Nervous Diseases

598 VI. Nervous diseases in children..........599 VII. Organization of neurological care in the USSR . 605 I. Classification of nervous diseases and their relationship with diseases of other organs and systems. Nervous diseases is a collective definition for diseases of the nervous system. Nervous diseases are usually divided into organic or anatomical ones, on the one hand, and functional ones, on the other. The latter are sometimes viewed as diseases of the nervous system without an anatomical substrate. This division arose in an era when pathological anatomy and histology were considered the highest criterion for distinguishing nosological units. The imperfection of such a classification is demonstrated by the fact that, for example, until recently chorea, double athetosis, Parkinson's disease, torticollis, tics, epilepsy, myoclonus, and similar disorders—in which improved histological techniques subsequently revealed structural changes in the brain—were described as neuroses or functional nervous diseases. Conversely, it turned out that structural changes with a specific localization do not always lead to impaired function. Thus, for example, certain tumors, even after reaching a large size, sometimes produce no symptoms and are discovered accidentally at autopsy. As new aspects of the function of living tissue in general and nerve tissue in particular began to be uncovered, anatomical and histological principles of classification proved clearly insufficient to encompass the entire diversity of deviations from the norm observed in nervous diseases. At the same time, authors often, unilaterally carried away by the achievements of a particular branch of science, purely mechanistically applied them to explain impaired nerve function. Thus, for example, Oppenheim explained functional nervous diseases by molecular changes in nerve elements and wave-like dynamic processes caused by sharp sensory or sensory-perceptual irritations. Such an explanation is clearly inadequate because it reduces biological and psychoneurological phenomena to mere physical ones. Sahli's point of view is no more satisfying; according to him, nervousness and neurasthenia depend on changes in the nerve potential within the projection system, while hysteria depends on changes in the associative and commissural systems. Such a view is unacceptable both for its mechanistic nature and its speculativeness: functional hemianesthesia and paralysis in hysteria could with equal right be explained by the disruption of the function of projection systems. But such reasoning fundamentally contradicts the integrity and unity of the nervous system's function. No more successful are attempts to mechanically transfer the achievements of biological chemistry into neuropathology when functional nervous diseases are reduced exclusively to disturbances of assimilation and disassimilation processes. Little is explained either by Goldscheider's definition of functional nervous diseases as fluctuations in the threshold of neuron irritation, or by Veraguth's changes in neurotonus. The views of Monakow and Mourgue on the problem of functional nervous diseases lead into the quagmire of vitalism. Emphasizing the importance of hereditary predisposition, which boils down to an innate insufficiency of the endocrine-vegetative apparatus and the "protective function" of the blood-brain barrier, the authors put forward some immaterial principle as the basis of nervous and mental activity—horme, the mother of instincts, and syneidesis, the principle of self-regulation of functions. While fully recognizing the importance of barrier function impairment and the endocrine apparatus for the pathogenesis of nervous diseases, we must regard the vitalistic ideas of Monakow and Mourgue as a manifestation of the dead end into which bourgeois neuropathology has fallen. Monakow's concept, which contributed so much to the materialistic substantiation of psychoneurology, turned out to be clearly akin to the idealistic concepts of Bergson. The studies of Pavlov on conditioned reflexes, on the phenomena of excitation and inhibition, of Ukhtomsky on the dominant, of Vvedensky on parabiosic processes, and the works of Orbeli on the influence of the vegetative nervous system on the function of the cerebrospinal system have revealed new and extremely important aspects of nerve function, bringing to the foreground neurodynamic processes that are disrupted in nervous diseases and that can be disrupted even without gross structural changes in the brain. Extremely important for understanding the essence of functional nervous diseases are further facts characterizing the influence of electrolytes, mono- and bivalent ions, acidosis, and alkalosis on the excitability of the nervous system. The vegetative nervous system and, as already mentioned, the endocrine system play an exceptionally large role in the pathogenesis of functional nervous diseases. Sometimes the entire clinical picture is reduced to just one of the aforementioned factors. Thus, for example, neurasthenia and hysteria are entirely attempted to be reduced to a disturbance of neurodynamics, to an "unbearable" struggle for the individual between the processes of inhibition and excitation in the cerebral cortex and to a "breakdown" similar to the one that I. P. Pavlov experimentally induced in laboratory dogs. But neuroses cannot be explained by physiological "breakdowns" alone. Such oversimplification is based on ignoring the new properties that distinguish human nervous-psychic activity from biological activity, which are connected with human production and social existence. In contrast to such a mechanistic understanding, dialectical cognition takes into account "the unfolding of the entire totality of moments of reality." Therefore, we can approach an understanding of the pathogenesis of nervous diseases only by taking into account all the factors and regularities to which human nervous-psychic activity is subject—namely, physical-chemical, physiological, and biological, as well as socio-economic, which are the specific regularities of human activity. Not artificial abstraction of one particular side of a phenomenon, but an analytical-synthetic study of the features of the healthy and diseased brain in the entire totality of its connections with the organism and the environment provides the key to understanding nervous diseases, both in the presence of structural changes in the brain and in their absence. Nervous diseases cannot be considered exclusively as diseases of the nervous system. Mental diseases are usually demarcated from nervous diseases in the strict sense of the word, encompassing those brain disorders where mental symptoms are in the foreground. From this, of course, it does not follow that in certain nervous diseases, such as brain tumors, multiple sclerosis, or polyneuritis, there are sometimes no clearly noticeable deviations in the patient's psyche. However, in these cases, mental defects are concomitant symptoms that may also be absent. In addition, there are significant groups of patients who stand, as it were, on the border between nervous and mental illness. In so-called neuroses, purely mental components stand out so much, especially in the subjective complaints and experiences of the patients, that they can with equal right be attributed to both nervous and mental illnesses. This synthesis of psychiatry and neurology finds practical reflection in the establishment of neuropsychiatric dispensaries, neuropsychiatric organization, and the scientific cooperation of neuropathologists and psychiatrists both in print and in special societies (see Neuropathology, Psychiatry). However, neuroses (especially neurasthenia and hysteria) testify with no less certainty to the closest connection between nervous diseases and diseases of other organs (internal, urogenital, eyes, ears, etc.). Neuralgias, for example (including sciatica), are sometimes connected with malaria, tuberculosis, diabetes, or pelvic organ disease. Polyneuritis is sometimes caused by diabetes, and cerebral hemorrhages by heart disease or hypertension. The reverse relationship also exists, i.e., disturbances in the work of internal organs are noted in nervous diseases. This particularly applies to the pathology of the vegetative nervous system (see Vegetative neuroses), for example, spasms of the pylorus, esophagus, cardiac phenomena in certain "organic" neuroses, crises in tabes dorsalis or epilepsy, obesity, emaciation, diabetes insipidus and mellitus in encephalitis or tumors of the diencephalon, disorders of the bladder, rectum, and genital apparatus in diseases of the spinal cord or brain, etc. The interrelationships between the brain and the liver are peculiar and not entirely clarified (see Wilson's disease). The connection between the glands of internal secretion and the nervous system is especially intimate, which determines the participation of the nervous system in endocrine diseases and vice versa. Examples include nervous symptoms in thyroid diseases, tetany in parathyroid disease, epileptic seizures in disorders of the genital sphere, the insular apparatus, etc., and conversely, dysfunction of certain glands of internal secretion, such as the ovaries, in diseases of the diencephalon. From all the indicated examples, it clearly follows that not only the phenomenology, but also the course, prognosis, treatment, and prevention of nervous diseases depend on the state of the entire organism. Singling out nervous diseases on the principle of diseases of a definite system or organ, one should not forget the close interdependence of the functions of all organs and systems of the living organism. The unified complex structure of the organism and the integrality of its reactions and behavior are largely based on the peculiar role of the nervous system, which regulates all bodily functions and connects the organism with the internal and external social environment through its receptor and effector parts.

This role can be understood only by taking into account the complexity and dynamic nature of the structure, which includes contradictory elements of a physico-chemical, physiological, and evolutionary-historical order, the latter in phylogenetic, ontogenetic, and social aspects. Nervous diseases and their clinical manifestations must be considered in view of the complex and integral reaction of the diseased organism under new conditions. Not so much deficit symptoms, but rather the reaction characteristics of the newly emerged integral structure, the peculiar function of the entire diseased organism, are the subject of analysis in the study of any nervous disease. Thus, in diseases of the extrapiramidal system, the organism exhibits completely different reactions than in a disease of the pyramidal system, but their clinical analysis may reveal differences in different individuals. Lesions of the cortical segment of the visual apparatus are perceived by the patient in a completely different way than a disease of its peripheral part, and differently by different patients, depending on the state of vessels, age, past diseases, etc. Moreover, these lesions may subjectively even go completely unnoticed by them. In view of the intimate connection existing between individual parts of the nervous system, as well as between the latter and all organs, it is not surprising that a pathological process localized in a certain place of it often affects the function of other parts of the nervous system, as well as the function of internal organs.

For practical, diagnostic, and therapeutic purposes, however, it is extremely important to resolve the question of whether we are dealing in each given case with a focal local disease of the nervous system or with a diffuse, disseminated, or finally, a systemic disease. Focal, local diseases can include injuries (cut, stab wounds, contusions), further tumors, and finally circulatory disorders (embolisms, thrombosis, hemorrhages). Obviously, focal diseases, as already mentioned, are also manifested clinically in the disturbance of activity of areas remote from the focus. Thus, in brain tumors (see Brain), symptoms of increased intracranial pressure are observed completely independently of the location of the tumor. In head injuries or skull wounds, aside from local changes, there are almost always disturbances in the circulation of the cerebrospinal fluid, ventricular and subarachnoid systems. In thrombosis of any cerebral artery, a number of symptoms must be attributed to the simultaneous disease of many other cerebral vessels.

Diffuse nervous diseases predominantly include infections, both acute and chronic (see Myelitis, Encephalitis, Multiple Sclerosis). Finally, one can distinguish a group of systemic nervous diseases in which a specific system is predominantly affected. These include infantile paralysis (see Heine-Medin disease), localized mainly in the system of anterior horn cells, tabes, which frequently affects the system of posterior columns, funicular myelitis or combined sclerosis, Erb's spastic paralysis, amyotrophic lateral sclerosis, and so on. Finally, the most numerous group of systemic diseases consists of certain hereditary diseases, such as Friedreich's hereditary ataxia, spinal muscular atrophies, certain familial diseases of the striatal system, such as hereditary chronic chorea, etc. However, regarding many systemic diseases, it has been proven that they are based on diffuse pathological foci, from the fusion of which the appearance of a primary lesion or degeneration of any single system arises.

By neurotropic ectodermoses, some authors mean diseases of the nervous system caused by an ultravisible filterable virus having a biological "affinity" for the nervous parenchyma. These include Heine-Medin disease, epidemic encephalitis, and rabies, and some (Levaditi) also include herpes, as well as (Spielmeyer, Spatz) Borna disease (see Myelitis). Regarding the role in the pathogenesis of nervous diseases of the blood-brain barrier, see Barrier function; on the significance of the cerebrospinal fluid, the vascular system, the pathways of infection penetration into the nervous system, and on the reactions to it on the part of the nervous system, see Brain.

To an even greater extent than the localization of the process, the clinical picture of nervous diseases is determined by the patient's heredity, constitution, sex and age, past illnesses, the state of his internal organs, especially the cardiovascular system, the socio-economic conditions among which he grew up and works, and the peculiarities of his daily life and labor. The great diversity of clinical pictures observed in the same nervous disease (cerebral syphilis, neurasthenia, vascular diseases, etc.) must find their explanations only in the analysis of all the factors indicated above. Thus, lead poisoning of the nervous system proceeds differently in a typesetter than in a painter, differently in an alcoholic than in a non-drinker, differently in a pyknic than in an asthenic, and so on. To an even greater extent than the clinical form of a nervous disease, the nervous morbidity itself depends on socio-economic conditions. Thus, an epidemic of meningitis acquires a particularly threatening character among infants of miners under conditions of brutal capitalist exploitation. The forms of labor in capitalist countries create completely different prerequisites for diseases of the nervous system than the socialist forms of labor in the USSR, causing its premature exhaustion and wear. Specific social and living conditions finally reflect in the most direct way on the development of the organism, on its constitution, on the manifestation of hereditary traits. M. Krol.

II. Statistics of Nervous Diseases. According to the international nomenclature of diseases and causes of death of 1920, the class of diseases of the nervous system and sensory organs includes encephalitis, meningitis, tabes dorsalis, other diseases of the spinal cord, cerebral hemorrhage (cerebral apoplexy), paralyses, progressive paralysis, other forms of mental illness, epilepsy, eclampsia (non-puerperal), infantile convulsions, chorea, hysteria and neuralgia, neuritis, softening of the brain, other diseases of the nervous system, diseases of the organ of vision, diseases of the organ of hearing in connection with diseases of their cerebral centers. This does not include lethargic encephalitis, epidemic cerebrospinal meningitis, and acute poliomyelitis. The revision of the nomenclature at the Paris Conference in 1929 introduced no changes into this system. The nomenclature of diseases and causes of death adopted in the USSR since 1931 assigned tabes dorsalis and progressive paralysis to the class of infectious diseases, and added cerebral arteriosclerosis to the diseases of the nervous system. The materials given below are based on the 1920 international nomenclature. Where possible, sensory organ diseases were excluded. Mortality from diseases of the nervous system and sensory organs in various states is about 10% of all mortality, and fluctuations over different years are relatively small. The lowest figure is given by Switzerland, where out of 100 deaths in 1927, 6.8 deaths are due to diseases of the nervous system and sensory organs. The highest figure in the same year falls on Scotland: 12.9 per 100 deceased. Table 1 shows the distribution of mortality from diseases of the nervous system and sensory organs in various countries for 1925-28.

Table 1. Percentage ratio of those who died from diseases of the nervous system and sensory organs to the number of all deceased. States 1925 g. 1926 g.: 1927 g. England and Wales Belgium . . . Hungary . . . Germany . . Netherlands . . N. Ireland New Zealand Norway . . USA .... Czecho-Slovakia Switzerland . Sweden ... Scotland . . 8.7 10.3 8.7 11.2 10.8 12.0 8.2 9.0 8.7 9.2 9.1 9.3 11.0 10.7 9.7 8.2 12.9 1928 g. 9.1 8.9 10.5 11.1 9.1 7.2 13.3 Per 100,000 population, death from diseases of the nervous system and sensory organs claims about 125 lives annually (Table 2). Table 2. Mortality from diseases of the nervous system and sensory organs per 100,000 population. States Scotland . . . Hungary .... N. Ireland . France .... Czecho-Slovakia England and Wales Belgium . . . Germany . . . Norway .... Netherlands . . Sweden .... New Zealand Switzerland . . 1925 g. 1926 g. 1927 g. 1928 g. 164 - - - -. - - - In this table, the mortality numbers are arranged in descending order, and this order is preserved for all years. As might have been expected already from Table 1, Scotland occupies the highest place, and Switzerland the very last. Those who died from cerebral hemorrhage, apoplexy occupy a rather prominent place among those who died from diseases of the nervous system and sensory organs. Table 3 illustrates mortality from cerebral hemorrhage (cerebral apoplexy) per 100,000 population in various countries in recent years. Thus more than half of the deaths from diseases of the nervous system and sensory organs are due to cerebral hemorrhage. Mortality from cerebral hemorrhage and other nervous system diseases by sex in Germany (per 10,000 population of each sex) is shown in Table 4. Table 3. States 1926 g. 1927 g. 1928 g. Scotland..... N. Ireland ... England and Wales . . Hungary ....... Germany ...... Czecho-Slovakia . . . Belgium ....... 108 92 81 79 70 65 63 69 59 49 47 111 96 87 82 64 69 65 55 63 48 46 60 70 Table 4. Years Cerebral hemorrhage (cerebral apoplexy; Other nervous system diseases 1913.........

6.4 6.2 7.8 6.2 8.2 6.0 6.7 6.5 5.2 6.6 4.9 6.6 4.7 6.1 6.1 5.4 4.2 4.1 3.9. Death from cerebral hemorrhage for various years in both men and women stands at the same level, showing almost no fluctuations, whereas death from other diseases of the nervous system in both men and women, while being at almost the same level in the pre-war year and the first year of the war, shows a clear downward trend in the post-war year and in recent years. The distribution of mortality from diseases of the nervous system by age in Germany (per 10,000 population of the corresponding group) is shown in Table 5, with deaths from cerebral hemorrhage excluded. Table 5. 1926 1927 1928 Age m. f. m. f. m. f. 0-1 year... 67.7 52.9 62.8 48.3 57.9 45.2 1-5 years... 6.8 5.8 6.3 5.8 5.7 5.4 3.5 2.9 3.3 2.9 3.3 2.8 4.2 3.3 4.1 3.4 4.0 3.0 9.7 8.0 9.7 8.3 9.3 8.1 12.8 12.7 14.7 13.6 13.9 13.7 5-30 years... 3.9 30-60 years... 60-70 years... Average... 5.2 4.2 4.9 4.1 4.7 3.9. The highest mortality rate from nervous system diseases is found in infants, being slightly lower in girls than in boys. In subsequent ages it drops and only rises slightly towards old age, remaining almost the same in both men and women. In mortality from cerebral hemorrhage (cerebral apoplexy), we encounter the opposite phenomenon. In Germany, with an average mortality per 10,000 population from the above-mentioned cause in 1926 of 6.0 for men, 32.5 die at the age of 60-70; at the age of 70 and older, 96.3, and the remaining ages account for 5.8. For the same year in women, with an average mortality of 6.5, the age of 60-70 accounts for 30.1; the age of 70 and older accounts for 92.1; the remaining ages account for 4.6. In 1927, with an average mortality in men of 6.3, the age of 60-70 accounts for 32.4; 70 and older accounts for 99.0; the remaining ages account for 6.5; in women with an average of 6.6, the age of 60-70 gives 29.2; 70 and older gives 85.5; the rest give 4.7. In the cities of the Belorussian SSR, there are about 9 deaths from nervous system diseases per 100 deaths, in the cities of the Ukrainian SSR about 9.7, and in Moscow approximately 8. In Moscow, mortality from nervous system diseases for 1926, starting from the age of 20, is very insignificant, but at the age of up to 1 year it accounts for 4.9% of all causes of death, at the age of 1-4 years nervous system diseases account for 8% of deaths, from 5 to 9 years - 11.6%, from 10 to 14 years - 13.5%, and from 15 to 19 years - 12.5%. Morbidity. According to Zemsky surveys, visits for nervous system diseases at the end of the 19th and beginning of the 20th centuries constituted about 3% of all visits. In Moscow Governorate in 1926 and in urban-type settlements of the Belorussian SSR in 1925, 4% of all illnesses were due to nervous system diseases. The morbidity of individual forms of nervous system diseases in the city of Minsk in 1925 is presented in Table 6, with the ratio given here to all nervous system diseases (per 100 illnesses). More than half of all nervous system diseases are neurasthenia and hysteria. Cerebral hemorrhage occupies the lowest place. The nature of morbidity by gender and individual forms can be illustrated using materials from Moscow and Moscow Governorate for 1926 (per 1,000 population) (Table 7). The morbidity of nervous diseases by gender and age in Moscow and Moscow Governorate for 1926 is given in Tables 8 and 9. Cases of disability from nervous system diseases across all industries for 1925-28 amounted to 3.9. The number of illness cases and days of disability by industry in Moscow and Moscow Governorate is given in Table 10. Disability from nervous system diseases. Of the total composition of male labor invalids examined by the Moscow Bureau of Medical Expertise for 1924, disability from all nervous system diseases accounted for 14.8% at an average age of 38, while disability from hystero-neurasthenia accounted for 4% at an average age of 34, and from organic nervous system diseases 3.7 at an average age of 44. In the same year, among women, disability from all nervous system diseases was received by 8.7% at an average age of 40; from hystero-neurasthenia - 3.8% at an average age of 38; from organic nervous system diseases - 1.4% at an average age.

Rubber ...... { Sewing.......{ Animal processing ! products......j ₂ Printing Food processing Metallic Woodworking Textile (1 b c Processing of mineral | [ 2 substances 4.2 88.4 10.3 179.7 7.3 145.5 7.9 190.4 5.4 98.6 6.4 111.0 5.5 105.6 5.4 112.9 3.3 63.2 3.0 66.8 2.8 78.6 3.6 76.0 10.3 198.4 7.8 148.1 5.9 123.0 5.1 101.6 4.4 84.2 5.4 121.2 4.4 92.9 4.2 91.2 2.8 60.6 1.9 41.0 3.5 4.2 67.7 74.5 9.1 7.5 147.6 129.6 6.4 7.9 99.5 116.4 5.5 7.1 86.3 98.4 6.2 8.4 130.9 176.1 3.7 4.5 80.2 69.4 4.5 6.6 72.6 95.7 3.8 4.6 68.9 80.1 3.0 4.1 88.8 80.1 3.0 3.2 61.8 60.9 2.6 3.8 56.9 94.5 and |c c co <m O» *-* 0.2 0.2 0.3 9.9 9.4 10.0 0.3 0.5 0.7 8.0 21.1 18.0 0.2 0.2 0.3 17.6 10.2 12.9 0.5 0.4 0.3 27.9 12.1 9.9 0.3 0.3 0.4 6.6 16.6 14.1 0.2 0.5 0.5 13.8 20.2 20.9 0.2 0.4 0.3 8.6 13.4 12.2 0.3 0.3 0.3 14.5 12.7 10.3 0.2 0.2 0.4 12.8 5.2 14.8 0.2 0.2 0.2 7.3 7.6 8.8 0.1 0.1 5.8 0.3 7.1 hysteria and neurasthenia 0.2 0.2 0.2 0.2 0.2 8.3 11.5 10.9 11.2 11.0 0.4 0.4 0.6 0.7 0.4 14.5 19.1 29.9 30.5 14.0 0.5 0.2 0.3 0.3 0.3 18.0 15.8 16.1 11.3 11.4 0.3 0.3 0.4 0.5 0.3 10.7 22.5 15.5 14.4 12.4 0.3 0.2 0.2 0.2 7.1 7.3 7.6 24.9 14.1 0.3 0.3 0.3 0.3 0.2 11.9 15.4 11.9 17.9 12.9 0.3 0.3 0.3 0.2 0.2 10.6 16.5 19.6 11.1 11.3 0.3 0.3 0.3 0.2 0.3 10.6 17.3 19.1 19.0 12.9 0.3 0.3 0.2 0.3 5.4 14.3 16.2 25.2 0.2 0.1 0.1 0.2 0.2 6.2 8.0 7.2 9.9 9.2 0.1 0.1 0.1 0.1 0.2 2.1 12.2 3.9 9.1 16.1 1.6 30.4 5.9 81.5 2.0 37.4 3.7 72.3 2.5 47.1 2.1 36.6 2.0 38.2 1.3 30.5 1.2 13.4 1.2 25.5 0.9 24.6 neuralgia neuritis 1.2 1.0 1.2 23.7 18.5 21.8 3.5 2.3 2.1 54.9 30.6 31.7 2.1 1.6 2.7 43.1 26.5 41.1 2.8 2.0 2.3 57.7 36.7 35.1 2.6 2.1 2.8 43.3 44.3 83.3 1.4 0.9 1.2 27.0 18.6 16.2 1.8 1.2 1.2 43.1 18.6 19.9 1.0 0.8 1.0 18.8 14.7 19.3 1.0 0.7 0.8 23.4 25.8 19.5 1.0 1.0 1.1 20.5 17.7 19.1 0.8 1.0 1.6 21.0 18.9 44.6 1.4 18.4 1.9 24.2 2.6 33.1 2.0 32.6 1.6 17.1 2.3 17.0 1.9 23.7 1.8 23.2 1.5 21.7 1.0 15.0 1.1 14.9 1.3 1.2 18.3 15.4 2.7 2.7 43.6 28.7 3.0 2.0 41.3 14.9 1.4 1.3 22.1 10.6 0.9 2.6 15.1 33.1 1.3 1.1 12.9 12.8 2.1 1.8 26.4 17.5 2.0 1.6 25.5 17.4 1.5 1.0 24.8 16.5 1.0 1.0 14.7 14.7 0.7 0.9 7.8 13.0 1.5 18.5 2.0 26.8 2.9 24.0 2.4 19.4 3.1 45.5 1.6 14.0 2.9 31.1 1.8 19.7 1.6 15.2 1.1 15.8 1.2 14.3 1 ^ and c~ m C» a> 1 ^ '^н 0.2 4.5 0.4 12.6 1.0 18.2 0.4 10.6 0.1 5.1 0.1 1.7 0.2 3.9 0.2 6.8 0.2 4.9 0.1 2.1 0.2 12.6 0.2 4.4 1.7 27.4 1.4 25.0 0.5 6.0 0.1 1.2 0.2 6.5 0.2 5.4 0.8 19.1 0.1 2.6 0.1 2.5 0.3 5.5 1.6 18.9 1.7 26.7 0.6 9.0 0.4 8.9 0.2 3.2 0.5 9.0 0.3 5.7 0.4 5.5 0.2 3.9 0.2 5.1 age of 44 years. As can be seen, the male half produces both a greater number and a slightly younger age of disabled persons from diseases of the nervous system. Disability from diseases of the nervous system by occupational groups in the city of Moscow is shown in Table 11. Table 11. Disability from diseases of the nervous system by occupational groups in the city of Moscow. (Ratio per 100 examined.) Name of occupational groups Diseases of the nervous system Including organic diseases of the central nervous system 1925 year 1926 year 1925 year 1926 year. All office workers . . . All workers .... Metalworkers .... Printers..... Chemists...... Food and tobacco workers Leatherworkers ..... Woodworkers ..... Construction workers ..... Textile workers . . . 13.7 14.4 21.2 20.5 17.2 15.8 16.1 12.5 9.7 8.4 8.4 13.6 13.7 18.4 16.0 14.7 14.9 13.1 11.2 12.1 11.6 7.6 3.3 3.0 3.0 3.5 5.0 4.0 5.1 3.9 3.4 2.3 3.4 2.0 2.1 4.4 1.5 1.8 3.2 3.1 3.6 1.3 2.5 P. I. Kurkin, in his data on the morbidity of Moscow Governorate for 1898-1902, points out that among chemical production workers, diseases of the nervous system accounted for 47.3 per 1,000 patients, while among fibrous material processing workers it was 28.1, cement production 25.5, mechanical 18.0, and patients with diseases of the nervous system in Zemstvo clinics accounted for 29.2. For the city of Tver in 1925, various professions gave the following figures for diseases of the nervous system per 1,000 population (Table 12). Table 12. Profession Men Women Spinning factories . . . Entire city without factories 324.8 138.9 119.1 106.3 91.1 555.5 206.2 156.5 97.9 Leatherworkers lead all others (just as in diseases with loss of working capacity; see Table 10), and the remaining listed professions also show a much higher indicator than the city as a whole, with women having a significant preponderance everywhere. In the works of S. M. Bogoslovsky, based on data from 120,000 workers and office employees examined during the course of "dispensarization" at Moscow enterprises, we find the following distribution of persons affected by diseases of the nervous system per 100 examined persons by sex, age, and length of service in the profession (Table 13). Up to 40 years of age, the prevalence of nervous system diseases increases with length of service in both sexes, among both production and auxiliary workers. At the age of 40–59 years, the prevalence drops sharply in these groups and shows significant fluctuations with length of service, with production and auxiliary workers, women, and all office workers showing a clear tendency to decline with increasing length of service. The maximum prevalence of neurasthenia falls on office workers: 24.1% in men, 23.3% in women; production workers show half this figure: 12% for men and 12.3% for women; the minimum is found in the group of auxiliary workers: 9.6% for men and 10.5% for women. Further on, from the same author we find that neurasthenia mainly affects the younger age group (20–39 years). If we distribute this group by length of service in the profession (Table 14), we notice a fairly distinct increase in prevalence with increasing length of service. Table 14. Percentage relation to the number of examined. Length of service Production workers Auxiliary workers Office workers Age m. f. m. f. m. f. 14-19 years 12.4 12.4 10.9 10.4 14.1 12.9 20-39 years Up to 1 yr. . . . 13.9 13.3 10.7 11.9 20.9 24.1 40-59 years 1-5 yrs. . . . 14.9 14.5 12.2 13.4 23.9 25.6 Length of service in profession 5-8 yrs. . . . 15.7 14.8 14.2 10.3 19.9 18.7 Up to 1 yr..... 8 yrs. and more .... 5.1 7.7 9.5 16.4 17.1 16.5 1-5 yrs. . . . 17.5 18.3 19.1 11.4 5-8 yrs. . . . 13.1 15.1 12.4 8 yrs. and more Up to 1 yr. . . . 1-5 yrs. . . . 5-8 yrs. . . . 8 yrs. and more Production workers Auxiliary workers Office workers m. f. m. f. m. f. m. 14.1 12.9 20.9 24.1 23.9 25.6 19.9 18.7 17.1 16.5 table 10), the remaining listed professions also give a much higher indicator than the city, and everywhere we have a significant preponderance in women. "This circumstance," writes S. M. Bogoslovsky, "seems to indicate that among the groups of 'production' and 'auxiliary' workers combined by us, professions associated with hazards contributing to the onset of neurasthenia predominate." According to the same author in Table 13, for every 1,000 examined persons, those affected by hysteria accounted for 5 men and 62 women among production workers, 5 men and 73 women among auxiliary workers, and 8 men and 153 women among office workers. Hysteria is encountered much more frequently among office workers than among workers.

R. Muniche. III. Etiology. A number of diverse exogenous and endogenous factors play a role in the etiology of nervous diseases. Socio-economic 4.6 9.6 13.0 14.2 14.7 17.7 9.3 7.4 20.8 23.9 23.5 23.5 18.3 18.2 17.5 26.7 31.7 26.5 30.4 22.8 22.8 23.8 38.2 41.6 39.9 44.1 42.0 40.2 44.3 The first category includes political factors, living conditions, and occupational conditions. The second category boils down to hereditary factors, the significance of which can be traced for the majority of nervous diseases. These hereditary factors manifest themselves particularly clearly in that group of nervous diseases which are called "hereditary" or "familial" in the narrow sense of the word, i.e., which reveal a more or less significant accumulation of similar cases in a family. These forms are characterized by a regular numerical ratio of sick to healthy siblings, a specific type of hereditary transmission determined for each form, and mandatory similar illness in the second monozygotic twin. Regarding these forms, the view prevailed for a long time that they are characterized, in addition, by homology (identical manifestation of the disease in all sick family members), homochrony (onset of the disease in all sick family members at the same age), and a progressive course. However, these three features turned out to be characteristic of the discussed group of diseases only very relatively. Thus, the external manifestation of hereditary predispositions with respect to many diseases of this group turned out to be very sensitive to the modifying influence of the rest of the hereditary mass, due to which clinical forms that deviate far from the main type can often be produced here in one or another generation of the family, for example, in a family with Huntington's chorea, individual cases resembling Wilson's disease may appear, or in a family with Friedreich's familial ataxia - cases resembling Pierre Marie's hereditary cerebellar ataxia. The onset of the disease at the same age characterizes only brothers and sisters of the same generation, while in different generations of the same family, significantly greater variations are possible. Finally, the course of hereditary nervous diseases is by no means necessarily steadily progressive: thus, remissions and exacerbations are often observed here, frequently in connection with very clear exogenous moments (acute infections, overwork, trauma, childbirth, etc.), even a subacute or acute onset, cessation of the process in later phases, and sometimes far-reaching improvement. Furthermore, it is characteristic of this entire group that there is an absence of inflammatory phenomena both clinically and upon pathoanatomical examination, in particular the absence of changes in the cerebrospinal fluid, a tendency toward a very high symmetry of the process, and a preferential involvement of motor functions. Anatomically, these diseases are based for the most part on a chronic degenerative process affecting more or less selectively one or another system ("abiotrophy" of Gowers), sometimes combined with a blastomatous component (proliferation of Schwann sheath cells in hypertrophic neuritis) or with a dysplastic component (cerebellar hypoplasia in Pierre Marie ataxia, many congenital anomalies in the structure of the neuromuscular apparatus in individuals who subsequently develop progressive muscular atrophy, etc.). Genetically, the majority of forms of this group of nervous diseases are characterized by autosomal and monomeric heredity, in some cases dominant (Huntington's chorea, myotonia, hereditary tremor, facioscapulohumeral type of myopathy, most forms of Charcot-Marie amyotrophy, Pierre Marie hereditary cerebellar ataxia, etc.), in others recessive (Friedreich's ataxia, various subspecies of amaurotic idiocy, certain forms of spastic paraplegia, genuine epilepsy and myoclonus epilepsy, etc.). Incomplete dominance is often encountered, especially frequently a greater or lesser limitation by one or another sex (more often male), as for example in Duchenne pseudohypertrophy, Erb's juvenile form, etc. Recessive heredity through the r-chromosome, previously often assumed for many hereditary nervous diseases, in reality occurs significantly less frequently; it can be considered proven for Leber's hereditary optic atrophy, for certain rare forms of myopathy, and also perhaps for Scholz's diffuse sclerosis and for Pelizaeus-Merzbacher disease. Most congenital structural anomalies are inherited in a dominant manner. Di- and polymeric heredity was admitted by some authors both as recessive heredity (genuine epilepsy) and dominant heredity (myopathy, hepatolenticular degeneration); the latter, however, cannot yet be considered precisely proven. Anticipation (earlier onset and more severe course in younger generations) still remains unproven for hereditary nervous diseases, although recently this issue is being raised again with respect to certain forms, e.g., with respect to atrophic myotonia, in which we often find only a cataract in the patient's ancestors. Very common in hereditary neuropathology is the so-called intermediate heredity, when heterozygotes for the recessive gene reveal a number of "minor traits" that make it easy to distinguish them from genotypically healthy people. The genetic study of hereditary diseases of the nervous system further revealed that many forms isolated in their time (myopathy, hereditary ataxia, and many others) are actually artificial collective groups. Thus, at present, a lively clinical-genetic revision is taking place in this field, as a result of which the classifications of these forms promise to change in the most essential way. It must be added that phenomena of polymorphism (when the same hereditary factor under different conditions can manifest differently) as well as the reverse phenomenon, when the same trait can be caused by completely different genes, are extremely characteristic of this entire group—a circumstance that significantly complicates the study of these forms and until recently forced many authors to admit in hereditary neuropathology only large nosological groups connected to each other by endless "transitional" forms. Alongside this group of diseases, those must be placed in which the realization of the pathological process requires the simultaneous presence of not only a hereditary factor, but also a specific external agent. These include, for example, familial palsies of the facial nerve, as well as other peripheral nerves, syringomyelia, toxico-infectious ataxias, etc. We say that in such cases a special "vulnerability" of one or another system is inherited, but we still know nothing about the closer characterization of this special structure. Apparently, the hereditary component of many psychoneurotic reactions, which have been genetically studied still very insufficiently and undoubtedly possess a significantly more complex gene structure than simple systemic abiotrophies, should also be placed in this same group. Finally, hereditary factors can be traced in many other nervous diseases of exogenous etiology as factors determining the localization of the process (familial tendency to cerebral arteriosclerosis) or some features of its course. It is important to keep in mind that the mere accumulation of similar cases in a family is not sufficient to recognize a given nervous disease as genotypically determined. Such an accumulation may depend on a familial infection (syphilis), on difficult labor with a narrow maternal pelvis, or on poor living conditions in the family (familial mercury poisoning in artisans); in other cases, it may also be the result of pure chance, especially with relatively frequent nervous diseases (multiple sclerosis).

S. Davidenkov. Trauma plays a tremendous role in the etiology of nervous diseases (see below - occupation and nervous diseases, and war and nervous diseases). Frequently, trauma causes a nervous disease only by joining other harmful factors. Thus, paralysis of the radial nerve occurs if a person in a state of alcoholic intoxication puts their arm under their head during sleep. During chloroform anesthesia, paralysis of the brachial plexus occurs from excessive abduction of the arm. Paralysis in the extremities can also develop from tying up a delirious typhoid patient. Upon falling, a hemorrhage into the brain or spinal cord occurs, more frequently in arteriosclerotics. The connection recognized by some authors between trauma and certain chronic nervous diseases, for example, gliosis, brain tumor, or epilepsy, can also be understood only in the sense of provoking endogenous (genotypic) pathological factors. - Any acute or chronic infectious disease can produce a complication in the form of inflammation of the brain, spinal cord, or peripheral nerves (see Encephalitis, Myelitis, Rabies). - Among intoxications, alcohol and lead take first place (see Alcoholism, Lead, and below - Nervous diseases and profession). Among other poisons for the nervous system, aside from occupational ones, one can mention arsenic (attempted suicide or murder, excessive dosage of a medicinal preparation, etc.), mercury, nicotine, carbon monoxide. Poisons for the nervous system are formed within the body itself, such as sugar (in large quantities), intestinal poisons, etc. - Vascular diseases are a frequent cause of nervous diseases. Circulatory disorders in the brain during arteriosclerosis, hypertension, thrombosis, embolism, vascular spasm or paralysis, hemorrhages can cause the most diverse disruptions of brain function, from severe paralysis, epileptic seizures, and ending with functional neurasthenic phenomena such as headaches, rapid fatigue, inability to concentrate, forgetfulness, etc. Similarly, diseases of internal organs, as already mentioned, can cause nervous diseases, especially tuberculosis, diabetes, gout, and other metabolic disorders. In kidney inflammation, hemorrhages in the brain are encountered relatively frequently. At the same time, cerebral symptoms also accompany the poisoning of the body during uremia. Diseases of the endocrine organs, by causing changes in the excitability of the nervous system, must frequently be regarded as an etiological factor in nervous diseases. Thus, it has been noted that epilepsy sometimes develops in people with defects of the thyroid gland, sexual glands (eunuchoid type), adrenal glands, etc. (see also Tetany, Basedow's disease, Myxedema). Undernutrition, especially insufficient consumption of vitamins, causes neuritis and other nervous diseases. - There are some data on the significance of sex and age. Hysteria, vasomotor and vegetative neuroses, Basedow's disease, and chorea are encountered more frequently in women (three girls to one boy). Tetany occurs in women almost exclusively during pregnancy or lactation. Conversely, in men, many forms of muscular atrophy (especially Duchenne pseudohypertrophy), diseases of the peripheral neuromuscular apparatus, neurasthenia, intermittent claudication, and certain forms of optic nerve atrophy prevail. (On special diseases of children and adolescents, see below - Nervous diseases in children.) Ankylosing spondylitis, tabes and other luetic diseases, and neuralgias which are almost absent in early childhood, including sciatica, hypertension, arteriosclerosis, and paralysis agitans, are typical for middle age. Characteristic of old age are cerebral arteriosclerosis, pseudobulbar paralysis, hemorrhages into the brain and membranes, arteriosclerotic muscular rigidity; the decrease in elasticity, increase in stiffness, stooping, etc., typical of the old person, are associated with changes in the striatal system of the brain. In old people, some nervous diseases proceed atypically, for example, epidemic cerebrospinal meningitis. - Among socio-economic factors for nervous diseases, the organization and conditions of labor are of immense importance. Production relations in capitalist countries, based on the exploitation of "free" labor, on capitalist rationalization and Fordization, and the competition, crises, unemployment, uncertainty about the morrow accompanying them, the urbanization of capitalist countries with intense paces and the pursuit of profit, with the glaring contrasts of the immeasurable enrichment of the few and the pauperism of the broad toiling masses, create all the conditions for the most rapid wearing out of the nervous system. The labor environment in capitalist countries is such that "labor," in the words of Engels, "turned into its opposite: from a source of health and physical perfection of the working human organism, it became a source of a whole series of harmful influences on the human organism." First of all, as a result of this, the nervous system gives way. Indeed, with the development of capitalism, the number of neuropsychiatric diseases is growing significantly. "Neurasthenia" itself, first described in 1883 by Beard, was explained by him through the high and intense pace of life. A purely mechanical view of the intensification of paces as an etiological factor was also transferred by some researchers into the environment of the Soviet Union. Regarding mental workers and responsible workers, a completely false theory even arose concerning "acquired psychiatric disability" under the influence of "wearing out" factors leading to arteriosclerotic changes in cerebral vessels. Under the influence of further observation, the entire groundlessness of isolating such a group became clear. In the conditions of socialist construction and socialist methods of work - shock work and socialist competition - the creative enthusiasm of workers, their purposefulness create maximally optimal prerequisites for "a peculiar increase in vital energy, which increases the individual capacity for work of individual persons" (K. Marx). And indeed, statistics undeniably prove that the development of shock work leads to a decrease in nervous diseases. Thus it was, for example, in the group of oil workers who fulfilled the five-year plan in 2¹/₂ years. This, of course, does not at all remove the extremely negative significance of violating the rules of psychohgiene (see), especially in the field of mental work. Only by this can one explain the frequency of neurasthenia among mental workers in amounts exceeding the average norm.

Nervous diseases and profession. The mutual dependence of profession and nervous diseases is expressed first of all in the fact that the action of a number of occupational hazards leads to diseases of the nervous system. On the other hand, the presence of a nervous disease of one origin or another in turn affects professional activity, influencing working capacity and suitability for a profession. The specificity of occupational diseases is extremely relative, since changes in production conditions and social-economic relations lead to a change in the sanitary-hygienic characteristics of a profession. Moreover, in the majority of cases, especially in chronic diseases, there is a summation of a number of pathogenic factors, including those of a non-occupational nature. Nervous diseases arising as a result of the influence of the external environment of occupational work have been studied best. This includes a large group of occupational neurotoxicoses. In acute occupational poisonings, there is usually a picture of a general effect on the centers of the nervous system with the development, in diverse combinations and to varying degrees, of symptoms of its excitation and paralysis (e.g., in poisonings with gasoline, aniline, nitrobenzene). More specific pictures can develop as a result of chronic poisonings. In such cases, certain regions or systems are sometimes electively affected. To explain this phenomenon, two theories have been proposed: one speaks of the physical-chemical affinity of poisons (or their derivatives in the organism) for certain divisions of the nervous system, while the other attempts to link the preferential lesion of certain areas with the peculiarities of their angioarchitectonics. However, there is no data to consider this selectivity specific or absolute. The duration of exposure, the amount of poison, the pathway of entry, the combination with additional harmful factors, as well as the characteristics of the nervous system in each individual case can modify the picture of the lesion. Frequently, anatomical changes are diffuse; however, the clinical picture of occupational neurotoxicoses can be quite characteristic due to the prominence of the lesion in certain areas. Most often in occupational poisonings, there are symptoms of damage to two divisions: the cerebrum and the peripheral nerves, which should be taken into account in early diagnosis. As regards the peripheral nervous system, polyneuritis is usually observed here, less commonly neuritis of the plexuses, mononeuritis, and neuralgia (lead, arsenic, carbon disulfide). The optic and auditory nerves are especially sensitive to poisons. There is reason to think that lesions of the spinal cord are also frequent in polyneuritis. Pure pictures of spinal lesions are rare and in any case little studied (for example, toxic spinal amyotrophies). Symptoms from the cerebrum are common: various degrees of consciousness disorders, especially in acute poisonings, delirious states, epileptiform seizures (e.g., in lead poisoning), emotional disorders, memory disorders (carbon monoxide poisoning). Sometimes acute or chronic psychoses develop (carbon monoxide, illuminating gas) and states of persistent mental enfeeblement. Practically more important are initial lesions in the form of various neurotic states, usually non-specific and recognized only on the basis of a combination with other mild symptoms of poisoning: neurasthenic states in chronic saturnism, hysterical states in galosh makers (benzine), so-called erethism in mercury poisoning, etc. In these cases, symptoms of damage to the autonomic nervous system are also common. Sometimes autonomic syndromes are manifested in the form of separate disease entities (lead colic). Among other divisions of the nervous system, symptoms of damage to which are observed in occupational poisonings, it is necessary to single out the cerebellum (mercury poisoning). In acute poisonings, coordination disorders are common, explained probably by the simultaneous lesion of the cerebellum and the cerebrum. Of particular interest is the predilection for lesions of the globi pallidi in carbon monoxide poisoning, although changes in other parts of the brain are also frequent in this poisoning. Chronic manganese poisoning (in workers grinding ore) also leads to the development of a picture of basal ganglia disease. Since the blood vessels are also affected in a number of poisonings, the development of various focal symptoms is possible (lead, carbon monoxide), as well as pictures of cerebral arteriosclerosis (lead). Most phenomena of occupational neurotoxicoses pass if the patient timely leaves the harmful production. However, in some cases, persistent changes remain or even a tendency to progression is observed (carbon monoxide). The prevention of occupational poisonings of the nervous system boils down to carrying out measures for the sanitization of production, and in individual cases to the transfer to other work of persons who have proved to be particularly susceptible to the corresponding poison. Besides poisons, other factors of the external environment can lead to occupational nervous diseases. Thus, in those working under conditions of high air temperature (stokers, tunnel workers), overheating of the heat centers can cause the development of a stroke. The chronic influence of high temperature on the development of nervous diseases is little studied. Cooling of individual parts of the body, especially during physical work, predisposes to the development of rheumatic diseases (muscles and peripheral nerves). When struck by electric current, various symptoms of central or peripheral nervous system disease are described. In those working under conditions of increased atmospheric pressure during their transition to normal pressure, symptoms of caisson disease may develop (neuralgic pains, spastic paralyses, less commonly cerebral symptoms). Of great social significance in view of their severity are occupational traumas of the nervous system (construction workers, miners, transport workers) in the form of concussions of the brain, skull or spine fractures with damage to the brain and spinal cord, cerebral hemorrhages and hematomyelia. Those professions where traumas of the extremities (especially upper ones) are frequent yield correspondingly large figures of peripheral nerve injuries. Aside from hazards inherent in the work environment, the work process itself as such can be a cause of the occurrence of nervous diseases. Most often, this is a matter of slow trauma, for example, in the form of compression or stretching of the nerve trunks of the extremities with the development of occupational neuritis. On the upper extremities, neuritis of the ulnar and median nerves (ironers, tanners, turners working with pneumatic tools, etc.) or of the entire brachial plexus (heavy loaders, blacksmiths, etc.) is observed most often. On the lower extremities, diseases of the sciatic nerve and lumbo-ischialgia are common in persons of heavy physical labor. Predisposing to the development of these lesions are anomalies of the spinal structure (cervical ribs, spina bifida sacralis), anomalies of the position of L_v, concomitant infections and intoxications (especially alcohol and lead). The possibility of the development of neuritis solely from overwork (without nerve trauma or simultaneous intoxication) in the sense of a pure 'wear-and-tear disease' (Edinger) is not recognized by everyone. Significantly more often than neuritis, as a result of local overexertion, occupational myalgias, neuralgias, and neuromyalgias develop (in seamstress-ironers, typists, those engaged in packing a large number of small items, etc.). A large group of occupational nervous diseases is represented by occupational coordination neuroses or occupational dyskinesias. They are the consequence of overwork of the central apparatuses (possibly striatal) coordinating complex complexes of automated professional movements. Examples of this group of nervous diseases are writer's cramp, coordination neuroses of telegraphers, pianists, violinists, etc. A combination of professional dyskinesia with phenomena of local neuro-muscular overexertion is frequently noted. Diseases due to general overwork represent various reactions of the organism (most often neurasthenic forms) to the entire sum of labor and everyday life hazards. It is therefore not surprising that neuroses found and find especially favorable soil among the industrial proletariat of capitalist countries thanks to the summation of the influence of occupational fatigue, difficult living conditions, and the negative affective coloring of experiences associated with professional activity (oppressed, dependent position in production, uncertainty about the future, dissatisfaction with social and economic status, etc.). In the positive affective coloring of experiences associated with labor processes lies an extremely valuable opportunity for increasing work productivity without a corresponding increase in fatigue phenomena (see above). For a whole range of non-occupational nervous diseases, the profession may have the significance of a provoking, auxiliary, or worsening and disease-course-modifying factor. Occupational conditions can be of significance in worsening the course of syphilitic diseases of the central nervous system (overwork, trauma), cerebral arteriosclerosis (mental overwork, poisonings), multiple sclerosis (fatigue, cooling), hereditary degenerations (overwork, poisonings).

Syringomyelia may develop in connection with occupational injuries, which explains the frequency of this disease in persons engaged in heavy physical labor. Cooling and minor occupational injuries worsen the course of certain diseases of the autonomic nervous system (for example, in Raynaud's disease). Another side of the interaction between occupation and nervous diseases lies in the possibility of a favorable influence of occupational activity on the course of diseases. Already the rational choice of profession, achievable only under the conditions of the socialist system, cannot fail to have a favorable effect on the course of many chronic nervous diseases, since work adapted to the capabilities of the organism increases general tone and resistance to various harmful influences. First of all, the favorable influence of occupational activity affects the course of neuroses. But even with certain forms of cerebral arteriosclerosis, the continuation of occupational work in many cases helps to maintain the tone of the nervous system and protects the psyche from premature decline resulting from inactivity. Nervous diseases as a factor influencing occupational activity. Nervous diseases often pose the task of changing professions in adults or selecting a profession in adolescents. Furthermore, curable nervous diseases, in view of the slowness of recovery processes in the nervous system, sometimes entail a prolonged loss of working capacity. Many chronic organic diseases of the central nervous system lead to full or partial disability. However, data from hospitals, outpatient clinics, and medical expert bureaus show that not a few patients with such diseases as tabes dorsalis, lues cerebrospinalis, syringomyelia, cerebral arteriosclerosis, neurogenic muscular atrophy, etc., continue working in their profession for a long time. In some cases, nervous patients remaining in production are substandard workers, which is manifested, for example, in the significant frequency of accidents among them. But with proper job placement, many chronic nervous patients, especially when the process subsides or with various residual phenomena, as well as during remissions, can be rationally utilized for productive labor. Particularly much can be achieved in young patients, when healthy parts of the nervous system can compensate for lost or diminished functions through exercise. A necessary condition for this is the retraining of such patients.

B. Serebryanik. War and Nervous Diseases. The nervous system during the imperialist war was especially affected in connection with epidemics of typhus, cerebrospinal meningitis, and epidemic encephalitis. Typhus affects both the peripheral and the central nervous system, causing neuritis, polyneuritis, myelitis, and especially encephalitis. Epidemic cerebrospinal meningitis frequently rages even in peacetime in barracks and military units. Out of 58 epidemics described in France, 39 affected exclusively the military population. Sometimes the epidemic was limited only to a specific regiment or a specific barracks. During the Austro-Hungarian war, a small outbreak was observed in the barracks of the Alexander Regiment in Berlin when the regiment mobilized its reserves and the population of the barracks increased from 2,108 to 3,182 people. During the imperialist war, cerebrospinal meningitis raged on various fronts and in rear units. For example, in the British Navy, mortality from meningitis was quite high, reaching 52.9% in the first year of the war, 35.6% in the second, and 36.2% of all cases in the third. In the land forces of all belligerent states, epidemics of cerebrospinal meningitis were also observed. Among the preventive measures to which attention was paid, especially in the last war, we shall mention only hand hygiene, handkerchief hygiene, and combating overcrowding in barracks and infirmaries. Epidemic encephalitis under the guise of sleeping sickness was described for the first time in 1916 during the imperialist war. Practically, so-called military neuroses and psychoses are especially important. In addition to the military factor, not the least role in their development is also played by the predisposition of the sick subject, the state of his neuropsychic, especially emotional sphere, his consciousness, and purposefulness. Etiological factors of military nervous diseases include, besides wounds, contusions, and cave-ins, continuous shelling, especially from heavy calibers, creeping barrages, gas attacks, airplane bombardments, grenade explosions, carbon monoxide poisoning, combat gases, hunger, exhaustion, infectious diseases, trench life, siege in a fortress, etc. In a significant portion of traumatic neuroses and psychoses developing in connection with the listed factors, we are dealing with organic changes in the central nervous system and in other body systems (increased muscular excitability, increased labyrinthine excitability, edema, cardiac dilation, etc.). Despite the abundant literature treating the question of the impact of war on organic nervous diseases, and despite the fact that overwork and privations, injuries and infections associated with war a priori must aggravate any disease, the experience of the imperialist war does not provide us with sufficient material to judge the significance of war for the origin or course of organic nervous diseases. Leaving aside injuries of the nervous system and infections, it is necessary to dwell further on polyneuritis and epilepsy. The increased incidence of polyneuritis in connection with war is recognized by all authors. Part of this depended on increased infectious diseases (acute intestinal catarrhs, dysentery, malaria, trench fever, typhus, septic diseases), while part was connected with chilling, frostbite, dampness, and overwork. Thus, for example, during the war of movement, neuritis of the lower extremities became more frequent. In positional war, according to some authors, the predominance of neuritis of the lower extremities was not observed. Engel observed among the soldiers of his regiment, which was at an altitude of 2,000 m for 11 months, a significant increase in polyneuritis after periods of rain. Among his regiment, the labor battalion suffered particularly, consisting of people unaccustomed to the mountains. Oppenheim frequently found lesions of the upper extremities and explained this by the pressure of the rifle and backpack on the plexus. Pain in the shins was frequently observed, which was explained by the influence of footwear, periostitis, neuritis of the branches of the saphenous nerve innervating the periosteum, and flat feet. Authors point out a rather poor prognosis for military neuritis. In the majority of cases of military epilepsy, seizures or signs of the given subject's predisposition to epilepsy already existed before the war. However, the significance of cranial wounds or contusions, emotions, overwork, exhaustion, malnutrition, etc., is recognized by all authors. It is interesting to note that according to Behague's statistics relating to the imperialist war, only 12.11% of those wounded in the skull contracted epilepsy; according to Claude, 10%; according to Guillain, 10.14%; according to Villaret, 20%; according to Sollier, 15%; and according to Cestan, 11%. Thus, if one takes into account the circumstance that out of millions of participants in the war who were subjected to all the indicated traumas, only a relatively small part fell ill with epilepsy, one must recognize that a significant share in the etiology of military epilepsy must be attributed to endogenous or exogenous factors present in the given subjects even before the war. This, of course, does not diminish the significance of the military factor, which in a certain percentage of cases provoked the manifestation of latent epilepsy. Graves' disease became more frequent during the imperialist war, especially in men. Its classical form with all the main symptoms was not always noted, and so-called formes frustes were encountered more frequently. It is not subject to doubt, however, that the concept of Graves' disease was frequently broadened. Nevertheless, one must recognize that in connection with significant overwork and even more often with severe emotional shock after shelling by heavy calibers and the like, Graves' disease arose quite acutely. It is interesting to note that according to some authors, Graves' disease began to be observed more frequently in the rear, especially among women whose close relatives were at the front. If we thus summarize the data on the impact of war on nervous health, especially based on the materials of the imperialist war, we can say that among organic diseases of peacetime, only polyneuritis, epilepsy, and Graves' disease became more or less noticeably more frequent under the influence of military actions, and that obviously mainly in subjects whose nervous system was labile even before the war. Infectious diseases and traumas, however, produced a significant number of nervous diseases. The practical conclusions that must be drawn from these data boil down first of all to the fact that it is necessary in peacetime to devote maximum attention to strengthening nervous health. The upbringing of a conscious, purposeful fighter fearlessly ready for all sacrifices to defend his socialist fatherland from the class enemy is one of the most powerful prerequisites for protecting the nervous health of working people from numerous military traumatizations. Syphilis and Nervous Diseases. Syphilis is a frequent etiological factor in nervous diseases. From this alone follows the enormous social significance of neurosyphilis. It is further intensified when, as in the early stages of progressive paralysis, the disease remains unrecognized. Neurosyphilis proceeds in the most diverse clinical forms, which depends on the fact that the infection remains in the body for decades, being modified under the influence of the most diverse conditions of constitution, social and domestic conditions, treatment, and other diseases. Finally, according to some authors, peculiar characteristics of the causative agent also play a role (see Progressive Paralysis). Syphilitic diseases of the nervous system manifest themselves either in the form of vascular and meningeal syphilis corresponding to the secondary or tertiary stages of syphilis (so-called mesenchymal neurosyphilis), or in the form of syphilis of the brain tissue itself, the parenchyma itself (so-called ectodermal syphilis). The former forms include simple "non-specific" infiltration of the meninges corresponding to the second or even the first stage, meningomyelitis, gummous encephalomyelitis, specific basilar meningitis, specific vascular changes characteristic of the tertiary stage, and chronic poliomyelitis. To the second group belong predominantly progressive paralysis, tabes, and spinal spastic paralysis. Already in the very earliest stages of syphilis, an increase in cellular elements (so-called pleocytosis), a positive Wassermann reaction, and globulin reactions can be detected in the cerebrospinal fluid. Some authors attach special significance to such latent neurosyphilis, seeing in it the result of a disruption of the blood-brain barrier and guided by pleocytosis when prescribing specific treatment. Sometimes nervous symptoms appear or intensify under the influence of the provoking action of specific treatment (neuro- or meningo-relapse). The tertiary period of syphilis usually corresponds to generalized so-called cerebrospinal syphilis. Its frequency is estimated by authors at 4–5% of all those who contracted syphilis. Finally, regarding tabes dorsalis and progressive paralysis, we can cite, for example, the statistics of Pilcz and Mattauschek, who collected follow-up data regarding 4,134 Austrian officers who contracted syphilis. Of this number, 4.75% contracted progressive paralysis, 2.37% tabes, and 3.19% cerebrospinal syphilis. Diseases of the nervous system in congenital syphilis are determined at approximately 4.81%. (See also Progressive Paralysis.) IV.

General principles of diagnosis of nervous diseases. The general principles of diagnosis of nervous diseases are based on the analysis of subjective complaints of the patient, data on heredity and medical history, the study of the conditions of his everyday life and profession, and the results of the examination of his general status and the special condition of his nervous system. Clinical examination of the psyche, sense organs, movement and sensitivity, cranial nerves, reflexes, and vegetative functions is supplemented by X-ray examination, sometimes after the introduction of contrast agents, special studies of electroexcitability (and chronaxie where possible), general examination of other organs, especially the cardiovascular system, and laboratory data, particularly analysis of the cerebrospinal fluid. The most responsible moment in the diagnosis of a nervous disease is deciding whether the patient's complaints or the disorder of nervous function depend on structural changes in the nervous system itself, or whether they are caused by disturbances in the work of other organs or systems of the organism (vascular system, hematopoietic organs, general infections, metabolic disorders, gynecological diseases, diseases of the eyes or ears, etc.). In the initial stages of any disease, nervous subjective complaints of patients can significantly mask the entire picture of an internal or surgical disease. The same applies to organic nervous diseases. By the intensity and extensiveness of the patient's subjective complaints and symptoms, the physician may be misled and diagnose a functional nervous disease where one is dealing merely with an excessive reaction of the organism to an organic core located in a «mute» area of the brain and therefore not giving symptoms for the time being (tumor, multiple sclerosis), or while the organic symptoms are still insufficiently convincing. From this it follows that the diagnosis of neurasthenia or hysteria does not yet exclude another organic disease of the nervous system or other organs. Diagnosis is further complicated by the fact that functional, especially hysterical reactions of the patient, can in many respects resemble symptoms and symptom complexes (syndromes) characteristic of organic nervous disease. All the more valuable for diagnosis are symptoms that do not occur in purely functional nervous diseases, such as changes in the optic fundus, pupillary disorders, Babinski's reflex or other so-called pathological reflexes, changes in the cerebrospinal fluid, and so on. No less essential is the analysis of the distribution of paralyses and sensory disorders, the posture of the patient and his limbs, typical of organic disease. In view of the high differentiation of the nervous system, a disease of any part of it causes very characteristic symptoms of deficiency or irritation. From the combination of these symptoms, one can therefore determine the localization of the pathological process. However, the clinical picture of a nervous disease is determined not only by the defect, the loss of function of the diseased part of the nervous system, but to an even greater degree by how the entire rest of the nervous system continues to function under newly created conditions. Diagnosis must take into account «compensations», «readjustments», reorganizations, shifts in neurodynamics, the general condition of the patient (first of all his vascular system), age, past illnesses, and his entire «premorbid» state. It must reckon with the interdependence of functions of individual parts of the nervous system, with double innervation of muscles, with synergies, with trainability, with the influence that the center exerts on the periphery (for example, areflexia in cerebellar tumors) and the periphery on the center (for example, ataxia in polyneuritis), the autonomic nervous system on the brain and the brain on the autonomic nervous system, and individual «floors» of the nervous system upon one another. Therefore, the establishment of a certain specific syndrome is still far from decisively determining the localization of the pathological process with absolute precision. Thus, for example, dizziness and ataxia can be caused by some disease of the peripheral nerves, the vestibular apparatus, the oculomotor nerves, the cerebellum, the brainstem, the frontal or temporal lobes of the brain, etc. Analysis of all symptoms, the history of the sequence of their development, information about previously existing and currently disappeared symptoms can help correct diagnosis. However, determining the localization of the pathological process represents only part of the diagnostic work, since the same localization and the same status can be given by different diseases. For example, in the extrapyramidal system, a tumor, encephalitis, hemorrhage, chronic degenerative process, syphilis, etc., can localize and give similar pictures. Therefore, the next step in diagnosis is determining the nature of the disease. This is aided by data from the anamnesis, the onset and course of the disease, as well as to a no small degree by a general clinical examination (for example, of the heart, blood, etc.) and laboratory data, e.g., serological data, examination of the cerebrospinal fluid, and so on. Finally, in some difficult cases, the establishment of the nature of the process is made on the basis of the therapeutic effect, by prescribing, for example, quinine or mercury against neuralgia, or tooth extraction, or treatment of oral sepsis, or tuberculosis, etc. In rare cases, one has to resort to exploratory laminectomy or trepanation of the skull. The diagnosis of a nervous disease, finally, besides the nature of the disease and its localization in the nervous system, must encompass all the most important data from the pathology of everyday life and profession, from heredity and the entire past history of the patient, in order to understand why a given disease in a given subject manifests itself precisely in this way and not otherwise. Including the analysis of exogenous daily hazards to the nervous system from the conditions of everyday life and profession—hazards that aggravate and exacerbate, and sometimes cause, nervous diseases—diagnosis approaches closely to prophylaxis, to the regulation of the patient's lifestyle, to the prohibition, for example, of wine, tobacco smoke, work in hot shops, night work, sodium chloride, etc., for an epileptic. Thus, differential diagnosis (either-or) should be supplemented by integral diagnosis (both-and), which corresponds to the integrality of the patient's organism, the synthesis of all his past with all his present in its dialectic development and in its relations with the entire external environment. In the latter, the nervous system plays the most important role. Thus, we go from the diagnosis of the symptom, from the diagnosis of localization, through the diagnosis of the nature of the disease to the diagnosis of the structure of the entire clinical picture, including the sick person not only with all his pathological symptoms of deficiency and irritation, but also with all the peculiarities of the function of his nervous system under «new» pathological conditions and with all the hazards of everyday life and profession, which largely determine his reaction as well. Finally, the most important moment in the diagnosis of nervous diseases is taking into account so-called atypical cases. In the initial description of a number of forms of nervous diseases, authors usually, purely empirically, without grasping the essence of the pathological process and its modifications in a particular case, singled out a combination of 2–3–4 most striking symptoms into a special nosological unit. Thus, Charcot singled out the triad of multiple sclerosis. Thus, certain forms of myopathies were singled out. With the further development of our knowledge, it invariably turned out that what was considered specific for a given nervous disease or nosological group was completely nonspecific for it. Thus, Charcot's triad is also encountered in encephalitis, in cerebellar tumors, in «pseudosclerosis», and so on. Moreover, it turned out that «specific» symptoms do not exist at all. Now «the diagnosis of multiple sclerosis is made even in the absence of all symptoms of the triad, which is encountered no more often than in 8–10% of all cases of multiple sclerosis.» For Tay-Sachs amaurotic idiocy, Jewish origin of the patients was considered specific. Forms in Jewish children were described exclusively as Tay-Sachs disease. With the help of such a vicious circle, the myth of «specificity» was maintained. At present, they are beginning to abandon even this «specificity». It is becoming increasingly clear that what was described as separate nervous diseases, separate nosological units, is nothing other than syndromes that can be encountered in the most diverse nervous diseases. A nervous disease is not the sum of symptoms. In a given concrete setting, each symptom can be modified, even turn into its opposite (for example, high knee jerks in tabes dorsalis, insomnia in epidemic encephalitis, etc.). Meanwhile, the diagnosis of a nervous disease is frequently made on the basis of the presence of a certain combination of a known number of symptoms (Charcot's triad in multiple sclerosis, the triad of symptoms in tabes, Basedow's disease, etc.). Such diagnoses are examples of crude empiricism in medicine, which takes phenomena as they are directly reflected in cognition. Meanwhile, the diagnosis of a nervous disease is cognition, of which Lenin says in his conspectus on Hegel: «Cognition is man's reflection of nature. But this is not a simple, not an immediate, not a complete reflection, but a process of a series of abstractions, the formulation and formation of concepts, laws, etc., which... embrace conditionally, approximately the universal lawfulness of ever-moving and developing nature.»

It goes without saying that in a scientific, dialectical diagnosis, the empirical is contained in a "sublated" form. With regard to nervous diseases, such a diagnostic approach is all the more important because in the struggle for healthy nerves, the diagnostics of "atypical" and initial forms of nervous diseases is no easy task, yet at the same time it is a crucial prerequisite for the timely adoption of therapeutic and preventive measures. V. Prophylaxis. The most radical measure in the struggle for healthy nerves, first and foremost, is the overcoming of capitalism and the destruction of the entire legacy of capitalist production relations, which are the main cause of nervous morbidity among the working masses of town and country. The new labor norms in the USSR: the five-day week, the seven-hour working day, and for certain professions an even shorter working day, leaves, housing construction for workers, the construction of socialist cities, agro-cities, and green cities, proceeding alongside the industrialization and collectivization of the countryside, the dining hall as a workshop of the enterprise, the revolution in everyday life, the elimination of illiteracy, the cultural revolution, and the enhancement of cultural services for the working people are the most important factors in the struggle for healthy nerves, in particular in the struggle against alcoholism, drug addictions, domestic syphilis, and religiosity. Of no less importance for strengthening nervous health and in the combat against nervous morbidity are the new forms of socialist labor in the USSR: shock work, socialist emulation, and brigade work. At their core lie prophylactically extremely important positive emotions and socialist purposefulness, which undoubtedly act in an invigorating, tonic manner on the brain and the entire organism. The prophylaxis of nervous diseases further includes such most important elements of Soviet public health as the protection of motherhood and infancy, the entire system of health protection for children and adolescents, physical culture, sports grounds, school sanitation, servicing of the Pioneer movement, vocational selection, and so on. Specialized neurological care in the USSR is a more independent branch of practical medicine than in Western Europe, where it is provided by specialists and institutions in psychiatry, and more often in internal medicine. At the center of the specialized preventive struggle for healthy nerves stands the psychoneurological dispensary or the corresponding department of a unified dispensary. It must study the factors traumatizing the nervous system with the aim of devising ways to eliminate them. It must catch the initial forms of nervous diseases with the aim of treating them or applying a number of preventive measures from the field of neuro- and psychohgiene (see). Occupations and workshops that are particularly unfavorable in terms of nervous morbidity must be specific objects of the dispensaries' work. In particular, this also applies to the party active, responsible workers, the Red Army, proletarian youth in factories, collective farms, and educational institutions. With the aim of fighting for the healthy nerves of workers, collective farmers, the poorest peasants, and the working intelligentsia, rest homes, sanatoriums for nervous patients, and physiatric institutions have been included in the Soviet public health system.

M. Kroll. VI. Nervous diseases in children. Due to a number of anatomical, physiological, and immuno-biological reasons, the nervous system of children is much more sensitive to various harmful factors of endo- and exogenous nature than the nervous system of adults. The reaction of a child's nervous system to various environmental influences is also completely different. Because of these reasons, a whole range of nervous system diseases is observed exclusively or predominantly in childhood, while others have a peculiar character uncharacteristic of adults. The peculiar picture of nervous system diseases in childhood and the application of special measures to combat them make it necessary to separate them into a special discipline. Data on the number of both organic and functional nervous diseases in children's outpatient clinics of Leningrad, where school-age and preschool children undergo universal examination, show that children with various abnormalities of the nervous system make up more than 33% of the total number of children who underwent medical examination (Iogiches); according to Krichevskaya, they make up even more than 50%. The same figures are given by reports of doctors from children's prophylactic outpatient clinics in Moscow, where nervous diseases rank second after anemia (Kapustin). According to Gundobin, diseases of the nervous system account for about 4% of all childhood illnesses. According to his data, child mortality from nervous system diseases in the pre-war period accounted for 12% of total child mortality in Leningrad. According to the Rauchfuss Hospital in Leningrad, the number of nervous-system-ill children in 1924 was 2.5%, and in 1925, 4.8% of all diseases; thus, the number of nervous diseases has undoubtedly had a tendency to increase recently (Iogiches). According to Maslov, the nervous system turns out to be most vulnerable in the first years of life, as well as at the age of about 12 years. According to Iogiches, the largest number of diseases occurs at the age under 1 year, then up to 5 years the incidence gradually drops and subsequently changes little up to 14 years. Of great interest are the data of the statistical bureau of the Moscow Department of Health on nervous system diseases for 1926, processed separately for Moscow and Moscow Governorate (see table - incidence per 1,000 children) (see also Childhood Diseases). These data show that the number of nervous diseases in children and adolescents in the governorate (which includes rural areas) is significantly less than in Moscow, and that they generally increase significantly with age. Very interesting and important in terms of vocational guidance is the fact that adolescents working in various industries have an unequal number of nervous system diseases. Thus, according to a survey of working adolescents in Leningrad (1923-1924), among metalworker adolescents there were 4.7% of nervous-system-ill, among woodworkers 2.72%, tanners 1.53%, textile workers 1.73%, chemists 1.05%, printers 0.68%, garment workers 0.40%. Among the causes causing nervous diseases in children, hereditary factors play a prominent, but far from the only role. In addition to neuropathic burden, the latter include various chronic and acute poisonings of parents (alcohol, morphine, lead, etc.), their chronic diseases (malaria, tuberculosis, syphilis, etc.). Close kinship of parents, their advanced age and significant difference in their age, traumatic moments - bruises of the abdomen, falls and other injuries of the pregnant mother, mental trauma, her acute infectious diseases, etc., can also have the same significance. All these factors can lead to disorders in the development of the embryo and, in particular, to anomalies in the development of the nervous system. These include various anomalies of the skull, spine, and brain, such as acephalia, anencephalia, further microcephaly, porencephaly, cerebral hernias, spina bifida, meningocele, myelocystocele, various cortical aplasias and dysplasias, congenital aplasia of cranial nerve nuclei (Moebius's nuclear atrophy), various sclerotic processes as remnants of early-incurred brain diseases, congenital hydrocephalus, etc. When such children survive, they exhibit severe changes in the nervous system - paralysis, hyperkinesia, speech disorders, etc., as well as constitutional neuro- and psychopathies, various degrees of dementia. The factors indicated above may be the cause of premature birth and associated pathological changes in the brain and corresponding clinical manifestations in the form of various forms of infantile cerebral palsy and certain changes in the psyche. Neuropathic heredity plays a particularly large role in various forms of constitutional neuro- and psychopathies and in the so-called hereditary organic diseases of the nervous system, predominantly manifesting in childhood. The latter include the group of amaurotic idiocy, of which some forms develop in the 1st year of life (Tay-Sachs), others at the age of about 2 years, still others at 6-7 years, and finally the fourth in adulthood. It is interesting to note the connection established recently (Bielschowsky, Homburger) between amaurotic idiocy and another familial disease - Niemann-Pick splenomegaly, confirming the opinion expressed by many authors about a peculiar metabolic disorder in these forms. Friedreich's disease, usually developing at the age of 6-15 years, familial spastic diplegias at the age up to 15 years, various forms of myopathies, of which the spinal form (Werdnig-Hoffmann) begins already in the 1st year of life, and other forms (see Dystrophia musculorum progressiva) depending on the type at various times starting from 3 years and even earlier and ending in adulthood, Thomsen's disease often starting already in early childhood, all belong to this same group. A whole range of extrapyramidal diseases also belongs to this group, such as Wilson's disease, pseudosclerosis, torsion dystonia, double athetosis, myoclonus epilepsy, which also develop mostly in the second half of childhood. Oppenheim's congenital myatonia, appearing already at birth or in the first months of life, as well as other rarely occurring diseases such as Pelizaeus-Merzbacher disease, Bielschowsky's disease, Hallervorden-Spatz disease, various diseases in the area of the visual apparatus, such as Leber's disease, hereditary paralyses of external eye muscles, etc., also belong here. Cerebral hemorrhages occurring in difficult, protracted, and artificial births and in asphyxia are of immense importance in the development of organic diseases of the nervous system. According to careful studies by many authors, normal births can also be the cause of cerebral hemorrhages. Kowitz, out of 5,989 autopsies of children, found predominantly fresh hemorrhages in 25% of 1,203 stillborns and in 26% of 911 children of the first weeks of life. Stern, out of 2,682 autopsies of newborns, found hemorrhages in 16.89%. Schwartz, in 230 cases of children younger than 5 months, found naked-eye hemorrhages and softenings in the brain in 65% as a consequence of birth trauma. Ylppö found hemorrhages in the brain and its membranes in premature infants: in 90% of fetuses below 1,000.0 g, in 76.5% up to 1,500.0 g, in 35.5% up to 2,000.0 g, and in 26.7% up to 2,500.0 g. These hemorrhages can cause various disorders of the central nervous system, predominantly in the form of various types of infantile cerebral palsy, dementia, and epilepsy. Taking into account these findings and the fact that the physiological central nervous system at birth is an organ far from completing its development, it becomes clear that the consequences of birth trauma are discovered in a number of cases only after various times following birth. Severe abnormal births can also be the cause of diseases of the peripheral nervous system (such as obstetrical paralysis, facial nerve palsy). Furthermore, diseases of the nervous system in children are closely related to general diseases, such as rickets, various digestive tract disorders; finally, one of the most important factors, especially for organic diseases, is various infectious diseases. Some of the primary infections affect almost exclusively or predominantly children, especially young children, such as cerebrospinal meningitis and poliomyelitis, or Heine-Medin disease. In the epidemic of cerebrospinal meningitis described by Flatten, 57.7% of the sick were under the age of 5 years. According to Neklyudov, 5.8% fell ill up to 1 year, 75% up to 3 years; according to Netter, the percentage of infants is 35.46%; according to Hirsch, 15%. In poliomyelitis, children under 5 years old make up from 61% to 90% of all cases in cities and from 37% to 63% in rural areas. Meningitis very often produces very severe complications of immense importance for the child's future, predominantly in the form of hydrocephalus, damage to the visual and auditory apparatus, rendering children completely incapable of working life.

Poliomyelitis, on the contrary, in a large number of cases causes various paralyses of the limbs without affecting the intellect at all, and thus creates physically disabled, but intellectually completely normal children, whose fate in recent years has been the subject of lively concern in most states of Western Europe and America, where this disease has recently become widespread. According to Leegaard, 58,5% of all patients remained disabled; according to Zappert, in 1905 it was 75,4%, and in 1903-1912 it was 56,7%; according to Biesalski, in Germany, according to the 1925-1926 census, there are 28,615 cripples who became such after suffering from poliomyelitis in childhood. It must be pointed out that this disease also claims a very significant number of victims in the USSR. Data, far from exact, show that the number of children who became cripples due to this disease in the USSR is numbered in many thousands. Severe lesions of the nervous system are also caused by epidemic encephalitis, which does not spare even children of the earliest age. It causes peculiar changes in the motor and vegetative spheres and severe mental changes that make children completely disabled. Thus, according to Howe, complete recovery occurred in only 42%, and various changes were detected in 38%. As for general infections, it must be said that there is no such infection that in children, especially of early age, could not be complicated by phenomena on the part of the nervous system with diverse consequences on the part of both somatic and mental health. This increased predisposition of children to lesions of the nervous system in various infectious diseases also finds its explanation in the anatomical and physiological characteristics of the child's brain. Its rapid growth and the enhanced metabolism associated with it, as well as the abundance of vessels, create its instability and favor the onset of inflammatory processes. Acute infections also include chorea (see). Secondary infections must include tuberculous meningitis, which is one of the most hopeless diseases of childhood. Syphilitic diseases of the central nervous system in children are very often observed, as well as tabes dorsalis and progressive paralysis. Brain neoplasms in the form of cysts, tubercles, and gliomas are also frequently encountered. A colossal role in childhood, especially in infancy, is played by various types of convulsions, which have far from identical significance for the child's future. The cause of these convulsions is also changes in the central nervous system of the child. Convulsions can be both general and local in nature. They can be observed already in the first days after birth and then are usually the consequence of hemorrhages. Very early they can be a manifestation of genuine epilepsy, spasmophilia, and a precursor of developing neoplasms. They can also be caused by various infections and intoxications, but can also be a manifestation of a neuropathic constitution. The prognosis of these convulsions is of course different, and therefore the question of their correct diagnosis is one of the most difficult and responsible tasks of pediatric neuropathology. In addition to convulsive states in childhood, a whole series of other seizures are also encountered, which also have completely different diagnostic and prognostic significance. These include epileptic petit mal, pyknolepsy (see), narcolepsy (see), salaam spasms, laryngospasm, tetany, spasmus nutans, Staupchen. Finally, it is necessary to point out the colossal number of functional diseases of the nervous system among children. Their cause can only partly be seen in the aforementioned hereditary burden. The harmful influence of the environment has a colossal significance in their development. They can not only serve as a reason for the development of reactive neuro- and psychopathical states, but by deepening and strengthening constitutional neuro- and psychopathies, they significantly complicate the fight against them. These influences become especially understandable if one takes into account the characteristics of the child's psyche, its imitative nature, impressibility, and affectivity. Constitutional neuropathies can be observed already from early childhood, but often appear or develop only under the influence of improper upbringing. A very important factor is the overfatigue of the child, which may take place already in early childhood, but acquires particularly great importance in school and preschool age. Living conditions also play no small role, such as nutrition, family discord, housing conditions, etc. So-called critical ages, especially the period of puberty, require particularly careful treatment. Among individual nervous phenomena of preschool and school age, headaches, dizziness, insomnia, night terrors are especially widespread (see Children's diseases, features of children's morbidity). Bedwetting, various tics, and stuttering are observed quite often. Masturbation plays a major role (see). It is also necessary to point out the so-called difficult-to-raise children, consisting predominantly of severe neuro- and psychopaths and socially neglected children, who make up the main core of homeless children, the upbringing of which requires special care and attention. The diverse causes of diseases of the nervous system in children also indicate the paths along which rational prophylaxis and therapy should proceed. The health of the parents is one of the main conditions for healthy offspring, and therefore the prophylaxis of diseases coincides on the one hand with eugenics. Measures safeguarding the correct course of pregnancy, correct labor and delivery, care for the mother and infant, etc., play a colossal role. All these measures are carried out by maternal and infant welfare institutions. Care for older children and adolescents lies with child and adolescent health institutions. Among them, one can note preventive outpatient clinics, forest schools, colonies, children's towns, health-improving grounds, etc. Physical culture plays a colossal role in all these institutions. Dispensation of the child population is of great importance in terms of prophylaxis. In addition to normal living and upbringing conditions, the correct dosage of physical and mental labor is the most important factor in creating a nervously healthy child and adolescent. A person's natural predisposition to one or another role in the labor process, the combination of his mental and physical characteristics, and his vital forces make him more capable of a certain activity and unsuitable for another. The mismatch of a given work with natural data cannot but cause, other things being equal, a faster wearing out and the manifestation of certain diseases, especially with a predisposition to them. Correct vocational guidance taking into account all the data of the child or adolescent is therefore a necessary prerequisite for rational prophylaxis. In hereditarily burdened families, correct upbringing in many cases can have a great influence and often prevent the manifestation of constitutional diseases of the nervous system. As for the therapy of nervous diseases, in many respects it coincides with prophylaxis and boils down predominantly to eliminating the factors supporting one or another anomaly. Of great importance, especially in young children, is the elimination of general somatic defects. Improvement of nutrition, staying in the fresh air, and sufficient sleep are of great importance in this regard. Various methods of physiatry, climate- and hydrotherapy can prove very useful, but must be applied taking into account constitutional characteristics. Drug therapy plays a very insignificant role and boils down to strengthening treatment. A therapeutic and educational approach to nervously ill children is of great importance. A calm atmosphere, correct distribution of activities, an even and calm attitude towards the child, the development of internal inhibitions, and finally the development of social attitudes are the most important principles of such an approach. The establishment of special schools and boarding schools for such children, as well as for children with various intellectual defects, plays an important role (see Defectiveness). It is also necessary to point out the need to create institutions for preparing children with organic diseases of the nervous system, but possessing sufficient intellect, for professional activity, which is quite possible thanks to the successes of orthopedics and technology. The correct combination of orthopedic, electro- and kinesiotherapeutic measures will not only give them the opportunity to become persons useful to the country, but will significantly reduce the burden of expenses for the maintenance of these patients on the part of the State.

I. Prisman. VII. Organization of neurological care in the USSR. In pre-revolutionary times, the organization of neurological care as such did not exist. An insignificant number of beds were embedded in general somatic departments of hospitals, and only university clinic beds for nervous diseases were specially allocated. No records of neurological attendance were kept, and special institutions of this type were almost entirely absent. The imperialist war, which revealed a huge number of neuropsychiatric diseases, served as an impetus for organizational measures in this field, and only since the time of the October Revolution, from the moment of the emergence of a single Soviet medicine, did these measures take on effective forms. A neuropsychiatric section was formed under the People's Commissariat of Health, which manages the registration of morbidity, the planning of new institutions, the expansion of the network of old ones, etc. At present, special neurological departments have already been deployed in a significant number of hospitals, special receptions for nervous diseases are conducted in dispensaries and outpatient clinics, physical therapy installations are adapted for the treatment of nervous patients in various hospitals, outpatient clinics, and polyclinics, and the institute of psychoneurologist consultants is gradually expanding in those medical institutions where special departments are absent. In the largest centers, special sanatoriums for nervous patients have also been organized. However, it must still be noted that there is an insufficiency in the organization of this type of care. The training of a larger number of psychoneurologists, the opening of prophylactic institutions, the expansion of bed and sanatorium care—all this in the plan of healthcare development will make it possible to provide for the working people. Finally, in the system of Soviet healthcare along the lines of the struggle for healthy nerves, a significant place is occupied by research institutes, such as the Institute of Neuropsychiatric Prophylaxis in Moscow, the Institute of Higher Nervous Activity under the Communist Academy, the Bekhterev Institute of Brain in Leningrad, the Ukrainian Psychoneurological Institute in Kharkov, the State Institute of Physiatrics, Orthopedics, and Neurology in Minsk, and many others. Lit.—see literature to the article Neuropathology.