudden  onset  and  the  sudden  disappearance  ol 
Ihc  attacks,  the  expiratory  dyspnoea,  the  low  position  of  the 
dikphragm.  etc.,  can  well  be  explained.     It  is  clear  that  this 
btiMdiial  spasm  forms  an  impediment  much  more  easily  over- 
come by  inspiration  than  by  expiration,  and  that  this  difliculty 
acipiration  must  of  necessity  not  only  influence  the  alveoli, 
but  also  the  smaller  bronchi,  from  which  the  inspired  air  can 
only  imperfectly  be  forced  out;    hence  arise  dyspnoea  and 
mphysema  during  expiration.    On  auscultation,  sibilant  rhon- 
<Uare  heard  all  over  the  chest.     But  all  this  does  not  ex|>lain 
tbe  cause  of  the  spasm.     This  may  be  sought  (or  in  an  inde- 
pendent aSection  nf  the  bronchial  mucous  membrane,  a  view 
which  possibly  may  be  supported  by  the  presence  in  the  sputa 
ol  aithmaiics  of  Ihe  su-called  "Curschm,tnn*s  spirals"  (spiral 
libnads  which  must  be  looked  upon  as  casts  ol  the  finest  bron> 
tUoles^  and  of  so-called  ha^mosiderin  cells  found  by  v.  Noor- 
<l«i.  which  are  identical  with  pigment  cells  (Zcitschr.  (.  klin. 
Med..  XX,  I.  2).    Or  we  may  assume  a  reflex  origin.    Thus  Ley- 
dm  maintained  thai  certain  pointed  octahedral  crystals  which 
ticdijcovered  in  the  sputa  of  asthmatics  irritated  the  mucous 
"wmbrane.  and  produced  the  spasm.     Many  observations,  how- 
ewr,  allow  us  to  doubt  the  correctness  of  this  latter  view. 
Uhiabecn  established,  on  the  other  hand,  beyond  doubt  (Vol- 
lolioi,  Hack.  Sommerbrodt).  that  certain  diseases  of  the  nasal 
'•"Koiis  membrane  (polypous  growths,  chronic  catarrh,  etc.) 
•"Tjive  rise  (o  asthmatic  attacks — reflex  neurosis :  possiblv 
"•f  part  in  the  production  of  these  is  played  by  the  reflex 
<iiUuiioo  of  the  vessels  in  Ihe  bronchi.il  mucous  membrane, 
■tch  was  by  Stilrk  and  Weber  supposed  to  take  place  in  con- 
■eclioii  with  the  bronchial  spasm,  a  theory  which   was  after- 


130 


WSSASSS  OF  THE  OtA.VfAL  .VEMVES. 


ward  cuiitirmcd  by  Sommcrbrodt.  With  reference  to  this  con- 
nection I  have  convinced  myself  from  lon^  experience  with 
such  cases  that  the  above-mentioned  affections  only  lead  t» 
uathnia  in  persons  with  a  nervous  prctlispusiliun  :  they  are  only 
the  "agrals  prvvocatturs"  not  the  real  cause  (Uris^^and.  Rcvuc 
de  mid.,  likjo,  12).  This  is  especially  the  ose  in  children 
(Blache.  I^tiidc  siir  Ta-sthmc  chcj;  Ics  etifaiils,  Paris,  1890). 

Symptoms. — The  cbanicteristic  leatures  of  the  disease  are 
the  paroxysms  of  distress  and  dyspn<i:a.  previous  to  which  the 
patient  may  for  days  complain  of  general  malaise,  be  low-spirit- 
ed, and  troubled  with  digestive  disturbances,  diarrhcea,  etc. 
The  attacks  begin  quite  suddenly,  usually  at  night,  more  rarely 
in  the  daytime:  during  them  the  respiration  is  changed, so  that 
Ihc  breathing  in  inspiration,  but  more  especially  in  expiration, 
becomes  labored  and  accompanied  by  a  loud  wheezing.  This 
may  last  only  a  few  hours  or  may  continue  for  days,  and  may 
be  repealed  at  varying  intervals.  Toward  the  end  of  the  attack 
moist  riles  can  be  heard  on  auscultation,  and  there  is  expecto- 
ration which  contains  the  above-mentioned  spirals  and  crystals. 
Del  ween  ihc  attacks  the  patient  enjoys  perfect  comfort. 

i£tiology. — The  xtiology  of  the  disease  is  but  little  known. 
No  doubt  hereditary  predisposition  does  exist,  and  persons 
with  a  neuropathic  family  history  fall,  usteris parOms^  more  easy 
victims  to  asthma  than  others.  Just  of  what  nature  the  exciting 
cau^s  of  the  actual  outbreak  are  we  are  as  yet  unable  to  say. 
\Vc  have  repeatedly  observed  thai  hysterica!  persons  suffer 
from  asthm.itic  conditions,  which,  on  examination  of  the  respir* 
atory  organs,  prove  to  be  of  a  nervous  origin.  In  these  in- 
stances the  patients  are  for  days  troubled  with  piimxysmal 
dyspmca,  their  expiration  is  diflicuti  and  wheezing,  while  noth- 
ing abnormal  is  found  on  auscultation  and  percussion.  We  shall 
later  on  have  more  to  say  about  this  hysterical  asthma. 

Thul  the  inhalation  of  certain  kinds  of  dust  muy  give  rise  to 
asthma,  while  not  a  frequent,  is  certainly  a  welLaiilhenticated 
observation.  We  may  especially  find  this  connection  when  the 
same  obnoxious  causes  have  been  acting  frequently  and  through 
a  rather  prolonged  period  of  time,  as  is  the  case  in  those  who 
follow  certain  occupations  (millers,  bakers,  etc.):  in  the  same 
way  it  is  well  known  that  repeatedly  drug!;;ists  have  been  af- 
fected regularly  with  asthmatic  attacks  while  occupied  with  the 
pulverization  of  ipecacuanha  root,  and  that  the  dust  of  certain 
kinds  of  grain--lor  instance,  of  oats— causes  such  disturbances 


DISEASes  OF  rt/E  t'AGVS  {PXEVMOCASTKtC  .\'£JtyE\.     \2\ 


\ 


t 
I 


Id  Ihose  enga^^ed  in  thrashing  (cf.  Hirl.  Krankhciten  dcr  Ar- 
bdier,  1S71.  Bd.  i,  p.  12). 

The  asliima  which  <levclops  under  ihe  influence  of  certain 
fefccins  has  tu  be  classed  amun^  these  cases,  and  in  this  con- 
ncdjoii  the  so-called  lead  asthma  (asthma  saturninitmjisdeserv- 
rocntion.  This  is  a  very  peculiar  disease,  which 
Is  in  vt^ry  acutely  only  a  few  minutes  after  the 
has  been  taken  up.  Though  to  the  highest  degree  dis. 
Imping  !■>  the  piitieni.:i  fatal  ouicotne  in  it  has  never  been 
oolccl  icl.  Ilirt.  (?/».  ((■/..  Bd.  iii.  }«.  40).  This  trouble  is,  however. 
CTcn  among  leiid- workers,  quite  rare,  so  that  we  may  assume 
Aat  among  one  hundred  affccti<)n5  due  to  working  in  lead  two 
ioftsnces  at  most  ot  this  above-described  asthma  occur.  As  to 
iWinode  of  origin,  wc  do  not  know  whether  to  refer  it  to  the 
ictioi)  o(  the  poison  on  ihe  central  nervous  system,  or  on  the 
peripheral  nerve-endlnys  of  the  vagus. 

Treatroeat. —  We  are  noi  acquainted  with  any  specific  (or 
bronchial  asthma  :  the  much-recommcnded  iodide  of  potassium 
Ux>-5.o(xxx  to  Ixxv  grs.)  a  day)  often  fniU.  and,  as  a  rule,  wc  do 
■Dt  Kcomplish  much  with  the  usual  nervines,  arsenic,  quinine, 
bromtde.  etc.  From  Ihe  use  of  electricity  we  have  never  seen 
Uf  lasting  heneht.  Wcllconducted  hydrothcrapcutic  meas- 
am  may  produce  a  decided  decrease  in  the  frequency  and  the 
WKiity  of  the  attacks.  For  the  treatment  of  the  attack  itself 
Wean  foremost  recommend  pyridin,  which  w.is  suggested  by 
S(t.  It  i&  a  product  obtained  in  the  dry  distitiation  of  organic 
wUlances.  a  colorless  fluid  which  easily  evaporates  in  the  air. 
F«  ibe  therapeutic  tis«  half  a  teaspoonful  of  it  has  to  be  poured 
Misballow  dish,  and  this  inhaled  three  to  four  times  daily  in 
sdoscd  room.  The  smell  is  horrible,  and  often  disgusting,  but 
*i»  many  instances  the  action  was  found  extremely  beneficial. 
AtMwn  as  the  pyridin  evaporates  the  patient  becomes  easier, 
'he  frriings  of  distress  arc  relieved,  the  heart's  action  is  more 
f^pilar.  The  effect  is  not  always  lasting;  still.  I  have  seen 
tats  ill  which  daily  regular  inhalations  used  for  several  weeks 
lure  nut  only  cut  short  the  individual  attacks,  but  have  also 
dctreued  their  frequency.  Of  course,  with  this,  as  with  all 
othfrrrmedies,  we  may  be  disappointed.  Krom  the  inhalaiion 
t^  the  lumes  of  burning  saltpetre  paper,  which  has  recently 
aftatn  been  recommended  by  Kochs,  I  have  only  seen  transient. 
ne*fr.inv  tasting  effects.  The  same  holds  for  the  well-known 
sinmunium  cigarettes,  for  amyl  nitrite,  and  the  vapors  of  tut- 


122 


I}/S£ASES  OP   THE   CRAUIAL  JVH/ffES. 


]>cntinc.  More  good  may  be  expected  from  the  administration 
af  linct.  lobeliEB,  which  often  works  like  a  charm  (linct.  lobcl.. 
5.0  ( III  Ixxv) ;  ai\ux  lauroccr..  1 5.0  ( 3  iv).  Sig. :  1 5  to  20  drops 
every  two  hours).  An  alkaloid  "  lobeliii "  has  been  used 
by  Nunes  {Rio  de  Janeiro,  1889).  With  the  extract  o(  que- 
bracho, which  has  been  recommended  by  Fenzoldt.  I  have  no 
large  cxiiLTicncc  ol  ray  own.  Hyoscyamine,  together  with 
small  doses  of  strychnine,  given  several  times  a  day,  has  been 
used  by  Walker  (Lancet,  August  20,  1 887.  p.  368^ 


LITERATL'RB. 
IlicrmCT.    Uebcr  t^ronchialAnihina.    VullcmanD'tche  Sammtung  klin.  Voriii^r 

Muhuux.    The  I'athogLTic§is  of  A&thmalic  Aiuckfc.    Jogrn.  <le  Bnix.,  vo\.  luiii, 

p.  305.  18S1. 
Hi<-i{cl  unil  Edinjier.     IJcutschc  Zcitschr.  (.  klin.  M«l..  1881. 
HJick.     Ucbcr  ricic  upcratirc  RailicAlbchandtung  bmiitimicr  rocinm  von  Mt- 

grttne,  Asthma,  Heulicber.  sowie  tAhlrckhcr  verwandter  Entchrinungcn. 

|8»3. 
Schech.     Die  sogen.  Kettcxncurosen  unci  ihre  Ilciiehuni^n  lu  den  Krankhciicn 

d«r  Niiw  and  <la  Kachcni.     Uaycr.  Xnil.  IntelligenibL,  Bd.  uxi,  p.  ja. 

1S84. 
SchiifTcr     Auider  i'raxisi  Naticnleiden  und  Kcllcxncurocen.     Ucutach.  m«l. 

WotlicnKhr..  pp.  23.  14,  1884. 
Sommctbroilt.    Miiihcilungcn  von  llciliingcn  palholog.  Zusifinde,  wclchc  dufch 

RellcxvorK*ngc  von  der  Naw  lier  beiucrkl  wurdcn.     Bcri.  klin.  Wochen' 

icht.,  pp.  10.  11.  1884. 
.Sommrrlirodi.     I'ebcr  N;i*cntrflcxncijro»cn.     Ilml..  No.  11.  1885. 
Siv.  lrt:rm:iiti.     Bull,  dc  TWr4|K'iil..  June  yo.  1885,  vol.  cviii,  p.  {19.     (Recom- 
mends pyridin.) 
Uicmicr.     Bc-riincr  Win.  Wochen schr.  41,  1886. 
Kochx.    Beittiijf  /ur  Ktnntnis.i  der  Vetbreniiungsproducle  des  Sal|>rten'^l>ien» 

und  dcr  Uruchcn  dct  Asilima  broiii:hialc.    Ccntralbl.  {,  kilo.  Mud..  Bd.  irii. 

p.  40.  1886. 
Grocco,  I'ieiro.    Sulb  |)a(oIO|^a  dci  nervi  cardiaci.     Riviit.  cRn.  di  Rolo);ru.  p. 

11.  1886. 
Duweaud.    Dc  I'asihme  d'nrigine  naxale.     Thisc  dc  P.tn£.  r887. 
Calineltes.     Le*  nevrosc*  rirtrxe*  d'oripne  iiosnle.     I'rojir.  mid..  No.  28.  p.  30. 

1887. 
Vnaa^.    On  Dyipniv;!,  e»j>ecially  on  the  Dyxpncca  of  Axlhma  and  Bronchitis, 

and  ihe  Eflccts  oi  tht-  Niintrs  upon  it,     Lancet,  July  9.  1887,  p.  51, 
Sit.  Germain.    Die  cinUchi-n  Liingcnkninkhdlcn,    Translated  into  ticrman  Ity 

M.Salocmin.     Berlin,  DUmmler,  1887. 
Bragclmann.     lleher  Asihma.    Deutsche  Medlclnal-Zcitung.  39W«y..  1888L 
V.  Ua*cb.     Wiener  Mnl.  /Ag..  1S88.  33.  34 
Granc her- Uai bier.      Dc  t'astlime   cbu    In  cnraniv     Ga«.    mid.    dc    Parii, 

1SS9.  16. 


0/SJSAS£S  OF   THE   fACfS  {PATgl/AfOGASr/t/C  JVexyXy.     133 


I 


Hsch.    Uk  logenanntc  na»ate  Fi>nn  dea  Bronctiutlnlluna.    Vulkminn's  Samn»- 

bitig  kiln.  Vonrtl),f.  1889.  No.  344. 
Sdinlilt.  Ad.     Zur  Kenntnivi  dcs  Asthma  branchUlc.    CcnimlbL  f.  tilin.  Med.. 

it^i,  3$  (Exjkinbuiicin  ol  Asthmatic  Spuu  (or  Tibrin). 

B.  CaKIJIAI-   AhTECTIONS  DUE  TO  LESIONS  OF  THE  VaCUS. 

riie  !iU|>crioT  and  iiiferior  cardiac  branches  are  given  off  from  the 
UTflcal  and  ihorairic  purtiitns  uf  the  va]{us ;  they  join  the  cardiac 
bnachcs  tif  the  syin{>aibctic  to  form  the  cardiac  plexus  (superficial 
and  deep).  It  has  nut  yet  been  (Ictermincd  of  nhat  character  these 
Mmare:  there  is,  however,  no  doubt  hut  that  we  have  to  distin- 
|nbli  Inhibitory  fibres,  the  slimulntion  of  which  diminishes,  and 
Moderator  tibre^i.  the  Ntimulation  of  which  increa»^«  the  number  of 
bcirt  beats.     The  sensory  nerves  of  the  heart  are  also  (umiKhed  by 

tJKVIgUS. 

An^na  Pettoris. 

Among  ihe  neuroses  of  the  hcurl  which  probably  are  caused 
b>'>  4)^'urbance  in  the  vagus,  wc  shall  lirst  consider  angina 
hystcricii  or  angina  |i«ctori»  (sleiiucardin.  cardi:iu  neuralf^ia. 
nervous  heart  pain),  a  disease  of  the  true  nature  ol  which  our 
kaourledge  is  as  yet  ijuite  imperfect,  though  its  symptoms  have 
been  rcc(^nizcd  for  more  than  one  hundred  years  (Ileberden. 
l"/2).  Its  cardinal  symptom  is  a  piercing,  burning,  paroxysmal 
piin  in  the  region  of  the  left  nipple,  attended  with  a  sensation 
0*  impending  death  :  it  often  radiates  into  the  left  arm,  and  even 
<k>«n  to  the  finger  ti|)s,  and  may  continue  lorminulcs  or  hours. 
It  inuaily  begins  without  any  premonition,  and  surprises  the 
[otient  by  day  at  his  work,  or  wakes  him  up  at  night  out  o!  his 
•Itcp.  The  severity  cA  the  pain  diEfers;  in  some  cases  it  is 
moderaic,  in  others  it  reaches  an  insupportable  degree.  Dysp- 
WHi  is  not  always  present ;  the  respiration  remains  somciimes 
reguhrand  quiet,  although  the  patient  suffers  from  a  distress, 
iflg  feeling  of  anxiety,  and  his  skin  is  covered  with  a  cold  sweat. 
Darinfr  the  intervals,  the  patient  feels  perfectly  well,  unless 
there  is  a  co-exisling  lesion  of  the  heart  muscle  or  valves. 

The  diagnosis  may  present  snnie  difficulties,  since  intcrme- 
diiie  conditions  between  angina  pectoris  and  bronchial  asthma 
an  met  with,  or  a  combination  of  the  two  conditions  may  occur. 

The  prognosis  depends  mainly  upon  the  question  whether 
"e  have  to  deal  with  a  vagus  neurosis,  or  whether  some  com- 
pfiation  co-exists.  If  the  myoairdium.  owing  to  disturbed  iii< 
tractrdial  circulation  (caused,  for  instance,  by  athernma  of  the 
coronary  arteries  and  insuflicieni   blood  supply  to  the  myocar- 


■ 


124 


/>/S£AS£S  OF  TflR  CRANIAL  .VSfifES. 


diuiii,  or  by  syphilis),  lias  undergone  pathological  changes, 
death  may  occur  during  an  attack.  Such  cases  are  not  rare, 
and  I  have  recently  again  had  occasion  to  observe  an  instance 
of  this  kind,  in  a  matt  ol  ruhust  appearance  who  sutlercd  from 
stenocardia,  and  who,  while  in  apparently  good  health,  died 
suddenly  in  an  attack  within  two  minutes  after  its  ons«t ;  the 
arteriosclerosis  was  very  pronounced.  Sudden  death,  however, 
is  never  to  be  feared  unless  the  heart  is  organically  diseased. 
It  is  impossible  to  give  an  absolutely  favorable  prognosis  with 
regard  to  recovery,  because  here  also  we  do  not  possess  any 
remedy  which  is  capable  of  doing  away  with  the  attacks  en- 
tirely. But  the  same  suggestions  as  have  been  made  (or  the 
treatment  of  bronchial  asthma  apply  lo  cases  o(  angina  pectoris, 
and  about  the  same  results  have  been  obtained  in  both.  11  in- 
ternal treatment  can  not  be  dispensed  with,  digitalis  may  in  the 
first  place  be  tried,  rhen  strophanthus,  and  finally  arsenic, 
which  latter  mav  with  advantage  be  combined  with  strychnine. 
With  the  linct.  piscidia:  erythrina;.  which  is  supposed  lo  lower 
arterial  tension  and  which  has  been  recommended  by  l.i^geois. 
I  have  no  personal  experience.  It  is  prescribed  as  follows: 
Tinct.  pise.  (■rythr.,6o.o(3  tv) ;  tincl.  veratr.  virid.,  io^(3ijss.): 
tinct.  aconiti,  1 5.0  ( ill  225).    Sig. :  1 5  to  20  gtt.  t.  i.  d. 

For  the  attacks,  freshly  prepared  amyl  nitrite,  a  few  drops 
(5  to  to),  to  be  carefully  inhaled  by  the  patient,  is  the  most  use- 
ful trcatmcni :  besides  this,  inhalations  of  chloroform  and  hypo, 
dermic  injections  of  morphine  deserve  recommendation,  as 
they  relieve  the  patient  at  once  from  the  intolerable  torments 
ol  his  condition.  The  severe  states  of  collapse  following  these 
measures,  observed  by  Bamberger,  are  probably,  after  all.  quite 
exceptional. 

Murrcll  recommends  a  systematic  treatment  with  nitro- 
glycerine (Therap.  Monatshcftc,  [S90,  iv.  11),  beginning  with 
0.0001,  increased  gradually  100.003  p.  die.  From  external  meas- 
ures, such  as  the  application  of  hot. water  bags  or  ice-bags  over 
the  heart,  as  well  as  from  hot  baths.  1  have  seen  no  good  result. 

The  a;liology  of  the  disease  is  as  obscure  as  its  nature :  here 
we  must  again  carefully  discriminate  between  the  cases  where 
the  angina  pectoris  is  merely  a  symptom  of  some  orgimic  heart 
disease  (disease  of  the  coronary  arteries,  fatly  hearr,  valvular 
disease),  and  where  it  appears  as  an  independent  affection — i.  e., 
where  no  heart  lesion  can  be  demonstrated,  The  latter  form 
is  disproportionately  less  frequent  (Gauthier),     Males  and  those 


MSJtMSXX  OP   Tllf.    VAGUS  il'MFASMOQASTItiC  JVAXI'A).     125 

■ 

in  age  seem  especially  predisposed  to  llic  disease 
[(Crautbier) ;  yet  the  author  hns  atsu  seen  cuses  where  displace- 
l^tof  the  ulcrus  was  accumpanicd  by  stcmitaniia.  as  well  as 
io(  undoubted  aiiguia  pei;lom  in  children  ttiirireti  ti>  til- 
tttn  years  of  age.  Psychical  disturbances,  such  as  are  found 
ill  hvNterical  pntietits.  also  the  inntience  of  ct-riain  poisons — 
e.g.,  tobacco— deserve  some  considcrati'm.  Pcycr  (Ziirich) 
claims  to  have  observed  a  ctmncction  between  stenocardia 
aad  tpennatorrhcea  (Wiener  med.  Pressc,  1893.35).  That  an- 
gina pectoris  is  a  vagus  neurosis  can  reasonably  be  accepted, 
as  the  sensory  hbres  of  the  heart  arc  furnished  by  the  vagus, 
ami  a%  pnin  is  the  most  prominent  symptom  of  the  trouble. 
I'lTjiumably  the  sympathetic  is,  however,  also  concerned,  nnd 
siRic  are  even  inclined  with  Lancereaux.  who  several  limes 
luiiiid  this  nerve  vascularized,  to  regard  the  cardiac  plexus  of 
the  sympathetic  as  the  chief  seat  of  the  disease;  but  e%'en  were 
ihii  so,  wc  could  not  exclude  some  participation  of  the  vagus. 
A  publication  of  I-croux,  who  found  at  tbe  autopsy  a  bronchial 
gUiid  and  the  right  vagus  grown  together  in  a  case  where  an. 
iginal  seizures  bad  existed  until  just  before  death,  appears  also 
l|u  ipeak  in  favor  of  an  implication  of  the  latterncrvc.  Fre- 
LqDCotly  no  anatomical  lesion  can  be  found. 


I-ITKKATl'KK. 

LhbV    Zwt  L.ehrc  •ran  den  vuomolor.  Neurotcn  (Anf^ina  peciorii).     Inaux. 

Dm..  Hrraliu,  187$. 
iUkui     I^dinli.  Med.  joum.,  March.  iSSt,  vol.  xxvi.  p.  TfSg. 
UKkduic.  Jnhn  N.    A  Oinintiviiion  lo  the  Pat liology  and  Ttr.it mcnl  of  llie 

RofNratory  V*»omotor  NeuroiM.    Nt:w  York  Med.  Jouni,.  t'civ  z6,  1887. 
Hwtud.    The  Weekly  Med,  Rev..  St.  Lou^,  7,  18S7.     (Recommends  perw- 

■mnoc  wilh  mliite*— iodide  of  nxlium.  gr.  nv-xk  daily  for  a  >«ar  or  a  year 

Ml  a  halfk 

iLi  OkK:    L'ongine  de  poiirine  h)-it^nque.     O.  Ooin.  P.iTis,  1887. 
fVwBMdL    Die  untitle  l>y«pnoc  unit  das  cardulc  Atthm.i.     Klin.  Zeh-  und 

Snafrjijen,  1,  3.  4.  '887. 
^•fbrta     Traill  dc  I'angiiie  dr  poltrinc     I'ari*.  Dekhaye,  1887. 
MwtgmiiiB,     BdlraK  iur  Kennlnim  der  Heraneurown.    Deuische  meil,  Wo- 

dwiHChrH  1K88,  45. 
[LilahMty,    DcT  Nerv.  vagtis  und  d'K  An^tia   prclori^.     tictliner  klin,  \V<t- 

Atiurhr..  18S9,  jx 
^f  tinkit.  VnTiiiilt  1-/  4/.     Vrrtwndliingen  de«  X.  Congresses  fur  innere  Medicin. 

DniiMrhe  Mrd--i^ig,.  1891,  y}.  \>  ^ytt  trf.    (InlenntinK  dlticuMiun,) 
rl      IhrrtmpT  kiin.  WMlinmhr,,  1891,  21, 
LHv.     Otr  nrrvMr    1 1 iTjschnai; ))<■  1  Nrunulhenia  VAxomoloria)  und  Hire  Be- 
(uadliinc.    WmlMden,  Bcrgninnn,  i89i- 


126  DISEASES  OF   THE   CRANIAL   NESVES. 

Nervous  Palpitation  of  the  Heart. 

Secondly,  we  have  to  speak  of  the  so-called  nervous  palpi- 
tation of  the  heart,  palpitatio  s.  hyperkinesis  cordis,  by  which 
term  we  designate  a  paroxysmal  increase  in  the  frequency  and 
strength  of  the  heart's  action,  which  is  not  only  objectively 
noticeable,  but  also  subjectively  felt  by  the  patient.  Pain  is 
absent,  and  in  pure  cases  at  least  there  is  no  dyspnoea.  Palpi- 
tation appears  more  frequently  as  an  independent  affection  than 
angina;  the  attacks  usually  begin  suddenly,  often  at  night.  If 
the  patient  be  lying  on  his  left  side,  he  is  seized  with  a  feeling 
of  oppression  and  anxiety,  the  pulse  is  accelerated,  and  its  rate 
may  be  increased  to  more  than  two  hundred  beats  to  the  min- 
ute; sometimes  the  second  heart  sound  is  curiously  clicking 
(cliquetis  m^tallique)  and  the  first  extraordinarily  weak,  the 
carotids  throb,  the  radial  pulse  becomes  hard  and  full.  Dehio 
(cf.  lit.)  has  examined  the  pulse  curves  by  means  of  a  Dudgeon 
sphygmograph,  and  found  the  pulse  waves  higher,  the  decline 
steeper,  the  first  elastic  elevation  decidedly  nearer  to  the  base 
line  of  the  curve,  and  the  dicrotic  elevation  lower  than  normal. 
He  attributes  this  condition  to  an  increase  in  the  frequency  of 
the  beats,  and  a  decrease  in  the  duration  of  the  individual  ven- 
tricular contraction.  Besides  the  palpitation,  the  patient  com- 
plains of  ringing  in  the  ears,  dizziness,  and  faintness.  The 
attacks  usually  pass  of!  in  a  few  minutes,  disappearing  as  sud- 
denly as  they  came  on,  and  the  patient  soon  feels  perfectly  well. 
Their  frequency  is  extremely  variable  ;  they  may  appear  once, 
twice,  or  more  often  daily,  or  only  after  long  intervals  of  weeks 
or  months. 

That  here  we  also  have  to  deal  with  a  neurosis  of  the  vagus 
seems  only  a  rational  assumption.  The  seat  varies;  it  may  be 
either  central  or  peripheral,  but  in  most  cases  we  are  unable  to 
positively  say  which  it  is.  Sometimes  we  arc  justified  in  as- 
suming that  such  conditions  depend  upon  a  central,  bulbar 
nuclear  affection,  just  as  we  may  probably  refer  a  temporary 
diminution  of  the  vascular  tonus  to  a  transient  paresis  of  the 
vaso-motor  centre  in  the  medulla  oblongata  (Dehio),  The  pub- 
lication of  differ  (Revue  dc  mod.,  1890,4)  shows  that  neiiritic 
conditions  of  the  vagus  may  also  be  found. 

it  is  very  important  in  these  cases  of  palpitation  to  look  for 
further  coexisting  affections,  after  the  removal  of  which  the 
nervous  palpitation  often  disappears  snddenlv,  and  never  re- 


» 


OfXXASXS  O/-'  THE  VACUS  {rXF.UMOCASTJtlC  A'EKfE).     127 

[cun.  Tu  this  class  belong  chiefly  the  aiiiemias  of  the  young, 
Liantiugmus  juvenilis,  habitual  constipation,  gout,  and  malaria, 
[Ud  accordintjiy  we  are  able  lo  bring  alxiut  a  marked  improve- 
xtatal  in  the  palpitation,  which  in  such  cascii  is  only  symp- 
|.b>inatic.  by  improving  the  condition  of  the  blood,  by  proper 
Irc^tbtion  ol  the  IkjwcIs.  by  promotion  of  the  excretion  of  uric 
Mcjd.aiid  by  combating  in.ilaria  by  means  of  quinine,  according 
jhilbc  indications  in  each.  If  such  indications  (or  therapeutic 
;iire-«  are  wanting,  we  have  lo  fall  back  upon  the  narcotics 
Incrvinc!!,  unreliable  as  they  arc  in  their  .iclion.  In  hyslcr- 
al  i>crM>ns  certain  mechanical  manipulations,  pressure  on  the 
[ibdomen,  momentary  compression  on  the  neck,  and  the  like. 
I  may  be  of  service.  Applicaiiun  of  the  ice-bag  to  the  cardiac 
{Rgion  may  occasionally  be  beneficial ;  the  psychical  treatment 
[bhlie  patients,  repeated  assurances  that  these  attacks  are  never 
|bul,  and  that  they  arc  quilc  amenable  to  treatment,  is  not  to 
[be  underrated ;  in  the  case  of  children  ejspecially  this  has  been 
liuund  very  effectual. 

The  aetiology  is.  unless  the  palpitation  is  secondary  lo  an 
underlying  disease,  quite  obscure.  Under  what  conditions 
individuals  in  other  respects  quite  sound,  with  a  good  family 
bislory,  and  who  present  no  symptoms  of  neurasthenia,  can 
be  attacked  by  such  transient  pareses  of  the  vagus  we  do  not 
know.    In  suspicious  cases  we  should  think  of  masturbation. 

uti:rature. 

Ter.     Ud)CT  TcRcclorischc  Vagtisncumnc.      DeutKhex  Arch.  f.  kliti. 

Med.  ntvli.  J.  4.  P-  ^7.  1880. 
LnpT.L   UebcrVainitUIi'nuni;.  Wiencrmrd.  Wocl)enKhr..kX]d,}0.3i,  iSSl. 
IVi    IVagcrmcd.  Wochcnschr,.  No.  44.  ■'^84. 
fMoglll    The  Ciouty  Ncunucs  of  xhr^  Heart.    Edinb.  Med.  Joutn..  xxx,  p^ 

Ml,  November,  1884. 
Sanmiab,  Mar,     [>r  I'aUtir  |>aral)-|jque  du  ctrur,  d'origine  bulbaire.     l.Tnc^ 

pkale.  ri.  6.  IL4I],  iS&ty 
OAta    U«b«  netvtiMs  Hcriklopffn.     IVlcrth.  nicd,  Woehcnschr.  August  S 

m<l9.  1BS6. 
<*>(Wiuic  Nol.    A  Contribution  lo  the  f  ailiology  and  Trealnient  oi  the  Kcspln- 

••H  Vaso-nioior  Ncurows.     New  York  Med.  Joum..  Kcbryaiy  36,  1887, 
(MtL    Urber  iwrrtees  Mcnklopfen  unU  sunsiigc  viuf  InncrvalionMlorunjfci) 

bmhoHk  HcnaflectloncD.    Detiixche  Mcd.-ZiK..  1890,  49^ 

TMhycitrtiia. 

In  rare  otses,  in  pcopir  otherwise  healthy,  but  more  fre- 
quentlv  in  those  a0ected  with  heart  disease,  wc  meet  with  a 


128 


JifSBASES  OF  THR  CKANtAl.  NP.SVR^ 


transient  acceleration  o(  the  heiin's  aciiun  {lachycardia).  which 
usually  lasts  for  several  hours,  after  which  the  pulse  rate  again 
bccotites  normal.  These  attacks  are  acconipnnied  by  a  feeling 
III  great  aiixicry,  ami  are  iishrrcd  in  by  vawi-tnotor  disturbances 
^-e.  g.,  circumscribed  tlusliiugs.  The  number  of  the  pulse 
beats  may  reach  200  or  more.  Pressure  upon  the  vagus  in  the 
neck,  a  dr^iught  of  cold  water,  or  similar  slinmlaiioi)  o<  the 
peripheral  ends  of  the  vagus  often  may  cut  short  an  attack 
against  which  we  possess  no  other  remedy.  Whether  in  a 
given  case  irritation  of  the  accelerators  or  a  paroxysmal  paraU 
ysis  uE  the  vagus  is  responsible  for  the  attacks  has.  according 
lo  Notbnagel  (Wiener  mcd.  Blatter,  i,  2,  3.  1887),  to  be  decided 
in  the  following  way:  A  great  increase  in  the  frequency  ol 
the  pulse,  accompanied  by  a  weak  heart-beat,  and  perchance 
another  disturbance  of  some  nerve  path  belonging  lo  the  vagus, 
speak  for  paralysis  of  this  nerve;  whereas  a  strong  impulse, 
fullness  of  the  peripheral  arteries,  with  high  tension,  associated 
with  other  symptoms  of  vaso-motor  irritation,  is  in  favor  of 
stimulation  of  the  accelerators,  Traube  assumes  that  some 
cases  are  due  to  a  temporary  ansemia  in  the  medulla  oblongata, 
in  consequence  of  which  a  paresis  of  the  inhibitory  nerves  en- 
sues. To  this  class  seems  to  belong  the  ctse  related  by  Dehio 
{<{.  lit).  The  affection  is  met  with  equal  frequency  in  both 
sexes;  it  is  more  liable  to  occur  in  advanced  age;  in  women 
the  climacteric  period  seems  to  predispose  to  it  (Stokes,  Kisch). 

The  mode  in  which  nicotine  acts  upon  the  vagus  is  uf 
great  interest,  and  certainly  deserves  a  closer  study  than  has 
been  given  to  it  hitherto. 

Chronic  nicotine  poisoning,  as  it  is  found  in  smokers,  and 
only  occasionally  in  tobacco  workers,  is  not  always  well  adapted 
lo  throw  much  light  on  this  subject,  for.  whereas  it  is  well 
known  thai  the  nicotine  when  brought  into  direct  cont.tct  with 
the  nerves  paralyzes  them  rapidly,  it  is  by  no  means  common  to 
find  paralysis  of  ihe  vagus  in  the  course  of  nicotine  intoxication. 
As  a  rule,  it  is  true  that  the  hearl's  aclion  is  increased,  yet  cases 
occur  in  which  there  is  a  slowing,  so  that  we  are  led  to  think  of 
a  stimulation  of  the  vagus,  such  as  happens  after  drinking  cold 
water,  where  the  pulse  Rite  may  be  reduced  to  thirty  or  twenty 
beats.  Owing  lo  the  miserable  arrangtrments  for  ventilation  in 
tobacco  factories,  we  have  from  lime  to  time  occasion  to  study 
the  action  of  nicotine  in  th(»se  employed  in  them,  although  the 
disease  is,  as  has  been  said,  by  no  means  frequent.     Kisch  has 


i>/S£/tSSS  OF  THE  VACUS  {PXEUMOOASTK/C  yRlfl'K),     t2q 

recently  called  attention  to  a  form  of  tachycardia  whicti  oc- 
cnrs  at  the  menopause,  and  which  he  is  inclined  to  attribute 
tOcliangcR  in  the  ovaries  (Wiener  mcd,  Presse,  1R91.  19). 

GiMTs  which,  in  consequence  of  a  vagus  neurosis,  present  a 
uDultaneous  disturbance  in  the  circulatory  and  respiratory 
apparatus,  occur,  but  arc  rather  unconunou.  A  case  to  the 
point  has  been  published  by  Tuczck  (Dcutschcs  Arch.  f.  klin. 
Med..  1877,  xxi.  I),  and  two  others  by  Kredel  (ibid.,  1882,  xxx. 
[L  547).  For  the  respiratory  apparatus  acute  emphysema,  with 
il;>|)tio»t  »m)  symptoms  of  calarih,  were  noted;  they  were  Rf- 
locutcd  with  tachycardia  (asthma  cardiacum,  according  to 
Kmlel),  and  the  existence  of  a  paralysis  of  the  va^us  fibres 
tt|;ulating  the  heart,  in  conjunction  with  a  stimulation  ol  those 
picsidtng  over  the  lungs,  whereby  spasm  of  the  muscles  ol  the 
bnHKhi  was  produced,  was  assumed.  At  the  autopsy  the 
auM  was  found  to  be  pressure  exerted  upon  the  vagus  trunk 
bf  a  rapidly  swelling  lymph  gland.  The  attacks  lasted  from 
ivtJvc  to  thirty-six  hours.  Some  of  the  patients  had  organic 
faon  disease. 

LITERATtJtcE. 
La|a.    U«ber  WagmAAtaang.     Wttiier  meil.  WochirnKhr..  nnxi.  yi,  31,  1881. 
^V^t%.  UtbrrTarlij^antk.    DruiK-h.  Arch  f.  kim  MeiL.Ihl.xuti.  11^^.311.4. 
U)(riM.    Neuriti*  ol  ihe  Vagi  cmiwqueni  upon  the  Action  of  Alcohol    80c 

dr  MM.  <fe  PmK  July  16  and  33.  1887. 
Mb    Tachrnnlic  MCh  drr  Punclkm  rtnn  H)<trop*-AKim.     IVlrrab.  tned. 

tl'tdwntchr,.  I.  M<T  14.  1887. 
Fmw|Uk     IJrtrr  Ok  chrtinuchc  TilMhvnxiflunj;  tiiul  ihrcn  F.infloM  auf  du 

Hm  and  doi  Magm.     Wkncr  n>«L  WochcnKhr.,  No*.  ii'i4.  1SS7, 
Spijlrt    IkDtKhr  tnrd  WodMmchf..  No.  38.  18S7. 

h^.   OHrW-Auulm.  iBM.  nli.  p.  193. 

BwM.    RevM  At  mU.  1889.  9^  Ia 

IWMM.  DcbTad^avdiribMbTabanlaKpalmiL  TUMikl>Hk.iS89. 

^^^ft.    nops  wtfl^  1890L  37' 

Bm   Kriwl)  M«d  Jon.  iSqn  i{.  3. 

Brsdycardta  i/^aSvf.  slow)  is.  on  the  whole,  eren  lets  often 
nd  with  than  tachycardia :  io  this  cooditioo  the  Dumber  of 
t^  pvlw  beats  mar  (all  to  hall  the  normal— i.  c  to  3S-42.  a 
cnxStioa  which  maj  also  be  found  io  perfectly  healthy  iodi' 
*^ii>ls>  Sooetiaa  bradycardia  seems  to  be  a  peculiarity 
niMiaua  to  aevcnl  a»eaben  ol  the  same  family.  After  pro- 
^{n)  fattia^  aad  is  the  poerpeial  state,  it  may  occvr  with- 
out aajr  oiher  aboorsalttr.  SoaetiacB  K  is  aasocialcd  with 
f 


130 


D/SSASBS  OF  THE  CRAKIAL  /SERVES. 


cerebral  nCTcctions,  with  chronic  articular  rheumatism,  with  dis- 
eases of  th«  digestive,  circulatory,  and  uropoctic  organs,  or  with 
certain  intoxications  (lead,  alcohol,  cotlcc).  Lunz,  among  others, 
has  recently  called  attention  to  the  association  of  bradycardia 
with  epileptic  attacks,  the  so-called  Adams-Stokes  disease  (Neu- 
rol. Centralbl.,  1893,  xii,  4,  p.  t.|2).  In  old  men  it  is  sometimes 
seen  as  an  idiopathic  vagus  neurosis,  a  condition  for  which  no 
physiological  explanation  can  be  given  (cf.  Grob,  Deutsch. 
Arch.  f.  klin.  Med.,  1S88.  xlii,  p.  574;  also  Ricgcl,  Zcitscbr.  f. 
kiln.  Med.,  1S90,  xvii,  3,  4,  p.  231:  also  Dehio,  Petcrsburger  med. 
Wochenschr.,  1892,  t.  In  these  articles  also  the  theories  of 
the  pathogenesis  of  the  alTection  are  discussed).  We  have  thus 
far  no  means  with  which  to  treat  this  condition  successfully, 

It  scarcely  belongs  within  the  scope  of  this  book  to  treat  of 
disorders  of  the  cardiac  rhythm,  arrhythmia  cordis,  which  is 
sometimes  found  in  obesity,  more  often  in  the  course  of  brain 
diseases,  in  intoxications  (tobacco,  coRcc,  digitalis),  and  above 
all  in  organic  diseases  of  the  heart.  Baumgartcn  has  published 
a  comprehensive  study  treating  of  this  condition  (Disturb- 
ances of  the  Heart  Rhythm  with  Reference  to  their  Causa- 
tion and  their  Value  for  Diagnosis,  Transact,  of  the  Assoc, 
of  American  Physicians,  18S8).  Kummo  and  Ferranini  have  at- 
tempted to  investigate  this  condition  experimentally  (Riforraa 
mcd.,  December.  1887,  278-287),  but  much  is  still  obscure. 

C.    TUE    D[STURll.\NCES    OF   THK    DiGESTtVE  ORGANS    DUE   TO 

Lesions  of  the  Vauus. 

The  vagus  forms  two  sastric  plexuses:  the  one,  the  anterior, 
situated  on  the  anterior  surface,  and  the  other,  the  posterior,  sitti- 
aled  on  the  posterior  surface  of  the  smaller  curvature  of  the  stomach. 
The  first  plexus  is  formed  by  the  left,  the  second  by  the  right,  a 
somewhat  stouter  nerve.  The  t)riinche!(  of  the»e  plexuses  asst^ciate 
with  fibres  from  the  sympathetic  which  accompany  the  ramifications 
of  the  coronary  arteries;  a  part  of  the  fibres  which  appertain  to  the 
right  (posterior)  vagus  go  on  to  the  cccllac  plexus,  and  can  in  a 
careful  dissection  be  traced  to  the  spleen,  the  liver,  the  kidneys,  and 
small  intestine. 

The  muscles  of  the  cc^ophagus  and  stomach  are  also  innervated 
by  the  vagus ;  its  sensory  fibres  conduct  the  impulses  concerned  in 
the  reflex  actions  of  deglutition,  sobbing,  and  vomiting. 

Among  the  disorders  of  the  digestive  organs  caused  by  dis- 
ease of  the  vagus,  the  so-called  stomach  and  iutcstinal  neuroses, 


mSE^SSS  OF  THF.   I'ACt/S  IPATFOWOCASrA/C  Xf.xr/C).     131 


I 


M  find  affections  of  the  motor,  sensory,  secretory,  and  perhaps 
ib(i  of  the  trophic  fibres.     Among  the  motor  neuroses  we  have, 
ucordiiig  to  Glax  (Klin.  Zeil-  und  Slrcilfragen,  1887,  i.  Heft 
6),  irritative  and  dcprc!«sive  forms.      The  former  mniiilcst  ihem- 
aJtes  in  simple  perisialijc  unrest  of  the  stomach,  or  in  nervous 
belching  or  vomiting,  the  latter  in  nervous  atony  of  ihe  stom- 
ach, or  insufliciency  of  the  cardia  or  pylorus.     Merycism,  or 
niminalion,  must  also  be  claiiscd  among  the  motor  neuroses. 
Among  the  sensory  disorders  we  find  cardialgia  and  hepataU 
pA.    Of  the  secretory  neuroses,  nervous  dyspepsia  is  the  most 
inporlant.    To  this  chiss  also  belongs,  in  all  probability,  the 
illed  oesophagismus.     The  claim  of  A rnd t  ^ Deutsche  med. 
chenschr.,  1886,  xiv,  5)  that  the  round  ulcer  of  the  stomach 
ihoold  be  t^arded  as  "  originating  in  a  neurotic  affection,  an 
■ifio>ortropho-neurosis(of  the  vagus),"  is  deserving  of  further 
ttmtigation. 

TbeK  vagus  neuroses  are  rarely  met  with  alone  in  other- 
wbc  healthy  persons ;  more  often  they  appear  in  conjunction 
■ith  other  diseases,  especially  general  affections  of  the  nervous 
sjfteni,  particularly  hysteria  or  tabes.  Sometimes  they  arc 
■uodllcd  with  affections  of  the  uterus,  such  as  displacements 
(l^edti,  Thcrap.  .Monatsh.,  1892,  2) ;  finally,  ihcy  are  met  with 
liipr^;naiicy.  Possibly  some  have  a  reflex  origin.  According 
lo  Leva  (MUnch.  med.  Wochcnschr.,  1S90.  3o,  21)  this  is  the 
CJK  ta  merycism  ;  but  here  we  also  find  anomalies  in  the  score- 
tin  of  the  ga&tric  juice,  a  circumstance  which  may  be  of  a:tio. 
Icgicil  Importance.  In  most  cases  of  rumination  which  have 
ben  observed  the  patients  have  eaten  copiously  and  rapidly 
■od  have  overloaded  their  stomachs  ivith  imperfectly  masli- 
cainl  food  (cf.  Alt,  Berlin,  klin.  Wochenschr.,  t8S8,  16,  27: 
B<iii,ibid.,  31 ;  jUrgcnsen.  ibid.,  46;  also  the  above-mentioned 
■nicic  ol  Leva,  and  one  by  Singer  in  the  Deutsch.  Arch.  f. 
Hin,  Mfd..  1891,  li.  Heft  4.  5,  articles  in  which  especially  the 
Kiatiiin  of  rumination  and  vomiting  is  diiicussed). 

Tbc  other  motor  neuroses  of  the  stomach  and  intestinal 
tna  will  be  discussed  iit  the  cha[.ter  on  Hysteria. 

Cardialgia  fgastralgia,  gastrodynia)  is  a  disease  of  the  sen- 
*wy  nerves  which  occurs  mostly  in  paroxysms.  Romberg, 
diflinguishing  two  forms,  assumed  the  one  to  be  due  to  a 
lifpervstheua  of   the  vagus  branches   going   to  the  stomach 


I3» 


D/S£AS£S  OP  THE  CRANIAL  NERVES. 


{*'gastrocl>'iiia  ncuralgica"),  the  other  to  a  hypcrarsthi'siaof  the 
solar  plexus  (neuralgia  cmliaca).  There  have  been,  however, 
cases  coming  under  noiicc  which  can  not  be  classed  under  cither 
ol  these  heads,  and  cvrn  more  which  do  not  permit  of  a  deci- 
sion as  to  which  of  the  two  forms  we  are  dealing  with. 

The  characteristic  symptoms  of  gastrodynia  are  violent 
paroxysmal  constricting  pains,  starting  in  the  region  of  the 
stomach  and  radiating  to  the  back;  the  face  becomes  livid,  the 
hands  and  feet  cold,  (he  pulse  smaller  and  intermittent,  attd  a 
feeling  of  unutterable  anguish  and  distress  lakes  possession  of 
the  patient.  If  in  the  presence  of  these  symptoms  careful  ex. 
amination  has  excluded  the  existence  of  any  organic  stomach 
lesion — e.  g..  acute  or  chronic  catarrh,  gastric  ulcer  or  tumor — 
if  there  is  no  evidence  of  gall  stones,  and  ihe  patient  has  pre- 
viously at  times  been  subject  to  neuralgia  in  other  parts  of  his 
body,  we  make  our  diagnosis  with  some  amount  of  certainly, 
Bui  in  alt  cases  this  can  only  be  done  after  careful  and  repeated 
examination  before  and  after  meals  ;  not  uncommonly  we  find 
that  pain,  which  is  present  while  the  stomach  is  empty,  is  re- 
lieved by  the  ingestion  of  food,  and  the  patient  states  that 
uniform  firm  pressure  on  the  epigastrium  has  often  a  beneficial 
alleviating  effect,  both  conditit>ns  not  generally  observed  in 
organic  diseases  of  the  stomach. 

In  the  treatment  of  these  cases  we  must  first  of  all  endeavor 
to  remove  any  primary  cause,  and  in  this  connection  mental 
and  physical  overstrain,  excesses  in  vencry,  masturbation,  or 
uterine  affections,  must  be  thought  of.-  Besides  the  external 
application  of  blisters  to  the  epigastrium,  arsenic  given  for  sev- 
eral weeks  is  to  be  recommended.  During  the  attack  morphine 
can  often  not  be  dispensed  with.  The  diet  has  to  be  care- 
fully regulated,  but  not  restricted :  on  the  contrary,  it  is  ad. 
visable  for  the  patient  to  take  four  or  five  times  daily  sub- 
stantial but  easily  digested  food. 


I 


I.ITEHATUliE, 

Sawyer,  J.    Clinical  Lecture  on  Ihe  Trcalmcnt  of  Castralgia. 
13.  1887. 


Lancet.  August 


I 
I 


Of  great  practical  importance  is  the  so-called  hepaialgia  or  nerv- 
ous biliary  colic,  which  was  lirst  described  b^  Andral  in  1817,  and 
which  has  been  studied  more  recently  by  Frertchs.  Fllrbringer,  and 
Talma  (cf.  I'ariscr,  OciHsch,  mcd.  Wochcnschr..  1S93,  _ni).  Thi* 
allectioii  i»  usually  seen  in  anKinic  women;  it  manifests  itself  io 


O/SeASSS  OF  THB  VAGUS  (P/fEUMOCASTXlC  A'EJtf/i).    133 


[itroxysinal  pains,  which  arc  as  severe  as  those  of  a  true  biliary  colic; 
thej  ue,  however,  more  reKtricied  to  the  hepatic  region,  and  never, 
nen  after  recurring  for  yeant,  lead  to  febrile  inllainmatory  affections 
of  the  liver,  ihc  gall-bladder,  or  the  gall-duc(&  (Fiirbrtnger).  Anti- 
neurasthenic  treatment  is  often  of  no  avail. 

I  Nervous  Dyipcpiia. 

The  disease  known  as  nervous  dyspepsia  is  an  extremely 
common  netirnsis  of  the  vagus,  especially  in  females.  It  is 
charactciized  by  a  loss  of  appetite,  painful  sensations  in  the 
region  of  the  stomach,  frequent  vomiting,  and  stiti  more  fre- 
quent belching:  besides  these  the  patients  generally  .sutler  from 
other  nervous  symptoms — dull  headache,  vertigo,  palpitation; 
they  are  easily  tired,  complain  of  a  lump  in  their  throat  (globus 
hystericus),  at  limes  have  a  voracious  appetite,  and  obstinate 
constipation  is  seldom  absent.  The  motor  functions  of  the 
K  slom-ich  are,  as  a  rule,  more  or  less  disordered,  and  sometimes 
"  secretory  anomalies  are  observed  ;  indeed,  only  rarely  do  both 
the  motor  and  chemical  functions  remain  intact  (Herrog, 
Zcilschr.  f.  klin.  Med..  1890.  xvii.  3. 4).  In  rare  cases  periodical 
spells  of  vomiting  have  been  noted  (twenty  to  thirty  in  the 
tweniy'iour  hours),  accompanied  by  acute  circumscribed  swell- 
ings ol  the  skin  (angio-neurotic  tcdrma.  Striibing.  Quincke). 
Although  the  patients  feel  very  poorly,  their  state  ol  nutrition 
remains,  nevertheless,  for  a  long  time  remarkably  good  ;  only 
in  a  few  cases  do  we  observe  a  rapidly  increasing  and  marked 
ansmia.  It  is  still  doubtful  whether  the  condition  is  essentially 
a  disease  of  the  peripheral  nerves  ol  the  stomach  or  a  general 
netirosis  (neurasthenia  dyspcpiica.  Ewald).  We  would  refer 
the  reader  to  a  most  intere».ting  and  comprehensive  article 
which  has  been  written  on  this  subject  by  Lcubc(Berl.  klin, 

■  Wochcnschr..  No.  21.  1884). 
In  making  our  iliagnosis  we  are  brought  face  to  face  with 
no  inconsiderable  difficulties.  The  claim  of  Leube  that  wc  arc, 
in  the  presence  of  the  .nbove-dcscribed  symptoms,  justified  in 
thinking  of  nervous  dyspepsia  if  a  stomach- w.tshing  six  to 
•even  hours  after  the  meal  shows  the  stomach  to  be  empty, 
ha*  been  opposed  bv  Ewald  and  others.  These  have  shown 
that,  on  the  one  hand,  the  stomach  may  be  empty  seven  hours 
alter  a  meal  in  cases  of  ulcer,  and.  on  the  other  hand,  may 
contain  remains  of  food  in  nervous  dyspepsia  after  the  same 
ac.     To  be  sure,  an  increase  of  hydrochloric  acid  (hyper- 


134 


DJSF.ASES  OF  TUE  CKANIAI.  NEItVEt. 


acidity)  is  a  common  condition  in  gastric  ulcer.  The  results 
of  stomach>washing  arc,  however,  certainly  not  always  pathog- 
nomonic, but  we  must  rallicr  for  the  purpose  of  diagnosis  take 
inio  account  the  course  of  the  disease  and  the  general  condition 
of  the  patient.  But  in  spile  of  the  greatest  care  experienced 
men  not  seldom  in  these  cases  are  led  into  error.  Under  cer- 
tain circumstances  the  hyperemesis  nervosa,  a  motor  neurosis 
of  the  stomach  occurring  in  pregnant  women,  especially  in  the 
lirst  mtmths  of  pregnancy,  may  closely  simulate  the  disease. 

In  the  treatment  our  attention  has  chiefly  to  be  directed  to 
the  proper  nutrition  of  the  patient.  Of  medicines,  arsenic, 
quinine,  chloral  (i.o  (grs.  xv)  several  limes  a  day),  should  be 
resorted  to.  Saline  purgatives,  a  course  of  treatment  at  Carls- 
bad,  as  well  as  the  use  of  electricity,  are  of  no  avail,  A  stay 
in  the  mountains,  hydrotherapy,  sea-baths,  all  should  be  tried 
in  succession,  and  last,  but  not  least,  the  possibilities  of  psy- 
chical treatment  must  not  be  forgotten. 


I.ITEKATURE. 

Cherrbewsky.    Contributiona  1  la  pathologic  d»  nerrotes  inlalinales.     Reme 

(le  mc<l.,  3.  1S84. 
Schule.    Arch.  f.  t^'ch.  a.  Nnv«nhrankhcii«i, xv,  3,818. 1SS4.  (Nervous Dysprp- 

sit.  wtih  A  Kcrtex  Vagus  NeunKtt&uft  Coinplicaiian.— -Respiratory  UiAciiiiy.) 
Alll>uil.     Xisccral  NcurosM.     Lancet,  i.  ri,  13.  14,  18S4. 
Ihrin^      Pic  nrnijfn;  Dy«pcp»ic  um)  ilire  Folgckrankhdien.     V.  Vol]un»ui*« 

SdminlunK  klin.  \'orlrtls«.  No.  183. 
NtiffUb.     NcuriMM  of  the  Stomach,     Russ.  Mnl..  36-iS.  1887. 

(F.tophag%smms. 

Spasmodic  dysphagia,  known  as  oes<">ph3gismus  (spasm 
the  gullet),  is  an  affection  which  sometimes  follows  dyspeptic 
symptoms  and  protracted  vomiting,  sometimes  irritation  of  the 
fauces  by  hot  fix>d.  irritating  subsLinccs  (mushrooms,  red  pep- 
per, etc.).  Sometimes  the  spasm  is  seen  to  occur  retlexly  in 
consequence  of  uterine  diseases,  and  quite  frequently  in  hys- 
teria. As  an  independent  affection  it  is  rarely  ever  ob5;er\'ed. 
In  all  cases  it  is  characterized  by  the  fact  that  the  patient  from 
time  to  time  (periodically)  finds  it  difficult,  or  is  even  un- 
•ble,  10  swallow  his  food :  thai  when  it  reaches  a  certain 
p4Mnt  it  is  regurgitated,  and  that  the  sound  which  is  intro 
duced  for  the  purpose  of  ex.imination  ts  stopped  at  the  same 
place:  if  this  point  is  situated  in  the  upper  portion  of  the 
cesophagus.  usually  violent  pain  is  experienced  on  the  tnges- 


DtSKASES  OF  TUB  VAGUS  {PNEUMOGASTRtC  NERVE^.     135 


I 


tion  more  espccinlly  of  cold  food,  a  circumstance  which  makes 
the  patient  object  to  inking  his  nourishment,  and  consequently 
leads  to  emaciation,  although  the  loss  of  flesh  is  here  consider- 
ibly  less  than  in  stenosis  of  the  oesophagus  caused  by  new 
growths,  because  in  the  former  case  the  patient  is  able  at  times 
to  swallow  his  food  without  any  diBicuIty. 

Predisposed  to  uisophagismus  are  nervous,  easily  excitable, 
hysterical  persons,  in  whom  the  affection  often  suddenly  makes 
its  appearaoce  after  some  emotion  without  the  previous  exist- 
race  of  any  symptoms  referable  to  the  wsophagus.  It  has 
olten  followed  the  suppression  of  the  menses,  or  has  appeared 
during  pregnancy  and  lactation.  Sometimes  no  other  :etto< 
logical  (actor  could  be  discovered  than  injuries  to  the  gullet 
,vear9  previous  to  the  spasm — bums,  injury  by  sulphuric  acid, 
Clc.  No  definite  statement  is  warranted  as  to  the  duration  and 
the  course  of  the  disease,  as  both  vary  greatly,  but  this  much 
may  be  said  with  certainty,  that  in  pure  cases  the  prognosis  is 
ilways  good,  that  complete  recovery  is  almost  always  eflcctcd 
by  the  repeated  use  of  the  sound  and  by  the  application  of  the 
laradic  brush. 

LITERATURE. 

ChMMfltac    Joum.  tie  mM.  ci  de  chir.  pnt..  p.  31 1,  1846. 

Uuihira.     Gnt.  mfd.  dc  l.yon.  p.  101,  iSji. 

I.enilnin.     Arch,  i/Jknbc..  jme  fix.,  I.  xi.  p.  293.  1858. 

Vigr^    Cu.  do  Mp..  Scpicinbrc  35.  1S69. 

Aunfdd.     L'Union.  73.  1S71. 

Koike.    TniiiAAct.  uf  the  Clin.  Socidy,  t-ol.  ri.  1873. 

Rous.    Th^  de  faria.  No,  10;.  1873. 

Srniili.     DttbL  Quan.  Jotirn,  March,  1864. 

IVUT.    C^i.  d(«hA|>.  83,  1S75. 

Uockenxlc.  Murcll.     Mvit.  1'i(ncs  and  Gae..  OcIol>cr  11.  1S76L 

Eto)-.    ConiribuiioR  to  the  Knowledge  »(  (Esophajpsmus.     Cai.  hebct,  imc 

\t'ne.  L  xrii,  46.  47.  50,  tSSo. 
Stnbing.     Ucbt-r  ai-um  angloncuroiischcs  CEdem.    itcitMhr.  lur  klin.  Mnt.,  Bd. 

hi.  5.  "Ms- 
Mdlm.    Ein  Fall  vun  DyKph«Kie  nebtl  Bcmerkungen.    Birrl.  klin.  Woc)i«ischr„ 

8,  18S8.     (.Symptoms  of  (K«<ipha(;us  Sl«ni>si«  lasting  for  Nineteen  Ynn.1 
Lcwin.    DcJtrSgc  »ur  P.nhologk  d«  V-igu*     Inaug.-lJiMerl..  rctersljurn,  iHSB, 
EdlaccT.    Vaxiiuimrosen.     Krprinied  rrom  Eulenburg's   Rctl-Encyctopadie, 

X  Aiill. 
V    Schkrti.     Zur   EWIijindlunK  dci  nervown   MaKenkr^inkhritcn.     Itcrl.  klin. 

WochffiMhr..  1891.10. 
Holm.  Ilanld.     Den  dprulc  VngiiskJlme«  Anaiomi  og  TathDlogi.    Nonk  Ma- 

gaiifi  (.  Liefer iilenitk..  1891,  p.  1. 
BocMmU,  E.     UriirMgc  «ur  Kcnnlniss  dcr  Vagiunmiotcn.      Inaug.-Uuert., 

Delw,  1893. 


CHAPTER  IX. 

THE  DISEAGES   OF   THE   ACCKgSORV    NKRVR. 

The  acceSHorius  consists  of  two  pnrtK,  both  of  wliich  have  n  scpa- 
raie  origin  and  exit.  The  upper  one  belongs  entirely  lo  ilie  vagun, 
emerKCft  with  it,  and  is  hence  called  acce-isorius  vagi.  The  lower  one 
begins  at  the  level  uf  the  frnl  cervical  nerve  (cf.  Kig.  i6),  and  can  be 
traced  as  fur  down  as  the  level  of  (he  sixth,  sometimes  even  of  the 


to  a. 


tjfC.II 


Fit  t&.—C*om  MCnOH  THaoucii  thi  CsHvtCAt.  Conn.  t.f.C.II.  pdrtcrior  cool' 
tlw  ■nond  CwImI  ncrrc  XI.  fibia  of  Acc«wriu>.  r.<>..interlnt  honl.  C/.,pane- 
rior  hom.  C.  I,,  laleral  horn.  //',  Onll't  column.  H*.  Butdoch'f  toluiDa.  S,  Ulenl 
oduiDD.     r,  anicriDr  column,    g.  lubsuntU  e^UnnH  of  pcaierior  born. 

seventh  cervical  nerve  roots;  this  is  the  spinal  portion,  the  accei>Mi- 
rius  spinalis.  After  having  passed  upward  to  the  foramen  magnum, 
close  to  the  cord,  it  unites  inKide  the  slcuti  with  the  portion  belong' 
ing  to  the  vagus  to  form  for  a  while  a  common  trunk,  the  accessorius 
communis,  which,  soon  after  leaving  the  skull  through  the  jugular 
foramen,  again  divides  into  two  branches,  the  accessorius  vagi  then 
becoming  the  inner,  the  accessorius  spinalis  the  outer  branch. 
'36 


77/Jr  OtSEASES  OF  THE  ACCESSORY  NERVE. 


137 


The  nuclctit  of  the  former  portion  has  been  Oescribed  in  the 
two  previous  ctiapier*;  that  of  the  spinal  portion  is  in  the  region 
of  the  anterior  horn  uf  the  cervical  cord.  Since  the  latter  is  pro- 
vidcd  with  motor  cells,  tlie  purely  motor  nature  of  the  spmal  por- 
tion ifi  evident  (Schwatbc).  According  to  Decs  (AUgcm.  Zcitichr. 
f,  I'liychiatric  von  Lachr,  bd.  43,  Heft  45.  '887).  the  nucleus  of  the 
acceRSorius  i«  divided  into  three  portions,  the  upper  being  situated  in 
the  centre  of  the  anterior  hum,  just  above  the  first  cervical  nerve; 
Ihc  middle  at  ihe  lateral  border  of  the  anterior  horn  from  the  sec- 
ond to  the  fourth  cervical  nerve;  and  the  lowest  at  the  base  of  the 
lateral  horn  from  the  fourth  to  the  sixth  cervical  nerve.  The  large 
multipolar  (motor)  nerve  cells  which  form  the  nucleus  are  arranged 
like  a  ronary. 

We  may  have  centnii  as  well  as  peripheral  diseases  of  the 
acccssoriiis,  and.  as  is  the  case  in  other  motor  crania)  nerves, 
the  diseases  may  be  of  a  paralytic  or  of  aii  irritative  nature 
(hyperkincsis,  spasm — akinesis.  paralysis). 

AtXESSORIUS  Si'ASM.  SPASMODIC  WRVNECK,  SPASMODIC 
ToRTtcoi.t.is  {T'ti  Hotaioire,  Niel-kramff). 

Since  the  accessoriiis  supplies  the  sterno-cleido-mastoid  and 
the  trapezius  (with  its  posterior  larger  portion),  it  is  these  two 
muscles  which  present  disturbances  in  affections  of  the  nerve. 
Either  of  them  may  be  affected  by  itself,  by  a  clonic  or  a  tonic 
form  of  spasm ;  hence  there  exist  quite  a  variety  ol  clinical 
pictures,  especially  as  the  disease  may  also  be  unilateral  or  bi- 
lateral. The  stcrno-clcido-mastoid  is  about  as  often  the  seat 
of  a  clonic  spasm  as  the  Irnpe/ius,  whereas  the  tonic  form  is 
very  rarely  seen  in  the  latter  muscle. 

By  the  rhythmical  contractions  ol  oncstcrno-cleido-mastoid 
the  head  is  moved  to  one  side  in  a  very  characteristic  manner ; 
the  chin  is  turned  toward  the  opposite  (well)  side  and  is  ele- 
vated, while  the  ear  is  approached  to  the  clavicle.  Contracture 
ol  this  muscle  (the  tonic  spasm)  fixes  the  he.id  in  this  position 
— caput  obstipum  spasliciim.  If  both  stcrno-cleido-mastoids 
are  affected,  the  head  is  drawn  alternately  first  to  the  one,  then 
to  the  other  side  (clonic  form),  or  it  is  pulled  strongly  forward 
and  bent  t<)ward  the  chc*it  (tonic  form  of  the  spasmV 

Contractions  of  the  trapezius  draw  the  head  backward  and 
toward  the  diseased  side,  elevate  the  shoulder,  and  approach 
jlhe  scapiiln  to  the  vertebral  column.  .\  tonic  spa.sm  in  the 
'same  locality  entails  fixation  o(  the  head  in  this  position. 


138 


D/SSASSS  OF  THE  CRANIAL  NERVES, 


A  simultancnus  spasm  of  the  stcmo-clcidn-mastoid  and  the 
trapezius  of  the  same  side,  in  which  the  facial  muscles  also 
sometimes  lake  part,  is  known  1o  occur  more  frequently  than 
an  alTcctiun  of  both  trapezii  or  of  both  stemo-clcido-mastoids 
alone.  The  directions  of  the  movements  and  the  positions 
which  result  from  such  spasms  can  be  made  out  from  what  has 
been  just  said. 

The  occurrence  of  such  afTeclions  is  either  in  paroxysms  or 
else  wc  have  permanent  contractions,  only  ceasing  or  abating 
during  sleep.  Recovery  is  exceptional.  All  therapeutic  meas- 
ures, not  excluding  the  electrical  and  chirurgo^orlhopadic 
treatment,  are  usually  unsuccessful.  The  thermo-caulery  may 
be  tried.  Any  internal  medication  would  have  to  be  con< 
ducted  according  to  the  principles  described  in  the  treatment 
of  facial  spasm. 

The  causes  of  the  disease  differ  widely.  Cerebral  tumors, 
meningitis,  foci  of  softening,  as  well  as  caries  of  the  cervical 
vertebra;,  new  growths  in  the  medulla  oblongata,  may  give  rise 
to  central,  while  cxtcnial  influences,  cold,  etc.,  may  give  rise  to 
peripheral  affections  of  the  nerve.  There  are,  moreover,  well- 
authenticated  cases  on  record  of  rcfies  spasm  in  the  distri- 
bution  of  the  accessorius  arising  from  irritation  by  worms, 
uterine  trouble,  fright,  and  other  emotions.  As  a  rule,  no 
^etiological  Liclor  can  be  detected.  An  epileptic  who  came 
under  my  observation,  a  single  woman,  twcnty^seven  years  ol 
age.  presented  at  times  a  sp-ismodic  loriicollis.  the  contnictions 
being  extremely  violent,  sometimes  lasting  for  weeks,  and  again 
being  almost  entirely  absent  lor  the  same  length  oi  time. 

Accessorius  Pai*%lvsis. 

This  very  rare  affection  may  take  in  one  or  both  of  the 
above-named  muscles.  Unilateral  paralysis  of  the  sterno-cleido. 
mastoid  produces  a  wry  position  of  the  head,  in  which  the  chin 
is  somewhat  elevated  and  directed  toward  the  diseased  side. 
Turning  of  the  head  is  difficult  but  not  impossible,  as  other 
muscles  arc  brought  into  play.  Bilateral  paralysis  ot  the  muscle 
causes  the  head  to  be  held  straight,  and  is  characterized  by  the 
absence  of  (lie  |)romincnce  which  the  normal  muscle  produces. 

Unilateral  pandysis  of  the  trapezius  allows  the  scapula  to 
sink  downward,  causing  the  distance  between  its  internal  mar. 
gin  and  the  vertebral  column  to  become  greater.  As  a  con- 
sequence, the  arm  falls  forward,  the  clavicle  becomes  more 


TltR  MSHAHES  OF  THE  ACCESSORY  NERVE. 


139 


I 
I 


prominent,  the  supraclavicular  lossa  more  marked,  and  tbc 
puftteriur  upper  angle  of  the  scapula  can  be  distinctly  IcU. 
'oltinlary  elevation  of  the  shoulder  and  the  motion  of  the 
ipula  toward  the  spinal  column  is  ititerlered  with,  and  bc- 
oomcs  only  possible  with  the  aid  of  the  levator  anguli  scapulK 
and  the  rhomboidci.     The  arm  can  not  well  be  raised'  above 
the  hprizonlal  position  in  spite  ol  Ilie  scrratus  which  acts  nor- 
mally, because  the  action  of  the  upper  third  of  the  trapezius  is 
lost.     The  paralysis  of  both  trnpe/ii  ,iIlows  both  shuulders  to 
unk  outward  and  forward,  so  that  the  back  appears  more 
curre<) ;  the  ability  to  support  the  he-id  in  the  upright  posture 
is  sometimes  interfered  with.     Simultaneous  paralysis  of  the 
slcrno-ck-ido-mastoids  and  the  trapc/.ii  gives  a  combination  of 
both  clinical  pictures.     If,  in  addition,  the  inner  (sm.-it]er)  por- 
tion of  the  nerve  takes  pan.  the  resulting  paralysis  of  the 
laryngeal  muscles,  the  velum  palati,  and  the  jiharyngeal  mus- 
cles manifests  itself  by  hoarseness,  the  nasal  tone  of  the  voice, 
and  difficulty  in  swallowing.     The  increase  in  the  {re<iuency  ol 
ihe  pulse,  which  has  in  such  cases  been  observed  by  Seelig- 
mlUler.  must  be  attributed  to  the  simultaneous  affection  of  the 
cardiac  branches  of  the  vagus.     Prognosis  and  treatment  arc 
ibc  same  as  in  the  spasmodic  affections,  and  little  more  can  be 
.|Md  about  the  aztiolc^y.    These  forms  of  paralysis  have  been 
known  to  occur  in  consequence  of  certain  occupations,  e.  g..  in 
watrrcarricrs  (Sectigmllller),  and  in  the  course  of  tabes  it  has 
been  seen  as  a  bulbar  affection,    We  tnay  also  imagine  an  injury 
lu  Ihe  nuclei  of  the  nerve  during  difficult  labor,  and  if  we  find 
tyiapioms  of  paralysis  in  the  muscles  of  the  neck  in  new-born 
children,  who  (or  the  first  ^^"^  J'cars  of  life  are  unable  to  hold 
the  head  simight.  such  a  possibility  ought  not  to  be  forgotten 
(Cowers). 

l-lTflLVTUKE. 

Swlfmuflcr.     Arch.  f.  Psych,  lii.  t.  p.  43J.  187J. 

KnpB'.    IlrolMchi.  ubcr  Krnmpfc  im  llcmchc  dc«  AccessorUis  und  dcr  obercn 

Cnvtcalnerrcn.     Diss.  In^iUK..  Gottinxen.  1875. 
■tnult.    Doppdodligr    t^hriiuny   dcs   Acccssorius  Willisii.      Dnitschr  mwl. 

W«hrn*cl>r,.  17,  1885. 
™hrtinr  Wrniltke.     l"h)wolcnjie  iler  Bcwc|;un|[fiv.  pp.  (88  tl  of.    Catsci  U. 

"'niui.    UcHliM-r  Uin.  Wochcntchr..  No.  8.  1887. 

^  KrfWr.     Druische  ftted.  Woclienichr..  1887.  mii.  »;. 

^«*«1L    TanKotlH  ocularis.     Dull.  mM..  1890.  jo. 

^>^n.    Ciampe  ronciiuivcik  du  cou.     Kcvuc  dc  miA.,  1S91,  4. 


CHAPTER   X. 


DI8RASKS  or   THE    HVrOULOSSAL    NKRVt. 


The  ten  to  fifteen  bundles  of  fibres  of  which  the  hypoglossal 
nerve  consist*,  ax  it  einergei>  from  the  medullit  oblongalii  in  the 
groove  between  the  anterior  pyramid  and  the  olivary  body,  unite  to 
form  two  lart;er  bundles,  which  leave  the  dural  space  separately,  and. 
after  their  entrance  into  the  hypoglossal  canal,  the  anterior  condyloid 
foramen,  become  a  single  stem,  which  leaves  the  cranial  cavity  by 
this  canal.  Outside  the  base  of  the  sktiU  it  passes  along  to  the 
mesial  side  of  the  vagus,  at  lirst  obliquely  downward  and  forward, 
then  obliquely  upward,  runs  on  the  outer  surface  of  the  hyoglossut 
muscle,  and  »oon  reaches  the  region  where  the  genioglo&sus  muscle 
radiates  into  the  tongue.  There  are  various  communications  be- 
tween the  hypoglossus,  the  vagus,  the  anterior  branches  of  the  upper 
cervical  nerves,  and  the  lingual  branch  of  the  trigeminus. 

The  cortical  area  of  the  hypoglossal  nerve  is  found,  according  to 
Kxner,  in  the  lower  portion  of  the  anterior  central  convolution  and 
the  adjoining  portion  of  the  inferior  frontal  convolution,  as  shown  in 
Fig.  iS.  Its  nucleus  is  i^iiuated  in  the  Door  of  the  fourth  %-entri- 
cte,  where  its  very  large  nerve  cells  which  measure  up  to  60  ^i  in 
diameter,  closely  resemble  the  large  multipolar  cells  of  the  ante- 
rior horn  in  the  cord.  After  the  closure  of  the  central  catial  it  is 
situated  to  the  ventral  side  of  the  latter.* 

The  root  fibres  of  the  hypoglossus  certainly  arise  in  pari  from 
the  nucleus  of  the  same  r^ide.  To  what  extent  the  nucleus  of  the 
opposite  side,  as  well  as  the  group  of  nerve  cells  situated  in  its 
neighborhood  and  the  above-mentioned  nucleus  ambiguus,  can  be 
considered  sources  of  origin  for  them,  and,  moreover,  whether  direct 
fibres  of  the  hypoglossus  have  thdr  origin  in  the  cerebrum,  is  still 
undecided. 

While  in  certain  of  the  cranial  nerves^for  instance,  in  the 
facial — peripheral  affections  occur  at  least  as  frequently  as  cen- 
tral, in  the  c^isc  of  the  hypofiiossal  ibis  is  not  tnic.  Often  as 
its  nuclei  lake  part  in  the  mo«  diverse  diseases,  especially  of 
the  cord  and  medulla  oblongata,  it  is  rare  that  a  peripheral 
140 


[ 

I 


D/Se^S£S  OF  THE  HYPOGLOSSAL  NERVE. 


141 


afleclton  comes  under  observation.  Thut,  in  a  given  case,  the 
disturbance  is  peripheral  and  not  cenlral,  more  especially  not 
bull>ar,  wc  may  conclude  from  the  absence  oi  other  nympioms 
of  bulbar  disease,  and  irom  the  possible  presence  of  complete 


e» 

'  >!.~Sltn:Krtci«L  OtitOIX  «F  niR  CHtnui.  Nkrveh.  I^Xtf,  the  min  cnaUl 
■<"•.  Ct.  intmoT  root  of  Ihc  linl  orrvital  ncrrs.  tit,  anierlcir  column  nt  Ihn  Kpiiial 
<o>i  ct,  bleni  o>luiDa,  f».  antprim  pmmidx.  0.  aliviUT  body.  P.  I'.,  \nmt  Varolii. 
<  feMUal  ccnICBUU  bod)*,     t.  Ulpnl  crnicuUt*  bodr.     Ic,  tubei  dnsr.     k.  |il(uiUit7 

,  ^tt^.    P,  trnbnl  fieitHKle.    Sy,  n^aa  of  the  linun  of  Sjtnui.    a,  curian  klUontii. 

I  r.  MmmI  of  KMl.     7»,  ofMic  (baluDiu. 

^^^ciion  of  de^neration,  as  Hrb  (cf.  lit.)  has  done  in  his  rccenU 
[y'lticribcd  case.  The  sycnptoras  otherwise  are  the  same  as 
'"the central  disease. 

Central  paralysis  of  the  hypi^lossus  may  be.  in  the  first 
plscc.  of  cortical  origin.  According  to  Exncr,  as  has  been 
Wted.  the  cortical  area  for  the  tongue  is  situated  close  to  the 


142 


DISEASES  OF   THE   CRANIAL  NERVES. 


point  whtrc  the  middle  and  inferior  fronlal  convolutions  join 
the  anterior  central  convolution,  and  it  is  very  probable  that 
injury  to  this  region  causes  a  motor  disturbance  in  the  tongue. 
In  a  case  ol  tubercular  meningitis,  Matthes  (NEiinchener  med. 
Wochcnschrift,  1892,  49)  has  observed  a  hypoglossal  paralysis, 

Fimirt  of  [iotaiuio 

Parirl'it  M-f 


Pie-   18.— COKTICXL  CBNTBn  OF  TKK  L.EFT   HEKI4PHEHB.      (Aftct  COWCR&) 

which  he  attributes  to  a  localized  tubercular  meningitis  at 
(he  convexity  over  the  centre  for  the  hypoglossus.  On  the 
whole,  central  palsies  of  this  nerve  are  rare. 

The  bull>ar  lesion  of  the  nerve,  or  rather  of  its  nucleus,  is 
somewhat  better  understood ;  it  has  undoubtedly  been  ob- 
served, if  not  frequently,  at  least  repeatedly,  that  this  lesion 
can  occur  unilaterally.  There  is  then  an  atrophy  of  the  nu> 
cleus.  in  which  the  nerve  cells  and  the  medullated  fibres  be- 
come decreased  in  number  or  disappear  entirely,  while  the 
roots  appear  as  line  threads.  In  such  cases  (see  especially  Fig. 
29)  the  tongue  is  protruded,  not  straight,  but  deviates  toward 
one  side,  and  be  it  remembered  toward  the  affected  side  (m. 
genioglnssus  and  gcniohyoideus);  it  shows  fibrillary  twiich- 
ings.  and  an  atrophy  of  the  diseased  side — hcmiatrophia  lingux 
—which  in  such  a  case  looks  flabby  and  shrunken  in  compari> 
son  with  the  full  and  firm  healthy  half:  it  is  wrinkled,  con- 
tracted, and  much  smaller  than  the  latter  (cf.  Figs.  29  and  3a 
showing  my  two  cases).  The  electrical  examination  shows 
either  normal  reaction  or  reaction  of  degeneration;  that  the 


J>/SeAS£S  OF  THE  HYPOGLOSSAL  NERVE. 


'43 


bttcr  may  also  occur  in  central  lesions  lias  been  demonstrated 
by  one  of  my  cises,  which,  however,  did  not  come  to  autopsy. 
Speech,  mastication,  and  deglutition  often  sutTcr  considerably  ; 
on  the  other  hand,  the  heulthy  half  of  the  tongue  may  develop 
so  satisfactory  and  vicarious  an  activity  that  little  disturbance 
ii  observable. 

Unilateral  paralysis  of  the  hypoglossal  nerve,  due  to  periph. 
cral  causes  (Birkctt,  Neurol.  Centra Iblatt,  1891,  24)  has  been  ob- 


Flf.  a^— HKMtATitinniiA  Lmou-c  ipenonal  oliMrvatlon). 

•frrcd  as  a  result  of  traumatism:  further,  also,  in  diseases  of 

klhe  vcncbral  artery,  as  the  result  of  newf  growths  in  the  me- 

'dulli  oblongata  and  in  caves  of  embolic  softening  in  the  region 

<^  the  nucleus  (lltrl>.      Whether  it  can  be  also  of  saturnine 

b*n|>jn  Mcms  to  me  to  be  doubtful,  in  spite  of  the  report  of 

i^tauk.     In  a  recently  published  article  by  Koch  and  Marie 

'ct  lit.)  may  be  found  all  the  cases  observed  up  to  the  present 

lime  collected  and  minutely  annlyzcd.     A  case  of  congenital 

k.^pOflossal  panilysis  has  been  observed  by  [-"rancotte  (Anna!. 


1 


■44 


DISEASES  OP  THE  CRANIAL  NERVES, 


de  la  soc.  mSd.-chir.  de  Liige,  1889),  which  is  undoubtedly  sn 
instance  of  infantile  nuclear  degeneration  (Mobius). 

In  bilateral  paralysis  of  the  hypoglossal  the  longttc,  atrophic, 
wrinkled,  and  shrunken,  lies  uhnost  motionless  on  the  floor  of 
the  mouth;  the  patient  can  not  protrude  it,  and  has  entirely 
Inst  control  over  it.  Speaking  and  chewing  are  rendered  diffi- 
cult, even  quite  impossible.  This  sad  picture  is  seen  not  infre- 
quently in  Ouchcnnc's  pr<^rc5sive  bulbar  paralysis,  occasionally 


FIR'  jo.— llBMuniOPHiA  LiHOirx  (ptnoiuJ  obwrvMlon). 

in  progressive  muscular  atrophy,  very  rarely  in  tabes.  The 
hemiatrophy  of  the  tongue,  too,  occurs  much  less  frequently  in 
the  course  of  tabes  than,  to  judge  from  the  communications — 
for  instance,  those  of  Ballet  (cf.  lit.) — would  seem  to  be  the 
case. 

The  peripheral  form  of  the  affection  may  yield  to  electrical 
treatment  (faradization  and  galvanization);  the  central,  so  far 
as  we  know  at  present,  is  not  amenable  to  any  treatment. 

Hypoglossal  spasm  occurs  sometimes  unilaterally,  some- 
what more  frequently  bilaterally.      U  is  an  exceedingly  rare 


D/SEASSS  OP  TUE  HYPOGLOSSAL  IfESVH. 


MS 


_  (iisa 
■  alta 


affection,  in   regard  to  wliich   (iierc  have  been  but  few  good 

publications.    There  is  a  paroxysmal,  invoiuntary  spasm  ol  the 

tongue,  by  which  it  is  protruded  and  retracted,  roiled  violently 

around  in  the  mouth,  and  so  roughly  pressed  against  the  tccth 

(bat  it  may  be  quite  severely  injured.     In  some  instances  there 

occur  short  rhythmical  twitchings  in  the  whole  tongue  which 

(iUappcar  at  times.     Bcrgcr  observed  an  aura  before  such  an 

attack,  which  consisted  in  a  sensation  of  tension  and  swelling 

Ihc  tongue.     In  Dochmann's  case  the  attacks  occurred  espe- 

lly  at  night,  and  were  so  violent  that  the  patient  was  awak> 

CDcd  from  her  steep  by  the  sudden  spasmodic  protrusion  of  the 

loogue.     In  one  o(  my  own  cases  the  muscles  of  mastication 

took  part  in  the  affection  in  such  a  way  that  before  the  actual 

Iqrpogtossal  spasm  occurred,  the  lower  jaw  was  for  half  or  a 

whole  minute  spasmodically  jerked  to  and  fro.  up  and  down. 

Aiwr  these  movements  had  ceased  the  moulh  remained  half 

open,  and  the  turning  and  rolling  movements  of  the  tongue 

OMiincnced  and  lasted  for  about  one  tninnte.     These  attacks 

reclined  ten  to  twenty  times  a  day  ;  they  came  on  for  the  first 

time  three  days  after  an  epileptic  6t.  and  have  lasted  unaltered 

cwTjjnce  (for  three  years).    The  patient  is  otherwise  perfectly 

healthy,  and  h.is  a  good  family  history.     The  pathogenesis  of 

llw  disease,  its  an.itomical  seat  (irritation  of  the  hypoglossus 

centre?  cortical  or  bulbar?),  is  obscure.     As  an  accompanying 

V'plo'n  of  chorea  and  hysteria  it  is  by  far  more  common  than 

u  in  Independent  affection.    Possibly  the  so-called  auctioneer's 

1«MB  (Zenncr,  Berliner  klin.  Wochcnschrift.  1887.  17).  which 

it  aused  by  overexertion  (speaking  and  shouting),  should  be 

taxied  as  a  form  of  hypoglossal  spasm.    The  treatment  is  the 

ame  as  in  paralysis  of  the  tongue. 

l.ITHKATtniE. 
I.  PtmMi  */  Ihf  //fjvgLutal  AVtv.     fffitatrt^i*  lingm*. 
'•"liKlailc.     A  TTMlt»e  on  ihe  Dvwram  of  Ihc  Tonpic.     London.  1873. 
^^.    ltdirj]c  tut  t>iAgnoM.il(  il«r  LaKf  und  IlcBchaTenhclt  vt)ii  Kt.itikhcttv- 

•wtlrn  iln  OliUin^la.     t>rol*clwt  Aieh.  f.  klin.  Me<l,.  xxiv.  p.  418,  (884. 
™t    Df  llifciiinirDphie  At  la  1.iiik*ic      Arch.  Ac  Neurol.,  vji,  to.  1884. 
'"''•   ITrtirr  HrtnUimphic  dcr  /ungc.     BH.  klin.  WiKlienwhr.  Na  14,  188$. 
"   CiB  scltcwrr  Fall  von  .-iiro|>hi<chrr  IJIhinung  Att  N,  hypogl.    Tleuitches 

Afch.  t  klin.  Med.,  xmvii,  p.  16;,  t88;. 
'^'fcn.    Dc  Hi^inijirophic  ik  U  Inngue.     Kcvue  titens.  <)«  Uryngolnglr, 

•I'oiolngip,  et  lie  r)uiiot4)|;ie. 
""■ik.  E,     Ifehcr  utuminc  Hemiairophie  dcr  Zunge.     BerL  klin.  Woclicn- 
Khr.,  luit.  3j,  1886, 
10 


146  DISEASES  OF  THE  CRANIAL  NERVES. 

Sauer.     Fall  von  traumat.  Hypoglossus-  u.  Accessoriusl^hmung.    Inaug.  Diss., 

Gdttingen,  1886.     (Unilateral  Luxation  between  Atlas  and  Epistropheus.) 
Peel.    Beri.  klin.  Wochenschr..  No.  19,  1887.    {Hemiatrophy  of  Tongue,  wiih 

Left-sided  Recurrens  Paralysis.) 
Koch  et  Marie.     H^miatrophie  de  la  langue.     Revue  de  m^.,  viii,  i,  188S. 
Morison.     Brit.  Med-  Joum.,  July  14.  1888.     (Unilateral  Paralysis  of  the  Hypo- 

g'lossal  in  Consequence  of  Traumatism.) 
Limbeck,     Prager  med.  Wochenschr.,  1889,  16. 

Pasquier  et  Marie.    Simiiologie  de  la  langue.     Progiis  mid.,  1891 ,  1 1, 
Birkett.     Neurol.  Ceniralbl.,  1891,  34. 
Lange,  F.      Ueber  Zungenbewegungen.      Arch.  f.  klin.  Chir,   1893,  xlvi,  3, 

p.  634. 

a.  Hypeglosial  Spaim. 

Berger.     Ueber  idiopathischen  Zungenkrampf.     Neurol.  Centralbl.,  i,  3,  i88z. 

Dochmann.     Petersb.  med.  Wochenschr.,  i,  1883. 

Wendt     Unilateral  Spasm  of  the  Tongue.     Amer.  Joum.  Med.  Sc.,  clxxvii,  p. 

173.  Jan.,  1885. 
Erienmeyer.    Centralbl.  f.  Nervenheilk,,  ix.  No,  J,  1886.     (Case  of  Idiopathic 

Spasm  of  the  Tongue.) 
Bernhardt.    Ueber  idiopathischen  Zungcnkrampf.     Ibid,,  No.  11,  18S6. 
Lange.  F.     £in  Fall  von  beiderseitigem  idiopathischem  Hypoglossuskrampf. 

Bin  Bciirsg  zur  Lehre  vom  Riiter-Roltett'schen  PhKnomen.     Arch.  f.  klin.' 

Chir..  1893.  xlvi.  Heft  4. 


CHAPTER   XI. 


lUICtTAKKOVS  AFFECTION  OF  SEVERAL  CRANIAL  NF.RVES — MULTtPLR 
PAKALYSIS   or   TMB  CRANIAL    NE8VE6, 

V  AtTER  having  thus  considered  the  lesions  of  the  individual 
cnnial  nerves,  it  remains  for  us  to  inquire  under  what  condi* 
tions  several  o(  them  may  be  sinniltancously  affected,  and  into 
iV  symptoms  thus  produced.  Accordinj;  to  the  observations 
coAectcd  up  to  the  present  time,  an  affection  of  this  kind  may 
blvc  its  scat  in  the  peripheral  or  in  the  central  course  of  the 
nerfeSjas  well  as  in  the  cortical  or  nuclear  centres.  Only  cer- 
uinof  the  affections  of  this  latter  kind  are  to  be  ref^rdcd  as 
Independent  diseases,  while  the  peripheral  lesions  arc  always 
Qiilj  p,irtial  manifestations  of  other  conditions.  In  rare  cases 
isidiultaneous  peripheral  lesion  of  several  crania!  nerves  may 

t  occur  in  consequence  of  traumatism,  operative  interference, 
etc.  A  case  in  point,  in  a  patient  operated  upon  by  Israel,  has 
hetB  published  by  Rcmak  (Bcrl.  klin.  Wochcnschr..  7,  1888). 
Aarciooma  of  the  neck  was  extirpated,  and  by  the  operation 
'l>e  Bcccssorius,  the  hypoglossus,  and  the  sympatheticus  were 
"'iuT«l,or  rather  resected.  The  symptoms  caused  by  the  acci- 
itM  were  accurately  described  by  Rcmak.    Other  instructive 

|t»n.duc  to  iraumatisiij,  have  been  described  by  MObius  (c(. 
AiiKJng  the  ^nera]  diseases  in  which  multiple  cranial  nerve 
Wont  may  occur  are  chiefly  tuberculosis  and  syphilis. 
Tnbercular  mcninj^itis  ntlacks.  by  preference,  the  mem- 
"Ow  al  the  base,  and  implicates  most  of  the  cranial  nerves 
**«fging  in  that  region,  as  we  have  seen  in  our  account  of  the 
<li«ases  of  the  mcninKes.  I-:itcly  Kahlcr  {of.  lit.)  has  again 
("reeled  attention  to  the  fact  that,  in  consequence  ot  syphilis, 
.  >)*ril>hcral  neuritis  of  the  cranial  nerves  sometimes  de%-elops, 
"tl  titti  we  may.  besides  general  cerebral  symptoms,  have  a 
pTDgreuive  slow  parulysts,  which  attacks  one  cranial  nerve 

147 


I 


l^g  DfSF.ASES  OF  THE  CRAXIAI.  NBUl'RS.  ^ 

after   the   other  in    irregular   succcssirm   (cf.  also  Rnthmann, 
Deutsche  Med.-JItg..  1893.  46). 

Alter  diphtheria  peculiar  forms  of  paralysis  are  observed, 
which  chiefly  take  in  the  muscies  uf  the  soft  palate  and  the 
pharynx.  Since  these  muscles  arc  innervated  by  certain  of  the 
cranial  nerves,  and  the  disease  is  unquestionably — e.g.,  when 
the  paralysis  is  unilateral — often  of  peripheral  origin  (central 
diseases  can  nut  in  alt  other  cases  be  excluded),  we  shall  devote 
a  few  lines  to  the  consideration  of  their  nerve  supply. 

The  innervation  of  the  palatal  and  pharyngeal  muscles  Is  by  no 
means  one  uf  the  clearest  <.*lia|ilcrs  in  neurology.  W'c  do  not  know 
exaetl}r  which  of  the  cranial  nerve*  arc  cimcerned.  nor  their  mode  of  ■ 
distribution.  Of  the  palatal  muscles  the  levator  palati  is  the  most 
important.  This  receives  motor  fibres  throuKh  the  large  su|>crf)cial 
petrosal  (of  the  trigeminus)  from  the  spheno- palatine  KanKlton,  which 
come  from  the  facial  and  which  also  innervate  the  aiygos  uvuIec. 
Whether  or  not,  however,  the  vago-accrssorius  and  the  gtosso-pbar- 
yngeus  arc  also  concerned  in  the  innervation  of  iheiie  muwlcs.  as 
Cowers,  for  instance,  seems  to  think,  basing  hi>  argument;*  ujxin  clin- 
ical observations,  is  not  as  jret  decided.  With  regard  to  the  pharyo-  ■ 
geal  muscles,  it  is  generally  assumed  that  the  stylo-pharyngcus  and 
the  middle  constrictor  are  supplied  by  the  gto.tso- pharyngeal  nerve, 
and  that  the  palato-pharyngcus,  the  superior  and  inferior  constrict- 
ors, arc  innervated  by  the  vagus.  The  participation  of  the  accesso- 
rius  isdouhtfgl  (Schwalbe).  Wc  sec  then  that  the  nerves  concerned 
in  a  paralysis  of  the  pharynx  arc  the  facial,  the  glosso- pharyngeal, 
the  vagus,  possibly  also  the  fifth  anil  the  accessonus. 

Pharyngeal  paralysis  may  be  cither  unilateral  or  bilateral. 
The  unilateral  form  can  only  be  diagnosticated  if  the  patient  is 
made  to  move  the  soft  palate,  for  instance,  in  saying  "AIi!" 
While  during  rest  it  appears  to  be  perfectly  symmetrical,  the 
base  of  the  uvula  deviates  somewhat  on  motion  towards  Ihc 
affected  side,  so  that  on  that  side  a  little  way  from  the  median 
line  there  is  a  slight  depression  not  present  on  the  well  side  ; 
sometimes  also  the  soft  palate  is  a  little  lower  on  the  para- 
lyzed side  even  during  rest.  In  the  bilateral  complete  paralysis 
of  the  soft  palate,  the  latter  hangs  down  flaccidly  and  the  uvula 
appears  elongated ;  on  deep  respiration  and  on  phonaliun  it 
remains  motionless,  and  the  reflex  movements  evoked  by  tick- 
ling the  mucous  membrane  arc  lost.  Speech  becomes  marlc< 
ediy  altered,  the  voice  acquires  a  nasal  tone,  due,  of  course,  lo 
the  cavity  of  the  nose  not  being  shut  oR  during  pbonation; 


PQST-DiPHTtlERiTJC  PARALYSIS. 


'49 


I 


I 
I 
I 


betice  also  the  pronunciation  of  the  explosive  consonants 
"F"  and  "B"  becomes  tmpo^iblc,  owing  to  the  imperfect 
compression  o(  the  air;  they  sound  like  "  M."  Closure  o( 
the  anterior  tiarcs  removes,  as  Duchcnne  has  shown,  this 
disability.  Front  the  same  cause  also 
Hiiids  are  regurgitated  throiigli  the 
aose  on  attempts  at  swallowing,  and 
deglutition    in    general    becomes    difficult. 

Recent  examinalions  of  the  nerves  (Arn- 
heim.  Arch.  I.  Kindcrkrankheilen,  1892,  xiii : 
and  Hochhaus,  Virchow's  Archiv,  1892,  cxxiv. 
Heft  2>  have  demonsiraled  that  lesions  arc 
present  in  various  peripheral  nerves,  not  only 
those  going  to  the  muscles  of  the  palate  and 
the  fauces.  Hansemann  also  has  described 
(Virchow's  Arch.,  1889,  cxv,  Heft  3)  the  condi- 
tion of  the  cranial  nerves  in  diphtheria.  .'\b. 
sencc  ol  the  knee-jerks  has  been  repeatedly 
found  associated  with  paresis  of  the  palate  in 
diphtheria  (Bcrl.  klin.  Wochenschr.,  March  3a 
1S85,  p.  304). 

The  prognosis  in  post-diphtheritic  paralysis 
is  not  unfavorable  if  the  velum  palati  alone  is 
paralyzed.  If.  on  the  other  hand,  the  muscles 
ol  the  ucsophagus  also  take  part,  the  outlook 
becomes  graver  on  account  ot  the  inability  of 
the  patient  to  take  nourishment,  and  all  the 
more  so  if  feeding  by  the  stomach-tubc  is  not 
constantly  and  airefully  practiced.  If  this  is 
not  done,  aspiration  pneumonia  or  inanition 
may  bring  about  a  fatal  issue. 

The  electrical  treatment  ought  lo  be  begun 
as  early  as  possible.  It  consists  in  the  direct 
faradisation  or  galvanization  of  the  velum  and 
the  frequent  excitation  of  reflex  movements  ol 
deglutition  by  stimulation  of  the  throat.  The 
uvula,  the  pillars  of  the  pharynx,  etc.,  are  di- 
rectly touched  and  repeatedly  stimubted  by 
means  of  the  curved  button  electrode  (cf.  Fig. 
31).  The  movements  of  deglutition  are  ob- 
tained if  the  anode  is  placed  on  the  neck  and 
the  cathode  (button  electrode)  is  quickly  drawn 


Flf.    31.—  PHAHVlf- 

CEAL  aud  Ladti'- 

OMU     Et-El-TMIIMt 

UtCXT  rVK    MAKIIM 
<tll>  HKCAKI'IU  niB 

Ctj'MKXxl.      <Afl*r 
Km.) 


ISO 


DISEASES  OP  TUE  CXAA'iAL  A'ERVES. 


over  one  of  ihc  lateral  surfaces  of  the  larynx,  six  to  ten  cells 
stilficing  for  the  purpose.  These  gymnastics  of  the  phar- 
yngeal muscles  constitute  an  excellent  remedy  which  can  not 
be  replaced  by  any  other.  It  oltea  leads  rapidly  to  rc> 
covcry. 

Central  diseases  of  several  cranial  nerves  at  the  same  lime 
may  also  occur,  and  that.  too.  not  only  in  their  intracerebral 
course — which  for  but  few  uf  them  is  known,  and  for  those 
only  imperfectly — but  also  in  the  centres  themselves.  As  a 
matter  of  fact,  our  knowledge  about  the  centres  situated  in  the 
cortex  is  also  very  incomplete,  since  we  must  again  confess  our 
comparative  ignorance  of  the  anatomy.  Still,  we  shall  not  go 
too  far  if  we  assume  that  extensive  cortical  lesions  may  impli- 
cate several  ccntre<>  together,  and  there  is  no  doubt  but  that 
they  may  be  affected  after  or  rather  during  an  apoplectic 
attack  by  "  indirect  action." 

IJTERATURE. 

Reinlurd.    Deutsche  med.  Wochcnschr.  1885.  No.  19.    (Subcu(an<xHia  Injec- 

lions  in  the  Rfgion  of  the  Neck  nf  0.001  (gr,  ^)  of  Str)'chnia  daily.) 
Koihmann.     lUiil .  itlS5.  Na  ;z.    (t'aralynis  of  the  MuKJes  oi  Respiration  after 

Diphihtri.!.) 
H.-inscmann.     Virchow'*  Arehif,  1889,  c«v,  Heft  3, 
HallagFT.     The  I'aralyses  adet  IJiiiiiiheria.     IIoi|i.  Tid.,  1890,  4. 
Garcia  y  MansilU.     Nature  and  Tivaimcnt  of  ilie  I'osvdlphlhefitlc  Paralyses. 

Rivisiadin.  cte  lot  hospilalcx.  1891.  31. 
Suckling.    Uni.  Med.  Jouni..  Mxy  iS,  [891.    (Three  Cases  of  Taraly^s  of  the 

Diaphragm  aficr  Di|>hthcri.i.) 

Of  eminently  practical  importance  are  the  nuclear  aflecttons 
of  the  cninial  nerves.  Referring  the  reader  to  the  preceding 
chapters  for  the  anatomical  position  of  the  individual  nuclei, 
wc  will  only  remind  him  of  the  fact  that  these  nuclei  are  situ. 
atcd  in  the  gray  matter,  partly  ol  the  mid-  and  'tween-  brain, 
partly  in  the  medulla  oblongata.  The  portion  situated  above 
the  latter  extends  from  the  posterior  wall  of  the  infundibuluiD 
in  the  third  ventricle  to  the  level  of  the  nucleus  of  the  abdu- 
cens.  and  embraces  the  nuclei  of  the  eye  muscles  (Wernicke). 
The  other  nuclei  belong  to  the  lower  portion. 

Clinical  observations  now  leach  us  that  either  of  these  por- 
tions may  be  allccled  by  itself,  and  we  may  with  Wernicke  call 
the  disease  ol  the  upper,  polioencephalitis  superior;  that  of  the 
lower,  polioencephalitis  inferior.  According  to  the  course,  we 
distinguish  in  cither  case  an  acute  and  a  chronic  form,  so  th| 


POUOESCEPUAUTIS  ( WERNICKE). 


'51 


there  are  altogether  four  clinical  pictures  of   these  nuclear 
nffeclions. 

Polioencephalitis  superior  acuta  has  only  been  observed  in 
very  few  instances.  The  b<-st  observations  we  owe  to  Wernicke. 
According  to  htm,  this  is  esscntialty  an  acute  inflammatory  dis- 
ease of  the  nuclei  o(  the  ocular  muscles,  and  proves  fatal  in  from 
ten  days  to  a  fortnight,  the  focal  symptoms  consisting  in  an 
associated  paralysis  of  the  eye  muscles,  the  general  symptoms 
\xxn^  grave  disturbances  o(  consciousness.  The  walk  presents 
a  [leculiar  combination  of  spasm  and  ataxia.  Anatomically, 
foci  of  acute  softening  arc  found  in  the  region  of  the  nuclei, 
which  are  cither  due  to  obstruction  of  the  blood-vessels  or 
to  inflammatory  inflltration  of  the  tissues,  ^tiologically,  the 
abuse  of  alcohol  may  be  mentioned. 

With  reference  to  the  diagnosis,  the  presence  of  n  tumor  in 
the  region  of  the  corpora  quadrigemina  should  be  considered 
IB.  Sachs,  New  York.  Di5.eascs  of  (he  Mid-brain  Region,  Am. 
Jour,  of  the  Med.  Set.,  March.  i8gi). 

Polioencephalitis  superior  chronica  was  described  in  iS6S 
by  von  Graefe,  and  called  by  him  ophthalmoplegia  progres. 
UTi.  The  first  published  case  presented,  according  to  von 
Graefe  (BcH.  klin.  Wochenschr.,  ii,  i86S),  a  peculiar  clinical 
lecture : 

"Gt^dually  all  the  muscles  concerned  in  the  movements  of 
the  eye  become  paralyzed,  so  that  there  results  first  a  diminu- 
tion in  the  range  of  sight,  and  hnally  complete  immobility  o( 
the  eyeballs.  The  levator  palpebrfe  superioris  is  wont  to  be 
implicated,  although  the  consequent  ptosis  is  rarely  as  marked 
u  that  occurring  in  complete  oculo-motor  parnlysis.  It  is  re> 
narkable  that,  on  examination  for  reaction  to  light  and  accom- 
otodation,  the  sphincter  pupillae  as  well  as  the  ciliary  muscle 
prcKittno  changes.  This  condition,  which  we  very  rarely  find 
■n  other  extensive  oculo-motor  panilyses.  seems  here  constant 
"ul  ctiaracterislic  of  this  disease.  Another  feature  which  dis- 
linpiishes  this  form  from  other  associated  paralyses  in  the  dis- 
''itHltion  of  the  third,  fourth,  and  sixth  nerves  is  the  progress 
of  tbedisease  f^ari passu  in  the  antagonizing  muscles.  Thus  we 
wrerfind  a  marked  strabismus  divcrgcns  owing  to  a  dominat- 
'>% oculo-motor  paralysis,  because  here  the  external  rectus  loses 
■U  functions  sufficiently  to  neutralize  the  tendency  to  devta' 
t'O'l.aiid  the  si^ht  of  the  patient  is  therefore,  in  spite  of  the 
HUciued  paralysis  of  the  eye  muscles,  affected  much  less  than 


IS2 


DISH  ASKS  OF  Tin:  CRAHHAL  SERVHS. 


in  simple  oculo-mutur  or  abduccns  paralysis,  .  .  .  Still,  a  ccr- 
tain  degree  of  asymmetry  in  the  affection  of  the  difTcrcnt  mus- 
cles of  one  eye,  as  well  as  in  the  development  of  the  whole  dis. 
CISC  in  the  two  eyes,  may  at  times  be  iouiid."  (Cf.  Wernicke. 
loc.  cit.,  vol.  iii,  p.  463.) 

With  the  exception  ol  this  associated  ocular  palsy,  which, 
developing  progressively,  may  remain  stationary  without  being 
completely  symmetrical,  the  patient  enjoys  good  health  and 
complains  neither  ol  headache  nor  of  symptoms  of  increased 
intracranial  pressure.  In  isolated  instances  bitllur  paralysis 
has  been  known  to  be  later  superadded,  and  in  others  the  dis- 
case  wus  found  associated  with  multiple  sclerosis  or  with  gen- 
eral paralysis  (Dallct,  Progress  m£d.,  1893,  23).  Anatomically, 
the  aflection  depends  either  upon  a  primary  disease  of  the 
nerve  nuclei  or  upon  a  diffuse  sclerotic  process  In  which  the 
nuclei  take  part.  In  exceptional  cases,  which  in  their  na- 
ture are  as  yet  entirely  obscnre,  no  organic  changes  what- 
ever have  been  found,  although  the  cliniKil  picture  corre- 
sponded exactly  to  thai  described  by  von  Graefe.  (Hiscnlohr 
and  OppL-nhcim.) 

Not  less  interesting,  and  at  the  same  time  of  far  greater 
practical  importance  because  relatively  far  more  frequently 
met  with,  is  the  fourth  and  last  of  (lie  affections  under  consid- 
eration— ii  disease  the  first  accurate  description  of  which  we 
owe  to  Duchcnne,  ol  Itoulognc,  and  which  after  him  has  been 
carefully  and  successfully  studied  by  German  investigators 
(Wachsmuth,  Kussmaul,  l^cyden) — the  chronic  progressive 
bulbar  paralysis. 

Progressive  Bulbar   Paralvsis. 

PaMfytit  tf  On  T9iigut.  tkt  So/I  Palalr.  and  Ike  Ufi  {liiulttitnt.  1960),  CUll*-latUl 
i^rynxtal  Pantfyiit  (  Tnnm/aii\  ('.Anmu  Pnigr/itint  HuJtar  Pctraiyiit  (  ff  W4/- 
mttl\,  181V4I,  Atnf^u  BmUar  Pamiyiii  {tjydin),  tlidi^r  fftuttar  Paralyiii  (Kuii- 
mau/f,  PtAttHiefAxiilii  In/trttr  Ctrtnua  { tVtrnitkt). 

Duc/if fine's  Disiase. 
Symptoms  and  Course. — In  the  majority  of  instances  the 
onset  of  progressive  bulbar  paralysis  is  very  gradual,  and  only 
rarely  do  we  meet  with  cases  in  which  it  is  ushered  in  by  an 
apoplectiform  attack.  After  having  complained  for  weeks, 
perhaps  months,  of  drawing,  tearing  pains  in  the  neck  and  the 
back,  the  patient  discovers  of  his  own  accord  or  froiji  the  re. 
marks  of    his  relatives  that  the  enunciation  of  certain  words. 


BULBAR  PARALYSIS. 


■S3 


I 


ft 


especially  those  containing  /,  r,  and  long  e.  has  become  very  dif- 
Gcult.  W  tie  happen  10  use  a  word  containiiii;  all  these  letters 
(for  instance,  reel),  he  becomes  painfully  conscious  of  his  indis- 
liiict  enunciation.  In  vain  he  alleinpts  to  repeat  (he  trouble- 
tome  words  over  and  over  again  in  order  to  correct  his  mis- 
take. He  only  becomes  more  convinced  that  the  movements 
of  his  tongue  have  become  clumsy,  and  that  he  has  lost  his 
former  ease  and  fluency  o(  speech;  and,  in  truth,  it  is  the  on- 
aiming  paresis  of  the  lingual  muscles  which  is  the  main  cause 
of  the  disturbance. 

The  tongue,  which  can  not  be  raised  to  the  normal  extent, 
ao  no  longer  be  approached  sufficiently  to  the  hard  palate, 
uid  thus  the  long  e,  lor  the  pronunciation  of  which  the  move- 
ment is  necessary,  can  only  be  pronounced  with  difficulty.     In 
the  same  way  all  the  finer  musctitar  movcmcnis  required  lor 
the  formation  of  the  Unguals  are  imperfect,  and  con&equcntly 
the  enunciation  of  these  sounds  is  bad.    The  disease  progresses 
and  the  articulation  becomes  worse  and  worse,  the  less  per- 
lectly  the  lingual  muscles   arc   innervated,  and   other  letters, 
ij.g,  finally  also  i/and  n.  begin  to  suffer,  so  that  conversation 
*lth  the  patient  becomes  very  uncomfortable,  as  certain  words 
areslroost  unintelligible  and  others  at  least  difficult  to  under- 
tOnd. 

The  lips  also  begin  to  do  their  duty  badly,  so  that  the  enun- 
citlion  of  the  so-called  labials — o.  u.  a,  b,p — gradually  becomes 
iodininci.  The  presence  of  stnmgers  with  whom  he  has  to 
eaovcrsc  cicitcs  the  patient,  and.  avoiding  all  society,  he  pre 
ftn  the  quiet  monotony  of  the  family  circle,  where  nobody 
WaBto  pay  much  attention  to  the  change  in  his  speech  {"ala- 
liiiad  anarthria").  Moreover,  a  change  in  the  features  of  his 
lKt:tt  first  slight  and  only  noticed  by  the  patient  himself,  but 
Iftiinore  perceptible  and  evident  also  to  his  friends,  gradually 
Viilests  itself,  which  serves  as  an  additional  reason  for 
"dudon  (Ftg.  32).  When  laughing,  it  appears  to  him  as  if 
■  Certain  tension  in  his  lips  prevented  the  usual  play  of  the 
■WBth.  In  the  attempt  to  whistle,  the  lips  can  not  be  puckered 
•  •ell  as  formerly:  the  muscles  of  the  cheek  have  become 
•■ote  rigid  and  inactive,  and  as  the  disease  projiresscs  the 
*ioic  lower  half  of  the  face  assumes  a  characteristic  appear- 
•■ce— a  peculiar  lachrymose  and  astonished  expression — which, 
"i»  easily  seen,  is  due  to  Ihe  drooping  of  the  lower  lip  and  to 
^^  deepening  of  the  na&o-labial  fold.     The  upper  Italf  of  the 


>S4 


J>/SSASES  OF  THE  CRAKtAL  XERVBS. 


face,  the  forehead  and  eyes,  do  not  take  part  in  the  change, 
but  remain  entirely  iionnnl.  Nevertheless  the  |>atient*s  lace  is 
much  disfigured,  and  later  ou  in  the  disease  may  have  become 
almost  unrecognizable. 

While  thus  quite  gradually  symptoms  have  arisen  which  i 
make  the  patient  a  very  pitiable  object,  and  which  arc  bound  ^ 
sooner  or  later  to  interfere  with  his  position  in  society,  the  sad 


Kl(.  JJ,— FaCUL  ExratMIOTI  IK  PRnoRFMivr  Bl'LBAS  pAKALVSR.     (After 
LEVDKH,   KICIIIIORST.J 

truth  dawns  upon  him  that  even  the  functions  absolutely  neces- 
sary for  the  exisicnce  of  life  arc  failing.  Eating,  in  which  up 
to  this  time  no  trouble  was  experienced,  he  now  hnds  difficult. 
It  takes  a  longer  time  to  swallow  the  food,  and  in  a  later  stage 
even  mastication  becomes  impaired.  Not  only  do  the  move- 
ments of  the  lower  jaw  become  weaker  and  less  energetic.  ■ 
owing  to  paresis  of  Ihc  muscles  of  mastication,  but.  since  the 
powerless  tongue  is  unable  to  get  the  food  (rom  between  the 


BULBAR  rAKALYSIS. 


ISS 


checks  and  gums  into  the  n^ion  ol  the  pharyngeal  muscles, 
Ibe  iormatioii  of  the  bolus  is  impossible.  Spoons,  fingers,  and 
Ike  like,  have  to  be  used  instead,  or  the  patient  has  to  hold  his 
head  far  back  to  get  the  fuud  to  slide  down.  Even  drinking 
auses  much  discomfort,  as  the  liquid  may  get  into  the  larynx 
ind  thus  give  rise  to  violent  coun:iiin{r,  or  may  be  regurgi- 
btcd  through  ihc  noKc,  either  condiiion  being  due  (o  weak- 
Dcss  ol  the  pharyngeal  and  laryngeal  muscles. 

The  implication  of  the  larynx  is  very  distressing,  and  may 
indeed  become  dangerous.  Tlic  voice  at  times  fails,  speech 
becomes  irksome,  and  the  tone  is  monotonous;  production  of 
tte  higher  notes  as  in  singing  becomes  impossible;  later  on  a 
mirkcd  hoarseness  and  finally  aphonia  follow,  so  that  the  pa- 
tient can  only  express  himself  in  whispers,  which,  owing  to  the 
above-descnbcd  motor  changes,  are  quite  unintelligible.  At 
t^  utae  time  the  absence  of  a  firm  closure  of  the  glottis,  and 
Ihcrclorc  the  inability  to  cough  forcibly,  gives  rise  to  various 
dblurbances  in  the  respiratory  apparatus,  owing  to  the  dis- 
abllily  to  dislodge  mucoid  masses  which  may  have  collected  in 
the  air  passages. 

Another  symptom  which,  though  not  constant,  is  frequently 
met  with,  is  ihc  marked  increase  in  the  secretion  of  the  sali%-a. 
This  occurs  usually  rather  early  in  the  disease,  and  not  infre- 
lly  such  patients  are  seen  going  around  constantly  holding 
_  r  handkerchiefs  to  the  mouth  to  prevent  the  saliva  from 
trickling  away.  On  examination,  the  secretion  is  found  to  be 
nKid.  This  flow  of  saliva  is  due  to  an  actual  increase  in  the 
woittit  secreteil,  as  several  careful  investigators  ha%'c  shown, 
tl»«^  they  do  not  agree  as  to  the  exact  amount. 

Two,  three,  even  five,  years  may  pass  before  any  new  symp. 
*«»arc  added  to  those  just  described.  These,  however,  pro- 
pwivcly  gain  in  inrensity.  and  it  is  especially  the  change  in 
Ac  katurcs  which  becomes  more  accentuated,  owing  to  the 
fQAHinily  Increasing  atrophy  in  the  muscles  of  the  lips  and  the 
Aeelu;  the  palatal  reflexes  become  markedly  decreased  and 
Swlly  lost;  ibc  tongue,  shrunken  and  distinctly  smaller,  lies 
•■Boblle  on  the  floor  of  the  mouth,  and  can  neither  be  pro- 
"wfcd  nor  moved  in  any  direction.  Fibrillary  tremor  is  then 
■<  tneommonly  marked.  On  the  electrical  examination 
(»Wch  is,  by  the  way,  very  hard  lo  make),  we  may  find  reac- 
liMi  <W  degeneration  in  the  lingual  as  well  as  in  the  pharyngeal 
niiscle&. 


'56 


mSRASKX  OP  THR  CRANlAl  KSK^RS. 


The  inability  to  lake  food  properly  is  usually  ihe  cause  of 
death  ;  the  patient  pines  away,  and  gradually  dies  (rocn  inanj. 
tton  without  having  the  blissful  benetii  <>(  a  dulled  conscious- 
ness to  guide  him  insensibly  through  his  tormenting  suQerings. 
Only  in  occasional  instances  disease  ol  the  respiratory  organs, 
caused  by  aspiration  of  food,  hastens  the  tennination  (aspira- 
tion pneumonia). 

Pathological  Anatomy. — There  is  hardly  another  disease  of 
the  nervous  system  with  the  anatomical  basis  o(  which  we  arc 
better  acquainted  than  bulbar  paralysis.  Duchennc  pronounced 
the  process  to  be  a  primary  pigmentary  degeneration,  and 


I 
1 


►iS'  iV-  (.  ^■         -I      '  iiiJI  THRllVOW  -IMC.  UPKKH   IVlttllON  OF  T»IK   MEIIl't  t.1  OXLOMOATAi 

On  ih«  Ipft  Ihc  healthy,  on  the  hchi  iI'f  dlK.u«t  mnlulla.  kk  un  Ihr  tell  ihr  noroul, 
kk  on  ihp  righi  Ihe  dueawd  hj-pocloHUi  ducIciu  (tile  ncne  celli  are  olmou  entlnly  «b- 
not  on  the  richl  ude). 

atrophy  of  the  large  nerve  cells  in  the  nuclei  of  the  me- 
dulla oblongnia,  an  a,ssertinn  which  has  received  complete  con- 
Armatiun  from  all  subsequent  investigators.  Microscopical 
examination  shows  atrophy  of  the  nerve  cells.  This  is  shown 
in  Fig.  33  in  the  nucleus  of  the  hypoglossal ;  the  cells  have 
in  this  case  completely  disappeared,  having  previously  di- 
minished in  sii!e  and  lost  their  processes.  At  the  same  time 
we  hnd  the  connective  tissue  increased,  the  walls  of  the  vessels 
in  the  nucleus  thickened.  Similar  changes  arc  found  in  the 
nucleus  of  the  vagus  accessory  and  Ihe  glosso-pharyngeal 
nerves  (the  so-called  lateral  mixed  system,  ci.  page  107}.  The 
former  may  become  diseased  in  consequence  of  an  ascending 


I 

I 

I 


BULBAR  PARALYSIS. 


'57 


iiH^' 


neuritis  :  a  myelitis  may  be  caused  by  a  similar  process  in  the 
nerves  of  the  luwer  extremities  (Cupfer.  Revue  de  m^d.,  1890). 
Since,  as  we  have  said  before,  the  upper  part  <>(  the  face  always 
remains  normal  during  the  di^^ease,  wc  have  to  assume  ihal  llie 
6t>res  tonervaling  these  muscles  arise  from  a  special  centre. 
This  is  supposed  to  be  a  part  of  the  abductor  nucleus  (Mey- 
i»ert),  which  has  thereh)rc  come  to  be  designated  by  the  com- 
puMtc  name  of  (aciaUabdncens  nucleus.     This  and  the  rcmain- 
infrtiuclei,  with  the  exception 
of   those   mcniinned    above, 
were  always  found  to  be  in- 
icL     The  atrophy  also  cx- 
endntoihcrooi  hbres,  which 
the  naked  eye  olten  a]»- 
tr  smnllcrand  of  a  grayish 
"AoT.    F-'roro  the  lajKijiraph- 
poMtionof  the  nuclei  bc- 
Ihc  floor  of  the  fourth 
tricle,  us  it  is   approxi- 
ilcly    represented  in    Fifi. 
.  wc  caa  easily  understand 
,  nn  the  one  hand,  the 
■gical    process,    alitr 
..f4    attacked   the  hypo- 
ft>liMH.us.  next  implicates  the 
•rinj;  vagus,  and,  on 
Iter  hand,  how  the  mo- 
tor part  of  the  trigeminus 
uually  remains  unaffected. 
10  that  paralysis  of  the  mus- 
clcv  ol  mastication  is  very 
ninr.    But  why  the  auditory 
Mc'instantly  exempt  and  the 
IkU  (Kirlially  affected  are 
drcuriKlances  which  need  to  be  further  investigated.    A  com- 
pter counterpart  to  bulbar  paralysLs  is  found  in  the  so-called 
P«>Bres5ivc  muscular  atrophy,  a  disease  in  which,  as  we  shall 
•«  Utcr  on.  the  gray  anterior  horns  of  the  spinal  cord  and 
'wir  nerve  cells  arc  aflccted  precisely  in  the  same  way  as 
Ibc  bulbar  nuclei  in  the  disease  wc  are  now  discus-sing-     The 
"^r"  cells    ol    the   anterior   lu.rns    constitute    the    troplioki- 
"•ciic  centres  (or  the  muscles  supplied  by  the  spinal  nerves,  an 


■>K'   34.— THK   fyMTKRtOR   (tteaSAIJ   ASMCT 

OF  no.  Mei'uu^Ohloikiat*.    i.  pmwf- 

ot oiiBmiNrilr*.  >.  |ifclun(li><d  pinral  ctind. 
J,  oonxiniquidnpniina.  4.  mptncv  |i(dan> 
clc  J.  mlddtc  pnluncle.  b,  inlcrinr  pedun* 
cIf  of  cFntctlua.  7,  itrl9>  acimlo.  H,  lu* 
nk.  icm.    9.  obci.    ■«,  fvniniL  cnciL 


»S8 


D/S£^S£S  or  THS  CflAXlAt.  ^VEKVES. 


office  which  the  bulbar  nuclei  fulfill  for  those  supplied  by  the 
craninl  ticrves.  In  both  diseases  there  .trc  atrophy  nod  decrease 
in  the  functional  power,  and  in  both  the  disturbance  is  strictly 
motor,  while  sensation  is  absolutely  intact.  This  essential  simi- 
larity between  the  two  diseases  explains  why  not  rarely  one  is 
associated  with  the  other — in  other  words,  why  they  may  com- 
plicate each  other.  \Vc  may,  indeed  we  frequently  do,  meet 
with  cases  in  which  bulbar  paralysis  is  accompanied  by  atro- 
phy o(  the  muscles  of  the  extremities,  while,  on  the  other  hand, 
in  progressive  muscular  atrophy,  bulbar  symptoms,  disturb- 
ances in  deglutition  and  speech,  may  be  found. 

Another  analogy  exists  between  bulbar  paralysis  and  amyo. 
trophic  lateral  sclerosis,  a  disease  in  whii;h  not  only  the  nerve 
cells  of  the  anterior  gray  honis,  but  also  the  motor  tract 
in  the  lateral  columns  of  Ihe  spinal  cord  arc  affected.  All 
these  diseases,  viewed  from  an  anatomical  standpoint,  if  not 
identical,  certainly  arc  closely  related  to  each  other,  and  only 
differ  in  the  position  of  the  lesions;  it  is  therefore  advisable  to 
consider  and  study  them  from  a  common  point  of  view,  as  the 
understanding  of  the  individual  symptoms  will  thus  be  much 
less  difficult. 

Diagnosis. — As  to  the  diagnosis,  we  need  not  be  doubtful  if 
we  always  remember  that  the  disturbances  are  confined  to  the 
motor  functions  of  the  nerves  governing  the  muscles  of  the  tips, 
tongue,  pharynx,  and  larynx.  Oppcnheim  has  recently  called 
attention  to  rhythmical  twitchings  of  the  velum  palati  and  of 
the  internal  and  external  muscular  tissue  of  the  larynx,  which 
he  considers  to  be  of  diagnostic  value  in  diseases  of  the  posterior 
fossa  of  the  skull  (Neurol.  Ccutralbl..  iSScj.  5),  If  we  find  any 
well-marked  sensory  changes,  if  the  patient  complains  of  pain 
or  paraeslhesias  and  the  like,  we  either  have  to  give  up  the 
diagnosis  of  bulbar  paralysis,  or  we  have  In  search  for  some 
complication.  The  peculiar  facial  expression,  the  increased 
flow  of  saliva,  the  tremulous  atrophic  tongue  partially  or  even 
completely  immobile  as  it  is,  the  disturbance  in  speech  and 
deglutition,  when  taken  together  are  so  characteristic  that,  if 
intelligently  observed  and  studied,  they  will  make  our  diog. 
nosis  clear. 

There  is  only  one  case  in  which  we  may  be  doubtful ;  cer- 
tain foci  of  disease  in  the  brain  may  produce  symptoms  simu- 
lating bulbar  paralysis,  so  much  so  indeed  that  the  name  pscudo. 
bulbar  paralysis  has  been  given  to  the  condition  (which  later  on 


BULBAR  PARALYSIS. 


^%^ 


will  be  described  more  at  length);  nevertheless,  with  due  care> 
(illness  we  can  avoid  a  mistuke.  The  most  important  point  to 
observe  in  the  differential  diagnosis  is  the  course  of  the  disease. 
While  in  progressive  chronic  liulbiir  paralysis  this  is  slow,  but 
always  progressive  toward  the  latal  end.  in  the  spurious  torm 
rcmissiuns  may  occur,  su  that  for  years  the  patient  may  be  im- 
proved, though  he  finally  also  succumbs  to  Ihcdisc.isc.  Besides 
this,  pseudo-bulbar  paralysis  is  often  attended  with  cerebral 
(Yinptoms,  headache,  apoplectiform  attacks,  etc. 

Prognosis.— The  prognosis,  as  we  should  expect  after  what 
has  been  said,  is  altogether  unfavorable.  There  is,  according 
to iiur  present  knowledge,  no  cure  lor  the  true  bulbar  paralysis, 
and  one  ought  to  be  carelul.  therefore,  not  to  deceive  the  family 
*itb  promises.  As  suun  as  the  diagnosis  is  made  they  ought 
lobe  informed  of  the  unfavorable  outlook. 

Treatment. — The  only  treatment  from  which  any  success 
may  be  expected,  if  begun  early,  is  the  systematic  use  of  elcc- 
liidty:  faradization  and  galvanization  of  the  threatened  mus- 
dts,  especially  o(  those  of  (he  tongue  and  pharynx,  frequent 
lalion  of  the  movements  of  deglutition,  according  to  the 
Detbod  already  described,  arc  the  only  measures  which  deserve 
ctmfidence.  With  the  exception  of  this  local  treatment,  there 
i>im(bing  that  affords  even  a  temporary  benefit,  I  have  never 
Kcn  any  lasting  cSect  from  hydrotherapy,  but  stilt  this  trcat- 
neot  is  very  trequenlly  advised  just  at  that  stage  of  the  disease 
"hen  electricity  might  do  some  good.  Internal  remedies  are 
Li(  W)  avail ;  the  occasional  symptomatic  use  of  atropine  ('/,  (o  i 
iniUigramme  ('/,„  to  ',/„  gr.)  daily)  to  diminish  the  salivary  secre- 
tioa  may  be  indiaitcd.  It  scarcely  needs  to  be  mentioned  that 
Ihr  chief  duly  of  the  physician  in  the  later  stages  of  ihcdisease 
i*tupay  the  most  careful  attention  to  the  general  nutrition  of 
the  p.-iiient. 

Etiology.— The  ailiology  is  still  obscure.  It  is  true  that 
Ihertare  patients  affected  with  the  disease  who.  owing  to  their 
MQiptlion,  have  made  rather  excessive  use  o(  the  muscles  of 
llie  tipc.  tongue,  and  palate  (glass-blowers,  musicians).  These 
CMC*,  however,  are  so  rare  that  it  would  seem  very  forced  to 
Mlriljutc  any  ^etiological  importance  to  this  factor.  The  same 
■»iy  be  said  about  syphilis,  the  truth  being  that,  in  most  cases, 
tbeause  b  absolutely  obscure,  and  all  we  can  say  is  that  males 

K persons  adv.inced  in  life  seem  to  be  more  frequently  at- 
!d  by  the  disease  than  others.     Heredity  but  rarely  plays 


l6o  DISEASES  OF   THE   CRAfflAL  NERVES. 

a  part,  and  the  influence  of  cold  remains,  in  connection  with 
this  disease,  as  obscure  as  with  all  other  nervous  affections. 

LITERATURE. 

Mobius.     Ueber  mehrfache  H  i  rnn  erven  la  hmung.     Erlenmeyer'sches  Centralbl. 

f.  Nervenhk.,  1887,  x,  15,  16. 
Oppenheim  und  Siemerling.     Die  acute  Bulbarparalyse  und  die  PseudobulbSr- 

paralyse.     Charitf-Annalen,  1887,  nii, 
Unverrichi.     Ueber  multiple  HimncrvenlShmung.     Fortschr.  d.  Med.,  1887,  14. 
Pel.     Berl.  klin.  Wochenschr.,  1887,  xxiv,  29. 
Mobius.     Centralbl.  f.  Nervenhk.,  18S7.  x,  ij.  16. 
Aclamkiewiez.     Halbseicige    fortschreitende    GehimnervenlShmung.      Wiener 

med.  Wochenschr.,  r889.  2. 
Scheiher.     Berl.  klin.  Wochenschr.,  1889,  xxvi.  28.     (Unilateral  Bulbar  Paral- 
ysis.) 
Reinhold,     Deutsches  Arch,  f  klin.  Medicin,  1889,  kIvi,  Heft  i. 
Mendel.     Neurol.  Centralbl,  1890,  16. 
Howard  H.  Tooih.    Study  of  a  Case  of  Bulbar  Paralysis,  with  Notes  on  the 

Origin  of  Certain  Cranial  Nerves.     Brain,  1S91,  56. 
Senator.      Acuie   BulbSrlahmung  durch  Blutung   in  der  Oblongata.     Reprint 

from  CharitS-Annalen,  xvi,  Jahrg. 
Senator.      Bulbarlahniung    ohne  anaiomischen   Befund.      NeuroL  Centralbl, 

1892,6. 
Remak.     Beri,  klin.  Wochenschr.,  1893,  44. 


PART  in. 

DISEASES  OF   THE  BRAIN  PROPER. 

The  more  autopsies  we  see  the  more  ll>e  fact  is  brought 
boDC  to  us  that  brain  lesions  arc  Ircqucnt))*  present  which 
not  diagnosticated  during  life.  This  is  by  no  means 
irily  the  fault  of  the  di<ignostician,  (or  undoubtedly 
Unr  focal  lesions  ol  the  brain  may  exisi  wiihotil  giving  rise 
hi  uy  symptoms.  Rccenily  G.  Schmid  has  published  an  in. 
tcresting  collection  o(  such  cases  (Virchow's  Archiv.  1893. 
ctniv,  i).  On  ibc  other  hand,  of  course,  we  frequently  sec 
tases  presenting  symptoms  which  make  us  at  once  suspect  the 
niitence  of  a  brain  lesion. 

la  such  cases  we  have  to  ask  ourselves  two  questions:  Ir) 
Wkweis  the  scat  of  the  lesion.'  (2)  What  is  its  pathological 
Mttwt?  To  the  physician  both  of  these  questions  are  of  in- 
iwcil;  to  the  patient,  more  especially  the  latter. 

The  examination  which  searches  lor  the  seat  of  the  lesion 
''ill  gire  us  ihc  topical  diagnosis  (mrof  =  place) :  the  exam- 
faadon  concerning  the  nature  of  the  lesion,  the  pathological 
%w*is. 

The  endeavor  to  localize  cerebral  lesions— that  is,  to  make 
diagnosis — has  only  of  comparatively  laic  years  re- 
Ttttcntion,  and  tnuch  uf  the  work  so  far  done  can  not  be 
'^^^  more  than  an  attempt,  in  many  c:tscs  indeed  only  a  weak 
<•<•  The  celebrated  discovery  of  Uroca  (rS^n).  that  certain 
<liititfbances  uf  speech  were  often  found  associated  with  lesions 
*lk  third  left  frontal  convolution,  the  discovery  of  Fritsch 
•■J  Hiuig(i87o)  that  stimulation  of  certain  areas  of  the  cortex 
pfWlKc*  contractions  in  certain  definite  groups  of  muscles  on 
'••f  opposite  side  oi  the  body — these  and  various  other,  patho- 
■fiol,  observalions,  lo  which  reft^rence  will  be  made  later, 
'ttltcttraost  probable,  nay.  almost  certain,  that  definite  puns 
or  jrcM  of  the  cortex  are  always  connected  with  certain  func- 

II  i6t 


i62 


DISEASES  Of  THE  BRAIN  PFOfKR. 


lions  of  the  brain  ;  in  other  words,  that  these  functions  can  be 
localized  ;  and,  notwithstanding;  the  many  uncertainties  and 
niinierous  contradictions  between  the  results  of  experiments 
on  the  one  hand  and  those  obtained  from  clinical  observutiuns 
on  the  other,  it  is  this  doctrine  of  cerebral  localization  which, 
though  still  undeveloped,  must  be  considered  as  the  basis  of 
all  further  investigation  in  ihc  ticid  of  cerebral  pathology. 

Equal  stress  must,  however,  be  laid  upon  the  examination 
into  the  nature  of  the  lesion.  A  certain  symptom — for  instance, 
a  persistent  hemiplegia — is  always  the  result  of  a  lesion  of  the 
motor  tract ;  a  lesion,  however,  which  can  be  produced  in 
quite  a  variety  of  ways.  It  may  be  due  to  cerebral  hwmor- 
rhasje,  to  a  tumor,  an  abscess,  etc.  It  is  therefore,  especially 
with  regard  to  the  prognosis,  of  the  greatest  importance  to 
determine  the  exact  nature  ol  the  lesion  in  a  given  case,  but 
both  questions  ought  always  to  be  investigated  with  equal 
care  if  we  wish  to  arrive  at  as  exact  a  diagnosis  as  circum- 
stances permit.  In  the  following  pages  these  two  modes  of 
diagnosis  will  be  considered  separately,  and  we  shall  first  speak 
of  what  is  known  about  cerebral  localiz.ation,  while  in  a  later 
chapter  the  pathological  side  will  be  discussed. 

I.  The  SrtJDV  of  Ckrebrai.  Lesions  with  Refkkrsck  td 
TiiKiR  SiiAT— Toi'iCAi.  Diagnosis — Doctkine  of  Local- 
ization. 

Two  classes  of  symptoms  produced  by  cerebral  lesions 
must  be  distinguished:  first,  general  or  diHuse  (Griesinger). 
and.  secondly,  local.  The  former,  so  far  as  they  concern  the 
subjective  feelings  of  the  patient  and  the  disturbances  of  the 
vegetative  functions  (temperature,  pulse,  respiration,  condi- 
tion of  unne),  are  to  be  observed  and  described  in  this  con. 
nection  in  the  same  way  as  in  diseases  of  other  organs.  The 
latter— the  local  sympioms^in.iy  be  divided  into  two  classes, 
namely,  the  direct  and  the  indirect.  We  call  those  symp- 
toms direct  which  are  produced  by  a  persistent  disturbance  in 
the  functions  of  a  certain  part  of  the  brain.  They  are  also 
called  focal  symptoms  (Oriesinger).  By  indirect  symptoms  wc 
mean  those  which  arc  only  produced  by  transient  conditions 
—changes  in  circulation,  by  compression,  etc. — and  which  arc 
in  a  way  concomitant  symptoms  of  the  former.  They  may  be 
entirely  absent :  on  the  other  hand,  they  may  be  so  prominent 
as  to  make  a  topical  diagnosis  impossible. 


CEKEHKAI.  LOCAUZATlOh'. 


163 


» 


Destruction  of  a  circiimscnbed  area  in  the  brain  gives  rise 
to  symptoms  of  paralysis,  or  less  frequently  to  sympLonis  of 
irritation.  The  former,  where  wc  have  to  ^jcal  with  a  loss  of 
function,  are  also  (after  Goltz)  called  syinptums  of  destruction 
{AHsfallssymptcmt),  and  if  the  funclion  is  not  lost  but  is  only 
impaired,  symptoms  of  impairment  (Hemmungssympfome).  The 
latter — namely,  the  irritative  symptoms — are  usually  due  to  a 
so-called  indirect  action. 

It  is  not  always  possible  to  say  whether  a  sycfiptom  is  of  a 
direct  or  of  an  indirect  nature.  For  instance,  if  wc  tind  a  pa- 
tient in  an  unconscious  state  with  a  hemiplegia,  this  hemiplegia 
may  be  a  direct  focal  symptom  or  it  may  have  been  produced 
indirectly.  In  the  latter  case  it  will  disappear  in  a  few  hours  or 
days,  in  the  former  it  will  be  persistent.  Or,  if  a  patient  suHer- 
inf  from  the  wmsequences  of  a  cerebral  ha:morrhaKc  presents, 
as  is  often  tfie  case,  disturbances  in  speech.  This  may  again 
be  a  focal  symptom  or  not.  If,  after  consciousness  has  been 
regained,  the  speech  becomes  gradually  but  steadily  better, 
then  the  aphasia  was  produced  indirectly.  If,  however,  speech 
remains  unintelligible  for  months  or  years,  it  is  clear  that  we 
have  to  do  with  a  focal  symptom.  Therefore,  in  acute  lesions 
we  can  only  alter  a  certain  time  lias  elapsed  discriminate  be- 
tween direct  and  indirect  symptoms. 

The  Irrilaiive  symptoms  consist  either  of  general  epilepli- 
lorm  convulsions  or  of  partial,  mvolunlary  movements  of  the 
extremities  (liemichorea.  athetosis). of  tremors,  contractures,  or 
forced  movements  of  the  whole  body.  Wc  shall  repeatedly 
have  occaMon  to  refer  to  these  phenomena. 

Not  all  of  the  symptoms  have  an  equal  value  for  the  lo- 
calization of  a  lesion.  It  is  important  first  to  note  their  mode 
of  onset,  whether  this  is  sudden  or  f^radual :  whether  several 
symptoms  have  made  their  appearance  at  the  same  time  or 
ooc  after  the  other,  and  so  on,  for  in  acute  lesions,  for  instance, 
only  those  symptoms  which  appear  synchronously  are  of  im< 
ponance.  If  n  patient  who  has  a  hemiplegia  presents  a  paraly- 
sis of  the  uculo.motor  of  the  opposite  side,  and  wc  learn  that 
thi»  latter  has  existed  before  the  onset  of  the  hemiplegia,  no- 
body certainly  will  think  of  connecting  the  two  or  look  upon 
them  as  being  symptoms  due  to  one  focal  lesion.  This  would 
only  be  allowable  it  both  had  set  in  at  the  same  time  Rafter  an 
scute  lesion). 


I6^^  D/SEASSS  OF   THR   BRAttf  PKOPEK.  ^M 

BuC.  even  apart  from  the  mode  of  onset,  the  symptoms  are 
not  of  equal  value  in  the  localization.  Some,  it  is  true,  as 
hemiplegia,  together  with  contra-lateral  oculo-motor  paralysis, 
are  almost  pathognomonic  (for  a  lesion  hi  the  cms),  and  their 
simultaneous  appearance  is  therefore  extremely  important : 
white  others.  a»  the  conjugate  deviation  in  severe  hemiplegia, 
are  found  in  different  lesions,  and  are  therefore  less  sifrnificant; 
still  others,  as  oplic  neuritis  and  all  the  general  symptoms 
(headache.  v(;rtigo,  unconsciousness),  are  absolutely  valueless. 

We  see.  therefore,  thai  by  no  means  all  cases  can  be  used 
for  the  study  of  the  topical  diagnosis,  but  only  those  in  which 
the  affection,  in  the  first  place,  remains  chronically  station- 
ary; secondly,  in  which  it  is  circumscribed  and  isolated  (Noth- 
nagel);  and,  thirdly,  where  the  surroundings  of  the  locus  are 
as  little  as  possible  implicated.  These  three  conditions  are 
best  fulfilled  in  instances  of  haemorrhage  or  embolus,  or  rather 
in  the  cases  ol  softening  produced  by  these  accidents,  and  the 
largest  contingent  of  cases  which  permit  a  topical  diagnosis  i% 
therefore  made  up  of  these.  They  are  rendered  more  suitable 
lor  our  purpose  the  longer  the  time  that  has  elapsed  after  the 
first  onset  (according  to  Nothnagel.  six  to  eight  weeks),  as  only 
then,  as  we  slated  above,  arc  we  able  to  separate  the  direct 
from  the  indirect  symptoms.  In  other  cerebral  affections — c.  g., 
meningitis,  encephalitis,  and  especially  tumors — a  local  diagno- 
sis should  only  be  attempted  with  the  greatest  circumspection, 
and  even  then  errors  can  not  be  altogether  excluded. 

Sj-iH/ifoms  Rf/erabtf  ta  Cortical  Ltsions. 

In  speaking  of  cortical  lesions.  "  surface  lesions."  it  must 
not  be  forgotten  that  the  clinical  meaning  of  the  term  is  differ- 
ent troin  the  anatomical  one.  Anatomically,  it  implies  that  the 
medullary  layer  situated  below  the  cortex  is  intact,  while  clin- 
ically we  speak  o(  conical  lesions  even  if  the  white  matter 
lakes  part  in  the  pathological  process  as  well ;  but  so  little  at. 
tcniion  lias  been  paid  to  this  difference  in  the  autopsy  reports, 
which  have  been  published,  that  it  seems  an  almost  hopeless 
endeavor  to  distinguish  whether  the  symptoms  reported  in  a 
given  case  were  due  lo  changes  in  the  cellular  elements  of  the 
cortex  itself,  or  to  changes  in  the  fibres  of  the  medullary  layer 
situated  immediately  beneath.  Pick  (Zeitsch.  ftlr  lleilkunde, 
1889.  X.  I)  has  shown  how  important  it  is  to  make  a  micro- 
scopical examination  ;  this  is  even  more  necessary  if  we  find 


COKTlCAt.  /JiS/OXS. 


165 


I 

I 


I 


ndary  degenerations  in  the  spinal  cord — macroscopically 
ihc  cortex  may  present  no  abnormality  in  stich  cases. 

We  possess  quite  a  considerable  amount  of  material,  but  it 
a  by  DO  means  easy  to  make  a  judicious  and  successful  use  o[ 
it.  Certain  methods  have  to  be  employed  in  order  to  arrive  at 
correct  conclusions,  methods  which  have  been  developed  in 
such  an  excellent  way  by  Exner  (cf.  lit.).  It  would,  for  exam- 
ple, be  incorrect  to  assume  a  certain  cortical  area  to  be  the 
centre  (or  the  motor  (unction  of  an  extremity  sim|tly  because 
in  many  cases  a  lesion  of  this  area  was  found  where  a  paralysis 
in  that  extremity  had  existed  during  life.  This  "  method  of 
positive  cases,"  as  Exner  has  called  it,  is  therefore  uncertain, 
because  there  are  quite  different  circumscribed  cortical  regions, 
a  lesion  in  which  gives  rise  to  the  same  symptoms:  and  since, 
moreover,  facts  go  to  show  that  such  a  method  may  lead  us  to 
wrong  conclusions,  it  ought  to  be  discarded.  Much  more  pref- 
erable, however,  is  the  so-called  "  method  of  negative  cases  " 
(Exner).  according  to  which  "  we  have  to  mark  out  the  lesions, 
lound  in  all  the  cases  in  which  a  given  function  was  not  inter- 
fered with,  and  unite  them  on  one  hemisphere."  U  the  number 
of  cases  is  sufficiently  large,  while  on  the  remaining  parts  of  the 
cortex  we  find  markings  indicating  lesions,  the  area  for  the 
(unctions  in  question  will  remain  free. 

Still  better  results  are  obtained  by  the  method  of  percent- 
ages |lixner).  The  cortex  is  divided  into  arbitrary  helds,  and 
for  each  of  these  fields  we  determine,  first,  how  often  it  has 
been  diseased  in  a  given  number  ol  cases ;  secondly,  in  how 
many  of  the  cases  the  symplom  which  we  are  studying  was 
present.  The  ratio  between  these  two  results  is  best  given  in 
percentages.  Only  through  this  indispensable,  although  some- 
what tedious,  method  can  we  ascertain  ih^t  the  fields  o(  the 
right  cortex  arc  different  from  those  of  the  left,  and  that  cer- 
tain areas  exist  of  which  a  lesion  always,  and  others  ol  which  a 
Icftioa  not  always  but  frequently,  produces  a  certain  symptom. 
The  former  Exner  calls  "  absolute,"  the  latter  "  relative."  corti- 
cal  areas. 

Wc  do  not  always  find  cortical  lesions  at  the  autopsy  in 
cases  in  which  certain  symptoms,  which  would  have  led  us  to 
suspect  their  existence,  have  been  noted  in  life.  On  the  other 
hand,  they  arc  found  in  cases  where  we  have  hardly  'elt  justi- 
fied in  expecting  them.  There  is  no  doubt  that  no  inconsider- 
able part  of  the  cortex  can  be  diseased  without  giving  rise  to 


l66 


mSSASKS  OF  THE  BHAIX  PROPFS. 


Fie.  ^— RMiin  Ki:ni.ii-iiuiil  (Aticr  Kxam.i  Tha  pawlfBi  tbaAri  In  KpitMM  the« 
poru  of  tb*  aiHGi  whiili  can  lie  injured  wiihoDi  civlBB  rtM  lo  Miiuiy  ur  molar  dhiafb- 
MICH ;  the  tiUnk  tntx  >re  tiKiUit  <nd  Mnaoff. 


ft-  ,16  -  l-Krr  Hrmsn'oiK.     pAIWr  tKXBB."    Thih  ilitKmm  iihnm  tliat  ihf  mirtoc  < 
tciuory  orcu  U«  of  ^rulcr  cilvnt  uii  Ihc  Irfl  llimi  on  tlin  iiKtil  hcmi'iiliFiv 


THE  BKAIN   CORTEX. 


167 


■y  symptoms.  It  is  this  part  which  h;LS  been  called  the  cor- 
tical area  of  latent  lesions  (F.xncr),  and  it  is  certainly  a  matter 
thy  of  note  that  rhc  extent  o(  this  area  \s  smaller  on  the 
than  on  the  right  hi;mispherc,  whereas  the  motor  area — 
that  is.  the  area  in  which  a  lesion  is  followed  by  motor  disturb- 
-is  larger  and  more  developed  on  the  left  than  on  the 
It  side  (cf.  Figs.  35  and  36).  The  first  represents  the  right, 
tlie  second  the  left  hemisphere.  On  both  all  the  lesions  are 
indicated  which  have  produced  neither  sensory  nor  motor 
disttirbnnccs.  The  blank  hclds  are  iherelure  sensory  and 
motor — their  g^rcater  extent  on  the  lelt  side  is  at  once  ap. 
parent. 


F^  jj.— CoMvouiriun  avd  Pmu'H»  or  nit  Laikral  A>v«ct  or  tiik  fiMAia. 
(AA«  &CKIK.t    PuaKtUunlK  =  tnnUkl  Iiuur.  ot  Ant  ittnpotal  fiuure. 

Before  we  go  into  the  description  of  (he  individual  lesions 
o(  the  cortex  wc  will  briefly  refresh  our  memory  on  the  unat* 
omy  (il  the  parts. 

The  thin  gray  covcrins  which  surrounds  the  white  matter,  and 
*bich  lias  txrcn  called  brain  cortex,  picsenls  on  each  heint»|ihere 
three  kurfacc* — n  lateral,  a  iMKal,  and  a  median.  The  two  lateral 
(arm  the  cnnvcxity,  the  two  hutal  the  base  of  the  cerebrum.    The 

rliriim  is  divided  into  lobei.  which  can  a};aiii  be  subdivided  into 
lution&  or  gyrL     To  t>c  able  tu  loualixc  and  corrcetly  describe 


|68 


DISEASES  OF   THE   BRAIN  PROPEK. 


cotiicat  lesions  wc  must  be  thoroughly  familiar  with  the  position,  as 
veil  as  the  names,  of  the  dilfcrciU  convolutions.  The  following 
illustrations  arc  intended  to  facilitate  the  study  of  the  convolutions 
and  the  fissures  or  sulci  separating  them.  Kig.  37  representti  thou 
on  the  lateral  surface  (convexity),  Fig.  jfl  (hiise  on  the  ba«al,  aiul 
1''<S-  40  those  Oh  the  median  :ts]iect  of  the  cerebrum. 


Pig.  jBl— CowvaLUTioHH  AHti  Fissures  ax  nvc  R<s>;  ot'  die  (iKitia,    (Diac 
aJUt  EcKEH.l     lllrDKhcakcl  =  trura  Mrvlitl.     tlalUn       onrpm  (allmuin 

In  Fig.  37  are  included  the  frontal,  parietal,  temporal,  and  oc- 
cipital lobes,  so  far  as  their  convolutions  and  iissures  belong  to  the 
lateral  surface — in  other  words,  belonging  to  the  frontal  lobes,  the 
three  frontal  and  the  anterior  central  convolution  (gyrus  centralis 
anterior,  pit  frontal  aitemlani').  and  belonging  lo  llic  parietal  lobe, 
Ihc  posterior  central  convolution  (gyrus  centralis  posierior,  or  pli 
pariftiU  af(tHi/ant) ;  between  the  last  two  it  seen  the  fisMire  of  Ro- 
lando. Further,  a  part  of  the  upper  and  the  entire  lower  parietal 
lobe  are  shown,  which  latter  is  subdivided  into  the  supra-naargioal 


TUB  KRAIN  COKTHX. 


cunvolution  in  front  and  llie  angular  gyrus  (///  covAr)  behind ;  be* 
longing  tu  the  temporal  lube  we  have  the  three  temporal  convo- 
lutions, of  which  the  first  (uppermost)  lic»  between  the  Assure  of 
Sylvius  und  ii  vcrjr  deep  fisstirc  running  parallel  to  it,  the  Ko^callcd 
parallel  fis«ure  or  first  temporal  Assure.  The  fissure  of  SylviuK  has 
two  branches,  and  Ihe  portion  of  the  corlcx  between  them  is  called 
the  '■  operculum,"  Belonging  to  the  occipital  lobe,  finally,  there 
arc  three  irregular  ami  not  ain'ays  easily  distinguishable  occipital 
conviilutions,  between  which  two  occipital  fissures  have  been  de- 
scribed. . 

In  order  to  determine  from  the  outside  of  the  skull  the  position 
of  the  Assure  of  Rolando  we  proceed,  according  lo  Kdhler  (Deutsch. 
/.eitsch.  f.  Chir.,  1891.  xxxii,  5,  ^  iit  the  following  manner  (cf.  Fig. 
39) :  A  line,  a,  is  drawn  over  the  mid-  ^ 

die  of  the  stkull  from  the  forehead  to 
the  external  occipital  protuberance. 
A  second  line,  ^,  is  drawn  at  right 
angles  with  this,  passing  through  the 
anterior  boundary  of  the  external 
auditory  mealiiK;  parallel  with  this 
KCond  line  we  draw  a  third  line,  c, 
passing  through  the  posterior  margin 
of  the  mastoid  proce»»,  so  that  It  cut* 
the  sagittal  line,  a,  two  inches  behind 
Ibe  line  c.  A  fourth  line,  if,  starting 
from  the  point  where  a  and  /  intersect,  and  running  obliquely  down* 
ward  so  that  it  meets  the  line  />  two  inches  above  the  external  audi- 
tory meatus,  will  indicate  the  direction  of  the  central  fissure. 

On  the  basal  a>pect  we  »ee  thuxe  part»  of  the  three  frontal  con- 
volutions which  ate  included  in  the  base,  of  which  the  first  (upper- 
most) is  here  called  the  gyrus  rectus;  then  the  tractus,  with  the 
sulcus  olfactorius;  next  the  uncinate  gyrus,  which  belongs  to  the 
gyrus  fornicatus,  and  which  will  be  better  seen  on  the  median  aspect ; 
further,  the  basal  part  of  the  third  temporal  convolution  (gyrus  tern- 
porali*  inferior)  and  two  lobules,  which  belong  to  both  (he  temporal 
and  occipital  lobe,  the  inner  (median)  one  called  the  lingual  lobule, 
the  one  more  external  the  fusiform  lobule. 

The  median  surface  (Fig.  40)  thows  jn  the  middle  the  corpus 
callosum  (in  front  the  genu,  behind  the  splenium) :  immediately  be- 
low is  the  "M])tum  lucidum,"  immediately  above  the  gyrus  forni- 
catus. the  temporal  part  of  which  is  called  the  hippocampal  convolu- 
tion, and  is  continuous  with  the  uncinate  gyrus.  Above  the  gyrus 
fornicatus,  and  separated  from  it  by  the  calloso-marginal  fissure,  are 
the  frontal  convolutions ;  farther  back,  the  paracentral  lobule,  which 


nt-j*. 


170 


PtSBASES  OF  THE  BKAIN  P/tOPEK. 


meets  ihc  centra!  convolutinnit.     Behind  tliin  and  belonging  to  ihc 
parietal  lobe  is  the  praecuneua,  and  still  farther  back  llie  cutieus  (of 


/iMuim  Jlijipoe. 


Jimbria    or   ToriAih. 
Fi(.  40,— COKVoi.uTios*  *sr>  Fiwure*  "f  riiK  Mi;niA:c  Akpbct  or  riiK  Bkaim, 
Th*  putUrior  ponlona  if  thi  Ihalannw  and  llw  cnu  ccnbri  ar>  cm  (dl. 

the  occipital  tobe).    The  latter  i»  bounded  by  Iwo  deep  fissures— 
below  by  the  calcarine,  in   front  by   the   occipito-parietal    fis.iure. 


PSb.  4i>— CotrvoLUTian  or  thr  Ulamp  or  Kkie.  (J.  K.)  nam:  vum^  vt  rkmovim* 

II IK  Ol-eXCULUH. 


TUF.  MOTOR  CENTRES. 


171 


tending  from  the  posterior  pan  of  the  corpus  callosutn  to  the 
unciiiJite  gyruft  is  the  liippocampal  fissure. 

Covered  by  the  above- me titioiicd  operculum,  in  tlic  depth  o(  the 
fi&sure  of  Sylvius,  i»  the  lot>u&  itilermediuH  &.  operto>,  the  Ko-called 
island  of  Rcil,  on  which  five  to  seven  small  convolutioim  are  seen. 
Their  position  is  shown  in  Fig.  41,  whcic  the  operculum  lias  been 
icmoved. 

In  I-'ig.  42  the  topograpliii;:il  rclnlions  between  the  surface  of  the 
brim  aiid  the  surface  of  the  skull  are  illustrated. 


F^.  4s.— ToroDKAniiCAL  KKtA-noii*  nKTwcKa  mc  Kxtciooh  or  thk  Sxvll  akd  tub 
SuarArKii*'  riiK  Brajx.  ( Altar  Fxxkr.)  C.  fivunol  Rc^ando.  f.  C.  ■sierioi  Cdn- 
tMt  //  v.,  pi«lc<r>artvnu«l«<inv»lu>ii<n.  SS^S^,,  Ojaun of  i^jMui.  r,  (cmpwrnl  Itte. 
f,  fmnul  kte.    P, ,  aiipsr.  P,, ,  kmsr  putsUI  loba.    O,  oodidul  tobe.    Ch,  otKbdhasL 

A»  Ktnted  above,  the  localization  of  the  motor  centres  by 
iFrilsch-Mtl/tj'  and  (hat  o(  the  speech  centre  by  Brr»ca  paved 
I  ihc  way  for  a  number  ol  discoveries  which,  based  partly  upon 
clinical  observations,  partly  upon  the  less  trustworthy  ex|>cri> 
mcnls  on  animals,  eventually  will  lead  to  a  complete  and  ac- 
curate [ihysio.palhi)logicni  topography  of  the  brain  cortex. 
Thus  farour  Isuowicdgc  is  scanty  and  uncertain,  and  tiicceiilrcs 
which  we  shall  here  describe  as  being  determined  arc  almost 
all  relative,  in  the  sense  of  Exner  (cf.  page  165).  the  only  exccp- 
being  the  so-called  motor  region  of  the  cortex.  On  the 
[ht  hcmtsptiere,  the  paracentral  lubule,  the  anterior  central. 


172 


DISEASES  OF   THE  BRAIN  PROPER. 


and  the  upper  half  of  the  posterior  central  convolution,  on  the 
left  hemisphere,  the  paracentral  lobule,  the  upper  three  fourths 
of  both  central  convolutions,  and  a  part  of  the  upper  parietal 
lobule,  constitute  the  absolute  cortical  area  for  the  upper  ex- 
tremities (Exner).  The  absolute  cortical  area  for  the  lower 
extremities  is  situated,  on  the  right  hemisphere,  in  the  para- 
central lobule,  and  in  the  upper  third  of  both  central  convolu- 
tions; on  the  left  hemisphere,  in  the  paracentral  lobule,  the 
upper  half  of  the  posterior  central  convolution,  and  the  greater 
part  of  the  superior  parietal  lobule. 

The  cortical  area  for  the  facial  nerve  is  situated  in  the  lower 
end  of  the  anterior  central  convolution  ;  in  front  of  this  and  in 
the  adjoining  portion  of  the  second  and  third  frontal  convolu- 
tions is  the  centre  for  mastication  (Hirt),  In  the  region  of  the 
island  of  Reil  we  find  the  voice-centre — i.  e,.  the  centre  for  the 
movement  of  the  vocal  cords  (Rossbach) ;  in  the  frontal  lobe 
that  of  the  muscles  of  the  neck  (Fraenkel) ;  in  the  angular 
gyrus  that  for  the  external  ocular  muscles.  Haab  (Ziirich, 
1S91)  has  attempted  to  determine  the  centre  for  the  pupillary 
reflex. 

Of  the  so-called  sensory  centres — i.  e.,  the  areas  in  the  cortex 
where  conscious  sensation  takes  place — we  know  the  psycho- 
optic  to  be  situated  in  the  occipital  lobe ;  the  psycho-acoustic 
in  the  temporal  lobe ;  that  for  smell  and  taste  in  the  uncinate 
gyrus  (Ferrier).  The  cortex  of  the  frontal  lobe  and  that  of  the 
temporo-occipital  region  are  the  seat  of  the  higher  intellectual 
processes  (Flechsig). 

The  so-called  thermic  centre  discovered  by  Eulenburg  and 
Landois  corresponds  to  the  motor  region,  and  the  tactile  regions 
for  the  different  parts  of  the  body  also  are  identical  with  the 
motor  centres  (Exner,  Tripier). 

Furtherinvestigations  must  show  whether  the  centres  which 
we  have  been  wont  to  regard  as  being  situated  in  the  medulla 
oblongata — for  example,  the  centre  for  salivation,  that  for  deg- 
lutition, that  for  the  movements  of  the  stomach  and  intestines 
(vomiting  and  defecation),  for  sneezing,  coughing,  etc. — are  also 
situated  in  the  cortex.  The  results  of  the  treatment  by  sug- 
gestion make  the  assumption  of  such  centres  necessary.  Nev- 
ertheless, while  the  "  area  of  latent  lesions  "  (Exner)  is  still  as 
large  as  it  is  at  present,  an  explanation  of  this  kind  is  pre- 
mature. 


ril&  BKAIN  CORTEX. 


173 


I 


LITERATURE, 

t.'«btr  (Icn  heutijttn  Stand  der  Frage  von  der  Localbalion  im  GrtiKihim. 

V.  VolkiiunnK  S.imml,  klm.  Vonr.  l.cip^lg.  1877,  113. 
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Kathnag*-!.     Topische  l>mgni»tik.  /«■.  est.,  pp.  yjtfet  sf<i.  (inaiiy  rd'eri-otes). 
Munk.     Zw  ["hinuiUigic  <kr  CroxshirnrinHc.     Crsummclte  Mltthrtlungtn  aus 

den  Jahim   1877-1880.      Berlin.   1881.     Ctmlratbl.  r.  Nnvcnhk..  1881.  17: 

1S83.  II. 
f.inrT.     Untenucbiingrn  librr  die   t.ocal>s»linn  drr  FuncUonen  In  dcr  Grou- 

hinihndc  Ae»  Mrnvcbcn.     Wicn.  iBSi. 
Golii.     L'ChM  (IIf  Vrrticlitungcn  dcs  C^rusihirns.     Bono,  iSSt. 
llrthikiK.     Zur  An.iinmic  und  r.ntwickclungtgefchichic  An  Leiluiigsbaliiini  inn 

l^foatiKin)  (let  Mrmchen.     Arch.  f.  Anal.  u.  Phyniol.,  1S81,  i.  p.  13, 
FIrchslg.     Plan  des  nim«chtich«n  Gchimv     Leipzig,  1883. 
(lulu.     Uetm  die  Vrmchlungcn  dcs  GrwshlmB.     j  Abhandlungen.     Arch,  d, 

ffA.  Iliyslol..  1884,  xxiiv.  9,  la 
*,  Cuddra     Vthrt  ilic   t'r.ij-c  dtrr  Localisiition   <!cr   Funcilonen  der  Onxt^ 

himrindc     Crntrall)!,  f.  Ntivcn^k,,  188^,  viii.  19, 

luni.     ;^ur  t'h)»iul<)Kic  de»  Crtnshirn.i.     Berlin.  188;. 
C«nirall)4.  f  Nrrvcnhk.,  iSSj,  viii.  10.  11. 

tl  Pltres.     Recherchct  eipj-iimrnlalrs  el  cnti<|ucs  sur  rodl.ibilil^  des 
ii^tva  ctrfbraux.     Arclt  Ac  Phyi-iol..  188$,  1.  2, 
Eulenburtr.     llcber  Am  Wumrcvnirum  iin  Grosslum.     VeihandL  d.  phytlol. 

Ccselbcd.  In  Hnlin,  1885,  i& 
Luaani  and  Sctillll.     Di«  LocalUallon  auf  der  Gro»hirnriiide  (Gemiin  by  O. 

PMnkd).     LetpriK.  iSSfi. 
RoMhach.     Ileiiroii  nvt  I.ocnlixation  dr»  rorlimten  SlinimcenlTums  beim  Men- 

tchen.      DcuimIm-s  Arch.  f.  klin.  Metl,,  iSqi.  xtvi, 
Bechicrew  and  Mislawskt.     Arch.  T.  Anat.  u.  i'liysiol..  1891,  J,  6.     (Drain  Ceiv- 

tr^  fur  Movemrnii  of  ihe  \',i)pna  in  Animals.) 
Fevrter.     The  Croonian   Lecture*  on  Cerebral   Localballon.     London.  SmMi. 

Elder  &  Co..  iSga 
HoacI      Ptr  Ceniralwin'tiingeti.  ein  Ccnlralorniui  der  HinierstMnge  uml  des 

TrKftrmitiua.     AnJi.  f  I'lych.,  t8qi.  xxW.  1. 
Coldstetn.     Physiolo);ie.  Paihologie  und  Chirurpe  de»  Gro«htmft.     Schmidl's 

Jalirb.,  iSy.!.  ccxoiii.  p.  87. 

Charcot  rt  ["itrM.     £iude  cniiqiie  el  clinique  de  la  docirine  ilct  lac.-ili.%.itiun)i 
RKHricn  dant  I'teorcc  de»  hfmispti^rcx  ctr&tn-M  de   Ihoinme.     Pans. 


IM3- 


Deatsches  Arch.  f. 


Vener.     Ucber  die  wnwrtelten  Funcilonen  dcs  GmMhimx. 

klin.  Med..  18S3.  xxxii.  p.  4S6. 
AlcKaniler.    Ein  Fall  vmi  giimiii6ien  GeiehwiiUlen  in  iler  llimrtnik.    lireslauer 

Iml  ZeliKhr..  1884.  u- 
Rinentlul.      Fall  vnn   oorticater  Keniiplesic  mil  Woniaubbcit,      Ccnirallil.  f. 

N«itM>lik.,  1B84,  vn,  I.' 


•74 


It/SSASSS  OF  THE  BKAJN  PROP  Eft. 


BergCT.    ZuT  Localisation  <ler  conicaJcn  SchsphXrc  bcini  Mcnschen.     BrtsUucr 

3I»tl.  Zeitschr.,  iSSj.  I,  3-5. 
Desno^.     Locilii^tiona  c^rebmlo,    Gai.  hebdoni.,  188$.  xxxit,  47. 
Runipf.    Ucbcr  sy[>hiliti»chc  Mono-  und  Hcroiplcgim.   Tagebl.  d.  Nalurforscher- 

Vers.  in  Stmviburg.  ittSj. 
KohkT.    Zur  Canuisiik  (I«t  reinen  irauinaiischm  RindeDlS&ionoi.     Cbarii^ 

Atioftlcn.  iSil6,  >i.  p.  538. 
JaQcwaf,    Juutn.  of  Nerv.  and  Menl.  Discaan,  1886.  xii,  4$. 
Buiian.     Tli<r  Muscular  Sense,  il*  Nature  anil  Conical  LocaUuiion.     London, 

Clowes  &  Sons.  \t9^ 
tlowtra.    a.  a,  o.,  1886,  pp.  loj  ''  ^'9- 
Rcichard.    7,ur  Fnge  cicr  I  Jim  localisation  mil  hesondcrer  BctuclMlchtJgung  der 

oorticalen   Sehslcirungen.     Arth.  f.    Psych,    u.  Nervenkh-i  1886,  xriii.  3; 

1887.  xlx.  I. 
Joflfroy,     Arch,  de  Physiol.  Fchruar>-  x  5,  1887,     (Monoplcgi.i  of  Che  Lower  Ex- 

irtmiiies.  Lesion  in  the  I'aracenlral  Lobule.) 
Leydcn.     Iteilrag  zur  Lchre  von  der  LocaliMiion  im  Cchifii.     DrtilKhc  mcd> 

Wochrnsrlir..  1887.  47. 
Bouvercl.     Ljon  mfd.,  1887.  l»-i.  p.  337. 
Bernhardt.     Ein  full  von  HirTirin<lenuta.\ie.     Ibid.,  1887,  51. 
Horsley,  Vicior.     Brain  Surgery,     Hrii.  Med,  Joum..  1886,  it.  670-675. 
Ceci  (Genova).     Eniipare^  pro|^e>iriva  siniilra  inizialJis  due  mesi  dopo  di  un 

traunijk  alia  regloiieparieialcdcstraegiunia^id  eniiplecia cotnpleia.    Kinsla 

clin,.  Setl.,  1887. 
Ilun,  H.     A  Clinical  Study  of  Cerebral  Localiution.    Amer.  Joum.  M«l.  5c„ 

1887. 
Nolhnagel.     Ueber  Di;i|(no.itik  bci  Cichimkrankheiten.     Deul:Khe  med.  Wo* 

chcnsiclir.,  18H7.  xiii,  ij.  16. 
Scngcr.     Ucbcnopischc  Himdiagnoslik  imd  Himchirurgic,  etc.    Dcutsdte  mcd. 

Wochenschr.,  1S87.  xiii,  10-13. 
Chaulfiinl.     Ue  la  cicitf  subite  p-ir  Wsions  combinto  des  deux  lobes  ocripltales. 

Revue  dc  mill,.  1888.  z. 
Welt.  Leonore.     l^eber  Cb.iniktervcraridiTunEen  des  Menschen  In  Folgc  «m 

Lisionen  des  Sttmhirns.      Deutsrhes  Arch.   f.   hltn.   Med.,  xllt.   Heft  4. 

(Wcftkcniiig  of  Intelligence.  Deterioration  of  Character.) 
Dam.    The  Cortical  Localiulion  of  Cutaneous  Senutions.    Joum:  Nerv.  and 

Mcni.  Diseases.  1888.  xv.  tijo~684. 
Eckhardt.      Neurol.   Centralbl,,    i88g,   3.      (Cortical    Area    for    Secretion    of 

Saliva.) 
Totnac«-wski.     Pctcrthurgcr  mcd.  Wochenschr,  1889^4.     (Cortical  Areas  for 

the  Nen*c»  of  Special  Sense.) 
Ljiwcnth;tl.    Deutsche  rned,  Wochenschr..  1889.  IJ. 
Haab.     Der  IJimrindenrellex  det  I'upillc.     Zurich.  Miller.  1891. 

The  speech  centre,  which,  as  we  have  seen,  is  silimlcd  par 
ty  in  the  frontal,  partly  in  the  temporal  lobe  ol  the  led  hemi- 
sphere, is  certainly  ol  larger  extent  than  is  commonly  sup- 
posed. It  is  well  known  that  ader  Qouillatid  in  iftsj  iiad 
pronounced  the  frontal  brain,  and  Marc  Dax  in  1836  the  lelt 


APHASIA. 


I7S 


hemisphere,  to  be  the  seat  ot  speech,  Broca  claimed  that  the 
posterior  part  of  the  third  left  frontal  convoltition,  the  pars  opcr- 
cularis,  or,  as  it  Inter  was  called,  thu  re<;iuii  of  Bruci,  contained 
the  speech  centre  ;  and,  indeed,  in  speech  disturbances  a  lesion 
of  Ihis  very  region  has  most  frequently  been  found  at  the  au- 
y.     There  arc,  however,  other  parts  of  the  cortcs.  as  the 
d  of  Keil,  the  central  LX>nvuliitiuns,  and,  above  all.  the  tem- 
poral lol>e,  more  especially  its  upper  convolution,  which  arc 
connected  with  speech  and  which  are  of  no  less  importance, 
us  we  have,  alter  much  laborious  work  and  alter  many  carc- 
iul  observations  and  comparisons,  come  to  the  conclusion  that 
a  different  form  of  speech  disturbance  (aphasia)  is  produced 
according  as  the  lesion  is  one  of  the  frontal  or  ol  the  temporal 
lube — (of  the  left  side  only).     In  the  former  case  the  patient 
I        buwg  [he  word  which  he  wishes  to  pronounce,  but  can  not  do 
f        W  because  he  has  lost  the  memory  for  the  movements  ncces- 
oxf  lor  speech — ^i.  c.,  he  no  longer  knows  how  to  use  his  tongue 
>nd  tips  in  the  act  of  speaking — motor  aphasia.    If  the  lesion  is 
>itu3ied  in  the  third  left  frontal  convolution  (Broca 's  region),  we 
*pealc  of  cortical  motor  aphasia ;  it  it  is  situated  in  the  white  mat- 
icr  of  the  hemispheres,  in  the  posterior  portion  ot  the  internal 
cap<n]le,orin  the  Icftcrus,  we  speak  of  subcortical  motor  aphasia. 
H         In  the  latter  case — i.  e.,  if  the  lesion  is  in  the  temporal  lobe — 
"  'he  patient  knows  exactly  what  he  wants  to  say,  and  he  has  no 
•^'fticuliy  in  repeating  it 
'^    it  is  spoken  for  him  ; 
^\xx  he  can  not  find  the 
fJ^piWiSion    for    himself, 
••c     has  "forgotten"  the 
•■'ird — sensory    aphasia. 
That  the  understanding 
"J  Words  is  situated  in  the 
—^  l<^ni[ioral  lobe,  more  par- 
^Ucularly  in  the  first  tern- 
pf>nil    convolution,    was 
^rsi  Mated  by  Wernicke, 
who  also  originated  the 
tcmis  motor  and  senst>ry, 

Cortical  and  subcortical,  aphasia.    The  anatomy  ol  the  subcor- 
tical sensory  aphasia  has  as  yet  hccn  only  imperfectly  studied. 
In  the  diagram  of   Wernicke  which  is  shown  in  Fig.  43,^ 
repFcitcnU  the  motor,  x  the  sensory  speech  center ;  the  latter 


*■•(■  4*      WcBMCKtN  ScHtUA  foil  TIIK  COKTICAL 
UjUnURIlM  or  SfEIXH. 


i;6 


D/SEASKS  OP  THE  B  ft  A I  A'  PROPER. 


is  the  terminus  of  the  ccnlripetal  palh  of  the  auditory  nerve 
a  X.  the  furmcr  is  the  beginning  of  the  centrifugal  path  /  im 
going  to  the  muscles  used  in  speaking:  4 -/an  assumed  associa- 
tion jaCh  between  both  :  y  is  situated  in  the  third  (ront.il,  x  in 
the  first  temporal  convolution.  According  as  one  ur  the  other 
of  these  centres  or  the  connection  between  them,  or  both  cen- 
tres, were  destroyed.  Wernicke  distinguished  four  cardinal 
types  of  aphasia : 

1.  I^estruction  of  the  centre  ,i- — motor  aphasia.  Mobility 
of  the  muscles  used  in  speech  is  retained,  but  the  patient  can 
either  not  speak  at  all  or  only  say  a  few  words  or  syllables. 
Understanding  and  memory  ni  words  are  intact. 

2.  lieslrticlioii  of  the  centre  x — sensory  aphasia,  "word 
deafness  "  (Kussmaul).  The  patient  can  use  as  many  words  as 
ever,  but  in  speaking  they  arc  mixed  up.  The  understanding 
of  words  is  lost,  although  the  power  of  hearing  is  not  interfered 
with. 

3.  Destruction  of  the-  association  path  x  y.  situated  in  the 
insula(?)— the  so-called  conduction  aphasia  of  Wernicke.  The 
patienr  can  use  as  many  words  as  ever,  but  in  speaking  ihey 
arc  mixed  up.     The  understanding  of  words  is  retained. 

4.  Destruction  of  both  centres,  x  and  y — total  aphasia. 
Power  and  understanding  of  speech  are  lost, 

II  wc  then  consider  as  proved  thai  a  certain  group  of  motor 
and  sensory  memory  pictures  are  localized  in  the  brain ;  if  wc 
further  agree  that  the  former  correspond  to  certain  groups  of 
muscles  which  serve  a  common  purpose,  the  latter  to  the  dis- 
tribution of  a  sensory  nerve — ^it  is  not  difficult  to  conceive  that 
this  same  arrangement  may  exist  for  all  the  muscles  and  lor 
all  the  sensory  nerves.  It  is  certainly  easy  to  understand  the 
occurrence  of  other  motor  defects  in  cases  of  aphasia.  Thus 
there  may  be  loss  of  simple  movements  (c.  g.,  of  the  power  to 
put  out  the  tongue),  or  more  complex  ones  (e.  g..  writing  may 
become  impossible — agraphia ;  afhasif  dt  la  main.  Charcot). 
Again,  we  have  a  patient  who,  in  consequence  of  a  cortical 
lesion  in  the  central  tcrminniion  of  the  optic  nerve,  no  longer 
recognizes  his  letters,  and  has  thus  lost  the  faculty  of  reading 
(■•alexia  ");  or  the  visual  memories  may  be  lost  .illogclhcr  (not 
only  those  nl  letters),  and  a  condition  ensue  which  Munk  calls 
psychicjil  blindness. 

In  examining  a  patient  affected  with  aphasia,  with  a  view 
of  determining  which  path  has  become  interfered  with,  we  may 


APHASIA. 


i;? 


meet  with  considembte  difficulty,  nnd  the  diagnosis  of  the  par- 
licutar  type  ol  aphasia  with  which  wc  arc  dealing  is  often  not 
easy,  fur  the  cases  are  not  so  sharply  defined  or  so  well  charac- 
tcriicd  as  we  might  be  led  to  expect  from  the  simplicity  of 
the  schemata.  On  the  contrary,  we  often  meet  with  combina- 
tions of  the  different  types  or  with  transiiion  forms  of  aphasia 
in  which  even  the  most  experienced  clinician  will  venture  a 
differential  diagnosis  only  with  much  reservation.  Take,  for 
instance,  the  different  degrees  of  thai  form  of  speech  disturb- 
ance knuwn  as  ataxic  aphasia,  in  which  the  patient  is  unable  to 
pronounce  a  word,  though  it  constantly  is  floating,  as  it  were, 
before  his  mind.  This  inability  may  go  so  far  that  the  patient 
can  only  pronounce  a  few  words  or  syllables  (monophasia), 
that  he  involuntarily  confounds  words  without  being  in  the  least 
uncertain  about  thtrir  meaning;  or  it  may.  on  the  other  hand, 
only  amount  to  a  slight  disturbance,  shown  by  some  misplace- 
ment or  omission  of  some  letters,  as  in  saying  dy  instead  of 
dry,  turk  instead  of  Irutk.  and  the  like.  In  Ihc  latter  case  wc 
speak  uf  syllabte-siumbling  <.Sr/Arwi/t>//frH).  Likewise  we  have 
different  degrees  of  the  so-called  amnesic  .iphasia,  where  there 
may  be  loss  or  only  slight  impnirment  in  the  memory  for  words 
(sometimes  only  lor  words  ol  foreign  languages  which  have 
been  learned  later  in  life^  As  the  faculty  of  writing  and  read- 
ing may  often  be  more  or  less  altered,  it  is  important  that  it 
should  be  minutely  examined  into;  the  patient  is  asked  to  spell 
individual  words,  then  to  read  sentences  without  spelling,  then 
lo  write  spontaneously  and  to  dictation,  and  finally  to  copy 
word«.  in  the  case  of  a  patient  who  is  left-handed,  his  ability 
lo  write  with  the  left  hand  should  always  be  tested.  Every 
C3»e  of  aphasia  must  be  carefully  studied  by  itself,  and  each 
one  gives  opportunity  for  interesting  observations. 

In  general  we  may  be  guided  by  the  following  rules: 
t.  If  we  find  a  patient  whose  sanity  is  established,  who  pos- 
ts a  normal  aculcnegs  of  hearing  and  understands  what  is 
said,  but  is  unable  to  repeat  sentences  or  to  speak  spontaneous- 
ly, and  can  only  utter  individual  words  and  syllables,  we  may 
BHume  a  lesion  of  the  third  frontal  convolution,  possibly  of  the 
lowest  part  ol  the  anterior  central  convolution. 

3.  If  a  patient,  although  able  to  speak  without  diflicutly, 
docs  not  understand  simple  questions,  then  the  first  tem]M>ml 
convolution  is  diseased  (i>r/cA').  If  the  understanding  of  words 
b  only  impaired,  then  only  a  part  is  aSectcd. 


i;8 


J>/S£AS£S  OF  TJIE  BRAI.V  PKOPf.K. 


3.  If  the  paiient  has  tost  the  (acuity  o(  reading,  although 
there  is  no  motor  aphasia  to  be  noted,  we  have  to  deal  with  a 
lesion  of  the  cortical  centre  for  vision  (cf.  page  172). 

4.  A  disease  of  the  conical  speech  centre  does  not  exist  if 
the  patient  grndiially  regains  speech  which  he  had  suddenly 
lost :  if  in  such  a  case  the  hemiplegia,  which  has  simultaneously 
appeared  after  an  apoplectic  stroke,  persists,  the  white  sub- 
stance near  the  cortex  is  usually  diseased  (Gowcrs). 

We  should  be  going  beyond  the  limits  of  this  work  if  we 
attempted  to  discuss  the  aphasic  symptom-complcx  in  all  its 
difficult  and  not  rarely  obscure  delnils ;  there  exist  »  l.trf;e 
number  of  interesting  special  articles  on  this  subject,  to  the 
most  important  of  which  references  will  be  luutid  at  the  end  of 
this  chapter.  While  recognizing  the  steady  advance  which  has 
been  made  totvard  the  interpretiition  of  these  most  complicated 
disturbances,  we  arc  ever  reminded,  by  the  constant  difliculltes 
which  arise,  how  far  we  are  from  a  complete  understanding  o( 
them.  Almost  every  case  shows  peculiarities  which  do  not  fit 
into  any  of  the  schemata ;  and  while  today  a  successful  investi- 
gator claims  to  have  cleared  up  some  obscure  point  in  the  diffi- 
cult field  of  aphasia,  to-morrow  another  one  proves  that  this 
conclusion  was  after  all  too  hasty,  and  that  only  he,  the  sco 
ond  investigator,  has  really  settled  the  question.  In  a  word, 
there  is  hardly  a  single  point  in  the  problem  of  aphasia  which 
is  nut  still  the  subject  of  controversy.  The  tendency  to  schema- 
tize is  very  prevalent  in  Germany,  and  in  opposition  (o  these 
too  schematic  conceptions  of  aphasia,  [English  and  French  in- 
vestigators have  pointed  out  the  variations  ol  the  inner  speech 
— i.  e.,  of  the  thinking  processes  necessary  lor  speech — and 
the  differences  which  may  be  bound  up  with  the  individual 
peculiarities  of  the  person  who  speaks,  writes,  or  reads.  But 
these  objections  are  slow  to  be  appreciated  in  Germany. 
Whether  a  person  reads  by  spelling,  or  whelher  after  consid- 
erable practice  one  may  read  without  spelling,  whether  the 
optical  images  of  letters  arc  necessary  in  the  process  of  writing 
or  not — these  and  many  similar  problems  still  await  their  solu- 
tion, and  can  be  cleared  up  only  by  untiring,  careful  observa- 
tion of  cases. 

For  the  beginner  it  is  not  only  desirable  but  necessary  to 
have  the  matter  presented  to  him  somewhat  dogmatically, 
and  this,  according  to  our  experience,  will  be  best  and  most 
easily  accomplished  with  the  aid  uf  schemata,  of  which,  besides 


APHASIA. 


179 


I 


the  above-mentioned  one  of  Wernicke,  quite  a  number  have 
been  brought  out.  The  one  we  have  deemed  most  suitable  and 
the  best  fitted  for  teaching 
purposes  is  probably  that 
which  Lichihctm  has  de- 
veloped (Arcl).  r.  Psych., 
1SS4.  XV,  3).  It  has  been 
here  given  in  Figs.  44,  45. 

The  reflex  arc  neces- 
sary lor  repeaiinj;  words 
contains  the  centre  for  au- 


■  ditory  images  of  words,  A : 


I 


i 


!» 


»"!«■«- 


the  centre  for   motor   im- 
ages,  M\    the    centripetal 
parh    for  auditory  impres- 
sions, a  A  ;  the  connecting 
path,  A  M;   the    centrifu- 
gal motor  path,  J/w, 
B  b  the  place  where 
coaccpts  are  formed — 
voluninry   speech   nc- 
ecuitates  a  centrifugal 
(Mh  Irom  if  ^brain  cor- 

tu)  to  A/.     O  is  the 

ontre   for  the  visual 

laages  of   Icilers.    E 

iltbe  centre  for  the  in- 

vrvaiion  of  the  mus- 

d«  required  in  writ- 
ing;.   Now,  according 

toihe  path  aRcctcd,  wc 

diuinguish  seven  dif- 

(crtnt  forcnsof  aphasia. 
I.  Interruplion   in 

•V  point  M.     Broca's 

"Mior)  aphasia, 
J-  Interruption   in 

f'ini  A.     Wernicke's 

(leiiory)  aphasia. 

3.  Interruption    in    the   path    MA.     Conduction   aphasia 
(Wernicke). 

4.  Interruption  in  the  path  MB.    A  variety  of  motor  apha> 


Pic*.  M.45.-LJCH'nii:iU'!l  KCIIKH*  IU.L'*TIUTtlCO  TMK 
St.VlJI   Dirt-KHENT  KOKHS  OF  AniAtlA.     •,  A,  COk- 

tripeUl  paih  r<rr  auditory  ImpwMloai.  A,  ccnue  lor 
■wliiwy  inuK**.  it,  omtic  lor  mouu  touea.  M, 
m,  rantrifncal  mMot  puh.  B,  the  plww  *he>c  ixsa- 
npCt  art  (nnnfd  O,  Um  (cdik  lor  tUihI  Inwcts. 
B,  c«alT«  Inmi  whidi  lb«  orpuw  ot  wridnn  are  Inner. 
TMad.  iTfac  wvto  dlfltnnt  lorms  ol  ii^ula  ban 
bam  tDdkaudln  Fie.  44bT  (he  numtwn  1-7.1 


iSo 


mSEASES  OF  TJ/E  BRAW  PROPER. 


sia:  tbe  faculty  of  repeating  words  and  sentences  being  re- 
tained. 

5.  Intcrniptiori  in  the  path  Mm.  Variety  of  motor  apha- 
sia ;  the  power  of  expressing  thoughts  in  writing  being  re- 
tained. 

d.  Interruption  in  the  path  A  B.  A  variety  of  sensory  apba- 
sia  ;  the  patient  being,  however,  able  to  repeal  spoken  language. 
to  read  aloud,  and  write  from  dictation. 

7.  Interruption  in  the  path  A  a.  Inability  to  understand 
spoken  language  and  to  write  from  dictation,  or  to  repeat  spo- 
ken  language.  Nos.  6  and  7  have  so  far  been  observed  only  in 
rare  instances  (e.  g..  by  I'ick,  Neurol,  Ccntralbl.,  189a  21). 

As  to  the  occurrence  of  aphasia,  it  is  most  frequently  sei-n 
as  a  sequence  to  an  apoplectic  attack,  cither  as  a  direct  or  indi- 
rect symptom :  in  the  latter  case  it  is  transient,  and  lasts,  as  we 
shall  Ncc  later,  a  few  minutes,  hours,  or  days.  In  the  former  it 
persists,  and  may  trouble  the  patient,  though  he  may  retain  his 
full  mental  vigor  to  the  end  ol  his  life.  The  most  common 
form  is  motor  aphasia,  which  appears  in  widely  different  grada- 
tions ;  thus,  in  some  cases  the  patient's  speech  may  be  just  a 
little  thick,  while  in  others  it  may  be  altered  so  that  it  is  no 
longer  intelligible.  After  what  has  been  said,  it  is  easy  to  un- 
derstand that  these  defects  chiefly  occur  after  ha-morrhage  in 
the  left  ^idcof  the  brain^that  is.  with  a  right-sided  hemiplegia; 
but  it  would  be  a  decided  error  to  suppose  that  they  occur 
only  or  always  in  those  cases,  for  motor  aphasia  may  be  found 
in  connection  with  a  left-sided  hemiplegia,  and  it  may  be  want. 
ing  in  the  right-sided  form.  Other  diseases  of  the  brain  also 
may  implicate  the  cortiail  speech  centre  and  give  rise  to 
aphasia.  Among  these  may  be  mentioned  general  paralysis, 
psychoses  (Lloyd,  Francis,  Lancet.  July  7,  1*88),  processes  of 
softening,  chronic  meningitis,  tuberculous  deposits,  etc.,  and 
traumatism  of  the  left  hemisphere,  in  which  case  aphasia  may 
be  the  only  symptom.  Aphasia  has  also  been  observed  in  acute, 
especially  infectious,  diseases — e.  g..  typhoid  and  scarlet  fever. 
Most  instances  of  this  latter  form  occur  in  children.  It  has 
also  been  observed  in  the  puerpend  state.  Of  special  interest  is 
that  form  of  total  or  motor  aphasia  which  sometimes  suddenly, 
sometimes  gradually,  comes  on  after  a  fright.  That  after  a 
fright,  such  as  makes  "  the  hair  stand  on  end,"  the  voice  may 
refuse  to  perform  its  duty,  even  Virgil  seems  to  have  known 
full  well,  as  we  sec  from  the  verse,  "  Stettruntqtie  ama,  vox /au- 


APHASIA. 


181 


(Aus  httiit."  The  nature  o(  this  (orm  is  uncertain,  still  it  is  bj 
no  means  impossible  thai,  just  as  wc  tind  thnt  vasomotor  S|>asm 
acting  on  the  facial  vessels  will  produce  pallor,  so  wc  may  h-ive 
u  similar  coiiditiun  in  those  finest  dislriliii lions  ol  the  middle 
cerebral  artery  which  supply  the  region  of  Broca.  That  the 
sfMsna  in  these  %'esscls  is  usually  of  longer  dtiraiioii  and  pro- 
duces more  serious  and  more  lasting  consequences  lliau  the 
spasm  of  the  cutaneous  vessels,  may  be  explained  by  the  differ- 
ence in  their  arrangement,  as  well  as  by  the  difTcrcncc  in  the 
(unction  oi  the  parts  which  they  supply. 

It  is  not  organic  changes  of  the  cortex  which  produce  the 
symptoms  in  this  case,  the  disturbancts  being  entirely  of  a 
futicliuna)  chanicter,  and  this  frij^ht  aphasia  lh(.'rcfore  consti- 
tutes a  transition  form  to  those  instances  in  which,  though  the 
aphasia  may  have  lasted  for  years,  no  changes  are  found  at  the 
autopsy,  cither  in  the  cortical  or  subcortical  area  for  speech. 
No  doubt  there  is,  besides  the  aphasia  due  to  actual  lesions  in 
the  cortex,  also  a  functional  form  which  wc  may  imagine  lo 
originate  in  different  ways,  and  it  is  at  least  probable  thai 
variations  in  the  blood  supply  of  the  centres  play  an  important 
part  In  this  connection,  Grashey  (cf.  lit.)  has  shown,  in  an  in- 
genious piece  ol  work,  that  wc  have  to  recognize  a  third  form 
ol  aphasia,  in  which  neither  the  centres  nor  the  conducting 
paths  arc  insuHicient  in  their  functions,  but  which  is  simply  due 
lo  a  diminished  <luralion  of  the  sensory  impressions,  giving  ijsc 
to  a  disturbance  in  perception  and  association,  and  thus  to  an 
aphakic  condition.  Maybe  it  is  this  aphasia  of  Grashey  which 
wc  find  after  concussion  of  the  brain  and  after  acule  diseases, 
but  it  is  dilHcult  to  diagnosticate  it.  and  to  diflerenliate  a  func- 
tional disturbance  of  the  centres  from  a  diminished  duration 
ol  sensory  impressions,  A  correct  diagnosis  is,  however,  ol  no 
small  importance  in  the  question  ol  prognosis. 

The  outlooW  is  absolutely  unfavorable  in  cortical  lesions 
where  the  centre  is  destroyed  by  processes  of  softening,  tuber- 
culous deposits,  atrophy  of  the  gray  cortex,  etc.,  bnl  is,  of 
countc,  maicrially  better  if  the  centres  remain  intact,  and  are 
only  temporarily  rendered  unable  to  perform  their  lunclion.  for 
tbea  speech  returns  gradually,  if  not  wholly,  partially,  and  it 
can  not  be  denied  that  systematic  exercise  and  regular  instruc- 
tion In  speaking  are  capable  of  hastening  an  amelioration,  nay, 
even  a  cure,  especially  if  the  patient  be  still  young. 

The  aphasia  ol  children,  which  wc  sometimes  find  after 


182 


DtSHASES  OF  TUB  BKAIN  PKOPER. 


aculc  inlcclious  diseases,  fright,  or  as  n  consequence  of  intcs- 
linal  worms  ("  reHcx  aphasia  "),  in  the  course  of  acute  infantile 
cerebral  palsy,  or  of  epilepsy,  and  occasion  ally,  but  very  rarely. 
after  a  cerebral  hjcmorrhagc,  is  in  no  olher  way  to  be  disiin- 
gtiished  from  the  aphasia  oi  adults  except  in  its  prognosis.  Q\vi\.- 
Axcn,  tatcris paribus,  vXw^'js  stand  a  better  chance  of  improve- 
ment or  recovery  from  aphatiia  than  adults,  no  doubt  because 
It  is  easier  to  educate  in  them  the  well  half  of  the  brain  to  per- 
form the  function  of  the  damaged  one.  If  tlie  disturbance  is 
only  functional,  as  I  saw  in  one  case  which  was  due  to  an  o\'er. 
dose  of  santonin,  in  which  the  disorder  in  speech  only  lasted  a 
few  hours,  the  outloolc  is  still  more  favorable,  and  complete 
recovery  may  be  confidently  expecled;  but  if  the  function  of 
one  speech  tract — that  is,  the  left — be  impaired  by  cortical  or 
deep-seated  lesions,  even  then  it  is  in  chiklreu  usually  not  very 
difficult  to  educate  the  right  side  to  some  vicarious  action,  espe- 
cially  in  cases  where,  before  the  lesion,  the  children  have  been 
taught  to  use  both  hands  equally.  The  possibility  of  a  cere- 
bral disease  should  be  thought  of  in  Ihc  gymnastic  cultivation 
and  development  of  the  body  of  children;  the  extremities  ol 
both  sides  should  be  exercised  and  strengthened  equally,  the 
children  should  be  made  ambidextrous;  only  then  can.  in  a 
case  of  necessity,  the  right  hemisphere  fully  take  the  place  of 
the  left. 

A  treatment  for  the  aphasia  ns  such  does  not  exist.  In 
cases  of  functional  aphasia  the  only  thing  necessary  is  to  con- 
vince the  patient  that  liis  condition  is  not  serious.  If  this  dues 
not  lead  to  any  improvement,  we  should  try  hypnotism,  from 
wliich  astonishing  results  have  sometimes  been  obtained.  If. 
on  the  other  hand,  lite  aphasia  is  due  to  organic  changes,  such 
as  hicmorrhage  or  embolism,  in  our  treatment  we  must  be 
guided  by  the  principles  discussed  in  the  chapter  dealing  with 
these  conditions. 

literati;  KE. 

Wernicke.     Lehrbuch  der  Cehimkrnnkhciifn.  1881,  png.  366. 

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I 


CO/tT/CAl  UOTOft  PAKALYSIS, 


183 


I 


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We  have  re|>cate(lly  pointed  out  that  the  motor  disturb- 
ances produced  by  cerebral  diseases  are  either  due  to  destruc- 
tive or  irrilaiive  Ie5i<ms.  The  farmer  consist  of  paralyses  and 
pareses,  the  latter  of  involuntary  movements  in  different  groups 
muscles — ihc  sn-c.illcd  spasms.     Those  disturbances  which 

dtK  to  affections  of  the  cortex  (cortical  motor  disturbances) 


tS4 


D/SEASES  OF  THE  BRAIN  PROPER. 


present  much  that  is  characteristic  and  interesting.     They  nil! 
be  considered  presently. 

The  motor  centres,  the  motor  area  of  the  cortex,  comprise, 
as  has  been  stated  above,  the  two  centnil  convolutions,  the 
puracentra)  lobule,  and  the  parts  lying  immediately  adjacent. 
Upper  and  lower  extremities,  neck  and  face,  have  their  own 


T 


k 


I,0ilitml»riiivlaa 


Pbiu 


"^^^^^^^^ \ 

Vj-Vrtt — ■.-.jvi, 1 


&r~£r'i£.~*il'*'^  Conical  Alivt   fpvyciin- 


I  ^—  •  ^M  PifnnMil  met. 


■  -^— Frontal  eQrliD>p0niln« 

UvkulL  \ 

_. — i>^^  T(aipiitiMM(li4»1   I'll!  I-  1 
cv-psnliM  UKituli. 


bpsnliM 
Anu  uhI  p«t.  nrcbellu. 
poo  doc  laKiculi' 
'  T«cni4niat  mdixion  anil 
lup.  peduncle  of  «tit- 
bcUuin. 
■  Ana  hnriculirU. 


t 

F%.  46.— DiAORAM  fflKm-iKO  TMK  DiHKL-T  SrinXH  or  FmHsa  (Ft^nuia, : 


Special  centres,  which  are  distinctly  separated  from  one  an. 
other  in  the  central  convolutions.  Thence  fibres  converge," 
as  is  shown  in  Fig.  46,  into  the  anterior  Hvo  thirds  of  the 
posterior  division  ol  the  internal  capsule.  One  thing  at  once 
becomes  apparent  irom  this  arrangement,  namely,  that  in  cor- 
tical lesions  the  paralysis  or  paresis  may  easily  be  confined 
to  one  extremity,  an  arm  or  a  leg,  while  ii  the  lesion  aOccls 


CORTICAL  MOTOR  PASALYStS. 


185 


^ 


^ 


the  tract  lower  down  in  the  brain — for  instance,  in  the  region 
ol  the  capsule—the  paralysis  must  extend  over  the  whole  hall 
of  Ibe  body.  A  paralysis  of  one  extremity  only  is  called  a 
monuplegia  (monoparesis),  in  contradistinction  to  a  hemiple- 
gia, which  means  paralysis  of  one  side  (half)  of  the  body,  and  it 
is  a  perfectly  warrantable  conclusion,  sufficiently  confirmed  by 
post-mortem  evidence,  that,  if  the  patient  presents  a  paralvMS 
d  only  one  arm  or  one  leg.  we  are  dealing  with  a  cortical  lesion. 
A  hemiplegia  is  only  then  likely  to  be  of  cortical  origin  if  its 
dcvclopmeril  indicates  that  liie  lesion  beginning  in  one  motor 
centre  has  gradually  encroached  uponanother.  Ilgoes  without 
laying  that  in  diagnosticating  cortical  lesions  we  must  not  rely 
on  a  single  symptom,  but  all  must  be  considered,  and  especial 
care  must  be  taken  not  to  confound  a  paralysis  of  cortical  with 
ooc  of  peripheral  origin.  One  great  distinction  between  these 
two  is  to  be  found  in  the  maimer  of  onset.  While  a  paralysis 
of.  cortical  origin  may  develop  quickly  in  a  few  hours,  a  periph. 
eral  one  will  be  more  gradual,  and  only  reach  its  (uU  extent 
after  weeks  or  even  months.  Moreover,  the  latter,  the  periph- 
eral, is  easily  recognizable  by  the  changes  which  lake  place  in 
the  electrical  excitability — c.  g  .  if  reaction  of  degeneration  and 
visible  atrophy  in  the  muscles  can  be  dcmonsiralcd.  The  ab- 
sence of  cerebral  symptoms,  which  are  rarely  entirely  wanting 
in  cortical  affections,  is  also  characteristic  of  peripheral  disease. 
Great  pain  may  be  entirely  absent  in  the  central,  but  is  com- 
monly present  to  a  greater  or  lesser  degree  in  the  peripheral 
variety.  Remembering,  then,  these  points,  and  making  it  a 
routine  practice  never  to  omit  the  electrical  examination  in 
doubtful  cases,  we  are  not  likely  to  make  an  error  in  the 
diagnosis. 

In  conical  lesions  the  loss  of  motion  is  usually  not  absolute, 
and  we  find  more  frcciucntly  a  paresis  than  an  actual  paralysis. 
The  disorder  docs  not  necessarily  affect  a  whole  extremity,  an 
arm  or  a  leg:  it  m.iy  be  confined  to  the  distribution  of  special 
nerves,  or  even  to  portions  of  these,  the  so-called  dissociated 
hemiplegias  {cl.  also  Pick.  Prag.  med.  Wochenschr.,  1891,  25-27). 
Sometimes  the  affected  arm  or  leg  can  be  moved  in  Mo,  though 
a  strong  effort  may  be  required,  and  it  is  only  in  the  fingers 
and  toes  thai  the  loss  of  power  is  complete. 

A  characteristic  symptom  is  the  inability  of  the  patient  to 
execute  complicated  movements,  such  as  buttoning  his  coat, 
cuunting  money,  and  so  forth,  acts  which  are  performed  awk- 


186 


D/S£AS£S  OF  THE  BRAIK  PROPER. 


wardly  and  with  difficulty,  owing  to  a  loss  of  the  motor  im- 
ages. This  condition  has  been  called  ataxia,  and  in  these  cases 
we  have  a  "  cortical  ataxia."  The  lesion  has  to  be  referred  to 
that  part  of  the  cortex  which  contains  the  sensory  area  {fuhl- 
sfiAare  oi  Munk)  for  the  aflected,  that  is.  the  ataxic  extremity. 
The  trouble  is  very  dislrcssirig  lo  a  patient  in  a  brachial  as  well 
as  in  a  crural  munuptcgia.and  becomes  almost  unbearable  il  the 
sensory  disturbances,  which  we  shall  shortly  describe,  are  super- 
added (of.  lit.,  Observations  of  Bernhardt). 

In  infective  tumont,  gummata,  Itibcrclcs  at  the  surface  ol 
Ihe  brain,  we  occasionally  meet  with  symptoms  of  irritation, 
such  as  monocontractures,  which  depend  upon  an  irrita|ion  in 
the  correspond! rift  portion  of  the  motor  path  (Wernicke).  They 
are  not  seldom  accompanied  by  sharp  pains.  In  such  cases  the 
difTerential  diagnosis  between  a  hysterical  and  a  true  organic 
cortical  lesion  may  cause  considerable  difficulty  (cf.  chapter  on 
Hysteria). 

Of  the  greatest  practical  importance  are  the  epileptiform 
attacks  which  occur,  either'with  or  without  loss  of  conscious- 
ness, as  a  consequence  of  direct  or  indirect  irritation  of  the 
cortex.  |[  they  occur  in  the  further  course  of  the  monoplepia, 
the  onset  of  which  was  apoplectiform,  the  diagnosis  of  a  corri- 
cal  lesion  can  be  made  with  a  high  degree  of  probability.  In 
some  cases  the  convulsions  are  not  general,  but  only  appear  as 
localized  twitchings  or  spasms, confined  loone  half  of  the  body 
or  one  extremity  ;  they  may  be  clonic  (that  is,  an  alternation  in 
quick  succession  oC  contractions  and  relaxations)  or  tonic  (that 
is,  steady  contractions  lasting  for  some  time),  and  may  be  of 
considerable  intcnsiiy :  their  occurrence  later  in  parts  already 
paralyzed  would  indicate  a  disease  of  the  bruin  surface,  though 
we  m.iy  not  alw.iys  be  able  to  say  whether  the  irritation  of  the 
cortex  depends  upon  a  direct  or — as,  lor  instance,  in  tumors, 
which  cause  an  increase  ol  the  intracranial  pressure — an  indi- 
rect action.  In  the  latter  case,  also,  general  or  partial  convuU 
sions  may  ensue. 

The  use  of  the  term  cortical  epilepsy  (or  Jacksonian  epi- 
lepsy, after  l-Iughlings  Jackson,  who  first  described  these  con- 
ditions) is  liable  to  give  rise  to  misconceptions,  and  it  must  be 
remembered  that  the  so-called  cortical  epilepsy  has  nothing  in 
common,  except  the  name,  with  the  classical  genuine  epilepsy. 

The  epileptiform  seizures  due  to  conical  lesions  show  cer- 
tain fundamental  differences  Irom  the  classical  attacks.     Con- 


COK17CAL  MOTOR  PAXALYStS. 


187 


• 


tciousness  is  retaitied,  a  feature  which  ^vcs  the  whole  attack 
an  entirely  diflercnt  aspect.  A  ceriain  kind  of  aura  occurs 
here  also  :  the  |ia(tenl  knows  when  the  convulsions  are  coming 
on,  cither  by  slight  twitching  in  the  fingers  or  toes,  or  by  (op 
micaltnn  and  other  symptoms,  which  occur  only  in  the  nlTected 
cictrcmity.  But  all  the  other  symptoms — the  cry.  the  fall,  the 
biting  of  the  tongue,  etc. — arc  absent.  The  p-niient  sees  and 
watches  the  twitching  of  his  extremity:  not  rarely  he  has  x'io- 
lent  pains;  he  tries  lo  hold  the  extremity  in  a  fixed  position  or 
asks  others  to  do  so.  and  attempts  tu  avoid  injuring  himself. 
After  the  convulsions  he  feels  weak  and  unstrung,  but  oidy  in 
consequence  of  the  increased  muscular  work.  Headache  and 
all  (he  various  post-epileptic  syniptoms  arc  absent,  or.  at  any 
rate,  are  not  connected  with  the  attack  as  such. 

The  degree,  the  duration,  and  the  frequency  o(  the  attacks 
vary  considerably;  sometimes  only  a  more  or  \c^  marked 
twitching  appears  in  the  affected  limb;  sometimes,  however, 
the  attack  manifests  itself  in  shaking  movements,  which  may 
become  so  violent  thai  the  bed  shakes  and  the  patient  anxiously 
cries  lor  some  one  10  assist  him  and  to  hold  him.  If  violent 
pains  have  been  present  during  the  movements,  they  are  ivont 
lo  persist  alter  the  attack,  and,  combined  with  (he  motor  weak- 
ness in  the  affected  extremity,  are  often  productive  of  great 
sufTcring.  The  duration  also  varies.  I  have  seen  cases  in 
which  the  attack  was  over  in  from  a  quarter  of  a  minute  to  one 
minute:  on  the  other  hand,  I  have  seen  instances  in  which  it 
has  lasted  (or  a  quarter  of  an  hour.  If  such  prolonged  attacks 
occur  .It  frequent  intervals— two,  three,  or  six  limes  a  day—the 
state  o(  the  patient  may  be  very  pitiable ;  and,  indeed,  the  car. 
rying  on  of  the  individual's  occupation  may  be  interfered  with 
by  this  partial  epilepsy  much  more  than  it  often  is  incasesof  the 
classical  disease.  In  other  instances  months  intervene  between 
the  attacks.  The  whole  course  of  the  malady  is  eminently 
chronic :  the  patient  may  suffer  for  years,  or  lens  of  years,  with- 
out  there  being  any  other  symptom  present.  Death  occurs 
rither  from  an  extension  of  the  brain  lesion  or  as  a  result  of 
»«>rae  intercurrent  disease.  Pitres  has  called  attention  to  the 
fact  that  so-called  equivalents  may  occur  in  Jacksonian  epilepsy 
also,  and  has  pointed  out  that  they  may  be  of  a  sensory  or  of  a 
pftvchlcal  nature  (Revue  demW.,  t888,viii):  the  former  belong 
to  Charc'it's  ffiUfsU  partieHf  sensitivf  (Lemons  du  Mardi  h  la 
Salpctri6re.  it^.  pp.  2oand  368)  ;  the  latter  manifest  themselves 


1 88 


J>/SSASES  OF  THE  BRAIN  PROPER, 


in  visual,  auditory,  Dr  olfactory  hallucinations  without  any 
marked  signs  ol  motor  irritation. 

With  reference  to  the  diagnosis,  it  should  be  mentioned 
that,  jn<tt  as  in  the  case  of  genuine  epilepsy,  cortical  epilepsy 
may  be  simulated  by  urxmic  attacks  if  the  latter  arc  confined 
lo  one  side  {Chauftard.  [)e  I'ur^mie  convulsive  ^  forme  de  l"£pt- 
lepsie  Jacksoniennc.  Arch.  gin.  dc  mid.,  July,  1897).  Fur- 
thermore, attacks  which  resemble  very  closely  those  of  Jack- 
^nian  epilepsy  may  occur  in  hysteria:  in  these  cases  the 
>rcsencc  of  other  hysterical  manifestations  will  prevent  an 
error  in  diagnosis.  Mendel  has  repeatedly  observed  cases  of 
general  paralysis  in  which  Jacksonian  epilepsy  was  the  initial 
symptom.  The  foci  which  were  found  at  the  autopsy  were  in 
each  case  situated  in  the  right  psycho-motor  region,  and  the 
(paralytic)  speech  disturbance  occurred  in  the  terminal  stage. 
whereas  usually  this  is  one  of  the  early  symptoms  o(  general 
paralysis. 

The  sensory  disturbances  which  are  produced  by  the  aflec- 
lions  of  the  brain  cortex  arc  remarkable,  and  by  no  means  fully 
understood.  As  we  have  seen  before,  they  do  not,  as  a  rule, 
cause  pain,  but  rather  manifest  themselves  in  alterations  ol 
sensation,  known  as  parscsthesias.  Thus  the  patient  may  speak 
of  a  curious  numbness  or  dcadness;  or,  again,  he  may  have  a 
sensation  as  of  anis  crawling  under  the  skin,  a  feeling  as  if  the 
part  had  gone  to  sleep,  etc.  There  may  also  be  a  distinct  in- 
crease in  p:iin  perception,  a  slight  "analgesia,"  a  diminution  or 
loss  of  pressure,  touch,  and  tcmpcralure  sense,  and  oftcncr,  as 
it  seems,  in  disciises  ol  (he  parietal  lobes  a  more  or  less  pro- 
nounced disturbance  of  the  muscular  sense,  in  consequence  ol 
which  the  patient  can  wiih  closed  eyes  cither  give  no  account 
at  all  or  only  a  very  imperfect  one  of  the  position  of  his  ex- 
tremities. If,  as  often  happens,  the  above-described  awkward- 
ncss  in  motion  (ataxia)  coexists  with  these  changes,  we  may  be 
tempted  to  refer  the  trouble  not  to  the  cortex,  but  to  the  spinal 
cord  ;  more  especially  arc  we  liable  to  think  of  tabes,  although 
the  ataxia  is  produced  in  an  entirely  different  manner  in  the 
two  diseases.  However,  the  differential  diagnosis  will  in  most 
cases  present  no  dilTicuIlies  if  we  take  into  consideration  all  the 
symptoms,  and  examine  into  the  condition  ol  the  patellar  re- 
flexes,  the  reaction  of  the  pupils,  and  ascertain  whether  there 
lire  bladder  symptoms  and  whether  lancinating  p.iins  are  pres- 
ent or  not.    These  sensory  changes,  we  must  not  forget,  are 


THE  CENTRUM  OVALE. 


189 


by  no  means  always  observed  in  cortical  lesions,  and  in  the 
cases  in  which  they  existed  the  white  matter  of  the  brain  has 
o(ten  been  found  to  be  likewise  the  scat  of  disease;  they  are 
tbcFcfure  in  no  way  to  be  regarded  as  pathogiiomaiiic,  and  we 
hive  to  be  cautious  in  using  them  (or  diagnosis.  The  same  is 
tVCBit  lo  a  greater  decree  of  the  vaso-motor  and  trophic  changes, 
1  fclalion  of  which  to  the  brain  cortex  is  still  obscure. 


SyMfifoms  Referabit  lo  LesioHs  0/  the  While  Matter  of  the 
Hemispheres  anii  {jsifHS  of  Ike  Hasal  Ganglia. 

looking:  at  the  anatomy  of  the  parts,  wc  notice  that  the  fibres 

mniTii;  (mm  the  cortex  pass  through  the  while  matter  of  the  hemi- 

Dhete,  which  in  the  region  of  the    frontal   and   parietal  lohes   is 


Fronts  lA* 


»f  inlmuU 
cajmult 


AW. 


PotUrior  liat 
tmpnJt 


A'uel  eaudat 


I 


nf.ft.—roKmKt>w  mi  FintiRS  ntoM  the  Intciuial  CAr«t*LB  to  nii  Cuvs  Cebbbm, 
Tte  Ifcahiini  i»  rcjimcnM  »  tnnsi-ucni.  (Dlatp^uDOHiK  ifur  WKHHiciCit  and 
Cmmmk.) 

detlsnated  centrum  scniovale  Vieussenii.  Turning  toward  the  hrain- 
ttvtn,  in  Its  nciffhborhood  they  appear  arranged  in  bundles  placed 
•idc  by  side,  completing  by  their  convergence  what  has  long  been 
knowfl  at  (he  cotuoa  radiata.     VVith  thit,  corona  radiaia  begin*  the 


190 


J>/S£^S£S  OF  THE  BRAtN  PROPER. 


eat  nerve  tract  which  connects  the  hemispheres  with  all  parts  of 
the  tiruin  situutcd  lower  down,  and  finally  with  the  spinal  cord.  That 
|)art  of  the  medullary  path  through  which  the  corona  radiala  is  con- 
tinued into  the  crura  cerebri  is  called  the  internal  capsule.  As  is 
seen  in  Fig.  47,  this  is  situated  anteriorly  between  the  caudate  and 
the  lenticular  nucleus,  posteriorly  between  the  lenticular  nucleus 
and  the  optic  thalamus.  The  point  where  the  two  segments  meet  is 
called  the  genu  or  knee  of  the  capsule. 


Venfiic.  tatrr. 
f'ffifrift  ttpt.  pttlue. 
A'urf.  eaud, 
Tornu 

■Comoiit$.  antrr. 
Commin.  m^ia 
Tania  ttmifireufant 
Thalamta 
CuHmiM.  potfr. 
— Piimalflmd 
JPuleinar 
Oorpiint 


fig.  4S.— View  op  thb  Vehtxicles  on  Horizontal  SBcnov.    (Atier  Eodkikjc) 

From  the  internal  capsule  the  Tibres  reach  the  crusla  (pes  pcdun- 
culi  cerebri),  whence  they  pass  through  the  lower  (anterior  or  ven- 
tral) portion  of  the  pons  and  enter  the  medulla  oblongata  as  the 
anterior  pyramids.  At  the  lower  end  of  the  medulla  most  of  tbem 
decussate  and  pursue  a  downward  courtie  in  the  lateral  columns  of 
the  spinal  cord  on  tb«  opposite  side.     This,  the  most  important  of 


THE  INTERNAL  CAPSULE. 


191 


all  direct  syMcin«  of  fibres,  was  discovered  by  Oeiters  in  1865,  and 
tnMt  carefully  studied  by  FIccIimi;  in  iS;6.  It  is  generally  known 
IS  the  lateral  pyramidal  tract,  and  it  represents  the  path  for  the 
voluniary  movcmcnU.  A  lesion  of  it  is  therefore  of  grave  conse- 
quence fur  the  motor  functions. 

tig.  48  reprenents  a  horixonlal  section  which  shows  the  relative 
poiition  uf  the  caudate  nucleus  to  the  optic  thalamu»,  the  corpus 
callosum,  the  fornix,  the  two  white  commissures,  the  anterior  and 
the  posterior,  the  gray  middle  commissure,  the  pineal  gland,  and  the 
corpora  quadrigemina. 

fig.  49  is  a  third  horizontal  section  through  the  cerebrum  at  a 
lower  pUnc.     Both  are  taken  from  l!^diiiger. 


Tbnite 


nf.  «o^-KoaBOirr«t  Sbcthmi  iHULnjoK  no  ItMAm.  Kvtvrc  k  PinckkI  BsKAorn 

■BLOW  1HAT   lumKKLMl.ll  IM    t  lO.   4S.     itUINOkll.) 

F>S^  50>  5t,  and  5a  arc  three  so-called  frniital  8ection^  of  which 
Ihe  first  is  made  ihrotigh  the  anterior  commissure,  the  Kecond  In 
front  of.  Ihe  third  behind.'the  middle  (gray)  commissure.  They  also 
fthow  Ihe  courK  of  the  internal  and  external  capsule,  and  the  situa- 
tion of  the  so-called  ba»al  ganglia,  the  c;iudatc  and  the  lenticular  nii- 
^clcus  (together  known  as  the  curpus  striatum),  and  the  optic  thuUmui, 


192 


DISEASES  OF   THE  BRAIN  PROPER. 


In  another  frontal  section,  Fls.  53  (after  Edingcr),  the  dirccti' 
of  the  fibres  is  illustrated  diagrammatically. 


S^t,  ptHue. 

Jfurl.  rtmdal. 

Capf.  int. 

2lucl.  Until 

Qenutrvm 


nes* 


Pities  has  Tccommendcd  a  eeries  of  frontal  sections  iii  order 
licilitaie  in  our  descri))tions  of  autopsies  a  more  accurate  locali 


Jltut.  emiA 


CarpM  rtlhuUB 
Cntm  /»r*. 
TJiaimn. 
Jntwta 
CapK  tnt 
Xiiel.  Uutiform. 
Cfipv.  trt. 
Clatutr. 


Ton  of  Iniona  and  tumors  within  the  very  extensive  whiti 

of  the  brain,     Nothnagel  has  modiTied  somcwtiat  thcae  scctiotu 


PITXKS-  SF.CT/OAfH. 


■93 


Pilres  with  regard  to  their  position  and  desiKDatinn.  The  table  on 
page  194  contains  the  necessary  explanation.  With  the  help  of  these 
MCtions  wc  need  not  content  ourselves  any  longer  with  locating  in  the 


K*r7.  eauJ. 


TMamtm 


CiimmiB*ra  ■»<<: 


ttKTfnUMft. 


/MgAacU. 


!■"■«-  S* 

.9»-S.i.— So-e«LtJ:i>"Fiio!iT*(.  Scn'iDMs"  Tnmovom  Tint  Rraih.    PIc-  <to,  ikraoth 
iJkc  anictlorcoincalaure.     t'\g.  $'■  1°  '"■■>!  °l  nie  middle  commluure.     h'lc.  m.  btbiad 
ilv  middle  commtaurc.     ■''tc.  5.1,  ImmedUlely  Uhlnd  Ihe  chUsm.    Tbe  ndiuing  Abn« 
arc  ihown  dli^cTaotniaUcallx  In  Ihe  lut  lUDsirailoD.    (AHet  KDinom.) 
•3 


19+ 


D/SEAHtiS  Of  TIIH  BRAIN  PROPER. 


post-mortem  accounts  a  tumor  "in  (he  anterior  part  of  the  brain,"  "in 
the  temporal  lobe,"  clc,  but  u-c  give  the  one  or  more  sections  which 
coiicspond  to  the  situation  of  the  ncoplusm,  and  so  attain  an  accu- 
racy which  IS  indispensable  fur  the  after-use  of  our  autopiiy  record*. 

PITRE-VNCITHNACEL  fltONTAL  SECTIONS. 


DMiBHUioB. 

PdIbu  whMc  ntilou  Me 
mtAt- 

Immediairly  in  rrant  of 
nenu  of  torpus   calla- 
iiUm. 

CiIM  by  Ptm* 

rnin|iiim  ■ dliii  im 

N«hnta*l, 

A 

C<]u])«  pr^fraiiialc. 

C«nlri  ovalii  pan  fron(aU> 
anterior. 

B 

iiuining  «I  ihe  bcginiiiii)* 
of  litMirv  of  Sjlviu). 

1 

Coupe  pMiculo> 

front  «Jc. 

Coupe  frontal*. 

Pws  frontolb  media. 

B, 

BetWMn    anierior    ecn- 
■rml   and    frontal    cod* 
volationk. 

Pan  fronlaJIs  |>OTiorio«. 

C 

Through    die    litnire    of 
RolandoL 

Part  ccninti»  aDlcilo*. 

D 

Ttuongh  ascendins  parie- 
la]  convojuiion. 

Through  pancul  lobo  J 
nn.    poslcrior    to    tJw 
fiuure  of  Rolando. 

Coupe  pariAolc 

Pan  oeotntlit  pmloior. 

E 
1 

Coup*  pMlculo-pa> 
iteta1«. 

Pan  ptrUtaUi.            ^- 

F 

Thiouch  occipital  loli«. 

Coupe  occlpltalc. 

Pan  occlpltaUt. 

Fit.  S4-— POHTTS  AT  WinCIt   TRR   FlTkltS-NmtlHAOKL  SRCnOBS  AKB  MAEIB.     Thl^  (Jl 

ran  parallel  witb  (be  fiuufE  of  Kotando. 

Figs.  55-^10  repreMfiii  diagrammatical ly  Pitres'  sections.     From 
Fis.  54  vre  can  ^et  an  idea  of  the  points  on  the  surface  of  the  brain 


iSS/OJVS  Of  CENTRUM  OVAi 


195 


It  which  the  sections  are  to  t>c  made  (cf.  i'itrcK.  KechercheB  sur  t«» 
Itxionsdu  centre  ovale  dcs  hifmisphires  c^r^braiix  6tu(li^sau  point  dc 
ne  tics  localisations  c'6r(bTjles,  ['.iris,  1S77). 

,1 


!%ciclllill  A. 


^  SS-— k  I,  ^  fini,  woond,  uk)  ihlid  [tonul  omvohiUofiA.    «.  prxlnaul  (uckuliu  of 

ilw  wotrum  «nilcn«le. 

'  WTeean  likcwisi;  avail  ourselves  of  the  charts  of  the  human  brain 
Published  by  Exner  (two  plates,  with  twelve  UuigiumN  Wicti.  Brati- 
"""!«=»,   iJ(S8).     On  the  plates  the  disi-ovcrcd    lesion  (:;in  lie  easily 

^''•cciJoff,  and  thus  the  extent  and  situation  of  it  rcprc*enied. 

ScMion  B.    tB,  NolbiiJi:*!.) 


(^fl—f  Md  ^  i*M  lad  Hcond  Ironlal  fOQTotocloni.  ^  aAiA\i  pcdleulo-fKiDtil  (Mdra- 
hk  «,  ootpos  cttbann.  ^  Budcui  »udaiuL  0.  Internul  cifinilc.  7.  Icnlkuki  nuckiK 
I,  Um4  of  RaiL    ft,  Ki.  11,  nipertor,  luddle.  Mid  Infarior  Irooul  fkioaill. 

With  reference  to  the  lesions  in  the  centrum  ovale.  !t  should 
6c  itated  that,  as  a  rule,  the  symptoms  produced  by  them  are 
MBitar  to  those  which  we  find  in  lesions  of  the  corresponding 


DISEASES  OF    THE   BHAIN  PROPEK. 

SnnioaC. 


Flf.  JT' — '>  1^1  (maul  coavolulinu.  a.  .<(,  4,  luperior.  middle.  And  iafirto*  (rontal  ftKfcoU. 
5,  cupiu  callomiD.  (•.  nudmi  UkudMiu.  7,  ofAtc  ituUjuuuiL  S,  IdUtiuI  capmlcu  $•  k>>' 
tknbr  nudeiu.    ■<>,  daustrum. 

area  of  the  cortex.    Thus  we  shall  meet  with  motor  disturb- 
ances if  the  fron to- parietal  fasciculi  of  the  corona  radiata,  which 


Sectiou  u 


rie-  $3.— >,  anierjor  milnl  conmlutlnn.  a.  oorpui  catlsaum,  .1,  caiKkto  noclaH-  4.  op<te 
Ihilamiu.  s-  ■"'cnikl  <ap«iile.  ft,  iskod  of  Rrii.  ;,  lenliniUr  naekot.  B,  Mttnul 
<ap«ile.    %  tompcitiil  CobcicuIu*.    va,  n.  ti,  «up(ri<>r,  middto,  inlnior  parteUJ  lockuB. 


LESIONS  OP  ceyr/tt'M  oyAi.E. 


W 


nke  their  origin  in  the  motor  area,  arc  diseased  :  while  lesions 
in  the  prefrontal  or  occipital  bundles  may,  and  indeed  vcrj 
otien  do.  not  evoke  any  symptoms.     1 1  the  left  (inferior)  pedic> 


SKtiim  v.. 


I>  - 1.  luf  ilaf  pvinil  tua-iculiu.     i,  («qnu  Mlliouni.     j.  iuirtvyt  pirwu]  rucKUlUi. 
4  uxlA,  caudklc  nuclciu.    5.  optic  Ihalamut, 

■'lo-fxonlal  bundles  in  addition  are  affected,  the  patient  will 
***>  be  aphasic,  the  aphasia,  however,  being  of  long  duration 
^^^y  U  the  lesion  extends  close  up  to  the  cortex.     Lesions  ia 

SMtiiHl  V. 


to— I,  ocdplttl  ooBraluliant.    1,  oodiiiul  (*iirkuluB  of  ihr  ominrni  Minlnnlc. 
&)-to— FtrBB^NOTUMAOCL  iiEcTiOHs,  Uic  poMiiun  111  which  ii  muk  (icu  \tf  Ibe 

tlir  white  matter  of  the  occipital  lobe  may  produce  hemianopia, 
iotbe  temporal  lobe  auditory  disiurb:inces.  Whether, however, 
diKUCs  in  the  parietal  lobes  ever  produce  sensory  changes — 


iqS 


DISEASES  OF    THE   UKAIN  PROPER. 


an;esltiesia,  for  instance — and  whether,  as  a  consequence  of  any 
lesion  in  the  cenirum  ovale,  vaso-motor-trophic  changes  may  be 
developed,  is  unknown. 

The  idea  that  the  basal  ganglia  were  true  motor  centren,  and 
that  the  common  form  ol  hemiplegia  was  due  to  lesions  thereof, 
has  been  given  up,  and  we  have  learned  irom  the  investigations 
oJ  Flechsig  and  Wernicke  thai  direct  connections  between  the 
motor  Lcntres  of  the  cortex  and  these  basal  ganglia  do  no! 
exist.  Moreover,  it  has  been  proved  by  numerous  thoroughly 
reliable  observations  that  destruction  of  (he  lenticular  or  o(  the 
caudate  nucleus  does  not  necessarily  give  rise  to  a  motor  pa- 
ralysis. One  or  bolb  lenticular  nuclei  have  repeatedly  been 
found  destroyed  in  cases  in  which  there  was  no  sign  of  paraly- 
sis (L(^pine.  Nothnagel.  Ediriger,  Heboid).  In  order  that  this 
may  not  ensue,  it  is  only  necessary  that  the  internal  and  per- 
haps also  (lie  outer  capsule  remain  intact.  As  soon  as  the  for- 
mer (the  inner  capsule)  is  eitlier  directly  or  indirectly  im- 
plicated, we  have  a  hemiplegia  which  is  either  transient  or 
persistent,  according  to  the  nature  of  the  lesion  in  the  capsule. 
Whether  the  lenticular  or  the  caudate  nucleus  alone  is  diseased 
can  not  be  determined  from  the  symptoms. 

There  is  no  doubt  but  that  lesions  of  the  thalamus,  espe- 
cially of  its  anterior  and  middle  part,  may  occur  without 
symptoms,  and  it  is  impossible  to  say  whether  motor  paralysis 
is  ever  produced  by  lesions  of  the  thalamus,  for  in  all  instances 
in  which  this  may  have  been  the  ca.sc  the  motor  paralysis  may 
also  have  been  a  result  of  damage  to  neighboring  parts  I  pedun- 
cles, internal  capsule). 

Better  founded  is  the  idea  that  lesions  ol  the  pulvinar,  the 
posterior  part  of  the  thalamus,  give  rise  to  defects  in  sight — 
crossed  amblyopia  or  homonymous  bilateral  hemianopia;  but 
the  possibilitv  that  the  posterior  part  of  the  optic  tract  is  inter- 
rupted  can  even  then  not  be  excluded.  The  athetoid  move- 
ments and  symptoms  of  motor  irritation  (hcmichorea.  post- 
hemiplegic tremor,  athetosis)  are,  even  if  a  connection  actually 
exists  between  ihem  and  lesions  of  the  tlialanius(Greif,  cl,  lit.), 
certainly  not  characteristic  of  such  lesions.  The  same  holds 
good  for  the  disturbances  in  the  muscular  sense  which  have 
been  observed  in  diseases  of  the  thalamus  (Meyncrt.  Jackson). 
The  relation  between  these  latter  and  loss  of  the  movements  of 
facial  expression  in  the  course  of  central  facial  paralysis  has 
been  spoken  ol  tn  Part  II,  Chapter  V.     Recently  Nothnagcl 


THE  COKI'OKA  fiVADRIGF.MlNA. 


'99 


has  again  published  a  clear  case  of  this  kind  (Zeiisch.  1.  klin. 
Med..  1889,  xvi,  5.  6.  p.  424). 

lycsions  of  the  internal  capsule  produce  symploms  varying 
according;  as  the  anterior  ur  posterior  limb  is  attacked.  Pure 
capsule  lesions — i.e.,  those  in  which  the  caudate  as  well  as  the 
lenticular  nucleus  remain  intact — have  rarely  if  ever  occurred. 
Fissures  have  been  occasionally  known  to  occur  without  hav- 
ing necessarily  produced  any  motor  disturbances  in  life  (cf. 
Nolhnagel,  loe.  cit.,  p.  273).  The  functions  of  the  anterior  limb 
of  the  internal  capsule  arc  obscure,  and  lesions  of  this  pan  do 
not  produce  any  symptoms.  With  the  posterior  limb  we  arc 
better  acquainted,  and.  above  all.  this  one  fact  is  well  estab- 
lished, that  »  lesion  of  the  anterior  two  thirds  of  the  posterior 
limb  gives  rise  to  the  usual  typical  ht-tniplcgia.  with  paralysis 
of  the  lower  facial  branches.  A  very  small  lesion  at  the  knee 
may  produce  an  isolated  facial  paralysis.  H  the  posterior  por- 
tion of  the  anterior  two  thirds  is  the  chief  seat  of  the  disease, 
the  paralysis  is  most  marked  in  the  leg.  The  posterior  third 
of  the  posterior  limb  is  occupied  by  the  sensory  fibres  (/<■  farrt' 
four  sfHsili/oi  Charcot),  and  lesions  of  that  region  cause  a  loss 
ol  sensation  on  the  opposite  side  o(  the  body  ("  hcmiana^sthe- 
»ta,"  Oppenheim.  Charit^-Annalen.  i88g.  xiv.  p.  396),  in  which 
often  the  nerves  of  special  sense  arc  impticatcd,  and  hearing, 
smell,  and  taste  (on  the  anx-stheiic  side)  are.  if  not  lost,  at  least 
diminished.  Often  hemiplegia  is  accompanied  by  hcmian.-es- 
thesia,  because,  if  ihe  one  portion  of  the  capsule  is  aflcctcd.  an 
indirect  and  transitory  implication  of  the  other  may  occur.  Usu- 
ally such  a  hemianitsthesia  soon  disappears  in  the  same  way  as 
Ihe  indirect  motor  disturbance  often  soon  passes  off  in  cases  of 
persisient  hernia na'sthesia.  Whether  the  symptoms  of  motor 
irritation  (the  so-called  posl-hemiplegic  chorea,  for  instance), 
which  arc  a  not  rare  accompaniment  of  hemiplegia,  are  due  to 
disease  of  the  inlernal  capsule  or  to  disease  f>i  the  neighboring 
basal  ganglia,  is  as  yet  undecided. 

By  the  corpora  qu.-idrigcmina  wc  mean  that  peculiar  eminence 
which  by  a  crucial  furrow  is  M:paraicd  into  four  parts  (bodies),  and 
torm»  the  potiterior  homuUry  of  ihe  third  vcncrielG.  In  front  it  is 
bounded  by  the  commissure  whirh  unites  the  two  thalami-,  nn  it 
rests  the  pineal  gland  {cnnartum).  The  anterior  pair  of  brKlieH, 
which  are  called  the  nates,  are  larger  than  the  posterior,  the  testes. 
The  appearance  and  structure  which  these  two  pairs  of  bodies  pre- 
Knt  III  the  lower  mammals,  justifies  the  cuncliision  that  they  are  tu- 


300 


D/SEASES  OF  TUB  Bit  A  I. V  PXOPBfl. 


tally  different  from  each  other.  Above  the  corpora  quodrigemina  is 
Mltinlcd  ihc  splcniiim  of  the  corpus  callosura  ;  between  the  two  is  the 
transverse  fissure  of  ilichiit  (ihe  fiKKiira  choroidca). 

The  frontal  section  through  the  anterior  pair  of  the  corpora 
q u 3d ri gemma  (Fig-  6i)  shows  the  three  divisions:  the  cnista,  teg- 
mentum, and  qiiadrigcminal  ganglia.  Toward  the  outer  side  is  the 
pulvinar,  with  the  lateral  geniculate  body.     Emerging  below  the  pul- 

Carp.  ^mlA 
A»t.  mrpBra        ,„f^ 


Atf.  kmffiliJ.  tuiuBr 


Heti  nliefeuf 


Tig.  6t.— DlAOWLMMATlC   CKaa»«£CTIOH    ntHOlfOH    THK    ANrBXIOM   COSPORA   QUAPRI- 

alMiNA.    (After  f.ninoRR.) 

vinar  i»  the  crus,  which  contains  the  pyramidal  tract.  Between  it  *nd 
the  tegmentum,  in  which  is  seen  the  red  nucleus,  is  situated  the  sub- 
stantia nigra.  Uelow  the  aqueduct  arc  the  root  fibres  of  the  motor 
oculi,  and  in  characteristic  transverse  section  the  posterior  longitu- 
dinal bundle.  The  position  of  the  latter  is  miide  still  clearer  io  the 
longitudinal  section  rei>rekenied  in  Fig.  62. 

The  manner  in  which  the  fibres  from  the  red  nucleus  pass  under 
the  posterior  pair  of  the  corpora  quadrigcmina  toward  the  middle 
line  and  then  decussate  with  the  fibres  of  the  opposite  side — the  mj- 
called  "crossing  of  the  brachia  conjunctiva"  {»up.  peduncle*  of  the 
cerebellum) — is  represented  in  Fig.  6j, 

Isolated  lesions  of  the  corpora  quadrigemina  arc  almost  ds 
rare  as  similar  lesions  of  the  cupsule:  nearly  always  neighbor- 
ing stiiicturcs  arc  implicated.  The  data  which  we  possess  in 
this  connection  seem  to  indicate  that  lesions  of  the  anterior  pair 
produce  visual  disturbances,  amblyopia,  amaurosis,  and  toss  of 


rZ/JT  COtlPOttA  QVAOttlCeMrNA. 


201 


;)U[)ilbry  reaction.     Fliysiologically  imporlant  is  the  (act  that 
a  root  going  to  the  opttc  tract  is  given  ofl  from  this  anterior 


I 


'k-  te— IjOHDimiiiMju.  Sat-nox  TKiKvucti  ttiit  RKcron  of  riiii  Cobpox*  (>u»d«i- 
oeatKAor  •  Hmus  Fotrt's  Twi:<rn--(ioMT  WEicn  Oui.  (Afto  Kl'Ikuem.)  SIioh« 
Ukw  Ik  poMolDc  loDKMudUuU  bBodk  tmniiuHs  in  ibc  Duckiu  of  ihc  (culo-mouit  ii«n«. 

P*'!".  and  that  radiating  fibres  pjtss  to  the  niicicus  of  the  third 
"cvc,  so  tbat  a  connection  exists  between  stimulation  o(  the 


ng.  ty—DmatuuHmATK  II(Mi»m>t4i  StK-iinx  TKMovOM  -me  LdtLVMAriOH  op  thc 
SumitiM  PUKtHcua  ur  ttit,  Ci-HtnuxUM.    (A(Ur  Enmou.) 


302 


I?/SeAS£5  Of  THE  HRAIK  PROPER. 


nplic  nerve  and  slimulaiion  of  the  oculomotor  (pupillary  re- 
Ilex)  (Mendel).  Authors  seem  to  diflcr,  however,  abfiut  the 
extent  lo  which  this  reflex  13  influenced  by  disease  of  thi;  ante- 
rior pair  o(  ilie  corpora  quadrigcmina.  Impairment  o(  certain 
movements  of  the  eyes,  especially  the  upward  motion  of  the 
Ixdl,  has  been  repeatedly  noted  by  competent  observers  (Cow- 
ers). Xolhnagel  assumes  that  a  lesion  of  the  same  ocuto-motor 
bmnches  on  both  sides,  without  the  existence  of  an  alternating 
paralysis  of  the  extremities,  speaks  for  a  lesion  of  the  corpora 
quudrigemina  (cf.  loc.  ti4.,  p.  230).  As  to  the  function  of  the 
posterior  pair  of  the  corpora  quad  ligcmina.  all  explanations  arc 
uncertain  and  hypothetical.  Baginsky  assumed  them  to  have 
n  singular  significance  for  the  ear.  as  the  anterior  pair  for  the 
eye — an  idea  in  support  of  which  further  evidence  is  needed: 
and  the  disturbance  of  equilibrium  which  has  been  ascribed 
to  disease  of  these  bodies,  and  which  recently  has  again  been 
studied  by  Eiscniohr  (Deutsche  mcd.  Wochcnschrift,  1890,  42). 
may  well  be  produced  by  pressure  upon  the  neighboring  ver- 
miform process  of  the  cerebellum.  On  this  point  nothing  posi- 
tive is  known. 


TV" 


I  optirt/0 


^■-. 


LmutUem  tnul 

PyramiH'J  rrmtt        lo 

Kit-  6(.— SMITTiM.  SKCTION  TirRODGII    tto.is  AKI>   W«DVI.t-*  OOUJieOAT*.      (Aftof    Mt»- 

DKl~)  /.  anivriur  lonimiminL  f,,  pulvlnar,  i.  iuIbUDIU  bier*,  r.  Icirmentoin  ol 
cnii  r*rrbn.  r,,  nd  nuclvuK.  /,  [•»  pcilunculL  a,  poiu.  r.  hn»Cloa>u>  nocleat  »ilh 
fihrw  FnuTC>n|:  fnmi  iu  «i,  corpiu  <iu«dr(emilnum  jinlcrliu.  "^  oortK"^  quadripaii- 
num  pcBteriiu.  >,  ann  ItnliruUii*.  1,  Vici|.d'Affr'i  bundle  a,  4qHli;  rnut.  A|.  «Mn^ 
nil  ttulannn-mnt  of  opHc  tract.  *«.  inunMl  ItuUmiw-raal  al  opilc  iraci.  v,  uUvary 
bnHy,  «.  ikntfiriar  pf nmid.  t.  poAerinr  hiaglludtail  bodjr.  If.  Icxus  cxnikm.  ».  m, 
valve  iif  VlvUMm*.  m.  t,  MpfnartH  bundk.  at,  abduocns  nudeui  vlih  rmptElnc  llbtw. 
M,  nperior  pnlunck  of  ronbellum.    iv,  ocuto-mouw  nudnu  ailh  «in«)£in|;  fibres. 

The  crura  cerebri  emerge  (rom  the  pons  Varolii  as  two  thick 
cylindrical  white  bundles  of  fibres;  on  leaving  it  they  diverge. 


ISSJOJV.I  O/-'  THE  CRURA    CEREBRI. 


»i 


ing  between  them  the  posterior  perforated  space  and  the 
corpora  nibicantia  (mam miliaria  s.  candicantta).  The  situation 
o(  the  crusta  and  the  tegmentum,  and  the  masses  ol  fibres  con> 
laincd  in  them,  is  unce  mure  shown  in  Fig,  64,  which  represents 
1  longitudinal,  sagittal  section  made  almost  in  the  middle  line 
Kicgmcntum  ;  5,  substantia  nigra;  /.crusta).  That  the  crusta 
(arms  the  path  (or  the  voluntary,  the  tegmentum  the  path  for  the 
rcHcx  movements,  and  that  the  latter  also  contains  the  sensory 
pathM,  as  Meynert  assumes,  has  not  yet  been  proved  by  physi- 
ology. That  the  crusta.  however,  contains  the  motor  path — 
naely.  the  pyramidal  tracts— is  a  (act  established  beyond 
doubt ;  hence  its  lesions  will  (or  the  present  be  of  more  prac. 
bail  interest.  Only  a  small  number  o(  instances  of  lesions  in 
tke  tegmentum  have  been  reported,  A  case  of  Buss  (cf.  lit.) 
ted  ataxia  of  all 
cxtremitic-s,  ana:s-  ytto.. 

s,  disturbances  of 
tbenuscuiarsensc.  and 
nalection  of  the  right 
lirpogloKSUS.  At  the 
wop&y  a  local  lesion 
■»  lound  in  the  teg- 
ttenrnm  of  the  crus 
ud  the  pons. 

Considering  the  re* 

UIoo  which  the  third 

W'TC  bears  lo  the  mc- 

diu  \»t\  of  the  crus 

crcbH,  as  is  shown  in 

%  65.  we  can  well  un- 

drruand  that  in  lesions 

of  ihc  tatter  the  oculo. 

niiitor  is  not  rarely  im- 

plicaied,  and  autopsies 

hafe  frequently  demon. 

Untcd    tliat   wherever 

jfl  oculo-motor  paraly- 

sa  tuu  been  associated  with  paralysis  of  the  extremities  on  the 
opposite  side,  the  lesion  is  situated  in  the  crus  cerebri.  For 
esample.  in  a  patient  with  oculo-motor  paralysis  of  the  right 
aide  and  hemiplegia  of  the  left  side  (if  bi^th  come  on  at  (he 
time!),  we  may  without  hesitation  diagnosticate  a  focal 


Fir  65— Caow  wxmow  niMUoii  tiii:  KroMd  or 

THR   AirnttlQM    COHrOHA   QuADHiaKUIKA.     fW.A, 

■Mrriot  tnfpora  qiudrlEOUllw.  f.  r..  ^jwj  mUUf 
uoynd  ihc  aqueduct  ol  S)>lvtiu.  «f..  ariuedDit  of  SjrU 
ttoi,  ■///.  nudrui  of  thf  ihlrd  nem.  kl.,  posterior 
lonptudiaal  hundlc.  r. ».,  rod  nucleus  (tctcnwoUim). 
nr,  lubKsnUa  oiRn  (locui  nicM«.  /.  ctntinl  pe- 
duncl*. 


204 


DISEASES  OF   THE  BKAIN  PXOPKK. 


lesion  in  the  right  crus  cerebri ;  if,  in  addition,  anesthesia  exists 
on  the  paralyzed  side,  an  implication  ol  the  tegmentum  must  be 
suspected.  Mendel  has  called  attention  to  the  (act  that  patients 
with  tumors  of  the  crura  sometimes  urinate  frequently.  How 
far  this  observation  may  be  taken  as  confirmalory  of  the  view  of 
Budge,  who  holds  that  the  centre  lor  the  secretion  of  uriiie  Is 
situated  in  the  peduncles,  future  studies  will  have  to  teach  us. 
The  pons  Varolii,  which  coimccts  the  two  hemispheres  of 
tbe  cerebellum,  contains,  us  wc  have  said  above,  the  nuclei  for 

several  nerves  and  the  fibres  passinj^ 
from  them  to  the  brain.  The  nuclei, 
which  are  situated  in  the  upper  seg- 
ment, are  those  of  the  fifth,  the  facial, 
and  theabdiicens.  Since  the  pons  natu- 
rally also  contains  the  motor  fibres,  situ- 
ated, as  we  said  above,  in  the  lower  or 
ventral  segment,  while  in  its  dorsal  part 
one  meets  the  sensory  bundles,  pontine 
lesions  may  produce  a  complication  of 
symptoms  as  characteristic  as  those  fol- 
lowing lesions  in  the  crus.  As  we  have 
attempted  to  make  clear  in  Fig.  66.  the 
fibres  of  the  facial  nerve  decussate  higher 
up  than  the  motor  fibres  of  the  pyrami- 
dal tracts.  Keeping  this  fact  in  mind, 
wc  can  easily  understand  that  a  lesion  of 
the  lower  part  of  the  pons  concerns  the 
facial  fibres  after  their  decussation,  the 
fibres  going  to  the  extremities,  howev- 
er, before  they  cross,  and  consequently 
gt%'es  rise  to  a  facial  paralysis  on  the 
side  of  the  lesion,  but  a  paralysis  of  the 
extremities  on  the  opposite  side  (hemi- 
plegia altcrnans)  (Gubler.  1^59).  A  le- 
sion ol  the  upper  part  of  the  pons  con- 
cerns both  of  these  paths  before  (heir 
decussation,  and  produces,  therefore, 
hemiplegia,  with  a  facial  paralysis  of  the  same  side,  which,  how> 
ever,  is  distinguished  from  the  typical  hemiplegia  in  that  the 
facial  paralysis  in  this  case  resembles  somewhat  the  peripheral 
type,  as  it  takes  in  all  three  branches  o(  the  facial,  and  as, 
though  but  rarely,  reaction  of  degeneration  may  be  present. 


FIr.   fi&— DIUCHAU    SHOIVIMO 
■niE  DlCVUWTlUNtir  THE 

Fimiia    001  no    TO   TtiK 

EXTkUMITICX,       USD      Or 

TiiCNa:    ooiHo    to    the 

FaCK,  I*  TIIK  VtlKt  KHU 
llEDULUt  OnLOKIMT*..    F 

fjciol  fihroL  E.  Abn*  pv 
iii(  Id  ilie  (iirtmitlei.  /*, 
pOD*.  tK  mnlulU  oblon- 
fMU.  fyx,  itociUMUaii  of 
the  p7nimld4l  tncti.  a.  ■ 
foou  tn  ilie  vpptf.  A.  ■ 
focus  tn  Uie  lou'cr^  pari  of 
Ibe  pons  (Ui«  loilpt  u  iltu- 
Med  belov  ihc  dniuuilon 
of  th(i  fitaii  fitucti. 


LEStOXS  Of  TUE  CESEBELLUM. 


ao5 


I(,  then,  wc  meet  witli  a  paralysis  which  nfTecis  the  facial 

on  one,  the  Kxtrcmiiics  oti  the  op|>ositc  side  (.altcmaling  paraly- 

|lis),  simultaneously,  wc  are  justitied  in  assuming  the  lesion  to 

situated   in   the  pons,  and  more  especially  in  its  lower  [jart. 

tralysis  first  occurs  in  the  face  alone,  and  ricics  not  develop 
in  the  extremities  until  later,  and  if  the  whole  process  is  grad- 

»ual.  it  may  arise  from  a  itimor  at  the  base  of  the  brain.  If,  be- 
sides the  symptoms  <lescnbcd,  the  patient  complains  of  pain  tn 
liie  (ace,  the  trigeminus  is  included  in  the  lesion.  A  jKiralysis 
ol  the  external  rectus  points  to  the  implication  of  the  abducens 
nerve,  in  which  case  a  paresis  uf  the  internal  rectus  of  the  other 
fjdc  not  rarely  coexists,  so  that  a  conjugate  deviation  of  the 
eyeballs  toward  the  paralyzed  side — that  is,  away  from  the 
lociis^may  occur. 

Bilateral  lesions  of  the  pons  must  be  thought  of  in  com> 
_UMd  paralyses  of  the  extremities   and    cranial    nerves,  or  in 
ul  bilateral  facial  paralysis  or  bilateral  paralysis  of  the 
citmnities  (either  of  both  legs  or  of  all  four  extremities). 

(The  diagnosis,  however,  as  a  rule,  can  not  be  made  with  cer- 
tainty. 
Convulsions  will  be  observed  if  by  acute  lesions  the  spasm 
centre,  as  Nothnagel  calls  it.  becomes  excited.  Tonic  spasms 
ia  tlM  paralyzed  limbs  arc  not  uncommon.  Anarthric  speech 
dltiurbances  in  bilateral  affections  of  the  pons  have  been  noted 
b;  Marlcowski  (Inaugural  Dissertation,  Dorpat.  1890).  Psychi- 
til  changes,  which  occur  in  connection  with  lesions  in  the  pons, 
•w  very  irregular  in  their  <jccurrcncc,  and  assume  the  most 
L  divmificd  lorms.  They  deserve  a  more  careful  study  than  has 
H  U  ret  been  devoted  to  Ihem.  Their  entire  absence  has  been 
~  nfpMtcdly  noted.  Ana-sthi-sias  in  the  distribution  of  the  tri- 
^  icminu),  as  well  as  in  the  extremities,  are  comparatively  fre- 
B  9iKnt.  but  we  arc  not  at  present  able  to  utilize  them  for  the 
~    purpose  t»l  topical  diagmwis. 

To  enable  us  to  |M>int  with  certainly  to  the  cerebellum  as 
ibeMat  of  disease,  the  implication  of  the  venniform  process  is 
occcssary,  since,  as  Xolhnagel  has  pointed  out.  we  may  have 

tnieanivc  disease  in  the  hemispheres  without  the  mnnilestaiion 
of  a  ftingfe  symptom  during  life.  In  the  cases,  however,  in 
irbtch  the  vermiform  proiT&s  is  alTecied,  marked  disturbances 
of  c<»-ordination  and  equilibrium  ensue;  the  patient  staggers 
and  complains  of  severe  vertigo  on  walking  and  standing, 
Thb  U  almost  a  pathognomonic  symptom,  especially  if  it  be  as- 


MSEASSS  OF   THE  BRAIN  PHOPEK. 


socialcd  with  occasional  spells  of  more  or  less  serious  vomiting. 
Since,  however,  cerebellar  ataxia  may  be  absent  in  tumors  of 
the  vermiform  process  (Eisenlohr),  we  are  not  surprised  that  it 
is  often  very  diBiciilt  to  make  a  diagnosis. 

Lesions  of  the  middle  peduncles  of  the  cerebellum  produce 
highly  characteristic  symptoms,  so  that  a  diagnosis  can  be 
made  with  a  fair  amount  of  certainty.  The  body  is  involun< 
tarily  gyrated  around  its  longitudinal  axis  ("forced  movement"). 
This  symptom,  however,  can  only  be  observed  as  a  consequence 
of  irritation  of  the  peduncles,  but  is  absent  if  the  latter  are 
wholly  destroyed — c.  g.,  by  hemorrhage.  Sometimes  the  pa- 
tient li.is  an  irresistible  inclination  to  lie  on  one  side,  and  this 
is,  if  the  remaining  symptoms  point  in  the  same  direction,  also 
to  be  estimated  as  a  forced  movement,  or  rather  a  ■•  forced  posi- 
tion." It  is  not  uncommonly  accompanied  by  a  corresponding 
twist  of  the  head  and  eyeballs.  'I'his  phenomenon,  however,  is 
not  a  pathognomonic  symptom  for  lesions  of  the  middle  pe- 
duncles. The  direction  in  which  the  body  is  turned  is  some- 
times toward  the  diseased  side,  sometimes  away  from  it,  a  fact 
for  which  no  explanation  has  as  yel  been  found. 

For  lesions  of  the  other  peduncles  of  the  cerebellum  (the 
Superior  and  inferior)  no  diagnostic  points  are  known. 

The  loweat  part  of  the  ence|)haIon  is  called  the  medulla  oblon- 
gata. It  becomes  continuous  below  with  the  spinal  cord  on  a  level 
with  the  lower  margin  of  the  foramen  magnum.  On  its  anterior 
(lower,  ventral)  aspect  we  observe  the  pyramidii  with  their  decusM- 
tion,  and  the  olives,  while  to  the  outer  side  of  these  arc  to  be  found 
the  restiform  bodies,  the  inferior  peduncles  of  the  ceccbcUum.  The 
last  contain  the  so-called  direct  cerebellar  tracts,  which,  coming  from 
the  outermost  portion  of  the  lateral  columns  in  the  cord,  pass,  through 
the  anterior  commissure  of  the  vermiform  process,  to  the  cortex  of 
the  ccTcbcllum.  That  a  relation  exists  between  the  olives  and  the 
cerebellum  is  apparent  from  the  fact  that  wherever  we  have  a  con- 
genital atrophy  of  the  cerebellum  these  bodies  are  also  atrophic 
(Ftech«ig), 

On  the  posterior  (dorsal,  upper)  aspect  is  the  floor  of  the  fourth 
ventricle,  the  fovea  rhomboidalis  (Fig.  6;).  which  is  bounded  below 
by  the  diverginjt  restiform  bodies,  above  by  the  diverging  superior 
peduncles  of  the  cerebellum.  The  median  columni  are  called  the 
posterior  pyramids  (funiculi  graciles),  They  are  the  continuations 
of  GoU's  columns  of  the  spinal  cord.  To  the  tracts  situated  to  the 
outer  side  of  these  the  name  funiculi  cuneati,  or  Burdacb's  columns* 
has  been  given. 


THE   MEDULl^   ORLOXGATA, 


207 


To  diagtiosticale  the  medulla  oblongata  as  the  seat  of  a 

sion  is  only  possible  if  the  nuclei  in  the  floor  of  the  fourth 

Ventricle  are  diM^ased.  in  wbich  case  we  get  the  clinical  picture 

[ol  bulbar  paralyMii.    Other  characteristic  symptoms  do  not 

[ciiu,  and  more  especially  it  must  not  be  forgotten  that  foci  in 


ht^— TiKCoMntCnOM  OPIllECrHLUt  l.l.l.'M  -witlx.  th*  mMbr&Tn  (■upnnnriwdun' 
iln).  5:  '.  Iht  pooa  (niditlc  ptdunciMl.  7:  c.  (he  mnJutU  obluiiipiu  (inlniiit  pHlun- 
dB  or  raMlIonB  ImiUmj.  \  i,  founh  vcniricla.  >,  »i\w  wuMiu.  1,  luiiiculi  (rmdln. 
%  klDOnciB.    R^  CDtporaquwIHip-miiiA. 

iV  RieHuIln  may  give  rise  lo  a  paralysis  only  in  the  extremities, 
•hich  presents  nothing  characteristic  during  life.  If,  however, 
(lie  nerve  nuclei  of  the  medulla  are  implicated,  a  characteristic 
picture  is  presented  which  can  hardly  be  mistaken.  Another 
putotol  which,  in  making  our  topical  diagnosis,  we  must  not 
W  sight,  is  the  (act  that  certain  brain  lesions  may  give  rise 
loasimiUr  combination  of  symptoms  constituting  the  clinical 
^ure  of  the  disease  which  wc  have  described  above  as 
pKudo-bulbar  paralysis.  Other  diseases  of  the  meduli:i — trau- 
Hutism,  acute  and  gradual  compression.  hEemorrhage,  and  cm> 
ooliwn — arc  of  no  prjictical  significance,  since  Ihey  cause  death 
'''quickly  that  a  certain  diagnosis  is  impossible.  Hence  wc 
•fflpass  them  over  without  further  remark. 

LITERATURE. 

OfHi   Tkalamm. 

Die  Bedeulung  der  Sebhiii[cl  auf  (inind  von  expcrimcnlcIlcD  un<l 
puholoKlwhcn  Ditlni,     Virchow's  Archtv,  1887,  ex,  Krft  3,  p.  333. 
K)ihrw.    Zur  CjuuUlik  ikr  SeKhugelaJliecUonen.     Med.  ObMienije.  1891.4. 


208 


I>/S£ASSS  OF  THE  BKAfN  PSOPHH. 


1 


(Russiiin.    Tuinor  in  iht  LcK  Thalamus,  with  Loss  of  the  MorcmflnU  f< 
Facial  Expression  in  ihc  Op|)osite  Side  of  ihe  Face) 
Eisenluhr.     Deul.ichc  Zdlschr.  (.  Ncrvcnlik.,  r893.  iii,  4.  5- 

Cmra  Orriri. 
Brivuiid.    Dtgtncralions  secondaim  dan6  Ic  P&loncuk  cMbral.   PublkatioM 

do  I'rogcis  mid.,  1879. 
TorioijcwkId.       Zur    I'alhologie    des    Gruuhtmschcnkcb.       Inau{[.>Di«Mrl.i 

Brcstau.  iSiti.  i 

Schtadcr.      Kin  Cirasshirnschenkdhcrd   mit    sccunilKrrn   Dcgencntionen  d4 

lYramidc  und  Haubc.     Iiiaug.-Dissen.,  Halle,  1884.  • 

Lrubc.     Dcuischcs  Arch.  f.  klin.  Med..  1887.  xl,  i.  p.  370. 
Buschke.     7.Mt  CuiiiMik  der  ]1erdcrkninkung<:n  det  Himichenkeb,     Inaug.- 

Dissert.,  llertin.  189!. 
Bannister.    Jouin.  of  Ncrv.  and  Ment,  Diseases,  i8c)0.  xr,  9. 

Pomi. 
Senator.    Zur  Dlagiuniik  der  HerderkrankungeD  in  der  BfOdcft  and  den  vcM 

ISngcnen  Mariie,    Arch.  f.  I>s)%h.  a.  Nervenhtc.  1883,  xlv.  3,  pp,643<r«fii 
Bleuler.    Zur  Ca^uisiik  der  Hrtdcrkinnkungen  der  Bnicke.     lnau|{.-Di!uert.| 

Leipiis-  1885. 
Mcyw.     Beiirag  *ur  Lchrc  der  Degentrationen  der  Schleifc,     Arch.  f.  pRjrch,  tt 

Nervenhk..  1886,  xvii,  a,  pp.  439  et  stg.  ' 

Markowski.    An-b,  f.  fsycli.  u  Nervciilik..  1891,  xxiii.  a. 
Delbanco.     BcliTJIgc  tur  Kyrnptnm.tiologie  und  Diagniwtik  der  Gochwiilste  dea 

Pons  Varolii.     Inau^.- Dissert..  Uerlin,  1891. 
Poncr.     Hrit.  Med.  Joutn,.  April  18,  1891. 
Btui^ch.    Zur  Ciuui-ttik  der  poniilcn  Hcrderkraiikungen.      Neurol.  CenlralbU 

1 891,  I. 
DiDcr  (Pittsburg),     Amcr.  Jouni.  of  ihc  Med.  Sciences,  November.  1891. 
Moeli  und  Miirincsco.     Arch.  f.  p»jch.,  1891,  ww.  3. 
Kolisch.     Wiener  klin.  Woclienachr.  1893,  14. 
Siarr.     New  ^'ork  Med.  Record,  February  6.  r893.  xliiL 

CnrWUum. 

KrauKt     ITelicr  TuI)crkclknoten  des  Cerebellum.     Innug.-Dtuert..  Bcriin.  r888/ 
Bposler,  Frank  C.     Abscess  of  the  Cerebellum  following  .Suppurative  Otili^ 

Media.     Philadelphia  Med.  Times.  August  I.  rllSS. 
Gowen.    Lancet.  18901 1,  18,  p.  9SS,     (Functions  of  the  Ceiebellum.) 
BOhm,     Ueber  cerebri lare  Atanle  nebst  elnem  caauistisclien  lieiirag«  nir  Lchn 

von  den  Kleinliimgcschwiilsicn.     In.iug.-Disserl.,  Strassburg,  t89f.  I 

Cramer.     Ueiintgc  xur  palhologi^chen  Aivaiomle  und  atlgemrincn  l'atha1ogl& 

Jena,  1891.  xi.  I.     (UniUteral  Ain^hy  of  ihc  Cerebellum.) 
Luciani.     I)a»  Klein  him,     Leip^i);.  liesuld,  1893. 

Spilxka.    Deiitadie  med.  Wnclien»chr..  1S87,  S,  p.  157.     (Focal  I.eslcir»  at  tbei 

I^vel  ol  the  Traniiilan  from  the  Pons  10  the  Medulla  ObloncJiia.) 
Goldberg,  Lud«ig.    Tumoren  der  Oblongata.     I naug.- Dissert,.  Jena.  1889. 


PATHOLOGfCAi.   lit  AC  If  OS/ S. 


«9 


11.  TiiE  Study  of  Cbrebrai.  Lesions  with  Reff.rence  to 

THEIK    PaTIIOI.OUICAL   NaTURE. 

Pathological  Diagnosis.— We  )iavc  before  pointed  out  tliat 
ith«  qtiestion  as  to  the  nature  of  a  bnitn  disease  is  not  only  of 
ffnterest  to  tlie  physician,  but  of  the  greatest  importance  to  the 
:  patient,  as  on  this  the  prognosis  as  well  as  the  mode  of  treatment 
rlums.     An  error  in  the  topical  diagnosis  may  deserve  the  cen- 
JMIe  of  scientific  criticism,  but  does  not  necessarily  entail  dam- 
age to  the  patient.    If,  on  the  other  hand,  we  mistake  the  nature 
of  the  lesion  in  a  given  case — if,  for  instance,  a  disease  of  the  vcs- 
»els  is  taken  for  a  new  growth,  if  the  tuberculous  or  syphilitic 
DMurc  of  the  aScction  is  overlooked,  nr,  again,  a  severe  alcoholic 
intoxication  is  diagnosticated  where  in  reality  an  apoplexy  exists 
—when  such  errors  have  intluenced  the  treatment,  not  only  op- 
jionunitics  may  be  lost  tor  the  patient  which  may  never  present 
themselves  again,  but  an  unfavorable  event  of  the  disease  may 
Kiually  be  brought  about  or  at  least  precipitated.     On  these 
gniunds  we  ought  to  be  particularly  careful  and  conscientious 
In  forming  this  part  of  our  diagnosis,  and  no  symptom,  how. 
"er  small  it  may  seem,  should  he  overlooked,  as  we  never  know 
^  that  it  may  later  perhaps  become  of  diagnostic  value. 

In  looking  over  the  several  pathological  processes  which  \\qtc 

Wncera  us,  we  find  that  their  number  is  comparatively  limited. 

F'm  ol  all.  we  shall  devote  our  attention  to  diseases  of  ihe  blood- 

'*McU,  which  so  frequently  arc  the  cause  of  cerebral  lesions. 

"c  )h.ill  have  to  determine  the  nature  of  these  diseases,  and 

orclully  distinguish  the  affections  of  the  blood-vessels  from  the 

'^Cfiodary  changes  produced  by  them.    The  clinical  symptoms, 

the  complaints  of  the  patient,  and   the  objective  signs  are  a 

"Ji^a  consequence  ol  tlie  latter  only,  and  it  is  therefore  not  the 

"'sewcof  the  blood-vessels  which  we  have  practically  to  deal 

*"h,  but  the  changes  in  the  brain  substance  which  they  entail. 

'^nc clinical  manifestations  vary  according  to  the  seat  of  the  dis- 

*•*<!  vessel  and  the  portion  ol  the  brain  supplied  by  it.     The 

*/«iIUoms  we  shall  describe  in  detail  later;  but  first  lei  us  si>eak 

"  'ht  pathological  nature  of  the  diseases  of  the  cerebral  vessels. 

•"ttrrlrt-es   nr   THE    nR.MX    hue   T"    disease  of  THE   BI.OOD-VESsr.l-S. 

^  Diseases  of  the  Cerebral  Vessels  and  their  Conse- 
^tlciKcS. — The  arteries  of  the  brain  ace  derived  from  the  internal 
^'fiiili  and   the   tusilar,  which  is  formed   by  the  two  vcttcbrals. 


2IO 


DISEASES  OF   THE  BRAIN  PROPER, 


The  internal  carotid  gives  off  two  terminal  branches,  the  anterior 
cerebral  (arter.  corpor.  callos.)  and  the  middle  cerebral  (arter.  foss. 
Sylv.).  The  basilar  divides  into  the  two  posterior  cerebrals  (arter. 
profund.  cerebri).  These  receive  on  each  side  a  communicating 
branch  from  the  internal  carotid,  the  so-called  posterior  communi- 
cating artery,  while  the  two  anterior  cerebrals  are  connected  by  an 
anterior  communicating  branch,  so  that  a  closed  circle  (or  rather  a 
heptagon,  according  to  Hyrtl)  of  arteries  is  formed,  known  as  the 
circle  of  Willis,  an  arrangement  which  is  of  the  last  importance  for 
the  distribution  of  the  blood  in  the  brain  (cf.  Fig.  68). 


Fig.  6(1. — DiAGMAH  SHOWING  THE  CIRCLE  OF  WiLLis.  The  carotids  with  the  anterior  and 
middle  cerebral  arteries  and  the  baaibr  with  Ibe  posterior  ctrebi^  are  connected  b)^ 
communicating  branches. 


The  fact  that  the  left  carotid  comes  off  from  the  aorta  nearly  in 
a  straight  line  with  the  blood-current  in  the  arch,  while  the  innomi- 
nate, which  gives  off  the  right  carotid,  leaves  the  aorta  almost  at 
right  angles,  easily  explains  the  greater  frequency  of  embolism  on 
the  left  side.  A  somewhat  similar  condition  exists  in  the  vertebral^, 
where  the  left,  often  the  larger  one,  arises  from  the  subclavian  at  its 
highest  point.  Thi.i  is,  however,  of  less  moment  for  cerebral  lesions, 
as  the  blood  has  first  to  pass  the  basilar  before  entering  the  brain 
substance. 


TtlF.   CEKhHKAl.    rSSSXiS. 


311 


Of  Ibe  three;  be fofc- mentioned  arteries— the  anterior,  middle,  and 

JpOKtenor  cerebrals — each  one  supplies  lw<i  sets  of  vessels  totally  dis.. 

jlinct  from  each  other — namely,  first,  the  so-called  cortical  arteries; 

second,  the  arteries  of  the  basal  ganglia.     The  imjiorlanl  dillerence 

between  these  two  tiystemt;  consists  in  the  fact  that  the  former,  a» 

Heiibner  and  Durct  have  shown,  p»<«e«K  anastntmises, uhile  the  latter 

are,  as  they  have  been  called  by  f'ohnheim,  terminal  arteries — that  is, 

■ihcy  do  not  communicate  with  each  other,  but  pa&s  directly  into  the 

H'«Api Maries.    The  signihcancc  of  such  an  arrangement  is  apparent,  and 

^wt  Nhall  not  be  surprised  to  hnd  that  occUiMnn  of  an  artery  of  the 

second  set  almost  always  produces  death  of  the  parts  Nup[)licd  by  it. 

_        Of  the  three  cerebral  arteries,  the  middle,  the  Sylvian  artery,  has 

Bby  far  the  widest  distribution  and  is  the  most  important ;  for  while 

Ihe  anterior  supplies  the  corpus  callosuni.  the  gyrus  rectus,  the  para- 

, central  lobule,  and  the  precuneus;  the  posterior,  the  crus,  the  tcm- 

}ral,  and  the  occipital  lobe,  and  the  cuneits  sending  also  a  few 


I 


I— The  CoRtiCAL  nivrKiKrTi"!i  wr  tiii  Uidciu:  CHunuL  Auriritv.    •Mut 

HAWMT.)  From  left  tu  HeIiI  the  fire  branche*  ate  nuiwd  u  lollcm;  The  Inferior 
(rooul  bnadi  la  Breca'i  (unToluiiun,  ihp  ucendlOK  ttontkl  brandi.  ib«  aRandint;  parie- 
lal  bnacti,  Itw  panrto-iphRiaidal,  wid  Uk  ipbenorftUl  bnsdMa. 

branches  to  the  optic  thalamus  {arter.  optic.  po«lertor,),  it  remain*  for 
Ihe  middle  cerebral  to  supply  the  whole  lenticular  and  the  caudate 
nucleus,  and,  above  all,  the  internal  capsule.  Moreover,  the  central 
and  cortical  motor  region,  the  cortical  areas  concerned  in  the  process 
of  speech  (on  the  left  side),  the  cortical  centre  for  hearing,  probably 
tiso  for  vision,  depend  on  this  artery  for  their  nutrition. 

Its  cortical  distribution,  its  subdivixion  into  the  frontal,  parietal, 
parieto-sphenoidal,  and  sphenoidal  arteries,  is  made  clear  by  Fig.  69. 


312 


D/SX4^S  OF  THE  BKAIN  PKOPE/t. 


Its  distribution  to  the  lenticular  nueleuH  is  illustrated  in  Fig.  70. 
The  internal  artery  of  the  corpus  striatum,  also  called  the  tenticolar 
artery,  goes  to  the  first  and  second  segment  of  the  lenticular  nucleus, 
while  the  external  hritnchcs  are  the  so-called  Icnticulo-striate  and 
lenticuto-optic  arteries.  Among  the  former,  the  one  which  supplies 
the  third  segment  of  the  lenticular  nucleus,  the  upper  portion  of  the 
internal  capsule,  and  the  caudate  nucleus  deserves  special  mention. 
It  is  so  frequently  the  seat  of  hioinorrhage  that  Charcot  has  called  it 
"farlir*  de  rh/merrJutik  (/r^raU."     Mendel  has  attempted  to  show 


f\g.  7a.~Vua-irtM.  Si»7nu!c  TiinnL-XMr  TUB  Ckrimiai.  IICHiiinii>«K«,  Ohk  Cimtimk- 
Tiu  uKiiiKD  Tiic  CuusH.  Slhonri  ihB dkBrfbulbw  of  tbe  middle  onliiml  may  In  the 
knikulBT  omcleiu. 


eiperimentally  the  physical  reasons  why  ruptures  are  es|)ectally  prone 
to  occur  at  this  place  {Berliner  klin.  Wochcnschr.,  1891,  14).  The  ac- 
count of  these  experiments  and  the  discussion  which  followed  their 
presentation  at  the  llcrlin  Medical  Society,  in  the  session  of  May  37. 
1S97.  are  well  worth  reading  (IJeuti-che  Med.-Ze:tg.,  1891.  46). 

The  'tween-hrain  and  the  mid-brain  are  mostly  supplied  by  the 
posterior  communicating  and  its  branches,  the  cerebellum  by  several 
so-called  cerebellar  branches  (arlcr.  ccrcbcll.  super,  et  infer.)  coming 
from  the  vertebrals ;  the  pons  and  medulla  oblongata  altto  by  branches 
of  the  vertebrals,  which  arc  the  so-called  rami  iid  pontein  and  rami 
ad  medullam  obtungatam. 

The  internal  carotid  and  the  basilar  measure  4  mm.  in  diameter;  the 
vertebrals.  3.5  mm.(l.uHchka).  The  blood  pressure  in  thccarotid  is  gen- 
erally taken  to  correspond  tu  from  140  to  ibo  mm.  Hg.  How  guarded, 
however,  we  ought  to  be  in  accepting  such  siaicmcnts  has  been  shown 
by  Loewcnfcld.  who  drew  attention  to  t  lie  variations  in  the  development 
of  the  cerebral  arteries;  and  it  seems  at  least  possible  that  this  itt  of 
considerable  aitiologicul  significance  for  different  cerebral  affections. 


I 


CEREHKAL   UjKMOKItMACE. 


213 


LITERATURK. 

Opclb  c  BruKia.  Arch,  di  ptichi.itria,  science  penalc.  etc.,  16S6,  Fmc.  i.  lOn 
ibe  Action  of  Certain  Dru(^  upon  the  Cerebral  Ciicululiun.) 

LoewmfHd.     Arch.  f.  Ps>'ch.  u,  Nervenkr.iiikh..  1687,  xviir.  j. 

HdccL    Vircbow'i  Arcli..  1890,  cxix.  licit  i. 

GdgeL     Die  Mcctunik  dcr  BlulvrtMir);uii^  (le«  Hirns,  Stult);3rl,  Knkc.  1890, 

Lcwy.  Die  Krgutiiung  dci  Illiiibcwcgung  im  Him.  Virchow't  Anb.,  1S901 
cxxii.  I,  I. 

Mrndd.     Ncurolug.  CenlFalbl..  1891, 14. 

KolUka.     Ibi<l..  1891.  16.     (On  ihc  IKood  Supply  ofthc  Brairt.) 

(icuhey.  F.xp«rimrn telle  Dcilrilgi?  xmx  Lchrc  von  der  lilutcirculaticn  in  Act 
SchSdcl-Kuckgtat Collie.     Fesisthrift,  Miinchen.  189!. 


1.  Certbral  Htemorrhage,  Hamorrhagia  Cer^ri  {Periartrriiiis 

Ctrtbraiis,  Miliary  Aneurisms  of  ihe  Cerebral  Arltries'). 

Pathological  Anatomy  and  ^^.liology. 

Of  alt  cerebr.1l  aCTcciiuns,  hemorrhage,  the  result  ol  the 
nipturc  of  a  vcti^cl,  is  by  far  the  most  important  and  the  most 
(requent.  As  we  should  expect,  haemorrhages  of  various  kinds 
Bay  be  produced  by  traumatism  (itijurv  to  Ihc  skull,  with  or 
■ithout  fracture).    They  may  occur  between  the  inner  side  ol 


'  Ti.~-CKit[iiajtL  Asrear  y\uym  ah  Aiiiruxmc  Foci,-*,    ma,  luituif  anmriim.    Ut, 
**>nnMlkiiuo(bkaJiMlutk(iul*eiitillalljm|>hi|M(«.    (An«t  COH.11L  anil  k^milit.) 

^c  sl(u|]  and  the  loosened  dura  mater,  or  in  the  sac  of  the  dura 
*"  that  of  the  pia  (submeningeal  haemorrhage);  but,  disregard- 
■"6  these,  there  is  one  affection  especially  which  gives  rise  to 
nrcbral  haemorrhage — namely,  a  diffuse  periarteriitis — which 


214 


DISEASES  OF   THE  BffAW  PJIOPEK. 


Fie-    7a.— MiuARV    AoRUitiaii    op    A    Skau 
AnrcRv  or  tiii;   t.KXTicuukK   Nucleus 


wns  first  described  by  Charcot  and  Buuchard  in  1868.  In  this 
process  a  ttiickenini;  uf  the  lymph-sheaths  and  subsequent 
changes  in  the  muM:iilans  take  place,  by  which  the  formation  of 
miliary  aneurisms  is  favored  (cf.  Figs.  71  and  72.)     Rupture  of 

these  aneurisms  then  gives 
rise  to  h.-emorrhages,  and 
so  frequently  is  this  the 
case  that  the  authors  be- 
fore mentioned  found  this 
condition  in  Kvery  one  of 
seventy  ■ seven  consecutive 
cases  which  came  under 
their  observation. 
For  the  rupture  of  these  aneurisms  it  is  by  no  means  always 
necessary  to  have  any  extraordinary  exciting  cause,  such  as  aii 
elevation  of  the  blood  pressure,  which  may  temporarily  be  pro- 
duced by  bodily  exertion,  sneezing,  coughing,  vomiting,  and  the 
like,  or  which  may  permanently  exist  where  the  heart  is  hyper- 
trophied,  as  in  valvular  disease  or  in  cases  of  contracted  kid- 
ney. In  many  of  the  instances  nothing  of  the  kind  can  be 
demonstrated. 

The  size  of  the  aneurisms  varies  from  0.3  to  I  mm. :  their 
color  and  consistence  often  differ  grc.illy.  Their  favorite  scat 
is  in  the  thalamus,  the  corpus  striatum,  the  convolutions,  and 
the  pons,  while  they  arc  less  frequently  met  with  in  the  cen- 
trum ovale,  the  crura,  and  the  medulla  oblongata.  Sometimes 
only  two  or  three,  at  other  times  as  many  as  several  hundred, 
have  been  detected  in  one  brain.  On  being  squeezed  they  arc 
found  to  contain  white  corpuscles,  fat  droplets,  and  amorphous 
granular  masses. 

The  haemorrhage  which  is  produced  by  their  rupture  con- 
sists when  fresh  of  a  dark-colored  I()Ose  coagulum.  The  wall 
of  the  "focus"  is  red  and  spotted  with  punciiform  haemor- 
rhages (capillary  apoplexies),  and  presents  a  ragged  and  torrm. 
appearance.  (>radua11y  the  dark  color  becomes  lighter,  ih) 
neighboring  parts  are  infiltrated,  yellowish,  and  very  sof 
flemon-colored  uedema).  As  a  rule,  the  locus  is  later  en- 
capsuled  by  a  layer  of  neuroglia,  the  fibrin  masses  become 
mixed  with  the  d^br'ti  of  the  nerve  elements,  and  we  get  £ 
smooth-walled  cavity  with  liquid  contents,  the  so-called  apo^ 
pleclic  cyst,  occupying  a  smaller  space  than  the  origina 
hemorrhage.     If   the   walls  approach  each  other  before  ih 


AirtOl.OCY  OF  CKKEHRAL   UMMORRHAGE. 


3IS 


!um  is  Iransformcd.  a  great  increase  oi  fibrillated  con- 
nective tissue  takes  place  and    we  get  a  si^called   apoplectic 
r. 

The  cflect  of  the  hiemorrhage  varies  according  to  its  post- 
iJcm.  according  to  the  calibre  ol  the  ruptured  vessel,  upon 
lich  depends  its  amoiinl.  and  according  to  the  rapidity  or 
iwness  with  which  the  blood  escapes.  The  favorite  scat  for 
hxmorrhugcs  is  in  the  large  ganglia  (Charcot.  Andral,  Ro- 
choux):  with  decreasing  frequency  thej'  are  found  (Noth- 
oiigcl)  in  the  rcmaitiing  portions  of  the  cerebral  hemispheres, 
much  more  rarely  iti  the  pons  and  the  ccrcbelhim.  The  fre- 
quency is  directly  influenced  by  the  size  of  the  different  cere- 
bral  vessels  and  by  the  blood  pressure.  The  dianicicr  of  the 
vessels  of  the  brain  stem  is  considerably  larger  than  that  of 
tbofce  going  to  the  cortex.  The  above-mentioned  ''  artery  of 
ecrcbnil  hemorrhage"  is  of  an  especially  large  calibre  (i'/, 
mm.t.  and  causes  therefore  when  it  bursts  a  particularly  large 
and  extensive  hemorrhage,  because  the  bleeding  is  prolonged. 
"  The  Iniumulic  effect  ol  the  ha;morrhage,"  as  Wernicke  calls 
it.  is  equal  to  the  product  of  the  mass  of  effused  blood  into  the 
square  of  the  rapidity  with  which  it  is  poured  out.  which  latter 
depends  directly  upon  the  blood  pressure  in  the  vessels. 
I  loice  it  follttws  that,  as  regards  the  effect  of  a  haimorrhage, 
titc  blood  pressure  is  of  more  importance  than  the  calibre  of 
*  he  vessel. 

£tiology. — In  examining  into  the  etiological  factors  con- 
C'crncd  in  a  cerebral  ha-morrhage,  we  must  distinguish  those 
^^liich  produce  the  disease  of  the  vessels  from  those  which 
*^4ttcily  cause  the  hemorrhage :  in  other  words,  the  pre<lis- 
F*Qsii»g  from  the  exciting  causes. 

About  the  former  not  much  ts  known:  nevertheless,  con- 

**^trable  influence  in  the  ciusation  of  arterial  disease  must  be 

■•cribcd  to  age.  as  we  can  not  deny  that  it  is  decidedly  less 

'■"^uently  to  be  observed  in  the  young  than  in  older  persons, 

**»d  that  the  sm:illest  percentage  of  apoplexies  is  found  between 

'H«6(ih  and  thirtieth  years  of  life.     Still,  to  lay  so  very  much 

**»wi  Upon  the  signltiaince  of  age  is  not  warranted  by  experi- 

^'•cp.    The  fact  that  cerebral  haemorrhage  is  by  no  means  rare 

'•*   people  fn>m   twenty  to  thirty  years'old  clearly  shows  that 

'•»»!i;uy  aneurisms  may  occur  even  at  a  comparatively  early 

Period  of   life :  nor  are  these  c.nse<i  by  anv  means  always  those 

^  pcrions  laboring  under  hereditary  disadvantages,  since  even 


3l6 


D/SEMS£S  OF   THE  BRAIK  PXOPEJt. 


members  of  perfectly  healthy  families,  while  still  young,  may 
(all  victims  to  a  stroke  of  apoplexy.  The  influence  of  heredity 
as  well  as  that  of  age  has  undoubtedly  been  overrated  in  this 
connection.  It  is  true  there  are  families  in  which  apoplexy 
seems  to  be  a  natural  occurrence,  but  such  instances  arc  excep- 
tional, while  on  the  other  hand  the  arterial  disease  develops  in 
an  infinitely  larger  proportion  of  cases  apparently  without 
special  hereditary  cause-  Sometimes  the  development  o(  the 
disease  seems  to  be  favored  by  a  peculiar  "habitiis"  Thus, 
corpulent  individuals  o(  medium  height,  with  short  neclcs, 
bro.id  tharaces.  who  on  the  least  exertion  or  excitement  become 
purple  in  the  lace,  have  usually  been  looked  upon  as  particu- 
lady  predisposed  to  apoplexy,  and  in  many  cases  with  justice; 
yet  those  who  have  in  an  extensive  practice  seen  how  oltcn  tall, 
spare  individuals  with  narrow  chests  die  from  cerebral  hemor- 
rhage, will  readily  give  up  the  idea  that  an  apoplectic  habitus 
is  a  eondilio  sine  quS  non. 

The  r6U  which  sex  plays  can  not  be  denied.  The  disease  is 
much  more  frequently  observed  in  males  than  in  females,  while 
with  embolism,  as  we  shall  see,  the  reverse  is  true.  To  explain 
this  predisposition  in  males,  other  factors — namely,  the  mode  of 
life — must.  I  think,  be  taken  into  account,  and  here  it  is,  in  the 
first  place,  the  occupation,  and,  secondly,  the  abuse  ol  alcohol, 
which  roust  be  considered.  Notwithstanding  Ihc  fact  that  wc 
know  very  little  about  the  Influence  of  occupation  on  the  for- 
mation of  miliary  aneurisms  our  statistics  of  fatal  cases  of  cere- 
bral harmorrhage  in  the  different  trades  being  somewhat  unre- 
liable, still  we  have  some  sure  grounds,  the  correctness  of 
which  can  scarcely  be  called  in  i^ucstion.  That,  for  instance, 
the  working  in  certain  poisons,  especially  in  lead,  predisposes 
to  arterial  disease,  and  consequently  to  apoplexy,  is  indisputa- 
ble. In  his  thesis  on  enccphalopalhia  and  arthralgia  saturnina, 
prepared  under  my  auspices,  Schuiz  (Urcslau,  1885)  points  out 
the  frequency  of  the  so-called  hemiplegia  saturnina,  and  calls 
attention  to  the  fact  that  Bcrgcr  has  made  similar  observations. 
In  the  second  place,  those  who  are  exposed  to  radiating  heal — 
workers  at  furnaces,  pud  die  rs — arc  in  danger,  especially  if  their 
work  is  connected  with  much  bodily  exertion,  and  this  can 
hardly  surprise  us  if  we  remember  how  much  circulatory  dis- 
turbances are  favored  by  such  circumstances.  The  same  may 
be  said  of  occupations  which  necessitate  uncomfortable  posi- 
Lions  of  the  body,  as.  for  instance,  is  the  case  in  agate  polishers. 


.ar/oiocy  OF  cekebkal  hm.uokhiiage. 


217 


I 


I 


who  constantly  have  to  lie  on  their  abdomens,  or  in  coal  miners, 
who  bave  to  remain  in  a  stooping  position  all  the  tim«. 

In  regard  to  the  abuse  of  alcohol  we  refer  not  only  to  the 
confirmed  drunlcardi^,  but  much  rather  to  that  class  of  indi- 
viduals who  habitually  consume  more  alcohol,  especially  beer, 
ihan  is  good  for  them.  Such  men  rarely,  if  ever,  get  drunk, 
but  they  drink  several  limes  a  day  one  or  twoglasses  of  beer, 
do  not  take  enough  exercise,  and  become  fat  and  predisposed 
to  fatty  heart  and  arterial  disease,  especially  artcrio-scterosis, 
which  uQection,  \vc  may  say  finally,  is  the  real  cause  of  the 
greater  frequency  with  which  apoplexy  is  met  with  in  men 
ihan  in  women.  The  fatty  heart  may  be  present  even  without 
iny  marked  obesity. 

The  important  influence  of  syphilis  in  the  origin  of  cerebral 

itxiDorrhage  is  proved  by  many  irrefutable  observations,  and, 

ODKidering  the  part  played  by  it  in  disease  of  the  cerebral 

vessels,  this  can  easily  be  explained.     We  shall   mention   it 

igiin  in  this  chapter,  and  later  dwell  more  particularly  on  the 

lymptoms  peculiar  tothesyphtliiic  hemiplegia.    Exceptionally, 

lumiplegta  occurs  after  diphtheria,  sometimes  in  conjunction 

■Uh  a  paralysis  of  the  palate,  sometimes  independently.     In  a 

girloged  fifteen  under  my  care,  hemiplegia  developed  fourteen 

days  after  diphtheria  without  any  simultaneous  disturbance  of 

coucjousncss,  and  only  slight  improvement  was  noticed  after 

Kvtral  years  (cf.  also  Seifert.  Neurolog.  Centralblatt,  1893,4). 

Villi  equal  rarity   is  this  complicating  sequela  found  after 

<tlKr  acute  diseases — tor  instance,  scarlatina. 

Sometimes  no  exciting  cause  can  be  demonstrated,  but  if 
Mch  be  observed,  they  are  always  associated  with  a  sudden 
■we  or  less  marked  increase  of  the  blood  pressure.  People 
•Jlli  diseased  cerebral  vessels  are  not  rarely  suddenly  attacked 
lijan  apoplectic  stroke  after  strong  emotion,  hard  bodily  cxcr- 
"Dt,  during  violent  attacks  of  coughing,  sometimes  also  in  a 
^  bath  and  after  a  full  meal.  Christian  (Arch,  de  Neurol., 
"^9^  S3),  and  Hollinger  in  his  monograph  on  late  traumatic 
•poplcxy  (Festschrift  fUr  R.  Vircliow,  1891),  have  pointed  out 
ihat  traumatism  may  also  lead  to  apoplexy. 

How  it  comes  about  that  the  coldest  months  of  the  year 
T*W  the  largest  percentage  of  victims  of  apoplexy,  and  why  it 
■  thil  in  the  twenty-four  hours  there  are  two  periods  with  a 
■uitoum  and  a  minimum  death-rate,  if  such  be  actually  the 
cuccan  not  be  explained.     Such  has,  however,  been  claimed 


2lS 


msEASKS  OF  TItE  BHAlfi  PFOPEtl. 


by  Sormnni,  who  based  his  statements  upon  an  extensive  study 
ol  statistics  (Riv.  clin.,  ser.  2.  i.  12  Diccmbre.  1871).  The  same 
author  is  also  inclined  to  attribute  to  the  barometric  pres- 
sure some  influence  on  the  mortality,  as  in  liis  opinion  sudden 
changes  in  the  weather  materially  increase  the  mortality  from 
apoplexy. 

Symptoms  and  Course—The  rupture  o(  a  tair-sizcd  cere- 
bral vessel  is  always,  no  mailer  what  part  o(  the  brain  is  afiectcd 
fay  it,  attended  with  more  or  less  violent  symptoms. 

Only  in  exceptional  cases  is  it  preceded  by  premonitory 
indications  (pra.'monitorium  apoplccticiim  of  Bocrhaave).  Oc- 
casionally there  are  temporary  sensory  disturbances  in  the 
extremities  of  one  side,  formication,  numbness,  a  feeling  of 
heaviness  in  the  limbs,  pain  in  the  soles  of  the  feet,  certain 
choreiform  movements  in  the  face  and  arms  (hcmichorca  prie- 
hemiplegica,  Raymond),  symptoms  which  indicate  that  thin^ 
arc  not  going  in  their  usual  order.  The  patient  may  also  com- 
plain of  headache  and  a  feeling  of  fullness  in  the  head,  which 
makes  itself  manifest  on  the  least  provocation,  on  the  slightest 
emotion,  or  after  a  small  amount  of  wine  has  been  taken.  Bui 
rarely  enough  arc  such  premonitions  sufficiently  appreciated 
by  the  patient,  and  only  too  often  are  they  incorrectly  inter. 
prctcd  by  the  physician.  Usually  they  are  overlooked,  and  arc 
first  remembered  when  the  catastrophe  is  either  imminent  or 
has  already  taken  place. 

When  the  attack  does  come  on,  the  patient  gradually  or 
suddenly  loses  consciousness,  and  remains  in  (his  condition  for 
a  few  minutes,  hours,  or  even  for  a  day  or  two,  according  to 
the  severity  of  the  "stroke."  The  higher  the  blood  pressure, 
and  the  greater  the  rapidity  with  which  the  blood  escapes,  the 
more  pronounced  and  severe  are  the  general  symptoms,  which 
collectively  are  called  "  apoplectic  stroke  "  (the  "  insuk  "  of  the 
Germans).  The  way  in  which  the  disturbance  of  conscious- 
ncss  comes  on  varies  very  widely  in  diftercnt  cases.  Thus  one 
patient  may  (or  some  hours  before  the  actual  attack  present  a 
peculiar  excitement,  he  is  restless  and  bewildered,  may  even 
have  forgotten  the  ins  and  outs  of  his  own  house,  his  speech  ts 
agitated,  etc. ;  another  patient  may  complain  of  headache  and 
vertigo;  a  third  of  a  feeling  of  hejit  in  his  head  and  of  general 
prostration  ("different  forms  of  delayed  stroke").  All  these 
premonitory  symptoms  which  we  have  described  may,  how- 
ever, be  absent,  and  a  person  apparently  enjoying  the  best  o( 


THE  APOPLECTIC  ATTACK. 


219 


Iwalth  muy  suddenly,  as  if  "struck  by  lightning,"  sink  to  the 
ground  and  lie  there  unconscious  {apcpUxtt  fouiiroyanti). 

If  we  WTK  called  to  such  a  case,  the  luUowin^  ctmdiliuits  will 
present  themselves  to  us  on  our  first  exiiniitiulton  :  The  patient 
Iks  on  his  bed  as  if  asleep;  his  respiration  is  either  quiet  and 
deep  or  loud  and  stertorous ;  he  can  not  be  aroused  in  any  way, 
not  even  by  strong  irritatiun  of  the  skin  (pricking,  tickling) :  his 
eycH  arc  closed,  and  the  pupils,  usually  of  medium  size,  neither 
noch  dilated  nor  much  contracted,  have  lost  their  power  to 
react  With  every  expiration  the  checks  arc  slightly  puScd 
oot,  and  it  is  often  soon  apparent  that  one  corner  ol  the  mouth 
it  lower  than  tlie  other.  The  extremities  arc  relaxed,  and  when 
taiscd  drop  loosely.  The  tendon  reflexes  are  absent  in  severe 
Q5C8,  and  neither  the  cremasteric  nor  the  plantar  reflex  can  be 
ntxained.  The  pulse  is  full,  somewhat  slow  :  the  temperature 
normal,  jKrhaps  slightly  subnorn).tI ;  the  urine  presents  no 
changes,  or  may  contain  a  (race  ol  albumin,  rarely  uf  sugar. 

This  condition  may.  as  we  h.ive  said  before,  last  several 
ninuics,  several  hours,  or  even  one  or  two  days.  It  is  modi> 
M  gradually  according  as  the  hietnorrhage  sooner  or  later 
oooies  to  a  stop  or  continues  without  interruption  until  a  fatal 
result  ensues.  In  the  former  case  the  patient  gradually  begins 
to  react  to  strong  stimuli,  and  may  open  his  eyes  for  a  short 
while.  M-hen  called  loudly  or  when  water  is  thrown  over  him ; 
^  may  give  a  loud  yawn  and  show  some  voluntary  motion 
'4  the  extremities.  Grtidually  consciousness  returns,  and  the 
pUicDt  attempts  to  make  himself  understood  by  gestures  and 
*onl»,  and  in  the  most  favunible  instances,  which  arc,  how- 
ner.  unfortunately  very  rare,  the  physician  can  (eel  assured 
ihjt  everything  has  cleared  up.  that  the  patient  is  again  in  pos- 
WioQ  of  perfect  consciousness,  of  the  power  of  speech,  and  of 
•Wtioo.  In  such  cases  the  "general "  symptoms  have  disap- 
Ptlred  without  leaving  behind  any  of  those  belonging  to  the 
•Mood  class,  namely,  the  so-called  (ocal  symptoms  (Grie- 
•■itr),  and  we  speak  of  a  ■'slioke  without  focal  symptoms." 

Bat  the  bleeding  may  continue,  although  only  under  low 
PQiare.  ind  only  cease  very  gradually ;  then  the  symptoms 
•tac  but  slowly  and  the  recovery  is  only  partial ;  the  patient 
■0  lor  days  in  a  slate  o(  somnolence,  and  repealed  cxatnina- 
lioM  show  (hat  one  comer  o(  the  mouth  is  distinctly  lower 
uiaihc  other,  and  that  the  saliva  dribbles  from  it  involunta^ 
'■y.    II  wc  can.  by  strung  stimuli,  evoke  spontaneous  move- 


220 


n/SHASES  OP  THH  HRAt.S'  PfiOPBR. 


ments,  k  becomes  evident  that  only  one  side  is  moved,  that  only 
one  arm  or  one  leg  is  raised,  while  tlie  other  side  remains  per> 
[ectly  motionless,  and  after  consciousness  is  fully  restored  the 
certainty  is  lorccd  upon  us  that  one  side  of  the  body  is  de- 
prived of  its  power,  or,  as  we  say,  is  p:iralyzed.  This  we  call 
a  "str<ikc  wiih  focal  symptoms."  At  this  stage,  however,  we 
arc  unable  to  decide  whether  the  focal  symptoms  are  the  result 
of  a  dcstruclion  of  nerve  paths  or  centres — in  other  words, 
whether  they  arc  direct  and  therefore  incurable — or  whether 
they  depend  upon  indirect  action,  so  that  the  loss  of  function  is 
only  temporary.  It  [he  latter  be  the  case,  wc  speak  of  "indi- 
rect "  focal  symptoms. 

Again,  the  ha:m(>rrhage  may  not  cease  at  all.  but  conltnue 
with  increasing  blood  pressure;  then  the  patient  remains  un- 
conscious, the  breathing  becomes  irregular  and  more  rapid, 
and  assumes  the  so-called  Chcyne-Stokcs  type,  the  pulse  be- 
comes  more  rapid  and  small  in  volume,  the  face  grows  pale 
and  haggard,  the  saliva  getting  into  the  trachea  produces  the 
well-known  tracheal  rattling,  the  temperature  rises  gradually 
but  noticeably,  and  the  patient  dies  without  having  come  to 
himself,  and  after  a  period  of  unconsciousness  which  may  have 
lasted  many  hours  or  even  several  days  and  nights. 

If,  in  the  course  of  a  "  delayed  stroke,"  the  breathing,  until 
now  quiet  and  regular,  suddenly  gives  place  to  a  rapid,  irregu- 
lar, stertorous  respiration,  and  if  at  the  same  lime  the  partial 
unconsciousness  deepens  into  a  profound  coma,  the  rellexes 
become  lost,  and  tetanic  convulsions  of  the  whole  body  and 
hemicontracture  of  the  paralyzed  side  make  their  appearance, 
then  we  can  assume  that  the  ha;morrhage  has  burst  through 
into  a  ventricle,  and  give  an  absolutely  unfavorable  prognosis, 
because  in  a  few  hours,  more  rarely  in  one  or  two  days,  death 
almost  invariably  follows.  The  haemorrhage  itself  in  such 
cases  is,  as  can  be  demonsinated  at  the  autopsy,  generally  by 
no  means  copious,  but  the  fact  that  it  is  found,  even  if  the 
ependyma  of  the  ventricles  be  thickened  and  hardened,  speaks 
most  clearly  for  the  high  arterial  pressure  under  which  the 
blood  escapes  (Wernicke).  The  bursting  of  the  blood  into  the 
fourth  ventricle  is  the  most  rapidly  fatal,  and  it  is  in  these  eases 
that  we  sometimes  observe  nystagmus. 

The  disturbance  of  consciousness  in  its  many  gradations, 
from  the  slight  vertigo  to  the  deep  coma,  is  the  most  character- 
istic, or  at  least  the  most  important,  symptom  of  an  apoplectic 


APOi'LBCTlC  EQUIfAlBNrS. 


221 


^ 


¥ 


Ic  produced  by  ha;morrhagc.and  it  ought  not  to  be  under- 
rated,  even  if  it  docs  not  become  futly  developed,  but  only 
■mounts  to  a  traiinicnt  .slight  speech  disturbance,  accompanied 
br  a  IccUng  of  faintncss  and  weakness.  There  are  patients  in 
Whom  such  disturbances  occur  several  times  before  the  onset 
"(  a  real  attack.  Such  patients  complain  of  transient  vertigo, 
iligbt  weakness,  and  heaviness  in  one  or  the  other  hand  or 
l»»t :  they  can  at  times  not  find  the  right  word,  the  correct 
txpression,  or  lose  speech  entirely  for  a  short  while.  All  these 
intiicationg  are  premonitions,  not  direct  forerunners  of  the 
tttack,  but  symptoms  which  warn  us.  indicating  that  the  brain 
ii  subject  to  alterations  in  the  blood  pressure,  a  condition  which 
may  lead  to  serious  consequences  if  the  arterial  walls  arc  dis- 
eased ("  apoplectic  equivalents"). 

Complete  absence  of  all  disturbance  of  consciousness  is  a 
rare  exception,  and  can  only  be  found  when  the  blood  escapes 
quilc  slowly,  so  that  the  increased  pressure  rises  only  very 
);railually.  and  to  no  great  degree.  The  patient  then  is  seized 
with  a  sudden  weakness,  purely  physical ;  he  sinks  into  a  chair, 
uid  after  a  few  moments,  during  which  time  there  is  not  the 
^igtitcst  disturbance  oE  consciousness,  he  becomes  aware  of  a 
Kit  oi  difficulty  in  moving  the  extremities  of  one  .side,  which, 
in  the  most  unfavorable  instances,  in  a  short  time  passes  into  a 
genuine  paralysis  of  that  side  (focal  symptoms  without  stroke). 
Here  may  also  be  meniiuned  the  cases  obscr\-ed  by  Romberg. 
Grates,  Andral,  Senator,  and  others,  in  which  after  a  hcmf- 
pkgui  DO  trace  of  hasniorrhage  was  found  at  the  autopsy,  but 
wljra  diffuse  hypcra;mia  of  the  brain  could  be  demonstrated — 
"pteudo-aiioplexy." 

On  the  other  hand,  it  is  not  a  %-cry  unusual  occurrence  that 
ipalieiit  awakening  in  the  morning  after  a  quiet  night's  re«l 
^  himself  paralyzed  on  one  side :  in  such  cases  we  are,  of 
cwrie,  not  able  to  decide  how  much  bis  consciousness  would 
hlTc  been  impaired  bad  he  been  awake. 

In  every  hemiplegia  that  occurs  in  the  course  and  as  a  con- 
fluence of  cerebral  hn:morrhage  there  is  a  possibility  of  re- 
(eienilion  to  a  greater  or  less  extent;  but  whether  this  regcn- 
niiufl  will  lake  place,  and  when,  and,  moreover,  whether  it 
*^l  be  complete  or  not.  are  questions  that  can  not  at  once  be 
"^Klded.  They  all  depend  on  the  condition  ol  the  cortico-mus- 
^r  tract,  as  we  have  pointed  out  before — upon  whether  this 


333 


DiS£/ISES  Of   THE   BKAIM  PKOrEH. 


be  actually  interrupted,  w  hcther  its  fibres  in  places,  (or  instance 
at  the  internal  capsule,  be  completely  deslroyed.  or  whether 
their  (unction  be  only  leinpurarily  ittipaircd  in  cnriacqiiencc  of 
the  increased  blood  pressure,  so  that  alter  the  cessation  ol  the 
hemorrhage  a  riititulto  in  Mtrgrum  of  the  nerve  tissue  can 
follow.  In  the  latter  case  the  paralysis  disappears  after  a  few 
hours  or  days,  while  after  an  actual  interruption  o(  the  cortico- 
muscular  tract  the  hemiplegia  is  incurable,  and  the  patient  is 
deprived  of  the  free  uscol  the  affected  limbs,  and.  even  though 
he  may  regain  after  a  long  time  some  power  of  motion,  his 
movements  will  always  remain  awkward  and  restricted. 

Sometimes,  and  this  is  nut  very  rare,  a  patient  may  have 
an  apoplectic  stroke  after  which  the  paralysis  disappears 
quickly  and  entirely,  but  which  is  in  a  few  days,  on  some 
slight  provocation,  followed  by  a  second  attack,  accompanied 
by  a  severe  permanent  hemiplegia,  which  under  certain  cir- 
cumstances can  cause  death.  Such  a  possibility  should  always 
be  thought  of,  and  wc  would  here  say  that  the  prognosis,  no 
matter  how  slight  and  favorable  the  apoplexy  may  seem,  should 
always  be  very  guarded. 

Among  the  "concomitant  symptoms"  which  only  excep- 
tionally persist  tor  any  length  of  time,  and  ought  therefore  to 
be  regarded  as  indirect  focal  symptoms,  may  be  mentioned  a 
peculiar  deviation  of  the  eyes  and  Ihc  head — the  "  dH.<ialion  eon- 
jugiUf"  ol  Provost — generally  toward  the  side  of  the  lesion,  so 
that  the  eyes  "look  toward  the  disca.sc.focus."  This  has  been 
thought  to  be  associated  with  a  lesion  in  the  upper  parietal 
lobule.  PrivosI  and  T,andouzv  gave  this  rule  :  •"  Le  malade 
regarde  son  hfimisph&rc  alt6r*  s'il  y  a  paralysie— il  regardc  scs 
membrcs  convulses  s'il  v  •*  excitation  "  (the  patient  looks  to- 
ward the  damaged  hemisphere  if  he  have  a  paralysis;  if  there 
be  irritation  he  looks  toward  the  convulsed  limbs).  This  is 
seen,  for  instance,  in  the  so-called  cortical  epilepsy,  which  we 
have  spoken  of  on  page  187.  The  htad  seems  forcibly  turned 
to  one  side,  and  the  eyes  arc  turned  so  far  over  to  the  canthus 
that  we  arc  scarcely  able  to  lest  the  condition  of  the  pupil; 
along  with  this  symptom  there  is  found  almost  always  a  more 
or  less  marked  dullness  of  the  sensorium.  Why  this  condition 
is  generally  transient  is  explained  by  the  fact  that  the  muscles 
of  the  eyes  and  neck  can  be  innervated  from  both  hemispheres, 
so  that  even  if  one  side  becomes  incapable  of  working,  the 
other   can    act  vicariously  for  it.      Only  in    bilateral  huimor- 


THE  CEHEBKAt.  HEMIPLEGIA. 


22J 


I 


I 


rhages  which  produce  a  permanent  paralysis  uf  the  eye  mus- 
cles is  conjugate  deviation  found  to  persist. 

Unilateral  ocuUvmotor  paralysis  on  the  side  o{  the  hcmi. 
plegia  is  very  rare:  it  is  supposed  to  be  associated  with  lesions 
u(  the  lower  parietal  lobule. 

Ader  3  severe  attack  there  may  be  a  transient  polyuria  last* 
ing  lor  one  or  two  days;  the  specific  gravity  of  the  urine, 
which  is  then  (aintly  acid,  may  be  1.003  <^r  i-ooi;  at  times,  but 
not  always,  albumin  or  a  trace  of  sugar  can  be  demonstrated 
(Locb.  Prafjermed.  Wochenschr.,  1892.  50).  This  some  authors, 
amnng  them  OUivicr.  were  inclined  to  attribute  to  an  action 
(Ki  the  centres  situated  in  the  floor  ol  the  fourth  ventricle,  the 
exUtencc  of  which  Claude  Ilcrnard  had  already  demonstrated. 
This  polyuria  after  an  apoplexy  does  not  persist,  while  this 
tnay  be  the  case  in  tumors  of  the  posterior  fossa,  in  local  lesions 
of  the  pons  or  the  medulla  oblongata,  where  it  has  to  be  looked 
uptin  as  a  focal  symptom  (Kahler.  /eilschr.  f.  Heilk..  vii.  2,  3, 

Id  proceeding  to  the  examination  of  a  Ircsh  hemiplegia — 
iku  Is  to  say,  one  of  a  few  days'  or  weeks'  duration — the  foU 
toaing  points  nnisr  be  borne  in  mind  : 

The  facial  and  the  hypoglossal  nerve  deserve  the  most 
wtcntion  (cf.  also  Koenig.  Deutsche  Mcd.-Xcitg.,  1892.  2$.  p. 
J^V  The  former  is  injured  in  its  central  course,  and  shows  a 
gurjlyxis  or  only  a  paresis  in  its  lower  branches,  while  the  \i\\- 
per  branch  is  intact;  the  patient  is  unable  to  inflate  the  para- 
IjFttd  cheek,  and  can  not  whistle,  while  wrinkling  of  the  fore- 
ieid  on  the  paralyzed  side  presents  no  difBculty.  Careful 
uamination  shows  distinctly  that  the  disturbance  on  the  para- 
l/Hd  side  of  the  lace  is  much  more  marked  on  attempting 
nioDUry  movements  of  one  side  alone,  whereas  those  of  ex- 
pnaton — for  instance,  laughing,  crying — arc  at  least  passably 
Waited.  This,  again,  may  be  explained  by  the  fact  that  mus- 
dfs  used  involuntarily  arc  innervated  from  both  hemispheres. 
Tlie  duration  of  the  facial  p.iraiysis  varies;  sometimes  the 
Werencc  between  the  two  sides  of  the  face  disappears  almost 
oiniplctcly  in  a  (ew  days,  while  in  other  instances  it  may  be 
•oiioeablc  for  weeks  or,  in  rare  exceptions,  even  during  the 
*l<ole  lile.  In  this  point  it  resembles  the  speech  disturlnnce 
^ncd  by  a  lesion  of  the  hypoglossus,  a  disturbance  consisting 
Otntially  in  faulty  articulation,  which  is  noticed  by  the  patient 
•ore  tlian  by  those  who  converse  with  him.     It  may  disappear 


224 


D/SF.ASES  Of--  THE  HHAIN  PKOt'fUf. 


in  a  few  hours,  but  may  persist  for  months,  even  years,  when 
improvement  in  the  affected  side  lias  gone  on  (or  a  long  while, 
and  gratifying  progress  has  already  been  made.  A  paralysis 
of  the  same  nerve,  or  rather  of  the  genioglossus  muscle  sup- 
plied by  it,  is  also  responsible  if  the  patient  is  unable  to  pro- 
trude the  tongue  straight;  il  is  deviated  to  the  paralyzed  side 
because  the  wl-II  genioglossus  is  stronger  than  the  diseased  one, 
and  consequently  pushes  the  tongue  over  toward  the  side  of 
the  latter. 

The  condition  of  the  soft  palate  is  not  the  same  in  all  cases. 
The  velum  may  be  considerably  lower  on  the  paralyzed  than 
on  the  well  side,  but  it  may  also  occupy  its  normal  position. 
The  uvula  is  at  times  deviated  to  the  well,  at  times  to  the 
paralyzed  side,  and  again  at  other  times  its  position  may  be 
unchanged.  These  changes  do  not  give  rise  to  any  noticeable 
disturbance  of  function. 

Examination  of  sensibility  in  the  first  few  days  reveals  de- 
cided alterations.  Sensibility  to  pnin  in  most  cases  is  dulled, 
and  sensibility  to  touch  and  pressure  is  decreased,  though  to 
a  less  marked  degree.  The  patient  feels  a  pin  prick  either  not 
at  all  on  the  affected  side  or,  at  any  rate,  with  less  acuieness. 

Of  the  nerves  of  special  sense,  it  is  especially  the  optic  which 
takes  part  in  the  disturbance.  The  apoplectic  atUick  may  be 
followed  under  certain  circumstances  by  hemianopia  of  the 
corresponding  side  (Gowcrs),  often,  too,  by  amblyopia. 

Smell  and  taste,  as  a  rule,  do  not  suffer  to  any  great  extent ; 
but  there  is  a  decrease  in  hearing  power,  so  that  the  patient  is 
no  longer  able  to  understand  words  spoken  in  an  ordinary  tone 
at  a  distance  of  fifteen  or  twenty  feet.  Such  a  decrease  is  not 
rare,  yet  an  absolute  (unilateral)  deafness  never  seems  to  follow 
as  a  result  of  an  apoplectic  attack. 

With  regard  to  mobility,  examination  shows  that  either 
the  extremities  of  one  side  of  the  body  arc  completely  para- 
lyzed (hemiplegia)  or  thai  the  power  of  movement  in  them  is 
impaired  (hemiparesis).  In  the  latter  case  the  arm  is  usually 
more  affected  than  the  leg  and  the  hand  more  than  the  arm. 
Indeed,  the  movements  in  the  .shoulders  and  elbow  joint  may 
be  as  good  as  normal,  while  those  of  the  fingers  are  very  awk- 
ward ;  in  such  cases  the  leg  can  generally  be  moved  quite  well. 
The  muscles  of  mastication  and  those  of  respiration  are,  for 
the  reasons  above  mentioned,  almost  intact,  the  muscles  of  the 
trunk  are  only  slightly  implicated,  and,  if  at  all,  the  change  is 


TItE  CBREBKAL  ftEAliPlECIA. 


225 


only  apparent  in  the  trapezius,  so  that  the  shoulder  of  the 
afiected  Mile  is  raised  less  energetically  than  its  Icllow. 

The  tendon  and  skin  reflexes  arc,  in  the  first  few  days  »(ter 
^hc  attack,  decreased  or  even  lost  on  the  allccied  side,  a  condi< 
Bion  which,  as  we  shall  sec  shortly,  soon  becomes  materially 
duinfccd. 

The  sensorium  usually  clears  up  in  from  one  to  four  days. 

specially  in  light  cases.    The  patient  again  becomes  conscious 

his  surroundings,  and  recollects  quite  well  all  incidents  which 

[bppened  nearly  up  to  the  lime  of  the  attack.     Thence  on.  there 

of  course,  a  blank  in  his  mind.    On  awakening,  at  first  he 

Ibu  no  (dea  of  what  has  happened  to  him.     His  frame  of  mind 

tttfin  according  to  the  degree  of  his  bodily  helplessness,  but. 

u  a  rule,  is  better  than   we    might  expect,  considering  the 

dunage  which  has  been  done.     Sleep  is  for  weeks  much  intcr- 

kred  with.     The  patients  are  extremely  restless;  they  throw 

iliemselves  about  in  bed.  and  are  unable  to  remain  in  one  pnsi- 

liimfor  any  length  of  time. 

The  further  course  depends  upon  whether  the  hemiplegia 
;>rovcs  to  be  an  indirect  or  a  direct  focal  symptom. 

The  slighter  cases  ol  indirect  hemiplegia,  when  Ihey  have 
M  completely  passed  off  after  several  weeks,  arc  at  any  rate 
gtacnilly  improved  The  one-sidedness  of  the  face,  seen  at 
li«  beginning,  has  disappeared  :  the  tongue  is  now  protruded 
Xlif^ht.  speech  is  again  norm:il.  the  k'g  can  be  moved  almost 
» (irely  as  ever,  and  the  only  thing  which  is  left  as  a  reminder 
d  the  dangers  through  which  the  patient  has  passed  is  a  ccr- 
Oioawkwardness  in  the  movements  of  the  affected  h.ind. 

The  graver  cases  of  indirect  hemipl«gia  need  fr<im  two  to 
U»ttc  months  for  complete  recovery.  For  weeks  after  Ihc  at- 
t«k  the  patient  presents  marked  disturbances  in  motion  as  well 
VKosation,  and  only  ]xi)nlully  and  with  the  help  of  a  stick  can 
M  liobbic  about  his  room,  while  the  arm  and  hand  arc  almost 
"Vflai  Vet  a  constant  progressive  improvement  of  the  par- 
■l*tt(l  limbs  enables  >is  to  recognize  the  favorable  tendency  o( 
"•ecMe  and  to  predict  with  certainty  a  complete  recovery. 

la  cues  of  direct  hemiplegia  also  the  course  of  the  disease 
^yissume  many  varieties.  All  are  char-ictertzed  by  the  per- 
**>tnice  ol  the  (ocal  symptoms.  The  attack,  too,  wc  should 
■tvp  in  mind,  need  not  be  particularly  severe,  nor  need  the 
filial  general  symptoms  have  been  especially  grave  ;  <mly  the 
QvJBgate  deviation  of  the  eyes  and  head  is  a  symptom  which 


226  DISEASES   OF   THE  BRAIN  PROPER. 

preferably  occurs  in  grave  hemiplegia.  Its  presence,  therefore, 
permits  a  priori  of  an  unfavorable  prognosis  with  regard  to 
complete  recovery. 

In  the  first  three  or  four  weeks  things  remain  apparently 
about  the  same ;  the  paralyzed  side  is  flaccid  and  about  five 
ninths  to  one  degree  centigrade  warmer  than  its  fellow,  the 
slightest  motion  is  impossible,  speech  remains  impaired,  and 
the  face  is  one-sided.  It  is  not  until  from  three  to  six  months 
have  passed  that  we  are  able  to  notice  a  slight  improvement  in 
the  power  of  motion,  so  that  the  patient  (who  is  still  confined 
to  bed)  is  able  to  move  with  ease  some  of  his  toes,  perhaps  also 
the  lower  leg,  while  in  the  thigh  motion  is  still  incomplete,  and 
in  the  arm  and  hand  quite  impossible.  In  such  cases  all  the 
improvement  that  can  be  expected  is  but  small  and  the  damage 
which  the  stroke  leaves  very  apparent.  After  from  six  to 
twelve  months  the  patient  again  begins  to  be  able  to  use  the 
paralyzed  leg.  which  in  the  meantime,  in  consequence  of  the 
flaccid  condition  of  the  ankle,  has  become  longer.  The  walk  is 
then  very  characteristic.  Flexion  in  the  hip  being  insufficient, 
the  aflected  leg  is  brought  forward  by  the  aid  of  the  pelvis,  so 
that,  trailing  along  the  ground,  it  describes  a  half  circle  around 
the  sound  one.  The  centre  of  gravity  of  the  body  then  is 
transferred  to  the  paretic  leg,  the  knee  joint  passively  extended, 
and  the  leg  thus  used  as  a  stilt  (Wernicke).  If  improvement 
goes  on,  the  movement  ol  circumduction  gradually  disappears 
and  the  paretic  leg  is  simply  dragged  behind.  The  gait  is  so 
characteristic  that  the  diagnosis,  especially  when  simultaneous- 
ly there  is  a  paretic  condition  of  the  upper  extremity,  can  be 
made  at  a  glance. 

The  upper  arm  is  slightly  abducted,  the  forearm  flexed,  the 
hand  hangs  down,  the  fingers,  which  are  fixed  in  a  somewhat 
flexed  position,  are  completely  useless,  and  the  patient  is  un- 
able to  grasp  large  or  small  objects.  The  arm  can  hardly  be 
raised  at  all,  and  the  movements  of  the  forearm  on  the  upper 
arm  arc  very  limited.  In  the  lower  leg  extensor  are  more  fre- 
quently developed  than  flexor  contractures,  and  it  is  remark- 
able that  in  the  morning,  when  the  patient  awakens  after  a  Ions; 
sleep,  how  slight  they  are  and  how  little  they  trouble  him. 
whereas  in  the  co.ursc  of  the  day  they  arc  materially  increased. 

Contractures,  which  are  in  old  hemiplegias  hardly  ever  ab- 
sent, arc  most  likclv  to  be  atlribnlcd  to  a  shortening  of  the 
muscles  produced  by  disuse.     This  idea  is  suf)ported  by  the 


TUP.  CHRERltAL  HtiMlPLEGlA. 


727 


fact  that  by  systematic  passive  exercise,  begun  as  soon  as  pos- 
[sibic,  we  arc  able  to  prc%-cnt  contractures;  and  if  they  exist,  a 
[proper  galvanic  treatment,  which  takes  the  place  of  passive 
motion,  perceptibly  diminishes  them.  It  is  tnic  it  remains 
unexplained  why  contractures  are  not  tound  in  all  cases,  and 
why  in  some  the  paralyzed  extremities  remain  for  life  flaccid. 
That  anatomical  changes,  too.  especially,  as  Charcot  assumes, 
the  secondary  degeneration  of  the  pyramidal  tract,  arc  not 
without  influence,  and  that,  at  any  rate,  the  contractures  are 
more  marked  the  farther  this  secondary  degeneration  advances 
can  not  be  denied. 
H  A  symptom  which  accompanies  contractures,  but  which 
Boften  occurs  much  earlier,  is  an  increase  in  the  tendon  reflexes 
f  on  the  piiralyzed  side.  Tapping  of  the  triceps  and  bice]>s 
tendon  of  the  arm.  of  the  patellar  tendon,  and  the  tendo 
Achillis  evokes  lively  muscular  contractions.  From  the  last 
named — the  Icndo  Achillis — we  can  also  obtain  the  so-called 
nnkle  clonus,  of  which  phenomenon  we  shall  speak  later.  Even 
tapping  of  bones  is  attended  by  jcrkings,  which  arc  best  seen  in 
the  leg  when  the  tibia  is  struck  {"  periosteal  reflex  ").  Here 
again  we  must  leave  the  question  open  whether  this  increase 
in  the  reflexes  is  due  lo  the  degeneration  in  the  pyramidal 
tracts  or  merely  connected  with  the  suspension  of  certain  re- 
flex-inhibiting influences  in  the  brain.  In  favor  of  Ihc  latter 
hypothesis  speaks  the  fact  that  this  increase  in  the  reflexes  is 
occasionally  observed  as  early  as  a  few  days  after  the  stroke, 
at  a  lime  when  there  can  be  no  question  of  degeneration  in  the 
spinal  cord. 

With  the  skin  reflexes  it  is  just  Ihc  reverse ;  they  arc  usual- 
ly entirely  lost  on  the  panily/cd  side  or  are  ai  least  decidedly 
diminished.  This  is  especially  the  case  (or  the  abdominal  and 
cremasteric  reflexes,  which  can  only  in  exceptional  cases  be 
obtained  on  Ihc  affected  side. 

Sensation  either  returns  soon  after  (he  initial  disturbance  or 
■is  permanently  lost.  In  the  latter  case — J.  e.,  where  besides  the 
hemiplegia  there  exists  also  a  hemiana^lhesia — the  lesion  is  lo 
be  located  in  the  posterior  portion  of  the  posterior  limb  of  the 
internal  capsule.  The  hemian:csthesia  takes  in.  in  pronoimced 
Leases,  the  whole  half  of  the  body,  including  the  mucous  mem- 
iranes,  and  extends  as  far  as  the  median  line.  Face  and  trunk 
ire  equally  affected ;  occasionally  we  may  find  that  the  tri- 
geminus remains  exempt. 


228 


mSEASES  Of   THH   BRAIN  P/tOfEfl. 


I 


In  slight  cases  the  disturbance  is  confined  to  the  extremities 
and  concerns  more  the  sensibility  to  touch  than  the  sensibility 
to  pnin,  The  patient  feels  the  prick  of  a  pin,  but  is  unable  to 
direct  his  fingers  properly  if  the  eyes  are  closed ;  he  makes  _ 
mistakes  in  recognizing  objects  which  are  given  him  to  fcel:M 
he  is  unable  to  fasten  small  buttons,  etc.  Changes  in  the  mus- 
cular sense  also  may  exist  for  a  considerable  time,  the  patient 
being  unable  with  his  eyes  closed  to  give  any  information 
about  the  position  into  which  his  hand  has  be*^'n  brought. 

In  examining  sensation  in  hcmiplcgics.  Uppcnheim  (el.  lit.) 
has  noticed  that  at  time^  bilateral  impressions  are  appreciated 
only  on  one  side;  that,  for  instance,  if  a  patient  is  pricked 
simultaneously  in  the  right  and  left  thigh,  he  only  perceives 
one  prick — namely,  that  on  the  well  side. 

One  of  the  rarest  of  sensory  disturbances  is  the  persist- 
ent hypcrajsthesia  of  the  paraly/ed  side,  described  by  M.  H. 
Fischer  (Arch,  dc  phys.  norm,  ei  path..  February  i;,  1887,  ix. 

p.  [85)- 

The  psychical  condition  is  not  always  the  same.     In  certain 
cases  the  patients  seem  to  have  regained  all  their  former  lacul> 
lies  satisfactorily,  so  that  a  careful  examination  brings  to  light 
nothing  more  than  a  slight  loss  of  will  power  and  of  the  capa- 
city for  grasping  ideas  ;  but  in  other  instances  the  patient  be- 
comes mentally  weaker  and  at  (he  same  time  irritable.     He  » 
easily  made  to  cry  and  is  liable  to  sudden  changes  of  temper 
Such   patients  are,  however,   notwithstanding  their  apparent 
obstinacy,  very  manageable  and  easily  guided.     Again,  there 
arc  cases  in  which   the  mental  weakness  becomes  very  aji- 
parent.    The  patient  forgets  the  commonest  things,  the  nunw 
bcr  and  the  names  of  his  children,  confuses  things  and  placet. 
does  not  know  what  day  of  the  week  and  what  season  of  the 
year  it  is,  etc. ;  at  the  same  time  he  may  have  different  Ae- 
Itisions  and  hallucinations.     Some  cases  finally  go  on  to  com- 
plete dementia,  which  takes  a  course  not  unlike  that  of  gener>l 
paralysis.     Lcgrand  du   Saullc  has  published  an  interesting 
study  of  such  disturbances  among  the  apoplectics  of  the  Saliir- 
trifere  (tiaz.  des  ht>p..  6871,  r88i). 

In  the  further  course  of  severe  hemiplegias  where  regcn- 
erntion  is  impossible  to  any  great  extent,  motor  disturbances 
which  we  have  designated  as  posthemiplegic  (cf.  lit.  under 
treatise  of  tireidenberg)  may  follow.  One  of  these  is  the  W- 
called  hemichorca,  consisting  of  involuntary  irregular  move- 


I 


I 


THE  CRREBHAt.  IIF.MlPLEiUA. 


239 


»ments  in  ihc  paralysed  limbs,  which  become  aggravated  by 
every  mental  emotion  and  voluntary  movement  and  which  en- 
tirely cease  during  sleep.     These  movements,  which  are  best 
Hudicd  on  the  upper  extremity,  occur  more  ircc)uently  after 
cerebral  infantile  hemiplegia  than  in  any  other  aflection.     The 
"hemiataxia  "  dcscrilwd  by  Grassct  (cf.  lit.)  is  closely  related 
l«»  hemichorca.  and  ought  to  be  regarded  as  a  variety  of  it. 
■According  to  Charcot,  the  scat  of  the  lesion  in  these  cases  is  in 
Bthe  posterior  portion  of  the  inlcntat  capsule,  the  posterior  part 
Ho(  the  optic  thalamus,  and  in  the  foot  of  ihc  corona  radiata. 
■The  so^allcd  hcmiathctosis  will  be  considered  in  the  chapter 
on  the  cerebral  palsies  of  children. 

A  second  class  of  motor  disorders  is  made  up  of  those  pc> 
culiar  involuntary  movements  which  have  been  described  as 
"associated  movements."  They  are  observed  in  the  paralyzed 
extremity  when  the  patient  moves  the  corresponding,  unaf- 
fected, one  :  thus,  lor  instance,  if  a  patient  uses  his  right,  well 
vrm.  the  paralyzed  arm  makes  similar  movements,  of  course 
being  restricted  to  a  lesser  or  greater  extent  by  any  contract- 
ures which  may  be  present.  These  movements  have  nothing 
in  common  with  the  so-called  rcfJes  movements  which  are 
loimd  to  occur  in  the  paralyzed  limb  on  stimulation  of  the 
sound  one  by  the  prick  of  a  pin.  the  faradic  current,  etc.  A 
peculiar  instance  of  " associated  movements"  in  an  old  hemi- 
plegia I  had  the  opportunity  of  observing  for  months.  It  was 
«  follows:  Every  time  the  patient  yawned  the  left  arm  was 
niscd  involuntarily  at  the  shoulder-jfiini,  and  w.is  kept  up 
while  the  yawning  continued  ;  as  soon  as  it  ceased  the  arm 
dropped  down  helplessly.  Sometimes  one  sees  the  sound 
Hlinibs  make  involuntary  movements  if  the  patient  attempts  to 
Hit^  the  aHecled  ones,  and  again  and  again  I  have  seen  patients, 
Bsirsining  to  bend  the  paralyzed  leg.  become  greatly  astonished 
"»t  the  Hexion  which  took  place  in  the  well  leg  without  any 
such  intention  on  their  part.  That  in  intended  movements  ol 
certain  muscle  groups  the  antagonists  begin  to  make  invoUin- 
t»ry  movement.s — that,  lor  instance,  if  an  extension  ol  the  flexed 
lini^rs  be  attempted,  the  Hexion  at  first  becomes  more  forcible 
before  extension  begins  (Mitzig)^is,  according  to  our  experi^ 
_<i)ce,  very  exceptional. 

^p      There  arc  other  as.<iociatcd  movements  which  occur  in  the 

paralyzed  hall  ol  the  face  when  the  sound  side  is  moved  ;  thus, 

Jor  instance,  in  laughing,  the  muscles  of  the  paralyzed  side  arc 


230 


V/SEASKS  O/-'    THE  BXAJA'   PJfOPEJt. 


seen  to  contract  equally,  or  even  more  strongly,  than  those  of 
the  well  side. 

Various  theories  have  been  proposed  to  explain  »&sociated 
movements  (Wcslphal,  Dcncdikt,  Broadbcnt,  Ross),  but  m»nc 
of  lliem  can  be  taken  as  entirely  explaining  the  facts.  It  is 
by  no  means  impossible  that  all  such  motor  disturbances  arc 
reflex  in  nature  (Charcot  and  Brissaud  ;  cf.  also  Senat<ir.  L'fber 
Mit-  und  Ersatzbewcgungcn  bci  Gel^hmtcn.  Berliner,  klin.  Wo- 
chenschr..  1892.  1).  ■ 

As  a  third  posthemiplegic  phenomenon  we  have  the  tremor.  ^ 
It  is  not  rare,  and  that  form  especially  which  occurs  on  volun- 
tary movements  of  the  afTccled  side  is  rallicr  frequently  met 
with  ;  on  the  other  hand,  wc  shall  very  rarely  have  the  oppor- 
tunity of  observing  this  tremor  while  the  extremities  arc  at 
perfect  rest.  Relatively,  the  largest  number  ol  cases  who 
presented  tremor,  in  my  experience,  showed  sensory  changes, 
which  consisted  of  paroxysms  of  pain  in  the  affected  extremi- 
ties. On  a  cursory  exiimination  this  tremor  may  be  mistaken 
for  unilateral  paralysis  agitans  (hcmiparalysis  agitans),  espe- 
cially as  the  number  of  oscillalions  is  about  the  same  in  both 
afTections,  4>,  to  ;Vi  >'■  ^  second.  Pronounced  intentional 
tremor,  which  wc  look  upon  as  a  pathognomonic  symptom  in 
multiple  sclerosis.  I  never  have  observed  in  hemiplegia.  Prob- 
ably the  cause  of  this  posthemiplegic  tremor  has  to  be  sought 
in  the  general  increase  of  reflex  activity,  which,  as  we  may 
remark  here  by  the  way,  is  observed  besides  only  in  a  very 
few  cases  of  tremor  of  a  diflercnt  nature.  Here  it  seems  to 
play  the  most  important  r^/f. 

Of  great  interest,  as  well  as,  at  times,  o(  no  small  practical 
importance,  is  the  fact  that  in  cases  of  incurable  hemiplegia 
the  non-paralyzed  side,  that  is,  the  apparently  well  extremities 
undergo  certain  changes  which  we  are  compelled  lo  regard 
as  pathological.  Thus,  I'itres  has  found  that  the  well  arm 
loses  somewhat  in  strength,  and  that  this  Es  often  more  marked 
in  the  beginning  of  the  hemiplegia  than  later  on.  On  an  aver- 
age the  loss  amounted  to  about  58  or  40  per  cent,  while  no  in- 
crease in  the  tendon  reflexes  could  be  demonstrated  at  the 
same  lime.  The  well  leg  becomes  weaker,  and  indeed  in  a 
more  marked  degree  than  the  arm,  the  strength  being  reduced 
in  some  cases  even  by  one  half.  The  patient,  though  able  to 
move  that  leg  with  perfect  ease  while  in  bed.  finds  it  almost 
useless  to  attempt  to  stand  or  walk.     Pitrcs  was  also  the  first 


THE  CERKISMAL   HEMiPUiOtA. 


SJI 


(0  notice  that  the  patellar  rcftcs  of  the  sound  side,  as  well,  is 
abnormally  active,  an  observation  which  is  daily  conlirmed. 
The  presence  of  the  ankle  clonus  is  noted  by  Wcstphal  iind 
Dcjcritie.  All  authors,  however  (Haltopeuu,  Brissaud,  Vtri:}, 
agree  that  it  is  extremely  unusual  to  hnd  the  later  contrac- 
tures on  Ihc  non-paralyzed  side.  On  the  whole,  these  changes, 
which  occur  on  the  so-called  unaffected  side,  arc  more  marked 
and  of  greater  significance  to  the  patient  than  we  should  be  led 
to  suppose  from  a  superficial  examination. 


I-ITERATURF.. 
Ucbcr  l'seiula>A|io|)Jexten  im   (iehirn. 


liuuj[.-DiM«rL,   Biciilau, 


I 


I 

I 


MKJtm. 

iWi. 

LoewmfeM.  Sluilitn  ubrr  Aeliologie  uiul  Palhox«i)c>e  <ler  xpantanen  HirnMut> 

iMgen.  Winbailcn.  1886. 

HnchKauK.  Brrlinrr  klin  Wochenschr,,  1887,  t,     (Meningilic  Hemiplegia. j 

■.urwenfrlil.  7.ur  l^^hrc  von  <len  Miliiiranvuriitinen  dcs  Mimt.    Wiener  med. 

WocJicmchT.,  il«7,  47.  _^^^^^ 

dnidcnhcrg.     Arch.  f.  Pf)-ch..  18S6.  xvii,  1.    (Post-hciiiiptc^c  Molor  Di^iurh- 

10cm.  I 
Stqihan,     Rrvuc  tic  mM.,  iSS?.  3.    IPrt-  and  I'oM-hcnnlplcgic  Tremor) 
Bnsuutl  CI  M^inc.     Prngrtt  n\tA..  1887.  %.  7.     (The  Condilion  of  the  Facial  m 

Hf&lencal  HcmipleKia^) 
Wcmkkr.     Bcilincr  klin.  Wochctischr.  18891,  4S 
SduAin'.     Ilcitnig  lur  l.chic  v»n  dcr  !ii;cun<ljlrcn  und  muliiplcn  DcKcneralion. 

Viti-h.  Arch..  i8</x  cMii,  1.  2. 
Schnbrr.     Areh.  f,  lS)'ch..  1890.  xtii.  1.  p.  I3i.     ("  Aihelosis  sputi».") 
Citmi.     Vcrauch  dnrr  F.rklSiunK  Tur  iUh  vrrachicdene  Vcrhallen  der  Sdinen- 

rcflnc  luch  Hlrnbtuiuiij^n.     Wiener  mcd.  Wothenschrifi.  1890.  jj, 
SinuH.     Zwcihuaden  un<l  funfiig  Ffflle  von  rrchi«-  und  linht-Kiliger  Henti- 

plejpc  -  tin  Beiirag  lur  Frage  nach  der  functionellen  Venchiedenheil  twMler 

Hcmbfihltrrn.     Inaug.-DiMcn..  Beriin.  1890. 
VUok.     Gu.  degli  o»p«dali.  189:. 

Trophic  vasomotor  changes  are  not  uncommon  in  the  par- 
alyzed limbs.  While  in  the  beginning  of  u  hemiplegia  the 
»kin  ol  the  afTccted  side  is  warmer  and  redder  than  that  of  the 
well  side,  it  btxomes  cooler  as  the  disease  progresses,  and  fre- 
quently assumes  a  somewhat  cyanotic  color.  The  trdema 
often  BCen  in  the  afTccted  extremities  is  due  to  the  absence  <>( 
muscular  movement  and  the  consequent  slowing  of  the  blooil 
and  lymph  current.  In  a  palicnt  who,  two  years  before,  had  a 
pretty  severe  apoplectic  attack  with  persistent  speech  disturb- 
ance.  I  have  repeatedly  observed  slight  repetitions  of  the 
orrhage,  during  which  the  5|«.'cch,  which  had  consider- 


333 


ntSEASKS  OF    THE   BKAIX  rjfOPEX. 


ably  improved,  again  became  entirely  unintelligible.  Siinul 
lancously  there  was  developed  on  each  such  occasion  over  the 
whole  body,  and  not  merely  over  the  paralyzed  rtf^ht  side,  an 
urticarial  rash  which  persisted  as  long  as  the  cerebral  symp- 
toms lasted.  No  doubt  this  was  due  to  a  disturbance  in  the 
vaso-motnr  innervation  of  the  vessels  of  the  skin,  which  reap- 
peared wilh  ihe  transient  increase  in  the  intracranial  pressure. 
Charcot  describes  an  acute  malignant  bed-sore  which  appears 
two  or  three  days  after  the  onset  of  the  hemiplegia  in  the 
ffluieal  region,  beginning  as  a  red  spot  and  developing  in  a  few 
days  into  a  brown,  dry  eschar  six  to  seven  centimetres  broad. 
It  always  ends  fatally,  and  is.  according  to  Charcot,  a  purely 
trophic  disturbance,  an  alteration  in  the  tissue,  which  we  can 
attribute  only  to  nervous  influences. 

The  nutrition  of  the  muscles  which  for  years  have  been  par- 
alyzed usually  suflcrs  but  little.  We  can  easily  understand 
that  a  slight  degree  of  atropliy.  due  to  inactivity,  occasionally 
manifests  itself,  yet  the  excitability  to  both  electrical  currents 
remain;^  normal.  Only  in  exceptional  cases  is  there  pronounced 
muscular  atrophy  in  the  affected  limbs  when  these,  although 
their  motion  is  impaired,  can  still  be  used  to  a  certain  extent. 
In  such  cases  the  atrophy  can  not  be  referred  to  inactivity,  but 
we  must  rather  assume  a  lesion  in  the  trophic  centres  of  the 
cortex,  the  seat  of  which  is,  however,  siill  unknown.  Since 
these  conditions  have  received  considerable  attention  of  late, 
wc  add  here  some  references. 

UTERATURB. 

Quinckr.     Tlctilschn  Arch.  t.  klin.  Med.,  i$8S.  xUt,  $. 

ItDcichtriiir.     t.'eher  die  fruhztriili;^  Muskclalrophie  bci  cicr  ccrcbriilcn  Uihtnung. 

Dcutsilics  Afch    f.  klin.  Med.,  Novnnhrr.  1889,  xlv,  5.  <>i    (Atrophy  on 

llic  Third  Pay  aftrr   HrmiplcKiii:    ihe  Inian  was  llioughl   ii>  t>e  ifl  the 

ihaUinu!!.) 
Ciwiiluhr.      Muskclairophic  und  cleciriKchc  ETregbarkeitirerifnderungen  lid 

llimhenl«n.     Ncur.  Crotralbl.,  1890,  1. 
Daiksi-Iiewilicli.     Zwcl  KillU-  von  fruhxeiiigrr  MiiskcUlrophk  tm  eiiiem  Hrmi- 

(ilegikcr      Neurol.  Ccniralbl,.    1891.  10.      <D,   regards  it  u  «  cerebral 

amyi>lTO|>hy.) 
MMiritofT.     Arch.  tl«  Neitr..  1891.  htlH.  p.  461. 
Sli-lner.     i;cb<T  die  Muskdnirophie  bd  der  cerebralen  Hemiptc^e.     Deutsche 

Zcitxchr.  f.  Ncrwnhk..  1893,  ill,  4.  5. 

The  simultaneous  appearance  of  a  hjemorrhage  in  each 
hemisphere  is  exceptional.     It  needs  hardly  to  be  stated  that 


DlAGXOSrs  OF  CEKEBHAL  HEMORRHAGE. 


3J3 


luch  an  ucciilcnt  must  necessarily  give  rise  to  the  gravest 
symptoms :  bilateral  hemiplegia — that  is,  paralysis  of  all  four 
cxiremiiies — bilateral  facial  and  hypoglossal  paralysis,  aniauro- 
tis  and  total  anaesthesia. 


Diagnosis. — The  diagnosis  of  cerebral  haemorrhage  may 

^ve  rise  tu  considerable  dilhculties.     It  is  easy  only  when  a 

suddenly  or  gradually  developing  unconsciousness  is  followed 

by  a  paralysis  or  paresis  of  one  side  in  a  patient  not  suffering 

Intm  any  valvular  disease  of  the  heart.     Under  such  circum- 

H    stances  the  case  is  absolutely  clear,  and  even  the  most  cautious 

H     rliagnoulidan,  if  he  can  exclude  hysteria,  may  safely  assume  a 

^1     cerebral  ba-niorrhage  with  cuns<H|uent  hemiplegia. 

H  It  is  a  diScrent  matter  where  we  have  to  make  a  diagnosis 

at  a  time  when   we  are  unable   to  ascertain   the  presence  or 

extent  of  the  paralysis,  but  where  wc  arc  restricted  to  an  in> 

Iicrpretatiun  of  the  unconsciousness  of  the  patient.  Under 
these  circumstances  wc  have  to  be  familiar  with  the  conditions 
which,  besides  cerebral  h:emorrhage,  are  capable  of  giviny  rise 
lo  unconsciousness,  and  be  acquainted  with  the  characteristic 
oani testations  which  each  offers. 

In  the  lirst  place  wc  may  have  to  deal  with  a  simple  faint- 
ing fit.     The  concomitant  symptoms — the  wax-like  pallor  of 
the  face,  the  small,  frequent  pulse,  the  cold  sweat  which  covers 
face  and  body — are  not  likely  to  allow  us  to  mistake  the  con- 
H  djiion  for  one  of  apoplexy,  especially  as  the  gravest  sytnptom 
^  — the  loss  of  consciousness — as  a  rule,  is  not  of  long  duration, 
but  vanishes  rapidly  if  the  patient  is  bid  down  wtlh  the  head 
lowr.  the  face  sprinkled  with  cold  water,  or  if  ammonia  or  eau 

»dc  Colf^ne,  etc.,  be  held  to  the  nose.  The  success  or  non- 
tscocss  of  these  measures  will  help  us  to  settle  the  differential 
diagnosis  in  a  few  miruites. 

Secondly,  we  may  have  before  us  an  epileptiform  attack 
^without  convulsions  or  the  coma  which  so  often  follows  epilep- 
tic fits.     Mere  the  loss  of  consciousness  is  also  complete,  and 
'      *Hc  diagnosis  can  only  be  made  if  we  can  obtain  a  history  of 
^  P«"evious  epileptic  convulsions,  or  if  wc  are  able  to  assume  this 
^•"ota  scars  on  the  tongue.     In  the  absence  of  such  evidence 
'"C  cnJor  of  the  lace  may  sometimes  be  of  value  to  us ;  in  some 
T>llcplic»  this  is  very  pale,  in  cerebral  hasmorrhagc  of  a  pur- 
?1i)ih  color,  yet  this  rule  by  no  means  always  holds  good,  and 
•hiiuld  therefore  be  accepted  (um  grane  salts. 


234 


MseASES  Of--  rue  brain  pkopkk. 


The  unconsciousness  su  often  occurring  in  the  course  of 
a  meningitis  may  be  rccogni/ed  from  the  temperature  and  the 
pulse,  the  poculiur  drawing  in  ol  the  abdomen  (scuphuid  abdo- 
men), the  jactitations,  the  rigidity  of  the  ncclc.  and  p'l^sibly 
from  ihe  existence  of  choked  disks.  The  possibility  ol  an 
internal  pachymeningitis  haemorrhagica  must  be  thought  of 
when  the  development  of  the  condition  has  been  characterized 
by  sudden  exacerbations  and  remissions,  and  when  at  the  same 
time  a  history  of  alcoholism  can  be  obtained. 

In  the  beginning  and  iit  the  course  of  progressive  paraly- 
sis  of  the  insane  (dementia  paralytica)  apoplectiform  attacks 
occur  which  resemble  those  produced  by  cerebral  hemorrhage 
very  closely  indeed,  and  which  can  be  recognized  as  belonging 
to  the  former  disease  only  from  the  previous  history  of  the 
patient  (and  later  from  the  results  of  the  autopsy).  If  we  can 
get  no  information  from  the  history  the  differential  diagnosis 
is  impossible. 

Intoxication  with  chloroform  and  alcohol  may  be  Attended 
by  complete  loss  of  consciousness.  An  individual  in  the  uncon- 
sciousness of  alcoholic  intoxication  is  just  as  hard  to  arouse  as 
one  in  apoplectic  or  epileptic  coma,  and  the  diagnosis  may  pre- 
sent some  difficulties  under  certain  circumstances — when,  for 
instance,  nothing  can  be  learned  about  the  cause,  or  what  has 
immediately  preceded  the  loss  of  consciousness.  Usually,  h<)W. 
ever,  it  is  easy  enough.  Sometimes  the  smell  of  the  ingested 
substance  puts  us  on  the  right  track,  sometimes  prompt  reac- 
tion to  energetic  stimuli  applied  to  the  skin  may  make  i>ur 
diagnosis  clear.  As  long  as  we  are  not  sure  of  our  ground,  we 
ought  to  abstain  from  all  therapeutic  measures.  Of  opium  or 
of  morphine  poisoning  we  need  only  think  when  the  pupils  of 
the  patient  are  conspicuously  small.  A  degree  o(  myosis  as 
high  as  we  find  in  opium  poisoning  has  only  its  parallel,  and 
then  but  rarely,  in  haemorrhages  into  the  pons,  which  arc 
rapidly  fatal. 

Uremic  coma  can  easily  be  escluded.  if  we  arc  able  to  ex. 
amine  the  urine, and  can  detect  neither  albumin  nor  tube  casts: 
besides  this,  with  the  history,  the  examination  of  the  heart  tor 
a  possible  hypertrophy  should  not  be  forgotten. 

Diabetic  coma,  finally,  is  characterized  by  a  peculiar  fruity 
odor  which  comes  from  the  mouth  of  the  patient.  It.  of  course, 
only  enters  into  the  question  i(  sugar  can  be  demonstrated  (or 
has  previously  been  repeatedly  detected)  in  the  urine. 


I 

I 


O/AGXOS/S  OF  CEk'EBftAL   IIMMORKIIAGE. 


235 


I 


I 

and 


It  is  not  common  to  encounter  any  difficulty  in  decidiii{; 
which  side  is  paralyzed;  nevertheless  1  have  seen  instances  in 
which  this  was  the  case,  Thns  it  occasionally  hapjwns  ihal. 
owing  (o  the  deep  coma  in  which  the  patient  lies,  the  limbs  of 
both  sides  fall  equally  flacctdly  when  allowed  to  drop,  white  ni» 
(liflerence  can  be  discovered  in  the  two  sides  o(  the  face.  In 
such  cases  it  is  well  to  Ihrow  some  tce-waler  over  the  patient, 
Dpon  which  it  wilt  be  observed  that  he  wilt  malcc  movements 
of  defense  only  wiih  the  non-paralyiied  side,  and  the  lacial 
musck-H  will  contract  only  on  that  side. 

The  anatomical  nature  of  the  hemiplegia  may  remain  en- 
tirely otMcure,  and  only  in  certain  cases  are  wc  able  to  ^ive  a 
decided  opinion  about  it. 

Whether  hemiplegia  following  a  stroke  is  due  to  ha;mnr> 
rbas;e  or  embolism  am  only  be  determined  by  accompanying 
circumstances.  The  existence  of  valvular  lesions  and  of  athe< 
toma  speaks  for  embolism;  nephritis,  heart  hypertrophy,  albu- 
min uria.  for  haemorrhage;  yet  this  rule  has  many  exceptions, 
and  we  may  assume  that  in  about  half  the  cases  a  correct  diag- 
nosis is  impossible  (cf.  Dana,  Med.  Record,  1891.  p.  30). 

The    meniuf^ilic   hemiplegia    has  these  points  in  common 

h  the  hemorrhagic— namely,  the  paralysis  on  one  side  and 
(be  "  conjugate  deviation  "  ;  but,  as  we  have  before  pointed  out. 
to  meningitis  we  generally  have  the  characteristic  rigidity  ol 
the  neck  and  the  scaphoid  abdomen;  where  these  latter  symp- 
toms are  not  even  suggested,  a  differential  diagnosis,  or  rather 
the  rect^nilion  of  a  hemiplegia  as  of  meningiiic  origin,  is  im- 
possible. 

The  hysterical  hemiplegia,  finally,  if  it  persist  (or  a  long 
tiine,  and  if  other  hysterical  symptoms,  as  anaesthesias  or  con- 
tractures, arc  wanting, can  never  with  any  certainty  be  diileren- 
ibtrd  from  that  depending  upon  cerebral  hwmorrhagc.  Bolh 
may  present  Ihc  same  peculiarities,  and  a  decision  as  to  which 
condition  wc  are  dealing  with  may  be  beyond  the  powers  even 
<A  the  practiced  diagnostician.  We  are  indebted  to  Charcot 
for  a  new  symptom,  to  which  he  lias  drawn  attention,  and 
which  is  said  to  be  characteristic  of  hysterical  hemiplegia — 
tamely,  a  paroxysmal  spasm  of  the  muscles  of  the  cheek  of  one 
side,  associated  with  an  excessive  deviation  of  the  tongue  to 
the  aame  side.  This  "  glosso-labial  hetnispasm  "  never  exists  in 
orgsnic  lesions  of  the  pyramidal  tract,  and  is  therefore  pathog- 
nic  for  hysterical  hemiplegia  (Urissaud  and  Marie.  c(.  lit.). 


A 


2i0 


D/sEMses  or  the  BUMfx  r/iorEK. 


I(  the  question  of  the  anatomical  scat  of  the  haemorrhage  is 
to  be  considered  in  our  diagnosis,  we  mu&t  in  the  first  place 
not  forget  that  the  mere  exiHtencc  nf  a  hemiplegia  is  not  suf- 
ficient to  give  us  an  answer,  for  as  long  as  we  do  not  know 
whether  to  regard  it  as  a  direct  or  indirect  symptom,  wc 
can  say  nothing  positive.  If  we  further  add  that  even  an  indt> 
rcct  hemiplegia  may  persist  for  years,  we  can  easily  see  with 
what  difliciilties  we  meet  in  attempting  a  topical  diagnosis.  It 
may  be  quite  true  that  in  a  great  many  cases  where  an  apo- 
plectic attack  is  followed  by  hemiplegia,  the  lesion  is  situated 
in  the  internal  cnpsnie.  and  we  have  become  accustomed  lo  as. 
sociatc  in  our  minds  a  certain  typical  clinical  picture — that  is, 
hemiplegia  with  more  or  less  marked  sensory  changes — with  a 
lesion  in  the  internal  capsule.  We  must,  however,  in  making  a 
diagnosis  of  that  kind,  always  keep  in  mind  that  an  indirect 
hemiplegia  may  be  produced  by  lesions  in  any  part  of  the 
brain,  by  lesions  in  the  frontal,  in  the  parietal,  the  occipital 
lobe,  of  the  thalamus,  of  the  lenticular  nucleus,  of  the  external 
capsule,  and  that,  as  we  have  also  said,  the  duration  of  such  in- 
direct hemiplegias  is  by  no  means  always  restricted  to  a  period 
either  of  a  few  days  or  a  few  weeks.  Hence  a  certain  reser- 
vation must  ever  be  observed  by  a  prudent  diagnostician,  and 
he  should  speak  with  some  certainty  only  when  he  h.is  some 
other  direct  focal  symptom  to  guide  him.  Among  these,  wc 
have,  for  instance,  sensory  aph.-isia  for  the  (left)  temporal  lobe; 
(or  the  occipital  lobe,  hemianopia ;  for  the  optic  thalamus  (with 
a  high  degree  of  probability),  posthemiplegic  chorea ;  for  the 
crura,  alternating  oculo-motor  paralysis:  (or  the  pons. alternat- 
ing facial  paralysis.  According  to  Diirck.  it  is  possible  at  au- 
topsy to  determine  approximately  the  age  of  the  hajmorrhagc 
from  the  condition  of  the  red  corpuscles  (whether  tliey  are 
normal,  discolored,  swollen,  shrunken,  etc.).  and  from  the  ana- 
tomical and  chemical  condition  of  the  blood  pigment.  If  these 
points  arc  taken  into  consideration,  its  age  within  a  period  of 
from  one  lo  seventy-two  days  may  be  estimated  (ct.  Virch. 
Arch..  iSg2,  cxxx.  Heft  i,  p.  89). 

Prognosis.— After  all  that  has  been  said,  we  hardly  need  to 
add  anything  about  the  prognosis.  Any  cerebral  haemorrhage 
is  a  gnive  event,  which  puts  the  life  nf  the  patient  in  danger,  or 
rather  it  is  a  symptom  which  denotes  that  a  grave  arterial  dis- 
ease, without  which  a  h;vmorrhage  never  occurs,  has  reached 
a  slate  dangerous  to  life.     1(  once  a  haemorrhage  has  occurred 


\ 


fHOCA'OStS  fy  CEREBRAL  HEMORRHAGE. 


237 


I 


I 


I 


I 


vre  are  not  sure  but  that  it  may  be  repeated  at  any  moment, 
since  the  condition  which  favored  it.  the  briitleness  of  the  ar- 
lerial  walls,  means  a  lastin};  incurable  prcdispusilton  to  a  fresh 
luemorrhage. 

In  the  presence  of  a  recent  apoplectic  attack,  it  is  impossi< 
ble  for  us  to  give  a  certain  prognosis,  or  to  predict  what  wilt 
follow.  The  severity  of  Ihe  disturbance  of  consciousness  is  in 
a  way  indicative,  and  we  may  say  that  the  severer  this  is 
found  lo  be — in  other  words,  the  greater  the  traumatic  effect  of 
ihe  hasmorrhage — the  less  favorable  is.  actfris  /laribus,  the  out- 
look with  regard  to  life,  as  well  as  with  regard  to  recovery. 
Yet  exceptions  occur,  and  even  a  very  severe  coma  which  has 
persisted  for  hours  does  not  only  not  always  produce  death, 
but  need  not  necessarily  leave  behind  it  focal  symptoms,  as 
hemiplegia  or  the  like,  and  such  patients  may  then  be  well  for 
years  afterward.  Unfortunately,  so  favorable  a  result  is  rarely 
met  with.  As  a  rule,  a  haemorrhage  of  any  considerable  size 
i»  either  fatal  or  is  followed  by  a  hemiplegia. 

.As  to  the  difference  in  the  prognosi<i  for  the  individual,  in* 

direct  as  well  as  direct  (ocal  symptoms,  most  that  deserves 

mention  has  already  been  spoken  of.     The  indirect  symptoms, 

u  a  rule,  disappear  alter  a  certain  time,  und  a  rfstitutio  in  in' 

tfgmm  is  not  impossible :  the  direct  ones  are  only   curable 

when  vicarious  innervation  takes  place  from  the  unaffected 

bnaispherc  which  assumes  the  function  iif  the  damaged  one. 

Thi*  can  be  the  case,  for  instance,  in  unilateral  lacial  and  hypo> 

gkesal  paralysis,  and  in  the  lateral  ilcviation  of  Ihe  eyes  {lesion 

ot  the  lower  parietal  lobule) ;  it   may  also  occur  in  motor 

■phasia  if  the  patient  is  still  capable  ol  learning  to  speak  with 

Ut  right  hemisphere  (lesion  ol  the  region  of  Bnjca).    On  the 

ui^r  hand,  it  docs  not  occur  in  cases  of  direct  hemiplegia  due 

luilnion  of  the  internal  capsule  :  then  the  paralysis  is  incur- 

*bk,and  the  improvement  which  may  lake  place  is  always 

Wfy  imperfect,  ahhough  a  properly  conducted  treatment  may 

*Bcei  some  amelioration,  and  thus  conduce  much  to  the  well- 

tsioR  f»l  t  he  patient. 

Treatment. — The  primary  affection,  the  disease  of  the  ar- 
'"w  to  which  cerebral  ha:morrhagc  is  due.  is  beyond  Ihe 
^tb  of  therapeutics.  W'e  possess  no  remedy  which  can 
^uie  the  miliary  aneurisms  to  disappear,  and  our  efforts  are 
wofiacd  to  combating  those  symptoms  which  accompany  and 
I^OK  which  follow  the  haemorrhage.    Thus  we  have  to  deal 


238 


P/SEASRS  OP  THR  BRAIN  PROtEk. 


with  (ii  the  apoplectic  attack  itself;  (2)  the  anatomical  changes 
whicli  are  produced  in  the  brain  by  the  hemorrhage:  (3)  the 
foc:il  symptoms,  the  paralysis  (or  paresis)  of  one  side  ;  and.  in 
general,  all  motor  and  scnsorj-  disturbances  rclcrablc  to  the 
Attack. 

(d)  The  treatment  ot  the  attack  itscU  varies  according  as  we 
have  to  deal  with  a  suddenly  or  gradually  developing  apo- 
plexy. In  the  lormcr  case  wc  may  assume  that  Ihe  hxmor- 
rh.ige  has  already  stopped  when  we  first  sec  the  patient, 
whereas  in  the  second  case  the  presumption  that  the  bleeding 
is  still  going  on  is  justifiable,  and  hence  all  measures  which 
tend  to  arrest  the  hemorrhage  arc  strenuously  indicated  nt 
once.  One  o(  these  is  venisection,  which  produces  a  fall  in 
the  blood  pressure,  and  should  always  be  resorted  to  in  cases 
in  which,  after  (or  during  or  perhaps  before)  a  harmorrhage.  the 
carotids  are  found  throbbing.  Ilie  action  of  the  heart  is  tumul- 
tuous, and  the  face  red  and  congested.  The  success  is  some- 
times surprising.  The  patient,  who  just  before  was  comatose 
and  moitonless,  with  stertorous  breathing,  immediately  altera 
free  bleeding  begins  to  breathe  more  quietly,  and  evidently 
with  greater  ease.  He  stirs,  opens  his  eyes,  and  becomes  cor- 
scious.  in  such  a  case  venesection  was  the  only  measure  indi- 
cated ;  it  could  not  have  been  replaced  by  anything  else — in 
short,  it  has  saved  Ihe  patient's  life.  The  compression  o(  the 
carotid  artery,  which  Spencer  and  Ilorsley  recommend  as  a 
result  o(  their  experiments  upon  animals,  will  probably  be  re- 
sorted to  only  in  rare  instances  (Brit.  Med.  Joum.,  March  2. 
i&Sc)).  If  the  pulse  is  small,  the  face  pale,  and  the  heart  sounds 
arc  weak,  no  one  will  ever  think  of  taking  away  blood,  Then 
the  administration  of  stimulants  will  be  found  useful;  of  course, 
they  have  lo  be  given  with  great  caution,  and  be  selected  care. 
fully.  Vinegar  enemata.  sinapisms,  and  ether  injections  may 
be  tried.  Changes  in  the  blood  pressure  of  the  brain  ought  lo 
be  avoided  most  carefully;  they  may  be  produced  by  turning 
the  patient  in  bed.  by  shouting  at  him  frequently,  and  by  other 
attempts  to  wake  him  from  his  coma.  The  physician  will  have 
lo  warn  the  friends  against  doing  this,  and  do  his  best  to  have 
ihe  patient  left  ijuiet  and  undisturbed.  If  ilie  face  is  congested, 
he  will  order  his  head  to  be  placed  high  and  have  him  kept  in 
one  position.  Local  bleeding  from  the  head  is.  if  not  directly 
harmful,  absolutely  useless.  If  bleeding  is  indicated  at  all.  we 
shall  choose  venesection  :  cupping  and  leeching  are  matters  of 


TREATMENT  OF  CEHEBRAL  HMMORRHAGB. 


239 


!(0  much  detail  and  arc  so  slow  in  their  action  that  they  can  not 
be  recommended. 

Immediately  aflcr  the  attack  has  passed  off  and  (he  patient 
has  regained  consciousness  the  cliici  task  of  the  physician  is  to 
Bsee  that  he  has  absolute  rest     Even  more  than  any  other  sud- 
Bden  illneK!.  apoplexy  produces  the  greatest  excitement  and 
V  conftlcrnation  in  a  family,  and  it  can  hardly  be  wondered  at 
that  this  fnvcs  place  to  the  greatest  joy  when  the  patient,  who 
has  already  been  given  up.  is  seen  to  return  to  life,  and  that 
each  member  uf  the  (amily  is  anxious  to  express  his  feeling  of 
satisfaction.    All  such  outbursts  may  be  very  harmful  to  the  pa- 
ticnt.  and  these  demonstrations  must  be  crushed  by  the  physi- 
cian with  iron  tirmticss  in  order  to  avoid  any  emotion  on  the 
part  of  the  patient :  besides,  he  should  give  directions  as  tu  8 
proper  bed  which  will  answer  all  the  therapeutic  and  hygienic 
requirements  of  the  case,  and,  above  all.  from  the  very  first 
due  precautions  against  bcd-sore3  ought  to  be  taken.     Proper 
arrangements  should  be  made  for  the  reception  of  the  stools 
ind  the  nrinc.     The  head  ought  to  be  covered  with  thin  com. 
K  (iresscs,  cooled  with  ice-water  or  with  a  light  ice-bag  that  will 
eicrt  nil  pressure.    The  application  of  cold  must  not.  however. 
be  carried  too  far.  since  by  a  contraction  of  the  peripheral 
vessels  we  run  a  risk  of  producing  an   increase  in  the  intra* 
cranial  blood  pressure,  which  vi-ould  be  the  opposite  of  what 
we  are  attempting  to  do.     Any  simple  medicine  which  con- 

IUins  acids  or  cream  o(  tartar  or  tartar,  boraxat.  and  the  like, 
a  sufficient  tor  the  first  few  days,  during  which  the  patient 
onKht  to  be  fed  upon  a  light,  nourishing,  but  unstinuilating 
(i)  The  treatment  of  the  focal  lesion  in  the  brain— that  is, 
ol  the  place  where  the  harmorrhagc  has  occurred— should  not 
btb^iin  until  a  considerable  time  has  elapsed  after  the  gen- 
ual symptoms  have  abated.  This  will  usually  be  from  about 
tour  to  six  weeks  after  the  attack.  Whether  it  is  actually 
xiy  to  wait  so  long  we  do  not  know,  but,  as  a  matter  of 
)t.  we  are  afraid  to  undertake  any  active  measures  at  an 
Wiicr  moment,  and  certainly  if  a  physician  should  go  contrary 
•o  trxdition,  and  if  accidentally  another  ha-morrhage  should 
*t«r,  he  would  by  himself  open  to  severe  censure  on  the  part 
"*  the  family. 

Ott  the  other  hand,  it  seems  more  than  doubtful  whether 
•tare  able  to  influence  the  disease-focus  in  any  way  by  treat- 


h 


340 


DISEASES  OF  THE  BXAIK  PROPEK. 


ment  or  succeed  in  Imstcning  the  absorption  which  we  desire. 
It  is,  however,  supposed  that  this  can  be  accomplished  in  two 
wa^'S  :  namely,  by  internal  and  external  remedies,  by  polassitim 
iodide  and  mercury,  and  by  galvanic  treatment  rcspcctivelv. 
The  iodide  treatment  is  based  on  the  supposed  absorbent  pro|>- 
criics  of  the  druR.  Whether  it  possesses  such  a  power  to  any 
great  degree  is  doubtful,  and  the  (act  that  it  so  frequently  fails 
to  give  good  results  seems  to  speak  very  much  against  it.  ()n 
the  other  hand,  there  is  no  question  but  that  iodide,  if  used  for 
any  long  period  ol  time,  acts  dclctcriously  on  the  stomach,  and 
Spoils  the  appetite  and  may  lead  to  symptoms  of  intoxication. 
An  unprejudiced  practitioner  who  docs  not  administer  medi- 
cine in  a  routine  way  will  therefore  .ilways  first  ask  himself 
which  of  thetwo  is  the  lesser  evil — xvhcthcr  he  should  renounce 
such  help  as  is  supposed  to  be  derived  from  the  remedy  in  the 
process  of  absorption  and  keep  the  patient's  appetite  in  a  good 
condition,  or  whether  he  should  depend  upon  the  more  than 
doubtful  action  of  the  drug  and  at  the  same  time  ruin  the  pa- 
tient's digestion.  But  if  we  have  once  decided  to  administer 
iodide  of  potassium,  let  it  tje  done  boldly,  and  let  2.0,  3.0,  $.0 
(30,  45  to  75  grains)  a  day  in  one  or  two  doses  be  given  in  hot 
milk.  Given  in  this  way  the  administration  of  the  drug  is  less 
likely  to  be  followed  by  unpleasant  effects  than  if  we  order  a 
tablcspoonful  three  times  a  day  of  a  solution  of  iodide,  4.0  to  8jO; 
water,  200  ( 3  i  -  3  i j  to  3  vj).  The  mercurial  inunctions  to  the 
portion  of  the  skull  corresponding  to  the  focus  arc  not  harmful 
if  any  symptoms  of  intoxication  arc  watched  for  and  salivation 
is  at  once  treated  energetically  ;  but  their  success  is  in  no  way 
greater  than  that  obtained  with  potassium  iodide. 

With  regard  to  the  galvanic  treatment,  it  must  first  of  all 
be  absolutely  admitted  that  it  is  possible  to  act  upon  the  brain 
with  the  galvanic  current.  The  peculiar  phenomena  which 
occur  during  galvanization  of  the  head — vertigo,  seeing  of 
sparks,  etc.,  the  cerebral  nature  of  which  can  not  be  doubted— 
speak  strongly  in  favor  of  such  a  possibility,  and  the  experi- 
ments of  Loewcnfctd  on  animals  seem  to  indicate  that  these 
are  due  to  an  influence  on  the  circulation  in  the  brain.  Whether, 
however,  the  galvanic  current  possesses,  besides  this  undoubted 
action  on  the  vaso-motor  nerves,  definite  catalytic  projierties, 
and.  if  so,  in  a  measure  sufficient  to  enable  us  with  its  help  to 
influence  the  discascfocus,  nobody  knows.  We  will  suppose 
this  and  hope  that  it  is  so,  because  it  is  the  only  weapon  upon 


TRKATMHNT  OF  CEftF.BKAL  UtiMt/'l.HafA.  24I 

hick  wc  have  lo  depend.  The  best  and  most  reliable  electro- 
;bcr3f>euti$ts,  Erb  at  their  head,  with  his  unusually  wide  cx> 
n'encc,  ndniit  the  scarcity  of  positive  rcsuUs  front  such  a 
liratmeni,  and  acknowledge  that  in  by  (ar  the  greater  number 
of  cases  tbcy  arc  negative  (Erb.  Ilandbuch  dcr  Electrotbera- 
*'e,  page  320,  Leipzig.  1882),  .Yet  cases  may  occur  where  the 
ysician  is  forced  to  resort  to  galvanization  of  the  head — 
"the  electrical  treatment  of  the  brain."  He  should  therefore 
be  familiar  with  the  mode  o(  application.  Only  large  electrodes 
ought  to  be  used.  Fig.  73  represents  the  head  electrode  of 
Erb.  The  anode  being  placed  on  the  forehead,  the  cathode  on 
the  neck,  weak  currents  without  make  or  break  should  be  al- 


} 


f%.  1^— Tks  IjiRot  ItSAD  CLsnaooB  icovRKBn  wtiH  Sfowos)  of  Ckii. 

Icved  10  pass  through  the  head  of  the  patient  for  from  one 
tninutc  and  a  half  to  two  minutes.  Transverse  and  oblique 
oitTots  may  al»o  be  tried.  (Details  are  to  be  found  in  Hin. 
Lcbitach,  /iv.  (-/>.,  page  165.) 

(()  The  treatment  of  the  hemiplegia  and  the  posthemiplegic 
Botordiiiurbances  demands,  if  any  success  is  lo  be  expected, 
■Wb  perseverance  on  the  part  of  the  patient  as  well  as  of  the 
phfiician.  If  we  can  not  familiarize  ourselves  with  the  idea 
**t  far  weeks  and  months  the  same  procedures  and  manipU' 
'•tiona  have  to  be  gone  through  in  exactly  the  same  way,  wc 
'*i»U  not  begin  the  treatment  at  all  nor  order  it  to  be  under, 
^keii.  Wc  shall  then  at  least  spare  ourselves  the  disapp<iinl- 
"njt  oi  a  failure  :  yet  with  patience,  and  where  the  ncccssiiry 
^^Ans  arc  not  wanting,  it  should  l>e  imdert-iken.  The  cases 
■•hicha  syMcmatic  treatment  for  a  long  time  has  benefited 
^W  patient  very  materially  arc  numerous  enough,  and  ihey 


243 


DISEASES  OP   THE   RKAl.K  PKOtEM. 


wuuld  undoubtedly  be  met  with  more  freqiienlty  if  a  (air  trial 
were  ^ven  it  more  often  than  if>  unfortunately  the  case.  Oross> 
\\\i\\\\\  has  shown  that  suggestion  plays  a  prominent  part  in  the 
results  ui  this  treatment  (Die  Erlolge  dcs  Suggcstionsthcrapic  bci 
nicht-hysterischen  Uihmungen,  Berlin,  1892),  Since  there  can 
be  no  question  of  regenerating  destroyed  brain  tissue,  his  aim 
is  U)  produce  an  iinproventenl  in  the  general  cerebrul  energy. 
To  this  point  wc  shall  return  later. 

From  internal  medicines  absolutely  no  effect  on  the  hemi- 
plegia is  10  be  expected,  and  even  the  most  sanguine  thera- 
peutists, whose  faith  in  drugs  is  unbounded,  abstain  here  from 
fruitless  attempts.  The  same  may  be  said  about  the  posthemi- 
plegic motor  disturbances,  and  if  we  here  make  menti<m  of  the 
use  of  veratrine  (0.002  to  0.003  tf-  'U  '**  '/■]  -i  ^^y  '»  P>"*) 
against  the  posthemiplegic  tremor,  it  is  only  to  declare  the  utter 
futility  of  this  medicament.  We  have  here  also  to  resort  chiefly 
to  electrical  treatment,  but  with  this  difTcrcnce,  that  the  good 
results  observed  are  much  more  frequent  and  much  more 
marked  than  in  treating  the  disease-focus.  Definite  rules  (or 
the  electrical  treatment  of  the  focal  lesions  as  well  as  the  hemi- 
plegic  and  the  posthemiplegic  phenomena  can  not  be  given. 
Every  experienced  electrotherapeutist  follows  certain  rules 
and  principles  which  he  has  found  out  for  himself  in  the  course 
of  years  trom  personal  observation.  Thus  one  claims  only  to 
accomplish  his  end  with  quite  weak,  while  the  other  has  seen 
better  results  from  the  use  of  strong  currents.  The  one  uses 
galvanism,  the  other  by  preference  the  faradic  current.  Every 
one  adduces  reasons  for  his  own  method,  which,  as  a  rule,  are 
strongly  combated  by  other  writers  who  claim  to  possess  in- 
finitely more  experience. 

Above  all,  the  wishes  of  the  patient  should  guide  us  in  de- 
ciding which  mode  of  electrization  should  be  chosen.  One 
man  tvill  have  a  genuine  idiosyncrasy  against  the  faradic  cur- 
rent, and  more  especially  a^in.<tt  the  faradic  brush.  Another 
can  not  stand  strong  galvanic  currents;  they  excite  him,  make 
him  nervous,  and  disturb  his  sleep.  In  a  very  general  way  we 
may  lay  down  the  rule  that  in  paralytic  conditions  most  is 
accomplished  by  the  galvanic  current,  with  frequent  makes 
and  breaks,  so  as  to  produce  contractions  of  the  muscles.  In 
conditions  of  irritation,  especially  contractures,  on  the  other 
hand,  most  is  accomplished  by  local  fiiradiiaiion.  Wc  hardly 
need  to  insist  that  the  greatest  attention  must  be  given  to  lire 


\ 


TKEATMENT  OF  CEKEBRAL  HEMIPLEGIA. 


243 


I 


UlC( 

^  in 


grou|»8  of  musck-s  most  severely  aflcctcd — lor  instance,  in  the 
upper  extrt;inities.  tu  the  extensors.  The  funidic  treatment 
niiiy.  e5pccially  tl  contructurcs  arc  threatening,  be  begun 
earlier  thnn  is  allowed  by  our  rule  given  above,  even  twelve 
to  fourteen  days  after  the  cessation  of  the  general  symptoms, 
without  any  danger  to  the  patient. 

I'alients  in  good  circumstances  expect  their  physician  to 
(end  them  to  a  watering  place  every  year,  ns  a  stay  there  is  a 
pleasant  change  from  the  monotonous  electrical  treatment,  and 
«i-e  can  not  blame  anybody  fur  putting  great  failh  in  it.  Un- 
fortunately, these  hopes  are  not  by  any  means  justi6ed.  and 
by  a  course  of  treatment  at  Oeynhausen.  Wildbad,  Gastcin, 
ind  Kagatz. 'where,  by  the  way,  the  temperature  of  the  balhs 
Might  not  to  exceed  93*  F„  painfully  little  is  .iccomplished,  cer- 
tainly a  great  deal  less  than  by  electrization  or  this  alternated 
with  massage.  The  latter  ought  to  be  mrricd  out  only  by 
well-trained  masseurs,  and  only  with  the  greatest  care.  From 
the  cold-water  treatment  we  also  have  seen  little  success  on  the 
whole,  although  it  is  decidedly  to  be  preferred  to  the  simple 
bot  baths  and  the  like.  This  also  must  be  administered  care- 
fully, and  must  be  adapted  to  ihe  idiosyncrasies  of  the  )xitient. 
1  rule  which  is  unfortunately  not  always  observed.  Hydro 
therapeutics  can  not  be  learned  in  the  clinics,  where  only  an 
occafiitinal  remark  is  made  about  it.  but  deserves  and  demands 
I  practical  study  in  establishments  where  this  treatment  is  in- 
telligently and  carefully  conducted.  The  reason  why  it  is  not 
esteemed  everywhere  as  highly  as  it  ought  to  be  is  because  it 
is  frequently  not  understood.  Those  who  wish  to  acquire  the 
theory  of  this  treatment  thoroughly  I  would  refer,  among 
other  works.  10  the  excellent  text-book  of  Winternitz. 

White  we  have  seen,  then,  how  helpless  therapeutics  is 
inst  cerebral  haemorrhage  and  its  consequences,  wc  have. 
(M  the  other  hand,  the  satisfaction  of  knowing  (hat  so  much 
lucccM  is  promised  by  a  timely  and  appropriate  prophylaxis, 
that  wr  must  rccf>mmend  it  most  earnestly  to  all  individuals  of 
X  Kk-calle<l  a|>oplcctic  habit,  all  who  are  inclined  to  cerebral 
CMigcslion,  all  patients  with  a  heart  hypertrophy,  and.  finally, 
all  thoitc  with  hereditary  tendencies.  They  should  try  to  avoid 
putting  on  too  much  flesh,  and  shun  everything  which  would 
cnnducc  to  the  production  of  an  undue  increase  in  the  blood 
pressure  Among  the  most  important  rules  upon  which  wc 
must  insist  arc  moderation  in  eating,  regulation  of  the  bowels. 


344  DISEASES  OF   THE   BRAIN  PROPER. 

frequent  exercise  in  the  open  air,  systematic  gymnastics  in- 
doors— for  instance,  on  the  "ergostat"  of  Dr.  Gartner,  of 
Vienna,  a  small  apparatus  which  can  easily  be  kept  in  the 
room  and  on  which  a  large  amount  of  work,  measured  by 
kilogramme-metres,  can  be  done  (the  work  can  be  prescribed 
in  kilogramme-metres).  This  apparatus  I  can  highly  recom- 
mend, as  I  have  very  often  seen  good  results  from  its  use.  To 
avoid  increase  in  the  blood  pressure,  the  use  of  alcohol,  coffee, 
and  other  stimulants,  finally,  all  excitement,  be  it  sexual  or  of 
any  other  kind,  should  be  interdicted.  Unfortunately,  these 
warnings  of  the  physician  are  not  listened  to  until  it  is  already 
too  late,  and  men  who  will  protect  themselves  in  time  and  give 
up  some  pet  habit — the  customary  nap  after  dinner,  or  the  like 
— in  order  to  avoid  a  danger  that  only  threatens,  are  few  and 
far  between. 

2.  Embolism  and   Thrombosis  of  the  Cerebral  Arteries, 
Eiieephalomaiaeia . 

Pathological  Anatomjr.^We  have  already  adverted  to  the 
fact  that  the  arteries  of  the  cortex  anastomose  among  them- 
selves, while  those  of  the  basal  ganglia  are  what  we  call  ter- 
minal arteries ;  from  this  it  is  evident  that  the  embolus  has 
quite  a  different  significance  where  it  plugs  up  an  artery  of 
the  former  type  to  that  which  it  possesses  when  the  ob- 
structed vessel  is  a  terminal  artery,  and  no  collateral  circula- 
tion is  possible,  fn  the  first  case  the  collateral  circulation 
compensates  for  the  damage,  while  in  the  second  case  we  arc 
bound  to  have  a  necrosis  in  the  areas  supplied  by  the  ob- 
structed artery,  a  '■  focus  of  softening."  It  is  unnecessary  to 
dwell  much  upon  the  important  bearing  of  this  fact;  suffice 
it  to  say  that  the  arteries  usually  concerned  are  the  main 
branches  and,  above  all,  the  middle  cerebral.  The  reason 
why  embolic  processes  arc  more  frequent  on  the  left  than  on 
the  right  side  has  already  been  explained.  Brain  emboli  origi- 
nate in  the  same  manner  as  emboli  in  other  organs;  among 
the  causes  are  diseases  of  the  left  heart— chronic  endocarditis, 
mitral  disease,  and  weak  heart — aortic  aneurisms,  more  rarely 
diseases  in  the  pulmonary  circulation.  Thus  in  certain  cases 
[Hirulent  particles  may  pass  from  the  lungs  into  the  pulmonary 
vein  (in  ulcerative  bronchitis,  gangrene  of  the  lungs,  etc.),  and 
bf  carried  into  the  svstcmic  circulation.  In  a  case  reported 
by  Diihnhardt  a  doublcd-up  cchinococcus  vesicle  was  the  cause 


SUeOUSM  Of  TIIH  CEREBKAL  ARTERIES. 


«4S 


<A  embottsin  in  the  left  art.  fnssnc  Sylvii,  the  lelt  art.  prof, 
cerebri,  und  thcartcr.  basilaris  iNcurol.  Centralbl.,  1890.  No,  19). 
Pilichen  (c(.  lit.)  has  also  shown  that  certain  poisons,  cspc- 
ci:illy  carbon  monoxide,  ^ippear  tu  sometimes  produce  soften- 
ing of  the  brain  substance.  According  to  him,  the  CO  while 
circulating  in  the  blood  acts  injuriously  on  the  nutrition  of 
the  vessels,  and  brings  about  fatty  degeneration  and  calcihca* 
lion  in  them,  tience  there  finally  results  a  necrosis  of  the 
liisue.  Il  is  possible  that  phosphorus  acts  in  a  similar  way. 
Age  plays  a  still  less  important  rSk  in  the  aetiology  ol  embol- 
ism than  in  that  of  h»:morrhagc,  whereas  the  influence  of  sex 
not  be  denied,  as  it  is  well  known  that  by  far  more  women 
'««  attacked  by  cerebral  embolism  than  tnen  :  it  is  possible  that 
this  is  the  case,  owing  to  the  greater  fretjuency  with  which  we 
find  articular  rheumatism  with  its  accompanying  heart  lesions 
in  the  female  sex,  especially  in  its  younger  members.  The 
puerperal  state  may  also  have  something  to  do  with  it. 

•  Thrombosis  ol  ihe  cerebral  arteries  is  either  produced  by 
an  atheromatous  process  which  narrows  the  lumen  o(  the  ves- 
sel, and  by  slowing  the  blood  current  gives  rise  to  co.igulation, 
or  by  an  abnormal  proncness  of  the  blood  to  coagulate.     The 

tfir»t  happens  frequently  in  old  people,  and  we  can  fairly  say 
that  atheroma  is  just  as  often  the  cause  of  senile  softening  as 
tniliary  aneurisms  arc  the  cause  of  cerebral  ha:morrhaRe.  The 
sttmormal  tendency  to  coagulate  (hyperinosis).  which  the  blood 
presents  in  the  puerperal  state,  in  pneumonia,  etc..  is  rarely  or 

»>icvcr  the  only  cause  of  coagulation.  It  can  not  be  said  to  do 
»n«re  than  favor  it.  and  hence  we  need  not  go  further  into  Ihe 
cjuesliun.    0>nstdcrable  general    increase  in   the  intracranial 

IT  ■ '  e  may  give  rise  to  thrombosis  (compression  thrombosis), 

.  -  •  the  pressure  exerted  on  the  vessels  which  occurs  some- 
times in  iMMlar  meningitis.  If.  in  addition,  the  arterial  walls  are 
ItseAsed — fur  instance,  by  rubcrculosis  or  syphilis— Ihe  coit- 
liliun*  are  still  more  favorable  for  Ihe  formation  of  thrombosis. 
According  to  Ocrhardt,  the  hemiplegias  which  occur  in  the 
ruurse  ol  basilar  meningitis  are  due  to  thrombosis  with  second- 
iry  Mtflening. 

Finally,  we  should  remember  that  traumatism— a  fall  or  a 
alow  upon  the  he:id — may  produce  a  disease  in  the  arteries 
which  long  alter  may  give  rise  to  Ihrombosis, 

the  necrosis  of  the  brain  tissue  which  follows  the  cutting 
i  the  arterial  blood  supply  is  called  softening,  encephalo- 


246* 


DiS£ASES  Of  THE  BflAtX  PHOrEK. 


malacia,  and  wc  speak,  according  lo  the  special  {etiological  lac- 
tor,  of  a  traumatic,  an  embolic  or  tlirombolic.  and  an  atlieroma> 
tous  (senile)  sultcning.  The  process  15  as  folloivs  {Wernicke): 
The  vessels  in  the  area  (rom  wliich  the  blood  supply  is  cut  ufl 
collapse,  the  Lymph  spaces  dilate  and  through  aspiration  be- 
come filled  with  cerebro-spinal  fluid,  so  thai  the  whole  tissue 
appears  soaked,  and  the  recent  locus  ol  softening  shows  a  de- 
cided increase  in  volume;  the  nerve  fibres  and  nerve  cells  then 
become  macerated  in  the  fluid,  and  soon  undergo  destruction. 
With  the  microscope  we  delect  varicosities  ol  the  nerve  fibres, 
myelin  drops,  and  the  neuroglia  and  the  connective  tissue 
appear  irdemntoiis.  If  many  red  corpuscles  arc  present,  the 
coloring  matter  coming  from  them  gives  to  the  whole  locus 
u  yellowish  tint ;  such  a  discoloration  is  especially  seen  in  the 
cortex  (///i^fir/j  yi»M«*-j,  Charcot) ;  the  white  matter  which  lies 
beneath  is  usually  of  a  lighter  tint.  I(  then  no  sufficient  col- 
lateral blood  supply  is  established,  which,  as  seems  not  impos- 
sible in  a  recent  focus,  might  produce  complete  regeneration, 
there  commences  lo  develop  in  from  thirly-six  to  loriy-eight 
hours  a  fatty  retrograde  metamorphosis  of  the  necrotic  tissue, 
Polynuclear  leucocytes  emigrate  from  the  dilated  blood-vessels 
and  invade  the  necrotic  tissue:  they  take  up  the  fatty  parti- 
cles, and  some  reach  the  blood  current  again  through  the 
lymph  channels  as  compound  granular  corpuscles.  The  latter, 
which  arc  invariably  present  in  foci  of  softening  more  than  two 
days  old,  on  account  of  their  infiltration  with  fat  granules,  are 
larger  than  the  normal  leucocytes.  A  pari  of  them  seem  to 
undergo  fatty  degeneration,  others  seem  to  be  transformed  into 
myelin  drops,  especially  in  old  foci.  A  quite  gradual  absorp- 
tion of  the  dead  and  disintegrated  brain  tissue  takes  place,  and 
a  so-called  cysl  is  formed,  which  am  not  be  distinguished  from 
that  following  a  brain  hwniorrhagc;  more  rarely  wc  find  a 
cicatrix  of  connective  tissue,  which  becomes  as  hard  as  car- 
tilage, and  grates  under  the  knife.  Softenings,  which  from  thff 
onset  take  a  chronic  course,  have  frequently  been  found  I 
form  sclerotic  cicatrices,  so  that  the  soficniiig  can  eventually- 
become  a  sclerosis  (Wernicke). 

In  softening  of  the  cortex  quite  considerable  areas  may  be- 
come deficient,   which   are    partly   replaced    by   serous   fluid 
partly  by  thickened  pia.    The  convolutions,  which  sometime! 
remain,  present  a  yellowish  discoloration,  appear  atrophic,  an 
arc  of  a  firm  sclerotic  consistence. 


CEKEBRAl.  EMBOLISM. 


■  24? 


H  Symptoms  and  Diagnosis. — Just  as  in  hemorrhage,  we 
H  may  in  embolism  haw  symptoms  which  have  to  be  regarded 
^1  a»  premonitory  of  ihc  regular  attack.  They  resemble  very 
V  clfwdly  those  above  described,  and  chiefly  consist  ol  vertigo, 
I  lieadache,  an  occasional  feeling  as  of  pins  and  needles  in  the 
limbs,  etc.  The  headache  may  be  especially  prominent ;  it 
i;  may  persist  (or  weeks  with  undiminished  intensity.  »i)d  ttien 
H  disappear,  or  be  lullowed  by  a  distinct  deficiency  in  memory 
H    or  beginning  mental  decline. 

H         The  attack  proper,  which  occurs  at  the  moment  the  lumen 
H    of  the  vessel  is  completely  obstructed  by  the  embolus,  may 
^    simulate  the  a|)uplcctic  attack  so  closely  that  it  may  be  abs<> 
lutely  impossible  to  distinguish  the  one  from  the  other.     All 
ihe  above-described  differences  in   the  nature  and  degree  o( 
disturbance  of  consciousness  may  be  met  with  here  also,  and 
though  it  is  true  that  at  times  the  attack  sets  in  with  more  vio- 
lent  epileptiform  convulsions,  that  the  face  is  less  congested 
and  respiration  less  disturbed,  these  points  arc  by  no  means 
sufficient  (or  a  differential  diagnosis.     It  is  supposed  that  com- 
Hplctc  loss  o(  consciousness  speaks  more  against  embolism  and 
Hior  haemorrhage,  and  the  early  disappearance  of  the  paralytic 
^kymptoms  present  point  rather  to  embolism.    Gerhard!  con> 
Hsidcrs   (fieri,  klin.   Wochenschr..    May   2  and  9.   1S77)  a   welU 
Vproouunced  aphasia  to  be  in  favor  of  embolism  in  doubtful 
cases. 

In  embolism  the  attack  is  not  evoked  by  an  increase  in  the 
blo<Kl  pressure,  as  in  apoplexy,  but  by  a  "  negative  pressure." 
**  Since  the  vessels  lying  to  the  peripheral  side  of  the  embolus 
buddenly  collapse,  and  the  blood  contained  in  the  capillaries 
lows  into  the  veins  owing  to  the  i-/j  a  ftrgo  exerted  by  the 
contraction  of   the  vessels,  a  vacuum  is  suddenly  formed  in 

KHe  ti5sue,  and  hence  a  negative  bk«)d  pressure  is  produced" 
Wernicke,  toe,  ett.,  p.  133).  In  its  efforts  to  fill  up  the  empty 
»f>acc.  the  brain  parenchyma  is  bound  to  be  subjected  to  a 
r«»<>rc  or  less  considerable  tniction  from  all  sides,  which  may 
»*"»melimes  lead  to  disintegration.  1(  only  a  very  small  area  is 
^fTccled  by  the  embolus,  a  regular  attack  may  not  lake  place 
»«»d  consciousness  not  be  lost:  it  it  is  very  large,  various  in- 
*J  «  rcct  symptoms  may  .tppear,  and  indeed  even  the  non.afTecled 
"*^misphcrc  be  implicated.  But  even  after  a  severe  stroke  and 
*>licr  consciousness  has  been  lost  (or  quite  a  long  time,  a  favor- 
^^Ic  event  is  by  no  means  impossible,  because  the  tissue  does 


248 


I>/S£AS£S  Of  THE  BRAIN  rKOPHK, 


not  necessarily  disintegrate,  as  in  lia;morrhagc.  but  an  equaliza- 
tion o(  the  blood  pressure  can  take  place,  which  will  cause  the 
disappcamncc  of  all  the  symptoms. 

Cerebriil  thrombosis  rarely  gives  rise  to  a  stroke,  owing  to 
the  slowness  with  which  the  process  lakes  place,  and  when  an 
apopleciilorm  att.ick  actually  does  occur,  it  must  be  due  to  ihe 
previous  obstruction  of  other,  neighboring,  vessels.  We  had 
»  considerable  area  dependent  for  its  blood  supply  on  a  single 
vessel  which  before  remained  open,  but  has  novr  gradually 
become  so  narrow  that  the  pressure  in  it  becomes  too  low  lo 
keep  up  the  function  (Wernicke). 

The  necrosis  (softening,  enccphalomalacia)  to  which  the  ob-  » 
siruction  of  an  artery,  if  lasting  sufficiently  long,  is  bound  to  \ 
give  rise,  manifests  itself  by  certain  focal  symptoms,  which 
may.  just  as  in  haemorrhage,  be  divided  into  direct  and  indi- 
rect. Among  the  indirect  the  hemiplegia,  often  attended  with 
hcmiana;sthesia,  which  closely  resembles  that  described  above, 
is  the  most  important.  Monoplegias  also  and  hemianopia  may 
set  in  without  a  definite  stroke,  and  m-iy  be  produced  indirectly 
from  the  focus  of  softening,  which  lies  in  close  proximity  to 
the  pari  the  functions  of  which  are  interfered  with,  if  an  cm- 
bolus  obstruct  an  artery  which  can  communicate  by  anasto- 
moses with  those  of  neighboring  areas,  and  thus  the  dam.ige 
can  be  compensated,  wc  shall  meet  with  transient  focal  symp- 
toms (Wernicke),  which  at  the  most  require  eight  days  (or 
complete  recovery. 

To  determine  the  exact  seal  of  the  focus  of  softening,  we 
must  go  to  work  with  the  same  caution  as  in  making  a  topical 
diagni>sis  of  a  cerebral  h;eniorrhage.     Here,  as  there,  wc  have 
lo  look  for  direct  foail  symptoms,  and  it  is  to  these  that  most 
attention  should   be  given  in  our  examination;  on  the  other 
hand,  wc  must  not  forget  that  a  focus  of  softening,  even  if  i 
be  of  considerable  cxlenr.  may  pass  through  all  its  phases  with- 
out a  single  symptom.     No  one  region  of  the  brain  seems  tu  bes 
more  exposed   to  softening  than  another.     We  found  that  the 
numbei'  of  ti.xnmrrhagcs  at  the  base  largely  preponderated  ovc 
those  in  the  cortex  ;  in  embolism  this  is  not  Ihe  case.    It  is  only^ 
because  the  surface  covered  by  the  cortex  is  much  larger  than 
that  of  the  brain  stem  that  we  find  in  the  latier  numerically 
(ewer  cases  of  softening  than  in  the  cortex  (Wernicke)>.     The 
thalamus  and  pons  arc  only  rarely  the  seat  o(  isolated  soften 
tng,  while  hxmorrliagcs  arc  lound  there  much  more  frequently 


PSKUPO-nCl.n^R  /'AXALYStS. 


249 


I 


whereas  the  medulla  oblongata  is  more  commonlj-  the  seat  o\ 
softening  (cf.  Berlin,  klin.  Wochenschn,  1S91.  24).  To  diag- 
nusitcnte  hemorrhage  in  the  medulla  oblongata  during  life  iti 
practicalljr  impossible,  as  in  these  cases  deatJi  is  almost  instnn- 
laneous. 

Prognosis. — The  prognosis  in  embolism  is,  tateris  f^ribus. 
in  general  better  than  that  oi  haemorrhage.  Not  only  is  the 
OMtlooic  for  complete  ncoytvy  more  favorable  even  if  the 
attack  has  been  severe  and  has  lasted  for  a  considerable  time, 
but  in  most  cases  the  danger  to  life  is  far  less  than  in  apoplexy. 
Indirect  action  upon  the  medulla  oblongata,  in  consequence 
which  the  urine  may  contain  albumin  or  sugar,  is  n  rare 
urrence.  Kven  a  softening  of  considerable  extent  may  ex- 
ist  for  a  relatively  long  lime  without  the  manifestation  of  any 
^rave  general  svinploms.  Yet  an  unfavorable  turn  is  not  im- 
possible, and  this  should  always  be  feared  if  a  sudden  and 
marked  elevation  of  temperature  takes  place. 

Treatment. — The  treatment  is  very  limited;  indeed,  embo- 
lism as  such,  and  the  necrosis  produced  by  it.  arc  entirely  out  o( 
its  reach.  It  can  only  be  directed  against  the  attack  or  cxmsisl 
of  the  prophylactic  measures  by  which  we  may  hope  to  prevent 
the  occurrence  or  repetition  of  the  accident.  The  latter  un- 
doubtedly is  the  more  important,  and  much  can  be  accomplished 
by  repealed  local  bleeding  from  the  head  (I^bordc).  a  proce- 
dure which  is  also  indicated  in  the  treatment  of  the  attack  itself, 
i*5  the  cerebral  circulation  is  possibly  favorably  influenced  by 
it.  That  absolute  rest  is  strongly  indicated  in  cases  where  heart 
disease  exists,  needs  hardly  to  be  mentioned.  Where  there  is 
»  reasonable  suspicion  of  syphilis,  potassium  iodide.  2X>  to  5.0 
<^^.  xxx-lxxv)/»ffl  die,  ought  to  be  exhibited. 

WScrc  there  are  multiple  foci  of  softening  the  symptoms 
lurally  depend  on  their  seat.  At  the  autopsy  a  number  of 
uch  foci  may  be  found  which  could  not  be  diagnosticated 
uring  life  because  they  were  too  small  and  were  situated  in 
lied  imiifferent  places.  If  several  portions  of  the  brain  are 
»  fleeted, c-ich  of  which  gives  rise  to  a  focal  symptom,  there  may 
t>g  a  complication  of  the  most  varied  clinical  manifestations. 

0(  great  practical  interest  is  the  observation  to  which  of 
^4kte  years  attention  has  repeatedly  been  called,  namely,  that 
'^»ci  of  softening  may  occur  in  that  cerebral  portion  of  the 
muscular  tract  which  contains  the  fibres  destined  to 


350 


DlSRASes  OF  THF.  ItltAIN  moPEK. 


supply  the  muscles  used  in  spenking  and  swallowing.  These 
fibres  pass  from  the  lower  third  ol  the  central  convolutions, 
where  the  supjioscd  centres  for  the  hypoglossiis  and  facial  arc 
situated,  and  end  in  the  nuclear  region  of  the  medulla  ob- 
longata. Such  foci  have  again  and  again  been  found.  Some- 
times they  were  bilateral  and  situated  in  the  basal  ganglia, 
especially  the  lenticular  nucleus,  sometimes  on  one  side  only — 
e.  g.,  in  the  right  corpus  striatum — and  it  has  been  observed 
that  they  sometimes  give  rise  to  a  complication  ul  symptoms 
which  simulate  most  closely  those  of  Duchcniic's  bulbar  paral- 
ysis. The  fact,  however,  should  be  especially  emphasized  that 
the  occurrence  of  such  a  focus  on  one  side  is  sufficient  by  itself 
to  produce  all  these  symptoms  (Lupine  and  Kirchhoff,  cf.  lit.). 

The  disturbances  which  go  to  make  up  the  clinical  picture 
arc  at  times  exclusively,  always  chiefly,  referable  to  speech 
and  deglutition.  They  resemble  at  first  sight  so  much  those 
of  bulbar  paralysis  that  the  name  pseudo-bulbar  paralysis,  or 
paralysis  glosso-Iabio-pharyngea  cerebralis.  seems  justifiable. 
Still,  there  arc  some  points  which  should  help  us  to  avoid  mis> 
takes.  Thus,  while  the  beginning  ol  the  true  bulbar  ]>aralysi8 
is  slow  and  gradual,  the  cerebral  form  often  sets  in  quite  sud- 
denly with  apoplecttfortn  symptoms ;  in  the  pseudo-bulbar 
paralysis  there  is  a  manifestation  of  other  cerebral  disturbances 
which  do  nut  occur  in  I)uchenne*s  disease.  Again,  the  latter 
runs  an  uninterrupted  progressive  course,  while  in  the  cerebral 
paralysis  long  remissions  are  frequently  met  with.  A  certain 
asymmetry  of  the  paralysis,  which  is  especially  noticeable  in 
the  orbicularis  oris(Berger),  favors  the  diagnosis  of  the  cerebral 
as  opposed  to  the  bulbar  alTcction.  Far  more  important  than 
all  these  points  is  the  condition  of  the  paralysed  muscles,  which 
show  no  atrophy  (Lercchc,  cf.  lit.),  and  of  the  tongue,  which 
also  does  not  become  atrophied  in  the  pseudo.b»lbar  paralysis, 
and  hence  does  not  assume  the  appearance  so  eminently  char- 
acteristic of  the  true  bulbar  form.  Consequently  there  are  no 
changes  to  be  made  out  in  the  electrical  cxcilabilily.  whereas 
in  Duchennc's  disease  reaction  of  degeneration  is  the  rule.  11. 
finally,  we  add  that  in  the  cerebral  form  the  laryngeal  muscles 
seem  lo  be  not  at  all  or  only  slightly  adecied,  we  have  sufficient 
data  to  solve  the  question  of  dilTcrcntial  diagnosis  in  most  cases 
satisfactorily  (cf.  the  excellent  article  by  Oppenheim  and  Sie- 
mcrling). 

The  prognosis  with  regard  to  life  is  just  as  unfavorable  in 


PSBUIH>-HULffAi!  rAttAt-YSiS. 


251 


L  ihe  o 
■  itiat  i 


I 


ihc  one  as  in  the  oilier  form,  only  this  should  be  borne  in  mind, 
itiat  in  the  pscudo-bulbar  paralysis  remissions  may  occur ;  that 

therefore  can  with  a  clear  conscience  give  the  patient  good 
s  of  improvement.  The  duration  ol  the  disease  may  be 
much  longer  than  is  ever  the  case  in  the  genuine  bulbar  paral- 
ysis. 

The  treatment  is  not  so  hopeless  as  in  Uuchenne's  disease. 
The  galvanic  current  intelligently  applied,  and  careful  galvan- 
iialiun  of  the  brain  and  peripheral  faradization  of  the  paretic 
rauM^lcs,  frequent  excitation  of  the  muscles  of  deglutition,  as 
was  described  on  page  149.  all  may  be  tried  with  the  justifiable 
eipcclation  of  effecting  at  least  a  transient,  sometimes  indeed 
a  quite  gratifying,  improvement. 

LITERATt'WB. 

^tcr.     L«ltrbuvh  (im  allgcm.  itod  spccicllcn  palhol.  Annlomie.     Eiil.  ii.  /rail, 

188s. 
mcben.      Zur  AelwIoKJe  (l«f  tlinwnvricl^ung  nnch    Kotilcndunslvcrgiflunt;, 

nchtl  dnigcn  Benierkunf^  4ur  Himqueltchung.     Viirhow'v  Arch.,  Btl- 

ci».  Hrh  1.  i8S«. 
WKhwiL     Zur  PathulufiH!  rlcr  Encrph.ilomnt.icic.     Innug.-DiKi^,  Breslmi,  18S7. 
^lotbv    Bdtrai;  4ur  ]>Aiholug:le  dcr  (idtimrrwckhunK-     InuuK.-Diss..  Bresliui, 

l«87. 
Guchholc     L'cbcr  V<:fiindcruiii;rn  *n  den  Cetilam  tier  (lirnl)4n«.  XIV.  Wniulrf> 

tcrummlunK  dei  suditcu lichen  Ncuruloj^cn.    Arcli.  f.  I'^ycli,.  1889,  %%i,  i. 

p.448- 
UilumL     Ein  I'lll  von  srcunclXrer  ErkrAnfcung  des  Sehhu|{e1>  uml  dcr  Regia 

wtnhaljniica.    Arcl»  f  P*>Th„  1S93,  wr,  j. 
Mwlmwi,     Zur  Kmninisi  ikr  I^mholie  und  Thrombo^p  dcr  t'lrhimanrruti, 

«c    BrtL  klin.  Wochenschi..  1S94.  1. 

>Ua.    l/ebrr  I'KtidobulbArp.ualyM.     Inaug.-lM&am..  Unsliiu.  iSBa 

Voakke.  ht.   tit.,  pp.  w8  tt  itf..  1881. 

KWllMa;     Arch.  f.  I>»>ch.  und  NtrrvcnkniTikh..  p.  131,  1881. 

Km    BnHn.Julr.  1881. 

B>|n.  <>     Paralysis  ^liMso-lal>ii>-pKir>'nK(Ni  ctrcbnilis  {Psrudo-tnillMr  paraly- 

*).    OnsJ.  Kr/il.  Zduchr..  3  //  «v..  1884. 
"ifufaiiii  and  Sic-mcrling,     Ulc  aciiic  ItullidriMnilyir  und  die  Psruiln-hulMlr- 

fvalpr.    CluM^-Anniikn,  1887.  xii.  p.  jji. 
iktaifte.    Dniucbp  innL  WocltciuctiT..  1888.  jj. 
(•"Kfcr.    £t(Hlc  Mir  la  panilysie  {[louo-lnbiie  cirf  brak  A  TArmr  pMudo-bunwire. 

Tiirik.  1890. 
WnnwT,    Zur  t^hr«  von  dw  tVudo-hutbKrpamlysc.     Pragrr  mrd.  Wochcn- 

Khnfl.  1890,  ig,  JO. 
(•Uttirllc.     Dcs  paralysks  |)wudo-bu1bain:s  d'origiiic  cir^br.dc.     MunijicIlicT, 

idgj. 


,252 


D/S£ASSS  OF  TUB  HRAI.S'  PKOPhR. 


3.  Etidarlcriitii  (Sjfphilitua). 

This  process,  first  accurately  described  by  Mciibnerin  1874? 
nfTects  more  especially  the  vessels  at  the  base  of  ihe  brain. 
The  walls  become  opaque,  show  grayish  translucent  or  whitish  J 
thickenings,  and  the  vessels  may  tinally  be  converted  into  firm, 
grayish-while  cords.  The  new  (issue  which  ciicroiichcs  upon 
the  lumen  ol  the  vessel  either  originates  in  the  intitna  by  an  jn>  ■ 
crease  of  the  endothelial  cells,  which  become  transformed  into 
connective  tissue  (Heubner). or  is  derived  from  the  nutrient  ves- 
scls  ol  the  media  and  advcntitia,  and  consists  therefore  ol  emi'  ■ 
grated  cells  ftiaumgarten).  On  account  of  this  tendency  1<) 
thickening  and  corisetiucnt  obliteration  of  Ilie  vessels.  C.  Fricd- 
lUnder  has  proposed  for  the  process  the  name  endarteriitis  ob-  ■ 
litcrans.  While  not  denying  that  lleubncr,  who  has  studictl 
ihe  question  most  carefully,  has  arrived  at  important  results, 
we  must  at  the  same  time  affirm  that  the  arterial  disease,  which 
he  describes  as  specific  in  nature,  is  not  peculiar  to  syphilis, 
but  that  wc  find  the  same  changes  wherever  we  have  a  chronic 
inflammatory  process  with  Ihe  formation  of  granulation  tissue, 
as,  for  instance,  as  a  consequence  ol  alcoholism  (C.  Fricd- 
lUnder).  This  one  fact  remains  of  the  greatest  practical  impor-. 
tance,  that  in  the  course  of  syphilis  the  cerebral  arteries  arc 
very  frequently  diseased,  and  that  as  the  outcome  ol  this  dis- 
eased stale  the  most  diverse  cerebral  symptoms  may  arise. 
Chorioretinitis,  for  example,  has  been  observed  by  Oswald 
(Deutsche  Mcd.-Ztg..  1888,  86).  That  under  certain  circum> 
stances  a  hemianopia  can  be  the  result  of  such  disease  is 
proved  by  the  inlcrcsting  case  reported  by  Treitel  and  Daum- 
gartcn  (Virch.  .^rcb..  Bd.  cxi,  Hefl  2.  1S88),  where,  as  a  conse- 
quence of  gummatous  arteriitis  obliterans  of  the  arleriu  cor- 
poris callosi  dextra,  although  the  optic  nerves  were  intact,  a 
unilateral  temporal  hemianopia  had  developed.  Furthermore, 
it  is  to  be  remembered  that  often  enough  an  autochthonous 
thrombosis  due  lo  this  arterial  disease  gives  rise  loan  attack 
which  can  not  be  distinguished  from  the  abovc'dcscribcd  true 
apoplectic  stroke  with  consequent  hemiplegia.  If  recovery 
takes  place  in  these  cases  the  same  thing  may  be  repealed  sev- 
eral times,  and  it  is  especially  in  syphilitic  diseases  of  the  ar- 
leries  that  this  is  relatively  frequent.  The  patient  suffers  from  I 
intense  p.iroxysmal  headaches,  occasionally  loses  his  conscious- 
ness, and  presents  a  transient   hemiplegia,  but  again  recovers 


\ 


DILATATION  OF  TUB  ARTERIES  OF  THE  BRAIN. 


253 


I 


'ly  well,  until  finally  he  succumbs  lo  a  graver  stroke.  This, 
then,  is  the  usual  course  which  the  disease  takes.  It  can,  of 
course,  only  be  diagnosticated  where  the  history  of  syphilis  is 
clear. 

The  recognition  may  sometimes  he  diHicult  if  other  cerebral 
sy>n|>lnms  arc  present,  such  as  speech  disturbance;^,  intention 
tremor,  decrease  in  memory,  and  the  like,  when  we  arc  liable 
to  think  of  multiple  sclerosis,  or  progressive  paralysis  of  the  in- 
«ive.  and  it  may  only  be  the  amenability  of  the  disease  to  spe- 
citic  ircatmcni  which  will  clear  up  all  doubts.  This  consists  in 
the  use  of  bold  doses  of  potassium  iodide,  4.0-6.0  (3  j~  3  jss.)  a 
^y  in  hot  milk  until  sixteen  ounces  are  taken,  and  an  ener. 

\c  course  of  inunctions — thirty  to  (ilty  inunctions  of  2.0-2.5 
();r.  xxx-xl)  ung.  hydrarg.  It  should  be  begun  as  soon  as  pos- 
Mble.  as  the  patient  is  in  no  way  injured  by  this  procedure, 
while  the  benefit  may  be  most  conspicuous. 


4.  Dilatalian  of  Ike  Arltrifs  0/  tht  Brain. 

Aneurisms  of  the   cerebral  arteries  may  be  of  traumatic 
origin  or,  what  is  more  common,  may  depend  upon  endarteri> 

Iiiis,  and  in  this  latter  case  syphilis  again  deserves  special  men- 
lion,  a»  among  fifty  cases  of  brain  syphilis  there  were  found 
ux  instances  with  aneurisms  (Heubner).  Spillman  reports 
Utcen  cases  in  which  following  syphilis  aneurisms  of  the 
iMllar  artery  were  found  (Ann.  de  Dermal,  et  de  Sypli.,  1S86, 
'  rii.  p.  641).  Further,  there  is  the  embolic  origin  of  aneurisms, 
which  must  not  be  forgotten  (Ponhck). 

Dilatations  have   been  noted   in  the  basilar  artery,  in  the 
middle  cerebral,  and,  though    but    rarely,  in   the  vertebrals. 
Three  cases  of  basilar  aneurism  have  been  reported  by  Noth- 
I'Aagcl  (Topischc  Diagnostik.  p.  526) ;  others  by  Watson  (Lancet, 
(October   13,  1888.  p.  719).     The  symptoms  presented  nothing 
mctcristic,  but  varied  much,  and  even  symptoms  referable 
to  the  pons  were  not  in  all  cases  present.    Vertebral  aneurisms, 
described   by   Cruvcilhier.  I-cbcrt.  and    others,  have  ncca- 
kion.itly  been   found  to  be  attended   with  occipital  neunilgia. 
I^ibtalion  of  the  vertebrals  produced  by  atheromatous  degen. 

■W'T-aiiiin  may  affect  the  surrounding  pansand.  as  a  consequence 
•»l  Uructuml  ch.inges  produced  in  the  neighborhood  of  the 
'v>{ru».  lemd  to  attacks  of  tt^itching  in  the  velum  palati  and  to 
^tave  respiratory  disturbances  (Oppenhcim  and  Sicmerling). 
Aneurisms  of   the  ophthalmic  or  internal  carotid  in  the 


«S4 


DKSKASSS  OF  THE  BRAtX  PXOPBlt. 


cavernous  sinus  may  give  rise  to  a  pulsating  exophltinlmus. 
wbich  can  by  appropriate  manipulation  be  temporarily  pressed 
back  into  ihc  urbit.  The  pulsation  of  the  eyeball,  which  mav 
bc  propagated  to  tlie  forehead  and  temple,  is  a  source  of  grcul 
annoyance  to  the  patient.  In  connection  with  multiple  aneu- 
risms, such  as  have  been  observed  by  Patilicki.  for  instance, 
fvisting  simultaneously  in  the  basilar,  the  anterior  communi- 
cating, and  the  middle  cerebral  artery,  epileptiform  convul- 
sions and  psychoses  have  been  noted.  Definite  p.ithognomon- 
ic  signs  do  not,  however,  exist,  and  the  diagnosis  intrp  '.■ilam 
is  only  exceptionally  made  with  certainty.  According  to  Oer- 
hnrdt.  there  can  at  limes  be  heard  between  the  mastoid  process 
and  the  thick  cords  o(  the  muscles  of  the  neck  a  murmur  refer- 
able to  the  cerebral  arteries;  it  is  systolic  or  continuous,  and 
is  heard  on  one  or  both  sides  if  the  patient  refrains  from 
breathing  or  swallowing.  Nevertheless,  it  is  rather  cjcccji- 
tional  that  a  (small)  .-iiicurism  of  the  cerebral  arteries  is  diag- 
nosticatcd  correctly  during  life.  In  larger  arteurisms.  which 
produce  characteristic  focal  symptoms,  this  will  at  times  be 
easier,  especially  when  etiological  data — e.  g.,  traumatism — 
are  present. 

5.    The  Neurosfs  of  the  Arttrits  of  thi  Brain  {Anatnia  and 
Hyperamia  0/  lh<-  firatn). 

The  vaso-motor  nerves  of  the  cerebral  and  meningeal  arter- 
ies arise  partly  from  the  cervical  sympathetic  (Dondcrs  and 
Callenfels),  partly  from  certain  cranial  nerves  (Nothnagel), 
They  may  be  excited  or  paralyzed  idiopathically.  or  re8exly. 
especially  from  the  stomach,  and  the  resulting  conditions, 
although  as  yet  only  imperfectly  understood,  are  of  great 
practical  importance.  Both  stimulation  and  paralysis  are,  of 
course,  usually  only  temporary,  while  in  the  intervals  and  in 
the  normal  state  the  vasn-motor  nerves  as  well  as  their  centres 
are  in  a  state  ot  moderate  tonus.  If  the  stimulation  should 
frorp  any  cause  be  more  than  is  necessary  to  maintain  this 
normal  tonus,  a  spasmodic  contraction  of  the  smaller  arteries 
takes  place,  the  absolute  amount  of  blood  in  the  brain  becomes 
diminished,  the  patient  gels  pale,  complains  of  dizziness,  and 
loses  consciousncss^in  other  words,  "  faints  "  (acute  nervous 
cerebral  an;emia).  At  the  same  tinTe  the  heart's  action  is  weak- 
ened, the  pulse  is  small,  the  face  and  body  are  covered  with 
cold  perspiration,  and  if  this  irritation  is  frequently  repeated  a 


XEUHOSES  OF  THE  CERBliRAl.  ARTBRIES. 


ass 


certain  predisposition  to  slight  changes  in  the  blood  pressure 
becomes  gradually  established,  a  condition  oi  things  which  is 
lavored  by  the  mobility  of  the  ccrcbro-spinal  fluid.  The  at- 
tacks now  occur  on  the  slightest  provocation,  and  in  the  in- 
tervals  between  them  the  |>atienl  complains  of  dnil  headache, 
vertigo,  etc.,  the  face  at  the  same  time  usually  being  of  a  pale, 
w-ax-likc  color.  Certain  general  diseases,  especially  chlorosis 
and  pernicious  anaemia,  greatly  predispose  to  these  paroxys- 
mal vascular  spasms :  in  fact,  cerebral  anivmia  is  not  infre- 
quently one  of  the  symptoms  of  general  anxmia,  as  ir  is  ob- 
served, for  instance,  after  frequent  and  profuse  bleeding  from 

iiorrhoids. 

Among  the  (etiological  factors,  certain  occupations  play  an 
important  Hlc.  Working  in  lead  especially  may  give  rise  to  a 
chronic  vascular  spasm,  and  thus  to  a  cerebral  anaemia,  which 
is  associated  with  almost  constant  headache  (cnccphalopathia 
mumina). 

Tanqucrel  des  Planches,  the  best  modem  authority  on 
saturnine  affections,  has  described  this  condition,  and  il  ha& 
again  and  again  been  made  the  subject  of  the  most  careful  in- 
quiries. It  would  be  beyond  the  scope  of  our  present  work  to 
t'pcak  nf  these  in  detail :  those  interested  in  the  subject  will 
find  references  at  the  end  of  the  chapter;  suffice  it  only  to  say 
here  that  this  saturnine  anxmia,  if  the  obnoxious  action  of  the 
metal  is  continued  and  the  disease  is  once  established,  may  pro- 
duce in  the  workers  severe  cerebral  attacks,  epileptiform  con- 
Tulsiuns,  and  the  like. 

The  treatment  of  acute  cerebral  anaemia  consists  primarily 

ui  placing  the  patient  in  an  appropriate  position — that  is,  with 

the  head  low  or  at  about  the  same  level  as  the  feel,  so  as  to 

aid  the  blood  flow  to  the  brain  ;  the  use  of  stimulants  (wtne, 

brandy,  coflec),  occasionally  a  subcutaneous  injection  of  ether, 

(nay  be  indicated.     Those  who  are  familiar  with  the  procedure 

inflate  the  Kustachian  tubes,  as  Kessel  recommends :  this 

r4ouche"  is  said  to  be  an  excellent  method  of  producing 
jiidly  an  increased  flow  of  blood  to  the  anaemic  brain  (Laker, 
^Vicn.  mcd.  Presse,  1891,  25). 

Kur  chronic  cerebral  ana'niia  galvanization  of  the  brain  or 

**t  the  cerebral  sympathetic  may   be  tried.     As  u   matter  of 

coune,  attention  must  also  be  paid  to  a  possible  primary  cause, 

and  "rvcry   pernicious  atiological    factor  removed  (change  of 

"ccujxiliim,  etc.). 


2S6 


P/SE^SHS  Of  TUP.  nUAIN  PKOPER. 


The  opposite  condition,  a  paralysis  o[  the  vaso-motor  nerves. 
produces  u  dilatation  of  the  cerebral  vessels,  and  thus  an  im- 
mediate overlilling  o(  the  same.  This  can  be  deniunst rated  by 
ophthalmoscoiiic  examination.  Often,  but  not  always,  the  vcs. 
sels  of  the  face  share  in  the  disturbance ;  the  countenance  uf 
the  patient  assumes  a  piirplish-red  color,  he  complains  of  throb- 
bing in  his  temporals  and  carotids,  of  headache,  ol  buzzing  in 
the  cars  (acute  nervous  hyperemia) — in  general,  of  about  the 
same  symptoms  as  we  have  described  in  the  vascular  spasm, 
the  only  diflcrencc  lying  in  the  color  of  the  face.  It  is  ob- 
served in  certain  individuals  regularly  after  the  use  of  quite 
moderate  quantities  of  alcoholic  beverages  (wine,  beer),  or,  just 
as  the  ana'mia,  after  emotions,  stning  bodily  or  menial  exer- 
tions, too  much  study,  etc :  the  abuse  of  tobacco  may  also 
give  rise  to  it. 

On  account  of  the  very  varied  manifestations  of  the  aSec- 
lion  different  forms  of  cerebral  hypcraimia  have  been  distin- 
guished (Andral.  Eichhorst).  Thus,  a  ccphalalgic,  a  psychical, 
a  convulsive,  and  an  apoplectic  form  have  been  described, 
according  as  cither  headache  or  psychical  excitement,  with  in- 
somnia or  epileptiform  attacks  or  periods  of  unconscioustiei^ 
(which  latter  arc  not  rarely  followed  by  cerebral  hemorrhage), 
are  the  most  prominent  symptoms.  The  transition  between 
these  ■■  forms  "  is,  however,  so  gradual,  and  so  seldom  are  they 
sharply  defined,  that  for  practical  purposes  it  docs  not  seem 
worth  while  to  make  the  distinction.  We  have  repeatedly  ob- 
served marked  contraction  of  the  pupils,  while  in  ana-mia  they 
are  more  frequently  dilated  and  react  sluggishly.  As  we  have 
pointed  out  above,  simple  cerebral  hyperarmia  may  produce 
hemiplegia,  which  can  easily  be  confounded  with  the  apoplectic 
form  (pseudo-apoplexy). 

The  treatment  is  rather  unsatisfactory  ;  it  is  true  wc  may 
in  acute  attacks  of  cerebral  hyper:tmi,a  give  early  relief  io  a 
patient  by  placing  him  in  an  appropriate— that  is,  nearly  sil- 
ling— posture,  by  applying  ice-bags  to  his  head,  or,  finally,  by 
free  venesection ;  but  these  atucks  are  so  frequently  rcpCJitcd 
in  individuals  predi-sposcd  to  them  that  the  question  of  such 
treatment  is  not  of  so  much  importance  as  of  the  adoption  for 
months  and  years  of  a  careful  dietetic  regime.  Besides  keeping 
the  bowels  well  open — a  thing  which  should  never  be  omitted 
— the  patient  must  be  advised  to  take  enough  exercise,  even 
practice   gymnastics ;    he  should   be   cautioned  against    indul- 


DISEASES  OF  TUB  C£ff£fiJfAl   VELVS. 


257 


rnce  in  heavy,  indigestible  foods,  and,  above  all,  in  alcoholic 
averages.  A  yearly  visit  to  places  liltc  Marietibad.  followed 
Pby  a  stay  in  a  pure  mniinlain  air,  moderate  but  daily  cxcur- 
[sions  on  foot,  the  occisioiiul  um:  of  Carl^^bad  water  under  the 
direction  of  the  physician— all  these  may  be  prescribed  with 
[advantage.  Much  caution  should,  however,  be  used  with  the 
[fk^alled  cold-water  treatment,  which,  like  scu-balhs,  may  only 
[hcn-asc  the  hyperiemia.  This  applies  equally  to  the  massage 
rlrcaimcnl,  which,  unless  carried  out  in  accordance  with  cer- 
'lain  indications  and  fixed  rules,  and  under  the  supervision  o(  a 

rompclcnt  medical   man,  often   is  productive  of  more  harm 

than  good  in  this  disease. 


I  LITERATURE. 

Tuiqurrcl  d«  IHanchn.  Lrad  [>iiicasi-s  :  wSih  Noics  and  Additions  on  ihe  Usr 
of  ihr  LeA«l  I'ipe  ami  in  SututiluiM.  By  Sxmuel  L.  Danji,  Lon«ll.  184S, 
■Dd  BiMion.  i8ja 

Rtittloat.     Gat.  dcK  hAp..  6S-71,  1873. 

Iln)[n',  O.     BnlmcT  Iclin.  WochenKhr.,  n,  14.  p.  tS3,  1874. 

JI^AiMT/.     Cu.  dc  PaiH.  I.  i.  187,^ 

Bmchtai.    Cm.  dcs  hA|x,  14.  1875. 

lipinc    U31.  <k  Pjiris.  47.  187S- 

II>n.    Kinnkhdtcn  drr  Arlwiict.  iii.  49,  187$. 

HweiKti.     Wim^Rili.  Con^f).  H)..  li.  y>,  iSKt. 

Ilibbli.    2ur  i:n<:r|>halo|Miliia  saturiims.     Allg.  ZeilschT.  1  P«>'<:h.,  uxtx,  1.  3, 

I«t3. 

CUilltr.    Contriliuiiun  &  I'Mude  |»tho;,'6nique  du  salurnbme  cer^bro>«pina). 

lYmc  ik  fJin^.  No,  101.  18S].  p|>  45  rf  iff. 
kkili.  I*iiul.     Uclirr  F.iii.'«'j>halo|M(hi.»  und  Arihnilgia  t^aiumiaa.     Inaug.-Uira. 

VrjiiiLiv.  1H8;. 
fimtf.     New  Vurit  M«li<-;ik  Record.  Novrnibcr  13.  1886 
iMgwiid.    Hypcrhimic  chionii|ue  du  cervcau  ct  dc  la  iikh'IIc  ^pinirrt,     I'rogr. 

nhU  9<.  1887. 
Wai|luL  Alrx.     Ucbrr  Encrphalop.-iihu  saturnin.-i.     Arcli.  f.  l'i)«K.,  xix,  3. 

R  Diseases  of  the  Cerebral  Veins  and  Sinuses.— The  blood 
f"™  ihe  htJiM  and  meninges  j§  earned  hack  toward  the  heart  by  the 
""nnal  jugular  vein.  This  vessel  emerges  from  the  jugular  (orn- 
"Ml  and  after  its  junction  with  the  external  jugular  becomes  Ihe 
wnwon  jufiilar.  which,  after  it  ha«  in  turn  received  the  stibtlaviiin, 
■^ciUcdthc  innominate  vein.  The  lu-o  innominate^  together  fwrro 
"It  Mi{icnor  vena  cava. 

Uctwecii  ilie  two  layers  of  the  dura  mater  there  exist  spaces 
"web  CDnTe)r  venous  blood  but  arc  without  valves.  These  are 
^kA  «nii!te».  The  vein*  of  the  Cnrlex  cmi>!y  themselves  into  the 
iMKttiidinal  stnus  (sni.  faldf,  ma) ),  which  terminates  behind  in  the 

IT 


258 


P/SSASSS  or  THE  BRAlff  PROPER. 


lorcular  Herophili  (connueiii  »iiiiium}.  The  mode  in  which  the  veins 
empty  into  the  stnu&— namely,  in  the  direction  opposite  to  that  of 
the  blood  current  in  the  latter — produces  a  slowing  of  the  circuta- 
lioR,  and  thus  explains  the  frequent  occurrence  uf  coagula  in  the 
veins  of  the  cortex  and  the  sinus.  The  deep  cerebral  veins  are  col- 
lected into  two  trunks,  winch  are  known  as  the  veins  of  Galen,  The^ 
again  unite  into  one,  the  vena  magna  Oaleni.  They  convey  the 
blood  from  the  ventricles  to  the  sinus  rectus  (pcrpendicularisi), 
which  in  its  turn  empties  itself  into  the  torcutar  Herophili.  The 
blood  from  the  inner  ear  goes  into  the  cavernous  sinus  which  is  situ- 
ated at  the  Mde  of  the  sella  turcica;  that  from  the  mastoid  cells 
into  the  lateral  sinus,  which  at  the  jugular  foramen  pahttet  into  the 
ao-called  bulb  of  the  interna)  jugular  vein.  The  veins,  ihems^elves 
anastomose  but  little  with  each  other,  nhile  the  sinuses  do  m>  freely. 
It  is  important  to  note  the  cotnmunications  between  the  mtracranial 
and  the  extracranial  veins — for  instance,  of  ihc  nasal  with  the  ante- 
rior end  of  Ihc  longitudinal  sinus,  the  ophthalmics  with  the  sinus 
cavemosus  and  the  facial  veins,  etc. — and  the  communications  made 
by  the  venu:  diploiiiicK,  for  only  then  can  wc  understand  how  patho- 
logical proccMes  can  extend  from  the  outside  of  the  skull  to  the  in- 
side, and  how  occasionally  we  find  an  external  swelling  in  affections 
of  the  sinuses. 

Here  it  is  more  especially  thrombosis  with  which  we  have 
to  deal,  which  may  occur  in  the  veins  as  well  as  in  Ihc  sinuses. 
The  di>>tinction  is  not  always  easy  in  li(c  nor  even  after  death, 
because  alter  death  the  venou;^  thrombosis  may  extend  into 
the  sinus  and  be  taken  lor  a  sinus  thrombosis. 

If  only  one  vein  isaSected  the  mischief  may  be  but  slight. 
Usually,  however,  it  takes  in  one  or  two  ol  the  larger  veins, 
which  become  obstructed  during  the  course  of  exhausting, 
acute,  especially  infectious  diseases  or  after  an  injury,  lor  in- 
stance, a  blow  on  the  head.  The  preponderating  number  o(  the 
patients  are  children,  and  at  times,  especially  during  the  hot 
season,  quite  young  children,  in  which  cases  a  special  aetiologi- 
cal  datum  can  not  be  found.  The  symptonns  are  the  follow, 
ing:  Hemiplegia,  ushered  in  by  convulsions  and  lasting  only  a 
few  weeks,  is  followed  by  a  permanent  weakness,  not  infre-  , 
quentty  by  occasional  spasms  in  the  arm.  The  development  ■ 
of  the  child  is  then  usually  faulty,  for  apart  from  the  occasional 
atrophy  in  one  arm  or  in  one  leg  or  of  the  whole  side,  epilepli- 
form  convulsions  may  persist  (or  years,  which  not  rarely  have  ■ 
an  injurious  influence  on  the  menial  developmcnlof  the  patient, 
hi  such  cases  at  the  autopsy  often  thrombosis  of  the  longilu 


1 

1 


DISF.ASF.S  OF   THF.   CF.RF.BRAL  VF.tUS. 


2S9 


I 


dinit  sinus  and  o(  the  veins  empt^'ing  into  it  is  demonstrable. 
In  adults,  such  a  thing  as  a  thrombosis  ol  the  cortical  %'cins  is 
extremely  rare. 

Sinus  thrombosis  may  have  one  of  two  causes.     Either  we 
have  a  general  disease  which  favors  the  coagulation  of  \\w 
blood — as  in  children  profuse  diarrhtra,  acuic  infectious  dis- 
eases, in  old  people,  tuberculous  and  carcinomatous  processes 
— or  neighboring  parts,  as,  for  instance,  the  skull  bones  or  the 
skin  of  the  scalp  are  diseased  (erysipelas),  an  extension  of  the 
process  becoming  possible  on  account  of  the  communications 
between  the  extracranial  and  intracranial  vessels  above  de- 
scribed.    \Vc  distinguish   the  true  inflammatory  thrombosis, 
which  afTccts  the  later:il,  the  petrosal,  and  the  cavernous  sinus, 
Irom  the  soollcd  marantic  thrombosis,  which  often  occurs  in 
the  superior  longitudinal  isinus.     In  both  cases  the  secondary 
symptoms  of   engorgement,  which   are  especially    marked    in 
thrombosis  of  the  longitudinal  &inus  and  which  manifest  them, 
wives  in  so-called  meningeal  ha;morrhngcs.  are  of  the  greatest 
importance-     Such  meningeal  hieniurrliages  are  found  in  chil> 
drcn  (post  mortem)  as  thick  congula  distributed  over  ihc  cor- 
tical motor  centres,  where  they  have  in  life  given  rise  to  a 
curious  combination  of  paraly^^  and  spaKm,  the  power  of  spon- 
Uncous  movements,  however,  being  retained{Gowers).   Choreic 
movements   complete   the    picture    which   congenital   chorea, 
bilateral  athetosis, and  double  spastic  hemiplegia  present,  cases 
which  arc  difficult  to  interpret  and  still  more  diflicult  to  diag- 
imticate.      In    these   patients,  too,  the  mental   development 
rcmiins  imperfect,  and  their  irregular  movements  and  cnnlrac- 
lurci  (often  most  marked  in  the  calf  muscles)  give  them  the 
appearance  of  helpless  cripples. 

The  diagnosis  of  sinus  thrombosis  can  only  be  made  with 
4>|  certainty  if  to  the  general  symptoms  (headache,  somno- 
wet,  paralyses  in  the  distributions  of  the  cranial  nerves)  signs 
"i  added  which  point  to  circulatory  disturbances  peculiar  to 
linits  thrombosis.  Thus,  for  instance,  symptoms  of  engorge- 
1^1  in  tbe  ophthalmic  veins,  manifesting  itself  by  prominence 
"I  (he  eyeball,  (rdcma  of  the  lids,  congestion  of  the  retina,  etc., 
point  to  obstruction  of  the  cavernous  sinus;  (edematous  swell, 
wgs  behind  the  ear  to  affections  of  the  lateral  sinus,  and  finally 
tynptoms  of  p.issivc  hyper;emia  in  the  nose — epistaxis,  marked 
■iwen  in  the  veins  of  the  tcmpund  region,  in  small  children 
lalhen  ol  the  anterior  (.acial  veins  situated  bctwcn  the  large 


36o 


DtSEASF..'!  OP    THE   RHAllf  PROPER. 


fontnnellc  and  tlie  temples  (Gerliardt)— to  implication  of  the 
tungitudinal  sinus.  Fain  and  swelling  of  the  corresponding 
side  of  tlie  neck  may  be  signiricant  of  a  jugular  thrombosis, 
etc.  All  these  conditions  arc,  however,  but  rarely  met  wiih. 
and  they  arc  more  easily  found  in  the  books  than  demonstrable 
in  the  patient.  The  duration  ol  a  sttius  thrombosis  varies  be- 
tween several  days  and  three  to  at  most  lour  weeks.  The 
prognosis  is  usually  unfavorable  and  the  treatment  unsatisfac- 
tory and  purely  symptomatic. 

l.ITKKATt^RK. 

Powell.  Ca«e  of  Idiupaihic  I'hronihoxJs  i>r  Ccretiral  Sinus  and  Veins  o(  Calcn 
in  «  Young  Woman.     Lancci.  lJiM.-«inlicr,  1888.  ij,  13.  |>.  1134. 

Uonley.  A  Cane  of  Thrombosis  of  ihc  Lnngiiurtin.i)  Sinus,  together  with  the 
Aiilcrior  froiilal  Vein,  musing  Localiicil  Foci  of  H*m(irth,ifre.  which 
prodiicect  Remarkably  Lomli^fd  Conical  Epilcp&y.     Itrmn.  Ajiril.  1K88. 

MilicMtwcif;.  Subilunlc  llliitiing  .iiis  abnorm  vcrUud'Dilrn  CtchimvenetL 
Neurol.  CMitralbl.  1889.  7. 

Fcirnri.  Oblitfritiion  cxpidiocnialr  (1»  »inus  (I«  la  <lurc-ni4re,  ric.  Arch.  ital. 
debiol.,  1889,  xi,  p.  171. 

Zaufitl.  2tir  Otithlclite  der  operallven  Uehandlung  der  Sinusihroinboic  in  Folge 
von  Olliis  media.  Pf.ij;cr  med.  Wochenschr,,  1891,  3.  (Ligation  of  the 
Internal  JtigiiUr  Win  .ind  OpFiiiiij;  iif  the  Thrombosed  Sinus.) 

I'arkur  (Liverpool).     Itcrliner  kli".  Wochcnschr,  1891.  xni*.  la 

Zitm.  Wiener  klin,  Wochentchr.,  1893.  v,  36-3S.  (Sinus  ihrnmbosis  xfA 
Exophihalmus.) 

Elirentlorfcr  Wiener  med.  I'rcsse.  1893,  xtxiij,  19^  aa  (Sinus  ihrombosis  dur- 
ing ihc  Puerperal  .Si.ntc.) 

BJickletx.     Arch.  I.  Pttych.  u.  Nen-enhh..  1893.  xxv.  t. 

INFLAMMATORY     PROCESSES    IN     THE     BKAIN     SUUSTANCK. 

/.  PuruUnt  Encf^phalitis — BraiH  Abictss. 

Pathological  Anatomy. — Circumscribed  pus  formations  in 
the  substance  of  the  brain,  which  anatomically  differ  in  no  war 
from  pus  form;ilions  in  oilier  orjrans.  are  called  brain  abscesses, 
and  wc  speak  of  ihcm  as  encapsulated  and  non-encapsulaicd, 
accordtnfi  ;is  to  whether  or  nt>I  Ihry  are  definitely  .separalcd 
from  the  surrounding  tissues  by  sclerotic  thickening.  In  the 
former,  n  membrane  of  connective  tissue  incloses  the  abscess, 
which  contains  a  thick  pus  ;  in  the  latter,  disintegrated  nerve 
tissue  and  crystals  of  cholestcrin  are  found  in  conjunciion  with 
the  frequently  very  ftttid  pus,  and  the  abscess  walls  arc  formed 
by  a  soft  layer  of  brain  tissue  intilirated  with  pus.  and  sur- 
rounded by  areas  of  yellowish  softening  and  oedema.     In  the 


BKAIS  ABSCESS. 


361 


^ 
^ 


to 


icned  Areas  compound  granular  corpuscles  are  found  in 
t  numbers.  The  size  of  the  abscess  may  vary  from  that  of 
thai  of  ai)  apple,  and  it  may  even  take  in  nearly  (lie 
hemisphere.  The  larger  the  abscess  the  more  marked 
arc  the  signs  of  increased  iutracranial  pressure,  the  more  flat- 
tened and  Indistinct  ihe  con  vol  11  lions  on  ihe  surface  of  the 
brain,  and  the  <lrii:r  and  more  aclhcrciu  becomes  the  pia  mater. 
Should  the  abscess  break  through  into  one  of  the  ventricles, 
pus  may  eventually  be  found  in  all  of  them,  and  Ihe  cpcndyma 
(hen  appear  cvdematous.  If  it  reaches  the  surface  ul  the  brain 
il  may  give  rise  toa  diffuse  purulent  meningitis  (VVernickc). 

Etiology. — .-Etiologically.  injury  is  of  the  greatest  impor- 
tance.  though  it  need  not  necessarily  have  aflectcd  the  skull 
itself,  but  may  produce  an  abscess  just  as  well  if  contined  to 
the  »oft  parts ;  in  such  a  case,  the  inHammutiim  extends  through 
the  bone,  and  the  infectious  material  penetrates  into  the  brain 
from  the  flesh  wound.  If  we  have  no  open  wound,  no  break  of 
continuity  in  the  soft  parts,  then  even  extensive  destructions  of 
the  brain  sul>stancc  often  do  not  lead  to  an  abscess  formation, 
just  US  in  the  fractures  of  the  skull  healing  occurs  without  sup- 
puration provided  that  the  external  air  is  excluded  from  the 
injured  parts  of  the  brain. 

Besides  traumatism,  suppuration  occurring  in  the  neigh- 
borhood of  the  brain   may  cause  a  bniin  abscess;  thus,  in 
rare  instances,  it  is  a  purulent  parotitis  or  suppuration  in  the 
nasal  cavity,  or,  more  frequently,  caries  of  the  petrous  portion 
ol  the  tetnporal  bone  or  suppuration  in  the  middle  ear.  which 
becomes  the  starting  point.     For  years  an  otitis  media  may 
persist  and  be  attended  with  a  purulent  discharge  front  the 
external  ear  without  any  brain  symptoms,  but  suddenly  this 
running  may  slop,  the  pus  is  retained,  and  probably  gives  rise 
to  the  caries  of  the  bone,  on  account  of  which  the  petrous  por- 
tion may  become  so  soft  that  it  can  be  cut  with  the  knife:  a 
brain  abscess  then  develops  either  In  the  temporal  lobe  ur  in 
one  of  the  hemispheres  o(  the  cerebellum. 

Suppuration  in  the  bronchi,  putrid  bronchitis,  bronchiecta> 
sis  f Bicrmer).  lurthermore,  ulcerative  endocarditis  and  pyemia, 
may  a's't  give  rise  lo  bnun  abscesses,  which  are  then  dcsig. 
tiatcd  as  "metastatic"  abscesses.  Idiopathic  abscesses — that 
fs,  thove  In  which  no  setiotogical  factor  could  be  discovered 
— have  been  observed  by  Strlimpcll  in  some  cases  ol  epidemic 
cercbro-bpiual  meningitis. 


362 


DISEASES  OP  THE  BJtAtX  P/tOPER. 


Symptoms. — The  symptoms  of  a  brain  abscess  are  divided 
into  general  and  local.  There  may,  however — and  this  is  ol 
much  practical  imp^trtance — be  no  si(;ii  of  brain  mi^htef  at  all. 
A  man  may  not  complain  of  anything  worth  mentioning,  save. 
perhaps,  of  an  occasional  headache,  and  nt  the  autopsy  a  brain 
abiwc&s  be  discovered.  Quite  a  number  of  these  cases  arc  well 
authenticated,  and  there  can  be  no  doubt  as  lo  their  existence  ; 
to  be  sure,  we  ought  not  lo  forget  to  add  that  the  place  in 
which  such  an  abscess  is  developed  must  be  in  a  si»-called  in- 
different region. 

.Among  the  general  symptoms  the  one  most  constant  and 
the  most  distressing  to  the  patient  is  headache;  it  can  by  no 
means  always  be  localised,  but  more  frequently  affects  the 
whole  head,  and  may  last  with  greater  or  less  severity  for 
weeks  or  even  months.  Occasionally  the  torture  is  such  that 
the  patient,  incapable  of  doing  anything,  is  forced  to  remain 
quietly  in  bed.  although  no  other  symptoms  may  be  present. 
Very  often,  it  is  true,  disturbances  of  the  scnsorium  may  ap- 
pear after  the  headache  has  lasted  for  a  long  time;  a  strange 
apathy  takes  possession  of  the  patient,  his  sleep  is  disturbed, 
and  his  general  condition  is  aggravated  if.  as  is  common, 
febrile  movements  set  in,  which  may  be  attended  with  convul- 
sions, which  arc  mostly  unilateral.  Attacks  of  vertigo.  some> 
times  severe  enough  to  cause  great  anxiety,  and  sometimes 
only  transient,  occur,  and  not  rarely  there  are  spells  of  vomit* 
ing.  sometimes  lasting  (or  days,  and  acting  very  delcleriously 
on  the  patient.  The  ophthalmoscopic  examination,  as  a  rule, 
does  not  reveal  any  fundus  changes ;  choked  disks  are  only  ex- 
ceptionally found,  certainly  much  more  rarely  than  in  brain 
tumors.  The  focal  symptoms  of  cerebral  abscess  are  almost 
exclusively  direct.  This  is  a  (act  which  is  easily  understood  if 
we  consider  their  mode  of  origin;  Ihey  are  produced  either 
by  a  direct  destruction  of  the  brain  substance  or  by  the  pre- 
ceding cedema  and  the  attendant  "  preparatory  softening " 
(Wernicke),  both  of  which  processes  arc  strictly  local.  At  the 
same  time  we  must  not  lose  sight  of  the  fact  that  the  pan 
affected  by  this  "  preparatory  softening  "  is  still  capable  o( 
regeneration.  Indirect  focal  symptoms  have  only  been  ob- 
served in  cerebellar  abscesses  ;  in  such,  paralyses  of  the  abdu- 
cens  .ind  other  nerves  have  been  noted  (Wernicke). 

How  different  local  symptoms  show  themselves,  and  which 
are  characteristic  of  lesions  of  the  different  parts  of  the  brain, 


BftAtN  ABSCESS. 


263 


discussed  iibove  (page  162  et  ttq.")'.  suffice  it  here  to 

Tadd  that  abscesses  of  the  so-called  motor  region  produce  hemi- 

jileijias,  which  appear  in  a  very  characteristic  manner— namely, 

Mcp  by  step.     In  abiice&ses  o(  the  uccipital  lobe  hemianopia  is 

iihe  direct   local  symptom  which,  il  properly  used,  may  settle 
the  diagnosis.    The  direct  local  symptom  of  the  temporal  lobe 
—  Ihc  crossed  deafness — can  only  rarely  be  accurately  deter- 
mined,  as  the  suppuration  of  the  middle  ear.  which  we  have 
shown  often  to  be  a:tiolugjcally  connected  with  brain  abscess. 
h  mostly  bilateral,  and  as  tcsling  of  the  hearing  in  palicnts, 
whose  menial  activity  is  somewhat  dulled,  is  very  difficult. 
»ince  Ihcy  are  usually  unable  lo  appreciate  any  decrease  in 
hearing  on  one  side.     In  general,  we  must  confess  that  tcx)  little 
attention  has  been  paid  to  the  testing  of  the  hearing,  and  thai 
_  the  examinations  have  not  been  made  with  sufficient  care. 
H        In  no  one  of  the  few  reported  cases  of  abscess  of  the  pons, 
V  Ihc  medulla  oblongata,  and  the  cerebellum  have  direct  local 
Ktymptoms  been  observed,  ur  at  least  noted  with  any  certainly  ; 
^Ihe  general   symptoms,  which   arc    mentioned   in   connection 
with  the  abscesses  of  the  cerebellum,  must  be  attributed   to 
^  pressure  produced  by  the  growing  abscess, 
f      Course. — The  disease  may  pursue  its  course  in  one  of  three 
diRerent  ways: 

(t)  It  assumes  from  the  onset  a  tumultuous  character, 
whether  it  originate  from  a  traumatism  or  disease  of  the  mid- 
dle car.  Violent  pains^at  first  local.  later  spreading  over  ihc 
»  whole  head,  and  lasting  fiom  two  to  four  days — together  with 
marked  elev.itionof  temperature  and  paroxysms  of  convulsions. 
are  followed  by  grave  disturbances  of  consciousness.  These 
may  last  lor  three,  four,  even  eight  days,  when  the  patient, 
without  regaining  consciousness,  dies  in  a  restless  delirium, 
presenting  the  picture  of  one  sufTcring  from  severe  organic 
dueasc.  • 

■  (s)  These  paroxysmal  symptoms  lose,  after  a  few  weeks. 
their  acute  character,  and  become  less  and  less  marked  ;  the 
p.itient  seems  to  feel  better,  and  he  may.  indeed,  be  free  from 
ail  ln>uble  for  several  months.  Even  the  headache  seems — at 
KJeast  at  certain  times — to  have  vanished.  This  stale  of  absnlule 
V(or  retative)  latency  may  be  of  variable  duration,  and  may  by 
ihe  inexperienced  diagnostician  be  mistaken  for  complete  re< 
covery.  bul  it  is  doubtful  whether  this  latter  ever  occurs.  It 
certainly  happens  much  more  frequently  that  after  this  period 


2&4 


DtSEAS^lS  Of  THF.   BRAIN  PROPER. 


o[  latency  the  initial  symptoms  again  make  their  appearance, 
this  time  to  continue  without  iiitcrinission  until  death.  The 
duration  of  the  whole  disease  comprises  then  three  to  six 
months  or  more  ;  it  is  extremely  rare  that  lhe[>eriod  of  latency 
lasts  for  years. 

(3)  The  onset  of  the  disease  is  insidious  and  chronic.  The 
patient,  who  presents  slight  fever  and  general  symptoms,  grad- 
ually becomes  emaciated.  He  complains  of  headache  and  dis- 
turbed sleep,  and  from  time  to  time,  apparently  without  rcjson, 
is  taken  with  chills;  he  begins  to  have  a  cachectic  appearance, 
and  bears  on  his  lace  the  imprint  of  a  grave  disease.  In  such, 
withal  very  rare,  cases  our  patient  is  suffering  from  phthisis 
and  the  brain  abscess  is  of  a  tubercular  nature.  The  dura- 
tion of  this  form,  as  a  rule,  does  not  exceed  three  or  fotir 
mtmths. 

Diagnosis.— In  the  diagnosis  »vc  may  have  to  differentiate 
between  brain  abscess,  purulent  meningitis,  meningeal  haemor- 
rhage, and  brain  tumor.  If  the  course  of  the  abscess  is  very 
acute,  as  has  been  described  above  (eight  to  ten  days),  then  it 
is  often  impossible  to  distinguish  it  from  an  acute  purulent 
meningitis,  an  error  which  is  the  more  excusable  when  all  direct 
focat  symptoms  which  often  accompany  an  abscess  arc  wanting. 
Remissions  point  rather  to  the  existence  of  a  brain  abscess. 

From  meningeal  haimorrhage,  which  just  as  abscess  may 
be  the  consequence  of  traumatism,  it  is  also  distinguished  by 
its  course.  Traumatic  meningeal  haemorrhages  usually  give 
rise  to  epileptiform  attacks,  which  arc  to  be  referred  to  the 
effect  of  the  entrance  of  the  blood  between  the  dura  and  the 
skull  on  the  motor  centres.  They  arc  immediately  followed 
by  a  coma,  which  lasts  until  death.  In  abscesses  the  insensi- 
bility usually  lasts  onl}*  a  few  hours,  and  only  after  a  marked 
improvement  has  again  taken  place  do  alarming  symptoms 
make  their  appearance. 

A  brain  tumor  can  be  differentiated  from  an  abscess  by  the 
fact  that  id  the  former  febrile  symptoms  arc  absent,  while  on 
the  other  hand,  in  the  latter,  choked  disks,  which  arc  a  fre- 
quent sign  in  brain  tumor,  are  only  exceptionally  noted.  The 
course — more  especially  as  regards  the  remissions,  which  arc 
well  marked  and  often  of  long  duration— Li  characteristic  of 
abscess:  a  tumor  usually  is  steadily  progressive.  Finally,  we 
are  justified  in  diagnosticating  an  abscess  if  alter  a  protracted 
and  varying  course  the  disease  suddenly  terminates  with  ccr- 


BRAIN  ABSCESS. 


26s 


^ 


^ 


tain  severe  symploms  ol  collapse  and  dealli.  When  this  occurs 
it  is  probable  that  an  abscess  existed  which  has  perforated 
either  into  the  veiitriclcrs  or  to  the  surface.  In  aises  of  trauma- 
lism  or  in  cases  in  which  the  cerebral  symptoms  were  preceded 
bjan  otitis  media  we  should  always  think  first  of  brain  abscess. 

The  seal  of  the  abscess  can  only  be  determined  with  any 
certainly  if  characteristic  (ocal  symploms — lor  instance,  hemi- 
Mopta  or  sensory  aphasia — arc  present.  Incases  of  hemiplis 
gia  we  can,  from  the  order  in  which  the  compnncnt  monoplegias 
occur,  draw  a  conclusion  as  to  (he  point  of  origin  uf  the  ab- 
scess.  Thus,  if  at  first  a  paralysis  of  the  leg,  together  with 
marked  sensory  disturbances,  arc  the  prevailing  symptoms, 
and  only  later  the  arcn  and  facio-lingual  region  become  nftecicd, 
we  (nay  conclude  that  the  abscess  is  proceeding  from  behind 
forward,  while  if  the  symptoms  occur  in  the  reverse  order, 
then  the  frontal  lobe  may  have  been  the  starting  point  and  the 
abscess  be  extending  backward.  In  cases  of  traumatism  the 
abscess  is  to  be  located  in  very  close  proximity  to  the  injury. 
Where  there  is  a  history  of  otitis  media  it  usually  establishes 
itself  in  the  temporal  lobe  or  the  ccrcbelUim.  The  white  mat- 
icr  is,  in  the  cerebrum  as  well  as  in  the  cerebellum,  by  far  the 
most  common  sent.  In  the  brain  stem  it  occurs  only  very 
rarely,  while  in  this  situation,  as  we  have  seen,  hxmorrhagc 
and  softening  are  more  common. 

Prognosis. — The  prognosis  is  ahsoUitdy  bad  with  regard  to 
recovery  and  doubtful  with  regard  to  life.  We  can  sec  from 
what  has  been  said  that  spontaneous  cures,  most  probably  never, 
theraivculic  cures  quite  rarely,  take  place.  It  is  well  to  be  very 
guarded  In  giving  an  opinion  as  to  the  duration  of  life,  and  we 
should  never  forget  that  even  during  a  seemingly  excellent 
ite  of  health  suddenly  grave  symptoms  m-iy  develop  which 
lead  to  a  r.ipid  termination. 

Treatment — Of  an  effectual  treatment  we  can  only  speak 
in  (hose  cases  in  which  an  operation  is  feasible.  Since  this — 
'tiephining  of  the  skull,  splitting  of  the  dura,  opening  of  the 
■itwcess  with  the  knile — must  always,  however,  even  if  con- 
ducted with  the  strictest  antiseptic  precautions,  be  regarded 
a»a  grave  undertaking,  we  shonhl  only  resort  to  it  when  the 
location  of  the  abscess  has  been  established  with  some  cer. 
taiaty.  If  this  has  been  done,  operative  measures  are  at  once 
indicated,  and  should  be  carried  out  without  delay,  provided, 
o(  course,  that  the  abscess  be  in  a  part  accessible  to  the  knife, 


266 


JttSBASES  OP  THE  BRAIN  PXOPf.K. 


which.  \vc  need  not  say,  is  hardly  the  case  in  the  basal  ganglia, 
the  pons,  the  medulla  oblongata,  and  the  cerebellum. 

But,  unfortunately,  an  operation  is  in  (he  greater  number 
o[  cases  not  (enKible  on  account  of  the  uncertainty  in  the  top- 
ical di^i^HOsis.  Then  our  treatment  can  only  be  symptomatic, 
and  wc  arc  coiihncd  to  local  bleeding,  hypnotics,  bromides, 
etc.,  which  ellect  but  little.  For  that  matter  the  results  of  a 
so-called  succes.5ful  operation  are  not  always  lasting  cither,  and 
repeatedly  one.  two.  or  lour  weeks  after  the  pus  has  been 
evacuated  an  untavorable  outcome  has  taken  place— c.  g.,  in  the 
case  ol  Wernicke-Hahn  (cf.  lit.). 

LlTEkATtmE. 

Wernicke  und  Hahn.     Idiopalhischcr  AhscMS  t!**  OcclpilAltappcns  ittttch  Tw- 

(uniiltun  cnilecM.     Virchaw's  Arch..  Ilii.  Uxtvii.  i8Si. 
GrecHlielil.     K«inarlu  on  a  Case  of  Cerehral  Absceu  with  Otili*.  succnafully 

irc-iicd  by  Oprraiion.     Brit.  Med,  Journ,.  ii,  W,  1887. 
FiAnkFl,  A.     Uebcr  den  lubrrcutoitcii  Him.-ibicniX.     DcuUclie  metl.  Wochen- 

whr.  18.  1887. 
Sommcnille.     Analyvls  of  tlic  Urine  in  Two  Cbm»  of  Cerebral  AlM«e»».     L411- 

cci.  ii.  II.  1887.     (Incfcaw  of  iIk- wnhy  phospliaies.) 
t.lnk.     TrnuniAt.  Gelm niibsccss.     Wiener  ninl.  Wcichenschr..  No.  ja  1887. 
Roma.     New  York  Med.  Kerord.  xnij,  July  $.  1887.     (Brain  abtceu  following 

a  puruli'nl  oiiiis  inedi.*.! 
LAcher.     Muncliener  ined.  Wochenwhr..  ixiiv.  33,  1887. 
Barr,     Glisgnw   Med.  Joum..  Kxviii.  SciHemlier  3,   1887.     <VCTy  protr.icieil 

cou pte — luiij;  iniermiMions,) 
V.  Berifmann.     Die  chinirKi^che  Ilehnndlurii;  von  Himknuikheilen.    (Brain  ab- 
scess, etc.)     Arch.  f.  klin.  Clnrurjjie,  liU.  36,  4.  1887. 
V.  BcrKmiinn.     Ueui«lie  Med.-2iy..  1888.  100.    (Recover)'  fromi  h™n  abscest ) 
Mahr.     Wiener  med.  HlJiUcr,  1R88.  23.     (Ree-overy  from  brain  abice**.) 
Crawford- Renton.    Cerebral  Abiceu  uHer  Orbital  IVrioHlitis.    Ophthalm.  Ko 

view.  1888.  V.  ]>o6-l>0& 

3.  NoN-su/fpurathv  Encfpltalilis  and  its  ConsrqHences  {"At/ir/asis"). 

A.  IN  ADULTS. 

There  is  no  question  but  that  inflammatory  processes,  acute 
as  well  as  chronic,  occur  in  the  brain  which  show  no  tendency 
to  suppuration,  although  our  knowledge  of  their  pathogenesis 
and  iheir  symptomatology  is  very  imperfect.  These  processes 
take  place  preferably  in  quite  early  childhood,  or  even  during 
intra-uteriiie  life  ;  only  exceptionally  may  they  occur  in  adults, 
as  a  consequence  o(  the  abuse  of  alcohol.  They  arc  then  cir- 
cumscribed inflammatory  processes,  occurring  partly  in  ihc 


DIFFUSE  CEKEB/tAl   SCLEMOSIS. 


367 


I 


cortex,  partly  in  the  white  matter,  which  admit  of  regeneration. 
11  brgcr  areas  are  affected,  the  tissue  becomes  shrunken  and 
o(  a  distinctly  firmer  consisleacc,  so  that  it  cuts  almost  Mkc 
leather.  Just  how  these  changes  are  brought  about,  in  what 
way  the  nerve  tibrcs  of  the  white  matter  waste  and  the  coti- 
oecti%-c  tissue  increases,  which  of  the  two  processes  is  the  pri- 
mary and  which  the  secondary,  can  not  as  yet  be  determined 
with  any  certainty.  Peculiar  disturbances  in  nutrition  in  cer- 
tain areas  of  arterial  distribution  may  give  rise  to  delects 
which  cause  a  distinct  sinking  in  of  the  surlacc  of  the  brain 
(Kundratj,  •■  porencephaly  "  (l-'ig.  74).     At  times  we  find  a  true 


dcitricial  tissue,  which  chanictcrizcs  ihc  terminal  process  of  the 
diSuio  cerebral  sclerosis.  The  n)acroscopic  appearance  of  the 
biia  is  similar  to  that  in  the  "induration  cartilagineuse  "  of 
Cnntllhicr  ;  microscopically,  the  same  histological  elements  as 
'rcscenlnall  degenerative  processes  of  Ihc  gray  and  white 
"Wtfrol  the  brain,  spider  cells,  .tiuI  compound  granular  cor. 
fuscles.  arc  noted  (Kasi).  Marie  and  Jcndrassik  (cl.  lit.)  see 
•"I  perivascular  changes  the  chief  factor  which  under  certain 
anriiauunces  brings  about  a  lobar  atrophy.  At  limes  we  have 
^iVal  undoubtedly  with  the  consequences  of  a  uniform  arrest 
"^••i  tltTcIopment  which  especially  takes  in  one  hemisphere,  and 
'■'e  iiatumical  cause  for  which  is  not  understood.  The  cir- 
"tmicribed  inflammatory  foci  m.ny  also  be  found  in  both  hcmi- 
S*HM.  in  which  case  wc  speak  o(  a  double  lobar  sclerosis- 


368 


J>/S£^SES  OF  THE  B ft  A IX  PftOr£R. 


The  clinical  course  of  the  disease  is  practically  unlcnown. 
Probnbly  there  dues  not  exist  any  well-detincd  cuitslatit  clinical 
picture,  btit  the  symptoms  vary  according  to  the  analomicul 
scat  of  the  process.  They  are  symptoms  ot  paraljMS  or  of  irri- 
tation, and  arc  partly  "  cortical  symptoms  "  and  partly  to  be 
referred  to  disease  of  the  cerebral  vessels  (cf.  Fiiedmann.  Arch, 
f.  Psych,.  18S9.  xxi,  2.  page  4,f>i).  In  the  few  cases  in  which  a 
diagnosis  could  be  made  during  life,  apoplecitlurm  attacks, 
rhythmical  choreic  movements.  longer  or  shorter  spells  of  un- 
consciousness, were  observed.  The  difficulty  of  grouping  and 
correctly  interpreting  the  symptoms  is  chicfiy  owing  10  the 
impossibility  of  an  early  diagnosis.  Mencc  it  will  be  the  chief 
task  oHuturc  observers  to  direct  Iheir  attention  to  the  initial 
stage,  for  only  after  wc  have  once  become  familiar  with  the 
development  and  the  anatomicil  changes  in  this  hrst  stage  can 
we  hope  to  elaborate  an  efficient  mode  of  treatment,  which, 
we  need  not  say.  at  present  is  absolutely  wanting.  The  irra. 
tional  trials  with  potassium  iodide  we  can  certainly  not  regard 
as  such. 

B.  IN  CHIIJJKKK. 

Cerebral  Patsy  of  Children — PoUo-encfphalilis  {Slriimpell'). 

Pathological  Anatomy. — In  view  of  the  comparatively  fre- 
quent occurrence  of  cerebral  palsies  in  children,  it  is  rather 
to  be  wondered  at  that  so  extremely  little  is  known  about 
their  pathogenesis  and  their  initial  stage,  more  especially  with 
reference  to  the  anatomical  changes  that  occur.  This  may 
perhaps  be  accounted  fur  by  the  difliculty,  and  sometimes 
even  itiipossibility,  of  making  an  caily  diagnosis.  At  a  time 
when  we  are  able  to  recognize  the  disease  wc  usually  have  to 
deal  with  a  process  which  has  already  passed  through  all,  or 
almost  all,  of  iis  dilTcrcnl  stages.  It  is  the  same  with  the  le- 
Rions  which  we  find  :  they  in  no  wise  explain  the  exact  nature 
of  the  disease,  but  only  give  us  an  idea  uf  the  many  various 
wavs  in  which  the  brain  with  its  meninges  may  be  altered  in 
early  childhood  as  a  consequence  ol  the  disease,  which  was 
most  prnb:ihly  intra-ulcrine.  General  cachexias  ol  the  parents 
— e.g.,  svpliilis — may  be  the  cause  when  ihe  adectlun  begins 
during  inlra-ulcrinc  lile  ;  in  Ibis  case  marc  than  one  child  may 
have  the  disease.  During  the  act  of  birth  iraumniisms  roar  I 
produce  unilateral  or  bilateral  conical  hasmorrhnge.  After 
birth,  infectious    diseases    (pertussis,  scarlatina,  tuberculosis. 


CEHEfiHAt.  PALSY  OF  CHllDXEV. 


369 


^diohthcria.  syphilis)  pUy  the  most  important  rdU  in  the  causa- 
The  case  which  is  briefly  described  on  page  377  (Fig. 

"^^S)  shows  thai  injuries— from  a  fall,  for  example — may  also 
precede  the  aflfcclion.  We  do  ncit,  however,  know  of  what 
aature  this  process  is.  whether  it  is  a  sinus  thrombosis,  as 
rers  claims,  or  an  inflammation  leading  to  alrnphy,  as  in 
tingo- myelitis  chronica.  Neither  can  we  tell  wliL-ther  the 
iacrense  in  the  connective  tissue  which  has  been  noted  by  many 
authors  is  a  primary  one.  and  what  part  the  disease  of  the  ves- 
scli,  the  thickeiiinji  of  their  walls  (Hayem,  and  others),  plays 
in  the  pnKess  :  but  one  thing  is  certain,  that  the  disease  is  not 
confined  to  the  gray  cortex  alone  (as  Siriimpell  has  assumed, 
and  tor  which  reason  he  has  proposed  the  name  polio-encepha- 
litis, analogous  to  polio-mycliiis,  cf.  lit.),  but  that  the  white  mat- 
ter as  well  may  be  implicated.  This  is  shown  by  ihc  case  pub- 
lished by  Kast  (cl.  lit.),  and  also  by  the  following  observation, 
which  was  made  in  my  wards,  and  which  I  propose  to  relate 
here  in  brief,  as  autopsies  in  cases  of  this  class  arc  rare : 

Magdalcna  St.,  iwcnty-onc  years  old,  coming  from  a  healthy  fam- 

f,  WHS  taken  sick  in  her  second  year  with  violent  fever.     Aocord- 

ng  tu  her  mother's  aecoiinl,  she  hud  convulsions  for  four  days  and 

'iiur  nights.     When  she  wanted  to  get  out  of  bed  after  thi«  her  left 

ude  was  found  lu  be  paralyzed.     In^de  of  three  months  her  condi- 

(in  was  so  far  improved  thai  she  coutd  walk,  although  with  a  limp. 

Tiradoally  the  left  lower  leg  became  smaller  and  somewhat  curved, 

knil  (khc  cnmplntned  of  pain  tn  the  whole  limb.     The  upper  cxtreni- 

iiy  did  not  at  Tif*!  take  part  in  the  atrophy  ;  it  was,  however,  almost 

■plctely  powerless.     For  two  years  the  convulsions  did  not  re- 

kpi>ear;  but  for  the  last  four  years  the  patient  had  had.  on  an  avcr- 

k^c,  about  one  epileptiform  attack  every  three  weeks,  in  which  she 

riiet  ber  tongue  and  passes  her  urine  involuntarily.     The  following 

t  ftn  extract  of  the  note  made  on  October  15.  18^5 : 

Head :  Kight  parietal  region  painful  to  percussion  ;  in  the  region 

I  f  the  left  glabella  and  the  hairy  part  of  the  scalp,  on  the  same  side, 

«'(  ate  Ncvcral  areajt  of  anaesthesia.     I'upillary  reactions  and  move- 

►  «it9  of  the  eye  muscles  normal.    Nothing  abnormal  in  ihc  distribu- 

><iaof  the  facial  and  hypoglossal  nerves.     On  the  right  side  hearing 

■Bich  below  normal,  on  the  left  there  is  complete  deafness.     On 

:  *»(  anicnor  third  "f  the  left  half  of  the  tongue  taste  is  lost.     Uvula 

^ct«)ghl  and  movements  of  the  soft  palate  normal. 

TtttQk :   On  the  left  half  of  the  chest  touch  and  the  prick  of 
pu  are  not  perceived;  temperature  sense  seems  decidedly  sub- 
l«>oniul. 


a7o 


DiSSASES  OF  THE  BKAIN  PMOPEK. 


Upper  Kstrcmitieg:  The  whole  left  upper  exlreinity,  including 
the  hand,  is  shorter  and  smaller  than  the  rijctit ;  motion  of  the  wrist, 
especially  extension,  i&  impaired.  The  hand  is  flexed  on  the  fore- 
arm, and  only  with  force  cAn  the  Rcxion  be  overcome.  The  thuml) 
is  drawn  into  llie  hollow  of  (he  hand,  the  zciX  of  the  fingers  urc 
slightly  Hexed.  Motion  in  the  shoulder  joint  normal ;  in  ihe  elbow 
joint  extension  is  slightly  impaired.  There  is  a  general  decrease  in 
the  sensibility.  Electrical  reactions  arc  found  to  be  normal  for  lioth 
currents,  on  direct  as  well  as  on  indirect  stimulation.  The  right  upper 
extremity  docs  not  show  abnormity  with  regard  to  development,  size. 
mobtliiy,  or  sensibility. 

The  left  lower  extremity  is  considerably  smaller  and  shorter  than 
the  right :  sensibility  is  the  same  a^  in  the  corresponding  upper  ex- 
tremity ;  the  same  holds  for  the  electrical  condition.  Tendon  and 
skin  rcdexes  are  retained  on  both  sides. 

■J'he  epileptic  attacks  continued,  and  occurred  about  every  sixth 
or  eighth  day;  the  intelligence  became  more  and  more  impaired.  A 
tuberculous  process  in  the  left  lung  was  superadded  to  the  already 
existing  trouble,  and.  in  <;onse<|iicncc  of  general  (atture  of  strength, 
the  patient  died  on  March  ii,  18K6. 

Autopsy:  Eighteen  hours  after  death.  Extract  from  the  post- 
mortem record :  After  opening  the  skull  the  pia  is  seen  to  be  con- 
siderably thickened  at  different  places,  especially  over  the  right 
hemisphere.  In  volume  the  right  hemisphere  is  not  much  smaller 
than  the  left ;  the  anterior  and  posterior  central  convolutions  on  the 
right  side,  especially  in  their  lower  half,  arc  markedly  atrophic,  the 
gyri  are  shrunken  to  about  a  third  of  their  natural  Mxe;  the  mar- 
ginal and  the  angular  gyrus  present  jhe  same  atrophic  condition. 
The  upper  right  parietal  lobule  is  less  atrophic,  nevertheless  the  gyri 
are  here  also  remarkably  narrow.  I'he  portions  of  Ihe  first  and  sec- 
ond frontal  convolutions  bordering  on  the  central  convolution  appear 
also  atrophic.  On  section  the  gray  matter  is  hcen  to  be  considerably 
diminished. 

The  ventricles  appear  markedly  enlarged.  On  frontal  sections, 
after  Pitres'  method,  no  important  changes,  with  the  exception  of  the 
shrinking,  either  in  the  centrum  ovale,  or  in  the  basal  ganglia,  can 
be  observed  macroscopically ;  on  microscopical  examination  K]>ider- 
cclls  and  fat-granules  arc  found  in  considerable  numbers  nut  only  in 
the  gray  cortex,  but  also  in  the  white  matter. 

This  observation  determines  us  in  m:iinlaining  with  Kast 
the  old  dcsi{;naiion,  "cerebral  palsy  of  children."  a  n.imc  by 
which  nn  definite  pathological  change  h  implifd,  .ind  in  aban- 
doning the  term  polio-encephalitis,  to  which  the  pathologic.it 
changes  do  certainly  not  always  correspond,  especially  as  (he 


CEREBRAL  PALSY  OF  CUtLDREN. 


ri\ 


latter  name  has  already  been  proposed  by  Wernicke  for  the 
disease  uf  the  gray  matter  around  the  third  and  fourth  vcn> 
t  rides. 

Symptoms. — The  symptoms  of  this  disease-group  diUer 
according  as  the  pathological  process  is  conhncd  to  one  hemi> 
sphere  ur  attacks  both. 

In  the  former  case  the  symptoms  and  the  course  are  so 
characteristic  that  a  correct  diagnosis  can  almost  always -be 
made  during  lite.  The  disease  usually  sets  in  brusquely,  the 
symptoms  are  violent  and  can  not  be  overlooked.  The  child 
is  seized  with  a  high  fever;  soon,  sometimes  only  a  few  hours 
later,  twitchings — at  first  only  in  one  extremity,  later  in  the 
whole  side — appear;  at  times  the  whole  body  may  be  con. 
vulscd :  this  may  last,  with  but  slight  interruptions.  lor  from 
oiie  to  three  or  even  four  days,  and  be  accompanied  by  per- 
sistently high  tempcraiurc.  The  symptoms  now  abate,  the 
convulsions  become  less  frequent,  but  after  their  disappearance 
the  child  is  found  to  ha\»:  lust  the  use  of  the  limbs  of  one  side 
—hemiplegia  infantilis  spastica  (Benediki).  II  an  early  and 
careful  examination  be  made,  a  moderate  facial  paralysis  is 
noted,  the  condition  of  the  extremities  being  very  nearly  the 
same  as  has  been  described  on  page  226.  The  condition  of 
the  facial  nerve  in  this  affection  has  recently  been  studied  by 
W.  Koenig  (Deutsche  mcd.  Wochcnschr.,  i!)93,  42).  Itcrc.as 
in  the  common  cerebral  hemiplegia,  the  arm  is  pressed  against 
the  thorax,  ihc  forearm  flexed  at  right  angles  with  the  upper 
arm,  the  hand  flexed  and  adductcd.  the  fingers  bent.  The  leg 
is  dightly  flexed  at  the  knee  joint,  the  foot  extended  ;  not  un- 
commonly (he  big  toe  is  in  marked  dorsal  flexion.  The  sensi- 
bility is,  as  a  rule.  m>t  much  altered.  After  several  weeks  the 
little  patient  regains  enough  power  to  perform  the  coarser 
movements  with  the  leg,  while  lor  a  considerably  longer  lime 
the  arm  does  not  lake  part  in  the  improvement.  If  the  child 
was  able  to  walk  before  the  onset  of  the  disease,  it  will  gener- 
ally regain  this  (acuity  after  a  lime,  but  its  gait  will  always  be 
haltuig. 

The  further  course  of  the  disease  is  not  the  same  in  nil 
cases,  and  it  has  been  our  experience  that  it  differs  according 
as  the  initial  convulsions  contituie  or  cease.  This,  therefore,  is 
an  Important  point  to  consider  in  the  prognosis  for  the  relative 
recovery.  It  will  also  decide  the  question  whether  the  child, 
while  bodily  more  or  less  a  cripple,  is  in  addition  to  be  mcn< 


272 


D/SIiAS£S  Of  THE  HHAtff  fKOrE/t. 


tally  defective  and  totally  useless  to  the  community.  What 
conditions  determine  the  conliniiaiicc  ol  the  convulsions, 
whether  this  is  inOucnccd  more  by  the  nature  ol  the  lesions 
or  more  by  lljeir  scat,  we  are  unable  to  say. 

As  a  rule,  the  attacks,  even  if  they  should  have  a  tendency 
to  continue,  (to  not  recur  for  months,  for  one,  two,  or  even 
lour  years,  after  the  acute  period  of  the  disease  has  passed 
ofT.    Then,  however,  they  may  return  on  any  provocation — 
alter  a  fright,  maltreatment,  sometimes  during  the  second  den- 
Ittion — at  first  ni  long  intervals  ol  months,  then  more  Ircqucnllv. 
At  firsl  they  may  be  slight  and  of  short  duration,  then  more 
severe,  until  5n»lly  they  resemble  in  every  point  the  classical  - 
attacks  of  epilepsy — in  other  words,  the  hemiplcgic  or  hemi-  \ 
paretic  patient  has  now   become  an  epileptic.     As  has  been 
stated,  the  influence  which  these  attacks  have  upon  the  nnental 
development  of  the  child  is  very  detrimental.     Much  more 
often  than  is  the  case  in  idiop-ithic  epilepsy  docs  the  patient 
become  weak-minded.     The  condition  of  speech  found  in  this 
disease  is  interesting.     II  the  patient  had  fully  acquired  speech 
previous  to  the  attack,  it  is  only  affected  il  the  lesion  is  on  ihc 
left  side  of  the  brain,  in  which  case  the  symptoms  do  not  diller 
from  those  which  we  have  described  under  left-sided  cerebrdl 
hemorrhage.     If.  on  the  other  hand,  the  patient  has  not  yet 
learned  to  speak,  he  will,  in  case  the  hts  continue,  either  not 
learn  at  all  or  only  ver)'  itnpcrfectly.  and  his  talk  will,  even  if  ■ 
his  mind  is  only  slightly  impaired,  be  quite  unintelligible;  but 
olten  Ihc  attacks  do  not  recur,  so  that  the  mental  development, 
progresses  normnlly.     In  such  cases  speech  likewise  reaches  &,■ 
gratifying  degree  of  development  even  if  it  had  not  yel  been 
fully  acquired  or  had  been  lost.    The  healthy  hemisphere  takes 
on  vicariously  the  work  of  the  injured  one  (cf.  page  1S2,  remarks 
on  aphasia  of  children).  j 

Independently  of  the  epileptiform  attacks,  there  may  occu4 
changes  in  the  extremities  which  are  in  a  way  analogous    to 
those  described  above.     An  especially  characteristic  symptom 
is  the  pronounced  spastic  condition  which  manifests  itself    i" 
an  increase  ol  the  reflexes,  rigidity  and  spasm  of  the  muscJfs 
— hemiplegia   inlanlilis  spastic.1.      This   rigidity    is  especiaf'v 
well  marked   in  the  muscles  of   the  hand  and  the  calves,  a"*' 
leads,  prelei^bly  in  the  former  location,  to  contractures,  whk^ 
however,  differ  from  others,  inasmuch  .is  they  cease  durinj 
rest  and  sleep  and  only  appear  on  voluntary  motion.    Bew- 


CEREBRAL  PALSY  OF  CHILPRE.V. 


373 


"dikt.  above  others,  has  pointed  out  thai  at  one  lime  one.  at 
another  time  another,  f;roiip  o[  muscles  may  be  affected  :  that, 
e.g.,  in  walking,  the  loot  may  be  held  normally,  while  ag-ain 
in  the  same  (out  we  may  see  a  talipes  calcaneus,  or  at  another 
time  a  talipes  cquinus.  Similar  conditions  arc  observed  in  the 
hands :  thus  the  fingers,  which  appear  to  be  in  a  state  of  immo- 
bile flexor  contraction,  may  at  other  limes  present  a  remarkable 
degree  o(  mobility.  We  shall  shortly  discuss  carefully  the 
entirely  involuntary  movements  of  the  affected  hand  which  are 
noted  in  the  course  of  this  disease.  E,  Kemuk  has  shown  that 
such  a  spastic  paralysis  with  contracture  may  lead  toa  luxation  ; 
in  the  case  which  he  reports  a  retroglenoid  subacromionlux^ 

Ition  developed  (Berlin,  klin.  Wochenschr..  1S93.  52). 
In  almost  all  cases  ol  infantile  cerebral  paralysis  an  arrest 
in  development  or  growth  becomes  apparent  in  the  affected 
ctircmiiics.  Thb  may  be  only  instgniticant.su  as  to  be  hardly 
appreciable.  On  the  other  hand,  the  limbs  may  in  all  their 
dinrnsions  be  considerably  smaller  than  the  corresponding 
OKS  of  the  sound  side.  Occasionally  the  tvhole  half  ol  the 
body,  trunk  and  head  as  well,  share  in  this  arrest,  and  we  have 
"hat  is  called   u   general    hemiatrophy.      Borgherini   has  ob- 

Ivned  this  to  occur  a  few  day<i  after  the  onset  of  the  disease 
(Deutsch.  Arch.  (.  klin.  Med.,  xl,  5.  6). 
The  following  illustralions  of  cases  from  my  clinic  rcprc 
**nt  (liflcreni  tyjMrs  of  the  cerebral  pamlyses  of  children  : 
Rgs.  75  and  76:  Hemiatrophy  of  the  whole  left  side  of  the 
'X'clt.     E|tilepti(orm  attacks.     Dementia. 

Figs,  77  and  78;  tlemialrophy  of  the  whole  left  side  o( 
'he  body.  Cause:  Traumatism.  No  fits.  Intelligence  nor- 
n»al 

Fig.  79:  Atrophy  of  the  left  upper  and  lower  extremity 
^'''^sectiun  of  the  knee  joint).    Epileptiform  attacks,  with  a  mod- 
kte  degree  ol  dementia. 

Fig*.  81  1084:  Atrophy  of  the  paralyxed  side,  very  slight. 

't  perceptible.    All  three  patients  sufler  from  epileptiform 

kttacks  and  arc  demented.     All  three  present  contractures  on 

^c  affected  side,  either  in  the  wrist  (Fig.  81,  and  also  Fig.  75) 

U)  the  ankle  joint  (Figs.  K3  and  84). 

All  these  eight  cases,  which  came  under  my  obscrvatfon, 
°«T"'i>i!cd  upon  disease  of  the  right  hemisphere.     Whether  thi« 
'i-  i<  ali»>geihcr  more  fre<]uenily  attacked,  and.  if  so,  how  the 
be  explained.  1  dare  not  at  present  decide. 


274 


DISEASES  OE  THE  BftAllf  PROPEH. 


If  both  hemispheres  are  affected,  the  symptoms  are  very 
diflercnt,  and  the  diagnosis  is  much  more  difTicuk.  Freud  has 
classified  all  these  affections  as  instances  of  cerebral  diplegia,  a 
term  which  may  be  accepted  without  reserve,  as  it  is  purely 


descriptive,  and  is  noncommittal  so  far  as  regards  the  pattio- 
logical  process.  He  divides  the  cases  into  four  groups :  i.  The 
general  cerebral  spasticity  tirsl  described  by  Little  and  called  by 
the  Bnglish  authors  Little's  disease.  2.  The  paraplegic  spas- 
ticity (so-called  spastic  paralysis).  3.  The  bilateral  hemiplegia. 
4.  The  bilateral  chorea  and  athetosis.  The  latter  will  be  referred 
to  again  (page  384).  Little's  disease  and  spastic  paralysis  arc 
frequently  congenital;  in  the  latter  affection  especially  predis- 
posing and  hereditary  influences  play  some  pari,  and  several 
members  in  the  same  family  may  develop  the  disease  (N'cwraark, 


I 
I 


CEKKfigAf.   PALSY  OF  CtllLDREX. 


V% 


A  Contribution  to  ihc  Study  of  the  Family  Form  of  Spastic 

Paraplegia.  Aracr.  Journ.  Med.  Sci.,  April.  1893).    (Cf.  Fig.  80.) 

Diagnosis. — The  diagnosis  of  thr  tinilatcral  affection  is,  as  a 

rule,  easy.  AS  the  acute  onset  with  Ihc  consequent  hemiplegia 


fit.  jc 

Thp  patient,  vrho  is  now  ihirl>'4ix  yean  oUi.  wu  talten  ill  incnrlrchiidhood 

^ith  in  Bculc  vioteni  frvrr  and  canvtilstons ;  ihc  iauer  lailcii  for  icrcral  days. 

*^l  aftrr  ilut  dikappcnrcil,     Ftf>m  ihni  lime  ihr  left  Hdr  did  not  develop  M  well 

"**  Xhr  nj-hi.  ftothai  now  ilvr  tcft  upjwr  eiiremiiy.  whith  on  bt  moied.  with 

'*'1kuliy  tmly.  in  the  ihoulilrr  and  dhow  joiciis,  is  scvtn  centimetres  shonff 

"-*n  the  rlfht,  whik  tlw  left  lower  cxlrcniity  is  three  ceniimeircs  shorter  than 

"^  fiUtiw.     The  whole  hatr  of  the  body  hu  shared  in  the  uiro|tliy,  which  is  also 

^«II  marked  i«  the  natn.    The  circumference  of  ihc  left  upjier  arm  m^'atum 

I        ^***'t' ceMimeircs  aitd  a  half.tkttof  the  left  teg  three  centimetres  Icm  than  thai  of 

I        **^  cormponding  ntremtty.    When  the  paiicnt  wa.i  fourteen  yc;>rs  old  the  con- 

I        "^Uigna  reappeared,  and  he  hu  util  one  or  two  epik|i(irom)  aiiacks  a  week. 


276 


DISEASES  OF  TUB  BRAIN  PROPER. 


is  characteristic  enough ;  but  if  the  patient  come  from  a  phlhi»> 
icalfamilyand  is  himseH  tuberculous,  some  doubt  may  arise. 
\Vc  may  have  a  case  of  tuberculosis  of  the  brain  to  deal  wilh, 
which  sometimes  resembles  in  its  onset  the  cerebral  palsy  of 
children.     High  fe%-er  and   convulsions  are  not  absent,  and  se-' 


verc  motor  disturbances  occur  also.     The  fact,  however,  thai    la  , 
cerebral  tuberculosis  generally  Ihc  base  of  the  brain  with   i"tj 
nerves,  especially  I'le  oculo-moior  and  abducens,  arc  implicilcd, 
and,  further,  ihal  it  runs  a  rapid  and  fatal  course,  will  cnah'c 
us  to  inake  a  correct  diagnosis. 

Spinal  and  cerebral  infantile  paralyses  can  not  be  con- 
founded with  each  other  if  wc  keep  in  mind  th.il.  in  the  Uttci", 
one  whole  side  of  the  body  is  affected;  that  the  musclci  -vc 
rigid,  the  reflexes  increased  ;  that  convulsions  occur  not  only 


CEUBBRAL  PALSY  OP  ClIILDftElf, 


277 


at  the  onset,  but  also  in  the  further  course  of  the  disease ;  that 
(he  mind  becomes  impaired,  etc.  In  the  spinal  form,  either 
one  limb  alone — arm  or  leg — is  affected  or  both  arms  or  both 
le^,  and  the  reflexes  in  the  paralyzed  extremities  are  lost — 
signs  enough  to  enable  us  to  differentiate  between  the  two 


Tbr  puieni.  mm-  Ihiny-four  yenn  old.  ML  nl  th«  age  of  ihicc,  IVo<n  a  hif[ti 
tttet-ttool  «ad  injuroil  ihe  ri^i  »idc  of  his  l>c;ul.  He  lost  a  conMikrablc  nmaunt 
«f  tilood,  and  wu  unciMixcmi^  for  quite  a  long  time.  Six  monih^  nftcr  ihe  in- 
jury  the  airopby  of  Ihe  Icfi  side  of  the  tiody  became  apparent.  fir»1  in  the  u|)p*T. 
then  in  ihe  lower  cxircmity.  With  ihe  cxccpiion  of  ibis  utrophy.  whirh  h» 
mow  takpn  in  the  wb(4c  half  of  the  liody.  DK-ludini;  ihe  thonx  (coTn]>arc  the  left 
»Hh  the  n)(hl  mamina).  the  |Kiticnt  is  peffrcily  healthy.  He  has  T\r\rt  h.icl  epi- 
Irpurnnn  aiudu,  Uwtb  are  no  hemuiihctoid  movementt,  and  no  (Htxhical  allcr- 
Uiona  what«vir. 


278 


mSEASES  OF  THE  BRA  IX  PROPER. 


nffeclions.  A  hemiplegia  due  to  cerebral  haemorrhage  can  ia 
most  case!)  be  excluded,  owing  to  its  rarity  in  childhood.  Such, 
moreover,  would  usually  not  be  associated  with  any  muscular 


The  I 


He.  rt- 


years  ol  age,  had.  when  six  months  i 
plrclic  tlruJic."  and  never  learned  how  to  walk  properly,  since  the  left  half  of  ih^^  ' 
body  waa  paralysed  up  to  her  second  year.  The  powrci  of  mocion  ha&  ioipewec:^ 
la  A  cenain  ntent :  the  left  leg,  howet-er.  and  the  left  arm  have  remained  be— ^ 
liind  in  dcvelnpmenl.  so  much  so  that  the  ami  is  eiKbl  centimcires,  the  le@^F 
iwenty'fit-e  ttniiiiietres,  shorter  than  the  corresponding  limb  of  the  right  «i(fc  "^ 
The  shonenitig  of  the  leg  i*  partly  iliie  to  a  reaeclion  of  the  knee  joint  per-  "■ 
formed  ihirtceri  jeiirs  ago  (the  re*son  for  which  procedure  could  not  be  mad^  ' 
out).  Patient  suffers  from  cpilepiifonn  at  lacks,  occurring  once  a  month  :  \hty^^ 
laat  from  a  quarter  to  ihrec  qunttcrs  of  an  hour,  and  comiil  of  more  or  less  »io— ^ 
lent  convulsions.  Durinj;  the<ie.  consciousness  is  sometimes  completely 
tamed.     Thi:rc  is  nu  imcc  ul  dementia. 


CSKEBKAL  PALSY  OF  CHILDREN. 


279 


I 


atropby.  In  the  diagnosis  of  the  bilateral  affection  wc  must 
take  into  consideration  the  possibility  of  a  nuiltiple  sclerosis, 
Friedreich's  disease,  brain  tumor  (especially  tubercles),  menin. 
gitis,  and  cerebral  syphilis.  In  many  cases  it  is  impossible  to 
cumc  to  a  satisfactory  conclusion. 

Prognosis. — The  prognosis  qumd  vaUtudxHfm  is  absolutely, 
ifuoad  viiam  relatively,  unfavorable.  Complete  recovery  is  im- 
possible, and  has  never  been  observed.  11  the  patient  does  not 
succumb  during  the  first  days  of  the  disease,  he  will  remain  a 
cripple  all  his  life,  his  mental  condition  being  good  only  in  the 
most  favorable  cases.  Under  unfavorable  conditions  he  may 
be  epileptic  and  wealc-minded,  and  to  a  greater  or  lesser  extent 
deprived  of  the  use  of  his  limbs.  The  utmost  we  can  expect  is 
that  the  diseased  side  may  atrophy  only  to  a  moderate  degree, 


The  bmlly  fonn  •■■a  jiamptqiU:  <i.  fourteen  ye-ini  old:  i.  lixUen 

loM:  r.  ihineen  )'«ar>tiM.  lii  ilie  lint  tlw  diieuc  bc-g^in  sA  the  age  of 
I  and  A  tulf,  in  ihe  socond  ai  one  and  a  half,  in  the  third  at  nine.    The 

*ncHbcr  h^  cleren  chiklren,  ci^hi  nf  whom  are  living  (among  ihcm  the  tliree 

^«tkiil»J.    (Abcr  Ncvmurk.  San  Francisco.) 


zto 


DISEASES  OF  THE  BKAIS  PROPER. 


that  the  patient  may  be  sound  enough  in  other  respects,  bodily 
and  menially,  and  thus  be  capable  ol  making  his  own  living 
(Fins.  77  a»d  78). 

Treatment — The  treatment  is,  on  the  whole,  entirely  un- 
satisfactory.    Even  by  the  light  uf  an  early  diagnosis,  we  are 


Fiir.  8.. 

The  pniirnl  in  now  fony-four  yean  o1<l.  The  ilate  ofomcl  oftlte  iliwue 
C4I1  nui  lie  (leliniiely  dclcrmincii.  She  uiOi^red  rrom  epll^irortn  vodvuImoiis 
from  e^rly  chiklhood  up  to  hrr  Irnih  year:  ihne  hjtve  now  rniirdy  diMppeared. 
Al  limes,  however,  a  " /tV  t-om'tf/t'/ "  <in  t lie  distribution  of  (be  lefl  faciAt)  tt 
nolcd.  The  devdo{irMcnt  of  tlic  kl't  half  of  ihe  body  h;is  been  retarded,  the 
upper  cjiirctnity  hrine  iwo  centimetres,  the  lower  ihrw  ceniimeirM,  shorter  than 
the  conespondinK  Umb  uf  tbe  riglit  side.  There  is  alM  a  dffercBCC  of  from 
four  10  five  centimetres  tii  ihc  circtinirercnce  of  the  linil»  of  the  two  sides. 
The  Khouldrr.  elbow,  nnd  wriii  j<nnls  are  cotitracled,  the  firu  being  in  a  pou. 
tlon  of  adduction,  the  second  in  one  of  Acxion,  and  the  third  in  exicnsiun. 
Marked  degree  of  dementia. 


I 


CEREBHAL  PALSY  OF  CUILDKEN, 


281 


The  patient,  who  i«  now  twenty-two  j-tara  or  ngt,  wax  taken  ill  with  con- 
vulUons  In  catly  childhood.  Th«>-  ceased,  but  after  an  interval  of  ten  yiars  rc- 
ajipcarcd  In  his  foiiriccnih  yv»'c,  and  have  conilntjcil  up  10  the  jirctrnl  lime, 
ttcinic  qtiite  severe  and  reeuiririK  frequently.  From  childhood  he  has  Hif- 
ferrd  from  a  severe  mulor  speech  disturbance,  and  is  only  ahle  to  utter  a  few 
unintelliKiMe  Kyllnbla,  and  thnt  with  k'c-ii  effort :  at  such  timet  Almost  all  the 
niwcles  of  the  Iwily  are  dITecied  with  a«!tcx:iaie(l  mowment*.  Atrophy  of  the 
Itft  tide  i»  to  be  noicfl.  The  circumfrrence  of  the  left  upper  arm  measures 
three  centimetres,  llut  of  the  left  forearm  two  cenlimelrcs.  that  of  the  Ihigh 
four  centimetres,  aitd  that  of  the  leg  two  centimetres  lew  than  the  eonrtjiontU 
ing  meuurcmenit  on  the  nghl  nde.  The  left  arm  is  one  centimetre,  the  left 
Vg  ooe  centimetre  and  a  half,  shorter  than  tJie  right  arm  ami  richt  leg  respecl- 
W^.  The  tefi  hand  and  lingers  aic  in  llexor  contraction,  faticnt  is  modcr- 
Utly  demented. 


282 


I>/S£JSES  OF  THE  BRAIN  PROPER. 


not  in  a  posilion  citlier  to  prevent  the  continuance  of  the  epi- 
leptiform attacks  or  to  wurd  oQ  the  changes  in  the  afiecied 
extremities,  the  symptoms  of  irritation,  the  atrophy,  etc,  Tlic 
symptomatic  treatment  of  the  epileptitorm  attacks  by  the  dif- 
Icrent  bromides  and  the  galvanization  of  the  atrophic  parts  is 
alt  that  lies  in  our  power,  and.  unfortunately,  little  enough  is 
accomplished  by  these  means. 

While  we  do  not  attempt  to  give  a  detailed  account  of  the 
patholt^y  of   cerebral  diplegias  (Freud,  Leipzig  und  Wien, 


Fit.  M- 

1S93),  two  questions  must  be  discussed,  namely,  (1)  under  what 
conditions  do  contractures.  (2)  under  what  conditions  do  cer- 
tain movements,  which  are  independent  ol  the  will  of  the  pa- 
tient, develop?     Unfortunately,  we  arc  not  able  to  answer  these 


CEREBRAL  PALSY  OF  CHILDREN. 


383 


questions  satisfactorily.  With  regard  to  the  iirst,  the  idea  de- 
serves to  be  mentioned  that  the  extent  of  the  cerebral  lesion 
the  secondary  degeneration  depending  upon  it  arc  of  some 
litioincc. 

The  same  uncerl^iinty  exists  in  regard  to  the  second  qucs- 
tion.    We  are  not  acquainted  with  the  immediate  conditions 
uch,  in  the  course  of  the  cerebral  palsies  of  children,  give 


Tbc  onset  of  lh«  <li»uue  can  not  delinitcly  be  ^%t-A.  vince  ihe  mother  of 
the  patient  dors  noi  rrmcmbcr  ii.  and  t)i«  paiiciil  herself,  who  is  now  dghtoen 
)e>n  aid,  U  demenied  and  coraplcicly  dt-privcd  of  the  power  of  itpeech.  The 
bn,  hiiwrtrr.  thai  the  illneu  becan  in  early  chiklhoud  with  convulsions  i*  un- 
quntloiM^  ;  il  u.  himercr,  not  known  how  long  ihcy  Luted  nor  what  followed 
tlMnt.  When  the  i^lrl  wu  five  yean  old  >he  wu  not  yet  ab)e  to  walk,  because 
tin  left  leg  wM  moved  only  with  (tifficuliy.  and  (he  foot  frradually  uMininl  in 
aqniao^raruk  pathlim,  whkh  can  Kiill  hr  noted.  Patient  now  M-alks  on  the 
MIer  edge  of  her  foM.  and  the  Icfc  b  Kiuxely  mot  ed  at  tlie  knee  joinl.  The 
bh  opper  exirvniilf  can  tic  moved  voluntinly  in  the  sbuuMcr  and  etbow  jdnts; 
rhe  Anicm  and  titc  bnnd  present  athrtoid  miivenieriii.  while  in  llie  facial  mu«- 
clrtof  thr  left  side  a  mnrked  ••  lit  eeavultif"  is  noted.  M.iihed  dril>t>Iin]{  of 
ulivK.  Pitkeni  no  tonger  siiflrni  from  epiiteptic  attacks,  but  has  from  time  to 
time  pertodn  <>f  cidlentent.  during  which  she  becomes  agi^mslvc. 


384 


D/S/CASeS  Of    THE  Bit  A  IK  PROPER. 


rise  to  peculiar  (unilateral  or  bilateral)  motions  in  the  affected 
extremities,  which  present  the  roUowing^  characteristics: 

The  patients  arc  absolutely  unable  to  keep  the  fingers  and 
the  toes  o(  the  affected  side  still :  they  arc  in  constant  motion 
day  and  night,  during  waking  and  sleeping,  without  inlcmip- 
tion.  If  wc  observe  these  movements  more  closely,  %vc  find 
ihem  to  be  relatively  slow,  rhythmical,  and  monotonous.  The 
fingers  seem  to  be  directed  with  a  definite  aim.  as  if  they  were 
attempting  to  seize  something,  and  it  is  easily  remarked  that 
the  normal  limits  of  the  movements  are  exceeded — the  fingers 
arc  hyper-extended,  the  toes  are  elevated  almost  at  right  angles 
or  fasten  themselves  to  the  floor  like  cUws,  etc.  (cf.  Fig.  85). 
AH  this  is  only  possible  in  consequence  of  an  unusual  stretch- 
ing of  the  ligaments,  which  also  admits  of  positions  of  distinct 
subluxation.  The  will  of  the  patient  has  hardly  any  influence 
over  these  movements,  and  only  in  light  cases,  and  then  but 
temponirily.  may  the  patient  succeed,  by  firm  pressure  of  the 
affected  hand  upon  the  body,  or  by  fixing  the  fingers  with  the 
unaffected  hand,  in  restricting  a  little  the  abnormal  excursions : 
as  soon  as  the  mechanical  impediment  is  removed,  they  will, 
however,  begin  again  with  increased  vigor, 

The  muscles  of  the  forearm  present  a  firmer  consistence,  a 
certain  degree  of  hypertrophy.  The  arm  feels  hard,  and  the 
surface  temperature  is  0,5"  to  t"  C.  (0.9*  to  t.S*  F.)  higher  than 
on  the  opposite,  sound,  side  ;  not  but  what  the  muscular  strength 
is  materially  lessened  and  sometimes  so  much  diminished  that 
the  examination  with  Duchcnne's  dynamometer  yields  aston- 
ishing results.  With  the  affected  arm  the  patient  can  hardly 
lift  five  kilogrammes,  notwithstanding  the  apparently  good  de- 
velopment of  the  muscles,  while  with  the  well  arm  five  to  eight 
times  as  much  work  can  easily  be  done.  In  the  muscles  of  the 
lower  extremity  a  similar  condition  may  be  noted ;  not  infre- 
quently the  ankle  joint  takes  part  in  these  movements  of  the 
toes,  and,  in  exceptional  cases,  the  knee  joint  as  weU.  Other 
muscles  than  those  of  the  extremities  are  not  affected. 

The  first  who  studied  these  movements  carefully  was  Ham- 
mond, of  Nexv  York,  in  tS/i.  He  gave  them  ihc  special  name 
atfiftosis  ia-Ti0tifu)  and  raised  them  thus  to  the  dignity  of  a  sepa- 
rate disease,  which,  in  our  opiaion,  they  never  deserve.  Athe- 
tosis— and  by  this  we  mean  the  athetoid  spasms— does  not  con- 
stitute a  disease,  but  merely  a  symptom.  It  is  the  expression 
ol  cerebral  affections,  the  anatomical  basis  of  which  is  variable. 


t 


i 


4 


THE  ATHETOID  MOVEMENTS. 


285 


Only  in  the  rarest  instances,  one  could  almost  sajr  never,  do 
athetoid  movements  occur  alone  without  any  other  symptoms, 
tmost  always  they  are  associated  with  other  disturbances. 


Tlw  (wltimt.  now  twenty-nine  ]»r!t  old.  tras  Ukcn  at  thf  wge  of  six  monihs 
Mhui  '*a|nf>lcctic  Mrokr"  fitltownl  by  convuUions.  which  nl  hnt  ncmnvd 
*l  long  Inivmb,  l;>lvr  (nor*  r(v<(urnilj',  tn,,.  ahoiil  once  every  Iwo  weeks ;  ihcy 
piT*niied  nil  the  ehancierisiica  of  F|)ilcpiiform  jci/ures.  ^uitc  curly,  peculiar 
Inralunt^rv  tiMWrmenlt  npfienred  In  the  Iffl  ruiicmilies,  more  panifulnrly  In 
< tie  Ir ft  arm.  which  musr  hi-  ontilikrrfl  n»  nll>elui<l.  At  resiilar  Imcnrjl^the 
Aofrn  an'  rxtmiled  jiid  ji){iiin  ilr.iwn  inlti  the  hulUm'  of  the  h«inl.  this  licing  re« 
pulnl  4l»iut  tiliy  iiriici  *  minute.  In  the  left  (not  hlmibr,  althixigh,  of  course, 
bs*  prDcumiKt:*]  inovrnMrnis..  o<cutnnK  rsfwialli-  in  the  .inkk  Joint,  nrr  noted. 
At  atMMil  iti«  aic  i^r  live  (he  comuUiMif  rrappcorcil.  although  iK^-uniii);  vnih 
dimxiiihrd  frequency,  t  e..  from  ihrre  to  five  limes  n  )mir,  The  |>aiicnl  is  cii- 
tUblc.  iraKtble,  and  ai  times  even  violent.     Inieltigeitoc  is  normal. 


286 


J>/S£AS£S  OF  TUB  BRAIX  PHOPEK. 


cither  psychical  (the  patients  arc  mentaily  undeveloped,  de- 
mented, sometimes  of  a  chanfj^eable,  irrtlnble  disposition)  or 
somatic,  such  as  para1y!<cs  or  spasms  in  the  distribution  of 
difTereiit  nerves — for  instance,  the  (aci;il — contractures,  etc. 
Again,  the  patient  may  be  subject  to  epileptiform  attacks  which 
recur  at  intervals  of  various  lengths. 

If  we  thus  affirm  that  every  athctosis^be  it  the  much  rarer 
bilateral  form  (see  above),  be  it  unilateral,  the  "  hemiathctosis  " 
— is  only  to  be  regarded  as  a  symptom,  wc  are.  on  the  other 
hand,  willing  to  admit  that  there  are  individual  cases  where 
the  athetoid  movements  arc  such  a  prominent  and  dominating 
feature  of  the  case  that  wc  may  overlook  others,  or  at  least  not 
be  inclined  to  attribute  any  importance  to  them.  So  it  is  in  an 
instance  reported  by  Gnauck.  who  speaks  of  a  primary — that 
is,  idiopathic — athetosis,  but  who  has  noted  a  simultaneous 
jMiresis  of  the  facial  and  a  hemiana;sthesia  of  the  affected  side. 
Wc  can  hardly  call  this  an  idiopalhic  affection,  but  must  rather 
look  upon  it  as  a  prehcmiplcgic  phenomenon  (cf.  page  218); 
and,  similarly,  some  explanation  can  be  fotmd  for  the  few  re- 
maining cases  published  as  "idiopathic"  athetoses,  some  of 
which  were  congenital.  These  movements  arc  always  a  symp- 
tom of  cerebral  disease.  That  they  are  occasionally  met  with 
in  the  course  of  other  diseases— e.  g.,  spinal  affections,  cspe. 
cially  tabes — there  can  be  no  doubt.  The  pathological  changes 
observed  in  cases  which  had  presented  athetoid  movements 
during  life,  in  addition  to  those  found  in  cases  of  cerebral  pal- 
sies of  children,  consisled  in  small  foci  ol  softening  in  the  b.isal 
ganglia,  the  thalamus  (Lauenstein),  the  corpus  striatum  (Schuiz). 
and  in  the  temporal  lobes  (Kwald).  although  wc  can  in  none  of 
these  instances  be  certain  that  the  lesions  found  were  actually 
the  cause  of  the  movements.  After  cerebral  harmorrhage 
whci-c  we  have  a  lesion  of  the  internal  capsule,  in  old  hemiple- 
gias therefore,  bemiatheloid  movements  are  occisionally  seen, 
yet,  in  comparison  with  the  frequency  of  cerebral  hemlplegiis 
in  aduils.  these  arc  very  rare,  certainly  much  rarer  than  in  the 
S(>callcd  infantile  hemiplegias.  We  see,  therefore,  that  cortical 
lesions  and  lesions  of  the  cortico-muscular  tract  as  well  as  of 
the  basal  ganglia  may  give  rise  to  athetoid  movements,  al- 
though we  do  not  understand  the  ttexus  ctusa/ii,  if  indeed  such 
exist.  In  our  opinion,  disease  of  the  cOrlex  undoubtedly  plays 
the  principal  part  in  the  causation  of  athetosis,  and  wc  can  all 
the  more  reckon  upon  the  occurrence  of  athetoid  movements 


THE  ATltETOtD  MOVEMENTS. 


a87 


If  ihe  conical  disease  has  appeared  in  early  childhood  and  has 
been  cllhcr  entirely  confined  to  or  has  affected  more  particu* 
Iwly  Ibe  motor  region,  the  central  convolutions,  and  the  adja- 
cent portions.  In  lesions  of  the  other  parts  of  the  brain,  espe- 
cially ul  the  basal  ganglia,  the  thalamus,  the  lenticular  nucleus, 
and  the  caudate  nucleus,  alhcCuid  movements  are  only  excep- 
tionally developed,  the  conditions  which  favor  iheir  occurrence 
being  then  wholly  unknown.  That  there  is  a  cerebral  lesion 
which  produces  no  other  symptom,  whether  psychical  or  so- 
matic, than  these  movements  is  unlikely,  and  consequently,  as 
we  said,  the  name  "  athetosis,"  as  indicating  a  separate  disease, 
can  not  be  held  to  be  justifiable. 

Keeping  well  in  mind.  then,  the  characteristics  of  the  move- 
ments which  have  just  been  described,  and  especially  after 
having  had  occasion  to  study  their  peculiarities,  one  can  hardly 
mistake  them  lor  anything  else.  A  good  point  to  remember 
is  that  they  continue  during  sleep,  so  that  the  patients  have  to 
Mop  or  at  least  impede  them  by  mechanical  applianccs- 

We  shall  give  up  the  ide.t  of  chorea  or  hcmichorea  which 
we  might  entertain  should  the  athctoid  movements  be  accom- 
panied by  facial  spasm,  if  after  observation  of  the  patient  we 
have  been  convinced  that  the  movements  persist  when  he  is 
asleep.  Furthermore,  the  duration  ol  the  disease  and  the  fact 
that  it  resists  all  therapeutic  measures,  more  especially  the  pro- 
tracted use  of  arsenic,  are  facts  not  reconcilable  with  the  diag- 
H  nusis  of  chorea.  Other  points  of  dtlTcrcncc  will  be  found  in 
H    Ihe  chapter  on  the  latter  disease. 

H        We  possess  no  specific  which  will  put  a  stop  to  these  athe. 

H  mid  movements;  their  treatment  is  that  of  the  primary  dis- 

^^^asc,  and,  as  this  is  usually  beyond  our  reach,  the  outlook  in 

Hi^thetosEs  is  necessarily  very  gloomy.     If  Hammond  chiims  to 

linve  efTccted  a  cure  by  stretching  the  median  nerve,  we  may 

t>c  pardoned  for  asking   how   long  this  cure  lasted :  and  if 

^nauck  has  seen  the  movements  disappear  after  the  use  of  the 

j^lvanic  current  and  the  intcrn.il  administration  of  potassium 

^^liromidc.  we  are  justified  in  assuming  that  in  his  case  the  aflcc- 

^■tion  was  due  to  a  functional  disturbance  of  the  motor  area. 

^^  '^Vhal  lasting  good  results  can  be  accomplished  by  hvoscinc.  a 

drug  which  has  been  used  by  I^ib,  1  have  not  as  yet  been  able 

to  establish  with  the  material  at  my  disposal. 


I 


288  DISEASES  OF   THE  BRAIH  PROPER. 


LITERATURE. 

Strumpell.     Uebcr  di?  acute  Encephalitis  der  Kinder.     Polioencephalitis  acuta, 

cerebrale   Kinderlahmung.      Vortrag  gchatten  auf  der   S7ten  deutschen 

Naturforscher-Versammlung  zu  Magdeburg. 
Jendrassik  et  Marie.     Conlribution  i  I'^tude  de  l'h£miatrophie  cMbrale  par 

sclerose  lobaire.    Arch,  de  Physiol.,  i,  1885. 
Richardi6re,     £iude  sur  Ics  scleroses  encdphaliques  primitives  de  I'enfancc. 

Havre,  1SS5. 
Marie.     Himiplegie  c^rfbrale  infantile  et  maladies  infectieuses.     Progr.  ni£d., 

xiii,  2me  s£r.,  No.  36,  i88j. 
Bernhardt,  M.     Ueber  die  spastische  Cerebral  paralyse  im  Kindesalter.     Vir- 

chow's  Arch.,  I)d.  cii.  1885. 
Bernhardt.     Jahrbuch  f.  Kinder heilk.,  N.  F..  ixiv,  p.  384,  1886. 
Kasl.   Zur  Analomiedercerehrnlen  KinderlShmung.   Arch.  f.  Psych.,xviii.  2, 1887. 
Mathicu.     Progr.  med.,  2,  p.  29,  1888.     {Cerebral   Infantile  Paralysis  as  a  Con- 
sequence of  Traumatism.) 
Wallenberg.     Verfinderungen  der  ner\'oser»  Centralorgane  in  dnein  Fallc  von 

cerebraler  KinderlShmung.     Arch.  f.  I'sych.,  xix,  2,  1888. 
Benedikt.     Berliner  klin.  Wochenschr.,  1888,  51. 
Hoven.     Arch.  f.  Psych..  1888,  xix,  3. 
Audry.     I.es  Porencephalies.     Revue  de  m*d..  1888.  6,  7. 
Schmaus.   Zur  Kenninissderdiffusen  Himsbterose.  Virchow's  Archiv,  1888. cxiv. 
Pilliel.     Arch,  de  Neurol.,  September,  1889.  53. 
Slriimpell.     L'eber  primare  acute  Encephalitis,     Leipzig,  1890. 
Sibol.     Arch.  de.  Nfuroi,.  1890,  xix,  57. 
Sachs  and  I'tterson.     A  Study  of  Cerebral  Palsies  of  Eariy  Life,  based  upon  an 

An.iiysis  of  One   HundrL-d  und   Pi irty  Cases.     Journal  of  Ncrv.  and  Mcnt. 

Discasrs.  May,  iSi/a. 
Freud   und   Kit.     Klinischt   Stu<iie  ul)er  die  halbscilige  Cere  brail  ah  mung  der 

Kinder.     Mono^jraph,  Wi^'il,  r8gi, 
Chaslin.     Contribuiinn   A  I'tiude  de  la  Sclerose  cerehrale.     Arch,  de  m^d.  ex- 

pcrim.  vX  il'.inat.  p.ith.,  iKiji,  2. 
Sachs.  H.  (Ni-w  York),     Cimtribiiiicms   to  the   Palholo^y   of  Infantile  Cerebral 

P.ilsies.     New  Yr)rk  Mrd.  Jiiurii..  May  2,  1891, 
Sachs   (New   Vi>rki.      Die    HirnliihmunEcn   der  Kinder.     Samml.   klin.   Vortr, 

N.  F,  1K92,  46.  47. 
.Michailonslii.     I^-tude  ilinique  sur  I'alheiose  double.     Th^sc  de  Paris,  1891. 
Freud.     Zur   Kcnntnisi.  der  cerebntlen   Diplegien  ini    Kindesalter.     Leipzig  u. 

Wieii.  1893, 

Bidim.     l-'ss.ii    sur  I'hi'niichori'c  syniplonialique  des   maladies   de  I'encephale. 

Kevue  ile  lued..  iH.^fi. 
Bourni'ville  ei   I'illiel,     Deux   cis  d'athclose  double  avec  imbecillile.     Arch,  de 

Ni'uriil,.  xiv,  Ni),  4;,  18M7. 
C.erlint,'.     Teber  Allielosis.     bLiui;.- Miss.,  Kiel,  1887. 
Kuhiiiii.     Crinirihii/iiine  1  liiiir  ,1  alio  siiidui  dell'  atetusi  e  del  paramiocluno  molte- 

plii-e.      KiriirtiiJ  rin-clii"i.  ly'^.  I1SH7. 
{Cf,  also  ihi;  texl-hoiik,'.  i.l  Sirunipell,  Scfliguniller,  Eichhorsl.) 


attAt/f   TUMOHS. 


389 


IIRAIN   TUMORS. 

Pathological  Anatomy. — Brain  tumors  may  be  cither  sharp- 
ly circumscribed  or  ditluse,  iii  llie  latler  otsc  Ukiii^  the  pl:icc, 
as  it  were,  of  (he  brain  substance  proper.  The  most  common 
— e.  g.,  the  gliomata,  the  curciiiumata,  and  the  surcomata — 
occur  in  bolt)  varieties.  The  clinical  manifestations  ol  brain 
tumors  depend  upon  the  nipidity  of  their  growth  ;  ihis,  again. 
u[Hm  their  anatomical  nature.  Among  the  most  important  and 
the  most  Ircqucnt  (orms  ol  tumors  must  be  mentioned : 

['he  glioma. a  form  which  is  peculiar  to  the  central  nervous 
system,  but  is  found  much  mure  fretiuently  in  the  cerebrum 
than  in  the  brain  stem  or  the  spinal  cord.  It  is  formed  by 
an  increase  in  the  cells  of  the  neuroglia,  the  axis  cylinders  in 


Flf.  aSi— CUOKA  TKLAiTOiicTAricUH.    (Afut  ZiiuL.KK,)    hmoiAl  HCiion  ibroueh  the 
!«•».    d,  tijchi  Mrninim  wmlonle.    t,  sUoma  Id  the  lefi  bcntephcrc. 

the  involved  region  first  becoming  swollen,  and  the  nerve 
fibers  then  destroyed.  If  the  newly  formed  cells  are  small  and 
com ])3ra lively  few  in  number,  and  if  their  fibril-like  processes 
Jorm  a  tiensc  network,  ihen  the  tissue  of  the  growth  is  firm 
and  solid ;  if  the  cells  arc  numerous  the  tissue  is  softer.  On 
section,  the  glioma  looks  gray,  grayish-red.  or  yellowish,  some- 
times  variegated,  and  if,  as  is  m)t  uncommonly  the  case,  it 
contain  areas  of  haemorrhagic  softening,  the  tumor  may  be 
filled  with  opaque  more  or  less  fluid  masses.  The  diameter  of 
a  glioma  may  measure  from  three  to  eight  centimetres.     The 

»9 


tgo 


U/SBASES  Ofi  THE  BRAIN  PROPER. 


transition  into  the  adjoining  substance  of  the  brain  may  be 
graduitl  or  abrupt,  and  the  tumor  appear  macroscopically 
sharply  dehncd.  The  aHectcd  part  of  the  brain  is  enlarged, 
but  keeps  its  normal  configuralion  while  the  ventricles  are 
often  dilated  (Fig.  86).  I 

The  tumor  nearest  related  in  texture  to  the  glioma  is  the  ' 
sarcoma;  it  occurti  in  soft  nodes,  which,  on  section,  present  a 
marrowy,  grayish-white  appearance.  It  is  seen  much  more 
frequently  at  the  base  than  at  the  convexity  of  the  brain,  and 
not  uncomnioiily  is  found  to  originate  from  the  dura,  from  the 
periosteum  of  the  skull  bones,  or  from  the  skull  itself  (osteo- 
sarcoma). According  to  the  character  of  the  cells,  we  distin- 
guish a  round-cell  sarcoma,  a  spindle-cell  sarcomu,  a  5bro- 
sarcoma.  etc.  In  size  they  may  vary  from  that  of  a  walnut 
to  that  of  a  man's  fisL.  and  may  be  solitary  or  multiple. 

The  carcinoma,  which  appears  usually  in  the  brain  or  in 
the  dura  as  fungus  durxmatris  secondarily  to  carcinoma  of  the 
breast,  lung,  or  pleura,  is  found  especially  in  the  ventricles  as 
a  soft  tumor  (cf.  Fig.  87),  displacing  the  neighboring  brain  sub- 
stance, and  giving  rise  to  hydrops  ventricutoruni. 

Clinically  of  great  importance  are  the  tubercles  and  the 
syphilomata  (gummala),  which,  although  they  show  macro- 
scopically  as  well  as  histologically  much  similarity,  can  with 
certainty  be  distinguished  by  the  presence  or  absence  of  the 
tubercle  bacilli.  They  also  may  be  cither  sharply  defined  or 
may  intiltr-ite  the  tissue  ;  they  appear  on  section  as  yellowish, 
cheesy  tumors  consisting  in  pan  of  granulation  tissue.  The 
"solitary  tubercles,"  which  may  reach  the  size  of  a  bazelnul.  ■ 
are  single  or  multiple:  they  occur  by  preference  in  the  pons. 
In  the  cerebellum,  and  in  the  cortex.  Syphilomata  more  fre- 
quently originate  in  the  dum  mater,  and  thence  invade  the 
brain  subslancc. 

The  psammomata.  which,  coming  also  from  the  dura,  arc 
characterized  by  calcareous  concretions  imbedded  in  them :  the 
cholesteiilomala.  which  on  section  have  a  lustre  like  that  of 
mother-of.prarl :  the  lipomala.  often  found  in  the  corpus  callo- 
Sam ;  the  enchondromata,  which  originate  especially  from  the 
bones  of  the  base — all  these  are  clinically  of  little  importance. 
as  they  produce,  owing  to  their  relatively  small  size,  either 
only  insignificant  or  no  symptoms  at  all.  Hence  we  may  well 
omit  them  in  our  description. 

At  the  autopsy  we  can  often  demonstrate  the  consecutive 


BRAt.V  TUMORS. 


291 


changes  produced  by  a  general  compression  of  the  brain.  The 
skull  bones  themselves  in  young  people  may  appear  perforated 
,Wtd  riddled  with  holes,  there  may  be  gaps  in  the  dura  or  signs 
of  in(l;i(im)alory  irril.ttiun.  cerlaii)  areas  may  be  rough  and 
tliickcncd.  presenting  a  velvety  appearance,  the  convolutions, 
flattened  and  presM^d  against  each  other,  have  lost  their  dis- 
tinctness, the  pia  looks  dry  and  anivmic.  Ccrtaiii  alleralioiis 
o(  shape  seem  always  to  occur  if  the  pressure  reaches  a  con- 


^ 


lt#r.— PAnLLAxvCAniiwoHA  IN  IKK  TKI«n  VtHTKictj:.  (Afier  ZiccLKM.)  Prnaul 
MCMaa  tlimii^  Uu  licaln.  •!.  tumor  wiib  c]«k  4,  rishi  iluljuiuu>.  r.  teaUoiiu  nucJoHL 
4,  fclltnwl  opmlt.  /.  TMnUleuuclnu.  /,  led  UuUmiu.  ; ,  lenllcuUt  nudeiu.  4,  iMcT' 
Ml  tB>Willi     t,  dlUic4  bttnl  ««nukic. 

liderable  degree :  thus  a  pressure  in  one  hemisphere  exerting 
ftsclf  from  above  downward  changes  more  especially  the  shape 
of  the  insula  and  the  portions  of  the  temjioral  and  parietal  lobes 
which  cover  it  in  (Wernicke).  This  eltect  must  be  attributed 
not  unly  to  the  increase  in  volume  of  the  tumor,  but  also  to  the 
increased  amount  of  the  lUiid  in  the  ventricles,  the  hydrops 
vcntriculorum  (internal  hydrocephalus)  which  almost  con- 
ftaatjy  accompanies  tumors.  No  doubt  this  internal  hydro- 
cephalus itself  is  due  to  pressure  on  the  venous  trunks  in  the 
brain,  and  it  occurs,  therefore,  earlier,  and  is  more  marked  if 
the  large  venous  trunks  coming  from  the  tela  choroidca  are 
preSKd  upon  by  the  tumor  (Wernicke). 

On   the  cranial  nerves  signs  of  pressure  have  also  been 


29Z 


ffiSEASeS  OF  THE  BKAIN  PftOPEt!. 


noted.  The  optic  tract,  the  oculo-motorius.  the  abducens 
(Tiirck)  have  been  found  compressed  by  lightly  stretched 
vessels,  and  an  exudation  into  tlic  sticath  of  the  optic  nerve 
has  been  observed  (Leber).  In  some  cases  we  find  a  more  or 
less  widely  spread  softening  in  the  parts  surrounding  the 
tumur.  in  others  ll»is  may  be  entirely  absent:  i(  the  softening 
is  of  a  ha:inorrhagic  character,  this  must  be  attributed  lo  a 
cutting  ofF  of  the  arterial  blood  supply  produced  by  the  cere- 
bral compression  and  lo  venous  stasis.  Sometimes,  in  the 
neighboring  vessels,  there  develops  an  arteriitis  obliterans  with 
its  sequelae  (C.  Fried  lender}.  Cranial  nerves  in  the  immediate 
neighborhood  of  carcinomata  and  syphilomata  arc  found  to  be 
iutiltrated  with  the  tumor  elements  (Wernicke). 

Etiology. — The  aetiology  of  brain  tumors  is  entirely  ob- 
scure :  we  do  not  know  in  the  least  whether  certain  external 
influences  increase  the  predisposition  to  tumors  in  ihc  brain  or 
not,  just  as  we  are  entirely  ignorant  of  the  a*tiology  of  tumors 
in  general.  Although  the  common  idea  exists  that  traumatism 
may  be  the  starting  point  for  a  new  growth,  it  is  dilTicult  to 
understand  the  connection :  certainty,  however,  this  factor 
plays  an  infinitely  smaller  part  in  tumor  than  in  brain  abscess, 
and  the  occurrence  of  a  brain  tumor  fallowing  an  injury  is 
probably  for  the  most  part  accidental.  No  doubt,  in  some 
kinds,  hereditary  predisposition  must  not  be  disregarded,  as 
in  carcinomata  and  tubercles,  but  even  this  loses  some  of  its 
significance,  because  malignant  brain  tumors,  especially  car- 
cinomata. are  usually  secondary,  as  we  have  said.  Nothing 
remains,  then,  but  to  inquire  how  far  age  and  sex  influence 
their  occurrence.  With  reference  to  the  former,  it  is  supposed 
that  some  brain  tumors,  such  as  tubercles,  predominate  in  the 
young,  while  carcinomata  and  sarcomata  are  chiefly  found  ia 
older  people  ;  othcrs^e.  g..  myxomata  and  sometimes  glioniala 
— are  congenital  (Virchow).  As  to  sex,  older  and  more  recent 
authors  (Lebcrt.  Friedreich,  Hasse)  agree  that  males  are  more 
Hnble  to  brain  tumors  than  females,  and  Wernicke  has  calcu- 
lated that  the  proportion  is  about  three  to  two. 

Symptoms. — The  symptoms  we  are  wont  to  observe  in 
brain  tumors  arc  due  to  the  mechanical  influence  which  the 
tumor  exerts  by  general  or  local  compression  of  the  skull  con- 
tents, and,  further,  to  destructive  or  irritative  actions  which 
depend  upon  certain  vital  peculiarities  of  the  growth,  the  irri- 
tation mostly  accompanying  the  infective  neoplasms.     Oneur 


mtAtiV    TfAfOffS. 


i9S 


\ 

f 


the  other  of  these  just-mci»tionecl  factors  will  influence  the 
clinical  picture  of  the  disease  in  a  mure  or  less  characteristic 
manner,  and  as  one  or  the  other  is  more  prominent  the  whole 
aspect  of  the  disc:ise  will  vary. 

With  reference  to  the  former,  tlie  increased  intracranial 

pressure,  il  it  appears  acutely,  we  have  first  a  displacement, 

then  an  increase  of  tension,  in   the  ccrcbro-spinal   fluid.     In 

chronic  processes  the  latter  docs  not  necessarily  occur,  but  us 

the  skull  cavity  gradually  becomes  encroached  upon,  some  of 

ibe  fluid  may  be  absorbed  or  the  brain  become  atrophic.     As 

the  intracranial  pressure  becomes  higher  the  circulation  ia  the 

brain  and  its  membranes  is  retarded,     What  ts  the  cause  of 

this  retardation,  wlielher  the  diminution   in   the  lone  of   the 

vessel  walls  produces  such  an  increase  in  the  tension  of  the 

cerebro-spinal  fluid  that  by  compression  a  narrowinj*  in  the 

capillaries  is  produced,  or  whether  ffuxionary  hypcricmias  come 

■  into  play,  we  are  not  able  to  decide  definitely.     At  any  rate,  it 

m  the  IiIo<k1  current  in  the  interior  of   the  skull  frequently  undcr- 

I  goes  II  slowing,  there  is  a  tendency  to  increased  transudation 

H«nd  lymph  formation,  and  with  it  a  danger  of  oedema  of  the 

H  brain  (c(.  von  Ber^mann,  Die  Lehre  der   Kopfverlelzungen, 

^Stuttgart,  1880,  pp.  3i^3(h)- 

H  The  symptoms  to  which  this  increase  of  the  intracranial 
lension  gives  rise,  and  which  one  h.is  frequently  the  oppor- 
tunity of  studying  in  (he  course  of  brain  tumors,  may  be  di- 
vided into  general  and  focal.  The  former,  fur  the  knowledge 
of  which  we  have  to  thank  especially  I-eyden,  Munz.  and 
Durct,  usually  appear  in  a  regular  sequence  and  are  always 
tlte  name  for  the  same  degree  of  pressure. 

The  most  conspicuous  and  earliest  to  appear  is  the  head- 
ache.    The  patient  complains  of  nothing  but  his  head,  which 
feels  heavy  and  dull.     Every  movement  causes  p.tin,  and  this 
B  becomes  at  limes  so  violent  that  the  patient  feels  as  if  he  were 
B  losing  his  reason.    The  pain  seems  diffuse  and  can  not  be  locaU 
W  ized.     It  is  in  front  on  the  forehead,  behind  over  the  occiput, 
ft  to  the  right,  to  the  left :  il  torments  him  evcrvwherc,  and  the 
f  lightest  lap  with  the  finger  anywhere  upon  his  head  is  intensely 
disagreeable.    Sometimes  there  comes  an  hour  or  two  of  relief. 
allbough  the  patient  feels  by  no  moans  well  and  is  never  with- 
out pain  even  in  sleep.     The  scat  of  this  pain  which  is  due  to 
the   general  increase  of  the  inlracrani:)l  pressure  produceil  by 
ihe  tumor,  is  not  known.     It  is,  however,  not  likclv  to  be  in 


394 


DJXRM.IKS  OF  TIfH  /tftA/N  PKOP/iS, 


I 


the  substance  o(  llie  brain  iisell,  unless  it  be  perhaps  in  the 
corpora  quntlrtj^emlna  and  the  thalami.  We  should  rather 
look  for  its  position  in  the  (iura.  wiiich  derives  its  nerve  supply 
from  the  trigeminus  (cf.  page  61).  II  the  fibres  of  this  nerve 
are  compressed  by  the  tumor  in  the  posterior  fossa,  then  there  I 
is  not  the  vague  pain  taking  in  the  whole  head,  but  another 
welUdelined  headache  relerred  by  the  patient  to  the  back  nl 
the  head  and  neck  only,  a  trigeminal  or  occipital  neuralgia  ■ 
which  is  not  a  general  but  a  focal  symptom.  This  double  sig- 
nificance of  the  headache  may  become  a  very  valuable  point 
in  the  topical  diagnosis.  Entire  absence  of  headache  is  rare, 
and  wc  fail  In  find  this  symptom  only  when  the  growth  o( 
the  neoplasm  is  slow.  Its  occurrence  with  unwonted  vehe- 
mence has  repeatedly  been  noted  in  aneurisms  situated  near 
the  dura.  Occasionally  it  disappears  when  definite  focal  symp- 
toms become  established,  and  it  naturally  is  more  obscured  in 
the  later  stages  of  the  disease,  when  the  patient  becomes  som- 
nolent, lis  existence  is  then  only  apparent  from  the  fact  that 
the  hall-unconscious  sufferer  frequently  puts  his  hand  to  his 
head  and  moans. 

A  second  general  symptom  is  afforded  by  the  epileptiform 
convulsions,  which  cither  aflcct  the  whole  body  or  are  confined 
to  one  side  and  during  which  consc'ousncss  may  or  may  not 
be  completely  lost.  They  arc  by  no  means  so  frequently  asso- 
ciated with  brain  tumors  as  headache,  still  their  occurrence  is 
common  eiioiigli  to  he.  of  diagnostic  value  (rl.  IJremcr  and  Car- 
son, Amer.  Journ.  Med.  Sci..  September.  1S90).  They,  too,  may 
constitute  a  focal  symptom,  as  is,  for  instance,  not  rarely  the 
case  in  cortical  tumors  ul  the  frontal  or  p;>rietal  lobes,  which 
partly  exert  local  pressure,  partly  irritate  the  cortex.  We 
must  not  suppose  that  these  two  symptoms,  although  they  are 
both  of  an  irrtlalive  nature,  always  go  hand  in  hand.  Hither 
one  or  both  may  be  present,  sometimes  the  one  as  a  general, 
the  other  as  a  focal  symptom-  Convulsions  occur  in  about 
fifty  per  cent  of  all  cases  of  brain  tumors.  WcU-marked  hys- 
tcroid  convulsions  have  been  observed  by  SchJinthal  in  a  case 
of  tumor  in  the  corona  radiata  of  the  fronl-il  lobe  (Berlin,  kh'n. 
Wochcnschr.,  1S91,  10). 

The  psychical  changes  constitute  a  third  general  symptom, 
which,  however,  disturbs  less  the  patient  himself  than  his 
friends.  A  certain  slowness  in  thinking  is  occasionally  noticed 
in  the  patient,  at  first  temporary,  but  later  more  constant 


BRAIN  TUMORS. 


395 


fnabiltly  to  apprcciulc  properly  the  commonest  details  uf  daily 

Ililr  which  had  never  been*  before  remarked  in  him.  At  the 
s.inie  time  the  (caitires  become  dull  and  lose  their  animated  ex- 
|iri'ssi()ti.  hi^  niuvcmenis  slow  and  awkward,  he  grows  careless 
tn  all  his  doings,  and  this  listlcs<)nc»s  about  everything  going 
on  around  him  may  be  carri<.'d  to  such  an  extent  that  he  lets 
\\\t,  tirtne  and  (kccs  pass  (rom  him  without  showing  any  con- 
cern or  attcmpiin<;  to  satisfy  his  needs  in  a  proper  maimer. 
■  Onidually  he  begins  to  show  occasional  signs  of  bewilderment. 
Tilings  thai  he  meets  with  every  day  he  no  longer  recognizes. 
Hi»  own  house  seems  strange  (o  him.  he  (orgcis  the  way  to  his 
(lining- rot tm  or  bed-room,  and  has  to  be  shown  there,  etc.  Me 
even  forgets  how  to  read  and  to  wriic.  how  to  solve  the  sim- 
H  [)lest  mathematical  problems  which  would  not  give  the  slight- 
"  c»t  diflicully  to  an  eight-year-old  child,  and  gmdnally  he 
becomes  more  and  more  demented,  until  lids  condition  ]);isscs 
into  one  of  deep  coma  and  death.     In  other  cases  the  intclli- 

tgence  seems  to  remain  intact  for  a  long  while,  and  only  the 
weakness  of  memory  strikes  one.  The  friends  of  the  patient 
Iwcorac  alarmed  on  noticing  that  he  forgets  things  which  he 
has  said  or  done  only  one  or  two  days  or  even  a  (cw  hours  be- 
fore, that  he  does  not  remember  the  visits  of  the  physician 
who  comes  daily,  but  complains  of  not  having  seen  him  for  a 
long  lime.  Vet  although  he  may  be  troubled  with  bodily  pain. 
the  patient  may  seem  at  the  same  time  cheerful,  inclined  to 
I,  and  to  look  ai  things  from  the  humorous  side,  and  it  is  not 
tit  later  thai  the  other  mental  defects  also  begin  to  show 
themselves,  and  not  infrequently  the  physician  is  not  consulted 
until  the  friends  discover  that  the  patient  is  no  longer  capable 

Iol  conducting  bis  own  aRairs.     Actual  speech  disturbnnccs  do 
not  usually  occur.    Certain  peculiarities  ol  speech  which  do 
come  on  and  make  it  different  from  that  in  health  are  due  lo 
the  cslcnsive  loss  of  memory  ol  the  patient,  owing  to  which  he 
fcas  ilifTtcully  in  finding  the  right  expressions,  and  often  mixes 
them  up,  etc.    This  makes  hJm  uncertain  in  speaking,     lie  talks 
»li»wly.  and  his  deliberation  becomes  quite  noticeable. 
In  consequence  of  the  increased  intracranial  pressure,  not 
Tirrly  disturbances  in  ihc  sensorium  occur.     The  patient  is  in 
a  da/ed  cimdition.  has  a  constant  desire  to  sleep,  and  is  drowsy. 
H  The  pulte  U  often  slow  at  first  (lortyfivc  1o  lilty*tive  beats 
per  minute)  and  irregular,  similar  to  that  which  we  may  ob. 
icrve  in  apoplexy.     This  retardation  is  finally  folh^wrd  by  an 


296  DISEASES  OF  THE  BRA  IK  PSOfEtf. 

increase  in  the  frequency  in  the  number  of  beats.  In  other 
words,  the  primary  irritation  Ikis  given  way  tu  paralysis  of  the 
vagus. 

Tttgelher  Willi  llie  action  of  the  heart,  respiration  is  aflcctctl. 
During  cotna  it  Is  deep,  slow,  and  often  stertorous;  with  the 
continued  increase  o(  the  cerebral  compression  it  becomes 
irregular  and  shallow.  IVcp  inspirations  arc  interrupted  by 
long  pauses,  in  one  o(  which  the  patient  dies. 

Slight  vertigo,  sometimes  attended  with  vomiting,  is  not 
uncommon.  The  latter,  whicli  is  cerebral  in  origin,  has  certain 
peculiar  characteristics.  It  usually  occurs  on  the  slightest 
provocation.  It  iii.ty  be  provoked  by  a  simple  change  in  the 
position  of  the  body,  and  often  comes  on  in  the  early  morning 
and  without  the  existence  uf  any  stomach  trouble.  Without 
any  retching  large  amounts  of  watery  clear  stomach  contents 
are  repeatedly  thrown  up.  and  .-ifter  a  short  while  the  patient 
(eels  perfectly  well.  Sometimes  the  vomiting  is  the  forerunner 
of  apoplectiform  attacks,  in  which  the  patient  may  be  uncon- 
scious for  hours.  Such  attacks  are  due  to  a  sudden  increase  in 
the  intracranial  pressure,  either  from  hiemorrhage  into  the  sub- 
stance of  the  tumor  or  from  sudden  hydrocephalic  exudations 
(Wernicke), 

That  papillitis  is  extremely  common  in  brain  tumor  wc 
have  said  before.  We  may  add  here  that  it  may  exist  without 
headache,  for  the  increase  in  the  intracranial  pressure  sufficient 
to  produce  papillitis  does  not  necessarily  produce  an  appre- 
ciable irritation  of  the  dura,  and.  on  the  other  hand,  if  head- 
ache exists  witluiut  papillitis,  it  is  not  referable  to  the  cere- 
bral compression  but  to  irritation  of  the  dura.  We  should 
never  forget  that  papillitis  may  exist  without  any  visual  dis- 
turbance, and  hence  never  omit  the  ophthalmoscopic  cxamina- 
tion  in  suspicious  cases,  no  matter  whether  the  patient  com- 
plains of  trouble  with  his  eyesight  or  not.  Again,  the  patient 
may  only  complain  of  one  eye.  while  the  other  seems  to  per- 
form its  function  normally,  and  yet  profound  changes  be  found 
in  either  fundus. 

If  in  the  course  of  a  brain  tumor  the  patient  develops  in 
addition  to  papillitis  an  early  blindness,  then  the  amaurosis  has 
to  be  interpreted  as  a  focal  symptom,  and  the  tumor  located  in 
the  cerebellum,  as  neoplasms  in  this  situation  are  usually  at- 
tended with  verv  marked  internal  hydrocephalus,  especially  of 
tthe  third  ventricle,  the  floor  of  which  becomes  distended  and 


HKAttf  rtwoxx. 


297 


presses  upon  Ihe  chiasm  situated  under  it  (Turck).  Moreover, 
early  amaurosis  may  be  produced  by  tumors  in  ihc  region  of 
ihe  corponi  qiiadrigcmiriii.  especially  those  of  the  pineal  fjland, 
by  basal  neoplasms,  which,  jusl  a»  those  of  the  pituitary  body, 
press  on  the  chiasm  and  the  beginning  of  the  optic  tract,  or 
which  raise  the  base  of  the  brain  from  the  ha»e  of  the  !it;ull, 
so  thai  the  artery  of  (he  curpiis  callosum  is  made  tense  and 
compresses  the  optic  nerve  (TUrck). 

The  visual  disorders  which  occur  in  the  course  of  brain 
tumors  ha%-e  been  group<"d  in  the  following  manner  by  Hirsch- 
berg  (Neurol.  Ccntralbtatt.  iSgi,  )$): 

(I)  Attacks  of  blindness— epileptiform  amaurosis,  (z)  Per- 
manent visual  disorders : 

A.  Produced  by  changes  in  the  brain :  a  Homonymous 
brmianopia  (destruction  of  one  or  both  visual  centres  in  the 
occipital  lobe).  0  Crossc<l  hemianopia  (tumors  in  the  region 
of  the  anterior  or  jiostcrior  angle  of  the  chiasm.  7  Bilateral 
hemianopia — total  amaurosis. 

B.  Produced  by  changes  in  the  eye-ground :  a  Enlarge- 
ment of  the  blind  spot  {not  noticed  by  the  paticntj.  ff  Nar. 
rowing  of  the  field  of  vision.  7  Diminution  of  the  central 
acutencss  of  vision,  due  either  to  anatomical  changes  in  the 
retina  or  to  interruption  of  the  nerve-fibres  leading  to  the 
retina. 


In  considering  ihe  (ocal  symptoms  produced  by  brain 
tumors  wc  must  first  of  all  slate  that  these  may  be  entirely 
absent,  just  as  we  have  seen  is  sometimes  Ihe  case  in  brain 
abacess.  Instances  of  this  kind  have  repeatedly  come  under 
observation,  and  it  was  on  this  very  account  found  impossible 
to  make  a  certain  diagnosis  during  life.  Absence  of  both  gen. 
eral  and  local  symptoms  is  very  rare,  and  only  possible  when 
the  new  growth  is  very  limited,  and  situated  at  an  inditlerent 
place.  Further,  there  are  symptoms  which  we  are  justified  in 
taking  for  focal  symptoms,  but  which  are  in  reality  due  to  the 
general  compression.  The  most  important  one  of  this  nature 
is  hctniplcgia.  \Vc  may  in  a  case  of  brain  tumor  find  a  well- 
marked  hemiplegia,  which  persists  without  any  amelioration, 
and  be  induced  to  call  it  a  focal  symptom,  and  yet,  to  our  sur> 
prise,  at  the  autopsy  a  tumor  may  be  found  in  an  entirely  in- 
different  area — for  inslancr,  in  Ihc  white  matter  of  the  frontal 
ibes — a  connection  which  we  could  not  reckon  upon.     An  in- 


agg  DISEASES  OF   THE  BRAIN  PROPER. 

stance  of  this  nature  t  had  published  in  an  inaugural  disserta- 
tion. This  was  the  case  of  a  man  fifty  years  of  age  who  suffered 
from  mitral  insufficiency,  and  who  was  seized  with  a  grave 
right-sided  hemiplegia  which  persisted  unchanged  for  months, 
associated  with  speech  disturbances.  Papillitis  could  never  be 
demonstrated.  The  case  was  then  supposed  to  be  one  of  em> 
holism  in  the  left  middle  cerebral  artery,  but  at  the  autopsy  a 
round-cell  sarcoma  the  size  of  a  walnut  was  found  in  the  white 
matter  of  the  frontal  lobe,  in  the  pars  frontalis  media  of  the  left 
hemisphere  (Steinberg,  Beitrag  zur  Localisation  der  Himtu< 
moren,  Inaugural  Dissertation,  Breslau,  1886).  For  the  hemi- 
plegia to  be  uncrossed — that  is,  to  be  situated  on  the  same  side 
as  the  tumor — is  certainly  very  exceptional ;  in  our  case  it  was 
crossed.  If  focal  symptoms  make  their  appearance  compara- 
tively early,  we  mostly  have  to  do  with  basal  tumors  which 
produce  fatty  degeneration  and  gray  atrophy  of  the  involved 
cranial  nerves,  notwithstanding  the  no  inconsiderable  power 
of  resistance  which  such  nerves  possess.  Besides  the  optic 
(unilateral  papillitis)  and  the  oculo-motor  (ptosis),  the  fifth,  the 
facial,  the  abducens,  and  the  hypoglossus  are  then  relatively 
frequently  affected.  Of  the  fifth,  usually  only  the  sensory  por- 
tion is  implicated;  sensory  disturbances  in  the  face,  tic  dou- 
loureux, later  ancesthesia  in  its  area  of  distribution,  occur 
much  more  frequently  than  paralysis  of  the  muscles  of  masti- 
cation. The  facial  is,  on  the  contrary,  affected  in  its  whole  dis- 
tribution— a  fact  which,  in  conjunction  with  the  reaction  of 
degeneration  in  the  paralyzed  muscles  which  also  exists,  is 
characteristic  of  the  peripheral  origin  of  the  paralysis  (cf.  page 
89).  The  whole  hypoglossus  is  involved,  which  causes  not 
only  the  tongue  to  be  protruded  to  one  side,  but  also  leads 
to  atrophy  in  the  affected  muscles;  swallowing,  mastication, 
and  speech  are  necessarily  affected.  The  hypoglossus  paral- 
ysis, however,  is  much  rarer  than  that  of  the  facial.  Com- 
bined affections  are  found : 

(rt)  0{  the  oKactory,  the  optic,  the  oculo-motor,  and  the 
first  branch  of  the  fifth  in  tumors  of  the  anterior  fossa. 

ib)  Of  the  chiasm,  the  oculo-motor,  the  first  branch  of  the 
fifth,  and  the  abducens  in  tumors  of  the  pituitary  body. 

(r)  Of  the  oculo-motor,  the  patheticus,  the  chiasm,  in  tumors 
of  the  middle  fossa,  if  situated  above  the  dura,  of  the  three 
ocular  nerves  and  the  fifth,  if  situated  below  the  dura:  and, 
finally, 


BRAIN  TUMORS. 


299 


the  auditory,  the  glc 


I 
I 


(1/)  Of  the  (acial.  ihc  trigcmini 
pharyngeal,  the  v»g(is.  the  accessorius.  and  the  abducens  in 
tumors  of  the  posterior  fossa. 

Diagnosis. —  It  is  the  object  uf  our  diagnosis  in  a  given  case 

'to  determine  first  the  presence,  then  the  position,  and  finally 
the  nature  of  a  tumor.  The  tirst  question  inn,  as  is  apparent 
Irntn  what  has  been  said,  by  no  means  always  be   answered 

[with  certainty  ;  especially  is  this  difficult  if  cither  only  general 
or  only  local  symptoms  are  present.  Among  the  former,  head- 
ache, we  have  said,  plays  the  most  important  rSU.     It  may  last 

I  for  years  without  any  other  signs  to  lead  us  lo  suspect  a  tumor, 
and  il  is  in  such  instances  thai  wc-  can  easily  understand  how 
this  tnay  be  inislaken  for  simple  habitual  headache  or  hemi> 
crania,  where  the  pain  may  also  attain  an  almost  unbearable 
intensity.  Yet  in  hemicr.mia  and  its  allied  alTecttons  there 
occur  remissions,  and  there  are  cimsiderable  periods  of  time 

I  during  which  the  patient  is  perfectly  free  from  pain;  whereas 
in  the  course  of  a  brain  tumor  this  never  hapiicns.  Here  wc 
find  no  intervals  of  relief,  but  the  patient's  sufferings  arc  unin- 
terrupted. Moreover,  a  headache,  no  matter  how  severe  it  be, 
whtcl)  is  materially  improved  by  the  exhibition  ol  salicylates, 
bromide,  or  caffeine,  etc.,  wc  can  hardly  refer  to  a  serious 
organic  brain  disease.  If,  however,  it  persists  uninHuenced  by 
all  the  ordinary  therapeutic  measures,  this  ought  lo  put  us  on 
our  guard,  and  make  us  look  further  for  focal  symptom;^ — 
unilateral  papillitis,  lor  instance — which  may  he  present:  yet 
we  should,  on  the  other  hand,  nut  lose  sight  of  the  fact  that 
there  arc  quite  a  considerable  number  of  cases  of  pure  migraine 
which  do  not  yield  to  remedies,  and  which  have  to  be  regarded 
as  incurable. 

Convulsions,  although  less  often  than  headache,  may  be  the 
only  striking  symptom.  If  they  last  lor  months,  appearing  at 
moderately  long  intervals,  wc  may.  in  the  absence  of  any  other 
symptoms  pointing  to  a  tumor,  think  o(  idiopathic  epilei>sy. 
Here,  also,  the  therapeutic  test  may  throw  light  upon  the 
subject.  Large  doses  of  bromide  usually  diminish  the  fre- 
quency as  well  as  the  severity  of  epileptic  atUicks.  at  least  (or 
a  lime,  and  the  favorable  intlncnce  of  the  drug  is  often,  indeed, 
quite  striking:  while  if  the  seizures  are  due  lo  an  organic  cere- 
bnil  lesion,  bromides,  even  il  they  be  continued  for  a 
cncd  pcrifxl,  have  but  iitlle  effect.  Such  fruitless  trials  p' 
direct  our  attention  again  to  the  possible  existence  ol  a 


398 


DISEASES  OF  THE  BRAtX  PKOPRK. 


Stance  of  this  nature  I  had  published  in  an  inaugural  dis&crta' 
tion.  This  wa!i  the  case  of  a  man  fifty  years  of  age  who  .suHered 
from  mitral  insulTicicncy.  and  wlii>  was  seized  with  a  grave 
right-sided  hemiplegia  which  persisted  unchanged  fur  mnnihs, 
associated  with  speech  distil rhances.  Papillitis  could  never  be 
demonstrated.  The  case  was  then  supposed  to  be  one  of  em- 
bolism in  the  left  middle  cerchral  artery,  but  at  the  autopsy  a 
round-cell  sarcoma  the  size  o(  a  walnut  was  found  in  the  white 
matter  ol  the  frontal  lobe,  in  ihe  pars  Irontalis  media  of  the  left 
hemisphere  (Steinberg,  Beitrag  zur  Localisation  dcr  Hirntti- 
moren,  Inaugural  Dissertation,  Brcslau,  1886).  For  the  hemi- 
plegia to  be  uncrossed — that  is,  to  be  situated  on  the  same  side 
as  the  tumor — is  certainly  very  exceptional ;  in  our  case  it  was 
crossed.  If  local  symptoms  make  their  appearance  comi>ara- 
tively  early,  we  mostly  have  to  do  with  basal  tumors  which 
produce  fatty  degeneration  and  gray  atrophy  of  the  involved 
cranial  nerves,  notwithstanding  the  no  inconsiderable  power 
of  resistance  which  such  nerves  i)ossess.  Besides  the  optic 
(unilateral  papillitis)  and  the  oculo-molor  (ptosis),  the  fifth,  the 
facial,  the  abdticens,  and  the  hypoglossus  arc  then  relatively 
frequently  affected-  Ol  the  fifth,  usually  only  the  sensory  por- 
lion  is  implicated:  sensory  disturbances  in  the  face,  tic  dou- 
loureux, later  ansesthesia  in  its  area  of  distribution,  occur 
much  more  frequently  than  paralysis  of  the  muscles  of  masti- 
cation. The  facial  is.  on  the  contrary,  affected  in  its  whole  dis- 
tribution— a  (act  which,  in  conjunction  with  the  reaction  of 
degeneration  in  the  paralyzed  muscles  which  also  exists,  is 
characteristic  of  the  peripheral  origin  ol  the  paralysis  (c(.  page 
89),  The  whole  hyptiglnssus  is  involved,  which  causes  not 
only  the  tongue  lo  be  protruded  to  one  side,  but  also  leads 
to  atrophy  in  the  affected  muscles;  swallowing,  mastication, 
and  speech  arc  necessarily  affected.  The  hypoglussus  paral- 
ysis, however,  is  much  rarer  than  that  of  the  facial.  Com- 
bined affections  arc  found : 

(<i)  Of  the  olfactory,  the  optic,  the  oculo-motor.  and  ilie 
first  branch  ol  the  fifth  in  tumors  of  the  anterior  fossa. 

(*)  Of  the  chiasm,  the  oculo-motor,  the  first  branch  of  the 
fifth,  and  the  ahduccns  in  tumors  of  the  pituitary  body. 

(r)  Of  the  oculomotor,  the  patheticus.  the  chiasm,  in  tumors 
of  the  middle  fossa,  if  situated  above  the  dura,  of  the  three 
ocular  nerves  and  the  fifth,  if  situated  below  the  dura:  and, 
finally, 


HKAIN   TtfMORS. 


299 


iJ)  Of  the  facinl.  the  trigeminus.  Ihe  auditory,  the  glosso- 
ptiaryngcal.  the  vagus,  the  uccc»soriu$,  and  the  abduccns  in 
tumors  ol  the  posterior  fossa. 

Diagnosis. —  It  is  the  object  of  our  diagnosis  in  a  given  case 
to  determine  first  the  presence,  then  the  position,  and  linally 
the  nature  of  a  tumor.  The  hrst  qtic>itioii  can,  as  is  apjtarent 
from  what  has  been  said,  by  no  means  always  be  answered 
tvilh  certainty :  especially  is  this  difficult  if  cither  only  general 
or  only  focal  symptoms  arc  present.  Among  the  former,  head- 
ache, we  have  Siiid.  plays  the  most  important  r^if.  It  may  last 
(or  years  without  any  other  signs  to  lead  us  to  suspect  a  tumor, 
and  it  is  in  such  in!«t.inccs  (hal  wc  can  easily  understand  how 
this  may  be  mistaken  lor  simple  habitual  headache  or  hemt- 
crania,  where  the  [uiin  ntiiy  also  attain  an  almost  unbearable 
intensity.  Yet  in  hemicrania  and  its  allied  affections  there 
occur  remissions,  an<i  there  are  considerable  periods  of  lime 
daring  which  the  paiient  is  perfectly  free  from  pain  ;  whereas 
in  the  course  ol  a  brain  tumor  this  upvct  happens.  Here  we 
iind  no  intervals  of  relief,  but  the  patient's  sufferings  are  unin- 
terrupted. Moreover,  a  headache,  no  matter  how  severe  it  be. 
which  is  materially  improved  by  the  exhibition  of  salicylates, 
bromide,  or  cafleine.  etc.,  we  can  hardly  refer  to  a  serious 
nrganic  brain  disease.  If,  however,  it  persists  uninfluenced  by 
all  the  ordinary  ihcrapeulic  me.isiires,  this  ought  to  put  us  on 
■>ur  guard,  and  make  us  lo<)k  further  for  focal  symptoms — 
unilateral  papillitis,  (or  instance — which  may  be  present;  yet 
wc  should,  un  the  other  hand,  not  lose  sight  of  the  fact  that 
there  are  quite  a  considerable  number  of  cases  of  pure  migraine 
which  do  nut  yield  to  remedies,  and  which  have  to  be  regarded 
U  incurable. 

Convulsions,  although  less  often  than  hcad.-iche,  may  be  the 
ly  Klriking  symptom.     If  they  last  for  months,  appearing  at 

:len)tely  long  intervals,  we  may.  in  the  absence  of  any  other 
symptoms  pointing  lo  a  tumor,  think  of  idio)>athic  epilepsy. 
Here,  also,  the  therapeutic  test  may  throw  light  upon  the 
subfect.  Large  doses  of  bromide  usually  diminish  the  fre- 
quency as  well  as  the  severity  ol  epileptic  attacks,  at  least  for 
a  time,  and  the  favorable  inlluence  of  the  drug  is  often,  indeed. 
v|uite  striking :  while  il  the  seizures  arc  due  to  an  organic  cere- 
bral )e!ii<m,  bromides,  even  if  they  be  continued  for  a  length- 
coed  |h:m<m),  have  but  litilc  cITect.  Such  fruitless  trials  should 
^rcct  uur  attention  again  lo  the  |>ossiblc  existence  of  a  tumor. 


■*  til 


300 


DISEASES  OF  THE  BRAIN  PROPEK. 


\ 


and  lead  us  to  search  for  further  symptoms  which  may  help 
the  distg-nosEs. 

If  the  patient  complains  of  nothing  further  than  attacks  ot 
vt-Ttigo  and  vomiting,  if  psyclilcal  changes,  headache,  and  con- 
vulsions are  absent,  then  the  diagnosis  remains  uncertain, 
because  vertigo  can  be  produced  by  m;my  different  causes,  and 
cerebral  vomiting  i»  met  with  in  affections  so  different  from  one 
another  that  it  is  simply  impossible  to  diagnosticate  a  brain 
tumor  Irom  these  two  symptoms  alone.  They  even  do  not 
necessarily  indicate  a  bniin  disease,  as  we  may  have  to  deal 
with  M^nifere's  complication  of  symptoms,  with  a  stomach- 
neurosis,  or  a  spinal  disease — e.  g..  tabes.  The  gastric  crises 
of  the  tabetics  may  resemble  very  closely  the  attacks  of  vomit- 
ing in  the  course  of  a  brain  tumor. 

Among  the  organic  diseases  ol  the  brain  which  may  be  mis- 
taken for  a  new  growth  are  brain  abM;ess  and  meningitis.     The 
former — the  abscess — is  almost  always  associated  with  febrile 
movements,  and  rarely  with  papillitis ;  moreover,  there  are  the 
characteristic  remissions,  so  that  the  patient's  general  condition 
may  be  excellent  for  years.     If  we  keep  these  points  in  mind, 
and  if  we  make  it  a  rule  never  to  diagnosticate  a  brain  abscess 
unless  wc  can  obtain  in  the  history  some  a:tiological  datum, 
such  as  an  otitis  media,  traumatism,  etc.,  the  differential  diag- 
nosis will  usually  present  little  difficulty.     In  meningitis,  lever     , 
is  the  most  important  symptom.     Papillitis  is  more  frequent    "I 
here  than  in  abscess,  and  hence  ol   less  value  in  the  differential 
diagnosis  between  tumor  and  meningitis,  yet  the  early  delirium    _ 
and  the  jactitations  are  sufficiently  characteristic  symptoms  to  I 
be  of  diagnostic  value. 

Other  diseases  to  be  considered  are  chronic  cerebral  sclero- 
sis associated  with  arterial  disease,  and  lobar  sclerosis.  The 
absence  of  grave  general  symptoms,  the  usually  much  slower 
course,  the  appearance  of  multiple  sclerotic  foci,  the  absence  of 
papillitis,  are  often  points  enough  on  which  to  base  a  diagnosis. 

Finally,  the  possibility  of  contusing  brain  tumor  with  pro- 
gressive  paralysis  »\  the  insane  (dementia  paralytica)  and  with 
chronic  alcoholism  ought  to  be  spoken  of.  This  can,  of  course, 
only  happen  in  those  cases  of  brain  tumor  where  apoplectiform 
att:icks  occur,  where  headache  is  either  absent  or  only  slight, 
where,  however,  the  mental  disturbances  are  marked,  and 
where,  owing  to  the  defective  memory,  the  altenitiuns  in 
^eech  become  a  prominent  feature  of  the  case.     The  course 


BKAftV   rUMORX. 


301 


will  clear  up  all  doubtful  cases.  If  we  are  dealing  witli  a 
dementia  paralytica  wc  shall  not  have  to  wait  long  for  the 
,  |pp(';ir:iiicc  of  the  chariiclcristtc  delusions  of  grandeur,  and  ihc 
|«ti(-'nt  will  bcc<imc  bewildered  and  have  transitory  periods  ol 
cxcitemeni,  whereas,  with  the  tumor,  stupor  and  somnolence 
»re  developed.  In  chronic  alcoholism  tremor  and  the  occur- 
rence of  slotnacli  and  liver  atlections  are  usual.  Above  all,  a 
conscientious  use  of  the  history  will  guard  us  fnim  an  error  in 
the  diagnosis. 

The  seat  of  the  tumor  wc  can  only  attempt  to  determine 
when  we  have  reliable  focal  symptoms  to  aid  us.  but.  as  we 
have  observed,  such  may  be  abi>cnt.  and.  as  it  seems,  this  is 
n»re  especially  the  case  in  soil  tumors  occurring  in  the  ventri- 
cles and  sometimes  in  the  frontal  lobes,  which  give  rise  to 
nj-mptoms  of  general  compression  only  ;  even  tumors  of  the 
lounh  ventricle  arc  by  no  means  necessarily  associated  with 
well-marked  and  ch'-iracteristic  symptoms,  so  that  often  only  a 
probable  diagnosis  is  possible  (Josef.  Zeitscbrift  f.  klin.  Med., 
18S9.  xvi,  3,  4).  It  is  furthermore  perfectly  certain  that  a  great 
(art  of  the  basal  ganglia,  the  lenticular  and  the  caudate  nu> 
deuK.  also  the  anterior  portion  of  the  thalamus,  the  corpus  oil- 
tosum,  the  fornix,  the  choroid  plexus,  and  finally  the  cerebellum, 
urith  the  exception  of  the  vermiform  process,  may  be  the  seat 
of  neoplasms  with  a  complete  absence  of  all  local  symptoms. 
On  the  other  hand,  tumors  of  the  motor  area,  of  the  occipital 
and  temporal  lobes,  ol  the  pulvinar.  of  the  crus,  the  pons,  the 
medulla  oblongata,  and  of  the  vermiform  process  of  the  cere- 
bellum, often  manliest  themselves  clinically  by  characteristic 
focal  symptoms,  which  we  here  need  not  describe,  as  they  have 
been  considered  above  in  detail.  Wood  (Univcrs.  Med.  Maga- 
^ne.  1889,  April.  No,  7)  reports  a  case  of  tumor  in  the  lempoml 
iobe  running  its  course  without  giving  rise  to  symptoms.    Suf- 

»*icc  it  only  to  add  that  destruction  of  the  pulvinur,  no  less  than 
^dcitruclion  of  the  occipital  loljc,  ni.ty  give  rise  to  hemianopia, 
^h.-tt  an  early  oculo-molor  paralysis  points  to  the  existence  of  a 
^uraor  in  the  cms.  while  severe  general  syni|>tom8— tonic  coi>- 
'^fulsjons.  without  the  loss  of  consciousness,  staggering  gait — 
i  (idirate  a  neoplasm  in  the  vermis  of  the  cerebellum.  Tumors 
•  »l  the  medulla  oblongata  may.  if  general  symptoms  arc  absent, 
simulate  bulb.ir  paralysis  in  llieir  course.  Vertigo  has  often 
been  noted  in  connection  with  such  tumors.  Other  symptoms 
%e  changeable  and  uncertain  ;  somclimcSt  indeed,  there  are  no 


^ 


303 


DiSEASKS  OF   THE  «KA/X  fiXOPE/t. 


symptoms  at  sll.  Paralysis  uf  the  abducens  points  to  the  pos- 
terior fossa  as  the  scat  of  the  neoplasm.  The  affections  of  other 
nerves,  which  are  important  in  this  connection,  have  been  men- 
tioned above. 

Where  we  have  amaurosis,  the  pupillary  reaction  to  light 
Ougfht  to  be  carefully  examined.  Its  presence  denotes  thai  the 
optic  nerve  and  trad  arc  intact,  and  the  new  growth  can  only 
be  situated  in  the  central  optic  fibres,  while  il  it  is  absent  or 
much  diminished  we  have  to  deal  with  a  lesion  of  the  optic 
nerve  or  tract.  Even  with  the  existence  of  papillitis  the  pupil- 
lary reaction  may  be  present.  Then  the  occurrence  of  the 
former  with  the  central  lesion  must  be  considered  as  an  acci- 
dental coincidence.  If  we  think  il  possible  that  the  amaurosis 
is  due  to  double  hcmianopia.  we  may  examine  for  the  so-called 
hemianopic  pupillary  reaction  (described  on  page  .J5)  to  throw 
light  upon  the  question. 

The  existence  of  focal  symptoms,  however.'does  not  always 
facilitate  the  dtagnosiii  as  much  as  wc  might  suppose.  This  is 
especially  true  if  the  general  symptoms  are  very  grave  and 
pronounced.  As  wc  have  remarked,  a  hemiplegia  must  not 
always  be  taken  for  a  focal  symptom,  and  we  must  again  insist 
that  its  presence  is  of  no  value  for  the  topical  diagnosis.  Wc 
need  not  mention  that  various  disturbances  may  be  produced 
by  indirect  action  which  baffle  all  altcropis  at  a  topical  diag- 
nosis (cf.  the  lecture  of  Jastrowilat.  the  reference  to  which  is 
given  at  the  end  of  the  chapter). 

The  nature  of  the  tumor  can  in  some  cases  not  be  deter- 
mined, while  at  other  times  it  may  be  very  apparent.  The 
course  of  (lie  disease  is  o(  less  value  in  this  question  than,  for 
example,  the  history  of  the  patient's  previous  diseases:  and  the 
fact  th.-it  certain  tumors  show  preference  for  certain  portions  <A 
the  brain,  sometimes  also  the  age  of  a  patient,  are  likely  to 
a0ord  us  valu.ible  hints. 

Where  syphilis  has  existed,  we  have  to  think  of  gtimmala. 
If  the  family  history  he  one  of  tuberculosis  or  carcinoma,  brain 
tubercles  or  secondary  carcinoma  uughl  to  be  considered.  .A 
chronic  cerebral  affection  in  a  child,  attended  with  headache 
and  convulsions,  is  strongly  suggestive  of  solitary  or  of  multi- 
ple cerebral  tubercles.  Tumors  of  the  cortex  are  more  likely 
to  be  of  a  syphilitic  or  tuberculous  nature,  while  those  o\  the 
b.ase  are  preferably  sarcomata;  those  of  the  while  maltcr.  the 
centrum  ovale,  gliomata. 


I 


I 


HKAtN  rujaoxs. 


30i 


I 


! 


Prognosis.— The  prognosis  in  brain  tumor  is  generally  un* 
bvorablc.  and  death  within  one  or  two  years  after  the  appear- 
ance i>(  the  first  symptoms  may  be  predicted.  Spontaneous 
rcc(»vcry  is  unheard  ol.  and  improvement  as  a  consequence  of 
treatment  is  very  rare  and  has  only  been  observetl  in  cases  o( 
gummatous  or  tuberculous  neoplasms.  Here  it  occurs  beyond 
(question.  conse()ucnll>'  the  prognosis  is  much  less  gloomy  in 
these  than  in  other  tumors.  In  general,  the  course  is,  in  spile 
o(  all  treiilment,  steadily  progressive.  Tlie  patient's  sufferings 
increase  in  severity,  and  the  agony  is  only  blunted  by  the  dull- 
ing of  the  scnsoriiim.  Death  occasiotially  sets  in  suddenly,  as 
a  nile  only  after  a  protracted  state  of  marasmus  in  consequence 
of  cxhiiusiion. 

Treatment. — The  treatment  is  in  the  vast  majority  of  cases 
of  no  avail.     Only  in  rare   instances  can   we   by  a  systematic 
administration  of  potassium  iodide  (5,0  to  8,0  [grs.  Ixxv  to  3ij| 
(Uily  in  hot  milk  for  one  and  a.  half  to  two  monllis)  effect  a 
Mticcablu  improvement.     Whether  this  is  due  to  iJie  direct 
Kiion  of  the  ii^lide  on  the  tumor,  or  whether  only  (he  second- 
uy  changes,  the  softening,  the  cx^dema,  the  accumulation  ol 
luid  in  the  ventricles  are  influenced  thereby,  we  do  not  know. 
A«  a  matter  of  fact,  however,  the  improvement  docs  occasion- 
ally occur,  and.  \yc  it  explicitly  stated,  not  only  in  cases  of  gum- 
aaln,  but  also  in  other,  malignant,  neoplasms,     tlcsides  iodide 
«i  potassium,  arsenic  seems  at  limes  to  have  a  beneficial  action, 
JctKutficicnt  positive  observations  arc  wanting  on  this  point. 

The  (lueslion  of  operative  inlcrferenee,  if  such  appear  indi- 
atcd,  involves  the  same  ])rinciples  which  we  have  set  forth  in 
ooaiKction  with  operation  for  abscess,  and  which  ought  to 
tvAt  us  here  also.  Symptoms  pointing  unmistakably  to  an 
cmUtion  into  the  ventricles  justify  trephining  and  tapping  of 
the  btenil  ventricles  (or  the  purpose  nf  lowering  the  intra- 
tnnial  presS'Ure.  The  posterior  fossa  is  always  a  sort  of  a  ntfli 
^  tiugrrr  (Wernicke),  lieadache,  vertigo,  and  vomiting  are 
•O  be  treated  symptr)malically.  Instructive  cases  of  brain  lu- 
•ors,  in  which  an  operation  was  performed,  have  recently  been 
IHiWshcd  bv  I£rb(Deutsclie  Zeiischr.  fllr  Ner^-enheilk.,  ii'(t892>. 


1.ITERATURR. 
mr    Svmplom.iiulof^    uiul 


tihwutur     IWrlin.  Hirscliw.iW.  188.. 
"Wiiw.    Drri   Fllle  nxn  Tu)>rrt:clffrwliwii1sicn  im  Miiicl 
A»(h.  r.  Psych,  u.  Ncfvenkr.  «ii.  3.  1881. 


DiagniMiili    rier    HimBC- 
und   Nachhitn. 


304 


/)/S£AS/!S  OF  THK  BHAIN  PROPER. 


SinimpcIL    Kin  Fall  i-om  Grtiirnlumor  roil  centralw  clnMltigtr  TaubhciL    Neu- 
rol. Cenlnlbl..  No.  16.  1881. 
Aiulry,  J.    LcKiumcun  [Ir;^ plexus choriciidcs.    Rrvuedero^d.,  vi.  11,  p.  897, 1886. 
Sldiilwrg.     Ikitraj;  lur  Localisation  <Ict  tlimtuinotvn      lnaug.-t>iM..  Ureslau, 

1886. 
Hcuiwr.     Virchow'j  Arvhiv.  Bd.  1 10,  p,  9,  1887,     (On  Tumors  of  the  Pilultary 

Itodv.) 
Tuubncr.     Iliid..  Dil.  1 10.  p.  9;,  1687.     (On  Lipoma  of  tlie  Brain.) 
U<il).     Bum.  xxuvili.  fi,  334.  1887.     (Tumor  or  \\v:  I'inea)  tiljnd.i  ^| 

lluichin^nn.     Ibid.,  p,  323.  1SS7,     (Ncopla<m»  in  both  Corp.  Sinat.i.)  ^1 

Briegcr.    Berliner  klin,  Wochcnsclir,.  No.  47,  1887.    (Case  of  Sarcoma  of  ihcPla.) 
Birdsall,     Phil^d,  Mcil.  an<l  Surg.  RepoHcr.  Ivi.  April  18.  1887. 
ChurMm.     Brit.  Mi-d.  journ..  May  28.  18S7. 

L«clcrc.    Trois  cas  ilc  lumcurs  intracr.iniennn.     Keviie  ik  tnkA..  tt.  1887, 
Sokolc-IT.    CUiiim  lips  Crnir.ilncncnsj-stems,     Dmlschcs  ArcK.  f,  klin.  Mrd,.  IW. 

45-  Hell  4.  5.  p.  443.  1887. 
Jaisirowitf.     Ileitriigc  tat  Lucalinaiion  \m  Grosslilm  und  dcrcn  praktisclie  Vcf- 

wefihung.     ElcrUncr  klin.  Wochcnschr..  kkIv.  49,  sa  1887. 
Schmidt- KimplcT.     Arch.  (.  .Augcnhcilk.,  xviii,  i.  1887.    (Glioma  of  (he  Pons. 

The  au(hor  speaks  of  paralysis  of  (he  ocular  muiclet  and  ihc  origin  <i( 

choked  disks  .J 
Schwdniu.     Philarf.  Mrd,  and  .Surg.  Rep.,  Ivij.  October,  1887.    (Tumor  of  the 

I'ituiiary  liudy.) 
Osier.     Juutn.  of  Nervous  and  Mcnla!  Disease).  1887.  II,  13.    (Choleslcatoma 

of  thr  Third  VrnirJrle.) 
Siemens.    Tunioren  m  dcr  moiorischen  Region.    Berliner  ktln.  WorhcnschnK. 

1888.  15, 
Moppr.     Fall  von  Tumor  dcr  VierhuKi-l.    Inaug.-Disun.,  Ilalle.  18S8. 
Kaufnunn.  A.     Vierteljalirschr.  fur  gcrichll.     Med..  Januar,  1888.    {Accident 

rollowcd  by  Brain  Tumor) 
R.-ith.    Arch.  f.  Ophihalm..  1SS8.  wxvi.  4.    (Tumon  of  the  Hypophysis.) 
Dudley*,     nrain,  Jiiniury.  1889.    (SymiXoms  of  Tumor  appearing  Thrcr  I>>yfi 

after  Injury.) 
Hafncr,     ISrrlincr  klin,  Wociim«hr..  1889.  31.    (Hymploms  oJ  Brain  Tubkii-' 

appearing  Kive  Yenriufler  Tmumalism.) 
P*an,  Ballel  el  G^lineau.     Acail,  de  mtd.  dc  Pari*.  F^vr.  19.  1889^ 
Noihnagcl     Wiener  mcd,  Prruc,  1889,  xxn.  3.    (Diagnosis  of  I'unMW  in  ibca 

Corpora  Quadrigeniina-) 
Oppenheim.     Arch.  f.  Psych,  und  Ncrvenkr.inkh,,  1B89.  «i.  J,  p.  560.    (O 

irilmtlon  [o  ihe  Paihobg)'  of  Tumors  in  (he  Cerebrum.) 
Chri^l      Dcuisclies  Arcli.  t.  klin.  Med..  1890,  >i!vl.  5,  fi. 
ICvrald.     Itcrltnc-r  klin.  U'ochrn<ichr..  1S91,  ta     (Forced  Movements  in  C 

of  Tubercles  of  ihe  Brain.) 
V.  Hippel,     Virchow's  Arck.  1891.  c»xv(,  1.    (Tumors  of  the  flypophysis.) 
Kutlnrr.    ZurCaxulsiik  der  Himtumorcn.     Berliner  klin.  Wochenschr,.  1S93.  J?-" 
Giesc.    Zur  Caiuislik  der  Balkcntumoren.    Areh.  f.  Psych,  u,  Ncrvcnkr..  1891 

miil,  J, 
Ackennann.     Ucultche  mcd,  WochcntKhr..  1893.  31. 
V.  Bramaxn.     Arch.  f.  klin.  Cliir..  1893,  xlv,  a.    (Extirpation  of  Brain  Ttunut^) 


PAMASITKS  OP  THE  BJfA/.V. 


JOS 


* 


I 


APPENDIX.— I'ARASITES  OK  THE  BRAIN. 

Among  the  parasites  luttiid  in  llic  brnin  the  cyslicerct  nnd 
the  cchinococci  are  the  must  iniportant. 

The  former — the  cysticcrci — are  found  quite  frequently  it 
the  autopsy  when  ihcir  existence  during  life  was  not  diagnas- 
ticatcd  or  eveti  suspected — a  prool  thai  they  may  be  present 
vtthout  giving  rise  to  any  symptoms,  or  that  they  may  pro- 
duce a  clinical  picture  such  as  is  often  due  to  other  causes. 
The  cysLs.  which  arc  rarely  single,  but  mostly  multiple, 
uDounling  as  they  may  to  one  hundred  or  more  in  number, 
have  their  seat,  some  in  the  meninges,  sonic  in  the  substance 
oi  the  brain,  in  the  gray  as  well  as  in  the  white  matter:  some- 
times they  arc  Ircc  in  the  ventricles.  They  may  be  so  nuiner< 
(ms  that  the  whole  surface  of  the  brain  is  studded  with  iheni. 
Their  sue  may  vary  from  that  of  a  bean  to  that  ol  u  walnut, 

iftd  but  rarely  exceeds  that  ol   the  latter.     They  contain  a 

KKHis  fluid.     At  a    place    where  the   cyst  wall    is  somewhat 

thickened   are  situated  the  neck  and   head,  the  latter  often 

dnply  pigmented,  and  to  be  recognized  on  closer  examlna- 

^n  by  a  crown  of  houklets 

»«!  Slickers.    The  parts  sur- 

rouwling  the  cyst  are  either 

periectly  normal  or  in  a  statt- 

^  isAammatory    softening. 

Thii  biicr  is  found  as  a  rule 

*l)r  when    the  cysticercus 

u  dead  and  has  undergone- 

■Usages.     If  the  cyst  sends 

"oitfiTcnicula  it  assumes  the 

'ft*  nf  a  bunch  of  grapes. 

""1  hence    is   called  cysti- 

^*fcia  raccmosus(\^irchow, 

*'«chand).     It  is  estimated 

'**«  the  [Kirasites  live  from 

'*>  recto  MX  years.    After  their  death  they  are  changed  into  cal- 

^ftous  concretions,  surrounded  by  a  connective-tissue  inem- 

'^nc.  which  in  their  interior  contain  cholesterine  and  fat. 

It  is  impossible  to  sketch  a  clinical  picture  produced   bv 

^>«if«rci  in  the  brain,  because  this  varies,  of  course,  with  the 

^^1  of  the  cysts.     I  had  oi:casion  in  the  past  few  years  to  ob- 

**rre  lour  cases  in  my  clinic,  and  ol  these  only  one  was  diag- 


^i^^ 

■*       ^    ' 


Fl(.  KS.-Clniiiti,k.  I.-  KuKH<ni;s 
(Afwr  Uari'iiahii.) 


3o6  DISEASES  OF  THE  BRAIH  PSOPBJt. 

nosticated  during  life,  and  this  one  not  because  it  presented 
characteristic  symptoms,  but  owing  to  the  history  of  the  pa- 
tient, from  which  we  learned  that  he  was  in  the  habit  of  fre- 
quently eating  raw  pork.  In  all  four  cases  the  patients  suffered 
from  epileptiform  attacks  with  convulsions,  sometimes  with, 
sometimes  without,  loss  of  consciousness.  Two  of  them  were 
in  the  intervals  between  the  attacks  temporarily  completely 
bewildered,  and  were  sometimes  for  hours  not  able  to  fioA 
their  way  in  the  ward  where  they  were  staying,  did  not  recog- 
nize their  fellow-patients — in  short,  presented  conditions  which, 
considering  the  attacks  which  they  were  subject  to,  were 
looked  upon  as  epileptic  equivalents.  Motor  disturbances 
were  not  observed  in  any  of  the  cases ;  all  of  them,  however, 
complained  at  times  of  headache  and  vertigo.  In  one  case 
three  cysts  the  size  of  a  pea  were  found  imbedded  in  the  left 
lenticular  and  caudate  nucleus,  the  internal  capsule  being 
spared,  so  that  the  patient  had  had  perfect  use  of  the  right 
extremities.  Id  another  case  there  was  found  a  focus  of  soften- 
ing the  size  of  a  pea,  in  which  the  calcified  remains  of  a  cysti- 
cercus  could  be  demonstrated,  in  the  left  half  of  the  middle 
segment  of  the  pons  immediately  below  the  middle  line,  with- 
out there  having  been  during  life  any  noticeable  symptoms  of 
destruction.  A  third  case  showed,  besides  numerous  vesicles 
imbedded  in  the  gray  cortex,  cysticerci  swimming  free  in  the 
fluid  of  the  ventricles,  the  amount  of  which  was  considerably 
increased.  The  high  grade  of  hydrocephalus  was  probably 
responsible  for  the  mental  enfeeblement  of  the  patient,  a  con- 
dition for  which  during  life  the  epileptic  attacks  had  been  held 
accountable;  these,  in  their  turn,  were  doubtless  connected 
with  the  parasites  in  the  cortex.  Cases  presenting  a  course 
which  resembles  that  of  the  progressive  paralysis  of  the  insane 
I  have  myself  not  had  occasion  to  observe.  According  to 
Wernicke,  such  instances  are  not  rare  (/if.  cit.,  in,  373). 
Michael  has  described  a  case  in  which  the  presence  of  a  free 
cysticercus  in  the  fourth  ventricle  gave  rise  for  a  considerable 
period  of  time  to  a  picture  simulating  diabetes  mellitus 
(Deutsch.  Arch.  fUr  klin.  Med.,  1889,  xliv,  5,  6). 

Hence  it  is  evident  that  a  diagnosis  of  cysticerci  and  echi- 
nococci  in  the  brain  can  only  be  made  if  we  know  that  the 
patient  has  had  a  tapeworm,  or  if  we  have  been  able  to  demon- 
strate cysticerci  in  the  muscles,  the  eyes,  etc.  H  in  such  cases 
epileptiform  attacks  set  in,  which  alternate  with  conditions  of 


fA/lAStTES  Of  TUB  BKA/.V. 


307 


I 


I 


and  if  we  are  able  to  exclude  syphilis  and  tuberculosis, 
we  arc  justified  in  suspecting  the  presence  of  parasites,  espe- 
dally  of  cysiicTrci. 

The  R;tiulogy  of  cysliccrci  in  the  brain  is  that  of  cysticerci 
in  any  other  part  of  the  body :  th<iy  will  develop  in  persons 
who  often  give  tlie  parasites  a  chance  to  invade  their  body,  as 
is,  for  instance,  the  case  with  butchers,  and  hence  they  occur 
relatively  fretjuently  in  such  individuals.  Therapeutics  in  this 
case  is  powerless :  \vc  have  no  menus  of  destrnying  the  parasite. 

Echinocucci  are  usually  found  in  single  solitary  vesicles 
on  the  tree  surface  of  the  brain  or  the  ventricles.  Their  ycl- 
towish  mucoid  contents,  surrounded  by  a  cyst-wall  and  a 
connective-tissue  capj-ule,  can  break  through  to  the  outside, 
and  be  evacuated  through  the  nose,  the  ears,  etc.,  and  a  sort  ol 
spontaneous  recovery  take  pLicc. 

Echinucucci  of  the  brain  often  do  not  present  any  peculiar 
symptoms  which  could  be  used  for  diagnosis.  The  clinical 
picture  by  which  they  manifest  themselves  is  usually  that  of  a 
tumor,  but  when  they  have  perforated  lo  the  outside  we  may 
be  able  to  <lcmonsirale  on  the  protruding  tumor  lluclualion 
and  pulsation.  II  ihcy  perforate  into  the  orbit  they  give  rise 
In  a-dema  ol  the  lids  and  csophthalmus.  Westphal  has  ob- 
served a  case  in  which  over  ninety  cysts  were  evacuated  lo 
the  outside. 

Thai  actinomycosis  may  occur  in  the  human  brain  is  shown 
by  the  publication  of  Bollinger  (cl.  lit.),  where  a  tumor  in  the 
third  ventricle  is  described  which  contained  numerous  charac- 
lertstic  granules.  Often  the  diagnosis  remains  obscure,  as  hap- 
pens sometimes  also  in  actinomycotic  affections  of  the  lungs; 
the  process  in  the  brain  may  remain  latent  (Orlow,  cf.  lit.). 

LITERATURE. 

Vtrchow's  Anh..  Dd.  7$.     Brrsl.  ami.  Zciiuhr..  1881. 
Urbcr  ffcn  Cyst,  rac«nt.  6r.%  Gchirns.     ErlAnera.  rSfti, 

C]r*tic«n:uR  ccrabh  multiplex  Im  einem  ijUhr.  Kinilc.     [li»l.  Sntl. 
Zciuchr..  No.  m  1881. 

'  CyslicCTkrn  Im  vienen  X'enirikcl.     Inaufr.^DJtH .  Iktlin.  1886. 
Ffrier  Cy«(iccmi»  Im  Clchini,      t^cuuclio  Arch.  f.  kliii.  Mcil,, 
B7.    (Ni>  convulskmi.) 
BnlDii|[rT.     tVbrr  pnmSrr  A<-lliKHnyc>i>«n  im  Uchim  <la  Men»chen.     Munch. 

mnl,  Wochcnschr.  |>.  7S9,  1887, 
,  Cagd.     Fin  Tall  ron  C)>iic«i:us  l>Fim  Menschcn  aIk  Bcitrag  lur  thiigno«tik 
dri  Cyaiicrrcus  crrrbn.     Prij^rr  idfi}.  Wochrnichr..  xiii.  1,  1888. 
■mf.    Cyk1kcn)ue  ilu  ccrvnu.     Kncfphair,  viii,  1,  1888. 


3o8  DISEASES  OF   THE   BKAIN  PROPER. 

Manasse.    Ein  Fall  vun  Cyst.  Thalami  optici.     NeuroL  Centralbl.,  1888,  J3. 
Hanimcr.     Zur  Casuisiik  der  sogenannlen  freien  Cysticerken  in  den  Himven- 

trikeln.     Prager  med.  VVochensehr..  1889,  xiv.  21. 
Bitot  et  Sabraz^s  (Uordeaux).     £tude  sur  les  cysiicerques  en  giappe  de  I'en- 

ciphale  el  de  la  moSlle  chez  rhoinme.     Gaz.  mfd.  de  Paris,  1890,  Ui,  27-30, 

32-34- 
Wiesmann.    Correspond  en  z  hi.  f.  Schweiier  Aerzte.  1890,  xx,  11.     <Cysticercus 

between  the  Crura  Cerebri  ;  Paralysis  of  all  Four  Extremities.) 
Bostrbm  (Giessen).     Untersuchungen  uber  die  Aciinamykose  des  Menschen. 

BeiirSge  zur  path.  Anat.  u.  all^.  Paih.  von  Ziegler  u.  Nauwerck.  1890, 

ix,  I. 
Orlow.      Zur  Fr.ige  von   der   aclinomykorischen    Erkrankung  des  Hims  und 

seiner  HSule.     Deulsche  med.  Wochenschr.,  1890,  16, 

CONGENITAL    UISKASES — KVIIROCF.PHAI.US — MENINGOCELE — POREN- 
CEI'HALV — ABSENCE    ItK    CERTAIN    PARTS    OF   THE    8RAtN. 

Our  knowledge  of  the  collections  of  fluid  in  the  brain, 
which  are  described  under  the  general  term  of  hydrocephalus, 
is,  on  the  whole,  very  defective,  and  this  is  even  more  true 
of  the  causes  which  bring  about  the  abnormal  increase.  We 
know  that  the  fluid  is  either  contained  between  the  meninges 
or  within  the  ventricles,  and  speak  accordingly  of  a  hydro- 
cephalus externus  and  internus.  We  know  further  that  it  may 
collect  very  rapidly  or  very  slowly.  In  the  former  case  we 
have  a  hydrocephalus  acutus,  and  in  the  latter  a  hydrocephalus 
chronicus.  Finally,  we  know  that  the  conditions  under  which 
ii  develops  may  sometimes  exist  during  intra-utcrine  life,  or, 
again,  may  appear  much  later,  and  we  consequently  distinguish 
the  congenital  from  the  acquired  form.  But,  after  all,  the  dis- 
tinction which  we  gain  by  this  is  only  superficial.  About  the 
exact  manner  of  development  of  any  of  these  forms  there  pre- 
vails a  great  difference  of  opinion,  and  the  question  under  what 
circumstances  hydrocephalus  may  develop  as  an  independent 
idiopatliic  disease  can  not  be  satisfactorily  answered.  There 
is  no  doubt  but  (hat  in  bv  far  the  greater  majority  of  cases  we 
have  to  do  with  a  congenital  disease,  and,  as  a  matter  of  fact, 
this  form  plavs  in  praetice  ihe  most  important  rSU. 

The  congenital  hydrocephalus  is  very  rarely  external,  but 
is  much  more  often  internal.  It  may  be  well  developed  at 
birth,  so  thai  Ihe  diciimference  of  the  skull  measures  sixty  or 
seventy  cenlimctrcs  or  more.  The  skull  bones  then  are  usually 
so  thin  thai  their  thickness  scarcely  amounts  to  that  of  a  sheet 
of  paper.  The  fonlanellcs  and  sutures  arc  separated  by  wide 
gaps.     The  distention  of  the  ventricles  may   be  so  enormous 


/lYD*lOC/ir//ALVS. 


309 


'Ihat  they  form  a  large  cavity  which  is  surroundcfl  by  brain 
substance  one  and  a  half  to  two  cenlimelrcs  thick.  The  lat- 
eral ventricles  are  usually  dilated  to  a  much  greater  extent 
than  the  third  and  luurth  :  still,  these  latter  may  also  be  mud- 
crslely  distended.  The  whole  brain,  more  particularly  the 
bisal  structures,  presents  the  signs  of  an  increased  intracranial 
pressure;  they  are  flattened  out,  the  corpus  callosum  may  suf- 
ffcr  considerably  from  pressure  (Schroder.  Allgem.  Zeitschrifl 
\\.  i^ychialrie,  1888.  xliv,  4,  5),  the  commissures  are  stretched, 


->■ 

the  loramen  o(  Miinroe  is  very  large,  the  walls  of  the  ventricles 
are  often  covered  with  gmnulatiuns,  the  ependyma  inflamed 
and  in  pbccs  slightly  thickened.  The  colorless  serous  fluid, 
the  amount  ol  which  may  be  as  much  as  one  and  a  hall  litres, 
contains  99  per  cent,  of  water,  0.3  per  cent,  albumin,  traces  of 
ults.  and  so  forth,  and  the  sp.  gr.  is  1.004  to  '-006  (cf-  Anton, 
^ur  Anatomic  dcii  l-Ivdroccphalus  u.  s.  w.,  Med.  Jahrb.  84, 
.  Jahrg.  188S,  N.  V.  iii,  I  left  4.  p.  135,  from  Mcynert's  clinic). 


3IO  D/SEASES  OF  THE  BttAIN  PROPER. 

The  most  conspicuous  symptom  of  hydrocephalus  is  the  pe- 
culiar enlargement  of  the  head.  This  is,  however,  not  always 
apparent  in  the  first  weeks.  Sometimes  one  and  a  half  or  two 
months  may  pass  before  the  increase  in  size  begins  to  be  notice* 
aUe.  The  circumference  of  the  head,  which  at  birth  meas- 
ures forty  centimetres,  and  a  year  later  forty-four  centimetres, 
rapidly  becomes  greater,  and  every  week  a  half  or  one  centi* 
metre  is  added  to  it,  so  that  after  a  certain  time,  often  only 
after  a  few  months,  the  head  has  reached  in  circumference  a 
size  which  it  does  not  generally  attain  to  before  the  age  of 
puberty — viz.,  fifty  centimetres.  If  the  distention  of  the  skull 
is  equal  on  all  sides  it  becomes  spherical,  and  forms  a  striking 
contrast  to  the  smallness  of  the  face,  which,  of  courw,  does 
not  take  part  in  the  enlargement.  If,  however,  this  is  more 
marked  in  the  sagittal  diameter,  the  skull  assumes  a  dolicho- 
cephalic form,  and  its  appearance  is  no  less  bizarre.  This  is 
still  more  accentuated  by  the  enormously  enlarged  veins  which 
as  blue  cords  run  over  the  skull.  The  eyes  are  frequently  di- 
rected downward.  This  may  depend  upon  an  insufficient  in- 
nervation of  the  eye  muscles.  The  appearance  of  a  child  with 
a  well-developed  hydrocephalus,  the  enormous  head,  which,  if 
the  child  is  held  erect,  rolls  from  side  to  side,  the  small  trunk 
which  with  its  shrunken  limbs  looks  as  if  it  was  only  an  append- 
age of  the  head,  the  idiotic  facial  expression,  are  together 
characteristic  enough  to  warrant  the  diagnosis  without  any 
further  examination,  which  would  reveal  various  motor  dis- 
turbances, spasms  of  the  muscles,  and  sometimes  increased  re- 
flexes. It  need  hardly  be  stated  that  the  intelligence  develops 
only  in  a  very  imperfect  manner  or  practically  not  at  all.  Most 
of  the  children  never  learn  to  speak  or  at  least  only  imper- 
fectly. They  are  not  able  to  play  like  others,  their  conduct  is 
silly  and  senseless,  their  habits  are  dirty,  and  they  require 
much  painst.iking  care  and  nursing.  In  exceptional  cases  their 
mental  development  reaches  a  somewhat  higher  stage  and  they 
are  able  to  comprehend  certain  things,  so  that  under  particu- 
larly favorable  circumstances,  as  in  a  well-conducted  home  for 
feeble-minded  children,  it  m.iv  be  possible  to  give  such  children 
an  amount  of  knon'led<^c  and  skill  which  is  quite  remarkable. 
The  appearance  of  epileptiform  attacks,  which  are  always  to 
be  anticipated,  often  greatly  interferes  with  such  attempts. 

The  course  is  either  chronic  or  acute.     The  issue  is  always 
unfavorable.      The  children   either   die    during  or  soon  after 


//  VI>ftOC£P//A  l.  US. 


%M 


I 
I 
I 


I 


I 


birth,  or  they  attain  an  age  uf  a  few  nionths,  or  finally  they  may 

lire  (our  or  five  years,  while  it  is  very  exceptional  fur  thcni 

t»  live  longer  and  to  reach  the  age  of  puberty.     If,  however, 

this  happens,  the  head  ceases  to  gruw  and  remains  of  the  same 

iize  or  becomes  even  a  little  smaller,  and  the  skull  ossifies.     If 

death  occurs  fn  an  earlier  stage,  this  happens  cither  during  a 

convulsion  or  comes  on  gradually  as  a  consequence  of  general 

marasmus.     There  is  no  question  but  that  in  (ace  of  this  affec- 

lion  therapeutics  is  powerless.     We  may  well  omit  the  usual 

inunctions  of  the  skull  with  mercurial  ointment  or  the  painting 

with  tincture  of  iodine,  as  well  as  the  internal  administration 

■'{  iodide  o(  potassium,  without  any  feeling  uf  self-repruach,  fur. 

often  as  these  measures  have  been  used,  rarely  has  any  good 

result  from  them    been  seen.     Good  general  nursing  of  the 

child,  later  a  well-conducted  simple  instruction  as  far  as  this  is 

feasible,  finally,  symptuniatic  treatment,  more  especially  of  the 

more  dominating  symptoms,  as  the  epileptiform  seizures,  which 

are  best  met  with  bromides,  is  more  rational   than  any  other 

more   or  less  futile  measures,  not  excluding  puncture  of  the 

head  .ind  other  surgical  interference.    That  we  are  ignorant  ol 

the  a:tiology  we  have  said  above,  and  would  only  add  here 

that  the  statement  that  syphilis  and  alcoholism  in  the  parents 

nre  predisposing  causes,  is  without  foundation. 

The  idiopathic  hydrocephalus  which  appears  later  in  life 
may  be  connected  with  atheromatous  processes  and  focal  dis- 
eases in  the  brain.  Owing  to  the  rarity  of  its  occurrence.  how< 
ever,  it  has  been  hut  little  studied,  and  the  pos.sibility  that  even 
ID  such  cases  we  have  in  reality  to  deal  with  the  secondary, 
deuteropalhic.  hydrocephalus  is  by  no  means  excluded. 

The  secondary  hydrocephalus  has  at  times  to  be  attributed 
Id  disturbances  of  the  circulation,  at  times  to  general  disorders 
(if  nutrition.  Among  the  former  may  be  mentioned  active  hy- 
peremias of  the  brain,  occurring  in  consequence  of  the  abuse 
ol  alcohol,  and  venous  stasis,  as  it  is  seen  in  valvular  diseases  of 
the  heart  and  emphysema.  There  arc.  besides,  the  circulatory 
disturbances  caused  by  circumscribed  mcningitidcs,  tumors, 
and  abscesses,  by  which,  (or  example,  obstruction  of  the  aque- 
duct of  Sylvius  may  be  brought  about  {Seel igm 111 Icr).  .Among 
the  disturbances  in  nutrition  there  arc  certain  forms  ol  anic- 
mia.  general  dropsy,  phthisis  pulmonalis  (Callender),  The 
aflection  may  run  a  very  acute  course  and  prove  fatal  in  a  few 
days.    On  the  other  hand,  it  may  be  eminently  chronic,  and 


312 


DISHASKS  OF  TUP.   BKAIN  PROPKIf. 


then  the  symptoms  need  nut  by  any  me:tns  be  characteristic, 
and  it  may  he  the  more  difficult  to  make  a  diaj^nosis.  as  the  tn- 
crcabc  in  the  size  ul  tiic  head  h  wont  not  to  lake  place.  Some- 
times the  symptoms  are  those  ol  brain  tumor ;  again,  those  o(  a 
spastic  spinal  p:ir;ilysis  may  predominate. 

The  so-called  hydroccphaUis  ex  vacuo,  a  (orm  which  devel- 
ops in  old  people  under  the  influence  of  a  general  atrophy  o( 
the  brain,  must  also  be  looked  upon  as  a  secondary  hydroccph- 
ulus.  It  is  associated  with  mure  or  less  pronounced  dementia. 
About  etiology  and  treatment  nothing  need  be  added  to  what 
has  been  said  on  congenital  hydrocephalus. 

Under  certain  circumstances  there  are  found  defects  in  the 
bony  skull  cap  which  allow  the  contents  to  protrude.  By  this 
the  dura  and  galea  as  well  as  the  skin  are  raised  hemispheric- 
ally,  constituting  what  is  called  a  brain  hernia  or  ccphaloccle. 
and  wc  speak  ot  an  cnccphalocele  if  the  brain  substance  and 
the  pia  are  both  contained  in  the  dural  sac,  while  if  only  the 
dropsical  soft  meninges  arc  to  be  found  in  it,  it  is  called  a  me- 
ningticelc.  Whether  a  local  decrease  of  resistance  of  the  mcnn- 
branuiis  skull  and  defects  ot  ossification,  or  perhaps  abnormal 
adhesions  of  the  meninges  with  the  amnion,  are  the  cause  of 
such  anomalies  has  as  yet  to  be  decided.  Clinically  they  pos- 
sess no  significance. 

The  above-mentioned  defects  (page  367),  which  we  call  por- 
encephaly (Hcschl),  may  also  be  congenital.  Some  gyri  may 
be  entirely  or  partly  absent,  so  that  clefts  or  (unntUsliapcd 
openings  or  pits  are  formed.  The  defective  areas,  unless  there 
be  a  communication  with  the  ventricles,  arc  covered  with  pial 
tissue,  and  the  empty  space  is  filled  up  with  fluid  which  col- 
lects in  the  subarachnoidal  tissue ;  or,  again,  the  neighboring 
convolutions  are  pressed  together  over  the  gap,  and  instead  of 
a  hollow  we  only  find  a  deep  cleft  (cf.  Zicglcr,  Pathol.  Anat., 
ii.  636). 

Very  remarkable  is  the  fact  that  certain  parts  of  the  brain 
may  be  entirely  absent.  This  has  been  observed  for  the  corpus 
callosum.  the  fornix,  the  corpora  albicantia.  the  gray  commis- 
sure, and  others.  With  reference  to  the  absence  ot  the  corpus 
callosum  %*arious  hypotheses  have  been  put  forward.  It  has 
been  thought  to  be  connected  with  the  development  of  the 
base  ot  the  skull  and  to  depend  upon  the  angle  which  the 
petrous  portions  of  the  two  temporal  bones  form  with  each 


AftSf.NCB  Of  CmtTAl.V  PASTS  OP  THE  fittAf.V. 


3IJ 


N 
^ 


k 


Other  (Kictiter,  Virchow's  Archtv,  106,  1886).  Kuufmann  has 
described  a  case  where  the  corpus  callosum  was  completely 
absent  ami  where  its  formation  had  never  even  begun,  so 
thai  the  commencement  of  the  disturbance  in  dcvch>pmcnc 
hid  to  be  referred  to  a  time  between  the  third  and  fourth 
months.  In  this  case  the  high  grade  of  internal  hydroceph- 
alus which  was  present  had  to  be  looked  upon  as  the  cause 
(Arch.  (.  Psych,  und  Ncrvcnkrank.,  1887,  xix,  Dd.  iii,  page  769). 
This,  in  all  probability,  is  more  frequently  than  is  generally 
supposed  the  immediate  cause  of  congenital  malformations  due 
to  arrest  of  development  which  is  principally  the  result  of 
traumatism  during  birth,  protracted  labor,  asphyxia  in  consc. 
qucncc  ul  compression,  etc.  Deficiency  in  the  region  of  both 
fissures  of  Rolando  are  especially  of  interest  because  they  may 
simulate  in  their  clinical  manifestations  spastic  spinal  paralysis, 
although  the  resemblance  is  somewhat  obscured  by  the  simul- 
taneous presence  of  cerebral  symptoms  ;  and  there  is.  of  course. 
«very  possible  gradation,  from  the  pure  picture  of  a  sp3.stic 
spinal  paralysis  in  which  only  the  lower  extremities  are  affected, 
to  that  in  which  the  arms  are  implicated  and  cerebral  symp- 
toms are  well  marked.  Schultzc  (Deutsche  mcdicinischc  Wo. 
«henschrilt,  !■;,  1889)  has  observed  the  spastic  rigidity  in  the 
lower  extremities  in  more  than  one  member  of  the  same  family 
<cf.  Kig.  80). 

Sometimes  certain  parts  o(  the  brain  are  only  imperfectly 
developed.  Such  a  condition  has  been  found  in  certain  gyri, 
the  opiic  ihalamf,  the  corpora  qundngemina.  the  corpora  stri- 
ata, and  others.  Schrtitcr,  among  other  writers,  has  described 
Such  a  delect  in  the  corpus  cullosum,  which  in  his  case  was 
abnormally  short  (Allgem.  Zcitschr.  f.  Psych.,  1888,  xliv,  4,  5). 
"The  cerebellum  may  also  remain  very  much  behind  in  devel- 
•^jpnirni.  so  that  under  certain  circumstances  il  scarcely  attains 
the  size  of  a  walnut.  The  causes  ol  such  local  malformations 
4rc  usually  as  obscure  as  their  clinical  manifestations  during 
lite. 


DISEASES  OF  THE  SPINAL  CORD. 


What  we  have  said  above  about  the  diseases  of  the  brain 
holds  good,  with  certain  limitations,  also  for  those  of  the  spinal 
cord.  The  anatomy  of  the  cord  certainly  offers  less  difficulty 
than  that  of  the  brain,  and,  especially  as  regards  the  finer 
structure  of  the  organ,  has  been  more  minutely  examined  into 
and  is  better  understood ;  but  in  the  physiology  there  exist  still 
so  many  points,  some  obscure,  some  still  under  discussion,  that 
the  pathology  remains  here  also  very  incomplete.  To  give  a 
description  of  the  diseases  of  the  spinal  cord,  especially  when 
questions  of  its  physiology  and  pathological  anatomy  are  to  be 
discussed,  is  an  extremely  difficult  undertaking,  and  were  it 
accomplished  far  better  than  I  have  been  able  to  do  it,  would 
still  stand  in  need  of  a  lenient  judgment.  We  shall  adopt  the 
same  arrangement  as  in  our  account  of  the  cerebral  diseases, 
and  divide  the  subject  into  three  parts.  The  first  will  contain 
the  diseases  of  the  membranes  of  the  spinal  cord,  the  second 
those  of  the  spinal  or  peripheral  nerves,  the  third  those  of  the 
white  and  gray  matter  of  the  cord. 

3'4 


PART   I. 
l}/S/i^SES  OF   THE  SPINAL   AfF.N/NGES. 

The  spinal  meninges  arc,  on  the  whole,  not  frequently  dis- 
nsed  atone ;  more  often  the  inflammation  spreads  from  the 
(soft)  membranes  of  the  brain  to  the  piu  of  the  cord,  or  from 
the  surrounding  structures  to  the  dura  spinalis.  The  one  of 
(neatest  practical  interest  among  iht-  afTeciionsiif  the  meninges 
ul  the  cord  is  the  pachymeningitis  cervicalis  hypcrtrophica, 
which  wc  shall  shortly  describe. 

Of  the  anatnmy  but  little  needs  to  be  added  to  what  has  been 
Slid  on  page  j.  The  spinal  portion  uf  the  du»  is  iliinncr  than 
the  cerebral;  it  widens  into  a  large  cylindricid  sac,  which  i»  by  no 
meant  Ailed  up  by  the  spinal  cord.  This  dural  xac  extends  beyond 
ibe  lower  en<l  of  the  spinal  cord  (conus  medullaris),  and  tcfmirtatcs 
is  a  cone-shaped  point  at  the  level  of  ihe  second  sacral  vertebra; 
all  these  are  points  too  well  known  to  be  dwelt  upon  here  at  length. 
The  conus  tncdullaris  ends  in  the  liliim  lerminatc,  a  filiform  process 
which  is  ac4'ompunicd  by  ilic  longitudinal  nerve  bundles  coining 
from  the  luinhai  and  sacral  portion  of  the  cord,  which  conMitute  the 
<3iada  etjuina.  The  ao-called  ligamentum  denticutatum  is  a  Hat  band 
which  by  its  inner  edge  is  connected  with  Uie  pia  and  externally  by 
ft  Inollied  edge  to  the  dura  matef ;  the  arachnoid  lies  in  such  close 
coniact  with  the  dura  that  the  subdural  space  is  only  a  capillary 
»fMce,  whcrcUK  the  subarachnoid  space,  situated  between  the  arach- 
iwid  and  the  pia,  is  of  considerable  width.  The  denticulate  li|;ament 
divides  it,  lhouf(h  incompletely,  into  an  anterior  and  a  jMisIerior 
half.  In  contradistineiion  to  tlic  pia  raalcr  of  the  brain,  that  of  the 
>pin«l  cord  presents  two  ditlcrcnt  layers  of  connccitvc  tissue,  the 
atiter  one  of  which,  very  well  developed  in  man,  passes  into  the  sub- 
arachnoideal  irabccul»,  while  the  inner  is  made  up  of  a  single  layer 
of  circular  bundtcd  of  fibrillac  (Schwalbe)  {viJt  Fig.  90). 


3i6 


DISEASES  OP  Tt/£  SPINAL  MEXINCES. 


CHAPTER    I. 

INFLAMMATIOK»  OF  TKK   DURA   UATRK. 
PACHVMKSINUITIS   Sl'lNALIS. 

While  in  the  cerebral  purtiuii  of  the  dura  ilie  inner  surface 
is  the  usual  scat  of  the  inflammation,  wc  find  that  the  spinal 
dura  mater  may  be  diseased  on  its  outer  as  well  as  on  its  inner 
surface:  yot  the  clinical  recognition  and  separation  of  these 
two  forms  is  very  often  impossible. 

The  inflammation  of  the  outer  surface  of  (he  dura,  the 
■pachymeningitis  spinalis  externa,  or  the  inflammation  of  the 


^^"m 


Lit. 


jur. 


r.*. 


Id.*. 


FiR.  9a>  — CKon^ecTtoiii  thkolcii  tjh  Vhutcdhai.  Columw  akd -nut  SnsiAL  Coi® 
(DlADIUNHAnL-AL).  ff^.  L.tpidattA  ipocs.  n/.  I ,  lubdufal  ipuzr.  nr.i.,  tutttn^ 
■Kiidtpaoc.  (./.,  Innet  periDaileum  u(  vertebra.  ■/.  h.  .  dura  mater.  iii/..jir>chiicild.  /.  r., 
poMarinr  upliial  root.     /.  4.,  denticulate  ll£«ineiit.    *.  r.,  onieilor  iplnol  (oM.    lAIMr 

ClCllKOKtlT,) 


connective  tissue  between  the  dura  and  the  vertebral  column, 
peripachymeningitis,  is  a  very  rare  disease,  and  probably  only 
occurs  secondarily.  The  inflammatory  changes,  which  at  times 
are  most  marked  on  the  posterior  surface,  consist  of  a  thick- 
ening and  cellular  inliliration  of  the  dura;  sometimes,  also. 
the  membrane  may  be  found  covered  with  dense  cicatricial 
deposits  (Eichhorst).  The  chief  causes  are  caries  or  tuber- 
culosis ol  the  vertebra*,  piciiritis.  psoas  abscess,  syphilis,  puer- 
peral pyiemia.  suppuration  in  the  peritonea!  cavity,  and  In 
exceptional  cases  the  disease  may  have  its  origin  in  a  neuritis 


tNFlAMMA  riO.VS  Of  THE  DUKA  MA  Tf.ft. 


3'7 


migrans.  The  clinical  picture  depends  largely  upon  the  impli- 
catton  of  the  nerve  roots  and  of  the  spinal  cord.  If  the  cord 
)s  compressed  by  the  ihitkcning.  the  symptoms  of  a  pressure 
paralysis,  lo  which  wc  shall  have  occasion  to  rclcr  later,  make 
their  appearance.  I(  the  nerve  roots  are  implicated,  there  are 
violent  paroxysmal  pains  which  run  along  the  vertebral  col- 
umn and  radiate  inio  the  extremities.  Rigidity  of  the  neck 
and  tenderness  on  pressure  over  the  spinous  processes  of  the 
vertebrae  are  rarely  absent,  but  are  not  sufficient  to  warrant  a 
diagnosis,  as  they  may  be  found  just  as  well  in  an  inflammation 
of  the  pia.  To  make  a  definite  diagnosis  will  in  any  case  only 
be  possible  if  accompanying  signs  are  taken  into  consideration, 
more  especially  those  of  any  primary  disease.  It  is  always  a 
difficult,  sometimes  even  an  impossible,  task. 

The  inflammation  o(  the  internal  surface  of  the  dura  mater 
usually  develops  in  the  cervical  portion  of  the  cord :  follow. 
i&^  Charcot,  who  first  described   the  anatomical  and  clinical 


tk.4. 


V-* 


*.r. 


h 


Tx,  91.— CWOW  ttCTlOW  THMOit'OII    Tilt    UlDDLK  OT  TMC  CCIirrCAI.   KSTtAMOUmTT  IK 

PAOiVKENiMtrriS  CKBviCALt*  KrPKKiKopHiLA.      /tv..   Uikkwwl  dun.     <*./.<-.. 
\y  lonnacl  cavMtts.    m.r.,  ncmMOola.    (Aftn  CKAjicnr.) 


tMTcs  of  the  disease,  il  has  been  called  pachymeningitis  cer- 
vicalis  hypertrophies ;  the  inflammatory  new  formation  and 
thickening  of  the  connective  tissue,  which  are  most  marked  on 
the  posteriur  inner  surface  of  the  dura,  exist  in  circumscribed 
areas  (Fig.  gi);  this  compresses  the  ner\'e  roots,  which  pass 
thnkugh  the  membrane  at  these  places,  and  finally  even  the 
curd,  and  may  give  rise  to  the  formation  of  channel-like  cavi' 


318 


DISEASES  OF  THF.    SPINAL  NHX/XGRS. 


ties  (i». /.  e.  ill  Fig.  91).  If  the  compression  continues  for  a 
considerable  time  it  leads  to  secondary  degeneration  of  the 
pyramidal  tracts  in  ihe  spinal  cord,  as  well  as  of  the  motor 
nerves  originating  in  the  jKirts  diseased,  and  to  atrophy  of  the 
muscles  supplied  by  rhem. 

Symptoms. — The  symptoms  of  the  disease  arc  mostly  the 
outcome  of  the  participation  of  the  nerve  roots  ami  the  spinal 
cord.  The  disease  may  well  be  divided  into  two  stages,  each 
having  its  characteristic  symptoms.  To  the  first  belong  the 
pains,  to  the  second  the  paralyses  (Charcot).  The  pains  vary 
exlremely  in  intensity  and  exlenl;  as  a  rule  they  are  confined 
to  the  region  of  the  neck,  whence,  occurring  in  paroxysms  of 
increasing  severity,  they  radiate  into  the  upper  extremities  and 
arc  accompanied  by  paraislhcsias  in  the  arms,  tingling  and 
formication  in  the  finger  tips.  The  grip  is  u-sualty  markedly 
diminished,  and  a  test  with  the  dynamometer  shows  (hat  the 
palit'nl  is  able  to  lift  only  tun  to  fifteen  kitognimmes.  Not 
rarely  trophic  disturbances,  in  the  form  of  vesicular  eruptions. 
roughness  and  desquamation  of  the  epidermis,  arc  noted.  The 
sensation  of  stiffness  in  the  neck  and  of  difficulty  in  moving  the 
head  troubles  the  patient  a  great  deal,  and  gives  to  him  a  siili. 
quite  characteristic  appearance.  He  carefully  avoids  tuniing 
his  head  in  any  direction,  and  tries  to  make  up  for  this  rigidity 
of  his  neck  by  turning  the  whole  body,  which  he  docs  slowly 
and  in  a  somewhat  awkward  way.  The  most  careful  examina. 
tion  of  the  cervical  region,  percussion  of  the  spinous  processes, 
hot  sponges  applied  to  the  skin  over  them,  and  the  like,  dties 
(tot  always  reveal  an  increased  sensitiveness. 

Gradually,  that  is  to  say,  in  the  course  of  two  or  three 
months  or  more,  the  patient  gets  accustomed  to  his  pains,  mi 
much  the  more  so  as  they  become  less  severe  in  the  further 
course  of  the  disease.  On  the  other  hand,  he  discovers  to  his 
great  distress  that  the  motor  power  of  his  upper  extremities  is 
becoming  more  and  more  impaired.  The  stage  of  paralysis,  as 
a  rule,  is  'immediately  preceded  by  a  peculiar  heaviness  and 
sitflness  in  the  shoulder  and  elbow  joints.  The  patients  notice 
that  they  arc  unable  to  raise  their  arms  as  high  as  before ;  if 
they  arc  females,  that  they  can  not  arrange  Iheir  hair  them- 
selves any  more,  owing  to  the  impairment  in  the  upward  and 
Uickward  motion  of  the  arms,  movements  which  finally  become 
totally  impossible. 

The  elbow  joint,  too.  becomes  stiffened,  and  the  motions 


/XFl^MMATIoys  OP  THE  DURA  MATER. 


319 


t 

I 

t 


o(  the  wrist  and  finger  joints  become  visibly  impaired.  The 
disability  is  not,  however,  usually  equal  in  both  arms  and 
hands,  as  one  hand  may  be  ahnost  useless,  while  the  (unction 
ol  the  other  is  not  much  interfered  with.  Still,  in  .some  in- 
stances, the  trouble  may  progress  in  both  arms  /ari  passu. 
Curiously  enough,  not  all  the  muscles  ol  the  (orearms  become 
affected,  but  more  especiully  those  supplied  by  the  ulnar  and 
median  nerves,  while  the  extensors,  which  are  supplied  by  the 
musculo-spinil,  remain  more  or  less  intitct.  The  afTectiun  ol 
the  muscles  maniiests  itself  by  an  increasing  atrophy  and  weak- 
B  Bcss,  which  allows  an  ovcraction  of  the  healthy  antagonists — 
^^  the  extensors — so  that  the  hand,  although  by  no  means  in  all, 
but  only  in  the  well-marked  cases,  assumes  a  very  character- 
istic position.  It  is  dorsally  Hexed,  and  the  hngcrs,  which  arc 
tbent  in  the  second  and  third  joints,  give  to  it  the  appearance 
o(  a  claw  <rig.  92).    About  the  development  ol  this  position 


^  9L— PdHnoM  or  THi  IIako  in  pArNVNF.VTxaiTis  CnvKAi.ia  KrpKRnioipHiCA. 

(Charcot.) 


wc  shall  have  more  to  say  when  speaking  of  the  ulnar  paraly- 
sis. The  dilhculties  arising  from  this  diminished  molar  power 
*re  considerably  aggravated  by  the  parresthcsias  in  the  finger 
tips.  The  patients  are  unahle  tn  lake  hold  <if  small  objects — 
piiu,  stcri  pens,  etc^they  are  unable  to  attend  to  their  own 
titilet  because  they  can  not  feel  small  buttons,  and  so  forth. 
They  become  more  and  more  helpless,  and,  what  is  of  the 
greatest  significance  for-  patients  belonging  to  the  working 
classes,  they  become  incapacitated  lor  work  and  unable  to  earn 
Uicir  living.  This  may  indeed  be  the  case  at  quite  an  early 
period,  when  the  patient  is  otherwise  in  a  comparatively  fair 


320 


OtSEASES  OF  TUB  SP/XAl  MBN/A'GES. 


condition,  especially  in  Icmalc  patients  who  do  fine  hand-woric 
(sewing,  knilling,  embroidering).  The  whole  condition  be- 
comes worse  and  worse,  Anns  and  hands  become  stiver  and 
slilTer.  nniil  finally,  although  not  in  all  instances,  a  complete 
paraplegia  of  the  upper  extremities  develops.  Whether  or  not 
lo  these  symptoms  a  paresis  or  paralysis  of  the  lower  exireml- 
lics  or  bladder  disturbances  are  added  will  de]>end  entirely 
upon  the  extent  to  which  the  spinal  cord  takes  part  in  the  pro- 
cess. It  can  in  no  case  cither  be  predicted  or  excluded  with 
certainly. 

Course. — The  course  of  the  disease  is  always  chronic  and 
extends  over  years.  Alter  the  period  of  pains  has  passed  the 
patients  are,  as  a  rule,  free  from  them  forever,  and  only  suHer 
Irom  the  helplessness  which  results  from  the  motor  disturb- 
ances. Owing  to  this  they  reciuirc  scrupulous  care,  have  lo 
be  dressed,  undressed,  fed.  etc..  by  an  attendant.  Recovery 
or  even  an  improvement  is  an  extremely  raic  outcome.  To  he 
sure.  I  have  seen  a  cured  patient  in  the  clinic  of  Charcot,  but 
from  the  minuteness  with  which  this  case  was  described,  from 
the  feeling  of  justifiable  |>ride  which  accompanied  '  the  demon- 
stration, one  could  well  see  how  extremely  rare  a  cure  must  be. 
Remak.  too.  speaks  of  the  curability  of  the  disease  (Deutsch. 
med.  Wochensclir..  1887,  No.  2(5).  I  myself  am  unable  to  pre- 
sent such  a  case.  The  patients  in  my  wards,  after  unsuccess- 
ful trials  of  all  proposed  modes  of  treniment,  have  long  given 
up  ail  hopes  of  any  marked  improvement. 

Diagnosis. — The  disease  may.  especially  in  its  onset,  possibly 
be  confounded  with  either  spinal  leptomeningitis  or,  as  we 
shall  later  show,  with  syringomyelia.  It  is  nalural  that  tumors 
of  the  vertebral  column,  if  they  be  situated  m  the  region  of 
the  cervical  enlargement,  should  produce  in  the  initial  stage 
the  same  symptoms  as  a  paclivmcningilis.  The  further  course, 
however,  will  soon  settle  the  diagnosis.  Besides  (liesc  there 
are  two  more  diseases  which  may  in  the  mind  of  the  beginner 
give  rise  to  some  diflficulties  with  regard  lo  the  differential 
diagii()sis--namcly,  progressive  muscular  atrophy  and  amyo- 
trophic lateral  sclerosis.  It  is  true  th.tt  a  patient  with  .1  ]>achy. 
meningitis  may  sometimes  jtresent  the  appearance  of  a  roan 
suflcring  from  progressive  muscular  atrophy  ;  but  the  two  dis- 
eases should  never  be  confounded,  inasmuch  as  in  the  latter 
affection  the  initial  stage  is  not  accompanied  by  jxiin.  and  the 
stiff  neck  has  never  been  known  to  occur  in  il.     The  idea  of 


IKFLAMMATIOSS  OF  TItK  DURA  .VATF.fl. 


3" 


^^  amyotrophic  lateral  sclerosis  will  prob;ibly  also  be  discarded, 

^■fts  in  this  disease  the  lower  exircmilic<t  .ire  implicated,  and  as 

^^uMlculty  in  swallowing,  a  si^n  which  indir^tt-s  <^xtonsiuii  uf  the 

^^^RKcss  to  the  medulla  oblongata,  will  usually  not  be  very  late 

in  appearing.     Wc  may  say  that   the  diagnosis  of  cervical 

IMchynieningilis  can,  if  the  case  is  carcltilly  examined  and  U 

the  course  o<  the  affection  is  taken  into  consideration,  almost 

ulways  be  correctly  and  definitely  made  out. 

k  Etiology.— \\'c  are  wholly  ignorant  of  the  aetiology  of  the 
disease.  Sume  maintain  that  ihc  abnsc  of  alcohol  is  ul  some 
importance  in  this  connection,  others  the  living  in  damp  houses. 
Whether  syphilis  has  any  such  inllucnce,  and,  il  so,  what  is  its 
mode  o(  action,  is  not  as  yet  established.  There  is  no  doubt  that 
the  aflection  is  more  common  among  the  working  classes  and 

■  Ihc  lower  grades  of  society,  but  what  are  the  conditions  and  in- 
fluences which  .icl  as  direct  causes,  if  such  there  be,  we  arc  not 
able  to  say. 

Treatiaent. — The  treatment  comprises  local  as  well  as  gen- 
eral therapeutic  measures.     The  former  consist  in  the  applica- 
tion qI  strong  counter-irritants — c.  g.,  the  painting  twice  daily 
with   tincture  of  iodine,  in  the  use  of  irritative  ointmcnis  or 
ffloxs.    The  application  of    Paqucltn's  cautery,  with    which 
punclilorm  scars  on  the  skin  are  produced  (the  so-called  fwittts 
df  frtt  of  the   French),  only  deserves  preference  because  it  is 
less  painful  than  the  others.     Any  lasting  result  can  not  be  ex- 
pccie<i  (rom  il.     No  more  is  effected  by  general  or  internal 
ireaiment.  and  It  Is  impossible  to  give  the  Indications  for  any 
Itanicular  remedy.    Iodide  of  potassium  has  l>cen  used  in  order 
that  iomrthing  might   be  done,  without,  however,  producing 
anything  else  than  disorders  of  digestion.     If  the  patient  in- 
sifcU  on  taking  medicine,  a  placebo  ought  to  be  given — acids, 
hitters,  etc.      In   no  case  were  we  able  to  sec  any  beneficial 
cflectft  from  warm  baths  and  hydrotherapy  in  general.     The 
only  measure  which  at  least  modified  the  symptoms  somewhat, 
in  that  it  gave  the  patients  for  a  time  more  freedom  of  motion 
i^in  their  paretic  extremities,  was  electricity,  more  especially  the 
^kutaneous  faradization  with  the  brush  on  the  neck  as  well  as 
^nip  and  ihiwn  the  limbs.     If  the  constant  current  is  used  it 
Bought  CA|K:cially  to  be  applied  to  the  muscles  innervated  by  the 
nlnar  and  mc<)f»n  nerves.     By  repeated  closing  and  opening 
o(  the  current  muscular  contractions  should  be  elicited. 


chapter  ii. 

the  inflammations  of  the  soft  spinal  meninges. 

Leptomeningitis  Spinalis. 

The  soft  membranes  are  rarely  ever  by  themselves  the  seat 
of  inflammation,  whether  of  an  acute  or  a  chronic  type.  Such, 
however,  may  exceptionally  occur  as  the  result  of  traumatism, 
of  overexertion,  carrying  heavy  loads,  or  as  a  consequence  of 
exposure  to  cold  after  sleeping  on  the  damp  ground  in  camping 
out,  etc.  (Braun,  of,  lit.).  But  in  the  greater  number  of  cases 
we  have  to  do  with  the  extension  of  an  inflammatory  process 
of  an  infectious  nature,  as  in  epidemic  cerebro-spinal  menin- 
gitis, or  in  tubercular  meningitis,  both  diseases  which  affect 
the  membranes  of  the  brain  as  well  as  those  of  the  spinal  cord. 
That  there  are  instances  of  meningitis  secondary  to  other  dis- 
eases, and  under  what  circumstances  they  occur,  we  have 
already  stated  above.  Here  we  only  wish  to  draw  attention 
to  its  connection  with  acute  articular  rheumatism,  of  which 
Krabbel  (Inaugural  Dissertation,  Bonn,  1887)  has  reported  an 
instance. 

Pathological  Anatomy. — Pathologically  the  acute  spinal 
meningilis  is  divided  into  three  stages.  The  first  is  character- 
izcd  by  a  diffuse  reddening  and  swelling  of  the  meninges,  more 
especially  of  the  pia;  the  second  by  the  appearance  of  a  puru- 
lent or  fibri no-purulent  exudation  upon  this  membrane.  This 
may  occur  gradually,  and  may  vary  considerably  in  extent :  it 
may  be  found  over  the  whole  length  of  the  pia  (always  more 
on  the  posterior  surface),  or  may  be  confined  to  circumscribed 
areas.  In  the  third  stage  the  pus  becomes  reabsorbed  and 
thickening  of  the  pia  vvith  therformation  of  adhesions  between 
it  and  the  dura  takes  place. 

That  the  nerve  roots  also  participate  in  the  inflammation  is 
evident  from  the  hyperjemia  of  their  blood-vessels,  the  infiltra- 
tion of  the  interstitial  connective  tissue,  and  the  eventual  de- 
331 


mf-'LAMMATIONS  Of   THE  SOFT  SPINAL  MKNINGES. 


323 


) 


i 


generation  ol  the  mwlullatcd  nerve  fibres.  If  we  remennbcr 
the  many  processes  by  which  the  pia  is  united  with  (he  spina) 
c'ird  itself,  it  is  nut  suqmsing  that  the  latter  is  implicated. 
On  cross-sect iun  il  looks  in  places  injected,  u'denialous,  and 
it  seen  to  bulge :  on  the  other  hand,  there  arc  undoubtedly 
instances  In  which  the  cord  does  not  take  part  In  the  tnflam- 
maiion. 

The  chronic  (orm,  which  seems  very  rarely  to  occur  pri- 
marily,  and  then  only  after  the  protracted  abuse  o(  alcohol,  is 
usually  preceded  by  the  :icute  disease  or  is  secondary  to  difier> 
cnl  spinal  lesions  or  various  alTcctions  of  the  vertebra:.  The 
[Mlholo^ical  changes  occurring  here  can  well  be  compared 
wiih  those  ol  ihc  acute  form.  In  this  condition  we  find  thick- 
cniog  and  opacity  of  the  tissue,  masses  of  newly  formed  con- 
acclive  tissue,  and  adhesions  to  the.  dura.  There  is  turbidity 
ul  the  sjiinat  Muid,  which  is  abnormally  increased,  and  somr- 
limcs  abnormal  formation  ol  pigment.  The  brownish-red  and 
black  specks  often  seen  are  to  be  looked  upon  as  the  remains 
u(  previous  hicmorrhugcs.  in  which  the  coloring  matter  of  the 
blcNtd  has  undergone  changes  (liichhorsl).  In  consequence  of 
the  extraordinary  development  of  the  processes  of  the  pia.  this 
membrane  adheres  very  tirmly  to  the  cord,  so  that  it  can  not 
be  stripped  off  without  loss  of  substance  of  the  cord.  Here, 
again,  the  nerve  roots  arc  implicated,  as  is  evident  from  their 
cbange<i  appearance.     They  look  flattened  and  atrophic. 

Symptoms.-  In  the  acute  form  pain  undoubtedly  plays  the 
princi|>al  part.  Even  in  the  initial  stage,  which  docs  not  diflcr 
bom  that  of  other  acute  diseases  in  most  of  the  symptoms 
(chill,  general  malaise,  loss  of  appetite,  disturbed  sleep,  ele- 
vation of  temperature),  the  pain  along  the  spinal  column  is 
very  marked.  The  patients  are  constantly  troubled  with  it  in 
whatever  position  ihcy  may  lie.  although  it  is  especially  sharp 
on  any  attempt  to  move  or  to  sit  up  in  bed.  At  the  same  time 
they  IccI  an  unwonted  stiffness  in  the  muscles  of  the  back,  and 
have  difficulty  on  motion.  On  careful  examination  o(  the  back 
wr  find  that,  althou-;h  Ihc  spinous  processes  ol  the  vertebra: 
arc  tender  on  pressure,  and  by  the  slightest  lap  or  by  the 
touch  of  a  hoi  sponge  p;iin  is  evoked,  this  is  in  no  way  com- 
{tarablc  to  thai  felt  by  the  patient  without  any  extraneous  in- 
terference. This  persists  obstinately,  and  usually  in  the  further 
course  of  the  disease  may  radiate  into  the  anns  and  legs, 
owing,  o(  course,  to  the  implication  of  the  nerve  roots.    The 


324 


DISEASES  OF  Tll£  SPINAL  MENINGES. 


same  (actor  also  accounts  for  (lie  differcni  hypcncsthcsias  ot 
the  skin,  the  girdle  sensation,  the  muscular  p^iins.  etc.  Rigid- 
ity of  t'lc  neck  is  only  observed  if  ihe  process  has  attacked  the 
cervical  portion,  If  the  spinal  cord  itstdf  becomes  implicated, 
spinal  symptoms,  bladder  disturbances,  increased  reflexes,  and 
extensive  sensory  disturbances  make  their  appccirance.  AH 
these  symptoms  may  persist  unchanged  for  weeks,  the  patienl 
feeling  very  badly  and  complaining  of  constant  violent  pain. 
H  the  disease  take  a  favorable  turn  the  pains  gradually  abale 
and  the  patient  gets  relief ;  but,  on  the  other  hand,  tht-  sym[>- 
toms  of  irritation  may  give  place  to  those  of  paralysis,  and  as 
anatomical  changes  go  on  in  the  nerve  roots  (degeneration, 
atrophy),  we  have  analgesias  and  anaesthesias,  the  muscles  be- 
come more  and  more  incapable  of  performing  their  functions, 
they  undergo  marked  atrophy,  and  on  electrical  examinAtinn 
distinct  reaction  of  degeneration  is  found.  There  is  direct 
danger  to  life  (i)  if  the  process  extends  upward  to  the  medulla 
oblongata;  in  that  case  death  may  occur  in  a  few  days:  (2)  il 
owing  to  an  extensive  myelitis,  bed-sores  develop  which  lead 
to  the  utter  exhaustion  of  the  patient.  Recovery  may  be  com- 
plete or  incomplete:  in  the  latter  case  pareses.  parxsthesias. 
and  bladder  disturbances  arc  left  behind  as  the  result  of  irrepa- 
rable anatomical  changes. 

The  symptoms  of  the  chronic  do  not  differ  much  from  those 
of  the  acute  form.  The  pains,  however,  are  occasionally  less, 
pronounced.  They  vary  with  regard  lo  their  violence  and  scat ; 
sometimes  they  are  most  marked  high  up  between  the  shoulder 
blades,  sometimes  lower  down  in  the  back,  so  as  lo  interfere 
more  or  less  completely  with  stooping;  not  rarely  they  arc 
found  to  radiate  toward  the  front  of  the  thorax,  sometimes  on 
one,  sometimes  on  both  sides.  Even  slighter  degrees  of  pain 
are  sufficient  lo  seriously  interfere  with  the  occupation  of  the 
pntient,  especially,  of  course,  if  the  arms  or  legs,  or  what  is, 
however,  rather  rare,  all  four  extremities  are  implicated.  Sen- 
sory changes  are  found  in  both  the  acute  and  Ilir  chronic  form  ; 
an  implication  of  the  cord  itself  leads  to  the  same  symptoms 
of  irritation  or  paralysis  which  we  have  before  mentioned. 
The  disease  may  drag  out  its  course  through  a  numl>cr  of 
years  and  still  there  may  follow  a  relative  recovery  ;  complete 
recovery  I  have  never  seen. 

DiagnosE8.~To  make  a  correct  diagnosis  of  this  disease 
much  cx|)cricnce  and  carefulness  is  nec<rssary.     Acute  spi 


INFLAMMATIONS  OF   THE  SOFT  SPINAL  MENINGES. 


325 


menin^tis  tn»y  be  mistaken  for  muscular  rheumatism  and  lum- 
bagti,  the  chronic  form  tor  what  was  formerly  called  spinal 
irrilation  and  cord  diseases.  A  differentiation  from  the  former 
may  be  facilitated  by  an  examination  of  the  spinous  processes 
lor  tenderness  on  tapping  or  touching  with  a  hoi  sponge.  In 
simple  muscular  rheumatism  the  spinous  processes  are  not  sen- 
sitive, whereas  the  different  muscles  are  found  to  be  tender  it 
pressed  or  kneaded.  loimbago  pains  are  recognized  by  their 
greater  severity,  their  frequent  change  in  locality,  and  their 
lesser  persistency.  Spinal  irritation  iihould  only  be  diagnos- 
ticated in  ver>-  ana*mic  hysterical  individuals:  and  the  further 
course  and  linal  outcome  of  the  disease  will  guard  us  against 
the  assumption  of  the  existence  of  a  cord  disease,  for,  if  this  be 
present,  the  issue  is  always  unfavorable. 

Treatment. — With  reference  to  treatment,  little  is  to  be 
added  tu  what  has  been  said  on  page  321.  Here,  too,  local 
measures — counter-irritation,  etc. — must  first  be  tried,  and  in 
case  they  should  be  found  uf  no  avail,  prolonged  tepid  baths 
{93°  Fahr.  for  from  half  an  hour  to  an  hour  and  a  half)  should 
be  substituted.  Electricity  should  also  be  used  in  the  form  of 
the  faradic  brush  applied  over  the  painful  muscles.  Ocnlle 
massage,  if  practiced  by  a  competent  person,  is  strongly  to  be 
recommended,  and  ought  to  be  continued  (or  a  long  time. 
The  administration  of  iodide  of  potassium,  (or  which  no  indi- 
cation whatever  exists,  is  to  t>c  condemned. 


CHAPTER   III, 

HEMORRHAGE  INTO  THF.  SPINAL  MEMBRANES MENINGEAL  APOPLEXY 

— PACHYMENINGITIS   INTERNA    HiCMORRHAGICA. 

The  vessels  nourishing  the  spinal  meninges  are  the  anterior  and 
posterior  spinal  arteries,  arising  from  the  vertebral  artery,  which  in 
its  turn  comes  off  from  the  subclavian.  They  join  with  a  succession 
of  small  branches  which  enter  the  spinal  canal  through  the  interver- 
tebral foramina  and  form  median  vessels,  which  run  in  front  and 
behind  the  cord  along  the  longitudinal  fissure,  having  numerous  hori- 
zontal anastomoses.  Both  of  these  arteries  send  constantly  fine 
horizontal  twigs  into  the  substance  of  the  cord,  while  others  are  dis- 
tributed to  the  pia.  The  capillary  network  is  decidedly  denser  in 
the  gray  than  in  the  white  matter. 

The  occurrence  of  a  haemorrhage  between  the  membranes 
of  the  spinal  cord  (" intrameningeal"),  or  between  the  dura 
and  the  bony  vertebral  canal  ("  extrameningeal "),  is,  on  the 
whole,  very  rare.  If  one  of  these  two  forms  occurs  more  fre- 
quently than  the  other,  it  is  the  latter,  the  extrameningea!,  the 
so-called  apoplexia  epiduralis,  so  named  because  the  blood  es- 
capes into  the  epidural  space.  The  haemorrhages  between  the 
dura  and  the  arachnoid — apoplexia  subduralis — and  those  be- 
tween the  arachnoid  and  the  pia^apoplexia  subarachnoidalis — 
which  break  into  the  space  filled  with  the  cerebrospinal  fluid, 
are  much  more  uncommon.  If  we  find  on  the  inside  of  the 
dura  encapsulated  foci  of  variable  size  which  contain  products 
nf  decomposition,  ha:matoidin  crystals,  detritus,  etc..  then  we 
speak  of  a  pachymeningitis  interna  hasmorrhagica.  The  loose 
blood  coagula  may  be  found  of  such  a  size  that  they  compress 
the  cord  and  the  nerve  roots.  On  the  other  hand,  there  may 
be  nothing  more  than  punctiform  extravasations  of  blood,  in 
the  neighborhood  of  which  the  vessels  of  the  dura  appear  more 
than  usuatlv  full.     That  these  coagula  are  to  a  certain  extent 


I 


I 


MEX/A'GEAl.  ArOfLUXY.  327 

cipidle  of  being  absorbed,  and  that  ihcy  do  not  necessarily 
irreparably  damage  thpcord  and  the  nerve  roots,  is  proved  by 
the  cases  which  take  a  favorable  course. 

Etiology. — With  reference  to  the  ietiulogy,  it  may  be  said 
that  such  hicmorrhagcs  may  be  evoked  by  overexertion.  They 
occur  by  preference  in  men,  and  more  especially  in  laborers 
who  do  hard  work,  such  as  carrying  heavy  loads  and  who 
drink  a  great  deal  of  alcohol.  They  may  also  follow  tranmalic 
influences,  either  direct  injury  to  the  bodies  of  ihc  vertebra; 
or  severe  concussions  affecting  (he  whole  body,  such  as  one 
might  receive,  for  instance,  in  a  collision  between  two  railroiid 
trains,  in  which  case  sympUtms  arise  which  simulate  very 
much  the  clinical  appearances  o(  railway  spine,  which  wc  shall 
describe  later.  Secondary  meningeal  apoplexies  occur  in  the 
course  of  infectious  diseases — scarlet  fever,  small-pox,  typhoid 
fever,  etc.  Also  in  epileptics  they  are  not  rare,  and,  according 
lo  Hasse,  are  often  associated  with  heart  hyperlropliy. 

Symptoms. — The  symptoms  very  closely  resemble  those  of 
ipinal  meningitis,  only  that  the  onset  is  always  very  sudden — 
"apoplectiform."  A  person  in  perfect  health  may  feel  sud- 
iply  a  violent  circumscribed  pain  in  the  back  which  differs  in 
ee  and  extent  in  dilTcrcnt  cases,  and  which  if  the  hxmor- 
rliage  is  extensive  may  in  a  few  hours  give  place  to  complete' 
pinilysis  of  the  legs  (more  rarely  of  the  arms).  In  milder 
cases,  while  the  pains  gradually  abate,  sensory  disturbances, 
[Anesthesias  and  anesthesias,  gradually  develop,  also  slight 
motor  disorders,  weakness  in  the  muscles  of  the  extremiltcs, 
MHQclimes  also  signs  of  motor  irritation — trembling,  twitching. 
etc.  The  main  characteristic  of  a  meningeal  hiemorrhagc 
which  is  purely  spinal  is  the  complete  freedom  from  disturb- 
ances of  consciousness.  The  course  and  the  duration  of  the 
disease  depend  uptm  the  extent  of  the  harmorrhage  and  ils 
capability  of  being  absorbed.  It  is  necessary  to  have  seen, 
carefully  studied,  and  analyzed  several  cases  of  this  nature  in 
order  to  properly  understand  and  correctly  recognize  a  new 
insUincc.  The  implication  of  the  spinal  cord  itself  necessarily 
gives  rise  to  what  are  known  as  "  spinal  symptoms  "  (increased 
reflexes,  bladder  disturbances,  persistent  paralyses),  as  wc  have 
rejM-aic<lly  stated, 

Diagnosis. — The  diagnosis  is  easy  in  the  cases  with  charac* 
icriMic  onset  if  we  are  satislicd  with  ihe  diagnosis  of  ■•  menin- 
geal apoplexy,"  whereas  it  is  very  ditficult,  nay.  often  impossi* 


3l8  i>/StAS£S  OF  TUB  SPINAL  ME.VINCES.  ^| 

blc,  to  determine  the  exact  kind,  whether  it  is  epidural  or  sub- 
dural Again,  lo  determine  its  situation  is  cumparativcly  easy 
if  we  remember  that  in  alTcctions  ol  the  lumbar  cord  the  legs, 
bladder,  and  I  he  rectum  mainly  suffer,  whereas  aflecUons  of 
the  dorsal  region  give  rise  to  symptoms  ol  irritation  in  the  dis- 
tribution of  the  intercostal  nerves,  and  those  of  the  ccr\'ical 
portion  lo  motor  and  sensory  disturbances  in  the  upper  ex- 
tremities. If  the  scat  be  still  higher  up — in  the  medulla  ob- 
iongaui— bultxir  symptoms,  disorders  of  respiration  and  deglu- 
tition, will  not  be  .ibsciit.  and  the  case  will  be  fatal  in  a  short 
time. 

Progfnosis.— The  prognosis  depends  upon  the  extent  of  the 
haemorrhage.  Cases  with  a  favorable  outcome  have  repeatedly 
been  observed.  Implication  of  the  cord  and  the  neiTrc  roots 
makes  the  prognosis  more  unfavorable. 

Treatment.— In  the  treatment,  our  first  duty  in  a  recent 
case  should  be  to  procure  alisolutc  rest  in  bed  and  apply  tee 
over  the  supposed  seat  ol  the  trouble,  to  arrest  the  haemor- 
rhage, if  possible,  or  to  prevent  the  return  of  it.  If  the  irrita- 
tion seems  to  be  localiired.  local  bleeding  may  be  indicated. 
The  further  treatment  is  the  same  as  in  acute  meningitis. 

Tumors  of  the  spinal  meninges  are  of  no  practical  impor- 
tance, because  they  can  never  be  diagnosticated  with  certainty. 
Although  we  know  well  from  the  report  of  autopsies  that  just 
as  in  the  cerebral  we  may  in  the  spinal  meninges  find  psam- 
momata.  sarcomata,  myxomata,  gummata.  carcinomata,  etc.,  and 
that  their  seat  may  be  epidural,  subdural,  and  subarachnoidal, 
we  arc  never  able  to  recognize  definitely  from  the  symptoms 
observed  during  life  cither  the  nature  or  the  seat  ol  a  tumor  in 
the  meninges  of  the  cord.  The  reason  is  ver>'  simple.  The 
tumors,  as  long  as  they  are  very  small,  produce  no  symptoms, 
and.  i(  they  grow,  give  rise  to  symptoms  which  depend  upon 
the  compression  of  the  cord  and  the  nerve  roots  and  can  not 
be  distinguished  from  those  produced  by  pachymeningitis  and 
leptomeningitis  spinalis.  They  consist,  therefore,  of  signs  of 
motor  and  sensory  irritation  and  later  of  paralysis,  which  vary 
according  to  the  scat  of  the  tumor.  If.  for  instance,  only  one 
half  of  ihc  cord  is  compressed,  we  may  have  a  clinical  picture 
which  resembles  that  of  a  unilateral  lesion  of  the  spinal  cord, 
viz.,  paralysis  and  hypcrpcsthesia  on  the  side  of  the  compression, 
ana;sthesia  on  the  intact  side.     A  case  of  this  kind  has  been  re- 


TUMOKS  OF  rUE  SPINAL  MENINGES. 


329 


» 


ponctl  by  Charcot  (cf.  Ut.).  Innumerable  variations  are  pos- 
lible.  according  to  the  size  and  scat  of  the  tumor,  and  the  less 
we  are  able  to  fully  diagnosticate  tlie  case  during  life  the  more 
taiportant  and  instructive  it  will  be  to  examine  and  describe  as 
carefully  as  possible  wliat  is  found  at  the  autopsy. 

UTERATURE. 

Bmin.     Bcmcikungrn  uber  die  Mcningiiis  spinalis,  baonilcrs  aach  FclcliUgcn, 

M  Oflkieren.     OeulMrhe  mililSrirtil.  i^eiiachr..  1871,  1,  3.  4.  p.  116. 
Uyitrit.     Klinik  dn  Ruckcnntukskntnkheiicn.     DcTlki.  1874,  1.  pp.  44]  tt  itf. 
Ouicoi.     Klinitchc  VonrMge  ubcr  Kranlthcilcn  des  Ncrvcnsysienw.    German 

by  VriiKt.  Siuiifan,  187S.  it,  83  tt  se^. 
Unubach.     Arch,  f,  Psych,  und  Ncn-vnkr..  18S4.  xv,  ^  4S9.    {Lipoma  of  ihr 

Spinal  Meiunxet.) 
Hint.     Vie  U  pach]rineninKflc  ccrvicalc  hypcnrophlquQ  cunttlc    Arch.  g<n<r.. 

Juifi.  ittSA,  p.  641. 
KaTfnoni).     Da  difKrcntes  rormes  de  Icplo-inytiim  tuberculeusev    Kcvue  dc 

cnM..  March.  1886.  vi.  j, 
Senator.     U'ebcr  cinigc  FUle  von  epulcmischrr  Cei«bnMi>inalTnenin);iUt.  cic. 

Chahit-Aniulen.  1886.  xi.  p.  a88. 
finuich.    Zur  Pathologic  dcr  CrtcbrosplnaUncningtlis.     Ibid..  1886.  p.  S>S> 
WorhieltMiim.     Fonschrillc  Her  Med.,  1887.  v.  19. 
Ekhbont      Kandbuch  dcr  spceitllen  Pathologic  und  ThcTii|itc,  y  Atifla^c. 

Wim  und  Lripttg.  1887.  iii.  166  rt  t^. 
GolilKhmidL    Ccniralbl.  f.   U»clcri6lotne  und  PaiaaUenknnde,  1S87.  ii,  31.  p. 

6491     (The  Dlplococctis  InlracenulaHs  Meningitidis.) 
Hagnire.    A  Case  cf  Idiopaihic  S«ippuraiion  of  the  Spinal  Dura  Maler.    Lancrt, 

Hr  7.  1S87,  p.  9. 
Oamtt.     Uchrr  multiple  Angioaarcomc  der  Pia  maler  spinalis  mit  hyalinrr  Dr- 

gmeralion.     I  naug.- Dissert..  Marburg,  1S89. 
Vogt.     Ucber  Meiungiti^  i^tualiv      Ueutschc  mcd.  Wochctuchr.,   18S9,  38. 

(From  Jurgcnscn's  Clinic.) 


PART    II. 
DISEASES  OF   THE  SPINAL   NERVES. 

The  nerves  of  the  spinal  cord,  which  are  called  spinal  or  periph- 
eral nerves,  arise,  as  is  we!l  known,  by  an  anterior  smaller,  and  a 
posterior  larger  root.  These  are  flat  bundles  of  fibres,  loosely  sur- 
rounded by  the  arachnoid,  which  pass  into  the  intervertebral  foram- 
ina, where  the  posterior  roots  form  a  swelling,  the  ganglion  inter- 
vertebrate,  and  emerge  from  the  spinal  canal,  the  two  roots  having 
united  to  form  a  common  round  trunk.  This  again  divides  after  its 
exit  from  the  canal  into  two  branches,  an  anterior  and  a  posterior. 
The  anterior,  usually  the  larger,  forms  numerous  anastomoses  with 
the  branches  above  and  below  it,  the  so-called  ansse,  which  are  col- 
lectively called  plexuses.  The  posterior,  smaller  nerves,  pass  back- 
ward between  the  transverse  processes  of  the  vertebrae,  and  are 
distributed  to  the  muscles  and  the  skin  of  the  back. 

Of  the  thirty-one  pairs  of  spinal  nerves,  there  are  eight  cervical, 
twelve  dorsal,  five  lumbar,  five  sacral,  and  one  coccygeal.  The  pos- 
terior as  well  as  the  anterior  branches  contain  fibres  from  both  roots. 
The  anterior  roots  are  motor  (Charles  Bell,  1811).  They  supply, 
besides  all  the  muscles  of  the  trunk  and  extremities,  the  unstriped 
muscles  of  the  iiUernal  organs  and  the  unstriped  muscles  of  the  ves- 
sels. The  posterior  roots  are  sensory,  but  we  should  keep  in  mind 
that  the  anterior  most  probably  contain,  besides  the  motor,  also  tro- 
phic and  secretory,  and  the  posterior  roots,  besides  the  sensory,  also 
fibres  for  the  reflexes  (cf.  also  Sass,  Deutsche  Med.-Ztg.,  1890,  12). 

The  peripheral  nerves,  just  as  the  cranial,  may  be  affected 
independently  or  secondarily,  and  as  the  result  of  some  pri- 
mary disease  in  other  parts.  In  cases  of  the  first  class  over- 
strain plays  an  important  rSle,  often  also,  as  we  have  seen  to 
be  the  case  in  diseases  of  the  cranial  nerves,  exposure  to  cold 
and  traumatism,  while  in  those  of  the  second  class  a  great  many 
factors  come  in,  more  especially  infections,  intoxications,  and 
general  cachesiae:  of  these  we  shall  speak  when  we  treat  of 
the  individual  nerves. 
330 


DISRASF..S  OF   TUB  PF.ttrPltKRAL  NERVES. 


331 


II  wc  inquire  into  the  anatomical  character  of  the  disease 
wc  shall  in  many  instances  have  to  admit  thai  wc  arc  unable 
tt)  find  any  anatomical  chanjrcs  whatever  in  the  affected  nerves. 
This  is  true  in  many  cases  o(  mild  neuralgias,  but  also  in  some 
o(  ihc  severe,  even  ol  the  severest,  types.  The  examination  ol 
pieces  of  the  irigeminus,  (or  instance,  which  were  cut  out 
where  a  resection  had  been  made  un  account  of  intolerable 
ptin  has  by  no  means  always  revealed  appreciable  changes  in 
the  nerve;  on  the  contrary,  this  has  on  microscopical,  as  well 
as  on  macroscopical,  examination  repeatedly  hccn  found  to  be 
abwlutcly  normal.  In  other  instances,  however,  an  inllamma- 
\v\n — i.  «..  a  neuritis — could  be  demonstrated  as  having  been 
Ihe  cause  ol  the  trouble.  In  such  cases  there  is  seen  in  the 
scute  stage  an  exudation  in  the  interslitial  tissue  and  an  abun- 
dant infiltration  of  the  same  with  round  cells,  a  condition  which 
gives  rise  to  a  swollen  and  o-dematous  appearance  of  the  nerve 
("purulent  neuritis ").  If  this  inDnmmalion  continues  fur  some 
time  the  process  goes  <m  to  degeneration,  under  the  influence 
ol  which  a  part  of  the  myelinc  sheath  is  destroyed  and  com- 
pound granular  corpuscles  are  formed.  The  axis  cylinders 
l^encrally  remain  for  some  time  intact.  In  some  bundles  there 
nay  be  found  nerve  fibres  completely  atrophied,  while  the 
ih^th  is  somewhat  thickened  and  irregularly  contracted,  pre- 
senting a  wavy  outline.  This  increase  and  condensation  of 
the  connective  tissue  makes  the  nerve  look  more  and  more 
like  a  cord  of  connective  tissue,  which  is  thinner  or  thicker 
than  normal  according  to  the  amount  of  the  newlv  former] 
tissue:  s^imetimes.  also,  it  is  in  places  irregularly  thickened 
(neuritis  nodosa).  The  pigment  deposits  found  have  to  be 
looked  upon  as  the  remains  of  previous  hemorrhages.  Even 
after  extensive  destruction  of  the  nerve  fibres  by  the  connect- 
ive tissue,  regeneration  is  to  a  certain  degree  possible,  as  the 
peripheral  nerves  possess  this  power  to  a  considerable  extent, 
a  point  which  is  ol  importance  for  the  prognosis.  According 
»  Ihe  advance  of  Ihe  process  is  centrifugal  or  centripetal  we 
•peak  of  a  descending  or  an  ascending  neuritis.  A  neuritis 
migrans  has  also  been  described.  If  the  process  occur  simuU 
taneously  at  different  places,  we  sjwak  of  a  multiple  or  a  di-S- 
Bcniinaled  neuritis  tl^yden.  Roth).  From  Ihe  researches  of 
Schcube  we  should  be  led  to  regard  the  so-called  beri-beri,  or 
kak-ke.  a  disease  ivhich  occurs  epidemically  in  Jnpan.  as  a 
multiple  neuritis.      In  very  chronic  cases  the  inflammatory' 


3J2 


0/SEAS£S  Of   Tim  SPINAL  NER%'ES. 


\ 


cbangcs  in  the  connective  tissue  are  so  slight  in  comparison  to 
the  degenerative  process  in  the  nerve  fibres  that  it  is  prefcra. 
ble  to  speak  in  those  cases  (as  Sirilmpcll  has  proposed)  of  a 
"primary  ciironic  degenerative  atrophy  of  the  ncn.'CS."  instead 
of  a  neuritis. 

The  symptoms  of  neuritis,  of  course,  vary  according  to  the 
position  and  the  (unction  of  the  affected  nerve,  as  we  snail  show 
in  the  following  pages.  The  symplomatolog>'  of  the  primary 
multiple  neuritis ^r  f.x<elUnce  we  shall  describe  later. 

The  periptienil  nerves  may  also  be  the  seat  of  neoplasms, 
which,  when  developing  in  them,  usually  start  from  the  connect. 
ive  tissue.  Only  rarely  do  they  consist  of  newly  formed  nerve 
fibres,  and  deserve  properly  to  be  called  neuromata;  much 
more  frequently  they  arc  fibromata,  which  may  be  found  as  ■ 
solitary  or  as  multiple  new  growths,  and  which  not  uncom- 
monly may  give  rise  to  thickenings  and  nodular  swellings, 
which  can  be  easily  demonstrated  and  felt  on  the  nerves.  Ex- 
tensive tumors,  where  numerous  nerve  trunks  are  united  by 
connective  tissue  into  a  compact  mass,  the  so-called  plexiform 
neuro-libromata,  are  rare.  Malignant  neoplasms,  carcinomata, 
and  sarcomata  of  the  peripheral  nerves  are  sometimes  met 
with.  That  here,  also,  the  symptoms  depend  on  the  seal  ol 
the  new  growth  is  self-evident  (c(,  Kniuse  on  Malignant  Ncuro-  J 
mata  and  the  Occurrence  of  Nerve  Fibres  in  them.  Volk-  * 
mann'sche  Sammltmg  klin.  VortrUge.  293.  294,  1887,  Deutsche 
Med..Zcitung.  1888,  No.  15). 

We  shall  first  speak  of  the  affections  of  the  motor  and  the 
sensory  nerves  which  innervate  the  muscles  of  the  extremities 
and  the  trunk,  and  certain  internal  organs  which  arc  not  con- 
nected with  the  cranial  nerves,  and  after  that  we  shall  turn  our 
attention  to  the  trophic,  the  vaso-motor,  and  the  secretory 
fibres  as  far  as  our  scanty  knowledge  on  these  points  will 
allow.  An  appendix  will  be  devoted  to  the  primary  aSections 
of  the  muscles  supplied  by  the  spinal  nerves. 

A.    DtSEASKS  OF  THE  MOTOR   KHm  SENSORY  NERVES. 
/.  Diseasts  of  the  CervUai  Ntnvs. 

Of  the  four  upper  (smaller)  cervical  nerves,  the  first,  which  is 
called  the  suboccipital,  emerges  between  the  occipital  bone  and  the 
atlas.  The  anterior  branches  of  these  four  form  the  plexus  known 
u  the  plexus  cervicaliti,  which  is  situateil  opjiosite  the  correspond- 


THE  CERVICAL  PLEXUS. 


333 


la{  renebne.  From  this  plexus  coric.  besides  (he  muscuUr  branchM 
to  the  scalenus,  the  tongas  colli,  etc.,  the  phrenic,  which  is  formed 
clucily  by  llie  fourth  cervical  nerve,  and  which  for  the  most  part  is 


'.  n-— DUoaUtMATIC  0UTt.l9CI  OF  THK  CUVICAL  AMO  BlUCHIkl,  PLKXVMS.      (AfUT 

ScirWAUH*.;  tV-F///,  root*  of  the  owlud  novo,  ll/ttl.  rnnu  o(  Oie  finrt  llire« 
ifitHl  Bcno.  /If,  pmcrlot  brMictt*-/,  ot  (be  mcddJ,  f^.  •'  ilw  ihlrd  nrrKal 
Mnc  I,  Miliriar  branch  orf  the  ftnl  oerrful  nem  and  loop  i>f  uiiiiin  wUh  ItM  «cand. 
)>  mhU  fMdptla)  noTtL  j,  great  auricular  narva.  j,.  twporfclal  arvical  nenc  .)n, 
liMwlllltialhH  tMiichca  to  tha  ifaacmidnia  nnni  from  th*  ncond  and  ihinl.  jX  fonl- 
■Mri(Mll(lothaBeca»iw1iu  from  Ibslhlnl  and  liiunh  ncmea.  4,  (upnKlaiinilAi  nrms. 
if  pkMMk  mtwn.  Brachial  |>laiu:  i'-V/lI.  anij  /) .  tba  file  raoti  lit  U"'  htacMal 
A"*-  5,  rbe»hBlcl  nam.  j,,  uipnaopular.  s„.  pcMerim  tboncic.  6,  ntm  lu  iha 
mUitIiu  mwKla.  ;,  7 .  inner  and  mjt«  anterior  thoracic  nnva,  \  B,.  R„.  (ufatcapa- 
hr  amv,.  JTC.  niMcakMniUMODii.  JV.  mediai)^  6*.  ulnar.  US.  muKuln^filial.  it, 
H',  nvrvr  tik  Wrutere.    r,  timmAn.    f .  ■;  InMeotal  oovta.    lA, 


*  aMor  nerve,  the  superficial  cervical,  (he  auricularis  magnus,  (he 
°ccifiit«lb  minor,  anil  several  commnnicating  branches  to  the  tipper 
Wtiral  |{angli(in  and  (he  ganelifnttn  plexus  of  the  vagus  f  I-'ig.  9.1), 
The  anterior  branches  uf  the  four  lower  (the  stouter)  cervical 


334 


i>/SSAS£S  OF  THE  SPINAL  liBRVES. 


nerves,  after  they  have  |iaK»cd  between  the  anterior  and  mtddte 
scalenus  and  have  reached  the  aupractavicutar  fnssa,  form,  in  ccmi- 
junctiod  wiih  the  anterior  bratich  of  the  first  dorsal  nerve,  the  so- 
called  brachial  or  subclavian  plexus,  which  may  be  divided  into  a 
smaller  or  supraclavicular  portion  situated  above,  and  a  larger  infra- 
clavicular portion  situated  below,  the  clavicle.  From  the  former  are 
given  off,  besides  the  suprascapular,  only  the  three  subscapular 
nerves,  the  anterior  and  posterior  thoracics,  and  the  rhomboid  nerve. 
The  larger  portion,  which  has  also  been  ciiUcil  the  axillary  plexu», 
furnishes  tlic  large  nerves  which  supply  the  entire  upper  extremity, 
the  circLimtlex  (axillaris),  the  median,  the  ulnar,  ihc  musculo-spiral 
{radial)  and  cutaneous  branches,  namely,  the  nerve  of  Wrisbcrg.  the 
iniernal,  and  the  {longest)  external  or  musculo-cutancous  nerve, 
which  has  also  been  called  pcrforans  Gasscri  {cf.  Knic,  lieilrag  xur 
Frage  der  Localisation  der  motonschen  Fasern  im  Plexus  brachia- 
tiK,  Inlemat.  kiln.  Kiind^chau.  1889,  14). 

Just  as  wc  have  seen  in  speaking  of  ihe  cranial  motor 
nerves— c.  g.,  the  oculo-molorius,  the  abduccns,  and  the  facial 
— the  motor  disturbances  of  the  spinal  nerves  may  be  of  a  I 
paralytii;  or  of  an  irritative  character.  In  the  former  case  the 
mobility  of  the  muscles  supplied  by  the  aflccled  »crvc  is  di- 
minishcd  (paresis)  or  completely  lost  (paralysis).  In  the  latter  I 
we  have  symptoms  of  motor  irritation  which  arc  not  under  the 
control  of  the  will,  the  so-called  spasms.  These  consist  cither 
of  transient  muscular  contractions  or  of  a  lasting  state  of  spas- 
modic contractinn  nf  one  or  of  several  muscles.  The  former 
we  call  clonic,  the  latter  tonic,  spasm. 

On  the  whole,  paralytic  symptoms  arc  much  more  common 
in  the  distribution  of  these  plexuses  than  symptoms  of  irritation. 

In  Ihe  sensory  disturbances  wc  can  equally  distinguish 
paralytic  from  irritative  conditions,  the  former  giving  rise  to 
anxsthesia,  the  latter  to  hyperesthesia.  The  anaesthesia  is 
characlerij-ed  by  the  fact  that  external  (mechanical,  chemical, 
or  thermic)  stimuli  arc  cither  not  perceived  .it  all  or  with  di> 
minishcd  acuteness,  whereas  in  hyperesthesia,  on  the  contrary, 
even  very  weak  stimuli  are  felt  to  be  abnormally  strong  and 
unpl&isant.  The  latter  condition  is  usually  attended  with 
symptoms  of  sensory  irritation,  manifested  by  pronounced 
pains  or  by  parxslhesias — that  is,  abnormal  sensations  of  prick- 
ing, formication,  numbness,  or  a  "  furry  feeling." 

The  affections  of  the  sensory  fibres  of  the  spinal  ncrs*es 
manifest  themselves  chiefly  by  symptoms  of  iirilalion.     They 


THE  BRACHIAL   PLEXUS. 


335 


are  always  associated  with  more  or  less  pain  and  are  called 
neuralgias.  That  these  also  occur  in  the  cranial  nerves  has 
already  been  stated,  and  the  trigeminal  neuralgia  (cf.  page  68) 
may  be  taken  as  a  type  of  them.  The  neuralgic  pains  are 
usually  very  violent,  but  are  rarely  or  never  constant.  They 
appear  periodically  and  follow  fairly  accurately  the  distribu- 
tion of  the  afiected  nerve.  The  diagnosis  is  rarely  difRcult. 
Peripheral  anaesthesias — that  is,  such  as  are  only  due  to  affec- 
tions of  the  peripheral  nerves  or  their  end  organs — are,  as  we 
said,  rare. 


CHAPTKR  1. 


LRillONS  OP   THE   CERVICAL   PLRXUS. 


Thk  cervical  plexus  is.  on  the  whole,  much  less  frequently 
aflccted  wilh  motor  disturbances  than  the  brachial.  Among 
the  nerves  belonging  to  it,  it  is  the  phrenic  more  especially 
which  may  present  symptoms  ol  paralysis  or  ot  irritation  :  yet 
neither  paralysis  nor  spasm  of  the  diaphragm  due  to  disease  ol 
the  phrenic  is  of  any  great  practical  importance,  since  such  an 
aflection  scarcely  ever  occurs  by  itself,  but  is  much  more  often 
met  with  only  when  associated  wilh  other  diseases,  Paralysis, 
for  instance,  is  observed  in  the  course  of  progressive  muscuKir 
atrophy,  in  hysteria,  probably  also  in  lead  poisoning.  Trauma- 
tism or  mechanical  compression  produced  by  tumors  or  ab- 
scesses in  the  neck  may  be  tht-  cause.  Recently  it  has  also 
been  observed  in  tabes  (Berliner  klin.  Wochenschr.,  1893, 
xvi).  Among  the  signs  of  paralysis  of  the  diaphnigm  there  is 
one  which  is  very  conspicuous,  n-imcly,  the  faulty  expansion 
in  the  epigastric  region  during  inspiration.  Instead  of  becom. 
ing  prominent,  as  is  the  case  in  the  normal  condition,  the  cpi- 
guslriutii  is  drawn  in.  and  when  we  lay  our  hand  on  it  we  can 
feel  that  the  diaphragm  does  not  descend.  If  only  one  of  the 
phrenic  nerves  is  thus  allccied  this  phenomenon  is  present  only 
on  one  side,  while  the  other  half  of  the  diaphragm  performs 
its  function  prupcrly.  Besides  this,  hardly  any  other  symp- 
toms arc  observed  in  uncomplicated  cases  if  the  patient  remains 
at  rest,  whereas  if  he  exerts  himself  a  distinct  dyspnnea  and  an 
increase  in  the  frequency  of  the  respirations  become  tipparent. 
The  obstinate  constipation  which  such  patients  compl.'^in  of 
can  well  be  understood  if  we  remember  the  part  which  the 
diaphragm  takes  in  the  abdominal  pressure. 

8p.ism  of  the  diaphrnj^m.  at  least  the  tonic  form  of  it.  is  not 
more  common  than  paralysis.  Patients  aflccted  with  this  suffer 
from  great  shortness  of  breath  and  quickly  become  cyunoscd. 
330 


LSS/OJVS  Of   THE  CERi'lCAL   PLEXUS. 


n? 


Bcoti 


The  markedly  prominent  epi^slrium  remains  with  the  dia- 
phragm immobile  and  is  tender  to  the  touch,  and  only  the 
upper  part  of  the  thorax  shows  shallow  rcspimlory  movements, 
1(1  some  cases  of  tetanus,  tonic  spasm  of  the  diaphragm  seems 
to  be  the  cause  of  death.  It  occurs  almost  never  by  itself  with- 
out some  accompanying  or  underlying  alTcclion.  except  in  hys- 
terical persons.  On  the  other  hand,  the  clonic  form  of  the 
spasm,  the  so-called  hiccough  (singultus),  is  extremely  common. 
Everybody  is  familiar  with  the  short  clonic  movements  of  the 
diaphragm,  which  are  accompanied  by  inspiratory  sounds  and 
hich  vary  in  frequency  and  severity,  occurring  sometimes  in 
ch  rapid  succession  that  eighty  or  even  a  hundred  may  be 
tinted  in  one  minute.  Severe  protracted  hiccough  may  be- 
come very  troublesome,  indeed,  even  dangerous,  if  sleep  is  for 
a  long  time  seriously  interfered  with.  This  is,  however,  only 
the  case  if  singultus  occurs  as  a  symptom  in  the  course  of 
other  diseases — e.  g.,  in  apoplexy,  in  peritonitis,  in  chronic  gas- 
tric catarrh,  etc.  Even  when  it  appears  as  a  reflex  neurosis— 
e.  g.,  in  the  course  of  a  chronic  gastro-ententis — it  may  cause 
a  great  deal  of  trouble  to  the  piiticnt  (Dcbio,  Berliner  klin. 
Wochenschrift,  1889,  33).  As  a  rule  it  is  arrested  without  any 
interference  on  the  part  of  the  physician  by  popular  methods, 
&uch  as  holding  the  breath,  closing  the  glottis  and  then  at- 
tempting an  expiration. 

Therapeutics  is  almost  powerless  in  the  f.tce  of  affections 
of  the  motor  hbrcs  of  the  phrenic.  In  paralysis,  electrical 
itimulation  of  the  nerve,  in  the  (tonic)  spasm,  chloroform  and 
morphine,  have  been  recommended  :  yet  these  measures  are  by 
no  means  reliable. 

The  sensory  fibres  which  the  phrenic  takes  up  in  its  course, 
and  which  arc  distributed  to  the  pleura,  the  pericardium. and 
the  pcritonfcum,  may  also  be  affected.  Neuralgia  of  the 
phrenic  is  rare,  or  perhaps  we  had  better  say  is  undoubtedly 
but  rarely  recognized.  The  pains,  starting  at  the  base  of  the 
thoTVi  at  the  puinis  corresponding  to  the  insertions  of  the 
diaphragm  and  radiating  in  all  directions,  arc  taken  for  rheu- 
matism of  the  chest  muscles  or  intercostal  neuralgia,  and  it  i» 
odIv  in  cases  10  which  the  pain  is  felt  directly  over  the  scalenus 
I  Mticus  and  corresponds  to  the  course  of  the  nerve  that  the 
^B  liiagQosis  is  made  correctly.  Valleix's  painful  points  can  occa- 
^m  tionally  be  demonstrated  on  the  spinous  processes  of  the 
^^jiiuuer  cervical  vertcbrse  and  at  the  points  of  insertion  of  the 


J38  DtSe.ASBS  OF  Tlie  SPISAl.  HERVES,  ^ 

dupliragm.  Respiration  is  interfered  wilh  only  witen  the  mo- 
biliiy  ol  the  diaphragm  is  at  the  same  time  impaired. 

The  JCliology  o(  the  disease  is  obscure  ;  more  especially  are 
wc  ignorant  of  the  conditions  under  which  it  may  occur  in- 
dependently. It  seems  not  to  be  a  rare  accompaniment  of 
Graves'  disease,  of  angina  pectoris,  and  of  sclerosis  of  the 
coronary  arteries. 

Another  apparently  more  important  neuralgia  in  the  region 
of  the  cervical  plexus  is  the  occipital  or  cervico-occipilai  neu- 
ralgia, which  alt.icks  by  preference  the  occipitalis  major,  but 
also  the  minor,  further  the  auricularis  miignus,  the  subcutancus 
colli  and  the  tympanic  nerve  or  plexus,  which  belong  to  the 
glosso-pharyngeal  nerve  (Jacobson's  anastomosis).  The  pa- 
tients complain  of  pain  in  the  whole  occipital  region,  in  the 
neck,  often,  too.  in  the  cars.  Much  more  rarely  the  pain  radi- 
ates in  a  forward  direction  to  the  cheek  and  the  lower  jaw. 
The  so-called  otalgia  nervosa  may  give  rise  to  such  cxcruciat- 
ting  pains  that  the  patient's  consciousness  may  become  clouded 
(Gompcrtz,  Centralbiatt  (.  d,  ges.  Therap.,  1890,  Hcfi  5),  and 
very  severe  pains  may  also  be  produced  by  an  affection  of  the 
tympanic  plexus.  In  such  cases  it  is  important  to  examine  for 
ulceration  around  a  tooth  or  in  the  tarynx.  Such  patients 
dread  every  motion  of  the  head,  and  carefully  avoid  every 
cause  for  laughing,  as  this,  as  well  as  sneezing,  chewing,  and  so 
forth,  is  liable  to  bring  on  an  attack.  The  consequent  rigid 
position  of  the  neck  is  quite  characteristic  for  this  form  of  neu- 
ralgia. Painful  points  can  sometimes  be  found  at  the  exit  of 
the  occipitalis  major — that  is,  about  halfway  between  the  mas- 
toid process  and  the  spinous  processes  o(  the  cervical  vertcbrec. 
Where  they  are  absent  the  disease  may  be  conlounded  with 
torticollis  rheumatica:  yet  such  a  mistake  may  be  avoided  by 
remembering  that  the  neuralgia  is  not  constant,  but  char.icter- 
ized  by  intervals  of  perfect  ease. 

The  course  of  an  occipital  neuralgia  is  often  tedious,  but 
on  the  whole  it  is  not  unfavorable,  and  complete  cures  are 
not  rare.  The  prognosis  is  bad  only  when  there  exists  some 
organic  lesion  of  the  nerve,  caused,  for  instance,  by  disease  of 
the  cervical  venebrjc.  If,  as  is  usually  the  case,  no  definite 
cause  can  he  found,  cncrgciic  countt-rirrilation  to  the  skin. 
local  bleeding,  galvanisation,  the  application  of  moist  or  dry 
heal,  or  the  use  of  nnlipyrin  or  phenacetin,  will  usually  effect 
a  cure  or  at  least  an  improvement.     Subcutaneous  injections 


I 
* 

I 
I 

I 


I 

I 


LESIONS  OF   THE  CERVICAL   PLEXUS. 


339 


of  morphine  we  shall  probably  in  most  cases  be  able  to  dis< 
pense  with.  The  removal  of  every  deleterious  cause  should, 
of  course,  be  insisted  upon.  Under  certain  circumstances  the 
occupation  has  something  to  do  with  it.  Thus,  I  have  found 
that  the  stevedores  of  the  London  docks,  who  carry  extremely 
heavy  weights  on  their  backs  which  press  upon  the  neck  and 
the  occiput,  arc  frequently  subject  to  occipital  neuralgia  (cf. 
Hirt,  Krankheiten  der  Arbeiter,  iv,  91). 


CHAPTER  11. 

LESIONS   OF   TKE   SKACMIAL    PLCXOS. 

The  brachial  plexus  may  be  diseased  in  its  supra-  or  infra- 
clavicular portion.  Tbe  affections  of  the  latter,  undoubtedly 
the  more  frequent,  are  of  greater  practical  importance  than 
those  of  the  former. 

Here,  too,  the  motor  disturbances  are  more  prevalent,  sen- 
sory disturbances  in  the  region  of  the  brachial  plexus,  espe- 
cially neuralgias,  being  decidedly  exceptional.  In  a  case  re- 
ported by  Stern  (Berliner  klin.  Wochenschr.,  1S91,  46).  the 
compression  exerted  by  a  bandage  had  produced  an  affection 
of  the  whole  brachial  plexus,  with  consequent  arrest  in  growth 
and  extensive  atrophic  paralysis. 

In  the  supraclavicular  portion,  the  posterior  thoracic — 
which,  coming  from  the  fifth  and  sixth  cervical  nerves,  supplies 
the  serratus  magnus — is  affected  in  an  interesting  and  very 
striking  manner. 

The  so-called  serratus  paralysis  is  quite  frequently  due  to 
the  calling  of  the  patient,  as  certain  occupations  seem  particu- 
larly to  predispose  to  it.  If  prolonged  pressure  is  frequently 
exerted  on  the  nerve — as,  for  instance,  is  the  case  in  people 
who  carry  heavy  loads  on  their  shoulders,  or  if  the  shoulder 
muscles,  especially  the  serratus,  are  overexerted,  as  happens, 
for  instance,  in  mowing,  in  certain  manipulations  of  tailors, 
shoemakers,  etc. — the  paralysis  has  been  known  to  develop 
rapidly.  Occasionally  such  a:tiological  factors  are  alssent,  and 
we  are  forced  to  fall  back  upon  the  still  obscure  influence  of 
what  is  called  "  catching  cold." 

The  condition  is  quite  characteristic  whether  the  arm  be  in 
a  state  of  motion  or  at  rest.  In  the  latter  position  the  scapula 
appears  elevated  and  approaches  with  its  lower  angle  the  ver- 
tebral column  more  than  normally,  the  inner  median  margin 
having  an  oblique  upward  and  outward  direction.  The  cause 
340 


LESfOXS  Of   THH  HKAaHAL  PLEXUS. 


341 


ol  this  deformity  is  to  be  sought  in  the  overaction  of  the  an- 
tagonists— the  rhomboids,  the  levator  anguli  scapula:,  and  the 
trapezius  (Fig.  94>.  On  moving  the  arm,  the  palienl,  we  imd. 
can  raise  tt  only  to  the  horizontal  position,  owing  to  the  ab- 
sence of  the  action  ot  the  serratus.  which  pushes  the  scapula  lor< 
ward.     As  soon  as  we  produce  artificially  the  action  of  this 


Flc.9^^C*M  or  Rraitr-nDtK  Sekhitvs  I'akalvsu  ik  a  Mam  TiiiitTV-rtvc  Vmu 
iw  Aac    Pertka  n(ihcKaf«U»lili  the  jumlianipiii;  down.    >Afi«r  tlKiiiKimr.) 

muscle  by  fixing  the  shoulder  blade  and  pushing  it  forward, 
complete  elevation  o(  the  arm  is  possible.  If  the  patient  al- 
Icmpts  this  s.imc  motion  himst-U  the  scapula  is  approached  to 
the  spinal  column.  If  the  arm  is  raised  in  front  of  the  chest 
the  inner  ed^c  o(  ihe  scapula  is  elevated  and  stands  ofl  from 
Ihc  thorax  in  a  wiiiglike  fashion,  so  that  wc  arc  able  to  touch 
the  inner  surface  o(  llie  bone  (Fig.  9i).     Besides  a  moderate 


34J 


DISEASES  OF  THE  SPIXAL  KRKVES. 


impairment  in  adduction,  which  sumewhat  interferes  with  ihc 
folding  of  the  arms  across  the  chest,  there  are  no  other  abnortni< 
ties  to  be  mentioned.  Espcciully  is  it  to  be  noted  that  there 
are  no  decided  sensory  changes  lo  be  perceived  in  a  pure  scr- 
ratus  paralysis.  As  this  affection  is  not  rarely  met  with  in  the 
course  of  progressive  miisciikir  atrophy — sometimes  this  dis- 


Fie.  «s-— Thb  mhk  Cue  WITH  T«e  Amu  habbo. 

ease  begins  with  a  serratus  paralysis — it  is  not  to  be  wondered 
at  that  the  muscle  at  fault  is  suiiietimes  found  to  l>e  wasted.  In 
the  traumatic  paralysis  the  atrophy  comes  on  very  late — many 
years  after  the  traumatism.  The  muscle  remains  intact,  elec- 
trical reactions  arc  normal— reaction  of  degeneration  being  by 
no  means  always  demonstrable — and  yet  there  is  no  improve, 
ment.     The  prognosis,  on  the  whole,  is  bad  ;  the  disease  even 


l£S/0/ifS  OF  THE  BRACHIAL  tLEXVS. 


343 


I 


ja  Lhc  most  favorable  cases  is  of  very  long  duration,  and  may 
lor  weeks,  months,  or  years.  Often  it  is  not  curable  at  all, 
Uid  the  patient  is,  :is  it  were,  maimed  (or  the  rest  ol  hi&  days. 

Not  too  much  hope  m\%\\\  lo  be  placed  in  the  electrical 
treatment,  no  matter  in  what  form  electricity  be  etnploycd  :  in 
grave  cases,  at  least,  such  hopes  :ire  doomed  to  disappointment. 

The  paralyses  o(  the  pcctoralis  miijor  and  minor  (^interior 
thoracic  nerves),  of  the  rhomboidci  and  the  levator  anguli 
scapula?  (muscular  branches  from  the  third,  fourth,  and  fifth 
cervical  nerves),  of  the   liiti^simus  dorsi.  subscapularis,  and 


ne-  «fik— PMmoti  or  tui  Hkau  in  Spaui  or  tmk  Sruwivti  Catitis  oh  tkb 

Rkiit  Si  DC. 

teres  major  (subscapular  nerves),  finally,  those  ol  the  siipra- 
»p(natus  and  infraspinatus  (suprascapular  nerve),  have  by  them- 
selves no  practical  im|K)rtance,  alrhoiigh  isolated  aScctions  of 
the  last  nerve  have,  of   late  especially,  been  repeatedly  ob- 
■enred.    Thus  Bernhardt  has  reported  an  instance  ocairrinf^ 
.after  coniusiun  of  the  shoulder  joint  (Krlcnmcycr's  Cent ralbl. 
li.  Nervenhcilk..  18R9.  7):  F.  Sohulze.  11  case  in  which  ilic  atTec- 
rtion  was  produced  during  birth  (Arch.  f.  GynUc,  1SS8,  3): 
[.Sperling,  one  in   which,  after  neuritis  of   the  whole  brachial 
lus,  an  improvement  took  place  in  all  branches  except  the 


344 


D/S£AS£S  OF  TUB  SFINAL  NE/fVES. 


suprascapular  (Neurol.  Ccntralblatt,  1890,  10):  finally,  Hcuzler 
has  reported  a  case  in  which  he  fourd  atrophy  of  the  muscles 
supplied  by  this  nerve  ([)cut!U:he  mcd.  Wochciischrift,  1890.  51). 

Spasms  ot  the  muscles  cuncenicd  here  are  also  unusual.  A 
characteristic  position  of  the  head  is  evoked  by  a  unilateral 
spasm  of  the  spleiiius  capitis  (Fig.  96).  Bilateral  spasm  of  the 
deep  muscles  of  the  neck  produces  a  strong  retraction  of  the 
head,  while  spasm  of  the  rhomboids  alters  the  position  of  the 
shoulder  blades,  etc. 

Of  the  ner^'es  belonging  to  the  infraclavicular  portion  o( 
the  brachial  plexus  none  is  so  frequently  the  seat  of  disease  as 
the  continuation  of  the  posterior  irunlc  of  the  plexus,  which 
becomes  the  musculo-spiral  or  rndial  nerve,  and  supplies  the 
skin  and  the  muscles  of  the  extensor  surface  of  the  arm. 


Fie-  97-— Ml)*CVUO-«PIBAL  PAKALVnS. 


The  musculo-spiral  paralysis  can  better  than  any  other  form 
be  recognized  at  a  glance.  A  patient  with  paralysis  of  the 
extensors  is  unable  on  stretching  out  the  arm  to  raise  the  hand, 
while  lateral  motion  is  diflicult.  Dorsal  flexion,  which  is  per- 
formed by  the  extensor  carpi  radialis  and  the  extensor  carpi 
iilnarts.  is  impossible,  abduction  and  adduction  difficult,  the 
hand  hangs  down  flaccidly  ("  wrist-drop."  cf.  Fig,  97).  and 
when  rested  upon  the  table  can  not  be  raised.  On  a  more 
careful  examination  it  is  noticed  that  the  first  phalanx  of  the 
fiexi^d  (iiigers  can  not  be  extended  without  assistance,  but  that 
if  this  phalanx  is  passively  extended  the  patient  cart  straighten 
out  the  others  himself.  The  first  condition  is  due  to  ihc  paraly- 
sis of  the  extensors,  which,  as  is  well   known,  on  the  dor 


% 


LESIOMS  OF  TUB  BRACHIAL  PLEXUS. 


34S 


I 


surlaccof  ttie  first  phalanx  pass  into  an  aponeurosis:  the  sec- 
ond to  the  preservation  of  the  function  of  the  interossei,  which 
arc  Mipplicd  by  ihc  ulnar  nerve.  Since  its  extensors  arc  »Iso 
implicated,  ihe  thumb,  of  course,  can  not  be  actively  extended. 
Dcilhcr  can  it  be  abducted,  because  the  muscles  concerned  are 
alfto  paralyzfd.  Some  intercslint;  conditions  will  be  found  on 
examination  of  the  forearm  in  extension  and  flexion.  If,  for 
instance,  the  forearm  is  extended  and  pronated,  supination  is 
impossible,  because  the  supinator  brcvis  is  paralyzed.  During 
Bexion  of  the  forearm,  however,  the  biceps,  which  is  intact, 
can  perform  supination  without  difficulty.  If  the  forearm  is 
in  A  position  of  supination  it  is  easily  flexed  by  the  intact 
muscles,  the  biceps  and  the  brachialis  anticus,  while  if  it  is 
half  pronated  flexion  is  imperfect,  owing  to  the  paralysis  of 
Ihc  supinator  longus.  The  characteristic  prominence  formed 
by  the  belly  of  this  muscle  when  the  forearm  is  Hexed  is  abso* 
lutely  wanting.  Any  participation  of  the  triceps  in  the  paral- 
ysis is  only  observed  if  the  lesion  js  high  up  {"  crutch  palsy  "). . 
Usually  the  injury  is  situated  where  the  nerve  turns  over  the 
humerus  or  lower  down,  in  which  case  naturally  the  normal 
lunctinn  of  the  triceps  is  not  interfered  with.  Isolated  paral- 
^^is  of  the  triceps  is  very  rare :  a  case  of  this  kind  has  been 
published  by  Oppenheim  (Rerlin.  klin.  Wochcnschr.,  1S89.  44). 
The  patient  was  a  weaver,  and  the  aflection  was  regarded  as 
having  been  due  to  his  occupation.  Permanent  trophic  dis- 
turbances, shown  by  pronounced  wasting  of  the  affected  mus- 
cles, are  rare  in  ca.ses  of  pressure  paralysis,  while  they  arc  fre- 
quent in  the  paralysis  developed  as  n  consequence  and  in  the 
course  of  lead  poisoning. 

The  flexors,  otherwise  perfectly  healthy,  also  become  weak- 
ened, because  ihcir  points  of  insertion  arc  approximated  to  Ihc 
points  of  origin  more  closely  than  under  normal  conditions,  on 
account  of  the  constant  drooping  of  the  hand,  and  hence  Ihe 
interference  with  motion  is  ag^ra\Tited.  The  patient  can 
hardly  use  the  hand  at  all ;  he  is  unable  to  lake  hold  of  any- 
thing, the  finer  manipulations  necessary  for  writing,  drawing, 
etc.  arc  impossible,  and  in  the  majority  of  cases  he  is  unfit  for 
work  or  for  making  a  living  during  the  whole  course  of  the 
disease. 

Sensory  changes  are  rarely  sufliciently  marked  lo  add  much 
to  his  troubles.  Sometimes  parivsllirsi.i.s  may  be  complained 
of — a  feeling  of  cold,  numbness,  furmicatioD,  and  the  like; 


346  DISEASES  OF  THE  SPINAL  NERVE&. 

sometimes,  also,  there  is  a  distinct  decrease  of  sensibility,  so 
that  zones  of  anaesthesia  can  be  made  out.  Pagenstecher  has 
published  the  results  of  his  study  of  these  conditions  in  an 
article  (Arch.  f.  Psych.,  1892,  xxiii,  3,  p.  838),  in  which  will  also 
be  found  a  careful  collection  of  references  to  the  literature. 
On  the  other  hand,  a  source  of  great  annoyance  is  found  in 
the  peculiar  painless  swellings  of  the  extensor  tendons  on  the 
back  of  the  hand.  These  node-like  swellings  have  been  de- 
scribed by  Gubler  as  tenosynovitis  hypertrophica,  and  are  to 
be  attributed  to  mechanical  influences  acting  injuriously  on  the 
tendon. 

The  duration  and  course  of  a  musculo-spiral  paralysis  may 
vary  greatly,  and  it  is  often  hard  to  give  an  opinion  on  these 
points  at  the  very  onset  of  the  affection.  An  electrical  exami- 
nation, which  reveals  the  reactions  of  the  muscles  and  nerves 
to  the  faradic  and  galvanic  current,  is  the  only  means  by  which 
we  can  arrive  at  an  opinion  as  to  the  duration  of  the  disease. 
.  The  conditions  are  the  same  as  those  we  described  as  existing 
in  facial  paralysis,  and  it  suffices,  therefore,  to  refer  the  reader 
to  that  chapter.  But  here  again  be  it  stated,  a  prognosis  should 
never  be  given  without  a  previous  electrical  examination  of 
nerves  and  muscles. 

The  aetiology  of  musculo-spiral  paralysis  is  interesting  from 
the  fact  that  it  is  fairly  well  understood.  While,  as  all  con- 
fess,  the  cause  of  most  nervous  diseases  is  absolutely  unknown, 
and  we  therefore  are  forced  to  fall  back  on  uncertain  explana- 
tions, such  as  exposure  to  cold,  it  seems,  according  to  our 
present  knowledge,  that  musculo-spiral  paralysis  always  can 
be  traced  back  to  one  or  two  kinds  of  causes,  viz.,  mechanical 
or  chemical.  There  are  quite  a  number  of  lesions  due  to 
mechanical  or  traumatic  causes.  Frequently  a  man,  when 
greatly  fatigued,  drunk,  or  exhausted,  goes  to  sleep,  using  his 
arm,  usually  the  left,  as  a  support  for  his  head ;  the  latter, 
pressing  on  the  nerve  in  the  lower  third  of  the  humerus,  gives 
rise  to  an  injury  in  a  relatively  short  time,  or  the  arm  support- 
ing the  head  of  the  sleeper  may  press  with  its  outer  side 
against  a  chair  or  the  like  and  a  paralysis  be  the  result.  This 
is  the  so-called  "  sleep  palsy."  Next  we  have  compression 
happening  to  the  patient  as  a  consequence  of  his  daily  occu- 
pation, due  to  pressure  from  ropes,  handles  o(  water-jars  (as 
in  the  water- carriers'  paralysis  of  Rennes),  etc.;  sometimes 
in   infants  this  paralysis  occurs  from  too  much  compression 


ISS/OXS  OF  TUB  BKACHIAL  PLEXUS. 


347 


» 


on  the  arms  by  loo  tight  swathing-clmhcs:  iiomclimcs  too 
tight  plastcr-ol-Paris  l^ndagcs  have  been  the  cause:  and, 
fiiutlty,  ^11  clirccl  injuries  to  the  nerve — stab  wounds,  blows, 
gunshot  wniiiids,  anil  coiiipressioii  ol  the  nerve  b)'  iibnurmu) 
callus  formation  alter  fracture  of  Ihc  humerus — must  also  be 
mentioned. 

The  lesions  due  to  chemical  causes  may  be  the  result  of  the 
action  of  certain  poisons,  among  which  lead  deserves  to  be 
mentioned  first.  It  is  a  fact  no  less  remarkable  than  well  au- 
ihenlicated,  to  which  we  shall  again   refer  when  speaking  of 

tiead  poisoning  in  general,  that  this  agent  acts  by  preference 
: 


li.  mUnaar  t*fpi  r«^atit  inriar 
It.  atifti^t  4ifitoram  Mmmmw 
Jf.  nUnaar  miitimt  Jif/iti 
M.  olMwr  nutisii 

tl.  ttttntor  irrvu  yoUieU 
M.  ralntwr  ttuwiit 
l>al>M» 


.V<rnu  BiiunAi-ftitrvni 
il.  wMuw  lai^ 


y\f.  gK-HOTOtl  PMim  or  TKL  UiKULO-aniUt.  Nrmvx  anu  tiu  Mutcuu 
>ui-i-tut>  mr  (T. 


on  the  muscle!)  which  arc  supplied  by  the  musculo-spiral  nerve. 
This  muscuIo-«piral  paralysis,  however,  unlike  the  form  which 
is  produced  by  mechanical  action,  is  not  an  inde|K-ndent  dis> 
caM.  but  merely  a  symptom  of  a  general  intoxication.  Accord* 
iog  to  (he  commonly  received  opinion  (Leyden  and  others),  the 
(jaralvMs  de|}ends  upon  a  degenerative  atrophy  of  the  motor 
peripheral  nerve  fibres,  to  which  is  often  superadded  a  spinal 
affection.  It  differs  in  its  clinical  aspect  from  the  mechanical 
legion,  inasmuch  as  the  supinator  longus  and  the  triceps  remain 
intact.  Of  late  years  several  cases  have  been  published  where, 
after  subcutaneous  injections  of  ether  into  the  extensor  surface 
of  the  forearm  (or  tlierapetiric  purposes,  a  musculo-spiral  pa- 
ralytta  appeared  (Kalkenheini.  Aruoxan.  Kcniak,  1 1.  Ncuniaim, 


348 


DISEASES  OF   THE   SPINAL  NERVES. 


cf.  lit.).     In  using  the  drug  in  this  way  this  possibility  ought  to 
be  thought  o/. 

In  contradistinction  to  the  frequency  with  which  paralysis 
is  found,  signs  of  irritation  in  the  distribution  of  the  musculo- 


\-riH 


lOtM 

Fig.  1)9.  Fig.  loa 

The  Distribution  of  the  Cutaneous  Nerves  or  the  Arm  and  Hand.  (After 
ErctiHORST. )  Fi^.  99,  volar  suj-far^  of  the  u^^wr  extremity,  ijf ,  supradavicular  ntrve. 
■iax,  circumflu  nerve,  ymd,  internal  cutaneous  Derve.  4^/,  eitemaJ  culajieous  nerve, 
Si-m.  cutaneous  medius.  (mr,  median  nerve.  7h,  ulnar  nerve.  Fig.  100.  ise.  supra- 
clavicular nerve,  xax.  ciicuraflex  nerve,  yps.  superior  posterior  cutaneous  nerve. 
ScP',  inferior  posterior  cutaneous  nerve,  *riiid,  inlemaJ  cutaneous  nerve.  6i-*i,  median 
cutaneous  nerve.  7c/,  eitemal  cutaneous  nerve,  Sii,  ulnar  nerve,  gra,  musculo^piial 
nerve,     lante,  median  nerve. 

Spiral  nerve — that  is,  spasms — are  extremely  rare.  They  have 
been  observed  most  often  after  manual  overexertion — gymnas- 
tics, etc.  (Hochhaus,  Deutsches  med.  Wochenschr,,  1886,4;: 
Laqueur,  xiv.  Wanderversammlung  der  siidwestdeutschen  Neu- 
rologen,  Arch,  f.  Psych.,  1889,  xxi,  2,  p.  660). 

In  the  treatment,  electricity  not  only  plays  the  chief,  but  the 
only  r^/e.  From  the  motor  points  (Fig,  98)  the  muscles  ought 
to  be  stimulated  with  the  constant  current,  and,  besides  this, 


/.£S/OyS  OF  THE  HRACHIAL  FLEXVS. 


J49 


i 


frequent  extensive  applications  ol  the  laradic  brush  tu  the  skin 
nl  ihe  afTecicd  arm  ought  to  be  practiced.  That  the  cause,  il 
such  should  be  present — (or  instance,  pressure  o(  crutches,  o( 
dislocated  bones,  etc, — ought  to  be  removed,  is  self-evident. 
Hcusner( Barmen)  demonstrated  before  the  Association  of  Nntu- 
ralists  in  Halle  |i.S<)t)  an  apparatus  by  means  of  which  the 
ftction  of  the  extensors  is  replaced  by  rubber  cords;  this  appa- 
ratus has  proved  to  be  satisfactorj^.  The  sensory  disturbances 
which  may  be  found  in  the  distribution  of  the  musculo-spiral 
we  shall  mention  when  considering  ccrvico-brachiul  neuralgia. 
The  mode  of  distribution  of  the  cu- 
taneous nerves  of  the  upper  extrem- 
ity is  illustrated  in  Figs.  99.  100,  101. 

The  median  and  ulnar  nerves  supply 
lofEcthcr  the  innervation  of  the  museleft 
and  the  skin  of  the  inside  of  the  fore- 
arm and  the  hand,  the  former  innervating 
alno*t  at)  the  ITcxorb  of  the  forearm,  the 
pronator  radn  teres,  and  the  pronittor 
quadraius,  the  ftexor  carpi  radiali»,  the 
Dcxor  sublimis  digilorum,  and  a  part  uf 
Ihe  profundus,  leaving  the  Hcior  carpi 
alnarit  to  the  ulnar.  Amung  the  thenar 
muiiclcit  the  median  nupplics  the  abduc- 
tor brevis,  the  opponent,  the  outer  head 
of  ih«  flexor  brevis,  further,  the  first 
three  lumbncalcs.  while  it  again  leaves 

to  the  ulnar,  besides  the  one  flexor  mentioned,  the  antichcnar,  the 
adductor  brevis  pollicis.  the  deeper  head  of  the  Hcxur  brevis  pollicis, 
the  fourth  tumhrtcatis,  and  all  the  interos^ci. 

Both  nerves  have  this  in  common:  that  they  only  rarely 
become  a0ectcd  by  thetnsclves.  much  more  rarely  than  the 
musculo-Kpiral,  and  that  they  arc,  unlike  the  latter  nerve,  liable 
10  disturbances  not  only  in  their  motor  but  also  in  their  sensory 
fibrc».  We  shall  have  to  speak,  therefore,  not  only  of  paral- 
yses, but  also  ot  neuralgias.  With  regard  10  the  sciiology.  we 
may  cotuider  it  as  the  rule,  just  as  in  musculo-spiral  paralysis, 
thai  motor  disturbances  only  occur  as  a  consequence  of  me- 
chanical injury,  provided  there  be  no  other  disease  present  — 
e.  g..  progressive  muscular  atrophy  and  the  like ;  while  neural- 
pas  may  appear  under  other  circumstances — e.  g.,  after  acute 
dtaeaaes,  after  exposure  to  cold,  sometimes  also  without  any 


FfK-  Kii.— DHraiRnHKn  or  thk 
SBmoHT  NCHVUoit  Tiir.  UtcK 

or     TKK     KlHOaiU     iKHAL'MII. 

r.  nnuculi>«pir>l  iwrvc.    m,  ul* 
Dar  ntrvc    m,  locdiui  iwrrc 


350 


I>/SEASES  Of   TtiS  Sl'INAL   NEKl'ES. 


demonstrable  cause.  The  ulnar  paralysis  may  be  caused  bjr 
certain  occupations,  as  Duchcnne  has  already  observed  re. 
peatcdiy  in  workingmen  who  arc  obliged  to  press  the  elbow 


Pig.    (Oa.      HVTOK  PCIIKTS  or   TKr    MeUIAK   NSHVE  and  THt:   Ml-^CLEt  •UI'TIJSD  kV  IT. 

firmly  upon  a  hard  surface.     It  is  not  a  rare  occurrence  in 
Those  who  have  to  use  the  ulnar  side  ol  the  hand— hypothcnar 
eminence — a  great  deal  to  strike  certain  instruments  (cabi- 
net-makers, dyers,  cobblers,  etc.). 
•v. 


jir.iiiiHini 


ilJUtormryi  •^•muU 

rig,  i«3. 


.Vnrof 


RJ}..  Ittt  It 

M  ■uUwrfnr  mi-iiti  MfM 
W  Btlmtftttmit 


A  pure  median  paralysis  is  chiefly  characterized  by  the  in- 
ability to  pronalc  the  forearm  and  to  flex  the  hand,  as  wc  can 
easily  understand  from  the  anatomy  of  the  parts.  A  very 
slight  flexion  of  the  hand  toward  the  ulnar  side  is,  however. 


LESIOXS  OF  THE  liftACIIlAL  PLEXUS. 


35' 


k 


rendered  possible  by  the  action  of  the  intact  flcxur  carpi  ul. 
oaris.  The  tcrntinal  phalanges  can  not  be  bent,  but  in  the  first 
phulangcs,  which  arc  under  the  control  of  the  intcrussci.  this 
mutiuti  is  nut  impaired.  The  part  of  the  flexor  profundus  digi- 
tonini  which  is  supplied  by  the  ulnar  makes  it  possible  for  the 
patient  tu  seixe  some  objects  with  the  third,  fourth,  and  fifth 
fingers.  The  extended  and  adductcd  thumb,  which  tics  in 
close  apposition  to  the  index  finger,  is  almost  useless. 

On  the  other  hand,  wc  find  in  ulnar  paralysis  that  the 
thumb  can  not  be  pressed  against  the  index  finger  on  account 
of  the  paralysis  of  the  adductor  pollicis,  that  the  terminal 
phalanges  of  the  fingers  can  not  be  straightened,  the  first  ones 
nut  flexed  (paralysis  of  the  intcrossci),  and  that  the  little  finger 


.■  A/I* 


IT,  oUbslpr  rnWun  HgUi 
FIc.  ia4.-)loTO«i  ISHitn  or  thi  Vu(*ii  Nmvi:, 


is  almost  wholly  useless.  With  the  median  paralysis  the  ulnar 
lorm  has  this  in  common,  that  flexion  at  the  wrist  joint  is  greatly 
impaired.  In  the  latter  cs|)ccially  lateral  movement  toward 
the  ulnar  side  is  interfered  with  owing  to  the  paralysis  of  the 
flexor  ulnaris.  lastly,  the  difficulty  which  is  experienced  by 
the  patient  tn  spreading  his  fing<.-r<i  apart  and  bringing  them 
together  again,  movements  which  arc  indeed  almost  impos- 
sible, greatly  facilitate  the  diagnosis  of  ulnar  panilysis,  which, 
however,  lor  that  matter,  is  always  simple. 

Muscular  ;iirophics  not  uncommonly  develop  in  both  o( 
these  paralyses,  but  more  frequently  in  the  ulnar  form.  The 
intcfXKseal  spaces  on  the  back  of  the  hand  become  sunken  in. 
and,  if  the  wasting  affects  chiefly  the  iiiterossei  and  the  lumbri- 


353 


D/SSj4S£S  Of  rUH  SPtNAL  KEMX-RS. 


cales,  the  hand  assumes  a  peculiar  appearance.  Il  becomes 
not  unlike  a  claw,  since  the  healthy  antagonists — the  extensor 
digitorum  communis  and  the  flexor  digitonim — produce  a  dor- 


sal  Rexion  of  the  Brst  phalanges  and  a  complete  palmar  flexion 
o(  the  second  and  third  (cf.  Fig.  105).  This  is  called  the  "  claw 
hand."  the  "  main  m griffe"  of  the  French. 

Atrophy  confined  to  the  anlithenur  eminence  I  have  repeat- 
edly observed  in  cabinet-makers.  They  themselves  attribute 
it  to  the  continued  use  of  the  plane. 

The  allections  of  the  sensory  fibres  of  the  median  and  ulnar 
nerves  may  cither  occur  alone  or  be  found  associated  with 
those  of  the  motor  fibres.  In  the  latter  case  wc  have  to  con- 
tend with  disturbances  of  sensibility,  parxslhesias.  numbness, 

A'  miiinrij-twIaMM 

M,  (pmAm'm  iHrinii 


Fig;,  n'i     " "  i.'iMs  i>F  tHK  UvscL'UKiVTJkHEovs  NKJtvK  ASft  nir  HL-mj» 

ll/PPUBD  W»   IT. 

anaesthesia,  and  pains,  sometimes  cjuitc  well  pronounced,  which 
arc  most  marked  in  the  initial  stage  of  the  paralysis.  In  the 
tormer  there  arc  genuine  ncuratg;ias.  acute,  spontaneous,  tanci- 


LESIOXS  OF  THE  BRACHIAL  PLEXUS. 


3S3 


i 


BHig  pains  which  follow  the  course  of  the  nerve  and  winch 
are  inlensified  by  pressure  upon  it.  Such  pains  are  more  frc> 
quently  observed  in  the  distribution  of  the  median  than  in  that 
ol  the  ulnar,  but  they  are  nut  common  iti  cither  of  these  rc- 
fftons.  1  have  known  them  to  occur  occasionally  after  acute 
diseases,  especially  adcr  typhoid  fever.  In  their  course  they 
differ  in  no  way  from  other  neuralgias.  The  only  fact  remark- 
able is  that  atrophy  of  the  interossei  and  the  "claw  hand" 
may  develop  in  their  course  even  when  there  are  no  motor 
<li^tu^t>ances  present.  A  rt-lapse  in  a  case  of  ulnar  neuralgia 
in.-iy  occur  after  an  interval  of  years,  but  no  satisfactory  expla* 
bation  for  this  has  been  discovered. 

lastly,  wc  have  to  consider  in  ihe  upper  arm  the  musculo- 
cutaneous and  the  circumflex  nerves  (Fig.  106),  cither  of  which 
may  he  affected  by  itself  or  in  connection  with  other  nerves  of 
the  plexus.  The  former  supplies  the  coraco-brachialis,  the 
brachialis  anttcus,  and  biceps  :  the  latter,  the  deltoid. 

Lesions  of  the  motor  fibres  of  the  muscu to-cutaneous,  which 
are  only  met  with  independently  after  injury  due  to  surgical 
operations,  impair  and  completely  prevent  flexion  of  the  fore- 
arm on  the  upper  arm.  In  lesions  of  the  circumflex,  motion 
of  the  arm  away  from  the  trunk  is  diflicult,  and  even  rendered 
impossible,  if,  as  often  happens  in  the  course  of  the  disease,  the 
deltoid  atrophies.  This  atrophy  is  readily  rect^nized  by  the 
fLittening  of  the  shoulder,  and  is  often  associated  with  reaction 
ol  degeneration  (cf.  Windscheid,  Neurol.  Centralblatt,  1892,  7). 
OccaMonally  the  participation  of  the  sensory  fibres  of  the  cir- 
cumflex is  more  prominent;  the  patients  then  complain  of 
violent  neuralgic  pains  (llemi,  cf.  lit.),  which  are  aggravated  if 
any  attempt  is  made  to  move  the  arm.  It  is  important  in  such 
caaes  to  make  a  careful  examination  of  the  shoulder  joint,  and 
Ircquenily  we  shall  find  a  chronic  inflammation  here  to  be  the 
luu  of  the  neuritis.  Keccntly.  F.  Scimltzc  h.-is  carefully 
udied  the  so-called  acrop:ira;sthcsia  (Deutsche  Zcitschrift  f. 
crvenheitk.,  1893,  iii,  p.  300). 

In  other  cases,  again,  we  can  not  make  out  any  organic 
hanges  in  the  joint,  and  we  have  to  think  of  a  joint  neurosis, 
or  information  on  this  point  the  reader  is  referred  to  the 
haptcr  on  Hysteria.  A  severe  concussion,  a  fall  upon  the 
Ider,  which  at  first  produces  hardly  any  symptoms,  may 
rtw  to  disease,  Listing  for  years,  in  which  both  the  joint 
^the  nerves  of  the  plexus  take  part. 


3S4 


J>/S£AS£S  OF  THE  SPIS'AL  HERl'ES. 


In  any  one  of  these  affections  of  the  nerves  of  the  arm  we 
should  in  the  treatment,  besides  aiming  ut  the  removal  of  the 
cause  if  such  be  found,  make  use  as  soon  ns  possible  ol  the  gnl- 
vaoic  current.  It  is  a  mistake  lo  lose  time  with  other  meas- 
ures, such  as  bathing,  massage,  rubbing,  and  the  like.  Where 
the  electrodes  arc  to  be  applied  may  be  learned  from  the  illus. 
iRitions,  in  which  the  motor  points  arc  accurately  given.  We 
need  hardly  say  that,  besides  the  electricity,  various  placebos, 
rubbing  and  passive  motion,  may  be  used  to  quiet  the  patient's 
mind. 


Not  uncommonly  several  nerves  of  the  brachial  plexus  arc 
paralyzed  at  the  same  time.  Duchennc  was  the  first  to  de- 
scribe such  instances  in  children  in  cntiscquence  of  obstetrical 
(ipenitions,  such  as  version  and  subsequent  extraction,  the 
Prague  method  of  extraction,  etc.,  and  designated  this  form  as 
"  puralysie  obst<Stricalc  infantile  du  mcmbrc  supirieur,"  or 
birth  palsies.  Independently  of  the  French  investigator,  Erb 
has  given  us  an  excellent  well-defined  picture  of  such  a  paraU 
ysis.  The  lesion  which  affects  the  plexus  f^ives  rise  to  a  simul- 
taneous paralysis  of  the  deltoid,  the  biceps,  the  brachialis 
anticus.  and  the  supinator  longus,  and  the  patient  can  neither 
move  his  upper  arm  away  from  the  body,  nor  approach  the 
forearm  to  the  upper  arm.  The  whole  extremity  hangs  down 
daccid,  while  the  fingers  and  hand  retain  their  mobility.  The 
lesion  in  such  cases  must  be  situated  at  a  point  where  the  cir- 
cumflex and  the  musculo-culaiieous  and  the  mu&culo-spiral  are 
still  close  together — i.  e.,  at  about  the  exit  of  the  sixth  cervical 
nerve — between  the  scaleni.  and  it  is  from  this  so-called 
■' Hrb's"  or  "supraclavicular"  point  (cf.  Fig.  107)  that  we  are 
able  to  stimulate  simultaneously  all  these  four  above-mentioned 
muscles.  If  the  infraspinatus  is  also  taken  in,  the  arm  is  in 
a  position  of  internal  rotation,  and  can  nut  be  turned  out- 
ward. 

This  paralysis,  which  Erb  has  aptly  termed  "combined 
shoulder-arm  palsy,"  is  often  a  very  tedious  and  troublesome 
affection.  The  longer  it  lasts  the  more  the  nutrition  o(  the 
muscles  suffers,  and  the  most  varied  degrees  of  atrophy,  which 
is  often  especially  marked  in  the  deltoid,  arc  seen.  On  elec- 
trical examination  we  find  that  the  faradic  and  galvanic  excita- 
bility of  the  nerves, although  not  completely  lost,  is  diminished, 
as  is  also  the  laradic  excitability  ol  the  muscles,  while  the  gal- 


I 
I 


LESIONS  OF  THE  BRACHIAL  PLEXUS. 


35S 


vanic  excitability  of  the  same  has  undergone  qualitative  as 
well  as  quantitative  changes,  a  coiiditkiti  which  Erb  has  dcsig- 
iTiitcd  as  partial  reaction  ol  degeneration.  Someliineg,  also, 
there  is  present  complete  reaction  of  defeneration  (cl.  page 
91).  If  ihe  sympathetic  is  also  implicated  (SecligmU)ler).  the 
ensuing  paralytic  symptoms,  contraction  of  the  pupil,  narrow- 
liig  of  (he  palpebral  fissure,  and  retraction  of  the  bulb  on  the 
aflcctcd  side,  arc  further  sources  of  annoyance  to  the  patieitt. 


MTK  \it.  pittn.) 


Br<ttlkiitl  lirtra 


KrVt  r^^mrlmimhr  point 
Fie.  1*7. 


How  the  participation  of  the  sympathetic  is  to  be  explained. 
whether,  as  Klumplce  (cf.  lit.)  holds,  by  a  lesion  of  the  commu- 
nicating branch  of  the  first  dorsal,  wc  can  not  decide.  If  the 
wnsory  fibres  arc  also  implicated,  the  patient  comphiins.  in 
ftddiiion  10  the  motor,  also  of  sensory  disturbances,  not  only  of 
great  difficulty  in  moving  the  arm.  but  also  of  pains,  numbness, 
and  forroiuition. 

The  Ircaiment.  ol  course,  consists  in  the  use  nf  etectricily. 
galvanic  stimulation  from  Erb's  point,  and  the  application  of 


356 


DISEASES  OF  THE  SPtXAL  NERVES. 


ihc  laradic  brush,  which,  acting  rcfleitly,  oflen  give  very  good 
results. 

Peculiar  and  very  curious  motor  phenomena  in  the  upper 
extrcmiticii  arc  observed  in  conncctiun  with  and  us  a  direct 
consequence  of  certain  callings.  Such  occur  in  cases  where 
no  particular  exertion  of  the  muscles  might  lead  us  to  think  of 
a  peripheral  lesion  of  the  plexus  as  the  result  of  overstrain,  but 
in  persons  whose  occupations  bring  into  play  complex,  co-ordi- 
nated movements.  Since  in  many  cases — hut  by  no  means  in 
all — a  faulty  cn-nrdinatinn  nf  the  movements  is  the  cauM:  of  the 
afleciion,  we  may  for  the  present  accept  the  name  of  •'  co-ordi- 
nation occupation  neurosis,"  which  was  proposed  by  Benedilct, 
at  the  same  lime  insisting  upon  the  fact  that  il  only  fits  a  cer- 
tain small  number  of  cases. 

Anions  the  occupations  which  relatively  frequently  give 
rise  to  the  disturbance  in  question  the  most  important  certainly 
is  writing,  and  writer's  cramp — mnfrigraphia,  graphospasmus — 
is  one  of  the  nervous  diseases  to  which  most  careful  study  has 
been  devoted.  Nevertheless,  our  knowledge  is  extremely  lim- 
ited, and  we  must  confess  that  we  have  not  as  yet  got  be- 
yond the  description  of  the  symptbms.  The  pathogenesis  and 
tlierapeutics  are  ttrra  imogniltt. 

In  ilie  tirst  place,  we  ought  to  state  that  only  in  a  fractional 
number  of  cases  have  we  to  deal  wilh  a  cramp  or  spasm  :  more 
often  the  conditions  are  the  following :  The  patient,  after  having 
for  weeks,  perhaps  months,  noticed  that  while  writing  the  hand 
becomes  tired  more  easily  than  before,  finds  one  day  that  he  is 
utterly  unable  to  write  another  line  without  great  strain;  as 
soon  as  the  pen  is  taken  into  the  hand  the  sensation  of  fatigue 
comes  on;  hand  and  arm  drop  as  lE  paralyzed,  while  at  the 
same  time  the  patient  may  complain  of  mnrc  or  less  intense 
pain  in  the  forearm,  upper  arm.  and  possibly  in  the  shoulder. 
The  writer's  cninip  in  such  cases  is  iii  reality  a  writer's  paral- 
ysis. In  other  instances,  as  soon  as  the  penholder  is  clasped 
the  hand  bi-gins  to  tremble  and  the  handwriting  becomes  un- 
certain and  tremulous,  which  is  all  the  more  striking  because 
on  examination  the  patient's  hand,  especially  the  right,  proves 
to  be  quite  steady  if  it  is  not  used  in  writing.  Sometimes  there 
is  an  actual  spasm  when  the  penholder  is  seized,  which  attacks 
the  muscles  of  the  hand  as  well  as  those  of  the  forearm,  so  that 
hand  and  arm  make  involuntary  movements  or  they  become 
stifT  and  immobile  (clonic  and  tonic  spasm).     The  pen  is  either 


/JSS/OXS  OF  TUF.  BKACHIAL  FLKXUS, 


357 


irregularly  jerked  to  and  fro  or  firmly  pressed  a^ninst  Ihe 
paper :  in  both  cases  writing  is  absolutely  impossible.  On 
furlher  examination  nothing  else  is  discovered,  and.  what  is 
more  especially  interesting,  the  patient  is  able  to  do  anything 
else  with  his  hands,  even  the  finest  work.  He  is  able  to  draw 
(with  a  pencil!,  play  the  piano,  etc.;  moreover,  the  electrical 
eiaininatiun  of  the  apparently  seriously  affected  muscles  scl- 
diim  reveals  anything  abnormal  worthy  of  mention.  Dubois 
(Schweiz.  Corrcspondenzbl.,  1887,  5)  found  the  excitability  (or 
both  currents,  especially  in  the  thenar  muscles,  increased. 
Sensibility  is,  on  the  whole,  normal.  Pains  only  occur  un 
forced  attempts  to  write  :  in  short,  the  patient  can  do  anything 
demamled  of  him  except  write. 

Analogous  lo  the  affections  just  described  are  Ihe  condi- 
tions of  falii;tte  in  the  muscles  of  people,  cliicfly  professionals, 
who  play  the  piano  a  great  deal.  In  them  not  only  tbc  light 
hand,  but,  especially  in  female  patients,  the  left  also  is  affected. 
Pain  and  weakness  m.ny  become  so  marked  in  both  hands  that 
piano-play  in);  has  to  be  given  up  completely.  This  becomes 
the  more  necessary  when  the  symptoms  persist  during  rest  as 
well,  and  not  only  when  the  patient  is  playing.  Such  disturb^ 
anccs  are  also  noted  in  telegraph  operators,  cigar-makers, 
and  in  milkers  of  cows;  also,  but  rarely,  in  tailors  it  is  pro- 
duced  by  the  frequent  handling  of  the  heavy  shears,  etc.  In 
all  cases  it  is  evident  that  the  occupation  is  the  sole  cause, 
although  we  do  not  know  how  and  upon  what  organs  it  acts 
injuriously.  It  is  very  unlikely  that  the  disturbance  is  of  a 
peripheral  nature,  the  negative  result  of  the  examination  of 
muscles  .ind  nerves  and  the  uselessness  of  any  treatment  sccm< 
ing  lo  indicate  this.  We  can  not  accept  either  the  theory 
which  altempis  to  explain  the  symptoms  by  a  primary  weak- 
ness o(  certiiin  muscles  and  a  secondary  spasm  of  the  antago- 
nists (Zur.ulelli).  or  that  which  assumes  the  spasm  to  be  of 
a  reflex  nature,  starling  from  the  sensory  nerves  of  the  skin 
(Fritz):  or,  finally,  the  explanation  that  we  have  to  deal  with  a 
disturbance  in  conduction  of  the  nerve  muscle  apparatus  used 
in  writing ;  but  we  arc  rather  of  opinion  that  the  weakness  and 
the  motor  disturbances  of  the  upper  extremity  arising  in  con- 
sequence of  Ihe  occupation  are  of  a  central  nature  and  are  to 
be  referred  lo  the  brain  cortex.  The  situation  of  the  centres 
ODflcerned  in  writing  and  in  other  movements  which  depend 
upon  a  co-ordinated  action  of  the  muscles  of  the  bands  is  un- 


358 


DISEASES  OP  TltE  SPtXAL  NERVES. 


known.  These  centres  in  consequence  of  overexertion,  but  also 
often  without  any  appreciable  cause,  arc  thrown  into  a  state  ol 
paralysis  or  irritation  which  jjives  rise  to  corresponding  dis- 
Itirhanccs  in  the  extremities.  I'crhaps  this  may  at  times  arise 
simply  as  the  result  of  a  general  increased  nervousness  which 
may  have  a  hereditary  origin.  It  is  evident  that  besides  those 
alleclions  which  are  due  to  a  functiuiial  disturbance  of  the  cor- 
tex there  arc  those  in  which  anatomical  lesions,  whether  ol  the 
central  organs  or  of  the  peripheral  nerves  may  be  the  cause  of 
the  same  symptoms  as  those  now  under  cofisideration.  Thus 
we  may  sometimes  meet  with  cases  of  old  almost  cured  hemi- 
plegias in  which  as  the  only  remaining  disturbance  a  slight 
difficulty  in  writing  or  similar  occupations  may  be  present. 
The  same  may  happen  in  slight  disseminated  scleroses  of  certain 
collections  of  fibres  in  the  spinal  cord,  or,  finally,  as  I  have  had 
occasion  lo  observe  repeatedly,  in  the  initial  stage  o(  tabes,  and 
the  disturbance  at  the  first  glance  may  suggest  to  us  writer's 
cramp.  Hence  we  should,  first  of  all,  endeavor  to  decide 
whether  the  trouble  is  an  independent  affection  or  wliclher 
it  is  to  be  regarded  merely  as  a  symptom  of  an  underlying 
disease. 

The  prognosis  is  usually  unfavorable.  Only  in  the  rarest 
instances  are  we  able  to  afford  the  patients  any  decided  last- 
ing relief,  a  fact  of  which  we  should  inform  the  friends  before 
taking  churgc  ol  the  case.  Only  when  we  arc  able  to  gel  hold 
of  the  patient  in  the  earliest  stages  of  the  trouble  and  can  in- 
sure him  perfect  rest  and  the  removal  of  the  exciting  cause, 
such  as  writing,  piano-playing,  telegraphing,  etc.,  lor  weeks  and 
months,  is  it  sometimes  possible  to  effect  an  absolute  cure.  If 
this  can  not  be  done,  and  if  the  rest  is  not  complete,  the  success 
of  all  our  attempts  becomes  very  uncertain  and  the  result  will 
usually  be  disappointing.  W'c  may  try  massage,  as  has  been 
done  also  by  some  non-professional  specialists  with  transient 
success.  Galvanism,  faradism,  rubbing  with  different  external 
applications,  hydrotherapy,  gymnastics,  may  be  advised.  The 
result  is  usually  the  same  as  if  strychnine  or  atropine  is  in- 
jected hypodcrmically  ori(  ihediflerent  nervines  be  given  inter- 
nally for  months.  Writing  may  be  facilitated  by  using  a  pen. 
holder  passed  through  a  potato  or  through  a  wooden  ball  fitted 
to  the  hollow  of  the  hand,  or  by  using  Xussbaum's  bracelet. 
The  advice  to  educate  the  left  hand  to  write  is  always  good 
because  it  gives  the  right  hand  a  rest.    Yet  the  value  is  by  no 


l£SfOXS  OF  THE  nitACHlAL  PLEXUS, 


3S9 


means  lasting,  because  the  motor  disturbance,  as  a  rule,  shows 
itseU  soon  in  that  hand  also,  a  fact  which  is  an  additional  argii- 
tDcnt  in  favor  of  the  central  nature  of  the  disease. 


The  simultaneous  aReclion  of  several  sensory  nerves  of  the 
brachial  plexus,  analogous  to  the  motor  disturbance  in  the 
sbouldcr-arm  palsy,  is  not  common.  When  it  does  occur  the 
pains  arc  very  violent  and  deprive  the  patient  of  the  use  of 
ttie  csclrcmity.  The  ccrvico-brachlal  neuralgia  may  affect  all 
the  sensory  branches  of  the  brachial  plexus,  so  that  the  whole 
upper  arm,  forearm,  and  hand  arc  painful ;  but  it  may  also  be 
confined  to  the  area  of  distribution  of  one  nerve,  often  the 
musculo-spiral  or  median  (cf.  Nourric.  De  la  n^vratgie  brachiale 
double.  Thfrsc  de  Paris,  1889). 

Painful  points  can  sometimes  be  demonstrated  in  the  region 
vi  the  circumflex  nerve  over  the  scapula,  of  the  median  in  the 
bend  of  the  elbow,  of  the  musculo-spiral  in  the  lower  third  of 
the  humerus,  and  of  the  ulnar  at  the  internal  condyle.  Vaso- 
motor and  trophic  changes  may  be  entirely  absent,  yet  the 
skin  of  the  fingers  not  rarely  looks  glossy  and  atrophic  ("  glossy 
fingers").  Here,  again,  traumatism,  mechanical  pressure— by 
tumors,  aneurisms,  etc. — arc  the  most  prevalent  causes  of  the 
neuialgia.  It  may  occur  reflexly  after  amputation  of  the 
fingers  or  the  forearm.  A  bilateral  neuralgia  of  this  kind  is 
suggestive  of  a  spinal  disease,  more  especially  of  pachymenin. 
gitis  ccrvicalis  hypcrtrophica. 

The  treatment  is  in  the  main  the  same  as  in  other  neural- 
gias. Besides  narcotics  the  electrical  treatment  should  be  be- 
gun  as  soon  as  possible.  Descending  currents  through  the 
diseased  nerve,  as  well  as  the  application  of  the  anode  over  the 
aOcctcd  plexus,  are  to  be  recommended.  The  faradic  brush  is 
usually  borne  well  and  is  of  use,  although  the  manipulation 
itvcll  may  nut  be  very  agreeable  to  the  patient.  In  rare  in* 
stances  wc  must  have  recourse  to  energetic  counter-irritants 
t<i  the  skin.  We  have  repeatedly  made  very  successful  use  of 
\\ic  fvinis  lir  /tH  with  Paquclin's  cautery. 

Para;slhestas  and  ana;sthesias  arc  quite  common  in  the  dis- 
tribution of  the  brachial  plexus.  They  are  not  always  con. 
hned  to  one  nerve.  Tpper  arm  and  forearm,  the  hands  also, 
are  frequently  affected,  particularly  when  the  occupation  ne- 
cessitates overexcrtiim  ol  them— e.  g.,  in  brick-makcrs.  Again 
they  are  caused  by  the  action  of  cold  and   hot  water,  olteti 


360 


J>/SEAS£S  OF  THE  SPINAL  NERVES, 


also  by  wftter  containing  lye  (anfesthesiaLivntricum.nnd  tlie  mat 
dts  bassins  of  the  women  engaged  in  unwinding  the  silk  from 
the  cocoons  in  the  silk>spinning  mills,  etc.).  Tor  such  patients 
the  only  remedy  lies  in  •ibsteiilion  from  this  kind  of  wurk. 


I.ITKRATURE. 
Uiiant  <•/  ikt  CfFvitat  Pbsm. 

Peter,  M.     Neumif^ia  phrvnica.     Arch.  gti-\iT.,  1871.  6me  s£t..  xvii,  p.  303. 
Ert>.     Hflndbgch  dcr  Kraiikhdlcn  dcs  NcrvcnByiicniB.    3.  AuD..  1876b  A.  pp. 

114.  135- 
Sirilmpell.    Lix.iii.,  1887.  p.  31. 

y.nr.  <il.,  1S87.  pp.  47.  79.  8;. 

C3M  \A  I'enislcnl  Hiccough  ;  Nenopsf ;  Remnrlui.     Lancet.  188}. 


Eichhoret. 
Stei'eniion. 
i.  1043 


L/ileiu  ■>/  Iki  Brukial  PItsmt. 
I.  Paralysis  of  ihe  Serratus. 

Bergrr.  O.     Die  LHlimung  do  Thonicicua  longu^    Hatnliutioniscbriri.  Dre»- 

lau.  1873. 
Brack.    Eit\  Fall  von  ScrraitislShmunf  nach  aculer  Krankhdt  (T)phci((T).    In 

aug.-DJKMTt.,  VfsiW..  1873. 
Lewinski.     Ufbcr  Uic  L3hrnuiig  des  Srrraiiu  amicus  majw.    Vitchow's  Arcltiv 

1878,  Ixiiv.  4.  p,  473. 
Lewinski.    'Iw  Uiugnoae  tier  Scrra.(u»liilimun|;.    Vircliow's  Archiv.  1881.  luxtv, 

I.  p.  7i. 
nfiumli-r.     Isolirtc  I.ahmunf;  <lft  Serrat.  ant.  ra^j.     Arch,  f.  Psydt.  und  Ncrvcn 

kninkhcitcn.  1882,  xiv,  3.  p,  7»i. 
Dixoci  Mann.    Srrr,i(u«  l^nnilysis.     Lancet,  February.  1884,  ).  \.  6. 
NofTin.inn.     Uolirit  periphery  LHhmiini;  iIck  Nerv.  supnucapul.  aninlr.    Neurol 

Ccntr.-ilbl..  1888,  9,     (Pains  aiitl  Alfupliy  of  llie  Muscles  suppbed  by  ilu 

Nerve.) 
Bunlinn.  K<i&«  K.     l'ar.ilyM«  of  (he  Scmtus  Magniu>    Joumul  of  Nerv. 

Mcnl,  l)i«catn,  189a,  sv,  p.  67. 

I.  Mujculo.spinil  I'aralyMs  (not  including  the  Saturnine  Foem). 

Fischer,    Ziii  I-chrr  von  dcr  Ulhniurig  dcs  N.  radialls.    Dculsches  Arch.  f.  klin. 

Med.,  1876.  xMi,  4.  5.  39*. 
Onimus,     Gnj.  Iicliitom..  1871,  2me  s6r.,  xv,  15. 
\Vhit!ic)n.     Mu%culo.%|)ir7il  Paralysis  in  Consequence  of  Pressuir  cxened  li)*  a 

Piece  of  U'jiic.    Edinb.  Med.  Journ.,  1881.  xitvii.  p.  724. 
Doycr.     He  In  pamlysie  du  ncrf  radial  par  compression  icnijioraire.     Th^K  dc 

Pari*.  i8$3. 
Joffroy.     Du  rAle  de  la  compression  dans  In  production  (te  U  paralytic  radlale. 

Compt.  rend,  gtnfr.,  May  14.  1884,  p.  184. 
Arnoian.    (,lax.  liebd..  i88j,  ixxii.  z,  3, — tl.  Remuk,    Oerliner  klin.  Worhrn»chr., 

1885.  «"'■  S-^-H,  Neumann.     Neurol,  Ceniralbl,,  1885.  iv.  4.— l-'.ilkcniicim. 

Miitbeilungen  nus  tier  mcci,  Klfnik  ru  Konigslwrg,  18GS.    (Muscuto-splnl 

Par^lyti^  afler  Subcuianeous  Injection  of  Elber.J 


I 


LSS/O/fS  OF  THE  BRAClllAl.  PLEXUS. 


36. 


^ 


I  «t  Dcjcrinr.    Rechrrches  cliniqucs  ct  np^rimentalcs  sat  la  puilyiie 

ntdiale.    Compt.  rrnd.  hclHl.  Ac  \a  Soc.  Ac  DhiL,  1886.  1 ;.  p.  1S7. 
ScKribcr.  M.     Kin  Va.\\  van  ^chwcrcr  cumpliclitcr  SchlkflahtnunK  am  linken 

Arme.     Neurol.  Ccntriilhl..  1886.  v,  ij. 
Kolmer,  H.     Em  Fall  von  Kldchiciligcr  mumatlscher  (Druck)  Lahmung  der 

Setvi  raili.il..  uln.  uiid  mcdUn.  tmistr.     Deutsche  mrd.  Wocliciudir.,  18M. 

10. 

r Chicle.     Sllning    Atr    Berlinn  G««t1sch4fl  T.   P*)-ch.  a.  Ncivenkrankhciltrn 
VDin  g  Juli.  1H88.     (Tniunuiic   ^tu»culo- spiral   P«al)-Hs  cured  by  Sec- 
nndary  Nerve  Suture.) 
TiW 
Mrl 
l-oa 
Leu 
Ha 
BaU 
l-hil 


I 


3.  Median  niul  Ulnar  Paralpis. 
llcrnKanll.     Uehet  den  Bereich  der  ScnsilKlilSls-Siorung  nn  Hand  uml  Fifi|;cr 

M  Llhmung  dcs  Medianuft.  sowie  lur  I'aihulogie  der  Kaduih»p«raJ]iMn. 

Arch.  f.  l'*>Th.  uml  Ncricnkr.  187s.  v.  3, 
TiWen.    Tfi>phoncur>b»«  after  Itijurj*  t»  ihe  Median  Nerve.    New  York  Med. 

Record,  Sejiientber  11.  18B6.  \x\.  p.  30,  4. 
MrN'auifhi.     L'In.ir  Nfuralgia.     Brit,  Med.  Jouia,  April  30.  1887.  p.  93J. 
I'oore.     Lancet,  Seplembei.  18S3.  ii.  10.  13. 
Leudtl  {de  Rouen).    Gai.  m<d.  dc  I'^ns.  September  1  ^  1 88 j. 
lieu,  Juliu*.    Ueber  Tempcr^iturcn  und  derm  Mcuting  bci  UlnaruUhmungen. 

Itcrtinet  klin.  WochcnKhr.,  18S6,  xxlii,  y>. 
BaUet  (>■    AcddeniB  constcutifs  k  la  compressimt  hahltuellc  du  cubital  chci  un 

OovTieremployi  AauvtafTM  Ic  vvire.     Kcvuede  mM..6,  iSSj. 
ItiihoTii.     I>e  la  nivnte  p^riphjrique  du  cubital  consecutive  ^  la  A^-re  typhotde. 

Tlt^M'  lie  ^Mit.  188^.  No.  1 19. 
ENkfiburg,     Ueber  Lilhmuni;  (lurch  poliicilichc  Fessetung  (ArrestantenUhm- 

unc)  der  Hand.     Neurol.  Ccniralbl..  1889.  4. 
Rir«Ser.     Medianus- Neurit i*.     hlUnch,  incd.  Wochentchr.,  la.  1889. 
SientPl     DeiitMhe  nteil.  Wucheiudir..  iltiS,  xiv.  31.    (Four  Ca^n  of  Trauma- 

lism  o(  llie  Ulnar  Nenf.J 

4.  MusculivCutaneuu*  and  Circumflex  rnralyiis. 

Hcon.    [>e  la  itivri1){tc  circoiiltexe  ou  anilbirc     ThiM  de  raris.  1883.  No.  17;. 
FauveL     Drs  paralyHU  tiautnaiiques  d'origine  pfrtphiriquc.    'these  <k  Vmm, 

1885.  No.  37 1. 
I>anu1ris.    Zuf  Dia^rnoM  uimI  Prof|;noM  dcr  Axillaridlhmung.     Munch.  ownL 

\V»chciuchr..  1S88,  21.  12. 
Ilruns.     Isuliric  Laliniunj:  der  linken  Flex.  poll.  long,  dunh  Ueberanstrvnguni; 

( I}ruinn>cr'«  Paralysis).     Neurol,  Ccnirjlbl ,  1890.  11. 
vnn  Zander.    Trammlerlahmuri);.     Jnaujc.-UiMCrt.,  Uerliii.  1&91. 

S-  Plexus  Paralysis— Combined  Shoulder-arm  Palsy. 

Ba«luKtl.     Ueitnff  t\a  Lehre  von  ilcn  LShnMtigen  tm  Ikrciche  d«  Plexus 

biwhldis.    Zeiischf.  liir  klin.  Med,.  188a.  Iv.  3.  p.  41 S- 
I'tmntll.    Zwei  Kalle  iwi  der  Form  der  "  combinfrten  SchuUcrarmlahmung." 

Neurol.  Ceniullil..  1881,  13. 
Klumi>ke.    Cnniiihutlon  it  l'6tude  des  p.-imlysics  radicubires  du  plexus  brachiaL 

KniN  du  mtd..  Juitlct-Scpi..  1885. 


363 


DISEASES  OP  THE  SFINAt  SERVES. 


Vinajr.    Taralyaies  nidiculaitcs  tu^ifricurcs  tin  plexus  brachial,  d'onginc  profes- 

sitiiMielle.    Lyrtn  iiicd  .  ;3.  18G&. 
tSemhardt.    Neurol,  Ccniralbl.,  1SS6,  6,  p.  141, 
Riiiii-.    Utuiiclie  Zdlschr.  f.  Chiiurg..  1886.  xxiv.  3,  4. 
Murult.     Einigc.  xum  Thcil  chirurgischc  Uiihciiungcn  im  Itercichc  d«9  V\kk. 

brachiali».    Schweii.  Cancsiponitentbl.,  18SS.  xvhi,  t%. 
Mi(l<lcli)(»rpr.    Wiener  incd.  Woiheiisclir.,  1888.   14-     (Pressure  Pais)-  of  ihe 

Musi:u1i>-spifal  and  Ulnar  Niivcs.) 
Jolly.    On  Uirlh  PabJcM.     Briii»!i  Med.  Journ..  18S9.  6. 
Arcns.     Uciirag  rur  I'xthuloglc  ilcr  Eiitbimlun^'iljfhnmngen.     Insug.-Di&Mn., 

Goitin^en.  1B89. 
Lesiyn^ky.  W.    A  Cuntflbuiiun  lo  the  Clinical  Study  of  Kpontnneous  Dcgen- 

er.itive  Ncuriii«  of  the  Itrachial  Hlcius.    Jouni.of  Ncrv.  and  Ment,  Discabcs, 

January  1.  1890,  iv. 
Schacfcr (Owiosh).    UeberArbeitaparesen.    FrvmMenders  Pulyclinic.     Inaug.- 

Dissert.,  Drrlin,  1B90L 
rfeilTeT.    ZwfI  FBIIe  vein  IJIhtnunErler  unlcren  Wuncin  (let  I'lexus  brachlalis 

(Klunipke'a  I'ar.ilysiO.     Deuisclie  Zeruchr,  f.  Nervcnhb..  1891.  i.  5,  & 
OriaiiolT.      C.is  [Ic  pnr.itysie  raiJiculairc,   brachiale  toule.      Arch,  de  Ncur., 

Novrmhrc,  iSyr,  66. 
Ucrnliarili.     L'elm  eincn  Fall  von  doppelseiti),'cr  tr^numatisclicr  LS.)imuni;  im 

Bereiche  dcs  Plexus  brachialis.     Neurol.  CenimM,  1891,  9.     (Prudoecd 

durins  ^n  oper.-ition  by  exceaive  ttilduclion  of  both  Mboulijcn.) 
He^it    Ein  fall  von  dopiielsci tiger  Neuritis  de»  I'lcxus  hraehialis  (»bere  Wuriel. 

neuriiis)  bei  Plithitii  pulmonum.    Berliner  klin  Wochensrhr..  189J.  51. 
d'Antros.  Lfon.     l.'.ivcnir  dcs  purul>-Hii.-n  i>bii£  I  tickles  dti  metnbre  xup^rieur. 

Ket-uc  mens,  des  mal.idies  de  I'enfaiicc.  Octobre.  1891. 
Rirdcr.     Die  SirinttfigrrlUhmiing.     Munch,  mcil  Wochenfchr.,  1893.  7. 
Bniun,  H.     Die  Urueklilhmungen  lr»  Oebiele  dcs  Plexus  broch,     Deutsche  meil. 

VVuchenichr..  1894.  3. 


d.  Co-ordination  Occupation  NeuroKS. 

N3pi;L«.    Pboiographer's  Cramp.     Revue  d'Hygiine,  Noiemlwr.  1879^ 
MObiuB.     Berliner  klin.  Wochcnschr..  1880,  xvii,  st.    (Cramp  from  rtaying  the 

Zither.) 
Dally.    Joiirn,  de  Thirapem,.  1882.  3,  4. 
Kobinson.     Casct  tA  Telegrapher's  Cramp.     Brit.  Med.  Joum..  Navemlicr. 

1883. 
Poore.     Brain.  T883.  p.  23).     f Sawyer's  Cramp.) 
Vigoumiix.     Progr.  mid.,  1882.  x.  3. 
Nussli.ium.     B.iyer.  ;lnll.  Inielligenxbl.,  i88>.  Rxix,  39.     (Dcsctiplion  »f  the 

Bracelet.) 
Viltcmin.     Arch.  d.  mM,  el  de  pharm.  milil,.  1S83.  pp.  91-95. 
Poure.     A  Ci«e  of  Hammerman'*  Cramp.     Lancet.  AuKUSt  ii.  18S6,  8. 
L.ttlenianil.     De  U  cntnpe  ilea  icrivains  et  son  traiicment.    Tliise  de  i'aris, 

1887. 
iViore.    The  Lancet.  1887.  3311.    fWriier's  Cramp.) 
C.-iborian.    Coinritiution  A  I'itude  des  spasmes  profcssionncls.    Thbc  de  Parift, 

1887. 


O/SEASES  OF  THE  DORSAL  A'SXVES. 


363 


I 


hMre.    On  Ceruin  Condiltimi  of  (he  Hand  and  Arm  which  Interfere  with  the 

I'crfurmance  of  I'TofessJonal  Acts,  ctpecj^lly  I'lano-playing.     Unii&h  Med. 

Joum.,  Fctmur>'  36,  18S7. 
Zenner.     Berliner  klin.  Wochenschn,  1887.  17. 
Chambafit.    Coninbutiun  \  rfiiulogk  el  i  la  ^'mptomatologie  des  bnpMenco 

fonctionelks.    Rcruc  dc  rnW..  1887.  vii.  6,  pi.  464.    (Occupation  Neurosct.) 
Henschen.    Writer's  Cramp,     l'|«alfl  lackaic  forrnmgs.     Forhandlinf;.  1888. 
Ktcltcl.     Contributionti  uuv  |>araly>i»  el  aux  anfMhisics  rfflexcf.     Arch.  dc. 

fhysiol.  norm,  el  Paihiil..  18S3,  7. 
Tnrlieft.    Contribution  i  Ifiudc  dcs  n^^ntlgics  du  tnctnbrc sup^rieur.    Thise 

Inaugur..  Paris,  1884. 
Cosier.    ZumCapilddct  Artwitspnrcscn.    Berliner Itlln.Wochensrhr..  1884.83& 
S(|uirc,  J.  Edward     Some  Caitei  uf  Local  NumbncM  of  ihe  F.xi remit irti,  with  a 

CompafiiMjfi  between  Local  Syncope  and  Ni|thi  I'alijr.    Lancet.  December, 

iSSs.  U.  33. 
Bernhardt.     Ueber  eine  weni)[er  bekannle  NeuroM  dcr  EdFcmitaieo  betonden 

dcf  obrren.    Ceiitrolbl.  f.  Kenenhic,  1886,  Ix.  2. 
Kctnalc.    Ziir  F^tlhntoglc  des  Meikcrkramprcs.     Deutsche  nicd.  WochenichT., 

1889.  I  J.  p.  I  i8. 
Weiss.  M.  (Wfen}.     Die  Elelctn>lheTJpie  cler  pcripheren  ([raphiiiclven  Slorungen, 

CcnlralU,  t  «1.  ges.  Therajnc.  1891.  it.  4.  p.  19J. 

//.  Diifasis  of  Ihe  Dorsal  Ncr^Yt. 

Th«  anterior  (ventral)  divisions  of  the  twelve  dorsal  nerves  are 
called  the  intercoKliil  ncrve»,  since  ihcy  nm  in  Ihe  intercostal  spaces. 
They  supply  the  iiiteTCtuial  niii*,cle>.  ihe  levaiores  costartim,  the 
scTTAti  p<>&tici,  and  the  three  broad  abdominal  muacles.  To  the  in* 
tceucnent  of  the  chest  and  abdomen  tliey  supply  ciilaneous  branches. 
The  posieiior  divisions  of  the  dor»al  nerves  are  divided  into  internal 
and  external  branches.  The  former  are  dislribulcd  to  the  deep 
mtiscles  of  the  back,  sending  nerves  to  the  rhomboidci  and  the  latis- 
ftimtiN  dorsi ;  the  latter,  passing  between  the  longissimus  dorsi  and 
the  ucrulumbalis,  also  furnish  numerous  muscular  branches.,  and,  to- 
gether with  the  internal,  supply  the  skin  of  the  back  as  far  down  as 
the  crest  of  the  ilium. 

The  sensory  as  well  ns  the  motor  fibres  of  the  dorsal  nerves 
may  become  the  scat  of  disease,  but.  and  this  is  practically  ol 
much  importance,  the  anttrior,  the  intercostal  nerves,  arc  more 
subject  to  sensory  disturbances,  while  the  diseases  of  the  pos^ 
tenor  brunches  are  almost  exclusively  motor  affections. 

The  disease  of  the  anterior  brannhes,  the  so-called  intercos- 
tal neuralgia,  is  found  with  relative  frequency  in  the  female 
sex,  especially  in  those  of  middle  age.  ./f^tiologically,  oc> 
CDiKition  .ind  hard  work  in  general  are  of  some  importance- 
Servant  i;irls  and  women  o(  the  poorer  classes  suffer  more 


3^4 


P/S£AS£S  OF  THF.  SPIXAL  NF.KVP.Sl 


{rcquently  than  others.  I  have  seen  many  such  instances,  and 
have  found  it  besides  in  the  cniinie  of  phthisis  pulmonatis  when 
associated  with  peripheral  neuritis.  Traumalism,  aortic  aneu. 
rism,  and  spinul  affections,  may  also  give  rise  to  intercostal 
neuralgia. 

The  pain  appears  in  paroxysms  and  attacks  more  frequently 
the  left  than  tlie  right  side,  and  almost  exclusively  the  anterior 
or  lateral,  rarely  the  posterior,  portion  of  the  nerve  trunks.  It 
often  follows  the  course  of  the  nerve  and  at  times  reaches  a 
degree  of  intensity  most  distressing  to  the  patient.  The  re- 
spiratory movements,  more  especially  coughing  and  sneezing, 
cause  great  agony.  Three  tender  points  can  usually  be  demon- 
strated— one  close  to  the  vertebral  column,  one  in  the  middle 
of  the  course  of  the  nerve,  and  one  close  to  the  sternum — 
called  respectively  the  vertebral,  lateral,  and  sternal  points. 
The  fact  that  frccjiiently  after  cessation  of  the  p.Tin  a  herpes 
zoster  appears  is  of  great  interest,  although  the  question 
whether  we  have  to  regard  the  latter  as  a  genuine  trophic  dis-  « 
turbancc  or  simply  as  an  extension  of  the  iriH;innuatit)n  from  | 
the  nerve  endings  to  the  skin,  as  Gubler  thinks,  is  still  unset- 
tled. For  the  prognosis  it  is  without  significance.  In  all  cases 
of  intercostal  neuralgia  the  prospect  for  complete  recovery  is 
slight.  Although  we  may  succeed  sometimes  in  cuttinfi;  short 
the  individual  attacks,  we  can  never  be  certain  tiiat  they  will 
not  recur,  and  there  are  persons  who  all  their  life  long  arc 
condemned  to  suffer  from  this  disease. 

The  diagnosis  is  not  always  simple.     Rheumatism  of  the 
chest  muscles  can  easily  be  taken  for  inlercoslal  neuralgia,  and 
vice  vt-Tsd.     In  such  cases  wc  shall  find  it  useful  to  observe 
%vhcther  motion  has  any  influence  on  the  pain  or  whether  this    _ 
exists  independently.     If  there  is  a  history  of  traumatism,  neu-  I 
ritis  is  always  to  be  thought  of.  only  wc  must  beware  of  being 
deceived  by  malingerers,  and  to  avoid  this  the  condition  of  the    _ 
abdominal  reflex  and  the  pupil  should  be  examined  into.    The  I 
former  in  the  case  of  neuritis  is  increased,  the  latter  often   di- 
lated on  the  side  of  the  pain.     This  fact  was  first  established 
by  SeeligniiJIlcr,  and  shows  that  the  sympathetic  is  often  im- 
plicated here  just  as  in  the  affections  of  the  brachial  plexus 
(Deutsch.  med,  \Vochenschr.,  1887.  45). 

In  the  treatment  morphine  plays  the  most  important  rSU, 
and.  as  a  matter  of  fact,  it  is  of  much  more  value  than  the  much- 
lauded  subcutaneous  injections  of  osmiumlne  (one  syringeful  of 


D/SEAS£S  OF  THE  DORSAL  NERVE&. 


36s 


^ 


¥ 


loe-pcr-cent  soliilion  at  a  dose),  for  this  not  only  frequently 
disappoints  us.  but  also  produces  I0c.1l  troubles,  small  ubscesses, 
etc..  so  tliat  llic  patient  is  left  almost  in  a  worse  condilion  than 
t»c/ore.  The  (anidic  brush,  the  " points  de  feu"  with  Paquclin's 
cautery,  blisters  applied  to  the  painful  points,  may  be  tried ; 
but,  on  the  whole,  these  means  effect  but  little, 

Among  the  intercostal  neuralgias,  the  so-called  mastodynia 
(the  irritable  breast  of  Cooper),  a  neuralgia  of  the  mamma,  is 
to  be  included.  This  is  a  not  very  frequent  affection  of  the 
female  after  puberty,  and  may  be  connected  with  lactation.  It 
is  a  very  painful  and  distressing  trouble,  against  which  u&ually 
all  remedies  are  tried  in  vain,  so  that  in  desperate  cases  the 
patient  herself  suggests  ampulaiioti  of  the  breast  to  get  rid  of 
the  dreadful  suffering.  Thca*tiology  is  obscure.  Traumatism 
is  rarely  the  cause.  Ill-fitting  corsets  may  have  some  influence, 
but  women  with  well-devclopcd  and  those  with  small  breasts 
arc  equally  liable  to  the  affection.  The  byperassthesia  of  the 
skin  often  binders  a  careful  examination  by  palpation.  With 
the  lEps  of  the  fingers  we  should  endeavor  to  determine 
whether  there  arc  hard  nodules  in  the  li&sue.  which  to  the 
inexperienced  often  suggest  beginning  carcinoma.  In  some 
cases  my  patients  have  derived  some  transient  bcnefil  from 
suspension  of  the  breast  and  the  application  o(  hot  cloths. 
Here  aKo  morphine  is  indispensable  (cf.  Tcrrillon,  Des  iieu- 
ralgicsdu  scin;  Progr.  m<Sd.,  1886,  xiv,  10). 

The  motor  disturbances  affecting  the  muscles  of  the  back 
supplied  by  the  posterior  branches  of  the  dorsal  nerves  arc 
generally  paralyses.  We  arc  far  from  being  familiar  with  the 
symptoms  uf  the  affections  of  every  one  of  these  muscles,  and 
must  content  ourselves  for  the  present  with  mentioning  the 
p.iralysis  of  the  erector  sjtina;,  the  sacro-lum balls,  and  the  Ion- 
gissimus  dorsi.  which  lUiiv  be  affected  in  the  lumbar,  dorsal. 
orcerrical  portion  of  the  vcrtcbnil  column.  Bilateral  paraly. 
sis  causes  curvature  of  the  spine  b.Tclcward  (kyphosis),  unilat- 
eral paralysis  lateral  curvature  (scoliosis).  Pandysis  or  ]>arc- 
sts  of  the  erectors  in  the  lumbar  region  gives  rise  to  a  charac- 
teristic walk  and  a  characteristic  position  of  the  body.  The 
upper  part  of  the  body  is  bent  strongly  backward,  so  that  the 
lumbar  part  of  the  vertebral  column  is  markedly  curved  for- 
ward. If  by  any  movement  the  upper  part  of  the  body  is 
brought  forward  so  that  its  centre  of  gravity  is  no  longer  be- 


j66  DISEASES  OF   THE  SPINAL   SERVES. 

hind  ttiat  of  the  whtjle  body,  the  patient  falls  fonvard.  or,  ff  the 
patient  sits  on  the  floor,  he  has  the  greatest  difficulty  in  getting 
up.  The  manner  in  which  he  raises  himseU  is  so  characteristic 
of  paralysis  of  the  erector  muscles  that  wc  have  represented  it 
in  Figs.  Io8  to  1 1 1.  The  patient  first  gels  upon  all  fours,  and 
then  climbs,  as  it  were,  with  his  hands  up  his  own  legs,  con. 


Fis-  «*. 


Fig.  io» 


Rl*.  iiQ.  KiE-  III. 

Flp.  loB-i  1 1  flliutraie  Uie  mtnnct  Id  which  a  child  whow  ckciors  tpiiut  «n  (MntjrMd  1,-M 
up  (rom  Ibt  fcround.    'Afler  Gowktts.) 

stantly  endeavoring  to  bring  the  upper  part  of  the  body  as  far 
back  Ds  possible  by  inuvem(;nts  in  the  shoulders  and  the  arms 
so  that  the  abdominal  muscles  may  resume  the  duly  of  balanc- 
ing the  body.  This  mode  of  getting  up  can  best  be  studied  in 
pseudo-hypertrophic  paralysis. 

///.  Diseases  of  the  Lumbar  Nenvs. 

The  posterior  lumbar  nerves  are.  like  the  doreal,  divided  into 
outer  and  inner  branches,  which  are  distributed  to  same  of  the  mus- 
cles of  the  b.ick  and  the  skin  of  the  lumbar  and  jflutcal  region.  The 
anteriijr.  by  far  the  stouter,  are  connected  each  with  the  c<irre»pond- 
ing  ganglion  lumbale  of  the  sympathetic.  They  form  the  lumbar 
plexus  which  lici  behind  and  in  ihc  pso,ns  muscle.  Its  branches  arr 
( Fig,  III):  ( I )  The  ilto-hypogastric  nerve,  for  the  transvcrsalis  and 
the  internal  oblique;  (i)  the  ilio-ingninal,  for  the  skin  of  the  p<ibc« 
and  the  genitals  (N.  scrotales  et  labialrs  anieriores) ;  (.;)  the  genitu- 
crural,  which  divides  into  the  external  spcimaiic  or  genital  branch 


/JiS/O.VS  OF  THE  LUMBAR  NERVE&. 


367 


and  the  lumbo-ini;uinaI  or  crural  bmnch,  the  former  Kiip|)lying  the 
ipcrniattc  cord,  ilie  creinatitcr  muiicle,  and  the  te»tts,  the  latter  the 


I1|.  ■».— niAoKtuHjuK  Oim-rxK  or  the  Lvmbak  aha  S*ciul  PiBxt**!*  DXll, 
ttk  dcowl  nam.  L/  t'.tkt  Ave  lumbar  nema.  S/  I'  thr  Aw  ncnl  iwnti.  C  /. 
Uh  OonyC**)  Bmr  1,  llir>hjpoeu*rk  nerve.  ■',  Ulo-lD|[Ulnal  iiem.  1,  i:*i>ila-<ni- 
nl  Mn«.  a",  (Uternal  cnaueoiu  nemol  the  Ihlcti.  r'lir,  uileriurtniral  nttvr.  ^A/, 
•UMHOr  oarvc  3,  Mperimr  cliUeol  atm,  it,  gnU  tcUIic  Dem.  4,  small  geiMic 
. ,  4*1  Infickir  elHleal  nene.  5.  Inferior  pudend*!  nerie.  %'.  postnior  cuunrnw 
tol  llil|[fc  and  Ici;.  (1,6,  brueh  10  rititurktoc  Inttraui  uid  cemetliw  aaperkir.  6'.  6'. 
kNMch  to  Ik*  ir«iMl)ui  Mfecl-w.  iiiuitrriiiu  fcoorli,  «itd  hip  )u<nl.  ].  twli^  In  the  pjrl- 
InnitL  S,  pulii'  mm.  g.  vlKrial  iinDtbM.  9*,  twis  lo  Itie  lentor  «ai  to,  perfoiai- 
\at  tMianm  —nn.    ii.  oxqicHibruidiM. 


368 


DISEASES  OF   THE   SPINAL  NERVES. 


skin  in  the  inguinal  region;  (4)  the  external  cutaneous,  for  the  skin 
down  to  the  knee;  (5)  the  obturator,  which  gives  off  a  posterior 
branch  to  the  obturator  ext.  and  adductor  magnus  and  an  anterior 
branch  to  the  skin  of  the  inner  side  of  the  thigh ;  and  (6)  the  anterior 


V 

\ 


V^ 


cp 


\! 


\pet.tmjj 


tW^V 


Uitij 


iSi 


1   'if. 


I  \ 
ts  \\\ 

i 


cti 


tOi 


Fig.  113.  Fig.  114. 

Areas  of  Distklbutwn  of  the  Cutaneous  Nehves  of  the  Lower  Extremcty. 
(After  Henle.)  ¥\e.  iij,  anterior  surface,  i,  middle  cuUneous  mrve.  a.  exiirnal 
cutaneous  nerve.  3,  i!io- inguinal  nerve.  4,  genito-cniial  nerve.  5.  eilernal  spermatic. 
6.  posterior  cutaneous  nerve.  7,  ol>turator  nerve.  S,  intenval  saphenous  ner\'e,  9.  citm- 
municatiiig  peroneal.  10,  supetficial  peroneal.  11,  deep  peroneal.  12,  conimunicaiing 
tibial.  Fig.  114,  posterior  surface,  i.  posterior  cutaneous  nerve.  3,  eitemal  cutaneous 
nerve,  .j,  obturator  nerve.  4,  median  posterior  femoral  cutaneous.  5,  communkating 
peroneal,  b.  saphenous  nerve.  7.  communicating  tibial.  S,  plantar  cuUneuus.  9,  me- 
dian plantar  nerve.     10,  lateral  plantar  nerve. 


crural  (five  miliimetres  in  width),  giving  muscular  branches  to  the 
anterior  periphery  of  the  thigh  and  having  also  cutaneous 'branches 
— middle  cutaneous,  internal  cutaneous,  and  the  long  or  internal 
saphenous  nerve  (cf.  Figs.  113  and  114). 


LBSIOKS  Ofi  Tits  LUMBAR  NERVES. 


369 


All  the  nerves  of  this  plexus  contain  sensory  as  well  as 
motor  iibrcs.  and  hence  may  be  aflcctcd  in  both  ways.  However, 
these  afleclions  do  not  often  appear  independently,  whereas 
ihey  are  frequently  observed  as  symptoms  of  central,  more  espe- 
cially of  spinal,  diseases,  and.  above  all,  of  tubes.  Our  dcscrEp. 
tion  of  them,  therefore,  will  here  be  very  brief. 

Among  the  sensory  disturbances  we  have  First  to  mention 
the  lumtxvabdominal  neuralgia,  in  which  the  hip  joint  is  alTected 
in  much  the  same  way  as  the  shoulder  joint  in  cervico-brachial 
neuralgia,  so  that  the  whole  lumbar  tcgion  down  to  the  but- 
tock is  intensely  painful.  Of  greater  practical  imporunce  is 
what  Cooper  has  described  as  "  irritable  testicle,"  neuralgia 
•permatica  or  neuralgia  of  the  testicle,  which  either  only  forms 
a  part  of  the  lura bo-abdominal  neuralgia,  or,  as  Rulcnbcrg  and 
others  assume,  is  a  neuralgia  of  the  sympathetic  nerve.  The 
sjKintaneous  pain  and  the  tenderness  m.iy  attain  such  a  degree 
as  to  lead  to  temporary  psychical  disturbances.  Genenilly 
only  one  testicle  is  alTectcd,  and  most  of  the  instances  are 
found  in  young  people.  Uenda  has  cured  a  case  of  this  neuraU 
gia  by  the  application  of  a  bandage  which  exercised  a  continuous 
pressure  upon  the  inguinal  region;  it  is  impossible  to  explain 
the  modus  operandi  of  this  measure  (Berlin,  klin.  Wochen- 
schr..  1890.  38).  Further,  we  would  mention  the  crural  nciiraUi 
gb,  and  (he  obturator  neuralgia,  afleclions  which  manifest 
themselves  by  jxain  following  exaclty  the  course  of  the  respect- 
ive nerves.  The  existence  of  tender  points  is  not  constant  and 
Ibcir  scat  varies. 

The  treatment  must  be  cirried  out  according  to  the  prin* 
dples  which  we  shall  describe  later  in  our  account  of  sciatica. 

Even  less  frequently  than  the  sensory  do  the  motor  disturb- 
ances occur  by  themselves.  If  present,  they  are  mostly  of 
spinal,  nirely  of  peripheral,  origin.  Paralyses  in  the  distribu- 
tion of  Ihe  crural  nerve,  which  interfere  with  the  ftmction  of 
the  illo-psnas  and  the  quadriceps,  make  it  impossible  (or  the 
palient  to  l>cnd  the  thigh  at  the  hip  joint  and  to  extend  the  leg 
alter  it  has  been  flexed  on  the  thigh.  Paralyses  of  the  obtura- 
tor ticrve  interfere  with  the  adduction  of  the  thigh  and  the 
patient  is  no  longer  able  to  cross  the  affected  leg  over  the 
other.  On  the  other  hand,  a  contracture  of  these  muscles  fol- 
lowing  myelitis  may  necessitate  the  resection  of  the  nerve,  an 
operation  which  may  be  followed  by  immediate  relief  (Lauen- 
stein.  Centralbl.   f.  Chir.,  1S92.  Ii).      F6r6  and  Perruchct  have 


370 


Dixy.ASES  OF  rue  spiral  jveares. 


published  an  exhaustive  study  upon  the  traumatic  origin  of 
neuralgia  of  the  obturator  nerve  (Kcviic  dc  Chir.,  18S9.  ix,  7, 
p.  J74).  Disorders  in  the  nerves  of  the  {gluteus,  the  tensor  vajn- 
nx  femoris,  and  the  pyrifortnis  impair  rotation  of  the  ihigh 
inward  and  outward.  Abduction  is  also  hindered,  while  the 
actions  of  walking,  standing,  and  more  especially  climbing 
stairs,  are  performed  awkwardly.  For  details  the  reader  is 
referred  to  DuchcnncAVcrnicke,  pages  261  and  following,  where 
the  normat  and  pathological  physiiology  of  these  muscles  is 
carefully  discussed. 

IF.  Diseases  of  the  Sacral  and  Cotcygca!  Ntrvts. 

The  posterior  small  branches  of  the  sacral  nerves,  four  of  which 
leave  the  vertebral  canal  throujfh  the  posterior  sacral  foramtna  and 
llie  fifth  tliruu^h  the  foramen  between  the  sacrum  and  coccyx,  form 
numerous  anastomoses,  and  thus  constitute  what  ts  known  as  the 
posterior  sacral  plexus.  The  anterior,  much  larger,  branches  pass 
into  the  pelvis,  where  the  first  three  and  a  part  of  the  fourth,  to- 
gether with  the  lumbo-sacral  cord  (resulting  from  the  junction  of  the 
fifth  and  a  part  of  the  fourth  lumbar  nerves),  go  to  form  the  (anle- 
riar)  sacral  plexus.  The  plexus  is  triangular  in  form  and  rests  upon 
the  pyridirinis  muscle.  The  several  nerves  unite  without  much  in- 
terlacement into  an  upper,  large,  and  a  lower,  small,  cord  or  band. 
The  upper  is  formed  by  the  union  of  the  lumbo-sacral  cord  with  the 
first  and  second  and  the  greater  part  of  the  third  sacral  nerves  and 
Is  continued  into  the  great  sciatic  nerve.  The  lower  becomes  the 
pudic  nerve.  The  plexus  gives  origin  to  a  number  of  collateral 
branches — the  superior  and  inferior  gluteal,  the  small  sciatic,  and 
perforating  cutaneous  nerves  and  branches  to  the  pyriformis,  obtura> 
lor  iniernus,  gcmelli,  and  quadratus  femoris.  The  great  sciatic  nerve, 
the  largest  nerve  of  the  body,  divides  into  the  internal  pophleal  and 
external  popliteal  or  peroneal,  the  latter  again  dividing  into  the 
anterior  tibial  and  musculo-cutancous,  the  former,  which  becomes 
the  posterior  tibial,  terminating  in  the  inlernat  and  external  plantar 
nerves.  The  pudic  nerve  divides  into  the  inferior  hxmorrhuidal,  the 
perineal  nerve,  and  the  dorsal  nerve  of  the  penis  or  clitoris. 

The  anterior  branch  of  the  coccygeal  nerve  is  distributed  to  the 
integument  over  the  back  part  and  the  side  of  the  coccyx.  It  is 
joined  by  a  branch  from  the  fifth  sacral  nerve,  while  the  posterior 
division  is  lost  in  the  fibrous  structures  on  the  back  o(  the  coccyx. 

The  affections  of  the  sacral  plexus,  which  appear  independ- 
ently of  any  other  disease,  are  chiefly  sensory  in  nature.  Mo- 
tor disturbances,  although   they  arc  perhaps  numerically  as 


L£S10A'S  OP  THE  SACKAL  PLBXUS. 


37' 


common  as  the  former,  are  in  the  great  majoHly  of  instances 
ivmptomalic  of    spinal  disea&e.      Careful   stndies    upon   the 
lesions  of  Ihe  scleral  and  lumbar  plexus  have  been  published  by 
paries  K.  Mills,  in  the  Medical  News.  June  15,  189I. 

Sciatica. 

Among  the  sensory  disturbances  there  is  especially  one 
disease  which,  owing  to  its  relative  frequency  and  obstinate 
resistance  to  treatment,  has  attained  to  much  practical  impor- 
tance — namely,  the  aiTcclion  of  the  sensory  fibres  of  the  sciatic 
nerve,  the  sciatic  neuralgia  or  sciatica,  malum  Cotunnij  (Co- 
tugno.  1764).  This  may,  as  autopsies  have  shown,  be  due  (o 
an  organic  disease  of  the  nerve,  a  genuine  neuritis,  or  to  a  func- 
tional neurosis.  In  Ihe  former  there  exist  varicose  dilatations 
of  the  blood-vessels  ol  the  nerve,  swelling,  increase  in  volume, 
alterations  in  consistency,  and  a  collection  of  serous  exudation 
in  the  nerve  sheath  (Cotugno,  Jasset).  In  the  Jailer  no  anatom- 
ical changes  can  be  detected.  The  neuritis  may  be  due  to  dis- 
ease of  the  neighboring  structures,  to  a  tenosynovitis  in  the 
tower  leg  (Erb),  to  affections  ol  the  vcrtcbrx  (spondylitis,  car- 
cinoma), or  may  nppcar  independently,  in  which  case,  leaving 
cold  out  of  consideration  for  a  moment,  we  have  usually  to 
deal  with  mechanical  injuries,  either  as  the  consequence  of 
wounds,  fractures,  or  as  the  result  ol  protracted  pressure  (tu- 
mors of  the  pelvis,  aneurisms,  hernia,  uterus  gravidus.  engorge- 
ment of  the  venous  plexus  of  the  pelvis,  habitual  constipation, 
etc.).  The  occupation  must,  moreover,  be  taken  into  consid- 
eration in  the  artioiogy  uf  sciatica.  It  may  exert  an  injurious 
influence  in  one  of  two  w,iys.  either  through  the  overexertion 
which  it  entails  or  through  the  exposure  to  frequent  sudden 
changes  of  temperature.  Of  the  former  we  have  instances  In 
those  who  work  with  the  sewing  machine  for  weeks  and 
months  for  several  hours  a  day.  and  in  those  who  are  always 
lifting  heavy  weights  (stevedores,  blacksmiths,  etc.).  To  this 
class  is  thought  to  belong  "  U  Umbxigo  da  /iwgrroHs"  de- 
fcribed  by  Maisonneuvc  (llirt,  Krnnkheiten  der  Arbeiler,  iv, 
90).  Of  the  latter  we  have  instances  in  puddlers  and  those 
who  work  at  smelting  furnaces,  etc.  Sciatica  is  frequently 
seen  among  such  people,  and  seems  to  affect  more  cummonly 
he  left  leg,  probably  because  in  throwing  the  coal  into  the 
urnacc  it  has  to  be  extended  more  forcibly  (Chicne,  of  Edin> 
h,  and  Hirl). 


372 


DISeASSS  OF  THE  SPINAL  JVEX^ES. 


As  a  symptom  sciatica  is  often  seen  in  spinal  allcctions 
(myelilis,  spinal  meningitis),  in  diseases  of  the  general  nervous 
system,  especially  in  tabes,  where  it  often  appears  bilaterally, 
also  in  diabetes.  As  a  sequela  it  has  been  described  us  follow- 
ing  typhoid  (ever.  Whether  malarial  intoxication  can  ever  be 
the  cause  of  it  is  uncertain.  It  ts  sometimes  seen  in  the  course 
of  syphilis.  In  lead  and  mercury  poisoning  it  plays  an  entirely 
secondary  rii/f. 

Symptoms. — Among  the  symptoms  of  sciatica  pain  is  the 
most  imporiaiit.  The  motor  disturbances  which  sometimes 
occur  in  the  course  of  the  disease — tremor,  clonic  spasmtidic 
movements,  the  difficulty  and  awkwardness  in  moving  which 
interfere  to  a  greater  or  less  extent  will)  standing  and  walking 
—have  to  be  looked  upon  simply  as  the  result  ul  the  pain. 
This  varies  greatly.  At  first  it  may  be  dull  and  quite  bearable, 
but  later  boring  in  character,  extending  over  the  whole  lower 
extremity  and  persisting  without  intermission,  so  that  it  con. 
stantly  occupies  the  attention  of  the  patient  and  forces  him  to 
a  frequent  change  of  position ;  or,  again,  it  may  appear  in  at- 
tacks, with  intervals  of  comparative  case,  so  that  the  patient 
(eels  fairly  comfortable  and  is  able  to  follow  his  occupation. 
During  the  seizures  it  may  be  of  such  excruciating  intensity 
that  it  can  only  be  compared  with  Fothergill's  faceache  or  the 
lancinating  pains  of  tabes. 

The  patient  suffers  usually  more  intensely  at  night  after 
going  to  bed,  or  at  least  he  complains  more  at  that  time,  often 
because  he  can  not  bear  the  extension  of  the  leg,  often  perhaps 
because  his  attention  is  then  less  liable  lo  be  distracted.  Yet 
even  in  the  daytime  the  pain  may  reach  a  considei-ablc  pitch, 
especially  when  the  patient  has  been  making  attempts  to  walk 
or  has  been  standing  too  much.  He  may  have  perfect  ease  for 
hours  when  lying  quietly,  and  yet  a  few  moments  a(  flexion 
and  extension  of  the  affected  extremity  arc  sullicicnt  to  throw 
him  hack  into  the  most  distressing  condition.  The  extent  of  (he 
pain  also  varies ;  generally  it  is  felt  over  the  whole  posterior 
surface  of  the  thigh  and  the  distribution  of  the  external  poplit- 
eal nerve.  It  may  radiate  into  the  region  of  the  healthy  sciatic 
and  the  lumbar  plexus  o(  the  affected  side.  The  posterior 
tibial  nerve  usually  remains  intact.  Examination  almost  always 
discloses  the  existence  of  tender  points,  one,  for  instance,  at 
the  exit  of  the  nerve  from  the  pelvis,  one  at  the  lower  margin 
of  the  gluteus,  one  in  the  popliteal  space,  one  on  the  capitulum 


LESIOS'S  OF  THE  SACRAL  PtJiXVS. 


373 


I 

I 


I 


ila:.  There  may  be  uthcrs.  but  their  occurrence  is  uncer- 
tain and  their  position  changeable. 

Sometimes  patients  with  sciatica  are  seen  to  put  all  their 
weight  upon  the  healthy  leg  in  order  to  diminish  the  pain  in 
the  aflcctcd  extremity.  This  causes  the  trunk  to  be  bent  to- 
ward the  healthy  side  and  the  costal  margin  to  approach  the 
ilium,  a  position  which  may  become  so  habitual  that  a  genuine 
scoliosis  may  be  developed,  the  convexity  ol  which  is  directed 
toward  the  healthy  side ;  in  exceptional  cases  the  reverse  is 
the  case — namely,  the  convexity  of  the  curvature  is  directed 
toward  the  affected  side.  Rcmak  (cf.  liu)  is  of  opinion  that  the 
patient  is  able  to  convert  the  "normal"  into  the  "abnormal" 
scoliosis  as  his  comfort  may  demand,  while  Bri.s!>aud  regards 
the  abnormal  position  as  the  result  of  a  reflex  spasm.  I  have 
known  several  cases  in  which  this  secondary  scoliosis  per- 
sisted after  considerable  improvement  of  the  primary  aflection, 
whereas  in  other  instances  1  have  seen  it  disappear  when  the 
cure  of  the  sciatica  was  complete. 

If  we  have  to  deal  with  a  genuine  neuritis  trophic  changes 
will  be  found  to  develop,  especially  more  or  less  marked  atro- 
phy of  the  muscles  in  various  regions  supplied  by  the  sciatic 
nerve  (Uuinon  et  Parrnentier  and  others),  with  reaction  of  de- 
generation (Konne).  The  patellar  reflex  seems  in  such  cases 
to  be  considerably  diminished.  An  exaggerated  knee  jerkin 
the  course  of  a  peripheral  neuritis  has.  un  the  whole,  to  be 
looked  upon  as  exceptional  (StrUmpell,  MObius).  In  sciatica  I 
have  never  seen  it.  If  the  trouble  is  purely  functional  the 
muscles  and  reflexes  remain,  even  after  years  of  sulTering, 
unaltered.  Other  sensory  changes — diminution  of  the  sensi- 
bility, anesthesias,  pantsihesias — occur,  but  lake  a  very  sec- 
itndnry  position  to  the  donunaling  feature  of  the  disease,  which 
is  pain. 

Course.— The  course  as  well  a<i  the  duration  varies  greatly, 
but  we  may  state  as  an  undeniable  fact  that  it  is  excepticmal 
to  find  cases  which  last  but  a  .<;horl  time  and  end  with  com- 
plete recovery.  Mostly  it  is  a  question  of  months  and  years 
before  any  decided  lasting  improvement  is  brought  about. 
On  the  other  hand,  remissions  arc  not  rare.  They  may  last 
lor  months,  and  the  condition  of  the  patient  may  be  such  that 
he  begins  to  be  confident  of  a  permanent  cure,  when  suddenly, 
often  without  any  appreciable  cause,  sometimes  in  consequence 
ol  a  long  walk,  the  pain  again  makes  its  appearance  with  un- 


374 


D/SEASES  OP  THE  SPINAL  NERVES. 


diminished  intensity  and  the  treatment  has  to  be  started  all 
over  again.  The  more  frequent  such  relapses,  the  more  gloDiny 
becomes  llic  outlook  tor  complete  recovery. 

Diagnosis. — Great  care  should  be  exercised  in  the  diagno- 
sis, and  wc  should  tirst  endeavor  to  decide  whether  the  trouble 
has  to  be  regarded  as  an  idiopathic  aGfection  or  as  a  symptom 
ol  anullier  malady,  and  more  especially  Itt  bilateral  sciatica 
should  wu  be  nn  the  lookout  for  a  spinal  disease  or  a  disease  of 
the  general  nervous  system,  such  as  tabes.  The  examination 
of  the  ttrinc  lor  sugar  should  never  be  omitted.  H  this  ]>rovcs 
negative,  and  if  wc  can  exclude  general  nervous  diseases  with 
certainty,  wc  should  proceed  to  analyze  the  pain,  to  examine 
into  its  nature,  the  time  of  its  occurrence,  its  seat  and  extent, 
and  should  keep  in  mind  that  there  are  other  than  nervous  af- 
fections that  are  associated  with  violent  pain  in  the  lower  ex- 
tremities; for  instance,  acute  rheumatism  of  the  lumbar  muscles, 
lumbago,  also  inflammations  in  the  hip  joint,  chronic  hip  dis- 
ease, malum  cox»;  senile,  as  well  as  gouty  alfections  and  psoas 
abscesses.  In  all  such  instances  the  immobility  of  the  extrem- 
ity, which  also  exists  in  a  pure  sciatica,  makes  the  examination 
difficult,  and  only  after  persistent  repetitions  shall  wc  be  able 
to  obtain  a  clear  idea  as  to  the  true  nature  of  the  trouble.  Al- 
though it  may  be  going  too  far  to  say  with  Hutchinson  that 
out  of  twenty  cases  diagnosticated  as  sciatica  in  nineteen  there 
exists  no  trouble  whatever  in  the  nerve  {Medical  Times  and 
Gazette,  1883,  vol.  i.  No.  J648,  page  35),  there  can  be  no  ques- 
tion but  that  here  many  diagnostic  sins  are  committed  and 
that  there  arc  many  cases  called  sciatica  alter  a  superficial  ex- 
ploration whicli  later  prove  to  be  something  entirely  dilTerent, 

Treatment. — The  treatment  ol  sciatica  should  vary  accord- 
ing as  the  neuralgic  pains  constitute  merely  a  symptom  or 
result  from  an  independent  affection  of  the  nerve  itsell.  In  the 
former  case  our  therapeutic  measures,  of  course,  must  be  di- 
rected against  the  underlying  disease  (diabetes,  tabes,  syphilis, 
etc.).  If  we  have  to  deal  with  sciatica  as  an  affection  by  itself 
our  treatment  should  be  systematic  and  carried  out  on  dcfi- 
nile  lines.  Our  first  rule  should  be  never,  or  at  any  rale  only 
in  exceptional  instances,  to  withdraw  blood.  If  there  are  old 
scybalous  masses  in  the  bowel  which  press  upon  the  nerve 
and  thus  cause  the  pain,  considerable  and  lasting  improvement 
may  be  brought  about  by  the  removal  of  these,  and  a  course 
at  Carlsbad  or  Maricnbad   may  cure  sciatica  in  such  cases 


1 


I 

I 
1 
I 


ISS/O.VS  OF  THE  SACRAL  PLEXUS. 


375 


I 

I 
I 


I 


more  quickly  and  surely  than  the  most  careful  use  of  electrici- 
ty. Next,  especially  when  we  have  grounds  for  suspecting 
in  inflammatory  condition  of  the  nerve,  we  should  try  the  ap- 
plication of  counter-irritants  to  the  skin,  fly.blistcrs  or  the 
so^alled  /w/«/*  dt  feu  (witK  Paquclin's  thermo-cauiery).  The 
former  more  particularly,  which  have  been  used  by  Cotugno 
and  Valleix,  deserve  to  be  recotit mended,  as  they  prove  gen- 
erally very  effectual  if  used  early  in  the  disease;  they  may  be 
applied  alonfi  the  course  of  the  nerve  on  the  thigh  or  in  the 
sacral  region  (Anslie).  Loss  benefit  is  usually  derived  from 
irritating  inunctions  and  plasters,  which  may,  however,  be 
given  a  trial  ;  (or  instance,  we  may  employ  one  ol  Betz's  plas- 
ter*—empl.  oxycroc.  i5.o(5ss.):  arg.  nitr.  pulv.,  i.o(grs.  xv) — 
allowing  i(  to  remain  on  the  skin  until  it  drops  off  of  its  own 
accord.  Among  other  drugs  for  inunctions  besides  vcratrine 
[0.1  :  10  tardj  the  narcotics  (preparations  of  opium.  bclladonDa. 
hyoscyamus)  may  be  useful.  Finally,  the  chloridc-of-raclhyt 
spray  may  be  recommended.  This,  however,  should  be  used 
with  great  care ;  otherwise  it  may  be  followed  by  a  cellulitis, 
erysiijclas.  or  even  gangrene.  The  desired  effect  does  not  al- 
ways follow  (cf.  Steincr.  Deutsche  Med.-Ztg.,  189I,  I02,  p. 
1158). 

From  internal  medicines  I  have  never  seen  any  lasting  good 
results;  besides  antipyrin  and  antitebrinc,  iodide  ol  potassium 
has  been  used  Irom  time  immemorial,  also  quinine  and  all  the 
nervines.  Krccntly  solaninc  has  been  recommended,  fifteen  to 
twenty  centigrammes  (grs.  ijss,-iijss.)  a  day.  In  my  own  expe- 
rience this  drug  docs  not  possess  much  value;  neither  docs  the 
oil  of  turpentine  given  iniemally  in  capsules  containing  fifteen 
raininis  ten  or  twelve  limes  a  day.  In  short,  I  consider  all  in. 
temal  medicines,  unless  the  case  be  one  of  syphilis,  as  useless 
and  inadvisable,  for,  owing  to  the  long  duration  of  the  trouble, 
they  would  have  to  be  taken  for  months  with  great  detriment 
10  the  stomach  and  to  the  digestion.  More  is  accomplished 
by  external  measures — massage  and  electricity.  Both  have  the 
disadvantage,  however,  that  they  act  very  slowly  and  that  their 
application  causes  more  or  less  violent  pain,  a  remark  which 
applies  more  particularly  to  a  systematic  and  an  energetic  use 
r>f  massage  (Schreibcr  and  others).  The  faradic  brush  and  the 
combined  current  used  by  De  Waiteville  are  also  very  painful, 
but  both  can  be  recommended  wiih  a  clear  conscience.  With 
regard  to  the  best  manner  in  which  the  electricity  should  be 


376 


J3/SSAS£S  Of  TUB  SPIXAl.  Nf.RVES. 


given,  as  we  have  said  before,  we  now  repeal  thai  every  one  lias 
his  own  method,  in  which  he  has  most  confidence  because  he 
is  most  familiar  with  it. 

If  we  are  forced  to  send  our  patients  to  the  springs,  we  may 
first  of  all  recommend  non-medicated  hot  springs  or  hot  brine 
spring:s.  Among  the  former  may  be  mentioned  Gustein,  Her- 
kulcsbad,  Johannisbad,  Tcplitz-Schiinau,  and  Wildbad  ;  among 
the  latter,  Wiesbaden.  Nauheim,  Rchme.  and  Baden-Baden. 
At  hot  sulphur  springs,  (or  instance.  Landeck.  Teplilz-Trenc- 
sin,  and  I'istydn  in  Hungary,  such  patients  do  very  well,  but 
it  is  advisable  not  to  raise  their  expectations  too  high,  as  often 
the  results  of  a  stay  at  the  springs  arc  not  very  striking.  Sea- 
bathing  is  not  always  borne  welt  by  patients  with  neuralgia. 
At  any  rate,  it  is  well  to  begin  with  places  on  the  Ilaliic  and  to 
select  first  those  where  warm  sea- water  baths  can.  if  necessary, 
be  also  obtained— c.  g..  Colberg,  Misdroy,  Zoppot.  and  others. 
In  severe  cases,  particularly  if  there  occur  transient  attacks  of 
intense  pain,  morphine  can  not  be  dispensed  with.  Subcuta- 
neous injections  in  proper  amounts  and  at  the  proper  time 
will  do  the  patient  no  harm,  but  will  afTord  him  unspeakable 
relief,  such  as  can  be  expected  from  no  other  drug. 


I.1TKRATURE. 

Albert.     Eine  eigenlhumlicbe  Arl  der  TinaUkoliose.     Wiener  med,  Prfs«, 

}A%\t.  i8S6,  xxvi. 
Nicobiliini.    Urt>M  cine  Art  dc«  J^usammcnhtingcs  iwi«chcn  Itchus  und  Skoliosc. 

Ibid..  1886. 16.  27. 
Vinay.     P«rAl)'&tc  rudiculaire  du  ncrf  >itiati(iuc  par  coinpreMion  k  c«ase  <lc  roc- 
couch  cm  em.     Rcvuc  dc  m^d,.  1887.  7. 
Babinski.    Sur  unc  iljfonnutiun  pnrticuliire  du  Ironc  catiafe  par  la  tcutiqiic. 

Arch.  d<-  Neurol..  18SS,  1.1.  43.  1, 
Bernlunlt.     Ueber  Pcrttneu.ilahmunKcn.     Original bericht  der  CcMUschftfl  f. 

Psych,  u.  NiTvcnkb.  xu  Uerbn  aw  November  11,  1888.     Neiiroi  Centralbl., 

1888,  33. 
Seliudcl.     (Jcber  Istbias  scoliotica.     Arch.  f.  Win.  Chii..  iSftS,  38.  1. 
Weiss.     Zur  Thcnpk-  dcr  Ischias.    Cmtralbl.  f.  d,  g«.  TTierap..  1889.  vii.  t, 
Texier.     U^furinalion  pacliculibe  du  trunc  causae  par  la  sciaiique.     Thisc  de 

I-aib.  1888, 
Brissatid.     Des  scolioses  dans  les  nJvralg^es  sclallques.    Arch-  de  NcuroL,  Ju).. 

1S90. 
Gorlun.    Wiener  kliri.  Wocherwchr.,  1890,  ;4. 

V.  BonsdorlT.     Finska  ISkarevallsk,  h.indl..  1S90.  xixli.  J.     (Ischlaa  Scoliolica.) 
Guinon  ct  P.inncnlicr.     Arch,  de  NcuroL,  1890,  S9- 

Juinski.     PnCKlad  Ickankl.,  1S90,  %\\\.  7.  8.     (Skoliosis  fo)lo»-in|[  Sciatica.) 
Cussenbaucr.     Pragcr  mcd.  Wocbcnscbr.,  1890,  xv,  17,  18. 


W.S/OKS  OP  THE  SACRAL  PLEXUS. 


377 


^B  Popper.    Ueulxlve  meil.  Wochcnuchr,,  1890.  4}.     (PcroncAl  Pnlty  produced  by 
^V         Mechanickl  Cuuics.i 

V  Renuk.      Altcmircnde  Skoliose  bci   IscKias.      Dcultchc  m«l.    WochcBSchr, 
1891.  7. 

•  Charcot.  J.  O.,  «  MeifTc,     Un  cas  de  sciailque  avec  (uraly^ie  amyoirophique 
dint  le  domninr  du  poplilt.  detcrmin^c  par  I'usagr  cxag£r£  <k  la  niatlunc  A 
coudre.     I'liifiri'i  m^d..  1891.  No.  14. 
Lamy.     Deux  t»,s  ilc  KiBt\qu«  &|iiL&inudiijue.     I'rogrh  in^d.,  1891,  3. 
Remalc     Ucbrr  lochias  scoliotics.     Deutsche  m«l.  Wochcnschr,  1891.  17. 
Higicr.      Fiinf  Kiillc  von   Iichias   xcalioticA.      Ueuixchc  med.  Wochcnschr. 
189a.  37- 

»OtMm,  Otcar.    Fll  FatI  ar  ischial  scoliotica.     lly-gjca.  1891. 1,  Iv.  p.  334. 
Klamroih.     Berliner  kliit.  Wocheiischr.,  i8</3.  38.  pag.  960L 
Iluncmunn.     Arch.  i.  Gyn.,  1891.  xlii,  j.  pag.  489.     (Panty&is  in  ihe  distribution 

of  the  Scuilie  Nerrc  as  a  Conscijuenix  of  Ch>kl1>inh.) 
Sachs.  W.     Kin  lleitrag  lur  Frage  der  Ischias  scoliotica.     Arch.  i.  klin.  Cbir, 
1893.  xlvi.  He  ft  4. 

Far  less  (requeiitly — vre  might  say,  only  exceptionally— are 
the  individual  branches  of  the  sciatic  nerve  the  scat  o(  neural- 
gia; tbtis  we  may  have  an  affection  o(  the  plantar  nerves,  and 
sometimes  the  hyperesthesia  in  their  distribution  may  be  so 
marked  that  the  patient  is  absolutely  prevented  from  standing 
or  walking.  Barbillon  (cf.  lit.)  has  itevuted  a  careful  study  lo 
this  sccalled  plantar  hypern;sthcsia  without,  however,  being 
able  to  decide  whether  the  disorder  is  of  spinal  origin,  or 
whether  it  has  to  be  regarded  as  a  so-called  dermatalgia,  or 
again  as  a  disturbance  in  the  nutrition  of  the  fitie  nerve  end- 
ings. The  first  explanation  is  supported  by  the  fact  that 
usually  both  feet  arc  affected :  the  last  that  it  often  occurs  in 
people  who  have  to  stand  a  good  deal.  It  has  often  been 
known  to  occur  as  a  sequela  of  typhoid  fever.  Cures  are  said 
lo  have  been  effected  by  blisters,  or  by  the  application  of  a 
spnty  of  methyl  chloride ;  bathing  the  feet  fur  some  lime  in 
hot  salt  solution  has  also  been  recommended.  The  neuralgia 
of  the  external  plantar  nerve  which  S.  K.  Morion  has  described 
u  mctalarsalgia  (Annals of  Surgery,  June.  1A93).  manifests  itself 
in  [>an«ysms  of  p.iin  in  an  area  extending  from  the  ihirti  to 
the  fifth  metatarso-plialangeal  joint;  during  these  paroxysms 
the  patient  is  unable  to  walk  and  is  forced  tu  take  off  his  shoe. 
Badly  fitting  shoes  and  Iraumalisin  seem  lo  be  ihe  causes  of  the 
affection.  Sometimes  it  may  be  neccssar)*  to  resect  the  head 
of  the  fourth  metatarsal  bone. 

The  pudic  nerve,  which  supplies  the  bladder,  the  rectum, 
the  perimcum,  and  the  external  gciiilals.  is  often  the  scat  of  neu- 


378 


DtSEASeS  OF  THE  SPhVAI.  yERVES. 


ralgias  which  are  sometimes  purely  cutaneous  and  show  them- 
selves by  an  extreme  tenderness  u(  the  skin  of  the  penis,  the 
scrotum,  the  region  of  the  anus,  and  the  mons  Veneris.  In 
many  instances  the  testicle  is  affected  and,  as  we  have  pointed 
out  above,  becomes  very  tender  and  the  seat  of  violent  paroxys- 
mal pains.  Although  there  may  be  intervals  in  which  the  neu- 
ralgia disappears,  the  tenderness  and  irritability  remain  as  long 
as  the  disease  of  the  nerves  is  present. 

Other  nervous  affections  of  the  male  urinary  apparatus  have 
been  studied  by  OberlUnder  (cf,  lit.),  who  has  called  attention 
to  the  fact  that  varicocele,  chronic  gonnrrhcca,  hydrocele  mul- 
lilocularis.  tuberculosis,  carcinoma,  etc.,  frccjuenlly  give  rise  to 
such  disorders,  and  indeed  not  only  do  the  just  mentioned  cuta- 
neous  forms  occur,  but  also  a  peculiar  neuralgia  of  the  urethra, 
which  becomes  particularly  distressing  during  coitus  and  mic- 
turition, is  frequently  known  to  develop  under  the  influence  of 
such  alTcctions.  The  remains  of  a  gonorrhcca  together  wilh 
chronic  dyspepsia  may  produce  a  chronic  hyperarsthesia  o(  the 
mucous  membrane  of  the  bla<ldcr,  to  which  little  attention  has 
been  paid  as  yet.  The  pain  appears  periodically,  affects  the 
whole  bladder  region,  and  radiates  into  the  urethra  and  the 
ureters.  Slight  errors  of  diet  may  evoke  violent  exacerbations 
of  the  trouble.  Neuralgia  of  the  bladder  is  found  in  neurasthe- 
nia, but  also  at  times  in  the  initial  stage  of  tabes ;  hence  it  would 
be  necessary  to  decide,  if  wc  have  diagnosticated  a  neuralgia  of 
the  bladder,  whether  it  is  due  to  a  cystitis  or  a  spinal  disease, 
or  whether,  on  the  other  hand,  it  constitutes  an  a0ection  by 
itself. 

The  neuralgia  of  the  prostatic  gland  has  recently  been 
studied  by  Preyer  of  Ziirich  ;  he  distinguishes  a  hypcrjcst hesia 
of  the  organ  proper  from  a  hyperaesthesiaof  the  prostatic  por- 
tion of  the  urethra,  and  thirdly  describes  an  irritability  of  the 
muscular  portion  of  the  gland.  Paroxysmal  pains  and  spasms 
of  the  sphincter  vesica;  are  the  most  prominent  symptoms  of 
the  affection.  The  treatment  consists  partly  in  attending  lo 
the  general  health,  partly  in  surgical  measures,  the  passing  of 
sounds  etc.  (Berlin,  Fischer,  1891). 

Anaisthcsia  of  the  raucous  membrane  of  the  bladder  and  of 
the  urethra  as  well  as  loss  of  [he  muscular  sense  ol  the  bladder 
make  it  impossible  for  the  patient  to  say  with  the  eyes  closed 
whether  he  is  voiding  urine  or  not.  It  may  happen  to  tabetics, 
in  whom  the  condition  is  not  infrequently  met  with,  that,  hav- 


\ 


lESJOXS  OF  THE  SACKAL  PLEXUS. 


m 


vag  given  up  all  attempts  to  micturate  after  unsuccessful  strain- 
ing, tfaey  pass  their  urine  involuntarily  and  become  only  con- 
scious of  the  fact  when  Ihcy  feci  ihc  dampness  oi  their  clothes. 
This  anaesthesia  does  nut  seem,  however,  to  occur  as  an  inde- 
pendent disease,  but  would  appear  to  be  always  of  central 
origin. 

The  motor  disturbances  affecting  the  muscles  which  expel 
the  urine  and  those  wtiicli  close  the  bladder  may  be  of  an  irri- 
tative or  a  paralytic  nature,  the  former  constituting  what  is 
known  as  slranjjury  :  the  latter  arc  by  the  laily  comprehen<Icd 
under  the  name  of  "  weakness  of  the  bhddcr."  Both  may  be 
.  ^mptoms  of  chronic  inllammaliun  of  the  urethra  or  of  certain 
' ^inal  diseases,  and  may  also  occur  independently,  as  purely 
nervous  affections.  The  desire  to  urinate  every  few  minutes. 
a  desire  which  is  increased  after  drinking  alcoholic  beverages, 
(s  not  infrequently  alternated  by  spastic  conditions  of  the  mus- 
cles of  the  bulb  which  give  rise  during  micturition  to  spas- 
modic excruciating  pains  in  the  perinicum  which  radiate  to  the 
thighs  and  the  buttocks. 

In  nil  cases  of  this  kind  the  treatment  is  generally  begun  with 
the  usual  ami. neuralgic  remedies,  of  Lite  years  also  with  co- 
caine. However,  the  result  is  often  very  unsatisfactory.  We 
should  always  carefully  search  for  possible  underlying  abnor- 
mities, such  as  an  elongated  adherent  prcpulium,  insuflicientiy 
dilated  or  light  strictures,  flexion  or  version  of  the  uterus,  or 
pathological  changes  in  the  rectum.  If  such  be  found  the  neu- 
ralgia is  to  be  regarded  as  a  reflex  neurosis,  and  we  have  to 
direct  our  therapeutic  efforts  to  the  primary  cause,  by  which 
procedure  wc  may  be  able  to  improve  and  eventually  cure  the 
neundgia.  To  the  same  class  of  reflex  neuroses  belongs  the 
enuresis  nocturna,  which  is  rather  common  among  children. 
The  trouble  can  usually  be  traced  to  irritation  in  the  urethra 
or  at  the  orifice,  such  as  inflammatory  conditions,  slight  adhe- 
sions of  the  mucous  membraite  far  back  in  the  urethra,  too  nar- 
row an  orifice  of  the  urethra,  and  the  like.  It  has  been  claimed 
that  the  urine  sometimes  contains  an  irritating  substance  which 
produces  reflexly  the  enuresis,  which  can  be  controlled  by  the 
wimini>(ratinn  of  mild  narcotics.  (Aqua  Amygdal.,  amar..  etc. 
— Rohde,  Berl.  klin.  Wochenschr.,  1893,  42).  Here,  of  course, 
attention  to  such  primary  disorders  is  the  first  step  in  our 
treatment,  and  dilatation  of  the  posterior  portions  of  the  ure- 
thra with  diLttors  made  for  the  purpose  will  often  be  followed 


38o 


DISEASES  OP  T/fE  SPINAL  NERVES. 


by  striking    results  (OberliUider,  Uerliner  klinische  Wochen- 
schrilt,  i8S8,  31). 

By  coccygodttiia  we  mean  a  neitralgin  which  is  character- 
ized by  pain  over  the  region  of  the  coccyx.  The  affeclion  is 
more  frequently  met  with  in  women  than  in  men,  and  the  pain, 
which  shows  paroxysmal  exacerbations  and  comes  on  more  par- 
ttcularly  during  the  iicl  of  defecation,  may  attain  to  a  (rightful 
pitch.  The  causes  of  the  affection  arc  obscure,  yet  we  arc 
probably  not  far  from  being  correct  in  assuming  that  in  many 
cases  it  is  of  reflex  origin,  as  in  men  especially  treatment  of  the 
genitals — a  diminution  of  an  abnormal  sensitiveness  of  the  pars 
prostatica  ureth.,  etc. — may  be  followed  by  surprising  results. 
In  some  cases  the  pains  appear  during  sleep  without  any  ap- 
preciable cause,  in  others  they  have  been  known  to  occur  after 
traumatism.  I  have  repeatedly  observed  them  in  neurasthenic 
and  hysterical  patients.  The  excision  uf  the  coccyx,  an  opera- 
tion which  in  desperate  cases  has  been  undertaken  for  relief  o( 
the  pnin,  should,  of  course,  not  be  resorted  to  until  all  other 
means,  particularly  energetic  application  of  the  fara^ic  brush, 
have  been  thoroughly  tried. 


LITERATURE. 

Hammond.    Neiiralgi.i  of  ihc  Trsiicle.     Neurol.  Conlribul,,  1S81.  L  3. 

Sultoii.    Crural  Neunilgia  in  Dcntisis,     Lsncct.  1881,  ii.  4. 

Engtrlhardl.    Zur  Grnc«e  ilcr  ncrvoM>ii  Symplomcncomplexc  bei  •uiAlomischen 

VcTJiti(leriin){«Tn  in  den  Scxu^lur^^jncn.     SlutlKari,  Enk& 
Englisch.     Ucber  (-iiie  besundcrt.'  Fonii  dcr  HSmcirrhRgjc  an  den  UiitcrcxirODi- 

iSlcn  (Hx-mnrrh.igia  ncunlgica).     Wicn.  rar<l.  ItlSltcr,  188;.  24--16. 
Barbillun.     llypcnt^ihesu  pluntw  bilatcnliii.     I'mgr.  in6d..  i88j.  %m,  19. 
Sirunnpdl  iind  Multius.     Uebcr  Slcignung  <!or  Schncnirllric  bci  ErkranktuiK 

periphercT  N'erven.     MDnch.  mc<l.  Wochcntchr,  1886.  ixxiii,  14. 
S.  Laachc.     Norsk  Maguz.  f.  LUdTvidensk.,   1886,  4  K.,  i,  19.     {Hyperiraih. 

plani.-ir,) 
Obcrlttndi^r.    Zur  Kennlnbs  dcr  nervuMrn  ICikrankunKcn  am  Hamapfuraie  des 

Mannrs.    Volkmann'srhc  Sfliiiniluiig  klin.  VorlT.,  1886.  275. 
Adamkiewicit.    Ein  Mtltcncr  Fall  von  Nctiralj;ic  im  N.  pudrndu  conimunls  mil 

^lucklichcm  Au^gange.     Breal.  KtiiI.  Z^ftschr.,  1886,  8, 
Poihrral.     N*vralgic  visiealc.     ProgrJsmW..  1887.  17. 
NiMine.     Berliner  ktin.  Wochcn.ichr.,  1887,  45. 
HugliM  (St.  Louis),     Weekly  Met).  Rev..  March  tJ.  1887-    (Plantar  Hn»era»- 

thcsia.  Neuritis  N.  PInntaris  Intcmi,  in  Consequence  of  Overexertion.) 
I'eyer.    Zwei  FiiUe  vimi  Neuralgic  de*  Sleitrabdns  b«  MSnncm.    Cenlralbl.  f. 

klin.  Med..  1888.  ix.  37. 
Bemh.irdl,    Klin.  Hearst;  ^nr  I.rhrevonder  Inncn'-iIionderDIasedesMastdarmi 

und  dcr  GescbleclilsfuncUun.     Berliner  klia.  Wocbcn§chr.,  1888.  ixv,  31. 


lESWyS  OF  TUB  SACRAL  PLEXUS, 


381 


I 

\ 


I 


V.  .Swicrkki.      Zur  opcnitlven   l)eh:ii)(Ilung   der  Cuccjrgodynk.      Wien.   mcd. 

IfUM,  18S8,  xxix,  31. 
OrillV.  M.     Zcilsdir.  f.  Gcburtili.  und  Gynacologic,  18S8,  xr,  3,  p.  344. 
Mills,  Lttions  of  Die  Sacra)  and  Lurnlur  PIciuses.     Mol.  News.  June  1  \.  iSS^. 

As  10  llie  motor  disturbances — and  of  these  wc  will  take  up 
fir^t  the  paralyses  which  occur  in  the  diMribution  ol  the  sacral 
plexus— here,  loo,  those  of  the  sciuiic  nen'c  arc  the  most  im- 
portant. Stich  lc!»iun<i  may  affect  the  nerve  high  tip  in  the 
pelvis,  or  soon  after  its  exit  from  it.  or  still  lower  down  in  its 
branches.  The  6rst  arc  almost  always  caused  by  ir.iuni:)iism 
«r  pressure  exerted  for  a  comparatively  long  time — e.  g.,  by  a 
pr^nant  uterus,  the  child's  head  during  labor  (Vinay).  tumors, 
etc.  The  others  often  constitute  a  symptom  of  some  other 
disease. 

External  popliteal  (peroneal)  paralysis,  in  which  the  mus< 
cles  of  the  anterior  surface  of  the  leg  are  a  fleeted  (the  exlen- 
sors  of  the  toes,  the  tibialis  amicus,  and  the  pcronci).  is  easily 
recognized.  The  foot  hangs  down  tiaccidly,  it  can  not  be 
dorsally  flexed,  abducted,  nor  adducted.  As  a  result,  walking 
\%  very  much  impaired,  since  the  point  of  the  foot  often  trips 
over  prominences  on  the  floor,  but  by  raising  the  thigii  higher 
than  usual  the  patient  somewhat  overcomes  the  difficulty.  As 
the  point  of  the  foot  or  the  outer  margin  is  first  put  to  the 
ground  in  an  awkward  manner,  the  g:iil  is  very  peculiar  and 
highly  characteristic  of  this  form  o(  paralysis.  Contractures 
of  the  calf  muscles,  which  may  later  develop  secondarily,  give 
rise  to  a  permanent  position  of  talipes  cquinus  or  talipes  cquino- 
x-arus.  External  popliteal  paralysis  may  be  brought  on  by  the 
iKcupation  of  the  patient.  It  has  been  seen  as  the  result  of 
pressure  in  those  who,  from  the  nature  of  their  work,  have  to 
be  constantly  in  a  kneeling  position,  as.  for  instance,  asphalt 
pavers  (Bernhardt). 

Internal  popliteal  paralysis,  which  implicates  the  muscles  of 
the  back  of  the  lower  leg  (the  Hcxors.  the  tibialis  posticus)  and 
the  muscles  of  the  soles  of  the  foot  (adductor  and  abductor 
hallucis  and  the  intcrossei).  interferes  with  the  plantar  flexion 
uf  the  foot  and  with  flexion  and  lateral  motion  ol  the  toes.  As 
a  result  the  patients  are  unable  to  stand  on  tiptoe,  II  the  in- 
tcrossei take  part,  a  condition  is  developed  similar  to  that 
which  is  seen  in  the  hand  and  which  we  have  described  on 
page  352,  The  toes  assume  a  claw-likc  position  owing  to  the 
iact  that  the  first  phalanx  is  dorsally  Hexed  while  the  second 


382 


msSASSS  OF  THE  SPINAL  NEKf'ES. 


and  tliird  are  iu  plnnt.nr  flexion.  Here  also  secondary  con- 
tractures may  appear  (uf  the  tibialis  amicus,  triceps  sura:), 
wliicl)  give  rise  to  a  paralytic  clubfoot  (pes  planus,  pcsequinus, 
pes  calcaneus). 

Paralysis  of  the   whole  sciatic  makes  it  impossible  for  the 
patient  to  lU-x  the  lower  leg  on  the  thigh,  to  approach  the 


A'.  ohlnrMrr  — 
M.jHttiatiU 

3f.  odAtrloT  temgM 


H.  popliltaltt  KTlimut 
if.  liUnlU  imrirtu 
M.  f/lmnor  hingtu 

if.  peronrut  lonrfiu 
if.  prronna  Arviia 

At.  rjimior  hrttu 
poUicit 


31.  autaitr  irrmii 


A',  eniralu 

if.  Ittuar  mjini* 


if.  ^adnapi  friuitrit 
31.  rttha  ftunn-il 
M.  «tiirrtu 
if.  raaut  fttrmmt 

if.  vo^w  Mfntw 

JT,  jToifrMiHnjiii 
if.-jlna 


31,  fttm  lontpit 

M.  oMiMjr  mMmi 
digUi 


-^     if.  imltf^inl  dfrt^n 
F](,  IIS.— MoTOH  I*i>ixTS  FOR  T1IR  NiRvn  unt  Muk-lb*  or  thk  Avmitioa  Sukfack 

OF  TKc  Leo. 


heel  to  the  buttock,  and  to  rotate  the  thigh  (M.  obturator  in- 
lernus),  Paralysis  o(  one  sciatic  alone  does  not  make  walking 
absolutely  impoMiiblc,  becauw  the  leg  fixed  in  the  knee  joint  is 
moved  forward  by  the  muscles  of  the  thigh,  and  so  is  used  as  a 
stilt  (cl.  page  226,  gait  of  the  hcmiplcgic).  Alter  a  certain  time 
muscular  atrophies  begin  to  be  noticeable,  and  later  become 


LSSIOXS  OF  THE  SACRAL  PUiXUS, 


383 


ry  marked.  The  afTcclion  o[  the  hip  joint,  which  sometimes 
develops  in  the  course  of  the  paralysis,  but  which  also  at  times 
has  to  be  looked  upon  as  the  forerunner  or  immediate  cause  of 
the  paralysis,  produces  more  or  less  marked  shortening,  so  that 
the  patient  with  his  affected  lower  extremity  presents  a  picture 
like  one  of  those  shown  in  Figs.  117  and  118.  This  peripheral 
alTection  of  the  sciatic,  which  is  to  be  regarded  as  a  neurilis 
in  the  sense  described  above  on  page  331,  can  hardly  be  mis- 


mrn 


Uriatie  ntrre 

AiUttttof  niapima 

SttitisttuKmuta 

StinimimhrtinotMa 

iHiritl /ri/itileal 


liiileiita/  iraJ) 
Bolimt 


Flour  ftinmimit 

It.  jittvr  lanymt  poUttit 
l\>ttrrior  tibial  i 


FIk-  I1I1.-1I0TOH  Poi9<Ts  FOK  TMB  ScuTK  Nekvb  A»i>-nie  lluscLEB  surrucp  dt  rr. 

taken  for  anything  else.  The  dilTiculiy  in  moving  one  leg. 
which  may  amount  to  an  actual  paralysis,  may,  il  is  true,  also 
be  the  consequence  of  a  central  cortical  affection — a  mono* 
plegla  or  monoparesis.  In  this  case,  however,  the  pains  are 
by  no  means  a  prominent  symptom,  nor  do  we  find — and  this 
is  the  most  important  point  of  distinction — either  atrophy  or 
•hortcning.  The  differential  diagnosis  between  cortical  and 
peripheral  paralysis  has  been  spoken  of  on  page  18;.     The 


3*4 


DISEASES  OF   T/fP.   SPtffAl.   XSKI^es. 


treatment  of  the  aQcctinn  is  to  be  conducted  according  to  the 
principles  which  we  have  discussed  in  speaking  o(  other  periph- 
eral paralyses. 


Tie-  1)7.— Case  or  PcairanHAL  S>i  »ti:- 

AKII  ATKOPIiy  tiy  THE   A>"<    I.I 


<■>    IM.  S<:uil>.   Ncai-E  WITH  SMORTKniM 

I   XIBUtlTY   (panoMi  OtMTVMlOMJ. 


The  observations  which  some  yean  ago  were  published  by  Wesl- 
phal  about  a  periodically  recurrinft  paralysis  of  all  four  extremities 
have  as  yet  no  practical  imporlance,  since  we  do  not  know  anything 
about  it«  nature.  The  same  may  be  said  about  the  peculiar  parent 
of  the  lower  lej;  and  Toot  which  Zenker  has  described  (Berliner  klin* 
ischcr  Wochenschtift,  October  8,  1883),  and  which  has  to  be  regarded 
as  an  occupation  neurosis.  It  occurs  not  rarely  in  persons  who  have 
to  remain  a  long  time  in  a  kneeling  or  squatting  position,  and  such 
inMnnces  have  been  known  to  occur  in  potato  pickers.  It  manifests 
Ititelf  in  a  more  or  less  pronounced  seniuiry  or  motor  paralysis  of  the 
lower  part  of  one  or  both  lower  extrciniiies. 


L£S/OfffS  Of  TIIR  SAVRAI.  PLRXUS. 


385 


isms  in  these  musclus  arc  rure  and  aru  therefore  of  but 

little  practical  importance;  n  case  of  tic  convulsif  in  the  ilio> 

;  psoas  has  been  described  by  Klempcrcr  (Deutscbc  Med.-Zig., 

1890,  86).      Bernhardt  has  described  a  case  in  which  there 

were  spasms  in  tJie  region  of  the  N.  peron.  dext.  supcrfic,  with 


I 


nc-  (*>>—' 


SEVRiriit  or -niK  SaATtc  N>:iw    .ini  Siwwixkino 


■Hu  Ai*iOi>HV  OF  IIIK  AfrxcTKD  ExTKUUTT  ipTTViiii  ufcafrrUiooV 


clonic  twltchings  in  the  peroneiis  longus  ami  I  i>  (Bcrl,  kiln. 
Wdchenschr.,  1S93.  17).  Schultze  has  describtJ  spastic  cot>- 
«lilions  ici  the  tensor  fasci?c  lata;  (Deutsche  Zcitschr.  i,  Nerven- 
heilk,.  1893.  iii).  Spasmodic  Ionic  contraction  of  the  hip  mus- 
cles has  been  described  by  Stromcver  as  spastic  contraction  of 
the  hip.  A  case  of  spasm  confined  to  the  qundratus  lumbonim 
has  come  under  my  notice  in  an  hysterical  woman.  It  is  illus- 
trated  tu  Figs.  119  and  120.     Tonic  spasm  of  the  quadriceps 

"5 


386 


D/S£jtSES  Of  THE  SPINAL  KRK¥E&. 


gives  rise  to  extension  of  the  leg  in  the  knee  joint :  it  is  some* 
limes  known  to  occur  in  neuralifias  of  tiiv  joint.  The  vcrj- 
painliil  cninip  in  the  call  muscles,  wliicit  sometimes  occiit> 
after  great  cserlion.  sometimes  also  in  the  course  of  certain 
grave  general  diseases — lor  example,  cliolera — is  well  known. 


Plpi.  ((9,  tia— COKTIUCTUM   IN   THK  QUMIBATUa   LUMKIKUH   (pOMBal  obMnUioKi. 

Clonic  spasms  of  the  muscles  of  the  lower  extremities  may 
be  observed  in  iiyslericiil  patients.  The  so-called  "saltatory 
spasm  "  (Bjinjberger,  Wiener  medicinische  Wochenschrift,  May 
4.  18591.  which  forces  the  patients  whenever  their  feel  touch 
the  ground  lo  jump,  is  not  an  independent  aflection,  but  only  a 
symptom  ol  central  disease.  The  increase  ol  the  reflexes. 
which  is  generally  present,  is  in  favor  of  this  view.  Of  the 
li'calnieni  we  shall  speak  in  the  chapter  on  Hysteria. 


MUlTiPlB  .V£t/ff/r/& 


387 


UTERATLKE. 

[CtltlfiMnn.      Fall  vtm  MgcD.inntcn  ultaiodfchcn    KrSmpfcn.      Ucrtincf  kiln, 

Wochoiiclmfi.  i){67.  iv.  ly 
[Ffry.    Ueb«r  ultaiuriKhcn  Kellcxknnipf.    Arch.  I.  INjvlt.  u.  Ncrvcnlik..  i87(. 

rt.  I. 

Ktu.     UebcTUIUturiiictien  Kcllevkrarnpf.     Nruti^.  C«nU^bl.,  1683.  ij,  14. 
Kiillmaim.     Dnitschc  mctl,  WiH-hmschr.  1883.  ix.  40. 


V,  Nfuriris  imvli'iti/^  Snvra/  S/n'na/  Nerves  at  flu  Same  Time — 
Multiple  XfM  rilis — PolyiUHril  is. 

Just  as  we  have  seen  that  several  of  the  cranial  nerves  can 
be  affected  at  the  same  time,  so  none  tlie  less  is  this  Hue  of  the 
sifinal  nerves.     It  is.  however,  not  many  years  since  it  has  been 
shown  that  such  mulljplc  nerve  affections  may  occur  primarily, 
thai  Ihey  arc  often  o(  an  inflammatory  nature,  that  they  give 
rise  to  numerous  symptoms  which  may.  under  certain  circum- 
stances, be   misinterpreted,  inasmuch  as   they  may  simulate 
those  of  central  lesions.     The  affection  is  known  as  multiple 
'neuritis,  and.  as  we  said,  our  knowledge  of  it  is  of  quite  recent 
date  (Dum^nil,  Eisenlohr,   Leyden.  StrUnij>ell.   Vierordt,  and 
I  others).     We  may  confidently  expect  that  in  the  near  future 
Iwe  shall  obtain  further  information  upon  certain  points  in  con- 
[nection  with  this  disease  which  have  not  as  yet  been  cleared  up. 
As  we  have  above,  on  page  331.  devoted  some  time  to  the 
[description  of  the  anatomical  features  of  the  disease,  it  remains 
xir  us  here  to  speak  first  of  the  symptoms  of  multiple  neuritis. 
Mt  i;^  remarkable  to  note  that  the  onset  frequently  resembles 
I  that  of  an  acute  infectious  disease :  there  are  fever,  general 
malaise,  dull  headache,  apathy,  etc.;   soon  pains  make  their 
ap^tcarancc.  first  in  the  liimbiir  region  and  the  back,  then  in 
the  c«>urse  of  the  large  nerve  trunks.     These  are  followed  by 
an  impairment  of  mobility,  especially  in  the  lower  extremities, 
which  makes  the  patient  very  anxious;  the  legs  arc  heavy, 
they  are  moved  only  by  a  strong  effort,  and  not  without  pain. 
■  and  the  patient  is  easily  fatigued.    The  reflexes  are  diminished 
or  lust,  electrical  excitability  is  dccre.ised,  but  the  pains — and 
thift    should    be  emphasized — usually   soon   abate  and   other 
.sensory  disturbances.  p:ir;vslhesias  .ind   anxsthesias.  are  only 
[exceptionally  met  with  (IJ;irrs,  Amer.  Journ.  Med.  Sc,  Fcbnu 
rr.  1889),  the  disorder  chiefly  affecting  the  mt>tor  apparatus, 
"peatcdljf   case*  have   been   <)l«frve<l    in    which    the    motor 
turbanccs  made  their  appearance  quite  suddenly,  an  onset 


2S& 


D/SEASES  OF  TUB  SPfXAL  .VKXt^ES. 


which  we  cuuld  almost  cnll  ajjoplectUurm.  Wtihout  any  prc- 
mttnitor)'  symptoms  there  come  on  violent  rndi'iliii^  pains, 
with  motor  paralysis.  Sometimes  tre  I'md  atrophy  in  certain 
groups  of  muscles  ;  reactiun  uf  dcgcncrulion  can  soon  alter  be 
demonstrated :  sometimes  thickening  and  a  considerable  in- 
crease in  the  subcutaneous  tissue  develop.  If  this  lakes  place 
in  the  palm  of  the  hand  wc  have  the  "  flat-hand,"  in  which  the 
normal  hotlow  is  absent,  a  cunditiun  analogous  to  that  of  "tlat- 
foot "  (Liiwciifcld,  2  Faile  neuriiischcr  "  Fl^tt-hand."  MUnchcncr 
mcd.  Wochenschr..  1S89,  24).  Besides  muscular  atrophy  we 
may  tind  ataxia,  and  this  symptom  may  indeed  be  very  marked, 
so  that  it  dominates  the  whole  picture  and  makes  it  resemble 
that  o(  tabes.  In  such  cases  the  term  pseudo-tabes  pcripherica, 
instead  of  simply  multiple  neuritis  or  polyneuritis,  is  very  ap- 
propriate. 

If  the  pains  are  very  intense,  and  if  we  hnd  more  or  less 
well  marked  swellings,  while  other  sensory  disorders  are  only 
slight,  the  case  may  be  one  of  acute  primary  polymyositis,  a 
condition  which  has  been  well  described  by  StrUmpcll.  This 
is  especially  likely  to  be  the  case  if  the  pains  arc  localized  in 
certain  muscles  ( Deutsche  Zeilschr.  f .  Ncrvcnhk.,  i,  5,  6).  Lewy 
has  also  furnished  some  important  practical  contributions  to  our 
knowledge  of  this  disease  (Berlin,  kliii.  Wochenschr.,  1893,  18). 

No  description  of  the  course  of  the  disease  which  would 
fit  all  cases  is  possible,  because  this  varies  and  presents  pecul- 
iarities according  to  the  pathogenesis.  Dejerinc  has  described 
a  case  of  hiemorrhage  in  the  region  of  the  brachial  plexus  which 
was  followed  immediately  by  paralysis  of  the  arm  <Compt. 
rend,  hcbdom.  dcs  stances  de  la  Soc.  de  Biol.,  185(0.  No.  27); 
but  such  a  sudden  onset  is  exceptional.  If  a  multiple  neuritis 
occurs  in  the  course  of  another  disease,  its  manifestations  are 
not  the  same  as  when  it  is  a  primary  afTeclion,  which  has  de- 
veloped under  the  influence  uf  some  special  cause.  Among 
the  conditions  in  which  polyneuritis  may  develop  wc  would 
mention  phthisis  pulmnnalis,  diabetes  (Charcot,  Arch,  de  Neu- 
rologie,  Mai.  1890.  xix.  57).  tabes,  articular  and  muscular  rheu- 
matism, polyarthritis,  and  finally  the  puerperal  state  (Desnos, 
Pinard,  et  Jofiroy.  TUnion  mijd..  1889,  14).  It  has  repeatedly 
been  described  as  a  sequela  of  typhoid  fever,  of  smallpox,  of 
scarlet  fever,  of  diphtheria,  of  carcinoma  (.-\uchi.  Revue  de 
mid..  1890,  X.  10),  and  ol  leprosy  (Arning  und  Nonne.  Virch- 
Arch,.  1893,  cxxxiv.  Melt  2) — "infectious  form"  of    Leyden. 


MULTIPi.E  NEumrts. 


589 


As  an  independent  disease  it  may  be  caused  by  overexertion. 
Tw<i  cases  which  we  have  described  were  due  to  prolonged 
work  with  the  reiving  machine  (cf.  lit.).  It  in:>y  also  appciir, 
and  this  is  unciucsiiunably  much  more  common,  as  a  conse- 
({uence  of  the  action  of  certain  poisons,  more  es]>ccially  alco- 
hoi,  nitrobcnzine,  auiiinc  (f<oss  and  Uury),  carbon  monoxide, 
bisulphide  of  carbon,  lead,  arsenic,  and  mercury — the  "toxic 
(orro  "  of  I-cyden.  Besides  these  two  there  is,  according  to 
Leyden,  a  third  variety,  the  so-called  atrophic  (ana:mic,  ca- 
chectic) lomi,  which  develops  after  a  lonf;  and  severe  sickness, 
somewhat  in  the  manner  recently  described  by  Oppcnhcim 
and  Sienierling. 


Fit.  iH.'AntDPMT  nr  TiiK  llt'Hri.Eii  or  tk«  Kmitr  t'mH  Arm  in  CctxsKgVKNcn  or 
A  FKurrvRK  or  nts  IIumkkv*  S«vu<  Ykaju  tvxVKKSvt  {pcnoul  obwnMkui). 

Sometimes  sensory,  sometimes  motor  disturbances  are  the 
predominating  symptoms.  In  the  nctirilis  of  phthisical  pa- 
tients both  arc  marked  to  about  the  same  extent.  Occasionally 
certain  nerves  seem  to  be  more  liable  to  sufler — (or  instance, 

.  according  to  Mitbius.  during  the  puerperal  state,  the  median 
imd  ulnar,  the  terminal  branches  of  which  are  affected  either  in 

I  both  hands  or  only  in  the  one  which  is  used  more  extensively, 


3go 


DISEASES  OP  TJIE  Sf/JVAt.  KKKl'ES. 


u;>  a  rule  the  right.  In  tabes,  on  the  other  hand,  no  region 
seems  to  be  cscropt,  and,  us  Oppenhcim,  Siemerliiig.  Piirc», 
Vuillard.  and  others  have  observed,  not  only  ihe  |>cri[)heral 
spinal,  but  also  the  cranial  nerves  may  be  attacked  by  the 
neuritis — for  example,  the  vagus  and  its  laryngeal  branches, 
and  the  ocular  nerves.     Korsakow  and  Serbski  have  described 


Fig.  in.— PAHiBTHl. 


.-l.il  ;...'.':. .t~4i.;    J^.i..;i'L£  NEUftlTtt. 


the  mental  symptoms  which  may  be  associated  with  multiple 
neuritis  (.Arch.  t.  Psycti  und  Nervcnk..  iSgi,  xxiii,  i,  p.  112). 

The  neuritis  which  occurs  in  the  course  o(  joint  afTections 
often  leads  to  considcnible  atrophy  in  those  muscles  which  arc 
supplied  by  the  affected  nerve  twigs.  Chronic  inflammation  <>( 
the  synovial  membranes  caused  by  sprains,  chronic  inflamma- 
tions of  joints,  articular  rheumatism,  frequent  attacks  of  gout, 


jaVLTIPLE  S-HVKITIS. 


39» 


raumalism,  fractures  which  give  rise  to  some  impediment  in 
the  circulalion — all  these  causes  may  bring  about  extensive  mus- 
cular aimphics.  A  case  to  the  point  is  illusirated  in  Fig.  121  ; 
the  paiieni  was  a  boy,  tiliecn  years  old,  who  had  sustained  a 
fracture  of  the  upper  arm  when  he  was  eight  years  old.  The 
fracture  healed  slowly,  and  was  (oUowcd  by  atrophy  of  the 


Fie.  i»3.— l''--'i-'i.iit.i.i-.  1.11:1  M..,^■.^J-l^;l  ll!.LruT.B  Nn/MTlit 

right  upper  arm  and  the  muscles  of  the  chesL  References 
bearing  on  these  atTcclions  and  upon  "  reflex  atrophies,"  which 
we  shall  soon  mentioti.  will  be  found  on  page  396.  The  case 
which  wc  have  illustrated  in  Figs.  122  and  123  was  that  of  a 
young  man  who  suflcred  from  a  panarthritis,  and  who  in  con- 
sequence of  his  joint  aiTcclion  dt-veiopcd  muscular  atrophy  in 
all  four  extremities,  more  especially  in  the  upper  arms  and 


393 


DISEASES  OE  TUE  SPINAL  NERVES. 


thighs.  The  hip  and  shoulder  joints,  as  well  as  the  knee  and 
elbow  joints,  had  been  swollen  and  painful  for  years.  That 
this  atrophy,  which  may  be  due  to  an  inflammation  of  the  fine 
end  twigs  of  the  nerves,  may  also  be  caused  reflezly  by  the 
joint  aflection  has  been  shown  by  Charcot.  If  the  hip  joint  is 
attacked,  the  flattening  of  the  buttock,  the  abnormally  high 
position  of  the  gluteal  fold,  the  marked  prominence  of  the  tro- 
chanter on  that  side,  are  striking  features.  If  the  upper  ex- 
tremities, especially  the  hands,  are  the  seat  of  the  disturbance, 
the  atrophy  gives  rise  to  deformities  which  are  either  of  the 
extensor  or  the  flexor  type  (Charcot). 

Peculiar  and  manifold  are  the  manifestations  of  that  variety 
of  neuritis  \vhich  is  produced  by  the  abuse  of  alcohol.  For 
the  sake  of  simplicity  we  may  distinguish  two  cardinal  forms 
of  this  aflection,  although  the  clinical  pictures  of  the  two  can 
often  not  be  well  separated  from  each  other.  In  the  first  the 
motor  disturbances  and  the  atrophies,  in  the  second  the  sensory 
disorders,  are  the  prominent  symptoms.  In  the  former  case 
the  patients  complain  of  violent  tearing  and  drawing  pains  in 
the  lower,  more  rarely  in  the  upper  extremities,  which  are  rela- 
tively rapidly  followed  by  a  marked  difficulty  in  walking.  The 
gait  of  the  patient  is  distinctly  ataxic  and  resembles  most 
closely  that  of  a  tabetic,  with  the  exception  that  in  the  latter 
no  diminution  in  the  strength  of  the  muscles  can  be  noted, 
while  in  alcoholic  neuritis  it  can  undoubtedly  be  demonstrated 
and  is  to  be  explained  by  the  muscular  atrophy  which  occurs 
comparatively  early  and  which  is  particularly  seen  in  the  ex- 
tensors. The  degree  to  which  walking  in  particular  and  mo- 
tion in  general  is  interfered  with  is  very  variable.  Sometimes 
the  patient  can  hardly  raise  himself  in  bed  without  assistance, 
sometimes  he  may  for  months  be  able  to  get  about  fairly  well 
without  help.  It  is  interesting  to  note  that  the  patellar  reflex 
is  lost  very  early  and  completely,  a  circumstance  which  may 
lure  not  the  inexperienced  alone  into  making  a  diagnosis  of 
tabes  dorsalis.  This  is  still  more  likely  to  occur,  and  the  mis- 
take is  more  excusable,  if  the  action  of  the  alcohol  has  also 
manifested  itself  on  the  ocular  nerves,  so  that,  e.  g.,  we  may,  in 
addition  to  the  symptoms  mentioned,  encounter  a  paralysis 
of  the  abducens,  which  1  have  myself  seen  several  times  in 
alcoholic  neuritis,  and  which  Suckling  {cf.  lit.)  and  others  have 
described  ;  or,  again,  the  oculo-motor  may  be  affected  and 
the  patient   may    complain   of   diplopia.      Pierson,   Eisenlohr, 


Afvir/pi./i  A'RV/ftr/s. 


393 


^ 


Stfiimpell,  and  others  have  reported  cases  in  which  the  facial 
nerve  was  implicated.  Vagus  neuroses  have  been  reported 
in  this  connection,  especially  tachycardia,  l>y  Dejerine.  I(  we 
iidd  to  this  the  frequency  with  which  Romberg's  sign  (swaying 
while  standing  with  the  heels  and  toes  together  and  eyes 
closed,  in  consequence  of  the  disturbance  of  the  muscular 
sense)  is  found  in  the  disease,  if  we  remember  that  stomach 
symptoms  occur  in  both  affections — in  alcoholism  as  vomitus 
matutiims  in  consequence  of  a  chronic  g:isiriits.  in  tabes  as  gas- 
tric crises  in  consequence  of  disease  of  the  vagus  nucleus — we 
can  not  be  surprised  at  the  frequency  with  which  alcoholic 
paniljsis  is  taken  for  tabes.  Nevcribclcss,  it  is  nut  so  difficult 
to  avoid  such  a  mistake,  more  especially  if  we  have  a  chance  to 
examine  the  patient  repeatedly  and  do  it  carefully  enough. 
We  should  particularly  note  the  condition  of  the  pupils.  The 
absence  of  the  Argyll- Robertson  sign  and  the  absence  of 
bladder  symptoms,  both  ol  which  are  very  common  in  tabes, 
will  be  si<;ntficant  features.  In  alcoholic  neuritis,  further,  the 
nerve  trunks  are  usually  painful  and  the  c<jursc  of  the  disease 
differs  in  the  two  maladies.  In  tabes,  as  wc  know,  the  outcome 
is  very  unfavorable,  while  in  alcoholic  neuritis,  if  the  causo  is 
removed,  it  is  usually  good.  Rvcn  the  individual  symptoms 
may.  If  analyzed  carefully,  give  us  some  valuable  diagnostic 
hints.  For  example,  it  will  hardly  be  very  difficult  for  the  care- 
ful examiner  to  distinguish  the  morning  vomiting  of  alcoholics 
from  the  paroxysmal  spontaneous  vomiting  of  tabes,  which 
appears  now  and  ag:iin  and  may  not  reappear  for  months. 

The  second  form  of  alcoholic  neuritis  may  run  its  course 
without  giving  rise  to  any  decided  motor  disturbances.  The 
patient  then  only  complains  of  pains  which  sometimes  run  along 
ihe  nerve  trunks,  becoming  very  violent, and  may  resemble  the 
lancinating  pains  of  tabes.  He  may  complain  of  localized  hy- 
pera'St hcsias  and  anaesthesias,  of  formication  and  numbness,  all 
o(  which  symptoms  are  especially  marked  iu  the  lower  extremi- 
ties. Various  vasomotor  and  trophic  disturbances  are  not 
uncommon.  ClMlema  may  occur  and  disappear  again,  skin 
eruptions,  perforating  ulcers  (Mclbing.  Beitr^ge  zur  klin.  Chi- 
rurgic,  iHSq.  v.  3).  circumscril>ed  areas  of  an  hyperidrosis.  and 
ichlhyolic  changes  nf  the  epidermis  (Kulcnburg)  may  be  noted. 
Brissaud  has  published  studies  upon  the  influence  ol  the 
trophic  centres,  especially  in  toxic  neuritis  (Arch,  de  Neur.. 
1891.  xxi.  63). 


394 


DISEASES  OF  THE  SPINAL  NERVES. 


In  all  cases  the  psychical  condition  ou^ht  to  be  carefully 
considered.  It  may  present  changes  very  early  in  the  disease. 
Thus  Oppenheim  has  reported  instances  in  which  the  alcoholic 
neuritis  occurred  simultaneously  with  delirium  tremens. 

It  has  long  been  known  that  neuritis  may  be  produced  arti. 
ficially,  and  that  it,  for  example,  often  occurs  as  a  consequence 
of  subcutaneous  injections  of  ether;  but  this  has  only  been 
carefully  studied  of  late  years.  Cases  of  this  kind  impress 
upon  us  the  necessity  of  being  cautious  in  giving  the  injections 
for  therapeutic  purposes  and  of  avoiding  especially  a  too  deep 
insertion  of  the  needle  where  we  should  be  liable  to  strike 
branches  of  the  musculo-spiral  or  other  nerves.  Paralysis  of 
the  extcnsoi^  of  the  Bngers  has  been  relatively  often  observed. 
References  bearing  upon  this  subject  will  be  found  at  the  end 
of  this  chapter. 

In  the  treatment  of  neuritis  our  first  aim  should  be  to  re- 
move the  cause ;  only  when  this  is  possible  can  we  hope  for 
permanent  results.  The  therapeutic  measures  differ  according 
as  the  case  is  recent  or  of  old  standing.  If  the  former  is  the 
case,  the  salicylates,  antipyrin,  phenacetin,  and,  if  the  pains  are 
very  intense,  morphia  are  indicated.  According  to  our  experi- 
ence, inunctions  are  of  comparatively  tittle  value ;  nevertheless 
an  ointment  containing  chloroform,  veratrin,  and  morphia  may 
be  tried.  Wet  packs  (Priessnitz  bandages)  are  sometimes  serv- 
iceable, and  warm  baths  (at  90"  to  95°)  may  be  beneficial,  but 
cold  water  is  usually  dreaded  by  the  patients.  The  most 
important  measure  in  these  cases  is  the  electrical  treatment. 
Where  this  can  not  be  used,  or  where  it  can  not  be  properly 
applied,  it  is  impossible  to  do  much,  and  it  is  then  best  to  leave 
the  case  to  Nature,  a  course  which  frequently  results  in  re- 
covery, though  this  is  apt  to  be  slow.  The  constant  and  the 
combined  current  (De  Watteville)  should  be  used  somewhat  in 
the  manner  described  for  the  treatment  (or  the  motor  nerves 
in  my  Text-Book  on  Electro- Diagnosis  and  Electro-Therapeutics 
(Stuttgart,  Enke,  1893,  pp.  142,  143).  Next  to  the  correct  ap- 
plicilion  of  electricity,  the  most  important  point  to  remember 
in  this  treatment  is  that  we  must  not  give  it  up  too  soon,  and 
that  we  should  not  dcsp.iir  if  at  first  no  results  can  be  seen. 
Several  weeks,  even  two  or  three  months,  will  be  necessary  in 
any  grave  case.  Sometimes  even  the  protracted  use  of  elec- 
tricitv  has  no  effect,  and  we  may  well  sav  that  the  treatment  of 
multiple  neuritis  is  rarely  a  grateful  task. 


MULTIPLR  AfBL'/llTlS. 


395 


I 


V 


It 


LITKKATURE. 

A  MtiltifJf  tVmritit. 

Sinimpctl.     7.iit  KennlniM  Art  niiilti|ilcn  dc^iKmliven   NcuriliK.     Arch,  t 

l^>ch.  0.  Ncri'cnkrJiikli.,  18S3.  »iv.  2. 
Hm.    llriii.i^iurP.iihoIvgirilcrniuUiplcnNcuRlk    Neurol.  On rralbl.  1884,  31. 
Upprnhcim.     Multiple  Nruriii--^     DcuiKhct  Arch,  f.  kiln.  Med.,  1S85.  Ud.  jft. 

Heft  S.  6,  |>.  561. 
Buuanl.     Pfimlyias  (kpmdcnl  upon  IVtiphcr,  Neuritis- '  Lanc«l,  November  s8, 

D«cnil)ef  f  J.  1885. 
PUm  cl  Vailbnl,     Peripheral  Neurilit  in  Tubemilosls.     Revue  de  m^l..  1886, 

No.  3.    lL*ti!ni  iM-  Aitiociated  with  AtTn|>hy  i>r  Sensory  l)i»litfbMce«.) 
Francude.     Nfvrite  muliiple.     Ktvuc  de  mid..  1886,  Nol  5. 
Opprnhrim.     Urber  Jntcrslitiellc  Neuiiiis,  ihr  VorkuniriiEn  liei   Nctveti>  uml 

Midervn  Ertcraiikunt.'efi.     Neurul.  Ceniralbl.,  il$86.  No,  tl,  ppL  i}5  ri  11^. 
UMuloiigo     Le  ncuriii  multiple  [lerifericlie  )iniiiiUvees|ieciu1niente(ldUrurina 

<li  polincuritc  acuu.    Oai.  ttegli  ospiuli,  1886.  Nus.  SJ.  jA.  $S-4i. 
Hitm  et  VailUnl.     N6vriic%  jifnphftiqucx  dant  Ic  liiunutLime  chinniqu^.    Ke- 

vue  de  mM..  18S7,  riii.  6.  p.  4^6. 
Cnmuilic.    Oinlribution  A  r^iidr  dc  l«  pathogenic  des  n^rites  pf nplvrn(|urs. 

THtw  de  Pan*.  1887. 

LVtiet  .Neuritis  pueipcralit.     Muiicliencr  mnL  WixImHClir.,  1^7.  No. 

9.     (Aiiucks  tiKMl  frr(|ucntly  the  ulniii  and  the  miiliiiii  nerve.) 
Suddnunn.     Nnirol.  CVntnilbl..  1S87, 17.     (i'eculiur  Cuniltiion  (muimI  in  »  Case 

of  Ncuntit  a(  ihr  ltra<  hial  t'leiu»  coming  on  .-iftcr  Typhoid.) 
CioUtlLim.    On  ihr  to^cnllcd  Multiple  Neutiiik.     Mcdycyna.  lUt?,  xr.  13-28. 
UpfirahHra  und  Siemerltnt;-     UeittX)^-  tut  I'niholiiKie  dcr  Xabn  tIrirMlH  luid 

drr  |>nipheri««bcn  NftvRiMlcianlcunKcn,     Arch.  (.  Piych.  und  Ncrveukh., 

1887.  wiii.  I.  2. 
Ikibois.      Uebrr  n[K)plectirormes   tlin»el<cn  ncuriliKhrr  Lahmurigm,      Conv- 

nfKiiHlenibt.  (.  8chuiri(.  Ae(/ie.  18X8,  14. 
Senaiuc      I'dier  iicuir  niiilii|ile  MyiMilit  bci  Neuritis.     Deutsche  nwd,  W^ 

chrtiKhr.  t888.  xiv.  13. 
(MilHain.    /niichr.  t  hliii.  Med..  1888.  xiv,  4. 
Dury.     rrnpliemJ  Neuritis  in  Acute  Rheumatism  arxl  the  Relation  at  Muscular 

Amiphy  to  AfTectiunf  of  tiK  Joints.     From  tlic  Medical  Chronicte,  June. 

18X8. 
KInmpke     [let  polyn^rilc*  en  g^<ntl  «i  des  juralysict  ct  atrophies  Nitumti>es 

en  parlirulirr.     I'aris,  F.  AU.in,  iKSi*' 
Udik><Dar]Hi).     Uetier  die  hrkr^nkuiiycn  dcr  pcriphemi  Nerven  M  Lepra. 

IVtcrtlMrgrr  nied.  W'xritensclir..  1X89.  41. 
lobiu*.     Untnii-  >ui   Lrhre  von  dee  Nruriti*  purrpcnlb.     Muncheiter  med. 

Wiiclimtchr.,  18901  14. 
f  akticnfclcL     Nentitis  mubiplex  cum  glycosuria     Deutsche  med,  W<Khenschr., 

HnoK      I'ebrt  nruntisclte  Uhtiiuiif-rn  lirim  t)i;ilirtes  mdlitus,     ("  Diabcli«c)ie 

Lllhiniini;en. "1     Brilinrr  klin.  VVorl>rn«chr..  1890.  13. 
Fffnkel.  A      IVIw-f  niiilliiilr  Neuriiji      Diutsche  ni«l.  WoclienKhr,,  1S91,  (3. 
lU.     Ucbec  mullipte  Ncurllis.     Wtrn.  Holder.  1891. 


jl^  DISEASES  OF   THE   SPINAL  NERVES. 

Lloyd.  Forms  of  Pseudo-tabes  due  to  Lead,  Alcohol,  Diphtheria,  etc.  Med. 
News,  1891,  14. 

Engel-Reimers.  Beiirttge  zur  Kenntniss  der  gonoirhliischen  Nerven-  und 
Ruckenmarkserkrankungen.  Jahrbiicher  der  Hambuiger  Staats-Kran- 
kcnanstalt,  1893. 

Leyden.  Ueber  Polyneuritis  mercurialis.  Deutsche  mcd.  Wodienschr.,  1893,  31. 
(Mercurial  Treatment  of  Syphilis.) 

Ross  and  S.  Bury.    On  Peripheral  Neuritis.     London,  Grifltn  &  Ca.  1893. 

Giese  und  Pagenstechar.  Beiirag'  lur  Lehre  von  der  Polyneuritis.  Arch.  f. 
Psych,  und  Nervenkrankh.,  1893.  xxv,  i.  p.  III. 

Mills,  Charles  K.  Neuritis  and  Myelitis  and  the  Forms  of  Paralysis  and  Pseudo- 
paralysis following  Labor.     University  Med.  Magazine,  May,  1893. 

t.  AkoheSt  Neuritit. 

Fischer.     Ueber  eine  eigenlhiimliche  Spinalerkrankung  b.  Trinkem.     Atch.  f. 

Psych.,  1882. 
Dreschfeld.    Brain,  July,  18S4.  p.  100.     (Chronic  Alcoholism :  Ataxia  in  Men, 

Atrophies  in  Women.) 
Broadbent     On  a  Form  of  Alcoholic  Spinal  Paralysis.     Med.-Chir.  Transact, 

vol.  hcvii. 
Chaivot.     Les  paralysies  alcooliques.    Gai.  des  h6p.,  1884,  No.  99. 
Kruche.     Die  Pseudotabes  der  Alkoholiker.    Deutsche  Med.-Ztg..  1884,  No.  73. 
Moeli.      Statist,  u.  Klin,  liber  Alkoholismus.    Charit^Annalen,  1884,  'a,  p.  534. 
Schulz.     Neuritis  der  Potaloren.     Neurol.  Centralbl.,  188;,  Nos.  19,  30. 
Hadden.     Cases  illustrating  the  Symptoms  of  Chronic  Alcoholism.      Lancet, 

October  3,  1885,  p.  6ia.    (Hyperzsthesia  of  the  Skin,  Vomiting,  no  Patellar 

Reflex,  Plantar  Keflex  retained.) 
Bernhardt.     Ueber  die  multiple  Neuritis  der  Alkohotisten.     Zeitschr.  f.  klin. 

Med..  1886.  !ii. 
Biissnud.     Des  pamlysies  loxiques.     Th*se  d'agrigation  de  Paris,  1886, 
Oellinger.     foude  sur  les  paralysies  alcooliques.     Thtse  de  Paris,  1885. 
Dejerine.    Contribution  k  I'^luUe  du  la  nivrite  alcooiique.    Arch,  de  Phys.,  18S7, 

X.  5mc  ser.,  p.  248. 
Witkowski.     Zur  Kenntniss  der  multiplen  A Ikohol neuritis.     Arch.  f.  Psych,  u. 

Nervenkrankh.,  1SS7,  xviii,  3,  p.  809. 
Bonnet.     Arch,  lie  neurologic.     Juillct.  r887,  pp.  79  tl  seg. 
Suckling.     Ophthalmople),'ia  cxtvrna  due  10  Alcohol.     BriL  Med.  Joum.,  March 

3.  1888. 
Eichhorst.     Niuritis  fascians  alcoholica.     Virchow's  Archiv,  1888,  112,  2. 
Siemerling.     Kurze   Bemerkungtn   zu  der  von  Eichhorst  sugenannten  Neuritb 

fascians.     Arch.  f.  Psych.,  1888.  xix.  3. 
Cuilleniin.    Annales  Mid. -Psych..  Mars.  1888,  7me  sfr..  2.    (Alcoholic  Hysteria.) 
Wladur,  Martin.     Wiener  med.   Presse.  1888.  xxix,  lo.     (Angioneurosis  of  the 

Vessels  of  the  Mead  as  a  Ki-suit  of  Alcohol  and  Nicotine  Intoxication.) 
Sharkey.     Alcoholic  I'iiralysis  of  ihe  Phrenic,  Pneumogaslric,  and  other  Nerves. 

Transactions  of  ihe  Palhol.  Society,  1888,  xxxix.  p.  27. 
Schaffer.     Neurol  CVnlrallil.,  1889,  viii.  6. 
Siemerling.     Chariti-Annalen.  18S9.  xiv.  p.  443. 
Buzzard.     Brit.  Med.  Journal.  June  21,  1890. 


DiSEASRS  OF  THH  TROP/flC  AA'D  l'ASO-MOTX}X  JVUKt'KS. 


397 


I 


f,  JVnm'/ii  minJ  fy  SiitfHliUH-'ttt  tu/nlimt  ef  Btktr. 

SilnU.    TMk  iiiDug..  Bonlcaui.  1884. 

KritiAk  uikI  Mendel     Uerlincr  kUn.  WocheoMhr..  1K85.  xttj.  5.  pp.  76,  77. 
ll.idra.     KItiung  <kr  B^d.  nicil  Gi^scllxch.,  v,  Juni  3.  iSSj. 
|Sir«  et  VAilbrcL     l)cs  ntnitn  titovoqutca  |»r  les  injections  d'tfihei  au  volsi- 
nugT  (lc«  troncs  nenrux  dejt  menibres.     Cu.  nif<l.  ile  I'jris.  Miti  18.  itUi?, 

No.  32. 

4.  MutttUMT  Ainfhy  a/ttrjmni  ami  Bene  thimt—" Ht/ltx  AInfkj"  (C'itfniOV 

CtttfcoL     1^.  mill..  Juln-Ju>ne(.  it{8>. 

HanitMi.     Recberches  ci|>£iimeitules  ct  clmiques  sur  Irs  atrophies  ilea  mcm- 

bre*.     Valence,  iS8s. 
UactumiM.     Conirlbulion  k  I'tiudc  iXn  atn>|ihies  musculurea  &  distance,  appd- 

Ifes  enoor«.  "airophics  rtflexcs,"    Thi*e  de  l^iriit.  1883.    <The  irophk 

fom  of  ihc  nerve  ceiilteii  is  diminished  uccording  \a  this  suthor) 
Cornltlflfi.     lYDgr.  mid..  1883.  ».  ai.  p,  405.     (Muscular  Aitophy  jifier  Atlaeks 

0/  (ioiit  MmuUting  Progressive  Muscular  Atrophy.) 
S>nini|trU.     Munch,  ined.  Wochenschr.,  1&88,  13.     (Muacutar  Atrophy  After 

Acme  Antcitlar  Khctinijiiism,) 
Wkhnun       Dcr  rhnin.  CclcnkrheuniaiismuR    und  seine    Beiiehuii)[cn    turn 

Nervensyitem.    Neuw-ied.  189a 
Raymond.     Rccherchcs  cxp^rimeniales  tur  la  pathoginie  des  ain>phi<^  musm- 

toirei  consjculives  aux  aithritcs  Iraumaitijuu.    Revue  de  tniA.,  18901  x,  3. 
ibmulh.     Myopaihiei  n^vritique».     Ibid..  189016. 
Darkichcwitsch.    AiropJi.  niusc.  arthmpath.     Neurol.  CetitraUil..  1891,  13. 
Liirieille.     Sur  unc  arthnte  spJciale  du  |Med  avec  dcfomiaiion  observfe  chn  les 

vclocipcdiUM.     I'arii,  1891, 
Itaploy  el  Caiin.     An:h.  %in.  de  tvM..  1891.  1.    (.Muscular  Atrophy  after  Joint 

Disease.) 
Mugh.  Lane.    DeuiKhe  Med.-Ztg..  1B93,  191    (The  Neuroses  in  Chnuuc  Kheu- 

ruiomI  Anhriib.) 
Cbannt.    Atnyoirophies  «pjciale5  riflexes  d'origine  MlkuUlrc.    I'ro^is  mtA.. 

1S93.  13. 

B.  Diseases  of  the  Trophic  and  Vaso-motor  Nekves. 

In  spile  of  the  epoch-making  labors  of  Sumuet  (ct.  lit.),  who. 
after  Kornbcrg,  was  the  first  to  postulate  the  existence  of  dcfi- 
Dite  "  trophic  "  nerve  fibres  for  the  regulation  of  the  nutrition 
<A  Ihc  tissues,  we  are  to-day  still  unable  to  demonstrate  such 
fibres,  nor  do  wc  know  whether  there  exist  purely  trophic 
centres,  or  whether  the  trophic  influence  is  exerted  by  some 
tXQIres  already  well  known — viz.,  by  the  motor,  sensory,  or 
vaso-motor.  On  the  other  hand,  the  existence  of  such  a  direct 
trophic  influence  of  the  nervous  system  upon  the  tissues  can 
not  be  called  in  rjiiesiion.  Ag»in.  we  can  not  as  yet  decide 
i»bcthcr  or  not  this  influence,  u|K>n  which  the  nutrition  of  the 


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VtSBASes  Of  THE   TROPHIC  AND  VASO-MOTOR  NERVES, 


399 


11 


^thological  procc&scs  in  the  pcripheml  nerves  may  also  have 
ihe  same  elTect.     Among  the  central  allections.  which,  how- 
ever, ttiuy  remain  latent  inx  a  long  time,  so  that  one  might  be 
led  lu  regard  ihe  trophic  changes  as  in(lc]>endent  aflectEons.  we 
uitibl  mention  in  the  ^rst  place  tabes — which  we  shall  discuss  in 
this  cnnneciion  later — hysteria,  certain  cerebral  diseases  due  to 
changes  in  the  vessels,  such  as  apoplexy  with  the  acute  bedsore, 
nf  which  we  have  spoken  on  page  232.  and  again  diseases  ot 
the  gray  axis  ol  the  spinal  cord  (Jarisch),  among  others  the 
"  paralyste  g^n^rale  spinale  ant^rieure  subaigue"  (Pitres  el 
Vaillard,  Prog,  mi^'d.,  1888,  35),     To  the  diseases  of  the  periph- 
L'Cral  nerves,  and  the  infectious  diseases  in  the  course  of  which 
ophic  disturbances  may  occur,  we  have  already  alluded. 
At  present  we  can  form  no  idea  how  many  diseases,  not 
ly  of  the  nerves  and  of  the  muscles  but  also  of  other  organs, 
we  Khali  have  to  call  "trophic"  when  we  have  once  become 
belter  acquainted  with  the  p*)siiion  ol  the  trophic  centres  and 
[fibrei,  than  wc  arc  now.     For  the  present  the  term  is  restricted 
I  a  small  number  of  afieclions.  and  it  will  suffice  to  say  a  lew 
words  about  the  most  important  among  them,  and  first  about 
Ihe  tmpho-neuroses  of  the  skin. 

Anomalies  of  secretion  which  have  to  da  with  the  sebaceous 
'as  well  as  (he  sweat   gLinds  arc  not   tinconimon.      It   is  well 
known  that  scbcjrrha-a.  for  example,  may  occur  after  long- 
standing menstrual  disturbances,  chlorosis.  ann:mia,  after  over- 
cxrrlion,  or  as  a  consetjuence  of  to<t  great  sexual  excitement. 
inaMurbation,  etc.,  especially  in  young   individuals,  whereas 
imtnished  secretion  of  the  sebaceous  glands,  as  found,  for  in> 
c.  in  ichthyosis  and  in  ^cnilc  atrophy  of  Ihe  skin,  is  com- 
tively  rare.     The  purely  nervous  origin  of  this,  as  well  as 
i»<  hyperidrtMis  ami  anidrosis.  can  hardly  be  questioned.     Hy< 
pcridrtKls  is  seen  on  one  side  alone  or  on  both  sides  in  central 

Idiseiucs — fur  instance,  in  some  diseases  of  the  medulla  oblon- 
gata (Traube>,  of  the  spinal  cord  (spinal  apoplexy,  myelitis),  and 
Dt  the  entire  nervous  system  (tabes,  hysteria).  It  also  *»ccurs 
reHexlv  <  Kaymond).  The  anidrosis  appears  in  peripheral  facial 
paralysis  in  dementia  paralytica,  and  in  certain  skin  afTcctions, 
Mich  .TS  psoriasis,  lichen,  and  ichthvosis. 

.\m<ing  the  skin  affections  associated  with  exudation  we 
have  erythema  nodosum,  urticaria,  and  a  disease  probably  akin 
lu  it.  the  angio-nruroiic  tedeina  {Quincke),  which  appears  some- 
limes  quite  suddenly  on  ditlercnl  parts  of  the  body,  the  patient 


400 


D/SEASES  OF  THE  SPIXAL  XERVES. 


feeling  otherwise  perfectly  well.  The  hydrarthrosis  interniit- 
tcns.  which  F6r6  has  regarded  as  an  articular  angio-ncurosis 
(Reviic  dc  Neurol.,  1893,  17),  and  cutaneous  swellings  of  nerv- 
ous origin  accomi>anying  the  menses  (E.  BoenJCr.Volkni.Sararnl. 
kliii.  V'ortr.,  1888,  xi.  No.  513),  have  been  described.  Again, 
we  have  certain  forms  of  eczema,  prurigo,  herpes  zoster,  and 
others,  althougli  (heir  nervous  origin  is  not  established  beyond 
doubt.  As  every  one  of  these  affections  presents  in  its  devel- 
opment, in  its  clinical  significance,  and  in  its  treatment,  so  much 
that  is  by  no  means  cle:ir,  we  deem  ourselves  hardly  called 
upon  to  enter  into  a  detailed  dcscripiion  of  them  here.  Some, 
as.  for  instance,  the  herpes  zoster  in  the  course  of  facial  paraly- 
sis, have  been  mentioned  above  (cf.  page  90).  Equally  obscure 
is  the  origin  of  cutaneous  haemorrhages — as,  (or  instance,  the 
ecchymoses  which  occur  in  tabes  after  severe  attacks  of 
pain— of  the  pigment  hypertrophies  (e.  g.,  in  lepra),  of  the 
anomalies  of  cornificalion  (keratosis  and  ichthyosis).  o(  the 
lucvus,  which  is  said  to  be  due  to  intra-utcrine  disease  of  the 
Spinal  ganglia,  of  the  atrophic  conditions  of  the  skin  (striae  and 
maculx  atrophicx),  of  the  so-called  glossy  skin  fglossy  fingerst. 
of  the  pigment  atrophies  (vitiligo),  u(  the  atrophy  of  the  hair, 
and  the  atrophies  or  deformities  of  the  nails,  changes  which  vre 
meet  with  in  the  most  varied  nervous  affections  and  under  the 
most  varied  circumstances. 

An  interesting  angio-ncurosis  is  the  so-called  night  palsy, 
which  has  been  described  by  Ormcrod,  Hcrnhardt,  and  others. 
It  consists  in  numbness,  pain,  and  a  feeling  of  weakness  occur- 
ring at  night  in  the  upper  extremities.  I>istinct  anaesthesia  and 
actitat  paralysis  are  not  present.  Women  arc  afTeclcd  more 
frequently  than  men,  and  seem  to  be  particularly  prone  to  ilH 
the  menopause. 

I-ITERATURE. 

Samuel.    Die  iTophisclien  Ncrvcn.     Leipiit;.  18601 

Lustig.     Zur  Lehrc  vun  ilcn  vasomaiorischcn  Nrurosm.    Iaaug.-Dlu>,  nreil«u< 

"87  s. 
Akx.-inHcr.     l.itncel,  1881.  i.  25.  36. 
Slillet.     Wiener  mt'd.  Wochcnschr..  1B81.  5.  (t. 
Scrllgniijiler,     Ucbcr  Hydrops  ^iTlicutoruiti  inCcrmillcnt.    DttiUche  Bwl.  **■ 

chenschr..    1880,    5,   6.     (It  by  Secligmllllcr  icgardcd  as  4  vm**"**' 

neurosis.  J 
Schwimmer.    Die  neuropalhischcci  Dennalosen.    Wlon  U.  Leijutt;.  iSj. 
WeiM.    I'raiter  Zciltichr.  t.  Ilcilk,.  Scpiembcr  ij.  18S;.  vi.  6.    <ZostCT ewebi*''" 
Kopp.     Die  Trophoiicuruscii  tier  Haul.     Wicn,  1886.  Brjumiiller. 


I 

I 

I 
I 


HAY.VAUD'S  DfSEASE. 


■\o\ 


^^enaulL     Note  reblive  dts  troubtu  trophiques  excqttioncU  il'orjginc  ibumuu* 
^B     male    Cu.  hvhti.,  rtt87.  xl"i>  34- 

^Baymoiwl.    Dnrphulnnn  dc  U  face.     Arrh.  de  nrurol..  1888,  43,  p.  ji, 
^BTbom*.     Ucbcr  da^  Verhnllcn  ilcr  Artericn  bri  Supriuirliiinlncunlgie.     Ueul> 
Kbcs  Awh,  f,  kitn.  Med..  1888.  Bd.  jilm.  Hcfi  4.  5. 

Srfvui.     EkiKliMi  Med,  anA  Hutg,  Journ.,  Ociobcr.  1S88,  riin.  ly 

Auchd  CI  Ltspinaue.    Cas  d'Knthranirliiluic.     Kc\*uc  dc  itiM,  18S9.  11. 

ScheibrT,    Fialkvon  Traphoiirutuiii     Review  ii;  Wiener  inccl.  freMc,  18901 17. 

]avi.  M.     Ikriincr  Win.  Wochecischr,  1890,  4,  5. 
^^iniuncr,  P.     Einige  neuere  Arbeiien  liber  Irophischc  Ncnen.    Dnitiche  mr<\ 
^H      WochcnKhr.,  1893.  t. 

^^iuVe.     Zur  Aeiiolofpe  dr*  "  acuien  angUincurolitchcn  *'  ofkr  "umschricbcoen 
Haut<id«ms."     Berliner  kliii.  Wiichenschf,,  1891,6. 

Gerhsrdl.     Ucber  Kr^ihrnmelatgic.     IVulsclic  ni«.\.  Wochenschr..  1891.  yf. 

\timge».     [>Fr  pnkiiKhc  Ar/1.  xi^i.  \o.     (Cnxc  of  F.iyihromrlalpa.) 

I'o^.     PaU  von  I^ryihrtimela1|{ie.     i^ter  med.-chir.  i'resM^.  1893, 
^KiUenburj;.     Ueber  Er)-ihroinrlalgie.     Oeulschc  mcd,  Wocliensehr..  1893.  $a 
^Ktwla  und  Bcndit.    Ueber  ErythTumeblKie.    lierliner  kltn.  Wochcnschr.  1894. 3. 

^B  The  so-called  symmeirical  gangrene  of  the  fingers  and  toes 
^^sclerodactyly)  which  was  first  described  in  1882  by  Raynaud, 
and  wtiich  has.  alter  liiin,  been  called  Raynaud's  disease,  comes 
on  wilh  ihe  following  symptunis :  The  fingers  appear  at  times 
as  il  dead  {"doigts  dt  taort").  at  another  lime  they  tnrn  a  dark- 
red  color  and  burn  vioiently.  Gnidually  disturbances  in  nu- 
irition,  at  first  only  transitory,  later  permanent,  develop,  and 
blebs  form,  which  open,  leaving  u  sore  which  heals  with  loss 
(A  sul>stancc.  The  nails  fall  out  and  are  not  replaced,  whole 
Its  die,  the  necrosis  being  symmetrical  on  both  sides,  and 
none  of  the  usual  causes  of  gangrene — such  as  disease  i>f  the 
Heart  or  of  the  blood-vessels,  seplicxmia,  traumatism,  etc.— 
■re  present.  The  disease  is,  however,  very  rarely  met  wilh  in 
its  full  development,  while  li<;hter  grades,  in  which  we  have 
only  to  deal  with  a  transient  spasm  (or  paralysis)  of  the  vcsfirls, 
especially  in  the  hand,  arc  not  uncommon.  In  such  instances 
the  hands  become  bluish  and  icy  cold,  and  we  have  a  condition 
known  as  local  asphyxia.  Raynaud's  disease  may  be  con- 
founded with  peripheral  neuritis,  ergotism,  diabetes,  and  senile 
gai^renc.  It  should,  however,  not  be  dilBcult  to  avoid  such  a 
miftakc  if  we  Inlie  into  consideration  the  characteristic  course 
of  the  disoaM:  :md  the  absence  of  any  of  the  a'linlogical  factors 
before  mentioned.  In  the  treatment  favorable  results  have 
been  repeatedly  obtained  by  bathing  the  hands  in  warm  water 
and  the  application  of  alcoholic  menthol  !4>luiion  with  a  camel's- 
ir  brush. 


W^. 


402 


DISSASES  OF  THF.   Sf/A'AL  .VEflt'tS. 


LITERATURE. 
Weiss.     Ucbcr  wgea.  symmclrischc  Gangran.    Z«it»chr.  t.  llrlHi..  iSSi,  til.  p. 

=33- 
Ktdiattel.    Zetuchr.  i.  kiln.  MetL,  1883.  vi.  j.  p.  977. 
Luu.    Bayr.  Snil.  Intell.-BI..  18S4.  %.%\\.  14. 
Schuli.    Ileuiuh.  Arch.  f.  klin.  Med..  18&;.  xxxv.  p.  183. 
Vulpivi.     Gu.  ties  h6j>.,  1884.  9- 
Lauer.    Ucber  localt-  Asphyxic  und  symmeirische  CansrSn  <ler  EitreRUUUcn. 

Innug.'Diss.,  Sirasstiurg.  1HS4. 
Iltics  ci  VnilUrd,     Arch,  dc  I'hys.,  January.  1885,  jtih;  iir.  v.  p.  103, 
HochenegK-    Vcber  ftymmciriftchc  Gangrttn  und  locnlc  Asphysie.    Wimer  mccl. 

Jahrb,,  188;.  4.  pp.  569-658. 
Shaw.     R.-iynuu(l'i  Disifiuc.     New  Votk  Med.  Joum..  December  18.  1886. 
t'uwcll.     Brii.  Mill.  Joum,.  Janiur)'  ya,  1886.  p.  303. 
ColdKhniidl.    Gangrinc  symmJtriquc  et  Kl^nxjcnnie.    Revue  ilt  nie>].,  Mai, 

1887.  p.  404. 
Wifif-tirswonh.     Pcripherat  Neuriiis  In  Ra)naud*s  Dimmc.    Urii.  Med.  Joum.. 

Januiir>-  8.  188?. 
PoDin.    Uai.  dfs  lifip,,  July  36,  1887.  U.  90. 
FcHi,  R.  Hingsioii,     L;ir>i:ci,  Decrmber.  1888.  ii.  3$. 
Tannnhill,     GI-iaKOW  Med.  Juurn..  nccember,  1S68.  xxx,  6. 
BntRiJinn.     Filk-  voii  syniinctrischc  GangrSn.     Deutsche  Mcd.-Ztg..  i88g,  37, 

StunndDrf  (New  York).     Symmetrical  Cinifrene.     Med.  Record.  May.  1891. 40- 

Schciber.     Wiener  mcd.  WuchensLhr.,  1892.  39^43. 

Kornfeld     Wicnrr  mcd.  Prrssr.  1S91.  47.  48,  501  ji. 

H.iig.     T^.^n^acli^m.1  of  llie  .Med.  Society  of  Lomlon.  1892. 

Dcliio,     Deuluhe  Zeitschr.  f.  Neri'eiilik..  1893.  iv, 

Gcrmcr.     Raynaud 'schc  Kr.inkheii.     Inniig.-Diiiv.  Ilerlin.  t893. 

Undoubtedly  a  close  relation  exists  between  Raynaud's  dis- 
ease and  scleroderma.  In  this  latter  very  rare  aSeclion,  which 
also  depends  upon  tropliic  disturbances,  the  skin,  alter  havin)r 
presented  (edematous  swellings  in  the  first  stage,  becomes  later 
hard  and  immovable,  so  that  it  Is  impossible  to  pick  up  a  told 
of  it  between  the  fingers.  The  affected  parts,  more  particularly 
the  face,  neck,  anil  the  upper  portion  of  the  chesl.  where  fre- 
quently 3  diffuse  increase  in  the  pigment  is  noticeable,  are  im- 
peded in  their  movements,  the  play  of  the  features  is  lost,  the 
mouth  can  not  be  completely  opened,  the  eyes  can  not  be 
closed,  and  rotation  of  the  head  becomes  impossible,  etc.  The 
patient  feels  a  sensation  of  discomfort ;  the  coldness  of  the 
skin,  which  reminds  one  of  that  of  a  corpse,  is  most  distressing, 
and  a  slight  fall  in  the  outside  temperature  is  sufficient  to  bring 
about  cyanosis.  Quite  gradually  the  atrophic,  the  terminal, 
stage  comes  on,  in  which  the  skin  gets  as  thin  as  paper,  remain- 


immATKopntA  faciaus. 


403 


^ 


ing^,  however,  5rmly  fastened  to  the  underlying  tissues,  so  that 
it  is  still  impossible  to  pick  up  .1  fold.  With  these  changes  is 
associated  an  atrophy  of  the  muscles,  which  has  to  be  regarded 
{uirtly  as  a  Iropho-ncurosis.  partly  as  an  atrophy  due  to  inac 
tivity,  and  the  patient  becomes  helpless  and  unfit  lor  work. 
Alter  the  disease  has  lasted  for  several  years,  if  convalescence 
has  not  set  in  in  the  second  stage,  a  general  marasmus  develops 
which  leads  to  a  falat  issue.  An  effectual  treatment  is  not 
known.  Warm  baths  simple  ointments,  the  consinni  current, 
internally  tonics,  iron.  c«id-livcr  oil.  etc.,  may  be  tried,  but  we 
are  not  justified  in  placing  any  confidence  in  them. 

LITERATURE. 

Thibientc     Revue  de  tn^d,,  1890,  \. 

HoJb.     Mitnch.  mtd.  Wocliciischr,  1891.  x%x\x,  %\. 

Newmufc.     Amcr,  Joum.  .Med.  Sciences.  1891.  dv,}    (ComplicMion  of  Sckro- 

tlcrma  and  Hemiatrophy  of  the  Face.) 
Vudcfvetdc    Jount.  de  mM..  de  c)ur,.  ct  dc  (ihaTn)..  1893.  li.  3$.  p.  561.    (No 

pMtbotogical  changes  w-crc  found  in  the  nervaiu  tj-Mon.) 

The  next  affection  to  which  we  shall  call  attention  is  as  re- 
sarkable  as  it  is  mre.  Accordini;  to  our  present  ideas,  it  has 
abo  to  be  ranked  among  tlie  tropho-neuroscs.  We  are  refcr> 
ring  to  a  very  gradually  developing  atrophy  of  the  face  (some- 
times ushered  in  by  pain  and  panesthesias),  which  may  appear 
on  one  or  both  sides,  and  generally  embraces  equally  the  skin, 
the  subcutaneous  tissue,  the  muscles,  and  the  bones.  The  begin- 
ning is  usually  us  follows :  Whitish  spots  appear  on  the  skin  of 
the  lace,  which  sink  in  more  and  more  and  are  accompanied  by 
a  diminution  of  the  fatty  tissues  below;  gradually  the  atrophy 
increases  in  extent,  and  nothing  escapes  with  the  exception  of 
the  musculature,  and  this  only  occasionally  and  for  a  certain 
time.  The  alTecled  side  is  sunken  in.  and  the  skin  assumes  a 
whitish-brown  discnloration.  The  bones,  especially  the  upper 
(aw.  and  with  it  the  teeth,  atrophy  :  the  latter  fall  out.  as  well 

the  hair,  which  often  appears  of  3  light  color  or  distinctly 
IfRiy.  The  bone  atrophy  is  the  more  marked  the  younger  the 
patient  at  the  onset  of  the  disease  (Virchow).  If  the  dise.-ise  is 
confined  10  one  side  only — hemialrophia  facialis— the  mcdi;«n 
line  forms  a  sharply  defined  border  and  the  diagn<>sis  is  very 
plain.  If  both  sides  arc  affected,  .is  happened  in  Eulenburg's 
ciw  alter  measles  (Lchrb.  der  Ncrvcnkrankh,.  1878.  ii,  p.  620). 
it  may  be  more  difficult  to  recognize  the  .-iflcction.    The  grooves 


404 


ly/S^ASSS  Of  THE  SPINAL  N£Ft'BS. 


and  furrows  which  are  found  in  the  laoc  greatly  disfigure  it 
(Fig.  124).  The  corresponding  half  ol  the  tonfj^e  becomes 
small,  and  often  presents  ga|>-likc  retractions  such  as  wc  dc- 
scribed  in  hemiatrophy  oi  the  tongue  (Figs.  29  and  30).  Among 
the  muscles  not  only  those  supplied  by  the  facial,  but  also  thoac 


ftg,  »«.— HiMIAittoniu  Paciauo  (pcnooaJ  ubMrtiUinil. 

supplied  by  the  trigeminus,  are  implicated.  The  extension  of 
the  atrophic  process  to  the  neighboring  shoulder  and  even  to 
the  upper  arm  is  not  unusual.  Sensibility  h  not  altered  in  the 
affected  region. 

Most  of  the  few  cases  observed  clinically  have  never  come 
to  autopsy.  Of  great  interest,  therefore,  was  the  result  of  an 
examination  which  Mendel  was  enabled  to  relate  before  the 
Berlin  Medical  Socitrly.  on  such  a  patient  who  had  died  of 
phthisis,  and  who  had  previously  been  examined  by  Romberg, 
and  later  on  by  Virchow  (Deutsche  .Mcd.-Ztg.,  188S.  xxxiii,  p. 
407).  On  examining  the  origin  of  the  trigeminus,  all  the  other 
roots  were  found  to  be  normal :  only  in  the  descending  root 
could  atrophic  changes  be  reco>;ni2ed.  a  fact  which  would  in- 
dicate thai  the  trophic  fibres  must  be  contained  therein. 


D/SF.ASKS  OF  THE  MUSCLES. 


*fi^ 


I 


Other  obscrvatiuns  (Ruhcmanii)  nlso  point  to  a  very  iiili- 
niatc  connection  between  facial  atrophy  and  the  trigeniinus; 
however,  more  post-mortem  observations  conhrmaiory  of  tho&e 
ol  Mendel  are  needed  to  clear  up  the  p;uhology  oi  the  disease. 

Of  the  Kliology  liltic  that  is  positive  is  known.  Age  and 
sex  seem  to  have  little  influence.  The  disease  has  been  known 
to  occur  at  all  limes  of  life  and  also  to  be  congenital  ;  il  has 
been  observed  in  both  sexes.  According  to  Lcwin,  the  fre- 
quency with  which  the  two  sexes  are  attacked  is  in  the  ratio  of 
.six  males  to  nine  females.  Hereditary  predisposition  is  cer- 
tainly not  a  (oitditw  sinf  qiid  nm.  because  there  are  cases — among 
others,  the  one  I  have  reported  myself — in  which  the  patients 
belonged  to  quite  healthy  families.  Sometimes  it  has  happened 
that  the  atrophy  was  preceded  by  other  nervous  affections — 
trigeminal  neuralgia,  migraine,  epilepsy,  etc, — but  this  is  by  no 
means  the  rule.  In  a  few  cases  the  disease  has  followed  in- 
juries about  the  face  or  of  the  cervical  sympathetic  (Seclig- 
mUller);  more  frequently  no  cause  whatever  could  be  demon- 
sirated,  and  it  was  impossible  to  make  any  conjecture  as  to  the 
stiolc^y.  The  outlook  for  recovery  is  absolutely  bad,  and 
therapeutics,  so  far  as  our  knowledge  goes,  is  powerless. 


» 


LITERATURE. 

Eulenburg.    l/cbrr  progrcsbvr  Gcsichluirophic  und  Sclcrodcmtie.    Zcit«chr.  t 

klin.  Med..  iXli:,  v,  4. 
Wolff,  J.     Viic)iuw'<i  Areliiv.  1883,  xeW.  3,  p.  393. 
PuimI.     a  Case  of  ITogre«ivc  K*cial  Hernial rojihif.    The  Med.  Kec,  Apnl  16, 

18S7. 
Ibnvis«.     Liuu^i,  DcccmlKr  31,  1887. 
Hm-/.     Archiv  (.  KmdcTlirilktmdc.  rSS?,  viij,  p  ?ji. 
Uiwenfeld.     Vebcr  cinen  Fall  h.illi*eiliKti  Aitc)|)hie  tier  Gnidilv  und  Kaumns- 

culaiur.     Munch,  med.  Woclicnaclit.,  18S8,  xxtv.  jy. 
McnilcL     l/ebei  Hcmbiropht.i  fncinlin.     Ueuiachc  .M«l.-Zg[.,  1S88,  33. 
LOwmfcld.    Munch,  med.  Wochirnschr.  1888,  23,  14. 
Sachs.  B.     ProKttMiiF   Faci.1I  Hnnialrophy  whh  tome  Unusual  Symptoau. 

Med.  Reconl.  >tnn;h  (5,  189a 
HopiMT-SejIer.     Deuiichw  Arch.  i.  kiln.  .Med.,  1889,  xllv,  5,  6. 
Ctdirami.     Hcrlincr  klin.  Wochcht.chr,.  18S9,  3.  p.  5$. 
Ruhemann.     IVuiwhc  med.  Wochrnschr..  i88<t,  3,  55. 
FrofnhoUl-Tn!u.    Uebcr  HemlaiTDphU  (nc.  prog.    Inau^.-DiMCTt..  Dorpai,  1893. 

APPBNDIX.— DISEASES  OF  TIIE  MUSCLES— PRIM ARV  MVOPATHIES, 

Dis<*ascs  of  the   muscles,  which  consist  in  alterations  in 
their  volume  (which  is  generally  diminished,  less  frequently 


4o6 


DtSSASHS  OF  THE  SPINAL  JVSJfrSS. 


increased),  und  consequent  disturbances  of  function,  may  occur 
under  the  most  varied  conditions.  They  may  be  produced  by 
cerebral  affections,  as  we  have  ptiintcd  out  on  page  232.  where 
we  spoke  of  the  possibility  of  an  aflectiun  of  trophic  centres  in 
the  cortex ;  they  may  be  the  result  of  spinal  diseases,  as  mc 
shall  later  find  out  in  discussing  syringomyelia  and  progressive 
muscular  atrophy,  but  they  may  also — and  this  is  what  intcr- 
esls  us  here  more  especially — occur  independently  of  any  cen- 
tral disease  as  primary  myopathics. 

Considered  from  an  anatomical  standpoint,  this  disturbance 
in  the  nutrition  of  the  muscles,  the  dystrophia  muscularis  pro- 
gressiva of  Erb,  the  myopathia  progressiva  primitiva  of  Char- 
cot, consists  either  in  a  diminution,  a  wasting  of  the  muscular 
tissue,  owing  to  which  the  volume  of  the  part  affected  becomes 
smaller:  or  during  the  p-ithologiciil  process  there  may  come 
about  an  increase  in  volume,  which  is  cither  due  to  an  actual 
increase  and  abnormal  growth  ol  the  nmscles — a  genuine  mus- 
cular hypertrophy— or  to  a  growlh  of  the  interstitial  fatty 
tissue,  in  which  latter  case  m'c  speak  of  a  pseudo-hypertrophy 
of  the  muscles.  Sometimes  both  conditions  arc  found  in  one 
and  the  same  individual,  so  that  ccruiu  muscles  appear  atro- 
phied, while  others,  in  consequence  of  the  simultaneous  de- 
velopment of  fat,  appear  strikingly  large  and  hyperlropliicd. 
The  microscopical  examination  (Oppcnheim  and  Sicmerling, 
MUnzer.  and  others)  shows,  besides  an  increase  of  connective 
tissue,  a  moderate  development  of  fat. and  in  the  pscudn-hyjicr. 
Irophic  tissue  a  considerable  increase  in  the  inierstitial  con- 
nective tissue  between  the  individual  fibres,  which  latter  have 
retained  their  transverse  striaiion  (Charcot.  F.  Schultze, 
Strlimpellj.  The  genuine  hypertrophy  which  is  seen  in  places 
must  be  regarded,  according  to  SlrUrapcIl,  as  compensatory. 

About  the  xtiology  of  primary  mvopathics  wc  know  very 
little.  It  should,  however,  be  mentioned  that,  according  to  all 
the  observations  made  up  to  the  present  lime,  they  belong  en- 
tirely to  early  life,  developing  as  they  do  before  the  twentieth 
year.  Heredity  plays  frequently  a  /■<?/*■  in  the  disease,  since  mrf 
uncommonly  several  cases  occur  in  the  same  family.  DShn- 
hardt  raises  the  question  (Nciirol.  Centralblatt,  1890.  23)  whether 
there  might  not  occur  a  lesion  of  the  spinal  cord  during  fo;t;il 
life  or  during  the  act  of  birth ;  if  this  should  be  shown  to  be 
true,  the  mother  or.  as  the  case  may  be,  parturition  will  have 
to  be  regarded  as  an  xtiological  factor. 


JUl'hNiI.E  MUSCVIMK  ATROftlY. 


407 


I 


Lesage  has  shown  that  they  also  may  follow  cermin  other 
diseases,  as,  for  example,  typhoid  fever  (cf.  lit.).  In  such  in- 
stances wc  hnve  to  deal  with  a  secondary  lijximaiosts,  develop- 
ing  in  circumscribed  areas  of  the  body,  as  the  result  of  certain 
arterial  changes. 

In  our  present  state  of  knowledge  we  seem  justified  in  as- 
suming that  these  myopathics  occur  regularly  in  certain  groups 
of  muscles,  so  that  different  '*  types  "  can  be  distinguished,  and 
thai  on  the  whole  the  upper  hall  of  the  body,  particularly  the 


ne.os.'— S»CftUJU>  jL-vrjiiLK  Mi'icvMB  ATMiMiv  iEmbj  I  pcnoMi  obwnitiM). 

wppcr  cxtremilies.  are  more  often  and  more  severely  attacked 
by  the  pathological  process  than  the  lower  parts,  especially  Ilic 
leg^.  The  latter,  however,  may  also  be  affected,  in  which  case 
the  muscles  supplied  by  the  peroneiis  arc  especially  apt  tik  suU 
Icr  (Sachs.  The  Peroneal  Form  ol  Leg  Type  ol  Progressive 
Muscular  Atniphy.  Brain,  1890).  It  is  important  always  lo 
observe  whether  the  face  remains  intact  or  not.  as  in  the  for- 
mer case  wc  are  dealirtg  with  the  hereditary  muscular  atrophy 


4oS 


DlStiASjtS  OF  THE  SPIXAL  />•£/!  VKS. 


which  Erb  has  described  as  tbe  "juvenile  form":  in  the  latter. 
with  the  (orm  which  Landuuzy  and  Dcjcrinc  have  described, 
and  which  has  by  them  i>een  called  "  inyo)Kiihie  atrophtqiie 
progressive," 

The  so-called  "  juvenile  muscular  atrophy  "  which  develops 
in  early  youth,  more  ottcn  iu  boys  than  in  girls,  attacks  by 


n^  it&— Ji;vKini.K  UincuLAR  Avimfmv  4E*«>  tpmcmal ofaMtmloo). 

preference  (he  pcctoralcs.  the  trapezius,  the  lalissimus  dorsi. 
the  !>erralus  ma>>;iius.  the  rhomboidei,  the  sacro-luiubalis,  and 
the  longissimus  dorsi,  while  the  majority  of  the  muscles  of  the 
forearm,  the  sterno-cleido-niastoidcus,  the  levator  nnguli  scapu* 
la:,  the  coraco- brachial  is.  th«  tcrctts,  the  deltoid,  the  supra- 
spinatus  and  infraspinatus,  remain,  as  a  rule,  intact.  The  small 
muscles  of  the  hand,  which  in  spinal  atrophy  become  affected 
so  early  and  in  such  a  typical  manner,  are  here  not  implicated 


JUVENILE  MUSCULAH  ATKOrtlY. 


409 


't^ig-  '3€).  tt  is  hardly  necessary  to  enter  into  a  description  n( 
the  disturbances  of  function  which  necessarily  must  result  from 
disease  of  so  many  muscles.     If  wc  remember  how  much  im- 

I  piiired  are  the  movements  of  ihc  arm,  which  can  not  be  raised 
ibovc  the  horizontal  position,  etc.,  wo  can  understand  llie 

^gravitj'  of  the  child's  aAliction.     If,  us  in  the  long  course  of 


Pic.  »}■— Juvcuii.B  MiincULAti  AntopifV  'Cii>|  <pnwnul  (AwttmIcm). 


Elic  disease  not  uncommonly  hapiKns,  the  process  extends  to 

the  lower  half  of  the  body,  the  glutei,  the  peronei,  the  qundri- 

C:c|>K,  and  tibialis  nnticiis  become  implicalc<l  and  the  patients 

^Rl   tirst  walk  with  an  uncertain  gait,  then  waddle  in  a  char 

^pctcrinttc  manner,  and  finally  Jose  the  use  of  their  legs.    The 

"tiiplicalion    of   the    muscles   supplied    by   the   bulbar   nerves. 

^»-hich  has  been  observed  by  Ucrnbandt  (cf.  lit,),  of  course  lias 

^p  very  decisive  influence  u|K>n  the  duration  and  course  of  the 

<li  sense. 

I-'tbrillarj^«d^)ings  in  the  afiected  muscles,  as  wc  sec  it  so 


410 


DISEASES  Of--  THE  SPINAL  NBRyKS. 


comraooly,  we  may  say  regularly,  in  the  so-called  progrewivo 
muscular  atrophy  (spinal),  is  here  wanting  with  the  same  regu> 
lartty.  Neither  can  any  changes  in  the  electrical  excitability 
be  demonstrated,  with  ihc  exception,  of  course,  of  a  diminution 
due  to  the  disappearance  of  a  more  or  less  lar^je  number  of 
muscle  fibres.  The  course  of  the  disease  is,  as  we  said,  erni* 
ncntly  chronic.     It  may  extend  over  a  sp;ice  o(  twenty  or  thirty 


Fit.  ■■&— JfTKMi.K  lliicvLAH  Atropnt  (Ekb)  I pmxul  obi«ntioD). 

years,  since  bulbar  symptoms  occur  but  nircly,  and  we  can 
only  look  for  a  fauil  issue  if  the  process  involves  the  diaphragm 
and  respiratory  disturbances  result.  The  diagnosis  never  pre- 
sents any  difficulties.  After  careful  examination,  taking  into 
account  the  distribution  of  the  atrophy,  the  onset  of  the  disease 
in  early  life,  with  the  fact  that  more  than  one  member  of  the 
family  areaflectc<l.  the  long  duration  of  Ihe  disease,  the  absence 
of  fibrillary  twitchings.  we  can  not  mistake  the  myopathic  for 


PKOGPessfyK  ATttormv  myopathy. 


41  r 


the  5pinal  form.  The  treatment  inusl  consist  chiefly  in  good 
care  und  nursing.  All  attempts  to  arrest  the  process  by  the 
application  of  electricity  ur  the  use  of  massat^e,  baths,  or  in- 
ii-rniil  medicines,  have  proved  lo  be  oi  no  avail. 

The  lacio-humero<&capular  type  of  muscular  atrophy  ot 
I^ndouzy  iind  Dejerinc,  the  "  progressive  atrojihic  myo|wthy," 
u  lorm  which  had,  however,  already  been  described  by  Du- 
chennc  under  the  name  ol  "  progressive  muscular  atrophy  o( 
infancy,"  may  manifest  ilscU  before  the  appearance  of  any 
other  symptoms  by  a  markedly  laic  development  n(  the  intel. 
ligence  (Fillet,  Kevuc  de  m^..  1890.  S).     The  atrophy  begins 


N 


»^— PnOOiCMUVi  Atkoi-IIIC  U>     i"  i   h.      Irubtillr  KicbMCllicf)in<<>Di)ilrlel)'. 
lAder  MAHit  and  Guiukml) 

id  the  muscles  of  the  face,  and  our  attention  is  attracted  by  the 
listless,  sleepy  expression  of  the  face,  the  smooth  forehead,  the 
faulty  movements  ol  the  mouth,  the  inability  lo  whistle  and 
to  keep  the  lips  together.     At  ihe  same  time  there  is  a  condi> 
tton  of  lagophthalmus.  so  that  the  patient,  in  spite  of  the  great- 
est exertion,  is  unable  10  shut  his  eyes  (cl.  Fig.  129).    Gradually 
the  muscles  ol   the  upper  extremities  and   the  trunk  bcc<imc 
affccrted  in  almost  the  same  distribution  as  in  the  juvenile  paral- 
ysis.    The  course  Is  the  same  in  both  these  forms.     Here  also 
there  are  no  fibn'lhirv  twitchings  and  n<»  ch.Tnges  in  the  elec- 
trical excitability,  and  although  the  pseudo-hypertrophy  of  the 


412  DISEASES  OF  THE  SP/JVAL  JVEXFES. 

muscles,  which  we  shall  presently  describe,  is  not  uncoramon 
in  the  juvenile  form  and  is  here  never  present,  there  is  no  ques- 
tion but  that  the  two  affections  are  identical,  and  that  only  in 
some  cases,  from  reasons  not  as  yet  understood,  the  inteistitial 
connective  tissue  becomes  early  increased,  while  in  others 
nothing  else  can  be  demonstrated  but  simple  atrophy,  with  in- 
crease in  the  number  of  muscle  nuclei  and  here  and  there  the 
formation  of  vacuoles  in  the  fibres.  The  diagnosis  is  so  much 
facilitated  by  the  "  myopathic  facies  " — that  is,  the  expression 
produced  by  the  sinking  in  of  the  cheek,  the  somewhat  depend- 
ent  lower  lip,  and  the  inability  to  close  the  eyes — that  the  ex- 
perienced diagnostician  is  frequently  able  to  recognize  the 
disease  at  the  first  glance.  Marie  and  Guinon  have  called 
attention  to  the  possibility  of  confounding  the  disease  with 
lepra  ansesthetica.  in  the  course  of  which  also  weakness  of  the 
facial  muscles  exists  (cf.  lit.).  It  is  interesting  to  note  in  this 
connection  that  sometimes  disturbances  of  function  in  the  facial 
muscles  may  constitute  a  congenital  defect  which  under  ccr- 
tain  circumstances  may  be  followed  by  an  actual  atrophy; 
further,  that  in  sisters  or  brothers  of  individuals  who  sufier 
from  this  myopathy  which  we  have  just  described,  a  certain 
imperfection  in  the  development  of  the  facial  muscles  may  he 
found,  although  the  disease  never  breaks  out  in  them.  These 
are  facts  which  StrUmpell  especially  has  pointed  out,  but  the 
cause  still  remains  wholly  unexplained.  About  the  treatment 
we  need  add  nothing  to  what  we  have  said  with  reference  to 
the  juvenile  form. 

The  third  form  of  the  muscular  diseases  now  under  consid- 
eration— the  so-called  pseudo-hypertrophy — is  connected  with 
an  increase  in  the  interstitial  adipose  tissue  which,  in  spite  of 
the  atrophy  of  the  muscle  fibres,  lead  to  an  apparent  increase 
in  the  volume  of  the  affected  parts.  The  disease  was  known 
and  described  by  Griesinger  in  1864,  and  again  by  Duchenne 
in  1868.  It  begins  generally  in  the  muscles  of  the  trunk  and 
attacks,  in  contradistinction  to  the  two  forms  just  described, 
by  preference  the  lower  parts  of  the  body,  the  muscles  of  the 
back,  loins,  and  thighs.  Though  for  a  long  time  the  patient 
can  use  his  arms  and  hands  just  as  well  as  usual,  the  walk, 
owing  to  the  alTection  of  the  erector  muscles  of  the  spine, 
becomes  altered  in  the  characteristic  manner  which  we  have 
described  on  page  363.  The  condition  of  the  patient  may  re- 
main unchanged  for  years  before  the  arms  also  take  part  in 


PSEVDO-nYI'RKTROPmC  MUSCULAR  ATKOl'IIY. 


4<3 


process.  When  this  happens  it  occurs  in  the  same  man- 
as  in  the  juvenile  form.  The  diagnosis  is  very  much 
Mcih'i.'itcd  by  the  appearance  oi  the  patient.  The  enlarge- 
ment u(  the  calf  muscles,  the  thighs,  and  the  glutei  (which 
are  sometimes  colossal),  give  to  him  the 
appearance  of  a  ^iunl  and  suggest  u  su- 
pernatural strength  yc\.  Fig.  130):  but 
the  fact  that  these  great  masses  feel 
sjiongy  and  soft,  and  that  the  electrical 
excitability  is  considerably  decreased 
owing  to  the  diminution  in  the  number 
ol  the  muscle  fibres,  readily  explains  why 
these  sturdy-looking  persons  ure  feeble 
and  without  strength,  and  almost  wholly 
deprived  of  the  use  nf  their  limbs. 

In  its  onset  the  di.scasc  resembles 
closely  the  other  lorms.  Here  also  only 
children  become  affected,  more  especial- 
ly  those  between  the  ages  ol  four  and 
aine.  Again,  the  disease  may  occur  in 
several  members  of  the  same  family,  so 
that  we  must  undoubtedly  assume  a  hc< 
reditary  predisposition :  and  here  also 
the  fibrillary  twiichings  are  not  met 
with.  Duration  and  treatment  arc  the 
same  as  in  the  juvenile  atrophy. 


tMoniv  or  itii:  Huki.u 
or  TH«  Lkih  with  At- 
KDPHT  or  INK  Ucm.M 
or  Tile  Back.   (Arm  I)v- 


1  Congenital  atrophy  of  the  muscles 
may  be  found  in  cases  of  malformation 
nf  the  arms  and  hands.  Fig.  131  repre- 
sents a  boy  aged  thirteen  in  whom  the 
lorearms  are  absent ;  some  of  the  fingers 
are  grown  together  and  some  deformed. 
A  similar  case   has  been   reported   by 

Wilkin  (Lancet,  page  1265,  December  14.  1887).  where  there 
was  atrophy  ol  the  biceps  and  the  brachialis  anticus. 

Absence  of  certain  individual  muscles  is  rarely  observed, 
h-is  reported  a  case  in  which  there  was  .in  almost  entire 
ncc  of  both  trapezii  (Neurolog.  Centralbl.,  i.  laSg).  Among 
earlier  insLinces  the  peclorales  (Ziemssen).  the  biceps  (McAI- 
liNter).  the  delloid.  and  gastrocnemius  (Grubcr).  were  wanting. 
sc>  possess  no  clinical  interest. 


"  III 
^was 


4<4 


DISEASES  OF  THE  SP/JVAl  A'E/fl'ES. 


The  sensory  disturbances  which  arc  peculiar  to  the  tiius-| 
clcs,  but  about  ihe  exact  nnalomiciil  nature  of  which  we  Icnuvv  ' 
nothing,  arc  called  myalgias  or  muscular  rheumatisms.     .Klio- 
logically,  overexert  ion.  strains  (possibly  rupture  ol  certain  mus- 
cle fibres,  which  may  happen  during  gymnastic  exercises  or: 
other  violent  bodily  exertion),  must  be  mentioned  in  this  coo- 
nectioT).    Sometimes  we  arc  unable  to  find   any  such  cause, 
and  we  have  to  attribute  the  trouble  to  the  influence  o(  cold. 


(iT  Ui*  aiuKlea  of  the  upper  wmi  (pcncoal  obBcrvaUonV. 

There  are  persons  who  for  years  or  tens  of  years  suffer  fnitn 
myatgic  pains  which  come  and  go  .ind  may  disappear  (or  cer- 
tain periiMls  of  time  completely,  and  it  is  just  possible  th^' 
chronic  intoxications — e.  g..  alcohoiism,  perhaps  also  circ«l»- 
tory  disturbances — have  a  predisposing  influence.  Among 
such  myalgias,  which  may  be  very  painful,  even  sufficicni'y 
so  as  to  interfere  with  the  occupation  of  the  patient  fi>r  ^ 
longer  or  shorter  period  of  time,  we  have,  for  instance.  '^" 
torticollis  rhcumatica,  in  which  the  muscles  of  the  mtk.  i^^ 


MYALGIAS. 


4>5 


I  myalgia  lumbalis  (liimtKigo),  in  which  the  mu»:!csof  the  loins. 
■  the  myalgia  jniercustalis.  in  which  the  intercostnl  muscles  are 
(attacked.     The  shoulder  muscles  may  also  be  aflcctcd,  and 
rthe  myalgia  in  this  region  may  become  very  obstinate  without 
any  implicalton  of  the  brachial  or  cervical  plexuses  being  de- 
nmnstruble.     In  the  diagnosis  we  must  think  of  the  possibility 
of  an  implication  of  the  nerves  and  cndcavorto  exclude  neu- 
ralgia.    We  must  further  remember  (hat  central  diseases  may 
give  rise  to  muscular  pains.     The  inexperienced   may  mistake 
the  lancinating  pains  of  tribes  for  chronic  muscular  rheumatism, 
and  thus  obscure  the  correct  diagnosis  for  years.    It  will  hardly 
be  difficult  to  avoid  confounding  muscular  rheumatism   with 
articular  rheumatism   if  wc  take  into  consideration  the  gen- 
eral condition  of  the  patient,  the  appearance  of  the  joints,  the 
temperature,  pulse,  etc.,  which  in  the  former  affection  remain 
normal. 
I        In  ihc  treatment  we  should  first  of  all  endeavor  to  detect 
any  underlying  cause,  and.  if  such  exists,  remove  it.     In  re- 
cent cases,  besides  subcutaneous  injections  of  morphine,  salj. 
cylic  acid  may  be  tried  internally :  yet  we  should  not  spend 
much  lime  with  it  if  we  perceive  no  effect,  but  should  rather 
prefer  local  applications— irritants  to  the  skin,  poultices,  mus- 
tard plasters,  liniments,  also  massage  and  electricity — especially 
if  the  affection  remains  localized.     If  this  is  not  the  case,  but  if 
the  pains  travel    round  the  body  and   the  course   assumes  a 
more  chronic  type,  treatment  by  sweating,  steam  baths,  also 
mud  baths  or  b.iths  of  Pinus  sihrstris.  the  non-mcdicatcd  hot 
I  springs  (Gastcin.  Johannisbad.  Teplitz)  or  the  sulphur  springs, 
lamnng  others  PistyAn,  in  Hungary,  will  be  recommended.     As 
[a  last  resort,  we  may  ad  vise  the  patient  (o  goto  3  well-conducted 
[bydrotherapcutic  establishment  (GrSfenbcrg.  Kaltenleutgeben, 
fKa»sau,  etc.). 

LITERATURE. 

Laiuloutf  et  Dc)criM.     IV  U  mjmpnthic  airofihi(|ue  prDSraslv«.     Kevue  de 
m6d..  r«nicr-Mar«.  |8S{. 
JiaiAe  tt  Orinofi.   Formes  clintques  <Ic  la  m)x>tMlhie  progressive  primhive.    IbkL. 
Ociohrc.  r«85. 
/cMphal.     UobcT  cinlce  FBItr  i-on  prngrcsoh-cr  Mudcehtropbie  mil   Iklheili* 
|[niig  ilcr  OrtMhtsmuskclfi,    OMrit^Ann.ilen.  188$- 

Kcvitton   nmogmphlque  <lc&   airoplvirs    niusmUire*    pragreiiuves, 
PlDfT.  mM..  Man  7.  \W% 
»rf.     Nnirol  Ccniralbl..  iSS}.  Iv,  t.    (Impliulian  of  ihc  Facial  Musclet 
iMvcnile  kluKubr  Atrophy.) 


4l6  DISEASES  OF   THE   SPINAL   ffERVES. 

Krecke.  Munch,  med,  Wochenschr,  1886.  xxxiij,  14-16.  (Implication  of  I  he 
Facial  Muscles  in  Muscular  Atrophy.) 

Ladame.  Conlribulionil'eludedelamyopalhie  atrophiquc  progressive.  Revue 
de  mtA..  Ociobre,  1886. 

Landouzy  ec  Dejerine.  Nouvclles  recherches  sur  la  myopaihie  atrophiquc  pro- 
gressive, elc.     Revue  de  m^d.,  Decembre,  18S8. 

Lichlheim.  Ueber  hereditare  progressive  Muskelatrophie.  Schweiier  Corr- 
BI,.  1888,  xviii,  19,  p.  603. 

Bernhardt.  Ueber  cine  herediiare  Form  der  progressiven  spinalen,  mit  Bulbar- 
paralyse  complicirten  Muskelatrophie.    Virchow's  Archiv.  [888.  Bd.  1 1 5,  2. 

Lesage.  Note  sur  une  forme  de  myopathic  hypertro]ihique  secoridairc  i  la 
fi6vre  typhoide.     Revue  dc  mid.,  1888,  viii,  11,  p.  903. 

Sachs,  Progressive  Muscular  Dysirophies.  Journal  of  Nerv.  and  Ment.  Dis- 
eases, November,  1888, xiii,  11. 

Slern.  Ein  Fall  von  progressi\-er  Muskelatrophie  (juvenile  Form,  Err>),  mit  halh. 
seitiger  Betheiligung  des  Cesichtes.  Mittheil.  aus  d.  med.  Klinik  in  Kdmgs- 
berg.     Leipiig.  Vogel,  1888. 

Lichlheim.  Ueber  hereditare  progressive  Muskelatrophie.  Centralbl.  f.  Net- 
venheilk.,  18S8,  xi,  20. 

Souza,  Antonio  Veiga  de.  Zwei  FSIle  von  juveniler  Form  dtr  Muskclairojihie. 
Inaug.-Dissen..  Kiel.  1888. 

Troisier  el  Guinon.  Deux  nouveaux  cas  de  myopaihie  progressive  primitive 
chez  le  pSre  et  la  fiile.     Revue  de  mfid.,  1889,  ix,  i. 

Rfmond.  Une  observation  d'atrophie  musculaire  myelopathique  i  type  scapulo- 
humeral.     Progr.  mkA.,  1889,  2. 

Winkler  en  van  der  Weyde.  Primaire  mjopalhie  (type  facio-scapulo-humi'rall 
Kccombineerd  med  ophlhelmoplcgia  proj^r.  superior.  NeiliTl.  Wecklil.. 
1889.  i,  3. 

Schfulhaucr.  Histol.  Unlersuchung  eines  Falles  von  Pseudohypertrophic  di'r 
Muskeln,     Arch,  f  I'sych,  u.  Nervenkr.,  1889,  xx.  3. 

Herringham.  Muscular  Atrophy  of  ihc  Peroneal  Type afTeiling  many  MemK'rs 
of  a  Family.     Br.iin,  1889.  xi,  p.  230. 

Pal,  Ueber  einen  Fall  von  Muskel hypertrophic  mit  nervosen  SymptoiTii'n, 
Wiener  klin,  Wochcnschr.,  1889,  ii.  10. 

Aucrbach.  Zur  F'rage  der  wirklichen  culer  scheinbaren  Muskel  hypertrophic. 
Ccnlralbl.  fur  ilie  med".  Wisscnsch.,  1889,  4,5. 

Limbeck.  Fall  ion  complctcni  Cucullarisdefccl.  Prager  med.  Wochcns- lir., 
t88g,  \\v,  36. 

Hi(/ig.     Arch,  f.  Psych,  u.  Nen'enkh.,  i88g,  xxi.  2.  p.  650. 

StiiiUing.  Deutschcs  Arch.  f.  klin.  Med.,  1889,  45.  3,  4.  (Congenital  and  Ac- 
quired Defect  of  the  Pectoral  Muscles.) 

Gombault.  Sur  I'elal  de,^  nerfs  periphcriqucs  dans  un  cas  de  myopathic  pro- 
gressive.    Arch,  (le  med,  c>r|)^rim,  et  d'anat.  path.,  1889.  ;, 

Duda.  Fall  von  Pseudohypirtrophie  der  Muskeln.  Inaug.-Dissert,,  licrlin. 
T889, 

Muselier,  Maladies  gfnerales  chroniques  et  amyotrophiques,  i~,ii.  nii-rt., 
1889,  20. 

Klaas  van  Roon.  Over  chronischi:  en  jirogrcssive  alrophie  van  spicren.  .AUi 
proofsch,,  Utrecht,  1H89. 


PKfMA/tV  MYOPATHIES. 


417 


'  cl  Doon^n.    Myop.  prOKr.  primlt.  (l)|)e  LAnilouty).     Revue  de  mM.. 

189ft  4- 

tAnncquin,    Arch,  de  m^d.  et  dc  pharm.  mil.,  1S9CV  xr,  4.    (Alrophy  or  (he 

Rhomboid  Muicles.) 
tBran*  ct  Krcdd.     Forischr.  d.  Med,.  1890.  1.     (Congcniul   Defect  of  the 

Pectoral  MuKleit.) 
'  ItlctKhow&ky.    Neurol.  Centralhl.,  tSqo.  1, 
Krallmnnn  el  Haushjiier.     Retue  dc  m6il,.  1S90.  6. 
Koni;hi  e  Levi.    Coniribuiiune  alio  studio  delta  <lislro(i3  mniwol.ire  pro^retBVa. 

Regg:io  Emili.t.  1891, 
Ciidmnnn,  P.     Dcultchc  med.  Wochm^chT.,  1891,  34. 

IKmuu.  William  C.     Mu»cului  Atrophies.    A  Clinico-Pdiholiigical  SitMly.    The 
BufTilo  Medical  and  Surgical  Journal.  ApnI.  i8gi. 
IsneL  A.     Ueber  Uystcopbia  muNculurum  progrcuiva.     I naug.- Dissert.,  Fici- 
burg,  L  B.,  1891. 
Eib.  W.     DyMrophia  miKCuUriK  progressiva.     \'olknMnn's  S.imml.  k8n.  Vortr., 

N«ie  Folgc.  Noi-ertiber.  1892.  2. 
Mwm(tr.     Zur  Lchre  von  der  Dystrophia  muse,  progressiva.    Zeltschr.  f,  Uia, 

M«l..  189J.  ii»ii.6, 
Sciutor.      Ueber  acute  Pulymjositb  und    Neuromyositis.      Deutsche  med. 

Woehenschr..  1893.  39. 
HIgier  (Wanaw),     Ueber  primkrc  und  secundSre  Amyotrophicn  organischet 

und  dynainiKher  Naiur.     Ibid..  1S93.  38.  39. 
Situmpcll.     Dcuische  Zciischr.  f.  Nervcnhk.,  1893.  p.  471. 


PART  HI. 

DISEASES  OF  THE  SUBSTANCE  OF  THE  SPINAL 

CORD. 

Diseases  confined  to  the  substance  of  the  spinal  cord  are 
rarer  than  those  of  the  brain  substance.  The  cause  of  this  may 
lie  in  the  fact  that  not  only  are  the  vessels  of  the  spinal  cord 
actually  less  frequently  the  seat  of  disease  than  those  of  the 
brain,  but  also  that  when  they  become  diseased  the  conse- 
quences entailed  are  generally  not  of  so  grave  a  nature  as 
those  resulting  from  lesions  of  the  cerebral  vessels. 

As  in  cerebral  diseases,  here  also  two  questions  must  ever 
be  kept  in  view  by  the  physician  :  (i)  Where  is  the  spinal  lesion 
situated  ?  (2)  What  is  its  nature  ?  As  we  shall  see  later,  it  is 
especially  the  second  which  is  of  importance  for  the  prognosis 
and  choice  of  treatment.  Both,  however,  are  of  equal  weight 
for  the  proper  recognition  and  conception  of  a  given  case.  As 
in  the  study  of  the  brain  lesions,  the  topical  and  pathological 
diagnosis  should  here  no  less  go  hand  in  hand. 

I.   CONSIDEUATEON   OF  SpINAL  DISEASES   WITH  REFERENCE  TO 

THEIR  Seat — Topical  Diagnosis. 

As  a  thorough  acquaintance  with  the  anatomy  of  the  parts 
is  of  the  highest  importance  in  making  a  topical  diagnosis, 
some  remarks  on  these  points  may  in  this  place  not  be  un«a^ 
ranted. 

Without  being  separated  by  any  sharp  line  of  demarcation  fmn" 
the  medulla  oblongata,  the  spinal  cord  extends  from  the  upper  mar- 
gin of  the  arch  of  the  atlas  to  the  first  lumbar  vertebra,  where" 
ends  in  the  conus  medullaris.  From  this  point  it  is  seen  as  a  innS 
filiform  continuation — the  filum  terminale.  The  Cauda  equina  con- 
sists of  the  longitudinal  nerve  bundles  which  accompany  the  fil""' 
terminale.  and  corresponds  to  the  lumbar  and  sacral  part  of  ih' 
vertebral  column.  As  it  is  apparent  that  the  diflerent  pairs  of  nerves 
418 


ANATOMICAL  RELATIONS. 


4>9 


I 


do  not  teave  the  spinal  cord  at  the  level  of 
the  vcrltbrtc  after  which  they  arc  named, 
but  that  they  most  net'e»sarily  do  so  higher 
up,  it  it)  ini|Hirtant  i<)  know  to  what  nerves 
certain  parts  of  the  vertebral  column  cor- 
respond. Thus  wc  mu&t  rcRicmber  thai  the 
first  three  cervical  vertebra:  correspond  to 
the  origin  of  the  third,  fourth  and  fifth  cer- 
vical nerves,  and  that  the  seventh  cervical 
Tcriebra  corresponds  to  the  first  dorsal 
nerve.  The  spinous  process  of  the  fifth 
dorsal  vertebra  corresponds  to  the  origin 
of  the  seventh,  that  of  the  tenth  to  the 
twelfth  pair  of  dorul  nerves.  Opposite 
the  eleventh  dorsal  vertebra  originates  the 
first,  between  the  eleventh  and  twelfth  the 
second,  opposite  the  twelfth  the  third  and 
fourth  lumbiir  nerves.  Between  the  twelfth 
dorsal  and  first  lumbar  vcricbra  the  fifth 
lumbar  and  first  !uicr;il  nerves  take  their 
origin,  the  other  sacral  nerves  opposite  the 
first  lumbar  vertebra.  The  cervical  en- 
largement corre^pondit.  ihctcforc,  to  the 
spinous  processes  of  the  cervical  vertebra:, 
the  lumbar  enlargement  to  the  spinous  pro- 
cesses of  the  last  dorsal  venebr«.  All 
these  relations,  and,  moreover,  the  fact 
that  the  spinous  processes,  which  alone  can 
be  our  guides,  ate  not  always  on  the  same 
level  as  their  corresponding  vcrtcbrs,  arc 
demonstrated  in  Fig.  ija. 

The  relation  between  the  white  matter 
and  the  gray  which  it  incloses  becomes  ap- 
parent in  a  transverse  section  of  the  spinal 
cord.  Here  we  see  also  that  an  anterior 
and  a  posterior  fissure  divide  the  spinal 
cord  into  two  halves.  These  fissures,  how- 
ever, do  not  meet,  but  are  separated  from 
each  other  by  the  so-called  "commissures" 
which  connect  the  two  halves  of  the  cord. 
The  anterior  part  of  the  gray  matter,  the 
so-called  "anterior  horn," does  not  present 
the  same  diameter  and  form  throughout, 
and  in  the  cervical  and  lumbar  enlarge- 
ment is  larger  than  tn  the  dorsal  part  of 


fkU 


I>li 


m 


'I 


'^ 


10. 


t.t[ 


S< 


FiB  1.13.— Tn«  RirtJiTioiii  ow 
Titi  Omoiw  or -niE  NmvM 
m  THE  Bonir.*  oi'  rltB  Vui- 
risR.c  *sc  nil  Srtnou* 
ymoatm*.  (AfxrCowcM,! 


4« 


DISEASES  OF  SUSSTAXCE  OF  SPIXAL  COftD. 


the  cord  (cf.  Fig.  134).  From  this  anterior  hom  proceed  the  xnI^ 
rior  nerve  roots  and  |>aita  through  tlie  white  matter  which  1ir«  cxtet- 
nally.    The  posterior  horn  '\%  much  &inaller  and  extends  alitum  to 

the  entrance  of  the  posterior  roots, 
which  reach  it  after  passing  through 
the  external  part  of  the  postcfiw 
columns  ("root  zone"  of  Chai- 
cot).  The  arrangement  o(  the 
white  s-ubsiance  aod  its  subdivi- 
sion into  columns  and  tracts  b 
determined  (1)  by  the  existence 
of  the  above-mentioned  fissures, 
(1)  b)-  the  entrance  of  the  nerve 
roots,  (3)  by  the  shape  of  the  gray 
matter.  We  distinguish  roughly 
an  " antero-lateral  column"  and 
a  posterior  column  on  each  side. 
The  farmer  contain  (it)  the  crossed 
lateral  or  pyramidal  tracts,  {b)  the 
direct  cerebellar  tracts,  (^)  the  an- 
terior direct  pyramidal  tracts,  also 


Fig.  lai.— ScHUMB  OP  TUB  Coxournsc 
Paths  in  the  Spixai.  Coho  at  Tue 

LaVKt.  at  IKl  KirTH   DoBitT.  Nkhvk. 

(Afur  FLKClliia,)  kv,  anlerlor.  ka. 
pcaterior  root.  «,  direct.  /,  atjouA  pf- 
niinldal  irBCM.  A,  anitriiircoluninETmnd 
bundle,  e,  Ciell'*  culumn.  i,  Ilurdoch't 
celumni.  r  txA /.  vAx^  laltnU  pftthk 
A,  clireL-l  cciebelliu  Iracu. 


called  columns  of  TUrck  or  un- 
crosud  anterior  columns.  The  posterior  columns  consist  of  the  col- 
umns of  Goll  (at  the  inner  side)  and  the  columns  of  Burdach,  which 
latter  have  also  received  the  name  "root  zone"  (cf.  Fig.  13 j). 

I'hyKiologically,  the  spinal  cord  it  primarily  important  as  a  great 
conducting  system,  and  next  as  the  seat  of  numerous  centres.  The 
motor  impulses  originate  in  the  brain,  and  travel  down  along  the 
antero-latcral  column  chiefly  in  the  crossed  pyramidal  tract  of  iIk 


IV-  ■,»!-— CHow-sRCTiod  T11H0UC11  Tiie  SnHAL  Conu  at  DirntHEirT  Li:v»ul  «.fcrf 

o(  (he  trcond.     #.  \evt\  of  the  HTFnih  frrvKal  nrUrbn.    c.  lent  o(  the  tBCOad.    t.  k"l 
of  th«  thud  lumbar  Trrtcbra.    i.MlU  QuAIX.) 

Opposite  side,  the  decussation,  as  has  been  repeatedly  poinle<l  out 
taking  place  for  the  most  pari  In  the  medulla  oblongata,  ThrOUE'' 
the  large  ganglionic  cells  of  the  anterior  horns  these  crossed  pytiB'' 
dal  tracts  are  continued  into  the  anterior  nerve  roots  and  le*^' 
as  such  the  spinal  cord.  The  sensory  impressions  are  transniiK''' 
through  the  posterior  roots,  hence  (some  passing  through  the  ^^ 


^am 


TIIF.  REFLEXES. 


421 


ttero-lateral  columns)  they  reach  the  posterior  horns  and  at  once  cross 
(over  to  the  opposite  side  of  the  spinal  cord.  The  further  course  of 
the  sensory  fibres  as  ihcy  pass  to  the  braiti  is  not  clearly  understood; 
especially  imperfect  is  our  knowledge  with  regard  to  those  for  (he 
different  t|ujiliiie8  of  «cniui(ton — e.  g.,  the  sense  of  touch.  It  seems, 
however,  that  the  central  frr^y  substance  mum  be  looked  upon  as 
the  path  for  impressions  of  pain  (of.  the  inve»iigatii>n»  of  Rdinger 
aliuat  the  continuation  of  the  posterior  spinal  roota  up  to  the  brain, 
Anatom.  Aniciger,  iH^  iv,  4). 

I  We  know  that  reflexes  originate  by  the  stimulation  of  a  sensory 
nerve,  lly  thi»  an  impulse  is  conducted  to  a  centre,  and  hence  is 
transferred  to  a  motor  nerve — reflex  ate  (l-'ig.  135).      Among  such 


Ifls.  ijs-'-tti"''-rK  Arc  M,  mmot  puh.   S,  vimoFf  jMik.   mi,  MMOf  (oiiiBtM*,  t, 

PreAcx  movements  ue  distinguish  (1)  sVin  rellexes,  caused  by  irrita* 
hion  of  the  skin,  (i)  tendon  reflexes  which  are  produced  by  tapping 
Ion  a  tendon.  To  the  former  belong  the  plantar  teflcx,  the  centre  for 
'which  is  situated  in  the  lower  part  of  the  lumbar  enlargement,  the 

gluieJil,  the  anal  retlcx  (Rossolimo,  Neurol.  Centralbt,,  1II91,  9).  the 
icremisteric,  and  the  abdominal  reflexes,  which  arc  obtained  hy  irri- 
|tating  the  skinof  the  buttocks,  the  anus,  the  inside  of  the  thigh,  and 

the  abdomen  respectively.  If  we  find  these  present  in  a  patient  we 
FiOiay  assume  the  centres,  n-hich  are  s.iiuaied  in  the  lumbar  and  the 
[donal  cord  respeciii-ely,  to  he  intact. 

One  of  the  diagnnstically  most  important  signs  is  the  condition 
^of  the  ko-called  palvllar  reflex.     When  the  tendon  of  the  quadriceps 


422 


It/S£AS£S  OF  SVBSTAXCE  OF  SPIRAL  COKD. 


fcmoris  is  lapped,  a  reflex  contraction  of  this  muscte  ensues  by 
which  the  leg  is  jerked  forward  with  more  or  lc«s  vigor.  This  ii 
found  in  most  hcallhy  persons.  It  has  been  called  by  Erb  "paieltiu 
tendon  reflex  ";  by  Westphal,  who  doubled  its  reflex  nature,  "knee 
phenomenon  " ;  by  Gowers,  "  knee  jerk." 

To  3  certain  e.xtent  the  mode  of  tapping  this  tendon  and  the 
position  of  ihe  patient  arc  matters  of  indifference,  The  only  points 
to  remember  are  these :  The  lower  leg  should  be  held  perfectly  loose, 
and  no  superfluous  clothing  should  prevent  the  proper  Ktrikingof 
the  tendon.  The  simplest  way  is  to  place  the  patient  on  the  edge  of 
a  i.ibte,  remove  all  etothint;  from  his  legs,  then,  while  conversing 
with  him  about  indifferent  matters  so  as  to  distract  his  attention 
from  what  is  going  on,  to  observe  the  effect  of  the  percussion  of  the 
patellar  tendon.  The  exact  determination  of  the  strength  of  the 
rcilex  by  means  of  the  rcflcxograph  (Ilechterew,  Neurol.  Centralbl., 
iSga,  a)  can  be  dispensed  vriih  in  every-day  practice. 

If  we  find  the  rctU-K  present,  we  may  at  once  conclude  thai  the 
spinal  cord  at  a  certain  place — that  is,  from  the  second  to  the  fourth 
lumbar  or  first  sacral  nerves,  according  to  Westphal — is  intact. 

If,  on  the  other  hand,  the  reflex  is  not  obtained  on  the  first  and 
after  repeated  examinations,  the  patient  ought  to  be  directed  to  in- 
terlock his  bent  fingers  and  pull  strongly  (jcndrassik),  and  only  if 
the  knee  jerk  does  not  occur  after  repeated  trials  in  the  way  de- 
scribed, should  we  assume  its  absence  (Jcndrassik,  Neurol,  Central- 
blatt,  1885,  iS).  It  has  for  some  time  been  Jendrassik's  experience 
that  the  tendon  reflexes,  more  particularly  the  patellar  refiex,  is 
much  enforced  if  the  other  muscles  of  the  body  are  put  into  strong 
action  (Dcutsch.  Arch.  f.  klin.  Med.,  xxxiii).  Tliis  method  of  Jen- 
drassilc  is  an  excellent  and  indispensable  means  in  doubtful  cases  fur 
establishing  the  presence  or  absence  of  the  knee  jerk.  Sternberg  has 
recently  investigated  various  conditions  under  which  the  tendon  re- 
flexes meet  with  inhibiting,  diminishing,  or  increasing  influences  in 
the  spinal  cord  (Die  Sehnenreliexe  iind  ihrc  Hedeutung  fUr  die  P»- 
thologic  dcs  Nervcnsystems,  Leipzig  und  Wien,  Oeutike,  1895). 

Itesides  the  patellar  reflex,  the  Achilles  tendon  reflex,  and  the 
ankle  clonus  (the  foot  phenomenon  of  Westphal)  must  be  mentioned. 
The  latter  consists  of  a  succession  of  clonic  contractions  of  the 
tendo  Achillis  which  occur  on  a  shaqj  dorsal  flexion  of  the  foot.  Tu 
the  violent  shaking  movements  of  the  whole  leg,  which  occasionally 
occur  under  these  conditions,  the  very  inappropriate  name  of  spinal 
epilepsy  has  been  given. 

If  the  reflex  excitability  is  much  increased,  a  simple  tapping  on 
the  front  of  the  lower  leg  is  suflicient  to  produce  a  contraction  of  the 
calf  musclci.     This  is  what  the  English  writers  call  the  "  front  tap." 


tOCALIZATtOy  OF  SPiNAL  COHD  LEMONS. 


423 


Whether  all  thcM  so-called  icndon  reDexeii  are  really  of  refiex 
luature.  or  whether  they  are  not  rather  phenomena  due  to  a  direct 
stimulation  of   the   muscles  (Wesiphal),  is  still  an  unsettled  ques- 
tion. 

The  same  tinccitainty  exists  about  a  symptom  which  has  by  Wcst- 
ll  been  (eimcd  "paradoxical  contraction/'  and  which  consi&le  in  a 
\k  remnininj;  in  tetanic  contraction  for  quite  a  lime  after  it  hus 
been  passively  shorleiivtl.  For  itistance,  if  we  flex  the  foot  of  a 
puiient  lying  in  bed,  the  tibialis  anticus  may  under  certain  conditions 
remain  for  some  time  in  a  state  of  contraction;  its  tendon  becomes 
prominent,  and  only  gradually  relaxes  and  allows  the  foot  to  return 
to  its  normal  position  of  rest.  Only  rarely  has  this  phenomenon 
been  observed  in  other  mu&cle». 

Further,  reflex  centres  are  found  in  the  lumbar  region  of  the 
ttptnal  cord  for  the  emptying  of  the  bladder  and  rectum,  for  the  erec- 
tion of  the  penis  and  the  ejaciilaiion  of  the  semen — retlexex  whit  h  are 
concernrd  with  the  scsual  functions.  According  to  the  tcscatches  of 
Sarbo  (Arch.  f.  rsych.,  1893,  xxv,  >)  the  centre  is  situated  between 
the  levels  of  the  first  and  fourth  sacral  nerres. 


I.llKriATL-KE. 

—  ^Ldinbaril.  Pie  Varialionen  tlrK  norm-ilcn  Kniesiotses  und  <ler«n  VnUUtiuH 
■  uir  IMligkeit  <les  Cent r.>lneTvcn systems.  Arch.  f.  Anal.  u.  lliysioL,  1889, 
^^  Sujiplcmenlbanil,  p.  J^J. 

KupfertxT);.     nriing  «ur  Kcnnini«  dcr  Haulrrflne   bci  Nervengewinden. 

Iiuuu.-Disterl..  Kreil>urj[.  l88<». 
llcncilKt.    tin>f,-cqtMlti4iiic  Vdrwi.i!cndcsKnirpl)Jinonien«.   Nnrol.Ct-niralbl.. 

18891  19- 
£rbra.     Ncuc  l)e'tn|[e  rur  Keniilni»  dei  RcUcw.    Wiener  med.  Wochenschr., 
H        189a  kI,  31  el  u^. 

'binkler.     Localisation  und  klinischn  Vcrhaltcn  dcr  Dauchreflcxc    Deutsche 
Zritschr,  r.  Ncrienhk.,  1891,  ii,  4. 
EichhorsL    l>anMtoxcr  PaiclLtrsrhiKiirrflcx.     CralnlM.  f.  blin.  Med..  1893.  )i. 
4>*tg«l,    DiiklnUKhc  IViifun);  iter  H.iulrcflexc.     Deutsche  med.  WuclKASchr., 

1893.8. 
StfTitberg.    Die  Schtwrnrcflc^p  un<l   ihrc  Be<lciitung  fur  die  t'alhologic  des 
ft  NervduyMcms.     LrijMis  uiul  \\'icn.  Deultcke,  189]. 

With  regard  to  the  Iwali/alion  of  tbc  spinal  cord  lesion. 
two  quesliuns  arise:  (i)  Which  portion  of  the  cord  is  dis- 
riued  ?  Ik  it  the  cervical,  dorsal,  or  lumbar?  (a)  Which  part 
ol  the  cross  section  of  (he  cord?     Is  il  the  gray  or  the  white 

•  matter,  or  boll)  ?  The  first  question  can  be  answered  without 
diAiculty  In  cases  vthere  the  vertebral  column  is  diseased  :  we 
only  need  to  examine  the  latter  by  pressinj;  upon  the  vcrlcbrae 
or  by  applying  a  but  t>pongc.  etc.,  over  ihcm.     Those  spots  at 


424 


D/SBASES  OP  SVBSTAXCE  OF  SP/XAA  CORD. 


which  tcndeniess  is  cliciti-d  by  the  apjilication  ore  the  seal  o( 
the  disease.  The  occurrence  ol  spontaneous  jNiin  is  rarer  in 
diseases  of  the  cord.  It  should,  above  all,  be  reiiictnbercd  that 
lesions  o(  ihc  spinal  cord,  as  such,  wherever  (hey  may  be, 
almost  never  produce  pain  in  the  back,  but  that  this  is  in  a 
majority  o(  cases  due  to  trouble  in  the  muscles  or  their  nerves. 
It  is  a  characteristic  (eature  of  these  pains  that  they  become 
especially  marked  after  prolonged  standing  and  stooping,  and 
that  they  are  very  bad  on  rising  in  the  morning.  They  may 
occur  someiimes  after  a  quick  movement,  in  which  case  some 
muscle  bundles  have  been  overstretched  or  even  torn.  Pains 
in  the  back  which  persist  lor  months  and  years  unaffected  by 
any  therapeutic  measures  justify  a  suspicion  of  the  existence 
of  an  aortic  aneurism  which  may  be  pressing  against  the  vcrte. 
bral  column  or  of  enlarged  carcinomatous  abdominal  glands 
(Johnson,  British  Medical  Journal,  February  u.  1881).  In  dis- 
ease of  the  vertebral  column,  especially  if  it  be  cancerous,  pain 
in  the  back  is  a  prominent  symptom,  as  we  have  said. 

Hut,  leaving  out  the  tenderness  on  pressure,  there  are  other 
symptoms  which  may  help  us  to  decide  what  segment  ul  the 
cord  is  diseased  in  a  given  case. 

Diseases  ol  the  cervical  cord  generally  produce  symptoms 
of  motor  or  sensory  irritation  or  of  paralysis  in  the  upper 
extremities,  pains,  parxsthcsias,  feelings  of  weakness,  jerkings. 
and  the  like  in  arms,  hands,  and  fingers,  to  which  may  be 
added  also  trophic  disturl>anccs.  Muscular  atrophies  and  loss 
of  rellexes  in  the  upper  extremities  arc  often  observed.  The 
lower  extremities,  however,  remain  intact,  and  the  patellar  re- 
flex is  present  and  sometimes  increased.  Repeatedly  a  very 
decided  slowing  of  the  pulse  (as  low  as  thirty-two  beats  to  the 
minute  in  a  case  of  Lebrun's.  Bull,  dc  TAcad.  de  mid.  dc  Bel- 
gique.  I,  1887,  1)  has  been  met  with  in  lesions  of  the  cervical 
cord,  and  has  been  attributed  to  a  chronic  state  of  irritation  of 
the  vagus  due  to  compression  or  some  similar  influence. 

Affections  of  the  dorsal  cord  arc  mostly  accompanied  by 
sensory  disturbances,  parxsthcsias  in  the  back,  intercostal  neu- 
r.ilgias,  aching,  boring  pains,  which  sometimes  radiate  into  the 
lower  extremities.  AnxMhcsias,  though  they  are  not  the  nile, 
may  be  found.  If  a  distinctly  circumscribed  zone  of  anaes- 
thesia is  made  out,  it  corresponds  exactly  to  the  place  where 
the  lesion  in  the  spinal  cord  is  situated  (c(.  what  wEU  be  said 
about  lesions  of  one  half  the  cord  on  page  456). 


I 


m^^ 


LKSfOXS  OF  TIIF.  CXA  Y  MA  TTER. 


48$ 


Lesions  of  the  lumbar  cord  eiUftil  symptoms  in  tlic  lower 
extremities,  tfiving  rise  (o  weakness  and  paralysis,  sometimes 
also  jerkirigs  and  stiffness;  furthermore,  lo  pnins,  numbness, 
anicsthcbias  of  the  legs  and  feet.  The  reflexes  are  lost  and 
vesical  and  rectal  symptoms  arc  present,  the  former  consisting 
o(  retention  or  dribbling  of  the  urine,  pains,  strangury,  etc.  Of 
course,  the  symptoms  may  greally  vary  according  as  the  whole 
Iransverse  section  or  only  some  or  even  one  system  of  fibres 
alone  is  affected  in  the  given  level  of  ihe  cord.  Fracture  of 
(be  6rst  lumbar  vertebra  causes  a  lesion  of  the  conus  ter- 
minalis:  a  lesion  at  the  level  of  ibe  second  lumbar  vertebra 
and  below  it  gives  rise  to  affections  of  the  cauda  equina;  the 
clinical  symptoms  of  these  conditions  have  been  ably  described 
by  Valentine,  who  worked  under  Licblhcim ;  besides  (he 
symptoms  above  referred  to,  he  has  called  attention  to  the 
atrophy  of  certain  muscle  groups  (the  glutei,  flexors  of  the 
thigh,  muscles  of  the  lower  leg  and  foot)  and  the  reaction  uf 
degeneration  occurring  in  them. 

An  answer  to  the  second  (|uesiion  demands  a  thorough  ac- 
tpiaintancc  with  the  symptoms  produced  by  lesions  of  ilic  dif- 
ferent portions  of  the  cross  section.  These  we  will  therefore 
now  consider. 


I.   I.ESIOXS  OK  THE  CRAY  MATTER—"  POLIOMVEl.lTIS. 

In  giving  the  name  poliomyelitis  (itoXm?,  gray)  to  all  spinal 
affections  confined  to  the  gray  matter,  wc  must  at  once  insist 
that  these  lesions  are  almost  entirely  limited  to  the  anterior 
portion  of  the  gray  matter,  the  anterior  horns,  and  more  espc- 
cially  to  the  large  ganglionic  cells  in  them.  Other  portions 
have  only  rarely  been  found  affected,  and  then  only  in  connec- 
tion with  the  just-mentioned  lesiim.  The  diseases  of  the  gray 
substance  proper  which  have  come  under  observation  were 
confined  lo  the  groups  of  ganglionic  cells  of  which  we  have 
just  spoken.  Clinically,  there  are  two  such  diseases  lo  be  dis- 
tinguisbed.  namely,  poliomyelitis  anterior  acuta,  or  spinal  pa- 
ralysis of  children  (infantile  spinal  paralysis),  and  progressive 
muscular  atrophy. 


CHAPTER   I. 

POLIOMYELITIS    ANTERIOR    ACUTA — INFANTILE    SPINAL    PARALYSIS. 

Infantile  paralysis,  first  accurately  described  by  Jacob  von 
Heine  in  1840,  is  one  of  the  best-known  diseases  of  the  spinal 
cord,  both  as  regards  its  anatomical  seat  and  its  clinical  course. 
As  has  been  demonstrated  beyond  doubt  by  Charcot,  Provost, 
and  Jo0roy,  it  is  an  acute  inflammation  of  the  anterior  horns, 
or  rather,  as  is  usually  the  case,  of  one  of  them.  This  leads  to 
an  atrophy  and  sclerosis,  so  that  a  dense  tissue  remains,  con- 
taining the  dilated  vessels  and  small  remains  of  ganglionic  cells, 
which  are  not  rarely  found  to  be  calcified  (Friedlander,  cf. 
Fig.  136).      The  seat  of  the   process  is  usually  either  in  the 


Fig.  ijG.  — Transverse  Section  from  the  Cervical  Portion  of  the  Spinal  Cord. 
Airopliy  anil  sclerosis  of  ihe  right  anterior  honi.     (After  Charcot.  ) 

cervical  or  the  lumbar  enlargement.  In  the  former  case  the 
paralysis  affects  the  upper,  in  the  latter  the  lower,  extremity. 
The  secondary  dcfjeneration,  which  ensues  as  a  consequence  o( 
the  atrophy  of    the    ganglionic   cells,  extends  to  the  anterior 

416 


/XFA.VTILE  SP/A'AL  PARALYSIS. 


4*7 


nerve  roots,  the  motor  nerves,  and  the  muscles  supplied  by 
Ithem.     It  is  n  genuine  degenerative  atropby,  just  as  much  as 
(he  one  described  as  coming  on  after  peripheral  paralyses. 

Symptoms.— The  clinical  picture  ol  the  disease  is  very 
characteristic.    The  onset  bears  a  striking  resemblance  to  that 
of  cerebral  infantile?  paralysis,  described  on  page  271.     In  the 
midst  of  perfect  health  the  child  is  suddenly  seized  with  head- 
[ache,  vague  pains  in  the  limbs,  and  fever,  the  temperature 
reaching  104"  F.  or  even  more;  he  becomes  stupid  and  som- 
nolent, and  soon,  while  complete  unconsciousness  is  developed. 
I  general  convulsions  set  in,  which  last  usually  from  one  to  three 
'days  and   then  disappear      The   patient's  condition   becomes 
I  better,  consciousness  is  fully   ri'gnin('<l.  lie  become*,  bright  and 
ulkalive,  and  the  relatives  think  that  the  malady  has  already 


Flf,  ■a.'-'-An**!.  InI-AMIU.   rAMM-Y- 


i 


-mtlon). 


Spent  itself,  when  unfortunately  a  nu>re  carelul  examination  re- 
veals that  the  movements  of  the  child  are  impaired,  that  one, 

'more  rarely  both,  upper  or  lower  extremities  arc  paralyzed. 

'The  paralysis,  which  usually  affects  one  arm  (Fig.  137)  or  one 
leg,  has  developed  rapidly  and  reached  a  considerable  extent. 


428 


D/SEASES  OF  SL'BSTAXCF.   OF  SPIMAL  COflD. 


which,  however,  is  rarely  mniiUained.  On  Ihe  contrary,  as 
■  rule,  it  partially  recedes  and  confines  itself  to  certain  mus- 
cles, which  then  remiiin  permanently  paralyzed.  According 
lo  Beevor  (cl.  lit.),  the  affection  sometimes  embraces  groups 
of  muscles  corresponding  lo  those  which  Ferrier  in  his  ex- 
periments on  monkeys  savv  contract  after  stimulation  of  the 
djITcrcnt  cervical  nerve  roots.  In  the  majority  of  cases  the 
paralysis  takes  in  one  leg.  The  paralyzed  muscles  rapidly 
atrophy,  and  the  electrical  cxcilabiliiy  undergoes  quantiiaiive 
as  well  as  qualitative  changes — reaction  of  degeneration.  The 
whole  extremity  is  stunted  in  its  growth,  and  even  the  bones 
may  be  found  several  ccntimclrcs  shorter  than  those  of  the 
other  leg.  The  appearance  of  such  an  extremity,  in  which  at 
first  all  passive  motions  arc  possible,  is  quite  characteristic. 
The  skin  is  pale,  cyanotic,  and  feels  cold,  but  retains  its  sensi- 
bility completely.  Skin  and  tendon  reflexes  arc  lost,  but  there 
arc  no  vesical  symptoms.  Later  on  secondary  contractures 
develop,  among  which  Ihe  so-called  "  paralytic  clubfoot  "  is  the 
best  known.  In  consequence  of  the  paralysis  of  the  peroneal 
muscles,  their  antagonists,  the  calf  muscles,  become  perma- 
nently contracted  and  cause  the  point  of  the  loot  to  bang 
down.  In  the  arms  analogous  conditions  may  be  found,  the 
non-paralyzed  antagonists  always  assisting  in  the  production 
of  the  contractures. 

Roughly  speaking,  this  is  the  course  in  most  cases,  only 
occasionally  the  initial  fever  may  be  slight  enough  to  be  over- 
looked and  the  paralysis  develop  without  the  child  ever  ha%*ing 
taken  to  his  bed.  In  rare  cases  the  convulsions,  instead  of  last- 
ing for  days,  continue  for  weeks.  In  others,  again,  several 
months  may  pass  before  the  onset  of  the  actual  paralysis:  but 
all  these  arc  the  exceptions,  which  need  not  contuse  us  in  mak- 
ing a  diagnosis.  The  further  genyral  development  (with  Ihe 
exception  of  that  of  the  paralyzed  extremity)  is  perfectly  nor. 
mal.  and  neither,  as  happens  in  the  cerebral  infanlile  paralysis, 
does  the  mind  become  in  any  way  impaired  nor  do  the  initial 
convulsions  ever  recur.  The  child  grows  up  in  gmxl  health, 
but  always  remains,  especially  if  one  leg  is  aflected,  a  cripple. 
It.  as  often  happens,  contractures  or  a  spontaneous  paralytic  lux- 
ation o(  the  hip  develop,  the  patient  has  (or  years  to  be  under 
the  care  of  the  surgeon,  and  needs  braces  and  the  like.  K  an 
arm  is  allcctcd.  the  capability  of  the  patient  for  making  his  liv- 
ing is  naturally  considerably  and  permanently  intcrtcrcd  with. 


\ 


/Xf^.Vr/Ui  SPINA/.  PARALYSIS. 


4*9 


^ 


Diag;nosis. — It  is  not  difficult  to  avoid  mistaking  the  disease 
lor  an)'  other  it  we  bear  in  mind  the  characteristic  onset,  the 
lociilizalion,  the  behavior  of  the  [Kiralysis  itself,  the  flaccid  con- 
dilion  of  the  muscles,  the  absence  of  the  reflexes,  and  the  cold 
and  cyanotic  skin.  Where  we  find  a  hemiplegia — i.  c.,  where 
the  arm  and  leg  of  the  same  side  are  paralyzed — we  should  in 
children  always  first  think  of  infantile  spastic  hemiplegia  (page 
371),  as  it  is  one  of  the  rarest  exceptions  for  the  spinal  paraly< 
sis  to  take  on  this  distribution.  Confusion  with  the  syphilitic 
pseudo-paralysis,  also  known  under  the  name  of  Parrot's  dis- 
ease, is  avoided  by  remembering  the  fact  that  in  this  disease 
the  panilysis  makes  its  appearance  iromcdiatcly.orat  least  wilh> 
in  a  few  days,  after  birth  (Dreyfouss,  Revue  de  mid.,  aofit  i8$5. 

while  Heine's  paralysis  of  children  does  not  occur  at  such 

early  age. 

Prognosis.— The  prognosis,  as  soon  as  the  iniiLil  acute 
Kvmploms  have  passed,  is,  so  far  as  life  is  concerned,  absolutely 
favorable  ;  so  far  as  the  recovery  of  function  in  the  affected  ex- 
tretnity  is  concerned,  equally  unfavorable.  Any  notable  im- 
provement is  very  rare,  complete  cure  out  of  the  question. 
These  points  should  be  carefully  considered  before  inducing  a 
poor  and  struggling  father  to  let  his  child  undergo  year  after 
year  .in  expensive  and  useless  course  of  treatment. 

iCtiology. — Of  the  ;etiology  of  the  disease  we  know  noth- 
ing. It  is  doubtful  whether  cold  is  ever  a  causative  factor.  It 
(s  possible  ihat  infectious  influences,  the  action  of  certain  micro- 
organisms, will  at  some  time  be  proved  to  be  the  cause  of  the 
disease.  For  the  present,  however,  this  is  nothing  more  than 
a  hypothesis  which  has  not  gained  any  firmer  ground  Irom  the 
report  of  Cordicr  of  an  epidemic  of  the  disease  (Lyon  m£d., 
1888,  I,  2).  In  a  small  village  thirteen  children  were  inside  of 
(wo  months  taken  ill  with  anterior  poliomyelitis  and  four  died. 
According  to  Cordicr,  the  appearance  of  the  disease  in  sum- 
mer, the  sudden  onset,  the  similarity  in  course,  speak  for  an 
infectious  origin,  the  infection,  as  he  supposes,  taking  place 
through  the  air  passages. 

Treatment. — Little  more  is  known  about  the  treatment  than 
nbout  the  aetiology.  All  measures  to  cure  or  even  merely  to 
improve  this  rapidly  developed  paralysis  are  more  or  less  use- 
leiLS.  Electrical  treatment  with  the  faradic  or  galvanic  current, 
fcystematic  massage,  gymnastic  exercises,  together  with  rubbing 
with  all  sorts  of  salves — all  these  have  been  tried  without  any 


430 


DISEASES  OF  SUBSTAXCB   OF  SPINAL   CORD. 


noteworthy  success.  In  a  few  cases  1  have  seen  the  mclhiKl- 
ical  use  of  heat,  in  the  form  of  hot  sand  baths,  warm  packs,  etc.. 
bring  about  at  least  a  pcrcepiible  impro%'en:jent :  but  even  here 
this  was  out  of  proportion  to  the  care  and  trouble  which  had 
been  taken.  Certain  it  is  that  the  influence  of  the  different 
baths  has  been  greatly  overrated,  whether  it  be  the  brine 
baths  of  Kvcuznach,  Hclchenliall.  Kolbcrg,  or  the  chalybeate 
springs  o(  Pyrmont,  Flinsberg.  Schwalb;ich,  or  the  sodium 
waters  of  Kchme,  Soden,  or,  finally,  the  non-medicated  hot 
springs  ol  Castcin,  Johannisbad,  and  many  others,  each  of 
which  has  its  advocates.  The  most  appropriate  appear  to  be 
those  last  mentioned,  but  in  most  cases  we  shall  even  then  find 
that  while  perhaps  the  child's  general  condition  is  improved 
and  it  becomes  strong  owing  to  the  good  hygiene  and  fresh 
air.  the  paralysis,  (or  the  sake  of  which  all  has  bten  undertaken, 
remains  absolutely  unchanged  and  presents  no  improvement. 

In  view  of  these  unsatisfactory  results,  the  interesting  but 
still  scanty  communications,  according  to  which  the  growih 
of  bone  can  artificially  be  increased,  deserve  our  deep  interest. 
In  1887  HeUcrich  proposed  to  tic  round  the  affected  (paralyzed, 
atrophic)  limb  elastic  rubber  tubing  so  as  to  pro<luce  an  arti- 
licial  engorgement,  and  through  this  a  more  active  nulrition 
of  all  the  tissues,  including  the  bones.  Schtiller  also  bus  re- 
ported before  the  Berlin  Medical  Society,  November  28,  18S8 
(Deutsch.  Med.-Ztg.,  1888,99,  page  11S2).  several  cases  which 
were  thus  treated  and  which  showed  decided  improvement 
Tu  judge  from  his  communication,  this  treatment  undoubtedly 
should  be  tried  in  all  suitable  ciises.  It  is,  however,  a  proced- 
ure which,  as  well  ,^s  the  orthopaedic  Treatment  so  important 
for  the  prevention  of  dcConniiies,  should  not  be  undertaken 
without  consulting  u  surgeon. 


I 
I 

I 

I 


UTIvRATURE. 

Charcal.    t.«ctUTeii  on  the   I)i>ea-«cs  of  the  Nervous  SjrKiccn,  driivered  at  La 

Salpttriire.     Tr.iiulaicd  by  tieorgc  SJgcrwn.     New  S}HknlMin  Society. 

L.on(ton,  1877. 
FrierilKnder,  C.    Uebcr  Vcrk.ilkung  der  C.-in);)icnzelten.     Virchow**  Archlv, 

1881,  S8.  t. 
Rockwiix,     Deutsche  Zcilschr  f.  Chir,.  1883.  \\t..  i.  3. 
Sahli.     PcutwhM  Arrhiv  f.  klin.  Med..  1883.  xnxiii.  3.  4. 
Loreni.    Ueber  die  Entsichung  der  Gi-lenksconlriW turcn  nach  spinaler  Ktmt(r> 

IShmuiig.     Wiener  med,  Woehenschr.,  1887.  17-31. 
K.ucn-iki.     Die  der  ijiinalen  KliiilerlSlitDUdS  Tol^ndcn  CelcnkscontracturcD 


a/ftoytC  AMTESIOK  POUOMYEUTIS.  431 

und  die  panJyttschc  Luxation  dcr  Hurtc    Archiv  f.  klhu  Chir.,  1888,  37,  3, 

p.  >t6. 
Rkdcr.  Hermann.     Pdiomyvllils  ant.  acuU.     Miincli.  mrd,  Wocliciuchr.  1889, 

%wn.  2. 
Luknburg.    SubKuteamyi>trophiKheSpinullahinunx'*><t  pandyibchn^SchultM^ 

Krirnktnohlaffung.  Hchaxidluiig  durch  Anhioilesc.      Ikriiner    klh).   Wo 

chciuchr,  189%  4,  ;,  3S, 
Ko*rrit>rrg.      Die    DiOcrtnialdiagnoM   iter   Poliomyclilb   nnlrrior  acuU   uixl 

chronic.-i  adultoruin  und  dcr  Neuritis  roulliplox.     liuug.-Di&Ktt.,  HciikU 

berg.  189a 
Gokbchckler.      Veber  Poliomyelitis  anterior.     Zeitschr.  Ttir  klin.   Med.,   1893, 

ixtil.  Heft  ;.  6. 
Stcmcrling.     Acuter  Befund  bti  spin.iler  KindeTl;thmur>|[.    DeutKlie  Nfcd.-Ztg., 

1891,96. 
Kohnaumtn.      Schr)iitscrien  Uiitcrxuchung  eincs  Fulles  vod  ipinalcr   Kinder- 

Uhmung.     Ibid,,  p.  556. 
Miirie.  P,     Lefoftt  sur  let  maladies  dc  la  moclk.     Pnris.  Masson.  1891.    (This 

work  should  be  consulted  Tor  each  chatilcr  of  this  ponioit.) 

Though  the  lesions  of  the  gray  anterior  horns  when  occur- 
ring in  children  are  well  understood,  both  in  Iheir  nnutomicul 
and  ihcir  clinical  aspect,  yet  when  the  same  process  takes  place 
in  adults  our  knowkd^e  becomes  very  tiinited.  Merc  the  mu- 
lerial  at  our  disposal  is  still  so  small  that  only  in  rare  excep- 
tions can  we  say  definitely  whether  we  are  dealing  really  with 
an  anterior  poliomyelitis  and  not  rather  with  a  peripheral  dis- 
ease, a  multiple  neuritis.  Clinically,  the  dilferenlial  diagnoi^is 
between  the  two  can  only  be  made  in  the  initial  stage,  as  the 
jtcriphenil  disease  is  accompanied  with  pains  and  sensory  dis- 
lurhatices  which  arc  absent  in  the  central  aflcction. 

A  patient  is  taken  ill  with  grave  general  disturbances— 
(ever,  somnolence,  convulsions,  delirium,  etc. — and  within  a 
shun  lime,  perhaps  in  one  or  two  weeks,  a  widespread  paralysis 
in  all  four  extremities  is  developed.  The  paralyzed  muscles 
become  flaccid  and  atrophy,  the  tendon  reflexes  disappear; 
sensation,  however,  as  well  as  bladder  and  sexual  functions, 
present  no  abnormity.  With  a  history  like  this  we  must  think 
of  a  lesion  of  the  anterior.gray  horns.  Thi*  idea  becomes  more 
than  a  conjecture  if  on  examination  the  aiTt-cied  muscles  are 
found  to  be  such  as  arc  supplied  from  ganglionic  cells,  which 
m<ist  probably  lie  in  close  proximity  to  one  another  in  the 
spinal  cord.  In  such  cases,  as  Kcmak  has  shown  so  bcaulilully. 
certain  types  of  paralysis  arc  observed — the  forearm  type 
(paralysis  of  all  the  extensors  without  the  supinator  longus) 
and   the   upper-arm  type   (paralysis   of   the   biceps  brachialis 


432 


DISEASES  OF  SUBSTA.VCE  OP  SPINAL   COKD. 


amicus,  delloid,  and  the  supinator  lungus) — but  unfortunately 
such  instances  arc  rare,  and  therefore  even  quite  an  experi- 
enced physician  may  feel  uncertain  about  the  diagnosis. 

The  difficulty  becomes  greater  if  the  paresis  or  paralysis  is 
not  extensive  and  does  not  develop  rapidly,  but  slowly  and  by 
fits  and  starts.  In  these  cases  not  rarely  a  temporary  improve- 
ment may  be  noted  and  arouse  hopes  of  complete  recovery, 
unfortunately  never  justified.  These  arc  the  instances  in  which 
we  find  not  complete  but  partial  reaction  of  degeneration  in 
the  paralyzed  muscles — intermediate  form  of  chronic  anterior 
poliomyelitis  (Erb),  It  %iiz%  ivithout  saying  that  wc  must  have 
the  other  symptoms,  especially  the  loss  of  reflexes,  even  to  jus- 
tify a  conjectural  diagnosis.  Moreover,  it  is  necessary  that  there 
should  be  absolutely  no  sensory  changes,  and  that  bladder  and 
sexual  functions  should  be  normal.  Of  the  points  of  difference 
between  anterior  poliomyelitis  and  tabes  we  shall  speak  later. 

We  can  hardly  expect  much  from  any  treatment.  Elcc 
tricity,  however,  should  be  tried,  if  for  no  other  reason  tfian 
that  something  is  done.  Duckworth  recommended,  besides, 
belladonna,  iron,  quinine,  and  cod-liver  oil,  and  claimed  to  have 
cured  cases  with  these  remedies. 

With  reference  to  the  aetiology,  nothing  certain  is  known. 
Whether  traumatism  can  ever  cause  anterior  poliomyelitis  re- 
mains dnubtful,  notwithstanding  the  report  of  Gibbons  (Mod- 
Times  and  Gazette,  September  5.  1885).  He  had  among  his 
patients  a  hoy  nine  years  of  age  who  after  a  fall  on  his  knees 
developed  the  symptoms  of  an  anterior  poliomyelitis  (and  re- 
covered completely  !).  In  cases  of  chronic  anterior  poliomye- 
litis which  came  to  autopsy,  sometimes  atrophy  in  the  gangli- 
onic cells  of  the  anterior  horns  through  the  whole  length  of 
the  cord,  as  well  as  atrophy  of  the  anterior  roots,  was  observed, 
while  the  peripheral  nerves  remained  intact  (Oppenheiin). 

LITEBATURE. 

Eib.     Ut'Iier  (la^  Vorkommeti  der  chnn.-atmph.  Sptnnllthmting  l»fm  Kini't 

Neurol.  Ceniralbl..  1883, 11,  B. 
Remhanlt.     Virchow'it  An:hiv.  1883.  Rd.  9s,  p.  3691 
Duckwonh.     Clinic.nl  Lecture  on  Subacute  Anterior  Spinal  Paraljuit  (A* 

Comual  Myelitis)  in  the  A<lii1t.     Lanrci.  November  14,  i88(. 
Lecleic  ei  Bliinc.     I'aralyiiic  spinale  dr  Tadultc.     Lyon  mdd..  i886h  $1. 
Buss.     Eln  scltener  Fall  von  airopliiicher  SpinallShmunj;  ([\iliom  ant.  cb"" 

adult.)  mit  Uc'icrgAHg  in  ficulc  B;ilb]trmyelitis.     Berliner  kllii.  Wochcnviit' 

18S7,  No.  a«. 


\ 


caxomc  anterior  poliomyelitis.  433 

Oppenheim.     Ueber  Poliomyditis  ant.  chron.     Deutsche  Metl.Zig.,  1887.  95, 

p.  1087. 
Oppenheim.     Arch.  f.  Psych,  u.  Nen'enkr..  1888.  xix.  2.  p.  381. 
Raymond.     On  Essential  Myopathies.    Gaz.  des  hop.,  1888.  i$o. 
Hoffmann  (Heidelberg).     Ueber  progressive  neurasthenische  Muskelatrophie. 

Arch.  f.  Psych.  U,  Nervenkr,  1889.  xx,  3. 
Hig'ier.     Ueber  primSre  und  secundSre  Amyotrophien  orgnnischer  und   dy- 

namischer  Natur.     Deutsche  med.  VN'ochenschr.,  1893,  37,  38. 


19 


CHAPTER    ir. 

ATROPHIA    HUSCULARIS    PROGRESSIVA    SPINALIS PROGRESSIVE 

MUSCULAR    ATROPHY. 

Progressive  muscular  atrophy  was  first  described  by  Du- 
chenne  and  Aran  in  1849  and  1850,  and  was  recognized  by 
Cruveilhier  in  1855  as  a  spinal  affection.  Thanks  to  the  work 
of  Lockhart  Clarke,  and  especially  that  of  Charcot,  the  occur- 
rence of  a  pathological  process  restricted  to  the  gray  substance 
of  the  spinal  cord,  which  is  accompanied  by  a  muscular  atrophy 
of  typical  distribution,  is  now  established  beyond  the  slightest 
doubt. 

Pathological  Anatomy. — The  process,  which  is  usually  most 
pronounced  in  the  cervical  cord,  consists  again  of  an  atrophy 
and  transformation  of  the  gray  anterior  horns  into  a  fine  fibrous 
tissue  containing  spider  cells.     The  large  ganglionic  cells  are 
partly  or  wholly  destroyed,  or  at  any  rate  are  diminished  in 
number  and  perceptibly  smaller.     Here,  too,  the  lesion  extends 
to  the  anterior  nerve  roots  and  corresponding  fibres  of  the 
motor  nerves.     On  microscopical  examination  we  find  that  ihe 
muscles  supplied  by  them  retain  their  transverse  striation,  bul 
the  fibres  are  decidedly  diminished  in  size.     Some  fibres  also 
show  the  so-called  degenerative  atrophy — that  is,  a  fatty,  wai- 
like  degeneration,  with  increase  of  the  interstitial  conneciivc 
tissue  and  multiplication  of  the  muscle  nuclei.     Which  of  the 
described  processes  has  to  be  regarded  as  the  primary  one,  in 
other  words,  whether  the   disease  actually  does  start  in  ibe 
gray  matter  of   the   cord,  and  not  perhaps   in  the   peripheral 
nerve  endings;  whether  both  processes  may  occur  at  the  san"^ 
time,  or  whether  they  may  succeed  each  other  in  the  same 
individual,  and  at  what  age  they  occur,  all  these  points  have 
recently  given  rise  to  much  controversy,  as  has  also  the  qufS- 
tion  of  the  importance  of  hereditary  influences.     Those  who 
wish  to  inform  themselves  more  thoroughly  on  this  subject 
are  referred  to  the  articles  by  Hoffmann  (Deutsche  Zeitschr. '■ 

434 


PftOCKESSfVE  MUSCULAR  ATROPHY. 


435 


'Ncrvcnhtilk.,  1893,  Hi,  6.  p.  437).  Strlimpeil  (ibid.,  p.  471).  Bern- 
luirilt,  Ueber  die  spiiwl-neurolischc  Form  dcr  Muskclatrophic 
(Virch.  Arch.,  rSgj,  cxxiii.  Heft  2),  and  others. 

Symptoms. — The  onset  of  the  disease  is  in  many  cases  very 
characteristic.  The  p.ttirnt  begins  to  complain  of  weakness  in 
the  arms,  sometimes  more  in  the  right  than  in  the  left,  which 
soon  interferes  to  some  extent  with  his  ordinary  actions.  Sen- 
sory changes  and  pains  are  absent — a  point  which  is  of  vast 
diagnostic  importance.  Not  many  weeks  after  these  symptoms 
ha%*c  appeared  the  competent  observer  will  notice  a  peculiar 
flatness,  a  sunkcn-in  condition  ol  the  ball  of  the  thumb,  while 
at  the  same  time  the  thumb  is  more  than  usually  approximated 
I  to  the  second  metacarpal  bone  ("ape  hand,"  Fig.  138).  The 
'  intcrosscal  spaces  on  the  back  of  the  hand  are  sunken  in  and 


lA  ij»— PRooHuugvK  UVMCUB  ATlMniv.    {M^»t  KictiHomcT.)    ('!(.  ijS.  •(• 
bawl    Fls-  139^  MnlMB^B  tniarauaiJ  •pan*  oa  ilv  l>Mk  o4  th*  haod. 

terminal  phalanges  of  the  fingers  are  in  incomplete  exten- 
sion (Fig.  139).  The  hollow  of  the  hand  seems  flattened  (atro- 
phy ol  the  lombricalcs),  and  the  atrophy  of  ihe  muscles  of  the 
thenar  and  hypnthenar  becomes  more  and  more  apparent.  As 
Ihe  lunctiun  of  the  intcrossci  becomes  disturbe<l  to  a  greater 
extent,  the  same  claw-like  position  of  the  fingers  develops 
which  has  been  described  on  page  349  as  occurring  in  affec- 
tions ol  the  ulnar  nerve  ("  claw  hand,"  "'  main  en  gf'ffe  ")■ 

After  this  condition  has  thus  for  weeks  or  months  under- 

no  marked  rh-tngc.  the  disease  bcginfi  lo  attack  cither  the 

:lcs  ol  the  fureariii,  or,  passing  over  these,  implicates  the 


436  DISEASES  OF  SUBSTAXCE  OP  SPf.VAl  COKD. 

muscles  of  the  shoulders  and  with  special  preference  the  del- 
toid. In  the  former  case  the  extensors  arc  attacked  earlier  and 
more  seriously  than  the  flexors.  The  muscles  of  the  trunk  and 
legs  are  cither  later  or  never  aflcctcd,  but  if  invasion  of  ihe 
diaphragm  and  other  respiratoiy  muscles  occur  this  may  prove 


Pif,  l^a— PHI0*HIE»IVC  bl-lNAL   UUSCULAK 


'  pcnan»l  otaenalinX 


fatal,  as  may  also  an  extension  of  the  process  from  the  cord  w 
the  medulla  oblongata,  in  which  case  the  symptoms  of  pr^ 
gressivc  bulbar  paralysis  are  superadded  (page  154).  U  1^'* 
do6s  not  take  place  and  the  respiratory  muscles  arc  spared,  the 
disease  may  last  for  years  and  tens  of  years,  and  death  ison'j 
caused  by  an  intercurrent  acute  malady. 


fe 


i 


PROGKBSStVB  MVSCULAK  ATROPttY. 


4J7 


Apart  from  the  characteristic  onset,  the  following  signs 
help  to  mak<;  the  diagnosis  certain;  0)  Fibrillary  twitchings 
in  the  adecied  muscles,  which  can  at  limes  be  produced  by  tap- 
ping the  muscles,  but  which  are  often  seen  to  appear  of  their 
own  accord  and  continue  without  interruption.    (2)  The  con- 


ns- Mi.^PnooscMiVB  SniuL  Mi/kllar  Atrotiiv  (paraonal ofcwrvuloa). 

diiion  of  the  electrical  excitability,  which  depends  directly  on 
the  number  of  muscle  fibres  left.  If  the  greater  number  of 
the  libres  are  wasted,  then  the  excitability  for  both  currents  is 
equally  decreased.  If  all  the  fibres  of  a  muscle  have  disap- 
peared and  only  fat  and  connective  tissue  remain,  the  excita- 
bility of  tbe  muscle  is  completely  lost.    It  is  only  exceptionally 


438 


e/SSASES  OF  SUBSTANCE  OF  SP/.VAL  CORO. 


that  the  excitability  also  tmdcrgocs  qualitative  changes  and  wc 
find  reaction  o(  degeneration.  (3)  The  loss  of  the  tendon  re- 
flexes, which  is  sufficiently  explained  by  the  disappearance  o( 
the  ganglionic  cells,  a  part  ol  the  retlex  arc.  1 1  is  only  because 
the  lower  extremities  arc  rarely  aHccted  that  the  patellar  re- 
flexes arc  usually  retained.  (4)  Sensibility  remains  everywhere 
and  lor  all  kinds  of  impressions  intact  (touch,  pressure,  pain, 
tempcmlure).  The  coldness  and  bluene$s  of  the  hands  is  to  be 
attributed  to  the  disuse  of  the  muscles.  True  trophic  disturb- 
ances of  the  skin,  as  well  as  bladder  and  rectal  symptoms,  are 
usually  ab.scnt- 

Diagnosis. —  Remembering,  then,  the  different  points  just 
alluded  to,  the  diagnosi.s  should  be  easy,  and  it  will  not  be 
difficult  to  avoid  confounding  the  disease  with  myelitis,  neu- 
ritis, or  syringomyelia.  The  flaccid  paralysis,  the  absence  of 
all  symptoms  of  motor  irritation  and  sensory  disturbances,  is 
especially  of  moment  in  differentiating  this  disease  from  mye- 
litis. More  particularly  characteristic  is  the  commencement, 
the  onset  of  the  disease  in  the  small  muscles  of  the  hands.  If 
this  has  been  well  pronounced,  an  error  in  diagnosis  is  unpar- 
donable. 

.(Etiology.— With  reference  to  the  aetiology  a  little  morci* 
known  about  this  disease  than  about  spinal  infantile  paralysis; 
for  certain  cases  at  least  it  has  been  shown  that  overexertion 
of  the  muscles,  as  happens  sometimes  to  those  who  work  with 
the  sewing  machine,  has  a  causative  influence,  or  at  any  rale 
the  disease  has  been  preceded  by  some  overexertion  of  ihc 
muscles,  to  which  we  are  then  justified  in  attributing  an  :clio 
logical  importance.     The  conditions,  however,  under  whic^i 
paralysis  and  fatigue  of  the  muscles  lead  to  atrophy — why,  \*j^ 
instance,  the  serratus  magnus  (Chvostek)  is  in  some  cases 
first  thus  affected— we  arc  wholly  ignorant  of,  just  as  wc 
not  know  the  conditions  under  which  the  genuine  hypertropl — ^H 
develops  which  wc  often  find  in  the  biceps  of  blacksmitte""^' 
Recently,  again,  attention  has  been  called  tu  the  f.ict  that  tH 
disease  may  be  hereditary,  by  Bernhardt  (\*irchow's  ArcH 
1889,  1 15.  3)  and  by  VVerdnig  (Arch,  f,  Psych.,  xxii,  3). 

Little  need  be  said  about  the  therapeutics:   there  is  ir 
effectual   treatment,  and   all   measures  that  have  been  tri 
have  not  been  efficient  in  hindering  tlic  progress  of  the  di 
ease. 


I 


LBSiOAS  OF  IVt/lTE  MATTER  OF  StINAL  CORD. 


439 


I 


I 


LITERATl'RK. 

Chvosiek.    Oesicrr.  Zdtschr.  \.  praki.  Hcilk..  1871,  svii,  13-16. 

LcKklun,  Ciller.     Mcij.-Chtr,  Transact..  187}.  Ki.  p,  103. 

Charcot.     Leciurt;^  i>ti  [he  ni-icaio  of  the  Nervous  System.  dHivrivd  at  the 

Salptlh^rc.     Tr^n&taied  liy  G«orgc  Sigerson.     New  ^lieitham  Society. 

LomIoo,  1877- 
Pierrei  ei  Troiwcr.    Arch,  tie  phifiiol.,  1875,  imc  \k\..  it,  a. 
Bode.    Caituist.  Rciirttgc  (tir  Actiologic.  Symplomc  und  Dutgnusc  dcr  progress. 

Musk«blru|>hie.     Inaux-Disten..  Halle,  18S1. 
Westph*).    Charlti-Annjlen,  tSSti,  kI.  p.  357.    {riogreuive  Muscular  Atiopliy, 

with  Implication  cf  the  Facial  Mu*ctcs,) 
Schuliic.  F.     Ucbcr  den  niil  Hyiicrlrophic  vcrbiindcnen  progrenivcit  MuskeU 

schvmnd  und  flhnllchc  Krankheiltfotmen.     Wieshadcn.  Bvri^tann.  1886. 
Landouiy  «  Dejerine.     NoiivcUcR  rechcrches  cliniqun  «  aniitotna-p.itholo|;i(iues 

Kir  la  mjropaihic  airophiigue  pro|[icsMve  1  piuiiot  de  sis  obHcrvatiiinK  nou- 

fHles  doiil  une  at-ec  auiop&te.     Kcvue  dc  ni^d.,  18S6,  vL  I3.  977-1017, 
Charcot  et  Marie.    Sur  unc  (oime  paniculi^rc  d'atrophic  niuKuUirc  progmsirr, 

etc.     Ibid..  |SS&  vi.  3,  p.  97. 
Lailanve.    Coniribuiioit  A  r^ludc  dc  la  myopallitc  airophlque  proKfruivc.    Ibid., 

1886.  vl.  lo,  p.  817. 
Sirumpcll,  A.     I>cuim;I)cs  Arch.  f.  klin.  Med..  1887.  Dd.  KUi.  1-3.  p.  330. 
Itcrnhardt.     Ucbcr  clncn   Fait  von  (juvcnilcr)  progrriiuvrr   Muthrtairophie  mil 

B«thc)lt{CunK  der  GeaichTunuiCulatur.     tkibiicr  Uiit.  Woi:hcnM.-hr..   1887, 

No.  41. 
SpUbnann  et  >tnu«halter.    Obftcrt'aiion  de  n^yopatbie  proi^ressire  primitive  1 

type  facio-iapulo. humeral.     Kcvue  de  n><d.,  1888.  vi 
Rsymond.     Alroi^ks  muKulaircs  et  tnalailies  airophi<|urs.    Paris.  Doin.  t889. 
Sach*.  TbcPcroncalKonnorLcg-(>i)caM'ro|[rc»ivcMu»cuUT Atrophy.  Br«m, 

189A  »)»ii'.  p.  447- 
OoinbdulL    Sur  I'^iat  des  nerfs  |>^ri|thH()Ucs  dans  un  cas  de  mj-opathie  pro- 

gmsirc:.     Arch  de  m^l  expirim..  iS'^o.  t.  4-  S- 
BemhJtnlL     Ncurtipatholi>t;iKlic  lleubachtungen.     Zdtftchr.  f  kbit.  Med.,  ivii. 

Suppl.-Hca.  1889. 
FRyhan.     Ihid..  4.  1891.  x<(- 
Bfwu.    Schmidt'i  Jahrbuclier,  1894.  ccxti.  No.  3. 


II.   LESIONS  Ol'  THE  WHITE  MATTER  OF  THE  SI'INAL  CORI>— 
•*  LEUCOMVE  LITIS." 

While,  as  wc  ha%-c  said  on  page  434,  the  lesions  affecting 
[the  gray  mailer  (poliomyelitis)  arc  almost  entirely  confined  to 
I  one  portion  of  il — namely,  the  anterior  horns — we  shall  soon 
see  th.it  this  is  dillcreiit  with  the  lesions  of  the  white  matter, 
W  which  the  general  name  Icucomyclilis  may  be  given  (Xnwet, 
white).  Here  different  parts  can  be  attacked,  cither  alone  or 
in  conjunction  with  others,  and  it  is  of  great  importance  to 
diUcrcntiate  between   the  clinical   symptoms  which  occur  in 


44° 


D/SEASSS  OF  SVBSTAKCe.  OF  SPIJfAL  COKD. 


ihc  diseases  ol  the  different  columns  or  "systems"  (Flechsig), 
hence  called  "  system  diseases." 

The  afTectton  is  either  a  primary  one.  when  it  is  often  im- 
possible to  ascertain  any  xtiologica)  factor,  or  it  occurs  sec- 
ondarily and  as  a  consequence  of  certain  affections  of  the 
brain  and  the  spinal  cord  itself,  such  as  traumatic  inftamma- 
tiotis  and  compression.     We  shall  consider  both  separately. 

A.  Primary  Lesions  of  the   White  Coiumns. 

Regarded  from  an  anatomical  standpoint,  the  primary'  tract- 
degenerations  of  the  white  substance  consist  in  adestrSctionof 
the  nerve  fibres  and  a  simultaneous  increase  of  the  neuroglia. 
The  medullary  sheaths  are  the  first  to  disappear;  the  axis  cylin- 
ders, which  are  more  resistant,  do  not  degenerate  till  later. 
Compound  granular  corpuscles,  which  remove  the  detritus 
from  the  diseased  regions  (Ziegler),  accumulate  in  the  lymph 
sheaths  of  the  vessels.  The  increasing  neuroglia  crowds  in 
and  displaces  the  empty  ncI^-c  tubes,  a  process  which,  in  con- 
junction with  the  thickening  of  the  walls  of  the  vessels,  whicb 
develops  at  the  same  time,  is  described  under  the  name  of  scle- 
rosis, or  gray  degeneration. 

An  affection  confined  to  one  nerve  tract  or  system  has  up 
to  this  time  only  been  observed  in  the  anlero-lateral  but  not  in 
the  posterior  columns.  In  the  former,  the  anatomical  arrange- 
ment of  which  has  been  described  above,  we  meet  especially 
frequently  wilh  sclerosis  of  the  so-called  crossed  pyramidal 
tracts,  ibut  the  lesion  does  not  necessarily  extend  over  the 
whole  length  of  the  tract,  but  may  be  only  partial  (Westphal)' 
Most  of  the  cases  which  have  come  under  observation  were, 
however,  not  pure  instances,  but  presented  other  anatomical 
changes  as  well,  and  there  is  only  one  case  reported,  by 
Drcschfeld,  in  iS8i,  which,  viewed  from  an  anatomical  stand- 
point, can  pass  for  a  pure  lateral  sclerosis. 

The  primary  sclerosis  of  the  lateral  columns — spastic  spinal 
paralysis,  tabes  Jorsale  sptismodiqiie — was  first  described  by  Erb 
and  Charcot  in  i^y^,  and  characterized  by  them  as  a  motor 
paralysis  with  remarkable  increase  in  the  tendon  reflexes;  and, 
indeed,  if  we  examine  such  patients,  all  we  find  is  that  they 
have  lost  to  a  greater  or  lesser  extent  the  use  of  their  legs; 
they  arc  unable  to  walk,  the  feet  arc  glued,  as  it  were,  to  the 
floor,  and  the  patient  can  only  shutTlL-  along,  the  inner  margin 
of  the  foot  never  leaving  the  ground.     At  the  same  time  the 


PKtMAKY  /.ES/OXS  Of   THE  WHITE  COLUMNS. 


441 


I 


muscles  feel  tirm  and  hard,  the  leg^  arc  in  extension,  and  any 
attempt  at  flexion  is  diflicult.  1(  such  a  patient  is  made  to  sit 
on  the  edge  of  a  tabic  the  legs  do  not  hang  down  flaccidly,  as 
might  be  eicpectcd,  but  are  thrown  into  a  state  of  tetanic 
tremor,  produced  by  contractions  of  the  quadriceps  extensor. 
There  is  an  enormous  cxaggcratinn  of  the  patellar  reflexes,  and 
IIk'  ankle  clonus  is  obtained  without  the  »li{{hlcst  difliculty. 
With  the  exception  of  the  inability  to  walk,  the  patient  has  no 
subjeclive  complaints;  neither  sen&alion  nor  the  functions  of 
the  bladder,  rectum,  or  the  sexual  apparatus  show  any  abnor- 
mity. An  implication  of  but  one  of  these  would  at  once 
exclude  the  diagnosis  of  lateral  sclerosis,  as  would  also  (and 
this  should  be  especially  remembered)  the  existence  of  any 
muscular  atrophy.  The  very  characteristic  spastic  or  spasiic- 
paretic  walk  of  the  patient,  the  traces  which  his  feet  leave  on 
a  gravel  path,  for  instance,  and  which  can  be  followed  up  as 
distinct  continuous  streaks,  the  shuffling  noise  which  accom- 
panies every  step  when  he  attempts  to  walk  about  the  room, 
these  ire  of  great  diagnostic  value;  the  examination  of  the 
soles  of  the  patient's  shoes,  which  appear  thinner  and  moi% 
worn  down  on  the  inner  side,  will  be  of  interest  and  value. 

The  disease  may  be  congenital  (Lorcnz.  Ilernhardt,  cf.  lit.), 
and  may  occur  in  more  than  ore  member  of  the  same  family, 
as  wc  have  slated  above  (page  274),  but  it  oltcn  begins  later  in 
youth  or  in  middle  life,  attacking  first  the  one  then  the  other 
leg.  without,  as  a  rule,  extending  to  the  arms  or  trunk,  yet  the 
upper  extremities  arc  said  to  be  occasionally  affected  (Slrilm- 
petl).  The  disease  may  last  years  or  tens  of  years  without  pre- 
senting any  decided  change  for  the  worse.  Death  is  brought 
about  by  intercurrent  diseases.  It  is  not  known  whether,  as  in 
progressive  muscular  atrophy,  overexertion  is  of  a;liological 
importance ;  instances,  however,  in  which  acrobats  (Donlcin) 
and  bod'Carriers  (Munler)  yt^rt  attacked  seem  to  suggest 
Ibis.  Mof^an  pointed  out  that  exposure  to  cold,  such  as  long 
standing  rn  water,  may  be  the  immediate  cause  of  the  disease 
(Mortem,  l^incel,  January  19,  1881). 

The  form  of  spastic  paralysis,  analogous  to  a  tabes  devel- 
oping on  a  syphilitic  basis,  which  has  been  regarded  by  Charcot 
ua  transverse  syphilitic  myelitis,  and  which  has  been  studied 
carefully  first  by  Erb.  later  by  Muchin,  P.  Marie,  and  Kowa> 
lewsky  (Neurol.  Centralbl.,  1893.  IJ).  must  be  regarded  as  a  dis- 
tinct disease.     It  occurs  much  less  frequently  than  tabes,  and 


442 


D/SBASES  OF  SUfiSTjtXCK  OF  SP/XAC  COKD. 


differs  (rom  the  spinal  paralysis  just  described,  inasmuch  as  here 
wc  find  sensory  and  trophic  changes  as  well  as  eye<musclc  paU 
sies.    The  differential  diagnosis  may.  however,  be  impossible. 

Much  more  (reqitcnt  than  a  lesion  confined  to  the  crossed 
pyramidal  tracts  is  one  which  implicates  not  only  these,  but 
with  them  the  posterior  columns  and  the  direct  cerebellar 
tracts,  in  which,  although  not  always,  Clarke's  columns  take 
part.  The  anatomical  character  ol  this  "combined  system 
disease"  which  results  from  these  lesions  h.is  been  repeatedly 
described  (Westphal,  Gowcrs,  Striirnpell).  The  symptoms 
vary  according  to  the  distribution  of  the  lesion;  thus,  if  the 
disease  of  the  lateral  columns  extends  low  down,  while  the 
posterior  columns  in  the  dorsal  and  lumbar  region  present  no 
changes,  rigidity  of  the  muscles  and  increase  of  the  reflexes 
M-ill  be  found.  If.  on  the  other  hand,  the  disease  in  the  poste- 
rior columns  extends  farther  downward,  these  symptoms  will 
be  absent,  the  lesion  in  the  lateral  being  neutralized,  as  it  were, 
by  that  in  the  posterior  columns  (Wcstphal). 

Not  rarely  tlie  affection  seems  to  depend  on  faulty  devclo|>. 
ment,  a  condition  which  wc  may  meet  with  in  more  than  one 
member  of  the  same  family,  and  which  may  be  hereditary.  In 
these  cases  the  disease  appears  in  early  childhood,  and.  as  wc 
said,  sometimes  in  several  children  of  the  same  family.  It  has 
been  called,  after  the  author  who  first  described  it,  Friedreich's 
"  hereditary  ataxia."  Senator  (cf.  lit.)  has  called  attention  to 
the  possibility  of  a  congenital  atrophy  of  the  cerebellum,  the 
meditll.1  oblungata,  and  the  spinal  cord.  The  motor  disturb- 
ances in  the  children  begin  in  the  feet,  the  walk  becomes  awk- 
ward, lliey  stumble,  and  in  passing  over  small  obstacles  have 
to  look  at  their  feet  to  keep  from  falling,  etc.  (Fig.  142).  The 
paicllar  reflexes  disappear;  the  arms  are  not  affected  until 
later,  and,  indeed,  they  are  by  no  means  always  implicated. 
The  second  motor  disturbance  establishes  itself  in  the  muscles 
of  the  tongue  and  the  lips  which  are  necessary  for  speaking, 
and  this  produces  a  very  characteristic  defect  of  speech  of  mo- 
tor  origin.  Finally  the  muscles  of  the  eyes  become  implicated, 
and  there  resulls  a  distinct  nystagmus.  The  combination  ol 
these  three  symptoms  is  pathognomonic  for  this  rare  disease. 
It  has  no  connection  with  tabes  and  sensory  changes,  and  blad- 
der symptoms,  manifestations  which  arc  probably  never  want- 
ing in  cases  of  tabes,  are  never  met  with  in  the  disease  under 


y 


fJt/EDRElCJfS  D/SEASK. 


443 


'considcrnlion.     Korean  it  be  mistaken  for  multiple  sclerosis, 

I  ns  vertigo  and  "scanning  speech  "  arc  never  associated  with 

it.     The  course  is  tedious,  the  prognosis  always  unlavorable, 

the  muscles  undergo  atrophy  in  consequence  of  inactivity,  and 

contractures  occur  in  the  joints. 

Similar  symptoms  arc  obscr\'cd  in  adultH  in  cases  of  com. 
bined  lateral  and  posterior  sclerosis ;  yet  there  arc  certain 
peculiarities  to  which  Cowers  especially  has  drawn  attention. 


Vic-  Lfi-— FMcnncinil  DiauuiK.    The  imkni  it  Iwld  uixWi  ihc  irau. 
(Alur  CHAurrkHD,  i    (SMtuio*  mM..  t^a,  N<i.  jj.) 

i'Thc  disease  was  named   by  him  "ataxic  paraplegia."    The 
lower  extremities  are  ataxic  and  paretic,  which  gives  rise  to  an 
H  uncertain,  swaying  walk  ;  but  this  is  associated  with  pararsthe- 
Bsias,  weakness  ol  the  sphincters,  and  decrease  of  the  sexual 
^bpwer.     The  patellar  reflexes  arc  at  first  increased,  and  only 
^8?  times  become  lost  later  in  the  disease.     Such  an  increase  is 
never  known  in  hereditary  ataxia.     During  the  period  of  in- 
crease, rigidity  of  the  muscles,  spasm,  and  ankle  clonus  are 
present.     It  is  evident  that  cases  of  this  kind  may  be  mistaken 


444  D/SF.ASES  OP  SVBSTA.VCE  OP  SPIXAL  CORD. 

fur  tabes,  especially  if  the  patellar  reflexes  are  alisent,  as  excep- 
tionally occurs.  Then  the  history  may  be  of  use  to  us,  as 
syphilis  seems  to  possess  no  etiological  importance  whatever 
ill  ihc  combined  sclerosis,  while  exposure  lo  cold  and  over- 
exertion seem  to  be  of  considerable  moment. 

LITERATURK. 

Sfaitit  Sfinal  Pantfyiii. 

Le>-[lcn.     Arch.  f.   Psych,  u.  Ncrvenkrdnkh.,  1878,  viii,  i,  p,  761.     (Experi- 

meniatly  l^roduced  Spln^tl  Kctcrosi&.) 
Mdbius.    y.\n  ipruiiichrn  Spin iil paralyse.    SchmiiJt's  Jabrb.,  1880,  Bd.  clnmiii, 

p.  (15.     (Miiny  red- nn CIS.) 
Donkin.     Biit.  Med.  Joum,,  December  9,  1B81.     {Spastic  PampIegU  in  an 

Acrobat.) 
WcsiphdI.      LVber  cincn  Fall  von  sog.  spastischcr  Spiiulparalyse  nut  anaL 

Qcfunik.    Arch.  f.  Piych.  u.  Ncrvcnkmnkh..  i8!<4.  xv,  I.  214. 
Pitres.    Un  cas  de  paralysic  g^n^rale  splnak  sntcrlcure  tubaiguC  suivi  d'auiop- 

sie.     I'rogr.  miA..  1888.  35. 
Knmh.     I'lbcr  ^pa^iischc  SpiD.-itparalyse  mit  Dementia  paralytica.     Kiel.  18SJ, 
Kicli:inl«i>n.     Cum  o(  Infantile  Spastic  Paralysis.     Lancet.  November.  188S, 

ii.  19- 
Biiicli.    Ikitrilgc  lur  Pathologic  der  spaitischc-n  Spinal  paralyse.    Inaug.-Diuert., 

Bcrlm.  iSyOL 
Fecr.     Ucbcr  die  angeborcne  spnslischc  GlicdiTstarrc.  Mttlhcil.  nus  item  Kin- 

dertpiial  zu  Iktsid.    Jahrli.  f.  Kindcrhcilk.,  1B91.  pp.  116-190. 
l^reni.     Lieber  angehoreiie  ipailische  Paralyse.     Deutsche  Med.-Zlg.,  1891,93. 
Williamson.    TheChsngrs  in  ihf  Spinal  Cord  iii  a  Case  of  Syphilitic  Paraplegia; 

.Sclerosis  of  the  Lalcr^il  I'yrairid.-il  Tracts.  an<l  Goll's  Columns  with  IV- 

rlphcral  Sclerosis.     Medical  Chronicle,  Manchester,  1891.  xiv.  pp.  36(>-i;c> 
£rb.     Ucbcr  syphililischeSpiiialptralyse.     Neurol.  Ccntralbl,,  1891,6. 

Fritdttifk't  Ditftiif, 

Drnuue.     Dc  I'ataxie  h^rjiliiaire.     Paris  iSSi.     (Maladic  tic  Friedreich.) 

Kijtinicyer.    Virchow's  Arch.,  1883,  Bd.  xci,  2. 

Erlcnnteycr.    Ceniralbl.  f.  Ncrvcnhctlk.,  1883,  vl,  17. 

Wille.    Schweixcr  Currespundenzbl,.  1S84,  xiv,  3. 

Musso.     Riv.  din,,  1884,  xxiii.  10. 

Longuet.     l.'Union,  1SS4,  73. 

Schuixe,  F.     Aich.  f.  Psych,  u.  Ncr\-enl(r3nkb..  1884,  xv,  1.  p.  j6a. 

.Seguin,    Nc*  Yiirk  Med.  Record,  1885.  xxvii,  19. 

Sinkler.    Joum.  of  Ncre.  and  Mem.  DiscJtscs.  i88j,  xii,  J. 

Ormcrod.     Mcd.-Chir.  Tranwcl.,  iSSj.  Ixriii,  p.  147. 

Jud»on,  S.  Bury.     Brain.  July.  1886.  ix. 

Slintiing.     MUnch.  nicd.  Wochenschr,,  1887,  Bd.  xxxiv,  21. 

Charcot.     Progr.   m6d,.  1887,  13. 

Rulimcycr.     Ueber  herediiSrc  Ataxic.     Virchow's  Arch..  1887,  1 10,  i. 

Ormerod.     Hrain.  1888,  xxii^  and  xl. 

Gilles  de  la  'ruurclte.     Noui-.  tconograph.  de  la  Salpjir.,  1888,  3. 


SSCO.VDAJtY  ISS/O.VS  Of  THE   WHITE  COLUMNS. 


445 


I 


\t.    Li  malaxtie  i)c  Friedreich.    CicnKr,  Schuchtrcit,  18S9. 
Dtjrrinc  ct  Lclulte.     La  nulodie  de  FricUreich.     Me<t.  Modeme,  1890,  i.  17.  p. 

331. 
Mcniel.     Arch,  t  I'tych.  u.  Ncr^^nkrnnkh.,  1S90,  p,  160^ 
l)t<x^q  «  MjriitMCo.     Arth.  cic  Neurol..  1890.  xw.  No.  57. 
Mml    Cumplcic  Sclerosis  or  Coil's  Columns  and  Chronic  Spina)  Lcplotnen- 

ingilis,  wilh  Detfenerative  Changes  In  ihr  Fibres  of  the  Anler.  nnd  Posl. 

Roots.     AnicT.  Joum.  Med,  Sciences,  a.  Januiiry,  1891. 
Ccieel,  R,     Ueber  hemliiare  Ataxic.    Sil7ungst>ericht  dcr  Wiinburgcr  ph)-).- 

mrd  Ccstlkchjfi,  1H9:. 
Senator.    Berliner  ktin.  Wochenschr..  189^  11. 


V 


I  C^mUurJ  Sjit/m  DitMiet. 

Kshlrr  und  Pfclt.    Arch,  f,  ["sych.  o.  Nenfenkrankh..  1877,  sill.  p.  151, 

{"revoot.    Arch.  <\e  )>h)>iol.,  1877.  sme  str..  tv.  3.  4,  j.    (CocnUncd  Sclerosis  of 

Ihe  Pouerior  an<l  Literal  Trad*.) 
IStruiBpell.     Arch.  f.  IHych.  u.  Nervcnkfankh.,  18S0,  xl,  I. 
Edcs,     The  Somewhat  Frequent  Occurrence  of  Regeneration  of  the  Poslero- 

laicral  Column)  of  ihe  Spinal  Ciinl  in  so-called  S|niial  Concuujon.    Boston 

Med.  and  Sorg.  Journ..  September  11.  1881. 
tnaan.     Do  tabu  combing  (auio-spaxmodique)  ou  scKrotc  posl^ro-latf  rale  de 

la  morlle.    Arch.  de.  Neurol..  1886.  ai.  lii. 
^Cowen.    Ataxic  Paraplegia.     Lnncet.  1886,  ii.  1,  3, 
Babinskl  et  Clurrin.     Sclirose  mMulUire  sy«i^matJ(|ue  comlnnfc.     Revue  de 

trM..  iS8(>.  iii.  II.  pl  961. 
Suuinpell.     I'elJTT  cine  bcj^titnmic  Form  der  primSrvn  combinirtcn  Syslcmer- 

■  bmnkuni;  ilei  Kiickcnm.irlu.     Arch,  f.  r»)-ch.,  CIc.  1886.  xtii,  I. 
BErtlcki  el  Kylialkiit.      Zur  Fi.igc  ubei  die  combin.  S)rsicinnkr3nkun£cn  des 
H        Kucknunirks.     Ibid..  1RS6.  xvii,  3. 

HDoiu.     Progmsit-c  S|ms|Ic  Ainva  (Combined  FaAcicul.ir  Sclerosis)   and  tbe 

■  Combined  Sclerosis  of  the  Spinal  Cord.    The  Med.  Record,  July  i.  1887. 
Adamklewic/.     Wiener  n>ed.  Wijcheiuchr..  1888,  17. 

Ktevrlic/.     Arch.  f.  ISych.  u.  Nervciikrankh..  1889.  ax,  1.     fMjvltlis  Trans- 

veriu.  SyrtnKom)'elia,  Multiple  SclrrmiK,  anil  Srcnndary  DeKencralioni.) 
FraiKolie.     £tu<lc  vtt  I'anaiomie  p.-iihulogique  dc  la  modle  epinifav.    Arch,  de 

■  Neurol.  1S90.  xix.  S7. 

^^^P  fi.  Setomlary  Ltswns  of  tkt  While  Columnt. 

H  Lesions  o(  the  motor  centres  of  the  brain  cortex,  or  lesions 
of  ihc  path  between  these  centres  and  the  motor  ganglia  of  the 
spinal  cord.  Ihe  so-called  cortico-nnisculnr  tract  or  pyramidal 
tract,  give  rise  to  a  descending  degeneration  of  the  motor  fibres 
00  the  same  side  as  the  brain  lesion.  This  secondary  degen- 
eration is  in  the  cord  continued  in  the  crossed  pyramidal  tract 

iof  the  opposite  side,  while  the  direct  pyramidal  tract  presents 
only  trac«  of  it.     About  the  causes  of  this  sclerosis  wc  possess 

I  just  as  little  dctinitc  knowledge  as  about  the  clinical  symptoms 


446 


DISEASES  OF  SUBSTAffCE  OF  SPtNAL  COKO. 


U 


by  which  it  manifests  itself.  The  former  is  sought  in  the  cut- 
ting off  of  the  parts  from  their  trophic  centres,  and  with  regard 
to  the  latter  it  is  gcnerallj'  supposed  that 
the  gradual  developing  rigidity  of  the  mus- 
cles, the  increase  of  the  reflexes,  and  the 
later  contractures  depend  on  lliis  degen- 
eration.  The  cases,  however,  in  which  at 
the  autopsy  an  exten- 
sive degeneration  was 
found,  while  during 
life  not  a  trace  of  such 
symptoms  was  pres- 
ent, do  not  speak  much 
in  favor  of  this  view. 

Lesions  of  the  whole 
transverse   section   of 
the  cord  also  produce 
secondary     degenera- 
tion, which,  however, 
extends  not  only  down- 
ward (in  the  pyrami- 
dal tracts),  but  also  up- 
ward— (i)  in  the  inner 
segment  of  the  poste- 
rior columns  (Goll,  cf. 
Pig-  '43)'  i>i>d  (2)  in  the 
direct  cerebellar  tracts 
(Flechsig),  which  arc 
in     connection     with 
Clarke's  columns  (cf. 
Fig.  I44.I-     While  this  ascending  degcner. 
ation  is  physiulogically  extremely  interest- 
ing, as  ii  indicates  that  the  trophic  centres  of  these  two  tracts 
must  be  situated  nmre  peripherally  (as,  for  instance;  in  Clarke's 
columns),  wc  are  not  as  yet  able  to  attribute  any  clinical  im- 
poriancv  to  it. 


Ucscocmm  Dkcuih- 

ATIOJI  111  Tut  SnsuL 
CuHD.  A.  prlnurr  ^n* 
□(  dt^aeiaUan  llotbiiK 
B,  degBtcTWJaa  r4  tM\'% 
coluaiDi  UxciMllni;  ^  C. 
dcc<B<i>llcin      □(      Uie 

(dondullns.i.  (After 
COWKMA.) 


Fte.  ■M.—SCCOHDAKr  .\x- 
CCl'MMI  AKV  OOGOII- 
I  MO    DBOEVCIUTNn   IH 

A  Tmnvuibk  Arnc- 
Tiott  or  TKK  Urm 
DnRMi.  Cor  IK  Th«  as- 
nndioc  dqcfocntioa  oc 
cuiria^  in  Goll'i  eotaniu 
and  Uk  ilimt  cmbtlbi 
tracU,  Itw  dmvndini;  dc- 
i:Fnmt>nn  in  Itar  croisnl 
PTranidjil  Itaiti.  t  Aflei 
&TKUNPei.t.j 


HI.  LESION'S  OF  THE  GRAV  AND  WHITE  MATTER  OF  THE 
SI'INAU  COR[>. 

Charcot  and  Joflroy  were  the  first  to  show  Ihat  the  large 
ganglionic  cells  of  the  gray  anterior  horns  and  the  pyramidal 
tracts  can  be  affected  simultaneously  by  a  disease  which  pro- 


AMYQTKOPltlC  LATERAL  SCLEROSIS. 


447 


I 
t 


I 
I 

I 


I 
I 


duces  charactcrislic  clinical  symptoms,  but  it  was  not  unlil 
FIcchsig  announced  his  discovery  ol  the  system  of  conducting 
fibres  that  these  clinical  ol>scrvations  became  fully  understood. 
Now  we  know  that  the  disease  tvhich  the  tVench  authors,  foI> 
towing  Charcot,  have  termed  i<{ir4>it  latfraU-amyotrolihiqtte — 
amyotrophic  (more  properly  myo-atrophic)  lateral  sclerosis — 
consists  of  a  lesion  of  the  cortictvmuscular  tract,  which  begins 
as  a  degenerative  atrophy  in  the  lumbar  cord,  and  which,  as 
Charcot  and  Marie,  and  more  recently  Rott  and  Mouraloff 
(Moscow.  1890),  have  pi>in(ed  out,  can  be  traced  as  far  as  the 
motor  nerve  cells  of  the  central  convolutions.  Attention  has 
already  been  called  to  the  fact  that,  just  as  the  nerve  ceils 
of  the  anterior  horns,  in  the  same  way  the  motor  nuclei  ol  the 
medulla  oblongata  may  be  implicated,  and  thus  the  clinical 
picture  o(  progressive  bulbar  paralysis  develop.  The  two  dis- 
eases are  therefore  analogous,  and  akin  to  them  is  a  third — 
namely,  the  progressive  spinal  muscular  airo|»lty — in  which 
utTcctJon  also  the  large  nerve  cells  are  diseased,  as  we  have 
already  pointed  out  above.  From  the  nerve  cells  the  atrophy 
spreads  toward  the  periphery  to  the  anterior  nerve  roots  and 
the  muscles  supplied  by  llicm. 

That  the  clinical  manifesutions  are  strictly  motor  and 
trophic,  and  that  no  sensory  changes  can  occur,  we  can  well 
understand  from  the  anatomical  distribution  uf  the  lesion. 
The  patients  at  first  complain  of  weakness  in  the  arms  and  the 
hands,  which  soon  interferes  with  their  occupation.  This  loss 
o(  strength  increases  fairly  rapidly,  and  the  atrophy  in  the 
muscles  of  the  hand — the  thenar,  the  anlithcnar,  and  interossci 
—becomes  more  and  more  apparent. 

The  muscles  of  the  arms  also  waste,  more  especially  those 
of  the  extensor  side,  and  the  former  roundness  of  the  shoulder 
is  soon  lost  owing  to  the  atrophy  of  the  deltoid.  The  triceps 
and  other  muscles  also  then  take  part  in  the  lesion,  and  the 
helplessness  of  the  patient,  who  has  but  little  use  of  his  up. 
per  extremities,  rapidly  increases.  At  the  same  time  the  ten- 
don  reflexes  arc  increased,  and  tapping  of  the  bones  of  the 
forearm  elicits  lively  contractions  of  the  muscles  ("periosteal 
reflex  •■). 

That  the  so-called  "  jaw-jerk."  which  has  been  described  by 
De  Waticwillc,  is  characteristic  of  the  disease  1  am  very  much 
inclined  to  doubt,  since  in  a  number  of  perfectly  healthy  per- 
sons 1  found  it  in  some  present,  in  some  absent.     It  certainly 


44» 


2>/S£ASES  OF  SUBSTAXCE  OP  SPINAL  CORD. 


docs  not  possess  anj-  diagnostic  value.  This  jerk  may  be  pro- 
duced by  pressing  down  the  lower  jaw  by  means  o(  a  broad 
paper-cutter  and  tapping  the  latter  with  a  percussion  hammer 
near  the  teeth.  The  lower  jaw  will  then  respond  with  a  con- 
traction of  the  muscles  of  mastication. 

In  a  relatively  short  time  the  paralysis  of  the  upper  ex- 
trcmiiies  becomes  so  complete  that  not  even  the  slightest  motion 
is  possible,  and  gradually  contractures  develop  (by  preference 
in  the  wrist  and  elbow  joint).  In  the  lower  extremities  the 
same  changes  may  be  noted,  but  they  make  their  appearance 
later  and  do  not  reach  such  a  high  degree.  Here,  loo,  we 
have  first  wt-akncss,  dilBculty  in  walking,  and  general  awkward* 
ncss  in  making  tnovements.  then  rigidity  and  sliSness  of  the 
muscles,  enormously  increased  patellar  reflexes  and  ankle  clo- 
nus, later  on  total  immobility  atid  contractures  in  hip,  knee, 
and  ankle  joints. 

A  case  in  one  of  my  wards,  a  woman  thirty-four  years  of 
age,  has  been  for  two  years  without  power  of  motion,  and  is  so 
entirely  deprived  of  the  use  of  her  lour  extremities  that  wich- 
out  assistance  she  is  unable  to  make  even  the  slightest  motion 
with  either  fingers,  hands,  arms,  toes,  feet,  or  legs.     The  dis- 
ease goes  on  to  invade  the  motor  nuclei  of  the  medulla  oblon> 
gat.1,  and  hence  is  produced  difficulty  in  swallowing,  which 
ultimately  amounts  to  a  total  inability  to  get  food  down,  and 
the  patient  dies  of  starvation.     At  other  times  a  disturbance  of 
the  respiratory  apparatus  may  bring  about  a  fatal  issue.     It  is 
exceptional  that  the  whole  course  of  the  disease  comprises  a 
period  of  more  than  two  or  three  years.     The  diagnosis  is  not 
alwayse.isy,  though  it  is  not  difficult  to  differentiate  ihediscase 
from  progressive  muscuLir  atrophy  if  its  duration  and  the  con- 
dition of  the  reflexes  are  borne  in  mind.     But  it  is  not  always 
possible  to  decide  between  this  and  hysterical  conditions — forei* 
ample,  the  hysterical  amyotrophia — as  Charcot  showed  shortly 
before  his  death  (Arch,  dc  Neurologic.  i8gj,  xxv,  74).     Of  tiK 
cause  of  the  disease,  as  well  as  of  effectual  means  wherewith  to 
combat  it,  wc  arc  equally  ig^norant. 

LITERATURE. 

dnrcot  M  Marie.     Arch,  dc  Neurol..  1885.  i.  j8.  29, 
Kojcwnikolf.    Ccntralbl.  f.  Ncrvrnhcllli..  1885,  viii,  16. 
Dc  Wjittcvville.     Neurol.  CcriraM.  iSSGw  \:  3.    (Jaw-jerk,) 
Rybalkin.    Ccnlralbl.  f.  Nervcnhcilk..  1886,  Ix,  8.    Jaw-jak.) 


rjt/tJVSFf.XSE  MYHUTIS. 


449 


Neurol.  Cetitralbl.,  \%tib.  v,  13.     |Amyoirophk  Lainral  Scl«fi)sis  Coni- 
pbcattil  l>y  Uetncntia  Paralytica.) 
itiuk.    Ohkcri'ationfi  dc  «cl(totc  latf  raJc,  amyolropluqwi  <!■£.    Arcltde  Neuinl., 
1887.  jxa,  p.  387. 
I'Miusa.    Kit'isu  clinbcA.  June.  iftS?. 
'  Lcnnmalm.     t/p»dl«  Hlcaiefuren.  F'urh..  1887,  xxii,  7. 
Flaraii<L    Contribuiion  i  I'iiudc  <le  U  sctdrosc  lat^ralc  amyotrophiquc.    Thtte 

de  I-aris.  1887.    (••  Maladk  de  CKarcot.') 
Roiighi  e  \x\\.    Conlributione  alio  «ludio  delta  SclenMi  blende  amioiralica. 

Rcgj^o  Emilia.  1S88. 
Kiuc.    DcutKbes  Arch.  i.  klin.  MecL,  1889,  iJir.  5. 6,  p.  533. 
JofTroy  el  Achard.     Note  sur  un  cajt  dc  Ml^rote  lal^rale  amyoiropbiqiM.    Arch, 
de  hl«il.  eipirim.  et  d'Anat.  juih..  1890.  pp.  434-44& 

While  the  diseases  of  the  cord  which  we  have  studied  so 
far  were  confined  to  certain  systems  of  (ibres — in  other  words, 
were  "system  diseases" — the  afTcctioti  now  to  be  considered 
does  not  present  this  peculiarity,  but  the  process  which  aflects 
the  gray  as  well  as  the  white  matter  is  more  or  less  widely  ex- 
tended over  the  cross- section  of  the  cord,  forming  a  small 
number  of  large  or  numerous  small  foci.  In  other  words,  the 
disease  is  what  we  call  "asystemic"  or  diffuse.  It  isnn  inftam- 
mation  of  the  cord,  which  according  to  its  course  is  called  an 
acute  or  chronic  myelitis,  and  to  which  the  name  transverse 
myelitis  has  also  been  given. 

Patholos^caJ  Anatomy. — Anatomical  changes  may  in  such 
s  be  scarcely  demonstrable  even  though  thcscvercsl  para- 
lylic  symptoms  may  have  existed  during  life.  This  is  more 
especially  true  in  cases  of  spinal  paralysis  due  to  pressure, 
occurring  in  consequence  of  dise^ise  uf  the  vertebra.'.  Here 
we  must  assume  that  even  moderate  pressure  is  (Mpabte  of 
bringing  about  a  break  in  conduction  without  any  destruction 
of  ncr^'c  elements.  Usually  in  cases  where  changes  can  be 
demonstrated  we  find  a  diminution  in  the  size  and  an  atrophy 
of  the  nerve  fibres.  The  axis  cylinders  may  appear  swollen 
and  may  have  lost  their  myeline  sheath.  The  nerve  cells, 
which  are  not  affected  until  Inter,  become  shrunken  and  lose 
their  processes.  According  to  Fricdmann.  the  degeneration  be- 
gins in  a  circumscribed  portion  of  the  cell,  secondarily  the 
nucleus  and  the  processes  degenerate,  and  finally  the  whole 
cell  shrinks  or  disintegrates  (Neurol.  Centralbl.,  1891,  7;  of. 
also  FUrstner  and  Knoblauch.  Arch.  (.  Psych.,  1891,  xxili,  1). 
While  thus  the  nerve  tissue  undergoes  disintegration  the  sup. 
porting  tissue  increases,  the  meshes  of  the  neuroglia  become 


acut 
■  myc 

I 


450 


D/SE^SSS  OF  SVBSTAXCE  OF  SPiNAL  CORD. 


broader,  and  in  it  are  seen  the  cells  of  the  supporting  tissue 
first  described  by  Deiters,  which,  owing  to  their  luinieruus  prtv 
cesses,  have  also  been  called  spider  cells.  In  the  mciibcsof  the 
neuroglia  rcliculum  compound  granular  corpuscles  are  found 
which  have  taken  up  the  lat  and  disintegrated  nerve  substance. 
These  arc  leucocytes,  and  in  turn  undergo,  sooner  or  later,  de- 
slriictton.  The  vessels  are  dilated  and  changes  are  seen  in 
their  walls,  consisting  of  thickening  or  hyaline  degeneration. 
In  cases  where  this  process  h.is  run  its  course  in  a  compara- 
tively short  time  the  cord  is  found  al  the  autopsy  to  be  soft 
and  of  a  grayish-red  color,  whereas  if  the  process  has  been  slow 
the  cord  appears,  in  consequence  of  the  increase  of  the  support- 
ing tissue,  hardened,  or,  as  we  say,  "  sclerosed." 

Macroscopically,  litllc  is  to  be  seen.  At  the  most  some 
portions  may.  when  the  cord  is  put  into  Milller's  fluid  for  the 
purpose  of  hardening  it,  look  light  yellow,  while  others  arc 
dark  green.  The  former  are  the  riiscased  parts,  which  can  not 
become  stained  because  the  myclinc  sheaths,  which  are  turned 
green  by  chromium,  arc  absent.  With  this  exception  all  in- 
formation about  the  pathological  changes  must  be  derived  from 
the  microscopical  examination  of  fresh  as  well  as  of  hardened 
sections. 

According  to  the  location  ol  the  process  we  dislinguisha 
dorsal  myelitis,  the  most  common;  a  lumbar  myelitis,  the 
rarest:  and  a  cervical  myelitis,  a  relatively  frequent  form,  la 
the  first  and  second  the  upper  extremities  arc  entirely  intact. 
while  they  are  implicated  if  the  process  is  situated  in  the  cer- 
vical cord. 

Symptoms.  — It  is  very  natural  that  the  clinical  manifesw- 
tions  ot   myelitis  should,  on   the  whole,  very  much  resemble 
those  which  we  have  learned  to  recognize  in  the  "  system-db- 
eflscs,"  and,  as  a  m.itter  of  fact,  almost  all  that  will  be  dcscrib«I 
has  already  been  said.     I  k-re,  as  there,  we  have  to  do  with  ini'> 
tor.  sensory,  and  trophic  disturbances,  with  changes  in  the 
reflexes  and  symptoms  referable  to  the  bladder  and  rectum 
The  motor  disturbance*  may  consist  of  symptoms  of  panik>is 
and  irritation.     The  f<)rmer  are  usually  the  more  prominent"' 
the   two,  and    weakness   of    the   legs,   which   sooner  or  latf 
amounts  Incomplete  palsy,  is  one  of  the  chief  symptoms  oU 
myelitis.     As  a  rule,  both  legs  are  about  equally  aficcicd-' 
paraplegia :  sometimes  one  retains  its  strength  longer  than  ik* 
other.  Recording  to  the  extent  to  which  the  pyramidal  traclS 


T/lA.VSr/i/tSS  .UY£Ur/S. 


4S' 


I 


diseased.  II  not  the  Ic^  but  the  arms  are  paralyzci),  the 
is  situated  in  tlie  cervical  cord.  The  symptoms  of  irri- 
tation  consist  ol  twilchings.  which  occur  sometimes  spontane- 
ously, sometimes  as  the  result  of  slight  stimulation  ol  the  skin. 
In  many  instances  the  removal  of  the  bedclothes  and  the 
change  of  temperature  resulting  therefrom  arc  sufficient  to 
cause  quite  protracted  clonic  spasms  of  oneur  both  legs.  This 
and  similar  phenomena  seem  to  be  of  reflex  origin. 

The  sensory  changes  are  less  regularly  met  with  and  are  of 
less  importance  than  the  motor  disturbances.  There  arc  in- 
deed cases  where  they  arc  almost  entirely  absent,  or  where  they 
at  least  do  not  annoy  the  patient  or  do  not  become  marked 
until  relatively  !atc  in  the  course  of  the  disease.  They  consist 
mostly  of  pararathesias.  numbness,  formication,  also  of  decrease 
in  sensibility,  which  may  amount  to  a  complete  anaesthesia, 
varying  in  extent  and  situation,  .^ctual  pains,  which  arc  suffi. 
cient  from  their  duration  and  intensity  to  cause  much  suffering 
to  the  patient,  and  which  arc  so  commonly  seen,  as  we  shall 
learn,  in  tabes,  belong  in  this  disease  to  the  exceptions.  In 
fact,  we  may  say  that  they  arc  usually  absent,  or,  at  any  rate, 
not  ai  all  severe.  If  we  are  able  to  detect  sensory  changes  on 
the  trunk  itself,  the  level  up  to  which  these  extend  gives  us 
valuable  indications  as  to  the  seat  ol  the  myelitis.  If  it  is  tn 
the  lumbar  cord,  sensibility  is  intact  above  the  navel :  if  in 
the  lower  dorsal,  above  the  middle  of  the  sternum.  Sensory 
changes  in  the  neck  and  upper  extremities  indicate  the  seat  to 
be  in  the  cervical  cord.  The  more  prominent  the  sensory  dis- 
turbances and  the  |>ains,  the  greater  is  the  extent  to  which  the 
gray  matter  of  the  posterior  horns  and  the  posterior  columns 
participates  in  the  inflammation  or  degeneration. 

Trophic  disturbances  appear  when  the  trophic  centres — 
that  is.  the  ganglia  of  the  anterior  gray  horns — arc  diseased. 
Thus,  if  we  are  able  to  demonstrate  atrophy,  with  reaction  of 
degeneration  in  Ihc  legs,  this  denotes  a  lesion  of  the  gray  an- 
terior horns  in  the  lumbar  cord,  while  the  same  condition  in 
the  arms  indicates  a  disease  of  the  anterior  horns  in  the  ccrvi. 
cal  cord.  The  electrical  examination  should  never  be  omitted 
in  such  cases,  because  it  may  happen  that  the  legs  present  a 
certain  degnre  o(  atrophy  without  the  presence  of  any  reaction 
of  degeneration.  This  atrophy  is.  then,  purely  the  result  of 
Isuse — the  atrophy  of  inactivity.     Oiher  trophic  disturbances 

vaso-motor  changes  in  the  skin  arc  not  the  rule.     Herpes 


452 


DISEASES  OF  SUBSTANCE  OF  SPmAt  CO/tD. 


and  urticarial  eruptions,  slight  oedema  and  changes  in  the  sweat 
secretion  occur,  but  possess  neither  diagnostic  nor  prognostic 
value. 

One  symptom  remains  still  to  be  mentioned,  because  k(i 
rarely  wanting,  but  rather  plays  an  important  rJfic  in  myelitis^ 
and  causes  end Ic^  annoyance;  and  discomfort  to  the  paiicnl— 
namely,  the  bed-sores  which  occur  in  the  sacral  region,  and 
become  the  more  extensive  the  less  the  care  exercised  in  ibe 
nursing  and  (or  the  cleanliness  of  the  patient.  This  is  one 
of  the  most  important  trophic  disturbances,  and  one  which, 
even  with  the  most  careful  attention,  can  not  in  all  cases  be 
avoided. 

The  condition  of  the  skin  as  well  as  the  tendon  reflexci 
depends  (i)  on  the  state  of  the  reflex  arc  in  the  spinal  cord,  {i) 
on  the  stale  of  the  Hbrcs  coming  from  the  brain,  which  have 
probably  an  inhibitory  function.     I(  the  reflex  arc  is  normal, 
but  the  conduction  of  the  inhibitory  fibres  interrupted,  then 
the  corresponding  reflex  is  increased,  while  if  the  re(!cx  arci* 
diseased  the  reflex  is  lost,  no  matter  whether  the  conduction 
of  the  inhibitory  impulses  be  intact  or  not.     This  holds  (or  the 
skin  as  well  as  tendon  reflexes.    Therefore  in  cases  of  lumbar 
myelitis  not  only  the  skin   but  also  the  tendon   reflexes  are 
diminished  or  lost  in  the  lower  extremities.    Those  concerned 
are  the  patellar  reflex,  the  reflex  arc  of  which  corresponds  to 
the  cord  between  the  second  and  fourth  lumbar  nerves;  the 
tendo-Achillis  reflex,  the  arc  of  which  corresponds  to  the  fini 
sacral  nerve;  (he  cremasteric  and  abdominal  reflexes  whicfc 
have  their  arc  at  the  level  of  exit  of  the  first  lumbar  and  a  por- 
tion of  the  cord  between  the  fourth  and  seventh  dorsal  ncrm 
respectively.     On  the  other  hand,  in  a  dorsal  or  cervical  nw 
litis  a  marked  increase  of  the  tendon  and  skin  reflexes  of  tfi< 
lower  extremities  takes  place,  because  the  (supposed)  inbibi- 
tory  influences  are  cut  off. 

A  symptom  which,  perhaps,  causes  the  patient  himscK  morf 
annoyance  than  any  other  is  the  disturbance  in  the  funcrioaf  ^ 
the  bladder,  which  in  a  myelitis  is  hardly  ever  totally  absent 
At  first  there  is  some  difficulty  in  micturition,  which  mayC"' 
in  complete  retention,  so  that  the  patient  can  not  void  I"* 
unnc,  but  requires  to  be  caUieterized.  In  the  later  stage** 
the  disease,  however,  the  urine  is  passed  involuntarily,  ih'^ 
being  either  a  consUinl  dribbling  (incontinentia  iirlna;)  orfW 
time  to  lime  an  involuntary  cvacuaition  ol  the  bladder.   '■ 


TKA.vsyE/tsn  M  yf.t./r/s. 


4S3 


I 


I 


either  case  ihe  patients  can  not  dispense  with  a  portiihle  urinal. 
Occasionally  there  is  a  painful  burning  sensation  when  the  urine 
is  passed  (ischuria)  so  that  the  patient  dreads  every  evacuation 
o(  the  bladder.  As  might  be  expected,  cystitis  frequently 
develops  in  these  cases,  partly  owing  to  the  length  of  time  that 
the  urine  remains  in  the  bladder,  partly  owing  to  the  frequent 
use  of  the  catheter.  The  rectal  symptoms  consist  either  of  a 
most  obstinate  constipation,  or,  if  the  sphincter  ani  becomes 
paralyzed,  of  incontinence  of  faeces  (incontinentia  alvi).  which 
a^ravates  to  a  very  serious  extent  any  bed-sore  that  may  be 
present.  For  the  localization  of  the  myelitic  process  neither 
bladder  nor  rectal  syn\ptoms  can  be  used.  They  are  always 
present  at  whatever  level  tlie  lesion  may  be. 
'  Etiology. — Ol  the  xtiology  of  myelitis  little  is  known.  It 
seems  justifiable,  however,  to  divide  the  causes  into  those 
which  act  chemically  and  those  which  act  mechanically,  the 
former  being  either  of  an  infectious  or  of  a  toxic  nature.  That 
infectious  diseases  may  produce  myelitis  is  shown  by  the  fact 
that  it  occurs  occasionally  after  diphtheria  and  gonorrhcen 
XL.cyden,  cl.  lit.),  more  frequently  after  small-pox,  and  also  dur- 
ing the  course  ol  syphilis,  and  that  the  inlluenceor  poisons  may 
at  least  favor  the  development  of  myelitis  has  been  upheld 
since  the  action  of  arsenic,  of  mercury,  and  of  lead,  and  the 
symptomatology  of  the  resulting  intoxications  have  been  more 
accurately  studied.  I^yden  has  recently  published  studies 
upon  the  relation  between  grave  anxmias  and  some  forms  of 
chronic  myelitis:  Eisenlohr,  upon  the  connection  of  primary 
atrophy  of  the  mucous  membrane  of  the  stomach  and  intestines 
and  myelitis. 

Among  the  mechanical  causes  the  most  important  is  pres- 
sure, which  can  be  exerted  upon  the  cord  by  structures  sur- 
rounding it.  as  happens,  for  instance,  in  spinal  meningitis  and 
meningeal  tumors.  Of  greater  importance  in  this  connection 
is  the  chronic  caries  of  the  vertebne  (malum  Pottii),  spondyl- 
•rthrocace.  the  tubercular  spondylitis,  and  carcinoma  of  the 
vertebra:  (cl.  Figs.  14S  and  146).  in  which  either  the  dislocated 
(diteased)  vertebra:  themselves  or  the  caseous  and  inflamma- 
tory products  which  arc  found  between  the  dura  and  ihe  bone 
may  exert  a  compressing  influence-  That  there  arc  still  other 
causes  which  may  give  rise  to  myelitis  we  do  not  deny ;  we 
would  only  mention  bodily  fatigue  and  exposure  to  cold,  but 
arc  inhnitely  rarer.     On  the  other  hand,  there  exists  not 


454 


D/SSASES  OF  SUSSr^yC/i  OP  SPINAL  COKD. 


the  smallest  ground  lor  the  assertion  that  sexual  excesses  ever 
produce  it. 

Course. — The  course  in  general  is  the  (ollowiufi :  After  the 
]Kitient  has  for  weeks  and  months  managed  with  difhculty  to 
get  around,  his  legs  becoming  weaker  and  weaker,  he  has  to 
take  to  bed  or  to  the  rolling  chair,  where  he  spends  one.  two, 
even  four  years,  harassed  by  various  afflictions,  among  whicb 
the  bladder  symptoms  and  the  motor  disturbances  are  espe- 
cially prominent.  Recovery,  if  it  occurs  at  all,  is  only  vcr)- 
exceptional,  and  the  prognosis  must  therefore  always  be  very 


Tit-  MS-  'kt.  '46.  _ 

COUfUETV   IlTTKIUIUFTIOK  Or  CONDUCTtOM  OP  THR  SPIKAI.  CORCi  IMmtlKI   LIFE.      FV 

■4S.  anlerior.  Fig-  M^  pcalrrlor  HipMl  of  the  ipiiuti  cord.  TTi«  iluta  nlMtr  to  Hliidrf 
and  (i>klt<rj  baik.  Circulat  mmprpviinn  ami  narniv-inc  v(  lh«  -qiinal  n>nl  >x  K  \n  cam*- 
qumtF  of  cjidnoma  of  tht  vrtlFbtir  in  a  wiiman  ihitlj-l'iur  ytxn  <A  ngt.  NiUiml  illt 
Tlw  dravHiii'  u  maile  (rom  a  Irmli  (irepaialiun.    { A(E«'  Eickhomst.) 

unfavorable.  Death  occurs  iti  consequence  o(  bed-sores,  which 
arc  seldom  absent,  or  is  at  least  precipitated  by  them,  .Some 
patiems  die  from  intercurrent  diseases,  others  from  the  cystitis. 
The  course  ot  ihc  so-called  pressure  myelitis  and  its  resulting 
pressure  paralysis,  the  symptoms  of  which  have  before  been 
alluded  to  on  page  424.  is  so  far  characteristic  Ihal  wc  can 
here  distinguish  a  pnidromal  stage,  a  sla^e  of  trritalion,  and  a 
stage  of  paralysis.  The  protninetil  features  of  ihc  first  are 
rigidity  oi  the  vertebral  column,  dull,  vague  pains  in  the  back, 
and  the  first  signs  of  a  commencing  deformity.  In  the  second 
stage  we  have  severe  neuralgic  pains,  hypera-sihcsias.  iKincs- 
thcsias.  and  girdle  sensations.  In  the  third,  finally,  paralytic 
symptoms,  increased  refiexcs,  vaso-motor  and  tr<iphic  disturb- 
ances (herpetic  eruptions,  muscular  atrophies.  l>cd-sores,  etc.). 


TJtAiVSI'fiK.IS  AfVEUrfS. 


4S5 


This  distinciion,  liuwcvcr.  is  only  possible  in  isolated  cnses. 
Bladder  and  rectal  symptoms  are  absent  in  no  case  of  pressure 

■  paralysis. 

F  In  our  prognosis  we  must  not  leave  otit  of  consideration 
the  possibility  tlint  the  tiiHummatory  new  formations  in  the 
vertebra;  may  disappear,  and  thus,  the  cause  which  pnKlticvd 
the  break  in  the  conduction  ceasing  to  act,  it  may  be  possible 
for  the  spinal  cord  to  recover  completely  all  its  normal  func- 
tions, provided,  of  course,  that  none  of  the  nerve  elements  have 
been  destroyed. 

ft      Treatment. — The  treatment  of  any  case  of  myelitis  necessi> 

^tates  much  patience  on  the  part  of  the  sufferer,  because  weeks 
and  months  may  pass  before  any  sign  of  improvement  can  be 
perceived,  and  much  circumspection  on  the  part  of  the  pliy- 
sician,  because  we  are  never  able  to  say  beforehand  how  cer- 
tain measures  are  going  to  be  borne  by  the  patient,  and  because 
what  often  helps  one  is  harmful  to  another;  hence  one  must 
proceed  carefully  and  systematiadly,  and  as  it  is  likely  that 
the  course  of  the  disease  is  going  to  extend  over  years,  one 
should  always  have  something  new  and  as  yet  untried  in  re- 
serve. If  the  diagnosis  has  once  been  made  with  certainty,  it 
is  our  duty  to  inform  the  patient  in  a  delicate  w.iy  of  the  true 
state  of  affairs,  and  how  seriously  his  capacity  for  following  his 
occupation  will  be  interfered  with;  further,  to  see  th.tt  he  ia 
properly  fed  on  a  nourishing  diet,  and  obtain  for  him  as  far  as 
possible  mental  and  bodily  rest.  It  is  a  gross  error  to  recom- 
mend such  patients,  who  arc  easily  fatigued  and  who  on  the 
slightest  provocation  are  attacked  by  all  sorts  of  pains,  to  take 
as  much  exercise  as  possible,  or  even  to  prescribe  gymnastics 

Jor  them. 

■  The  electrical  treatment  is  indicated  and  ought  to  be  begun 
early.  The  coni^tant  ciirreni  should  be  applied  near,  the  s*-at 
of  the  lesion  (the  anode  iKiitg  ]>laced  on  the  tender  parts  ol  the 
spinal  column  If  there  be  such),  the  faradic  to  the  periphrrnl 
parts,  especially  the  lower  legs-  flefinite  rules  can  not  be  laid 
down,  il  I!)  best  to  seek  information  from  a  reliable  texl-lKiok, 
and  to  try  which  mode  of  treatment  is  best  borne  by  ihe  pa- 

Kirnt  and  by  which  most  is  acc<implished.  Tepid  baths— 84" 
D  88'  Fahr. — three  or  (our  times  a  week  for  fnim  fillcen  to 
thirty  minutes,  best  taken  in  the  forenoon,  usually  have  a  favor- 
able influence,  and  are.  if  not  of  lasting  benefit  lo  the  pnlieni, 
lucnily  productive  of  at  least  a  transient  feeling  ot  comfort. 


456  i>/SEASBS  OF  SUBSTAXCB  OF  SPINAL  CORD.  ^H 

The  addition  of  rock-salt,  sea-salt,  nt  tyc  (one  or  two  quarts) 
should  only  be  ordered  if  the  patient  himself  seems  to  lay  much 
stress  on  it,  as  we  can  not  expect  any  especial  effect  iroin 
them.  Neither  should  we  raise  our  expectations  too  liigh 
when  we  recommend  warm  brine  baths  containing' carbonic- 
acid  gas,  or  non-mcdicatcd  warm  baths,  or  mud  balhs  and  the 
like.  Of  course  every  patient,  rich  or  poor,  expects  us  to  send 
him  in  summer  to  the  springs,  but  he  will  gradually  find  out 
that  the  success  attained  dues  not  compensate  for  the  expense 
and  the  trouble  which  the  yearly  course  al  such  places  entails, 
and  that  it  is  wiser  to  remain  in  his  comfortable  home  or  to 
betake  himself  into  the  country  and  enjoy  the  mountain  or  for- 
est air  in  some  place  where  he  can  live  in  peace.  The  life  in 
modern  watering-places  is  not  adapted  for  a  patient  with  mye- 
litis. Mild  cold-water  treatment  in  an  intelligently  conducted 
sanitarium  (Oraefcnberg,  Nassau,  Elgersburg.  and  others)  may  I 
well  be  recommended.  All  internal  medicines  {strychnine, 
silver,  ergotine,  iodide  of  potast^ium,  etc.)  are  of  no  avail.  The 
treatment  of  the  retention  of  the  urine  and  the  consequent 
cystitis  must  be  carried  out  accordinK  to  strict  surgical  princi- 
ples. In  the  treatment  of  a  compression  myelitis  we  must  not 
forget  the  necessary  extension  apparatus,  braces,  etc.,  for  the 
vertebral  column.  These  means,  however,  belong  to  the  do- 
main of  orthopaedic  surgery. 

Sometimes  the  effect  of  a  unilateral  section  of  the  spiiial 
cord,  where  we  consequently  again  have  a  lesion  of  the  gray  as 
well  as  the  white  matter,  can  be  observed  in  those  rare  in- 
stances in  which  traumatism,  a  tumor,  or  the  like,  has  rendered 
the  half  of  the  cord  incapable  ol  performing  its  functions.  The 
clinical  picture  resulting  from  such  a  lesion  is  much  more  rarely 
observed  than  we  should  be  led  to  suppose  from  the  accounts 
in  the  tcxi-books.  The  disease  is  called  Brown-S^uard's  spi- 
nal paralysis.  It,  in  short,  manifests  itself  as  a  motor  paralyjii 
on  the  side  of  the  lesion,  and  a  sensory  paralysis  on  the  oppo- 
site side.  This  is  explained  by  the  distribution  of  the  fibres, 
inasmuch  .is  the  sensory  fibres  cross  over  to  the  other  side  soon 
after  their  entrance  into  the  cord,  while  the  motor  fibres  pass 
upward  to  the  medulla  oblongata  without  crossing  (cl.  Fig- 
147) ;  thus.  if.  for  instance,  the  lesion  be  in  the  right  half  of  the 
lumbar  cnrd,  a  paresis  of  the  right  leg  ensues,  tvhile  the  left  is 
anesthetic:  if  the  lesion  is  high  up  in  the  right  half  of  the 


BMOIVy'Sf.QVAKD'S  PARALYSIS. 


45? 


I 


cervical  cord,  the  right  arm  and  right  leg  are  paralyzed  ("spi- 
nal hemiplegia"),  and  the  other  half  ol  the  body  is  anaisthelic. 
The  Tact  that  on  the  side  on  which  there  is  motor  paralysis 
there  is  often  a  hypera-sthesia  (Kiver  has  reported  a  case  in  the 
Neurol.  Centralbl.,  1891, 
No.  2,  in  which  there  was 
no  hype  nest  hcsia)  for  ccr- 
tain  qualities  of  sensation 
— with  the  exception  of 
the  muscular  sense,  which 
appears  diminished  —  is 
explained,  according  to 
Brown -S6qiiard,  by  the 
fact  that  the  fibres  for  the 
muscle  sensibility  do  not 
cross  over  as  the  other 
sensory  fibres.  Above  the 
bypcncsthetic  there  ts  an 
atissthetic  zone,  due  to 
the  destruction  of  the  pos- 
terior nerve  roots.  Fur- 
ther, there  is  an  increase 
o(  the  rcllexcs  on  the  side 
aflccted  with  motor  paral- 
ysis, owing  to  the  cutting 
off  of  the  inhibitory  influ- 
ence, as  well  as  a  vasomo- 
tor paralysis,  manifesting  itself  by  an  elevation  of  tempera- 
lure.  On  the  ana:sthc(ic  side  the  reflexes  arc  normal :  a  narrow 
hypersesthetic  zone  (on  the  trunk)  is  here  also  noticeable  above 
the  area  ol  anxsthcsta. 

On  the  whole,  the  descriptions  which  wc  possess  of  unU 
lateral  cord  lesions  arc  of  no  great  practical  use.  because,  as 
has  been  stated,  the  clinical  picture  just  described  is  but  rarely 
distinct  and  complete,  and  may  pre5«nt  all  kinds  of  variations 
(cl.  Hoflmann.  [leuisch.  Arch.  f.  klin.  Med.,  18S6,  38,6,  where 
three  cases  of  this  class  which  occurred  in  Erb's  clinic  are 
described). 

LITERATURE. 

Pnbody-     New  Vorfc  Medkiil  Record,  Febniary  S,  iSSj,  iriii 

ChjqirniKT.     Hfvuc  d'hyi*,,  Miirch  j.  iHSj.  v. 

iUrkntr.     Laikci.  November  jo.  18S6.  ii.     (M)«litto  afkcr  Mcasics.) 


Fic.  Ill-— SC'isuA  OF  TIIB  Oouus  or  -nir 
Nb«vr  Fimm  n  tiiR  SnnAL  Cokol  *,  u»- 
crawd  motor  flbnw.  t/,  uncmuol  vmo-owiiw 
(ibn*.  tm,  uncniwnl  fibna  for  iha  i— initor 
(enx.     I.  dcmaMlntc  tciUMf  iibiw.     (Allcr 

BlM>W»-Slqi-ASIX) 


458  DISEASES  OF  SUBSTANCE  OF  SPINAL   COED. 

Crassct  el  Eslor.     My^Iite  cervicale.     Revue  de  miA.,  1887,  vii,  2. 

Schiitz.     Prager  metl.  Wochenschr..  1887.  xii,  38.     (Cure  of  Myelitis.) 

Cramer.     Arch.  f.  Psych,  u.  Nervtnkrankh..  1888,  xix,  3,  p.  667. 

Kroger.  Beilrage  zur  Pathologic  des  Ruekenmarkes.  (Recovery  from  Com- 
pression Paralysis.)     Dorpat,  1888.     Inaug.- Dissert. 

Cessner,    Arch.  f.  Augenheilk.,  1888,  xix,  1.    (MyelitisAcutaafter  Loss  of  Blood.) 

Herter,  A.  Christian.  A  Study  of  Experimental  Myelitis.  Joum.  of  Nerv.  and 
Ment.  Diseases.  1889.  xiv. 

Schmaus.  Die  Compressionsmyelitis  bci  Caries  der  WirbelsSule.  Wiesbaden, 
Betgmann,  1889. 

Schaffer.     Neurol.  Centralbl.,  i8gi.  8. 

Oppenhcim.     Zum  Kapiiel  der  Myelitis.     Berliner  klin.  Wochenschr.,  1891,  y. 

Rosenbach.  P,  und  Schtscherback.  Ueber  die  Gewebsvetanderungen  des 
Ruckenmarks  in  Folge  von  Compression.    Vireh.  Arch.,  Ixxii. 

Eulenburg.  Spinale  Halbseitenlasion  mil  cen'ico-dorsalem  Typus  nach  In- 
fiuenza.     Deutsche  med.  Wochenschr.,  1892,  38. 

Leyden.     Zeitschr.  I',  klin.  Med.,  1892,  xxi,  I,  2,  5,  6. 

II.  Spinal  Lesions  regarded  from  their  Pathological 
Asi'ECT— Pathological  Diagnosis. 

I.  affections  of  the  sriNAi.  cord  due  to  diseases  or 

THE   BLOOD-VESSELS. 

A.  Diseases  of  the  Arteries  of  the  Spinal  Cord  and  thdr  Consequences. 

The  vertebral  arteries  which  arise  from  the  subclavian,  and  which 
unite  to  form  the  single  basilar  artery,  give  off,  after  having  entered 
the  skull,  an  anterior  spinal  anti  a  posterior  spinal  artery  by  which 
the  spinal  cord  is  supplied  with  blood.  The  anterior  spinal  arteries 
of  both  sides  unite  to  fonn  a  vessel  which  runs  along  the  spinal  cord 
ill  the  anterior  spinal  fissure,  while  the  posterior  spinal  arteries  anas- 
tomose freely  with  each  other  without,  however,  completely  uniting; 
the  horizontal  branches  run  along  the  septa.  White  and  gray  matter 
are  nourished  in  tlie  same  way,  but  the  capillary  network  of  the 
latter  is  much  denser  than  that  of  the  white  substance. 

The  venous  blood  is  collected  into  two  fairly  large  veins,  which  are 
called  the  central  veins  of  the  spinal  cord,  'i'hey  anastomose  freely 
among  themselves,  and  are  connected  with  the  anterior  and  posteriiir 
spinal  veins.  From  (hem  the  venous  blood  passes  into  the  vertebrals, 
ivhich  empty  into  the  innomiiiate  or  the  subclavian  vein.  About  the 
diseases  of  the  spinal  veins  up  to  the  present  nothing  is  known. 

/,  Sfiiiii/  Ihcmorrhagf — Hirmorrliagia  {or  Apoplexia)  McdnUii 
Spina  lis —  Hic  matomyilia. 

While,  as  we  have  shown  above,  a  primary  haemorrhage 
from  the  cerebral   vessels  is  uiie  of  the   most  common  causes 


i{^..\tA7VUY£UA. 


459 


of  lesions  of   the  brain,  sjwntaneous  hjcmorrhages  from  the 
spinal  arteries  arc  exceedingly  rare,  and  iiiflecd  it  seems  hardly 
possible  that  a  hsemurrhage  could  take  place  into  the  sub- 
stance of  the  cord,  so  5rnily  held  together  as  it  is  by  the  tough 
Hpb  mater,  without  the  previous  existence  of  alterations  in  its 
consistence;  besides,  the  anatomical  conditions  of  the  arteries 
are  such  that  the  blood  pressure  is  decidedly  lowered  bclorc 
Uic  blood  wave  reaches  the  spinal  cord :  furthermore — and  this 
is  perhaps  the  most  important  reason  for  the  rare  occurrence 
of  haemorrhage   into  the  cord — miliary  aneurisms,  which  in 
the  brain  arc  the  most  frequent  source  of  ha;morrhage,  arc 
never  found  here.     For  these  reasons  the  existence  of  primary 
s|Ktntancous  spinal  ha:morrhages  has  been  absolutely  denied, 
and  it  has  been  assumed  that  in  every  case  changes  in  the  con- 
sistence of  the  cord  substance  must  have  preceded.     VVc  fully 
agree  with  those  who   believe   in    their   extreme   nirily.   but. 
never1hctcs<i.  we  arc  of  the  opinion  that  under  certain  condi- 
_  tions   primary  ha'niorrhages  actually  do  occur.     Such  condi> 
f  tionsurc:  (l)  in  old  persons  the  coexistence  of  cerebral  ha:m- 
orrhages  in  consequence  of  arterial  disease:  (2)  the  presence 
of    such    artiological   factors   as    excessive   muscular   exeriinn 
(heavy  lilting,  ciitlinf;  wood,  etc.);  (j)  the  sudden  and  violent 
suppression  of  haemorrhages  in  other  places  (the  menses,  ha;m. 
—^orrhoids.  etc.):  (4)  the  exposure  to  a  sudden   marked  diminu- 
Btion  of  atmospheric  pressure,  as  happens  to  those  who  follow 
Bccrtain  occupations,  .is,  for  instance,  workers  in  compresses) 
Riir  in  building  bridges  or  winning  amber  (c(.  Mirt.  Gcwcrbc- 
Hkrankheiien  im  Han<lbuch  der  spec.  Patliologie  und  Thcrapie. 
^MO^  i.  third  edition,  reprint,  pp.  83  rt  seif.). 
^F    The  pathological  condition  is  cither  one  of  capillary  hicm- 
orrhages  or  of  a  hwmorrhagic  infiltration  in  which  the  escaped 
blood  extends  between  the  nerve  fibres  along  the  course  ol  ihc 
vessels,  or  finally  wc  have  ha:morrbrtgic  foci,  in  which  the  bkKKl 
coining  from  the  vessels  in  larger  quantities  presses  the  nerve 

ttissiir  apart  and  forms  a  sort  of  cavity.  The  focus  usually  ex. 
tcnd>  In  the  longitudinal  direction  ol  the  cftrd.  Haemorrhage 
)aiay  occur  at  any  level  of  the  spinal  cord  and  in  any  porlirm  of 
ihc  cross-section,  and  may  produce  the  same  change:!,  in  ils  sub- 
stance  as  cerebral  ha>morrhage  produces  in  the  brain— changes 
with  which  we  have  become  familiar  in  a  previous  chapter. 

Clinically,  spinal   apoplexy   is   characterized    by    paralysis 
with  a  &udden  ousel,  sometimes  attacking  the  p;itient  without 


460 


DISEASES  OF  SUffSTAJVCE  OA  SP/XAL  CO/fD. 


any  premonition  and  while  he  is  apparently  in  the  best  of 
health:  he  suddenly  sinks  to  the  ground  without  losing  con- 
sciousness, and  is  deprived  of  the  use  of  his  limbs;  occasion- 
ally prodromata,  such  as  tearing  pains  or  formication  in  the 
limbs,  may  precede  for  hours  or  days.  The  extent  and  the 
degree  of  the  paralysis  depend  entirely  on  the  seat  ol  the 
ha;morrhagc ;  il  may  be  confined  to  one  half  of  the  body,  or  to 
both  legs  or  to  both  arms,  or  it  may  take  in  all  (our  extremilics 
simultaneously.  It  develops  extremely  rapidly,  and  reaches  its 
fullest  extent  within  twenty-four  hours.  If  this  is  not  the  case 
it  is  not  a  spinal  hxmorrhagc  with  which  we  are  dealing.  Pains 
and  rigidity  ol  the  back  and  clonic  muscular  twitchings  are 
equally  constant,  as  are  the  bladder  symptoms,  which  are  prob- 
ably never  absent  in  ha^matomyelia.  With  regard  to  sensation 
and  the  reflexes  no  general  rule  can  be  given,  yet  an  increase 
of  the  reflexes  immediately  after  the  catastrophe  is  not  exactly 
rare.  Ocalh  may  occur  within  a  tew  hours,  an  event  which  is 
especially  likely  to  lake  place  if  the  ha-morrhagc  is  situated 
high  up.  In  other  cases  the  patient  lives  for  days  and  weeks, 
and  dies  from  the  effects  of  bed-sores,  of  a  cystitis,  etc.  Finally, 
at  leasl  relative  recovery  is  not  excluded ;  the  patient  may  either 
get  over  the  effects  of  the  lesion,  or  he  may  be  left  with  motor 
or  sensory  disturbances  of  the  most  varied  kinds.  The  diflcr- 
ential  diagnosis  between  hxmatomyclia  and  hxmatorrhacliis 
(meningeal  apoplexy)  has  been  discussed  above-  For  the  treat- 
ment we  may  try  the  application  of  ice  to  the  spinal  coliimn 
and  the  internal  administration  of  ergotine.  The  success  at 
these  measures  is  always  very  doubtful,  and  a  careful  attcnlton 
to  the  nutrition  and  the  cleanliness  of  the  patient  should  in  all 
cases  be  considered  the  thing  of  most  importance. 

J.  Embolism  attii  Thrombosis  of  fhr  SfitMa/  ArlrrifS  and 

Myelomalacia. 
Embolism  of  the  spinal  cord,  the  de%'clopment  of  which  hat 
been  studied  experimentulty  by  Pa  num.  is  extremely  rarei» 
man,  probably  owing  to  tlic  smallness  of  the  spinal  arteriesin<l 
the  fact  thai  they  arise  at  right  angles-  The  symptooisbT 
which  emboli  manifest  themselves  arc  not  definitely  knw**: 
possibly  ihere  is  a  connection  between  embolic  processes  w 
the  so-called  choreic  movements,  but  this  is  still  hypothetical- 
It  is  about  the  same  with  arterial  thrombosis,  the  indepf""' 
cnt  existence  of  which  is,  to  say  the  least,  doubtful,  but  $>»'*■ 


ENnAftTEK/r/S  SPIJVAUS. 


461 


\ 


Is  Leyden  has  pointed  out  {Riickenmarkskrankheitcn,  ii.41). 

iiseasc  of  ihc  spinal  vessels  is  extremely  common,  the  occur- 
rence of  arteri:ii  ttirombosis  is  very  e.isity  possible.  Not  only 
^the  inflammatory  processes  in  the  spinal  cord,  which  are  ac- 
companied by  arterial  disease,  but  also  the  senile  changes, 
which  consist  in  fatty  degeneration  and  thickening  of  the  ves- 
sel walls,  predispose  to  it.  The  necrosis  which  occurs  in  the 
substance  of  the  spinal  cord  in  consequence  of  arterial  obstruc- 
tion is  similar  to  that  described  on  page  244  as  occurring  in 
the  brain  substance.  The  condition  ol  softening  is  called  mye- 
lomalacia (cf.  also  Kcdiich.  Ueber  cine  cigcnthumliche.  durch 
GelAssdegencration  hervorgerufeue  Frkrniikung  der  KUcken- 
markahinterstr^nge,  Fragcr  Zcitschr.  i.  Itcilkunde,  1891.  sii). 

J.  EndaTteri(i%  {typhiiitua). 

That  the  spinal  arteries  participate  in  the  process  which 
Hcubncr  has  shown  to  occur  in  the  cerebral  arteries  (page 
2;:),  according  to  competent  observers,  does  not  seem  to  ad- 
mit ol  doubt.  It  is  equally  certain  that  this  process  plays  here 
relatively  smaller  r^le  than  in  the  brain.  Heubncr  himseK, 
Knapp.  Leyden,  and  others  have  reported  interesting  observa- 
tions bearing  on  this,  and  it  seems  that  an  endarteritis  oblit- 
cnins  in  the  spinal  cord  leads  cither  to  a  myelitis  or  a  multiple 
sclerosis.  RumpI,  in  his  excellent  treatise  on  The  Syphilitic 
Diseases  of  the  Nervous  System  (page  349),  has  published  in 
full  a  very  interesting  case  of  syphilitic  disease  of  the  spinal 
arteries,  which  was  followed  by  a  similar  rcjwrt  by  Knapp 
<Ncurol.  Cenlralblatt,  1885,  21).  and  another  by  Gracfr(Arch. 
f.  Hsych.  und  Nervcnkr.,  1882,  sii,  3).  There  arc,  however, 
only  comparatively  few  cases  to  be  found  in  the  literature,  and. 
fn  Almost  all,  syphilis  of  the  brain  coexisted  with  syphilis  of 
the  spinal  cord,  and  endarteritis  obliterans  was  almost  always 
demonstrable  in  the  brain  as  well.  Two  interesting  cases 
have  been  reported  by  Schmaus  (Deutsch.  Arch.  f.  klin.  Med., 
iSSg,  vol,  xliv,  2,  3.  p.  244).  In  one  of  them  the  syphilitic  af- 
fection took  the  form  of  an  arterial  disease,  running  a  subacute 
course  with  hyaline  fibrous  thickening  of  the  intima  and  simul- 
t:inrous  inflammatory  infiltration  ol  the  whole  ve^rl  wall, 
which  was  lollowcd  by  an  irregular  disseminated  patchy  scle- 
rosis of  the  white  matter,  a  marginal  sclerosis,  and  a  degenera- 
tion t>(  Goll's  columns  in  the  cervical  c<ird.  That  the  degen- 
ctmtioQ  of  the   nerve  jvarenchyma  was  attributable  to  the  low 


462  f>fSSASSS  OF  SVltSTAJ^CB  Of  SP/AfAl  COSD.  ^ 

Stale  of  ntilrtlioi)  In  consequence  of  dimiiitition  in  the  blood 
supply  seemed  beyond  doubt.  As  for  the  symptoms,  sensory 
disturlwinces  f|>.iii)s,  par;esthcsias,  hypcraesthetic  zones)  and 
motor  dbturbunccs  (at  first  fatigue  and  tinully  complete  [mn- 
plegia).  furthermore  incontinence  of  the  urine  and  ficces.  con- 
stituted the  clinical  picture.  In  the  second  case  a  svphillric 
degeneration  of  the  vessel  walls  combined  with  a  poliumyclilis 
was  found.  With  our  present  knowledge  we  must  cnnteot 
ourselves  with  diagnosticating  a  diffuse  affection  of  the  spinal 
cord,  a  transverse  myelitis,  a  tumor,  and  the  like.  The  diag- 
nosis of  a  syphilitic  disease  of  the  arteries  must  be  made  with 
reservation  during  life,  and  must  only  be  assumed  when  llie 
luetic  history  is  certain. 

f  LITKRiVTURE. 

EvrakI     Udi^syphililisiheOriisu^rkraiikung.   BtTl.  Win,  Wochenscbr.,  i$89,4K. 
Kei'ndds.    SyphJIilic  Uisc-uconhc  Spinal  Cord.    Um.  Mcd.JiMirn.,  iS89,p.  IIII. 
Siemcrling.     Arch.  f.  Psych.,  18901  xjtii,  i. 
Mtillcr.    Siu<ticr  aivtr  ryggnvArgasyfilia.    Nonlisk.  med.  Arfc,,  1890,  XxU,  4.  N(k  II 

^.   Dilatalittn  of  fht  Spina!  Arlfrits. 

Wc  know  very  little  about  aneurisms  of  (he  spinal  arteries. 
Besides  the  case  reported  by  Liouvillc,  which  is  also  quoted  bj" 
Leyden  {he.  (it.,  2,  p.  42).  none  can  be  found  in  the  literature. 
The  question,  therefore,  whether  syphilis  may  give  rise  to 
aneurisms  here  can  not  be  answered.  It  is  possible  that  bodily 
exertion  has  a  predisposing  action.  A  symptomatology  and  a 
therapy  do  not  exist  for  aneurisms  of  the  spinal  cord.  (Spen- 
cer, Sequel  of  a  Case  of  Traumatic  Aneurism  of  the  Spine, 
Brit.  Med.  Journ.,  1891,  December  5.) 

I  5.  Nfurases  cf  the  SfiiKal  Arteries.  ^^| 

The  vaso-molor  nerves  of  the  spinal  arteries  behave  jus^ 
like  those  that  supply  the  cerebral  vessels,  and  upon  whelhcr 
they  are  in  a  state  of  irritation  or  in  one  of  paralysis  the  amount 
of  blood  in  the  spinal  cord  depends.  But  easy  as  it  is  to  dem- 
onstrate hyperieniia  and  anaemia  of  the  cord  in  the  cadaver,  it 
is  difficult,  on  the  other  hand,  to  say  in  what  way  changn><* 
ihe  amount  of  blood  in  the  spinal  cord  influence  the  health  of 
the  patient,  and  ivhethcr  a  greater  or  Icsst-r  fullness  of  the  ft*- 
sels,  or  frequent  l^uctuations  between  the  two,  are  atieinicu 
with  any  marked  symptoms.  All  views  on  this  subject  »f^ 
entirely  hypotlieiical.     The  palhologic.1l  changes  in  the  sjiin* 


Af£C'»OS£S  OF  THE  SPINAL  ARTEHtES, 


m 


Hcord,  due  to  an  artificial  transient  anictnia  produced  by  liga- 
Htion  of  the  abdominal  aorta,  Spronck  (Arch,  de  physiot.  norm, 
ct  p.ithol.,  September   I.  lS88,  xx),  (ollowing  out  the  earljr  re- 
searches of  Bricger  and  Ehrlich,  has  lately  dcmonslratcd.  with- 
■out.  however,  throwing;  any  further  light  upon  the  clinical 
symptoms  caused  by  spinal  .-inxmia. 

ijince  the  time  ol  Peter  Franck  ( 1 791)  there  has  been  a  wide- 
spread opinion  that  hypera-mia  of  the  spinal  cord  can  give 
rise  to  a  number  of  symptoms  of  irritation,  some  of  which 
bcin^;  motor,  some  sensory,  iO|relhcr  make  up  the  clinical  pic* 
ture  ot  what  has  been  described  as  spinal  irritation.  But  the 
(act  that  it  was  found  impossible  to  accurately  define  a  clinical 
picture  indicative  of  this  condition  and  the  difficulties  which 
arose  in  the  diagnosis  have  led  most  observers  to  abandon  the 
term.  The  disease  used  to  be  described  somewhat  as  follows: 
The  patients,  who.  as  a  rule,  are  females  belonging  to  the  best 
classes  of  society,  complain  of  an  occasional  feeling  of  fatigue 
und  of  pains  in  the  back,  which  are  intensified  by  the  erect  pos- 
ture. Walking  becomes  difficult,  and  the  gait  is  that  of  an  old 
t person ;  ibey  walk  with  a  bent  b:ick  and  take  each  step  with 
care.  Painful  sensations,  parnesthcsias,  formication,  and  numb- 
ness in  the  lower  extremities  arc  complained  of.  The  functions 
of  ifie  bladder  are  more  or  Ic^  disturbed  :  often  there  exists  a 
uterine  catarrh.  The  patient  is  low-spirited,  and  has  a  tend- 
ency to  hypochondriacal  notions.  On  examination,  we  find  the 
reflexes  either  normal  or  cxaggirratfd  ;  sensibility  is  somewhat 
aScctcd,  and  disseminated  anaesthetic  plaques  are  demonstra- 
ble. A  certain  tenderness  over  the  s'ertebrcc  is  almost  always 
noted:  it  is  usually  more  pronounced  in  the  lumbar  and  dorsal 
than  in  the  cervical  region.  The  course  of  the  disease  is  cmi. 
nently  chronic;  often  months  and  years  pass,  notwithstanding 
all  therapeutic  measures,  before  any  decided  improvement  oc- 
curs, and  ihosc  unfavorable  cases  in  which  the  patient  finally 
becomes  bed-ridden  and,  after  having  been  lor  years  affected 
with  paresis  or  paralysis,  falls  at  last  a  prey  to  an  intercurrent 
malftdy,  are  by  no  means  exceptional.  A  cause  was  often  looked 
for  in  vain.  Overexertion  or  sexual  excesses  were  regarded  as 
sometimes  indirectly  giving  rise  to  the  disease  1  at  times  the 
immoderate  indulgence  in  lokicco  was  blame<l,  but  more  fre. 
(|ucnily  »ll  such  (actors  were  wanting,  and  a  congenital  weak- 
ocs*  of  the  nervous  system  had  to  be  made  responsible  for  the 
kflcction. 


464  />/SEASES  Ot-   SUBSTANCE  OF  SPINAL  COHD. 

Further  investigations  must  teacli  us  tu  what  e):tcnt  ibe 
aScctton  described  by  M<)bius  under  the  term  akinesia  algcra 
is  ^alilied  to  replace  "spinal  irritation."  Certainly  only  Ibe 
severest  lorm  o(  the  tatter  could  l>c  represented  by  this  condi- 
tion, which,  according  to  MiSbius,  is  characterized  by  severe 
pain  on  the  slightest  exertion,  so  that  there  exists  a  total  inabil- 
ity to  move.  Tiie  observations  o{  Mijbius  have  been  confirmed 
by  many  others,  but  it  is  not  yet  clear  whether  the  condilion 
represents  a  separate  disease  or  not. 

The  treatment  in  this  condition,  just  as  was  the  case  lor 
spinal  irritation,  should  be  local  and  general.  The  forracr  con- 
sists in  the  early  and  energetic  use  ol  the  Paquclin  cautery  and 
of  the  constant  current  (descending);  the  latter  in  the  use  ol 
tepid  baths  and  tonics.  Yet  often  all  measures  arc  fruitless,  and 
it  is  advisable  to  be  very  guarded  in  giving  an  opinion  with 
regard  to  the  duration  and  probable  outcome  ol  the  disease. 


l.rrKKATlJkE. 

M^AIus.     Akinesia  algtra.     Ucutiiche  Zcitschr.  t  Norvenhlc..  1891,  i.  I,  3. 

Konig.     Ccnlralbl  f.  Kcn'cnhk..  l8gj,  «i.  p.  97. 

Iktbbiut.     UeuUchc  /cilschr.  t.  Ncnenhk.,  1893,  ii,  5. 

Longard.     Ibtd..  189a,  ii.  j. 

£rb.    Ibid,.  1893.  ill.  \~\ 

Putnam.     Baiinn  Meet,  and  Surg.  Jmim.,  189Z.  cxxvii.  \o. 

Moj-cr.    Med.  Standard.  Chicago,  January,  1893,  xiti,  1. 

That  a  chronic  anaemia  of  the  substance  of  the  spinal  COfd 
may  give  rise  to  a  paralysis,  especially  of  the  lower  cxircmi- 
ties.  which  may  last  for  years,  seems  probable  according  to  ihc 
thesis  ot  Meunicr  (Paris.  [886),  yet  nothing  certain  can  be  slid. 
especially  as  in  the  cases  in  question  it  may  be  difficult  inei- 
clude  hysteria. 

Just  to  what  cla.s5  we  must  assign  those  instances  of  paraly- 
sis, described  more  especially  by  Russell  Reynolds,  which  de- 
pend on  the  imagination — whether  they  arc  due  to  funciioml 
disturbances  in  the  spinal  cord,  or  whether,  under  the  influncc 
of  psychical  activity  in  consequence  of  auto-suggestion,  a  dis- 
ease of  the  whole  nervous  system  develops — is  not  known. 

The  various  disturbances  in  the  sexual  functions — (of  in- 
stance, the  impotcntia  cncitndi,  which  i.s  quite  a  common  ra*"- 
testation  of  a  functional  disturbance  of  the  sptnal  cord  in  yonnf^ 
and  middle-aged  men — we  shall  enlarge  upon  in  the  chapli' 
on  neura!<tticfiii;i. 


I 


ACUTE  AtYEUnS. 


465 


n.   ISFLAJIMATORV   I'K*)CESSES  IN  THE  SUBSTANCE  OF  THE 
SflNAl.  COKI>. 

/.  t*uruUni  Myditis — Abuess  0/ the  Spinal  Cord. 

Wbile  circumscribed  pus  fonnnlions  in  the  brain  subsrance 
are  by  no  means  rare,  the  (ormaiion  of  an  encapsulated  pus 
(ocuB  in  the  spinal  cord  is  one  o(  the  greatest  exceptions.  Al- 
thougKLeyden  succeeded  in  producing  such  foci  expcrimen- 
tally  in  dogs,  the  clinical  observations  in  man  arc  so  few  that  it 
%*>  impossible  to  lormulatc  from  them  a  dchnitc  symptoma- 
tology- Pathologically,  it  is  interesting  to  note  lliat  Ollivier 
and  Jaccoud  (quoted  by  Lcyden,  loc.  eit..  li,  205)  have  seen  ab- 
scesses which  varied  in  size  from  that  of  u  bean  to  that  of  a 
ha/el-nut  and  were  filled  with  a  grcenish-whitc  pus.  They 
were  situated  some  in  the  cervical,  some  in  the  dorsal  cord. 
The  symptoms,  on  the  whole,  were  those  of  a  grave,  acute  soft- 
ening. In  an  article  by  Ullmann  (Zeitschr.  f.  klin.  Med.,  1889, 
xvi.  3.  page  39)  an  interesting  discussion -on  .ipinal  abscesses 
and  an  exhaustive  collection  of  references  wiSl  be  found. 

2.    The  NoN-fiuriiUnt  Myelitis. 

Inflammatory  pnKcsscs  in  the  spinal  cord  are  very  fro> 

quent.     In  the  majority  of  cases  they  are  ol  a  chronic  type 

and  less  often  acute.    With  reference  to  their  situation,  we  have 

already  stated  that  ihey  may  implicate  the  white  as  well  as  the 

gray  matter. 

A.  Thr  Acute  Form. 

As  we  said  on  page  449.  we  have  in  acute  myelitis  a  process 
which  is  characterise*!  by  the  death  of  the  nerve  elements  and 
n  secondary  increase  of  the  connective  tissue.  In  (he  acute 
stage  a  change  in  the  consistence  of  the  cord  takes  place  ;  the 
parts  become  softened  and  appear  swollen  and  Infiltrated.  Sec- 
lions  of  the  cord  arc  not  so  distinct,  and  the  demarcation  be- 
tween the  white  and  gray  matter  is  less  sharp.  The  color  may 
be  reddish  (hiemorrhauic).  yellowish-red.  rusty  brown,  whitish, 
or  of  any  intermediate  shade.  The  extent  ol  the  process  of 
«ottening  varies.  It  may  be  spread  over  the  whole  or  only  a 
pmrt  of  the  cross-section,  and  may  extend  longitudinally  for  a 
greater  or  less  distance.  Sometimes  disseminated  loci  are 
found  not  only  in  the  cord,  but  can  also  be  demonstrated  in  the 
brain.     We  shall  speak  about  these  later. 

In  exceptional  cases,  which  are  difficult  Id  explain,  abso> 


466 


DtSSASES   OF  SUBSTA.VCE   OF  SP/.VAL   COSO. 


lutely  no  changes  were  found  at  the  autopsy,  although  itic 
course  of  the  disease  seemed  in  every  way  to  suggest  iin  acute 
lesion.  These  pntionts  were  (or  the  most  part  young,  and  up 
to  the  time  of  their  illness  vigorous  persons.  After  a  short 
prodromal  stage,  in  which  there  were  headache  and  some  (ever, 
ihcy  were  attacked  by  a  flaccid  paralysis  of  both  legs,  which 
developed  in  a  few  days.  To  this  was  added  in  a  very  short 
while  paresis  of  both  arms,  so  that  the  helplessness  of  the  pa- 
tients reached  an  unusual  degree.  The  condition  of  the  reflexes  _ 
and  the  electrical  excitability  varied  in  the  few  cases  reported  \ 
up  till  now.  According  to  the  records,  the  functions  of  the 
bladder  and  rectum  as  well  as  sensibility  remained  normal 
The  prognosis  is  very  doubtful.  Sometimes  bulbar  symptoms 
appear,  and  the  patient  dies  within  from  eight  to  fourteen  days 
after  the  onset.  Sometimes  the  course  is  more  protracted  and 
some  improvement  occurs,  which,  however,  is  never  coniplete. 
The  affection  which  presents  the  clinical  picture  just  described  is 
called  Landry's  paralysis  (1859),  paralysu  ascetidanlt'  aijiut;  aculc 
ascending  spinal  paralysis,  although  it  is  not  definitely  known 
%vhelhcr  we  actually  have  to  deal  with  a  spinal  affection  and 
not  rather  with  a  very  acute  infectious  peripheral  ncurilis. 
Until  we  possess  the  results  of  a  larger  number  of  anatomical 
examinations  it  is  of  no  use  to  theorize  any  more  about  ibc 
nature  of  the  disease  (cf.  Schultze,  Schwarz,  Bernhardt,  von 
Recklinghausen,  and  Klebs  (who  found  hyaline  tliromboses). 
Mijnch.  mcd.  Wochcnschr..  1890,  52,  pp.  923  ft  sfg). 

With  regard  to  the  a;tiology  of   Landry's  paralysis,  al>ou( 
which  so  little  is  known,  it  is  possible  that  it  may  be  caused  by 
infectious  diseases,  for  instance,  by  whooping-cough  (Miibiusv 
t)(  great  interest  is  the  communication  of  Cursctnnanii  (Vfr- 
handl.  des  fiinften   Congresses  (tir  inncre  Med.,  Wiesbaden. 
1886,  p.  469),  in  which  he  speaks  of  a  case  of  acute  asceixfinj 
paralysis  where  at  the  autopsy  typhoid  bacilli  were  found  io 
the  spinal  cord.     U  may  also  develop  in  the  course  of  perni- 
cious ana>mia  (cf.  also  Minnich,  Zeitschr.  f.  klin.  Med-.  tSpi. 
xxi.  t.  3). 

The  symptomatology,  diagnosis,  and  treatment  o(  ac" 
Rtyelitis  have  been  discussed  on  pages  450  to  456. 


LITERATURE. 

Sctiuliz^.    n«rlin«r  klin.  Wocheiischr.  1883,  y^ 
tlofTmann.     Arch,  f.  Psych,  unii  Ncrxcnkrankh..  1884.  xr, 


14OL 


spfXAL  rcvoxs. 


467 


iBtmhardl.    ZeilcchT.  f,  kirn,  Med..  1886.  p.  391. 

I^ilrcs  Fi  VAillard.     Arch,  de  phyKiol.  norm,  ct  pathol.  Kvr.  r887,  p.  149, 

>ixon  Mann.     British  Med.  Jouin..  Maich  16,  188;. 
Flvnuiow.     Zwci   F9llr  i-on  aculvr  aufstcigcndcr  Spitvalpral.      Ihrtcrsb.  rned. 

Wocbenschr..  1888.  46. 
Schwin.    Zcltschr.  f.  klin.  Med..  18SS,  xtv,  3.  p.  193. 
Woodward.     Rmish  Med,  Joum.,  November  y  1888. 

tNeuwtnk  uiul  Raith.     Zur  pathol.    Anatomic  dcr  Landry'Khen  Uhmung. 
Bcglcr's  Betira^  lur  pailiol.  Anni.  und  allgeto.  PiUhoL,  1S89,  He<t  I. 
Bchmef.     Die  Ijindry'sche  l^mlyse.     Inaug.-ni&K'Tl..  Berlin,  1890. 
Le>'den.     Uebcr  goniwrholMihe  Myelitis.     Z«it5chr.  fur  klin.  Med..  1891,  ku,  ;,  6, 

p.  607. 
Eixcnlohr.    Ueber  primlttc  Alrophie  der  M>gen-  und  Darmschlcimh«ut  tind 

deren    Buiehun^    <u    ichwerrr  AnKmte-  und    Rtickennutrkterkrankung. 

Deutsche  nied,  Wocheniclir,,  1S9:.  49, 
HIavi.     Poliomyelilis  acuta  di&MtnlnaU  (Pjiralysis  Landry).     Arch.  tioMme«  de 

mhL.  1891.  t.  IT.  Kuc.  2. 
ABki.    Zur  Aeliologic  der  Paral.  mc.  aeul«.     ZciWhr.  {.  klin.  Med..  189J.  xxiii 

5.6. 
Lejrdrn.     Multiple  Neuritis  und  aufsieigendc  acute  Paral]rM  nach  InSuaua. 

ZciUchr.  f.  klin.  Med.,  1894.  ixiv,  1,  3. 
Jolljr.    Uebcr  uute3iu(»tci^eii<le  i\ird)y»e.    Berlinef  klin.  Woe hcnschr..  161M.  U. 

II  B.  The  Chronic  Foim. 

Chronic  myelitis  is  much  mure  commonly  observed  than 
the  acute  (orm.  It  is  charncterized  by  the  death  of  the  nerve 
elements  mid  a  consequent  increase-  ol  the  supporting  elements, 
which  gives  to  the  tissue  a  peculiar  firm  appearance  and  con- 
sistence— sclerosis.  That  this  sclerosis  is  (requently  confined 
to  certain  nerve  tracts,  giving  rise  to  the  so-called  "  system-dis- 
Heases,"  we  have  pointed  out  above  on  page440.  On  page  451 
"will  be  found  some  account  of  the  sensory,  motor,  and  trophic 
changes  which  .ire  found  in  these  affections.  It  is  in  all  cases 
of  great  importance  to  look  to  rhe  condition  of  the  reflexes,  as 

■this  may  have  a  decisive  significance  for  the  diagnosis.  The 
disturbances  nf  the  bladder  and  rectum  in  chronic  myelitis  and 
the  treatment  ol  the  disease  have  been  discussed  above. 


IP 


IM.  Spinal  Ti'mors. 
Pathological  Anatomy.  —  In  the  spinal  cord,  just  as  in  the 
brain,  liit-  glioma  is  relatively  the  most  frequent  form  of  pri- 
lary  neoplasm.  What  has  been  said  on  page  289  about  its 
Icvelopment  holds  good  here  also.  The  cervical  and  dorsal 
part  ol  the  cord  seem  by  preference  to  be  the  seat  of  the  gli- 
OOM.  Sarcomata,  which  from  the  onset  present  a  sarcomatous 
nature,  and  gliosarcomnla — that  is,  glioniata  with  unusually 


468 


JJ/SKASES  OF  SUBSTAA'CB  OF  SP/A'AL  CORD. 


marked  proUrcration  of  cells — have  been  observed,  althuugh  but 
rarely  as  primary  tumors.  Angiomatn,  small  reddish,  probably 
congenital  (Virchow)  foci,  have  been  found,  and  Ganguillct  has 
observed  a  cylindroma  in  the  lowest  portion  of  the  spinal  curd. 
Solitary  tubercles  and  syphilomata  arc  much  rarer  here  than 
in  the  brain.  Cnrcinomata  usually  start  from  the  veriebnvKnd 
afterward  spread  to  the  spinal  meninges.  The  secondary 
chanj^es  are,  of  course,  not  nearly  so  well  marked  here  as  thow 
found  in  the  brain,  since  the  spinal  cord  is  in  a  position  lo  ofltr 
greater  resistance  to  the  growth  that  presses  upon  it,  Only 
when  the  tumor  has  reached  some  considerable  size— c.  g.,  tliat 
of  a  hazel-nut — do  symptoms  analogous  to  tht-  so-called  "indi- 
rect symptoms  "  in  the  brain  make  their  appearance. 

.£tiology. — The  astiology  is  absolutely  unknown.  Though 
in  certain  cases  traumatism  has  been  made  rcsjwnsiblc  lor 
gliomata  in  the  spinal  cord,  we  arc  still  in  complete  if^iio 
ranee  about  the  real  cause,  as  we  confessed  ourselves  to 
be  when  treating  of  their  occurrence  in  the  brain.  The  in- 
fluence of  age  and  sex  here  is  the  same  as  in  tumors  o(  lh( 
brain. 

Symptoms.-~If  a  patient  complains  of  persistent  patnsaml 
stiffness  in  Ills  back,  if  at  the  same  time  there  are  found  sensory 
disturbances  in  the  form  of  parivsthesias.  circumscribed  arcv 
of  anaesthesia,  and  motor  disturbances  in  the  form  of  slowly 
but  steadily  progressing  paralysis  o(  one  or  more  extremities, 
the  suspicion  that  a  tumor  of  the  meninges  or  ol  the  cord  itseli 
exists,  is  justifiable.  The  likelihood  is  greater  i(  other  spinil 
affections  can  lie  excluded  and  i<  occasional  remissions  iii  (he 
progress  of  the  disease  can  be  noted.  It  is  true  the  diagnosis 
of  spinal  tumors  always  remains  a  very  difficult  thing,  and  nl 
times,  for  instance,  wc  may  not  be  able  to  definitely  diffcreati- 
ate  a  myelitis  from  a  spinal  tumor.  This  is  easily  understood 
if  wc  consider  that  spinal  tumors  may  give  rise  to  the  most 
varied  clinical  pictures,  according  to  their  position  ami  !i« 
and  according  to  the  greater  or  lesser  involvement  ofibf 
white  or  gray  matter.  There  is  no  doubt  but  that  a  tuax" 
of  the  spinal  cord  may  give  rise  to  symptoms  of  a  comprt*- 
sion  myelitis,  of  labcs,  or  of  a  mycliiis,  and  that  if  it  be  con- 
fined to  one  sidu  it  may  produce  the  symptoms  of  a  BrO"«'' 
S^quard  paralysis.  Roth  (cf-  lit.)  claims  that  loss  of  the  tem- 
perature SL'nsc  is  frequently  observed  in  spinal  glioma,  and  I^' 
this,  combined  with  analgesia,  paresis,  and  muscular  atroptiy- 


SPWAL    TVAfOJlS. 


469 


sufficient  to  settle  the  diag^nosis.  The  considerable  mate- 
rial which  Koth  has  at  his  diKpo»:il  makes  his  monograph  very 
vaUi.nblc.  It  is  only  to  be  expected  that  vaso-molor  us  well  as 
trophic  s)'inptoiii«  should  be  found.     To  interpret  these  must 

pK  IcU  to  the  physician's  skill  in  diagnosis,  upon  which  so  much 
depends  in  the  r<.-cu^nition  of  tumors  of  the  cord.  Sudden 
changes  in  the  spinal  symptoms,  temporary  remissions,  then 
again  sudden  changes  for  the  worse,  sliould  all  be  made  to 
have  ihcir  proper  diagnostic  value.  In  cases  of  well-marked 
paraplegia  d<>ti»rosa,  where  we  have  tearing  ]>ains  in  the  small 
of  the  back,  radiating  into  the  exircmilics,  together  with  atro- 
phy of  the  muscles  of  the  lower  legs,  we  should  always  think 
of  one  or  several  tumors  of  the  cauda  equina.  In  these  cases 
contractures  of  such  severity  sometimes  develop  that  the  heels 

Uoucli  llic  buttocks  (Leyden). 

t      Prognosis. — The  prognosis  depends  upon  the  nature  and 

■lie  seat  of  the  tumor,  although  the  ultimate  outcome  is  always 
unfavorable.  If  the  growth  be  benign  and  be  situated  in  a 
relatively  indiflerent  area,  the  patient  may  last  for  years,  and 
even  enjoy  periods  so  free  from  discomfort  that  he  may  deem 

f  recovery  r)uite  possible. 
Treatment. — The  treatment  can  only  be  of  any  avail  if  sur- 
gical interference — that  is.  excision  of  the  tumot — is  possible. 
IjA  case  o(  this  character  has  been  reported  by  Oowers  and 
plorsley.     An  oval  myxoma  which  had  pressed  upon  the  cord 
was,  after  removal  of  the  spinous  processes  of  the  third,  fourth, 
and  tilth  dorsal  vertebne,  excised,  and  the  patient  recovered 
completely.     Bruce  and  Mott  (cf.  lit.)  diagnosticated  iitfra  vitam 
a  tumor  which,  originating  in  the  fifth  left  dorsal  nerve,  pressed 
upon  the  middle  of  the  dorsal  part  of  the  spinal  cord  :  the  pa- 
tient presented  the  symptoms  of  a  compression  myelitis  and 
died.     At  the  autopsy  softening  with  ascending  and  descend* 
ing  degeneration  was  found.    The  authors  regret  in  their  paper 
not  having  decided  upon  an  extir]>ation  of  the  lumor. 
L      .All  other  means  are  fruitless.     If  there  is  any  suspicion  that 
■the  case  is  one  of  syphilis,  inunctions  with  mercury  ought  tn 
be  given  a  trial. 

UTKKATtlKK. 

iinil  HMvet.     A  Cjisr  of  Tumour  <rf  itie  Cefvic*!  Regloti  of  ll»r  Sjilfle. 
Jciurn.  of  Nptv.  ami  .Men!.  DiM-.)t««,  18)19.  tiv,  p.  llH. 
irr.     A  Coninltuilwi  m  iIm  fjitholofiry  of  Solitary  Tulirrch)  or  the  SpMtl 
Cord.    Joum.  nf  Ncrv.  him)  Mcnt.  l>iiwwv«,  1S90,  xv,  p.  631. 


470 


i>/S£ASES  OF  SUBSTAA'CE  OF  SPtffAL  CO/ID. 


Laqu<rr.     Uebcr  Compression  drr  Cauda  rquina.     Neurol.  Ccitinlbl.,  1891,7. 

(LymphiinKioma  Cavemoxum  Out.Mflc  of  (he  Dura  ;  Kenxn'ol.) 
Culentiurg.      Jteiu^g  tu  ticn    KrkcutikuncL-n  ilea  Coiius  n>edullaris  and  Aa 

Cauda  cquinn  bcim  Wcibc.     Zeiischr  I.  klin.  Med..  1891,  xvUL  5.  6. 
Rditi.    Com|>Tcssiun  <ler  Cauda  c(|utna  <luich  ein  Lymphangioma  cavtmosum. 

Operative  Hcllung.    Arcli.  t  klin.  Chir.,  1891.  xUi,  Heft  4. 


APPENDIX.— l'AKASlTf:S  IS  THE  SPINAL  COW). 

About  parasites  in  the  spinal  cord  we  mny  look  in  vain  for 
infonnution  in  the  text-books,  probably  because  their  occur- 
rence is  very  unusual,  and  also  becauiw.  if  they  are  present. 
they  may  not  give  rise  to  any  symptoms.     Out  here  we  ought 
to  make  at  least  brief  merilion  of  the  cysticerci  which  have 
been  found  nut  only  in  the  brain,  but  also  in  the  spinal  cord. 
Leydcn  devotes  only  a  few  words  to  this  subject  in  his  Klinilc 
dcr  RUckcnmarkskrankhcitcn  (1.445):  '■Still  more  rare  [than 
the  cysticerci  in  the  br:iin  ],  and  as  yet  uf  no  clinical  significance 
whatever,  arc  the  cysticerci  which  may  develop  ...  in  the 
adnexa  of  the  spinal  cord,  etc."     I  have  shown  in  a  case  which 
came   to  my  notice,  and  which    I   have  reported  (c(.  lit.),  ihat 
cysticerci  of  the  spinal  cord — there  were  fifteen  or  iwcniyin 
the  dural  sac — may  give  rise  to  symptoms  simulating  those  of 
tabes:  some  clinical  sig^nificance  has.  therefore,  to  be  alirib- 
uled  to  them.     That  the  symptoms  of  spinal  irritation,  whidi 
arc  associated  with  such  parasites  in  Ihe  cord,  are  not  to  t>e 
attributed  to  the  incre.ised  intraspinal  pressure,  but  that  ilie; 
are  of  a  reflex  nature,  seems  beyond  doubt.     To  diagnos-licMe 
intra  vititM  the  existence  of  intraspinal  parasites  is  only  posi)()ic 
in  exceptional  cases,  as,  for  instance,  if  the  patient  is  a  bulchtr 
b)'  trade,  or  if  his  frequent  indulgence  in  raw  meat  gives  riw 
to  the  suspicion  of  cysticerci:  but  even  in  the  most  lavonhle 
cases  the  diagnosis  can  not  claim  to  be  more  than  conjectural- 

Almost  as  rarely  do  we  find  echinococci  in  the  vcrteb''' 
canal.  A  case  of  this  nature,  however,  which  is  ol  a  groi 
d«al  of  interest,  has  been  published  by  Jaenicke  (c(.  lit.).  A» 
echinococcus,  which  had  existed  in  the  subpleural  tissue  in  y^ 
region  between  the  ninth  and  the  twelfth  dorsal  vertebra,  l)cn^ 
traled  into  the  vertebral  canal,  and,  owing  to  the  compros* 
thus  exerted  upon  the  spinal  cord.  g,A\i'  rise  to  such  cbaractc- 
tstic  symptoms  that  the  diagnosis  intra  vifaw  was  to  a  certW 
degree  justifiable.  More  recently  Friedeberg  has  reportctl  a 
case  of  this  kind  in  (he  Ccntralbl.  t.  klin.  Med.,  1893.  xiv.  s<- 


V.  CUNtiGNITAL  DISEASJ:S — MyHRORRIIACIIIS — SpIKA  BtFlDA. 

To  a  collection  ol  fluid  in  Ihc  skull  we  have  given  ihe  name 
i^-druccphalus  (page  JoS) ;  sitnilurl}'  a  like  culli-ction  in  the 
rertebral  caoal  we  call  liydrorrhachis,  and  specify  two  forms  ol 
he  disease — the  hydroirhachis  externa  and  interna — accord- 
Dff  as  ilie  fluid  is  situated  in  the  meshes  ol  the  pia  or  between 
Jic  meninges,  or,  on  the  other  hand,  in  the  interior  of  lite 
ipinal  cord.  In  the  latter  case  we  find  a  dilatation  of  the  ccn- 
ral  canal,  which  is  either  uniform  throughout  or  beaded. 

At  the  autopsy  we  not  rarely,  instead  ol  the  normal  central 
banal,  the  ordinary  diameter  of  which  measures  from  one 
enth  to  one  millimetre,  lind  a  canal  with  a  diameter  of  two, 
ve.  or  even  ten  millimetres  ("  hydromyelia  ").  or  alongside  of 
he  usual  canal  abnormal  cavity  formations ("  syringomyelia  "); 
luring  life,  on  the  other  hand,  such  conditions  are  by  no  means 
lltet)  cot;reclIy  recognized.  The  practical  significance  of  these 
bnormities  is  not  great,  as,  for  one  thing,  the  signs  during  life 
re  so  uncertain  and  changeable  that  a  correct  diagnosis  has 
llmost  to  be  regarded  as  accidental,  and,  secondly,  because  the 
disease,  even  if  rccoj^nized.  is  not  at  all  accessible  to  any  ircat- 
nent.  Notwithstanding  this,  it  is  of  course  desirable  that  the 
treitent  state  of  our  knowledge  of  hydromyelia  and  syringo- 
yelia  should  be  given  briefly  here. 

With  reference  to  the  origin  of  hydromyelia.  it  is  more  espe- 
ia\ly  abnormities  in  development  which  we  have  lo  dc.il  with, 
nd  rarely  does  the  influence  ol  pressure — e.  g.,  a  tumor  in 
be  posterior  fossa  of  the  skull— Kxime  in.  For  the  devch>p* 
lent  of  syringomyelia,  central  gliosis,  with  secondary  disinte- 
nition  and  cavity  formation,  is  said  to  play  an  important  part 
Fr.  Schultzc).  It  has  recently  been  doubted  that  congenital 
cvclopmental  anomalies (L/Cvden.  Kahler  and  Pick,  StrilmpeU, 
Jid  others)  are  necessary  for  the  occurrence  of  the  alteration, 
toscnbach  and  Schtschcrback  (Virchow's  Arch..  1S90.  csxit, 
left  I )  have  shown  cstperimentally  that  cavities  may  develop 
)  compression  myelitis  as  a  result  ol  direct  or  indirect  pressure, 
'hese  cavities  may  connect  with  the  fourth  ventricle,  and  cx- 
end  through  the  medulla  oblongata  as  far  as  the  conus  terint- 
alis.  and  in  a  cross-section  two  or  more  lumina  may  lie  seen. 
They  are  of  varijiblc  lengths,  and  arc,  as  a  rule,  situated  in 
be  lower  cervical,  in  the  donuil  cord,  and  especially  in  close 
roximity  to  the  central  canal,  sometimes  also  in  tlie  i>o«tcnur 


47* 


DISEASES  OF  SVBSTAXCM  OF  SPWAL  COXlt. 


horns.  Their  width  varies  from  a  half  to  ten  millimetres  ;  their 
contents  are  sometimes  watery  and  thin,  sometimes  milky  and 
viscid.  The  relation  of  the  central  canal  to  these  cavities  varies 
so  much  that  no  rule  c:in  be  given  on  this  point.  Id  certain 
instances  it  rcm.iins  intact  in  its  whole  length. 

The  clinical  symptoms  which  are  observed  in  syringomyelia 
were  first  described  by  Morvan  in  1883  under  the  term  ol 
par£sic  analgt-sique  it  panaris :  hence  the  condition  b  some- 
times called  Morvan's  disease. 

There  are,  more  especially,  three  symptoms  which  Rhoutd 
arouse  a  suspicion  of  syringomyelia,  namely,  (1)  localized  mus- 
cular atrophies,  more  especially  in  the  upper  extremities:  (2)8 
widespread,  non-typical  hemiana'sthesia  (especially  analgesia): 
and  (3I  trophic  disturbances  of  the  skin  and  deeper  parts  (whit- 
low, phlegmon),  also  of  the  bones  and  joints,  the  former  breiik- 
ing  more  easily,  the  tatter  showing  a  widening  of  the  capsular 
space,  and  being  covered  with  villi  of  varying  size  and  consist- 
ence which  arc  more  or  less  hypcraimic  (Ssokolow,  Nisscn,  cf. 
lit.).     Extensive  neuropathic  destructions  of  bones  and  jointi. 
which  occur  in  consequence  of  the  analgesia,  arc  met  with 
(Karg).      The  muscular  atrophy  ol  the  upper  extremities  is 
always  associated  with  more  or  less  pronounced  paralysis,  as 
we  might  expect  in  lesions  of  the  anterior  gray  horns.    In  such 
instances  amyotrophic  lateral  sclerosis  or  peripheral  ncurilJi 
mav  suggest  itself  as  a  diagnosis.    The  sensory  changes  are 
readily  explained  by  the  fact  that  the  posterior  commissure, 
Goll's  columns,  and  the  posterior  horns  are  preferably  the  seat 
of  the  affection.     In  one  of  Schlippel's  cases  (Arch.  d.  Heilk.. 
1874.  XV.  p.  44)  general  anaesthesia  was  found.     It  should,  hou- 
ever,   be  said   that  in  many   instances,  instead  of   anxsthcui. 
hypersesthesia  has  been  found,  which  suggested  the  lancinating 
p.iins  of  tabes  (Hoffmann,  Eisenlohr),  and  that  often  all  sensorr 
changes  are  absent,  so  that  even  these  symptoms  are  far  from 
being  pathognomonic.     The  condition  of  the  reflexes  varit-i 
much,  as  does  also  the  appearance  of  trophic  and  vaso-rooti* 
disturbances  under  the  form  of  exanthematous  eruptions,  veii- 
cles,  ulcerations,  erysipelatous  swellings,  etc.,  which  arc  sonK> 
times  present,  sometimes  absent. 

From  what  has  been  stated,  it  is  obvious  that  we  may  n«<i 
with  insurmountable  difficulties  in  attempting  to  make  a  diaf:- 
nnsis  in  cases  of  syringomyelia,  as  has  been  shown,  lor  ex- 
ample, by  Charcot  in  one  of  his  masterly  lectures  (Arch.  iJ* 


I 

i 


Sr/.VA  BIFIDA. 


475 


Neurol..  1891,  xxii,  No.  65).  Toxic  paralyses,  leprous  neuritis, 
I  pachymeningitis  ccrviculis  hypertro[ihia>,  trauma  of  the  spinal 
cord,  even  amyotrophic  lateral  sclerosis  and  tabes,  may  pre- 
sent symptoms  which  suggest  syringomyelia,  and  the  rcsem- 
blnnce  may  be  so  great  that  not  infrequently  the  real  scat  of  the 
disease  may  only  be  discovered  at  the  :iutupsy. 

Sumcwiiat  related  to  these  dilatations  of  the  central  canal 
are  those  congenital  cystic  tumors  which,  penetrating  through 
the  walls  of  the  vertebral  column,  make  their  appearance  below 
the  skin  on  the  back.  U  the  cyst,  the  size  of  which  may  vary 
'  from  that  of  a  walnut  to  (hat  of  a  man's  list,  is  situated  in  the 
'  middle  line  over  the  sacrum,  it  is  called  a  sacro-tumbar  myelo- 
meningocele, or  spina  bifida.  The  skin  over  the  tumor  is  cither 
normal,  or  the  seat  of  a  hypertrichosis;  the  latter  is  the  case  in 
spina  bifida  occulta  (Joacliimsthal,  Berlin,  klin.  Wochcnschr., 
1S91.  22;  Jones,  Brit.  Med.  Journ..  1891,  p.  173;  Bariels.  Bcr- 
;  liner,  klin.  ^Vochenschr..  1892.  33;  Brunncr.  V'irch.  Arch.,  cxxix, 
p.  246;  Joachimsthal,  Virch,  Arch.,  1S93,  cxxxi.  p.  488).  Below 
the  skin  arc  found  the  bulging  dura  and  arachnoid.  The  con- 
tents of  the  sac,  which  has  sometimes  smooth,  sometimes  rough 
walls,  arc  as  clear  as  water,  and  identical  with  the  cerebro- 
spinal fluid.  The  spinal  cord  is  attached  to  the  inner  wall  of 
the  sax  by  a  broad  tuse.  or  at  its  point  of  entrance  divides  into 
several  strands  which  pass  directly  into  the  wall  of  the  cyst. 
^Thc  coexistence  of  a  hydromyelus  with  a  spina  bifida,  llie  for- 
mer causing  an  atrophy  of  the  substance  of  the  spinal  cord  and 
I  communication  between  the  central  canal  and  the  cavity  of 
the  spina  bifida,  is  a  rarity. 

I  In  a  child  Ixirn  with  spina  bilida  we  find,  as  we  stated,  in 
the  middle  of  the  back,  in  the  region  of  the  sacrum,  a  soft, 
doughy,  elastic,  not  rarely  fluctuating  tumor,  which  c:>n  be 
made  smaller  by  pressure.  The  position  of  the  child  influ- 
ences the  condition  of  the  sac.  It  is  tense  in  the  erect  posture ; 
when  the  child  lies  down  it  becomes  flaccid  and  soft,  a  fact 
which  must  be  referred  to  the  communication  usually  existing 
between  it  and  the  cranial  cavity. 

Although  the  child  thus  affected  may  at  first  develop  fairly 
rnnrmally,  his  life  is  endangered  from  the  first  moment.     Not 
lonly  doc*  the  pressure  exerted  upon  the  spinal  cord  by  the  in- 
creasing tumor  lead  to  motor  and  sensory  changes,  as  well  as 
blad<lrr  symptoms,  but  there  exists  a  constant  menace  to  life 
)ich  the  rupture  of  the  sac  would  entail,  an  accident  which 


474  DISEASES  OF  SUBSTANCE   OF  SPINAL   CORD. 

is  favored  by  the  gradual  thinning  of  the  overstretched  skin. 
Such  a  rupture  is  almost  always  followed  immediately  by  con- 
vulsions and  death. 

The  EEtiology  is  not  known.  Possibly  we  have  to  do  with 
a  developmental  anomaly,  possibly,  as  Virchow  believes,  with 
an  early  formation  of  partial  hygromata  (hydromeningo- 
cele). 

The  treatment  of  spina  bifida  belongs  to  the  domain  of  the 
surgeon.  We  may  either  endeavor  to  get  rid  of  it  by  repeated 
puncture  and  subsequent  injections  of  a  solution  of  iodine  in 
glycerine  (Morton),  or  we  may  content  ourselves  with  method- 
ical compression.  Owing  to  the  danger  of  meningitis,  how- 
ever, the  whole  treatment  should  always  be  undertaken  with 
great  care. 

LITERATURE. 
/.  Syringomyitia. 

Kronthal.     Zur  Pathologic  der  HAhlenbildung  im  Riickenmark.     Neurol.  Cen- 

iralbl.,  1889.  20. 
Miura.     Virchow 's  Archiv,  1889,  cxvii,  3,  p.  435. 
Dejerine.     Soc.  de  Biol,  de  Paris,  Stance  du  25  Janvier,  1890.     (Changes  in  the 

Cutaneous  Nerves  in  Syringomyelia.) 
P.  Rosenbach  und  Schtscherback.     Zur  Casuistik  der  Syringomyelic.     Neural. 

Cen(ralbl.,  1890.  8. 
Uruhl.     De  la  Syrnngomyeiie.     Paris,  1890. 
Holschewnikoff.     Virchow's    Archiv,    1890,    cxix.    Heft    l.      (Changes   in   the 

Peripheral  Nen-es.) 
Frnncotte.     Arch,  de  Neurol..  1890.  56-58. 
JofTroy  el  Achard.     Arch,  de  niM.  e.'(])^rim.,  1890.  p.  540. 
Knrg.     Arch.  f.  klin.  Chir.,  1890,  xli.  Heft  1. 

HofTm.inn.  J.     .Syringomyelic.     Samml.  klin.  Vortr.,  N.  F.,  1891,  20. 
Ssokolijw.     Wratsch.  1891.  23-25.     (Joint  Affections  in  Syringomyelia.) 
Sch.-ifrcr  und   Preisz.      Hydrorayehe   und    Syringomyelie.     Arch,    f    Psych,  u. 

Ner^'enkh.,  1891.  xxili,  t. 
Iiernh:irilt.  M.     Deutsche  med.  Woehenschr.,  1891,  xvii,  8. 
Charcot.     Progr^s  mM.,  1891,  4. 
Charcot,     .^rch.  de  Neurol..  rSgi.  xxii.  No.  65. 
Nissen.     Arch.  f.  klin.  Chir.,  1892,  xliv.  p.  204.     (Joint  Affections  in  Syrins'*- 

myelia.) 
K(i|i])en.     Deutsche  Med.-Ztg.,  1892,  64,  p.  744. 

Oppenheim.  Ibid.,  1892.  97,  p.  1138.  (On  Typical  Forms  of  Gliosis  Spin^li') 
Sihli-singer.  Zur  Klinik  der  Syringomyelie.  Neurol.  Centralbl,  1893.  *».  -"■ 
IkTnliardt,    M.      Liier.ir-histor.    Bcitrag    zur    Lehre   von    der    Syringomj*- 

Deutsche  med.  Wcchcnschr.,  1893,  32. 
Minor.     Arch.  f.  Psych,  u.  Nen'enkh.,  1893,  xxiv,  p.  693. 
Opptnheim.      Ibid.,  1893.  xxv,  2.     (A   Typical  Form  of  Gliosis  Spinalis.) 
Lcilcrc  el  Chapuis.     Gaz.  hebdoiii.  ik  nicd.  el  chir.,  1893,  2.  sir,  xxx,  51. 


SPINA   BIFIDA. 


475 


a.  PaTontis  and  Spina  Bifida. 

Jaenicke.     Ein  Fall  von   Echinococcus  dcs  Wirbelcanales.     Breslauer  5ml, 

Zeilschr.,  1879,  21,  November  7, 
Dullinger.     Die  osteoplast ische  0|«:ration  der  Hydrorrhachis.     Wiener  med. 

Wochcnschr.  1886.  xxxvi,  46. 
V.  Recklinghausen.     Virehow's  Archiv,  1886.  cv,  %,  3. 
Brunner.     Ibid.,  1887.  cvii,  3, 
Hirt.     Ein  Fall  von  Cysticerkcn  im  Riickenmarke.     Berliner  klin.  Woctienschr,, 

1887.  3. 
V.  Recklinghausen.     Unlersuchungen  iiber  Spina  bifida.     Virehow's  Archiv, 

1887.  105,  pp.  243,  275. 
Holt.     Remarks  upon  Spina  Bifida.      New  York  Med.  Joum..  November  5, 

1887. 
Bland  Sutton.     On  Spina  Bifida  Occulta  and  its  Relation  (o  Ulcus  Perforans 

and  Pes  Varus.     Lancet,  July  1,  1887,  ii. 
Beneke.     Fall    von    unsymmetrischer    Diastetnato-myelie    mit    Spina    bifida. 

Leipzig.  1888,  Festschrift. 
Wichmann.     Wiener  med.  Wochenschr.,  1888,  24,  p.  837. 
Ribbert.     Beiirag  zur  Spina  bifida  occulta  lumbo-dorsalis.     Virehow's  Archiv, 

1893,  cxKxii,  Heft  %. 
Scholl.     Fall  von  Spina  bifida  occulta  mit  Hypertrichosis  lumbalis.     Berliner 

klin.  Wochenschr.,  1894,  ;, 


DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 


I\  diseases  of  the  general  nervous  system,  the  brain  and 
spinal  cord  and  the  nerves  which  come  off  from  them  all  share 
in  the  morbid  process,  yet  the  extent  to  which  the  different 
parts  are  implicated  varies  very  much  in  different  cases.  Some, 
times,  in  so  far  as  clinical  symptoms  would  lead  us  to  con- 
clude, the  trouble  lies  mostly  in  the  brain,  sometimes  in  the 
spinal  cord.  In  the  latter  case,  again,  we  may  have  a  more 
marked  implication  of  the  substance  of  the  cord  itself,  lesions 
of  certain  tracts,  or  perhaps  the  lesions  of  the  peripheral  spinal 
nerves  mav  come  more  into  the  foreground.  Between  such 
extremes  there  exist  manifold  intermediate  forms,  but  to  say 
much  about  the  course  of  these  diseases  which  would  be  appli- 
cable to  ail  becomes  all  the  less  possible  because  a  second 
point  has  to  be  taken  into  consideration,  namely,  whether,  and 
if  so  how  far,  the  whole  orf^anism  shares  in  the  disease  of  the 
nervous  system.  This  [jarticipation  varies  in  many  ways,  and 
there  arc  diseases  of  the  general  nervous  system  which  can  ex- 
ist [or  years  without  any  serious  implication  of  the  general  or- 
ganism :  while  there  are  others,  and  these  are  far  more  numer- 
ous, ill  which  sooner  or  later  the  nervous  disease  grows,  as  it 
were,  into  a  general  disease,  in  which  the  organs  which  have  to 
do  wilh  digestion,  circnialion,  secretion,  excretion,  sometimes 
even  respiralion,  are  affected  more  or  less  seriously.  That  the 
course  of  the  disease  and  the  prognosis  must  sometimes  be 
materially  influenced  by  this  we  need  not  say,  and  one  rule  is 
forcibly  impressed  npon  ns  by  such  cases,  a  rule  which  must 
never  oc  lost  si!,^ht  of  by  the  physician,  viz..  never  in  a  case  of 
disease  of  the  genera!  nervous  system  to  content  ourselves 
wilh  an  exaniinalion  of  ihe  nervous  system,  but  to  remember 
47*. 


D/SEAfieX  OF  rUH  GENP.ftAI.  .ve.RVOVH  SYSTKM. 


^77 


fiat  the  same  care  must  be  devoted  to  all  organs  without 
exception.  This  rule,  self-evident  enough  to  the  conscientious 
libserver,  we  have  dared  to  <?mpliusize  again  because  ii  is  more 
especially  in  nervous  diseases  that  it  has  been  allowed  t<i  (all 
into  abeyance.  As  to  the  pathology  o(  the  diseases  which  we 
are  about  to  consider,  our  knowledge  is  unfortunately  in  many 
respects  very  scanty,  and  in  mniiy  of  them  no  lesions  at  all 
have  been  found  after  death,  although  the  assumption,  that  in 
llie  majority  of  cases  some  anatomical  changes,  macroscopical 
or  microscopical,  must  have  been  present,  would  appear  to  be 
justifiable.  Unly  for  cerlaiii  of  the  diseases  in  this  category, 
as  tabes,  dementia  |>aralytica,  multiple  sclerosis,  and  cerluin 
chronic  intoxications,  have  anatomical  changes  been  dennm- 
^Iratcd.  and  even  here  we  are  not  always  clear  about  their 
significance.  Again  and  again  it  has  happened  that  after  an 
accurate  analysis  <»f  the  clinical  symptoms  a  diagnosis  hits  been 
made  intra  vttam  and  this  and  that  anatomical  change  has  been 
rcckuncd  upon  with  certainty,  and  then  at  the  autopsy  the 
whole  nervous  system  was  found  to  be  abM)lutely  intact. 
Among  such  cases  we  may  mention  that  of  Westphal,  where 
a  niulliple  sclerosis  w,-is  diagnosticalctl  :  that  ol  Killian.  a  sup- 
posed chronic  myelitis,  a  certain  rase  of  ophthalmoplegia  ex- 
terna progressiva  ol  Eiscniohr  and  an  apoplectic  bulbar  pa- 
nlysis  of  Senator  (Neurol.  Centralbl.,  1892,  6).  Instead  ol  the 
pathological  condition  expected,  the  brain,  spinal  cord,  and 
Ibeir  nerves  were  found  to  be  absolutely  normal.  On  the  other 
hand,  it  has  happened  that  where  hysteria,  epilepsy,  or  chorea 
had  been  diagnosticated  and  one  had  prophesied  most  confi- 
dently that  the  condition  of  the  central  nervous  system  would 
be  found  normal,  the  autopsy  has  shown  extensive  changes — 
multiple  loci  in  the  spinal  cord  or  in  the  brain  cortex,  recent 
or  old  areas  o(  softening,  etc.  To  such  errors  even  the  most 
reliable  observer  is  exposed,  and  it  is  just  the  man  who  has 
observed  accurately  the  greatest  number  of  cases  and  assisted 
at  the  post-moriem  examination  of  them  who  will  be  most  cau- 
tious in  his  diagnosis  and  in  his  prophecies  as  to  what  will  prob- 
ably be  found  at  the  autopsy. 

Uncertain,  then,  as  is  the  condition  ol  our  pathological 
knowleilge  in  these  cases,  still,  if  we  decide  to  treat  ol  diseases 
ol  the  general  nervous  system  not  simply  one  after  the  other, 
but  to  adopt  some  arrangement  into  groups,  it  is  best  lo  base 
Itiis  in  a  general  way  on  the  conditions  which  we  find  alter 


478 


DISEASES  OF   THE   GENERAL   NERVOUS  SYSTEAf. 


death,  and  to  distinguish  two  classes,  the  first  including  those 
nervous  diseases  in  which  up  to  the  present  time  no  anatomical 
changes  have  been  demonstrated  at  the  autopsy,  diseases  which 
we  therefore  call  functional  neuroses  ;  the  second,  those  dis- 
eases which  are  always  associated  with  known  anatomical 
changes. 


PART   I. 


.jy/SSASES  OF  THE  GENERAL  NERVOUS  SYSTEM 
WITHOUT  ANY  RECOGNJIABI.E  ANATOAflCAt 
BASIS. 

■*  Functional  Neukoses." 

In  almost  all  affeclions  which  belong  to  this  group  the  so- 
called  individual  predisposition — that  is.  the  personal  inhciiicd 
[>eculiarities— play  a  jiromiticiit  rSli\  and  In  X\\\s  connection  the 
careful  studies  of  Anton  {Wicn,  Iliildcr.  1890)  ujion  the  con- 
genital diseases  of  the  nervous  system  are  ol  undoubted  value. 
Nevertheless,  it  must  be  said  that  in  many  of  these  cases  no 
anatomical  changes  whatever  have  been  discovered.  In  pres- 
ence of  ttie  number  of  these  conditions  it  would  seem  desirable 
to  divide  them  into  smaller  groups,  an  undertaking,  however, 
that  presents  the  greatest  difficulties,  because  any  classification 
I  must  always  appear  to  a  certain  extent  forced.  But  inasmuch 
as  no  ]>athological  anatomy  enters  into  the  question,  it  may, 
for  practical  purposes.be  justifiable  to  group  these  affections 
according  to  the  influence  which  the  neurosis  exercises  upon 
the  general  condition  o(  the  patient.  It  will  be  found  that 
while  some  of  them  (though  these  cases  are  lew)  disappear 
after  running  a  shorter  i>r  longer  course  without  leaving  be- 
hind them  any  bad  effects,  or,  even  when  they  last  for  years. 
never  entail  serious  general  symptoms,  there  arc  others  which 
are  characterized  not  only  by  their  long  duration,  their  obsti- 
nate resistance  to  treatment,  and  their  tendency  to  recur,  but 
also  by  the  baneful  influence  which  they  exert  on  the  general 
system.  The  former,  for  the  sake  of  brevity,  we  shall  desig- 
nate as  mild,  the  latter  as  grave  neuroses,  although  we  do  rir>t 
mean  to  exclude  the  possibility  that  now  and  again  among  the 
ordinarily  mild  ly|>es  we  may  encounter  a  serious  disease  run- 
ning a  tedious  course,  while  among  the  grave  forms  we  may 
have  cases  of  far  less  severity  than  usual. 

459 


48o         D/SEASES  OF   THE   GENERAL   NERVOUS  SYSTEM. 

A  further  classification  might  be  made  according  to  the 
symptomatology.  It  is  true  that  the  symptoms  present  so 
many  variations  that  it  appears  difficult  to  arrive  at  any  prin- 
ciple according  to  which  we  can  conveniently  group  the  dis- 
eases, despite  the  fact  that  in  some  cases  the  symptoms  point 
rather  to  a  cerebral,  in  others  more  to  a  spinal  affection.  Nev- 
ertheless, since  we  find  that  in  some  cases  the  motor  nerves,  in 
others  the  sensory  nerves,  and  again  in  others  the  trophic 
nerves,  are  pre-eminently  implicated  in  the  morbid  process,  we 
may  for  the  present  utilize  this  fact  in  the  arrangement  of  our 
groups.  It  is  scarcely  necessary  to  state  that  we  are  in  no 
wise  satisfied  with  this  classification,  and  look  upon  it  only  as  a 
temporary  makeshift,  to  be  superseded  as  soon  as  some  better 
method  shall  have  been  discovered. 


FTRST   CROUP. 


ATEt/Jtoses  WHICH  are  wq.\t  to  kvx  their  covrse  with. 

OUT    ANY    F.SSEXTIAL    IHPUCATIO.V    OF     THE    GRNEEAI. 
OKGAXISM. 


A.  AFFECTIONS  IN  WHICir   THE  MOTOR   NERVES  ARE 
CHIEFLY  IMPLICATED. 


I 


I 


CHAPTER   I. 

CHOREA — CHOREA  ST.  VITI — ST.  VITVS's  DANCE— RAI.l.l»UUS — UllLAK- 
CHOLIA   SALTAKS— SYDF.KKAU'h    DlftF.ASK. 

The  term  chorea  no  less  ihan  epilepsy  is  often  too  loosely 
.ippIicH.  A  person  may  suffer  from  cht>rc.i.Iike  motor  disturb- 
ances wiilioul  having  genuine  chorea.  Various  cerebral  and 
ipinal  affections  are  capable  of  producing  such  symptoms:  but 
a  careful  observer  will  rarely  find  difficulty  in  deciding  whether 
they  arc  the  outcome  of  a  functional  neurosis  or  of  anatomical 
lesions  in  the  central  nervous  system. 

By  chorea,  in  the  sense  in  which  tlic  term  will  I>e  used  here, 
we  mean  a  functional  neurosis  churncterized  by  the  occurrence 
of  peculiar  irregular  movements  entirely  beyond  the  control 
of  the  patient.  They  appear  in  the  upper  extremities  and  in 
the  face,  as  well  as,  though  to  a  lesser  extent,  in  the  lower  ex- 
tremities and  in  the  trunk.  They  attack  only  the  voluntary 
muscles,  and  may  persist  for  days,  weeks,  and  even  months 
uninterruptedly,  escept  during  sleep.  If  these  movements,  as 
is  f  retiiiently  the  case,  are  confined  to  one  side  only,  to  one  half 
of  the  face,  to  one  arm  and  the  corresponding  leg,  we  speak 
of  a  hcmichtirea.  The  distinction  which  is  made  in  some  of 
the  older  books  between  chorea  major  and  chorea  minor  has 
become  superfluous,  since  the  symptoms  which  were  formerly 
described  as  constituting  the  clinic:d  picture  of  chorea  major 
do  not  represent  an  independent  disease,  but  belong  to  the 


483 


mSEAsaS  OF  TUB  GENERAL  NEfiVOVS  SYSTEM. 


domain  of   hysteria.     Ilcncc  we  can  also  dispense  will]   (he 
(Icsignalion  "  chorea  minor." 

The  "choreic "  movements  may  appear  independently 
where  it  is  impossible  to  find  any  coexisting  symptorus  ol 
another  disease,  or  they  may  be  no  more  than  symptoms  of 
another  afieclion,  be  it  of  the  brain  or  spinal  cord.  Our  exam- 
ination will  have  to  decide  between  these  two  possibilities. 
Wc  shall  deal  here  only  with  the  idiopathic,  genuine  chorea, 
and  we  need  hardly  say  that  only  this  form  is  to  be  regarded 
as  a  mild  neurosis  in  the  sense  pointed  out  abo%'e. 

Symptoms. — To  describe  the  choreic  movements  in  detail 
is  not  easy,  because  they  present  very  many  variclics  in  de. 
gree  and  extent.  In  the  relatively  severe  cases  all  the  muscles 
participate,  the  head  is  thrown  about  and  shaken,  the  neck  U 
twisted,  the  forehead  is  wrinkled  and  smoothed,  the  eyelids 
closed  and  opened,  and  the  eyeballs  rolled  around.  The  facial 
muscles,  including  those  of  the  lips  and  the  mouth,  t-ike  part  iii 
the  movements,  thus  giving  rise  to  the  most  varied  expressions 
—t.  g.,  those  of  terror,  an\iely,  or  joy^accordiiig  to  the  par 
ticular  muscles  most  strongly  affected,  llassc  slates  that  the 
lip  ol  the  nose  may  be  moved,  though  I  myself  have  never 
seen  this.  Very  conspicuous  arc  the  movements  of  the  tongue 
muscles,  since  they  interfere  wilh  speiiking,  chewing,  swallow- 
ing, and  with  the  protrusion  of  the  tongue,  which  in  the  worst 
cases  become  entirely  impossible.  If  the  muscles  connected 
with  the  (unction  of  respiration  arc  affected,  disorders  in  breath- 
ing arc  encountered;  the  implication  of  the  muscles  of  the 
trunk  gives  rise  to  rotatory  and  other  involuntary  movements 
of  the  body ;  the  patient  rises  and  falls  down  again,  and  may 
work  himself  into  the  most  peculiar  and  marvelous  positions 
("/t»/iV-  Hes  muscifs"). 

In  the  great  majority  of  cases  the  movements  d<»  not 
lake  place  in  the  way  wc  have  described,  except,  perhaps, 
the  twitchings  of  the  face,  but  are  confined  to  the  upper  ex- 
tremities, or  are  at  any  rate  most  marked  here.  Shoulden, 
arms,  and  fingers  arc  constantly  in  motion,  the  affected  mus- 
cles twitch,  the  arms  arc  extended  and  flexed,  the  fingers 
spread  apart,  and  so  forth.  A  similar  restlessness  is  observed 
in  the  muscles  of  ihc  thigh  and  caif,  the  feet  arc  alternately 
lifted,  the  toes  moved,  although  the  lower  extremities  are  g«i- 
crally  attacked  to  a  lesser  extent.  Sometimes  the  movements 
are  gone  through  with  lightning  quickness,  in  which  rare  in- 


SYMProATS  Of  CHOKE  A. 


483 


to  i 
■  how 


stances  the  nntne  chorea  electnca  is  juslifiabie.  In  milder  cases 
the  patients  m;iy  at  times  be  able  to  remain  perfectly  quiet,  and 
only  slight  twiichings  in  tbe  arms,  the  fingers,  perhnps  also  tn 
ihc  facial  muscles,  will  betray  the  existence  of  the  disease.  It 
is  A  characteristic  feature  of  idiopathic  chorea  that  all  move> 
ments  entirely  cease  when  ihc  patient  is  asleep,  although  going 
to  sleep  tniiy  be  rendered  somewhat  difficult.  Once  asleep, 
however,  such  patients  rest  C]uicrly,  and  are  not  disturbed  by 
muscular  utiresl. 

That  the  intended  movements  arc  influenced  by  the  patho- 
logical ones  goes  without  saying,  and  it  is  quite  possible  that 
at  a  lime  when  the  disease  is  slill  at  (ts  beginning  and  has  not 
yet  been  recognixed,  but  is  already  exerting  its  intUience  upon 
the  voluntary  movements,  the  patient  may  be  simply  regarded 
as  awkward  and  clumsy.  II  this  happens  to  children  who  have 
to  write  in  school,  or  recruits  who  have  to  drill  and  learn  the 
diUcrcnt  manipulations,  much  unpleasantness  for  the  patient 
may  arise  from  this  condition,  which  might  have  been  avoided 
by  a  carelul  examination  by  a  physician.  Generally  the  vol- 
untary movement  is  normal  in  its  lirst  phase,  but  soon  the 
muscles  begin  to  be  seized  by  the  spasms  and  ihe  patient  is 
not  able  to  carry  out  the  movement  intended.  This  is  noticed 
in  dressing;  or  eating,  or  in  other  ordinary  actions  of  daily  life. 
but  most  of  all  is  it  seen  in  writing,  playing  the  piano,  or  in  the 
performance  of  other  movements  re<|uiriiig  a  high  degree  of 
coordination,  and  may  even  be  marked  if  wc  ask  the  patient 
to  put  out  his  tongue. 

His  apparent  awkwardness  excites  the  patient  very  much, 
and  the  more  he  tries  to  execute  the  intended  raovemenl,  the 
more  he  tries  to  govern  his  unmanageable  muscles  in  the  usual 
manner,  the  less  he  succeeds  .ind  the  more  he  is  annoyed  by 
tlie  involuntary  movements.  Only  a  few  particularly  well 
disciplined  patients  arc,  at  the  height  of  the  disease,  able  to 
keep  their  muscles  lor  a  few  moments  at  absolute  rest.  The 
reflex  and  automatic  movements  are  not  interfered  with. 
Protective  movements  arc  performed  as  by  healthy  persons; 
coughing  and  sneezing  arc  dune  normally :  neither  do  the  car* 
diacor  respiratory  movcmcnls  sniTer, 

The  sensibility  is  in  no  way  interfered  with.  Tenderness 
over  Ihespine  may  be  present, although  not  regularly.  Other- 
wise nothing  abnormal  can  be  noticed  in  the  domain  o(  the 
sensory  nerves,     it  is  remarkable  to  note  that  there  is  no  sense 


484        D/SF.AXES  OF  TtlR  CEXEJtAL  ATEXfOVS  SYSTEM.         ■ 

of  fatigue,  which  we  certainly  should  expect  after  such  exces- 
sive muscular  action.  The  body  temperature  and  the  urine 
remain  normal  throughout  the  disease  if  no  complications  are 
superadded.  On  the  other  hand,  the  psychical  condition  of 
the  patients,  especially  if  they  be  young  people,  undergoes 
more  or  less  marked  changes,  which  constitute  a  prominent 
feature  of  the  disease  if  the  course  be  prolonged  ;  children  who 
have  up  to  this  time  been  kind,  obedient,  diligent,  and  willing, 
become  willful,  peevish,  and  spiteful ;  although  learning  nicely 
and  without  difliculty  and  making  good  progress  in  school  be- 
fore they  had  any  symptoms  of  chorea,  they  become  slow  al 
grasping  and  understanding  what  they  arc  taught:  the  easiest 
things  must  be  repeated  and  impressed  upon  ihem,  and  often 
enough  they  are  forgotten  again  in  a  few  hours.  If.  and  this 
is  not  rarely  the  case,  an  impediment  in  speech  is  added  iii 
consequence  of  the  choreic  movements  of  the  tongue,  the  chil- 
dren become  wholly  un5t  for  school.  It  is  at  this  time  no 
longer  necessary  to  advise  keeping  the  child  at  home,  since 
the  teachers  themselves  will  no  longer  permit  it  to  attend. 
The  influence  of  the  disease  upon  the  psychical  functions  is 
generally  much  less  marked  in  adults. 

In  the  idiopathic  uncomplicated  chorea  the  described  mani- 
festations persist  usually  for  several  weeks  with  varying  inten- 
sity. From  the  onset  to  the  cessation  of  the  disease  from  sixty 
to  ninety  days  may  elapse  (sixty-nine  days,  Sfie:  eighty  days, 
JUrgensen;  eighty-nine  days,  Ricckc),  yet,  as  wc  shall  sliow 
later,  the  treatment  is  not  without  inllueuce  upon  its  duration. 
By  far  the  most  frequent  issue  is  recovery,  although  the  possi* 
bility  of  a  relapse  is  by  no  means  excluded,  and  in  giving  a 
prognosis  this  feature  should  be  taken  into  account.  Dcalb 
from  chorea  is  a  very  uncommon  event,  and  occurs  only  in 
very  weakly  children  or  when  complications  arise;  Powell. 
Haiidiord  (Brain,  18S9).  and  others  have  reported  fatal  cases  of 
chorea:  in  most  instances,  however,  wc  are  justified  in  giving 
a  good  prognosis. 

Complications. — The  complications  and  the  relation  that 
chorea  bears  to  other  diseases  deserve  much  attention,  more 
particularly  as  this  rcLitinn  is  to  a  great  extent  still  obscure. 
In  the  first  place,  articular  rheumatism  must  here  be  men- 
tioned, the  connection  of  which  with  chorea  everybody  knowrs, 
but  which,  however,  is  not  interpreted  by  all  authors  in  the 
same  manner.     While  the  French  writers  especially,  among 


SVMPTOMS  OF  CIIOkEA. 


4«S 


I 


1  Sie  and  Roger,  regard  rheumatism  as  an  almost  regular 
precursor  of  chorea,  Ja  Germany  there  is  much  diversity  of 
opinion  on  this  point.  Several  authorities  (Lebert,  Eichliorst. 
Sirllmpcll)  only  !>tatc  that  the  two  affections  arc  relatively  fre- 
quently found  together;  others,  with  Briegcr,  draw  attention 
to  the  alternating  appearance  of  the  two  (I)crlincr  klin.  Woch- 
eiischrift,  1886,  xxiii,  10);  others,  again  (Henoch,  Litten).  look 
upon  rheumatism  as  "the  most  important  and  best-founded 
cause  of  chorea":  while  some,  in  contradistinction  (o  the  rest, 
deny  the  existence  o(  any  connection  between  the  two  affec- 
lions  (Romberg,  v.  Nicmcycr,  Prior).  However  obscure  ibis 
association  may  be.  (o  deny  it  absoliilcly  would  be  to  set  facts 
at  defiance.  According  to  our  own  opinion,  we  have  to  deal 
with  a  common  noxious  agent>  an  infection  which,  if  chiefly 
localized  in  the  brain,  gives  rise  lo  choreic  movements,  while  if 
it  affects  the  joints  it  causes  acute  rheumatism  in  them.  Most 
probably,  we  may  almost  say  unquestionably,  it  is  the  same 
infecli<^us  material  which,  il  afTecling  the  heart,  produces  endo- 
carditis and  myocarditis,  for  chorea  is  as  frequently  connected 
with  valvular  disease  of  the  heart  as  with  articular  rheumatism, 
though  the  one  relationship  is  as  obscure  as  the  other. 

II  chorea,  or,  we  had  better  say,  if  certain  (orms  of  chorea 
are  actually  to  be  traced  to  an  infection,  we  can  not  be  sur- 
prised  if  choreic  movements  arc  found  lo  appear  after  other 
infectious  diseases — c,  g..  whooping-cough,  typhoid  fever,  diph- 
theria, or  cholera. 

The  possibility  that  chorea  has  some  connection  with  epi- 
lepsy can  not  a priori\x,  thrown  aside.  I  have  twice  had  occa- 
sion to  observe  children  who  up  to  the  age  of  puberty  had  re- 
peatedly suffered,  as  it  seemed,  from  genuine  chorea,  and  who 
afterward  became  subject  to  epileptic  attacks.  It  is  true  the 
tongue  was  not  bitten  in  these  paroxysms,  but  otherwise  all 
the  signs  of  a  classical  epilepsy  were  present,  not  excluding  the 
aura.  K  later  communication  of  Marie  ^Progr.  mid..  1886.  xiv, 
p.  39),  in  which  the  occurrence  of  ovarian  hyperarsthesia  in  the 
course  of  chorea  is  mentioned,  led  us  to  the  idea  that  possibly 
the  above-mentioned  attacks  were  of  a  hystertctl  nature,  and  to 
question  whether  there  may  not  be  certain  forms  of  St.  Vitus's 
dance  which  could  be  designated  as  hysterical. 

Lastly,  those  very  rare  cases  of  tropho-neurotic  disturb- 
ances in  chorea  are  of  interest ;  thus,  bald  spots  on  the  skull 
(Escherich.  Mitth.  aus  dor  med.  Klinik  zu  WUrzburg.  188^  ii). 


486 


OiSKASES  OF  TUE  GEXERAl.  XER%'OVS  SYSTEM. 


or  in  places  absence  ol  pigment  in  the  hair  or  the  skin,  were 
noted  (MSbius.  Schmidt's  Jahrb.  d.  gcrichtt.  Med.,  1886,  vd. 
ccix.  p.  251).  How  these  are  brought  about  we  are  utterljr  un- 
able ro  explain. 

Diagnosis.— It  is  usually  not  difficult  to  recognize  chorea  if 
we  remember  that  yoimg  patients  of  the  female  sex,  who  arc 
often  also  anicmic,  form  the  largest  contingent  of  the  cases, 
that  the  twiichings  chieliy  affect  the  upper  extremities  and  the 
face,  and  that  they  arc  entirely  independent  of  the  will  of  the 
patient.  Their  disappearance  also  during  sleep  is  an  impurtani 
point,  and  this  fact  by  itself  would  distinguish  them  from  the 
alhetoid  muvemenls.  These  latter,  possibly  the  twitchings  ol 
the  tic  convulsif,  the  tremor  of  paralysis  agitans,  the  shaking 
movements  of  the  intention  tremor  of  multiple  sclerosis,  finally, 
certain  muscular  spasms,  which  Lcclerc  and  Koyer  {cf.  lit.) 
have  designated  as  pseudo-choreas,  must  more  especially  be 
taken  into  consider.-ition,  but  they  ought  never  to  render  the 
diagnosis  really  difficult. 

Pathology. — Our  knowledge  o(  the  pathology  o(  idiopathic, 
uncomplicated  chorea  is  very  imperlcct.  The  changes  which 
have  been  found  thus  tar  do  not  seem  to  be  essential.  Repeat- 
edly capillary  emboli  have  been  found  at  the  autopsy  in  the 
thalamus  and  the  corpus  striatum,  often  they  could  not  be  dem- 
onstrated (Dana,  Brain,  1S90,  xUx).  The  cxperimcntsof  Money 
on  guinea-pigs  and  dogs  ([.^ncct,  1881;,  I,  p-9S;)  would  indicate 
very  decidedly  that  chorea  can  be  caused  by  capillary  emboli. 
Their  mode  of  action,  however,  remains  unexplained.  The  ob- 
jections which  Litten  has  raised  against  the  embolic  theory. 
that  the  demonstration  of  embolic  processes  in  ordinary  cases 
of  chorea  is  not  proved,  and  that  in  spite  of  the  diversity  ol 
the  localization  of  the  foci  of  softening  in  the  brain  the  clin- 
ical picture  is  always  the  same,  can  not  bt:  regarded  as  cchk 
vincing. 

The  communication  of  Flcchsig,  who  in  the  two  inner  ante- 
rior segments  of  the  lenticular  nucleus,  but  nowhere  else,  found 
small  hodics  in  the  lymph  sheaths  of  the  vessels,  some  of  which 
were  larger,  some  smaller  than  bluod.corpuscles,  has  as  yet 
been  neither  confirmed  nor  overthrown.  "  Their  arrangement 
resembled  that  of  glandular  structures:  thev  were  strongly  re- 
fractive, very  firm,  and  almost  like  chalk,  although  they  con- 
lained  no  lime.  In  alkalies  they  slowly  swelled."  Though 
their  chemical  nature  is  unknown,  they  resemble  in  the  main 


I 


JETIOI.OCY  OF  CUOlie.A, 


487 


I 


thai  malertal  which  von  Recklinghausen  has  termed  "  h^-a- 
line."  This  observation  has  not  as  yet  been  interpreted,  and 
Flechsig  himself  declines  to  ^ive  a  decided  opinion  as  to 
whether  the  bodies  have  been  formed  in  the  blood  or  lymph 
vessels  or  whether  they  have  10  be  rcRarded  as  products  of  de- 
generation  Irom  ganglionic  cells  and  nerve  fibres.  Allhongh 
we  have  10  admit  that  lesions  in  the  lenticular  nucleus  may 
cause  choreic  movements,  we  can  as  yet  make  little  use  of 
these  bodies  as  an  anatomiail  cause  for  the  disease.  Wullen< 
berg  regards  them  as  non-essential  (Arch.  \.  Fsych.,  1891,  xxiii, 
1.  p.  197).  Earlier  observations  ol  conditions  which  were  con- 
sidered as  significant  for  chorea — that  is,  hyperfcmia  of  the 
brain  and  the  spinal  cord,  lesions  of  the  corpora  quadrigemiiia. 
tubercles  in  the  cerebellar  peduncles,  inflammatory  conditions 
in  the  vertebrye.  and  spinal  irritation  resulting  Oicrelrom — pos- 
sess only  historical  interest. 

Although  we  are  then  siill  unable  to  say  anything  definite 
about  the  nature  of  the  disease,  the  assumption  that  we  have 
before  us  an  affection  ol  the  entire  nervous  system,  in  which, 
to  be  sure,  the  brain  takes  the  most  prominent  part,  seems  the 
most  probable.  Whether  certain  portions  of  the  brain  arc  par- 
ticularly qualified  to  produce  choreic  movements — whether,  be- 
sides being  produced  by  irritation  of  the  cortical  motor  cen. 
tres,  they  may  also  lie  brought  about  by  lesions  of  the  basal 
ganglia ;  further,  whether  this  irritation  can  ever  be  attributed 
to  infectious  material,  microbes,  or  the  like,  whether  it  can  ever 
be  connected  with  fungous  growths,  such  as,  for  example,  Nati- 
nyn  has  found  in  the  pia  belonging  to  the  species  of  the  dado- 
thrix  or  leptolhrix,  or  whether  we  have  to  assume  an  autoin- 
toxication, as  in  epilepsy,  urxmia,  etc.  (Duchateau,  Thfrse  dc 
Paris,  1893) — all  these  remain  open  questions,  and  we  must  also 
leave  undecided  whether  or  not  the  alteration  of  the  blo<xl  de- 
pending upon  the  soH^'alled  rheumatic  diathesis  is  sufficient  for 
the  development  of  the  disease. 

Etiology. — Among  the  causes  of  chorea  heredily  plays  an 
important  rdlt,  as  it  does  in  all  diseases  of  the  general  nervous 
system.  This  factor  is  more  important,  since  heredity  can  here 
not  only  be  called  an  indirect  predisposing  circumstance,  ow- 
ing to  which  an  individual  is  more  prone  to  one  or  the  other 
nervous  disease,  but  because  there  exists  actually  a  hcrcditar>' 
form  of  chorea  which  is  handed  down  from  generation  to  gen- 
eration and  which  for  a  great  many  years  may  remain  in  the 


4SS 


D/SE/ISES  OF   THE   CEKERAL   NERVOUS  SYSTEM. 


family.  This  chorea  hereditaria,  or,  as  it  is  also  called,  Hunt- 
ington's chorea,  has  nothing  in  common  with  chorea  but  the 
name  ;  it  is  produced  by  anatomical  changes  which  have  been 
characterized  by  Oppenheim  and  hloppe  as  a  miliary  dissemi> 
naled  cortical  and  subcortical  encephalitis  (Arch.  f.  Psych,, 
1893,  XXV,  3).  It  does  not  come  on  in  childhood,  and  hardly 
ever  appears  before  the  age  of  thirty  or  forty.  It  is  character- 
ized by  peculiar  motor  disturbances  resembling  those  of  alh& 
tosifl  (p.  384),  and  not  rarely  leads  to  pronounced  mental  deteri- 
oration. It  is  incurable.  The  conception  that  it  is  a  progres- 
sive doulilc  athetosis  seems  to  me  worthy  of  consideration  (cf. 
Rcmak.  Neurol.  Centralbl..  1S91.  11,  12;  Krohnthal  und  Kali- 
schcr,  ibid.,  1892,  19:  Greppin,  -Arch.  f.  Psych.,  1892,  xxiv,  1; 
and  others).  There  arc  "chorea  families"  in  which  a  whole 
generation  never  remains  free  from  the  disease,  and  only  cer- 
tain members  arc  exempt.  On  the  other  hand,  there  exists  also 
a  chorea  congenita  (Rau.  Iiiaiig.-I>issert..  Berlin.  1887).  which 
has  to  be  attributed  to  an  affection  of  the  mother  caused  by 
fright,  etc.,  during  pregnancy  (Fox,  liichtcr,  MJlbius.  Oppen- 
hcim).  It  has  long  been  known  that  pregnancy  itself  may  to  a 
certain  extent  predispose  to  chorea,  as  is  shown  by  the  so-called 
chorea  gravidarum.  Age  and  sex  play  a  certain  rSU  among 
predisposing  causes,  inasmuch  as  the  young  and  the  female 
sex  are  especially  prone  to  it.  Among  439  cases,  322  (that  is, 
seventy-three  per  cent)  were  girls,  and  34o(that  is,  seventy-four 
per  cent)  were  between  the  ages  of  five  and  fifteen  ;  411  (thai  is, 
ninety-one  per  cent)  were  between  the  ages  of  five  and  twenty 
(Mackenzie).  In  rare  cases  old  people  become  subject  tochorea 
(chorea  senilis),  The  oldest  of  my  patients  was  cighty-onc,  the 
oldest  of  Mackenzie's  patients  even  eighty-six. 

Among  the  exciting  causes  there  arc  two  kinds  which  arc 
particularly  important — the  one,  psychical  excitement,  partlcw- 
iarly  fright  and  anxiety;  the  second,  frequent  contact  with  In- 
dividuals suffering  from  chorea,  which  awakens  an  impulse  to 
imitate  the  pathological  movements  and  gives  rise  to  what  wc 
then  call  chorea  imit;ituria.  The  latter  Is  far  less  important  than 
the  former.  Epidemics  of  chorea  have  often  been  described: 
Wichniann  has  observed  one  in  Wildbad  (Deutsche  med.  Wo- 
chcnschr.,  1890,  30).  The  lime  which  elapses  between  the  recep- 
tion of  the  noxious  influence  and  the  development  of  the  dis- 
ease usu.illy  comprises  from  five  to  seven  days,  sometimes  only 
one  day.    Sometimes,  again,  the  cflcct  follows  the  cause  immo- 


TREATMENT  OF  CHOKE  A. 


489 


I 

I 
I 


I 
I 

I 


diaiety,  this  being  so  in  ten  per  cent  of  all  cnses  caused  by 
(righL  Besides  Inght.  bodily  or  mental  overexertion,  particii- 
liirly  the  Inltcr,  may  provoke  the  disease.  According  to  Mac- 
kenzie's report,  sixteen  per  cent  of  all  cases  observed  are  at- 
tribiilablc  to  this  cause. 

Treatment. — Cases  o(  uncomplicated  chorea  get  well  with. 
out  any  interference  on  the  part  of  the  physician,  but  the  re- 
sults of  wide  and  varied  experience  have  taught  us  that  with 
certain  measures  we  arc  able  to  cut  short  the  duration  of  the 
disease  to  a  no  inconsiderable  extent.  With  reference  to  the 
internal  treatment  it  is  interesting  to  follow  up  the  different 
phases  and  changes  through  which  this  has  passed  in  the  last 
half  century.  When  the  spinal  c<)r<l  was  suppitsed  to  be  the 
seat  of  the  disease  much  was  thought  of  strychnine,  which  had 
been  recommended  by  Trousseau  and  which  was  administered 
in  the  form  of  a  sirup.  Later,  when  to  the  rheumatic  basis  of 
chorea  a  prominent  place  w.is  given,  colchicum  and  quinine 
were  preferred.  Again,  camphor,  potassium  iodide,  and  hy- 
drocy ante-acid  preparations  were  prescrilied  when  irritation  of 
the  sexual  organs  was  held  to  be  the  starting  point  of  the  dis. 
case.  Venesection,  leeches,  cups  to  the  head  and  along  the 
vertebral  column,  were  employed  for  a  time  on  the  authority  of 
Sydenham.  Alt  these  measures  have  now  more  or  less  fallen 
iiilD  oblivion,  and  even  the  zincum  oxidum  album,  once  so 
warmly  recommended  by  Hufeland,  has  had  to  give  way  to 
cilhcr  remedies.  Among  those  still  valued,  arsenic,  which  was 
introduced  by  Konil>crg,  stands  hrsl.  It  is  best  given  in  the 
(iirm  of  Fowler's  solution,  in  doses  of  from  three  lo  five  drops 
three  times  a  day,  the  dose  being  gradually  increased  to  twenty 
or  thirty  drops  a  day.  The  medicine  ought  to  be  well  diluted 
with  water.  Instead  of  Fowler's  solution  we  might  prescribe 
the  waters  of  the  Ronccgno  or  Levico  springs  in  duses  of  a 
tcaspoonful  to  a  tablcspoonlul  three  times  a  day.  At  the  same 
lime  we  must  be  on  the  lookout  for  intoxication,  which  has 
been  known  to  lie  produced  even  by  small  quantities  of  the 
drug,  as  was  proved  by  a  case  of  my  own.  The  arsenic  treat- 
men!  is  to  be  continued  until  either  the  symptoms  abate  or 
digestive  disturbances  make  their  appearance,  which  would 
contra-indic.ite  its  continuance.  Wc  usually  attain  our  end  in 
from  fifty  to  sixty  days. 

Next  to  arsenic  wc  prefer  the  salicylate  of  physostigminc 
:),  which,  in  the  form  recommended  by  Kiess  i,Uerliner 


490 


DiSHAS/iS  OF  THE  GENERAL  A'EKfOfS  SYSTEM. 


klintschcr  Wocheiischrift.  1887.  22),  may  be  injected  hypoder- 
mically  twice  a  day  in  the  dose  of  one  milligrnmrae  (Vi,  gr.). 
Excellent  results  may  be  obtained  with  this  mode  ol  treatment, 
and  the  duration  nf  the  disease  may  be  reduced  to  thirty  nr 
forty  days.  We  need  hnrdly  insist  that  this  dni^  must  be  ad- 
ministered most  cautiously,  because  cscrinc  poisoning  has  been 
observed  (Loddcrsiiidt.  Berliner  klin.  Wochenschr.  18S8.  17). 
As  soon  as  any  bad  eRccts  begin  to  show  themselves,  such  as 
nausea,  vomiting,  etc.,  it  is  advisable  to  discontinue  the  mcdi> 
cine  at  once  for  a  coiisiderahic  time.  With  regard  to  exalgin, 
so  highly  spoken  ol  by  Datia  (Journal  of  Nervous  and  Mental 
Diseases.  1892,  July),  at  present  i  must  suspend  judgment; 
from  small  doses  I  have  observed  but  little  effect,  while  larf^ 
doses  did  not  seem  to  be  always  well  borne  (c(.  also  Joris. 
Wiener  mcd.  I'rcssc.  1892,  44).  Anlipyrin,  which  has  been  rcc 
ommendcd  by  Legroux  and  others,  1  have  completely  aban- 
doned. The  results  obtained  with  this  drug  arc  uncertain  and 
transient.  We  were  never  able  to  note  cures  within  from  six 
to  twenty-seven  days  with  this  remedy,  such  as  Legroux  has 
reported.  If  Ihcse  medicines  leave  us  in  the  lurch  wr  may  with 
caution  prescribe  chloral,  morphine,  opium,  under  the  influence 
of  which  the  movements  may  temporarily  abate. 

Among  other  measures  we  may  mention  the  use  o(  cold 
water  and  electricity,  which,  although  only  ol  secondary  im- 
portance, may  not  be  without  good  effects.  We  have  in  differ- 
cnt  places  spoken  of  the  cold-water  treatment,  and  wish  again 
to  repeat  here  that  extremely  low  temperatures  arc  unneces- 
sary, but  that  hip  baths  of  84*  F.,  with  cold  affusions  (o  the 
back  (81°  lo  7;"  F-)  and  wet  packs  seem  sufficient.  In  the  elec- 
trical treatment  the  constant  current  is  chiefly  to  be  used,  whicli 
is  made  to  .tct  alternately  upon  the  brain  and  the  spinal  coni 
(Hirt.  /w.  cit.,  p.  i8r). 

Sometimes  all  these  means  of  treatment  which  wc  have 
just  described  arc  ineffectual.  The  patients  lake  medicine, 
undergo  the  cold-water  treatment,  etc.,  and  no  improvement  k 
noticeable,  fn  such  instances  a  change  of  climate  is  to  be 
recommended;  the  patient  may  be  advised  to  travel,  and  be 
kept  away  from  his  family  for  some  time;  excitable  indivul- 
uals  especially,  in  whom  psychical  influences  increase  the  motor 
irritation,  are  to  be  secluded  as  much  as  possible.  Visits  nf 
friends  or  members  of  the  lamily  should  be  interdicted.  Chil- 
dren should  be  kept  away  from  school,  and  should  be  spared 


I 
I 

I 
I 


TflEA  T.VEXr  Of  CHOKEA. 


49' 


•ny  mental  exertion.  Even  at  home  ihey  should  not  be  made 
10  work :  they  should  be  encouraged  to  suppress  the  move- 
ments as  much  us  possible,  and  a  !-ni;i)l  reward  should  be  prom- 
iscd  if  (hey  succeed.  In  this  manner  olten  a  good  deal  is  at- 
tained. Only  in  exceptional  cases  need  the  patient  be  in  bed 
for  any  length  of  time — namely,  if  the  twitchings  arc  very  vio- 
lent and  likely   to  lead   to  bodily    injury.     In  such   instances 

[the  use  of  narcotics,  as  suggested  above,  becomes  more  espe- 
cially warrantable.  We  shall  later  have  occasion  to  S|>eak  of 
the  treatment  by  suggestion;  the   results  obtained   with   this 

rmethod  arc  somclimes  quite  satisfactory. 


LITERATURE. 


^ _..,. 

V  Vauitch.     £iudF  sur  ti-s  chor^i-s  dcv  aduliet.    Thi*e  de  I'arit,  1S83. 

Prlpcr.    Chorea  bcl  Typh.  abdom.     DcutschcninL  WocliciiKhr.,  1885.  8. 

tOickinMxi.    On  Chores,  wiih  Rcfcrtncc  10  its  Suppotcd  Origin  in  Emboltm). 
Luicct.  January  1,  1S86. 
Liiten.    DelirSgc  xur  Anlolugie  drr  Chonra.    Chariif-Annal..  1S86.  xi.  p.  365. 
llirnhaum.      t'cbcr  ilie  Chorea  tier    F.twachkrnriv.     Inniig.-DiiscR..   Berlin. 
K         1886. 

BHawkiflt.    Charm  and  Epilepsy,     t.ancct.  Jnnuary  i.  1886. 
HiLandois.     DeuiKlicniod.  WochaL^chr.,  1KK7.  31. 

BiMackmiic  Kr|Mn  on  Chortn.  lint.  Med.  Joum..  Fi^bniary  >6,  1887.  <R«. 
H  pon»  (>f  the  Colkcilve  InvMtigation  Comnilucc  of  ihc  British  Medical  As- 
^       Mcbiion.) 

Koch.  P.    7.\a  [.chrc  von  <Ier  Ch.  minor.     DeuiMhcs  Arch.  f.  klin.  Med..  1S87. 

■L  S.6- 
Schweinitt.     Euiniinittion  of  the  Eyes  in  Fifty  Cues  of  Chorea  in  Children. 

New  York  Mnl.  Joutn..  June  JJ.  1888. 
Suckhng.     Dni.  Mrd.  Journ..  April  18.  1S88.    (Senile  Chorea.) 

tCombf.     Lea  r^latiimi  pallio|;Jni<|ues  de  la  cliorfe     IVog.  mjd..  iSSS,  16,  pt 
JOOi 

Hoffmann.     Uvbrr  Ch.  chrotika  progmtira.     Virchow's  Archiv.  1S88.  fid.  iii. 

II,  J.    (Hunlin|;(on'K  Choren.) 
Schromann,     [>rultclir  med.  Wochenvhr..  t8S8,  siv,  3). 
Mendd    Cenlnill>l.  t.  Nervcnhrilk..  188S.  xi.  tj. 
Lunolt.    Ch.  hfr^liLiin:.     Krvuc  At  mM..  1888.  8. 
ChautTrnu-     \x\  lic^i  rootdm^s  nvrc  f  miction  brtisque  et  inralonlaire  dea  eris 

■i  ilrs  inuti  arttrul^.     Thisc  de  Ui^nle.iux,  1888. 
^Hrrtmgham.     Chfnnic  Hcmtlt.iry  Chorea.     Krain.  188S.  xl.  p.  41$. 

nko.    2ui-  Frage  der  Localitalion  dcf  Chorea.    CentralbL  t.  NcrvenhcUk., 
188S.  «l.  32. 
[KSppel  el  DuceUier.    Un  eas  dc  choree  hjrtdiiain  dc  t'adullc.    Enctfphak. 

1S88.  \\\\.  6. 
PaiellK.    ConiritrailoM  nnaiomo-juioluska  e  clinica  alia  ttuilio  dclU  corea  nti- 
non.    I'adova.  1888. 


492 


DISEASES  OF   THE  GENERAL   NERVOUS  SYSTEM. 


Sinkler.    Hereditary  Chorea.    Boston  Medical  and  Surgical  Joum.,  October  15, 

1888,  cxix. 
Sturges.    The  Rekiion  of  Chorea,  to  Rheumatism.     Lancet,  1S89,  i,  3. 
Hegge.     Ueber  den  Zusammenhang  zwischcn  Chorea  minor  mit  dcr  Polyar- 
thritis rheum,  und  der  Endocardilis.     Wiener  med.  Blatter,  1888,  41,  41, 
Schadle.    Chorea  of  the  Soft  Palate.    Phila.  Med.  and  Surg.  Rep.,  Octobtr  14. 

1 888.  lix. 
Gairdner.     Case  of  Nerve  Disease  with  Choreic  Movements.     Glasgow  Medic.il 

Joum,,  1889,  xxxi,  I. 
Biernacki.    Fall  von  chronischer  hereditSrer  Chorea.    Berliner  klin.  Wochensehr., 

1890,  xxil. 
Remak.     Ueber  Chorea  hereditaria.     Neurol.  Centralbl.,  1891,  ii. 
Jolly.     Ueber  Chorea  hereditaria.     Ibid. 

Dreves.    Ueber  Chorea  chronica  progressiva.    I naog.- Dissert.,  Gdttingen,  iSgr. 
MacCann.      Chorea   Gravidarum.      Brit.   Med.  Joum,,    November    14.    [8yi, 

p.  1046. 
Lewis.     Amer.  Joum.  Med.  Sci.,  1892,  3.  p.  251. 
Mobius.     Ueber  Seelenstorungen  bei  Chorea.     Miinchener  mecl.  Wochensehr.. 

1893,  51,  52. 
Guillemet.     De  la  mort  dans  la  choree  de  Sydenham,     Thdse  Ac  Paris,  1893. 
Dana.     Amer.  Journ.   Med.  Sci,,  January,   1894.     (Microbes  as  the  Cause  of 

Chorea.) 


CHAPTER    II. 


TETANV — TKTANIL.LA — TETANUS   INTER  Ml  TTKNS. 


The  name  tetany  (Corvisart)  has  been  given  to  a  neurosis 
which  is  chAractemed  by  paroxysmal  tonic  muscular  spasms, 
during  which  consciousnr&s  remains  undisturbed.  The  spasms 
arc  oltcn  confined  to  the  flexors  n(  the  fingers  and  o(  the  wrist 
)oint.  and  only  rarely  attack  the  muscles  of  the  lower  cxtrcm- 
jiics;  they  arc  always  bilalcml.  The  fingers  are  drawn  to- 
gether and  the  hand  assumes,  to  use  Trousseau's  comparison, 
the  shape  which  the  obstetrician  gives  it  when  introducing  it 
into  the  vagina.  With  these  spasms,  which  arc  o(  (jrcai  inten- 
sity, so  that  the  affected  muscles  feel  tense  and  hard  as  boards. 
are  Msociale<l  slight  flexion  at  the  elbow  joint  and  a  moderate 
adduction  of  the  upper  arm.  hl^rard  claims  that  the  pressure 
of  the  thumb  upon  the  other  fingers  may  be  so  strong  as  to 
lead  to  pressure  gangrene,  but  this  is  unquestionably  very  rare, 
tf  the  lower  extremities  are  affected  the  feet  assume  n  position 
of  plantar  flexion,  and  ihc  big  toe  is  drawn  under  the  second 
or  third.  Sensory  disturbances  are  usually  entirely  absent, 
except  that  the  contracted  muscles  arc  painful  on  pressure  and 
the  skin  over  them  is  covered  with  a  copious  sweat. 
K  These  attacks,  which  vary  a  good  deal  in  frequency  as  well 
^^as  in  duration,  may  be  produced  by  pressure  upon  the  lai^er 
nerve  trunks  or  the  Larger  arteries  of  the  upper  extremities, 
as  Trousseau  found  accidentally,  by  applying  a  venesection 
bandage  :  thus,  by  pressure  upon  the  median  nerve  or  the  bra- 
chial artery,  a  spasm  may  be  produced  of  exactly  the  same 
nature  as  the  spontaneous  ones.  This  is  called  Trousseau's 
si^.  and  is  considered  to  be  of  great  diagnostic  importance. 

The  attacks  scarcely  ever  occur  suddenly  and  uneupcctedly. 
Generally  Ihcy  are  preceded  by   prodromal  svmptoms.  which 

klast  for  a  few  minutes  and  consist  in  a  painful  drawing  sensa- 
lion  ol  the  hands  and  arms.     Previous  to  the  first  attack  such 


494 


DISEASES  OF  THE  GB.VEflAL  XERPOUS  SYSTEM. 


sensations,  together  with  formication,  feelings  of  coldness,  eta, 
may  have  existed  for  weeks.  The  attacks  last  rarely  more 
th,in  five  or  ten.  usually  they  arc  over  in  one  or  two  miiiutcx 
and  it  is  only  in  very  exceptitmal  instances  that  they  go  on  fur 
several  hours.  Their  frequency  also  varies,  as  vrc  have  said. 
Some  patients — just  as  now  and  then  happens  in  epilepsy — 
have  not  more  than  one  all  their  life,  some  have  several  a  day, 
and  in  others  again  weeks,  months,  or  years  pass  between  the 
indivitltial  attacks,  and  the  disease  may  extend  over  twenty  or 
thirty  years.  Jaksch  (cf.  lit.)  distinguishes  an  acute  recurrent 
and  a  chronic  tet.iiiy.  and  thinks  that  certain  forms  occur  in  the 
course  of  grave  cerebral  disorders.  In  all  cases,  however,  pro- 
vided there  exist  no  complications— such  as  joint  alTcctions — 
the  outcome  is  favorable,  and  in  no  case  can  any  lusting  bad 
eflecls  upon  the  organism  in  general  be  noticed.  In  the  inter- 
vals the  patient  docs  not  complain  of  anything  and  feels  in 
perfect  health.  Only  an  objective  sign  is  demonstrable,  which 
betrays  that  everything  is  not  going  on  normally — namely,  an 
increase,  not  only  of  the  eieclrical,  but  also  of  the  mechanical 
excitability  of  the  nerves — a  condition  to  which  Erb  has  called 
attention.  Even  a  weak  current  produces  a  marked  effect,  and 
by  simply  stroking  the  face  with  the  finger  it  is  possible  to 
elicit  lively  contractions  of  the  muscles  supplied  by  the  facial 
nerve.  Although  (his  sign  is  not  constant,  since  it  has  in  cases 
of  tetany  been  looked  for  in  vain,  even  after  the  most  careful 
examinations,  and  although  wc  must  not  forget  that  it  occurs 
not  in  tetany  alone,  but  also  in  organic  diseases  of  the  spiitnl 
cord^^;.  g..  in  glioma — it  remains,  nevertheless,  very  valuable, 
and  must  certainly  be  taken  into  account  in  the  diagnosis. 

The  anatomical  seat  of  the  disease  is  still  obscure.  It  bus 
been  referred  to  the  most  varied  parts  of  the  nervous  system, 
to  the  cerebrum,  the  cerebellum,  the  spinal  cord,  the  periph- 
eral nerves,  even  to  the  sympathetic,  which  seems  anyhow  tu 
be  the  part  of  the  nervous  system  which  is  blamed  lor  affec- 
tions we  cannot  locate.  All  these,  one  after  the  other,  have 
been  suspected  of  playing  a  rSle  in  (he  pathogenesis  of  tetany. 
but  proofs  have  never  been  brought  forward  for  the  correct 
ncss  of  any  of  these  views  (cf.  also  the  theories  proposed  bj 
Schlcsinger  in  the  Neurol.  Centralblatt,  (892.  3). 

The  least  probable  theory  seems  to  be  the  one  which  is- 
sullies  ilie  disease  to  be  of  a  peripheral  nature.  This  can  hardly 
be  bruiighl  into  accord  with  the  fact  that  the  affection  has  been 


TSTAyy, 


495 


t 


'Icnown  to  follow  psychical  influences,  (or,  just  as  we  have  seen 
'to  be  the  case  in  chorea,  and  as  we  shall  soon  Icam  lor  epi- 
lepsy, this  disease  also  can  be  brought  about  by  imitation,  and 
indeed  there  have  been  instances  recorded  where  in  this  nian> 
icr  even  small  epidemics  of  tetany  appeared  in  schools  (Mag- 
nan,  Oaz.  dc  Paris,  1876.  50,  and  Gaz.  des  hflp..  1876.  141). 
The  disease  has  further  been  observed  in  women  who  are  suck- 
ling infants,  in  young  mothers  and  wet  nurses ;  and  so  frC' 
qucntly  has  this  been  the  ease  that  Trousseau  felt  himself  jus- 
tified in  terming  tetany  "  la  coniraclurc  des  nourrices,"  It  has 
also  been  seen  associated  with  variuus  affections  of  the  stomach 
especially  dilatation.  (Loeb,  Deutschcs  Arch.  f.  klin.  Med..  iSi!^. 
xlvi.  Heft  1,  assumes  thai  in  such  cases  there  occursan  absorp- 
tion uf  poisonous  products  which  act  upon  the  nervous  system.) 
Quite  inexplicable  are  those  cases  occurring;  after  extirpation 
ol  goitres  iN.  Weiss.  Falkson,  \.  Eisclsbcrg.  and  others)  and 
alter  infectious  diseases,  especially  scarlet  fever  and  typhoid. 
All  this  speaks,  however,  in  favor  ol  the  central  nature  of  the 
disease,  as  does  also  the  fact  that  the  occupation  may  have 
some  causative  influence,  in.-ismuch  as  people  who  have  to  use 
ihcir  arms,  hands,  and  fingcrsa  great  deal — telegraph  operators, 
seamstresses  (.NIadcr,  hiirt)— arc  relatively  fre(|ueutly  subject 
to  it  According  to  our  opinion,  the  cortical  nature  of  tetany 
is  as  probable  as  the  cortical  nature  of  writer's  cramp.  In  this 
connection  it  is  to  be  noted  that  von  Frankl-Hochwart  has 
repeatedly  observed  psychoses  developing  in  the  course  of 
tetany  (JahrbUcher  f,  I'sych.,  l8c>0.  \\.  1,  2). 

The  great  rarity  with  which  the  affection  occurs  makes  ft 
Ipractically  of  little  importance.  If  we  add  to  this  that  the 
cases,  which  we  see,  run  without  exception  a  favorable  course, 
one  can  understand  why  but  little  is  to  be  said  of  the  treatment. 
If  any  interference  be  necessary  or  desirable  we  may  avail  our- 
selves of  the  galvanic  current,  placing  the  anode  over  the  af- 
fected parts  and  the  cathode  in  some  indifferent  place.  This 
may  be  repeated  two  or  three  times  a  week,  each  lime  a  mod- 
erate current  being  allowed  to  pass  for  from  three  to  five  min- 
utes. During  the  attack  this  procedure  is  sometimes  quite 
benefictal,  whereas  upon  the  course  of  the  disease  it  has  as  little 
influence  as  the  well-known  nervines.  We  have  used  tepid 
baths  with  success,  inasmuch  as  the  patients  felt  very  comfort* 
able  in  them  and  claimed  to  be  able  to  notice  a  diminution  in 
Uie  frequency  of  the  attacks.     It  is  our  opinion,  however,  that 


496        DISEASES  OF  TUB  GEXERAL  NERVOUS  SYSTEM. 

even  the  baths  can  be  dispensed  with,  and  that  it  is  best  not  to] 
subject  the  patient  to  any  therapeutic  measures  at  all. 

LITERATURE. 

Schultic.  Fr.     Uchcr  Teianie  und  die  mcchanische  Errfghartcit  dcr  pcripJierm 

NrrvrnMSrnmc.     Deul^chc  med.  Wochensichr.,  iSSi,  20.  21. 
Mader.    Uebcr  die  l)«iicliung  dcr  BcscliStilgung&krilmprc  lur  Telanle.    Wiener 

nidd.  BISUcr.  t883.  16, 
Ledcrer.    Jahrb.  f.  Kindcrheilk..  1883.  nil,  4. 

ttaginsky.    Tetaiiie  bfi  SSuglingen.     Archivf.  Kinderhrlllc..  1886.  vili.  %. 
Mpyncn.     Archiv  t  Gyn..  f887.  "».  3- 
Sthoiicn.     Berliner  klin.  VVochensclir.,  1888.  xxv.  14. 
HofTm-iiin  ( H fiddlier >■  I.     Zur  Lchrc  von  dcr  Teianic.     Deottches  Arthtv  r< 

klin.  Mnl..  t83S.  xliii.  1. 
Prankl-Mocliw^ri.  v.     Ucber  mvdiaiii»che  und    clektrJsciic  Cmrgbuknt  da 

Nc-rvcn  und  Muskc-ln  M  Tel.inie.     Ibid..  1S88.  xlili.  1. 
Escheiich.     Itliopaihische  Tctunie  Im  Kindeialtcr.    WicDcrincd.  WMKcnsclir,, 

1890,  40, 
V.  Jak.ich.    Kliniiche  Drilrtt^  lur  Kcnntniu  dcr  Teianie.     Zeiucbr.  i.  klis. 

Med..  1890;  xvrl.  3,  4. 
V.  Frankl-Hochwan.    UicTctanie.    (From  Nothnagel's  Ginic.)    Berlin,  Hiridi- 

w.ild,  1891. 
Eulcrbur^;.     Anikcl  "  Tctatiie  "  in  Eulcnbur^'a  Real-EncyclopCdle,  3.  Aitll. 
Heim.     Uclicr  Td.mie  lici  Cnsrrckta»ie  u.  s.  w.     Honn,  1893.  Inaug.-Disieit 
Nicolajevic    Ueber  die  Be/ichungen  dcr  Tetanic  lur  HyMcrie.    Wiener  kSs- 

Wochenschr..  1893.  vi.  29. 

Tbomsen's  Disease.— Under  the  name  of  Thomsen's  dtM3K 
an  alTccl-oii  has  been  described  which  is  charactcriKed  by  "tome 
spasms  in  the  muscles  during  voluntary  movements."  When  any 
muscle  is  moved  votuniurily,  ati  it  contracts,  a  tonic,  painless  spun 
comes  on  which  eilher  greatly  impedes  the  intended  movement  or 
completely  frustrate*  it.  If  the  patient  wishes  to  perform  cenats 
motions  a  sensation  uf  fatigue  is  felt  in  the  part  and  a  resistanct. 
which  he  lias  first  to  overcome  before  the  intended  movement  can  bt 
execiilcd.  Objects  which  he  is  holding  in  his  hands  he  can  net  k( 
go  at  once  and  put  down.  If  he  opens  his  month,  he  can  not  doK 
it  without  the  aid  of  his  hand  (Fig.  14K] :  he  can  not  rise  from  kit 
chair  without  assiating  himself  with  his  arms  (Fig.  149).  Kunnisf. 
dancing,  gymnastics,  the  manipulations  of  the  military  drill,  11* 
absolutely  impossible,  and  any  such  attempts  diatrcsiS  him  T(r<t 
much  and  bring  him  into  the  most  annoying  situations.  If  l^ 
musculature  of  the  tongue  is  implicated  a  motor  speech  distarbann 
is  added.  Sensory  disorders  arc  not  found,  and  in  general  t^t 
patients  are  perfectly  well  if  they  do  not  attempt  to  move.  ^ 
jeciively  may  be  noted,  beitide*  the  increased  excitability  to  the 
galvanic  current,  an  unusually  strong  development  of  the  muKuli' 


T/lOJtrSEJf'S  D/SEASE. 


497 


ture  and  an  incrca&cd  power  which  seem  almost  to  belie  the  com- 
plaint* of  the  patients  that  they  are  embarias&cd  in  their  movemefit*. 
Heretlit)-  xtundt  fur  a  great  deal  in  the  disease,  which  was  evi- 
dent from  the  flrx  from  the  devcriptiun  which  Thoniiten  himself  gave 


Cllolc*.  A| 


iiv  ol  PliUwlclphii,  iDlcriMtloul 


in  1876.  He  reported  that  in  his  own  family  in  Ttve  generations  more 
than  twenty  person*  had  suffered  from  it.  Often  it  is  congenital, 
hence  SlrUmpell  has  prop«>«ed  the  name  myotonia  congenita. 

The  nature  of  the  malady  is  still  a  matter  of  conjecture.  The 
fact  that  on  galvanic  stimulation  of  the  muscles  the  contractures  arc 
stow  and  very  prolonged,  lasting  even  as  much  as  thirty  seconds — 
myotonic  reaction  of  Rrb — the  observation  of  Krb  that  on  micro- 
scopical examination  the  muscular  fibres  are  seen  to  be  broader,  the 
nnclct  multiplied,  and  the  inieistiiial  connective  tissue  incrcaMrd,  arc 
not  points  sufficient  to  warrant  a  definite  decision  about  the  scat  of 
the  disease.     Still,  the  possibility  that  wc  ate  actually  dealing  with 

33 


498 


D/SEASES  OF  THE  CE.V£/tAL  NERVOUS  SYSTEM. 


an  affection  of  the  muscles  \%  hf  no  means  excluded.  In  favor  of 
this  latter  view  U  the  case  reponed  by  Dejerine  and  Sottas,  in  which 
changes  wer«  to  be  demongtrated  onlf  in  the  muscles  (cf.  Deutsche 
Mcd.-Zlg.,  1893,66.  p.  J41). 

The  dUeasL-,  which  interferes  greatly  with  the  occupation,  is  wont 
to  last  throughout  the  entire  life.    The  patients  learn  to  accominodjitc 


fie- 149.— Thumikn's  Ubkuil    (AlletCbuta  K.  UlUf.) 

themselves  to  a  certain  extent  to  the  inconvenience,  and  by  allowing 
for  it  are  able  in  a  measure  to  hide  their  awkwardnesx.  In  counirir^ 
where  military  service  is  compulsory  any  one  sufTcring  from  mj^oionii 
is  exempt.  No  treatment  has  a.'t  yel  been  promulgated  for  this  rare*' 
of  affections. 

UTERATURE. 

Thomsen  (in  Ktippctn),    Tonisehc  KrUmpfe  in  wittkljtiich  bewcglen  MibW^ 

Arch.  f.  I'sych.  u.  Nervenkh.,  i8?6,  vi.  j. 
Wciclimann.    Ucbet  Myotonia  intcrnii (tens congenita.    I naug. -Dissert.,  Vialitt 

1883. 


THOMSEN'S  DISEASE. 


499 


Mttbius.    Schmidt's  Jahrbiicher,  1883.  Bd.  cxcriii,  p.  336. 

Rieder.     Deutsche  miliidrSrztl.  Zeiig.,  1884,  xiii. 

Pitres  ct  Dalltdet.     Arch,  de  neurol.,  1885,  x. 

Eulenburg  und  Melchert.    Berliner  klin.  Wochenschr.,  1885,  xxii,  38. 

Erb.     Die  Thomsen'sche  Krankheit.    Leipzig.  Vogel,  1886. 

Fischer.    Neurol.  Centralbl.,  1886,  v,  4. 

Buzzard.     Lancet,  May  13,  1887,  i,  30. 

Jacoby.    Joum.of  Nerv.  and  Ment  Dis..  1887,  xiv,  3. 

Blumenau.  Ueber  die  eleklrisrhc  Reaction  der  Muskein  bei  derThomsen'schen 
Krankheit.     CenCratbl.  (.  Nervenheilk..  1888.  xi,  33. 

Dana.  Thomsen's  Disease.  Joum.  of  Nerv.  and  Ment.  Diseases,  April  4,  1888, 
N.  S..  xiil. 

Martius  und  Hansemann.    Virchow's  Archiv,  1889,  cxvii,  3. 

Fleming.  The  Alienist  and  Neurologist,  1890,  si,  p.  5[.  (Typical  Non- 
congenital  Myotonia.) 

Hughes.     Ibid.,  p.  63. 

Dreschfeld.    Thomsen's  Disease.     Brit.  Med.  Joum.,  Febniary  11,  1890,  p.  439. 

Hale  White.    Extract  from  the  Guy's  Hosp.  Reports,  1890,  xlvi,  p.  339. 

Fries.     Neurol.  Centralbl.,  1S93,  p.  40,  3. 

Del  prat.  Thomsen'sche  Krankheit  in  einer  paramyolonischen  Famille 
Deutsche  med.  Wochenschr,  1891,  83. 


CHAPTER    III. 


PARALYSIS  AClTAKe — SKAKIKG    PAtSY — PAKKIK&OM  S   DISEASE— 
CIIOK8A    PKOCUKftlVA. 


i 


Among  the  diseases  of  which  we  arc  treating  in  this  part 
paralysis  agitnns  is  the  gravest,  but  happily  also  the  rarest,  lor, 
according  to  slatisltcs  of  my  own  cases,  only  about  o^j  per 
cent,  or  one  tn  two  hundred  and  twenty-nine,  of  alt  affcctiocu 
of  the  nervous  system  were  instances  of  paralysis  agitani 
Within  the  some  sixty  years  which  have  passed  since  Parkin- 
son's description  appeared,  certain  symptoms  of  the  disease 
have,  it  is  true,  been  studied  more  carefully,  but  our  knowl- 
edge of  the  a;tiolngy,  the  anatomical  scat,  the  treatment,  etc.  , 
has  not  improved  to  any  extent,  and  in  fact  our  progress  Im  J 
been  unsatisfactory.  " 

Symptoms. — The  first  thing  observed  by  the  patient  is  a 
feeling  of  weakness  in  the  extremities,  followed  soon  after  bv  > 
slight  tremor,  which  at  first  only  occurs  temporarily.  It  is 
more  marked  in  the  upper  extremities,  especially  in  the  riglil 
arm,  yet  it  is  also  noticeable  in  the  legs,  and  exceptionally  tn 
the  head.  The  old  idea  that  the  head  is  always  exempt  from 
the  tremor  of  paralysis  agitans.  and  that  this  exemption  is 
(tstcris  paribus,  characteristic  of  the  affection,  is  untenable.  I" 
rare  inst.inces  the  tremor  is  confined  to  one  half  of  the  body, 
whereas  the  other  remains  quiet. 

The  tremor  consists  of  uniform  oscillating  movements,  the 
oscillations  being  nithcr  few  in  number,  not  more  than  (nw 
fbur  and  three  quarters  to  live  and  a  half  per  second  (Cnunot. 
whereas  the  tremor  of  Graves'  disease,  for  example,  prescnis 
from  nine  to  nine  and  a  half  oscillations  per  second  (Mjrici 
The  lengths  ol  the  oscillation  waves  have  been  studied  by  Marie, 
Cramer,  and  others,  and  the  hand  writing  of  the  patients  has  gen- 
erally been  utilized  for  such  observations.  The  oscillations  wcic 
recorded  on  paper  by  means  of  a  Marey's  drum  or  rubber  bolt. 
Soo 


1 
( 


P/iKALYSIS  AGITANS. 


SOI 


which  the  patient  was  made  to  hold  loosely  in  his  hand.  Re- 
peatedly with  perfect  regularity  of  the  wave  lengths  a  varia- 
bility in  their  height  cuuld  be  denionsIrate<l.  the  physiological 
cause  for  which  is  not  entirely  clear.  It  is  not  infrequently 
seen  that  the  tremor  increases  on  forced  attempts  at  moiion. 
and  passes  inlo  a  regular  "shake,'*  so  that  the  patient, although 
nut  entirely  helpless,  becomes  very  awkward  in  feeding  himself. 
It  is  a  fact  of  considerable  diagnostic  importance  that  the 


nc.  ijo.— SrtctMBH  av  Hanuwiiitimi  or  Pa-tiknt  wrm  Cajulvsu  Aanui*  (puvaul 

oUcmtiun), 

movement!)  during  rest  in  bed  do  not  cease,  hut  continue  and 
hinder  the  p;ilient  from  getting  to  sleep,  and  fin  contradistinc 
_  tion  to  what  we  find  in  chorea)  do  not  disippear  even  during 
Ktound  slumber.    Indeed,  the  intensity  of  the  tremor  may  remain 
undiminished  in  bed,  :iikI   I  know  of  instances  in  which  the  pa- 
tients procured  for  themselves  iron  bedsteads  in  order  to  avoid 
the  annoying  creaking  of  the  wooden  bed  caused  by  the  vio. 
lent   shaking.      In  other  cises  the  condition  improved   ti|>nn 
lying  quietly  in  bed,  and  falling  asleep  was  facilitated  by  the 
use  of  certain  arlitices.    Thus  Eichhorst  relates  of  one  of  his 
patients  that  he  always  carried  a  little  twig  between  his  teeth 
•    so  as  to  keep  his  jaw&  quiet,  and  one  of  my  own  cases  untjr 


503        DISEASES  OF  THE  GENERAL  XERVOUS  SYSTEM. 

could  obtain  comfort  and  a  certain  amount  of  rest  fn  his  fingers  < 
and  arms  by  rolling  small  objects— for  instance,  little  wooden 
balls  which  he  had  made  fur  the  purpose — between  Ins  fingcrsj 
and  thumb.  With  the  aid  ot  these  he  also  could  go  to  sleep. 
If  by  accident  he  left  these  balls  at  home,  he  unconsciously 
picked  up  other  objects  which  might  be  lying  belore  him,  such 
as  matches,  or  he  rolled  bread  pellets,  and  so  on,  and  only  felt 
comfortable  when  his  fingers  were  occupied  with  something 
of  this  sort.  The  change  in  the  handwriting  caused  by  tliis 
tremor  is  illustrated  in  Figs.  150  and  151. 

In  connection  with,  and  probably  as  a  consequence  of,  the 
trembling  movements,  gradually  a  condilion  develops  in  which 

FIc.  151.— SretiMUc  or  Kamiiwritiiio  i>t  X'l.nt.sr  vhjh  Pamalvhiii  AaiMHs  i 

obsenalion). 

the  patient  gets  easily  tired,  the  muscular  strength  diminisli«. 
and  the  muscles  assume  a  certain  rigidity  which  influences  the 
posilion  of  the  body  and  the  extremities  when  at  rest  as  well 
as  on  voluntary  motion.  The  position  of  the  body  is  chanc- 
tcristic.  Not  only  the  head,  which  affords  a  good  deal  of  K- 
sistancc  to  passive  movements,  but  also  the  whole  trunk  is 
somewhat  bent  over,  and  it  appears  as  if  the  patient  was  !' 
every  moment  ready  to  fall  forward.  The  arms,  which  arc 
bent  at  the  elbows,  arc  in  close  apposition  to  the  trunk,  the 
thumb  rests  against  the  fingers,  so  that  the  hand  assumes  some 
such  position  as  it  would  in  writing,  the  fingers  themselttJ 
being  flexed  in  the  metacarpal  joints  (Fig.  152).  The  kn*« 
arc  so  close  together  that  the  trousers  are  rubbed  against  each 
other  by  the  trembling  movements,  and  walking  is  not  a  littlt  1 
interfered  with.  The  legs  are  usually  slJghlly  flexed  at  ihf 
knee  joints,  while  nothing  remarkable  can  be  noticed  abciul 
the  joints  of  the  toes.  The  patient  impresses  one  as  being  fa 
a  constant  stale  of  uncertainty  and  perplexity,  an  impressi(« 
which  is  only  diminished  to  a  certain  degree  by  the  very  cbir-  *' 


PARALYSIS  AGITAKS. 


SO3 


acteristic  fades.  The  rifridity  being  also  marked  in  the  mus. 
cles  supplied  by  the  seventh  nerve,  the  face  has  an  expression 
of  majestic  calm,  nay,  even  of  sublimity.  The  patient  seems 
Inaccessible  to  psychical  emotions.  His  smile  is  hardly  per- 
ceptible, since  the  lowec  portions  of  the  face  more  especially 
are  almost  immobile.  Only  the  wrinkling  of  the  forehead  is 
somewhat  more  marked.  Sometimes  the  patients  have  a 
peculiar  piping  voice,  such  as  an  actor  assumes  when  playing 
the  part  of  an  old  man  on  the  stage. 

We  have  already  alluded  to  the  fact  that  voluntary  move- 
ments are  somewhat  impeded.  This  is  due  not  only  to  the 
tremor,  but  also  to  the  already-mentioned  general  weakness. 


an  or  HaifiM  unt  rixoiMt  im  PAKALnn  Aoitah  (u  K  boUbic  a 
ptnv    <A(ict  EicmioiMT.) 


I 


lie  is.  therefore,  helpless,  and  needs  some  one  to  assist  him  If 
he  wishes  to  sit  up  in  bed  or  even  to  change  his  position.  If 
he  is  in  a  sitting  posture  rising  is  dillicult,  sometimes  impos- 
sible. The  act  of  walking  is  not  normally  performed,  for  lie- 
sides  the  bent  position,  which  in  walking  becomes  even  more 
exaggerated  than  in  standing,  the  |Mttient  once  started  has  an 
irrrsisliblc  tendency,  owing  lo  the  displacement  of  his  centre  of 
gravity  forward,  to  hurry  ahead  :  his  steps,  at  first  short  and 
tripping,  become  fiuickcr  and  longer,  and  so  great  may  be  the 
force  with  which  he  involuntarily  rushes  forward  that  if  there 
is  no  one  there  to  stop  him  he  falls  on  his  face  with  great  vio- 


504        OiSF.ASES  OF  THE  CBlfEHAL  S'ERVOVS  SYSTEM. 

Icncc.  The  same  pliciiomcnon,  which  is  called  "propulsion," 
mav  somclitncs  be  anilici;illy  produced  by  pulling  the  paiiait 
forward  by  the  coat  while  he  is  walking  quietly.  He  then 
goes  (aster  and  faster,  and  finally  breaks  into  a  run  alarming  lo 
the  bystanders.  Much  more  rarely  do  we  find  a  similar  con. 
dition  in  the  backward  niotiun  ("  retropulsion "),  so  (hat  the 


patient  if  pulled  from  behind  walks  backward  faster  and  faster. 
to  fall  over  in  a  short  lime.  Charcot  looks  upon  these  plw- 
nomena  as  forced  movements,  a  view  which  has.  however, 
never  been  substantiated.  Thcv  may  possibly  be  explained  no 
purely  physical  grounds  as  being  due  to  the  displacement  ot 
the  centre  of  gravity  of  ihc  body  (Striinipell). 

Trophic  changes,  with  the  exception  perhaps  of  the  Irnn- 
sieni  appearance  of  purpuric  spots  symmetrically  on  the  arms 
and  legs  ("senile  purpura"),  arc  not  met  with.  Changes  in 
the  electrical  excitability  of  the  muscles  do  not  occur,  or  are, 
at  any  rale,  not  the  rule.    Sensation  and  reflexes  remain  entirely 


fiAHALY&IS  ACtTA.VS, 


sc>s 


fnormal,  and  bladder  as  well  as  rccui)  symptoms  arc  not  pres- 

lent.  All  increase  in  ittc  body  temperature  can  never  be  dem- 
onstrated ubjcctivcly,  although  patients  complain  at  times  q( 
subjective  feelings  of  increased  hca(  and  a  disagreeable  tend- 
ency to  sweat  a  good  deal,  which  is  especially  pronounced 
when  lying  in  bed,  so  that  they  often  sleep  uncovered  or  with 
but  little  over  them.  U  any  cerebral  or  spinal  symptoms  make 
their  appearance  these  have  to  be  regarded  as  complications. 
They  do  not  belong  to  the  clinical  picture  of  paralysis  agttaos 
as  we  know  it  now. 

I  Cases  in  which  muscular  weakness  and  rigidity,  with  all 
their  inconvenient  consequences,  were  present,  in  which,  also, 
the  so-called  propulsion  was  marked,  but  the  tremor  was  ab- 
sent,  have  been  reported  (^Amidon,  New  York  Medical  Record, 
1S83.  xxiv,  31),  but  such  .ire  rare. 

I  The  nature  of  the  disease  is  not  yet  understood.  U'e  do 
nut  even  know  whether  to  refer  it  to  the  brain  or  to  the  mus- 

,  cics.     Much  less,  of  course,  do  we  know  where  the  exact  seat 

ithould  be  sought  for  in  the  nervous  system.  Before  the  labors 
of  Charcot  and  Ordenstcin,  paralysis  agitans  was  often  con- 
founded  with  multiple  sclerosis,  and  various  anatomical  lesions 
were  then  described  as  underlying  the  paralysis  agitans.  Later 
the  error  was  cleared  up.  and  even  to  the  present  day  we  arc 
not  acquainted  with  any  anatomical  basis  for  the  disease. 

)  Etiology. — In  this  respect  also  our  knowledge  is  very  in- 
complete. Of  course  here,  .is  in  all  other  nervous  diseases,  he- 
redity and  the  impurliince  of  a  neuropathic  family  history  must 
bespoken  of,  yet  the  rarity  with  which  the  aflcciion  occurs  shows 
that  this  factor  alone  is  seldom  sutTicicnt  to  cause  the  disease. 
Hence  other  exciting  causes  must  come  into  pl-iy.  but  it  is  a 
fact  difficult  to  undersund  why  the  same  factors  which  so  often 
give  rise  to  chorea  so  rarely  produce  a  shaking  palsy.  The 
causes  for  all  these  diseases  arc  always  the  same,  or  at  least 
simitar,  and  it  is  here  also  in  the  first  place  that  psychical  emo- 
tions of  fright  and  anxiety  are  of  moment.  The  French  phy- 
sicinns  have  at  no  time  seen  develop  so  many  cases  of  paraly- 
sis agitans  as  during  the  lime  of  the  siege  in  iS^i.and  for  years 
after  the  relative  frequency  of  the  trouble  in  the  Paris  hospi- 
l;«l<i.  particularly  in  the  Salpi^triire.  acted  as  a  reminder  of  the 

I  terrible  hours  which  the  besieged  must  have  gone  through. 

[In  private  pnicticc  we  also  have  occasion  to  find  that  psychical 

Icauscs  bring  about  the  disease  :  more  frequently,  however,  at 


506 


/>/S£ASSS  OF  TUB  GENERAL  NERVOUS  SYSTEM. 


least  in  my  own  experience,  no  cause  at  all  can  be  found.  The 
influence  of  exposure  to  cold  and  of  overexenion  of  course  hns 
here  also  been  thought  to  be  of  aetiulogical  significance  with, 
out  there  being  any  i^rouiids  for  such  an  assumption :  on  the 
other  hand,  Ihcrc  is  no  question  but  that  certain  infectious  dis. 
cases — e.  g.,  intermittent  fever,  pertussis,  typhoid  fever — may  be 
followed  by  a  paralysis  agitans,  a  connection,  however,  which, 
although  certain  in  its  existence,  is  still  obscure  tn  its  nniure. 
Nothing  definite  is  known  about  the  influence  of  age  and  sex. 

Diagnosis. — After  what  has  been  said  little  needs  to  be 
added  with  regard  to  the  diagnosis,  which  is  almost  always 
easy.  It  is  certainly  not  h.-ird  to  avoid  mistaking  paralysis 
agitans  for  multiple  sclerosis  or  chorea,  and  chronic  alcoholism 
is  easily  excluded  if  we  take  into  account  the  characteristics  vA 
the  tremor,  its  continuance  during  sleep,  and  the  whole  course 
of  the  disease.  It  may  be  sometimes  diOicuU  to  differentiate  a 
shaking  palsy  from  the  ordinary  tremor  senilis  if  the  latter 
occurs  as  early  as  the  forties,  at  a  time  of  life  during  which 
paralysis  agitans  is  not  rare,  and  it  is  the  more  necessary  to  be 
careful,  since  the  number  of  the  usci]t:itiuns  in  both  affections 
is  about  the  same — that  is.  ranges  between  (our  and  six  per 
second.  The  muscular  weakness,  ihe  peculiar  rigidity  which 
accompanies  the  movements,  Ihe  characteristic  facial  cxpres- 
sion.  the  posture,  the  "  propulsion,"  etc.,  will  in  most  cases  be 
suflicient  to  clear  up  the  diagnosis.  Oppcnheiin  has  observed 
that  the  so  called  traumaiitr  neurosis  may  present  the  picture  of 
paralysis  agitans  (I'seudo-i'aralysis  Agitans;  Charii^-Annalen, 
1889,  xiv,  p.  418). 

Treatment — The  treatment  is  entirely  fruitless.  We  have 
not  as  yet  seen  any  results  from  any  of  the  therapeutic  mcas' 
urcs  employed.  Neither  with  baths  nor  with  massage  (Ber- 
bez.  cf.  lit.)  nor  with  galvanism  has  anything  been  achieved, 
and  all  internal  medicines  arc  of  no  avail.  It  is  impossible  to 
give  particular  indications  for  the  treatment,  and  it  must  there- 
fore remain  for  the  physician  in  every  case  to  treat  alternately 
with  baths,  massage,  and  electricity,  according  as  he  sees  fit. 
As  long  as  he  does  not  do  the  patient  any  harm,  it  does  not 
matter  much  which  mode  of  treatment  he  decides  to  use. 
Lately  Rrb  has  recommended  the  muriate  of  hyoscitie  injected 
subcutancously  or  taken  internally.  This  is  said  to  exert  a  very 
good  influence  upon  the  tremor,  hut  whether  this  effect  is  last- 
ing, and  whether  the  bad  after-effects  which  occasionally  appear 


I 

I 

I 

I 
I 


I 


i 


UiCJtAtA'E. 


V>7 


after  a  prolonged  use  of  the  drug  are  not  a  grave  objection  lo 
its  administration,  is  not  as  yet  decided.  My  own  experiences 
with  it  were  not  favorable.  Charcot's  "vibration  treatment," 
by  which  a  quieting;  or  even  benuinbiiiji;  effect  is  aimed  at,  was 
further  studied  by  Gillcs  de  la  Tourette  (Pn>gr6s  m^d.,  i8()2, 
3;).  This  -lutliur  has  constructed  a  special  apparatus  in  the 
shape  of  a  helmet.  Five  thousand  to  :^ix  thousand  vibrations  a 
fninute  arc  said  lo  produce  a  hypnotizing  effect  and  to  diminish 
the  tremor.  I  am  inclined  to  think  that  the  result  is  chiefly 
due  to  suggestion. 

LITERATUHE. 

Hnnunn.     Vrhtt  Paralysis  t^/Ont.     Berlin.  HinchmM.  1888. 

UblovIc.     Cuniribuiion  1 1'^lude  de  la  niiladic  dc  Parkinson.    Tliiw  dc  i'uis, 

18H7.    (De  quelques  formn  nnunnAlu.) 
Huber.    MyogrApKiKbc  StudKn  bei  VaaL  agtl.   Virchow't  Afcb..  1S87,  to8, 1, 

P-4S. 
Teissier.    PitlMS^nie  de  la  paralpie  aptans.     \.yrm  mM.,  1SA8,  Iviii,  38. 
Weber.     Paralysis  A(,'ii.-ins,  with  Cases.    Juuiti.  of  Nerf.  and  Ment.  Diseiues, 

July?.  1*88.  N.  S..  JCiii. 
t>utU.    Sur  un  ea<  de  Paralysie  SKilanx  \  forme  htmipl^ipque.  avec  attitude 

anomute  de  la  \He  ct  du  trtinc.    (>ai,  mM.  tie  l^ris,  i88q.  }8.  p.  W9. 
Martha.     Elixlc  cliniijue  tur  In  p^imlysie  Agiuiit.     V»ny  Stcinheil.  itiSS. 
Peterson.     A  Clinkal  Siudy  of  ('oily-«even  Caacx  of  I'anlysis  Agitaiu.     New 

Vork  Med.  Journ,.  October  ir.  r89o. 
fUdden.     Pantlysi*  Agilans  in  a  Young  Man.     Ilnin.  189a 
Sua.     Peicrebunter  med.  Wochenschr.,  n.  K.,  1891,  riii,  19,  10. 
Kollrr.     Virrhow's  Archiv.  1891.  cxxv.  p.  3S7. 
Leva.     DeulM-hc  Z«i(»cbr.  L  Nervenhk..  1891,  i,  I.     (Condition  of  the  Urnie  in 

Paralysis  AKiUns.) 
Knacher.     Zriischr.  f  Hcilkunde.  189}.  xili.  6.  p.  445. 
Dana.     New  York  Med,  Joum..  1893.  57.  Ng.  ly 


a  AFFECTIONS  IN  WHICH  THE  SENSORY  NERVES  ARK  CHIEFLY 

IMPLICATED. 

The  only  affection  which  can  at  present  be  assigned  lo  this 
group  is  one  which  deserves  a  good  deal  of  attention,  on  ac- 
count not  only  of  its  frequency,  but  also  of  the  obscurity  which 
siill  exists  with  regard  to  its  pathogenesis.  It  is  a  mal.ndy 
which  never  seriously  endangers  the  patient's  life,  but  never- 
theless produces  grave,  almost  unbearable,  suffering. 

Migraine  {HemicraNta). 

The  disease  manifests  itself  in  attacks,  while  in  the  intervett- 
tng  periods  the  patients  are  usually  perfectly  well  and  in  no 
way  give  evidence  of  the  severity  ol  the  affliction  of  which 


508 


D/SSASSS  OF  THE  GBNEHAL  SERVOVS  SySr£,V> 


they  are  the  subjects.  The  paroxysms  are  usually  preceded 
lor  several  hours  by  prodromal  symptoms,  general  lassitude, 
chilly  feelings,  a  tendency  to  yawn,  buzzing  in  the  cars,  and  the 
like.  If  the  reguLir  attack  is  going  to  begin  in  the  morning. 
the  patient  wakes  up  repeatedly  during  the  night,  and  is  thus 
able  to  predict  with  certainty  that  the  headache  is  coming  on. 
The  pain  is  sometimes  confined  to  one  side  of  the  head,  and, 
according  lo  statistics,  the  left  seems  to  be  the  one  more  com- 
monly implicated  :  but  the  seat  often  changes  during  the  attack, 
so  that  the  patient  complains  now  of  the  left,  now  of  the  right 
side  of  the  head.  Sometimes  a  distinct  pallor  is  noticeable  on 
one  side  during  the  att.ick,  associated  with  dilatation  o(  the 
pupil  and  increase  in  the  salivary  secretion,  while  in  other  in- 
stances one  half  of  the  (ace  is  flushed  and  hot.  the  arteries  pul- 
sating strongly,  and  the  pupil  contracted.  In  the  first  case  we 
designate  the  hemicrania  as  spastic  (sympathico-tonica,  con- 
nected with  stimulation  o(  the  sympathetic);  in  the  latter  as 
paralytic  (connected  with  par.tlysiso[  the  sympathetic).  The 
former  has  been  described  by  Du  Dois-Reymond,  the  latter  by 
Mi>llendorf.  in  both  cases  after  observations  made  upon  them- 
selves. But  these  conditions  arc  not  constant  cither,  and  if  one 
h.ts  seen  many  attacks  of  migraine  he  knows  full  well  that  the 
patients  often  change  color — they  are  now  pale,  now  flushed, 
now  complain  of  a  feeling  of  heat  in  the  head,  now  of  cold. 

If  the  pain  is  very  violent  the  patient  shows  ge»er.il  con- 
stitutional symptoms.  In  a  bad  attack  he  lies  for  hours  com* 
plctcly  apathetic,  meeting  every  question  and  every  source  of 
disturbance  with  unmistakable  signs  of  disgust.  He  refuses 
nourishment  entirely,  owing  to  a  feeling  of  utter  discomfort 
and  an  almost  uncontrollable  desire  to  vomit.  Only  after  copi- 
ous vomiting  of  bile-like  mucoid  masses  docs  his  conditiua 
gradually  improve,  the  amelioration  beginning  with  a  violent 
desire  for  food  and  a  polyuria  following  the  attack,  which  is 
finally  ended  by  a  refreshing  sleep.  When  vomiting  docs  not 
occur  the  patient  suffers  for  a  longer  period.  Sometimes  the 
eyes  participate,  and  photophobia,  flitting  scoloinata.  even 
hemianupia,  have  been  observed  during  the  attack.  Th»e 
are  instances  of  the  type  which  Fire.  Oalezowski.  Dardignac, 
and  others  have  described  as  wi^raint-  opiithalmiqm.  In  place 
of  the  Hitting  scotoinata,  visu>tl  hallucinations  are  observed  in 
exceptional  cases  (Weir  Mitchell,  Amer.  Jour.  Med.  Sd.,  1887, 
October,  p  415). 


MIGRAINE. 


SO? 


It  13  not  uncommon  for  the  attacks  not  to  reach  their  full  de- 
irelopment ;  in  which  cases  only  certain  symptoms — flitting  sco- 
tomata,  vomiting,  vaso-moior  disturbances,  or  the  like — may 
appear.  Such  isolated  symptoms  may  be  called  "  hemicranic 
equivalents  "  (MObius). 

The  duration  of  the  attack  varies  from  a  (cw  hours  to  a 
whole  day  ;  it  rarely  lasts  longer,  and  if  it  docs,  this  fact  should 
always  make  us  doubtful  as  to  the  diagnosiR.  In  the  intervals 
the  patients  as  a  rule  feel  well :  still,  if  the  attacks  are  very  se- 
vere and  frequent,  occurring,  for  instance,  as  often  as  once  or 
twice  a  week,  the  after-ellects  may  be  so  tasting  that  the  suffer- 
ers never  enjoy  perfect  health.  Indeed,  the  attacks  may  occur 
with  such  frequency  thai  we  have  what  F^ri  calls /At/ ^rwd/ 
migraineux  and  MObius  status  kemicranicus,  a  condition  in  which 
transitnri-  psychoses  may  develop  (Zacher.  Berliner  klin.  W'o- 
chenschrifi,  June  1 1. 1892).  Fortunately,  such  a  rapid  succession 
of  the  seizures  is  uncommon.  Once  a  month  or  six  or  eight 
limes  a  year  is  the  rule,  not  counting  slight,  ab<irtivc  attacks. 

The  course  of  migraine  is  always  extremely  tedious,  some- 
times lasting  through  a  whole  lifetime.  In  women  the  climac- 
teric period  occasionally,  but  by  no  means  always,  exerts  a 
beneficial  influence.  At  the  time  of  menstruation  the  attacks 
seem  to  be  especially  apt  to  occur:  and  even  if  no  definite  at- 
tack makes  its  appearance,  women  who  are  subject  to  migraine 
Complain  of  more  or  less  severe  headaches  at  such  periods. 
Not  infrequently  the  disease  has  an  unfavorable  influence  on. 
the  disposition  and  appearance  of  the  patients:  they  become 
peevish  and  ill-tempered,  and  even  in  the  intervals  between  the 
attacks  are  by  no  means  amiable  or  sociable.  They  are  wont 
to  restrict  themselves  considerably  in  their  social  intercourse — 
tor  one  reason,  because  they  are  rarely  able  to  make  engage- 
ments for  definite  times  on  account  of  the  possibility  of  the 
occurrence  of  one  of  their  attacks.  The  trophic  disturbances 
which  are  sometimes  superadded,  as.  for  instance,  the  prema- 
ture gray  hairs,  make  such  patients  look  older  than  they  rcilly 
.are:  on  the  other  hand,  there  are  individuals  who,  notwith- 
jstandtng  the  severity  of  the  attacks,  retain  for  a  long  time  their 
Ijrouthful  freshness  and  vivacity. 

With  regard  to  the  pathological  anatomy  and  thepathogen- 

we  know  scarcely  anything ;  it  appears  not  unlikely  that 

in  cortex  more  especially  and  its  sensory  elements  are 

ily  the  scat  of  the  affection,  and  it  seems  more  and  more 


5  to 


/>/S£AS£S  OP  THE  GENERAL  NERVOUS  SYSTEM. 


probable  that,  besides  the  itiflucncc  which  must  be  attributed 
heredity,  here  too.  as  has  been  cUiimed  lor  certain  cases  of  epi- 
lepsy, aiitn-intoxication  is  to  be  regarded  as  a  not  improbable 
factor.  But  it  must  be  admitted  that  this  is  only  a  suppusition. 
and  Ihat  wc  arc  without  any  certain  knowledge  on  this  point. 

Recovery,  if  it  ever  occurs,  is  certainly  very  rare,  and  can 
probably  never  be  regarded  as  Ihc  result  of  treatment.  If 
aphasia  or  motor  disturbances  are  persistently  associated  with 
hemicrania.  the  latter  is  to  be  regarded  merely  as  a  symptom  of 
an  underlying  organic  disease,  and  nothing  definite  can  be  said 
with  regard  to  the  prognosis.  1  n  this  connection  must  be  men- 
tioncd  the  case  ol  Oppenheim,  in  which  a  thrombus  uf  the  in- 
ternal carotid  artery  was  found  to  be  the  cause  of  the  headache 
and  of  the  other  symptoms  (Charile-Annalen.  xv,  Jahrg.).  The 
prognosis  is  relatively  favorable  if  in  the  intervals  between  tlie 
attacks  the  patient  enjoys  sound  and  healthful  sleep.  Unfortu- 
nately, ill  the  majority  of  cases  they  are  deprived  of  this,  and 
in  order  to  procure  it  arc  forced  to  resort  to  artificial  means,  ul 
which  the  bromidesarethc  most  popular.  It  is  not  always  easy 
to  understand  the  cause  ol  the  sleeplessness (i5rfrr/»«M) in  migraine, 
and  lor  that  matter  in  all  nervous  diseases  ;  it  is  especially  diffi- 
cult to  do  so  when  this  is  the  only  symptom  and  absolutely 
nothing  else  can  be  delected,  when  individuals  otherwise  healthy 
are  wholly  or  almost  wholly  deprived  of  sleep  for  weeks;  and 
yet  it  is  just  the  discovery  of  this  primary  cause  that  is  of  the 
greatest  importance,  as  it  will  guide  our  action  in  the  treat- 
ment :  and  only  when  this  is  found  can  we  reasonably  hope  for 
improvement  from  our  efForls.  Sometimes  wc  have  to  deal 
with  a  gastric  catarrh  which  until  this  lime  has  been  over- 
looked, a  hypern:mia  of  the  liver,  and  the  like,  and  after  the 
successful  treatment  of  these  by  Carlsbad  water,  etc.,  sleep, 
which  in  spile  of  all  bromides  and  morphine  has  in  vain  been 
sought,  returns  of  its  own  accord.  Sutncliiiies  a  marked  grade 
of  anxmia  may  He  at  the  bottom,  easily  recognizable  by  the 
pallor  of  the  skin,  the  small  pulse,  and  the  cold  extremities 
In  such  cases  cod-liver  oil,  iron,  and  quinine  are  more  service- 
able than  the  usual  hypttotics.  which  arc  rarely  well  borne. 
In  all  nervous  patients  suffering  from  insomnia  it  is  advisable 
to  examine  the  thoracic  and  abdominal  as  well  as  the  sexual 
organs,  and  only  to  treat  the  sleeplessness  symplomattcallr 
when  repeated  examinations  have  given  negative  results.  This 
symptomatic  treatment  consists  above  all  in  the  careful  use  of 


I 


I 


MIGRAINE. 


Sii 


I 


massage,  which  should  be  supervised  by  the  physician,  a  prac- 
tice from  which  we  have  obtained  very  gratifying  results. 
Next  comes  the  systematic  galvanization  of  the  brain,  for  the 
technical  details  of  which  the  reader  is  referred  to  my  book  on 
electro-diagnosis,  pp.  186  tt  trq.  As  a  last  resort  we  have  the 
administration  of  quieting,  calminjj. and  slee|>-producing  drugs, 
among  which,  notwithstanding  .ill  the  new  hypnotics,  morphine 

Bsiill  holds  the  first  place.  Besides  this,  chloral,  paraldehyde, 
urcthan,  hypnonc,  coniinc,  lupiilinc,  suKonal.  and  amylene  hy- 
drate  (tertiary  amyl  alcohol),  which  has  recently  been  rccom- 

■  mended  by  von  >iering,  m.iy  be  tried.  The  last  is  best  given 
tn  doses  of  three  and  a  half  to  four  grammes  (nit-lx)  in  one 
dose  once  in  tweiity>lour  hours,  and  seems  often  to  liave  a  favor- 
able action.  Un  account  of  the  bad  taste  of  this  drug  the  addi- 
tion of  correct ives^lr)r  instance,  the  oil  of  peppermint,  which 
somewhat  masks  ihc  taste — is  to  be  recommended.  (Amylcnc 
hydrate.  7.o(«i«v):  aq.  menth.  pip.,  40^0  (3"):  ol.  menth.  pip., 
t.o(^xv):  syrup,  simpl,,  30.0  (Sj).  Sig. :  Half  to  be  taken  at 
night.)  The  sleep  after  it  is  deep  and  quiet,  and  unpleasant 
after-effects  arc  rare.  Nevertheless,  it  is  well  to  be  careful  in 
its  administration,  .is  symptoms  ol  intoxication  may  appear,  as 
Dielj!  has  reported  (Deutsche  McdicinaUZciiung.  1S88,  iR).  Tri- 
onal  has  been  recommended  by  Schultzc  (Therap.  Monalsch., 
i.S9t,  October):  its  effect  has  also  been  studied  by  Brie  (Ncu. 
rot.  Centralbl.,  1892.  34).  who  h.is  found  it  very  useful  in  dosc& 
of  from  I  to  2  grammcs(r5  to  30  grains),  without  noting  any  bad 
after-effects.  The  reports  with  regard  to  meihylal  and  chlo- 
ralamid  arc  still  conflicting  (cf.  lit.). 

The  medicinal  as  well  as  the  general  treatment  of  migraine 
is.  on  the  whole,  the  same  as  that  of  habitual  headache,  which 
has  .ilre.idy  been  discussed  on  page  6;.  It  may  be  added  that 
Ihc  so-called  mtgrSnin,  a  combination  of  antipyrin.  citric  acid, 
and  caffein,  in  certain  proportions.  prc|>arcd  by  Overlach.  is 
deserving  of  further  trial  (Deutsche  mcd.  Wochcnschr.,  1893. 
xix,  47). 

I.ITERATl!RE. 

H ,  /.  Migrant, 

HKJI^BcrlinCT  kiln.  WochenMhr.,  18SS,  30. 
■■■mn.     I'rocr^  mtA..  18SS.  39, 

Danfiso*^     Rrrue  <le  miA..  OcIoIkt  10.  18SS.  viiL 

*N«ftcl.     DcuiMhr  Mml.-Ztg..  1S90.  14.  p^  i}7.  , 

Itencdikl.     Wkncr  nicil.  Prmsc,  1891.  ft, 
Haig.     Brain,  Not-ember,  1S93.  p.  ija 


512 


DISEASES  OF  THE  GEh'ERAL  SERVOVS  SYSTSM. 


».  tnMmniti  inuf  ilyfiolitu 

Umoine.    Car  mitl.  de  Patin,  1887,  18.    (MtlhyUL) 

I-enu>nuli.     L'Union  miA..  188;.  9.    (MclhylaL) 

lllingu'onh.     Insomnia.     Med.  frcssand  Circ,.  August  19.  iSSft. 

Kcichmann.    Chlorabmul.  eln  ncuet  Schlafmiitcl.    Deui*chc  mcd.  Wochen 

1889.  3r. 

Jaslrowiti.    SchlafTosigkcir.     Ihid..  lEiSq,  31. 

Mauthner.    Schlarkrunkheiieii,     All^.  iCdischr.  C  I'lj'chintr.,  1891,  xl^ii,  &. 
Uric.    Trional  sis  Sc)ilRl*miiid.     Nrurot.  Ccniralbl..  1891.  xi.  34. 
Filchne.      Ucbcr    das    llypnal-HOcbsl.      Bcrliocr    klin.  Wodiouchr..   \i^\. 

XXI,  y 
Koppcra.    Wirkung  des  TrionaJs.    tnaug.-DiswR^  Wunbui;^.  1893. 

C.  AFFECTIONS  IN  WHICH  THE  TROPHIC  NERVES  ARE  CHIKFLV 

l.\iri.ICATEl>. 

Our  acquaintance  with  the  few  affections  to  be  described 
under  this  head  is  of  very  recent  date.  Since  their  pathogoie- 
sis  and  their  scat  are  as  yet  obscure,  and  since  we  liavc  to  ojii- 

fine  ourselves  toihc 
description    d(   (he 
most  striking  syinp- 
A  \f'    »f  ^     toms,  it  is  impossi- 

ble to  say  whether 
the  place  here  sv 
signed  to  ihcm  i> 
correct  or  not. 


t.  ACROMEGALV  i_P.  Mari^ 

Under  the  name  of  acro- 
megalia {oKpov.  exlremilT) 
Marie  described,  in  i8tt6,  a 
peculiar  tion-congenital  hy- 
pertrophy of  the  hands,  (cet. 
and  head,  to  which  affection 
attention  had  previously 
been  drawn  by  Fritsche  and 
Klebs  (cf.  lit.).  The  extrem- 
ities appear  increased  in 
length  as  well  as  in  breadth. 
The  bones  of  the  face,  esp^ 
cialiy  those  of  the  cheeks 
and  the  lower  jaw.  present 
considerable  enlariji-menl 
(cf.  Fig.  154),  and  the  mcav 


\ 


f''K- 'S*-— -<.  ""'  l""'i  I  !«■  ii(  .1  im11™i  under 
Ihe  c»t»  iif  I'lili-  IT  '.I,i!H>,  ill  I'irH.  iff,  ■ 
tower  J4»  u'}kirTi  iiiinib.idy  vruuld  corrMpood 
(othc  »i«  tj(  I  111'  iMii<-"l. 


ACItOMECALY, 


5'3 


lurements  of  the  skull  arc  above  normal.  In  the  same  way  the 
|ip8,  cars,  nose,  and  tongue  are  found  enlarged,  whereas  all  the 
tuscles  are  feeble.  The  skin  appears  yellowish  and  pale,  but 
is  otherwise  normal.    The  tliyruid  gland  was  almost  always 

rvery  atrophic  in  the  cases  observed  up  to  the  present  lime. 


FiC'  tsj.— Case  op  Acroheoalv.    (AlWr  P.  MAIira.) 

<  Tn  spite  of  their  gigantic  appearance  the  patients  are  feeble 
and  without  strength.  The  sexual  functions  arc  lost  early  and 
completely  (Freund,  cf.  lit.). 

The  onset  of  the  disease  dates  back  to  early  childhood,  and 
it  has  to  be  regarded  as  an  abnormity  in  development  (Freund) 
"  which,  probably  beginning  as  early  as  the  cutting  of  the 
second  teeth,  certainly  sets  in  energetically  at  the  period  of 
puberty,  and  consists  in  a  rapidly  developing  enlargement  of 
the  facial  part  of  the  skull,  which  by  far  exceeds  the  physio, 
logical  limits  of  growth.  This  increase  is  especially  marked 
in  the  lower  jaw  and  also  in  the  extremities,  with  (heir  girdle 
attachments,  while  the  rest  of  the  skull  and  the  trunk  arc  only 
secondarily  altered."  The  observation  of  Gerhardt,  whose 
patient  was  perfectly  well  up  to  his  sixtieth  year,  does  not  agree 
with  this  view  {Berliner  klin.  Wochenschr.,  1890.  52). 

A  relatively  large  number  of  cases  have  come  to  autopsy 

3J 


SI4 


D/SF.ASES  OP  THE  GEXERAl.  NERi'OVS  SYSTEM. 


since  Marie's  publication,  and  from  the  number  of  instances 
reported  tlie  disease  would  seem  to  be  by  no  means  rare.  The 
results  of  these  autopsies  have  not  been  very  satisfactory,  (or 
besides  a  more  or  less  pronounced  increase  in  the  volume  of 
the  hypophysis  tlJol'i^.  Oauthicr,  Holsti).  nothing  worthy  of 


Fie.  ■56.~AcH(niEa*i.r.    (Afwr  BucitWALD  ) 

note  has  been  found ;  and  since  we  know  nothing  of  the  (ii«c- 
tion  of  the  hypophysis,  this  finding  has  thus  far  proved  of  Wvk 
value  for  the  understanding;  of  the  pathogenesis  of  the  diseax- 
Nor  is  our  information  any  more  salislaclory  so  far  as  cauK 
and  treatment  are  concerned. 

According  to  Goldschcidcr,  who  established  the  fact  iW 
the  giant  growth  is  not  confined    to  the  distribution  of  asf 


ACROMEGALY. 


S'S 


I 

I 


I 
I 


special  nerve,  being  found,  for  instance,  in  the  hand,  in  that 
of  the  mtisculo^pirul  and  the  median,  more  rarely  in  that  of 
the  tihiar,  the  etiological  influence  of  the  trophic  hbres  is  still 
a  matter  of  doubt.  Pel  (Berliner  klin.  Wochcnschr.,  1891,  3) 
ot>serred  s  case  in  which  psychical  traumatism  during  mcn> 
struation  was  followed  by  acromegaly, 

LITERATURE. 

Fribche  und  Kkbs.    Briing  nir  Paihologio  dcs  Rinenwuchso.    Ldpilg, 

(8S4. 
Marie.    Surdeux  cu  O'Akromfsalie.     Revue  de  mtd.,  1S86,  iv,  4,  p.  X97, 
Ffaniiel.  O.     Orulschc  mcil.  Wochcnschr.  188B.  3*. 
The  •ame.    Ueuuche  tAtA.-7.\%..  1S8S.  48,  p.  581. 
Erb.     l>euUcha  Arch.  f.  klin.  Mccl^  Fcbnur  4.  18SS.  xviL 
Bfoca.     Un  iquelrtlc  d'Akromigalic.     Arch.  g*n.  tie  in*d-  Dwcmbcr.  1S8S. 
Atlkr.     BtMlun  Med.  and  .Suq;.  Joum..  November  21,  188S,  exit. 
Ffeund.  V.  A.    Uvber  Akromegjilie.    Volkm^nii'iclic  Sammlung  klin.  Vonrlge. 

1889.  319.  330  (I  I.  Sft.,  Hrti  i?.  30). 
Vinhow.     Ein  Kail  und  ein  Skelcii  vi>n  Akromej^lie.    Bertiner  kli.i.  Wochen- 

Khr,.  1889.  5, 
GoIilicbcidcT.     Arch.  f.  Anat.  u.  Physio),,  Physiol,  Ablheilung,  1889^  1,  ). 
Stundby.    AcnMncgnly.    BrJi.  Med.  Jouni.,  January  5,  |8S^ 
Miric.  P.    L'Akram^K'lie.     £tuiJe  cliinque.     I'nriti,  1889. 
HultchcMnUkaS'.     Ein  Pali  von  Syringomyelic  uml  cig«nihiimlichrr  IVgrncr*- 

lign    der   p<Ti[iheren    Ncrven.    v«rt)unden    mit    irophiKhcn    Storungcn. 

(AknxBegaly.>    Virchuw'i  Arthiv,  189a,  cxix.  Heft  r.  p.  la 
ReckllngbniiBcn.  v.     Ucbcr  die  Akromeg.ilic.  Njchbchrid  lur  \'or»tebendcn  Ab- 

lundlung.     Ihid..  1890,  p.  36. 
Tmul     Ririsu  ctinka,  1^1.  Hefi  $. 
Lnthauer.     Deulf<-he  mnl,  Wochcnschr,,  i89r,  47. 
I>ucheuinm.    Contrilniiion  &  I'ttude  ajiaioini(|ue  M  clinkjua  de  rAkram^atic. 

Paris.  Bailli^.  189X 
Murray.  G.     Arroine|pily.    Brll.  Mrd,  Joum..  Febnnry  37.  1891- 
Amold.     Akromei^lic.  P»chyakrie  oder  Osiiiii?     ziegkr'ft  B«ilr.  1.  ]»ihoL 

AAat.,  1891.  I.  Ilefi  I, 
WAxt.     Ein  Fall  von  Akto«ncg»lie  fnit  biiemporaler  llcmianoptie.     Deulsche 

med.  WothtriMchr,  1891.  17. 
('•auihin.     Progiii  ni^I..  1893.  I. 

Kolui.    Ein  FaII  i-on  AkrotnrgAlJr.     ZrilKhr.  T.  ktin.  Med.,  xx.  4-^ 
fiauM.     Deuuche  n>cd.  VVuchenKhr.  1891,  40. 
Fralntrh.     Allg.  Wiener  mrd.  Zig..  1891.  37, 
.Souquc«  et  Gaine,     Nquv,  Icono^mph.  ilr  la  S-ilptiri^,  1893.  j. 
CmJcr.    Med.  CorrespondentiL  d.  Wurleinb.  Irtll.  Lande*veretnn.  Ixiti,  1S93. 

16. 
Anu>U.     Wrircrc  Hritrtlge  «ir  Aknimegalterragie.     Virchow's  Arcbiv,  1894, 

cuav.  Heft  1  (wilh  munerous  rcfeicnces). 


s«« 


DISEASES  OF  THE  GE.VEJRAL  JfEKVOUS  SrSTEJU. 


2.  OSTEOARTHROl'ATHV. 

Another  affection  depending  on  trophic  alterations,  which 
In  milder  cases  also  manifests  itself  by  changes  in  the  hands 
and  feet,  was  described  in  1890  by  P.  Marie  under  the  name 
ostfoarthropathie  hyffrlrophianu  piuu»niqne.  The  condition  is 
characterized  by  a  colossal  increase  in  the  finger  nails,  the 
terminal  phalanges  of  the  fingers  and  toes  becoming  thick- 
ened, and  the  nails  assuming  a  shape  which,  when  seen  front 
the  side,  remind  one  ol  a  parrot's  beak  (cf.  Fig.  157).  The 
resemblance  which  the  fingers  bear  to  drumsticks  justifies 
the  term  "drumstick  fingers"  (cl.  Fig.  158).  In  more  pro- 
nounced cases  the  ends  o(  the  bones  of  the  forearms  and  ol 


ng.  ■s;.-OsTKoMr»BapATHT.    (After  (Ui-zisK:  Rmie  de  nU.,  iSi|>t,  H.  i.) 

the  tibia  and  fibula  also  become  thickened.  The  (undamenol 
difference  between  osteoarthropathy  and  acrutncgaly  lie*  i" 
the  fact  that  tn  the  latter  wc  have  an  enlargement  of  all  tbe 
terminal  portions  of  the  extremities  as  well  asol  the  face.  Thf 
aetiology  of  the  affection,  according  to  Marie,  is  to  be  soui^> 


OSr£OAKTHltOPATHY. 


5'7 


in  the  existence  o(  pulmonary  affections  in  which  extensive  dc- 
:  composition  of  pus  occurs,  (or  which  rcasou  this  writer  has 


I 


ri([.  ijS.    OmaMKTii»or*inr. 
(AhcfSt-iLutANM  wkIHavhulteii;  ttcmc dc  (dM..  iflgo,!,  5.) 

employed  the  term  pncumique.  For  details  in  connection  with 
this  alTection  the  reader  is  referred  to  (he  special  articles  men- 
tioned below. 

LITERATURE. 

Man«.    Revu«  de  mtd,.  1890.  ■,  1  (the  originiil  ankle). 

S|iillmaiin  ci  HaunKilier.     [bid.,  189a  x.  5. 

Leftbrc    Th^  de  Paris,  1891.     [)cs  d^formatMns  o&ito-utkubirrt  consfctl- 

tives  a  dcR  maladies  de  I'apfMracI  plniro-iMilmonaire. 
Certuirdu    Beriiner  klin.  Wocbeiuchr.,  1890.  xviii.  Ji. 
Arnold.     Bcitr.  i.  path.  Anai.  u.  allg.  Path..  1891,  a,  1. 
Rauticr.    Revue  de  mfd..  1891.  xi.  1. 
MalMua.     MuikK.  med.  WochcnKlir.,  1891.  13. 
Minor.    Neurol.  Ccniralbl.,  1893.  16,  p.  565, 


5>8 


DISEASES  or  TtfE  CENEKAl.  NERVOUS  SYSTEM. 


APPENDIX.  — I.  ORAVES"  DISEASE— BASEDOW'S  DISEASE  (OLOTZAW- 
UESKKANKHEir,  CAfllEXIE  EXOPHTM ALMIQUE) — kXUPUTH ALIIIC 
OOlTlte — TACHVCAKDIA   STRUMOSA   £XOI>HTH ALUICA. 

This  condition,  first  described  by  Carry,  later  by  Graves, 
and  which  in  Germany  is  generally  known  as  Basedow's  di;;- 
casc,  is  an  aflectiun  o(  the  general  organism  in  which  certain 
symptoms  referable  to  the  central  nervous  system  arc,  as  a 
rule,  the  most  prominent  features.  According  to  our  present 
conceptions,  which  are,  however,  not  fully  established,  exoph- 
thalmic goitre  can  not  be  regarded  as  a  disease  of  the  ncn'ous 
system  in  the  stricter  sense,  since  the  anatomical  scat  of  the 
aScctiDn  is  situated  not  in  the  nerve  tissues  but  in  the  ihyruid 
gland.  The  anatomical  changes  which  have  thus  far  been 
found  in  the  nervous  system  (Sattler,  Filehne.  and  others)  are 
not  constant,  and,  as  it  seems,  not  essential  for  the  pathogenesis 
of  the  disease. 

Symptoms. — The  three  symptoms  which  are  regarded  as 
characteristic  of  Graves"  disease  arc  (i)  an  excited,  accelerated 
action  of  the  heart,  wiih  visible  pulsation  in  the  arteries  of  the 
neck  :  (z)  enlargement  of  the  thyroid  gland  :  (3)  exophthalmos. 
As  a  rule,  the  heart  symptoms  arc  the  first  to  appear.  The 
increase  in  the  frequency  of  the  pulse  is  variable.  We  may 
count  from  a  hundred  to  a  hundred  and  fifty  beats  a  minute, 
and  not  infrequently  the  intensity  of  the  heart  beat  is  more 
forcible  than  normal,  a  circumstance  which  adds  much  to  (ht 
discomfort  of  the  patient.  Auscultation  does  not  always  re- 
veal abnormalities.  Occasionally  a  systolic  soufHe  is  audible, 
but  this  is  often  absent.  Enlargement  of  the  heart  also  has 
been  observed.  The  extraordinarily  strong  pulsation  in  the 
carotids,  which  is  very  conspicuous  and  easily  felt,  is  in  re- 
markable contr.-ist  to  the  smallness  of  the  pulse  wave  in  the 
radial  artery  (Parry). 

The  swelling  of  the  thyroid  is  rarely  very  great  It  is  usu- 
ally symroL-trical.  In  the  gland  itself  pulsation  cnn  be  easily 
seen,  and  on  palpation  a  distinct  thrill  is  communicated  to  tbr 
hand.  1  may  say  that  1  have  repeatedly  seen  cases  in  which 
the  volume  of  the  gland  chnnired  from  time  to  time,  and  that 
this  change  became  perceptible  in  a  comparatively  short  tiiae. 
sometimes  even  in  a  few  hours. 

.\n  arterial  souffle  is    heard  over  the  gland,  the  cause  "I 
which  is  to  be  sought  in  a  hypertrophy  of  the  Icit  ventricle 


GflAl'RS'  DtSEASE. 


5<9 


and   a  disproportionate  enlargement   of  the   thyroid  artery 
(P.  Guttmann,  Deutsche  mcd.  Wochcnschr.,  1893.  11). 

The  exopluhalmos,  which  is  proUably  always  bilateral,  also 
differs  in  degree  in  diScrciit  cases.  In  the  majority,  however, 
it  is  so  marked  that  the  protruding  eyeballs  can  not  be  com< 
pictcly  covered  by  the  lids  during  sleep.  This  gives  to  the 
patient  an  appearance  which  to  the  layman  is  both  peculiar 
and  repulsive  (Fig.  159),  and  is  still   more  aggravated  if  the 


Pit  t3»— GiuvECi'  Ohbaic  (p«niMul<itiMrvaiio<i). 


Upper  eyelid  docs  not  follow  the  downward  motion  of  the 
ball,  and  thus  allows  a  zone  of  the  sclerotic,  t  to  2  mm.  in 
width,  to  become  visible  attovc  the  cornea.  This  defective  co- 
operation  of  the  lid  and  ball  (Gniefe*s  symptom),  which  hap< 
pily  does  not  occur  very  often,  makes  the  |):iticnt  frequently 
an  object  of  horror  to  those  about  him.  The  almost  com- 
plete absence  of  the  involuntary  winking  of  the  lid  (Stellwag's 
symptom)  is  quite  con<;picuous,  especi.tlly  since  the  voluntary 
movements  can  be  made  as  well  as  before.  We  can  then  easily 
I  understand  that  our  patients,  particularly  when  they  are  ladies 
of  the  better  classes,  avoid  as  far  as  possible  the  contact  with 
friends  and  acquaintances,  as  well  as  with  strangers. 


S20 


D/li£ASS.S  OF  THE  CEXE/tAL  y£/trOl/S  SVSTKM. 


Ophthalmoscopically  only  one  characteristic  sign  lias  been 
noted — namely,  the  spontaneous  pulsation  of  the  retinal  vessels, 
discovered  liy  O.  Becker.  This  is  not  confined  to  the  disk, 
but  can  be  observed  in  the  retina  as  well.  With  this  exception 
there  are  no  changes  in  the  fundus,  and  eyesight,  accommodit- 
tion,  and  pupils  are  entirely  normal.  Only  on  the  cornea  we 
occasionally  hnd  a  decrease  in  sensibility,  probably  due  to  the 
want  of  moisture  on  the  ball,  the  normal  quantity  of  the  bchry> 
mal  fluid  not  being  sufficient  on  account  of  the  undue  evap- 
oration which  takes  place,  because  the  two  lids  arc  far  apart, 
and  winking  only  rarely  occurs  (Berger,  Arch.  d'Ophth.,  1894, 
FAvrier). 

Insufficiency  of  convergence,  a  symptom  first  described  by 
MObius.  is  sometimes  observed.  If  the  patient  be  asked  to 
look  at  a  near  point,  one  eye  will  soon  be  found  to  deviate  out* 
ward. 

Narrowing  of  the  field  of  vision  has  been  described  by 
Kast  and  Wilbrandl  (Arch.  f.  Psych.,  1890.  xxii.  2), 

Among  the  subjective  symptoms,  in  addition  to  the  annoy- 
ing palpitation  already  mentioned,  a  tendency  to  free  pcrspira- 
tion  may  be  noted.  Even  slight  exertion  produces  a  feeling  of 
heat,  more  especially  in  the  head  and  neck,  so  that  the  patient 
preferably  remains  in  cool,  shady  places,  and  sleeps  with  as 
little  covering  as  possible,  etc.  An  actual  elevation  of  temper- 
ature is,  however,  not  always  objectively  demonstrable.  This 
tendency  also  accounts  for  the  blushing  evoked  by  the  least 
bodily  exertion  or  mental  emotion.  Both  symptoms  I  have 
not  infrequently  seen  to  occur  unilaterally.  Trousseau  has 
mentioned  the  fact  that  the  most  gentle  stimulation  of  the  skin 
of  the  face  and  neck  produces  a  deep-red  mark,  designated  by 
him  as  tofht  tfribraU.  a  phenomenon,  however,  which  can  ap- 
parently not  always  be  evoked.  All  these  symptoms  arc  at- 
tributable to  asthenia  of  the  vaso-motor  nerves,  as  is  also  the 
decrease  in  the  resistance  which  the  skin  offers  to  the  electri- 
cal ciirrcnl,  first  observed  by  Charcot  (the  Charcot-Vigouroul 
symptom),  the  saturation  of  the  skin  with  fluid  resulting 
from  the  dilatation  of  its  capillaries  rendering  it  a  better  con- 
ductor than  it  would  naturally  be  in  the  dry  state.  In  a  healthy 
individual  using  an  electro-motive  force  of  from  ten  to  liflecii 
volts  the  resistance  amounts  to  from  four  to  five  thousand 
olims.  while  in  the  course  of  this  disease  it  measures  from 
three  to  six  hundred  ohms,  and  only  increases  when  the  paiicnc 


I 

I 


CRAVES  D/SEASE. 


5*1 


improves.  Eulenburg  has  shown  that  the  presence  of  this 
symptom  may  be  ol  great  value  tor  the  diagnosis,  but  its  ab- 
sence proves  nothing  (Cenlralblalt  f.  klin.  Med.,  1890.  1). 

Various  nervous  disturbances  often  accompany  Graves' 
disease,  among  which  we  should  first  mention  a  peculiar  para* 
paresis  of  the  legs  (cffondeincnt  dcs  jambes).  a  giving  way  of 
the  legs,  as  it  is  called  by  the  English  authors,  a  condition 
which  is  associated  with  a  flabbiness  of  the  muscles  and  a 
diminution  or  loss  of  the  patellar  reflexes  (Charcot).  Eulen- 
burg rrgards  the  jiymptoms  as  a  manifestation  of  hysteria,  and 
as  comparable  to  asiasia-abasia  (Neurol.  Centralbl..  1890,  23). 
The  digestive  tract  may  be  implicated,  and  we  may  have  a 
well-marked  intestinal  atony  (Fcdern,  Wiener  Klinik.  1891, 
M&rz).  Occasionally  copious  vomiting  of  watery  bile  occurs, 
and  this  symptom  may  be  ol  such  persistency  as  to  seriously  re- 
ducc  the  strength  of  the  patient.  Vertigo,  biiz/ing  in  the  ears, 
sleeplessness,  occasional  transient  dyspncea,  have  also  been  ob- 
served. Falling  out  of  the  hair  ol  the  head  and  eyebrows  ts 
not  rare,  and  1  have  seen  a  case  of  a  peasant  woman,  thirty* 
eight  years  old,  who,  toward  the  end  ol  the  disease,  when  she 
was  extremely  emaciated  owing  to  the  persistent  diarrh<ca 
and  vomiting,  had  become  completely  bald.  As  complications, 
bone  disease  (osteomalacia,  Kuppen,  Deutsche  Med,-Ztg.,  1893, 
25,  p.  296),  chorea,  epilepsy,  psychoses  (Schenk,  lnaug..Dis- 
sert.,  Berlin,  1890),  e.g.  mania,  melancholia,  neurasthenic  in- 
sanity (Hirschel,  Jahrb.  f.  Psychiatric,  1S93,  12},  diabetes,  tabes 
(Joffroy,  TimotheeH,  lnaug..Dissert.,  Berlin,  1893),  and  Addi- 
son's disease  (Oppcnheim)  have  been  observed. 

Course. — We  should  keep  in  mind  that  remissions  may 
occur  during  the  course  of  the  disease,  and  may  last  even  for 
months  or  years  before  further  deterioration  leading  to  death 
takes  place.  For  the  prognosis  a  knowledge  of  the  fact  that 
such  remissions  can  occur  is  of  great  importance.  Cases  which 
pursue  a  rapid  course  from  the  beginning  are  exceptional. 
The  onset  of  the  disease  may  be  either  brusque  or  quite 
gradual.  In  the  first  case  twelve  to  fourteen  hours  are  suffi- 
cient lime  for  the  development  of  the  three  cardinal  symp- 
toms :  in  thf  latter  these  appear  gradually — first  the  palpitation. 
then  the  swelling  of  the  neck,  and  finally  the  protrusion  of  the 
eyeballs. 

Of  great  interest,  because  relatively  frequently  met  with. 
are  the  coses  in  which  the  disease  does  not  reach  its  full  devel- 


;22        D/SEASES  OF  TUB  GENERAL  NERVOUS  SYSTEM.  ^ 

opRient :  only  certain  symptoms  are  well  marked,  while  others 
may  be  hardly  perceptible  or  even  absent.  Trousseau  calls 
these  instances  "  for  met  frusles"  {fruslf — abortive),  and  attrib- 
utes much  importance  to  them.  P.  Marie  has  subjected  them 
to  a  careful  study  in  his  excellent  monograph  (c(.  lit.),  and  has 
shown  that  the  goitre  as  well  as  the  exophthalmos  may  be 
wanting,  in  which  case  wc  shall  only  find  the  tachycardia,  very 
olten  accompanied  by  a  symptom  to  which  he  has  given  special 
attention — namely,  the  tremor.  This  tremor  shows  a  great 
regularity  o(  rhythm,  and  consists  of  about  eight  or  nine 
oscillations  in  a  second.  Ernst  Cramer,  in  his  observations 
made  in  my  w.Trds.  w.is  generally  able  to  confirm  Marie's 
results.  (Ucber  das  Wescn  dcs  Zitterns.  I naug.- Dissert., 
Brt^slau.  i886.'i 

Prognosis. — The  prognosis  seems  to  be  especially  unfavor- 
able  in  man  and  in  old  age.  Youth  is  by  no  means  exempt 
from  the  disease,  since  Ehrlich  (I naug.- Dissert.,  Berlin,  1890). 
Krunthal  (Berlin,  klin.  Wochenschr.,  1893.  27),  and  others  have 
reported  cases  of  Graves'  disease  at  the  ages  of  ten,  twelve, 
and  thirteen.  Female  patients  have,  on  the  whole,  a  belter 
chance  for  recovery,  especially  if  they  become  pregnant 
(Charcot). 

Etiology. — We  are  not  yet  able  to  say  anything  definite 
about  the  a-tiology  of  the  disease,  although  it  scrms  fairly  cer- 
tain that  heredity  and  an  alteration  in  the  thyroid  gland  have 
to  be  regarded  as  indispensable  for  the  development  of  the 
disease ;  all  other  factors,  such  as  emotions,  bodily  overexer. 
tion  (mountain  climbing),  cold,  other  diseases  (e.  g.,  influenzal 
are  certainly  less  important  and  arc  probably  never  capable  by 
themselves  of  producing  the  dise.ise. 

Pathological  Anatomy. — With  regard  to  the  anatomical 
changes  it  must  be  stated  that  the  thyroid  gland  always  shovr5 
a  peculiar  hyperplasia  which  differs  Irnm  the  ordinary  goitre 
(William  S.  Greenfield,  Brit.  Med.  Journ..  1893,  December  9th). 
The  vascular  development  was  never  found  to  be  very  striking: 
microscopically  an  enormous  increase  in  the  secreting  tissue 
was  observed.  According  to  Greenfield,  this  hyperplasia  may 
exist  for  years  before  any  symptoms  of  Graves'  disease  make 
their  appearance.  The  changes  which  have  been  found  in  the 
sympathetic  nerve  of  the  neck  and  its  ganglia  are  not  constant, 
and  although  enlargement  and  thickening  of  the  ganglia  and 
of  the  nerve  have  often  bceti  noted,  wc  can  not  draw  any  coo 


G/fAt'£S-  D/S£AS£. 


523 


I 


lusioRS  from  these  results,  especiallysince  several  cases  are  on 
record  in  which  the  sympathetic  was  perfectly  normal. 

In  view  o(  thfsc  results  the  disease  must  be  regarded  as 
due  to  a  supcrsecrciion  of  the  product  o(  the  ihyiuid  glnnd 
which  has  a  toxic  action.  This  assumption  has  received  strong 
support  from  the  expcrimoiils  of  Grcrnlicld.  By  giving  dried 
thyroid  extract  to  healthy  individuais  he  produced  tachycardia. 
irritability,  irregular  elevations  oi  temperature,  and  a  tendency 
to  perspiration.  George  R.  Murray  (Lanct-t,  1893,  ii.  20v  No. 
vember  iilh)also  favors  this  view,  and  JoHroy  looks  upon 
Graves'  diseue  as  a  direct  aScction  o(  the  thyroid  gland 
(Progr,  m^-d..  1893,  2,  s.,  xviii). 

Treatment. — The  most  important  pan  of  the  treatment 
consists  in  the  (total  or  partial)  removal  of  the  thyroid  gland, 
though  there  is  by  no  means  a  general  agreement  in  regard  to 
this  point,  and  it  is  still  doubted  by  some  whether  a  complete 
cure  ever  follows  surgical  interlcrence.  It  seems  ceruin,  how- 
ever, that  operation  at  any  rate  gives  relatively  the  most  favor- 
able results.  It  often  happens  that  only  certain  symptoms 
are  rcmovcfi  by  such  procedures.  Thus.  \  have  seen  a  case  in 
which  half  a  year  after  the  operation  the  exophthalmos  still 
persisted,  while  the  subjective  symptoms,  especially  the  very 
disagreeable  tachycardia,  had  completely  disappeared.  In 
every  grave  case  of  exophthalmic  goitre,  therefore,  the  ques- 
tion of  operative  interference  should  be  carefully  considered. 

Hack,  I  loppmann.and  others,  have  reported  cases  )n  which 
destruction  of  the  swollen  erectile  tissue  of  the  nose  by  the 
galvano-cautcry  brought  about  an  improvement  in  some  of  the 
symptoms:  thus  the  exophthalmos  at  once  disappeared  on  the 
side  of  the  operation.  In  view  of  such  cases,  a  rhinoscopic 
examination  is  always  indicated.  In  other  respects  Graves' 
dise.ise  is  treated  as  all  other  general  diseases  of  the  nervous 
system  or  of  the  entire  organism.  Cold-water  treatment  has 
been  warmly  recommended,  he  it  in  the  form  of  wet  packs  or 
of  prolonged  douches :  patients  in  g<iod  circumstances  should 
be  sent  every  year  tu  a  hydrotherapeutic  establishment,  since 
such  courses  arc  frequently  followed  by  an  appreciable  though 
perhaps  a  not  very  marked  improvement.  Another  procedure 
which  deserves  attention  is  the  galvanization  of  the  neck. 
The  cathode  is  placed  over  the  angle  of  the  tower  jaw.  while 
the  anode  is  applied  over  the  lower  cervical  vertebra;  (on  the 
opposite  side);  the  current  should  be  weak, and  only  applied 


524        i>^S£AS£S  Of  THE  GENERAL  S'EltVOUS  SYSTEM.        ■ 

for  a  minute  to  a  minute  and  a  half  at  a  time  ;  often  the  symp- 
toms diminish  steadily  after  ten  or  fifteen  sianees.  usually  after 
twenty  or  thirty,  an  improvement  follows  which  may  last  for 
years  (Erb.  IJenedikt,  Guttmann.  Mor.  Meyer,  and  others). 
Whether  this  result  Ls  to  be  attributed  to  an  action  upon  the 
vagus  or  the  sympathetic  can  not  be  decided,  since  both  these 
nerves  are  influenced  by  the  current  in  the  galvanization  of 
the  neclc. 

hitcrnal  remedies  arc  of  comparatively  little  value.  The 
tincture  of  strophanthus  (two  to  ten  drops  every  six  hours  for 
four  weeks),  which  has  been  recommended  by  Browcr.  often 
leaves  us  in  the  lurch,  and  belladonna  and  iron  arc  only  of  value 
in  those  mild  cases  occurring  in  young  female  patients  which 
are  apt  to  show  well-marked  remissions.  In  these  an  improve- 
ment of  longer  or  shorter  duration  may  occur  under  various 
drugs,  but  since  this  also  happens  when  none  at  all  arc  given, 
we  have  no  right  to  attribute  it  to  any  particular  medication. 
The  marked  improvement  which  sometimes  occurs  during 
pregnancy  has  already  been  spoken  of. 

I  LITERATURE. 

Bat«ylow.  T.     Kvophihalmus  duieh  HyperlK^hie  A«%  Zvllgcwcbrs  in  Att  Augcn- 

liohle.     Caliper's  WochenMbr.  f.  d.  ges.  Heitkunde..  1S40.  No.  13.  pt  197: 

und  No.  14.  p.  130. 
TrouMcnu.    Du  goilre  cxophlh.     Union  ntiA.,  Nos.  143.  143,  14^  147:  Ca^ 

hcbdoni^  pp.  319. 167  :  Gai.  dcs  hAp..  i860,  Nos.  1391  143. 
Oppolxrr.    tJcbcr  Itucdnw'sche  Krankhdt.    Wiener  med.  Wochcnschr.  tStt, 

Nus.  48  u.  49. 
ChvoMck.     WcitCTv  B«iiRlge  lur  Pathologic  und  ElekirMhentpte  (kr  Basedow- 

'tchcn  KtankhciL     Wiener  med.  Ptcsse.  1873,  No*.  33.  37.  }3.  39.  4I-4& 
EutcntHirjE  el  t^utlnunn.    Die  p4tholo([ie  des  SympaOucusL    Berlin.  1873.  |fL 

31  tt  tf^. 
SatlltT  in  OrSre-SiinuMh'  Handbuch  der  Augrnbrilkande.    Lepdg.  Eni^laMRn. 

1680.  vi. 
Mjme,  P.    Contribution  A  I'iludc  el  au  diagnostic  dc9  (ormes  fru«ies  de  b 

nwiUilic  ik  [UsrtUnv.     Aux  Hutcjiux  du  Progris  mfd..  Pant,  188& 
Sainie-M^c.  M.    Coiitntiuiion  &  I'Aude  de  U  nuladie  de  Uasedow.    TMsed^ 

Pari*.  18S7. 
Vlgmroux.    Sur  )e  Inilement  «l  stir  quelques  partirabriUs  diniqws  dc  b 

nuladic  Ae  Biicdow.    IVogrte  m6d..  1SS7,  No.  43. 
Eatcnburg.     Ucrliacr  klin.  Wochcoschr..  1889, 1. 
J.  Rund-ReynaMs.    Lancet.  1890,  348r. 

Kitmniel.    Deutsche  med.  Wodwnschr^  189a.  30..    (Rcn»oval  ofGoitrc.) 
Lrmke.     IVutschc  mcd,  Wochenschr.  1891.  s. 
MObklS.     Dmtschc  Zrit>cbr.  f,  Nervcnhk..  iSvl,  I.  $.  6, 
Dreesmaan.     Deutsche  nicd.  Wochcnxhr..  1893.  J. 


MY.X<EDE.\tA. 


5*5 


I 


I 

I 
I 


I 
I 


I 


Drttrmaver.    HeulMhe  Med.-Ztg.,  1891.  103. 

Wrlle.    Arch,  t  klin.  Chtr..  1891,  xliv.  Heft  3. 

Mrndd.    Deutsche  mvd.  Wochenuhr.  1893.  ;.    (PaihologinI  Anatomy.) 

Illaicus.    WcMn  und  Uehamllunx  des  Mi>rbus  Boscdowli,    Deui&clie  .Med.-Ztg., 

Joffrof.    Nature  et  trajtemeni  dn  goitre  Oiththalm.     Troj;^  mH...  1894,  10-13. 

Marie.  P.     Dtul&clie  Mcd.-Zig..  1894.  39.  p.  33;. 

Mannheim.     Dcr  Morbus  Or.ivcsii.    Berlin.  1894,  Hirschw^ld. 

Mobios.    Schmidt's  Jahrb..  ccali.  3.  p.  134,  1894. 

II.  MVXtEDEMA  (GULL  AS1>  ORD^  CACHEXIA  PACHVDERMIQUE 

(CHARCOT). 

Myxoedema  should  be  considered  immediately  after  Graves' 
disease,  because  it  may  be  regarded  clinically  as  \vcU  as  ana- 
tomically as  the  direct  opposite  of  the  latter  aflectjon  (Green- 
field). While  in  Graves"  disease  we  ha%'e  a  hyperplasia  of  the 
tissue  of  the  thyroid  and  a  hypersecretion,  we  find  in  myxoe- 
dema  an  atrophy  and  replacement  «f  the  secreting  tissue  by 
hard  fibrous  tissue— myxa-dcma  atrophicum.  Myxtrdcmalous 
symptoms  have  also  been  observed  in  cases  in  which  the  thy. 
roid  gland  had  been  removed  by  operation— myxtedcma  oper- 
ntivum.  The  cause  of  the  spontaneous  degeneration  is  not 
known:  the  fact  that  the  disease  has  been  known  to  occur  a 
number  of  times  after  exposure  to  wet  and  cold  is,  o(  course, 
not  sufficient  to  establish  the  a:tiologicat  Jmportanct  of  these 
factors. 

The  general  swelling  has  been  found  to  be  not  an  oedema, 
but  to  depend  upon  the  development  of  a  mucin-containing 
myxomatous  new  formation ;  in  the  skin,  the  connective  tissue, 
in  the  saliva  and  the  blood. mucin  can  be  demonstrated  incon- 
siderable amount.  Kracpelin  has  observed  an  increase  in  the 
diameter  of  the  red  blood>corpuscles,  as  well  as  an  increase  in 
the  specific  gravity  of  the  dry  residue  of  the  blood  (Dctitschcs 
Arch.  I.  klin.  .Med.,  xlix,  6.  p.  587).  Symptomaiically  the  dis. 
ease  manifests  itself  by  a  peculiar  swelling  of  the  whole  face, 
the  skin,  especially  in  the  region  of  the  eyelids  and  the  cheeks. 
ap])earing  tt-demaious.  The  lips  are  not  completely  closed, 
and  the  saliva  dribbles  from  the  comers  of  the  mouth.  Owing 
to  the  stumpy  thick  nose  and  hatf.opened  eyes  the  face  be- 
comes somewhat  uncouth  and  common- looking,  and,  later,  ex- 
pressionless and  crctinlike  (cf.  Fig.  160).  The  patients,  cspe- 
cially  i{  they  are  females,  grow  to  look  so  much  alike  that  they 
appear  as  il  they  all  belonged  to  the  same  family.     The  color 


526        D/SF.ASF.S  OF  THE  GEXERAI.  NERVOVS  SYSS'EM. 

of  the  face  is  pirle,  the  sitin  Eg  waxlike,  but  docs  not  pit  on 
pressure.  The  ndcma  of  the  rest  o(  the  Imdy  has  the  same 
character  as  that  of  the  face.  The  skin  of  ihe  neck  forrnsfulds. 
the  hands  arc  thickened.  On  the  hard  wrinkled  skin  circum- 
scribed thickenings  can  be  seen,  hair  and  nails  fall  out,  the 
teeth  become  curious,  the  secretions  diminish  and  dry  up. 
Anienorrhoea  is  common.  The  lungs,  heart,  and  large  vessels 
present  no  abnormities.  On  examination  the  urine  is  found 
to  be  negative,  while  the  temperature  is  subnormal.  Among 
the  concomitant  symptoms  must  be  mentioned  sensory  and 
motor  disturbances,  uncertainty  in  the  gait,  and  general  lasM- 
tude.  Such  patients  get  easily  fatigued,  and  their  mental 
faculties  deieriurate  {IiUolie  myxoedfrnattMst,  Fig.  l6i). 


Will 


Mi 


Fig.  tOoL— Ca»  or  HvxtzpEitit.    (After  Cnarcdt.) 

The  disease  is  not  e:isily  mistaken,  but  Lassar  has  called 
attention  to  the  fact  that  certain  erysipelatous  swelling  nay 
give  to  the  face  an  expression  similar  to  that  secci  in  niyo^ 
dema. 

The  modem  treatment  of  myj^axlema  is  very  satisfaclory- 
Thc  principle  is  to  replace  the  missing  or  degenerated  thyroid 


U  YXGP.DEMA. 


sv 


f;liind.  This  cnn  be  done  either  by  implanting  a  gland  into  the 
peritonea!  cavity  (Uorslcy).  by  injecting  thyroid  juice  (Murray), 
or  by  giving  it  by  mouth  (VVichniann).  The  best  thyroid  lo 
be  used  (ur  the  purpose  is  that  of  the  sheep.  Burmughs,  Wel> 
come  &  Co.,  in  London,  have  made  compressed  tablets  o( 


(Aftw  BouiuitviLLK :  ArIl  dc  K<ur.,  tH9t^  lii,  56.) 

powdered  thyroid,  each  one  o(  which  contains  five  grains  o( 
the  substance.  Wiclimann  has  obtained  excellent  results  from 
their  administration  {Deutsche  med.  Wochcn&chr.,  189343).  P* 
Marie  has  also  spoken  very  favorably  of  the  thyroid  treatment 
(Deutsche  Mcd.-Ztg.,  1894.  29.  p.  335). 


LITERATURE. 


Tnuisao* 


CutL    On  a  Cnriinoid  SijIf  tuprnrning  in  Ailull  Life  in  Women. 

Ikms  of  the  Clin.  Soc^ii^ty,  iS;4.  vii.  \k  18a 
Ont.    On  MjnKEdrnu.     Med.-ChiT.  T»nuirilDns.  187S.  Ixi,  p.  57. 
lIoiRiTi'ind.    On  Myxcedrma  wiih  SpcHal  Reference  to  ii»  Cerebral  and  Nerv> 

ou»  SjmjkUBU.     Neurol.  Com n button s.  1886,  i.  5,  p.  36. 


528         DISEASES  OF   THE  GENERAL   NERVOUS  SYSTEM. 

Charcot     Gai.  des  hSp.,  1881,  10. 

Saville.    Case  of  Myxcedema  in  a  Male     Btit.  ^fed.  Joum.,  December  3,  1887, 

p.  1116, 
Palon.    Glasgow  Med.  Joum.,  December,  1887. 
Reverdin.    Contribution  i  I'itude  du  inyxtEdime  consicuiifi  I'eiclirpation  torale 

ou  partielle  du  corps  thyrolde.    Revue  m£d.  de  la  Suisse  romande,  1887, 

5.6. 
Zielewicz.    Berliner  klin.  Wochenschr.,  1887,  22. 
Munk.     Untersuchungen  iiber  die  Schilddriise.    Sitzungsber.  der  konigl.  preuss. 

Akad.  d.  Wissensch.,  1888. 
Probnik.     Die  Folgen  der  Exstirpation  der  Schilddriise,    Arch.  f.  experim.  Paih. 

u.  Pharm.,  1S8S.  xxv,  2. 
Conclusions  of  the  Myxcedema  Committee.     Brit.  Med.  Joum.,  June  2,  1888,  p. 

1 1 62. 
Mosler.     Ueber  Myxodem.    Virchow's  Arch.,  cxiv.  Heft  3. 
Cousot.     Idiotie  avec  cachexie  pachydermique.      BulL  de  la  Soc.  ment.  de 

Belgique.  1881,  ji. 
Manasse.     Berliner  klin.  Wochenschr..  1887,  47. 
Horsley.     Brii.  Med.  Joum.,  February  8,  1890. 
Bircher.    Samml.  klin.  Vortr.,  1890,  No.  357. 
Buzdygan.     Wiener  klin.  Wochenschr.,  1891,31. 
Murray.    Brii.  Med.  Joum.,  October  8,  rSgi,  and  August  17,  1892. 
Howili.    Ugeskrift  for  Laeger.,  1892,  7-9.  p.  109. 
Laache.     Deutsche  med.  Wochenschr..  1893.  11. 
Lundiz.    Edinb.  Med.  Joum.,  1893.  xxxviii,  p.  996. 
Kinnicutt,     New  York  Med.  Record.  1893,  xliv,  15. 
Relm.     Ueber  die  Myxodemform  des  Kindesallers  und  die  Erfolge  der  Behand- 

lung  mil  Schilddrusenexlracl.     Vcrhandl.   d.   Congr.   f.  innere  Med.,  1S93. 

xii,  p.  224. 
Vermehren.     St offwechsel untersuchungen  nach  Behandlung  rait  Glandula  ihy- 

rcoidea  an  Individuen  mit  und  ohne  Myxodem.     Deutsche  med.  Wochen- 
schr.. 1893,  xix,  43. 


SECOND  GROUP. 


NEU/IOSES  I.V  WHICH  THE  ESTIRE  OKGA.S'iSM  /S  MOKE  OJf 
LESS  SSyEXEtr  IMPLICATED. 


I 


CHAITER    1. 


NCt'R ASTHENIA — KBKVOUS   rxrVSTRATION. 


Nhurastiiknia  (o,  privative;  o^/mk,  force)  or  neiroiis  ex- 
haustion is  an  affection  of  the  ncni'ous  system  with  which  the 
^ncral  practitioner  meets  very  Irequently,  and  is  one  o(  those 
diseases  which  may  give  rise  to  a  f^ood  deal  of  error  in  diag* 
iiosis  and  prognosis.  At  the  same  time  it  makes  the  most 
boundless  demands  upon  the  forbearance  of  the  physician  and 
upon  the  patience  of  the  sufferer.  The  disease  is  a  child  of  the 
modern  mode  of  living,  ol  llie  desire  to  become  rich  as  soon  as 
possible,  and  wc  look  for  it  in  vain  in  the  old  text-books.  AU 
thoiigh  it  may  in  earlier  times  have  occurred  now  and  then, 
the  neurologists  had  neither  opportunity  nor  occasion  enough 
in  study  it  intimately.  This  has  only  become  possible  quite 
recently,  and  it  is  certainly  a  fact  of  significance  that  neur.as- 
tt)cni:i  has  been  "discovered"  in  that  continent,  the  inhabit- 
ants of  which  have  the  reputation  of  working  the  quickest. 
of  living  at  the  highest  pressure,  and  therefore  of  being — of 
course  will)  exceptions — more  nervous  and  aging  sooner  than 
those  of  the  Old  World,  to  wit,  in  America.  Beard,  to  whom 
wc  owe  so  many  excellent  observations,  so  many  splendid 
hints  for  therapeutics,  described  it  first  and  gave  it  the  name  it 
bears.  Whereas  the  disease  prior  to  Beard's  publication  was 
unknown,  it  soon  began  to  prevail  in  such  a  striking  manner 
and  to  be  diagnosticated  so  frequently  that  one  is  almost  led 
to  think  that  this  diagnosis  is  often  arrived  at  in  cases  where 
something  else  exists,  some  organic  affection  possibly  more 
ditTicult  to  recognixe.  The  disease  in  question  is  not  organic 
and  not  associated  wiih  any  demonstrable  anatomical  altera* 
lions.  Nobody  has  ever  succeeded  in  finding  any  character- 
istic anatomical  changes  in  individuals  who  have  suffered  for 


530 


mSJSASES  OF  THR  GENERAL  XEHVOVS  SYSTEU. 


years  from  the  most  pronounced  neurasthenic  mamtcstatioos 
and  then  have  died  from  some  intercurrent  disease.  A  large 
number  of  subjective  complaints,  many  of  which  fit  into  other 
clinical  pictures,  make  it  intelligible  why  a  diagnosis  of  neuras- 
thenia is  often  made,  sometimes  without  any  sufficient,  careful 
consideration  of  all  the  factors  which  ought  to  b«  taken  into 
account.  It  is  comfortable  and  presumes  nothing.  Its  possi- 
ble incorrectness  can  frequently  not  be  demonstrated,  and  it 
therefore  rapidly  attained  a  great  popularity  among  physicians. 
Symptoms. — The  first  traces  ol  the  disease  develop  very 
gradually  and  imperceptibly.  Sometimes  they  assume  more 
of  a  cerebral,  sometimes  more  of  a  spinal  character,  so  that  it 
has  been  thought  justifiable  to  distinguish  a  spinal  and  a  cere- 
bral  neurasthenia  (Encephaiasthenia,  Althaus.  Deutsche  mcd. 
Wochenschritt.  1894.  13).  For  the  cases  in  which  the  symp- 
toms of  derangement  of  digestion  were  most  prominent  the 
term  gastric  neurasthenia  was  coined,  under  which  head 
we  may  possibly  class  certain  of  the  sn-callcd  nervous  dys- 
pepsias. Schott  (Deutsche  mcd.  Wochenschrift.  1890,  34) 
h.as  called  attention  to  the  neurasthenia  cordis.  In  the  ma- 
jority of  cases  the  patients  complain  of  getting  easily  and 
rapidly  fatigued  after  the  bodily  exertion  which  is  ass<Kiatcd 
with  their  ordinary  daily  doings,  whether  at  home  or  in  thfir 
business,  alter  walks,  gymnastic  exercise,  etc.  Things  which 
they  used  to  do  without  the  least  difficulty  lire  them  greatly. 
In  going  distances  which  were  formerly  covered  with  case  they 
have  to  rest  half  way,  and  require  more  time  to  accomplish  a 
given  task.  Not  always  are  definite  pains  present.  At  times 
there  are  aches  in  the  back  and  loins  severe  enough  to  be 
troublesome.  Sensory  <listurbance$,  p.-ir%sthesia5,  formication 
in  the  extremities,  or  numbness,  are  rarely  absent.  These  feel- 
ings distress  the  patient  and  may  make  him  fear  he  has  tabes, 
and  the  idea  that  he  is  suffering  from  some  spinal  trouble  is 
fostered  by  the  circumstance  ihat  the  sexual  power  is  usually 
decidedly  diminished,  be  it  that  the  patient  is  unable  to  hav< 
connection  as  often  as  before,  be  it  that  the  erection  of  the 
penis  is  incomplete  or  Ihat  no  ejaculation  of  semen  occurs. 
For  married  patients  this  weakness  is  a  source  of  great  dislrcM 
and  often  is  a  very  prominent  symptom,  and  frequently  it  is 
this  that  finally  decides  them  to  consult  a  physician,  a  step  which 
has  been  again  and  again  deferred.  The  more  we  have  lodcal 
with  neurasthenias  the  more  frequently  shall  we  make  the  <*■ 


NEUKA  STHEXIA. 


53> 


I 
I 


strvation  tliat  the  !>cxiial  functions  are  in  the  majority  of  cases 
in  some  way  ur  other  »l1ecte<l,  »nd  that  the  sexual  neurasthenia 
particularly  deserves  the  most  careful  attention  ol  the  physi- 
cian. To  determine  whether  the  complaints  of  a  iKiticnt  with 
regard  to  his  disordered  sexual  functions  depend  upon  oi^anie 
disease  or  upon  neurasthenia  we  have,  besides  a  careful  cxum- 
inalion  of  the  genitals,  to  examine  the  urine.  It  is  well  known 
thai  the  urine  of  neurasthenics  not  rarely  presents  a  decided 
increase  of  urates,  oxalates,  and  phosphates,  and  that  not  infre- 
quently spermatic  fluid  is  passed  during  micturition  or  during 
defecation  (Beard  and  Rockwell,  cf.  lit.).  Where  the  patients 
complain,  as  they  so  commonly  do,  of  impotence,  we  shall 
have  to  determine  what  form  we  arc  dealing  with,  and  whether 
organic  disease,  more  particularly  atrophy  of  the  testicles,  is 
the  underlying  cause.  Sometimes  there  exists  only  a  decrease 
in  the  sexual  di;sire,  while  the  power  remains  the  same ;  some- 
times a  decrease  in  the  power  and  an  increase  in  the  desire,  so 
that  the  ejaculation  of  semen  occurs  too  early,  sometimes  he- 
(orc  the  insertion  ol  the  penis.  Again,  both  sexual  desire  and 
power  diminish  pari  passu,  or  finally  the  petftttta  toetmdi  is  iror- 
nial  but  there  is  absence  ol  spcrmaloroa  ("aspcrmatism  "), 

All  changes  of  this  kind  are  noticed  by  the  patient  and 
their  significance  is  ever  cxa^eraled  by  a  fervid  imagination. 
Even  in  the  cases  in  which  in  reality  there  is  no  disease  and  in 
which  the  impotence  depends  entirely  ujton  psychical  inllu- 
enccs.  it  makes  itself  disagreeably  felt,  and  we  must  not  forget 
that  such  a  "  psychical "  impotence,  in  spite  of  all  cncounigement 
and  all  assurances  on  the  part  of  the  physician  is  sometimes 
more  difficult  to  cure  than  one  which  depends  upon  organic 
disea^  of  the  sexual  apparatus.  Every  abortive  attempt  at 
coitus  exerts  a  depressing  influence  upon  the  paiieni  lor  a  con- 
siderable lime  and  is  quite  liable  to  lead  to  a  second  failure, 
although  all  other  conditions  lor  the  normal  performance  of 
the  act  may  be  favorable  (FUrbringcr,  cf.  lil.>. 

The  disturbances  o(  the  cerebral  functions  which  appear  in 
the  course  of  neura.sthcnia  are  very  manifold.  First,  the  pa- 
tient is  down>hearted  and  wornetl  and  sees  everything  in  the 
blackest  colors,  and.  above  all,  despairs  of  recovery.  He  be. 
comes  irritable  and  impatient,  unsociable  with  his  friends,  and 
feared  by  his  family.  In  his  work  he  is  less  efficient.  Duties 
which  he  previously  performed  without  trouble  seem  hard  to 
him  and  require  twice  or  three  limes  as  long  for  their  accom- 


5J2 


DISEASF.S  OF  THE  GF.XEKAL  XEKFOVS  SYSTEM. 


pHshment.  Cases  in  which  this  is  nut  a  prominent  feature,  but 
where  ihc  working  power  rcmaiiis  unchanged,  are  met  with, 
hut  arc  exceptions.  Tiie  sleep  is  usually  disturbed  ;  some- 
times a  protracted  insomnia  adds  to  the  trouble.  Headache  is 
not  the  rule,  but  the  p;ilient  often  complains  of  a  disagreeable 
pressure  in  his  head,  which  is  accompanied  with  a  slight  feel- 
ing of  di/Jiiness.  All  functions  share  in  the  disorder,  the  appc 
tite  becomes  bnd,  the  bowels  sluggish,  the  action  of  the  heart 
feeble,  and  vaso-moior  disturbances  in  the  form  of  persistent 
coldness  of  the  hands  and  feet  manifest  themselves.  The  gen- 
eral condition  of  the  patient  is  very  pitiable  in  the  higher 
grades  of  neurasthenia,  and  it  is  necessary  for  the  physician 
to  make  a  must  careful  vxamiiiulion  so  as  not  lo  go  astray  io 
the  diagnosis. 

The  objective  examination,  in  contradistinction  to  what  the 
manifold  complaints  of  the  patient  miglu  lead  us  lo  expect,  re- 
veals strikingly  little.  Organic  changes  can  not  be  demon- 
strated anywhere.  Thoracic  and  abdominal  organs  are  healthy; 
nothing  abr>ormal  can  lie  detected  in  the  domain  of  the  crani.ii 
nerves  or  in  the  fundi  of  the  eyes.  The  condition  of  the  pupiU 
varies.  Transient  differences  in  their  size — that  is,  unilaiera! 
dilatation,  without,  however,  any  abnormity  in  the  pupillan 
rcffex — is  certainly  met  with.  The  dilatation  may  either  al- 
ways be  on  the  same  side  or  change  at  limes  lo  the  other  eye 
The  phenomenon  is  usually  marked  when  the  general  condition 
is  bad,  while  it  disappears  il  decided  and  lasting  improvement 
IS  once  established.  The  claim  that  tasting  inequality  of  the 
pupils  is  always  a  sign  of  organic  disease,  as  Beard  thinks,  mu>l 
certainly  be  somewhat  modified  (f*eliz.ieus).  I  have  myself 
seen  differences  in  the  pupils  persist  for  eight  or  ten  months 
and  then  disappear  and  the  patient  gel  well. 

The  peripheral  nerves  as  well  as  the  tendon  and  skin  re- 
flexes are  normal.  Tenderness  over  the  vertebra;  rarely  is  ab- 
sent, but  is  of  no  signiricancc. 

Diagnosis. — When  we  have  once  sufficiently  informed  mir- 
selves  about  these  points  the  diagnosis  will  usually  present  W 
little  difficulty.  At  first,  it  is  true,  wc  may  be  easily  led  astray 
and  think  of  organic  diseases  of  the  brain,  especially  pro- 
gressive paralysis  of  the  insane  or  a  brain  tumor,  ycl  tlie  liu- 
thcr  course  of  the  disease  will  soon  clear  the  mailer  up.  Tbr 
suspicion  of  tabes  which  may  arise  on  account  of  the  cercbrjl 
and  particularly  of  the  spinal  symptoms,  the  disturbances  c^ 


NEVRASTIlKNtA. 


533 


I 


the  sexual  fnnctiuiis,  and  so  (oiih.  will  be  discarded,  owing  |o 
the  persistence  of  the  patellar  rcllcxcs,  the  absence  ol  actual 
bhidder  symptoms  and  pronounced  sensory  disturbances,  an- 
KStheiiias  and  hypera-sthesias.  iis  well  as  ol  actual  motor  weak- 
ness. Fibrillary  twitchings,  such  as  are  observed  in  proj^rcss- 
ivc  muscular  atrophy,  may  here  also  be  met  Hitli,  but  (hey 
arc  seen  rarely  and  their  occurrence  varies  a  |;;u<)d  deal.  From 
hysteria  neurasthenia  is  distinguished  by  the  fact  that  the  con- 
stant change  of  the  symptoms  which  is  so  characteristic  of  hys- 
teria, besides  the  circumscribed  neuralgias,  the  contractures. 
the  spasms,  etc.,  is  here  not  observed.  Still,  to  make  a  diag- 
nosis, repeated  and  careful  examinations  are  needed,  to  which 
the  patients  do  nut  submit  as  willingly  as  hysterical  men  and 
women. 

.Etiology. — In  every  case  in  which  hereditary  influences 
can  be  excluded  the  prime  cause  of  neur.is(hcnia  is  unques- 
tionably to  be  looked  for  in  an  overtax  of  the  nervous  sys- 
tem. This  is  brought  alwiut  in  many  ways,  by  excessive  men- 
tal work  or  by  hubiluat  bodily  overexertion.  It  may  he  at- 
tributable to  repeated  emotions  or  to  sexual  excesses.  Under 
the  latter  head  we  may  put  masturbation,  which  is  a  wide- 
spread evil  among  the  young  of  both  sexes  and  the  practice  of 
which  not  only  may  begin  very  early,  but  may  be  continued 
much  longer  than  the  physician  himself  might  suspect.  One 
may  say  that  there  arc  but  few  neurasthenics  who  have  not 
during  their  youth  been  addicted  to  this  habit  for  a  longer  or 
shorter  period  of  time.  "Sexual  pcr\-crsion "  (Spilzica)  and 
the  various  kinds  of  "psychical  masturbation"  may  also  be- 
come of  aitiological  siguilirancc.  Even  in  married  life,  where 
the  satisf.iclion  of  the  sexual  desire  is  otherwise  well  regulated. 
the  coitus  interruplus  sive  rcservatus,  which  is  practiced  to 
avoid  loo  great  an  increase  in  the  family,  may  afford  a  cause 
lor  neurasthenia.  In  my  experience  very  few  men  have  been 
able  ti>  practice  with  impunity  for  years  this  coitus  interniptus, 
and  it  is  the  boundcn  duty  of  the  physician  to  inquire  with 
much  tact  but  still  with  perseverance  into  this  question. 

In  some  cases  the  abuse  of  tobacco  may  lead  to  neurns- 
thenia,  so  that  the  latter  has  to  be  looked  upon  directly  .is  a 
nicotine  poisoning,  and  must,  of  course,  be  treated  accordingly. 
Persons  whose  occupation  necessitates  work  not  only  energetic, 
but  also  associated  with  the  emotions  fartists,  students,  finan- 
ciers, speculators,  etc.),  also  those  whose  occupation  entails  at 


534 


D/SHASES  OF  THE  GENBRAL  KEKVOVS  SYSTEU. 


the  same  time  bodily  as  well  as  mental  strain,  are  all  more  or 
less  neurasthenics.  Not  rarely  repeated  losses  of  a  consid- 
erable qnantily  of  blood  produce  neurasthenia  by  causing  a 
general  ana:mia,  yet  wc  must  delinitcly  slate  that  the  neuras- 
thenia may  occur  very  well  in  such  cases  without  the  anemia. 
Traumatism  also  may  cause  neurasthenic  conditions.  About 
these,  which  are  usually  intermediaie  forms  between  this  dis- 
ease and  hysteria,  we  shall  have  to  speak  later,  under  the  head 
of  "  traumatic  neurftses."  Finally,  neurasthenia  has  been  known 
to  occur  alter  infectious  diseases,  typhoid  fever,  cholera,  vari. 
ola.  In  these  cases  the  bad  state  of  nutrition  and  the  faulty 
condiiion  of  the  blood  have  to  be  held  responsible. 

Treatment. — The  treatment  of  neurasthenia  is  one  of  the 
most  troublesome  tasks  which  the  physician  encounters.  It  is, 
of  course,  not  suffictcni  to  give  the  patient  a  prescription  and 
let  him  go.  We  must  frequently  exauiitie  him,  not  only  on  our 
own  account,  but  for  his  own  sake  as  well,  because  he  is  com- 
forted by  the  attention  and  solicitude  of  the  pjiysician.  although 
the  examination  itself  is  usually  dis.igrccablc  to  him.  There  arc 
neurasthenics  who  are  actually  relieved  by  repeated  examina- 
tions, although  nothing  is  ever  prescribed.  They  gain  there 
from  the  quieting  conviction  that  somebody  is  looking  out  for 
them,  and  this  gives  them  hope,  lint  here  also  the  direct 
psychical  treatment,  such  as  we  usually  find  to  be  of  value 
in  hysteria,  is  of  the  greatest  importance.  The  patient  musi 
again  and  again  be  encouraged  and  told  that  all  his  organs  arc 
healthy,  that  it  is  only  a  nervous  overstiain  which  he  ts  suffer- 
ing from,  a  deficit  in  his  nerve  capital  which  it  is  somewhat 
difficult  to  replace.  To  e);ert  a  mental  inlluence  u|K)n  the  pa- 
tient in  this  manner  time  is  necessary,  and  those  physicians  who 
can  not  afford  sutlicicnt  time  for  the  purpose  should  not  take 
charge  of  a  grave  case  of  neurasthenia  at  all. 

If  hypochondriacal  notions  are  prominent  features,  so  Ihni 
the  patient  is  beyond  the  reach  ol  consoling  and  encouraging 
words,  the  question  whether  or  not  he  should  be  removed  lo 
an  institution  must  come  under  consideration.  In  addition  to 
the  fact  that  change  of  air  and  scene  exerts  in  itself  a  favorable 
influence,  it  is  advisable  to  place  a  neurasthenic  after  a  certain 
time  among  diRcrcnl  surroundings,  so  thai  he  has  to  meet  with 
different  people  and  has  something  fresh  to  occupy  his  mind 
with,  and  care  should  be  taken  to  keep  him  constantly  ut»dcr 
the  guidance  of  a  physician.    As  supplying  such  rcquiretneots 


I 


A'EVKASrifEXrA. 


S35 


■  sanitaria  for  nervous  people,  in  which  insane  cases  arc  not  re> 

■  ccivcd,  are  to  be  highly  recommended.  Of  course  the  pecu- 
niary c<indition  nf  the  family  must,  before  decidinf:  upon  this, 
be  taken  into  account,  since  all  establishments  of  this  kind  in 
which  patients  are  well  cared  for  are  rather  expensive.  Some- 
limes  in  the  more  favorable  instances  a  slay  of  from  four  lo  six 
months  is  sufficient  to  bring  about  a  very  decided  improve, 
ment.  in  which  case  even  families  who  are  not  very  well  off 
sh<mld  be  able  to  afford  the  expense. 

There  are  especially  two  factors  from  which  much  is  to  be 

■  expected  in  the  treatment  of  neurasthenia,  and  these  are  elec- 
tricity and  hydrotherapy,  pariicularly  the  cold-water  treat- 
ment.    With  regard  to  the  f<irnier  it  may  well  be  stated  that 

■  there  is  no  other  nervous  affeclion  in  which  its  application  Is 
followed  by  such  excellent  results  as  here.  Used  at  (he  pro|»er 
lime  and  in  proper  doses,  so  to  ^peak,  it  i$  most  benclicial, 

■  The  method  which  is  best  employed  and  to  which  we  give  by 
(ar  the  prelercncc  is  the  so-called  jjener-i!  faradization  as  rec- 
ommended by  Beard  and  Rockwell,  as  welt  as  the  general  gaU 

ft  vani/iition.  The  results  are  especially  strikinf^  if  we  make  use 
oi  the  brush,  which,  in  Beard's  method,  is  not  only  applied  to 
the  back — although  it  is  kept  here  longest — but  (with  the  ex. 
ception  ol  the  head)  all  over  the  body.  .Mihough  the  patient 
may  compliin  ol  disagreeable  and  painful  sensations  for  the 
five  or  eight  minutes  during  which  the  sitting  lists,  the  after 
effects  which  soon  follow  are  most  gratifying.  The  patients 
(eel  invigorated  and  leave  ihc  physician  with  a  sense  of  having 
gained  a  new  lease  ol  life.  According  to  our  experience  the 
fanidi/alioti  as  advised  by  Beard  is  superior  in  its  action  lo  the 
electrical  baths,  which  arc  much  more  circumstantial  and  have 
not  been  as  yet  sufficiently  studied. 

With  reference  to  the  cold-water  treatment,  to  which  we 
have  repeatedly  called  attention  in  different  places,  we  must  in 
this  more  than  in  any  other  affeclion  warn  against  ovcrzcal- 
ousncss  and  insist  upon  caution.  Low  tempenitures  are  lx)n)e 
very  badly  by  these  nervous  and  irritable  patients.  They  be- 
come  excited  and  sleepless,  and  our  aim  is  not  only  fnislraled. 
bul  actually  more  harm  than  good  is  done.  However,  if  wc 
cautiously  begin  with  a  temperature  ol  from  86^  to  78°  F..  and 
confine  our  measures  to  gentle  rubbings,  affusions  of  short 
dunition.  cool  hip  baths,  also  of  short  duration,  and  avoid 
douches  altogether,  it  care  is  taken  at  the  same  time  to  insure 


536        D/SEASES  OF  THE  GEA'E/tA/.  XEftyOUS  SYSTEM. 


proper  nourishment  and  exercise  for  ihe  patient,  tlic  best  (onn 
of  which,  perhaps,  is  a  walk  in  the  woods,  the  results  arc  en- 
couraging and  lasting,  il  nt:ither  physician  nor  client  lose  their 
patience  loo  soon.  A  course  of  treatment  of  this  kind  can  not, 
however,  be  compressed  into  the  usual  four  weeks  o(  a  summer 
vacation,  but  to  do  any  good  six,  eight,  or  ten  weeks  should  be 
lakcn.  Sometimes  sea  baths  will  be  more  useful  than  the 
simple  cold-water  treatment,  but  then  also  care  must  be  taken 
in  their  selection.  For  the  excitable  and  nervous  who  suffer 
from  insomnia  the  places  on  the  Baltic  will  on  the  whole  be 
preferable  to  those,  on  the  North  Sea,  while  the  latter  are 
especially  adapted  for  very  prostrated  patients  and  individuals 
suffering  from  cerebral  aniemia. 

A  long  stay  in  pure  mountain  air.  at  a  not  too  high  altitude 
and  where  the  barometer  is  not  too  low.  is  usually  beneftcial 
to  neurasthenics.  Daily  systematic,  but  not  forced,  tramps  in 
the  mountains,  continued  (or  weeks,  do  more  good  s<.»n)etimes 
than  all  the  medicines  of  the  pharmacopa-ia  lakcn  during  the 
long  winter.  The  internal  medicines  arc  anyhow  of  not  much 
avail  in  the  treatment  of  neurasthenia.  Iron,  quinine,  arsenic, 
the  stomachics,  all  will  disappoint  us:  all  will  sometimes  ac- 
complish nothing;  they  rather  tend  to  derange  the  digestion, 
and  with  this  take  away  the  last  remn.mi  of  the  patient's 
courage.  The  only  drugs  necessary  will  be  such  as  are  re- 
quired (or  the  proper  regulation  of  the  bowels. 

Among  the  above-described  symptoms  there  arc  two  the 
treatment  of  which  deserve  special  mcniioii — tirst,  the  sleep- 
lessness; secondly,  the  impotence.  About  the  former  nothing 
needs  to  be  added  to  what  has  been  said  on  page  162.  To 
meet  the  latter  much  is  to  be  expected — if,  of  course,  organic 
disease,  spermatorrhoea,  and  the  like,  have  been  excluded — from 
the  local  application  of  electricity,  A  lai^c  electrode,  the 
anode,  is  placed  over  the  lumbar  cord,  while  the  cattiode  is 
moved  from  the  external  inguinal  ring  down  along  the  sper- 
matic cord  or  applied  without  being  shifted  (Brb).  With  this 
may  be  combined  Ihe  application  of  the  faradic  brush  over 
the  whole  genital  region.  One  electrode,  the  cathode,  ni*y 
also  be  placed  in  the  rectum,  the  other  upon  the  sacrum  or 
perineum  (Mtibius).  Finally,  a  bladder  electrode,  which  has 
the  shape  of  a  catheter,  and  which  is  insulated  up  to  its  metal- 
lic tip.  may  be  introduced  into  the  urethra  as  far  as  the  iassa 
navicularis,  while  the  anode  is  applied  over  the  lumbar  cordt 


I 

I 

I 

I 


I 
I 
I 


NEVRASTIIESiA. 


537 


and  ut  the  negative  pole  the  current  is  made  and  broken  sev- 
eral times.  From  this  method,  which  has  been  recommended 
more  especially  (or  paralysis  of  the  bladder  and  incontinence 
of  urine,  wc  have  repeatedly  seen  good  eflccis  in  the  treatment 
I  of  impotence. 

The  feeding  system  of  Weir  Mitchell,  which  has  also  been 
recommended  in  neurasthenia,  we  shall  discuss  in  the  chapter 
on  hysteria. 

1.ITERATURR. 

IWard.    On  Ncoraiiheni.v     New  York.  i8*a. 

Eocnluhr.     Drutsche  med.  Wochcntchr..  18S4,  x,  ^^,     (Diflcrcntul  Di.<£iiosis 
between  Tabes  and  Nctirislhcnia.) 

Bcanl  und  Kockwtll.     Die  sexutrilc  NcunudMrnie.     Wtaii.  l88s- 

Mobiiu.     Die  NctvosiiSt.     Lciptig.  1S85.  3.  Aufl. 

Thai'cf.     NeuiuihcnU.     Phil.  Mcil.  and  Suqi.  Report.,  1886.  lir.  17,  18. 

IJenIt  ilovell.     On  »oiiie  Condifion*o(  NeurusllirniA.     Londiw.  1886.  ChurchilL 

Avcibeck.     Die  .tculc  Neursslhcnir.     Deutsche  McML-Ztg..  I886,  tii.  30^  31, 

Langslcin.  H.    Die  Nciirasllicnic.     Wien.  1886. 

Mitchell.  S.  Weir.     An  tCs^y  on  the  Treaiinent  of  Cerkilti  Funns  of  Neuras- 
thenia and  H>'sleriA.     Phila..  Llp|Hncotl.  1885. 

I'berrk-     Die  fiincliiinelk-n    Nrurntcn  bcim  wcitilichen  C^MrhK-chl  and  ihre 
BeiwhunKtn  ^U  den  Sesualleidcn.     Uerlin,  Neuwied.  1886. 

Clark.    Some  Obscrvaiions  concerning  what  is  called  Ncuraaibenia.    Lancc4. 
January  I,  18S6,  L 

KralTt-Ebiiig.  V,      Ucbcr  NcurasiheiilA  sexu.ilift  bctm    Mann.     Wiener  med. 

Prcsse.  1887,  xiviii,  S-  &■ 
'T.  Senusen.     Die  Neurasthcnie  un<l  ihre  Bchandlun^.    Lripi>K,  Vogel,  18B7. 

Hanc.    Ein  Mlleiicr  FaU  scxueller  Ncuraslhrnic.     Wicnei'  mcd.  Klmik,  i,  j. 

Ptppinskold.     On    ncunulhenirns   ratckomst  bUnd    hn>]>|i«.iil>ctar«.     Fin»ka 

IlakaiviJilUk.  lundl..  1S87.  ikit.  11. 
Burkun.    ilci liner  Uin.  Wochenschr..  18S7.  xxiv,  4(.  (Recommend*  Weir  Milch- 
ell'*  trcaltnenl.) 
Mathieu.     Ncura&ihtnlc  et  h)-«irlc  comhinfci.    rrogr.  mid.,  1888L  xvi.  yx 
t-cmoine.    PathoRtnie  el  irailemrnt  de  la  neurasthfnie.    Ann.  tnM.  pcych.. 

Sepitetnbre.  1S88.  jnie  ser.  viii. 
Wcblier.    A  Sludy  i>f  Arterial  Tension  in  NeuraMhenia.    B<M(nn  Mcd.  and 

SurjE.  Joum.,  May.  1888.  rxviii.  18, 
Furbrin^cr.    Zur  Kennlniu  der  linpotenita  genemndj.     neuitelie  mcd.  Wo- 

chcMchr..  1888.  xtv.  i%. 
W^KMir,    Zur  Bexrifliibeiiiimniung  uni!  Thmpie  der  Neiiraslhenie.    Schwcinr 

CoerespDndenzbl..  1S88.  xviii,  9. 
Ptiiiiwua.     Zur  DifltrcniialdHgnoae  der  NeuraMhenie.    Deuiwhc  .Med-Ztg.. 

1889^  17.  38. 
LOwenfeld.    Die  modeme  Dehandlung  <ler  NervenKhwUche  (NrunstbcnleV  der 

H>^erle  und  vervrandier  t.eiilcn.     Wiesbaden,  ttcrpnann,  1889^  1.  Aufl. 
IMm-lMM.     Dc  ta    Neunuth^nie  ct  de  I'h)  ktiro^ncvrasihi nic  lraumaik|uc. 
Progrte  mfd.,  1S90. 49. 


I 


538         DISEASES  OF   THE   GEffERAL   NERVOUS  SYSTEM. 

Bouyer,     La  neurasthinie  (ipuisement  nerveux).     Paris,  Bailliire.  1890. 
Boltey.      Hydrothirapie  et  Neurasihinie.      Revue   U'hygiine  thfrap.,   Fevr. 

1892. 
Jacobs.    Gen.  Tijd.  voor  Nederld.  Indie.,  1892,  xxxii,  5. 
Sollier.     Sur  une  forme  circulaire  de  la  neurastlifnie.     Revue  de  \r\kA..  1893. 

xiii,  12. 
Miiller  (Alexanderbad).     Handbuch  der  Neurasthenic.      Leipzig,  Vogel,   1893. 

(Indispensable  Tor  special  studies.) 
Kothe.     Wesen  und  Behandlung  der  Ncurnsthenie.     Weimar,  1894. 


CHATTER    II. 


IIYSTKRIA. 


Hysteria  has   this  in  common  with  neurasthenia,  that  it 

docs  not  depend  upon  any  demonstrable  analomicnl  lesions  of 

the  nervous  system,  but  it  differs  from  it  in  the  fact  that  for 

—  its  development  a  certain  predisposition  on  the  part  of  llie  pa- 

f  ijcnt  is  absolutely  necessary.     Although  wc  are  not  as  yvt  in  a 

po<iition  to  say  ol  what   nature  this  predisposition  is,  wc  must 

•  assume  that  the  whole  nervous  system  of  a  hysterical  patient, 
central  a&  well  as  peripheral,  is  in  some  points,  which  wc  are 
still  unable  to  determine,  different  Irom  that  of  healthy  indi- 
vtduals.  The  greater  extent  to  which  these  persons  observe 
themselves  (Oppenheim),  the  increased  impressionability,  the 
hyperesthesia  of    the  central   nervous  organs,   the    increased 

■  sensitiveness  ol  the  peripheral  nervous  system,  ilie  diminished 
energy  with  which  influences  coming  from  outside  as  well  as 
from  within  are  met.  the  lower  general  power  of  resistance 
and  self-control,  these  arc  on  the  whole  the  trails  which  charac- 
■  terixc  hysterical  persons,  and  explain  why  the  symptoms  are 
so  manifold  and  change  sit  rapidly,  and  why  in  no  other  disease 
ol  the  nervous  system  can  be  lound  a  train  uf  manifestations  so 
diverse  and  so  numerous. 

■  Only  by  unwearied,  long-conlinucd  study  has  it  been  possi* 
blc  to  show  that  even  for  the  apparently  arbitrary  appearance 
of  the  different  symptoms  there  exist  certain  laws.  In  a  man- 
ner which  none  before  or  after  have  been  able  to  rival,  hysteria 
has  been  studied  by  Charcot  and  his  pupils,  to  whom  we  owe 
the  most  interesting  observations  and  investigations  ol  the  past 

»twu  decades. 
LITKRATURE. 

H>i*e.  Kranl()i«ilen  df%  NenentysU^mv  In  Virchow's  llandliiKh <kr  tpecicDen 
PAihuiogM  uml  Thcmiiic.    Krlnngm.  r869.    (Confalns  the  oldtrr  liicraiurc.) 

Briquet.  Tr»tf  ctlaiquc  ct  ih^mjirulitiuc  itc  )'ll|%ijric.  pjrK  iH;*).  (Orininal 
■nkk,  Dpon  uhich  all  the  uudies  on  hpteria  It)-  the  Frencli  authors  are 
butd.) 

539 


540        1>/S£AS£S  OF  THE  GENERAL  A'EJtrOt/S  SYSTEM.        H 

Charcot     Klininlie  Vorlrlic'^  "''"'  Krankheiien  da  Nenenaystemi.    G«ri^| 

lunslalion  by  Fcucr.  Siuiigdn.  1874. 
Charcot.    Nciie   Unicnucbuntren   uber  die  Krankhritcn  ilc«  NFTvemyilems. 

bc^ondcrs  libcr  Hysteric.    German  traiuUtion  by  Freud.    Wten  und  Let[h 

ng.  18S6. 
Freud.     Beitriige  lur  CasuiMik  der  Hystctie.    Wiener  nied.  Wixh«iMchr.,  1SS6 

49.  SO. 
Mol»u«.     Uebn-drn  RegrilTder  HyMcrie.    Ccntralbl.  L  Nen-enhk.,  1S8S,  xi.  3. 
Theinies.    Traill  ilfmeniaire  d'Hygiine  ei  de  Tbinipie  de  I'Hysitne.    faris. 

ie89. 
Charcot.     Lc^ns  du  Mardi  1  la  S.-)lp4iriire.    I'aHt.  1889.    (Polic Unique,  1887^ 

1S8S.) 
Gillesdc  U  Tnurcilc.    Trnii^  cllnique  ct  th^Mpcuiii|ue  de  ('byMirlr,  d'xpita 

ren^^eineni  dc  la  Salpftricrc     Paris.  1891. 
Gilles  de  ta  Tountte.     Die  Hysierie  nach  <leii  Lvhren  der  Salp£(ritfc.     German 

Irnn»l;ition  by  Kail  Grubr.     Wien.  Ucuilckc,  189}. 
Breuer  und  Ficud.     Ucber  <lrii  ptyrhisibm  Mechanismus  hyaleiixcbcr  Wh 
I        noinene.     Neurol.  CciilralbL.  1893,  xii.  1,  2. 

Symptoms. — For  the  sake  of  simplicity  wc  shall  divide,  in 
our  dei^cription of  the  disease,  the  s>'iii]>(oms  into  cerebral,  spinal, 
and  mixed — that  is,  pertaining  to  the  entire  nervous  system. 

The  cerebral  may  n^ain  be  subdivided  into  psychical  and 
somatic  symptoms.    The  disposition  of  the  patients  is  excitable, 
anxious,  often  changeable,  someiimes  passing  from  the  depths 
ol  gloominess  to  the  most  exalted  hilarity.     The  tendency  In 
speak  of  nothing  else  than  of  their  own  woes,  the  constant  at- 
tempt to  greatly  exaggerate  these,  and  to  excite  sympathy  in 
their  friends  and  physicians,  the  thoughtless  di-tnands  which 
they  expect  to  be  satisfied  at  a  moment's  notice,  and  the  incon- 
siderate outbreaks  o!  anger  if  this  is  not  done — all  these  are 
characteristic  features  of  the  disease  with  which  we  meet,  not 
in  all  indeed,  but  at  any  rate  in  a  large  majority  of  cases.    The 
tendency  to  get  easily  frightened  is  very  common,  and  during 
a  state  of  the  highest  psychical  excitement  hallucinations  may 
temporarily  exist.      In  pure  cases  of   hysteria,  however,  wc 
need  never  be  afraid  that  these  will  persist  long  or  lead  to  anv 
serious  outbreak  on  the  part  of  the  patient.     Exceptionally  nn 
instance  of  "  hysterical  sleep  "  comes  under  our  notice,  into 
which  the  patient  has  fallen  after  certain  prodromal  symplomJ 
have  existed  for  several  hours.    The  peculiarities  of  this  curi- 
ous condition,  (he  "  lethargic  hystirique,"  which  may  last  for 
many  days,  the  condition  of  the  organs  of  circulation  and  di- 
gestion, the  characteristic  signs  by  which  the  hysterical  sleep 
may  be  discriminated  from  other  states  of  coma,  have  recently 


HYSTERIA. 


S4t 


been  described  by  Gtllcs  dc  la  Tourctte  in  a  careful  monogniph 
(Arch,  dc  Neurol.,  tSSS,  43,  44),  and  lately  by  Locwcnfeld 
(Arch.  f.  Psych.,  xxii  and  xxiii).  The  paroxysmal  appearance 
of  a  marked  tendency  to  sleep  (narcolepsy)  has  been  studied 

I  by  BOhm  and  Dchio  (cf.  lit.). 
Among  the  cranial  nerves  there  is  not  a  single  one  which 
may  not  at  one  liim-  or  another  in  the  course  of  hysteria  pre- 
sent symptoms  of  paralysis  or  irritation.  More  than  the 
others  the  nerves  o(  special  sense  are  interesting  for  their 
anarsthcsias  and  hyperaeslhcias.  The  nerves  of  smell  and 
hearing  are  those  must  frequently  atlcclcd,  and  both  functions 
may  be  so  much  impaired  that  the  patient  can  smell  and  hear 
nothing.  They  may.  on  the  other  hand,  become  so  acute  that, 
if  we  may  believe  her  oxvn  statements,  she  is  able  to  distin- 
guish any  one  from  a  number  of  perfumes,  or  to  single  out  an 
individual  by  the  sound  ol  his  voice  amid  the  hubbub  of  a 
Bcrowd,  or.  again,  to  recognize  people  (ar  off  by  their  step,  and 
™  so  forth.  These  and  similar  faculties  have  in  Mesmcr's  time 
already  been  spoken  of  a  great  deal,  and  have  given  rise  to 
much  deception  and  trickery.  The  opticus  is  also  not  rarely 
afTected.  Besides  the  cases  where  hysterical  patients  suddenly 
become  blind  in  one  or  both  eyes  without  there  being  any 
changes  in  the  disk,  there  are  instances  of  decrease  in  the 
acuteness  of  vision,  contraction  of  the  field  of  vision,  or  com- 
plete or  partial  loss  of  color  sense.  When  the  last-named  con- 
dition occurs  the  perception  of  blue  and  yellow  is  retained 
longest,  while  that  of  violet  and  green  disappears  much  ear- 
lier. We  must  ol  course  expect  numerous  variations  and  com- 
binations. I  have  seen  in  the  same  individual  hysterical 
changes  in  the  one  eye  and  tabetic  changes  in  the  other.  The 
ocular  muscles  rarely  participate  in  the  disease:  hysterical 
paralysis  of  them  is  exceptional,  as  is  also  the  occurrence  of 
hysterica)  nystagmus,  on  which  subject  1  have  expressed  my 
opinion  elsewhere  (cf.  lit.). 

Among  ihe  other  nerves  of  special  sense  that  of  taste  may 
occasionally  present  alterations.  The  patients  lose  their  taste 
either  completely  or  only  for  certain  substances  (sour,  salty), 
or  there  may  exist  such  a  perversion  of  this  faculty  that  every- 
thing tastes  nauseous  and  disgusting,  or  that  everything  tastes 
of  salt  or  of  vinegar,  and  so  forth.  Actual  hallucinations  of  the 
wnse  ol  taste,  although  not  so  frequcnt'as  hallucinations  of  the 
sense  ol  smell,  arc  not  unheard  ol. 


542 


DfSBASES  OF  THE  GElfRRAL  NERVOUS  SYSTEM. 


The  trigeminus  is  generally  implicated.  Faceacbe  and 
headache,  among  others  the  kind  which  is  confined  to  a  small 
spot  and  is  known  as  clavus,  arc  comparatively  frequent.  The 
sciilp  is  someiimts  so  markedly  tender  that  the  patients  can 
not  stand  the  slightest  pressure,  not  even  the  touch  of  the 
cum b,  and  in  order  to  avoid  the  pain  ihey  abstain  from  all 
care  and  proper  attention  to  the  hair.  The  pain  in  the  head 
may  also  be  confined  to  one  side,  and  resemble  in  every  detail 
that  of  hcmicrania. 

What  needs  to  be  s.iid  about  the  facial  nerve  in  this  connec- 
tion has  already  been  treated  of  in  Chapter  V,  Part  II.     Tic 
convulsit,  as  well  as  facial  paralysis,  may  be  hysterical  in  na- 
turc;  however,  we  must  not  forget  that  facial  spasm  and  hys- 
teria may  well  coexist,  and  that  a  tic  convulsif  occurring  in  the 
course  of  hysteria  is  not  necessarily  of  hysterical  origin.     The 
determination  of  [his  question  is  less  important  (or  the  diag- 
ncjsis  than  for  the  prognosis.     The  outlook  in  non-hysterical 
tic  i<  very  bad.  in  the  hysterical  variety  relatively  favorable 
(Guinon.  Revue  dc  m£d.,  juin,  1887),     Of  much  interest  are 
the  many  forms  of  vagus  neuroses  which  we  meet  with  in  the 
course  of  hysteria :  they  may  aflect,  in  the  manner  described  in 
Chapter  VIII  of  Part  II,  the  organs  of  respiration,  circulation, 
and  digestion.     Among  the  first,  not  only  the  larynx  but  the 
lungs  also  are  sometimes  attacked.      The  laryngeal  muscles 
become  the  seat  of  violent  spasm,  "  hystcrtcit   spasm    of  the 
glottis."  during  which  the  patient  is  afr.tid  she  is  choking,     in 
exceptional  cases   patients    have   died   in   such    attacks  (Leo, 
Deutsche  med.  Wochenschr.,  1893.  34).     The  (unctions  ol  the 
vocal  cords  may  become  so  much  interfered  with  thai  the 
patient  is  only  able  to  make  herself  understood  in   whispers; 
to  speak  out  loud  is  impossible  ("  hysterical    aphonia  ").    The 
laryngoscopical  examination  reveals  nothing  abnormal,  with 
the  exception  of  some  ana:sthcsia  of  the  mucous  membrane  of 
the  fauces,  which  greatly  facilitates  the  examination  (cf.  page 
I  tj).     Peculiar  disturbances  in  speech— for  example,  a  stutter- 
ing, which,  in  contradistinction  to  the  ordinary  type,  comes  on 
acutely — have  been  frequently  obsrrvcd  and  carefully  studied. 
For  the  recognition  of  this  symptom  and  its  differentiation  from 
ordinary  stuttering  verbal  suggestion  may  be  used  (c(.  the  cliap- 
tcr  on  Hypnotism).  The  respiratory  muscles  may  be  affected  in  a 
peculiar  and  very  striking  manner ;  the  acceleration  in  the  num- 
ber of  respirations  may  attain  such  a  degree  that,  instead  of 


\ 


ilY^TERlA. 


S43 


fifteen  or  sixteen  respirations  a  minute,  we  may  count  (rom 
eighty  to  one  hundred.    On  the  other  hand,  they  may  be  dimEih 

'  i^hed  in  Ircquency.  und  the  patient  breathe  from  eight  to  ten 
limes  a  minute,  but  in  a  labored  way,  showing  signs  of  a  regu* 
lar  dyspnu;a,  nut  infrequently  with  audible  wheezing  in  inspi- 
ration and  expiration  ("  hyHtcrical  asthma").  A  dry  and  b;irk> 
ing  cough,  which  is  distrei^sing  not  only  to  the  patient  but  aImj 

I  to  all  who  surround  her.  is  sometimes  observed,  and  paroxysms 
of  yawning,  sobbing,  laughing,  or  crying  ("  hysterical  laughing 
or  crying  fits  ")  may  persist  lor  hours. 

Sometimes  fulluwing  aphonia,  sometimes  occurring  abrupt- 
)y  and  unexpectedly  without  it.  in  rare  instances  a  complete 
dumbness  sets  in  ;  the  patient  has  either  actually  lost  the  con- 
trol ol  her  speaking  apparatus  or  will  not  make  use  of  it;  in  a 
word,  she  is  completely  mute,  and  no  amount  of  admonitions, 
entreaties,  or  threats  can  succeed  in  eliciting  a  single  word. 
This  condition  of  "mutismus  hystericus'*  may  be  of  variable 
duration.     In  one  instance  which  came  under  my  notice  the 

'patient  maintained  silence  from  the  5th  of  September  to  the 
2ttih  of  April  ol  the  following  year.  She  found  her  voice  again 
at  once  on  hearing  of  the  unexpected  death  of  her  mother.  In 
this  connection  the  articles  of  Natier,  Huysmann,  and  of  Kay- 
*er  (Thcrap.  Monalsh.,  October,  1893,  vii.  p.  500),  who  recom- 
mends  autolaryngoscopy  as  a   useful  means  of  treating  this 

[symptom,  may  be  referred  to. 

The  circulatory   ()rgans    more    especially  the   heart,  take 

[relatively  the  smallest  share  in  the  disease.     Hysterical  tachy- 

jcardia  may  occur,  but    it    is  rare   and   never   well    marked: 

in   the  apparently  severest  atlaclcs,  which    we   shall  de. 

ribe   later,  the  pulse  is  <|utet.     To  stenocardia  we  have  re- 

llerred  on  page  123. 

Cases  of  so-called  "aorlic  hysteria,"  a  condition  which  has 
been  described  by  (*<>sl.  of  New  York  (Med.  Rec,  iSgi,  16). 
and  which  is  charactcriiced  by  relaxation  of  the  aorlic  walls  in 
consequence  of  diminution  of  the  vascular  tonus,  simulating 
a  tumor,  are  of  a  very  rare  occurrence, 

\  The  digestive  tract  and  the  muscles  pertaining  to  it — which, 
(ust  as  the  pharyngeal  muscles,  are  innorvated  ai  least  partly 
by  the  gUisso-pharyrigeal  and  not  by  Ihe  vagus  alone — may  be 
the  seal  of  various  hysterical  manifestations.  The  muscles  of 
the  pharynx  may  present  symptoms  of  paralysis  or  of  irrita* 
lion.     In  the  former  case  deglutition  is  much  interfered  with, 


544 


D/SEASES  OF  THE  GENERAL  SBRVOVS  SYSTEM, 


and  may,  indeed,  be  impossible  ("hysterical  deglutition  panl 
ysis"). 

A  peculiar  affection  of  the  muscles  of  the  (esophagus, 
which  are  supplied  by  the  vagus,  consists  in  a  spasmodic  con. 
traction  which  gives  rise  to  a  very  vivid  sensation  of  a  ball 
rising  up  from  the  region  of  the  stomach  and  sticking  in  the 
throat.  This  "globus  hystericus"  is  so  frequently  met  with  in 
hysteria  and  is  usually  so  well  marked,  that  it  has  been  looked 
upon  as  pathognomonic  for  ihe  disease. 

The  musculature  of  the  stomach  and  the  intestines  is  liable 
to  disturbances.  According  to  most  authors,  paralysis  of  these 
muscles  produces  a  distention  of  the  bowels  and  of  the  whole 
abdomen  which  may  be  simply  enormous  ("  meieorismus  hys- 
tericus "  ) ;  this  is  sometimes  associated  with  colicky  pains.  A 
certain  amount  of  the  air,  which  frequently  collects  in  large 
quantities  in  the  bowels,  escapes  through  the  mouth  with  a 
loud,  sobbing,  gurgling  noise  (singultus,  ructus  hystericus). 
Talma  (Wcckblad  van  het  Ncdcrl.  Tijdschr.  voor  Gcneesk., 
1886,9)  claims  that  the  cause  of  hysterical  tympanites  is  to  be 
souglil  in  a  spasm  of  the  diaphragm.  As  evidence  in  favor  ol 
his  view  lie  argues  that  under  chloroform  narcosis  the  disteo- 
tion  will  disappear  without  the  emission  of  gas;  and.  secondly, 
that  the  position  of  the  diaphragm  is  abnormally  low, 

Vomiling  is  one  of  the  most  frequent  occurrences  in  hys- 
teria: sometimes  it  is  very  profuse  and  may  persist  for  houre: 
it  may  be  so  intraclablc  a.s  to  iveakcn  the  patient  considerably; 
on  the  other  hand,  slight  vomiting  may  occur  daily  for  weeks 
without  afTecting  the  patient's  strength.  Usu.illy  warcry 
masses  arc  thrown  up  which  bear  no  proportion  to  the  quan- 
tity of  food  ingested.  In  one  of  my  cases  the  amount  vomited 
was  eight  or  ten  limes  as  large  as  that  taken  in. 

Affections  of  the  accessorius  are  not  rarely  seen  in  the  form 
of  spasmodic  torticollis,  while  affections  of  the  hypoglossusaK 
very  exceptional.  "" 

LITERATURE. 

Parinaud     Annal,  d'Oculislc.  1886.  xcvj,  I,  3.    (Aniesthcsfa  of  the  Retina.) 
Bri««auil  ct   Nt.iric.     Progits  m£d.,  1B86,  xv,  5,  7.     (Dtriation  Taciale  diw 

I 'h*  mi  pi,  hyii^rique.) 
Cuinon.     Rcvuc  tie  nijd.,  1887.  vii,  &    fTic  convulsif.) 
Huet    Hytlerii:;)!  FndAl  Parcsifi.     Nedrrl  WcekhUd,  1887.  it,  31. 
Borel.     Annal.  il'Oculihte,  1887.  xc\-iii,  5.  6.    (llysiericAl  Alliectiocis  of  the  £;< 

MuscIm.  etc.) 
Schlctmger.     Wiener  med.  BIttUer.  188S.  xi,  3. 


I 
I 


HYSTKMiA. 


S45 


I 


Peck.  New  Yurk  Mexl.  Rcc..  March.  iSltS.  xxxiii.  (Hj-sicrkal  Coma.) 
F^ri.  Migrtun*  o(ihthaiinu|ue  hjM^riquc.  Aich.  <ic  Nmrol,.  1890,  6a 
Remak,  E.     Zur  Srmiolik  A<x  h)-«tr  tine  hen  Deviation  der  Zungv  und  <les  Cc- 

Mchlo.     ElctlincT  klin.  WtKheniclir..  1891.4a 
Leber.     I*rriphcrc  S*:hnervcna4Teciionen  bci  H]rUrr)c.     D«ultclie  incd.  WocheB- 

Khr.  1^1.  33. 
Hhag.    SchUfaitJcken  und  h)i>nolische  Suggestion.    Berliner  klin.  Wochen- 

Khr.  1893.  38. 
iTtcbonki.     Monaischr.  f.  Ohtenhk..  1S93.  11. 
r^r^,  Ch.     Svnuinc  mid..  1S83,  liti.  5a 
Uloc<|.    Gm.  des  hAji.,  1893,  13;. 

Janet.  P.     £ut  roenul  de«  llysl^ri<|iie«      t'^rii.  RuefT,  i&ij. 
Knics.     Die  cin&eiiigcn  ceiiinitcn  Sclisiotjri^eii  und  ibrc  Ucjicliung  lur  lljsierie. 

INrurol.  Cvnirall*),,  i8(>3,  I?, 
Ikihm.     t/cher  Narkolepiiie.     lnau;;.-DiMen..  Heriin,  1893. 
Dehia    PailiologlMhc  Schtadu&iXntJe.    PeicnburKcr  n>ed.  Wochcnscbr.,  1893, 
11. 

Ilyitniial  Sfftth-JiitHti»iKn. 

Pelte«ohn.     Ilerllnet  ktin.  Wochcnschr,  1890,  30. 

ISooleker.    Ch.tnt6.Aniulcn.  1890.  xv.  p.  373, 

Rcsciiliikch,  O.      Ueber  functionelle  UhnmofC  der  tpnchlkhen  Laulgebung. 

Deutsche  mcd.  Wochenichr..  1890^  46. 
D^iUcI  el  TusicT.     Du  b^aiemeni  h]rM^i)ue.      Arch,  dc  NeuroL,  Julllet.  1890, 

No.  SB. 
Kr«m<T.     L*eher  hjveriMhcs  Stollcm.     Prager  med.  \Vochen»rhr.  i8qi,  sir. 
CI>crTJn.    A  propot  du  Mgaiemcnl  hysltrM)uc     Arch.de  Neurol.,  Mai,  1891. 

N0.6J. 
HIgier.    I'eticr  hvnetitehes  Stoiiem.    Iki4lner  klin.  Wo:henichr..  1893,  m. 
SciflerL     Dir  Bchnndltinj;  <lrT  hysteriKhen  Aphunie.     Ibid.,  1893.  44. 
Zodkr     TaII  I'vn  hysierischcr  Sluinntheii  \<m  tweijUiriger  Dauer.      NeuroL 

Centnilbl.,  i&m,  2. 

One  nf  ihe  most  remarkuble  cerebral  aflections  which  may 
occur  in  ihc  counie  of  hysleria  is  an  apoplectiform  attack  with 
consequent  hcniiptc^ia.  which  in  many  instances  is  associated 
with  complete  hcmiana'sihesia.  This  hemiplegia  may  develop 
with  symptoms  similar  to  those  of  the  form  following  arterial 
disease,  and.  as.  we  have  already  pointed  out  above,  it  may  be 
extremely  difficult  to  distinguish  a  hysterical  hemiplegia  irom 
wic  due  to  organic  disease.  This  is  especially  the  case  il  there 
are  no  other  hysterical  symptoms  to  aid  us.  If  the  uniUtcr;il 
•paiim  o(  the  muscles  of  the  check,  described  by  Charcot,  and 
before  him  by  Ortxlic  (iSto),  which  is  said  to  be  characteristic 
of  hysterical  hemiplegia,  be  present,  the  diagnosis  is  easier. 
All  the  syinptoms  associated  with  a  cerebral  hemiplegia — for 
instance,  tremor,  the  associated  movements,  even  atrophy  of 
the  muscles  of  the  side  aflcctcd — may  accompany  the  hyster- 


546 


J>/SSASES  OF  THE  GBXEKAl.  A'EfiyOVS  SYSTEM. 


ical  variety.  The  opinion  formerly  prevalent,  lliat  wliere«r 
ihcrc  exists  atrophv  this  must  needs  depend  nj>on  an  organic 
lesion  in  tlie  brain,  spinal  curd,  or  the  nerves,  has  beert  proved 
to  be  erroneous.  The  hysterical  atrophy  may  not  differ  from 
that  due  to  organic  disease;  it  may  devdup  comparatively 
rapidly,  may  remain  for  a  long  time,  and  disappear  again  jusi 
as  rapidly  when  motion  returns.  Fibrillary  twitchings  in  the 
atrophic  muscles  and  reaction  of  degeneration  are  absent. 


FtK-iA).— i^leniibovn  tn  Pie.  i6j,  thiT«  mnntht  prrvfou*  to  Ibe  ilnw  nVa  tW  fMa* 
ot  Fig.  ibj  WM  laluH  I  |xnuiul  oliMrvttiua  t. 

Whether  the  large  ganglionic  cells  in  the  ariierior  horns  have 
anything  to  do  wiih  the  occurrence  of  .-itrophy.  and,  il  si>> 
what  is  the  nature  of  the  influence,  we  do  not  know, 

I  will  here  mention  only  one  of  the  cases  of  hysteric*! 
atrophy  which  have  come  to  my  notice  and  which  isquiw 
unique,  owing  to  the  intensity  and  the  rspidil)'  with  whtd> 
An  :itruphy  of  the  entire  muscular  system  developed.  The 
clinical  history    of  the  case,  ot  which  two  pictures  (Fig*.  l& 


MYSTRKtA. 


547 


and  163)  »re  here  given,  will  1>e  found  in  an  article  by  me  in 
the  Deulsclic  .mcd.  Wochenschrift.  The  time  which  elapsed 
between  the  taking  of  the  two  pictures  was  abuul  three  raonlhs. 


UTERATURE. 
mMnsld.     Afch.  de  NeuroL.  Juillet.  1886^  vii.    (Aira|>hy  iu  Hysierical  Panly- 

CtiMtfbrd.    Cu.  hl^bd..  1.  *..  1886,  kniii.  31.     (Atrophy  of  the  LcA  Ut>pe*  Ci- 

imnlty,  HystcncA]  MunuplcgU.  a«  a  Kcsuti  of  Tnuin.i  m  Ji  Young  Mjin.) 
,  MmuIorkol    L'atrDlu  miixcoUrr  nrllc  (MnlHi  isivnchr    Napoli.  I>eikcfi.  1886. 
De  l*apo|dcxie  h)->i6ri<|ue.    Arch.  K^nir  de  mM.,  18S6,  No.  34. 
iroitln.     Arch.  Ae  Keurol..  1886.  xii,  p.  30).    (Hy^tcrlnl  M(mo|t)eKU  of  Sii 
Monih*'  SlwidinK.  cured  itnmrdutcly  by  ^ijtEeriian.) 

ski    Zur  Diagnow  dn  li)'Mer  HcntiplcjiK.    CcnmlbL  f.  Ncrvcnhdik.. 
is.  6. 

Cm  t)'«pof)lexie  hyst.  avec  auli)p«ie.    Ann.  mcd.- psych..  7  M;iri. 
1S87, 
Hnkwutl.     Arch,  dc  phyn.  aomn.  el  |nihol..  1887.  }.    (HyWeric^  Ilemiplefia 
With  AUvphy.) 


S4S 


D/SEASES  OF  THE  CEXEKAL  XERl'Ol/S  SYSTEM. 


Achanl.     De  I'npoplcxie  hyxrfnquc.    Arch.  ^inir.  Ae  miA.,  Janv.,  xHy, 
Monvsik.    C«niralbL  C  Ncnenhalk.,  1888.  ».  ao.    (Hysioncal  Sympiocna  in 

Bnin  Syphilis.) 
Souquea.    Hcmtpligie  hysi<rK|Ue  (cbcx  un  vtlumifll.    Cai.  de  Harti,  1889^  i. 

Among  ihe  spinal  symptoms  ol  hysteria,  motor  and  .sensory 
p;iralyscs  play  the  most  important  nUc.  With  hysterical  pi- 
ticRts  we  can  not  feel  certain  for  a  single  day  or  hour  thai 
some  sort  of  paralysis  will  not  occur,  for  it  is  characteristic, 
we  may  say  pathognomonic,  of  hysterical  paralyses  that  ihcj 
appear  quite  suddenly,  and  happily  often  disappear  as  quickly, 
it  may  even  be  after  persisting  for  months  and  years.  There 
is  no  characlerisiic  distribution  of  the  hysterical  motor  dis- 
turbances; they  may  take  in  only  one  extremity,  or  mav  ex- 
tend to  both  legs  or  both  arms,  so  that  these  arc  perfectly 
useless.  l£xaminalion  shows  that  the  paralyses  are  usually  uf 
a  flaccid  type.  We  may  frequently  make  the  observation  thai 
the  patienls  arc  not  completely  robbed  of  the  use  of  the  af- 
fected limbs,  but  (hat  they  have  lost  the  \vill  to  use  them. 
Especially  is  this  apparent  when  they  are  asked  to  perform 
co-ordinated  muvcmcnts.  A  patient,  though  able  to  move  the 
right  arm,  may  .issert  that  she  is  unable  to  write ;  though  she 
is  able  to  move  her  legs,  any  attempt  at  walking  is  an  utter 
failure ;  on  rising,  her  legs  give  way  under  her.  and  she  simply 
is  unable  to  keep  herself  on  her  feet.  The  inability  to  stand 
and  walk,  which  is  sometimes  found  in  cases  of  hysteria,  was 
first  studied  by  Paul  Blocq,  and  was  termed  by  tiim  astasia- 
abasia  (Arch,  de  Neurol.,  Janvier,  18S8.  xv.  No.  43);  when  the 
patient  is  in  a  recumbent  position  the  sensation,  the  muscular 
power,  and  the  coordination  of  the  legs  present  no  abnormilT. 
Miibius,  who  among  others  has  studied  this  condition  car^ 
fully,  has  called  atteniion  to  the  fact  Ihat  the  patient  knows 
nothing  of  its  origin  ;  that  it  develops  through  (unconscious) 
auto-suggcslion,  but  that  Ihe  subsequent  amnesia  hides  from  tlie 
patient  the  true  origin  of  this  suggested  alrcration.  "  Tlic 
suggested  idea  docs  not  become  a  part  of  consciousness  in  the 
waking  state ;  it  docs  not  become  a  molivc  for  the  will,  as  do, 
for  example,  fixed  ideas,  but  acts  subconsciously"  (Mtibiuf). 
Charcot,  in  his  Lemons  du  Mnrdi.  h.is  distinguished  a  paralytic 
and  an  ataxic  form  of  hysterical  abiisia  (Le^n  du  5  Mars.  i!!89)> 
A  critical  review  by  Mijbius  ol  all  the  cases  published  up  lo 
1890  will  be  found  in  Schmidt's  Jahrhiicher,  1S90,  ccxxvii.  p.  sS- 

Symptoms  uf  motor  irritation — for  instance,  isolated  inus- 


HYSTEIilA. 


549 


I 


cular  spasms — are  far  less  frequent.  Of  much  interest  arc  the 
involuntary  muvements  which  arc  now  and  nL^iu'n  observed.  1 
had  a  lady  under  treatment  who.  without  wishing  it,  but  with< 
out  being  able  tu  resist  the  inclination,  would  for  hours  at  a 
stretch  keep  on  raising  both  arms  and  letting  them  lall  again 
without  the  least  feeling  of  faTigtie. 

Clonic  muivcutar  spasms,  in  the  muscles  of  the  face  as  well 
as  in  the  extreintiies.  which,  appearing  in  paroxysms,  usually 
arc  symmetrical  in  their  distribtilinn.  and  are  not  sulhcient 
to  produce  movements  of  the  affected  limbs,  have  been  de- 
scribed by  Friedreich  as  paramyoclonus  multiplex,  and  by  iiee- 
Hgmttllcr  as  myoclonia  congenita.  That  they  arc  of  hysterical 
origin  is  more  than  probable.  The  ttouble  is  rare,  and  is  in 
most  instances  to  be  regarded  as  an  emotional  neurosis.  The 
strength  of  the  muscles  and  their  electrical  excitability  remain 
uttallcrcd,  and  sensory  changes  arc  absent.  Sometimes  there 
are  tender  points  along  the  spine,  which  are  best  treated  by 
the  anode  of  the  constant  current.  Other  mrasiircs  are  not 
necessary,  especially  as  recovery  seems  to  be  the  usual  out- 
come (cf.  lit.). 

Closely  related  to  though  not  identical  with  myoclonus  Is 
the  group  of  symptoms  which  has  of  more  recent  years  been 
described  as  "  maladic  dcs  tics  convulsils."  Irregular  move* 
mentsltaving  the  nppraranceof  intended  m<tv<-ments.  but  which 
have  become  automatic,  occur  in  the  lace  and  in  the  extremi- 
ties: they  may  be  confined  to  one  side.  It  is  not  improbable 
that  imitation  or  even  direct  suggestion  may  play  an  important 
uUe  in  the  production  ol  these  movements  <Toh:ir>ki,  N'eurol. 
Centralbl.,  1893,  16).  Menial  abnormities  arc  rarely  absent  in 
such  patients;  thus  we  hnd  "a  tendency  to  the  formation  of 
fixed  ideas — i.  c,  a  low  degree  of  mobility  o(  the  contents  of 
consciousness  and  the  frequent  repetition  of  the  same  psychical 
processes"  (Toharski).  The  movements  present  the  following 
peculiarities:  They  have  a  psychical  character:  they  are  re. 
pented  in  a  monotonous  manner  :  ihcy  appear  purposeful ;  but 
since  the  will  has  nothing  to  do  with  their  appearance,  they 
occur  without  effort  on  the  part  of  the  patient ;  at  times  they 
can  be  suppressed  by  an  effort  of  the  wilt.  Fibrillary  twitch- 
ings  and  involuntary  contractions  in  certain  muscles,  especially 
in  those  of  the  face  and  the  neck,  more  rarely  o(  the  bands, 
have  been  observed  (Toharski).  I  have  reported  a  case  in 
which  this  condition  was  associated  with  allochiria,  and  which 


550        D/S£AS£S  OF  TltE  GEXE/lAl  XERVOUS  SYSTEM. 

1  succeeded  ifi  curing  by  verbal  suggestion,  at  the  Intcrnalional 
Congress  in  Rome  (cf.  Wiener  med.  Pre&se,  1894). 

UTERATfRE. 

Starr.  Allen.     Taritinyoclon.  Mull.,  with  a  Rejiorl  of  a  Case.    Jouin.  of  Netr.and 

Mcni.  DlsiM^FK  |8!I7.  xiv,  p.  416,    (The  &i>a»nis  appeared  Imtncdiatcly  a&ct 

lifting  heavy  objects.) 
RybaUin.     Ccicrih.  med.  Wochenichr..  1887.  44.  pl  366, 
Marina.     Uebn  Paraniyoclon.  mull,  und  liJIupaihischc  Mui>kdki£inpfe.    ArtK 

r.  l^)Yh.  untl  Ncn'cnkh,.  i6tl8,  xix.  5.  p.  684. 
Zidwn.     Ucbci  Myoclonus  und  Myoclimic    IbJd.,  1S68.  xix.  3.  p.  46$. 
Pelpcr.     Ucbcr  Myoclonic.     Deutsche  med,  Wuchenschr.  1890.  i$b 
Unverrichi.    Die  Myoclonic,     [^jpiig  u.  Wicn,  Dcuiickc,  1891, 
ColilHani.     Neurol.  Ccntrjlbl,  189!.  4. 
Weiss.  M.     Ucbcr  Myoclonie.     Wicntr  Klinik,.  1893.  Heft  5. 
Jolly.    UebcT  die  sogcn.  Maladie  <les  Tics  cum  uJtiti.    Ch.nrilf-Aitnaleii,  tSgi. 

p.  740. 
Buringh  Bockhotidt  cl  J.  van  der  Wcyilc.    Mahdie  dc«  tics  convulsifg.    Wtckli 

van  he(  Ncdcrl.  Tijd«chr.  voor  (lenecsk,,  189}.  p.  3691 
Scidinaiiiu.     Malaitm  dvi  lie  K.  Accad.  nicd.  di  Kvinu.  1893. 

Often  combined  with  paralyses  of  the  extremities  are  joint 
cotilractures,  which  as  a  rule  appear  suddenly,  atid  may  per- 
sist for  months  and  years.  When  occurring  in  the  upper  ex- 
tremities, ill  the  elbow,  in  the  wrist,  and  in  the  finger  joints, 
they  arc  usually  flexor  contractures;  in  the  knee  and  ankle 
joints,  extensor  contractures.  The  way  in  which  they  disap- 
pear under  chloroform  narcosis  \%  very  remarkable.  Individ- 
u;d  muscles  may  also  be  the  scat  of  contractures,  and  we  have 
described  a  case  on  page  38;  in  which  during  the  erect  postun 
a  contracture  in  the  quadratus  lumborura  made  its  appe.irance. 
which  disappeared  when  the  patient  lay  down. 


LITERATURE. 


Zesas.    Zur  DUTereniialdLigniMe  der  Odenknniroara.    Chir.  CcntralbL.  ■: 

hiii,  i& 
PitrcK.    De  I'analK^ie  cb«  les  hy«t  jriqucK  i  I'iiat  de  willc  cl  dans  le  sommrf 

hypnulique.    Joum,  de  mit\.  At  Uonkaux,  1886,  (ol 
MUllcr.    Mitth.  d.  Vercino  d.  Acfile  in  Stci<Tmart[,  1886.  xxiL    (IiMnMlnt 

Senftury  Clianj^ex.) 
Lichtn-itx.    Lcs  antsihfsia  hystMques  <to  mu(|ueus«  t\  ila  oi^gnna  dn  ■m^ 

et  let  ion»  hysttroginct  dct  muqiKu«n.     Cnris,  1 S87. 
F«lcone.    l><ru<!u:he  med.  Wochenichr,.  iH8£,  xii.  41.    (S|)0«uacou3  TaUiiS 

Out  of  the  N.iils.) 
WmiI.     thlUdelphia  Med.  and  Surg.  Rep-.  1887.  ML*  J.    (Hysierical  tUmor- 

t)-sis.) 
Rkhcr.  Paul.    P.tralysles  ct  oontncuns  h>'5t..  Paris,  189a.  Ddn. 


1 


IIYSTEKIA. 


551 


I 


Among  the  scnsnry  disorders  the  dimimilion  or  complete 
of  sensibility  is  llie  must  important :  this  m»y  be  so  exten. 
sive  that  the  patients  can  feci  nothing  on  any  part  of  the  sur- 
face of  the  body,  not  excluding  the  mucous  membranes  (con- 
junctiva:, nose,  tongue,  motilh,  vagina,  rectum),  so  that  one  can 
touch  them  with  the  hot  iron  (t  her  mo-cautery)  or  prick  thcni 
with  knives  and  needles,  and  they  will  not  make  the  slightest 
sign  or  attempt  to  draw  away  the  part;  nay,  more,  there  are 
cases  in  which  the  deeper  tissues  take  part  in  the  anaesthesia, 
so  that  (olds  of  skin  maybe  transfixed  and  tine  needles  thrust 
into  the  muscles  down  to  the  bone  without  (he  knowledge  o( 
the  patient  if  she  be  blindfolded.  Besides  the  general  abolition 
of  sensation,  we  may  meet  with  circumscribed  spots  of  anaes- 
thesia, anarstheiic  zones,  on  the  back,  on  the  hands,  etc.  The 
hemianicslhcsia,  which  is  strictly  confined  to  one  side,  and  which 
impliotes  the  mucous  membranes  as  well  as  the  skin,  has  already 
been  mcntionc<l.  These  sensory  changes  also  may  appear  and 
disappear  suddenly. 

Less  common  arc  the  hypcriesthesias,  which  probably  never 
take  in  the  whole  body,  and  never  even  one  whole  half  of  the 
body,  but  are  usually  confmcd  to  circumscribed  areas,  to  cer- 
tain internal  organs,  or  by  preference  to  certain  joints.  These 
circumscrilxTd  areas,  Charcot's  hysterogenic  loncs,  vary  in 
their  situation :  they  may  be  on  the  back,  on  the  chest,  in  the 
extremities,  or  elsewhere.  .Among  the  internal  organs,  in 
women  ihc  ovaries,  in  men  and  boys  the  testicles,  arc  the  parts 
that  usually  suflcr.  The  ovarian  hypera'Sthesia,  which  Ch.ircot 
has  studied  very  carefully,  is  closely  related  to  the  "major 
attacks"  to  bcdescribc<l  later.  That  it  is  actually  Ihc  ovaries 
which  give  rise  to  the  acute  pain  when  pressure  is  made  over 
them  Charcot  has  proved  on  pregnant  women ;  during  preg- 
nancy the  position  of  the  ovaries  is  changeil,  and  it  was  l(nm<l 
that  there  was  a  corresponding  change  in  the  position  of  the 
tender  points.  The  women  who  suffer  from  this  hyperarsthcsia 
ire  in  Paris  called  ••  ovariennes." 

Neuralgiform  pains,  which  often  afTecl  the  joints  and  which 
■re  very  obstinate,  arc  so  common  in  the  course  of  hysteria 
that  whenever  we  finfl  a  joint  neuralgia  we  should  think  ol  and 
search  for  a  hysiericil  b:isis.  Dnxlie  has  subjected  them  to  a 
•mry  accurate  study,  anfi  has  pointed  out  that  it  is  at  limes  ex* 
tremely  hard  to  difteretitiate  between  a  neuralgia  and  an  actual 
disease  of  the  joint.     The  hip  attd  knee  arc  must  usually  attacked. 


553 


DISEASES  OF  THE  GEXERAL  XERVOVS  SYSTEM. 


The  joint  is  painful,  especially  on  pressure  or  on  motion :  hence 
such  patients  arc.  a,s  a  rule,  found  in  bed  or  lying  on  the  sols. 
On  closer  examination  the  puin  proves  not  to  be  confined  to 
one  spot,  but  to  be  distributed  over  more  or  less  large  areas  ol 
llie  lower  extremity.  Tlie  patient  cries  out  if  pressure  is  made 
ill  the  neighborhood  of  the  hip  or  the  knee  or  lower  down  over 
the  malleoli.  She  seems  to  be  especially  sensitive  when  watch- 
ing and  following  our  manipulations;  but  if  the  physician  is 
able  to  divert  her  attention,  pressure  over  an  otherwise  painful 
point  will  often  evoke  no  complaint.  In  the  course  ol  the  dis> 
ease  the  glutei  may  undergo  some  atrophic  changes;  now  and 
then  traiii^icnt  swellings  arc  noted.  On  the  other  hand,  there 
are  instances  in  which  hysterical  joints  are  the  only  cause  which 
keeps  the  patient  persistently  in  bed.  and  in  which,  in  spite  of 
an  inactivity  lasting  for  years,  not  n  trace  of  atrophy  can  be 
recognized,  while  the  general  health  shows  no  signs  of  impair- 
ment (cf.  lit.).  All  these  and  other  spontaneous  pains,  which  we 
need  not  dwell  upon  here,  occurring  in  hysterical  individuab 
arc  to  be  regarded  as  being  of  psychical  origin,  and  therefore 
as  pain  hallucinations  (StiUmpcU,  Hoist). 


I 


Among  the  abnormities  of  the  secretory  organs,  those 
which  concern  the  urine  chiefly  deserve  our  attention.  Hys- 
terical ]>aticnts  may  urinate  very  little  and  not  without  diffi- 
culty (ischuria).  On  the  other  hand,  wc  find  some  who  urinate 
frequently  and  pass  almost  incredible  amounts  (cf.  Mathieu,  La 
polyurie  hysi^rique.  Revue  nturol..  ;893,  19).  In  the  former 
case  the  specific  gravity  is  high  and  the  solid  constituents  o( 
the  urine  are  increased  in  amount.  In  the  latter  the  urine  re 
semblcs  almost  clear  water,  ll  would  be  erroneous  to  assume 
that  the  small  or  large  amount  of  urine  always  depends  upon 
ihc  amount  o(  water  ingested.  Indeed,  patients  who  drink 
hardly  anything  may  void  very  large  quantities  of  urine,  while 
those  who  drink  a  good  deal  m.ty  pass  only  a  (ew  drops  at  a 
time.  Here,  again,  as  with  the  manifestations  of  hysteria  in 
general,  no  hard-and-f.-i<)t  rule  can  be  given,  nor  can  anything 
certain  or  constant  be  said  about  the  salivary  and  sweat  secre- 
tions, since  they  arc  equally  subject  10  variations. 

Among  the  trophic  disturbances  we  will  only  mention  the 
hysterical  oedema,  which  occurs  as  the  white  or  as  the  blue 
type :  the  former  is  soft  in  character,  and  the  skin  pits  on  pros- 
sure  ;  the  latter  is  hard,  is  associated  with  diminished  surface 


UYSrE/tlA. 


553 


Jlcmpcralurc.  and  tlic  skin  sometimes  presents  a  peculiar  raot- 
l.llcd  iippearancc  (Charcot;  cf.  also  Athanassio,  Des  troubles 
<  Irophiqiies  dans  I'hyst^rie,  Paris,  1890). 


-that 


ihose 


I 


The  combined  hysterical  manifestations- 
originating  in  the  bruin  as  well  as  in  the  spinal  ci»rd — consist  uf 
the  so-called  "paroxysms"  or  "attacks,"  in  which  conscious- 
ness is  not  lost,  as  in  epilepsy,  but  which  are  associated  with 
convulsions.  Vague  pains,  ructiis,  yawning,  the  globus  hys- 
tericus, ischuria,  etc.,  may  constitute  the  premonitory  signs, 
which  arc  immediately  followed  by  violent  respiratory  move- 
ments, regular  respiratory  spasms,  with  laughing,  screaming, 
weeping,  barking,  and  linally  the  climax  is  reached  in  muscubr 
spasms  and  convulsions  resemblitig  Xhmc  of  epilepsy.  During 
such  paroxysms  the  whole  body  may  be  thrown  from  side  to 
side,  and  it  may  be  impossible  to  restrain  the  patients,  because 
they  exhibit  a  strength  far  greater  than  that  which  they  ordi- 
narily possess.  Alter  the  ht — which  may  last  from  half  an  hour 
to  an  hour — has  spent  its  force  there  follows  a  condition  of  gen- 
eral prostration,  which  usually  docs  not  lust  long  and  is  fre- 
quently accompanied  by  polyuria.  It  is  just  these  attacks 
which  make  the  "home  treatment"  (or  hysterical  patients  so 
very  difTicull  or  finally  even  impossible,  li  has  been  found  by 
experience  that  the  sight  of  such  patients — of  the  various 
contortions  into  which  their  bodies  are  thrown  and  the  gro- 
tesque positions  they  assume— has  nn  injurious  effect  on  the 
other  members  of  the  family,  especially  if  there  are  young 
girls  amcmg  them.  Such  a  scene  and  the  consequent  mental 
excitement  have  been  known  to  cause  similar  attacks  in  other 
females. 


Duration  and  Course. — The  ditralion  and  course  of  hyste- 
are  by  no  means  uniform,  although  this  much  may  be  said. 
Fthat  it  is  always  chronic  and  may  Inst  for  years  and  tens  of 
'  jears-     There  are  patients  who  from  the  time  of  puberty  until 
I  afler  the  involution  period  are  hysterical,  and  thus  never  attain 
[to  the  full  enjoyment  of  life.    At  the  beginning  of  the  trouble 
Ihcre  is  usually  nothing  more  than  a  certain  tendency  to  nerv- 
ousness, a  certain  proneness  to  eccentticiiii'S.  annoying  to  the 
patient  and  still  more  so  to  the  family.    Soon  various  pains, 
which  are  apt  to  frequently  change  their  seat  and  to  vary  in 
intensity,  make  their  appearance,  and  certain  rc&piratory  phe- 


554 


d/sejISEs  of  the  cenekal  sekvovs  system. 


nomcna,  perliaps  shorinrss  of  breath  or  a  barking  cough  for 
which  physical  examinaiiun  reveals  no  cause,  begin  to  ailract 
our  attention. 

Severe  iiiutor  disturbances  are  by  no  means  noted  in  all 
cases ;  even  contractures  arc  not  very  common.  On  the  other 
hand,  there  are  tew  cases  in  which  the  sensibility  does  not  at 
various  times  undergo  striking  changes.  Ana-slhcsiasand  an.il. 
gesias  alternating  with  hypersesthesiasand  neuralgias,  especial- 
ly of  the  joints,  and  persistent  headaches,  all  help  to  sour  the 
disposition  ul  the  patient.  During  menstruation  the  condition 
is  usually  aggravated.  The  patient  is  still  mure  excitable  than 
usual,  and  her  complaints  are  louder.  In  those  in  whom  the 
paroxysms  arc  an  important  feature  o(  the  case  this  is  more 
especially  true,  and  sometimes  the  first  menstrual  period  is  the 
signal  tor  the  first  attack,  which  is  at  regular  intervals  followed 
by  others.  In  many  cases  of  hysteria  "attacks  "  never  occur. 
The  patients,  indeed,  may  without  any  provocation  have  fits  o( 
crying,  laughing,  and  screaming,  but  no  convulsions.  With 
advancing  age,  and  when  the  sexual  functions  arc  becoming 
inactive.  \  he  liysterieal  phenomena  fade.  As  the  hair  turns  gray 
the  disposition  becomes  calmer  and  more  equable,  and  even 
egotistical,  exacting,  peevish  women,  who  have  tormented  their 
families  continually  and  who  were  extremely  hard  to  manage,  be- 
come yielding,  amiable  old  ladies  after  the  hysterical  manifesta- 
tions have  once  left  them.  Still  there  arc,  unfortunately,  excep- 
tions in  which  these  persist  even  after  the  seventieth  birthday. 

The  prognosis  may  be  inferred  from  our  dcscrtpiiun  of  the 
course  ol  the  disease.  Doubtful  as  it  always  is,  it  is  made  stilt 
more  gloomy  from  the  fact  that  persons  who  have  for  ye.irs 
suffered  from  hysteria  are  apt  to  be  subject  later  in  life  lo 
actual  organic  nervous  diseases,  especially  of  the  br<iin  (Pehl- 
mann,  Inaug.-Dissert,,  Leipzig.  18S7). 

Hysteria  was  thought,  as  the  name  indicates,  to  occur  ex- 
clusively in  members  of  the  female  sex.  That  it  is  more  preva- 
lent among  them  there  can  be  no  question,  but  Charcot  and 
his  pupils  have  shown  convincingly  that  it  does  occur  in  men 
and  boys,  and  that,  too,  much  more  frequently  than  might  a 
/>rhri  hnvc  been  supposed.  From  him  we  have  learned  that  it 
occurs  frequently  among  the  French  soldiers.  Further  inves- 
tigations may  prove  that  this  would  hold  good  not  only  for 
ihc  French  but  also  for  other  armies.  Age  seems  to  Iiivc 
much  less  influence  than  was  at  first  assigned  to  it.     Hyslent 


HYSTEIilA. 


5S5 


I 


in  cliildren  is  by  no  means  rare.  The  (ull  development  of  all 
hysterical  manifestations  in  the  young,  who  arc  far  from  being 
sexually  mature,  proves  that  puberty  and  the  sexual  or<;ans  are 
of  less  importance  in  the  causation  of  this  neurosis  than  has 
formerly  been  supposed. 


I 


LIIEKATUKE. 

IVbmv.     C^i.  (Ics  Hdp..  1886.  30.    (Hyaima  in  the  Male.) 

Tucick.     Ikflincr  kliii.  U'ochcnuhf.,  1886.  xaiII.  31-}3. 

FfTuA     Wiener  med,  UUiticr.  1BS6.  ix.     (Hyslcna  in  the  Male.) 

Dmcbrfid     Med.  Chronicle.  188b.  v.  3.    (Ily«ma  tn  Ihe  M»l«  aDer  Traunu.) 

DupoiKhel.     L'hyM^rir  ilans  lariii^.     Riviic  dc  niM.,6  Janl.  18S6,  vi. 

jjrutcf).     Nedcrl,  Weckbl..  1887.  ii,  1  j.     (Myitirri.i  in  Soidicrt.) 

KicM^fcld.     IliKirnc  hri  Kiitdcrn.     Inaut-.-Oisteit,.  Kiel.  11)87, 

Dubois.     Schwciter  CotTe»|iondcnil>t..   1887.  ivii,   13.     (Hysterii  la  Men  and 

ChiUren.) 
CouMan.     Aich.  dc  m^l,  ci  dir  |>hamt.  mil..  1S87.  x,  5.     (Hysteria  in  ilic  Mak.) 
Handford.     Ilniish  Med.  Joum..  October.  1887. 11.     (tl)iuena  in  a  Mule.) 
^loricoun.     C.14.  dcs  HA)!,.  1887,  6.    (HyMcna  in  (he  Mile.) 
Enj^hberX'      Wienrr  mcd.  U'orhcnscbr..  1S88.  xxxnli.  14.     H)-stctia  In  a  Uoy 

aged  Thirteen.) 
Lees,  David,     lancet.  June  33,  1K88, 1.     (H)Uerla  In  Two  Uoys.) 
Ray.     llyUerin  in  ihc  Nrgro.     New  York  MrIk'aI  Krcord.  July  3.  1S88.  x»ir. 
CUric     Joum.  of  Menl.  Sc.  J.inunry-.  18S8.  xxiiii.    (ll)'Slaia  in  the  Mal«'.> 
Biioi.     L'hyM^ie  mAlc  dans  Ic  ten  ice  <lc  M.  litres  A  I'hApU^  Si.  Amhi  tk 

nofiknux.  Parit,  189a 
Retschauer.     Iniiu|[.-Diswrt..  Uerlin.  1890.     (Cue  of  HystcrU  la  «  Man  after 

External  Urethrotomy.) 
Sollkr.     Iji  France  mfd..  1891.  3S.     ilnfnntde  Hvsirri»HiihConvuI»i>«  rorm.) 
Duvoinin.      t'rbcr  inf4nlilc  Hy^vrie.     InnuK.-UuMrt..  IbM^t.  1891. 
Chaufltier.     Srnuinr  mM..  1891.  jS.     (H)«eria  in   ibc   New-bom(!)  and   tn 

Children  Two  Vears  of  Age.) 

Diagnosis.— The  diagnosis  of  hysteria  may  at  one  time  be 
ver}'  easy,  at  another  we  may  encounter  no  inconsiderable  dif1i> 
culdcs.  When  we  have  an  array  oi  evcr.%-arying  symptoms 
occurrins  apparently  without  order,  when  the  patients  com. 
plain  tu^ay  of  this,  to-morrow  of  that,  while  the  physical  signs 
show  no  grounds  for  their  troubles,  it  does  not  need  an  expert 
to  suspect  and  diagnosticate  a  hysterical  condition.  If,  on  the 
other  hand,  the  discti^e  sets  in  suddenly  without  previous  dis- 
orders of  any  Wind,  in  one  case  with  a  hemiplegia,  in  anollicr 
case  with  a  severe  hip  trouble,  it  may  be  by  no  means  easy  to 
say  whether  and.  if  so,  why  the  hemiplegia  is  of  hysterical 
origin,  and  wlielhrr  or  not  Ihc  joint  affection  is  to  be  regarded 
as  a  hysterical  coxalgia. 


556 


DISEASES  0J-'  THE  GENERAL  NERVOUS  SVSTEAf. 


The  following  points  will  in  the  majority  of  cnscs  be  found 
sufficient  to  clear  up  any  difhcullics  which  the  diagnosis  pre- 
sents : 

With  regard  to  the  cerebral  symptoms,  and  more  especially 
those  belonging  to  the  affections  of  certain  of  the  cranial  nerves, 
we  have  in  previous  chapters  pointed  out  some  features  char- 
acteristic of  the  hysterical  varieties.  It  will  be  necessary  in 
every  se;>aratc  cisc  to  exclude  scrupulously  anatomical  lesions 
and  to  determine  whether  there  arc  in  addition  to  those  bc^ 
longing  to  the  cranial  nerves  other  symptoms  which  point  to  a 
hysterical  condition.  II  such  be  found,  and  more  especially  iE 
our  objuctive  examination  gives  negative  results,  the  diagnosis 
of  hysteria  is  wtrraniablc. 

These  rules  arc  pariicuiariy  applicable  where  we  have  lo 
decide  whether  a  hemiplegia  is  hysterical  or  due  to  a  lesion  in 
the  internal  capsule,  whether  a  coriiraclure  has  to  be  regarded 
as  hysterical  or  cortical  (page  184),  and  whether  the  disturb- 
ances of  the  respiratory  organs  depend  upon  diseases  of  the 
lungs  or  the  larynx,  or  arc  to  be  referred  to  a  neurosis  of  the 
vagus  or  of  the  recurrent  laryngeal  nerve. 

The  recognition  of  the  hysterical  nature  of  spinal  manifesta* 
tions  belonging  to  the  motor  apparatus  may  give  rise  to  the 
greatest  difficullics.  It  Is  upon  the  electrical  examination  that 
wc  must  rely  in  deciding  whether  the  paralysis  ol  an  extremity 
depends  or  not  upon  a  peripheral  cause — that  is,  upon  a  neuri* 
lis.  A  well-marked  reaction  ol  degeneration  always  points  to 
a  chronic  inflammatory  condition.  The  age  of  the  patient  is 
of  some  value,  hfysterical  paralyses  occur  between  the  agcsol 
fifteen  and  thirty. and  more  particiilurly  in  women.  Further, 
we  observe  nhnosl  always  nssi)ci;iit.-d  with  hysterical  paralyses 
grave  sensory  disturbances  which  are  not  necessarily  prcscni 
in  the  other  kinds  (cf.  Luinbroso.  Lo  Sperimentale,  Fircnzc. 
1887;  reference,  Neurol.  Ccntralbl.,  1888,  7).  The  existence  of 
muscular  atrophy  is  not  sufficient  to  determine  the  organic 
nature  of  the  paralysis  becau.se  an  atrophy  of  muscles  does  not 
exclude  hysteria,  as  we  have  pointed  out  above  (Brissaud, 
Arch,  dc  physiol.  norm,  et  pathol..  Avril,  i887,p.339).  Schlapo- 
bercki  (Inaug.- Dissert.,  Berlin.  1895)  has  pointed  out  the  sig- 
nificance of  relapses  in  the  hysterical  paralyses. 

Contractures,  if  of  hysterical  origin,  set  in  suddenly,  and  arc 
almost  always  accompanied  by  other  hysterical  manifestations 
mctcorism,  ovarian  hypera^lhesia,  and  ischuria.     Where  such 


UYSTF.firA. 


S57 


I 
I 


i^toms  arc  absent  we  must  be  very  careful  in  our  exami- 
nation am)  take  into  account  Ihc  possibility  of  an  anatomical 
lesion  cither  of  central  or  of  )>enpheral  origin  (c(.  Otocq.  Des 
Contractures,  Tliisc  de  Paris,  1888;  Progr.  mid..  l««8,  xk,  p. 

397). 

Hysterical  muscular  spasms  may  be  taken  for  tetany,  as 
the  case  of  Caiger,  in  the  Lancet  of  August  20,  1RS7,  shows. 
To  the  frequent  occurrence  of  rhythmical  sjxism  tn  certain 
groups  of  muscles  in  hysteria,  Pitres  has  drawn  attention  in  an 
article  in  the  GaJt.  mid.  dc  Paris,  1SS8,  13. 

Trembling  and  shaking  movements,  which  somewhat  re- 
semble those  of  inlenlinn  tremor  as  they  become  more  marked 
on  voluntary  motion,  have  been  noted,  but  are  rare  (Charcot, 
Progr^smid..  1S90.37).  The  possibility  of  mistaking  such  con- 
ditions  for  multiple  sclerosis  (or  vice  ivrs^)  should,  however, 
always  be  kept  in  mind.  In  our  account  of  the  latter  disease 
we  shall  come  txick  again  to  the  points  for  the  differential  diag- 
nosis between  the  two  conditions. 

The  sensory  changes  in  hysteria,  the  anarsthcsias,  affect,  as 
wc  s:iid.  not  only  the  skin,  but  nbo  the  deeper  tissues,  so  that 
needles  may  be  inserted  down  to  the  bone  without  being  felt. 
Usually  all  qualities  of  sensation  take  part  in  the  disorder,  so 
that  the  so.callcd  muscular  sense  is  also  lost  and  the  patients 
are  unable  after  closing  their  eyes  to  give  any  account  of  the 
position  of  their  limbs.  Pronounced  anursthcsia  is  found  dur- 
ing ihc  hysterical  paroxysms.  An  anivsthesia  extending  over 
the  whole  body  and  taking  in  all  the  mucous  membranes  is 
almost  always  hysterical  in  nature.  These  grave  sensory  dis- 
turbances render  explicable  the  pn<>sibilily  that  patients  some- 
times for  some  reason  or  another  produce  sores  on  their  own 
bodies.  With  regard  to  such  lesions  which  may  at  limes  be 
mistaken  for  those  of  lupus  or  carcinoma  the  reader  is  referred 
to  the  Deutsche  Mcd.-Ztg.,  1S9;.  8S  (.\ccount  of  the  session  o( 
the  Berlin  Medical  Society.  October  26.  1892). 

Hype  nest  hcsias  and  neumlgias  occurring  in  hysteria  arc 
typical  in  th;U  ihey  are  very  changeable,  so  that  to-ilay  cranial. 
to-morrow  spinal,  nerves  are  the  scat  of  the  pain.  Neuralgias 
of  joints,  if  org:inic  disease  can  be  ruled  out  and  il  they  are 
very  ntmtinaie  and  resist  all  the  ordinary  therapeutic  measures, 
may  be  safely  looked  upon  as  hysterical.    The  "attacks"  may 

mistaken  lor  cpiU-plic  fits.  The  important  point  to  remcm- 
ir  in   this  connection  is  that  in  the  hysterical  attacks  con- 


558        DISEASES  OF  TUP.   GENERAL  NERVOUS  SYSTEU.  ■ 

sciousness  is  never  lost  as  completely  as  in  epilepsy.  Biting  o( 
the  tongue  is  an  exception  in  the  lormer.  The  liysterical  at- 
tacks arc,  moreover,  attended  with  noisy  laughing  and  crying, 
etc.,  while  epileptics,  with  the  exception  of  the  initial  cry 
(which  is  not  constant),  pass  through  the  whole  convulsive 
sta^e  quietly  and  without  uttering  a  sound.  It  has  been 
claimed  that  there  never  occurs  an  elevation  of  tcm]>craturc 
during  the  hysterical  seizure,  while  the  epileptic  fit  is  accom- 
panied by  a  slight  rise,  1.2"  lo  i.S*  F.  This  statement  can  not 
easily  be  controlled,  and  certainly  needs  further  confirmation. 
Finally,  it  should  be  remembered  that  hysterical  attacks  may 
in  some  instances  be  produced  by  pressure  upon  the  ovaries  or 
the  testicles,  while  in  epilepsy  this  is  never  the  case. 

Pathogenesis  and  Etiology.— About  the  nature  of  hysteria 
we  arc  absolutely  in  the  dark.  Xut  one  of  the  many  attempts 
to  explain  the  disease  can  be  regarded  as  more  than  a  vague 
hypothesis.  This  one  fact  may  be  rcijardcd  as  certain,  that 
the  existence  of  grave  anatomical  changes  is  excluded,  or,  at 
any  rate,  is  highly  improbable,  otherwise  the  suddenness  with 
which  the  symptoms  come  and  go  would  be  absolutely  iiiex. 
plicablc.  The  old  idea  that  the  uterus  must  be  held  rcsponsi-  I 
ble  in  every  case  and  under  all  circumstances  for  the  disease, 
which  was  consequently  called  hysteria  (i^r^ia),  has  been 
shown  to  be  untenable  by  the  number  of  cases  observed  in  ■ 
men  and  young  children  :  and  the  more  cases  we  see.  the  clearer 
it  becomes  that  the  hysieriiis  occurring  in  males  and  in  lillte 
children  furnish  a  considerable  proportion  of  the  total  number,  ■ 
and  the  more  ridiculous  becomes  the  term  "  hysteria,"  which 
sooner  or  later  will  be  given  up  completely.  The  influence  of 
the  sexual  organs  on  the  disease  will  be  discussed  later,  but  we 
would  state  emphatically  that  the  opinion  thai  these  are  always 
the  starting  point  of  the  disease  is  indefensible. 

But  how  shall  we  explain  the  disease?  If  we  agree  that  all 
symptoms  of  hysteria  have  certain  characteristics  in  common, 
they  may  pi-rhaps  all  together  be  traced  to  an  increased  excita- 
bility oi  the  whole  nervous  system,  to  the  quicker  response 
to  stimuli  from  without  and  within.  Just  .is  we  have  morbid 
conditions  in  which  the  excitability  of  the  nerves  and  the  mus- 
cles to  the  electrical  current  is  found  to  be  increased,  we  may 
imagine  also  an  analogous  condition  in  which  all  the  nerves, 
including  the  nerve  elements  of  the  central  organs  of  the  bmin. 


HYSTERtA. 


5S9 


I 


I 


especially  o(  its  cortex,  those  of  the  spinal  cord,  and  also  of  the 
peripheral  nerves,  are  in  a  constant  stale  ol  abnormal  or  pntlio- 
logical  excitability.  That  in  such  a  state  the  imagination  plays 
an  imporlanl  riU  is  self-evident— not,  however,  in  the  sense  that 
all  the  suflcrings  of  which  the  patient  complains  arc  imaginary 
and  merely  dc|>end  upon  the  imagination;  we  rather  mean  that,  in 
the  condition  described,  the  ideas  arc  consciously  or  unconscious* 
ly  influenced  by  the  will,  they  are  formed  and  disappear  more 
quickly  and  are  constantly  changing.  Such  a  quick  and  unnat< 
Ural  change  can  not  but  exert  an  unfavorable  influence,  tirst  upon 
the  mind  and  disposition,  and  later  upon  the  bodily  condition. 

In  reality  it  is  in  the  majority  of  cases  a  disturbance  ol  tlie 
psychical  equilibrium  which  produces  the  disease.  It  is  not 
impossible  that  careful  study  of  the  a-tiology  may  do  much 
toward  a  clearer  understanding  of  the  nature  of  the  malady : 
Guinon  has  shown  this  in  his  excellent  monograph,  Les  agents 
provocateurs  dc  I'hyslirie,  Paris,  1889.  The  causes  may  be 
subdivided  into  direct  and  indirect.  To  the  former  belong  a 
hereditary,  physical  as  well  as  psychical,  predisposition  of  ihe 
individual.  There  is  no  doubt  that  only  those  persons  can 
become  hysterical  who  are  from  birth  so  predisposed,  because 
Ihey  have  a  nervous  system  which  presents  the  peculiarities 
that  we  have  just  described.  This  congenilal,  because  heredi- 
t:try,  predisposition  finds  favorable  conditions  for  further  dcvel- 
opmcnt  in  (d)  sex,  (^)  age,  (c)  education,  (d)  nationality  or  race 
of  the  patient.  That  the  female  sex  and  those  just  arriving  at 
the  age  of  puberty  are  prone  lo  the  disease  we  have  said  before, 
although  the  male  sex  and  other  periods  of  life  besides  that  o( 
puberty  arc  by  no  means  exempt.  The  hysteria  which  occurs 
in  early  childhood,  and  which  has  been  observed  between  five 
and  ten  years  of  age,  deserves  special  study. 

Much  must  be  attributed  in  the  causation  of  hysteria  to  a 
faulty  education.  The  brain  may  be  overtasked  at  Ihe  ex. 
pense  of  the  body,  and.  in  consequence  of  too  little  firmness 
on  the  part  of  the  parents,  capriciousness,  inconslderntencss. 
lack  of  truthfulness,  of  energy,  and  of  will  power  arc  fostered 
in  ihc  child,  and.  finally,  when  the  children  have  behaved  badly, 
the  mysterious  threats,  especially  of  injudicious  servants,  o( 
sending  after  them  wild  beasts,  ghosts,  ■•  Ihe  black  man,"  etc. 
can  drive  them  into  such  a  chronic  stale  of  fear  that  ihey  can 
not  go  into  a  dark  room  without  palpitation  and  the  most  tn> 
tense  feeling  of  terror.     All  such  and  many  other  mistakes  in 


jfio        DISEASES  OF  THE  CEKERAL  NERVOUS  SYSTEAT.        ^ 

the  early  education  of  the  child  become  indirectly  causes  of 
hysteria.  The  occupatiun  may  have  an  influence  if  it  be  at$o- 
cialfd  with  bodily  and  mental  overexertion,  and  in  certain  call- 
ings the  possibility  ol  intoxication  (lead,  mercury,  bisulphide  oi 
carbon,  etc.,  must  not  be  forgotten)  (Rouby,  Contribulinn  k 
r^tude  dc  Thyst^ric  toxiqitc,  Thfesc  dc  Paris,  1889).  As  I" 
race  the  Slavonic  (Poles.  Russians),  the  Latin  races  (the  French 
and  the  Italians),  and,  above  all,  the  Semitic  peoples,  are  more 
liable  to  hysteria  than  the  Teutonic.  The  severest  forms  of 
hysteria  are  seen  in  French  women  and  in  Polish  Jewesses. 
This  may  depend  upon  the  national  characteristics;  the  lively, 
impetuous  temperament  which  we  find  on  an  average  more 
frequently  in  the  Slavs,  etc..  than  in  the  Teutons,  forms  a  par. 
ticularly  favorable  soil  for  the  development  o(  hysteria. 

Among  the  direct  causes  disorders  of  the  sexual  organs 
play  the  most  important  part,  and  in  both  sexes  this  factor  it 
equally  potent.  We  must  not  think  that  the  affection,  which, 
C5pcci:illy  in  women,  may,  from  a  gynaxrological  standpoint,  be 
very  insignificant — for  instance,  a  flexion,  or  a  change  in  posi- 
tion of  the  uterus — has  in  itself  much  to  do  with  the  matter:  it 
is  much  rather  the  idea  that  the  trouble  exists,  and  the  anxiety 
lest  it  should  interfere  more  or  less  materially  with  coitus  and 
parturition,  which  constitute  the  direct  cause  of  the  depres- 
sion of  spirits.  The  conjugal  obligations — coitus,  pregnancy, 
parturition — play  such  an  important  rSU  in  the  life  of  every 
woman,  if  she  h.is  not  missed  her  calling,  that  the  mere  idea 
that  the  sexual  organs  are  diseased  or  incapable  of  performing 
their  function  is  sufficient  to  give  a  severe  shock  to  her  hap- 
piness. In  a  man  it  is  much  less  the  potenlia  generaHdi  than 
the  potftlia  cocmtdi  that  causes  him  anxiety.  The  above-meti- 
tioncd  psychical  impotence,  if  it  exist  for  a  long  time,  in  itself 
suffices  to  bring  about  a  hysterical  condition,  and  sexual  neu- 
rasthenia is  not  rarely  accompanied  by  pronounced  hysterical 
manifestations,  so  that  we  can  well  speak  of  a  coexistence  ol 
the  two  diseases. 

Secondly,  fright  ought  to  be  mentioned  as  a  direct  cause 
of  hysteria:  a  girl  upon  whom  an  attempt  at  rape  has  been 
made,  or  a  man  who  has  been  attacked  by  a  robber,  may  be- 
come the  subject  of  a  hysteria,  which  may  last  for  years,  or 
may  even  be  incurable.  It  is  not  necessary  in  such  cases  that 
fright  be  assocLitcd  with  any  trauma,  the  mental  shock  suff- 
cing  to  produce  all  the  symptoms. 


HYSTERIA. 


561 


w   bcci 


y 

by 


I 


I(  bodily  injuries  arc  associated  with  fright  the  parts  aflccted 
frequently  become  ihe  seat  ol  hysterical  diMirdcrs.  Thus,  wiih 
a  history  of  a  lesion  of  the  hip  joint,  after  the  injury  has  long 
been  recovered  from,  we  may  hnd  a  hysterical  coxalgia,  etc. 
It  is  important  to  recognize  the  fact  that  an  injury  inflicted 
n  a  person  who  is  already  suffering  from  hysleria  or  who 
heredity  is  predisposed  10  Ihc  disease,  may  be  followed 
different  consequences  than  would  be  the  case  in  a  normal 
individual.  Thus  a  fall  un  the  back  which  has  produced  noth> 
ing  more  than  a  contusion  of  (he  soft  parts  may,  in  a  hysterical 
Individual,  lend  to  a  monoplegia  or  a  paniplegia  of  the  lower 
extremities,  while  such  an  accident  would  have  had  no  such 
results  in  a  healthy  individual.  I  have  seen  a  number  of  such 
cases,  to  which  the  term  hyslero-traumatic  affeciion,  rather 
than  traumatic  hysteria,  w<iuld  be  applicable.  In  this  connec- 
tion the  |>aper  of  Miura.  Sur  Irois  cas  de  iiiuiiopl^gie  brach. 
(Arch,  de  Neurol.,  1S93,  xxv.  7;).  should  be  mentioned. 

The  psychical  iranmalism  ni.iy  be  of  such  a  nature  as  to 
have  an  immediate  influence,  or  may  act  gradually  and  insidi- 
ously. Among  the  former  we  have  fright,  emotions  of  anger, 
rarely  ol  joy ;  to  the  latter  belong  grief,  anxiety,  wounded  sell- 
rcsjwct  or  vanity,  and  the  like. 

A  special  kind  of  ncunisis  due  to  fright  has  of  recent  years 
been  much  discussed  and  carefully  studied  by  many  investiga- 
tors, although  thus  far  no  unanimous  conclusions  in  regard  to 
its  nature  have  been  arrived  at.  To  this  condition  which  thirty 
years  ago  was  described  under  the  name  of  commotio  medullx 
spinalis,  or  railway  spine,  the  term  "  traumatic  neurosis"  is  now 
often  applied.  Certain  investigators  claim  that  the  aHection  is 
an  entity /vr  J/ which,  like  any  other  distinct  disease,  should 
have  its  own  name  ;  others  disagree  on  this  point  and  regard 
the  old  name  as  sufficient ;  still  others  consider  both  terms  to 
be  incorrect,  and  simply  speak  of  an  "  accident  neurosis." 

Whether  this  aflcciion  is  to  be  regarded  as  a  form  o(  hys- 
teria is  a  question  of  very  little  practical  importance.  It  is 
certain,  however,  that  a!tiologically  as  well  as  symptomalically 
the  two  mnditions  show  much  that  is  alike.  The  "  traumatic 
neurosis"  is  producetl  by  the  fright  alone,  the  bodily  trauma 
is  a  non-essential ;  the  latter  may  be  present  or  not,  but  the 
ncurf^is  appears  if  the  psychical  shock  has  been  sufficient. 
Hence  we  see  that  etiological ly  we  have  here  the  same  factcir 
that  frequently  leads  lo  hysleria.  So  far  as  the  subsequent 
J6 


562      Diseases  of  the  ce.vbral  nervous  system. 


manifestations  arc  concerned  the  results  arc  similar ;  the  sub- 
jective symptoms  more  especially  are  often  of  a  typically  hys- 
terica) character,  though  neurasthenic  disturbances  are  also 
eticountered.  Motor  and  sensory  disorders  arc  met  with. 
Among  the  former  may  be  mentioned  a  general  motor  weak- 
ness, an  abnormal  pioneness  to  latigue,  among  the  latter  pain 
in  the  head  and  back,  paraisthesias,  hyperesthesias,  and  anarv 
thcsias.  Narrowing  of  the  visual  field,  diminution  in  acute- 
ness  of  vision,  photophobia,  disorders  in  color  vision  or  hyper- 
esthesias of  the  auditory,  olfactory,  and  gustatory  nerves  have 
been  observed.  Again,  wc  may  find  cutaneous  anxsthcsias, 
situated  chiefly  on  the  back,  in  the  shape  o(  irregular  plaques, 
or  having  the  distribution  of  a  well-marked  hcmiansslhcsia 
hysterica:  at  other  times,  again,  they  may  extend  over  the 
he.-id,  neck  and  upper  chest  (doll's  head  form).  In  all  case». 
however,  the  results  of  two  separate  examinations  may  differ 
as  the  anesthesia  may  shift  its  place  or  vary  in  extent.  The 
rules  for  making  sensory  examinations  have  been  excellently 
formulated  by  Goldscheidcr  (Neurol.  Ccntralbl.,  1892.  12). 
The  skin  and  the  tendon  reflexes  vary  as  they  do  in  hys- 
teria. L'rinary  symptoms  may  be  present  or  absent.  While 
walking,  and  in  general  in  making  any  motion,  the  patient 
avoids  all  movement  of  his  spinal  column.  He  fixes  his 
trunk  and  moves  with  his  back  held  stiff,  using  his  hands  as 
much  as  possible  whenever  he  wishes  to  change  his  position 
(Oppenheim). 

Psychical  abnormilics  appear  chiefly  under  the  form  of  de- 
pression, fear,  irritability,  hypochondriacal  depression,  and  the 
like;  these  symptoms  are,  however,  not  always  due  to  the  bo 
cident,  but  often  result  from  the  trouble  and  annoyance  enlailcd 
by  the  interminable  negotiations  before  the  degree  of  disability 
and  the  amount  of  damages  to  be  paid  arc  settled  upon. 

It  must  be  remembered  that  every  patient  with  a  so-called 
traumatic  neurosis  who  has  any  damages  to  claim  is  suspected, 
if  not  of  simulating,  at  least  of  exaggerating  his  symptoms,  and 
it  is  certainly  well  for  the  physician  to  be  cautious.  On  the 
other  hand,  it  would  be  absolutely  wrong  to  regard  all  sudi  a 
patient's  complainis  simply  as  exaggerations  01  lies.  We  must 
examine  him  carefully,  and  in  no  case  should  an  expert  opinion 
be  given  alter  a  single  examination  (Burcbardt,  M,  Prakt. 
Diagnostik  der  Simulation  von  GcfUhlsllfhmnng,  SchwerhUrig- 
keit  unj  Schwachsichtigkeii,  IJerlin,  Enslin,  1S91). 


I 
I 

I 
I 
I 

I 


JiYSTEKU. 


563 


H  The  objective  symptoms  which  are  Ireqtiently,  though  not 
B  regularly  observed,  art*,  of  course,  valuable  for  the  purpose  of 
excluding  simulation.  They  are:  (t)  The  concentric  narrow- 
ing of  the  visual  field  (especially  for  red  and  green)  when  this 
is  found  to  be  constant  on  repeated  examinations  (Schmidt- 
Kimpler,  Deutsche  mcd.  Wochenschn,  1392,24)1  (2)  a  peculiar 
narrowing  ol  the  visual  field  which  was  hrsl  described  by 
Fiirster  in  cases  of  anxsthcsia  retina:.  The  value  of  this 
sym|>tom  has  recently  been  pointed  out  again  by  Kiinig  (Ber- 
liner  klin  Wochcnschr.,  1891,  ji)  and  by  Flaczck  (ibid..  1R92,  35). 

■  "The  essential  features  of  (his  symptom  may  be  thus  summa- 
rized :  Objects  moved  into  l!ic  field  from  the  periphery  to  the 

•  centre  can  be  seen  farther  out  than  those  which  arc  moved  in 
the  opposite  direction;  if  the  patient  fixes  the  while  spot  of 
the  prrimeter  and  we  now"  make  two  examinations,  in  the  one 
bringing  the  object  in  from  the  periphery  and  marking  the 
points  at  which  it  becomes  visible,  in  the  other  moving  the 
object  from  the  centre  to  the  periphery  and  mat  king  (he  points 
at  which  the  object  ceases  to  be  seen,  we  shall  obtain  two  fields 
of  vision  of  une()unl  siie,  the  former  being  the  larger  in  every 
direction  "  (Kiinig).  Simulation  is  here  excluded  unless  the 
patient  knows  the  symptom  and  has  practiced  with  the  perim- 
eter. (3)  WcAnd  (hat  it  we  press  on  painful  poinls(in  Iraumatic 
neuralgia)  the  heart's  action  becomes  increased  so  that  (he 
pulse  may  rise  from  nineteen  to  thirty  beats  to  the  quarter  of  a 
minute  (Mankopfl).  a  condition  wtiichcan  only  very  rarely  be  pro- 
duced at  will  by  the  patient.  The  absence  of  Mankopfl's  symp- 
tom does  not.  however,  necessarily  prove  simulation  (Strauss. 
Berliner  klin.  U'<ichcnschr.,  1892,48).  (4)  Rumpf  hasdescribed 
a  sign  which  he  has  called  "  traumatic  reaction  ol  the  muscles." 
II  a  strong  (aradic  current  be  allowed  to  pass  through  a  (pain- 
ful) muscle  for  from  one  to  two  minutes,  the  muscle  does  not 
at  once  return  to  its  position  of  rest,  as  it  would  under  normal 
conditions,  but  presents  for  a  considerable  time  fibrillary  or 
even  clonic  (wilchings  (Dctilsche  med.  Wochenschr..  1890,9). 
II  we  add  (5)  the  quantitative  diminution  of  the  galvanic  exci- 
tability of  the  molar  nerves  which  has  also  been  pointed  out 
by  Rumpf  {loc.  cit.).  we  have  at  our  command  means  sufficient 
to  meet  the  attempts  of  simulators,  who,  according  to  some 
physicians,  are  constantly  increasing  in  number. 

■  Among  all  (hese  symptoms  there  is,  with  (he  excepdon  of 


5(S4        J?/SEASSS  OF  TUP.   GE.VERAl.  NF.ftVOUS  SYSTEM.        V 

notnonic,  and  the  clinical  picture,  which  we  possess,  is  nol 
sufiicientW  definite  la  warrant  us  in  regarding  the  uffeclioo  as 
a  disease  by  itseil.  After  a  personal  experience  with  sixty- 
eight  cases,  and  alter  a  perusal  of  the  literature,  1  must  still 
regard  it  as  belonging  to  the  category  of  hysteria,  an  opinion 
which  is  not  shaken  by  the  (act  that  Schmaus  has  described  as 
following  spinal  concussion  anatomical  changes  consisting  in 
a  necrosis  of  the  axis  cylinders,  which  often  occurred  long 
after  the  trauma  (Schmaus.  MUnchencr  nicd.  Wochenschr.,  1890. 
281  also  Arch.  f.  klin.  Chir.,  1891,  xlii.  Heft  1),  In  all  cases  of 
hysteria,  particularly  in  the  neurosis  produced  by  fright,  we 
can  scarcely  be  cautious  enough  in  our  prognosis.  It  is  always 
very  uncertain  so  far  as  complete  recovery  is  concerned, 
especially  in  individuals  who  arc  badly  endowed  psychically, 
in  cases  with  a  bad  heredity,  and  in  alcoholics.  It  may  also  be 
said  that  the  hurdi-r  the  former  occupation  of  the  patient  the 
worse,  c<eUris  pariims,  is  the  prognosis. 

With  regard  to  the  very  important  and  difficult  pnictiati 
questions  we  may  with  Ronier  (irrenlrcund,  iSSy,  xxi,  9,  10) 
mention  the  following:  i.  Is  the  disease  the  consequence  or 
the  exclusive  consequence  of  the  accident?  2.  Is  it  curable, 
and,  if  so,  in  what  time?  3.  Will  the  patient  be  completely  or 
partially  incapacitated  ?  The  discussion  ol  such  questions  can 
not  here  be  entered  upon;  the  general  points  of  view  from 
which  they  can  be  answered  will  be  found,  however,  in  what 
hiis  been  said  aba%*c. 

LITERATURE. 

Charcot.     Vru^r.  raiA  .  188$.  xiil.  18. 

Oppenhpiin.     Arch,  f.  Pii^-ch.  u.  Ncncnkh.,  1885.  nvi.  3. 

Troisier.    Cm.  hctMlom.,  1886,  i.  s£r.,  xxiii.  18.     (Hysterica]  Paralysis  m  a  RC' 

Sull  of  TrAumj.) 
Charcot.    Wiener  nicfl.  Wochenschr,,  1886,  xxxvL  30. 11.     (H)-5terica]  0»a%i* 

as  A  Result  of  Tr:iunia  in  u  M;iii.) 
Dcbovc  ct  Cnirtn.     Kcmarqucs  sur  I'hyslfric  tTaumatique.    Gu.  hebdora.,  1X7. 

2.  sit.,  WW,  43. 
Vlbert.    Ann.  d'Hy;;.  |iubl.,  IHe..  1SS7.  xviii.  13.    (K^iilwTiy -Spine  conMknd 

from  a  Merfico-lfgal  Point  i>t  View.) 
Lyon.     Kncfphnle.  1888.  viii,  i.    (Hysteria  afier  Grare  Trauma.) 
Charcot.      Atthrnlgle  hystiro  trauinatique  du  gmou.      Progiis  mM.,   ^Vi■ 

xn,  4. 
Bemhintl,      Deutsche  metl.  Wnrhcnschr..  1S88,  13. 
Siruin|ieil.     Uclier  die  Iraumntischcn  .Scumscn.     Berliner  Klinik.  FiKlter,  18W 

xvi.  Heft  3. 
Gnust^l.     Hyttiro-traumaiUmc.     Lrcons  rccueilliei,  Monipdikr,  1S88. 


HYSTEK/A. 


565 


[Oplcr.  F,     Beiing  cur  Lehre  von  den  Iraumal,  Aflircltonm  des  Rtlckenniaiia, 

Itiaug.-Iiissnt..  HcrUn.  Schadc.  1888. 
l)^£in>k)'.     Itcrliner  Uin.  Wi)chen»chr.,  iSSS,  3. 
Woltr.     t»Kf  K.iila';<) -Spine.     Dcoischc  Mcd.-Zlg..  1S8S.  79.  to. 
OcnilianJL    Vun  den  ^Igciii.  u.  (raumu.  Neuroscn.    Berliner  kiln.  WochcnKbr.. 

1889.  !> 
Sirpp.     DcuixSe  nml.  Wochcnschr,  1889.  4. 

UrasMl.     Lc^nx  mi(  rh)'«£ro-ifaumaiiame.     Parit,  IxcroKnict,  l8S9> 
Mejct,  Monu.     Uctlmcr  kiln.  Wochcnschr..  1889.  y 
AucriMch.     Dk  iraiunadtche  llyslcne  bcim  Mani>c.     Inau^.-UisMn^  St(M»- 

Uirg.  1889. 
StrumpeU.     Uehcr  (mumatiKlK  Hysitrie.     Munch.  mrJ.  Wochcn»chr.,  1SS9.  &. 
Eilenluhr.     Ikrliner  Uin.  WocKcnKhr,,  r8S9.  53. 
CuiK     Uclicrdcn  dugnoMiticlMin  Wtrrihcinxclner  S)inplonie<l«r  Iraumatudwn 

Ncunnr.     Inaug.-DisHrt..  Ucrlin,  1S9J. 
Cramer  (Eticrtualilct-     Munch.  mc<l.  Wochcnschr.,   1891,  i.  3.    (CoBUllU  on 

eacclltni  summary  ol  ihe  mofc  recent  (M|ieT».) 
SchulKr.  Fr.    Udwr  Nrurwm  ufkI  Ncuruptychcucii  nuch  Trauma.   Volkmann's 

S.)inml.  IcUn.  V'i>nr.,  1891,  iv,  v.  14.  , 

nige.     Kartway  InfUrfe!t.      Liimlon.  r.iffon  &  Co..  1891. 
Wkhinniin.  Kiitf.     Ucr  Wcrthdcr  Syni|Hotnc4l«rsiigcn.  iraumatisclien  Neurose 

u.  K.  w.     Kraunwhwcig.  Vieucg.  1891. 
Oppmhrim.     Uie  intumaL  Neuniscn  u.  «.  w..  3.  AulL     Berlin,  llirvchivakl. 

l89t. 

Frenixl.  C  S.     EIn  Ucbrrblick  liber  den  f|:rgTnvrBnige«i  Stiind  <lrT  Frage  tan 

den  u)(;rn,  traumat.  Neuroien.     V'oikmann's  Sjniml.  klin,  Vtirtr.,  n.   F., 

1891.  ji. 

iFriednwnn.     Munch,  ncd.  Wochmsrhr,  1893.  30. 
[  l)mn^     Keuere  .Arlieiicn  ulier  itir  imunwt.  Ncuroien.    Schmkll's  JahrU,  1893, 

ccxxxiv.  |v  35;  1873.  ccxixvilt.  |>.7^    (This  |>«pcr  1*  in(lb|)ensalik  for  any 

one  inakiii);  a  ^(lecol  Mudy  of  ihc  xuh)rct.) 

The  syaiplomb  that  appeitr  atlcr  a  person  h»s  been  struck 
by  lightning  Mimetimcs  resemble  the  array  ol  sympioms  ob- 
served in  traumatic  neuroses.  Paralyses  in  the  ricri'esot  spe- 
cial  sense,  and  motor  and  sc»S4)ry  paralyses,  iippcar  and  last  (or 
a  shr>rtcr  or  longer  time.  In  the  spring  of  1889,  when  thun- 
derstorms were  so  frequent,  I  had  (he  opportunity  o(  examin- 
ing  a  man  who,  u&  a  consequence  o(  bein^  struck  by  li);htnitif(, 
|oo  recovering  consciousness  after  three  quarters  of  an  hour. 
presenied  loss  of  the  power  of  sipht  and  smell  on  ihc  side  on 
which  the  li^httiin^  had  entered  and  left  the  bi>dy,  while  on 
the  same  side  hcurinfi;  was  diminished,  and  there  was  total  an- 
teMhesia.  These  symptoms  were  associated  with  an  obstinate 
insomnia.  By  hypnotism,  frequently  rciH-aled.  we  were  enabled 
to  lessen  this  insomnia,  and  under  the  use  of  the  galvanic  cur. 
rent  and  the  (aradic  brusli   the  hernia nicsthcsu  disappeared. 


I 


566       I>/S£ASES  OF  THE  GEKEKAL  NEftVOVS  SYSTEM.  I 

The  nerves  nf  special  sense  implicated  becnme  ftilly  normal 
after  a  month's  trcitment.  In  this  case  moior  disturlxinccs 
were  never  seen.  According  to  the  investigations  of  Limbeck 
(Prager  nied.  Wochenschr.,  1891,  13),  we  have  to  distinguish 
belwccn  direct  and  direct  paralyses  due  lo  lightning:  he  re 
gards  only  the  furracr  as  due  to  an  action  upon  the  nervous 
system,  and  has  observed  that  the  sensory  paralysis  disappears 
sooner  than  the  motor.  For  further  symptoms  in  such  cisej 
and  for  the  post-mortem  coiidiiions  found  after  death  by  light- 
ning,  wc  would  refer  the  reader  to  Scbmitz's  article  in  the 
Deutsche  Med.-Ztg.,  1887,  73,  74,  in  which  further  references 
on  the  subject  may  be  found. 

Treatment. — The  treatment  of  hysteria  is  always  a  very 
tedious  riiatier.  ;ind  for  the  physician  sometimes  the  most  lire- 
some  and  thankless  task  imaginable,  and  one  to  which  he  should 
only  devote  himself  if  he  be  assured  of  the  implicit  confidence 
of  his  palicnt,  so  far  as  this  is  possible  in  the  case  of  hysterical 
individuals.  This  confidence  is  indispensable  because  the  treat- 
ment of  the  disease  does  not  consist  in  the  main  in  the  admin- 
istration of  drugs  in  a  routine  fashion — valerian,  asafictida.cas- 
toreum.  and  the  nervines — but  must  dcpetid  more  upon  the 
psychical  influence  by  which  wc  endeavor  to  diminish  ihcatv 
normal  scnsitiveiiess  of  the  patient  to  external  and  internal 
stimuli,  to  arouse  her  energy,  and  to  strengthen  her  will  poll- 
er. This  is,  we  admit,  much  more  easily  said  than  dooe,  a&J 
we  shall  often  have  to  confess  that  the  patient's  views  about 
her  trouble  have  not  changed  in  the  least,  that  she  is  as  irri- 
table as  ever,  that  her  moodiness  and  capriciousncss  are  in  nu 
way  improved  in  spile  of  all  our  lectures — in  a  word,  that  we 
have  obtained  no  positive  result  after  "  preaching  reason  '*  lor 
hours.  Still,  we  must  not  allow  ourselves  to  become  dtscour 
aged,  but  ever  again  and  again  renew  our  efforts  to  obtain  the 
desired  end. 

If  wc  clearly  see  that  these  are  fruitless,  and  especially  i/ 
we  arc  convinced,  as  is  often  the  case,  that  the  family,  far  frotn 
assisting  the  physician,  are  virtually  acting  against  him  during 
his  absence,  we  must  impress  upon  them  the  necessity  ol  re-  ■ 
moving  the  patient  to  some  institution.  French  physicians  Lir 
the  greatest  stress  upon  isolation  in  such  cases,  and  arc  inclined 
to  attribute  the  relatively  favorable  results  of  Ihcir  irealmcnt 
to  this  factor.     In  this  country  j>eople  are  not  so  easily  p<^ 


MYSTEK/A. 


5«7 


I 

I 


I 


I 


laded  to  3^r«e  to  this  procedure  ns  \n  Paris,  where  in  the  city 
itself  or  in  the  suburbs  there  are  various  admirably  conducted 
institutions  which  receive  only  hysterical  |>ntients.  With  us, 
therefore,  home  treatment  ought  lirst  to  be  tried.  In  France 
this  is  usually  discarded  from  the  tirst.  It  is  a  diderent  matter, 
ol  coursct  it  we  have  to  deal  nut  with  a  mild  degree  of  hy»> 
teria,  but  with  hystero  epilepsy  and  major  attacks.  Then  a 
transference  to  an  institution,  as  soon  as  practicable,  ought  (o 
be  urged. 

The  bodily  treatment  may  be  cither  general  (that  is,  direct- 
ed to  tlic  nutrition,  to  the  condition  of  the  blood,  and  the 
strength  of  the  patient)  or  symptomatic  (that  is,  intended  to  re- 
lieve the  troubles  of  the  patient  as  they  arise).  In  the  treat- 
ment ol  contractures  we  should  never  make  use  of  plaster-of- 
Paris  bandages  (Charcot). 

With  reference  to  the  nutrition,  it  was  Weir  Mitchell  and 
Playfair  who  first  recommended  absolute  rest  in  bed,  with 
massage,  electricity,  and  copious  (ceding.  Their  patients  were 
forced  to  take  considerable  quantities  ol  milk,  meat,  bread,  etc., 
and  it  was  found  that  with  the  increase  of  the  body  weight  the 
hysterical  symptoms  and  attacks  diminished.  Uf  late  years 
good  results  have  been  obtained  from  this  practice  by  Bins- 
wanger  (Allgem.  /eilschr.  f.  Psych.,  i88j,  xl,  4),  and  the  com- 
munications of  Lcyden(BcrI.  klin.  Wochcnschr.,  I8S6,  xxiii.  16) 
and  Durkari  (ibid.,  1886,  16)  should  encourage  us  to  further 
trials  with  this  mclh<Ml,  although  as  far  as  my  own  experience 
goes  the  results  have  by  no  means  always  been  brilliant.  The 
cases  in  which  the  excessive  ingcf^tion  ol  food  was  badly  borne 
and  led  to  a  disagreeable  gastric  catarrh  were  by  no  means  un- 
common, and  even  where  the  food  was  well  assimilated  the  de- 
sired results  were  not  always  obtained  tcl,  alM>Gilles  de  la  Tou- 
retlc  el  Chatelineau.  Xa  nutrition  dans  rhystiric,  Progrds  m^l.. 
■888,  viii.48  ;  1889.  ix,  18,  ig.  31).  That  muchatteniion  has  tube 
paid  to  the  nutriiton  there  can  be  noqucstion,  and  the  increase 
in  the  body  weight  usually  can  be  regarded  as  a  favorable  indi- 
cation. To  attain  this,  however,  in  many  cises,  not  absolute 
rest,  but,  on  the  contrary,  systematic  muscular  exercise  is  need- 
ed. Well-rcgulate<l  home  gymnastics,  undertaken  according^ 
to  definite  principles  (.Schrcbcr,  Angcrstcin.and  Eckler),  are  to 
be  preferred  and  will  be  oltcn  found  an  excellent  means  of 
combating  the  distressing  insomnia. 

In  certain  cases,  to  be  selected  of  course,  with  care,  general 


568        D/SEASES  OF  TIIR  CEKEHAL  XRRVOUS  SYSTEM. 


faradization  as  recommended  by  Beard  and  Rockwell  is  of 
great  service.  The  palienl  for  llii*  purpose  is  placed  npnii  a 
stool  with  bis  bare  (eel  upon  a  moisi  large  electrode,  which  is 
connccled  with  the  negative  pole  o(  Ihe  secondary  coil.  With 
the  anode,  which  consists  of  a  large  sponge  electrode,  all  parts 
of  the  body  are  treated  in  succession.  Instead  o(  the  moist  we 
may  avail  ourselves  of  a  dry  electrode  in  the  form  of  a  soil 
brush.  The  pain  which  is  caused  by  the  latter  method  is,  at 
least  with  strong  currents,  quite  considerable  ;  nevertheless,  the 
method  deserves  warm  rccommendatiou  in  ceriain  hysterical 
affections  and  especially  in  joint  neuralgias. 

About  the  influence  and  the  value  of  static  electricity  as  a 
ihcrapfutic  agent  our  experience  is  not  sufficient  lo  warrant 
any  detinite  conclusions.  It  is  not  easy  to  judge  of  the  useful- 
ness of  the  treatment,  as  it  is  usually  combined  with  other 
measures,  the  iherapeiiiic  stgniBcance  of  which  must  not  be 
left  out  of  considcraiion.  Whether  the  action  of  static  elec- 
tricity differs  essentially  from  that  of  the  faradic  and  galvanic 
current,  and,  if  so,  in  wh.it  this  difference  consists  and  under 
what  circumstances  the  one  or  the  other  is  indicated,  we  are 
not  as  yet  in  a  position  to  say,  Clemens  has  used  it  with  good 
results  in  cases  of  hysteric;il  aphonia  by  applying  one  pole  with 
condensers  directly  over  the  muscular  branches  of  the  acccsso- 
rius  as  spark- producing  electrode  (Therap.  Monalshefte,  tSgo, 
iv,  Heft  8,  p.  402). 

It  is  rare  that  we  treat  a  case  of  grave  hysteria  without  ai 
one  time  or  another  during  the  course  of  the  disease  being 
obliged  to  resort  to  massage— for  one  thing,  because  the  pa- 
tient desires  as  much  variety  as  possible  :  but  at  the  same  lime 
we  must  not  overlook  the  fact  that  by  its  use  many  of  the  pa- 
tient's troubles  arc  considerably  relieved.  This  is  not  the  place 
to  enter  into  the  minute  details  of  this  method  of  treatment. 
They  may  be  found  in  the  writings  of  Schrcber,  Rcibmayr. 
Zabludowski,  and  others. 

The  cold-water  treatment  is  indicated  where  we  desire  tn 
harden  the  constitution  against  exiernal  influences,  changes  of 
temperature,  etc.  We  should  be  very  carciul,  however,  in  env 
ploying  low  temperatures,  and  the  water  with  which  the  pa- 
tient is  sponged  or  in  which  hip  balhs  and  the  like  are  taken 
ought  to  be  al  least  So"  F.  For  the  use  of  ice-cold  douches,  in 
the  way  recommended  by  the  French,  certain  facilities  are 
requisite.    The  pressure  of  the  water  should  be  very  great  and 


I 

I 


\ 


MYSTEKIA. 


S(59 


ihe  duration  of  the  bath  should  be  so  short  (from  ten  to  fifteen 
seconds)  that  the  patient  hus  not  time  to  become  aw.tre  how 
cold  the  water  really  is.  I  have  watched  this  practice  repeat- 
edly in  some  o(  the  well-known  hydrothcrapeulic  establishments 
of  Paris,  and  have  had  occasion  to  notice  the  immediate  benefi- 
cial effects  following  the  application.  The  lasting  results,  as 
Charcot  and  others  arc  quite  convinced,  arc  so  marked  that  (in 
F^aris)  cold  douches  arc  considered  to  be  indispensable  in  the 
treatment  of  hysteria.  It  would  be  a  very  desirable  thing  if 
the  necessary  arrangements  (or  this  treatment  could  be  inlr<». 
duccd  into  our  hydrutherapcutic  institutions.  The  ordinary 
shower  bath,  which  comes  down  upon  the  juitieni  just  about 
like  rain,  is,  of  course,  not  sufficient.  In  the  treatment  ol  M>me 
of  the  particularly  disiressini;  symptoms  it  is.  of  course,  in  the 
first  pUicc  the  paroxysms  which  deserve  our  ariention.  because 
they,  more  than  any  other  o(  the  hysterical  phenomena,  are 
liable  to  render  home  treatment  almost  impossible.  We  may 
tomclimes  be  able  to  cut  short  an  attack  by  steady  pressure 
with  the  hand  over  the  ovaries  continued  lor  some  time,  but 
this  can  be  better  accomplished  by  allowing  ihc  patient  to  in- 
hale a  little  chloroform.  To  guard  against  a  rcpelitinii  ol  the 
attacks  we  have  no  reliable  means,  yet  co<il  piulongcd  bcitlis 
with  affusions  of  colder  water  deserve  a  thorough  trial.  If 
these  do  not  seem  to  be  beneficinl,  and  i(  the  jwiticnt  complains, 
before  the  onset  of  every  attack,  of  pains  in  the  ovarian  region, 
and  if  wc,  moreover,  can  succeed  in  bringing  about  an  attack 
by  pressure  over  the  (tender)  ovaries,  the  qucsiion  ol  oi^phorcc* 
t()my  has  to  be  considered.  The  family  relaiiims,  especially 
the  sterility  which  naturally  follows  the  operation,  have  to  be 
taken  into  considcniti<m,  nor  should  we  forget  that  the  opera- 
tion has  olien  by  no  means  l>ccn  followed  by  the  desired  cflect, 
although  the  fact  that  it  frequently  exerts  a  favorable  influence, 
ns  Hegnr  and  Schriklcr  have  seen,  can  not  be  questioned. 
Whether  the  ovaries  are  actually  diseased  or  not  is  altogether 
of  minor  importance.  It  is  the  presence  of  pain  immediately 
before  or  after  the  attack  in  the  region  of  these  organs  which 
should  suggest  an  operative  interiercocc.  Cauleri/atiouol  ihc 
clitoris,  advised  by  Frie<ireich,  is  a  procedure  which  should 
only  be  resorted  lo  in  the  most  exceptional  cases.  In  all  in- 
stances the  sexual  organs  ought  to  be  carefully  examined,  and 
small  operations,  such  as  dilatation  of  the  cervical  canal,  repo- 
kjtion  (^  the  uterus  when  in  a  position  of  flexion  or  version,  if 


S70 


D/SEAS£S  OF  THE  GESERAL  NEHVOUS  SYSTEM. 


indicated,  should  be  undert»ken.    V'aginiscnus,  if  it  cxUts.sbould 
aUn  be  treated. 

The  motor  and  sensory  disturbances  have  to  be  met  in 
the  nnanncr  indicated  above.  In  cases  where  we  suspect  nia 
lingering  or  Hillliil  exaggeralion,  procedures  which  are  diu 
grceable  or  even  painful  arc  to  be  preferred — fur  inslunce,  the 
cold  baths,  the  fnradic  bntsh.  the  actual  cautery,  etc.  The 
more  minute  details  of  Ihc  treatment  must  be  left  to  the  pcr> 
sonal  tact  of  the  physician,  whose  capability  of  individualiza- 
tion, of  treating  every  case  by  and  fur  itself,  should  make  it 
unnecessary  for  us  to  enlarge  upon  all  the  principal  phases  of 
this  disease.  With  regard  to  the  internal  medication,  let  i! 
Suffice  to  warn  against  the  use  of  narcotics,  especially  morphine. 
which  can  not  be  given  in  a  disease  of  such  long  duration  in 
effectual  doses  without  creating  the  habit. 

UTER.VTURK. 

Stein.    Uie  allgemeine  Elcklriution  <lo  menichliclxrn  Kfirpcrsi.     Halle,  iM]. 

3.  Aull. 
Widmer.    Schwciier  ComspnntltTiib)..  16S6,  Kvi.  9-1 1,    <Cun  through  Cattn- 

Uon.) 
R«ibmayr.     Die  Technik  tier  MasMgc.     Wlcti.  1886.  s.  Aufl. 
Tail.  L,aw«on.      Lancci.   1887,  li,   35.      (Cure   cRtxted    b)-  the  RetnorjJ  of 

Pessarits.) 
Pitre*.     Progris  m(ri,.  1837.  iv.  8.    (Sialic  Elortricily.) 
Gtcfliee.     Ue  I'^leclricil^  tutique  ei  de  s«  appliCAtiaru  i  ia  ih^pnib^ 

Piiriv  1887. 
Zabtuduwski.    Zur  Indlcniion  unil  Technik  ilcr  Mastagc    Berliner  kttti.  VTocicn- 

schr.  1887,  j6. 
Biirkan.    Berliner  kiln.  WocHienschr.  1888,  n«iv.  45-47. 
Gilierinaiin.    beutsche  Med.ZiK  ■  1888.  U.  14.    (Feeding  Syxtem,) 
Oidier.    Sur  riteciricit^  rjrulii{ue  dans  rHyslfri^uc    L}<on  ra6d..  1888,  bikp 

356- 
Dutton.    Lancet.  June  t}.  1888.  f.     (Miuaage.  Feeding  S^nlem,  SeduBOn.) 
BielichowKky.    Ucbcr  InDiicniclrkiriciiai,  tic.    Therap.  Munatsh..  Mirj.  i*to 
Hin.     Lelirbuch  <ler  Etcklrudiagnjstik  uiul  Elckirulher^pic.    StuKgul.  Kolc- 

1S93.  pp.  xiT  tl  stq. 


CHAPTER  III. 


triLKPSr— FALLINC  SIC KNK&S— MORBUS   SACEIt— HORKUfi  COMITIALIB. 

The  term  epilepsy  is  olten  misused,  inasmuch  as  it  h  ap- 
plied not  only  to  liie  genuine  classical  epilepsy,  but  also  to  many 
conditions,  characterized  by  convulsive  atucks.  in  which  on 
careful  cxaminaliim  wc  can  detect  various  other  abnormities, 
and  which,  unlike  genuine  epilepsy,  have  a  tangible  cause.  If 
a  person  in  consequence  ol  traumatism,  of  fright,  of  peripheral 
irritation  (pressure  upon  a  sensitive  scar),  or  in  consequence  of 
cerebral  syphilis,  etc..  becomes  "  epileptic" — thai  is  to  say.  suf- 
fers from  convulsions  with  or  wiibout  loss  of  consciousness — 
these  convulsions  clinically  m.iy  resemble  very  closely  those  of 
genuine  epilepsy,  but  patholoKically  as  well  as  gcnclically  the 
biwo  conditions  are  entirely  different. 

For  all  such,  cases  the  term  "epilepsy"  ^s  unjustifiable. 
I  Traumatic  epilepsy.  Irif;ht  epilepsy,  and  reflex  epilepsy  are 
[  not  genuine  epilepsy.  The  difference  is  still  greater  between 
[the  so  called  Jacksonian  and  the  genuine  epilepsy.  Injackso- 
>nian  epilepsy  the  convulsive  attacks  depend  upon  a  disease  of  a 
portion  of  the  cortex.  Hence  the  term  "cortical  epilepsy  "  is 
also  applied  to  this  condition  (cf.  p.  i8^>. 

[  The  genuine  epilepsy  is  a  general  neurosis,  and  we  do  not 
know  that  it  ever  produces  a  permanent  anatomical  alter.tlion 
in  the  brain,  and  that  the  changes  arc  not  rather  molecular  in 
character,  appearing  from  time  to  time  in  the  brain,  most  prob- 
ably in  the  brain  cortex,  and  leading  to  the  "epileptic  attack  " 
Mnd  then  disappearing  again.  About  the  riVi-  of  auto-imoxica- 
tion  we  shall  speak  later. 


I 


jEtiologjr. — We  are  not  acquainted  with  any  essential  cause 
(or  classical  epilepsy.  Physicians  with  a  lai^e  experience  have 
often  enough  occasion  to  sec  geniiinr  epilepsy  develop  without 
tticrc  being  any  appreciable  etiological  lactor. 


572 


D/SEASeS  OP  THE  GEXERAL  iVEATOt/S  SrsrSM. 


It  has  been  the  custom  of  most  writers  to  distinguish  prcdis- 
posing  or  general  (roin  exciting  or  special  causes;  only  the 
former  arc  of  importance.  The  latter  have  an  influence  only 
upon  llic  frequency  and  the  severity  of  the  individual  attacks, 
but  are  never  responsible  for  the  production  of  the  disease. 
Among  the  former  heredity  has  been  given  the  first  place,  and 
there  is  no  doubt  that  hereditary  neuropathic  tendencies  in- 
crease the  susceptibility  to  nervous  diseases  in  general  and  cer- 
tainly to  epilepsy ;  but  this  heredity  does  not  by  itself  suffice 
to  make  of  an  otherwise  healthy  individual  an  epik-ptic.  For 
this  usually  an  additional  cause  is  nceded~-for  Instance,  syphi- 
lis. If  an  individual  with  hereditary  tendencies  acquires  syphi- 
lis, he  is  more  likely  to  become  epileptic — that  is,  to  suffer  from 
a  genuine  epilepsy,  which  is  neither  preceded  nor  followed  by 
any  appreciable  anatomical  changes,  cither  in  the  brain  or  in 
its  vessels — than  a  person  infected  with  the  s-imc  disease  but 
burdened  with  no  family  taint  (cf.  Kowalewsky,  Uerlincr  kliii. 
Wnchenschr.,  1894,  4).  Important,  therefore,  as  heredity  m-iy 
be.  it  h  in  itself  not  siilTicient  to  constitute  a  cause  for  epilepsy, 
The  manner  in  which  the  tendencies  were  acquired  is  also 
irrelevant,  and  the  quesiiim  whether  the  (alhcr  or  mother,  or 
both  were  given  to  alcoholism,  and  whether  both  or  eitherol 
the  two  was  intoxicated  at  the  moment  of  generation  of  the 
child  has  no  si;^niticancc.  Notwithstanding  the  relative  fre- 
quency with  which  epilepsy  occurs,  the  number  of  cases  would 
be  much  larger  if  cither  of  these  factors  could  have  a  decided 
influence  in  the  causation  o(  the  dise.ise. 

Age  and  sex  seem  to*bc  of  little  moment  in  thisconnectiun. 
Although  it  is  true  that  in  the  majority  of  cases  tiic  disease 
affects  individuals  in  the  first  half  of  their  lives,  more  especially 
between  the  ages  of  ten  and  twenty,  the  attacks  miiy  begin 
much  later  and  may  not  appear  until  alter  the  age  of  forty  or 
fifty.  Indeed,  cases  in  which  the  first  convulsion  made  its  ap- 
pearance between  the  sixtieth  and  the  seventieth  year  have  been 
recorded  (c(.  Mendel.  IJie  Epilepsia  "tarda,"  Deutsche  med. 
Wochenschr.,  1S93,  45).  With  regard  to  sex,  it  has  been  noted 
that  during  the  period  ol  puberty,  between  twelve  and  sixteen, 
more  girls  than  boys  become  epileptic;  if.  however,  the  aver- 
aj^e  of  all  cases  be  taken,  the  difference  between  the  numbers  in 
the  two  sexes  is  very  slight,  and  in  early  childhood — from  the 
fourth  to  the  seventh  year — it  is  nil,  the  cases  being  eciually 
distributed  between  the  two  sexes. 


EFflBPSV. 


573 


I 


Among  the  so-called  esciling  causes  intercurrent  gastric 
afTccliuns  play  a  very  iinporlant  part :  overloiiding  of  the  siom. 
ach  or  the  ingestion  of  unusually  indigestible  food  often  pro- 
duces an  "attack"  which  without  this  ietiological  factor  would 
have  occurred,  only  later,  or  perhaps  not  at  all.  1  have  had  lor 
years  a  gentleman  under  observation  who  after  eating  pork 
an<l  beans  invariably  has  an  attack  a  few  hours  later.  Indi- 
gestion is  all  the  more  hurtful  i(  the  stomach  has  been  over- 
loaded before  going  to  bed. 

Certain  substances  which  arc  taken  into  the  system,  whether 
as  food  or  for  the  sake  of  their  agreeable  effects,  or  again  as 
medicines,  arc  very  dangerous  to  the  epileptic.  Among  these 
are  alcohol,  mushrooms,  certain  spices  (cayenne  pepper  and 
paprika),  also  all  narcotics,  more  especially,  as  wc  have  learned 
in  more  recent  ycai-s,  cocaine.  The  "  cocaine  epilepsy  "  has  been 
described  by  lletmann  (Deutsche  med.  VVochcnschr..  1889,  12). 
Under  certain  circumstances  other  medicines — aniipyrine.  for 
example — may  act  as  puisons  and  provoke  an  epileptic  attack 
(cf.  Tuczck,  Die  Antipyrin-epilepsie,  Berliner  klin.  Wochenschr,, 
1889,  17).  In  view  of  the  wide  employment  of  aniipyrine  with- 
in a  comparatively  short  time  since  its  dlsc<tvery,  and  the  popu. 
Lirity  which  it  enjoys,  on  account  of  which  it  is  used  in  all  po»- 
nible  kinds  of  perfectly  different  diseases,  this  observation  must 
be  regarded  as  pi>ssessing  great  practical  inipuriance. 

It  is  gciiemlly  knoivn  that  anything  which  exerts  a  sud- 
den influence  upon  the  cerebral  circulation  may  be  the  direct 
cause  tor  an  individual  attack,  although  it  is  an  open  question 
whether  the  bUKtd  current  is  accelerated  or  retarded  by  these 
influences.  In  an  epileptic,  who  has  been  free  from  att.icks 
for  years,  a  seizure  may  suddenly  develop  in  conse<|uencc  of 
fright ;  indeed,  a  person  who  has  been  apparently  well  up  to 
that  time  may  have  an  epileptic  seizure  in  consequence  of  (right 
and  the  disease  may  then  continue  for  the  rest  of  his  life.  Such 
a  condition  seems  only  possible  in  individuals  whoare  predis- 
posed tu  the  dise;ise,  and  in  whom  it  only  needs  a  slight  stimu- 
lus to  produce  the  attack.  The  (right  is  the  drop  which  causes 
the  full  vessel  to  overflow,  but  which  in  an  empty  vessel  would 
make  no  dtlTcrence;  a  sound  person  never  becomes  an  epilep- 
tic owing  to  (right. 

In  the  second  place  we  have  traumatisms  and  more  espe- 
cially injuries  to  any  ]>ortion  of  the  head.  It  may  happen  that  a 
person  previously  perfectly  well  is  taken  with  an  epileplic  ht 


574 


D/SEASES  OF  THE  CEXERAL  NERVOUS  SYSTEia. 


after  a  fall  or  blow  upon  the  head  and  post  mortem  not  the 
slightest  changes  can  be  detected  in  the  brain.  In  such  cases 
wc  should  always  carefully  examine  the  skull  and  overlook  no 
scar,  however  trivial,  because  any  one  may  be  the  cause  of  the 
first  epileptic  attack.  IE  this  is  the  case  wc  have  the  so-called 
*'  reflex  epilepsy,"  which  has  already  been  mentioned,  and  which 
in  the  stricter  sense  is  not  genuine  epilepsy.  Reflex  attacks 
may  also  be  determined  by  painful  cicatrices  on  the  peripheral  ■ 
nerves  on  any  part  of  the  body,  or  by  the  existence  ol  ulcer- 
ative processes,  for  instance,  of  the  linger  nails.  In  one  of  my 
patients  it  was  possible  every  time  to  produce  an  attack  by  ■ 
pressure  upon  the  diseased  matrix  of  the  nail,  ttie  same  thing 
occurring  also  when  he  accidentally  struck  it  against  anything. 
The  amputation  of  the  terminal  phalanx  was  followed  by  com- 
plete recovery  after  all  other  measures  had  proved  fruitless. 
In  a  similar  manner  polypi  of  the  car  ("  ear  epilepsy  "),  inflam- 
matory processes  in  the  car.  intestinal  parasites,  an  incarcerated 
hernia,  and  lastly  diseases  of  the  sexual  organs,  in  the  male  as 
well  as  in  the  female,  may  give  rise  to  epileptic  attacks.  Fur- 
ther,  we  must  mention  the  influence  of  the  imitative  impulse 
upon  the  occurrence  of  epileptic  attacks.  If  nervous  individu- 
als frequently  see  cpiieptiform  convulsions  it  may  happen  lltat 
they  succumb  to  them  themselves.  In  the  royal  prison  ol 
Breslau  I  have  known  thirteen  of  a  large  number  of  female 
inmates  who  were  working  logclher  in  a  room  to  become  epi- 
leptic a  short  time  after  another  prisoner,  who  had  been  suf- 
fering from  epilepsy  for  years,  had  been  brought  into  the  same 
ward. 

I  have  reported  the  occurrence  of  an  epidemic  in  a  school 
(Berliner  klin.  Wochensch.,  189J,  50).  Bad  air,  especially  in 
taf^s,  where  there  is  a  good  desil  of  tobacco  smoke  and  poor 
venlilatinn.  predisposes  the  epileptic  to  attacks,  especially  ii 
loud  talking  or  music  is  going  on.  The  mental  excitement 
produced  by  such  stimuli  may  precipitate  an  attack.  Epilep- 
tics should  be  warned  not  to  go  to  dances,  since  the  many  dif- 
ferent factors  which  arc  here  combined  may  aid  in  producing 
an  attack. 

The  manner  in  which  an  epileptic  patient  can  spend  hislif^ 
the  possibility  of  doing  justice  to  the  requirements  of  his  call- 
ing and  of  being  a  more  or  less  useful  member  of  society,  liw 
outlook  for  improvement  or  even  recovery— all  these  questiw* 
depend  in  the  main  upon  the  "  attacks  "  to  which  he  is  subjcc:, 


EPtLEPSy. 


57S 


their  nature,  Ihcir  duration,  their  frequency,  their  after- 
cts.  and  so  forth.  Hetice  it  is  our  hrst  duly  in  taking 
charge  ol  a  case  o(  epilepsy  to  study  carefully  the  attack  itscil. 
Symptomatologr.— The  "  Attack." — There  are  cases  in 
which  the  attack  occurs  suddenly  and  unexpectedly,  so  that 
the  patient,  until  now  in  apparently  perfect  health,  falls  to  the 
ground  as  il  struck  by  lightning.  In  others — more  numerous — 
it  is  announced,  so  to  speak,  by  certain  premonitions,  which,  to 
maintain  Galen's  old  expression,  we  call  aursc. 

In  the  study  even  of  the  aura  we  can  not  help  being  struck 
with  the  (act,  which,  on  a  closer  examination  of  the  attack,  is 

■Klill  more  impressed  upon  us.  that  no  two  cases  of  rpiltpsy  are 
■like,  that  almost  every  one  has  its  own  peculiarities,  so  that  a 
comprehensive  description  is  almost  impossible.  The  premo- 
nitions are  countless  and  many  attempts  have  been  made  to  di- 
vide them  into  classes.  Bven  if  we  have  obtained  a  classifica- 
tioa  we  are  (ar  from  possessing  with  it  a  description  ol  all. 

First  of  all,  we  may  subdivide  the  aunc  into  psychical  and 
somatic.  In  the  former  case  the  patient  may  either  become 
surpri<iing]y  quiet  and   look   meditative,  or  he   may  present 

Iat^ns  of  excitement,  walk  anxiously  up   and  down  the  room, 
•nd   seem   bewildered.     The  transition  from  the  aura  to  the 
•ctual  pre-cpileplic  disturbance  of  consciousness,  the  pre-epilep- 
tic  insanity,  i.s   not  appreciable  Olendel,   Eulenhcrg's  V'icrtel- 
iuhnschrifl,  N.  F..  l8«5.  Bd.  42.  licit  2).     This  prodromal  state 
^knay  extend  over    several    hours,   although   it   may  not  last 
^■nger  than  thirty  seconds  or  a   few   minutes.     In  two  cases 
^Hn   patients    told    mc    that,    immediately    before    the   attack, 
^reminiscences  of  bygone  days  forced  themselves  upon  their 
minds,  and  that   portions  of   their  past   lives  rapidly  passed 
before  them.     A  psychical  aura  of  this  kind  is  rare.      Some- 
times an  irresistible  desire  in  the  patient  to  run  away  constitutes 
the  aura.    Just  as  wc  shall  see  in  the  form  of  epilepsy  called 
epilepsia  procursiva,  (he  patient  escapes  from  his   home  and 
runs  great  distances.     While  he  is  running  he  is  seixed  with 
the  attack.     Midway  between  the  cases  in  which   there  is  a 
psychical  and  those  in   which  there  is  a  somatic  aura  come 
Hnhose   instances  in   which   the  patient  complains  of  vertigo, 
Hviolcnt   headache,  and   sli};ht  disturlxknces  of   consciousness, 
^bymptoms  which  m,'iy  last  but  a  very  short  lime,  and  which, 
indeed,   m.iy    be    of    such    brief    duration    that   the    patient 
■Jias  nut  time  to  guard  himself  against  falling.     Here,  loo,  be- 


S76 


DISEASES  OF  TUB  GENERAL  NERVOUS  SYSTEM. 


I 


long  the  hallucinations  which  occur  in  the  dornnin  of  the 
nerves  of  special  sense,  which  we  are  accustomed  to  call 
"special  sense"  aura:.  The  patient  hears,  sees,  smells,  tastes 
things  which  cither  are  not  there  at  all  or  are  in  reality  differ- 
ent Irom  what  he  deems  them.  I  know  instances  in  which  im- 
mediately before  the  tit  the  patient  thinks  he  is  standing  in  a 
sea  of  li^ht :  mnsl  intense  brightness  surrounds  him,  and  he  \i 
cogni7ant  of  wonderful  light  eSccls.  In  other  ciscs  again  the 
patient  thinks  he  is  standing  amid  utter  darkiics;^.  he  sees  noth- 
ing, and  the  densest  obscurity  reigns  everywhere.  To  this  _ 
class  belong  the  instances  reported  by  Hcincmann  in  which  ■ 
bilateral  amauroses  constituted  the  aura  (V'irchow's  Arch,, 
I02,  3,  1885,  p.  522).  The  optic  as  well  as  the  auditory  aura: 
vary  in  didcrcnt  patients.  Sometimes  they  hear  delightful 
melodies,  sometimes  they  find  themselves  amid  the  wildest  tu- 
mult of  confused  noises.  Comi>lclc  los-s  of  hearing,  transient 
deafness,  which  would  be  analogous  to  the  transient  umauro> 
sis,  I  have  never  had  an  opportunity  to  note. 

Sometimes,  not  often,  the  patients  imagine  they  hear  dis- 
tinctly different  voices.  Then  the  aura  is  n  genuine  hallucina- 
tion and  inlriiiges  upon  the  domain  of  pre-cpileptic  insanity. 
Well-pronounced  gustatory  and  olfactory  auric  do  occur,  but 
are  decidedly  less  frequent  than  those  just  described. 

The  somatic  aura:  arc  cither  motor,  sensory,  or  vaso-mol 
The  motor  more  frequently  consist  of  symptoms  of  irritation 
than  of  paralysis.    There  are  isolated  twitchings  in  the  fin- 
gers or  toes,  in   the  arms  or  legs,  which  progress  from  the 
periphery  to  the  centre;  conlracliircs  in  certain  fingers  have 
also  been  observed.     In  addition  to  or  in  the  place  of  these  ■ 
there  may  be  twitching  movements  of  the  head  or  neck,  twitch- 
ings  of  the  facial  muscles,  or  well-marked  strabismus.     Paretic 
symptoms,  heaviness  and  fatigue  in  the  extremities,  are  morf  f 
rare.     Spasm  of  the  glottis,  bronchial    asthma,  palpitation  oi  ' 
the  heart,  retching — all   have   to  be   regarded  as  varieties  of 
motor  aurse. 

The  sensory  aur.-c  consist  of  peculiar  paresthesias  in  the 
extremities,  formication,  numbness  in  the  fingers,  the  [>3ticat 
feeling  as  if  these  were  working  their  way  up  to  the  head  ori" 
the  heart.  Not  uncommonly  they  arc  associated  with  a  pii> 
nounccd  feeling  of  anxiety  and  oppression.  The  sensatiooi 
which  appear  in  the  extremities,  sometimes  in  the  fingers, 
sometimes  in  the  toes,  are  cxtretnely  variable,  from  a  plciuaxi 


{ 


EPILEPSY. 


177 


'slight  tingli 


painful 


■^' 


I 


£ 


burning  and  stinging,  wliicli,  as  wc 
have  said,  proceeds  from  the  periphery  to  llic  centre. 

In  vaso-motor  aura:  the  hands  become  cold  and  pale,  the 
neous  veins  look  less  full  than  normally,  and  the  patient 
plains  that  he  is  getting  cold.  A  general  feeling  of  chilli> 
ness,  a&socialed  with  chattering  of  the  teeth,  has  also  been 
noted  (Douty.  Lancet,  March  20.  1SS6).  In  other  instances, 
possibly  on  account  of  a  paralysis  ol  the  vaso-motor  nerves, 
blushing  of  the  stein  and  sweating  occur.  The  degree  of  liill- 
ness  of  the  cutaneous  vessels  and  the  larger  veins  of  the  skin 
in  some  cases  sufficient  to  tell  the  patient  whether  or  not  he 
will  shortly  have  a  fit. 

Innumerable  transition  forms  and  countless  combinations  of 
dilTerent  kinds  of  aurje  occur.  No  definite  laws  can  be  given, 
and  we  must  here  again  recall  the  inexhaustible  varieties  of  the 
^prodromes  by  which  the  attack  may  be  ushered  in. 

The  question  whether  the  origin  of  the  aura  be  central  or 
peripheral  c;*n  not  as  yet  be  answered.  Certain  facts  point  to 
the  first  possibility,  others  to  the  second  (cl.  Oliver.  Lancet, 
April  31,  18SB,  page  769).  That  the  aura  may  have  an  anulom> 
ical  basis  is  proved  by  the  case  reported  by  Hughlings  Jack- 
son ilirit.  Med.  Journal.  February  25,  1888).  The  patient,  u 
man  of  fifiy.thrce  years  of  age.  complained  regularly  of  a  hor- 
rible, indescrilxible  stench  which  immediately  preceded  every 
attack.  At  the  autopsy  a  tumor  was  found  situated  in  the 
lemporo^phenoidal  region.  We  would  remark,  by  the  vruy, 
that  this  case  is  a  point  In  favor  of  Ferricr's  localization  of  the 
tense  of  smell. 

The  attack  itself  is  characterized  by  complete  loss  of  con- 
tousness,  and  is  sometimes  ushered  in  by  an  initial  piercing 
TV  or  a  noise  like  the  roar  of  a  wild  beast  which  the  patients 
emit  at  the  moment  of  falling.  This  cry  is  by  no  nieaits  10  be 
regarded  as  the  expression  of  (ear  or  surprise,  as  it  docs  not 
occur  until  consciousness  is  lost  and  is  a  reflex  act.  It  is  ob- 
rvcd  in  alxiut  fifty  per  cent  of  all  cases,  while  in  the  remain, 
der  it  is  either  absent  or  replaced  by  tears.  A  tonic  muscular 
contraction  accompanies  the  cry.  The  head  is  at  the  moment 
of  the  fall  drawn  backward  or  to  one  side,  the  jaws  arc  pressed 
together,  the  bcick  is  spasmodically  curved,  and  the  fingers  are 
clenchc<l  over  the  adductcd  and  flexed  thumb.  Kespiration 
ceases,  because  the  muscles  performing  the  function  take  part 
the  spasm,  and  the  face  becomes  discolored  and  cyanotic. 
37 


5/8 


D/SF.ASF.S  OF  THE  GENEKAL  NEkVOVS  SVSTKXr. 


A  convulsi%-e  tremor  runs  over  the  wliolc  body,  and  in  ihc 
nuisclc.-<i  of  the  face  as  well  as  in  the  rigid  extremities  twitcb 
ings  begin  to  a[>i)ear.  which  spread,  and  spare  no  part  of  ihe 
body.     The  head  is  violently  knocked  against  the  floor  or  Ihe 
couch,  the  tongue  rolled  around  in  the  nioiiih,  protruded,  per- 
haps, and  retracted  altcrnalely,  so  that  it  is  often  injured  by 
the  teeth  :  the  eyeballs  are  deviated,  the  pupils  dilated  and  in- 
active.    Arms,  legs,  and  trunk  are  now  the  seat  of  violent,  ir. 
regular,  rapidly  changing  jerkings.     The  mechanism  o(  these 
motions  has  been  studied  by  Unverriclit  ^Ueber  tonischc  und 
klonische  Muskelkrampfe.    Leipzig.  1890).    Corneal  and  skin 
reflexes  arc  lost.    The  tendon  reflexes  can  be  obtained  if  the 
tetanic  rigidity  of  the  e\iremiiies  allows  it.     The   pulse  if 
slightly  quicker,  the  respiration  greatly  hurried.     With  eadi 
expiration  the  saliva,  often  foaming  and  mixed  with  the  blociii 
coming  from  the  injured  tongue,  bursts  forth  and  covers  the 
Hps.    The  temperature  remains  normal.     In  more  prolncletJ 
cases  it  may  rise  from  one  fifth  to  half  a  degree  Fahrenheit 
The  involuntary  evacuation  of  urine  and  fa;ces,  possibly  aUoof 
semen,  is  not  rare.     In  one  case  only  have  I  seen  the  attack 
regularly  associated  at  its  onset  with  vomiting. 

Gradually  the  body  becomes  covered  with  sweat  in  col)S^ 
quencc  of  the  excessive  muscular  strain ;  next,  the  convulsions 
lose  some  of  their  violence,  the  limbs  gradually  become  le» 
rigid,  the  cyanosis  disappears,  respiration,  though  it  may  siiU 
be  difficult  and  snoring,  becomes  more  regular,  the  comi 
abates  and  passes  insensibly  either  into  a  deep.  long  sleep  or 
gives  place  immediately  to  complete  consciousness,  so  that  iB 
some  cases  the  patient  may  in  a  few  minutes  again  be  in  an 
apparently  perfectly  normal  condition,  without,  however,  hav- 
ing the  slightest  idea  of  what  has  been  going  on  during  llie 
attack. 

We  have  said  that  the  symptoms  immediately  preceding 
the  attack  present  an  endless  variety  of  forms ;  the  same  must 
be  said  of  those  that  belong  to  the  period  following  it-  Th«c 
"  post-cpileptic  "  phenomena  may  again  be  divided  into  psychi- 
cal and  somatic.  The  psychical  phenomena  are  very  inierejt- 
ing,  because  they  are  not  always  of  the  same  inlcnsily,  but 
may  assume  all  gradations  between  .t  complete  insanity  ("poft- 
epileplic  insanity,"  post-cpileptic  moria,  Samt)  and  a  slight 
bewilderment.  In  the  first  case  the  pnlienl  has  to  be  regarded 
as  a  m.idman,  and  must  not  be  held  responsible  for  his  aciiun*. 


F.PtLEPSY. 


%n 


I 
I 


not  excluding  any  crime  that  he  may  commit  at  such  times: 
in  the  lallcr  he  resembles  a  drunken  man,  who,  although  he 
inter  can  not  remember  what  has  happened,  will  answer  ques- 
lions  if  they  are  repeated  often  enough  and  in  a  .sutTicicntly 
loud  lone.  Not  uncommonly  there  exist  on  first  waking  up 
speech  disturbances,  in  the  form  of  a  motor  or  sensory-  aphasia, 
which  lasts  from  a  few  minutes  to  several  hours.  Total  apha< 
sia  following  the  attack  has  also  come  under  my  notice,  and  I 
have  seen  it  persist  (or  half  an  hour.  The  patient  appeared  to 
have  regained  consciousness  pretly  well,  he  understood,  appar- 
ently, the  questions  which  were  asked  him,  but  was  not  able  to 
answer  ihem  in  any  other  way  than  by  signs.  FUrslncrhas  re- 
ported instances  of  post-cpilcptic  stammering  (Arch.  1.  Psych, 
und  Ncrvcnkrankheiten.  lSS6,  xvii,  z). 

Among  the  sJimatic  postepileptic  phenomena  there  is,  be- 
sides the  difference  in  the  size  of  the  pupils,  which  is  of  some 
value  for  the  diagnosis  of  nocturnal  allacks  occurring  during 
sleep,  a  concentric  contraction  of  the  field  of  vision,  which  may 
last  (or  twcnly-lour  hours.     Of  this  I  have  been  able  to  con- 

ince  myself  several  limes  positively.  Purthcr.  (here  arc  cer- 
tain conditions  of  motor  irritation,  "cortical  movemenls " 
(Kindenbewegungcn  of  i^acher),  which  consist  of  cither  lypl- 
clonic  twitchings.  or  of  choreoid  or  alhctoid  movements, 
and  which  may  persist  (or  hours.  Contractures,  occurring 
more  frequently  in  the  upper  than  in  the  lower  extremities, 
usually  on  one  side,  have  been  observed  only  in  exceptional 
iLemoine,  Deutsche  Mcd.-2lg.,  1888,  30).  Among  the 
motor  changes  there  arc  circumscribed  reddenings  which 
may  occur  symmetrically  on  both  sides  of  (he  body  in  (be 
most  diverse  places.  Transient  incre.ise  of  the  patellar  rcflcs. 
transient  albuminuria  ixwX  violent  vomiting  are  common  after 

pileptic  attacks. 
As  to  the  time  at  which  (he  attack  may  be  expected,  we 
tnay  broadly  say  that  there  is  not  a  moment  in  the  life  of  the 
'patient  in  which  he  can  (eel  safe  (nmi  them  ;  that  any  particu- 
iir  lime,  either  of  (he  day  or  o(  the  night,  is  especially  danger- 
ous in  this  regard  can  not  be  maintained.  This  much  only  can 
be  said,  that  in  some  individual  cases  the  (its  occur  only  during 
the  night  while  the  patient  is  in  bed  and  asleep;  this  so-called 
epilepsia  nocturna  possesses  great  practical  imporlance.  be- 
cause it  may  persist  (or  a  very  long  time  unremarked  and  un- 
recognized, especially  if  the  patient  sleeps  alone.     If  such  be 


t^ 


S8o 


I>/SEMSES  Of  THE  GENERAL  NERVOUS  SYSTEM. 


the  ca!ic,  ttic  dingnosiR  cnn  only  be  made  from  certain  charac- 
teristic signs  observed  in  the  morning — from  ihc  pain  of  the 
bitten  tongnc,  tlic  dull  headache,  the  slight  extravasation  of 
btood  into  the  conjunctiva:,  or  the  unequal  pupils  {jViiV  sHfira). 
[n  one  of  my  cases  of  nocturnal  epilepsy  there  occurs  after  cacli 
attack  a  deep-red  spot,  the  size  of  the  pnim  o(  the  hand,  on  the 
forehead,  which  does  not  begin  to  fade  nnltl  one  or  two  days 
have  passL-d.  For  years  the  attacks  in:iy  be  confined  to  the 
night,  and  may  go  on  without  interfering  to  any  extent  with 
the  patient's  business  and  social  life.  Above  all,  he  is  not  ex- 
posed to  the  usual  injuries  caused  by  the  falls,  but  he  never 
can  feel  absolutely  certain  that  some  time  or  other  an  attacic 
may  not  occur  during  the  day.  These  nocturnal  fits  arc 
heralded  by  an  irregular  respiration,  snoring,  grunting,  or 
moaning.  Convulsions  may  not  occur  at  all,  but  the  whole 
body  gets  into  a  condition  of  tetanic  rigidity  which  is  followed 
by  a  relaxation  of  the  muscles;  during  the  whole  time  the 
patient  docs  not  awake,  and  has  no  consciousness  of  what  bn» 
been  going  on. 

There  are  certain  things  which  seem  to  exert  an  unfavor- 
able influence  upon  the  severity  and  the  frequency  of  the  fiU, 
and  against  which  the  patient  must  be  strictly  and  rcpcatcdlj' 
cautioned.  These  have  been  mentioned  on  page  S75-  It  need 
only  be  added  here  that  coitus  does  not  always  have  a  bad  in- 
fluence, and  that  there  is  no  reason,  from  the  physician's  point 
of  view,  tor  forbidding  it  altogether.  Whether  the  clim.itc  hflS 
anything  to  do  with  the  fits  we  are  not  sure,  and  the  idea  of 
the  supposed  influence  of  the  moon  must  be  relegated  to  the 
domain  oE  the  unknown.  It  is  interesting  to  note,  howenr, 
that  when  an  epileptic  is  taken  ill  with  typhoid  fever,  pneumo- 
nia, facial  neuralgia,  etc..  he  may  hope  to  enjoy  immunity  from 
the  attacks  as  long  as  these  diseases  last.  This,  however,  does 
not  hold  good  for  pregnancy  ;  according  to  Ncrlinger,  to  wlwm 
we  owe  an  interesting  monograph  on  the  relation  between 
child-bearing  and  epilepsy  (Heidelberg.  Winter.  1S89),  ft  dimt 
nution  of  the  attacks  during  gestation  is  observed  only  in  rare 
instances. 

On  the  other  hand,  there  arc  cert.iin  things  which  exert  ■ 
favorable  influence,  either  by  aborting  or  preventing  for  cer- 
tain periods  the  occurrence  of  the  attacks.  Mow  these  factors 
work  is  quite  inexplicable.  Among  the  former  may  be  men- 
tioned the  application  of  a  tight  bandage  or  strap  to  the  pirt 


EPfLErsy. 


o)  ihe  body — e.  5.,  the  finger  or  Iiand — in  which  the  motor 
aiira  occurs;  to  the  latter  belongs  frequent  cpistaxis.  as  I  have 
repeatedly  had  occasion  to  observe  ;  if  it  was  profuse  it  seemed 
10  produce  an  intermission  in  the  occurrence  of  the  attacks 
which  lasted  for  a  relatively  long  time. 

Besides  the  classical  attack  which  we  have  just  described, 
and  which  is  known  as  "gram!  ma/,"  there  occurs  ihe  rudimen- 
tary abortive  attack,  as  it  were,  which  has  received  the  name 
"fieiil  mal."  Of  this  latter  kind  there  exist  countless  varieties. 
There  may  be  nothing;  more  than  a  momentary  vertigo,  with- 
out any  loss  of  consciousness ;  this  is  termed  epileptic  vertigo ; 

['Or  in  place  of  or  following  this  there  may  be  a  brief  loss  of 
consciousness,  lasting  but  a  few  seconds,  the  "abs^nif"  of  the 
French  writers,  of  the  onset  and  the  duration  of  which  the 
patient  is  unable  to  give  any  account.  An  individual  may  in 
the  middle  of  any  kind  of  occupation — speaking,  eating,  read. 
ing,  and  so  (orth — suddenly  stop  what  he  is  doing  ;  lor  an  in- 
stant he  stares  vacantly  before  him.  remains  as  he  is,  standing 
or  sitting,  and  immediately  after  the  "  attack  "  resumes  his  oc- 
cu)Kition  as  il  nothing  had  happened;  the  unrinishcd  sentence 

,  is  alter  a  short  pause  completed,  the  spoon  which  was  ready 
to  bring  the  food  to  the  mouth,  alter  a  short  stop  reaches  fts 
goal.  If  an  "absence"  occurs  to  the  patient  on  the  street  when 
he  is  out  walking,  he  keeps  on  mechanically,  loses  his  way  per> 
haps,  and  only  finds  it  again  when  consciousness  returns.  The 
instances  in  which  such  periotls  take  in  a  much  longer  time, 
during  which  the  patients  undertake  voyages,  spend  money, 
transact  business  of  which  they  are  not  conscious  later,  or  do 
things  which  arc  against  their  intention  and  entail  disagreeable 
consequences,  must  also  be  looked  upon  as  coming  under  the 
head  of  epilepsy.  They  are  undoubtedly  rare,  and  up  to  this 
time  have  been  carefully  observed  only  by  French  physicians, 
more  especially  by  Charcot  (•'  aittomatisme  awMatoirf  "),  Insig- 
nificant as  /vtil  mal  may  seem,  it  often  has  a  very  deleterious 
effect  upon  the  general  condition  of  the  patient,  especially  upon 
the  mind  :  we  should  be  cautious,  therefore,  with  our  prognosis. 
There  are  still  other  seizures  in  which  typical  convulsions 
do  not  occur,  but  in  which  the  patient  suddenly  begins  to 
walk  first  forward,  then  backward,  to  run  around  in  a  circle 
(•' mauiffttfitts  de  manig€"),  or  spin  round  and  round;  or  lie 
may  rush  out  of  his  house  and  run  for  long  distances  without 
knowing  why  or  whither.     This    form,  which  has  been  dc- 


583 


D/S£AS£S  OF  THE  GENERAL  .SERX'OVS  SVSTF.M. 


scribed  by  Gourncvillc,  t^damc,  Wcinstock  (TnAugur.-Diss«r 
Berlin,  i88g),  and  others,  is  calltxl  "running  epilepsy,"  cpi- 
tepsta  procursiva.  It  oltcn  appears  in  childhood,  and  later 
gives  place  to  the  usual  classical  attacks.  Us  frequent  com. 
bioation  with  moral  insanity  is  intcrcsring.  Anatomical  changes 
have  not  been  found  in  the  cases  which  came  to  autopsy  up  to 
the  present  {cf.  BUttncr,  Allg.  Zeitschr.  f.  Psychintrie,  1891. 
xlvii,  Heft  5). 

Again,  instead  of  the  convulsive  riliacks,  we  may  have  from 
lime  10  time  transient  psychical  disturbances,  which  consi&l 
of  stales  of  excitement  or  depression  :  iti  such  instances  we 
speak  of  "epileptic  equivalents"  (Saml),  We  must  leave  to 
the  psychiatrists  the  task  of  investigating  their  cause  and  their 
significiince.  From  a  medico-legal  point  of  view  these  puzzling 
conditions  possess  great  interest. 

About  the  frequency  of  the  paroxysms  no  definite  state- 
ment is  possible.  There  arc  people  who  during  their  whole 
life  have  not  more  than  one.  two,  three,  six,  or  ten  attacks,  and 
again  there  arc  others  in  whom  ihcy  recur  once  a  week  or  still 
more  frequently.  Sometimes  there  arc  certain  periods  in 
which  they  increase  in  frequency,  and  others  of  months  or 
years  during  which  only  an  occasional  attack  occurs,  [n  rare 
instances,  in  periods  of  the  former  kind,  the  fits  may  succeed 
each  other  so  closely  that  there  may  be  one  or  even  many 
every  day.  Before  the  patient  has  had  time  to  regain  his  full 
consciousness  another  attack  looms  up.  This  is  what  we  call 
the  status  epilcpticus,  Hat  lii  mat.  The  tcinpcrature  may  rise 
steadily  (or  from  three  to  eight  days  as  much  as  5*  to  7°  F.,  so 
that  it  may  reach  104°  or  106°  F.  If,  then,  in  the  intervals 
consciousness  does  not  become  fully  restored,  but  the  patieol 
remains  dull  and  bewildered,  there  is  very  great  danger  lliat 
death  may  occur  during  the  status  epilcpticus.  and  the  friends 
should  he  made  acquainted  with  the  seriousness  nf  the  siluiv- 
tion.  Only  in  e^ception3l  cases  docs  rccDvcry  take  place  and 
the  temperature  fall  to  normal  again  (Witkowski,  Ccber  epi- 
leplisches  Fieber  u.  s.  w..  Berliner  klin.  Wochenschr.,  1886, 
xxxiii.  43,  44). 

Course. — The  course  of  the  disease,  the  general  condittw 
of  the  patient  in  the  intervals  between  the  ait.icks.  the  itiAu- 
ence  ol  the  attacks  upon  the  mind  and  body — all  these  may 
present  great  variations. 

The  course  is  very  chronic  and  the  disease  lasts  in  most 


SPfLXPSV. 


583 


cases  years  .ind  tens  of  years.  Frequently  the  patient  is  sul>. 
jvct  to  the  adectinn  during  his  whole  life.  The  earlier  the  first 
attacks  make  their  appcinince  the  less  chance  is  there  of  their 
complete  disappearance.  In  some  cases  of  "  late  epilepsy," 
"  ffUfpsit  fartihff,"  in  which  the  affection  does  not  begin  until 
late  in  life,  it  may  hapjteii  that  the  attacks  completely  cease  as 
unexpectedly  as  they  came  on.  Slill,  a  course  so  favorable  as 
this  is  rare  and  can  never  be  predicted  with  certainty.  Mendel 
has  pointed  out  that  this  late  form  runs  in  general  a  milder 
course,  and  that  the  mind  is  less  likely  to  become  affected  in 
these  cases.  If  the  disease  has  set  in  in  early  childhood,  the 
influence  of  the  period  of  puberty  is  generally  very  marked. 
The  attacks  become  more  frequent,  and  in  women  the  increase 
in  number  is  observed  every  month  at  the  time  of  the  menses 
until  the  time  of  the  mcnnpause.  Pregnancy  has  little  influ- 
cncc  on  the  attacks,  according  to  my  own  experience;  some- 
times it  appeared  as  if  shortly  after  conception  the  number  of 
(its  was  considerably  lessened,  while  in  other  women  there 
seemed  to  be  no  change. 

The  general  condition  in  the  intervals  between  the  attacks 
is  by  no  means  the  same  in  all  cases.  In  some,  loriitnately  not 
rare  cases,  the  paroxysms  do  not  cause  any  bad  effects  (or 
years  and  nothing  morbid  can  be  discovered.  The  mental  fac. 
ulties  develop  normally  or,  il  already  developed,  rem.Tin  good. 
The  disposition  is  cheerful,  social  intercourse  is  enjoyed,  as 
there  is  nothing  in  the  bodily  condition  to  interfere  with  such 
pleasures.  The  pres<'nce  of  epilepsy  d<x.'s  not  necessarily  pre- 
vent  the  full  development  of  a  genius,  as  is  proved  by  the  uni- 
versally quoted  historical  examples  of  Ca:sar,  Alexander  the 
Great,  Uousseau.  Napoleon  I,  and  <)thers. 

In  other  instances  llic  general  condition  in  the  intervals 
leaves  much  to  be  desired,  and  as  a  rule  it  is  the  psychical  part 
of  the  man  which  suffers  most  unpleasantly.  Either  the  dispo* 
sitJon  of  the  patient  is  changed  for  the  worse,  so  that  he  is 
easily  excited,  irascible,  suspicious,  peevish,  unsociable,  and 
disagreeable  to  those  around  him,  or  the  mental  faculties 
suffer,  he  Ixrcfuucs  dull,  slow  in  grasping  ideas,  indifferent,  anx- 
ious, abstracted,  and  so  unreliable  in  his  vrork  that  he  is  no 
longer  able  to  fulfill  his  duties  as  a  man  of  business  and  as  a 
g(KKl  citizen. 

In  such  cases  we  are  sometimes  able  to  note  bodily  defects, 
as,  tor  example,  abnormities  in  the  (orm.-ition  of  the  skull,  in 


584 


DISEASES  OF  THE  GEXERAL  NERVOUS  SYSTSAf. 


tlie  furm  ol  the  auricle,  in  the  condition  and  arrangement  of 
the  teeth,  and  quite  frequently  flal-toot  (F^rA  et  Demanlkd, 
jKuriial  do  I'Anat. ct  dc  la  Physiol.,  i8gi,  5).  Such  "signs  of  do- 
generation."  however,  are  often  absent. 

The  final  issue  of  the  disease  is  almost  always  the  same. 
The  patient  remains  an  epileptic  all  his  life,  from  time  to  time 
having  attacks,  and  finally  dies  from  some  intercurrent  malady. 
The  mental  faculties  may  remain  throughout,  on  the  whole, 
good  and  the  capacity  ol  the  patient  for  following  his  calling 
be  retained.  In  other  instances  the  mind  becomes  gradually 
impaircd,  so  as  to  necessitate  the  transference  of  the  patient  to 
an  institution,  or  again,  in  very  exceptional  cases,  there  may  be 
complete  recovery  or.  at  any  rale,  so  marked  a  decrease  in  the 
frequency  of  the  attacks  that  the  patient  may  well  regard  him- 
self as  cured.  This  cure  may  come  about  spontaneously  or 
may  be  caused  by  some  unexpected  psychical  emotion,  pnr- 
licularly  a  fright.  However,  wc  should  beware  of  being  too 
precipitate  in  callinij  a  patient  "  well,"  because  now  and  then 
even  after  intermissions  of  years  an  attack  may  again  make  if 
appearance. 

Death  rarely  ever  occurs  during  an  attack,  but  iudirccffT 
the  paroxysms  may  ciuse  a  fatal  issue.  The  patient  during 
a  fit  may  receive  serious  injuries;  he  may  fall  upon  his  face 
and  be  suffocated,  or  fall  into  the  water  and  be  drowned.  The 
average  life  of  epileptics  is  considerably  shorter  than  that  uf 
other  persons. 

Pathogenesis. — The  pathogenesis  of  the  epileptic  attack  ii 
totally  obscure ;  although  we  know  from  the  experiment*  of 
Kussmaul  and  Tenner  that  the  source  of  the  attacks  must  be 
sought  for  in  the  brain,  the  exact  scat  of  the  disease  is  not  known. 
Since  the  work  of  SchrOder  van  der  Kolk  special  attention  hxs 
been  given  to  the  medulla  oblongat.i,  and  the  discovery  by 
Nothnagel  of  a  "  spasm  centre  "  in  the  pons  seemed  to  alTofd 
mnch  support  to  the  "  bulbar  theory."  but  of  late  years  this  has 
(alien  more  and  more  into  discredit,  and  it  is  now  the  brain  cor- 
tex which  is  regarded  as  the  starling  point  of  the  convulsions 
(llitzig,  Albertoni.  Francket  Pit  res,  P.  Rosenbach).  For  alooff 
lime  the  motor  area  was  thought  to  be  the  only  region  coiv- 
cerned,  but  recently  Unverricht.  who,  with  his  convincing  ex- 
periments on  animals,  has  proved  himself  the  most  sucocaful 
defender  of  the  cortical  theory  (after  extirpation  of  an  area  in 


KFlLEfSV. 


585 


I 


corlcx  he  found  that  he  cnulcl  not  obtain  spusms  in  the 
muscle  groups  corresponding  to  it^  has  shown  thut  excitation 
I'of  the  posterior  cortical  regions  is  also  capable  o(  producing 
an  attack,  hence  that  these  too  possess  cpilcpto<^cnic  proper- 
ties, and  tlial  irritation  oE  the  same  may  by  extension  of  the 
stimulus  to  the  motor  area  give  rise  to  general  convulsions 
(Deulsch.  Archiv  \.  klin.  Med.,  1&88.  44.  ■)• 

Binsvvangcr  agrees  that  in  the  lateral  portions  ol  the  (toor 
of  the  fourth  ventricle  there  are  points  the  stimulation  of 
which  gives  rise  to  spasms,  which,  however,  he  considers  10 
be  of  a  reflex  nature,  and  assumes  the  reflex  centres  to  be  sit- 
ft  uatcd  in  the  dorsal  hall  of  the  pons.  According  to  his  opinion, 
"  these  represent,  as  it  were,  a  collecting  station  for  the  centres 
of  the  spinal  cord,  and  can  not,  in  the  physiological  sense,  lie 
termed  "s|>asm  centres."  He  mainiains  that  we  never  can 
succeed  by  electrical  or  mechanical  stimulation  of  the  pons  in 
producing  real  epileptic  attacks  (Arch.  f.  Psych,  u.  Nerrenkh., 
18S8,  xix,  3). 

However  probable    an  association   of  the  cortex  wjlh  the 

appearance  of  symptoms  of  motor  irritation  may  seem,  such 

Kan   association  is  far  from  explaining   the   increased   salivary 

Hijwcretion,  the  involuntary   evacuation   of  the    bladder,  the  in- 

|nmse  in  the  frequency  of  the  respirations,  etc.,  and  we  must 

(or  the  present  leave  the  question  open  whether  or  not  such 

» phenomena  depend  upon  some  influence  acting  on  certain  cen- 
tres in  the  brain  and  spinal  cord,  the  situation  and  function  of 
which  we  do  not  as  yet  know.     The  question  raised  by  J^ichcn 

»as  to  the  significance  of  the  subcortical  ganglia  in  thecausa- 
tiun  of  an  epileptic  attack  deserves  lo  be  looked  into  more 
closely  ;  for  the  present  only  this  seems  certain,  viz.,  that  (in 
dt>g<i)  the  clonic  pan  of  the  convulsive  movements  produced 
by  stimulation  of  the  cortex  is  connected  with  the  corlcx  itself, 
while  the  tonic  and  the  running  movements  seem  lo  be  ol  sul». 
^  cortical  origin  (XIII.  W'andcrversammlung  siiddeulschcr  Neu- 
■  rologcn.  Archiv  f.  Psych.,  1889.  xx,  3.  p.  ;84V  The  possibil- 
ity cnn  not  be  excluded  that  in  man,  as  in  animals,  both  regions, 
tthc  cortex  as  well  as  the  bulb,  may  be  responsible  for  the 
Dltack. 
In  the  second  place  we  arc  entirely  ignorant  of  the  cause  of 
the  attack:  it  is  unlikely  that  a  palpable  anatomical  alteration 
exists,  and  the  claim  of  Chaslin  (Note  sur  I'anatomie  patholo- 
giquc  de  r^pilepsie.ditc  essentielle.  Journal  desConnaiss.  mid.. 


$86 


D/SEASES  Of   THE  GENERAL   XERi'OUS  SYSTEM, 


1889,  5  s.  X,  12).  that  a  gliosis,  which  he  designates  a  "sclerose 
nevrogli<iiie,"  is  to  be  regarded  as  the  cause  of  epilepsy,  is  by 
no  means  proved.     Much  more  plausible  is  the  llicory  that  the 
amount  of  Wood  in  the  brain  is  of  importance  in  this  connection, 
but  the  different  writers  have  never  been  able  to  agree  whether 
an  increase  or  a  diminnlion  in  the  amount  of  blood  is  the  cause. 
Many  clinical  observations  speak  in  favor  of  ana-mia:    thus 
Leyden  has  seen  epileptic  attacks  in  cases  of  aortic  stenosis 
undoubtedly  as  the  result  of  a  temporarily  instiflicient  blood 
supply  ;  Sommer  noted  their  occurrence  in  a  case  of  anchylosb 
of  the  atlas  which  had  produced  narrowing  o(  the  vertebral 
canal  in  its  tipper  portion  (Vircliow's  Arch.,  rSgOj  cxix.  Heft  2, 
p.  362).     Results  pointing  in  the  same  direction  have  been  ob- 
tained by  Sutnikow  in  his  experimental  studies  on  hypcncmia 
and  anemia  ot  the  brain  and  its  relation  to  epilepsy  (PftUgcr's 
Arch.,  1892,  xc,  p.  609).    On  the  other  hand.  Bechierew,  whose 
opinion  is  based  on  experiments  of  Todorsky,  holds  that  during 
the  attack  there  occurs  an  increased  blood-flow  to  the  brain 
and  a  dilatation  of  the  capillaries,  and  that  this  condition  ts  the 
cause  of  the  attack.     We  see,  therefore,  that  the  question  is  by 
no  means  decided  ;  we  should  also  think  o(  the  possibility  that 
vaso-motor  changes,  or  a   rapidly   or    gradually   developing 
autointoxication,  perhaps  by  ptotnaincs  (Qcncdikt)niay  pro- 
duce the  attack.    Since  epileptic  attacks  are  also  sure  to  occur 
after  acute  infectious  diseases  (influenza,  typhoid   fever),  also 
after  vaccination  (.Mthaus),  an  infectious  origin  can  not  be  ex- 
cluded.    But   whatever  may  eventually  be  shown  to  be  the 
cause,  a  hereditary  abnormal  excitability  of  the  psychomotor 
centres  has  to  be  regarded  as  ^  (ondtlu)  iint  qua  nan. 

A  peculiar  kind  of  epilepsy,  which  is  said  only  to  occur  in 
heart  disease,  has  been  described  by  l,«moine  (Dc  I'^pilcpsic 
d'originc  cardiaque.  Revue  de  m£d.,  vii.  May  5, 1877) ;  yet  wnce 
the  connection  is  not  absolutely  proved,  and  since,  moreover, 
the  attacks  themselves  presented  no  peculiarities  of  their 
own.  we  shall  limit  ourselves  to  saying  that  they  disappeared 
under  the  administration  of  digitalis. 

\'on  Jaksch  (Zcitschr.  t.  kiin.  Med-  1885,  x,  4)  has  shown 
that  epileptic  attacks  may  be  produced  by  auto-tntoxication. 
not  only  by  urea,  but  in  a  similar  way  also  by  acetone,  )o 
cases  of  "epilepsia  acetonica  "  large  amounts  of  acetone  were 
found  in  the  urine,  which  besides  contained  neither  sugar  nor 
albumen.      The  physiological  connection  between  the  occur. 


EP/LEPSr. 


587 


Rnljpf  acetone  in  large  quantities  in  the  urine  and  epilcpli- 
ittack-s  is  not  as  yet  (uily  established,  nor  do  we  know 
how  poisons — (or  instance,  lead— introduced  into  the  oi^anism 
from  outside  are  able  to  produce  such  attacks;  as  a  matter 
of  (act,  however,  lead  workers  suffer  so  frequently  from 
epilepsy  that  we  are  justified  in  assuming  the  existence  of  a 
definite  "  epilepsia  saturnina  "  (Hirt,  Krankhciten  der  Arbeiter, 

•  iii.  49)- 
Briefly,  epileptic  attacks  may  occur  as  a  symptom  also  fn 
meningitis,  dementia  p:iralylica,  during  delirium    tremens,  in 
sclerotic  processes,  more  especially  in  sclerosis  of   the  cornu 

■  Ammonis.  They  may  be  associated  with  tumors,  hydro- 
ccphalus.  or  abscess  of  the  brain,  in  which  cases  they  are  the 
result  of    the    increased    intracranial    pressure,  as   we    have 

H  pointed  out  above.  From  what  has  been  said  in  this  and  in 
previous  chapters  it  will  be  understood  that  these  and  the  so- 
called  epileptiform  attacks  above  mentioned  have  in  all  probii- 
bitity  nothing  to  do  with  (h:  genuine  classical  epilepsy. 

B  Diagnosis. — Wc  can  well  understand,  then,  how  cautious 
we  must  be  in  our  diagnosis.  Only  after  repented  and  careful 
examinations,  alter  which  we  are  able  to  exclude  organic  brain 
diseases,  abnormities  in  metabolism,  in  consequence  of  which 
abnormal  or  poisonous  substances  occur  in  the  urine  (urea, 
sugar,  acetone),  are  wc  ji)sti5e<t  in  making  the  diagnosis  of 
genuine  epilepsy.  The  skin  and  tendon  rcHcxes  should  always 
be  carefully  examined.  Sometimes,  from  the  absence  of  the 
abdominal  or  creni.-isteric  reflex,  or  from  a  unilateral  increase 
of  tlie  patellar  reflex,  wc  may  be  able  to  diagnosticate  an 
org.inic  brain  trouble  when  we  otherwise,  without  any  inquiry 

^into  the  condition  of  the  reflexes,  might  have  regarded  the  case 

^*s  one  of  genuine  epilepsy. 

Quite  frequently  wc  meet  with  malingerers  who,  (or  some 
reason  or  other,  feign  epilepsy.  The  situations  in  which  the 
simulation  of  this  disease  would  be  likely  to  be  advantageous 
to  the  deceiver  are  quite  numerous,  and  it  would  be  impossible 

_  lo  enter  into  the  consideration  of  them  here ;  we  will  only  mcn- 

Btion  that  epileptics  are  exempted  from  military  service,  good 
grounds  enough  for  many  to  sham  this  disease.  The  more 
cunning  the  malingerer  the  more  perlcct  will  be  the  attack, 
not  excluding  the  foaming  at  (he  mouth  (made  by  soap)  and 
I  the  (not  very  deep)  wounds  oi  the  tongue  ;  there  will  be  con* 


S88 


DISEASES  Of   THE   CEXEJtAl.   S'EXVOUS  SYSTEM. 


tbly 


ic(Icigncd)loss  ol  consciousness  is  possibly  pro- 
ihaii   is  iitrcfssary :    if   ihe  rogue   lias  courage 


I 


vubions,  and  the  (feigned)  loss  of 

lunged    more    _      -.  .  j  .    „_-     .  -  „- 

enough  he  will  not  betray  himself  either  by  a  reflex  motion  ul  ■ 
defense,  or  even  by  the  slightest  twitching,  il  hot  scaling  wax 
is,  as  a  test,  dropped  on  dis  chest.  Under  certain  circuin 
stances  it  may  be  extremely  difficult  to  unmask  ilic  fraud;  it 
might,  indeed,  be  impossible,  did  we  not  know  one  reflex  over 
which  the  will  has  no  power,  namely,  the  pupillary  reaction  in 
light,  which  in  the  epileptic  is  lost,  in  the  malin;;;erer  naturally 
is  retained.  In  doiibttul  cases,  therclorc,  this  reflex  has  tu  he 
carefully  observed,  and  the  further  measures  should  depend 
upon  its  condition, 

Treatment.— The  treatment  of  epilepsy  confirms  the  old 
experience  thai   the  greater   the   number  of   remedies  which 
become  known  and  are  recommended  for  a  disease,  the  more 
difficult  and  uncertain  becomes   the  cure.      In  the  course  of 
centuries  such    an    array  of    medicaments  have    been    recom- 
mended to  combat  this  disease  that  there  is  hardly  a  drug  ia 
the  shops  which  has  not  at  one  time  or  another  been  regarded 
and  praised  a$  an  infallible  "specific"    Unfortunately,  all  these 
claims  have  been  proved  to  be  false.     We  are  to-day  as  little 
in  a  position  to  cure  epilepsy  as  we  were  one  or  five  centuries 
ago.     Only  by  the  discovery  of  some  causes  which  may  pni- 
duce  epilepsy,  the  removal  ol  which  lies  in  our  power,  has  any 
progress  been  made  in  the  treatment  of  the  disease.    This  more 
particularly  applies  to  the  above  mentioned  reflex  epilep&ifs, 
and  the  Jacksonian  variety,  which,  it  is  true,  is  not  a  genuine 
epilepsy.     Here  a  cure  is  possible— nay,  we  may  say  even  cer- 
tain— il  we  are  able  to  remove  the  cause.     To  discover  it  muft 
be  the  physician's  aim.    Sometimes  it  consists  of  a  bone  splinter 
which  has  been  left  alter  an  injury  to  irritate  the  cories,  iii 
which  case  a  cure  will  invariably  be  effected  by  the  operaiion 
of  trephininfj  for  the  removal  of  the  splinter.     The  principJfs 
which  should  guide  us  in  such  an  operation,  the  (oremostol 
which  is  to  make  as  large  an  opening  as  possible,  have  been 
formulated,  among  others,  by  V.  Horsley  at  the  Trench  Con- 
gress for  Surgery  (Wien  Med.  Presse,  1891,  16).     In  other  in 
stances  painful  cicatrices  h.ive  to  be  excised  or  aficctionsoi 
the  inlestinni  tract  or  the  sexual  apparatus  treated.    In  chiliirm 
the  natural  openings  of  the  body  have  to  be  examined  lor  the 
possible  presence  of  a  foreign  substance,  the  removal  of  which 
would  then  be  absolutely  necessary. 


EPILEPSY. 


589 


iich  arc  the  favorable  cases  in  which  it  is  in  (he  power 
of  the  pliysician  to  bring  about  a  cure.  Uiiforluuutcly,  their 
number  is  nut  great.  In  the  largest  majority  of  instances  we 
are  not  able  to  lind  any  c:iuse.  the  removal  of  which  would  re- 
move  also  the  disca&c  ;  but  tn-day,  as  centuries  ago,  wc  are  re- 
duced to  the  sad  necessity  of  trying  all  sort*  of  remedies,  trust- 
ing  to  gwid  luck  that  at  some  time  wc  may  hit  upon  one  which 
is  truly  efficacious.  Before  relying  upon  the  action  of  any 
drug,  or  together  with  the  administration  of  the  remedy  chosen, 
strict  attention  sliould  be  paid  to  the  condition  of  the  stomach  ; 
indigestion  should  be  prevented,  or  if  it  exists  shttuld  at  once 
be  treated,  if  necessary  by  emptying  the  stomach  with  the 
lube  (Alt.  Mtlnch.  nicd.  Wochenschr,,  1S94.  14).  The  fiict  that 
I  have  observed  the  occurrence  of  attacks  to  be  more  (re(|uent 
when  much  food  w.i8  given  which  was  rich  in  nitrogen,  has 
prompted  me  to  limit  the  use  of  nitrogenous  articles  of  food 
and  to  advise  total  abstinence  from  meat  at  least  three  days  in 
the  week.  Some  epileptics  have  improved  their  condition 
considerably  by  becoming  vegetarians:  whether  they  ever  re- 
cover absolutely  under  that  regimen  I  am  unable  as  yet  to 
decide.  To  counteract  any  intestinal  sepsis  Fir6  recommends 
naphthol  and  salicylate  of  bismuth. 

Atnong  the  internal  medicineslheso-cilled  specifics  possess 
an  interest  purely  historical :  fnim  artemisia  (in  hot  beer.  10  to 
30  grm.  at  a  dose — grs.  1  jo  lo  joo)  and  Valeriana  down  to  M]uilla, 
gratiola,  sedum,  cardaminc,  and  hellebore,  many  herbs  have 
been  lauded  as  effectual.  .-\<af<elida,  caslorenm,  and  camphor 
have  been  recommended,  although  no  better  results  have  been 
obtained  from  them  than  from  silver  nitrate,  ammonio-sulphate 
of  copper,  an<l  arsenic.  ,\  great  sensation  was  created  by  Mcg- 
hn's  pills,  which,  in  addition  to  zinciim  album  contained  hyos- 
cyamus.  Some  have  sti-orn  by  oxide  of  zinc,  and  Merpin,  for 
instance,  claimed  that  out  of  forty-two  cases  he  cured  twenty- 
eight  with  it.  To  unprejudiced  judges  who  continued  their 
observations  for  a  sufhciently  long  time  these  "cures"  could 
not  hold  their  ground.  They  proved  to  be  deceptive,  and  we 
were  as  helpless  as  before.  Keconrse  was  had  also  to  narcol. 
ics,  and  much  was  hoped  from  the  action  first  of  opium  and 
later  of  ether  and  chloroform.  It  is  true  that  here  and  there 
an  attack  has  been  cut  short  by  inhalations  of  the  latter,  but 
that  U  all.  It  is  not  to  be  wondered  at  that  under  such  dr. 
cumsiances  secret  remedies  were  used  to  a  tremendous  extent: 


590 


DISEASSS  OP  THE  CBNEKAL  KTERVOVS  SYSTEM. 


and  to  what  a  pitch  the  humbug  and  impudence  were 
ricd  may  be  seen  {rum  the  compoiution  of  some  such  remedies, 
for  itislance.  the  epilepsy  powder  of  the  Institute  for  Deacon- 
esses in  Dresden,  which  consisted  of  charred  bone  of  magpies 
which  had  to  be  shot  at  some  time  during  the  twelve  oighls 
following  Christmas,  and  again  from  the  epilepsy  powder  of 
W'eplcr,  which  was  nothing  but  charred  and  pulverized  hemp 
thread  (cf,  Richter,  Das  Cchcimmittclunwcscn,  Leipzig.  1871. 
pages  IS.  16).  ■ 

A  new  era  in  the  treatment  of  epilepsy — that  is,  of  the  at>* 
ucks — was  initiated  when  Locock  in  1853  recommended  bro- 
mide o(  potassium,  which  obtained  a  wide  acceptation  through 
the  elTurts  of  Legr:md  du  SuuUe.     Its  power  of  diminishing  \\\i 
reflex  irritability  and  of    towering  the  blood  pressure  in  the 
brain  has  placed  it  first  among  the  aniiiipasmudics,  and  Io-(l.iy 
it  has  to  be  regarded  as  the  best  and  most  important  medicine 
in  the  treatment  of  epilepsy.     In  order  nut  to  be  disappointed, 
however,  in  our  expectations,  it  is  necessary  that  wc  should  be 
familiar  with  the  proper  regulation  of  the  dose  and  with  cer- 
tain unpleasant  effects  which  are  apt  to  arise  in  the  course  of 
the  treatment.     The  small  and  moderate  doses  of  0.5  to  4  grm. 
a  day  (grs.  viij  to  3j)  formerly  used  arc  generally  ineflectuaL 
It  is  necessary  to  employ  much   larger  amounts,  which  are 
best  given  in  one  dose.     It  is,  moreover,  better  to  combine  the 
three  bromides,  viz.,  the  bromides  of  potassium,  sodium,  and 
ammonium,  in  equal  parts  than  to  give  bromide  of  potassium 
alone.     The  minimum  daily  dose  (or  adults  in  cases  of  prti- 
nounccd  epilepsy  is  eight  grammes  (3ij),  >i"d  we  should  fol- 
low Mendel,  who  advises  that  it  should  be  taken  in  valerian 
tea  immediately  before  going  to  bed  (potassium  bromide,  am- 
monium bromide,  Jia  2.5  (grs.  xxxviij);  sodii  bromidi,  3.0 (grs. 
xiv).     For  children  and  young  people  up  to  sixteen  yearsof 
age  the  daily  dose  should  be  half  a  gramme  (grs.  vij)  for  every 
year.     If  the  two  drachms  are  not  sufiicient— that  is,  if  an  at- 
tack still  occurs  now  and  then — ihc  dose  may  be  increased  to 
ten  or  twelve  grammes  (  "  ijss.  I0  3  i'j).  and  this  continued  until 
four  or  five  hundred  grammes  or  from  six  to  nine  ounces  an 
taken. 

In  this  w.\v  I  have  treated  hundreds  of  epileptics  in  private 
as  well  as  in  dispensary  and  hospital  practice,  and  have  let  iJip 
no  opportunity  for  observing  the  action  of  the  bromides.  Tbis 
action  is  by  no  means  the  same  in  all  cases.    There  are  peopk 


I 
I 


F.PILEPSV. 


591 


n  tvhom  an  idiosyncrasy  against  tli<:  mt-dicinc  rapidly  dcvel* 
ops.  so  that  it  is  impossible  lor  ihcm  to  take  it  any  more.  It 
nauseates  them  and  may  cause  voniilinj;,  and  after  repeated 
unsuccessful  trials  to  resume  the  treatment  we  have  to  discon- 
tinue it  entirely.  In  other  instances  the  desired  eflect  on  the 
attacks  may  show  ilscK;  but  after  a  lew  weeks  the  patient  be- 
gins to  complain  of  general  bodily  and  mental  ieebleness,  a 
constant  desire  to  sleep,  some  loss  of  memory,  and  other  symp- 
toms, so  that  Ihe  dose  has  to  be  diminished.  At  the  same  time, 
sometimes  without  these  symptoms,  an  eruption  on  the  skin 
appears,  more  especially  an  extensive,  obstinate  acne  distributed 
over  (ace.  trunk,  and  extremities,  which  is  most  distressing, 
especially  to  young  female  patients.  1  have  seen  this  eruption 
particularly  after  the  prolonged  use  of  small  doses,  and  have 
also  seen  it  disappear  comp;initively  rapidly  under  the  use  of 
mild  laxatives  and  the  administration  of  arsenic  in  the  furni  of 
Fowler's  solution.  Finally,  cases  come  under  our  notice  in 
which  bromide,  no  matter  in  what  form  or  dose  it  be  given,  is 
entirely  without  elTect.  The  attacks  twcur  just  as  they  did 
previous  to  the  administration  of  it  Here  wc  have,  of  course, 
again  to  suspend  the  treatment,  more  especially  if  symptoms  uf 
intoxieuliim  appear  in  addition  to  the  continuance  ol  the  fits. 
II  we  wish  to  express  the  elTects  of  bromide  in  epilepsy  by 
ipcrcentagcs,  wc  could  say  that  in  about  ninety  per  cent  of  all 
cases  the  paroxysms  diminish  in  number  and  violence,  that  in 
about  as  many  signs  of  bromism  appear  which  render  neces- 
sary a  diminution  of  the  dose  or  gradual  suspension  of  the 
medicine.  In  from  two  to  three  per  cent  of  all  cases  bromide 
is  borne  so  badly  that  it  has  very  early  to  be  discontinued, 

»l(  it  is  established  beyond  doubt  that  the  bromides  exert  a 
[avorable  action,  we  must  insist  upon  their  prolonged  use  for 
months  and  years.    To  add  some  variety  to  the  treatment  they 
may  be  combined  with  belladonna  and  pills  may  be  ordered 
which  contain  both,     1(  every  evening  two  centigrammes  (gr. 
V»)  of  belladonna  and  two  grammes  (grs.  xxx)  of  bromide  arc 
iven,  about   the  same   results  are  obtained   as   with  eight 
rammes(~ij)  of  bromide  alone,     [fit  Extr.  bcllad..  0.5  <grs. 
ijss.);  pot.  brom.,  sodii   brom.,  ammonii  brom..  SA  15  (5^5. 
circ.) :  pulv.  et  succ.  liq.,  US  q.  s.  u(.  f.  pil.  No.  50.     Signa :  One 
to  two  pills  in  Ihe  evening.]     When  the  action  of  llie  bromide 
radually  becomes  lessened  owing  to  Ihe  establishment  of  a 
tolerance,  Ihc  ndminislratian  of  belladonna  is  also  indicated. 


I 


592 


D/S£ASES  OF  THE  GESEHAL  NERVOUS  SYSTEH. 


I. 


nnd  it  may  then  be  given  in  the  form  of  Trousseau's  pills.  (3 
Extr.  bell..  Fol,  bell..  Jill  i.o  (grs.  xv).  succ.  q.  s.  ut.  f.  pil.  No,  lOO, 
Signa  :  One  to  two,  later  three  to  (our,  or  even  six  pills,  in  the 
evening.) 

Compared  with  bromide  and  belbdonnn.  which,  accordinf^ 
to  our  opinion,  are  the  only  reliable  drugs  to  be  used  in  the  in- 
ternal treatment  of  epilcjjsy,  the  medicaments  which  have  been 
recommended  of  late  year.'! — curare  (considered  to  be  ineffect- 
ual by  Buurncvilte),  antipyrine  by  Beaumelz.  tinct.  simulo  (the 
(ruit  of  Cappnris  cortaaa).  which  has  been  used  by  While — do 
not  play  any  important  rSU;  and  only  deserve  a  trial  in  desper- 
ate cases.  With  my  trials  with  borax,  which  has  recently  been 
so  often  recommended,  I  have  been  somewhat  disappointed. 
On  the  other  hand,  amylene  hydrate,  recommended  by  Wilder- 
muth  (cf.  lit,),  must  be  given  a  trial  in  cases  of  distressing  bro- 
niism  or  if  the  attacks  increase  to  an  alarming  extent.  The 
watery  solution  «f  Kahlbaum's  preparation,  in  the  proportion 
of  one  to  ten,  is  the  best  to  use  in  doses  ol  from  twenty  to  forty 
grammes  (3  v  to  3x) — i.  e.,  two  to  four  grammes  (jss.  to  Z'\) 
of  the  drug  itself.  U  may  be  given  in  wine  or  water  or  in  a 
glass  of  beer,  well  shaken  up.  and  from  five  to  eight  grammes 
of  the  drug(3)ss.  to  3ij)may  thus  be  used  daily.  Flcchsig 
(Neurol.  Ccntralbl.,  1893.  7)  has  recommended  extr.  opii.  0.2- 
0.3  p.  d.  (3-4J  grains)  fur  six  weeks,  followed  immediiitcly  by 
large  doses  of  the  bromides.  I  have  no  personal  experience 
with  this  treatment. 

Surgical  interference  h.is  also  been  resorted  to.  at  first  wHh 
the  view  of  innuenciiig  or  dimitushinj^  the  amount  of  blood  in 
the  brain.  Several  times  ihc  carotids  have  been  ligatcd,  »od 
two  casts  thus  treated  were  reported  as  completely  cured 
(llasse,  Krankheiten  dcs  Nervensystems,  p.  397).  Owing  to 
the  great  difficulties  of  the  operation  and  the  gnivc  responsi- 
bility which  the  physician  takes  upon  himself,  this  measure 
will  only  in  exceptional  cases  be  made  use  of.  With  blecdii^. 
strong  revulsives  to  Ihc  skin,  such  as  Autcnrieth's  ointment  10 
the  shaved  head,  mr)xas.  setoiis.  blisters,  and  purgatives,  possi- 
bly the  same  results  can  be  obtained. 

More  recently  both  vertebral  arteries  have  been  ligatcd 
(von  Baracz.  cf.  lit.).  !n  my  clinic  the  ligation  of  one  verir 
bral,  the  right,  was  performed  several  months  ago  by  Jantckc 
without  any  noticeable  effect  upon  the  frequency  or  the  seW- 
ity  o(  the  attacks:  hence  the  patient  was  not  willing  tosulxnit 


EP/uwsy. 


S93 


the  ligation  of  the  other.  The  operative  treatment  ol  trau- 
Fina(ic  epilepsy  aims  at  the  removal  ol  bone  splinters  which 
press  upon  and  injure  the  brain  cortex ;  but  the  operation 
should  only  be  performed,  as  von  Rergmann  holds,  if  the  con- 
vulsions constantly  occur  in  the  same  groups  of  muscles  and 
extend  in  a  characteristic  manner,  or  if  transient  hcniipareses 
occur.  At  the  operation  the  affected  area  of  the  cortex  has  to 
be  carefully  excised.  If  the  attack  begins  like  a  flash  without 
an  aura  and  is  associated  with  opisthotonus,  etc..  operative 
measures  are  contraindicaled.  Neurotomy  of  the  sympnthetic, 
a  procedure  described  by  von  Jaksch  (Wicn  mcd.  \Vocbcn- 
schrift,  1S92, 16,  17),  has  produced  a  cessation  of  the  attacks  for 
several  months  in  a  number  of  instances;  but  wc  do  not  knovr 
whether  it  is  capable  of  bringing  about  a  permanent  cure. 

Marshall  Hall's  advice  to  perform  tracheotomy,  on  the 
ground  that  the  spasm  of  the  glottis  is  productive  of  the  as- 
phyxia and  the  clonic  spasm,  is  purely  and  entirely  of  histor* 
ical  interest.  The  operation  has  been  performed  several  times 
without,  of  course,  the  least  benefit  to  the  patient.  The  same 
may  be  said  of  the  cauterization  of  the  glottis  with  nitrate 
r>(  silver,  suggested  by  Brown-S6quard.  which  has  been  justly 
condemned  in  such  cases. 

In  connection  with  the  surgical  treatment  we  should  men- 
tion the  application  of  strips  of  cantharidal  plaster  around  the 
forearm  or  lower  leg  in  which  the  motor  or  sensory  aura  oc- 
curs. Only  when  the  aura  constantly  appears  tn  the  same 
member  can  any  success  be  expected  from  this  measure,  which 
has  been  recommended  by  Buzitard.  The  plasters  must  re- 
main  on  for  a  considerable  time.  Following  the  advice  of  Buit- 
zard,  I  have  ordered  the  application  of  these  plasters  in  some 
cases,  without,  however,  having  been  able  to  sec  any  good  re- 
sults. In  one  instance  of  partial  epilepsy  a  transfer  was  pn>> 
duced  by  the  application  of  the  plaster  (Hirt,  Neurol.  Central. 
bbtt,  1884,  I). 

Finally,  we  can  hardly  be  surprised  that  attempts  have  been 
made  to  combat  epilepsy  by  electrical  treatment.  L'nfortu- 
nately,  the  results  with  this  have  been  even  less  encouraging 
than  those  from  internal  medication.  Neither  the  attacks  them- 
selves nor  the  so-called  "epileptic  change  in  the  brain,"  the 
nature  of  which,  as  wc  have  above  stated,  is  still  obscure,  have 
been  influenced  by  It  in  any  way.  The  constant  current  was 
emploved  and  the  sympathetic  galvanized  by  passing  the  cur- 


594 


DISEASES  OF  THE  GES'f.RAL  NEKVOUS  SYSTKM. 


rent  from  one  mastoid  process  to  the  other,  and  attempt!) 
were  made  to  influence  the  cerebral  hemispheres,  and  more 
especially  the  motor  regions,  according  to  Erb's  method 
(Erb,  liandbuch  der  Electrolhcrapic,  p.  5S1).  In  other  cases 
the  current  was  passed  through  the  lobes  o(  the  thyroid 
ginnd.  as  Sighicelli  (Kiv.  sperim.  di  freniatr,  iSSS.  vol.  xiii,  3) 
has  more  recently  done,  but  in  none  of  them  could  any  last- 
ing success  be  remarked.  No  better  results  have  been  ob- 
tained with  the  faradic  current  in  all  its  different  modes  i>I 
application. 

Although  with  all  our  treatment  we  are  practically  power- 
less against  the  disease,  it  would  be  very  wrong  to  assume  that 
to  the  epileptic  the  physician  can  be  of  no  use  and  can  not  im- 
prove his  condition  in  any  way.    On  the  contrary,  there  is 
hardly  another  class  of  patients  affected  with  nervous  diseases 
who  require  so  much  a  physician's  advice,  and  hardly  another 
class  who  have  to  be  so  carefully  watched  by  him.    Above  all, 
attention  has  to  be  paid  to  the  general  condition.     The  bowels 
must  he  kept  regular  and  the  skin  and  muscles  stimulated  I0 
their  proper  activity  by  appropriate  cold-water  treatment  and 
home  gymnastics.     The  patient  should  constantly  be  wariiH 
against  every  kind  of  excess.     Too  large  a  supper,  a  few  glasses 
of  wine  or  beer  taken  too  quickly,  any  indigestible  food,  ex- 
cesses in  '.vHcre — all  these  may  give  rise  to  an  attack,  the  con- 
sequences of  which  arc  incalculable.    To  guard  against  these, 
therefore — in  other  words,  to  employ  prophylactic  measures— 
is  the  chief  task  of  the  physician  who  is  taking  charge  of  an 
epileptic.     Besides  this,  ihe  bromides,  or.  if  these  arc  not  suil- 
abic.  the  next  best  treatment,  should  be  begun.     Finally,  care 
must  be  taken  that  the  pnlicnt  does  not  hurt  himself  during  the 
fit.  and  against  this  he  should  be  protected  as  well  as  possible. 
All  tight  clothing  must  be  removed  and  all  ordinary  emergen- 
cies provided    for.     .\  regular  treatment  of   ihe  attack  iiieM 
we  do  not  possess,  and  all  attempts  to  cut  it  short  should  be 
avoided.     Even  inhalations  of  amyl  nitrite,  which  O.  Bergcr 
suggests,  chlorolorm.  and  similar  remedies  are  only  allownWe 
if  administered  with  the  greatest  caution,  and  it  would  be  bet- 
ter still  to  discard  them  entirely. 

Note. — Eclampsia  is  one  of  those  terms  which  up  to  the 
present  do  not  convey  to  our  minds  any  clearly  defined  clinical 
or  pathological  picture.     It  is  a  term  under  which  are  coinprc- 


I 


ECLAMPSIA, 


595 


H  as  IK 
Ktorti 


hcnclcd  the  most  heterogeneous  conditions  which  hnvc  not  the 
least  cotincction  with  each  olhcr.  If  a  woman  during  preg- 
nancy or  during  parturition  without  any  appreciable  cause 

iJBDnsciousness  and  (alls  into  convulsions,  which  may  recur 
times,  and  which  Ircquently  lead  to  a  fatal  issue,  we 
speak  of  eclampsia  gravidarum  or  parturientium.  tl  children, 
as  not  uncommonly  occurs,  have  paroxysms,  consisting  of  dis- 
tortions of  the  face,  trismus-like  clinching  of  the  teclh,  general 
ms,  and  more  or  less  marked  disturbances  of  consciousness, 
we  designate  the  affection  ae  eclampsia  infantum,  and  use  the 
same  term  if  at  the  onset  or  in  the  course  of  acute  diseases  or 
certain  intoxications  (more  particularly  lead  poisoning)  attacks 
occur  characterized  hy  (bilateral,  more  rarely  unilateral)  con- 
vulsions and  loss  of  consciousness,  which,  therefore,  difTer  clin- 
ically cither  not  at  all  or  only  slightly  from  the  genuine  epilep- 
tic seizures.  The  nature  of  the  attacks  is  as  obscure  as  their 
ictiology.  Whether  in  eclampsia  parturicntium  the  diminished 
excretion  of  urea  has  to  be  held  responsible  for  the  convulsions, 
And  ihcy  thus  are  to  be  regarded  as  ura:mic,  whether  in  the 
convulsions  of  children  reflex  action  plays  the  chief  rdie.  or 
whether  wc  have  to  deal  with  autointoxication  in  which  dia- 
cctic  acid  occurs,  in  the  urine,  or  whether  in  all  cases  the  pres- 
ence of  a  bacillus  is  necessary  (Gerdes.  cf.  lit.) — all  these  ques- 
tions have  to  be  left  to  future  investigations.  Every  one  ad- 
mils  that,  in  the  second  form,  dentition,  digestive  disturbances, 
or  intestinal  parasites,  play  a  certain  part,  yet  there  are  cer- 
tainly other  factors  which  deserve  consideration  in  this  connec- 
tion— for  instance,  heredity,  a  general  neuropJitbic  diathesis, 
the  health  of  the  parents,  and  the  possible  existence  ol  rickets. 
The  convulsions  of  children  (eclampsia  acuta  infantilis)  are 
extremely  common.  Clinically,  all  cases  of  this  kind  are  very 
much  alike,  whereas  aitiologically  difTcrcnt  cases  differ  greatly. 
In  a  given  case  we  shoiiUI.  first  of  all.  try  to  determine  whether 
wc  have  to  deal  with, anatomical  lesions  (of  the  cortex,  etc.), 
r  whether  these  can  be  excluded ;  and  only  by  the  most 
reful  examination  can  we  avoid  errors  and  are  we  able 
to  make  n  correct  diagnosis.  Conical  diseases  (cerebral  ith 
paralysis),  epilepsy,  spinal   paralysis  of  children,  the 

I  stage  of  acute  diseases,  etc.,  must  be  uken  into  cott- 

ilion. 
The  prognosis  is  always  doubtful,  both  in  adults  and  {a 
hitdren,  and  the  danger  is  usually  greater  in  pregnant  and 


inUlc 


596 


DISEASES  OF  THE  GENERAL  NERVOVS  SYSTEM. 


parturient  women  than  in  children.  Death  not  rarely  occurj 
during  the  convulsions,  as  we  have  said  above,  and  wc  may 
assume  that  out  o(  a  hundred  oiscs  of  this  kind  there  are  thirt)', 
forty,  often  fifty  who  die,  and  the  danger  increases  with  ibi; 
duration  of  the  labor  and  the  long  continuance  of  the  pains.  In 
children  a  fatal  issue  is  often  brought  about  by  a  spasm  of  Hie 
glottis,  rarely  by  exhaustion.  Recovery  frequently  is  incom^ 
plete,  and  there  may  be  left  some  psychical  disturbances,  amau- 
rosis or  disturbances  of  speech,  etc. 

About  the  trcAlment  of  eclampsia  the  opinions  are  even  at 
the  present  time  very  much  divided.    In  pregnant  or  parluri- 
enl  women  cold  affusions  in  a  warm  bath,  as  recommended  by 
Scanzoni,  also  the  application  of  large  cantharidal  plasters  to 
the  neck,  ought  to  be  resorted  to  as  soon  as  possible  ;  from  the 
nervines    wc   can    expect   nothing.      Mild    laxatives,   cautious 
venesection,  regulation  of  the  functions  of  diuresis  and  dia- 
phoresis arc  in  most  cases  indicated.    Often  we  have  no  time 
to  think  of  such  measures ;  in  urgent  cases  Veil  (cf.  lit.)  has 
recommended  large  doses  of  morphine,  beginning  with  three 
centigrammes  (circ.  gr.  ss.)  and  increasing  the  dose  tolwoor 
three  decigrammes  (grs.  iij-  grs.  ivss.)  a  day.    The  eclampsia  of 
children   is.  according  to  some — among  them  Henoch — beM 
treated  by  inhalations  of  chloroform,  which  will  soon  stop  the 
convulsions.     One  ought,  they  think,  to  first  cut  shoi;t  the  con- 
vulsions, and  then  proceed  to  find  out  their  cause.     Sometimes 
ihis  advice  is  good.  viz..  in  cases  in  which  there  exists  no  cere- 
bral lesion.     If  one  docs  exist,  or  if  there  are  grounds  for  stis- 
peeling  it,  the  inhalation  will  prove  to  be  of  no  use,  and  miy 
rather  have  a  bad   eScct.      It  will  therefore  be  necessary  to 
attempt  to  settle  this  question  by  as  short  an  examination  as 
possible.     If  wc  are  unable  to  make  up  our  minds,  a  tepid  baib 
and  careful  affusions,  vinegar  enemala,  or  evaporating  lotions, 
etc.,  to  the  skin  can  do  no  harm.     For  the  beginning  this  suf- 
fices ;  afterward  it  may  be  advisable  to  prescribe  ice  to  ihe 
head  in  congestive  conditions,  possibly  even  leeches  10  the 
head,  and  in  cases  where  collapse  seems  imminent,  vinegar  Cll^ 
mata.  strong  wine,  or  injcciions  of  ether.     The  nervines  may 
as  well  be  discarded  in  the  treatment  of  the  convulsions.  aS 
they  do  no  good  in  this  stage  ;  they  niay.  however,  be  used  later 
when  the  immediate  danger  has  passed.     Wrapping  the  chil- 
dren in  warm  moist  sheets  (after  the  method  of  PriessnJul 
while  ice  is  kept  to  ihe  head.  I  have  known  repeatedly  to  be 


EPnEPSY. 


597 


eflcctual.     On  the  whole,  even  ihcse  measures  are  not  rcltablc. 
and    lite  piit't    which    a  physician   plays   in  the  presence  of 
Heclampsia  ol  children  is  by  no  means  enviable. 

I 

■  Soun 


H>biR- 


I 


UTERATIIRE. 
1.  EPILGPSV. 

tJnwmcht.     ExjxrimenKllc  und  klinlKhc  Unicriuch.  iiher  Epileptic. 

Ulionucliril't,  UrcsUu,  1883.     (Coniaini  all  th«  oltkr  rrficrcncn.) 
Sourncvilltf,  Comtuuicn  et  S^las.     Rwherche*  clin.  ct  ih^rapeut.  xur  I'tjiilep- 

»ie,  ITiysiifw,  rte.     Paris,  f8«6.  vol*,  i-vi. 
Erlraine)cr.     Die  Principien  dcr  EpilrpiirlKh.-indlung.     Wlcsbsdcn.  iSSA. 
HotnCii.    B«ilr3|[  lur  Lvhre  t-on  (l«ii  ejiilvpiugeneii  Zonen.    Ccnintlbl.  f.  Ncrvcn* 

hcilk..  1S86.  No.  6 
OiMl>fcaw«ky.     Ucbcr  die  Alteralion  der  SeniibilitKl  bci  Epile]>tiK:hen.    MfiL 

ObonrtnM,  1886^  9. 
UnveirichL     Uebcr  (rt|>erimcnlrllc  Epittpsie.     Vcrtiandl.  des  CongTCMO  fitf 

inncn  Med..  Winbatkn,  \t%j. 
LciiicsikMrl     Wteiier  tned.  Wucbenichr..  1SS7.  j.  6.    (On  Epilepitic  EtpihalenU^) 
Vnier.     DcuiMhes  Arch.  f.  klin.  Med..  1887.  ltd.  %\.  Hcfl  3.  4. 
V.  tkijETiunn.    Die  operative  nchnndlung  dci  imunuii.iclicnEpileiiae.    Deui»che 

mlUiarilnil.    Zig..  18S7.  ivi.  8. 
BoatnevUle  el  Brioon.     Dc  I'tpilepsje  procunivc.    Arch,  dc  NeuroL,  NorcmbK; 

18SK.  xvi. 
Alane.  )>.     hMgr,  mfi)..  tSSS.  Kr.  43. 
Htif.     NeuToi  Ccntralbl..  |8S3.  vil.  5.    (Connection  of  Epilepsy  wtlh  ihc  Evcrr- 

lion  vS  Ure^) 
BtniwanKFr.     Arch.  f.  Pi>'ch.  a.  NcTvenkrankb.,  1888.  xii,  ).    {Experinicnial 

Studies  on  the  Paihogenesit  of  the  AiMck.) 
Foumier.    (iai.  dn  hAp..  18S8.  Ixi.  10;.     (Epilepty  nnd  Syphilis.) 
Lcmoine.     Sur  U  pAlho£{aie  de  r^>ilcp«iie.     t^ot;r.  ni^l..  iSSS.  16. 
LjMbmc.     Uchcr  procuruve  Epiteptir.     Inicmal.  klin.  KuntUchau.  1889. 
V.  Baraci.     Wienct  tned.  Wocheokchr..  r889.  7,  S.    (Ugaticm  of  the  Vcnebrat 

ArleriM.) 
fM.     Note  wir  I'tini  iVk  forreii  et  mit  le  iremhletneni  cha  ten  fjiitepliquca 

aprfa  les  jiita4|iia.     Nour.  iconof^.  de  U  Sjdpjir..  rSSq.  ii.  1. 
Wigmwonh  an'l  llickcrton.    On  n  Conncciton  between  Epilepsy  and  Errors  of 

Ocular  Refraction.     Drain.  1889.  xliv,  p.  468. 
WlMcmttiih.     Am)knhyiiral  inil'n  Kp>lcp»ic.    Neurol.  CcniralbL.  1889,  1$. 
Pfclia«hv.    Tbtse  de  I.yon.  1S89. 
ZacdiL    Lo  spcrim..  1890.  Jan. 
Meanig.     Deutsche  med,  Woclicnachr.  189a  36. 
Mairel.     Progr.  mtd.  1891.  41.     (Trratmer»l  wiih  Doran.) 
Eulenlnirs.      Uel>et  den  jelii|[en  Stand  dcr  Epilepii&behandkini;.      Tbcrap. 

Monauh.  1891,  \\.  11.  13. 
Cerner  and  Sachi.    The  Surgical  Treatment  of  Epilepsy.     Am.  Jotim.  Med. 

ScL  1691.  November. 


598        DISEASES  OF  THE  CEHERAL  NERVOUS  SYSTEM. 

Ktimmel.    Deutsche  mecL  Wochenschr.,  1892,  23. 

Babes.    Ibid.,  1893,  12. 

Eloy.    La  mtthode  de  Brown-.S<quard.    La  mMication  oirhidique,  thyrradinM, 

puicrfatique,  capsuUire  et  cirtbrale,  ks  injections  d'cxtraits  organiqiwi,  la 

transfusion  nerveuse.    Paris,  1893. 
PoehL     Spcimin  bd  Autmntoxication.     Berliner  Idin.  Wochenschr.,  1893,  3& 
Serin.     Deutsche  med.  Wochenschr.,  1893,  41. 
Beekhaus.   Ueber  den  Einfluss  intercurrenter  Kiankhciten  und  phyaol.  Processe 

auf  die  Epilepsie.     Inaugnr.-DisserL,  MOnchcn,  1893, 
Bouraeville  H  Cwnet    Pn^.  niCd.,  1893,  49,  5a    (.Spcrniin  Injections.) 

h.  JatJUmUn  EfUrftj. 

Unger.    Wiener  med.  Blltter,  1886,  xi.  40-^44.     (Jacksonian  E[»Ieps]r  in  Onl- 

dren.) 
Mendel.    Ueber  Jaclcstm'sche  Efnlepsie  und  Psychose.     Allgem.  Zdtschr.  I 

Psych,.  1887,  44,  3. 
ChaufTaid.    De  rurfmie  convulsive  i  Torme  de  I'i^Hlepsie  Jacksonieniw.    Arch. 

g<n<r,  de  mtA.,  July,  1887,  pp.  5  tl  stq. 
Bouchard.    Les  auto-intoxications  dans  les  maladies.    Paris,  1887. 
Lloyd.    Boston  Medical  and  Surreal  Journal,  October  15. 1888,  cxix.    {Cure  bf 

trephining;  and  incising  the  Motor  Region.) 
Lowenfeld.     Ueber  Jackscm'sche  Epilepsie.     MUnchener  med.  Wochenschr, 

1888.  XXXV,  48. 

Pitres.     Revue  de  mM.,  1SS8,  viii,  8,     (Oioical  EquivalenU  of  Jacksonian  Epi- 
lepsy.) 
Jackson,  Hughlings.     Brain,  July.  1888,  xi. 
Berbez.     Gaz.  des  h6p.,  1888.  50. 

II.  Eclampsia. 

Lewandowski.    Berliner  klin.  Wochenschr,  1885.  xxii,  37, 

Ballantyne.    Sphygmographic  Tracings  in  Puerperal  Eclampsia.    Edinb.  Md. 

Journ.,  May,  1885,  xxx,  p.  1007. 
ProuK.    On  the  Treatment  of  Eclampsia  Infantum.    Bull.  g^n^.  de  thirap,,  Mif 

15,  1885.  cviii.     (Recommends  belladonna  and  chloral  hydrate.) 
Rosenstein,  L.     Die  Pathologic  und  Therapie  der  Nierenkrankheiten.    Berlin. 

1886,  3  Aufi. 
Soltmann,  0.    Eclampsia  infantum.     Real-Encyclopadie  der  gesammten  Heil- 

kunde.    Wien  und  Leipzig,  1886. 
Virchow,  R.     Ueber  Fettembolie  u.  Eclampsie.     Berliner  klin.  Wochenjchr.. 

1886,  xxiii,  30. 
OslholT.    BeitrSge  zur  Lehre  von  der  Eclampsie  und  UiStnie.    v.  Volkmann's 

klin.  VortrSge,  1886,  266. 
Stumpf.    Miinch.  med.  Wochenschr.,  1887,  xxxlv,  35,  36. 
Pfannenstiel.     Cenlralbl  f.  GynSkoI.,  1887,  xi,  38.     (Death  from  Apoplexy.) 
Baginsky.     Archiv  f  Kinderheilk.,  1S87,  xi,  1.     (Acetonuria  in  Eclampsia.) 
Veil.     Ueber  die  Behandlung  der  puerperalen  Eclampsie.     Volkmann's  klm. 

Vortt3ge,  1887,  No.  304. 
Hermann,  Ernest.     Transactions  of  the  Obstetrical  Society  of  London  for  the 

year  1887,  vol.  xxix,  pp.  S39-548.     London,  1888, 


ECLAMPSIA.  5£)C) 

Lantos.     Beitr^se  lur  Lchre  von  der  Eclampsie  und  Albuliiinurie.    Arch.  r. 

Gynilkol.,  1888,  xxxii,  3.  p.  364. 
Feustell.     BeitrSge  zur  Pathologic   und  Therapie  der  puerperalen  EcUmpsie. 

Inaug.-Diss.     Berlin,  18S8. 
Love.     Weekly  Medical  Review,  iSSo,  xix,  i.     (Eel.  infani.) 
Olshausen.    Deutsche  Med.-Ztg.,  1891,  103;  and  1892,  9. 
Herff.     Miinch.  med.  Wochenschr.  1891.  5. 
Gcrdes.      Ueber  den  Ec lam psie- bacillus,  etc.      Eleutsche  med.  Wochenschr., 

1892,  i6. 
Hofmeister.     Zur  Charakteristik  der  Eclampsie-bacilius  Gcrdes'.     Fortschr.  d. 

Med.,  1893,  II,  13. 
Favre.     Virchow's  Archiv,  1893,  cxxvii,  i. 
Diihrssen.     Arch.  f.  GynSk.,  1892.  Heft  3. 
Haegler.     Centralbl.  f.  GynSk.,  1892,  ji. 
Doderlcin.     Ibid.,  1893,  i. 


CHAPTER   IV. 

BYSTERO-EPILEPSY — MAJOR    HYSTERIA — HYPNOTISM — TREATMENT  BV 

SUGGESTION. 

The  reason  why  we  have  not  treated  of  the  disease,  we  are 
about  to  describe,  in  immediate  connection  with  hysteria,  but 
have  placed  it  after  the  chapter  on  epilepsy,  is  because  the  "at- 
tacks" of  hystero-epilepsy  appear  to  the  observer  as  a  result, 
or  perhaps  we  had  better  say  as  a  sort  of  mixture,  of  hysteria 
and  epilepsy.  It  would,  however,  be  a  mistake  to  infer  from 
this  that  the  affection  has  any  close  physiological  or  patholog- 
ical connection  with  epilepsy.  It  is  more  likely  that  we  ought 
to  regard  it  as  a  higher,  or  indeed  the  highest,  grade  of  hys- 
teria (cf.  page  553). 

The  "  major  attacks "  have  been  studied  exclusively  bv 
Charcot  in  the  Salpetrifere.  To  him  alone  and  some  of  his 
pupils,  more  particularly  P.  Richer,  we  owe  our  knowledge  of 
their  nature  and  characteristics,  and  of  the  rules  and  definite 
laws  which  they  appear  to  follow.  Almost  every,  nay,  we  can 
well  say  every  publication  on  hytero-epilepsy  that  did  not 
emanate  from  the  Salpetrifire  was,  at  any  rate,  based  upon 
Charcot's  observations  and  communications,  and  hardly  any- 
thing new  has  come  from  any  other  source. 

The  attacks  can  usually  be  divided  into  four  distinct  peri- 
ods, though  one  or  other  of  them  may  so  predominate,  as  re- 
gards its  duration  and  intensity,  that  the  rest  are  somewhat 
obscured.  The  first  period  embraces  the  epileptiform  attacks; 
the  body  is  suddenly  shaken,  respiration  stops,  the  palicnl 
lets  fall  anything  she  happens  to  be  holding  in  her  hands,  and 
is  thrown  to  the  ground.  She  is  now  seized  with  general 
convulsions  or  there  develop  rapidly  extensive  contractures 
affecting  almost  all  the  voluntary  muscles.  In  the  second  stag^c, 
which  immediately  follows  this,  the  patient  is  bounced  up  .ind 

down  in  bed,  she  assumes  marvelous  positions,  stands  on  her 
600 


i/yS  TERO-BFllEPS  K. 


601 


'  head,  curves  the  body  in  the  form  of  an  arch  {are  He  tcrde), 
and  howls  and  roars  at  the  same  lime  like  a  wild  beast.  This 
is  the  period  of  major  movements,  "clownism."  It  is  fol- 
lowed immediately  by  certain  hallucinations,  under  the  influ- 
ence of  which  the  patients  assume  postures  indicative  of  the 
most  varied  passions,  the  "aitiiuiies  patsiotttllcs"  of  the  French. 
The  face  takes  on.  according  to  the  particular  hallucination, 
nn  expression  of  anger,  rage,  devotion,  love,  voluptuousness, 
curiosity,  pain,  etc.,  which  would  give  us  the  impression  that 
the  patient  is  passing  in  her  mind  through  a  period  of  her  life 
the  details  of  which  are  unusually  vivid  in  her  memory.  The 
postures  and  expressions  may  change,  although  sometimes 
they  remain  the  same  throughout  this  stage.  That  of  the 
"crucified  "  has  obtained  a  certain  degree  of  celebrity,  because 
it  seems  to  be  particularly  frequent.  Finally,  the  fourth  stage 
is  marked  by  a  delirium,  in  which  hallucinations  recur  with 
the  greatest  persistency,  some  patients  imagining  they  see 
animals,  others  terror-inspiring  objects  of  different  kinds,  and 
so  forth.  Automatic  movements  are  nol  rare;  sometimes  an- 
aesthesias or  at  least  analgesias  arc  noted.  This  delirium  re> 
sembtcs  in  many  respects  an  alcoholic  intoxication.  The  dura- 
lion  and  frequency  of  the  attacks  %'ary  greatly.  Some  only 
last  from  one  to  hvc  minutes,  and  recur  ten.  twenty,  or  even 
one  hundred  times  a  day  {^tat  dt  ma/).  It  is  a  characteristic 
feature,  and  one  very  valuable  in  the  differential  diagnosis,  that 
firm  pressure  upon  the  ovaries  invariably  suffices  to  cut  short 
an  attack. 

If  this  prenture  is  exerted  conntantly,  a%  can  be  done  by  meant 
of  belts  provided  with  pads,  the  iitUick^  may  l>c  ke|)t  ulT  fur  quite  a 
considerable  time.  At  llie  celebrated  t>all  which  every  year  at  mi- 
carfmf  is  given  to  the  hysterical  and  bystcro-cpiicptic  patients  of 
the  Sali>^triire,  in  which,  of  course,  only  females  take  part,  each 
dancer  wears  her  belt.  If  this,  owing  to  the  movements  in  danc- 
ing, slips  from  it«  proper  place,  no  that  the  prexsure  ih  taken  off 
the  ovaries  even  for  a  moment,  a  major  attack  comes  on,  and  the 
patient,  twisting  and  iiiming  herself  and  presenting  the  most  in- 
crcdit>lr  (tisloilions,  is  removed  from  the  ball-room,  without  causing 
the  least  Interruption  in  the  dancing. 

The  outlook  for  complete  recover)"  in  major  hysteria  is  not 
fttvorsble.  All  attempts  to  cure  the  patients  remain  in  many 
{ostances  fruitless,  as  we  may  observe  in  the  Salp£tri^re,  where 


602        D/SEMS/iS  OF  THE  GEXEHAL  XERVOUS  SYSTEM.        V 

some  palients,  in  spite  o(  the  best  care  and  the  most  excellent 
treatment,  remain  (or  years  without  presenting  any  marked  or 
latiling  improvcmi-iit  cither  with  regard  to  the  violence  or  the 
Irequency  o(  the  attacks. 

Sometimes,  especially  if  the  patients  come  early  enough 
under  the  care  of  the  physician,  inimcdiiite  removal  from  their 
homes  into  an  instituliuii  docs  much  good.  The  attacks  become 
rarer  and  cease  entirely  after  a  few  months.  The  treatment  in 
these  institutions  consists  in  the  "feeding  system,"  which  we 
have  menrioncd  on  jKige  566.  as  well  as  the  ice-cold  douches, 
to  which  we  have  also  alluded  above. 

The  brilliant  success  o(  Charcot  in  the  treatment  of  hystero- 
epilepsy  i<i  due  to  these  three  factors:  (1)  The  removal  Irom 
home,  (3)  the  cold  douches,  and  (3)  the  feeding  system.  With 
the  removal  of  the  ovaries,  the  use  of  static  electricity  and  the 
magnet,  the  results  have  been  shown  to  be  much  less  favorable, 
and  we  may  consider  that  these  procedures,  so  far  as  the  treat. 
raent  of  the  major  attacks  goes,  have  in  the  main  been  dis- 
carded (cf.  the  references  to  mctallotherapy). 

Reliable  and  correct  as  are  the  descriptions  given  by  the 
Charcot  school  of  the  major  attacks,  which  wc  may  incidenLil- 
ly  remark  are  very  rarely  seen  in  Germany,  accurately  as  wc 
can  follow  up  the  different  phases  or  periods  of  the  attack  in 
many  such  palients.  we  slill  must  be  very  careful  in  accepting 
the  accounts  of  the  influence  of  hypnotism  upon  hystero-epi- 
leptics  and  the  conditions  produced  thereby, 

In  the  Salp^lri^rc  the  patients  were  hypnotized  by  means 
of  fixation  of  the  eyes,  by  the  action  of  a  bright  light,  or  the 
sound  of  an  instrument  called  a  tam>tam,  or  by  similar  means; 
and,  as  every  one  must  know  who  has  been  present  at  Charcot's 
experiments,  certain  individuals  were  hypnotized  in  a  very  few 
seconds.  According  to  Richer,  who,  as  we  said,  has  made  the 
most  careful  studies  nf  this  subject  in  conjunction  with  Char> 
cot.  which  appeared  in  various  numbers  of  the  Arch.de  Neurol, 
from  i88t  to  1883,  there  may  be  distinguished  four  different 
stages:  (1)  The  cataleptic.  (3)  the  stage  of  suggestion,  (3)  ttic 
stage  of  lethargy,  (4)  the  stage  of  somnambulism. 

In  catalepsy,  whether  artificially  produced  or  whether  oc- 
curring spontaneously,  as  it  does  in  hysteria  in  very  exceptional 
cases,  the  members  of  the  body  remain  in  any  position  tnia 
which  they  have  been  put.  Thus,  if  wc  passively  bend  the  arm 
at  the  elbow  and  raise  it  up,  it  remains  fixed  va.  this  position. 


L 


HYPNOTISM, 


603 


\ 

I 
I 


I 
P 


I 
I 


Flexion  or  extension  in  any  joint  can  be  produced  without  (he 
slightest  resistance  on  the  part  of  ihc  patient — " fitxtbililas 
(crea " ;  even  the  most  unusual,  uncomlorUble,  and  strangest 
attitudes  arc  retained  without  any  difficulty.  How  (his  most 
remarkable  regulation  of  the  necessary  innervation  is  brought 
about  we  do  not  know  as  yet,  neither  have  we  Ihe  slightest 
(grounds  whereupon  to  base  any  theory  by  which  we  could 
seek  to  explain  this  condition,  which  is  not  infrequently  also 
associated  with  disturbances  of  consciousness. 

The  state  of  hallucinations  excited  by  slight  stimulation  of 
the  special  senses  (in  reality  by  suggestion),  and  designated  as 
automatism,  is  characterized  by  total  analgesia.  The  eyes  re- 
main open,  and  it  is  a  remarkable  (act  that  positions  which  arc 
given  to  the  body  evoke  the  corresponding  expressions  of  the 
face,  and,  vUt  tvrsa,  the  body  assumes  the  corresponding  posi- 
tion if  on  the  face,  by  faradization  of  the  muscles,  a  certain  ex< 
pression — e.  g.,  of  sadncsn,  hilarity,  spite,  voluptuousness,  or 
fear — is  produced.  Dy  firmly  shutting  the  eyes  of  the  patient 
it  is  claimed  that  the  second  stage  may  be  converted  into  the 
third,  the  automatic  into  the  stage  of  lethargy.  In  this  latter 
(he  excitability  of  all  the  nerves  and  muscles  is  greatly  in- 
creased, so  that,  for  instance,  slight  pressure  upon  the  stem  of 
the  facial  nerve  suffices  to  bring  about  contractions  in  all  the 
muscles  supplied  by  that  nerve.  The  ooniraclion  l.-tsts  much 
longer  than  the  stimulation,  and  therefore  takes  on  a  tetanic 
charaaer.  At  the  same  time  the  patient  is  apparently  com- 
pletely unconscious,  and  there  is  total  anwslhesia.  Now  it  is 
impossible  to  create  hallucinations.  The  tendon  reflexes  are 
greatly  cxag^rated.  If  we  now  stroke  the  patient  lightly  over 
the  top  of  the  head,  the  hypercxcitability  vanishes  and  a  new 
stage  comes  on,  that  of  the  hysterical  5omn.-imbulism.  In  this 
condition  the  patient  is  susceptible  to  external  influences,  inas- 
much as  the  organs  of  special  sense  are  performing  their  func- 
tions to  a  certain  degree.  He  answers  questions  (with  clo&ed 
eyes  and,  .is  it  were,  aulomaticnily).  carries  out  instructions, 
and  so  forth.  By  tncal  stimulation  of  (he  skin — for  instance, 
by  vigorous  rubbing — we  are  able  to  produce  omtraclures. 
By  energetic  pressure  upon  the  eyes  the  patient  can  again  be 
transferred  from  the  somnambulisiic  lo  the  lethargic  condi- 
tion. The  occurrence  of  hallucinations  and  illusions  is  not 
constant. 

For  a  long  lime  the  theory  that  this  condition  was  peculiar 


6o4        DISEASES  OF  THE  CS-VEKAL  XEEt'Ol/S  SYSTEM.         ^ 

to  hysterical  patients  when  hypnotized,  jit&t  as  the  other  condi* 
tions  were  peculiar  to  them  when  awake,  was  nut  doubted,  nnd 
the  so-called  major  hypnotism,  as  the  hypnosis  ol  the  hystcro- 
epileptics  was  called,  created  everywhere  great  astonishment 
and  admii'ation,  especially  in  those  who  could  actually  observe 
it  in  Charcot's  clinic  at  the  SalpClriiirc.  It  is  only  more  re- 
cently that  doubts  have  been  raised  about  the  correctness  o( 
these  claims  of  Charcot.  Many  are  inclined  to  believe  that  the 
above-described  four  stages,  which  the  hypnosis  ol  hysteria 
presents,  can  be  produced  in  any  hypnotized  individual,  and  not 
only  in  those  who  are  hysterical. and  that  therefore  the  "major 
hypnotism  "  is  no  neurosis  at  all  and  has  no  characteristics  of 
its  own.  Whether  the  members  of  the  Salpfiriire  school  will 
be  able  to  defend  their  former  assertions,  and  what  arguments 
they  can  put  forth,  and  whether  they  will  be  able  to  continue 
to  uphold  the  existence  of  dilTcrcnt  .stages  of  hysterical  hypno- 
sis after  all  possible  sources  of  error  have  been  excluded,  we 
can  not  tell.  Mow  they  will  be  able  to  demonstrate  the  ncuro- 
muscular  hyperexcilabiliiy  as  physiological  and  not  perhaps  as 
produced  voluntarily,  as  many  are  inclined  to  think  now,  has  to 
be  left  to  the  future  to  decide,  and  more  especially  to  the  abso- 
lutely necessary  repetition  of  the  experiments.  Here  it  is  our 
part  only  to  show  on  what  grounds  Charcot's  doctrines  have 
been  attacked,  what  proofs  have  been  brought  forward  to  show 
his  doctrine  to  be  untenable,  and  to  state  clearly  the  stand- 
point which  is  now  generally  held  as  regards  the  origin  and 
the  phenomena  of  hypnotism. 

This  is  not  the  place  to  enter  into  a  consideration  of  th; 
mysticisms  and  the   charlatanisms  of  a  man  who  a  hundred 
years  ago  propounded  the  doctrine  of  the  so^ialled  magnetic 
fluid,  which,  emanating  from  the  magnetizcr.  and  being  capable 
of  spreading  itself  in  space,  could  receive  all  impulses  of  nK>> 
tion  and  impart  them,  but  as  a  matter  of  historical  interest  and 
justice  we  arc  compelled  to  state  lh.it  it  was  Franz  Mesmer, 
born  in  1733,  who  gave  the  first  impulse  to  a  movement  which, 
founded  on  his  arrogant  and  wild  teachings,  has  passed  through 
manifold  phases,  and  to-day  still  exists,  now  that  it  has  been 
found  possible  to  sift  the  chaff  from  the  wheat.    Magnetism  ti> 
day  has  succumbed  to  the  same  fate  as  alchemy,  and  has  been 
discarded,  but  both  bore  good  fruit;  the  one  opened  the  door 
to  chemistry,  the  other  to  hypnotic  suggestion  (Bcrnheim). 

The  fact  that  there  is  no  such  thing  as  a  magnetic  fluid,  that 


UYPKOTiSM. 


hypnosis  and  the  phenomena  occurring  during  it  arc  entirely 
subjective  in  nature,  and  arc  to  be  attributed  to  external  in- 
fluences upon  the  nervous  system,  was  disco%*crcd  by  J.imes 
Braid,  of  Manchester,  in  1S41,  and  we  are  justified  in  opposing 
"  braidism  "  to  ■•  mesmerism  "  just  as  wc  oppose  truth  10  lalse- 
hood.  Braid  concentrated  the  attention  of  those  he  wanted  to 
put  to  sleep  by  making  them  keep  their  eyes  fixed  upon  a 
bright  object ;  he  assumed  that  the  faligue  of  the  levator  pal- 
pcbne  supcrioris,  which  was  simuluineously  produced,  was  the 
cause  of  a  sleep  during  which  the  imaginatiun  was  so  active 
that  spontaneous  mental  pictures,  as  well  as  impressions  im- 
parted by  others  (■■  suggestions  ").  obtained  the  power  of  actual 
perceptions.  If  such  impressions  are  imparted  frequently,  ac- 
cording to  his  observation,  a  certain  habit  is  established,  so  that 
it  becomes,  caUrh  paribus,  easier  and  easier  to  put  the  patient 
to  sleep.  Braid  was  also  acquainted  with  the  fact  that  corre- 
sponding sensations  and  passions  can  be  produced  in  hypno- 
tized persons  by  putting  (heir  facial  muscles  and  their  extremi- 
ties in  appropriate  positions,  although  he  made  no  attempt  to 
cxpbin  these  phenomena  physiologically.  This  has  only  been 
done  quite  recently,  and  even  then  the  study  was  evoked  only 
by  a  purely  external  stimulus,  viz.,  the  exhibitions  which  a 
Danish  magnetixcr  named  Hansen  gave  in  the  German  cities. 
The  impression  which  these  made  upon  the  public  at  large  was 
of  such  an  exciting  and  uncanny  nature,  and  the  whole  thing 
was  so  puzzling  to  men  of  learning,  that  physiologists  and  neu- 
ropathologists were  impelled  to  approach  the  subject  to  see 
whether  the  apparently  supernatural  and  inexplicable  could 
not  be  traced  to  natural  physiological  laws.  One  ol  the  most 
prominent  physiologists.  Heidenhain.  put  forward  the  theory 
that,  by  weak  but  steady  stimulation  of  the  nerves  of  special 
senftc,  the  cells  of  the  cerebral  cortex  were  induced  to  discon- 
tinue for  a  time  their  activity,  thus  causing  the  subcortical 
reflex  centres  to  fall  into  a  slate  of  irritation,  partly  because, 
owing  to  this  inactivity,  the  reflex  inhibitory  inlluencc  of  the 
cortex  was  suspended,  and  partly  because  every  impulse  reach- 
ing the  brain  was  propagated  to  a  limited  area  which  nece»- 
•arily  led  to  stronger  excitation  of  the  part  of  the  cxcito- 
motor  apparatus  Ix-longing  to  it.  With  this  ingenious  hypoth- 
esis, which  many  others — Weinhold,  of  Chemnitz,  Grtltzner, 
IRumpf,  Bcrgcr,  and  Schneider  among  them — have  accepted, 
wc  had  to  be  satisfied,  and  for  the  physiologists  the  interest 


eo6        DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 


in  ifae  matter  was  thus  exhausted,  and  the  subject  was  aban> 
duncd. 

In  patliolc^y  and  general  practical  medicine,  including,  aa 
we  shall  see,  surgery  and  obstetrics,  the  matter  obtained  a  new 
and  increased  significance  when,  mure  recently,  the  observa- 
tions, which  twenty  years  before  had  been  made  by  an  investi- 
gator in  Nancy,  Li^-bcault,  were  again  taken  up.     Li^bcault  had 
published  u  work  in  t866  with  the  title  Du  sommeil  et  des 
^tats  analogues  considdr£s  surtnut  au  point  du  vuc  dc  I'actioft 
du  moral  sur  le  physique,  in  which  he  expanded  the  observa- 
tions of  Braid ;  he  showed  that  it  only  needed  a  concentra- 
tion of  the  attention  un  a  single  idea,  viz.,  the  idea  of  going 
to  sleep,  to  make  the  body  immobile,  and  to  produce  a  certain 
kind  of  sleep,  which,  however,  differs  from  the  physiological 
form  (suggestion  theory  of  hypnotism).     The  same  author  was 
the  first  to  show  that  neither  an  optical,  an  auditory,  nor  a  tac- 
tile stimulus  was  necessary  to  bring  about  hypnosis,  but  that 
the  impressions  from  outside,  the  suggestions  that  the  sleep 
must  and  will  occur,  arc  perfectly  sufficient ;  the  hypnotiicd 
sleeper — whose  ideation,  in  contradistinction  to  that  of  the 
ordinary  sleeper,  remains  in  contact  with  that  of  the  hypnotiicr 
^-can  be  influenced  by  the  latter  in  his  ideas  and  actions.    The 
fundamental  observations  of  Li^bcault  remained  unappreciated 
for  twenty  years ;  the  work  was  not  read,  hypnotism  remained 
a  curiosity,  and  it  seemed  inadvisable  for  a  scicntihc  physician 
to  occupy  himself  with  it.  unless  he  were  willing  to  gain  for 
himself  the  reputation  of  a  charlatan  or  of  a  man  whose  actions 
were  suspicious  or  even  dangerous.    The  credit  of  bringing 
to  light  the  work  of  Li^bcault,  wc  might  almost  say  of  having 
discovered  Li«5be.iull,  belongs  to  Bcmheim.  of  Nancy,  whose 
merit  was  still  more  augmented  by  his  own  c«>ntributions  to 
the  subject,     lie  published  his  first  article  on  hypnotism  in 
18S4,  and  with  his  book,  I>e  la  suggestion  ct  de  ses  applica- 
tions k  la  thirapeutique,  he  has,  to  use  a  popular  but  expressirt 
phrase,  "  hit  the  nail  on  the  head."     He  and  the  Nancy  school 
have  to  be  regarded  as  the  founders  of  the  successful  attempt 
to  make  a  5ystem.iiic  use  of  hypnotism  for  therapeutic  pur- 
poses, and  should  the  treatment  by  suggestion  ever  be  gen- 
erally accepted,  and    beci)me   an    integral  part  of  our  ttier* 
peutic  armamentarium,  althnugh  at  present  there  seems  liit'< 
prospect  of  this,  Bernheim  will  be  mentioned  as  its  scientific 
originator.     For  the  adverse  attitude  which  prominent  c)in>- 


I 


I 


I 


HYP.VOr/SM. 


607 


I 


I 


ctahs  and  physicians  in  general  show  even  to^ay  toward  ihe 
treatment  by  stiggeslioii  there  exist  a  variety  ol  reasons  which 
it  is  nut  necessary  to  discuss  in  the  present  work.  This  vne 
point  only  need  be  emphasized  here.  In  order  to  employ  the 
treatment  by  suggestion  with  any  real  success,  not  only  lime 
and  patience,  but,  above  alt,  much  experience  is  needed,  which, 
of  course,  not  every  one  possesses.  Curiously  enough,  there 
exists,  even  among  medical  men,  a  widespread  naive  opinion 
that  anybody  can  hypnotize,  and  that  the  treatment  by  suggest 
tion  is  a  branch  of  therapeutics  that  comes  to  a  man  without 
any  study  or  practice.  It  is  interesting  and  even,  in  a  way. 
amu&ing  to  see  how  many,  especially  of  the  younger  physi< 
cians,  who  have  had  a  chance  to  obscr\-e  the  results  of  the 
treatment,  make  a  few  attempts  at  random,  and  if  they  do  not 
succeed  almost  from  the  very  first  in  obtaining  good  results, 
immediately  begin  to  talk  and  write  about  the  treatment  as 
"humbug,"  which  once  for  all  should  be  regarded  as  unscien- 
tific. The  habitual  use  of  hypnotism  is  denounced  as  danger- 
ous, the  condition  produced  as  a  pathological  one  which  may 
ruin  the  whole  organism,  or  at  least  the  nervous  system,  etc. 
Nobody,  certainly,  who  is  acquainted  with  hypnotism  will 
deny  that  pathological  conditions  may  be  produced  by  it  and 
that  it  may  be  dangerous,  but  is  this  a  ground  upon  which  to 
simply  discard  it  without  a  further  hearing?  Have  we  given 
up  chloroform  narcosis  because  it  has  now  and  tlien  proved 
dangerous  in  the  hands  of  the  inexperienced  and  careless  oper- 
ator,  or  have  we  given  up  the  use  of  morphine  on  account  of 
Its  poisonous  action  when  used  too  Irecty  and  for  loo  long  a 
period  of  time?  As  in  all  other  measures,  wc  must  recognize 
here  indications  and  contraindic:itions,  and  this  c:tn  be  done  in 
the  majority  of  cases  without  dilhculty  ;  and  as  everything  in 
this  world,  especially  in  the  practice  of  medicine,  even  the 
smallest  Ojwralion — that  of  vaccination,  for  example — has  to  be 
learned,  so  the  art  of  hypnotizing  has  to  be  acquired,  and  one 
can  expect  to  comprehend  the  subject  and  to  have  success  with 
the  pmciice  of  the  treatment  by  suggestion  only  after  careful 
and  painstaking  study. 

il  is  very  important  to  remember  that  it  is  never  necessary 
to  produce  sleep  in  order  I0  achieve  therapeutic  results,  and 
the  terms  "hypnosis,  hypnotizing,  hypnotism."  are  therefore 
not  well  chosen.  Only  a  moderate  degree  of  bodily  and  men- 
ul  fatigue  suffices  for  the  production  of  excellent  results,  aivi 


6o8        DISEASES  OF  THE  GENERAL  NEHVOVS  SVSTEAf.  ^ 

it  is  entirely  unnecessary  to  bring  about  a  liypnolic  cundilioB 
with  amnesia,  which,  if  n-ptatcd  frequently,  tvould  unduubu 
edly  have  a  bad  influence  upon  the  patient.  This  mild  degree 
of  fatigue  is  produced  as  fuUuws:  The  patient,  having  been 
placed  in  a  conifuriahle  armed  chair,  is  asked  to  think  of  noth- 
ing else  than  of  going  to  sleep.  Wc  "  suggest"  to  him  that  be 
is  beginning;  to  feel  tired,  that  he  is  no  longer  able  to  cotn- 
plctcly  open  his  eyes,  which  arc  already  beginning  to  close, 
etc.  At  the  same  time  he  is  asked  to  look  steadily  at  two  fin- 
gers uf  the  hypnotizer,  which  at  first  arc  held  directly  in  front 
of  his  eyes,  but  arc  gradually  lowered,  by  which  procedure  the 
closing  of  the  eyes,  which  wc  desire,  is  easily  accomplished. 
Now  either  a  difficulty  in  moving  the  arms  or  legs  is  suggested, 
a  loss  of  sensation  in  certain  parts  of  the  skin,  or  some  similar 
idea.  The  tone  of  voice  in  which  all  this  is  said  should  not  be 
loud,  but  monotonous.  The  same  suggestions  must  again  and 
again  be  repeated,  and  care  must  be  taken  that  disturbing 
noises,  the  slamming  of  doors  or  the  striking  of  clocks,  and 
such  like,  be  not  heard,  so  that  the  mind  of  the  patient  may  as 
much  as  possible  be  conccniralcd  upon  the  hypnotizer.  Some- 
times, but  by  no  means  always,  the  very  first  attempt  to  bring 
about  hypnosis  is  successful,  as  I  havc'scen  in  some  of  Ford's 
as  well  as  We tlcrsl rand's  cases,  and  the  hypnosis  may  be  so 
profound  that  wc  can  already  venture  to  give  therapeutic  sug- 
gestions. Sometimes  the  first,  second,  and  third  attempts  (ail 
completely  or  partially  ;  then  wc  must,  if  no  contraindicalioiis 
exist,  try  again  and  again,  but  under  no  consideration  shouM 
the  individual  trials  be  prolonged  beyond  two  or  three  min- 
utes. Without  question  external  circumstances  are  of  great 
significance.  11  a  patient  who  is  to  be  hypnotized  enters  a 
room,  in  which  eight,  ten.  or  twelve  persons  are  lying  sound 
asleep  stretched  out  on  easy-chairs  and  sofas,  and  is  left  sitting 
there  quietly  for  a  quarter  of  an  hour  without  any  attempt  to 
put  him  to  sleep,  his  suggestibility — that  is,  his  susceptibility— 
will  sometimes  be  materially  increased,  and  it  will  be  a  com- 
paratively easy  matter  to  hypnotize  him.  But  there  arc  cer. 
tain  internal  conditions  also  which  may  throw  great  obstacles 
in  our  way,  and  which  must,  therefore,  not  be  overlooked. 
Thus,  if  a  patient  does  iint  believe  that  he  can  be  put  to  slcei^ 
or  if  he  makes  up  his  mind  to  resist  us.  a  certain  amount  uf 
finesse  is  necessary ;  we  have  to  outwit  him  in  order  to  produce 
hypnosis  without  his  consent  or  even  against  his  will.    Sudi 


IJYPNOTISM. 


609 


exceptions,  and  the  behavior  of  the  physician  who  has  to  con. 
tend  with  them,  can  not  here  be  treated  of.  Only  one  artifice 
we  may  mcntinn  which  wc  have  repeatedly  used  with  very 
good  results  in  pmducin);  the  fatigue  quickly  and  surely.  We 
apply  a  large  curved  sponge  electrode  (anode)  to  the  forehead. 
a  second  to  the  neck,  close  the  circuit  and  allow  a  very  weak 
(constant)  current,  just  sufficient  to  produce  the  characteristic 
iistc  upon  the  tongue,  to  pass  through  the  head  for  a  few  sec- 
onds, and  then,  without  the  knowledge  of  the  patient,  open 
the  circuit  and  tell  him  that  the  electricity  passing  through  the 
brain  will  put  him  to  sleep,  and  as  a  matter  of  fact  ihts  "sug- 
gested ■'  current  docs  so  very  promptly  and  surely.  Secondly, 
ttie  mental  condition  of  the  patient  may  stand  in  our  way.  It 
is  an  observation  confirmed  by  all  investigators  that  it  is  diffi- 
cult or  impossible  to  hypnotize  insane  patients,  and  that  hys- 
lertcal  patients  and  hystero-epiteptics  are  the  least  favorable 
subjects.  In  the  domain  of  psychiatry  the  treatment  by  sug- 
gestion, so  far  as  we  can  judge  at  present,  remains  without 
signiti<:ance  :  on  the  other  hand,  it  seems  as  if  certain  disturb- 
ances in  nutrition — (or  example,  general  anasmia  and  chlorosis 
— facilit.ite  liypnoliotion  greatly,  while  an  absolute  conTxlcncc 
in  the  physician,  the  absence  of  all  attempts  to  analyze  and  to 
test  our  procedures  on  the  part  of  the  patient  while  we  are 
trying  to  hypnotize  him,  will  also  materiully  increase  the  sus- 
ceptibility to  suggestions.  If  all  (actors,  favorable  and  unfa- 
vorable, are  taken  together,  we  may  say  that  by  far  the  greater 
numl>er  of  j«oplc  can  be  hypnotized  ;  perhaps  one  might  go  so 
far  as  to  say  all,  without  exception,  are  susceptible  if  lime  and 
circumstances  allow  sufficient  repetitions  of  the  trial.  For  hos- 
piral  practice  the  dictum  of  Bernheim  may  for  the  present  be 

t accepted,  that  the  physician  who  does  not  succeed  in  hypno- 
tizing eighty  per  cent  of  his  patients  for  therapeutic  purposes 
does  not  understand  the  method. 
The  manner  in  which  hypnosis  comes  on  and  the  phenomena 
observed  during  this  state  are  extremely  varied.  Sometimes 
the  eyes  close  suddenly  and  the  patient  is  .islcep  at  once ;  more 
frequently  this  Is  preceded  by  twilchings  of  (he  lids  and  moist- 
ure in  the  eyes,  which  arc  repeatedly  closed  and  opened. 
Sometimes  the  lids  arc  shut  during  hypnosis,  sometimes  a  fine 
tremor  is  noticeable  in  Idem  :  again,  fibrillary  twitchings  in  the 
muscles  of  the  face  may  be  remarked.  The  hypnotic  influence 
does  not  always  produce  sleep,  and,  as  wc  have  said,  (his  is  not 
w 


I 


6lo       DISEASES  OF  THE  GENERAL  XEKVOUS  SYSTF.At.        V 

necessary  for  therapeutic  purposes;  but  there  are  different  de- 
grees, (rom  the  waking  state  to  slight  dullness  of  the  senses  and 
somnolence,  and,  hnally,  deep  sleep,  which  latter  is  called  soni' 
nambultsni.     Beniheim  in  his  explanation  bases  his  arguments 
upon  the  ideas  of  Luys,  that  the  different  layers  o(  the  cortex 
are  endowed  with  different  functions  :  those  nearest  the  surface 
arc  supposed  to  serve  lor  the  sensorium,  the  middle  ones  tor 
the  mental  faculties,  and  the  deepest  for  the  transference  of  the 
will.     He  distinguishes  accordingly  nine  degrees  of  hypnosis, 
and  characterises  them  in  the  following  manner:  (t)  The  pa- 
tient  remains  quiet  with  closed  eyes  during  the  suggestion,  but 
can  open  them  without  ditTtculty  when  asked  to  do  so,  and 
claims  not  to  have  slept  at  all.    (2)  The  patient  is  not  able  to 
open  his  eyes  when  asked.    (3)  The  patient  presents  suggested 
catalepsy  and  analgt-sia,  and  remains  in  the  position  in  which 
he  is  placed,  but  is  able,  after  it  has  been  suggested  to  him,  to 
change  from  one  position  to  another  without  assistance.    (4) 
The  patient  is  no  longer  able  by  himself  to  overcome  the  sug- 
gested catalepsy,  and  automatic,  rotatory  movements,  espcciallj 
of  the  arms,  can  be  evoked.    (5)  Besides  the  catalepsy,  con- 
tractures can  be  produced  which  the  patient  himself  is  not  able 
to  do  away  with.    (6)  The  patient  presents  an  automatic  obe- 
dience: he  stands  motionless  il  ordered  to  do  so,  he  rises, 
walks,  and  acts,  in  fact,  just  as  the  hypnotizer  may  suggest 
Intelligence  and  the  activity  of  the  senses  arc  intact  in  these 
six  stages.    The  patient  on  awakening  remembers  everything 
that  has  been  done  to  him.    (7)  In  the  seventh  stage  the  palieoc 
presents  the  same  phenomena  as  in  the  preceding  six  stages, 
but  on  awakening  has  quite  forgotten  what  has  been  going  on. 
(8)  Besides  this  amnesia  on  coming  to,  hallucinations  can  be 
produced  during  hypnosis  which  vanish  after  the  return  to  the 
normal  condition.    (g>  The  suggested  hallucinations  persist 
after  waking  up — post-hypnolic  suggestions — everything  thit 
can  be  produced  in  a  patient  when  in  a  state  of  hypnosis  CM 
be  brought  about  after  he  has  awakened  simply  by  suggesting 
to  him  during  hypnosis  that  it  will  happen  alter  he  has  awak- 
ened.    In  this  possibility,  of  exerting  an  inQucncc  upon  thcfio- 
tientfor  a  longer  or  shorter  lime  after  he  is  awake,  lies  the  whole 
therapeutic  significance  of  the  treatment  by  suggestion.    This 
(post-hypnotic)  action,  which  in  certain  cases  can  be  obtaiixd 
in  no  other  way  than  by  suggestion,  is  sufficiently  imporwnl 
to  warrant  and  insure  to  hypnotism  a  lasting  place  in  »cicacc. 


HYPNOTISM. 


6ll 


H  It  is  unnecessary  to  distinguish  nine  different  stages  of  hyp* 

f  DOlism  as  [lernhein)  di<l ;  three  arc  quite  sufficient  (Ford). 

The  first  is  the  stage  of  somnolence,  corresponding  to  Bern. 

_  heim's  first   stage ;    the    second   is  that  ol    hypotaxin  (light 

f  sleep),  embracing  all  the  stages  from  the  second  to  the  sixth 

of  Bcrnheim  ;  the  third  is  the  stage  of  deep  sleep  (sonmam. 

bulism),  corresponding  to  the  seventh,  eighth,  and  ninth  of 

Dernhcim's  classification.      It  is  oi   practical  importance  to 

note  that  frequent  trials  usually  increase  the  susceptibility  of 

the  patient,  and  that  as  a  result  it  is  usually  quite  easy  to 

produce  the  condition  of  fatigue  ("somnolence")  necessary 

■  lor  therapeutic  purposes. 
What  are,  then,  the  diseases  in  which  we  can,  with  good 
conscience  and  good  hopes  of  success,  venture  to  employ  the 
treatment  by  suggestion  ?  Wc  need  hardly  say  that  affcciionii 
in  which  we  have  tu  deal  with  inHammatury  processes,  new 
growths,  infections,  or,  in  a  word,  with  organic  lesions,  do  not 
belong  to  this  class;  and,  us  a  matter  of  fact,  it  would  hardly 
enter  any  one's  head  to  attempt  to  cure  pneumonia,  typhoid 
■fever,  brain  tumors,  syphilis,  tetanus,  etc.,  by  means  of  hypno- 
tism. It  is  a  different  matter  if  wc  arc  dealing  merely  with  cer- 
t.iin  symptoms  of  such  maladies — tor  instance,  insomnia,  difli- 

■  culty  in  breathing,  or  pains  of  the  most  varied  kinds,  not  exclud* 
•inf;  the  lancinating  pains  ot  tabes.     Ilerc  hypnotism  should,  at 

least,  be  given  a  trial,  yet  the  main  field  in  which  the  treatment 

■by  suggestion  should  be  employed  will  not  be  the  diseases  we 

have  mentioned,  but  rather  all  those  which  we  have  designated 

and  described  as  functional  disorders  of  the  nervous  .system. 

■  Here  motor  as  well  as  sensory  disturbances  can  be  influenced, 
the  latter  having,  caterii  puribMs.  a  belter  prognosis.  Neural- 
gias,  especially  tic  douloureux,  arc  often  difficult  to  treat,  and 

Blhe  migraine-like  paroxysmal  headaches  can  not  always  be  per- 
manently removed.  Among  the  general  diseases  of  the  nerv- 
ous system,  epilepsy,  the  classical,  hereditary  migraine,  and 
hysteria,  as  a  whole,  have  a  very  unfavorable  prognosis.  On 
the  other  hand,  certain  individual  symptoms  of  hysteria  (the 
vagus- neuroses,  ana:sthcsias.  paralyses)  arc  very  amenable  to 
the  treatment.  Further  details  relating  to  this  subject  1  have 
treated  of  in  a  paper  read  before  the  International  Congress  in 
[Rome  (Wien  med.  Prcsse,  1894,  22).  to  which  the  reader  is  re- 
tlerred.  I  would  call  attention  again,  however,  to  the  treatment 
[of  alcoholism  and  of  certain  functional  speech  disturbances 


6t3 


O/SSASSS  OF  TUB  GENERAL  NERVOUS  SYSTEM. 


(stuttering,  stammering),  since  my  results  in  these  conditions 
were  especially  favorable. 

According  to  Forcl.  it  is  possible  to  influence  certain  so. 
matic  functions  to  some  extent — e.g..  the  menstruation  :in<l 
digestion — in  such  a  manner  that  the  menses  can  be  brought  on 
at  a  certain  day  and  a  certain  hour,  and  u  regular  evacuation 
of  the  bowels  every  day  can  be  insured  by  suggestion.  Al- 
though these  accounts  come  from  the  most  indubitable  source, 
the  experiments  must  again  be  tested  and  confirmed.  They 
can  certainly  only  be  successful,  we  should  think,  in  individuals 
who  have  been  repeatedly  hypnotized  and  are,  as  it  were, 
"trained."  With  the  treatment  of  alcoholism  by  suggestion 
Forcl  also  has  had  uncommonly  good  results  in  his  instt. 
tution.  The  heaviest  drinkers  were  not  only  for  a  lime,  but 
lastinjrly  cured  :  but  no  little  influence  certainly  has  here  to  be 
attributed  to  the  temperance  societies  of  which  such  individ- 
uals were  led  to  become  members,  f  have  been  able  to  obtain 
good  results  without  this  help.  The  behavior  nf  morphinists 
toward  suggestion  requires  further  study.  The  results  so  far 
obtained  seem  not  to  be  very  encouraging.  The  communica' 
tion  of  Wetlcrstrand  (cl.  lit.)  thai  it  is  possible  in  idiopathic 
epilepsy  to  diminish  the  frequency  and  severity  of  the  attack; 
deserves  to  be  remembered,  and  the  procedure  should  be  tried 
in  cases  in  which  bromides  arc  not  well  borne.  Finally,  wc 
would  call  attention  to  the  anesthesia  and  analgesia  which  can 
easily  be  produced  by  suggestion,  and  which  in  surgery,  as 
well  as  in  obstetrics,  may  be  very  useful.  I  was  present  at 
Forel's  clinic  at  the  extraction  of  two  obstinate  teeth,  which, 
after  the  proper  hypnotization,  were  taken  out  without  the 
slightest  sign  of  pain  on  the  part  of  the  patJcnL  Possibly  the 
pains  during  labor  may  be  removed  by  hypnotism.  The  ao- 
aesthesia  of  the  mucous  membrane  of  the  fauces  may  be  very 
valuable  in  making  laryngoscoptcal  examinations  and  the  like. 


h 


/lYPXOTISM. 


613 


1 

I 


^^^^^^  LITERATURE. 

I  1.  H)^olistn — Treaiment  by  Su|^citiun  (from  Ibe  Year  1SS7). 

^B  a.   Gmrrml. 

All  th«  older  f«(«T«nRs  han  bran  MUccied  b;  JlJtilui  (cf.  Schmidi's  JahifaAcbcr,  i8St,  Od. 

'»>.  p.  73). 

Birillon,     l.a  su(;:gruian  el  jx%  apjilic.-t lions  A  la  pf4b|fug>e.    (lat.  des  h6pi.. 

1S87.  113. 
Biniwangcr.    Dcuuclic  med.  Wodicnschr.,  18S7,  xiU,  42.    (Present  Sute  t4 

Hypnolism.) 
Foniaii  rl  S^gatd.    EUmenIs  de  mjdecine  suggtsilvc.     Paris.  O.  Doin.  18S7. 
Ikmhcim.     De  In  nuKt^tion  el  rfc  ses  applic^iiiuns  &  la  ihtrapruiiquc.     Pam, 

18S8.  deuutinc  Mtion. 
B:)krUchcr.    Mtinch.  nicil.  U'uchmschr.,  18S8,  ixxv,  30. 
KrolTi-KlHui;.     Einc  cxpcrimc-nirlle  Stuilic  auf  dcm  CcImc'c  des  llypnoiiMnut. 

Slullfpin,  1S88.— EnuHsh  triiniblion  l>y  Charlct  G.  Chaddock.    G.  P.  Put- 
nam's Sonv    TI1C  KnickcrixKker  Vma,  1889^ 
Muck.    Zur  EinfuliTung  inriaa  StudiumdeaHypnolisinusund  thierachcn  Mag* 

tietinnui.    ncrtin  und  Nruwicd.  18S8. 
SchrciMk-Noiunt;.  v.     Ein  Ucitrag  zur  thcra|in](itchen  Verwerlhuni;  da  Hy|>> 

nolismus,     Leipzig.  Voj^tl.  188S. 
Seeliicnullcr    Dermodcrne  Dypnoiismus.     Deutsche  med.  Woehcnichr.,  |8$8, 

"'*■  3'-34- 
SaHis.     Ucbcf  hypfwit,  Sugg<-Mion(n.  dercn  Wcscn.  klinbehe  und  simrrcchiliche 

BeikulunK.    Ncuwicd.  1888. 
Cony.    UoMon  Med.  and  SurK-  Juum..  Not-embcr  so,  1888,  Ulx.     (Tberapeuilc 

Value  or  Hypnolism.) 
Forel.    Schweit.  Comap.-BJ..  1888.  xviii,  13.    (The  Value  of  Hypnoltsnt  far  the 

Geflwul  i'tMctilioncr) 
Hrncf.    ItoUon  Mrd.  and  Surg.  Jtiutn..  November  to.  18B8.  cax. 
Mason.     Ibid..  November.  1SS8. 

benthdm.     Hy|>noM:  durcli  Su}Xestion.    WIcn.  med.  Pmse,  188S,  uvai.  a& 
JendrasMk.    Neurol.  CemrAlhl..  18RS.  10,  li. 
Mcynen.    Ueber  Ilf-pnotbmuv    Wten.  med.  Pksm.  1888,  sxi(,  14. 
W«1m,  D.     Pnger  med.  Wocheitichr..  1888.  xiu.  k>.  11. 
Freud.    Wiener  mrd.  IttHiirr,  1888,  xi,  }8.  39. 

V.  Krain-EI>ini[.     Ucbi-r  Ilj-pnoliimu.v     DeuiKhc  Med.-Zij;..  1SS8.  16.  p.  I96. 
I><-stM)tr.     BtblMgrxphie  dci  niodcrnen  Hypnoiisnius.     Ekilin,  1888. 
Liftieault.     Du  lommeii  provoqu^.     nruMJmc  /ililion,  Pativ  1889. 
LWgeois.     De  la  sugijeslion  el  du  vimnambuliimc  dans  kura  rappons  avecia 

jurtfprudencc  c(  U  niMccinc  l^ale.    V*t\i,  Doin.  1S89. 
HaieriacbiBr.    Die  Sii)!t(rtliv  iherapic  and  ihre  Technik.    Siuirfpn.  1889. 
Bcaunia.    Le  somiumlmlisme  provoqui.    Etudes  phyaiolofiques  ct  ptycholo- 

fique*.    i3e,  Paris,  1886. 
Binmngcr.    Thera|>.  Mon.ilth..  1889,  1-4. 
CUka de  la  Tourellc.    [)ct  M) pnoiismut  x-om  Sundpunkic  dcr  gcrkbtL  Mcdkin. 

t  Author.  German  iraniUtion,  Hnmburg.  IS)!?. 
_: 


I 


6l4 


DiSBASES  OF  THE  GENERAL  SEftVOVS  SVSTK.V. 


I 


Moll.     Per  Hypnotiimus.     i.  Auflngc.  Berlin.  1890. 

Pitrct.     De  la  nicmoirc  lUnt  I'tl^pnoiiinic.     (>at.  mM.  de  Pari*.  1890,  Na  47, 

f'orel.     Der  Hypnoiismus.  stinc  jtsychophysiol.  u.  i.  w.  Bcdeulung  und  jeine 

H^indh.ihung,  i,  AuR,.  Stiiitgari,  1891, 
Wctierslnind.     Der  Hypnulismu!!  und  svine  Anwendung  in  (kr  prakliKhen 

Mcdicin,  Wirn  und  Ixipi'ig,  1891. 
Moll.     Dcr  Rappurl  in  tier  Hypnoie.     Untenuchungcn  uber  den  thterischen 

M.-^^etitmui.     Ltipttg,  1891. 
Liebe:iuli.     Ucr  kilnslliclic  Schaf  und  die  ihm  Xhnliclim  ZusUtfldc.     Ccmun 

iran^Ution  by  Darnbluth.     l.eipti>;  imd  Wirn,  Dciiiickr.  189:. 
Btnswunger.     Uebcr  die  Erfolgc  di-r  SuKgtsiivilicrapie.     Wtcbl»den.  1893. 
Groetman.     Zrilschrin  Tur  Hypnoiismut.  Suggest ionMhcta[»e,  u.  x.  w.,  1893.  iir, 

Jahij;..  nctlin.  Herm.  BrieK'T. 
Hindi.    SuggL-siion  unci  Hypnosc.    Kuraes  Lehrbtich  far  Aenie.  Leipzig.  Abd, 

1893. 
Hcclcer.    Ucber  Autosuggestionen  xwithrend  (let  hypnoiischcn  Schlnfcs.  Zciisdir. 

r,  Hypnoi.,  ii.  t,  t?. 
Kuhner.     Psych (iihcrapie.     Dcrprakt.  Aral..  1893,  5. 
V.  Cor\-al.     Sug^esiionstherapie.  ISychoiherapie.      Eulmburg's  Rcal-EflCjrclo- 

pttrlic.  J.  AuU. 
IIcncdicL     Hyptioti.stnus  unil  Suggestion,  Eine  klinisch^psychologUche  Stodk 

Leipiig  ui>d  Wien.  1S94. 
Crossmann.      Die    Bcdruiung   der    hypnoiischfn    Suggcilion   nls  FleilcnitKl 

(iulachien  und  Hcilberichte  Ucr  hervomigcndslcn  wisaenitctuti lichen  Va- 

trcter  dcs  Hypnoii&nius  iter  Gc^'cnwait.  Dcutsclie  AusgHbc,  Itcriin.  1894. 

I  /,  S^ia/  ( t^ariiiut  Oufi  tund  er  tnMfJ  iy  HyfnofU  S»ggrtiimi), 

Soltier.     Progrfs  m^d.,  1887,43.     (Hystcro-epileptic  Attacks  uid  to  have  be«ii 

cureil.) 
Mialeu    Ca*,  des  hflp.,  1887.  t  ■&     (HypemnMis  Gravidarum  cured.) 
BirdMll.     Bciston  Med.  and  Surg.  Joum.,  November  10,  t88S,  cxix,     (Tremor.J 
Frey.     Wien.  mod.  Presse.  cuis.  5a  %\.     (Neuralipa  of  ihc  Fifth  cured.) 
Frty.     Ibid,,  xxii.  ^\.     (Sleeplessness  cured.) 
Baierlachn.      MunEhener   med.    WochenKhr.,    188S,   xxxr,    39,     (Rejiort  of 

Cases.) 
HKckel.     Die  Rolle  der  Suggestion  bei  gewissen  Eraclidnui^cn  dci  llyitcnc 

und  dea  Hyitnoiiainus.    Jcnu,  18S8. 
Forcl.    Schwcii.  Correspond, -Bl..  1888.  xviH,  6. 
Nonne.     Neurol.  Cenlr.ilbl.  18S8.  vii.  7.  8. 
Riboi.     Revue  miA.  de  la  SuiiiM  rom..  Mars.  1888,  i-iii.  3.    {Hysterical  Hmi- 

plegia  cured.) 
Scheinm.inn.      Deutsche  mcd.  Wochenschr..   1889,  at.      (Hysterical  Aithonn 

cured,) 
MichaH.      Deutsche   Med.Ztg,.   1889.  63.      (Epilepsy  Temporarily  impnirw'. 

Hystero-cpilepty  and  Hysterical  Aphonia  cured.) 
Batth.      Sugf^eMiun    bei   Ohrenlciden.      Zeil^clir.   f.   Ohrenlik..   18S9.  nii-  X 

Ladame.      Internal,  klin.    Rundschau.    1890.   zi,    31.     (Cnvins  for  AictM 
cured,) 


HYPNOTISM.  6lS 

T.  Schrenck- Not  ling.     Die  Suggestion  sthera.pie  be!  krankhaften  Erscheinungen 

dcs  Geschlechtssinns.     Stuttgart,  1892, 
Etonaih.     Deutsche  Zeitschr.  f.  Nervenhk.,  1892,  2  und  3. 
Stembo.      Die  therapeutische  Anwendung  der  pr^ypnatischen  Suggestion. 

Petersburger  mcd.  Wochenschr.,  1892,  37, 
Hilzig.    Schlafaltaken  und  hypnot.  Suggestion.     Berliner  klin.  Wochenschr., 

1892,  38. 
Grossmann.      Die    Erfolge    der  Suggestionstherapie    bei  Influenza.      Berlin, 

Briber,  1892. 
Schafler.    Netihautreflexe  wShrend  der  Hypnose.    Neurol.  Centralbl.,  1893,  xii, 

33.  24- 
Talzel.     Drei  FSIIe  von  nicht  hysterischen  Uthmungen  und  deren  Heilung 

mittelst  Suggestion.    Zeitschr.  f,  Hypnot.,  1893,  ii,  1. 
Forel.     Die  Heilung  der  Sluhlverstopfung  durch  Suggestion.    Eine  praktische 

und  tlieoretische  Studie.     Berlin,  1894. 


-  "l 


-^:;=5-=5 "     PART  11. 

DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM 
WITH  KNOWN  ANATOMICAL  BASIS. 

The  anatomical  changes,  which  are  found  in  the  diseases 
belonging  to  this  category,  concern  the  central  nervous  system 
as  well  as  the  peripheral  nerves.  The  former  always  suffers, 
the  latter  are  only  in  certain  cases  affected.  Whether  the 
changes  in  the  peripheral  nerves  are  to  be  regarded  as  second- 
ary, or  whether  the  entire  nervous  system  becomes  affected  in 
alt  its  parts  at  the  same  time,  so  that  the  peripheral  and  the 
central  lesions  progress  pari  passu,  can  not  be  definitely  de- 
cided. The  nature  of  the  anatomical  changes  will  be  discussed 
under  the  head  of  each  individual  affection.  Combinations  of 
the  functional  neuroses  and  organic  diseases  of  the  nervous 
system  are,  on  the  whole,  rare.  Such  instances  have  been  care- 
fully studied  by  Oppenheim  (Neurol.  Centralblatt,  1890,  16). 

CHAPTER   I. 

MULTIPLE   SCLEROSIS DISSEMINATED    SCLEROSIS INSULAR    SCLE- 
ROSIS— SCLEROSE   EN    PLAQUES SCLEROSIS    CEREBRO- 

SPINALIS   DISSEMINATA    S.    MULTIPLEX. 

Although  multiple  sclerosis  is  not  one  of  the  common 
affections  of  the  nervous  system,  it  is  desirable  and  important 
for  the  general  practitioner  to  possess  a  clear  understanding  of 
it,  because  the  clinical  appearances  by  which  the  different  cases 
manifest  themselves  vary  within  such  wide  limits  and  rcminii 
us  now  of  this,  now  of  that  spinal  or  cerebral  affection,  with- 
out ever  completely  simulating  any  one  definite  disease.    The 
typical  course  given   in  the  books  is  not  st^ry  often  met  with 
in  practice.     Much  more  commonly  one  or  the  other  of  the 
classical  symptoms  is  not  found  at  all,  or,  if  present,  is  only  vei7 
slightly  developed.     On  the  other  hand,  symptoms  are  occa- 
616 


MULTIPLE  SCLEROSIS. 


617 


siohally  encountered  which  are  not  included  in  the  usual  de- 
'  scriptiuns  ol  the  disca<tc.  In  a  word,  multiple  sclcro&is  is  quite 
inconstant  in  its  nianilestatir)ns,  a  circumstance  which  often 
makes  the  diagnosis  very  difficult.  In  the  investigation  into 
the  pathology  as  well  as  the  clinical  aspect,  Charcot  has  dune 
admirable  and  lasting  service. 

Symptoms  and  Course. — The  course  of  a  classical  case  is 
usually  as  (ollows :  The  patient  first  complains  of  general  symp- 
:  toms — headache,  vertigo,  digestive  disorders— soon,  also,  of 
scn&ory  disturbances  in  the  upper  and  lower  extremiiifs,  slight 
weakness,  and  u  readintss  to  become  fatigued.  These  symp. 
toms  may  persist  for  months,  yet  relatively  early  one  or  several 
apoplcctilorm  attacks  may  occur  which  sufficiently  indicate 
the  seriousness  of  the  condiiion.  It  strikes  the  patient,  as  well 
!  as  those  who  surround  him,  as  a  peculiar  thing,  that  whenever 


i.. 


'i-^..vfi- 


'■-^^tr- 


■-M. 


»V-W 


J^ 


-nil/ 


FIC.  (64.— SPKctMKK  nr  H*if|WTMTiiw  ni  *  Cua  or  UtitTirtj:  Scumum*.    (kh  \Msm 
\))^Mm)  H«iiriatie SMncr,  Mb 48 laliic kiL    Bmtau,dn  igJiMi) 


he  attempts  to  pick  up  something  with  his  hands,  or  to  make 
any  other  movcniciit,  a  tremor  appears,  in  exceptional  cases 
implicating  the  facial  muscles  also  (Cohn,  Deutsche  tncd.  Wo- 
chenschr.,  l8<)0,  13),  hut  usu.-illy  confined  to  the  upper  extremi- 
ties, which  frustrates  the  intended  movement  more  or  less  com- 
pletely. If  he  attempts  to  raiite  a  full  glass  to  his  mouth,  he 
spills  some  of  the  contents.  If  he  attempts  to  taxi,  the  food  is 
jerked  08  his  fork.  etc.  Co-ordinated  movements,  such  as  are 
required  for  writing  or  playing  the  piano,  become  difficult,  the 
handwriting  becomes  almost  illegible  (Fig.  164),  and  the  condi- 


6i8 


D/XEASES  OF  THE  GENERAL  XEXVOUS  SYSTEM. 


'lion  is  materially  aggravated  it  the  tremor  is  not  confiiicdTo 
tlic  upper,  but  if  also  the  lower  exlrcmiues.  the  trunk,  neck, 
and  head  arc  attacked,  so  that  on  voluntary  movements — on 
attempts  to  walk,  (ur  instance — the  whole  body  first  begins  to 
tremble,  and  tinally  shakes  so  violently  that  the  patient  is  forced 
to  sit  or  lie  down  at  once.  This  symptom,  which  i$*almost 
pathognomonic  for  multiple  sclerosis,  or  at  any  rate  most  sig- 
nificant, is  called  "intention  Irenior,"  a  term  which  docs  not. 
however,  imply  that  the  tremor  is  "  intentional,"  but  only  that 
it  appears  on  voluntary  ("  intended  ")  movements.  During  rest 
no  trace  of  it  is  observed.  When  the  patient  lies  quietly  and 
undisturbed  in  bed  no  tremor  is  present,  whereas,  if  he  is 
spoken  to,  examined,  made  to  answer  questions,  and  the  like,  a 
tremor  over  the  whole  body  develops,  which,  of  course,  pre- 
sents various  degrees  of  intensity.  It  is  most  marked  and 
characteristic  if  the  patient  is  asked  to  bring  his  hand  slowly 
to  an  object — for  instance,  to  a  pin  laid  upon  the  table.  At  first 
the  motion  is  fairly  good  and  steady,  he  trembles  but  little  or 
not  at  all,  but  the  closer  he  approaches  to  the  pin  the  more  un- 
steady becomes  the  hand  and  the  larger  become  the  excur- 
sions of  the  tremor,  so  that  to  grasp  the  pin  becomes  impos- 
sible. In  some  exceptional  cases  1  ha%'e  seen  the  shaking 
movements  appear  on  one  side  only,  so  that  the  patient  was 
capable  of  performing  normal  movements  with  one  hand  and 
one  leg,  when  those  of  the  other  side  had  become  entirely 
useless. 

In  this  intention  tremor  the   eye  muscles  also   take  part; 
as  soon  as  the  patient  attempts  to  (ix  a  point  with  his  eyes 
nystagmus  appears,  which,  however,  differs  from  the  tremor 
of  the  other  voluntary  muscles,  inasmuch  as  it  docs  not  com- 
pletely disappear  during  rest.     As  a  subjective  symptom  the 
very  annoying  sensation  of  giddiness  must  be  mentioned  in 
this  connection,  which  leaves  the  patient  only  when  he  lt« 
quietly  in  bed,  whereas  it  otherwise  impedes  him  a  good  deal 
in  his  movements,  especially  in  walking.    Owing  to  the  faulty 
innervation  of  the  tongue  and  larynx,  we  meet  with  a  peculiir 
speech  disturbance;  the  patient  talks  slowly,  in  a  monotonous 
tone,  and  awkwardly,  and  his  speech  is  scanning,  as  he  makes 
a  pause  after  each  word,  almost  after  each  syllabic,  so  that  it 
takes  him  a  much  longer  time  to  express  his  thoughts  than  a 
healthy  man:  "  Yes— doctor— I— am— very — much— fa— liguH 
—and — worn-out."    As  this  is  spoken  in  the  manner  indicateii. 


I 


A 


MULTIPLE  SCLEROSIS. 


619 


\ 
I 

I 


without  any  change  ol  intonation,  it  is  very  characteristic  in- 
deed, and  it  i»,  together  with  the  intention  tremor  and  the 
nystagmus,  pathognomonic  for  multiple  sclerosis.  It  impresses 
itself  so  much  upon  the  mind  that  once  heard  it  can  never  be 
iorgotten  or  misinterpreted. 

To  give  a  physiological  explanation  of  the  intention  tremor 
is  out  of  our  power,  and  it  is  more  especially  not  clear  why 
it  is  so  extremely  common  in  multiple  sclerosis,  where  we  have 
such  an  irregular  distribution  of  the  anatomical  lesions,  where* 
as  in  most  of  the  other  cerebral  affections  it  is  absent.  Whether 
Charcot's  idea  is  correct,  according  to  which  the  long  persist- 
ence of  the  axis  cylinders  in  the  sclerotic  foci  has  some  connec- 
tion with  the  tremor,  or  whether  we  should  hold  with  StrUm- 
peil  that  the  loss  of  the  myclinc  sheaths,  in  consequence  of 
which  an  abnormal  diffusion  of  the  ner\-c  current  from  fibre  to 
fibre  occurs,  is  responsible  (or  this,  we  can  not  decide,  nor  have 
we  any  proof  of  the  correctness  of  Stephana  view(cl.  lit.) that 
the  existence  of  sclerotic  foci  in  the  thalamus  gives  rise  to  the 
phenomena,  nor  of  Cramer's  (cf.  lit.)  that  the  intention  tremor 
has  to  be  explained  as  analogous  to  the  tremoi;  which  comes 
OR  after  hard  muscular  exertion. 

Though  we  may  be  justified  in  looking  upon  these  three 
symptoms  as  constituting  in  a  manner  the  typical  picture  of 
multiple  sclerosis,  we  must,  as  we  have  said  above,  at  once 
familiarize  ourselves  with  the  fact  th.it  even  these  may  not  all 
be  pronounced,  or,  again,  that  there  may  be  others  to  be  found 
in  conjunction  with  them,  developing  in  the  course  of  the  dis- 
ease. Among  these  latter  we  may  mention  certain  spastic 
symptoms — rigidity  of  the  muscles,  increased  tendon  and  sitin 
reflexes,  the  above^iescribed  spastic  walk — which,  together,  arc 
liable  to  simulate,  at  least  fora  time,  the  picture  of  spastic  spin.i) 
paralysis.  This  is  the  more  likely  as  there  are  no  sensory  dift. 
turbuices  at  all  to  be  noted  in  multiple  sclerosis:  only  in  rare 
exceptions  paresthesias  arc  obser\-ed,  owing  to  which  tabes 
and  myelitis  may  be  diagnosticated,  especially  if.  as  sometimes 
happens,  bladder  disorders  are  superadded.  A  careful  study 
of  the  sensory  changes  has  been  made  by  Freund  {.Arch.  f. 
Psych.,  iS90-'93,  p.  319).  That  bladder  di.^ascs  are  by  no 
means  so  rare  in  multiple  sclerosis  as  was  formerly  supposed, 
has  been  pointed  out  by  Erb.  and  after  him  by  Oppcnheim 
(Deutsche  Med.-Zlg..  18S9,  yi\  Glycosuria  will  be  found  asso- 
ciated with  the  disease  if  there  arc  foci  situated  in  the  Htxtr 


620       O/SSASSS  OF  THE  GENERAL  KERVOUS  SYSTEM. 


of  ihc  fourih  ventricle  (Richardiire.  Revue  de  mdtl.,  Juillct, 
188;). 

Participation  o(  the  optic  and  other  cranial  nerves  is  not 
very  rare,  yet  it  is  here  much  less  importaiu  for  the  diagnosis. 
and  much  lc»)  significant  {or  the  course  of  ihc  disease  than,  lor 
example,  in  tabes.  Diplopia  is  nirely  met  with;  and  equally 
uncommon  is  the  neuritis  and  atrophy  of  the  optic  which  leads 
to  amaurosis.  Uhthoff  (cf.  Iit.)has  pointed  out.  in  an  adminible 
study,  that  if  optic  atrophy  occurs  it  is  not  like  the  primary 
atrophy  in  tabes,  but  that  here  it  Is  a  secondary  process,  which 
follows  an  active  increase  ol  the  fine  conneclive-tissuc  elements. 
U  is  self-evident  that  various  disorders  of  sight  are  .associated 
with  this,  yet  they  often  present  temporary  improvement,  and 
have  usually  a  less  serious  issue  than  those  of  tabes.  In  gen- 
eral, it  is  characteristic  of  multiple  sclerosis  that  its  course  is 
not  uninterruptedly  progressive,  but  that  it  shows  remissions, 
during  which  the  hopes  of  the  patient  as  well  as  of  his  friends 
for  his  complete  recovery  are  aroused.  I  have  seen  instances 
in  which  such  remissions  lasted  for  years  and  the  symptoms 
disappeared  to  a  great  extent,  and  in  which,  just  owing  to  this 
peculiarity  in  the  course  of  the  disease,  the  di.ignosis  could  be 
made  with  some  certainty. 

Cerebral  manifestations  arc  not  uncommon,  and  frequently 
3  siisht  degree  of  dementia  develops,  which  to   the  patient 
himself  makes  his  condition  more  bearable.     Ii  must  also  be 
regarded  as  a  sign  of  beginning  mental  weakness,  I  think,  that 
in  some  cases  the  patient  frequently  laughs  boisterously  without 
a  cause.    One  of  my  patients  had  spells  of  loud  laughter,  which 
lasted  from  one  to  three  minutes,  and  which  appeared  usually 
without  sufficient  motive.    1  have  nc%*er  had  occasion  to  observe 
pronounced  states  of  depression  or  exaltation  in  the  course  of 
this  disease.     The  vertigo,  which  of  course  must  also  be  re- 
garded .is  a  cerebral  symptom,  has  been  spoken  of  above. 
Apoplectiform  attacks  iu  the  beginning  of  the  disease  arc  not 
rare ;  epileptiform  seizures  may  be  found,  if  the  cerebral  cort« 
is  more  especially  implicated. 

It  lias  been  shown  by  Charcot  that  in  certain  cases  die 
development  ol  the  symptoms  appears  to  be  abortive  and  ihe 
affection,  one  might  almost  say.  remains  talent  and  can  only  be 
recognized  by  the  peculiar  sh:iking  tremor.  Me  proposed  (of 
these  instances  Trousseau's  designation,  ■■/<)»■/«« /rwfrf."a'"i 
it  seems  that  in  multiple  sclerosis  such  forms  arc  observed  rcb* 


^^i 


MULTIPLE  SCLEROSIS. 


631 


[tivcly  frequently.    Soiicqucs  studied  these  carefully  under  (he 
Jireclion  of  Charcot  (I'rogrfts  mid.,  1891, 11),   As  an  example  of 
[the  general  course  which  the  disease  may  run  I  insert  here  the 
following  history  of  a  patient  in  my  wards,  who  is  still  living : 


I 


Paul  W.,  thirty-one  years  old,  began  to  be  sick  ten  years  ago 
during  his  military  service.  At  first,  at  times  be  could  not  feel  his 
TiAe  in  his  left  arm,  and  then  in  the  same  year  he  was  often  conscious 
of  a  slight  feeling  of  fatigue,  which  was  associated  with  vertigo.  He 
had  a  good  deal  of  difficulty  with  his  arms  and  his  legs;  they  always 
felt  as  if  they  were  asleep,  and  any  muscular  action  necessitated 
the  greatest  exertion.  He  could  not  go  through  his  salutes  in  the 
proper  manner,  and  he  was  repeatedly  punished  on  this  account. 
At  the  s:ime  time  he  had  now  and  then  vomiting  and  w<::ikness  of 
the  bladder  for  quite  a  long  time,  so  that,  on  coughing,  small  quan* 
titles  of  urine  were  passed  involuntarily.  On  examination,  we  are 
told,  Romberg's  sign  was  absent  and  the  patellar  reflexes  were  in- 
creased. A  few  months  later,  marked  weakness  in  the  right  arm  and 
the  right  leg  became  manifest,  and  the  acutcncss  of  hearing  became 
diminished  on  that  side.  The  pjtttent  complained  of  an  annoying 
double  vision.  In  1879  he  had  some  difficulty  in  swallowing;  the 
bolus  would  Mick  in  his  throat,  so  that  he  had  to  force  it  down.  In 
1880  pronounced  deliberation  in  speaking  is  said  to  have  been  notice- 
able, and  the  patient  at  that  time  also  complained  that  he  could  not  lay 
his  tongue  upon  certain  words  which  he  wished  to  use.  The  s[>ccch 
di«turbance  soon  passed  off,  but  the  patient  sullcred  from  various 
troubles  till  January,  1884,  in  which  month  I  saw  him  for  the  first 
time.  He  then  presented  the  symptoms  of  an  incipient  tabes,  but  it 
was  noted  as  a  remarkable  feature  that  the  patellar  reflexes  were 
retained.  The  lancinating  pains,  however,  the  paresis  of  the  legs, 
the  diplopia,  the  paresis  of  the  bladder,  the  unsteadiness  which  ap- 
peared  especially  in  the  dark,  seemed  sufficient  to  warrant  the  diag- 
nosis  of  tatKs.,  and  in  the  out-patient  department  this  diagnosis  was 
made,  alihotigh  with  some  reservaiion.  The  patient  declined  to 
enter  the  hospital.  He  was  therefore  ordered  galvanism,  but  was 
lost  sight  of  in  the  summer  of  1884.  Two  years  later  he  was  treated 
at  a  hoi>pital  in  this  city  for  six  months.  Although  I  was  unable  to 
obtain  a  record  of  the  case.  I  heard  that  the  tabetic  symptoms  were 
very  indistinct,  and  that  the  condition  suggested  rather  a  spastic 
paralysis.  The  patient  was  again  lost  sight  of.  Finally,  on  Janu- 
ary 8,  1888.  he  was  admitted  to  the  medical  ward  of  the  city  alms- 
houne,  where  he  still  remains.  From  a  note  made  on  January  to, 
1&88,  the  following  in  extracted:  The  patient  is  a  well>nourished 
man ;  as  he  bes  quietly  in  bed,  the  general  aspect  suggests  nothing 


fSSS  OF  THE  GENERAL  NERVOUS  SYSTEM. 

lurma];    ii,  however,  he  is  asked  to  perform  any  movement,  ihe 

lie  body — trunk,  head,  and  extremities — is  seized  with  a  violent 

ting  tremor,  which    makes  it   difficult    for   him    to  get  up,  and 

passible  for  him  to  walk  without  assistance  from  another  person. 


even  when  supported  by  two  canes.  If  he  is  allowed  to  discontinue 
all  attempts  at  moving,  the  tremor  gradually  abates,  and  five  or  ten 
minutes  later  he  is  perfectly  quiet  again.  The  patient  is  unable  to 
feed  himself,  and  can  not  occupy  himself  with  anything.  The  Dus- 
cular  strength  is  retained  everywhere.     In  the  domain  of  the  cranial 


MULTIPLS  SCLBKOSIS. 


623 


TVM  nothing  but  nysta^us  can  be  noticed,  which  is  especially 
II  marked  on  (lie  right  »ide.  The  facial,  hyitoglos-sal,  etc.,  are 
rmal.  The  tongue  is  protruded  steadily  and  siraisht.  Speech  is 
■r,  although  not  distinctly  scanning.  There  are  no  motor  or  &cn- 
7  speech  disturbances.      The  tendon   reflexes  in  the  upper,  but 


lily  in  the  lower  extremities,  are  increased,  and  the  skin 
exes  are  without  exception  well  marked.  Sensory  changes  can 
irhcre  be  demookt rated,  and  the  bladder  disturbances,  which  were 
■ent  ofl  previous  occuionK,  have  disappeared.  The  spinal  column 
(lovbert  lender  on  pressure.     Among  the  subjective  complaints 


I 


^^issjISHs  op  the  general  nervous  system. 

of  the  patient  the  dizziness  is  alone  to  be  mentioned,  which,  however, 
even  if  the  shaking  movements  were  not  present,  in  itself  would  be 
sufficient  to  keep  him  from  doing  anything. 

As  a  result  of  this  examination  the  diagnosis  of  multiple  sclerosis 
was  made,  and  will  certainly  be  proved  to,  be  correct  at  the  post-., 
mortem  examination.  It  is  iaterestiDg,  however,  that  in  this  case 
the  course  of  the  disease  suggested  in  its  initial  stages  Thomsen's 
disease  (although  not  congenital),  later  tabes  (with  retained  knee- 
kick),  then  spastic  spina!  paralysis  (conjectural  diagnoEis),  before 
the  picture  of  insular  sclerosis  developed. 

Diagnosis. — The  diagnosis  presents  difficulties  Id  almost 
every  case,  owing  to  the  protracted  course  and  the  changes  in 
the  picttire  of  the  disease  during  the  diRerent  periods.  Even 
the  most  careful  examination  will   not  always  keep  ps  Jrom 

MJ 

^^^  /n2) 

F^.  167.— SpectuEN  OF  Hakdwritino  or  a  Patient  (hat-uaeer)  with  a  Hercd- 

RUL  TaEHOR. 

errors,  and  we  must  never  be  surprised  if  the  autopsy  does  not 
always  confirm  the  diagnosis  made  during  life.  The  case  of 
Westphal,  in  which  a  multiple  sclerosis  was  diagnosticated, 
but  where  post  mortem  no  lesions  at  all  were  found,  has  been 
alluded  to  before.  In  another  instance,  reported  by  Frey  (cf. 
lit,),  there  was  found,  instead  cf  the  confidently  expected  foci 
of  sclerosis,  a  leptomeningitis,  and  simitar  errors  would  not  be 
difficult  to  find  on  a  careful  perusal  of  the  literature.  The  pos- 
sibility that  we  are  dealing  with  hysteria,  in  a  given  case,  must 
always  be  considered,  and  then,  of  course,  great  weight  must 
be  laid  upon  the  presence  of  other  symptoms  which  would 
indicate  such  a  condition.  The  difference  between  intention 
tremor,  as  illustrated  in  Fig.  164.  and  other  tremors,  can  be 
seen  by  a  comparison  with  Figs.  165-168. 


MULTIPLE  SCLEROSIS. 


6as 


Patholog:ica]  Anatomy.— The  anatomical  changes  of  muU 
tiple  sclerosis  arc  t'xtrcmely  characteristic.  Even  with  the 
naked  eye,  here  and  there,  grayish-white  (oct  are  seen  in  ihe 
brain,  in  the  white  matter  of  the  liemispheres.  in  the  walls  ul 


the  lateral  ventricles,  in  the  corpus  callosum,  in  the  pons,  and  on 
its  surface,  in  the  medulla  oblongata,  in  the  floor  of  the  fourth 
ventricle,  and  in  the  spinal  cord,  where  the  white  matter  is 
decidedly  more  aflcclcd  than  the  gray.  The  foci  are  distrib- 
uted in  a  very  irregular  manner ;  somclimcs  they  arc  more 
Dumerous  in  the  brafn,  sometimes  they  are  more  numerous  in 


626       nrSKASES  OF  TKF.   GBt/EftAL  iS'F.RVOVS  SYSTEM, 

the  cord,  often  tliey  are  found  scattered  equally  over  tl 
tire  central  nervous  syslem.  If  they  arc  situated  on  the  sur- 
face, they  are  seen  ihrouj^h  the  pia,  and  arc  somewliat  more 
prominent  than  the  parts  which  surround  them.  They  arc 
generally  harder  and  firmer  than  the  rest  of  llic  substance,  and 
on  section  they  assume  a  light-pink  color  when  exposed  to  Ihc 
air.  If  they  are  examined  microscopically,  they  arc  found  to 
consist  of  reticulated  fibrillary  supportin;;^  tissue,  and  contain 
only  a  few  intact  nerve  fibres  ;  after  the  death  ol  the  mcdullarr 
sheaths,  the  axis  cylinders  are  preserved  for  aii  extiaordinarir 
length  of  lime  (Charcot).  Secondary  degenerations  in  the 
spinal  cord  are  often  absent  (Sirtimpell).  yet  they  are  occasion- 
ally seen  (VV'erdnig),  The  vessels  show  an  increase  in  the 
nuclei,  later  a  thickening  of  their  walls,  and  are  seen  as  yellow 
dots  in  the  sclerotic  foci.     Whether  the  disease  of  the  vessels 


Ftc.  i«»— CucoifcBEirno)!  THxnijoH  THt  CKKVicAr.  EHutttaENsn  OP  THE  Snmi 
Conn  IK  «  C-UE  OF  Ui'i.tipli:  SrLsiutKi.  Iliinlimnl  in  ctniic  add  The  lict-w 
colored  arau  in  the  white  nuticr  ntittwnt  (he  (deroiic  lad,    (Afiet  Bramwku.) 


actually  {lives  rise  to  the  foci  is  not  yet  established  (Fig.  ifij^ 
Disease  of  the  peripheral  nerves  has  never  been  demonstrated 
in  multiple  sclerosis. 

iEtiology. — About  the  xtiolngy  we  know  practically  noth- 
ing-. It  is  possible  that  heredity  deserves  some  considerali<M 
in  this  connection,  but  there  arc  relatively  many  cases  in  whicli 


fjtos/s. 


this  factor  can  positively  be  excluded.  The  influence  of  infec- 
tious diseases  upon  the  development  of  insubr  sclerosis  has 
recently  again  been  dwelt  upon  by  Marie  (cf.  IJL).  Typhoid 
(ever,  variola  (Sottas.  Gaz.  dcs  hflp.,  iSgz.  44).  scarlet  lever, 
measles,  whooping^oiigh,  iiilluenza  (Massalungo,  Silvestri, 
Revue  neurol..  1895,  i,  23).  and  inlerminent  (ever  have  repeat, 
tfdly  been  known  to  precede  the  disease,  although  the  material 
at  our  disposal  is  not  as  yet  sufficient  to  prove  a  causative  rela- 
tion between  the  two.  With  regard  to  syphilis  the  connection 
here  is  by  far  less  definite  than,  for  instance,  in  tabes  (cl.  the 
case  of  Buss.  lit.).  Age  and  sex  seem  to  be  of  some  signifi- 
cance, inasmuch  as  children  and  aged  people  seem  to  be  ex- 
empt. W'estphal  and  others  have  only  exceptionally  seen  it  in 
children.  Strflmpcll  has  observed  it  in  a  man  of  sixty.  Both 
sexes  seem  lo  be  attacked  with  about  the  same  frequency,  t 
hiive  set-n  a  case  in  which  alter  a  severe  traumatism  (fait  Irom 
a  ladder)  the  three  cardinal  symptoms  of  multiple  sclcri>sis  de- 
velopcd  ;  nevertheless  I  am  not  convinced  that  the  case  was 
not  one  of  traumatic  neurosis.  The  question  c:in  only  be  settled 
bjf  the  autopsy. 

Treatment. — An  effectual  treatment  for  multiple  sclerosis 
not  exist.     We  possess  no  remedy  which  will  arrest  the 

Klopment  of  the  foci.  The  syinplomattc  treulment  must 
always  be  tried,  however,  and  the  patient  particularly  seeks 
relief  from  the  annoying  tremor.  For  this  we  may  administer, 
although  without  raising  our  expectations  too  high,  vcrairine, 
physostigminc,  one  to  three  milligrammes  (grs.  V^-'/^)  daily,  in 
pills,  or  solanin,  recommended  by  Grosset  and  Sar<la,  and  even 
icrmed  by  these  authors  "  mfjictimf»t  Ju  /aistfau  pyramUial" 
<Progr.  tTv6d.  1888.  27).  It  may  be  given  in  doses  of  from  two 
10  three  centigrammes  (grs.  '/j-'/,l  from  three  to  five  times 
daily.  In  other  respects  the  treatment  is  the  same  as  in  iiiye- 
l)tis(cf.  page45S)■ 
R0V%lii  (M(Nlfna).    Sclcron  iiiulli[iU  <kl  midolk)  ipinalc  complk^aa  Mic«M. 

RrSK^o  Ennlia.  1S84. 
Mafic.  P.    rrogrfe  mU.,  1884.  xii.  ij,  16.  iS.    (Muliiple  Scleroito  and  Inkc- 

CtikciburK.     N«utoI.  ConlnlU.,  tS&4.  11. 

tlitt.     DiffierctiiulduKnnKr  insiKlten  ttysierie  unO  multipler  Sclrtow.     Bml. 

InU.  Zeiuchr..  1S8}.  mi.  11. 
tnuhoOl     Uriicr  Nraritis  opiic.i  lici  ratitlipkr  SckroK.     lktlln«r  klU.  Wocbco' 

tchr.  iSSj,  16. 


62S 


DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM, 


KoeppeiL    Arch.  f.  hych.  u.  Ncrrenlcraiikhdtai.  1886,  zvS,  I,  p.  63.    (Anv 

tomical  Examination.) 
Cramer,  E.     Ueber  das  Wesen  dcs  JStterns.    Aus  der  Krankenabdieilung  da 

BresUuer  Annenhauses.    (Prof.  Hirt.)    Inaug.-Dissert.,  fireslau,  1886. 
Moncorva    Sulla  ctiologia  delU  aclerosi  a  placche  mi  bambini  e  spccialmmto 

sulla  influenza  palogcnica  della  aifilida  ereditaiia.    Napoli,  1887. 
Gilbert  et  Lion.    Contribution  i  I'jtude  de  la  sclerose  en  plaquea  4  forme  pora- 

lytique  de  la  variiij  himipi^que:    Arch,  de  phya.  nonn.  et  palhol.,  3(m 

sir.,  Juillet,  1S87.  p.  116. 
Unger.    Ueber  multiple.  inselfSrm.  Sclerose  im  Kindesalter.    Ldpzig  u.  Wien, 

1887,  TiSplitz  u.  Deuticke.    (NeuroL  Centralbl.,  1888,  3.) 
Oppenheim.    Berliner  klin.  Wocheiuchr.,  1887.  48. 
Stephan.    Zur  Genese  dea  Intentionnremor.    Arch.  f.  Psych,  u.  NeTvaUaank- 

heilen,  1886,  zviii,  3  uhd  1887,  su,  i.     (With  sixty-one  references.) 
Buss.    Berliner  klin.  Wochenschr.,  1887,  sxiv,  49.    (Multiple  Sderosic  in  a 

Child  with  Hereditary  Syphilis.) 
Werdnip    Ein  fall  von  disseminirter  Sclerose  des  RiickenmariEcs,  Tcibundai 

mit  secund&ren  Degenerationen.      Med.  Jahrb.,  Wien,  1889,  Jahi;.,  S|. 

Heft  7,  p.  335- 
UhthofT.    Untersuchungen  liba  AugenstSrungen  bei  multipler  Herdsderost 

Arch.  f.  Psych,  u.  Nervenkrankhejten,  1889,  xxi,  i. 
Charcot.    Sclerose  en  plaques  et  hystirie.    Gas.  hebd.,  1889.  2me  tir.,  nri,  7. 
Buss.     Deutsches  Arch.  f.  klin.  Med.,  1889,  5,  & 
Chaslln.    Arch,  de  m£d.  expfrim..  1891,  3. 
Nolda.    Arch.  i.  Psych.,  1891,  3,  p,  $6$. 
Closer.     Zdtschr.  f.  klin.  Med.,  1892,  3.  4. 


CHAPTER   II. 


TABES   DORSAL1S — LOCOUOTOR    ATAXIA    (rOSTERIOR   Sf>l?<AL 
SCLKKOSIS — LEUCOMVKLITIS  POSTERIOR  CMROKICA). 

TllK  second  of  tlic  diseases  belonging  to  this  group  cer- 
tainly deserves  to  be  considered  as  one  of  the  most  important 
of  those  with  which  we  arc  acquainted,  not  only  because  it  is 
to  be  reckoned  among  the  diseases  of  the  nervous  system  which 
occur  relatively  Ircqucntly,  and  with  which  the  general  practi- 
tioner is  not  rarely  brought  face  to  face,  but  also  because  its 
clinical  picture  presents  so  many  essential  differences  that  it 
requires  a  large  experience  to  fed  at  home  with  it  on  all  occa- 
sions. Nr}body  questions  the  importance  of  the  recognition  of 
the  disease  in  its  early  stages  if  only  on  account  of  its  bciring 
upon  the  treatment,  but  many  do  not  appreciate  the  ditticultics 
which  this  early  diagnosis  entails.  The  more  cases  of  tabes 
we  sec,  the  more  we  are  surprised  at  the  protean  charocter  of 
the  symptoms,  and  the  more  arc  we  convinced  that  almost 
every  case  offers  some  point  of  particular  Interest,  and  that 
occasionally  even  an  expert  can  be  sure  of  the  diagnosis  only 
afler  repeated  examinations  and  long  observation. 


I.ITKRATirRF. 

/.  CfnfUi.  Momogntfki,  tit. 

Adamklvwirf.      Die  Kilckcnmnrksschwindsucht.     Wien.  Ttfpliti  a.  Dcuilckc, 

1888. 
Siriimprll,     t'ehrr  Wnen  unil  BEhandlung  <lcr  Tabes.     MitlKh.  xatA.  Wo- 

clicnwhr.  i8go,  39. 
KouHiUngc.    CDnlriliutinn  a  I'ilude  <lu  tatxs  et  <)c  I'KysKric.    I'htsi-  dr  PnTin. 

1893, 
Minor,     NpiirnI  CcniralW.,  1B93. 
M»biu».    Schmiilf*  JalirbuchtT.  tSiM.  ocxli.  p.  7),    (Ninth  Report  on  Ta1>cs.) 

Symptoms. — The  symptomatology  of  tabes  is  so  comprc. 
hcnsivc  that  in  order  to  get  a  clearer  idea  of  it  we  shall  in  our 
description  separate  the  cerebral  from  the  spinal  symptoms. 

The  cerebral  symptoms  which  appear  in  tite  course  ol  the 

6»} 


630 


I>ISEASKS  OF  THE  GES'EKA!.  KERVQVS  SYSTEM. 


disease  are  referable  eillier  to  ttie  craninl  nerves  or  lo  the  bnio 
substance.  When  the  latter  is  alTccted.  it  is  sometimes  the 
cortex,  at  other  limes  the  white  substance,  or  again  the  basal 
ganglia,  which  arc  most  deeply  implicated. 

In  consideriitg  the  cranial  nerves,  we  shall  find  that  there  ts 
hardly  a  single  pair  which  can  not  be  alTectcd  and  in  which 
lesions  have  not  been  repeatedly  described  i»  cases  of  labes. 
However,  as  we  shall  see  later,  not  all  of  them  arc  implicated 
with  the  same  frequency.  Among  them  the  nerves  supplying 
the  muscles  of  the  eye  arc  most  commonly,  the  facial  most 
rarely,  attacked.  Between  these  extremes  we  may  put  in  de- 
scending order  the  vagus,  the  optic,  the  fifth,  the  olfactory,  the 
glosso-pharyngeal,  the  accessorius,  the  hypoglossal,  and  lasily 
the  auditory.  I  have  observed  three  cases  in  which  several 
pairs  of  nerves  were  involved  at  the  same  time  and  in  which 
the  onset  of  the  disorder  was  somewhat  acute. 

The  lesions  of  the  olfactory  nerve  possess  no  great  prac- 
tical significance,  and  it  is  not  quite  certain  that  they  arc  not 
more  frequent  than  is  generally  supposed.  They  consist  of  a 
weakening  or  even  total  loss  of  the  sense  of  smell,  or  in  the 
perception  of  peculiar,  often  disgusting  odors,  as  we  hate 
shown  on  page  26.  We  do  not  know  whether  these  changes 
are  due  to  anatomical  lesions  or  only  to  some  functional  dis- 
turbances, and  but  little  is  known  about  the  course  of  such  dis- 
orders of  the  sense  of  smell.  Occasionally,  when  examining 
into  the  condition  of  the  sense  of  taste,  one  may  accidentally 
discover  an  affeciion  of  the  sense  o(  smell  without  being  able 
to  ascertain  how  long  it  has  already  existed,  as  it  can  easily 
have  escaped  the  notice  of  the  patient.  Only  those  who  uk 
tobacco  or  snufl  perceive  the  defect  very  early  and  appeal  W 
a  physician  for  advice  and  help.  Unfortunately,  we  can  do 
but  litilc.  The  treatment  of  these  affections  has  been  dealt 
with  on  page  27. 

The  roost  frequent  lesion  of  the  optic  nerve  in  tabes  i* 
atrophy  or  gray  degeneration.  Usually  both  eyes  become  af- 
fected, if  not  simultaneously,  at  least  within  a  short  time  of 
each  other,  and  it  is  quite  rare  for  one  eye  to  be  diseased  while 
the  other  remains  healthy  for  any  great  length  of  lime.  The 
patients  complain  that  everything  seems  as  if  covered  by  a 
gray  veil.  The  loss  of  vision  is  particularly  rapid  at  first :  i< 
then  becomes  much  slower,  and  the  complete  amaurosis  occuH 
much  later  than  one  would  have  expected  from  the  brusqi"^ 


■MH 


TABES  DO/tSAUS. 


631 


I 


I 


onset  of  the  trouble.  Along  with  this,  a  narrowing  (not  al- 
ways concentric)  of  the  visual  field  appears,  as  the  peripheral 
portions  of  the  retina  arc  the  first  to  become  impaired  in  their 
limctlons.  The  perception  for  color  may  also  be  aSected,  as 
wc  pointed  out  un  page  34.  The  order  in  which  these  changes 
occur  is  not  always  the  same.  As  a  rule,  however,  the  loss  of 
color  perception  and  the  narrowing  of  the  visual  field  precede 
the  lessening  in  acuteness  of  the  central  vision,  and  it  Is  excep- 
lional  to  find  diminished  acuteness  of  vision  and  marked  dis> 
turbance  of  color  sen&e  combined  with  a  normal  visual  field. 

With  regard  to  the  frequency  of  the  affection  ol  the  optic 
nerve  in  tabes,  the  usual  statements  ol  authors  hardly  give  a 
correct  idea  ;  the  more  careful  our  examinations  are  the  more 
oJicn  do  wc  find  them.  According  to  my  experience,  it  may 
certainly  be  s:ud  that  they  occur  in  sixty  per  cent  of  all  cases 
(cf.  the  excellent  piece  of  work  of  Martin,  r)e  Talrophie  du  nerf 
Dptique  et  sa  valcur  prognostiquc  dans  la  scl^-rosc  dcs  cordons 
posl^rieurs  de  la  moelle,  Paris,  Assclin  ei  Houzeau,  TS90). 

The  ophthalmoscopic  examination  shows  a  pale  gniyish 
white  or  bluish  while,  but  not  pure  white,  discolor.1t ion  of  the 
disk,  which  is  thought  to  be  produced  by  the  obliteration  of 
numerous  fine  vessels  in  the  optic  nerve.  When  the  ambly- 
opia is  marked,  but  no  perceptible  changes  in  (he  disk  arc 
found,  we  must  think  of  a  retrobulbar  degeneration  of  the  optic 
nerve.  From  a  pathological  st.indpoint  we  arc  dealing  with  a 
degenerative  atrophy,  first  of  the  medullary  sheaths,  and  then 
of  the  axis  cylinders.  The  theory  that  these  changes  are  due 
to  an  action  of  the  sympathetic  nerves  or  to  changes  in  the 
vaso-molor  nerves  brought  about  by  the  spinal  disc.isc  is  quite 
untenable,  (or  the  process  is  a  neuritis  in  which  we  have  u 
wasting  of  the  nerve  fibres  and  changes  in  the  interstitial  tis- 
sue, such  as  have  been  described  on  page  351. 

For  the  optic  atrophy  the  outlook  is  altogether  unfavor- 
able :  although  a  slight  impro%-cment  or  a  temporary  arrest  of 
its  pnigrcss  may  give  the  patient  a  delusive  hope  of  recovery, 
the  termination  is  aUv.iys  in  total  blindness.  It  is  true  that 
the  process  may  take  several  years,  during  which  the  patient 
is  still  able  to  find  his  way  about  by  himself  with  the  aid  of  a 
Stick. 

With  such  a  prognosis  we  shall  not  be  surprised  if  the 
treatment  is  without  avail.  The  subcutaneous  injections  of 
strychnine,  one  milligramme  (grs.  'i.)  twice  daily  in  the  neigh- 


6i2 


DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 


bnrhond  of  the  eye,  as  proposed  by  some,  are  of  vatuc  only 
because  they  give  the  patient  the  comforting  satisfaction  that 
something  is  being  done  for  him,  but  they  really  have  no  cura- 
tive properties,  and  it  is  improbable  that  they  even  postpone 
the  unfavorable  issue. 

In  a  few  isolated  cases  transient  lachrymation  has  been  ob- 
served {Patrolacci,  Thfrsc  de  Montpellier,  1886;  K6r6,  L'Enc^ 
pliale,  1887.  vii.  4), 

The  nerves  which  supply  the  eye  muscles— the  third,  the 
patheticus,  and  the  abducens — the  affections  of  which  have  aK 
ready  been  considered  in  Part  II,  Chapter  111,  frequently  be- 
come attacked  in  the  course  of  labcs.  Besides  the  insuffi- 
ciency of  convergence,  the  central  form  of  which  may  be 
termed  motor  asthenopia  (Hiibscher,  Deutsche  mcd.  Wo. 
chenschr.,  1893,  17),  one  often  encounters  a  diplopia  resulting 
from  a  panilvsis  of  the  ocular  muscles.  This  may  appear  sud- 
denly, and  after  a  longer  or  shorter  duration  disappear  as 
quickly  ;  or,  :igain,  it  may  recur  repeatedly  and  be  a  source  o( 
great  annoyance  to  the  patient  in  his  daily  occupations.  An 
abducens  paralysis  may  also  occur  by  itself,  and,  finding  this, 
one  should  always  look  for  a  commencing  tabes,  for  it  is  fre- 
quently the  first  sign  of  this  disease  in  an  apparently  quite 
healthy  person.  If  the  affection  remains  stationary,  it  is  to  be 
regarded  as  being  due  to  a  nuclear  Jesion ;  the  same  remarks 
apply  to  a  ptosis  which,  occurring  by  itself,  is  also  a  suspicious 
sign,  and  should  lead  us  to  took  for  tabes.  In  cases  of  oculo- 
motor paralysis  the  lesion  is  also  relatively  frequently  nuclear 
(page  46).  Waitevillc  (Neurol.  Centralbl..  1887,  10)  has  called 
attention  to  a  paralysis  of  the  movcmcnis  of  convergence,  espe- 
cially in  the  initial  stages  of  tabes.  Borel,  in  a  paper  published 
under  the  direction  of  [..andolt  in  Paris  {.Arch,  f.  Ophthalm., 
Novembre,  1887),  has  dealt  with  the  same  symptoms.  Several 
of  the  extrinsic  eye  muscles  may  be  affected  at  the  same  timft 
and  an  ophthalmoplegia  externa  is  not  infrequently  observed 
in  the  course  of  tabes. 

The  behavior  of  the  intrinsic  eye  muscles  is  not  less  inter- 
esting, and  the  condition  of  the  pupils  deserves  the  most  thor- 
ough examination  ;  they  are  rarely  normal  and  of  the  same  size 
in  both  eyes.  Frequently  some  abnormity  of  reaction  is  de- 
monstrable :  the  marked  contraction  (inyosis),  the  difference  in 
the  size  of  the  two  pupils  (anisocona),  and  the  loss  of  the  light 
reflex   have  already  been  mentioned.     These  changes  force 


{ 


TABSS  DOJISALIS. 


6J3 


US  '  to  assume  a  lesion  in  the  floor  of  the  fourth  ventricle 
JOuillcry). 

The  ophthalmoplegia  interna  of  Hutchinson,  in  which  be> 
'sitles  the  loss  of  the  li^ht  rvflcx  there  is  :i1su  paralysis  of  the 
mus<:Ics  of  accommodation,  is  much  rarer.  The  pupils  of  those 
■alTlicted  with  tubes  may  frequently  be  found  to  dilute  promptly 
and  normally  under  strong  and  painful  irritation  ol  the  skin,  as, 
for  CTcaiitpk-,  that  produced  with  the  faradic  brush. 
B[  The  rdle  which  the  affections  of  the  fifth  nerve  ptay  in  this 
disease  is  quite  suburdinale;  paralytic  conditions  of  either  it« 
motor  or  sensory  branches  as  the  result  of  tabes  have,  it  seems, 
never  been  observed  except  in  Wcstphal's  case,  in  which  there 
was  degeneration  of  the  ascending  root  of  the  fifth,  and  among 
the  signs  of  irritation  only  the  headache,  tnict-ablc  to  the  nerve 
endings  in  the  dura,  is  occasionally  met  with.  A  certain  rela- 
tionship is  said  to  exiKt  between  tabes  and  genuine  migraine, 
but  in  considering  these  cases  one  must  make  sure  that  the  mi- 
B^^ine  has  not  been  inherited,  and  furthermore  note  whether 
^thc  attacks  become  more  or  less  severe  after  the  development 
of  ihc  tabetic  symptoms.  According  to  some  observations,  in 
such  cases  the  headache  o(  the  migraine  becomes  less  and  less 
severe,  and  eventually  disappears,  while  the  nausea  and  vomit- 
ing still  persist,  so  that  it  is  then  impossible  to  say  whether  wc 
are  dealing  with  a  gastric  crisis  of  tabes  or  with  an  abortive 
attack  of  migraine.  In  certain  cases  of  hemicrania,  il  there  has 
been,  for  instance,  a  syphilitic  Infection  at  some  previous  limPt 
it  is  always  well  to  examine  carefully  for  any  traces  ol  tabes, 
more  especially  for  the  absence  of  the  patellar  reflex.  Occa- 
sionally one  meets  with  parxsthesias  in  the  face,  the  patient 
oimplaining  of  a  sensation  as  if  one  half  of  the  face  and  the  lips 
were  swollen ;  this  is  probably  also  due  to  an  affection  of  the 
ascending  root  of  the  fifth  nerve. 

Lesions  of  the  facial  nerve  arc  so  rare  in  tabes  that,  when 
they  occur,  one  can  not  help  raising  the  question  whelliiT  they 
are  not  lo  be  regarded  merely  as  accidental  complications. 
Among  three  hundred  and  forty-live  cases  of  locomotor  ataxia, 
I  have  observed  only  two  in  which  any  of  the  muscles  supplied 
by  the  facial  were  affected. 
H  About  the  same  may  be  said  of  the  auditory  nerve.  There 
Vis  no  question  but  that  lesions  ol  this  nerve  may  be  caused  by 
tabes  nr  develop  in  the  course  of  the  disease,  but  they  are  very 
ire  indeed  ;  ihey  manifest  themselves  by  a  diminution  or  a 


634 


DISEASES  OP  THE  GENERAL  NERVOUS  SYSTEM. 


total  loss  of  the  power  of  licaring.  The  patients  complain  o( 
deafness,  which  may  have  developed  gradually  or  have  come 
(in  acutely.  In  both  cases  the  symptoms  are  due  to  organic 
disease  of  the  nerve ;  in  the  former  we  have  to  deal  with  a 
gradual  gray  degeneration  of  the  nerve  trunk,  in  the  latter 
with  a  nuclear  affection.  Too  few  cases,  however,  of  involve* 
mrnt  of  the  atidiiory  nerves  in  tabes  have  as  yet  been  ob. 
served  to  enable  us  to  speak  with  much  certainty  of  their  pa- 
thology (Hermct,  L'Union  mi^d.,  1884.86:  Morpurgo,  Arch.  I. 
Obrenhlk.,  1S91,  xsx,  26).  Under  what  conditions  the  so-called 
Meniere's  symptoms  appear  in  the  course  of  tabes  requires  to 
be  studied  more  closely.  I  have  seen  them  in  two  of  my  cases, 
but  they  disappeared  again  in  a  few  weeks,  and  in  these  cases, 
unfortunately,  no  anatomical  ex-iminalion  o£  the  internal  ear 
could  be  made. 

Functional  disturbances  of  the  nerve  of  taste  have  now  and 
then  been  described  in  the  course  of  tabes.  In  a  few  instances 
as  in  the  case  of  Erbcn,  which  we  considered  on  page  108.  the 
nucleus  of  the  glosso-pharyngeal  nerve  was  degenerated,  and 
during  life  such  derangements  of  the  sense  of  taste  existed  thai 
the  patient  was  at  times  unable  to  distinguish  sweet  things 
from  those  which  were  acid  or  salty.  To  these  lesions  no  great 
practical  significance  can  be  attached. 

On  the  other  hand,  there  is  a  great  v.iriety  of  manifcsta. 
tions  associated  with  tabes  which  are  due  to  lesions  of  the 
vagus.  In  this  connection  wc  have  disturbances  more  gener- 
ally of  the  digestive,  but  also  of  the  respiratory  and  circulatory 
organs.  They  occur  with  irregularity,  and  may  disappear 
again  quite  suddenly.  Following  the  suggestion  of  Charcot, 
we  designate  ihcm  "crises."  Of  those  affecting  the  digestiit 
system  the  so-called  "pharyngeal  crises"  are  relatively  the 
rarest.  These  consist  of  paroxysmal  movements  of  degluti- 
tion, which  occur  from  twenty  to  twenty-four  times  a  minute, 
and  succeed  one  another  in  this  way  for  ten  or  twenty  minutes: 
the  attacks  may  be  associated  with  a  noisy  inspinition,  and 
may  suggest  hysterical  singultus :  in  some  cases  they  can  tw 
produced  at  will  by  pressure  on  the  side  of  the  larynx  (Oppen- 
hcim). 

The  gastric  crises  (Charcot)  are  far  more  frequent ;  they 
consist  of  paroxysmal  attacks  of  retching  and  vomiting,  during 
which  the  patient,  without  any  particular  exertion,  may  vomit 
lat^e  quantities  of  strongly  acid,  slimy,  or  watery  material,  some- 


TASES  DOItSAUS. 


«3S 


I 

I 


I 


jttraes  of  ft  blackish  appearance,  after  which  he  feels  greatly  re- 
lieved. These  attacks  arc  rcjMrated  (or  several  days,  sometimes 
tor  a  week  or  two,  once,  twice,  or  even  odener,  every  day,  and 
then  disappear  entirely  fur  a  longer  or  shorter  period.  In 
gome  cases  the  vomiting  is  associated  with  cardialgia,  but  tisii- 
ally  it  is  uncomplicated.  It  is  not  at  all  connected  with  the 
taking  of  food  ;  indeed,  it  not  infrequently  occurs  early  in  the 
morning  when  the  stomach  is  empty,  and  if  the  patient  be  a 
drinking  man  it  may  arouse  a  suspicion  of  the  morning  vomit- 
ing of  drunkards.  The  diflcrrntial  diagnosis  is.  however,  not 
at  all  difficult ;  if  the  vomiting  be  associated  with  vertigo,  a 
sensation  of  anxiety,  and  a  quickening  of  the  pulse,  It  can  not 
be  considered  simply  as  a  "gastric  crisis."  This  paroxysmal 
vomiting  is  of  the  greatest  importance  for  the  diagnosis  of 
tabes.  It  is  frequently  regarded  as  dependent  ujion  some 
stomach  trouble  and  treated  as  such  lor  a  long  period  without 
any  sign  of  improvement,  until  finally,  perhaps  by  accident, 
our  attention  is  drawn  to  some  other  symptom  which  places 
ihe  diagnosis  beyond  doubt.  If  a  person  have  paroxysmal 
vomiting  and  complain  occasionally  of  violent  rheumatoid  |Kiins 
in  the  legs,  we  should  examine  most  carefully  for  iat>es,  and  wc 
shall  frequently  be  surprised  at  the  case  with  which  wc  can 
make  a  diagnosis,  and  wonder  that  wc  had  ever  been  under  the 
impression  that  the  patient  had  simply  "  chronic  gastritis  "  and 
**  rheumatism."  The  statement  of  Eckert  (Die  intcstinalen 
Erscheinungen  der  Tabes,  Inaug.-Diss.,  Ilerlin,  1S87)  that  gas- 
tric crises  must  be  divided  into  those  of  central  and  those  of 
reflex  origin  deserves  to  be  investigated  more  closely.  In  the 
central  form  he  assumes,  besides  a  general  condition  of  irrita- 
tion in  the  bniin,  some  affection  of  the  nucleus  of  Ihe  vagus,  in 
Ihe  reflex  form  a  peripher,il  irritation  of  the  vagus  which, 
under  certain  circumstances,  may  be  produced  by  the  ingesla. 
He  holds  that  in  the  latter  cases  the  %-oniitlng  is  not  associated 
with  any  distressing  nausea,  so  that  the  patient  suffers  rela- 
tively little. 

Sometimes  intestinal  dlstiirb-inces  manifest  themselves  by 
intense  "  lightning  "  pains  alxiut  the  rectum  ami  anus,  the  "  anal 
crises  ■' :  in  other  cases  by  tenesmus,  which  forces  the  patient 
to  go  frequently  to  stool,  though  he  is  able  to  pass  little  or 
nothing  :  and  [.istly  by  the  so-called  tabetic  diarrhtra, about  the 
causation  of  which  we  arc  absolutely  ignorant.  This  diarrhcea 
may  be  more  or  less  persistent,  and  be  followed  by  an  equally 


636        D/SBASES  OF  THE  GENERAL  NERVOUS  SYSTBV.  ^ 

protracted  and  obstinate  constipation.  Incontinence  of  fxces 
is  rarely  present,  thougli  on  rectal  examination  we  shall  occa- 
sionally discover  sensory  disturbances,  particularly  anscsthesta 
of  the  mucous  membrane.  Paresthesias  may  also  occur,  and 
the  patient  may  experience  a  sensation  as  if  be  had  a  foreign 
body  En  the  rectum. 

By  "laryngeal  crises"  wc  mean  those  paroxysms  of  dysp- 
na-a  which  may  occur  when  the  palient  is  lying  down,  or.  in 
other  cases,  only  when  he  attempts  to  move  or  walk  about. 
Sometimes  they  appear  in  the  form  of  peculiar  suQocative  at- 
tacks,  accompanied  by  violent  coughing,  and  are  often  pre- 
ceded by  a  sighing  or  whistling  inspiraiion.  These  attacks 
may  last  several  minutes,  during  which  the  suffering  may  be 
so  intense  that  the  patient  gives  up  all  hopes  of  recovery. 
Attacks  of  even  moderate  intensity,  in  which  a  long,  sonorous 
inspiration  follows  several  short  expirations,  are  most  disagree- 
able  for  the  patient,  and  appear  very  serious:  under  some  cir- 
cumstances they  may  be  mistaken  for  whooping-cough.  These 
crises  arc  caused  by  changes  of  temperature,  speaking  for  a 
long  time,  or  by  strong  odors,  smoking,  etc.  The  result  of  the 
laryngoscopic  examination  is  freciucntly  negative ;  in  other 
cases  one  Jinds  p^iralysis  of  some  of  the  laryngeal  muscles; 
here  also,  in  all  probability,  wc  should  distinguish  a  central 
and  a  reflex  form. 

Abductor  paralysis — t.  e.,  paralysis  of  the  muscles  that  opec 
the  glonis— sometimes  occurs  among  the  early  signs  of  tabes, 
and  may  lead  to  serious  danger  of  suffocation;  but  wc  are 
unable  lo  say  whether  this  should  be  attributed  exclusively  lu 
paralysis  of  the  abductors,  or  to  spasm  of  the  adductors  atone, 
or  to  both  conditiims,*  We  may  consider  the  condition  de- 
scribed by  t»r^y  (Brain,  January.  18S8).  in  which  the  voice 
often  breaks  and  takes  on  a  high  falsetto,  asa  kind  of "  laryngeal 
ataxia." 

Attacks  of  angina  pectoris,  with  all  its  characteristic  symp- 
toms, are  rarely  met  with  in  tabes,  though  Vulpian,  among 
others,  has  seen  them  (Kevue  de  m6d.,  1885.  v,  i). 

Lesions  of  the  acccssorius  arc  considered  as  rarities  in  the 
course  of  tabes.  They  are  occasionally  found  associated  with 
a  posticus  paralysis  when  the  outer  branch  of  the  spinal  acces- 
sory is  also  affected  ;  the  stcrno-clcido-mastoid  and  trapezius 
muscles  then  show  atrophic  changes.  In  a  case  observed  br 
Martius  there  was  an  atrophic  paralysis  of  the  upper  portions 


TABES  UOKSAUS. 


6l7 


\ 


of  both  trapezii,  while  the  sterno-cleido-mastoids,  which  also 
receive  fibres  from  the  cervical  plexus,  were  not  aflccted. 
Whether,  and  if  so  under  what  circumsunces,  one  or  both  of 
the  two  nuclei  of  the  accessory  nerve  are  affected  (the  luicleiis 
accessorius  vagi  and  the  nucleus  spinalis)  wc  arc  absolutely 
ignorant.  It  is  also  uncertain  whether  syotptoms  of  irritation 
in  the  domain  of  the  acccssorius — c.  g.,  torticollis — ever  occur 
in  the  courM;  oi  talH's. 

Among  the  lesions  of  the  hypnglossus  there  is  one  which 
deserves  a  special  mention  in  this  place— that  is.  the  hemi- 
atrophy of  the  tongue  described  above,  which  Ballet  (lit.  jwigc 
144)  stated  was  relatively  often  observed.  He  even  went  so 
far  as  to  say  that,  when  one  found  this  hemiatrophy,  tabes 


T\f.  ija— ll8»iiATK)«ir  or  tiik  Tokoub  iw  ak  .nii:. -i;:!^ 
Child  ipencn;^  obaerratiait>. 


)-f«nxrTt.y  llutTcir 


should  always  be  suspected.  We  can  only  agree  with  him  lo 
a  limited  extent.  Wc  have  certainly  found  hcmi.itrophy  in 
cases  of  tabes,  but  one  should  remember  that  it  is  in  ilscit  a  rare 
afTection.  and  that  it  exists  more  often  independently  than  asso- 
ciated with  tabes.     In  addition  to  the  two  cases  mentioned  on 


638 


D/SEASES  OF  THE  GF.XEKAf.  A'EXfOl/S  SySTEif. 


pagjcs  143  and  144  1  have  recorded  another  (Fig.  i;o)  in  which 
there  was  likewise  iiu  (race  ol  locumutor  ataxia,  li  seems  that 
The  hypoglossal  nucleus  is  not  very  liable  to  ihe  degenerative 
processes  of  this  disease. 

Cerebral  disturbances  of  the  most  manifold  variety  appear 
in  the  course  of  tabes,  and  in  the  first  place  attention  must  be 
called  to  the  paroxysms  of  vertigo  which  come  over  the  pa- 
tient when  he  looks  up  or  makes  quick  movements  ol  the  head, 
and  which  impel  him  to  seize  the  nearest  object  to  prevent 
himself  from  falling.  There  may  also  be  found  psychical  de- 
pression and  a  feeling  of  dread  and  anxiety,  which  in  some 
cases  may  be  followed  by  well-marked  psychoses.  Among  the 
not  very  rare  forms  of  psychoses  in  this  disease  we  may  men. 
tion  paranoia,  melancholia,  and  simple  dementia  :  but  far  more 
frequent  and  important  than  all  these  taken  together  is  gcn^ 
cral  paralysis,  which  very  frequently  accompanies  tabes.  Bui 
here  we  must  try  to  make  out  which  ol  the  two  affections  was 
ihc  first  to  develop,  (or  in  some  instances  the  tabes  precedes  the 
paralysis,  while  in  01  hers  the  reverse  is  the  case.  The  pn>ccss 
can  extend  from  the  brain  to  the  cord  or  from  the  coni  to  the 
brain,  as  the  case  may  be.  and  Westphal  was  certainly  justilied 
in  making  the  statement  that  "  in  certain  persons  there  is  a 
peculiar  disposition  ol  the  nervous  system,  and  that  this,  under 
the  influence  of  diflcrent  e-xciting  causes,  the  action  of  which 
we  do  not  understand,  expresses  iiscti  in  the  form  o(  affections 
either  of  the  spinal  or  cerebral  portion  of  the  nervous  system  or 
o(  the  peripheral  cranial  nerves,  the  different  aflcctions  coming 
on  in  some  cases  nearly  at  the  same  Lime,  in  other  cases  ai 
varying  intervals." 

Epilepsy  occurring  in  connection  with  tabes  has  already 
been  considered  in  the  chapter  on  the  former  disease.  On  this 
subject  Schliepcr,  working  luider  my  direction,  has  published 
an  article  (Inaug.-Oiss.,  Breslan.  1884). 

The  cases  of  hemiplegia  wiiich  occur  in  the  course  o(  tabet 
are  mostly  of  the  indirect  variety — that  is,  they  disappear  in  a 
shorter  or  longer  lime — and  do  not  owe  their  origin  to  the 
rupture  of  vessels  or  to  lesions  o(  the  internal  capsule.  The 
face  is  usually  only  slightly  aflccted,  and  that  only  for  a  short 
time,  and  the  extremities  are  not  wholly  paralyzed,  but  are 
only  in  a  paretic  condition,  which  usually  disappears  without 
any  sort  of  treatment.  I  have  repeatedly  seen  such  cases  oi 
hemiparests  come  on  without  any  wanting  and   with  only  J 


\ 
I 


TAffSS  JtO/tSAl/S 


639 


I 


1^ 


ght  disturbance  of  consciousness  and  entirely  disappear  ict 
a  relatively  short  lime.  A.  IJcrnharcil  (Arcliiv  (.  Psych,  u. 
Nervenkrankheitcn,  1883,  xiv,  I)  has  recorded  instances  in 
which  they  were  accompanied  by  aphasic  conditions. 

1.1TEKATUKE. 

r.   Tif  ttrtiit  anJ  lAf  Cntmal  XrrtHi. 

Ilergcr,     D«*  ttoublci  ocuUlm  ilans  Ic  t.ibrs.  tic.     Kcvue  ilc  m*il,.  iS/ga,  3. 
Schultie.    Arch.  f.  Pnych.,  1889.  nxt,  i.     (I'.-ini lysis  of  the  Muscles  of  Masiica- 

llon.) 
Cluiaigner.     Dcs  irouMcs  auilitifs  dans  Ic  lalin.    Tti^w  Ac  Paris,  1889. 
Mati"-'*-     Arch.  C  Pt}'ch..  1S91,  *xi,  I.    (Symptomi  rcTeniMe  lo  Ihe  Ear  and 

Minor.    ZdiscKr.  (.  klin.  Med..  1891.  y6.     (H«m!|>)egla,  «tc.) 

Charbcrt.    Cutlrubcs  i,  (l{-tiiit  c^>hj|ique  cxmcifris^  jur  la  Kdondo  3"*. 

y-,  4-.  ;-  el  6**  jNtiro  crAniennes.     Protrrb  tntd.,  1891,  30, 
uiOery.     Ucbcr  <tic  io|>i«rlie  DiagncKiik  dcr  PupdmrcrKbdnungen  bcl  der 

Tabei.     I)mt«chr  tncd.  Wochcnschr..  1891.  ji. 
Cliixwick.     Tabciinil  Bulliarsympioni*n.     Newrol.  C«nlni1l>l .  iSyj.  u. 
ICuti-nhurg,     Uebcr  <-ini^c-  Faille  von  T.ibcs  mil  Dcihriliguii);  (ks  V'jgus  und 

AccMSorws.     Inaug.'DiMcn.,  licTljn,  1893. 
Ilhrrg.    Chufli^AniMiIen.  1893.  p.  J03.     (AccwaorUii  Para>)sis.) 
LaJhlle.     Dn  CriMs  gasinque*.    Cu.  dct  hAp.,  1894.  ^ 

B  So  gre.it  importance  has  been  attached  to  the  spinal  symp* 
toms  that  they  ustully  occupy  the  ^renter  part  ol  nil  dei^crip- 
liontt  of  the  clinical  history  ol  the  affection,  and  have  been 
allowed  to  predominate  so  far  that  all  other  symptoms  have 
been  treated  of  "as  being  of  little  moment,  and  as  if  the  only 
lesion  was  that  in  (he  spinal  cord.  And  stilt,  it  is  not  rare  to 
meet  with  cases  in  which  the  spinal  manifestations  have  been 
for  a  long  pcriixl  of  very  tittle  importance,  and  with  a  few  in 
which  they  have  never  attained  to  any  prominence,  while  the 
Ktnajority  of  the  troublesome  symptoms  were  due  tu  affections 
Hd(  the  brain  and  its  ncrv<:s,  and  the  lesions  of  the  peripheral 
Vnervesgave  rise  lo  more  marked  symptoms  than  those  ol  ihe 
spinal  cord.  Observations  of  this  kind,  the  number  of  which 
will  be  rapidly  increased  by  conscientious  ex.-)minalions,  f^>  to 
show  that  the  entire  nervous  system  participates  in  the  morbid 
process,  and  to  consider  this  participation  to  be  the  rule  is 
Absolutely  necessary  lor  a  correct  comprehension  of  the  pathol- 
ogy of  this  disease. 

The  symptoms  produced  by  the  spinal  lesions  concern  mo- 
tility, sensibility,  and  the  reflexes. 


640        DlSf.ASES  OF  THE  GENERAL  NERVOUS  SYSTEM. 


I 
I 


The  disturbances  of  motility  are  mnnifold:  tliey  depend 
partly  on  a  decrease  in  the  strength  of  (he  muscles,  partly  on 
disturbances  of  co-ordination.  The  first  is  not  %'ery  common; 
on  the  contrary,  one  can  frequently  observe  that  the  mere  _ 
strength  in  the  extremilies  has  not  been  at  all  aflecicd,  and  ■ 
yet  the  motility  has  suffered.  This  condition  depends,  then, 
upon  a  faulty  co-ordination,  and  is  broadly  deMgnatcd  as 
•'ataxia."  Movements,  such  as  walking,  writing,  taking  hold 
of  an  object,  etc..  for  the  proper  execution  of  which  the  simul- 
taneous working  together  of  several  muscles  is  necessary,  arc 
designated  as  "  co-ordinated."  For  such  movcmeols  more  than 
a  simple  innervation  of  the  muscles  is  requisite;  it  is  necessary 
that  each  concerned  should  receive,  so  to  speuk,  the  proper 
amount  of  innervation  and  at  the  proper  lime,  so  that  the 
contraction  of  the  various  muscles  may  take  pluce  at  the  right 
moment.  It  is  only  ivht-n  all  thtse  various  factors  are  pnij*- 
erly  combined  that  the  movement  is  correctly  cvccutcd,  and  if 
one  of  them  be  disturbed  the  entire  movement  becomes  ataxic. 
Even  if  not  pathognomonic,  it  is  certainly  very  characlerisiic 
of  tubes  that  in  the  later  (rarely  in  the  earliest)  stages,  ccrtaia 
movements  become  ataxic,  particularly  those  of  the  lower  e\- 
trcmitics,  and,  above  all,  the  gait.  Such  abnormities  are  mcl 
with  much  less  frequently  in  the  upper  extremilies.  and  the 
movements  necessary  for  writing,  handling  a  spoon  in  eating. 
and  the  like,  usually  remain  normal. 

The  gait  of  a  tabetic  is  readily  recognized  even  by  one  who 
has  had  little  experience  in  that  direction  ;  one  notices  particu- 
larly that  the  patient  exerts  his  eyes  almost  as  much  as  his  fed. 
that  he  watches  every  step,  and  in  passing  over  small  obstackf. 
as  for  example  a  curbstone,  determines  exactly  where  he  mu*I 
place  his  foot.     It  he  ceases  to  use  his  eyes  in  this  fashion  lot 
any  reason,  even  for  a  short  time,  the  movements  of  the  legs 
become  uncertain,  and  he  is  in  danger  o(  (ailing.     But  not  even 
with  the  help  of  the  eyes  can  he  walk  witliout  difficulty.    He 
does  not  step  out  in  the  usual  way  ;  the  legs  are  thrown  out 
loosely,  and  in  putting  the  feet  to  the  ground  the  heels  comf 
down  first  ("strutting  gait").     The  manner  in  which  the  feet 
are  raised,  the  legs  thrown  out,  the  stamp  with  which  the  frtt 
touch  the  ground,  readily  enable  one  to  diagnosticate  the  ta- 
betic gait  at  a  distance,  and  we  shall  seldom  make  a  mistake  tl 
we  consider  a  person  who  walks  in  this  manner,  supported  on 
a  stick  or  by  an  attendant,  as  affected  with  locomotor  ataii-i' 


TABES  DOKSAUS. 


65l 


ich  ns  greetings  and  stoppir 


uilk 


lets  of  politeness. 

I  the  street,  do  not  afFord  these  persons  much  pleasure,  for  they 
distract  their  attention,  which  has  to  be  kept  undivided  if  ihey 
would  walk  in  safety. 
The  uncertainly  and  insufficiency  of  the  innervation  of  the 
different  groups  of  muscles  is  apparent  not  only  in  the  walk. 
but  even  while  the  patient  is  standinf;  still.  He  is  nut  able  m 
stand  up  straight  without  tottering,  parlicularly  when  he  closes 

■.his  eye«,  and  he  sways  to  and  fro  and  (alls  unless  some  one  is 
at  hand  to  sup|>ort  him  (■■  Romberg's  sign  ").  The  smaller  the 
supporting  basis— that  is.  the  nearer  together  the  fcet—llic 
more  pronounced  does  the  phenomenon  become.  In  some 
cases  it  may  be  accompanied  by  irregular  contractions  of  the 
call  muscles. 

■  The  much  rarer  ataxia  of  the  upper  extremities  produces 
inability  to  write,  to  play  the  piano,  to  sew.  etc.  With  closed 
eyes  the  patient  is  unable  to  describe  circles  in  the  air  wiih  his 

Barms,  to  bring  the  tips  of  the  index  lingers  together  Irom  n  dis- 
tance, or  tf>  touch  the  end  of  the  nose  quickly  with  his  finger. 
All  such  movements  are  carried  out  with  more  or  less  irregu- 
larity. It  is  exceptional  for  the  upper  extremities  to  become 
affected  at  an  early  period  or  severely  :  as  a  rule,  we  can  not 
detect  ataxic  movements  in  them  in  the  earlier  stages,  and  when 

Kthey  do  occur  they  can,  at  least  in  some  instances,  be  traced  to 
some  special  cause.  In  the  case  of  Bernhardt  (Zcitschr.  I.  klin. 
Med.,  i8S8,  xiv.  3.  p.  289)  they  were  due  to  the  occupation  ol 

ftthe  patient.  Remak  (Berlin,  klin.  Wochcnschr.,  iSSa  22)  has 
also  published  a  similar  case  of  ataxia  afleciing  only  the  upper 
extrcmilics.  It  was  associated  with  cphidrosisunil-iteralis.  The 
helplessness  of  the  patient  reaches  the  most  exircme  degree 
when  the  ataxia  affects  all  four  extremities;  as  in  the  case  of 
Fort  (Hublin  Journal  of  Medical  Science.  3d  s..  1886.  clxxiiiV 

B       But  we  must  also  distinguish  between  spinal  and  cerebral 

'or  the  so-called  cortical  ataxia  (page  186).  A  conclusion  im- 
portant   for  the   differential  diagnosis    may  be  drawn  from 

^obscr\-ing  the  influence  which  the  eyes  exert  over  the  co-ordi- 

"nated  movements.  In  spinal  ataxia  these  Ijecome  belter  regu- 
lated and  more  certain  when  they  are  under  the  control  of  the 
eyes,  while  in  cortical  ataxia  this  factor  has  no  influence. 

_        The  physiological  cause  of  ataxia  is  not  as  yet  positively 

^known.  but  even  to-flay  is  a  source  of  contention  and  still  the 
object  of  continued  investigations.     While  some,  as  IJene<likt, 

4> 


64= 


D/SBASES  OF  THE  GElfERAL  NEfSVOUS  SySTEM. 


Cyon,  and  Jaccoud,  consider  that  wc  have  to  do  with  a  disturb- 
ance of  the  reflex  activity  in  the  cord,  others,  with  Friedreich, 
and  after  him  Erb.  are  of  the  opinion  that  there  is  a  disturbance 
in  co-ordinating  fibres,  the  course  of  which  they  confess  c:>n 
not  as  yet  be  made  out.  Thirdly,  others,  with  Lcydcn  at 
their  head,  consider  disturbances  of  sensibility  to  be  respon- 
sible for  the  ataxia.  According  to  these,  interruption  of  con- 
duction in  the  sensory  tracts  of  the  gray  mailer  causes  a  brc^ik 
o(  the  reflex  arc  between  the  scnsury  nerves  of  the  muscles 
and  the  motor  nerves.  "Owing  to  this  interruption,  the  un- 
conscious regulation  of  the  movements,  which  adapts  them 
to  the  state  of  coiitrnciion  or  relaxation  of  the  nuisculiUure, 
disappears"  (Wernicke),  and  ataxia  is  the  result.  This  "sen- 
sory ataxia  "  has  always  had  many  opponents,  for  one  was 
obliged  to  confess  that  ataxia  often  occurs  when  no  sen. 
sory  changes  are  found ;  but  in  spile  of  this  fact  some  one  i$ 
constantly  returning  to  this  theory,  which  has  found  a  strong 
advocate  in  Goldscheider.  In  a  comprehensive  article  (Zeil- 
schr.  f.  klin.  Med.,  \8S$,  xv,  i,  2)  he  subjects  the  meaning  of  the 
term  "muscular  sense"  to  a  fresh  examination,  and  comes  to 
the  conclusion  that  lour  factors  arc  combined  in  the  formation 
ol  the  muscular  sense,  viz.;  (i)  the  sensibility  to  active,  (2)  tu 
passive  movements,  (3)  the  perception  of  position,  and  (4)  the 
perception  ()f  weifiht  and  resistance,  fie  then  states  that  tn 
all  cases  of  ataxia  in  which  the  sensibility  had  been  tested  the 
examination  had  been  imperfect  in  some  detail ;  he  points  out 
that,  for  example,  in  the  otherwise  admirably  conducted 
observations  of  Friedreich,  the  examination  of  the  sensibility 
to  movement  was  omitted.  According  to  his  view,  therefore, 
it  is  only  necessary  to  perfect  the  eicaminntion  of  the  sensibility 
in  order  to  come  to  the  conclusion  that  sensory  disturbances 
are  responsible  for  the  ataxia. 

When  one  considers  that  wc  are  ignorant  of  the  origin  of 
the  normal  co-ordination,  and  remembers  that  it  is  not  congeni- 
tal  but  must  be  learned  by  practice,  in  which  controlling  and 
correcting  influences,  which  arise  from  the  periphery,  come 
into  ptav.  it  is  not  difficult  to  agree  with  .Strlitnpell.  who  con- 
siders t1i:it  the  ataxia  takes  its  origin  from  the  dit>appearance 
or  insufficiency  of  those  regulating  influences,  because  "the 
possibility  of  successfully  tnmsferring  Ihem  to  the  tnotor  ap- 
paratus is  removed."  Wc  should  then  have  to  regard  the  gray 
fiubstance  and  the  ganglionic  cells  as  the  place  where  this 


I 

I 

I 


TABES  DORSAUS. 


«43 


I 


transfer  probably  occurs.  Which  of  Ihc  theories  above  tnen- 
lioiicd  will  at  last  be  reco);iii2ed  as  the  correct  oiK.  and  whether 
or  nol  other  factors,  which  have  not  yet  been  considered,  pliiv 
a  part  in  the  prodnclionof  the  ataxia,  it  is  at  present  impossible 
lu  state  (cf.  Rutnpf,  Sensibilit^tsstUrungen  und  Ataxie,  Leipzig. 
Mifschwald.  1889). 

Later  on  in  Ihc  course  of  tabes  there  is  a  diminution  tn  the 
actual  strength  of  the  voluntary  muscles,  particularly  in  those 
of  Ihc  lower  extremities.  This  first  manifests  Itself  by  wea- 
riness on  walking,  which  gradually  increases,  and  finally  ends 
in  total  panilysis  (par;iplegia).  The  patient  first  notices  that 
he  has  to  rest  in  the  course  nf  walks  which  he  previously 
was  in  the  habit  of  taking  without  any  feeling  o(  fatigue,  th.tt 


»F%.  «7).— Seeciars  op  IU»i>w«itijio  in  «  C*»r  o*  Tsilimw  in  T»om 
I  pcnoiul  ubwraliofi). 

it  lakes  him  much  longer  than  formerly  to  cover  a  parlicul-ir 
distance,  and  that  he  is  in  general  unable  to  take  the  exercise 
tu  which  he  was  formerly  accustomed.  As  the  disease  advances, 
the  power  of  locomotion  becomes  more  and  more  diminished, 
and  llie  patient  is  only  just  able  to  drag  his  legs  along,  and 
at  last,  becoming  unable  to  move  at  all,  or  even  stand  wilhtmt 
help,  is  obliged  to  spend  the  rest  of  his  life  in  the  invalid's 
chair. 

Signs  of  motor  irritation  arc  rare  and  are  limited  to  parox- 
y»mal  twiichings  in  the  fingers  and  toes :  5<HTietimes.  however, 
.involunury  movements  occur  in  the  limbs  which  the  |>alient 


644        f>/SEA.'iES  OF  THE  GR.S'F.KAt.  NERVOUS  SYSTKM. 


has  absolutely  no  intention  of  moving.  Stintziiig  (Centr.iI 
Ncrvcnhcilk.,  1886.9.  3),  for  example,  observed  an  involuntary 
flexion  of  the  hip  joint  when  the  patient  coughed.  SimiUr 
associated  movements  in  the  lingers  or  toes  have  been  de- 
scribed by  Siriinipcll  (Neurol.  Centralblatt,  1887,  vi,  1)  and 
Uppcnhcim  (Sitzung  der  Charitd-GcscUschalt,  20  MUrz,  18S4). 

The  athetoid  and  choreiform  movements  described  by 
Andry  (Kcvuc  dc  mcd.,  1887.  1).  sometimes  found  in  tabetics, 
are  to  be  regarded  as  due  to  simultaneous  disease  ol  the  lateral 
columns,  and  accordingly  rather  as  complications.  Wc  must 
regard  the  tremor  as  one  of  the  signs  of  motor  irritation,  al- 
though  wc  arc  at  present  unable  to  localize  its  anatomical  scni. 
This  symptom  is  sometimes  observed  either  in  the  initial  stjige 
or  in  the  further  course  of  the  disease.  If  the  upper  extremities 
become  aflccted  by  it,  the  handwriting  is  altered,  in  the  man. 
ner  represented  in  Fig.  171. 

The  disturbances  of  sensibility  in  tabes  are  either  experi- 
enced subjectively  by  the  patient,  or  can  only  be  discovered 
by  an  objective  examination.  Their  number  is  exceedingly 
large,  and  it  is  safe  to  say  that  in  almost  every  case  some  iiUvf- 
esting  observation  of  this  character  may  be  made.  Symptoms 
of  irritation  alternate  with  those  of  paralysis,  and  one  also 
meets  with  other  different  disturbances  of  sensation  which  be- 
long to  neither  ^f  these  groups,  and  which  are  more  variable 
in  tabes  than  in  any  other  aflcction. 

.Among  the  subjective  symptoms  we  shall  consider  fir«l  Iht 
symptoms  of  irritation,  more  particularly  the  pitins.  which  in 
the  life  of  tabetics  play  such  an  important  part.  They.  too. 
arc  of  a  changeable  nature,  and  vary  considerably  in  their 
situation  and  intensity.  In  the  first  place  we  desire  lo  direct 
attention  to  the  muscular  pains,  which,  if  they  occur  at  ilHi 
come  on  very  early  in  the  course  of  the  disease,  and  affect 
sometimes  the  shoulders,  sometimes  the  legs,  and  recall  the 
well-known  muscular  pains  which  follow  severe  exertion  in 
the  gj-mnasiuni,  mountain  climbing,  rowing,  etc.  As  a  nile. 
it  is  true,  they  are  not  very  intense,  but  when  they  come 
on  suddenly,  without  any  appreciable  cause,  the  patient  i> 
obliged  lo  remain  perfectly  quiet  for  several  hours,  for  every 
motion  is  difficult  lo  him,  and  if  he  persists  in  his  attempts, 
movement  becomes  impossible  on  account  of  the  feeling  of 
weakness  and  fatigue  which  at  last  overcomes  him.  Piif« 
calls  these  pains  "  crises  dc  courbalure  rousculairc  "  (Progr. 


TAfiKS  DORSAUS. 


645 


mea!ri884.  xii.  28),  and  considers  ihat  ihey  arc  precursors  o( 
labes. 

I  We  must  separate  from  these  the  nervous  pains  of  tabetics 
which  arc  dependent  upon  irritation  ol  the  postcrit>r  roots. 
They  are  usually  situated   in  the  lower  extremities,  and  mani- 

ficst  themscUxs  either  as  dull,  boring  sensations,  or  as  sharp 
pains  which  last  for  hours  and  then  disappear  for  a  time  ;  they 
may  also  be  (cit  in  the  back  and  sacral  region,  and  lor  years  be 

I  attributed  to  rheumatism,  lumbago,  etc.  As  long  as  only  these 
pains  exist,  Ihc  life  of  the  patient  is  bearable,  although  it  may 
tie  marred  and  his  occupation  interfered  with,  but  there  is  a 
Mcond  class  of  nervous  pains  which,  appearing  and  disappear- 
ing like  lightning,  arc  known  as  shooting  or  lancinating  pains. 
'•  douUvn  fMlguruHles."  It  is  these  that  make  the  existence  ol 
the  tabetic  most  miserable,  and  make  him  wish  that  he  were 
dead ;  it  is  these,  again,  that  can  reach  an  intensity  which 
causes  the  most  resolute  stiHerer  to  lose  his  energy,  and  con- 

'%'erts  him  into  a  complaining  and  whining  weakling.  They 
also  occur  paroxysmally,  and  may  continue  for  minutes,  hours, 
or  even  days,  and  then  di&appcar  (or  variable  periods,  some- 
limes  for  months.  In  many  cases  they  recur  often,  some- 
limes  every  week,  but  they  then  usually  only  last  for  a  few 
moments. 

In  some  cases,  in  connection  with  these  attacks,  cutaneous 
ecchymoses  may  develop,  which  are  to  be  noted  in  the  por- 
tions of  Ihe  body  subjected  to  the  pain,  and  may  attain  a 
considerable  size,  so  that  one  who  docs  not  know  their  sig- 
nilicance.  on  examining  the  patient,  may  come  lo  the  conclu- 
sion that  he  has  been  injured  by  a  blow  or  a  fall.  In  still 
rarer  instances  swellings  have  liccn  observed  instead  of  the 
ecchymoses,  which  in  the  same  manner  as  the  latter  di&appcar 
in  a  few  days. 

Along  with  these  pains  the  patient  may  suHcr  wilh  hyper- 
.-tsihcsias  of  Ihe  skin  to  such  an  extent  that  in  certain  parts  ol 
the  botly— very  frequently,  for  Instance,  on  ihe  back— he  can 
not  bear  the  slightest  pressure,  and  even  his  clothes  will  be  a 
source  ol  annoyance  to  him.  These  cutaneous  hyperarsthcsias 
may  persist  for  months  unchanged  without  being  affected  tn 
the  least  by  Ihe  paroxysmal  pains. 

Among  the  symptoms  of  sensory  irritation  the  80.called 
girdle  sensation  may  also  be  reckoned.  This  likewise  occurs 
paroxysmally,  at  which  times  the  patient  exjiericnces  a  feeling 


6146 


X>/SEMS£S  Of  THE  GEKEkAL  NERVOUS  SYSTEM. 


as  if  n  belt  were  being  drnu-n  Around  his  chest  and  abdomen, 
which  iiUcrJcrcs  with  his  breathing. 

Manifestations  of  sensory  pitralysis  may  also  be  subjectively 
perceived  by  the  patient.  Not  infrcqucnily  he  will  say  Uiat 
he  docs  not  Icel  the  contact  of  the  cluihing  on  certain  pohiuiis 
of  the  body,  or  thai  the  soles  of  the  feet  are  without  sensatiun. 
In  n  case  under  my  ubservaiiun  the  patient  complained  ol  a 
widespread  loss  of  sensation  in  the  perineal  region,  which  on 
objective  e?camination  proved  to  be  ana-slhetic  as  well  as  the 
inner  surfaces  of  both  thighs.  To  the  anaesthesias,  which  are 
particularly  unpleasant  to  the  patient,  belong  those  affecting 
the  mucous  membranes — as,  lor  example,  that  of  the  rectum — 
owing  to  which  the  bowel  may  empty  itself  without  the  patient 
being  conscious  of  it.  Again,  there  may  be  an».*slhesia  of  the 
testicle,  often  associated  with  atrophy  (Pitres),  and  loss  of  sen- 
sation in  the  mucous  membrane  of  the  sexual  organs — as  o(  Ihc 
vagina,  for  example — owing  to  which  the  j>lcasunible  sensa- 
tions attending  coitus  arc  either  absent  or  greatly  diminished. 

Among  the  perverted  sensations  which  arc  cxi>crienceti 
subjectively  may  be  mentioned  the  alterations  of  feeling  in  the 
soles  ol  the  feet,  owing  to  which  it  appears  lo  the  patient  that 
he  is  not  walking  upon  solid  ground,  but  rather  upon  a  suit 
yielding  surface,  such  as  moss,  cotton,  etc.  To  these  may  be 
added  the  sensation  as  of  ants  crawling  over  the  skin,  a  feetinR 
ol  numbness,  which  usually  appears  in  the  lower  cxlreniitiw, 
but  sometimes  also  in  the  hands.  In  the  latter  case  it  tiuy 
become  impossible  for  the  person  lo  write,  sew.  etc..  in  spite 
of  the  fact  that  he  may  be  suflcring  from  no  disturbance  of 
motility  whatsoever. 

Many  anomalies  of  sensation  in  labes  can  only  lie  discov- 
ered by  means  of  objective  examination.  They  constitute  the 
second  group  of  sensory  disturbances  to  which  we  rcfencd 
above. 

We  would  here  insist  upon  the  necessity  of  making  the 
examination  as  carefully  as  possible,  and  of  remembering  i« 
the  first  place  that  when  the  patient  is  repeatedly  examined  he 
ceases  to  give  us  his  attention  and  makes  careless  answers  1" 
the  inquiries  made  of  him  ;  and  in  the  second  place  that  ihert 
arc  certain  sensations,  the  so-called  spontaneous  sensatiunii 
which  the  patient  experiences  without  any  external  irritation 
whatever.  Rosenhach  (Deutsche  med,  Wochenschr.,  18S9,  ij) 
holds  that  accumulations  ol  weak  sensory  stimuli  occur,  tlte 


TABES  DOKSAU& 


647 


ft 


ntcrvals  between  which  vary  according  to  the  strength  of  ihc 
stimuli  anil  the  better  or  worse  condition  of  the  ))alienl.  If 
one  remembers  this  and  the  fact  that  the  so  called  aftcr-sensn^ 
tions  must  also  be  taken  into  account  when  miiking  the  test, 
one  will  be  able  to  avoid  gross  errors,  B.  Stern  (Arch,  (. 
Psych,  und  Nervcnkrankhcitcn,  1S86,  xvii.  2)  has  not  been  able 
to  cunhrni  the  sintenient  of  Belmont  (Gax.  m^.,  1877,  19)  that 
points  of  predilection  exist  lor  the  disturbances  of  sensation  in 
tabetics,  as,  fur  example,  in  the  soles  of  the  feet,  the  areas  about 
tlie  malleoli,  and  the  lower  cxtremiiies  in  general.  Were  it 
true,  it  might  constitute  a  new  source  o(  error  in  the  cxamina* 
lion  of  the  anomalies  of  sens^ition.  The  methods  of  examina- 
tion arc  as  simple  as  possible,  and  the  necessary  instruments 
are  an  induction  appaniius.  Weber's  arsthesiomeler,  needles, 
mounted  brushes,  and  test  tubes  tilled  with  hot  and  cold  water. 
With  these  one  is  able  in  most  cases  to  obtain  all  the  necessary 
information. 

Among  the  symptoms  of  irritation,  hypcnesihesias.  as  we 
ilatcd  above,  arc  not  of  very  frequent  occurrence,  but  when 
they  do  occur  they  can  very  easily  be  recognized.  They  are 
frequently  quite  transient,  so  that  a  point,  which  yesterday  was 
sensitive  to  the  slightest  touch,  presents  to-day  a  perfectly 
normal  condition.  The  exaggerated  sensitiveness  is  probably 
always  conhncd  to  the  perception  ol  pain,  but  Is  not  found 
associated  with  the  other  qualities  of  sensation.  We  recognize 
another  symptom  of  irritation  in  the  so-called  double  percep- 
tion of  painful  impressions,  polvivsthcsiii  (Fischer),  by  which 
is  meant  that  from  one  external  irritation,  as  the  prick  o(  a 
needle,  the  patient  experiences  two  painful  sensations  in  suc- 
cession. 

In  the  objective  examination  of  the  sensibility  the  symptoms 
of  paralysis  play,  without  doubt,  the  more  important  r^e.  In 
the  fin-t  place  there  arc  the  anaesthesias,  which  may  afTecl  all 
(pialities  of  sensation,  the  sense  ol  pain,  touch,  and  temperature. 
The  most  interesting  is  an  analgesia,  to  which  Bergcr  first 
directed  altrntinn.  who  demonstrated  that  while  the  patients 
reacted  normally  to  slight  stimuli,  they  scarcely  did  so  at  all  to 
stronger  ones.  We  must  consider  it  as  an  anomalous  analgesia, 
when  a  patient  experiences  only  one  kind  of  p.Tin  in  response  to 
the  most  varied  kinds  o(  painful  stimuli.  It  sometimes  hap{iens 
that  the  tabetic  can  not  tell  the  difference  between  the  action 
oi  the  thcrmo-caulery,  the  simple  prick  of  a  needle,  or  a  violent 


64& 


DISEASJiS  OF   THE  CEXERAL   NERVOUS  SYSTEM. 


pinch,  and  desiKnatcs  the  pain  produced  by  these  various 
agents  as  simply  a  burning  one.  The  painful  sensation  on 
electrical  stimulation  mav  also  become  abolished,  so  that  wc 
can  apply  the  strongest  currents  or  the  (aradic  brush  to  Hie 
most  sensitive  parts,  such  as  the  inner  surfaces  of  the  thighs, 
the  perinKum,  or  the  scrotum,  and  the  patient  not  gi%'e  the 
slightest  evidence  of  pain. 

Lastly,  delayed  sensation  is  to  be  considered  as  a  syoiplotn 
of  a  paralytic  nature.  In  these  cases,  when  the  patient  is 
pricked  with  a  needle,  he  docs  not  experience  pain  until  one, 
two,  or  three  seconds  later.  Goldschcidcr  has  attempted  a 
physiological  explanation  of  these  phenomena  (Deutsche  Med.- 
Ztg,,  1S90,  43,  p.  484).  The  delay  of  perception  may  vary  for 
the  dilTerent  qualities  of  sensation — for  example,  for  touch  and 
pain — as  OsthofI  and  Rcmak  have  pointed  out. 

We  must  attribute  to  disturbances  of  the  muscular  sense, 
which  we  alluded  to  in  discussing  the  cause  of  ataxia,  tJie  (act 
that  the  patient  with  his  eyes  closed  is  unable  to  state  accu- 
rately in  what  position  his  extremities  arc,  and  if  one,  lor  ia- 
stance,  changes  the  position  of  a  limb,  he  is  not  at  all  certain 
into  what  position  it  has  been  put.  He  is  unable  to  estimate 
the  weight  of  an  object  placed  in  his  hands,  and  so  forth.  All 
these  conditions  are  to  be  remembered  when  one  is  testing  the 
muscular  sense,  and  at  the  examination  one  will  have  to  ascer- 
tain what  is  the  minimum  change  of  position  which  can  still 
recognized  by  the  patient. 


I.ITERATfRK. 
3.  The  Spirml  Cord. 
a.  Mftifr  anil  Sniioty  Ditsrdtrt, 
Runipf.    SFn9lbiliiaiis«>t>rungen  und  Ataxic.      Dcuischcs  Arch.  f.  kEn- 

|8«9.  t. 
(lolilicheitlcr.    Ilcrlincr  klin.  Wochcnschr.,  1890.  46. 
Uinswangrr.     Ihiil..  1890,  3i,  32. 

Quinrkc.    Zeilschr.  f.  klin.  Med..  1890^  5.    (Auocialei!  ScnsaiiotM,  etc) 
Wngncr.  K.     Ucbrr  die  BcMthuiiKcn  iIlt  Bewc^un|fM:m|>lin<lvng  tut  Auxk  U> 

Tabikrrn.     Inaug.-Dlwcrt,.  nrrtin,  1891, 
Runuwikl.    Vewutli.  ilie  Unache  der  Ataxic  bci  Tabea  zu  erkllren.    Itiitnui 

klin.  Rundsirhau.  1S91.  17.     (Tl)is  xuli^or  optnins  aiaxin  by  a  difflbulic" 

in  the  cxcii.-ibiliiy  .ind  conduciiviiy  of  Ihc  motor  nerve*,} 
Dubuc.    Ua  douleurs  rulHur^intn  laMiiqucs.    T)i^  de  Bordeaux,  1S99. 
Gmssei.    Du  vrriige  dcF  aiaxiques  (signc  de  Romberg).     Arch,  de  Noirti. 

1893.  73.  74- 


i 


TABES  />ORSAlJS. 


649 


Of  the  disturbances  of  the  reflexes,  lltose  conitcctcd  with 
the  lUcin  interest  us  less  than  those  connected  with  the  tendons: 
o(  the  latter,  the  patellar  reflex  is  the  most  important,  the  ana- 
lumical  localization  fur  which  is  in  the  so-called  root  zone 
(Weslphal).     This   xoiie    is   siiiiuled   at    ihe   Junction  of  the 

■  lower  dorsal  portion  of  the  cord  with  the  lumbar  enlargement 
at  llie  level  ol  exit  of  the  second,  third,  and  fourth  lumbar 
nerves  (cf.  page  422),  and  constitutes  the  area  which  the 
roots  entering  to  the  median  side  of  the  posterior  horn  must 
traverse  in  order  to  reach  the  substantia  gelatinosa  of  the  pos- 
terior horn.      If  this  field  is  degenerated  the  patella  tendon 


A. 


H  FIC.  i7«.-  Tw-o  Cjikti  nr  Tahch.    i  ARet  WtarniAL.) 

^LJ.  Thr  linrt  4  A  Oiow  lb*  limit*  ot  llic  hi-ciIImI  "  roM  inn*  "  Thr  d(K*npratliui  t*  (irncMW- 
^B  tax  'n»n  viUiin  (iioinl  Ibcm.  bul  onlji  rtathci  Ihe  bcmlet  linv.  The  pwdlw  nOcm 
^B        «<tr  Rtkintd  until  death. 

^p'#.  Tfcc  dcfCMnUcni  ti  prnpmlni;  from  *lllila  cnuwiRt,  *nil  hii<  ciiuMlid  far  Inui  iha 
V        "  rodl  MNW."    The  pauUu  nduo  were  toM  Ave  yean  bcf on  dMiK 


rcflcx  disappears,  but  if  it  is  normal,  the  reflex  is  preserved 
icf.  Fig.  i;:.  \  and  H).  The  rare  cases  in  which  it  remains 
preserved  on  one  side  also  confirm  the  localization  assumed 
by  Weslphal :  at  the  autopsy  it  has  been  repeatedly  noted  (cf. 
IJcrlin.  klin.  W'ochcnschr.,  1887,  31,  p.  586)  that  there  was  a 
degeneration  of  the  posterior  columns  and  of  the  "  root  zone  " 
on  the  affected  side,  while  this  zone  on  the  healthy  side  w.i9 
intact. 

The  disappearance  of  llic  patellar  reflex,  "  Westphal's  sign," 
was  formerly  considered  as  pathognomonic  of  tabes,  and  when- 
ever the  knee  jerk  could  not  be  obtained,  the  diagnosis  was 
made  wiihout  hesitation.  This  was  the  standpoint  taken  in 
the  earlier  works  ol  Wcstphal.  Krb,  and  others,  and  it  must  be 
confessed  that  "  Westphal's  sign  "  is  observed  in  by  far  the 
jfTeatcr  number  of  cases  of  tabes,  and  usually  early  in  the 
[Course.     However,  it  began  to  be  doubted  that  the  rule  was 


650 


D/SEAS£S  Of  THE  GENERAL  NERVOUS  SYSTEM. 


without  exceptions,  and  toward  the  end  of  the  seventies  sev- 
eral undoubted  cases  of  tabes  were  reported  (Berger.  Foumier) 
ill  which  the  patellar  reflex  was  retained  to  the  end  of  life,  and, 
since  then,  other  similar  cases  have  been  added.  \Vcslph.il 
himself  pointed  out  that  the  Icnee  phenomenon  might  persist 
with  degeneration  of  the  posterior  columns  (Arch,  f.  Psych. 
«nd  Nervenkrankh.,  18S6,  17,  2),  and  preci>ely  at  this  time  I 
myself  reported  two  such  instances  (Berlin,  klin.  Wocheoschr., 
1886,  to).  Accordingly,  it  is  an  undeniable  fact,  and  one 
which,  aniilomically.  can  be  readily  explained,  that  under  cer- 
tain circumstances — that  is,  whenever  the  "  root  zone  "  remains 
free  from  degeneration — the  patellar  reflex  may  continue  to  be 
present  during  the  entire  course  of  the  disease.  By  repeated 
and  accurate  examination,  in  which  Jcndra&sik's  tnclhod  ol 
re-en  force  me  nt  should  not  be  forgotten,  one  is  sometimes  able 
to  follow  up  the  gradual  disappearance  of  this  rcllex,  and  to 
observe  that  the  time  of  its  diminution  and  final  disappearance 
may  diller  in  the  two  legs — for  example,  the  reflex  may  still  be 
well  marked  on  one  side,  alter  it  has  completely  disappeared 
on  the  other.  Among  others,  Goldflam  has  reported  observa- 
tions on  this  point  (.Neurol.  Ccntralblatt,  1888.  19),  and  has  su|>- 
pusfd  th.Tt  iiitcrlerence  with  conduction,  produced  by  p:nh(i- 
logical  changes  in  the  peripheral  nerves,  may  also  be  the  cause. 
Eichliorst  has  reported  a  case  in  which,  although  the  patellnr 
rcllex  had  been  absent,  the  autopsy  revealed  no  changes  in  the 
rout  zone,  but  a  parenchymatous  neuritis  of  both  cniral  nerves. 
The  patellar  reflex  which  has  once  disappeared  in  the  course  of 
tabes  can  never  reappear,  since  destruction  of  the  correspond- 
ing portions  of  the  cord  has  taken  place,  but  in  trauniattc  MU- 
roses  this  may  very  well  happen,  and  in  doubtful  instances  it 
may  become  an  important  point  in  the  diHcrential  diagnosis. 
The  patellar  reflex  can  only  be  increased  in  tabes  when  there 
is  a  coincident  degeneration  of  the  lateral  columns. 

While,  then,  for  the  reasons  we  have  given,  "  Westphal's 
sign"  can  not  be  regarded  as  pathognomonic,  there  are  sitll 
others  which  should  warn  us  against  laying  too  much  stress  on 
the  condition  of  the  patellar  reflex  in  the  diagnosis  of  tabes. 
Unquestionably  it  may  also  disappear  under  certain  circum- 
stances in  the  course  of  other  affections — as,  for  example,  to 
certain  diseases  of  the  brain — if  the  muscular  tone  necessary  to 
its  production  has  been  lost;  also  in  neuritis,  poliomyelitis, 
diabetes,  chronic  alcoholism,  and  in  aflections  of  the  knee  joint 


I 

I 


TABES  DOJtSALlS. 


6si 


I 


when  llie  movements  of  the  Icndon  arc  interfered  with.  When 
wc  add  that  it  can  not  be  deinunstmted  in  all  healthy  persons 
— a  small  number  being  entirely  without  it,  as  IJcrger  and 
others  have  stated — and  moreover  consider  the  fact  that  in  old 
age  and  in  conditions  o(  marked  nervous  exhaustion  it  may 
entirely  disappear  without  any  apparent  reason,  perhaps  from 
a  diminished  lone  in  the  muscles,  we  shall  have  sufficient 
grounds  (or  not  overestimating  its  significance,  important  as 
it  may  still  be  for  the  recognition  of  tabes.  The  measure- 
ments of  its  strength,  which  have  lately  been  made  a  good 
deal  of.  may  for  the  present  be  omitted  in  practice  without 
dtsadvanlagc  for  the  diagnosis. 


l.lTERATt'RE. 
3.  Spinal  Coftl. 

RoKTohcim.    Arch.  C  I*«)-Gh.  u.  N«Tvmlch.,  1884.  xr,  1.    (Eipcrimcnul  Studies 

on  the  "  Trn<IoN<|>h«nunieiM."l 
Z«nitcr.     The  Kncc-|>)iciioniniMi  in  l^Komotor  AlaiiiK.    JtMim.  of  Nvrv,  anil 

Mern.  DitcJixc,  N.  S.,  April.  1884. »,  1. 
Delpiai.     Nettrrld.  TijilKhr.  vmr  Genccskumle.  lt86,  Jl.     (Three  Ca*ra  of 

II  at>n  iti  which  the  fdlclUr  Reflex  peruttcd  uniil  Mtlhin  a  Few  Huurs  bc- 
Tiirc  l)e3ih.) 
Wruptial.     L^cbcr  I'ond.iurr  <lc«  Ki<irplilEnninms  bc<  Urt^ncration  iter  1linier> 
UifriKe.     Anh.  f.  lH)cl>.  u,  N<r*cnkh,.  1886.  xvii.  j. 
klitchelL  ^Vet^,  und  Morris,     Tei^ilon-jirrk  and  MuHi:te-jerh  in  Dinrnsei.  expeciiilly 
will)  KcfTrcncc  lo  I'wicnur  Sclcrusis  of  the  Spinal  ConJ.    New  Yurk  NteiL 
Rccont,  1SB6.  %\\.  I. 
Kr4UM,  E.    ttciinii;  lur  Localiuilon  dea  PUclbrrclleKea  bel  T«bes  u.  s.  w. 

Neurol.  Crntrnlhl..  188A.  r.  10. 
Ilirt.    Uelwr  TibcK  mil  eriutleneii  PatellaTrertexen.    Berliner  klin,  WocbenKhr. 
■  S86.  Xtiii.  lu 

tWmptiat.     Zwri  ntHe  von  Tubes  mit  erhaltrncm  Knieph&nontcn.     Berliner 
klin.  WotlirriMhr..  1S87.  xxiv.  5. 
Minor.     Zur  Frjgp  iihi-r  die  l.ocAliMtton  des  Palrllanrltcxcs  bel  I'ahei.     Ccn- 

tlralhL  t  Nrrvpnhk..  1H87,  «,  6. 
XVe&i|>luL     Aniitoniischcr  iJefuivd  hci  etnsciligem  KnicphXnamen.     Arrh.  t 

I'Sjrch.  u.  Nervcnkh..  1S87.  xvilt.  1. 
CoUftim.    UelwT  die  t'ngleichheil  dct  Kniephlnomeoi  bci  der  Tatm.    NeuroL 

Ccntralbl,  iltSti.  vii,  19^  la 
Warren.  Hyniton.  I.onilMird,    The  Variations  of  the  Normal  Knee-jerk  and 

their  KrI.iliun  1A  ihr  Activity  of  the  Central  Nervous  SyMcm.     Anier. 

Jogrrv.  o*  I-sjehol..  1887.!.  1. 
Mcfcr.    Barftncr  klin.  WochcnKhr..  1SS8.  3.     (InAwnce  of  Phjrsoiligmine  on 

Ibe  Tendon  KcHexes.) 


653 


D/SEASBS  OF  TI/E  GSX&JtAl  XEKVOUS  SVSTnU. 


Uenedikc.    Qualluttve  Verlndenin^n  (lc»  Ki)iejihSni>ineos.     NcuroL  Cenlnilbl., 

1S89.  17, 
Ivichhontt.      Virchow's   Arch.,    1891.  cxiv,    I.      [ralellar   Reflex   in   Cenictl 

Tabes.) 
(iolJRam.     Berliner  klin.  \Vochcntchr„  1891.  8.     (Reappeanncc  of  ihc  pAidLr 

KcflM.) 
Vucctic.  M^ric.     )naug.-Dit»cn.,  Wicn,  1893. 


The  reflex  centres  for  the  functions  ol  the  bladder,  rectum, 
and  scxn.1l  apparatus,  which  arc  situated  in  the  lumbar  portion 
ut  the  cord,  are  naturally  also  greatly  disturbed  in  the  course 
of  tabes.  The  reflex  processes,  which  come  into  action  here, 
are  but  little  understood,  but  Ihcir  pathological  condition  has 
been  studied  with  great  care.  Mucli  attention  has  been  directed 
toward  the  bladder  troubles  of  tabetics,  and  attempts  have 
been  made  to  distinguish  between  the  dillcrcnt  kinds  of  aflcc. 
tions.  They  are  mutor  or  sensory,  or  both,  according  as  only 
the  one  or  the  other  or  both  centres  have  been  destroyed  by 
the  degenerative  process  in  the  cord. 

Among  the  motor  disturbances  there  are  symptoms  of  irri- 
tation as  well  as  of  paralysis,  which  may  affect  equally  the 
sphincter  and  the  detnisnr.  so  that  the  will  may  have  but  little 
inHuenue  over  them,  or  finally  none  at  all.  According  as  one 
or  the  other  condition  is  the  more  prominent,  the  complaints 
ot  the  patient  differ :  sometimes  he  is  obliged  to  strain  for  a 
long  lime  before  the  bladder  will  begin  to  empty  itself,  and 
even  then  the  stream  is  often  interrupted ;  sometimes  he  is 
unable  to  urinate  at  all  in  the  erect  posture,  but  must  squat 
down  or  sit  on  the  closet  to  bring  the  abdominal  muscles  into 
action  in  order  to  expel  even  a  few  drops  of  urine,  and  the  act 
of  micturition  may  take  so  long  that  the  patient  feels  ashamed 
to  use  the  public  conveniences.  In  other  cases,  where  there  i^ 
not  only  paresis  of  the  detrusor,  but  at  the  same  time  a  spasm 
ol  the  sphincter,  the  patient  can  not  urinate  at  all.  and  the  re- 
tention must  be  relieved  by  means  of  the  catheter;  in  other 
instances,  again,  where  there  is  a  paresis  of  the  sphincter,  be 
has  to  urinate  very  frequently.  Long  before  the  bladder  is 
full— every  hour  or  two — he  (eels  an  irresistible  desire  to  empty 
it,  which  he  must  satisfy  or  run  the  risk  of  an  in%'oltintary  pas- 
sage ot  urine.  He  is  unwilling  to  underlake  railroad  journeys, 
to  go  into  society,  to  lectures,  or  to  the  theatre,  for  fear  that 
he  will  not  be  able  to  reach  a  convenient  place  in  time  where 
he  can  urinate  in  peace.     Paresis  of  the  sphincter  is  often « 


I 


I 

I 
I 


TABES  DOHSALIS. 


n  why  the  patient  sleeps  poorly,  because  he  has  to  get  up 
and  if  he  sleeps  soundly  he  docs  not  apprc- 


Sftcn  to 


IE 
pa; 


male 

When 

cotighs  or  sneezes  the  under-^rments  arc  moistened  wiih 

urine,  and,  despite  his  utmost  efforts,  he  is  unable  to  prevent 

In  the  more  marked  degrees  of  weakness  of  the  sphincter 

'there  i<>  an  involuntary  trickling  or  aii  occasional  discharge  of 

Murine,  which  (he  patient  is  unable  to  predict ;  this  necessitates 
the  constant  wearing  of  some  sort  of  receptacle ;  otherwise 
the  patient  is  surrounded  by  such  an  ainmoniacal  odor  that  the 
^incontinence  is  recognizable  without  any  examination.  If  there 
a  combination  of  retention  and  incontinence,  it  manifests  it> 
elf  in  the  following  manner:  After  long  slr.iining  the  urtnc  is 
Ppassed  in  a  moderately  strong  stream,  but  this  suddenly  ceases, 
and  can  only  be  started  again  after  renewed  eflorts.  Some- 
times, after  the  patient  has  strained  in  vain  for  a  long  lime  and 
has  given  it  up  in  despair,  the  urine  is  passed  involuntarily. 
These  and  many  other  facts  of  the  same  description  are  only 

tto  be  discovered  after  careful  and  repeated  questionings  and 
txa  mi  lint  ions. 
Sensory  disturbances  may  manifest  themselves  (i)  by  more 
or  less  intense  pain  before  and  during  the  act  of  micturition, 
which  may  distress  tlic  patient  greatly  and  make  him  dread  to 
relieve  his  bladder  (the  "crises  t'/suaUs''  of  Charcot).  The 
|>ain  maybe  situated  either  in  the  hypogastric  region  or  ex- 
tend down  into  the  urethra  {crises  x-fiico-urilhraUs).  Painful 
strangury,  forcing  the  patient  to  urinate  every  hall  hour,  when 
ic  only  passes  a  few  drops,  has  also  been  observed.  On  the 
ther  hand,  (3)  there  may  be  a  diminution  in  Sensibility,  su 
in  consci|uence  of  the  antcsthesia  of  the  mucous  mem- 
ine  of  the  bla<idcr  and  urethra,  the  flow  of  urine  is  not  no> 
ticed,  and  the  p;iiienis.  especially  when  there  is  a  weakness  of 
the  sphincter  at  the  same  time,  do  not  know  whether  they  are 
urinating  or  not,  and  only  become  aware  of  the  fact  when  they 
feel  the  chilly  sensation  proceeding  from  the  damp  clothes.  A 
rather  rare  manifestation,  which  may  be  observed  after  violent 
bladder  crises,  is  the  appearance  of  hai^maturia,  which  must  be 
attributed  to  capillary  ha-morrhagcs  into  the  bladder  or  ure- 
thra:  the  bloody  character  of  the  urine  may  be  a  source  of 
new  anxiety  and  worry  to  the  unfortunate  patient,  already 
greatly  bmken  down  by  the  agonixing  pains.  These  htcmor* 
rhages  may  be  considered  as  an.ilngous  (o  the  ccchymoses  in 


6s4 


DISEASES  OF  THE  CENEkAL  SERVQUS  SYSTEM. 


Ihu  skin  occurring;  after  the  intense  lancinating  pains,  whf 
wc  mciUioiied  above  on  pag«  64;. 

The  most  troublesome  rectal  symptom  is  the  very  obstinate 
constipation.     Incontinentia  alvi  and  an.'csthesta  of  the  rectal 


Fie.  t7J— A  Cask  or  Ckamcot^  Joun-  m  a  TAsmi:  (pcraatui  obsemliaaV 


mucous  membrane,  in  consequence  of  which  the  patient  is  not 
aware  o(  the  act  of  defecation,  and  so  soils  himself  unoon- 
SCtously,  arc  among  the  rarer  occurrences. 

The  centre  for  the  sexual  functions,  the  scat  of  which  is 
also  in  the  lumbar  enlarfjement,  is  under  the  control  not  oolj' 
of  rcHex  but  ahc>  of  cerebral  influences.  If  the  palh  coming 
from  the  psychical  centres  is  interrupted,  the  performance  ol 
the  function  is  faulty ;  if  the  path  from  the  inhibitory  centres  is 
disturbed,  the  sexual  reflex  activity  is  increased  and  priapi?ni 
may  occur.  Pitrcs  (Progr.  ined.,  1884.  xii.  J7),  under  the  name 
of  "  crisfs  cliloridieanfs"  has  described  in  women  conditions 


i 


^^^^^^^^"^  TABUS  DOSSAUS.  ^^^        655 

which  consisted  of  periods  of  voluptuous  excitement  accom- 
paiiied   by   secretion,  .niialogous;  to  the   violent  erections  and 

■  spermatorrhoea  (ound  in  men  in  the  initial  stages  ol  mbes. 
Such  cases  arc,  however,  at  least  in  Gcrmanv,  exceptional. 
Not  infrequently  tabetics  have  been  knuwn  to  preserve  their 

■virility,  and  even  after  the  beginning  of  the  disease  to  beget 
one  or  even  several  heiilihy  children.  Only  later  does  the 
sexual  power,  and  with  it  the  desire,  become  diminished,  and 

I  Coitus  lose  its  charm,  so  that  it  is  undertaken  more  rarely,  the 
act  being  s^imelinies  incomplete.  A  normal  condition  of  the 
nerves  necessary  for  the  erection  of  the  penis,  associated  with 
>  paraly&is  of  those  going  to  the  ejaculntor  seminis,  so  that 
while  coitus  and  orgasm  are  normal,  the  semen  is  not  emitted 
till  later,  and  then  very  slowly— a  condition  which  Bernhardt 
has  oiKierved  after  injury  (Deulsch.  Med.-Ztg.,  1888,48)— has 
H  been  known  to  occur  also  in  the  course  of  tabes. 
B  T'>c  vaso-motor  and  trophic  centres  in  must  cases  are  not 
afTecled.  In  the  majority  of  instances,  symptoms  of  this  char, 
ncter  are  entirely  absent  during  the  whole  course.  In  some, 
however,  peculiar  symptoms  attract  our  attention,  as,  for  ex- 
ample, a  local  hypcridrosis.  which  Ollivier  (Gaz.  hebdom., 
tScptemhre  7,  1883.  xxx,  36).  I^aymond  and  Arlbaud  (Revue  de 
med.,  1884.  4.  j),  and  others  have  obscr^'cd  on  the  hands  and 
(ect.  In  a  case  of  tabes  we  have  also  seen  the  sweat  secretion 
on  the  hands  so  increased  that  wc  were  able  to  note  the  forma- 
tion of  small  drops  and  walch  them  unite  to  form  a  steady 
dripping.  In  another  case  there  was  unilateral  sweating,  the 
hyperidrosis  appearing  after  every  meal  on  the  lek  half  of  the 
head,  (ace,  and  neck.  I  do  not  care  to  risk  an  opinion  as  to 
how  far  an  assumption  of  an  affection  of  the  sympathetic  would 
_  here  be  justifiable. 

f  Greater  practical  importance  must  be  attributed  to  the 
changes  which  are  observed  in  the  nails  and  teeth  of  those 
affected  with  tabes.  The  nails  are  either  deformed,  becoming 
twiste<l  or  marked  by  deep  furrows,  or  fall  out  entirely  from 
the  fingers  as  well  as  from  the  toes,  as  JofTroy  (L'lJnion.  1883. 
106),  Bonieux  (Th^e  dc  Paris.  1883,  No.  237),  Hay-Margiran> 
diirc  (Thise  de  Paris,  1883,  No,  75I,  and  others  have  observed. 
The  loss  of  the  nails  ("  la  chuU  ihs  ongiti  ")  is  (mt  rare  in  tabes, 

»anri  is  in  some  cases  to  be  attributed  lo  the  temporary  cessa* 
tion  of  growth  of  the  nnil  matrix.  In  others  an  ccchymosis 
uoder  itte  tiail  may  be  the  exciting  cause.     Under  certain  cir- 


6;6 


DtSEASES  OF  THE  GENERAL  XEXl'OUS  SYSTEU. 


\ 


cumstances  llic  nail  of  Ihe  great  toe  falls  off  allt^cthcr,  wilfiowt 
pain,  with  only  a  slight  itching  scnsuliun,  and  the  newly  lormcd 
nail,  which  is  often  rough  and  irregular,  soon  shares  the  fate  ol 
its  predecessor. 

It  iii  occasionally  observed  that  the  teeth  become  loosened 
without  any  pain  and  (all  out  without  the  :ippcarance  of  any 
symptoms  ol  inHanimalinn,  Ihe  tooth  iiscll  being  intact.  This 
arises  from  some  disturbance  in  the  nutrition  of  the  jaw,  a  rare- 
fying ostitis  which  is  connected  with  a  lesion  of  the  nucleus  of  ■ 
ihc  trigeminus  (Vallin  and  Demange).  In  this  way  the  patient 
may  lose  all  hh  teeth  in  a  few  months.  It  is  very  inlcrcsiing 
to  note  that  this  may  be  connected  with  laryngeal  crises,  a  fact 
which  would  indicate  that  there  may  be  some  truth  in  the  view 
advanced  by  Buzzard  (British  Med.  Journal,  February  ii^ 
1886),  according  to  which  the  centre  lor  bone  nutrition  lies 
quite  close  to  that  of  the  vagus. 

The  so-called  wrt//rr/i>rfln/(/«/>tVrf (perforating  ulcer),  which 
begins  with  the  formation  of  a  bleb  and  leads  to  abscess  forma- 
tion and  necrosis  of  the  tendinous  and  bony  portions  ol  the 
feet,  is  due  to  snme  trophic  disturbance,  and  may  become  a 
source  of  great  discomfort  to  the  p.iticnl. 

Affections  n[  the  bones  and  joints,  which  arc  also  of  trophic 
origiji.  belong  to  the  more  Irequcnt  complications  of  tabes. 


Flu.  174-  Fie-  »7S. 

Fi|E.  J74.— Crmiiw  op  ni8  I-litAi)  or  thk  KvMEitm  ik  TAhes  Dokmlu    Pif.  ■f^' 
Ndrmal  HuMKKua.    (Alter  Charcot,} 

The  bones  become  extraordinarily  brittle  and  fractures  fre- 
quently occur  without  pain,  and  one  could  almost  say  wilhuol 
(he  knowledge  of  the  patient.  The  seat  of  such  fractures  is 
most  commonly  in  tlie  femur,  and,  more  especially  in  old 


I 


TABES  DOftSAllS. 


657 


I 


I 


women,  in  the  neck 
o(  that  bone.  This 
remarkable  fragility 
is  of  especial  mo- 
ment when  it  occurs, 
us  it  sometimes  does, 
in  the  bones  of  the 
spinal  column,  and 
particularly  in  its 
inmbar  portion,  and 
gives  rise  to  spondy- 
lolisthesis without  it 
being  pa<:siblc  to  de- 
cide whether  or  not 
the  cartilages  and 
ligaments  were  first 
afTccled  and  the  dis> 
case  of  the  bones 
was  only  secondary 
(Krocnig,  Xcitschr. 
I  klin.  Med..  1888, 
3ctv,  r,  2). 

Among  the  joint 
affections  which  arc 
not  essentially  differ- 
ent from  those  pro- 
duced by  arthritis 
deformans,  the  "rtf. 
tkropatkie  d(s  ataxia 
y«rt  "  or  "  Charcot's 
joint,"  because  it  was 
first  described  by 
him,  deserves  par- 
ticular mention.  Ac- 
cording to  his  de- 
scription, there  dc 
vclops  in  the  course 
of  one  night,  with' 
out  any  appreciable 
cause  and  without 
pain  or  febrile  move- 
ment, a  swelling  of  a 

4> 


Fie.  il^i— SKKLRTOif  OF  ji  T*BKTtr  FnoT.  (AflarCMAa- 
OfT.i  (The  ur%4nal  (i  tn  ihc  pallMUii(ka)  mummib  of 
CtumM^  dsfiuisieM  la  Ihc  &U|»<uMn  ht  Pwia.)  1-5. 
ntKUtanal  boaea.  t,  InWnul  o«iKtr«f«  booc  t-  ■"■■1* 
lUt  cunelfonn  bone.  8.  fragBtM  of  the  Mmt*!  «ni*l' 
■nm  bone.  9.  <ubo4d  bnat.  ic  uid  ii,  IracntMt  lA 
th*  tcafkoM  boM,  ta  and  ij,  (krc  tmnfim.  14.  ih« 
cacaloiMUM. 


6s8         DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM. 

Joint— for  instance,  the  knee,  shoulder,  elbow,  or  hip.  In  the 
course  of  a  few  days  there  is  noted  a  collection  of  fluid  in  the 
joint  and  in  the  periarticular  bursre,  and  on  puncture  a  lemon- 
yellowish  transparent  serum  can  be  withdrawn.  In  one  or  two 
weeks  later  one  is  able  to  make  out  more  or  less  well-marked 
crepitation,  due  to  changes  in  the  joint  surfaces.  The  joint 
becomes  extraordinarily  movable,  and  luxations  frequently 
occur,  especially  when  the  ends  of  the  bone  are  worn  away 
(Figs.  174  and  175). 

Occasionally  the  tarsus  is  affected  by  the  process.  In  such 
cases  a  marked  swelling  of  the  foot  occurs  in  a  relatively  short 
time,  the  joints  become  affected  in  the  way  stated  above,  and 
at  the  post-mortem  examination  the  tarsal  bones  are  found  to 
be  altered  in  the  manner  represented  in  Fig.  176  ("tabetic 
foot"). 

The  real  cause  of  the  affection  is  not  vet  known.  While 
Charcot  considered  it  due  to  an  atrophy  of  the  anterior  gan- 
glionic cells  in  the  cord,  Virchow  pointed  out  that  it  might  be 
due  to  a  state  of  lowered  nutrition  of  the  bone  following  a 
disturbance  of  nerve  influence.  Oppenheim  and  Sjemerling 
demonstrated  a  degeneration  in  the  peripheral  nerves,  and  ac- 
cording to  Volkmann  the  analgesia  produced  by  tabes  creates 
a  predisposition  to  the  occurrence  of  the  joint  affection  which 
he  attributes  to  disturbances  in  the  cartihges.  Rotter  divides 
the  cases  into  three  groups — true  arthritidcs  deformantes. 
primary  fractures  of  the  joints,  and  a  third  class  in  which  there 
are  most  pronounced  changes,  but  in  which  we  are  unable  to 
determine  whether  they  arc  due  to  an  arthritis  or  a  primarv 
fracture. 

We  may  add  th.Tt  arthrcctomy  has  lately  been  performed 
several  times  for  tabetic  affections  of  the  knee  joiiit.  and  has 
been  followed  by  success  (Wolff.  Sitzung  der  Berliner  nicd. 
Gcsellsch.,  7.  Miir-z,  1888,  Deutsche  Mcd.-Zlg.,  iSSS.  22.  p.  26S1. 


LITKRATURE. 

3.  Spinal  Cord. 

e.    Vasomolor  and   Tivphk   Cha<igi-s. 

Porliiher.     These  de  P;iris,  1884.     (Trophic   Changes  in   the  Preaia\ic  SPS" 

of  TabL-s.) 
Russolvmmo.     Arch,  f.  Psych,  u.  Ncrveiikh.,  1884,  \v,  3.     (Trophic  Changes  in 

the  Skin.) 


TABES  DOSSAUS. 


659 


I 


jAHOWsky.     Wilier  mcd.  Pm«c.  iS8s,uvl,S,     (On  EiianllMinaious  Eniplioiu 

in  Talieiici.) 

Koflhiani).     Hcrtiner  kiln.  Wochcnschr..  i8Sj.  iili.  13. 
Drownc  aiMl  d'Arc}-  Powrr.    St.  Buiholomcw's  HosfHUl  Reports.  18S6;  xviil. 

("  Mai  iKifunnt  du  pied."] 
Cilipp^.    Cak  (h-K  Mp..  1886.  5lt.    (AffiKiions  ofihe  Tecih.) 
Knxii);.     Wirbckrkrankungcri  <kr  Tabikcr.     Ueutichc  Med.-Ztg..  1886,  tU, 

101. 
HiiMc    Da.H  llaniiifjcctchwiir  unil  "cin  VcihUlniu  lur  Tsbcs.    Si.  PMcnburgcr 

incd.  Wothrtisthr.  N.  h..  1886.  iii,  16-38. 
M^nitrier.     Annal.  de  dermal,  ct  6}'ph.,  1S86.  vii.  1.    (Mai  Pcrforanl  affecting 

the  Hands.) 
MollM«.     Lyon  m«l..   iSS?,  Iv.  p.  377.     (Onset  of  Tabo  with   Trophfc 

ChangM^) 
Suckling.     Urii.  Med.  Joum.,  April  6.  tSSj.     (Pcrfotaiir^;  Ulccf  u  the  Fir«t 

Syinptum  of  T^bcs.) 
Marshall,  J.  G.     L.mcci.  Januan-,  t8$5,  i.  t, 
Joffroy.    Cjt.  dcs  hAp..  1885.  133.    (Tal.eik  Fool.) 
KtcKanlifrtt.    Revue  de  inM..  Vivr.  3.  1S86,  ri.    (AnhropUhy  in  l1»e  Fingcr- 

JointM.) 
Andmon,  J.  WsILkc.    Brain.  1S861  KKHtv,  p.  114.    (Anhropaihy.) 
Ko«inti>w.     Med.  Ohserv.,  1S86.  17. 

LrtwcnfcUL     AIuiKh.  m«L  WuchcnKhr^  1887.  xxxir,  20,     (Anhropathy.) 
Kuiter.    Arch.  f.  klin.  Cliir.  1887.  xx»vi.  1.     (Anhrupiiihy  erf  Tabes,) 
Kramrr.     fragitr  med.  Woclipnsihf,,  1887.  xii.  33,     (Tnlwttc  Foot.) 
Kahldcn.     VirchoM's  Archiv,  1887.  ci(.  1.    (Arthrop;iihy.) 
fdricr.     New  York  Mctl.  Ki-L-ord.  Octolx-r.  1V87.  txiii.  iS.    (Anhrapalhy.) 
Dana.     Elation  Mrd.  and  Surg.  Jnum..  Octnhcf  17,  1887,  cxvil.    (Anhropathy.) 
Paolidt*.     I>M  anliTi>|)allties  iaUli<|un  du  pied.     Nouv.  Ironogr.  lie  la  Salpttr., 

IS88.4.5- 
Collier  and   Hit.     Traniuicttnnii  of  the  Pathol.  Sockly.    18S8,  xxsii.  p.  31. 

(Charc«4'«  Joint  in  lite  Knee.) 
Kmt«l.      Die  Anhn>|wihim  und  Spoctianfmciurcn  bri  Tabes.     \'iitkRiann't 

Samml.  klin.  Vortr..  18S8.  309,  Chir,  Nr. 
I>rjerine.    Surl'nlropliic  muiculaire  des  alaxiijuct.     I'arb.  l88^ 
Sucktins,     {Int.  Med.  Juurn,.  lS6'}.  p.  1009.     (Muscular  Alraphy.) 
VemruU.     Hull.  mM..  1S90.  76.     (I'alhologica)  Fractufca.) 
KOnig.     Progr.  mM..  1891,  44- 
Roain.    Zur  Lchrct-ondenlrophiKhrn  KklererkrankunKtntKtTaliet.   t>cutKhe 

Zcitschr.  r.  Nervrnkh.,  l8^i.  $.  <^. 
Slrnir.    Afihro|h)ihia  uhidonim,     Inaug-Divierl.,  tlerlin,  1S91. 
Coblacheider.     Atiuphiuhe   Lfihinung  bci  T.-itio.     Zcitschr.   f.  klifl.   Med., 

1891.S.6. 
Croue.     Ueber  Mutliebirophie  bei  Tabes.     Inaujt.-niwert .  Ilrtlm.  iSqi. 
Xipkau.    Airophische  Lihmungen  bei  Tabes.    Inau^.-Uisscit..  [kilin,  l8g). 

For  (he  last  few  years  only  we  have  known  that  the  pcriph- 
|«ral  nerves  play  a  lar^c  and  important  part  in  tabes:  previous 
\%o  (his  Tiirck  und  later  Friedreich  had  reported  alterations 


66o         DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM. 

in  the  mixed  nerves,  but  we  were  ignorant  of  their  character 
until  the  pubtication  of  the  work  of  Westphal  (1878),  which  was 
soon  followed  by  other  articles,  among  them  those  of  Dejerine, 
Pitres  and  Vaillard,  Oppenheim  and  Siemerling,  Sakaky  and 
Pierret.  The  results  of  their  work  showed  that  the  peripheral 
nerves  suffer  a  parenchymatous  degeneration,  a  destructive 
process,  which,  being  associated  with  an  increase  of  the  peri- 
neurium,  a  proliferation  of  the  nuclei,  and  extensive  connective- 
tissue  formation,  leads  to  a  final  atrophy  of  the  nerve  elements. 
This  peripheral  neuritis  is  not  necessarily  followed  by  marked 
symptoms,  but,  according  to  our  views,  it  is  the  main  factor  in 
the  production  of  the  analgesias  which  are  often  observed  so 
early  in  the  course  of  tabes,  and  to  which  O.  Berger  has  already 
directed  attention.  Under  certain  circumstances  this  neuritis 
may  produce  deformities;  thus  if  it  involve  the  nerves  which 
supply  the  muscles  of  the  plantar  surface  of  the  foot  these 
latter  atrophy.  The  muscles  concerned  are  those  of  the  inner 
surface  of  the  foot  affecting  the  great  toe,  those  of  the  outer 
surface  to  the  little  toe,  the  flexor  brevis  communis,  and  the 
interossei;  the  plantar  aponeurosis  retracts,  and  the  toes  be- 
come flexed  and  immovable  (Fig,  177), 

If  larger  nerves  be  affected  by  the  process,  the  symptoms, 
which  are  characteristic  of  neuritis,  and  which  have  been  de- 
scribed on  p^ge  386,  make  their  appearance.  They  are  chieflv 
pains,  motor  disturbances,  and  muscular  atrophies.  To  this 
class  belong  the  musculo-spiral  paralyses  caused  by  tabes,  de- 
scribed by  Striimpcll  (Berl.  klin.  Wochenschr.,  1886,  xxiii,  37). 
lesions  of  the  median,  described  by  Remak  (ibid.,  1887,  xxiv, 
26),  and  lastly,  lesions  of  the  peroneus  loni;us.  as  described  bv 
Joffroy  (Gaz.  hebdom.,  1883,  xxxii,  48).  Lately  Dejerine  has 
described  a  widespread  muscular  almphy  in  tabetics,  which 
has  its  origin  in  a  peripheral  neuritis  (Neurite  motrice  peri- 
ph^riquc  dt's  ataxiqucs,  Revue  de  m^d.,  18S9,  2).  The  obser- 
vations  of  Rcmak  seem  to  indicate  that  the  muscles  which 
are  subjected  to  an  unusual  strain  in  the  patient's  occupniinn 
are  particular ly  prone  to  become  atrophied.  In  confirmnlion 
of  this  I  can  add  two  cases  of  my  own :  (0  In  a  cigar-maker. 
who  exerted  particularly  the  first  three  fingers  nf  the  riirht 
hand  in  making  the  cigar-tips,  atrophy  developed  in  the  muscles 
of  the  bal!  of  the  thumb  supplied  bv  the  median.  (2)  A  den- 
tist with  tabes,  who  overexerted  the  musculature  of  the  hand  in 
filling  teeth  and  in  other  manipulations,  came  under  my  obser- 


TABSS  DOSSAUS. 


661 


vation  on  account  of  an  atrophy  of  the  hypothenar  muscles 
supplied  by  the  ulnar.     Similar  cases  arc  not  uncommon. 


I 


Pis-  177.— PUMTAB  Fluiq)*  or  Tus  Tou  ta  thr  Covrb  or  Tams 
rpenuiuU  otwervauoa). 

It  is  not  at  all  rare  in  the  course  of  tabes  for  the  peripheral 
nerves  to  be  attacked  by  neuralgias:  the  sciatic  nerve  calls  for 
first  mention,  as  it  is  usually  affected  early  in  the  disease  and 
very  severely.  Wc  have  already  stated  on  page  372  that 
double  sciatica  is  more  particularly  a  frequent  accompaniment 
of  tabes.  Bnuiches  of  the  pudic  nerve  may  also  be  aflcctcd, 
and  often  rcclo-vcsical  neuralgia  may  be  a  source  of  great 
trouble  (Xcftcl,  Arch.  f.  Psych,  und  Ncrvenkrankheitcn,  1880^ 
to):  in  this  the  patients  complain  ol  a  painful  burning  sensa- 
tion in  the  rectum  after  each  defecation,  which  is  often  fol- 
lowed by  marked  depression  of  spirits,  and  the  longer  the  in- 
terval between  the  acts  of  defecation  and  the  firmer  the  con< 
sistcncc  of  the  stool,  the  more  intense  becomes  the  sulTering. 
After  all,  it  is  not  easy  to  distinj^uish  the  peripheral  Irum  the 
above-described  central  afleclion,  which  may  run  a  similar 
course. 

I.ITKRATl'BE. 

4.    Tkt  Ptriflurtl  Xtrvei. 

Sakatcy.    Arch.  f.  Pij-ch.  uihI  Nen-cnkh.,  16S4.  iv.  1.    (tV^ncraiion  of  the 

.    PrriphrraJ  Nefvc«.) 
Stem.  Uolktv,     \\m\..  ivii.  y    (Anomalie*  nf  Senutlon.) 

UjiiHrnhrim  umt  Siemirling,      AkH.  f.  I^ych.  u.  Ntrvrtlkh,.  1887.  «vlH.  a.     {SU 
fcciMtis  of  the  I'chphcral  Nervex.) 


662 


DfSF.ASF.S  OF  T/IE  GEh'ERAL  KERVOVS  SYSTEM. 


Dcjcrine.     Gw.  dc  Parin,  188B.  10.  1 1.  12. 

Dcjeriiie.     Revue  ile  in^.,  1 889.  ix.  j,  3.  4, 

Dtjtnne  «  Sollier.     Areh,  iJc  mid.  cipirimcnt.,  1889,  f.  », 

DcJL-rinc.    K-KlinliiilSlimunK  bci  Taba.     UcuIm-Hc  Mcil.-Ztg..  tSgoi  so.  ]>.  331, 

UieniackL    Aiulgc&ic  dcs  Ulnanuummcs.     NcuruL  Ccu[r.ilb4..  1S94.  ?• 

We  will  now  attempt  to  say  something  as  to  the  relative 

frequency  i)f  the  symptoms  and  the  lime  of  their  occurrence, 

Itit,  of  course,  such  statements  can  not  lay  claim  to  accuracy, 

'and  tan  only  serve  to  give  an  approximale  idea  concerning  Ihc 

points  in  question. 

Among  the  most  frequent  symptoms  belonging  to  the  brain, 
arc,  as  wc  have  already  shown,  lesions  of  the  cranial  nerves, 
and  particularly  of  the  oculomotorius.  by  which  transient  diplo- 
pia and  irregularities  in  the  condition  of  the  pupils  (anisocoria, 
myosis)  are  produced ;  next  come  lesions  of  the  abducens. 
Almost  as  frequently  will  one  recognize  disturbances  of  the 
vagus,  amoiifj  which  the  gastric  crises  deserve  particular  men- 
tion. Among  the  .<ipinal  .symptoms  belonging  to  this  category 
the  first  to  be  mentioned  are  the  maniluld  disturbance  of  sensi- 
bility, among  ihcin  cutaneous  analgesias,  particularly  in  the 
lower  extremities,  then,  the  paresthesias  and  the  lancinating 
pains  which  occur  more  particularly  in  the  legs  :  how  far  these 
symptoms  in  a  given  case  are  due  to  disease  (irritation)  of  the 
posterior  spinal  niots  or  to  lesions  of  the  peripheral  nerves  can 
only  be  determined  by  microscopic  examination.  At  all  events, 
degeneration  of  the  peripheral  nerves  in  the  most  varied  cuta- 
neous areas  is  to  be  classed  among  the  regular  occurrences  in 
tabes.  The  disappearance  of  the  patellar  reflex  and  some  form 
of  the  various  bladder  troubles  are  almost  constant  accompani- 
ments oi  the  aflcctinn,  and  tliesc,  taken  in  connection  with  the 
symptoms  just  mentioned,  must  be  considered  as  the  founda- 
tion for  the  diagnosis. 

Lesions,  particularly  atrophy,  o(  the  optic  nerve,  symptomi 
of  irritation  and  paralysis  in  the  domain  of  the  fifth  nerve,  and 
ataxia  of  the  lower  extremities,  are  frequent  but  less  rcgulnr 
occurrences. 

Less  frequently  met  with  arc  the  laryngeal  crises,  due  tn 
lesions  of  the  vagus,  and  affections  of  the  nerves  ol  taste  and 
of  the  acccssorius ;  the  same  may  be  said  of  the  psychoses, 
hemiplegias,  and  atlacics  of  epilepsy  observed  in  the  course  of 
tabes.  Certain  disturbances  of  sensibility,  the  so-called  recta! 
crises,  cutaneous  hyperacslhesias,  neuralgias  of  the  peripheral 


TABES  DOSSAUS. 


66l 


spinal  nerves,  paraplegia  of  the  leps,  the  tremor,  and  disturt>> 

aiiccs  in  the  sexual  functions  also  belong  to  this  category.     The 

k  trophic  disturbances,  the  muscular  atrophy,  the  falling  out  ol 

'  the  nails  and  hair,  the  "  tnal  perforant  du  pied''  and  Charcot's 

disease  of  the  joints  arc  aho  comparatively  rare. 

To  the  symptoms  which  occur  only  seldom,  one  might 
almost  say  exceptionally,  belong  those  referable  to  the  hypo- 
glossal,  the  auditory,  and  the  facial  nerves;  among  the  motor 
disturbances  of  spinal  origin,  the  so-Called  associated  move- 
ments and  ataxia  of  the  upper  cxircmitics,  among  the  sensory 
disturbances,  the  so-called  polyxsthesias,  double  sensations,  and 
delayed  sensations  belong  to  this  class  ;  marked  diminution  in 
the  muscular  strength  is  also  exceptional. 

As  to  the  lime  at  which  these  various  symptoms  severally 
arise,  it  is  even  more  difficult  lo  give  reliable  data,  since  there 
exists  no  uniformity  ;  still,  one  can  state  with  some  amount  of 
certainty  that  next  to  a  feeling  of  slight  weariness,  particularly 
in  the  legs,  the  lesions  of  the  oculo-motor  and  abduccns  are 
often  the  first  to  make  their  appearance ;  the  disturbances  of 
sensibility,  particularly  analgesia  and  panesthesia.  as  a  rule 
Lalso  occur  early,  while  lancinating  pains  make  their  appear- 
'  ancc  at  a  later  period.  The  gastric  crises  are  observed  rel;u 
tively  early,  and  bladder  troubles  are  among  the  more  frequent 
occurrences  before  the  disease  has  advanced  very  far.  The 
dis:tppcarance  of  the  patellar  reflex,  as  it  usually  constitutes 
one  of  the  initial  symptoms  of  the  disease,  ptays  an  imfK>rtant 
part  in  the  diagnosis,  as  we  have  already  shown.  Pronounced 
motor  disturbances,  particul;irly  ataxia  of  the  lower  extremi- 
Xiici,  are  often  not  observed  until  later  in  the  disease,  often  only 
alter  years :  and  paraplegia  of  the  legs,  when  it  occurs  at  all. 
characterizes  the  last  siages  of  the  disease.  Optic  atrophy 
sometimes  makes  its  appearance  relatively  early ;  in  other  in* 
stances  it  occurs  only  at  a  late  period  and  comes  on  very  grad- 
ually. For  the  time  of  its  occurrence  no  definite  rules  can  be 
laid  down.  Hemiplegias,  epileptic  attacks,  and  psychical  dis- 
turbances, if  ihcy  occur  at  all.  manifest  themselves  sometimes 
earlier,  sometimes  later.  As  far  as  our  own  observations  go. 
the  trophic  disturbances  mentioned  above,  particularly  the 
muscular  atrophies  and  Charcot's  joint  aflcctiun,  usually  belong 
lo  the  later  stages. 

The  course  of  tabes  is  rarely  markedly  influenced  by  com- 
iplicatlons,  but  such  may  nevertheless  occur.     Lesions  of  the 


664        -DISBASBS  or  TBS  GBIfBSAL  HSMVOUS  SYSTEM. 

pyramidal  tracts  iii  the  spinal  cord  (Eulenbur^f,  Deutsche  med 
Wochenschr.,  1887,  3$),  valvular  diseases  <A  tiie  heart,  espe- 
'  daily  aortic  -insufficiency,  Gnves*  disease,  peroicious  aiuemia, 
diabetes,  general  paralysis,  and  bulbar  paralysis  are  to  be  re- 
garded as  complications.  Coexisting  hysterical  symptoms  we 
may  at  times  not  be  aUe  to  distinguish  from  those  arising  from 
the  tabetic  changes. 

*  LITERATURE. 

Oppcnhcim.     Beriiner  Icfin.  Wodteiachr,  iSft4.  zzi,  381     (HenicraiiiK  aad 

Tabes.) 
LeicbtenstNi).    Deutsche  med.  Wocfaemchr..  1884.  x,  ja.   (PemidooB  Anarais 

and  Tabes.) 
Oppenhein).    BerUner  Idio.  Wochenschr.,  1885.  ufi,  49.    (Diabates  conplkal- 

ing  Tabes.) 
Reumont     Ibid..  1885,  sxUi,  13.    (Diabetes  with  T^xs.) 
Grasset    Arch,  de  NeuroL,  JuUlet.  1886,  tL 
rucber.    CentralbL  t  Ncrveokh.  a.  P^chiatr.,  1886,  ix,  18.    (Diabetes  whfa 

Tabes.) 
Leyden.     CentralbL   f.  klin.    Hed.,    18B7,  viii,   i.     (CanBac  Afiectioos  widi 

Tabes.) 
Eulenburg.     Deutsche  med.  Wochenschr.,  xiti,  35.     (Tdxs  comlMiied  with 

Motor  System  Disease  of  the  Spinal  Cord.) 
Croedel.     Deuische  med.  Wochenschr.,  188S,  xiv,  25.     (Cardiac   AfTeciions 

with  Tabes.) 
Stransky.    Prager  med.  Wochenschr.  1888.  xiii,  25.     (Tabes  with  Muscular 

Atrophy.) 
Lichtheim.     Deutsche  Med.-Ztg.,   1890,  16.  p.   187.     (Tabes  and  Pernicious 

Anxmja.) 
Jolly.     Miinch.  med.  Wochenschr.,  1891,  23.  p.  406.    (Tabes  with  Hemiatrophja 

Faciei.) 
Kuh.  Sidney,    Arch.  f.  Psychiat.  u.  Ner\enkh..  1891,  xxii.  3.    (Comphcation  with 

Meningitis  Cerebro-spinalis.) 
Souchay.    Tabes  mit  HenafTeclionen  complicirt.     Charit£-Annaten,  1893.  xviiL 
Marie  et  Marinesco.     Revue  neuroi.,  1893,  la    (Tabes  with  Graves'  Disease.) 

Course. — About  the  general  course  of  the  disease  the  fol- 
lowing remarks  will  hold  good  in  a  large  number  of  cases :  A 
middle-aged  person  who  has  become  infected  with  syphilis 
some  years  previously,  usually  from  eight  to  fifteen  years  be- 
fore, begins  to  complain  of  slight  fatigue  on  walking  and  occa- 
sional pains  in  the  lower  extremities.  In  spite  of  all  treatment 
the  pains  continue  to  be  troublesome,  and  occasionally  become 
so  severe  that  they  disturb  the  patient's  rest  at  night  or  even 


TABES  DOXSA/./S. 


«5 


I 


I 


I 


render  sleep  impossible.  At  the  same  time  it  appears  to  him 
that  his  vision  is  becoming  affected,  and  he  complains  particu- 
larly that  he  sees  double,  and  in  consequence  suffers  from  ver- 
tigo. The  diplopia  may  last  only  lor  a  few  moments  at  a  time. 
The  vertigo,  which  at  the  onset  ol  the  trouble  was  insignifi- 
cant, becomes  more  and  more  pronounced,  more  especially  in 
the  dark,  so  much  so  that  it  is  almost  impossible  for  the  patient 
to  pass  through  a  dark  room  without  help.  He  also  discovers 
that  he  staggers  or  falls  to  one  side  in  the  morning  when  in 
washing  he  covers  his  face  with  the  towel,  and  only  regains  his 
equilibrium  when  his  eyes  are  free  again.  Only  rarely  do  dis- 
orders in  the  innervaliim  of  the  larynx  occur  in  the  incipient 
stage  ol  the  affection,  but  an  abductor  paralysis  may  b«  found 
very  early  (Grabower,  Deutsche  mod.  Wochcnschr.,  1893,  18), 
and  the  laryngeal  examinalion  should  therefore  never  be 
omitted  in  suspicious  cases.  Finally,  he  complains  that  he  is 
obliged  to  pass  water  more  often  than  usual,  and  that  he  con- 
sumes more  time  and  must  exert  himself  more  when  urinating 
than  previousiy.  The  objective  examination  shows  thai  there 
is  widespread  ana»thirsia,  particularly  analgesic  areas,  about 
the  lower  extremities,  and  a  loss  of  the  patellar  reflex.  He 
may  be  inconvenienced  in  this  way  for  years  without  his  cun* 
dition  becoming  serious.  He  suffers  more  or  less  all  the  time, 
sometimes  quite  severely,  but,  on  the  whole,  his  existence  is 
quite  bearable.  The  state  of  his  mind  is  hopeful,  lor  the  diiily 
occupation  has  not  yet  been  interfered  with  by  the  disease. 

The  aspect  of  affairs  is  quite  different  when  the  patient  suf- 
fers from  gastric  disturlKinccs.  The  appetite  becomes  poor, 
and  occasionally — sometimes  lor  weeks  at  a  time— there  is  morn- 
ing vomiting,  which  is  quite  profuse  and  occurs  as  soon  as  the 
patient  awakes,  when,  without  effort,  watery,  slimy  masses  are 
discharged.  After  lasting  for  a  longer  or  shorter  time  this 
ceases,  probably  only  to  return  later  on.  The  appearance  of 
the  patient,  which  was  previously  natural,  now  becomes  al- 
tered (or  the  worse.  The  skin  becomes  yellow  and  wrinkled, 
and  his  friends  and  acquaintances,  who  have  not  seen  him  for 
some  time,  begin  to  inquire  about  his  health.  At  the  same  time 
a  new  symptiim  makes  its  appearance,  and  he  notices  that  his 
gait  is  becoming  uncertain  and  that  in  walking  he  must  invoke 
his  eyes  to  aid  his  legs,  which,  instead  of  carrying  out  the 
movements  he  intends,  are  thrown  out  in  a  peculiar  aimless 
manner,  so  that  if  he  be  not  led  or  supported  he  runs  the  risk  of 


666 


OISEASES  OF  THE  GENERAL  NERVOUS  SVSTEM. 


tumbling  down.  This  trouble  in  walking,  which  is  associatcft, 
perhaps,  with  occasional  gastric  and  more  rarely  with  larvn- 
{;eal  crises,  may  likewise  continue  lur  yenrs ;  but  if  tbe  ataxia 
implicates  the  upper  extrcmilics,  as  happens  in  a  small  propor> 
tiun  of  the  cases,  it  may  so  interfere  with  the  patient's  occup- 
tinn  that  he  may  be  unable  to  ccmtinue  it.  In  the  meanwhile 
the  bladder  symptums  become  more  prominent  and  are  aggra- 
vated to  such  an  extent  that  it  becomes  necessary  lor  the 
patient  to  wear  some  sort  o(  receptacle,  while  the  marked  con- 
traction or  inequality  of  the  pupils  is  apparent  even  to  the 
layman. 

Gradually  another  change  for  the  worse  in  the  gait  comes 
on.  The  legs,  which,  although  thrown  out  in  the  characteristic 
manlier,  in  other  respects  performed  their  duty  and  even  en- 
abled the  patient  to  cover  considerable  distances,  begin  to  be 
fatigued  on  the  slightest  exertion  :  ihey  become  heavier  and 
heavier,  and  it  becomes  more  and  more  diflicuil.  and  ai  last 
needs  the  greatest  effort,  ti>  walk  at  all.  The  legs  arc  so  weak 
that  they  arc  no  longer  able  to  support  their  owner,  who  is 
forced  to  take  to  the  invalid's  chair,  and  in  this  he  ends  an 
existence,  the  last  years  of  which  arc  as  wretched  as  could  be 
imagined,  especially  if  atrophy  of  the  nplic  nerve  has  robbed 
him  of  sight  and  the  lancinating  pains  make  his  days  and  nights 
miserable.  When  the  disease  progresses  in  this  or  a  similar 
manner  its  duration  varies  from  tctt.  fifteen,  even  to  twenty 
years  or  more.  It  can,  however,  be  considerably  shorter.  I 
have  seen  cases  in  which  only  from  three  to  five  months 
elapsed  between  the  beginning  of  the  alTection,  from  the  first 
appearance  of  the  disturbances  in  the  movements  of  conver- 
gence of  the  eyes,  to  the  appearance  of  well-marked  paralysb 
of  the  legs. 

On  the  other  hand,  there  are  cases  in  which  the  course  may 
extend  over  a  space  of  thirty  or  more  years  ;  in  these  paralytic 
symptoms  may  not  come  on  at  all,  and  the  ataxia  m.\v  continue 
to  the  end.  There  arc  tabetics  who  during  their  entire  illness 
arc  hardly  prevented  at  all  from  carrying  on  their  work :  they 
are  always  able  to  be  up  and  about,  and  it  appears  as  if  the 
different  symptoms  never  attained  iheir  full  development. 
These  arc  the  so-called  "  formes  frusUs  "  of  the  French,  analo- 
gous to  those  with  which  we  have  already  become  ac<|uaintcd 
in  Graves'  disease  and  in  multiple  sclerosis.  Again,  in  other 
cases,  tabes  sets  in  with  brusque  symptoms,  such  as  apoplcctt- 


rASSS  DORSAUS. 


667 


form  attacks,  disturbances  of  speech,  anri  lesions  of  the  oplic 

(nerve,  and  then  pursues  a  mild  course  for  a  long  period — vio- 

hcnl  symptoms,  such  as  laryngeal  crises,  intense  ncur,ilf;ias, 

fete,  only  occurring  occasionally  ;  ihcie  are  the  so-called  alyp. 

ical  lorms  of  the  authors. 

Proni  what  has  been  said  it  is  evident  how  ditficult  it  is 

make  a  positive  statement  concerning  the  general  course  of 
the  ftfTection.    Scarcely  one  case  follows  (he  same  course  as 

>ther,  and  it  often  requires  a  great  amount  o(  caution  and 
friencc  to  enable  one  to  take  a  correct  view  of  all  that 

:urs. 

Just  as  much  uncertainty  exists  about  the  prog-ntwis,  which 
H%  influenced  by  various  (actors.  One  most  important  question 
is,  of  how  long  standing  Es  the  disease,  for  in  recent  cases  in 
which  there  are  no  other  symptoms  than  dtsturtinnccs  of  sen- 
sibility and  absence  ol  the  knee  jerks,  and  the  course  of  which 
has  not  as  yet  exceeded  three  or  lour  months,  and  in  which 
(here  is  no  ataxia,  the  prognosis  is  not  at  all  unfavorable,  and 
the  disease  is  under  some  conditions  curable.  Advanced  cases 
of  tabes  in  which  there  are  numerous  spinal  and  cerebral  symp- 
toms oflcr  a  much  more  scrinns  prognosis,  but  even  here  the 
possibility  of  cure  is  not  excluded,  though  the  highest  percent- 
age of  recoveries  is  estim.-ited  at  one  per  cent  lEulenburg).  Ol 
course,  one  can  not  expect  thai  the  anatomical  changes  will 
disappear,  and  at  the  autopsy  a  widespread  dcgcneralion  of 
Uhe  posterior  columns  has  been  found  in  cases  'in  vrhich  during 
life  all  symptoms  had  practically  disappeared.  In  the  majority 
of  the  soculled  recoveries  from  tabes  one  is  led  to  believe  that 
there  was  a  misLnkc  in  the  diagnosis,  and  that  these  were  cases 
of  chronic  nicotine  poisoning,  peripheral  neuritis,  hysteria, 
neurasthenia,  etc.  The  prognosis  of  old  cases  with  [>;iraplcgia 
of  the  legs,  paralysis  of  the  bladder,  and  so  forth.  \s  altogether 
unfavorable,  and  anv  attempts  at  cure  are  not  only  useless,  but 
may  even  interfere  with  the  comfort  of  the  {mttent. 

It  is  a  matter  of  indifference,  so  far  as  the  pn>gnosis  is  con- 
cerned, whether  one  is  able  to  dcmonstnitc  that  the  patient  has 
at  one  time  or  other  been  infected  with  syphilis  or  not :  a  so< 
called  specific  or  luetic  tabes,  especially  when  the  infection  has 
taken  place  ten  or  twenty  years  previously,  dtKS  not  afford  a 
belter  outlook  than  the  more  rare  idiopathic  affection. 

It  is  clear,  then,  th,al  one  must  be  very  cautious  in  prcdicl- 
,ing  the  duration  of  the  disease ;  one  can  nut  say  delinitely  how 


668        DISEASES  OF  THE  GEXEftAL  AESrOt/S  sySTEV. 


many  years  a  tabetic  patient  has  to  live,  and  just  as  little  should 
one  attempt  to  make  a  positive  statement  as  to  how  long  the 
patient  will  be  able  to  work.  The  condition  may  remain  quite 
endurable  (or  months  or  even  years,  and  the  outlook  may  ap- 
pear quite  hopeful,  particularly  in  regard  to  the  capacity  (or 
work,  and  yet  suddenly  a  marked  change  may  take  place  ;  pro. 
nounced  ataxia,  cerebral  symptoms,  or  the  like  may  mani(est 
themselves,  which  render  the  patient  incapable  of  (oUowing 
any  occupation.  The  more  cases  one  sees,  the  more  cautious 
docs  one  become  in  givinjr  a  prognosis,  and  the  more  distrust- 
ful of  the  reports  of  so*caIlcd  cures— at  least  when  old  cases  are 
concerned. 

Diagnosis. — As  one  can  readily  see  from  what  has  been 
said,  the  diagnosis  of  tabes  is  sometimes  one  ut  the  simplest 
possible  tasks  for  the  physician  :  in  other  instances  it  can  not 
be  made  with  certainty  for  a  long  time.  Thus  it  may  under 
certain  circumsUnces  be  very  difficult  to  differentiate  between 
the  disease  under  consideration  and  complicated  cases  of  syph- 
ilis of  the  brain  and  spinal  cord. diabetes, or  hysteria.  ]t  seems 
perfectly  possible  (or  one  to  consider  a  severe  case  of  neuras* 
thenia  for  a  long  time  as  one  of  tabes,  but  the  further  course 
and  fin.il  success  of  therapeutic  measures  will  demonstrate  the 
error.  When  in  the  course  of  tabes  the  sensory  and  bladder 
disturbances  are  only  sli|;htly  marked,  there  may  be  question 
of  the  existence  of  a  chronic  anterior  poliomyelitis,  but  usually 
the  lancinating  pains,  the  para'sthesias.  the  affection  of  the  eye 
muscles,  and  the  mere  fact  that  bladder  symptoms  exist  at  all. 
afford  sufficient  grounds  on  which  to  base  a  diagnosis.  In  dis- 
eases of  the  vertebral  column,  in  the  course  of  which  lancinat- 
ing pains,  "  Westplial's  sign."  and  bladder  symptoms  may  be 
(ound,  an  examination  will  reveal  that  the  vertebral  column 
itseU  is  affected,  and  the  spinous  processes  are  pain(ul  on  pres- 
sure— a  condition  which  is  sufTicicnl  to  settle  the  diagnosis. 
The  mistake  of  considering  a  tabophobe,  or  a  person  who  im- 
agines he  has  tabes,  as  a  real  tabetic,  can  only  occur  when  a 
careful  examination  is  neglected,  and  the  physician  is  afraid  to 
adopt  any  energetic,  psychical  as  well  as  somatic,  treatment. 
As  soon  as  this  is  instituted  the  tabetic  symptoms  will  turn  out 
to  be  mere  hypochondriacal  notions,  and  recovery  will  quickly 
follow. 

It  is  of  practical  importance  to  note  that  the  various  symp- 
toms occurring  in  tabes  arc  also  observed  in  other  affections. 


I 
I 


4 

i 


19ES  rWRSAUS. 


669 


I 


I 


In  these  cases  there  is  much  room  for  errors  in  diagnosis,  the 
most  important  of  which  wc  wish  to  bring  to  the  reader's 
attention. 

Paralysis  of  ihe  eye  muscles  and  pupillary  symptoms  are, 
as  wc  ha%'c  remarked,  very  common  in  the  course  of  tabes. 
Another  affection  in  which  they  also  occur  is  multiple  sclerosis. 
Here,  however,  diplopia  as  well  as  strabismus  arc  rare,  white, 
on  the  other  hand,  nystagmus  is  very  frequent,  and  the  pupil- 
lary reaction  to  light  is  preserved.  Myosis  occurs  in  thisaffec 
tion  as  well  as  in  tahcs.  but  whereas  in  the  former  the  pupils 
contract  still  more  under  the  influence  of  light,  in  tabes  they 
usually  remain  immobile  under  the  same  circumstances. 

Symptoms  referable  to  the  optic  nerve — amblyopia,  for  in. 
Stance— arc  also  observed  as  the  effect  of  different  poisons  (page 
39).  In  such  cases  the  history  will  be  of  great  assistance  to 
us  in  making  the  diagnosis.  Amblyopia  developing  in  the 
course  of  multiple  sclerosis  is  not  accompanied,  as  in  tabes,  by 
a  contraction  of  the  fitltl  of  vision,  nor  docs  it  steadily  grow 
worse;  but  remissions  occur,  and  the  impro%*emenl  may  even 
list  for  a  considerable  time.  It  has  already  been  shown  on 
page  620  that  the  opiic  atrophy  of  multiple  sclerosis  differs  in 
important  points  from  that  occurring  in  tabes.  It  should  also 
be  remembered  that  there  is  an  optic  atrophy  in  which  the 
morbid  process  is  confined  to  the  optic  nerve,  and  in  which  it 
is  impossible  to  demonstrate  any  general  nervous  disease. 

The  various  visceral  "crises,"  in  which  tabes  abounds,  can 
likewise  be  produced  by  independent  affections  of  the  vagus. 
Here  one  must  rely  upon  the  more  characteristic  symptoms  of 
tabes,  particularly  Wc^lphal's  and  Romberg's  signs.  That 
"gastric  crises  "  alone  can  not  enable  one  to  make  the  dJag* 
nosis  is  all  the  more  to  be  insisted  upon  since  l.)cbove  has 
observed  them  in  neurasthenics  (Soc.  dcs  h(»p.,  stance  1888, 
xij.  28). 

The  motor  disturt>ances  which  we  find  here,  and  of  which 
the  most  important  is  the  ataxia  of  the  lower  extremities,  ap- 
pear not  only  in  the  course  of  tabes,  but  also  in  other  <liseases 
in  which  one  is  unable  sometimes  to  ascertain  their  anatomical 
basts.  This  is  more  es|iecially  true  of  the  so-called  (unctinnnl 
Ataxias  (Gallard.  Jaccoud).  which  develop  sometimes  wiih. 
sometimes  without,  sensory  disturbances,  and  arc  associated 
with  no  other  symptoms.  .Itasia  has  likewise  been  observed 
developing  slowly  or  quickly  after    diphtheria    <Berl,    klin. 


6;o 


I>/S£ASES  OF  TUB  GENERAL  NERVOUS  SYSTEM. 


Wocheiischr..  18R7,  49,  p.  930).  after  quickly  succeeding  pr«__ 
nancies,  and  in  the  course  u(  diabetes;  and  the  (Question  ntust 
remain  undecided  whether  it  is  to  be  cunsidercd  as  the  expres* 
sion  of  a  se\'cre  jjcneral  aflection.  of  a  faulty  composition  of 
the  blood  iiiid  an  imperfect  innervation  dependent  upon  it.  or 
as  the  result  of  a  peripheral  neuritis  developing  under  the 
influence  of  an  infectious  agent.  However,  it  can  not  be  diffi- 
cult in  a  given  case  to  determine  whether  the  ataxia  is  to  be 
regarded  as  of  spina!  or  tabetic,  or  as  of  functional  or  of  in< 
(cctious  origin.  In  cases  of  hys-teria  the  differential  diagnosis, 
as  has  been  already  pointed  out,  may  present  very  great  diffi- 
culties (Pseudo-tabes  hysidriquc,  Gaz.  m&J.  de  Paris.  Sepiembrc 
20,  rSgo). 

The  lancinating  pains  occur  also  in  affections  of  the  verte- 
bral column,  e.  g.,  in  Pott's  disease,  when  the  posterior  roots 
are  irritated,  but  the  deformity  and  the  tenderness  of  the  vcr. 
tebrx  upon  pressure  will  make  the  diagnosis  clear. 

Other  pains,  following  the  course  of  various  larger  nerves, 
which  can  last  for  weeks  or  months  without  marked  exacerba- 
tions, and  be  accumpaniijd  by  par»:sthcsi.-is,  formication,  numb- 
ness, etc.,  are  observed  not  only  in  tabes,  but  also  in  peripheral 
neuritis,  following,  for  example,  the  abuse  of  alcohol.  If  to 
these  a  temporary  loss  of  the  patellar  reflex  be  added,  we  have 
the  picture  of  what  is  called  pseudo-tabes,  and  a  cautious  and 
often -repeated  examination  is  necessary  in  order  to  make  the 
differential  diagnosis.  The  history  and  the  further  course  of 
the  disease,  which  in  alcoholic  neuritis  m.iy  become  favorable 
after  the  removal  of  the  cause,  should  always  be  taken  into 
consideration  (Higicr,  Deutsche  mcd.  Wochenschr,  1891,34; 
Fournicr,  Miinchener  med.  Wochenschr,.  1892.  10). 

\Vc  have  already  pointed  out  on  page  6jo  the  circumstances 
under  which  VV'estphars  sign  may  be  present,  and  we  can  not 
insist  too  strongly  that  it  is  an  error,  or  at  least  a  too  ha^ty 
conclusion,  to  think  only  of  tabes  whenever  the  patellar  reflex 
is  absent.  On  the  other  hand,  we  must  not  imagine  that  its 
presence  puts  tabes  out  of  the  qiieBtion,  foi  the  possibility  of 
ihc  existence  of  this  disease  is  not  at  all  excluded  when  the 
reflex  is  found  to  be  normal. 

Pathological  Anatomy. — Considered  from  the  palhologieal 
standpoint,  tabes  represents  a  degenerative  process  in  which 
the  entire  nervous  system  takes  part.  The  reason  that  we  have 
been  unable  to  demonstrate  in  all  cases  the  participation  ol  all 


I 


I 

I 


T^BES  DOflSAUS. 


67 1 


nerves — that  in  many  cases,  (or  example,  the  cord  seems  to 
the  part  most  involved  while  i)ie  brain  and  its  nerves  appear 
less  affected — lies  in  the  (act  that  we  have  been  accustomed  to 
examine  ilic  cord  with  the  greatest  accuracy,  while  the  brain 
and  peripheral  nerves  were  considered  only  of  secondary  im- 
portance; and.  secondly,  in  the  fact  that  many  cases  are  ter> 
niinaied  by  intercurrent  diseases  before  the  degenerative 
process  has  had  time  to  develop  in  all  directions. 

This  degeneration,  which  consists  principally  in  the  death 
of  the  nerve  elements  and  an  increase  ol  the  supporting  tissue 
<L.eyden),  presupposes  a  certain  change  in  the  nervous  system. 
the  nature  of  which  we  do  nut  as  yet  know,  and  which  is 
peculiar  to  the  individual  cither  as  the  result  ol  hereditary 
influences  or  which  has  been  acriuircd  later  through  syphilitic 
infection.  The  congeniul  predisposition  is  not  suflicient  to 
prfKluce  an  outbreak  of  the  disease.  For  this  some  one  of  cer- 
tain  exciting  causes,  of  which  wc  shall  speak  Liter,  is  needed. 
Oti  the  other  hand,  the  changes  produced  in  the  nervous  sys- 
tem by  a  syphilitic  infection  are  able  of  themselves  to  lead  to 
the  production  of  tabes.  As  to  the  manner  in  which  heredity 
works  in  the  production  of  these  changes,  wc  are  not  in  a  posi- 
tion even  to  hazard  a  conjecture,  nor  are  we  by  any  means  cer- 
tain of  the  precise  mode  of  action  of  syphilis.  In  this  latter 
,  however,  it  is,  according  to  our  idea,  most  probable  that 
he  changes  are  a  result  of  a  syphilitic  affection  ol  the  blood- 
vessels. It  is,  in  our  opinion,  less  likely  that  a  poison  ("  toxlne  "), 
which  affects  the  nervous  system,  is  developed  secondarily,  in 
which  case  tabes  would  have  to  be  regarded  as  a  post-syphilitic 
allection,  just  as  paralysis  of  the  solt  palate  is  a  post-diphtbe- 
riiic  affection  (Strllmpcll):  and  it  would  be  still  harder  to  im- 
agine that  the  syphilitic  virus  becomes  localized  in  the  nervous 
system,  and,  as  stich,  later  produces  the  disease  (Rumpf).  One 
could  in  the  last  case  not  help  but  ask  how  it  is  possible  for 
ten.  fifteen,  or  more  years  to  cLipsc  between  the  syphilitic 
infection  and  the  appearance  of  the  ftrst  tabetic  symptoms,  a 
circumstance  which,  on  the  other  hand,  could  be  easily  ex- 
plainefl  by  .issuming  the  existence  of  anatomical  changes  which 
arc  due  to  a  diminution  in  the  blood  supply  and  require  a  rela* 
lively  long  time  for  iheir  development. 

The  degeneration  begins  probably  always  in  the  peripheral 
nerve.s.  The  terminations  of  the  cutaneous  sensory  nerves  may 
be  the  first  to  become  affected.     The  admirable  researches  of 


A 


6;i 


D/SEAS£S  OF  TUB  GBXEXAL  NERVOUS  SYSTEX. 


Dcjcrinc,  Oppenhcim.  Sicmerling,  and  others,  have  clearly 
dcmuti<>i rated  itic  participation  of  the  peripheral  nerves  in  the 
tabetic  process,  and  there  is  no  doubt  but  that  they  appear  just 
as  much  dej^eneralcd  as  the  posterior  roots,  in  which  the  atro- 
phy was  shown  to  be  most  marked  between  the  spinal  g'anglia 
and  the  cord,  while  the  peripheral  portion  was  often  relatively 
quite  free  (Dcjcrine.  Compt.  rend,  dc  la  Soc.  dc  biol.,  1883,  p. 
215).  The  defcrce  to  which  the  several  cutaneous  nerves  arc 
attacked  varies.  Those  of  the  legs  arc  usually  more  affected 
than  those  of  the  upper  extremities.  No  delinite  rule  can  be 
said  to  exist.  Somclinics,  and  this  often  happens,  the  pcriph. 
era!  ends  of  certain  of  the  cranial  nerves  arc  the  first  to  be- 
come diseased— c.  g.,  those  of  the  optic,  the  oculo-moior,  and 
the  abduccns — and  then  the  symptoms  described  above  appear 
ill  the  initial  stage.  .\\.  any  rate,  the  first  symptoms  develop 
in  consequence  of  lesions  of  peripheral  end  organs. 

The  degenerative  process  in  the  cord,  which  occurs  later, 
is  the  most  prominent  pathological  feature  at  the  autopsy,  and 
formerly  was  considered  the  only,  or  at  least  the  only  charac- 
teristic, lesion.  This  explains  why  tabes  was  and  is  still  con- 
sidered, by  the  majority  of  authors,  as  a  disease  of  the  spinal 
cord.  According  to  our  idea  this  is  not  true.  It  is  rather  an 
affection  of  the  entire  nervous  system,  in  which  the  cord  (s 
not  even  the  first  part  to  become  affected,  but  later  is  altered 
in  such  a  characteristic  and  striking  manner  that  we  cannot 
be  surprised  if  the  other,  less  marked,  conditions  were  over- 
looked, Though  the  changes  in  the  cord  have  long  been  rec- 
ognised, the  views  as  to  their  origin  arc  still  conflicting  and 
the  most  varied  interpretations  have  been  put  forward.  We 
do  not  care  to  enter  into  an  account  of  ihc  controversies,  but 
will  only  bring  before  our  readers  succinily  the  conclusions 
arrived  at  as  to  the  nature  of  the  affection.  It  consists  prob- 
ably of  a  primary  degenerative  atrophy  of  the  nerve  fibres, 
which  is  followed  by  a  secondary  increase  of  the  supporting 
tissue.  As  the  degeneration  takes  place  slowly,  few  compound 
granular  corpuscles  arc  found,  and  only  in  older  cases  can  cor- 
pora araylacca  be  demonstrated.  The  grayish  discoloration  of 
the  posterior  columns  depends  upon  the  destruction  of  lite 
medullary  sheaths.  A  marked  degree  of  atrophy  is  to  be  no- 
ticed in  the  posterior  columns,  and  in  advanced  cases  the 
entire  cord  appears  narrower  and  thinner  than  is  normal. 
On  cross-section  it  is  readily  demonstrable  that  besides  the 


I 


TAlfES  DOKSAIIS. 


6;3 


posterior  columns  the  posterior  gray  bonis  and  the  posterior 
ruoiit  also  become  atrophied.  The  condition  ol  the  i>osicriur 
roots  has  been  carefully  studied  by  Leydcn,  who  noted  the 
(rcqiicnt  atrophy  in  Ihem  ;  according  to  his  conception,  the 
changes  in  the  posterior  columns  arc  a  result  of  the  chiingcs  in 
the  posterior  roots,  so  that  we  have  "  a  progressing  affection  ol 
ihc  sensory  portions  of  the  spinal  cord,"  This  view  is  still 
upheld  by  leydcn.  in  spite  of  various  objections  which  have 
been  raised  against  it  (Kediich,  Marie,  and  others ;  sec  the  latest 
article  of  Leydcn  in  the  ifeilschr.  f.  klin.  Med.,  1S94.  xxv.  1,  2). 
Moreover,  it  is  of  interest  to  note  that  certain  portions  of  the 
cord  seem,  .is  a  rule,  to  be  spared,  while  others  are  almost 
always  involved  in  the  degeneration  which  affects  both  sides  of 
the  cord  symmetrically.  The  lesion  is  of  the  character  which 
we  have  learned  to  recognize  in  the  so-called  "  combined  system 
diseases  " — thai  is,  certain  systems  of  fibres  which  have  certain 
anatomical  and  physiological  relations  to  one  another  become 
diseased,  while  others  are  unaffected.  It  is  also  seen  that  not 
all  portions  of  the  posterior  columns  are 
implicated  equally  (Strtimpcll).  but  that 
ihe  extent  of  the  lesion  differs  according 
lo  its  situation.  For  example,  it  is  most 
severe  in  the  lumbar  region,  in  which 
only  the  nnierior  part  is  left  intact,  the 
middle  and  posterior  portions  being  dc-  i-v  ■]& 


* 


Fit. «».  Ffc.  iHo. 

FV.  lift— SBCTKMr  -nitiovoii  tii*  CcHvrCAL  Oorb  m  a  Cam  or  Cnnimncvita  X\wr». 
He.  in-— ^'K'^O''  niRoktiii  niR  LlMua  Cciiid  ih  Tam*.  V\t.  tfa—Sn^fm 
niantT.ii  THt  C»vic*i.  Cou>  id  a  Cam  op  AinrAlnclti  TAau.     (Afi*r  Sthlm- 


jjenerated.  In  the  cervical  region  there  are  to  be  distinguished 
(our  fields  on  cither  side,  of  which,  two.  GoU's  columns  and  a 
pan  of  nurdach*s  columns,  the  so-called  lateral  root  fields  (into 
which  direct  fibres  enter  from  the  posterior  nerve  roots),  appear 
43 


674 


DISEASES  OF  TffS  GENERAL  NERVOUS  SYSTEM. 


degenerated,  while  two  others,  one  anterior  and  lateral,  the 
other  posterior  and  external  (the  posterior  outer  fields  of 
Sirtlmpell),  appear  normal  (Figs.  178,  179,  and  180).  Such  a 
distribution  ol  the  lesion  is  frequently  observed,  but  naturally 
not  found  in  all  cases.  Wc  have  already  mentioned  that  the 
posterior  gray  matter  is  involved  in  the  process.  Lissauer 
deserves  credit  for  having  demonstrated  (Arch.  f.  Psych,  und 
Nerveiikrankheiten,  18S6,  xvii,  p.  y}<i)  that  here  the  affection  of 
the  fibres  in  Cbrlce's  columns  should  be  distinguished  from 
(hat  of  the  fine  and  large  root  fibres  in  the  posterior  horns.  _ 
Physiologically  this  discovery  can  not  as  yet  be  utilized.  f 

O!  the  lesions  in  the  medulla  oblongata  and  the  brain,  pro- 
duced by  tabes,  the  former  affect  the  cranial  nerves  at  their 
nuclei  or  in  their  peripheral  course.  Uf  the  manifold  $ymp< 
toms  produced  thereby  wc  have  spoken  before.  On  the  other 
hand,  we  may  have  lesions  of  the  cortex,  an  implication  of 
which  in  many  cases  can  not  be  called  into  question.  We  also 
said  that  some  of  the  nuclei,  particularly  those  of  the  eye  mus- 
cles, of  the  vagus,  and  of  the  hypoglossus,  are  affected  more 
often  and  more  severely  than  others,  while,  for  instance,  the 
facial,  the  auditory,  and  the  glossopharyngeal  remain  as  a  rule 
intact,  a  fact  for  which  we  have  no  explanation.  According  to 
Jendrassik's  conception  (Deutsches  Arch.  f.  klin.  Med..  18S&, 
xliii,  6),  the  brain  is  the  primary  scat  ol  the  tabetic  process,  so 
that  the  sensory  disturbances  and  the  ataxia  are  to  be  consid- 
ered as  of  cortical  origin,  and  the  degeneration  in  the  posterior 
coliimns.and  perhaps  those  of  the  direct  cerebellar  tracts,  as 
secondary  processes.  Until  the  cortex  has  been  examined  mi- 
croscopically in  the  initial  stages  of  the  affection,  and  some 
constant  changes  have  been  demonstrated  in  it  after  dt-alh.  this 
theory,  like  all  the  others,  will  remain  nothing  more  than  a 
bare  hypothesis,  and  can  be  neither  contradicted  nor  yet 
accepted.  Such  a  pathogenesis,  hnwever,  is  not  impossible, 
though  it  is  not  dilTicult  to  bring  forward  objections  to  it. 

La.stly,  it  should  be  mentioned  that  Basso  (Ann.  univers.  <li 
med.  et  chin,  June,  1886)  considers  tabes  to  be  an  affection  o( 
the  sympathetic  system,  under  the  inlhience  ol  which  the  cerc- 
bro-spiiial  lesions  develop.  He  thinks  that  the  anatomical 
changes  in  the  nervous  system  arc  al  first  caused  by  functional, 
and  later  by  organic  disease  of  the  blood  vessels,  and  holds 
that  when  taken  in  lime  tabes  is  curable. 


I 

,1 

i 


TABKS  DOSSAirS. 


675 


LITERATI!  KE. 
6.  P-tlM--j;it.tl  Atohtmy, 

A(toint:i«wici.    Die  AnatomUchen  Vcrilndcningcn  bd  Tabes.    Congr.  Inlmutt. 

de  Copeiiluituif.  1886. 
Pick.     Arch,  f,  Psych,  u.  Nrnenkh  ,  1SS9.  3.     (Anatomical  Condition  tn  a  Cue 

with  Alwenrc  tit  one  Knet-JiTk.) 
Flcduig.     1st  die  Tubes  tine  Syslemeikr.inkung  ?     Neurot.  CeniralM.,  18S9.  1. 
Schmkia.    DeuiKhc»  Arch.  (.  klin.  Metl.,  :Six>,  ilvi.    (ln){>lical)on  of  the  Ljlcral 

Cdiunn*.) 
lUj-mond.    Coniribuiion  A  ranaiomic  piliologique  <lu  tabes,  etc.    Rcrue  de 

m^l..  1891,  1. 
Brutolo.    Suite  locaJiuuioni  anatomo-piatolofpclie  c  suUa  jutogcncsi  delta  talx 

donali.     tiull.  d.  Kicnie  mud..  April.  1S91.  Ilcft  4,  p.  1S7. 
ofl.    VirclMiw's  Anhiv,  1893,  cxTviit.  i.     (The  Degeneration  of  (be  Posterior 

Colamns  fonncrly  rcj-ariM  as  characteristic  of  Tabes  b  oLm  IouimI  in 

Lepra  Ana:siheiic.>.) 
\Vollcnbcri[.     Arch.  f.  t'*j-ch.  w.  Ncn*nkli.,  1891,  jtii*.  3. 
hNonnc.     Ibid.,  p^  jt6; 
^Krauts.  E.     Ilnd..  ttXn,  3.  3. 
Rcillich.     Wiener  Jahrt).  t.  Pt)-ch.,  1891,  t,  3.     (Condition  of  the  Posterior 

Rool^> 
Leyden.     Dctilfche  Med.-Zlg.,  1893.  96,  p.  tool. 
Lcyden,     NfuioI.  CcninlbL.  1894.  1.  a. 
Marie.  P.     £iude  compdrjiivc  An  Miionf  mf<lotliure3  dans  U  jtaralysie  gfainA^ 

el  dam  Ir  t.-i)i».     C.a/.  des  h/lp..  Jnnr.  16.  1894. 
l.cyden.    Zt'itschr.  f  klin.  Med.,  1894,  ixv.  t,  j, 

Etiology. — In  spcnking  of  the  sctiotogy  of  tabes,  one  must 
constantly  distinf^uish,  as  is  evident  frani  the  views  expressed 
above,  between  the  non-syphiliiic  and  the  syphilitic  affection. 
In  the  first  case  one  should  above  all  take  into  contudcration 
the  hereditary  conditions  in  order  to  comprehend  the  congcrv- 
ital  predisposition  which  is  necessary  for  the  production  o(  the 
dtsease.  By  this  u*c  do  not  mean  to  class  tabes  among  the 
hereditary  diseases  in  the  ordinary  sense  of  the  word,  for  it 
certainly  can  not  come  in  this  category  ;  on  the  contrary,  we 
are  jusliAed  in  assuming  that  direct  inheritance  of  it  is  quite 
rare.  By  heredity  in  this  connection  we  mean  a  general  neu^ 
>3thic  inherited  tendency,  or,  in  other  words,  that  in  the 
(imily  of  the  patient  all  kinds  of  neuroses,  not  excluding  psy. 
choses.  have  occurred  repeatedly.  Not  only  the  parents,  but 
also  more  diMant  rcLitivcs.  e.  g.,  aunts,  uncles,  or  grandparents, 
rinay  hare  suffered  with  general  paralysis,  epilepsy,  melancho- 
lia, hysteria,  migraine,  etc.,  and  it  is  just  this  heredity  whicn 
iti  the  presence  of  exciting  causes  is  sufficient  to  open  the 


676        DiSBASES  OF  THE  GENERAL  NF.RVOVS  SYSTEM. 

door  to  the  tabetic  process.  The  labors  of  Charcot  (Arch. 
^hw^T.  de  m^d.,  Sept.,  1SS3)  and  the  comprehensive  statistics  ol 
Ballet  and  Landouzy  (Arch,  de  neurol.,  1886,  vii.  20)  have 
thrown  an  interesting  light  upon  this  subject,  and  have  bril- 
liantly substantiated  the  view  which  Trousseau  expressed  at  an 
eiirlier  period,  th»t  ta[)cs  was  (in  the  sense  of  the  word  as 
expressed  above)  hereditary.  Among  the  German  authors 
Mubiits  has  occupied  himself  particularly  with  this  subject 
(Allg.  Zcitschr.  f.  Psych..  1S83.  xl,  1,  2). 

The  exciting  causes  which  relatively  Ircquently  lead  to  the 
development  oj  tabes  (in  those  with  hereditary  tendencies)  con. 
sist  (d)  in  exposure  to  cold  and  wet,  to  sudden  changes  of  tem- 
perature, and  to  prolonged  living  in  damp  lodgings ;  (^)  in 
traumatic  influences;  (r)  in  certain  (actors  due  to  the  daily  oc- 
cupation, the  most  important  of  which  is  overexertion.  The 
opinion  th:it  sexual  excesses  may  lead  to  tabes,  which  has  been 
expressed  by  vaiious  authors,  must  be  given  up  as  without 
proof. 

1  have  n?ver  questioned  but  that  exposure  to  cold,  sudden 
changes  of  temperature,  and.  particularly,  severe  wettings,  may 
play  an  important  part  in  the  xliology  of  the  affection  ;  still,  to 
me  the  following  case  was  particularly  convincing  1  The  pa- 
tient, a  general  agent  for  several  hail-insurance  companies,  fifty- 
eight  years  old.  had  h;id  syphilis  thirty-nine  vears  before,  since 
which  lime  he  had  been  perfectly  well.  In  ,\ugust.  1885,  while 
estimating  the  damage  caused  by  a  hullstorra,  he  was  drenched 
to  the  skin,  and  was  obliged  to  spend  several  hours  in  his  wet 
boots.  Three  months  later  the  first  tabetic  symptoms  made 
their  appe-irancc— paresthesia  and  anaesthesia  of  the  tegs,  loss 
of  the  pntctlar  reflexes,  etc, ;  by  Christmas,  1885.  he  was  mark- 
edly ataxic,  and  in  the  spring  of  1SS6  he  was  unable  to  pursue 
his  calling.  In  the  summer  of  1886  he  suffered  with  intestinal 
crises  and  intense  lancinating  pains,  and  eighteen  months  from 
the  beginning  o(  the  afTcction  he  had  paraplegia  of  both  legs. 
In  the  early  p,-trt  of  1887  he  died  from  an  intercurrent  attack 
of  pneumonia.  When  tabes  develops  in  one  well  on  in  the  fif- 
ties, there  must  be  some  particular  cause  for  it.  and  in  this  case 
it  was,  without  doubt,  the  wetting.  Similar  cases  can  easily  be 
found  if  the  history  be  careTully  taken. 

The  r6U'  which  traumatic  influences  play  in  the  production 
01  the  affection  is  just  as  certain.     In  r)ne  of  my  cases,  a  gov- 


I 

I 


I 


crnment  official  of 


high  position, 


who  had  been  affected  with 


rjiS£S  DOKSAUS. 


677 


syphilis  twenty-nine  years  before,  met  with  an  accident  on  a 
glacier  in  the  summer  of  1884.  He  Icll  and  slid  some  distance 
on  a  snow  field  with  great  rapidity,  but  no  bones  were  broken 
and  no  dislocation  occurred.  A  few  months  later  the  lirst 
tabetic  symptoms  made  ihcir  appearance,  and  now  the  disease 
is  well  developed.  Again,  a  fall  from  a  height  may  be  the 
cause  (Oppenhcim) :  Strauss  reports  numerous  traumatic  cases 
<Faits  pour  scrvir  k  litudc  dc8  rapports  dc  traiimatisme  avec 
le  ubes.  Arch,  de  phys.,  Nuvembre,  1886).  From  his  com- 
munication it  is  npp.ircnt  (1)  that  years  may  elapse  after  (he 
accident  before  the  disease  makes  lis  appearance,  and  (2)  that 
the  traumatism  may  have  an  influence  in  determining  the  scat 
ol  the  early  symptoms,  particularly  of  the  lancinating  pains,  so 
that,  lor  example,  after  a  fracture  ol  the  lower  part  ol  the  left 
leg  the  pains  will  first  make  their  appearance  at  that  point,  and 
so  forth.  In  an  article  by  Spillman  and  Parisot  (Traumatisme 
p^riph^rique  ei  tabes.  Revue  de  m^d.,  1888,  3)  there  is  a  table 
which  gives  the  different  forms  of  injury  which  have  been 
followed  by  tabes.  Of  great  interest  also  is  a  case  reported  by 
Blocq  and  OnanofI  (Arch,  dc  m£d.  cxp.  et  d'Anat.  pathol.,  p. 
387.  1892)  in  which  there  was  a  combination  of  tabes  and  Irau- 
matic  neurosis. 

I  have  already  jwiinted  out,  in  my  book  on  diseases  ol  the 
laboring  classes,  that  the  occupation  is  not  without  importance, 
and  more  especially  overexertion — (or  instance,  at  the  sewinj; 
machine — or  hard  bodily  labor  in  general  may  be  the  cause 
o(  the  outbreak  <>(  the  disease  in  those  who  are  predisposed  10 
It.  However,  the  percentage  of  such  cases  is  not  large.  Hof- 
mann  gives  an  instance  which  may  be  classed  partly  with  those 
cases  in  which  the  occupation,  partly  with  those  iti  which  trau- 
matism, is  the  exciting  cause.  The  patient  was  a  laborer  en- 
gaged in  cutting  tin  plates,  and  in  the  course  of  his  work  his 
body  was  shaken  from  six  to  ten  thousand  times  daily  :  under 
the  influence  of  these  shocks  the  disease  developed  (Arch.  1. 
Psych,  und  Nervenkrankhciten,  1S8S,  xvlii,  2.  439). 

Concerning  the  syphiUlic  tabes,  which  has  been  studied 
with  the  greatest  care  by  Fournier  and  Erb,  it  is  an  undoubted 
fact  that  syphilis  by  itself  is  usually  a  suflicient  cause  for  the 
disease,  and  that  no  other  exciting  factor  Is  needed  for  its  de- 
velopment. 

\Vc  do  not  know  what  percentage  of  persons  who  have  had 
syphilis  become  tabetic,  but  wc  do  know  lor  certain  that  the 


A 


6;S        DISEASES  OP  TUB  CENEftAL  NERVOUS  SYSTEM. 


great  majority  of  tabetics  have  had  syphElis  at  some  time  or 
other — according  to  Erb,  sixty  per  cent ;  according  to  Foumicr, 
ninety  per  cent.  Syphilis  is  more  (rcquetitly  followed  by  tubes 
than  hereditary  and  exciting  causes  put  together.  Out  ol  three 
hundred  and  (orty-five  cases  of  tnbcs  which  I  have  seen  in  the 
last  few  years  of  my  practice,  in  sixty-six  a  syphilitic  history 
was  not  obtained,  while  in  the  other  two  hundred  and  seventy- 
nine  cases  it  was  demonstrated  with  certainty,  so  that  my 
figures,  although  they  do  not  quite  correspond  to  those  of 
Fournier,  give  eighty  per  cent.  Minor  points  out  in  his  statis- 
tics (Wyestnik  psychiatri  i  nervipaioiogii,  i88i!,  vi)  that  tabes 
is  much  rarer  in  Russia  among  the  Jews  than  among  the  other 
Russians,  which  is  simply  due  to  the  fact  that  the  former  are 
less  frequently  syphilitic.  The  communication  of  N^cl  also 
deserves  consideration.  He  found  in  M03  cases  of  tabes 
forty-six  per  cent  of  syphilitics,  and  out  of  1,450  other  pa- 
tients only  nine  and  one  hall  per  cent.  The  time  which 
elapses  between  the  infection  and  the  first  appearance  of 
tabes  varies  from  a  few  months  to  one.  two.  live,  fifteen 
years  or  more.  The  severity  of  the  syphilis  docs  not  ap- 
pear to  stand  in  any  relation  to  the  severity  of  the  tabes; 
for  one  can  observe  very  pronounced  tabetic  symptoms  alter 
an  apparently  trivial  and  quickly  healed  primary  sore,  whereas 
sometimes  alter  the  most  severe  type  of  syphilis  the  general 
affection  of  the  nervous  system  only  appears  in  its  mildest 
form. 

The  influence  which  age  and  sex  exert  in  the  production  o( 
the  disease  can  only  be  considered  in  the  non-specific  cases. 
It  is,  however,  only  of  slight  importance:  for,  although  It  is 
true  that  males  arc  far  more  frequently  aflected  than  females 
(the  proporliim  being  seven  tp  two),  and  although  most  ol  the 
patients  arc  middle-aged,  these  facts  can  very  well  be  accounted 
for  by  the  nature  of  the  several  exciting  causes,  which  make 
it  comprehensible  why  men  in  the  prime  of  tile  furnish  rela- 
tively the  greatest  contingent  of  cases.  For  the  special  con- 
ditions under  which  the  disease  may  occur  in  childhood,  and 
the  peculiarities  presented  by  tabes  in  children,  the  reader  is 
referred  to  the  articles  mentioned  on  page  679. 

Lastly,  it  must  be  confessed  that  in  a  lew  cases,  which, 
however,  form  an  exceedingly  small  fraction  of  the  whole  num- 
ber, no  xtiologicnl  factor  can  be  made  out — neither  hcrediLiry 
predisposition,  nor  exciting  causes,  nor  syphilitic  infection,    .^t 


I 


4 


TABES  DORSAUS. 


679 


present  u'c  can  only  acknowledge  our  ignorance  of  their  palho* 
genesis.  ' 

^^^  LITCRATURe. 

^^^P  ;,  /Etiottgy  (Afi.  Sex,  M-.J. 

^Pnincc.    Jnum.  nf  N«rv.  and  Mrni.  ni^ra^rs,  18S9,  xill.    (Malniia  »  Causr.l 
H  Cuiiibault  vi  It^llcl.    Arcb.  de  mcd.  ex|>cnin..  cic,  18^9^  j.    (On»c(  U  the  Age 
H  of  Seven.) 

V  Qernhnnli.     Neurol.  CcntralbL,  1890. 13.     (Work  with  the  Sewing -machine.) 
KlFn>|Krcr.    Anivkng  von  Frerichi  und  Leyden.  1S90,  iviti,  i. 
Tick.    ?M>  Ixhrevon  den  Tabcsformcn  im  Kindculier.    Zeitschr.  f  HeiHtaBde, 

iSyi.ni. 
Hi1dirtw«ndi.     Liebcr  Ta)>ts  in  <Ien  Kinclerjnhrcn.    liuug.-K^KTt..  Berlin,  1893. 
[  Krh.     I>jc  Actiologie  iter  T^bcs.     VnUinanit't  Samml.  klin.  Vnrir.,  1891.  53. 
iFnedncliMO.     Tal>es  bein  n-ciblichcn  GcKhlccliL       lnaug.-Ui»sc(1.,   BerliB, 
>893- 

Prognosis. — From  what  has  been  said,  wc  may  infer  what 
j  the  prognosis  will  be.  Thoufjh  il  is  not  absolutely  unfavorable 
\  fUMui vititm.  inasmuch  as  the  p-tlicnt  may  linger  on  for  year;:, 
land  sometimes  tens  of  years,  one  should  not  forget  that  in 
Igeiicral  the  course  is  unfavorable,  that  the  patient  will  suffer 
greatly  at  times,  and  that  the  linul  lot  of  the  t.ibctic  is  almnst 
always  a  total  inability  to  work  or  gain  a  living.  In  discuss- 
ing the  prognosis  as  to  complete  recovery,  the  question  arises. 
Is  tabes  ever  curable,  nr  is  there  even  a  possibility  of  cure? 
This  qtiesiion  is,  with  the  proper  restriciiuns,  tu  be  answered 
■in  the  affirmative;  it  is  possible  to  cure  tabes,  but  only  fresh 
cases  o(  luetic  origin.  Advanced  cases.  In  which  degeneration 
in  the  cord  has  taken  place,  are  incurable ;  we  possess  no  means 
of  bringing  the  lesion  to  a  standstill  or  causing  it  to  disappear. 
Il  is  evident  that  the  chances  for  the  successful  treatment  of 
recent  cases  are  incre.isL-d  the  younger  the  i>;itient  and  the 
better  his  general  conslilulion.  The  prognosis  is.  cfr/cm />«/-i:. 
^ns.  less  favorable  in  individuals  with  a  neuropathic  tendency, 
in  whom  the  disease  breaks  out  in  consequence  of*  some  ex- 

I  citing  cause,  than  in  fresh  specific  cases. 
Treatment. — In  taking  charge  of  a  case  of  labcs  wc  roust 
first  see  that  we  ourselves,  as  well  as  ihe  patient,  clearly  under- 
stand how  much  can  be  expected  from  any  treatment.  1(  his 
•  is  one  of  those  exceptional  cases  in  which  the  prognosis  is 
relatively  favorable,  we  m.-iy  tell  him  so:  but  in  most  instances 
it  will  be  our  painful  duly  to  make  hira  acquainted  with  the 
seriousness  of  the  situation,  of  which  he  will  often  be  entirely 


68o         DISEASES  OF   THE   GENERAL   NERVOUS  SYSTEM, 

ignorant.  We  must  tell  him  with  gentleness  that  a  complete 
recovel'y  can  not  be  hoped  for,  and  that  all  that  it  is  possible  to 
accomplish  is  to  relieve  some  of  his  symptoms  and  to  keep  him 
in  such  a  condition  that  he  can  as  long  as  possible  carry  on  his 
occupation.  There  is  no  disease  in  which  it  is  more  out  of 
place  to  arouse  in  the  patient  vain  hopes  of  recovery  than  in 
tabes. 

The  choice  of  the  therapeutic  measures  themselves  depends 
upon  the  stage  of  the  disease  in  which  we  find  the  patient — 
that  is,  upon  how  long  he  has  been  sick.  In  old  cases  the 
greatest  caution  ought  to  be  observed,  and  one  should  not 
forget  that  rash  therapeutic  interference  may  do  more  harm 
to  the  patient  than  good.  The  value  of  a  treatment  is  often 
quite  problematical ;  its  harmfulness  is  too  often  quite  evident. 
Hygienic  and  dietetic  measures,  conscientious  nursing  and 
cleanliness,  injections  of  morphine  in  severe  attacks  of  pain, 
occasional  cool  baths,  ever-repeated  kindly  encouragement, 
these  constitute — if  we  leave  out  the  suspension  method,  of 
which  we  shall  speak  later — the  only  treatment  which  old  cases 
of  tabes  need,  or,  for  that  matter,  can  stand.  But  the  recent 
cases  also  demand  a  great  deal  of  care  and  forethought.  In 
view  of  the  duration  of  the  treatment,  protracted  as  it  will 
probably  be,  all  circumstances  have  to  be  taken  into  account— 
the  constitution,  the  age,  the  occupation,  and,  above  all,  the 
pecuniary  situalion  of  the  patient. 

As  syphilis  is  at  the  bottom  of  so  many  instances  of  tabes, 
the  question  whether  we  are  justified  in  expecting  anything 
from  an  antisyphilitic  trealmcnt  should  be  mooted,  but  only  in 
exceptional  cases  can  we  have  such  a  hope — that  is,  only  when 
either  signs  of  syphilis  arc  still  present,  or  when  the  time  that 
has  elapsed  since  their  disappearance  is  relatively  short  (not 
longer  than  a  few  months  or  at  most  a  year).  Such  cases  are 
very  rare;  generally  years,  perhaps  twenty  years,  will  have 
gone  by  during  which  the  patient  has  been  apparently  per- 
fectly well,  and  then  the  antisyphilitic  treatment  is  of  no  avail. 
If,  however,  wc  wish  to  institute  it  for  any  reason,  possibly  be- 
cause the  patient  himself  insists  upon  it,  bold  doses  ought  to 
be  given,  (our,  six,  even  eight  grammes  (  3  j- 2  ij)  of  potassium 
iodide  a  day,  and  from  three  to  si\  grammes  (grs.  xlv-  "  jss.)ol 
mercurial  ointment  rubbed  in  daily.  In  all,  two  or  three  hun- 
dred grammes  (;vj-5i'i)  of  potassium  iodide  and  the  same 
amount  of  mercurial   oiiitment   ought  to  be  used.     Recently 


TABES  nOXSAL/S. 


681 


» 

^ 
^ 


^ 


^inkier,  in  Erb's  clinic,  has  made  careful  observations  with  re- 
^j^rd  to  the  influence  and  the  justilicaliun  of  the  treatment  by 
mercurial  inunctions  (Berliner  klin.  W'ochenschr..  1893,  15,  16); 
he  comes  to  the  conclusion  that  in  hlty-eighl  out  o(  seventy- 
one  cases — i.  e.,  in  about  eighty  percent — one  or  several  symp- 
toms were  improved  by  the  treatment. 

If  we  have  resolved  to  try  internal  medicines,  knowing,  of 
course,  that  there  is  none  which  acts  favorably  upon  the  dis- 
eased  nerve  elements,  we  may  bc^in  with  silver  nitrate  in  doses 
ol  one  centi|;ramme  (gr.  '/,)  in  pill  form  three  times  a  day  tor 
four  or  six  weeks,  after  which  time  it  may  be  combined  with 
ergotin  (arR.  nitr., 0.3  (grs.  ivss.);  exir.  secal.  com..  3.  (grs.  ilv): 
pulv.  et  cxtr.  quass..  q.  s.  ut  f.  pil.  no.  30),  of  which  also  one 
pill  is  to  be  taken  three  limes  a  day.  Finally,  a  trbl  may  be 
made  with  the  salicylate  of  physost limine,  of  which  one  milli- 
gramme <nr.  ■/«)  in  pill  form  may  be  jjiven  three  times  a  day 
(or  a  month,  as  recommended  by  Meyer  in  his  paper  on  the 
Influence  of  Physostigmine  upon  the  Patellar  Reflex  (Berlin, 
klin.  Wochcnschr.,  1888,  2).  With  these  drugs  we  may  be  (airly 
confldent  that  we  are  doing  no  harm,  and  often  wc  may  per- 
ceive a  distinct  improvement  in  the  condition  ol  the  pntirnt, 
although  we  <ire,  of  course,  not  able  to  dclinitcly  decide  whether 
this  is  actually  to  be  attributed  to  the  medicine  or  not.  We 
would  recommend  these  remedies  more  warmlv  than  any  other, 
even  Ihan  slrychuinc.  which  has  been  administered  subcuiane- 
ously  in  doses  of  from  three  to  five  milligrammes  (gr'/^-'/n), 
gradu.illy  increased  to  one  centigramme  (gr.  '/,)  in  twenty-four 
hours,  (or  repeatedly  after  these  injections  we  have  observed 
the  occurrence  of  pains  which  had  not  been  present  for  months. 
In  the  treatment  of  the  individual  symptoms  we  must  resort  to 
the  same  measures  ih.tt  we  should  adopt  when  these  appear  in 
Ihc  course  ol  other  diseases  nr  by  themselves;  (or  instance,  fur 
the  lancinating  pains,  as  in  other  neunilgias,  we  shall  be  obliged 
to  give  antipyrine  and  aniifebrinc,  which  have  recently  been 
recommended  by  lupine,  Suckling,  Germain  8^e.  G.  Fischer, 
and  others,  but  wc  shall  be  driven  to  Ihc  conclusion  finally, 
that  for  the  relief  of  these  pains  there  exists  only  one  drug  by 
Ihc  help  of  which  the  patient's  painful  existence  may  be  ren- 
dered  at  all  bearable — viz..  morphine,  which  here  more  than 
in  any  other  disease  wc  are  justified  in  using  in  large  amounts. 
The  application  of  a  tight  bandage  to  the  limb  in  which  the 
lancinating  pains  are  present,  as  ndvoc-ited  by  LcidylMcd. 


683 


DISEASES  OF  TUE  GEJiTB/tAL  NEJtVOUS  SYSTBAf. 


News.  August,  1891,  29),  1  have  repealedly  Tound  efficacioti 
the  combination  of  pressure  and  warmth  seems  so  beneficial  to 
many  cases.  Gastric  and  laryngeal  crises,  headache,  etc.,  are 
to  be  treated  symptomaiicalty. 

In  addition  to  the  internal  medication,  it  is  the  electrical 
treatment  which  deserves  special  consideratiun.  This,  if  used 
at  a  period  early  enough,  may  be  followed  by  excellent  results, 
and  may  alone  sometimes  be  capable  o(  effecting  a  cure  or  aa 
arrest  of  the  morbid  process.  On  the  other  hand,  if  we  do  not 
select  our  cases  properly — lor  example,  if  we  treat  old  cases 
like  recent  ones — we  may  do  more  harm  than  good  with  it.  It 
may  give  rise  to  severe  pains,  and  make  the  patients,  who 
until  they  were  treated  by  electricity  were  in  a  fair  condition, 
begin  to  suffer  terribly  and  soon  lose  confidence  in  the  physi* 
cian.  Electricity  m.iy  also  prove  successful  against  the  motor 
disturbances,  nut  so  much  against  the  ataxia  as  against  the 
wcikness  in  the  legs  ;  also  in  combating  anaesthesias  and  par- 
fcslhesias  in  the  hands  and  feet  it  may  have  some  eflect,  whereas 
it  is  usually  of  little  avail  against  the  lancinating  and  rheuma- 
toid pains.  How  to  use  the  electricity,  whether  in  the  form  irf 
the  faradic  or  the  galvanic  current,  it  is  impossible  to  say  in  a 
few  words.  Every  one  forms  for  himself,  in  the  course  of  years 
of  practice,  his  own  technique,  and  gives  preference  to  this  or 
that  method  ;  the  one  prefers  the  galvanic,  another  the  (aradic ; 
again  one  will  recommend  the  ascending,  another  the  descend- 
ing current  through  the  spinal  cord  ;  the  one  believes  in  moist, 
the  other  in  dry  electrodes,  especially  the  brush.  Among  all 
the  dilTerenl  methods,  besides  the  excellent  general  faradization 
advised  by  Dcard  and  Rockwell,  the  faradic  brush  applied  10 
the  back,  as  recommended  by  Rumpf.  has  perhaps  met  with  a 
more  favorable  reception  than  any  other  pniclice,  and  justly 
so.  We  prefer  it,  so  far  as  electrical  treatment  goes,  to  all  other 
modes.  Details  on  the  subject  may  be  found  in  my  text-book 
on  Electro-diagnosis  and  Electro-therapeutics,  in  which  all  the 
points  necessary  for  the  practitioner  to  know  are  discussed. 

In  a  large  number  of  cases  the  cold-water  treatment  has 
been  found  to  be  extremely  beneficial.  The  action  of  the  water 
on  the  peripheral  nerve  endings,  the  influence  which  a>ld 
douches,  wet  packs,  moist  ("  Pricssnitz's  ")  abdominal  bandages, 
cool  baths,  etc.,  exert  upon  the  circulation  in  the  vessels  of  the 
skin,  and  thus  upon  the  terminal  nerve  twigs,  is  often  so  favor 
able  that  marked  improvement  during  and  after  a  stay  in  » 


I 

I 

I 
I 


i 


TABES  DOSSAUS, 


683 


I 


I 


hydrothcrapciitic  establishment  is  not  rarely  seen.  Even  in 
cases  in  which  sensury  and  motor  disturbances  have  attained 
to  such  a  degree  that  but  little  can  be  hoped  for.  a  carefully 
conducted  cold-water  treatment  may  be  quite  beneficial  in 
improving  the  general  condition  of  the  paiicnt  imd  raising  his 
spirits. 

On  the  other  hand,  we  would  emphatically  warn  against 
the  use  of  warm  or  hot  as  well  as  steam  and  sweat  bitths.  As 
a  rule  Ihey  are  ol  no  avail,  but  often  evoke  the  lancinating 
pains.  Unfortunately,  the  physician  is  not  always  in  a  position 
to  prevent  (his.  since  the  patients,  who  believe  implicitly  in 
the  rheumatic  nature  of  their  pains,  use  them  at  random  with- 
out his  orders  often  lor  months  and  years.  There  are  a  great 
many  tabetics  who  during  the  course  nf  their  disease  have 
taken  many  hundreds  ol  steam  baths  without  perceiving  ihe 
slightest  benclit  therefrom. 

From  the  springs  we  can,  on  the  whole,  expect  but  little, 
and  especially  old  cases  with  paraplegia  and  severe  bladder 
troubles  should  be  spared  the  trial.  The  disadvantages,  the 
overexertion  attendant  upon  the  journey,  and  the  Lick  of  home 
comforts,  in  the  case  of  these  patients  especially,  will  far  out- 
weigh any  good  results  obtained  from  the  baths;  nor  should 
we.  as  we  said  above.  leave  out  of  sight  the  necessary  cost 
which,  even  with  the  most  modest  pretensions,  is  not  incon- 
siderable. One  should  never  forget  that  the  disease  is  likely 
to  last  a  very  long  time,  that  the  patient  will  soon  be  unable 
lo  earn  any  irtoney,  and  that  lor  him  there  can  be  no  greater 
misfortune  than  lo  find  that,  heedlessly  or  yielding  to  over, 
persuasion,  he  has  spent  all  his  worldly  gmids  ol  which  now 
he  stands  in  the  greatest  need,  There  exist  not  a  lew  of  such 
helpless  patients  in  whose  caM^s  just  this  ]x>int  was  overlooked. 
and  it  is  especially  our  younger  colleagues  who  seem  rather  too 
prone  to  disregard  it.  Ksuchandolhcr  objections  do  not  exist, 
it  is  most  advi<iablc  to  recommend  places  where  warm  brine 
baths  can  be  taken,  as  in  Kehme-Oeynhauseit,  this  place  having 
become  famous  for  the  treatment  of  tabes  especially,  though  it 
is  my  experience  that  patients  get  along  there  no  better  and  no 
worse  than  at  other  springs  of  the  same  kind — e.  g.,  Nauheim 
— and  it  only  deserves  to  be  warmly  recommended  owing  lo 
the  excellent  arrangements  which  we  there  find,  particularly 
the  facilities  for  moving  helpless  invalids  from  place  lo  place. 
Chloridc'.of-sodiuin  springs  containing  iodine  and  bromine — 


684         ^/SEASES  OF   THE   GENERAL  NERVOUS  SVSTEAf. 

for  instance,  K5nigsdorf-Jastrzemb,  Kreuznach,  Goczalkowitz, 
Krankenheil — may  be  tried  without  fear  of  doing  any  harm ; 
while  the  nonmedicated  hot  springs  of  Gastein,  Teplitz,  Johan- 
nisbad,  VVarmbrunn,  PfaSers,  and  the  hot  snlphur  springs  of 
Landeck,  Aachen,  Trentschin,  Pistydn,  Baden  near  Vienna,  and 
Baden  in  Switzerland  should  be  prescribed  only  with  great 
caution,  and  the  baths  should  never  be  taken  too  warm,  never 
above  a  temperature  of  80"  to  90°  F.  Among  the  chalybeate 
springs,  first  Cudowa,  then  Pyrmont,  Flinsberg,  Schwalbach, 
and  St,  Moritz  (Engadine)  deserve  to  be  tried. 

The  results  of  massage  in  the  treatment  of  tabes  are  not  sat- 
isfactory. There  is  no  objection  to  giving  massage  in  a  care- 
ful manner  50  as  to  improve  the  nutrition  of  the  muscles  and 
to  stimulate  metabolism,  especially  in  cases  of  young,  compar- 
atively  robust  patients  ;  but  we  are  hardly  justified  in  building 
much  upon  such  a  procedure  and  in  expecting  to  bring  about 
a  lasting  improvement  in  the  sensory  or  motor  disturbances.  I 
have  known  instances  in  which  the  general  condition  of  the 
patient  was  influenced  for  the  worse  by  massage,  and  in  which 
certain  symptoms,  especially  the  lancinating  pains,  appeared 
to  be  aggravated  after  its  use. 

Of  only  historical  interest  is  the  operation  of  nerve  stretch- 
ing, which,  in  the  first  half  of  the  eighties,  was  by  some  claimed 
to  be  an  excellent  me.nns  in  the  treatment  of  tabes,  the  sciatic 
nerves  being  usually  chosen  for  this  operation.  They  were  laid 
bare  bv  cutting  through  the  gluteal  muscles  and  "stretched" 
according  to  different  methods.  The  result  was  in  many  cases 
at  first  very  striking.  Pains,  bladder  disorders,  and  anxsthe- 
sias  vanished,  and  the  operation  was  undertaken  comparatively 
frcquentlv.  Soon,  however,  it  was  found  that  what  had  been 
regarded  as  a  success  was  of  no  long  duration,  and  that  the 
old  troubles  returned,  and,  finally,  after  it  had  been  repeatedly 
demonstrated  at  the  autopsy  (Striimpell,  Rosenstein)  that  the 
elongation  of  the  nerves  not  only  had  not  exerted  the  slightest 
benehcial  effect  upon  the  morbid  process  in  the  spinal  cord, 
but  that  several  times  at  the  place  where  the  nerve  had  been 
stretched  a  neuritis  had  developed  and  extended  to  the  sub- 
stance of  the  spinal  cord,  giving  rise  to  a  myelitis,  the  praclice 
was  given  up,  and  can  be  looked  upon  to-day  as  having  been 
definitely  discarded. 

Finally,  various  other  modes  of  treatment  should  be  men- 
tioned which  we  m.iy  collectively  call  the  mechanical  methods. 


TABES  DOKSALfS. 


685 


Graduated  exercises  consisting  in  the  execution  first  of  sim- 
pl<:  muscular  movements,  later  of  simple  co-ordinated,  .ind 
finally  of  cuniplex  co-urdinaied  movements  (Frenkel.  Miln- 
ctiencr  mcd.  Wochenschr..  1S90,  52),  it  is  claimed,  bring  nliotit 
a  decided  improvement  in  the  ataxia.  Again  we  have  the 
treatment  acconliiig  to  the  method  of  Messing,  by  which  a 
permanent  support  ot  the  spinal  column  is  attempted :  the 
patient  is  provided  with  a  corset  made  of  cloth  which  he  has 
to  wear  for  years  day  and  night,  and  which  transfers  the 
weight  of  the  body  to  the 
pelvis  and  relieves  the  fpinat 
column.  Certain  clinicians, 
among  them  Jiirgcnscn  (cf. 
lit.)  have  spoken  favorably  of 
this  procedure,  while  MUller, 
o(  Stuttgart,  would  prefer 
another  form  of  apparatus, 
since  he  considers  llessing's 
corset  inefficient  (Mcd.  Cor- 
respondenzbl..  d.  WUrtemb. 
iirzll.Landesvcreins.  1890. 15). 
Frequent  extension  of  the 
spinal  column  is  attempted 
in  the  method  by  suspension 
first  advocated  by  Motschu- 
Itowsky  (Wratsch,  iHSj,  17- 
21)  and  later  by  Charcot. 
The  results  obtained  with 
this  mode  of  treatment  in 
the  Salfitltriire  were  favora^ 
ble  enough  to  induce  many 
clinicians  in  Germany,  Eng- 
land, and  America  to  m.ike 

further  iiial  of  it,  and  at  present  we  possess  quite  an  imposing 
array  ol  articles  treating  of  the  "  suspension  method  "  and  the 
re:9ults  obtained  by  it.  According  to  some  authors  the  cere, 
bral,  according  to  others  the  spinal  symptoms  are  improved 
by  it.  The  procedure  is  &aid  to  be  without  danger,  but  in  one 
instance  the  immediate  consequences  were  fatal ;  it  should  l>c 
said,  however,  1h.1I  in  this  case  the  suspension  was  undertaken 
I  without  the  physician's  supervision  (Gorccki.  Lyon  mid..  i8)f(), 
I    20).     Allhaus  (cf.  lit.)  has  attempted  to  give  an  explanation  of 


Fig.  tgi.— Sv«r(n»o9i   App«m*m  vhd  in 
T>iE  Trkatmcmt  <>r  Taimk 


686         DISEASES  OF   THE   GENERAL  NERVOUS  SYSTEM. 

the  mode  of  action  of  this  treatment.  According  to  his  opinion, 
the  meningitic  adhesions  over  the  posterior  columns  are  loos- 
ened, so  that  the  nerve  fibres,  especially  the  superficial  ones, 
gain  in  power  of  conduction,  the  sclerosed,  thickened  neuroglia 
becomes  looser,  and  the  pressure  upon  the  nerve  tubes  is  thus 
diminished.  He  also  thinks  that  suspension  should  only  be 
used  in  older  cases,  because  in  recent  ones  it  might  lead  to 
inflammatory  conditions.  The  possibility  that  this  loosening 
does  take  place,  as  Althaus  claims,  can  not  be  disproved,  but 
this  much  is  certain,  that  for  those  instances  in  which  improve- 
ment is  said  to  have  shown  itself  after  only  one,  two,  three, 
or  ten  suspensions,  this  theory  affords  no  explanation. 

The  results  which  I  have  seen   from   the   method   by  sus- 
pension both  in  my  clinic  and  in  private  practice  are  by  no 
means  encouraging.     Outside  of  an   improvement   in    vision, 
which  I  have  been  able  to  note  and  which  Bechterew  (Neurol. 
Centralbl.,  1893,  iS)  also  observed,  I  have  not  in  a  single  in- 
stance been  able  to  persuade  myself  that  any  marked  or  lasting 
improvement  took  place.     The  account  which  intelligent  and 
unprejudiced  patients  gave  of  themselves  after  the  thirtieth, 
fiftieth,  and  eightieth  suspension  corresponded  almost  exactly 
to  that  which  they  had  given  prior  to  the  institution   of  the 
treatment.     In  opposition  to  Althaus,  then,  it  is  my  conviction 
that  anatomical  changes  are  not  produced  by  suspensionTbut 
that  the  transient  improvement  has  to  be  referred  to  the  influ- 
ence of  suggestion.     The  patients  hear  of  a  new  treatment  for 
their  incurable  disease,  they  subject  themselves  to  it  with  much 
pleasure  and  confidence,  and  by  autosuggestion   produce   an 
improvement  in  some  functional  impediment  (for  example,  in 
the  ataxia),  which   may  be  quite  marked,  but  which   is  never 
lasting.     Four  times  during  the  act  of  suspension  I  myself  met 
with   rather  unpleasant  accidents:  in  two  cases   the  patients 
lost  consciousness  and  had  to  be  rapidly  taken  down,  and  were 
only  then  with  some  difficulty  recalled  to  life;  in  two  other 
instances  severe  laryngeal   crises  appeared,   so   that   the  pro- 
cedure had  at  once  to  be  stopped.     Such  accidents,  of  course, 
make  a  very  bad  impression  upon  the  patient,  and   bring  the 
results,  which  are  in  any  case  doubtful,  still  more  into  ques- 
tion.    Careful  examination  is  necessary  before  the  suspension 
is  used,  and  if  there  exists  a  disease  of  the  heart  or  of  the  ves- 
sels it  should  under  no  consideration  be  undertaken.    We  need, 
of  course,  hardly  add  that  while  the  patient  is  suspended  he 


TABBS  130/tSAUS.  687 

should  be  carefully  watched.  Benuzzi  has  recently  attempted 
to  replace  the  suspeiisioti  by  simple  sirclcliitig.  and  claims  that 
with  his  method  the  spinal  curd  is  extended  much  more  de- 
cidedly. The  legs  arc  held  at  the  ankle  joints  with  a  towel 
and  are  pulled  over  the  head  until  the  knees  touch  the  lore- 
head.  Hencdikt  has  seen  good  results  from  this  method  in  a 
number  of  cases  (Wiener  med.  I'resse,  1892,  i).  I  myscU  soon 
abandoned  the  procedure,  owing  to  the  (act  that  it  is  s^ry  dis- 
agreeable  to  most  patients.  1  must  admit,  however,  that  it  is 
deserving  of  further  trial  in  suitable  cases. 


LITERATURE. 

8.    Ttatmeul. 

JtirgcnMn.     Ueber  die  roechanische  B«hanillun|;  dcr  Tatxs  nacK  dcm  System 

Hewing.     Druuchc  Tncil.  Wuiilictisciir..  18S9,  40. 
Lcydra.    Berliner  Uiii.  Worhftivhr,.  1S94,  17.  18. 
L^tde.    Du  ir.tiicnicni  ^lccln((u<:  Uu  (aba.     TbiM  dc  Bordeaux,  1893. 

TrraMfiH  tf  "SMiffMnim.'' 

Charcot.     Dc  la  suBprn&ion  <Ui>t  le  tnuicmeni  dc  t'aiaxic  locomolrice  pragma 
live  ct  dc  quclquea  aulrea  maladie*  du  systime  ncmvx.    Progris  m^. 

1889.). 
Wiir  MiiehHI.     Med.  Nrw«,  April  13.  1889. 
Cberncl.    ^^'ienc^  mttl.  BISlier.  i88y.  lii,  5. 
Dana.    New  York  Medkal  Record.  April  1  $,  iSSjK  nmr. 
Cillrc  4k  la  Tourcttr.     Prugris  mid..  1SS9,  xvit,  S.    <T«chiiii)iM  of  Stitpciunn.) 
MoTlun.    New  York  Med.  Record.  April  15.  1S89,  mmv. 
Aliliaut.     Lancet.  A|>rll  13.  t889.  p.  i6ol 
Watiewinc.    On  ihc  TreaimfW  by  Sutpeniion  or  l.ocomotor  Ataxy.    Loiwtoti. 

1S88. 
V. Opcnchowdii.   German  iransbtlonofMotihukowski'ilBvcstipatloivt.    Ikrlincf 

Itlin.  WochenMhr.  1889.  1^ 
Itcneaikt.     Wiciier  meet.  WochtMChr..  1889.  45.  46. 
Hauvtuliet  d  Adam.     >*To];rii  mM.,  tiitf.  44. 
Ctllet  lie  la  Tourette.    Arck  lie  Neurol.,  Juillet.  1889.  xviil,  No.  5). 
Pinehcrli.     Rituta  vencta  dl  Klenic  med.,  1889^  Otiobrc. 
Ro»enb<tuiD.    Deulxbe  Med-Zig.,  1890.  39^  p.  444. 
LcAnuinn.    Iliid..  1890.69. 
CMgftty.    Liuic«l,  January  18,  1890. 


CHAPTER   111. 

DEMENTIA    PARALYTICA    PROGRESSIVA — GENERAL    PARALYSIS    OF    THE 
INSANE — GENERAL    PARESIS — SOFTENING    OF   THE   BRAIN. 

While  in  tabes  we  have  learned  to  recognize  a  disease  of 
the  general  nervous  system,  in  which  the  spinal  cord  chiefly  is 
the  affected  portion,  we  find  that  in  dementia  paralytica,  on  the 
other  hand,  ihe  brain  is  pre-eminently  the  part  attacked,  whereas 
the  spinal  cord  and  the  peripheral  nerves  do  not  suffer  so  regu- 
larly nor  to  so  marked  a  degree.  In  its  distribution  the  lesion 
of  the  cord  is  either  diffuse  or,  as  in  tabes,  confined  to  the  pos- 
terior columns.  With  regard  to  the  affections  of  the  spinal 
nerves  a  more  careful  study  is  still  necessary,  and  more  espe- 
cially this  question  needs  to  be  answered  whether  here,  as 
seems  indeed  very  probable,  primary  degenerative  processes, 
analogous  to  those  of  tabes,  can  also  be  demonstrated. 

jCtiology.^The  manilold  points  of  resemblance  between 
general  paralysis  and  tabes,  to  some  of  which  we  have  drawn 
attention  above,  are  found  first  in  the  tetiology  of  the  two  dis- 
eases. In  the  former  as  well  as  in  the  latter  hereditary  tenden- 
cies  are  of  much  significance.  A  person  belonging  to  a  familv 
in  which  nervous  diseases  of  any  kind  have  been  prevalent  is 
more  prone  to  develop  general  paralysis  than  a  member  of  a 
healthy  family.  However,  this  factor  is  in  the  majority  of  in- 
stances  not  suflicicnt  in  itself  to  bring  about  the  disease,  certain 
exciting  causes  being  also  necessary,  and  experience  has  taught 
us  that  it  is  chiefly  overstrain  of  the  nervous  system,  and  more 
especially  of  the  brain,  which  favors  its  development.  Such 
e.xcessive  demands  which  arc  made  upon  the  brain  are  numer- 
ous. Chief  among  them  is  mental  overstrain,  caused  by  loo 
close  attenticm  to  work  and  worrying  over  business — too  much 
scheming,  calculating,  etc. — so  that  we  are  not  surprised  that 
bookkeepers,  accountants,  bankers,  Stock  brokers,  authors, 
actors,  etc.,  form  the  relatively  largest  contingent  of  cases. 
Besides  this,  deep  emotions,  repeated  or  long-lasting  sorrows 
or  care,  the  struggle  (or  existence,  disappointed  hopes,  baffied 

69S 


DEMENTIA  PARALYTICA. 


6S9 


ambitlnns,  and  fright,  may  attain  an  xtiotogical  importance. 
On  hearing  the  history  of  a  general  paralytic,  one  at  least  ol 
theKC  factors  will  hardly  ever  be  absent.  Bodily  overstrain, 
forced  marches,  excesses  rt  Ventre  and  the  like,  can  be  made 
responsible  to  a  less  extent.  Excesses  in  JiacJio,  tlic  habitual 
abuse  of  alcohol,  only  rarely  lead  to  general  paralysis,  but 
sometimes  a  condition  is  produced  by  such  excesses,  the  "  pseudo- 
paralysis a  potu,"  which  resembles  general  paralysis,  but  which 
is  quite  distinct  from  it.  and  belongs  to  chronic  alcoholism. 
There  is  no  question  but  that  the  occupation  may  furnish 
causes  (or  the  disease  ;  thus,  those  which  cnt.-iil  at  once  bodily 
and  mental  work,  or  those  in  which  the  workers  must  (or 
a  long  time  remain  in  very  hot  rooms,  and  again  working  in 
poisons,  especially  in  lead  (Snell,  Vogel,  and  others),  are  par- 
ticularly dangerous.  0(  great  interest,  finally,  is  the  (act  that, 
like  tabes,  general  pandysis  may  be  caused  by  trauniiiiisnt 
either  to  the  head  or  the  back,  so  that  wc  have  a  traumatic 
progressive  paralysis  which  is  quite  analogous  to  the  traumatic 
tabes.  In  this  latter  category  we  must  also  place  the  insolation, 
(sunstroke,  licit  stroke)  wluch  has  been  known  to  lead  to  gen. 
eral  paralysis  (Bonnet  and  Paris,  Ann.  m£d.-psych.,  Novcmbre, 
1834,  6,5.  12). 

Besides  the  congenital,  however,  there  exists  also  an  ao> 
quired  predisposition,  which  differs  (rom  the  former,  inasmuch 
as  no  other  exciting  causes  arc  needed  (or  the  production  o( 
the  disease,  since,  just  as  is  the  case  in  tabes,  it  atone  is  suffi- 
cient to  bring  about  general  paralysis.  We  refer,  of  course,  to 
syphilis.  The  same  highly  important  rJle  which  it  plays  in 
tabes  it  plays  here  too.  An  individual  who  has  had  syphilis 
has  much  greater  cause  to  (ear  general  par.alysis  than  one  who 
has  never  been  inlected.  According  to  the  statistics  of  Rieger 
(cf.  lit.),  the  one  is  sixteen  or  seventeen  times  as  liable  to  the 
disease  as  the  other.  These  figures  correspond  very  closely 
with  those  founded  on  my  own  experience.  Out  of  two  hun- 
dred and  fifty-seven  paralytics  a  hundred  and  seventy-one  had 
been  syphilitic,  and  out  of  two  hundred  and  sixty  patients  with 
other  diseases  only  fourteen.  Heredity  and  all  the  exciting 
causes  taken  tf^cther  do  not  give  rise  to  as  many  cases  of  pa- 
ralysis as  does  syphilis  alone  :  but  here  again,  as  in  talKS.  we 
must  leave  the  question  open  as  to  how  syphilis  acts,  whether. 
as  I  myself  am  inclined  to  think,  the  syphilitic  .irterial  disease 
is  responsible,  or  whether  we  arc  dealing  with  a  toxic  action 
44 


690 


DISEASES   OF   THE   GENERAL  NERVOUS  SYSTEM. 


SO  that  general  paralysis  has  to  be  regarded  as  a  post-syphititie 
affection.  Whatever  our  decision  on  this  point,  the  fact  that 
general  paralysis  may  be  the  result  of  syphilis  is  universally 
acknowledged,  and  the  numerous  writings  which  we  possess 
on  the  subject  are  all  without  exception  in  favor  of  this  view. 

The  influence  which  has  been  ascribed  to  age  and  sex  can 
usually  be  explained  by  that  of  syphilis.  Males  are  more  fre- 
quently attacked  than  females,  the  ratio  being  seven  men  to 
two  women.  Those  in  the  prime  of  life  furnish  the  largest 
contingent. 

Symptoms. — The  symptoms  of  the  disease  are  partly  psy- 
chical, partly  somatic,  and  this  will  not  surprise  us  when  we 
learn  that  the  seat  of  the  affection  is  preferably  in  the  brain, 
and  more  particularly  in  the  psycho-raotor  region  of  the  cere- 
bral cortex.  The  psychical  manifestations  differ  very  greatly, 
and  it  is  more  especially  in  the  prodromal  stage  that  these 
variations  are  most  noticeable.  This  is  a  feature  equally  well 
marked  here  as  in  tabes,  and  the  main  difference  between  the 
two  consists  in  the  fact  that  in  general  paralysis  the  clinical 
picture  of  the  prodromal  stage  is  dominated  by  the  psychical 
manifestations.  The  patient  becomes  unabie  to  concentrate 
his  mind  for  any  length  of  time.  He  gets  easily  fatigued  when 
he  has  exerted  himself  mentally,  he  becomes  forgetful,  and  is 
no  longer  able  to  comprehend  and  deal  with  matters  which  he 
previously  understood  perfectly.  He  is  found  to  be  indifferent 
in  the  performance  of  his  duties  and  careless  in  keeping  his  ap- 
pointments ;  he  becomes  unreliable  and  absent-minded.  When 
writing,  he  makes  mistakes  in  spelling,  and  presents  a  slowness 
in  thinking  and  a  general  dullness  of  intellect  which  are  quite 
foreign  to  him.  At  the  same  time  his  disposition  presents 
alterations.  Previously  tolerant  and  kind,  he  becomes  now  ill- 
humored,  moody,  and  irritable  ;  on  the  slightest  provocation 
he  loses  his  temper  and  may  even  be  inclined  to  violence.  His 
character  is  not  the  same  as  it  was;  his  will  power  becomes 
weak :  he  loses  his  energy  and  his  moral  individuality ;  he 
allows  himself  to  be  influenced  and  overpersuaded  by  anybody, 
and  even  thus  early  does  things  for  which  he  can  give  no  clear 
motive  ;  he  gradually  loses  all  consideration  for  others  in  his 
social  intercourse;  he  neglects  his  appearance,  his  dress  looks 
untidy,  he  becomes  indecent,  commits  nuisances  on  the  open 
streets,  tells  obscene  stories  before  his  children,  and  so  forth. 


DF.MEXT/A   PAKALYTtCA. 


In  exceptional  cases  the  paticnl  hiinseK  is  to  a  ccrtnin  extent 
conscious  of  these  changes  which  arc  going  on  in  him.  They 
Burprise  him,  and  he  speaks  about  them  to  his  most  intimate 
friends  and  expresses  a  (car  that  some  serious  disease  is  coming 
on ;  but  in  the  great  majority  of  cases,  he  does  nut  in  the  lea&t 
fipprcciate  his  condition,  which  worries  and  troubles  his  family 
so  much.  Months,  even  years,  may  thus  pass  and  no  new  mani- 
festations make  their  ap|>c3rance.  It  is  only  the  occurrence  of 
certain  somatic  symptoms  which  gives  to  the  clinical  picture 
a  different  aspect.  Among  these  latter,  besides  a  very  trouble* 
some  ophthalmic  migraine,  which  is  frequently  observed,  there 
are  especially  two  on  accountof  which  the  physician  is  consulted, 
namely,  insomnia  and  the  alteration  in  speech.  The  former 
is  all  the  more  striking  because  the  patients  often  by  day  and 
at  their  work  are  overpowered  by  sleep,  while  at  night  they 
lie  awake  fur  hours  without  being  able  to  rest.  The  latter 
manifests  itseU  by  a  difDcully  in  pronouncing  certain  words. 
The  patient  stutters,  misplaces  letters  and  syllables,  leaves  syU 
lableii  out;  in  a  word,  presents  the  group  of  symptoms  known 
as  "syllable  stumbling  "  (Sylbrnslo/pfm).  At  the  same  time  the 
voice  loses  ils  usual  timbre  ;  it  becomes  harsh  and  its  former 
modulation  is  gone. 

For  the  examining  physician,  the  associated  movements  fn 
the  facial  muscles,  the  fibrillary  tremor  and  twitching  of  the 
tips,  and  the  trcmulousness  of  the  protruded  tongue  arc  suffi- 
cient to  lead  him  to  the  diagnosis,  and  the  inequality  of  the 
pupils  which  may  appear  at  this  stage  is  an  important  sign. 
Ballet  has  shown  that  other  ocular  symptoms  m:iy  be  utilized 
(Progrfes  m^..  1 893,  33 :  cf.  also  Oebcckc,  Allgcm.  Zeitschr..  f. 
Psych.,  1S93.  lleft  1,  2.  p.  169).  The  motor  dislurbances  (Le^ 
moinc  et  Lccordonnier,  tiaz.  mdd.  dc  F'aris,  1889,  November  2) 
further  manifest  themselves  in  a  change  in  the  handwriting  and 
in  the  gait.  The  writing  shows  uncertainty  and  irregularity  ; 
the  letters,  which  are  usually  larger  and  written  more  awk- 
wardly than  before,  become  tremulous;  the  paper  is  covered 
with  blots:  the  words  arc  incorrectly  written,  inasmuch  as 
letters  or  entire  syllables  arc  omitted  or  misplaced.  The  gait 
becomes  awkward  and  clumsy  and  the  patient "  shuffles  .ilong  "  ; 
he  is  one-sided,  and  small  obstacles  in  his  path  arc  apt  to  cause 
him  to  fall. 

This  initial  stage,  which  in  its  duration  varies  from  a  few 
months  to  one,  even  two  or  three  years,  is  followed  by  a  stage 


6^2         DISEASES  OF   THE   GENERAL   NERVOUS  SYSTEM. 

which  is  generally  characterized  by  a  rapid  increase  in  the 
psychical  excitement  ("  maniacal  exaltation  ").  The  patient — 
previously  quiet,  sullen,  apparently  occupied  with  his  own 
thoughts — now  becomes  noisy,  talkative,  all  the  time  restless 
and  in  a  state  of  excitement ;  without  noticing  his  surround- 
ings and  his  friends,  he  lives  with  a  sense  of  perfect  comfort; 
he  is  young,  handsome,  extremely  strong,  and  immensely  rich ; 
he  has  studied  all  sciences ;  he  occupies  himself  with  absolutely 
preposterous  but  to  him  feasible  "schemes;  he  is  going  to  dry 
up  the  Atlantic  Ocean,  he  is  the  Emperor  of  China,  he  is  Na- 
poleon, Christ,  he  is  the  chief  among  the  gods,  etc.  In  the 
dreamlike  play  of  his  imagination  all  these  fantasies  arise,  but 
the  patient  is  not  able  to  give  them  any  logical  connection. 
Without  critical  faculty  he  stands  out  a  pitiable  victim  o(  the 
most  bizarre  delusions  of  grandeur.  At  the  same  time  his 
memory  rapidly  fails  him,  especially  for  recent  events ;  what 
he  did  to-day,  yesterday,  the  last  visit  of  the  physician,  etc.,  he 
does  not  remember,  whereas  the  reminiscences  of  long-past 
years  can  still  be  called  up.  He  does  not  know  the  day  of  the 
week  or  even  the  name  of  the  month  and  the  season  in  which 
he  is  at  present.  People  with  whom  he  used  to  deal  in  busi- 
ness he  no  longer  recognizes ;  he  confounds  them  with  other 
persons,  etc.  The  lack  of  judgment  of  the  patient  has,  of 
course,  a  decided  influence  upon  his  actions ;  he  buys  things 
recklessly,  squanders  his  money  in  a  most  foolish  manner,  he 
makes  debts,  commits  easily  discoverable  frauds,  which  he  de- 
nies  with  the  utmost  calmness  when  he  is  found  out.  Assaults 
of  which  he  may  be  guilty,  misdemeanors  against  the  public 
order,  offenses  against  the  public  morals,  etc.,  not  infrequently 
lead  to  trouble  with  the  authorities  and  to  the  arrest  of  the 
patient. 

In  by  far  the  smaller  number  of  cases  the  above-described 
initial  stage  is  followed,  instead  of  b)'  the  maniacal  exaltation, 
by  a  stage  of  depression.  The  patient  believes  himself  perse- 
cuted by  everybody,  and  his  life  menaced  ;  he  hears  voices,  and 
he  is  always  troubled  with  a  presentiment  that  something  ter. 
ribic  is  going  to  happen.  He  cries,  laments,  begs  for  help,  and 
so  forth.  In  other  instances  hypochondriacal  delusions  gain 
the  upper  hand.  The  patient  imagines  that  he  is  made  oi 
glass,  that  he  can  not  eat,  that  he  is  unable  to  urinate,  that  he 
has  no  head,  and  the  like.  The  lack  of  all  power  of  criticism 
in  these  delusions,  and  the  inability  to  systematically  elaborate 


^^^^^^^^™^        DEU£STIA  PARALYTICA.  ^^^^693 

^n>em,  and  the  usually  rapid  course  o(  this  stage,  distinguish  the 

■  general  paralytic  from  the  paranoiac. 
Quite  gradually  in  the  course  of  time  the  general  aspect 
chansjfs,  the  exciietncnt  abates  and  disappears,  and  the  intel- 
lectual impotency  increases.  The  paliccit  spends  his  days  with, 
out  a  thought  or  care,  writing  and  reading  become  to  him  lost 
arts,  he  forgets  his  own  name,  and  his  social  position,  he  be- 
comes oblivious  of  his  family,  and  in  general  takes  no  interest 
whatever  tn  the  outside  world.  This  is  the  stage  of  dementia, 
lie  becomes  uncleanly  in  his  habils.  hts  eating  and  drinking 
must  be  watched,  and  step  by  step  the  psychical  life  approaches 
more  and  more  its  extinction ;  the  patient  no  longer  lives,  he 

ITCgetates. 
It  is  of  great  practical  importance  and  interest  to  study 
the  somatic  disturbances  which  occur  in  the  course  of  the  dis- 
ease  associated  with  the  psychical  ones,  and  which  arc  caused 
by  the  simultaneous  affection  of  the  spinal  cord  (and  periph- 
eral nerves).  The  diminution  of  sensibility,  that  of  the  skin  as 
well  as  of  the  nerves  of  special  sense,  particularly  of  the  opticus, 
the  absolute  inactivity  of  the  pupils,  the  decrease  in  the  per- 
ception of  pain,  the  changes  in  the  electrical  excitability  of  the 
muscles,  which.at  first  is  increased,  later  diminished,  the  (not 
regular)  loss  of  the  tendon  reflexes,  the  appearance  of  trophic 
Bdisturbances  (ichthyosis,  F6r£),  the  tendency  to  bedsores,  the 
perforating  ulcer  of  the  fool  (««/  jHrforanl  tiu  firti,  cf.  page 
6f;/i),  all  point  to  a  participation  of  the  spinal  cord  in  the  mor< 
bid  process.    Sometimes,  tiuiie  early,  peculiar  attacks  occur, 

■  which,  associated  with  loss  of  consciousness,  are  cither  accom- 
panied by  transient  hemiplegias  or  convulsive  movements,  and 
which  therefore  either  deserve  the  name  of  apoplectiform  or 
epileptiform  seizures.  They  are  designated  as  "  paralytic  at- 
tacks." Under  ccrt-iin  circumstances  they  appear  very  fre- 
quently, from  ten  to  fifty  limes  in  one  day,  and  they  may  then 
keep  the  patient  in  an  almost  constant  condition  of  uncon- 
sciousness. The  elevation  of  temperature  which  accompanies 
these  attacks  is  not  considerable,  the  occurrence  of  albumin 
in  the  urine  not  constant.  Among  the  alTeclions  of  the  cranial 
nerves  which   have   been   but   little  studied  In  their  connec- 

■  lion  with  general  paralysis  may  be  mentioned  more  particu- 
larly the  optic  atrophy,  which  is  seen  in  ten  per  cent  oi  all 
cases.  The  nerves  of  the  ocular  muscles  also  frequently  be- 
come involved,  the  Implication  of  the  trigeminus  and  of  the 


694 


DISEASES  OF  THE  GENERAL  NERVOUS  SYSTEM, 


facial  being  less  common.  Of  the  nuclear  aflections  of  the 
vagus  coming  on  in  the  course  of  this  paralysis  nothing  defi- 
nite is  known. 

The  duration  of  the  disease  varies  much.  In  the  "  galloping 
form,"  in  which,  owing  to  the  sleeplessness  and  inability  to  take 
sufficient  food,  the  strength  rapidly  fails,  it  may  require  only  a 
few  months  to  bring  about  a  fatal  issue.  At  other  times  the 
disease  may  last  two,  three,  five,  or  even  more  years,  out  of 
which  no  small  proportion  is  liable  to  be  spent  in  an  asylum, 
as  it  is  out  of  the  question  to  keep  the  patient  at  home,  in 
spite  of  all  the  care  and  devotion  possible  on  the  part  of  the 
family. 

Pathological  Anatomy. — The  questions  as  to  the  anatom- 
ical nature  of  the  disease  have  unfortunately  not  been  as  yet 
answered  satisfactorily,  and  there  is  still  a  great  deal  of  diver- 
sity of  opinion  among  the  authorities  on  this  point,  although 
the  macroscopical  appearances  are  usually  very  characteristic, 
the  atrophy  of  the  brain,  especially  in  the  anterior  regions, 
being  very  striking.  Although  no  one  can  doubt  that  the  con- 
volutions are  diminished  in  size,  that  the  frontal  and  the  parie- 
tal lobes  weigh  less  than  in  a  normal  brain,  yet  the  precise 
mode  in  which  this  atrophy  comes  about,  what  are  the  micro- 
scopical changes  in  the  nerve  elements  of  the  cortex,  and  what 
is  the  primary  process  in  all  this,  are  not  as  yet  decided,  but  re- 
main the  subject  of  much  controversy.  According  to  Tuczek, 
there  is  a  marked  primary  atrophy  of  the  fine  medullated  nerve 
fibres,  particularly  in  the  outer  layers  of  the  cortex,  in  the 
tangential  "  association  "  fibres,  which  run  parallel  to  the  sur- 
face. The  gyrus  rectus  is  said  to  be  relatively  the  earliest 
attacked,  later,  the  remaining  frontal  brain  and  the  island  of 
Keil,  then  the  temporal,  but  the  occipital  lobes  never.  This 
view,  according  to  which  the  atrophy  is  the  primary  process. 
is  in  all  probability  correct,  although  it  is  still  combated  bv 
some  authorities  (Mendel),  who  look  upon  the  death  of  the 
nerve  fibres  as  the  secondary,  upon  the  increase  of  the  in- 
terstitial tissue,  the  thickening  of  the  vessel  walls,  and  the  ap- 
pearance of  spider  cells,  as  the  primary  process  ("encephalitis 
interslitialis  "). 

Analogous  changes  in  the  ganglionic  cells  have  frequently 
been  noted  (Binswanger.  Mendci,  Gudden) ;  a  peculiar  aggre- 
gation of  nuclei  associated  with  disease  of  the  vessels,  degener- 
ation of  the  capillaries  (Kronthal,  Neurol.  Centralbl.,  1890,  22), 


DEMENTIA  PARALYTICA, 


695 


changes  in  the  bodies  of  the  cells  in  the  large  pyramids  of  the 
paracentral  lobule,  changes  in  the  nucleoli  and  nuclei,  and 
sclerous  and  atrophy  of  the  cells  are  not  uncommonly  found 
in  this  connection. 

But,  besides  the  cortex,  the  deeper  regions  also  arc  the 
seat  of  alterations,  and  the  manifold  changes  which  the  white 
matter  of  the  hemispheres  may  undergo,  have  been  studied 
amoi^  others  by  Fricdmann.  He  describes  four  different 
forms  o(  atrophy  of  the  fibres  of  the  while  matter,  the  number 
of  the  fibres  diminishing  in  a  manner  analogous  to  that  which 
has  been  shown  by  Tuczcit  to  be  true  for  the  cortex.  The 
central  ganglia  of  the  brain  do  nut  remain  cscmpL  Lissaucr 
describes  a  degeneration  extending  from  behind  forward,  by 
which  the  pulvinar  Is  often  only  partially  implicated,  the  in- 
ternal geniculate  body  sometimes,  the  external  geniculate 
body  never;  he  is  of  opinion  that  this  degeneration  is  pres* 
cnt  in  cases  in  which  well-marked  sensory  focal  symptoms 
accompany  the  paralytic  attacks,  but  admits  that  these  changes 
in  the  thalamus  are  by  no  means  constant.  Wcstphal  has 
shown  that  the  pyramidal  tracts  or  the  posterior  columns 
of  the  spinal  cord  are  also  often  affected,  a  fact  which  prob- 
ably accounts  fur  a  not  inconsiderable  part  of  the  motor 
disturl>anccs. 

The  condition  of  the  pia  varies.  Frequently  it  is  adherent 
over  large  areas  of  the  underlying  cortex,  so  that  it  can  not 
be  stripped  oS  without  luss  of  substance  ("  decortication  ").  In 
rare  instances,  although  it  is  nowhere  adherent,  in  places  it 
is  thickened,  of  greater  consistence  than  normal,  and  contains 
variable  nmuunts  o(  fluid  in  its  meshes.  Whether  the  latter 
condition  is  only  a  later  stage  of  the  former — that  is.  whether 
adhesions  only  exist  at  first,  but  later  disappear — is  not  defi- 
nitely known. 

A  case  reported  by  Rey  (cf.  lit)  shows  that  exceptionally 
all  the  symptoms  of  progressive  panitysis  of  the  insane  may  be 
observed  during  life,  and  yet  at  the  autopsy  nu  change  be  fuund. 
The  same  thing,  as  we  have  mentioned,  has  been  known  to 
occur  in  connection  with  multiple  sclerosis. 

Diagnosis. — The  diagnosis  may  present  some  difliculty,  inas- 
much as  in  certain  forms  of  chronic  alcoholism  the  egoism  may 
be  exaggerated  as  in  general  paralysis,  and  inasmuch  as  cere- 
bral  syphilis,  brain  tumor,  senile  dementia,  finally,  chronic 
meningitis,  especially  the  diUuse  syphilitic  basal  form  (Oppen- 


696         DISEASES  OF   THE   GENERAL   NERVOUS  SVSTEAf. 

heim),  and  multiple  sclerosis,  may  more  or  less  resemble  gen- 
eral paralysis  in  their  course  and  their  symptoms.  In  alcohol- 
ism the  hallucinations  are  wont  to  be  a  prominent  feature,  the 
speech  disturbances  are  less  marked,  and  the  ideas  are  worked 
out  in  a  more  connected  manner.  The  tremor  and  the  history 
in  cases  of  chronic  alcoholism  wilt  also  assist  ns  in  our  diagnosis. 
In  cerebral  syphilis  also  the  history  as  well  as  the  age  of  the 
patient  (who  is,  as  a  rule,  younger  than  the  paralytic)  must  be 
taken  into  consideration.  Brain  tumors  present  a  similarly 
progressive  course,  but  the  stage  of  exaltation  is  absent  and 
the  characteristic  delusions  of  grandeur  do  not  occur;  in 
place  of  them  we  have  stupor  and  somnolence.  Senile  de- 
mentia, of  course,  occurs  in  people  of  advanced  age,  and  is 
characterized  by  a  tendency  of  the  process  to  remain  stationary 
for  some  time. 

In  meningitis  we  have  febrile  symptoms ;  the  choked  disks, 
which  are  found  comparatively  frequently  here,  and  the  de- 
lirium which  occurs  early  will  guard  us  against  errors.  In 
multiple  sclerosis,  finally,  we  have  the  scanning  speech  and 
the  intention  tremor,  and  when  the  disease  is  well  developed, 
it  can  not  be  mistaken  for  general  paralysis.  In  certain  forms, 
however,  the  differentiation  may  be  impossible.  The  most  im- 
portant points  to  be  remembered  in  the  diagnosis  of  general 
paralysis  are,  then,  the  following:  The  pronounced  psychical 
weakness,  which  even  in  the  initial  stages  is  the  most  promi- 
nent feature  of  the  disease  ;  the  constantly  progressive  course  ; 
the  motor  as  well  as  the  sensory  changes,  the  former  of  which 
give  rise  to  more  or  less  marked  alterations  in  the  speech,  the 
handwriting,  and  the  walk,  the  latter  to  changes  in  the  im. 
pressionabiiily  to  external  stimuli  and  to  marked  interference 
with  the  functions  of  the  nerves  of  special  sense — the  cutaneous 
sensibility,  the  sense  of  taste,  hearing,  and  smell.  With  this  in 
mind  we  shall  make  a  correct  diagnosis  at  least  in  a  good  many 
cases;  to  avoid  errors  completely  will  be  impossible  even  to 
the  most  experienced. 

Prognosis.— We  need  hardly  say  much  about  the  prognosis. 
From  the  above  description  we  can  welt  infer  how  unfavorable 
it  must  be.  Almost  all  cases  prove  fatal  in  a  few  years,  and 
the  outlook  for  complete  recovery  is  worse  here  than  in  tabes. 
To  be  sure,  it  has  been  claimed  that  such  may  occur  in  pro- 
gressive paralysis  (Wendt,  Voisin),  but,  in  the  instances  in 
which   it  was  observed,  the   possibility  that  the   case  was  not 


DEMENTIA   PARALYTICA. 


697 


Dne  oi  dementia  paralytica,  but  nttlier  one  of  the  so-called 
seu(lQ-paruly!>c<i,  such  as  are  known  to  occur  alter  the  abuse 
of  alcohol,  can  not  be  excluded  with  certaintjr. 

Treatment. — In  the  treatment  of  the  disease  we  must  chiefly 
endeavor  to  keep  away  all  excitement  from  the  patient,  and, 
since  this  is  best  and  most  easily  accomplished  in  an  asylum,  it 
is  the  first  duty  of  the  physician,  after  he  has  once  made  the 
diagnosis  definitely,  to  urge  the  family  to  transfer  the  patient  to 
some  such  institution.  Only  then  is  it  possible  to  guard  the 
patient  as  well  as  the  family  against  all  the  accidents  and  fatali- 
ties to  which  he  is  otherwise  necessarily  exposed.  This  step 
must  be  taken  as  early  as  possible,  not  with  the  idea  that  the 
patient  will  be  cured,  but  with  the  conviction  that  only  in  an 
institution  is  he  safe,  and  that  there  alone  it  will  be  possible  to 
secure  for  him  the  proper  care  and  nursing  so  necessary  for 
one  in  his  condition.  Where  there  is  a  history  of  syphilis,  the 
treatment  with  inunctions  must  of  necessity  be  given  a  trial, 
however  slight  may  be  the  prospect  of  success.  Once  decided 
upon,  let  the  antisyphititic  treatment  be  pursued  with  vigor: 
at  least  three  to  four  hundred  grammes  ( 5  ix- 5  xij) 'of  mer. 
curial  ointment  should  be  used  altogether,  to  which  must  be 
added  from  two  to  three  gnimmes  (grs.  xxx-xlv)  oi  the  iodide 
of  potassium  daily  for  a  good  while.  The  chloride  of  gold  and 
sodium,  a  remedy  which  years  ago  was  highly  esteemed  for  its 
antisyphilitic  action,  has  again  been  brought  back  from  oblivion 
and  used  in  cases  of  general  paralysis  (Boubila,  Hadjcs.  and 
Cossa.  Annal.  mid.-psych.,  1892,  1,  2) ;  the  results  arc  not  better 
than  those  obtained  with  any  other  drug.  To  meet  the  out- 
breaks of  exaltation  and  the  insomnia  the  usual  hypnotics, 
which  are.  however,  of  little  avail,  should  be  tried.  Sulphonal 
in  doses  ol  two  or  three  grammes  (grs.  xxx-xlv).  methylal  in 
doses  of  from  five  to  eight  grammes  (grs.  lxxv-3ij),  by  the 
mnuth  (Mairct  and  Combemale).  morphine,  from  one  and  a 
half  to  three  ccntignimmes  (grs.  '/,-'/>)  hypodermically,  chloral, 
paraldehyde,  possibly  also  hyoscynmine.  should  be  tried  in 
turn.  The  cold-water  treatment  and  baths,  .ilso  galvanism  [o 
Ihc  brain,  are  decidedly  contramdicatcd.  .Ml  such  pnnrcdures 
are  likely  only  to  increase  the  excitability  of  the  patient,  to 
give  him  all  kinds  of  unpleasant  sensations,  and  to  make  his 
troubles  worse,  without  being  in  any  way  of  benefit  to  him  or 
relieving  his  condition. 


6g8        DISEASES  OP  TOE  GENEgAt  tfEXVOUS  SYSTEM. 

LITERATURE.  . 

.  ,0.  ^mptpmt. 

StrilmpelL    Neurolog;  CentralbUtt.  i8S8, 5.    (General  Paral^  combined  .with 

Tabes  in  a  Child  aft^  Syphilii.of  the  Father.) 
Jelly.    Boston  Med.  and  Surg.  Joupt.  July  3,  1888.  cxix.    0>nadon  of  Ten 

Years.) 
Rottenbiller.    Centralbl.  T.  Herfenheitkunde,  1889.  in,  i.    (Observations  on  the 

Temperature.) 
Buchholz.    Das  Verhaltender^I^nbd  Dementia  paralytica.    Inaiic.<DiaMfU 

Breslau,  1889. 
WendL    Allgem.  Zeitachrift  f.  Psych..  1S89,  xlvi  i;    {Recovery.) 
Voisin.    Bull  de  thtoipeut,  Mai  15,  1889.    (CurabilUy  of  General  Paralyais.) 
Gerlach.     Arch,  t  Psych,  u.  Nervehlch.,  1889,  xk,  3.    (Changoi  in  the  Galvanic 

ExciUbility.)_ 
Ascher.    Allgem.  Zeitschr.  f.  Psych.,  1S89,  slvi,  i.    (Course  and  Etiology  oT 

General  Paralyus.) 
GodeV    Revue  miA.  de  la  Suisse  rom.,  April.  18S9,  u.  4.    (Paeudo-paraJysis 

caused  by  Alcoholic  Excesses.) 
Ueycr  und  Weber.    Peptonurie  bei  allgemeiner  Paralyse.    Bericht  tiber  die  If- 

lenanstalt.  Basel,  1889. 
Blocq.    Arch,  de  Neurol.,  November,  1889^ 

Ascher.    Aphasie  bei  allgemeiner  Paralyse.    Allg.  Zeitschr.  C  Psych..  1893,  1.  x 
Redlich.    Zur  Charakteristik  der  reflecfotiachen  PiiiHllenstarre  bei  pr(q;res5tver 

Paralyse.     Neurol.  Centralbl..  1893,  la 
NScke.    Allg.  Zeitschr.  f.  Psych,,  1S92,  i,  2,    (Kalalonic  Symptoms.) 
Kiinig.     Ibid.,  1892,  i,  2.     (Transient  Speech  Uisiurbances.) 
Neisser.     Ibid.,  1S92,  3.     (Combination  of  General  Paralysis  and  Progressive 

Muscular  Atrophy.) 
Raymond.  F.    Semaine  med.,   1892,   25.     (Relation  of  General   Paralysis  to 

Tabes.) 
Rendu,     lliid,.  1892,  31. 
Pierret.     Ibid,,  1892,  41. 

Nageoite.    Tabes  et  paralysie  gfn^rale.     Paris,  1893,  Steinheil. 
Marie,  P.    Extr.liis  des  Bulletins  de  la Soc.  mfd.  des  hflp.  de  Paris.    Stance  du 

12  Janv.  189;. 

*.   Pathological  Analoity. 

Tuezek.     Beilrag  jur  pathologischen  Anatomic  und  Paiholc^e  der  Paraiysf' 

Berlin.  Hirschwald,  1884, 
Zaeher,     Arch.  f.  Psych,  u,  Nervenkh.,  1884,  xv,  2. 
Savage.     Jouni.  of  Menial  Sc,  January,   1884,  xxix.      (Pachymeningitis  and 

Paralysis.) 
Camuset.     Annal,  mfdieo-psychol,,  Novembre,  1884,  6me  sir,,  xii.    (Changw 

of  the  Dura  Mater  in  General  Parai_vsis.) 
Mendel.     Allgem.  Zeitschr.  f.  Psych.,  1885,  xli,  4.  j.     (The  Ganghonic  Ccllsof 

Ihe  Brain  Cortex  in  Genpral  Paralysis.) 
Baillarger.     Ann.  med.-psychol.,  1886.  xliv,    1.     (Diminution  in  Weight  of  il* 

Cerebrum.) 


DEMENTIA  PARALYTICA. 


699 


I 


I 


I 


Mr)'ncn,    Vom  Mechaiiismus  ikr  ]>rofres»iv«n  Paralyse.    Wiener  med.  Dlatlcr, 

1887.  X.  17,  18. 
ZAcher.     Da&  VcThaltnidcr  marlch.-iIiiKen  Neneofajwrn  u.s.w.     Arch.  (.  PE}ch. 

u.  Xcrvcrkh..  1887,  xvii),  1. 
Zaclwr.    Acch.  f.  Pqrch.  u.  Ncnenkh.,  1888,  xtx,  3.    (General  Pjiraty&ls  bsw- 

datcd  with  Focal  Lesioiu  in  the  loienul  Ca|>sule.) 
Rejr.    Ann.  in^,-p»ych..  Mars,  1689,  ymc  iit.,  ix.  i.    (During  Life  Sj-mpioms 

of  General  I'valysiv^  al  the  Autopsy  no  ChAitKcs  Touml.) 
Bin«wangcr.     Ahg.  Zrilschr.  f.  Ps)xh..  18S6.  xlil.  4.    (Pjlhotogical  HiM<ila|nr.> 
CoielU,  Roaolino.     Le  alterailoni  dei  nervi  penfenci  netk  parnlisi  gmttak  |>io- 

grcuiva  in  tappurtu  con  i  loio  nuclei  central!  di  ot^iiH:.    AtiniiJi  iti  Nc^ro> 

V'f,\*.  Num-a  iicria,  1891,  ix. 
Hochc.    Beiliitf^e  tur  Kcnnintu  des  anatoiniKhen  Wrhallcns  dcr  mcRfchlichm 

Riickenniarluwuriteln  bci  dcr  Ucnicntia  paralytica.    Hcidellxn;.  Homuig, 

1891. 
JofTroy.    Contribution  A  rAnatomie  patliolo£H)ue  dc  la  Paral)-s)e  gisiit.     Arch. 

de  mM.  cxp.  et  d'Anat.  pathol.,  1893,  ]>.  841. 

t.  .-F-titlefy  ami  Otewrrttmte. 

ThomMn.    Die  praktiiche  Bedcutunt;  der  S)'|>luli«-l'aral)-sefra|fe.    AUg.  ZeitKhr. 

i.  Pij-ch.,  1890.  xKi,  J, 
Rouchaud.    Annal.  mM.  psychol.,  1891,  7  %b,  xiii.  3. 
Mvilhon.     Ibid.,  r89t. 
Uonnri.    KappoHs  dc  la  Syphilb  et  de  la  Paraljrnc  g£f>tnde.    Tbtee  dc  Paris. 

1S91. 
Charcot  cl    Itlocq.       Paralysle  gcntralc  chci    I'adotesocnt.      Scmaiiw  mtA„ 

1891.6. 
K^gii.     Syphilis  cl  paratysie  ([^ncrale.     Arch,  cllniqucn  de  Itoid,,  1892,  i,  J,  8. 
Orlwkc.     Zur  Actiologic  dcr  Paralyse.     Allg.  Zciischr.  f.  IS)ch.,  189:.  1.  3. 
IVrson.     neiichl  ubcrdic  Priiathcilnntlalt  u.  ».  w.  lu  Pitna,  Drcvlcn,  i%^y 
Mivcl- Laval liJe.     Kcvue  de  mtA.,  t893.  I.    (S}'philiK  and  Gcncr.il  I'arjilyw.) 
Niconleau.     Annal.  med.-ps)'ch,.  1893.  7.  8.    (Catiscx  of  General  Para)yxi«.> 
Wi);1eMK<orth.     liritish  Med.  Joum.,  Marclk  r893,  15.    (General  I'aralywk  <lur< 

mg  Puberty.) 
FMmkr.     Syphilis  cl  parahste  g^n^rale.     Re^uc  nevrol.,  1893.  lo> 
Wesiphal,  A.    Charity- .A nnalcn.  i8'>3.  p.  719.    (Genernt  Paraty^ntn  Women,) 
Oiaitton.     I^ssai  sur  Ics  tjpports  dc  In  pat.ity&ic  gfn^rale  cl  Syphilis.    '1  Mk 

4k  I'ariii,  1893. 


CHAPTER  IV. 
SYPHILIS  or  THZ  GENERAL    HBBTOUS   SYSTEM. 

'In  different  places  in  our  book,  in  the  chapters  oa  diseases 
of  the  brain  as  well  as  in  those  treating  of  affections  of  the 
spinal  cord,  we  have  had  occasion  to  point  out  the  rSU  which 
syphilis  plays  as  an  setiological  factor  in  various  diseases.  We 
have  also  shown  that  tabes  and  the  progressive  paralysis  of  the 
insane  are  to  be  regarded  as  the  main  representative  of  affec- 
tions of  the  general  nervous  system  depending  upon  syphilitic 
infection.  It  only  remains,  therefore,  in  the  present  chapter  to 
add  some  general  remarks  %0\  what  has  already  been  stated. 

No  part  of  the  nervous  system,  whether  of  the  brain  or  of 
the  spinal  cord,  is  exempt  from  the  chance  of  becoming  impli- 
cated in  the  syphilitic  infection,  and  remembering  how  the 
blood-vessels  are  affected  by  syphilis  this  is  easily  understood. 
Clinically,  it  is  especially  interesting  if  we  are  able  to  recognize 
diseases  of  the  cerebral  cortex  and  symptoms — e,  g.,  monople- 
gias— resulting  therefrom,  as  syphilitic,  but  the  corona  radiata 
and  the  basal  ganglia,  the  pons,  the  medulla  oblongata,  and  the 
cerebellum,  all  may  become  the  seat  of  syphilis,  and  syphilitic 
affections  of  the  base  of  the  brain  are  relatively  common.  In 
many  cases  it  is  difficult  to  make  a  certain  diagnosis,  especially 
if  the  patient  denies  the  primary  sore  and  no  trace  of  it  can 
be  found,  for  the  clinical  symptoms,  of  course,  are  the  same, 
whether  the  brain  lesion  depends  upon  syphilis  or  not. 

Symptoms. — Among  the  manifold  symptoms  which  occur 
in  brain  syphilis  we  may  mention  polyuria  and  polydipsia, 
which  have  been  subjected  to  careful  study  (cf.  lit.).  If  focal 
symptoms  are  present  it  is  easier  to  make  a  diagnosis  than  in 
their  absence.  In  the  latter  case  it  may  sometimes  be  impos- 
sible to  decide  upon  the  diagnosi9»of  brain  syphilis;  we  may 
be  dealing  with  a  case  of  cerebral  neurasthenia. 

With  reference  to  the  spinal  cord  the  matter  is  somewhat 
more  simple,  because  syphilitic  disease  here,  which  does  not 
implicate  also  the  brain,  as  in  tabes  and  general  paralysis,  is 
700 


SYPHILIS  OF  THE  GENERAL  NERVOUS  SYSTEM. 


TOl 


rather  rare.  It  is  nnt  a  common  thing  to  find  disease  o(  one 
system  of  tibres  or  discnse  u(  sever»l  systems  combined  de* 
pending  upon  syphilis,  and  the  cases  in  which  lateral  sclerosis, 
for  example,  was  attributed  to  tliis  have  been  published  as 
rarities.  It  is  of  pathological  interest  to  note  that  the  rout 
bundles  usually  present  a  marked  and  extensive  participation 
in  the  process.  In  a  case  reported  by  Siemcrling(cf.  lit.)  there 
were  gummatous  growths  o(  the  pia.  which,  although  they  had 
extended  into  the  substance  of  the  cord,  had  not  attacked  any 
"system  "  in  its  whole  extent,  so  thai,  as  is  often  the  case,  the 
spinal  symptoms  here  also  were  not  at  all  prominent. 

We  can  not  assume  that  the  spinal  nerves,  cither  motor  or 
sensory,  ever  become  diseased  alone,  but  we  must  rather  look 
upon  their  implication  as  a  partial  manifestation  of  a  general 
affection.  If  in  exceptional  cases  we  find  a  neuritis  of  the 
sciatic  or  of  the  muscuto-spiral  nerve,  etc.,  which  we  have  to 
regard  as  of  syphilitic  origin,  perhaps  because  it  rapidly  passes 
off  under  antisyphilitic  treatment,  the  manifestations  of  cerebral 
and  spinal  syphilis  have  either  existed  previously  and  have  not 
been  recognized  or  their  presence  later  has  to  be  l<H)kcd  for. 

Diag^nosis. — The  diagnosis  is  based  first  upon  the  history  of 
the  patient  and  the  presence  of  signs  of  the  primary  sore.  If 
ihese  are  established,  it  is  relatively  easy  ;  if  not,  we  must  look 
for  other  signs  to  help  us.  Secondly,  the  other  organs— for 
instance,  the  skin,  the  visible  mucous  membranes — all  must  be 
examined  for  the  possible  existence  of  syphilitic  lesions.  Re- 
peated and  careful  search  may  sometimes  clear  up  much  that 
is  obscure,  although  the  p;itient"s  account  may  be  imperfect. 
Thirdly,  it  must  be  remembered  that  the  symptoms  of  cerebral 
syphilis  are  extremely  changeable,  and  are  rarely  ever  of  long 
duration.  To^ay,  matters  may  look  as  if  the  patient's  life 
were  in  danger,  while  to-morrow  he  is  apparently  perfectly 
fe  again.  The  rapidity  with  which  the  changes  in  the  con- 
■  tfition  follow  each  other,  just  as  in  hysteria,  the  extraordinary 
circumstance  that  apoplectiform  att-icks  occur  in  younger  and 
epileptiform  attacks  in  older  persons,  in  doubtful  cases  are  in 
favor  of  the  dingnosis  of  syphilis  of  the  nervous  system.  In 
every  instance  we  shall  do  w*ll  to  pay  careful  attention  to  the 
condition  o(  the  eye-muscles  (Uhlhoff,  Arch.  f.  Ophthalm.,  1893, 
I)  and  the  pupillary  reaction ;  the  latter  may  temporarily  dis- 
appear and  reappear:  the  same  peculiarity  may  be  found  in 
the  condition  of  the  patellar  reflexes,  an  anatomical  explanation 


\1 


^02        DISEASES  OP  TMS  GElfESAL  IfEXVOUS  SYSTEM. 

for  which  has  thus  far  not  been  arrived  at.  Finally,  the  thera- 
.peutic  test  is  of  some  value,  inasmuch  as  the  successful  ami- 
syphilitic  treatment  makes  the  existence  of  syphilis  almost 
certain,  although  a  failure  does  not  warrant  the  contrary  con- 
clusion. 

Prognosis. — The  prognosis  must,  above  all,  be  influenced  by 
the  time  which  has  elapsed  since  the  primary  infection  and.be- 
fore  the  first  appearance  of  the  nervous  symptoms.  The  longer 
this  period  of  incubation  the  worse  is  the  prognosis.  Accord- 
ing  to  my  own  experience,  from  6ve  to  nine  years  is  the  most 
common  time.  Occasionally  the  infection  of  the  nervous  sys- 
tem manifests  itself  earlier,  and  in  quite  exceptional  instances 
two  years,  or  even  one  year,  after  the  primary  lesion ;  but  often 
the  interval  which  elapses  is  longer  than  the  time  above  given. 
Cases  in  which  the  spinal  or  cerebral  symptoms  did  not  appear 
till  after  twenty  or  twenty-five  years  I  have  never  seen  get 
well.  The  second  question  of  importance  is,  how  long  the 
nervous  symptoms  have  existed  before  energetic  antisyphilitic 
treatment  was  commenced.  Often  as  it  remains  without  effect, 
a  trial  of  it  is  still  indicated  if  not  more  than  two  or  four 
months  have  elapsed  after  their  appearance.  If  they  have 
existed  for  half  a  year  or  longer,  nothing  can  be  expected  from 
any  such  treatment,  and  it  need  not,  therefore,  be  begun.  In 
such  cases  the  prognosis,  of  course,  is  worse  than  in  the  others. 
Thirdly,  a  good  deal  depends  upon  the  kind  of  symptoms  by 
which  the  infection  of  the  nervous  system  manifests  itself. 
General  symptoms,  headache,  vertigo,  epileptiform  attacks, 
allow,  ctEteris  paribus,  of  a  more  favorable  prognosis  than  focal 
symptoms,  such  as  monoplegias,  hemiplegias,  and  paralyses  of 
certain  nerves.  The  worst  outlook  is  afforded  by  those  in- 
stances in  which  the  brain  and  the  spinal  cord  are  equally 
severely  attacked,  as  in  tabes  and  progressive  paralysis  of  the 
insane. 

Treatment. — The  manner  in  which  the  treatment  is  to  be 
conducted  must  be  made  to  depend  upon  the  individual  case, 
the  age,  the  nutrition  of  the  patient,  and  so  forth,  and  no  rule 
applicable  to  all  cases  can  be  laid  down.  Only  one  remark, 
which  has  repeatedly  been  made*  before  in  this  book,  we  wish 
here  again  to  emphasize,  namely,  that  if  we  have  once  decided 
upon  adopting  the  antisyphilitic  treatment  we  must  do  so 
energetically,  giving  iodide  of  potassium,  one  to  six  or  eight 
grammes  (grs.  xv-3  jss.-3  ij)  daily,  in  one  or  two  doses  in  hot 


SYPIllUS  OF  TUB  GENERAL  NERVOUS  SYSTEM. 


703 


mitk.  continued  for  from  six  to  ten  weeks,  and  inunclions  of 
blue  ointment,  (rom  three  to  five  grammes  (grs.  xlv-Ixxv)  a 
day.  continued  for  from  four  to  six  weeks.  All  necessary  pre- 
c:iiitions  arc  self-evident.  Finally,  we  should  not  neglect  to 
lamiliari^c  ourselves  with  the  progress  which  lias  been  made 
in  the  modern  ircalment  of  syphilis,  and  consider  whether  lite 
subcutaneous  use  of  mercury  is  advisable,  and,  if  so.  what  the 
exact  mode  of  its  administration  should  be. 


LITERATURE. 

ipenheim.    Zur  KetintnUt  d«  lyphJIii.     Erknithtingen  <lc£  Ccntr4lnef\'eti- 

sysicni*.     BerlliKr  khn.  WocheniKhr.,  18S9,  48. 
Zi«iit«n.     Syphilis  <lcs  Nctvcn^yycinB,     Klin,  VoOt..  iv,  November  3.  1S88, 
Warrirt.     Britiili  Mvii.  Joutn.  Srptcmlwr.  18S8.    (Two  Cuct  of  tlr.un-Sjiihilis 

in  Onr  Family.) 
JurKciM.     Uerltncr  klJD.  Wochtiischr..  188S.  »xv,  33.     (Sjrphilis  of  the  Spinal 

Cn«l.) 
Oppcnhclm.     Berliner  kl in.  Wochenschr.  18S8.  53. 
Sicm«rling.    Arch.  T.  l*»>Yh,  u.  Scrvcnkh..  1888,  xx.  I.    (CoDgcniial  Syphilis  of 

the  Uraia  ;)n<l  Sjiitiul  Cuid.) 
Naun>n.     Miiihcilungcn  £U»  iler  mediciiiischco  Ktiitlk  lu  KMi|;)tKfg.    Lcipui. 

VoKcl.  1888. 
Siemcrting.    Atch.  f.  Pt)Th..  1890.  1. 1. 
Nounyn.    Die  Progmisi-  der  «yphilit.     Ericnnkucigen  ilct  Nerreiiiyucmt,  XIII. 

Wxnilervcnuimmtung  iler  (UflwcU<lcut*chcn  Ncuiolufcn,    Arch.  f.  l'»fch. 

U.  Ncrvenlih..  18S9L  xx.  1. 
SKiigcr.    Zur  Kcnniniss  dcr  Ncrvenrrkrtnkungefl  (n  (I«r  Fr(lht>erio(le  <lcf  Syphl- 

lit.    Jahrb.  cl.  Hamburger  !Jt.-iatsitniMkcnjnM.ilicii.  II.  J.-ihrj;,,  189a 
Sachs.  B.     New  York  Med.  joutn,.  Sept,  19,  1891. 
HtitchiiiMn,  Jr.    Syphiliiic  Disease  of  the  OccijMlAl  Lotie  wiib  I'crforalion  of 

Cranium.     British  Med.  Joura.,  Miin-h  11,  1S91. 
Joflroy  ei  Leii«nn«.    ConlrDniiiuti  i  I'^iikIc  <Ic  la  syphitls  cMIWiilc.    Afch.  do 

meil.  expcrim.  M  d'anai.  pathol.,  1891,  3, 
Schulf.  K.     NniTol.  Cmlrnlbt.,  1891.  19. 
G<^lflam.     Riick<'nnMrks)|>liilis.     Wiener  Klintk.  3.  93. 
Cowers.    Syplulb  und  Ncnciuysicm.    German  b)-  LehfeUlt.  Dcrlin.  Karser, 

1 89  J. 
Cnopf  (Niirnberg).     Munch,  mrd.  Wochcnschr..  18913.  11.    (Cue  of  Ccrtbnl 

Syphilis,  t 
Picic    Zur  KennlnHft  der  ccrebro-S|>iiMkn  Sypliilis.      Zeitschr.  f.  HriUiunile. 

1891.  4-  >■ 
Nonne.     Ikitifii[c  tw  Kennlniss  <Ict  syphilit    Erkninkunscn  dcs  Rdckenmarks. 

Hamburg.  1893. 
Obermrier.     Deutsche  Z«-iischr.  f.  Ncrrcnhk-,   1893.  iii.  1-3.    (Two  Cases  of 

Gummaiou*  Mcnintiio* ) 
Ca)kiew)cji  (WnrMw).     Svphilis  du  sy»tfmc  ncrvctix.     Paris,  Dailliirc,  1893. 
Kowalcwsky.    Arch.  f.  Dermal,  u.  Syph..  1S93. 


INDEX. 


n 


Abducens,  analomjf  of,  44 ;  paralysis  of, 
49  ;  paralysis  of.  in  Ubes,  63a  ;  pkralysis 
of.  in  brain  tumor,  39B. 

Abduclor,  paralysis  of,  113  ;  paralysis  of, 
in  tabes,  636. 

Abscess,  of  the  brain,  360;  of  the  spinal 
cord.  465. 

Accnsorius.  anMomy  of,  136;  lesions  of, 
in  labes,  636  ;  paralysis  of,  138  ;  spasm 
of,  137. 

Accommodation,  errors  of,  as  a  cause  of 
headacfae.  65. 

Acromegaly,  512. 

Adam^^tokes  disease,  730. 

Adductor  spasm,  114. 

A|«pusia,  loS. 

Agraphia.  176. 

Agrypnia,  510, 

Akinesia  algera,  464. 

Alalia,  153. 

Alcoholic  neuritis,  3153. 

Alcoholism,  treatment  of,  by  suggestion, 
611. 

Alexia,  176. 

Amaurosis  in  brain  tumor,  si/b, 

Amaucosis,  epilepliform,  33.  , 

Amaurosis,  epilcpiiform,  in  brain  tumor, 
397. 

Amaurosis  partialis  fugai,  38. 

Amblyopia,  alcoholic,  39  ;  lead,  y)  ;  to- 
bacco, 39. 

Amblyopia,  central,  3a. 

Amyotrophic  lateral  xclerosii.  447. 

Anxmia,  cercl)ral.  254  ;  spinal,  4I11. 

Anxslhesia  of  blaildcr,  378. 

Anxsthesia,  doll's  head,  5(12  ;    gustaloria, 

lo3;   hysterical,    551,   557;    laryngeal, 

m  ;  in  transverse  myelitis,  4;)  ;  in  tabes, 

646 :    in   traumatic   Deuroses,   56a ;    of 

45 


trigeminus,  73 ;  in  unilatenl  cord  lesions, 
456. 

Analgesia,  in  synngomyclia.  471 ;  in  tabes, 
647. 

Anarthria,  153. 

Aneurisms,  of  cerebral  arteries,  ajj  ;  mil- 
iary, 314  :  of  spinal  arteries,  462. 

Angina  pectoris.  113. 

Angio-neurotic  a-dcma,  133,  359. 

Angiomata  of  spinal  cord,  46S. 

Anidrosis,  399. 

Anisocoria,  48  ;  in  general  paralysis,  691  ; 
in  neurasthenia,  532  ;  in  tabes,  632. 

Ankle  clonus,  433. 

Anlipyrine  as  a  cause  of  epilepsy,  ;73. 

Anosmia,  36. 

Ape-hand,  435. 

Aphasia,  amnesic.  177  ;  in  children,  tSl  ; 
conduction,  176,  179  ;  diaf^osis  of,  177  : 
Grashey's,  i3i  ;  motor,  176.  179;  total, 
176  ;  refl".  182  ;  sensory.  176,  179. 

Aphonia,  hysterical,  542. 

Apoplectic.  e(|uivalenis,  321  ;  stroke,  3tS. 

Apoplectiform  attacks,  in  general  paraly- 
sis. 693  ;  in  hiemaloma  dur.r  malris,  6. 

ApoplCKie  foudroyantc,  219. 

Apoplenies.  capillar^',  214. 

Apopleiy,  cerebral.  313;  hysierical,  545  ; 
menial  condition  in,  32S  ;  pn>gTe--sive. 
6  ;  sensibility  in.  234.  33B  ;  spinal,  4$^  : 
spinal-men ingeal,  336  ;  trophic  changes 
in,  231. 

Arai:hnoid,  anatomy  of,  3. 

Aran-Duchenne  type  of  progressive  mus- 
cular atrophy,  434. 

Argyll  Kobcnson  pupil,  48  ;  in  tabes,  see 
loss  of  light  reflex,  633,  669. 

Arsenic,  as  a  cause  of  multiple  netuitts 
389. 


7o6 


INDEX. 


Arriifthmk  cordb,  tjo. 

Aitcrica,  cerebral,  309 ;  diloulion  of,  353 ; 
embolism  and  Ihrombotit  of,  344  ;  nen- 
roM*  of,  as4. 

Arteries,  qiioal,  458  ;  dilatation  of,  463  ; 
embolism  oad  (hromboiiii  of,  460 ;  neu- 
roses of  46s. 

Aileiy  of  cerebral  beemonhage,  313. 

Arthropathy  in  Ubes,  657. 

Aspermatism,  jji. 

Asphyxia,  local,  401. 

Aspiration  pneumonia  in  bulbar  paralyiia, 
156. 

Associated  movements,  339. 

Associated  movements  in  tabet,  644. 

Astasia  abasia,  54S. 

Aslbma,  bronchial,  tiS;  cardiac,  139; 
hysterical,  I3o.  543  \  saturnine,  131 ; 
ihjmicum,  114. 

Ataxia,  cortical,  t86 ;  in  diabctea,  670  ; 
after  diphtheria,  669 ;  functional,  669  ; 
hereditary,  443 ;  locomotor,  639 ;  after 
pregnancy,  670  ;  in  tabes,  640. 

Atheimd  movements  in  tabes,  644. 

Athetosis,  3B4:  bilateral,  359. 

Atrophy,  mnscukr,  congenital,  413 ;  in 
hemiplegia,  333  ;  hysterical,  546  ;  myo- 
pathio,  406. 

Atrophy,  muscular,  pn^ressive  spinal,  434. 

Atrophy,  optic,  33;  congenital,  34;  in 
general  paralysis,  693 :  in  multiple 
sckrosis,  630  ;  in  tabes,  630. 

Attncii,  apoplectic,  21B  ;  Bpopl eel i form ,  in 
general  paralysis,  693 ;  apoplectiform, 
in  hoimaloma  durx  oniric.  6  ;  epileptic, 
S7S  ;  hysterical  553  ;  hystero-epileptic, 
600. 

Auditory  nerve,  analomy  of,  95  ;  hyper- 
itslhesia  of.  97  :  paralysis  of,  97  ;  paraly- 
sis, rheumatic,  1)7  ;  in  tabes,  G63. 

Aura,  epileptic,  575. 

Automatism  in  hypnotism,  603. 

Basal   gtuiglia,   anatomy  of,  19S  ;  lesions 

of.  193. 
Basedow's  disease,  518. 
Uedsore,  acute,  malignant.  331. 
Beri  beri,  331. 
Birth  patsy,  354. 
Bladder,  an:esthesia  of,  37S  ;  disturbances 

of.  in  myelitis,  4;z  ;  disturbances  of,  in 

tabes.  652. 
Elepharoptosis  cerebral  is.  46. 


Blepharospasm,  7^ 

Btachta]  pleaus,  anatomy  of,  334 ;  diaeata 

of,  3*X 
Bradycardia,  139, 
Brain   abscen,  460 ;    Mtiology    of^    s6t ; 

dii^nosis  oE;  364 ;   prognosis  of,   36j ; 

symptoms  of,  361. 
Brain  syphilb,  700. 
Biain    tumor,     3E9 ;     Ktidogy  oi,    393, 

choked  disc  in,  396  \  diagnoda  of^  399 ; 

epileptiform  cimvuLuiHis  in,  394 ;  focal 

symptoms  in,  397 ;  mental  change*  in, 

S94  ;    nature  of,  303  ;     Mkt  of^  301 ; 

symptoms  of,  393. 
Breast,  irritable,  365. 
Bromides  in  epilepqr,  J90. 
Brown-Stqnard's  paialyus,  456. 
Bulbar  paraly^  159. 
Burdacb's  columns,  43(X 

Cacbexie  eaophthahaiqae,  JiS. 

Cachexie  pachydeimique,  535. 

Cadaveric  position  of  vocal  cords,  116. 

Capsule,  internal,  anatomy  ot,  190;  le- 
sions of,  199. 

Carcinoma  of  brain,  ago ;  of  coid,  468 ;  of 
Tcrtebite.  453. 

Cardiac  branches  of  vagus,  133. 

Cardialgia,  131. 

Caries  of  the  spine,  diseases  of  the  cord  la, 
453  ;  pachymeningitis  spinalis  due  to, 
316. 

Catalepsy,  602. 

Cauda  equina,  tumors  of.  469. 

Cavity  formation  in  cord,  471. 

Centrum  ovale,  1S9. 

Centrum  ovale,  lesions  of,  19J. 

Cephalalgia,;/.  Headiche. 

Cephalocelc,  313. 

Cerebcllai,  abscess,  263,  265  ;  ataxia,  tj- 
Equilibrium,  loss  of,  in  diseases  of  tie 
cerebellum  ;  peduncles,  lesions  of.  206 ; 
tract,  direct,  430. 

Cerebellum,  lesions  of.  305- 

Cerebral  lesions,  pathological  diagnosis  oT. 
309  :  topical  diagnosis  of,  163. 

Cerebral  palsy  of  children,  268, 

Charcot's  joint,  657. 

Cheyne-Slokcs     breathing    in    apoplcit. 

320. 

Chiasm,  optic,  anatomy  of.  39  ;  lesions  of, 

34- 
Choked  disc,  </.  Papillitis. 


^^^^^^^^^^^^^^              ^^^^^^^^^^^^^^^^H 

CholettcsMnu  of  brdn,  2^. 

byitcria,  S4I ;  in  tab«*,  Ajo;  nultiple                     ^^ 

Chorda  lympuii,  l«nom  of.  i%. 

affectioint  of,  147. 

CKore*.  4S1  ;  conj[GiiiIat,  4B8  ;  hcndiinrj. 

Crcmailcric  rcHci^  411. 

4^;    ltunIiIl|;Ion'^,     4S3  ;    imluiotia. 

Ciim,  anal,  in  tabes  I^S ',  triaet,  (aa- 

4SS ;  major  ind  minor.  4S1  ;  in    pr«g- 

trie,  6>4;    laiyuccal,  63b:    phoiyncoal, 

1          nancy,  4^3  ;   vcnilc,  46S  ;  Sjnlsnhaiii'i, 

6J*. 

481. 

Crura  cerebri,  sol. 

;      CirdeofWillii.  llo. 

Cmlch  paliy.  ^4;. 

Ciratmflci  nerve.  p>irJy>ii  of,  }}}. 

Cryini;  liti  in  hysitria,  ^3. 

CUw-tumd,  Jix  ^yy 

Cyil.  apoplectic.  3I4<                                                    ^^^M 

Ctonni.  anVle.  4>3- 

CyuiccKiu.  of  biinjn,  yt; ;  ot  tpinal  cord,                ^^^^| 

Clowkixm,  but. 

^^H 

Chib  fool,  pwaljttic,  438. 

^^^^1 

Cocaine  at  a  cause  of  qnlepxy,  }7J. 

DaiiTmalil'i  craatp.  3S7.                                         ^^^^H 

Coccygeal  acrvei,  aniiom)'  of,  j;o. 

DcafncM  bi  hytietl^  M<  i  •■>  nwitagtata,              ^^^^| 

Coccyeodyaia.  3S0. 

10;  ia label,  6)4;  ■onl.  tjb.                                 ^^^^| 

Colcl-wnicr  ireilmcnl  in  hj-*icria,  j68. 

Oegenentioo,  of  i>f  rvn.  333  ;  rvaclioa  <it,                ^^^^| 

CoIm  vUioD.  diilurbincct  i>f.  in  papillilit. 

4t ;  wooiHlaf)',  44s :  »iett*  of,  in  tpttty-              ^^^H 

JJ  ;  in  (ntm.  6)1  ;  in  hyitcri&.  541. 

ilct,  584.                                                              ^^^1 

Coma,  iB  ccr«liral  iMmorrhai:*.  no ;  dif- 

l>r|;l«(ilKin  paraljils  hyilcrical,  S44.                          ^^^" 

ferekilil  ilia|[B(iws  oif.   ajj  ;   cpllc|iiic. 

l>(nic>iiU  in  btatii  tuuiui.  395. 

353  ■  in  I'achyincnintiitLi  inlorna  turmur- 

Iktmenlla  potBlytkn.  tM. 

rlu|[lca.  (i. 

l>epRttloa  la  (cnrmi  paralyiii,  Oya.                       ^^^. 

CoMbiMd  yfuem  MtetM,  443. 

l>cvUltun,  conjii|[ile,  51.                                             ^^^^^| 

ComIKMbIdd  myclliU,  45) 

UcviaiHD  ol  cyct.  primary,  ji ;  wttiHMlafy,                ^^^^| 

CottCMHion,  fplnaL  e/.  'I'raatnallc  nearo- 

^^^1 

M*. 

Diabdo,  hncc-jctk  is, 650;  niallipk  nn,-                ^^^^| 

Coajogato  deviation  of  rye  3m. 

rilli  (nllawlnit.   ytS;  aiaala  foUowtnK,                            ^ 

C'lMlncluita  In  liifaiilik  ccrcUtal  palkle*. 

67a.                                 _^^^^ri 

s;3 :  in  *pina1  pamlyili,  41H  ;  In  heml- 

]>iaplirn|[Tn,  piralyut  of,  336,  ipMOi  oF.                ^^^^| 

lileula.  23b;  In  hylcla,  sjo.  556. 

^^M 

Couvcrijiacw,  tiunflicicncy  of,  in  (iravct' 

DianliiEa,  ta  Ubes,  63s.                                          ^^^^H 

'           diuoiic.  JM. 

Dlfuw  tdeniHi,  ccrehtal,  (67.                                   ^^^^H 

COavotiiliaini  of  ibc  btain,  167. 

DiffniMM  decttodc.  71.                                            ^^^H 

CoovDldoni,  cpilepiiforai.  In  brain  ittmot. 

Dlceilivc  dtMntbaneet  In  alTNIioiU  tt  ibc                ^^^H 

399 :    in  cetcbral   paUln  of  children. 

ngni,  130.                                                                  ^^^^1 

371  ;  u  f  cnenti  ponlyiU.  6g]. 

DIpktheria,  ataxia  foUowtni;,  6^91  hmil>              ^^^^| 

C<>iml>iani,hyiienM:pilep(ic.6oo:  infan- 

pkc>i  faUo«in|£.  117 :  laryniceal  jiataly-                ^^H| 

lile.  1/.  Edimpiia  ;  puerpcnl.  $95  ;  in 

■inMloHtnf.  113;  UryncMl  aaa^iheiia                ^^^^ 

ipiaal  pi[»|ir*ii  afcluMrca.  417. 

folhmuiit    iij:    pbuyncral    ptniy*h                         ^ 

1     Co-onUoMicMk,  ditturtiancct  of,  tn  tnbea^ 

foUowlntt.  149:  neu rill*  follow  1^,  jU:                ^^HH 

1         640. 

ocnlu-nvolor  paralyMt  lollou-liif .  4(h                        ^^^^^| 

1     Comn  Amnionii  in  rpilepiy,  s8;. 

Diplegia,  cerebral,  ail ;  facial,  »6.                               ^^^^ 

1      Corpora  albicanlij,  toy 

DI|lopia.  cmited.  51 ;  boimnf-niou,  ji  j                 ^^^^J 

C^rpont^aaingemma.  199:  teiiiMuof.ioo. 

■UHMCslat,  46 ;  in  laliet,  ftja.                                  ^^^^| 

Ca(p<tt  callMun,  abwnce  of.  313- 

Donal  nervo,  363.                                                 ^^^^H 

C«1x*l,  aMNb,t66;  cpilrp«T>  >^  :  <^>or 

Douhk  tmagM,  eiantlaatlon  fur.  JI.                          ^^^^H 

dtoariwacw.  18]  ;  Mwoiy  diiliubaiKOa 

Double  riiMin.  t/.  Diplopia.                                        ^^^^H 

iSK. 

Dnchenne'i  ducakc,  ija.                                                     ^^M 

Co«cli.  tt]r4i«rieal.  nj. 

Dura  mater,  cercbnL  3  ;  fploal.  jiA^                                 ^H 

Conilh,  Ingcnitnal.  yd. 

Dyipepsia.  nerreai.  133. 

Cnnial  imtw,  dii«atn  of.  14  :    in  apo> 

Dyipbai^ia,  spoimodie.  1 34. 

pleay,   m :    In  brain   tumor.  398 ;    in 

Dyiliophy,  pngnaaiTc  mutcular.  406. 

7o8 


INDEX. 


Eu-  ditcMC,  in  brdo  i&scets,  361 ;  snd 

meningUU,  10. 
EcdirinoMi,  cntaneotts,  in  Uba,  645. 
Echinococcut,  of  bnin,  307 ;  of  ipinal 

cord,  470, 
EclampEia,  594. 

Embolism,  cerebral,  344  ;  i^nil,  460. 
Encepbalitii,  non-mppurative,  166  ;  puru- 
lent, 360. 
Encephalocele,  313. 
Enccphalomalacia,  344. 
Encepbalopatbj,  utumine.  3{J. 
Enchoadroma  of  brain,  390. 
Endaiterids,   cerebralia  iTpluIitica,   353; 

spinalb  iTphilitica,  461. 
Endocarditis  and  chorea,  485. 
EnvKHt  noctonia,  379. 
Epilepsia,  acetonica,  586 ;  ptocnnlra,  583. 
Epilepsy,  cortical,  1S6 ;  and  tieait  diieaee, 

$86 ;    Jacksonian,    1S6 ;     reflex,     574 ; 

■atumine,  5S7 ;  and  STphilis,  573 ;  Iran- 

matic.  573. 
Epileptic,  abwDce,  $81 ;  attack,  J75 ;  aura, 

575  ;    equivalents,   583,   insanity,   5B3 ; 

Tertigo,  s8i. 
Erector  spiue,  paialysu  of,  365. 
Erythema  nodosum,  399. 
Erythromelslgii,  398. 
El  her,  subcutaneous  inject  ion  of,  as  a  Cause 

of  musculoE-piral  paralysis.  347, 
E<(uilibriuni,    loss   of,    in    diseases   of  the 

cerebellum,  205. 
Equivalent,    apoplectic,    zzi  ;    epileptic, 

582  ;  hemicranic,  509. 
Ex  ophthalmic  goitre,  51B. 
Eye    muscles,   paralysis  of,  4g  ;    in   btain 

tumor,  izqS  ;  in  mcninigiiis   I3,  t6  ;  in 

Inbes,  631. 

Facial  nerve,  anatomy  of,  77  ;  in  labes.  633. 

Fnctal  paialysis,  bulbar,  84  ;  electrical  re- 
actions in,  91 ;  movements  of  expression 
in,  83  ;  peripheral,  87  ;  pontine,  84,  85  ; 
prognosis  in,  91  ;  rheumatic,  89. 

Facial  spasm.  78. 

Facio-lingual  monoplegia,  84. 

Fce<ling  system  (Weir  Mitchell),  567. 

Fifth  nerve,  if.  Trigeminus. 

Fi>BUTes  of  brain.  16S. 

Flexibitilas  cerea,  603. 

Klexor  contractures  in  meningitis,  14. 

Foot-clonus,  (/.  Clonus. 

Forced,, movements,  306 ;  positions,  306. 


Fonnes  frasies,  in  Gravci'  dbeie,  539 ; 
in  multiple  sclerodi,  6ai> ;  in  tabes,  UA. 
Fothergill's  faceache,  6S. 
Fourth  nerve,  tf.  Patheliciu. 
Fractures  in  tabes,  656. 
Friedreich's  disease,  44a. 
Front  tap,  433. 

r 

Gait,  in  multiple  neuritis,  393  ;  in  paeado- 

hypeitn^hy,  36;;  in  qtailtc  pMaljsii, 

44a ;  in  tabes,  64a 
Gangrene,  qrmmetriol,  401. 
Gasserian  gan^ion,  j6. 
Gsslralgia,  131. 

Gastric  branches  of  vagus,  130. 
Gastric  crises,  634 ;  vertigo,  lOt. 
Gastrodynia,  133. 
General  paralysis,  688 ;  teticdogy  of,  688 ; 

pathological  anatomy  of,  694 ;  and  tabe^ 

638 ;  treatment  of,  697, 
Gerlier's  disease,  loi. 
Giddiness,  tf.  Vertigo. 
GiUes  de  la  Tourette's  ditease,  tf.  Haladie 

des  tics  conralsifi. 
Girdle  sensation  in  labca,  645. 
Glioma  of  the  brain,  sSg  ;  of  the  qiiiud 

cord,  467. 
Gliosis  in  syringomyelia,  471. 
Globus  hystericus.  544. 
Glossopharyngeal  nerve,  anatomy  of,  107; 

lesions  of.  108. 
"Glossy  skin,"  400. 
I  Glottis,  spasm  of,  114;  hysterical,  542. 
Gluteal  reflex,  431. 
Goitre,  exophthalmic,  jlB. 
GoH's  columns,  420. 

Graefe's  symptom  in  Graves'  disease,  W- 
Grand  mal,  581. 
Graphospasm,  356. 
Graves'  disease.  518. 
Gray  matter  of  spinal  cord,  diseases  of,jl5- 
Gubler's  tumor,  cf.  Tenosynovitis. 
Gyri,  cerebral.  167. 

Ilxmaloma  duis  mains,  4. 

H^matomyelia,  458. 

Himalorrbachis,  tf.  Meningeal   hatnW' 

rhogc,  326. 
Hematuria  in  tabes,  653. 
HiBmorrhagc,  cerebral,  213  ;  spinal,  45*' 

spinal-meningeal.  316. 
Hair,  falling  out  of,  in  Craves'  disease.  S'l- 
I  Hallucinations  in  hysteria,  541. 


^^^^^V                                                                          1 

llcoilache,   zlioloQr  of.  6,1;    uiatomkal 

HypcriUrcwit,  399;  of    th«   face,  6q:    I«                           ^I 

MAI  of,  Ai  ;    in  brain  i^phitii.  703  :  m 

Uk\bH  parolyus.  9a                                                     ^^^^H 

brain  tumor,  Z93:    in  pachymeniniiitii. 

Hypcriuntxii  (ordii,  ia6>.                                       ^^^^^| 

6  ;  trcatmcill  of.  fj. 

Hypeiir«[iJi<r  of  niiatdet,  41a.                            ^^^^^^H 

Ileatmi;,  rfiilutbane**  of,  t/,tilao  Andilrny 

Hypnoliim,  ftott,                                                 ^^^^^^H 

Dcrvc,  9S ;   in  ni|[iu<:m>.  i)S ;  In  facial 

Hypogloual   nerve,  aaalomy  of,  140:  in               ^^^^^^ 

paralftii,  a. 

hcnuplcgin,   aa) :    panlfiii   of,    141 ;              ^^^^| 

Hurt.  •JTcciioiu  of.  in  v^ia  letloiw,  tS] ; 

q>aHn  uf.  144  ;  in  lali«>,  637.                                   ^^^^| 

in  Cravti'  diKosc,  jtS. 

llytleria,  S39.                                                          ^^^H 

Hurt  diicuc  anil  chi>i«i,4ft3;  and  est- 

Hyueria,  aorlic.  S43 :  in  ">«  nule,  |J4.                             ^^^ 

tcJiun,  144. 

Hytlorical,  aphooid.    $41 ;  Btthwa,  343  ;                  ^^^^| 

I  Icmiaamlhoia,  in  ilitc»«t  of  ih<  Inlcr- 

cnnmUioni,  353:  bcmknntlKctM.  345;                 ^^^^| 

nol  cnpculc,  199,  aa;  :  lij*ici4c«l.  S45  • 

boniipleKia,  343;  bdwria,  339;  nrar>l-                ^^^^H 

in  lyringooijclia.  471. 

Kla.  )}t :  panlyib.  548 ;  vonltinc.  3M-              ^^^| 

Hcmianopia,  34 ;  in  c«Kbr«l  typhilK  36 ; 

Hy»tcr<X|ii)rpty,  600.                                       ^^^^^^^ 

eumioaticin  for,  36 ;  oKilloUiig.  )6. 

Hytterogtsic  toitet,  S3t.                                        ^^^^^^| 

Itcmianupic  pujtillajr  ttaclloa,  35. 

^^^^^H 

Mcmiataxia,  3>q. 

Keaiathctotit,  1.^, 

Imilntion  cpilepoy,  374.                                                         ^^| 

KcMiatruphia,    facUlIt,    403;     lUiEiMln, 

lncc|ualil]r  of  pupih.  </.  Aniueonl,  4B.                              ^^| 

144. 637- 

Infantile, cerebral  paIiy,tAS:  <ianvml>ia«M.                         ^H 

II«atichot«a,  481 ;   pMt  hcmiplcgk.  nS : 

</.   Eclunpua,  3<h  ;  hcinii>Usia,   171  ;                         ^H 

prtk(rmtplr|;i<.  llS. 

spinal  polty.  4t6.                                                                ^H 

Ilcaiicnnia.  )u;. 

Infeclidiu  ditcoies  and  ni»inGiiii,  1 1.                                 ^H 

Hcmiopia,  34. 

lnf(«aibi(al  neuralgia,  69.                                                      ^H 

Il«npl«pa,    914;    kltcmatinc.  95,   M4; 

Inuinity,  post-epileptic,  378;  pivefiilF]*-                         ^H 

MnbnL  *a4 ;  direct,  21} :  in  gcnoial 

373-                                                                                ^1 

|M)aJyilii,6Qj;  hjiMcrkiU,  545 ;  indirvct. 

InMtmnia.  trcaIiM«t  of,  310,                                                ^^| 

aat;  lafaalib  tfUMlIc,  371 ;  (xM-iliph- 

Intula,  1/.  Island  of  Rcil.                                                     ^^| 

Ihtrtlto,   SI? :   tpuul.  4S7 :    in    labn. 

Iniulu  iclcrinis.  if.  Multiple  uleiowh                      ^^^^H 

639- 

Intention  trcmar,  61B.                                                   ^^^^H 

llcaiiparcil*,  3x4. 

IntcicfHtal  Bcnrolgia,  363.                                       ^^^^H 

llcniMciioa  ofilM  ifilwtl  mnl,  4$& 

Internal  cipaule,  190  :  l«MiMn  of,  I99.                        ^^^^| 

H««iit|>MM,  ilouo-Uiial.  81. 

tnlcmal  popliteal  nerve,  3S1.                                       ^^^^| 

lltfMUlgta.  1)1. 

Involuntary  sioveiucnii  in  tabes,  643,  (44,                        ^^| 

D     HwcillMiy  auii*.  44S> 
1     tlttadliarr  chofM.  43S. 

Hcipci,  lahlAli*.  in  nenfngllU.  18 ;  CMlcr, 

Iiritllion.  ipinul,  4^3.                                                                   ^^| 

Island  of  Reil.  171.                                                                        ^^| 

Ischuria,  byitciieal,  %%%                                         ^^^^H 

364.  400, 

^^^^1 

Hip  mukclei,  ijMum  «f,  38}. 

Joctuonian  epilepty.  136.                                              ^^^^| 

Mvitllnglon't.  chorea.  4^!^ 

Jaw-jcifc.  447-                                                               ^^^H 

llfilrviliiiMl),  4001 

Jdnt,  CharcoiV  byi :  hyKtcrita),  jji.                ^^^^^H 

llrilToc«|ihtli»,  yA. 

Javenile  nuiiculai  atro|>h)>,  406.                           ^^^^^^H 

WyAmmytSXit,  471. 

^^^^H 

llTdnvrhachli,  471. 

KakJie,  Jji.                                                                   ^1 

Ilfpencuils  In  facial  pmljnii,  Sq. 

Kakosoiia.  jCl                                                                         ^H 

1      H]rpccrinla,  DtrthraL,  1(4 ;  iprn*).  4fiS. 

Kn<<r<JDtk,    413;     crntrv     for,    491;     in                  ^^^^| 

Il]r7>er«ubc«l*.  of  audiioiy  Mno.  gfa ;  tn 

ditonic   ■looholiin^  byt;    in   dlabefe^                ^^^^| 

BrownJiAiiianJ't   |Mnlir^i«,  457 ;  hjrt- 

630;  <«lieaiipU|pa.M7.93i;  in  b(rt4i-               ^^^H 

ivrieaJ,   jji,   JJ7 ;   larynccat.   iij:    in 

ury  uaxia,  441;  tn  wulllplo  tclcrmls,                ^^^^| 

menlsgllU,  is;  plantar,  377  1   In  tabo. 

bI9:   in  neurlllt,  391;  650;    la  lalie^                ^^^^| 

6*S- 

^^M 

Kyphmla,  365.                                                         ^^^^^^^ 

7IO 


IND£X. 


lAlma-f^txxa-Uxjagtil  paraljnii,  151. 

LachtytnatioD,  iiaDsient,  in  label,  633. 

Landnatiiig  p«iiu  in  labci,  645. 

Luidiy's  panlysU,  466. 

Laryngeal  anKitheiia,  iij. 

Laryngeal  ataxia  in   tabei,  636  ;  Iiypcr- 

anlheiia,  115. 
Laiyogeal  moides,  paisly^  of,  113,  116 ; 

ipasm  of,  114. 
Laiynglsmiu  itiiduliu,  114, 
Latenl  uJeroda,  440. 
Lateial  icleiosii,  amyotnqiliic,  447- 
Laughing  fits  in  hyiteria,  543. 
I. cad  palsy,  347. 
Lenticulo-oplic  aiteiy,  lis. 
Lenticalo-striale  arteiy,  aia. 
Leptomeningitis,  cerebral,  S  ;  qtinal,  3aa. 
Lethargy  in  hypnotism,  603. 
Lencomyeliiis,  439. 

Levator  patpebne,  paralyni  of,  tf.  Ptosis. 
Lightning,  neurawt  caused  by,  565. 
Lipoma  of  brain,  390. 
Localisation,  cerebral,  163,  i6s,  171 ;   of 

spinal-cord  lesions,  433. 
Locomotor  ataxia,  619. 
Lumbago,  415, 
Lumbar  cord,  lesions  of,  435. 
Lumbar  nerves,  366. 
l.umbo-abdominal  neuralgia,  369. 

Mnl  pcrTorant  du  pic<^,  656. 

Maladie  des  licii  convul^ifs,  549. 

Malum  Cotunnii,  371. 

Maniacal  exaltation  in  general  paralysis, 
693. 

Mankopfs  symptom.  563. 

Massage  in  hysteria,  56S. 

Maslication,  paralysis  of  muscles  of,  59, 

Mastication,  spasm  of  niusL-les  of,  58. 

Maslodynia.  36 j. 

Mastoid  disease  and  meningitis,  10. 

Median  nerve.  349;  paralysis  of,  350; 
sensory  alfections  of,  352. 

Medulla  oblongata,  206  ;  lesions  of,  307. 

Meniere's  disease.  99,  103. 

Meningitis,  epidemic,  symptoms  of,  13 ; 
diagnosis  of,  IS. 

Meningitis,  gummatous.  9 ;  idiopathic 
purulent,  is;  pscudo-.  hysterical,  19; 
serous.  iS  ;  tuberculous.  10  ;  in  adults, 
16 :  tuberculous,  in  children,  15;  spi- 
nal. 311. 

Mercurial  tremor,  624. 


Merycism,  131. 

Mesmerism,  604. 

MetaUnalgia,  377. 

Meteorism,  S44. 

Meteoroli^lical  condition  and  mcnli^Ittt, 

II. 
Middle  cerebral  artery,  an. 
Higiaine,  507  \  ofdittudBiic  508. 
Miliary  aneurianu,  314. 
Mimic  facial  spasm,  78. 
Mind-blindneis,  176. 
Mind.dcafne*s,  tf.  Word-deafiies,  176. 
Miners'  nystagmnt,  53. 
Mogigraphia,  35*- 
Honocontracttue,  186. 
Monoparesis,  tBs-  f 

MoQopt^lia,  cortical,  tSj  ;  fiicial,  84. 
Monoplegia,  facio-lingaal,  84. 
Motor  centres,  184. 

Motor  disturbances  in  Graves*  disease.  511. 
Motor-ocali,  tf.  Ocolo-motorioi,  43. 
Motor  point*,  of  arm,  347,  350^  351 ;  o( 

bee  and  neck,  93,  3SS  :  of  leg,  381,383. 
Multiple  neuritia,  387. 
Hnltiple  iderosis,  G16. 
Mnscular  atrophy,  juvenile,  408 ;  pragtci' 

sive.  434- 

Muscular  rheumatism,  414. 

Muscular  sense  in  tabes.  641. 

Musculo-cutaneous  nerve,  lesions  of,  353. 

Musculo-spiral  nerve,  paralysis  of,  344: 
in  lead  poisoning,  347  ;  paralysis  due  to 
snbcuianeous  injeciion  of  ether,  347. 

Musculo-spiral  nerve,  spasm  of,  34S. 

Mutism,  hysterica],  543. 

Myalgia,  414. 

Myelitis,  acute,  465  ;  cervical,  4Z4  ;  chron- 
ic, 467  ;  dorsal.  424  ;  lumbar.  42S  ; 
purulent,  46; ;  transverse.  450  ;  Irans- 
veise  syphilitic,  44I. 

Myelomalacia,  460. 

Myoclonia  congenita,  549. 

Myoclonus  mulliplex.  549. 

Myopathy,  progressive,  atrophic,  411. 

Myosis.  spinal,  46  ;  in  tabes,  633. 

Myotonia  congenita,  497. 

Myxoedema.  525. 

Nails,  falling  nut  of,  in  tabe«,  655. 
Nasal  disease  and  asthma,  119. 
Nerve -si  retching  in  tabes,  684. 
Neuralgia,  cervico-oceipital.  338  ;  cceli"* 
132  1  crura],  369 ;  of  external  genitiii< 


7" 


377 ;  hr»lef  Icil,  5S7  ;  iorra-oiUiat,  69 ; 
inicroottal,  ]6 J ;  lumbo-abdominAl.jbij: 
o(  pKHlitc,  37s  :  qiermatic.  J6q ;  mpnr 
Mbiial,  69 ;  iriccmiiul.  CS  :  of  imthra, 
J78. 

N  curat!  lien  in,  js^. 

Ncurllik,  331  ;  dne  to  aloohol.  jgl ;  due 
to  umte,  389 :  mfe<tioa>.  jSd ;  tnicraia. 
I  )]i :  nodou.  331 ;  maltiplc  ^7 ;  mill* 

^^_     •»  a  idiucnce  of  olba  disruci,  i$$ ; 
^B   afHic,    •/.    PapiliitU ;    puiulcDt,   331 ; 
^^^    iclro-bulbar,  39. 
I        Ncuro-filiroma  plciironiie,  333. 
Neuromii,  331. 
Neuroici.    coiucd     bjr     lightiUDg,    565 ; 

tnoMalic,  jbi. 
Niraiine  pononioj;,  isS. 
Nigin  fokj,  400. 

N7«ugnMi,  53;.  in  Friedmch's  dbcaie, 
441 :  ill  inultipk  tckraiu,  618 ;  oxciUa- 
totini,  S3- 


NUbti 


Obtanuor  nerve,  panljnit  of.  jOi). 

ipitol.  lobe,  loiont  of,  17s,  176;  ncu- 
nlgia.  jjS. 
Onlar  ttmgp,  48,  too. 
Oculo-moaot  Merve.  anatumy  of.  41. 
Ocalo-niMur  parklvui.  cctilral.  46  :    a>iii< 
jikto,    47:     ctiilical.    46;     pciipheral. 
4S  :  rhounialic,  4;. 
CKcuiMilio*  ii«iirow*,  3J(iL 
(KdcMia,  ■ngioacuiottc,  133,  319^ 
(K>v(ihai;itaiu>,  134. 
CK*upliai;iit,  tpahni  of,  134. 
LHfaciory,  o«ittte,  35  ;  ncivn.  anatomy  ol, 
>5 ;  »erve,  li}|icrmili<h>i  ol.  17  ;  nerve, 
cealral  I«>i1im»  of.  3;  ;  netve.  perl|iheMl 
lotion*  olt  37  ;  ncf  vr.  In  tabc*.  frja 
0|ili:halinla  paralytica,  74. 
c^ililhalmnfilqtU.  cxietna,5o;lnteRU,so: 
pnvrc«*ii^  iSt. 
y        l>plk-.  atrophy.  1/.  At mfiliy.  optic,  33 :  cen- 
I  m.  )o  :  chiaim.  sg.  34 ;  nrrvc,  «nal- 

I  uniy  of,  19 ;    ncnc,  diicaw*  of.  jo : 

I  neiiriik  ■"/.  Papillitii ;   neurltt*.    rtlru. 

^^  bulliar,  33:  raidulioo,  anaiomy  of,  30; 
^^m  niliatian.knontof,  35;  lhalamui,1etion* 
j^V    <rf.  I9t ;  Incl.  34. 

Otlta^Komi  of  brain,  39a. 
Oklao-arlhropaihy,  jib. 
L>tiii>  mcilia.  Bi  a  cause  of  brain  abtccn, 
abi ;  w  a  cause  ol  meningiiii,  10. 


OvariAn  hypetxitlieua,  i%T. 
Oiqracoia,  97. 


Pachymrninciiu.  cerebral,  4;  oervicalla 
hypcciiuphica.  317 :  intetiu  hxmur- 
rhagio.  4 ;  tpiaalit,  316. 

FAiDi,  lanciMliof,  ta  labe^  &ts. 

Palate,  innervation  <rf,  I4S. 

Talpitaiiun  ol  the  heaif.  196. 

Paby,  canibi]ieil*lioalikr4rtn.3Ss:  niBhi, 

Papilliiii.  30;  in  brtia  abtcev,  fl6a ;  ia 
brain  mmor,  )■  ;  in  mcotnitiii*,  13 ;  la 
nenropalliic  Jnilividuali,  33. 

Papillu-reliniiifc  3a, 

ParacuHi  Williui.  i>S. 

Paraituxical  coniraction-  433. 

Pinritlmia  in  ttbtf.  tub. 

Parageviia.  10^ 

Paralyiii,  acute  a.<ic«tiitiiag,  466 ;  ■£■!«■•, 
500;  BrowB-Sequaid't,  41^:  boUiar, 
■  53;  ONlital.  185:  glono-labloUotyn* 
seat,  l$i:  |[l<M>»iab*i>>fdiat7n|;ea  an- 
b«»l>i.  350;  hyvlencal,  {48;  tnraiitll* 
ipiul,  4x6;  Laniliy'i,  466;  |M»i-dlph- 
Ihetilic,  146  ;  pteudi>b«lbar,  ayi, 
paeudowliyperirophic,  419;  i|iMlic  tfi- 
nd,  44'. 

Paramyocloout  Muttiplea.  544. 

Panplaeia,  alailc.  443. 

I'aiatitta  of  bnln,  >>$. 

I'anaiim  of  oonl,  470. 

Patkttt  lobc^  168. 

ParkbiMti't  dliw«ie,  ^oo. 

Patellar  relict.  ■*/.  Knee-jerk. 

Palheiknv  aniiony  of.  43 :  kriont  of.  4i> 

Peduncle*,  of  cetebclliani,  9o6 :  of  crrr- 
brum.  301. 

I'erf'iratlni;  nicer  of  ihe  fooU  6j6. 

PcrUttciili*,  313. 

Perimoiiic  eaamlnalioa.  jH. 

rcroiicaJ  panlyiia,  t/.  PopUteal  ntrvs. 
external,  pantytia  <rf. 

relit  Mai,  jBi. 

Itiaryiii.  paralyii*  of.  14S. 

riKink  (laralytit,  116^ 

Itirenk  nerve,  noralcla  oC,  337  :  ptnly- 
ui  of,  3)6 :  >pawn  uT,  3361 

Pla  matrr,  cvreiml,  3:  tplnol,  315. 

PliM«l  ^and,  tuaior  of,  aqft- 

PiirebKottinaccI  MctianK  194. 

Piiuliaiy  body,  tumor  of.  997,  sgB. 

Plaque*  janneh  346. 


713 


INDEX. 


Plexus,  bntchial,  letiooi  of,  340. 

Plexus,  cervical,  mnatomy  of,  331 ;  lesions 
of,  336. 

PlcEus,  lumbar,  lenoni,  sfifi. 

Hexus,  sacnl,  lesioni  of,  37a 

Pneumogastric  nerve,  r/.  Vagoi. 

Points,  lender,  in  inleicoital  nearalgi*, 
364 ;  in  sciatica,  373 ;  Id  trigemiiial 
neunlgia,  6S. 

Pcdio-encepha]itis(Strtmpell},i68;  (Wer- 
nicke), 150. 

PoUomydilis,  anteiior  acuta,  416 ;  chron- 
ica. 43a. 

PotyKsthesia  in  tabes,  647. 

Polydipsia  in  brain  syphilis,  700. 

Polyneuritis,  cf.  Mnlti[de  neuritis,  3S7. 

Polyuria,  in  brain  iy]^ilis,  700;  in  hys- 
teria, sja  ;  in  neningitii,  14. 

Pons,  204. 

Pt^iteal  nerve,  external,  paralysis  of,  381. 

Popliteal  nerve,  internal,  paralysis  of, 
381. 

Porencephaly,  367,  319. 

pMt-diiJitheritic  paralysis,  14S. 

Post-epileptic  phenomena,  57B. 

Posterior  fossa,  tumor  of,  399. 

Pott's  disease,  453- 

Pre-epilcptic  insanity,  575. 

Pregnancy,  ataxia  ful lowing,  670. 

Pressure  myclilis,  453. 

Professional  spasms,  356. 

Progressive,  bulbar  paralysis,  152  ;  muscu- 
lar atrophy.  434  ;  ophthalmoplegia.  15 1  ; 
paralysis  of  the  insane,  6SB. 

1'rosopatgia,  6S. 

Propulsion,  J04. 

Psammoma  of  brain.  290. 

I'seudo-apoplcxy.  321. 

Pseudo-bulbar  paralysis.  15S,  250. 

Pseudo-hypertrophy  of  muscles,  366,  412. 

Pseudo-meningitis,  hysterical,  19. 

Pseudo-tabes  peripherica,  388. 

Psychical  blindness,  176;  deafness,  176; 
condition,  after  apoplexy,  228  ;  in  brain 
tumor,  295. 

Psychoses  in  tabes,  63S. 

Ptosis  47  ;  in  tabes,  632. 

Puerpcml,   convulsions,    594 ;    eclampsia, 

S94- 
Pulmonary  branches  of  vagus,  I18. 
Pulse,  In  brain  lumnr,  29;  :  in  menitijfitis, 

la  ;  slowing   of,  in    lesions   of  cervical 

cord,  414. 


Pnlvinar,  30^  35,  198. 
Pupil,  Argyll  Robertson,  48. 
Pu[h1,  inequality  of,  cf.  AniMCoria. 
Pupillary  reaction,  48 ;  hemianopic,  33. 
Pyramidal  tract,  anatomy  of,  4aa 

Qoadnttus  lumboium,  spasm  of;  385. 
Quadrigeminal  bodies,  anatomy  of,  199  \ 

lesions  of,  aoa 
Quinine  as  a  cause  of  amblyOfHt,  40. 
Quinine  in  H<ni^'s  disease,  loj. 

Radial  paraljtu,  ef.  Musculo-ipiral  peral- 

rsb,344. 

Railway  ipine,  s6i, 

Raynaud's  disease,  4DI. 

Reaction  of  degeneration,  91. 

Rectal  symptoms  in  tabes,  651. 

Recton,  centre  for,  413. 

Recurrent  laiyngeal  paralynt,  I13. 

Reflex,  abdominal,  431 ;  arc,  431 ;  cre- 
masteric, 421 ;  gluteal,  431 ;  patellar, 
cf.  Knee-jeik,  421;  periosteal,  447; 
plantar,  431 ;  pupillaiy,  rf.  Pupiltaiy 
reaction ;  tendo  Achilles,  433. 

Reflexes,  deep  and  EupeiAdal,  431  :  in 
^loplexy,  335,  aa7 ;  in  epUep^.  547. 

Relation  of  cortex  to  skull,  169. 

Respiratoiy  organs,  diseases  of,  in  vsgus 
affeclions,  llS  ;  nerves  of,  118. 

Rest  cure,  567. 

RetropuUion,  504. 

Rheumatic,  acusticus  paralysis,  97  ;  oculo- 
motor paralysis,  45 ;  facial  panlysii, 
B9. 

Rheumatism,  and  chorea,  4S4 ;  muscular, 
414. 

Rickets  and  laryngismus  stridulus.  114. 

Rigidity  of  muscles  in  paralysis  agitans, 
502. 

Rigidity  of  neck'in  meningitis,  13. 

Rinne's  lest,  104. 

Romberg's  sign,  (m. 

Root  zone.  420,  649. 

Ructus  hystericus,  544. 

Sacral  nerves,  37a 

Salivary  secretion  in  facial   paralysis.  Si; 

in  bulbar  paralysis,  155. 
Saltatory  spasm,  386. 
Sarcoma,  of  brain.  390  ;  of  cord,  467. 
Scanning  speech.  6r8. 
Scar,  apoplectic,  215. 


^^^^^^^^^P                                                                                           ;i]          ^^^1 

Scailel  Errrr,  iniit[i|ilc  neudii*  (i>I1owIb(, 

Speech,   centre   fw.   179;    la   doncalia          ^^^^H 

368. 

pouljiicB,   &i)i       dl*iiutiai>i,'e(  of,    r/.           ^^^^^M 

Sdaiica.  3?>- 

Aphakia ;  is  Filedrcivh't  diiicaae,  443 ;            ^^^^^| 

Sciatic  HMvr.  jiaralyili  of,  389. 

in  ibuIii|>1k  itrlerw^it,  t)l9,                                   ^^^^^M 

ScltmdNCtyif .  401. 

SpliiiKtcr^  dl>turlMiicck  of,  la  cunt  <li>-           ^^^^| 

Scicrodcmi*,  ^as. 

ca»ct,  4S1  ;  in  uUa,  652.                                   ^^^H 

HeUtv^  sn  |>tiu|uc».  616 

Spmk  Iiiridn,  473.                                                      ^^^^M 

Sclcrorit,  unyotrophic  Uteml,  447;  com- 

Spinal,  npoplcky,  458  ;  bcfnipltgia,  457  ;           ^^^^| 

hhied  potterior  and  lilcial,  441 :  diflnte 

irriutiuu.    4(13:    Icplomcnincitu.    3x1:           ^^^^H 

ccf^ral.tt?:  cliM('mlni(cd.6l6;  Uteiat. 

inuKiildrBliophy.431 ;  pocliymeniaitMis            ^^^^^| 

^^-.lohat.tttj:  n)u[tlpie,6i6;  poilcrioi 

316;   p«ndy>i\   acote  aKcu<lln|[.  M*>:           ^^^^| 

i|Hnal,  Ai<^ 

panlpii,  tlrofa-SM|uanl'»,  436;  |iat»-           ^^^^| 

^H  SeoliMls  30j. 

iyiii  in  cbildiea,  496 ;  parajyua,  tfiuiic,            ^^^^| 

^KSooUmIi  In  KUtlca,  373. 

^^^1 

^^Kfiooioma,  ccMnl.  39:  AiliioE.  3S  ;  Mmple. 

Spinal  (onl,  aJnccHi  of.  46S  ;  oaalomy  ot,            ^^^^| 

m  ^ 

4lS;  UwhI  9iipj<)xof.4sS;  ooinprewjoa            ^^^^| 

f         Sclmrihfca.  399. 

0^.  43} ;  coDciuuoa,  1/.  Trau*aiic  aoi*          ^^^^H 

'          Sccielion,      anotnalio     of,    in     hytteria. 

loict;    oongcnilal    diseaan    of.    471  ;            ^^^^H 

iM- 

kicmorttiagc    inlu,    4S9 ;    paramci  of,            ^^^^^| 

470;  wftcningof, 4601  ijplilla uf. 461  ,            ^^^^^| 

Senile,  ehorea.  4SH  ;  lorteninif,  Z46  ;  tic- 

lutnort       467.                                                       ^^^^1 

moF.  S06,  61  ]. 

Spondyloithtoorc.  4S3<                                           ^^^^| 

Scnun}',  ■phi'-ia.  17b,  179  ;  oonducilon  in 

Spondylitic  luhcrcnUr,  4S3.                                ^^^^H 

coid,  430;  crou-vty.  199 ;  diiturbaocn 

StMui  epikpliciu,  $93                                       ^^^^M 

»  apopldy,  337, 3iS ;  diilnrbance*,  cgt- 

Siell'Tig'i  tymptocn,  519.                                         ^^^^H 

(ical.  tM;  dliiuibiuicu  in  neurnilhcnu. 

SlcnMBidia.  133.                                                      ^^^^H 

S3o;  diriorbiuicci  in  peripheral  nerTc 

Surao-ckido-auitokl,   paralytb  of,  ijB;           ^^^^| 

l««ioni.  334  ;  in  loho,  (^s. 

ipaam  of,  137.                                                       ^^^^H 

Semilui.  p«ralyiii  of,  34a. 

Strabtiniut,  47.                                                          ^^^^^| 

Senal  fiutclJoni,  diilurbuicci  of,  ik  imii- 

SIriic  alro^icc.  40OL                                                ^^^^| 

mlbcni*,  $30 1  in  tabes.  634. 

Stroke,  apoplecllc.  aiS  :  tn  Mrclxil  ctn-            ^^^^| 

Shaking  paUy.  s°^ 

bollun,  347.                                                           ^^^^H 

Shoulilct-aim  |KiralyiiB,  3^4. 

SueK^lion,  liy|iaollc  A04.                                       ^^^^H 

ShoultltT  muuloi.  pxralyiii  of.  13^  iji); 

Superior  ol>11c]nc  niawlc,  t'h                                  ^^^^| 

tpoKni  of.  i]S. 

Surglctkl  treaiiumt.  of   alitcew,   163  ;    of            ^^^^| 

SlnuUliun  in  epitcpty,  iij. 

tumor,  3n).                                                            ^^^^^M 

Singulla*.  337 ;  in  hyileria,  344. 

Snipeniilon  tmimcnt  in  taltct.  U5.                        ^^^^^| 

^^L  Sinmt  ifaramtMMh,  i;S>. 
^^P  Stnntn,  cctpbral.  l$j. 

Sydenham'^  ilitca'c.  t/.  CliorCB.                              ^^^^^| 

Sylloble-iiluintilin);.  6qi.                                           ^^^^H 

Stilh  nerve,  r/.  ralhelicvs. 

Syncope  and  apopleiy,  333.                                     ^^^^H 

SUb  ffn^lons  in  meningitw,  14,  18. 

Syphilid,  and  dcmcalia  paralyllca,  6^ ;  of             ^^^^| 

SIcKp,  kyuartnl.  34(h 

the  ncrroui.  lyUcm.  700 ;  of  the  >|Naal             ^^^^| 

SlecMMby.  Mb. 

conl,  461  ;  and  labci.  677,                                         ^^^^M 

SIceplcHDrw,  ;io. 

Syphilitic  bull  i»cnin^ti>.  %                                 ^^^^M 

Sincll,  ccnirr  for,  ti ;  diitarb*ncM  of,  16 1 

^phikinu  ol  ktaia,  tqix.                                          ^^^^M 

etaminaltou  ei,  3^. 

^pbitoiMi  of  cord.  468.                                             ^^^^1 

Snheniag,  cercbnl,  </.  EncaphalonulMi*, 

^ringomy«)ia,  471.  473                                            ^^^H 

144:  "tutllpic  foci  of,  349;  tplfiol,  «/. 

SyMem  tliieaH*.  cembiatd,  44a.                                 ^^^^| 

Spiot)  myelomkUiel*,  46a 

Sytf «n  diteaHt  of  the  ipiaal  cwd,  44U                   ^^^H 

Somnaaibnliun,  6ot. 

^^^^M 

Spasm,  bronchial,  iiS:   at  giMiK  114; 

Tab««.  «Ad  alMhotltM.  3Q> ;  donallt,  taq :            ^^^| 

whniory,  3*6. 

|M(«(lo-,3M.                                                     ^^^H 

^^^&MMn«  ntfliuiu,  79. 

Tabetic  foot.  AjL                                                 ^^^H 

714 


INDEX. 


Tachei  cMbmle*,  15. 

Tachfcaidia,  137. 

TRcbjrurdia  itnimosa  eK^tlulmiM,  518. 

Tiiloi'i  cramp,  357. 

lulipet,  in  infantile  patsjr,  tf.  Clnb  foot, 

43B ;  in  external  popliteal  paraljnii,  3S1. 
Tmtc,  examination  of,  loS  ;  diiordei*  of, 

106  ;  disordenof,  in  ladal  paralalia,  88. 
Teeth,  Uling  out  of,  in  tabei,  656. 
Tegmentam,  303. 
Telegraphen'  ciamp,  357. 
Temporal  lobe,  169.    . 
Tendon  reflexes,  tf.  Reflexea,  431. 
Tensor  fascise  lotie,  ipasm  of,  385. 
Tenosynovitii    hypeitiophica    in    wriit- 

drop,  346. 
Terminal  arteries,  91 1. 
Tettlcle,  irritable,  369. 
Tetaoilla,  493- 
Tetastu  intenaitteiis,  493. 
Tetany,  493- 

Thalamnv  optic,  30,  35,  198. 
Third  nerre,  cf.  Oenlo-motorina. 
Thomsen's  diseaw,  496.  . 

Thoracic  nerve,  anterior,  343 ;  posterior, 

340. 
Thrombosii,  cerebral,    245 ;    hdiu,    958 ; 

spinal,  460  ;  venous,  356. 
Thyroid  gland,  in  Graves'  disease,  518  ;  in 

myxixdcma.  515. 
Thyroid  treatment  of  myxoedema,  527. 
Tibia!  nerve,  ef.  Internal  poplileal. 
Tic,  convulsif,  78  ;  douloureun,  63  ;  rola- 

toire,  137. 
Tinnitus  aurium,  97. 
Tobacco  amblyopia.  39. 
Tongue,  alrophy  of,  144  :  hemiatrophy  of, 

144.  C37  1  paralysis  of,   144 ;  spasm  of, 

144- 

TorUcottis,  137  ;  rheumatic,  414. 

Tracts,  of  cord,  430 

Trapezius,   paralysis   of,    13S  ;  spasm   of, 

137- 

Traumatic,  neuroses,  5G1 ;  objective  symp- 
toms of.  563  ;  reaction  of  mu!,cles,  563. 

Traumatism,  in  meningitis,  10 ;  in  tabes, 
676. 

Tremor,  alcoholic,  fifi  ;  in  Graves'  dis- 
ease, 531;  in  hemiple(;ia,  Z30;  hyster- 
ical, 557;  intention,  6l3;  in  multiple 
sclerosis.  61S  ;  senile,  633  ;  in  tabes,  643, 
644. 

Trigeminal,  cough,  76  ;  neuralgia,  68. 


TrigemioDt,  anatomy  of,  $6;  aacitbetia 
of,  73)  central  leiiaat  a(  58;  cstr*- 
ctsnial  lesioiu  of,  68 ;  Intn-cnnlal 
levoDa  of,  61 ;  peripheral  leiioiu  0^  to ; 
nudei  of,  56 ;  panlyni  at,  73, 

Triamiu,  58. 

TroddeaiU,  tf.  Pathetkna. 

TrojAic  distnibancei,  in  apopte^,  931 ; 
1b  choica,  485;  in  hyateia,  553;  U 
•yrinpnnyelia,  473  ;  in  tabes,  655, 

Trophic  uetrei,  397;  genna]  aSectioos 
in  which  they  are  chiefly  implicated, 
51a. 

Trouswau'i  dgn  in  tetany,  493, 

Tubercle,  of  brain,  390 ;  of  cord,  468. 

Tubercular  disease  of  the  spine,  453. 

Tabercuhir  meniDgitis,  9. 

Tumor,  ceiebral,  389 ;  spinal,  467  ;  of 
spinal  meiiii^[eal,  398. 

Twitdilngt,  fibrillaiy,  in  dutmic  mnacnlar 
atrophy,  437  ;  in  neniastlieniB,  533. 

Ulcer,  perforating,  656. 

Ulnar  nerve.  349 ;  panly^  of,  351 ;  sen- 

soty  afliections  oC  353. 
Uppei-atm  type  of  paby,  431. 
Urtemia  and  apoplexy,  334. 

Vagns,  anatomy  of,  no  ;  lesions  of,  in. 

Valleix's  points,  68. 

Variola,  multiple  neuritis  following,  3S8  ; 
myelitis  following,  453. 

Vaso-molor  changes  in  labes.  655. 

Vaso-motor  oervea,  397. 

Veins,  cerebral,  257  ;  spinal,  45S. 

Venesection  in  apoplexy,  23S. 

Vermiform  process  of  tlie  cerebcHum,  205. 

Vertebral  artery,  aneurism  of,  353. 

Vertigo,  99 ;  epileptic,  581  ;  laryngeal, 
101  ;  Minitre'a,  99,  103  ;  in  multiple 
sclerosis,  620 ;  nasal,  76 ;  ocular,  48, 
100  :  paralyzing.  lOt ;  a  stomacho  livso, 
101. 

Visual  centre,  30. 

Visual  Helil,  contraction  of,  in  hysteria, 
S41  ;  contraction  of,  in  tabes,  631  ;  con- 
traction of,  in  traumatic  neuroses,  563  ; 
erroneous  projection  of,  48  ;  examina- 
tion of,  36  ;  sectorial  defects  of,  33, 

Vocal  cords,  paralysis  of,  113;  spasm  of, 

114- 
Voice  in  paralysis  agitans,  503. 
Vomiting,  in  brain  tumor,  39b  ;  cerebellar. 


INDEX. 


;'s 


ao6  ;  cerebral,  i!  ;  in  Graves'  disease, 
Sai  ;  hysterical,  5-14, 

Weir  Mitchell  trealmenl,  567. 
Westphal's  sign  in  tabes,  650. 
While  substance  of  card,  439. 
Willis,  circle  of,  no, 

Wor  l-blindnes-s,  (y.  Psychical  blindness, 
170. 


Word-deafness,  176. 
Wrist-drop,  344. 
Writer's  cramp,  356. 
Writing,  disturbance:!  of,  176. 
Wry-neck,  137. 

Zones,  hysterogenic,  5JI. 

Zoslcr,  herpes.  364,  400. 
Zoster  ophlhaiiiiicus,  69. 


THE    END. 


A  TEXT-BOOK  OF 
GENERAL    SURGERY. 

Br  DR.  IIEKMANn'tILLMANNS, 

PnunMua  m  tiia  I  HivaaairT  or  Laovc. 

VOLUME  I. 

7'A<  Prineipk*  of  Surgertf  atit  Surffiral  Pathology.  Orttrnd  #«/<■ 
gnverMiitg  Ofentliaiu  u/id  Ihf  Ap/ilifiili-m  of  tfrrtuiitjf.  TraxMlatciJ  fmai 
the  ifaini  (l«miuii  i-rllil'in  by  Joay  Ituotiw,  Jl.  D.,  and  Bvua*ui  T.  Tiutiw, 
U.  D.     Wtlh  Ul  JUMtrali««*. 

VOLfME  II. 

Itftjional  Surijfry.  Tnuislal«i1  from  the  fooHh  Oomian  mlltlMi  by  IlKMiatii 
T.  TlUIoN.  M.  I)..  N««  Ynrk.  With  flT  lUutlrxiliM:  VA^icA  hj  Uwu  X. 
Snxxm.  U.  I)..  Protmwr  of  Siincvry  Id  ihn  N««  Vtifk  I'niivnliy. 

VOI.rMK  111. 

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1'.  Til.T>>,v,  M.  P..  Xcir  Ynrk.  ITt'A  Xf'  llliMralion*.  VMtnl  by  Lkwin  A. 
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S^'wimiT,  w  pmcDtB)  In  lh«  pnaent  roJamc^  b  » truulaUoa  vf  bb  worko  "n  'luiaaM, 

tnu  ToluiiUM.  lb*  Kvnml  uf  aliicli  aill  bkiii  ba  en  |'n>«. 

V>itB>a  I,  llivnui.  (InsbNar  ar>  tlrmicju.  PAtuoumc,  1«  lupcly  ibratMl  latW  Mtv- 
■tiln*)  iif  til*  »«cMi*l  ntiMiplai  wbloh  vuilnrUe  •  mIUI  aunrlol  •tnivluN  Tbb  >|>|-aK  ih4 
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larttmiaara.  aft*r-lra*UiiMit,  and  the  Miolnirj.  ratbtJugy,  aii<l  tniiliiMll  or  the  vukua 
auritifal  dbwi>. 

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THE   PRINCIPLES  AND  PRACTICE 
OF   MEDICINE. 

Designed  for  the  Use  of  Pivetitiojters  and  Studentt  nf  Medidne. 

By  WILLIAM  OSLER,   M.  D., 

Pdlnrsf  ibeRoyilCotlinof  PbyridaB*,  LaWloe;  PnfMWt of  Uedicne m ds  JobM Bnlom Onha- 

•in',  ud  Phyudin-in-Cbicfof  nu  Jolmi  Hopkiu  HiMfriad,  Buliiaar*;  fccmcrif  Fnicaior  tf 

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M-EDICAL  GYNECOLOGY: 


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A  TREATISR   ON   THE   DISKAStS  OH   WOMEN 
FROM  THI=  STANUfOlNT  OF  THE  PHYSICIAN. 

By  Alexander  J.  C.  Skene,  M.  D., 

of  CynttcAogy  in  Ihc  Lona  Itlmd  CqIIck^  Hn>piU!.  B'ooklyn,  N  Y. ;  (v- 
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Ion  hiKlily  apptcciaictl.  riiit  work  coinmendi  iitcll  nol  ouly  in  (lie  gcnen]  mm- 
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"  In  lh«  npid  >ln*clo|>ineni  of  evnecolo^^y  duilng  recent  yean,  the  Mrsical  nde  of 
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ncKlevI  from  «  mcilud)  tUnil|Kiitit.  Thi*  ctccllmt  aildilion  to  the  tilemurE  (if  meJ- 
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heredity,  lexuil  typci.  and  functionn  are  dtMiibed  al  Icngttt  All  ibc  (anciloaial  a«i9 
oricanic  dttorden  peculiar  lo  women  are  dlicuueil  In  an  cKC^ptlonatlf  rational  anl 
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THE  DISEASES  OF    • 
INFANCY  AND  CHILDHOOD. 

For  the  U.te  of  StiuienU  and  Practitionere  of  Medicine. 
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^'  TKis  ni;i;niti<vTit  wrrk  i-  otk'  of  ilie  m-'r^t  vahxabk  rewQt  contributions  to  niedioil  tit^^r- 
aturi'.  It  will  rapi'Uy  win  its  wny  t"  a  fmiu  r.uib  tritb  I'tlivT  st^uidird  w  ■rt-.  upon  kindn-d 
:«iihjivtf.     It  is  UP  Dearly  i^>iii|'!i-ie  aa  ii  trv^atL^.:  u|koij  thb  subjrct  cao  be." 

Virpaia  XediCAl  Semi-ttoatlily  : 

'-  WIkii  I'oi;  n.\-ji!r  ir»-  itMi'liinpi  oi'  a  dniid.>  ■■r  tw,.  aif"^  snd  pimparts  the  inculcati'ini 
ot'  tc-il;iv,  he  i\.u  M.ii!\T'y  lulp  rix^^yrniiiiij  tliut  ■  ■>'.il  IbitL,-^  hav#  p«MAJ  away,  and  all 
tl;iiLj>  lull-  (■■■■■'Til'  mn.'  T\v  v.>liiiih>  Ivlorv  it'  L-  pnt'tieally  the  ris>ird  ••(  infomiati.in 
oK-..t;ii.J  '>>  lUe  a.i:h  •!  I'rotii  eiiton  vear*  ■■!*  sivi.il  fruJy  and  pFaotiw.  ?o  that  nearly  eitrj' 
J  .i>jt.t  i-  |rv-.:;:..l  fnii,  rh  ■  -iaiid|i.>!in  oi  iviv.i-i»l  .^K-en-fltion  and  eipericnee.  TJjf 
iiif-Tiiin'i  ■!!  .-ii,-'i  •'  tli.n-fTi-  rv!i.il>',e.  1"t  |ir.  U-''X  i'  a  >-l>>*e  oliwrier  and  a  careful  jtudenl 
of  111-,  div  t  ^'1,"^' "1  V  ,  -  .  l:i  ^ln'rt. '"ri!^  S-'l:  .ipT'car.  ti^  u*  t'' Iv  the  U-ii  all-r*'und.  up-ln- 
,irti-  !■-■»  lor  i'rj.,':iti  ■iK-ri  ai;.l  siuJiuti  'f^'LilJ^;!'*  iii-ca.-i.'s  ib»t  wc  ku-'W  olV 

MedicnJ  Progress: 

"  Tho  Wi.^rk  ^vT^'-re  ".:*  N  ."'nf' TiTu.-h  rv:!e\':*  _"^ir  er^ili*  u-^^n  tb^*  dttininiished  aullThf. 
Pr.  ll^"'^:  !::»*  l-'-ir  'ki.!i  k!i^«!i  ;u  a  ni  *^t  :n-i;>'rl  115  ii;d  ni:;i-:akiQi7  invft.iii.'aT.jr.  an<t  in 
'i:i^  vo/jiiie  hi'  5':#'.jl:i-  :i  a:  r<-p:itLiii''D.  Thv  w-Tt.  we  may  say  in  a  a'nleniV.  i&  fully  up 
to  -.tv  rr  i,;!tvn;i;;r*  ■  (  i'..<  :;ii.<-i.  an  I  ihen.  :?  r.  ■  advicce  bn-wn  t>  f*diattii3  nhieli  iias 
■.■A  'riiii  t_l:>-  dealt  »;'.h  a,v-rd;:ij  !■■  :;?  n!.-r.:-i." 


D.    APPLETOS   AND  COMPANY.   NEW   YORK. 


April,  m». 


^iEDI 


AWD 


HYGIElSriO    WORKS 

D.  APPI.E70N  AND  COMPANY.  72  Fifth  Atrnnr.  Nem  York. 


ACl.DE  (JOEIN).  Tilt'  Fockct  Phkmacy,  wllb  Tli^mitfutk  loihx.  A  rUvmt 
of  ibo  Clinical  A|>iillc-*tloua  of  liritwdko  ni)np(i<l  lo  ()>r  I'lKkrl-raw,  fur 
tli«  TrnatuieDt  of  fUiiergracien  aDtl  Ami?  liti<«»«ii.     ISmo.    Clotli,  |2.0i>. 

KARKKIt  (FORDYCE).  On  ::»<ui-8)vknow.  A  PopuUr  Tnclia*  l»r  Tnt>»lor* 
■nd  tl'i.-  Guoural  RwuU-r.    Siiull  Itino.    Clotli,  TS  cent*. 

HAKKLIi  (FUKDYCK).  On  Puurporal  DiMwa.  Olinica)  I^lorM  d«liv»r«d  It 
B«t)rt  ue  llcw)>iul.  A  Couna  tit  Lecture*  rn]uabl«  alik«  lo  tli«  8udwt  ud 
tll«  f  rnofitiutiiT.     Tbiri]  MliliiMl.     Svo.     Clutb,  f^.OU  i  thi^ti,  $C.(W. 

UAKTHOLUW  (RIlIIEItTS).  A  TimIIm  oo  MaUriit  Uttlicn  iml  Tl<er»|mHin 
Mfllh  fdlllM.  Rifti^cil,  enUrirad,  and  adajiUdlo  "Tli«Ncw  I'lurmBCOpob. 
8»o.    Cloih,  in.iHi;  dIm'p,  |il,DO. 

BAKTIIOI-OW  (rtOBKI{T8>.  A  Truitiw  on  t(.«  rrttclioe  .>f  MmJIoIb..  fur  Ibo 
Uiir  [>f  Hliidi'nU  luicl  I'mi^titioner*.  tetMlb  HIHm,  rnvixil  and  riiUrgad 
evi>.    Clulh,  in.UCt;  Khecp,  (o.oa 

BAKTIIULUW  (ROBI^:i{TS).  Oii  tU  ADbiKtinUiii  IwtwMn  ll»dIoln««  «»•!  U- 
I«r««i)  I{«iuv<liri>  anil  Diiciuu'i.  Uciog  the  C'Hrtvflght  L«rtur«a  for  Um  Yoar 
imo.     Svo.     Ululh.  il.ii. 

BAOTIAS  III.  I-'IIAKLTOX}.  i'anilin*:  CccebrBl,  Biilliftr.  idiI  Spinal.  A 
MhouhI  uI'  I>in|;uu-i«  tor  Stwlvnli  and  PraolltiMicro.  With  ISS  [llii>lrM- 
IMDH.    Sinall  Avo,  STl  |<aitc*.    Clulli,  (1.041. 

BA&TIAN'  (II.  C-1IARI.TOX).  ParalrsU  frtun  Hrain  Dimam  in  ita  CoianKb 
Kmhih.     With  lllnnlrHtioiM.     ISmu,  S40  |>airr«.     Oolh,  $1.79. 

BILLKUTII  (THKOIlOlii.  Cmwrnl  Sargiea)  Palliolw  and  Tberapomlri.  A 
T«xt-Buok  for  Siodcnta  and  l*h7«lciuH.  TrtMlatad  bvn  lb*  t«iitli  iirmian 
e<]lt>ua.  bv  ^|>l^cin)  piriiiiiBioa  of  th«  iinthor,  bjr  Chtrl<«  E.  llftokU;,  U.  I>. 
nru  Imritaa  *dlU«*.  r*>lw4  ant  falannd.    «vo.    Clulli,  9A.00;  atiwfi,  (COO. 

ROYCE  (ItlRKItT).  A  r«i(-Book  ot  Morbkl  lll.ioWv.  For  Madeota  and 
I'rartitioncrs.     Wiib  1:m  Culurul  IUittiraii<iB«.    Ctulh,  |T.AO. 

IIRAUWKU.  IRVROM).  Dt««««a  of  lb«  Heart  ami  Tbonrk  Aorla.  Illu<» 
iratcd  wiih  -.■><!  Wool-Enffrariiig*  and  69  Utboarapb  PUto— aliowiiiic  01 
rtgur«»— in  all.  SIT  lllnatrallon*.    »ro.    Clirtb.  I9.U0:  alMep,  Itf.VO. 

KKYANT  (JOSEPH  D.l.  A  Uanaal  of  OprraiiT*  Sarirrrr.  Km  lAOaa.  mlir< 
aad»lancf4.     TM  lllualntion^.     Hvn.     CloUs  lA.OO ;  tliMp,  |«.M. 

BtntT  ISTEi'liEN  S.y  Exptoratioa  of  th«  riif.i  in  )l(«lih  ami  1Mww«l  •«•, 
SIO  paiRs.     With  llln>trn(ion*.     Clolh,  (LAO. 

CAUPBEI.L(F.  R.J.  Thi-  UnRuaRc  of  Mnlirin*'.  A  Uabual  irl  ring  tlia  Oriel  a. 
KtvtnotoKT.  PrunuucinlJon,  nnd  MiniiiDi;  of  tli«  Yeiliiiical  Temil  funad  la 
Ucttical  CtMfBturo.    8vu.     C]o|b,  fS.W. 


OABMIOHAEL  (JAHEB).  DImms  io  Obfldre^  A  Haand  for  Btadento  ami 
PractitioDen.  Ilinstnited  wtth  Thtrt;-oM  Cbarta.  12mo,  BVl  pagw. 
(SfCDUiTa'  Sune.}    Olotb,  tS.OO. 

CHAUVEATJ  (A.).  The  Companitive  AaaXomj  of  tlie  DranMtlcatod  Animab. 
ReTiwd  and  eDluged,  witL  the  co-operalion  of  8.  Arlolng,  Diraetor  of  tiM 
Ljons  Veterinarr  Bcbool.  Beoond  KdrII*)!  edition.  TraaNated  and  adited 
b;  George  Fleioinp,  O.B^  LL.D.,  F.R.O.T.S.,  late  Prbu^  Taterinar? 
Bargeoo  of  the  British  Ann;;  Foreign  OorreepondiDg  Member  of  the 
8ooi6t£  Boyale  de  Hidedoe,  tai  of  the  Bod&fi  Rorale  da  HMedne  Fnb- 
liqne,  of  Belginm,  etc.  Hto,  lOSi  pages, with  580  lUanrationa.  Cloth,  $7.00. 

OORNIXQ  (J.  L.}.  Brain  ExbauatJMt,  wHh  iocdo  Prettmloai?  Conilderatioiif 
on  Uerebral  Djnaotica.    Grown  8ro.    Ctbtb,  (9.01). 

OOBNINO  (J.  L.).  Local  Anmtlieda  in  General  Medlcineand  Bormn.  Baioft 
the  Fractica]  Application  of  the  Aittbm''a  Keoent  IHsoonriBa.  With  lilna- 
trationa.    SmaU  8to.    Cloth,  $1.86. 

CmtBIEG  (ANDREW  FO-  Tlie  Menopauae.  A  Ooasldaratioti  of  tha  Phe- 
nomeoa  which  ooonr  to  Women  at  the  Close  of  the  Ohfjd-bearing  Period, 
with  Incidental  AIIobIodb  to  their  Relationship  to  Heaatmatlon.  '  Also  a 
Particular  Conaiileratioa  of  tlie  Premature  (especisllj  the  ArtifitAsl)  Hcno- 
psnse.     ISmo,  asi  pages.    OloUi,  |8.00. 

TtATIDSON    (ANDREW).      Geograpbioal  Pathologj:   Aa  Inqniry  into  the 

Geographical   Distribatlim  of  Inactive   and    Climatio  Dissasn.    S  vols. 

Svo.    Cloth,  $7.00. 
DEHOH  (£.  B.).     DiMuses  of  tbe  Ear.     A  Text-Book  for  Praotltfoaara  and 

StndeDta  of  Hedidqe.     With  8  Colored  Plates  and  IBS  lUoatratioas  fn  the 

text    8to.    Ctoib,  tO.O0;  sheep,  (6.00. 

DEXTER  (FRANKLIN).  Tbe  Anstomy  of  the  Peritonanun.  ISno.  With 
89  culored  UluiiraUons.    Oloth,  |1.S0. 

DOTY  (ALVAII  II.).  A  Muoaal  of  loBtruciiun  in  the  Principlea  of  Prompt 
Aid  to  tbe  li^urcd.  IneludiDit  a  Chapter  on  Hygiene  and  the  Drill  Regala- 
lions  for  the  llo8[)ital  Corija,  C.  S.  A.  Designed  for  Uilitar;  and  Civil  Dst. 
Second  cdiUsB,  reiteed  Hd  eilirged.     121  I  Hast  rations.    t2aio.     01otU,¥1.50. 

ELLIOT  (GEORGE  T.).  Ohstttric  Clinic :  A  Practical  Contribution  to  theStndir 
ot  ObatetricB  nud  the  Dijeaaes  of  Women  and  Children,    8»o.    Cloth,  t4.6tf. 

EVANS  (GEORGE  A.).     Hand-Book  of  Bistorical  and  Geographical  Phthisi- 

ology.     With  Special  Reference  to  the  Distrihation  of  CcmanmpUon  in  tbe 

United  Stalea,    8»o.    Cloth,  |2.00. 
EWALD  (0.  A.).    Lectures  on  the  DiBeasea  of  the  Stomaoh.     B7  Dr.  0.  A. 

Ewald,  Professor  of  Pathology  and  Therapeutics  in  the  Cniveraiij  of  Berlin, 

etc.    Translated  from  the  German  by  special  permipsion  oF  tbe  antlior,  b; 

Morria  Manges.  A.M.,  M.D.    Sttend  mUUm,  rcfbed  uul  narfasgc4.    Cloth, 

$5.00;  ahoep,  t'l.OO.     {Sold  only  by  »vh»criplioa.) 
FLINT  (AUSTIN).     Medical  Ethics  and  Etiqaette.     Commentaries  on  tbt 

National  Code  oF  Ethics.    ISino.    CJoth,  60  cents. 

FIJNT  (AUSTIN).  Medicine  of  the  Future.  An  Address  prepared  for  the 
Annual  Meeting  of  tbe  British  Medical  As^ciation  in  188G.  With  Portrtii 
of  Dr.  Flint.     J2mo.     Clolh,  $1.00. 

FLINT  (AUSTIN,  Jb.).  Teit-Book  ot  Human  PhjMologj;  designed  for  the 
Use  of  Practiticnera  and  Ktudents  of  Medicine.  Illustrated  with  three 
hnndred  and  sixteen  Woodcuta  and  Two  Plates.  Fearth  Miltlaa.  nTlK<> 
iKperisI  Svo.     Cloth.  $6.00 ;  sheep,  $7.00. 

FLINT  (AUSTIN,  Jr.).  The  Physiological  Effects  of  Severe  and  Protracted 
Muscular  Exercise;  with  tipecial  Relcrence  to  its  Inflaenoe  npon  the  Excre- 
tion of  Nitrogen.    12mp.    Ulolh,  $1.00, 


3 


FLINT  (AtlSTiy.  Jh.).  The  S<Mir«e  of  MiiMutar  Power.  Afv-umt'iiU  tad  Ooa* 
(Jdwook  drawn  frara  ObMrvattoo  np<ia  tli«  lluriiaii  SiiliJ«ci  itDiUr CuodiUan* 
ol  ]to*t  and  of  Muooular  Ex«ralw.     ISmo.    Clolb,  tl.iKl. 

F14NT  (AUirriN,  Jr.).    PbjaloloKy  of  Uaii.     D«^)[B«d  lo  re|ir«MBt  111*  Eilil- 
iogSlatoof  Flijni>loai«il8cHiiMa»a|iplMd  U>  Uw  PaDcliunaof  Iho  Iliunna 
Hndy.    CoRipl«t«  in  S  vol*.,  tlva.    I'«r  vol.,  eiolh.  |4Jl>;  abaop,  fa.DO. 
*,*  Vota.  1  >oi)  11  can  be  liad  in  diitli  an'l  ulit^p  tiiiidin]! ;  Vol.  Ill  in  alit^p 
onlf.    Tol.  IV  Is  mt  |>r<MDt  out  of  print. 

FUMT  (ADSTIN,  Jr.).  UbhiuI  of  Cbominl  Eiuniauiou  of  the  Urine  III 
DIlMii;  villi  Uriel  Direction*  fur  tlia  KxoinlDadon  of  tlw  roost  Com nou 
TaHMlM  of  llrinarr  Calculi.     ICevWd  «ditloii.    Uino.    Ooth,  $l.0<>. 

I-'USTER  (FRANK  P.).  IllgalniUd  Eii<'7duf>icJi«  Uedlcal  Dlviioiiar;  :  lhln< 
»  IHutionarT  o{  Iba  Tecbnini  T«rtiia  ni>«J  hj  Wrilara  ixi  Mnlivino  ani)  lti« 
Collalvrnl  .'^cifiiroi  in  the  l^tin,  EnglUli,  FroitcK,  aixl  (irmitn  ljuiKiia|t«a. 
Th«  work  i.on«i>t>  of  Four  Volnmvn,  and  i*  hiIiI  la  Part*;  TtirM'  Pari*  10 
a  VolaiBO.     {Sold  #nfy  by  nib*eriplion,i 

FOSI'ER  (FKANK  P.).  A  KcfrrcncrUo'ik  of  Prw'ti.al  TherapMlica,  bj 
tarluu*  writers.  In  Two  Vulacnc^.  Eilitvd  liy  Frank  P.  Fo>l«r,  H.  D^ 
EdlMf  at  TIk-  N«»r  York  U«(licnl  Joiironl.  Ctotli.  i&  >V ;  tfacep,  t«M9; 
lialf  morocco.  t<.5(i,  <'aoh  vutume.    (.SdM  ottlp  Ay  mbterij'tic*.) 

FOtlRNlER  (ALFRED).  Svpbllia  aixl  UarrlaM  Tran«lal«l  b?  P.  Albwi 
Morrow.  U.  D.    8vo.    Ulotfa,  $S.OD;  Bti««]>,  fSM. 

FKIKDLAN'liKK  (CAUL).  Tb«  V-*  of  il.o  HW<3M0|)«  In  Clnictl  and  Patbo- 
Ii>i(ic«l  Euminnlitx)*.  Hecood  tolilion,  «nlnn{«]  and  inprovod.  with  ■ 
Uliroiuulilliufiruph  Plui«.  Trnn<liit(4l,  »itb  lh«  ponniaMOU  of  tli«  Kulbor, 
by  Henry  C.  tVw,  M.  D.    Stv.    CU.lli.  f  1.00. 

CUCIIS  (ERNEST).  Tcxt-ltuok  of  Oi-Mbalniolofcy.  By  I>t.  Krn«M  Fuolu, 
Proftwor  of  Oiihtlialniolofcv  iu  tlic  I'liivcraity  of  Vienna.  With  178  Wood- 
cola,  Aolhomcd  iraniilalioo  froni  the  Mooud  ^nlar^ed  and  linproTcd  Ger- 
I  edition,  by  A.  Duan«,  U.  I>.     Clulb,  in.Uii;  eUvtp.  $0.00. 


QARMANY  (JASPER  J.I.  Op6raiit«  Miiriwry  on  the  Cadavff.  Wilb  Ttro 
Color»d  Diairraiiia  »bowlDg  Ibe  Collawral  Circalatlon  after  IJ^turM  of 
Arteripa  of  .\rni,  Abdoinm.  and  Lowor  Extrvmily.  Stnall  8*0.  Clolb, 
9S.00. 

UERSTER  (ARI'AI)  <!,).  Tb»  Rnl«>  of  Amtptio  anil  Antbcf>(lc  Sursory. 
A  Praotitwl  TrMiliM  f»r  (lifi  r«e  of  t*tudeot*  and  lUo  (ieiMtral  PnudtloMr. 
UlnatrM«sl  wilb  uwr  two  liundro)  1I110  En|:ravitt)!B.  8vo.  Clolb,  fO.OO; 
ifa««1S  tS.DO. 

UIBSON-RrsSELL.  Ph>MPaI  Dlagoofis:  A  Cable  to  Uptbod>of  CMsImI  la- 
*«atifntion.  Uy  O.  A.Ulbf^in,  M.  I>..  ad4  ffltUaoi  Riiawll.  )l. l>.  H'itb 
lot  llIiMtratioii*.     I4mn.    (STiii>ii.vi^'.>iR>ini.)    Clolb,  |d. 00. 

HOrLET  (JOHN  W.  S.).  IHmmmoI  U.o  TrlMry  AppBratn^  Part  L  Pbla*. 
maaie  Afle«tion*.  Hoine  n  Serira  of  Tw«'lvi>  [.•■cturf*  dolircrvd  ilarlDfftiM 
aotnnifi  of  ISSI.  With  mi  Addrnduin  on  RplaniKW  ttt  Drtne  from  no- 
■Ulle  Obatmetion  in  fcldcrly  .M«o,    Clolb.  |I.M. 

GROSS  rSAUUF.L  MfX  \  PnoUral  TrMliw  on  Tnmon  of  tke  UUBiaaiT 
UUnd.     Illii*trat*d.    Sro.    ClolK  $3.ni>. 

ORrBER  (JOSEF).  A  T«i:-Book  ..f  ilio  hWoFH--  »r  ibe  Ear.  Trvndalwd 
fraiB  Ibe  *fyM>tii1  (li'tiunn  nlittim  l>v  >Tipoial  pcrisMslon  of  tlia  aiitbor.  and 
•■lllvd  by  l%d<>'iir.l  Uw.  M.  I>.,  mid  CoWman  Jewrit,  U.  I>.  With  IAS  llliu- 
tratiiKia  and  70  C<>)i>rv<l  Ki^'irv*  tin  Two  LitbograpMo  Ptatirm  8vo.  Olotli. 
|4.ftO :  «litte]>,  $1.M. 


a^KUOKt)  (V,  A.).  A  TmtiM  on  DiNnw  Of  tli«  Karvom  Bjttaa.  Vltb 
tbft  OoUamwatlon  of  Orawie  Vi  Hammond,  K.  D,  WttJ^ono  hiadnd  and 
okhteen  inaatrattoDS.  Sktk  tdUn,  with  comodoBB  imil  addillmu.  iwn. 
(Ml),$5.00;  aliaep,t6.00. 

HAMMOND  (W.  A.).  A  Treatbs  on  Iiuanitjr,  tn  Itt  Maffloal  BdaUoBi.  8*0. 
Olotb,  95.00;  ibnp,  |8.00. 

HAMMOND  (W.  A.).  Olinioal  Leetaraa  on  DlaiMna  of  tha  Nanooi  Qraton. 
DoliTDred  at  Beltenio  Hospital  Mo^oal  Ooll^.  Edltod  hj  T.  M.  K.  Oroaa, 
M.  D.    Bto.    Oloth,  $8.60. 

HIBT  (LUDWIG).  The  Diseae^B  of  the  Nervous  S^steiii.  A  Teit-liooh  for 
Pbjridana  and  Btodcnta.  Transkleil,  witli  permission  of  the  AiithiT,  by 
AtignirtHooh,  M.D,,  aasiateil  by  Fnink  R.  Smiih,  A.M.  (Cantab.).  M.  D., 
Aaaittant  Phjdriana  to  the  JoIids  Hopkins  Tlo^pital.  With  on  lotroditv- 
lion  hj  William  Osier,  M.  D.,  F.  K.  V.  P.,  Professor  of  Medicine  in  the  Jobna 
Hunkins  Dnivt-rsItT,  and  Pb^Bicinn-io-Chiel'  to  the  John^  Hopkins  HdaiiitaJ, 
BuMmore.    8to,  671  pBgea.    With  1T8  lllastrations.    Clotb,  $.1.00  ;  sheep, 

'HOFFHANN-ETLTZaCANH.  Aaal^U  of  tbo  [Trioe,  v^  Sp«dal  Batonn 
to  DiaesMB  of  tha  ITrinarj  Apparataa.  Bj  M.  B.  HoffnMm,  Frofcaaor  in 
the  Uulfanltj  of  Qrita,  and  S.  UHanun,  Tatar  in  tha  UalTWii^  of 
Tienoa.    TIM  aAllM,  miMl  ui  tUMftL    Sro,    Olott,  >9.0b. 


HOLT  (L.  EMUETT).  Tha  DiMBsn  of  Tofanor  and  Childhood.  Bro.  Oloth, 
9«.00 ;  aheep,  $7.00 ;  half  moraooo,  |7.60.    (Sold  tnlf  ty  mOKriptiom.) 

HOLT  (L.  EMMETT).  The  Oara  aod  Faediog  of  Ohadren.  A  Catoobiam  for 
the  Uie  of  Motbera  and  Ohlldran'a  Nnrara,     Iflmo.    Goth,  SO  eeitta, 

HOWE  (JOBEPB  W.).  Emei^ndei,  and  how  to  treat  tfaem.  Foortb  editioo, 
reiised.    8vo.     Clotb,  99.S0. 

HOWE  (JOSEPH  W.).  The  Breath,  and  the  Diaeasea  nbioh  give  it  a  Fetid 
Odor.  Witb  Direotions  for  Treatmeni:.  Hecead  cdHleB,  revised  and  corrected. 
12mo.    Olotb,  tl.OO. 

eOEPPE  (FERDINAND).  Tbe  Uetbode  of  Bacteriological  Inveatigation. 
Written  at  tbe  reqneat  of  Dr.  Robert  Eoob.  Tranalated  bj  Hermana  H. 
Biggs,  M.  D.    Illastrated.    8vo.    Oloth,  fS.GO. 

JAOOOUD  (S.).  The  Curability  and  Treatment  of  Pulmonary  PhtbUis.  Trana- 
lated and  edited  by  Montagu  Labbook,  H.  D.    Svo.    Oloth,  |t.O0. 

KEYES  (E.  L.).  A  Practical  Treatise  oa  Genito-Urinary  Diseasea,  inclading 
Syphilis.  Being  a  new  edition  of  a  work  with  the  aame  title  by  Van  Baren 
and  EeyeB.  Almost  entirely  rewritten.  Witli  Illnstratione.  Sto.  Olotb, 
$S.OO;  sheep,  tS.OO. 

EETES  (E.  L.).  The  Tonic  Treatment  of  Syphilia,  including  Looal  Treatment 
of  Lesions.    8eMBd  edlUto,    8to.    Olotb,  $1.00. 

LEGG  (J.  WIOKHAM).  On  the  Bile,  Jaundice,  and  Bilious  Diaeoaes.  Witb 
Illustrations  in  Ohromolithograph;.    Svo.     Clotb,  $6.00;  aheep,  $7.00. 

LOBING  (EDWARD  G.).    A  Teit-Book  of  Ophthalmoscopy. 

Part  1.  Tbe  Normal  Eye,  Dotermination  of  Refraction,  and  Diseases  of  the 
Media.  With  131  JHustratious  and  4  Chromolithographs.  Svo.  Buck- 
ram. $6.00. 


LllRlNO  {KDWARIi   G.)-     A  T«xt-Hook  of  OfilitbnlinoMOpr. 

Pan  II.  IiWsM-^  i>l  ilin  ItplJna,  Optic  Nrrv«,  ud  Choroid:  tbeir  Vuli> 
(^«  ottd  Oiinplioationii.  Tliv  iiiaiiaMTipl  <>l  llii*  trolnmr,  whkb  ihe 
aathor  HnNbvd  jiisl  |>ri<ir  to  liii  ilrAtb.  Iiu  lw«n  thoraaff My  edited  antl 
rsTiaei]  bj  I'.  B.  Luriuji,  M.  U.,  of  WaaliingUw,  D.  <X,  vid  U  bow  ImwmI 
in  lli«  «aiiie  t'ljlu  ai  tlie  Drat  valaaic  rroftiMly  UluMnud.  Put  ]l. 
baoknm,  f^.OO.    Two  Parta,  buckniu,  110.00. 

LUSK  (WILLIAM  T).  Tb«  ScImm  sikJ  Art  of  Mldwlfwr.  V||b  94<  llliiatra- 
Uoiia.    I'Mrtli  Mllt«a,  rrilttd  and  faUnpA.    8to.    Ctirth.  $0.00;  abtvp,  tS.OO. 

UAKCY  (lll^NKY  O.).  T)ie  Aontotii;  m<l  Sureir^l  Ticatwi-nt  of  lUrsLa. 
4to,  witti  nbixit  alil7  fall-pngo  llftllvl;|i«  and  LltljO(;r«|iliic  KeprKxIiKiiitifiB 
from  tlt9  Ulil  Uaatcra,  and  nnnteroa*  lilaslratkmii  iu  ih«  Teil,    (SrU  «nlf 

MATHEWS  (JOSEPH  U.).  A  TreUUe  on  DlaeMfa  of  tbe  B«rliiiii.  Aon*. 
and  ^igcnoiil  FI«xaro,  Hvn,  WItK  *\x  OliroraollthoKranha,  juiil  IMnatra- 
tliiD*  lu  the  tvxu    SrtMd  r^ltlM.    {S^d  mljf  ly  lU^HptUn.) 

UILLR  (WESLEY).  A  Tvit-Hook  a(  Animal  VUjtMogj.  wHh  Inlnxliietor; 
ObaplM*  on  (ientral  Hiologf  uitl  a  full  TreMOMBt  i^  RapriMlBCtlMi  for 
0tM«iU  of  Honian  and  Oo(ii]Mmive  HadMiiew  Wu.  With  BD6  Iltsitn- 
lian*.    CloU),  tS.OO;  stieep,  fl.OO. 

HILLS  (WKSLEY).  A  T»l-BM>k  of  Compniniive  l>bTrii>|pirr.  For  SndaBia 
and  PrBctitioom  «(  VetvrlDarj-  MmIIoIbo.    Soutll  Svo,    (^^olll,  $8.00. 

MUKKOVr'  (PKIN'Ce  A.).  A  Ajiu>m  of  (lenilo- Urinary  DI*«mm,  HrpIitMoffv, 
and  Ilcnnulolog;.  Bv  ywioiM  AutlK>n.  Id  Three  Volume*,  lieauliAiliv 
Uttturai«l.  VuJ.  I.  UenlhKBiiBBrjr  Dlteatw^  Vol  11.  iffiibllographr. 
Vol.  III.  I)ennBUil..|ir.     (StIJ  »»tg  if  ni*erlftta».) 

THE   NEW    YOItK    MEDICAL  JODRSAL  (Weekly).     E<lited  l.j  Frank  P. 
Fo««r,  H.  D.    TertDt,  $J(.OI>  per  aaoDPn. 
BiattlOi  Caae*.  ctotb,  60  centa  each. 

"Seir-Rlndcr"  (Uim  U  uMd  for  umporary  btBillng  only),  90  centi^ 
OnuAL  iKbsx.rrom  Apr4l,l8U,toJtiBo,  l8;S(t$Tala.).   8ro.   Cloth,  10  eta. 

NIEMEY'ER  (FEMX  VOX).  A  Text-Book  of  PrM)tl«Bl  Ifedkla*,  with  partlon- 
lar  rcfercoca  to  PItTiioIoify  noi)  rmholnnical  Anatomy,  OoBtatnlng  nil  Ibi 
Bntbor'a  Additiunii  aud  Kwii'iDiis  in  tli«  eifthth  aail  laet  Oernu  etillMk. 
Traaatattd  by  Ue»nt«  II.  llDoipbruya.  M.  U.,  and  Cbarl«B  E.  Rarkl^y,  IL  P. 
Irol*.    Bro.    Cloth.  )».00;  ilieep,  ttl.OO. 

IflGUTINOALE  (FIX>RENCE>.     Note*  on  NnrMng.     lino.     CSolh,  70  cent*. 

OSLER  (WILI.IA  M).  Leolore*  on  Aofint  Pertorii  and  AIIM  Sutei^  Smnll 
Bvo.     lUiialntiMl.    Clotk,  |l  JO. 

OSLER  (VILLIAM).  Ixetnrt*  imi  the  DlaicBoehi  ot  Abdonlnal  Tamon, 
Small  Svn.     lllnUmtriL    OUith,  $I.AO. 

08I.KR  (WILLIAM),  The  Prinnple*  nnd  Pr»rti«e  of  HodloiBe.  DeeiKoed  for 
tl>«  t;*n  of  rrnrtiiionor*  nnd  Htodrnl*  »r  Medirioe.  fcnK  (dlUaa,  retlxd 
aU  nlanifd.    Clolh,  «5.»l ;  tbrep,  tS.&O ;  lialf  moroccO,  $7.00.    {S«U  tmlp 

PELLEW  (0.  E.).  A  Uanaal  ot  Practical  Uedlcd  a>«mUlry.  IIbio.  With 
inuatratlon*.    Cloth,  $1.00. 


• 


e 

PnELPS  (CHARLES).  Tnninetic  lojaries  of  iht  Brain  aod  its  Uembranes. 
With  a  Special  Sta<l;  of  Piatol-Sbot  Woanda  of  ibe  Head  id  tbeir  Medico- 
Legal  and  Snrftical  Relations.  8vo,  6S9  pase».  With  fortj-nioe  lUnstr«- 
tioDS.    Clotb,  $5.00.    {Sold  only  (y  tubteription.) 

PIFPABD  (DENRT  G.).  A  Practical  Treatjae  od  Diseases  of  tbe  Skin.  By 
Hear;  6.  PifTard,  A.  M.,  M.  O.,  bmUM  hj  Robert  U.  Fuller,  M.  D.  With 
flft;  fbll-page  Original  Plate*  ud  thirt;-three  Illiutrationa  in  the  Text. 
4to.    {SM  only  by  Mt&fcrtptiM.) 

POMEROY  (OREN  B,).  Tbe  Diagoori*  and  Treatment  of  Diieaaes  of  the  Ear. 
With  One  Honclred  lIlnatratioDB.  NetMi  etllUa,  revised  and  enlarged.  8to. 
Olotb,  (8.00. 

POORE  (O.T.).  Onteotomj  and  OBteoolosls,  for  tbe  Correction  of  Deformitier 
of  tba  Lower  Limb*.    GO  lUnBiration*.    6to.    Clotb,  $2.S0. 

QTIAIN  (RlCnARD).  A  Dictionarj  of  Uedicine,  inclnding  General  Pathologj, 
General  Therapeo tic*,  H^ene,  and  tbe  Diseases  peouliar  to  Women  and 
Children.  By  Various  Writers.  Edit«d  by  Sir  Riobard  QnatD,  Bart., 
H.  D.,  LL.  D.,  eta  Assisted  by  Frederick  1  humas  Boberts,  M.  D.,  B.  Sc., 
and  J.  Hit«hell  Brnoe,  U.  A.,  U.  D.  With  an  American  Appendix  by 
Bamnet  Treat  Armstrong,  Ph.  D.,  M.  D.  In  two  Tolumes.  {Sold  only  by 
luiteription.) 

RANNEY  (AMBROSE  L.).  Applied  Anatomy  of  tbe  Nervous  System,  being  ■ 
Study  of  this  Portion  of  tbe  Haman  Body  from  a  Standpoint  of  its  General 
Interest  and  Practical  Utility,  designed  for  Cse  as  a  Text-Book  and  as  a  Work 
of  Reference.  Sewi  edttiM,  reTtoei  ut  NlUKCd.  Profnsely  [[Instnited.  Svo. 
Cloth,  |S.OO;  sheep,  $6.00. 

ROBINSON  (A.  R.).  A  Manual  of  Dermatology.  Revised  and  corrected.  6vo. 
Olotb,  »6.00. 

BOSOOE-SCHORLEMMER.    Treatise  on  Cbemistrj. 
Vol.  1.  Non-Metallic  Elements.    9vo.    Cioib,  $5.00. 
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Vol.  3.  Part    I.    The  Chemistry  ot  the  Hydrocarbons  snd  their  Deri.-utivei'. 
8vo.     Clotb,  $6.00. 

To).  3.  Part  II.    TbeChetuistrjof  the  Hydrocarbons  sod  their  DerivaiiveB. 

8io.    Cloth,  $5.00. 
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Vol.  S,  Part  V.     The  Chemittry  of  the  Hydrooarbons  and  their   Ueriva- 

lives.     8vo.     Clotii,  $3.00. 

ROSENTHAL  (1.).  General  Phjainlosy  of  Musclesiind  Nerves.  With  75  Wood- 
cuts.   12mo.    Clotb,  $1.50. 

8A YRE  (LEWIS  A.).  Practical  Manual  of  tlie  Treatment  of  Club-Fout.  Fenrtk 
edlUei,  eaJineil  aad  terrettN.     12mu.    Cloth,  $1.25. 

8ATRE  (LEWIS  A.).  I-ectures  on  Orthopedic  Surgery  and  Diseases  of  the 
Joints,  delivered  at  Bellevne  lIo»pita!  Medical  College.  New  cdltlMi,  illus- 
trated with  »ii  Engravings  on  Wood.     8vo.     Clotb,  $5.00 ;  sheep,  $G.OO. 


SCUULTZE  (B.  S.).  TLo  PalliotO);?  and  TreeuacDi  of  UhplxMBnU  ol  ll>* 
llleru*.  TrstteUttd  from  ih«  tioriiian  b;  JatiiMoii  J.  llwnB,  N.  A.,  el«.; 
ajul  edil«l  by  Aitliiir  V.  Mmciiii,  M.  ti.,  «lr.  With  one  buixImJ  and 
imeutj  lUtimriilioni'.    Dvo.    Clotli,  (8.30. 

SHIELD  (A.  MAl{UAr>ITKK).  »atg\eiii  Anau-wj  tor  titndcDta.  JZno. 
(MroKXTH'  Suuu.)    Cloili.  tl.Tlk 

SHOEMAKKK  (JOHN  V.).  A  T«)i-l)o»k  uf  (>i>r»vo  of  lU  fiklo.  Bli 
UhrotnuliihoLTaiili*  aiid  nuiiiiTtiun  KngraTing*.  Tlijnl  nliUoii,  rerlsetl 
iu>il  enlitrgciL     t>vu.     I'lotb,  tS.UD;  thetf,  t^.OO. 

mUVSOS  (JAUESY.).  ScUctixl  Work*:  AnMthm.u.  DiMuei  ol  WonvD. 
3  voU.     8vi>.      Per  vt>lam«,  clotli.  $8.00;  nboep,  $4.00. 

SIUK  (J.  UAlCIUSj.  Tbe  f^tory  <>1  no  IJrc.  &lil*d  Iijr  liU  Sou,  U.  llan«D. 
tsiiu*.  it.  If.     Willi  Portnut.     laniu.    Cloib,  (l.&U. 

aKEN£  (AI.EXA.N]>EK  J.  0.).  A  T*il-Uook  on  Um  IHmmc*  of  Waa,«it. 
l)ltMtrat«<i  witb  two  liundrod  ui<l  tltly-laur  lllimtratkiat,  of  wbicit  u«* 
liunitrcd  aod  nixtj-livo  eru  uri^lual,  hhJ  uioe  rhramaiitbagraiiba,  Herooid 
mUImmi.     8vu.     (.ieU  okI]/ bf  lubterijrtioii.t 

3KENr.  (AI.IuXANDI:K  .1.  O.  Ifvdiual  G^necoliM?.  A  TfMtlM  on  U.« 
UiaeaMtt  of  Wotii^ii  Iruin  tbo  &uoJ[>oiBt  ul  Ui«  Vhrtioian.     Vi-i>.     With 

UlllltlrBllUDB.      Cluth,  $&.O0. 

8T£INE[t  <JOUANXV.  Compaoilliim  orui.lldreb'a  OiMaM*.  A  llaiid-thK-k 
(or  rraclltioMn  and  Stod«nla.  TranslaliKl  trum  ihit  •ocuad  UonnaB  editkMi. 
bj  LawMMi  Talc    8to.    Clnth,  $8.Au ;  (Ji««>p,  $4.A<), 

8TEVEKS  (OEOItOE  T.)  Funrtluiial  Nervou*  Dia«eM»:  Tbsir  CauM*  anil 
ibeir  Traainiont.  Mnixrir  for  tli«  CoiKWraaof  1081-1^83.  Ai:ail#iiil»  liajti 
d«  M4d«ci&«  do  ltdjiiquo.  Willi  a  HvpidaniMl,  on  ilia  Aiiumiliv*  iri  He- 
ryactioBaiKl  A(«i>Diiuiidati<to  i>f  tlie  Ejt,  andol  ibetlmUr  MumIc*.  8mall 
DtO.    Wttb  UK  l'bulo|;ra|>liic  PlalM  nliO  larira  IlluslntiKU.    Chili,  tS.blK 

STONE  (K.  KItENOII).  Clwuentatfr  Uodcra  MoliiiiK-.  iacNidlii(  Piiix-ipln  u( 
Palboluj.7  and  ot  TliMvpeatloa,  witb  taaiij'  IVfiil  Memoranda  aud  ^'alnabla 
Tat)l««  i>(  Ktffrr«iiL'(>.  Aooomjianled  hj  fockvl  F«vrr  Lliarla.  I>«al«ii«d  for 
Ui«  (.'lu  d  Siiid«iit»  and  I'racUtlvner*  ul  M«<lk-in«.  la  irall«(-bow  form. 
•  lib  jiockolH  oD  each  eoiar  for  Ifemoranda,  Tecnperatora  Charts  ale* 
Kuan,  tork,  t^  AO. 

STRECKF.R  (ADOU'II).  Shi>ft  Ti-xi-ltook  q(  OrRaiiii;  Cbwniairy.  Bj  Dr. 
Joliannr*  WlaliMiiiia.  Trnti»lat«d  and  r<]|[«d,  with  ExIvimI**  AdililiiMii^  b* 
W.  U.  llo>lf;kiJi»uti  Hud  A.  J.  Urerotiwajr.    6iOl    Clolb.  $a.Oa 

SntCUPELI.  (ADnT.PII).  A  Taxt-Bot^  of  Mfdk.-iti«^  ri>r  Stiidaat* and  Trac- 
litioiwrs.  Tr^iialntiMl,  l>v  i.vrmiMoti.  from  lb«  *>aili  (iuraaJD  cdltlua 
iij  Hcrmaii  K.  Vickrrjt,  A.  B..  M.  )>.,  iBKmfitir  iu  Cliiiirnl  ModMnc,  Uar- 
Tiril  Ui-ilit^  itehool,  etr.,  and  Pliilip  Cvumlin  Kiia|>|i.  l'li;ni(4iB  toUol* 
ratMiUlA  wiUi  DLH««ea  oflbu  Nvrvonn  Sju«ii),  livMvtt  City  llaa|>ltal,  «(c 
With  E4Utor{al  Not«a  bj  Fmlorick  l\  tUiattnck.  A.  U.,  H.  If.,  Jackton  E'ri>- 
faaaor  of  Ullnloal  Uedliriii*.  Itiu van)  3J«Jical  School,  pU.  8«ooim1  Amavicaii 
(dUioo.  WiUi  111  lllmtiration*.  Sto,  961  pacaa.  (Tlotb,  M-00;  •been, 
17.00, 

THAYER  (WIU.IAU  HYDNKY).  Lcaurt*  on  tli*  Ualarial  Fema.  With 
iLiMC«oB  Clurl*  HDd  ihrcv  Litbograpbh)  Plaloa  «ho«bif  tbe  Panuilo  of 
ToniNB,  Onotidiao,  aiKl  .EHlivu-AuUBinal  Fevora,  Sanfll  8r»,  USA  lutcctL 
Cloth,  W.00.  '^^ 


TBOJIAB  JL  flAnijAEn). 


TBOMFBCnr  (W.  GIUCAKJ.    ftaalfcj  PMilK  wllh 


TBCniSOV  (I.  AKIBCB).^  OidfaMa  tf  ZBBla^^    WU  Oftrtj^n 


TILLMAHire  (HXHXAIO).     A Ttet-Book of  8«|nt.    V«l. L    TteMi. 


BBr(M7  MS  wugluM  FlAafa0>    ftio.  , 

|tat^-«M  UartratiaM.  TJoirtai  lyJoto  B^»rfc  M.D-  mat  B«Ai»h 
T^TDtai^  M.D.  TU.  II.  BiflMranRnx  via  l£  ksini  mi 
MWtiw  UhMbalku.    TrwJMri  bj  Ba^taidB  T.  TfHoa,  11.1)1.    KiA 


OLTZMASN  (BOBKBI).    ftwia,  or  Ph  ia  O*  Cita^  «d  fa  _    _  _ 
TnMbMl^P«BMaa,VrDr.iri)iarB.PIttt.    Ukwk    OleA,«Lao. 


TAV  BDBEK  (W.  H.).  I— law  ^on  Mumm  of  At  Baatw.  — d  Oc  &«^ 
fM7  of  th>  L»w«r  Bvwcl,  Mhcnd  >t  Bdton*  Boalullbdfaa]  CbDat. 
fclilllW,nHitM*i^Wpi.    Bra.    Olotk,  «UN};  riNap,  ILOO. 


VAH  BUBEK  (W.  H.).  Lmlww-o  A*  PrfMiplM  nd  PnotlM  of  Smmr. 
IMInndaBdIvrMHMpltdlMUOoUtca.  Edtted  br  Lawto  A.  8ll» 
■OD,]LD.    Bto.    OIoO,  tkOS;  dwip,  tB.00. 

VOGEL  (A.).  A  Pnctieal  Tr««tiM  on  the  I>tMa«ea  of  ChUdreo.  Tmialatad 
and  edited  b;  H.  Raphul,  1L1>.  ThM  1m»Im  frNi  the  i%fen  Strmm  («- 
UN,  RTtnl  ■■<  Mlut*^  Dliutrated  b;  nz  Utbo^npfaio  Pktw.  8*d. 
aoth,  t4J>0 ;  «he«p,  16.50. 

VON  ZEI8SL  (DERUANN).  Outlines  of  the  Patholog?  and  Treatment  of 
g^philis  and  Allied  Venereal  Diaeaaea.  SccMd  ctfllaa,  reviaed  t^  ilaiiml)- 
ian  von  ZelM.  Anthorized  edition.  Tranilsted,  with  ^otea,  bj  B.  ha- 
pliael,  H.  D.    Svo.    Oloth,  fi-OO;  sheep,  $0.00. 

WEBBER  (8.  ti.).  A  Treatise  on  Netroos  Diaeaaes:  Their  Symptoms  and 
Traatment.   A  Text-Book  for  Stodenta  and  Practitiunara.   8vo.   ci(^,  (B.OO. 

WEEKa-SHAW  (CLAKA  B.).  A  Text-Book  uf  ^larfdog.  For  the  Dae  of 
TnuDiDg-Sohools,  Families,  and  PrJTate  Stadents.  Hecond  edition,  rvTieed 
nnd  eola^ed.  19ido.  With  Illustrations,  Qoeations  for  Beriew  and  Ex- 
amioation,  and  VooabnlaiT  of  Medical  Teniia.    ISino.    Cloth,  %l.7S. 

WELLS  (T.  SPENCEB).    DiiraxM  of  the  Overiea.    8vo.    Cloth,  $4.60. 

WOKCESTEB  (A.).     Honthl;  KoraiDg.    Setairi  edldaa,  retlied.    Oloth,  $1.38. 

WTBTH  {JOHN  A.).  A  Tert-Book  on  Sargerj:  General,  Operati»e,  and  Ha- 
ehanlcal.  Frofnaelj  iUnatrated.  lUH  e4ltt««,  ntImA  ni  Wlarged.  Sto. 
^Sfl4  mlf  If  tuiMi^f van,) 


LANE  MEDICAL  UBRARY 


To  avoid  fine,  this  book  should  be  returned  on 
or  before  the  date  lut  itamped  below. 


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