Appendix Cæci, of Which the Patient Shortly Afterward Died, to Cause

so intense a pain near the edge of the ribs that the passage of gall-stones or renal calculus was at first suspected.

There seems to be as much variation as to modes of onset and duration among the visceralgias as among the superficial neuralgias, but the tendency to short typical attacks of frequent recurrence seems to be greater with the former.

The visceral neuralgias are quite closely enough related to certain of the superficial neuralgias to show that they belong in the same general category. The two affections are often seen in the same person, and not infrequently at the same time or in immediate succession. Thus in the case of the patient just alluded to above, the attacks of deep-seated neuralgia in the neighborhood of the right flank are at times immediately preceded by severe neuralgia of the face or head. Similarly, intercostal neuralgia may occur in immediate connection with neuralgias of the cardiac or gastric nerves.

The phenomenon of tender points is not entirely wanting in the visceralgias, though less constant and definite than in the superficial neuralgias.

The liver and the uterus especially become the seat of more or less localized tenderness, and possibly the tenderness in the ovarian region which is so common, and so often unattended by real inflammation, is, in part, of this order.

The secondary results of the visceralgias are not easy to study. Besides the disorders of secretion and function above alluded to, swelling of the liver with jaundice and paresis of the muscular walls of the hollow viscera may be mentioned as having been ascribed to neuralgia.

It is not known to what degree neuritis occurs as a cause or {1216} complication of these neuralgias, and this is a question which is greatly in need of further study.

Migraine, or Sick Headache.

This is often classified as an affection of a different order from the neuralgias, but there seem to be no real grounds for this distinction.

The superficial neuralgias themselves are probably not one, but a group of affections, with the common bond of severe and paroxysmal pain.

Neither is what is called migraine always one and the same disease.

Although in its most typical form it presents very striking characteristics, such as a marked preliminary stage, with peculiar visual and sensory auras, sometimes occupying one entire half of the body, a short and regular course and periodical return, deep-seated pain without tender points, and prominent unilateral vascular disorders, yet these symptoms shade off by imperceptible degrees into those of neuralgia of the fifth pair, or more often into one or another form of unilateral neuralgic headache which stands midway between the two.

The vascular phenomena of migraine are believed by various observers, as is well known, to constitute the primary and essential pathological feature of the disease, and to be the cause of the pain. But this is a pure hypothesis, and as a matter of fact the cases are abundant in which no greater vascular changes are present than in other neuralgias of equal severity.

Migraine seems to occupy an intermediate position between the grave neuroses, especially epilepsy, and the neuralgias of neurosal origin.

The symptomatology will be described at greater length below.

GENERAL ETIOLOGY.—The causes of neuralgia may be divided into predisposing and exciting causes.

The most important of the first group are—

1. Hereditary tendencies;

2. The influences associated with the different critical periods of life;

3. The influences attached to sex;

4. The action of constitutional diseases, such as phthisis, anæmia, gout, syphilis, diabetes, nephritis, malarial poisoning, metallic poisoning.

The most important of the second group of causes are—

1. Atmospheric influences and the local action of heat and cold;

2. Injuries and irritation of nerves;

3. Irritation of related nerves (so-called reflex and sympathetic neuralgias);

4. Acute febrile diseases.

In most cases more than one cause is to blame, and each should be separately sought for.

PREDISPOSING CAUSES.—1. Hereditary Tendencies.—It is generally admitted as beyond question that neuralgias are most common in families in which other signs of the neuropathic taint are prominent. Such affections as hysteria, neurasthenia, epilepsy, asthma, chorea, dipsomania, and even gout and phthisis as it would seem, are akin to the neuralgic tendency.

{1217} The neuropathic family is thought to contain, in fact, a much larger number of members than this, but there is danger of exaggerating the importance of an influence of which we know as yet so little.

It should be remembered, moreover, that even where an inherited taint is present its influence may be but slight as compared with that of some special exciting cause.

Some neuralgias are more closely associated with the inherited neuropathic diathesis than others. The connection is especially close in the case of migraine; then follow other forms of periodical headache and the visceral neuralgias. Even the superficial neuralgias are more or less subject to this influence. This is thought to be especially true of the facial neuralgias.

Reasons will be offered later for suspecting that many cases usually classed as neuralgia, and characterized by gradual onset and protracted course, are essentially cases of neuritis; and there is need of further inquiry as to how far hereditary influences are concerned in producing them, and whether such influences act by increasing the liability of the peripheral nerves to become inflamed, or only by increasing the excitability of the sensory nervous centres.

2. Age.—Neuralgia is oftenest seen in middle life and at the epochs marked by the development and the decline of the sexual functions. The affection, when once established, may run over into advanced age, but cases beginning at this period are relatively rare and very intractable (Anstie).

Childhood is commonly said to be almost exempt from neuralgia, but, in fact, there seems no sufficient reason for withholding this term from the so-called growing pains of young children so long as it is accorded to the almost equally irregular neuralgias of anæmia in the adult. The same remark applies to the attacks of abdominal pain in children, which often seem to be entirely disconnected from digestive disorders.

Adolescents and children also suffer from periodical headaches, both of the migrainoid and of the neuralgic type. These are obstinate and important affections. Migraine especially, coming on in early life, points to a neuropathic constitution, and will be likely to recur at intervals through life, or possibly to give place to graver neuroses.

3. Sex.—Women show a stronger predisposition than men to certain forms of neuralgia, as to the other neuroses, but it is generally conceded that whereas neuralgias of the fifth and occipital and of the intercostal nerves are met with oftenest among them, the brachial, crural, and sciatic neuralgias are commoner among men. This probably indicates that the neurosal element is of greater weight in the former group, the neuritic element in the latter.

4. Constitutional Diseases.—The blood-impoverishment of phthisis and anæmia, the poison of malaria, syphilis, and gout, and the obscurer {1218} forms of disordered metamorphosis of tissue, undoubtedly predispose to neuralgia and the other neuroses, as well as to neuritis and others of the direct causes of neuralgic attacks.

Anstie regards the influence of phthisis as so important as to place it fairly among the neuroses. Gout is likewise reckoned by some observers among the neuroses, but we tread here upon uncertain ground. Anstie does not regard gout as a common cause of neuralgia, but most writers rate it as more important, and gouty persons are certainly liable to exhibit and to transmit an impaired nervous constitution, of which neuralgia may be one of the symptoms. The neuralgias of gout are shifting, irregular in their course, and sometimes bilateral.

Syphilitic patients are liable to suffer, not only from osteocopic pains and pains due to the pressure of new growths, but also from attacks of truly neuralgic character. These may occur either in the early or the later stages of the disease. They may take the form of typical neuralgias, as sciatica or neuralgia of the supraorbital nerve (Fournier), or they may be shifting, and liable to recur in frequent attacks of short duration, like the pains from which many persons suffer under changes of weather, anæmia, or fatigue.

There are other obscure disorders of the nutrition, as yet vaguely defined, in connection with which neuralgia of irregular types is often found. Some of these are classed together under the name of lithæmia, and are believed to be due to imperfect oxidation of albuminoid products.

Diabetes seems also to be an occasional cause of neuralgia, especially sciatica, and Berger, who has recently described them, says that they are characterized by limitation of the pain to single branches of the sacral nerves, by a tendency to occur at once on both sides of the body, by the prominence of vaso-motor symptoms, and, finally, by their long duration and obstinacy. There may not, at the moment, be any of the characteristic symptoms of diabetes present.

Chronic nephritis also causes neuralgia, either directly or indirectly; and severe neuralgic attacks may accompany the condition, which is as yet but imperfectly known, characterized pathologically by a general arterio-fibrosis and by increased tension of the arterial system.

True rheumatism does not appear to be a predisposing cause of neuralgia.

Anæmia, both acute and chronic, is a frequent cause of neuralgia, both through the imperfect nutrition of the nervous tissues, to which it leads, and, it is thought, because the relatively greater carbonization of the blood increases the irritability of the ganglionic centres.

Even a degree of anæmia which might otherwise be unimportant becomes of significance in the case of a patient who is otherwise predisposed to neuralgia; for such persons need to have their health kept at its fullest flood by what would ordinarily seem a surplus of nourishment and care.

Under the same general heading comes the debility from acute and {1219} chronic diseases, and the enfeeblement of the nervous system from moral causes, such as anxiety, disappointment, fright, overwork and over-excitement, and especially sexual over-excitement, whether gratified or suppressed (Anstie), or, on the other hand, too great monotony of life; also from the abuse of tea, coffee, and tobacco.

Lead, arsenic, antimony, and mercury may seriously impair the nutrition of all the nervous tissues, and in that way prepare the way for neuralgia.

IMMEDIATE CAUSES.—1. Atmospheric and Thermic Influences.—Neuralgia is very common in cold and damp seasons of the year, in cold and damp localities, and in persons whose work entails frequent and sudden changes of temperature. Exposures of this sort may at once excite twinges of pain here and there over the body, and may eventually provoke severe and prolonged attacks of neuralgia.

The action of damp cold upon the body is complicated, and it exerts a depressing influence on the nervous centres in general which is not readily to be explained. One important factor, however, is the cooling of the superficial layers of the blood, which occurs the more easily when the stimulus of the chilly air is not sufficiently sharp and sudden to cause a firm contraction of the cutaneous vessels, while the moisture rapidly absorbs the heat of the blood. From this result, indirectly, various disorders of nutrition of the deeper-lying tissues or distant organs; and, among these, congestion and neuritis of the sensitive nerves.

Neuralgia often coincides with the presence or advent of storms. A noteworthy and systematic study of this relationship was carried on through many years under the direction of S. Weir Mitchell by a patient of his, an officer who suffered intensely from neuralgia of the stump after amputation of the leg. The attacks of pain were found to accompany falling of the barometer, yet were not necessarily proportionate to the rapidity or amount of the fall. Saturation of the air with moisture seemed to have a certain effect, but the attacks often occurred when the centre of the storm was so remote that there was no local rainfall. It was impossible to study the electrical disturbances of the air with accuracy, but a certain relationship was observed between the outbreak of the attacks and the appearance of aurora borealis.

This patient's neuralgic attacks were almost certainly of neuritic origin, and it is possible that the exacerbations were due to changes of blood-tension in and around the nerve-sheaths. It is also possible that they were the result of circulatory changes and disordered nutrition of the nervous centres, already in a damaged condition from the irritation to which they had been exposed.

2. Injuries and Irritation of Nerves.—Wounds and injuries of nerves and the irritation from the pressure of scars, new growths, and aneurisms are prolific causes of neuralgic pain, partly by direct irritation, partly by way of the neuritis which they set up. Neuralgias are likewise common during the period of the healing of wounds, as Verneuil long since pointed out. The pain may be near the wound itself or in some distant part of the body.

Neuralgia due to the pressure and irritation of tumors, new growths, {1220} or aneurisms requires a special word. The pain is apt to be intensely severe, but what is of especial importance is that the symptoms may not present anything which is really characteristic of their origin, except their long continuance; and this should always excite grave suspicion of organic disease.

These attacks of pain may be distinctly periodical; and this is true whether they are felt in the distribution of the affected nerve or of distant nerves.

Not only are direct injuries of nerves a cause of neuralgia, but sudden concussion or jar may have a like effect—whether by setting up neuritis or in some other way is not clear. Ollivier reports a case where a blow beneath the breast caused a neuralgia which eventually involved a large portion of the cervico-brachial plexus; and the writer has seen a like result from a blow between the shoulders.

Peripheral irritations, such as caries of the teeth (see below, under Facial Neuralgia) and affections involving other important plexuses, such as those of the uterine nerves, are a frequent cause of neuralgia, and should always be sought for. They act in part by setting up neuritis, and in part evidently in some more indirect manner, since the neuralgia which they excite may be referred to more or less distant regions, forming the so-called—

3. Reflex and Sympathetic Neuralgias.—The term reflex, as here used, is ill chosen, and the term sympathetic only covers our ignorance of the real processes involved, and which we should seek for in detail. Thus, disease of the uterus or ovaries may cause facial, mammary, intercostal, or gastric neuralgia.

Hallopeau suggests that some of these results may be brought about by the pressure of enlarged lymphatic glands attached to the affected organ.

Another important centre of nervous irritation is the eye. Slight errors of refraction, or weakness of the muscles of fixation, especially the internal recti, are a source of frontal headaches and other nervous symptoms, and even of typical migraine, to a degree which is not usually appreciated. It is improbable that in the latter case the irritation acts as more than an exciting cause, but it may nevertheless be a conditio sine quâ non of the attack.

Acute and chronic inflammations of the mucous membrane of the frontal sinuses, perhaps even of the nasal membrane, are likewise important; and although it is probable that the opinions sometimes expressed as to the significance of these causes are exaggerated, it is equally true that obstinate and, as it were, illogical persistence in their removal will sometimes be richly rewarded.

It is especially worthy of note that there need be no local sign whatever to call the attention of the patient to the presence of the peripheral irritation.

Nothnagel has described neuralgias which come on in the first week of typhoid, and are to be distinguished from the general hyperæsthesia of later stages. He describes an occipital neuralgia of this sort which finally disappeared under the use of a blister. Other acute diseases may have a like effect. The writer has seen a severe facial neuralgia in the {1221} first week of an insidious attack of pneumonia in a person who was not of neuralgic habit, and before the fever or inflammation had become at all severe.

PATHOLOGY AND DIAGNOSIS.—In surveying the clinical history of the neuralgias and the circumstances under which they occur, we have grouped together a large number of symptoms of very different character from each other, and we have now to inquire to what extent these symptoms are really united by a pathological bond.

Two opposite opinions have been held concerning the pathology of neuralgic affections. According to one opinion, every neuralgic attack, no matter how it is excited, is the manifestation of a neurosis—that is, of a functional affection of the nervous centres—to which the term neuralgia may properly be applied. This view is based on the resemblance between the different forms of neuralgia, or the apparent absence, in many cases, of any adequate irritation from without, and the fact that the persons in whom neuralgias occur usually show other signs of a neuropathic constitution.

According to the other opinion, the various forms of neuralgia are so many different affections, agreeing only in their principal symptom, and are due sometimes to congestion or anæmia of the nerves or the nerve-centres; sometimes to neuritis, the pressure of tumors, or the irritation of distant nerves; sometimes, finally, to a functional disorder of the nervous centres. The arguments in favor of this opinion are that the difference between the symptoms of the different neuralgias as regards their mode of onset and decline, their duration, the persistence of the pain, and the degree to which the attacks are accompanied by organic changes of nutrition in the tissues and in the nerve itself, are so great as to make it appear improbable that we are dealing in every case simply with one or another modification of a single affection.

This is a valid reasoning, and it is certainly proper to exhaust the possibilities of explaining the symptoms that we find in a particular case by referring them to morbid processes which we can see or of which we can fairly infer the presence, before we invoke an influence of the nature of which we understand so little as we do that of the functional neuroses. At the same time, it must be distinctly borne in mind that the symptoms of certain neuralgias, and the relation which the neuralgias in general bear to other neuroses, can only be accounted for on the neurosal theory, and that in a given case we can never be sure that this neurosal tendency is not present and is not acting as at least a predisposing cause. It is especially important to bear this possible influence in mind in deciding upon prognosis and treatment.

We may now review briefly the signs which should lead us to diagnosticate or suspect the presence of the various special causes of neuralgic symptoms.

Neuritis is indicated by the presence of organic disorders of nutrition affecting the skin, hair, or nails, or of well-marked muscular wasting; by pain, not only occurring in paroxysms, but felt also in the intermissions between the paroxysms, or continuous sensations of prickling and numbness, even without pain; by tenderness along the course of the nerve; by anæsthesia, showing itself within the first few days of the outbreak of a neuralgia; by persistent paralysis or paresis of muscles.

{1222} Neuritis may be suspected, even if one or all of these signs are absent, in the prolonged neuralgias which follow wounds or strains of nerves or exposure to damp cold, or which occur in nerves which are in the immediate neighborhood of diseased organs; also where the pain is relieved by compression of the nerve above the painful part, or, on the other hand, where pressure on the nerve excites a pain which runs upward along the course of the nerve.

It may also be suspected in the large class of superficial neuralgias which follow a regular and protracted course with gradual onset and decline, and where the pain is felt not only in the region of distribution of a nerve, but also along its course—that is, in the nerve-fibres (either the recurrent nerves or the nervi nervorum) which are distributed in the sheath of the main trunk or the adjoining tissues.

It must be remembered that the study of neuritis, and especially of chronic neuritis, is still in its infancy, and that we are by no means in possession of its complete clinical history.

The presence of congestion of the sensory nerves or nerve-centres may be inferred with some degree of probability where neuralgic attacks of relatively sudden onset and short duration occur in parts which have been exposed to heat or cold, or in connection with suppression of the menstruation, or, it is said, as a result of intermittent fever. The exacerbations of pain which take place in cases of chronic neuritis under changes of weather and after fatigue are very likely due to this cause; and the same may be true of some of the fleeting pains which occur in chlorotic and neuropathic persons who are subject to fluctuations of the circulation of vaso-motor origin.

The same vaso-motor influences which cause congestion may also cause the correlative state of anæmia, which becomes thus a cause of transient and shifting though often severe attacks, which may be irregular in their distribution. General anæmia is also a predisposing cause of severe typical seizures, as has been pointed out above.

The pressure of new growths or of aneurisms is to be suspected when neuralgic attacks are unusually severe and prolonged, recur always in the same place, and occur in persons who are not predisposed to neuralgias. The pains from this cause are apt to be relatively continuous, but they may, on the other hand, be distinctly paroxysmal, and may occupy a part of the body far removed from the irritating cause.

Bilateral pains should also excite suspicion of organic disease, though they may be due to other causes, such as gout, diabetes, and metallic poisoning.

Neuralgic attacks may be supposed to be of neurosal origin when they are of sudden onset and short duration, or when they occur in persons of neuropathic constitution, and, by exclusion, when no other cause is found. These conditions are best fulfilled in the case of migraine and the visceral neuralgias. It must, however, be borne in mind that the neuropathic predisposition is sometimes well marked even in the case of the superficial neuralgias, especially the epileptiform neuralgia of the face.

GENERAL TREATMENT.—To treat neuralgia with satisfaction it is {1223} necessary to look beyond the relief of the particular attack and search out the causes by which it was provoked. As has already been remarked, these are usually multiple, and among them will be found, in the great majority of cases, some vice of nutrition or faulty manner of life.

It is safe to say that any dyscrasia occurring simultaneously with neuralgia, whether gout, phthisis, malaria, or diabetes, should receive its appropriate treatment, whatever theory we may hold as to the real connection between the two conditions.

In protracted neuralgias it is always proper to assume that neuritis may be present—i.e. to treat the nerve itself by galvanism and local applications. Local irritations, such as diseases of the eye, ear, teeth, nose, or uterus, should be sought out and removed; and attention may here be called again to the fact that a neuralgia may be due to some local condition which does not of itself attract the patient's attention.

Patients who are subject to pain at changes of weather or on exposure should be suitably protected by clothing, and should have their cutaneous regulatory apparatus strengthened by baths and friction. The best protection, however, is incapable of entirely warding off the effect of atmospheric changes upon the nervous centres. Vaso-motor changes of neurotic origin can be, in a measure, prevented by removing the patient from the influence of irregularity of life and emotional excitement and through an improved nutrition.

If the patient has been subjected to chronic fatigue or nervous strain, not only must these be avoided, but their action should be counteracted by the requisite rest and tonic treatment.

Long hours of sleep at night may often be supplemented to advantage by rest during certain hours of the daytime. If the patient cannot take active exercise, massage is indicated, and in some cases of anæmia this may advantageously be combined with the wet pack, in the manner described by Mary Putnam Jacobi.

Where these measures cannot be carried out, the writer has found it of much service in these, as in a large class of debilitated conditions, to let the patient rub himself toward the end of the forenoon in a warm room with a towel wet in cold or warm water, and then lie down for an hour or so or until the next meal. If acceptable, the same operation may be repeated in the afternoon.

Neuralgic patients are apt to be underfed, and even where this is not distinctly the case, a systematic course of over-feeding, with nourishing and digestible food, such as milk, gruel, and eggs, given at short intervals, is often of great service if thoroughly carried out. The full benefit of this treatment cannot always be secured unless the patient is removed from home, and, if need be, put to bed and cared for by a competent nurse.

A change of climate, and especially the substitution of a dry and warm for a moist and cold climate, will sometimes break up the neuralgic habit, for the time at least. In making choice of climate or locality, however, the physician should keep distinctly in view the end that he desires to gain. Thus, the debility or anæmia which is the essential condition of many neuralgias may often be relieved by surroundings which {1224} would not be thought favorable to the neuralgic tendency as such. Oftentimes the sedative influence of quiet country life is all that is required.

Of the tonic drugs, cod-liver oil, iron, arsenic, and quinine are by far the most important, and it is often well to give them simultaneously. Iron may be used in large doses if well borne, for a short time at least. Quinine may be given in small doses as a tonic, or in larger doses to combat the neuralgic condition of the nervous system. This remedy has long been found to be of great value in the periodical neuralgias of the supraorbital branch of the fifth pair, but its usefulness is not limited to these cases. It may be of service in periodical neuralgias of every sort, and often even in non-periodical neuralgia.

When the attacks recur at stated intervals care should be taken to anticipate them with the quinine by about four hours, even if the patient has to be waked in the early morning for the purpose. Single doses of fifteen, twenty, or even thirty grains may check the attacks where smaller doses have failed. Such doses cannot, however, be long continued, and are not to be classed as tonic.

Of other remedies which directly influence the neuralgic condition, the following are the most important: opium, aconite, gelsemium, phosphorus, belladonna, chloride of ammonium, cannabis Indica, croton-chloral, electricity, hydropathy, massage, counter-irritation, subcutaneous injections of water, chloroform, osmic acid, etc.; surgical operations.

Opium is usually employed only for the momentary relief of pain, but it has also been claimed that in small and repeated doses it may exert a really curative action. This should not, however, be too much counted on. Opium should never be used continuously for the simple relief of pain unless under exceptional circumstances, the danger of inducing the opium habit is so much to be dreaded. Moreover, both patient and physician are less likely to seek more permanent means of cure if this temporary remedy can always be appealed to. It is best given by subcutaneous injections of the various salts of morphine. The dose should always be small at first (gr. 1/12 and upward), unless the idiosyncrasy of the patient is already known; and there is probably no advantage in making the injections at the seat of pain or in the immediate neighborhood of the nerve supplying the affected part, except such as might attend the injection of any fluid (see below).

Belladonna (atropia), which is so often given with morphine to diminish its unpleasant effects, seems at times, even when given alone, to have an effect on neuralgia out of proportion to its anæsthetizing action, which is very slight. It is considered to be especially useful in the visceralgias.

Aconite, given, if necessary, in doses large enough and repeated often enough to cause numbness and tingling of the lips and the extremities for some days, will sometimes break up an attack, especially of trigeminal neuralgia, better than any other means; but its use is liable to depress the heart, and it is a dangerous remedy if not carefully watched. Some patients complain that it causes a marked sense of depression or faintness, and a feeling of coldness; and indeed its full therapeutic effect is sometimes not obtained until such symptoms as these are induced to some degree. The use of the crystallized alkaloid, aconitia, has the advantage of ensuring certainty of dose.

{1225} The susceptibility of different persons to this drug is so different that the dose should first be as small as 1/400 gr., but this may be repeated every three hours, and gradually increased to 1/100 gr., or until its physiological effects are felt. Patients must sometimes be kept under its influence for weeks together. It is, however, a remarkable fact that occasionally a few full doses will secure an immunity from pain for a long period. Although most useful in facial neuralgias, the writer has known it to be effective in brachial and mammillary neuralgia. Aconitia can now be had in granules of 1/400 gr., or can be given in alcoholic solution.

Gelsemium is also occasionally very useful in facial and even in intercostal neuralgia, and is said to be of special service in the neuralgia due to carious teeth. The commencing dose of the fluid extract is five minims, which may be gradually increased to twenty, or until a slight degree of muscular prostration, ptosis, or dilatation of the pupil is induced.

The use of phosphorus has been revived of late years, chiefly through the efforts of J. Ashburton Thompson, and it is at least occasionally of service. Success is said to be best obtained by full doses (about 1/20 gr. every three or four hours, up to 1/5 or 1/4 gr. daily for some days), watch being kept for signs of gastric irritation. The best preparation is an alcoholic solution (Thompson's), such as the following:

Rx. Phosphorus, gr. j; Abs. alcohol, fluidrachm vi. Dissolve with heat. Glycerin, fluidounce iss; Alcohol, fluidrachm ij; Spts. peppermint, minim v. One teaspoonful represents gr. 1/20.

Electricity, if properly used, is capable of temporarily, and even radically, relieving the neuralgic state. The forms most often employed are faradic and galvanic electricity, though frictional electricity has also been coming into use of late, mainly as a substitute for faradism. The galvanic current is by far the most efficacious of all. This probably acts mainly by directly inducing better nutritive and better functional conditions in the nerves and nerve-centres, but the fact that it is often of use in cases of undoubted neuritis seems to indicate that it may also influence the grosser structural changes in the affected parts, if such are present. It is impossible to explain its action more exactly, and the teachings of physiological experiments do not lend us much aid.

It is probably not of much consequence which pole is used in the neighborhood of the affected nerve. It should be remembered that the peripheral nerve-trunks are so deeply buried that the electrodes cannot be directly applied to them, as they are to the exposed nerve of a frog in the laboratory, and, further, that instead of being isolated they are surrounded with tissues of good conducting power, into which the current must rapidly flow off. For these reasons the nerve near which either electrode is applied is virtually exposed to the action of both poles in almost equal degree; and although it is more customary to use the positive pole in the neighborhood of parts which are considered to be in a state of irritation, yet clinical experience has not justified the conversion of this custom into a rule. Neither is the direction of the current of material consequence.

{1226} It is, however, very important in acute cases to take care that the current-strength should not be rapidly changed; and for this reason the electrode should be drawn slowly to a distance from the nerve before it is removed, or left in situ while the current is gradually diminished by a suitable rheostat. As a rule, the former method is the more practicable.

In the treatment of acute cases moderate currents and short applications, frequently repeated, are the best. On the other hand, in cases of long standing, especially cases of sciatica, strong currents are sometimes more effective, and even interruptions and reversals of the current may be in place.

The choice of a battery is not a matter of indifference. Any stationary battery of high interior resistance will answer the purpose, but most of the portable (zinc-carbon) batteries in common use are objectionable, for the reason that their interior resistance is so low in proportion to that of the body that it may almost be counted out as a factor in determining the strength of the current. The latter is liable to rise, therefore, quite suddenly as the resistance of the body—i.e. the vascularity of the skin—becomes modified. This objection is obviated if a large, constant resistance (water or graphite rheostat) is attached to the battery and kept always in the main circuit.

Faradism probably owes its efficiency to the indirect effects of stimulation of the sensitive nerves of the skin. This may be produced either by the wire brush, which causes a sharp irritation and reddening, and is to be compared with the counter-irritants, or by the milder application of a moist or dry electrode or the hand of the operator. The latter procedure may be compared to the superficial manipulation which is sometimes so grateful, especially in nervous headaches.

The value of electricity as a general tonic should be remembered in this connection.

Hydropathy.—Douches and baths of various kinds have doubtless proved of much value in the treatment of neuralgia. The majority of them, however, are difficult of application for the general practitioner, and we confine ourselves to mentioning the tonic and soothing action of the wet pack and of the prolonged warm bath, which should be followed by sponging with cool water, and used under every possible precaution against exposure.

Long-continued local applications of gentle heat (bags of sand or salt, or hot water) are often temporarily grateful, and in the treatment of chronic cases the daily application of hot water or ice-bags to the spine is said to have a good effect. In acute and subacute neuritis, and in those forms of neuralgia in which neuritis plays a large part, such as sciatica, the persistent application of ice-bags along the course of the affected nerve, even for days together, is sometimes of great service. Even where we cannot be sure that neuritis is present, long-continued applications of ice may be of use, but alternations of cold and heat, on the other hand, are usually to be carefully avoided. This treatment is safer in chronic than in acute cases, though it may be useful in either.

Counter-irritation.—A spray of ether may be substituted for ice when only a temporary chilling is desired, for its counter-irritant effect. This {1227} has even been used on the face, the eye being protected by some suitable covering, and a good deal of benefit is to be hoped for both from this and from the similar use of chloride of methyl.

Debove has found the chloride of methyl, used in this manner, singularly effective in the treatment of sciatica. A considerable and long-continued counter-irritation is thus made over a large surface and without great pain. The neuralgia is said to be greatly relieved and a rapid cure sometimes affected.

Counter-irritation is also practised by making applications of cutaneous irritants, such as blisters, mustard, turpentine, chloroform, or of the actual cautery carried in light superficial stripes over the skin, and repeated if necessary at short intervals. As a rule, the counter-irritation is more effective the larger the surface which is covered.

The use of the cautery and of blisters is in place in almost every form of neuralgia where the temporary disfigurement is of no consequence.

Of other cutaneous applications, aconite and chloroform liniments, menthol in substance or in alcoholic solution (drachm j or drachm ij to fluidounce j), aconite and veratrine ointments, are the most useful. A strong aconitine ointment, made with Duquesnet's aconitia and lard (drachm j to ounce j), has been recommended by Webber to be used in portions of the size of half a split pea, but, though effective, it needs to be employed with great caution.

These applications act in part as irritants, by keeping up a play of sensitive impressions in virtue of the lodgment which they effect in the skin, but also, no doubt, by reducing the sensitiveness of the cutaneous nerve-fibres, and thus removing one source of excitation of the diseased nervous centres. The remarkable temporary benefit sometimes obtained from the instillation of cocaine into the eye in cases of neuralgia of the ophthalmic division of the fifth nerve bears testimony in favor of this explanation.

Surgical operations for neuralgia are of three kinds—section (neurotomy), removal of a piece of nerve (neurectomy), and nerve-stretching. The two former operations are of course rarely practised, except upon the purely-sensitive fifth pair of nerves, the latter upon mixed nerves also.

Neurectomy is now almost always substituted for simple neurotomy, and sometimes still more effective means are taken to prevent the reunion of the nerve, such as doubling over the cut end, destroying the nerve throughout the length of the bony canal in which it lies, and even plugging the canal with cement.

The inconvenience following nerve-section is as nothing compared to the pain of a severe and intractable neuralgia. It has rarely happened that the disease has been increased by the operation, and under proper antiseptic precautions the surgical risks are not great. There is some chance of permanent cure, and a much greater chance of securing an immunity from pain for a long period.

It is important to remember that when the neuralgia occupies the distribution of several branches of the fifth nerve, an operation on the one primarily or most severely affected may relieve the pain in all. On the {1228} other hand, the converse may be true, inasmuch as the same district is supplied by recurrent fibres from several different sources. Before any operation is decided on it should be remembered that even in apparently desperate cases of trigeminal neuralgia the persistent and thorough use of tonic and other remedies may in the end be crowned with success, perhaps at the moment when it is least expected.

During the past few years the operation of nerve-section has been to some degree superseded by that of nerve-stretching, as being less serious in its immediate (though not necessarily in its remote) consequences, and sometimes more efficacious. Hildebrandt, indeed, raises the question whether the traction which is apt to be exerted when a nerve is cut is not an important element in bringing about the result. On the other hand, cases are reported where neuralgia which had not been relieved by stretching was cured by resection.

The best showing for the operation is in the treatment of sciatica, but most of the other superficial nerves, including the intercostals, have been successfully treated in the same manner.

On the other hand, this treatment is not without its dangers. Apart from the risks of the operation itself, cases have been reported in which the spinal cord has been injured, so that chronic myelitis has been set up, and a greater or less degree of paralysis—rarely permanent, it is true—may be induced by the direct injury to the nerve.

This means of treatment is therefore certainly to be thought of in serious and obstinate cases, but not lightly decided on.

A substitute operation for sciatica is the so-called bloodless stretching, in which, the patient having been etherized, the thigh is forcibly flexed on the pelvis, and then the leg extended on the thigh and the foot on the leg (dorsal flexion), and held for a short time in this position. A very material degree of stretching of the sciatic nerve is doubtless possible in this way, and a number of cures have been thus effected. But, though less dangerous than the stretching of the exposed nerve, this operation is not a trifling one.

In one case of sciatica the writer has seen a neuritis of some severity lighted up by this operation, perhaps because the disease was in too active a state, although it had lasted some months. The operation is probably most indicated in chronic cases.

The anatomical effects of nerve-stretching are manifold. Nerve-fibres are usually destroyed in greater or smaller number, and the conducting power of the nerve correspondingly impaired. Small blood-vessels are broken and the circulation and nutrition of the nerve-trunks altered, and it is probable that adhesions in and around the nerve-sheaths, where such exist, are severed. The nerve-fibres ramifying in the inflamed sheaths of the large trunks may also be ruptured, and it may be that the displacement of the fluid contents of the nerve brings about better nutritive conditions. It is also probable that the operation either directly or indirectly affects the nutrition of the nerve-centres, and although this is not without its dangers, the chances are in favor of a beneficial result.

{1229} Another means of directly acting on neuralgic nerves is by subcutaneous injections of water, chloroform, ether, osmic acid, nitrate of silver, and other substances. The deep injection of water over the affected nerve is attended with but little danger, and is occasionally successful. The similar use of chloroform, in doses of 15 to 30 minims, is much more often effective, but sometimes causes great pain, and even abscess. It has been mainly used in sciatica, also in other neuralgias, even those of the fifth pair. In this case the injection is best made through the buccal mucous membrane. This treatment is not without danger of causing collapse, or even death, probably due to the wounding of a small vein. In one case of sciatica treated by the writer the chloroform probably entered the nerve itself to some extent, as the injection was followed by very severe pain lasting for several hours, and eventually by some degree of muscular wasting. The neuralgic pain, which had continued obstinately for a long period, was, however, cured, and had not returned at the end of some days, when the patient was lost sight of.

Osmic acid has been used recently in the same way, and the reports show about an equal number of successes and failures. The dose is about 8 minims of a 1 per cent. solution, and the injection may be repeated at intervals of a few days. It has been used successfully in various parts of the body, including the face and the fingers. The injection causes no great pain, but occasionally, though rarely, excites abscess.

Under the general heading of massage a number of manipulations may be grouped which are of value in the treatment of neuralgia, even of long-standing cases of sciatica and the like. When, as often happens in the case of sciatica, the nerve is the seat of congestion and exudation, strong and deep kneading along its course, with vigorous stroking upward in the direction of the lymph-vessels, is the important part of the treatment. Besides this, however, the prolonged and gentle manipulation of the painful region may greatly relieve the patient for a time, apparently by acting on the sensitive nerves and exerting a sort of inhibitory action, in which it is not at all impossible that an influence upon the attention analogous to that of Braidism plays a part.

A striking instance of the effect of this treatment is seen in the case of nervous headaches, which are often very greatly relieved by a series of gentle, monotonous movements of the finger-tips, as well as by the domestic remedy of gently and persistently combing or brushing the patient's hair. A still more efficient application of a similar kind is the regular vibration communicated by a large magnet or by the instrument devised by Mortimer Granville. A thoroughly satisfactory explanation of the action of this treatment is yet to be furnished.

There is no doubt that in the treatment of neuralgia a persistent and thorough use of the remedies suggested is usually the key to success. Nevertheless, special cases are sometimes reached by special means of treatment, and the following are appended as occasionally useful: Ammonio-sulphate of copper (grs. ij-vj, taken in divided doses in the course of the day); salicylate of soda, in full doses; caffeine; tonka (fluidrachm j of the fluid extract at repeated intervals of a few hours); oil of turpentine; muriate of ammonia.

{1230} Special Forms of Neuralgia.

MIGRAINE AND PERIODICAL HEADACHE.—In many of the recent treatises upon nervous disease migraine and headache are removed from the category of the neuralgias and placed in that of the functional affections of the sympathetic vaso-motor system of nerves. This classification is based upon the fact that in many of these cases marked vascular changes—congestion or anæmia, as the case may be—are observed in the external tissues of the affected parts, while the sensations of the patient often lead us to infer the presence of similar conditions within the cranium. The pain and the other symptoms of the outbreak, it is thought, are due to the changes in blood-tension in the cortex cerebri or in the region of expansion of sensitive nerves, or, in part, to the spasm of the muscular walls of the vessels themselves. This theory is seductive from its appearance of pathological simplicity and exactness, but the writer believes, with Anstie, Latham, Allbutt, and other observers, that it is not borne out by clinical experience, and that its adoption tends to cloak the wider relationship that exists between the sensory neuroses.

Migraine, nervous headache, and the superficial and the visceral neuralgias hardly differ more fundamentally from each other than individual cases of either affection differ among themselves. It is not improbable, as we have seen, that all the phenomena of some neuralgic attacks are wholly or in part the expression of irritation of the sensory nervous system from without; but in many cases, on the other hand, the signs of the neurosal tendency are clearly marked, and there is hardly one of the symptoms of a typical migraine of which the analogue may not be found, though perhaps faintly pronounced, in one or another form of superficial neuralgia, while the relation of both to the whole family of the neuroses is still more clearly evident.

Migraine is a disease of youth and middle life, characterized, in its most typical form, by attacks of severe headache of a few or many hours' duration, of gradual onset and decline, ushered in by well-marked auras involving one or more of the cerebral functions, and terminating in nausea or vomiting or profuse secretion of pale urine, or in some other critical nervous outbreak. The pain is usually, but not invariably, deep-seated. It may be confined to one side of the head, most often the left, or may involve both sides, either from the outset or in the course of the attack. The forehead or temple is usually the first part to become painful, but in severe or prolonged seizures the parietal and occipital regions are prone to be affected likewise.

The auras are manifold and important. On the day before an attack the patient may feel remarkably well, or may complain only of such sensations as thirst or giddiness. The attack itself is apt to be ushered in by visual hallucinations of dazzling and vibrating points or serrated images, sometimes with prismatic outlines, accompanied by a loss or obscuration of vision over one-half or some other portion of the field, which lasts half an hour or more, and sometimes clearing up in one part while it advances in another. Simultaneously or immediately after this there may be {1231} tingling and a sense of numbness of the tongue, lips, hand, or one-half of the body, sometimes followed by partial hemiparesis, and, if the right side be affected, by more or less aphasia or mental confusion. Occasionally the other special senses are affected. Sometimes the aura may constitute the whole of the seizure.

The writer has observed a case in which migraine was represented throughout boyhood by repeated attacks of subjective numbness and tingling of the entire right side of the face, the right arm, and the right half of the body, with aphasia and hemianopsia, followed during many years by trifling headache or none at all; later in life by severe pain. Here migraine as well as neuralgia in other forms was a well-marked family disease.

These auras are especially worthy of notice, because they occasionally point to epilepsy, an affection with which migraine is allied.

The pain may begin on the same side with these prodromal symptoms or on the opposite side. Sometimes drowsiness is a marked symptom throughout the attack, and this differs in significance from the sound, refreshing sleep with which the paroxysm often comes to an end. Sometimes the arteries of the affected side seem strongly contracted, as shown by pallor and coldness of the face and dilatation of the pupil (angio-tonic form); sometimes, on the other hand, they are dilated and pulsate strongly, or the latter condition may follow the former (angio-paralytic form). The radial pulse may show corresponding modifications. These vascular phenomena are often, however, entirely wanting.

Migraine appears to be slightly more common in women than in men. The liability to the attacks often shows itself in extreme youth, usually increases at puberty, and generally ceases at the age of forty or fifty. The attacks sometimes recur at regular intervals of a week, a month, etc., but, on the other hand, they may remain absent for years unless brought on by some exciting cause.

ETIOLOGY AND CLINICAL RELATIONS.—Migraine is a directly inheritable disease, and one which stands in a close relationship to the other grave neuroses, as well as to the neuropathic temperament. Cases are occasionally seen in which the migraine of youth gives place to epilepsy in later years. It is often met with also in families and individuals of neuralgic tendency, and in fact it shades off into neuralgia of the fifth and occipital nerves on the one hand and into periodic nervous headaches on the other. It frequently occurs in gouty persons, and is thought to be related to the brow ague of malaria. The attacks may be brought on by any of the causes which depress the vitality of the nervous system, and by various special irritations, among which errors of refraction are prominent.

The PROGNOSIS is unfavorable in well-marked cases, in which the habit of regular recurrence is established, and where the neuropathic predisposition is pronounced and no special exciting cause can be found. On the other hand, there are many cases where the tendency is less deeply rooted, and where with the removal of the exciting cause or causes the outbreaks cease.

Finally, there is great probability that the disease will cease of itself with advancing years, not always, however, without having left its mark on the patient's mental and bodily vitality.

{1232} The TREATMENT should be directed first to the detection and removal of special sources of irritation, whether in the eye, stomach, uterus, or elsewhere. Causes of anxiety and mental strain should be as far as possible avoided, and great caution enjoined in the use of stimulants and narcotics. The nutrition should be maintained at its highest level by tonics, and, if need be, by electricity, massage, and hydropathy. Sometimes, besides this a special diet is advisable, for it seems beyond question that some patients have fewer headaches if they abandon all animal food, while others—whether because of a gouty tendency is not clear—do best on a nitrogenous diet with exclusion of sugar and starch.

Of the drugs used to control the liability to the attacks, the most important is cannabis Indica, given in doses of about half a grain of a good preparation of the extract several times daily for weeks or months together. Valerianate of zinc and the iodide and bromide of potassium in full doses are also recommended, but are less efficacious.

In the treatment of the attack itself, besides absolute rest and quiet, large and repeated doses of guarana or caffeine, either alone or combined with drachm doses of bromide of potassium, are sometimes of use if given at the very outset.

It is thought by some observers that ergot or ergotin is of value if the vessels are dilated, and conversely nitrite of amyl or glonoine if they are contracted. It must not be forgotten, however, in case of doubt, that the throbbing due to the latter drugs may increase the pain.

The writer has known a strong faradic current applied with the moistened hand to the back of the neck to relieve an attack, and prolonged but gentle manipulation of the painful area with the finger-tips may have a like effect if the pain is not too severe; as, for example, toward the end of a paroxysm.

Neuralgias of the Fifth Nerve.

Three varieties of these neuralgias may conveniently be distinguished:

1. Ordinary facial neuralgia, analogous to the neuralgias of the other superficial nerves;

2. Intermittent supraorbital neuralgia, sometimes called brow ague, though by no means always of malarial origin;

3. Epileptiform neuralgia (tic douloureux).

These varieties are of course closely allied, and have many features and causes in common.

THE ORDINARY FACIAL NEURALGIA is a painful and obstinate malady, although not so serious as the typical tic douloureux. The pain may remain fixed in one position or it may shift from one part of the face to another; and the latter is especially common in those forms which occur in anæmic or ill-nourished persons. It associates itself readily with occipital neuralgia, and sometimes also with neuralgia of the pharynx and other parts. It occurs most often in persons of neurotic tendencies or impaired nutrition, and may be provoked by disorders of the ears, teeth, and even distant organs. The possibility of aneurisms of the internal carotid or of cerebral tumor should also be borne in mind, and signs of herpes zoster and locomotor ataxia carefully sought for.

{1233} The relation of caries of the teeth to neuralgia of the fifth pair forms a very important chapter, which is admirably treated by J. Ferrier. Opinions on this subject are conflicting and unsatisfactory, and the fact that many patients have had nearly all their teeth drawn in the vain attempt to get cured of one of the severe forms of facial neuralgia often creates an impatience of further investigation in the matter. Ferrier points out that as a rule it is not the severest cases of epileptiform tic douloureux that arise in this way, but, on the other hand, that it is a mistake to conclude, because a neuralgia is benefited by medical treatment and made worse by fatigue, exposure, etc., and because it occurs in a person of neurotic temperament, that it is not likely to be due to this form of irritation. The teeth need not themselves be the seat of pain, and the disease in them may be detected only after diligent search.

The most important lesions are said to be caries, exostosis, and other affections involving the pulp-cavity, exposure of the sensitive dentine, ulcerations of the gums, injuries caused in extraction, and other diseases of the alveolar process. The wisdom tooth, by its pressure on other roots and on the gums, is not infrequently the one at fault.

Chronic inflammation of the mucous membrane of the nose or pharynx is said to be an occasional cause of neuralgia of the face, as well as of the upper portions of the body.

THE INTERMITTENT NEURALGIA OF THE SUPRAORBITAL is an interesting affection to which too little attention has been paid. One variety seems to bear a certain relationship to migraine, inasmuch as it occurs under similar circumstances—i.e. in distinctly neuropathic individuals and families, and in attacks of about the same duration and periodicity of recurrence.

Another variety approaches the other neuralgias in the longer duration of the attacks, but is characterized by a daily seizure which recurs with absolute regularity, coming on usually at about nine in the morning and increasing in severity for an hour or so, then persisting unchanged until midday or later, when it gradually diminishes, finally disappearing in the course of the afternoon. As a rule, it is brought on by catarrh of the frontal sinuses, often following an acute attack of coryza. A certain amount of neurosal predisposition is often found in this form, and the first attacks may show themselves in early youth, rarely in the decline of life. The writer has seen one family in which a number of members in at least two generations have been attacked in this way, the seizures having been brought on by exhaustion or coryza, or both combined.

This form of neuralgia is often greatly controlled by quinine if given in sufficiently large doses (15 to 20 or 25, or even 30, grains) and as long as four hours before the attack.

Lange thinks the action of galvanism is remarkably successful, but the writer's experience does not fully bear this out.

Seeligmüller speaks very highly of the effect of the nasal douche, used for the sake of curing the catarrh of the frontal sinuses, and potassic iodide may be useful by rendering the secretions more fluid.

THE EPILEPTIFORM FACIAL NEURALGIA, OR TIC DOULOUREUX, {1234} is a chronic affliction, characterized by the suddenness of onset and the severity of its paroxysms of pain, which may recur every few minutes with lightning-like rapidity, either spontaneously or brought on by motion of the jaw or the taking of food, and disappear again as quickly. After a group of such paroxysms as this there may be an intermission of some hours or days. During the attack the patient is apt to rub the seat of pain with great violence. The path pursued by the darts of pain may be either in the direction of the nerve-trunks or in an irregularly inverse direction.

In spite of their sufferings, these patients may present an appearance of health. In its worst forms, and especially in advanced life, this variety of neuralgia may be incurable, and at the best it is sure to tax the care and skill of the physician. Anstie thinks that it is apt to be associated with a taint of insanity.

The best TREATMENT consists in the most painstaking attention to hygiene, in the persistent use of galvanism, arsenic, cod-liver oil, quinine, aconite (see under General Treatment), and phosphorus. Croton chloral is occasionally of service.

As a last resort, surgical measures (see above) may be appealed to, but it should be borne in mind that even when the prospect seems most hopeless the relief under medicinal and hygienic treatment may really be near at hand. Where section of nerves is without result, the operation of tying the larger vessels, the carotid or vertebral, on the affected side may be tried, and offers some chance of success.

OCCIPITAL AND CERVICO-OCCIPITAL NEURALGIAS are second only to trigeminal neuralgia in severity, though, fortunately, less common, and either is liable by extension to give rise to the other.

Neuralgic pains in the occipital region may attend Potts's disease of the cervical vertebræ; and this is especially important to bear in mind because the osseous deformity is often wanting for a long time.

The writer has known a persistent pain in this region to be due to intracranial syphilitic disease, and to cease suddenly with the advent of more serious cerebral symptoms.

CERVICO-BRACHIAL AND BRACHIAL NEURALGIAS are less often indicative of the neuropathic taint than the facial neuralgias; and, on the other hand, they are, like sciatica, relatively often due to neuritis set up by injury, amputation, strains, enlarged cervical glands, periarthritis of the shoulder, etc., or associated with herpes zoster. When not due to an unremovable cause the prognosis is favorable. The treatment needs no special description.

INTERCOSTAL NEURALGIA is a very important form, both on account of its frequency and obstinacy, and because it is often associated both with anæmia and chlorosis and with affections of the visceral organs, especially the uterus. The distressing cardiac palpitation of neurasthenic patients often associates itself with pain in the left side, and there is an intimate connection between neuralgia of the cardiac plexus (angina pectoris; see below) and neuralgia of the intercostal and brachial nerves.

Pain in this region, often due to neuritis, may accompany acute and chronic thoracic disorders, and may be the precursor of herpes zoster. {1235} Caries of the vertebræ and meningitis should be thought of, and cancer if the neuralgia is very persistent, even if it is paroxysmal in character.

TREATMENT.—Besides the general indications for treatment referred to above, it is worthy of special note that nerve-stretching has been successfully tried for intercostal neuralgia. In one interesting case seven nerves were stretched at one operation. The reporter discusses the surgical aspects of the operation, and points out that the nerves should be sought for, not directly beneath the rib, but behind and beneath it, and thinks that the failure to bear this fact in mind might lead to puncturing the pleura.

MAMMILLARY NEURALGIA (irritable breast of Astley Cooper), though often met with in company with intercostal neuralgia, may occur entirely independently. It is sometimes bilateral, and is apt to be associated with irregularity of the uterine functions. Cutaneous hyperæsthesia is often present to a distressing degree, and small tumors of either temporary or permanent duration may make their appearance (A. Cooper), which, however, do not affect the prognosis.

There is no especially effective TREATMENT beyond what has been spoken of. Surgical interference is not especially to be recommended, though it has occasionally been useful.

LUMBO-ABDOMINAL NEURALGIA, or neuralgia of that part of the lumbar plexus which supplies the flank and abdomen and the external genital region. These neuralgias are apt to accompany those of the intercostal nerves and share in their significance.

The most important facts with regard to them are that they are intimately associated, in relation both of cause and of effect, with affections of the abdominal and the pelvic organs and of the testis. Neuralgias of the terminal branches of the lumbar plexus, the obturator and anterior crural nerves, though well recognized, are comparatively rare.

One of the chief respects in which they are important is in calling attention to the possible presence of disease of the hip-joint or of periarthritis of the hip, as well as of tumors or inflammation within the pelvis.

NEURALGIA OF THE SCIATIC NERVE is one of the most severe and common forms. While sharing in the common etiology and history of the other neuralgias, it is peculiarly prone to be due to peripheral causes, which give rise to thickening of interstitial and investing connective tissue of the nerve. The distribution of the pain may be coextensive with the whole distribution of the great and little sciatic nerve, but far oftener the patient indicates certain regions as the seat of his severest suffering; and these are especially the sacral region of one side, the neighborhood of the sciatic notch, the popliteal space, the calf, and the outer side of the foot and ankle. Not infrequently the whole course of the sciatic nerve is traced out by the darts of pain; and in this case it is the nerves which supply the sheath of the sciatic itself which are supposed to be the seat of the neuralgic process.

Sciatica is usually unilateral, but exceptionally bilateral, or attacks the two sides alternately. The tender points most often met with are at the sacro-iliac synchondrosis, the posterior border of the great trochanter, just beneath the head of the peroneal bone, below and behind the {1236} external malleolus, but numerous others are likewise noted by Valleix. Sometimes no tender points can be found. Sometimes, also, it is one or more of the collateral branches of the sciatic plexus that are the seat of the neuralgia, and the distribution of the pain and of the tender points varies accordingly.

It is in sciatica pre-eminently—in part, no doubt, because of the frequency of neuritis—that disorders of sensibility of the skin are noticed, as well as muscular paresis or spasm. This anæsthesia has been studied with great care by Hubert-Valleroux and others, and it has been shown that it is often confined to limited spots, a centimeter or so in diameter, within which the loss of sensibility may be nearly absolute. Nevertheless, their functional origin is proved by the fact that under faradization they may rapidly disappear.

The duration of an attack of sciatica varies from a week or two to months or even years, and it shows a marked liability to recur, especially with changes of weather. First attacks occur pre-eminently, though not exclusively, in middle life, and oftener in men than in women, evidently because they are oftener exposed to mechanical injury and, through their occupations, to sudden changes of temperature and the like.

The occasional causes are numerous, and include sudden wrenches and jars, even if not very severe, interpelvic pressure from tumors or impacted feces, etc. Gout, syphilis, and diabetes may act as predisposing and even exciting causes, and, it is said, gonorrhœa likewise. Periarthritic inflammations of the hip-joint and varicose veins frequently excite pains in the various sciatic nerve-branches which simulate true sciatica.

As has been indicated, although sciatica may be a pure neuralgia (see under Pathology), running its course without leading to any appreciable change in the nerve, yet subacute and chronic neuritis is very common, either as a primary condition or a complication, and its presence puts a graver aspect upon the case. The pain of neuritis, when severe, is relatively constant, remittent instead of intermittent, dull rather than lancinating, increased by motion and pressure; whereas the purely neuralgic pains are sometimes relieved by movement. It is, however, doubtful whether an accurate differential diagnosis is possible (see above). It is to this neuritis that the muscular atrophy is due which is often so marked, and it may likewise give rise to various cutaneous lesions of herpetic character. The severe pain that accompanies typical herpes zoster of this region is well known.

The TREATMENT of sciatica must vary with the probable cause of the disease and its stage of progress. Diathetic taints are to be met if present, and the greatest measure of physical health secured that the circumstances possibly admit. It is a good precaution in all cases to secure free evacuation of the bowels and to guard against hemorrhoidal congestions.

As against the neuralgia itself, the proper means vary with the acuteness of the attack and the presence or absence of neuritis. For the acute stage absolute rest is almost always desirable as a prime condition. Quinine, belladonna, aconite, and turpentine in full doses should be thoroughly tried, and special reference had to the periodicity of the seizures.

Frequent and extensive but superficial counter-irritation (actual {1237} cautery, blistering, ether, or chloride of methyl) is in place in this stage, and galvanism (constant current) is often of great service. It is probable that for the acute stage the prolonged use of mild currents is the best, whereas in more chronic cases the stronger, even very strong, currents, brought to bear as accurately as possible upon the nerve itself, are sometimes more useful.

Hydropathic treatment is in great repute both for acute and chronic cases, but as success in this way demands care and knowledge, the reader is referred to the special treatises.

In cases of long standing the continued application of ice-bags along the length of the limb for days together is often of excellent service, but this method of treatment is not without its dangers and needs to be carefully watched.

In chronic cases deep injections are of service, and nerve-stretching (see above) is in place.

THE VISCERAL NEURALGIAS have not received the attention which is due them both on account of their intrinsic importance and their constitutional significance. Not only are they found in common with the superficial neuralgias in the overtired and the underfed, but they point more strongly than the latter to the neuropathic diathesis, alternating with such symptoms as migraine, asthma, nervous dyspepsia, and insomnia. They occur also in the gouty and among the neuropathic descendants of the gouty, and as a result of functional and organic disorders of the viscera.

The pain of these neuralgias, though usually described as vague, ill-defined, dull, etc., yet often stirs the nervous system to its depths, causing nausea, faintness, sweating, prostration, reflex disorders of the secretions, and like symptoms.

ANGINA PECTORIS is a neuralgia probably of the pneumogastric and sympathetic nervous apparatus of the heart. The pain, which is usually of a heavy, dull, oppressive, or tearing character, and capable of rising to intense agony, is usually deep-seated, and felt to the left of the sternum and beneath the breast, often involving the left arm and side, and occasionally the left side of the face and neck, and even the leg of the same side or the right arm. It may also, as the writer has seen, be confined to the sternal region. In the case referred to this pain recurred every afternoon and evening with great regularity. Sometimes instead of pain the arm may be the seat of a tingling numb sensation only.

During the attacks the action of the heart may continue unchanged, or it may become slow and feeble or intermittent, yet without necessarily being the seat of organic disease. The onset of anginic attacks is usually, but by no means always, sudden, and their duration is commonly short. All the features of the attack, however, are subject to considerable variation, and nervous symptoms of a variety of kinds, which it is not necessary to detail, may precede or attend the seizure. In severe attacks the patient's anguish and prostration are extreme; the face and extremities become pale and cold, and a cold sweat breaks out.

In a large proportion of cases, especially the severest ones, these neuralgic attacks are associated with organic disease of the heart or blood-vessels.

A variety of causes have been suggested to account for the seizures, {1238} prominent among which is a widespread contraction of the arterioles, bringing a sudden strain upon the left ventricle of the heart. This theory is especially noteworthy because of the success which has attended the treatment by nitrite of amyl, which brings on a rapid vascular relaxation. In other cases spasm of this kind is manifestly absent. Fraenkel has recently defended the view that a momentary paralysis and over-distension of the left ventricle is the exciting cause. In other cases all sign of arterial or cardiac disease is and remains absent.

In this latter group the tendency to the attacks may cease under appropriate hygienic treatment. Thus, in an instance known to the writer a lady of usually good health suffered for several months from slight attacks of præcordial pain, with pain or a sense of numbness in the left arm, and often a feeling of breathlessness on very slight exertion. This condition had manifestly been brought about by prolonged physical and mental strain, and disappeared completely after a period of rest. Other such cases are described by Anstie, Allbutt, and others.

In judging of the significance of anginic attacks in a given case the signs of circulatory disease should first be studiously sought, and especially, as more likely to escape notice, indications of cardiac enlargement or weakness, or of increased vascular tension, or of chronic nephritis.

Dull pains in the intervals of the attacks are also regarded as important, as indicating the presence of neuritis of the cardiac nerves, which without doubt often exists. On the other hand, as pointing rather to a neurotic origin of the symptoms, a tendency, individual or inherited, to neuralgias of other forms, to asthma, migraine, and the other neuroses, is to be looked for.

Heredity plays a certain part in the etiology, and among the special causes of the non-organic form abuse of tobacco is said to be important.

The TREATMENT would be likely, of course, to be widely different according to the nature of the case, being on the one hand addressed to the circulatory apparatus, on the other to the health of the nervous system, in both cases following well-known lines.

In the treatment of the individual attacks the diffusible stimulants and the narcotics are of value when there is time to employ them. With regard to nitrite of amyl and the longer-acting nitro-glycerin, which have given so much relief in some cases, it would be premature to confine their use to the cases of demonstrable vascular spasm or even organic disease, and they are fair agents for trial in the apparently non-organic cases as well.

A patient of Romberg's used to get great relief from swallowing pieces of ice.

When the attacks are long continued or frequent, electricity, either as galvanism or by the wire brush, is applicable, and also counter-irritation over the chest, even by vesication.

GASTRALGIA (syns. gastrodynia, cardialgia, gastric colic, cramp of the stomach, etc.) may be associated with organic disease of the stomach or may occur as an independent neurosis. It is met with in individuals and families in which asthma, migraine, gout, etc. are found. In general it is common in persons of nervous, mobile temperament, and is moreover apt to point to temporary exhaustion from some cause, though this is by no {1239} means always true. The writer has seen several sensory disorders of this class at the period of life of which the menopause is the chief feature. The pains of apparently hypochondriacal patients doubtless belong sometimes in this group.

The pain of gastralgia is felt primarily at the epigastrium, whence it may radiate upward and backward along the œsophagus and through into the back, as well as laterally in various directions. Allbutt says that it is sometimes associated with anginiform attacks.

Other associated symptoms are dyspnœa, prostration, faintness, coldness of the extremities, or reflex changes in the action of the heart, which may beat feebly, rapidly, and irregularly, or more slowly than normal.

Apropos of the relation of gastralgia to organic disease, it is important to recall the fact that some of the organic diseases of the stomach, notably chronic ulcer and cancer, may fail to reveal their presence by any physical sign. In a case seen by the writer a cancerous growth had invaded the entire stomach, causing an enormous thickening of its walls, yet no tumor was to be felt, and the most marked symptoms were gastralgia and exhaustion.

The relations of gastralgia to the other purely functional disorders of the stomach are interesting and peculiar. It is beyond a question that every variety of digestive disorder, from simply delayed and painful digestion to pyrosis, the formation of gas, and constant vomiting, is much more often of purely neurotic origin than has been supposed.

The DIAGNOSIS of catarrhal gastritis as distinguished from nervous dyspepsia is indeed often difficult or even impossible. Leube has recently recorded a case where the matter vomited during life contained fungoid growths, such as are usually considered pathognomonic of gastritis, and yet at the autopsy the mucous membrane appeared perfectly healthy.

With these nervous disorders of digestion, which are by no means confined to hysterical patients, gastralgia may be variously associated, or it may occur independently of them all, or vice versâ. On the other hand, digestion may be attended with a sense of discomfort, often amounting to severe pain, yet without regular outbreaks. This symptom is classified by Allbutt as a hyperæsthesia of the stomach rather than as a neuralgia, but from this to true gastralgia there is only a sliding scale of difference. Sometimes a persistent neuralgic habit is set up by a local disorder which itself passes away entirely.

TREATMENT.—In acute attacks the aim is simply to relieve pain by whichever of the well-known methods promises the best. The real field for thought and care is in the treatment of the underlying states—first, those which, like gout, anæmia, syphilis, or nervous debility, predispose to the attacks; second, the local or special conditions which act as exciting causes. Sometimes it will be found that such patients have special idiosyncrasies with regard to the nature of food or time of meals.

In that condition of the system which is indicated by frequent or paroxysmal excess of uric acid in the urine a long-continued use of Vichy water or lithia is sometimes of service. If it be finally concluded that the stomach is in an hyperæsthetic, not in an inflamed, condition, it may not be advisable to diminish the amount of food, but, on the contrary, by one means or another, to increase it.

{1240} NEURALGIA OF THE UTERUS AND OVARIES.—Attention has repeatedly been called to the fact that affections of these organs may excite neuralgias in distant parts of the body or in the lumbo-abdominal nerves; but besides these the uterine and ovarian nerves themselves sometimes are the seat of neuralgia, and it is claimed that menorrhagia and metrorrhagia may occur as a consequence.

The other abdominal organs and the testis are occasionally the seat of neuralgic pains, and attacks which involve the liver may be followed by swelling of the liver and by jaundice.

It is not always easy to assert with confidence whether an attack of abdominal neuralgia affects the external or the visceral nerves.

NEURALGIA OF THE ANUS AND RECTUM is a well-marked and painful affection, and the tendency to it may be hereditary. The seizures themselves may come on spontaneously, especially after fatigue, or may be excited by slight irritations, such as the passage of hardened feces, or may follow seminal emissions. The pain may be accompanied by quick, clonic spasm of the perineal muscles.

The rapid injection of hot water into the rectum often at once relieves the attack.

* * * * *

We have not space to discuss at length the neuralgiform affections of the joints and muscles and those due to the metallic poisons and other causes which do not follow the course and distribution of special nerves.

In accordance with the belief which we have expressed, that neuralgic attacks are not always of the same nature, but are the manifestations of many different conditions, we should be inclined to include many of these irregular affections under the neuralgias instead of classifying them apart, as Anstie and most writers have done. Thus, a patient of the writer, a gentleman of middle life, who has had migraine since childhood and belongs to a neuropathic family, suffers on the slightest exertion from violent pain in both thighs, which comes on very gradually, beginning at the knees and spreading upward, eventually passing away after a night's rest. One might diagnosticate this as myalgia if he confined himself to topographical considerations, but the history of the patient and the regular march of the attacks point to a different conclusion.

{1241}

VASO-MOTOR AND TROPHIC NEUROSES.

BY M. ALLEN STARR, M.D., PH.D.

DEFINITION.—In the term vaso-motor and trophic neuroses it is intended to include a number of forms of disturbance of circulation and nutrition which are caused by disorders of the nervous system. Such disturbances may occur in any part of the body. They are not to be regarded as distinct diseases, but rather as symptoms of lesions in the peripheral or central nervous system. They may present themselves in various forms, as hyperæmia or anæmia or instability of vascular tone, as atrophy or hypertrophy or disintegration of normal tissue. Their consideration cannot, however, be assigned to any previous department of this volume nor relegated to various divisions of it; partly because in some cases they are to be traced to lesions of the sympathetic system, not elsewhere considered; partly because of our ignorance as to the exact location in many cases of the lesion of which they are manifestations.

It is probable that at a future time this chapter will disappear from a system of medicine, as the chapter on ascites has disappeared, and that the symptoms under consideration will be distributed among various departments as symptoms of ascertained lesions in various organs. For the present, however, they demand a separate discussion.

It is not possible to distinguish accurately in all cases between the vaso-motor and the trophic neuroses, for while in many features they are distinct, in a large proportion of cases they occur together. But it is not possible to ascribe all trophic changes to vascular disturbance, nor all vaso-motor changes to a defect or excess of trophic action. Hence a separate consideration of these allied subjects must be given. It is always to be remembered, however, that each may give rise to the other, and that in their pathology they are closely connected. Vaso-motor disturbances manifest themselves (1) by a dilatation of the vessels, producing redness, heat, and rapid metabolism in the part affected; or (2) by a contraction of the vessels, causing pallor, coldness, and malnutrition; or (3) by an alternation of these conditions and consequent temporary disturbance of function. Trophic disturbances may occur in consequence of such increase or decrease of blood-supply, or independently of any vascular change, causing (1) an abnormal production of tissue in an organ, or (2) a decrease in the size and number of its constituent cells, or (3) an actual degeneration of the elements which make it up, after which their place may be taken by another kind of tissue. Under all these circumstances the function of the part affected will be disturbed, and symptoms will be produced which will vary with the tissue or organ involved. Hence a {1242} general consideration of these symptoms must be given. Before proceeding to a detailed consideration of these neuroses it is necessary to review the physiology of the vaso-motor and trophic systems, in order to make clear the manner in which they perform their functions. And inasmuch as the pathology of these affections is best understood by comparison with experimental lesions made by physiologists in investigating their function, it will be treated together with their physiology.

Vaso-motor Neuroses.

PHYSIOLOGY.—Local Vascular Tone.—Since changes in the force and frequency of the heart's action, and variations in the total amount of blood in the body, affect the body as a whole, the state of circulation in any one organ or part must be dependent upon the degree of contraction or dilatation of its own vessels. This is known as the local vascular tone. It is under the control of a system of nerve-ganglia with their subservient fibres which are found in the middle coat of all arterioles (Fig. 56). The energy expended by these ganglia is manifested by a constant moderate contraction of the circular muscular coat of the artery—a contraction which is as constantly opposed by the dilating force of the blood-pressure within the vessel. An exact equipoise between these two forces never occurs, since each varies constantly, but in a state of health one never becomes permanently excessive. Considerable variations, however, in the local {1243} vascular tone are frequently observed. Thus each organ is influenced to a certain degree by every other, since an increase of blood in one part must involve a decrease in all other parts, the total amount of blood in the vessels being constant. Alteration in the heart's action is felt more quickly in some organs than in others, and thus the general blood-pressure by its variations may cause secondarily a disturbance of local vascular tone. The variations now under consideration, however, are not of this kind. They are such as are produced by influences acting directly upon the ganglia in the vessel-walls.

Local irritation is such an influence, and it may excite the ganglia to increased activity, so producing a contraction of the vessel and consequent pallor; or it may suspend the action of the ganglia, so producing a dilatation of the vessel and consequent flushing.

Another influence is irritation acting from a distance and conveyed to the local ganglia by nerve-fibres. These nerve-fibres can be distinguished from all others by their structure, being non-medullated, and by the fact that they have an indirect course, passing from the central nervous system to the sympathetic ganglia, and from these to the local ganglia in the vessels. The impulses sent along these nerves may affect the local ganglia in one of two ways, and either cause contraction by exciting the ganglia, or dilatation by inhibiting the action of the ganglia. The result produced has determined the names given to the impulse, to the fibre transmitting it, and to the centre whence the impulse proceeds, and hence vaso-constrictors and vaso-dilators are distinguished from one another.

The history of the development of the sympathetic nervous system, as well as its gross anatomy, affords distinct proof that it is not an independent system, as Bichat supposed, but is closely connected in its physiological action with the spinal cord and brain. Impulses which reach the sympathetic ganglia from a distance along the vaso-constrictor or vaso-dilator fibres originate in the central nervous system. The nervous mechanism which controls the local vascular tone is therefore a complex one, consisting not only of the set of local ganglia connected with larger sympathetic ganglia, but also of centres in the spinal cord connected with higher centres in the brain. The brain-centres in turn are complex, consisting of an automatic mechanism in the medulla regulating the action of all the subordinate parts below it, and of a series of cortical centres whose function it is to stimulate or inhibit the medullary mechanism. It therefore becomes evident that local vascular tone may be modified by local causes acting on the ganglia in the vessels—e.g. cold or heat; by changes in the sympathetic ganglia—e.g. the hyperæmia of the face in lesions of the cervical ganglia; by reflex action through the spinal cord—e.g. pallor produced by pain; by reflex action through the medulla oblongata—e.g. glycosuria following sciatica; or by conscious or unconscious impulses coming from the cortex—e.g. the blush of shame, the vaso-motor paralysis of hemiplegia.

Vaso-constrictors.—Such a mechanism, however complex in structure, would be easily comprehended if the constant manifestation of energy in the maintenance of arterial tone had its only source in the action of the local ganglia in the vessels, and was affected only occasionally by impulses {1244} from a distance, as has been thus far supposed. This, however, is not the case, as has been demonstrated by a series of experiments beginning with the brilliant researches of Claude Bernard. The classical experiments of the French physiologist were made upon the sympathetic cord in the neck of a rabbit. Division of this was found to produce a dilatation of the vessels of the ear. Irritation of the peripheral end of the divided cord produced a contraction of the vessels. Division of the spinal nerves connected with the cervical sympathetic and of their anterior roots, or irritation of the cut ends, produced effects similar in character to those caused by division or irritation of the cervical sympathetic. Destruction of the spinal cord in the lower cervical region, or division of the cord at any higher level up to the medulla, was followed by dilatation of the vessels. If the segment of the divided cord just below the section was irritated the vessels contracted. Destruction of the medulla at the calamus scriptorius and above it for three centimeters produced a general dilatation of all the vessels in the body, but division above this level had no effect. The initial congestion produced by these various experiments was accompanied by a rise of temperature in the part. It was followed after a time by a partial recovery of vascular tone, which was more complete the farther the division from the local ganglia. These facts warranted the conclusion that the energy expended by the local ganglia in holding the vessels in a state of constant moderate contraction is derived from the central nervous system, primarily from the automatic centre in the medulla, which in turn is reinforced by each of the secondary centres in the spinal cord and sympathetic ganglia; and also that while the medullary centres control the entire body, the cord and sympathetic centres control only those parts with which they are especially related. In order, therefore, to the maintenance of normal vascular tone the local ganglia must be intact, and they must be in connection with the sympathetic ganglia; these must be active, and must be connected with the spinal cord; the cord must be normal, and its tracts from the medulla must be capable of conduction; the medullary centre must be active, and not hindered or spurred by cortical impulses of a conscious or unconscious nature. Any injury to one or more of these parts will produce a vascular dilatation by interfering with the transmission of vaso-constrictor impulses from within outward, and any irritation of one or more of these parts may cause a contraction of the vessels by increasing the normal stimulus sent to the local ganglia by the vaso-constrictors.

Vaso-dilators.—The action thus far considered has been wholly of a vaso-constrictor kind, and the dilatation which has been mentioned has been due to cessation of the constrictor energy normally passing outward. This may be termed a passive dilatation. It is the kind produced by division of any one of the sympathetic ganglia or cords. But further experiments have shown that another kind of dilatation may be produced, traceable not to a mere cessation of constrictor impulses, but to an impulse of a positive kind sent to the local ganglia and resulting in a sudden suspension of their activity. Such an impulse is really an inhibitory impulse arresting the action of the ganglia in spite of the continued stimulus sent to them from the central nervous system. Its result is a dilatation of the arteries, produced by the blood-pressure within them, which may be termed an active dilatation. Thus, Bernard {1245} found that irritation of the chorda tympani caused an immediate flow of blood to the submaxillary gland because of the dilatation of its vessels. And Dastre and Morat have demonstrated a similar effect in the head and extremities after irritation of portions of the cervical sympathetic and of the peripheral nerves.

Much confusion has arisen from the use of the term active dilatation, and many explanations of its mechanism have been offered. At first it was supposed that a system of longitudinal fibres in the vessel-wall acted as opponents to the circular constrictor fibres. This theory, originating with Stilling and Duchenne, has been lately revived by Anrep and Cybulski. They hold that since a vessel elongates as well as dilates with every heart-beat, its total distension is the result of two factors—viz. transverse and horizontal distension. If one of these is neutralized, they claim that the other will be increased. Longitudinal fibres in the wall by preventing elongation may thus allow the entire force of the heart to be expended in dilating the vessel. This theory has not, however, been accepted, and with that of Schiff, that contractile elements of the connective tissue surrounding the vessel-walls could pull outward the walls and thus dilate the vessel, has lapsed, because of lack of demonstration of the necessary anatomical structure in all arterioles. Another theoretical explanation, that dilatation of the arteries is caused by contraction of the veins damming back the blood, is disproved by the fact proven by Dastre and Morat, that blood-pressure increases instead of diminishing in the veins during vaso-dilator action. Legros and Onimus, noticing the normal occurrence of a peristaltic motion of centrifugal direction in the arteries of the retina, which if increased produced a certain degree of hyperæmia, attempted to explain the phenomena of dilatation by supposing a sudden increase of peristalsis. But Vulpian has proved that the peristalsis is both too slight and too slow in its effects to account for the rapid action of the vaso-dilators, and Dastre and Morat have shown that the peristalsis, not being synchronous with the heart-beat, really impedes the flow of blood. The last theory to be mentioned has a chemical basis, and is known as the theory of attraction (Brown-Séquard, Severini.) According to this, the organs, when active, manifest increased metabolism, to maintain which the blood is drawn toward them by the chemical changes in progress. This theory was based on the fact that irritation of the chorda tympani causes an increased secretion of saliva as well as a congestion of the submaxillary gland. It is now known, however, that these two acts are independent of each other, as either can be suspended while the other continues. Hence this theory too has lapsed.

The view already stated, that vaso-dilators act by inhibiting local ganglia which cause contraction, is now accepted, especially since it is found that such inhibitory activity is constantly displayed by other parts of the nervous system, and is competent to explain the facts. The active dilatation produced by the inhibition of the action of the local ganglia is {1246} therefore to be clearly distinguished from the passive dilatation caused by the cessation of normal tonic impulses sent to them from higher centres. The former is a positive active vaso-dilator phenomenon. The latter is a negative paralytic vaso-constrictor phenomenon. The former is more effective, the dilatation being greater in degree and more permanent than the latter, and resembles exactly the dilatation produced experimentally by exhaustion of the activity of the local ganglia by over-stimulation of the constrictors.

An important point of contrast which has been established between vaso-constrictor and vaso-dilator impulses is that while the former are constant the latter are intermittent. Hence they cannot be regarded as opponents of one another. In a normal quiescent state vaso-constrictor energy is always being supplied to counteract the continued intravascular pressure ever renewed with the cardiac systole. The vaso-dilators are inactive. In an organ thrown into functional activity an increased flow of blood at once takes place, proportionate to the work being done by the organ. Such a functional hyperæmia might be produced either by a cessation of constrictor impulses or by an inhibition of their effects. It is by the latter means and through the vaso-dilators that it is produced, and it is probably the chief function of the vaso-dilator nerves to regulate the blood-supply in accordance with the need of a part. For this reason these nerves have been supposed to pass with the motor nerves to the muscles. As few organs exist without a possible use, it is probable that vaso-dilators pass to all parts of the body, as Vulpian asserts, though they have not been demonstrated in every organ or every part.

Like the vaso-constrictors, the vaso-dilators can be traced to the spinal cord, and their centres there are governed by a general centre in the medulla, which in turn may be affected by impulses from the cortex. A destructive lesion in any part of the vaso-dilator system does not produce as marked effects as one involving the vaso-constrictor system, since the symptoms of such a lesion will only appear when the vaso-dilators are called into play. When the vaso-dilator nerve to the submaxillary gland is cut, no change is observed until by some sapid substance put in the mouth its function should be excited, when the gland is no longer found to flush with blood as in the normal state. It is by means of the vaso-dilators that erectile organs become engorged with blood. Eckhard has shown the nervi erigentes of the penis to be vaso-dilator nerves. If they are destroyed, the organs will not respond to the wonted stimulus—a symptom which, however, would only be noticed at intervals. An irritative lesion of the vaso-dilator system may produce permanent congestion of an organ or part, but this seems to be rather more rare than a congestion from paralysis of the constrictors. It is seen in injuries of the peripheral nerves.

Origin of the Vaso-motor Nerves.—The exact course of the vaso-constrictor and vaso-dilator nerves has been traced from various parts into the central nervous system by the careful experiments of Dastre and Morat, and more recently by Gaskell. It is now established that they {1247} exist as separate nerves, although they often run together, and that they usually enter the spinal cord at different levels.

If the various spinal nerves be cut singly from above downward, and the effects noted, and if the peripheral ends be irritated and the effects noted, and if with proper care the results be analyzed and compared, it will be found that the anatomical connections of the segments of the spinal cord with the sympathetic ganglia, which are so evident at each level, are not the ones by which physiological impulses pass out at that level. The vaso-constrictors of the head, which can be traced to the superior cervical ganglion, do not come from the upper cervical region of the cord, as might be supposed from the connections of that ganglion, but from the first three dorsal nerves. They reach the ganglion through the sympathetic cord in the neck, having traversed the inferior cervical ganglion on the way. There are vaso-constrictors in the cranial cavity which accompany the third, fifth, seventh, and twelfth nerves to the eye, face, and mouth. It is still undecided whether they originate in the cord and medulla, issue in the spinal accessory nerve, and with it enter the cranium (Gaskell), or reach those nerves by way of the carotid and vertebral plexus from the inferior cervical ganglion (Dastre and Morat). The vaso-constrictors of the arm, which can be traced to the inferior cervical and upper thoracic ganglia and to the thoracic sympathetic cord, are derived from the seven upper dorsal nerves. It is true that division of the roots of the brachial plexus causes a slight dilatation of the vessels of the arm, but this is so much increased when the dorsal nerve-roots are divided that it is evident that it is through them that the constrictor fibres chiefly pass. The vaso-constrictors of the leg, which can be traced into the second and third lumbar ganglia and lumbar sympathetic cord, are derived from the five lower dorsal and first lumbar nerves, and only join the crural and sciatic nerves after passing through the abdominal sympathetic. The thoracic viscera are probably supplied partly through the branches of the inferior cervical and thoracic ganglia, and partly through the pneumogastric, the latter statement being disputed by Gaskell. The abdominal viscera are supplied partly through the splanchnic nerves, which are made up of fibres issuing from the cord in the fifth to the twelfth dorsal nerves inclusive, and partly through the pneumogastric. Thus the dorsal region of the cord is the origin of the majority of vaso-constrictor fibres in the body.

The origin of the vaso-dilators is also to be traced to the dorsal cord. The vaso-dilators of the bucco-facial region come from the second to the fifth dorsal nerves, whence they pass to the first thoracic ganglion, and thence by the annulus of Vieussens into the cervical sympathetic cord. Those of the eye, head, and ear come from the same ganglion, but have their spinal origin in the eighth cervical and first dorsal nerves. Those of the arm are traced into the upper thoracic sympathetic cord, which they reach from the five upper dorsal and last cervical nerves. Those of the leg are traced to the first and second lumbar ganglia and the lumbar sympathetic cord, which they reach from all the dorsal nerves from the sixth downward. Gaskell holds, however, that the vaso-dilators of the extremities pass out of the cord in the cervical and lumbar plexuses and accompany the cerebro-spinal nerves. The vaso-dilators of the thorax and {1248} abdomen are supposed to pass in the pulmonary plexus and splanchnic nerves, but this is not yet fully determined.

Gaskell believes that vaso-motor nerves can be distinguished from motor and sensory nerves in the spinal nerve-roots by the smallness of their calibre. He finds such fine fibres only in the spinal nerve-roots between the second dorsal and second lumbar segments of the cord (in the dog), and in the three upper roots of the spinal accessory nerve. According to his account, the vaso-constrictors issue from the spinal cord in both anterior and posterior nerve-roots as medullated fibres, and pass to the sympathetic ganglia lying on the vertebræ (proximal or lateral ganglia); there they lose their medullary sheath, and either end in cells whence new fibres issue, or more probably pass directly onward as non-medullated fibres, having a connection with the unipolar cells of the ganglia only for purposes of nutrition. The number of fibres issuing from any one ganglion is much greater than the number entering it from the cord; hence it is supposed that each medullated fibre splits up into a group of non-medullated fibres; which is possible, as the researches of Ranvier have shown that each axis-cylinder is made up of numerous fibrils. Leaving these ganglia, the nerves pass either to the second series of ganglia (distal or collateral ganglia), whence they issue in plexuses to enter the vessels, or to the vessels directly, where they divide in plexuses. It is in the meshes of the plexus that the local ganglia of the vessel-walls are found. The vaso-dilators are thought to differ from the vaso-constrictors in passing directly to the distal ganglia as medullated fibres, not being connected in any way with the proximal ganglia. Gaskell makes no statement regarding their limits of origin from the cord, except to state that the nervi erigentes issue with the sacral nerves. He agrees with the view that the vaso-dilators act as inhibitory nerves upon the local ganglia.

Vaso-motor Reflexes.—Thus far, reference has been made only to fibres whose direction of transmission is centrifugal, and whose exit from the spinal cord is by the anterior nerve-roots. There are other fibres, however, through which centripetal impulses pass, and these enter the spinal cord with the posterior nerve-roots. The function of these fibres is to transmit sensory impulses inward to reflex centres, and thus set in action motor mechanisms of a vaso-constrictor or dilator kind whose effects are produced at the periphery. There are, therefore, vaso-motor reflexes, as well as skin and tendon reflexes, whose centres are in the spinal cord. These reflex acts may be excited by impulses reaching the centre not only through the vaso-motor centripetal nerves, but also through the sensory nerves of the cerebro-spinal system. The effect of changes of temperature on the circulation in the skin (if the right hand be plunged in cold water there is a fall of temperature in the left hand), the effect of pain upon the color of the face and the size of the pupil, the red cheek on the affected side in pneumonia, the occurrence of glycosuria during sciatica,—are all instances of such reflex acts. Many vaso-motor affections are produced by irritation causing reflex effects at a distance from the seat of irritation—a fact always to be kept in mind. The utility of counter-irritation to the surface in diseases of the internal organs is explained by supposing that vascular changes are produced in those {1249} organs through reflex mechanisms set in action by the local irritation. While some of these reflexes may have their central mechanism in the local ganglia, it is probable that the majority are to be traced to the spinal cord. It is believed that the sympathetic ganglia are not the seat of reflex centres.

Since the vaso-motor nerves are connected almost exclusively with the dorsal portion of the spinal cord, it is very natural to conclude that the vaso-motor reflex centres are situated in this region; and the hypothesis has been advanced by Jacubovitch, and strongly urged by Gaskell, that the cells of the vesicular columns of Clarke, which are peculiar to this region, are the seat of these reflex mechanisms. This hypothesis gains some support from the pathology of syringo-myelia. In this disease the gray matter surrounding the central canal and the vesicular columns are destroyed. The characteristic symptoms are vaso-motor and trophic disturbances, consisting of changes in the vascular tone, changes of local temperature, and various eruptions, in some cases going on to ulceration in the skin and mucous membranes. It is, however, undecided whether the vaso-motor centres of the cord are limited to the columns of Clarke, or are situated in the gray matter surrounding the central canal, since both these parts are destroyed in this disease. That they are not located in the anterior or posterior gray cornua is determined by the fact that diseases limited exclusively to these areas do not cause vaso-motor disturbances. The situation of the various reflex centres for the various parts of the body is at different levels of the cord, as has been determined by the experiments already cited to establish the level of origin of the vaso-motor nerves. The exact location of the vaso-constrictor and vaso-dilator reflex centres for definite parts is yet to be ascertained.

Vaso-motor Tracts.—These reflex centres are connected with the medulla by tracts which lie in the lateral columns of the spinal cord, although it is not determined in which part of these columns. It is not possible as yet to separate the constrictors from the dilators in this tract, nor to determine whether it transmits impulses in both directions or only from above downward. Nor is the course of associating fibres between reflex centres at different levels known. In cases of transverse myelitis the control of the medulla is removed from the vascular centres below the lesion, and the lack of vascular tone seen in the paralyzed limbs, together with the susceptibility to local irritation, is the result of this division of the vaso-motor tracts.

{1250} Medullary Centres.—It has been stated already that a general vaso-motor centre with both constrictor and dilator powers is situated in the medulla. This lies in two divisions on each side of the middle line, in or just beneath the floor of the fourth ventricle, from the calamus scriptorius up to the level of the sixth nerve-nucleus. Each division governs the vascular tone of its own side of the body, and lesions in its region in man produce unilateral vaso-motor symptoms. This centre can be excited to reflex action by strong irritation locally or through the blood, in which case a general constriction or dilatation of the vessels of the entire body will ensue. It seems probable, however, that the general centre in the medulla is made up of a number of special centres, each of which governs a definite set of organs. The vascular tone of the thoracic and abdominal viscera is certainly regulated by a series of such centres. Brown-Séquard and Schiff have produced hemorrhages in the lungs, pleura, stomach, intestines, and kidneys at different times by destructive lesions of the medulla, and the well-known experiments of Bernard, in which by puncture of the medulla local hyperæmia of the liver or kidneys was caused, producing glycosuria or polyuria, confirm this view. Lesions of these parts in man produce similar effects. Charcot has shown that in cerebral hemorrhage ecchymoses may be found in the stomach, pleura, and endocardium, and that pneumonia is especially frequent upon the paralyzed side. De Jonge has been able to collect thirteen cases of diabetes mellitus in which a lesion of the medulla (hemorrhage or tumor) was found after death; and Flatten has proven the existence of similar lesions in diabetes insipidus. The connection of these centres with the liver and kidneys has been traced elsewhere. The medulla contains a special centre for the vaso-motor nerves of the abdomen, which are in the domain of the splanchnic nerves. This centre is excited reflexly by impulses reaching it through the depressor nerve of Cyon from the heart; so that when that organ is overburdened it may be relieved by a fall of arterial pressure produced by dilatation of the abdominal vessels. Whether the connection of the medulla with the centres in the semilunar ganglion which preside directly over these vessels is made by way of the spinal cord or by way of the pneumogastric nerve is still undetermined, though the researches of Gaskell favor the former view. Gastric and intestinal disturbances are certainly produced by nervous lesions in the medulla, but whether they are due to vascular changes is uncertain. The vomiting of mucus and blood, and the large watery evacuations which accompany mental shock or anxiety, as well as the polyuria associated with mental effort, have been ascribed to irritation of local centres in the medulla governing the gastro-intestinal and urinary organs by impulses received from the cortex above. The spleen is under the control of vaso-motor centres, since section of the splenic branches of the semilunar ganglia will produce a great enlargement of the organ, and irritation of the cut end of these branches will produce {1251} contraction. The medulla also contains a vaso-dilator centre for the erectile tissues of the genital organs, irritation of which by mental action or local disease causes impulses to pass to the nervi erigentes by way of the spinal cord, resulting in a flow of blood to the parts. Although a centre has been thought to exist controlling the circulation in the lungs, whose paralysis has been supposed to explain the occurrence of sudden pulmonary œdema without other known cause, no definite facts regarding it are known. That the action of the heart is under the control of the medulla is a fact too well known to require more than a mention. The physiology of the nervous control of the heart cannot be discussed here.

While these medullary centres are certainly influenced by impulses reaching them from the cerebral hemispheres, as is evident from the vaso-motor symptoms produced by mental action—e.g. pallor from fright, blushing, etc.—it is impossible to state in what portion of the hemispheres in man the higher vaso-motor centres lie. Eulenburg and Landois locate them in the motor area in animals. They are certainly beyond control of the will, and are wholly reflex in their action, a purely mental act in this case being the excitant of a purely physical result.

PATHOGENESIS.—From this review of the physiology of the vaso-motor system it becomes evident that disturbances of vascular tone may be produced by many different causes acting upon many various parts. They may be due to local affections of the part in which the symptoms are present, as in the case of erythema after burns or frost-bite, or congestion of any organ after injury. They may be due to affections of the vaso-motor nerves passing to the part affected, as in the case of vascular changes due to peripheral nerve lesions. They may be due to affections of the sympathetic ganglia connected with the part affected, as in the case of migraine, sudden flushing of one ear, certain cases of polyuria, and Basedow's disease. They may be due to lesions in the spinal cord affecting the vaso-motor centres or compressing the nerve-roots on their way to and from the sympathetic ganglia, as is the case in the various forms of myelitis and in Raynaud's disease or symmetrical gangrene, and in meningitis, tumors of the cord, or Pott's disease. They may also be caused by such conditions in the cord as cut off the vaso-motor centres from the medullary centres, such as transverse myelitis from compression or traumatism. They may be due to lesions of the medulla oblongata, as is seen in some cases of polyuria and glycosuria, and in cases of universal erythema following acute fevers. They may be due to diseases of the cerebral hemispheres, as is evident from the vaso-motor symptoms occurring in hemiplegia and hysteria. Finally, they may be of a reflex {1252} origin, dependent upon some obscure source of irritation in a part quite distant from the region in which the symptoms appear.

The DIAGNOSIS of the seat of the lesion in many cases of vaso-motor neurosis may be made if the organ or the exact limitation of the area affected be ascertained, and the history of the case, together with the concurrent symptoms of other kinds, be considered. In some cases no organic cause can be found, and in these a reflex cause should be diligently searched for.

SYMPTOMS.—A vaso-motor affection may manifest itself either by a spasm or a paralysis of the vessels. In angiospasm the part affected becomes pale, and irritation no longer causes a vaso-motor reflex. It looks shrunken, and if the skin over it is loose it may be thrown into folds or shrivelled, presenting the appearance seen in the hands after long immersion in hot water. The lack of blood in the part arrests the processes of metabolism which are normally constant, and if the condition continues this may result in such a disturbance of nutrition that ulceration, or even gangrene, may ensue. The local anæmia, combined with the cessation of metabolism, produces a fall of temperature in the affected part, which is then more easily affected by the temperature of the air than in a normal state, so that exposure to cold is very liable to cause freezing. These conditions necessarily produce an impairment of function, so that if the affection is located in the extremities, as the fingers, they are soon rendered useless. The term digiti mortui has been applied to this state. In the surface of the body angiospasm causes cutis anserina, pallor, numbness, tingling, slight anæsthesia, and analgesia. If it occurs in a limb, the finer motions are imperfectly performed, and in time the nutrition of the muscles may be so impaired as to produce atrophy and paresis. It may even lead to gangrene. Nothnagel has recorded five cases of sciatica in which the pain produced a reflex spasm of the vessels of the leg, which, persisting, resulted in partial paralysis, atrophy, lowering of temperature, pallor, and sensory disturbances. Ross mentions the sudden appearance of circumscribed patches on the hands and forearms of washerwomen, in which there is a pallor, coldness, and partial anæsthesia. These may be limited to the distribution of a single nerve, and may be accompanied by trophic affections.

Spasm of the veins may occur as well as of the arteries, or independently of them. In the latter case the blood will not pass out of the capillaries. The part will then be blue, swollen, œdematous, and painful; the temperature will be lowered by increased radiation of heat, and all the sensations and functions be impaired in greater or less degree. If this continues, nutrition may suffer, and in the end gangrene develop, which will take its course and lead to the throwing off of the part. Grainger Stewart has described such a condition occurring in both hands and feet. It may be likened to a severe form of Raynaud's disease.

Angio-paralysis is more frequent than angiospasm, and may be due either to paralysis of the vaso-constrictors or to excitement of the vaso-dilators. It shows itself by a bright-red or mottled appearance of the skin, and increase of local temperature, and more rapid processes of {1253} nutrition, together with an increase of secretion if the part is a gland or a mucous membrane, and an increase of sweat if it is the skin. In the latter case an increased sensitiveness to changes of temperature, a subjective sensation of heat, and hyperæsthesia and hyperalgesia may occur. The hyperæsthesia on the paralyzed side which is present in hemiparaplegia spinalis is ascribed to the vaso-motor paralysis. But these symptoms soon give place to others. The dilatation of the vessels, which at first caused an increased flow of blood to the part, produces a slowing of the blood-current in the part, just as a river runs less rapidly where it becomes wider. The slowing of the current in the skin allows of a more complete cooling of the part as the radiation of heat and the evaporation of moisture are increased, and the slowness of the renewal of blood impairs the processes of nutrition, so that to the first stage of redness, heat, and increased metabolism there ensues a stage of blueness, cold, and defective nutrition, and the function of the part may be impaired. In this stage it usually presents a mottled appearance, and may be slightly swollen and œdematous, and the continued increase of perspiration gives it a clammy coldness to the touch. In all of these conditions severe pain, sometimes of a burning character, is a very distressing symptom (causalgia). These conditions are seen in peripheral nerve-lesions, and give rise to the appearances which have been so admirably described by Weir Mitchell.

A peculiar combination of symptoms may be mentioned here, to which Weir Mitchell has given the name of erythromelalgia. This disease begins with tenderness and pain in the soles of the feet, which are soon followed by a marked distension of the capillary vessels. The congestion is attended by a sensation of burning pain similar to that produced by a blister. The surface is at first of a dull dusky-red color; later it appears purple. The redness is not uniformly distributed over the sole, but occurs in patches of irregular shape, being especially frequent over prominent parts exposed to pressure and friction, and the attacks seem to be brought on by long standing or walking. At first there is a rise of temperature in the affected surface, the arteries pulsate visibly, the veins are swollen, and there may be some œdema. Later, the foot is cold and pale. Sensations of touch and temperature are normal, but the part is so extremely tender that walking is impossible. There is no paralysis. One or both feet may be affected, but the patches of redness are rarely symmetrical. The hands are occasionally affected. The condition may occur in paroxysms or may remain for some time. It resists all known methods of treatment, although applications of cold relieve the burning pain to some extent and the tenderness enforces rest.

With angio-paralysis may be classed the taches cérébrales of Trousseau no longer considered diagnostic of meningitis, but denoting a weakened condition of vaso-constrictor action in the local ganglia of the vessel-wall which may occur upon local irritation of the skin in any severe disease affecting the nutrition of the general nervous system.

Actual rupture of the capillaries in the course of vaso-motor diseases is rarely observed, although the stigmata appearing in hysterical and cataleptic patients may be ascribed to this cause. In this connection tabetic ecchymoses may be mentioned, which appear suddenly without local injury, {1254} and resemble an ordinary bruise, running a similar course. They occur only in the course of locomotor ataxia.

In addition to these forms of vaso-motor affections there is a condition of instability of vascular tone which manifests itself by sudden transient changes in the circulation of various organs. This is a functional affection, usually due to malnutrition. It is seen in many cases of neurasthenia and hysteria, and manifests itself by sudden flushes or pallor, alternations of heat and cold, local sweating, attacks of mental confusion, and inability to use any organ continuously from disturbance of the power of the vaso-dilators to maintain a condition of functional hyperæmia. Little is actually known about the causes of this state of the vascular system, although much has been written about it. (For a fuller description the article on Neurasthenia may be consulted.)

Many functional derangements of the internal viscera have been ascribed to such vaso-motor instability with more or less probability, but hypothesis of this kind, however plausible, is evidently beyond confirmation. It is especially in affections of this kind that causes of reflex irritation are to be carefully sought. Cutaneous angio-neuroses, such as have just been described, may affect any part of the body. They usually appear suddenly, producing much discomfort and an impairment of function in the part if it is an extremity. They disappear as rapidly as they come. The duration of such attacks varies from a few minutes to several days. They are very liable to recur. If it is the vessels under the control of the cervical sympathetic which are affected, the symptoms will be those of migraine or of lesion of the ganglia. If it is the vessels in the extremities which are involved, the condition of digiti mortui or erythromelalgia or symmetrical gangrene may be produced.

A singular epidemic occurred in France in 1828 and 1830 which was termed acrodynia. Many persons were suddenly seized with vomiting and purging, and soon after the onset the extremities became red or mottled in blotches, swollen and œdematous, and hot, painful, and tender. The attacks lasted from a few days to two months, and during this time the skin became thick and hard, the muscles weak and subject to spasms, and the general health was impaired. Relapses occurred in many cases, but all finally recovered, and hence the exact nature of the disease was not ascertained.

COURSE.—In any case of vaso-motor neurosis the course of the disease and its termination will depend chiefly upon its cause. If the cause is some permanent lesion of the nervous system, the condition will remain, and in this case the termination will depend upon the severity of the symptoms. Angiospasm may be so severe as to lead to gangrene ana the separation of the part affected, or may be so slight as to cause only subjective discomfort and a little pallor. Angio-paralysis may lead to an extreme degree of congestion, which is attended by heat and pain at first, later by paræsthesia and coolness, with increased liability of the part to be affected by changes in the surrounding air. This stage is succeeded by one of less marked dilatation of the vessels and a spontaneous partial {1255} recovery, although the more moderate symptoms may continue indefinitely and seriously impair the function of the part. If the cause is a temporary derangement of function in the vascular mechanism, is reflex irritation which can be removed, or is a curable organic disease, the symptoms will subside rapidly or gradually and perfect recovery may follow. If the condition is one of irritability in the vaso-motor centres, producing alternations of flashing or pallor, such as is observed in nervous exhaustion, it may recur irregularly for a considerable length of time until the causative condition can be removed.

PROGNOSIS.—The prognosis must be determined in each case by a consideration of the cause of the affection, of the nature of the symptoms, of the severity of the disease, and of the possibility of success in both symptomatic and causative treatment. In the angio-paralytic cases an eventual spontaneous relief from much of the discomfort may be promised, although the duration of the symptoms cannot be predicted.

TREATMENT.—Treatment must be directed primarily to removing or diminishing the severity of the cause. A review of the section on Pathogenesis will indicate how wide a field this may include, and the reader must be referred to the special articles which are alluded to in that place for therapeutic measures. Special diligence is to be shown in searching for a source of reflex irritation. When the cause cannot be reached, and when the symptoms are of such severity as to demand immediate attention, treatment may be directed to them.

In all conditions of vaso-motor disease it is important to shield the part from external injury; for if the vessels are dilated they are liable to rupture, and any abrasion of the surface may produce serious inflammation and ulceration; and if the vessels are contracted any injury will be repaired slowly and imperfectly on account of the anæmia, and may even hasten the approach of gangrene.

Perfect rest, bandaging with cotton, and even the application of a light splint to the extremities will be advisable in cases of angiospasm. It is desirable to retain the animal heat, inasmuch as its supply is deficient. In angio-paralysis rest in a somewhat elevated position and applications of mild evaporating lotions are indicated in the early stage; later, the limb may be bandaged. It is not advisable to attempt by tight bandaging to counteract the effect of the vascular paralysis, for the nutrition of the limb is liable to suffer and gangrene may be induced.

Massage of a part affected with vaso-motor symptoms is of great service, since the circulation can be increased in the veins, and thus indirectly in the capillaries, and the nutrition of the part can thus be favored. It is more efficacious in angio-paralysis than in angiospasm. Too rough rubbing is of course to be avoided, lest the skin be injured. All counter-irritation is to be strictly forbidden.

Electricity has been used with varying results. According to Erb, moderate faradic applications contract the vessels; strong faradic applications, especially with the brush, dilate the vessels. The galvanic current at first contracts the vessels, but this is followed by a secondary dilatation, which will be greater and occur more rapidly the stronger the current used. Cathodal closures contract the vessels; the anodal {1256} continuous current dilates them widely. Stabile continuous currents through a nerve dilate the vessels which the nerve supplies. Inasmuch as vaso-constrictors and vaso-dilators pass together in many nerves, and are found together in all parts, it is impossible to apply electricity to either alone. In those cases, therefore, in which it has been ascertained which set of vaso-motors is affected, it is not always possible to produce a direct effect upon that set by electrical treatment. Erb recommends, in conditions of vaso-motor spasm a trial of the galvanic current, the cathode on an indifferent point, the anode being applied over the vaso-motor centres governing the part, and also over the area of the body which is affected, and held there while a moderate continuous current is passing, interruptions being avoided; or, the cathode being placed on the neck, the anode may be applied to the nerves passing to the affected part; or a strong continuous current may be sent through the nerve, its direction being changed several times during a moderately long application. Finally, the faradic brush applied to the part or a strong faradic current sent through its nerve may relax the spasm. In any case, all these methods should be tried before electrical treatment is abandoned.

In vaso-motor paralysis other methods are used. The cathode is placed on the part congested, and a weak galvanic current is employed with frequent interruptions or even with changes of the pole; or the cathode may be moved about upon the reddened skin while a mild continuous current is passing. A very weak faradic current with wet electrodes, or even a weak faradic current applied with a brush, may be of service. Here, again, various methods may be tried.

If the extremities are affected, it may be well to immerse them in a basin of water which is connected with one pole of the battery, and the current directed in the manner just described, according to the case. It must be confessed that no definite results can be predicted from the use of electricity in these cases, and much more experience is needed before definite rules can be laid down. The records show that in apparently similar cases opposite methods of application have produced favorable effects, while in other cases all methods have failed. Too much reliance should not be placed in electrical treatment. Erythromelalgia is an obstinate affection, and symptomatic treatment, directed chiefly to quieting the pain by opium and allaying the sensation of burning by cool baths, must be resorted to.

Internal remedies may be tried appropriate to the condition present. In angiospasm nitrite of amyl inhaled, or nitro-glycerin 1/100 gr. t. i. d., may give considerable relief, although both of these drugs are to be used with caution. Chloral hydrate is also of some service, and where the patient is in pain and suffers from insomnia this may fulfil several indications. In angio-paralysis ergot has been used with advantage. Oxygen inhalations are of service. Chloride of potassium may also be tried. It is evident, however, that such remedies, acting as they do upon the general arterial system, are not to be depended upon in the treatment of local conditions, since they have no selective action upon the affected part. The majority of the drugs known as sedatives and antispasmodics have been used in these conditions, but the records of individual cases show that they are not of much avail. Theoretical therapeutic measures based upon {1257} experimentation on animals have been fully discussed by Lauder Brunton, but practical experience has not yet been sufficiently extensive to warrant any further statements.

Symmetrical Gangrene.

SYNONYMS.—Local asphyxia, Asphyxie locale, Raynaud's disease; Symmetrische Gangrän.

DEFINITION.—Symmetrical gangrene is an affection of the nervous system characterized by arterial or venous spasm appearing in symmetrical parts of the body, especially in the phalanges of all the extremities, which may result in trophic changes or in gangrene. There are various stages in the disease, which have given rise to the various names by which it is known. The stage of local syncope, in which there occurs a moderate contraction of the arterioles and consequent pallor of the part, may be followed by a stage of local asphyxia, in which the complete contraction of the arterioles cuts off entirely the supply of arterial blood, and the regurgitation of venous blood produces cyanosis of the part; and this, if continued, may result in the gangrene of the part, which is then thrown off. Instead of a condition of local asphyxia, there may be a spasm of the smaller veins, resulting in a local erythema, which may go on to capillary stasis and then to gangrene. The spasm of the vessels may cease at any stage as suddenly as it began; and if this occurs in the first or second stage, no gangrene results.

HISTORY.—While isolated cases of this affection had been recorded as curiosities during the past two centuries, the disease was first studied with care by Raynaud in his Thèse de Paris in 1862. He collected twenty-eight cases which had been described with accuracy or had been personally observed in the hospitals of Paris, and after a thorough analysis of the symptoms defined the disease as “a neurosis characterized by an exaggeration of the excito-motor power of the cord presiding over the vaso-motor nerves.” He called particular attention to the condition of spasm in the vessels, and proposed the name asphyxie locale to designate the peculiar appearance of the parts affected. He also noticed the resulting gangrene as a new variety of gangrene, not dependent upon embolism or upon changes of an atheromatous nature in the coats of the vessels.

The condition was at once recognized by others, and several cases had been reported prior to 1873, when Raynaud published a more complete article on the subject in the Dictionnaire de Médecine et de Chirurgie under the title gangrene symmétrique; in 1874 he recorded five new cases in the Archives générales de Médecine, vol. i. pp. 5 and 189.

The disease, having been thus established as a definite nervous affection, began to be noticed in other countries than France; and Billroth in Vienna, Weir Mitchell, Mills, A. McL. Hamilton, and J. C. Warren {1258} in this country, and many other careful observers, published cases, together with more or less complete articles upon the disease. In 1882, Weiss produced a monograph upon the subject containing references to all the cases which had appeared; and this is still the most complete article to be found, although the essay of R. Lauer and the discussion of the disease by the Berlin Medical Society, as well as the short articles of Schulz and Lutz, deserve mention, for they contain additional observations of cases and numerous facts not to be found elsewhere.

SYMPTOMS.—The disease begins suddenly in all cases, and the constitutional symptoms are less prominent than the local ones. In some cases there are noticed a certain degree of mental disturbance, a condition of depression with a tendency to sigh and cry without cause, disturbed sleep with unpleasant dreams, irritability, and headache. A loss of appetite and disorders of digestion may follow, and then the local symptoms appear. In other cases, which seem to be the majority, the local condition develops without any such premonitory disturbances of the nervous and digestive systems, although these may ensue. The local symptoms first noticed may be paræsthesiæ or pain in all the extremities, usually limited to the tips of the fingers and the toes. These are continuous and severe, and are immediately followed (and occasionally preceded) by an appearance of ischæmia or of cyanosis or of erythema, in the order of frequency named.

(1) The fingers may look pale and dead, presenting the appearance of the so-called digiti mortui, and may be cold, painful, and anæsthetic. If this condition is moderate in degree, a certain amount of blood will continue to flow through the contracted arterioles, and then it corresponds to the description given by Raynaud of syncope locale. If it is extreme, the part may be wholly deprived of arterial blood, and then a true local asphyxia is present. In this stage the patients usually suffer considerably, although some do not complain of pain until the next stage. The ischæmia is attended with an impairment of sensation to touch, temperature, and pain, and finer motions become clumsy on account of the subjective numbness and actual anæsthesia. At the same time, the fingers look shrunken, the skin being thrown into folds, as if the hand had been soaked in hot water, or they may appear as if frozen, the skin being hard and immovable. The secretion of perspiration may be increased, and the fingers feel damp as well as cold, or it may be suspended. The local temperature is lowered. If the part is cut, little or no blood will flow. At this stage the arterial spasm may suddenly relax and the part return gradually to its normal condition, the cessation of the constriction of the arteries and the return of blood being usually accompanied by burning pain, which may last for some hours. The duration of such an attack may vary from a few moments to several days. If it continues longer, this stage is usually succeeded by the second stage, of cyanosis.

(2) The stage of cyanosis results from one of two conditions: either the arterial spasm is so complete that no blood passes into the part, in {1259} which case venous blood from lack of vis a tergo or in response to gravitation regurgitates into the capillaries, distending them and producing a state of blueness; or a venous spasm occurs, preventing the exit of blood from the part, which then becomes actively congested, and the blood in the capillaries, from want of renewal, soon becomes venous and produces the cyanotic appearance. The stage of ischæmia may be so short that it is hardly noticed, so that the patient's attention is first attracted by the swollen, blue, and extremely painful condition. The skin may be stretched, the tissue infiltrated with products of exudation, which can be pressed out, as can also the venous blood, and the surface may itch as well as be painful. Anæsthesia is rarely present in this stage, and there may even be hyperæsthesia. The part is cool from the increased radiation of heat and cessation of the processes of metabolism, the local temperature being lowered. The small vessels on the surface will be visibly injected, and capillary ecchymoses may rarely be seen. There is less liability to difficulty in movement in this stage than in the former one, as the sensations of the part are not benumbed, but if present it is due to the swelling. This condition, like that in the former stage, may cease suddenly, the recovery of the normal appearance being, as a rule, slower than after a simple ischæmia. The duration of this stage has varied from a few seconds to several days. It is usually followed by gangrene.

(3) The condition of local erythema is described here because it may lead to gangrene, and has therefore been considered by Weiss as one of the early stages of the disease. As a rule, however, it is not followed by the death of the part, and the affection in these cases is probably one of erythromelalgia rather than of symmetrical gangrene. Like the stage of ischæmia, the stage of erythema may appear suddenly. The part presents a bright-red or a mottled appearance—is hot and swollen, and painful. The vessels are visibly injected, the local temperature is raised, the secretion of sweat may or may not be increased, and the patient feels a burning sensation rather than pain. Hyperæsthesia to touch and temperature and pain is usually present, or the sensations are normal. The blood can be pressed out, but returns immediately. In this condition of hyperæmia slight injuries lead frequently to an inflammatory process, ulcers may form in the pulps of the fingers or around the nails, and the eschars may appear dark and even gangrenous; or an actual condition of gangrene may appear in the tips of the fingers, the exact method of its occurrence being a matter of dispute. The erythematous condition is much more likely to be permanent than are the other stages of the disease—another fact which has led to some hesitation in considering it a true stage. This condition of erythema may be due to a paralysis of the vaso-constrictors, the converse of the spasm occurring in ischæmia. It has also been ascribed to an irritation of the vaso-dilators; and this appears to be the more probable hypothesis.

(4) The stage of gangrene is always preceded by that of cyanosis, and the death of the tissue is due to the arrest of nutrition consequent upon a stasis of the blood. It is not necessary to invoke the injury of trophic nerves to explain its appearance. In the tips of the cyanotic fingers, on their palmar surface, beneath the epidermis, a small blister appears, filled with a dark serous fluid or with pus or blood. This soon ruptures, and a dark dry scab forms, beneath which an ulceration may go on destroying {1260} the corium, but not penetrating deeper. In the majority of cases the gangrene is limited to a small area of the pulps of the fingers, and only involves the superficial layers of the corium. The gangrenous spot is surrounded by a purple margin. When the sphacelus has separated a scar remains which is frequently insensitive. In other cases when the sphacelus is thrown off it leaves a deep ulcer, which may look as if the lost tissue had been cut out with a punch, and this gradually granulates and heals. In still other cases the entire skin of the terminal phalanx may become black and dry, presenting a true gangrenous appearance. Then a line of demarcation is formed, usually at the junction of the terminal with the middle phalanx; separation of the gangrenous part occurs, and a stump is left covered with thin, glossy skin. This extensive gangrene, involving an entire phalanx, is the exception rather than the rule.

While the gangrenous process is in progress in the tip of the finger the nails cease to grow, and may become bulbous and rigid; the epidermis elsewhere may become dry and desquamate, and ulceration around the root of the nail may take place. With the completion of the stage of gangrene, which may last from one to five weeks according to its extent, the local symptoms terminate.

It is the symmetrical distribution of the local symptoms just enumerated which is the peculiar characteristic of the disease. The fingers of both hands, the toes of both feet, symmetrically situated spots upon the back, trunk, thighs, legs, forearms, and arms (in the order of frequency named), are affected either singly or in combination. In the majority of cases fingers and toes are affected together, and a few spots are seen on the trunk. In many cases the toes escape. In a large number of cases the face has been affected, spots of cyanosis appearing on the nose or ears or lips. As a rule, the stage of gangrene only ensues in the tips of the extremities, but a few cases are recorded in which little areas of skin elsewhere have passed through all the stages of the disease. Pigmentation occurs in spots upon the body when the process does not go on to gangrene.

Among the rare symptoms which have occurred in some cases are great impairment of temperature, pain, and electric sensations in the affected extremities; swelling, pain, redness about, and effusion into, the joints; considerable loss of motion in the muscles of the hands and feet, with diminution of electric excitability, but no qualitative change; and oculo-pupillary changes ascribed to an irritation of the cervical sympathetic fibres at their origin in the spinal cord.

In addition to the constitutional symptoms mentioned, which may usher in the disease and may continue during its course, there have been observed temporary albuminuria, glycosuria, and hæmaturia. Fever never occurs as a symptom of the disease, and if present must be ascribed to some other condition. The special senses have been affected in a few cases. In one case a spastic contraction of the retinal arteries alternated with attacks of ischæmia in the extremities. The intellect is usually unaffected, but Weiss observed a case in which transient aphasia occurred, which he attributes to local spasm in the arteries of the cortex. The patient could find words only after long thought, and spoke slowly and with difficulty.

{1261} COURSE AND DURATION.—The onset of the disease is sudden. The symptoms in the first two stages may last only for a few minutes and pass off, or the disease may pass through all the stages and terminate in gangrene. It is usual for the first stage of ischæmia to last several days, varying in severity; for the second stage to last several days; and for the stage of gangrene to occupy about three weeks. The shortest duration of a single attack has been ten days, the longest five months. If the gangrene begins simultaneously in all the fingers, the duration will be shorter than if it proceeds to one after another. In one-third of the cases a recurrence of the disease within a year of the first attack has been observed, and it is probable that the proportion would have been larger had all the patients been kept under observation. In some cases three and four attacks have succeeded each other with some rapidity, some of the attacks being much less severe and shorter than others. In some cases the condition of gangrene has developed only in one out of three attacks. When the condition is one of local erythema the duration may be indefinite, the state becoming chronic and lasting for several years.

NATURE.—The nature of the disease is a matter of deduction from the study of the symptoms, no autopsies having as yet been made. As already stated, the symptoms are explained on the theory of a vaso-constrictor irritation in the stages of ischæmia and cyanosis—of a vaso-dilator irritation in the stage of erythema. Whether this irritation is the direct result of abnormal processes going on in the vaso-motor centres in the spinal cord, or is the reflex result of irritation arising elsewhere, is undetermined. Raynaud held that it must be of central origin, since in his cases galvanization of the spinal cord modified the arterial spasm. The latter observation has not been confirmed by other observers. Weiss believes that the condition may occur in response to irritation arising in the skin, in the viscera, or in the brain, and thus prefers the theory of reflex origin. This theory is adopted by several observers, who find a source for such irritation in the female genital organs in their cases.

ETIOLOGY.—The disease occurs in adult life, only two cases having been observed in persons fifty years old. It is most frequent between the ages of fifteen and thirty, although children and adults beyond the age of thirty are about equally liable. Females are more liable to it than males, four-fifths of the recorded cases having been in women. It occurs more frequently in the winter months, exposure to cold being a common exciting cause. Other exciting causes are nervous exhaustion, especially occurring in those who are predisposed to nervous diseases by heredity; general weakness from anæmia, malnutrition, or the occurrence of acute fever or exhausting disease; and mental agitation, a fright having preceded the attack in several cases. In women menstrual disorders and uterine disease have been considered as etiological factors. Occupation has something to do with its occurrence, since washerwomen, waitresses, and chambermaids are the class most often affected. In many cases, however, no cause of local irritation can be found.

DIAGNOSIS.—The diagnosis rests upon the development of vaso-motor symptoms in the extremities, situated symmetrically, going on to gangrene, in a person not afflicted with cardiac disease or with endarteritis of any kind, and not having been exposed to frost-bite or ergot-poisoning. The age of the patient, the symmetrical position of the symptoms, the {1262} persistence of the pulse in the main arteries, and the limitation of the gangrene to the tips of the extremities distinguish it readily from senile gangrene. The history of the case, the absence of itching, and the presence of pain during the arterial spasm which passes off when the spasm ceases, serve to separate it clearly from chilblains. Congenital cyanosis is produced by cardiac anomalies, and the entire body is affected. Ergot-poisoning can be ascertained by the history.

PROGNOSIS.—Life is not endangered by this disease, no fatal cases having been recorded. Recovery from an attack is certain, but the duration cannot be stated, as it will depend in any case on the character, the extent, and the severity of the symptoms. The possibility of a recurrence of the attack should be stated to the patient.

TREATMENT.—The methods of treatment have varied, and none are wholly satisfactory. If the causes can be met—e.g. anæmia, nervous exhaustion—they should be treated. If not, the disease itself may be attacked by means of electricity. Or the symptoms may be treated as they demand it. Electricity has been used by almost all observers. The faradic current produces an aggravation of all the symptoms except in the stage of erythema, and has been discarded. The galvanic current may be employed in several ways. Two methods are in use. In the first the positive pole is applied over the cervical region, and the negative pole over the lumbar region, a descending current being thus sent through the spinal cord. The current should be of moderate strength, not above twenty-five milliamperes, few patients being able to endure the strength implied in Raynaud's statement that he used sixty-four cells of a Daniel battery. The duration of the application should be ten minutes, and the electricity may be applied once daily. In the second method the anode is applied over the brachial or lumbar plexus, as the case may be, and the cathode passed over the affected extremity, the current being constant and care being taken not to break it suddenly. The strength, duration, and frequency should be the same as in the first method. From these two methods, separately or combined, Raynaud claimed to have seen favorable results. His assertions have not been confirmed by other observers who have followed his directions closely, and hence considerable doubt at present prevails as to the efficacy of the electric current. The so-called electrical application to the cervical sympathetic is certainly useless. In the stage of erythema a very weak faradic current applied to the hands in a bath may be of service.

Many observers have found that the progress of the case to recovery was quite rapid if the limb were put at rest in an elevated position, were kept warm by cotton batting or similar bandaging, and were kept clean with antiseptic lotions when the stage of gangrene set in. Massage is to be used in all cases, the limbs or affected parts being gently rubbed with the dry hand or with aromatic liniments or oils. All local injury, however, and especially counter-irritation, are to be carefully avoided. General tonic treatment, especially iron and cod-liver oil, is to be used in all cases.

The pain occurring in the early stages is often so severe as to require the use of opium or other narcotics. And when the nervous symptoms are especially aggravated, and irritability and insomnia give the patient discomfort, bromide and chloral may be employed.

{1263} Diseases of the Cervical Sympathetic.

ETIOLOGY.—Diseases of the cervical sympathetic ganglia or cord may be of two kinds—either irritative or destructive. They are produced by pressure upon the cervical ganglia or upon the sympathetic cord between these ganglia, by tumors, especially aneurisms, and enlarged glands; by abscesses; and by cicatrices of old wounds in the neck. They are also due to extension of inflammation from a thickened pleura in phthisis and chronic pleuritis of the apex. They may be caused by injuries, such as stab-wounds, gunshot wounds, etc. Any disease which produces marked irritation of peripheral branches of the sympathetic in the neck, or of the cerebro-spinal cervical nerves, may cause reflex phenomena resembling the symptoms of actual disease. From such phenomena it is not justifiable to conclude that the sympathetic cord and ganglia are the seat of lesions, and the only cases which will be considered here are those in which actual disease was proven to be present by an autopsy.

Inasmuch as the cervical sympathetic is in close anatomical connection with the spinal cord, especially with the eighth cervical to the second dorsal segments (the so-called cilio-spinal centre of Budge), and as the functions of the sympathetic are dependent upon the integrity of the spinal cord, it is evident that any lesion of the nerves uniting it with the cord, or any lesion in the cord itself at the levels mentioned, may produce symptoms which resemble closely those of disease of the sympathetic. Thus, cervical pachymeningitis, myelitis (especially from injury of the cord, or hæmato-myelia), and diseases of the cervical vertebræ which produce either or both conditions, may cause a train of symptoms somewhat similar to those to be described. A careful distinction must be made between primary and secondary disease of the sympathetic, between reflex and direct symptoms, between lesions in its substance and lesions in its governing centres in the spinal cord. The symptoms produced by affections of a reflex or central nature are rarely as numerous as those of disease of the sympathetic itself. An example of such a secondary affection is the combination of sympathetic symptoms occurring in progressive muscular atrophy. And, finally, since mental action of an emotional nature may cause flushing or pallor of the face, with profuse sweating and variations in the size of the pupil and prominence of the eyeballs, as well as palpitation or arrest of the heart, there is reason to believe that symptoms of sympathetic disease may be produced by cerebral lesions.

PATHOLOGY.—The pathological anatomy of the cervical sympathetic is obscure. This is probably owing to the fact that the ganglia are rarely examined, and pathologists have not been familiar with their histology. Lesions of the cervical sympathetic have been described in almost every imaginable form of disease, and at one time, when many obscure conditions were blindly termed sympathetic, the records were filled with descriptions of fatty degeneration or interstitial inflammation or pigment deposit in the ganglia. As no actual symptoms of disease of the cervical {1264} sympathetic, as now understood, were present in such cases, it is impossible to believe that the lesion was other than hypothetical.

The conditions which have been observed in a few carefully-studied cases of primary disease have been—(1) A parenchymatous inflammation of the cells of the ganglia, attended by swelling, loss of nuclei, granular and fatty degeneration, and by atrophy, together with a degeneration of the fibres issuing from the cells. (2) A sclerotic process in the connective tissue in and about the ganglia and in the nerves, resulting in such an increase in the interstitial tissue as to compress and injure the cells and axis-cylinders. These may be observed together in the later stages of the disease. (3) In a number of cases the capillaries within and about the ganglia have been found dilated, tortuous, and varicose, and hemorrhages from them are not rare.

SYMPTOMS.—The symptoms of irritation of the cervical sympathetic are dilatation of the pupil, widening of the palpebral fissure, protrusion of the eyeball, pallor of the entire side of the face and head, with slight fall of local temperature and possibly an increased secretion of perspiration, and an increased frequency of the heart. It is rarely that these are all observed in any case, dilatation of the pupil with slight pallor and rapid pulse being the only signs of irritation as a rule. Such irritation is a less common occurrence than might be supposed, many lesions which produce pressure even of a slight degree on the sympathetic having caused symptoms of a suspension of its function rather than of an increased activity. This is doubtless due to the non-medullated structure of the fibres, which thus lack protection from injury.

The symptoms of destructive disease of the cervical sympathetic are the converse of those just mentioned, and they are all present when the part is seriously involved. The patient will then have a marked contraction of the pupil, which no longer responds to light or to irritation of the skin of the neck, but may change slightly in the act of accommodation. It resists the action of mydriatics. The vessels of the choroid and retina may be dilated, as well as those of the iris, in which case the patient will feel a sense of weariness on any long-continued attempt to use the eyes. There is no actual disturbance of vision, and the cornea is not usually flattened, as was formerly supposed. There is a noticeable narrowing of the palpebral fissure, the upper lid falling slightly as in a mild state of ptosis, and the lower lid being slightly elevated. This is due to the paralysis of the muscles of Müller in the eyelids, which are controlled by the sympathetic. It is present in 90 per cent. of the recorded cases, and in many the apparent size of the eye is reduced a half. Retraction of the eyeball is a less constant symptom, and one which develops only after the disease has existed some time. It is due partly to the paralysis of the orbital muscle of Müller, and partly to the decrease in the amount of fat in the orbit behind the eye. A marked symptom, and one which is constant, is a dilatation of the vessels of the face, conjunctiva, nasal mucous membrane, ear, and scalp. This is attended by redness, a subjective sense of heat, and an actual rise of local temperature, which may exceed that of the other side by 1.5° F., measured in the auditory meatus or nose. This vascular congestion has persisted in some cases for three years. In others it has been followed much earlier (in nine months) by a partial or complete return to the normal condition, and {1265} even when the local temperature remains higher on the affected side, the visible congestion and the sensation of heat may have disappeared. The dilatation, succeeded by the contraction (normal tone), of the vessels has led to a division of the disease into two stages, and in a few cases the affected side has become paler than the other in the second stage. In both stages the part affected is less sensitive to changes in the external temperature.

An increased secretion of tears and of perspiration has been supposed to accompany dilatation of the vessels of the skin of the head inevitably. This is not a constant symptom, as the recent cases have demonstrated. And no definite statement of the effect of disease of the cervical sympathetic on the occurrence of dryness or dampness of the face can be made, both conditions having been observed. A difference between the degree of moisture on the two sides of the face on exposure to heat is usually present. Palpitation of the heart has been an annoying symptom to the patient in many cases, and is usually associated with a marked slowing of the pulse. This was reduced from 74 to 66 in Möbius' case, and remained slow for some weeks. The frequency of the heart may, however, be increased after the first period of slowing, but never reaches a very high rate (88 in the case cited). A slight atrophy of the affected side of the face has been observed in several cases, appearing after the disease has existed for some time. The muscles of the cheek feel flabby and are slightly sunken; but the condition does not approach in severity true facial hemiatrophy, nor is it sufficiently rapid to be considered due to a trophic disturbance. Changes in the secretion of saliva, dryness of the nasal mucous membrane, and symptoms referable to paralysis of the intracranial vessels, such as might be expected from the result of physiological division of the sympathetic, have only been occasionally observed. Glycosuria has been noted in a few cases.

COURSE.—The course of the disease has been divided into two stages, as already mentioned, the majority of the symptoms remaining permanently from the onset. The second stage is characterized by the cessation of the dilatation of the vessels, by the appearance of retraction of the eyeball, and by the development of slight facial atrophy. In the cases where the sympathetic is extensively destroyed by the lesion no recovery is possible. When it is simply divided by a wound there has been a considerable degree of recovery, probably due to a spontaneous union of the divided ends and re-establishment of the function. From these facts the prognosis can be deduced.

DIAGNOSIS.—The symptoms are so characteristic that there is no difficulty in reaching a diagnosis. The most important point in any case is to determine the cause, care being taken to consider all the possibilities already mentioned in discussing the causation. The symptoms of lesion are always unilateral.

TREATMENT.—If the cause can be removed, an indication for treatment is afforded. Sources of reflex irritation are to be eliminated. If the sympathetic has been divided by a wound, it may be well to unite the cut ends, as in suture of other nerves, although this has not yet been attempted; otherwise there is little hope from any method of treatment. {1266} Electricity has been applied in vain, and galvanization of the sympathetic in the neck is now regarded by all good authorities as useless.

Diseases of the thoracic and abdominal sympathetic ganglia and cords have been suspected, but nothing definite is known of their symptoms or pathology; the statements which have recently been made regarding visceral neurosis not being based upon any cases in which post-mortem lesions were found.

Trophic Neuroses.

TROPHIC NERVES AND NERVOUS CENTRES.—The nutrition of the body depends upon the nutrition of the individual cells of which it is made up. Each cell has the power of appropriating from the blood such substances as will preserve its existence, enable it to perform its functions, and produce a successor. Whether this power is inherent in the cell or is controlled by the nervous system is a question upon which authorities are divided. Those who hold the first position deny the existence of trophic nervous centres and of trophic nerves from those centres to the organs and elements of the body, claiming that this hypothetical trophic system has not been demonstrated anatomically, and that the facts urged in its support are capable of another interpretation. Those who believe in the existence of a trophic system have been able to demonstrate the existence of fine peripheral nerve-fibres passing to and ending in individual cells of the skin, glands, and other organs, and have brought forward a large collection of facts which merit a careful examination. They are as follows:

ATROPHY.—When a nerve is cut certain changes occur in it which are known as Wallerian degeneration. This affects the peripheral end of a severed nerve, the peripheral end of a severed anterior nerve-root, and the central end of a posterior nerve-root. To maintain its integrity a motor nerve must be in direct continuity with a normal cell of the anterior cornu of the spinal cord; a sensory nerve must be in connection with the intervertebral spinal ganglion on the posterior nerve-root. Nerves which pass between two such ganglia do not degenerate when cut. The degeneration consists in a coagulation of the myelin in the medullary sheath, a fatty degeneration of the coagulum, and a gradual absorption of the débris. The axis-cylinder is compressed, and finally disintegrated, by a mass of protoplasm which develops about the nuclei of the interannular segments, and after undergoing fatty degeneration its débris becomes mingled with that of the myelin, and is also absorbed. The sheath of Schwann, whose nuclei have in the mean time increased by a process of subdivision, is partly filled by the protoplasm (from which the new axis-cylinder develops if regeneration occurs), remaining as a fine {1267} thread of connective tissue when all other traces of the nerve-fibre have disappeared. There may be a proliferation of cells of the endo- and perineurium at the same time which aids in the transformation of the nerve into a connective-tissue strand. This process of degeneration involves the terminal plates by which the nerves join the muscles, but the terminations of the sensory nerves—i.e. tactile corpuscles—do not appear to be affected. The central end of the cut nerve may display a similar change for a distance not greater than one centimeter; it usually develops a bulbous swelling of connective tissue, and retains its conducting power indefinitely.

Degeneration in the tracts of the spinal cord occurs after various forms of lesion, and is similar in its processes to degeneration in the peripheral nerves. The increase in the connective-tissue elements is more noticeable in contrast with the parts unaffected, and from the density of the tract involved the result has been called sclerosis. The recent researches of Homen have shown that the process of degeneration begins in the entire length of the affected tract, and does not proceed from the point of lesion onward, as was formerly supposed.

When a muscle is separated from its connection with the central nervous system, either by a division of the nerve passing to it or by a destruction of the cells in the anterior cornu of the spinal cord from which that nerve arises, it undergoes an atrophy which is peculiar in being immediate and rapidly progressive, thus contrasting strongly with the gradual and slighter atrophy from disuse in cases of cerebral paralysis where the cells mentioned and the nerve-fibres are intact. There is at first a simple diminution in the number of the fibrillæ of which the muscular fibre is made up, together with an increase in the interstitial connective tissue nuclei. Then an albuminoid and fatty degeneration of the muscular elements occurs, with a proliferation of muscle-corpuscles or nuclei, and a gradual absorption of the débris. The interstitial connective tissue then increases rapidly, forming fibrous bands through the degenerated muscle which compress the few muscular fibres remaining, until as a result the muscle is transformed into a mere ribbon of connective tissue without any power of contractility. As these changes go on the electrical reactions change, the three degrees of reaction of degeneration corresponding to the three stages of atrophy described. These phenomena of nerve- and muscle-degeneration are observed in traumatic or idiopathic neuritis, in acute and chronic poliomyelitis anterior, in general myelitis involving the anterior cornua, and in bulbar paralysis.

The influence of the nervous system on the nutrition of the bones has also been ascertained. When a bone is developing, a lesion of the nerve to it, or of the deeper portion of the anterior cornua of the spinal cord from which these nerves arise, will modify and partly arrest its growth. This is often seen in anterior poliomyelitis and in hemiatrophy of the face occurring in children. In the adult a no less marked effect is produced, although the results are less noticeable. A condition known as {1268} osteoporosis is caused, consisting of an enlargement of the Haversian canals and an infiltration of fatty matter into them and an actual decrease in all the inorganic constituents of the bone, which loses in weight, becomes thinner and more fragile, so that spontaneous fractures may occur. This condition has been noticed more frequently in diseases of the spinal cord than in neuritis; it is said to occur in locomotor ataxia. It has been found in a few cases of long-standing hemiplegia and also in dementia paralytica, no explanation of its pathogeny in these instances, however, being offered. In a case of ataxia with a lesion in the medulla which involved the nuclei of the fifth, ninth, tenth, and eleventh nerves on one side, all the teeth of the upper jaw on that side fell out within a few weeks, those in the lower jaw remaining. Changes in the nutrition of the bones have also been recorded in cases of progressive muscular atrophy in the paralyzed limbs.

The condition of the skin and its appendages is influenced decidedly by changes in the nervous system, either in the nerves, in the spinal ganglia, or in the central gray matter. Here it is the sensory nerves which convey the trophic influence, not the motor nerves, as in the cases hitherto considered; and when the lesion producing trophic changes in the skin is central, it is situated in the posterior cornua of the spinal cord or in the gray matter near the central canal. The glossy skin seen on the fingers after injuries to the nerves is a type of such atrophy from disturbance of trophic impulses. Glossy fingers present a smooth, shining appearance, are dry from the diminution in the secretion of sweat, feel soft and satin-like to the touch from the marked thinning of the skin, and frequently show a defective or irregular growth of the nails, which may be ridged, curved, or deformed. They are red and mottled from accompanying vaso-motor paralysis, and are usually hot and painful. Changes in the pigmentation of the skin and hair are recorded as a not infrequent accompaniment of severe neuralgia and as a result of great mental anxiety. Thus in several cases of supraorbital neuralgia the eyebrow on the affected side has turned white; in infraorbital neuralgia the beard has become gray; and in both the hair has been observed to fall out. The sudden turning white of the hair is ascribed to a swelling of the hair by air within it. In one case, frequently cited, the hair and nails fell out after a stroke of lightning.

When a gland is cut off from its nervous connection with the cord or cerebral axis by section of its nerves, its function is impaired and its nutrition suffers, so that after a time it loses weight and undergoes a progressive total atrophy. This has been proven experimentally in animals in the submaxillary gland. It has been observed in the testicle in man after division of the spermatic nerve (Nélaton) and after destruction of the spinal cord by traumatic and idiopathic myelitis (Klebs, Föster). The sweat-glands are known to be under the control of a central {1269} nervous mechanism, as cases of hyperidrosis, anidrosis, and chromiodrosis prove; and an atrophy of them and of the sebaceous glands has been observed after nervous lesions.

Progressive hemiatrophy of the face is treated elsewhere. The following case of progressive hemiatrophy of the entire body may be mentioned here: A boy, aged fourteen, dislocated his ankle, which in a few days became swollen, red, hot, and painful. The inflammation extended up the leg, but did not involve the knee, and soon subsided. After a short time the foot began to atrophy. The atrophy extended up the leg, and involved the thigh; it then progressed to the trunk and the arm, and lastly to the face on the affected side, until in the course of two years there had developed a unilateral atrophy of the entire body. Muscles, fat, and bones were all affected, but no difference in the skin or hair of the two sides was noticed. Fibrillary tremors were present in the muscles. The electric reactions were not altered, but were gradually lost. There was a hypersensitiveness to touch and to cold, but no other sensory disturbance. The boy was alive and fairly well when the case was reported. It is unique.

These various instances of atrophy cannot be ascribed to simple disuse, since they differ markedly in their pathological changes and in the rapidity of their progress from such atrophy. Nor are they to be referred to vaso-motor disturbances, since in many cases no vascular changes are evident. Their distribution in the body often corresponds exactly with that of peripheral nerves, and they accompany nerve lesions too frequently to be explained on any theory of coincidence. There are many authorities, however, who refuse to ascribe them to a lesion of trophic nerves. In regard to the degeneration of nerves it is said that each nerve axis-cylinder is a part of the nerve-cell from which it arises, and hence destruction of the cell or division of the cylinder, by disturbing the unity of existence, results in the death of the part. The fibre shares all the changes of nutrition which the nerve-cell undergoes, and if separated from it necessarily perishes. To this it is replied that trophic paths and motor paths are distinct at some points in their course, at least in the central nervous system, since each can be affected alone. Erb, who has studied this subject carefully, believes that trophic are distinct from motor centres in the spinal cord, but that both impulses may be conveyed by the same axis-cylinder in the peripheral nerves—a middle ground which is widely accepted. It is now known that each axis-cylinder is made up of several fibrils, so that this theory gains probability. This would also explain the occurrence of atrophy in the muscles, the trophic centres being affected when the muscle atrophies, and unaffected when it is paralyzed without atrophy. Mayer, however, denies this explanation of the muscular atrophy, holding that the motor system, cell, nerve, and muscle-fibre, forms a nutritive as well as functional unit, and that the simple suspension of function, by interfering with the special {1270} conditions of nutrition attendant upon physiological excitement, is competent to cause a pathological change. To this it is replied that the parts of the motor system are not interdependent, since disease of the muscle does not produce degeneration of the nerve and of the cell, and the fact of a degeneration in a peripheral direction alone is evidence of central trophic influence. The attempt to ascribe trophic changes in the skin, nails, and hair to vaso-motor disturbance has been equally unsuccessful in covering all the observed cases.

If d is destroyed, the fibres from b and c perish with it, and the result is paralysis and atrophy of the muscle and degeneration in the motor nerve—e.g. poliomyelitis anterior. If b is destroyed, the muscle atrophies, and paralysis is a secondary result—e.g. progressive muscular atrophy. If c is destroyed, the nerve degenerates, and paralysis and atrophy of the muscle are secondary results—e.g. neuritis with reaction of degeneration. If a is destroyed, voluntary power is lost, but reflex power remains, and no atrophic changes occur—e.g. lateral sclerosis. If the motor nerve is cut between d and m, the result is the same beyond the division as when the motor cell is destroyed.]

{1271} HYPERTROPHY.—Trophic changes are not limited to the process of atrophy. There are conditions of hypertrophy of supposed nervous origin. Samuel considers the hypertrophy of one testicle which attends atrophy of the other from section of its nerve as an example of this. It has been ascertained that one kidney hypertrophies when the other is atrophied or extirpated. When the spleen is removed the lymphatic glands increase in size. But these facts are capable of another explanation—viz. that increased demand upon the organ leads to its increased growth. Hypertrophy of the skin and of the tongue is seen in cretins in contrast with the deformity of the body and atrophy of the limbs. A hemihypertrophy of the face has been noticed in several cases, the counterpart of hemiatrophy; and in one case a unilateral hypertrophy of the entire body was observed. The local thickening of the skin known as ichthyosis hystrix, and other hypertrophies of the skin, certain deposits of pigment, and vitiligo, have been ascribed to nervous causes. Mitchell has recorded cases of abnormal growth of the nails and hair after injuries to the nerves, and similar phenomena have followed central lesions. He has also described a thickening of the skin of the first three fingers and of the back of the hand following a wound of the brachial plexus. These conditions of the skin and its appendages indicate an abnormal activity in the cells of the affected part, a rapid metabolism and reproduction, resulting in an undue production of tissue, apparently dependent on nervous impulses reaching the cells from a distance. The insane ear may be mentioned in this connection as a trophic disturbance due to central lesion.

MYXŒDEMA (cachexie pachydermique) is a disturbance of nutritive processes characterized by a production of mucin, which is deposited in all the tissues of the body, but especially in the subdermal connective tissue. It is considered by the majority of authors a trophic neurosis, and is therefore considered here.

PATHOLOGY.—In the few autopsies which have been made an increase in the connective tissue of all the organs has been found, in the meshes of which a thick, transparent, slimy substance (called animal gum), consisting of mucin, is present. This may compress and destroy the parenchyma of the organs involved. There is also found a thickening of the coats (adventitia and media) of the vessels. An atrophy of the thyroid gland has occurred in every case, and experimental extirpation of the thyroid in animals produces symptoms so nearly identical with those of myxœdema that this is considered the chief pathological feature of the disease. Whether this atrophy is due to a compression by the mucin deposited, or is due to a disease of the trophic centres of the thyroid in the medulla, or is a primary affection of the gland, remains to be determined.

ETIOLOGY.—The actual causation is unknown. Cold and mental shock have been considered exciting causes in some cases. Women are much more liable to the disease than men, and it develops after the age of forty in the majority of cases. It may occur in childhood and result in a {1272} cretinoid state. Syphilis and tuberculosis do not appear to be etiological factors.

SYMPTOMS.—The disease begins gradually, and the nervous symptoms or the local œdema may appear together or in succession. The patient notices a thickening of the skin, which becomes dry, rough, and scaly. The thickening is uniform and involves the entire body. It is most marked where the subdermal connective tissue is loose, as in the cheeks, lips, eyelids, and in all parts where the skin is thrown into folds. The hands and feet do not escape. The thickened skin is hard, and does not pit on pressure, thus differing from ordinary œdematous swelling. It appears of a waxy color, and is free from perspiration, the sweat-glands becoming atrophied from pressure. The hair may fall out or become woolly and brittle, and may change its color. In a few cases spots of pigment have appeared on various regions. The nails are brittle. The teeth are carious. The mucous membranes show similar changes, and the mouth and tongue, rectum and vagina, may be so swollen as to impair their respective functions. Digestive disturbances, constipation alternating with diarrhœa, and uterine hemorrhages, which occur, are ascribed to this cause. Albumen is occasionally found in the urine, but is not a constant symptom. The nervous symptoms are constant. The patients complain of paræsthesiæ and anæsthesia of the extremities or over the entire body, and the special senses may be impaired, as well as the tactile sense. They are very liable to severe attacks of neuralgia. They suffer from subjective sensations of cold, and are easily affected by changes of temperature. Motion is interfered with; tremors occur early; movements become slow and awkward; the gait is unsteady; the voice is rough and nasal; but no true paralysis or muscular atrophy has been observed. The patella-tendon reflex is occasionally lost, but not in all cases.

These symptoms have been ascribed to the pressure of the mucin upon the terminal filaments of the nerves, and also to changes in the central nervous system. That the latter theory is probably correct is shown by the occurrence of mental symptoms in the majority of cases. The patients become apathetic and all mental action is slowly performed. Indifference to surroundings, loss of memory, and inability to concentrate the attention may be succeeded by transient delirium, hallucinations, and occasionally by delusions of persecution, and the patient finally lapses into a state of imbecility. If the disease develops in early life, education is impossible, and the patient remains in an infantile condition.

Whether the changes in the nervous system are due to pressure by deposit of mucin (Hadden), or are due to an altered nutrition of the most delicate tissues of the body consequent upon the general metabolic derangement (Horseley), is undetermined. In experimental myxœdema the degenerative processes have been found in the nerve-cells.

There are no symptoms referable to the heart or lungs, and if cirrhosis of the kidney and liver develop, their symptoms supervene upon and are secondary to those of myxœdema. High arterial tension has been noticed in the majority of the cases.

The COURSE of the disease is a chronic one, and is progressive. There are, however, intermissions in the severity of the symptoms in some cases. Recovery does not occur.

{1273} DIAGNOSIS.—The diagnosis from the accumulation of fat is made by observing the thickening of the nose, lips, fingers, and tongue, and the changes in the skin and its appendages. Scleroderma is not universal like myxœdema. In scleroderma the skin is harder and more adherent to subjacent parts, is not transparent and waxy, and the nervous symptoms are wanting. Cretinism seems to be closely allied to myxœdema, but is only observed before the age of seven and is accompanied by hypertrophy of the thyroid gland.

TREATMENT.—The treatment is only palliative. Simple nutritious diet, especially milk diet, with the use of such tonics as iron and quinine, has been found useful. The progress of the disease is hastened by exposure to cold, and in a very warm climate the symptoms may remain stationary for several years. Jaborandi or pilocarpine has been used in some cases with a moderate degree of success. Nitro-glycerin, gr. 1/100, has also been of benefit. For the paræsthesiæ and anæsthesia of the early stage the faradic brush has been applied, and for the motor weakness the faradic current, with the effect of relieving but not curing these symptoms. During the attacks of neuralgia morphine may be employed.

Inflammation.—The most important trophic disturbances are those which consist of an actual disintegration of tissue. These are very numerous. Herpes zoster, certain forms of eczema and pemphigus, lepra anæsthetica, scleroderma, acute ulceration of the fingers, perforating ulcer of the foot, acute bed-sores, keratitis with anæsthesia of the cornea, sympathetic ophthalmia, and various forms of joint disease, are examples of such trophic diseases. For the discussion of the skin and eye diseases mentioned the reader is referred to special articles on those subjects. In regard to lepra anæsthetica, it may be mentioned that in this disease lesions have been found both in the sensory nerves and in the posterior cornua of the spinal cord.

I have reported a case of acute ulceration of the ends of the fingers and toes occurring in an anæmic girl aged twelve, and persisting for more than a year, associated with cyanosis of the hands and feet, and with a tendency to rapid ulceration of any part of the body which happened to be exposed to pressure. The hair of the eyebrows, eyelids, and to a less extent that of the scalp, fell out during the disease. There was no local asphyxia and no appearance of gangrene; hence the case was not one of Raynaud's disease. Its symmetrical distribution, the lack of any constitutional organic disease or of any local cause for the production of the ulceration, and the anæmic and nervous condition present, all pointed to a disturbance of the central nervous system. It did not yield to treatment, either local or general or electrical. Mills has seen a similar case.

Perforating ulcer of the foot begins on the sole, beneath any of the metatarso-phalangeal articulations, preferably the first or the fifth, or under the heel, as a small pustule under the epidermis. This ruptures, and the ulcer which results begins to extend in a direction vertical to the surface, involving the deeper tissues or even opening into the joint and destroying the bone. It appears rather like a sinus than an ulcer, and is {1274} remarkable from the fact that it is not painful and is insensitive to touch, although it may prevent the patient from walking on account of extreme tenderness. The epidermis around the sinus is thickened and insensitive, and there may be anæsthesia of the entire sole of the foot, and even of the leg, although this is due to the neuritis present, which is also the cause of the ulcer, rather than to the ulceration. The circulation is sluggish in the affected extremity; it becomes cyanotic on exposure to cold, and seems peculiarly liable to become œdematous. The œdema may go on to suppuration, and involve the articulations, and ankylosis of the smaller joints may follow. This, too, is to be traced to the neuritis. The skin of the foot becomes pigmented, and may be dry or covered with offensive sweat. As the patient cannot walk while the ulcer remains, the condition demands treatment. Rest, moist warm applications, antiseptic lotions, scraping out the sinus, and other surgical means appropriate to the treatment of ulcers and sinuses do not often prove of benefit, and in obstinate cases recourse has been had to amputation of the foot. Electrical treatment has been tried in vain.

Such perforating ulcers may occur symmetrically on both feet, and may be numerous. They also occur rarely on the hands. They have been observed not infrequently in locomotor ataxia, occurring either early or late in the disease, and have appeared in patients suffering from dementia paralytica. The only constant lesion found is a degeneration of the peripheral nerve supplying the affected part.

Acute bed-sores (decubitus) develop in many cases of spinal and cerebral disease, but not in all. It is argued that anæsthesia of a part or simple pressure upon a part or irritation of an anæsthetic part will not explain their occurrence, and that they must be traced to a destruction of trophic centres in the cord or brain. No amount of attention to the position and cleanliness of the patient is thought to be sufficient to prevent them in some cases, and their progress is often so rapid as to remove them from the category of simple ulceration. Their most frequent seat is upon the buttocks, over the sacrum, on the heels, and over the scapulæ; but it is believed that in the conditions in which they appear in these places pressure on any part may cause one. They begin within a few hours after the occurrence of the lesion as irregular mottled patches of redness, in which there soon appear small or large vesicles filled with dark serum. These rupture, leaving little areas of ulcerated surface, which soon unite to form a large ulcer with softened, infiltrated, and bloody base and ragged edges. The tissues around and within the ulcer have a tendency to slough and to become gangrenous, and the process goes on rapidly until a considerable area of the surface is completely destroyed, together with the deeper structures, fat, muscles, and fasciæ, down to the bone, which may become necrosed. Acute cystitis is so frequently associated with acute bed-sore that it is traced to the same nervous cause, though here, again, another explanation is possible. The constitutional disturbance produced by these two affections may be increased by a true septicæmia, to which the patient succumbs; or metastatic abscesses may be formed, and pyæmia cause death; or, lastly, the ulcer on the back may lay bare the vertebræ and erode their ligaments, thus opening a way for the extension of suppuration to {1275} the meninges of the spinal cord. The duration may be from a few days to two weeks, and the prognosis is very grave.

Chronic bed-sores develop in a similar manner, although all the processes described occur more slowly and are much less severe. They do not show the tendency to extend so widely or so deeply, nor to become gangrenous. They remain stationary after attaining a certain size, and the tissues seem to lack all tendency to reproduction and repair. When the central lesion which they follow begins to pass away they heal; sometimes local treatment is successful; but in many cases they persist for years, always threatening the life of the patient from the possibility of their sudden aggravation or from the occurrence of the complications already mentioned in connection with the acute process.

Since neither form of decubitus occurs after lesion of the anterior cornua of the spinal cord, nor in sclerosis of the posterior or lateral columns, nor in those cases of locomotor ataxia in which extensive invasion of the posterior cornua is present, while they are particularly frequent as a complication of general myelitis, hemorrhage in the cord, and syringo-myelitis, it is argued that the trophic centres whose destruction is the cause of these bed-sores lie in the central gray matter of the cord, near to the central canal. In unilateral lesion of the cord the bed-sore occurs on the anæsthetic side of the body—i.e. on the side opposite to the seat of the lesion—a fact which may indicate a decussation of the trophic nerve-fibres in the cord, but which has also been urged in proof of the theory that the sore is always due to irritation of an insensitive surface.

The treatment of bed-sores belongs to the domain of surgery, the same methods being pursued as in the case of any large ulcer. The application of electricity to the sore has been tried, but the results are not sufficiently encouraging to warrant its recommendation.

Joint affections of neurotic origin are discussed in the articles upon Locomotor Ataxia, Hemiplegia, and Hysteria.

It is evident from this review that the nervous centres have some influence upon the activity of the cells of which the body is made up, and that they control the processes of growth, function, repair, and reproduction. The facts are too numerous, too varied, and too positive to admit of any other explanation. Trophic disturbances must therefore be considered as a set of symptoms referable to various lesions of the nervous system. It is evident from the preceding discussion that they may be produced by disease of the peripheral nerves; by disease of the ganglionic cells, which nourish those nerves; by disease of the spinal cord, especially in the region of the central gray matter; and, finally, by disease of the brain. Whether in the last condition the effect is a direct one, or is produced secondarily by an irritation of the spinal centres, cannot yet be determined. There are no trophic centres as yet localized in the cerebrum, but the pathological facts already mentioned warrant the conclusion that such centres will not long elude search. Certain facts observed in cases of infantile hemiplegia point to the motor area of the cortex as the seat of trophic centres for the motor mechanisms; since it is found that when the motor cortex is destroyed in early life the bones and muscles {1276} which it controls fail to develop properly. Trophic centres for sensory mechanisms are not yet discovered. Certain investigations of Luciani recently published point to the cerebellum as the part of the brain which governs the general nutrition of the body, but these need confirmation.

* * * * *

CONCLUSION.—While an attempt has been made here to consider vaso-motor and trophic neuroses separately, it must be admitted that in very many conditions the two are coincident. This follows inevitably from what has been stated regarding the localization of the vaso-motor and trophic centres in the spinal cord, and regarding the course of the vaso-motor and trophic nerves from the spinal centres to the periphery. These two classes of centres and nerves lie side by side in the central and peripheral organs, and it is less surprising that they should be jointly affected than that one should ever be involved alone. In any case of lesion of the peripheral nerves or of the central nervous system they may be expected. In all cases they are to be regarded as symptoms of such lesions rather than as distinct diseases.

{1277}

INDEX TO VOLUME V.

Abdomen, state of, in lead colic, 684 in tubercular meningitis, 726, 727

Abscess of the brain, 791, 792 of the spinal cord, 808

Achromatopsia, hysterical, 247

Aconite and aconitia, use of, in neuralgia, 1224, 1227 hypodermically in exacerbations of cerebral syphilis, 1015

Acoustic sensory disturbances in nervous diseases, 40, 41

Acrodynia, 1254

Acute affections produced by heat, 387 alcoholism, 586 cerebral anæmia, 776 encephalitis, 791 myelitis, spinal, 810 poisoning by alcohol in lethal doses, 596 simple meningitis, 716 spinal meningitis, 749 pachymeningitis, 747

Æsthesodic system of encephalon, localization of lesions in, 81 of spinal cord, localization of lesions in, 69

Affective mental disease, 153

Age, influence on causation of acute spinal meningitis, 750 of catalepsy, 315 of cerebral anæmia, 777 of chorea, 441 of chronic lead-poisoning, 680, 686, 688 of disseminated sclerosis, 883 of embolism and thrombosis of cerebral veins, 951 of epilepsy, 470 of family form of tabes dorsalis, 871 of general paralysis of the insane, 77 of hæmatoma of the dura mater, 707 of hysteria, 216 of hystero-epilepsy, 293 of insanity, 116, 117 of intracranial hemorrhage and apoplexy, 927 of labio-glosso-laryngeal paralysis, 1173 of migraine, 406, 1230 of myxœdema, 1271 of neuralgia, 1217 of paralysis agitans, 433 of progressive unilateral facial atrophy, 694 of syphilitic affections of nerve-centres, 1000 of tabes dorsalis, 856 of the opium habit, 650 of thrombosis of cerebral veins and sinuses, 983 of tubercular meningitis, 725 of tumors of the brain, 1029 spinal cord, 1090 of writers' cramp, 512 relation of, to limitation of the myelitis in infantile paralysis, 1147

Agraphia in hemiplegia, 957

Akinesis in nervous diseases, definition of, 42-44

Alalia (see Speech, Disorders of).

Alexia in nervous diseases, 31

Albuminuria in chronic lead-poisoning, 682, 689

Alcohol, influence on causation of acute meningitis, 716 of cerebral hyperæmia, 765 of intracranial hemorrhage and apoplexy, 929, 933 of tabes dorsalis, 854 of writers' cramp, 512 use of, in alcoholism, 642, 644 in cerebral anæmia, 789 in heat-exhaustion, 388 in insomnia, 380, 381 in the chloral habit, 677 in the opium habit, 673, 675 in thermic fever, 397

Alcoholic abuse as a cause of epilepsy, 472 insanity, 175, 202, 630-633

ALCOHOLISM, 573 Classification, 573 Definition, 573 Diagnosis, 637 of acute alcoholism, 637 of chronic alcoholism, 638 of dipsomania, 639 of hereditary alcoholism, 639 Etiology, 575 Alcohol, physiological action of, 580, 586 Alcoholic beverages, varieties and characters of, 578-580 Exciting causes, 578 Heredity, influence on causation, 576 Moral, social, and personal condition, influence on causation, 575, 578 Predisposing causes, 575 History, 574 Pathological Action of Alcohol, 586 Acute Alcoholism, 586-598 Symptoms, 587 Effects in persons of unsound mind, 594 Effects of different alcohols, 589-591 of acute narcotic poisoning, 597 of acute poisoning in lethal doses, 596 of convulsive form, 593 of corrosive poisoning, 596 of irregular form, 592 of maniacal form, 592 of ordinary form, 587 Pathological anatomy, 595 Varieties, 588 Chronic Alcoholism, 598-633 Symptoms, anatomical changes, etc., 599 Alcoholic cachexia in, 616 Atheroma in, 612 Biliary catarrh in, 607 Blood, disorders of, 615 Blood-vessels, disorders of, 612 Cerebral, 616 Delirium, alcoholic, and delirium tremens, 626, 630 Dyspeptic, 601, 602 Genito-urinary disorders, 612-614 Glands, disorders of, 602 Heart, disorders of, 610-612 Insanity, alcoholic, 630-633 Intestinal disorders, 601 Kidneys, disorders of, 613 Larynx, disorders of, 607 Liver, disorders of, 603-607 Locomotive apparatus, disorders of, 614 Lungs, disorders of, 608 Moral sense, perversion of, 624 Motion, disorders of, 620 Mouth and throat, disorders of, 599 Muscles, disorders of, 614 Nervous system, disorders of, 616 Obesity in, 615 Paralysis, alcoholic, 621 Pleuræ, disorders of, 610 Psychical disorders, 624 Respiratory system, disorders of, 607 Sensibility, general, disorders of, 619 Skin, disorders of, 615 Special sense, disorders of, 622 Spinal disorders, 619 Stomach, disorders of, 600 Tremor in, 620 Visceral derangements, 599 Will and intellect in, 625 Dipsomania, 635 Symptoms and nature, 636, 637 Hereditary Alcoholism, symptoms and forms, 634 Prognosis, 639 Synonyms, 573 Treatment, 640 Alcohol, withdrawal of, 642, 644 Ammonia, use of, 641, 642, 645 Baths and douches, use of, 641, 642, 643 Bromides, use of, 642, 645, 646 Cannabis indica, piscidia, and hyoscyamus, use of, 645 Chloral, use of, 641, 645, 646 Coca and cocaine, use of, 643, 646 Diet in, 643, 644 Emetics in, 642 Iron, use of, 643 Hypophosphites and cod-liver oil, use of, 644, 646 of acute form, 641 of chronic form, 642 of delirium tremens, 644 of dipsomania and hereditary forms, 645 Paraldehyde, use of, 641, 642, 645, 646 Prophylaxis, 640, 642 Quinia and opium, use of, 642, 643, 645, 646 Strychnia, use of, 641, 643, 646

Alcoholism, influence on causation of insanity, 119

Allochiria in tabes dorsalis, 832

Alum, use of, in lead colic, 691

Amaurosis in chronic lead-poisoning, 689

Amenorrhœa in the insane, treatment, 136

Ammonia, use of, in acute alcoholism, 641, 642, 643 in thrombosis of cerebral veins and sinuses, 989

Ammonio-sulphate of copper, use, in neuralgia, 1229

Ammonium chloride, use, in neuralgia, 1229

Amnesia in nervous diseases, 28

Amputation, question of, in tetanus, 559

Amyl nitrite, use of, in angina pectoris, 1238 in catalepsy, 338 in cerebral anæmia, 788 in chorea, 456 in epilepsy, 502 in hysteria, 286 in hystero-epilepsy, 311 in migraine, 414, 1232 in vaso-motor neuroses, 1256

Amyotrophic lateral sclerosis, 867

Anæmia as a cause of neuralgia, 1218 of thrombosis of cerebral veins and sinuses, 984 of vertigo, 425 and chlorosis, influence on causation of hysteria, 220 general, as a cause of spinal anæmia, 806 of the brain, 774, 777 of the spine, 805

Anæmic headache, 402

Anæsthesia, hysterical, 246 in acute myelitis, 819 in chronic alcoholism, 620 spinal meningitis, 753 in hemiplegia, 955 in hystero-epilepsy, 298 in injuries of nerves, 1182, 1185, 1186 in neuritis, 1191, 1192 in spinal meningeal hemorrhage, 752 meningitis, 750 syphilis, 1025 in symmetrical gangrene, 1259 in tumors of the brain, 1042 of the spinal cord, 1092 in unilateral spinal paralysis, 1166 of peripheral origin, 1198 Causes, 1199 Diagnosis, 1200 Symptoms, 1199-1201 Treatment, 1201 Varieties of, in nervous diseases, 35, 37

Analgesia, definition of, 35 hysterical, 246

Angina pectoris (see Neuralgia).

Angiomata in brain tumors, 1049

Angio-paralysis in vaso-motor neuroses, 1252

Angio-spasm in vaso-motor neuroses, 1262

Anidrosis in progressive unilateral facial atrophy, 696

Ankle-clonus in amyotrophic lateral sclerosis, 868 in diffuse spinal sclerosis, 888 in nervous diseases, 54 in spastic spinal paralysis, 862, 864

Anterior cornua, changes in, in amyotrophic lateral sclerosis, 867 in infantile spinal paralysis, 1133-1144

Antipyrine, use, in thermic fever, 397, 398

Antispasmodics, use, in hysteria, 278

Anus and rectum, neuralgia of, 1240

Aphasia in nervous diseases, 31 in cerebral anæmia, 776 hemorrhage, 941 syphilis, 1008 hemiplegia, characters and varieties of, 956, 960 post-epileptic, 481

Aphonia, hysterical, 239

Apoplexy, 917 of the brain, meningeal, 710

Apoplectic attack, symptoms of, 933-952 constitution, peculiarities of, 930

Apoplectiform attacks in tumors of the brain, 1040 type of acute myelitis, 817

Argyll-Robertson pupil in nervous diseases, 40, 51 in tabes dorsalis, 830

Arsenic, use of, in chorea, 454 in malarial form of cerebral anæmia, 790 in neuralgia, 1224 in paralysis agitans, 438 in tetanus, 559 in tremor, 432 in writers' cramp, 538

Arteries, cerebral, atheroma of, 991 in cerebral meningeal hemorrhage, 711 diseases of, in intracranial hemorrhage and apoplexy, 922

Arterial spasm in spinal anæmia, 806

Arthralgia, the, of chronic lead-poisoning, 684

Arthropathies in hemiplegia of apoplexy and intracranial hemorrhage, 962 in tabes dorsalis, 837

Asafœtida, use, in hysteria, 278, 285

Assimilation, alterations of, in nervous diseases, 59

Asthma, hysterical, 245

Asylums in the treatment of opium and alcohol habit, question of, 671 treatment of insane by removal to, 128, 130-135

Ataxia in tabes dorsalis, 831, 833, 848 in tumors of the brain, 1041 in tumors of the spinal cord, 1094 muscular, in general paralysis of the insane, 189, 193

Ataxic tremor, in nervous diseases, 47

Atheroma, in chronic alcoholism, 612 of the cerebral arteries, 991

Athetosis, definition and symptoms, 457 pathology, prognosis, and treatment, 46

Atmospheric and thermic influences as cause of neuralgia, 1219

Atrophy, 1266 degenerative, in nervous diseases, 54-57 facial, progressive unilateral, 693 in amyotrophic lateral sclerosis, 868 muscular, in chronic lead-poisoning, 687, 688 in hemiplegia from apoplexy, 962 in labio-glosso-laryngeal paralysis, 1172 in nervous diseases, 54 in neuralgia, 1214 in tumors of the brain, 1041 in tumors of the spinal cord, 1054 of anterior gray cornua in infantile spinal paralysis, 1133-1144 of bones and muscles in atrophic infantile paralysis, 1124 of brain, 170, 993, 994

Atropia, use of, in heat-exhaustion, 388 in labio-glosso-laryngeal paralysis, 1175 in tremor of spinal sclerosis, 905 in writers' cramp, 537

Auræ of epilepsy, characters, 475

Aural vertigo, causes and symptoms, 421

Auras in migraine, 1230

Autographic women, 351

Automatism, 228, 331-333

Base of brain, focal lesions of, 91

Baths, use of, in alcoholism, 641, 642, 643 in chorea, 455 in heat-exhaustion, 388 in the opium habit, 672, 673, 676 in thermic fever, 396, 397, 398 in tremor, 432 cold, use of, in spinal sclerosis, 903 hot, use of, in spinal sclerosis, 900, 903 sulphur, use of, in chronic lead-poisoning, 691 value of, in hysteria, 281, 282, 283 warm, use of, in acute myelitis, 823

Bed-sores, 1274, 1275 in tumors of spinal cord, 1096, 1098 malignant, in acute myelitis, 819

Belladonna, use of, in epilepsy, 501 in infantile spinal paralysis, 1155

Bell's palsy, 1202

Biliary catarrh, in chronic alcoholism, 607

Bismuth, use of, in vomiting of the opium habit, 675

Bladder, disorders of, in chronic alcoholism, 614 in tabes dorsalis, 829, 834, 836 in tumors of the brain, 1045 of the spinal cord, 1096

Bleeding, in acute myelitis, 823 simple meningitis, 720 in Bell's palsy, 1207 in cerebral hemorrhage and apoplexy, 976 hyperæmia, 774 in exacerbations of cerebral syphilis, 1015 in hæmatoma of the dura mater, 710 in spinal hyperæmia, 805 in tetanus, 555 in thermic fever, 398

Blindness, hysterical, 248 in cerebral anæmia, 776 word-, in nervous diseases, 31

Blisters, use of, in epilepsy, 502 in hæmatoma of dura mater, 710 in tetanus, 555 in thermic fever, 398, 400 in writers' cramp, 538

Blood, changes in, in chronic alcoholism, 615, 618 in the chloral habit, 662 in thermic fever, 391, 392

Blood-vessels, changes in, in chronic alcoholism, 612

Bluish line upon the gums, significance of, in chronic lead-poisoning, 682

Blushing, in hysteria, 253

Bones, atrophy of, 1267 changes in, in alcoholism, 614 state of, in general paralysis of the insane, 196

Brachial neuralgia, 1234

BRAIN AND SPINAL CORD, ANÆMIA AND HYPERÆMIA OF THE, 763 Abscess, 792 Diagnosis, 799 Etiology, 796 Morbid anatomy, 792 Prognosis, 799 Symptomatology, 795 Treatment, 799 Medical, 800 Derivatives, 800 Mercury, 800 Surgical, 800 Emptying contents, 800 Anæmia, 774 Diagnosis, 787 Etiology, 776 Morbid anatomy, 781 Appearances of, in cerebral anæmia, 781 Symptomatology, 782 Treatment, 788 Alcoholic stimulants, 789 Amyl nitrite, 788 Cannabis, 789 Cold pack, 789 Massage, 789 Morphine, 788 Hyperæmia, 763 Differential diagnosis, 772 Etiology, 765 Symptomatology, 768 Treatment, 773 Baths, 773 Bleeding, 774 Bromides, 773 Cathartics, 774 Cautery, 774 Chloral, 773 Derivation, 774 Diet, 774 Ergot, 773 Hypnotics, 773 Pediluvia, 773 Inflammation, 790 Abscess in, 791 Acute encephalitis of Strümpell in, 791 Accompanying endocarditis, 792 Miliary form, 792 of septic origin, 792 Post-paralytic phenomena of, 791 Sequelæ of, 791

BRAIN AND SPINAL CORD, CONCUSSION OF THE, 908 Definition and morbid anatomy, 908 Diagnosis, 909 Symptoms, 908 Mental state, 908 Pulse and temperature in, 909 Pupils, state of, 909 Treatment, bromide of potassium, heat and cold, use, 911, 912 of reaction, 911 Stimulants, use of, 911

BRAIN, ATROPHY AND HYPERTROPHY OF, 993 Atrophy during childhood, 993 Causes, symptoms, and treatment, 994 of the fully-developed, 994 Causes, morbid anatomy, and symptoms, 995 Treatment, 996 Hypertrophy, 996 Course, diagnosis, prognosis, symptoms, and treatment, 998 Etiology and morbid anatomy, 997

Brain and its envelopes, tumors of, 1028 and membranes, changes in, in acute simple meningitis, 719 in alcoholism, 617 in cerebral meningeal hemorrhage, 713, 714 in external pachymeningitis, 705 in general paralysis of the insane, 196 in hæmatoma of the dura mater, 708 in tubercular meningitis, 730-732 and spinal cord, diseases of membranes of, 703 lesions of, in insanity, 121 microcephalic, size of, 139 softening of, 918, 989 in children, 990 state of, in chronic hydrocephalus, 944 syphilis of, 1003

Brain-cortex, syphilis of (see Syphilitic Affections of Nerve-centres).

Brain, gross appearances of, in brain tumors, 1050

Brain-tire, treatment of, 358

Breathing, hysterical, 245

Bright's disease as a cause of intracranial hemorrhage and apoplexy, 930

Bromate of potassium, use of, in epilepsy, 501

Bromide of nickel, use of, in epilepsy, 500

Bromide of potassium, use of, in acute simple meningitis, 721 in acute spinal meningitis, 752 in chronic cerebral meningitis, 722 in concussion of spine, 911 in hæmatoma of the dura mater, 710 in hystero-epilepsy, 313 in insanity, 136 in melancholia, 160 in migraine, 1232 in tetanus, 558 in tumors of the brain, 1068

Bromides, use of, in alcoholism, 642, 645, 646 in cerebral anæmia, 789 hyperæmia, 773 in chorea, 455 in epilepsy, 499, 500 in insomnia, 380, 381, 382 in migraine, 414, 415 in spinal sclerosis, 905, 906 in the opium habit, 674, 676 in tubercular meningitis, 736 in vertigo, 427

Bronchi, disorders and lesions of, in chronic alcoholism, 608

Cachexia, alcoholic, characters, 616

Caffeine, use of, in migraine, 1232 in neuralgia, 1229

Caisson disease, a form of spinal hyperæmia, 804

Calabar bean, use of, in tetanus, 557 in tetanus neonatorum, 565

Cancer of the brain, 1049

Cannabis indica, habitual addiction to, 667 use of, in alcoholism, 645 in brain tumors, 1068 in cerebral anæmia, 788, 789 in migraine, 413, 415, 1232 in the opium habit, 676 in tetanus, 557

Capillary cerebral embolism, 979

Capsicum, use of, in alcoholism, 642

Carbuncles, as a cause of thrombosis of cerebral veins and sinuses, 985

Caries of teeth, as a cause of neuralgia, 1229, 1233

Caries of temporal bone, as a cause of tubercular meningitis, 725

Carotids, ligation of, as a cause of cerebral anæmia, 777

CATALEPSY, 314 Definition and synonyms, 314 Diagnosis, 334 from apoplexy and intoxication, 336 from epilepsy, 335 from simulation, 337 from tetanus, 336 Etiology, 315 Age, influence on causation, 315 Imitation, influence on causation, 319 Reflex irritation, 318 Sex and puberty, 318 History, 315 Pathology and duration, 334 Prognosis, 337 Symptoms, 320 of cataleptoid phenomena in the insane, 327 of hypnotic catalepsy, 322 of unilateral catalepsy, 324 Onset of seizures, mode of, 320 Pulse, respiration, and temperature in, 321 Reflex irritability, changes in, 321 Sensation, disturbances of, 321 Wax-like flexibility in, 321, 337 Treatment, 338 Cold douche, use of, 338 Electricity, use of, 338 Nitrite of amyl and nitro-glycerin, use of, 338 Music, use of, 338 Purgatives and tonics, use of, 338

Cataleptoid phenomena in the insane, 327

Cathartics in cerebral abscess, 800 in cerebral hemorrhage, 976 in cerebral hyperæmia, 774

Cauterization in vertigo, 427

Cautery, use of, in cerebral hyperæmia, 774 in spinal sclerosis, 905

Cephalic soufflé, diagnostic significance of, 779

Cerebellum, focal lesions of, 90 tumors of, symptoms, 1062

Cerebral anæmia, 774, 786 from emotional disturbance, 780 from ligature of carotid, 776 Arteries, occlusion of, 946 Congestion, active, insomnia from, 382 Hyperæmia in the insane, treatment, 136 Meningeal hemorrhage, 710 Meningitis, chronic, 721 Neurasthenia, 355 Paralysis, 917 Pia mater, congestion of, 715 inflammation of, 716 Symptoms of thermic fever, 390 Syphilitic insanity, 202 Tissue, alterations of, in epilepsy, 491 Veins and sinuses, thrombosis of, 982 occlusion of, 918

Cerebro-spinal sclerosis, multiple, 873

Cervical sympathetic, diseases of, 1263 Etiology and pathology, 1263, 1264 Course and diagnosis, 1265 Symptoms, 1264 Eye and pupil, changes in, 1264 Heart, disorders in, 1265 of irritation of, 1264 of destructive disease of, 1264 Secretions, changes in, 1265 Treatment, 1265

Cervico-brachial neuralgia, 1234 occipital neuralgia, 1234

Charcot's joint disease in tabes dorsalis, 830, 837

Cheyne-Stokes phenomenon, 777 respiration in tubercular meningitis, 728, 729

Child-bearing and cerebral anæmia, 778

Childhood, headache in, 405 Insanity of, 171

Children, cerebral hemorrhage in, 928 Hysteria in, treatment, 275 Softening of brain in, 990

Chloral, abuse of (see Opium Habit). use of, in acute simple meningitis, 721 in alcoholism, 641, 645, 646 in cerebral anæmia, 789 hyperæmia, 773 in chorea, 455 in epilepsy, 500 in hysteria, 276 in insanity, 136 in insomnia, 380-382 in migraine, 415 in tetanus, 558 in the opium habit, 673, 674, 676 in tubercular meningitis, 736 in vaso-motor neuroses, 1256

Chloroform, habitual addiction to, 667 use of, in hysteria, 286 in neuralgia, 1229 in tetanus, 551

Choked disc, in tumors of brain, 1035

Cholesteotomata, in brain tumors, 1049

CHOREA, 439 Definition, 440 Diagnosis and prognosis, 453 Duration, 449 Etiology, 440 Age and sex, influence on causation, 441 Climate, season, and race, 444 Heredity, influence on causation, 440 Rheumatism, influence on causation, 442 Reflex irritation and eczema, 444 Scarlet fever and pregnancy, 443 Social condition and over-study, 441 History and synonyms, 439 Morbid anatomy and pathology, 450 Symptoms, 445 during sleep, 445, 446 Heart, state of, in, 448 Mental condition in, 445 Movements, characters, and description of, 445, 446 Paralysis and post-paralytic stage of, 447 Pulse and temperature in, 449 Sensibility and reflexes in, 448 Speech in, 445, 448 Treatment, 454 Arsenic, use of, 455 Cimicifuga and conium, use of, 455 Electricity, use of, 455 Iron and zinc salts, use of, 455 Nitrite of amyl, bromides, etc., use, 455 Strychnia, use of, 455

Chorea, hysterical, 242 in tumors of the brain, 1039 post-paralytic, 447, 960

Chronic alcoholism, 598 et seq. cerebral anæmia of adults, 782 meningitis, 721 delirium tremens, 630 hydrocephalus, 740 lead-poisoning, 678 myelitis, 886 spinal meningitis, 752 pachymeningitis, 748

Cicatrices, myelitic, 815

Cimicifuga, use of, in chorea, 455

Circular insanity, 151

Circulation, obstructed, as a cause of spinal hyperæmia, 802

Classification of alcoholism, 573 of chronic lead-poisoning, 678 of mental diseases, 105-109

Clavus hystericus, 252

Cleanliness, importance in cerebral hemorrhage and apoplexy, 977

Climate, change of, value in neurasthenia, 358 in neuralgia, 1223 in spinal sclerosis, 903 influence on causation of chronic lead-poisoning, 680 of epilepsy, 474 of hystero-epilepsy, 291 of thermic fever, 389

Climate and season, influence on causation of chorea, 444 of hysteria, 218

Climacteric insanity, 173 period, cerebral hyperæmia in, 771

Climatic and atmospheric conditions, influence on causation of tetanus, 544

Clonic spasms, in nervous diseases, 45

Clonus, significance in nervous diseases, 54

Clot, of intracranial hemorrhage, changes in, 920

Club-foot, in family form of tabes dorsalis, 871 in infantile spinal paralysis, 1127

Coca and cocaine, habitual addiction to, 667 use of, in alcoholism, 643, 646 in the opium habit, 676

Cod-liver oil, use of, in chronic alcoholism, 644, 646 hydrocephalus, 775 in general paralysis of the insane, 201 in neuralgia, 1224 in tubercular meningitis, 735

Cold, influence on causation of Bell's palsy, 1203 of congestion of spinal membranes, 747 of neuralgia, 1219 of neuritis, 1190 of tetanus, 544 use of, in concussion of the brain, 911 in external pachymeningitis, 706 in thermic fever, 396-398

Cold and wet, as a cause of disseminated sclerosis, 884 of tabes dorsalis, 855

Cold pack, use of, in cerebral anæmia, 789

Colic, of chronic lead-poisoning, 683

Coma, 382, 785 alcoholic, characters of, 589, 598 description of, in nervous diseases, 26-28 in abscess of the brain, 796 in acute spinal meningitis, 750 in cerebral anæmia, 785 in chronic lead-poisoning, 688 in tubercular meningitis, 727

Complicating insanity, 174

Complications of hysteria, 258 of progressive muscular atrophy with atrophic spinal paralysis, 1149 unilateral facial atrophy, 699 of tumors of the brain, 1045 spinal cord, 1106

Compression of nerve-trunks, in hystero-epilepsy, 310

Concussion of the brain, 908 spinal cord, 912

Condition of brain in sleep, 775

Confusional insanity, primary, 167

Congestion of cerebral dura mater, 704 of pia mater, 715 of spinal meningitis, 746

Conium, use of, in chorea, 455 in paralysis agitans, 438 in tetanus, 557

Conjunctivitis in the chloral habit, 664, 665

Consciousness, double, in nervous diseases, 28 loss of, in cerebral hemorrhage and apoplexy, 933 in nervous diseases, 26 in occlusion of cerebral vessels, 952 perverted, in catalepsy, 320

Constitutional diseases, influence on causation of neuralgia, 1217 affective mental disease, 142

Constipation in chronic hydrocephalus, 743 in chronic lead colic, 683 in tubercular meningitis, 725, 729, 736 in tumors of the brain, 1045

Constriction about waist, sense of, in acute spinal pachymeningitis, 747 in disseminated sclerosis, 874 in spinal meningeal hemorrhage, 752 in spinal syphilis, 1025 in tabes dorsalis, 829 in tumors of spinal cord, 1093

Contact-sense in tabes dorsalis, 833

Contractures, hysterical, 244 in disseminated sclerosis, 888 in hemiplegia, 962 in hystero-epilepsy, 297 in infantile spinal paralysis, 1127 in inflammation of the brain, 791 in secondary sclerosis, 987 in tumors of the brain, 1039

Convulsions in abscess of the brain, 796 in atrophy of the brain, 994 in chronic lead-poisoning, 688 in hysteria, 236 in infantile spinal paralysis, 1116 in spina bifida, 759 in thrombosis of cerebral veins and sinuses, 986 in tubercular meningitis, 728 in tumors of the brain, 1039

Convulsive disorders, local, 461 form of acute alcoholism, 593

Co-ordination, disturbance of, in tabes dorsalis, 830-833 in family form of tabes dorsalis, 871

Copodyscinesia (see Writers and Artisans, Neural Disorders of).

Cord, spinal, lesions of, in alcoholism, 622 in tetanus, 549

Corrosive poisoning from alcohol, 596

Counter-irritation, use of, in acute simple meningitis, 721 spinal meningitis, 752 in cerebral meningeal hemorrhage, 715 in chronic cerebral meningitis, 722 spinal meningitis, 753 in concussion of the spine, 916 in external pachymeningitis, 706 in infantile spinal paralysis, 1155 in hæmatoma of dura mater, 710 in neuralgia, 1227 in neuritis, 1294 in sciatica, 1262 in symmetrical gangrene, 1236 in tubercular meningitis, 736

Coup de soleil, 388

Course of diseases of cervical sympathetic, 1265 of ecstasy, 343 of family form of tabes dorsalis, 871 of general paralysis of the insane, 178 of hysteria, 258 of hystero-epilepsy, 307 of infantile spinal paralysis, 1148 of insanity, 120 of myxœdema, 1272 of simple acute meningitis, 718 of symmetrical gangrene, 1201 of the opium habit, 657 of vaso-motor neuroses, 1254 of writers' cramp, 521

Cramp, writers', 504

Cranial conformation, vices of, as a cause of epilepsy, 470

Cranio-cerebral topography, in localization of nervous lesions, 93

Cranium, changes in, in chronic alcoholism, 617 in chronic hydrocephalus, 742, 743

Cretinism, 138

Crises clitoridienne, 836

Crises in tabes dorsalis, 835, 836

Croton chloral, use, in epileptiform facial neuralgia, 1234 in migraine, 415

Croton oil, use of, in cerebral hemorrhage and apoplexy, 976

Cry of tubercular meningitis, 726, 727

Curare, use of, in tetanus, 556 in tremors of spinal sclerosis, 905

Cutaneous sensibility, disorders of, in epilepsy, 476, 480

Cyanotic stage of symmetrical gangrene, 1258

Dancing mania, the, 222, 223, 439

Deafness, hysterical, 249 word-, in nervous diseases, 31

Death, apparent, 385 mode of, in delirium tremens, 630

Defecation, hysterical disorders of, 240

Definition of alcoholism, 573 of amyotrophic lateral spinal sclerosis, 867 of apoplexy, 917, 918 of athetosis, 459 of atrophy of the brain, 993 of catalepsy, 314 of chorea, 440 of chronic hydrocephalus, 740 lead-poisoning, 678 of eclampsia, 464 of ecstasy, 339 of epilepsy, 467 of hæmatoma of the dura mater, 707 of hysteria, 205 of hystero-epilepsy, 288 of infantile spinal paralysis, 1113 of insanity, 99 of labio-glosso-laryngeal paralysis, 1169 of neural disorders of writers and artisans, 504 of neuralgia, 1211 of progressive unilateral facial atrophy, 693 of spina bifida, 757 of stigmatization, 348 of symmetrical gangrene, 1257 of tetanus, 544 of trance, 344 of tremor, 429 of tubercular meningitis, 723 of tumors of the brain, 1028 spinal cord, 1090 of unilateral spinal paralysis, 1166 of vaso-motor and trophic neuroses, 1241 of vertigo, 416

Deformities, in tabes dorsalis, 871 in infantile spinal paralysis, 1127-1131

Degenerative changes in atrophy, 1266-1277

Deglutition, difficult, in amyotrophic lateral sclerosis, 868 in Bell's palsy, 1204 in cerebral hemorrhage and apoplexy, 935 in labio-glosso-laryngeal paralysis, 1170

Delirium, acute, 163 chronic, in alcoholic insanity, 632 in acute simple meningitis, 718 in alcoholism, 626 in chronic lead-poisoning, 688, 689 in nervous disease, 124 of cerebral anæmia, 785 tremens, 627

Delusional insanity, secondary, 203 primary, 167

Delusions, character of, in insanity, 168 in general paralysis of the insane, 187, 188, 190, 192 in katatonia, 166 varieties of, in nervous diseases, 22 with melancholia, 156, 157

Dementia, in alcoholism, 633 of general paralysis of the insane, 187 paretic, in inflammation of the brain, 791 in spastic spinal paralysis, 863, 865, 866 and simple, in disseminated sclerosis, 877, 878 primary, 164 secondary, 165 senile, 174 terminal, 203

Depression in cerebral anæmia, 782, 783 in mental disease, 20

Dercum and Parker on artificial induction of convulsive seizures, 213, 529

Development of language, 568

Diabetes, influence on causation of neuralgia, 1218

Diagnosis of abscess of the brain, 799 of acute mania, 162 of acute myelitis, 820 of acute narcotic poisoning from alcohol, 598 of acute simple meningitis, 729 spinal meningitis, 751 pachymeningitis, 748 of apoplexy, 963 of anæsthesia of peripheral origin, 1200 of athetosis, 459 of Bell's palsy, 1205 of capillary embolism, 981 of catalepsy, 334 of cerebral anæmia, 787 embolism, 981 hemorrhage, 963 hyperæmia, 771 meningeal hemorrhage, 714 syphilis, 1112 of chorea, 453 of chronic cerebral meningitis, 722 hydrocephalus, 744 of chronic lead-poisoning, 690 of combined form of sclerosis, 870 of concussion of the brain, 909 spine, 916 of congestion of spinal membranes, 747 of diffuse sclerosis, 890 of diseases of cervical sympathetic, 1265 of disseminated sclerosis, 885 of ecstasy, 343 of epilepsy, 493-496 of external pachymeningitis, 706 of family form of tabes dorsalis, 872 of functional nervous diseases, 63 of gastralgia, 1239 of general paralysis of the insane, 197 of hæmatoma of dura mater, 709 of headache, 405 of hydrencephaloid, 785 of hypertrophy of the brain, 998 of hysteria, 260 of hystero-epilepsy, 307 of infantile spinal paralysis, 1152 of insanity, 123 of labio-glosso-laryngeal paralysis, 1174 of migraine, 410 of multiple neuritis, 1197 of myxœdema, 1273 of nerve injuries, 1187 of neuralgia, 1221 of neuritis, 1194 of neuromata, 1210 of organic nervous diseases, 61-63 of paralysis agitans, 438 of progressive unilateral facial atrophy, 700 of simulation of sleep, 775 of spastic spinal paralysis, 866 of special paralyses in infantile spinal paralysis, 1123 of spina bifida, 755 of spinal meningeal hemorrhage, 760 of symmetrical gangrene, 1261 of syphilis of brain-cortex, 1020 of tabes dorsalis, 857 of the chloral habit, 665 of the opium habit, 659 of thermic fever, 396 of thrombosis of cerebral veins and sinuses, 987 of tubercular meningitis, 732 of tumors of brain, 1051, 1056 of spinal cord, 1098, 1100 of vaso-motor neuroses, 1252 of vertigo, 417 of writers' cramp, 521 principles of, in nervous diseases, 59-61

Diaphragm, hysterical paralysis of, 239

Diarrhœal affections of children as a cause of cerebral anæmia, 779

Diet in acute simple meningitis, 721 in acute spinal meningitis, 752 in alcoholism, 643, 644 in apoplexy, 975 in cerebral anæmia, 790 in cerebral meningeal hemorrhage, 715 in chronic hydrocephalus, 745 in epilepsy, 503 in external pachymeningitis, 706 in gastralgia, 1239 in hæmatoma of the dura mater, 710 in hyperæmia of the brain, 774 in the opium habit, 673, 674 in tubercular meningitis, 735, 736 in tumors of the brain, 1068 influence on causation of chronic lead-poisoning, 680

Diffuse myelitis, 886 sclerosis, 886

Digestive disorders as a cause of headache, 404, 405 in chronic hydrocephalus, 743 in neurasthenia, 356 in tubercular meningitis, 725, 726, 728 of chronic alcoholism, 599-602, 607 of the chloral habit, 661, 665 of the opium habit, 653, 657-659 symptoms of hystero-epilepsy, 297 of migraine, 409 of myxœdema, 1272 of tetanus, 551 of thermic fever, 390

Digitalis, use of, in alcoholism, 642, 645 in epilepsy, 500 in thermic fever, 397

Digiti mortui, 1252, 1254

Diplopia in disseminated sclerosis, 875, 876 in nervous diseases, 40 in tabes dorsalis, 829 in tumors of the brain, 1042

Dipsomania, 147, 636, 637

Disease of one lateral half of the spinal cord, 1165 Thomsen's, 461

Diseases, mental, 99 of nervous system, general semeiology of, 19 of peripheral nerves, 1176 of the membranes of the brain and spinal cord, 703

Dislocation in infantile paralysis, 1130

Disorders of sleep, 364 of speech, 568

Dizziness in general paralysis of the insane, 187, 195

Double consciousness in nervous diseases, 28 vision in nervous diseases, 40

Doubting insanity, 170

Douche, cold, in catalepsy, 338 in ecstasy, 338 in spinal sclerosis, 903

Dreams (see Sleep, and its Disorders).

Dropsy of the head (see Hydrocephalus, Chronic), 740 sleeping, 383

Dura mater, cerebral congestion, 704 cerebral hæmatoma of (hemorrhagic pachymeningitis), 707 Definition, etiology, and symptoms, 707 Diagnosis, 709 Duration and pathology, 708 Prognosis, 709 Treatment, 710 cerebral inflammation of (pachymeningitis), 703 external pachymeningitis, 704 Diagnosis and prognosis, 706 Etiology and symptoms, 704 Pathological anatomy, 705 Treatment, 706 internal pachymeningitis, 706 Treatment, 707 spinal, acute inflammation of, 747

Duration of acute mania, 162 of acute myelitis, 821 of acute spinal meningitis, 718 of amyotrophic spinal sclerosis, 868 of catalepsy, 334 of chorea, 449 of chronic hydrocephalus, 743 of delirium tremens, 629 of ecstasy, 343 of family form of tabes dorsalis, 871 of hæmatoma of the dura mater, 708 of hysteria, 258 of hystero-epilepsy, 307 of progressive unilateral facial atrophy, 699 of spina bifida, 759 of symmetrical gangrene, 1261 of tabes dorsalis, 839, 840 of tubercular meningitis, 729 of tumors of the brain, 1045 of the spinal cord, 1106 of vertigo, 418 of writers' cramp, 521

Dyskinesis, definition, in nervous diseases, 47

Dyslalia, 569, 572

Dyspepsia, headache from, 405

Dyspeptic symptoms of chronic alcoholism, 601, 607

Dysphagia, hysterical, 239, 245

Ear affections, hysterical, 249 influence on causation of acute pachymeningitis, 716 of external pachymeningitis, 704 disorders of, as a cause of abscess of the brain, 474 of epilepsy, 474 of vertigo, 421 in progressive unilateral facial atrophy, 698 middle, disease of, as a cause of thrombosis of cerebral veins and sinuses, 985

Eclampsia, 464 Definition, etiology, and symptoms, 464

ECSTASY, 339 Definition, 339 Course, diagnosis, and duration, 343 Etiology, 341 History and synonyms, 339 Prognosis, 343 Symptoms, 342 Treatment, 344

Eczema as a cause of chorea, 444

Education, improper, as a cause of hysteria, 218, 220 of speech in aphasia of hemiplegia, 979 relation of, to hysteria, 274

Electrical reactions in amyotrophic lateral sclerosis, 868 in Bell's palsy, 1205, 1206 in diffuse sclerosis, 890 in infantile paralysis, 1125 in spastic spinal paralysis, 864 of injured and divided nerves, 1184, 1188

Electricity, use of, in Bell's palsy, 1207 in catalepsy, 338 in chronic lead-poisoning, 691 in hysteria, 281, 286 in hystero-epilepsy, 311-313 in infantile spinal paralysis, 1156 in labio-glosso-laryngeal paralysis, 1175 in migraine, 415, 1232 in multiple neuritis, 1198 in myelitis, acute, 824 in myxœdema, 1273 in nerve injuries, 1189 in neuralgia, 1225 in neurasthenia, 360 in neuritis, 1194 in painless facial spasm, 462 in paralysis agitans, 438 of intracranial hemorrhage, 978 in progressive unilateral facial atrophy, 702 in sciatica, 1238 in spinal sclerosis, 901, 905 in symmetrical gangrene, 1262 in torticollis, 464 in vaso-motor neuroses, 1256 in writers' cramp, 534

Emboli, source of, in occlusion of cerebral arteries, 947-950

Embolic origin of abscess of the brain, 799 theory of origin of chorea, 452

Embolism, capillary, 979 and thrombosis of cerebral arteries, 946 of spinal cord, 808, 810

Emetics, use of, in alcoholism, 642 in hysteria, 285

Emotional attitudes in hystero-epilepsy, 301 causes of hystero-epilepsy, 293 state, in general paralysis of the insane, 179 states, abnormal, in nervous diseases, 19 strain, influence on causation of insanity, 118

Emprosthotonos in tetanus, 551

Encephalitis, acute, of Strümpell, 791

Encephalic mass, localization of lesions in, 81

Endocarditis, ulcerative, as a cause of abscess of the brain, 799 as a cause of capillary embolism, 980

Encephalopathy, the, of chronic lead-poisoning, 688

Enchondromatous brain tumors, 1070

Enophthalmos in progressive unilateral facial atrophy, 698

Entero-colitis of infancy, relation to thermic fever, 390

EPILEPSY, 467 Definition and history, 467 Diagnosis, 493 from syncope, 495 from vertigo, 495 from uræmic convulsions, 495 in children, 494 in malingerers, 496 Etiology, 468 Age and sex, influence on causation, 470 Exanthemata, relation of, to, 473 Excentric irritating causes, 471 Exciting causes, 471 Gastric causes, 474 Peripheral origin, 474 Preputial irritation as a cause, 473 Reflex causes, 472 Sexual causes, 473, 474 Syphilis, influence on causation, 470 Toxic causes, 472 Traumatic causes, 470, 471 Morbid anatomy and pathology, 488 Alterations of cerebral tissue in, 493 Hughlings-Jackson's cortical theory, 489, 490 Medullary theory of origin, 489 Theory of epileptic zones, 489 Prodromata, 475 Aural, characters of, 475, 476 Cerebral disturbances, 475 Cutaneous disorders, 476 Hearing and vision, disorders of, 475, 476 Motor disturbances, 476 Saliva, increase of, 476 Prognosis, 496 Age, influence on recovery, 498 Menstruation, marriage, and pregnancy, influence on recovery, 500, 501 Symptoms, 477 Frequency of attacks, 482 of immediate and remote effects of paroxysms, 481 Physical, 481 Post-epileptic aphasia, 481 Psychical, 481 Tendency to mania in, 482 of irregular forms, 483 of light attacks, or petit mal, 477 of major attacks, 477-479 Convulsions, characters, 477-479 Cutaneous state, in, 480 Duration of attacks, 478 Eyes, state of, in, 480 Pulse and temperature in, 480 Tendon reflexes in, 481 Tongue-biting, significance, 481 Urine, state of, 480 of psychical or masked forms, 483-486 of sensory epilepsy, 486 Hallucinations in, 487 Synonyms, 467 Treatment, 499 Abortants, use, 502 Amyl nitrite, use, 502 Belladonna and ergot, use, 501 Blisters, use, 502 Bromide, use of, 499-501 Bromate of potassium, use, 501 Cod-liver oil and hypophosphites, use, 501 Diet in, 503 Digitalis, use, 500 Galvanism, use, 502 Iodide of potassium, use, 502 Nitro-glycerin, use, 500, 502 of status epilepticus, 502 Strychnia, use, 500 Surgical measures, 502

Epilepsy, alcoholic, 624 influence on causation of migraine, 407

Epileptic attacks in cerebral syphilis, 1010 following hemiplegia, 955

Epileptic insanity, 149

Epileptiform facial neuralgia, 1233

Epistaxis in tumors of the brain, 1044

Ergot, use of, in acute myelitis, 822 in acute spinal meningitis, 721 in cerebral hyperæmia, 773 in epilepsy, 501 in migraine, 413, 1232 in infantile spinal paralysis, 1155 in insanity, 136 in spinal hyperæmia, 805 meningeal hemorrhage, 756

Ergotin, use of, in spinal sclerosis, 901

Erotomania, 148

Eruptions in nervous diseases, 57 simulated, in hysteria, 234

Erysipelas as a cause of cerebral hyperæmia, 765 of thrombosis of cerebral veins and sinuses, 985

Erythema, local, in symmetrical gangrene, 1259

Erythromelalgia, 1253

Essential vertigo, 426

Ether, habitual addiction to, 667 use of, in chorea, 455 in neuralgia, 1229 in tetanus, 556

Etiology of abscess of the brain, 796 of acute simple meningitis, 716 of acute spinal meningitis, 749 of alcoholism, 575 of atrophy of the brain, 994, 995 of Bell's palsy, 1203 of capillary embolism, 979 of catalepsy, 315 of cerebral anæmia, 776 of cerebral hyperæmia, 765 of cerebral meningeal hemorrhage, 711 of chorea, 440 of chronic hydrocephalus, 741 lead-poisoning, 679 of combined forms of sclerosis, 870 of congestion of the cerebral pia mater, 716 of spinal membranes, 746 of diseases of cervical sympathetic, 1263 of disseminated sclerosis, 883 of eclampsia, 464 of ecstasy, 341 of epilepsy, 468 of external pachymeningitis, 704 of family form of tabes dorsalis, 870 of general paralysis of the insane, 177 of hæmatoma of dura mater, 707 of hypertrophy of the brain, 997 of hysteria, 214 of hystero-epilepsy, 291 of infantile spinal paralysis, 1151 of insanity, 113 of intracranial hemorrhage and apoplexy, 927 of labio-glosso-laryngeal paralysis, 1173 of neural disorders of writers and artisans, 505 of migraine, 1231 of multiple neuritis, 1197 of myxœdema, 1271 of neuralgia, 1216 of neurasthenia, 354 of neuritis, 1190 of neuromata, 1209 of occlusion of cerebral arteries, 950 of progressive unilateral facial atrophy, 693 of sciatica, 1236 of spastic spinal paralysis, 864 of spina bifida, 757 of spinal hemorrhage, 809 of spinal hyperæmia, 802 of spinal meningeal hemorrhage, 754 of symmetrical gangrene, 1261 of tabes dorsalis, 851 of tetanus, 545 of tetanus neonatorum, 563 of the chloral habit, 661 of the opium habit, 649 of thermic fever, 388 of thrombosis of cerebral veins and sinuses, 982, 983 of torticollis, 463 of tubercular meningitis, 724 of tumors of the brain, 1028 of the spine, 1090 of vertigo, 418 of writers' cramp, 506 general, of syphilitic affections of nerve-centres, 999

Exaltation, in nervous diseases, 20

Exanthemata, as a cause of epilepsy, 473 of vertigo, 419

Excesses, influence on causation of general paralysis of the insane, 177 of insanity, 116, 119

Excision of the tumor in spina bifida, 762

Exciting causes of insanity, 118, 119

Exercise, necessity of, in hysteria, 275

Exhausting diseases as a cause of cerebral anæmia, 779 of tremor, 429

Exhaustion, insomnia from, 380

Exposure to cold and wet as a cause of tabes dorsalis, 855

Eye affections, hysterical, 247 in progressive unilateral facial atrophy, 698

Eye-strain, headache from, 304

Eyes, state of, in cerebral hemorrhage and apoplexy, 939 in chronic hydrocephalus, 743 in epilepsy, 479, 480 in tubercular meningitis, 725-727, 729 Disorders of, as a cause of vertigo, 424 in cerebral anæmia, 783 hyperæmia, 770, 772 in diseases of cervical sympathetic, 1264 in disseminated sclerosis, 875, 877, 878 in tabes dorsalis, 830-833 in the chloral habit, 664, 665 in the opium habit, 657 in tumors of the brain, 1035, 1042-1044

Facial atrophy, unilateral progressive, 693 expression in Bell's palsy, 1203 in cerebral hemorrhage and apoplexy, 939 in chorea, 445 in paralysis agitans, 434 nerve, paralysis of, in atrophic spinal paralysis, 1120 nerve, peripheral paralysis of (Bell's palsy), 1202 Diagnosis, 1205 Etiology, 1202, 1203 Symptoms, 1203 Facial expression, 1203, 1204 Muscles and organs affected, 1203, 1204 Reactions, electrical, in, 1205, 1206 Special senses and sensibility in, 1204, 1205 Treatment, 1206 Bleeding and counter-irritation in, 1207 Electricity, 1207 Iodide of potassium, 1207 Mechanical appliances and massages, 1207, 1208 neuralgia, 1232 epileptiform, 1233 spasm, painless, 462

Facies hysterica, 230

Faith-cure, 277

Family form of tabes dorsalis, 870

Faradic reactions, significance, in diagnosis of nervous lesions, 66

Fasting girls, 351 saints, 351

Fatty heart, in chronic alcoholism, 611

Febrile insomnia, 379

Feeding, forced, in neurasthenia, 359

Feet, condition of, in advanced tabes dorsalis, 838 in diffuse sclerosis, 888

Festination in paralysis agitans, 436

Fever, thermic, 388 and cerebral anæmia, 779

Fibrillary contractions in nervous diseases, 47

Fifth nerve, neuralgias of, 1233

Flexibility, wax-like, in catalepsy, 321, 337

Fontanels, state of, in chronic hydrocephalus, 741, 742 in tubercular meningitis, 727

Frauds of hysterical patients, 233, 234

Frequency of epileptic attacks, 483

Friedreich's disease, 870

Front-tap, in diffuse spinal sclerosis, 888

Functional nervous diseases, diagnosis of, 63

Gait in chronic lead-poisoning, 686 in diffuse sclerosis, 888 in general paralysis of the insane, 194 in paralysis agitans, 435 in spastic spinal paralysis, 863, 864 in tabes dorsalis, 831

Galvanic reactions, significance of, in diagnosis of nervous lesions, 66

Galvanism, use in insanity, 137

Ganglionic elements, condition of, in abscess of the brain, 793

Gangrene in vaso-motor neuroses, 1252 Definition, history, and synonyms, 1257 Duration, course, and nature, 1261 Etiology and diagnosis, 1262, 1263 of Reynaud's disease, 1259, 1260 Prognosis, 1262 Symmetrical, 1257 Symptoms, 1258-1260 Treatment, 1262 Electricity, 1262 Massage, rest, and tonics, use, 1262 Opium, use, 1262

Gastric crises in tabes dorsalis, 835 Disorders, as a cause of epilepsy, 474 Vertigo, 420

Gastralgia (see Neuralgia).

Gelsemium, use, in neuralgia, 1225 in painless facial spasm, 462

General paralysis of the insane, 176

Genital organs, disorders of, in chronic alcoholism, 614

Genito-urinary disorders of the chloral habit, 662, 663 of the opium habit, 654, 658

Genius, relations of, to insanity, 115

Glandular system, atrophy of, 1268

Gliomatous tumors of the brain, 1046

Gold, use of, in hemiplegia, 970 and sodium chloride, use of, in hysteria, 278

Gout, relation of, to chronic lead-poisoning, 685 to hysteria, 215

Guarana, use, in migraine, 1232

Gummatous brain syphilis, 1003, 1014 brain tumors, 1049

Gums, state of, in chronic lead-poisoning, 684

Gustatory sensory disturbances in nervous diseases, 41

Gymnastics, value of, in hysteria, 275, 280 in writers' cramp, 536

Gynæcological treatment of hysteria, 289

Habit, influence on causation of alcoholism, 577 opium, and kindred affections, 647

Hæmatoma of the dura mater, 707

Hæmatorrachis, 754

Hair, changes in, in progressive unilateral facial atrophy, 695

Hallucinations in alcoholism, 626, 631 in cerebral anæmia, 782, 784, 785 hyperæmia, 769 in delirium tremens, 627, 628 in hystero-epilepsy, 301 in nervous diseases, 21, 22 in the opium habit, 655, 658, 659

Handwriting in general paralysis of the insane, 183 in paralysis agitans, 435

Head, changes in, in chronic hydrocephalus, 742, 743 retraction of, in acute simple meningitis, 718 retraction of, in tubercular meningitis, 726, 727

HEADACHE, 401-414 Diagnosis, 405 Duration, 401 Symptoms, 402 from dyspepsia, 405 from eye-strain, 404 from sunstroke, 404 of anæmic and congestive form, 402 of hysterical and toxic form, 402 of organic and neurasthenic form, 403, 404 of rheumatic, pyrexial, and syphilitic form, 403 of sympathetic form, 404 Synonyms, 401 Treatment, 406, 413

Headache in abscess of the brain, 795 in acute simple meningitis, 717, 718 in anæmia of the brain, 783 in cerebral anæmia, 783 meningeal hemorrhage, 712 syphilis, 1003 in children, 405 in chronic cerebral meningitis, 722 in external pachymeningitis, 705 in hæmatoma of the dura mater, 707 in hyperæmia of the brain, 770 in the chloral habit, 663, 665 in the opium habit, 655 in thermic fever, 390 in tubercular meningitis, 725, 726 in tumors of the brain, 1033 spinal cord, 1096 periodical or sick, 1216, 1230

Head-pressure, sense of, in cerebral hyperæmia, 769

Hearing, disorders of, in alcoholism, 623 in Bell's palsy, 1204 in cerebral hyperæmia, 772 in hemiplegia, 955 in neuralgia, 1213 in progressive unilateral facial atrophy, 698 in tumors of the brain, 1030, 1043

Heart, disorders of, in angina pectoris, 1237 in chronic alcoholism, 610-612 in disease of cervical sympathetic, 1265 in labio-glosso-laryngeal paralysis, 1171 in neurasthenia, 356 in tabes dorsalis, 836 in the chloral habit, 662 in the opium habit, 654, 658, 659 influence on causation of embolism and thrombosis of cerebral veins, 951 of intracranial hemorrhage and apoplexy, 930

Heat, affections produced by exposure to, 387

Heat-exhaustion, 387 Pathology and treatment, 388

Heat, use of, in concussion of the spine, 911

Hebephrenia, 171

Hemianæsthesia, hysterical, 247

Hemianopsia in nervous diseases, 39, 40 in tumors of the brain, 1030, 1042

Hemicrania angio-paralytica, 409, 411 spastica, 409, 411

Hemiparaplegia in nervous diseases, 44

Hemiplegia, hysterical, 238 in cerebral hemorrhage and occlusion of cerebral vessels, 940, 954 in cerebral meningeal hemorrhage, 712 in infantile spinal paralysis, 1120 varieties in nervous diseases, 42, 43

Hemispasm in nervous diseases, 45

Hemorrhage as a cause of cerebral anæmia, 776 cerebral meningeal, 710 intracranial, 918 spinal meningeal, 754

Hemorrhages of spinal cord, 808

Hemorrhagic pachymeningitis, 707

Hepatitis, parenchymatous and interstitial, in chronic alcoholism, 604

Hereditary alcoholism, 634 Ataxia, 870 Tabes, 870

Heredity, influence on causation of alcoholism, 576 of angina pectoris, 1238 of cerebral hyperæmia, 765 of chorea, 440 of chronic hydrocephalus, 741 of copodyscinesia, 513 of epilepsy, 468 of general paralysis of the insane, 177 of hysteria, 214 of insanity, 113 of intracranial hemorrhage and apoplexy, 929 of migraine, 407, 1231 of neuralgia, 1216 of syphilitic affections of nerve-centres, 1000 of tabes dorsalis, 851 of tremor, 429 of tubercular meningitis, 724 of tumors of the brain, 1029

History of alcoholism, 574 of catalepsy, 315 of chorea, 439 of chronic lead-poisoning, 678 of ecstasy, 399 of epilepsy, 467 of general paralysis of the insane, 176 of hysteria, 207 of hystero-epilepsy, 289 of insanity, 109 of labio-glosso-laryngeal paralysis, 1169 of neural disorders of writers and artisans, 504 of progressive unilateral facial atrophy, 693 of spina bifida, 757 of symmetrical gangrene, 1257 of tabes dorsalis, 826 of the opium habit, 504 of tubercular meningitis, 723

Home, removal from, question of, in treatment of opium and chloral habit, 670, 671

Home treatment of the insane, 128, 130, 131, 133

Homicidal insanity, 146

Hughlings-Jackson on origin of epilepsy, 489

Hydrobromic acid, use, in epilepsy, 501

Hydrocele, spinal, 757

HYDROCEPHALUS, CHRONIC, 740 Definition and synonyms, 740 Diagnosis, 744 Duration, 733 Etiology, 741 Pathological anatomy and prognosis, 744 Spurious, in cerebral anæmia, 785 Symptoms, 741 Treatment, 745 by compression, 745 by evacuation of the fluid by puncture, 745 Medicinal, 745

Hydropathic treatment of hysteria, 282 of neuralgia, 1226

Hydrorachis (see Spina Bifida), 757

Hygienic treatment of chronic hydrocephalus, 745 of hemiplegia, 978 of hysteria, 274 of neuralgia, 1223 of tubercular meningitis, 735

Hyoscyamine, use, in painless facial spasm, 462 in torticollis, 464

Hyoscyamus, use, in alcoholism, 645 in brain tumors, 1068 in paralysis agitans, 438 in tremor, 432 in tremors of spinal sclerosis, 905 in tubercular meningitis, 736

Hyperæmia of the brain, 763 Spinal, 801

Hyperæsthesia, hysterical, 250 in acute spinal meningitis, 750 in acute spinal pachymeningitis, 747 in chronic alcoholism, 620 in chronic spinal meningitis, 752 in multiple neuritis, 1195 in symmetrical gangrene, 1259 in tumors of the brain, 1042 of the spinal cord, 1091, 1092

Hyperæsthesiæ, varieties of, in nervous diseases, 31-33

Hyperkinesis, in nervous diseases, 44-47

Hypertrophy, 1271 of the brain, 996

Hypnotic catalepsy (hypnotism), 322, 373

Hypnotics, use, in cerebral hyperæmia, 773

Hypnotism, 322, 373

Hypochondriacal form of general paralysis of the insane, 188 insanity, 150

Hypochondriasis, 154

Hypophosphites, use, in alcoholism, 644, 646 in general paralysis of the insane, 201

HYSTERIA, 205 Course, complications, and duration, 258 Definition, 205 Diagnosis, 260 from acute mania, 262 from general nervousness, 262 from hypochondria, 262 from multiple cerebro-spinal sclerosis, 267 from neurotic temperament, 261 from neurasthenia, 262 from spastic spinal paralysis, 267 from spondylitis, 268 from true joint affections, 270 of hysterical blindness and deafness, 271 of hysterical paralyses, 266 Etiology, 216 Age, influence of, 216 Anæmia and chlorosis, influence of, 220 Diatheses, gouty and phthisical, influence of, 214, 215 Education, influence of, 218-220 Heredity, influence of, 214 Imitation, influence of, 222-229 Kidneys, movable, influence of, 221 Local and sexual irritation, influence of, 220, 221 Menstrual disorders, influence of, 220 Race, climate, and social position, influence of, 217, 218 Sex, influence of, 215 History, 207 Pathology, 208-213 Prognosis, 272 Symptoms, 229 Aphonia, 239 Breathing, peculiarities of, 245 Chorea, 242 Clavus hystericus, 252 Contractures, 244 Convulsions and general spasms, 235-237 Dysphagia, 239-245 Ear affections, 249 Erotomania, 235 Eye affections, 247, 248 Facies hysterica, 230 Frauds and deceptions, 233 Insanity, 231-233 Joint affections, 251 Local spasms, 244 Locomotor ataxia, 240 Mental state, 230 Nymphomania, 235 Pain, 250 Paralyses, varieties and characters, 237-241 Phantom tumors, 255 Rectal, 240 Sensorial affections, 246-250 Simulating pregnancy, 254 Smell and taste, perversion of, 250 Spinal irritation, 251 Temperature and pulse, 252 Urinary secretion, state of, 253 Vaginismus, 246 Vomiting, 254 Synonyms, 206 Treatment, 273 Baths, use of, in, 282, 283 Bromides, use of, 276 Chloroform, use of, 285, 286 Climatic, 283 Cold, use of, 282, 283 Education, necessity of proper, 274 Electricity, use of, 281-286 Emetics in controlling seizures, 285 Exercise and gymnastics, use in, 275, 280 Gold and sodium chloride, use of, 279 Gynæcological, question of, 286, 287 Harsh measures, questionable value of, 276 Hydrotherapy in, 281, 282 in children, 275 Iron and zinc salts, use in, 278 Massage and Swedish movements, 280 Metallo-therapy, 284 Mind- and faith-cures, value of, 277, 278 Mitchell's rest-cure, 279 Moral, 276 Musk, valerian, asafœtida, etc., 278 Nitrite of amyl, 285 of contractures, 286 of paralyses, 286 of paroxysms, 285 Opium, use of, 278 Oöphorectomy, question of, 287 Prophylactic and hygienic, 274 Sea-bathing in, 283

Hysteria as a cause of disseminated sclerosis, 884 of vertigo, 425 distinguished from brain tumors, 1055

Hysterical headache, 402 insanity, 148

HYSTERO-EPILEPSY, 288 Definition and synonyms, 288 Diagnosis, 307 from true epilepsy, 308 from simulation, 310 Duration and course, 307 Etiology, 291 Age, influence of, 291 Emotional, 293 Painful menstruation, 293 Sex, race, and climate, 291 History, 289 Pathology, 291 Prognosis, 310 Symptoms, 293 Anæsthesia, 298 Contracture, 297 Digestive, 297 Hallucinations, 301 Hystero-epileptogenic zones, significance of, 298 of contortions and great movements, 301 of delirium, 301 of emotional attitudes, 301 of epileptoid period, 300 of irregular types, 302 of regular types, 293 of paroxysms, 293, 304, 306 Ovarian hyperæsthesia, 298 pressure, effect of, 299 Permanent, 307 Prodromal, 297 Treatment, 310 Compression of nerve-trunks, 310 Electricity, use of, 311-313 Metallic salts, use of, 313 Metallo-therapy, 313 Nitrite of amyl and nitro-glycerin, 311 Oöphorectomy, question of, 312 Potassium bromide, use of, 313 Torsion of abdominal walls to arrest paroxysms, 311 Varieties, 290

Ice, use of, in acute simple meningitis, 720 in cerebral meningeal hemorrhage, 715 in neuritis, 1194 in tubercular meningitis, 736

Idiocy, intellectual and moral, 138

Ill-health, influence on causation of insanity, 116, 117

Illusions in nervous diseases, 20

Imbecility, intellectual and moral, 138 in inflammation of the brain, 791

Imitation, influence on causation of catalepsy, 319 of hysteria, 222-229

Impotence in tumors of spinal cord, 1096

Impulsive insanity, 146

Inco-ordination in nervous diseases, 47-50

Inebriety, trance state in, 346

INFANTILE SPINAL PARALYSIS, 1113 Anatomical lesions, 1131 Atrophy of anterior spinal horns, characters, etc., 1133, 1138, 1139 nerve-roots and anterior columns of the cord, 1138, 1139 Autopsies, tables of, 1133-1136, 1139 Microscopic lesions, 1137 Theories interpreting the lesions of the cord, 1140-1144 regarding origin, premature, 1132 Complication with progressive muscular atrophy, 1149 Course of, 1148 Definitions, 1113 Deformities of atrophic paralysis, 1127 Criticism of theory of muscular antagonism, 1128 Dislocations in, 1130 Mechanism of, 1128, 1131 Muscular contraction in, 1127 Relation of weight and muscular forces, 1130 Diagnosis, 1152 from cerebral paralysis, 1152 from diphtheritic paralysis, 1153 from diseases of bony skeleton and articulations, 1154 from hæmatomyelitis, 1153 from lesions of peripheric nerves, 1153 from progressive muscular atrophy, 1153 from pseudo-paralysis of syphilitic children, 1153 of special paralysis, 1123 Atrophy in, 1124 Loss of faradic contractility, 1125 Negative symptoms, 1126 Temperature of skin, 1124 Etiology, 1151 Blood-poisons, influence of, 1151 Cold, influence of, 1152 Traumatism, influence of, 1151 History, clinical, summary of, 1114 Invasion, mode of, 1115 Pathogeny, 1144 Consequence of limitation of the myelitis to anterior horns of spinal cord, 1144 Relation between limitation of the myelitis and age, 1147 Trophic lesions of, 1145 Prodromata, 1115 Acute specific and apyretic diseases, 1116 Convulsions, 1116 Fever, duration of, 1115, 1116 Hemiplegia, 1120 Immunity of certain muscles and nerves, 1118 Paralysis, characters of, 1117 Crossed, and paralysis of trunk, 1120 Locality of permanent, 1119 of facial nerve, 1120 Significance and original extent of, 1117 Paralyzed muscles, combinations of, 1121-1123 Prognosis, 1149 Special paralyses, influence on locomotion, 1150 Symptoms in detail, 1114 Synonyms, 1113 Treatment, 1155 Belladonna, use, 1155 Counter-irritation, 1155 Electricity, 1156 Ergot, 1155 Heat, use of, 1157 Ice, 1155 Iodide of potassium, 1156 Locomotion, importance of maintenance of, 1159 Massage and Swedish movements, 1157 Mechanical appliances, 1159-1164 Stretching and manipulation of contracted and atrophied muscles, 1158 Strychnia, use of, 1157 Tenotomy, indications for, 1158, 1159, 1161, 1163, 1164

Inflammation as a trophic neurosis, 1273 of brain, 790 of external surface of dura mater of brain, 704 of nerves, 1189 of the dura mater of the brain, 703

Injuries, influence on causation of intracranial hemorrhage and apoplexy, 931 of peripheral nerves, 1182

Insane, acute alcoholism in the, 594 Cataleptic phenomena in, 327 Temperament, peculiarities of, 140

Insanity (see also Mental Diseases). Alcoholic, 631 Cerebral syphilitic, 202 Chronic alcoholic, 202 Circular, 151 Doubting, 170 Epileptic, 149 from gross cerebral lesions, 202 Homicidal, 147 Hypochondriacal, 150 Hysterical, 148, 230-233 Impulsive, 146 Increase of, question of, 112, 117 Influence on causation of hæmatoma of the dura mater, 707 of the opium habit, 651 Menstrual, 173 Moral, 143 of childhood, 171 of lactation, 782 Primary, 151 Primary, confusional and delusional, 167 Periodic, 150 Puerperal, 173 Secondary, delusional, 203 Suicidal, 146 Syphilitic, 175, 1017 Terminations of, in delirium tremens, 630 Transitory, 164

Insomnia, 379 in cerebral anæmia, 783 in delirium tremens, 627, 629 in the chloral habit, 665 in the insane, treatment, 137 in the opium habit, 655

Intellect, state of, in alcoholism, 625 in symmetrical gangrene, 1260

Intellectual pursuits, as a cause of intracranial hemorrhage and apoplexy, 931

Intercostal neuralgia, 1234

Intermarriage, influence on causation of insanity, 115

Intermittent neuralgia of supraorbital nerve, 1233

Intestines, disorders of, in chronic alcoholism, 601, 602

INTRACRANIAL HEMORRHAGE AND OCCLUSION OF THE CEREBRAL VESSELS, APOPLEXY, SOFTENING OF THE BRAIN, CEREBRAL PARALYSIS, 917 Atheroma of the Cerebral Arteries, 991 Diagnosis, 992 Prophylaxis and treatment, 992 Capillary Embolism, 979 Diagnosis, 981 Etiology and morbid anatomy, 979, 980 Prognosis and treatment, 981 Symptoms, 980 Intracranial Hemorrhage, 917 Appearances of old, 921 Clots, characters of, and changes in, 920 Definition of apoplexy, 917, 918 Etiology, 957 Age, 927-929 Alcohol, 929, 933 Apoplectic constitution, characteristics of, 930, 931 Bright's disease, 930 Exciting causes, 931 Heart disease, 930, 931 Heredity and sex, 929 Intellectual pursuits, 931 Narcotic poisons, 933 Obstruction to circulation, 931, 932 Season, 931 Situation of, 918-921, 923, 924 Traumatism, 932 Miliary aneurisms, causes, seat, and characters of, 921, 922 Pathology of hemorrhagic apoplexy, 925-927 Symptoms, 933 Consciousness, loss of, onset and degrees of, 933 temporary loss of, significance and causes of, 942, 943 Eyes, state of, 939, 941 Facial expression, 935 Headache and paræsthesia as premonitory signs, 946 Hemiplegia, 940 Mental disturbances and aberrations of special senses, 945 Muscular relaxation, 935, 939 Paralysis, 938 Pulse, state of, 939, 944 Respiration, 935 Retinal hemorrhages, 944 Sensibility, state of, 942 Speech, 939 Sphincters, state of, 941 Swallowing, 935 Temperature, 935-938 Tongue, state of, 939 Vertigo, significance of, 745 Vomiting, 935 Vessels, cerebral, state of, in, 922 Occlusion of the Cerebral Arteries, 946 Diagnosis between hemorrhage, embolism, and thrombosis, 971, 972 from apoplectiform attacks of intracranial syphilis, 967 from comatose form of pernicious intermittent fever, 966 from diabetic coma and sunstroke, 966 from epilepsy, 965 from hysteria, 966, 968 from injuries to the head, 966 from meningitis of the vertex, 967 from narcotic poisoning, 964 from uræmia, 965 localization of lesions in, 969 Etiology, 950 Age, influence of, 951 Heart and arteries, disease of, 951 Heart-weakness and hæmic dyscrasia, 951 Morbid anatomy, 946 Cerebral substance, changes in, produced by emboli and thrombi, 949 Emboli and thrombi, seat of, 947-949 source of, 947 Regions of brain usually involved in softening, 949, 950 Prognosis, 972-974 Symptoms, 952 Aphasia, 956-960 Arthropathies, 962 Atrophy, muscular, 962 Chorea, post-paralytic, 960 Mental condition, 956, 957 Motor paralysis, duration and course, 954 Reflexes, increased, rigidity and contracture, 962, 963 Sensation, state of, 955 Temperature, 960, 961 Urine, state of, 961 Word-blindness, 959 Treatment, 974 of cerebral embolism, 977 of attack, 977 Prophylaxis, 977 of cerebral hemorrhage, 974, 975 Artificial respiration, 976 Bleeding and purgatives, 976 Cleanliness, necessity of, 977 Prophylaxis, 974 Surgical measures, 977 of cerebral thrombosis, 977 of paralysis and later symptoms, 978 Electricity, use of, 978 Iodide of potassium and phosphorus, use, 978 Massage, use, 978 Silver, gold, and strychnia, use, 978 Re-education of faculty of speech, 979 Softening of the Brain, 918, 949, 989 Thrombosis of the Cerebral Veins and Sinuses, 982 Diagnosis, 987 Localization of the thrombus, 988 Etiology, 983 Age, 983 Anæmia, simple, as a cause, 984 Carbuncles and erysipelas as a cause, 985 Ear, diseases of, 985 of marantic form, 983, 984 Special diseases most likely to result from, 983 Prognosis, 988 Symptoms, 986 dependent on disturbances of cerebral function, 986 dependent on congestion and compression of other structures, 986, 987 Treatment, 988 Ammonia, use of, 989 Prophylactic, 989 Surgical measures, 989

Iodide of potassium, use of, after intracranial hemorrhage and apoplexy, 978 in acute spinal meningitis, 752 in Bell's palsy, 1207 in cerebral meningeal hemorrhage, 415 syphilis, 1016 in chronic cerebral meningitis, 722 in chronic lead-poisoning, 691 in epilepsy, 502 in general paralysis of the insane, 201 in hæmatoma of dura mater, 710 in multiple neuritis, 1198 in neuritis, 1194 in spinal sclerosis, 900 in thrombosis of cerebral veins and sinuses, 989 in tubercular meningitis, 736

Iodine, injection of, into sac of spina bifida, 762 use of, in acute spinal meningitis, 752 in chronic spinal meningitis, 753 and iodide of potassium, use of, in spinal meningeal hemorrhage, 756

Iridoplegia in tabes dorsalis, 829

Iron, use of, in alcoholism, 643 in catalepsy, 338 in chorea, 455 in chronic hydrocephalus, 745 in hysteria, 278 in hystero-epilepsy, 313 in neuralgia, 1224 in spinal meningeal hemorrhage, 756 in tubercular meningitis, 735

Irritability in tubercular meningitis, 725, 727

Irritable breast of Astley Cooper, 1235

Irritation, local, influence on causation of hysteria, 220, 221

Jaw reflex, in amyotrophic lateral sclerosis, 868

Jerking malady, hysterical nature of, 226

Joint affections, hysterical, 252 in tabes dorsalis, 830, 837 of chronic lead-poisoning, 684

Jumpers, the, hysterical nature of, 227

Jumping chorea, 244

Katatonia, 166, 327

Kidneys, disorders of, in chronic alcoholism, 612, 613 in the chloral habit, 662 in the opium habit, 654 movable, as a cause of hysteria, 221

Kinesodic system of encephalon, lesions, 86 of spinal cord, localization of lesions in, 71

Kleptomania, 147

Knee-jerk, alterations, in general paralysis of the insane, 195 in amyotrophic lateral sclerosis, 868 in chorea, 448 in diffuse spinal sclerosis, 888 in disseminated sclerosis, 875 in epilepsy, 481 in hemiplegia, 962 in nervous diseases, 152 in spastic spinal paralysis, 862 in spinal syphilis, 1025 in tabes dorsalis, 829, 835, 857, 858 in the chloral habit, 664 in tumors of the spinal cord, 1092 significance in diagnosis of hysteria, 265, 266

Lactation, prolonged, as a cause of epilepsy, 471

LABIO-GLOSSO-LARYNGEAL PARALYSIS, PROGRESSIVE, 1169 Definition, 1169 Diagnosis, 1174 Etiology, 1173 History, 1169 Pathological anatomy, 1172 Symptoms, 1170 Articulation, difficulty of, characters of, 1170, 1171 Deglutition, difficult, 1170 Facial expression, 1170 Heart, disorders of, 1170 Paralysis and atrophy of muscles of neck and extremities, 1172 Respiration, disturbances of, 1171 Tongue, condition of, 1170-1172 Synonyms, 1169 Treatment, 1174 Diet, 1175 Electricity, 1175 Metallic salts and quinine, 1175

Language, development of, 568

Laryngeal vertigo, 425

Larynx, disorders and lesions of, in chronic alcoholism, 607

Lateral sclerosis, 861

Lead, mode of action of, in the system, 689

LEAD-POISIONING, CHRONIC, 678 Channels of introduction into body, 680-682 Classification, definition, and history, 678 Diagnosis, 690 Etiology, 679 Age, sex, and diet, influence of, 680 Exciting causes, 680 Occupation, influence of, 681 Season and climate, influence of, 679, 680 Morbid anatomy and pathology, 689 Prognosis, 684, 687, 689 Symptoms, 682-689 Albuminuria in, 689 Amaurosis in, 689 Bluish line upon gums, significance of, 682 Disturbances of nutrition, 682 in animals, 690 of lead colic, 683 of the arthralgia, 684 of the encephalopathy, 688 of the paralysis, 685 Synonyms, 678 Treatment, 690 Alum, use, 691 Electricity and massage, use, 691 Opium, use, in colic, 691 Potassium iodide, use, 691 Prophylaxis, 690 Sulphuric acid and magnesium sulphate, use, 690, 691

Lead tremors, 429, 683

Leptomeningitis, cerebral, 716 spinal, 749

Lesions in the nervous system, localization of, 65

Lethargy, 344, 384 in cerebral anæmia, 782, 783 lucid, 385

Levinstein's method of treating the opium habit, 672

Ligation of the sac of spina bifida, 762

Lipomatous tumors of the brain, 1049

Lithæmic insomnia, 379

Liver, changes in, and disorders of, in chronic alcoholism, 603, 607

Local convulsive disorders, 461

Localization of functions of spinal cord, table showing, 77

LOCALIZATION OF LESIONS IN THE NERVOUS SYSTEM, 65 Cranio-cerebral topography, 93-98 in base of brain, 91 in cerebellum, 90 in encephalic mass, 81-93 in medulla oblongata, 79, 80 in peripheral nervous system, 65-69 in spinal cord, 69-79

Localization of abscess of the brain, 795, 800 of cerebral hemorrhage and embolism, 969 of thrombosis of cerebral veins and sinuses, 988 of tumors of the brain, 1056 of the spine, 1100

Lock-spasm of writers' cramp, 517

Locomotion, influence of special paralyses of, in infantile spinal paralysis, 1150

Locomotor ataxia, 826 hysterical, 240

Lordosis in atrophic infantile paralysis, 1131

Lumbo-abdominal neuralgia, 1235

Lungs, disorders of, in chronic alcoholism, 608 in the opium habit, 658

Lupulin, use of, in the opium habit, 676

Magnesium sulphate, use of, in chronic lead-poisoning, 691

Main en griffe in chronic spinal pachymeningitis, 749

Malaria as a cause of cerebral anæmia, 790 influence of, on the causation of chorea, 444

Malarial epilepsy, 472 neuralgias, 1212

Male sex, prevalence of hysteria in, 215

Malnutrition of brain in infants, 778

Malt liquors, characters of intoxication from, 591

Mammillary neuralgia, 1235

Mania, 161 chronic, 163 following epilepsy, 482 in alcoholism, 631

Maniacal excitement in general paralysis of the insane, 192 form of acute alcoholism, 592 of general paralysis of the insane, 188

Marriage, influence on recovery from epilepsy, 498 question of, in the insane temperament, 115, 141

Massage, use of, in hemiplegia, 978 in hysteria, 280 in infantile spinal paralysis, 1157 in lead palsy, 691 in melancholia, 160 in neuralgia, 1223 in neurasthenia, 360, 361 in progressive unilateral facial atrophy, 702 in symmetrical gangrene, 1261 in vaso-motor neuroses, 1255 in writers' cramp, 536

Mastoid cells, inflammation of, as a cause of thrombosis of cerebral veins and sinuses, 983

Masturbation, influence on causation of cerebral anæmia, 778 of epilepsy, 474 of insanity, 119 in the insane, treatment of, 137 of hysteria, treatment of, 276

Mechanical appliances, use of, in infantile spinal paralysis, 1159 in writers' cramp, 540 restraint in treatment of the insane, 135, 136

Medulla oblongata, degeneration of, in labio-glosso-laryngeal paralysis, 1172 localization of lesions in, 79

Medullary centres of the vaso-motor system, 1250

Megalopsia in nervous diseases, 40

Melancholia, 155 agitata, 158 cerebral nutrition in, 775 in alcoholism, 631 in children, 158 in general paralysis of the insane, 188

Membranes, spinal, congestion of, 746

Memory, loss of, significance of, in nervous diseases, 28-30

Ménière's disease, 422

Meningeal cerebral hemorrhage, 710 Diagnosis, 714 Etiology, 711 Pathological anatomy, 713 Prognosis, 715 Symptoms, 712 Synonyms, 710 Treatment, 715

Meningeal spinal hemorrhage, 754

Meningitis, acute, 716 and chronic, following thermic fever, 399 spinal, 749 chronic spinal, 752

MENINGITIS, TUBERCULAR, 723 Definition, synonyms, and history, 723 Diagnosis, 732 from acute simple meningitis, 733 from eclampsia, 734 from gastro-intestinal affections, 734 from hydrencephaloid disease, 734 from typhoid fever, 733 Etiology, 724 Age and sex, influence of, 725 Exciting causes, 725 Hereditary tendency to tuberculosis and scrofulosis, 724 Season, influence of, 725 Pathological anatomy and duration, 729 Prophylaxis, 736 Prognosis, 735 Symptoms, 725 Abdomen, state of, 726 Cerebral, 726-729 Constipation, 725-727, 729 Cry, 726, 727 Decubitus, 727 Eyes, state of, 726-729 Headache, 725-727 in the adult, 737-739 Paralysis and convulsions, 727, 728 Prodromal, 725 Pulse, respiration, and temperature, 726-728 Pupils, state of, 726-729 Sensitiveness to light, 725-727 Strabismus, 727 Stupor, 726-729 Tongue, state of, 726, 729 Vomiting, 725, 729 Treatment, 735 Bromides, chloral, and hyoscyamus, 736 Counter-irritation, value of, 736 Diet in, 736 Iodide of potassium, use, 736

Menorrhagia and amenorrhœa in the insane, treatment of, 136

Menstrual disorders, influence on causation of hysteria, 220 in the opium habit, 656, 658 insanity, 173

Menstruation, influence on recovery from epilepsy, 498 on causation of cerebral hyperæmia, 766 of spinal hyperæmia, 802 painful, influence on causation of hystero-epilepsy, 293

Mental condition in acute spinal meningitis, 750 in atrophy of the brain, 994, 996 in chorea, 445 in chronic hydrocephalus, 742, 743 in delirium tremens, 628 in disseminated spinal sclerosis, 877 in hemiplegia, 956 in hysteria, 230 in tabes dorsalis, 836 in tumors of the brain, 1037 of the spine, 1096 Defects and degeneration, states of, 138 Deterioration, primary, 70

MENTAL DISEASES, 99 Insanity, 99 Causation, 113 Age, influence of, 116, 117 Alcohol and nerve-stimulants, abuse of, 116, 119 Drugs, abuse of, 119 Emotions and mental strain, 117, 118 Classification of, 105, 109 Definition of, 99-105 Diagnosis of, 123-125 Exciting causes, 118-120 Heredity, 113 Ill-health, disease, etc., 116, 117, 119 Intermarriage, 115, 116 Occupation, 118 Pulmonary consumption, relation to, 119 Sex, 118 Social position, 117, 118 Vicious early training, 116 History, 109 Morbid anatomy and pathology, 121-123 Prevalence, 110-113 Prognosis, 125 Mortality, 126 Percentage of recoveries, 126 Treatment, 127 Asylums, methods of commitment to, 134 objection to, 127, 130 question of removal to, 127-135 Galvanism, use, 137 Home, removal from, question of, 128, 133, 135 Home, 131 Mechanical restraint in, 135, 136 Medicines, value of, in, 135 of cerebral hyperæmia in, 136 of constipation in, 137 of insomnia in, 137 of intercurrent diseases in, 136 of masturbation in, 137 of menorrhagia and amenorrhœa in, 136 Preventive, 137, 138 Rest and sleep, value of, in, 137 Sedatives and narcotics, use in, 133, 137 Insanity complicating, 174 Insanity from Specific Poisons, 175 Organic, 176 General paralysis of the insane, 176 Definition, 176 Diagnosis, 197 Etiology, 177 Age and sex, 177 Excesses, influence of, 177 Heredity, 177 Mental shock, 178 Syphilis, 178 History, 176 Morbid anatomy and pathology, 196 Prognosis, 200 Symptoms, 178 Delusions, characters, 187, 188, 190-192 Mental, 179, 190-193 Moral sense, perversion of, 190 of demented and paralytic form, 187 of hypochondriacal form, 188 Onset, mode of, 178 Physical symptoms, 193 Ataxia, 188, 189, 193 Bones, state, 196 Gait, 194 Handwriting, 183, 186, 193 Hyperæsthesiæ, 194 Knee-jerk, significance, 195 Pupils, state, 195 Remissions, 194 Sexual functions in, 195 Speech, alteration in, 194 Urine in, 1195 Prodromal, 178 Temperature in, 179 with melancholia, 188 with mania, 188 Synonyms, 176 Treatment, 201 Cod-liver oil, use, 201 Ergot, use, 201 Hypophosphites, use, 201 Potassium bromide and iodide, use, 201 Rest and quiet, value, 201 Insanity, chronic alcoholic, 202 from gross lesions of brain, 202 secondary delusional, 203 Terminal dementia, 203 Treatment, 203, 204 States of Mental Defect and Degeneration, 138 Circular insanity, 151 Constitutional affective mental disease, 142 Prognosis, 142 Treatment, 143 Epileptic insanity, 149 Hypochondriacal insanity, 150 Hysterical insanity, 148, 149 Idiocy, 138 Classification, 139 Impulsive insanity, or instinctive monomania, 146 Dipsomania, 147 Erotomania, 147 Homicidal insanity, 147 Nymphomania and satyriasis, 147 Pyromania and kleptomania, 147 Treatment, 148 Suicidal insanity, 146 Insane temperament, 140 Treatment, 141 Moral insanity, 143 Symptoms, 143-146 Treatment, 146 Periodic insanity, 150 Primary insanity, 151 Prognosis and treatment, 152 Psycho-neuroses, 153 Affective mental disease, 153 Prognosis and treatment, 154 Climacteric insanity, 173 Delirium, acute, 163 Dementia, primary, 164 secondary, 165 Treatment, 165 Doubting insanity, 170 Hebephrenia, 171 Treatment, 172 Hypochondriasis, 154 Prognosis and treatment, 155 Insanity of childhood, 171 Katatonia, 166 Mania, 161 acute, 161 Treatment, 161 simple, 162 Treatment, 162 Melancholia, 155 Agitata, 158 Duration and prognosis, 159 in children, 158 simple, 155 Treatment, 159 Asylums, removal to, 159 Narcotics and sedatives, use, 160 Tonics, use, 160 with delusions, 156 with stupor, 158 Menstrual insanity, 173 Primary confusional insanity, 167 Primary delusional insanity, 167 Primary mental deterioration or brain atrophy, 170 Puerperal insanity, 173 Senile dementia, 174 insanity, 173 Transitory insanity, 164

Mental emotion, influence on causation of neurasthenia, 354 influences as a cause of cerebral anæmia, 780 shocks, influence on causation of general paralysis of the insane, 178 strain, influence on causation of insanity, 118 symptoms of external pachymeningitis, 705 of general paralysis of the insane, 190

Mercurial tremor, 429

Mercury, use of, in cerebral hyperæmia, 1016 in chronic spinal meningitis, 754 in hæmatoma of the dura mater, 710 in spinal sclerosis, 900 in tetanus, 555 in tubercular meningitis, 736

Metallic salts, use, in catalepsy, 338 in labio-glosso-laryngeal paralysis, 1175 in progressive unilateral facial atrophy, 702

Metallo-therapy, use, in hysteria, 284 in hystero-epilepsy, 313

Metastasis as a cause of cerebral abscess, 796

Microcephalism, 138

Migraine, 406, 1216, 1230 Diagnosis and prognosis, 410 Etiology, 406 Age and sex, influence of, 406 Heredity, influence of, 407 Pathology and morbid anatomy, 410-413 Symptoms, 407 Circulation, disorders of, 409 Digestive, 409 Pain, seat and character, 408 Paroxysms, characters of, 408, 409 Synonyms, 406 Treatment, 413 Bromides, use, 414, 415 Caffeine and guarana, use, 414 Cannabis indica, use, 413, 415 Climate, change of, 413 Ergot, use, 413, 414 Galvanism, use, 414, 415 in childhood, 415 Indications for, 413 Morphia, use, 415 Muriate of ammonium and chloral, use, 415 Nitrite of amyl and nitro-glycerin, 414 Quinia, use, 414

Miliary aneurisms, relation of, to cerebral form of encephalitis, 792 hemorrhage, 921-923 tubercles in tubercular meningitis, seat and character, 730, 732

Mimicry in hysteria, 251, 255, 270-272

Mind-cure in hysteria, 277

Miryachit, the, hysterical nature of, 228

Mitchell's rest-cure in hysteria, 279 in neurasthenia, 358-362

Monoplegia, hysterical, 238 in nervous diseases, 44

Monospasm in nervous diseases, 46

Moral insanity, 143 management of spinal sclerosis, 906 sense, deterioration of, in chronic alcoholism, 624 treatment of hysteria, 276

Morbid anatomy of abscess of the brain, 792 of acute simple meningitis, 719 of acute spinal meningitis, 750 of acute spinal myelitis, 812 of amyotrophic lateral sclerosis, 867 of cerebral anæmia, 781 of cerebral hemorrhage, 919-927 of cerebral hyperæmia, 767 of cerebral meningeal hemorrhage, 713 of chorea, 450 of chronic spinal meningitis, 762 of chronic spinal pachymeningitis, 748 of congestion of cerebral pia mater, 716 of congestion of spinal membranes, 747 of delusional insanity, 169 of diffuse sclerosis, 886 of disseminated sclerosis, 874, 880-883 of external pachymeningitis, 705 of family form of tabes dorsalis, 872 of infantile spinal paralysis, 1132 of insanity, 121 of internal pachymeningitis, 706 of neuritis, 1190 of paralysis agitans, 433 of secondary scleroses, 893 of spastic spinal paralysis, 865 of spina bifida, 759 of spinal meningeal hemorrhage, 755 of tabes dorsalis, 840 of tetanus, 549 of tubercular meningitis, 729

Morbid anatomy and pathology of chronic lead-poisoning, 689 of epilepsy, 488 of writers' cramp, 526

Morbid somnolence, 344

Morphia, use, in acute simple meningitis, 721 in cerebral anæmia, 788 in hysteria, 276 in migraine, 415 in multiple neuritis, 1198 in neuritis, 1194 in spinal sclerosis, 905 in thermic fever, 398, 399 in the treatment of the opium habit, 673, 675 in tumors of the brain, 1068 in vertigo, 427

Morphœa, in progressive unilateral facial atrophy, 695

Morphine habit, 647

Mortality of chorea, 454 of insanity, 125, 126 of tetanus, 553

Motility, disturbances of, in spinal syphilis, 1025

Motion, disorders of, in chorea, 445, 446 in chronic alcoholism, 620 in diffuse spinal sclerosis, 888

Motor paralysis in unilateral paralysis of spinal cord, 1166

Motor symptoms of thermic fever, 391 weakness, in spinal hyperæmia, 803

Motory symptoms of nervous diseases, 42

Multiple and multiple degenerative neuritis, 1195 Diagnosis, 1197 Etiology, 1197 Nature and history, 1195 Pathology, 1196 Prognosis, 1198 Symptoms, 1195 Onset, 1195 Pain, characters, 1195 Paresis and atrophy of muscles, 1196 Sensation, disturbances of, 1195 Treatment, 1198 Electricity, 1198 Morphia, 1198 Salicylate of sodium and iodide of potassium, 1198 Rest, 1198

Multiple cerebro-spinal sclerosis, 873

Muscles, atrophy of, 1267 changes in, in alcoholism, 614 in injuries to peripheral nerves, 1182 degeneration of, in labio-glosso-laryngeal paralysis, 1173 employed in telegraphy, 508, 509 in writing, 505, 506 involved in infantile spinal paralysis, 1121 rigidity of, in paralysis agitans, 435

Muscular ataxia, in general paralysis of the insane, 188, 189, 193 atrophy in chronic spinal pachymeningitis, 749 in nervous diseases, 54 in poisoning by lead, 687, 688 in progressive unilateral facial atrophy, 696, 697 progressive, complicated with infantile spinal paralysis, 1149 contraction, in acute spinal meningitis, 750 system, state of, in the chloral habit, 662 rigidity in diffuse spinal sclerosis, 888

Music, use of, in treatment of catalepsy, 338

Musk, use of, in hysteria, 274

Murmurs, valvular, in chorea, 448

Myelitis, simple acute, 810 Ascending and descending, 816 Clinical history, 816 Diagnosis, 820 Influence of poisons on cord, 815 Limitation of inflammatory process, 816 Myelitic cicatrices, 815 Morbid anatomy, 812 Prognosis and duration, 821 Treatment, 822 Derivation and bloodletting, 823 Electricity, 824 Management of bed-sores, 823 Management of bladder troubles, 824 Position, 822 Rest, 823 Strychnia, 823 Warm baths, 823

Myelitis, chronic, 886 in unilateral spinal paralysis, 1168

Myxœdema, 1271

Narcolepsy, 346

Narcotic poisoning, acute, from alcohol, 597

Narcotics, influence on causation of catalepsy, 319

Narcotics and sedatives, value, in melancholia, 160

Nature of stigmata, 350 of symmetrical gangrene, 1261

Nausea and vomiting in lead colic, 684 in the opium habit, 653, 657-659

Neglect, treatment of hysteria by, 277

Nerve-centres, syphilitic affections of, 999

Nerve-roots, degeneration of, in infantile spinal paralysis, 1138-1140 lesions of, in tabes dorsalis, 840-842

Nerve-section in neuralgia, 1227 in tetanus, 560

Nerve-stretching in athetosis, 460 in neuralgia, 1228 in spinal sclerosis, 903 in writers' cramp, 538

Nerve-trunks, lesions, in multiple neuritis, 1196 in neuritis, 1191

Nerves, inflammation of, 1189 Anatomical changes in divided nerves and muscles, 1184 Changes in, in chronic alcoholism, 619 Diagnosis of, 1187 Divided, pain, seat and characters of, 1185-1187 Electrical reactions in, 1184, 1188 Immediate results of injuries to, 1182 Injuries and irritation of, as a cause of neuralgia, 1220 treatment of, 1189 Lesions of, in neuralgia, 1221 Peripheral diseases of, 1177 Changes in, in chronic alcoholism, 619 Injuries of, 1182 Regeneration and reunion of divided nerves and muscles, 1185 Sensation, disorders of, 1186, 1187 Skin, state of, 1183, 1187 Symptoms of incomplete destruction of, 1185 Trophic disorders, 1187 Vaso-motor, origin of, 1246

Nervous diseases, general semeiology of, 19 disorders of chronic hydrocephalus, 743 of chronic lead-poisoning, 685-689 of spina bifida, 759 of the chloral habit, 663, 665 symptoms of myxœdema, 1272 system, disorders of, in alcoholism, 616 in the opium habit, 656, 658, 659

NERVOUS SYSTEM, LOCALIZATION OF LESIONS IN THE, 65 Cranio-cerebral topography, 93-98 in encephalic mass, 81-93 in systematic lesions, 89 in focal lesions, 89 in base of brain, 91 in cerebellum, 90 in medulla oblongata, 79, 80 in peripheral nervous system, 65-69 in spinal cord, 69-79 of æsthesodic system, 69 of kinesodic system, 71

NERVOUS SYSTEM, GENERAL SEMEIOLOGY OF DISEASES OF, 19 Motory symptoms, 42-54 Psychic symptoms, 19-31 Sensory symptoms, 31-41 Trophic symptoms, 54-59 Principles of diagnosis in diseases of, 59 in functional diseases of, 63 in organic diseases of, 61

NEURALGIA, 1211 Definition, general, of, 1211 Diagnosis and pathology, general, of, 1221 Etiology, general, of, 1216 Age and sex, 1217 Atmospheric and thermic influences, 1219 Constitutional diseases, 1217 Injuries and irritation of nerves, 1219 Reflex and sympathetic causes, 1220 Symptomatology, general, 1211 of migraine, 1216-1230 of superficial neuralgias, 1211 Muscles, spasm and atrophy of, 1213, 1214 Pain, characters and distribution, 1212 Periodicity of attacks, 1212 Points douloureux, 1213 Secreting organs, disorders of, 1213 Sensation, altered, 1214 Skin, disorders of, 1212-1214 Special senses in, 1213 Urine, condition, 1212, 1213 Vision, disorders of, 1213 of visceral neuralgias, 1215 Pain, characters, 1215 Secretion of visceral organs, disorders of, 1215 Treatment, general, 1222 Aconite and aconitia, use, 1224, 1225, 1227 Belladonna and atropia, use, 1224 Change of climate, 1223 Cocaine, use, 1227 Counter-irritation, use, 1226 Diet, 1223 Electricity, use, 1225 Hydropathy, 1226 Hygiene, 1223 Injection of water, chloroform, and other substances, 1229 Iron, arsenic, and cod-liver oil, use, 1224 Massage, 1223, 1229 Neurectomy, 1227 Nerve-stretching, 1228 Opium, use, 1224 Phosphorus and gelsemium, use, 1225 Turpentine, oil of, use, 1229 Use of ammonio-sulphate of copper, salicylate of sodium, tonka, caffeine, and sal ammoniac, 1229 Varieties, migraine and periodical headache, 1230 Etiology and clinical relations, 1231 Age and sex, 1230, 1231 Prognosis, 1231 Symptoms, 1230 Auras and visual hallucinations, 1230, 1231 Sensation, disorders of, 1230, 1231 Pain, 1230 Treatment of, 1232 Cannabis indica, iodide and bromide of potassium, and caffeine, 1232 Diet, 1232 Electricity, 1232 Nitrite of amyl, 1232

Neuralgias of the fifth nerve, 1232 Anal and rectal neuralgia and uterine and ovarian neuralgia, 1240 Angina pectoris, 1237 Cervico-brachial and brachial neuralgia, 1234 Epileptiform, or tic douloureux, 1233 Facial neuralgia, ordinary, 1232 Treatment, 1234 Gastralgia, 1238 Intercostal neuralgia, 1234 Intermittent neuralgia of the supraorbital, 1233 Lumbo-abdominal neuralgia, 1235 Mammillary neuralgia (irritable breast of Astley Cooper), 1235 Occipito and cervico-occipital neuralgias, 1234 Sciatica, 1235 Treatment, 1236 Visceral neuralgia, 1237

Neuralgia complicating progressive unilateral facial atrophy, 699

Neuralgias in tumors of the brain, 1041

Neuralgic pains in hemiplegia, 956

NEURASTHENIA, definition, 353 Etiology, 354 Symptoms, 354 Digestive disorders, 356 Heart disorders, 356 Muscular strength, loss of, 356 of brain exhaustion, 355 Sensation and special senses, disturbances of, 356, 357 Sexual disorders, 357 Vaso-motor disturbances, 356 Treatment, 357 Change of climate, 358 Rest-cure, method of carrying out, 358, 362

Neurasthenia as a cause of vertigo, 425

Neurasthenic headache, 404

Neuritis, 1189 Etiology, 1190 Diagnosis, 1194 Morbid anatomy, 1190 Symptoms, 1191 Motor, 1192 Pain, characters, 1191, 1193 Reflex paralyses, 1193 Trophic, 1192, 1193 Sensation, altered, 1191, 1192 Treatment, 1194 Counter-irritation in, 1194 Galvanism, 1194 Morphia in, 1194 Salicylate of sodium and iodide of potassium, 1194

Neuritis as a result of neuralgia, 1214

Neuromata, 1208 Definition, 1208 Diagnosis, 1210 Etiology, 1209 Heredity and traumatism, 1209 Nature, varieties, etc., 1208, 1209 Symptoms, 1209 Treatment, 1210 in tumors of the brain, 1048

Neuromimesis, 251, 255, 270-272

Neuro-retinitis in tubercular meningitis, 729 and optic neuritis in tumors of the brain, 1035

Neuroses, trophic, 1266 vaso-motor, 1242

Nickel bromide, use, in epilepsy, 500

Night-terrors, 370

Nitro-glycerin, use, in catalepsy, 338 in epilepsy, 500, 502 in hystero-epilepsy, 311 in migraine, 414 in myxœdema, 1273 in vaso-motor neuroses, 1256

Numbness and formication in nervous diseases, 33 and tingling in hysteria, 256

Nutrition, bad, influence on causation of catalepsy, 319 disturbances of, in chronic lead-poisoning, 682

Nymphomania, 147 in hysteria, 235

Nystagmus in disseminated sclerosis, 877 in family form of tabes dorsalis, 871

Obesity in alcoholism, 615

Occipital neuralgia, 1234

Occupation, influence on causation of alcoholism, 575 of chronic lead-poisoning, 681 of hysteria, 218 of the opium habit, 650

Ocular causes of vertigo, 424

Œdema as a complication of cerebral anæmia, 782 in thrombosis of cerebral veins and sinuses, 986

Olfactory sensory disturbances in nervous diseases, 41

Onset of epileptic fit, mode of, 478 of tetanus, mode of, 549

Opisthotonos in acute spinal meningitis, 750 in hystero-epilepsy, 295, 296, 301 in tetanus, 551 in tetanus neonatorum, 564

Opium, abuse of, as a cause of tremor, 429, 430

OPIUM HABIT AND KINDRED AFFECTIONS, 647 Cannabis indica, Habitual Addiction to, 667 Treatment, 668, 677 Chloral Habit, the, 660 Diagnosis, 665 Etiology and synonyms, 661 Prognosis, 666 Prophylaxis, 668-670 Symptoms, 661 Circulatory, digestive, and respiratory disorders, 661, 662 Genito-urinary disorders, 662, 663 Muscular system, disorders of, 662 Nervous system, disorders of, 663, 664 of abrupt discontinuance of drug, 665 Psychical derangements, 664 Skin, disorders of, 663 Treatment, 668, 676 Curative, 666, 667 Chloroform, Habitual Addiction to, 667 Treatment, 668, 677 Cocaine, Habitual Addiction to, 667 Treatment, 668, 677 Ether, Habitual Addiction to, 667 Treatment, 668, 677 Opium Habit, the, 647 Diagnosis, 659 Etiology, 649 Age, sex, occupation, and luxurious habits, influence on causation, 650 Exciting causes, 652 Insanity, influence on causation, 651 Predisposing causes, 649 History, 647 Prognosis, 660 Prophylaxis, 668-670 Symptoms, 653 Digestive, 653, 654, 658 Genito-urinary disorders, 654, 658 Nervous system, derangements of, 658, 659 of chronic poisoning, 653 of withdrawal of drug, 657-659 Physiognomy in, 654 Respiratory and circulatory disorders, 654 Sexual disorders, 656, 658 Temperature in, 657 Synonyms, 648 Treatment, 668 Abrupt withdrawal of drug, Levinstein's method, 672-674 Alcohol and stimulants, use of, 673-675 Baths, use, 674-676 Bromides, chloral, lupulin, and paraldehyde, use of, 673, 674, 676 Coca, cocaine, and cannabis indica, use of, 676 Curative, 670 Diet in, 673, 675 Gradual diminution of drug, 674-676 of digestive disorders, 672-674 of nervous symptoms and insomnia, 673, 675, 676 Opium, use of, 673, in, 675 Removal from home, question of, 670, 671 Paraldehyde, Habitual Addiction to, 666 Treatment, 668, 677

Opium, use of, in hysteria, 278 in insomnia, 380-382 in lead colic, 691 in melancholia, 160 in neuralgia, 1224 in spinal concussion, 916 in symmetrical gangrene, 1262 in tetanus, 577 in the treatment of the morphia habit, 673, 675 in tubercular meningitis, 736 physiological action of, 652

Ophthalmoscopic appearances in cerebral anæmia, 787 in cerebral hyperæmia, 770 examination in tumors of the brain, 1035

Optic nerve, atrophy of, in disseminated sclerosis, 879 in tabes dorsalis, 834

Optic sensory disturbances in nervous diseases, 39, 40

Oöphorectomy, question of, in hysteria, 287 in hystero-epilepsy, 312

Organic headache, 403 Mental diseases, 176 Nervous diseases, diagnosis of, 61-63

Osmic acid, hypodermic use, in neuralgia, 1229

Osteomata in tumors of the brain, 1049

Osteo-myelitis, as a cause of cerebral abscess, 799

Ovarian neuralgia, 1240 pressure, effect of, in hystero-epilepsy, 298, 299

Over-exertion as a cause of disseminated sclerosis, 884 of spinal hyperæmia, 802

Over-study, influence on causation of chorea, 441

Over-work, influence on causation of cerebral hyperæmia, 354 of neurasthenia, 354

Oxygen, inhalations in vaso-motor neuroses, 1256

Pacchionian bodies, seat and nature, in brain tumors, 1050

Pachymeningitis, 703 Acute spinal, 747 Chronic spinal, 748 External, 704 Hemorrhagic, 707 Internal, 706

Pain, in angina pectoris, 1237, 1238 in cerebral syphilis, 1005 in diffuse spinal sclerosis, 889 in disseminated sclerosis, 874 in family form of tabes dorsalis, 871 in gastralgia, 1238, 1239 in hysteria, 250 in injuries of peripheral nerves, 1185-1187 in intercostal neuralgia, 1234 in lead colic, 683 in hyperæmia of the brain, 770 in migraine, seat, characters, and origin of, 408, 412, 1230 in multiple neuritis, 1195 in nervous diseases, varieties of, 33-35 in neuritis, 1191 in neuromata, 1210 in sciatica, 1235 in spinal syphilis, 1025 in superficial neuralgia, 1212 in symmetrical gangrene, 1258-1260 in writers' cramp, 519 Influence on causation of the opium habit, 649 Seat and character, in acute spinal meningitis, 750 spinal pachymeningitis, 747 in chronic spinal meningitis, 753 spinal pachymeningitis, 749 in external pachymeningitis, 705 in spinal meningeal hemorrhage, 754 in tabes dorsalis, 828 in tubercular meningitis, 725, 726 in tumors of the brain, 1033, 1034 in tumors of the spinal cord, 1091-1093

Pain-sense in tabes dorsalis, 833

Painters' colic, 683

Palsy, lead, 685

Pancreas, changes in, in chronic alcoholism, 602

Paracentesis in chronic hydrocephalus, 745 of the sac in spina bifida, 761

Paræsthesia, hysterical, 250 in migraine, 1230, 1231 in nervous diseases, general, 33 in progressive unilateral facial atrophy, 696 in spinal syphilis, 1025 in spinal hyperæmia, 802

Paralalia, 571

Paraldehyde, habitual addiction to, 666 use, in alcoholism, 641, 642, 645, 646 in the opium habit, 674, 676

PARALYSIS AGITANS, 433 Diagnosis, 438 Etiology and morbid anatomy, 437 Symptoms, 434 Synonyms, 433 Treatment, 438

Paralysis, alcoholic, 621 atrophic, of infants, 1113 cerebral, 917 festinans, 436 hysterical, 237 in acute myelitis, 816, 817 in acute spinal meningitis, 750 in atrophy of the brain, 994 in cerebral hemorrhage, 939, 954 meningeal hemorrhage, 712 syphilis, 1007-1010 in chorea, 447 in chronic hydrocephalus, 743 spinal pachymeningitis, 749 in encephalitis, 791 in hæmatoma of the dura mater, 708 in infantile spinal paralysis, 1118, 1123 in nervous diseases, definition of, 42-44 in spina bifida, 759 in the chloral habit, 664 in tubercular meningitis, 727 in thrombosis of cerebral veins and sinuses, 986 in tumors of the brain, 1040 of the spinal cord, 1091, 1093 Labio-glosso-laryngeal, 1169 Localized, in nervous diseases, 44 of chronic lead-poisoning, 685 of the insane, general, 176 Spinal spastic, 861 Spinal unilateral, 1165 Stage of, in writers' cramp, 518

Paraplegia, hysterical, 238 in acute myelitis, 817 in nervous diseases, 43 in tumors of spinal cord, 1093

Paraplegic spasm in nervous diseases, 46

Paresis in general paralysis of the insane, 189 and paralysis in multiple neuritis, 1196

Paretic dementia of alcoholism, 633

Paroxysms of epilepsy, characters of, 478 of hystero-epilepsy, characters, 293, 304, 306 of vertigo, characters, 417

Patellar reflex, alterations of, in acute myelitis, 818 in amyotrophic lateral sclerosis, 868 in chorea, 448 in diffuse sclerosis, 888 in disseminated (cerebro-spinal) sclerosis, 875 in epilepsy, 481 in general paralysis of the insane, 195 in hemiplegia, 962 in spastic spinal paralysis, 862 in spinal syphilis, 1025 in tabes dorsalis, 829, 835, 857, 858 in tumors of the spinal cord, 1092 significance in diagnosis of hysteria, 265, 266 tendon reflex in nervous diseases, 52

Pathogenesis of vaso-motor neuroses, 1251 of infantile spinal paralysis, 1114

Pathological action of alcohol, 586 anatomy of acute alcoholism, 595

Pathology of athetosis, 460 of brain syphilis, 1014 of diseases of cervical sympathetic, 1263 of catalepsy, 334 of chorea, 450 of chronic hydrocephalus, 744 lead-poisoning, 689 of hysteria, 208 of hystero-epilepsy, 291 of insanity, 121 of neuralgia, 1221 of progressive unilateral facial atrophy, 699 of tremor, 431 of tubercular meningitis, 729 of tumors of brain, 1046 of spinal cord, 1096 and morbid anatomy of atrophy of the brain, 995 of general paralysis of the insane, 196 of hæmatoma of the dura mater, 708 of hypertrophy of the brain, 996 of labio-glosso-laryngeal paralysis, 1172 of migraine, 410 of multiple neuritis, 1196 of spina bifida, 759 of unilateral spinal paralysis, 1167

Perforating ulcer of the foot, 1273

Periodic insanity, 150

Periodicity of attacks of migraine, 407 of neuralgias, 1212

Peripheral causes of epilepsy, 475 nerves, diseases of, 1176 injuries of, 1182 nervous system, localization of lesions in, 65

Pernicious anæmia, cerebral symptoms in, 779

Petit mal, symptoms of, 477

Phantom tumors, in hysteria, 288

Phosphorus, use, in neuralgia, 1225 in paralysis agitans, 438 in sequelæ of intracranial hemorrhage, 978

Photophobia in cerebral hyperæmia, 772

Phthisis, influence of alcoholism on production of, 609 of neuralgia, 1218 relation of, to hysteria, 214 to mental diseases, 119, 142

Physicians, responsibility of, in the formation of the opium habit, 649, 668

Physiognomy of acute alcoholism, 588 of acute simple meningitis, 717, 718 of delirium tremens, 628 of labio-glosso-laryngeal paralysis, 1170 of the opium habit, 654 of tubercular meningitis, 725-727

Physiological action of alcohol, 580

Physiology of dreams, 370 of spastic spinal paralysis, 865 of speech, 567 of tabes dorsalis, 840 of the vaso-motor neuroses, 1242

Pia mater, cerebral, chronic inflammation of (chronic cerebral meningitis), 721 Congestion of, 715 Symptoms, morbid anatomy, and treatment, 716 Inflammation of (acute leptomeningitis), 716 Diagnosis and pathological anatomy, 719 Duration and course, 718 Etiology and synonyms, 716 Prognosis, 720 Symptoms, 717 Treatment, 720 Bleeding in, 720 Counter-irritation, use, 721 Diet in, 721 Morphia, chloral, bromides, etc., use in, 721 Quinia, use in, 721

Pigment-scales and flakes, as a cause of capillary embolism, 988

Pilocarpine, use, in myxœdema, 1273

Piscidia, use, in alcoholism, 645

Pleuræ, disorders of, in chronic alcoholism, 610

Pneumonia, in alcoholism, 609

Points douloureux, in neuralgia, 1213

Poisoning of blood, influence on causation of infantile paralysis, 1151

Polyneuritis, 1195

Polyuria in cerebral syphilis, 1009 in hemiplegia, 961 in tumors of the brain, 1044

Porencephaly, 777

Position, influence of, in cerebral anæmia, 780

Post-epileptic aphasia, 481

Post-febrile insanity in cerebral anæmia, 786

Post-mortem examination, methods of, in tumors of the brain, 1050

Post-paralytic chorea, 447

Posterior columns, lesions of, in tabes dorsalis, 840-847

Posterior spinal sclerosis, 826

Pregnancy, influence, on causation of chorea, 444 on recovery from epilepsy, 498 Simulation of, in hysteria, 254

Pregnant women, occurrence of hysteria among, 221

Preputial irritation as a cause of epilepsy, 473

Prevalence of insanity, 110

Prevention of insanity, 137 of intracranial hemorrhage, and apoplexy, 974 of tetanus neonatorum, 565

Priapism in tumors of spinal cord, 1096

Prodromal symptoms of acute simple meningitis, 717 of tubercular meningitis, 725

Prodromata of acute myelitis, 821 of disseminated sclerosis, 874 of epilepsy, 475 of general paralysis of the insane, 178 of infantile spinal paralysis, 1115 of intracranial hemorrhage and apoplexy, 944-946

Prognosis of acute simple meningitis, 720 spinal meningitis, 751 spinal pachymeningitis, 748 of alcoholism, 639 of amyotrophic lateral sclerosis, 869 of apoplexy, cerebral hemorrhage, etc., 972 of athetosis, 460 of catalepsy, 337 of cerebral abscess, 799 of cerebral meningeal hemorrhage, 715 syphilis, 1013 of chorea, 453 of chronic hydrocephalus, 744 lead-poisoning, 684, 687, 689 spinal meningitis, 753 of constitutional affective mental disease, 142 of diffuse spinal sclerosis, 890 of ecstasy, 343 of epilepsy, 496 of external pachymeningitis, 706 of general paralysis of the insane, 200 of hæmatoma of the dura mater, 709 of hypertrophy of the brain, 799 of hysteria, 272 of hysterical insanity, 149 of hystero-epilepsy, 310 of hypochondriasis, 155 of infantile spinal paralysis, 1150 of insanity, 125 of labio-glosso-laryngeal paralysis, 1169 of melancholia, 159 of migraine, 410, 1231 of multiple neuritis, 1198 of peripheral anæsthesia, 1201 of primary delusional insanity, 152 of progressive unilateral facial atrophy, 702 of spina bifida, 761 of spinal concussion, 916 of spinal meningeal hemorrhage, 755 of symmetrical gangrene, 1262 of tetanus, 553 of tetanus neonatorum, 565 of the chloral habit, 666 of the opium habit, 660 of thrombosis of cerebral veins and sinuses, 988 of torticollis, 464 of tremor, 431 of tubercular meningitis, 735 of tumors of the brain, 1066 of the spine, 1106 of unilateral spinal paralysis, 1168 of vaso-motor neuroses, 1255 of vertigo, 418 of writers' cramp, 530

Progressive muscular atrophy in chronic lead-poisoning, 688

PROGRESSIVE UNILATERAL FACIAL ATROPHY, 693 Definition, synonyms, and history, 693 Diagnosis, 700 Duration, termination, and complications, 699 Etiology, 693 Symptoms, 694 Atrophy, seat and characters, 696, 697 Perspiration, modifications of, 696 Pulsation of carotids, weakness of, 696 Sensation, modifications of, 696 Skin and hair, changes in, 695 Special senses, state of, 697 Temperature of affected parts, 696 Treatment and prognosis, 702

Prophylaxis of abscess of the brain, 801 of alcoholism, 640, 642 of cerebral hemorrhage and apoplexy, 974 of chronic lead-poisoning, 690 of hysteria, 274 of the chloral habit, 668 of the opium habit, 668 of thermic fever, 396 of thrombosis of cerebral veins and sinuses, 988 of tubercular meningitis, 735 of writers' cramp, 530

Propulsion in paralysis agitans, 436

Psammomata in tumors of the brain, 1049

Pseudo-paralysis in nervous diseases, 44

Psychic causes of epilepsy, 472 symptoms of nervous diseases, 19

Psychical derangements of chronic alcoholism, 264 of the chloral habit, 664 symptoms of syphilis of the brain-cortex, 1017 et seq.

Psycho-neuroses (see Mental Diseases, 153).

Ptosis, hysterical, 238 in tabes dorsalis, 830

Puberty, influence on causation of catalepsy, 318 of migraine, 407, 411 influence on cerebral anæmia, 778

Puerperal insanity, 173 tetanus, 562

Pulmonary consumption, relation to mental diseases, 119, 142

Pulsation of carotids, weakness of, in progressive unilateral facial atrophy, 696

Pulse, state of, in acute alcoholism, 587, 588, 593 in acute simple meningitis, 717, 718 in acute spinal meningitis, 750 in catalepsy, 321 in cerebral anæmia, 784 in cerebral hemorrhage and apoplexy, 938 in chorea, 449 in concussion of the brain, 909 in epilepsy, 480 in hæmatoma of the dura mater, 708 in hysteria, 252 in migraine, 409, 411, 412 in tetanus, 551 in the chloral habit, 662 in the opium habit, 654, 657, 659 in thermic fever, 391 in tubercular meningitis, 726-728 and respiration in delirium tremens, 629

Pupils, dilatation of, in migraine, cause of, 411 hysterical dilatation of, 248 in acute simple meningitis, 717 in cerebral anæmia, 775 in chronic hydrocephalus, 741 in concussion of the brain, 909 in diseases of the cervical sympathetic, 1264 in disseminated sclerosis, 879 in epileptic fit, 480 in general paralysis of the insane, 195 in tabes dorsalis, 829, 830 in tubercular meningitis, 727, 729 loss of reflex of, in nervous diseases, 40, 51

Pus, characters of, in abscess of the brain, 793

Pyramidal tract, derangements of, in amyotrophic lateral sclerosis, 867

Pyromania, 147

Quinia, use of, in acute simple meningitis, 721 in alcoholism, 642, 643, 645, 646 in chronic lead-poisoning, 691 in intermittent neuralgia of supraorbital, 1233 in labio-glosso-laryngeal paralysis, 1175 in migraine, 414 in neuralgia, 1224 in paralysis agitans, 438 in sciatica, 1236 in spinal meningeal hemorrhage, 756 in thermic fever, 398 in vertigo, 427

Race, influence on causation of chorea, 444 of hysteria, 217 of hystero-epilepsy, 291 of thermic fever, 389

Railway sickness, 426

Rectum, hysterical disorders of, 240

Reflex causes of epilepsy, 472 of neuralgia, 1220 irritability, changes in, in catalepsy, 321 irritation as a cause of catalepsy, 318 of chorea, 444 movements, abnormal, in nervous diseases, 50 of patellar tendon in nervous diseases, 52 paralyses in spinal anæmia, 806 paralysis in neuritis, 1193

Reflexes, active, in spinal hyperæmia, 802 exaggerated, in spinal syphilis, 1026 in acute spinal myelitis, 818 in amyotrophic lateral spinal sclerosis, 868 in chorea, 448 in combined forms of sclerosis, 870 in diffuse sclerosis, 888 in disseminated sclerosis, 875, 877 in hemiplegia, 962 in spastic spinal paralysis, 862 in tabes dorsalis, 835 in tumors of the brain, 1041 of the spinal cord, 1092, 1094 tendinous in epilepsy, 481 vaso-motor, 1248

Religious feeling, extreme, as a cause of ecstasy, 34

Remissions in general paralysis of the insane, 194 in tubercular meningitis, 727

Respiration, artificial, in cerebral hemorrhage, 976 in acute spinal meningitis, 750 in anæmia of the brain, 777 in catalepsy, 321 in cerebral hemorrhage and apoplexy, 935 in concussion of the brain, 909 in labio-glosso-laryngeal paralysis, 1171 in the chloral habit, 662 in thermic fever, 390, 391, 395 in tubercular meningitis, 728 in tumors of the brain, 1044

Rest, value of, in apoplexy, 975 in concussion of the brain, 911 in hyperæmia of the spine, 804 in melancholia, 160 in myelitis, acute, 823 in neuritis, 1194 in symmetrical gangrene, 1261 in writers' cramp, 533 in vaso-motor neuroses, 1255 and quiet, value in general paralysis of the insane, 201

Rest-cure, value of, in hysteria, 279 in migraine, 413 in neurasthenia, 358, 362

Retropulsion in paralysis agitans, 436

Reynaud's disease, 1257

Rheumatic headache, 403

Rheumatism, influence on causation of chorea, 442, 452 of meningitis, acute, 716

Rigidity in hemiplegia of intracranial hemorrhage and apoplexy, 962

Rigors in acute simple meningitis, 717 spinal meningitis, 750

Romberg symptoms of tabes dorsalis, 830

Salaam convulsions, 463

Salicylate of sodium, use, in acute simple meningitis, 721 in neuralgia, 1229 in neuritis and multiple neuritis, 1194, 1198

Sarcomatous tumors of the brain, 1048

Satyriasis, 147

Scarlatina, influence on causation of chorea, 443

Schistorachis, 757

Sciatica, 1235 (see Neuralgia).

Scleroses, secondary, of spinal cord, 892

Sclerosis of crossed pyramidal tracts as a cause of spastic spinal paralysis, 865 Amyotrophic lateral spinal, 867 Definition, 867 Duration, 868 Morbid anatomy, 867 Prognosis, 869 Symptoms, 868 Combined forms of spinal, 869 Diffuse, 886 Morbid anatomy, 886 Prognosis, 890 Symptomatology, 888 Disseminated (cerebro-spinal), 873 Diagnosis, 885 Etiology, 883 Morbid anatomy, 874, 880-883 Symptoms, 874 Posterior spinal, 826 Treatment of, 898 Climate, 903 Cold baths, 903 Cold douches, 903 Ergot in early stages, 901 Faradic wire brush, 904 Galvanism, 901 Hot Springs, 900 Management of special symptoms and complications, 905 Mercury, 900 Mixed treatment, 899 Moral treatment, 906 Nerve-stretching, 903 Nitrate of silver, 901 Peripheral treatment, 902 Static electricity, 906 Tremors of sclerotic affections, 905

Sclerotic process in tabes dorsalis, 842-847 in general paralysis of the insane, 197

Scrofulosis, influence on causation of chronic hydrocephalus, 741 of tubercular meningitis, 724

Scoliosis in infantile spinal paralysis, 1131

Sea-bathing, use, in hysteria, 283

Sea-sickness, 426

Season, influence on causation of chronic lead-poisoning, 679 of hyperæmia of the brain, 765 of intracranial hemorrhage and apoplexy, 931 of tubercular meningitis, 725

Secretions, altered, in diseases of cervical sympathetic, 1265 in nervous diseases, 59

Sedatives and narcotics, use of, in insanity, 135, 136

Self-concentration, relation to trance and ecstasy, 347

Self-deception of hysterical patients, 233

Semeiology, general, of nervous diseases, 19

Senile dementia, 173 insanity, 174

Sensation, disturbances of, in catalepsy, 321 in chronic lead-poisoning, 686, 687 in hemiplegia, 955 in injuries to peripheral nerves, 1182, 1185, 1186 in multiple neuritis, 1195 in the chloral habit, 664 in tumors of the brain, 1042 of the spinal cord, 1091, 1092 Modifications of, in acute myelitis, 817-819 spinal meningitis, 750 pachymeningitis, 747 in cerebral atrophy and hypertrophy, 942 syphilis, 1008 in chronic spinal meningitis, 753 pachymeningitis, 749 in neuritis, 1191-1193 in neuromata, 1210 in progressive unilateral facial atrophy, 696 in symmetrical gangrene, 1259 in tabes dorsalis, 829, 832 Perversion of, in delirium tremens, 628 in diffuse spinal sclerosis, 889 in spinal hyperæmia, 802 meningeal hemorrhage, 752 syphilis, 1025

Senses, special, disorders of, in alcoholism, 622 in cerebral anæmia, 783 in cerebral hemorrhage and apoplexy, 942 in cerebral hypertrophy and atrophy, 995 in nervous diseases, 39 in neuralgia, 1213 in neurasthenia, 356 in progressive unilateral facial atrophy, 697 in symmetrical gangrene, 1266

Sensibility, alterations of, topographical distribution in nervous diseases, 37-39 Disorders of, in chronic alcoholism, 619 in chorea, 448 Loss of, in nervous diseases, 35-37

Sensorial affections of hysteria, 246 of special senses, in nervous diseases, 39

Sensory disturbances in cerebral anæmia, 783 epilepsy, 483, 486 symptoms of nervous diseases, 31

Sequelæ of thermic fever, 399

Serous apoplexy, 783

Sex, influence on causation of acute spinal meningitis, 450 of catalepsy, 318 of cerebral anæmia, 778 hyperemia, 765 of chorea, 441 of chronic lead-poisoning, 680, 686, 688 of disseminated (cerebro-spinal) sclerosis, 883 of ecstasy, 342 of epilepsy, 470 of family form of tabes dorsalis, 871 of general paralysis of the insane, 177 of hæmatoma of the dura mater, 707 of hysteria, 215 of hystero-epilepsy, 291 of intracranial hemorrhage and apoplexy, 929 of migraine, 406, 1231 of myxœdema, 1271 of neuralgia, 1217 of paralysis agitans, 437 of progressive unilateral facial atrophy, 694 of simple acute meningitis, 716 of tabes dorsalis, 852 of tetanus, 544 of the choral habit, 661 of the opium habit, 650 of tubercular meningitis, 725 of tumors of the brain, 1029 spinal cord, 1090 of writers' cramp, 512

Sexual disorders, of chronic alcoholism, 614 of hyperæmia of the brain, 778 of neurasthenia, 357 of the opium habit, 656, 658 of tumors of the spinal cord, 1096 excess, as a cause of spastic spinal paralysis, 864 of spinal hyperæmia, 802 of tabes dorsalis, 851, 852 of vertigo, 420 excitement, as a cause of ecstasy, 342 function, in general paralysis of the insane, 195 in tabes dorsalis, 834 instincts, perverted, in insane temperament, 146, 148, 161 irritation, as a cause of hysteria, 221 of reflex paralysis, 807 perversions, in general paralysis of the insane, 179, 180

Shaking palsy, 433

Sick headache, 406, 1216, 1230

Silver, use of, in hemiplegia, 978 in labio-glosso-laryngeal paralysis, 1175 in spastic spinal paralysis, 901

Simulation of sleep, 775

Simulations of hysterical patients, 230, 233-235

Skin, atrophy of, changes in, in injuries to peripheral nerves, 1183, 1185, 1186, 1187 Condition of, in neuralgia, 1212, 1213 Disorders of, in chronic alcoholism, 615 in hysteria, 234 in myxœdema, 1272 in neuritis, 1192 in progressive unilateral facial atrophy, 695 in tabes dorsalis, 837 in the chloral habit, 663 in the opium habit, 654, 658 in vaso-motor neuroses, 1252-1254

SLEEP, AND ITS DISORDERS, 363 Apparent death, test of, 385 Circulation of blood in, 774, 775 Brain, state of, during sleep, 367 Coma, 382 Disorders of, in cerebral anæmia, 782, 783 Hyperæmia, 769 Syphilis, 1000 Dreams, physiology of, 368, 369 Effect of, on choreic movements, 445 Hypotheses concerning nature of sleep, 364-366 Insomnia, 379 in the opium habit, 655 Febrile form of, 380 from active cerebral congestion, 382 from exhaustion, 380-382 Lithæmic form of, 379 Treatment, 380, 381, 382 Lethargy, 384 Lucid, 386 Night-terrors, 370 Sleeping dropsy, 383 Somnambulism, 371 Treatment, 378

Sleeping dropsy, 383

Smell, disorders of, in alcoholism, 623 in hemiplegia, 955 in neuralgia, 1213 in tumors of the brain, 1030, 1043 and taste, perversion of, in hysteria, 250

Social condition, influence on causation of chorea, 441 of hysteria, 218 of insanity, 117, 118

Sodium bromide, use, in epilepsy, 500

Softening of the brain, 917, 949, 989 Red and yellow, in abscess of the brain, 793 of the cord in acute spinal myelitis, 812 in spinal hemorrhage and embolism, 809, 810

Somnambulism, 371 Artificial, 373

Somnolence, morbid, 344 in tubercular meningitis, 726, 727

Spasm and twitching of muscles in tumors of spinal cord, 1091, 1094 characters and seat in writers' cramp, 515 Painless facial, 462

Spasms, general, in hysteria, 236 in neuritis, 1192 in tetanus, characters, 549, 550 Local, in hysteria, 244 in tumors of the brain, 1038 Varieties, in nervous diseases, 44-47

Spastic spinal paralysis, 861

Specific poisons, insanity from, 175

Speech, development of, 566

SPEECH, DISORDERS OF, 566 Classification, 568 Alalia, 569 Treatment, 570 Dyslalia, or stuttering, 572 Treatment, 572 Paralalia, or stammering, 571 Treatment, 571

Speech, disorders of, in amyotrophic lateral spinal sclerosis, 875, 876 in Bell's palsy, 1203 in cerebral hemorrhage and apoplexy, 941 in chorea, 445, 448 in disseminated (cerebro-spinal) sclerosis, 875, 876 in hemiplegia, 957-960 in labio-glosso-laryngeal paralysis, 1171 in paralysis agitans, 455 in the opium habit, 655, 658 in tumors of the brain, 1038 Physiology of, 567

SPINA BIFIDA, 757 Definition, etiology, history, and synonyms, 757 Diagnosis, 760 Pathology and morbid anatomy, 759 Prognosis, 761 Symptoms, 758 Treatment, 761 Excision and ligation, 762 Injection of iodine, 762 Paracentesis, 761

Spinal anæmia, 805 Treatment, 808 cord, affections of, chronic, inflammatory, and degenerative, 825 and its envelopes, tumors of, 1090 Disease of one lateral half of, 1165 Definition, 1166 Diagnosis, 1168 Prognosis, 1168 Symptoms, 1166 Anæsthesia, 1166, 1167 Paralysis, seat, 1166, 1167 Synonyms, 1165 Treatment, 1168 Diseases of membranes of, 703, 746 Embolism, thrombosis, hemorrhage, and abscess of, 808 Etiology, 809 Morbid anatomy of, 809, 810 Symptoms of, 809 Treatment, 809 Localization of lesions in, 69 Lesions of, in alcoholism, 622 in tabes dorsalis, 840 in tetanus, 549 disorders in alcoholism, 619 dura mater, acute inflammation of, 747 Diagnosis and prognosis, 748 Morbid anatomy, symptoms, and treatment, 748 Chronic inflammation of, 748 exhaustion, 802 hyperæmia, 801 inflammation, 802 Irritation, 802 Etiology, 802 Hysterical, 252 Passive, 802 Symptomatology, 802 Treatment, 804 Ergotin, 805 Local bloodletting, 805 Rest, 804 membranes, congestion of, 746 Etiology, 746 Symptoms, morbid anatomy, and treatment, 747 Inflammation and hemorrhage of, 746 meningeal hemorrhage, 754 Diagnosis and prognosis, 755 Pathological anatomy, 755 Synonyms, etiology, and symptoms, 754 Treatment, 756 meningitis, acute, 749 Diagnosis and prognosis, 751 Etiology and synonyms, 749 Morbid anatomy and symptoms, 750 Treatment, 751 Chronic, 752 Diagnosis, prognosis, and treatment, 753 Symptoms and synonyms, 752 Myelitis, acute, 810 Paralysis, spastic, 861 Sclerosis, posterior, 826 Syphilis (see Syphilitic Affections of the Nerve-centres).

Spine, concussion of, 912 Diagnosis, 916 Prognosis, 916 Symptoms, 915 Treatment, 916

Spirits, characters of intoxication from, 591

Spleen, changes in, in chronic alcoholism, 607

Springs, Hot, value of, in spinal sclerosis, 900

Staggering, significance, in nervous diseases, 49 in tabes dorsalis, 831

Stammering, 571

Starvation as a cause of cerebral anæmia, 781 condition of brain in, 781, 782

Status epilepticus, prognosis of, 498 Vertiginosus, the, 426 Treatment of, 428

Stigmatization, 348-351 Theories concerning origin, 350

Stimulants, use, in heat-exhaustion, 388 in collapse in opium habit, 673, 675 in thermic fever, 397

Stomach, disorders of and changes in, in chronic alcoholism, 600

Strabismus in chronic hydrocephalus, 743 in tubercular meningitis, 727

Strychnia, use, in alcoholism, 641, 643, 646 in chorea, 455 in infantile spinal paralysis, 1157 in intracranial hemorrhage and apoplexy, 978 in labio-glosso-laryngeal paralysis, 1175 in paralysis agitans, 438 in spinal hyperæmia, 805 in writers' cramp, 538 Myelitis, acute, 822, 823

Stupor in tubercular meningitis, 727, 728 Melancholia with, 158

Stuttering, 569, 571

Suicidal insanity, 146 tendency, in general paralysis of the insane, 191

Sumbul, use, in hysteria, 278

Sun, exposure to, as a cause of acute meningitis, 716

Sunstroke (see Thermic Fever). headache from, 390, 404 Influence on causation of cerebral hyperæmia, 764

Superficial neuralgia, 1211

Supposed discharge as a cause of cerebral hyperæmia, 766 of spinal hyperæmia, 802

Supraorbital nerve, intermittent neuralgia of, 1233

Surgical treatment of abscess of the brain, 800 of facial neuralgia, 1234 of tumors of the brain, 1067

Sweating, absence of, in progressive unilateral facial atrophy, 696 in the opium habit, 657, 658

Swedish movement, use, in hysteria, 280 in infantile spinal paralysis, 1157

Sympathetic cervical, diseases of, 1263 headache, 404 neuralgias, 1220

Symmetrical gangrene, 1257

Symptoms of abscess of the brain, 795 of acute alcoholism, 587 et seq. of acute cerebral anæmia, 776, 782 of acute myelitis, 816 of acute simple meningitis, 717 of acute spinal meningitis, 750 pachymeningitis, 747 of amyotrophic lateral sclerosis, 868 of angina pectoris, 1238 of apoplexy, 733 of athetosis, 459 of atrophy of the brain, 994, 995 of Bell's palsy, 1203 of capillary embolism, 981 of catalepsy, 320 of cerebral anæmia, 782 of cerebral hyperæmia, 768 of cerebral meningeal hemorrhage, 712 of cerebral softening, 981, 989 of cerebral syphilis, 1003 of chorea, 445 of chronic alcoholism, 598-633 of chronic cerebral meningitis, 721 of chronic hydrocephalus, 741 of chronic lead-poisoning, 682 of chronic spinal meningitis, 752 of chronic spinal pachymeningitis, 749 of combined forms of sclerosis, 870 of concussion of the brain, 908 of concussion of the spine, 915 of congestion of cerebral dura mater, 704 of spinal membranes, 747 of the pia mater, 716 of delirium tremens, 627 of diffuse spinal sclerosis, 888 of disease of cervical sympathetic, 1264 of disseminated (cerebro-spinal) sclerosis, 874 of ecstasy, 342 of epilepsy, 477 of external pachymeningitis, 704 of family form of tabes dorsalis, 871 of gastralgia, 1238 of general paralysis of the insane, 178 of hæmatoma of dura mater, 707 of headache, 402 of heat-exhaustion, 387 of hebephrenia, 172 of hypertrophy of the brain, 944-946 of hypochondriasis, 154 of hemiplegia, 954 of hypertrophy of the brain, 99 of hysteria, 229 of hystero-epilepsy, 293 of infantile spinal paralysis, 1114 of inflammation of the brain, 791 of injuries to nerves, 1183, 1185, 1186 of insanity, 120 of insomnia, 379-382 of intermittent neuralgia of supraorbital, 1233 of internal pachymeningitis, 706 of intracranial hemorrhage and apoplexy, 733 of labio-glosso-laryngeal paralysis, 1170 of melancholia, 155, 156 of migraine, 407, 1230 of moral insanity, 143-146 of multiple neuritis, 1195 of myxœdema, 1272 of nervous diseases, motory, 42 psychic, 19 sensory, 31 trophic, 54-59 of neuralgia, 1213 of neurasthenia, 354 of neuritis, 1191 of neuromata, 1209 of occlusion of cerebral vessels, 952 of painless facial spasm, 462 of paralysis agitans, 433 of primary insanity, 152 of progressive unilateral facial atrophy, 694 of sciatica, 1235 of secondary scleroses, 987 of spastic spinal paralysis, 862 of spina bifida, 757 of spinal hemorrhage, 809 hyperæmia, 802 meningeal hemorrhage, 754 syphilis, 1024 of symmetrical gangrene, 1258 of tabes dorsalis, 827 of tetanus, 549 of the chloral habit, 661 of the insane temperament, 140, 141 of the opium habit, 653 of thermic fever, 389 of Thomsen's disease, 461 of thrombosis of cerebral veins and sinuses, 986 of torticollis, 464 of trance, 344 of tremor, 430 of tubercular meningitis, 725 in the adult, 737 of tumors of the brain, 1030 of the spinal cord, 1091 of unilateral spinal paralysis, 1166 of vertigo, 416 of visceral neuralgia, 1215 of writers' cramp, 514

Syncope in cerebral anæmia, 790 Treatment of, 790

Syncoptic seizures in cerebral anæmia, 783

Syphilis as a cause of disseminated sclerosis, 886 of epilepsy, 471 of general paralysis of the insane, 178 of insanity, 119 of spinal meningitis, acute, 749 of tabes dorsalis, 852 of tumors of the brain, 1028

SYPHILITIC AFFECTIONS OF THE NERVE-CENTRES, 999 Brain-cortex, syphilitic disease of, 1017 Diagnosis, 1020, 1021 Symptoms, 1017 et seq. Relation to general paralysis of the insane, 1008-1021 Brain syphilis, gummatous, 1003 Diagnosis, 1012 Pathology, 1014 Prognosis, 1013 Symptoms and clinical history, 1003 Aphasia in, 1009 Epileptic attacks in, 1010 Eye-ground, changes in, importance of, 1003 Headache, seat and characters, 1003, 1005 of cerebral meningeal syphilis, 1003, 1012 Onset, mode of, 1003 Paralysis, mode of onset, seat, and characters, 1007-1010 Prodromes, 1003, 1004 Psychical symptoms, 1011 Sleep, disorders of, 1006 Special senses, modifications of, 1008 Treatment, 1015 Aconite, hypodermic use, 1015 Bloodletting, use, 1015 Mercurials, use, 1016 of the accidents or exacerbations of the disease, 1015 Potassium iodide, use, 1016, 1017 “Woods,” use, 1016, 1017 Etiology, general, 999 Time of development of symptoms after specific infection, 1001 Spinal syphilis, 1022 Diagnosis, 1026 Lesions, 1024 Relation to acute and subacute myelitis, and to acute ascending paralysis, 1022, 1023 Symptoms, 1024 Motility, disturbances of, 1025 Pain in, 1024 Sensation, perversions of, 1025

Syphilitic diseases of brain, in general paralysis of the insane, 197 headaches, 403 inflammation of spinal cord in diffuse sclerosis, 886 insanity, 175, 1017

Tabes dorsalis, 826 Diagnosis, 857 Etiology, 851 History, 826 Morbid anatomy of, 840 Physiology of, 840-846 Symptomatology, 827 The family form of, 870 Diagnosis, 870 Etiology, 871 Morbid anatomy, 872 Prognosis, 871 Symptoms, 871

Table of 100 cases of brain tumor, 1069 of 50 cases of spinal tumor, 1107

Taches cérébrales, 1253

Tarantismus, origin and nature of, 223

Taste, disorders of, in alcoholism, 623 in hemiplegia, 955 in neuralgia, 1213 in progressive unilateral facial atrophy, 697 in tumors of brain, 1030, 1043

Tea and coffee as causes of tremor, 429

Telegraphy, influence on causation of writers' cramp, 507

Temperature in acute simple meningitis, 717, 718 in cerebral hemorrhage and apoplexy, 937 in cerebral hyperæmia, 770 in cerebral meningeal hemorrhage, 713 in chorea, 449 in concussion of the brain, 909 in epilepsy, 480 in general paralysis of the insane, 179 in hemiplegia, 960 in hysteria, 252 in infantile spinal paralysis, 1115, 1124 in tabes dorsalis, 833 in tetanus, 551 in tetanus neonatorum, 564 in the opium habit, 656, 657 in thermic fever, 391 in tubercular meningitis, 726, 728 in tumors of the spinal cord, 1095 of face, in progressive unilateral facial atrophy, 696 of head, in tumors of brain, 1036

Tendon reflexes in chorea, 448 in epilepsy, 481

Tenotomy in writers' cramp, 538 indications for, in infantile spinal paralysis, 1158

Terminal dementia, 203

Termination of chorea, 449 of progressive unilateral facial atrophy, 699 of tumors of brain, 1045 of spinal cord, 1106

TETANUS, 544 Definition, 544 Diagnosis, 551 from hysterical spasm and cerebro-spinal meningitis, 552 from strychnia-poisoning and hydrophobia, 552 Etiology, 544-547 Age, race, and sex, influence on causation, 544 Atmospheric and climatic conditions, 544 Theories regarding origin, 546, 547 Traumatic causes, 545 Morbid anatomy, 548 Prognosis, 553 Symptoms, 549 Digestive and urinary organs, disorders of, 551 Mental condition in, 550 Prodromata, 549 Pulse and temperature in, 550 Spasms, seat and characters of, 549, 550 Treatment, 555-562 Alcohol, use, 559 Bleeding, use, 555 Calabar bean and cannabis indica, use, 557 Chloral and potassium bromide, use, 559 Conium, use, 557 Curare, use, 556 Mercury, use, 555 Opium, use, 557 Preventive, 561 Surgical measures, 559-562 Tobacco and anæsthetics, use, 566

Tetanus neonatorum, 563 Etiology, 563 Sims on displacement of occipital bone as a cause, 563 Morbid anatomy, 564 Symptoms, 564 Treatment, 565

Tetanus, puerperal, treatment, 562

Thermic fever, 388 Diagnosis, 396 Etiology, 388 Alcohol, influence on causation, 389 Race, influence on causation, 389 Post-mortem changes in and theories of the disease, 392 Sequelæ, 399 Symptoms, 389 Cerebral, 390, 391 Digestive disorders, 390, 391 Entero-colitis of infancy, relation of, to, 390 Motor system, disturbances of, 391 Synonyms, 388 Treatment and prophylaxis, 396 Antipyrine, use, 398 Bleeding, use, 398, 399 Blisters, use, 398-400 Cold and cold baths, use, 396, 397 Morphia, use, 398 of cerebral, 398 of pyrexia, 396, 397 of sequelæ, 398

Thomsen's disease, 461

Thrombosis of cerebral veins and sinuses, 982 of spinal cord, 808

Tic douloureux, 1233

Tinnitus aurium in hyperæmia, 772 in nervous diseases, 40, 41 in tabes dorsalis, 834

Tinnitus in cerebral anæmia, 780

Titubation, in nervous diseases, 49

Tobacco, abuse of, influence on causation of alcoholism, 577 of tabes dorsalis, 854 of tremor, 429 of writers' cramp, 512 use, in tetanus, 556

Tongue-biting in epilepsy, 481 state of, in cerebral hemorrhage and apoplexy, 941 in labio-glosso-laryngeal paralysis, 1171 in tubercular meningitis, 725, 726, 729

Tonic spasms in nervous diseases, 44

Tonics, use, in catalepsy, 338 in melancholia, 160

Tonka, use, in neuralgia, 1229

Torsion of abdominal walls in treatment of hystero-epilepsy, 311

Torticollis, 463 Etiology, 463 Prognosis, 464 Symptoms, 463 Treatment, 464 Electricity, use, 464 Exsection of spinal accessory nerve, 464

Toxic causes of epilepsy, 472 headaches, 402

Tracheotomy in tetanus, 561

Trance, lethargy, and morbid somnolence, 344-348 Symptoms, 345 Theories concerning nature, 346, 347

Transitory insanity, 164

Traumatism, influence on causation of abscess of the brain, 797 of acute spinal meningitis, 749 of cerebral hemorrhage and apoplexy, 932 of cerebral hyperæmia, 767 of cerebral meningeal hemorrhage, 711 of concussion of the spine, 912 of copodyscinesia, 514 of epilepsy, 471 of external pachymeningitis, 704 of infantile spinal paralysis, 1151 of neuritis, 1190 of progressive unilateral facial atrophy, 694 of spinal anæmia, 807 of syphilitic affections of the nerve-centres, 999 of tabes dorsalis, 855 of the spinal cord, 1090 of tumors of the brain, 1029

Treatment of abscess of the brain, 790 of acute simple meningitis, 720 of acute spinal meningitis, 752 of acute spinal pachymeningitis, 748 of alalia, 570, 571 of alcoholic insanity, 175 of alcoholism, 640 of angina pectoris, 1238 of athetosis, 460 of atheroma of cerebral arteries, 992 of atrophy of the brain, 994, 996 of Bell's palsy, 1206 of capillary embolism, 981 of catalepsy, 338 of cerebral anæmia, 788 of cerebral embolism, 979 of cerebral hemorrhage, 974 of cerebral hyperæmia, 773 of cerebral meningeal hemorrhage, 715 of cerebral syphilis, 1015 of cerebral thrombosis, 977 of chorea, 450 of chronic cerebral meningitis, 722 of chronic hydrocephalus, 745 of chronic lead-poisoning, 690 of chronic spinal meningitis, 753 of climacteric insanity, 173 of concussion of brain, 911 of spinal cord, 916 of congestion of cerebral pia mater, 716 of spinal membranes, 747 of constitutional affective mental disease, 143 of delusional insanity, 169 of dementia, primary and secondary, 165 of disease of cervical sympathetic, 1265 of disorders of speech, 569, 571, 572 of ecstasy, 344 of epilepsy, 499 of epileptiform facial neuralgia, 1234 of external pachymeningitis, 706 of gastralgia, 1239 of general paralysis of the insane, 201 of hæmatoma of the dura mater, 710 of headache, 406 of heat-exhaustion, 388 of hebephrenia, 172 of hypertrophy of brain, 998 of hypochondriacal insanity, 150 of hypochondriasis, 155 of hysteria, 273 of hysterical insanity, 149 of hystero-epilepsy, 310 of impulsive insanity, 148 of infantile spinal paralysis, 1155 of insane temperament, 141 of insanity, 127 of insomnia, 380-382 of intercostal neuralgia, 1235 of internal pachymeningitis, 706 of intermittent neuralgia of supraorbital nerve, 1233 of lead colic, 691 of labio-glosso-laryngeal paralysis, 1174 of mania, acute, 161, 162 of melancholia, 159 of migraine, 413, 1232 of moral insanity, 146 of myelitis, acute, 822 of myxœdema, 1273 of nerve injuries, 1189 of neuralgia, 1222 of neurasthenia, 357 of neuritis, 1194 of neuromata, 1210 of painless facial spasm, 462 of paralysis agitans, 438 of perforating ulcer of foot, 1274 of primary brain atrophy, 171 of primary insanity, 152 of progressive unilateral facial atrophy, 702 of puerperal tetanus, 562 of sciatica, 1236 of senile dementia, 174 of senile insanity, 174 of somnambulism, 378 of spina bifida, 761 of spinal anæmia, 807 of spinal hemorrhage, 809 of spinal hyperæmia, 804 of spinal meningeal hemorrhage, 756 of spinal sclerosis, 898 of stammering and stuttering, 571 of symmetrical gangrene, 1262 of syncope, 790 of syphilitic insanity, 176 of tabes dorsalis, 861 of terminal dementia, 203 of tetanus, 555 of tetanus neonatorum, 563 of the chloral habit, 676 of the opium habit, 668, 672 of thermic fever, 396 of thrombosis of cerebral veins and sinuses, 988 of torticollis, 463 of tremor, 432 of tubercular meningitis, 735 of tumors of brain, 1066 of tumors of spinal cord, 1106 of unilateral spinal paralysis, 1168 of vaso-motor neuroses, 1255 of vertigo, 426 of writers' cramp, 533

TREMOR, 429 Etiology, 429 Symptoms, 430 Treatment, 432

Tremor, ataxic, in nervous diseases, 47 hysterical, 244 in alcoholism, 620 in delirium tremens, 628 in disseminated sclerosis, 875, 876 in nervous diseases, 45 in paralysis agitans, 434-436 in spinal syphilis, 1025 in the chloral habit, 664 in the opium habit, 655, 658, 659 in writers' cramp, 518 muscular, in general paralysis of the insane, 195 of sclerotic affections, treatment, 905

Trephining, question of, in abscess of the brain, 800 in cerebral hemorrhage and apoplexy, 977 in epilepsy, 503 in tumors of the brain, 1066, 1067

Trismus, 549, 563

Trophic changes in injuries to peripheral nerves, 1183, 1187 disturbances in tumors of the brain, 1044 in writers' cramp, 520 of tabes dorsalis, 837 lesions in infantile spinal paralysis, 1145 nerve-centres, 1266, 1275

TROPHIC NEUROSES, 1266 Atrophy, 1260 of glandular and cutaneous systems, 1268 of muscles and bones, 1267 Wallerian degeneration, 1266 Hypertrophy, 1271 Inflammation, 1273 Bed-sores, acute and chronic, 1274, 1275 Ulceration of fingers, acute, 1273 Ulceration, perforating, of the foot, 1273, 1274 Myxœdema, 1271 Course and symptoms, 1272 Etiology and pathology, 1271 Diagnosis, 1273 Treatment, 1273 Electricity and tonics, 1273 Nitro-glycerin, 1273 Trophic Nerves and Nervous Centres, 1266 Symptoms of nervous diseases, 54-59 of neuritis, 1192

Tubercles, miliary, seat and character, in tubercular meningitis, 730, 732

Tubercular brain tumors, 1048 meningitis (see Meningitis, Tubercular), 723 in the adult, 737 simulated by cerebral anæmia, 786

Tumor of spina bifida, size, characters, etc., 758

TUMORS OF THE BRAIN AND ITS ENVELOPES, 1028 Complications and sequelæ, 1045 Definition, 1028 Diagnosis, 1051 from cerebral abscess, 1052 from cerebral symptoms of Bright's disease, 1053 from chronic hydrocephalus and softening, 1054 from dementia and mania, 1054 from early stage of posterior spinal sclerosis, 1055 from hysteria and malaria, 1055 from meningitis, 1053 from various forms of apoplexy, 1052 Localization of tumors of brain, 1056-1066 Duration, course, and termination, 1045 Etiology, 1028 Age and sex, influence of, 1029 Echinococci and cysticerci, influence of, 1030 Heredity, influence of, 1028 Injuries, influence of, 1029 Syphilis, influence of, 1028 Pathology, 1046 Methods of making post-mortem examination in cases of brain tumors, 1050 Varieties, structure, seat, and frequency, 1046-1050 Prognosis, 1066 Symptoms, 1030 Apoplectic attacks in, 1040 Ataxia and muscular atrophy in, 1030, 1041 Bladder, disorders of, 1045 Choked disc, neuro-retinitis and optic retinitis in, 1035 Chorea and choreic movements, 1039 Constipation in, 1045 Contractures and rigidity in, 1030, 1039 Epistaxis and hemorrhages from mucous surfaces in, 1044 Eye, disorders of, 1030, 1035, 1042-1044 Headache, characters and seat, 1030, 1033 Hearing, taste, and smell, altered, 1030, 1043 Mental disturbances, 1037 Neuralgias in, 1042 of multiple tumors, 1031-1033 Pain on pressure upon head, 1034 Paralysis, seat and characters, 1030, 1040 Reflexes, altered, 1030, 1041 Sensation, perversions of, 1030, 1042 Spasms, local and general, in, 1030, 1039 Temperature of head in, 1036, 1037 Trophic disturbances and disturbances of respiration, 1044 Vertigo in, 1034 Vomiting in, 1030, 1034 Will, impairment of, and defects of speech, 1038 Treatment, 1066 Ergot, cannabis indica, and hyoscyamus, use, 1068 Leeches, use, 1068 Morphia and potassium bromide, use, 1068 Surgical, 1066

TUMORS OF THE SPINAL CORD AND ITS ENVELOPES, 1090 Definition, 1090 Diagnosis, 1098 from caries of spinal vertebræ, 1099 from hysteria, 1100 from metallic and infectious diseases, 1100 from spinal congestion, hemorrhage, and meningitis, 1098 from traumatism, sclerosis, aneurism, and neuritis, 1100 localization of spinal tumors, 1100-1106 Duration and termination, 1106 Etiology, 1090 Age and sex, influence of, 1090 Traumatism, influence of, 1090 Pathology, 1096 characters, seat, and varieties of tumors, 1096-1098 vascular changes, 1098 Symptoms, 1091 Ataxia and atrophy in, 1094 Bladder, urinary and sexual disorders, 1096 Eye disorders, 1096 Headache in, 1096 Mental disturbances in, 1096 Pain, seat and characters, 1091, 1092 Paralysis and paresis, 1091-1093 Reflexes, altered in, 1094 Sensation, alterations of, 1091-1093 Sense of constriction about waist, 1091-1093 Spasms and twitchings in, 1091, 1092, 1094 Temperature of body in, 1095 Vomiting in, 1096 Treatment, 1106

Tumors, phantom, in hysteria, 255

Turpentine, use of, in neuralgia, 1229

Tympanites, hysterical, 240

Typhoid fever as a cause of abscess of the brain, 799 of anæmia of the brain, 781

Typhus fever as a cause of hyperæmia of the brain, 768

Ulcer of foot in tabes dorsalis, 839

Ulcerations in nervous diseases, 58

Ulcers, perforating, of the foot, 1273

Unconsciousness, in cerebral meningeal hemorrhage, 712

Unilateral catalepsy, symptoms, 324 epilepsy, 482 facial atrophy, progressive, 693 preponderance of symptoms in cerebral anæmia, 784 spinal paralysis, 1165

Urine, state of, in brain tumors, 1045 in cerebral hemorrhage and hemiplegia, 961 in chronic lead-poisoning, 682 in epilepsy, 480 in general paralysis of the insane, 195 in hysteria, 253 in myxœdema, 1272 in neuralgia, 1212, 1213 in symmetrical gangrene, 1260 in tabes dorsalis, 835 in the chloral habit, 662 in the opium habit, 654, 658, 659

Uterine and ovarian irritation as a cause of reflex paralysis, 807

Uterus and ovaries, neuralgia of, 1240

Vaginismus, hysterical, 246

Valleix's painful points in migraine, 408

Varieties of hystero-epilepsy, 290

Vaso-constrictors, action of, 1243

Vaso-dilators, action of, 1244

Vaso-motor cerebral disturbances in general paralysis of the insane, 179 disturbances in writers' cramp, 520 nerves, origin of, 1246

VASO-MOTOR NEUROSES, 1242 Course, 1254 Diagnosis, 1252 Pathogenesis, 1242 Physiology, 1242 Local vascular tone in, 1242 Medullary centres in, 1250 Origin of the vaso-motor nerves, 1246 Vaso-constrictors, 1243 Vaso-dilators, 1244 Vaso-motor reflexes, 1248 Vaso-motor tracts, 1249 Prognosis, 1255 Symptoms, 1252 Acrodynia, 1254 Angio-spasm and angio-paralysis, 1252 Cutaneous angio-neuroses, 1252-1254 Digiti mortui and gangrene, 1252-1254 Erythromelalgia, 1253 Functional, derangements of internal viscera, 1254 Ruptured capillaries in, 1253 Sensation, disturbances of, 1252, 1253 Taches cérébrales in, 1253 Treatment, 1255 Amyl nitrite and nitro-glycerin, 1256 Chloral hydrate and chloride of potassium in, 1256 Rest, massage, and electricity in, 1255

Vaso-motor and trophic neuroses, 1241 Definition, 1241 Reflexes, 1248 Symptoms of general paralysis of the insane, 189 Theory of pathology of hysteria, 211 Tracts of the spinal cord, 1249

Venous congestion in cerebral hyperæmia, 768

Ventricles of brain in cerebral anæmia, 781

Veratrum, use, in tumors of spinal sclerosis, 905

Verbigeration, in katatonia, 166

VERTIGO, 416 Definition, 416 Diagnosis, 417 Etiology, 418 Blood-poisoning, influence of, 419 Excessive venery, influence of, 420 Mechanical causes, 426 of aural form, 421 of essential form, 426 of gastric and senile form, 420 of laryngeal form, 425 of neurasthenic, hysteric, and anæmic forms, 425 of ocular form, 424 Prognosis and duration, 418 Symptoms, 416, 420-426 of aural form, 421 of essential form, 426 of gastric and senile form, 420 of laryngeal form, 425 of neurasthenic, hysteric, and anæmic forms, 425 of ocular form, 424 of status vertiginosus, 421 Treatment, 426 Bromides and hydrobromic acid, 426-428 Cauterization, use of, 427 Diet, 427, 428 Morphia, use, 426, 427 Nitrite of amyl and nitro-glycerin, use, 426 of aural form, 427 of gastric and senile form, 426 of optic form, 427 of status vertiginosus, 428 Quinia, use, 427

Vertigo, in abscess of the brain, 796 in cerebral anæmia, 777, 783 in tumors of the brain, 1035

Vessels of cerebrum, changes in, in chronic alcoholism, 617 state of, in cerebral abscess, 793

Violence, significance of, in nervous diseases, 24

Violin-playing as a cause of copodyscinesia, 511

Virchow on origin of progressive unilateral facial atrophy, 700

Visceral derangements of chronic alcoholism, 599 disturbances in diffuse sclerosis, 889 neuralgias, 1215, 1237

Vision, disorders of, in cerebral anæmia, 783, 786 in diseases of the cervical sympathetic, 1264 in disseminated spinal sclerosis, 878 in epilepsy, 476 in neuralgias, 1214 in tabes dorsalis, 830-833 hallucinations of, in migraine, 1231

Vitreous degeneration of cerebral cortex in disseminated sclerosis, 882

Vomiting, hysterical, 254 in acute simple meningitis, 718 in anæmia of the brain, 777, 783 in apoplexy and cerebral hemorrhage, 935 in cerebral meningeal hemorrhage, 713 in chronic hydrocephalus, 743 in chronic lead-poisoning, 684 in concussion of the brain, 908 in infantile spinal paralysis, 1117 in migraine, 409 in the opium habit, 653, 657-659 in tubercular meningitis, 725, 729 in tumors of the brain, 1030, 1034

Wallerian degeneration, 1266

Washerwomen's anæsthesia, 1199, 1201

Wasting diseases, influence on causation of copodyscinesia, 514

Water, hypodermically, in neuralgia, 1229 influence on causation of chronic lead-poisoning, 680

Wax-like flexibility in catalepsy, 321, 337

Welsh fasting girl, 352

Westphal-Erb symptom of tabes dorsalis, 830

Wet pack, use, in neuralgia, 1223

Will, impairment of, in tumors of the brain, 1038 and intellect, state of, in alcoholism, 625

Wines, character of intoxication from, 591

Wire brush, faradic, in spinal sclerosis, 904

Witchcraft, hysterical nature of, 226

“Woods,” the, use of, in cerebral syphilis, 1016

Word-blindness, in hemiplegia, 959 in nervous diseases, 31

Word-deafness, in nervous diseases, 31

Worms, influence on causation of epilepsy, 471

Wrist-drop, 686

WRITERS AND ARTISANS, NEURAL DISORDERS OF, 504 Definition, history, and synonyms, 504 Differential diagnosis, 521 from palsy from pressure, 526 from paralysis agitans and multiple sclerosis, 524 from paresis from slight lesions, 522, 523 from progressive muscular atrophy, 523 from teno-synovitis, 526 Duration and course, 521 Etiology, 505 Action of muscles used in telegraphy, 508 Action of muscles used in writing, 505 Age and sex, influence of, 512, 513 Cigarette-smoking as a cause of, 512 Hereditary influence and nervous temperament, 513 Manner of writing and holding the pen, 506 Musical-instrument playing, 511 Telegraphy, 507-511 Wasting diseases and traumatism, 514 Pathology and morbid anatomy, 526-530 Prognosis, 530, 531 Prophylaxis, 531-533 Symptoms, 514-521 Cramp and spasm, characters and muscles affected, 515-517 Electrical reactions in, 521 General, 520 Lock-spasm in, 517 Pain and modification of sensation in, 519 Paresis and paralysis, characters and seat, 518 Tremor in, 518 Vaso-motor and trophic disturbances, 520 Treatment, 533, 543 Arsenic, use, 537, 538 Atropia, hypodermically, 537 Electricity, use, 534-536 Gymnastics and massage, 536, 537 Local applications in, 538 Medication, value of, 537 Mechanical apparatus in, 540-542 Rest in, 533, 534 Strychnia, use, 537, 538 Tenotomy and nerve-stretching in, 538, 540

Zinc salts, use, in chorea, 455 in hysteria, 278 in hystero-epilepsy, 313 Valerianate, use of, in migraine, 1232

GENERAL INDEX.

Abdominal Glands, Diseases of, ii. 1182

Abortion, iv. 467

Acne, iv. 641 rosacea, iv. 647

Addison's disease, iii. 939

Alalia, iv. 569

Albinismus, iv. 647

Albuminuria, iv. 34

Alcoholism, v. 573

Alimentation, rectal, ii. 928

Alopecia, iv. 678 areata, iv. 680

Amblyopia, toxic, iv. 803

Amenorrhœa, iv. 183

Anæmia, iii. 887 progressive pernicious, iii. 898

Anæsthesia of peripheral origin, v. 1198

Aneurism, abdominal, iii. 821 thoracic, iii. 801

Angina pectoris, iii. 755

Angioma, iv. 688

Anidrosis, iv. 584

Ankyloglossia, ii. 349

Anthrax, i. 926; iv. 606

Anus, cutaneous eruptions and parasitic conditions of, ii. 892 syphilis of, ii. 900

Anus and Rectum, Diseases of, ii. 877 fissure of, ii. 888 prolapse of, ii. 881

Aorta, aneurism of, iii. 801, 821 atheroma of, iii. 800 perforation and occlusion of, iii. 824 rupture of, iii. 823 stenosis of, iii. 825

Aortic insufficiency, iii. 659 obstruction or stenosis, iii. 654

Apoplexy, cerebral, v. 917 pulmonary, iii. 293

Artery, coronary, diseases of, iii. 828 hepatic, aneurism of, iii. 840 inferior mesenteric, diseases of, iii. 839 pulmonary, diseases of, iii. 833 superior mesenteric, diseases of, iii. 836

Arthritis, gonorrhœal, ii. 102 rheumatoid, ii. 78

Ascaris lumbricoides, ii. 952

Ascites, ii. 1153

Asthma, Bronchial, iii. 184 Hay, iii. 210

Atelectasis, iii. 251

Athetosis, v. 457

Atrophy, v. 1266 facial, progressive unilateral, v. 694

Auditory canal, external, diseases of, v. 811

Auricle, external ear, diseases of, iv. 810

Baldness, iv. 678

Battey's operation, iv. 290

Barber's itch, iv. 723

Basedow's disease, iii. 761

Bed-bugs, iv. 733

Bell's palsy, v. 1202

Beriberi, i. 1038

Bile-ducts, catarrh of, ii. 1051

Biliary concretions, ii. 1058

Biliary passages, affections of, ii. 1051 occlusion of, ii. 1082

Biliousness, ii. 965

Bladder, atony and paralysis of, iv. 133 atrophy and hypertrophy of, in women, iv. 348 diseases of, iv. 123 functional diseases of, in women, iv. 349 hemorrhage of, iv. 134, 340 hyperæmia of, in women, iv. 339 inflammation of, acute and chronic, iv. 123, 126, 128, 341 neuroses of, iv. 132 new growths of, iv. 136 paralysis of, in women, iv. 350

Blood and Blood-glandular System, Diseases of, iii. 882

Boils, iv. 604

Bowel, compression and contraction of, ii. 857 stricture of, ii. 854

Bowels, hemorrhage from, ii. 830

Brain, abscess of, v. 792 atrophy of, v. 993 hypertrophy of, v. 996 inflammation of, v. 790 softening of, v. 989 syphilis of, v. 1003, 1017 and its Envelopes, Tumors of, v. 1028 Spinal Cord, Concussion of, v. 907 Diseases of Membranes of, v. 703 Hyperæmia and Anæmia of, v. 763, 774

Bright's disease, iv. 72

Bromidrosis, iv. 584

Bronchi, Diseases of, iii. 164

Bronchial Asthma, iii. 184 tubes, dilatation of, iii. 227

Bronchitis, acute and chronic, capillary, mechanical, pseudo-membranous, and rheumatic, iii. 169, 170, 171, 172, 173, 174

Caisson Disease, the, iii. 855

Calculi, hepatic, ii. 1058 renal, iv. 42

Callositas, iv. 662

Cancrum oris, ii. 338

Canities, iv. 678

Cannabis indica, habitual addiction to, v. 669

Carbuncles, iv. 606

Cardiac murmurs and their relation to valvular heart disease, iii. 651

Cardiac Thrombosis, iii. 718

Cardialgia, ii. 459

Cardicentesis, iii. 798

Caruncle, urethral, iv. 403

Catalepsy, v. 314

Cerebral arteries, atheroma, v. 991 meningeal hemorrhage, v. 710 paralysis, v. 917 veins and sinuses, thrombosis of, v. 982 vessels, occlusion of, v. 917, 946

Cervical sympathetic, diseases of, v. 1263

Cestodes or tape-worms, ii. 931

Chloasma, iv. 659

Chloral habit, the, v. 660

Chloroform, habitual addiction to, v. 667

Chlorosis, iii. 894

Cholera, i. 715 infantum, ii. 741 morbus, ii. 719

Chorea, v. 439 of the larynx, iii. 76

Chromidrosis, iv. 585

Chyluria, iv. 114

Cimex lectularius, iv. 733

Circulatory System, Diseases of, iii. 599

Clavus, iv. 663

Cocaine, habitual addiction to, v. 667

Cœliac axis, diseases of, iii. 841

Colic, hepatic, ii. 1058 intestinal, ii. 658 renal, iv. 42

Coma, v. 26, 382

Comedo, iv. 589

Constipation, ii. 638, 650

Convulsive disorders, local, v. 461

Copodyscinesia, v. 504

Corns, iv. 663

Cornu cutaneum, iv. 663

Coronary artery, diseases of, iii. 828

Coryza, iii. 41

Cough, nervous, iii. 71

Cranio-cerebral topography, v. 93

Cretinism, v. 138

Croup, spasmodic or false, iii. 70, 92 true, iii. 100

Culex, iv. 733

Cyanosis and Congenital Anomalies of Heart and Great Vessels, iii. 687, 712

Cysticercus cellulosæ, iv. 732

Cystitis, acute and chronic, iv. 126, 128 in women, iv. 341

Deaf-mutism, iv. 840

Deafness after cerebro-spinal meningitis, mumps, scarlet fever, etc., iv. 839

Death, apparent, v. 385

Degenerations, i. 72

Dementia, v. 164

Demodex folliculorum, iv. 732

Dengue, i. 879

Dentition, morbid, ii. 371

Dermatalgia, iv. 711

Dermatitis, iv. 600, 604, 611, 623

Dermatolysis, iv. 675

Dermoid cyst of the ovary, iv. 299

Diabetes insipidus, iv. 27 Mellitus, ii. 195

Diagnosis, general, i. 148

Digestive System, Diseases of, ii. 319

Diphtheria, i. 656

Disease, causes and prevention of, i. 175

Diseases, General, i. 229

Distomum hepaticum, ii. 1109

Drainage and Sewerage in their Hygienic Relations, i. 213

Dreams, v. 368

Ductus communis choledochus, occlusion of, ii. 1082

Dura mater, cerebral, congestion of, v. 704

Dysentery, ii. 777

Dyslalia, v. 571

Dysmenorrhœa, iv. 192

Dyspepsia, functional and atonic, ii. 436

Ear, internal, diseases of, iv. 835 middle, diseases of, iv. 817

Echinococcus of the liver, ii. 1101

Eclampsia, v. 464

Ecstasy, v. 339

Ecthyma, iv. 653

Eczema, iv. 625 marginatum, iv. 718

Effusions, i. 67

Elephantiasis, iv. 675

Embolism and Thrombosis, i. 56 of the spinal cord, v. 808 capillary, cerebral, v. 979

Emphysema, iii. 233, 249

Endocarditis, iii. 639, 640, 642, 643

Endometritis, acute and chronic, iv. 460, 462

Enteralgia, ii. 658

Enteritis, Pseudo-membranous, ii. 763

Entero-colitis, ii. 726

Epilepsy, v. 468

Epiglottis, inflammation and erosion of, iii. 109

Epithelioma, iv. 707

Epistaxis, iii. 50

Erythema, iv. 593, 595, 596

Erysipelas, i. 629

Ether, habitual addiction to, v. 667

Etiology, general, i. 125

Eye affections, from diseases of the digestive organs, iv. 749 diseases of the kidneys and skin, iv. 752 general system, iv. 800 nervous system, iv. 771, 796, 797, 799 respiratory organs, iv. 748 sexual organs, iv. 755 spinal cord, iv. 792 mental affections, iv. 791

Eye-ground and appendages, changes in, from diseases of the circulatory apparatus, iv. 738

Facial atrophy, progressive unilateral, v. 694 nerve, peripheral paralysis of, v. 1202 spasm, painless, v. 462

Fallopian tubes, dropsy of, iv. 295

Farcy, i. 909

Favus, iv. 715

Fibroma, iv. 686

Filaria medinensis, iv. 732

Fistulo in ano, ii. 897

Flea, common, iv. 733

Flea, sand-, iv. 732

Fluke-worms, iii. 946

Furunculus, iv. 604 of external auditory canal, iv. 813 of labia, iv. 362

Gad-fly, iv. 732

Gall-stones, ii. 1058

Gangrene, symmetrical, v. 1257

Gastralgia, ii. 459, v. 1238

Gastric catarrh, acute and chronic, ii. 463, 470

Gastritis, acute and chronic, ii. 463, 470

Gastromalacia, ii. 618

Gastrorrhagia, ii, 580

Genito-urinary System, Diseases of, iv. 17

Glanders, i. 909

Glossanthrax, ii. 368

Glossitis, acute, ii. 354-366 chronic, ii. 366-368

Glottis, œdema of, iii. 112 spasm of, in adults, iii. 74

Glycosuria, hepatic, ii. 973

Gnats, iv. 733

Goitre, iii. 974 exophthalmic, iii. 761

Gout, ii. 108

Graves' disease, iii. 761

Great Vessels and Heart, Congenital Anomalies of, iii. 687

Guinea-worm, iv. 732

Hæmatoma of the dura mater, v. 707

Hæmaturia, iv. 104

Hæmoglobinuria or Hæmatinuria, iv. 104

Hæmopericardium, iii. 788

Hæmophilia, iii. 931

Hæmoptysis, iii. 266

Hæmothorax, iii. 582

Hair, atrophy of, iv. 682 blanching of, iv. 678

Harvest mite, iv. 731

Hay Asthma, iii. 210

Headache, v. 402, 1216, 1230

Heart, adventitious products of, iii. 637 aneurism of, iii. 636 atrophy of, iii. 618 dilatation of, iii. 630 diseases of substance of, iii. 601 fibroid, iii. 607 hypertrophy of, iii. 619 malformations of, affecting primarily left side of, iii. 707 malformations of, affecting primarily right side of, iii. 702 malpositions of, iii. 601 murmurs, iii. 651 neuroses of, iii. 747 spontaneous rupture of, iii. 617 Valvular Diseases of, iii. 639 and Great Vessels, Congenital Anomalies of, iii. 687 clot, iii. 718 muscle, degeneration of, iii. 609

Heart's action, functional disorders of, iii. 747

Heat, Acute Affections produced by, v. 387

Hemorrhoids, ii. 882

Hepar adiposum, ii. 1046

Hepatic artery, aneurism of, iii. 840 calculi, ii. 1058 colic, ii. 1058 glycosuria, ii. 973

Hepatitis, interstitial, ii. 990 suppurative, ii. 1002

Hernia, cysto-vaginal, iv. 377 pudendal, iv. 398 recto-vaginal and entero-vaginal, iv. 378

Herpes iris, iv. 609 simplex, iv. 607 zoster, iv. 610

Hirsuties, iv. 669

Hodgkin's disease, iii. 921

Hydatid tape-worm, ii. 943

Hydatids of liver, ii. 1101 pulmonary, iii. 466

Hydrocele or cyst of the canal of Nuck, iv. 397

Hydrocephalus, chronic, v. 704

Hydro-nephrosis, iv. 56

Hydro-pericardium, iii. 789

Hydrophobia and Rabies, i. 886

Hydrothorax, iii. 570

Hygiene, i. 173

Hymen, atresia of, iv. 374

Hyperidrosis, iv. 583

Hypertrichosis, iv. 669

Hypertrophy, v. 1271

Hypnotism, v. 373

Hypochondriasis, v. 154

Hypostatic Pneumonia, iii. 258

Hysteria, v. 205

Hystero-epilepsy, v. 288

Ichthyosis, iv. 666

Icterus, ii. 975

Idiocy, v. 138

Imbecility, intellectual, v. 138

Impetigo, v. 651, 652

Indigestion, ii. 436 intestinal, ii. 620

Infantile Spinal Paralysis, v. 1113

Inflammation, i. 37; v. 1273

Influenza, i. 851

Insanity, v. 99 from gross lesions of the brain, v. 202 specific poisons, v. 175

Insanities, complicating, v. 174

Insomnia, v. 379

Intercranial hemorrhage, etc., v. 917

Intermittent fever, i. 592

Intestinal Affections of Children in Hot Weather, ii. 726 catarrh, acute, ii. 667 chronic, ii. 699 colic, ii. 658 indigestion, ii. 620 obstruction, ii. 830 ulcer, ii. 823 worms, ii. 930

Intestines, Cancer of, ii. 868 Lardaceous Degeneration of, ii. 874

Intussusception and invagination, ii. 844

Ixodes, iv. 733

Jaundice, ii. 925

Katatonia, v. 166

Keloid, iv. 685

Keratosis pilaris, iv. 660

Kidneys, abnormalities of, in shape, size, position, etc., iv. 19 Bright's disease of, iv. 72 chronic congestion of, iv. 69 cysts of, iv. 63 diseases of parenchyma of, iv. 69 floating, iv. 21 malignant growths of, iv. 60 parasites and tuberculosis of, iv. 64 and Pelvis, Diseases of, iv. 19

Kleptomania, v. 147

Labia, furuncles of, iv. 362 majora, phlegmonous inflammation of, iv. 391

Labio-glosso-laryngeal Paralysis, Progressive, v. 1169

Laryngismus stridulus, iii. 70

Laryngitis, Acute Catarrhal (False Croup), iii. 92 chronic, iii. 121 Pseudo-membranous (True Croup), iii. 100

Laryngoscopy and Rhinoscopy, iii. 19

Larynx, anæsthesia of, iii. 65 chorea of, iii. 76 Diseases of, iii. 109 disorders of motion of, iii. 69 hyperæsthesia of, iii. 62 morbid growths of, iii. 127 neuroses of, iii. 59 œdema of, iii. 112 paræsthesia of, iii. 63 paralysis and paresis of, iii. 78 perichondritis and chondritis of, iii. 117 spasm of, in children, iii. 70

Lead-poisoning, Chronic, v. 678

Lentigo, iv. 658

Leprosy, i. 785

Leptomeningitis, v. 716

Leptus, iv. 731

Lethargy, v. 384

Leucoderma, iii. 908

Leukæmia, iv. 697

Lichen ruber and scrofulosus, iv. 623, 624

Lithæmia, ii. 968

Liver, abscess of, ii. 1002 acute yellow atrophy of, ii. 1023 amyloid, ii. 1040 carcinoma of, ii. 1033 cirrhosis of, ii. 990 Diseases of, ii. 965 fatty degeneration of, ii. 1046 flukes, ii. 1109 hyperæmia of, ii. 982 parasites of, ii. 1101 the, in phosphorus-poisoning, ii. 1030

Localization of Lesions in the Nervous System, v. 65

Lung, Abscess of, iii. 296 brown induration of, iii. 256 cancer of, iii. 460 cirrhosis of, iii. 440 collapse of, iii. 251 congestion and œdema of, iii. 258 gangrene of, iii. 301 Syphilitic Disease of, iii. 447

Lupus erythematosus, iv. 689 vulgaris, iv. 693

Lymphangioma, iv. 689

Lymphangitis, simple, iii. 983

Macroglossia, ii. 349

Malarial Fever, Pernicious, i. 605

Malarial Fevers, i. 589 Hæmaturia and Hæmoglobinuria, iv. 107

Malignant Pustule, i. 926

Mania, v. 161

Mastoid disease, iv. 833

Measles, i. 557

Mediastinum, diseases of, iii. 861

Melæna neonatorum, ii. 832

Melanæmia, iii. 896

Melancholia, v. 155

Menière's disease, iv. 839

Meningeal hemorrhage, cerebral, v. 710 spinal, v. 754

Meningitis, cerebral, acute simple, v. 716 chronic, v. 721 tubercular, v. 723 in the adult, v. 737 acute and chronic spinal, v. 749, 752

Menopause, functional disorders in connection with, iv. 432

Menorrhagia, iv. 200

Mental defects and degenerations, v. 138

Mental diseases, v. 99 organic, v. 176

Mesenteric artery, inferior and superior, diseases of, iii. 836, 839

Metritis, acute, iv. 447 chronic, iv. 450

Microcephalism, v. 138

Migraine, v. 406, 1216, 1230

Miliaria, or prickly heat, iv. 654

Milium, iv. 592

Mitral regurgitation, iii. 669 stenosis, iii. 665

Molluscum epitheliale or contagiosum, iv. 661 fibrosum, iv. 686

Morbid growths, i. 105 processes, general, i. 35

Morphœa, iv. 672

Mosquitoes, iv. 733

Mouth, hemorrhage from, ii. 370 and Tongue, Diseases of, ii. 321

Mumps, i. 620

Muscular atrophy, progressive, iv. 540 system, diseases of, iv. 327

Myalgia, iv. 529

Myelitis, acute simple, v. 810 chronic, v. 886

Myocarditis, acute and chronic, iii. 604, 607

Myoma, iv. 687

Nævus pigmentosus, iv. 666

Nail, atrophy of, iv. 683 hypertrophy of, iv. 669

Nasal catarrh, chronic, ii. 42 passages, diseases of, iii. 42 morbid growths of, iii. 52

Nematodes or thread-worms, ii. 949

Nephritis, acute diffuse, iv. 82 acute parenchymatous, iv. 78 chronic diffuse, iv. 84 parenchymatous, iv. 80 suppurative, iv. 99

Nerve, fifth, neuralgia of, v. 1232

Nerves, affections of, in Medical Ophthalmology, iv. 771 of second pair of, iv. 771 of third pair of, iv. 780 of fifth pair of, iv. 785 of sixth pair of, iv. 789 of seventh pair of, iv. 790 peripheral, diseases of, v. 1176 injuries of, v. 1182

Nervous system, diseases of, general principles of diagnosis of, v. 59 general semeiology of, v. 19 motory symptoms of, v. 42 psychic symptoms of, v. 19 sensory symptoms of, v. 31 trophic symptoms of, v. 54

Neuralgia, v. 1212 of the fifth nerve, v. 1232

Neurasthenia, v. 353

Neuritis, v. 1189 multiple, v. 1195

Neuroma, iv. 686

Neuromata, v. 1208

Neuroses, Trophic, v. 1241, 1266 Vaso-motor, v. 1242

Night-terrors, v. 370

Œdema, laryngeal, iii. 112

Œsophagitis, acute and chronic, ii. 409, 416

Œsophagus, Diseases of, ii. 409

Œstrus, iv. 732

Onychauxis, iv. 669

Oöphorectomy, iv. 290

Opium Habit, the, and Kindred Affections, v. 647

Ophthalmitis, febrile and post-febrile, iv. 761

Ophthalmology, Medical, iv. 737

Optic nerve, affections of, iv. 771

Otology, Medical, iv. 807

Ovarian cysts, extra-, iv. 293

Ovarian tumors, iv. 297

Ovaries and Oviducts, Diseases of, iv. 282 malformations of, iv. 282 removal of both, iv. 237

Ovaritis, acute and chronic, iv. 283, 284

Ovariotomy, iv. 313

Ovary, cystic tumors of, iv. 301 dermoid cysts of, iv. 299 fibroid tumor of, iv. 297 hernia of, iv. 289 malignant disease of, iv. 298 prolapse of, iv. 286

Oviducts, cysts of, iv. 295, 296

Oxyuris vermicularis, ii. 950

Pachymeningitis, acute spinal, v. 747 chronic spinal, v. 748 external, v. 704 hemorrhagic, v. 707 internal, v. 706

Pancreas, degenerations of, ii. 1128 Diseases of, ii. 1113 hemorrhage into, ii. 1129 morbid growths of, ii. 1123

Pancreatic duct, obstruction of, ii. 1129

Pancreatitis, acute idiopathic, ii. 1118 chronic interstitial, ii. 1121

Paralalia, v. 571

Paraldehyde, habitual addiction to, v. 666

Paralysis Agitans, v. 433 Cerebral, v. 917 general, of the insane, v. 176 Infantile Spinal, v. 1113 Pseudo-hypertrophic, iv. 557

Parametritis, iv. 209

Paratyphlitis, ii. 814

Parotitis, i. 620

Parovarium, cysts of, iv. 293

Pathology, General, i. 33

Pediculosis, iv. 728

Pelvic hæmatocele, iv. 239 Peritoneum and Cellular Tissue, Inflammation of, iv. 208

Pemphigus, iv. 656

Perianal and perirectal abscesses, ii. 985

Pericarditis, iii. 769 chronic, iii. 784 tubercular, iii. 793

Pericardium, adherent, iii. 785 diseases of, iii. 769

Pericardial effusions, operative treatment of, iii. 794

Perihepatitis, ii. 982

Perimetritis, iv. 227

Perinephritis, iv. 102

Perisplenitis, iii. 964

Peritoneum, hemorrhage into, ii. 1180

Peritonitis, acute, ii. 1133 cancerous, ii. 1168 chronic, ii. 1161 local, ii. 1159 infantile, ii. 1172 tubercular, ii. 1165

Perityphlitis, ii. 814

Pertussis, i. 836

Pharyngitis, acute, tubercular, chronic, and syphilitic, ii. 390, 400, 402, 406

Pharynx, Diseases of, ii. 390

Phlebitis, iii. 843

Phlebolithes, iii. 853

Phlegmasia dolens, iii. 843

Phosphoridrosis, iv. 585

Phthisis, fibroid, iii. 440 pulmonary, iii. 391

Pia mater, cerebral, congestion of, v. 715

Piles, ii. 882

Pityriasis, iv. 621, 622

Plague, the, i. 771

Plethora, iii. 886

Pleura, Diseases of, iii. 483

Pleural cavity, growths in, iii. 583

Pleurisy, iii. 483 diaphragmatic, iii. 568 double, iii. 562 hemorrhagic, iii. 565 multilocular, interlobular, mediastinal, and rheumatic, iii. 564 purulent, iii. 539 tubercular, iii. 569

Pneumonia, catarrhal, iii. 353 croupous, iii. 307 hypostatic, iii. 258 interstitial, iii. 440

Pneumohydro-pericardium, iii. 791

Pneumonokoniosis, iii. 454

Pneumopericardium, iii. 790

Pneumothorax, iii. 573

Polyneuritis, v. 1195

Polyuria or diabetes insipidus, iv. 27

Pompholyx, iv. 655

Portal vein, diseases of, ii. 1095

Pregnancy, disorders of, iv. 405

Prickly heat, iv. 654

Proctitis, ii. 887

Prognosis, general, i. 167

Progressive Muscular Atrophy, iv. 540

Prurigo, iv. 639

Pruritus, iv. 711 ani, ii. 909 vulvæ, iv. 362

Pseudo-hypertrophic paralysis, iv. 551 membranous enteritis, ii. 763 laryngitis, iii. 100

Psoriasis, iv. 614

Psycho-neuroses, v. 153

Pudendal hernia, iv. 398

Puerperal fever, i. 984 tetanus, v. 562

Pulex irritans, iv. 733 penetrans, iv. 732

Pulmonary apoplexy, iii. 293 artery, diseases of, iii. 863 embolism, iii. 373 hydatids, iii. 466 obstruction, iii. 675 phthisis, iii. 391 regurgitation, iii. 676

Purpura, ii. 186

Pyæmia and Septicæmia, i. 945

Pyelitis, calculous and secondary, iv. 47, 53

Pyelo-nephritis, suppurative, iv. 99

Pylephlebitis, suppurative, ii. 1097

Pylorus, hypertrophic stenosis of, ii. 615

Pyopericardium, iii. 790

Rabies and Hydrophobia, i. 886

Rachitis, ii. 137

Rectal alimentation, ii. 928 pouches, dilatation of, ii. 885

Rectum, abscess about, ii. 895 effect of certain poisons and remedies on, ii. 911 hemorrhage from, ii. 890 inflammation of, ii. 887 neuralgia of, ii. 909 non-malignant stricture of, ii. 885 obstruction of, ii. 889 polypi of, ii. 882 rodent and lupoid ulcer of, ii. 889

Rectum and anus, cancer and malignant stricture and ulceration of, ii. 902 Diseases of, ii. 877 prolapse of, ii. 881 scrofulous and tubercular affections of, ii. 901 spasm of, ii. 909 syphilis of, ii. 900 ulceration of, ii. 893, 894

Relapsing Fever, i. 369

Remittent Fever, i. 598

Renal calculus, iv. 42 colic, iv. 42

Reynaud's disease, v. 1257

Rheumatism, acute articular, ii. 19 chronic articular, ii. 46 subacute articular, ii. 69 gonorrhœal, ii. 102 muscular, ii. 74

Rheumatoid arthritis, ii. 78

Rhinoscopy and Laryngoscopy, iii. 19

Ringworm, iv. 717

Rötheln, i. 582

Round ligament, solid tumor of, iv. 296

Rubeola, i. 557

Sanitary science, i. 173

Sarcoma, iv. 710

Scabies, iv. 726

Scarlet Fever, i. 486

Sclerema neonatorum, iv. 671

Scleroderma, iv. 671

Scleroses of the spinal cord, secondary, v. 892

Sclerosis of the spinal cord, amyotrophic lateral, v. 867 combined forms of, v. 869 diffuse, v. 886 disseminated, v. 873 posterior, v. 826

Scrofula, ii. 231

Scrofuloderma, iv. 698

Scurvy, ii. 167

Seborrhœa, iv. 586

Semeiology, General, of Diseases of the Nervous System, v. 19

Seminal Incontinence, iv. 137

Septicæmia and Pyæmia, i. 945

Sewerage and Drainage in their Hygienic Relations, i. 213

Simple Continued Fever, i. 231

Skin, atrophies of, iv. 676 Diseases of, iv. 581 hypertrophies of, iv. 658 inflammations of, iv. 593 neuroses of, iv. 711 new growths of, iv. 685 parasites of, iv. 715 secretions, disorders of, iv. 583

Sleep and its Disorders, v. 363

Smallpox, i. 434

Somnambulism, v. 371

Speech, Disorders of, v. 566

Spina Bifida, v. 757

Spinal Cord, Chronic Inflammation and Degenerative Affections of, v. 825 disease of one lateral half of, v. 1165 diseases of membranes of, v. 746 embolism, thrombosis, hemorrhage, and abscess of, v. 808 Hyperæmia and Anæmia, v. 763 membranes, congestion of, v. 746 meningeal hemorrhage, v. 754 meningitis, acute and chronic, v. 749, 752 paralysis, spastic, v. 801 sclerosis, v. 826, 867 869, 873, 886, 892 syphilis, v. 1022

Spine, concussion of, v. 912

Spleen, diseases of, iii. 962

Splenitis, iii. 962

Stammering and stuttering, v. 571

Steatoma, iv. 592

Stomach, anomalies in form and position of, ii. 617 atrophy of, ii. 616 cancer of, ii. 530 cirrhosis of, ii. 611 Dilatation of, ii. 586, 610 functional and inflammatory diseases of, ii. 436 hemorrhage from, ii. 580 minor organic affections of, ii. 611 non-cancerous tumors of, ii. 578 rupture of, ii. 618 simple ulcer of, ii. 480 ulcers of, other than simple, ii. 529

Stomatitis, ii. 321-348

Stomatorrhagia, ii. 370

Sudamen, iv. 586

Suprarenal Bodies, Diseases of, iii. 939, 949

Sycosis, iv. 649 parasitica, iv. 723

Sympathetic nerve, cervical, diseases of, v. 1263

Symptomatology, general, i. 148

Syphilis cutanea, iv. 699 hereditary, ii. 254

Syphilitic Affections of the Nerve-centres, v. 999

Syphiloderma, iv. 699

Tabes Dorsalis, v. 826 the family form of, v. 870

Tabes Mesenterica, ii. 1182

Tape-worm, ii. 931

Tetanus, v. 544 neonatorum, v. 563 puerperal, v. 562

Thermic Fever, v. 388

Thomsen's disease, v. 461

Thoracentesis, history of, iii. 586

Thorn-head worms, ii. 949

Thread-worms, ii. 949

Thrombosis, cardiac, iii. 718 and embolism, i. 56 of the cerebral veins and sinuses, v. 982

Thrush, ii. 331

Thyroid gland, diseases of, iii. 974

Tinea favosa, iv. 715 sycosis, iv. 723 versicolor, iv. 724

Tongue, hypertrophy of, ii. 399 inflammation of, ii. 354-368 malignant pustule of, ii. 368 ulceration of, ii. 369 vices and abnormalities of, ii. 348 and mouth, diseases of, ii. 321

Tongue-tie, ii. 349

Tonsils, Diseases of, ii. 379

Torticollis, v. 463

Trachea, Diseases of, iii. 133

Tracheitis, simple and complicated, iii. 133, 136

Tracheotomy, iii. 144

Trematodes or fluke-worms, ii. 946

Tremor, v. 429

Trichinosis, ii. 957

Tricuspid regurgitation, iii. 677 stenosis, iii. 671

Trophic Neuroses, v. 1242, 1266

Tuberculosis, i. 94 acute miliary, iii. 472

Tumors of the Brain and its Envelopes, v. 1028 of the Spinal Cord and its Envelopes, v. 1090

Typhlitis, Perityphlitis, and Paratyphlitis, ii. 814

Typhoid Fever, i. 237

Typho-malarial Fever, i. 614

Typhus Fever, i. 338

Ureters, diseases of, iv. 67

Urethra, dilatation of, in women, iv. 355 dislocations of, in women, iv. 361 prolapse of, in women, iv. 362 stricture of, in women, iv. 363

Urethral, caruncle, iv. 403 glands, in women, inflammation of, iv. 354

Urethritis in women, iv. 353, 355

Uridrosis, iv. 588

Urinary organs of women, diseases of, iv. 339

Urticaria, iv. 597

Uterine Functions, Disorders of, iv. 182

Uterus, Cancer of, iv. 274 Diseases of Parenchyma of, iv. 447 displacements of, iv. 147 fibrous tumors of, iv. 245 sarcoma of, iv. 271

Vaccinia, i. 455

Vaccination, i. 465

Vagina, atresia and prolapse of, iv. 376 cicatrices of, iv. 380 Diseases of, iv. 367 double, iv. 381 growths of, iv. 382

Vaginal cystocele, iv. 377 rectocele and enterocele, iv. 378

Vaginismus, iv. 384

Vaginitis, iv. 368

Varicella, i. 481

Variola, i. 434

Varioloid, i. 443

Vaso-motor Neuroses, v. 1242

Veins, diseases of, iii. 843

Verruca, iv. 664

Vertigo, v. 416

Vitiligo, iv. 677

Vocal cords, paralysis of, iii. 85, 86

Vulva, atresia of, iv. 373 diseases of, iv. 388

Vulvitis, iv. 389

Vulvo-vaginal glands, cysts, and inflammation of, iv. 396

Warts, iv. 664

Whooping Cough, i. 836

Wood-ticks, iv. 733

Worms, Intestinal, ii. 930

Writers and Artisans, Neural Disorders of, v. 504

Wry-neck, v. 463

Xanthoma, iv. 687

Yellow Fever, i. 640

END OF VOLUME V.