or toes, and is known as local syncope. It lasts var}dng lengths of time but
usually but for an hour or so and may occur following a chilling of the
extremities or emotional disturbance. As the reaction sets in the affected
parts become hot, reddened and painful. This is the stage of asphyxia and
may not affect all the fingers at the same time, one or more of the extremities
may be purple and livid while the whiteness of the others persists. The ears
and the tip of the nose may be involved in this state of asphyxia and more
rarely the limbs, the skin over them assuming a characteristic mottled appear-
ance. With the pain there may be swelling and itching. Chilblains may
occur as a complication of this stage. The attacks may recur from time
to time, being induced by exposure to cold or mental disturbances, disappear-
ing under the influence of warmth; the parts involved, may, after successive
attacks, become shrunken and indurated.

Few patients go on to the third stage, that of symmetrical gangrene. In
such this manifestation succeeds the stage of asph}'xia, one or more of the
fingers or toes becoming cold, dry and black in color, just as in dry gangrene.
A line of demarcation is formed upon the skin beyond which gangrenous
blebs may form and finally there may be sloughing away of the dead tissue,
although usually the loss of substance is slight. In rare instances symmet-
rical patches of gangrene make their appearance upon the limbs or body



ERYTHROMELALGIA. 833

and progress rapidly. Here the outcome may be fatal within a few days,
especially when the condition occurs in children.

An associated symptom which may be met is hasmoglobinuria which may
accompany the local manifestations or take their place; with this the urine
may contain red blood cells and albumin.

Other symptoms which have been observed are stupor and partial uncon-
sciousness, delusions, dimness of sight, urticarial and erythematous eruptions,
scleroderma, cutaneous oedema and joint swelling which may resiilt in enlarge-
ment of the finger joints and anchylosis. Peripheral neuritis may occur as
well as symptoms of disturbance of the digestive system.

The prognosis as regards the preservation of life is usually good, weak
and poorly nourished children, however, may succumb; those whose powers
of resistance are good may outgrow the predisposition to the disease.

Treatment. All individuals subject to this disease should receive treat-
ment calculated to improve their general condition, in the shape of tonics,
proper diet, etc., and should avoid exposure to cold and mental irritation.
During the attack the patient should be kept in bed and warmly covered, the
limbs should be elevated and the fingers and toes wrapped in cotton, artifi-
cial heat being supplied in the shape of hot water bottles, if necessary.
Rubbing the affected parts and the employment of galvanism and faradism
are often beneficial. Placing the limb in warm salt water and applying one
electrode to the spine while the other is put into the water has been recom-
mended. Good results have been reported from the administration of glyceryl
nitrate, gr. y^o ^^ sV (0.0006-0.0012) three times a day. The effect of
this drug is to relax the vascular spasm and thus to improve the circulation
of the part. Shutting off the supply of arterial blood of the limb by means
of a tourniquet or an elastic bandage for a few minutes and then releasing
the constriction wiU result in a reddening of the part owing to the relaxation
of the vaso-motor tension and is said to be beneficial. This procedure, in
severe types of the disease, must usually be frequently repeated in order to
prove effectual.

For the severe pain salipyrine, acetphenetidine and antipyrine may be admin- '
istered; this symptom, may, however, require the exhibition of codeine
or morphine; the last must be given with caution.

ERYTHROMELALGIA.

Definition. A rare chronic disease characterized by pain, hypersemia
and rise of temperature in the part affected, this usually being one or both
of the lower extremities. More seldom is the upper limb involved.

.Etiology. The causation of this affection is somewhat obscure. It
S3



834 DISEASES OF THE NERVOUS SYSTEM.

may occur with certain spinal cord lesions, and in diabetes mellitus. Arterio-
sclerosis seems to exert a certain influence in its incidence.

Pathology. The most constant morbid change is a chronic inflammation
of the arteries of the affected part. Weir Mitchell, who first described the
condition, suggests that it may be due to a neuritis of the nerve-endings while
another ^theory that has been advanced is that the lesions may be due to irri-
tation of the anterior horn cells of the cord.

Symptoms. These are first noticed in the ball of the foot or the heel and
consist of pain varying from vague discomfort and sense of weight to extremely
severe pain; swelling may appear later, especially after walking or standing.
The skin is reddened, the veins are dilated and there may be visible arterial
pulsation. Rest and elevation relieve the symptoms to a considerable degree.
The condition is usually relieved by cool weather, but not in every instance.

The prognosis as to life is favorable but the patient may be subject to recur-
rences at varying intervals.

Treatment. An attack may be aborted by bathing the limb with ice water.
The affected part should be kept elevated and compresses wet in cooling
lotions should be applied. Intermittent hot and cold douches may be em-
ployed and the use of the faradic current and of systematic massage may
prove beneficial. The pain may necessitate the administration of analgesic
drugs. The patient's general condition should be cared for and tonics should
be prescribed if necessary.

ANGIONEUROTIC (EDEMA.

Synonym. Giant Urticaria.

Definition. A disease characterized by the sudden occurrence of transient
localized oedematous swelling.

.Etiology. Heredity plays a definite part in the causation of this affection;
it seems to be more common in females than in males in the United States,
while the opposite is the case in Eiu-opean countries. It is more common in
individuals of nervous temperament. Attacks may be induced by exposure
to cold or any influence which reduces nervous tone. The giant urticaria
which occurs in digestive disturbances and in certain persons after eating
strawberries, crabs or lobsters is probably a variety of angioneurotic oedema.

Pathology. This disease has been considered to be due to a neurosis of
the vaso-motor system resulting in dilatation and an augmentation of the per-
meability of the blood-vessels.

Symptoms. The most frequently affected region is the face; more rarely
are the hands and genitals involved; the condition may occur, however, in
any portion of the body even in the throat and pharynx. In the last situa-
tion symptoms of asphyxia result and death has been known to take place.



MIGRAINE. 835

Digestive disturbances such as vomiting, colicky pains and diarrhoea, may be
associated with the cutaneous manifestations. The area affected is small,
as a rule being not over two or three inches in diameter, and varies in color
from pallor to deep red; itching and burning sensations may be present but
pain is rare. Periodicity has been noticed in the occiirrence of the attacks
and such associated symptoms as cardiac pain and haemoglobinuria have
been observed.

The disease is not dangerous to life except when there is involvement of
the air passages, but often is very resistant to treatment.

Treatment. This consists in the employment of all measures which tend
to improve the general condition of the patient such as tonics, especially those
which affect the nervous system (phosphorus, the glycerophosphates, quinine
and strychnine) ; in anaemic states arsenic and iron should be given and under
all conditions the insistence upon proper diet and exercise in the open air
is necessary. Hydrotherapeutic measures are often beneficial and hypnotism
has been suggested. This last form of treatment should, however, be employed
with caution. The local treatment consists in the application of a 10 percent,
ointment of ichthyol upon compresses of gauze. The routine administration
of glyceryl nitrate in doses of y-^-jj- to ^of a grain (0.0006-0.0012) three
times a day often produces excellent results. If, as has been suggested, the
oedematous condition is due to an increased permeability of the blood-vessels,
the treatment by dechloridation (elimination of sodium chloride from the diet)
may be tentatively prescribed. When gouty, rheumatic or purinaemic con-
ditions are present these should be corrected by appropriate treatment.

MIGRAINE.

Synonyms. Sick Headache; Hemicrania; Bilious Headache; Megrim.

Definition. A sensory neurosis characterized by headache, often unilateral,
and sometimes by nausea and vomiting and visual disorders.

iEtiology. Heredity seems to exert a definite influence upon the causation
of this disease. It occurs more frequently in women, especially those of
nervous temperament, and not seldom in those whose general physical condi-
tion is excellent. Pinrinaemic states predispose to its incidence and the con-
dition may be induced by eyestrain, menstrual abnormalities, mental and
physical over-exertion and alimentary disorders. Predisposing causes are
dental caries, and abnormal intranasal and nasopharyngeal conditions. In
chronic nephritis recurrent migraine is not uncommon.

Symptoms. The onset of the attack may be sudden or there may be pro-
dromata such as dizziness, ringing in the ears, spots before the eyes and pecu-
liar visions — the patient seeing imaginary animals, for instance. Temporary
hemianopsia or scotoma may be observed. The pain soon makes its appear-



836 DISEASES OF THE NERVOUS SYSTEM.

ance. It is usually frontal and on only one side although it may begin in
the temple or occiput. From the original situation it extends to one-half
or the entire head. In character it is continuous, sharp and boring. It is
increased by noise and a bright light. The appetite is lost, there is marked
nausea which may be followed by vomiting; the vomitus consists first of the
contents of the stomach — partially digested food or mucus — and later of
bile. If the vomiting takes place when the stomach is full the pain is often
relieved. Vaso-motor manifestations such as paleness of one side of the face
which may be followed by marked redness, may be noted. Arteriosclerosis of
the temporal artery on the affected side is not infrequent. The rate of the
pulse is usually not accelerated.

The attacks tend to recur periodically and their duration is variable, last-
ing from one to three days. The disease is an obstinate one, although the
prognosis as regards life is favorable. In certain instances the attacks, after
having persisted from youth, have disappeared after the age of fifty has been
reached in males, and after the menopause in females.

Treatment. This should depend upon the cause if this can be ascertained.
The diet and mode of life should be' carefully regulated. Some patients do
well upon an entirely vegetable regimen. The bowels should be kept regu-
larly open and any digestive derangement corrected. The eyes should be
examined by a competent ophthalmologist and proper lenses prescribed if
necessary. Intranasal and pharjTigeal conditions should receive appropriate
treatment. The urine should be examined for albumin and to ascertain if
the excretion of uric acid is sufficient. Should the migraine be due to purin-
asmic conditions these should be treated (see p. 252). In anaemia the admin-
istration of iron and arsenic is indicated. In neurotic patients all emotional
disturbance should be avoided.

The treatment by means of the bromides, especially potassium bromide,
may prove effectual. This drug should be given in doses of i to 2 drachms
(4.0-8.0) per day and continued if necessary for eight to twelve months.
The point of toleration should be ascertained and the maximum dose given
for six months; for the succeeding two to four months the dosage should be
gradually diminished and at the end of about one year the drug should be
stopped. When arterial h}^ertension is present glyceryl nitrate may be given
(tott to 5^ of a grain — 0.0006 to 0.0012). Here inhalation of amyl nitrite,
3 to 5 drops (0.2-0.33) may abort an attack.

In patients in whom the paroxysm is attended by marked nausea and vomit-
ing a thorough gastric lavage followed by a saline purge, if employed as soon
as any prodromata are noticed, may succeed as a preventive measure.

During the attack the patient should be kept in bed in a darkened room;
the nausea may be relieved by a cup of strong coffee or by 20 to 30
drops (1.33-2.0) of chloroform. Hot or cold compresses should be applied



FACIAL HEMIATROPHY. 837

to the head. The treatment of the attack otherwise consists in the admin-
istration of various analgesics such as salipyrine, antipyrine, or acetphenetidine.
The following formula may be recommended: I^ acetanilidi, gr. iii (0.2);
camphorae monobromatse, gr. ii (0.13); caffeinae sodiobenzoatis, gr. i (0.065).
One such powder may be taken every three or four hours. I^ acetphenetidini,
gr. viiss (0.5); siilphonmethani, gr. xv (i.o); three such powders may be
taken during twenty-foiu: hours. I^ acetanilidi, sodium bicarbonatis, aa gr.
iiss (0.16); caffeinae citrate, gr. i (0.065); extract! aconiti, gr. 2V (p.oo^).
One such tablet every three or four hours. Citrated caffeine alone in doses
of 5 grains (0.33) or caffeine sahcylate in the same dose may prove beneficial.
This drug may also be given hypodermatically — caffeine sodiobenzoate, 5
to 10 grains (0.33-0.66). Cannabis indica as the extract is considered by some
to be the most effectual drug in the treatment of migraine. Its beginning dose is
J grain (0.016). This dosage is gradually increased and the administration of
the drug may be continued for a considerable period. Aconitine (Duquesnel)
may be employed in doses of 4^ to 2^0 of a grain (0.00015-0.0003).
When heart weakness is present strychnine should be given at the same
time. This last drug is especially indicated in ophthalmic migraine. Tinc-
ture of gelsemium 10 to 20 drops (0.66-1.33) either alone or with | to
I grain (0.032-0.065) of extract of cannabis indica may relieve the severe
pain of an attack. Other drugs which have been advocated in the treatment
of this condition are ergot and guarana. When the attack is accompanied
by emesis it is usually best to administer medication hypodermatically or
per rectum. If the pain is conffned to the course of a certain nerve the over-
lying skin may be painted with a mixture of menthol, chloral and camphor.
When less drastic measures fail a tape seton may be passed through the skin
of the nape of the neck and allowed to remain in place for two or three months.

Electricity may be tried, preferably in the form of galvanism; one pole
should be applied over the cervical sympathetic and the other to the nuchal
region.

The employment of hydrotherapeutic measures, particularly as carried
out at one of the various spas, may benefit certain patients, perhaps rather
because of the enforced regularity of life than because of the baths themselves.
A sojourn at Vichy, Carlsbad, Evian or at some of the similar resorts in this
country may induce favorable results.

FACIAL HEMIATROPHY.

Synonym. Unilateral Progressive Facial Atrophy.

Definition. A rare affection characterized by a gradual wasting of the
integument, fatty tissues, muscles and bones of one side of the face.

.etiology. While this disease is obscure in its causation it is doubtless



838 DISEASES OE THE NERVOUS SYSTEM.

due to a neurosis of the trophic functions. It is more common in females
and may occur secondary to the infectious diseases and in s}Tingomyelia.

Pathology. In the only autopsy in which the findings were such as to
give evidence of the nature of the affection an interstitial neuritis of all the
branches of the trifacial nerve in its terminal stage was found.

Symptoms. The disease usually begins in childhood but in rare instances
may not appear until adult life. The atrophy more frequently affects the
left side of the face though bilateral involvement and patients who exhibited
atrophic areas on the back and arm of the affected side have been observed.
At its inception the wasting may aft'ect a definitely localized area upon the
face or may be diffuse. The skin and subcutaneous tissues are first affected,
then the bones, particularly those of the upper jaw, and finally the muscles,
especially those of mastication. In the unilateral U^e the atrophy is dis-
tinctly Hmited at the mid-line of the face and the facial appearance is
remarkable, giving the impression that the countenance is composed of two
halves from different individuals. There may be hemiatrophy of the tongue
and soft palate and the teeth may fall out as a result of the wasting of
the gums and alveolar processes; the skin often changes in color and the
hair of the affected side falls. The orbital fat is involved in the wasting
process and the eye is sunken. Motor and sensory symptoms are rare but
spasm of the facial muscles and disordered sensation may be present.

The disease is not dangerous to life but is of chronic course and little influ-
enced by treatment.

Treatment consists in the regulation of the patient's mode of life in ac-
cordance with proper hygienic considerations and the systematic employment
of electricit}^ and massage.

MYASTHENIA GRAVIS.

Synonym. Asthenic Bulbar Paralysis.

Definition. A condition characterized by progressive muscular weakness,
an increased susceptibility to fatigue and the presence of the myasthenic
reaction of Jolly — a tendency on the part of the muscles to exhaustion when
subjected to the faradic current.

iEtiology. The cause of this disease is unknown, although the infectious
diseases may exert an influence in its production.

Pathology. No definite pathological changes have been described but in
certain instances lymphoid infiltration of the muscular tissue and a prolif-
eration of the essential elements of the thymus, together with an infiltration of
lymphoid cells, have been found.

Symptoms. The disease occurs chiefly in the young; the muscles of the
eyes, face, and those of mastication and swallowing are first involved. Later



PERIODICAL PARALYSIS. 839

the affection spreads to the other muscles of the body. Walking may become
difl&cult and a characteristic feature is a rapidly developing fatigue following
the continued use of the muscles. Their power is, however, recovered after
resting. The myasthenic reaction is a pathognomonic symptom. Dyspnoea
may be present. The course of the disease is marked by remissions and
recoveries have been reported, although usually the patient dies from exhaus-
tion or dyspnoea. Strangulation while attempting to swallow has caused
death in some instances. There are no atrophic changes; spastic manifesta-
tions and tremors are absent.

Treatment is usually of slight avail. Rest, both mental and physical, is
an essential. Electricity is contraindicated, massage, however, may be
employed. Strychnine and antisyphilitic treatment may he administered
but little benefit is to be expected. When disturbance of deglutition is present
the patient may be fed by means of the nasal or stomach tube.

PERIODICAL PARALYSIS.

This is a rare and interesting condition which occurs in certain families
or in isolated individuals. It is characterized by a suddenly appearing
paralysis involving various groups of muscles.

It is probably due to autointoxication and in a number of cases a dimin-
ished excretion of kreatinine occurring shortly before and at the beginning
of an attack, has been observed.

Symptoms. The disease may appear suddenly and without assignable
cause in otherwise healthy individuals or prodromata in the shape of malaise
and weakness in the parts to be affected may be noticed. The limbs, especially
the legs, are chiefly involved in the paralysis, although paralysis of the entire
body has been observed. The cranial nerves and the special senses escape.
The reflexes are diminished or lost and faradic irritability of both muscles
and nerves is absent. There is usually no febrile movement nor acceleration
of the pulse although symptoms of acute cardiac dilatation may be present
in some instances. After a few hours or days the paralysis begins to disappear
rapidly and the patient quickly and entirely recovers. Recurrences are
frequent, occurring at intervals varying from a day or two to two or three
weeks. Seizures are rare after fifty years of age.

The paralysis is never permanent but patients sometimes die during an
attack.

Treatment. The administration of the alkaline diuretics, particularly
potassium citrate in doses of 20 to 30 grains (1.33-2.0) three times
a day is said to prevent or shorten the seizures. This fact is perhaps in favor
of the theory that the condition is due to the retention of toxic substances
which should be excreted in the urine.



840 DISEASES OF THE NERVOUS SYSTEM.

ADIPOSIS DOLOROSA.

Synonym. Dercum's Disease.

Definition. A rare condition characterized by the deposition of masses of
fat in the subcutaneous tissue of various parts of the body. These masses
are tender and painful.

etiology. The disease is one of women in the great majority of instances
and has been considered to be the result of the early incidence of menopause
and of atrophic changes in the thyroid gland. Its actual cause is unknown.

Pathology. The fatty deposits are denser than normal fat tissue owing
to the more abundant connective tissue supporting framework. Atrophy
and sclerosis of the thyroid gland have been observed and in one instance a
tumor of the pituitary body was found. There may be degeneration of the
cutaneous nerves with interstitial neuritis and the fatty tissue may contain
haemolymph glands.

Symptoms. As adult life progresses and the patient's adipose tissue in-
creases it is noticed that the fat is unevenly distributed and that burning, shoot-
ing pains occur referred to the deposits of fat; these continue to increase in
size and there is increasing weakness without signs of degeneration of the mus-
cular system. Cerebration may become sluggish but there is no true mental
disturbance. Irregular areas of h}rperaesthesia or of anaesthesia may be ob-
served and there is frequently loss of the patellar reflex.

The prognosis. The coiirse of the disease is chronic and recovery appears
to be impossible. Death occurs from some intercurrent affection.

Treatment. The administration of extract of the thyroid gland seems to
lessen the severity of the symptoms in certain instances; it is given to the
point of tolerance and may prove effectual. The pains should be controlled
by the coal-tar analgesics, antipyrine, salip}Tine or acetphenetidine; codeine
may also be employed and, in cases of absolute necessity, morphine.

ACROMEGALY.

Definition. A chronic disease characterized by abnormal growth, par-
ticularly of the bones of the face and extremities.

.Etiology. The affection is rather more common in women than in men
and usually begins between the ages of twenty and thirty years. Syphilis,
rheumatism and the infectious diseases have been considered as predisposing
to the condition but their influence in its incidence is not proven. In the
light of recent research it is deemed probable that acromegaly together with
gigantism and dwarfism, occurs as a result of a disordered function of the
pituitary body.

Pathology. The bony hypertrophy is uniform and symmetrical; it
affects both the shafts and extremities of the long bones; the maxillae appear



ACROMEGALY. 84I

increased in size due to enlargement of the antrum of Highmore; this with
a true hypertrophy of the mandible causes the characteristic increase in the
size of the face. In a very large percentage of the autopsies which have been
made in this disease, involvement, usually hyperplasia, of the pituitary gland
has been found which has led to the hypothesis that the affection is caused
by a functional derangement of this structure and that the pituitary body
presides in some way over skeletal growth and that the enlargement of the
bones in acromegaly results from a hypersecretion of this organ. Persist-
ence and enlargement of the thymus gland has been observed in certain
instances as has also enlargement of the thyroid body as well as atrophy of
this structure.

Symptoms. The head and face are much increased in size, the latter
especially so; it is much lengthened as a result of widening of the alveolar