Mental and Nervous Disorders

PLEASE Note: It is urged that the following introductory pages be consulted before reading the discussions of individual diseases which follow. The basic understanding of the causes and manifestations of the nervous disorders thus acquired will enable the reader to place a better evaluation on the particular nervous dis­ease in which he is interested.

General Considerations. The brain and spinal cord are composed of very fragile tissue. Both are protected by bones, the former by the skull and the latter by bony components of the ver­tebrae. In addition these organs are surrounded by durable fibrous cover­ings (the meninges), which provide further protection from injury.

Thus, despite their delicate nature, these or­gans of the central nervous system fare very well under normal conditions. But once they are attacked by disease, once their supply of blood is curtailed, or once they receive a mechanical impact violent enough to injure their delicate tissues, their welfare is in jeopardy. And when a part of the nervous system is deranged, other parts of the body, or even the entire body, suffer also.

In the case of nervous disorders, home treatment is usually not appro­priate. Furthermore, the outcome of most nervous disorders often depends upon whether the condition is recog­nized early enough to allow adequate and appropriate care to be given in time to save the life or at least to mini­mize permanent damage.

When symptoms develop which in­dicate disease of the nervous system, a physician should be consulted promptly. Every physician is trained in the recognition and handling of the usual nervous disorders, but a special­ist will be needed for those more com­plex.


Common Causes for Nervous Disorders
Many diseases and conditions in­volve the nervous system, some affect­ing only the organs of the nervous system but others, more general in na­ture, affecting additional parts of the body. The most common causes of nervous disorders are listed as follows:

A. Developmental Defects. When congenital faults of development affect the nervous system, the results to the individual depend upon just what part of the nervous system is affected and omthe degree of severity of the defect. Hydrocephalus an enlargement of the head due to an increase of cerebrospi­nal fluid within the brain is an exam­ple of developmental defects that may affect the central nervous system.

B. Infections and Inflammatory Dis­orders, These may affect the brain, spi­nal cord, or nerves just as they affect other tissues of the body. Two exam­ples are poliomyelitis and brain ab­scess.

C. Toxic, Metabolic, and Nutritional Disorders. These are conditions that often affect the entire body as well as the nervous system. Toxins produced by germs (as in tetanus, diphtheria, and botulism), absorption of certain heavy metals (such as lead), or the in­gestion of certain chemical agents (such as alcohol) , commonly cause damage to the brain and other tissues of the nervous system. Examples of metabolic disorders which affect the nervous system are phenylketonuria and diabetes. The nervous system is particularly susceptible to deficiencies in the diet, as when the B vitamins are insufficient.

D. Trauma. Although the organs of the nervous system are well protected by their bony coverings, falls or car accidents resulting in skull fracture or back injury may cause serious damage. In contusion, the delicate brain tissue is damaged by impact or by shearing stresses which pass through its sub­stance causing varying degrees of dis­ruption of the tissue.
Hemorrhage into the brain or spinal cord may cause damage by disruption of the tissue and also by the pressure of the resulting blood clot. In some cases of injury the healing process involves the develop­ment of extensive scars which may produce such irritation of the delicate tissues of the brain as to cause convul­sions. In some injuries certain of the nerves are torn, perhaps as they leave the brain to pass through the skull, or anywhere along their course to the structures they serve.

E. Vascular Disorders. The blood supply to the brain and spinal cord is very generous necessarily so because the cells of these active tissues are critically dependent on a continuous supply of oxygen and nutrient mate­rials. When the blood vessels of the body become diseased, the brain and spinal cord often suffer more quickly and more seriously than do other or­gans. Certain symptoms of senility are the result of a gradual diminution of the blood supply to the brain. When the blood supply to a particular part of the brain or spinal cord is shut off, the resulting symptoms are directly re­lated to the malfunction of this part. This is the usual background of a "stroke" in which a vessel becomes ob­structed.

F. Tumors. Tumors of the brain and spinal cord are classed as "benign" if they do not tend to grow rapidly and invade the surrounding tissue, or "ma­lignant" if they do grow rapidly and invade the surrounding tissues, thus eventually causing death. Tumors in­volving the brain or spinal cord are usually considered more serious than those involving other parts of the body because surgical treatment is more dif­ficult. Brain surgeons have become very skillful, however, in gaining ac­cess to most parts of the nervous sys­tem. The sooner a tumor of the brain or spinal cord can be treated, the more favorable will be the outcome.


Common Symptoms Produced by Nervous Disorders
Symptoms of nervous disorders differ in an important respect from symptoms of diseases involving primarily other parts of the body, mainly in that they arise from interference along the nerve pathways.


By comparing the human nervous system with a modern communications network, this peculiarity of nerve dis­order symptoms can be understood, the symptoms being caused by a "break in the lines," an interruption of the nerve fibers responsible for some particular activity of the body. That is, if the nerve fibers that control a group of muscles are severed, these muscles will be paralyzed even though they may be at a great distance from the actual site of the injury. Also, if some of the fibers which normally bring sensations from a certain part of the body to the brain are severed, the particular sensations carried by these fibers can no longer reach the brain and thus loss of feeling in that particular part of the body will result.

The important symptoms of nervous disorders are more directly related to the particular part of the nervous sys­tem affected than to the specific cause of the disorder. Although a few areas of the brain can be affected without producing specific symptoms, most areas, when involved by disease or other impairment of function, cause in­terference in the control of muscles, in reception of sensations, or in coordina­tion of speech.

The common symptoms which occur in connection with nervous disorders are listed as follows:
A. Abnormalities of Movement (of Muscle Action) . One of the functions of the nervous system is to control the activities of the muscles throughout the body. When those parts of the brain and spinal cord concerned with muscle activity become diseased or when the nerve connections between the central nervous system and the muscles are affected, the action of the muscles will be correspondingly al­tered and the particular type of these alterations will give a clue to the na­ture of the disease.

1. Weakness. Weakness consists of a reduced ability to use muscles in the normal manner.

2. Paralysis. Paralysis, in contrast to weakness, involves a total inability of a muscle or muscle group to respond to voluntary commands rather than sim­ply a reduced ability.

3. Spasticity (stiffness) . In condi­tions of health certain mechanisms cause the larger muscles of the body to remain firm, enabling a person to maintain his posture, for example, without his having to give continuous thought to the movements of his body. When the person desires to use these same muscles in some rapid movement, the mechanism which otherwise causes then& to remain firm is automatically canceled out so that they can now move quickly. In certain diseases of the brain and spinal cord this ability to release the muscles from their con­tracted state is lost so that they remain firm even when the person desires to move them quickly. Spasticity, there­fore, is somewhat different from paral­ysis because the muscles may still re­tain their power but lack their ability to respond quickly.

4. Involuntary (uncontrollable) movements. In certain disorders of the nervous system, such as chorea and athetosis, spontaneous, purposeless movements develop, involving certain muscles or muscle groups.

• 5. Gait disturbance. Walking is such a complex function that many types of disturbance of the nervous system may interfere with its normal progress. Gait may be altered by weakness, paralysis, spasticity, lack of coordination, dis­turbed sense of position, and even by hysteria.

6. Tetany. Tetany is a condition in which the muscles become abnormally responsive to stimulation. It occurs in the disease tetanus in conditions where the amount of calcium in the blood drops to low levels (as in hypoparathyroid­ism), or in conditions of alkalosis as when a person loses acid from the stomach by excessive vomiting or when a nervous person breathes too deeply with consequent loss of carbon dioxide from the body. Tetany also occurs in certain nervous disorders in which cells within the brain become abnor­mally responsive to the ordinary stim­uli.

B. Disturbances of Speech and Swal­lowing. Both of these functions require a high degree of integration of muscle action. Disturbances of speech are par­ticularly significant because they may indicate difficulty not only in the con­trol of the muscles by the brain but in the intellectual processes..

C. Convulsions. A convulsion usu­ally consists of the abrupt occurrence of violent involuntary contractions of the muscles, often accompanied by loss of consciousness.

D. Disturbances of General Sensa­tions. By general sensations we refer to those that come from the skin, the membranes, and the muscles (pain, temperature, touch, position) as op­posed to those which come from the organs of special sense (vision, hear­ing, equilibrium, taste, and smell).
When a given sensation is lost, such as of pain, temperature, or touch, we speak of "anesthesia," or else we speak of a loss of position sense. Oftentimes this loss of sensation is limited to some particular part of the body and the physician interprets from this clue what part of the nervous system is af­fected. If irritation of the sensory nerve fibers causes abnormal sensa­tions, such as the feeling of "pins and needles," we then speak of "paresthe­sia." If a normal sensory experience is exaggerated, we speak of "hyperesthe­sia.

E. Headache. Headache is perhaps mankind's most common symptom, oc­curring in many disorders of the ner­vous system. Its many causes and its possible involvements with other bodily ailments are summarized in the chapter of Volume 3 entitled "List of Signs and Symptoms" under Headache.

F. Dizziness. Dizziness is a very un­comfortable symptom in which the in­dividual receives a false sense of mo­tion. There are several possible causes of this symptom, some being more mysterious than others.

G. Impairment of Vision. Impair­ment or loss of vision should be taken seriously, and a physician who special­izes in diseases of the eyes or of the nervous system should be consulted for an evaluation. Not all impairments of vision relate to the eyes themselves, for the difficulty may be in the path­ways of nerve fibers that pass between the eyes and the brain or even in the tissues of the brain cortex. Oftentimes defects of vision follow a significant pattern; for example, a restriction in the right side of what is seen by the right eye and in the left side of what is seen by the left eye (bitemporal hemianopsia). A person may not no­tice such a pattern of sight loss unless he checks the vision of each eye sepa­rately.

H. Unconsciousness. The term "con­sciousness" is difficult to define, though the difference between the conscious and the unconscious state is easy enough to recognize. Perhaps the clos­est we can come to a definition of con­sciousness is to describe it as the nor­mal functioning of a person's mental faculties to the extent that he is aware of his present circumstances and alert to happenings around him.

Consciousness, in its broad sense, re­quires the normal functioning of the whole brain. Whatever interferes with a certain function of the brain interferes, to this extent, with the full ex­perience of consciousness. Placed in the order of increasing impairment of consciousness, we may mention such terms as dullness, lethargy, stupor, and coma.

A decrease in awareness of one's surroundings does not necessarily indi­cate a serious nervous disorder. It may only mean a temporary deficit in the blood supply to the brain, such as occurs in fainting, or the presence of toxins produced by germs causing some generalized disease.

However, it may indicate a concussion or pressure produced by a tumor. Impairments of consciousness must therefore be eval­uated by a physician. Hallucinations are false sensory expe­riences, the individual concerned seem­ing to hear, see, or smell something when, actually, his eyes, ears, or olfac­tory organs are not being stimulated in a manner to produce these sensations.

Since some hallucinations are the re­sult of abnormal stimulation of the brain areas where these sensations are ordinarily perceived, their occurrence justifies a study of the case by a physi­cian or a specialist in nervous diseases.

Delusions are false beliefs to which an individual adheres in spite of evi­dence to the contrary. A person with delusions may confuse his identity with that of another, or he may draw con­clusions that are false with respect to the information in hand. Delusions are more typical of mental disorders than of nervous disorders, but they may occur in either.

Consideration of the Individual Nervous Disorders
ABSCESS OF THE BRAIN.
An abscess of the brain is a localized infectious process with destruction of tissue. It is usually caused by the staphylococcus germ or sometimes by the streptococcus or the pneumococ­cus.

The infection may be introduced at the time of a fracture or a penetrat­ing wound of the skull or may spread from some neighboring area such as from an infection of the inner ear or an infection of the mastoid cells of the skull. In other cases, the infection orig­inates in the lungs or the heart and is brought to the brain by way of the bloodstream.

Some symptoms of brain abscess are generalized, relating more directly to the infectious process. These include chills, fever, loss of appetite, and a gen­eral feeling of illness. Other symp­toms are caused by the irritation of the covering membranes (the meninges) and, possibly, of the brain cortex. These include stiffness of the neck and convulsions.

Still other symptoms are caused by the disruption or compres­sion of certain nerve fibers as the ab­scess enlarges.
Abscess of the brain is always a se­rious condition and carries a mortality rate of up to 50 percent even with the best of care. It deserves prompt and adequate professional care. The treat­ment requires attention to the infection involved and to the need for surgical drainage of the fluid-filled abscess cav­ity.

AMYOTROPHIC LATERAL SCLEROSIS.
This is a rather rare, progressive disease which affects men more com­monly than women and typically oc­curs above age forty. There is a de­generation of the nerve cells and fibers which supply the muscles of the body, with more and more cells and fibers being involved as the disease pro­gresses. The average length of life af­ter onset may be expected to be about three years.

Weakness and atrophy of muscles are the characteristic manifestations.
The number of muscles thus involved gradually increases and various parts of the body may be affected, the most serious development being interfer­ence with breathing, swallowing, and chewing.

In spite of extensive studies, the cause of this disease is not yet known, nor has a satisfactory remedy been found. The patient should be encour­aged to avoid fatigue but remain as active as possible. Annual death rate in the United States from this disease is about one per 100,000 population.

ATAXIA.
A. Cerebellar Ataxia. This is a mani­festation of disease of the cerebellum that part of the brain located in the back part of the skull. Disease of the cerebellum from any cause may pro­duce the main symptom of ataxia, fail­ure of muscle coordination.

There is no loss of muscle power as in paralysis but rather a series of back-and-forth groping movements when any precise action is undertaken. Writing and speaking are seriously handicapped. The development of ataxia indicates the need for professional care by a spe­cialist in nervous disorders.

B. Friedreieh's Ataxia. This is an hereditary disease, dominant in some families and recessive in others, which usually begins in childhood or youth and is characterized by unsteadiness and tremor. In addition to the lack of coordination of muscle movements, there is a paralysis of certain muscles and a lateral curvature of the spinal column.

No specific treatment is known. The disease progresses slowly, with death occurring, usually, at about the age of twenty.

BELL'S PALSY.
CEREBELLAR ATAXIA.

CEREBRAL PALSY (LITTLE'S DISEASE).
This condition is characterized by weakness of certain muscles (more commonly in the legs) coupled with spasticity (stiffness) and with awk­ward, jerking movements. The extent of the involvement and the severity of the manifestations will vary a great deal from case to case.

There may be convulsions, impaired speech, and a degree of mental deficiency; but in many cases mentality remains quite normal. Some patients may be unjustly assumed to be mentally deficient be­cause of their awkwardness and diffi­cult speech.

The cause of cerebral palsy is not al­ways clear. Either localized or diffuse damage to the brain which may have occurred prior to the time of birth or during the birth process, may cause it. Other possibilities include an inade­quate supply of oxygen to the brain, mechanical injury, developmental de­fect, intrauterine encephalitis, and brain damage caused by some toxic agent.

Sometimes the infant appears to be handicapped from the time of birth with vomiting, irritability, and difficulty in nursing. In many cases the manifestations of the disease are noted first when the child is about six months old, the evidences being a delay in the ability to sit up, crawl, and stand.

Many children with this affliction are capable of living relatively normal Iives. The handling of a case centers around speech training, muscle reedu­cation, the wearing of braces, special tutoring in school, and vocational guid­ance.

CERVICAL RIB.
A small percentage of persons de­velop an extra rib on one or both sides, just above the usual first rib. This ex­tra rib is in the lower part of the neck. Resulting symptoms, when they occur, are caused by a squeezing of nerves and blood vessels leading to the arm and lying between the extra rib and the scalenus anterior muscle.

The symptoms are made worse when the arm is used for weight carrying or when it is raised for long periods above the head as in hanging up clothes or in washing walls. Usually the patient experiences no difficulty until adult­hood. The symptoms consist of pain, tingling, numbness, and coolness in the forearm and hand, often on the side of the little finger. The muscles of the hand in this same area may atrophy.

This combination of symptoms is typical of several circumstances which cause damage to the roots of those nerves which supply the arm. Some­times the symptoms occur when there is no extra rib, being caused only by the pressure produced by a large sca­lenus anterior muscle.

When the condition is not severe, the symptoms can be relieved by the avoidance of lifting with the involved arm and by care in supporting it by a pillow during sleep. For an overweight person, reducing often helps. In more severe cases, treatment requires sur­gery and involves the loosening of the attachment of the scalenus anterior muscle so that it no longer compresses the neighboring structures.

CHOREA.
Two principal diseases carry this name, As will be seen from the de­scriptions which follow, they differ greatly except that they present the common feature of purposeless, jerk­ing, involuntary movements.
A. Huntington's Chorea. This he­reditary disease is characterized by purposeless, jerking, involuntary move­ments and by progressive mental de­terioration.

Symptoms usually appear about age thirty or forty. The purposeless move­ments and the mental deterioration usually appear concurrently, but in some cases one group of symptoms precedes the other. The purposeless movements consist of grimacing, lurch­ing, and an unsteady, waltzing gait characteristic of drunkenness. As the disease progresses, the muscles become progressively weaker.

The mental symptoms vary from case to case, some patients being very cheer­ful and others suspicious, spiteful, and destructive. The intellectual faculties gradually deteriorate until the patient must be cared for in an institution. The disease usually progresses to death in about ten to fifteen years.

Many of the nerve cells throughout the brain and spinal cord show evi­dences of deterioration. The specific nature of the disease is not understood, but inasmuch as it runs in families as a dominant characteristic, it is advised that persons born into such families deliberately abstain from parenthood so as not to pass this disease on to their children.

B. Sydenham's Chorea (Saint Vitus's Dance). Sydenham's chorea is a dis­order of childhood characterized by rapid, involuntary, jerking movements which are irregular and purposeless. It occurs more commonly in females and is most frequently manifest be­tween the ages of five and fifteen.

As the illness begins, there is a clumsi­ness and a tendency to drop things. Presently the purposeless, involuntary movements begin and involve almost all muscles except those of the eyes. Purposeful movements can usually be executed but are performed in a jerky fashion. Coordination is poor, and a certain degree of weakness may de­velop. Chewing and swallowing may become difficult. Recovery usually oc­curs in six to ten weeks. In about one third of the cases, the illness recurs at some later time.

Although the exact cause of Syden­ham's chorea is not known, a relation­ship to rheumatic fever and priorstreptococcal infections seems probable. About half of all young patients with rheumatic fever develop chorea; and about three fourths of all chorea cases develop in persons who have had or are having rheumatic fever.

There is no specific treatment for Sydenham's chorea, but rheumatic fe­ver should be looked for and treated when present. It is advised that a child ill with this disease should be kept quiet at home or in a hospital. Sedation may be necessary. As much attention should be given to his peace of mind as to his physical comfort. Cer­tain procedures of hydrotherapy such as warm baths, fomentations, and con­tinuous flowing baths may be helpful.

CONCUSSION.

CONVULSIVE DISORDERS.
The cause of convulsions is not fully understood, but they are associated with a functional disturbance of the cortex of the brain such as can be demonstrated by the electroencephalo­gram (tracing of brain waves) . Chil­dren are more prone to convulsions than adults and may outgrow the ten­dency. In some instances, however, convulsions begin in later life.

A major ("grand mal") convulsion consists typically of the abrupt occur­rence of violent, involuntary contrac­tions of the body muscles, usually accompanied by loss of consciousness. The attack is often of short duration, but may recur.

Recurring convulsions are commonly called epilepsy. The duration and se­verity of the attacks may vary from case to case. In susceptible children, diseases with high fever or ordinary breath holding (such as during a tan­trum) may bring on convulsions. Con­vulsions may occur in persons with low blood sugar or low blood calcium.

They may occur when the blood's re­action becomes more alkaline than normal as in continued deep breathing, persistent vomiting with loss of acid from the body, or the taking of too much alkali by mouth. They may oc­cur when a confirmed alcoholic sud­denly stops drinking or when a person addicted to barbiturates suddenly dis­continues the drug.

Conditions that reduce the blood in certain parts of the brain or otherwise irritate it may cause convulsions: brain tumors, cerebral infections, brain in­jury, or diseases of the blood vessels within the brain.

Convulsions may occur in eclampsia, a serious complication of the latter pe­riod of pregnancy. They may also oc­cur in cases of tetanus (lockjaw) .

The occurrence of convulsions, es­pecially in an adult who has not been known to have convulsions previously, should be considered a clue to some underlying disease. Therefore the ser­vices of a physician should be secured promptly. It will then be the physi­cian's responsibility to discover the na­ture of the underlying condition and arrange suitable treatment. In the meantime, the patient should receive appropriate first-aid care.

DISK, HERNIATED.
ENCEPHALITIS.

In the present connection, it is im­portant to notice that certain nervous manifestations tend to appear after ap­parent recovery from the acute dis­ease.

Among patients who recover from epidemic encephalitis some later develop residual nervous disorders which are often grouped under the term "chronic encephalitis." Some develop, after ten or more years, a form of park­insonism.

Others develop disorders of the personality, including irritability and asocial types of behav­ior. Narcolepsy develops in some cases. Some develop various ab­normal movements of the muscles such as tics, grimaces, or tremors. Occa­sionally an oculogyric crisis occurs (uncontrollable turning of the eyes up­ward), which renders the patient help­less until it subsides, spontaneously or after rest.

EPILEPSY.
FACIAL PARALYSIS (BELL'S PALSY).
In facial paralysis the patient loses function of the muscles of facial ex­pression on one side of the face. These muscles are supplied by the facial nerve. Although the basic cause often is not known, the paralysis results from a malfunction of this nerve.

It is im­possible for the patient to close the eye or wrinkle the forehead on the affected side of the face. The mouth droops on the involved side and is drawn to the opposite side when the person smiles.

Facial paralysis often causes undue alarm because of its being confused with the same type of paralysis in a stroke. However, in a stroke the weak­ness is mainly in the lower part of the face with little or no involvement of the muscles about the eye and fore­head.

In favorable cases, improvement be­gins within two weeks. In a few cases recovery may take several months, and in rare cases, the paralysis may be per­manent.

What to Do
There is no specific remedy for facial paralysis, although some med­icines prescribed by the doctor may hasten recovery. During the course of the illness it is important to pro­tect the eye on the affected side, which does not close securely, so that its membranes do not become injured and infected.

A mild anti­septic solution designed for use in the eye should be dropped into the space behind the eyelids at least twice a day. It is also desirable to support the muscles on the affected side of the face during the time they are paralyzed so that the facial tis­sues do not become stretched by sag­ging. This can be accomplished very satisfactorily by elevating the cheek with two or three strips of scotch tape, which can also be used to hold the eye closed during sleep.

FAMILIAL PERIODIC PARALYSIS.
FRIEDREICH'S ATAXIA.

HEAD INJURIES.

The more common types of head in­jury are listed as follows:

A. Skull Fracture. Usually the ac­tual fracture of the skull is not serious in itself although concurrent injury to the brain may be. Skull fracture may be complicated, however, by bleeding which, if it occurs inside the skull, can cause damaging pressure against the brain.

Also when a fragment of the skull is depressed, the surgeon must re­lieve the pressure against the underly­ing brain tissue by elevating that por­tion of the bone which has been displaced. A compound skull fracture may permit the entrance of infection into the tissues of the brain. In some extensive skull fractures, the cerebro­spinal fluid, which is watery in appear­ance, may escape from the nose or from one or both of the ears.

B. Concussion. In concussion there has been sufficient shock to the brain to produce a lapse of consciousness. The severity is roughly measured by the duration of the unconscious period. Often it is associated with a loss of memory for events just preceding the head injury (retroactive amnesia) . In minor head injuries the period of un­consciousness seldom lasts more than a few minutes. In major injuries, the un­consciousness may last for several hours or possibly even several days.

C. Cerebral Contusion and Lacera­tion. In severe head injuries the sur­face of the brain may become bruised and torn. As a result there may be hemorrhage into the brain substance or into the space around the brain, and generally there is swelling of the brain tissue. In severe injuries with these complications surgical intervention may be necessary in order to control the hemorrhage or to relieve the in­creased pressure within the skull.

D. Hemorrhage. Hemorrhage into the brain substance often occurs in connection with a severe injury in which the brain is damaged. Fre­quently bleeding into the brain tissue occurs in many locations throughout the area of the injury without any sin­gle large accumulation of blood.
In many cases of head injury, associated either with skull fracture or with tearing of the membranes which surround the brain, bleeding will occur and an accumulation of blood will develop either between the skull and these membranes or between the mem­branes and the brain. Oftentimes such an accumulation of blood develops slowly.

As time passes and the blood clot degenerates, it absorbs fluid and swells. The swelling produces such pressure against the brain as may endanger the patient's life. This critical complication of hemorrhage inside the
skull may develop several hours or even several weeks after the original head injury.

The only satisfactory remedy is to remove the blood clot through a surgical opening.
It is important that the person who has suffered a severe head injury be observed carefully during his period of recovery. In case there is a secondary lapse of consciousness, impaired speech, or dragging or weakness of a limb, this should be reported promptly to the physician, for once the pressure produced by a blood clot becomes great enough to interfere with consciousness, the relief of the pressure must be accomplished quickly if the patient's life is to be saved.

E. Damage to the Cranial Nerves. In some cases of skull fracture, particu­larly those involving the base of the skull, there may be damage to certain of the cranial nerves at the site where they leave the skull. The nerve most commonly damaged is the olfactory nerve, which conveys impulses for the sense of smell. Other nerves, such as the optic nerve or the auditory nerve, may also be damaged.

Aftereffects tereffects of Head Injuries. In many cases of head injury certain symptoms follow which are collec­tively called the "postconcussion syn­drome." This group of symptoms, which may persist for some time after a head injury, includes headache, diz­ziness, difficulty in concentrating, and certain alterations in the personality.

The severity of the symptoms may not correlate with the severity of the in­jury. In favorable cases in which the individual receives adequate medical care, the symptoms gradually disap­pear. In other less fortunate cases the symptoms interfere with the patient's return to normal life, causing pro­longed disability.

Another possible complication of se­vere head injury is the later develop­ment of recurring convulsions. These are presumably caused by the irrita­tion of the brain by scar formation. Such convulsions are usually treated by the use of anticonvulsant drugs. In an occasional case, surgery is indi­cated.

HERPES ZOSTER.
The disease is self-limited, usually terminating after several days. In the meantime, the treatment consists es­sentially of relieving the intense pain by appropriate medication and of preventing secondary infection of the skin lesions. Occasionally, in elderly indi­viduals, the pain persists even after the lesions have healed (postherpetic neu­ralgia) .

HUNTINGTON'S CHOREA.
HYDROCEPHALUS.
Hydrocephalus is a condition in which the head enlarges because of an excessive amount of cerebrospinal fluid. Cerebrospinal fluid is a watery fluid most of which is produced within the internal spaces of the brain (ven­tricles).

It circulates slowly through­out the brain spaces and the space be­tween the exterior of the brain and the membranes which enclose it and the spinal cord. Normally the cerebrospi­nal fluid is absorbed at the same rate it is produced; but in hydrocephalus, there is either an overproduction of cerebrospinal fluid, a reduction of ab­sorption of the same, or a blocking of its normal flow.

Thus the amount of fluid gradually increases, producing pressure within the skull.
Many cases of hydrocephalus are congenital. In such a case the infant's head becomes enlarged and portions of the brain atrophy because of the in­creased pressure. Usually, the enlarge­ment of the infant's head is not notice­able until several weeks or months after birth. If the condition is not suc­cessfully treated, death may be ex­pected within months or a few years.

By certain surgical procedures the excess cerebrospinal fluid can be drained away through an implanted plastic tube which empties into a vein, a body cavity, or the heart itself. The opinion of a neurosurgeon should be obtained regarding the advisability of such treatment.

LITTLE'S DISEASE.
MENIERE'S SYNDROME.
This very troublesome form of ill­ness is characterized by attacks of ex­treme dizziness along with nausea and vomiting. The patient may complain of continuous ringing in the ear and progressive deafness. In most cases only one ear is affected at first, but later both may become involved.
Meniere's syndrome occurs in mid­dle life. The group of symptoms are probably caused by an increase of fluid within the semicircular canals and the inner ear. The basic cause of this de­velopment is not known, although it has been observed that this syndrome occurs in persons who experience con­siderable emotional stress.

The individual attack lasts from a few minutes to several hours.
There is no completely satisfactory treatment for Meniere's syndrome. A person with this difficulty is advised to consult a specialist in either nervous diseases or diseases of the ear. In ex­treme cases, surgical destruction of the semicircular canals and middle ear on one side is used as a last resort to obtain relief from symptoms.

MENINGITIS, ACUTE.
MENINGITIS, TUBERCULOUS.
Meningitis caused by a tuberculous infection is perhaps the most common type of this disease, except during epi­demics of meningococcal meningitis. Tuberculous meningitis develops sec­ondarily to a tuberculous infection in some other part of the body usually the lungs. And it may develop in a pa­tient totally unaware of any such infec­tion.

The disease occurs most frequently in children between one and five years of age, but it may occur at any age. The onset of the infection of the me­ninges (the coverings of the brain) is usually gradual with symptoms of irri­tability, drowsiness, headache, loss of appetite, vomiting, and a mild fever. The drowsiness may progress to stu­por, and convulsions may develop. Cer­tain of the cranial nerves may be affected with resulting difficulties in vision or hearing. Without treatment, tuberculous meningitis usually leads to death within about three months.

The patient should be under the care of a physician well informed on the intensive treatments of tuberculo­sis. Most important is specific drug therapy, but the patient's general nutri­tional needs must be met adequately, even to the extent of using artificial feedings as may be indicated. Treat­ment must be continued for weeks.

MENINGITIS CAUSED BY FUNGOUS INFECTIONS.
Several kinds of fungous infections may involve the meninges. Examples of fungous infections which may cause meningitis are actinomycosis, crypto­coccosis, candidiasis, cocidioidomyco­sis, blastomycosis, and histoplasmosis.

The symptoms are often those of a subacute meningitis. In other cases the onset of symptoms is sudden, and the disease progresses rapidly to a fatal outcome. The symptoms are headache, dizziness, vomiting, and, usually, stiff­ness of the neck.

Effective drugs are available for the treatment of most of these infections, but before beginning treatment the physician must identify the fungus which is causing the infection. This re­quires hospitalization and extensive laboratory procedures.

MONGOLISM.
Mongolism is a serious congenital condition characterized by mental re­tardation (intelligence quotient be­tween 20 and 50), stunted growth, small skull, coarse and scanty hair, flat face, depressed bridge of the nose, short and thick hands and feet, and a laxity of the ligaments. Mongolism oc­curs about once in 600 births and ac­counts for nearly 10 percent of fee­blemindedness.

Mongolism is usually associated with a defect in the chromo­somes which is designated as "trisomy 21." By this it is meant that the chro­mosomes designated as "pair 21" pro­duce three individual chromosomes rather than the usual two, giving a to­tal of forty-seven chromosomes in each cell of the body rather than the normal forty-six.

Because of the congenital nature of mongolism, it is understandable that no cure for it exists. The problem of caring for a child with this abnormality centers around training him to do as much as it is possible for him to doand sheltering him from life's competi­tions. Some cases are best cared for by relatives, whereas others would fare better if placed in an institution.

MULTIPLE SCLEROSIS.
This slowly progressive disease in­volves various parts of the central ner­vous system and presents numerous symptoms which tend to come and go only to return again in greater severity. The symptoms usually begin between ages twenty and forty, men and women being affected about equally.

In some cases the progression of the disease is so slow that the patient lives out a nor­mal life-span and dies of some other cause. In other cases the disease pro­gresses to a fatal outcome in five to ten years. Early in the course of the dis­ease the patient will appear to be per­fectly normal during the periods of re­mission.

At the time of writing, a tremendous amount of research is being carried forward in the hope of discovering the basic cause of multiple sclerosis, though as yet no definite cause has been established. The lesions of multi­ple sclerosis which interrupt the nerve pathways are characterized by a loss of the usual insulating material (myelin) which covers the nerve fibers.

The symptoms vary a great deal from case to case and from time to time in the same case. The mental symp­toms include lack of judgment, inat­tention, and, frequently, unwarranted optimism, but occasionally depression. There is often a reduced emotional control. In some cases there are con­vulsions; in some, abnormal or reduced sensations; and in others, paralysis in certain parts of the body. Some pa­tients have difficulty in finding the right words.

In many cases there are episodes of double vision or partial blindness. Scanning speech is a com­mon symptom as are also tremors and lack of coordination.

What to Do
As yet no cure is known for multi­ple sclerosis. Effort should be made, therefore, to help the patient live as nearly a normal life as possible, con­sistent with his physical and mental condition. He should use modera­tion in all he does and avoid fatigue. Physical therapy measures are useful in preventing deformities of those parts of the body that may be weak­ened or paralyzed.
MUSCULAR ATROPHY.

Another name for this disease is "fa­milial progressive spinal muscular at­rophy of childhood" a rare disease with many characteristics of a reces­sive hereditary disorder. In some fam­ily lines, however, it is transmitted as an incomplete dominant trait.

The on­set of symptoms is usually within the first year of life. Although the child is mentally alert and able to smile and recognize his family members, he does not learn to sit up and stand as a nor­mal child does. He has poor control of his head and there is difficulty in swallowing.

Eventually he develops difficulty in breathing. Inability to con­tract the muscles becomes progres­sively worse, and death usually occurs in about five years.

For purposes of comparison with other diseases it should be mentioned that the difficulty here is in the ner­vous control of the muscles, not in the muscle tissue itself. There appears to be a reduction in the number of nerve cells which normally activate the mus­cles and also a loss of the insulating laver (myelin) on the nerve fibers that serve the muscles. There is no satisfactory treatment for this disease. Physical therapy pro­cedures may be of some help.

MUSCULAR DYSTROPHY.
This is an inherited disease charac­terized by a progressive degeneration of muscle fibers with resulting weak­ness. It is to be differentiated from muscular atrophy because, in this dis­ease, the primary difficulty is with the muscle tissue rather than with the nerves which control the muscle.
The usual age of onset for muscular dystrophy is during childhood or youth. Occasionally it appears later.

It is usually the muscles in the shoulders, arms, and thighs that are affected first, with involvement of the smaller muscles of the hands and feet coming later. As the muscles become weaker, there is a tendency for the back to become swayed and the arms and legs to assume abnormal positions. Occasionally the disease becomes ar­rested spontaneously and the patient gets no worse.

There is no suitable treatment. The aim in caring for a patient should be prolong the period of time during which he can move about and engage in routine activities. The use of appro­priate braces and of surgical proce­dures to correct the deformities may help to keep the patient active.

MYASTHENIA GRAVIS.
Myasthenia gravis is a rare disease characterized by the development of muscular weakness which fluctuates from time to time and which especially affects the muscles about the eyes and face. The muscles of swallowing and those of the limbs are also affected in most cases.

The disease may begin at any age but most commonly in the sec­ond and third decades, beginning ear­lier in women than in men. The mus­cles fatigue quickly on use, the first few excursions being quite normal but the muscle power fading with contin­ued use.

Some cases progress rapidly to a fa­tal termination, with death being caused by failure of the respiratory muscles. In others, the patient lives on for years.

The immediate cause of myasthenia gravis is an alteration in the chemical activity at the junction between the nerve fibers and the muscle fibers. Pa­tients with this disease respond miracu­lously for short periods following the administration of one of the cholinergic drugs.

The use of such a drug does not cure the disease nor even retard its progress, but it does make life tempo­rarily more acceptable to the sufferer. Such drugs must be taken under the supervision of a physician, for there is danger of overdose with resulting se­vere weakness and other complica­tions. Tumors of the thymus gland are frequently associated with this condi­tion.

MYOTONIA.
In myotonia, of which there are sev­eral types, there is difficulty in relaxing the muscles after they have once con­tracted. Repeated use of the same muscles seems to "warm them up" so that their function becomes virtually normal. Many cases of this unique dis­order seem to have an hereditary back­ground. Some forms of myotonia ap­pear early in life, others later. In some cases the difficulty is aggravated by prolonged rest, by exposure to low temperatures, and by emotional excite­ment.

There is no satisfactory treatment for myotonia, but in many cases the dis­ease does not shorten life. Many vic­tims of the disease learn to live quite normally in spite of their handicap.

NARCOLEPSY.
Narcolepsy is a syndrome (group of symptoms) characterized by (1) the tendency to fall asleep spontaneously, even during the daytime and in spite of adequate sleep at night, and (2) the sudden occurrence of muscle weakness so severe that the patient falls even though he does not lose consciousness.

This is called cataplexy and usually comes in response to some surprisingemotional experience such as mirth, anger, or fear. The symptoms develop most com­monly during the second decade of life. Narcolepsy is relatively uncommon, but it occurs four times as frequently in men as in women.

It does not inter­fere with the usual life-span except as it introduces an element of hazard be­cause of the tendency to go to sleep even while otherwise occupied as while driving a car. Treatment consists of the carefully supervised use of drugs which tend to keep the individual awake.

NEURALGIA.
Neuralgia is generally considered to be a symptom rather than a disease. It consists of a series of attacks of acute pain in the area supplied by some par­ticular nerve, usually one of the cranial nerves located in the face or neck re­gion. In neuralgia, in contrast to neu­ritis, no demonstrable change occurs in the structure of the nerve involved.

Formerly, certain painful conditions such as sciatica were placed under the heading of neuralgia. Now it is recog­nized that sciatica is usually caused by a compression of one or more nerve roots by the herniation of an interver­tebral disk. The usual exam­ples of true neuralgia are trigeminal neuralgia, glossopharyngeal neuralgia, and causalgia.

A. Trigeminal Neuralgia (Tic Dou­loureux) . The trigeminal nerve is the sensory nerve to the face and consists of three branches, one supplying the skin of the forehead and eye, one sup­plying the skin of the side of the face between the eye and the mouth, and the third supplying the skin of the side of the jaw and the lower lip. One or more of these branches may be in­volved in trigeminal neuralgia.

Trigeminal neuralgia may occur at any time in adult life but usually begins about age fifty. It is somewhat more common in women than in men.
The pain is a lightning-like stab which occurs in paroxysms and usually lasts one or two minutes. In the early stages it may not recur for days. As the disease advances, the intervals be­tween paroxysms become shorter.

The pain of trigeminal neuralgia is usually so intense that the patient writhes in agony. In most cases there is some ac­tivity of the face that seems to trigger the attack—touching or washing of the face, exposure to cold, talking, eating, or drinking.

Trigeminal neuralgia usually persists regardless of medical treatment. The use of narcotic painkilling drugs should be avoided because of the great dan­ger of addiction. The injection of alco­hol into the involved nerve may cause temporary cessation of the pain for eighteen months, more or less.

Surgical procedures for destroying the sensory portion of this nerve have been more permanently successful in many cases. It is advised that the patient with tri­geminal neuralgia consult a specialist in neurology or neurosurgery.

B. Glossopharyngeal Neuralgia. In this type of neuralgia there are parox­ysms of pain which involve one side of the throat, the tonsil, the back of the tongue, and the middle ear. The symp­tom usually makes its first appearance after age forty and, strangely, affects males more commonly than females. The attack is often brought on by chewing, swallowing, talking, or yawn­ing. The attack of pain is brief, lasting only a few minutes but being so severe that the patient sometimes faints.

The use of drugs in the treatment of glossopharyngeal neuralgia is seldom completely satisfactory. Indiscriminate use of narcotics leads to addiction. Surgical treatment by severing or re­moving the involved nerve offers the best prospect of relief.

C. Causalgia. Causalgia, though nota typical example of neuralgia, is in­cluded here because of the element of excruciating pain. This symptom fol­lows injury to a nerve such as the me­dian nerve in the arm or the sciatic nerve in the hip, thigh, or leg. The pain, a persistent burning pain, is eas­ily aggravated by almost any stimulus such as exposure of the involved area to the air, a sudden noise, some star­tling experience, or mere emotional ex­citation.

It is believed that injury to the sym­pathetic nerve fibers contained in the injured nerve is responsible for this un­usual symptom. In some cases relief has been obtained by surgical severing of the sympathetic nerve fibers which supply this part of the body. A person with causalgia should consult a special­ist in neurology.

NEURITIS.
Neuritis is a condition in which de­generative changes occur in one or more nerves as a result of mechanical damage to the nerve, metabolic dis­turbance, or toxic insult.` When a sin­gle nerve is involved, we speak of mononeuritis; when many nerves are involved, we speak of polyneuritis.

Because most of the body's nerves contain several kinds of fibers, the symptoms appearing in neuritis cor­respond to the various types of nerve fibers injured. In the usual case there will be symptoms resulting from dam­age to the sensory fibers. These in­clude various kinds of discomfort, de­scribed as stabbing pains, burning sensations, sensations of tingling, the feeling of "pins and needles," and numbness.

Involvement of the motor fibers in a nerve produces weakness of the muscles which may progress to complete paralysis with eventual atro­phy of the muscles. Involvement of the autonomic nerve fibers may produce an increase in skin temperature in the involved area, sweating, and skin lesions. In other cases there may be paleness and dryness of the skin. The various types of neuritis are now dis­cussed.

A. Mechanical Damage to the Nerve. This may occur in connection with penetrating injuries, crushing injuries, or fractures of bones in which nerves are damaged. It may be caused by long-continued pressure against a nerve, as when an intoxicated person sleeps in a chair with his arm over the back.

B. Metabolic Disturbance of the Nerve Tissue. In this condition the damage is usually to many nerves, and therefore we speak of polyneuritis. It occurs in any condition or disease in which there is not a sufficient amount of thiamine (vitamin B1) in the diet.

This kind of polyneuritis develops in such diseases as beriberi and pellagra, and in alcoholism. The chronic alco­holic derives much of his energy from the calories contained in the alcohol and thus does not eat sufficient food to provide the required nutritional ele­ments, including thiamine. Other meta­bolic diseases, such as diabetes, may also cause polyneuritis.

C. Toxic Insults to the Nerves. Here we include the toxic conditions that come from diseases such as diphtheria, in which neuritis may develop because the toxin from the germs damages cer­tain nerves. Also, there are many chemicals and heavy metals which in­jure nerve tissue. These include alco­hol, carbon tetrachloride, and benzine among the chemicals, and lead, ar­senic, mercury, and bismuth among the heavy metals. Persons exposed to these substances in excess are prone to de­velop symptoms of polyneuritis.

Treatment of neuritis consists of dis­covering and removing the cause of the damage to the nerves. Once the cause is removed, recovery may be prompt in mild cases. In severe cases, however, in which damage to thenerves has been inflicted over a long period, the normal function of the nerve may never be completely re­stored. A good diet and high intake of vitamins may hasten recovery.

PALSY.
PARALYSIS AGITANS.
PARALYSIS, FAMILIAL PERIODIC.

Familial periodic paralysis is a rare hereditary disease characterized by re­curring attacks of profound weakness of the muscles of the trunk, and extrem­ities. Usually the muscles of breathing and those of the face remain normal.

The individual attack lasts somewhere between two and twenty-four hours. Attacks may occur every day or as in­frequently as once a year. The disease usually begins during the first or sec­ond decade of life, persists for a few years, and then improves over the next few years, with attacks becoming less frequent and less severe.

Interest­ingly, attacks usually occur after a pe­riod of rest or after a meal consisting largely of carbohydrate food. Often­times a person will suffer an attack upon awakening in the morning. In most cases attacks are associated with a reduction in the concentration of po­tassium in the blood serum.

Usually persons with this disease live out an average life-span, but oc­casionally death occurs because of in­volvement of the muscles of breathing.

In most cases the attack of paralysis can be relieved by the administration by mouth of potassium chloride. This is not advisable for all cases, however, because in some reduction in the con­centration of potassium in the blood serum is not the problem.

Noting this diversity, some scientists believe that the fundamental difficulty is in the body's metabolism of sodium rather than in the handling of potassium. In fact, when the amount of sodium in the diet is reduced appreciably, attacks of paralysis do not occur. The handling of a case of familial periodic paralysis should be under the direction of a physician.

PARESIS (GENERAL PARESIS).
PARKINSONISM (PARALYSIS AGITANS).
Parkinsonism is a chronic, progres­sive disorder, usually occurring in middle-aged or elderly persons, which is characterized by slowness of move­ment, rigidity of the muscles, involun­tary tremor, and progressive weak­ness.

The usual case of parkinsonism be­gins gradually and is without known cause. The rate of progress of the dis­ease will vary from case to case. Usu­ally the patient becomes gradually in­capacitated over a period of several years. Parkinsonism occurring earlier in life may be a sequel to encephalitis or to some circumstance in which the cells of the brain were deprived of their supply of oxygen for at least five to ten minutes and were thus perma­nently damaged. Such a circumstance may develop in connection with car­bon monoxide poisoning, asphyxia, or head injury.

The victim of parkinsonism presents a characteristic appearance. The mus­cles of his face become immobile so that he appears to stare and seems un­able to register his emotions. In ad­vanced cases, saliva often drools from the corners of the mouth.

The patient leans forward as he walks, moves with short steps, and may break into a run as though he were trying to keep from falling forward. Typically his arms are flexed at the elbows and he carries his hands near his abdomen. There may be tremors in various parts of his body,but the most characteristic one involves a repetitive movement by which the tips of the fingers brush past the ball of his thumb—the so-called "pill-rolling movement." The tremors are worse when the patient is tired or when he becomes excited.

Although weakness of the muscles develops gradually in parkinsonism, there is a rigidity which interferes with rapid movement of any part of the body. Speech becomes hampered both in volume of sound and in clarity of enunciation. Intellectual capacity is retained quite well until the terminal phase of the disorder.

Inasmuch as there is no satisfactory treatment for parkinsonism, the care of a patient with this disorder centers around keeping him active as long as possible, maintaining his morale by cheerful surroundings, and using such drugs as may minimize his tremors and reduce the rigidity of his muscles. Var­ious surgical procedures have been tried which aim to destroy those parts of the brain in which the tremors and the spasticity are activated.

It must b. realized, however, that the fundamen­tal cause of parkinsonism is a deteri­oration of certain cells within the brain. Further destruction of brain areas by surgery only serves to control some of the symptoms without altering the ultimate progress of the disease.

PHENYLKETONURIA.
Phenylketonuria is one of several he­reditary metabolic diseases, perhaps the best known of the group. The dis­ease, striking about one child in every 25,000, is caused by the lack of an en­zyme necessary to the proper synthesis of tyrosine (one of the essential amino acids). As a result of this metabolic defect, phenylalanine (a precursor of tyrosine) accumulates in the body's tis­sues and fluids and the excess is elimi­nated by way of the urine.

From the standpoint of our present consideration of nervous disorders, the importance of phenylketonuria is that children with this disease display men­tal deficiency of varying degrees and, in about half the cases, display awk­ward gait, tremors, and continuous purposeless movements of the hands. Epileptic seizures occur in about one fourth of the cases.

The mental deficiency of phenylketo­nuria develops gradually, beginning soon after birth. If the infant so af­flicted is placed on a special diet soon after birth—a diet which contains only a minimum of phenylalanine—he may not develop mental deficiency or the other neurological manifestations.

Of course, it is not easy to determine in the case of a young infant whether or not he is becoming mentally retarded and is possibly afflicted with phenyl­ketonuria. The only way to be sure is to make tests of the blood or urine. Some states require that these blood or urine examinations be carried out on all newborn infants as a means of de­tecting the occasional one whd would benefit by treatment for phenylketo­nuria and thus be spared the tragedy of becoming mentally deficient. The special diet must be adapted by the physician to the needs of the individ­ual.

POLIOMYELITIS.
POLYNEURITIS.
POSTEROLATERAL SCLEROSIS (COMBINED SYSTEM DISEASE).

Posterolateral sclerosis is a serious involvement of the nervous system as­sociated with pernicious anemia or other macrocytic anemias. In other words, the deficiency of vitamin B12, the cause of pernicious anemia, has its effect on the tissues of the nervous sys­tem, causing a degeneration of parts ofthe spinal cord. Tie egeneration in­terferes with the normal transmission of certain nervous impulses.

Oftentimes it is the symptoms of posterolateral sclerosis that first call the physician's attention to the possi­bility of pernicious anemia in a given case. The first symptoms usually con­sist of tingling and numbness in the skin of the toes and soles of the feet.

Soon the same sensations develop in the fingers. If the disease still goes un­recognized and untreated, these sensa­tions spread to the feet and legs and, possibly, to the thighs and lower parts of the body. The tingling and numb­ness of the fingers usually spreads to include the hands but seldom does it involve the upper arms.

Next is noticed an unsteadiness and stiffness in gait, which may be accom­panied by weakness of the muscles of the legs. The patient tends to stumble, especially when walking in the dark. As the weakness progresses, the knees may give way unexpectedly. The hands become clumsy.

In severe cases there is an involve­ment of the brain with certain psychic symptoms including loss of recent memory, ideas of persecution, and even stupor and coma. Commonly, vision is impaired with a developing blindness at the center of the visual field.

In untreated cases of pernicious ane­mia, the symptoms of posterolateral sclerosis become progressively worse. When treatment is begun early, at least by the time unsteadiness in gait is first noticed, there is a good prospect that the symptoms will disappear and, if treatment is continued consistently for the remainder of life, that the vic­tim of this disease can live out a normal life-span. If treatment is long delayed, however, the damage to the tissues of the spinal cord becomes so se­rious that normal conditions can prob­ably never be reestablished. Even in such cases, however, treatment may bring about a significant improvement.

Since posterolateral sclerosis is part of pernicious anemia, the treatment is one and the same. It consists of the administration, by intramuscular injec­tion, of vitamin B12. A case of perni­cious anemia with posterolateral scle­rosis should, of course, remain under the continuing supervision of a physi­cian.

RABIES.
RIB.
SAINT VITUS'S DANCE.
SCLEROSIS.

SCIATICA.

Sciatica is a term used to describe pain in the distribution of the sciatic nerve. This nerve derives its fibers from the spinal cord in the lower part of the back and passes through the but­tock and thigh into the leg. The usual cause of sciatic pain is pressure pro­duced by a herniated intervertebral disk.
SHINGLES.

SPINA BIFIDA.
Spina bifida is a malformation of the vertebral column which, in the more serious cases, involves the spinal cord.

It usually occurs in the lower part of the back and affects about three verte­brae. It is commonly associated with other congenital defects such as club­foot or hydrocephalus. In the least se­vere cases there are no symptoms relat­ing to the nervous system; the only clue to such a defect may be a dimple in the skin at the site of the deformity, a discoloration of the overlying skin, or a tuft of hair in this area. The deformity of the vertebrae can be dis­cerned, of course, by X-ray examina­tion.

In the moderately severe cases in which certain of the nerve roots are in­volved, the infant may show a tardi­ness in learning to walk or may have a clumsy gait. In the very severe cases there may be a wasting and weakness of the muscles of the legs and feet in addition to some diminution of the skin sensations in the areas of the buttocks and adjacent portions of the thighs.

In these more severe cases there is usually a protrusion of the membranes that normally cover the spinal cord, the protrusion appearing in the midline at the lower part of the back. 'his pro­truding sac of soft tissue may in some cases include portions of the large nerve roots.
In these cases an opening may be eroded in this protruding soft tissue through which cerebrospinal fluid may escape. There is then grave danger, of course, of an infection of the meninges with resulting meningitis.

The immediate treatment for ` spina bifida is reparative surgery. However, surgery will not restore functions of the nervous system already deficient. Fur­thermore, hydrocephalus sometimes develops as a complication after sur­gery.

The care of the patient includes a carefully planned program of reha­bilitation aimed to make it possible for the child, as he grows up, to live a rea­sonably normal life.

SPINAL INJURIES.
By the term spinal injuries we refer to those accidents that damage the vertebral column and may, at the same time, injure the spinal cord or some of the spinal nerves. The reason some spi­nal injuries affect the spinal cord or the spinal nerves is that a very close anatomical relationship exists between the vertebral column and its related supporting structures and the spinal cord with its emerging spinal nerves.

The vertebral column consists essen­tially of the bodies of the vertebrae plus their bony processes which extend to the sides and backward from the vertebral bodies. These bony proc­esses form a complete series of arches behind the vertebral bodies. It is within the spinal canal formed by these arches that the delicate spinal cord ( a downward continuation from the brain) is located.

The spinal nerves originate from the spinal cord and then pass outward on the right and on the left between the bony processes.

The greatest danger to the spinal cord occurs when the vertebrae are crushed or sharply bent on one an­other so that they pinch or crush the spinal cord, or when one vertebra is displaced in its relation to its neighbor so that the spinal cord is sheared. The spinal nerves which emerge between the bony processes of the vertebrae may be compressed or damaged by in­juries which bring pressure against them. There are four principal types of spinal injuries as indicated in the following descriptions:

A. Herniated Intervertebral Disks. The intervertebral disks are composed of fibrocartilage and dense connective tissue and are interposed between .the vertebral bodies to provide for cush­ioning and also to permit a certain amount of flexibility. Each of these intervertebral disks is composed of a softer central part, the nucleus pul­posus, and a surrounding ring of densetissue designated as the anulus fibrosus.

Injuries to the intervertebral disks constitute the most common type of spinal injury. When a disk is injured, the nucleus pulposus often herniates through the damaged part of the anu­lus fibrosus and brings pressure against an adjacent nerve root, causing dis­comfort and some loss of function.

Herniation of an intervertebral disk occurs most commonly in the lumbar region of the lower back. The second most common site is in the lower part of the neck. The usual cause of dam­age to a disk in the lumbar region is lifting while in a stooping or twisted position. At the time of this first injury the patient will usually suffer pain for a few days, experiencing a "catch in the back" or a "crick in the neck." The discomfort is caused by torn ligaments or strained muscles. It may be some time later, possibly after several inci­dents of discomfort, that the nucleus pulposus at the center of the interver­tebral disk actually squeezes out and brings pressure against the adjacent nerve root, causing the typical pain that radiates throughout the course of the nerve thus compressed.

The discomfort associated with a herniated disk located in the lower back usually consists of severe aching pain in the buttock and the back and side of the thigh and leg. Often numb­ness and tingling is felt in the same area. The pain is often aggravated by coughing or sneezing or by straining at stool. It may be made worse by twist­ing, stooping, or lifting.

Certain mus­cles in the thigh, leg, or foot may be­come weak. There may or may not be pain in the lower part of the back. When the damaged intervertebral disk is in the lower part of the neck, the pain involves the shoulder, the arm, the forearm, and the hand, the latter either on the thumb side or on the little finger side. Again there will be numbness and tingling in these areas with a weakness of certain mus­cles particularly the triceps muscle in the back of the arm.

Treatment for cases of herniated in­tervertebral disk falls into two catego­ries: conservative and surgical. Con­servative treatment consists of bed rest for several days or a few weeks in or­der to eliminate the mechanical pres­sure which has caused the interverte­bral disk to collapse and bulge.

In cases where the damaged disk is in the lower back, the patient's bed should be very firm so as to keep the struc­tures of the vertebral column in the most favorable position. A relatively unyielding mattress should be used, and this should be laid on plywood or other firm foundation.
For cases in which the injury is in the neck, it is often advisable to pro­vide traction.

This is arranged by at­taching a weight by a rope that runs over a pulley at the head of the bed so as to exert a continuous pull on a closely fitting head harness. As the pa­tient improves, he may be allowed out of bed during the daytime pro­vided he wears a supporting collar. The traction is usually continued at night for a longer time.

Surgical treatment for herniated in­tervertebral disk involves removing the nucleus pulposus pressing against the nerve root and, in some cases, inserting a bone graft to stabilize the cerebral column at the site of difficulty.

B. Sprains. A sprain of the vertebral column involves a stretching of the spinal ligaments which hold the verte­brae in place. Inasmuch as the cervi­cal portion (in the neck) of the verte­bral column is most flexible, this is the part most commonly sprained. It is this type of injury, occurring in the neck, that is called "whiplash." It oc­curs as a result of direct violence or of excessive muscle pull as when the head is suddenly thrown backward in an automobile accident.
In a sprain, the vertebrae are usually not displaced; therefore seldom does a sprain injure the spinal cord.

Symp­toms consist of pain on moving the neck, of local tenderness, and of stiff­ness.
Occasionally a person who has sus­tained this type of sprain becomes self-centered in his desire for sympathy or compensation. This attitude tends to prolong the symptoms even beyond the time required for the tissues to heal. Most physicians therefore advise these patients to return to their normal way of life within a reasonable period of time, encouraging them to ignore their continuing symptoms.

C. Dislocations. In a dislocation of the vertebral column an actual displace­ment of one vertebra in its relation to another takes place. Dislocations are often associated with fractures, torn ligaments, and injuries to the interver­tebral disks. Because of the displace­ment, there is great danger of injury to the spinal cord.

Dislocations may be caused by div­ing into shallow water or by falling on the head, shoulder, or even in a stand­ing-up position. A heavy blow such as causes the vertebral column to bend sharply in any direction may cause a dislocation. Symptoms consist of local pain, tenderness, and a deformity of the bony structures such as can be ob­served by X ray or by careful digital examination.

In any case of dislocation of the ver­tebrae, great care must be taken in handling the patient lest damage be done to the spinal cord. Even a slight movement of the patient's body might cause the displaced vertebra to com­press the spinal cord, with resulting permanent damage.
Immediate care of the case requires the same precautions as when the back is broken. If the patient must be transported, great care should be taken to avoid body or neck movement.


Usual hos­pital treatment for such a patient in­cludes traction of the head so that if the parts of the vertebral column which are injured shift their position, they will do so in the direction of their nor­mal position rather than in a direction that might press on the spinal cord.

D. Fractures. Fractures of the ver­tebrae are somewhat more common in the middle and lower back. Sometimes they consist merely of the compression of a vertebral body without its being displaced. As mentioned above under dislocations, fractures may well be as­sociated with damage to the interverte­bral disk or to the Iigaments that nor­mally hold the vertebral bodies in place. Fractures are usually the result of a fall or a direct blow on the back or of the intense pressures produced by convulsive muscle action as in a con­vulsion.

If there is no displacement of the bony structures so as to endanger the spinal cord or the nerve roots, fractures are not as serious to the patient's total welfare as are dislocations. Symptoms of a fracture consist of local pain, ten­derness, and muscle spasm. Treatment consists, usually, of the use of casts and braces to support the patient's back during the period of healing. For in­struction on the first-aid handling of persons with fractures of the vertebral column.

STROKE.
A stroke, commonly called apoplec­tic stroke or a stroke of paralysis, is caused by severe damage to some part of the brain resulting from an interrup­tion of the blood supply to this part. The exact symptoms in a particular case are determined by the specific part of the brain that has been dam­aged. The paralysis that commonly occurs in con­nection with a stroke.

Not all strokes are the result of some­thing that happens to the blood vessels inside the skull. Sometimes an obstruc­tion to the flow of blood develops in the vessels of the neck. Thus the brain is deprived of its usual blood supply just as effectively as when the mishap occurs inside the skull.

Usually certain warning signs indicate that the brain is not receiving a sufficient amount of blood. There may be "transient strokes" in which the symptoms last only a few minutes. It can then be de­termined by an X-ray study of the vessels (arteriography) whether the difficulty is caused by a narrowing of the vessels in the neck. If so, the lumens of these vessels may be enlarged by a surgical procedure (endarterectomy) .

SYDENHAM'S CHOREA.
SYPHILIS OF THE NERVOUS SYSTEM.
Syphilis is produced by a spiral-shaped germ, the Treponema pallidum. It is classed as one of the social dis­eases and is usually transmitted by sexual contact. it affects many organs and tis­sues of the body. In the present chap­ter we are concerned with its involve­ment of the nervous system.

Antibiotic drugs have brought about a marvelous improvement in the treat­ment of syphilis. When adequately used early in the course of the disease, they will prevent most of the serious complications from developing.

Syphi­lis could doubtless be stamped out within a few months or years if all who have the disease, throughout the world, would submit to adequate treatment. The facts that syphilis is transmitted by sexual contacts, however, and that syphilis patients are reticent to admit their social indiscretions, make it dif­ficult for physicians and health agen­cies to conduct a successful campaign against the disease.

Involvement of the nervous system is one of the later manifestations of syph­ilis, occurring typically in the so-called third stage of the disease. The germs of syphilis seem to remain quiescent in the tissues of the nervous system for many months or even several years af­ter they have entered these tissues. Then, for some unknown reason, they begin to produce damage so disastrous that even intensive treatment may not restore the patient completely to his previous condition.

A person .need not remain in uncer­tainty as to whether he needs treat­ment for a syphilitic infection. Blood tests for syphilis are now available at any doctor's office, at any venereal-dis­ease clinic, and at any public-health headquarters. More than this, it is pos­sible, by drawing a sample of the cere­brospinal fluid, to determine whether or not the germs of syphilis have en­tered the nervous system. If they have, the need for intensive treatment adapted to this complication is most urgent even though no symptoms of the involvement of the brain or spinal cord have yet appeared.

Syphilis affects the brain and spinal cord in several ways. It may produce a unique type of meningitis or it may in­volve, primarily, the blood vessels of these organs. It may produce degener­ative changes which seriously affect the intellect or cause a destruction of certain of the nerve pathways. In the present consideration we will discuss only the two most important manifes­tations of syphilis of the nervous sys­tem: (A) general paresis and (B) ta­bes dorsalis.

A. General Paresis of the Insane.
This is a serious late complication of syphilis, typically developing several years after the individual's first syphi­litic infection. It is serious because it destroys the intellect and progressively limits the victim's usual activities, bringing death, on the average, about three years after the first appearance of symptoms. Fortunately, general pa­resis of the insane is seldom seen now because most cases of syphilis receive adequate treatment in their earlier stages.

The general symptoms of this disor­der include headache, ataxia (unstead­iness of gait and station), slurred speech, tremor of the fingers and tongue, and mental deterioration.
Personality-wise there is a progres­sive impairment of the individual's ef­ficiency both in family life and in busi­ness. He begins to use poor judgment and is prone to make serious mistakes such as unnecessarily incurring debt or spending money for things not needed.

There is a progressive failure in mem­ory and a tendency to tell untruths. The individual becomes disoriented so that he no longer knows the time of day or the day of the week or month and is confused as to his whereabouts and the identity of himself and those he contacts. This leads to a dreamlike state. A person with this condition commonly has delusions, imagining himself to be somebody great. The emotions of joy and sorrow may alter­nate suddenly and without adequate justification. There is a rapid deteri­oration of moral and ethical standards. As the disease continues, the victim be­comes apathetic and finally completely demented.


Intensive treatment with antibiotic drugs may at least partially arrest the progress of general paresis; but, inas­much as the disease involves a degen­eration of nerve cells and nerve fibers, treatment cannot always be expected to restore the individual to his normal state. Because of such reasons it is urged that any syphilitic infection be treated intensively early in its course.
B. Tabes Dorsalis (Locomotor Ataxia) .

In this manifestation of syph­ilis it is primarily the spinal cord and the nerve roots that are affected. For­tunately this disease is much less com­mon now than it was before adequate treatment for syphilis became avail­able. Tabes dorsalis tends to develop from five to twenty years after the pri­mary syphilitic infection.

In the usual case, the first symptom is an aching pain in the legs, often con­fused with rheumatism. The pain be­comes progressively worse until it is described as knifelike. These pains come in bouts, usually occurring at least once during each twenty-four hours, the severity usually being more intense at night than during the day. In some cases the patient receives the impression of a tight girdle about his abdomen.

In others agonizing pains (so-called tabetic crises) develop in certain organs of the body. These ex­cruciating pains occur most commonly in relation to the stomach. They may last for several days, the pain being ei­ther continuous or intermittent. Any attempt to drink or eat causes vomit­ing. The pain may disappear as sud­denly as it begins, only to recur at a later time.
Various neuralgias, involving nerves here and there throughout the body, may develop as a part of tabes dorsa­lis.

There may be numbness and a feeling of coldness in various skin areas. Often the patient reports a sen­sation as though he were "walking on air." Certain areas of the skin may beless sensitive than normal, approach­ing a complete loss of sensation. The sense of position suffers greatly in most cases so that the individual becomes unaware of the position of his feet or legs except as he watches these and observes their movement and position.

With walking thus made difficult, the victim typically uses a cane and watches each step he takes. When he stands, he stands with his feet wide apart so as to brace himself because of his unsteadiness. There is often a loss of tone in the muscles of his ex­tremities so that they move in a flail-like manner. His strength and energy become progressively poor.

In well-established tabes dorsalis as well as in general paresis of the insane, the deteriorated nerve fibers cannot be restored even by intensive treat­ment. Once the damage has been done, repair is impossible. Again it should be emphasized that any syphilitic in­fection should be treated intensively as soon as possible after the infection has been acquired.

SYRINGOMYELIA.
This is an unusual disease in which a cavity develops in the central portion of the spinal cord causing a progressive destruction of the adjacent nerve fi­bers. The cause of the disease is un­known, but some evidence indicates that it harks back to a congenital fault of development. Exact symptoms de­pend upon which part of the spinal cord happens to be involved, whether a part up near the head or lower down.

The first symptoms often appear be­tween ages ten and thirty. The disease is slowly progressive but may remain stationary for several years. Some pa­tients live as long as forty years after the disease begins.

At first the patient notices loss of certain sensations—those for pain and temperature—in the particular part of the body related to the location of the cavity within the spinal cord. The sense of touch remains normal. This loss of sensation for pain and tempera­ture is usually brought to the patient's attention when he observes that he suf­fers no pain in some particular part of his body, even from a burn.
Another early evidence of the disease is progressive weakness and atrophy of certain of the small muscles such as those in the hands.

There is no satisfactory treatment for syringomyelia. The patient should be encouraged to remain active as long as feasible. In view of the danger of burns of the skin, now that the natural protective influence of pain and tem­perature has been lost, appropriate means to prevent injury to the victim should be employed.

Reasonable mea­sures should be taken to help the pa­tient retain an attitude of cheerfulness in spite of his handicap. In some cases surgery may provide partial relief of symptoms and may retard the progress of the disease.

TABES DORSALIS.
TIC DOULOUREUX.
TORTICOLLIS.
TRAUMA.
TRIGEMINAL NEURALGIA.

TUMORS.
A. Tumors of the Brain. There are various kinds of brain tumors. Some grow slowly, others rapidly. All kinds are hazardous because their increase in size brings pressure against the deli­cate tissues of the brain. Some invade the brain tissue itself, causing destruc­tion of the nerve cells and fibers as they do so.

Others remain Nvith. a brous capsule and inflict damage by the pressure which their growth pro­duces. Those which grow rapidly and invade the nervous tissue are usually the most dangerous and threaten the patient's life within the shortest period of time. Tumors of the brain occur at any time of life but are most common in early adulthood and middle age.

Based on the possibility of cure, tu­mors of the brain may be classed as ei­ther benign or malignant. Benign tu­mors are curable if they can be safely removed by surgery. An example of a benign tumor is the meningioma which develops in the membranes surround­ing the brain.
Malignant tumors are seldom cur­able because of their tendency to grow rapidly, to invade the tissues, and to re­cur after removal.

These may be subdi­vided into primary and secondary tu­mors. Primary brain tumors originate within the skull. An example of a pri­mary malignant tumor is the astrocy­toma-which consists of wild cells that have developed from cells which nor­mally support the nerve cells of the brain. Secondary malignant tumors are those which bud off from a tumor lo­cated in some other part of the body such as the breast or the lung. Small portions of such a tumor are carried by the blood to the brain where they be­come secondarily implanted.

Symptoms of tumors of the brain are of two types: (1) those that result from the pressure which the tumor produces, and (2) those caused by the destruction of nerve cells and nerve fibers. A tumor located in one part of the brain will produce a different group of symptoms from one located in some other part, even though the size of the two tumors may be the same.
Headache is often the first symptom of a brain tumor.

Inasmuch as head­ache is commonly produced by other causes, this symptom is not diagnostic except as it may persist unnaturally. Unexplained nausea and vomiting are also symptoms which occur commonly in brain tumor. In some cases weak­ness, awkardness, and/or convulsive seizures develop. In other cases there may be drowsiness, changes in person­ality, and strange conduct.

Treatment for tumors of the brain, always of course under the direction of a neurosurgeon, is either surgical re­moval or radiation therapy.

B. Tumors of the Spinal Cord. These are much less frequent than tumors of the brain, but are classified in about the same manner. Symptoms depend upon the particular groups of nerve fi­bers or of nerve cells destroyed or compressed as the tumor grows.

There may be weakness of certain muscles, also changes in the sensations relating to certain parts of the skin area—either abnormal sensations or the loss of sen­sation. Early surgical removal of a tumor of the spinal cord usually offers the best possibility of a favorable re­sult. Even then the outcome will de­pend upon how much tissue of the spi­nal cord has already been destroyed. In selected cases of tumor of the spinal cord, radiation therapy is preferable to surgery.

WRYNECK.
The first portion of this chapter was concerned with disorders in which organs of the nervous system are affected to the extent that the patient's general health is impaired or certain of his nor­mal abilities may be diminished or destroyed.

In this final por­tion of the chapter, devoted to mental disorders, we are dealing with abnormalities of the personality usually not based on disease as such but on the individual's unfavorable adjustment to life. We are concerned now with psychological problems rather than neu­rological problems. Physicians who specialize in such disorders are spoken of as psychiatrists.

Psychoneuroses

In the psychoneuroses the affected individual reacts in an abnormal man­ner to certain conflicting circumstances in his life but still retains his mental capacities to the extent that he is able to think normally and, for the most part, to exercise . normal judgment.

The person with a psychoneurosis often realizes that his reactions under some circumstances are different from those of other people. The psychoneuroses are not forms of insanity but, rather, personality disorders in which the behavior, the patterns of thinking, and the emotional responses are abnormal.

The several classic types of the psycho-neuroses will now be described, fol­lowed at the end with a paragraph on treatment.

THE ANXIETY REACTION.
In this type of emotional illness there are attacks of an unsettled state of mind characterized by apprehension, nervous tension, physical and mental fatigue, and panic. Attacks occurring at night may be associated with nightmares. The attack is often accompanied by physical symptoms of vomiting, diarrhea, and urinary ur­gency.

There is an overpowering dread of some imminent disaster. The attack may vary in duration from a few min­utes to longer periods. Usually the problem dates back in the individual's history to some intolerable thwarting experience.

THE DISSOCIATIVE REACTION.
This is similar to the anxiety reaction except that it is more intense. In this instance, the individual actually loses control of certain of his mental func­tions so that he experiences extreme stupor or loses his memory or conducts himself automatically without being aware of his actions or resorts to aim­less running.

THE CONVERSION REACTION (HYSTERIA).
In the conversion reaction the indi­vidual subconsciously converts energy pent up as a result of intense anxiety or frustration into some abnormal form of behavior or into some form of sup­posed illness.

The conversion reaction is a great imitator of many symptoms of disease, such as paralysis, anesthe­sia, blindness, or loss of consciousness. Oftentimes the physician's skill is taxed to tell the difference between the con­version reaction and actual disease. Typically, the nature of the conversion is such as to excuse the individual from facing up to some unpleasant reality of life.

THE PHOBIC REACTION (PHOBIAS).
In the phobic reaction, the individ­ual manifests an unreasonable, unjusti­fied anxiety regarding some particular situation. Consciously he recognizes that no actual danger is involved, but he finds himself unable to control his intense fear, even so.

Phobias may be directed toward high places, closed spaces, elevators, dirt, the danger ofcontamination, cancer, or certain ani­mals. Phobias represent a carry-over of some unresolved conflict. It is as­sumed that the phobia becomes sym­bolic of this conflict to the extent that the individual puts the true conflict out of consciousness by focusing on the phobia.

THE DEPRESSIVE REACTION.
In this type of psychoneurosis the in­dividual becomes downcast, pessimis­tic, unhappy. He feels that he is per­sonally inadequate. He lacks energy and becomes disinterested in most of the activities about him. The depres­sive reaction may be accompanied by certain symptoms relating to the body's functions, such as loss of appetite, con­stipation, headache, and sleeplessness. The condition is often associated with anxiety.

The attitude of discourage­ment may become so profound that the individual may secretly contemplate suicide and may even make an attempt in this direction. Proper precautions should be taken so that the patient with a depressive reaction is not left alone.

THE OBSESSIVE-COMPULSIVE REACTION.
An obsession consists of an almost uncontrollable urge to follow the same line of thought over and over. Often the thought is unwelcome but, try as he may, the individual finds it nearly impossible to banish it from his think­ing.

A compulsion consists of an un­reasonable urge to perform some act even though the act is entirely unnec­essary and may even be foolish in na­ture. A person may become obsessed with the thought that he is carrying a germ which could infect other mem­bers of his family and even cause their death.

As a result he may develop the compulsion to wash his hands fre­quently, particularly at certain times such as before eating, after shaking hands, or at fifteen-minute intervals. A person may develop the obsession that he is changing in appearance, and this may prompt the compulsion that Forces him to look in the mirror repeat­edly for evidences of such change.

A person with an obsession may be con­stantly troubled by obscene thoughts which are out of harmony with his standards of conduct. A religious per-;on may be obsessed by doubts re-larding the foundation of his beliefs. A person may develop the compulsion hat he must remove his clothes in a certain routine.

This may become so troublesome that if anything interferes with the routine, he will have to put its clothes on again and start the rou­tine all over. A person with a compul­sion may feel that he is forced to ouch all power poles as he passes hem on the sidewalk.
The obsessive-compulsive reaction is supposed to be a subconscious form of penance associated with guilt and self-condemnation.

The individual who de­velops these obsessions and compul­sions is not consciously aware of the background of his reactions. Treatment of the Psycho neuroses. Frequently the person with a psycho-neurosis will benefit by a series of con­versations with a psychiatrist intended to help him recognize the relationship between his present symptoms and the unsolved problems which lie at their foundation.

The patterns of thinking and acting are usually so firmly estab­lished that a mere explanation of the cause of the symptoms will not enable the individual to overcome them. The patient has to have time to reorient his thinking to the extent of accepting the facts of his unfavorable circum­stances and planning ways of being realistic rather than hiding behind ex­cuses or dodging the real issues.

Psychotic Disorders
The psychotic disorders include several forms of mental derangement any one of which constitutes "insanity" in the usual meaning of the word. When a person becomes ill with a psy­chosis, he loses control of his thinking and acting to the extent that his be­havior no longer is in harmony with accepted standards nor consistent with the realities of his situation in life.

Ef­forts to persuade him that his thinking is confused or that his actions are not acceptable do not change his abnormal patterns. The person with a psychosis is no longer able to carry his share of responsibility in the family or in the community. He may be irrational and irresponsible and, for his own good, may have to be required to comply with regulations that others consider best rather than being allowed to fol­low his own dictates.

Fundamental causes of the psycho­ses are still debated. Most psychiatrists feel that an hereditary factor some­times makes one person less able than others to adjust successfully to life's demands and that such an individual's personality may disintegrate under stresses in life that require greater ad­justments than the patient is capable of making. Others, however, believe that the psychoses are caused by some yet undiscovered abnormality of the chemical processes that occur within the nerve cells of the brain.

In some instances persons with a psychotic disorder become difficult to manage.
THE AFFECTIVE PSYCHOSIS (MANIC-DEPRESSIVE PSYCHOSIS).
This form of psychosis is character­ized by an exaggerated mood rather than by the inability to think. The af­fective psychosis tends to occur in at­tacks, between which the individual is reasonably normal.

The disturbances of mood may be in either direction, that of mania and ela­tion or that of depression and melan­choly. In one attack, mania may pre­dominate; in another, depression. In some patients, the mood in each attack shifts toward mania; in others, toward depression. In still other cases, there may be a shift from mania to depres­sion or vice versa in the same attack.

The first attack of affective psychosis typically occurs in young adulthood. It is assumed that heredity plays an im­portant role in setting the stage for the development of this illness. Without adequate treatment, the typical attack of affective psychosis may last about a year. With modern methods of treat­ment, the time is usually shortened to about three months.

In the manic phase of the illness, the patient is very much excited. There are tireless over activity and feel­ings of elation. The patient may be mischievous, to the extent of tearing his clothing, disarranging his room, and engaging in mild vandalism.

Com­monly he sings and shouts and even displays occasional delusions of gran­deur. He may become easily annoyed with those who try to restrain or con­trol him. He talks a great deal but not on sensible topics.

In the depressed phase the patient is downhearted and fearful and experi­ences feelings of inadequacy. He sleeps poorly, and all physical activity is accomplished with great effort. He may develop delusions by which he be­lieves that others are plotting to harm him. There may be attempts at sui­cide. In extreme cases a state of stu­por develops.

Treatment of the affective psychosis consists of three parts: placing the pa­tient in suitable surroundings, using shock therapy or drugs to hasten re­covery from the attack, and influenc­ing him by kind conversation to look forward to recovery and resumption of his usual activities. There is no essen­tial loss of mentality in the affective psychosis, and the patient is influenced by his surroundings and conversation to a greater extent than he appears to be. He may even understand quite well that he is ill. Most cases respond fa­vorably to kind treatment.

SCHIZOPHRENIA (DEMENTIA PRAECOX).
Schizophrenia is the most serious one of the group of mental disorders. Although recovery occurs in some cases in response to modern methods of treatment, many cases become chronic and progressively incapacitating.

The usual chronic nature of the illness can be emphasized by noting that less than 20 percent of the first ad­missions to public mental hospitals are for schizophrenia whereas about 60 percent of all who remain permanently in these hospitals are victims of this disease.
In schizophrenia the patient loses his ability to distinguish clearly between fantasy and reality. Both his ability to think and his emotional responses be­come confused.

It is generally assumed that some particular hereditary predisposition makes certain people susceptible to a breakdown of personality structure once they are subjected to difficult situ­ations. There are persons who live perfectly normal lives who have traits of personality that resemble, in mild degree, the victim of schizophrenia.

Presumably such persons would be­come ill with this type of mental dis­order should they become seriously distressed because of problems in their environment for which they could not find adequate solutions. The fact that some people respond more favorably than others to treatment suggests that the hereditary predisposition is more pronounced in some individuals than in others.

Schizophrenia may develop at any age, but it seldom appears in childhood or after age fifty. The disease often begins insidiously. As the victim be­gins to withdraw from reality, he ap­pears to others to be preoccupied. His conversations may assume an odd pat­tern, but the individual experiences no concern even when this is brought to his attention.

As the disease progresses, delusions, hallucinations, and odd mannerisms develop. In his delusions, the patient with schizophrenia often hears persons saying unkind things about him. He seems to live in a world apart and spends time staring at himself in themirror or smiling or laughing to him­self. His emotional responses are often inappropriate.

Treatment for schizophrenia has been modified a great deal in recent years. The use of drugs particularly adapted for psychotic disorders has now largely replaced the previous use of shock therapy. The use of psychotherapy and maintenance of a friendly, understand­ing attitude by workers in the hospital where the schizophrenic is placed con­tribute greatly to the success of the drug therapy. Although many cases do not recover completely, a large propor­tion respond well enough to be able to live relatively normal lives outside the hospital.

PARANOIA.
Paranoia is not a clear-cut disease in­dependent of those just described. It is a type of response seen in persons who may have schizophrenia or who may have affective psychosis. It is characterized by delusions in which the individual attempts to bolster his self-esteem by assuming that people are plotting against him. He craves recognition; but, having failed to ob­tain the acclaim he desires, he devel­ops false explanations which indicate that he has failed in life only because of the plottings and jealousies of oth­ers.

Paranoia may have its roots in child­hood because of experiences that de­prived the individual of the degree of social acceptance which most children receive. In these early stages, disap­pointment in life could have been over­come had the individual become successful in his chosen enterprises. Suc­cess in these would have brought about the recognition he desired. In persons who have found life to be disappoint­ing, however, it is easy for the early childhood experiences of sullenness and hatred to become exaggerated to the extent that a psychosis develops.

The delusions of paranoia often lead the patient to imagine himself as being some great person a king or queen. The paranoid may become danger­ous because of the possibility that he may do bodily harm to those he feels have plotted against him.

Many pa­tients will respond favorably, however, to the kindness and sympathy of some person whom they feel they can trust. It is such a person who may be able to bring about improvement in a case of paranoia as he tactfully persuades the patient to accept reasonable interpre­tations of his circumstances. Success­ful treatment of paranoia consists more of sympathetic relationships than of any specific therapy.

Organic Brain Syndromes
Many conditions of poor general health exert an influence on the func­tioning of the brain and may be responsible for symptoms similar to those produced by genuine psychotic disor­ders. The fundamental fault is with the systemic disease that has adversely af­fected the brain and only secondarily with the person's way of thinking or reacting to life's realities.

Many forms of illness cause tempo­rary mental confusion which we com­monly designate as delirium. Arterio­sclerosis, as it affects the vessels of the brain, is frequently the cause of men­tal confusion and excitement with deterioration of the intellectual capaci­ties. Tumors of the brain, general pare­sis of the insane (a complication of syphilis), chronic alcoholism, and other toxic conditions may also have such adverse effects.

Treatment of the organic brain syn­drome obviously consists of removing the cause of the problem if such re­moval is possible.