Charles L. (Charles Loomis) Dana.

Text-book of nervous diseases, for the use of students and practitioners of medicine online

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PLATE I



NERVOUS DISEASES

DANA




The Fiest Formal Union of Neuro- anatomy and Art. {Ste-phmius, 1545.)

" The avulsed calvarium hangs from a tree, showing the dura mater."



TEXT-BOOK

OF



NERVOUS DISEASES



FOR THE USE OF STUDENTS AND
PRACTITIONERS OF MEDICINE



BY
CHARLES L. DANA, A. M., M. D., LL. D.

PROFESSOR or NERVOUS DISEASES IN CORNELL UNIVERSITY MEDICAL COLLEGE; CONSULTING PHYSICIAN
TO BELLEVUE HOSPITAL; NEUROLOGIST TO THE MONTEPIORE HOSPITAL; NEUROLOGIST TO
THE woman's hospital; consulting PHYSICIAN TO THE MANHATTAN STATE
hospital; EX-PRESIDENT OP THE AMERICAN NEUROLOGICAL ASSOCIATION;
EX-PRESIDENT OP THE NEW YORK ACADEMY OP MEDICINE; CORRE-
SPONDING MEMBER or THE SOCIETE DE NEUROLOGIE, ETC.



EIGHTH EDITION



WITH TWO HUNDRED AND SIXTY-TWO ILLUSTRATIONS,
INCLUDING FOUR PLATES IN BLACK AND COLOR

\



NEW YORK

WILLIAM WOOD AND COMPANY

MDCCCCXV






Copyright, 1915, by
WILLIAM WOOD AND COMPANY



XHE MAPIiE PKESS YOKK FA



PREFACE TO THE EIGHTH EDITION

When the first edition of my book was published twenty-three years
ago there was no adequate description of the anatomy of the nervous
system in the English language. Hence, feeling the fundamental im-
portance of this subject to an understanding of neurology, I gave much
space to it. This need of anatomical knowledge of the nervous system
is now abundantly supplied by general and special text-books. I have,
therefore, left out a good deal of this part of my text. I have retained
and revised what was especially useful in diagnosis and for reference,
and have also changed, added to and improved the illustrations. In
this I have received help and skilled supervision from Dr. J. F. Guder-
natsch, of the Anatomical Department of Cornell University.

A large part of the rest of the book has been completely remodeled
and rewritten. This applies to the chapters on syphilis of the nervous
system, including paresis, tabes and the serology of nervous diseases.
Dr. David Kaplan, of the New York Neurological Institute, has furnished
me with data on this last subject which represent large experience and
bring the matter to date.

The chapter on acute anterior poliomyelitis has been rewritten by
Dr. Foster Kennedy in the light of recent discoveries, and the same has
been done for the chapter on epidemic cerebrospinal meningitis by Dr.
H. W. Frink. I am under obligations to both these gentlemen for their
excellent work.

Practically new chapters have been written on tumors of the spinal
cord and tumors of the brain. Dr. Charles A. Elsberg has allowed me
to use the statistics of his cases, so that I am able to present these topics
from the standpoint of modern neurological surgery as well as of medicine.

The chapters on methods of examination and diagnosis and on general
symptoms have been thoroughly revised and an endeavor made to include
the latest data. The number of epinomic signs and syndromes of neurol-
ogy has grown to a burdensome length. A descriptive list of them has
been prepared by Dr. Frink.

The chapters on the psycho-neuroses have been rearranged and in
parts rewritten and condensed. Neurasthenia has been pushed, as
modern views demand, much more into the background. Hysteria and
psychasthenia have been treated from the standpoint of descriptive rather
than of " dynamic" or analytic neurology. This it seemed to me was the
only way to make the subject intelligible in a work meant largely for

iii



IV PREFACE TO THE EIGHTH EDITION

students and practitioners. I trust that I have, however, given a measure
of justice to psycho-analysis, as it certainly has a place in the interpreta-
tion and occasionally in the therapeutics of the minor psychoses.

The subject of the disturbances of growth and metabolism and of
nervous function due to glandular disorders has brought out a large
literature in recent years, and this has been considered in the revision of
this edition.

The subject of therapeutics is difficult to discuss effectively in a trea-
tise that aims to be of moderate size. Methods and drugs and points of
view change so rapidly that I have decided to leave out the special chapter
on this subject. Treatises on electricity, massage, exercise, diet, mechan-
ical therapy, hydrotherapy, etc., are now many and accessible.

Many new clinical and anatomical illustrations have been added.
I am greatly indebted to Dr. J. B. Gere, of the Pathological Department
of Cornell University Medical College, for beautiful photographs of
spinal-cord and of nerve disease; to Dr. S. Wachsmann and the Montefiore
Home for photographs of clinical cases; and to Dr. R. S. MacRobert, of
New York Neurological Institute, for photographs illustrating methods
of examination. A modest tribute has been paid to the fathers of neuro-
anatomy in the reproduction and use of illustrations of the brain by
Stephanus, Willis, and Ruysch. They represent anatomical illustration
and art in the 16th, 17th and 18th centuries respectively.

The part of my work devoted to psychiatry will appear in a separate
volume. However, I have included in the present treatise articles on
the minor psychoses, as well as a chapter on paresis.

A treatise on neurology must usually be read, and studied in parts,
hence that portion of the original preface has been retained which sug-
gested to the reader a certain eclecticism of method in neurological
study. The principle then set forth holds good now though the lists
then given need revision.

My thanks are due to my publishers for their helpfulness and cheerful
co-operation.

New York City,

Sept., 15, 1915.



FROM PREFACE TO THE FIRST EDITION



As a special text-book the present work will be used by two classes
of readers, one consisting of those who simply consult it for reference in
connection with their cases, the other composed of students who desire
to ground themselves systematically in a knowledge of neurology. To
this latter class I venture some advice as to the method they should pur-
sue. Neurology is a difficult branch of medicine to master, nor is there
any royal road to it. Still, it can be made comparatively easy if its
study is undertaken in a proper and systematic way.

In using the present work, the student should first refresh his general
knowledge of nervous anatomy as furnished in ordinary text-books. He
should then go carefully over the anatomical descriptions here given of
the general structure of the nervous system and of that of the nerves,
spinal cord, and brain. A thorough knowledge of anatomy and physiol-
ogy makes clinical neurology comparatively easy, and in fact reduces
much of it simply to a matter of logical deduction.

The student should next master the general facts of nervous path-
ology, symptomatology, and etiology, for he will find common laws
underlying apparently the most varying phenomena. Finally, he must
begin to study the special diseases. The number of these is very great;
in the present work I have described 176. Many of these are rare, and
it would be wrong for the student to burden his memory with the details
about them. He need know only of their existence and general physiog-
nomy. There are, however, according to my enumeration, about 65
nervous diseases which are either very common or extremely important,
and it is these that the student should master and make part of his work-
ing knowledge. Since the distribution and names of the common and
rare diseases may be a useful guide, I append here a table and a list :





Peripheral


Spinal
Cord


Brain


Functional


Totals


Common and important dis-
eases

Pi,are


31
56


13

27


12
16


10
11


66
110








87


40


28


21


176



The common or important nervous diseases are:
General. — Neuritis, multiple neuritis, degeneration, neuralgia, par-
sesthesia (5).



VI PREFACE

Cranial Nerves. — Anosmia, optic neuritis, optic atrophy, ptosis,
ophthalmoplegia, abducens palsy, headache, migraine, trigeminal neural-
gia, facial spasm, facial palsy, tinnitus, vertigo, ageusia, wryneck (16).

Spinal Nerves. — Cervical neuralgia, hiccough, brachial palsies, single
and combined, brachial neuralgia, intercostal neuralgia, herpes zoster,
lumbar neuralgia, sciatica, leg palsies (10).

Spinal Cord. — Spina bifida, hemorrhage, pachymeningitis, lepto-
meningitis, poliomyelitis, transverse myelitis, acute and chronic, second-
ary degenerations, locomotor ataxia, the progressive muscular atrophies,
bulbar palsy, muscular dystrophies, spinal irritation (13).
, Brain. — Malformations, hypersemia, pachymeningitis, leptomenin-
gitis, simple, tuberculous, and epidemic, abscess, hemorrhage, embolism,
thrombosis, children's palsies, syphilis (12).

Functional.- — -Epilepsy, hysteria, the tics, chorea, tetanus, neuras-
thenia, spermatorrhoea, exophthalmic goitre, occupation neuroses, pa-
ralysis agitans (10).
New York City, 1892.



TABLE OF CONTENTS

CHAPTER I

Page
General Anatomy, Physiology, and Chemistry. The General Histology of

the Nervous System — The Neuronic Architecture of the Nervous SJ^stem . . 1

CHAPTER II

The Causes of Nervous Diseases 23

CHAPTER III
General Pathology 28

CHAPTER IV

General Symptoms 30

CHAPTER V

Diagnosis and Methods of Examination. Examination of the Reflexes —
Examination of the Disorders of Sensation — Cerebrospinal Fluid — Spinal
Puncture 39

CHAPTER VI

Hygiene, Prophylaxis, Treatment. Diet — Exercise — Hj^drotherapy —
Massage — Osteopathy — Climate — Electricity — Radiant Energy — Psycho-
therapy 60

CHAPTER VII

Diseases of the Peripheral Nerves. General Pathology — Hypersemia and
Anaemia — Angina — Neuritis — Degeneration — General Symptoms — Multiple
Neuritis — Sensory-motor Type — Sensori-ataxic Type — Endemic and Epi-
demic Types — Malarial — Acute Pernicious — Complicating Forms of
Neuritis and Neuritic Degeneration — Tumors 75

CHAPTER VIII

Motor Disorders of Cranial Nerves. The Ocular Muscles — General Symp-
toms — The Ophthalmoplegias — Third Nerve — Fourth Nerve — Sixth Nerve
— Muscular Asthenopia and Muscular Insufficiencies — Spasmodic Diseases

vii



VIU CONTENTS

Page
of the Ocular Muscles — The Motor Branch of the Fifth Cranial Nerve — The
Facial Nerve — Facial Spasm — Facial Palsies — The Glossopharyngeal Nerve
— The Pneumogastric Nerve and the Accessory part of the Spinal Accessory
— Vagotonia — Laryngeal Nerve Supply — Spinal Part of the Accessorius and
Upper Cervical Nerves — Torticollis — Paralysis of the Spinal Accessory — The
Hypoglossus — The Mechanism of Articulation 95

CHAPTER IX

Neuroses of the Motor Spinal Nerves. The Upper Cervical — The Lower
Cervical and Brachial Plexus — The Thoracic or Dorsal — The Lumbar
—The Sacral 126

CHAPTER X

Sensory Neuroses of the Cerebrospinal Nerves. Parsesthesia — Neuralgia —
Neuroses of the Nerves of Special Sense — The Olfactory Nerve — The Optic
Nerve — Trigeminal Nerve — Headache — Migraine — Seventh Nerve — Acous-
tic Nerve — Nervous Deafness — -Tinnitus Aurium — Vertigo — Glossopharyn-
geal Nerve — Upper Cervical Nerves — ^Lower Cervical Nerves and Brachial
Plexus — Intercostal Nerves — Lumbar Nerves — Peripheral Vasomotor and
Trophic Neuroses 145

CHAPTER XI

Diseases of the Spinal Cord. Anatomy and Physiology — Diagnostic Physi-
ology 200

CHAPTER XII

Diseases of the Spinal Cord. Malformations — Spina Bifida — Spinal Hemor-
rhage — The Caisson Disease — Spinal Meningitis — Myelitis and Myelo-
malacia — Poliomyelitis — Acute Ascending Paralysis 214

CHAPTER XIII

Scleroses, Degenerations, Syphilis. Locomotor Ataxia — Lateral Sclerosis —
The Combined Scleroses — Hereditary Spinal Ataxia — Hereditary Cere-
bellar Ataxia 248

CHAPTER XIV

The Progressts^e Muscular Atrophies and Muscular Dystrophies. Luetic
Spinal Atrophy — Hereditary Muscular Atrophy of the Peroneal Tj'pe —
Glosso-labio-larjrngeal Paralysis — Myasthenia Gravis — Amyotrophic
Lateral Sclerosis — The Progressive Muscular Dystrophies — Pseudo-
muscular Hypertrophj^ — Hemihypertrophy — Summary of the Hereditary
or Family Nervous Diseases — Arthritic Muscular Atrophy — Occupation
Muscular Atrophies 292



CONTENTS IX

CHAPTER XV

Page

Tumors and Cavities of the Spinal Cord. Hydromyelia — Gliosis and

Syringomyelia — The Recognition of Diseases of the Cauda Equina .... 318

CHAPTER XVI

Anatomy and Physiology of the Brain. The Cerebellum — The Glands of the

Brain — The Connecting Tracts — The Membranes — The Functions .... 333

CHAPTER XVII

Diseases of the Brain and Its Membranes. General Symptoms — Malforma-
tions — Purulent Cerebrospinal Meningitis — Epidemic Cerebrospinal Menin-
gitis — Tuberculous Meningitis — Hydrocephalus — Alcoholic Meningitis —
Hypersemia and Anaemia 367

CHAPTER XVIII

Diseases of the Brain. Inflammations— General Paresis — Multiple Sclerosis
— The Apoplexies — Softening — Sinus-thrombosis — Cerebral Palsies of
Children 395

CHAPTER XIX

Tumors of the Brain. Intracranial Aneurism 454

CHAPTER XX

Functional and Degeneratr^e Diseases. Epilepsy 474

CHAPTER XXI

The Psycho-neuroses. Constitutional Inferiority — Hysteria 488



CHAPTER XXII
Psychasthenia 507

CHAPTER XXIII

Neurasthenia. The Sexual Neuroses and Psychoses — Traumatic Nervous

Affections 514

CHAPTER XXIV

The Myoclonias or Twitching Spasms. Chorea of Sydenham — Hereditary
Chorea — Spasmodic Tic — Fibrillary Myoclonia — -Myotonia — Tortipelvis —
Tetanus — Tetany — Rabies and Hydrophobia 535



X CONTENTS

CHAPTER XXV

Page
Exophthalmic Goitre and Hyperthyroidism v. 553

CHAPTER XXVI

Professional Neuroses, Occupation Neuroses 560

CHAPTER XXVII
Paralysis Agitans 667

CHAPTER XXVIII

Trophic and Vasomotor Disorders. Hemiatrophy — Diseases of the Pituitary

Gland — Acromegaly — Myxoedema — Cretinism — Angio-neurotic CEdema . . 576

CHAPTER XXIX

The Disorders op Sleep. Insomnia — Hypnotism — Morbid Somnolence —
Catalepsy — Trance — Lethargy — Perversions and Disturbances — Mesmer-
ism — The Sleeping Sickness of Africa 586

CHAPTER XXX
Cranio-cerebral Topography 600

APPENDIX

The Function and Innervation of the Muscles. Muscles of Tongue, Palate
and Pharynx — Muscles of Head and Neck — Muscles of Shoulder and Upper
Extremity — Muscles of Arm, Forearm and Hand — Muscles of Back and
Lower Extremities 605



PAET I
DISEASES OF THE NERVOUS SYSTEM



CHAPTER I
GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY

In studying the phenomena of hfe in tlie human body, we as physicians
first learn about its normal structure and functions. We then note the
new phenomena which develop when disease comes on, the causes which
produce them, and the anatomical changes lying back of them; we group
our facts and give the disease a name. Lastly we apply the methods
by which the disorder can be expelled and future attacks prevented. In
fine, we investigate our subject just as we do that of any branch of natural
history. Our study divides itself, therefore, into

Normal anatomy and physiology.

Etiology, a study of the causes.

Symptomatology, a study of the morbid phenomena.

Pathology, under which we include a study of the morbid anatomy
and physiology.

Diagnosis, or the method of recognizing and separating out the dif-
ferent groups of diseases.

Prognosis, a forecast of the future course of the malady.

Treatment and prophylaxis.

GENERAL ANATOMY

The nervous system is derived from the ectodermal germ layer of
the developing ovum, and its constituents are modifications of epithelial
cells. These cells in the embryo are of two kinds: neuroblasts, which
develop into nerve-cells and fibres; and spongioblasts, which develop
into a supporting structure called neuroglia (His).

The nervous system is composed of:

(a) Neurons, which form the nervous tissue proper, and are made up
of nerve-cells, with their processes, one of which becomes an axis cylinder;
and neuroglia.

(6) Accessory tissue, consisting of connective tissue, blood-vessels,
lymphatics, and epithelium.



DISEASES OF THE NERVOUS SYSTEM



These tissues are united together to form the central nervous system,
consisting of the brain and spinal cord, and the peripheral nervous
system. This latter is composed of nerve-fibres, and structures attached
to the terminations of the nerves, called end-organs, and finally the
ganglionic or sympathetic nervous system is included in the peripheral
system.

The Arrangement of the Nervous System. — The subdivisions of these
parts, and their descriptions in detail, belong to general anatomy.
But there have been so many special subdivisions, and particular names
given to them in recent years, that I deem it necessary, in order to pre-
vent confusion, to describe briefly the subdivision accepted by modern
anatomists. The names here used are those adopted by the committee on
anatomical nomenclature of the German Anatomical Society, and they
have also been adopted by a large number of writers on neuro-anatomy.



vAjO^/j,



''""MAL/c



OPTIC VESICLE




Fig. 1.



-Showing divisions of embryonal human brain in third and fifth weeks.
(His.) (Cunningham.)



Beginning with the brain, we find that its particular subdivisions are
based upon the embryological development of this organ. As will be
shown in more detail later, the brain is developed out of three vesicles,
known as the anterior, middle, and posterior vesicles (Fig. 1). The most
anterior of these vesicles is the prosencephalon or anterior brain; the middle
vesicle becomes the mesencephalon or mid-brain, and the posterior vesi-
cle develops into the rhombencephalon or posterior brain.

The anterior vesicle develops two secondary vesicles : the anterior por-
tion of these, including the corpora striata, olfactory lobes and the cere-
bral hemispheres, forms the telencephalon (Fig. 2, 1 2), while the hinder por-
tion of this vesicle, which includes the thalamus and mammary bodies,
forms the diencephalon (I^). The middle vesicle is the mesencephalon,
and it includes the corpora quadrigemina and cerebral peduncles (II).



GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY



3



The posterior vesicle is divided, from before backward, into three different
parts: (1) the isthmus, which inchides the superior cerebellar peduncles
and valve of Vieussens, and part of the cerebral peduncles; (2) the
metencephalon or hind-brain, which includes the cerebrum and pons
Varolii; and (3) the myelencephalon or after-brain, which includes the
medulla oblongata.



Prosencephalon
(anterior brain).
II and 1=



Brain. <! Mesencephalon

(middle brain). H

Rhombencephalon
(posterior brain).
Ill and IV



1. Telencephalon.

2. Diencephalon.

[ 3. Mesencephalon.

4. Isthmus.

5. Metencephalon.

6. Myelencephalon.



Hemispheres.

Pars optica hypothalami.

Pars mammalians.

Thalamus.
/ Pedunculi cerebri.
\ Corpora quadrigemina.

Cerebellum.
Pons.
! Medulla oblongata.



These different parts can be understood better by means of the
accompanying figure (Fig. 2), which represents in a schematic way the
brain of a mammal.




Fig. 2.



They are intimately connected by strands of nerve-fibres, and are
connected closely also with the next portion of the nervous system, the
spinal cord. The brain and spinal cord are spoken of as the cerebrospinal
axis, and this is in close relation with the peripheral nervous system.

This peripheral nervous system is composed of two portions — -first,
the cerebrospinal mixed nerves, whose origin, distribution, and relations
are comparatively easy to follow; and second, the autonomic or sympa-
thetic nervous system. This portion of the nervous system is composed
of two sets of ganglia — one, the vertebral ganglia, i.e., the chain of gan-
glionic masses on each side of the vertebral column, and of certain ganglia
connected with the cranial nerves; secondly, a very large number of



4 DISEASES OF THE NERVOUS SYSTEM

ganglionic masses distributed in the viscera, and known as the peripheral
ganglia. The sympathetic nervous system is made up of multipolar cells
and of some medullated (white), but mostly of non-medullated (gray)
naked nerve-fibres.

Efferent white fibres pass out from the spinal cord through the anterior
roots and pass partly to the sympathetic ganglia and partly continue on to
the viscera, glands and blood-vessels. Afferent fibres originate in the
sympathetic ganglia and pass in part through the posterior roots to the
spinal cord; in part they turn and pass with peripheral nerves to the skin,
blood-vessels and glands.




Fig. 3. — Nerve cells of different types, a, Unipolar; h, bipolar; c, pyramidal cell;
d, Purkinje cell. (Villiger.)



THE GENERAL HISTOLOGY OF THE NERVOUS SYSTEM

The nerve-cells form the central body of the neuron and are minute
objects varying much in size. Thelargest are 0.1mm. (>^5 in.) in diameter
and are almost visible to the naked eye. The smallest are 0.7m (K500 in.)
in diameter; so that the average diameter is rather greater than that of a
white blood-cell. In shape nerve-cells are for the most part irregularly
spheroidal, but some are pyramidal, others spindle- or flask-shaped, and
others globular. They all give off one or more fine processes or poles
and hence, in accordance with the number of these, the nerve-cells are
often spoken of as multipolar, bipolar, or unipolar.

In most cells one of the processes is continued on a long way and
finally becomes a nerve-fibre. This process is called the axis-cylinder, or



GENERAL ANATOMY, PHYSIOLOGY, AND CHEMISTRY 5

neuraxon or axon (Figs. 3, 4 and 5 and Plate II). The other processes are
relatively short and are called protoplasmic processes, or dendrites. The
nerve-cell, then, is a protoplasmic body giving off several dendrites and
usually a single neuraxon, the whole forming the neuron. The dendrites
branch off irregularly and subdivide, but never anastomose. In some parts
of the nervous system they have upon them little nodules or buds, and
in the cerebral and cerebellar cortex these are so numerous as to give





Fig. 4. Fig. 5.

Fig. 4. — -Nerve cell showing dendrites, axon, collaterals, a, Axis-cjdinder-bifur-
cating at h; c, a collateral; d, varicosities of the dendrites. (Cajal.)

Fig. 5. — Nerve cells from anterior horn of spinal cord. (Cunninghmn.)

them the appearance of budded stalks. The dendrites are usually not
very long, but in some cells they extend a very great way, reaching many
times the diameter of the cell. The axis-cylinder process, or neuraxon, is
given off directly from the body of the cell, as a rule (Fig. 5). It very soon
becomes clothed with a thin sheath (myelin sheath) , and as it passes along
gives off branches at right angles, which form what are known as the
collaterals. The neuraxon and collaterals finally end by splitting up into a



6



DISEASES OF THE NERVOUS SYSTEM



number of fine branches, which lose their myelin sheath and form the
end-brush or terminal arborization. In some neurons instead of an end-
brush, there are several minute ovoid bodies which lie upon the cell or its
dendrites. They are called "end-buds" or terminal "buttons." They
are seen especially in the medulla and pons, but not in the cerebral or
cerebellar cortex. The axis-cylinder process or neuraxon does not anas-
tomose with other cells either through its own end-brush or through the
end-brushes of its collaterals. The end-brushes, however, pass in among
the dendrites of other cells, and sometimes closely surround the cell-body.
In this way one neuron comes into very intimate relation with others, but
there is never any true union. Each neuron of the nervous system is an
independent unit.




Fig. 6. — Ganglionic nerve cells, ultra-microscopical illumination. (Marinesco.)



The cell-body proper is composed of a cytoplasm. Within this lies
the nucleus and within the nucleus a nucleolus. The body proper is
not homogeneous, but is made up of a network of fine fibres or fibrillse
which pass in bundles from dendrite to dendrite and from dendrite to
the neuraxon, called the endocellular fibrillar network. Within its
meshes and arranged in a rather definite manner are certain stainable



Online LibraryCharles L. (Charles Loomis) DanaText-book of nervous diseases, for the use of students and practitioners of medicine → online text (page 1 of 61)