UihiiliilJ Will l liiliiliiiliiiiiiiliiill Mi ,!{ iij liliiiiiiir: nuiili W!!!l'iiilli!Mli.iil,,'!!!,.!li.ii ii [\W~\- if! fill!1;1!' t mm !M'i: i1 '< Mm'i i!li!i :i! '•= '. »!!!l lillfl uuv mm l!!l! 99999999955555 Soientifie and Medioal Books, and all objects For Sale by pTm Belmont 'Ave., Philadelphia, Pa. Surgeon General's Office i 'cc/ PREFACE. and always formed a considerable proportion of the dis- eases, and those the most obscure, by which the human system has been assailed. But they have vastly increased with the increase of civilization, and now constitute a far greater propor- tion of the diseases of mankind, than in past ages, and consequently demand far more attention. If this volume induces but a few, to investigate the affections of this system with care, to record and make known the facts they observe and thus add something to our knowledge of its functions and diseases, it will be all that the author expects. Hartford, Ct., Jan. 1st, 1810. CONTENTS. General Observations on the study op the Structure and Functions of the Brain, . 13 SECTION I. Structure ok the Brain, &c, ... 19 Weight of the human brain .... 20 Size of do........21 External and internal configuration of the brain . 22 Nerves proceeding from the brain, (cerebral nerves,) 25 SECTION II. Functions of the brain—methods adopted for as- certaining ...... 26 1st. By chemical analysis of the brain . . 27 2d. By dissection of the brain . . . .28 ■ Miscroscopical discoveries of Sir Everard Home, M. Bauer, and Professor Ehrenberg 29 3d. By experiments on living animals . . 32 Experiments of M. M. Flourens, Bouillaud, and Serres. Observations of Foville . 31 4 th. By comparative Anatomy . . . .39 Classification of Cuvier and Professor Grant 40 Superior size of the brain in the mammalia . 43 Vlll contents. Facial angle of Camper . . . .45 5th. By the Foetal condition and growth of the brain 46 Researches of Meckel, Tiedemann, Serres, Geoffroy, St. Hiliare, Remarks of Mr. Anderson 47 6th. By Pathological Observations ... 48 Difference in function of the cineritious and the medullary portion of the brain . 49 Cineritious portion of the brain for the manifestation of the intellect, the medullary for motion . 49 Inflammation of the membranes covering the con- vexity of the brain accompanied by delirium, In- flammation of those covering the base by coma, and convulsions without delirium ... 49 Condition of the brain in Insanity, M. Foville's re- marks . . . . . . . .56 The cerebellum not concerned in intellectual opera- tions ........ 66 Connection of the cerebellum with the motive powers 75 do. do. Genital organs 79 do. do. Stomach . 85 The integrity of one hemisphere of the cerebrum sufficient for the manifestation of the mental powers 89 Anterior lobes of the cerebrum the seat of the more important intellectual faculties ... 94 Functions of the Optic Thalami .... 93 Corpora Striata ... 98 Pituitary body ... 98 Pineal Gland . . . 99 Optic tubercles — corpora Quad- rigemina . . . .100 Corpus Callosum . . . 101 Fornix .... 101 Pons Varolii — crura cerebelli 103 Affections of the brain disturbing particular mental faculties.......108 Division of the skull into regions . . . 113 CONTENTS. IX Summary of our knowledge of the functions of the brain derived from pathology . . . 114 Examples from Dr. Bright of the correct method of investigating the diseases and functions of the brain 115 7lh. External examination of the skull — Phrenology 126 SECTION III. Diseases and Functions of the Medulla Oblongata 131 do. do. do. Spinalis 138 Marshall Hall's views of its functions . . 141 Spinal irritation . . . . . . .148 SECTION IV. Functions and diseases of the cerebral nerves . 149 Functions and diseases of the First Pair — Olfactory 149 do. do. Second—Optic . .151 do. do. Third — Oculo muscular 157 do. do. Fourth—Pathetic . 158 do. do. Fifth — Trigeminal . 159 do. do. Sixth — Abducentes . 164 do. do. Seventh — Facial . 164 do. do. Eighth — Auditory . 169 do. do. Ninth — Glosso Pharyngeal 170 do. do. Tenth — Pneumo Gastric 172 do. do. Eleventh — Lingual . 187 do. do. Twelfth—Spinal Accessory 187 SECTION V. Great Sympathetic nerve Anatomical account of Functions of 189 189 190 X CONTENTS. Diseases of Great Sympathetic nerve . .192 Effects on the eye, of division of, in the neck . 195 JNrt «♦ Diseases of the Brain, and of other parts of the nervous system. Inflammation of the Brain and its membranes 198 Increase of the Inflammatory diseases of the Brain 200 Causes of this increase . . . . . 202 Prevention ....... 206 Treatment.......207 Apoplexy ....... 212 Pathology.......215 Prevention ....... 216 Treatment......, 216 Epilepsy ........ 219 Causes........220 Pathology.......221 Prevention........227 Treatment.......227 Hypochondriasis ...... 231 Pathology ........231 Treatment.......238 Hysteria ....... 239 Causes....... 241 Pathology ... .... 242 Prevention ... .... 247 Treatment .... . 248 Tetanus ........ 249 Pathology....... . 252 Treatment . . . . . . 253 contents. XI Chorea — St. Vitus's Dance . . . 255 Origin of the name—'History of St. Vitus . 255 Causes ...•..•• 257 Pathology ......257 Treatment.......259 Delirium Tremens ...... 260 First account of the disease by Dr. Pearson . 260 Causes ....... 261 Pathology.......265 Treatment.......266 Neuralgia — Tic Doloreux .... 267 Causes ........ 268 Pathology.....' 269 Treatment.......272 Dyspepsia. ...... 275 Causes ........ 276 Pathology........279 Treatment . .... 284 Insanity .....••• 285 Number of the Insane in various countries and cities 285 Causes ...••••• 286 Pathology.......292 Prevention ....••• 293 Treatment .......293 Effects of mental attention on bodily organs 299 Influence of a morbid state of the Brain in causing Fever and Inflammation. .... xii contents. Bppt ntiiv. Note A. Affections of the fifth and sixth pair of nerves. . 319 Note B. Affections of the Auditory nerve . . . 320 Congenital deafness .....320 Causes of Accidental Deafness leading to Dumbness 325 lackish and gangrenous appearance. Scrofulous en- gorgements upon the neck. " Head. — Under the integuments of the cranium near he parietal protuberance of the right side, an ecchy- nosis existed about the size of a dollar. The cranium was rather thicker than usual. The meninges of the brain appeared healthy. The cerebrum appeared in a natural condition, except that it seemed to me compara- tively very large. Dissected subsequently by M. Ma- gendie, a small sanguineous effusion was found in the left posterior lobe, which did not appear to have existed long, and which was not more than two or three lines in diameter. The covering of the cerebellum being divided, the medulla oblongata cut at the occipital foramen, and the encephalic mass raised and inverted — the following appearances were observed: " A large quantity of serum was discharged, filling the occipital fossae. In place of the cerebellum, I found a gelatinous membrane of a semicircular form, attached to the medulla oblongata by two membranous and gelatinous peduncles. The one of these on the right side had been torn. Near these peduncles I found two small white isolated masses about the size of a pea. On one of these was found one of the branches of the fourth pair of nerves. The tuberculi quadrigemini were entire. On the posterior and inferior side there was the appearance of erosion, in the midst of which the orifice of the canal of Sylvius appeared. It extended a little upon the medulla oblongata, making a slight alteration in the restiform and in the olivary bodies. The fourth ventricle 72 DISEASES OF THE BRAIN. did not exist. There was no trace of a pons varolii, but without any appearance of want of substance. The anterior pyramidalia terminated in a fork by the cerebral peduncles. " Of the cerebral nerves, I could only find the origin of the first, second, third and fourth pair, which appeared in healthy state, except the latter, which was, as I have said, detached with the small white mass, of which I have spoken. Not having raised the brain myself, it was impossible for me to find the origin of the other pairs. They all, however, existed, and could be easily perceived through the openings of the dura mater. They, have moreover, been subsequently dissected by M. Magendie, and exhibited no peculiarity. " The cerebral substance was of the ordinary consist- ence, but the medulla oblongata appeared a little softened, especially about the erosion I have described, where there existed a kind of maceration. The occipital hollows were regularly formed, but appeared to me rather smaller than natural. The vertebral arteries existed. I cannot say how these were distributed, because they did not at first fix my attention. " Spine. — A considerable quantity of serum ran from the spinal canal. The spinal marrow offered nothing remarkable. " Chest. — Both lobes of the lungs crepitated, but their whole surface was covered with miliary tubercles, which were also found in the parenchyma. The cavity of each pleura contained two or three ounces of serosity. The pericardium and heart offered nothing in particular. " Abdomen. — The intestinal circumvolutions were of a deep red color. The mucous membrane of the stomach exhibited a number of red dots on a slate-colored ground, and near the anterior part and great arch, there were five or six brown patches. In the middle of each of DISEASES OF TnE BRAIN. 73 these, a small ulceration with elevated and perpendicular borders appeared. This membrane was otherwise of its ordinary consistence and thickness. " The mucous coat of the duodenum presented no ulceration. It was slightly red, and its follicles prominent. After this, throughout the whole tract of the small intes- tine, it was of a livid red color, presenting numerous ulcerations, especially about the ileo-coecal valve. The large intestines presented nothing in particular. " The mesenteric ganglions were larger than ordinary. The liver was of an extraordinary size, and of a pale color. "The Organs of Generation.— The finger could readily be introduced into the vagina. The hymen did not exist. The labia were of a lively red color, and bore the appearance of having been frequently irritated. The ovaries and uterus existed, but they appeared smaller than usual with girls of the same age. " The kidneys, spleen, &c. were in a natural state. " Conclusions. — This singular case is calculated to excite the particular attention of physicians of the physi- ological school, and presents no less interest for patholo- gists. I regret exceedingly, my inability to say anything relative to the moral condition of this child previous to its entrance into the hospital, and am still in the expect- ation of receiving further information. Should any particulars be offered, I shall immediately communicate them."* That the cerebellum is not concerned in intellectual operations is evident from the fact that inflammation of the arachnoid membrane over it, does not produce delir- ium, while it is well known that inflammation of this * Bull, de la Soc. Anat. —Rev. Medicale, April, 183L 7 74 DISEASES OF THE BRAIN. membrane covering the cerebral hemispheres produces violent raving. Such instances have been given by Re- camier, Martinet and others.* The following from Aber- crombie is to a like purpose. Case X. — "A lady, 45, liable to suppuration of the left ear, complained of pain in that ear, May 11,1821. On the two following days, the pain extended through the head with fever ; and on the 14th, she complained of general headache, and a violent and painful feeling of throbbing in the back part of the head. She was deaf, and inclined to drowsiness, but quite sensible ; pulse 120 and very strong; large blood-letting and the other usual remedies were actively employed on this and the following days by Dr. Thatcher and the late Mr. Bryce. I saw her on the 16th ; there was then a good deal of coma, but she was sensible when roused; the eye natural, the tongue clean, pulse 130; she still complained of headache when she was closely questioned, but did not make any com- plaint except when she was much roused. The pulse being now considerably reduced in strength, topical bleeding only was employed. In the evening she was more easily roused, and said she felt better; in the night she became again extremely restless and incoherent, and died early in the morning. There had been a slight discharge of mat- ter from the left ear early in the disease. " Inspection. — There was slight effusion in the lateral ventricles ; the brain in other respects was healthy. On the outer surface of the cerebellum there was a uniform deposition of thick puriform matter; it was most abund- ant on the left side. The pia mater of the cerebellum was highly vascular, the dura mater was healthy : there * Revue Medicale, 1823. DISEASES OF THE BRAIN. 75 was some purulent matter about the pituitary gland, and in the cavity of the ear, but there was no appearance of disease of the bones connected with the ear, or of the dura mater covering them." That some part of the cerebellum is connected with the motive powers, is rendered probable from the fact, that in nearly all the cases on record of disease of this part of the brain, some disorder of motion was obser- ved. This is the most common symptom in disease of this organ. Still the effect of disease of the cerebellum upon the motive powers varies very much. Generally there is a paralysis of the opposite side, sometimes a staggering like drunkenness, and sometimes only strabis- mus is noticed, and in some instances no disorder of motion at all, as the following cases show. Case XI. — An abscess in the cerebellum and rupture of the lateral sinus by Mr. John Douglass, Surgeon in Ed- inburgh. G. B. aged 19 years, was taken with a pain and heaviness in the forehead, for which he was plentifully blooded, vomited, purged, blistered, &c. Notwithstand- ing which he was obliged to sit always with his head leaning forward, otherwise his pain was greatly increased. His pulse in the mean time was good, he had no convul- sions, but his appetite was bad, his sleep broken, and in turning his eyes quickly, he had an addition of pain. After being three months in this way, he became free from pain, in an evening in the beginning of January 1737, eat the wing of a hen, drank a glass of strong ale, after which he slept well all night, next morning he cal- led for tea, and immediately after fell into a seeming faint, just as I happened to enter his lodging. 1 opened a vein in his arm, but he did not bleed, and in two minutes he died. When his head was opened, we saw two ounces of 76 DISEASES OF THE BRAIN. perfect pus contained in a suppurated tumor formed in the middle of the cerebellum, and an opening of the left lateral sinus of the dura mater, out of which a consider- able quantity of blood had flowed.* In this case it will be observed, no mention is made of paralysis or disturbance of the motive powers. In the 22d vol. of the Lancet, is a case quoted from the clinical lectures of the Baron Dupuytren, of a serous cyst developed in the right lobe of the cerebellum which lobe had entirely disappeared, without any alteration in the cerebral or general functions. In the 17th volume of the Lancet is the following case. Case XII. — Abscess in the cerebellum. Eliza Purt, aged 19, was admitted into Faith's Ward, St. Bartholo- mew's Hospital, on the 13th of January, under the care of Mr. Lawrence. She has paralysis of tlie portio dura of the right side ; during sleep the eyelid of the affected side is but half closed ; and when she laughs, the muscles of that side remain motionless, and thus a rather ludi- crous appearance is produced. She suffers severe pain in her head, but none of the functions of the body are disturbed. There are two excrescences in the meatus auditorius externus of the right side, attended with puru- lent discharge. She states that she has been subject to headache for the last twelve months, and that lately ex- cressences have appeared in the meatus. She has been married a fortnight, since which the pain in her head has increased to such an extent, as to compel her to come here to seek relief. The treatment which was adopted was antiphlogistic, and consisted of five copious bleedings from the arm, the * Edinburgh Medical Essays, Vol. V. Part IL DISEASES OF THE BRAIN. 77 application of leeches to the head, a blister to the nape of the neck, and active purging. These remedies were attended with considerable mitigations of her sufferings ; a portion of one of the excrescences came away, which also was productive of relief. The pain being still severe her head was shaved, and ice applied to it. She was then submitted to a course of mercury, which affected her system in a few days. These measures were not capable of arresting the disease, and she died on the 27th of January. Post-Mortem Examination, seven hours after death. Head. — Membranes of the brain perfectly healthy, the convolutions appeared paler than usual, and were much flattened, especially on the right side. There were no evidences of inflammation in the substance of the brain. Three ounces of very transparent fluid were found in the lateral ventricles. On dividing the tentorium, the right half of the cerebellum appeared enlarged, and its ante- rior part felt as if it contained fluid. When it was cut into, about half an ounce of thin, and very fetid pus es- caped ; the parietes of the abscess were of a blackish- green color, and the cerebellum was adherent to the meatus auditorius internus. On stripping off the dura mater from the petrous portion of the temporal bone, thick pus was seen on the upper surface of the superior wall of the tympanum. This was washed off, and ulce- ration of the bone beneath it was observed; there was an opening in it, through which a probe was passed into the tympanum, which when its superior wall was remo- ved, was found full of pus. There were two excres- cences in the meatus auditorius externus ; one attached to the lower part of the meatus, the other to the mem- brani tympani, and in this membrane were several small holes. The portio dura was examined and exhibited its 7* 78 DISEASES OF THE BRAIN. usual appearance. The thoracic and abdominal viscera were healthy. The uterus and ovaries were enlarged and in a state of congestion, and in the right ovary a very beautiful corpus luteum was found. In the third volume of the American Journal of the Medical Sciences is an interesting account of disease of the cerebellum by John Ware, M. D. of Boston. It is briefly as follows. Case XIII. — A lad ten years of age complained for some months of veiy severe pains in the head, recurring in paroxysms, and produced by the least irregularity or improper indulgence in eating. The stomach was ex- tremely irritable and vomiting often occurred. For a short time he appeared to amend, but owing^ apparently to eating of some indigestible food his paroxysms of pain returned, and he was finally seized of convulsions, and died in eighteen hours. Appearances on Dissection. The veins of the pia mater were unusually vascular, and five or six ounces of a straw colored fluid was found in the lateral ventricles. " The fornix, septum lucidum, and the thalami were unusually firm, and of unusual whiteness. The consist- ence of the other parts of the cerebrum was natural; numerous red points presented wherever an incision was made. On dividing the tentorium slight adhesions were found between this and the cerebellum. On the left crus cerebelli between the arachnoid and pia mater, a small globular tumor, was seen, one third of an inch in diam- eter, of the consistence of the cortical substance, and of a granulated texture. On the inferior surface of the ten- torium, near its attachment to the petrous portion of the temporal bone, on the left side, was a bilobated tumor* very firmly adherent, of firm consistence, of an oval form, about one inch in length. In the left lobe of the cere- DISEASES OF THE BRAIN. 79 bellum there were two, and in the right lobe three round tumors from one-half to three-fourths of an inch in di- ameter. On dividing one of them it was found to con- sist of a firm cyst, containing a substance of a greenish- yellow color, similar in its external characters to the matter found in encysted tubercles of the lungs. These tumors were imbedded in the convolutions of the cere- bellum, and by care could be removed without destroying the texture of the parts. Those in the left lobe were less firmly attached to the pia mater than those in the right. The substance of the cerebellum appeared less firm than natural, but no ramollisement existed around the tumours. The pia mater of the medulla oblongata was considerably injected, and a small quantity of serous fluid was found at the base of the brain. The thorax and abdomen were not examined. " During the whole course of this disease says Dr. W., the functions of the brain were unaffected in a remarka- ble degree. There was no failure of the powers of the intellect, memory, sensation, speech, or motion. There was never any thing peculiar in his gait; his manner of walking at different times was determined wholly by the amount of his muscular strength. He moved precisely as any other person would do who was equally weak. His countenance was melancholly and his eye rather heavy. He was generally silent and depressed, and easily moved to tears by very slight causes." By some the cerebellum has been considered the or- gan of the sensual propensities. Dr. Gall was the first I believe who advanced this opinion, though he does not consider, as I have already shown by a quotation from his writings, that the cerebellum has no other function. That some part of the cerebellum is appropriated to, or is the seat of this propensity, I believe we must admit, as the cases are very numerous of disease of this organ 80 DISEASES OF THE BRAIN. affecting the genital organs. I will refer to some of them. The following is from Hennen's Principles of Military Surgery. Case XIV. — Gaetano, a soldier of the ninth Portu- guese Cacadores, was struck by a piece of shell at Salamanca, in June, 1813. It shattered the superior part. of the occipital bone from within half an inch of the great knob on the left side, to the lambdoidal suture. An irregular angular portion of the left parietal bone, nearly an inch in length and about an inch in breadth, was also fractured and beaten inwards. He labored under most alarming symptoms, total insensibility, invol- untary discharge of feces, laborious breathing, irritabilty of pupil, and weak low pulse with occasional convulsive twitchings. The removal of the depressed portions of bone, and about an ounce of coagulum from the surface of the dura mater, on the second day after the wound, was attended with a diminution of most of the symptoms ; and with two copious bleedings, (which were employed to arrest approaching inflammation,) his recovery was per- fected by the November following; except that even then, the catheter was occasionally necessary to draw off his urine, the bladder not having recovered from a paralysis, which, for the first three weeks, was so complete as to prevent any evacuation without the use of an instrument. Of this, however he ultimately recovered. This man was subsequently attached to the mule with my medical stores, and repeatedly consulted me on the means of recovering his virility, which, he said, the shell had com- pletely carried away with it. Dr. Hennen adds, " Loss of the generative faculty and atrophy of the organs connected with it have been attributed to blows on the back of the head. The fact DISEASES OF THE BRAIN. 81 is certain, but whether this proceeds from injury to the organs of sensual love, or to a general loss of power, is a subject for future inquiry." '• Priapism is occasionally observed to occur in wounds of the head. In a case which lately occurred in the cavalry hospital near Edinburg, this symptom was particularly remarked in a hussar, who had suffered severe injury by a fall from his horse. The penis was in a state of priapism during the greater part of the two first days after the accident and towards the close of life he frequently rubbed the genitals violently with his hand. On dissection the dura mater was found exten- sively separated over the head. This separation included the tentorium cerebelli, and beneath its edge about four drachms of coagulated blood were found, the principal part of which lay on the cerebellum." Baron Larrey has furnished several cases showing that the cerebellum and the testicles act and react on each other in disease. " The genital organs seem to have a marked influence upon the cerebellum, for when they are removed by disease, or any other means, the occipital region of the cranium, and cerebellum gradually experience such a sensible reduction, that the occipital bumps which had been more or less protuberant before, disappear, and the whole occipital region of the head is diminished in proportion. We have verified this change of dimension in a great number of soldiers, who had been operated upon for sarcocele, and when one testicle only was removed, there was only a reduction of that portion of the cerebellum and occipital bump, which belonged to the same side with the extirpated testicle."* He men- tions this case. * Cliniquc Chirurgicale, &c. Par Le Baron Larrey. 82 DISEASES OF THE BRAIN. Case XV. — A soldier, who had been wounded in the occipital region by a splinter of wood, was attacked by all the symptoms of inflamed cerebellum, and in despite of every thing that was done, they were only dissipated by the appearance of an abscess in the nape, which opened spontaneously. In about three months after the accident he rejoined his regiment, and many years elapsed before he again came under Larrey's notice. He was then so extremely altered in appearance, that the author mistook him for a young conscript, who had been exhausted by some asthenic disease. He was thirty-two years of age, of middle size, but thin and pale, his eyes were depressed, his lips blanched, his hair, more especially that which covered his occiput was thin and bristled, and a feeling of pain and coldness was always experienced in the back part of his head. He was beardless, his voice was feminine, and some of the assistants were not without suspicion of his sex, a more minute examination was considered necessary. " To our great surprise," says Larrey, " we found his genital organs reduced to the size of those of an infant some months old. His penis was not more than five or six lines long, and two or three lines thick, it never exhibited any degree of erection, and his testicles were so wasted as scarcely to equal in size a small bean." Other cases are given by him which I think fully establish an intimate connection between the cerebellum and the genital organs. Dr. Rowel observed, at the hospital St. Antoine, an apoplectic female, seventy years of age. He remarked that menstruation which had ceased many years before, re-appeared during the course of the disease. From this circumstrnce he concluded that the apoplexy might be cerebellal; this was found to be the fact, and the uterus was filled with coagulated blood, and its tissue, DISEASES OF THE BRAIN. 83 as well as that of the fallopian tubes and ovaries, was phlogosed. " A girl, abandoned to a premature indulgence in venereal pleasures, prostrated herself to satisfy her desires, et se livre a toutes les manoeuvres de la mastur- bation. She fell into a state of nymphomania. She died, and an induration of the middle lobe of the cere- bellum was found, with other appearances of chronic inflammation of the part."* It is a curious but well-established fact, that hanging produces very frequently, if not usually, priapism and emission. Some infatuated beings have had recourse to suspension by the neck to produce those pleasures they have been unable to obtain by natural means. M. de Seze gives instances of this. The following was related to Mr. Levison by Dr. Travis of Scarborough. Case XVI. — " Some few years past an Italian Cas- trata singer at the opera was found suspended by the bedstead, and when a surgeon was called in the man was dead, although (as stated by the landlady of the house,) he had hung himself unintentionally. The facts of the transaction were thus stated by this woman to ihe jury summoned to sit on the body ; she said ' that the deceased had informed her, (when he came to lodge at her house) that he had been deprived, in the most barbarous manner, of certain essential parts for sexual gratification, but that at certain times he experienced a very powerful desire, and that he had accidentally dis- covered that by partially hanging himself he allayed the desire, and had certain delightful sensations,' and she assured the jury that she had been in the habit of cutting him down on many occasions ; and that during his last * Lancet, Vol. 19. 84 DISEASES OF THE BRAIN. pleasurable suspension she had heard a rapping at her street door, and ran down to answer it, but although she returned as quickly as possible, the gentleman's life was gone, &c. The medical gentleman called on the same occasion informed the jury, that as all executed criminals had priapism and emission, the account given of the Castrata was not improbable."* On the connection which exists between the cerebellum and the genital organs, Dr. Carswell, after stating that many cases have been recorded which prove that a functional relation exists between the cerebellum and testes, says, that he has " met with two cases in partic- ular, in which this relationship was manifested in a most remarkable manner. They occurred in two young men, from eighteen to twenty years of age, who reduced themselves to a state of the most appalling moral and physical degradation by the act of self-pollution. Both of them died from its effects ; one of them having often declared that he was compelled towards the gratification of a desire which he had no power to control, for he had frequently attempted the consummation of it after the prepuce had been excised as a means of prevention, and when the glans and part of the penis were in a state of active inflammation. In each of these patients the cerebellum was the seat of a tumor as large as a hen's egg, composed entirely of the medullary sarcoma,"f In Meckel's Archives of Physiology, for 1823, are detailed the particulars of the case of a boy two years of age, in whom a premature developement of the genital organs and of the occipital region was contem- poraneous. M. Serres has related some cases of chronic * Lancet, Vol. 19, p. 49. t Illustrations of the Elementary Forms of Disease. By Robert Carswell, M. D. DISEASES OF THE BRAIN. 85 inflammation and congestion of the cerebellum, in which erection of the penis was a constant symptom. Andral refers to cases of diseased cerebellum, accompanied by partial erection of the penis and erotic delirium. M. Menard enumerates priapism among the symptoms char- acteristic of inflammation of the cerebellum. In support of this view of the seat of the sexual pro- pensity, are cases of recovery from Nymphomania and Masturbation by remedies applied to the occipital region. Levison refers to a case of Nymphomania, cured by sha- ving the back of the head and applying ice over the cere- bellar region. The cure was rapid and complete. In the Gazette Medicale of Paris, 1835, M. St. Martin, writes from Turin, that Ferroresi cured a young girl af- flicted with violent Nymphomania, and two young men who suffered from the incorrigible habit of masturbation by the application of ice to the back of the head over the region of the cerebellum. The cerebellum of a young man long addicted to the habit of masturbation, was found, by Dr. Fuller, Physi- cian to the Retreat for the Insane, in this city, diminished and diseased. It appears also from pathological researches, that a close sympathy exists between the cerebellum and the stomach. In a former publication, I endeavored to show that many cases of indigestion or dyspepsia as the complaint is termed, arise from functional or organic disease of the brain. Every year's experience confirms me in the correctness of this opinion. But it appears to me that disease of the cerebellum more frequently affects the stomach, than disease of the cerebrum. Is it in con- sequence of the diseases of the cerebellum affecting the origin of the Par Vagum ? Cases like the following are not unfrequently seen. 8 86 DISEASES OF THE BRAIN. Case XVII. — "A medical man in the meridian of life, had been for a year liable to attacks of dyspepsia, with headache. In October, 1815, he had severe headach with fever, relieved by blood-letting: then complete want of digestion, headache, general emaciation, and frequent vom- iting, which occurred chiefly in the morning. He had va- rious uneasy feelings, which he referred to his liver, and his complaints were ascribed to this source by the most eminent practitioners whom he consulted. In August 1816, he had severe headache, and nothing agreed with his stomach; almost every thing being vomited. After some time, the pain was relieved, but the morning sick- ness and vomiting continued, with increasing emaciation, torpid bowels, frequent eructations, and hiccup. In the end of September, had twice a slight convulsion. Head- ache then periodical—mind entire, but conversation indu- ced headache, and sometimes convulsion. October 9, died suddenly in convulsion. Morbid Appearances. — " Four ounces of fluid in the ventricles. On the inferior part of the left lobe of the cerebellum, there was an encysted tumor, the size of a French walnut, besides a vesicular portion connected with it containing some yellow serum. The tumor was inves- ted both by the dura mater, and pia mater, and was at- tached by a small pedicle to the substance of the cerebel- lum, where it had formed a depression in which it was embedded. On the corresponding part of the opposite lobe, there was a small florid tumor the size of a large pea. The abdominal viscera were sound."* From these pathological facts, it is evident that we have not as yet fully ascertained the functions of the cerebel- lum. It is not to my mind, quite apparent that the cases quoted of disease of the cerebellum producing paralysis, *Med. Repos. Vol. vii, DISEASES OF THE BRAIN. 87 establishes the fact. The paralysis might have arisen from pressure or irritation of the medulla oblongata or the crura cerebri. Besides there has occurred extensive disease of the cerebellum, without disorder of motion. Some such cases have been already quoted, and others might be added. One thing is very remarkable, that when dis- ease occurs in the cerebrum, and in the cerebellum of the opposite side, the paralysis is always opposite to the side of the diseased cerebrum. The affection of the cere- bellum appears in such cases to have no influence. Andral alludes to this fact in his section on " Hemorr- hage of the Cerebellum." " When the hemorrhage of the cerebellum occurs simultaneously with that of the cere- brum, or a little time after it, but so that the blood is ef- fused on the right into the cerebellum, and on the left in- to the cerebrum, or vice versa, there, is paralysis only on the side of the body opposite to the hemisphere of the cerebrum in which the hemorrhage has taken place, that is, on the same side as the haemorrhage of the cerebellum, How then does it come to pass that, whereas the move- ment of the extremities of the right side are abolished in consequence of an effusion of blood in the left hemisphere of the cerebrum, the effusion which takes place simulta- neously into the right hemisphere of the cerebellum, has no longer the power of paralysing the extremities of the left side ?" The following are interesting cases illustrative of the same fact. Case XVIII. — Atrophy of one half of the Encephalon. This case was communicated to the Anatomical Society of Paris, by M. Bodey, and shows that a single lobe suffi- ces for the integrity of the intellectual faculties. The left lobe was atrophied, reduced to half its original volume, composed of close circonvolutions, small and slightly in- 88 DISEASES OF TI1F. BRAIX. durated, and had lost the faculty of controlling the move- ments of the right side of the body. The left side of the cranium was considerably thickened, and the serosity ac- cumulated in the correspondent lateral ventricle, had fil- led the void left by the gradual atrophy of the cerebral substance. The left peduncle of the brain had suffered a diminution of volume proportioned to the lessening of the lobe which it supported, a fact which astonishes no one at present, but which Bichat had difficulty in recon- ciling with his refusal to admit the fibrous structure of the encephalon. The intelligence in this case remained unaf- fected. In this same subject, one of the hemispheres of the cerebellum, was atrophied, but what is singular is, that while the left lobe of the cerebrum was effected, it was the right hemisphere of the cerebellum, that was atrophied."* Case XIX. — A man 42 years of age, died at the Ho- tel Dieu, on the 13lh of April, two days after his admis, sion, under symptoms of disease of the heart. He had from his infancy been affected with complete hemiple- gia of the right side ; the paralysed limbs were atrophic and the phalanges of the fingers dislocated backwards; the intellectual faculties, and the functions of the external senses were not in the least impaired. On post mortem examination, the lower extremities, were found infiltrated ; the pleura and peritoneum con- tained a considerable quantity of serum, and the left ven- tricle of the heart was hypertrophied. The most remark- able alteration was, however, observed in the brain ; the left half of the skull was twice as thick as the right, and the left hemisphere of the brain was accordingly much depressed, the right anterior lobe was larger than * Review Medicale, 1830. DISEASES OF THE BRAIN. 89 the left by half an inch ; the convolutions of the left hem- isphere were attenuated, flattened, of unusual consist- ence, and white color; the left lateral ventricle contained a large quantity of serum ; its parieties were so thin as to resemble a membrane ; the left thalamus opticus, corpus striatum, crus cerebri, and the left portion of the pons va- rolii, were atrophic. The alteration of the cerebellum was the inverse of that of the brain, its right hemisphere being atrophic, and smaller by a third than the left. This remarkable case having been read at the Academie Roy- ale de Medicine, by M. Gueneau de Mussy, under whose care the patient had been at the Hotel Dieu. M. Amussat remarked that he had observed several cases of atrophy of one of the hemispheres, and that in all of them the opposite half of the cerebellum had been atrophic. M. Ferrus made the same remark; in some of his ca- ses, however, the same side of the cerebellum had been atrophic, and most of the patients had been idiots, one of them, however, in whom the left hemisphere was found destroyed, and replaced by a small quantity of pulpeous matter, had up to the period of his death been in the full enjoyment of his senses and mental faculties."* All that we can properly conclude at the present time respecting the cerebellum and its functions, is, that this organ is not concerned in the operations of the intellect, but some part of it appears to be with the motive pow- ers, and also some portions of it with the sexual propen- sity. The close sympathy between the cerebellum and the stomach, is a fact deserving of attention. Thirdly. — Pathology also teaches us that the integrity of one hemisphere of the brain is alone sufficient for the * Lancet, Vol. xvi. p. 495. 8* 90 DISEASES OF THE BRAIN. manifestation of the mental powers. Cases are quite nu- merous in medical works of extensive disease of one of the hemispheres, without any mental disturbance. I have seen such myself and some have already been quoted. I will refer but to a few more, and those the most remark- able. A man mentioned by Dr. Ferriar,* died of dis- ease of the head, retaining his faculties entire, until the moment of his death, which was sudden. On examin- ing the brain the whole of the right hemisphere was found destroyed by suppuration. Mr. 0'Halloran,f re- lates the case of a man who from injury of the head had a large piece of bone removed on the right side, from which a great quantity of pus mixed with the substance of the brain was discharged. Mr. O'Halloran affirms that three ounces of brain were discharged at a dressing, and that the cavern in the brain was terrible. The pa- tient lived to the seventeenth day, and though paralytic on the left side, retained his intellect until the moment of his death. In the fifth volume of the Memoirs of the Med- cal Society of London, for 1798, is a case furnished by Mr. Waldron, and communicated to the Society by Mr. Abernethy, of a gun breech above three inches long, and weighing three ounces and a drachm, penetrating the cranium over the right side, above the frontal sinus, and remaining imbedded in the right hemisphere for two months, without producing disorder of the intellect. The case is certainly very extraordinary, and is detailed at great length and drawings given of the gun breech in the work to wrhich I have referred. The following is from Andral. Case XX. — A man, twenty eight years of ao-e, fell * Manchester Memoirs, Vol, iv, t Injuries of the head. DISEASES OF THE BRAIN. 91 when three years old, from the first story into the street, on his head. After this fall he remained paralysed on the left side. By degrees an habitual extension of the left foot on the leg was established so that on this side he walked only on the point of the foot. The left upper ex- tremity was completely deprived of motion ; no trace of contraction any where observed. The person had some education, and had profited by it; he had a good memo- ry ; speech perfectly free ; and his intellect such as is ordinarily met with in the generality of persons. Hav- ing entered the infirmary of Bicetre, where he lived, for a chronic affection of the chest, he was there seized wTith symptoms of acute peritonitis, of which he died. Post Mortem. — The vault of the cranium having been removed, the meninges of the right side were found transparent, and fluctuating through almost their entire extent. They were cut into, and a clear limpid serum like spring water, gushed forth. Between these menin- ges and the ventricles there existed not the slightest trace of nervous substance. These membranes con- stituted the upper wall of an immense cavity, the lower side of w7hich was formed by the optic thalamus, the cor- pus striatum, and all the other parts situate, on the level of these two bodies. Of the nervous mass above the ventricles there remained only that which, being anteri- or to the corpus striatum, forms its anterior wall. Nu- merous tubercles were in the two lungs, and several ul- cerations appeared on the surface of the small intestine. There was a perforation in the ileum, whence the perito- nitis which terminated the life of the patient. Remarks. — The lesion, discovered in this case, began from external violence, twenty-five years before the pe- riod when it came under our inspection. The atrophy of the brain was not probable here the primitive altera- 92 DISEASES OF THE BRAIN. tion ; it succeeded to other changes of an inflamatory na- ture which supervened immediately after the fall. The perfect preservation of the intellect up to the last moment is certainly a remarkable circumstance in a case where so great a portion of the brain had for a long time been removed. The same fact is proved by the effects of inflammation of one of the hemispheres of the cerebrum. " When inflammation," says Bouillaud, " only occupies a part, more or less extensive, of one of the cerebral hemispheres, and when the other hemisphere is in a healthy state, the intellectual and moral functions, at least ordinarily, present no notable lesion. It seems that in this case the healthy hemisphere suffices for the exercise of these functions. But if the inflammation of one hemis- phere spreads itself over the other hemisphere, a delirium of variable form occurs, according to the extent and in- tensity of the inflammation, and perhaps also according to the part affected either in one or the other hemisphere. A general delirium always exists when the partial irrita- tion generalizes itself, an accident unfortunately often seen." I might multiply proof to any extent, that when only one hemisphere of the brain is diseased, even to a great degree, the intellectual faculties many remain undistur- bed. It is true however, that in many cases when only one hemisphere appears to be effected, derangement or loss of the mental powers is observed. This undoubtedly arises from the extension of inflammation or irritation from the opposite hemisphere. Not unfrequently when a discharge is kept up from the brain by an opening in the cranium on one side, the intellect is not disturbed, but when the discharge is pre- vented, coma and loss of intelligence supervene. It will be noticed that in all these cases, one hemis- DISEASES OF THE BRAIN. 93 phere remained unaffected, but I am not aware that there is a single well authenticated case of both hemispheres being much injured without mental disturbance. Solly observes, " there are no cases on record in which the mental faculties have remained undisturbed, where dis- organization of the brain extended to both hemispheres." I apprehend the mind is often considered sound when it is not so. If after an injury of the head, the patient knows his former acquaintance and answers correctly a few questions, and does not rave, he is said to have no distur- bance of the intellect, but in such instances some of the mental powers may be disordered, notwithstanding it is unnoticed by inattentive observers. I have seen such. I have often seen persons after se- vere inj ury of the head, answer most questions correctly, know their acquaintances readily, and deemed by their friends to have no disturbance of mind, while a closer scrutiny has convinced me that this conclusion was incor- rect. That many of the mental faculties remain undisturbed when considerable disease of the brain exists, is not more surprising than that the power of digestion remains, as we know it often does, when the stomach is much diseas- ed. Neither on the other hand, is it surprising that a very little disease of the brain, a trifle of inflammation of one hemisphere should sometimes disturb the intellect, when we consider the close connexion of all parts of the brain, and its enclosure in a solid case which it completely fills, and consequently cannot be much affected in one part without other parts being disturbed and irritated. Here I wish to lay down a few principles which ought to guide us in studying the functions of the brain by the aid of pathological researches. First.—We may not always attribute all the symptoms noticed in a case of injury of the brain, to disturbance of 94 DISEASES OF THE BRAIN. the functions of the particular part of the brain injured ; for the injury itself may disturb the functions of other portions of the brain. Nevertheless, numerous cases of injury or disease of the same parts of the brain, followed by similar mental disturbance, might justify us in conclu- ding that the injured parts were especially devoted to the manifestation of the mental powers now affected. Second. — When we find certain mental faculties not disturbed by an injury extending to corresponding parts of both hemispheres, wre have a right to conclude that the portion of brain injured is not essential to the mani- festation of these faculties. For instance, when we find both sides of the cerebellum wholly disorganized, or the pons varolii, medulla oblongata, fornix, pineal gland, &c, without any disturbance of the mind, we may conclude that these parts are not essential to mental action ; and this conclusion is not overthrown by cases of disease of these parts, accompanied by disorder of the intellect, for in the latter cases the disorder of the intellect might arise from functional disorder produced in other portions of the brain from the organic disease of the parts we have mentioned. Fourthly: — Pathological investigations have not only shown us that different parts of the brain have different functions, but have rendered it probable that the ante- rior lobes of the brain are the seat of the more impor- tant of the intellectual faculties. " M. Breschet," says Andral, " has published the remarkable case of a girl fif- teen years of age, in whom the two anterior lobes were wanting. At the bottom of, and behind, the membran- ous pouch which replaced them, the two corpus striata were seen exposed. The head was very well formed. The girl was plunged into a complete state of idiocy; it was necessary to dress her and feed her; she was DISEASES OF THE BRAIN. 95 averse to walk, though she had the power of moving all her limbs with ease, and with equal facility; she was usually sitting, and remained so for entire days, alter- nately inclining the head from one shoulder to the other ; vision was entire ; the most perfect indifference existed for the quality of odors." In the 14th volume of the Medico Chirurgical Re- view is the following notice of a case of congenital ab- sence of the anterior lobes of the brain. " In the Annu- al Report of the new Anatomical Society of Paris, a preparation was shown by M. Lacroix, exemplifying the above mal-organization. The secretary of the society makes use of the following words : ' If the opinion which assigns to the anterior lobes of the brain the privilege of presiding over the higher intellectual operations, needed any new confirmation, it would find a powerful argu- ment in its favor in the case reported by M. Lacroix. In that case there was a complete congenital absence of the anterior lobes of the cerebrum, which were re- placed by a collection of transparent serum, communi- cating freely with the ventricles. This physical condi- tion was accompanied, not by a perversion, but by an almost entire nullity of the intellect and moral functions. Here was an experiment made by nature, more valuable for physiology than any vivisections of the anatomist.' The secretary remarks that this case tells both for and against the phrenologists ; for them, as showing the seat of intelligence to be in the anterior part of the brain ; against them, as showing that their skill could not have detected the cause of the idiocy, since the forehead was well formed, though full of water, and all the prominen- ces well marked. Almost at the same time that the above preparation was shown, another came under view, where the left 96 DISEASES OF THE BRAIN. hemisphere of the brain was found atrophied to one half its original volume, without any loss of intellectual facul- ties, the other lobe being entire. The atrophy was oc- casioned by an accumulation of fluid in the lateral ven- tricle of the side, and the opposite half of the body was completely paralytic." Otto remarks in his compendium of Pathological Anat- omy that in idiots the front lobes are usually small and shallow. This is confirmed by the observation of others. I do not know of any case on record of the anterior lobes of the brain being diseased without manifest disturbance of the intellect, but cases of disease of portions of both posterior lobes have been witnessed without producing any noticeable change in the mental powers. The fol- lowing is an instance of the kind, taken from the Medico Chirurgical Review for Oct. 1826. Case XXI. — Dr. Chambers has reported, in our respected cotemporary, the case of a woman, Mrs. Miles, whom we attended previously to her admission into St. George's Hospital. When she first applied to us, she complained of discharges of blood from the lungs by coughing. This was stopped by a few doses of super- acetate of lead and opium. She next complained of sickness at stomach, whenever she took food, together with pain in the occipital region of the head. Blisters were applied to both parts, and medicines were given to quiet the gastric irritability, but without success. The patient having but bad accommodations in the Little Theatre of the Hay-market, we sent her to St. George's Hospital. There the sickness at stomach and pain of the head were treated with the same want of success as be- fore. There was no tenderness of the epigastrium or abdomen, pulse from 80 to 90, tongue clean, skin cool, bowels constipated. The intellectual functions were DISEASES OF THE BRAIN. 97 never disturbed. Among the remedial agents, she was placed under the full influence of mercury ; an issue was inserted in the back of her head ; blisters were applied to her epigastrium; opium, subnitrate of bismuth, hagcal filaments of the par vagum, acting as a motor, and others in the manner of sensitive nerves. Or, to use the phraseology of Dr. M. Hall, the contraction of the oesoptiagus in deglutition is an excito-motory action — the filaments of the oesophageal nerves distributed in the mucous coat being the excitors, and those in the muscular coats being the reflex or motors." From other experiments by the same gentleman to de- termine the influence of the cardiac branches upon the heart, it was ascertained that section of the par vagum above the oirgin of these branches does not materially affect the heart's action. But he thinks severe injury of the brain or even mental emotion, affect the contraction of this organ, probably through the influence of the par TENTH PAIR OF NERVES. 175 vagum, as he found by removing portions of each par vagum in rabbits, and then crushing the brain, the action of the heart was not increased and enfeebled as in rab- bits whose heads were thus injured, but in whom the par vagum was entire. He also found, by experiments to ascertain the influ- ence of this nerve on the lungs, that division of one par vagum had no particular effect upon animals, even when sufficient was removed to prevent reunion. Divis'on of both did not annihilate the want of fresh air in the lungs, the " besoin de respirer," as Brachet supposed, but the " division of both pneumogastrics," he says, " in- variably proves fatal if the cut ends of the nerves are kept apart. The animal seldom if ever lives beyond three days, and generally dies sooner ; but when the cut ends of the nerves are allowed to remain in contact, it sometimes lives ten or twTelve days. There can be no doubt that the section of these nerves proves fatal by its effects upon the lungs. The congested state of the blood- vessels of the lungs, and the effusion of frothy s;:rura in the air-cells and bronchial tubes, may be considered as the characteristic and only constant appearance after death from section of the pneumogastric?." The influence of this nerve upon digestion is well known, as division and separation of the cut ends of this nerve arrests digestion, though the mode in which this is produced is not well established, whether it is by pro- ducing paralysis of the muscular contractions of the stomach, or by arresting the secretion of the gastric juice. This matter remains in uncertainty, though it is proba- ble that only the muscular contractions of the stomach are under the guidance of the par vagum, while other actions, such as nutrition, secretion and absorption are under the influence of the great sympathetic. We also know that any dimunition of the nervous influence, as 176 DISEASES OF THE section of the medulla spinalis or injury of the brain stops digestion. What light has pathology thrown upon this subject ? Numerous cases are on record of tumors pressing on this nerve, causing great difficulty of breathing. Andral has published a case of severe dyspnoea, which seemed to be wholly produced by compression of the par vagum by a tumor in the neck. Blandin relates a case of a tumor in the nerve itself, which caused difficulty of breathing and symptoms of angina pectoris. This nerve is also the seat of neuralgia, arising from irritation of this nerve, and giving rise to convulsive and periodical coughs, spasmodic asthmas, and spasms of the stomach, and nervous vomitings, &c. M. Jolly has published several cases of this kind in the Nouvelle Bibliotheque Medicale for 1826, and I presume they are much more frequent than are suspected. The following is a case. A female, forty years of age, had long been affected with severe paroxysms of cough, resem- bling hooping cough, and which came on every evening after eating. It was attended by vomiting and convul- sive agitation. Bleeding, purging, &c. were of no avail, and she was cured by tonics and anodynes. M. Gendin relates a case of convulsive cough, pro- duced by a wound in the neck, with loss of substance, which exposed this nerve to irritation. Prof. Albers, of Bonn, found the par vagum unusually large in fifteen cases of phthisis pulmonalis. Intermittant croup appears to arise from affections of this nerve, as the following cases show. • Case XLVII.— Recurrent Dyspnoea.— Death.— Dis- ease of a par Vagum. — A man, twenty-four years of age, had for a length of time suffered from most distress- TENTH PAIR OF NERVES. 177 ing dyspnoea ; the respiration was always short, hurried, and confused, and to appearances was affected by the action of the thoracic muscles alone, the lungs being mere- ly passive ; the horizontal position was quite intolerable ; the face was bloated ; the lips and alae nasi of a livid hue ; the eyelids oedematous. No sign of any disease of the heart could be detected by the stethoscope. During a paroxysm of severe dyspnoea, this patient suddenly expired. On dissection, a portion of the left par vagum was found quite enveloped in a mass of tuberculous glands, and the substance of the nerve itself was extremely indu- rated. Case XI/VIII. — Dyspnoea — Remarkable slowness of the pulse — Death — Disease of the Nervi Vagi.— Maria Cocchi, aged forty, had enjoyed good health till her thir- tieth year, when she had a severe attack of pneumonia: from that period the breathing had been always op- pressed. In October, 1832, having fatigued herself more than usual, had taken rather more wine than she had been accustomed to, she was seized with a stupor, which last- ed for several days, and during which she was scarcely conscious. On recovering from this attack, the respira- tion was more difficult than ever, and the pulse which was naturally slow, became extraordinarily so, beating only twenty-four times in the minute. The chest being carefully examined with the stetho- scope, the respiratory murmur was heard over every part; it was rather puerile: the sounds of the heart were regular, somewhat stronger, and might be heard over a greater extent than in health : the inference there- fore was, that there was dilatation with hypertrophy of this organ. The diagnosis was certainly puzzling. A 178 DISEASES OF THE variety of remedies was tried, but with no good effect. Before death, the breathing became stertorous, and the face as purple as ff she had been strangled. Dissection. —The head was examined, but no decid- edly morbid appearances found there. In the chest there were several recent pleuritic adhesions : the principal bronchial glands were greatly enlarged and loaded with a calculous matter : a considerable quantity of a yellow colored serum in the pleurae, and also in the pericardium ; the texture of the heart quite sound, but its volume some- what enlarged: a few patches of steatomatous degenera- tion were seen on the aorta : the pneumogastric nerves, a little below the larynx, were found imbedded in a mass of swollen glands, and these enveloped in cellular mem- brane, which was much loaded with blood: the right nerve seemed to have been most affected, and at one point it presented the appearance of having been " tirai- lle " and flattened.* The learned and ingenious Dr. Hugh Ley, it is well known attributes Laryngismus Stridulus,-)- &c, to en- larged glands pressing upon this nerve or its branches, and the cases quoted seem to confirm his views. It has been remarked that the corpus olivare appears to be the appropriate ganglia of this nerve. The following case from M. Jolly supports this opinion. A man had a series of anomalous symptoms, attributed by his medical advisers to some organic disease of the chest. The least * Medico Chirurgical Review, vol. 22, quoted from Rust's Magazine. t An Essay on the Laryngismus Stridulus, or Croup-like Inspiration of Infants. To which are appended, Illustrations of £he General Prin- ciples of the Pathology of Nerves, and of the Functions and Diseases of the Par Vagum and its principal Branches. By Hugh Ley, M. D., &c., &c. TENTH PAIR OF NERVES. 179 exertion of body or least mental emotion produced pal- pitation of the heart and tendency to suffocation. He was bled and starved, and died of general dropsy. The only morbid appearance was softening and vascularity about the corpora olivaria, at the origin of the par va- gum. I believe affections of this nerve are not uncommon, but are very frequently overlooked ; and, therefore, with the hope of attracting attention to this subject, I subjoin the following most interesting case from Dr. James John- son.* Case XLIX. — " Singular Case of Periodical Mono- mania, terminating in Suicide, with the Appearances on Dissection. By James Johnson, M D. " I think I may venture to assert that there is not a more remarkable — perhaps a more interesting case in the annals of medicine, than the following. " Mr. M'Kerrell, aged about 56 or 7, had spent nearly thirty years in the civil service of the East India Com- pany, and had risen to a high rank on the Madras estab- lishment. He returned home about six or seven years ago, with an ample fortune. He was a gentleman of highly cultivated mind, and great natural abilities. He had suffered some severe attacks of fever in India ; but arrived in his native land with a comparative sound con- stitution. He had made some excursions to the conti- nent, more for amusement than health, and, about four years previous to his death, had sustained an unsuccess- ful contest for the representation of Paisley. In this con- test he went through an immense exertion of body, and excitement of mind. He dated his chief bodily and men tal afflictions from this period. His digestive organs be » Medico Chirurgical Review, 1837. 180 DISEASES OF THE came considerably deranged, and constipation of the bow- els was a prominent feature of the malady, up to the very day of his death—which was occasioned by his own act. Very soon after the contest alluded to, he came under my care, and continued to consult me, with longer or shorter intervals, till the final and melancholy termination of his existence. At first, his corporeal ail- ments were alone referred to, and these were the com- mon symptoms described by the generality of dyspep- tics. There was an appearance in his manner, however, which led me to suspect some grievance kept in the back ground. The patient, being a man of great intelligence and knowledge of the world, he frequently detained me in conversations and discussions quite foreign to the ob- jects of my visit, and dismissed me without entering upon them at all. One day he appeared more than usually depressed, and, after some ordinary conversation, he re- marked that he thought me a man in whom he could confide, and who would not devulge a secret, if a pledge of secrecy were given. I observed, a little jocularly, that doctors were like priests, and confessions were held as secret by the physicians of the body as of the mind. But I observed, at the same time, that I had no wish or curiosity to become acquainted with secrets unconnected with my professional avocations. ' That,' said he,' I be- lieve ; but this is a secret directly connected with my health and happiness ; and I think its disclosure to a man of honor, and professional experience, might probably enable him to relieve me. But I had rather suffer the miseries which I endure, than confide the cause of them to a physician who would divulge it.' In that case, I readily pledged myself to secrecy, provided there was nothing in the secret of a criminal nature, and which the laws of God or man did not call upon me to make known, if necessary. He answered. ' if you find in this secret TENTH PAIR OF NERVES. 181 any thing criminal, I absolve you from your promise.' I then pledged myself. " It was with great difficulty, and tedious circumvolu- tion, that he came to the point, being apparently tortured with shame in the disclosure. At length it came out that he labored under an illusion, which came on regularly every second day, and lasted till he went to sleep. He would awake the next morning free from the hallucina- tion, and perfectly convinced that it was an illusion under which he had labored on the preceding day. At a later period, he often assured me that he was conscious of the illusion being such, and not a reality, on the days of its occurrence, though I have strong reason to suspect this statement, for up to the day of his death, he never would see me on the day of the illusion. The illusion itself let in no light on the nature of the complaint, and therefore the secret may be kept without any detriment to the his- tory of this extraordinary case. Unfortunately, the en- tity in which it consisted, presented itself so frequently, and was mixed up with so many other objects and sub- jects, that he could not walk a street without seeing it, unless he kept his eyes shut; he could scarcely read a page of a book without its crossing his sight; he could hardly, indeed, survey the furniture and other things in his room, without being reminded of this torturing illu- sion. His sufferings were of two kinds; one, directly connected with the illusion itself, which, according to his conviction, on alternate days, exercised a hostile influence on him, and was, as it were, an evil star, blasting every thing belonging to him by its malign radiation! The other, was an indescribable horror, terror, or sense of destruction, having no direct reference to the illusion, and a degree of which continued after the delusion vanished, that is to say, during the ' good days.' This was a part of the complaint which appeared, both to the patient and 16 182 DISEASES OF THE physician, as purely corporeal, the result of some disor- dered function or structure of the body. The illusion, on the other hand, had greater reference to the mental functions, though probably they were both the result of the same cause. " I made numerous and minute examinations of the general health, without being able to detect any palpa- ble cause for these strange phenomena. In respect to the head, this gentleman was highly gifted in intellectual powers, and his mind amply stored with varied and ex- tensive information. He never displayed the slightest aberration, or even weakness of mind, except as regard- ed the hallucination; and even that he regarded in its true light, when the mental cloud had passed away. There was no physical symptom of any cerebral or spi- nal affection. The senses and sensibility were perfect, as were all the muscular powers. He was, however, emaciated, and the emaciation gradually, though slowly, increased. " I frequently examined the chest, and it sounded well, in all parts; the patient could expand it freely; and he could take great exercise without any shortness of breath. He had no cough. The pulse was remarkably small, and generally slow. I confess that, at no period of my professional attendance, which lasted three years and a half, did I suspect any disease of the heart or lungs, though in both cases, I was mistaken, as the final event proved. " In respect to the abdominal viscera, there were many symptomsx of disordered digestion, but none of organic disease. He ate two meals of animal food daily, the aggregate being considerably more than a man in health, and using but moderate exercise, would naturally consume. The patient found it necessary to confine him- self almost entirely to plain animal food, with bread, and TENTn PAIR OF NERVES. 183 very little wine, or weak brandy and water. Any de- viation from this system occasioned considerable incon- venience, both as to the common symptoms of indiges- tion, and also as respected the main and permanent malady. The constipation of bowels, as before remark- ed, was very obstinate, and the faeces were generally in the form of scybala, even when aperients were employ- ed. All strong or drastic purgatives aggravated his complaints. The functions of the kidneys were very rarely disturbed. Thus, then, repeated examinations of the various organs, through the medium of their func- tions, disclosed to me no tangible or cognizable proof of structural disease. Yet such disease did actually exist, however humiliating may be the confession. This does not militate against the science of medicine, but only against my own powers of discrimination. " The regular, the unerring periodicity of the main symptoms, puzzled me not a little ; and this periodicity I could not help attributing to some physical, rather than to a moral cause. What tended to embarrass me still more was the fact that, on the * good day,' he could view the entity, whether simple, or in any of its combina- tions, with composure, while on the ' bad day,' or the day on which the illusion was in the ascendant, the suf- ferings which this unfortunate, and highly-gifted individu- al experienced, were such, that the narration of them often rendered me, as it were, a participator of his mise- ries, and deprived me of sleep. I can conscientiously say that I heartily repented of being the depositary of the secret, and the physician of the patient. " In the early part of the year 1834, while in Scot- land, Mr. M'Kerrell was suddenly seized with haemopty- sis, though not to any extent; and some of the most respectable medical practitioners of Edinburgh were con- sulted. I may mention Dr. Abercrombie, the late Mr. 184 DISEASES OF THE Turner, and Mr. Scott. The complaint subsided with- out any serious consequences; though there were a few very insignificant returns of it afterwards, for which I attended the patient in the succeeding year— 1835. " And now I suddenly lost sight of him, and knew not whether he had directed his steps. On the 15th of No- vember, I was summoned to him, and found him consid- erably altered in appearance. Although it was the ' good day,' he was evidently laboring under great mental de- pression and distress. He stated that he had been some time at Cheltenham, and had consulted an old and valued friend, who prescribed for him, but in vain, as his mental and corporeal miseries were now arrived at a degree of intensity, which human patience could not long bear, nor human strength resist. He had got much thinner, and complained that some aperient medicines which he had been taking at Cheltenham, increased rather than dimin- ished his sufferings. This, however, was probably imagi- nary. " The remainder of the tragic scene is well known to die public. When I parted from him on the 15th of No- vember, being his 'good day,' though a very wretched one, he desired me to call again on the 25th of the same month, which would also be his ' good day,' On Tues- day, the 24th, however, being the day of the illusion, he wrote a short letter to Mrs. Vickery, his landlady, an- nouncing his determination to commit suicide, and giving her some directions about his keys, and the place of his sepulture. He rang the bell about four o'clock, and or- dered a wine-glass. At a quarter before seven o'clock, he was found lying on the floor, dead, and nearly cold with an empty two-ounce phial labelled ' hydrocyanic acid,' of Scheele's strength, on the table, standing beside the empty wine-glass. In the bottle, there was a drop or two of the acid, exhaling the odor of almonds ! TENTH PAIR OF NERVES. 185 " Dissection, 27 hours after Death. — The body was examined by Mr. Henry Johnson (my son), and Mr. Bushel, in presence of Dr. Robert Lee, Mr. Harding, and myself. " The emaciation was very great. The deceased hav- ing fallen on his face, there were marks of contusion about the temple, and the face itself was rather of a bluish hue. The body exhaled an odor of Prussic acid. The eye did not present any particular appearance. The stomach was remarkably capacious, and its contents were sent to Dr. Turner, for analysis. In some portions of the mucous membrane of this organ, especially near the upper and inferior orifices, there were marks of re- cent inflammation, particularly in stellated patches, where slight marks of extravasation were perceptible. In sev- eral portions of the small intestines, the external hue wras dark, almost approaching to livid ; and the mucous mem- brane of these portions was vividly red, or of a dark red color ; but without extravation, or perceptible injection of the vessels. It resembled imbibition, or that which would be produced by steeping sound, yet dead parts, in blood. The large intestines were greatly distended by air, but exhibited no marks of disease of any kind. " The liver, spleen, mesentry, kidneys, and all the ab- dominal viscera, were perfectly sound. "Before a knife was laid on the body, I expressed a wish that the ganglionic centres might be carefully ex- amined, as I conceived that some irritation of the nerves of oro-anic life played an important part in the phenome- na exhibited by the patient. The solar plexus was there- fore minutely investigated; but nothing abnormal was perceptible. " In the thorax there was great and varied disease. The lungs were studded with tubercles, especially the superior lobes, and extensive adhesions existed between 16* 186 DISEASES OF THE the pleurae-costales and the p. pulmonales. None of the tubercles had broken down, so as to discharge their con- tents through the bronchial tubes. ' The heart was not larger than natural, or very little more than the ordinary size ; but the pericardium was universally adherent, by old, that is to say, by cellular attachments. The organ itself presented one of the fin- est specimens of ' simple hypertrophy,' which we have ever seen. The parietes of the left ventricles were an inch and a quarter in thickness; and the cavity was, with difficulty, discovered. It could not have contained more than four drachms of blood, if so much ; which is scarcely one-third of that which a normal ventricle would be capable of throwing out at each contraction. There was nothing abnormal in the arteries. The blood in every part of the body was perfectly fluid, and exhib- ited not a single coagulum in any vessel. " The brain was remarkably firm, and the vessels were rather congested; but there was no visible trace of dis- ease in the head. The skull was of unusual tliickness and density. " And now comes the most remarkable portion of the pathology. Upon the nervus vagus, or pneumo-gastric nerve of the left side, just before the recurrent is given off, there was affixed a hard jagged body, the size of a kidney-bean, or small nut, composed of calcareous mat- ter, and probably a diseased bronchial gland converted into this substance. The union of the nerve and this rugged mass was so intimate, that no dissection, without cutting the nerve or the calcareous body itself, could separate them. The foreign body, in fact, had penetra- ted, or at least invaded the nerve, which was thickened at this part. Lower down, and involving the cardiac, pulmonic, and oesophageal plexuses in a labyrinth of per- plexity, were several diseased bronchial glands, render- ELEVENTH AND TWELFTH PAIR OF NERVES. 187 ing the dissection a tedious and difficalt operation. The parts were all carefully removed, and the investigation conducted slowly, and at different periods, in the Kinner- ton-strcct Theatre of Anatomy, by Mr. Johnson, Mr. Tatum, Mr. C. Johnson, and others. The preparation is preserved in the museum, and may be seen by any gentleman there. " When wo consider that the nervus vagus rises in the medulla oblongata, but is chiefly distributed to the great organs not under our control, and that it communicates with almost the whole of the ganglionic nerves, we may form some idea of the irritation and disturbance pro- duced in the digestive, sanguiferous, and sanguific organs, by a jagged calcareous mass, implanted, as it were, into one of the most important nerves of the great vital vis- cera !" Eleventh Pair: — Lingual or Hyo-Glossal, Arises from the pyramidal body half an inch below the origin of the sixth pair, and goes to the muscles of the tongue, and to those of the os-hyoides. Experiments by Mayo and Fodera show that this is a nerve of motion only, and pathology supports this con- clusion. When irritated in an animal recently killed, the tongue becomes convulsed, and when both are divided it be- comes motionless. Twelfth Pair: — Spinal Accessory. — Mr. Bell, calls this the superior respiratory nerve. It arises from the cer- vical portion of the spinal marrow, commencing opposite the sixth or seventh cervical vertebrae, passes upwards and enters the skull and joins the pneumogastric, and passes from the skull in the same sheath with this nerve. in passing through the foramen lacerum, it divides into 188 DISEASES OF TnE CEREBRAL NERVES. two branches, an internal and external. The internal, after giving off some filaments to assist in forming the pharyngeal branch of the par vagum, becomes incorpor- ated with the filaments of the trunk of the ncrvus vagus. The external branch proceeds outwards, perforates the upper part of the sterno cleido-mastoideus, sends fila- ments to this muscle, and to the trapezius, and forms at the same time several anastomoses with branches from the cervical plexus. Dr. Reid already quoted, thinks from his experiments that it is not as Mr. Bell supposes a nerve of respiration. He states " that the sterno cleido-mastoideus and trapezi- us can assist in the involuntary movements of respiration after section of the spinal accessory, and therefore it can- not be called the special respiratory nerve of these mus- cles. As far as we can observe, the functions of the ex- ternal branch of the spinal accessory resemble those of the filaments coming from the cervical plexus with which it anastomoses so freely." " That the internal branch of the spinal accessory assists in moving the muscles of the pharynx we are sat- isfied, not only from the experiments just stated, but also from those upon the pharyngeal branch of the par va- gum. Of the probable destination .and functions of the other filaments of the internal branch of the accessory, we cannot pretend to judge without more extended in- quiries. We certainly do not consider that these experi- ments entitle us to assert that they are not motor fila- ments.*" * The dissection of Bendz, to which we have already referred, seem to show that these filaments of the accessory are distributed upon the larynx and oesophagus. They therefore probably assist in the move- ments of these parts. GREAT SYMPATHETIC NERVE. 189 SECTION V. GREAT SYMPATHETIC NERVE. The great sympathetic, trisplanchnic, ganglionic, great intercostal, are names given to a system of nerves, com- posed of a series of ganglions connected to each other by means of intermediary filaments, and of a few longer and larger cords. This system of nerves appears to be first formed and coeval with the punctum saliens. It extends from the base of the cranium down the side of the spine to the coccyx, and communicates by means of small filaments with the spinal nerves, and with sev- eral of the cerebral. The ganglions are irregular in shape, but generally roundish and of a reddish grey color, and seem to be made up of a network of numerous fascic- uli, enveloped in a double coat of cellular membrane. At its upper part, when concealed in the carotid canal, the Great Sympathetic has the appearance of a ganglionic plexus, sending off some small branches, two of which join or entwine around the sixth cerebral nerve, and another communicates with the Vidian branch of the fifth nerve. The opthalmic, the spheno-palatine, and maxillary ganglions, are by some classed among those of the great sympathetic. Passing down each side of the spine, it presents many ganglions, viz. 3 in the neck, called Cervical. 12 " " back, " Thoracic. 5 " " lumbar region, " Lumbar. 3 or 4 " " sacral region, " Sacral. 190 GREAT SYMPATHETIC NERVE. From these ganglions numerous filaments are given off, which interlace and form plexuses. Some filaments from the cervical and thoracic thus interlace and form the cardiac plexus, from which the nerves of the heart proceed, a branch also goes to each intercostal artery from the thoracic ganglion. From the fifth, sixth, sev- enth, eighth and ninth of these ganglions proceeds the great splanchnic or visceral nerve, which being joined by the lesser splanchnic nerve from the tenth thoracic gang- lion, passes through the pillars of the diaphragm and ter- minates in a large plexus called the semilunar plexus or ganglion, and which lies partly on the aorta near the ori- gin of the coelic and superior mesenteric arteries. This by uniting with its fellow and with other ganglia that are near constitute the solar plexus, or vast nervous net- work lying on the vertebral column, the aorta and crura of the diaphragm, and from which nervous filaments pro- ceed, and accompany the arteries to all the viscera of the abdomen. For further particulars respecting the anatomy of the great sympathetic, I refer the reader to Anatomical works. It is known that this nerve accompanies the internal and external carotids, the basilic and the brachial arteries and the femoral; and it is generally believed by anato- mists that filaments from it accompany all the arteries of the body to their ultimate distribution, and probably it is the source of the nervous power possessed by the capillaries. Weber observes that the muscular system is developed in proportion to the sympathetic nerve. From the general distribution of this portion of the nervous system, it is evident that its functions are impor- tant, and deserving of the most careful study and inves- tigation. But what the uses of this system of nerves are, has not been fully ascertained. GREA/T SYMPATHETIC NERVE. 191 Some as Petit, Winslow, Bichat, Reid and others have considered the ganglions as nervous centres, independent of each other, but communicating with one another and with the brain and spinal marrow. While others as Chaussier consider the sympathetic as a cerebral nerve, and some as Le Gallois, Beclard, Lobstein, &c., believe it to be a spinal nerve. Perhaps the most general opinion and the one entitled to most weight is that the ganglions are centres in which nervous power is developed, that they remove the parts they furnish with nervous energy, from the empire of the will, that these centres are however subordinate to the great cerebro-spinal system and do not prevent the transmission of strong impressions. From the experiments of Brachet, who believes the great sympathetic constitutes an independent nervous system, it appears that this system presides over the contractions of the heart, and by dividing the cardiac plexus and all its filaments, the circulation which went on well before was instantly arrested. Foetuses have come into the world well formed, but destitute of cere- brum, cerebellum, and medulla spinalis, hence the circu- lation must have been undisturbed. The ganglionic sys- tem in such was found perfectly well formed and well developed and according to Series and others even more than in other foetuses. In Graefe and Walther's Journal is a case detailed by Prof. Meyer of Bonn, of the absence of the whole cere- bro-spinal system. The being was a complete vegetable. No nervous filaments were to be found entering the mus- cles. The sciatic, crural, and obturator nerves were all wanting. It possessed however a ganglionic nervous system under the influence of which it must have grown. It also appears from M. Brachet's experiments that chymification or secretion of the gastric juice wholly de- 192 GREAT SYMPATHETIC NEJfcVE. pends on the ganglionic system, though this system has no effect upon the contractions of the stomach, as these probably depend on the pneumogastric. It also appears that the other secretions, absorption, exhalation, genera- tion and conception are dependent upon the ganglionic system. We know that in injuries of the spinal cord which paralyse the lower extremities and the rectum and blad- der, both as to motion and sensation, that secretion, ex- halation and absorption continue, showing that they are not dependant upon the cerebro-spinal system. What further light has pathology thrown upon the functions of the ganglionic system ? I regret to say that examinations of the condition of this system after death, have been too much neglected. Often, when most of the organs of the body are examined with great care, the great sympathetic and its ganglions are entirely over- looked. Professor Lobstein, who has given much attention to the functions and diseases of the great sympathetic, be- lieves that Hypochondriasis, Hysteria, Angina Pectoris, Lead Colic, and Incubus arise from a morbid condition of this nerve. We believe that physicians are very gener- ally of the same opinion as regards most of the above diseases, and also that numerous other nervous abdomi- nal affections have the same origin. Mr. Tealc, already mentioned, thinks the ganglionic system is subject to disease, and that its affections pro- duce Neuralgia of the heart and stomach, causing palpi- tations, flatulence, &c. The following cases from Lobstein* where examina- tion after death exhibited disease of this system, are worthy of attention. * De Nervi Sympathetici Humani Fabrica, &c. Auctore J. F. Lob- Btein, &c. Parisis, 1823. GREAT SYMPATHETIC NERVE. 193 Case L. — "A female of regular habits, had suffered from spasmodic and hypochondriacal symptoms, from the age of puberty, and had twice been attacked with incom- plete apoplexy, which left a slight paralysis of the right side of the face ; at forty-two, she was married, and be- came pregnant fifteen months after. At the eighth week of utero-gestation, a train of symptoms arose which sub- jected the patient to great misery. She had vomiting to such an extent, that, for three months, she immediately rejected every thing taken into the stomach; no relief being afforded by any internal medicine or external ap- plication. During the last seven days of her life, even a drop of water, when swallowed, was refused by the stomach. The internal fauces and the mouth first be- came inflamed, and subsequently mortified, from the con- tinued excitement of vomiting ; and the patient's fingers, in consequence of her sometimes putting them into her mouth, were ulcerated by the acrid discharge. The most distressing symptom of all, however, was a burning pain along the course of the spine, and in the lower part of the right hypochondrium, by which a constant jactitation was produced, and the strength of the patient exhausted. The only means by which this pain could at all be allevi- ated, was dry friction, so that the skin was quite exco- riated. The unfortunate patient at last died in a state of miserable extenuation. The body was examined forty-eight hours after death. Much attention was given to the brain, but no unnatural appearance of any kind discovered. The head was thought to be rather under the usual size, but the patient had not been deficient in mental endowments. The thoracic viscera were in a state equally sound; the stomach presented no organic lesion, although there had been black vomiting, neither did the rest of the alimentary canal, nor the urinary sys- tem, differ from their healthy condition, The liver wa$ 194 DISEASES OF THE soft and livid. The uterus, in the fifth month of pregna- cy, shewed no marks of disease, except some fibrous tumors in its substance, equalling walnuts in size. The cervix uteri was hard, perfectly closed at its external orifice, by which it had resisted the attempts made to procure abortion, and thus get rid of the vomiting by re- moving its cause. The foetus was healthy, and in its natural situation. The viscera were now all removed, and the semilunar ganglion cut out; it was not, indeed, converted into a foreign substance, but its color was in- tensely red, which was regarded as true and genuine inflammation, by some men of experience, and great cul- tivators of anatomy, to whom this observation was com- municated. The inflammation was so obstinate, that the ganglia were but little paler after three days' infusion in cold water; and I took care to have the right ganglion drawn in this state, and represented in the seventh plate of this treatise. Its upper part is of a vivid red, but the inferior, from which the mesenteric branches go off, is more livid. The splanchnic nerve appeared to me much broader than usual, before its entry into the ganglion." Case LI. — " The body of a girl was examined, who had been attacked with epidemic cough, which was con- verted by metastasis first into spasmodic vomiting, and then into atonic convulsions, which could not be over- come by any remedial means. In this case the left por- tion of the solar plexus was inflamed; the right being healthy." Case LII. — " A man, aged forty-seven, had a fibro- cartilaginous tumor, which adhered loosely to the spine, cut out. In two years, he returned to the hospital, hav- ing another tumor on the same site ; he was seized with tetanus, and died in two days. On opening the body, GREAT SYMPATHETIC NERVE. 195 were found, first, a vascular cyst well filled with blood, at the surface of the medulla spinalis, and a quantity of serum effused within the sac formed by the dura mater; secondly, very distinct inflammation of the semilunar ganglia." Case LIII. — "In a boy of ten years old, who died with symptoms of anxiety and oppression in the chest, and rattling at the pit of the stomach, in consequence of the retrocession of an exanthematous eruption, the author found a part of the sympathetic nerve inflamed, with phlogosis of the ninth and tenth thoracic ganglia, and two of the anastamosing brandies sent off from the cos- tal nerves." The effect of the division of the sympathetic nerve, in the neck, where it accompanies the par vagum, upon the eye, deserves notice. In a short time after this divis- ion, often very rapidly, the conjunctiva becomes red and swollen, projecting over the cornea. That it is the division of the sympathetic and not the par vagum that causes this, is evident from the fact, that the removal of the superior cervical ganglion of the sympathetic has the same effect. This nerve and its ganglia have been found inflamed after death from severe accidents, in which the constitu- tion sympathised with the injured part, as in severe burns. Its ganglia have been found inflamed in Tetanus, and some have supposed that this inflammation is the first link in the chain of morbid action, which produces Te- tanus. But as the ganglia of the sympathetic have been found inflamed without any tetanic symptoms, we can- not regard this inflammation as essential to Tetanus. In numerous cases of Colica Pictonum, the ganglia of the sympathetic in the abdomen have been found in a mor- bid state, swollen and inflamed. The same ganglia have been found inflamed after death, 196 DISEASES of the from severe fevers. Dr. Cartwright, in his Essay on the Fever of Natches, states, that in all his dissections, during the epidemic of 1823, he found the sympathetic ganglia inflamed. They were found in a morbid state in malignant Chol- era. Delpech* says : " The common and ordinary re- sult has been a remarkable alteration, principally of the semilunar ganglions. Those organs are more volumin- ous, and of a texture less dense than the nerves of the adjoining plexuses, have probably retained better the traces of the physiological alterations which they have experienced; they have often shown themselves swollen, red, more or less strongly injected, and sometimes soft- ened to a very remarkable degree. The injection which penetrates them, colors them red, when in all the re- mainder of the body the capillary system is injected black. This very remarkable phenomenon cannot fail to recall the painful sensation which occurs so constantly in the prodromes, and in the beginning of cholera, and the pre- cise seat which it occupies. " The solar plexus is likewise in an unnatural state, which is more or less obvious, but always perceptible by the size of the nerves which compose it, often by the red injection of their neurilema, and sometimes even by the softening of the nerves which form it, which are then ruptured by the slightest effort, or the lightest pres- sure. This plexus is then formed by broad red bands, and not by filaments of a greyish white, as in the natu- ral state. " The renal plexuses have presented sometimes altera- tions of the same kind, but they have not showed them- selves so frequently, and never with the same intensity. The affection appears to have been a simple extension of that of the adjoining nerves." * Etude du Cholera Morbus en Angleterre et en Ecosse, p. 196, GREAT SYMPATHETIC NERVE. 197 We know but little, it is true, of the functions of the great sympathetic, but enough to convince us they are important, and, considering our deficiency of knowledge of its pathology, we cannot but lament its condition is so little regarded in disease and in post mortem examina- tions. 17* Uavt XX, DISEASES OF THE BRAIN, AND OF OTHER PARTS OF THE NERVOUS SYSTEM. INFLAMMATION OF THE BRAIN, AND OF ITS MEMBRANES. It has already been remarked, that our knowledge at present, is not sufficient, to enable us to say confidently, what symptoms distinguish inflammation of the substance of the brain from that of its membranes, though some distinguished pathologists as Rostan, Lallemand, Bouillaud and others, conceive they can frequently decide from the symptoms whether the substance of the brain is affected or only its membranes, and even distinguish the different stages and degrees of inflammation. Fortunately these distinctions are not of very great practical importance. From what has been already stated when treating of the pathology and functions of the brain, it is evident that inflammation of the membranes that cover the superior and anterior portions of the brain, and inflam- mation of the cortical substance are accompanied by delirium, and that of the base of the brain and its membranes by coma, and often without delirium. It is, however, quite rare for the inflammation to be confined wholly to either of these portions of the brain. INFLAMMATION OF THE BRAIN. 199 The inflammatory affections of the brain and its membranes are known by different names, such as Arachnitis or inflammation of the arachnoid membrane, Meningitis or inflammation of all the membranes, and Cerebritis or inflammation of the substance of the brain. Phrenitis is a general term used for all the forms of inflammation of the brain, and of its membranes, attended with frenzy or violent delirium. Acute Hydrocephalus or dropsy of the brain, is but one of the forms by which inflammatory action of the brain terminates, the effusion being the consequence of the inflammation. The term is, however, deceptive and improper. It is not the water which is to be dreaded or which constitutes the disease, but the previous inflammatory action; if this is arrested no effusion takes place — if it is not, death ensues, and sometimes before effusion occurs. Inflammation of the brain terminates not only by effusion but by suppuration — the formation of false membranes and by softening or ramollisement of the substance of the brain. Though, as it has been said, it is impossible in many cases to determine from the symptoms what part of the brain is affected, yet in some I believe it is not. The duration of the disease is some guide to us. If a patient for a long time has severe and fixed pain of the head, slight confusion of ideas, partial loss of memory, dejected appearance and altered manner, with disturbance of some of the senses, followed by either paralysis, rigidity or contractions of the muscles or by convulsions ; we may properly infer that the disease is in the deep seated parts of. the brain, and probably of that form of disease which terminates in ramollisement of the brain, though this condition may be accompanied by suppuration or by extravasation of blood into the same organ. 200 INFLAMMATION Affections of particular senses or muscles, while others remain undisturbed and the mind clear, should lead us to infer organic disease confined to the base of the brain, and to the origin or course of the nerves of the affected sense or muscles. Examples of such affections of the brain have already been given, from which it is evident we may not unfre- quently determine from the symptoms the part of the brain diseased. The most characteristic symptoms of the inflammatory affections of the head are, fever, pain of the head which the patient considers of an unusual kind, increased sensibility of the eye to light, and often of the ear to sound and the skin to the touch. Sleeplessness, frightful dreams, sickness of the stomach, vomiting, pain of the limbs, retraction of the head, convulsions and delirium. In some cases convulsions are the first symptoms that attract attention. Generally, however, inflammatory affections of the brain in children are preceded by langour and indisposition to move, especially to hold the head down, irritable temper, startings in sleep, desire to be alone and away from the light. In one case which I saw and which proved fatal, that of a fine little girl nine years of age, so great was the inclination to be alone or away from the noise of the family, that for several evenings previous to her making any complaint, she was found sitting by herself out of doors. Often slight spasms about the muscles of the eye and face, and a staggering gait are noticed before any complaint is made. Such slight symptoms should awaken attention, and if accom- panied by pain of the head, vomiting, impatience of light or noise and febrile symptoms, should lead us to immediate exertions to prevent serious disease. The increase of inflammatory diseases of the brain of late years, is a subject to which I wish to direct OF TnE BRAIN. 201 attention, and I cannot more strikingly exhibit the fact of this increase than by referring to the Report of the City Inspector of the Interments in the City and County of New York for above thirty years, from the commence- ment of making returns of deaths to' the City Inspector in 1804 to the year 1838. From the tables of the deaths from different diseases it appears that while the population of New York has only quadrupled in the last thirty years, the deaths from inflammatory affections of the head, or from inflammation and Dropsy of the brain alone, has increased more than twelve fold. In the six first years of this period the deaths from these two diseases, which may be regarded as identical, were as follows :— 1805. 1806. 1807. 1808. 1809. 1810. Inflam. of brain, 17 16 15 17 18 12 Dropsy do. 16 22 30 28 28 42 1833. 1834. 1835. 1836. 1837. 1838. Ir.flam. of brain, 101 120 150 159 161 155 Dropsy do. 305 347 382 268 365 368 The population of the City of New York has risen during this time as follows :— 1805....., . 75.770 1810.......96.373 1815.......100.6*19 1820.......123.706 1825.......166.086 1830.......197.112 1835.......270.089 It will be perceived that the most alarming increase has been of Dropsy of the head, an inflammatory affection of the membranes of the brain and mostly confined to children, 202 INFLAMMATION It should also be noticed that other diseases of the brain such as Apoplexy, Epilepsy, Insanity and Convul- sions, are not at any period included in the above tables; these are classed seperately. I have examined the bills of mortality in other cities in this country and find that in all, there has been a vast increase of inflammatory diseases of the brain within the last half century. It also appears that the same diseases have of late greatly increased in England and France. = According to the late Dr. Davis, of London, eight out of forty-five deaths, in the Universal Dispensary were produced by Dropsy of the brain, and Dr. Allison states that forty out of a hundred and twenty patients die of this disease in the New Town Dispensary, London. Mar- shall, in his Mortality of the Metropolis, London, from 1629 to 1831 says that since 1790 deaths from Dropsy of the brain have been on the increase and to an alarm- ing extent, the number being for the last few years about 800 per annum. Dr. Coindet says that 20,000 deaths annually occur from the same disease in France. What are the causes of this recent increase of the in- flammatory diseases of the brain ? It will be seen from other parts of this work that other diseases of the brain and nervous system have also increased ; but our pres- ent inquiry is respecting the increase of the purely in- flammatory affections of the brain. This increase is mostly of that form of inflammation denominated Acute Hydrocephalus or Dropsy of the brain. What then are the causes of this disease ? These, as enumerated by authors, are blows or other injuries of the head, intesti- nal irritation, dentition, suppressed evacuations, repelled eruptions, intense and long continued mental application. OF THE BRAIN. 203 Golis* thinks the mechanical agitation of the brain in large active children by running, jumping &c, is a very frequent cause. He says the disease has much increas- ed of late, and attributes some of this to the less frequent eruptions on the heads of children than formerly. It will be observed that many of these causes are not more operative now than formerly, and therefore do not account for the increase. Some recent writers have attributed many cases to anxiety and mental agitation of the mother during preg- nancy. Golis observes, " that in the year 1809 when our imperial city, (Vienna) was bombarded, most of the children who were born after this frightful catastrophe in about twenty or thirty days after birth were seized by convulsions and died. Within the cranium were found traces of inflammation, and in the ventricles of the brain effusion of lymph and serum." Pinel mentions that out of ninety-two children born after the blowing up of the Ar- senal in London, in 1793, eight were affected with a spe- cies of aretinism and died before the expiration of the fifth year; thirty-three languished through a miserable exist- ence of from nine to ten months duration, sixteen died on coming into the world, and six were born with numerous fractures of the large bones. Early intellectual culture is considered by some a cause of this disease. A late writer observes, " the present plan of education in which the intellectual pow- ers are prematurely exercised, may be considered as one of the causes of the more frequent occurrence of this disease."! I am of the opinion that much of this increase of dis- • A treatise on the Hydrocephalus Acutus, by L. P. Golis. Trans. lated from the German, by Robert Gooch, M. D., London. t Medico Chirurgical Review, April, 1826. 204 INFLAMMATION eases of the brain in infancy and childhood, is to be attri- buted to a predisposition to disease of that organ derived from the mother, and to causes that too greatly excite and develope too early and too rapidly the cerebral organs. A tendency to disease of the brain may be given to the foetus in utero, either as we have seen by the mental agi- tation of the mother, or by inheriting from her a nervous temperament, or in other words a brain and nervous sys- tem so excitable that slight causes will disorder it. The mother who possesses an excitable nervous system, either inherited or acquired, whose mind is easily agitated, who has had much mental anxiety and excitement, whose brain has been developed disproportionably *.o the other organs of the body, imparts this predominance of the ner- vous system to her infant, and then during its infantile years, wrhen its brain is rapidly evolving and much blood is sent to it, this organ readily, and from very slight causes becomes diseased. A predisposition to disease of the brain may be inher- ited from either parent, though I believe it is much the more frequently from the mother in consequence of her mental agitation during pregnancy. It is not improbable, indeed it is supported by established facts, that striking peculiarities of character that distinguish one of a family from other members of it, are derived from this source. a If a mother," says Dr. Macnish, " while pregnant, is subjected to annoyances which fret and irritate her, the offspring will run a strong risk of inheriting a temper, similar to that under which she herself labored during gestation. Rizzo was murdered in the presence of Queen Mary, then pregnant with James VI. This mon- arch had a constitutional timidity of temperament, and a great horror of a drawn sword ; nor can it be doubted that the state of his mother's mind, while she was ence- inte, contributed to stamp upon him those peculiarities OF THE BRAIN. 205 which distinguished him in so marked and discreditable a manner from all the rest of the line of Stuart." Diseases of the brain are far more common among children remarkable for precocity of intellect and who have large heads. In such they are also more danger- ous. But this predominance of the brain, which produ- ces the precocity of the intellect and disposes the child to disease, is very often an inheritance from parents, one or both of whom, have cultivated the mind, or in other words exercised and developed the brain, at the expense of the other organs of the body. I have not any doubt but diseases of the brain will still increase, if the physical education of youth, especially of females, continues to be neglected ; if intellectual culture continues to be deemed by parents and instructors so essential that, infancy and youth must be chiefly devoted to it, and bodily labor and exercise neglected as a part of education. They will also increase if mothers are not particularly attentive to the preservation of their own health, espe- cially during gestation. Through that interesting portion of their lives, one of their highest duties is, to habitually cultivate calmness of mind, and equanimity of temper. Instead of agitating themselves with the existing topics of the times, and visiting places where their feelings are likely to be strongly agitated, they should strive to find enjoyment and health in attention to their domestic duties, and in daily, but gentle exercise in the open air. It is a truth which cannot be too often repeated, that nothing is more essential to the welfare of any country, than the preservation of the health of its fomales, and I am pleased to see by an increased attention to their phy- sical education, that many have become convinced of the fact. 18 206 INFLAMMATION Prevention. — From the preceding views of some of the causes of this disease, it is evident that preventive measures will often be serviceable. Attention on the part of mothers to their own health will do something to- wards diminishing the predisposition to disease of the brain in their offspring. As much may be done by them, by watchful care of their children during the first years of infancy and childhood. Their chief efforts should be directed to developing and perfecting the physical pow- ers of their offspring. This can rarely be accomplished if children are early confined at school, and attempts made to improve their minds and store their memories to the utmost extent. Some children, especially those that are quite robust and intellectually dull, may bear such treatment without much injury, but the generality will not. Those that submit the most readily to this course or who learn the most rapidly, whose minds are precocious and active, will be the most likely to be injur- ed. The parents of such should be apprised that al- though this precocity of mind, is not disease, it is akin to it, and should lead them to relax their attempts at mental culture and devote themselves to the improvement of their bodies. Sometimes this predisposition to disease of the brain as exhibited by mental precocity is manifested by sev- eral members of the same family, and child after child dies of Dropsy of the brain. In such cases the utmost care should be taken to prevent all excitement of mind and to cultivate the physical system. No attempts should be made to improve the intellect. The whole par- aphernalia of exciting play things should be dispensed with, and instead of carrying them to this and that place, to amuse them and to excite their curiosity, they should be left to pick up knowledge and to find amusement for OF THE BRAIN. 207 themselves in the kitchen and parlor and garden. In this way they will have sufficient exercise and develope harmoniously and naturally their physical powers. Treatment. — I regret to say that remedial measures for the relief of inflammation of the brain, when it is fully established are seldom successful. This makes me the more desirous that attention should be given to the means of prevention. It appears to me that the medi- cal profession are too neglectful on this subject. Sometimes when there are indications of approaching inflammatory disease of the brain, remedial measures seem to be very serviceable. An active purgative with rest, seclusion from light and noise, with cold applications to the head, sometimes appear to prevent the develop- ment of dangerous diseases of the brain. When inflammatory disease of the brain is fully indica- ted and fever is present, bleeding and cold applications, even of ice to the head and active purgatives should be resorted to immediately. When good leeches can be ob- tained, I prefer the application of a large number, to gen- eral bleeding. In some cases, especially those attended by convulsions, the spinal cord is more affected than the brain. In such, leeches should be applied on the course of the spine. In all cases of disease of the brain requi- ring active depletion, 1 prefer taking blood from the nape of the neck — from the hollow called the pit of the neck. In some attacks leeches should also be applied to the temples, behind the ears, and to the interior of the nose, so as to produce copious bleeding. Mercury has been strongly recommended by some to be given in Hydrocephalus until salivation is produced, but it is very difficult to produce this effect in children, and from what I have seen I believe that mercurial med- 208 INFLAMMATION icines are only beneficial in this disease by their cathartic effects. Blistering and pustulation are serviceable after the ac- tivity of the disease has been subdued by bleeding. Some- times recovery seems to result from a spontaneous erup- tion, this should encourage us in the use of external irritation. But though this active depletory treatment is requisite in many, if not most cases, yet I am well convinced that symptoms resembling those of acute Hydrocephalus are produced by too much depletion, and particularly by long continued purging with calomel. Cases of drowsiness, pain and heaviness of the head, accompanied by dilated pupil and coma, may arise from excessive depletion, and may be cured by nourishment — cordials and opiates, while they will prove fatal under an opposite course. The absence of heat and fever distinguishes these cases generally. It appears to me that opiates are too much avoided in some of the diseases of children, and that irritation from these diseases being thus unchecked, produces disease of the brain. Sometimes irritation of the bowels or irrita- tion from teething may be controlled by an opiate, and which if not thus quieted would lead to disease of the brain. M. Foville, in the «Dictionnaire de Medicine et de Chirurgie Pratiques,' has advanced a new method of pro- cedure in the treatment of this fatal disease. He recom- mends recourse to the trepan in violent cases. He says that the brain, occupying the whole interior of the skull, and being enveloped in a solid case, does not as other parts of the body receive pressure from the atmosphere. Consequently when more blood than usual goes to the brain, pressure of its substance must occur, and often does to such a degree as to destroy life. OF THE BRAIN. 209 He states the well-known fact, that bleeding does not so fully relieve this pressure on the brain as it does other organs, unless aided by the pressure of the atmosphere. And we know that in animals bled to death, though the lungs and other organs are pale and free from blood, yet the brain still contains a large quantity. M. Foville refers to numerous cases in which the removal of large por- tions of the skull by wounds and blows and even by fire was unaccompanied by severe inflammation or other bad symptoms. I am disposed to think this method deserves consid- eration and trial, considering the fatal tendency of the disease. I have often been surprised to notice that se- vere blows on the head which fractured the skull to such a degree as to make it necessary to remove considera- ble portions of it, have been followed by no bad conse- quences ; while on the other hand, I have frequently known slight blows upon the head, which in some instan- ces have not fractured the skull at all, and in others only the outer table, to be followed by inflammation and other alarming symptoms and death. I am therefore of opin- ion that an opening in the skull might be beneficial in such cases. I might quote numerous cases in support of the opin- ion that when a portion of the cranium is removed, then depletion seems to be very serviceable in prevent- ing and relieving inflammation of the brain. The follow- ing curious case from Wiseman'* will suffice. " A person was wounded near the Vertex by a punc- ture of a dagger. He sent for a Chirurgeon, who dressed his wound and cured it; during which the patient daily went abroad without any consideration of it. About * Chirurgical Treatise, by Richard Wiseman, Sergeant and Chirur- reon, Second Edition, London, 1636. 18* 210 Inflammation the seventeenth day, towards the full moon, as he was coming home one morning, he felt his legs faulter, and before he was got up stairs into his chamber his tongue failed him. His friends and servants put him into bed, and sent for me. They declared to me how he had been wounded such a day, and the manner of his being seized with the Paralysis. I saw a necessity for laying open the hairy scalp, and offered to go away that I might send for some of my servants to help me. He appre- hending that I was leaving him as deplorable, catched hold of me, and would have spoke to me, but could not. He made signs for pen, ink and paper, and endeavored to write, but could not form one letter. He then threw himself down in the bed, breathing out Jes. I prayed his patience, telling him I would return suddenly. But before I went, I let him blood ten ounces, and returned again within one hour, and we found he had lost the use of his arms. I considered the wound, and concluding a necessity of setting on a Trepan, I caused his head to be presently shaved, and a circular incision about the wound. Then raising up the hairy scalp, smooth off with my Spatula, I both saw and felt the bone, but could discover no fault in it. I dried up the blood with spong- es dipped in vinegar, raised up the lips round with my Spatula from the bone, and with a fresh sponge having dried up the blood, I looked again under them ; but could discover nothing ill in the bared Cranium. I then filled up the wound with dossils of dry lint, and applied a digestive ex terebinth, over the lips, embrocating the parts about cum oil. ros. and laid on a cataplasm efarin. hord. flor. rubr. balaust. in vino rub with syr. de ros. sice. &c. That day Sr. Fr. Pruj. gave him a visit, and prescribed him a Clyster, Cordials, Juleps, and what else he thought necessary. The next day was full-moon, at which time the brain is thought to rise high, and the vessels are OF THE BRAIN. 211 turgid: wherefore I deferred the setting on the Trepan, contenting myself with the letting him blood again. All this while he was in a fever, and deprived of his speech and limbs. The next morning, between 10 and 11 of the clock, in the presence of Sr. Fr. Pr. Sergeant Pyle, Mr. Arris and Mr. R. who thought himself concerned for his servant, and had first dressed him, I took off dressings and looked into the wound. We found no Fis- sure, however there was a necessity of perforating the Cranium. Wherefore without delay I began to work with the Trepan, which I much prefer before a Tre- phine, it being an instrument which doth its work lightly, and cutteth the bone equally, or how you please, without pressing so heavily upon the head, and is approved by all the Chirurgeons abroad, being much to be recommended before the Trephine. After I had bored the bone, and taken it out, I looked into the hole, and seeing the Dura Mater retaining its natural color, without matter or blood, I dressed it up with a Sindon dipped in ol. ros. with a little Resin warm. This way of dressing was objected against, as I expected ; but I dressed it up, and assured them that I would cure this patient without applying any other remedy to the Dura Mater than these two simple medicaments: but withal I was much unsat- isfied in myself, that such grievous symptoms, as loss of speech and limbs, with a fever, should afflict the patient, and yet no depressed bone or fissure, nor ought of mat- ter or Sanies appear upon the Dura Mater. This, I say, troubled me much, I fearing some other place, or that the blood lay putrified under the Dura Mater. But I dressed it up with a soft round Dossil next the Sindon, and the bone with liniment. Arcei, continued the Diges- tive to the lips of the wound, and applied an empl. de beton mag. over all, then laid him down in bed. Going presently out of his close room (where I was crowded 212 APOPLEXY. up with great lights burning near me) into the fresh air, I presently burst out with a violent coughing of blood ; yet the next day I dressed the patient again, and found his speech and limbs restored; but he was hot and his pulse quick. I opened his wound, and finding all as well as I could expect, I dressed up the Dura Mater again as before, with the same Oil and Resin, and after I had bound him up as is usual in these cases, I let him blood ten ounces, and advised the repeating of Clysters, &c, as occasion should offer. The Physicians and Chirur- geons visited him no more after the first dressing ; but I retained the young Chirurgeon that had first dressed his little wound, he dwelling near the patient. After three or four days dressing, this wound digested, and all the symptoms went off. Upon which consideration, I dimin- ished the quantity of the ol. ros. and increased the Resin; making good my word in curing him with those simple medicaments; I deterging and incarning as firmly and speedily this way as by any Sarcotic I ever used. While the bones were casting off, I cicatrized the lips as hath been set down in the preceding observations. Com- ing one day to dress him while the wound was cic- atrizing, he being abroad, I substituted the young Chirur- geon in my place ; yet I saw him dressed twice or thrice afterwards. He was well cured and remaineth so to this day." APOPLEXY. "Apoplexy," says a late writer, "is now infinitely more prevalent than in primeval times." It consists essentially in pressure on the brain, though this pressure may be produced in various ways — by extreme fulness and engorgement of the blood vessels, or by the extravasation of serum or blood. Some cases have APOPLEXY. 213 been reported in which no morbid appearances were discovered on examination after death. Such cases I apprehend must be extremely rare. An apoplectic attack is characterized by the loss of sensation, voluntary motion and intellect, while the respiration and the action of the heart continue. The respiration is, however, laborious, and generally stertorous, though in some cases it has been natural. The pulse is slow and full, especially at the commencement. In the latter stages it is small, feeble and intermittent. It is rare that an attack of apoplexy occurs without premonitory symptoms, though these are often so transient and variable as not to be regarded, while the general health remains good. These premonitory symp- toms are a sense of fulness in the head, giddiness, throbbing of the carotid arteries, ringing in the ears, head-ache, temporary loss of recollection, numbness in some part of the body, and partial paralysis. Apoplexy is a disease of civilized life, and one to which men are more subject than women. For the most part it is the result of full or luxurious living, excesses in drinking, diet or mental excitement. It is rarely seen among the laboring population unconnected with excess in the use of alcoholic drinks. Blacks are less subject to it than whites. It prevails in cities more than in the country. The sedentary, the idle and the meditative, are said to be most prone to it. According to Pousant, Monks are quite liable to it. The form of the body is said to predispose to Apo- plexy, as a corpulent habit, short neck and large head. Probably this disease does most frequently occur in per- sons of this formation as most authors so state, yet I have seen it as often in persons of a different formation. I fully agree with Dr. Cheyne who thinks that habits of life most strongly dispose to the disease. He says, 214 APOPLEXY. " I am persuaded there is so much more in the habits, than in either the original form or diathesis, that I ven- ture to affirm that in nineteen cases out of twenty of those who die of apoplexy the disease might have been averted or postponed by temperance." And he adds, " the daily use of wine or spirits, even in what is consid- ered a moderate quantity, will lead a man of a certain age and constitution to apoplexy as certainly as habitual intoxication." That this is true to the extent expressed, I can hardly believe, though I have no doubt the daily use of wine does strongly dispose persons to this disease. I have re- cently seen a fatal case of apoplexy in a person aged 45, moderately spare, whose appearance did not indicate an apoplectic tendency, but who for the last fifteen years had been in the wine trade, and in the daily use of wine, but not in excessive quantity. He was originally from a country town, and all his nearest relatives, parents, uncles and brothers I know, and none of them ever exhibited any tendency to this disease. Excess in diet will also cause it. I have known several attacks after a full dinner. Both Portal and Rochoux say that apoplexy is much less frequent in Paris since the practice of eating hearty suppers has been abandoned. Extremes of weather as to temperature, especially extreme hot weather, violent passions, great mental ex- citement and other causes determining more blood than usual to the head, cause this disease. Hence we find it to occur most frequently in the hot days of summer. The summer of 1838 was unusually hot, and the number of deaths in the city of New York from apoplexy, during the hot months was greatly increased over that of pre- ceding years. That great mental excitement causes apoplexy is APOPLEXY. 215 evident from the fact, that numerous instances have occurred of celebrated statesmen, lawyers and clergy- men being seized with it while engaged in their peculiar duties and making great mental efforts. Instances are also quite numerous of violent passions, as anger causing an attack. Such are to be found in Bonetus, Cheyne and other writers on apoplexy. I am inclined to believe that long continued and great mental exertion disposes to cerebral disease — thus we find that many of the most distinguished statesmen, lawyers and literary men who have died within the last quarter of a century have been attacked with some form of cerebral disease. Patliology. — As I have said some very rare cases of apoplexy exhibit on dissection no morbid appearance of the brain, but generally there is found great engorge- ment of the blood vessels, extravasation of blood or effu- sion of serum. Extravasation of blood may take place in any part of the brain or on its exterior surface, but it is most frequently found in the corpus striatum or in the thalami nervorum opticorum. It may proceed from the arteries or the veins. The arteries in the striated bodies^ the small branches in the base of the brain that proceed from the carotid and vertebral arteries, the communica- ting artery, the basilar artery, the1 internal carotid and the vessels of the Plexus Choroides have been found rup- tured in apoplexy. It has been supposed that sudden attacks of apoplexy attended by paralysis of one side, arose from extravasa- tion of blood, and into the hemisphere opposite to the affected side ; and that apoplexy from effusion of serum is more insiduous — the symptoms of oppressed brain manifesting themselves but slowly. These are I believe often distinctive signs, but not uniformly so, as sometimes after sudden attacks, with hemiplegia, no extravasation 216 APOPLEXY. of blood has been found, but effusion of serum or a very injected, turgid state of the blood vessels. Prevention. — Apoplexy is a malady of so grave a character that methods of prevention should be earnestly sought for and persevered in, whenever there are any indications of its approach; and, as it has been remarked, there are, not unfrequently, such indications. Preventive measures consist chiefly in avoiding every thing likely to excite the action of the heart or that hinder the free return of the blood from the head. The particular cause which disposes to apoplexy should be ascertained. If it consists in repelled eruptions or suppressed evacua- tions they should be restored. If the symptoms that indicate the approach of this disease are caused by too plenteous diet, by the use of stimulating drinks, the habits in these respects should be changed. If there is numbness of the limbs or any paralytic symptoms, bleed- ing and purgation should be resorted to. Often a seton or issue in the neck will long avert an attack. Above all, those threatened with apoplexy should renounce all business that occasions anxiety of mind, or that requires much mental effort, should take daily exer- cise in the open air by riding or walking, confine them- selves mostly to vegetable diet,' abandon all stimulating drinks, and sleep and eat but little. They should be par- ticularly careful during summer and not expose them- selves to the hot sun. Treatment. — When an attack supervenes, bleeding is the first and most important remedial measure. This not only lessons the circulation in the brain but favors absorption. In addition to prompt and copious bleeding from one or both arms, bleeding from the nose by incision in the pituitary membrane, where it covers the septum APOPLEXY. 217 of the nose, is salutary. All constriction of the dresa about the neck or chest should be removed, the head should be elevated and very cold water poured upon it from a heighth of five or six feet. Ice should also be applied at intervals to the head, stimulating injections administered, and soon as the patient is able to swallow, he should take a drop of croton oil every two hours until the bowels move. Every thing likely to excite the brain should be pre- vented from disturbing the patient, such as light, noise, company and conversation. I have recently witnessed a severe attack in a person whose age, habits, and form of body were such as to predispose to it — which was relieved by prompt bleed- ing from both arms — cupping the neck and temples — ice and ice-water to the head, stimulating injections and croton oil. After recovering from an attack, the patient should be interdicted all intellectual excitement, and live the remain- der of his life as devoid of care as possible. His diet should be of the plainest kind, and water his only drink. He should avoiil the extremes of heat and cold — and guard against all impediment to the free return of blood from the head by omitting neckcloths, or else wearing them very loosely, and be careful not to hold his head downwards. I am aware that bleeding in attacks of apoplexy has been deemed unnecessary and improper by some, and emetics and tonics recommended. Cases may occur where this course is proper, but I have never seen a case in which I supposed it would. In all the attacks which I have witnessed followed by recovery, bleeding had * been resorted to — in all those that have proved fatal where an opportunity was afforded for examining the brain after death, extravasation of blood was found, and 19 218 APOPLEXY. to such an extent that recovery from any course of treatment could not be expected. The following cases have occurred within a few weeks and will illustrate my views of practice. Case LIV. — Mr. L. K., aged about 65, full habit, large head, short neck, having exposed himself more than usual for several hours to the heat of the sun, suddenly fell deprived of sensation and voluntary motion. This occurred about mid-day. He was seen immediately — bled freely from both arms, his feet put in hot water and mustard sinapisms applied. His head was kept eleva- ted and ice-water poured upon it, and surrounded at intervals with bags of ice. He also had a stimulating injection administered, was cupped in the neck and on the temples and took in the course of the afternoon, four drops of Croton oil, which moved his bowels freely. He soon rallied a little, but remained nearly insensible during the day and night following, but gradually and completely recovered after a few days. In this instance it appeared to me at the time, and does now, that the immediate and active treatment saved the patient. He has since this attack, now three months, enjoyed good health. Case LV. — Mr. T., aged about 45, had been de- ranged in mind for about twenty years, but otherwise in good health. In July, 1839, immediately after supper, fell insensible, was placed on a bed, and bled copiously This did not relieve him and he expired in about four hours. I exam- ined his head and found large extravasations of blood into the corpora striata which had penetrated by ragged openings into the ventricles. There was also slight extravasation into the Pons Va- rolii. In this case there was no indication of an ap- EPILEPSY. 219 proaching attack, and after its occurrence probably no measures would have been of service. But the two cases for the first hour were very similar. In this last case the patient having been deranged for twenty years, I was surprised to find there were no adhesions of the membranes of the brain. The only appreciable change found in the brain was a very unusual hardness of the cortical portion. The outer part of it seemed like a dense membrane and could be pealed off from the inner, which was quite red. EPILEPSY. " Epilepsy," says Dr. Baillie, " has become much more frequent within the last twenty years than formerly." Though this disease has been witnessed from the most remote times, as we find accounts of it in ancient au- thors, yet it prevails but little among uncivilized nations to what it does in civilized and enlightened communities. " Epilepsy," says a late traveller, " as well as Apo- plexy, is nearly unknown among the Laplanders," and we believe it is among all barbarous tribes. Females are more frequently the subjects of this disease than males. But thouo-h this disease has always been known, and much has been written respecting it, it is still one of the most obscure diseases which afflicts mankind. A parox- ysm, or an Epileptic fit is most mysterious and unac- countable. A person apparently in perfect health sud- denly falls to the ground in a state of complete insensi- bility. He neither sees nor hears nor is he conscious of the most powerful impressions. His muscles immedi- ately become convulsed, and sometimes, those about the face especially, violently so. The eyes roll about, the 220 EPILEPSY. tongue is often thrust spasmodically forward while the face is livid, the breathing embarrassed and there is foam- ing at the mouth. The pulse is small, irregular and frequent. Little by little these symptomj abate, the breathing becomes freer, the pulse fuller, and more reg- ular, the countenance more composed and the patient is disposed to sleep. Sometimes the epileptic person has some warning of an approaching fit, such as confusion or pain of the head, dimness of sight, noise in the ears, giddiness, &c, and sometimes by what is called an aura or a sensation like a stream of cool air or subtile fluid ascending from the lower extremities. When this sensation reaches the head the patient becomes unconscious. In such cases a tournaquet applied just above the part first affected, has sometimes prevented an attack. Often the attack occurs in the night, during sleep. There is much difference in the violence of these attacks. In some the convulsive struggles are exceedingly violent, in others there are scarcely none at ail, the attack con- sisting only in loss of consciousness for a short time. Death sometimes occurs during a paroxysm, but not often, and patients suffer from them through a long life. In some cases years intervene between the attacks, but usually oiily a few weeks. Epilepsy is sometimes the precursor of insanity, and usually has a tendency to impair the intellect, though some epileptics possess their mental powers unimpaired to very advanced age. I have seen several cases in which the disease seemed to improve the intellect, at least for a time. It is a disease which affects all ages, though children and young persons about the period of puberty are most subject to it. The causes of an Epileptic fit are numerous, and in some cases it is difficult to say from what it does origin- EPILEPSY. 221 ate. All strong affections of the mind, those that increase and those that diminish the action of the brain appear to produce it, such as joy, anger, grief and terror, the last frequently causes it. Suppressed evacuations, repel- led eruptions, irritation of the bowels, worms, dentition and eating very heartily appear at times to give rise to it. _^ The use of alcoholic drinks is a very common cause A case is related of a person who received a fracture of the skull and ever afterwards was subject to attacks of Epilepsy if he indulged in alcoholic drink, but was wholly free from them so long as he abstained. In fact irrita- tion in any part of the body may give rise to Epilepsy. The proximate cause of Epilepsy is supposed to be sit- uated in the brain, as sometimes it results from injury of that organ, and in those who die during a paroxysm, the brain is found engorged with blood. In some who have long been subject to Epilepsy with- out mental disturbance, and who have died of other dis- eases, the brain on examination exhibited, no unnatural appearance. In most cases of Epilepsy however, some organic affection of the brain, its membranes, or of the bones of the cranium have been observed, but these affec- tions are, I apprehend, oftener the effect than the cause of Epilepsy. In those Epileptics who exhibit disturbance of the intellect, some organic affection of the brain is always found. M. M Brouchet and Casauvielh have published a valuable work on Epilepsy in connection with Mental Alienation, in which they state that the result of their researches show that Epilepsy is the^result of chronic inflammation of the white substance of the brain ; while mental alienation results from chronic inflammation of the cineritious or grey portion of the brain. These opinions though supported by many facts, can* 19* 222 EPILEPSY. not as yet be considered established. Further researches are necessary. The brain and nervous system of those who die of Epilepsy, should be examined with great care and whenever opportunity presents, should be compared with similar pans of those who have never been affected by the disease. Without this comparison slight varia- tions of color and consistence, might not be observed. As I have said, injury of the brain from external vio- lence sometimes disposes to attacks of Epilepsy. A depressed or carious portion of the skull by irritating the brain will cause these attacks, and they have been pre- vented by trephining and removing the injured bone. The following are instructive cases. Case LVI. — " Case of Epilepsy cured by Trepan- ning. By Henry Coates, of the Royal College of Sur- geons in London, and Surgeon to the Salisbury Infirmary. " James Goddard, astat. 33, a gentleman's coachman, was admitted a patient into the Salisbury Infirmary, July 28th, 1804. He stated, that about four years before, he was driving his master's carriage under a gateway, (not stooping sufficiently,) the crown of his head struck against a beam ; this at the time was not followed by any other symptoms, than a slight headache for a few days, and an inconsiderable swelling of the part, which soon subsided. Nothing occurred to remind him of the accident, till, about a year afterwards, when a small tumor appeared on the part on which he received the bruise, which, (to use his own language,) continued to swell without much pain, and at last burst. The wound was afterwards dilated by a surgeon, and healed with difficulty in about six months, and he says, that he continued perfectly well for about six months after- wards, when he was attacked with an epileptic fit while on the coach box ; and has since had repeated attacks of EPILEPSY. 223 them at intervals of from a week to a month. He now complains of extreme pain in his head, loss of vision of his left eye, numbness and coldness of the left side, par- ticularly of the foot; his general health and appetite are otherwise tolerably good. On examining the scalp, I perceived several small puffy ulcerations about the cen- tre of the coronal suture, which, on pressure, give him pain. He was directed to take some opening medicine. "July 29th, the appearance of the scalp indicating some further disease, I determined to ascertain the state of the bone, for which purpose I made an incision of about three inches in length in an oblique direction, beginning an inch in front of the sagittal suture and running backwards. The bone at the anterior part of the incision was found roughened, and a portion of it about the size of a shilling, porous, with a sinus in the centre, which readily admitted a probe being passed to the dura mater. " I now determined to remove the diseased portion of the bone, and applied a trephine, the crown of which was sufficiently large to include the whole of it. The operation was tedious from the extreme delicacy of the part, and care required in the use of the instrument. It was, however, completed without accident, and on extracting the bone, its internal surface had an honey- comb appearance. The dura mater was detached, but perfectly healthy. " The wound healed kindly, and I have seen him sev- eral times lately ; he continues wTell, and follows his usual occupation ; he has had no return whatever of the fits. The numbness and coldness of his left side is quite removed. The vision of his left eye is better, though not quite recovered."* * Edinburgh Medical and Surgical Journal, 1806, p. 428, 9. 224 EPILEPSY. Case LVII. — « Epilepsy of' thirty-three Years' stand- ing, cured by the removal of a Carious portion of the Cranium. " One of the inmates of the Hopital des Invalides, 63 years of age had been wounded at the battle of Marengo with a piece of a small shell (obus) in the forehead. He was immediately trepanned, and a portion of the bone extracted. The symptoms of commotion and of com- pression were succeeded by those of encephalitis. When these subsided, he was found to be paralytic on the right side, and to have lost completely ' la memorie des choses.' The wound never fairly healed, but remained fistulous; and scarcely a day passed over without an attack of epileptic convulsions. For the last thirty-three years, he had been in this deplorable condition, subjected to daily fits, totally deprived of his memory of things, and having a fistulous sore on his forehead. M. Larrey having de- tected with a probe a loose portion of bone, divided the integuments, and extracted it with a forceps. The wound and sore speedily healed up, the attacks of epilepsy have ceased to return, and his locomotive and mental faculties have become considerably improved. We are informed, however, that his memory of numbers and of " names is still very imperfect and wavering. — Lancette Francaise." Tumours pressing upon and involving nerves some- times cause Epilepsy. The following case is from the fourth volume of Med- ical Essays and Observations by a Society in Edinburgh, 1737. Case LVIII. — ,(An Epilepsy from an uncommon cause; by Dr. Thomas Short, Physician at Sheffield, and F. R. S. EPILEPSY. 225 " In July, 1720, a woman about 38 years of age was brought to me ; she had labored twelve years under an Epilepsy, which, from one fit a month, was come to four or five violent ones every day, each continuing an hour, or an hour and a half; by which she was rendered mo- pish and silly, and incapable to take care of her house and family. Her husband was reduced in his circum- stances from his affection and care for her, having got and followed all the advice he could. Evacuations of all kinds had been tried ; the epileptic and cephalic tribe of medicines had been ransacked, and many other medicines had been used in vain, the disease growing more severe. Her fit always began in her leg, toward the lower end of . the gastrocnemii muscles, and in a moment reached her head, threw ner down, foaming at the mouth, with terri- ble distortions of the mouth, neck and joints. Whilst I talked with her she fell down in a fit: I examined the leg, and found no swelling, hardness, laxness or redness different in that place from what was in the other leg: but suspecting from her fit beginning always at that part, that the cause of her disease lay there, I immediately plunged a scalpel about two inches into it, where I found a small indurated body, which I separated from the mus- cles, and then took it up with a forceps ; it proved a hard cartilaginous substance or ganglion, about the size of a very large pea, seated on a nerve, which I cut asunder, and took out the tumor. She instantly came out of the fit, cried out she was well, and never after had a fit, but recovered her former vigor both of body and mind." From an attentive examination of numerous cases of this disease and of much that has been written respects ing it, I am convinced that with many Epileptics there is a predisposition to this disease from an acquired or inherited greater sensibility or irritability, than other per- sons possess. 226 EPILEPSY. It is this peculiar condition of the whole nervous sys- tem that causes certain individuals to be. affected by mental or corporeal impressions that produce little or no effect upon others. Every practitioner has seen cases apparently arising from dentition, from worms or other intestinal irritation, and I have just quoted a case where disease of a nerve appeared to cause it. Such affections produce Epilepsy however, in consequence of the very ex- citable condition of the brain and nervous system, already alluded to. Thus many cases of Epilepsy I apprehend, arise not from organic disease of the brain, but from such an excitable state of this organ, that any violent irrita- tion in any part of the body transmitted to the brain will cause a rush of blood to it and produce an attack of Epilepsy. After repeated attacks and repeated conges- tions of blood in the brain, undoubtedly some organic changes will be found in this organ, but such changes are probably oftener effects than causes. No doubt this excessive irritability or excitability of the brain and nervous system is hereditary. It may be acquired by the mother by a life of bodily indolence and mental excitement, and be transmitted to her offspring, or it may be acquired by the child without hereditary tendency by neglecting to exercise and develope all the powrers of the body equally, and by constant excitement of the brain until it becomes the predominant organ and a nervous temperament produced. Epilepsy is sometimes epidemic or contagious among females of feeble constitution and excitable nervous sys- tems. Dr. Meyer of Bonn states that a girl at a school, attended both by boys and girls, was seized with Epilepsy, and soon after about twenty girls were similarly affected. Most of the girls were approaching the age of puberty and were of a highly excitable temperament. None of the boys were affected. EPILEPSY. 227 Prevention. — From what has been stated it is evident that preventive measures may be of great service. These are obvious ; consisting in efforts calculated to develope and strengthen the corporeal powers and not to unduly excite the brain and nervous system. With children and young persons who are strongly predisposed to this disease or exhibit a tendency to attacks of it, great care is necessary. Instead of seeking various amusements for them, and striving to excite their minds and exalt their sensibility, their minds should be permitted to run to waste, if I may so say, while the utmost pains should be taken to improve and strengthen the body by exercise in the open air. Treatment. — It is obvious that this should vary with the cause. If Epilepsy arises from organic disease of the brain or skull there is little or no hope of recovery, unless it arises from a depressed bone or from some defect of the skull that an operation may remedy. If it arises from irritation in other parts of the system it may often be cured. The physician then in attempting to cure Epilepsy should first examine and ascertain the condition of every part of the body, of every organ, and thus endeavor to find the source of irritation that causes the attack. The state of the stomach, bowels, liver, uterus, kidneys, &c, should be carefully examined. In cases where there is but little or no hope of recov- ery, much benefit may be derived from a very cautious course of diet. I have known a diet, consisting of one kind of vegetable, cause an interval in the paroxysms of Epilepsy of three months, while the interval was not over two weeks on ordinary diet of animal and vegetable food. In some instances, especially in children, it is necessary 228 EPILEPSY. to take away blood, not so much with a view of curing the disease, as to prevent disorganization of the brain, from the violence and frequency of the paroxysms. All Epileptics would do well to live by rule and abstemiously, avoiding all stimulating drinks and whatever is likely to excite the system. I have known some to be free from attacks while confined to a vegetable diet. Some cases seem to be kept up from habit, or from very slight irri- tation. Such are often benefitted by narcotics and tonics. Stramonium has been found particularly beneficial, and so have the preparations of Zinc in large doses.* The nitrate of silver has appeared to cure in many instances. Some French writers have great confidence in it. It should be given in large doses and continued for a long time. Setons and Tartar emetic pustules along the spine have proved beneficial. Turpentine sometimes cures. I have known a case which seemed to depend on disor- dered bowels cured by it, for five years. Mental emotions sometimes prove beneficial. Music has sometimes weakened, and at length subdued the par- oxysm. Powerful mental impressions often prevent attacks. Hence probably the efficacy of the powder of human skullsf and of medicines presented with mystery and formality. * I have used both these remedies with good effect in the following manner. Take of the seeds of Stramonium and of Myrrh equal parts, mix and make into two grain pills — of these one may be given, once in twelve and sometimes once in eight hours. The preparation! of Zinc should be given in large doses. Take of Oxide of Zinc two drachms, Extract of Gentian two scruples, make into forty pills with a few drops of some essential oil. Give one of these the first day, two the second, three the third, and thus increase to twelve and fifteen in the twenty-four hours. 11 have been applied to for some within a few dayi EPILEPSY. 229 On the whole the practice has been very empirical in Epilepsy. My own experience is in favor of a large seton in the pit of the neck, warm bathing, and a spare, vege- table diet. This course has lengthened the intervals of the attacks more than any other I have seen adopted. The following is a singular case.* Case LIX.—" The consequences of a Crown piece swallowed by an Epileptic man. Communicated to the College by Dr. Coyte, of Yarmouth, Norfolk. Read at tlie College, Nov. 11,1773. Mr.-------, aged about 46, has been from his infancy subject to Epileptic fits. " On the 12th of March, 1771, he was attacked with a very strong fii.; and the people who happened to be present, recollecting the custom of his introducing a crown piece between his teeth, which he constantly carried about him, to prevent the tongue from being bit, as formerly had been the case whenever he had a return of these fits ; with eagerness to serve him, let it slip down his throat. The surgeon, (Mr. Arnold, of Lowestoff,) was from home at the time this accident happened, but at his return found Mr.------- in violent agony, com- plaining of being choked, and of the impossibility of passing any thing into his stomach ; whenever he endeavored to swallow, he was greatly convulsed, and complained much of pain in both his ears, at which time the crown piece was so low in the oesophagus that it was impossible to get it back again: it remained only to pass it into the stomach, which with the concurrent advice of another surgeon, (Mr. Turner, of Yarmouth,) was accomplished: his throat was inflamed and very painful for a long time, * Medical Transactions of the College of Physicians of London, Vol, iii. p. 30. 20 230 EPILEPSY. attended with the utmost difficulty in swallowing; his health after this was much as usual, though his fits were observed to be not so violent or frequent as before. " Previous to an illness which he had lately, and on which account I was consulted, he had occasion to be employed in fixing wine in deep vaults, and sometimes stood, as it-were, upon his head, and complained soon after of a weight at his stomach, attended with a sickness and a bitter taste in his mouth: thus he had continued for some days with a fever ; and I found him on the 19th of Sept. 1772, feverish, languid and very sick at times, with a disagreeable bitter taste in his mouth ; no emetic having been ventured on to remove the cause of his pres- ent disorders, which appeared to me to be chiefly owing to foulness in the stomach and primse via); I ordered pulv. rad. ipecac, gr. ij. and waited the operation; it puked him presently,and brought away a large quantity of viscid bilious matter, and, without giving him the least un- easiness, relieved him greatly. I left him, with directions to Mr. Arnold, to repeat the Ipecac, gr. ij. pro re nata ;*it was repeated three times that day, and several times the day or two following; and his fever went off, and his health was returning ; when, on the 26th of November, 1772, in the morning, he was very sick, and vomited several times, and in vomiting brought up the crown piece without any pain, after it had lain in the stomach from the 12th of March, 1771, to the 26th of November, 1772. Mr. now enjoys a perfect state of health, and has had no return of the Epileptic fits since that time. "Yarmouth, (Norfolk,) July 6, 1773. " P. S. The crown piece appeared black, and some- what corroded round one part of the edge and surface." To what was the apparent cure owing ? To the silver, or to the irritation of the stomach produced by the crown piece ? HYPOCHONDRIASIS. 231 HYPOCHONDRIASIS. This disease is characterized by some dyspeptic symp- toms, such as* flatulence, uneasiness in the stomach or abdomen, extreme lowness of spirits and apprehension of great danger, from supposed disease of some part of the body. The hypochondriac talks perpetually of his bad health. Though his appetite remains good and he looks healthy, he will say he has lost his appetite and is constantly losing flesh. His countenance and manner show that he is sincere and that he is really apprehensive of the danger which he predicts. He is wholly engrossed with self—and constantly attentive to his own sensations. I have known a father, in whom I could discover no disease, regardless of the sickness and approaching death of a child, constantly saying that his own case was more severe and alarming. Though Hypochondriasis has been considered a dis- tinct disease, it does not appear to me to be anything but a form of insanity, or monomania, combined with dyspepsia. A disease of the brain, functional most usually, together with disorder of some of the digestive organs. Patlvology. — In treating of the sympathetic nerve it was observed, that Prof. Lobstein believed that dis- ease of this nerve was the cause of Hypochondriasis. M. Lower Villermay and others,attribute it to a morbid state, an excess of organic sensibility in the nervous structure of some of the abdominal viscera, especially of the stomach. M. Georget, very high authority, considers it a disease of the brain. 232 HYPOCHONDRIASIS. It is certain that this disease most frequently appears to arise from causes affecting the brain, such as moral affections of a painful nature — but on examination after death of those long hypochondriacal, very frequently no disease whatever has been found in the brain. That it is often a functional affection of the nervous system I think is evident. Its intermittent character, as frequently there are exemptions from it for years, shows that organic disease is not its cause. It has been cured by attacks of other disease, as intermittent fever. From several cases which I have seen, and from those I have found in medical works, I am inclined to believe that it is a disease essentially of the nervous system and usually of the brain — a variety of mental alienation consisting often in hallucinations of sense, or of sensibility relative to some organ of the body. Injury of the head sometimes causes it. Mr. C. aged about 30, a healthy and industrious man, was injured in the head by a board falling upon it. In a few weeks he appeared to have recovered from this injury, but com- plained of loss of strength — inability to walk — and that the sun when it shone on his head disturbed him very much. For several years he did not walk a step, but was almost daily placed in his wagon, with an umbrella which he continually carried over his head even when the sun did not shine. In this way he travelled much, trans- acted business and appeared in good health. The sincerity of his belief that he could not walk was once proved. His house caught fire while no one but himself was in it. He was found by the neighbors seated in his chair, scorched by the fire and nearly suffocated by the smoke. The following case also seems to indicate that the brain is the seat of this disease. HYPOCHONDRIASIS. 233 Case LX. — Mr. T. aged 50, a highly intelligent and respectable gentleman, complained of painful erections of the penis. He was asked if ho had taken Spanish flies, as they produced such symptoms. He said he had not; but after some months he became convinced that he had taken them in some cider, which had been given him by a female several months previous. On this he constantly dwelt and consulted many physicians to rid him of the effects of the Spanish flies. He was considered hypo- chondriacal, like men who are frequently so from fancied venereal disease, or fancied disease from mercury, which they have taken for the cure of it. He finally became deranged, idiotic, and died. It may tend to support some of the claims of Phrenology, that his manners changed very strangely as regarded females from the first attack of priapism. He became exceedingly attentive and polite to them, delighted to be in their company, and his conver- sation was mostly concerning them. Even when quite idiotic, if roused into conversation it would be in relation to women. Mental shock alone causes it. A young man having heard a lecture from Esquirol, on the hereditary nature of insanity, called to mind that some of his ancestors had been insane. He immediately became sick and soon after committed suicide. The disease appears to originate from a variety of bodily affections, which affections would not, I apprehend, pro- duce it, was not the brain and nervous system in a morbid or super-excitable state. A little disease of any organ of the body may give rise to Hypochondriasis when the brain is in this morbid condition. Bad teeth, causing pain of the head, supposed to arise from organic disease of the brain, have produced this disease, which passed away after the diseased teeth were extracted. Disease Of a single nerve has appeared to produce Hypochondriasis, 20* 284 HYPOCHONDRIASIS. The following is an interesting instance, from Ollivier on Diseases of the Spinal Marrow. Case LXI. — " A woman, 49 years of age who had previously enjoyed good health, began, in the year 1820, to feel strange pains through her body, originating in the left side of the chest, and caused, as she thought, by a small scirrhous tumour which was developed in the left mamma, but which was not painful on pressure. These pains increased in intensity, and deprived her of all enjoy- ment of life. She tried intoxication, but that rather aggravated than alleviated the evil. Still the tumour in the mamma remained stationary, and never became sen- sible to pressure. The unhappy woman was forever recounting the miseries she suffered ; and, at last, tired of existence, and wishing to deliver herself from the torturer she endured, she threw herself, on the 5th No- vember, 1822, from a window in the fourth story of the house where she lodged. She was carried to the hospital, where our author saw her immediately, with the follow- ing symptoms : — Stupor, pallor of the face, great dysp- noea, pulse small and slow, skin cold, paralysis and insen- sibility of the trunk and lower extremities. There were various injuries, of different parts of the body, which we shall pass over. She died on the evening of the 8th November. Dissection. — " In the head, the meninges were found thickened, but very little water in the ventricles. The body of the 10th dorsal vertebra was fractured trans- versely, but without the slightest displacement of the fractured portions. In the vertebral canal, opposite the fracture, there was an extravasation of fluid blood on the exterior surface of the dura mater. The medulla spinalis appeared of its natural color and consistence. " In the thorax, the small scirrhous tumour was exam- HYPOCHONDRIASIS. 235 ined, but presented no trace of inflammation or disease around it. There were various fractures of the ribs ; but the cause of the patient's long-continued sufferings was now brought into view. In the left side of the chest, and just above the arch of the aorta, was found a tumour of a pyriform shape, the size of a hen's eggt covered by, and adherent to, the pleura on one side, and on the other, it was in contact with one of the dorsal verte- brae. From the upper part of the tumour arose a white cord, the size of a goose-quill, which was traced into the foramen between the first and second dorsal vertebrce. On examining the spinal marrow, at this part, the fila- ments of the anterior and posterior roots of the first dorsal nerve were distinctly seen directing their course, as usual, to the foramen, for the formation of the first dorsal. This nerve, after issuing from the spine, gave off, as usual, a posterior branch. The anterior branch (after communicating with the great sympathetic, and giving rise to an ascending twig that passed on to unite with the seventh cervical) suddenly enlarged in volume, and proceeding about an inch from the point where it gave off the ascending twig, it terminated in the summit of the tumour. In this course, its colour was not altered — its neurilema was thickened, and it lost itself in, and became blended with, the tumour in question. This tu- mour was white and elastic, presenting some cartilaginous spots on its posterior surface. On slitting open the nerve which served as a peduncle, the neurilema of the nerve was found to expand itself and form a sheath, as it were, for the tumour. This last, when slit open, presented a pulpy surface, of a whitish colour, and appearing to be formed of concentric fibres, without a trace of vessel of any kind in its composition." No doubt this woman was considered hypochrodrical, and probably many cases so denominated, are perpetua- 236 HYPOCHONDRIASIS. ted if not caused, by physical disease in some part of the body, though I apprehend that generally the disease is merely functional. Men of well stored minds, those who devote them- selves to study and take but little exercise are thought to be most subject to it, though I have seen several in- stances among farmers and other laborers, all of whom however were men given to reflection. Aristotle re- marked that men of learning were most subject to this disease. It has been termed the disorder of literary men. A long list might be furnished of men illustrious for their literary labors who were hypochondrical. Tasso, Pascal, Zimmerman, Cowper, Dr. Johnson, Jean Jaques Rouss- eau are instances. The latter has thus vividly described his sufferings. " My health," says Rousseau, after he had gone into the country with Madame de Warens," did not improve I was as pale as death, and meagre as a skeleton; I had dreadful pulsation of arteries : — to finish myself, having read among other things a little physiology, I set to work to study anatomy ; and passing in review the multitude and the play of the parts which compose my machine, I was in expectation of finding them all put out of order twenty times a day. Far from being astonished at finding myself dying, I was only astonished that I continued to live ; and that I did not read a description of any malady which I did not at once believe myself to have. I am sure if I had never been ill, this fatal study would have made me so. Finding in every disease the symptoms of my own I thought I had them every one ; and I acquired in addi- tion one still more cruel of which I thought myself free the fantasy of curing myself. It is difficult to avoid this when one takes to reading books of medicine. By dint of exploring, reflecting, and comparing, I conceived that the foundation of all my ailments was a polypus of the HYPOCHONDRIASIS. 237 heart, and even a physician seemed struck with this no- tion. I exercised all the powers of my mind to find out how to cure a polypus of the heart, being resolved to undertake this wonderful case. It had been said that M. Fizes, of Montpellier, had cured a polypus of that sort: nothing more was requisite to inspire me with the desire of going to consult M. Fizes. The hope of being cured revived my courage and my strength." On his way to Montpellier he engaged in a flirtation with a certain Madame de Larnage, which, for a while at least, cured all his complaints. " So Madame de Lar- nage," he continues, " takes me under hand, and adieu poor Jean Jaques! or rather, adieu fever, vapours and the polypus! I forgot during my journey that I was a sick man." No doubt Hypochrondriacal persons may be injured, as was Rousseau by reading medical books, and they should be advised not to peruse them, but not so in my opinion as regards those who are in health. According to my observation, those persons who have, by reading or oth- erwise, obtained some correct knowledge of anatomy, of diseases, and of medicines, are less disposed to hy- prochondia than those who are quite ignorant on these subjects, and they are certainly less liable to be duped by quackery and made to believe they have disorder when it does not exist, and that certain medicines have miraculous powers and will cure every disease. The disease has, I believe, increased with civilization, ease and luxury. A predisposition is given to it by undue excitement of the brain and nervous system, by the de- velopement of this part of the organization dispropor- tionately to the rest of the body. When therefore the nervous system becomes thus charged as it were, with disease by over-excitement, the least disturbance of any other part of the fabric may serve to develope hypo- chondriasis. 238 HYPOCHONDRIASIS. It cannot, I think, always depend, as some suppose, on disease of the Great Sympathetic nerve — for this nerve appears to preside over the secretions, and must if diseased disturb digestion, generation, &c. But Ily- pochrondriacs frequently have good appetites. The worst case I ever knew, was that of a man who for sev- eral years remained in a recumbent posture, fully of the opinion that if raised up he should die ; yet he appeared to be in good health, had a good appetite, digested his food without difficulty, and had no loss of his generative powers. The Treatment. — In the first place the hypochondriac should change his habits, so as to remove the causes of his disease. He should quit his studies and ordinary pursuits and seek diversion and health by journeying — by daily riding and walking, even until fatigued. Often engaging in some new and exciting business is useful. Many cases may be cured by the adoption of such measures, without the use of medicines. Sometimes, however, local irritation may perpetuate the disease; therefore every organ and every tissue of the body should be examined and the cause of the continuance of the dis- ease, ascertained, and removed by appropriate remedies. Sometimes it is kept up by gastric or intestinal irritations produced by stimulants. These should be withheld. In other cases atony of the digestive organs seems to pro- long the disease, and then tonics are useful. It is not well to always regard Hypochrondrasis as an ideal disease, for often it arises from physical disorder. This disorder should be ascertained and removed, and then the general remedies alluded to for invigorating the body and diverting the mind will remove the hypochon- dia. But on the other hand it is not well to unite in opinion HYSTERIA. 239 with hypochrondriacs and regard, or pretend to regard the symptoms of which they complain, as indicating alarming disease. It is best, I think, to tell them the truth — that they probably have some disease, but that most of it is imaginary. In cases of long standing I have seen good result from compelling patients to exercise. A person in an adjoining town confined himself to his room for above; six years, believing that he was unable to walk out of doors — that it would kill him if com- pelled. I assisted in carrying him against his will, some distance from his house, leaving him to walk back to it of himself. lie did so, and has since then gradually recovered. Many other cases have come to my knowl- edge of long continued hypochondria cured in the same manner. Before resorting however, to any compulsory measures, the most careful examination should be made to see if the disease is not kept up by some physical disorder, that such measures would not be likely to re- move. In a subsequent chapter, on the Effects of mental at- tention on bodily organs, will be found remarks applicable to some of the forms of Hypochondriasis. HYSTERIA. It is difficult, without writing a volume, to describe this " protean disease." It is mostly confined to the female sex, though not so absolutely as some writers sup- pose. I have seen a genuine case in a young man, and other undoubted cases are reported by various writers. Dr. Trotter observes, that at the time of a great disturbance among the British sailors, many of them had hysteria. Dr. Armstrong saw several cases of Hysteria in men. Though regular attacks of this disease are not 240 HYSTERIA. common, and in truth are very unfrequent, in men, yet certain symptoms usually denominated hysterical when occurring in females, are not very uncommon in males. For the most part hysteria occurs in young and middle aged females, of delicate constitution, indolent habits, and highly susceptible nerves. In such as are easily affected by slight emotions of either pleasure or pain, and who give way to the impulse of their feelings. An attack or fit of hysteria is characterised by sighing, sobbing, laugh- ing or weeping, with a feeling of stiffness and suffocatio" about the throat, with some affection of the head, heart, the respiratory or muscular system. Sometimes the attacks are slight, consisting of alternate high and low spirits, sighing, laughing and weeping. In other cases there is violent pain of the head, great difficulty of breathing, convulsions, loss of voice, hoarse dry cough, and a sense of suffocation, with the feeling of a ball rising up into the throat. There is often retention of urine fol- lowed by a copious flow. The varieties of hysteria as described by writers are very numerous ; similating a great number of other dis- eases as Croup, Apoplexy, Epilepsy, Paralysis, Tetanus, Peritonitis, Diseases of the joints, as hip disease and white swelling, Disease of the spine, and of the breast. That such affections, purely nervous, though resembling organic diseases, exist, I have had abundant unpleasant experience; unpleasant, because of the protracted na- ture of such cases and the difficulty of curing them. In fact, there seems to be no symptoms resulting from organic disease, but what are also manifested without any appreciable organic lesion. But why are all these nervous affections denominated hysterical ? Some of them are witnessed in those who do not exhibit any other symptoms of hysteria. I have at the present time, three cases of that oeculiar spina' HYSTERIA. 241 affection, denominated by Sir B. Brodie, hysterical. Two of the three females thus affected, have never exhibited any other symptoms of hysteria. They have been cup- ped and leeched and had setons and issues along the spine, all without benefit. In fact, though many things seemed for a time to benefit them, I cannot say that any thing actually has. One having become enceinte appears to be rapidly recovering. Other cases I have seen re- cover, through the agency, I believe of the mind, or owing to a change of circumstances that powerfully affected the mind and changed the current of thought, creating new emotions. All these affections I believe, depend upon a faulty organization or disease, either functional or organic, of the brain. But we know so little of this organ, and the opportunities are so unfrequent for investigating the nature of these complaints by post mortem examina- tion, that it is impossible to say how the brain is affected, or what portion of it. Some of the varieties of ner- vous disease, I shall allude to again in the section on the Effects of mental attention on bodily organs. General Causes of Hysteria. — Hysteria is no doubt often hereditary, but it may also be acquired. It is often attended by positive disorder of some of the viscera, par- ticularly by a costive state of the bowels. This is, I apprehend, a consequence, instead of a cause of the dia ease. A predisposition is given to it by a course of life that excites the nervous system and enervates the physi- cal powers. Neglect of exercise in the open air, of bodily labor, with devotion to study — to reading, especially of works that kindle the imagination—much attention to music, late hours, hot rooms, and luxurious seats, tend to produce a susceptible and excitable state of the nervous ■ystem, that constitutes the first link in the chain of hya- 21 242 HYSTERIA. terical disorders. Females thus educated are susceptible of strong emotions from the most trifling causes, and experience great pleasure or pain from trivial amuse- ments or petty annoyances. The nervous system is thus kept perpetually in excitement, and is very easily disordered. A little additional irritation from disorder in some other part of the system, or mental emotion, may so disturb it as to produce an attack of hysteria. Pathology. — Morbid anatomy has thrown no positive light upon this disease. It has shown however, that it does not usually consist in organic lesion appreciable by our senses. Sir Benjamin C. Brodie, in his valuable Lectures Illus- trative of certain Local Nervous affections, observes, " I have in several instances examined the parts to which hysterical pains had been referred ; and in one very aggravated case of the kind I made a careful dissection of all the nerves by which they were supplied, but I have never been able to discover in them any thing different from what belonged to their natural condition. But every part of the body has its corresponding point in the brain, and a greater number of them have their corres- ponding points in the spinal chord also. Does the exam- ination of these organs lead to any more satisfactory result ? The best proof that it does not do so, is fur- nished by the following circumstance ; although so many die of other diseases, who have suffered from hysteria also, and the opportunities of examining the bodies of hysterical patients after death, are therefore sufficiently numerous, yet the works of the best morbid anatomists contain no observations whatever on the subject. I have had the opportunity of instituting post mortem examina- tions in three cases, in which the hysterical affections were of so aggravated a kind as to be directly or indi- HYSTERIA. 243 rectly, the cause of death; and you shall know the result. In one of them the patient labored under a very severe hysterical pain in the side, and was liable, among various other hysterical symptoms, to fits, in which she was scarcely conscious of her own actions. It must have been in one of these attacks that a great number of needles were introduced into one of her legs, which after- wards occasioned much inflammation and effusion of serum into the cellular texture. The patient died, and the body was most carefully examined, but no morbid appearances of any kind could be discovered in it, except what belonged to the oedematous state of the leg. An- other case is one to which I have referred already, in which the patient having long labored under an hyster- ical retention of urine, the bladder was found enormously distended, of a black color, the mucous membrane and muscular tunic being at the same time much attenuated. This patient was an unmarried female twenty-nine years of age. Having been previously indisposed for a consid- erable time, she was supposed to have sprained her wrist in lifting a heavy sauce-pan. From this time she was never free from pain, in the situation of the outer part of the lower extremity of the radius. The pain extended up the fore-arm, and downwards on the side. In November, 1814, about a month after the occurrence of the accident, she was admitted into the hospital. At this time the most careful examination could detect no alteration in the appearance of the limb, but she com- plained of a constant and intense pain, which extended from the supposed seat of the injury downwards to the fingers, upwards to the shoulder, and again downwards to the spine and sternum. She had great oppression and difficulty of respiration, occasional twitches of the mus- cles of the face, and any sudden motion of the hand ag- gravated all these symptoms, and then threw her into 244 HYSTERIA. a state approaching to that of syncope; in which she was almost unconscious of all that happened, lying with her eyes wide open, and at last recovering with an hys- terical sobbing. Her pulse was feeble, beating 120 times in a minute. Forty ounces of urine were drawn off from the bladder, but without any relief as to the other symptoms. The tongue became black and dry; the pulse more feeble; the belly tympanitic; the alvine evacuations being of a dark color. Then there was hic- cough and vomiting: she became weaker and weaker, and died after the lapse of fourteen days from the time of her admission into the hospital. After death the brain and the thoracic and abdominal viscera were very care- fully examined, but no morbid appearances were discov- ered in anyone of them, with the exception of the peculiar condition of the bladder, which wTas described formerly, and two ulcers of the mucous membrane of the ileum, each not more than half an inch in length, but occupy- ing almost the entire circumference of the intestine. The female, who was the subject of the third case had labored under a paralytic affection of the lower limbs {paraplegia), which Dr. Seymour believed, with good reason, to be connected with, and the consequence of, hysteria. A practitioner whom she consulted, however, thought it advisable to have recourse to repeated blood- letting and other methods of depletion. The result was, the formation of extensive sloughs of the nates and of the soft parts covering the ankles. The patient was now admitted into the hospital, in a state of great exhaustion, and soon afterwards died. The brain and spinal chord were most carefully examined, in the presence of many of you who are now present, but it could not be discov- ered that they differed, in the smallest degree, from their natural condition; nor were there any signs of dis* ease in the thoracic or abdominal viscera," HYSTERIA. 245 Some have placed the seat of this disease in the uterus. This is the most ancient opinion, and is embraced by some of the most distinguished of the moderns, though as it appears to me, on very insufficient evidence. The opinions of the ancients on this subject were founded upon extreme ignorance, or rather upon an entire mis- take as to the situation of the uterus. This is evident by the following quotation. " The uterus," says Aretaeus, " greatly resembles an animal. It moves itself to vari- ous parts of the body, sometimes upwards to the throat, then to the sides, oppressing the lungs, the heart, the dia- phragm, the liver, and the intestines. It is an animal within an animal, and is constantly wandering. It loves good odors and approaches them, but dislikes bad odors and flies from them." Their practice conformed to their theory, thus they applied pleasant perfumes to the pubes, and assafoetida &c. to the throat. They also equalled any of the moderns in attributing innumerable evils to the womb. Democritus in writing to Hippocrates says that " the womb is the origin of six hundred evils and innumerable calamities." Sydenham attributed hysteria to an " irregular flow of the animal spirits," but the majority of writers on this disease, have, I believe, considered uterine disturbance as its cause. Mr. Tate says that, " all the varieties of hysteria have one common cause, which is essential to its appearance ; namely, an irregular or defective men- struation." Some place the seat of it, rather vaguely, in the ner- vous system, while others as M. Georget, consider it a disorder of the brain. I am inclined to believe this opin- ion correct. The most inveterate case of hysteria I have ever witnessed was that of a young lady who was free from the disease until after a severe injury of her head by a fall. Her mother and sisters were never hysterical 21» 246 HYSTERIA. What physician but often sees disease of the uterus without any hysterical symptoms. We also see very hysterical females go through gestation and delivery as safely and in the same manner as females who are not subject to the disease. These facts daily noticed by phy- sicians, seem to be wholly irreconcilable with the idea, that disorder of the uterus is the cause of hysteria. Its exciting causes confirm me in the belief that the brain is the seat of the disease. Excitement of the feel- ings, disturbance of the affections, and a great variety of mental emotions produce an attack. The sight of a person in a paroxysm of hysteria some- times causes another to be similarly affected. In the Northern States it is very common in the winter for the young people of both sexes to assemble in large numbers for sleigh-riding. On one such occasion, when a large party had stopped at a public house and partaken of wine and other refreshments, a young lady was attacked with hysteria, and soon a majority of the females present were similarly affected. But why are females more liable to hysterical com- plaints than men? Because they have from nature a more delicate and susceptible brain and nervous system, a nervous system which I apprehend is not only more excitable, but endowed with sensibilities to which men are strangers. It is owing to this, to a difference in the brain and nervous system that gives to the female a greater intensity of emotions, more variable desires, quicker apprehension, and a more kindling imagination. The duties of a mother are so peculiar, requiring patient, long-enduring self-immolation in the discharge of them, that a nervous system different from that of man as to instincts and sensations is requisite. This delicate and susceptible nervous system of the female is easily disor- dered, especially by mental emotions. Hence anger, HYSTERIA. 247 terror, grief, jealousy, remorse, unfortunate love and prostrated hopes, by disordering this system produce hys- teria. The same emotions also derange the uterine functions not unfrequently. So strong impressions on the organs of sense, irritation of the alimentary canal, &c, may produce an hysterical paroxysm in a female by arousing into morbid action her very excitable nervous system. Prevention. — Methods of prevention are obvious, consisting in attention to the physical education of girls. On this subject I would say to parents, using for the most part the language of another, — Let your first care be to give your little girls a good physical education. Let their early years be passed, if possible, in the coun- try, gathering flowers in the fields, and partaking of all the free exercises in which they delight. When they grow older do not condemn them to sit eight listless hours a day over their books, their work, their maps, and their music. Half the number of hours, will in every respect, both as to mental and bodily improve- ment be the better for them. Let them partake of every active exercise not absolutely unfeminine. Let them rise early, and retire early to rest. Let them ride, walk, run, dance, in the open air. Encourage the merry ar,d innocent diversions in which the young delight; let them under proper guidance, explore every hill and valley; let them plant and cultivate the garden, and make hay when the summer sun shines, and surmount all dread of a shower of rain or of boisterous wind ; and above all, let them take no medicine, cordials, essences, except when the physician orders them. The demons of hysteria and melancholy might hover over a group of young ladies so brought up; but they would not find one of them upon whom they could exercise their power. Such advice, 248 HYSTERIA. to the parents and guardians of young girls, I deem it the duty of physicians to give, and to strongly remonstrate against the adoption of a different course. Treatment. — No disease is deserving of more careful study than hysteria, as some of its varieties similate other diseases of a grave character, and without careful inves- tigation, very erroneous practice may be adopted. The exciting cause should be sought for and removed. This often consists of intestinal or uterine derangement, which should be remedied, and then the whole system should be strengthened by tonics and exercise. During an attack the treatment should vary according to its intensity and exciting cause. Sometimes it is neces- sary to bleed freely to prevent sanguineous congestion in the head. This is very proper treatment in young females who are atacked by hysteria in consequence of the suppression of the catamenial discharge. Emetics are indicated if there are symptoms of gastric irritation such as retching and pain of the stomach. Stimulating enema particularly of turpentine, are often beneficial, and in all cases, a torpid state of the bowels should be avoided. When mental emotions cause the attack, laud- anum and sulphuric ether will usually relieve. Asafoet- ida, musk, castor, and valerian are also useful. After the removal of the local irritation and the sys- tem remains in an irritable and feeble state, then tonics, particularly the preparations of iron, nourishing diet, gentle exercise in the open air, pleasing occupations and agreeable society are useful. It should however ever be borne in mind that hysteria and many nervous diseases are increased by notice, and neglect is often the best remedy. Sometimes the return of a paroxysm is prevented by the fear of the remedy that is to be resorted to. Dr. Armstrong cured a young lady, or prevented a TETANUS. 249 recurrance of a paroxysm, by ordering her feet to be burned by a hot poker whenever a fit occurred. TETANUS. This alarming disease consists in violent spasms of the voluntary muscles while the mind remams unaffected. It has long been divided into idiopathic and traumatic — idiopathic when it arises from various general causes, as from cold, from sleeping in the open air, and from narcotic poisons. It also occurs in the course of other diseases, as in the latter stages of fever. It is called traumatic when it arises from injuries, wounds, burns, &c. M. Hall, divides the disease into central an 1 centripetal, the former, produced by disease within the spinal canal, the latter by wounds, or other injuries. I refer the reader to other works on Tetanus, partic- ularly to that of Curling, for a full detail of the symptoms and progress of this disease, though 1 wish to remark here what has not been noticed by many writers on Tetanus, that in some cases the most violent spasms produce no pain whatever. The following is a recent case of the kind. Case LX. — Edmund Avery, aged 18, while assisting in repairing a house, August 22nd., had one of his legs crushed by the falling of a part of the building. The tibia and fibula of his left leg, were fractured about midway between the ankle and knee. The bones at the place of fracture did not protrude, but there was a severe lacerated wound above the outer ankle which ex- posed the fibula, and another severe wound below the ankle. Sixty drops of laudanum were administered and after the limb was dressed he had but little pain and no 250 TETANUS. spasms during the night. The next day the pulse being full he was bled eighteen ounces. The fifth day the wounds began to discharge and appeared to be doing very well. He continued to improve, complained of but little pain, and had no spasms until the 2nd of Septem- ber, eleven days after the injury. On the morning of that day, after dressing the wound, which discharged freely, and appeared to be healing, he observed that he had taken cold he thought, as he had some soreness and stiffness of the throat. Tetanus was immediately sus- pected, though no symptoms were observed indicating any change or danger, excepting slight stiffness and soreness of the throat, which the patient attributed to a cold. Sixty drops of laudanum were administered, and soon after 100 drops by enema. Cupping along the spine was resorted to and blisters applied. The next day he was not able to open his jaws more than half an inch, the pulse was rapid, he was in profuse perspiration and complained of pain at the sternum. Spasms had become frequent, the diseased limb was drawn up and distorted; the other limbs and the muscles of his back were also affected by spasms, but throughout the whole of them he declared they were not painful, and just before he ex- pired observed that he should recover if he could get the phlegm from his throat. Opium and calomel were freely administered so long as he was able to swallow, and laudanum was given in enemas. He expired on the fourth day after the first appearance of the Tetanic symptoms. I consider this case unusual from the ab- sence of pain, and from the healthy apperance and free discharge of the wound even until his death. I exam- ined the leg and the wounds very carefully, but could find nothing unusual or that appeared to have given rise to the disease. The muscles, ligaments and nerves were TETANUS. 251 not inflamed, but on the contrary appeared rather more full and flaccid than natural. I witnessed a fatal case of Hydrophobia a few years since in this city, and the symptoms very closely resembled those of the case described. The case of hydrophobia was caused by a wound in the back of the hand from the teeth of a dog. The symptoms of hy- drophobia appeared in about two weeks, and the person died in three days. He was able to swallow, though not without extreme difficulty, and not without slight con- vulsions. Avery, sw allowed also with difficulty even the mildest liquids and those at all irritating he could not. The same dog, immediately, after having bitten the per- son alluded to, bit another in the thigh, producing a large ragged wound which however healed kindly and the gentleman has since enjoyed good health. The dog was killed soon after having thus attacked these individ- uals, but the same day he had bitten two other dogs, both of which afterwards sickened and died of hydrophobia. The symptoms they manifested were quite different. One ate and drank well throughout his sickness, though he had paroxysms of violent mania and convulsions, in one of which he died. When the paroxysms ceased, he appeared, well and his eyes natural. I examined his stomach, throat and brain. There was no inflammation in either or other marks of disease : but the stomach was crowded and distended with rags, wool, grass, straw, and balls of the hard manure of other animals. The other dog would not swallow and seemed perpet- ually mad and disposed to bite. He appeared to be in constant agony. His eyes were blood-shot. On exam- ining his body after death, the mucous membrane of the fauces and glottis was found inflamed, the brain and its membranes highly injected with blood, and there was some effusion of serum into the ventricles and between 252 TETANUS. the membranes. His stomach was natural. I regret that I was not able to examine the spinal marrow in any of the cases to which I have referred. This is about all 1 know of hydrophobia from personal observation. The only case I have ever witnessed, had I not known to have arisen from the bite of a dog supposed to be mad, I should have called a case of Tetanus, and not an un- common one. Pathology. — Inflammation of the spinal marrow, or its membranes are supposed by many of the most distin- guished pathologists, to give rise to tetanus. Certain it is, that inflammation of one or both of these structures has been observed after tetanus in numerous cases. Baron Larrey states that in the numerous inspections of the bodies of the soldiers who died of tetanus in the hos- pitals of Louvain after the battle of Waterloo, he contin- ually noticed traces of inflammation in the spinal cord, with serous effusion more or less of a reddish color within the sheath. Armstrong mentions a case produced by the odontoid process pressing on the spinal cord. In a case in the Massachusetts hospital there was softening of the spinal cord. Billard (Treatise on the Diseases of Infants,) says, he has seen but two cases of this disease in young infants, and that " on dissection he found nothing more than an effusion of a quantity of coagulated blood in the spine. The blood was effused between the two laminae of the tunica arachnoidea, and filled the whole of the medullary canal from the medulla oblongata to the sacral region." In the London Medical Gazette, for 1838, is a case in which only one half of the body was aff'eetea bv ieianus„ Extreme soreness of the skin was the first symptom of disease. It was cured by leeches over the spine. Numerous other instances might be referred to, showing TETANUS. 253 that disease of the spinal cord is very frequently found after death from tetanus, and this view of the disease ought to have much influence in its treatment. Curling, thinks tetanus consists in a peculiar morbid action in the tractus motorius, the intimate nature of which is alto- gether beyond our comprehension. In some cases no inflammation or other disease of the spinal cord has been observed after careful examination; and again the spinal cord has been found inflamed with- out symptoms of tetanus. It appears to me, however, that the disease is always dependent upon irritation, if not actual organic disease of the medulla spinalis, and is well explained by M. Hall's theory of the independent functions of this organ. Treatment. — When Tetanus arises from the partial division of nerves, the complete division of them will Eometimes immediately arrest the disease. I have seen this in one case relieve the most violent spasms. But in such cases the disease is not fully established ; when it is, it is seldom cured. General bleeding is rarely necessary. I have in sev- eral cases seen it resorted to, but never with benefit, and I have known Tetanus occur after injuries accompanied by profuse hemorrhage. Tonics and stimulants have sometimes proved beneficial. Dr. Hosack cured several cases of traumatic Tetanus by the liberal use of wine. In one case he administered three gallons in the course of three days, and the patient recovered. In all his cases the tetanic symptoms appeared immediately or shortly after the injury. General Moreau informed Dr. Hosack, that lock-jaw was of rare occurrence in an army when they first took the field, but that it was produced by the slightest wounds when the soldiers had become 22 254 TETANUS. fatigued and debilitated by long marches and frequent battles. The treatment should vary with the exciting cause, state of the pulse, duration of the disease. &c. 1 should commence the treatment by giving croton oil to move the bowels, and if the pulse was not feeble, should apply leeches and cups along the spine, then blisters or the actual cautery, to the spinal region, and administer opium freely by the mouth, and by enemas. If debility and feebleness of pulse 1 should give wine. In some cases, amputation of the wounded limb has saved the patient, but generally it has proved unsuccessful. The same may be said of mercury. Colcliicum I should think might be serviceable. In India they seem to have been quite successful in curing traumatic Tetanus. An anonymous writer in the London Medical Repository, vol ix, p. 300, says, " It is pretty generally known,*that in the symptomatic Tetanus from wounds which occur in the East Indies, about one in four recover; and the usual practice which is followed there, is the iise of mer- cury, both internally and locally, with the exhibition of large quantities of opium, spirits, or wine. S.>me have found the warm bath useful; and in the hands of others, the effusion of water of the temperature of the surround- ing atmosphere (which is about 80 deg. of Fahrenheit) has proved a powerful auxiliary in the treatment of the disease. It generally proves fatal before the seventh day. At first, the spasmodic affection is generally confined to the parts immediately above the wound ; but the whole side of the body is soon afterwards thrown into violent spasmodic contractions ; and if a tournaquet or tight ligature is placed above the wounded part, so as to compress the nerves, the spasms will be relieved, and very generally prevented recurring. This measure is fre- CHOREA--ST. VITUS'S DANCE. 255 quently of great use in enabling the patient to take a little sustenance, or to swallow his medicine." CHOREA--ST. VITUS'S DANCE.* This disease is characterised by irregular twitchings and involuntary contractions of various muscles of the body. It is a kind of muscular insanity, by which the limbs are irresistibly moved in various directions. It is often preceded by dyspeptic symptoms, pain of the stomach, flatulence, constipation, and tumid bowels. Sometimes vertigo, slight tremors, and illusions of sight occur, before the movements of the muscles are noticed. * " Chorus Sancti Viti, or St. Vitus's dance ; the lascivious dance Paracelsus calls it, because they that are taken with it, can do nothing but dance till they be dead, or cured. It is so called for that the par- ties so troubled were wont to go to St. Vitus's Chapels for help ; and, after they had dinced there awhile, they were certainly freed. 'Tis strange to hear how long they will dance, and in what manner, over stools, forms, tables ; ev,n great bellied women sometimes (and yet never hurt their children) wil. dance so long that they can stir neither hand nor foot, but scum to be quite dead. One in red clothes they cannot abide. Music above all they love; and therefore magistrates in Germany will hire musicians to play to them, and some lusty, sturdy companions to dance with them. This disease hath been very common in Germany, as appears by those relations of Schenkius, and Paracel- sus in his book of madn -ss, who brags how many several persons he hath cured of it. Folix Platerus {de Mentis Alienat. cap. 3.) reports of a woman in Basle whom he saw. that danced a whole month together. The Arabians call it a kind of palsie. Bodine, in his fifth book, de Repub. cap. 1., speaks of this infirmity; Monavius, in his last epistle to Scoltizius, and in another to Dudithus, where you may read more of it." — Burton's Anatomy of Melancholy, Vol. 1. " He, St. Vitus, was a Sicilian youth who, together with Modestus and Crescentia, suffered martyrdom at the time of the persecution of the christians, under Diocletian, in the year 333. The Legends respecting 256 CHOREA--ST. VITUS'S DANCE. In some cases the convulsive action of the muscles is slight, and confined to the face or to one side of the body, but not unfrequently they increase to such a degree as to prevent patients from walking, and from dressing or feeding themselves. A slight derangement or feebleness of the intellectual faculties is often noticed. It is usually unattended by fever, and in many cases no complaint is made of pain. In some cases there is pain of the head. It is sometimes connected with Epilepsy and Insanity, and sometimes terminates in these diseases. It bears a great resemblance to Hysteria and Epilepsy. The dis- ease is mostly confined to youth, and to those between the ages of eight and twenty, and who are of a nervous temperament. him are obscure, and he would certainly have been passed over without notice among the innumerable apocryphal martyrs of the first centu- ries, had not the transfer of his body to St. Denys, and thence, in tha year 836, to Corvey, raised him to a higher rank. From this time forth, it may be supposed that many miracles were manifested at his new sepulchre, which were of essential service in confirming the Ro- man faith among the Germans, and St. Vitus was ranked among tha fourteen saintly helpers (Nothhelfer or Apotbeker). His altars were multiplied, and the people had recourse to them in all kinds of dis. tresses, and revered him as a powerful intercessor. As the worship of these saints was however at that time stripped of all historical connec tions, which were purposely obliterated by the priesthood, a legend was invented at the beginning of the fifteenth century, or perhaps even so early as the fourteenth, that St. Vjtus had, just before he bent his neck to the sword, prayed to God that he might protect from the dancing mania all those who should solemnize the day of his commemoration, and fast upon its eve, and that thereupon a voice from heaven was heard, saying, " Vitus, tiiy prayer is accepted." Thus St. Vitus be- came the patron saint of those afflicted with the dancing plague, as St. Martin, of Tours, was at one time the succourer of persons in small-pox; St. Antonius of 'those suffering under the hellish fire,' and as St. Mar- garet was the Juno Lucina of puerperal women," —Hecker's Epidemica of the middle ages. CHOREA--ST. VITUS'S DANCE. 257 Causes. — The opinion of Dr. Hamilton that Chorea usually arises from the irritation of fecu'ent matter in the bowels is generally considered incorrect. It is said worms have produced it, and no doubt it does sometimes arise from intestinal irritation. It has been caused by falls on the head, and wounds penetrating the brain, also by fright, jealousy, anger, and other strong mental emo- tions. Females and youth, and those of a nervous tempera- ment are most subject to this disease. It is also hereditary. Repel'ed cutaneous eruptions, and the suppression of hab- itual discharges sometimes excites this disease. Dent'tion and parturition occasionally cause it, also onanism, and the retention or suppression of the menses. Sometimes it arises from the extension of other diseases of the ner- vous system, as epilepsy, hysteria, and mental alienation. Pathology. — Few die of this disease, hence but little light has heen thrown upon it, by post mortem examina- tions. When we notice the most characteristic symptoms of Chorea, arc, inability to combine^and regulate the motions essential to walking, standing, &c, and then call to mind that the researches of Rolando, Flourens, Bouillaud and Magendie, show that this power belongs to the cerebel- lum, we shall be lead to consider this organ the seat of the disease. I am disposed to believe this view of Chorea to be correct, though, no doubt, other portions of the ner- vous system, the cerebrum, the medulla oblongata and medulla spinalis are sometimes implicated, though I ap- prehend in such instances Chorea would not result, unless the functions of the cerebellum were disturbed. Serres found in one case the tubercula quadri- gemina inflamed. Dr. Armstrong alludes to a case in 22* 258 CHOREA--ST. VITUS'S DANCE. which increased vascularity of the spinal cord was ob- served. Not unfrequently the region of the cerebellum is the saat of pain, especially during the greatest violence of the disease. Boutelle refers to such instances. The same author states that he has known the disease to arise from falls on the head. The occipital region has been found hotter than natural in Chorea. In the 15th volume of tli3 Lancet is a cas3 of a girl who menstruated a little at six years of age, and fully when eight. The mammae were also developed at this age. This girl had no power to control the action of the voluntary muscles, and on examination the occipital region over the cer- ebellum was found to be very perceptibly hotter than natural. Other methods of treatment having proved unavailing, she was leeched over the cerebellar region, and had cold water applied to that part. Thi3 course arrested the spasmodic action of the mus- cles and stopped the menses for eight months, when both returned, and were again cured by the same means. In support of the opinion that the cerebellum is the seat of Chorea, it should be recollected that the disease occurs about the time of puberty, when there is supposed to be increased activity^ and rapid enlargement of this organ. In the 25th volume of the Medico Chirurgical Review, is an account of a fatal case of Chorea, in which, on careful examination of every part of the system but the spine, nothing unusual was discovered, except two small spicula of bone, one from the orbital plate of the frontal bone, the other from the sphenoid, a quarter of an inch in length. Dr. Stiebel, a late German writer on Chorea, who has had much experience in this disease, believes it arises from an irritation of the motor nerves of the spinal mar- row, or of the medullm oblongata, depending on inflamma- CHOREA--ST. VITUS'S DANCE. 259 tion or turgescence. He has usually found, some one of the vertebra? painful. Treatment. If there is pain of the head, or if it is unnaturally hot, or if there is tenderness or pain of any part of the spine, leeches and blisters should be applied to the back of the neck and along the spine. I usually apply blisters to the back of the neck, even if there is no pain of the head, and believe I have seen much benefit result from this practice. If disorder of the bowels or menstrual disturbance, the usual remedies for such com- plaints should be had recourse to, and then tonics and narcotics will usually effect a cure. The preparations of iron, especially the carbonate, are useful. Arsenic has sometimes arrested the disease after the failure of other remedies. Showering with cold water, or plung- ing the patient for an instant in cold water, has proved beneficial. Tiiis practice is recommended by Dupuy- tren. Antispasmodic and narcotic medicines are often neces- sary. Conium, stramonium, and morphine, particularly the latter, I have known highly serviceable. As mental emotion aggravates the disease, the utmost pains should be taken to preserve a quiet and cheerful state of mind. Nothing should be said to those afflicted with this disease respecting their involuntary motions, and their attention should be directed from them,as much as possible. Chorea uncomplicated with other disease, I believe, never proves fatal. Dr. Stiebel's course of treatment consists in leeches and blisters along the spine, and calomel given as a de- rivative. If not soon relieved by this course, he showers the back with cold water. He states that the disease is generally cured by this treatment between the four- teenth and twenty-first day, but should not this happen 260 DELIRIUM TREMENS. it may be left to nature, which almost always perfects the cure. The. preparations of iron he has sometimes found useful, but he appears to believe that many inert and useless medicines have acquired a reputation in the treatment of Chorea, merely from having been adminis- tered, at the time, nature was affecting a cure. DELIRIUM TREMENS. It is very singular, that this, now common disease, was almost wholly overlooked or not known as a distinct dis- ease, until within the last forty years. Unquestionably it is now vastly more frequent than in form:;r times, still it is not probable, that no cases occured before the time mentioned. They were confounded with phrenzy. The January number of the Medico Chirurgical Re- view, for 1839, contains three cases of this disease, taken from the works of Stoll. These cases occurred in 1773» and are detailed by him in a Chapter on the Causes and Seat of Phrenzy. The first account of this disease, thajt attracted the notice of the profession, was published in a small tract? by Samuel Burton Pearson, M. D. As it is brief, valua- ble and rare, I insert it here. " Observations on Brain Fever. By Samuel Burton Pearson, M. D. " Brain Fever. —At the earnest solicitation of several people who have been afflicted with this grievous mal- ady, 1 offer this small treatise to the public. Multifarious and repugnant theories on the science of life still continue to agitate the medical world. Galen's writings, after the extinction of literature for several ages, were a<*ain revived, and produced innumerable controversies. The DELIRIUM TREMENS. 261 accrimonious opposition of the Galenists and Arabians, and the complete overthrow of the latter, are well known to every reader. The chemists attacked the Galenists with fury, and they sustained a defeat. Different sects have originated from Stahl, Hoffman, Boerhaave, Cullen, and Brown. A medical review will convince any one how the faculty worry each other at the present day, about their differe.it dogmas, with much injury to them- selves and patients. For the above reasons I disavow all theory, and briefly state the circumstances as they occurred to me at the patient's bed side. Out of ninety- three cases that have been treated by the principles here adopted, not one has fallen a victim to the disorder; but, when a contrary mode has been attempted, few have recovered, and those only whose constitutions were sufficiently vigorous to resist its ravages. " I have called it Brain Fever, because it is universally known in Newcastle and its vicinity by that term. The same observation extends to putrid fever. Cause. — Frequent and excessive intoxication. Description.— It is preceded by tremors of the hands; restlessness; irregularity of thought; deficiency of mem- ory ; anxiety to be in company; dreadful nocturnal dreams, when the quantity of liquor through the day has been insufficient; much diminution of appetite, especially an aversion to animal food ; violent vomiting in the morn- ing ; and excessive perspiration from trivial causes. The above symptoms increase ; the pulse becomes small and rapid, the skin hot and dry ; but soon a clammy sweat bedews the whole surface of the body; confusion of thought arises to such a height, that objects are seen of the most hideous forms, and in positions that it is physi- cally impossible they can be situated ; the patient gen- erally sees flies or other insects, or pieces of money, winch he anxiously desires to possess; and often occu- 262 DELIRIUM TREMENS. pies much time in conversations of negotiation, if he be a commercial man. Often, for many days and nights, he will continue without rest, notwithstanding every effort is made on tha part of the physician to appease his mind by variety of conversation, and variety of stimuli. He frequently jumps suddenly out of bed in pursuit of a phantom, and holds the most ineffable contempt for the practitioner, if he do not concur in his proceedings. He commonly retains the most pertinacious opinion that he is not in his own house, and that some of his dearest rela- tions have sustained a serious injury. During the con- course of these symptoms, he often can answer medical questions properly for a short space of time, and then relapses into the raving state. Distinction. — It is distinguished from putrid fever, in never being contagious, or having purple spots; or ever having a cadaverous smell; or ever being received from human effluvia; and in the delirium being much more impetuous. It is distinguished from inflammation of the brain and its membranes, by not having so vehement a fever; or redness and turgescense of the eye and face; or impatience of light or noise; or hard pulse ; and by opposite causes, and opposite method of cure. Method of Cure.—A full dose of opium should be immediately administered in a glass of wine, and repeated in smaller doses for several hours successively ; the quantity of which should be regulated by the constitu- tion of the patient, habit of intoxication, degree of the disease, and other concomitant circumstances. The pa- tient, if he eagerly request it, may be allowed to walk from room to room, and the most consoling language should be used by his attendants. The debility of the system should be resisted by sherry grueL cold wine, and porter and soup ; which may be given in sufficient quan- tity, as the stomach, in this complaint, is very tenacious DELIRIUM TREMENS. 263 of what it receives. I never saw the bark, blistering, or effusion of cold water on the head, of any use. Every unnecessary restraint should be carefully avoided ; there- fore the strait-jacket, which is so universally employed, is the most injurious remedy that can be applied ; for, by the perpetual efforts the patient uses to rid himself from confinement, he excites profuse sweating, debilitates the muscular fibre, and soon exhausts the vital principle. If the above mode of treatment be successful, or at least affords the unhappy sufferer a chance of recovery ; the impoverishing the system by bleeding, strait-jacket, or abstinence from invigorating remedies and diet, must be extremely mischievous. Newcastle upon Tyne, July, 1801." This tract had but a limited circulation, confined chiefly to the friends and acquaintance of Dr. Pearson. He called it Brain Fever as it was generally known by that name in his neighborhood. Twelve years after this, in 1813, Dr. Armstrong, published in the Edinburgh Medical and Surgical Journal, two articles upon this dis- ease, which he denominated Brain Fever from intoxica- tion. He refers to the small tract of Dr. Pearson, and says, to tint '• he was first indebted for any thing like an accurate description of the disease." The same year Dr. Thomas Sutton, of London, pub- lished " Tracts " on the same disease, which he denom- inated ''.Delirium Tremens." It is qu te evident from the perusal of these early pub- lications on this disease, that it was well known at that time to the medical profession, but had not been de- scribed, as a distinct disease, or a disease arising from the use of intox eating liquor. The symptoms are well described by Dr. Pearson, also its cause, '• frequent and excessive intoxication." But, 264 DELIRIUM TREMENS. the long and habitual use of alcoholic liquors, without causing what is called intoxication, will produce it. I have seen several such cases. I have known individuals who exhibited the symptoms of Delirium Tremens, and on inquiry of some of their friends and associates, have been surprised to find them ignorant of the fact, that the individuals affected, made use of alcoh lie drink. On further inquiry, however, of servants, grocers or near- est relatives, I ascertained they had, lor a considera- ble time, used such liquors, but not so as to produce intoxication. It has been said that the use of opium, and other nar- cotics causes delirium tremens ; but this disease arises so very rarely from any other cause than the use of intoxi- cating liquor, that this may,w7ith propriety, be considered almost the sole cause. I have never seen a case pro- duced by any thing else, but a medical friend has assured me, that he once saw a genuine case from the use of opium. He was not certain. howrever, but the patient was in the habit of washing down the opium, with a little alcoholic drink. The disease sometimes, though rarely, arises from the use of only a small quantity of intoxica- ting liquor Dr. Sutton relates the cafe of a lady who had the delirium tremens, in consequence of the daily use of the Tincture of Lavender. According to my observation, the disease seldom attacks a person while in the use of intoxicating drink. It supervenes usually, after some slight ill;;ess, that has caused the relinquishment of the accustomed stimulus. A slight attack of pneumonia often precedes the delir- ium. The latter comes on after the patient is conva- lescent from the affection of the lungs. Sometimes, however, the disease appears to be the immediate consequence of intoxication. Individuals have gone to sleep deeply intoxicated, and waked up DELIRIUM TREMENS. 265 with delirium tremens. I have seen two cases that oc- curred without any relinquishment of spirituous liquor. Such cases I believe, are in someYespects different from those that occur after the usual stimulus has been with- held for several days. They yield less readily to opiates, and bear depletion better. Some even require bleeding. One of the patients thus attacked, was much benefitted by bleeding. Mental shock, has, I believe, considerable agency in causing this disease. A man was arrested for the crime of theft. He ap- peared at the trial to be in good health, until his daughter, the only positive evidence of his guilt, testified against him. Instantly his countenance changed, he trembled excessively, soon became delirious, and manifested the usual symptoms of delirium tremens for thirty-six hours, when he died. He was not considered an intemperate man, and was never known to be intoxicated, though he made use of spirituous liquor. I think the disease is sometimes caused by apprehension of it. A person who uses intoxicating drink to excess becomes fearful of an attack of delirium tremens, when-, ever he is affected with any disorder of the system. This fear prevents sleep. In this way, I am confident, I have seen two cases occur. Pathology. — I have examined with great care the bodies of five men who died of delirium tremens. In all these cases there was effusion of serum between the membranes of the brain, and the tunica arachnoidea was highly injected. This was more particularly true about the decussation of the optic nerves, and also in the cer- ebellum. The cerebellum in three cases seemed to be harder than natural and the corpus dentatum unusually 23 266 DELIRIUM TREMENS. soft and partially disorganized. Neither case exhibited disease of the stomach. Treatment.—From the success which attended the practice of Dr. Pearson, already quoted, it is evident that the course recommended by him is not a bad one. I have always relied upon opium, and have been so generally successful, that I cannot with propriety recommend any other course. I have however uniformly avoided a cos- tive state of the bowels and often combined calomel with the opium. I usually commence the treatment with small doses of calomel with two or three grains of opium given every two hours. If this does not produce sleep after four or five doses have been taken, I generally move the bowels, and then repeat the opium. I have given half an ounce of laudanum at a dose and with apparent benefit. The worst cases have been cured solely by opium. There may however be cases where opium would be useless or improper, and depiction necessary. I deemed bleeding necessary in one case, that of a young man of full habit and strong pulse, and in whom the disease oc- curred without any abandonment of intoxicating drink. The bleeding mitigated the violence of the delirium, but did not entirely overcome it. Opium however did. The bleeding I deemed necessary to prevent apoplexy or dis- organization of the brain. I have in several cases administered emetics, and seen them given by others, but have never witnessed much if any benefit from them. I have recently seen a case prove fatal in which emetics had been given. A long walk appears to benefit some patients. A man in this town broke from his keepers in the night and wandered about the town for several hours__the next NEURALGIA.--TIC DOLOUREUX. 267 morning he was tranquil, slept and recovered. A med- ical friend has cured by inducing strangury. I have seen one case that recovered without the use of any medicine. The patient for the most part was suffered to walk about accompanied by attendants. After three days of excitement, talking and travelling, he went to sleep and recovered. NEURALGIA.--TIC DOLOUREUX. An acute darting pain in the course of some of the nerves, occurring in paroxysms, produced by the slight- est touch, and without general fever, characterises this disease. Its history is interesting and instructive. Though it is now one of the most common diseases, yet the first pub- lished account we find of it, is that of M. Andre of Ver- sailles in 1756. Seventeen years after this, (1773) Dr. Fothergill communicated to the London Medical Society some remarks on this disease, to which he gave the name of " a painful affection of the face." Fothergill was not aware that any one had described it before himself; and in fact, the credit of making known the disease to the medical world, is due to him, as he it was, who first described it with such accuracy, as to enable others to recognise it, as a distinct disease. Though this painful disease is now so common in this country, that there are few physicians who have not seen many cases of it, yet it seems it was scarcely known here, thirty years ago. How is this to be accounted for ? Evidence of its being quite a recent disease in this coun- try, is as follows. In 1806 Dr. Gardner Jones, a respect- able physician in New York, was attacked by Tic Doloureux of the face. In 1809, he wrote an account of 268 NEURALGIA.--TIC DOLOUREUX. his sufferings to Dr. Rush, of Philadelphia, in which he says, " Of all the medical gentlemen with whom I have conversed respecting my complaint, only one has pro- fessed ever to have seen a case of the disease prior to my own ; nor can I recollect more than two who could recognise its singular features as described in any author they had read. To most practitioners, even those of eminence, the name itself is a perfect novelty. Since the attention of our physicians has been directed to this subject, one other case, but of much less asperity and poignancy than my own has been detected here." Dr. Rush recommended the use of belladonna and stramoni- um, but it is a singular fact, that neither of these, now common remedies, could be procured in New York. "I was disposed," says Dr. Jones, " to have tried them, and for this purpose took great pains to procure them, but ineffectually, as these articles were not to be found with the druggists or apothecaries, being seldom used in the practice of our physicians."* The disease has also greatly increased within a few years in other countries, " this distressing disease," says Dr. James Johnson, " becomes more common every day, and is on the increase, with a host of other nervous affections." Dr. Baillie observes, " that it has become more common of late years." The exciting causes of Neuralgia, are various. Ex- posure to wet and cold is the most common. Malaria, as has been ably shown by Dr. Macculloch, frequently gives rise to it. Stretching, pressure, or other injuries of the nerves, carious teeth, disorder of the stomach, or alimentary canal, or of the uterus, and spinal irritation also cause this disease. * The Philadelphia Medical Museum, Vol. 1, New Series, 1811. NEURALGIA--TIC DOLOUREUX. 269 Pathology. — It will not be disputed that the seat of this disease is in the nervous system, but at what point, it is difficult to determine. Not always in the nerve at the place of the pain, for the disease may exist for years, without any perceptible alteration in the nerve. Sir Henry Halford, thinks that its most awful form, affecting the branches of the fifth pair of nerves, is caused by dis- eased bone. He refers to a case arising from exostosis of the alveolar process, another from disease of the antrum highmorianum, and another from a tumour on the internal surface of the skull. Other cases might be referred to, in corroboration of this opinion. A late writer, Dr. Osborne, in the Dublin Journal of Medical Sciences, Nov. 1837, attributes the disease, to a partial paralysis of a nerve, sufficient to alter its mode of sensation, but not to obliterate it. Many cases of Neuralgia arise from some local injury of a nerve ; here the cause is obvious ; but in other cases the origin and the seat of ine disease are quite obscure. I am induced to believe that in such cases, the seat of the disease is most generally in the brain. The worst cases I have ever known, or of which I have heard, those that after harrassing persons with indescribable suffering and terminating fatally, have been found connected with organic disease of the brain. A deplorable case of this kind which I witnessed arose from a tumour at the base of brain. Innumerable are the pains in various parts of the body, which patients, laboring under disease of the brain, complain of, before any affection of this organ is suspected. Such patients attribute all their sufferings to disease of the part where the pain is, or to the stomach, which is often affected by nausea. Andral mentions a case of ramollissment of the brain, going on for a consid- erable time, while the only symptom of disease, was pain in the lower extremities. 23* 270 NEURALGIA.--TIC DOLOUREUX. I do not suppose that organic lesion will always be found in the brain, in cases of Neuralgia that originate there. The disease is no doubt merely functional in many cases, or the change in that portion of the cerebral structure destined to sensibility, and which change causes the disease, may not be obvious to our senses. Many cases of Neuralgia seem to arise from a highly irritable and excitable state of the nervous system. Some of these, are attributed to slight injuries, to a sprain, or bruise, or puncture. They continue, at intervals, for a long time, reproduced and kept up, by mental emotion, perhaps by the mental attention directed to the injured part. I have known a young lady suffer severely from intermittent neuralgia, affecting one of her fingers. Any excitement of mind, or any unusual mental effort when she was free from pain, would immediately reproduce it. But often the severest pain is in a part which has received no injury Such cases must arise from disease of the nervous system at some other point, either of the brain or in the course of the nerves that supply the pain- ful part. Injury of a nerve in its course often produces pain, no where but at the extremity of the nerve. After amputations, patients complain of pain in the fingers and toes of the amputated limbs. The following is one of the most interesting and instructive cases of this kind, of which I have ever heard : — It is from Hcnnen. Case LXI. — " A general officer, of distinguished gal- lantry, was struck by a round shot during a very despe- rately fought action, which buffing along his breast in an oblique direction, destroyed the arm, and left only the head of the bone and a very small portion of the shaft remaining. He was carried to an adjoining hovel, where the common amputation was performed under very un- NEURALGIA.--TIC DOLOREAUX. 271 favorable circumstances; the night was coming on, the supply of candles was scanty, and the enemy's shot were flying in all directions. The general was placed under my care on the day after the operation. The variety of cross accidents from fever and extensive sloughing, it is not within my purpose at present to enlarge upon, but the first attempt at clearing the ligatures, and making gentle pressure on them, was attended with pain so ex- cruciating, as to leave no doubt that each included a nerve, or was in a certain degree connected with some large nervous filaments. This agonizing sensation was not felt except the ligatures were pulled at, and then not in the stump itself, but was referred to the finger, thumb, wrist, elbow, or even to the external skin of the lost arm, as one or other ligature might be handled. I have some- times been led to think, that the general uniformly felt the same sensations when the same ligature was touched, as I generally made my attempts to extricate them in a regulated succession, and his complaints were often in the same succession of parts. More attentive observation, however, convinced me that this was not the case ; for if any one was pulled with more steadiness than the other, he complained of all the parts, suffering pain simultaneously. One small ligature, if pulled in an oblique direction inwards towards the axilla, always gave him imaginary pain about the elbow or in the skin; but if the same was pulled strongly and directly doivnwards, the fingers were complained of. He has, frequently, after the smarting of dressing was over, with great accu- racy pointed out on my arm the course of the internal cutaneous nerve, as the site of his ideal pain; often he has described that of the external: and, on one occasion, I, with utter astonishment, had the general neurology of my arm and fingers traced by him. But unless the liga- tures were pulled at, he had no other uneasy sensations 272 NEURALGIA. TIC DOLOUREUX. than those which usually occur in persons whose limbs have been amputated. Once only did I ever know him refer his pain to the seat of the sensorium itself. On that occasion, from using an artery forceps to the liga- tures, on which the slide moved rather stiffly, I exerted a greater force than I had intended. He convulsively put his hand to his head, expressed a sense of exquisite pain in his brain, involuntary tears dropped from his eyes, a paralytic contraction momentarily affected his mouth, a universal paleness spread over the uncovered parts of his body ; and, although unusually tolerant of pain, and of a most remarkable equanimity of temper, he uttered a piercing cry, and exclaimed, " that the agony in his head and neck was insufferable." The state of the collapse was so great, that I was obliged to send an aid- de-camp instantly for volatile alkali, and a glass of Made- ria, by which he was soon relieved; but the painful sensation, and the prostration of his strength, continued through the day. A British admiral was present on this and various other occasions, and observed to me, after I had confessed my inability to explain, even to my own satisfaction, the cause of all these sensations, " that he never saw the general dressed without applying mentally to the wonderful sympathy manifested on those occa- sions, the expression of Pope : 'it lives along the line.'" I believe we must be content with the fact, without seek- ing for the explanation." Treatment. — Some cases, have, for a while, at least, been relieved by surgical operations ; by cutting off the nervous communication between the painful part and the brain. See Case XLVI, p. 166. I have had recourse to this method in a few cases, but without permanent benefit, and on a review of the accounts published of this plan of treatment, we do not NEURALGIA.--TIC DOLOUREUX. 273 find it often successful. Still cases occur, no doubt, in which recourse to it would be proper. Applications to the painful part quite frequently afford relief. A hot solution of Sugar of Lead and Laudanum, and very hot water applied for a considerable time to the painful nerves, I have known remove the pain entirely. A plaster of equal parts of Extract of Belladonna and Soap Cerate, sometimes has the same effect. I have seen Veratria and Aconitine used in cases of great severity. An ointment made of 20 grains of Vera- tria to an ounce of lard, for awhile, gave almost complete relief. About half a drachm was rubbed over the pain- ful part three or four times a day. Its effects were immediate and soothing. After a few days, however, it ceased to have any good effect and was discontinued. It is used for a like purpose dissolved in hot alcohol. Ten to thirty grains of Veratria to an ounce of alcohol. This is rubbed on the skin, and produces no soreness unless the skin is very irritable. It causes, however, a tingling heat, which for a while relieves the neuralgic pain. Ve- ratria is also given internally. Turnbull uses the follow- ing pill. R. Veratriae, . . . gr. ii. Pulv. Rad. Glycyrrh, . gr. xii. Ext. Hyoscyam, . . gr. vi. Make into twelve pills, one of which may be taken three times a day. If there is a tendency to Costiveness, a few grains of compound rhubarb pill, may be substitu- ted for the two last ingredients. Aconitine has also been used for this disease. A late number of the Lancet, Jan. 6th, 1838, contains a notice by the Rev. Sidney Smith, of a severe case of tic dolou- reux, of seven years' standing, which was cured for eight weeks, to the date of the report, by the use of the Aconitine ointment — one grain to a drachm of lard. 274 NEURALGIA. TIC DOLOUREUX. I have used Granville's Counter-irritant, or the strongest Liquor Ammonise, in several cases ; but in none has it afforded relief for more than half an hour. The pain in one case was aggravated by it. Constitutional remedies have with me been more use- ful. I have derived the most benefit from Carbonate of Iron in large doses ; from one to four drachms, four times a day, usually combined with pulverised cinnamon or ginger, and care being taken not to have it accumu- late in the bowels. Arsenic is often very serviceable. I consider it one of the best of remedies in this disease. I have used Fowler's Solution, but prefer the following pill, the formula of which will be found in the second volume of the Asiatic Researches. Take of recent white arsenie thirteen grains, black pepper, seventy-eight grains, beat in an iron mortar for four days at intervals, then remove to a stone mortar, and with water make one hundred pills. Dose one, two or three times a day. Peruvian Bark and Quinine are efficacious remedies in intermittent neuralgia. The Extract of Conium, in large doses, has sometimes afforded relief and effected a cure when other remedies have failed. A medical friend had this disease in its most agonizing form, chiefly affecting the lower jaw. He took large doses of opium without any mitigation of his suffering, and without producing a tendency to sleep. He then had recourse to Extract of Conium, of which he took half an ounce in the course of a night. This afforded relief and seemingly affected a cure, as he has not been troubled with it for several years. Dr. James Jackson, of Boston, cured a severe case of this disease by the same remedy. He gave in the course of six hours, sixty pills of Extract of Conium, making three hundred grains.* • The New England Journal of Medicine and Surgery, VoL 2. DYSPEPSIA. 275 M. Jolly, in the article, Nevralgie, Dictionnaire de Medicine et de Chirurgic Pratiques, recommends the following: R. Ferri. Carb. Praep., . oz. ss. Sulph. Quinine, . . grs. xvi. Opium, . . . grs. iv. Mix and divide into sixteen powders, one of which is to be given every six hours. R. Ferrocyanate of Iron, . grs. xviii. Sulph. Quinine, . . grs. xii Opium, .... grs. ii. Make into twelve pills with conserve of roses, and give one three times a day. He also recommends the following sternutory, in Neu- ralgia of the face. Red Bark, {Cinchona rubra}) and com- mon snuff, equal parts. I have used with good effect in similar cases a snuff made of one drachm of common snuff, four grains of Quinine, and a quarter of a grain of Morphine. It has already been mentioned, page 148, that Mr. Tcale supposes many cases of Neuralgia arise from irri- tation of the Spinal marrow. In such cases he states there is tenderness over some of the Vertebrae, and leech- ing and blistering afford relief. An eruption on the skin, like nettle rash, has been known to remove the pain immediately. DYSPEPSIA. In a previous work, "Remarks on the influence of Mental Cultivation and Mental Excitement upon health," I stated my opinion that " a majority of the cases of Dyspepsia, especially among students, arose from disease 276 DYSPEPSIA. of the brain and nervous system, and were perpetuated by mental excitement." Subsequent observation has confirmed me in the cor- rectness of this opinion. Dyspepsia is a disease peculiar to man and to civilized man. Why is this so ? Some say because he pampers his appetite by numerous dishes and eats too much. But other animals than man, and men in an uncivilized state, savages and barbarians, eat, especially at times, much more than men in civilized countries, yet they digest what they eat without diffi- culty. Besides it is not true, that dyspepsia is confined to those who live luxuriously, who daily eat the richest and most nutritious food and drink good wine. The worst cases occur in students, clergymen, and those who have for the most part lived on plain food. The reason why civilized man is most subject to indi- gestion, is to me obvious. Every one knows that excite- ment and anxiety of mind impairs the appetite, and hinders digestion. This mental agitation consumes, or hinders the transmission of the nervous fluid or nervous power from the brain to the stomach, that is necessary to create an appetite, and to complete digestion. The same cause prevents the proper secretion of bile, and renders the bowels torpid. It is true that a full meal sometimes produces a severe attack of dyspepsia in one thus disposed to it. It is how- ever, because the stomach, from the cause above stated, is not able to digest it. Hence, those thus inclined to dyspepsia, must pursue one of two courses in order to prevent its attacks. They must either free themselves from anxiety and care, and avoid fatiguing mental labor, or else they must live quite sparingly and on unstimulating food. If they consume the nervous -fluid or energy, in labor of the DYSPEPSIA. 277 brain, they must require but little labor of the stomach. Not only the stomach, but every part of the body be- comes disordered, when thus robbed by the brain of their due proportion of nervous power. Thus we find in such individuals, there is not enough of this nervous power to heal wounds and other injuries of the body readily. Injury of nerves, that derange or cut off the commu- nication between the brain and the parts supplied by the injured nerves, produces atrophy of these parts. Thus Lobstein, relates the case of a man, aged 54, whose right leg ceased to grow, after an injury of the crural and sciatic nerves, received when a child. When the stomach becomes deranged from the cause mentioned, other organs as the liver, lungs, uterus, skin, &c, also become disordered from what is called sympa- thy. This sympathy is not, however, direct between the organs, but takes place through the brain; for all the sympathies depend on changes in this organ. In this way, and only in this way, do the viscera sympathise, and not by means of direct nervous connexion. When the brain has been overtasked and over-excited, then these sympathetic disorders are seen to increase. Now and then we are told of an individual, whose mental labors are great and who enjoys good health. In such instances the mental labor though it would be great and fatiguing to many, is not so to the individual. His large and well proportioned brain, accomplishes with ease, what would be exhausting labor to another, just as a man of largely developed muscular powers, will accomplish without fatigue what would prove severely injurious -to one whose muscular system was small and delicate. But we daily see numerous instances of men, who have never been dyspeptic, and we also see many who 24 278 DYSPEPSIA. are almost constantly so. The first class is composed for the most part, of men of happy temperaments, men who have but little anxiety of mind, wh:> are seldom long perplexed by any occurrence. These men have a good appetite, and indulge it; they eat each meal with enjoyment, and slowly, and without a thought, or any apprehension of distress from it. The other class is made up of a very different kind of men — men who are never so free from care — the per- plexities cf business, or seme kind of mental anxiety, as to be able to eat their meals slowly and happily. Among this class are to be found many who are so fearful of sinning aga:nst some theory of which they have heard or read, about the danger of eating animal ford, puddings, pies, &c.; or of drinking coffee, tea, or a glass of wine ; or of omitting to eat bran bread and todrink cold water, that their minds are perpetually agitated before and during their meals, an 1 afterwards occupied in watching and waiting for some sensations from the stomach to enable them to determine whether the meal is injurious or not. This class of persons are sure to complain of disorder of the stomach, if they indulge in any other than the most mild food, and in small quantity. Feeling disordered after a full meal or after having eaten of seme rich food, they attribute their bad feelings to the food they have just taken, when in fact, it ought to be attributed to the brain having robbed the stomach of that nervous power essential to carry on d'gestion. I do not mean to say that Dyspepsia always originates in this way. Undoubtedly, it frequently arises from pri- mary disease of the stomach. But I mean to say that numerous cases of this disease arise from primary disor- der of the brain, which disorder is the result of mental agitation. Is it not owing to this cause that the disease DYSPEPSIA. 279 prevails among mankind and not among other animals, and that it is more common in enlightened than in unen- lightened communities ? As the disease, of itself, is seldom fatal, we do not often have an opportunity of calling to our aid post mor- tem researches, in determining its seat. There are some cases, however, of death from what was considered dys- pepsia, where examination after death tended to confirm the view we have taken of this disease. I have already stated that disease of the cerebellum very frequently gave rise to dyspeptic symptoms. Case XIII, page 78, and Ca e XVII, page 86, and Case XXI, page 96, are instances of this. Two of the worst cases I have known, of Dyspepsia, and which were considered and treated by several phy- sicians as such for a period of seven or eight years, exhibited at length unequivocal symptoms of disorder of the brain. One has become deranged, the other has now epileptic fits. It may be said that disorder of the stom- ach produced the disease of the brain. I think this was not the case, for both the individuals had undergone much mental anxiety previous to their dyspeptic symp- toms, and were themselves of the opinion that this caused the disorder of the stomach. Some years since, a young gentleman, became from some unknown cause, quite dyspeptic. His stomach was very irritable, and for a considerable time even a small quantity of mild food would occasion distress and flatu- lence of the stomach, or it would be rejected. A cough, and symptoms of disease of the lungs ensued, and it was considered a case of latent or dyspeptic phthisis. Soon after, mental derangement occurred, and the patient remained insane for two years when he died. 1 was not present at the post mortem examination, but 280 DYSPEPSIA. have been assured by a physician who was, that there was no disease of the stomach, and but little of the lungs, but that the brain was greatly disorganised. I might quote from the works of medical writers nu- merous cases where dissection of those long considered dyspeptic, who complained only of the stomach, exhib- ited no disease of this organ, while the brain was found considerably diseased. Several such cases will be found in a late work by Dr. Wilson Philip.* He mentions the case of a student at Oxford, whose complaint was re- garded by his physicians, of that place, and of London, as dyspepsia, but which finally proved fatal, and on exam- ination after death, but trifling marks of disease were found, except at the base of the brain, and in the cere- bellum and medulla oblongata. Dr. Darwall, in an interesting paper on " Some forms of cerebral and spinal irritation," furnished several cases in support of his views that indigestion does not merely influence the nervous system, but that the nervous system is the source from which the indigestion proceeds. " Dr. Abercrombie, on Organic Diseases of the Brian, says, that ' Symptoms which really depend upon disease of the brain, are very apt to be referred to the stomach.' After mentioning several cases, in which for a long time the prominent symptoms were those of dyspepsia, and in which no trace of organic disease of the stomach was discovered after death, but tumors, or other disease of the brain, he says, ' Many other cases of organic disease of the brain are on record, in which the only morbid ap- pearances were in the head, though some of the most prominent symptoms had been in the stomach. Some of these resembled what has been called sick-headache, * A Treatise on the more obscure Affections of the Brain, &c, by A. P. W. Philip, M. D, DYSPEPSIA. 281 others were chiefly distinguished by remarkable distur- bances of the digestive functions.' Dr. A. adds this im- portant caution; — 'In cases of this class we must beware of being misled, in regard to the nature of the complaint, by observing that the symptoms in the stom- ach are alleviated by attention to regimen, or by treat- ment directed to the stomach itself. If digestion be impeded, from whatever cause, these uneasy symptoms in the stomach may be alleviated by great attention to diet, but no inference can be drawn from this source, in regard to the cause of the derangement.' This last quotation, I think explains a very common mistake — a mistake which is not only made by dyspep- tics themselves, but by writers on this disease. They suppose because low diet, &c. relieves the principal symptoms in the stomach, that therefore the disease is confined to that organ ; when in fact the disease is in the head, but is manifested only by the stomach, the liver, or some organ with which the brain sympathises, and the low diet gives relief, by lessening the too energetic action of the brain. Dr. Hastings, of England, has called attention to this subject, in the Midland Medical and Surgical Register of 1831. He says, that not unfrequently cases occur, which exhibit symptoms of disordered stomach, accom- panied by increased determination of blood to the head, alternate flushings and coldness, irregular spirits, &c.; and he states that in all the cases which terminated fatally, under his care, he found thickening of the mem- branes of the brain, and marks of chronic inflammation within the head. Dr. H. believes that many of the ner- vous symptoms of which dyspeptic persons complain, are produced by slow alteration of the brain, in conse- quence of chronic inflammation; and recommends 24* 282 DYSPEPSIA. leeches, co?d applications to the head, and issues in the neck, for the relief of such cases. M. Bayle has published in the Revue Medicale, several cases, exhibiting the connexion between disease of the brain and disorder of the stomach. He endeavors to show that disease of the stomach often produces insanity; but he mentions that many of his patients were remarka- ble for violent temper, or were melancholy, or exhibited some symptoms of nervous irritation, before they were much unwell; then the stomach became disordered, and finally derangement of the mind ensued. On dissection, the brain and its membranes were found diseased ; and here I apprehend was the original seat of the complaint, (produced probably by some moral cause.) which first manifested itself in change of temper, or slight nervous affections; then, as it increased, disordered the stomach by sympathy, and finally produced so much disease of the brain as to cause insanity. Dr. Burrows relates the case of a lady, who had been unwell for several years. She referred all her suffering to the stomach, and often said, that when she was dead, there would be found the seat of the disease. She died rather suddenly with fever and delirium, alter exposure in a very hot day; and on examining the body, no trace of disease appeared in the stomach or bowe's, but the brain exhibited marks of long standing disease. * Some cases and observations in a late work of M. Barras.f confirm the opinion I have advanced respecting the cause and seat of dyspepsia, though this writer does not believe, with M. Broussais and others, that it is an * Burrows en Inssn'ty, p. 236. t Traite sur les Gastralgics et les Enteralgies, ou Maladies Ncrven. eo dc 1* Estomac et des LiLstins. Par J. P. T. fiarras, M. D. DYSPEPSIA. 283 inflammatory disease, but that it consists in an affection of the nerves of the stomach, or what Dr. Johnson calls morbid sensibility of the stomach, bowels, &c. He con- siders the disease to be a gastralgia, and not gastritis. But what causes this gastralgia, or morbid sensibility of the stomach ? An attentive examination of the cases he has cited, will show that, very probably, the first cause of morbid action was a moral one. Most of the patients whose cases he relates, were of an irritable, nervous temperament, and previous to any symptoms of disease of the stomach, they had 'experienced severe domestic affliction,' had been ' melancholy,' or been afflicted by ' great mental suffering,' or had ' studied severely, or been exposed to constant turmoils.' One case terminated fatally. It was that of a lady 56 years of age, who had been subject to mental suffer- ings, ?nd constantlv complained of pain in the region of the stomach. Her physician predicted that disorder of the stomach would be found, but on examination no dis- ease of this organ was seen, but there was serous effusion into the ventricles of the brain. The following is a case which terminated favorably, and which M. Barras regards as primarily a disorder of the stomach. I believe it to have been from the first a functional disease of the brain. It is very similar to many cases that terminate in insanity, and I have no doubt this would, if the depleting plan of treatment had been continued, instead of that proposed by M. Barras. Case LX1I.—" Madam C, aged 43 years, of very ner- vous temperament, and subject to pains in her stomach, experienced a severe domestic affliction, in September, 1825. Immediately afterwards, the gastric affection was much aggravated, accompanied by spasms in the chest and sense of suffocation. For these, leeches were thrice applied, mucilaginous drinks prescribed, and the most 284 DYSPEPSIA. rigorous regimen enjoined. In November, she became affected with furious delirium, and in this state, she craved lustily for animal food, and sought to obtain it by main force. M. Barras was consulted, and advised that better nourishment should be allowed. Tiie digestion was distressing at first; but, by gradually habituating the stomach to animal matters, the digestion became easy, and, by the 15th December, the patient could drink a bottle of Bordeaux wine without inconvenience. With this power of receiving aliment, the strength and flesh returned—her mental aberration disappeared in a great measure, and there is every appearance of complete recovery." Treatment. — In every case of Dyspepsia, it is impor- tant to investigate the condition of the brain ; at the same time, that of the stomach, liver and other organs should not be overlooked. In some cases attention to these last organs is all that is required. Mercurial rem- edies are usually injurious, but in some rare instances when the liver is disordered, a few doses of blue pill may be of much service. Combinations of laxatives and tonics with alkalies are frequently useful. The preparations of iron, quinine or some of the vegetable bitters, combined with rhubarb or aloes, in such pro- portions as to give tone to the stomach and bowels, and to insure their regular action, are often very beneficial. But a very large class of dyspeptics, especially those who have long suffered from disorders of the stomach, Bhould be advised to seek restoration to health, not in the daily use of medicines, or in an unusual course of diet, but in judicious exertion of the body, in travelling through countries where the mind will be pleasantly occupied, in innocent amusements, cheerful company ordinary diet, inattention to their stomachs, and mentaX relaxation. INSANITY. 285 Where there is reason to apprehend organic disease of the brain, moxas, setons in the neck and cupping should be resorted to. INSANITY. The article on Insanity in the North American Re- view, for January, 1837, and in the American Journal of the Medical Sciences for November, 1838, the former being a review of Prichard, and the latter of Esquirol on Insan- ity, were prepared by the author of this work. To those articles he refers the reader, for details respecting this interesting disease that will not be found in this chapter. The following table, made up from the statements of Esquirol, M. Briere de Boismont and other good author- ities exhibits, perhaps, as accurate an account of the number of the insane in different countries, and in the large cities of Europe, as can at present be obtained. COUNTRIES. POPULATION. NO. OP INSANE. 1 'ROPORTIO England, 12,700,000 16.222 793 Scotland, 2,093,500 3.652 563 France, 32,000,000 32,000 1,000 Norway, 1,051,300 1,909 551 Belgium, 3.816,000 3 763 1,014 Holland, 2,302,000 2,300 1,046 Italv, 16,789,000 1,441 4,879 Spain, 4,085,000 569 7,181 U. States,* 12,866,020 16,000 800 Westphalia, 846 Saxony, 968 * The above estimate of the number of the insane is to a considera- ble degree, conjectural. In the nest census for this country, lunatics and idiots are to be included, 286 INSANITY. CITIES. POPULATION. NO. OP INSANE. PROPORTION. London, 1,400,000 7,000 200 Paris, 890,000 4,000 222 Petersburg, 377,000 120 3,133 Naples, 370,000 479 759 Cairo, 330,000 14 30,714 Madrid, 204,000 60 3,350 Rome, 154,000 320 481 Milan, 151,000 618 242 Turin, 114,000 331 344 Florence, 80,000 236 338 Dresden, 70,000 150 466 From the above table we learn tnat this disease, more frequently occurs in large cities than in the country : and that it prevails the most in enlightened and educated communities. In fact, insanity is almost wholly confined to the civilized races of men. It is rare among the uncivilized and uneducated Indians and Negroes. It is uncommon in China, Persia, Hindostan, Turkey and Russia. There is but little in Spain and Portugal, while it prevails to a great extent in England, Fiance, Ger- many, Norway, Holland, and in the United States. In these last countries, it is thought by those who have investigated the subject, to have considerably increased, within the last half century. This fact, says M. Belhom- me, cannot be doubted. Causes of Insanity. — A very common division of the causes of insanity, is into moral and physical. Modern writers, do not. however, agree as to the comparative influence of these causes. Tnis arises from some having included among physical causes, hereditary predisposi- tion and certain diseases, which others do not consider as properly belonging to this class. Most writers, however, attach the greatest impor- yjSANITY. 287 tance to moral causes. "The observations," says M. Georget, " which I have had in my power to make, the more numerous ones which I have compared in authors, have convinced me, that, among one hundred lunatics, ninety-five at least have become such from the influence of affections and of moral commotions : it is an obser- vation become almost proverbial in the hospital—the Salpetriere,— 'qu'on perd la tete par les revolutions d'esprit.' The first question that M. Pinel puts to a new patient who still preserves some remains of intelligence, is, Have you undergone any vexation or disappointment? Seldom is the reply in the negative. " It is," continues the same writer, 'in the age in which the mind is most susceptible of strong feelings, in which the passions are excited by the strongest interests, that madness is prin- cipally displayed. Children, calm and without anxiety, incapable of long and extensive combinations of thought, not vet initiated into the troubles of life, and old men, whom uV now vanishing illusions of their preceding age, and their increasing physical and moral weakness render indifferent as to events, are but rarely affected. The same remark applies to persons who in their consti- tution approach to the character of children or of old men."* It may also be urged in favor of this opinion, that the disease is comparatively rare among uncultivated nations; thouo-h they are exposed to the same physical causes. I fully concur in the opinion of M. Georget, that moral causes arc far more operative in the production of this di; ease, than physical ones ; and it appears to me, that those who have come to a different conclusion, have plrccd under the head of physical causes, many that ouv zro 6-/ ' M nVtHW ; Ijjll !;jB j j 1 i i ^ «!!!:.• \ P&e;;i,l 1 lit '' i J'*)1" lidiillll nii>' .» mi Mi i ill Ii]!::;:,! 038�5643