Complete Text (Part 14)

of latency. Intracranial Abscess, Onset slow. No signs of suppuration. Tempera- ture normal or nearly so. Headache usually intense, often accompanied by vertigo and vomiting. Optic neuritis in four-iifths of all cases, often intense. Pulse often slow. Course usually long and for the most part steadily progressive with mental failure toward the end. Convulsions or any form of focal or cranial nerve symptom may occur. Inherited or acquired predisposition to new growths sometimes apparent. Intracranial Tufnor^ Aneurism or Cyst, Onset slow, without fever and without intense optic neuritis or slow pulse. Patient alcoholic or syt^hi- 176 NERVOUS AND MENTAL DISEASES. litic. Organic disease indicated by spasm or par- alysis in the domain of cranial nerves, rarely in the limbs. Chronic Meningitis. B. Positive signs of disease of the brain or membranes absent but there is evidence that the cerebral vessels are diseased. 1 . The patient is past forty. The arteries are atherom- atous and pulse hard. Headache is throbbing and is increased by exertion or excitement. Heart often hypertrophied and some albumen is usually found in the urine. Arteriosclerosis, 2. Headache chiefly nocturnal and accompanied by in- somnia. Age and general condition exclude senile degeneration. Syphilis can not be excluded and is usually manifested by some of its characteristic signs. Premonitions of focal symptoms and rapid mental deterioration, without other assignable cause may shovsr that the cerebral circulation is greatly disturbed. Syphilitic Endarteritis, C. Headache follows a blow on the head. No positive signs of organic disease. Traumatic Headache, D. The headache forms part of the periodic attack of mi- graine or epilepsy. Complete freedom between attacks. Family history of similar attacks or of other neuroses common. 1 . Pain unilateral, at least at first, and accompanied by nausea and intolerance of light or noise, often by partial darkening of the field of vision or subjective sensations of light or color. Often complicated by hysteria. Migraine, 2, Headache precedes or follows an epileptic convulsion or an attack of petit mal. Epilepsy, E. There is no organic disease of the brain, membranes or vessels and the headache is not traumatic nor a part of a periodic neurosis. I. Headache appears at the same time as fever and usually disappears if delirium supervenes. There is THE PAINS OF NERVOUS DISEASE. evidence of a generiil infection, usually one of the specific fevers. Meningitis may sometimes be closely siimilated, especially as the pupils may be unequal (e.g:, in pneumonia or tonsillitis), the head retracted {e.g., in typhoid fever), or even optic neuritis be present in very rare cases, but other indications of organic disease arc absent. Infectious Fever. . A toxic substance is active in the system. Pain may be diffuse and dull or in definite areas and of a neu- ralgic character. a. The urine contains sugar and the patient suffers from polyuria, thirst, weakness, etc. Diabetes. b. The urine contains albumin or casts or its specific gravity and total quantity indicate deficient elimi- nation of urea. Pallor and edema are often manifest and there mayalso be a characteristic ret- initis. Uremia. c. Urine free from albumin and sugar, but at times is dark and deposits urates. Headache worse in early morning and tends to wear off during the day ; often accompanied by depression of spirits. Uric acid accumulations indicated by attacks of rheumatism, gout, tonsillitis, gravel, etc. Uric Acid Diathesis. d. History of excessive consumption of alcohol. There may be gastric catarrh, morning vomiting, characteristic odor of breath, tremor, insomnia, etc. Alcoholism. e. Digestion is perverted, as shown bj' abdominal distress, eructations, flatulence ur other symptoms. Headache is usually dull, comes on soon after eating or is a sequence of eating some particular food, and is temporarily relieved by purgatives and intestinal antiseptics. To be distinguished from the reflex pain of gastric or intestinal disease. Indigestion. f. Patient has lieen exposed to lead which may per- 178 NERVOUS AND MENTAL DISEASES. haps be found in the urine. There may be the blue line on the gums, colic with constipation or bilateral wrist drop. Plumbism, 3. No infective or toxic cause but the cerebral circula- tion is disturbed. a. Headache throbbing, follows excitement or exer- tion and may be associated with a flushed face or injection of the conjunctivae. Increased by cough- ing, sneezing, straining or lowering the head. Active Hyperemia, b. Headache dull and heavy. Return of venous blood obstructed by mitral regurgitation, tumor of the neck, constriction or other cause. Passive Hyperemia, c. Heart action weak or blood impoverished, as shown by pallor of skin and mucous membranes, faintness, low percentage of hemoglobin, paucity of red corpuscles, etc. Pain may be of a neu- ralgic character in definite areas. Anemia, 4. No infective, toxic or circulatory cause but there is a reflex disturbance. The pain, accompanied by super- ficial tenderness, is felt in definite areas and is generally called neuralgia. a. There is an error of refraction with overwork of the ciliary muscle, disease of the eye-ball or rarely a loss of muscle balance alone. The pain is mainly in the orbital region {e, g;^ strain of cili- ary muscle), the fronto-tcmporal region (e, ^., cyclitis) or the temporal region {e, g,^ glaucoma), sometimes back of the eye. In strain of the ciliary muscle the pain appears in the morning, is aggra- vated by near work and is relieved by rest of the eye. Often a complication of neurasthenia. Ocular Headache, b. The pulp of one or more teeth is diseased or the teeth are crowded by a faulty eruption. Reflex pain is felt in the naso-frontal area (upper in- THE PAINS OF NERVOUS DISKASB. cisors). the temporal area (second upper bicus- pid) or one or more of the other pain areas of the Bice and neck, according to the tooth affected. u oT reflex omfeiTcd pain ■ccordineto Ihe rocarcbn of Henry H«d. Generally described as neuralgia, although the areas of pain do not strictiv correspond to the distrib* tion of individual uer'es. Dental Headac c. There is disease of the tympanic cavity or dn NERVOUS AND MENTAL DISEASES. membrane. The pain is most intense in the ear and back of the angle oi the jaw, but may extend I of refle* or referreiJ pain according; to Ihe resear over the vertical and parietal areas. Aural Headache. i. Purulent otitis is followed by mastoid disease and then by signs of pyemia. The obstructed THE FAINS OF NERVOUS DISEASE. l8l jugular vein may sometimes be felt in the neck as a cord. Thrombosis of Lateral Sinus. {May exist with or -without meningitis or abscess.) d. The pain is felt in the fronto-nasal or orbital area Fig. 27. or rcBei or rererred pain accordinfcto llie rcMarebM orHcary Head. l82 NERVOUS AND MENTAL DISEASES. and is associated with disease of the nose or its adjacent sinuses, increasing or diminishing with it. Headache may sometimes be markedly in- creased by touching the middle turbinated bone with a probe and relieved by the application of cocaine. Rare. Nasal Headache, e. The headache is added to pain and tenderness in the sensory areas of certain spinal segments (Figs. 28 and 29) as a secondary reflex pain, due to disease of some of the viscera within the trunk, i. Aortic regurgitation, aortic aneurism or mi- tral stenosis with regurgitation is present. Headache in the forehead or temple, mainly on the left side. Pain and tenderness in some of the areas of the first six dorsal seg- ments, often subject to severe exacerbations (angina pectoris). Cardiac Headache, ii. Active pulmonary disease exists. Headache may be in any part of the cranium, except the occiput, mainly on the side of the dis- ease. Pain and tenderness in some of the areas of the first seven dorsal segments. Pulmonary Headache, iii . A painful disease of the stomach exists . Head- ache in the temporal, vertical or parietal re- gion. Pain and tenderness in some of the areas of the sixth to ninth dorsal segments. Gastric Headache, iv. An irritating disease of the intestine exists. Headache parietal or occipital. Pain and tenderness in some of the areas of the ninth to twelfth dorsal segments. Intestinal Headache, V. There is disease of the liver or its appendages. Headache temporal, vertical, parietal or oc- cipital. Pain and tenderness in some of the areas of the seventh to tenth dorsal segments. Hepatic Headache, THE PAINS OF NERVOUS DISEASE. ■83 vi. There is a piiinful disease of the kidney or ureter, most frequentiy calculus. Headache occipital. Pain and tenderness in some of the areas of the tenth to twelfth dorsal segments. Renal Headache. vii. There is disease of the prostate. Headache occipital. Pain and tenderness in some of the areas of the tenth to twelfth dorsal, first lumbar or first to third sacral segments. Prostatic Headache. viii. The ovary or testicle is diseased. Headache occipital. Pain and tenderness in area of tenth dorsal segment. Ovarian or Orchitic Headache. No infective, toxic, circulatory or reflex cause ap- parent. a. Nervous energy exhausted from any cause, par- ticularly by prolonged worry with overwork or other excess combined vvith impaired nutrition. The patient may for a short time exert normal mental and bodily jMiwers, but soon becomes fa- tigued and irritable. Sensations in the head are often described as queer and disagreeable rather than painful, such as tightness or looseness of the scalp, lightness, heaviness or increiised volume of the head, inability to think, etc. A lack of zest for ordinary nffairs and morbid fe-.irs are common- Painful and superficially tender spots are usually found along the spine as well as in the head. Ncu rasth enia. b. Headache appears and disappears in accord with III. Spi emotional changes Often limited to a pie (clavus). Vat present. Ill pain. Pain felt in o: iding into the sensorv art ing segments of the spinal cord. in response to suggestion. lall spot at vertex or in tem- is signs of hysteria may be Hysteria. ear the spinal column, often supplied by the correspond- J 184 NERVOUS AND MENTAL DISEASES. A. Accompanied by signs of organic spinal disease, such as deformity of the spine ; absence of knee-jerk ; typical clonus; degenerative atrophy of muscles with loss of faradic irritability (without signs of neuritis) ; the com- bination of paraplegia with more or less sensory loss, the upper limit of both corresponding to the function of a spinal segment ; impaired control of the bladder, etc. 1. Paraplegia, more or less sensory loss and impaired control of the bladder and rectum appear early. The upper limit of the motor and sensory loss corres- ponds to the function of a segment of the spinal cord and is often marked by a zone of hyperesthesia im- mediately above it. Spinal rigidity and radiating pains generally absent. a. Onset sudden. i. Simultaneous with severe injury to the spinal column. Fracture or Dislocation of Vertebrce^ Wound of or Hemorrhage into the Spinal Cord, ii. Without external violence. Hemorrhage into Cord, b. Onset gradual, acute or chronic. Vertebrae not diseased. Pain dull, not a prominent symptom. Myelitis, 2. Spinal rigidity accompanies pain. Corresponding radiating pains common. If paraplegia, sensory loss and impaired control of the bladder and rectum occur, it is later in the course of the disease. a. Deformity or swelling and deep-seated tenderness indicate disease of the vertebrae. . Paraplegia, sen- sory loss and impaired control of bladder and rec- tum eventually occur unless the disease is arrested, i. Patient most commonly a child, sometimes a young adult, rarely an elderly person. The tubercular diathesis is generally manifest but very rarely syphilis may be the cause. Pain THE PAINS OF NERVOUS DISEASE. usually of moderate severity, increased motion or jars and diminished by rest o£ the spine. Prominciice or lateral displacement of one or more spinous processes is the character- istic defonnity. Spinal Cartes. ii. Patient generally in the second half of life, sometimes with a history of tumor elsewhere or of predisposition to new growths or aneur- ism. The pain is very intense and is very greatly aggravated by motion, § The radiating pain is on the left side of the cheat. Characteristic thrill and mur- mur at the seat of pain and deformity. Aneurism Eroding Spine. S5 Radiating pain usually on both sides. No thrill or niurmur. Spinal Tumor. b. Localized spinal pain and rigidity gradually occur, most frequently in the cervical region, in a patient predisposed to arthritis deformans, evidence of which may be apparent in other parts of the body. Radiating pains and other root symptoms may occur but arc not follo^ved by paraplegia or other cord symptoms. Rare. Vertebral Arlhriiis Deformans. c. Nothing to indicate disease of the vertebrae. i. Onset sudden. No fever at first. spinal Meningeal Hemorrhage. ii. Onset acute, marked by chill and fever. Acute Spinal Meningitis. iii. Onset chronic. S History of alcoholism, syphilis or exposure to cold. Chronic Spinal Meningitis. §§ Evidence of predisposition to new growth. No other cause of meningitis. Intraspinal Tumor. B. Not accompanied by signs of organic spinal disease. I . Pain and superficial tenderness in the back and in the by I i88 NERVOUS AND MENTAL DISEASES. sensory areas of corresponding segments appears in connection with visceral disease and increases or di- minishes with it, constituting the referred or reflex pain of visceral disease. The correspondence of the painful areas to the particular organ diseased is shown in the following table, which is taken from the work of Dr. Henry Head. It must be remembered, how- ever, that febrile and toxic conditions without demon- strable localized disease may cause the same areas to become painful. Often called neuralgia. rWI^AW TklGTrAGlTTk SPINAL SEGMENTS WHOSE SENSORY CRANIAL AREAS IN WHICH %jM%\rAn XJk%3B$A*3MStXJm AREAS ARE PAINFUL. PAIN MAY ALSO BE FELT. Heart, I, 2, 3 dorsal (angina pectoris), Orbital. Lungs, 3,4 cervical, i, 2, 3, 4, 5 dorsal. Fronto-nasal, orbital, fronto-temporal, tem- poral. Ascending Aorta, I, 2, 3, 4 dorsal. Orbital, fronto-tem- poral. Arch of Aorta, 5, 6 dorsal, Fronto-temporal . Stomach, cardiac. 6, 7 dorsal. Fronto-temp., temporal. Stomach, pyloric. 8, 9 dorsal. Vertical, parietal. Liver and append- 7, 8, 9, 10 dorsal. Temporal, vertical, pa- ages, rietal, occipital. Intestine, 9, 10, II, 12 dorsal. Parietal occipital. Kidney and ureter. , 10, II, 12 dorsal, Occipital. Prostate, 10, II, 12 dorsal, 5 lumbar, i, 2, 3 sacral. Occipital. Ovary or testicle, 10 dorsal. Occipital. Rectum, 2, 3, 4 sacral. Epididymis, II, 12 dorsal. Oviduct, 11, 12 dorsal, i lumbar. Bladder, mucous membrane and neck. I, 2, 3, 4 sacral. Bladder, over-dis- tension and in- effectual con- traction. II, 12 dorsal, i lumbar. Uterus, in con- traction. 10, II, 12 dorsal, i lumbar. Uterus, OS, I, 2, 3, 4 sacral (5 lumbar very rarely). THE PAINS OF NERVOUS DISF^SE 1S9 2. The pain is most frequently in the lumbir, some times in the dorsal or cervical region, and is gen- erally worse in the morning, tending to wear off during the day. Th-ere is evidence of » rheumitic condition, such us rheumatism in other parts of the body, a history of previous rheumatic attacks, marked variations corresponding to changes in the weather, the alternation of scanty and excessive elimination of urates, great relief from the administration of salicy- lates, etc. Not a nervous disease, bnt included here because it must often be carefully distinguished from more serious diseases which are likely to be mistaken for it. Rkeumalism. 3. There are moderately painful and superficially tender spots along the spine and often in the head. Ner- vous energy is exhausted from some cause, usually by prolonged worry with overwork or other excess combined with impaired nutrition. The patient may for a short time exert normal mental and bodily powers but soon becomes fatigued and irritable. Queer sensations in the head are often complained of, such as tightness or looseness of the scalp, light- ness, heaviness or increased volume of the head, in- ability to think, etc. Morbid fears and a lack of interest in ordinary affairs are common. Ne urasthenia. 4. The pain comes and goes in accord with emotional changes or in response to suggestion. Although it and the accompanying superficial tenderness may appear to be intense, both disappear or are greatly diminished when attention is strongly engaged by something else. Various other signs of hysteria may be present. Often combined with neurasthenia. Hysteria. . Piiin felt in the trunk or extremities not accompimied by corresponding spinal pain nor definitely referred to the dis- tribution of certain nerve trunks. IpO NERVOUS AND MENTAL DISEASES. A. There are signs of organic disease of the brain or cord. 1. The patient has suffered a cerebral vascular lesion, most frequently softening in the region of the basal ganglia and the pain is due to irritation of the sen- sory tract. Post'hemiplegic Pain, 2. The pain consists of lightning pains in the lower limbs or trunk, or has the character of "crises" (gastric, laryngeal, vesical, rectal, etc.). Absence of knee-jerk with x\rgyll-Robertson pupil, ataxia or urinary difficulty makes the diagnosis clear. Tabes. 3. Pain may be like that of neuralgia or that of tabes. There is loss of sensibility to temperature and pain with preservation of touch. More or less paralysis occurs, usually atrophic in the arms and spastic in the legs, together with various trophic symptoms, the whole group of symptoms being such as might be caused by chronic disease mainly affecting the gray matter of the cord. Syringomyelia, B. There are no signs of organic disease of the brain or cord. 1 . Pain caused by arrest of circulation, which is usually in the extremities (fingers, toes, nose, ears) and symmetrical, but is sometimes unsymmetrical and may affect the trunk and proximal parts of limbs. The disease begins with local pallor and a feeling of icy coldness (local syncope), which, after a variable time, is followed by cyanosis (local asphyxia) and later by gangrene. The symptoms are aggravated by cold and relieved by warmth. In the cyanotic and gangrenous stages the pain may