Nervous diseases and their diagnosis: a treatise upon the phenomena produced by diseases of the nervous system

Front matter

7?

Shelfi

UNITED STATES OF AMERICA.

Preface

By way of apology for again trespassing upon the patience of the profession, the author of the present volume would say that the work is founded upon a hospital service continuous, except for one short period, for twenty-iBve years. Of this service fifteen years were spent in the medical wards of very large military or civil general hospitals, while for the last ten years nervous wards in the Philadelphia Hospital, aggregating one hundred and twenty-five beds, and the nervous clinic of the Hospital of the University of Pennsylvania, comprising over five hundred new cases annually, have been under the charge of the author. In his youthful days he also served as resident physician in an insane asylum, and more recently he has been connected with several such institutions as a consultant.

Notwithstanding this experience, the author would not have ventured to add a new book to the already long list of treatises upon nervous diseases had he not been strongly urged thereto by some of his former pupils, who insisted that the method of teaching which had been gradually evolved in the weekly clinics of the University Hospital was different from that commonly in vogue, and if followed out would give freshness to an old subject.

The defects of the work are perhaps better known to its author than they will be to any of its readers or critics, but they are not the result of lack of honest effort, and if the kindly judgment of brother practitioners should by any chance bring the work to another edition, whatever criticism it may receive

6 PREFACE.

will be thankfully accepted, thoroughly weighed, and duly acted upon.

In conclusion, the author desires to acknowledge his indebtedness to Dr. George E. De Schweinitz for much assistance rendered in various ways and places, but especially in the anatomical portion of the book, in the chapter on Eye Symptoms, and in preparing the index. Thanks are also due Mr. Joseph McCreery for his extraordinarily intelligent and suggestive reading of the proofs.

University of Pennsylvania, January 1, 1887.

Contents

INTRODUCTION. pages

General Discussion of Disease, and of Neurasthenia .... 17-22

Chapter I. Paralysis

Detection of Paralysis.

Functional Palsies, including Reflex, Assumed, and Hysterical Palsies.

Organic Palsies. OeneQ^al Palsies, including Hysterical, Alcoholic, Intermittent, Cerebral, Pons, Bulbar, and Lenticular Palsies. Hemiplegia^ including Spinal, Cerebral, Corpus Striatum, Thalamus Optici, Pons, Facial, Crossed Palsy. Paraplegia, Functional Paraplegia, including Reflex, Renal, and Hysterical Paraplegia. Organic Paraplegia, divided into Abrupt, Subacute, and Chronic Paraplegia. Abrupt Paraplegia, including Apoplexy into the cord and into its membranes, Haematomyelitis. Subacute Paraplegia, including Painful Paraplegia, Ascending Paralysis, Acute Central Myelitis, Multiple Neuritis. Transverse Myelitis, Cervical Pachymeningitis. Chronic Paraplegia, including Chronic Myelitis, Spasmodic Tabes, Amyotrophic Lateral Sclerosis, Multiple Spinal Sclerosis. Monoplegia^ including Hysterical Monoplegia, Double Monoplegia, Cerebral Monoplegia, both Abrupt and Progressive, Peripheral Monoplegia from pressure, as in Crutch Palsy, from disease of the nerves, and from poison. Multiple Palsy ^ divided into Cerebral, including Syphilitic, Sclerotic, and Spastic Infantile Paralysis, and Peripheral, including Diphtheritic Paralysis, Poliomyelitis, Local Muscular Atrophies, Joint Atrophies, Toxaemic Peripheral Palsies, Progressive Muscular Atrophy, and Pseudo-Hypertrophic Paralysis. Local Paralysis^ including Oculo-Motor, Trochlear, Trigeminus, Abducens, Facial, Glosso-Pharyngeal, Spinal Accessory, Long Thoracic, Sub-Scapular, Supra-Scapular, and Circumflex, Anterior Thoracic, Musculo-Cutaneous, Musculo-Spiral, Median, Ulnar, Spinal, Ilio-Hypogastric, Ilio-Inguinal, Intercostal, Anterior Crural, Obturator, Superior and Inferior Gluteal, Sciatic, External Popliteal,

Internal Popliteal, and Post-Tibial Nerves 23-95

8 CONTENTS.

Chapter II. Motor Excitements

PAGES

General Discussion, including definitions of Convulsions, Spasms, Choreic Movements, Tremors, Automatic Movements, and Contractures.

Convulsions, including Epileptiform, Hysteroidal, and Tetanic. Epileptiform Convulsions, including Idiopathic Epilepsy in its various forms, Reflex Epilepsy, Convulsions of Childhood, Pleuritic Epilepsy, Cardiac Epilepsy, Organic Epilepsy, Convulsions from Cerebral Hemorrhage, Epilepsy in General Paralysis, Toxaemic Epilepsy, and Uraemia. Hysteroidal Convulsion, including Minor Hysteria. Tetanic Convulsions, including Hysteria, Tetanus, Trismus Neonatorum, and Tetany. Local Spasms, Spasms of the Muscles of Organic Life, including (Esophageal, Rectal, and Urethral Spasm, Vomiting, Nervous Cough, Phantom Tumor. Spasms of Voluntary Muscles, including Laryngismus Stridulus, Occupation Neuroses, Cortical, Hysterical, Inflammatory, and apparently Causeless Spasms, also Facial Nerve Spasm in its various forms, and Spinal Accessory Spasms.

Tremors, Senile, Toxic, Paralysis Agitans, Multiple Cerebro-Spinal Sclerosis.

Chorea. General Chorea, including St. Vitus's Dance, Reflex Chorea, Chorea of Pregnancy, Hysterical Chorea, Rhythmical Chorea. Local Chorea, including Paralytic Chorea, Chorea of Stumps, Habit Choreas.

Contractures, including Cerebral, Infantile Paralysis, Meningeal, Neuritis, Hysterical, Lateral Sclerosis, and Thomsen's Disease.

Automatic Movements during Chorea Major, Psychical Automatism

and Miryachit 96-179

Chapter III. Reflexes

General Discussion, dividing Reflexes into Superficial and Deep. Superficial Reflexes, including Plantar, Gluteal, Cremaster, Epigastric, Erector-Spinal, Scapular, Palmar, and Cranial. Deep Reflexes, including Knee-Jerk and Ankle-Clonus . . 180-193

Chapter IV

disturbances of equilibration.

General Discussion.

Disturbance of Co-Ordination ; Loss of Co-ordination, including

Locomotor Ataxia, General Paralysis, Multiple Neuritis. TiTUBATiON, including Cerebellar Aff'ections and Rotatory Movements. Vertigo, including Organic, Cardiac, Epileptic, Hysterical, Peripheral,

Special Sense, Toxaemic, and Essential Vertigo .... 194-212

CONTENTS. 9

Chapter V. Trophic Lesions

PAGES

General Discussion, dividing lesions into Acute Destructive and Chronic

Lesions.

Acute Destructive Lesions, including Decubitus, Perforating Ulcer,

and Acute Symmetrical Gangrene.

Chronic Lesions, including those of Skin, Bone, Joints, Muscles, and

Nervous System, as seen in various diseases and poisonings ; also

Glosso-Labial Palsy and Progressive Facial Hemiatrophy . . 213-251

CHAPTEE VI.

SENSORY PARALYSIS.

General Discussion, including Modes and Instruments of Testing.

Visceral Anesthesias, including Throat, Eectum, Vagina, and Bladder.

Cutaneous Anesthesia, Hysterical, Psychic, Organic, and Toxasmic, including Metallotherapy.

Organic Anesthesias, including General Anaesthesia, Hemiansesthesia, Crossed Paralysis, and the Lesions which produce them.

Organic Paranesthesia.

Organic Monoanesthesia.

Local Anesthesias, including discussion of various nerve-distributions . . . 252-280

CHAPTEE VII.

exaltations of sensibility.

General Discussion.

Hyperesthesia. Hysterical Hypersesthesia^ including Genitalia, Breasts, Joints, and Back. Organic Hyper sesthesias.

Paresthesias.

Pain, Neuralgic Temperament. Pains in the Extremities^ including Gouty, Neuritic, Metallic, Spinal, Neuralgic. Trunkal Pains, Keflex, Rheumatic, Toxsemic Pains, Girdle-Pains, also Rectal, Gastric, Intestinal, Genital, Laryngeal, and Cardiac Crises. Head-Pains, Toxaemic Headache, including Rheumatic, Lithaemic, Uraemic, Alcoholic, Caffeinic, Gastric, Diabetic, Cardiac, and Pulmonic. Sympathetic Headaches, including Eye-Strain and Nasal Headaches. Nervous Headaches, including Anaemic, Congestive, and Hysterical Headaches, and Migraine. Face-Pains, Neuralgic, Reflex, Neuritic, Prosopalgic 281-316

10 CONTENTS.

CHAPTER VIII.

DISTUEBANCES OF THE SPECIAL SENSES.

PAGES

Hearing, including Nervous Deafness and Hypersesthesia.

Sight. Movements of the Eye^ including Strabismus, Secondary and Primary Deviation, Simple and Crossed Diplopia, False Projection of the Visual Field, Paralysis of Oculo-Motor, Trochlear, and Abducens Nerves, Ophthalmoplegia Interna and Externa, Associated Ocular Paralysis, Conjugated Deviation of Head and Eyes. Internal Ocular Conditions^ including Choked Disk, Atrophy of the Disk, Irregularities, Keflexes, and other Derangements of the Pupil, Amaurosis. Vision^ including Method of Testing, Functional, Organic, and Toxsemic, Hemianopsia in its various forms.

Taste, including Hypersesthesia, Anaesthesia, and Hallucinations.

Smell, including Hyperaesthesia, Anaesthesia, and Hallucinations . 317-356

CHAPTER IX.

disorders of memory and consciousness.

General Discussion.

"Word-Memory, including Aphonia, Aphaemia, and Aphasia in all its forms ; also Word-Blindness and Word-Deafness.

General Memory, including Exaltation and Failure of Memory.

Correlated Disorders of Memory and Consciousness, including Loss of Personal Identity, Double Personality, and Double Consciousness, or Periodic Amnesia, also Double Perception . . 357-376

CHAPTER X.

disorders of consciousness.

General Discussion.

Sudden Loss of Consciousness, including Hysterical, Epileptic, and Syncopal Loss of Consciousness, Sunstroke in both its forms. Apoplexy and Unconsciousness from Indirect Causes, such as Alcohol, Opium, and Uraemic and other poisons, and from Malaria, Emotional Excitement, and Acute Systemic Disorders.

Sleep, its Disorders and Accidents. Abnormal Wakefulness.

Morbid Sleep, including Coma-Yigil and other affections of Sleep in acute fevers, Nelavan, Trance or Lethargy, Catalepsy, Lucid Lethargy, Epileptic Sleep, Reflex Unconsciousness, Narcolepsy, Hysterical Sleep, Hypnotism, Sleep during Insanity, Toxaemic Sleep, such as Uraemic and Diabetic Coma.

Organic Stupor, or Coma. Non-Specific Stuporous Affections with Headache^ including Brain-Tumor, Meningitis, Pachymeningitis Haemorrhagica. Specific Stuporous Affections^ including Fulminating and gradually-developed Syphilitic Coma. Organic Stuporous Affections without Headache^ including Polioencephalitis.

Accidents of Sleep, including Sense- Shock, Night-Palsy, Somnambulism, Night-Terrors 377-419

CONTENTS. 11

CHAPTER XI.

DISTURBANCES OF INTELLECTION.

PAGES

General Discussion, including Abulia, Hyperbulia, Increase and Failure of the Mental Powers, Incoherence, Character, Hallucinations and Illusions, Delusions, Imperative Conceptions, Morbid Impulses and Morbid Desires, Nymphomania, Erotomania, Delirium in acute constitutional diseases, Classification of Insanity.

Complicating Insanities, including Acute and Chronic Meningitis, Acute and Chronic Periencephalitis, and Cerebral Sclerosis.

Diathetic Insanities, including Gouty, Epileptic, Hysterical, Syphilitic, Alcoholic (Delirium Tremens and Chronic Insanity).

Pure Insanities. Complete Insanities. Complete Non-Periodic Insanities, including Mania, Acute and Chronic ; Melancholia, Acute and Chronic; Katatonia; states of Mental Deterioration, such as Organic Dementias, Hebephrenia, Senile Dementia, Dementia of Cerebral Shock, Primary Confusional Insanity, Stuporous Insanity, Terminal Dementia ; Periodic Insanities, such as Periodic Mania, Periodic Melancholia, Circular Insanity. Incomplete Insanities^ including Monomania and Mania of Character 420-492

Introduction

The primary meaniDg of the word ^^ disease'^ is pain, uneasiness, or distress. In its derived or secondary significance it is defined by Webster as a deviation from health in function or in structure. In modern medicine the term has come to have a still more restricted technical meaning, being used to signify a simple or complex pathological process which is complete in itself. Thus, a simple enteritis is a disease ; but the enteritis of typhoid fever is a part of a complex pathological process which constitutes the disease known as typhoid fever. When the term disease is, as it ought to be, used in this narrow sense, the diseases of the nervous system are far fewer than the number usually assigned by standard authorities upon the subject.

The symptoms produced by pathological processes or diseases depend upon their seat ; and whilst it may be necessary to consider acute inflammation of the brain as a diflferent disease from an acute inflammation of the spinal cord, the various parts of the nervous system are so interwoven that we cannot draw lines between the various affections. Thus, a chronic poliomyelitis affecting certain regions of the medulla oblongata gives rise to the so-called glosso-labial paralysis, but when affecting the lower portions of the spinal cord it produces progressive muscular atrophy. Not rarely, however, both regions are simultaneously attacked, when, in deference to an unscientific and misleading nomenclature, the patient is said to suffer from two distinct diseases.

Partly led by considerations such as those just stated, and partly as the result of the exigencies of clinical teaching, in the course of years I have gradually adopted a method of instructing students which has seemed to me more in accord with the everyday needs of the medical practitioner, and more apt to lead to a practical understanding of diseases of the nervous system, than is that adopted in the ordinary treatises upon the subject. When

2 17

18 INTRODUCTION.

a case offers itself for examination, the physician raust needs travel from the symptoms back to the lesion, and not from the lesion to the symptoms. He does not say, this man has a clot in the brain, therefore he has hemiplegia, but he begins with the paralysis, and passes from it by the process of induction to the lesion. Hitherto the authors of text-books have travelled from the lesion to the symptoms. The present treatise is an attempt to follow the route which the practitioner must pass over daily.

Before entering upon the discussion of the individual symptoms produced by diseases of the nervous system it seems to me necessary to consider the subject of neurasthenia^ or nervous weakness, because the symptoms of this state are so indefinite and fugitive that it is almost impossible to marshal them into order.

Much effort has of recent time been wasted in attempting to make of neurasthenia a disease. It is a bodily condition which is frequently associated with various chronic disorders, and not rarely coexists with perverted functional activity of the nervous centres, which perverted nerve-functions may, however, exist independently of any perceptible neurasthenia, and are not simply the outcomes of the neurasthenia. It is an hal)itual foundation for hysteria, chorea, insanity, and various nervous diseases, but may exist without the superaddition of any of them.

The onset of neurasthenia is always gradual, although at times the condition appears to develop with great suddenness. Under these circumstances, however, the explosion has been preceded by a long train of more or less overlooked phenomena: thus, a gentleman who had long suffered from the premonitory symptoms of neurasthenia was one day seized with violent vertigo, accompanied by such prostration of strength that he had to be taken home from the street in a carriage. The symptoms vary greatly according to the portion of the nervous system which is especially affected, and also to some extent according to the etiology of the attack. Nervous exhaustion may in the beginning affect the whole of the nervous system, or it may be at first purely local and coexist with general nervous strength. Many cases of spermatorrhoea are instances of the local form of neurasthenia, the sexual centres being primarily affected; but as in these cases, sooner or later, the whole of the nervous system becomes implicated, so in other forms of the disorder the exhaustion, at first local, finally, if

INTKODUCTION. 19

neglected, implicates the whole organism. There are not rarely cases of brain-exhaustion in which the symptoms are at first purely local. Almost always the cause of a local neurasthenia is excessive use of the part : thus, cerebral asthenia is usually the result of mental overwork, sexual asthenia of sexual excesses, etc. When to the intellectual fatigue are added the depressing eifects of excessive anxiety or allied emotions, the symptoms from the first are more general. The exhaustion may affect chiefly a single function of the brain. As an instance may be cited the case of a postal clerk under my care, who has been accustomed to distribute five to eight thousand letters every day from a general mass into three hundred pigeon-holes, representing as many post-office districts, scattered over a large territory. As soon as the address is read there must be an instantaneous automatic recognition of the district to which the letter goes. It is at this place that, in the case now under consideration, the symptoms manifest themselves. Reading the address fails to produce immediate recognition of the locality to which the letter is to be assigned. Asked in what district such a post-office is, the clerk answers instantly, but seeing the address himself he hesitates, and sometimes balks so that he can distribute only about one-third as many letters as when in health. As in most cases of local nerve-exhaustion, in this patient some evidences of general implication exist, there being decided disturbance of the sexual organs.

A form of local neurasthenia which is frequently associated with brain-exhaustion is writer^s cramp. I have repeatedly seen it come on as the herald of a general break-down ; but under such circumstances the symptoms have usually not been those of typical writer's cramp : there have been not so much marked spasms as loss of power and distress in the arm on attempting to write.

In pure brain-exhaustion loss of the disposition to work is usually the first symptom, the sufferer finding that it constantly requires a more and more painful effort of the will to perform the allotted task. The basis of this difficulty is largely loss of the power of fixing the attention, and this by and by is accompanied by weakness of the memory. Disturbances of sleep are frequent. Various abnormal sensations in the head are complained

20 INTRODUCTION.

of. In most cases there is not absolute headache, but a feeling of weight or fulness, or an indescribable distress, usually aggravated by mental eflPort.

It is true that in some cases of very dangerous brain-tire cerebration is performed with extraordinary vigor and ease; the power of work is for the time markedly increased, and even the quality of the product may be raised ; the patient may glory in a wild intellectual exaltation, a sense of mental power, with an almost uncontrollable brain-activity. It is probable, however, that these cases are not instances of pure neurasthenia, but that there is an active congestion of the cortical gray matter. It is certain that they are very prone to end in serious organic braintrouble. In some cases of cerebral asthenia there are disturbances of the special senses, tinnitus aurium, flashes of light, and even the seeing of visions. Under these circumstances it is again probable that active congestion of the affected centres exists.

Severe cerebral neurasthenia may be associated with good spirits, but usually there is marked depression, and this perversion of function may finally go on to decided melancholy. The will-power, like all the other functional activities of the brain, is prone to be weakened ; morbid fears may finally develop ; and at last that which was at the beginning a simple brain-exhaustion may end in hypochondriasis or insanity. According to my own experience, such ending is, however, very rare, unless there is an inherited tendency to insanity.

Disturbances of sensation are common in neurasthenia, these disturbances taking the form in many instances of itchings or formications or similar minor ills. Neuralgia is often severe and its attacks frequent, but I am convinced that something more than simple nervous exhaustion is responsible for its production. I believe that there is a neuralgic diathesis or temperament which is often associated with neurasthenia, but may exist without it, and which probably has, at least in many cases, relations to a gouty ancestry. When such temperament exists, the neuralgic attacks are greatly aggravated by the coming on of neurasthenia. Hypersesthesia and anaesthesia mark the line where simple neurasthenia passes into hysteria. The same also is true of the peculiar tenderness over the spinal processes of the vertebrae, which is especially frequent in women, and is the chief symptom

INTRODUCTION. 21

of the so-called spinal irritation or spinal ansemia, — an affection which I believe to be a form of neurasthenia allied to hysteria.

In neurasthenia disturbances of the sexual organs are very common; in women great pain on menstruation, ovarian irritation, the so-called irritable uterus of Hodge, are closely connected with general nerve-weakness. In not a small proportion of the cases of uterine disorders which are locally treated, I believe the local disease is largely the expression of the general condition. It is well known that masturbation and sexual excess in the male may produce an exhaustion of the nerve-centres especially implicated, and also a general nervous exhaustion. This is the common history of spermatorrhoea. It is no less true that a general neurasthenia may produce a local weakness of the sexual centres, with symptoms at least resembling those of spermatorrhoea, — namely, great irritability of the sexual organs, with a practical impotence due to immediate seminal discharge whenever coition is attempted. I have certainly seen this condition result from excessive intellectual labor when there has been no sexual excess, and at a time when the muscular strength was still good. Such cases may, perhaps, be distinguished by the fact that unprovoked emissions are not nearly so apt to occur as in true spermatorrhoea.

In cases of nervous exhaustion the efforts of the diagnostician are chiefly directed to determining the cause of the exhaustion. In a very considerable proportion of cases which have been sent to me as suffering from simple neurasthenia, chronic malaria, chronic diarrhoea, Bright's disease, or other serious organic affection has existed : it is therefore essential that in every case of alleged neurasthenia a thorough examination be made to detect latent chronic disease. When no such disease can be found, the cause of the neurasthenia should be recognized. In rare cases it develops in women, without perceptible cause, at pubescence or at the climacteric.

Overwork, especially overwork combined with worry, and even continuous emotional depression, unaided by excessive work, are capable of producing a pure neurasthenia. As Samuel Jackson was accustomed to say, in his lectures at the University of Pennsylvania thirty years ago, ^^ Whenever the expenditure of nerve-force is greater than the daily income, physical bankruptcy sooner

22 INTRODUCTION.

or later results/^ It is to be remembered that the nerve-capital of persons differs almost as widely as does their moneyed capital. There are numerous families many of whose members are neurasthenics from birth, — Le,, are born with less power of creating nervous energy than is necessary to meet the requirements of the ordinary duties of life. There is every grade of natural endowment between the most feeble person, scarcely able to produce more nervous energy than is necessary for breathing, eating, and drinking, and the organism that is capable of enduring incessant toil. The development of neurasthenia is therefore not so much the result of a strain which is absolutely great, as of a strain which is excessive in its relations to the organism which has to bear it. I have seen not a few cases in which the neurasthenia has appeared to me to be an expression of premature old age. In such cases the rigid, atheromatous radial arteries occurring in a non-gouty or non-syphilitic subject have pointed to a similar excessive ripeness of tissue throughout the body.

DIAGNOSTIC SYMPTOMATOLOGY

OF

NERVOUS DISEASES.