before meals or two or three hours after.
The disadvantage of the bromide treatment is the likelihood of causing
bromism which is manifested by drowsiness and hebetude, digestive disorders,
cardiac distress and the t}'pical bromide acne. It is difficult to mitigate these
unpleasant symptoms unless the drug is stopped; the most approved measures
to prevent their occurrence are the employment of salt water baths, massage
and regular exercise with the administration of the bitter tonics, iron, cod-
liver oil and the mineral acids. The acne may be prevented by the adminis-
tration of arsenic, the unpleasant bromide eructations by combining the
bromide with an alkali, though this may disturb the bladder, this disturbance
may be relieved by giving the bromide in hydrobromic acid. The best
method of taking these salts is in carbonic or Vichy water in proportion of
about ^ drachm (2.0) to a glass full.
In some cases, especially those in which the drug causes digestive disturbance,
the bromides are ineffectual; in these obstinate cases they may be combined
with solanum carolinense (the fluidextract, J to 2 drachms — 2.0 to 8.0 — tliree
or four times daily) and for patients whose intolerance to the bromides neces-
sitates their omission, this drug alone may be prescribed.
It is said that if the sodium chloride of the diet is restricted or omitted
entirely the bromides will prove more effectual and smaller doses may be
Hydrated chloral and chloralamide are useful adjuncts to the bromides
but should be, especially the former, given with care. Five to ten grains (0.33-
0.66) of chloral may be combined with a diminished amount of bromide and
given with good effect. Another combination which is deserving of trial is
one of antip}Tine, 6 grains (0.40) and ammonium bromide, 10 grains (o.66j
given three times a day. Acetanilide may prove useful as also may mono-
bromated camphor in doses of 5 grains (0.33).
Other drugs which have enjoyed vogue in the treatment of epilepsy and
may be substituted for the bromides are the tincture of capparis coriacea,
I drachm (4.0) four times a day, belladonna, zinc iodide and oxide, sodium
borate, sulphonmethane and valerian.
In petit mal glyceryl nitrate given to the physiological limit is of service. Its
dosage varies mth the tolerance of the patient from y^-jj to 2t of a grain
(0.0006-0.0024). The bromides also are useful and antip}Tine, belladonna,
cannabis indica, ergot and general tonic treatment may be employed.
The treatment of the seizure. The patient whom an aura warns of a
coming attack is fortunate, for in amyl nitrite we have a fairly efficient means
of preventing its onset. This drug may be carried in the pocket in the form
of " pearls" or in a small bottle; the former may be broken at the appropriate
time and the contents inhaled. Other methods of aborting a paroxysm
are the inhalation of ammonia or chloroform, pressure over the carotid arteries,
the internal administration of alcohol or aromatic ammonia spirit. Brower
reports a patient whose aura began in the hand; about the wrist he wore a
noose of thread which, when the warning appeared, he would tighten thus
stopping the progress of the paroxysm.
During the attack the patient should be prevented from doing himself injury
and some such object as a spool, a bit of wood or a roUer bandage should be
inserted between the teeth to prevent biting of the tongue.
The status epilepticus should be combated by hydrated chloral given per
rectum and the stomach and bowels should be emptied by lavage or by emetics
and purges. Bleeding may be employed.
The treatment of epileptics at special institutions or colonies is strongly to
be advocated. Here the mode of life may be properly regulated, the mind
of the patient may be kept congenially occupied and physical work within
proper limits prescribed.
Hydrotherapy. Systematic hydrotherapeutic measures are a useful adjunct
to treatment; under their employment there is less likelihood of inducing brom-
8o8. ■ DISEASES OF THE NERVOUS SYSTEM.
ism and causing acne. By increasing the eliminative process of the organism
as well as by the stimulating and tonic effect the tolerance for the bromide is
increased and its toxic power diminished. For a patient accustomed to a cold
morning tub this measure may be prescribed, otherwise he may be given a
dry or alcohol rub before rising; later the cold packs followed by a vigorous
rubbing are admissible; when the patient's condition permits, a hip bath be-
ginning a^ 90° F. (32.2° C.) for five to eight minutes may be given, the tempera-
ture being reduced one degree per day, until 80° F. (26.1° C.) is reached.
Another useful procedure is the douche. Both this and the hip bath should
be followed by vigorous rubbing by an attendant. Other balneotherapeutic
measures will undoubtedly suggest themselves as indications arise
Jacksonian epilepsy may often be traced to head injuries and in cases of
this type there is possibility of cure by removal of pressure upon the brain
by surgical means. In other forms of epilepsy surgery can be of no benefit.
Diet. The dietetics of this disease is most important and the fact that
this element in the management of epilepsy can be properly regulated in
institutions is a strong point in favor of the employment of this form of treat-
ment. The restriction of salt is a distinct advance in the treatment of this
condition. The patient soon learns to do without sodium chloride and
equally readily accustoms himself to the use of sodium bromide in its stead,
and even may prefer it. The diet itself should consist of plain, nourishing
and easily digested foods. Starchy indigestion should be avoided by guard-
ing against a too exclusively vegetable regimen. For breakfast the patient
may have fruit, a cereal, eggs, toast, rolls or biscuit and milk, buttermilk,
or cocoa; at dinner a puree or clear soup is allowable with fish, meat or fowl,
vegetables and a simple salad, with fruit, plain puddings or ice cream as
dessert. Supper may consist of bread or rolls, cold meat, oysters, sweet-
breads or calf's brain and stewed fruit, with milk or cocoa.
Alcohol, tobacco, tea and coffee, sweets, fried foods and rich made dishes
should be avoided.
Synonym. Thomsen's Disease.
Definition. A disease characterized by hypertrophy of the muscles and by
tonic cramp on attempting voluntary movement.
.Etiology. Myotonia congenita is an hereditary affection appearing, in all
typical cases, in early childhood and in certain families. It had appeared in
the family of its first describer, Thomsen, for five generations. Males are
much more frequently affected than females and the disease is more frequent
in Scandinavia and Germany than in England or America. The cases of
acquired myotonia seem to differ somewhat from Thomsen's disease.
MYOTONIA CONGENITA, 809
Pathology. The muscles, especially those of the limbs, are larger than
normal and may be the seat of a true h)rpertrophy; they are, however, much less
powerful than their appearance would imply. Microscopically the muscle
fibres are sometimes enlarged and their nuclei increased although the results
of late research seem to show that this enlargement is not characteristic of the
disease; the intramuscular connective tissue may be increased and degenerative
and regenerative changes have been observed. The theory has been advanced
that the condition is the result of an autointoxication of the muscular tissue
due to disordered metabolism.
Symptoms. The onset of the disease occurs in childhood and is first evi-
denced by a muscular stiffness which causes a delay in voluntary movement.
There is no paralysis and when a movement is begun it is carried out. Rapid
and accurate movement is impossible and a contraction may persist after
its end has been accomplished. The arms and legs are chiefly affected;
the gait is disturbed, in that there is a hesitancy at the start, after
a few steps there is no difficulty in continuing. The condition is accentuated
by excitement or cold. Rarely the muscles of the face, eye or larynx may
There is no abnormality of sensation or of the reflexes; the so-called myotonic
reaction of Erb is present and characteristic of this condition, the galvanic
and faradic irritability of the motor nerves being quantitatively normal and
short contractions result from briefly acting stimuli. With continuous excita-
tion by either current the contractions slowly reach their maximum and
slowly relax, while vermicular, wave-like contractions pass from cathode to
There is no atrophy or considerable loss of power except in so far as the
stiffness interferes with movement.
The disease resists treatment but the patients are often able to educate
themselves so that the disability is but slightly noticeable.
Treatment consists merely in attention to the general health and the employ-
ment of massage and gymnastic exercises.
Definition. A disease characterized by clonic contractions of various
groups of muscles, usually of the extremities, occurring either in paroxysms
etiology. Little is known of the causation of this condition. Heredity
seems to be a factor in that many cases give a family history of various types
of nervous disease. It is a disease of adult life and is more often observed in
the male sex. It has been known to follow emotional disorders and fright.
8lO DISEASES OF THE NERVOUS SYSTEM.
Pathology. The morbid anatomy of paramyoclonus multiplex is still
Symptoms. The most marked symptom is the occurrence of clonic
contractions involving chiefly the muscles of the limbs and trunk, rarely those
of the face. They are bilateral, as a rule, sudden, and as many as 150 per
minute jnay take place. Tonic spasms have also been observed. The con-
tractions are increased by emotional states, are diminished by voluntary
movement and are absent diiring sleep. At times the patient may emit a
grunting sound which perhaps is due to involvement of the larynx and dia-
phragm. Between paroxysms there may be muscular tremors. In marked
types of the disease the movements may be vevy violent and the patient may be
with difficulty kept in bed. There are no mental, sensory or trophic symp-
toms and the electric reaction of the muscles is unchanged, though an electric
stimulus may incite a paroxysm. The tendon reflexes are exaggerated.
The prognosis with regard to complete recovery is poor, the condition,
usually persisting for a number of years, although it may prove fatal within a
Treatment consists in the employment of measures calculated to improve
the general health, tonics, out-of-door life, nourishing food, etc. All possible
excitement must be avoided. Arsenic, iron and phosphorus may be given
and a course of hydrotherapy at a suitable institution may prove beneficial.
The marked paroxysms of the severe types of the disease may necessitate the
hypodermatic administration of morphine.
Synonyms. Shaking Palsy; Parkinson's Disease.
Definition. A chronic nervous affection characterized by muscular tremors,,
weakness and rigidity.
^Etiology. The causation of this disease is obscure. It occurs most often
in individuals belonging to families in which other nervous diseases have
appeared, is usually seen after the age of forty and is more common in males
than in females. It may follow malaria and other infectious diseases and is
predisposed to by alcoholism and sexual excess. Of exciting causes, exposure
to cold, injuries, worry and mental over-exertion may be mentioned.
Pathology. There is no characteristic lesion but the disease is probably
the result of some change in the cerebral cortex. The theory has been ad-
vanced that it is due to prematiire senile changes in the brain. Dana suggests
that in paralysis agitans there is destruction and degeneration of the dendrites
of the cells of the anterior cornua of the cord interfering with the even progress
of motor impulses, leading finally to motor weakness and rigidity, owing to-
PARALYSIS AGITANS. 8ll
severence of the connection between these ceils and the brain, these mani-
festations having been preceded by a functional disturbance. According to
Gordinier the primary change is in the blood-vessels, later spreads to the
adjacent neuroglia and results in patches of perivascular sclerosis; the abnor-
malities which have been observed in the anterior horn cells and in those of
the motor cortex being due to diminished nutrition dependent upon the
Symptoms. Of these tremor, either constant or intermittent, and usually
first affecting the hands, is earliest noted. The onset of the disease is slow
as a rule although it may develop suddenly after exposure, trauma or emotion.
The tremor of the hands is characterized by movements of forefinger and
thumb resembling those made in rolling a pill; rotation and tremor of the
forearm is also present. The arm is seldom affected and the movements of
the lower Hmbs are most marked at the ankle joints. There may be nodding
movements of the head. The movements at first are absent during sleep
but finally remain present at all times. By an effort of will the patient may
check the tremor but it returns, often exaggerated in degree. It is increased
by excitement or emotion but may cease in states of excessive rigidity.
The accompanying muscular weakness is present in greater or less degree
and is most apparent when the tremor is marked. Entire loss of muscular
power is rare.
The rigidity is evidenced by impairment of activity, movement is stiff and
retarded. This symptom is progressive and results in the attitude typical
of the disease. Here the head and body are bowed, the elbows are flexed
and held away from the body; the knees may interfere in walking and the
patient may seem about to fall forward. He walks with eyes upon the ground
before him and takes quick, short steps, acting as if he were about to fall for-
ward and were endeavoring to prevent this calamity by continually changing
his center of gravity. If pushed backward he is likely to fall being unable
to maintain his balance. The facial appearance is changed being expres-
sionless and mask-like. Saliva may dribble from the partly open mouth or
if this is kept closed, it may be found full of this secretion owing to delayed
deglutition. The voice may be high-pitched and the speech slow, though if
the lips and tongue are involved in the tremor, the patient may stammer. The
reflexes remain unaltered or rarely are exaggerated. There may be altered
temperature sense but otherwise there is no sensory abnormality. The
skin may be thickened, particularly that of the forehead, it may flush easily
or perspire excessively. The temperature, bowels and bladder are unaffected
but there may be areas of heightened surface temperature.
The prognosis. The course of the disease is slow and gradual and, while
periods of intermission may occur, its progress is continually toward the
worse, lasting for years, the patient usually dying from intercurrent disease.
8l2 DISEASES OF THE NERVOUS SYSTEM.
Treatment directed to the arrest of the condition is unavailing, consequently
we can do little except to care for the patient's general health by the adminis-
tration of proper food and tonics. Fresh air, exercises, electricity, massage
and warm bathing are indicated.
With regard to drugs hyoscine hydrobromide in doses of gr. yj-g- to y^Q-
(0.000570.0006) or atropine, grains y^g- to -g-V (0.0006-0.001) may be given
hypodermatically two or three times a day, depending upon the severity of
the symptoms, and opium, arsenic, potassium iodide and duboisine may be
tried. Hot moist or dry compresses may be applied to the muscles if these
are painful and if hyperexcitability of the nervous system is present, the
bromides and hydrated chloral may be employed with benefit.
This term is applied to reflex convulsions occurring in children and to the
convulsions of the puerperal state in women.
Synonyms. Infantile Convulsions; Epilepsia Acuta.
Definition. Convulsions due to peripheral reflex irritation.
Etiology. Convulsions in children may result from very slight causes
usually reflex in character and due as a rule to digestive disorders, such as
inflammations, intestinal parasites, foreign bodies, faecal accumulations,
vesical calculi, rickets, nephritis, and the infectious fevers. Children of
neuropathic heredity are prone to exhibit this manifestation and it is the
result of a hyperexcitable state of the nerve centers permitting sudden, excessive
and transient discharges of nerve force.
Symptoms. The seizure may vary from mere twitching or clinching of the
fingers to marked convulsive paroxysms closely resembling those of epilepsy
(see p. 803). The attack may be single but often several convulsions may
appear following one another at intervals of hours or days. Rarely does
the seizure end in death. Frequently repeated convulsions may induce the
"convulsive habit" and from this epilepsy may result.
The attack may appear without prodromal symptoms or it may be pre-
ceded by malaise and restlessness. The seizure is often accompanied by
rise in temperature.
The prognosis of infantile convulsions depends upon the causative factor
and the age of the patient. Life is seldom endangered except in very young
infants and rachitic cases. Permanent brain impairment is rare but may
occur. Convulsions at the onset of an infectious disease are rarely fatal and
may not augur a severe type of the infection. Nephritic convulsions are
PUERPERAL ECLAMPSIA. 813
serious and in those of whooping cough and of asphyxia, the worst is to be
Treatment. The child suffering from convulsions should be kept perfectly
quiet. The mustard bath is better omitted and a mustard pack substituted.
The latter is made by adding to one quart of tepid water a tablespoonful of
mustard; a towel is wet in this and while dripping is wrapped about the patient's
body; outside this a blanket is wrapped and he is allowed to lie in it for ten to
fifteen minutes. At the end of this time the skin should be well reddened.
The pack may be repeated at intervals as indicated. Cold compresses should
be applied to the head. If the convulsion is of severe type chloroform sufl&-
cient to control it should be administered and at the same time an enema of
hydrated chloral dissolved in an ounce (30.0) of warm milk should be given.
A child of six months may receive 4 grains (0.26), a child of one year 6 grains
(0.4). This should be injected through a soft catheter passed high into the
rectum, the buttocks being held together to prevent its discharge. If neces-
sary the dose may be repeated in an hour. When the convulsions persist
when the chloroform is stopped and in spite of the hydrated chloral, morphine
should be administered hypodermatically. To a child of six months ^^g-
of a grain (0.0014) may be given; to one of one year ^V of ^ grain (0.0025),
to be repeated in one-half to one hour if necessary. If the heart is weak
chloroform may be contraindicated but morphine may be given. Oxygen
inhalations may relieve the condition, especially in states of asphyxia when
other treatment is of no avail.
The convulsions being under control it remains to prevent their recurrence.
This is accomplished by continuing the administration of chloral in gradu-
ally diminished doses, with the addition of sodium bromide, or if the chloral
is not well borne by stomach or rectum, antipyrine or acetphenetidine in small
doses may be substituted. In addition to the above treatment the gastro-
intestinal tract should be cleared of all possible irritant material by the adm.in-
istration of J to ^ a grain (0.016-0.032) of calomel every half hour up to six
doses and by thorough washing out of the colon by means of a soft catheter
and warm normal saline solution.
The further treatment consists in the regulation of the patient's food and
mode of life, together with appropriate medication for the underlying condition.
The actual causation of this condition is not definitely known but it undoubt-
edly is the result of a toxaemia due to faulty metabolism and elimination. It
is often associated with the albuminuria of pregnancy although it is by no
means certain that renal lesion is its causation. The convulsions are usually
8 14 DISEASES OF THE NERVOUS SYSTEM.
preceded by a feeling of fulness in the head, dizziness and arterial hyperten-
sion and may occur either before or after the uterus is emptied, usually, how-
ever, before that event. The convulsions are both tonic and clonic and the
condition is one which jeopardizes the life of the patient, consequently all
possible measures should be taken toward its prevention by frequent urine
examination during the later months of pregnancy and careful watching
on the j^art of both patient and physician for premonitory symptoms.
Treatment. This consists, if the con\Tilsions appear before the birth of
the foetus, in emptying the uterus as rapidly as possible. The treatment
for the compulsion itself is to be carried out by the administration of chloro-
form and the employment of other means applicable to such conditions.
If the arterial tension is excessive and cyanosis is present, venesection and the
withdrawal of a considerable amount of blood should be practiced, the fluid
withdra"wn being replaced by the injection of an equal or larger amount of
normal saline solution either directly into the vein or into the muscular tissues
of the thighs or buttocks. The drug most likely to be of service is veratrum
and it is best given hypodermatically in the form of the tincture, 30 to 40
minims (2.0-2.66) and repeated until the arterial tension has been reduced to
The toxaemia should be treated by the administration of two to three copious
(i gallon-4 litres) high rectal irrigations of normal saline solution at a tempera-
ture of 105-110° F. (40.5-43.5° C), daily; moderate diuresis and other means
calculated to assist elimination are indicated. While any symptoms persist
the diet should be entirely of milk.
Synonyms. Intermittent Tetanus; Tetanilla.
Definition. A nervous afl'ection characterized by bilateral intermittent
or continuous tonic spasms of the extremities, seldom involving one limb
only and rarely becoming general.
^Etiology. The condition affects both adults and children. In the former
it occurs in a so-called epidemic or infectious form in certain parts of Europe
among young workingmen, especially shoemakers and taUors; as a result
of digestive disorders and the infectious diseases; as a complication of various
nervous diseases, notably exophthalmic goitre, syringomyelia and brain
tumors; follo^vdng morphine, ergot, chloroform, alcohol and lead poisoning;
in urgemic states; in pregnant and nursing women; and as a result of removal
of the th}Toid gland. In the last case it is probably due to the excision of
the parath}Toid bodies which have been removed with the gland.
In children tetany has been observed in digestive disorders, in the acute
infectious diseases and in rickets.
Pathology. This is not definitely known. It is supposed that the para-
th}T:oid glands exercise a neutralizing effect upon some poisonous substance
produced by metabolism. This theory would account for tetany following
the removal of these bodies, and the production of this poison in such an
amount that the parathyroids are unable to neutralize it may account for the
disease in other cases.
Symptoms. The spasm of tetany is usually limited to the limbs and ex-
tremities. The thumbs are flexed into the palms; the fingers are adducted
and flexed at the metacarpo-phalangeal joints, remaining straight at the pha-
langeal articulations. There is flexion at the wrists and elbows and the arms
are folded over the chest. In the lower limbs the hips, knees and ankles are
extended and the toes adducted or there may be flexion of the knees and dorsal
flexion of the feet. The skin over the extremities may be oedematous. The
muscles of the face, neck and body are seldom affected, but rarely there may
be trismus with drawing out of the angles of the mouth. Tenderness and
pain accompany the spasm as a rule. The contractions in children usually
last only a few hours; in adults they may be prolonged for several days or
even weeks. When the condition is very acute there may be acceleration of
the pulse and elevation of temperature.