recovery can not be expected for several months. jority of cases, however, recover completely.

The ma

Treatment.-Cases due to cold and exposure are best treated by large doses of the salicylates; syphilitic cases, by the use of iodid of potassium in large doses. Warm fomentations are of use in many cases. In the severer cases a blister should be applied behind the ear. In case of severe pain, antipyrin and phenacetin are of value. The application of weak galvanic currents preserves the nutrition of the muscles and hastens recovery.

DISEASES OF THE AUDITORY NERVE.

Symptoms of the affection of this nerve consist in impairment of hearing or complete deafness. Disease in the labyrinth is the most frequent cause. It may be due to acute or chronic inflammation, spreading from the tympanum, to syphilis, or, in old persons, to degenerative changes. It may result from tumors and meningitis. Atrophy may occur in tabes, and may appear in elderly persons.

DISEASES OF THE GLOSSOPHARYNGEAL NERVE.

Very little is known of diseases of this nerve, owing to its numerous connections and absence of isolated lesions. It is most likely that paralysis of the nerve gives rise to difficulty in swallowing, and to loss of sensation in the roof and walls of the pharynx. It has as yet not been determined whether the glossopharyngeal nerve is a special nerve of sense or not.

DISEASES OF THE PNEUMOGASTRIC OR VAGUS NERVE. This nerve has a long course, being distributed to the pharynx, esophagus, larynx, lungs, heart, stomach, spleen, and intestines. Paralysis may occur from disturbance within the skull, such as injury, and from pressure by morbid growths, meningitis, or aneurysm. The nucleus of the nerve may suffer from inflammatory changes. Causes outside of the skull may be due to surgical operations in dividing the nerve or to compression by tumors.

Symptoms.-Division of the nerve in animals is followed by an increase of cardiac action, while the respiration becomes slower and more pronounced. The same symptoms occur when the nerve is divided in man from surgical operations or

from injuries. Paralysis of the vocal cords is likely to occur. There is difficulty in swallowing and vomiting is frequent. Treatment.-The treatment is symptomatic.

DISEASES OF THE SPINAL ACCESSORY NERVE. Diseases similar to those which give rise to disease of the pneumogastric also affect the spinal accessory. When the external part of the nerve is diseased, paralysis of the sternocleidomastoid and upper part of the trapezius occurs. This is followed by wasting.

Treatment. The treatment is symptomatic.

DISEASES OF THE HYPOGLOSSAL NERVE.

This is purely a motor nerve, supplying the muscles of the tongue. Paralysis occurs from cerebral lesions involving the fibers of the nerve from the cortex to its nucleus. Lesions of the nucleus are most often bilateral. Locomotor ataxia and syringomyelia give rise to unilateral disease. Peripheral paralysis is extremely uncommon.

NEURALGIA.

Definitions.-Neuralgia is a term used to denote pain in the course of a nerve, unattended by structural change. The border-line between neuritis and neuralgia can not be too closely drawn, but the term neuralgia should be used to express pain unattended by motor or trophic changes.

Etiology. Neuralgia is particularly a disease of middle life. It is rare in childhood and in old age, and occurs more frequently in men than in women. Some females show a hereditary tendency to neuralgia, and it is frequent in neurotic females. It is common in debilitated and anemic individuals, frequently accompanying overwork and worry. The disease is often unilateral, and when so, the left side is more frequently affected than the right. Cold is a common exciting cause, as are malaria and gout. Irritations of various kinds, such as a carious tooth, may produce neuralgia. Eye-strain is a predisposing cause.

Symptoms.-Pain is the most important symptom. It shows a marked tendency to periodicity, and is paroxysmal in nature, being described as burning, shooting, or darting in character, not increased by motion, and often relieved by

slight pressure or friction. There may be increased secretion of saliva and tears, and a slight elevation of temperature. Muscular twitchings may occur. The duration of an attack varies from an hour to a day or more. Neuralgias show a constant tendency to recur at irregular intervals.

Neuralgia is very common along the course of the fifth nerve, when it has been called tic douloureux. It may involve the branches of the fifth nerve, and when it involves the ophthalmic branch, a tender point at the extremity of the nerve-the supraorbital notch-is indicated by the patient. When it involves the second branch, the infraorbital region is painful, and in the inferior maxillary division the tender point is in the region of the zygomatic arch.

Other forms of neuralgia are known as cervico-occipital, brachial, neuralgia of the phrenic nerve (which is exceedingly rare), intercostal neuralgia, lumbo-abdominal neuralgia, visceral neuralgia, sacral neuralgia, coccygodynia, and neuralgia of the feet. By the term reflex neuralgia is meant pain due to disease in organs distant from the actual seat of pain. This may occur in diseases of the eye, ear, nose, and throat, in diseases of the stomach and liver, or in uterine disease.

Prognosis. The prognosis as regards recovery is good, although the disease is extremely stubborn, and shows a constant tendency to recur.

Treatment. It is especially important to treat the underlying condition: thus, if the disease be reflex, it is important to give attention to the affection giving rise to it; if it be anemia or malaria, these causes must be given full attention. Hygienic treatment is of importance. Change of scene and residence, with good nourishing diet, are necessary. Many drugs have been recommended for the treatment of the paroxysm-quinin, the coal-tar analgesics (such as phenacetin), antifebrin, and so on. A combination of phenacetin and caffein, or a combination of phenacetin and salicylate of sodium, may be of use. Morphin should be avoided if possible, as there is great danger of the patient acquiring the opium habit. Aconitin, gelsemium, and belladonna are valuable. Local treatment is sometimes of use; thus, hot and cold applications, liniments containing menthol, and occasionally electricity may be tried. In protracted cases surgical interference should be thought of. liant results.

Often surgery has rendered bril

DISEASES OF THE SPINAL CORD.

ACUTE SPINAL MENINGITIS.

Definition. This term includes the various acute inflammations which affect the spinal pia mater or dura mater. If the inflammatory condition involve chiefly the pia mater, the process is diffuse, and extends often to the internal surface of the dura mater. A separate affection of the dura, as in acute purulent inflammation, occurs only secondary to disease of the bone or from trauma.

Synonyms.-Acute spinal leptomeningitis; acute internal

meningitis.

Etiology. The disease is always due to infection from micro-organisms, and most frequently the micro-organisms are of the pyogenic group. In tuberculosis in which disease of the cerebral membranes also occurs the spinal membranes are likely to be affected. Cerebrospinal fever, an affection of the membrane of the cord, is almost constantly associated with inflammation of the membranes of the brain. The affection arises in the course of the acute infectious fevers, such as croupous pneumonia, scarlet fever, enteric fever, and smallpox, and in the course of pyemia and septicemia. The disease may result from direct or indirect injury to the spinal column, from fractures or wounds, or from operation on the vertebral column. This affords a ready access to bacteria causing infection. Acquired syphilis of recent origin may give rise to an acute inflammation of the membranes of the cord, but this is rare, the process being much more likely to be subacute-that is, nonsuppurative. The affection appears more commonly in men than in women, and is more frequent before early adult life than after this period. Exposure to cold and wet, traumatism, and overexertion may be said to be predisposing causes.

Pathology. In the first stage of the disease the internal membranes are hyperemic; later, an exudate forms, which may be fibrinous, semisolid, fluid, pus-like, or purulent. Microscopically, numerous leukocytes, a few red blood-cells, and fibrin are noted in the exudate. The inflammatory process may spread to the nerve-roots. When the pathologic process is of a tubercular nature, a gelatinous exudate is encountered, and

tubercles are noticed. The cord may be invaded by the pus, producing myelitis.

Symptoms. As the lesions are rarely entirely spinal, and as parts of the cerebral meninges are also involved, the purely spinal symptoms are likely to be masked by the cerebral symptoms. It is, therefore, rare that the symptoms should alone be associated with cord phenomena. The disease usually begins with well-marked chills and a temperature which is of the septic type. There is severe pain in the back, increased by motion, which radiates into the upper and lower extremities. Rigidity of the muscles of the back, and sometimes opisthotonos, occurs. Tonic spasm in the muscles of the extremities and of the abdomen and chest is prominent. Occasionally tonic spasm gives place to clonic spasm. Hyperesthesia is general and marked, the reflexes are exaggerated, and ankle-clonus is pronounced. There may be retention of urine and feces from paralysis of the sphincters. Kernig's sign may be present. (See page 251.) If the acute symptoms subside, paralyses show themselves, paraplegia being the most common form. The reflexes become normal, and finally disappear, so that loss of knee-jerks occurs late in the disease. In severe cases death may take place in a few days. In the majority of instances the duration is from one to two weeks. Even in cases in which recovery occurs, rigidity and weakness of the muscles may last for months or years.

Diagnosis. The direct diagnosis depends upon the severe pain in the back, radiating to the upper and lower extremities, and upon the rigidity of the muscles, the hyperesthesia, and the acute febrile course, with septic phenomena.

Prognosis.-Danger to life is imminent, and it is usually proportionate to the severity of the symptoms and the gravity of the fever. Traumatic cases are most liable to recover, especially when the affection occurs in persons in middle life; however, the prognosis must be put down as exceedingly serious.

Treatment.-Absolute rest in bed is important. If the patient can be induced to lie upon his side, it is better than to have him rest upon the back. Mild laxatives are useful. Severe pain should be counteracted by the use of opiates. Dry or wet cups along the spine are useful, followed by the application of ice-bags. Gowers favors mercurial inunctions. For the contractures and pain which arise during the course of the disease, hot baths and hot douches are of use. If there