Read Ebook: A system of practical medicine. By American authors. Vol. 5 by Pepper William Editor Starr Louis Editor

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INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277

ASHHURST, JOHN, JR., M.D., Professor of Clinical Surgery in the University of Pennsylvania.

CONNER, P. S., M.D., Professor of Anatomy and Clinical Surgery in the Medical College of Ohio; Professor of Surgery, Dartmouth Medical College; Surgeon to Cincinnati and Good Samaritan Hospitals, Cincinnati.

DAVIS, EDWARD P., A.M., M.D., Lecturer on Physiology, Rush Medical College, Chicago, and lately Medical Superintendent of the Presbyterian Hospital, Chicago.

EDES, ROBERT T., M.D., Jackson Professor of Clinical Medicine in Harvard University, Boston, Mass.

FOLSOM, CHARLES F., M.D., Visiting Physician for Nervous and Renal Diseases, Boston City Hospital; formerly Assistant Professor of Mental Diseases in Harvard University, Boston.

HAMILTON, ALLAN MCLANE, M.D., Consulting Physician to the New York City Male and Female Insane Asylums; Hudson River State Asylum for the Insane; Consulting Neurologist to Hospital for Ruptured and Crippled; Attending Physician to Hospital for Nervous Diseases; Member of the New York Neurological Society.

HUNT, WILLIAM, M.D., Surgeon to the Pennsylvania Hospital, and to the Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases.

JACOBI, MARY PUTNAM, M.D., Professor of Therapeutics at the Women's Medical College, New York.

LEWIS, MORRIS J., M.D., Physician to the Episcopal Hospital and to the Children's Hospital; Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases, Philada.

LLOYD, JAMES HENDRIE, A.M., M.D., Instructor in Electro-Therapeutics in the University of Pennsylvania.

LYMAN, HENRY M., A.M., M.D., Professor of Physiology and of Diseases of the Nervous System in Rush Medical College, Chicago; Professor of Theory and Practice of Medicine in the Woman's Hospital Medical College, Chicago; one of the Attending Physicians to the Presbyterian Hospital, Chicago, Ill.

MILES, FRANCIS T., M.D., Professor of Physiology and Clinical Professor of Diseases of the Nervous System, University of Maryland, Baltimore.

MILLS, CHARLES K., A.M., M.D., Professor of Diseases of the Mind and Nervous System in the Philadelphia Polyclinic and College for Graduates in Medicine; Lecturer on Mental Diseases in the University of Pennsylvania; Neurologist to the Philadelphia Hospital.

MINOT, FRANCIS, M.D., Hersey Professor of the Theory and Practice of Physic in Harvard University; Physician to Massachusetts General Hospital.

MITCHELL, S. WEIR, M.D., Member of the National Academy of Sciences; President of the College of Physicians of Philadelphia.

PUTNAM, JAMES J., A.B. , M.D. , Physician to Out-patients at the Massachusetts General Hospital; Clinical Instructor at Harvard Medical College.

SCHMIDT, H. D., M.D., Pathologist to the Charity Hospital of New Orleans.

SEGUIN, EDWARD C., M.D., Clinical Professor of Diseases of the Mind and Nervous System in the College of Physicians and Surgeons, New York City.

SINKLER, WHARTON, M.D., Physician to the Philadelphia Orthopaedic Hospital, and Infirmary for Nervous Diseases.

SPITZKA, E. C., M.D., Consulting Neurologist to the North-eastern Dispensary, and Physician to the Department for Nervous Diseases of the German Poliklinik.

STARR, M. ALLEN, M.D., PH.D., Professor of Diseases of the Mind and Nervous System, New York Polyclinic; Attending Physician to Department of Nervous Diseases, Demilt Dispensary.

WILSON, JAMES C., A.M., M.D., Physician to the Philadelphia Hospital, and to the Hospital of the Jefferson College; President of the Pathological Society of Philadelphia.

WOOD, HORATIO C., M.D., LL.D., Clinical Professor of Diseases of the Nervous System and Professor of Materia Medica and Therapeutics in the University of Pennsylvania; Neurologist to the Philadelphia Hospital; Member of the National Academy of Sciences.

FIGURE PAGE 1. DIAGRAM SHOWING THE ARC FOR REFLEX ACTION . . . . . . . . . . 51

DISEASES OF THE NERVOUS SYSTEM.

GENERAL SEMEIOLOGY OF DISEASES OF THE NERVOUS SYSTEM; DATA OF DIAGNOSIS.

BY E. C. SEGUIN, M.D.

ABNORMAL EMOTIONAL STATES.--Emotional manifestations, spontaneous or provoked from without, are, in the civilized adult, held in check directly or indirectly by the will, or by so-called strength of character. Extreme variations are allowed as being within the normal, from the stupidity of the peasant and the impassability of the hero to the sensitiveness and almost unrestrained reactions of the child or of the artist. Each individual must be judged by his own and his racial and family standards in this respect. It is more particularly when the dulness or over-active state observed is in contrast with the subject's habitual demeanor that the condition is called pathological.

Emotional dulness, or the complete absence of any emotional manifestation, may depend upon diminished sensibility to external influences; sluggishness of cerebral action, more especially in the range of sensori-ideal processes, or to general want of intelligence; absorption of the subject's cerebral powers in some special object, real or delusive. The first form is illustrated in various grades of idiocy and backwardness; the second, in fatigue, prostration, and in conditions of dementia; the third is well exemplified in cases of insanity where the patient is devoted to one delusion or dominated by hallucinations , in which case the subject may be told the most painful news, insulted most grievously, or threatened fearfully without manifesting grief, anger, or fear. In some instances absolutely no emotional life can be detected.

Emotional exaltation may be due to increased sensibility to external influences; to deficient self-control. The first condition is illustrated in neurasthenic and hysterical subjects and in forms of mania: slight or almost imperceptible provocations call forth reaction, a noise causes fear, a look anger or tears, etc.; the second mechanism is apparent in diseases where the cerebral hemispheres are extensively diseased and the cerebral power lessened , and in cases of simple debility or asthenia, as when we see a previously mentally strong man shed tears or start most easily in convalescence from acute disease.

It may also be stated, in general terms, that the emotions are manifested in inverse ratio to the subject's mental or volitional power. Psychologically, the emotions are intimately related, on the one hand, with sensory functions, and on the other with more purely mental functions. Anatomically, it is probable that emotions are generated in basal ganglia of the brain , in close association with the sensory areas of the cortex cerebri, while the volitional, inhibitory power is derived from regions of the cortex situated frontad. Clinically, we meet with abnormal emotional states in a great many diseases of the nervous system, more especially in hysteria, neurasthenia, and insanity.

DEPRESSION in the psychic sphere manifests itself by the presence of psychic pain , by slowness of emotive reaction and of intellection, and by the predominance of fear, grief, and other negative emotional states. This complex mental state is usually accompanied by corresponding physical symptoms--general debility, reduced muscular strength, slowness of visceral functions, and retarded metamorphosis. The features are relaxed and passive; the posture sluggish, indifferent, or cataleptoid; the animal appetites are reduced. It is seldom that the entire economy does not sympathize with the psychic state. In exceptional cases some emotions are abnormally active, as in hypochondriasis; or there may be abnormally active muscular movements, as in melancholia agitata. Usually, depression is a part of a more complex symptom group, as in hypochondriasis, melancholia, hysteria, the prodromal stage of mania or paralytic dementia, etc.; but sometimes it constitutes a so-called disease--melancholia sine delirio. Although depressed subjects often appear indifferent to their surroundings, and react slowly or not at all, it must not be supposed that their emotions are not subjectively active. They are often abnormally so, and psychic hyperaesthesia coexists with psychalgia. No anatomical seat can be assigned to the processes which constitute this state and the following; their psychic mechanism is unknown.

EXALTATION, or abnormally great mental activity , so-called psyclampsia, manifests itself by a pleased or happy subjective state, by increased reaction to external stimuli, by unusually abundant and rapid ideation, and by a corresponding increase of somatic activity, as shown by apparent excess of muscular power, of circulation, of visceral activity, and of the appetites. The entire being, in certain cases, becomes endowed with additional capacity and power. In the mental sphere this over-activity easily passes into incoherence and verbal delirium, while in the physical sphere it may translate itself into violence. Clinically, exaltation may show itself as an independent morbid state, known as mania sine delirio. It more commonly appears, with other symptoms, in the shape of ordinary mania, of delirium tremens, of dementia paralytica, etc. Exaltation often follows morbid depression, and these two states sometimes alternate for years . Exaltation, even when accompanied by violent muscular action, must not always be considered an evidence of increased nervous power. On the contrary, it is often a result of irritable weakness, and as such indicates a tonic and restorative medication.

Besides common hallucinations with their seeming reality and objectivity, we admit others which are less vivid, which do not startle or frighten the subject, and which are simply the outward projections of the patient's own thoughts . The subject of persecution by imaginary enemies may see around him the faces of his pursuers with appropriate expressions, or hears their insulting or threatening remarks, as outward plastic reproductions of his thoughts; but the patient himself recognizes the want of actual objectivity and clearness in these images. These we call, after Baillarger, psychic hallucinations or pseudo-hallucinations. Similar phenomena are observed in some sane persons under excitement and betwixt sleep and waking.

The mechanism of hallucinations is partly understood, and may be stated as follows: In some few cases a real disorder or defect in the peripheral sense-organ may give rise to false projections; for example, a tinnitus may become transformed into a distinct voice, a scotoma may be the starting-point of false pictures of a man or animal. The simpler hallucinations of pain, cutaneous, muscular, and visceral sensations may originate in irritation of the nerve-trunks . But the general or common genesis of hallucinations is in disordered states of nerve-centres, those for common sensations and the special centres or cortical areas in the brain. Thus, a morbid irritation of the cortical visual area or sphere will give rise to abundant hallucinations of sight; irritation of the auditory sphere to hallucinations of hearing, as sounds and voices, etc. It must be borne in mind that, however pathological hallucinations may be, they arise from the operation of a fundamental physiological law. In health we constantly refer our sensations or transfer them into the external world, thus creating for ourselves the non-Ego. All terminal sensory nerve-endings receive only elementary impressions or impulses from external agencies, and these are perceived and conceived as images, formed sounds, etc. in the appropriate cortical centres; then by the law of reference of sensations these elaborated, idealized conceptions or pictures are thrown outward again and contemplated as objective. In this physiological mechanism lies the kernel of truth which is included in idealism.

Hallucinations may occur without derangement of mind or impairment of judgment. Many instances are on record of transient or permanent hallucinations of various senses in perfectly healthy persons who were fully aware of the unreal character of what they saw or heard. Being of sound mind, they were able to make the necessary correction by reasoning or by the use of other senses. In very many forms of insanity hallucinations are prominent, though they also occur in quasi-sane conditions, as in hypochondriasis, hasheesh, belladonna, and opium intoxication, the stage between sleeping and waking, etc. As long as the subject is able to correct the false projections by reason or by the use of other senses he is considered sane.

Hallucinations are sometimes the cause of acts by the insane, some of them violent and even murderous actions. Hallucinations of sight and hearing are especially prone to lead to assaults, murders, etc. The occurrence for any length of time of acoustic hallucinations in insanity is accounted of bad prognosis.

DELUSIONS are synonymous, in a popular way, with false beliefs. Thus, we often speak of eccentric opinions, of fanatical or extravagant creeds, as delusions. In a certain sense probably all mankind cherish innumerable delusions. In a strictly medical and medico-legal sense, however, the term is applied only to false beliefs in respect to clearly-established, indisputable facts. Thus, a man who believes in Spiritualism or even in metempsychosis, or in the divinity of a certain personage, is not medically deluded; whereas, one who believes that a bare court is a flowering garden or that he himself is divine is deluded. The essential element in the conception of delusion is belief or conviction on the patient's part; and that is why delusions mean that the psychic functions are deeply and seriously impaired. Delusions may be conveniently divided into ideal and sensorial.

Ideal delusions are false ideas or concepts arising more or less spontaneously, or by morbid association in the subject's mind. For example: he believes that he is a god, that he has millions of money, that his soul is lost, that he has a thousand children, etc. Many of the delirious ideas experienced by insane patients are delusions, and so to a certain extent are the notions of hypochondriacs about their health.

Sensorial delusions are such as are founded upon illusions and hallucinations. The moment a subject is convinced of the reality of an illusion or hallucination, believes in its actuality, he is said to have a delusion. The change from illusion and hallucination to the state of sensorial delusion indicates a deeper psychic alteration--a failure of critical capacity or judgment. Examples: A man imagines the stump of a tree in front of him to be a human being, but by reasoning, by closer visual inspection, or by palpation he concludes that it is a tree, after all; this is a simple illusion. If he persists, in spite of argument and demonstration, in his assertion that the stump is a human being, he is said to have a delusion or to be deluded. If a person sees wholly imaginary flowers or hears imaginary voices, as long as he is capable of recognizing the falsity or want of actuality of these images or sounds he has a simple hallucination; if he ceases to make the necessary correction, and believes the flowers and voices to really exist, he has sensorial delusions. It should be borne in mind that sane persons may have hallucinations, and that some insane have no sensorial delusions; also, that some insane are capable of correcting, for a time at least or when closely questioned, their illusions and hallucinations. Apart from these exceptional conditions, delusions, sensorial and ideal, are most important symptoms of insanity. We also meet temporary delusions in toxic conditions and in the delirium of acute general disease, of low febrile states, starvation, etc. Delusions are sometimes named in groups, according to the prevailing type of mental action; then, we have exalted delusions, in which the false notions and beliefs are rose-colored or extremely exaggerated . Again, we speak of delusions of persecutions, where the patient fancies himself pursued, maltreated, insulted, or where he insanely follows up and persecutes others. Such classification is useful for purposes of clinical and psychical study.

Imperative conceptions or controlling morbid ideas and desires are ideal delusions presenting certain peculiarities; one of which is that of growth by accretion and assimilation by a sort of false logic and grotesque analogical reasoning, until from a mere fancy or notion the growth invades and governs the entire subjective life of the subject.

Therapeutically, the question of physical restraint or non-restraint in the management of violence might be discussed here, but the question is one which can be much better considered in connection with the general treatment of insanity, and the reader is consequently referred for information to the article on that subject.

LOSS OF CONSCIOUSNESS, COMA.--Suspension of all sensibility, general and special, with loss of all strictly cerebral reflexes, is met with in many pathological states. Its physiology or mode of production is unknown, but there are good reasons for believing that the lesion, vascular or organic, affects chiefly the cortical substance of the hemispheres. Its clearest manifestation, clinically, is after depressed fracture of the skull or after concussion of the brain, without or with abundant meningeal hemorrhage. In the last case unconsciousness or coma appears as an exaggeration of drowsiness or stupor; after a fall the patient may be able to walk into the hospital, but soon becomes drowsy, then stupid, and lastly completely insensible. In the first case, that of depressed fracture of the skull, the raising of the depressed bone is often followed immediately by return of consciousness; the patient seems to wake as from a deep sleep. In medical practice there are many analogous conditions of abnormal pressure causing coma, as in meningitis, cerebral abscess, hemorrhage, embolism of cerebral vessels, etc. Long-continued or fatal coma may be caused by general morbid states, as uraemia, acetonaemia, surgical hemorrhage, intoxication by narcotics, alcohol, ether, etc., and by asphyxia. Momentary loss of consciousness is induced in the various forms of epilepsy, lasting from a fraction of a second to one or two minutes, followed by the more prolonged coma of the asphyxial stage. Temporary unconsciousness is also caused by physical or moral shock, but in many such cases the heart is primarily at fault, and the condition is termed syncope. Although in practice it is most important to distinguish syncope from more strictly cerebral coma, yet it must be admitted that in both categories of cases anaemia of the brain is the essential factor or immediate cause of suspension of consciousness. This view of the pathology of coma is borne out by the fact that the condition may be produced at will, experimentally or therapeutically, by compression of both carotid arteries. It may be well to mention here the pseudo-coma of hysteria. In these cases consciousness is really present, as shown by responses to violent cutaneous irritations , by quivering of the closed eyelids and resistance to attempts to open them, by vascular or muscular movements evoked by remarks of a flattering or abusive nature made in the patient's hearing, and by cessation of the condition after complete closure of the nose and mouth for forty-five seconds or one minute . In the typically unconscious state, as in cases of fracture of the skull or of intracranial pressure by exudations, clots, tumors, etc., there are several objective symptoms to be noted. The pupils are usually dilated and immovable ; the pulse is reduced in frequency and retarded; it is sometimes full and bounding, or in other cases feeble and irregular. The breathing is often slow and irregular; the patient fills out his cheeks and puffs ; sometimes the Cheyne-Stokes type of respiration is observed. In hysterical or hypnotic impairment of consciousness these important symptoms are absent: the patient seems simply asleep. Although coma is, strictly speaking, a symptom, it so often appears as the leading one of a group that it deserves study almost as a disease. Indeed, there are few more difficult problems for the physician than the case of a comatose subject without a good history of the preceding condition, causes, etc. It is impossible here to consider all the possibilities of this problem in diagnosis; we can only state the chief and most probable pathological conditions which may cause coma.

The patient may be epileptic. The following signs of a past convulsive attack should be sought for: a bitten tongue, fleabite-like ecchymoses on the face, neck, and chest, saliva about the face and neck, evidences of micturition or of seminal emission in the clothing, etc. There is usually a small rise of temperature after a single fit, and consciousness soon returns without assistance, or a second seizure appears.

The patient may be suffering from surgical cerebral compression or concussion. Signs of injury about the head or other parts of the body, oozing of blood or sero-sanguinolent fluid from the ears and nose, will sometimes clear up the diagnosis. Especially suggestive of meningeal hemorrhage is a gradually increasing stupor without distinct hemiplegia.

The coma may be uraemic. In some cases anasarca and slow pulse point at once to this pathological condition. In all comatose cases without history the urine should be drawn with a catheter for testing, and signs of various forms of Bright's disease may be detected. The ophthalmoscope may yield most valuable indications by revealing retinitis albuminurica or neuro-retinitis.

The patient may be under the effects of a clot in the brain or of acute softening of a considerable part of the organ. Hemiplegia with conjugate deviation of the eyes and head is usually present, the head and eyes turning away from the paralyzed side, the patient looking, as it were, toward the lesion. A latent hemiplegic state may sometimes be determined by one-sided redness of the buttock, and by a slight difference of temperature between the two hands . The general temperature of the body exhibits a marked rise. After cerebral hemorrhage there is, according to Charcot and Bourneville, a fall below the normal during the first hour, followed by a steady rise to 106? or 108? F. at death in severe cases. After embolism or thrombosis, causing softening, the rise of temperature is less in extent and not as regularly progressive.

The subject may be simply drunk or poisoned by alcohol. In such a case the patient may usually be roused momentarily by loud speaking, shaking, or by painful impression; the breath is alcoholic; the cerebral temperature subnormal or normal. The urine must be tested for alcohol. It must not be forgotten that on the one hand intoxicated persons are most prone to falls causing fracture of the skull or concussion, and on the other hand that the early stage of coma from meningeal hemorrhage resembles narcosis.

The coma of congestive or malignant malarial fever is to be distinguished mainly by the absence of physical or paralytic symptoms, coinciding with a high rectal temperature. The spleen is often enlarged. Some would add that Bacillus malariae and pigment might be found in the splenic blood, withdrawn by a long, fine needle.

Toxic narcosis, from opiates, morphia, chloral, etc., are often difficult of diagnosis, except that from opiates and morphia, in which extremely slow respiration and contracted pupils, with lowered temperature, point at once to the cause.

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