v-y&^gm&S'Z. mmmmm mm MMMbtitiA.......tin..-. _ ..- ■.._ .....-- ..^——-.__»^.: 1 THE STUDY OF MEDICINE. BY JOHN MASON GOOD, M. D. F. R. S. F. R. S.L. MEM. AM. PHIL. SOC. AND F. L. 6. OF PHILADELPHIA. CONTAINING ALL THE AUTHOR'S FINAL CORRECTIONS AND IMPROVEMENTS. iFrom the last HottiKon Etrtttoit, WITH MUCH ADDITIONAL MODERN INFORMATION ON PHYSIOLOGY, PRACTICE, PATHOLOGY, AND THE NATURE OP DISEASES IN GENERAL. By SAMUEL COOPER, BURGEON TO THE KING'S- BENCH AND FZ.EET PRISONS ; SURGEON TO THE FORCES J AUTHOR OF THE DICTIONARY OF PRACTICAL SUR- GERY ; HONORARY FELLOW OF THE ACADEMY OF NATURAL SCIENCES AT CATANIA ; &C. &C. IN FIVE VOLUMES. , VOL. IV. BOSTON: PUBLISHED BY WELLS AND LILLY—COURT-STREET. AND J. & J. HARPER—NEW-YORK, /M°^« 1829. \Nb /-!"ri 3rii j J?y«^»-, j \ CLASS IV. NEUROTICA. DISEASES OF THE NERVOUS FUNCTION. ORDER I. PHRENICA. Affecting the Intellect. II. iESTHETlCA. Affecting the Sensation. III. CINETICA. Affecting the Muscles. TV. SYSTATICA. Affecting several or all the Sensorial Powers simultaneously. PHYSIOLOGICAL PROEM. The numerous and complicated train of diseases, we are now Thenewms entering upon, appertains to the highest function of visible be- function the ings ; the possession of which emphatically distinguishes animals J^fe ° from plants, and the perfection of which as emphatically distin- beings: guisbes man from all other animals : these are the diseases of the nkrvoi » j-t-^iion;—which, in the sphere of its activity, embrac- embracing ies tie powe.s of intellect, sensation, and muscular motion. Each the powers r . u • _!• r-j. j -ii i of intellect, ot. these powers evinces diseases of its own, and will consequent- sensatioo ly lay a foundation for a distinct order, under the class before us. and muscu- While, as there are also other diseases that affect several of lar motion- them simultaneously, we become furnished with a fourth order, which will complete the series. All these diversities of vital energy are now well known to be All depend- dependent on the organ of the brain,* as the instrument of the entonthe intellectual powers, and the source of the sensific and motory. brain":0 Though, from the close connexion and synchronous action of va- rious other organs with the brain, and especially the thoracic though for- and abdominal viscera, such diversities were often referred to merlyascrib- several of the latter in earlier ages, and before anatomy had viscera. traced them satisfactorily to the brain as their fountain-head. And of so high an antiquity is this erroneous hypothesis, that it * Perhaps, instead of the expression "organ of the brain," it would be more correct to say " nervous system ;" for it is not every animal that has a brain, and certain functions of the nerves, even in the human subject, seem to be independent of this organ. " A nervous system appears essentially composed of two parts; of a central organ, consisting of two chords; one corresponding with either half of the body, upon which nodular masses are generally placed ; and secondly, of other chords called nerves, derived from the central organ to the sentient surfaces, or contractile parts of the animal. In the star-fish, a radiat- ed animal, the central organ consists of a ring of white nervous matter, which surrounds the orifice of the stomach, and gives off opposite to the centre of each ray nerves for its sup- ply."—See Mayo's Outlines of Physiology, p. 252,2d edit. 1828.—Ed. VOL. IV. 1 2 cl. iv.] PHYSIOLOGICAL PROEM. Corrected by the study of anatomy. Class IV. has not only spread itself through every climate on the globe, ™sa,,M|Dt but still keeps a hold on the colloquial language of every peo- tinctuirs P'e ' an(' hence the heart, the liver, the spleen, the reins, and popular the bowels, generally, are, among all nations, regarded either language. literally or figuratively, as so many seats of mental faculties or moral feeling. We trace this common and popular creed among the Hebrews and Arabians, the Egyptians and Persians, the Greeks and Romans ; among every savage, as well as every civilized tribe ; nor is there a dialect of the present day that is free from it: and we have hence an incontrovertible proof, that it existed as a doctrine of general belief at a time when mankind, few in number, formed a common family, and were regulated by common notions. The study of anatomy, however, has corrected the loose and confused ideas of mankind upon this subject; and while it dis- tinctly shows us, that many of the organs, popularly referred t° as the seat of sensation, do and must, from the peculiarity of their nervous connexion with the brain, necessarily participate in the feelings and faculties thus generally ascribed to them, it also demonstrates, that the primary source of these attributes, the quarter in which they originate, or which chiefly influences them, is the brain itself. We are speaking, however, of man and the higher classes of animals alone ; for, as the scale in animal life descends, the or- gan of a brain is perpetually diminishing in its bulk, till at length it totally disappears, and its place is supplied by other fabrica- tions, as we shall have occasion to observe in the sequel of this introduction : which will lead us to take a brief notice of the fol- lowing subjects: I. THE GENERAL NATURE OF THE BRAIN, ITS RAMIFICATIONS AND SUBSTITUTES. II. THE PRINCIPLE OF SENSATION AND MOTION. III. THE INTELLECTUAL PRINCIPLE. Natural I. In man, and those animals, whose encephalon approaches figure and (\^e nearest to his in form, the brain is of an oval figure, sur- thebrai0. rounded by various membranes of different firmness and density, I. Nature of and consists of three principal divisions; the cerebrum or brain, the brain, properly so called, the cerebel or little brain, and the oblongat- ed marrow. The first forms the largest and uppermost part; the second lies below and behind; the third lies level with the second and in front of it; it appears to issue equally out of the two other parts, and in turn to give birth to the spinal marrow; which may hence be regarded as a continuation of the brain communicating with its different parts by the aid of numerous commissures, the querbdnder of the German writers, and extend- ed through the whole chain of the back-bone. They are simi- larly accompanied with a cineritious, or ash-coloured substance, which forms the exterior of the three first divisions, but the in- terior of the spinal marrow, and appears to derive its hue from the great number of minute vessels that appertain to it. According to Mr. Bauer's very delicate microscopic experi- its rainifica tions and substitutes. PHYSIOLOGICAL PROEM. [cl. iv. 3 ments, when the substance of the brain is made a subject of ex- Class IV. amination immediately after death, " abundance of fibres," to I- Nature of adopt the words of Sir Everard Home in relating these experi- [Jf ^3^. ments, "are met with in every part of it; indeed it appears, tionsand that the whole mass is a tissue of fibres, which seem to consist substitutes. entirely of an accumulation of globules, whose union is of so deli- Substance of cate a nature that the slightest touch, even the mere immersion ^rtjjj (0 in water, deranges and reduces them to that mass of globules, of Bauer's ex- which the brain appears to be composed, when examined with amination less accuracy or under less favourable circumstances." Mr. Bauer J-JJ^L, found, that the globules of the brain, as well as those of pus, are and the pre- exactly of the same size as those of the blood when deprived of v.'°™ ^ec- their colouring matter * And hence the doctrine of Prochaska,t J™ £; JJj and the Wenzels,| respecting the globular form of the ultimate theWenzels. particles of the brain, seems sufficiently confirmed.§ [When we cut into the interior of the brain, we find it to be Two sub- composed of two substances, which differ in their colour and con- *tanj*sof sistence, and are named the cortical or cineritious, and the medul- lary. The cortical, as its name imports, is on the outside, and is of a reddish-brown colour ; it is softer than the medullary, and considerably more vascular. The medullary matter, as Dr. Bostock has remarked, is, both from its aspect and relative po- sition, generally considered as constituting the nervous substance in its most perfect state ; and Gall and Spurzheim conjecture, that the use of the cineritious is to form or secrete the medul- lary part|| The particular facts, says Dr. Bostock, from which they derive their hypothesis, are, that the nerves appear to be enlarged when they pass through a mass of cineritious matter, and that masses of this substance are deposited on all the parts of the spinal chord, where it sends out nerves. In opposition to the above opinion, however, Professor Tiedemann states, that, in the foetus, the medulla is formed before the cortex, and he limits the use of the latter to the conveyance of the arterial blood, necessary to support the energy of the perfect nervous matter.Tj Sir Everard Home, from the above-mentioned microscopic Muscular disclosures, endeavours to show, that muscular fibres are minute fibres what: chains, formed by an attachment of one globule of blood to ano- p^,^. ther: and that vascularity in coagulaor extravasated blood, or in granulations produced by pus, is effected by the escape of minute * See Sir Everard Home's Croonian Lecture, Phil. Trans, for 1818. t Op. Min. torn. i. p. 342. J De Structural Cerebri, p. 21. } According to Prochaska, the. nervous pulp consists of flocculi, which are composed of globules, about eight times less than the red particles of the blood a ; and this account, in its essential parts,has been confirmed by the more recent and elaborate investigations of the WenzelsA. Bauer, whose researches confirm the existence of globules, found them larger and in greater proportion in the medullary, than in the cortical substance.—See Phil, Trans, for lijlS and 1821; also Bostock's Physiology, vol. i. p. 234.—Ep. || Recherches sur le Systeme Nerveux, i 2. ? See Anatomie du Cerveau, traduite par Jourdan, p. 128; Bostock's Elem. System of Physiology, vol. i. p. 223; Magendie, Physiologie, torn. i. p. 1G'2, &c. a Op. Min. p. 342. b De Structura Cerebri, p. 24, et seq. 4 CL. IV.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifica- tions and substitutes. Origin of nerves. Organs sup- plied with nerves in various proportions. General symmetry of the nervous system. Plexus. Ganglion. bubbles of carbonic acid gas from the living fluid; which hereby opens a path to a certain extent into the tenacious blood or pus that is extravasated or secreted. From the lower part of the brain, or, according to the latest researches, rather from the medulla oblongata, and also from the spinal chord, arises a certain number of long, whitish, pulpy, strings, or bundles of fibres, capable of being divided and subdivided into minuter bundles of filaments or still smaller fibres, as far as the power of glasses can carry the eye. These strings are denominated nerves; they are enclosed in sheaths of membrane; and, by their various ramifications, convey dif- ferent kinds or modifications of living power to different parts of the body, keep up a perpetual communication with its re- motest organs, and give motivity to the muscles. [The nerves are most copiously distributed to the organs of sense and volun- tary motion; the viscera are much more sparingly supplied with them ; the glands have still fewer nerves ; and some of the membranous parts are sometimes conjectured to be quite destitute of them. Generally speaking, the nerves, which sup- ply the organs of sense, proceed immediately from the base of the brain, or rather from the medulla oblongata; while most of the muscles (but not all) receive their nerves from the spinal chord. As Dr. Bostock has observed, there is much more ir- regularity with respect to the course of the nerves, which go to the viscera; they generally derive their immediate origin from some of the ganglia and plexuses forming part of the great sympathetic nerve, and they are connected with each other in a great variety of ways. The nervous system, viewed as a whole, however, and comprising the brain, spinal chord, and all their ramifications, is in general so symmetrical, that if the body were longitudinally divided into two equal halves, the ar- rangement of the brain and nerves in each half, would, with the exception of a few deviations from this rule, caused by the situations of particular viscera, precisely correspond.* In various examples, the fibrils of which adjacent nerves are composed, are reciprocally thrown across from one to the other, forming what is termed a plexus. As Mr. Mayo has explained, the nerves which proceed from the farther side of a plexus may be more numerous, or fewer, than those which enter it; but the essential result is, that nervous fibrils from different sources are brought together to form new trunks. A ganglion is a small nodule, usually flattened, of an oval or circular shape, and of a reddish-gray colour, which is found either on the trunk of a single nerve, or where two or more branches coalesce. Mr. C. Bell's opinion respecting the ganglions will be presently no- ticed. Scarpa supposes, that a ganglion is but a bed of gelati- nous membrane, in which the smallest fibrils of the nerves are arranged in new combinations. Others believe, that nervous filaments originate in the gray matter of ganglions.!] * See Bostock's Elementary System of Physiology, vol. t Mayo's Outlines of Physiology, p. 324, 2d edit. p. 228. PHYSIOLOGICAL PROEM. [cl. iv. 5 Class IV. I. Nature of the brain, its ramifica- tions and substitutes. Reason of the division of the brain into distinct compart- ments not clearly known. As the brain consists of three general divisions, it might, at first sight, be supposed that each of these is allotted to some distinct purpose; as, for example, that of forming the seat of intellect or thinking; the seat of the local senses of sight, sound, taste, and smell, and the seat of general feeling or mo- tivity. The investigations and experiments of Mr. C. Bell, and M. Magendie, to which we shall presently advert, pave the way to some important doctrines in respect to a few of these points, but leave us quite in the dark in respect to various others; and particularly as to the source of intellect; while it is diffi- cult to reconcile even the doctrines, which have thus been fairly deduced, with the motific, and even with the sentient powers that must exist in numerous cases of an extensive disorganiza- tion of the brain and in acephalous animals. The first and se- cond nerves and the portio mollis of the seventh sufficiently at- test their exclusive uses as nerves of the special senses ; while the distribution of the greater part of the third, of the fourth, and of the sixth nerves* to voluntary muscles, which receive filaments from no other source, prove clearly, that these nerves are voluntary nerves, as well as conducive to muscular sensa- tion. " Perhaps," says Mr. Herbert Mayo, "it is not unfair to argue analogically from the preceding instances, that the same surface of the brain or spinal chord furnishes to each voluntary muscle of the body its voluntary and sentient nerves, if the two are not identical."] There is in like manner reason for believ- ing, that the fifth nerve, which, at its origin, consists of two portions, is not only a nerve of voluntary motion, but furnishes branches to the special senses, and even communicates general sensation to the muscular fibres; and that its gustatory twig is a nerve of both touch and taste at the same time. J Several of these phaenomena may indeed be resolved, though not the whole, into that close interunion which some parts of the brain maintain with other parts by means of ganglions, commissures, and decussations of nerves; whence injuries on one side are often accompanied with loss of motion or feeling in the organs of the other side. So the curious and ingenious experiments, lately instituted by Dr. Philip,§ and to which we shall have occasion to return presently, sufficiently prove, that * It is a remark, made by Mr. C. Bell, that the principles and facts unfolded in his views of the nervous system, lead us to understand the " use of all the intricate nerves of the body, with the exception of the sixth. The sixth nerve stands connected with another sys- tem of nerves altogether; I mean the system hitherto called the sympathetic, or sometimes the ganglionic system of nerves; and of this system we know so little, that it cannot be matter of surprise if we reason ignorantly of the connexion of the sixth with it."—Na- tural System of the Nerves of the Human Body, p. 64.—Ed. t Anatomical and Physiological Commentaries, No. 2, p. 1. 8vo. Lond. 1822. \ The fact of the same nerve seeming to answer both for motion and sensation, is ac- counted for by the important discoveries of Mr. C. Bell and M. Magendie. Mr. Mayo's experiments and arguments tend to prove, that "the ganglionless portion of the fifth, and the hard portion of the seventh nerve, are voluntary nerves to parts, which receive sen- tient nerves from the larger or ganglionic portion of the fifth." By the expression sentient nerves, Mr. Mayo means-those, the division of which is followed by instantaneous loss of sensation in a part; by voluntary nerves, he means those, upon the division of which the will ceases to influence the muscles they supply.—Outlines, &c. p. 331, &c.—Ed. * Phil. Trans. 1815, p. 5—90. The same nerve seems at times Bubservient to different purposes, or different nerves to the same purpose. 6 ci,. iv.] PHYSIOLOGICAL PROEM. Class IV. stimuli of a certain kind, as spirit of wine, applied to the poste- !• Nature of rior part of the naked brain of an animal, produce the same ita ramifies- effect on the hearti and equally increase its action, as if applied tions and to the anterior part. To affect the heart, however, it seems substitutes, necessary that the stimulus should spread over a pretty large extent of the brain; so as to take in, by the range of its ex- citement, some of the ganglions of the brain, whose office, as Dr. Philip conceives, is " to combine the influence of the va- rious parts of the nervous system, from which they receive nerves, and to send off nerves endowed with the combined in- fluence of those parts."* He hence accounts for some organs of the frame being affected by every part of the nervous sys- tem, and others by only certain small parts of it; and the wide influence possessed by the great sympathetic nerve, which is less a single nerve, than a string of ganglions. We are also hereby shown why the intestines, like the heart, sympathize with every portion of the nervous system. From all this, however, it is clear, that there is much yet to be learnt concerning the actual arrangement of the brain, or of its partition into three divisions, and of the respective share which the different parts take in producing a common effect: and consequently it seems to be altogether a wild and idle at- tempt to subdivide these perceptible regions of the brain into still smaller and merely imaginary sections, and to allot to each of them a determinate function and faculty. That a sensorial communication, however, is maintained be- tween some part or other of the brain and every part of the body, and that this communication is conducted by the nerves, is unquestionable from the following facts : If we divide, or tie, or merely compress, a nerve of any kind, the muscle with which it communicates becomes almost instantly paralytic ; but upon untying or removing the compression, the muscle recovers its appropriate feeling and irritability. If the compression be made on any particular part of the brain, that part of the body becomes motionless which derives nerves from the part com- pressed. And if the cerebrum, cerebellum, or medulla oblon- gata be irritated, excruciating pain or convulsions, or both, take place all over the body :| though chiefly when the irritation is applied to the last of these three parts. For, according to the laws of the nervous action as collected from a variety of expe- * Phil. Trans. 1815, p. 436. An opinion formerly prevailed, that ganglia were intended to cut off sensation ; but Mr. C. Bell noticed, that every one of the nerves, which he took to be instruments of sensation, had ganglia on their roots. " Some very decided expe- riment," he says, "was necessary to overturn this dogma. I selected two nerves of the encephalon; the fifth, which had a ganglion, and the seventh, which had no ganglion. On cutting across the nerve of the fifth pair on the face of an ass, it was found, that the sensibility of the parts, to which it was distributed, was entirely destroyed. On cut- ting across the nerve of the seventh pair on the side of the face of an as1-, the sensibility was not in the slightest degree diminished. By pursuing the enquiry, it was found that a ganglionic nerve is the sole organ of sensation in the head and face ; and thus my opinion was confirmed, that the ganglionic roots of the spinal nerves were the fasces or funiculi for sensation." C. Bell's Nat. Syst. of the. Nerves, p. 34.—Ed. t Some of the observations of Flourens and Hertwig on this subject will be presently noticed.—Ed. Fanciful to pretend sub- divisions inscrutable to the senses, and to en- dow them with hypo« thetical powers. The brain maintains a sensorial communi- cation with the body by means of the nerves. PHYSIOLOGICAL PROEM. [cl. iv. 7 riments by Dr. Philip,* and stated in a subsequent paper to that Class IV. just referred to, "Neither mechanical nor chemical stimuli (ir- I.Natnre ritating the brain by a knife, or pouring spirits of wine upon it) pf the brain, applied to the nervous system, excite the muscles of voluntary tionsand"" motion, unless they are applied near to the origin of the nerves, mbstitutes. and spinal marrow." It is from the medulla oblongata that all the nerves of respiration take their rise ; and, hence, any sud- den injury or accident that interrupts its course, by putting a close to the respiration, induces death instantly.! The nerves issue in pairs, one of each pair being allotted to Number either side of the body. The whole number of pairs is forty ; and general of which nine rise immediately from the great divisions of the character of brain under which we have just contemplated it, and are chief- ly, though not wholly, appropriated to the four local senses; and thirty-one from the spinal marrow. We have thus far represented the spinal marrow as issuing Whether from the brain, in conformity with the general doctrine that the spinal has hitherto been held upon the subject. It has of late years, j"31"™^,,, however, been contended by various physiologists,;); and par- the brain, ticularly by Drs. Gall and Spurzheim, that the spinal marrow or the brain itself is the origin or trunk of the nervous system, and that, in- [r{?mi^L 1 r • . r ii •• • ... . mi spinal mar- stead of issuing from the brain, it gives birth to it. The argu- row? ment is derived from the existence of a spinal marrow alone the latter in acephalous monsters, and of a nervous chord without a j£Q^j^JJ brain, answering the purpose of a spinal marrow, in most in- Spurzheim. vertebral animals. Whence it is inferred, that the nervous Ground column is the radical part of the system, and that the brain is an of their increment from it in the more perfect classes.§ opinion. The question is not of much importance, though there is something ingenious in thus tracing animal life from its simpler forms. Yet the opinion seems to be in direct opposition to a Opposed by well-ascertained fact we shall have to advert to presently, aaQ\wt namely, that the magnitude of the brain and the extent of its intellectual powers hold an inverse proportion to the size of the spinal marrow, and, consequently, upon this hypothesis, to their apparent means of supply. Nor is it the mode of induc- tion usually adopted by physiologists on like occasions ; since they generally describe the arteries as issuing from the heart, instead of giving rise to it, notwithstanding that the heart, like the brain, has been found totally wanting in some monsters, and the circulation carried on by an artery and a vein alone, of * Phil. Trans. 1815, p. 444. t On the Nerves which associate the Muscles of the Chest in the Actions of breathing, &c. By Charles Bell, Esq. Phil. Trans. 1822, p. 284. :f Tiedemann, Anatomiedu Cerveau, contenant 1' Histoire de son developpe- inent dans le foetus, avec une exposition comparative de sa structure dans les aniinaux, trad, par A. J. Jourdan, &c. Paris, 1823. Serres, Anat. Comparee du Cerveau, &c. I Analomie et Physiologie du Systeme Nerveux, &c. par F. J. Gall et G. Spurzheim, 4to. Paris, 1810. The later investigatioHs of Tiedemann and Serres into the development of the nervous system of the human foetus, repre- sent the spinal chord, the medulla oblongata, the cerebellum, and the cerebrum, as formed in the succession here specified. Beclard, Additions a Bichat.—Ed. 8 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifica- tions and substitutes. System and ganglions of the inter- costal nerve. From its structure and exten- sive inter* course, an instrument of general sympathy. The human brain has no exact coun- terpart in other animals. which Mr. Hewson gives a very singular instance ;* and that most of the worm genera are equally without a heart, though they are in possession of circulatory vessels. We only see in these arrangements, that neither a brain, nor a heart, is essen- tially necessary to animal life : and that the great Author of nature is the lord, and not the slave, of his own laws; and is capable of effecting the same general principle by a ruder, as well as by a more elaborate design. There is one part, however, of the system of nervous power in the more perfect classes of animals that is particularly wor- thy of our attention, as furnishing a rule peculiar to itself, and being without a parallel in any other part; and that is the ori- gin, structure, and extensive influence of the great sympathetic or intercostal nerve, which forms a kind of system in itself, an epicycle within the two cycles of cerebral and vertebral influ- ence. It is connected both with the brain and spinal marrow, and may be said to arise from either. Admitting the brain to be its source, it is an offset from the sixth pair of nerves, on either side, and in its course receives a small tributary twig from the fifth, and branches from all the vertebral, from whose union and decussation it is studded with numerous ganglions or medullary enlargements, of which there are not less than three in the neck alone, tinted by an addition of cineritious substance ; a larger number in its line through the chest; and others as it descends still more deeply; independently of various conflu- ences of smaller branches that unite and form extensive net- works. Having reached the hollow of the os coccygis, it meets its twin from the opposite side, which has pursued a similar course, and been augmented by similar contributions. Thus equally enriched with the nervous stores of the brain and the spinal marrow, it sends off radiations as it takes the course of the aorta, to all the organs of the thoracic, abdomi- nal, and hypogastric regions, to the lungs, the heart, the sto- mach, and intestines, the bladder, uterus, and testes; and thus becomes an emporium of nervous commerce, and an instru- ment of general sympathy : and what is of infinite importance in so complicated a frame as that of man, furnishes to the vital organs streams of nervous supply from so many anastomosing currents, that if one, or more than one, should fail or be cut off, the function may still be continued. To this it is owing, in a very considerable degree, that the organs of the upper and lower belly exhibit that nice fellowship of feeling which often surprises us, and that most of them are apt to sympathize in the actual state of the brain. There is no animal whose brain is an exact counterpart to that of man : and it has, hence, been conceived, that by at- tending to the distinctions between the human brain and that of other animals, we might be able to unfold a still more mys- terious part of the animal economy, than that of sensation or •* On the Lymph. Syst. Part n. p. 15. PHYSIOLOGICAL PROEM. [cl.iv. 9 motion, and account for the superior intellect with which man Class IV. is endowed. I. Nature But the varieties are so numerous, and the parts which are jJ^g^J deficient in one animal, are found connected with such new tions and combinations, modifications, and deficiencies in others, that it is substitutes. impossible for us to avail ourselves of any such diversities. [The principle of improvement in the nervous system, But no throughout the ascending scale of animals is, as Mr. Mayo* ™aJy,IDg has explained, the progressive accumulation of nervous matter ground con- in larger masses upon that part of the central organ which is ceming the nearest the head or mouth. In proportion as this alteration J^J.0"1' from the simplest type of organization is effected, the animal human becomes more and more individualized, portions separated from intellect. it are found to be less capable of independent existence, and Principle the destruction of one organ is observed to produce more de- j£en™?n7he rangement of the rest.] nervous Aristotle endeavoured to establish a distinction by laying it system. down as a maxim, that man has the largest brain of all animals How com- in proportion to the size of his body ; a maxim, which has Pj£ ^Kby been almost universally received from his own time to the pre- Aristotle. sent period. But it has of late years, and upon a more extensive cultivation of comparative anatomy, been found to fail in vari- ous instances : for, while the brain of several species of the ^^"^j, ape kind bears as large a proportion to the body as that of man, fnavari0us the brain of several kinds of birds bears a proportion still lar- cases. ger. Sb'ramering has carried the comparison through a great Aristotle's diversity of genera and species:! but the following brief table maxim will be sufficient for the present purpose. The weight of the sffieriDg! brain to that of the body, forms In man from . . . . 5V to T3 Part- Several simiae ... ^ Dog ...... Tor Elephant......7±5 Sparrow..... ■£$ Canary-bird .... T*^ Goose.......T£o Turtle (smallest) . . . T^?7 Sb'mmering has hence endeavoured to correct the rule of and thus Aristotle by a modification under which it appears to hold uni- {joid^uni' versally ; and, thus corrected, it runs as follows : " Man has the venally. largest brain of all animals in proportion to the general mass of nerves that issue from it." Thus the brain of a horse gives only half the weight of that of a man, but the nerves it sends forth are ten times as bulky. The largest brain, which Sb'm- mering ever dissected in the horse kind, weighed only lib. 4oz., * Outlines of Human Physiology, p. 257, 2d edit. t Diss, de Basi Encephali. Gotting. 1778. 4to. G. F. Treviranus has given the results of a series of observations on the relative weight and breadth of the brain to that of several of its parts in different mammiferous animals: also a table of the proportion of the several parts of the brain to the greatest breadth of the spinal chord. The particulars may be found in the Edinb. Med. and Surgical Journ. for January 1829.—Editor. VOL. IV. 2 10 CL. IV.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifi. cations and substitutes. Rule ap- plies to ani- mals in the general de- scent of the scale of animal life. Distinctive character of the nervous structure of vertebral animals. In what re- spect varies as the scale descends. Nervous structure in invertebral animals. Possess a nervous chord pro* portionally larger than in vertebral animals, and enrich- ed with ganglions. Ganglions probably minute cerebels. while the smallest he has met with in an adult man was 21b. 5*oz. But the remark applies farther than to man : for this acute physiologist has been able to trace a direct proportion be- tween the degree of intelligence in every class of animals, and the bulk of the brain, where the latter bears an inverse proportion to the nerves that arise from it. And we may hence observe, in passing, as indeed we have already hinted, that the nerves seem rather to be a product of the brain, than the brain of the nerves: for it is much more easy to conceive how a fountain may become exhausted in proportion to the magnitude of its streams, than how a reservoir can be augmented in pro- portion to the minuteness of its channels.* Upon a general survey, I may observe, that the nervous structure of all vertebral animals, comprising the first four classes of the Linnean classification, mammals, birds, amphibials, and fishes, is characterized by the two following properties : Firstly, the central organ of the nervous system consists of a brain, with a long chord or spinal marrow descending from it; and, secondly, that both are securely enclosed in a bony case or covering. In man, as I have already observed, the brain is (with a few exceptions) larger than in any other animal in proportion to the size of the body; and, without any exception whatever, in pro- portion to the size of its dependent column. In other animals even of the vertebral classes, or those im- mediately before us, we meet with every variety of proportion, from the ape, which, in this respect, approaches nearest to that of man, to tortoises, and fishes, in which the brain does not much exceed the diameter of the spinal marrow itself. It is not, therefore, to be wondered at that animals of a still lower description, and without a vertebral column, should ex- hibit proofs of a nervous chord or spinal marrow, without a brain of any kind at the top; and that this chord should even be destitute of its common bony defence. And such is actually the conformation of the nervous system in insects, and, for the most part, in worms ; neither of which are possessed either of a cranium or a spine; and in none of which we are able to trace more than a slight enlargement of the superior part of the ner- vous chord, or spinal marrow, as it is called, in animals possess- ing a spine ; often consisting of one, and sometimes of two gang- lions, designed, apparently, to correspond with the organ of a brain; the descending column chiefly taking the course of the esophagus, and surrounding it. The nervous chord, however, in these animals is proportionally larger than in those of a su- perior rank ; and, though sometimes simple, as in molluscous worms, in other cases, as in insects, is possessed at various dis- tances of minuter ganglions or little knots, from which fresh * The doctrine that the nerves arise from, or are a production from the brain, has of late years been considerably weakened, if not quite refuted, by various facts, amongst which it is only necessary to mention here the exist- ence of nerves in acephalous monsters.—Ed. PHYSIOLOGICAL PROEM. [cl. ramifications of nerves shoot forth like branches from the trunk Class IV. of a tree, and which have sometimes been regarded as so many i. Nature distinct cerebels or little brains; having a close resemblance to of the brain, the subordinate system of the intercostal nerve in man, as we k* ramifica- have already traced it in its various ramifications and connex- Stitufes ions.* [On this part of the subject, Mr. Charles Bell has presented in animals, some rather different, but very ingenious views. In animals, which do which do not breathe by an uniform and general motion of their not b.rpathe< bodies, he observes, there is no spinal marrow, but only a long chort."3 compound and ganglionic nerve, extending through the body for the purpose of sensation and motion. In such creatures, the chord does not actuate the animal machine with alternate dilata- tion and contraction. There may be a motion of some part, which admits and expels air from a cavity, or agitates the water, and which motion is subservient to oxygenation of the blood ; and there may be a nerve, supplied to that apparatus, with sen- sibility and power suited to the function thus to be performed, and resembling our par vagum in office ; but there is no regular and corresponding distribution of a respiratory system of nerves to both sides of the body, and no arrangement of bones and muscles for a general and regular motion of the frame, like that which takes place in vertebral animals, and which is necessary to their mode of existence.!] In worms of apparently the simplest make, as zoophytes and Whether a infusory animals, no distinct structure can be discerned, and nervous particularly nothing like a nervous system. The hydra or ToTy^° nearly transparent polypus found so frequently in the stagnant and infusory waters of our own country, with a body of an inch long, and aniuials? arms or tentacles in proportion, seems, when examined by the largest magnifying glasses, to consist of a congeries of granu- Their pecu- lar globules or molecules, not unlike boiled sago, surrounded by ,iar make- a gelatinous substance ; in some tribes solitary, in others catenat- ed. And hence, whatever degree of sensation or voluntary mo- tion exists in such animals can only be conceived as issuing from these molecules acting the part of nervous ganglions detached, or connected. And on this account M. Virey has elegantly Virey's divided all animals into three classes according to the nature of classifica* their nervous configuration ; as, first, animals with two nervous ^Unf] systems, a cerebral and sympathetic, including mammals and from their birds, amphibials and fishes. Secondly, animals with a sympa- 8uPposed thetic nervous system alone, surrounding the esophagus, as mol- one"*"06 lusca and shell-fishes, insects and proper worms. And, thirdly, structure. animals with nervous molecules, as echini, polypes, and infusory animalcules, corals, madrepores, and sponges; all which in M. Virey's classification are included under the term zoophytes.! * See on this subject Sir E. Home's Croonian Lecture on the Internal Structure of the Human Brain, when examined in the microscope, as compared with that of fishes in- sects, and worms. Phil. Trans. 1824, p. 1. t C. Bell's Exposition of the Natural System of the Nerves of the Human Body, p. 23. Lond. 8vo. 1824. J When the nerves, the spinal marrow, and medulla oblongata (as Mr. Mayo observes) are proved to be sufficient for the continuance of sensation, volition, and the commonest 12 CL. IV.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifica- tions and substitutes. Touch the only sense common to all animals: hence sup- posed by Cuvier to be the base The only sense which seems common to animals, and which pervades almost the whole surface of their bodies, is that of general touch, or feeling; whence M. Cuvier supposes that the material of touch is the sensorial power in its simplest and un- compounded state; and that the other senses are only modifica- tions of this material, though peculiarly elaborated by peculiar organs, which are also capable of receiving more delicate im- pressions.* Touch, however, has its peculiar local organ, as well as the other senses, for particular purposes, and purposes in which unusual delicacy and precision are required : in man, this peculiar power of touch is well known to be seated in the of the other nervous papillae of the tongue, lips, and extremities of the fin- senses. Touch, though diffused generally, has its local organs, as well as the othersenses, when situat- ed in man. Vertebral animals the same num- ber of ex- ternal senses as man. Local sense of touch confined to mammals. gers. Its situation in other animals I shall advert to presently. The differences in the external senses of the different orders and kinds of animals consist in their number and degree of en- ergy. All the classes of vertebral animals possess the same number of senses as man. Sight is wanting in zoophytes, in various kinds of molluscous and articulated worms, and in the larvae of several species of insects. Hearing does not exist, or at least has not been traced to exist, in many molluscous worms and severals insects in a perfect state. Taste and smell, like the general and simple sejise of touch, seem seldom to be wanting in any animal. The local sense of touch, however, or that which is of a more elaborate character, and capable of being exercised in a higher degree, appears to be confined to the three classes of mammals, birds and insects; and, even in the last two, it is by no means common to all of them, and less so among insects than among birds. In apes and macaucoes, constituting the quadrumana of Blu- menbach, it resides partly in the tongue, and tips of the fingers as in man, but equally, and in some species even in a superior Exists in different organs in different tribes. instincts, we naturally suppose, that the cerebral masses which seem to grow in the scale of animals with their approximation to reason, are the seat of the higher affections of the mind. When, indeed, we read over an enumeration of the different affections of con- sciousness, and compare the phenomena of the mind with the anatomy of the brain, we bee not the most remote correspondence between the structure of the organ and the mutual dependence of the mental phaenomena. When, again, we compare the brain in man with the brain in the higher animals, we are surprised to find exactly the same com- plexity of structure, the same series and order of internal parts, the same general exterior structure in both. The brain, however, in the higher animals, (contrasted with their other organs in general, and their spinal chord and medulla oblongata in particular) is relatively smaller, than in man, and its external structure m«ch less complicated. The brain of the monkey, for example, has the internal parts of the same general form with those of the human brain; but the surface of the hemispheres, instead of the numerous intricate fur- rows and sinuosities, by means of which, the quantity of cineritious matter upon the cere- brum and cerebellum in man is so prodigiously increased, exhibits but a few straight de- pressions, and has proportionately a vastly less extent of the cortical superficies, and of the immediate medullary substratum. " It is here, then, that we are tempted to place the seat of reason ; and, as it appears that the human brain excels that of the monkey by the number and intricary of its folds and convolutions, so should we analogically be led to suppose, that the difference in mental endowments between one man and another may be connected with a greater amplitude of the surface of the brain in those who are most highly gifted."—(Outlines of Physiology, p. 298, 2d edit.) * Anatom. Comparat. i. 25. PHYSIOLOGICAL PROEM. [ci.it. 13 degree, in their toes. In the racoon (ursus lotor) it exists chief- Class IV. ly in the under surface of the front toes. In the horse, and cat- i. Nature of tie orders, it is supposed by most naturalists to exist conjointly Jne Dra,nt in the tongue and snout, and in the pig and mole to be confined |ionga™dC ' to the snout alone : this, however, is uncertain ; as it is, also, substitutes. though there seems to be more reason for such a belief, that in In quadru- the elephant it is seated in the proboscis. Some physiologists P^8- have supposed the bristly hairs of the tiger, lion, and cat, to be an organ of the same kind; but there seems little ground for such an opinion. In the opossum (and especially the Cayenne opossum) it exists very visibly in the tail; and M. Cuvier sus- pects, that it has a similar existence in all the prehensil-tailed mammals. Blumenbach supposes the same sense to have a place in the same organ in the platypus or ornithorhyncus as he calls it, that most extraordinary duck-billed quadruped which has lately been discovered in Australasia, and, by its intermixture of organs, confounds the different classes of animals, and sets all natural arrangement at defiance. The local organ of touch or feeling in ducks and geese, and in various some other genera of birds, appears to be situated in the inte- DJrd9- gument which covers the extremity of the mandibles, and es- pecially the upper mandible, with which apparatus they are well known to feel for their food in the midst of mud, in which they can neither see, nor perhaps smell it. We do not know that amphibials, fishes, or worms possess Whether any thing like a local sense of touch: it has been suspected in ?uch a sf°se some of these, and especially in the arms of the cuttle-fish, and ais a,^ in the tentacles of worms that possess this organ: but, at pre- fishes or sent, it is suspicion and nothing more. worms. In the insect tribes, we have much reason for believing such in what or- a sense to reside in the antennas or in the tentacles ; whence pn il exists the former of these are denominated by the German naturalists, ininsecls- fuhlhorner or feeling-horns. This belief has not been fully es- tablished, but it is highly plausible from the general possession of the one or the other of these organs by the insect tribes, the general purpose to which they apply them, and the necessity which there seems for some such organ from the crustaceous or horny texture of their external coat. The senses of taste and smell in animals bear a very near Taste and affinity to the local sense of touch; and it is difficult to deter- smell. mine, whether the upper mandible of the duck tribe, with which they distinguish food in the mud, may not be an organ of taste or smell as well as of toucli ; and there are some naturalists that in like manner regard the cirrous filaments or antennules at- tached to the mouths of insects as organs of taste and touch equally. Taste in the more perfect animals resides jointly in Seatof taste the papillae of the tongue and the palate ; but I have already inthehigher had occasion to observe that it may exist, and in full perfection, c,asses- in the palate alone, since it has been found so in persons who have completely lost the tongue from external force or dis- ease. 14 ci. iv.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifica- tions and substitutes. Nostrils the seat of smell where they exist. Differs in intensity in different animals, and why. Whether the cetace- ous tribes possess smell ? Whether atr.p hi bials or worms ? Possessed by fishes, and very acutely. Possessed by insects, but the or- gan not known. Hearing, its general or- gan the ear, though not always. In animals that possess the organ of nostrils, this is always the seat of smell; and in many quadrupeds, most birds, and perhaps most fishes, it is a sense far more acute than in man, and that which is chiefly confided in. For the most part it resides in the nerves distributed over a mucous membrane that lines the inte- rior of the bones of the nostrils, and which is called the Schnei- derian membrane, in honour of M. Schneider, a celebrated ana- tomist, who first accurately described it. Generally speaking, it will be found, that the acuteness of smell bears a proportion in all animals to the extent of surface which this membrane displays ; and hence, in the dog and cattle tribes, as well as in se- veral others, it possesses a variety of folds or convolutions, and in birds is continued to the utmost points of the nostrils, which in different kinds open in very different parts of the mandible. The frontal sinuses, which are lined with this delicate mem- brane, are larger in the elephant than in any other quadruped, and in this animal the sense is also continued through the flexi- ble organ of its proboscis. In the pig the smelling organ is also very extensive ; and in most of the mammals possessing proper horns, it ascends as high as the processes of the frontal bone from which the horns issue. It is not known that the cetaceous tribes possess any organ of smell: their blowing-holes are generally regarded as such, but the point has been by no means fully established. We are in the same uncertainty in respect to amphibials and worms: the sense is suspected to exist in all the former, and in several of the latter, especially in the cuttle-fish ; but no distinct organ has hitherto been traced out satisfactorily. In fishes there is no doubt; the olfactory nerves are very ob- viously distributed on an olfactory membrane, and, in several instances, the snouts are double, and consequently the nostrils quadruple, a pair for each snout. This powerful inlet of plea- sure to fishes often proves fatal to them from its very perfec- tion ; for several kinds are so strongly allured by the odour of marjorum, assafcetida, and other aromas, that by smearing the hand over with these substances, and immersing it in the water, they will often flock towards the fingers, and in their intoxica- tion of delight, may easily be laid hold of: and hence the ang- ler frequently overspreads his baits with the same substances, and thus arms himself with a double decoy. There can be no doubt of the existence of the same sense in insects, for they possess a very obvious power of distinguishing the odorous properties of bodies even at a considerable distance beyond the range of their vision ; but the organ, in which this sense resides, has not been satisfactorily pointed out. Reimar supposes it to exist in their stigmata, and Knoch in their anteri- or pair of feelers. The general organ of hearing is the ear, but not always so ; for in most of those who hear by the Eustachian tube only, it is the mouth : in the whale tribes, it is- the nostrils or blow-hole. It is so, however, in all the more perfect animals, which usual- ly for this purpose possess two distinct entrances into the organ; PHYSIOLOGICAL PROEM. [cl. iv. a larger and external surrounded by a lobe, and a smaller and Class IV. internal opening into the mouth. It is this last which is deno- 1. Nature of minated the Eustachian tube. The shape of the lobe is seldom the brain, found even in mammals similar to that in man, excepting among tious™!*^*" the monkey and the porcupine tribes. In many kinds, there is substitutes. neither external lobe, nor external passage. Thus in the frog, Eustachian and most amphibious animals, the only entrance is the internal, ,,lbe- or that from the mouth ; and, in the cetaceous tribes, the only o.gaTSries effective entrance is probably the same kind ; for, though these in different may be said to possess an external aperture, it is almost imper- kinds- ceptibly minute. It is a curious fact, that, among the serpents, Serpents the blind worm or common harmless snake is the only species generally that appears to possess an aperture of either sort; the rest have destitu.,e of a rudiment of the organ within, but we are not acquainted with organ"08 its being pervious to sound. Fishes are well known to possess a hearing organ, and the Fishes hear skate and shark have the rudiment of an external ear; but, and some like other fishes, they seem chiefly to receive sound by the in- havean, ternal tubule alone. **ge™al That insects in general hear is unquestionable ; but it is high- insects ly questionable by what organ they obtain the sense of hearing, hear, but The antennas, and perhaps merely because we do not know tl)e org.an their exact use, have been supposed by many naturalists to fur- nish the means : it appears fatal, however, to this opinion to observe, that spiders hear though they have no true antennas, and that other insects, which possess them naturally, seem to hear as correctly after they are cut off. The sense of vision exhibits perhaps more variety in the Sight: its different classes of animals, than any of the external senses. In 01 nan great- man, and the greater number of quadrupeds, it is guarded by an ^Jfanes In upper and lower eyelid; both of which in man, but neither of classes. which in most quadrupeds, are terminated by the additional de- fence and ornament of cilia or eyelashes. In the elephant, opossum, seal, cat kind, and various other mammals, all birds and all fishes, we find a third eyelid, or nictitating membrane as pjictifatine it is usually called, arising from the internal angle of the eye, membrane, and capable of covering the pupil with a thin transparent veil, its use* either wholly or in part, and thus defending the eyes from dan- ger in their search after food. In the dog this membrane is narrow; in oxen and horses it will extend over half the eye- ball ; in birds it will easily cover the whole; and it is by means of this veil, according to Cuvier, that the eagle is capable of looking directly against the noonday sun. In fishes it is almost always upon the stretch, as in their uncertain element they are exposed to more dangers than any other animal. Serpents have neither this nor any other eyelid, nor any kind of external defence whatever but the common integument of the skin. The largest eyes, in proportion to the size of the animal, be- Largest long to the bird tribes, and nearly the smallest to the whale ; F°por- the smallest altogether to the shrew and mole, in the latter of *,0D(:d eye" which the eye is not larger than a pin's head. ma est" The iris, with but few exceptions, partakes of the colour of iris. 16 cl.iv.] PHYSIOLOGICAL PROEM. Class IV. I. Nature of the brain, its ramifica- tions and substitutes. Pupil: Position of the eyes varies. Spiders multocu- late. Eyes of sepia. Polypes and zoophytes perceive light.though apparently without eyes. The sense probably general, but dull as that of general touch. Whether any tribe possesses other senses than the five common ? Suspected in the bat. Whether in migratory birds or fishes? Whether even in man? the hair, and is hence perpetually varying in different species of the same genus. The pupil exhibits a very considerable, though not an equal, variety in its shape. In man it is circular; in the lion, tiger, and indeed all the cat kind, it is oblong: trans- verse in the horse and in ruminating animals; and heart-shaped in the dolphin. In man, and the monkey tribes, the eyes are placed directly under the forehead ; in other mammals, birds, and reptiles, more or less laterally ; in some fishes, as the genus pleuronectes, in- cluding the turbot and flounder tribes, both eyes are placed on the same side of the head; in the snail they are situated on its horns, if the black points on the extremities of the horns of this worm be real eyes, of which, however, there is some doubt; in spiders the eyes are distributed over different parts of the body, and in different arrangements, usually eight in number, and never less than six. The eyes of the sepia have lately been detected by M. Cuvier; their construction is very beautiful, and nearly as complicated as that of vertebrated animals.* Polypes and several other zoophytes appear sensible of the presence of light, and yet have no eyes ; as the nostrils are not in every animal necessary to the sense of smell, the tongue to that of taste, or the ears to that of sound. A distinct organ is not always requisite for a- distinct sense. In man himself we have already seen this in regard to the sense of touch, which exists both locally and generally : the distinct organ of touch is the tips of the tongue and of the fingers, but the feeling is also diffused, though in a subordinate and less precise degree, over every part of the body. It is possible, therefore, in animals that appear endowed with particular senses without particular organs for their residence, that these senses are diffused, like that of touch, over the surface generally; though there can be no doubt that, for want of such appropriate organs, they must be less acute and precise than in animals that possess them. Whether there be any other than the five senses common to man and the higher classes of animals, may be reasonably doubt- ed ; but we occasionally meet with peculiarities of sensation that can hardly be resolved into any of them. Thus the bat appears to be sensible of the presence of external objects and obstructions that are neither seen, smelt, heard, touched, nor tasted ; for it will cautiously avoid them when all the senses are purposely closed up. And hence many naturalists have ascribed a sixth sense to this animal. It is equally difficult, by any of the known senses of fishes or of birds, to account for the accuracy with which their migratory tribes are capable of steer- ing their annual course through the depths of the ocean or the trackless regions of the atmosphere, so as to arrive at a given season on a given coast, or in a given climate, with the preci- sion of the expertest mariner. Whilst, with respect to mankind themselves, we sometimes meet with persons who are so pecu- * Le Regne Animal distribue d'apres son Organization, 4 tomes, 8vo. Pa- ris, 1817. PHYSIOLOGICAL PROEM. [cl.iv. 17 liarly affected by the presence of a particular object that is nei- Class IV. ther seen, smelt, tasted, heard, nor touched, as not only to be i. Nature conscious of its presence, but to be in great distress till it is re- of l.he . moved. The presence of a cat not unfrequently produces such ^mifica-8 an effect; and the author has himself been a witness of the most tionsand decisive proofs of this in several instances. It is possible, that substitutes. the peculiar sense may, in such cases, result from a preternatu- ral modification in some of the branches of the olfactory nerve, which may render them capable of being stimulated in a new and peculiar manner; but the individuals thus affected are no more conscious of an excitement in this organ of sense than in any other, and, from the anomaly and rare occurrence of the sensation itself, find no terms by which to express it. In Germany it has of late been attempted to be shown that every man is possessed of a sixth sense, though of a very differ- ent kind from those just referred to ; for it is a sense not only common to every one, but to the system at large ; and consists in that peculiar kind of internal but corporeal feeling, respect- ing the general state of one's health, that induces us to exult in being as light as a feather, as elastic as a spring; or to sink un- der a sense of lassitude, fatigue, and weariness, which cannot be accounted for, and is unconnected with muscular labour or dis- ease. To this sensation M. Hubner has given the name of cas- nesthesis, and several of his compatriots that of selbstgefuhl, and gemeingefiihl, " self-feeling or general-feeling;" and its organ is supposed to exist in the extremities of all the nerves of the body, except those that supply the five external senses.* I scarcely know why these last should have been excepted ; for the sen- sation itself is nothing more than a result of that general sym- pathy, which appears to take place between different organs and parts of the body, expressive of a pleasurable or disquiet- ing feeling, according as the frame at large is in a state of ge- neral and uninterrupted health, or affected by some cause of disquiet. II. As the nerves thus generally communicate with each II. Principle olher, and with the brain where this organ exists, it has been a ofsen8atjon question in all ages by what means they maintain this communi- an mo I0n" cation, and what is the nature of the communicated influence ? or, in other words, what is the fabric of the nerves, and the quality of the nervous power ?t Upon these points, two very different opinions have been en- tertained from an early period of the world, which, under dif- ferent modifications, have descended to our own times: for by many physiologists, both ancient and modern, the nerves have * Coinment.de Csenesthesi. Dissert. Aug. Med. Auct. Chr. Fred. Hubner, 1794.—Nature and Origin of Mental Derangement, by A. Crichton, M. D. 2 vols. 8vo. 1798. t " The question," says Dr. Bostock, " may be thus stated in direct terms. When an impression made upon an organ of sense is transmitted by a nerve to the brain, or when the exercise of volition is communicated to the nerve, so as to produce the corresponding effect upon the muscle, what change does the nerve experience, or in what way is it acted upon so as to admit of this transmission ?"—Elem. Syst. of Physiology, vol. i. p. 250.—Ed. VOL. IV. 3 18 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. II. Principle of sensation and motion. Nervous fabric, whether solid chords or hollow cylinders. Original meaning of the term nerve. Hypothesis of Hippo- crates and Galen; supposed an etheiial fluid; but ex- pressed themselves uncertain how it maintained a communi- cation with the rest of the body. The ques- tion still in an unsettled state. Hartley's hypothesis of vibratory strings not able to sub- vert the hy- pothesis of Sydenham and Boer- haave. Nervous fibres un- adapted to vibrations, as inelastic. been regarded as solid capillaments, or tense and elastic springs, operating by tremors or oscillations, like the chords of a musical instrument; and by others, as minute and hollow cylinders con- veying a peculiar fluid. The word nerve, which among the an- cients was applied to tense chords of every kind, and especially to bow-strings and musical strings, affords a clear proof how ge- nerally the former of these hypotheses prevailed among the Greeks. It was not, however, the hypothesis either of Hippo- crates or Galen ; for by them, while the nerves were regarded as the instruments of sensation and motion, the medium by which they acted was supposed to be a fine etherial fluid, elaborated in the organ of the brain ; to which they gave the name of ani- mal spirit, to distinguish it from the proper fluid of the arteries which was denominated vital spirit. " Not," says Galen, " that this animal spirit is of the substance of the soul, but its prime agent while inhabiting the brain."* But, with respect to the manner in which the animal spirit operates upon the nerves, they spoke with great modesty; for though they thought they had been able to trace a tubular form in some of the nerves, and particularly those of vision, they had not been able to suc- ceed in others. " And hence," says Galen, " it is impossible for us to pronounce absolutely, and without proof, whether a certain power may not be transmitted from the brain through the nerves to the different members; or whether the material of the animal spirit may not itself reach the sentient and mov- ing parts ; or, in some way or other, so enter into the nerves as to induce in them a change, which is afterwards extended to the organs of motion."t In a state not much less unsettled remains the subject at the present moment. Dr. Hartley, in the beginning of the seven- teenth century, revived the hypothesis, that the nerves are bundles of solid capillaments conveying motion, sensation, and even perception, by a vibratory power, and supported his opi- nion with great ingenuity and learning ;J but the opposite hy- pothesis, that they are minute tubes filled with the animal spirit of the Greek physiologists, had acquired so extensive a hold ever since the discovery of the circulation of the blood, which pre-supposes the existence of tubular vessels too subtile to be traced by the senses, that it never obtained more than a partial and temporary assent; and hence, from the times of Sydenham and Boerhaave almost down to our own day, the last has been the popular doctrine. In effect, no fibres of the animal frame can be less adapted to a communication of motion by a series of vibrations than those of the nerves, since none exhibit a smaller degree of elas- ticity ; and though we have little reason to confide in their tu- bular structure, or to believe that any kind of fluid is transmitted in this way, the close affinity which the nervous power is now * De Hippocratis et Platonis Decretis, Lib. vn. A. torn. i. p. 967. Ed. Basil. 1542. t Id. Sect. C. p. 969. % Observations on Man, his Frame, &c. his Duty, and his Expectations. 2 vols. 8vo. 1749. PHYSIOLOGICAL PROEM. [cl. iv. 19 known to hold with several of the gases that chemistry has of Class IV. late years unfolded to us, and the wonderful influence which n. Principle some of them possess over the moving fibres of the animal °[ide™*Jj°" frame, seem to leave no question, that the nervous power itself Je is a fluid,* though not, perhaps, of their precise nature, yet re- doubt, how sembling the most active of them in its subtilty, levity, and ra- ever, of a pidity of movement. Nor is there, upon this supposition, any ""^raj.*" difficulty in conceiving its transmission by solid fibres or capil- tiulA . laments of a particular kind, the neurilemma of Bichat, whilst which, like we behold the etherial fluids, now referred to, transmitted in ™re™doeil the same way by substances still more solid and unporous. not „eed But there is another question, closely connected with the pre- hollow yes- sent subject, that has also greatly interested physiologists both "k^.18 in ancient and modern times, and is not yet settled in a manner sjon> altogether satisfactory. It has appeared that the nerves are instruments both of sen- Whether sation and motion. Are these two effects produced by the same a*'ds*n'0°t"on nervous fibres, or by different? or by the same fluids, or by dif- a co,mnou ferent ? That there must be two distinct kinds of fibres or of power, or fluids is clear, because, as we shall have more particularly to [™l"^glninct observe when we come to treat of paralysis, the muscles of a The two limb are sometimes deprived of both sensation and motivity at effects must the same period, sometimes of sensation alone while*molivity {j.r0°med^tinct continues, and sometimes of motivity alone while sensation con- fibres or tinues. And hence Hippocrates and Galen, the last of whom fluids. has treated of the subject with great minuteness in many of his According writings, while they speak of only one kind of animal spirit, Qr^?i speak of two kinds of nerves, those of sense and of motion ; fromdistinct equally issuing from the brain, and mostly accompanying each setsoffibres. other, and forming parts of the same organs.t This distinction is supported by the concurrent observations How far and experiments of physiologists, and especially by the curious ^J^^n investigations of many of those of our own day, among whom physiolo- should be particularly noticed the names of Flourens, Rolando, gists. Charles Bell, Magendie, and Shaw. M. Rolando attempted to S"cl°pr0. show, by a long train of interesting but very painful experi- vinces of ce- ments, carried on through animals of almost every kind, that rebinm and t* • i t cerebellum the cerebrum is the ordinary source of sensation, and the cere- bellum of motion: for, ac^rding to his observations, in every instance in which the former is much broken down, or in any other way injured, drowsiness, stupor, or apoplexy, is sure to follow ; the animal being still capable of exercising locomotive power, but without any guidance or knowledge of what it is about, or where it is moving to. But the moment the cerebel- lum is wounded, the locomotive power is instantly lost.J These investigations were valuable as leading on to others more accu- rately conducted and followed up by more correct conclusions. * The editor's opinion of this hypothesis will appear in the sequel. t The curious fact of most of the nerves of motion (though not all) origin- ating from the spinal marrow, has been already stated.—Ed. % Saggio so- pra la vera Struttura del Ccrvello, &c. e sopra le Fonzioni dclla Sistema Nervosa. Sassari, 1809. 20 cz. iv.] PHYSIOLOGICAL PROEM. Class IV. II. Principle of sensation and motion. Such sepa- rate powers since con- firmed, but conversely ascribed. Principal experiment- ers on the uses of dif- ferent parts of the brain. Hemis- pheres. That these distinct portions of the brain are endowed with se- parate powers, as observed by Rolando, has been sufficiently as- certained by other pathologists ; and especially by M. Flourens,* who does not seem at the time to have been acquainted with Rolando's experiments, and consequently gives us the weight of an unconnected testimony. But it seems to M. Magendie! to be now better established, that the converse of M. Rolando's con- stitutes the law and order of nature : sensation appearing to be dependent upon the cerebellum, instead of upon the cerebrum, while motivity takes its rise from the cerebrum, instead of from the cerebellum. [If, however, the researches and experiments of Magendie oppose those of the foregoing physiologists, let it be remember- ed, that the results of his investigations disagree with many ob- servations made on this subject by physiologists of high reputa- tion. According to Mr. C. Bell, the nerves of the greatest num- ber of the voluntary muscles are derived from the medulla spinalis, and the best modern anatomists trace the origins of most of the other nerves to the medulla oblongata. If, there- fore, the origins of the nerves could be taken as a criterion, Magendie's views would not be at all tenable. But it is not by this test that the question can be settled, because the enquiry here refers, not to what nerves are concerned in sensation and voluntary motion, but to what part of the brain or cerebellum the power of regulating the voluntary action of the muscles is to be ascribed ? It is a question, therefore, that can only be set- tled by experiment. In order to determine the exact uses of particular parts of the brain and its appendages, numerous experiments have been performed,, which consisted in observing very carefully the ef- fects resulting from the injury of definite portions of those or- gans. The first researches of this description were those of Molinelli,J and they have been followed up by the more important experiments of Boerhaave, Haller, Zinn, Zimmermann, Fodera,§ Legallois,|| Krauss,H HertwigJl* and those of the physiologists already enumerated. Of alRfte experiments made on this sub- ject, those of Flourens are perhaps the most valuable. From them, which indeed confirm earlier observations, it results, that each strongly developed part of the brain is intended for the performance of particular function* the hemispheres of the cerebrum being the organ of the mental faculties (understand- ing, memory, and will), and the centre of all the perceptions :|| * Archives Genlrales de Medecine, i. n. Also, Rccherches Exp. sur le Syst. Nerveux. Paris, 1824. t Experiences sur les Functions, &c. Jouru. de Physiologie, torn. ii. iii. passim, 1822, 1823. X Comment. Bononiens. p. 130. § Magendie, Journ. de Physi- ologie, vol. i. 1823. || Exp. sur le Principe de la Vie. IF Diss, de Cerebri laesi ad motum Volunt. relatione. Vratisl. 1824. ** Hecker's Litterarische Annalen, &c. May 1826. tt The following criticism is entitled to consideration: " One of the most important points, which M. Flourens attempts to establish, is, that the lobes of the cerebrum are the exclusive seat of sensation and volition ; yet it seems quite evident, from the result of the experiments, that, after the removal of these lobes, sensation, although rendered feeble or obtuse, was by no means extinguished; while the functions which depend upon volition, such as the various kinds of locomotion, were still executed by the animal, although it was difficult to excite them into action."—See Bostock's Physiology, vol. iii. p. 374. PHYSIOLOGICAL PROEM. [cl. iv. 21 while the cerebellum is the organ in which the different muscu- Class IV. lar motions are regulated and directed to one common object, n. Principle In the corpora quadrigemina is seated the original active prin- of sensation ciple of the iris, the retina, and optic nerves. Irritation of ^,u mo l0n" the corpora quadrigemina, medulla oblongata, and medulla spi- qua3ri- nalis, shows, that these are the only parts of the nervous sys- gemina. tem connected with muscular contractions. Another inference is, that the power of sensation is a single one, and resides in a single organ. According to Hertwig's still more recent investigations, al- though the substance of the hemispheres is the centre of all the perceptions, it is insensible of external irritations. Irritations and even injuries of the hemispheres, he found, produce no in- voluntary motions of the muscles, merely weakness and paralysis of them, and always on the side of the body opposite to that on which the injury was inflicted. Hertwig's experiments also confirm the doctrine, that the operation of the hemispheres is in a crossed direction; that the consensus communis is not depend- ent on them alone, since it remains after they have been de- stroyed ; and that the respiration and circulation are also inde- pendent of them. With respect to the cerebellum, Dr. Hertwig found that its Cerebellum. substance was not sensible to immediate external irritations, by which also no motions of the muscles were excited ; but that the undisturbed operation of this organ is necessary to the pro- duction and co-operation of the muscles for a particular purpose, as flying, walking, &c. His experiments likewise tend to prove, that the action of the cerebellum on the voluntary muscles takes place in a cross direction; and that the uses of the senses, and all the other functions, depend very little on the action of the cerebellum. According to Dr. Hertwig, a superficial irritation or wound of Ponsvarolii. the pons varolii produces in animals some pain and temporary convulsions ; but deep, penetrating injuries cause, independently of the other effects, a permanent irregularity in the voluntary motions of the body, arising from a disturbance in the balance of the powers between the two sides of the body, or between its anterior and posterior parts. The pons exerts considerable in- fluence over the voluntary locomotive organs for the preserva- tion of the balance between them. Another conclusion, to which Dr. Hertwig's experiments led him, is, that the pons varolii has little influence over the senses and consciousness. With regard Medulla to the medulla oblongata, Dr. Hertwig, by experiments, corrobo- oblougata- rates the opinion that it has great influence over respiration, and also partly over the circulation. Hence its complete division destroys life by interrupting respiration. The same experiment- er infers, that, as injuries of this organ do not disturb the senses, the intellectual functions can have no dependence upon it.] Mr. Charles Bell has successfully followed up the distinct and Followed up established powers of the two departments of the brain* into the b7c- Bell spinal marrow, which he has sufficiently proved to consist of a spioal*6 marrow. * Idea of the Anatomy of the Brain, 1809. 22 ci. iv.] PHYSIOLOGICAL PROEM. Class IV. double chord ;* an anterior connected with the crura of the ce- ll. Principle rebrum, and productive of locomotion, and a posterior connected of sensation wjth the crura of the cerebellum, productive of sensation.t And an motion. ke nag farther shown, that these two distinct powers are commu- 8tratio™0n nicated to every part of the body by nervous fibres, according as Double" *^ev 'ssue from the one or the other of these respective chan- chordofthe nels: that, for the most part, every nervous fascicle distributed spinal chain. over the body and limbs has a double origin, and issues equally Like me- from both the anterior and posterior trunk of the spinal medulla, continued to and *s consequently alike sensific and modific; while those which every part proceed from one alone are limited in their power to the pecu- of the body. ijar property of their source,J of which the portio dura of the Strikingly seventh nerve affords a striking example: being, when uncom- inthePpor?tio bined, simply a nerve of motion, without the attribute of sensa- duraofthe tion, but exercising motion over all the organs of the face that seventh are connected with the function of respiration, whether in the nerve' cheeks, lips, and nostrils; and hence operating equally in the acts of speaking, singing, sucking, drinking, spitting, coughing, * The following is Mr. Bell's description : " Different columns of nervous matter com- bine to form the spinal marrow. Each lateral portion of the spinal marrow consists of three tracks or columns ; one for voluntary motion, one for sensation, and one for the act of respir- ation. So that the spinal marrow comprehends in all six rods, intimately bound together, but distinct in office ; and the capital of this compound column is the medulla oblongata. No doubt, he adds, these grander columns contain within them subdivisions; for if we lift up the medulla spinalis from the cerebellum, and look at its back part, we shall see more numerous cords, the offices of which will one day be discovered."—See Exposition of the Natural System of the Nerves, p. 20, 8vo. Lond. 1824. t " The anterior column of each lateral division of the spinal marrow is for motion, the posterior column is for sensation, and the middle one is for respiration. The two former extend up into the brain, and are dispersed or lost in it, for their functions stand related to the sensorium ; but the latter stops short in the medulla oblongata, being in function inde- pendent of reason, and capable of its office independent of the brain, or when separated from it. "It is the introduction of the middle column of the three, viz. that for respiration, which constitutes the spinal marrow, as distinct from the long central nerve of the animals without vertebrae, and which is attended with the necessity for that form of the trunk which admits of the respiratory motions."—Op. cit. p. 22. ^ The following account has been published by Mr. Mayo : " When a spinal nerve is di- vided in its course through the body, the parts supplied by it beyond the division are paralys- ed : they lose sense and motion. If the two origins of the spinal nerves be exposed in a young animal, and separately divided, different effects are produced. The section of the anterior root deprives of voluntary motion the part supplied by the nerve; the section of the posterior root deprives the corresponding part of the body of sensation, voluntary motion being left." These experiments were made by M. Magendie, and published by him in his Journal of Phys- iology. But, many years earlier, Mr. Bell had made experiments upon the spinal nerves, some account of which had been printed, and circulated among his friends, as well as deliv- ered in his lectures. The following is an extractfrom this account: " On laying bare the roots of the spinal nerves (observes Mr. Bell), I found that I could cut across the posterior fascicu- lus of nerves, which took its origin from the posterior portion of the spinal marrow, without convulsing the muscles of the back; but that, on touching the anterior fasciculus with the point of the knife, the muscles of the back were immediately convulsed." Mr. Bell was car- ried by these experiments (says Mr. Mayo) very near to the truth, but he failed at that time to ascertain it: he inferred from his experiments, indeed, that the anterior and posterior roots of the spinal nerves have different functions ; but in the nature of these functions he was mistaken. Upon the anterior root he supposed both sensation and motion to depend ; the posterior he considered an unconscious nerve, which might control the growth and sympa- thies of parts. Before Mr. Bell published any other account of the functions of these nerves, M. Magendie had given to the world the true theory of their uses. See Mayo's Outlines oC Physiology, p. 325, 2d edit, 1828, PHYSIOLOGICAL PROEM, [cl. iv. 23 and sneezing. And he has confirmed these discoveries by the Class IV. striking fact, that the nerves of the head, which issue like the IE Principle spinal medulla, from both departments of the brain, possess the of^e,,sa,.ion same double power, and are, in like manner, nerves of sensation andmoUoD- and motion ; of which the fifth pair offers a notable example, bestowing at the same time sensibility on the head and face, and performing various muscular motions common to all animals ; so as to be analogous to a double spinal nerve, or rather to the spine itself, and enriched, like the spine, with ganglions in par- ticular parts. Many of these experiments have since been re- Confirmed peated, and the results to which they have thus led, though in hy contem- some respects opposed by other experiments of M. Fodera,* Kta?*" have generally been confirmed by M. Magendie, Mr. Shaw, Mr. Broughton, and various other anatomists : and we hence see the reason of those frequent decussations, and other interunions of nerve with nerve, by which those possessing a single origin, and consequently a single property, hereby exchange filaments, and become enriched with a new power, the respective filaments being enveloped in the sanie 6heath. [In elucidating the uses of the fifth pair of nerves, and the Mayo's portio mollis of the seventh, Mr. Mayo seems to merit consider- researches. able honour. The inference which Mr. C. Bell drew from cer- tain experiments! was, that the branches of the fifth, which emerge upon the face to supply the muscles and integuments, are for sensation and voluntary motion jointly ; and that the use of the seventh (the branches of which are distributed to the same parts) is to "govern the motions of the lips, the nostrils, and the velum palati, when the muscles of these parts are in associated ac- tion with the muscles of respiration." In other words, according to Mr. Bell, the seventh is the nerve of instinctive motion to the face, and the fifth of voluntary motion and sensation. This the- ory, however, was afterwards proved to be erroneous by a series of experiments detailed by Mr.Mayo.J From these the conclu- sion was made, that the portio dura of the seventh nerve is a sim- ple voluntary nerve, and that the facial branches of the fifth are ex- clusively sentient nerves. In pursuing this subject, Mr. Mayo was led to observe, that there are muscles which receive no branch- es from any nerve but the fifth : these muscles are the masseter, the temporal, the two pterygoids, and the circumflexus palati. These muscles, he farther remarked, are supplied with branch- es from the third division of the fifth, that is to say, from the particular division of the fifth with which the smaller fasciculus or root of the nerve is associated. After some careful dissection, in the greater part of which he found that he had been antici- pated by Paletta, he made out, that the smaller fasciculus of the fifth is entirely consumed upon the supply of the above mentioned muscles, to which it is to be borne in mind, that twigs from the ganglionic portion are likewise distributed. "But (says Mr. Functions of Mayo) I had already ascertained by experiment, that almost all the portio dura, and * Recherches Experimentales, &c. Journ. de Physiologic Juillet, 1823. fiftQ nerve* t Phil. Trans, 1821, p. 413. % Anat. and Physiol. Commentaries, 1822. 24 ct. iv.] PHYSIOLOGICAL PROEM. Class IV. the branches of the larger or ganglionic portions of the fifth were of sensafP,e nerves of sensation- I proved this point in the ass, the dog, and andTotion! !be rabbi.t» respecting the second and third division of the fifth ; in the pigeon, respecting the first division. It was therefore thoroughly improbable, that the twigs, sent from the same part of the nerve to the muscles of the lower jaw, should have a dif- ferent quality, and be nerves of motion. For this function it was reasonable to look to the other nervous fibrils, which the mas- seter, and temporal, and pterygoid muscles receive ; in other words, to the branches of the smaller fasciculus or root, or ganglionless portion of the fifth. All this was made out before the publication of M. Magendie's discovery of the parallel functions of the double roots of the spinal nerves."* At the same time that we render praise to Magendie and Mayo for what they have done on this intricate subject, we feel sensi- ble of all the valuable and original experiments and observations communicated to the world by Mr. C. Bell. He has most ably explained, that the great error, which has misled anatomists in their conceptions concerning the nerves, has consisted in follow- ing, though with some license, the old hypothesis, that the nerves receive their influence from the brain, and confer it on remote parts of the body, and that they are endowed with the same powers. For (says he) whether we look upon the intricacy of the parts on dissection, or attempt to unravel the mystery of sensation, and voluntary and involuntary motion, performed by a single nerve, there is a complete discrepancy betwixt the fact Mr.C.Bell's and the hypothesis. In the view which Mr. Bell has taken of viewsofthe the nerves of the human body, there are, besides the nerves of nervous vision, smell, and hearing, four systems combined into a whole. Nerves, entirely different in function, extend through the frame : those of sensation ; those of voluntary motion ; those of respira- tory motion; and lastly, nerves, which, from their being defi- cient in the qualities that distinguish the three others, seem to unite the body into a whole, in the performance of the functions of nutrition, growth, and decay, and whatever is directly neces- sary to animal existence. These nerves, Mr. Bell remarks, are sometimes separate, sometimes bound together; but they do not, in any case, interfere with, or partake of, each other's influence. A nerve is seen to consist of distinct filaments; but there is no- thing to distinguish them, or indicate their offices. One filament may be for the purpose of sensation, another for muscular mo- tion ; a third for combining the muscles in the act of respiration ; but the subserviency of any particular filament to its proper of- fice can only be made out by tracing it, and observing its rela- tions, and especially its origin in the brain and spinal marrow. The key to Mr. C. Bell's system is in the simple proposition, that each filament has its peculiar endowment, independently of the other filaments bound up along with it; and that it contin- ues to have the same endowment throughout its whole length. Thus, if its office be to convey sensation, that power shall be- See Mayo's Outlines of Human Physiology, p. 331, et seq. 2nd edit. PHYSIOLOGICAL PROEM. [cl. iv. 25 long to it in all its course, wherever it can be traced; and at whatever point, whether in the foot, leg, thigh, spine, or brain, it may be bruised, pricked, or otherwise injured, sensation, and not motion, will result; and the perception arising from the im- pression will be referred to that part of the skin where the re- mote extremity of the filament is distributed. According to Mr. Bell, wherever we trace nerves of motion, we find that, previously to their entrance into the muscles, they interchange branches, and form an intricate mass of nerves, or what is termed a plexus. This plexus is intricate, in proportion to the number of muscles to be supplied, and the variety of combinations into which the muscles enter, while the filaments of nerves, which go to the skin, regularly diverge to their des- tination.*] There is much, however, in thi3 recondite subject, that still requires elucidation ; and particularly in regard to that continu- ation of sense and motion in many cases which we shall hereaf- ter have to notice, in which the brain, through a very consider- able extent, both in its white and cineritious substance, has been found in a mollescent or pulpy state ; often indeed entirely dis- organized, and as soft as soap: while, in other instances, the spinal marrow, through an extent of six or seven inches in length, has been found equally dissolved, and its chain com- pletely destroyed ;t one set of limbs being rendered rigid and motionless, with an augmented sensibility, at the same time that the sensation and mobility of the rest have been scarcely inter- fered with. And hence a separate and specific power has, from an early age, been ascribed to the nervous fibres themselves, while the brain has been contemplated as their radix. This, in truth, was the peculiar hypothesis of Glisson, and nearly so of Haller, with respect to the motory power; and Girtanner, who trod in the same footsteps, with a clear and comprehensive mind, considerably enlarged upon it, and gave to the moving en- ergy the name of vis insita, as, by way of distinction, he ap- plied that of vis nervea to the energy or power of feeling. And as he believed that other organs besides muscles, and indeed plants as well as animals, are possessed of fibres endowed with the same power, and that a brain is by no means essential for their production, he, in like manner, changed the name of mus- cular to that of irritable fibre ; and contended that a principle of Class IV. II. Principle of sensation and motion. Much eluci- dation still required respecting the continu- ance of these pow- ers in a dis- organized state of brain or spinal marrow. Hypothesis of Glisson, Haller, and Girtanner. Vis insita as contra- distinguish- ed from vis nervea. Why called irritable fibre. * See Exposition of the Natural System of the Nerves of the Human Body, 1824. t This point requires farther investigation. When the spinal chord is divided in experi- ments upon warm-blooded animals, or is compressed or lacerated, the lower part of the body is totally paralysed. This result, as Mr. Mayo observes, is so uniform, that we are bound to suppose an error in the narrative of two well-attested cas>es, on record, of sensation and vol- untary motion continuing after the division of the spinal marrow. Some violence is scarcely avoidable in opening the spinal canal; and if the spinal chord be already paitially divided, the operation of exposing it may easily complete the rupture. How slight a continuity of nervous fibre is sufficient to sustain the coininuiiication between parts of the medulla spinalis must be known to those who have attempted to destroy animals by pithing : a very slender layer of nervous substance will enable the animal to continue breathing, which, however, ceases instantly on its division. See Mayo's Outlines of Physiology, p. 285, 2d edit. Editor. vol. iv. 4 26 CL. IV.] PHYSIOLOGICAL PROEM. Class IV. II. Principle of sensation and motion. Oxygen conceived to be its principle, and galva- nic fluid since its discovery. Discovery of the last nearly anti- cipated half a century before. irritability is common to fluids as well as to solids, and co-exten- sive with organized nature.* By what means these fibres unite into solid masses or hollow coats, and what are their respective powers when thus compli- cated, shall be glanced at hereafter ;t at present, we must con- fine ourselves to their actuating principle, whatever that may consist in. Oxygen was at this time the popular aura of the philosophers, as caloric had been a short time before. Lavoisier had just proved its close connexion with several of the vital functions, and hence the chemical divinity of Girtanner was oxygen. He paid unbounded homage to its influence ; attempted to show that irritability, and even life itself, are dependent upon it; and that, in the animal system, it is distributed to every part by means of the circulating blood. But the still more striking properties of the galvanic fluid be- gan now to be discovered, and to captivate the general atten- tion ; and the time drew nigh in which oxygen was doomed to fall as prostrate before the shrine of galvanic aura, as caloric had fallen before that of oxygen. And it is curious to remark how nearly this discovery was not only made but completed in all its bearings, and by the very same means, about fifty years before the attention of Galvani was directed to the subject; for we are told in the Philosophical Transactions for 1732,J that the queen's physician, Dr. Alexander Stuart, being engaged in a course of experiments upon the frog, observed, upon thrust- ing the blunt end of a probe into the spinal marrow after decap- itation, that the muscles of the animal's body were thrown into convulsive contractions ; and that the same happened to the muscles of the head when the probe was thrust into the brain. And by additional experiments he advanced so far as to infer, that what the nerves contribute in muscular motion cannot be produced by oscillations or elasticity, but must be owing to a fluid contained in them; but which fluid he was unfortunate enough to conceive was a pure and perfectly defecated element- ary water ; using the word water, however, in a general sense, as merely opposed to sal volatile, or fermented spirits, which he thought the term animal spirits was calculated to import. Whatever be the nature of the active and etherial fluid which was thus supposed to exist by Stuart, and has since been at- tempted to be established by Galvani, it is presumed to have a powerful influence upon many branches or divisions of the ner- vous system, though not upon all.§ Its effects upon the muscles * Memoires sur 1'Irritabilite, considSree comme principe de vie dans la nature organisSe. Journ. de Phys. 1790. t See the introductory remarks to Order III. of the present class, Neurotica, Cinetica. X Vol. xxxvii. p. 324. i Although our author, as we shall presently find, makes the judicious distinction between the hypothesis of galvanism and electricity being identical with the imaginary nervous fluid, and the doctrine of their being only stimulants, by which the secretion of this fluid may be excited, and the action of the nerves continued, he does not seem to entertain the slightest doubt of the actual existence of a nervous fluid, and of its being a secretion, as if these cir- cumstances had been satisfactorily proved and demonstrated. The editor often regrets that PHYSIOLOGICAL PROEM. [cl. iv. . 27 of an animal for some hours after death are too well known to Class IV. be particularized: and Dr. Philip seems to have shown, by va- n.Principle rious trains of experiments,* that it is equally capable of main- of sensation taining respiration, and the operation of several of the animal *nd mo|,on- secretions, especially those that induce-digestion, for as long a affinity with period. But in drawing from such facts the corollary, that the the nervous "identity of galvanic electricity and nervous influence is estab- influence; lished by these experiments," he seems, like those who have provwfto anticipated him in the same doctrine,! to proceed farther than be the same. he is warranted: for we have no right to say more, than that galvanic electricity is a stimulus exciting the nervous influence into a state of continued secretion, or continued action; which may possibly be done by various other stimuli, as well as by that of galvanism. M. Rolando, however, has proceeded farther Fanciful than this; for while he regards the nervous fluid and that of ^"fj0™^" galvanism as identic, he contemplates the cerebellum and its ap- jecture of pendages as a galvanic machine, in which the cerebellum itself Rolando. constitutes the formative pile, the medulla oblongata the con- Dr. Good should have assumed these hypotheses as positively established facts, and that he did not rest satisfied with the less objectionable expressions, nervous power, nervous energy, or nervous influence, instead of the phrases, more frequently introduced into the last edition than the present, of " secretion of sensorial power, of the nervous fluid," &c. Azc. involving him in the most visionary speculations. The hypothesis of a nervous fluid, the product of se- cretion, is not essentially different from the notion of the existence of animal spirits. The principal ground of the latter, as Dr. Bostock remarks, " seems to have been the idea that the brain is a secretory organ ; an idea which was suggested by the great quantity of blood sent to it, and by some supposed resemblance in its structure to other secreting glands. (Descar- tes, Tractatus de Homine, } 14.) Yet, as nothing cognizable by the senses is produced by it, it was concluded, that it must secrete something of a subtile or etherial nature, peculiarly suited to the performance of the functions which belong to the brain, and which are so unlike those of other material substances. It must be recollected that, about two centuries ago, every thing that could not be otherwise explained was referred to the agency of some kind of refined spirit; an idea which appears to have been originally derived from the alchymists, and, after being incorporated with the metaphysics of the age, gave rise to a long train of. mysticism. Almost every philosopher of that period adopted more or less of these notions. Newton's ether is well known to have proved an abundant source of speculation to multitudes of those who called themselves his followers, and who seem unfortunately to have copied al- most the only error which this great man committed. Upon this slender foundation was built the hypothesis of the nervous fluid, or the animal spirits, as they have been termed ; yet their existence was assumed as an ascertained fact, and even their different affections and diseases were spoken of with as much confidence, as if the authors had been treating upon something, which was the immediate object of their senses, and with which they were perfect- ly familiar. The doctrine of the animal spirits has likewise become a subject of popular be- lief, and has given rise to a variety of expressions that are every day employed in our com- mon language. There does not, however, appear to be the least shadow of proof of their ex- istence, either from experiment or observation; there is no analogy in their favour; the structure and physical properties of the nerves do not seem adapted to the office that has been assigned them ; and, in short, the whole is an hypothesis entirely unfounded and quite gratui- tous." See Bostock's Physiology, vol. i. p. 253. * Phil. Trans. 1815, p. 5—90. t The researches of Valli led him to conclude that electricity and the nervous fluid were identical (Journ.de Phys. torn, xli.) And, as is remarked by Dr. Bostock, Mr. Abernethy goes still farther; for he regards some subtile fluid, analogous to electricity, not merely as the prime agent in sensation, but even as constituting the essence of life itself. "Singular as it may appear, we find this highly respectable and intelligent writer sliding into materialism at the very time when he is directing the force of his genius against this doctrine. (See Lect. on Hunter's Physiology, p. 26. 30. 35. 80, &c.) It is scarcely necessary to observe, that, met- aphysically speaking, the subtile or etherial agents, that are called into aid in our explana- tion of the vital phaenomena, are as truly material as the densest stone or metal." (See Bos- tock's Physiology, vol. i. p. 256.) 28 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. ductor in which the fluid is accumulated, and the spine and II. Principle nerves the channels through which it is conveyed to the mus- and motion C'eS f°r the PurP0Se of exciting voluntary motion. But this puts us into possession of only one-half of the powers of the brain,— the motific. For the sensific powers, M. Rolando has revived the old doctrine of vibrations, already noticed, and conceives that all sensations are commenced at the extremities of the nerves, and are conveyed from the circumference to the centre of the system by vibrating chords.* Result of Upon the whole, the nervous system seems to present itself, NerVous'17- in the different classes of animals, under various scales of elab- sysiem oration ; but, in every scale, to be a secernent organ through differently its entire range ; operating by means of two or more different but^'sVcer- Sets °^ ^res, wh'ch may be secretories or conductors of as nent organ : many different fluids, or modifications of the same fluid.t possesses In the higher and more complicated classes of animals it con- sols of m°re s*sts °* a cylindrical chord or spinal marrow, a central or gan- fibres, glionic compages and a brain, all communicating and acting in secretories harmony .J In some of the inferior classes, we find the cylin- ductors of dr'ca' chord alone, and in others the ganglionic compages ; different while, in the lowest of all, we trace a variety of distinct and fluids, or granular molecules, which seem to act the part of nervous gan- tions'of "a §"'i°nsi though we cannot discover their connexion. common The brain has so much of the general structure and charac- fluid. ter of a gland, as to be admitted by many to be an organ of this raU^ad-"6 kincl,§ This is a Point conceded even by Dr. Cullen, notwith- mitferftobe standing that, by supposing the energy of the brain to be a a gland. mere quality rather than a specific essence, and to be incapa- Cullen's ble of undergoing any change of recruit or exhaustion, he finds hypothesis. no adequate use for its glandular conformation. As we are jus- tified, however, by all the force of analogy in regarding it as a gland, though unquestionably a gland of a peculiar kind, and as we are equally justified, on the same ground of analogy, in regarding the nervous power or energy by which it maintains a communication with every part of the system as a fluid of a * Coster, Archives Generales de Me'decine. Mars, 1823. "t One objection to this hypothesis depends upon the fact, that, if it were admitted, we should not then have any clearer notions of the mode in which the brain and other parts of the nervous system perform their functions, than if no such hypothesis had ever been started. As Mr. Lawrence has observed, who understands muscular contraction better by being told, that an Archeus or subtile matter sets the fibres at work ?__Ed. | De Nervi Sympathetic! humani fabrica, usu, et morbis, &c. Auctore, J. Lobstein, Parisiis, 1323. ' i This doctrine, though adopted by some physiologists, is not espoused by others. When the comparison of the brain to a gland is made, we may enquire, whether it he in- tended to assume that the nervous fluid is secreted by the brain, and thence transmitted through the nerves ; or whether the brain only secretes its own nervous fluid, and the nerves theirs; ? Lastly, we may ask, who has ever seen this wonderful fluic', and how ma- ny kinds of it are fancied to exist? for the several parts of the brain have different func- tions; and some nerves are for sensation, and others for motion. In short, it is better to confess, that we know nothing of the way in which the brain and other parts of the ner- vous system execute their functions ; and, instead of talking about the secretion of the ner- vous and sensorial fluid, it may be wiser to rest satisfied with the less objectionable phrases of nervous action, nervous energy, nervous influence, sensorial power, &c.__Ed. PHYSIOLOGICAL PROEl^ [ct. iv. 29 peculiar kind, we are almost driven to tHCriecessity of contem- Class IV. plating it as the source from which this fluid issues, and by II. Principle which it is supplied as it becomes exhausted : and more espe- of ;!e"9a!!°" .hi /. i i' u i 1 a°d motion. cially when we reflect upon the enormous proportion ot blood which is sent from the heart to the head, as the most extensive laboratory of the entire frame, and which, according to Hal- ler,* amounts to one-fifth, or, on the lower estimate of Monro,t to one-tenth of the entire current poured forth from the left ventricle of the heart, while it is well known, that the weight of the human brain is not more than one-fortieth part of the entire body. It is probable that the nervous fluid, on its first secretion and ^r.vol)c ♦ • i • . i i c j.l li j nuia at first in its simplest state, is as homogeneous as that ot the blood; perhaps ho- but that, like the blood, it becomes changed by particular ac- mogei.eous; tions, either of the particular parts of the brain, or of particu- l\^^y lar nerves themselves, into fluids possessing different powers, particular and capable of producing very different effects. And as mo- actions, and dern experiments have induced us to believe, with Galen, that ^"^gdof the nerves are a continuation of the matter of the brain,J it is producing not improbable that many or all of them are endowed with different something of its secernent power, and are capable of assisting effect8, in the secretion of the same fluid in its simplest state, or in some of its simpler modifications. And we may hence see the Nervous reason of that complicated mechanism which distinguishes the ^"^^r" higher classes of animals, and how it is possible for a nervous the matter system to exist, thousrh with inferior powers, under a less com- or the brain, J .. c , . ..' a r and hence posite fabrication. probably This, however, is not mere conjecture: for in acephalous themselves and anencephalous monsters we are compelled to admit it as a secernent: fact; and in different ramifications of the nerves we can trace whence a such different effects actually produced : and as it has sufficient- "er.v°u* . ' • -ii u.ii system may ly appeared that the operative power is a quick and subtile exist under fluid, we are directly led to conclude, that such difference of aompara- effects must depend on a diversity of fluids, or on various modi- [^/^ fixations of a common fluid in different trunks or ramifications; Proofsof the last of which explanations is by far the simplest and easi- thig est.§ And hence, in certain parts of the system, the nervous HeDce influence becomes capable of producing the effect of sensation; sometimes in others of motion. And hence, again, the sensific influence a sensiSc . . . . r c power auu is rendered capable of exciting in one set of organs a sense ot £oinetinieg sight; in others, of hearing, smell, or taste; while that of a motory. touch is diffused over the surface generally. Tl,is *ie* This last, by its extensive diffusion, is, by Mr. Hunter, called "X common sensation ; and his view of the subject is in perfect con- Hunter's. * Elem. Physic, x. v. 20. t On the Nervous System, p. 3. J Hippocr. et Plat. Decret. Lib. ill. torn. i. p. 921. { These hypotheses are at once refuted by the consideration, that the different attributes of different nerves, or nervous filaments, are ascertained by the best modern physiologists, and particularly by the important experiments of M. Magendie and Professor Bell, to de- pend upon the nature of their origin or roots, and the particular manner, in which they are connected with certain portions of the brain, spinal chord, .fee. Their connexion or not with ganglions is another circumstance seeming to have r.iucli influence.— Editor. 30 Class IV. II. Principle of sensation and motion. A brain necessary where all the local senses are complete and perfect. Not neces- sary where only a ge- neral sense of touch. Mot i fie or irritative power of a lower de- scription thau sensific. cl. iv.] ^JYSIOLOGICAL PROEM. sonance with the pffcent. «It is more than probable," says he, " that what may be called organs of sense (local organs) have particular nerves, whose mode of action is different from that of nerves producing common sensation, and also different from one another; and that the nerves, on which the peculiar functions of each of the organs of sense depend, are not sup- plied from different parts of the brain. The organ of sight has its peculiar nerve : so has that of hearing; and probably that of smelling likewise : and, on the same principle, we may sup- pose the organ of taste to have a peculiar nerve, although these organs of sense may likewise have nerves from different parts of the brain ; yet, it is most probable, such nerves are only for the common sensations of the part, and other purposes answered by nerves."* We see farther, that, for the purpose of elaborating the ex- quisitely fine and active fluid that, differently modified, excites the local organ of sense, and excitest them in perfection, it is necessary that the nervous system should exist in its highest scale of fabrication, and be crowned with the apparatus of a brain, though this is not the only use to which the brain is sub- servient : and hence it was long ago pointed out by Galen, that it is from the brain alone the nerves appropriated to the local senses take their rise ;J for though we have instances of the existence of a few of these senses where the nervous system is found in a less finished form, they are never complete in number, nor apparently in acuteness. The sense of touch, on the contrary, which, as we have al- ready observed, is regarded by Cuvier as produced by the sen- sific fluid in its simplest and least compounded state, or, as Ga- len has it, "is the dullest and rudest of all the sentient pow- ers," flows for the most part, as the latter has also remarked, from the spinal marrow alone, since it is from this column that the nerves of touch almost exclusively arise. And hence we have little difficulty in conceiving how a sense of this kind may exist in mollusca, shell-fishes, and the larvae of insects, which have no other nervous system than a medullary column, with a slight increment at the upper extremity, or no increment what- ever ; and have no other sense, or none but in a very imperfect degree. The nervous power producing motion, and which has pro- perly been denominated irritative, appears to be of a still low- er description than that of touch. It is hence common to the * On the Animal Economy, p. 261. t Here it is to be observed, that the author speaks of the " fine and active fluid" as merely exciting the organs of sense, and not as the means by which the impressions re- ceived by those organs are communicated to the sensorium. But if we ask whether vision is excited by this imaginary fluid, or by the rays of light impinging upon the retina, the in- validity of the hypothesis, even in this shape, is immediately self-evident. On other oc- casions the nervous fluid is used in a different meaning, being nothing less than synonymous with nervous or sensorial power itself. In all this a great want of precision attends the hypothesis, which, to increase the confusion, extends itself also to the explanation of mus- cular action.—Editor. | De Instruments Odoratus. Edit. Basil, torn. i. p. 381. PHYSIOLOGICAL PROEM. [cl. iv. 31 great mass of muscular fibres, and is probably capable of being Class IV. secreted by these fibres generally; so that every fibre supplies n. Principle itself, where it receives no supply from any other source. Yet of sensation the proper source or reservoir of this modification of nervous and mot,OD- fluid seems to be a ganglionic system; that which, in the high- er classes of animals, we have already noticed as formed by the curious structure and ramifications of the intercostal nerve, and that which appears to be a copy of it in worms and zoophytes, who have no other nervous organization whatever. From the Hence the copiousness with which this central system furnishes a recruit involuntary to the involuntary organs, with which it is peculiarly connect- Srex- ed in mammals, we may see why these organs are able to per- hausted nor severe in one interrupted train of action, without exhaustion wearied. or weariness, from the beginning to the end of life ; and why Hence an several of them, as the heart, the lungs, and the stomach, exhibition should be able to exhibit proofs of irritative power for a con- Zq*"*^* siderable period of time after the death of the system, and es- death. pecially when roused by particular stimulants. Fishes in gene- ral have few pretensions to this structure, and hence they die sooner than most other animals, and exhibit little muscular ir- ritability afterwards. Yet, it is remarkable that in those gene- ra, which make the nearest approach to a ganglionic system, as the cod and carp, we have examples of a like power. The Strikingly fishmongers of the metropolis have taken advantage of this en- exemPllfied- dowment in the cod-kind, and introduced the fashion of crimp- Crimping of ing or corrugating the flesh by the stimulus of transverse in- cod-fisn' cisions ; and in some curious experiments on the carp, lately Singular instituted by Mr. Clift, he found its heart leaping, when out of instance in water, four hours after a separation from the body.* If the carp" apparently isolated molecules, found in the make of the polype Hence and various worms, are ganglions of nervous irritation, ex- spontaneous tending their vital influence through certain ranges or peri- of°poTyp°s pheries, we are also hence enabled to account for the peculiar and worms: tenacity with which the principle of life adheres to them, and and. ProPa- the wonderful power of reproduction, which belongs to detach- sections/ ed segments. The curious and striking experiments, which have lately This view been made upon animals by Dr. Philip and M. Le Gallois, con- supported firm the general view now offered so far as they bear upon it. hy var">us These have consisted in an examination into the different ef- periments. fects, produced on the heart and lungs by suddenly destroying or cutting off the communication of the whole brain ; by slow- ly destroying it; by destroying it in the posterior part alone, and in the anterior part alone; and by destroying, in like man- ner, the spinal marrow at the neck, or where it unites with the brain; in its middle or dorsal, and in its lumbar region. The animals operated upon were chiefly rabbits. According to the experiments of M. Le Gallois,f after the Experi- destruction of the brain, the action of the heart still con- ,"e"is ,?f. tinues for a considerable period of time unimpaired; while, * Phil. Trans. 1815, p. 90. + Experiences sur la Principe de la Vie, &c. 32 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. II. Principle of sensation and motion. Experi- ments of Philip. Conclusion of Philip from his own experi- ments, in accordance with the hints now proposed. III. Intel- lectual principle. on the destruction of the spinal marrow at its upper or cervi- cal extremity, this action becomes instantly so debilitated as to be no longer capable of supporting the circulation. Whence he infers, that it is from the chord of the spinal marrow, and not from the brain, that the heart derives the principle of its life and motions. The experiments of Dr. Philip* are at variance with the above of M. Le Gallois, and his conclusions are, therefore, some- what different. They seem to show, that both the brain and spinal marrow may be destroyed, and yet the heart continue to act forcibly and steadily, provided the lungs be excited by the arti- ficial breath of a pair of bellows. The brain and spinal marrow were destroyed by a hot wire, the animal being first stupefied by a blow on the occiput. Frogs and a few other animals were here employed as well as rabbits. It is not exactly stated how long, under this process, the heart continued to beat. Yet, contrary to what Dr. Philip seems to have expected, but in perfect concurrence with the hints I have just thrown out, he found that certain stimuli ap- plied to the brain, whether in the anterior or posterior part of the head, increased very sensibly the action of the heart, the animal being still prepared as just stated. The same effect en- sued when the same stimuli were applied to the cervical and even the dorsal part of the spinal marrow, but not when ap- plied to the lumbar. Dr. Philip hence concludes, that there are three kinds of vital power: muscular, possessed by the lowest kinds of ani- mals that are destitute of both the others; nervous, or that which is here denominated the medium of touch or simple feel- ing, chiefly derived from or dependent upon the spinal marrow, and possessed by animals somewhat more advanced in the scale of life ; and sensorial, constituting what we have just regarded as the medium of the local senses, and appertaining to the higher classes. He adds, that each of these may exist alone, and consequently independently of the rest; but admits that, where the nervous principle co-exists with the muscular, it ex- erts an influence over it, so that the latter may even be over- borne or destroyed by such influence ; and that when the sen- sorial co-exists with both, it exercises over both an equal de- gree of control. III. But the nervous organ in its most elaborate and perfect state, as in man, is not only the seat of sensation and motion, but of intelligence : it is the instrument of communication be- tween the mind and the body, as well as between the body and the objects by which the body is surrounded. And as a failure or irregular performance of its functions in various ways lays a foundation for an extensive division of corporeal diseases, so a like failure, or irregularity of performance in other ways, lays a foundation for as numerous a train of mental maladies. Of the nature of the mind or soul itself, we know little be- * Phil. Trans. 1815, p. 15 and 444. PHYSIOLOGICAL PROEM. [cl. iv. 33 yond what revelation has informed us : we have no chemical Class IV. test that can reach its essence ; no glasses that can trace its ill. Intel- mode of union with the brain ; no analogies that can illustrate lectual the rapidity of its movements. And hence the darkness that, Pm,clPle- in this respect, hung over the speculations of the Indian gym- oV^S nosophists and the philosophers of Greece continues without but little abatement, and has equally resisted the labours of modern met- k"own. e*- a physicians and physiologists. That the mind is an intelligent "velation. principle, we know from nature; and that it is a principle en- Nature dowed with immortality, and capable of existing after death in teaches a state separate from the body, to which, however, it is hereaf- intVlHgent: ter to be re-united at a period when that which is now mortal its other shall put on immortality, and death itself be swallowed up of Power3» and victory—we learn from the God of nature. And, with such in- "e-uliicn formation, we may well rest satisfied; and, with suitable mo- with the desty, direct our investigations to those lower branches of this body,taught mysterious subject that lie within the grasp of our reason. prettrna- I cannot, however, drop the subject altogether, without ob-tural com- serving that the discussion concerning the particular entity of munica}'on' the mind seems to have been conducted with an undue degree controver- of heat and confidence on all sides, considering our present sies con- ignorance of whatever substance has been appealed to as con- cer"in£ *'■ stituting its specific frame. often ex- Is the essence of the mind, soul, or spirit, material or imma- hibited an terial ? The question, at first sight, appears to be of the ut- ^"^"Jft most importance and gravity ; and to involve nothing less than conGdence. a belief or disbelief, not, indeed, in its divine origin, but in its Whether its divine similitude and immortality. Yet I may venture to affirm, "ateriaUr that there is no question which has been productive of so little immaterial? satisfaction, or has laid a foundation for wider and wilder er- The ques rors within the whole range of metaphysics. And for this plain factorv^nd and obvious reason, that we have no distinct ideas of the terms, pregnant and no settled premises to build upon. Corruptibility and in- wiln errors, corruptibility, intelligent and unintelligent, organized and inor- ^""affords ganic, are terms that convey distinct meanings to the mind, and a distinct impart modes of being that are within the scope of our compre- idea- hension. But materiality and immateriality are equally beyond our reach. Of the essence of matter we know nothing, and al- Essence of together as little of many of its more active qualities: insomuch jj1^" ,n°or that, amidst all the discoveries of the day, it still remainsa contro- many of its vertible position, whether light, heat, magnetism, and electrici- most active r, . , , , . • 1 *• .!• qualities. ty are material substances, material properties, or things super- jflg reiation added to matter, and of a higher nature. to light, If they be matter, gravity and ponderability are not essential ]iea}' maR- properties of matter, though commonly so regarded. And if electricity, they be things superadded to matter, they are necessarily immate- not known. rial, and we cannot open our eyes without beholding innumerable proofs of material and immaterial bodies co-existing and acting in harmonious union through the entire frame of nature. But if we know nothing of the essence, and but little of the quali- ties of matter, of that common substrate which ia diffused around us in every direction, and constitutes the whole of the visible vol. n. 5 34 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. III. Intel- lectual principle. Immaterial essences totally unknown. Whether extension be a distinctive property of matter. Whether possessed by space. In the pre- sent day ac- knowledged to be incor- poreal. W" hether solidity be a property of matter. Apparently Dot: but obliged to be taken for granted. Real char- acter of the mind as de- duciblefrom natural and revealed evidence j world, what can we know of that which is immaterial? of the full meaning of a term that, in its strictest sense, compre- hends all the rest of the immense fabric of actual and possible being; and includes, in its vast circumference, every essence and mode of essence of every other being, as well below as above the order of matter, and even that of the Deity him- self ? Shall we take the quality of extension as the line of separa- tion between what is material and what is immaterial ? This, indeed, is the general and favourite distinction brought forward in the present day; but it is a distinction founded on mere con- jecture, and which will by no means stand the test of enquiry. Is space extended 1 every one admits it to be so. But is space material ? is it body of any kind ? Descartes, indeed, contend- ed that it is body, and a material body; for he denied a vacu- um, and asserted space to be a part of matter itself: but it is probable that there is not a single espouser of this opinion in the present day. If then extension belong equally to matter and to space, it cannot be contemplated as the peculiar and exclusive property of the former ; and if we allow it to immaterial space, there is no reason why we should not allow it to immaterial spirit. If extension appertain not to the mind or thinking prin- ciple, the latter can have no place of existence; it can exist no where : for where or place is an idea that cannot be sepa- rated from the idea of extension. And hence the metaphysical immaterialists of modern time freely admit that the mind has no place of existence ; that it does exist no where ; while, at the same time, they are compelled to allow that the immaterial Creator or universal Spirit, exists every where, substantially as well as virtually. Nor let it be supposed that the difficulty is removed by add- ing to matter the quality of solidity in conjunction with that of extension, and hence distinguishing it as possessed of solid ex- tent ; for the quality of solidity is less characteristic of it than any we have thus far taken notice of, and is perpetually fleeing from us as we pursue it. That matter is infinitely divisible we dare not say, because we should hereby reduce it to mathemati- cal points, and because, also, there would, in such case, be no certain or permanent basis to build upon, and to ensure a punc- tuality of material cause and effect: and hence Sir Isaac New- ton was obliged to suppose, that it is possessed of ultimate atoms which are solid and unchangeable. But of these the senses can trace nothing, and our admission is nothing more than conjec- tural. Let not the author, however, be misunderstood upon this ab- struse and difficult subject. That the mind has a distinct na- ture and is a distinct reality from the body, that it is gifted with immortality, endowed with reasoning faculties, and capaci- fied for a state of separate existence after the death of the cor- poreal frame to which it is attached, are, in his opinion, propo- sitions most clearly deducible from revelation, and, in one or two points, adumbrated by a few shadowy glimpses of nature. And PHYSIOLOGICAL PROEM. [cl. iv. 35 that it may be a substance strictly immaterial and essentially Class IV. different from matter is both possible and probable; and will III. Intel- hereafter, perhaps, when faith is turned into vision, and con- 'ectual jecture into fact, be found to be the true and genuine doctrine u"1n-tpe't upon the subject. But till this glorious era arrive ; or till, an- al essence tecedently to it, it be proved, which it does not hitherto seem unknown, to have been, that matter, itself of divine origin, gifted even at present, under certain modifications, with instinct and sensation, and destined to become immortal hereafter, is physically inca- pable, under some still more refined, exalted, and spiritualized modification, of exhibiting the attributes of the soul ; of being, under such a constitution, endowed with immortality from the first, and capacitied for existing separately from the external and grosser frame of the body ; and that it is beyond the power of its own Creator to render it intelligent, or to give it even brutal perception, the argument must be loose and inconclusive : it may plunge us, as it has plunged thousands already, into er- . rors, but can never conduct us to demonstration. It may lead question us, on the one hand, to the proud Brahminical and Platonic concerning belief, that the essence of the soul is the very essence of the ,ton th« Deity, and consequently a part of the Deity himself; or, on the ]ia3 engend- other, to the gloomy regions of modern materialism, and to the ered pride: cheerless doctrine that it dies and dissolves in one common ?n,heot,ier grave with the body. gloom. It is no fair objection, however, against the immaterialist, that, in almost by contemplating the mind as a distinct essence from that of every view the body, man is hereby rendered a compound being, possessing ? j j^" r at one and the same time two distinct lives mysteriously united a compound in an individual frame, and running in parallel lines till the hour being: of death. For whilst the known and obvious laws and faculties of the mind and body are so widely different, as they are ac- knowledged to be on all hands, some such composite union has been and must be allowed under every hypothesis whatever. And least of all have the sceptical physiologists of the present and pecu- day any right to triumph upon such an objection ; who, drawing 1,arl?,s0., no light from nature, and rejecting that of sacred writ, contem- m0!!tscep. plate the mind as formed of the same gross modification of mat- tical physi- ter as the body, and doomed to fall with it into one common and "J^1*of eternal dissolution. For even these acute materialists, with all times. the aid of physiological, anatomical and chemical research, in- stead of simplifying the human fabric, have made it more clum- sily complex, and represented it sometimes, indeed, as a duad, but of late more generally as a triad, of unities, a combination of a corruptible life within a corruptible life two or three deep, each possessing its own separate faculties or manifestations, but covered with a common outside. This remark more especially applies to the philosophers of Hypothesis the French school: and particularly to the system of Dumas,* of Dumas: as modified by Bichat; under which more finished form man is 0fBichat. declared to consist of a pair of lives, each distinct and co-exist- * Principesdc Physiologie, 4 torn. 8vo. Par. 1300-3. cl. iv.] PHYSIOLOGICAL PROEM. Class IV, III. Intel. lectual principle. Hypothesis of Richer- and and Magendie. Hypothesis of Spurz- heim. ent under the names of an organic and an animal life ; with two distinct assortments of sensibilities, an unconscious and a con- scious. Each of these lives is limited to a separate set of or- gans, runs its race in parallel steps with the other; commencing coetaneously and perishing at the same moment* This work appeared at the close of the past century, was read and admired by most physiologists, credited by many, and became the po- pular production of the day. Within ten or twelve years, how- ever, it ran its course, and was as generally either rejected or forgotten even in France : and M. Richerand first, and M. Ma- gendie since, have thought themselves called upon to modify Bichat, in order to render him more palatable, as Bichat had already modified Dumas. Under the last series of remodelling, which is that of M. Magendie, we have certainly an improve- ment, though the machinery is quite as complex. Instead of two distinct lives, M. Magendie presents us with two distinct sets or systems of action or relation, each of which has its separate and peculiar functions, a system of nutritive action or relation, and a system of vital. To which, is added by way of appendix, another system, comprising the functions of generation.t Here, however, the brain is not only the seat, but the organized sub- stance, of the mental powers : so that, we are expressly told, a man must be as he is made in his brain, and that education, and even logic itself, is of no use to him. " There are," says M. Magen- die, "justly celebrated persons who have thought differently ; but they have hereby fallen into grave errors." A Deity how- ever is allowed-to exist, because, adds the writer, it is comfort- able to think that he exists, and on this account the physiologist cannot doubt of his being. " L'intelligence de l'homme," says he, "se compose de phenomenes tellement differens de tout ce que presente d'ailleurs la nature, qu'on les rapporte a un etre particuliere qu'on regarde comme une emanation dela Divinite. 11 est trop consolant de croire a cet etre, pour que le physiologiste mette en doute son existence; mais la severile de langage ou de logique que comporte maintenant la physiologie exige que Ton traite de l'intelligence humaine comme si elle etait le re- sultat de Taction d'un organe. En s'ecartant de cette marche, des hommes justement celebres sont tombes dans des graves er- reurs; en la suivant, on a, d'ailleurs, le grand avantage de con- server la m6me methode d'etude, et de rendre tres-faciles des choses qui sont envisagees generalement comme presqu' au-des- sus de l'esprit humain."—« 11 existe une science dont le but est d apprendre a raisonner justement c'est la logique, mais le juge- ment errone ou l'esprit faux (for judgment, genius, and imagina- tion, and therefore false reasoning, all depend on organization) tiennent a Porganization. II est impossible de se changer a cet egard ; nous restons tels que la nature nous a faits.J Dr. Spurzheim has generally been considered, from the con- current tenour of his doctrines, as belonging to the class of ma- * Recherches sur la Vie et la Mort, &c. t Precis Elementaire de Physiologie, 2 torn. 8\-o. X Precis Elementaire, &c. ut supra, passim. Paris, 1816, 1817. PHYSIOLOGICAL PROEM. [cl. iv. 37 terialists ; but this is to mistake his own positive assertion upon Class IV. the subject, or to conclude in opposition to it. He speaks, in- m. Intel- deed, upon this topic with a singular hesitation and reserve, lectual more so, perhaps, than upon any other point whatever; but as pn cip far as he chooses to express himself on so abstruse a subject, he regards the soul as a distinct being from the body, and at least intimates, that it may be nearer akin to the Deity. Man is with him also possessed of two lives, an automatic and an ani- mal : the first produced by organization alone, and destitute of consciousness ; the second possessed of consciousness dependent on the soul, and merely manifesting itself by organization. " We do not," says he, " attempt to explain how the body and soul are joined together and exercise a mutual influence. We do not examine what the soul can do without the body. Souls, so far as we know, may be united to bodies at the moment of conception or afterwards ; they may be different in all individu- als, or of the same kind in every one ; they may be emanations from God, or something essentially different."* The mind of this celebrated craniologist seems to be wonderfully sceptical and bewildered upon the subject, and studiously avoids the im- portant question of the capacity of the soul for an independent and future existence ; but, with the above declarations, he can- not well be arranged in the class of materialists. The hypothesis adopted by Mr. Lawrence,! and which is Hypothesis nearly the same as that of BichatJ and Cuvier,§ is altogether of of Lawrence a different kind, and, though undoubtedly much simpler than ^""basis'not any of the preceding, does not seem to be built on a more sta- m0re stable. ble foundation. According to his view of the subject, organized differs from inorganized matter merely by the addition of cer- tain properties which are called vital, as sensibility and irrita- bility. Masses of matter endowed with these new properties become organs and systems of organs, constitute an animal frame, and execute distinct sets of purposes or functions, for functions and purposes carried into execution are here synony- mous. " Life is the assemblage of all the functions (or pur- poses), and the general result of their exercise."|| Life, therefore, upon this hypothesis, instead of being a two- Regards life fold or three-fold reality, running in a combined stream, or in asamere parallel lines, has no reality whatever. It has no ESSE,pr inde- property of pendent existence. It is a mere assemblage of purposes, and casiona'l and accidental or temporary properties: a series of phaenomena,H accidental: as Mr. Lawrence has himself correctly expressed it;—a name without any s* res I essence ■ without a thing. " We know not," says he, " the nature of the a mere as_ link that unites these phenomena, though we are sensible that semblageof a connexion must exist; and this conviction is sufficient to induce PurP°?es> ' or series ol ~ „. . , „ r „,« « t i .„., phaenomena. * Physiognomical System, &c. p. 253, 8vo. Lond. 1815. r t Introduction to Comparative Anatomy and Physiology, &c. 8vo. 1816. | " La vie est l'ensemble des functions qui resiste a la 01011."—Recherches Physiologiques sur la Vie et la Movt, art. 1. 4 " Dans chaque etre, la vie est un ensemble qui resulte de Paction et de la re-action mutuelle de toutes scs parties."—Le Regno Animal, torn. i.; Introd. p. 16. || Introduction to Comparative Anatomy and Physiology, &c. p. 120. IT Ibid. p. 122. 38 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. III. Intel- lectual principle. Hence the human frame a bar- rel-organ, and life the music it plays, ceas- ing as the music ceases when the machine will no longer work. This hypo- thesis not new: but started by Aristoxe- mis, a pupil of Aristotle, who thus illustrated it, and named it the system of harmony. Opposed by all the other sects of material- ists in his day: especially by the Epi- cureans ; who united with the Platonists and Stoics. Their grounds of opposition applicable to the same doctrine in its present modifica- tion. us to give it a name, which the vulgar regard as the sign of a particular principle ; though in fact that name can only indicate the assemblage of the Phenomena which have occasioned its formation."* The human frame is, hence, a barrel-organ, possessing a sys- tematic arrangement of parts, played upon by peculiar powers, and executing particular pieces or purposes; and life is the music, produced by the general assemblage or result of the har- monious action. So long as either the vital or the mechanical instrument is duly wound up by a regular supply of food or of the wince, so long the music will continue : but both are worn out by their own action; and when the machine will no longer work, the life has the same close as the music; and in the lan- guage of Cornelius Gallus, as quoted and appropriated by Leo X., —redit in nihilum, quod fuit ante nihil. There is, however, nothing new either in this hypothesis or in the present explanation of it. It was first started in the days of Aristotle by Aristoxenus, a pupil of his, who was admirably skilled in music, and by profession a physician. It was pro- pounded to the world under the name of the system of harmony, either from the author's fondness for music, or from his com- paring the human frame to a musical instrument, and his regard- ing life as the result of all its parts acting in accordance, and producing a general and harmonious effect. How far Mr. Lawrence's revised edition of this hypothesis may prove satisfactory to other classes of materialists 1 cannot tell : but if he should succeed, he will be more fortunate than Aristoxenus, who pleased neither the other materialists, nor the immaterialists, of his day. From the latter, indeed, he could expect no countenance : but even the Epicureans, though they held that the mind was corruptible as formed of matter, which they had no reason to believe was then or ever would be other- wise than corruptible under any modification whatever, held, at the same time, that it had a substantive existence, distinct from that of the grosser frame of the body, and possessed of other and far higher properties; being formed of the finest, lightest, smoothest, and most moveable material elements, and hence ex- quisitely etherialized and volatile: —est aninii natura reperta Mobilis egregie, perquam constare necesse est Corporibus parvis, et lajvibus, atque rotundis.t The atomic philosophers, therefore, joined with the Plato- nists and Stoics in opposing the system of harmony, and that chiefly upon the two following grounds, which will apply with as much force to its present as to its primary form. First, ad- mitting that an assemblage and exercise of all the functions of the machine are necessary to maintain the phenomena of life, we are left as much in the dark as ever concerning the nature * Introduction to Comparative Anatomy and Physiology, &c. p. 122. 1 Lucret. De Rer. Nat. in. 204. PHYSIOLOGICAL PROEM. [cl. iv. 39 of the principle, by which this harmonious instrument becomes Class IV. gradually developed, and is kept in perpetual play. And next, III. Intel- that the life or well-beinar of the animal frame does not depend lectual i • c c l- A ... principle. upon an assemblage and exercise of all its functions or pur- r r poses ; since the mind may be diseased while the body remains unaffected, or the body may lose some of its own organs, while the mind, or even the general health of the body itself, may continue perfect.* In the darkness, therefore, which continues to hang over the General mysterious subject before us, I feel incompetent to enter into result *nd the question concerning the actual essence of the mind, and am ^^ perfectly content to take its general nature, powers, and desti- ny, from the only volume which is capable of giving us any de- cided information upon the subject; to follow it up as far as that volume may guide us; and to stop where it withdraws its as- sistance. Closely connected with the present question is another of Another nearly as much perplexity, and the consideration of which has subject not been attended with much more success, but which must not competed be passed by on the present occasion without being glanced at. herewith. Whatever be the nature or substance of the mind, the brain 3y wnat is the organ in which it holds its seat, and whence it maintains means the an intercourse with the surrounding world. Now it must be Ju*ndn"3,°- , . -iii c i_ • tains an obvious to every one who has attended to the operation ot his intercourse senses, that there never is nor can be any direct communication with the between the mind, thus stationed in the brain, and the external ^u0rrr°du°din8 objects the mind perceives ; which are usually, indeed, at some No direct distance even from the sense that gives notice of them. Thus, communi- in looking at a tree it is the eye alone that beholds the tree, j^'J}" 'eym while the mind only perceives a notice of its presence, by some between the means or other, from the visual organ. So, in touching this external table it is my hand alone that comes in contact with it, and com- th^external municates to my mind a knowledge of its hardness and other objects. qualities. What then is the medium by which such communi- What then cation is maintained? which enables the mind to have a per- is the medi- ception of the form, size, colour, smell, and even distance of ob- ^"cation? jects, correspondent with that of the senses which are seated on the surface of the body ? and which, at the same time that it conveys this information, produces such an additional effect, that the mind is able, at its own option, to call up an exact notion or idea of those qualities at a distant period, or when the objects themselves are no longer present ? Is there, or is there not, How at- any resemblance between the external or sensible object, and tempted to the internal or mental idea or notion? If there be a resem- byforme"6 blance, in what does that resemblance consist ? and how is it hypotheses. produced and supported ? Does the external object throw off Explanation r , . ,r.r f .. ic ' ai j *u of Epicurus. representative likenesses of itself in films, or under any other r modification, so fine as to be able, like the electric or magnetic aura, to pass without injury from the object to the sentient or- * Lucret. De Rer. Nat. in. 105—JoG. Lactam, in Vit. Epicur. Polignac. Anti-Lucret. Lib. v. 923. 40 ex. iv.] PHYSIOLOGICAL PROEM. Class IV. III. Intel- lectual principle. Of Aristotle. Of Plato and later psycholo- Of Berkeley and Hume. The obscu- rity of the subject prov- ed by the nature of the questions proposed. These hy- potheses thrown down by later wri- ters, who have little succeeded in establishing any other. The difficul- ty felt by Locke, who studiously avoided the abstruser part of the subject, and elucidated what was capable of elucidation in his Essay on Human Understand- ing. Character of this work. gan, and from the sentient organ "to the sensory, or mental pre- sence-chamber ? or has the mind itself a faculty of producing, like a mirror, accurate countersigns, intellectual pictures or images correspondent with the sensible images communicated from the external object to the sentient organ ? If, on the con- trary, there be no resemblance, are the mental perceptions mere notions, or intellectual symbols excited in the mind by the action of the external sense; which, while they bear no simili- tude to the qualities of the object discerned, answer the pur- pose of those qualities, as letters answer the purpose of sounds? or are we sure, that there is any external world whatever ; any thing beyond the intellectual principle that perceives, and the sensations and notions that are perceived; or even any thing beyond those sensations and notions, those impressions and ideas themselves ? Several of these questions may perhaps appear in no small degree whimsical and brain-sick, and more worthy of St. Luke s, than of a work of physiological study ; but all of them, and at least as many more, of a temperament as wild as the wildest, have been asked and insisted upon, and supported again and again in different ages and countries, from the zenith of Grecian science down to our own day, by philosophers of the clearest intellects in other respects, and who had no idea of labouring under any such mental infirmity, nor ever dreamed of the ne- cessity of being blistered and taking physic. The nature of the questions themselves, therefore, when put by the characters referred to, sufficiently manifest the obscurity of the subject to which they relate : and to enter into the dis- cussions to which they have given rise, would lead us to an ir- recoverable distance from the path before us. Those who are desirous of following them up, and of witnessing an exposure of their absurdity, cannot do better than apply themselves to the metaphysical writings of Dr. Reid, Dr. Beattie, Dr. Campbell, and Professor Stewart; who, if, on the overthrow of so many Babel-buildings, they have not been able to raise an edifice much more substantial in their stead, have only failed from the insuperable difficulty of the attempt. No man was more sensible of this difficulty than Mr. Locke, nor has taken more pains both to avoid what is unintelligible and unprofitable, and to elucidate what may be turned to a good account and brought home to an ordinary comprehension. It was his imperishable Essay on Human Understanding that gave the first check to the wild and visionary conceits in which the most celebrated luminaries of the age were at that time engag- ed; recalled mankind from the chasing of shadows to the study of realities, from a pursuit of useless and inexplicable subtilties to that of important and cognoscible subjects; or rather to the only mode in which the great enquiry before him could be fol- lowed up with any reasonable hope of success or advantage. To this elaborate and wonderful work, which has conferred an ever-during fame, not only on its matchless author, but on the nation to which he belonged, and even the age in which he PHYSIOLOGICAL PROEM. [cl. iv. 41 lived, the physiologist cannot pay too close an attention. It is, Class IV. indeed, of the highest importance to every science, as teaching ill. intel- us the elements of all science, and the only mode by which sci- lectual ence can be rendered really useful, and carried forward to ulti- Pnnc,P e* mate perfection ; but it is of immediate importance to every branch of physical knowledge, and particularly to that which is employed in unfolding the structure of the mind, and its con- nexion with the visible fabric that encloses it. It may, perhaps, be somewhat too long; it may occasionally embrace subjects which are not necessarily connected with it; its terms may not always be precise, nor its opinions in every instance correct; but it discovers intrinsic and most convincing evidence that the man who wrote it must have had a head peculiarly clear, and a heart peculiarly sound : it is strictly original in its matter, high- ly important in its subject, luminous and forcible in its argu- ment, perspicuous in its style, and comprehensive in its scope. It steers equally clear of all former systems: we have nothing Avoids all of the mystical archetypes of Plato, the incorporeal phantasms jjg^j"'^^" of Aristotle, or the material species of Epicurus ; we are equal- gon of form- ly without the intelligible world of the Greek schools, and the er times; innate ideas of Descartes. Passing by all which, from actual a^veio^e/ experience and observation, it delineates the features and de- the growth scribes the operations of the human mind with a degree of pre- and features cision and minuteness which has never been exhibited either from ils before or since ; and stands, and probably ever will stand, like earliest a rock, before the puny waves of opposition by which it has appearance. since been assailed from various quarters. The author may speak of it with warmth, but he speaks from a digested know- ledge of its merits : for he has studied it thoroughly and repeat- edly, and there is, perhaps, no book, to which he is so much indebted for whatever small degree of discrimination, or habit of reasoning, he may possibly be allowed to lay claim to. Upon one point he is perfectly clear, namely, that the chief Has been objections, at any time urged against this celebrated production, misunder- have proceeded from an utter mistake of its meaning, of which g0°°ee"SPn. he could give numerous instances, if such a digression were al- tial points, lowable, from the writings of many who have the credit of hav- ing studied it profoundly. The remark applies to several of the most popular psychologists of both North and South Britain, but especially in especially to those of the continent, and more particularly still France. to M. Condorcet, from whom the French in general have re- ceived an erroneous idea of several of its leading doctrines. It it to this book the medical student ought to turn himself for a Gives to the knowledge of the laws that regulate the development and medical itu- growth of the mind, as he should do to the labours of Haller or Jhy'iology Hunter for a knowledge of those that regulate the develope- of the ment and growth of the body, and I shall hence draw largely j™d:,*3n(] upon it through the remainder of this introduction. HuoteVgive The whole then of the metaphysical rubbish of the ancient that of the schools being cleared away by the purging and purifying energy °ody. of the Essay on Human Understanding, mankind have since been enabled to contemplate the body and mind as equally, at vol. iv. 6 42 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. III. Intel- lectual principle. What the mind is when first formed. Powers or faculties of the mind. Possibly a few slight impressions produced before birth ; and certainly instinctive tendencies. First im- pression of external objects. Idea, what, as employed by Locke. Ideas of sensation. Action of the mind on itself. Ideas of reflexion. Ideas are therefore of two kinds, objective and sub- jective : and only derived from these two sources. Number and nature of the ideas we possess birth, a tabula rasa, or unwritten sheet of paper ; as consisting equally of a blank or vacuity of impressions; but as equally ca- pable of acquiring impressions by the operation of external ob- jects, and equally and most skilfully endowed with distinct pow- ers or faculties for this purpose: those of the body being the external senses of sight, hearing, smell, taste, and touch; and those of the mind the internal senses of perception, reason, judgment, imagination, and memory. It is possible that a few slight impressions may be produced a short time antecedently to birth ; and it is certain that various instinctive tendencies, which, however, have no connexion with the mind, are more perfect, because more needful, at the pe- riod of birth than ever afterwards; and we have also frequent proofs of an hereditary or accidental predisposition towards par- ticular subjects. But the fundamental doctrine before us is by no means affected by such collateral circumstances. External objects first impress or operate upon the outward senses ; and these senses, by means hitherto unexplained, and perhaps altogether inexplicable, immediately impress or ope- rate upon the mind, or excite in it perceptions or ideas of the presence and qualities of such objects; the word idea being here employed, not in any of the significations of the schools, but in its broad, popular meaning, as importing " whatever a man observes, and is conscious to himself he has in his mind,"* whatever was formerly intended by the terms archetype, phan- tasm, species, thought, notion, or conception, or whatever else it may be which we can be employed about in thinking.! And to these effects Mr. Locke gave the name of ideas of sensation, in allusion to the source from which they are derived. But the mind, as we have already observed, has various pow- ers or faculties as well as the body, and they are quite as active and lively in their respective functions; in consequence of which the ideas of external objects are not only perceived, but retained, thought of, compared, compounded, abstracted, doubt- ed, believed, desired: and hence another fountain, and of a very capacious flow, from which we also derive ideas; viz. a reflex act or perception of the mind's own operations, whence the ideas derived from this fountain are denominated ideas of REFLEXION. The ideas, then, derived from these two sources, and which have sometimes been called objective and subjective, constitute all our experience, and, consequently, all our knowledge. Whatever stock of information a man may be possessed of, how- ever richly he may be stored with taste, learning, or science, if he turn his attention inwards, and diligently examine his own thoughts, he will find that he has not a single idea in his mind, but what has been derived from the one or the other of these two channels. But let not this important observation be forgot- ten by any one ; that the ideas the mind possesses will be fewer or more numerous, simpler or more diversified, clear or con- * Locke, on Human Understanding, b. i. ch. i. § 3. i Id. b. i. ch. i. j fi. PHYSIOLOGICAL PROEM. [cl. iv. 43 fused, according to the number of the objects presented to it, Class IV. and the extent of its reflection and examination. Thus a clock ill. Intel- or a landscape may be for ever before our eyes, but unless we Actual r . . 1 . 1 ,1 . To- . 1 principle. direct our attention to them, and study their different parts, al- j^^^. though we cannot be deceived in their being a clock or a land- the activity scape, we can have but a very inadequate idea of their charac- of the mind. ter and composition. The ideas presented to the mind, from which soever of these ideas of two two sources derived, are of two kinds—simple and complex. fromeach" Simple ideas consist of such as are limited to a single notion ofthe abo„e or perception; as those of unity, darkness, light, sound, simple sources. pain or uneasiness. And in the reception of these the mind is Simple 11* * 1Q639 Whclt passive; for it can neither make them to itself, nor can it, in any instance, have any idea which does not wholly consist of them; or, in other words, it cannot contemplate any one of them other- wise than in its totality. Complex ideas are formed out of various simple ideas, asso- Complex ciated together or contemplated derivatively. And to this class ,deas» w,,at belong the ideas of an army, a battle, a triangle, gratitude, ve- neration, gold, silver, an orange, an apple ; in the formation of all which it must be obvious that the mind is active, for it is the activity ofthe mind alone that produces the complexity out of such ideas as are simple. And that the ideas 1 have now refer- red to are complex, must be plain to every one ; for every one must be sensible that the mind cannot form to itself the idea of an orange, without uniting into one aggregate the simple ideas of roundness, yellowness, juiciness, and sweetness; and so of the rest. « Complex ideas are formed out of simple ideas by many ope- Formed out rations ofthe mind ; the principal of which, however, are some ^^ combination of them, some abstraction, or some comparison. variou3 Let us take a view of each of these. mental And first of complex ideas of combination. Unity, as I have operations. already observed, is a simple idea; and it is one of the most ?™f™ common simple ideas that can be presented to the mind; lor comi,jna. every object without, and every notion within, tend equally to tion. excite it: and being a simple idea, the mind, as I have also re- marked, is passive on its presentation : it can neither form such an idea to itself, nor contemplate it otherwise than in its total- ity ; but it can combine the ideas of as many units as it pleases, and hence produce the complex idea of a hundred, a thousand, or a hundred thousand. So beauty is a complex idea; for the mind, in forming it, combines a variety of separate ideas into one common aggregate. Thus Dryden, in delineating the beau- tiful Victoria in his Love Triumphant, Her eyes, her lips, her cheeks, her shape, her features, Seem to be drawn by Love's own hand ; by Love Himself in love. In like manner the mind can produce complex ideas by an Complex opposite process; and that is by abstraction or separation. ^^ 44 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. IK. Intel- lectual principle. Complex ideas of comparison- Hence complex ideas far more numerous than simple. Ideas possess a natural correspon- dence, or a natural congruity. Exemplified. Office of reason to trace out these con- gruities and incongrui- ties ; a just perception proofof sound mind, and source of real knowledge. Wise man, what. Ignorant man. Man of sagacity. Man of dulnesf. Man of wit. Thus chalk, snow, and milk, though agreeing, perhaps, in no other respect, coincide in the same colour; and the mind, con- templating this agreement, may abstract or separate the colour from the other properties of these three objects, and form the idea which is indicated by the term whiteness ; and having thus acquired a new idea by the process of abstraction, it may after- wards apply it as a character to a variety of other objects; and hence particular ideas become general or universal. Other complex ideas are produced by comparison. Thus, if the mind take one idea, as that of a foot, as a determinate measure, and place it by the side of another idea, as the idea of a table, the result will be a formation of the complex idea of length, breadth, and thickness. Or, if we vary the primary idea, we may obtain, as a result, the secondary ideas of coarse- ness and fineness. And hence complex ideas must be almost infinitely more nu- merous than simple ideas, which are their elements or materials ; as words must be always Air more numerous than letters. I have instanced only a few of their principal kinds, and have ap- plied them only to a few of the great variety of subjects to which they are referrible, and by which they are elucidated, in the great work on Human Understanding. It must, however, from this imperfect sketch, appear obvious that many of our ideas have a natural correspondence, con- gruity, and connexion with each other; and as many, perhaps, on the contrary, a natural repugnancy, incongruity, and dis- connexion. Thus, if I were to speak of a cold fire, I should put together ideas that are naturally disconnected and incon- gruous ; and should consequently make an absurd proposition, or, to adopt common language, talk nonsense. 1 should be guilty of the same blunder if I were to talk of a square bil- liard-ball, or a soft, reposing rock; but a warm fire, on the con- trary, a white or even a black billiard-ball, and a hard, rugged rock, are congruous ideas, and consequently consistent with good sense. Now it is the direct office of that discursive facul- ty ofthe mind, which we call reason, to trace out these natural coincidences or disjunctions, and to connect or separate them by proper relations: for it is a just perception of the natural connexion and congruity, or of the natural repugnancy and in- congruity of our ideas, that shows a sound mind, and constitutes real knowledge. The wise man is he who has industriously laid in and carefully assorted an extensive stock of ideas; as the stupid or ignorant man is he who, from natural hebetude, or having had but few opportunities, has collected and arranged but a small number. The man, who discovers the natural re- lations of his ideas quickly, is a man of sagacity ; and, in po- pular language, is said, and correctly so, to possess a quick, sharp intellect: the man, on the contrary, who discovers these relations slowly, we call dull or heavy. If he rapidly discover and put together relations that lie remote, and perhaps touch only in a few points, but those points striking and pleasant, he is a man of wit, genius, or brilliant fancy, of agreeable allusion and metaphor: if he intermix ideas of fancy with ideas of PHYSIOLOGICAL PROEM. [cl. iv. 45 reality, those of reflection with those of sensation, and mistake Class IV. the one for the other, however numerous his ideas may be, and in. Intel- whatever their order of succession, he is a madman ; he rea- lectnal sons from false principles, and, as we say in popular language, ^.'n?'P e* and with perfect correctness, is out of his judgment. a man" Finally, our ideas are very apt to associate or run together in Association trains; and, upon this peculiar and happy disposition of the of ideas- mind, we lay our chief dependence in sowing the seeds of edu- cation. It often happens, however, that some of our ideas have been associated erroneously, and even in a state of early life, before education has commenced ; and hence, from the difficulty sympathies of separating them, most of the sympathies and antipathies, the and anti- whims and prejudices that occasionally haunt us to the latest Patl,,es: period of old age. ^"dice? Such, then, is the manner in which the mind, at first a sheet j, . of white paper, without characters of any kind, becomes fur- recapiiula- nished with that vast store of ideas, the materials of wisdom and tion. knowledge, which the busy and boundless fancy of man paints upon it with an almost endless variety. The whole is derived from experience, the experience of sensation or of reflection; from the observations ofthe mind employed either about exter- nal sensible objects, or the internal operations of itself, perceiv- ed and reflected upon by its own faculties. These faculties are to the mind what organs are to the body: Hence they are its ministers in the production, combination, and reso- faculties to lution of different trains of ideas, and in supplying it with the w'hat organs results of its own activity. We sometimes, however, are apt to are to the speak of them as distinct and separate existences from the mind, boA7- or as possessing a sort of independent entity, and as controlling often f one another by their individual authorities, and occasionally, as distinct indeed, as controlling the mind itself: for we accustom ourselves existences, to describe the will as being overpowered by the judgment; or n"terronc- the judgment as being overpowered by the imagination ; or the mind itself as being carried headlong by the violence of its own ecj*emp' passions. By all which, however, we only mean, or should only mean, that the mind does not, on such occasions, exert its own faculties in a fitting or sober manner, or that from some diseased affection it is incapable of doing so. For the faculties Faculties of the mind are so many powers ; and, as powers, are mere at- "I"!e\ tributes of the being or substance to which they belong, and powers; not the being or substance itself. These, therefore, being all and all different powers in the mind or in the man to do several actions, ^^"^j, he exerts them as he thinks fit; but the power to do one action other. is not operated upon by the power to do another action : for the power of thinking operates not on the power of choosing, nor the power of choosing on the power of thinking; any more than the power of dancing operates on the power of singing, or the power of singing on the power of dancing,* as any one who reflects on these things will easily perceive. The body has its feelings, and the mind has its feelings also ; The mind has also its * Locke, p. 129. 46 cl. iv.] PHYSIOLOGICAL PROEM. Class IV. III. Intel- lectual principle. feelings a9 well as the body. These are called pas- sions. Examples. Hence the inind subject to various diseases as well as the body. Those dis- eases may be also constitu- tional and permanent, periodical and recur- rent, acci- dental and temporary. Illustrated. When the deviations from perfect souudness of body slight, hardly call- ed diseases; but only when severe or extreme. The same in the facul- ties of the mind. The mind and body reciprocally influence each other. Hence the mind an and it is the feelings ofthe latter which we call passions, a mere Latin term for the feelings or sufferings of colloquial language. The feelings ofthe body are numerous and diversified, as those of simple ache or ease, hunger, thirst, heat, cold, and a multi- titude of others. Those of the mind are still more numerous and more diversified, for they comprise the multifarious train of grief, joy, love, hatred, avarice, ambition, conceit, and perhaps hundreds more : all which, whether of body or mind, Mr. Locke has endeavoured to resolve into different modifications of plea- sure or pain, according as they are productive of good or evil. But the analogy we are thus conducting between the mind and the body holds much farther; for as the latter is subject to diseases of various kinds, so also is the former. The body may be enfeebled in all its powers, in only a few of them, or in only a single one. So also may the mind: " The powers of perception and imagination," observes M. Pinel, " are frequent- ly disturbed without any excitement ofthe passions. The func- tions of the understanding, on the other hand, are often per- fectly sound, while the man is driven by his passions to acts of turbulence and outrage." And these infirmities, whether of body or mind, may be constitutional and permanent, periodical or recurrent, or merely incidental and temporary. The body may be of a sanguineous temperament, of a plethoric tempera- ment, of a nervous or irritable temperament; and the mind may, in like manner, possess an over-weening confidence and courage, be characteristically dull and inactive, or be ever goaded on by restlessness and eager desire: it may be quick in apprehension and taste, but weak in memory; strong in judg- ment, but slow in imagination ; or feeble in judgment, but rapid in imagination : its feelings or passions may be sluggish, or all alive; or some passion may be peculiarly energetic, while the rest remain at the temperate point. When the corporeal deviations from the standard of high health are but slight, they are scarcely entitled to the name of diseases,—but when severe or extreme, they become subjects of serious attention. It is the same with the different states of the mind, with which I have just contrasted them. While sev- eral, or even all the mental faculties are slightly weak or slug- gish, or inaccordant with the action of the rest, they are scarcely subjects of medical treatment—for otherwise half the world would be daily consigned to a strait waistcoat: but when the same changes become striking and strongly marked, they are real diseases of the intellect; and, in the ensuing order, the genera will be found taken from the peculiar faculties of the mind that chance to be thus affected. The mind and the body bear also, in many cases, a reciprocal influence on each other ; which is sometimes general, and some- times limited to particular faculties or functions. It is hence that fever or cephalitis produces delirium, and vapours or low spirits dyspepsy. The mind, therefore, like the body, becomes an interesting field of study to the pathologist, and opens to his view an addi- PHYSIOLOGICAL PROEM. [cl. iv. 47 tional and melancholy train of diseases. It is these which will Class IV. constitute the subject ofthe first order ofthe class we have now in, intel- entered upon, and which are entitled to a deep and collected lectual .. ,. r ' l principle. attention. f , r . interesting piece of study to the pathologist. CLASS IV. NEUROTICA. order /.—ftftrenfca. DISEASES AFFECTING THE INTELLECT. Error, perversion, or debility of one or more of the Mental Faculties. The word phrenica is Greek, from the Greek noun . I. 53 the judgment has a new train of ideas presented to it, and must Geht. I. necessarily take a new direction. Yet it is difficult to conceive Ecphronia. how the judgment can be thus abruptly led astray if it continue Insanity. sound ; and hence it is more probable that the judgment itself Cra*1Des8, is at fault, and admits a train of ideas which, however congru- ous to themselves, are incongruous to those furnished by the fa- culty of perception ; or both may equally wander, and accom- pany each other in the visionary scene, as they at first associated in the real. It is obvious, however, if I mistake not, that both faculties are affected in the derangement of insanity jointly or in irregular succession. How far a morbid state ofthe mental faculties may in any case depend upon the mind itself, as distinct from the sensorium or instrument by which it is connected with the body, it is impos- sible for us to know till we become acquainted with the nature of this connexion, and perhaps also with the essence of the mind, which, in our present state of information, seems to be a hope- less subject of enquiry. But we may possibly obtain some in- Correct sight into the manner in which correct ideas of perception are ideas of per- changed in their nature and rendered incorrect or incongruous rendered in- by a diseased judgment, by attending to a process of variation correct by a that is frequently occurring in perfect sanity and acuteness of diseased mind. " The ideas we receive by sensation," says Mr. Locke, f3rther in adverting to this process, " are often in grown people altered explained. by the judgment without our taking notice of it." And he ex- plains this position by observing, that when a ball of any uni- form colour, as of gold, alabaster, or jet, is placed before the eye, the idea thereby imprinted in the mind is that only of a flat circle variously shadowed, with different degrees of light and brightness coming to the organ of sight. " But having by use been accustomed to perceive what kind of appearance convex bodies are wont to make in us ; what alterations are made in the reflections of light by the difference of the sensible figures of bodies, the judgment presently, by an habitual custom, alters the appearances into their causes; so that from that which tru- ly is variety of shadow or colour, collecting the figure, it makes it pass for a mark of figure, and frames to itself the perception of a convex figure and an uniform colour."* And the same change occurs still more conspicuously in looking at an engraving or a picture, in which the only idea presented by the eye to the perception is that of a plane variously shaded or coloured ; but which the judgment immediately changes and multiplies into other ideas of life and motion, and running streams, and fathom- less woods, and cloud-capt mountains. And if in a sane state we find the judgment capable of thus varying the ideas of percep- tion presented to it, we can have no great difficulty, I think, in conceiving by what means such a variation may be produced and may ramify into incongruities of great extravagance in a judgment deranged by disease. Nor is there much difficulty in conceiving how the paroxysm Whence re- missions or * Hum. Underst. Book n. Ch. ix. J 8. intermis- 54 ci» »v.] NEUROTICA. [ORD. I. Gem. I. Ecphronia. Insanity. Craziness. sions of the paroxysms in insanity. And how the disease couBned at times to par- ticular trains of ideas ? The corpo. real indica- tions vary as those of the mind. Remote cause of insanity. Whether a diseased condition of any part of the ence- phalon? How far this established by dissec- tions. should be subject to remissions or even intermissions more or less regular; or the derangement be limited, as we frequently find it, and especially in melancholy, to particular subjects or trains of ideas. For first all diseases have a tendency to remis- sions or intermissions ; but those connected with the brain or nerves more than any others, as is evident in hemicrania, epi- lepsy, hysteria, and palpitation of the heart. And next, there is no man in a state of the most perfect sanity, whose judgment is equally strong and exact upon all subjects ; and few whose judgments are not manifestly influenced and led astray by parti- alities, or peculiar incidents of a thousand kinds ; insomuch that we dare not, on various occasions, entrust to a man ofthe strict- est honesty and the clearest head a particular subject for his de- cision, whom we should fly to as our counsellor upon every oth- er occurrence. And it is not therefore very extraordinary that, in a morbid state of the mind, and particularly of that faculty which constitutes the judgment, there should be an aberration in some directions or upon some subjects which does not exist upon others. The corporeal indications differ as much as those ofthe mind, and generally as being governed by the latter. We have hence sometimes, as an opening symptom, an extraordinary flow of high spirits, at others extreme terror. The countenance is pale and ghastly, and strongly expressive of inward emotion ; the speech hurried and tremulous, and the extremities bedewed with a cold sweat. In other instances, the eye glares malig- nantly, the face is flushed, and evinces a dreadful ferocity ; the objects of terror become objects of vengeance, and the patient is furious. In some there is an unusual degree of suspicion, and an anticipation of evil, and a belief in imaginary plots or conspi- racies. In others great irascibility and malignity, and a desire to commit some act of desperation, vengeance, or cruelty. All this is often combined with head-ach, giddiness, throbbing ofthe temples, or impaired vision. There is little or no sleep, for the mind is in a state of too much excitement, though at times the patient lies listless and refuses to be roused.* Concerning therefore the remote or even the proximate cause ofthe disease, we have yet much to learn. From the view we have taken in the proem of the close connexion between the mind and the brain, it seems reasonable to conceive that the re- mote cause is ordinarily dependent upon some misconstruction or inisaffection ofthe cerebral organs : and hence every part of them has been scrutinized for proofs of so plausible an hypothe sis, but hitherto to no purpose whatever. The form ofthe cra- nium, its thickness, and other qualities; the meninges, the sub- stance ofthe brain, the ventricles, the pineal gland, the commis- sures, the cerebellum, have all been analysed in turn, by the most dexterous and prying anatomists of England, France, Ger- many, and Italy, but with no satisfactory result. The shape or thickness of the skull has been started, indeed, as a cause by * Annual Report ofthe Glasgow Asylum for Lunatics, 1821. CL. IV.] NERVOUS FUNCTION. [ord. i. 55 many anatomists of high and established reputation ; but the con- GeN. I. jecture has been completely disproved by others, who have Ecphronia. found the very structures supposed to be most certain of pro- l"«»»««y- ducing madness, exist in numerous instances with perfect sound- C,aziueM- ness of intellect. A particular shape ofthe skull seems, indeed, to be often connected with idiotism from birth or soon after birth, but with no other species of mental derangement what- ever Morgagni engaged in an extensive course of dissections upon Morgagni this subject, and pursued it with peculiar ardour: and his results are given in his eighth epistle from the second to the eighteenth article. In some cases, the brain was harder, in some softer, than in a healthy state ; occasionally the dura mater was thick- er, and was studded with soft, whitish bodies on the sides of the longitudinal smus. This sinus itself sometimes evinced polypous concretions ; and the pineal gland, or several of the glands in the plexus choroides were in a diseased state. Dr. Greding * with a like spirit of investigation, arrived at a like diversity of facts Meckel found the brain denser and harder than usual ;t Meckel. Dr. Smith} descried a bony concretion, and Plenciz and several others represent the brain as bony or calculous in various parts; while Jones, m the Medical Commentaries, found it softer than Jones usual with a thickening of the membranes and a turgescence of the ventricles. From all which, nothing precise or pathogno- Nothing monic can be collected, since all such morbid appearances have P'eciseor been traced under other diseases as well as under insanity pathogno- M. Pinel is firmly decided upon this point; and after a very ex- hitherto tensive course of investigations he asserts, with respect to the bee" co1' cranium, that there are no facts yet clearly established which lected* prove the faculties of the mind (except in the case of idiotism) Pineh to be, in any degree, influenced by its size, figure, or density : while with respect to the contents of the cranium, "I can af- firm," says he, " that I have never met with any other appear- ances within the cavity of the skull, than are observable on open- ing the bodies of persons who have died of apoplexy, epilepsy, nervous fevers, and convulsions :" and his successors M. Esquirol and M. Georget concur in the same remarks. The last, after having examined three hundred lunatics on their decease, to set- tle the point before us, thus concludes: " Toutes les alterations que nous avons observes sur les alienees de la Salpetriere sont consecutives au developpement de la folie, excepte celles des cerveaux d'idiotes, qui sont primitives et liees a l'etat intellec- tuel." The observations of Haslam are nearly to the same effect: for Haslam. they concur in showing that, except in so considerable a mis- formation of the skull or its contents, as to induce idiotism from an early period of life, as in the case of cretinism, nothing deci- * Vermischte Medicinische und Chirurgische Schriften. Altenb. 1781. t Hist, de l'Acad. Royale des Sciences, &c. Ann. 1760. Berol. 4to. 1761. X Med. Observ. and Inquir. vol. vi. 56 cl. iv.] NEUROTICA. [ord. »• What pe- riods of life most sub- ject to in- sanity. Gen. I. sive can be obtained in reference to insanity from any variations Ecphronia. 0f appearance that have hitherto been detected.* Cmdnen. The dissections of Greding extended to not fewer than two Greding. hundred and sixteen maniacal patients, the whole of whom, however, died of disorders unconnected with their mental ail- ments : three of the heads were exceedingly large, two exceed- ingly small; some of the skull-bones extremely thick ; others peculiarly thin; in some, the frontal bones were small and con- tracted ; in others, the temporal bones compressed and narrow. In a table containing an aggregate of the patients received into the lunatic asylum at Bicetre during a considerable part of the French revolution, from 1784 to 1792, by far the greatest number admitted were between the ages of thirty and forty : next, those between forty and fifty; next to these, patients be- tween twenty and thirty; then those from sixty to seventy ; and lastly, those from fifteen to twenty; below which we have no account of any admission whatever. Hence different stadia of life seem to exercise some control, and the period most exposed to the disease is that in which the influence of the passions may be conceived to be naturally strongest and most operative. " Among the lunatics confined at Bicetre," says M. Pinel, " du- ring the third year ofthe republic, and whose cases I particu- larly examined, I observed that the exciting causes of their maladies, in a great majority of instances, were extremely vivid affections of the mind ; as ungovernable or disappointed ambi- tion, religious fanaticism,! profound chagrin, and unfortunate love. Out of one hundred and thirteen madmen, with whose histories I took pains to make myself acquainted, thirty-four were reduced to this state by domestic misfortunes; twenty-four by obstacles to matrimonial unions which they had ardently de- sired to form ; thirty by political events connected with the rev- olution ; and twenty-five by religious fanaticism." Those were chiefly affected who belonged to professions in which the imag- ination is unceasingly or ardently engaged, and not controlled in its excitement by the exercise ofthe tamer functions ofthe un- derstanding, which are more susceptible of satiety and fatigue. Hence the Bicetre registers were chiefly filled from the profes- * From the dissections recorded by Dr. Haslam, his own inference is, that madness is always connected with disease of the brain or its membranes. Indeed he expresses a de- cided opinion, that insanity is not a disease of ideas, and is among the first who, in modern times,have regarded it as connected with disease of the brain, or its membranes__(See Obs on Madness and Melancholy, &c, p. 238, &c.) A similar opinion had been previouslv delivered by Dr. Marshall.—(See Morbid Anatomy ofthe Brain in Mania, &c.) Accord- ing to Greding, the pia mater and arachnoid membranes were hardly ever sound. The same fact was noticed by Dr. Haslam in thirty-seven out of thirty-eight dissections; also by J Werzel, of Mentz (Obs. sur le Cervelet, &c. trad, par M. Breton. Paris, 1811) • and Chia' rugi, of Florence (Delia Pazzia, &c. In Firenze, 1794.) M. Bayle considers chronic me- ningitis, a form of meningeal inflammation essentially and primarily chronic, as the most frequent pathological cause of mental derangement.—(traite des Maladies du Cerveau &c Paris, 1826.) The frequency of disease ofthe brain in insane persons is confirmed by' the researches of M. Calmeil.—(De la Paralysie considered chez les Alienes, &c Paris 1826 ^ —Editor. ' ' ) t According to Dr. Burrows, there are five times as many females insane from this cause as males. See Commentaries on the Causes, Forms, Symptoms, and Treatment moral and medical, of Insanity, 8vo. 1828.—Ed. ' What tem- peraments chiefly pre- dispose or pursuits ex- cite the dia- CL- 'v.] NERVOUS FUNCTION. [ord. i. rj iZ^hll^ artiS!S' painlGrS' scu,Ptors> P^ts, and musicians: Gen j while they contained no instances of persons whose hnp nf lif* v f • n",\phr:dominan; cxer,cise of ,he >^ &*£"* ™ssr naturalist, physician, chemist, or geometrician Craziness. sietUVfhdT,eaarH°thter0rganSthat aU° betray very prominent Whether signs of diseased action in insanity as well as the brain, as those °risinati"S ofthe epigastrium and the adjoining regions: and hence other fr°T *% LuTo°f^mh7!lSOU^f0r a ruem°te °r ev6n « P--ma e S^JST ThTl »k 3adym thGSe' rather than ia th* encephalon. «P'«*t™ ihis was the case among several, though not the majority of 0J!fhe-r i he Greek physicians, as we have seen already ,- and if to o gtT'' vervt^r ^^ M" PinGl ^ thG P^^e'cause in almost oSL every instance in our own day. It is here he supposes the dis- Pro™e ease to commence, and contends that the affection of the brain Pinel °f and ofthe mental faculties is subsequent to the abdominal syZ- oms, and altogether dependent upon them: and, in proof of this, he adverts to various dissections which have shown a con- siderable derangement, not only in the function but even in the structure of one or more of the abdominal organs, and particu- larly a displacement ofthe transverse colon. But this is to give a weight to the morbid appearances occ-i- v i. . sionally manifested in these organs, above what is aTwedtJ ."^2°" like misformations in the cranium. Yet there can be no doubt Ini"al or" that, m most cases of insanity, the brain and epigastrium suffer IVl^X jomtly • and that the disease may, and often doe? commence in jElyl some structural or functionary affection ofthe abdominal organs ™<^* is perfectly clear from the frequency of this complaint during- di?ease sP^farS' "^ -i f iId"bed •' US bel^ connected vvith a peculiar^ HZ'n^ state of the genital organs, as we shall presently have occasion to originate to show, and its following upon a sudden' suppression of the in eitt'er- menstrual or hermorrhoidal discharge. Nor is it difficult to account for this association of influence This asso- from the extensive distribution ofthe par vagum, and more par- ciatioivof ticularly of the intercostal nerve over the abdominal viscera • *"fluenee on which account a like sympathy is by no means uncommon in eXpla,ned■ various other disorders. Thus whil# a concussion or compres- sion of the brain produces nausea, sickness, and constipation worms are frequently found to excite convulsions or epilepsy The fair result ofthe whole enquiry appears to be, that in- Inference sanity, in everg instance, to adopt the language of Sir A. Crich- from the ton, "arises from a diseased state of the brain or nerves or ge-'eral en' both;"* but that in many instances this diseased state is a^'pri- V1"7' ttiary affection, and in others a secondary, dependent upon a morbid condition ofthe epigastric or some other abdominal or- gan : for, in whatever this morbid condition may consist, and whatever symptoms it may evince, it is not till the sensorium has by degrees associated in the chain of unhealthy action that the signs of insanity are unequivocal. And, in like manner, dys- peptic and other abdominal symptoms are not unfrequently brought on by a previous diseased state ofthe mind : and it is * Of Mental Derangement, vol. i. p. I3s. VOL. IV. 8 58 CL. IV.] NEUROTICA. [ORD. I. Gen. I. Ecphronia. Insanity. Craziness. Where the history of the incipi- ent symp- toms are clear, the disease may be assigned to its pri- mary seat. Proximate cause of insanity. Cullen's hypothesis. Crichton's hypothesis highly pro- bable ; and concurrent with the pathologic. al doctrines ofthe pres- ent work. hence peculiarly difficult, and perhaps in some cases altogether impossible, to determine, where we are not acquainted with the incipient symptoms, whether melancholy, or hypochondrias, has originated in the state of the abdominal viscera or of the crani- um; or in other words, whether the one or the other be a pri- mary or a secondary affection. When, however, we are made acquainted with the history of the incipient symptoms, we have a tolerable clue to guide us; and for the most part may safely decide that the region prima- rily affected, is that which first evinces morbid symptoms ; and hence, while we shall have little scruple in assigning the ori- gin of most cases of hypochondrism to a morbid condition of one or more of the digestive organs, we need have as little in assign- ing the greater number of cases of mania to a primary misaffec- tion ofthe brain or the nerves. In what that misaffection consists is a question that has never been settled to the present hour, and from our total inacquaint- ance with the nature of the connexion between the brain and the mind, it never will be in any very satisfactory manner. The morbid changes, indeed, which we have already seen are frequently to be traced in the structure ofthe brain, show very sufficiently that a considerable degree of diseased action has been taking place there; but as these changes are also found in other disorders ofthe head as well as in mania, and more especially as we cannot tell whether they have preceded or been pro- duced by such action, they give us little information as to the nature ofthe diseased action itself. Dr. Cullen has offered a series of ingenious arguments to prove, that mania consists in some inequality in the excitement ofthe brain,* or ofthe nervous power,t and, in most cases, in an increased excitement. Dr. Cullen's idea of the nervous power, as we have already had occasion to observe, is very far from being explicit: for he defines it " a subtile very moveable fluid included or inherent in a manner we do not clearly under- stand in every part ofthe medullary substance ofthe brain and nerves." While, in other parts of his writings, he represents it as never either recruited or exhausted, and thus conceives it to possess qualities beyond the ordinary endowments of living matter. Yet his general principle appears to be well founded, and Sir Alexander Crichton has availed himself of it in giving a fuller explanation of this highly probable hypothesis : and after appealing to the doctrine which has already been advanced and supported in the preceding pages ofthe present work, that the nervous power is a peculiar fluid secreted in the medullary sub- stance ofthe brain or the nerves, he endeavours to show, that the cause of insanities is a specific morbid action of the vessels which secrete the nervous fluid in the brain ;J and which may hereby be altered not only in quantity but in quality.§ * Pract. Phys. vol. iv. Aph. mdlxii. t Id. mjixliv. X Of Mental Derangement, Vol. i. p. 174. i Id. vol. i. p. 169. With respect to the hypothesis, here laid down, the editor ci. iv.] NERVOUS FUNCTION. [ord. i. 59 From the quickness of the external senses, the irascibility, Gen. I. heat of the skin, flushed countenance, and uncommon energy Ecphronia. which maniacs evince, we have reason to believe this mor- Insanity. bid action to be, for the most part, a preternaturally increas- Craziness- ed action; and we are hence able to account for the various exacerbations and remissions which it evinces, sometimes peri- odically, and sometimes irregularly. Yet as the health of the faculties ofthe mind must depend upon a healthy energy of the vessels, too scanty a secretion of nervous fluid must be as effect- ual a cause of mental derangement as too copious a flow; and hence torpor ofthe vessels ofthe brain may prove as certain a cause of a wandering mind as entony, and, consequently, ty- phous fever may become a source of delirium as well as inflam- matory. And as the various secretions can only be elaborated from the blood, and are often affected by its condition, we may see also how madness may be a result of acrid narcotics and oth- er poisons introduced into the blood by absorption, or a transfu- sion of blood from animals of a different nature, of which Dionis has given some very striking examples. That there is a tendency not only to an increased secretion Proofs that of sensorial power in the head in most cases of insanity, but to the sensorial an accumulation of it from all parts of the body, and especially powe.r-ls c ,i r 1 r i ■ ,.••••. J sometimes lrom the surlace, is clear from the patient's diminished sensi- increased in bility to external impressions, and his being able to endure the insanity. severest winter's cold, and a fasting of many days, without in- convenience or indeed consciousness. But that there is, in some Proofs that cases, a diminished secretion of this fluid, producing a general it is some- debility of the living fibre, is also clear from the great tendency mj^j|,ej manifested by some maniacs, whose brain gives no proof of in- creased excitement, to a gangrene in their extremities, and, where they are uncleanly, about the buttocks. The insensi- bility from this cause is sometimes so considerable as to affect, not only the diffuse organ of feeling, but some of the local sen- ses as well. And hence some patients lose their hearing, and others are capable of staring at the meridian sun without pain, or any change in the diameter ofthe iris.* Sometimes, howev- er, the increased secretion of sensorial power is so considerable as not only to affect the head, but to augment the corporeal sen- has already delivered his opiniomin the Physiological Proem. That the brain is an organ re- ceiving a very great supply of blood ; that its vessels are large and numerous; that an increas- ed determination of bloorfto the brain, or, ou the contrary, a diminution of the quantity con- veyed to it, must have an effect upon the cerebral functions ; that the vessels secrete from this blood the medullary and cortical substances, the fluid in the ventricles, and every kind "f m,,t" "imposing the various tissues of the brain ; and that the perfect or imperfect state ictual and nervous powers is intimately dependent upon the condition ofthe cir- U'.~ *U . I____A . n..A f^^ttr nf ...l.w.U nn flniikt «-. « U., _.,......:___A I> .. * _ 1 .1 only — render the subject at all more intelligible. u.»vi.u «. ti,c scucuuu ui me nervous r it might be better, therefore, to read "the production of nervous or sensorial power." Editor. * Blumenb. Bibl. I. p. 736. 60 cl. iv.] NEUROTICA. [ord. i. Gen. I. Ecphronia. Insanity. Craziues0. Insanity often a re- sult of he- red i try pre* disposition. Illustrated. Whether manifested by external signs. sibility generally. And hence Hoffmann makes accumulated sensation an ordinary symptom of this disease,* mistaking the exception for the general rule : and Riedlin gives us an instance of a maniac, who, instead of calling for and being able to endure large quantities of snuff, sneezed and was convulsed on smelling the mildest aromatics.t It is a melancholy reflection, that insanity is often the result of an hereditary predisposition. This, indeed, has been denied by a few writers ; but their opinion has unhappily been confut- ed by the concurrent voice of those who have thought different- ly, and the irresistible evidence of daily facts. Mysterious as the subject is, we have perpetual proofs, that a peculiarity of mental character is just as propagable as a peculiarity of corpo- real ; and hence wit, madness, and idiotism are as distinctly an heir-loom of some families, as scrofula, consumption, and cancer of others.J In most of the latter, we have already observed that something of a constitutional make or physiognomy is often discernible ; and the same is contended for by many authorities in the disease before us. Yet, if we examine the marks accu- rately, we shall find that they merge, for the most part, into the common symptoms of a sanguineous or a melancholic tem- perament: either of which constitutions exercises such a con- trol over the disease, as to give it a peculiar modification, what- ever be the nature ofthe exciting cause, which is, in truth, of little importance to the constitutional turn the malady may take, though well worth attending to in the moral treatment. " The violence of the maniacal paroxysm," observes M. Pinel," ap- pears to be independent ofthe nature ofthe exciting cause ; or, at least, to be far more influenced by the constitution of the in- dividual, and the peculiar degree of his physical and moral sen- the temper- sibility. Men of a robust constitution, of mature years, with ament than u 1 i 1 • 1 .■< < r . • • i . ' by the black hair, and susceptible of strong and violent passions, appear exciting to retain the same character when visited by this most distress- cause. jng 0f human misfortunes. Their ordinary energy is augment- Illustrated. ed t0 outrageous fury. Violence, on the other hand, is seldom characteristic ofthe paroxysms of individuals of more moderate passions, with brown or auburn hair. Nothing is more common than to see men with light-coloured hair sink into soothing and pleasurable reveries; while it seldom or never happens that they become furious or unmanageable. Their pleasing dreams however, are at length overtaken by, and lost amidst the gloom of an incurable fatuity. Those of the greatest mental excite- ment, of the warmest passions, the most active imagination, the * Opp. Suppl. ii. 2. t Lin. Med. 1696, p. 29. X In six-sevenths of the cases, which have come under the observation of Dr. Burrows He does not consider that the several forms of in- Modificn- tion of the disease more af. fected by hereditary predisposition was traced. sanity tend to transmit each its own kind from one generation to another; but on the contrary, that they mutually transmit one another ; so that mania, melancholia and hv pochrondriasis may be all remarked in different individuals of the same family.' He ad- mits, however, one exception to this rule in the instance of suicidal insanity. Probably" hypochondriasis may be another exception. Dr. Burrows does not consider hereditary in- sanity more difficult to cure, than other forms of it; which statement disagrees with what is commonly believed—See Commentaries, &c. and Edin. Med. Journ. No. 98, p. 123 ch. iv.] NERVOUS FUNCTION. [ord. i. Q{ most acute sensibility, are chiefly predisposed to insanity. A Gbn. I. melancholy reflection !—but such as is calculated to call forth Ecphronia' our best and tenderest sympathies." Insanity. It has long been a current opinion, that insanity is a disease . more common to our own country than to any other: and this whether opinion has of late been rendered more seriously alarming by more com- the following assertion of Dr. Powell, secretary to the commis- ^°n^°d sioners for licensing lunatic establishments, and which is given than other as the result of his official tables of returns from 1775 to 1809 «.ountries ? inclusive, divided into lustra or periods of five years each. " Insanity appears to have been considerably upon the increase : andwhether for if we compare the sums of two distant lustra, the one beffin- ?rlatean ning with 1775, and the other ending with 1809, the proportion maiady? of patients returned as having been received into lunatic houses during the latter period, is to that of the former nearly as 129 to 100." "The facts also," says he," which present themselves to the observation of the traveller, whatever direc- tion he may take through this country, and all the local infor- mation which we receive upon the subject, supply us, as I am led to think, with sufficient proof, that the increase must actually have been very considerable, though we cannot ascertain what has been its exact proportion."* The first part of this opinion, or that which regards insanity Is not a as a disease peculiarly prevalent in England, does not seem to Pfevalent rest on any established basis: for, calculating with Dr. Powell, apparently that the number of lunatic paupers, and those received into pub- so prevalent lie hospitals, which, under the act of parliament, are not cogniz- as,'n raany able by the commissioners, together with those neglected to be trje9. returned, compared with the returns entered into the commis- sioners' books, bear the proportion of three to two, which is probably far above the mark, still the aggregate number of in- sane persons for the year 1800, contrasted with the general cen- sus for the same year, will only hold a ratio of about 1 to 7300; while if we take, with Dr. Burrows, the proportion of suicides committed in foreign capitals as a test of the extent to which insanity is prevalent in the same towns, which is nevertheless a loose mode of reckoning, though it is not easy to obtain a bet- ter, we have reason to conclude, that insanity is comparatively far less frequent among ourselves, than in most parts of the con- tinent ; the suicides of Paris, Berlin, and Copenhagen, as drawn from tables collected by Dr. Burrows for this purpose, being, in proportion to the relative population of London, as 5 to 2 for the first, 5 to 3 for the second, and 3 to 1 for the third.f Nor does the idea that insanity is an increasing disease in our Nor an in- own country appear to rest on a stabler foundation. Taking creasing Dr. Powell's result as drawn from full and incontrovertible data, dliease- and comparing the supposed march ofthe disease with the ac- *£araina- knowledged march of the population, although the former may Powell't possibly be said to have overstepped the latter by a few paces, data, which r J r ' have led to * Med. Trans, vol. iv. p. 131, art. Observations on the Comparative Prev- a contrary alence of Insanity at different periods. conclusion. t Inquiry into certain errors relative to Insanity, &c.p. 93, 8vo. 1820. 62 cl. iv.] NEUROTICA. [ord. i. Gen. I. Ecphronia. Insanity. Craziness. Admitted by the writer him- self to be inaccurate; and opposed by other tables of Burrows, which seem to prove a retrogres- sion rather than ad- vance. General result. the difference will hardly justify the assertion, that " insanity is considerably upon the increase." And if we take into view the intensity of interest with which this subject has for the last twenty years been contemplated by the public, the operation of those feelings of humanity which have dragged the wretched victims of disease from the miserable abodes of prisons and neg- lected workhouses, and placed them under the professional care ofthe superintendants of licensed establishments, and, above all, the augmented number of such .establishments in consequence hereof,and the great respectability of many who have the manage- ment of them, thus giving the commissioners returns which, by the power ofthe Act of 20 Geo. Ill, they could not otherwise have been in possession of, we may, 1 think, fairly conclude that this apparent overstep, be it what it may, in the march of insani- ty beyond that ofthe population of the country, is a real retro- gression. At this conclusion, we might, I think, fairly arrive, even if the data selected by Dr. Powell were full and incontroverti- ble ; but he himself has candidly admitted, that instead of being full and incontrovertible they " are subject to numerous inac- curacies, and that any deductions which may be made from them must be imperfect." It is still more consolatory to learn, that the direct deduclions from the parochial and district establish- ments are not only not in accordance with Dr. Powell's, but such as seem to show that a retrogression, instead of an ad- vance has actually taken place. Dr. Burrows has industriously collected many of these, and, as far as they go, they lead to such an inference almost without exception.* Yet it is pro- bable, that even this inference does not give Os the precise fact, and that it as chargeable with an error on the favourable side, as the opposite account is on the unfavourable ; since the increase of licensed houses, whose returns seem to have swelled the list of the commissioners beyond its proper aggregate, has been considerably supported by a transfer from the establish- ments which have thus fallen off. And hence, allowing the er- ror on the one side to compensate that on the other, we are brought to the conclusion which, after all, appears more natu- ral, that the career of insanity is only varied in its uniformity by temporary contingencies, but that it is by no means a pre- valent disease in our own country. Disease modified by the idiosyn- crasy. Species 1. Ecphronia Melancholia___Melancholy. The discrepancy between the perception and the judgment limited to a single object, or a few connected objects, or trains of ideas : the will wayward and domineering. We have already stated, that whatever be the exciting cause of mental alienation, the symptoms are, in every instance * Inquiry, &c., ut supr. p. 66 et ilibi. cl. iv.] NERVOUS FUNCTION. [ord. i. 63 greatly modified by the prevailing idiosyncrasy, and hence, Gen. I. though a love of solitude, gloom, fear, suspicion, and taciturnity Spec.!. are the ordinary signs of the present species, these signs often Ecphronia. yield to symptoms widely different, and sometimes even of an Melan- opposite character; and we hence become possessed of the four cllolia' following varieties: * Attonita. Mute, gloomy, retiring melan- Gloomy melancholy. choly. 0 Errabunda. Roving, restless melancholy, Restless melancholy. evincing a constant desire to change the abode. y Malevolens. Morose or mischievous melan- Mischievous melancholy. choly; occasionally termi- nating in suicide, or the in- jury of others. 3 Complacens. Self-complacent and affable me- Self-complacent me- lancholy; occasionally re- lancholy joicing in a visionary supe- riority of rank, station, or endowment. The same variety of symptoms, as chiefly modified by the These va- prevailing temperament, are noticed by Fracastorio. "The "etiesob- phlegmatic," says he, " are heavy ; the sanguine lively, cheer- Fraclitwio. ful, merry, but not witty; the choleric are in rapid and per- petual motion, impatient of dwelling upon any subject. An acuteness of wit belongs to most of the varieties, but not to all."* And hence Diodes, in opposing Galen for holding, after By Dioclei. Hippocrates, that gloom and terror are pathognomonic signs of melancholy, observes, " Upon serious consideration, I find some patients that have nothing of these qualities, and others that ex- hibit every diversity of feeling: for some are sad without be- ing fearful; others fearful without being sad ; some neither, and some both." Besides these modifications, there is another of a very pecu- singular liar kind, noticed by Dr. Spurzheim in order to show that the modification faculties of the mind are double, and that'each hemisphere of "otiee,d b7 .ii. , . , .. , , . , , ■ . , Spurzheim. the brain contains a distinct set. As 1 have never met with an instance of this variety, I must describe it in his own words. "Tiedemann," says he, "relates the example of one Moser, who was insane on one side, and who observed his insanity with the other. Gall attended a minister, who, having a similar disease for three years, heard constantly on his left side re- proaches and injuries, and turned his head to that side in order to look at the persons. With his right side he commonly judg- ed of the madness of his left side ; but sometimes in a fit of fever he could not rectify his peculiar state. Long after being cured, if he happened to be angry, or if he had drank more than he was accustomed to do, he observed, in his left side, a tendency to his former alienation."! * De Intellectione, Lib. n. t Physiognomonical System, &c. p. 144, 8vo. 1816. 64 ci. iv.] NEUROTICA. [ord. i. Gen. I. It may appear strange to those who have not studied the ec. subject with much attention, that persons who are possessed of Ecphronia. a diseased or even a defective judgment should at any time be cholia!" ^f qu'pk an(l lively apprehension, and thus be witty without be- How wit or 1Dg ™.lse' ^ut the faculty of wit is dependent not so much on shrewdness tbe judgment as on the imagination, and particularly on the of remark memory, on the possession of a large stock of ideas stored up with little for ready use' and brouSht forth with rapidity. " And hence," judgment. sa3's Mr. Locke, " some reason may perhaps be given of that Illustrated comtnon observation, that men who have a great deal of wit, from Locke, and prompt memories, have not always the clearest judgment or deepest reason. For wit lying most in the assemblage of ideas, and putting those together with quickness and variety, wherein can be found any resemblance or congruity, thereby.to make up pleasant pictures and agreeable visions in the fancy ; judgment, on the contrary, lies quite on the other side, in se- parating carefully, one from another, ideas wherein can be found the least difference, thereby to avoid being misled by similitude, and by affinity to take one thing for another."* Hence the And hence we may easily account for that gaiety and those occasional ebullitions of a vivid fancy, which so often assume the charac- insane *er of wit in persons whose minds are deranged, and especially persons. in the sober faculty of the judgment. Yettaci- Mirth and wit, however, though sometimes found in the pre- gloom7more sent sPecies of insanity, are by no means its common characters; common but, on the contrary, as we have already observed, a love of to them. solitude, gloom, and taciturnity, and an indulgence in the dis- tressing emotions of the mind. And hence, whenever hypo- chondrism merges into actual insanity, it almost always takes this form; as melancholy, from a sort of natural connexion be- tween the two, often assumes many of the symptoms that es- sentially appertain to the hypochondriac disease ; the morbid state ofthe brain influencing the abdominal organs in the latter case, as the morbid state ofthe abdominal organ influences the brain in the former. Common The disease shows itself sometimes suddenly, but more ge- Sncholy. neral,v by slow and imperceptible degrees. Among the earliest symptoms may be mentioned head-aches, frequent attacks of giddiness, sudden confusion of ideas, a great disposition to anger, violent agitations when irritated, and an uncommon sensibility, of nerves, whereby the patient is apt to be carried to as great ex- cesses from causes of joy as from those of grief. There is a desire of doing well, but the will is wayward and unsteady, and produces an inability of firmly pursuing any laudable exertion or even purpose, on account of some painful internal sensation, or the perverseness of the judgment, led astray by false or er- roneous ideas which command a firm conviction in the mind-t And if the disease occur in a person possessing that tempera- ment which has been conceived to predispose to it, and was by * On Human Understanding, Book n. Ch. xi. Sect. 2. t Crichton, of Mental Derangement, passim. cl. iv.] NERVOUS FUNCTION. [ord. i. (35 the Greeks denominated melancholic, the external signs be- Gen. I. come peculiarly marked and prominent, " the patient," says Spec. I. Hippocrates, in his book on insanity, " is emaciated, withered, Ecphronia and hollow-eyed; and is at the same time troubled with ^oHa"" flatulency and acid eructations, with vertigo and singing in the External ears ; gets little sleep, and when he closes his eyes is distracted signs some- with fearful and interrupted dreams." timei> very The first variety most commonly commences with this 8 mng' character, and creeps on so gradually, that it is for some time far^„^a" mistaken for a mere attack of hypochondrjsm or lowness of attonita. spirits,* till the mental alienation is at length decided by the often wildness of the patient's eyes, the hurry of his step whenever commences he walks, his extraordinary gestures, and the frequent incon- If <|djUamj\ gruity of his observations and remarks. The first stage of the takenUn disease is thus admirably expressed by Hamlet: " I have of late, hypochon- but wherefore I know not, lost all my mirth, foregone all cus- drr'sm' torn of exercise ; and, indeed, it goes so heavily with my dispo- ]Ve]'., . . sition, that this goodly frame, the earth, seems to me a sterile Hamlet. promontory; this most excellent canopy, the air, look you, this brave o'erhanging firmament, this majestical roof fretted with golden fire, why it appears no other thing to me than a foul and pestilent congregation of vapours." But while the external world is thus in general falsely recog- Predomi- nized by the perception, or falsely discriminated by the judg- nance of ment, the mind is so completely possessed by some particular tra^o" trains of imaginary ideas, that the attention is perpetually turn- ideas. ed to them, and the judgment mistakes them for substances, and, so far as it is sensible of surrounding objects or scenery, is per- petually blending the vision with the reality. It is not that the patient's ideas are incongruous with themselves, but with the world around him; for the remarks of the melancholy man, when his attention is once correctly fixed, are for the most part peculiarly shrewd and pointed. But in the gloom that hangs Love of over him under the variety we are now contemplating, he can silence and rarely be brought into conversation, seeks for solitude, sits sol,tude' moping in one continued posture from morning to night; or, if he walk at all, seeks for orchards, back lanes, and the gloomiest places he can find. " One of the chief reasons," says Hippo- as noticed crates, in his epistle to Philopoemenes, " that induced the citi- by Hippo- zens of Abdera to suspect Democritus of craziness, was, that he crate9, forsook the city, and lived in groves and hollow trees, upon a green bank by a brook side, or by a confluence of waters all day and all night." Sauvages, under the variety of melancholia attonita, gives an Extreme extreme case of the present modification, though not from per- case from sonal knowledge. " The patient," says he, " never moves Sauvagef- from place to place, nor changes his posture: if he be seated he never stands up; if standing he never sits; if lying he never rises. He never moves his feet unless they are pushed aside by a by-stander; but he does not shun the presence of man: if * Falret, de l'Hypochondrie ct du Suicide, passim, 8vo. Paris, 1822. VOL. IV. 9 66 cl. iv.] NEUROTICA. [ord. i. Gen. I. Spec. I. * E. Me- lancholia attonita. Exciting causes. Striking exemplifica- tion from Magendie. Explained. asked a question he does not answer, and yet appears to under- stand what is said. He does not yield to admonition, nor pay any attention to objects of sight or touch : he seems immersed in profound thought, and totally occupied by foreign matters. Yet at times he is nrore awake: if food be put to his mouth he eats, and if liquor be presented he drinks." M. de Sauvages then adds, that this rare modification of the disease occurred once to Dr. James, physician to the elector of Saxony, in a man about thirty years old, who was terrified with the thought that the Deity had condemned him. It continued for four months during the autumn and winter; but the patient was at length restored to his right understanding.* Grief, and particularly for the loss of friends, discontent, se- vere disappointment, the dread of some real or imaginary evil, a violent and long continued exertion of any of the passions, and deep uninterrupted study, have frequently proved accidental causes or accessories of this variety of melancholy, where the peculiarity of the constitution has formed a predisposition, and have sometimes produced it even where no such predisposition can be traced. M. Magendie met with a singular exemplifica- tion of this from a cause few would expect, though not difficult of solution. The patient, an intelligent and agreeable man, though of a highly nervous temperament, had the misfortune, at the age of thirty-six, to meet with various crosses in business, and to have his wife become deranged in her confinement with her first child. All his energies were devoted to the recovery of his wife, whom he accompanied in travelling, which was re- commended to her; he nursed her with tender assiduity, and was a witness to all her sufferings of body and mind. In time she recovered ; but he himself, instead of giving way to joy, fell into a state of the most distressing melancholy—believed himself ruined, pursued by the" officers of the police, and about to take his trial for some heinous offence. Upon every other subject, his mind was sound. We have already observed, that the sudden cessation of any habitual drain, or other corporeal irritation, has occasionally proved a cause of melancholy; and we here find, that there is at times as much danger in a sudden cessation of mental as of corporeal irritation, the excited mind being as little capable of bearing the change in the one instance as in the other. And hence, whenever such an effect occurs in an irritable frame, the individual should be instantly roused to some new pursuit that may swallow up, though more agreeably, the whole ofthe surplus of sensorial power that has habitually been produced. In the state above-described, M. Magendie's patient continued for many months, when, from some unknown cause, the disease upon the mind was thrown upon the motific fibres, and he was attacked with a chorea ; the intellect re- covering its powers as the muscles of locomotion were more and more thrown into the most ridiculous but involuntary ges- * Nosol. Med. Class via. Ord. in. cl. iv.] NERVOUS FUNCTION. [ord. i. ($7 ticulations. He was restored from this and to perfect health by Gen. I. the use of tonics, and especially the sulphate of quinine.* Spec. I. Other excitements, by which the present species is produced, * E. Me- are, immoderate exercise, insolation, or long exposure to the lancholia direct rays of the sun, sudden transitions from heat to cold, pow- atton,ta- erful stimuli applied to the stomach. In the case related by Sauvages, the disease appears to have proceeded from a heated imagination exercised upon false views of religion: and perhaps there is no cause more common or more operative, especially in timid minds; and more particu- larly still where the conscience is alarmed by a review of a long catalogue of real delinquencies, and a dread of eternal reproba- tion. Few persons have given a more striking example of this than illustrated the Abbe de Ranee when first touched with remorse for the in the Abbe enormity of his past life, and before the disturbed state of his deRauc6: mind had settled into that turn for religious seclusion and mor- tification which produced the appalling austerities of La Trappe. and the "To this state of frantic despair," says Dom Lancelot in his austerities letter to La Mere Angelique pf Port Royal, " succeeded a black jr^e melancholy. He sent away all his friends, and shut himself up rai>pe" in his mansion at Veret, where he would not see a creature. His whole soul, nay even his bodily wants, seemed wholly ab- sorbed in a deep and settled gloom. Shut up in a single room, • he even forgot to eat and drink : and when the servant re- minded him that it was bedtime, he started as from a deep re- very, and seemed unconscious that it was not still morning. When he was better, he would often wander in the woods for the entire day, wholly regardless of the weather. A faithful servant, who sometimes followed him by stealth, often watched him standing for hours together in one place, the snow and the rain beating'on his head ; whilst he, unconscious of them, was wholly absorbed in painful recollections. Then, at the fall of a leaf, or the noise of the deer, he would awake as from a slum- ber, and, wringing his hands, hasten to bury himself in a thicker part of the wood ; or else throw himself prostrate, with his face in the snow, and groan bitterly. . The same causes operate in the production of roving or rest- $e. Me- less melancholy, forming the second variety, and exhibiting a laucholia modification which often depends obviously upon a difference of errabu,1E.Melan- or mischievous character, is perhaps the«most common form m°ieyoien». under which the disease makes its appearance. Sometimes Description. the patient is extremely passionate, and will quarrel furiously with every one alike, in whatever tone or manner he is ad- dressed, and expresses himself with great violence of language, Language occasionally with gross, unqualified abuse, but occasionally also sometimes in a style of repartee that never was evinced in a sane state. 8arcasl,c' More generally, however, he selects his objects of resentment; which are, for the most part, unaccountably taken from his near- est relations and kindest friends. Against these he harbours the blackest suspicion and jealousy, believing that they are haunt- ing him to take away his money or his life, or to put him to torture. He loads them with every term of the deadliest ha- sometimes tred, or scowls at them with contempt, and denounces them as ^ jvej.lcle fools and idiots. Under the distressing influence of this horrid hatred -i form of the disease, the mother abominates her infant family, and the wife her husband ; the most chaste become lascivious; impudence and lips, which have hitherto uttered nothing but the precepts and pro- and the language of piety, become grossly profane, and are the faneness* vehicles of oaths and impudence. The unhappy individuals The patient are at the same time not only sensible of what they say or do, occasionally but occasionally, sensible of its being wrong, will express their thb'and0 sorrow for it immediately afterwards, and say they will not do expresses so again. But the waywardness of the will, and its want of sorrow: control by the judgment, urge them forward in spite of their re]apSes. desire, and they, relapse into the same state almost as soon as they have expressed theij regret. Mr. Locke has, with great ability, pointed out the proper distinction between these two faculties ofthe desire and the will, and has exemplified it by the desire the chastisement with which an indulgent father frequently °hp|™j£by finds himself called upon to visit an offending child, and which he wills to perform though his desire is in the utmost degree reluctant. The disease before us is pregnant with examples of the same kind, and strikingly shows the correctness, with which this great master of his subject analyzed the human mind. We have already observed, that the peculiar turn or modifica- Case in tion of the malady depends in general far less upon the immediate proof that and exciting cause, than upon the constitutional temperament, cause™™^ or some operative principle which we cannot always develope. duces less And in proof of this it may be hinted, that I have drawn the influence principal lineaments of the description just laid down from the Jemp^8. case of a lady of about sixty years of age, respecting whom I ment. was lately consulted, and whose exciting cause has been, mani- festly, suppressed grief for the death of an only son, and sepa- ration from a daughter who was the remaining solace of her advancing years, in consequence of her having married a gen- tleman whose station is in a remote part of the globe. Pos- sessed by nature of a high and commanding spirit, and of a peculiar degree of energy and activity, she effectually succeed- 70 ex.. iv.) NEUROTICA. [ord. i. Gen. I. Spec. I. y E.Melan- cholia malevolens. Tendency to violence and abusive language accounted for. This me- lancholy condition capable of affording one conso- lation. ed, by a violent internal struggle, in subduing the pangs that at first suffocated her; and has for several years talked of her daughter, and her daughter's children, for the latter has since become a mother, w^hout emotion. But with the loss of fine feeling for her daughter, she has lost, at the same time, all fine feeling upon other subjects; and her judgment has sunk amidst the general wreck. The love of her nearest relations has turned to contempt or hatred ; the ardour and animation of her mind, which restrain her from taciturnity and retirement, have rendered her forward and invective; rational expostulation has yielded to sudden and unmeaning fits of violence and blows, and the voice of piety to exclamations that would formerly have shocked her beyond endurance. She, too, is often sensible of her doing wrong, and in letters of great sobriety and excellence, often complains of her own conduct, and the burden she is be- come to her friends ; but the intervals of sanity are only of a few hours' duration, and, with all her calmness, she is sure to re- lapse.* For many months she was intrusted in her own house to the control of a professional female attendant, who, with great dexterity, at length succeeded in obtaining a due degree of authority over her'without personal restraint; and, under the regimen of perfect quiet and seclusion from the world, she seemed to be in a fair way of recovery ; but the mischievous fondness of her nearest relations has since removed this faith- ful watchwoman, and her senses have again been bartered for her liberty. The symptoms most afflictive to the relations of the patient in this variety of insanity, are the tendency to behold them with indifference or even violent aversion, and to utter exclamations and employ language ofthe most offensive kind to a'serious and a delicate ear; and it is the symptom apparently most unac- countable to those who have not studied the disease with much attention. I have already remarked that, in insanity, the cor- poreal sensibility is greatly diminished, but it is not more so than the moral sensibility; and as the moral sensibility disap- pears, all moral restraint disappears also: and for the very reason that the insane man has little feeling of cold or hunger, he has also little feeling of decency or religion. In the present variety, the worst passions are in a state of excitement, and the language most freely employed is the language of the passion that predominates, and there being no longer any moral re- straint, it is employed in its utmost vehemence and coarseness. And as the fond affections have given way to the irascible, it should seem to follow of course, that the greater the love or friendship formerly, the greater the hatred at present. There is one consolation, however, though a small one that we may reap from this distressing contemplation, and to which the friends of the sufferer should not be indifferent. It is that, with this blunted sensibility of mind, the patient has no pain from a consciousness of his degraded condition. And it is sin- * Compare with the Report ofthe Glasgow Asylum for Lunatics, 1821. cl. iv.] NERVOUS FUNCTION. [ord. i. 7l gular to observe, what may also contribute to alleviate the dis- Gen. I. tress of the eympathizing heart, how completely his uncon- Spec. I. sciousness prevails even after a patient's restoration to health, so that few look back upon what they have undergone with the horror that would be expected ; while many, even in the ap- prehension of a relapse, contemplate it, and turn their eye to the abode of misery where they were lately inmates without dread. The fourth variety or self-complacent melanchply is per- cfE.Melan- haps less frequent than any of the rest; but it occurs occasion- ^e*™111" ally, and is often accompanied with a high-coloured and ruddy P ace°9* complexion, and other marks of a sanguineous habit: "Such escriP 10 persons," says Burton, " are much inclined to laughter, are witty and merry, conceited in discourse, pleasant, if they be not far gone, and much given to music, dancing, and to be in women's company." Aristotle gives the case of an inhabitant of Abydos, who, labouring under thi3 variety of the disease, would sit for a whole day as if he had been upon a stage, listening to visionary actors; sometimes acting himself, and oc- casionally clapping his hands and laughing as overjoyed with the performance.* Such persons have not unfrequently thought themselves called upon to undertake some desperate adventure, and are exquisitely elated with the new and lofty character they are about to embrace. These stimulant feelings are not unfrequently connected with The elated erroneous ideas of religion, and excite in the mind of the pa- fe*lins tient a belief, that he is supernaturally endowed with a power nected with of working miracles, or undergoing the severest mortifications erroneous without injury. The German Psychological Magazine is full of J.gif8ioof examples of this kind; and among others relates the case of a gens-d'armes, of Berlin, whose name was Gragert, of a harm- Striking less and quiet disposition, but rather of a superstitious turn of emplific"" mind. From poverty, family misfortunes, and severe military tion. discipline, he brought on a series of sleepless nights, and a mental disquietude that, according to his own report, nothing could dissipate hut a perusal of pious books. In reading the Bible, he was struck with the book of Daniel, and so much pleased with it that it became his favourite study: and from this time the idea of miracles so strongly possessed his imagina- tion, that he began to believe he could perform some himself. He was persuaded more especially that if he were to plant an apple-tree with a view of its becoming a cherry-tree, such was his power that it would bear cherries. He was discharged from the king's service and sent to the workhouse, where he conducted himself calmly, orderly, and industriously for two years, never doing any thing that betrayed insanity : at which time Dr. Pike examined him, that he might be discharged and sent to his family. He answered every question correctly, ex- cept when the subject concerned miracles : in regard to which he retained his old notions ; adding, however, at the same time, * Lib. de Reb. niir. 72 cl. iv.] NEUROTICA [ord. i. Gen. i. that, if he found upon trial after he was at home, that the Spec. I. event did not correspond with his expectation, he, would readily cM-Melan" relina.uish the thought, and believe he had been mistaken ; and placensC.0m confessed that he had already removed one error in his mind in this way; for there was an old woman, whom he had at one time considered as a witch, but whom he afterwards discovered upon trial to be no such thing. Upon the medical treatment of diseases of this kind, we shall not have to say much; but as the plan, chiefly advisable for the present species, is equally advisable for the ensuing, it will be most expedient to reserve the discussion of it till the latter has been described in its order. Medical treatment ExcitiDg causes. Puerperal mania pro- duced by sympathy: but the chain of sympathy not easy to be followed up. Species II. Ecphronia Mania.—Madness. The discrepancy between the 'perception and the judgment general; great excitement of the mental, sometimes ofthe corporeal powers. This species appears under almost infinite varieties of cha- racter, of which, however, it may be sufficient to mark the fol- lowing, modified for the most part by the predisposing causes that we have already noticed, as modifying the preceding species : « Ferox. Furious and violent madness. 0 Exultans. Gay and elevated madness. y Despondens. Gloomy, despondent madness. 3 Demens. Chaotic madness. The exciting causes, like the predisposing, are chiefly those already enumerated under melancholy ecphronia: as sudden and violent mental emotion; bad passions indulged habitually ; false views of religion, especially the dread of reprobation and eternal punishment; sudden reverses of fortune, whether from bad to good, or from good to bad; preying anxiety, or lurking discontent; deep protracted study, unrelieved from week to ' week by an interchange of exercise or society, and breaking in upon the hours of sleep; unkindly child-bed; a suppression of various periodical evacuations; and sometimes even a vir- tuous restraint of sexual orgasm in a vigorous constitution, without taking purgative or other means to reduce the irrita- tive entony. Of these one of the most frequent causes is that of child- bed, and recovery from child-bed, though it is not always easy to develope the immediate mode by which this change in the constitution acts upon the brain ; for *it has occurred not only where there has been some organic affection from puerperal fever, a sudden cessation of the lochia, or a sudden relinquish- ment of nursing, but where the recovery has been unattended with a single unfavourable symptom, and the mother has ar- dently persevered in the office of a nurse. It shows us, how- ever, very sufficiently, how strong is the chain of sympathy be- cl. iv.] NERVOUS FUNCTION. [ord. i. 73 tween the brain and many remote organs of the body, and es- Gew. I. pecially those subservient to the function of generation. SpecII. M. Esquirol, not long ago, communicated a paper to the So- Ecphronia ciete de Medecine upon this important subject, enriched with mdn,a' the results of the Hospital de la Salpetriere, for the years j,™ jnfl„. 1811, 12, 13, and 14. During these four years, eleven hun- enceofthis dred and nineteen women were admitted, labouring under men- c~us^:onnd tal derangement: of whom ninety-two (nearly an eleventh part different of the whole) had become deranged after delivery, during or periods. immediately subsequent to the period of suckling. In the higher ranks of society, the proportion of puerperal maniacs he calculates to be not less than a seventh of the whole. Of the above 92 cases, 16 occurred from the first to the fourth day after delivery ; 21 from the fifth to the fifteenth; 17 from the sixteenth to the sixtieth day; 19 from the sixtieth to the twelfth month of suckling: and in 19 cases it appeared after voluntary or forced weaning. Of the above 92 cases, 8 were idiotic, 35 melancholic, and Effects on 49 maniacal. The respective ages were as follows: 22 from jjjj™"^ 20 to 25 years; 41 from 25 to 30 years; and 12 above 30. age8. Fifty-six out of the ninety-two were entirely cured, and thirty- eight of these within the first six months. Fright was the most frequent cause.* I have said that a virtuously restrained orgasm in a full habit, Restrained and where no steps have been taken to reduce the entonic °[^^a vigour, has occasionally induced mania. There is a curious strikingly instance of the powerful effect of such a state related by Kern- illustrated nesius in his History of the Council of Trent, which, though it J^^ did not terminate in madness, proved quite as fatal. In the year 1419, Rossa, nephew to the king of Portugal, and arch- bishop elect of Lisbon, was taken seriously ill at Florence. His physicians told him that his disease proceeded from an exces- sive irritation of the genital organs, and that he would certain- ly die unless he committed fornication or married. With a courage worthy of a happier issue, he resolved on death, and met it without breaking his vow of celibacy.f The following instance, however, will prove that mania itself Additional is sometimes a consequence of the same firmness of mind. A "l"'^™, clergyman of exemplary character, and one of the most distin- 0wnprac- guished preachers I have the pleasure of being acquainted with, tice. was many years ago very unexpectedly attacked with a parox- ysm of mania, the cause of which it seemed impossible to unfold. He recovered in about six months, and returned to a regular and punctilious discharge of clerical duty. He is a man of exquisite taste, warm imagination, exalted and highly cultivated mind. With these qualifications, in less than a year after his re- covery, he married his maid servant, and the world imagined he was gone or going out of his senses a second time. A confi- dential statement of his situation soon proved to myself that no- * Quarterly Journal of Foreign Medicme, No. I. p. 98. t Kemnes. Concil. Trident. Part. iii. De Coelibatu Sacerdotum. VOL. IV. 10 74 cl. iv.] NEUROTICA. [ord. «• Gen. I. Spec. II. Ecphronia mania. Accidental causes of other kinds of transfer- red action. et E. Mania ferox. Sometimes commences suddenly. More commonly shows itself gradually. Origin as described by Monro. thing could be more prudent or praiseworthy, than the step he had thus taken, and which had excited so much astonishment among his friends. He was fully convinced, he said, though he had never communicated it to any one, that the cause of his un- fortunate malady was a genital irritation, exciting to a constant desire of matrimony, which he was not in a situation to comply with, and which compelled him to exercise from day to day a severe restraint upon his feelings. On being fully restored to health, he found the same morbid propensity beginning to re- turn. I felt, said he, it would again drive me mad if I did not relieve it, and my principles forbade me to think for a moment of relieving it immorally. To what respectable family could I now offer myself, having so lately been discharged from private confinement? The servant, who lived with me, was a very ex- cellent young woman ; her disposition was amiable, her mind well capable of cultivation, and her form and manners by no means unpleasing: and hence, after mature deliberation, I de- termined upon marrying her if she herself would venture upon so perilous a risk. He married her accordingly;—has ever since, for upwards of twenty years, enjoyed an almost uninter- rupted share of health, and has been more than ordinarily hap- py in his family. Other examples of a like kind are to be found in Paullini,* Martini,! and Vogel ;J but it is unnecessary to copy them. And hence, castration has been often advised, and sub- mitted to, and occasionally with success. It is from a like sympathy of action between the brain and other parts ofthe body, that we meet with instances ofthe one or the other species of disease before us, produced occasionally, and, perhaps, in habits of great sensibility, by suppressed irrita- tions of much smaller moment; as cutaneous diseases,^ a sup- pressed hemorrhoidal flux,|| or an ulcer of long standing sudden- ly dried up.lF Furious mania, constituting the first variety, sometimes makes its attack very abruptly, and commences with the patient's be- ing sensible of some indescribable movement in his head, which excites him to loud and sudden shrieks, at the same time that he runs up and down the room, and mutters something to him- self that is altogether unintelligible; though the symptoms, even in this abrupt and violent attack, admit of much diversity. More commonly, however, the disease is the work of time, and its growth is thus admirably described by Dr. Monro in his reply to Dr. Battie. " High spirits, as they are generally term- ed, are the first symptoms of this kind of disorder. These ex- cite a man to take a larger quantity of wine than usual, and the person thus afflicted, from being abstemious, reserved, and mod- est, shall become quite the contrary, drink freely, talk boldly, obscenely, swear, sit up till midnight; sleep little, rise sudden- ly from bed, go out a hunting, return again immediately, set all * Cent. in. Obs. 14. t Observazioni, ch. n. 10. | Beobachtungen, p. 9. i Act. Nat. Cur. vol. viii. Obs. 28. Descottes, Journ. de Med. torn. lxvi. Petit, Oeuvres posthumes, torn. iii. || Sanctacrux, De Melancholia, p. 29. Lentilius, Miscell. I. p. 36. If Forestus, lib. x. Obs. 24. cl. iv.] NERVOUS FUNCTION. [ord. i. 75 his servants to work, and employ five times the number that is Gen. r. necessary. In short, every thing he says or does betrays the Spec II. most violent agitation of mind, which it is not in his own power * E« Mania to correct. And yet, in the midst of all this hurry he will not ferox" misplace one word, or give the least reason for any one to think he imagines things to exist that really do not, or that they ap- pear to him different from what they do to other people. They who but seldom see him admire his vivacity, are pleased with his sallies of wit and the sagacity of his remarks ; nay, his own family are with difficulty persuaded to take proper care of him, till it becomes absolutely necessary from the apparent ruin of his health and fortune." This picture is drawn from a rank in life something above that of mediocrity, but its general features of ebullient spirits, and hurry and bustle, and " much ado about nothing," will apply to every rank. Such a person, says Sir A. Crichton, in allusion Progressive to the present description, cannot be said as yet to be delirious, symptoms. but that event soon follows, and he has then the symptoms com- mon to the disease, symptoms which only differ from a differ- ence in the train of thoughts which are represented in his mind. He begins to rave, and talk wildly and incoherently; swears as if in the most violent rage, and then immediately afterwards bursts into fits of laughter, talks obscenely, directs offensive and contemptuous language against his relations and those around him ; spits at them ; destroys every thing that comes in his way ; emits loud and discordant screams, and continues this conduct till he is quite exhausted. The state of rest which follows is generally short and sleepless; the patient is obstinate ; he will not speak a word, and clenches his teeth if any thing be offered him to swallow ; or else cunningly pretends to drink a little, but immediately squirts it out on the person who offers it. Instant- ly he again breaks out into all the wild and extravagant lan- guage and actions he committed before. If kept in strict coer- cion, he has often so much command over himself as to behave mildly and modestly ; and were it not for the general expres- sion of his countenance, and the peculiar glistening appearance and rapid movement of his eyes, he might impose on many of the by-standers, and make them imagine that the frenzy was over. The length of the paroxysm and of the interval varies greatly in different individuals. But, generally speaking, the Length of more violent the fit, the sooner it ceases from exhaustion; and paroxysm hence sometimes it ceases in a day or two, and sometimes runs ^£1" on to a month or even more : returning at the distance of a few weeks, or at certain periods ofthe year.* In the second variety or elevated madness, the passions, and 0. E. Ma- especially the irascible ones, are less busy, and the imagination ™**™l~ is chiefly predominant, and at work without ceasing. It is here *ns; we most frequently trace something ofthe ruling pursuit of their j,,™"^, former lives, so that the covetous man is still conversant about frequently relates to * The paroxysm is accurately and powerfully described by Spenser, Fairie the pursuits Queen, b. 11. cant. iv. xv. of former life. 76 cl. iv.] NEUROTICA. [ord. i. Gen. I. Spec. II- 0 E. Mania exultans. Phantoms of a pleasura- ble kind ; often amorous. Illustrated. The illusion often un- connected with the cause of the disease. y E. Mania despondens. State of the mind rarely explanatory of the ex- citing cause. Pathology. J E. Mania demens, Pathology. Description from Pinel. purchasing lands and tenements, and amuses himself with per- petually augmenting his possessions; while the devotional char- acter is for ever engaged in a routine of prayers, fastings, and ceremonies, visions and revelations, and fancies himself to be inspired and lifted into heaven. The phantoms are all ot a pleasurable kind, and mostly such as afford the deluded sufferer a vast opinion of his own rank or talents. Donatus gives the case of a lady at Mantua, who conceited she was married to a king, and would kneel down and affect to converse with him as if he were present with his attendants ; and if she found by chance a piece of glass in the street, she would hug it as a jewel sent her from her royal lord and husband.* He relates another case, from Seneca, of Senicio, a madman of considerable wealth, who thought himself and every thing about him great; that he had a great wife and great horses, and could not endure little things of any kind; so that he would be served with great pots to drink out of; great hosen, and great shoes bigger than his feet: " Like her," says Burton, " in Trallian, that supposed she could shake all the world with her finger, and was afraid to clench her hand lest she should crush the world to pieces like an apple."t Yet even here the train of thoughts or ideas, which occupy the mind ofthe maniac, in many instances throw no light what- ever on the nature or origin ofthe complaint; and we can still less avail ourselves of them, than in various cases of melan- choly. This is particularly observable in the third variety or de- spondent madness ; for though this modification of the disease may occasionally be produced by suspicion, terror, or a guilty conscience, it is far more frequently the result of a melancholic idiosyncrasy, or a debilitated state ofthe constitution at the time ofthe attack, in consequence of which the sensorial fluid is se- cretedj perhaps even less freely, instead of more so, than in a condition of health : so that the patient sinks by degrees into a state of insensibility; unless he should be roused with false courage, and find means to put an end to his existence before this period arrives. In dementia or chaotic madness, this state of sensorial exhaus- tion and consequent insensibility is still more obvious, though there is, perhaps, less constitutional tendency to the depressing passions. The judgment is here more diseased and weakened than in any other form, and, none of the kindred faculties as- suming a paramount power, there is a general anarchy and con- fusion in the ideas that flit over the sensory without connexion or association of any kind. And hence Pinel has admirably characterized it as consisting in a " rapid succession or uninter- rupted alternation of insulated ideas and evanescent and uncon- nected emotions ; continually repeated acts of extravagance ; * De Hist. Med. Mirab. lib. n. cap. I. t Anat. of Melancholy, Part i. sect. 3. X As this expression is quite an improbable hypothesis, it would be better to exchange it for " sensorial power is generated."—Ed. cl. iv.] NERVOUS FUNCTION. [ord. i. 77 complete forgetfulness of every previous state ; diminished sen- Gen. I. sibility to external impressions; abolition ofthe faculty of judg- Spec. II. ment; perpetual activity without object or design, or any inter- e- turbationes; affectu percitus vel commotus." We have already had occasion to observe, that the various Faculties of faculties ofthe mind are just as liable to be separately diseased the mind ua- as those ofthe body : for, as the faculty of digestion may be im- ease, paired, while that of respiration or secretion remains in perfect health ; so may the perception or the judgment be injured, The pas- while the memory or the imagination continues in its former sions ofthe activity. It is the same with the pathetic faculties. These, I jj'iibjj.*1" have stated, are to the mental part of the human frame what feelings, properly so called, are to the corporeal: and hence both may be excited pleasurably or painfully; they may be in May be in morbid excess or in morbid diminution ; and their influence may """'•"d equally vary, according to the peculiarity of the passion or the diminution. sense affected. Each will therefore furnish a distinct division Morbid pas- of diseases : the first constitutes the genus before us ; the second sions consti- will be found in the ensuing order. tutethepre- The present genus, however, has never hitherto been proper- 8 " gmiS' » Med. Trans, vol. vi. 86 cl. iv.] NEUROTICA. [ord. i. Gen. II. Empa- thema. This genus never hith- erto proper- ly arranged. Its species regarded by Pinel as modifica- tions of mania: by Sauvages nearly the same : by Crichton, as modifica- tions of insanity. Ungovern- able passion, though not insanity,still a mental de- rangement. How con- templated by the Greeks and Romans. Species, how distinguish- ed. ly arranged or digested. Pinel is constantly describing the spe- cies that belong to it in his general remarks and illustrative cas- es, but allots no place to it in his nosological arrangement, with the exception of the third species; which, as I have already ob- served, he has irregularly ranked as a subdivision of mania, un- der the name of manie sans delire ; although he admits, that the judgment and perception, and, indeed, all the reasoning faculties ofthe mind are in most cases undisturbed. In like manner, Sau- vages has incorrectly merged the whole family into a single spe- cies under the genus mania, to the utter confusion of both. It is not a little singular that Dr. Crichton, who has written so excellently on the diseases ofthe passions, and has illustrated his observations with such a variety of examples, should, both in his " Inquiry into the Nature of Mental Derangement," and in his u Synoptical Table," either have assigned no place to these dis- eases, or have transferred them, like Sauvages, to insanity, un- der his nomenclature, delirium ; although, as I have just remark- ed, the perception and the judgment (a diseased condition of which is usually appealed to as constituting pathognomonic symp- tom of insanity) are, for the most part, strikingly clear in empa- thema, and often peculiarly acute. This last faculty, indeed, is frequently perverted by the prevailing emotion or passion ofthe hour; as where a man, under the influence of despair, reasons himself into the lawfulness and expediency of suicide ; but the argument, though deflected, runs still in a right line ; or, in oth- er words, consists of correct reasoning built on a perception of false ideas as its premises, of which we have had various exam- ples in the philosophical suicides of Germany. In the greater number of cases, however, the judgment, instead of being per- verted, is merely overpowered by the impassioned emotion: there is neither false judgment nor false perception. Ungovernable passion, or empathema, nevertheless, though not strictly insanity, is as much a mental derangement as insanity itself. " Ira furor brevis est," is as clear a truth as is to be found in the whole learning of the Roman empire; and hence the elegant and fanciful mind of the Greeks added the term mania to that expressive of any passion or emotion whatever, when in a state of violence or misrule, as doximania, erotomania, chrysomania; and, in this sense, mania is often used in the colloquial language of our own day. For poetry or vernacular speech, mania, thus employed, is intelligi- ble enough; but it is not sufficiently correct for medical or phy- siological purposes, under which predominant passion must ne- cessarily be distinguished from delirium. The genus empathema has three species: the first characteriz- ed by the rousing power of the prevailing passion ; the second, by its depressing power; the third, by symptoms different from both, and which will be explained in its order. 1. empathema entonicum. impassioned excitement. 2-----------atonicum. impassioned depression. 3-----------inane. hare-brained passion. CL. IV.] NERVOUS FUNCTION. [ord. i. 87 Species I. Empathema Entonicum.—Impassioned Excitement. The predominant passion accompanied with increased excitement, ar- dour, and activity; eye quick and daring; countenance flushed and tumid. The varieties are innumerable : the chief are as follow : Gen^ II. a Laetitiie. Ungovernable joy. /3 Philautiae. Self-love. Self-conceit. y Superbiae. Pride. 3 Glorias famis. Ambition. i Iracundiae. Anger. £ Zelotvpiae. Jealousy. All these, and, indeed, all other passions whatever, are as ™ej^ons much direct and indirect stimulants to the mind as provocative a[*mJfacnctg foods, or drinks, are to the body. Employed occasionally, and tothemind: in moderation, both may be of use to us, and are given to us by nature for this purpose : but, when urged to excess, they throw and hence the system off its healthy balance, rouse it by excitement, or de- m,^r jj,;"'6" press it by exhaustion; and weaken the sensorial vessels, by the chievous: wear and tear they produce. As those we are now contemplating are attended with in- Hence creased action, they have some few symptoms in common, how P^88 widely soever they may differ in others; of which the chief gymploraa;n are, an augmented temperature and an accelerated pulse. If common: carried to such a degree that the judgment loses its power, or, in other words, the man has no longer any command over him- self, they betray themselves by their effect on particular fea- tures and particular organs, according as the emotion is of a painful or a pleasurable character, or as the pain or the plea- sure predominates in those cases which partake of both. There are some organs, however, that seem to be equally Sometimes affected under a vehement excitement of whatever may be the J'^j^ prevailing passion, as the brain, the heart, and the lungs; for by separate head-ach and apoplexy, palpitation and anhelation, are alike signs, or common to sudden fits of extreme joy, terror, and rage. The effecting thoracic effects are indeed the most striking; and hence it is organs. that the praecordia have been more generally supposed in all someorgans ao-es and countries to be the seat of mental emotion than the equally encephalon ; and the state of the heart as light and jumping for '^^nt joy, oppressed and breaking with grief, or black and bilious excitement with hatred, has been more commonly appealed to, than that of of all pas- the animal spirits; though the latter is the cause, and the form- S10ns- er the mere effect. It may be thought, perhaps, that the vulgar character of the Whence the heart, as indicative of hatred or revenge, is merely figurative, J^,1,"^ and has no foundation in nature. But this is not the case: for seat 0r an°"er, when long indulged, is well known to affect the functions hatred. of the liver, and has often laid a foundation for jaundice, and consequently for a deeper colour as well as other properties of the blood that circulates through the heart: a fact so well 88 cl. iv.] NEUROTICA. [ord. i. pleasurable or painful, and accord- ing to the respective kinds of pleasure and pain. Exempli- fied. Gen. ii. known, that the seat of anger has, in the poetical language of Spec. I. most countries, been transferred to this organ, and bilious or raTomcuni 3 choleric and irascible are convertible terms in the popular lan- guage of our own day. How differ- We have endeavoured to account for the difference of effect ar'e excited Prou*u?ed DJ the sensorial fluid in the different organs of local by different sensation, by supposing some degree of change to take place in passions. the nature of this fluid by the action of the respective sentient Whether nerves at their origin or extremity.* It is possible, that other changes may take place in the sensorium, from the influence of peculiar mental impressions, and that certain classes or ramifi- fication of nerves may be more affected by particular impres- sions, than others. And we may hence account, not only for the sympathy of the liver with the sensorium, when urged by anger, but for that of other organs, under other impassioned ex- citements ; and this not merely whether pleasurable or painful, but according to the peculiarity of the pleasure, or the pain, which forms the source of incitation. Thus, while anger stimu- lates the liver, fear has a tendency to produce a diarrhoea and incontinence of urine; grief disorders the stomach, and affects the lachrymal glands ; sudden fright divests the muscles of loco- motion, and produces palsy; while mirth throws them into in- voluntary action, and compels a man to leap, laugh, and sing. This, however, is to digress; for our present business is to contemplate the mental, rather than the corporeal, effects of the passions, when urged to excess, or intemperately pro- tracted. The instances of derangement, produced by a sudden fit or immoderate flow of joy, are numerous, and not difficult to ac- count for. As this impassioned emotion, when indulged with a rampant domination over the judgment, is a direct stimulus of a very powerful kind, acting not only on the nerves but on every part of the body, it cannot take place without producing great sensorial exhaustion, and consequently cannot be persevered in without remissions of languor and lassitude, like the effects of intoxication from strong wine or spirits. The misfortune is, that when the elevating faculties of the mind, and especially the imagination, are once let loose, by the operation of this passion, and both run wild together, the mental excitement will sometimes continue after the strength ofthe body is completely prostrated. And when this strength is sufficiently recruited for the external senses to convey once more to the perception true and lively impressions of the objects that surround them, the perception, which has been also morbidly affected by the vio- lence of impassioned paroxysms, will not receive or convey them in a true stale, and a permanent derangement is the con- * This and other hypotheses, founded on the presumed existence of a sen- sorial fluid, may satisfy readers disposed to be content or pleased with con- jecture; hut, until the reality of such fluid be proved, they can only be re garded as sports of the imagination. It is fortunate, however, that the occa- sional reference made to thein in the text does not impair the generally valuable character of the authors matter.—Ed. a. E. ento- nicum Laetitiae. Its stimu- lant effects. Succeeded by great corporeal exhaustion, sometimes while the mental ex- citement prevails. Whence a permanent inaccord- ance with impressions from exter- nal objects. cl. iv.] NERVOUS FUNCTION. [ord. i. 89 sequence. Cardan* gives the case of an artisan of Milan, who Gen. II. having had the good luck to find an instrument that formerly Spec. I. belonged to Archimedes, ran mad with the fit of transport into *E.ento- which he was hereby thrown: and Plutarch, in his life of Ar- ?,c"™ite taxerxes, has a like story of a soldier, who, having had the high Exen)pl;. honour of wounding Cyrus in battle, became so overjoyed that sed. he lost his wits from the moment. Boerhaavet and Van Swie- tenj relate cases of epilepsy that followed from the same cause. Occasionally the exhaustion of sensorial power, hereby pro- Exhaustion duced, is so sudden and total, that the whole nervous system sometimes seems instantaneously to become discharged of its contents, like '°ju,l,et" t i i ■ 1 1 i i ■ , i ■ • i i . . i ann t°'al a9 a Leyden phial loaded with electricity when touched with a to produce brass rod, and death takes place at the moment. There are death. various instances on record, in which a like fate has followed upon the injudicious production of a pardon to a culprit just on the point of his being turned off at the gallows. Valerius Maximus Exemplifi- relates two anecdotes of matrons who, in like manner, died of ed. joy on seeing their son's return safe from the battle at the lake Thrasis: the one died while embracing her son ; the other had been misinformed, and was at that moment lamenting his death. The power of surprise was added therefore in this case to that of joy, and she fell even before her arms could clasp him.§ Marcellus Donatus, Pechlin, and other collectors of medical curiosities, are full of incidents of this kind: and a case not very unlike occur- Farther red a few years since to the present author, in the person of an illustration. intimate friend and most exemplary clergyman. This gentle- man, who had consented to be nominated one of the executors in the will of an elderly person of considerable property with whom he was acquainted, received a few years afterwards, and at a time when his own income was but limited, the unexpected news that the testator was dead, and had left him sole executor, together with the whole of his property, amounting to three thousand pounds a year in landed estates. He arrived in Lon- don in great agitation ; and, on entering his own door, dropt down in a fit of apoplexy, from which he never entirely recov- ered ; for though he regained his mental, and most of hi3 cor- poreal faculties, his mind was shaken and rendered timid, and an hemiplegia had so weakened his right side that he was in- capable of walking farther than a few steps. Could this passion be employed as a medicine, and adminis- Thisemo- tered with a due regard to time and measure, from its powerful tion highly influence on the whole system, there can be no doubt that it "^'d be'* might be made productive of the most beneficial effects. And meted out there is hence no reason for hesitation in admitting many ofthe and em- wonderful cures, which are reported to have been occasionally £,°dicine'* operated by its sudden incursion. Corineus gives the case of a Hag been tertian ague thus removed ; Lory that of a stricture of the py- productive lorus with incessant vomiting ;|| and Trellian, what we should of wonder- less have expected, a radical cure of melancholy .IT ful c"rM; Exeniphfi. * De Sapientia, lib. ii. t De Morb. Nerv. lib. ix. cap. 12. ed« X Comment, torn. iii. p. 144. 4 Lib. ix. cap. 12. || De Melancholia, torn. i. p. 37. If Lib. xli. p. 17. VOL. IV. 12 90 cl. iv.] NEUROTICA. [ord- '• Gen. II. Spec. I. 0 E. ento- nicum Philauti*. Descrip- tion. y E. ento- nicum Superbiae. Description. Why sub- ject to more numerous mortifica- tions than self- conceit ? In the second variety we have noticed the predominance of self-conceit. The ordinary feeling here is still of a pleasura- ble kind, but never amounts to the paroxysms ofthe preceding: its effects therefore on the soundness of the mind are more gradual, but in many instances quite as marked. It is a vain and preposterous estimation of one's personal powers or endow- ments, accompanied with so immoderate a love of one's own self on this very account, as to make the possessor blind to every instance of superiority in another person, and hence to save him in a considerable degree from the pain he would otherwise endure; for the self-conceited man is not easily mortified or humiliated, and hence not easily cured of the malady. " A wise man," says Mr. Mason in his Treatise on Self-Knowledge, " has his foible as well as a fool: but the difference between them is, that the foibles of the one are known to himself, and concealed from the world ; the foibles of the other are known to the world, and concealed from himself. The wise man sees those frailties in himself which others cannot: but the fool is blind to those blemishes in his character which are conspicuous to every one else."* It was under the influence of this disease that Menecrates, as we learn from iElian, became so mad as seriously to believe himself the son of Jupiter, and to request of Philip of Macedon that he might be treated as a god. But it is not always that the man, thus deranged, falls into such good hands as those of the Macedonian monarch; for Philip humorously determining to make the madman's disease work its own cure, gave orders immediately that his request should be complied with, and invited him to a grand entertainment, at which was a separate table for the new divinity, served with the most costly perfumes and incense, but with nothing else. Menecrates was at first highly delighted, and received the worship that was paid to him with the greatest complacency, but growing hungry by degrees over the empty viands that were offered him, while every other guest was indulged with substantial dainties, he at length keenly felt himself to be a man, and stole away from the court in his right senses.t The passion of pride has a close affinity to that of self-con- ceit: but is less confined to self-endowments, and is a relative as the former is a personal vanity. The proud man may indeed have the same preposterous estimation for some supposed gift of person, but the grasp of the passion does not terminate here ; for he carries the same estimation to every thing that in the remotest degree appertains to him, and is hence as vain of his birth, or family connexions, his wealth, his estates, his country, his office, his honour, or his religion ; and he is hence open to more numerous mortifications, and is in fact more fre- quently mortified, than the mere egotist. Examples of a de- ranged mind from ungovernable pride are to be found in every rank of life ; but as those in the loftiest have the cup of intoxi- cation most frequently offered to them, and drink deepest of * Part I. Ch. VII. t Lib. xii. cap. 51. cl. iv.] NERVOUS FUNCTION. [ord. i. 91 its contents, it is here, among kings, and courtiers, and prime Gen. II. ministers, and commanders, that we are to look for the most Spec 1. striking instances of this malady. Many a crown won by good > K- ent0" fortune, and which might have been preserved by moderation, s^p™j,ia. has been lost by the delirium of pride and vain-glory; of which the history of Demetrius of Macedonia furnishes us with cipa^[y to' one of the most memorable examples: who, in his disgraceful be found. fall, was obliged to abandon, among the other idols of his heart, Exempu. the unfinished robe which was to have hung over his shoulders, fied. containing a magnificent embroidery of the sun, the moon, and all the stars of heaven, designed to have represented him as the sovereign lord of the whole. There is, however, another kind of madmen, to adopt the £rlde.of words of Burton,* opposite to these, "that are insensibly mad, what? and know nothing of it; such as affect to contemn all praise and glory, and think themselves most free when they are most f*£mv mad: a company of cynics, such as monks, hermits, and an- chorites, that contemn the world, contemn themselves, contemn all titles, honours, offices, and yet, in that contempt, are more proud than any man living. They are proud in humility, proud in that they are not proud. They go in sheep's russet, many great men that might maintain themselves in cloth of gold, and seem to be dejected ; humble by the outward carriage, when as inwardly they are swollen full of pride, arrogancy, and self- conceit. And therefore Seneca adviseth his friend Lucilius in fj"^"^*1 his attire and gesture, his outward actions especially, to avoid Seneca. all such things as are most notable in themselves; as a rag- ged attire, hirsute head, horrid beard, contempt of money, coarse lodging, and whatever leads to fame that opposite way."t When the passion of pride is united with that of ardent de- " Despair makes a near approach to heart-ach in the over- , E?ator£ whelming agony it produces, and its pressing desire of gloom cumdespe- and solitude, but, generally speaking, the feeling is more selfish, ration'»- and the mind more hurried and daring. Despair, as it common- Despair ly shows itself, is utter hopelessness from mortified pride, blast- l>ow distin- ed expectations, or a sense of personal ruin ; heart-ach is either fru0mhetne hopelessness from a sense of some social bereavement, or rel- preceding. ative ruin. The gamester, who cares for no one but himself, may rage with all the horror of despair; but the heart-ach belongs chiefly to the man of a warmer and more generous bo- som, stung to the quick by a wound he least expected, or borne down, not by the loss of fortune, but of a dear friend or rel- ative, in whom he had concentrated all his hopes. The well- illustrated. known picture of Beverley is drawn by the hand of a master, and he is represented as maddened by the thought of the deep distress into which his last hazard had plunged his wife and family; but if his selfish love of gaming had not triumphed over his relative love for those he had thus ruined, he would not have been involved in any such reverse. While Beverley was in despair, it was his wife who was broken-hearted. The sources of this most agonizing emotion are innumerable, Causes in- and, from the total shipwreck of all hope on which it is found- numerable. ed, there is no passion of the mind that drives a man so readily to an act of suicide. To live is horror: the infuriated sufferer Suicide a feels himself an outcast from God and man ; and though his [£ult"' judgment may still be correct upon other subjects, it is complete- ly overpowered upon that of his actual distress, and all he thinks of and aims at is to withdraw with as much speed as pos- sible from the present state of torture, totally regardless of the future, or falsely satisfying himself, by a perversion of his judg- ment, that there is no crime in his doing so. * Relatio dc Moibis anno 1720 YVarsaviiB curatis. Dresd. 1730. VOL. IV. 13 911 cl. iv.] NEUROTICA. [ORD- '• One ofthe severest causes of despondency is a conscience la- bouring under a deep sense of guilt for some —undivulged crime Unwhipt of justice ; and so severe has the anguish been in many cases, that the tor- mented wretch, thus haunted by himself, and hating the light of drvff7tS'" heaven> has been compelled, as the less evil of the two, to sur- cul'pr'ifto a render himself to the laws of his country, and court the disgrace surrender of of a public execution. Yet the same miserable feeling has imsetf to sometimes followed from an ideal cause, especially in a mind of natural timidity, or constitutionally predisposed to a gloomy view of nature : for such, by a mere exercise of their own medita- tions, but far oftener by the coarse but impassioned oratory of itinerant preachers, are induced to believe that the Almighty has shut them out forever from the pale of mercy, and that the bottomless pit is yawning to receive them; and, under the in- fluence of such an impression, they too frequently work them- selves up into a state of permanent insanity, or hurry them- selves by their own hands into the horrors of a fate from which they feel assured, that no repentance nor power of religion can save them. In the midst of great public calamities, the passion of ungov- great public ernable despondency is apt to become epidemic, and particu- and pecu-' '"""tyi as M- Falret has well observed, where the constitution of liariy in a relaxing at' Biosphere. Gen. II. Spec. II. c E. atoni- cuiii de.epe- rationis. Guilty conscience, justice. The feeling sometimes from imaginary causes; or false ideas excited by itinerant preachers. Common in Fall of the Roman empire. Revolution of France. Remedial treatment. Medicine Dot of much avail: but may some- times be employed advantage- ously. the atmosphere, from being moist and hot, and consequently re- laxing and debilitating, favours its spread. In 1806, the feeling of desperation was so common at Paris, that sixty suicides oc- curred during the months of June and July ; at Copenhagen, in the course ofthe same entire year, three hundred; and in 1793 about thirteen hundred at Versailles alone.* The sensation, however, whether general or individual, is most acute where there is little corporeal exertion, and consequently where there is time to cultivate and brood over it. Hence suicide is frequent in the distress of sieges, in the first alarm of civil commotions, or when they have subsided into a state of calmness, and the mischiefs they have induced are well pondered ; but it seldom takes place in the activity of a campaign, whatever may be the fatigue, the privations, or the sufferings endured. On the fall ofthe Roman empire, and throughout the revolution of France, self-destruction was so common at home, as at last to excite but little attention : it does not appear, however, to have stained the retreat ofthe ten thousand under Xenophon, and, according to M. Falret, was rare in the French army during its flight from Moscow. In all these varieties of empathema, the art ofthe physician can do but little ; and, in many of them, nothing whatever. Yet where the heart suffers acutely, and the mind is deeply deject- ed, sedatives and antispasmodic cordials may occasionally be found useful; and, as the abdominal viscera are greatly liable to be affected, the appetite to fail, the liver to be congested, and * Falret, de l'Hypochondrie ct du Suicide, 8vo. Paris, 1822. ci. iv.] NERVOUS FUNCTION. [ord. i. the bowels rendered costive, these organs must be watched, and Gebt. II. such relief be afforded as they may stand in need of. Where Spec. II. aperients are required, the warm and bitter resins will generally Empathema answer the purpose best, alone or combined with rhubarb. al0"icum' Where love is the cause of disease, and the fair patient is young and delicate, suppressed menstruation or even chlorosis is by no means unfrequent, followed by hysteria and other nervous af- fections that produce considerable trouble. In all cases of mental dejection, however, a kind and judicious Mnral friend is by far the best physician : medicines may do a little, resources. change of scene and country, of custom and manners, a little also ; but the soothing of tenderness and indulgence, and the voice of that friendship which knows how to discriminate op- portunities, and seasonably to alternate admonition with conso- lation, will accomplish more in the way of cure than all the rest put together. The despondency, produced by the real sense of a guilty conscience, or the visionary belief of eternal reprobation, may derive important and most salutary advantage from religious instruction, when conducted with a judicious attention to the exigency of the case. But much circumspec- tion and adroitness are requisite upon this point; for so rooted is the feeling to be extirpated, that no ordinary means will suffice for its eradication, while, if it be forcibly snapped off, it will shoot out the wider, and grow ranker than ever. The excitement of an opposite passion, or train of feelings, Excitement has sometimes been accompanied with success : for there are of opposite Instances, in which the slave of imaginary pain and misery has l'88*'0""' for ever forgotten his sense of visionary grievances under the d"n re- stroke of poignant and real affliction; and the miser, when re- verses have duced by a sudden reverse of fortune to actual beo-gary and so,ne,7" thus completely disencumbered of the load that has hitherto so especially much oppressed him, has returned to his sober senses, and u"der learned a juster estimate of worldly possessions. avarice and The same attempt has often been recommended in disap- gXvTn'ees. pomtments under the passion of love ; and, according to the How far concurrent report of the poets of ancient and modern times fu^es81"'1' many of whom profess to be well versed in this kind of disci- ioV'eopel€'sa pline, it has very generally been attended with success. Where the emotion has more of a corporeal than a sentimental origin, this may easily be conceived ; and it is possible, that it may also sometimes have occurred under a purer feeling; though for the honour of the human heart, I do not think this is much to be trusted to. Where the choice between two young Contingent persons of fair character is really imprudent, yet the affections assont ,ia° are so riveted as to bid defiance to all forcible attempts to un- HZZ^ fetter them, a promise of consent on the part of the reluctant parent at the distance of a given period of time, as a year and a half or two years, with an undertaking on the part of the lovers neither to see nor correspond wilh each other in the mean time, an engagement easily fallen into, has answered in many instances to which I have been privy. The ardour has gradually cooled on the one side or the other; the judgment has 100 cl. iv.] NEUROTICA. f0RD- »• Gen. II. been more impressed with the nature of the imprudence ; or a Spec II. more attractive form has interposed, and irretrievably settled atonk'm"1'1 the self to be Elias, and, like the prophet, had determined upon fasting forty days. The keeper, fearful that he would never Example. hold out, and that he should lose his patient, dressed up a man in the attire of an angel, who was introduced to him in no ordinary manner, and informed him, that he was commis- sioned from Heaven to bring him food. The supposititious Elias took it, was afterwards allowed to find out the trick, and thus, at the same time, found out his own imposition upon himself. From the influence which we have seen such enthusiasts, or j>a. Elatio even pretended enthusiasts, capable of producing upon the mind fariatica. * Anatomy of Melancholy, Part in. sect. iv. 1. 3. t Butler"? Lives of the Saints, in loco. vol.. IV. 1 1 106 CL. IV.J NEUROTICA. [ord. I. Gew. HI. Spec. I. tPA. Elatio fanatica. Description. Chiefly a delirium of ignorant and barbarous times. Trui h or falsehood of the principles appealed to, of no importance in producing the effect. Prophets of Baal. Phrygian priests. Indian Juggernaut, Lamism. Sufferings of the Waldensef. St. Bartho. lomew's day. Inquisition. Philip II. of Spain. Cure to be obtained chiefly by general instruction and a diffusion of genuine knowledge. of the multitude, when roused by the solemnity and awfulness of the revelations that are supposed to be disclosed to them, we can easily see how fanaticism, constituting the fourth va- riety of the present species, may obtain an ascendancy, and even rage with all the ramifying power of an epidemic : con- sisting of religious flights of the imagination, predominant over the natural feelings as well as the judgment, excited by the calls or doctrines of those who affect to be preternaturally gifted, or who possess an equal influence over the mind by the high sanction of priesthood, profound learning, or any other respected authority : and often urging to a voluntary and in- appropriate submission to severe privations, mortifications, and tortures ; or to the torture and massacre of those who profess different creeds. Examples, as in the last variety, may be found in every age and religion, but chiefly in times of gross ignorance and barba- rism ; where the general mind has been too little informed to distinguish between truth and sophistry, and the passions have been undisciplined to restraint. It is hence of no importance what religion or superstition is to be inculcated; for those that are true, and those that are false, have been equally laid hold of by enthusiasts and impostors to produce the same end, and effect the same triumph by means and machinery that could only be furnished from the infernal regions. Hence the blood and raving of the prophets of Baal; the Curetes or Phrygian priests, and the delirious votaries ofthe Indian Juggernaut; the cruel and senseless penances and punishments sustained in many of the convents and nunneries of Lamism, and still more so in those of many catholic countries. Hence the terrible suf- ferings of the Waldenses, the furies of St. Bartholomew's day, the fires of Smithfield, and the dark and doleful cells, the whips, and wires, and pincers, and pullies, aBd all the infernal paraphernalia of the Inquisition. Hence, in ancient times, the matrons of Canaan and of Carthage were instigated to throw their own children into the flames, and sacrifice them to the gloomy deity whose anger it was held necessary to appease; and hence in more modern days, Philip II. of Spain was goaded to impeach a son, of whom he was little worthy, before the Chamber of In- quisitors, to bespeak their condemnation of him, and to take effectual care that he should be poisoned, as soon as his sen- tence had been pronounced. The cure of these diseases belongs rather to colleges of general instruction, than of medicine. Individual cases of en- thusiasm and fanaticism have existed, and will probably continue to exist, in all ages; but when the general mind is well in- formed, and the social feelings and virtues are duly estimated and widely cultivated, the wild-fire will burn in vain, and meet with little or no fuel to support its rage. ct- 'v.] NERVOUS FUNCTION. [ord. i. \Q7 Species II. Alusia Hypochondrias.—Hypochondrism. Low Spirits. Gloomy ideas of real life ; dejected spirits; anxiety; dyspepsy; lan- guid pulse; indisposition to activity; eye oblique and scowling; countenance sad and sullen. The term HYPocHorroRus is taken from the anatomical com- Gen. III. pound hypochondria, to which region the disease was formerly SpKC-IL supposed to be altogether confined. Hypochondrias is here Explanation used instead of hypochondriasis, the common name, because, as 6c te^m.1*60* already observed on various occasions, iasis as a termination is limited, nearly with this single exception, to denote in the me- dical vocabulary a peculiar family of cutaneous diseases, as pityriasis, psoriasis, ichthyiasis, and many others. The author has felt the less difficulty in proposing this change, as hypo- chondriasis is of comparatively modern invention, and is not to be met with in the Greek or Latin writers; by whom the complaint is usually alluded to or described as a species of me- lancholy, or rather as a disease of the melancholic tempera- ment. It constitutes the third sort or species of this malady describ- How ex- ed by Galen, and which he regards as connected with a pecu- plained by liar state of the stomach; though, from its mental symptoms, Sj,1,™^'1 he does not incline to contemplate it as Diodes, a contempo- with^f™7 rary physician of reputation, had done in his Book of Gastric <-,|e8- Affections, as a simple disease of this organ. The controversy T|,e contro. has been in different times continued to our own day; and it versy not does not seem to be even yet universally settled whether by- yet settled. pochondrias should be regarded as a mental or a dyspeptic malady. M. Esquirol, and M. de Villermay,* contemplate it in the latter light; M. Georgetf and M. Falret, though a pupil of M. Esquirol, refer it in every instance to the brain as its prima- ry seat J In Pinel the disease seems to be included under Howar- alienation meniale, and its different varieties to be distributed, ranged by though without particular remark, amidst the five species into Pine1, which he has divided that genus. The present species bears so near a resemblance to several Close re- of the varieties of genuine melancholy as to be often distin- semblance guishable from them with great difficulty; and the more so as larTeTiesof it is no uncommon thing for hypochondrias to terminate in me- genuine lancholy, or for melancholy to be combined with hypochon- mfiJanch°Iy; drias.§ Both may be the result of a predisposing constitution, originate or may be primarily induced by accidental causes, where no from like such constitution exists : and the predisposition and the acci- causes- dental causes of the one may become those ofthe other: for the temperament known by the common name of melancholic, and characterized by a lean and dry corporeal texture, small and rigid muscles, a sallow skin, brownish-yelllow complexion, * Traite des Maladies Nerveuses, &c. t Sur la Folie—Physiologie du Cerveau. X De l'Hypochondrie et du Suicide, &c. 8vo. Paris, 1822. { Falret, de l'Hypochondrie, k:c. ut supra passim. 108 ci- !▼•] NEUROTICA [ORD- ' Gen. III. Spec. II. Alum hy- pochon- drias. Descriptive character. Ordinary corporeal causes. Diagnostics et A. Hypo chondrias autalgica. little relieved by redness of any kind, deep-black and coarse hair, eyes sunk in hollow sockets, large prominent veins, espe- cially in the hands and arms, with a tendency to solitude and private musing, is a common precursor of both. And in like manner a sedentary life of any kind, and especially severe study protracted to a late hour in the night, and rarely relieved by social intercourse, exercise, or nugatory amusements; a de- bauched and dissolute habit, or excesses in eating and drinking, may become causes of either of these maladies, from accessory circumstances that cannot be traced out even where the pre- disponent temperament does not seem to exist. But it is very justly observed by Sir A. Crichton, that even in those " whose health is much deranged, true melancholy seldom arises, except mental causes of grief and distress join themselves to the corpo- real ones: and this constitutes one of the characters which dis- tinguishes melancholia vera from hypochondriasis. The former may be said to be always excited by mental causes, and consists in various phenomena of grief, despondency, and despair; whereas the latter most commonly arises from corporeal causes, and its mental phenomena consist of erroneous ideas entertain- ed about the patient's own make or body."* The corporeal causes are usually a diseased condition of one or more of the digestive organs, and especially, as we shall presently have to observe, a displacement of some part of the colon. It is also not unfrequently a result of the sudden cessa- tion of some periodical or other habitual discharge, as that of an issue, or of a hemorrhoidal flux, a chronic ulcer, or some external eruption. The melancholy man seldom lives long, and his disorder often commences in the meridian of life. He frequently ter- minates his days by violence, or at the utmost never attains old age. The hypochondriac seldom becomes affected till after the meridian of life, and very generally continues to the stage of longevity. The common corporeal symptoms are a troublesome flatu- lency in the stomach or bowels, acrid eructations, costiveness, a copious discharge of pale urine, spasmodic pains in the head and other parts of the body, giddiness, dimness of sight, palpi- tations, general sleeplessness, and an utter inability of fixing the attention upon any subject of importance, or engaging in any thing that demands vigour or courage. The mental feelings, and peculiar trains of ideas that haunt the imagination and over- whelm the judgment, exhibit an infinite diversity, and lay a foundation for the three following varieties: « Autalgica. Vapours. (3 Perttesa. Weariness of life. y Misanthropic. Misanthropy. In the first variety, which is commonly distinguished by the name of vapours, or low spirits, the patient is tormented with * Of Mental Derangement, vol. iii. p. 235. CL. IV.] NERVOUS FUNCTION. [ord. i. 109 a visionary or exaggerated sense of pains or some concealed Gew. III. disease; a whimsical dislike of particular persons, places, or SpEc. II. things ; or groundless apprehensions of personal danger or *A- Hypo- poverty, chondrias m j- <- *. . . . . autalgica. Ureding gives an account of a medical practitioner, who ap- Description plied to him for assistance, under an impression that his stomach Exero.,ii_ was filled with frogs, which had been successively spawning tied. ever since he had bathed, when a boy, in a pool in which he had perceived a few tadpoles. He had spent his life in trying to expel this imaginary evil, and had travelled to numerous places to consult the first physicians of the day upon his obsti- nate malady. It was in vain to attempt convincing him, that the gurglings or borborygmi he heard were from extricated and erratic wind. He argued himself, says M. Greding, into a great passion in my presence, and asked me if I did not hear the frogs croak. 1 have under my care a hj'pochondriac of about fifty years of Additional age, who affords a sufficient proof, that Moliere drew his Ma- illustration. lade Imaginaire from nature, and hardly added an exaggerating touch. His profession is that of the law; his life has been uniformly regular, but far too sedentary and studious. Without having any one clearly marked corporeal affection, he is con- stantly dreading every disease in the bills of mortality, and complaining one after another of every organ in his body ; to each of which he points in succession as its seat: especially the head, the heart, and the testes. He now suspects he is going to have a cataract, and now frightens himself with an appre- hension of an involuntary seminal emission. It is rarely that I have left him half an hour, but I have a note to inform me of some symptom he had forgotten to mention, and I have often five or six of these in the course of the day. The last was to state, that shortly after my visit he had had a discharge of three drops of blood from the nose—a change which he thought of , great importance, and requiring immediate attention. His im- aginary symptoms, however, soon disappear, provided they are listened to with gravity, and pretended to be prescribed for; but not otherwise. Yet, in disappearing, they merely yield to others that can only be surmounted in like manner. His head is too much confused to allow him to engage in any serious study, even if it were prudent to recommend it to him: but, on all common subjects, he is perfectly clear, and will converse with shrewdness and a considerable extent of knowledge. His bowels are sluggish; his appetite not good, though he eats sufficiently ; his sleep is unquiet, but he has enough of it with- out opiates; his pulse is variable, sometimes hurrying on abrupt- ly, and without any obvious cause, to a huudred strokes in a minute; but often very little quicker than in a state of health. His tongue varies equally, and is irregularly clean, milky, and brownish, and then suddenly clean again. He is irritable in his temper, though he labours to be calm ; and is so rooted to his chamber, that it is difficult to drag him from it. He has now been ill about ten weeks, but it is during the winter, and the HO cl. iv.] NEUROTICA. [ord. i. Gew. III. Spec. II. •e A. Hypo- chondrias autalgica. An injudi- cious pe- rusal of me- dical books a frequent cause. Exempli- fied from Villermay. J. J. Rous- seau. Fancies en- tertained by the patient often ex- travagantly ludicrous. Marcellus Donatus. Trincavel- iius. season is too severe and inclement for him to venture abroad. I look forward to his restoration in the spring from exercise, change of air, and a course of tonic medicines. I have not found him complain of dysphagia globosa, or that sense of suffo- cation from the feeling of a constringing ball in the throat which is so common to hysteric patients, and which, from its being often also traced in the present disease, has been called by Pechlin suffocatio hypochondriacal but his spirits are in a state of almost perpetual depression. A superficial and injudicious perusal of medical books, ad- dressed to those who are not of the profession, has been a fre- quent source of this affection. M. Villermay distinctly states as one of its causes among his own countrymen a "lecture habitu- elle de Buchan." Rousseau admitted, that this was a powerful cause of hypochondrias in respect to himself. " Having read," says he, " a little on physiology, I set about studying anatomy; and passing in review the number and varied actions of the parts which compose my frame, I expected twenty times a day to feel them going wrong. Far from being astonished at finding myself dying, my astonishment was that I could live at all. I did not read the description of any disease which I did not ima- gine myself to be affected with: and I am sure, that if I had not been ill, I must have become so from this fatal study. Finding in every complaint the symptoms of my own, I believ- ed I had got them all, and thereby added another still more in- tolerable—the fancy of curing myself." The whims that are sometimes seriously entertained under this variety of the disease are so truly ludicrous, that " to be grave exceeds all power of face." One thinks himself a giant, another a dwarf; one is as heavy as lead, another as light as a feather. Marcellus Donatus makes mention of a baker of Fer- rara who thought himself a lump of butter, and durst not sit in the sun, nor come near the fire for fear of being melted. They are all extremely timid, and their fears are exercised upon tri- fles, or are altogether groundless. Some suspect their nearest and dearest friends of designing to poison them: others dare not be alone in the dark, lest they should be attacked with ghosts or hobgoblins. They dare not go over a bridge or near a pool, rock, or steep hill, lest they should be tempted to hang, drown, or precipitate themselves: and if they come to a place where a robbery or a murder has been committed, they instant- ly fear they are suspected. Trincavellius had a patient that for three years together could not be persuaded but that he had killed a man, and at length sunk into a confirmed melancholy, and made away with himself for fear ofthe gallows.t It is a melancholy reflection, that the wisest and best of man- kind are as open to this affliction as the weakest, and perhaps more so. Pascal himself was at one time so hallucinated with hypochondrism, as to believe, that he was always on the verge of an abyss into which he was in danger of falling. And, under * Lib. i. Obs. 31. 1 Consil. xm. Lib. i. cl. iv] NERVOUS FUNCTION. [ord. i. j\\ the influence of this terror, he would never sit down till a chair Gbw. III. was placed on that side of him on which he thought he saw it, Spec. II. and thus proved the floor to be substantial. * A- Hypo- It is frequently induced by too free a use of spirituous liquors, jj,1,^,^' the stomach and other digestive organs being hereby debilitated often jn_ and almost paralysed ; and, where this is the case, the disease is duced by an apt to terminate in that exhausted state of the nervous system excess of generally, and delirious condition of the brain, which by some Jf'",,",. writers has been called delirium tremens; in which the mind pcjjriom and body exhibit equal feebleness, combined with a high degree tremens, of irritability, and the patient often falls a sacrifice in a few what- days: previous to which, he is worn out with convulsive strug- gles, succeeded by a cold and general perspiration ; the pulse increases in rapidity and becomes thready, and the twitching of the tendons subsides into a tremor that spreads over the whole body ; the couutenance is pale and anxious, the patient mutters with incessant rapidity, and the delirium is constant, though easily interrupted by questions addressed to him. In one case, says Mr. Blake, who has given a good description of the com- plaint, the mind was so diseased, that the patient after being desired to put out his tongue, continued for nearly half an hour to push it out and draw it in alternately in quick succession whenever I looked towards him.* If before this extremity takes place a sound and refreshing sleep creep gradually over the frame, the irritability subsides, a healthful quiescence suc- ceeds to general commotion, and the mind and the body become by degrees re-invigorated. Under the second variety we meet with a totally distinct set £ a. Hypo- of morbid feelings and ideas; for the patient is here oppressed chondrias with a general listlessness and disgust; an irksomeness and wea- Per aesa- riness of life, often without any specific reason whatever. This is the melancholia Anglica of Sauvages, who describes it as com- Ascribed by mon to our own countrymen ; under the attack of which, says Stages to he, " languid, sorrowful, tired of remedies of every kind, they ch"ffly.,mei1 settle their affairs, make their wills, take leave of their friends by letters, and then put an end to their lives by hanging, poison, or some other means : exhibiting a wish to die, not from insa- nity or severe grief, but tranquilly from a mere taedium vitae, or irksomeness of existence." This may occasionally be the case ; This ac- but by far the greater number of suicides in our own country count not i i strict I v cor- proceed, not from hypochondrism, but a despondency produced rect.though by real losses, and belong, therefore, as 1 have already observ- trueocca- ed,to the genus empathema. Yet this miserable upshot occurs sionally. in a few instances from the feeling, or rather the want of feel- Common ing here assigned: the perpetrators of thq, horrid deed being ,°;ladnv.;a9"d generally those, who having been actively engaged in the hey- retirement day and meridian of life, have retired upon their fortunes with f™,jJ£i,.Mt a view of enjoying them in quiet; but who unhappily find them- {^"'^i,™ selves fitted for any thing rather than for quiet; who have no are not taste for reading, reflection, or domestic tranquillity, and are qualified for * Edin. Med. and Surg. Journal, Oct. 1823, p. 501. 112 cl. iv.] NEUROTICA. [ord- '• Gen. III. Spec. II. ,3 A. Hypo- chondrias periaesa. y A. Hypo- chondrias misanlhro- pica. Description. Medical treatment. Remedial process. too proud to return to the bustle of the world and the excite- ment of nicely balanced speculations. There is here a want of the habitual stimulus to a production of sensorial power; in consequence of which, the individual sinks into a state of low spirits and becomes unhappy. A like issue frequently follows upon a life devoted to all the pursuits of sensual gratification, in the course of which the individual has exhausted his stock of enjoyments, and worn out his powers of body and mind before he has reached little more than the midway of his existence. Every thing now palls upon his senses, and he has neither taste nor energy to engage in more rational pursuits. " A ride out in the morning, and a warm parlour and a pack of cards in the af- ternoon, are all that life affords," said a patient of Dr. Darwin's to him, a man of polished manners, about fifty years of age. He got tired of these in a few months, and having no other resource, shot himself.* Burton has well described the state of mind of many that are tormented with this most wretched malady :t but still more so those affected with the third variety, which is strikingly ac- companied with peevishness, general malevolence, and an ab- horrence of mankind. " They are soon tired with all things: they will now tarry, now be gone ; now in bed they will rise, now up, then go to bed ; now pleased, and then again displeas- ed ; now they like, by and by dislike all, weary of all; sequitur nunc vivendi nunc moriendi cupido, saith Aurelianus ;+ discon- tented, disquieted ; upon every light occasion or no occasion object; often tempted to make away with themselves; they cannot die, they will not live: they complain, weep, lament, and think they lead a most miserable life: never was any man so bad. Every poor man they see is most fortunate in respect of them ; every beggar that comes to the door is happier than they are ; jealousy and suspicion are common symptoms in the misanthropic variety. They are testy, pettish, peevish, dis- trustful, apt to mistake, and ready to snarl upon every occasion, and without any cause, with their dearest friends. If they speak in jest, the hypochondriac takes it in good earnest; if the small- est ceremony be accidentally omitted, he is wounded to the quick. Every tale, discourse, whisper, or gesture he applies to himself. Or if the conversation be openly addressed to him, he is ready to misconstrue every word; and cannot endure that any man should look steadfastly at him, laugh, point the finger, cough or sneeze. Every question or movement works upon him, and is misinterpreted, and makes him alternately turn pale and red, and even sweat with distrust, fear, or anger." As in this species, the body is more affected than in any other division of mental alienation, more may often be accomplished by medicine ; though we must by no means be inattentive to moral discipline. The skin is very frequently cold and without a free secretion, and hence, general friction with rubefacients * Zootiom. vol. iv. p. 90. Edit. 8vo. t Anatomy of Melanch. Part I. Sect. m. i. 2. X Lib. i. cap. vi. cl. iv.] NERVOUS FUNCTION. [ord. i. H3 and the warmer diaphoretics have often been found serviceable. Gew. III. The digestive organs are almost always torpid, and several of Spec. II. them, especially the stomach and liver, secrete their respective y A- Hy- fluids not only in too small a quantity, but of an unhealthy P"^^' quality, so as to be too viscid, too dilute, or morbidly stimulant. pjca. Some kind of acrimony, indeed, is almost always found in the Warm dia- stomach, and particularly that of acidity. And hence aperients, phoretics. carminatives, and particularly the tonic plan which has already Warm been recommended under limosis Dyspepsia, are manifestly called aPer,ents». c i • 11 /• i r , ■ 3 i ■ J and carnu- lor, and will often be found serviceable. natives. Post-obit examinations have also frequently pointed out ano- singular ther local cause, which otherwise we should little expect: and misplace- that is a displacement of the transverse colon.* M. Pinel, as Shorten we have already observed, regards this as a very common cause found on of insanity in all its forms: but there can be no question that it dissection. is a powerful and ready cause of the present species of mental alienation. M. Esquirol, who has found it as frequently as M. Pi- nel, tells us that this displacement sometimes consists in an ob- lique, and sometimes in a perpendicular direction of the intes- tine, so that its sinister extremity lies behind the pubes; whilst it has sometimes descended into the form of an inverted aorta even below the pubes and into the pelvis. No disease of the Generally organization has been found in any instance, and hence the || ".e.utlt of change of place must proceed from relaxation and debility and i,ence alone, where the misposition is not connate; on which account often an it may, in some instances, be an effect, as it is certainly a cause effect> in others. It is under these circumstances, that we chiefly meet Tight paiu with that pain in the epigastrium to which we have already ad- in.,,,e . verted, and which gives the feeling of a tight cord surrounding fro'|nat^l,,sUm the body in the line of distress ; and when such a symptom, cause. therefore, occurs, we have reason to suspect the cause of the disease to be produced by some derangement ofthe colon in re- spect to position. Under the operation of such a cause, the art How to be of medicine can do but little: temporary ease, however, may Pall,ated' be obtained by the pressure of a belt broad enough to support the whole of the lower belly; and it is possible that the intes- tine may gradually right itself under a course of the warmer tonics, as colurabo, canella alba, and cassum-muniar, or lose its morbid irritability by habit. But these are rare terminations; for more generally the displacement increases, and the disease itself gains ground and becomes more incurable. Congestions from weakness of vascular action in one or more Disease of the abdominal viscera, are a frequent result of the present often complaint, and not unfrequently a primary cause : and hence we JJ^riJjai y may see why the bleeding piles should be serviceable in so hemorrhage, or leeches *■ The facts in support of this doctrine have not been so numerous in this applied to country as in Fiance; and its correctness has even been doubted. In Paris, the amis. however, the opportunities of dissecting the bodies of insane persons have been for many years much greater than in London ; and when we find such authori- ties as MM. Pinel and Esquirol attesting, by recorded dissections, the truth of the cause here assigned for the present species of mental alienation, the fact, in relation to the natives of France, must at all events be admitted.—Editor. VOL. IV. 15 114 cl. iv.] NEUROTICA. [ord. i. Gen. Ill Spec. II. Alusia Hypochon- drias. Medical treatment. Chronic discharges to be re- newed whenever suddenly obstructed. Opium doubtful. Exercise, especially on horse- back. Moral man- agement. In the an- talgic va- riety some- times neces- sary to hu- mour the prevailing fancy. Exempli- fied. many instances as to obtain from Alberti the name of me.dicina hypochondriucorum,* and why leeches repeatedly applied to the anus, as reoommended by Schoenheyder, should often have a like beneficial effect.f This is of the greatest importance where the disease has been preceded by a periodical flow of blood from the hemorrhoidal veins ; and should point out to us the necessity of renewing any other discharge, or external irritation, to which the system may have been accustomed. Opium is a very doubtful medicine, though strongly recom- mended by Deidier and other respectable writers ; and readily had recourse to by hypochondriacs themselves to relieve their distressful sensations. Dr. Cullen asserts peremptorily, that he has always found a frequent use of opiates pernicious in hypo- chondriacs :~l and in many instances, in which I have myself been tempted to employ it, I have been compelled to withhold its farther use from its doing more mischief than good. It has often, in such cases, been exchanged for other sedatives, but rarely with any decided advantage. Exercise of all kinds should be encouraged in every modifica- tion ofthe disease, but especially exercise on horseback, though it is seldom in the first and third variety we can succeed in get- ting a patient to try it. The diet should be governed by the principles already laid down for treating indigestion. In the moral management, assiduous kindness and consoling conversation produce a deeper effect than they seem to do. Loquacity is always hurtful, but a talent for cheerful discourse, intermixed with interesting and amusing anecdotes, frequently draws away the patient's attention from himself, and becomes a most ueeful palliative. In the autalgic variety, in which he is perpetually haunted with a feeling of some dreadful disease which exists nowhere but in his own fancy, the hallucination, when we possess his confidence, should be removed by a candid statement of the fact, and, if necessary, friendly expostulation: but the moment we find the prepossession is too strong to be removed by argument, it is better to humour the conceit and to pretend to prescribe for it. It is sometimes necessary, indeed, for the hypochondriac is often possessed of great cunning, to drop all pretensions whatever, and to put him in good earnest upon a course of medicines for a disease we know he is as free from as ourselves. Thus a firm belief, that he has an inveter- ate itch, is a common delusion with a patient of this kind, and it will be often found impossible to persuade him that he is cured, till his whole body has been repeatedly rubbed over with sulphur or hellebore ointment. I had lately under my care a special pleader of considerable eminence, who in the course of this affection would have it that he had the pox. I at first ar- gued the point with him day after day, but to no purpose; he felt certain that he should never be well till he was not only salivated, but had used tonic injections for a gleet which he said * Dissert, de Hasmorrhoidibus. Halle. 1716. t Art Soc Med Hafn. n. p. 313. X Mat. Med. vol. ii. p. 245. Edit. 4to. CL. IV.] NERVOUS FUNCTION. [ord. i. 115 accompanied it,' though he had no discharge whatever. It was Gen. III. in vain to deceive him by supposititious medicines, for he was a Spec. II. man of considerable learning, and well acquainted with medical Alusia preparations, and I hence allowed him his heart's desire; he d^hon" rubbed in mercurial ointment every night, and for an injection „ ". used a solution of zinc. In a week, he persuaded himself he treatment. was well, and begged permission to desist from a farther use of the remedies; a permission, which was readily granted him. In the second variety, or taedium vitae, where the time seems Treatment to hang intolerably heavy on the patient's hands, from his hav- in t,,e ing, in a mistaken search after happiness, relinquished a life of "cr°"jl or constant excitement and activity for the fancied delights of rural tedium* retirement and quiet, the best and most radical cure would be a vilte- return to the situation that has been so unfortunately abandon- A return to ed: but, if this cannot be accomplished, the patient must be put £"tg?ur into a train of pursuits of some other kind. If he be fond ofthe sports ofthe country, he should weary himself in the day-time pmsuits with hunting or shooting, or even horse-racing, rather than be engaged in hypochondriacal from idleness; and spend his evenings in the ™.itn 8reat bustle of dinner-parties, or cards. And if he be capacified for "S higher and more useful occupations, let him plunge headlong spelts,17 into the public concerns of the parish and its neighbourhood, or a routine become a member of its select vestries, a trustee of the high- °f Puhlic ways, or a magistrate of the district. The habit of excitement u ies' must for some time be maintained, though it be afterwards let down by degrees: and the intermediate steps are of no great importance so far as they answer their purpose. We are not at present arguing the case upon a principle of ethics, or of re- ligion, but merely upon a principle of moral medicine. Yet I Happy have often known persons ofthe above description broken in by result of the degrees to a love of domestic quiet, for which they were by no various means fitted when they first entered upon it; and who, with a cases. love of domestic quiet, have settled also, as a more sober stage of life has advanced, and reflection has gained ground upon them, into a love of strict moral order, and the higher duties of a conscientious Christian, to which at one time they seemed as little disposed. GENUS IV. APHELXIA.—REVERY. Inactivity of the' attention to the impressions of surrounding objects during wakefulness. Aphelxia is derived from « has seldom been dipt into by physiologists. Dr. Darwin occa- JjJJjJ^ sionally touches upon it in various parts of his " Zoonomia," t0'medicine. and Dr. Crichton, in his " Inquiry into the Nature of Mental Derangement;" and it is well described and illustrated by La Bruyere in his " Characters:" but it yet remains to be annlyz- 116 cl. it] NEUROTICA. [°RD- ' Gew. IV. Aphelxia. Means of our becom- ■ngacquaint- ed with an external world : external senses : due secre- tion of ner- vous fluid : exercise of the faculty of attention. Power of the will in sum- moning the attention : Kevery de- pends upon this power intensely exerted, or wanted. Distinctive characters. ed, and reduced to a nosological method, and examined in a pa- thological view. A few leading ideas upon this subject have already been thrown out by the author, in his comment upon the present definition, in the volume of Nosology ; and of these he will avail himself in treating of it more at large. In order to our becoming acquainted with the existence of surrounding objects, or of an external world, as it is called by psychologists, three things are necessary : sound external sen- ses; a secretion ofthe nervous fluid (or, as it might be perhaps more correctly expressed, a due maintenance ofthe nervous and sensorial energy), apparently under different modifications, whereby they are made capable of being roused or excited by the different objects addressed to them ; and an exercise of the faculty of attention to the impressions which are thus produced. The will has, or ought to have, a power of calling this, as well as every other faculty ofthe mind, into a state of exertion, or of allowiug it to be indolent ; and it is chiefly upon this want of power, or the same power intensely exerted, that the pheno- menon of revery depends; thus giving rise to the three follow- ing species of mental aberration : 1. aphelxia socors. absence of mind. — INTENTA. — OTIOSA. ABSTRACTION OF MIND. BROWN-STUDY. In the first of these the attention is truant, and does not yield readily to the dictates ofthe will: in the second, it is riveted at the instigation ofthe will itself to some particular theme uncon- nected with surrounding objects: and in the third, it has the con- sent ofthe will to relax itself, and give play to whatever trains of ideas are uppermost, or most vivacious, in the sensory. Illustrated. Sometimes the will Species I. Aphelxia Socors. Absence of Mind. Truant attention; wandering fancy ; vacant or vacillating counte- nance. This is an absence, or vacuity of mind, too common at schools and at church ; over tasks and sermons ; and there are few readers, who have not frequently been sensible of it in some degree or other. In reading books in which we are totally uninterested, com- posed in a tedious and repulsive style, we are almost continually immersed in this species of revery. The will does not exert its power; the attention is suffered to wander to something of stronger attraction; or the imagination is left to the [day of its own nugatory ideas ; and, though we continue to read, we have not the smallest knowledge of the argument before us: and if the subject, to which the train of our thoughts is really directed, be of a striking ludicrous character, we may possibly burst into a laugh in the middle of a discourse of great gravity and serious- ness, to the astonishment of those around us. This is a common case, and may lead to great embarrassment. cl. iv.] NERVOUS FUNCTION. [ord. i. H7 We have nevertheless thus far supposed, that the will does not Gew. IV. exert its power, and sufficiently rein in the attention to the sub- Spec« '• ject addressed to it. It not unfrequently happens, however, Aphelxia that the will, for want of a proper habit, has lost its power, f0™"' either wholly, or in a very great degree, and cannot, with its p^er'for utmost energy, exercise a due control over the attention ; and want of it also happens in other cases, from a peculiarity of temper- lig- ament, or morbid state of body, that the faculty of the attention fh°e St™ itself is so feeble, that it is incapable of being steadily directed of attention for more than a few minutes to any object of importance what- t°ofpebIe ever, with all the effort ofthe will to give it such direction. StiS8"" The mind, under either of these conditions, is in a deplor- Either case able state for all the higher purposes of reflection and know- highly in- ledge, for which by its nature it is intended; since it is upon J"^0,"8,tc|. the faculty of attention that every other faculty is dependent for pansion,and its vigour and expansion; without it the perception exercises it- invigoration self in vain; the memory can lay up no store of ideas ; the judg- oft,"j.otner ment draw forth no comparisons ; the imagination must become blighted and barren ; and, where there is no attention whatever, the case must necessarily verge upon fatuity. In early life, the attention, like every other faculty of the Attention mind, is weak and wandering, is often caught with difficulty, and *eak in rarely fixed upon any thing. Like every other faculty, howev- jike^rfe oth- er, it is capable of being strengthened and concentrated; and er faculties, may be made to dwell upon almost any object proposed. But capable of this is a work of time, and forms one ofthe most important parts l^;l^or' of education : and, in the course of this discipline, it should not How this be forgotten, that the faculty of attention, when it first shows may be best itself, is more readily arrested by some subjects, than by others, ^oraPIlsu' and that it is hence of great moment to ascertain those subjects, and to select them in the first instance. The habit is what is chiefly wanted, and the quicker this is acquired, the more time we gain for transferring the same habit to other and perhaps more valuable purposes afterwards. This is a point seldom sufficiently considered in the course of But the education ; and, for want of such consideration, far more than method half the time of many boys becomes an entire blank, and is ^tended to lost, and not a few suffered to remain blockheads in the par- ticular department to which their hours of study are directed, who might discover a considerable capacity and genius, if the department were changed for one more adapted to their own taste, or, in other words, more attractive to their attention. There is a very singular instance of habitual absence of mind Singular related by Sir A. Crichton, in a young patient under the care of example of Dr. Pitcairn and himself, which, though some other circum- "*bl,ual . ■ . -i •,, • • -I, -i absence of stances appear to have combined with it, is ascribed consider- mind; ably to the error of education we are now speaking of, that of largely re- not duly studying the peculiar bent of a mind in many respects "r'].^| r*om singularly constituted, and drawing forth and strengthening the education. faculty of attention, which was in an especial degree weak and truant, by an employment of such objects and pursuits as were most alluring. This patient was a young gentleman of large 118 cl. iv.] NEUROTICA. [ord. i. Gen. IV. Spec. I. Aphelxia socors. Defect in this case not only in the mode of education, but proba- bly chiefly in a natural defect of the attention itself. fortune, who, till the age of twenty-one, and he does not seem to have been much more at the time of describing his case, had enjoyed a tolerable share of health, though of a delicate frame. In his disposition, he was gentle and calm, but somewhat un- sociable. His absence of mind'was extreme, and. he would sometimes willingly sit for a whole day without moving. Yet he had nothing of melancholy belonging to him; and it was easy to discover by his countenance, that a multiplicity of thoughts were constantly succeeding each other in his imagina- tion, many of which were gay and cheerful; for he would heartily laugh at times, not with an unmeaning countenance, but evidently from mental merriment. He was occasionally so strangely inattentive that, when pushed by some want which he wished to express, if he had begun a sentence, he would suddenly stop short after getting halfway through it, ds though he had forgotten what else he had to say. Yet when his atten- tion was roused, and he was induced to speak, he always ex- pressed himself in good language and with much propriety ; and if a question were proposed to him, which required the exer- cise of judgment, and he could be made to attend to it, he judged correctly. It was with difficulty he could be made to take any exercise ; but was at length prevailed upon to drive his curricle, in which Sir Alexander at times accompanied him. He at first could not be prevailed upon to go beyond half a mile ; but in succeeding attempts he consented to go farther. He drove steadily, and when about to pass a carriage, took pains to avoid it: but, when at last he became familiarized with this exercise, he would often relapse info thought, and allow the reins to hang loose in his hands. His ideas seemed to be for ever varying. When any thing came across his mind which excited anger, the horses suffered for it; but the spirit they exhibited at such an unusual and unkind treatment made him soon desist, and re-excited his attention to his own safety. As soon as they were quieted, he would relapse into thought: if his ideas were melancholy, the horses were allowed to walk slow; if they were gay and cheerful, they were generally en- couraged to go fast.* ■>• Perhaps, in this case, something might have been owing, as supposed by Sir A. Crichton, to an error in the mode of educa- tion ; but the chief defect seems to have been in the attentive faculty itself, and its labouring under a natural imbecility, which no mode of education could entirely have removed. We have had frequent occasions to observe, that the powers of the mind vary in different individuals as much as those ofthe body : and we have already offered examples of weak or diseased judg- ment, weak or diseased perception, and weak or vehement im- agination. In the case before us, the mental disease seems to have been chiefly confined to the faculty of attention; and we shall presently have to notice a similar imbecility of the memory, and even of all the mental faculties conjointly. * Of Mental Derangement, vol. i. p. 281. cl. iv.] NERVOUS FUNCTION. [ord. i. ng SpEews II. Aphelxia Intenta.—Abstraction of Minds , The attention wound up and riveted to a particular subject; with sympathetic emotion of the muscles and features connected with its general drift. In this species, the faculty of attention, instead of being fee- Gen. IV. ble, or contumacious to the will, is peculiarly strong, and vehe- Spec.II. mently excited, and acts in perfect co-operation with the will Faculty of itself. And, in many instances, the sensorial energy maintained j^"''™ is so great, and demands so large a supply of sensorial power, cuilarly " as apparently to exhaust the entire stock, except indeed the re- strong; serve, which is in almost all cases instinctively kept back for "".q1"/"" the use of the vital or involuntary organs. And hence, all the withPthe '°n external senses remain in a state of torpor, as though drawn wil1- upon for their respective contributions of sensorial power in Sensorial support of the predominant meditation : so that the eyes do not g^aTas'0 see, nor the ears hear, nor the flesh feel; and the muser may often to be spoken to, or conversation may take place around him, or he exl,.ai,st the may even be struck upon the shoulders, without any knowledge Scejt'what of what is occurring. i8 kept in Abstraction of mind may be produced by various causes, but rpserye f°r the following are the chief, and form two distinct varieties : organs: a Aphelxia a. pathemate. From some overwhelming pas- sion. 0 Aphelxia a studio. From intense study. Of the first variety we have already offered abundant ex- *A.inten- amples in the two preceding genera : and especially in the ca- ta * Pat,ie" ses of ungovernable joy or rapture, grief and depondency ; un- The in- der the influence of which the affected person is often as much dividual lost to the world around him, as if he were in a profound sleep sometimes and dreaming; and only hears, sees, and feels the vivid train of fosuotoe ideas that possess themselves of his mind, and rule it as a cap- world as in tured citadel. To these alone the attention is directed.; here a Prof°und it exhausts all its power, and the will concurs in the exhaustion; sleep* insomuch that the patient is said in some cases to have stared at the meridian sun without pain ;* and in others to have been undisturbed by the discharge of a cannon.} We meet with like proofs of this variety of revery in many 0 A. inten- cases of intense study, and especially upon abstract subjects, as ta 4 studio. those of pure mathematics, in which all the reasoning and more serious faculties of the mind, as the perception, the memory, and the judgment, as well as the attention, are jointly called into action, and kept equally upon the stretch. Of the power of this variety of revery in rendering an individual torpid and almost dead to all around him, we have a decided instance in Archimedes at the time of his arrest. When the Roman army instanced in had at length taken Syracuse by stratagem, which the tactics of Archimedes. this consummate engineer prevented them from taking by force, he was shut up in his closet, and so intent on a geometrical * Bluinenb. Bibl. i. p. 7J6. t Darwin, Zoonomiii, in. i. ii. 2. 120 cl. iv.] NEUROTICA. [0RD- '• Gew. IV. demonstration, that he was equally insensible to the shouts of Spec. II. the victors, and the outcries of the vanquished. He was calm- 0 k. inten- ly drawing the lines of a diagram when a soldier abruptly en- ta a studio. tered his room? and clapt a sword t0 his thr6at. " Hold, friend," said Archimedes, " one moment, and my demonstration will be finished." The soldier, surprised at his unconcern at a time of such extreme peril, resolved to carry him before Marcellus ; but as the philosopher put under his arm a small box full of spheres, dials, and other instruments, the soldier, conceiving the box to be filled with gold, could not resist the temptation, and killed him on the spot. The atten- tion here allowed by the will to bequiescent. Other rea- Bons why the external senses are vacant in this species. Studium inane of Darwin: admirably described by Cowper. Species III. Aphelxia Otiosa.—Brown-Study. Leisurely listlessness ; voluntary surrender of the attention and the judgment to the sportive vagaries of the imagination: quiescent muscles; idle gravity of countenance. The attention is equally summoned into action and dismissed at the command of the will. It is summoned in the last spe- cies : it is dismissed, when a man voluntarily surrenders him- self to ease and listlessness of mind; during which period, moreover, in consequence of this indulgence in general indo- lence, the external senses themselves unite in the mental quies- cence, and a smaller portion of nervous energy is probably ge- nerated for the very reason that a smaller portion is demanded; and hence the active senses without are as vacant and unstrung as the active senses within, and as blunted to their respective stimuli. The first playful ideas that float over the fancy in this case take the lead, and the mind relaxes itself with their easy and sportive flow. It is the studium inane of Darwin,* who seems, however, to have in some degree misapplied the name, or to have confounded the aberration with that of ecphronia or alusia. Cowper has admirably described it in the following verses: Laugh, ye who boast your more mercurial powers, That never feel a stupor, know no pause, Nor need one : 1 am conscious, and confess, Fearless, a soul that does not always think. Me, oft, has fancy ludicrous and wild Soothed with a waking dream of houses, towers, Trees, churches, and strange visages, express'd In the red cinders, while with poring eye I gazed, myself creating what I saw. Nor less amused have I quiescent watched The sooty films that play upon the bars Pendulous, and foreboding in the view Of superstition, prophesying still, Though still deceived, some stranger's near approach. 'Tis thus the understanding takes repose In indolent vacuity of thought, And sleeps, and is refresh'd. Meanwhile the face Conceals the mood lethargic with a mask Of deep deliberation, as the man Were task'd to his full strength, absorb'd, and lost. * Zoonom. m. i. ii. 2 ; and again, iv. n. iv. -, cl. iv.] • NERVOUS FUNCTION. [ord. i. 121 In the indolent mind, such indulgence is a disease, and, if not Gen. IV. studiously watched and opposed, will easily become a habit. Spec. III. In the j-tudious and active mind, it is a wholesome relaxation; Aphelxia the sensory, in the correct language of the poet, " sleeps and is 0tl0sa* refreshed," grows fertile beneath the salutary fallow, and pre- ^j11?^6 pares itself for new harvests. such ind'ul- This is more particularly the case where, in conjunction geuce a with an attention " screwed up to the sticking place," and d,iease ! long continued there, a spirit of ardent emulation is at the with the same time stirring, and distracted between the hope and fear ^"(0!°"ome of gaining or losing a distinguished honour or reward. I relaxation: have seen this repeatedly in young men who have been striv- Especially ing night and day, and week after week, for the first prizes where the of our English universities ; some of whom have indeed sue- a*^"110" 1S o * «pun fd on ceeded, but with a hectic exhaustion that has been recovered j,y a spjrit from with great difficulty; while others, in the full prospect of rivalry, of success, have been compelled to relinquish the pursuit, and £s ^hi'wHl to degrade. Illustrated." Yet even without this conflict of feeling, where the attention Evpn(,impie alone has been too long directed to one or to a variety of re- attention condite subjects without relaxation, the mind suffers considera- Jong bly, and its powers become shaken and confused; of which we mpnta|pUr. have an interesting example in the case of Mr. Spalding, a suits occa- scholar of considerable eminence in Germany, as drawn by smnally himself and communicated to the editors of the Psychological effusion. Magazine.* , His attention, he tells us, had been long kept Exemplified. upon the stretch, and had been still more distracted by being continually shifted from one subject to another, when, being called upon to write a receipt for money paid him on account of the poor, as soon as he had written the two first words, he found himself incapable of proceeding farther. He strove all he could, and strained his attention to the utmost, but to no purpose : he knew the characters he continued to make were not those he wished to write, but could not discover where the fault lay. He then desisted, and partly by broken words and syllables, and partly by gestures, made the person who waited for the receipt understand that he should leave him. For about half an hour, a tumultuary disorder reigned in his sen- ses, so that he was incapable of remarking any thing very par- ticular, except that one series of ideas of a trifling nature, and confusedly intermixed, forced themselves involuntarily on his mind. At the same time his external senses continued perfect, and he saw and knew every thing around him. His speech, however, failed in the same manner as his power of writing, and he perceived that he spoke other words than those he in- tended. In less than an hour he recovered himself from this confusion, and felt nothing but a slight hcad-ach. On exam- ining the receipt on which the aberration first betrayed itself, he found that, instead of the words " fifty dollars, being one half year's rate," he had written " fifty dollars, through the * Crichton'* Inquiry into Mental Derangement, i. 237. VOL. IV. 16 122 cl. iv.] NEUROTICA. [°BD- »■ salvation of Bra—" the last word being left unfinished, and without his having the least recollection of what it was intend- ed to be. Gen. V. Origin of the generic terra. Essential distinction between ephialtes or night-mare, and the pre. sent species: hence erro- neously united by Cullen. These affec- tions ouly to be fully un- derstood by a knowledge of the phy- siology of sleep and dreaming. General hints sub- servient to a develop- ment of these states of the body and mind. Many of the faculties of the mind, as well as of the body, at this time torpid. Hence the sensory crowded with ideas wanting the control of the will. GENUS V. PARON1RIA.—SLEEP-DISTURBANCE. The voluntary organs connected with the passing train of ideas, overpowered by the force of the imagination during dreaming, and involuntarily excited to their natural or accustomed actions ; while the other organs remain asleep. Paroniria, from w«g<* and «vwg«v, signifies " depraved, disturb- ed, or morbid, dreaming." So, in Dioscorides,* dvowugcs signi- fies " tumultuosis et malis somniis molestans." In treating of the genus ephialtes, or night-mare,t I en- deavoured to explain its course and nature ; and hereby point- ed out the essential distinction which exists between that dis- ease and the present, and the impropriety of uniting the spe- cies which belong to both of them under one head, as Dr. Cul- len has done in his genus oneirodynia ; since, with the excep- tion of their occurring in the night, and during sleep, and therefore involuntarily, they have little or no connexion, or re- semblance, in cause, symptoms, or even mode of cure. The three following species are so clearly and decidedly of one and the same family, as to prevent all dispute in their pre- sent position. They are here, however, associated for the first time in a genus distinct from ephialtes. 1. paroniria ambulans. 2.---------LOQUENS. 3.---------salax. The nature of these singular affections, and the means by which they are produced, have never yet been explained, and rarely, so far as I know, has any explanation been attempted. To understand them fully, it would be necessary for us to enter into a minute development of the physiology of sleep and dreaming, which the limits of the present work will not allow. On some future occasion, the author may, perhaps, follow it up into such a detail: but a few general remarks must suffice for the occasion before us. In sleep, accompanied with dreaming, the faculties of the mind bear a pretty close parallel with those of the body as to the effect produced upon them. Some of them, as the will, the perception, the judgment, are in a state of general torpitude, like the voluntary organs of the body ; while the memory and the imagination, like the vital or involuntary organs of the bo- dy, are in as high activity as ever. Hence, the sensory is as much crowded with ideas as at anytime; but, destitute of a controlling power, they rush forward with a very considerable degree of irregularity, and would do so with the most unshape- * Vol. ii. p. 127. t Vol. i. Ord. H. Gen. v. SLEEP-WALKING. SLEEP-TALKING. NIGHT-POLLUTION. cl. iv.] NERVOUS FUNCTION. [ord. i. 123 able confusion, but that the habit of association still retains some Gen. V. degree of influence, and produces some degree of consonance Paroniria. and proportion in the midst of the wildest and most extrava- Whence the gant vagaries. And hence, that infinite variety which takes ,deas re- place in the character of our dreams ; and the greater regulari- gortof cate- ty of some, and the greater irregularity of others. Hence, a nation in combination of thoughts, or ideas, sometimes only in a small de- dreain.ing: gree incongruous, and at other times most frantic and hetero- \em iegUlar. geneous; occasionally, indeed, so fearful and extravagant as to Dreaming stimulate the external senses themselves into a sudden renewal ideas some- of their fuuctions, and consequently to break off abruptly the ai^wild sleep into which they were thrown. Now, as the stimulant force of our ideas, in dreaming, is of- Sometimes ten sufficient to rouse the external senses generally, and to °"nfeathuS awake us all of a sudden; it may be of such a kind, and just of roused, and such a strength, as to excite into their accustomed action the why. muscles of those organs or members only which are more im- mediately connected with the train of our dreams or incoherent thoughts; while every other organ may still remain torpid. And hence the muscles chiefly excited being those of speech, Hence sleep some persons talk, or the muscles chiefly excited being those of t?lkinR,1. locomotion, other persons walk, in their sleep, without being jng*p0r ,„„. conscious, on their waking, of any such occurrence.* And, by nambulism. the same means, we may easily account for the third species of and night the genus, or that which consists in dormant and involuntary po salacity. Species I. Paroniria Ambulans.—Somnambulism. Sleep- Walking. The muscles of locomotion excited into their accustomed action by the force ofthe imagination during dreaming. In profound sleep, all the faculties ofthe mind, as well as all In profound the voluntary organs of the body, are in a state of inactivity or p^pe'a 0| e torpitude, and the only organs that preserve their active tenour the mind are the involuntary ones : so that, in this state, there is neither and body, thought nor idea of any kind. In dreaming, some of the men- {"^Xiary tal faculties only sleep, or are torpid, while the others, like the organs, io a involuntary organs of the *ody, continue wakeful or active: the state of somnolent faculties, we have already observed, are the will, orpi u the perception, and the judgment; the wakeful are the memo- ry and the imagination. It would not be difficult, if we had time, to show why the in- In dream- voluntary organs do not require rest, or, in other words, be- S? mental° come torpid like the voluntary ; nor why the will and the judg- faculties ment sooner associate in the general sleep of the external only sleep. senses than the imagination; but this would carry us too far Not difficult into the subject of animal physiology. There are two physio- w°hy t°he in- voluntary * Hennings, von den Traumern und Nachtwandlern. Weimar, 1784. organs do Horst, De Natura, Differentiis, et Causis eorum qui dormientes ambulant, &c. not require Leips. 1593, 8vo. rest. 124 ci. iv.] NEUROTICA. [ord. I. Gen. V. Spec. I. Paroniria arabulans. Sleep is a natural tor- pitude in- duced by fa- tigue and exhaustion. The exhaus- tion of some of the pow- ers ofthe body and mind only secondary. Some of the external organs of sense do not in every in- stance asso- ciate in the torpor or sleep of the rest. If the wake- ful sense be sight, the dreamer may per- ceive objects while asleep: if tenour of dream act powerfully upon loco- motive mus- cles, may walk, while the rest of mind and body are dormant. Dormancy of sleeping organ* increased. logical remarks, however, which it is necessary to make in(ex- planation of the morbid affection immediately before us. The first is, that sleep is a natural torpitude, or inertness, induced upon the organs ofthe body (with the exception ofthe involun- tary) and the faculties of the mind by fatigue and exhaustion. And the next is, that, in the production of sleep, it is not neces- sary that all these powers of body and mind should have been equally exposed to exhaustion : for, such is the effect of asso- ciation and habit, that as soon as one faculty or organ feels fa- tigue, or becomes exhausted, the rest participate in the same condition, and the sleep or torpitude becomes common to the whole. It is hence the body is made drowsy by mental study, and the mind by corporeal labour; that muscular exercise wea- ries all the senses, and the exertion of the senses wearies the muscles: though there can be no doubt, that the general ten- dency to sleep is also partly superinduced by the indirect ex- haustion sustained by the organs or faculties that have been less employed, in consequence ofthe share of sensorial energy which, as from a common stock, they have themselves contributed to- wards the support of the more active and hence more debilitat- ed powers. Now, it sometimes happens, either from disease or peculiari- ty of cpnstitution, that all the external organs of sense do not associate in the general action that has taken place, or yield alike to the general torpor to which it gives rise ; and that the auditory, the optical, or some other sense, continues awake or in vigour, while all the rest are become inert, as it does also, that such particular sense, like the muscles of particular mem- bers, as observed a page or two above, is awoke or re-stimu- lated into action in the midst of the soundest sleep, by the pe- culiar force and bent ofthe dream, while the rest still sleep on and are unaffected. If the external organ of sense, thus stimulated, be that of sight, the dreamer may perceive objects around him, and be able to distinguish them: and if the tenour of the dreaming ideas should as powerfully operate upon the muscles of locomo- tion, these also may be thrown into their accustomed state of action, and he may rise from his bed, and make his way to whatever place the drift of his dream may direct him, with per- fect ease, and free from danger. He.will see more or less dis- tinctly in proportion as the organ of sight is more or less awake : yet, from the increased exhaustion, and, of course, increased torpor ofthe other organs, in consequence of an increased de- mand of sensorial power from the common stock, to supply the action of the sense and muscles immediately engaged, every other sense will probably be thrown into a deeper sleep or tor- por than if the whole had been quiescent. Hence, the ears may not be roused even by a sound that might otherwise awake the sleeper. He may be insensible, not only to a slight touch, but a severe shaking of the limbs; and may even cough vio- lently without being recalled from his dream. Having accom- plished the object of his visionary pursuit, he may safely re- cl. iv.] NERVOUS FUNCTION. [ord. i. 125 turn, even over the most dangerous precipices, for he sees them Gen. V. distinctly, to his bed; and the organ of sight being now quite Spec. I. exhausted, or there being no longer any occasion for its use, it Paroniria may once more associate in the general inactivity, and the ambulans- dream take a new turn, and consist of a new combination of images. Somnambulism occurs in many persons without any manifest irritability predisponent cause, though it is generally connected with aeon- of habit siderable irritability of habit. A morbid state of the stomach, ^eonaep[e' where this habit exists, has very frequently proved an exciting cause. cause : of which Dr. Yeates has given us an example in the Morbid case of a young gentleman of ten years of age.* He was of a «|omachthe delicate frame, often troubled with sickness ; sometimes reject- often an ex- ed his food undigested, after having lain two days in his sto- citing cause. mach ; his bowels were costive, and the stools were dark, of- Ex€1DP' e • fensive, and ill formed. The sympathetic symptoms were fre- quent head-aches with occasional stupor, general coldness ofthe skin, and limpid urine. After being in bed for about two hours, he was wont to start up suddenly, as in a fright, dart rapidly into the middle ofthe chamber, or of the room adjoining, and walk about with much agitation. In this state he would run over quickly, but incorrectly, the transactions of the day; and he once attempted to spell a word which in the day-time he had spelt wrong, in doing which he jumbled a number of letters together. When spoken to, he would make a rational reply; and, in one of his sleeping perambulations, he called for an epitome of the History of England, which he was in the habit of reading; the nurse brought him a book, but not the one he called for; on perceiving the difference, he immediately threw it from him with great violence, and with expressions of anger and disappointment. On these occasions, his eyes were wide open, though he did not seem conscious of seeing, nor of his situation at the time. It was, says Dr. Yeates, a perfect state of dream throughout, though partaking of the acts of the waking state, for he would avoid objects walking about the room. His face was quite pallid at the time. In this case, much of the nervous hurry and agitation seems This case to have depended upon the debilitated and irritable state of the produced patient's frame. But where the affection proceeds from idiosyn- j^j"^"^8 crasy, or where there is no disturbance of the general health, and hence' the dreamer often proceeds far more coolly and collectedly ; and the mir|7 of the eyes, instead of being wide open, as though staring, are often ^ae,£ eep" not more than half-unclosed, in some cases even less than this; The eyes which has given occasion to marvellous stories of somnambulists are more or walking over dangerous places, or avoiding dangerous objects, ^ts°from with their eyes completely shut all the time. their wink- The remedial treatment which it may be necessary to pursue, ini?> ,iave we shall defer till we have briefly noticed the succeeding species, b"^^1""63 as the same treatment will apply to the whole. described as closed. * Med. Trans, vol. v. Art. xxvm. p. 444. 126 cl. iv.] NEUROTICA. [ord i. Gen. V. Spec. II. General principle explained. Organs of speech stim- ulated by the train of dreaming ideas. Organ of hearing sometimes associates in the wake- fulness : whence the dreamer able to hear, as well as to speak. Possible consequence of this. Species II. Paroniria Loquens.—Sleep-Talking. The muscles of speech excited into their accustomed action by the force ofthe imagination during dreaming. It is not necessary to dwell upon this species, as we have al- ready explained the general principles of the inordinate action in the preceding pages. As the train of ideas which form the dream, when peculiarly lively and immediately connected with the organs of locomotion, may stimulate those organs into their accustomed activity, and thus give the dreamer a power of walk- ing without consciousness ; in like manner, if a similar train of dreaming ideas be immediately connected with the organs of speech, these may also be equally influenced, and the dreamer be able to talk, without being conscious of it, or having any re- collection of such exertion when he awakes. And as, for reasons already specified, the organ of sight is sometimes, in the same way, roused from a state of sleep or torpitude to a state of wake- fulness, while all the other external senses continue somnolent, or, from idiosyncrasy or some local or accidental cause, do not join in the general repose, but continue vigilant during its do- minion; the organ of hearing may be roused in the same man- ner, or exhibit the same anomaly; and, in this case, the dream- er, who, under the influence of the last species of affection, is able to see as well as to walk, is able, under the present, to hear as well as to speak. Examples, indeed, are given, in which a bystander, obtaining some clue into the train of thoughts of which the dream is composed, has been able, not only to keep up an irregular conversation, but, by dexterous management, and the artful assumption of a character which he finds introduced into the dream, to draw from the dreamer the profoundest secrets of his bosom, the dreaming ideas generally consisting of those on which the dreamer is most employed when awake, or which lie nearest his heart. I have never met with a case of this kind in my own practice, but it is given as a fact by various physiolo- gists from the time ofthe Greeks and Romans to our own day. Species III. Paroniria Salax.—Night-Pollution. The sexual organs excited into venereal action by the force ofthe imagi- nation during dreaming. Species By Sauvages this affection is absurdly placed among the spe- Pel"Cil,ehI°* c'es °1 g°noirbcea, which, with great looseness of generic char- acter, is defined " passio, cujus prascipuum symptoma est fluidi puriformis vel seminiformis effluxus stillatitius ex urethra." This definition is, indeed, wide enough to embrace the affection before us ; but the absurdity consists in intermixing a natural discharge, produced by the ordinary orgasm, with morbid discharges, in which, in most cases, there is no orgasm whatever. Dr. Cullen, however, has continued to assign the same place, and the same name, to the present species, and this with still greater incon- neously by Sauvages: and by Cullen. cl. iv.] NERVOUS FUNCTION. [ord. i. 127 sistency : since he has struck out of his definition of gonorrhoea Gen. V. the epithet seminiformis, and confined it to a " fluxus humoris ex Spec. III. urethra prceter naturam.1'' So that he has been obliged to break Paroniria his own bounds, to introduce this natural flux into the place he sa aX" has allotted it. And hence, in laying down the treatment of gonorrhoea, in his Practice of Physic, he takes no notice of his gonorrhoea dormientium, as though feeling that it was altogether a different subject. We have already observed, that whatever part of the animal Physiology. frame is immediately connected with the tenour ofthe somnolent vision, it is often roused, under particular circumstances, from the general sleep or torpitude in which it had participated, and becomes wakeful, while every other part perseveres in the com- mon repose. During sleep, moreover, our ideas are often more ideasof lively and operative than during wakefulness, and this on two dreaming accounts; first, because, from the uninterrupted activity of the ™°r0e]™e]y involuntary organs, there is a more ready secretion of sensorial, wakefulness, as well as of most other fluids, in a state of perfect tranquillity; and why. and next, because the ideas that predominate at the time are not broken in upon, or weakened, by exterior impressions and disturbances. It is on this account, when the faculty of the judg- ment is stimulated into activity, instead of the ear or eye, or the motory powers, a man has sometimes been able to solve diffi- culties in dreaming, which proved too hard for him when vigi- lant. And to this effect Dr. Spurzheim : " Somnambulists," says he, " even do things of which they are not capable in a state of watching; and some dreaming persons reason sometimes better than they do when awake."* A singular and amusing instance Interesting of this occurred not many years ago to a very excellent and justly exemplifica- celebrated friend ofthe author's, the Reverend William Jones of tl0n" Nayland, Suffolk, who, among other branches of science, had deeply cultivated that of music, to which, indeed, he was pas- sionately attached. He was a man of irritable temperament, ardent mind, and most active and brilliant imagination ; and was hence prepared by nature for energetic and vivid ideas in his dreams. On one occasion during his sleep, he composed a very beautiful little ode of about six stanzas, and set the same to very agreeable music; the impression of which was so firmly fixed in his memory, that, on rising in the morning, he sat down, and copied from his recollection both the music and the poetry. It is hence not difficult to conceive, that members so irritable Hence sexu- as the sexual organs, when once the imagination leads energeti- alorgasm cally to the subject of concupiscence, should occasionally partici- idea's?'11 pate in the vision, and prove their sympathy by the result. In some morbid states of the body, and especially when ac- Seminal flux companied with local irritation, produced by inflammation, fibrous sometimes entony, the debility of old age, or a habit of vicious indulgence, ?uring s!eep • i « i_ z- .. i i -*i • ' 'rora various a seminal flux has sometimes taken place, without any connexion causes; but with the dream, and sometimes without either erection or turo-- thisdoesnot escence ; but this does not constitute the affection immediately u*e00fe|° * Physiognomical System, p. 175, 8vo. Lond. 1815. P Cle8' 128 cl. iv.] NEUROTICA. [ord. i. Ge\. V. Spec. III. Paroniria salax. The fact known to the Greeka and Ro- mans, and elegantly explained by Lucre- tius: with another effect, of a similar kind. Medical treatment. General principles to be attended to. Irritation the exciting cause : which may be entonic or atonic. Remedial process, when from entonic irritation. When from atonic irritation. Treatment. Undue ac- cumulation of power to be pre vented. Hence hard mattress: before us ; in which the stimulant power lies in the sensory, and is propagated from that organ to those of generation. The Roman poet, who so admirably unlocked the naturk of things to his contemporaries, by following the footsteps of Na- ture herself into most of her deepest recesses, directed his at- tention to this subject, among other physiological facts, and has elegantly explained it in the above manner; adducing, at the same time, another instance of the influence, which the ideas of dreaming sometimes exercise over the organs connected with them, derived from the evacuation of the bladder, which fre- quently takes place in children, whose dream is directed to this natural want, and who image to themselves the ordinary vessel employed for such purpose as at hand for their use : Pueri ssepe, lacum propter seu dolia curta, Somno devinctei, credunt se extollere vestem; v Totiushumorem saccatum corporis fundunt; Quom Babylonica, magnifico splendore, rigantur. Turn, quibus petatis freta primitus insinuantur, Semen ubi ipsa dies membris matura creavit, Conveniunt simulacra forise corpore quoque, Nuntiffl prBeclari voltus, pulchrique coloris, Qui ciet inritans loca turgida semine multo, Ut, quasi transactis saepe omnibus rebus, profundant, Fluminis ingenteis fluctus, vestemque cruentent.* In the medical treatment of all these species of paroniria, we must never lose sight of this principle, that, although in many instances their predisponent cause is a peculiar idiosyncrasy or habit, their exciting cause is, in all cases, general or local irri- tation : and that this irritation is of two very opposite kinds, which it also becomes us very particularly to attend to, namely, that of entony, or excess of power; and that of atony, or defi- ciency. It is to the former that Lucretius alludes, and which is by far the most common exciting cause : and where this exists, our first indication is to reduce the superabundant vigour by vene- section, purgatives, laborious exercise, and a limitation to a plain and spare diet. While, on the contrary, where the ex- citing cause is debility, our attention should be directed to a to- nic course of medicines, and particularly to those tonics which prove sedative at the same time that they strengthen the sys- tem. Several of the mineral acids are entitled to this charac- ter, and especially the sulphuric; and a still greater number of the vegetable bitters, and particularly the extracts of hop and lettuce. Dr. Cullen, indeed, as we have already observed, sup- poses a sedative power to exist in all the bitters, though not equally in all. How far the prussic acid might be usefully em- ployed for this purpose, I cannot say from personal practice. Our next object of attention should be to prevent all undue accumulation of the sensorial principle during sleep; and this may be accomplished in two very distinct and opposite ways. The first is the use of a hard mattress, with so small a covering of clothing that the sleep may be somewhat less sound than or- * De Rer. Xat. iv. 1020. CL. IV.] NERVOUS FUNCTION. [ORD. I. 129 dinary, and consequently more easily broken off. For the force Gen. V. of our dreaming ideas will always be in proportion to a certain Spec. III. degree of soundness in our sleep: I say, a certain degree ; be- Paroniria cause, if the fatigue, or exhaustion, or torpitude, be "extreme, 8alax> the sleep will become profound or lethargic, all the faculties of the mind will participate in it, and, as already observed, there will be no ideas of dreaming whatever. And hence the second mode of preventing an accumulation and nar- of sensorial, and especially of irritable power, will be the em- cotics. ployment of narcotics till the morbid habit is destroyed; for these, when carried to a sufficient extent, diminish vascular ac- tion, and consequently take off sense and motion so completely as to extinguish the vital principle altogether, and hence not only to suppress all power of dreaming, but even life itself. 1 had lately under my care, for the last species, a very modest Illustration. and regular young man, who was a student of Christ's College, Cambridge; and was alarmed at the idea of having his consti- tution undermined by its continuance. He was rapidly growing, of slender make, and of a relaxed habit. Nitre, which has been so often recommended as a sedative, in this case did no service; but, under the use of a pill, composed of one grain of opium and five of camphor, taken nightly, and draughts of myrrh, and infusion of columbo acidulated with sulphuric acid, he lost the tendency in a fortnight, after having been subject to the dis- charge for many weeks. His bowels were kept at the same time constantly stimulated by the pill of aloes and myrrh: and the cold-bath formed a part of his regimen. Pagani and De Cazelles* have recommended electricity; but the author has never tried its effects, having uniformly succeeded without it. Where either of these species, but particularly the two for- Where a mer, are connected with a morbid state of the stomach, the dis- secondary ease must be attacked in this quarter, as it was with great judg- ^primary ment and a favourable issue in the case quoted from Dr. Yeates. disease must be principally --------——------------------ attended to. GENUS VI. MORI A.—FATUITY. Defect or hebetude of the understanding. Moria is a Greek term from paps, "stultus, fatuus." It is Origin and here limited to its proper signification. Vogel employs it, use°fthe though with a different termination (morosis instead of moria), term. in the same or very nearly the same sense ; but he is almost Employed the only medical writer that does so. By Nenter and Sauva- hitherto in ges, moria is used to denote melancholia complacens, (self-corn- £' efc m placent melancholy), while by others it is employed synony- tions: mously with ancea or idiotism. To complete the confusion, mo- with much rosis [amentia morosis) is the name given by Sauvages to men- confusion tal imbecility (moria imbecillis), though, as already observed, he J^me'cla- had just before used moria in the sense of melancholy. It is ture. * Joum.de Medecine, torn, lxxiv. VOL. IV. 17 130 cl. iv.] NEUROTICA. [ord. i. Gen. VI. Moria. Derivatives from the common root. How dis- tinguished from the preceding genera. precisely in the signification now offered, that the term is em- ployed by Erasmus, in his celebrated treatise entitled " Moria Encomium,''1 or " The Praise of Folly," which he dedicated to Sir Thomas More. Mora, moror, morosus, morositas, are derived from this com- mon source; and uniformly import " waywardness, tardiness, dulness, impediment;" though the lexicographers, not having hit upon the right path, have wandered in different directions without being able to satisfy themselves. In Sauvages and Sa- gar, morositates are in fact " corporece moria,'''' defects or hebe- tudes of the bodily faculties. The preceding genera are founded upon a morbid perversion or misrule, a diminished or excessive excitement, of one or more ofthe powers ofthe mind, operating upon the mind itself or upon the body. The present is founded upon a natural or permanent dulness, or hebetude of one or more of the same powers, producing a deficiency in the understanding, which, however, may be regarded as the general frame or constitution ofthe mind, in the same manner as the body is the general frame or constitution of the organs, which form its separate parts. Moria, thus explained, will be found, as a genus, to em- brace the two following species: 1. MORIA IMBECILLIS. IMBECILITY. IRRATIONALITY. General remarks. et M. imbe- cillis stu- piditai. Generally other facul- ties besides the imag'iD- Species I. Moria Imbecillis.—Mental Imbecility. The defect or hebetude partial, or confined to particular faculties of the understanding. We have already observed, that all the faculties of the mind are as subject to a diseased disturbance as the organs of the body ; and hence all of them are liable to be affected by the present species. The whole of the varieties, therefore, under which mental imbecility is capable of being contemplated might form an extensive list: but it will be sufficient to confine our- selves to the four following: x Stupiditas. Dulness and indocility of the Stupidity. apprehension ; torpitude and poverty ofthe imagination. 0 Amnesia. Feebleness or failure ofthe me- Forgetfulness. mory. y Credulitas. Weakness and undue pliancy of Credulity. the judgment, with a facility of being duped. 3 Inconstantia. Instability and irresolution of the Fickleness. will. In stupidity, there is generally a dulness in several of the faculties besides the apprehension and the imagination; and sometimes, perhaps, in all of them: but then it originates in cl. iv.] NERVOUS FUNCTION. [ord. i. 131 these, and the rest are for the most part only secondarily dull, Gen. VI. as not being furnished with a sufficient number of ideas or in Spec I. sufficient rapidity for their use. Thus the judgment of a heavy * M. imbe- or stupid man is often as sound in itself as that of a man of ca- ".'J!9 stu" pacious comprehension ; and more so, perhaps, for a reason we pi.' a^'nd have already observed under alusia facetosa, or crack-brained apprehen- wit, than that of a man of facetious quickness of parts: but the fion obtuse heavy man requires time and patience to collect his ideas, and "IJjg'L compare them with each other; for they are neither furnished Y . ' to him in a free current from his memory or his imagination, j„(|gment nor does he readily apprehend or lay hold of them as they are often sound, offered from external objects to his perception, which in effect, t,,0"gll8loW: • ■ 11*' * aii(J GVCD is little more than a synonym for the apprehension—the appre- 80Under hension being the perception in a state of exercise, or exertion, than in There is hence a material difference in physiology, though, f30.6')0"' perhaps, little in practice, between ignorance and stupidity. Explained The former is want of knowledge, from want of its ordinary ^pprejie0. means; and by the use of such means may, perhaps, soon be 8iou, its gotten the better of: the latter is dulness in the use of such relation to knowledge as by ordinary means has been acquired, and exists Jj'0enpercep in the sensory, though in a state of stagnation or dormancy. Difference Mr. Locke has made the same distinction, though he has justly betweenstu- enough observed, that, for all practical purposes, the man of Pidity and stupidity had almost as well be without his knowledge as with pnoran.^' it. " He," says this admirable writer, " who, through this de- fon^Lo'cke. fault of his memory, has not the ideas that are really preserved there, ready at hand when need and occasion call for them, were almost as good be without them quite, since they serve him to little purpose. The dull man, who loses the opportunity whilst he is seeking in his mind for those ideas that should serve his turn, is not much more happy in his knowledge, than one that is perfectly ignorant. It is the business of the memory to furnish those ideas, which it has present occasion for, and in the having them ready at hand on all occasions, consists that which we call invention, fancy, and quickness of parts."* Stupidity or dulness of apprehension may be idiopathic; but Causes of it may also proceed from want of education, or education irre- stupidity, gularly conducted; for all the faculties of the mind, like the ^j™pa,h;c muscles of the body, become invigorated, and are rendered affection. more alert, by a well disciplined exercise. And hence stupidity Want of is a natural result of idleness ; as it is more particularly of idle- proper ness in conjunction with an undue use of wine and fermented e ucatl0n- liquors, which have a proverbial power of besotting the under- standing. It is also produced temporarily or habitually by vari- Local or ous corporeal diseases; as hemicrania, chronic inflammation or otherdis- dropsy of the head, gout in the head, and sometimes repelled ease' cutaneous eruptions or habitual discharges. Stupidity, like wit, is propagable ; and hence we frequently i9pr0pa. see it run from one generation to another; and not unfrequently gable. it forms a distinctive mark in the mental character of districts * Essay concerning Hum. Underst. B. 11. Ch. x. Sect. 8, 132 cl. iv.] NEUROTICA. [0Ri>- '• Gen. VI. Spec. I. * M. imbe- cillis stu- piditas. Illustrated. 0 M. imbe- cillis am- nesia. A worse evil than stupidity. The memo- ry in some persons strongly retentive. Newton. rascal. Retention of memory, how differs from quick- ness. Examples. Failure of memory shows itself in various ways. or nations: in many cases, indeed, where they border closely on each other. The Dutch have at least as much solid sense as their neighbours the French ; but they are certainly less quick; or, in other words, they have a duller fancy and appre- hension. Bceotia, in respect to chorography, was merely sepa- rated from Attica by Mount Cithaeron ; but, in respect to genius, the two countries were as far apart as the poles. So, in the Pacific Ocean, the natives of Otaheite learn every thing with facility; the natives of New South Wales have no aptitude, and learn nothing. The residence of a few missionaries amongst them for a short term of years has nearly civilized the former: the actual possession of the country for a far longer period, by a British public and a British government, with a perpetual in- tercourse, and the kindest encouragement, has made little or no impression upon the latter. A failure of memory, however, which forms the second spe- cies of mental imbecility before us, is a far more severe evil than dulness of perception with poverty of imagination : for, as all the sources of information, to which we have been privy, cannot be always immediately before us to excite the percep- tion, we must necessarily draw upon our recollection for those which are not so, and whose ideas or impressions we stand in need of. And hence the memory is the great storehouse of in- telligence ; and, in one sense at least, the Platonic doctrine is universally true, that " all knowledge is reminiscence." There are some minds in whom this faculty has been peculiarly reten- tive, as that of Newton, who made it answer the purpose of in- tuition ; and of Pascal, who is said never to have forgotten, till his health failed him, any thing he had ever done, read, or thought of. Retention of memory, however, is a different property from that of quickness. They may and often do co-exist; but they are also found separate: for there are mauy persons who can well catch hold of an entire song, an entire sermon, or a series of speeches in parliament, and can recite them almost, if not al- together, verbatim immediately afterwards, but who lose all re- collection of them in a day or two : while there are others, who are obliged to pause over the subject submitted to them, or to have it repeated for several times before they can get it by heart, yet who, when they have once fixed it in the memory, retain it as long as they live. Mr. W. Woodfall, the celebrated reporter of the parliamentary debates, was an instance of the former of these talents, in regard to his powers of apprehen- sion; the well-known Jedediah Buxton of the latter: though it should be remarked, that Mr. Woodfall retained with as much ease, as he first fixed, speeches in his memory. Failure of memory takes place in a variety of ways. It is sometimes general, and extends to every subject; but it is fre- quently far more manifest on some subjects than on others. Salmuth mentions a case, in which the affected person had for- gotten to pronounce words, but could nevertheless write them.* * Cent. n. Obs. 41. CL. IV.] NERVOUS FUNCTION. [ord. i. 133 Mr. J. Hunter was suddenly attacked with a singular affection of Gen. VI. this kind in December 1789, when on a visit at the house of a Spec. I. friend in town. " He did not know in what part of the house 0 M- imbe- he was, nor even the name of the street when told it, nor where ciU.Uam- his own house was: he had not a conception of any thing ex- °eS,a' isting beyond the room he was in, and yet was perfectly con- scious of the loss of memory. He was sensible of impressions jnforget- of all kinds from the senses, and therefore looked out of the fulness of window, although rather dark, to see if he could be made sen- word8, sible of the situation of the house. The loss of memory gra- dually went off, and in less than half an hour his memory was perfectly recovered."* This might possibly be connected with a gouty habit, to which Mr. Hunter was subject, though not at this time labouring under a paroxysm. The late bishop of Lan- Forgetful- daff, Dr. Watson, gives a singular case of partial amnesia in his nessoffami father, the result of an apoplectic attack. " I have heard him ,y namC8, ask twenty times a day," says Dr. Watson, " ' What is the name of the lad that is at college ?' (my elder brother) ; and yet he was able to repeat, without a blunder, hundreds of lines out of classic authors."t And hence, there is no reason for discredit- ing the story of a German statesman, a Mr. Von B., related in the seventh volume of the Psychological Magazine, who, hav- ing called at a gentleman's house, the servants of which did not know him, was under the necessity of giving in his name ; but unfortunately at that moment he had forgotten it, and excited Forgetful- no small degree of laughter by turning round to a friend who nesgofa accompanied him, and saying, with great earnestness, " Pray „*£'°W" tell me who 1 am, for I cannot recollect." From severe suffering of the head in many fevers, a great General for- inroad is frequently made upon the memory, and it is long be- getfuloess fore the convalescent can rightly put together all the ideas of ofle" his past life. Such was one ofthe effects of the plague at Ath- byfevS ens, as we learn from Thucydides: ™5 h ««< xtfn tXufimi Example icttytvTixa. xvctffTxvras rm Trecurav woia? nut yiyvotxr** ff M*irabe" ture, than from inactivity or a neglected education; or may j^" credu" possibly have been rendered so by intemperance; who are de- More gen- ficient in natural skill to use the evidence they possess of prob- erallyidio- abilities : and being incapable of carrying on a train of conse- pathic. quence.s in their heads, and of weighing exactly the preponder- ance of contrary proofs and testimonies, are easily misled, and rendered the dupes of every plausible sophist, and the play- things of every impostor. " There are .some men," says Mr. Locke, " of one, some but of two syllogisms, and no more; and others that can but advance one step farther. These cannot al- ways discern that side on which the strongest proofs lie; cannot constantly follow that, which in itself is the more probable opi- nion."* There is another imbecility we have noticed, as strangely in- mbeciii- and, as far as possible, removed or palliated : and whatever will Medical tend to invigorate the entire frame, as the metallic tonics, regu- * Human Understand. Book iv. Ch. xix. i 5. 136 CL. IV.] NEUROTICA. [ord. I. Spec i ^ °fv ' S,eep' exerc*se, and above all, cold bathing, must *M L [UpPy he fGSt To the arms of mental and moral instruction, cillis'incon-" ho^evfr^ tbf sicMy understanding must be chiefly intrusted; stantiae. and' where these are properly applied, the mind may often be Moral. rendered sufficiently sound for all the ordinary purposes of life, and even for some of its elegancies ; though it may never be distin- guished for terseness, brilliancy, or comprehension. The lead- ing aim should be to lay hold of the strongest faculty, and to make the direct cultivation of this an indirect cultivation of the rest. ■ Witlessness. Irra- a. M. de- mens stul- titia. Generally a natural infirmity: often ca- Species II. Moria Demens.- tionality. Defect or hebetude of all the faculties ofthe understanding. Of this species we have three varieties that seem to require a distinct notice: x Stultitia. Silliness. Lerema. Dotage. Anoea. Idiotism. Folly. Superannuation. Shallow knowledge, vacant countenance, light, frivolous fancy: for the most part with good nature ; sometimes with obstinacy. Impotence of body as well as of mind, from premature old age ; childish desires and pur- suits ; drawling speech or gar- rulous babble, composed of ideas for the most part asso- ciated by previous habit. General obliteration ofthe men- tal powers and affections; paucity or destitution of ideas; obtuse sensibility; vacant countenance ; imperfect or broken articulation ; with oc- casionally transient and un- meaning gusts of passion. The difference between the understanding of some men and rrH°thfSJS ffme'7et " is not eveTy rain«te variation from the standard of soundness that constitutes a disease whe ther in mind or body; but as soon as, in either case, such va- riation becomes a marked or serious evil, it is entitled to this name; and in the subject before us, falls within the ranffe of the first of the preceding varieties. This which is what we ordinarily denominate sillinesses generally a natural infirmity, and in some families appears to be hereditary. A well directed education, however, may do much bPttPrtK 's00^™^™/acuity that will bear cultivating better than the rest, and which points to the particular line to" cl. iv.] NERVOUS FUNCTION. [ord. i. 137 which the study of the individual should be especially address- Gen. VI. ed, and in which he may appear respectable. He may have Spec. II. imitative powers, and make a good painter or engraver, though * M.demeni he may not have creative powers, and make a good orator or st,,lthia- poet. He may be fond of arithmetic, and fitted for trade and pJ,i^n accounts, though he may not possess a taste for scientific sub- by jud°n icioua tleties, or be well calculated for any one ofthe professions. manage Dotage, when a mere result of old age, is hardly to be re- ment- garded as a disease, and is rarely accompanied by any efferves- ^ M,de' cence of the passions. But it often appears prematurely, and is lerema. especially accelerated by excessive indulgence in corporeal Causes. pleasures; sometimes by violent mental emotion, as anger, or by long continued grief. Under the two former of these causes, Description there is often combined with it an incessant garrulity, a very high degree of passionate but unmeaning effervescence, and puerile mobility. M. Pinel gives a striking example of this in Farther a person, whom he had frequently an opportunity of seeing, fro^pi^l " His motions," says he, " his ideas, his broken sentences, his confused and momentary glimpses of mental feeling, appeared to present a perfect image of chaos. He came up to me, looked at me, and overwhelmed me with a torrent of words without order or connexion. In a moment he turned to another person, whom, in rotation, he deafened with his unmeaning babble, or threatened with an evanescent look of anger; but as incapable of determined and continued excitement ofthe feelings as of a just connexion of ideas, his emotions were the effect of a mo- mentary effervescence, which was immediately succeeded by a calm. If he went into a room, he quickly displaced or over- turned the furniture, without manifesting any direct intention. Scarcely could one look off before he would be at a considerable distance, exercising his versatile fondness for bustle in some other way. He was quiet only when food was presented to him. Even at night he rested but for a few moments.1' A strong desire of food, however, is by no means common under this species: it is perhaps most frequently met with in the do- tage of old age: but, in premature lerema, we often find the appetite entirely banished, and a resistance to food of all kinds when offered. Idiotism, the third variety, is often the result, as we have y M. de- already observed, of an original misformation of the cranium, mensanoea. sometimes in respect to thickness, more frequently in respect often (rom to shape ; by both which the internal cavity, and consequently ^"ructure the capacity ofthe brain, are unduly diminished. ofthe The internal causes are habitual inebriety, excessive and cranium. enervating pleasures, violent agitation of the passions, whether Atother pleasurable or painful, as overwhelming joy, startling terror, j^nal"1 deep and protracted grief, or furious anger: tumours within causes. the cavity of the cranium ; apoplectic attacks; injury of the brain from external violence ; injudicious management in ecphronia; and especially an excessive use ofthe lancet. Idiotism, however, is more frequently congenital than acci- Morefre- dental; and it is melancholy to think, that it is also sometimes 1"entl>[ vol. IV. 18 congeoitaJ. 138 cl. iv.] NEUROTICA. [ord. i. Gen. VI. Spec. II. y M. de- mens ancea. Often united with palsy or epilepsy. Description Treatment. hereditary. Of those who are idiots from birth, many, more- over, are sooner or later afflicted with palsy or epilepsy, or both; a clear proof of the existence of some organic affection ofthe brain or nerves: the former being sometimes partial, and confined to the face only, or extending down one of the sides. Idiots rarely attain old age; they seldom exceed the term of thirty years; and when paralysis or epilepsy is concomitant, they usually die at a much earlier period. In idiotism, the ideas of sensation and of reflection appear to be equally inaccurate. There is a vague, unsteady, wander- ing eye, seldom fixed for any length of time upon one determi- nate object; a stupid expression of countenance, in which no sign of intelligence is portrayed ; a gaping mouth, from which the saliva flows constantly; a perpetual rolling and tossing of the head ; no memory, no language, no reason. The idiot has all the animal instincts, and some of the passions. Ofthe last, joy, fear, and anger, are those with which he is most frequent- ly affected ; but these are of a very limited kind. His joy is unmeaning mirth ; his fear a transient qualm ; his anger a mo- mentary fit of violence. The toys of children, and the gratifi- cation of hunger and thirst, are his only pleasures : bodily pain, or fear of bodily pain, his only distresses. It is said, that idiots have sometimes shown a strong sexual appetite; but this is not common, for they rarely seem to attend to any distinction of sex.* The treatment, where medical assistance can be of any use, must chiefly depend upon the nature of the case. Blistering and internal stimulants, to increase the action of the nervous system, and augment the habitual torpitude of the abdominal viscera, which are usually affected in this malady, offer the fairest chance of advantage. Accidental commotion of the brain, an occasional cause, has occasionally also proved serviceable, as has likewise a fracture of the cranium. Hence, too, fevers have relieved the disease ; and active paroxysms of mania have proved a complete cure; and I once knew a cure effected in a lad, who fell from the first floor of a house into the street; the torpitude or obstruction, or whatever was the cause, being hereby removed. CLASS IV. NEUROTICA. Various significa- tions of the order //.-arstftettca. DISEASES AFFECTING THE SENSATION. Dulness, depravation, or abolition of one or more of the organs of corporeal sense. jEsthetica is derived from utadxtofcxi, " sentio, et proprie sensu corporis." The term applies, however, to all the ex- * Crichton, Of Mental Derangement, i. p. 314. cl. iv.] NERVOUS FUNCTION. [ord. n. 139 ternal senses, and, in the language of Galen, peculiarly ex- Class IV. presses * xnrOqriKti dvtxptf, " the power or faculty of sensation." Order II. It must also be admitted, that it is occasionally applied to mental ;9Esthetica. sensation, as in Isocrates to Demonicus, thru tw iKuvm yiupw ordinal xurhvy " thus will you feel their mind or inclination." term and i,s The term has hence been used in different significations by comPollnds- different medical writers. It has seldom, indeed, been applied to the mind, but has strangely varied between expressing sen- sation generally, and the sense of touch alone. In Dr. Young's excellent volume on Medical Literature, it runs for the most part How used parallel with its meaning in the present work, and imports dis- hy Y°ung: eased action of all the corporeal senses ; but, with this appro- priation of the term, there seems to be an incorrectness in ap- plying it, as the same author does immediately afterwards, to defective memory, which he names dysa:sthesia internia, and ranks in the same list or genus with defect of the external senses. Sauvages, and, after him, Sagar and Cullen, have applied dysxs- Sauvages, thesiae to a morbid state of the corporeal senses generally; and Sagar. whence anaesthesias should in their hands have expressed atony, or total inactivity of these senses generally. But, while dyses- thesia extends to all the senses, anaesthesias is by the same writers limited to the single sense of touch ; with no small per- plexity to the young student. In the Physiological Proem to the present class, we have taken so full a survey of the connexion which exists between the brain and the corporeal senses, by means of the nerves, that it is not necessary to say more upon the subject at present; and 1 shall only therefore further observe, in these preliminary where one remarks, that where one of the senses is deficient, and especially sense defi- where naturally deficient, the rest have very frequently been c'e"l °r in a deep shade; while nyctalopia has been illustrated. used by most modern writers in the opposite sense of night- sight-acA, agreeably to the technical or implied meaning of opia when employed pathologically; in which case it always imports diseased vision, as though a contraction of the term paropia or paropsis: whence nyctalopia has necessarily been made to im- port day-sight, instead of night-sight, or that imperfection of vision in which the eye can only see in the day, or whenever there is a strong light. And hence hemeralopia, the opposite to nyctalopia, has been used, with the same confusion and con- tradiction of signification ; by the Greeks importing day-sight, being taken naturally or literally; by the moderns day-sight-ach, and consequently night-sight, being taken technically or by im- plication ; and hence Sauvages, " Graecis hemeralopia ; neoteri- cis nyctalopia." It is the luscitas of Beer ;* the day-blindness of Luscitas of various other writers. Beer. The disease is dependent upon a peculiar irritability of the Exposure to retina, produced by two very different causes: a sudden expo- t0.° s'rong sure to a stronger light than the eye has been wont to sustain ; *auS" and and a deficiency of the black pigment which lines the choroid wby. tunic. If the iris be weak and torpid, it is enlarged; if strong and contractile, diminished. From the first cause, this disease is common to those who live almost constantly in dark caverns or chambers, as mines, dungeons, or dark prisons; or who have recently had a cataract depressed or extracted, the growth of which has still more ef- fectually excluded the light from the retina. And, in all these Perpetual cases, we find it accompanied with a perpetual nictitation, from nictitat'°n- the sympathy, which prevails between the retina and the orbi- cular muscles of the palpebrae. Ramazzini asserts, that this complaint is common to the pea- Frequent sants of Italy who are employed in agriculture ; but in whom am°ng he is able to trace no other peculiarity than a considerable en- peasants largement of the pupil.j It is not difficult perhaps to assign a Explained. reason for such an affection among these people, though Ramaz- zini is silent upon the subject. The sky of Italy is peculiarly bright, its atmosphere particularly clear, and its temperature relaxingly warm. The peasants of Italy, therefore, are exposed to the joint operation of almost every cause that can produce habitual debility in the iris, and irritability in the retina. And Effects. * Lehre von der Augenkrankheiten, als Leitfaden zu seinen offentlichen Vorlesungen entvvurfen. Twey Bande, 8vo. Wien, 1817. t De Moibis Artificum, &c. 142 cl. iv.] NEUROTICA. [°rd- h. Geat. i. Spec. I. Paropsis lucifuga. How removed. Produced by an in- tense glare. Deficiency of black pigment a cause; and why. Hence com- mon to Albinoes. Sometimes found in old age. Constitutes the wall-eye in horses* Certain states of the eye, in which a strong light hinders vision. Natural to quadrupeds that prowl at night. we find these causes acting with renewed power at the time when the disease chiefly makes its attack, which we are told is on the return of spring, or rather at the vernal equinox, when a double flood of day breaks on them. And such is the dimness it produces, that the peasants lose their way in the fields in the glare of noon; but, on the approach of night, they are again able to see distinctly. It is hence necessary for them to keep for some weeks in the shade, or in comparative darkness, till the eyes recover their proper tone: and the weakness, and conse- quently the disease, subsides. And hence Ramazzini tells us, that in the course of the succeeding month, or, in other words, after they have taken due care of themselves, the peasants re- cover their sight. The glare of the sun, in tropical regions, and especially where reflected from bright chalk hills, has of- ten produced the same effect. A deficiency of the black pigment is occasionally found in persons of a fair complexion and light hair; and, as the retina is hereby deprived of the natural shade that softens the light in its descent upon this very sensible membrane, its morbid irrita- bility is not to be wondered at. Albinoes, who are without the common pigment that lies between the cuticle and cutis in other persons, are always deficient in this also; and hence are pain- fully sensible to light. Indeed, they are hardly able to open their eyes in a strong sunshine; they contract their brows, and keep the eyelids nearly closed during the day ; but no sooner does twilight come, than they are enabled to see quite distinctly. In old persons the same deficiency of black pigment is sometimes traced, but without painful vision ; for, at this time of life, the optic nerve is become more obtuse. In horses, this want of pigment constitutes what is called a wall-eye. [It is remarked by Mr. Lawrence in his Lectures, that there are many states of the organ, in which vision is very imperfect, even to blindness, in the strong light of the day ; and much bet- ter sight is enjoyed in twilight and the dusk; but, he has never seen such a state as an amaurotic affection, or what is here call- ed night-sight, dependent on disease of the retina, or optic nerve. In central leucoma of the cornea, in incipient opacity of the lens, in partial central opacity of the capsule, in contractions of the pupil from prolapsus iridis, or adhesion of the pupillary margin, connected with either ofthe former circumstances, the patient will see best in a weak light, and find vision very im- perfect in a strong glare. The enlargement of the pupil in the former, and its contraction in the latter state, sufficiently account for this difference. On the same ground, sight is much im- proved in some of these circumstances by the use of belladonna. In strumous ophthalmia, the intolerance of light often amounts to blindness during the day ; the symptoms remitting in the evening, at which period the eyes are opened, and the patient sees well.] Acuteness of night-vision is natural to various animals that prowl in the dark ; as cats, lynxes, lions, and perhaps all the feline genus; which save their eyes from the pain produced by cl. iv.] NERVOUS FUNCTION. [ord. ii. 143 broad day-light, by a closer contraction of their pupils than man- Gew. I. kind are able to effect; expanding them gradually as the night Spec 1. shuts in, till by the extent of the expansion, they are able to Paropsis see much better than mankind in the dark. Owls, bats, cock- UCI uga" roaches, moths, sphinxes, and many other insects, have a similar power. Where the disease proceeds from an accidental irritability of Treatment the retina, sedative applications, as the tincture of belladonna, w,1f" from and internal sedatives, as hyoscyamus and conium, have often causes, proved serviceable, and the more so when combined with the bark. In old age, or an early deficiency of the black pigment when from that covers the choroid tunic, medicine has very little chance of dffecl,ve success, and all we can hope for is to afford occasional relief by palliatives, if the irritation be violent, or accompanied with in- flammatory symptoms. Ordinary cause- Species II. Paropsis Noctifuga.—Day-Sight. Vision dull and confused in the dark : but clear and powerful in broad day-light. This species, the nyctalopia of neoteric authors, or night- Endemic in blindness, is said to be endemic in Poland, the West Indies, Bra- various zils, and the intertropical regions generally.* Its cause is "JjJ"^. precisely the reverse of that of the preceding species; and proceeds from too great, instead of too small, an habitual expos- ure to light, whence the retina becomes torpid, and requires a strong stimulus to raise it. At noon-tide, therefore, it is sensible to the impressions of objects ; but does not clearly discern them in the shade, or towards the close of day. [Hence, the present complaint is rarely met with, except in climates or situations where the light is very powerful. Between the tropics, as Mr. Lawrence observes, the full glare of a vertical sun in an un- clouded sky, and the strong reflection of the solar rays from the sea, or from a sandy soil, produce an excitement of the retina, to which we are wholly unaccustomed in our latitudes ; although, in some parts of Europe, analogous influences exist in a suffi- cient degree to cause the affection. Europeans in the West In- dies, and particularly soldiers and sailors, who are much exposed to the sun, often have the complaint. In all the cases, which Mr. Lawrence has seen, the disease commenced in the East or West Indies, and was brought to England, In the commencement, the person can see by moon-light, or Diagnosis. when the room is lighted by a candle; but, as the disorder pro- ceeds, he can see nothing after sunset; »nd, in the morning, vis- ion returns. There is no change of appearance in the eye, and, of course, as Mr. Lawrence has remarked in his Lectures, if the patient can see perfectly during the day, the organ can have undergone no important change. At first, a slight increase of irritability is remarked ; but, as the disorder increases, the * Hautesierck, Recueil d'Obseivations de Medecine, 1. ii. 144 °i» iv.] NEUROTICA. [ORD. 11. Gew. I. Spec. II. Paropsis noctifuga. Peculiarly frequent in some parts of France; often re- turning pe- riodically. Explained' Still more commonly at times in Russia. At what season. Easily cured. Instance of its having nearly led to extensive and serious mischief Amongst hens a natu- ral defect; whence called hen- blindness. pupil becomes rather dilated, and the case is alleged to termi- nate sometimes in amaurosis. The feeble light of night and twilight does not impress the retina, after it has been so strongly excited in the day, sufficiently for perfect vision.] Day-sight is said* to be endemic in some parts of France ; and particularly in the neighbourhood of Roche Guy on, on the banks of the Seine. And so general is its spread there, that in one village, we are told, it affects one in twenty of its inhabitants ; and, in another, one in ten, every year. It makes its attack in the spring, and continues for three months : sometimes, though in a slighter degree, returning in the autumn; there are indivi- duals who have had returns of the complaint for twenty years in succession. It passes off, after having run its course, or rath- er, perhaps, after having been treated with due medical atten- tion, without any inconvenience, excepting a weakness in a few eyes that renders them impatient of wind and strong light. The soil is here a dazzling chalk, and the keenness of the first re- flected light, after the dreariness of the winter, is probably one cause of so general an evil. [According to a statement, referred to by Mr. Lawrence, the disorder at one time prevailed exten- sively among some French troops stationed in Belleisle, under a combination of local peculiarities, calculated to act powerfully on the retina, and at a season ofthe year favourable to their in- fluence.] Perhaps, however, there is no part of the world in which this disease is found more commonly, or more decidedly, than in Russia: but then it is rarely found except in the Russian summer, when the eye is exposed, almost without intermission, to the constant action of light, as the sun dips but little below the horizon, and there is scarcely any interval of darkness. The malady, again, mostly makes its appearance at this time among the peasants, who protract their hard labour in the fields from a very early to a very late hour ; and at the same time exhaust and weaken themselves by their daily fatigue. The sight is soon restored by rest, a proper shade, and bathing the eyes with an infusion of any bitter and astringent vegetable. Dr. Guth- rie, in the Memoirs of the Medical Society of London, from which this account has been taken, gives also an example ofthe disease having appeared suddenly, a few springs before, in a de- tachment of Russian soldiers, who, being ordered to attack a Swedish post, at the moment of its incursion had nearly des- troyed one another by mistake. These men had been harassed by long marches, and been exposed night and day to the pierc- ing glare of an uninterrupted scene of snowy mountains ; both which causes had concurred in producing this effect. Sir Gilbert Blane has found it occasionally occur in scorbutic patients; but no such disease appeared in the Russian soldiery. Hens are well known to labour under this defect naturally; and hence they cannot ste to pick up small grains in the dusk of the evening, and so employ this time in going to roost: on which account the disease is sometimes called hen-blindness. * Mem. de la SociSte Royale de M6d. 1786. CL. IV.] NERVOUS FUNCTION. [ORD. II. 145 [AH practitioners, who have had opportunities of witnessing Gew. I. this disorder, concur in delivering a favourable prognosis. Spec. II. When it is recollected that Mr. Bampfield,* a naval surgeon, P^opsis saw in the East Indies about three hundred cases, and that they DOC,ifu6a- were all easily cured, without any permanent injury of sight, no doubt can be entertained of the generally favourable result Prognosis. of proper treatment, in which the avoidance ofthe cause ofthe affection is one of the most important things to be observed.] Tonics and gentle stimulants have been much recommended. Curative The bark may be freely employed internally, and blisters ex- ProceM- ternally, with the vapour of camphor, ether, or carbonated ammonia; and a few drops of the tincture of opium, the cit- rine ointment, or a minute portion of prussiate of iron, also in the form of an ointment, occasionally applied to the ball ofthe eye. In most of the endemic cases, it seems to be an intermit- When tent, as the preceding species appears to be occasionally; and, endemic, in such circumstances, a free use ofthe bark used to be the STmitteofc. plan chiefly depended upon. [Of late years, however, in con- sequence of the great and decided success, with which Mr. Bampfield cured every case, by means of blisters on the tern- Blisters and pies, and aperient medicines, this practice is now generally aperients. preferred. With it, Mr. Lawrence has occasionally associated cupping from the temples, or nape of the neck.] When the sight is once stimulated by the full light ofthe day, Sight some- it occasionally becomes peculiarly acute and vivid. Plenck as- *'«« acute serfs, that he has known some men labouring under this disease, 1" v,v.'.' evince so high an excitement of vision as to be able to distin- te™^' guish the stars at noon. Dr. Heberden has communicated a singular case of this spe- singular cies, which it will be best to give in his own words.f " A man, case of about thirty years old, had in the spring a tertian fever, for Peri°dical which he took too small a quantity of bark, so that the returns day"8l8ht' of it were weakened without being entirely removed. He therefore went into the cold bath, and after bathing twice he felt no more of his fever. Three days after this last fit, being then employed on board of a ship in the river, he observed, at sun-setting, that all objects began to look blue, which blueness gradually thickened into a cloud ; and not long after he became so blind as hardly to perceive the light of a candle. The next morning, about sunrising, his sight was restored as perfectly as ever. When the next night came on, he lost his sight again in the same manner; and this continued for twelve days and nights. He then came ashore, where the disorder of his eyes gradually abated, and in three days was entirely gone. A month after he went on board another ship, and after three days' stay in it, the night-blindness returned as before, and lasted all the time of his remaining in the ship, which was nine nights. He then left the ship, and his blindness did not return while he was upon land. Some little time afterwards, he went into another * See Med. Chir. Trans, vol. v. VOL. IV. 19 t Medical Transactions, vol, i. 146 CL. IV.] NEUROTICA. [ORD. 11. Gew. I. ship, in which he continued for ten days, during which time Spec. II. the blindness returned only two nights, and never afterwards. Paropsis noctifuga. Explained. I have observed, that nyctalopia noctifuga is often an inter- mittent affection. In the present case, it was distinctly ot this nature, and evinced a decided quotidian type. We are not ac- quainted with the exciting cause of this intermittent; but we know, that when once a circuit of action has been established in a weakened and irritable habit, it adheres to the system with almost invincible tenacity, and is re-called with the utmost fa- cility upon a repetition of such a cause. And hence the uni- form return of the affection on ship board, where it commen- ced, till a cure was obtained. Seat of affection chiefly the iris, as that of the pre- ceding two is the retina. a. P. lon- ginqua vulgaris. Species III. Paropsis Longinqua.—Long Sight. Vision only accurate when the object is far off. This is the dysopia proximorum of Cullen, the vue longue of the French. In both the preceding species the morbid affection seems chiefly to appertain to the retina; in the present species, it be- longs chiefly to the iris, which is habitually dilated, and not easily stimulated to a contractile action. " For it is well known," observes Dr. Wells, " to those who are conversant with the facts relating to human vision, that the eye in its re- laxed state is fitted for distant objects, and that the seeing of near objects accurately is dependent upon muscular exertion." The species offers three varieties, as follow: 0 x Vulgaris. Common long-sight. Paretica. Unalterable long-sight. Senectutis. Long-sight of age. Iris relaxed, but moveable ; cor- nea mostly too flat. Iris incontractile, pupil un- changeable, from partial pa- ralysis. Cornea less convex ; relaxation and hebetude common to all the powers of the eye. The first variety is common to every period of life, in which the iris is affected with an habitual relaxation. [The truth of the foregoing statement, that long-sight is dependent on the state of the iris, is not very manifest. No doubt, the pupil is often large ; but, it may be questioned, whether this may not be only an effect of the infirmity ; for nothing is more certainly established, than that this defect of vision, as well as the opposite one, called short-sight, is principally occasioned by a peculiarity in the refractive powers of the eye. In long- sighted persons, the rays of light are not collected in the pro- per place, the focus in which they would meet being behind the situation of the optic nerve. Like short-sight, it is, as Mr. Lawrence has observed in his Lectures, u merely consequent upon some circumstances in the transparent media of the eye, which, in all other respects, is perfectly natural. Now, the cl. iv.] NERVOUS FUNCTION. [ord. ii. ]47 eye, being in a great part of its functions a mechanical instru- Ges. I. ment, must be subjected to mechanical laws ; and we find, that Spec. III. a given configuration of the transparent media, a certain rela- «P. lon- tion of them to each other, and their position at a determinate ^.'u,?;., ■ ■ s* I Vulgaris* distance from the retina, are necessary to the formation of a Certain distinct picture upon that nervous expansion. There is a cer- conditions tain distance from the eye, which is called the point of distinct of tl,e vision, at which we can see objects in all their details with per- medir™" feet clearness. Every eye, considered as an optical instrument, essential to has its point of distinct vision. The latter, therefore, varies in Per.fect different persons, and is generally different in the two eyes of V18l0n' the same individual. Objects are not so distinctly seen, when moved nearer to, or farther from, the eye than this point. In ordinary well constructed eyes, the distance ranges from fifteen to twenty inches." Too flat a configuration of the cornea, or crystalline lens ; loo little distance between the retina and the lens; or too weak a refraction of the rays of light, from insuf- ficient density of the humours and transparent media ; total loss of the crystalline lens by operations for cataract; may be so many causes of long-sight. It has been remarked by Mr. Wardrop, that, when people advance in life, the cornea gradu- ally loses its convexity, perhaps from the humours of the eye being diminished. The change, however, is not absolutely re- stricted to old persons; for the same writer speaks of a girl, eight years of age, the cornea of whose eyes were observed to be remarkably flat, and her vision very imperfect from her in- fancy. In people much enfeebled by considerable evacuations, by numerous bleedings, or by disease, the quantity ofthe aque- ous humour diminishes, the convexity ofthe cornea is lessened, and they can only see objects at a distance.* The ingenious experiments of Sir Everard Home and the late Mr. Ramsden, recorded in the Philosophical Transactions, prove, however, that the sphericity of the cornea is altered according to the distance at which objects are viewed. Hence, an impairment of this power of accommodation in the eye may sometimes be concerned in the present infirmity, as well as in the opposite one of near-sight. In the present, the faculty, which the eye has of adapting itself to near objects, is presumed to be de- fective.] The second variety constitutes the disease called immuta- 0 P. lon- bility of sight by Dr. Young ;t and is admirably described by gi»qua Dr. Wells in the Philosophical Transactions, in an interesting £?re ica' case of a young person, about thirty-five years of age, whose Ca"e"om. retina was as sensible to the stimulus of light as ever; yet who, plicated from a paresis, or permanent dilatation of the pupil, saw near w'thparaly. objects with considerable confusion, but remote objects with adjoining6 perfect accuracy. The power of moving the upper eyelid was muscles. also lost. It vvas an extreme case of the disease before us, com- How imi. plicated with partial paralysis of the adjoining muscles, and may tatedi * See Wardrop1s Essays on the Moroid Anatomy of the Human Eye, p. 115. Portal, Anatomie Medicale. t Phil. Trans, year 1793. 148 cl. iv.] NEUROTICA. [ord. n. Gen. I. Spec. III. How remedied. j-P. longin- qua senec- tutis. The pres- bytia of many writers. Refractive power ofthe eye weak- ened. Remedial plan. be imitated by applying the tincture of belladonna. It was ea- sily remedied by the use of spectacles with convex glasses, by means of which the patient was able to read without difficulty in a printed book, whose letters he was scarcely able to distin- guish from each other before the spectacles were applied. The third variety, or that produced by old age, constitutes the presbytia, and presbyopia of medical writers, from ^ip«"» persons. The lens in such a case is generally smaller than na- catarracta- tural, and the capsule being unaffected, the opaque body ap- pears at a small distance behind the pupil. There is a marked interval between that aperture and the cataract; the iris has its full play; and the patient retains the power of distinguishing objects during the formation of the cataract, by the passage of light through the less opaque circumference of the lens. Mr. Pott's opinion, that the colour of a cataract affords no clue to its consistence, we find, from what has been here stated, to be at variance with modern experience. In the soft cataract, the lens is not soft in the circumference Signs of soft only, but its whole texture is changed, having various degrees cataract< of consistence, as that of cheese, jelly, or milk. Soft cataracts are larger than the hard; so that they press against the iris, and render its front surface convex. Their surface is distin- guished by a bluish kind of white. The opacity extends uniformly to the circumference of the lens; it intercepts the light more completely than the hard ca- taract does; and the patient at last retains merely the power of distinguishing light from darkness. Capsular cataracts are those in which the front, or back, of Of capsular the capsule ofthe lens is alone affected, and those in which the calaract- whole capsule is opaque. An opacity of the capsule does not begin in the centre, but in all parts of the membrane indiffer- ently : it is not uniform, but in spots or streaks, with less opaque or transparent intervals. To continue Mr. Lawrence's accurate description, these opaque portions have a glistening white, or bluish white appearance. In the anterior capsular cataract, Anterior the opacity always projects as far forward as the edge of the capsular pupil. The capsule cannot become extensively opaque with- cataract' out the lens being also affected ; and when the anterior portion ofthe membrane is opaque, the lens is in the same condition. We may have, Mr. Lawrence observes, a single streak of opacity in the capsule after iritis ; but that will not constitute a cataract: the capsule may be more extensively, yet partially covered by a new adventitious membrane, the rest remaining clear; but there is no such case as a capsule, generally opaque, containing a transparent lens. When the posterior part of the capsule becomes opaque, Posterior while its front portion and the lens continue transparent, the capsular opacity is situated at a marked distance behind the pupil: its cataract- situation corresponds to the known position of the capsule. It presents a concave surface, with partial streaks, the intervals of which are transparent. As Mr. Lawrence farther explains, the posterior capsular cataract has not that glistening white colour, which distinguishes the anterior, because it is seen through the lens, and acquires a yellowish and rather dull appearance. This change in the capsule is followed by opacity ofthe lens, which, however, may not occur for a considerable time. Mr. Lawrence 164 CL. IV.] NEUROTICA. [ORD. II. Gen. I. Spec. IX. Paropsis catarracta. Complicat- ed, or capsulo- lenticular cataract. Varieties of cataract, affecting both the lens and its capsule. Cataract complicated with glau- cosis. Cataract complicated with amau- rosis. adverts to two patients, who were attending the Ophthalmic In- firmary, in whom posterior capsular cataracts could be very dis- tinctly seen. One of them could read the large print of a bible, and, when the pupil was dilated with belladonna, the spaces be- tween the opaque radii, through which the light gained admis- sion to the eye, could be distinctly seen. As the lens becomes more opaque, vision decreases. What our author denominates complicated cataract, or the case in which both the lens and capsule are opaque, is very frequent. It is the capsulo-lenticular cataract of the Germans. Generally speaking, says Mr. Lawrence, the lens in these cases is soft, and the cataract large, often pushing forwards the iris, and impeding its motions. The streaks ofthe anterior portion ofthe capsule on a level with the edge of the pupil; the different tint of the opaque lens, seen through the less opaque parts of the capsule; and the considerable degree in which sight is interrupted, ow- ing to the bulk of the lens; are characteristics of this example of cataract. The varieties of appearance presented in the caspulo-lenlicular cataracts have afforded the German oculists abundance of opportunity for minute distinctions. Thus they describe the catarracta marmoracea, where the opaque capsule exhibits a marbled appearance; c.fenestrata, with bars, fancied to resemble those of a window; c. punctata, with spots, &c. Also the catarracta arida siliquosa, or dry-shelled cataract, in which the capsule has a thickened and corrugated appearance, and contains only the nucleus ofthe lens. This variety is often met with in children, and frequently mistaken for a congenital affection. In young infants, Beer says, it is manifestly produced by a slow and neglected inflammation ofthe lens and its capsule, excited by the stimulus of too strong a light. In adults, the case is generally the result of external violence. Schmidt sup- posed* that, in infants, the siliquose cataract might be caused by convulsions, attended with violent action of the muscles of the eye; but the correctness of this opinion is now beginning to be disbelieved. In a cataract, complicated with glaucoma, or glaucosis, as our author chooses to name it, the vitreous humour is first affected, and the lens subsequently. If, says Mr. Lawrence, the iris is altered in colour ; if the pupil is fixed in the dilated state; if the sight was lost, with considerable head-ach, and before the cataract had formed ; the eye may be inferred to be glaucomat- ous. The complication of cataract with amaurosis is denoted by the inability to discern light from darkness. The insensibility of the retina may not be totally destroyed, and thus the power of discerning the difference between light and darkness may ex- ist with a cataract, attended by imperfect amaurosis. Here as Mr. Lawrence explains, the practitioner must attend to the symptoms under which the loss of sight has occurred, as well as to the present state ofthe eye. Simple cataract comes on with- out pain; while, in amaurosis, there is often considerable pain in the head, or neighbourhood of the eye. In cataract, unat- «.. iv.] NERVOUS FUNCTION. [ord. 11. 165 tended with enlargement of the lens, or adhesion, the iris has Gen. I. generally its natural power of motion. A motionless or sluggish Spec IX. iris, and a fixedly dilated pupil, are therefore strong evidence Paropsis of an amaurotic affection, when they are not accounted for by catarracta- the particularities ofthe cataract itself.] Like paropsis glaucosis, or opacity of the vitreous humour, Has been a cataract has sometimes, though very rarely, ceased spontane- c,,red 8Pon" ously, or without any manifest cause* Helwig gives an in- SSl'wd- stance, in which the cessation was not only spontaneous but sud- denly, and den.t It has also, at times, been carried off by a fever.J carried off There is hence specious ground for conceiving, that some hy a fever' medicine might be discovered, capable, by some general or JJedidne specific action, of producing a like change, and proving a reme- might be dy for the disease; and the more so as we find ganglions and supposed other accidental deformities frequently removed from the ex- eerviceable: treme parts of the system by external or internal applications. But no such remedy has hitherto been discovered, or at least butnogen- none that can be in any degree relied upon, excepting in those eralorspe- cases of supposed but miscalled cataracts, which have consisted hmbem*7 in a deposition of lymph from an inflammation of the iris and discovered ciliary processes : for recourse has been had to mercurial pre- in the cura' parations both external and internal, as almost every other me- hitherto"58 tallic salt, aconite, the pasque-flower, or Pulsatilla, to protracted pursued. vomiting, electricity, and puncturing the tunics ofthe eyes, but without any certain advantage.§ This is the more to be lament- This to be ed, because, whatever surgical operation may be determined lamented, upon as most advisable, there is no guarding, on all occasions, becailseof against the mischievous effects which may result, I do not mean success of from the complication or severity of the operation ; for this, un- many °P* der every modification, is simpler and less formidable than the ev^Th' uninitiated can readily imagine; but from the tendency which dexterously is sometimes met with, from idiosyncrasy, habit, or other irrita- performed. ble principle, to run rapidly into a state of destructive inflam- Causes of ill mation, and in a single night, or even a few hours, in spite of success- the wisest precautions that can be adopted, to endanger a total and permanent loss of vision. I speak from personal knowledge, Illustrated. and have, in one or two instances, seen such an effect follow, after the operation had been performed with the utmost dex- terity, and with every promise of success; and where a total blindness has taken place in both eyes, the operation having been performed on both ; neither of them being quite opaque antecedently, and one of them in nothing more than an incipient state of the disease, and the patient capable of writing and read- * Haggendorn, Observ. Med. Cent. I. Obs. 50. Franc. 1698, 8vo. Ludolf, Miscel. Berol. torn. iv. 258. Walker, on the Theory and Cure of a Cataract. t Observ. Physico-Med. 23. Aug. Vind. 1680, 4to. X Velschius, Episagm. 20. The cases, which occasionally disappear spon- taneously, are generally such as have been induced by injuries of the eye, followed by manifest inflammation. The attempt to disperse other cataracts is now deemed a hopeless experiment.—Ed. i Beytruge zur Chirurgie and Augenheilkunst. Von Franz Reisinger, &c. Gbttingen, 1814. 166 cl. iv.] NEUROTICA. [*»». "■ Gen. I. Spec. IX. Paropsis catarracta. Hence all operations should be had re- course to with caution. Operation to be done only on one eye at a time. Cases in which the operation should be postponed. ing with it.* And hence it is far better, in the author's opinion, to have a trial made on one eye only at a time, and that the worst, where both are affected, and one is still useful, than to subject both to the same risk; for the sympathy between them is so considerable, that if an inflammatory process from any con- stitutional or accidental cause should show itself in either, the other would be sure to associate in the morbid action. [This advice is supported by that of Scarpa and Lawrence. The lat- ter offers the following arguments for the decision. If you re- store sight in one, it is sufficient for all useful purposes, and the patient will generally be satisfied. The other may be operated on afterwards, or be retained as a reserve in case the restored sight should fail, or be lost by disease or accident. When both are operated on together, they are not both necessarily involved in any unfavourable subsequent occurrence ; yet they are likely to suffer together from common causes, and, under such circum- stances, the patient loses all chance of regaining sight. On the other hand, if things go on unfavourably, it is a great conso- lation both to the patient and surgeon to know, that one eye only is risked. These arguments seem perfectly convincing. There are some cases, as Mr. Lawrence says, in which it is better for the patient to be content with very imperfect vision, than to submit to an operation, which may end in total blind- ness. The restorative powers, he observes, are feeble in very old persons; in them, and in cases, where the propriety of operating may be doubtful for other reasons, it is best to em- ploy the palliative aid of belladonna, as long as it will procure any degree of useful vision. He advises no operation, in such cases, until the patient is quite blind; until the sight is in that state, in which the failure of the operation can make it no worse. In general, he thinks, we should not operate till all * The prognosis, which should be regulated by circumstances, is here too discouraging. In order to counteract this impression, the judicious remarks of Mr. Lawrence upon this part ofthe subject are introduced. "The prognosis (he says) as far as the operation goes, is completely favourable when the affection is confined to the lens or capsule; when the sensibility ofthe retina is undiminished ; when the motion of the iris is unimpaired ; when the constitution of the patient is sound, and the health is good at the time of operating ; and when the patient is of a spare, rather than a full habit. Under these circumstances, we may say, that the prognosis is completely favourable ; that is, supposing the operator to understand the subject well, to select the kind of operation most suited to the particular species of cataract, and to possess sufficient manual dexterity for performing it in the most advantageous way. The prognosis will be particularly favourable in cases of congenital cataract; in those of young persons (in whom, however, it seldom arises except in conse- quence of injuries), and in the firm lenticular cataract of elderly persons. It is bad when the cataract is complicated with glaucoma or amaurosis; with a fluid state ofthe vitreous humour ; with a varicose condition of the blood-vessels; with dropsy of the eye ; or with a very contracted or closed pupil. Indeed, some of these circumstances would form de- cided objections to the operation. It is also bad when the cataract has been preceded, or accompanied by severe pains in the head, or in the eye; by muscae volitantes, sparks or flashes of fire before the eye, as all these circumstances indicate affection of the nervous structure. The prognosis is doubtful when cataract is the result of internal inflammation of the eye, or of that vascular disturbance, which comes under the head of congestion. The existence of considerable adhesions ofthe pupillary margin is also unfavourable, since the laceration and removal of the adhesions may excite inflammation in the iris and internal tunics. The prognosis is doubtful in cases of cataract affecting one eye, when the other is amaurotic or glaucomatous."—Ed. cl. iv.] NERVOUS FUNCTION. [ord. ii. 167 useful vision is gone. At all events, says he, this rule is abso- Gen. I. lute in doubtful cases. He mentions one exception; namely, SpecIX. where the cataract is mature in one eye, and immature in the Par°ps's other, the former may be operated upon, so as to give the pa- catarracta* tient the use of that eye while the cataract is forming in the other. Much difference of opinion prevails on the question, whether the operation should be done, when only one eye is affected, and the other is sound ; but on this topic we shall not enter, as it is generally discussed in surgical works, and shall merely mention, that it is a point of practice, on which a candid statement of cases is much desired.] The usual modes of operating for the cure of a cataract are Usual three : that of couching or depression ; that of extraction ; and ,nodc8.of that of, what is called, absorption. The first was well known operaUDg- to the practitioners of Greece and Rome ; and is ably described J^depref-5 by Celsus, who advises, in cases where the lens cannot be kept sion. down, to cut it into pieces with the sharp-edged needle, by Extraction. which means it will be the more readily absorbed. And, from Ab or t- this last remark, we have some reason for believing, that even c '0J^ 10D* the third of the above methods, that of absorption, was also knowntf known at the same time; as it is probable, indeed, that the the Greeks second, or the operation by extraction, was likewise ; since we and Ro" find Pliny recommending the process of simple removal or mans' depression in preference to that of extraction or drawing it fbJSion forth ; " squammam in oculis emovendam potius quam extra- and extrac- hendam,"* which Holland has thus honestly, though para- tioQ- phrastically translated, " a cataract or pearl in the eye is to be couched rather, and driven down by the needle, than quite to be plucked forth." In the East, however, both these plans appear to have been Depression pursued through a much longer period. Both are noticed by and «- the Arabian writers in general, and especially by Avicenna and ^'""^ Rhazes; and both seem to have been practised from time im- memorially memorial in India, and, according to the account of the cabira- inthe East- jas, with wonderful success. Dr. Scott was informed by one of the travelling operators, who, however, spoke without a regis- ter, that, in the operation of depression, this success was in the proportion of a hundred, who were benefited, to five, who ob- tained no advantage whatever. [Extraction consists in making an incision through the cornea, dividing the crystalline capsule, and letting the lens escape through the pupil, and the opening made in the cornea. There is a particular modification of couching, or depres- Reclination. sion, that was first suggested and practised by Willburg, and named reclination : in this the lens is not pushed downwards in a straight direction, but is turned on its axis, so as to be placed horizontally in the vitreous humour, behind the lower part of the iris, or, as is sometimes advised, at the bottom of the vitre- ous humour, between the inferior and external straight mus- * Nat. Hist. Lib. xxix. Cap. i. 168 CL. IV.] NEUROTICA. [ORD. II. Gen. I. Spec IX. Paropsis catarracta. Method of extraction by Adams. Method of absorption most ad* visable: and why. The preci- pitation of Maitrt-jan. Solvent power of the aqueous humour highly active : that of the vitreous humour weak. Principle of this method as practised by Adams. Cataract sometimes very rapidly dissolved and carried off. Kerato. nyxis. No mode of operating always the best. cles.* In this operation, the posterior surface of the lens is turned downwards; the anterior upwards; the superior margin is backwards ; the inferior forwards.] One form of extraction was introduced as an improvement by Sir William Adams : after detaching the cataract, he first passed it through the opening of the pupil into the anterior chamber by means of his needle, and then extracted it by an opening on the outer side of the cornea, instead of by one in its inferior part. The method is now very properly aban- doned. The simplest and least irritating of these operations, howev- er, is that by absorption, as it is now commonly called, as it was named precipitation by Maitre-Jan,t on his first noticing the disappearance of portions of the opaque lens ; but which in ef- fect is neither absorption nor precipitation, but solution, or dis- solution, as Mr. Pott correctly described it. But it should be known to the operator, that while the solvent power of the aqueous humour is wonderfully active, that of the vitreous is weak and inconsiderable : and hence the solvent or absorbent plan, practised by Scarpa, consists in dividing the cataract, after its separation, into small fragments, and passing them with the needle by which they are thus divided, through the pupil into the anterior chamber, which constitutes the seat of the aqueous humour, apparently in perfect coincidence with the method first practised by Gleize, and since recommended by Richter.J The fragments thus deposited are usually dissolved in a few weeks; and where the cataract is fluid, they have often been dissolved and absorbed in a few seconds; and some- times even before the needle has been withdrawn. [In the proceeding by absorption or solution, as it is some- times termed, the needle may be introduced either through the cornea and pupil, or behind the iris, as it is in the operation of depression, the pupil having been first dilated with belladonna. These two methods are distinguished by the appellations ofthe anterior and posterior operations. The anterior operation, in- vented by Buchorn,§ or rather by Conradi, has been named keratonyxis; a term derived from the Greek, and signifying puncture of the cornea. This practice was introduced into this country by Mr. Saunders, who does not seem to have been aware that it had ever been done abroad. As Mr. Lawrence has remarked, no person who understands the subject would advise either of these operations to be exclusively employed. Each method has its advantages, and is eligible under certain circumstances: our object then should be, not to select one operation, with the view of practising it in all cases; but to consider the circumstances which make one preferable to the other, and to select in each instance that which is best suited to the particular form of the complaint. * Frick, on Diseases of the Eye, 2d edit, by Welbank, p. 200. s Maladies de l'(Eil. Edit. sec. Troyes, 1711. X Chirurgisch des band x i Buchorn de Keratonyxide. Halae, 1806. + Traite rgische Bibliothek, cl. iv.] NERVOUS FUNCTION. [ord. ii. 169 The principles which should determine the preference in individual cases, and the details of the several operations, must be sought in works on surgery.] Species X. Paropsis Synizesis.—Closed Pupil. Dimness or abolition of sight from contraction or obliteration of the pupil. The term synizesis is derived from avn^u, " consido, coeo, Gen. I. coalesco;" and was used among the Greek grammarians, be- Spec. X. fore it obtained an introduction into the medical vocabulary, to Origin of signify the coalescence of two or more syllables into one. tl|!rems#pecific [The pupil may be simply contracted or closed ; or these chan- ges may be combined with opacity of the capsule, with an ad- ventitious membrane in the pupil, with adhesion of the iris either to the capsule or the cornea, with protrusion ofthe iris, displacement of the pupil, or opacity of the cornea. All these conditions of the eye are the consequence of severe inflamma- tion, either external or internal. As Mr. Lawrence correctly observes, it must also be recollected, that this serious inflam- mation may not have confined itself to the production of the foregoing evils, but may extend its effects to the nervous struc- ture of the eye, or to other parts of the organ. Hence, says he, it is necessary to ascertain correctly whether the loss of vision is produced by the changes of the pupil only, before a decision is made about an attempt to form an artificial pupil.] This species exhibits two varieties : » Simplex. Simple closure ofthe pupil. Simple closed pupil. 0 Complicata. Closure of the pupil corn- Complicated closed pupil. plicated with cataract, opaque coruea, or other changes specified above. The pupil sometimes becomes closed or obliterated from a <*P. synize- gradual contraction, and at length coalition, of the muscular "s«mplex. fibres of the iris, unattended with any other change or impair- ment of the eye. In all these cases it is a simple obliteration of the pupil. It is complicated when the obliteration is com- 0 p. synize- bined with an opacity ofthe cornea,with a cataract, with adhe- siscompli- sions ofthe iris to the cornea or capsule ofthe lens, &c. When cata" the disease is an effect of inflammation, it forms the atresia iridis Atresia of Dr. Schmidt of Vienna, who farther subdivides it into com- iridis of plete, incomplete, and partial, according as the vision is totally Schm,dt- destroyed, impaired, or confined to a part ofthe pupil.* The natural shape of the human pupil is circular, this being Form of the natural form ofthe fine fringe ofthe iris by which it is sur- ^epupjl rounded. But, in a few instances, the fringe or rays of the iris thediseaie. have evinced a different figure, and the pupil, in consequence, * Ueber Nachftaar und Iritis nach Staaropcralioncii. 4to. Wien. 1301. vol. iv. 22 170 cl. iv.] NEUROTICA. [ord. ii. Spe? ' X baS bee" f°Uncl oblonS' or heart-shaped* The first has occurred pec . mo?t freqUent]^ an(^ according to Albinus, has sometimes pre- sis comjn-6" ceded ,oss of vision-t Block gives an instance, in which the cata. disease was congenital and hereditary.^ Has been If the *r'3 contract irregularly, sometimes only a few of its found con- fibres spread across the pupil, while others are retracted : and hereditary. hence we have examples of double or more than double pupils, Double though of smaller dimensions than the natural circle. Solinus pupils how gives an instance of two pupils hereby produced,§ and Janin of produced. not less than five.|| Pupil five- Medicines in this disease are of little avail. In the first vari- Medical et^' ?n ex|ernal application of the tincture of belladonna, or a treatment solution of stramonium, which is said to answer the same pur- of the first pose,1T has occasionally effected a cure by destroying the con- vanety. tractile action; and so have dilute solutions of brandy, camphor, appert^ns11 or su,Phate of zinc> b7 their tonic °r stimulant power. When to surgery, the disease does not yield to this mode of treatment, or consists of the complicated variety, it belongs manifestly to the art of surgery, and its removal must be sought for in books on that subject: among the best of which may be mentioned, Mr. Guthrie's Lectures on the Eye, lately published, and Profes- sor Beer's Essay on Staphyloma and Artificial Pupil, publish- ed in 1804,** and his Doctrine of the Diseases of the Eye, corectomia', Published in 1817-tt According to the nature of the coalition, corodialysis. Beer employs three varieties of operation, incision, excision, and separation, which he distinguishes by the names of co- rotomia, corectomia, and corodialysis. The first is the simplest, and that most usually had recourse to. In the second, an incision being made, with a cataract knife, close to the edge of the cor- nea, and not larger than the third part of its circumference, the iris, if it protrude, is laid hold of with the hook; or, if no pro- trusion take place, the hook, introduced through the incision, is made to lay hold of the pupillary edge of the iris, which drags it through the wound when a sufficient portion of it is removed with a pair of scissors. In the third method, which is that origi- Rlf.Si*,.. nal,y ProPosed by Dr- Reisinger, the operation is performed with Sod. a double hook or hook forceps.^ * Eph. Nat. Cur. Dec. m. Ann. vu. vm. Obs. 21. t Anat. Acad. Lib. vi. cap. 3. X Medicinische Bermerkungeu, p. 1. i Vide Marcel. Donat. Lib. vi. cap. n. p. 619. || Memoires, &c. II Annual Report of the Liverpool Institution for Diseases of the Eve R„ Alexander Hannay, M. D. 1822. y y ** Ansicht der Staphylomatoien Metamorphosen des Auees, und der Ki;,. stlichen Pupillenbildung. 5 ' Ku"" t+ Lehre von der Augenkrankheiten, &c. ut supra. W See also D. Weller's Treatise Ueberkunstliche Pupillen, und eine beson- dere Methode, diese fertigen ; published in Langenbeck's Neue BibliothplA h n. st. 4. See also Dr. Schlagintweit Ueber den geeenwarti^en 7„ , 7Z kunstlichen Pupillenbildung, &c. Munchen, 1810. 6enWartI*en Zusta"d <*er CL. IV.] NERVOUS FUNCTION. [ord. ii. 171 Species XI. Paropsis Amaurosis.—Drop Serene. Dimness or abolition of sight, resulting from an affection of the nerv- ous structure of the eye, whether seated in the retina, optic nerve, or brain ; and ichether directly the result of organic changes in those parts themselves, or indirectly the effect of their sympathy with disor- der of other organs. This is the gutta serena of the Arabic writers, whence the Gen. i. term " Drop Serene" of our own tongue ; terms we have already Spec. XL explained under paropsis catarracta. Milton is well known to The gutta allude to this affection in his beautiful address to light, as he does ArXans.,he also to the cataract by him called suffusion, as the Latins call it Confounded suffusio ; but it is singular that, in the course of this allusion, he by Milton seems doubtful as to which of the two diseases he ought to as- with cataract cribe his own blindness: or suffu8ion' Thee I revisit safe, And feel thy sovereign vital lamp ; but thou Revisit'st not these eyes, that roll in vain To find thy piercing ray, and find no dawn. So thick a drop serene has quench'd their orbs, Or dim suffusion veil'd.* The term amaurosis is derived from the Greek xfixv^et, " ob- Origin of the scurus, caliginosus, opacus." The most common cause is a para- *pecificterm. lysis of the retina, usually in conjunction with a paralysis and Ordinary dilatation of the iris. Occasionally, however, this is rigidly contracted. From the different degree in which the disease presents itself, and from its assuming, at times, an intermittent type, it has three principal varieties: x Perfecta. Attended with total blindness. Complete amaurosis. 0 Imperfecta. With vision impaired, but not Incomplete amaurosis. altogether destroyed. y Intermittens. With periodical cessations and Intermittent amaurosis. returns. Plenck makes a distinct disease of an unalterable pupil, with Mydriasis or without injury of the vision, under the name of mydriasis. ofPIenck. When accompanied with injured vision, it is evidently a variety of amaurosis ; and it is questionable whether an unalterable pupil is ever to be traced without defective vision. It is probably to the cases, attended with contraction of the Pin or pin- pupil, that Shakspeare chiefly alludes by the term pin or pin-eye, ey€< whati the pupil being sometimes contracted to nearly the diameter of a pin's head ; though the synizesis is equally entitled to the name. I have quoted one example already under V. Caligo, which he calls web-eye; another is contained in the following couplet: ----Wish all eyes Blind with the fin and web. [In the former editions of this work, the author made the state The terms of the pupil the ground of two of his varieties of amaurosis, atonic and When the pupil was dilated, the amaurosis was termed atonic ; ^™°^sc obiection- * Par. Lost. in. 21. able. 172 CL. IV.] NEUROTICA. [ord. II. Gew. I. Spec. XL Paropsis amaurosis. Functional and organic amaurosis. Symptom- atic. Recent and inveterate amaurosis. Ordinary symptoms of amau- rosis. Pupil irre- gular and not clear. Position of pupil altered. Affections of the iris. when contracted, spasmodic. Thus the iris was more attended to, than the real seat of the disease, and incidental changes were mistaken for essential ones, and considered to be absolutely de- pendent upon atony and spasm. These errors the editor is hap- py to have the opportunity of expunging ; and in their place he has substituted the two varieties of perfect and imperfect amauro- sis, as cases admitted by every modern writer on diseases ofthe eye, and the distinct consideration of which is highly useful in practice. The intermittent amaurosis, the third variety adopted by the author, remains, though the principal examples of it are comprised in the subjects of day-blindness and night-blindness. Other better founded and more practical distinctions, than those formerly given by our author, are the organic and the sympathetic or functional; the former depending upon a diseased state of the retina or optic nerve; the latter consisting of a suspension of the functions of the nervous structure of the organ of vision, in conse- quence ofthe influence ofthe disease or disorder of some other part of the body on the eye. This last case is also sometimes denominated symptomatic amaurosis, being the mere effect of another disease, which is the primary one. In this point of view, the loss of vision, or paralysis of the retina, from various organic changes affecting the whole eyeball, as hydrophthalmia, fungus haematodes, &c, may be considered as a symptomatic amaurosis. Besides the important division of this disease into the perfect and imperfect, organic and functional varieties, some others, not noticed by our author, cannot be overlooked by the practitioner, because they make very considerable differences in the prognosis. The farther distinctions, here alluded to, are those of recent and inveterate, and of complicated amaurosis. Amaurosis is generally characterized by a very dilated state ofthe pupil, which is frequently not affected by any degree of light that is made to fall upon the retina. Sometimes the pupil is extraordinarily contracted. Hence, as already stated, the va- rieties formerly selected by the author of this work were badly chosen; because they were founded, not upon any intelligible differences in the condition of the retina, but upon incidental states ofthe iris. His second or spasmodic variety, indeed, as far as the definition went, might have signified rather synizesis, or impediment to vision from great and permanent contraction ofthe pupil. In amaurosis the pupil seldom retains its circular form, but becomes more or less irregular or angular. Neither does it commonly exhibit the clear appearance of a sound eye but a grayish, or dark green hue, resembling what is observa- ble in the eye of a horse. In certain examples, a whitish or greenish-yellow spot is perceptible apparently in the fundus of the eye, and a little to one side ofthe visual axis, with a splen- did disk, like the tapetum of sheep, or the coloured choroid of fishes. Another change in the pupil, noticed by Beer and all the most correct writers on amaurosis, is an alteration in its po- sition ; it is mostly drawn towards the internal and superior por- tion ofthe eye. The iris is in general very sluggish, or abso- lutely motionless; but in a few cases it preserves its usual pow- cl. iv.] NERVOUS FUNCTION. [ord. ii. er of motion,* and sometimes acts with greater rapidity than in Gen. I. a healthy eye. Amaurosis is ordinarily preceded by certain de- Spec' XL fects in the sight, and illusive appearances before the eye. One Paropsis ofthe most important is what is termed by writers the visus in- aniaurosis- terruptus. Thus, in reading, it seems to the patient as if sylla- Defects of bles, words, or whole lines were deficient; and he is obliged to vision in move the eye, or head, ere he can discern what seems wanting. the ear,7 If he look upon any other object, he will seldom see the whole Slase' of it, unless he make a similar motion of his eye or head. On other occasions, he will see the whole ofthe object, when it is held in a particular direction, but he loses it again as soon as this is altered. A common precursor of amaurosis is an appearance as if motes or small bodies were incessantly moving about in front of the eye. This is the visus muscarum, or muscce volitantes of sur- Muscas gical writers. When it is a dark-coloured speck, that the pa- v°litant<». tient fancies to interrupt his sight, it receives the technical name &°" of scotoma; for appearances of this kind maybe either single or very numerous, and of diversified shapes. They are most troublesome when the patient looks at very bright or light-col- oured surfaces. In incipient amaurosis every object frequently other appears to the patient as if it were surrounded by a zone of va- illusive negated colours; but sometimes things have a different look, aPPea™nces seeming as if they were enveloped in a mist, gauze, or net- tollieeye- work. In many cases, single objects appear to be double : this defect of vision is termed visus duplicatus, and proceeds from impairment of the faculty, by which the axis of vision in each eye is made to adapt itself to the object looked at. Amaurosis may present itself as an uncombined local affec- tion of the optic nerve or retina, or as conjoined with some oth- er disease ofthe organ or general system. Amongst the local Complica- complications are to be noticed cataract, fungus hasmatodes of tions. the eye, glaucosis, cirsophthalmia, hydrophthalmia, exophthal- mos, atrophy, paralysis of one or more muscles of the eyeball or lids, ophthalmitis, &c. The genera! complications especially meriting enumeration are, diseases of the nervous system, the debility from typhoid and other fevers, hydrocephalus, organic and functional diseases of the abdominal viscera, worms, preg- nancy, and diseases ofthe brain and cranium. Amaurosis is not restricted to any particular age or sex. Per- Disease not haps, on the whole, persons of middle age are most liable to it. restricted to Children are less liable to the disease than adults, but congeni- a6e or 8ex- tal cases are upon record. In Germany, an opinion prevails, Dark eyes that dark-coloured eyes are more frequently attacked by amau- m iv.] NEUROTICA. [ord. II. Gen. T. Spec. XL Paropsis amaurosis. the effect of slow inflam- mation of the retina. Debilitating causes. Sympathy of the eyes with the stomach. Worms. The disease in this country less frequently dependent on gastric disorder, than in Italy and Germany. Influence of hereditary disposition. Deficiency ofpig- mentum nigrum. tures on the diseases ofthe eye deserve to be republished with notes and illustrations from all the best writers on the subject, considers organic amaurosis as not essentially different from a very slow insidious inflammation ofthe retina, and not a disease of debility, as represented by numerous writers. His opinion on the pathology of amaurr Jis of course has great influence on the practice which he particularly inculcates; and which, in the early stage, is generally antiphlogistic ; in the second, mer- curial. The doctrine most usually adopted, however, refers a certain class of cases to debilitating causes ; as typhoid fevers, profuse discharges or evacuations, excessive venery, the suckling of in- fants, &c. That particular articles of food or medicine will produce amaurosis sympathetically is amply proved. It is true, that, in some of the examples of this fact, we ' are obliged to suppose the existence of an idiosyncrasy; as when a person is affected with blindness whenever he takes chocolate or bitters, which have not the slightest effect upon the sight of other persons. The sympathy ofthe eyes with the stomach and intestines is often illustrated in cases of worms, which, according to the ad- mission of every writer, are a not unfrequent occasion of amau- rosis. A child has been known to become amaurotic from ac- cidentally swallowing a bead, and to regain sight on the foreign body being voided by means of an emetic. In Germany and Italy, indeed, the opinion that amaurosis is very frequently prevalent on gastric disorder has been entertained to a great and perhaps an unwarrantable extent; we say unwarrantable, because, in this country, experience does not furnish evidence ofthe efficacy of the treatment which the doctrine naturally points out, and which, in the hands of Schmiicker, Richter, and Scarpa, has proved remarkably successful. Beer himself had little faith in the opinion, except in relation to the amaurosis from worms; and, in this metropolis, Mr. Lawrence's trial of the emetic practice has not given him an impression in its fa- vour. The great influence of hereditary disposition in producing amaurosis has been remarked by all the most correct observers. Beer in particular adverts to the frequent examples of this fact, and mentions a certain family, in which all the females who had not had children became amaurotic about the period ofthe ces- sation ofthe menses; and, what is very remarkable, it is stated, that this had been the case through three generations. One form of imperfect amaurosis, named amblyopia senilis, is ascribed by Beer to deficiency ofthe pigmentum nigrum. This case is commonly attended with a tremulous or vibratory mo- tion ofthe globe, the admission of light produces great uneasi- ness, and vision is seriously weakened. It is usually met with only in old persons; but sometimes occurs in others after fe- vers, and in the last stage of consumption.* Although it is de- * Vetch on Diseases of the Eye, p. 1 tt. CL. IV.] NERVOUS FUNCTION. [ord. ii. 175 clared to be incurable, the power of vision may be very usefully Gen. I. assisted with cylindrical shades, goggles, and other contrivances Spec. XL calculated to absorb light. Paropsis An amaurosis, rarely cured, is that arising from blows on the pm eyebrow, or injury of the frontal nerve. All cases, likewise, depending upon organic changes in the eye itself, optic nerve, brain, or orbit, do not admit of relief. The prognosis in every instance of complete amaurosis is unfavourable. The function- al and sympathetic forms of the complaint are generally more easy of cure than the organic ; but whether they can be reliev- ed or not will depend upon the circumstance, whether the ori- ginal complaint in another part of the body, with which they are connected, can itself be removed or not. The length of time that the loss of sight has prevailed, will also materially in- fluence the prognosis. Generally speaking, amaurosis that has been formed recently and suddenly, but without violence or im- moderate previous inflammation of the eye, is more easily cur- ed than that which has come on with greater slowness. The disease is absolutely incurable when accompanied by any change in the shape and dimensions of the eyeball. When amaurosis affects only one eye, unless it be from sympathy with a neigh- bouring part,* as a carious tooth, the other eye is in great dan- ger of being also attacked. The occasional mobility of the iris in this disease, and a moderate dilatation of the pupil, are no proof that the amaurosis will be more easily cured ; for the iris often regains its mobility without the least improvement in vi- sion, and sometimes the eyesight may improve, though the iris continue sluggish or even motionless. The treatment of amaurosis must of course be regulated by the view taken of the causes of the disease. Thus, notwith- Emetics. standing the fact, that emetics have not proved as successful in this couniry as they have abroad, they should be prescribed when bilious disorder ofthe gastric organs is evidently present, and unaccompanied with much determination of blood to the head. Richter has recorded the case of a priest, who became suddenly blind in a fit of passion, but recovered his sight imme- diately after taking an emetic. Schmucker cured many cases by a combination ofthe emetic and antiphlogistic practice, and the evidence of Scarpa is strongly in favour of the same meth- od. In general, it is to be taken into the account, that emetics and bleeding have been assisted with the simultaneous exhibi- tion of purgatives, so that it would be assuming too much in nu- merous examples to refer the success ofthe practice altogether to the emetics. Purgatives are, on the whole, in far greater Purgatives. repute for their good effects on amaurotic disorders, than the free employment of tartarized antimony. They are particular- ly indicated when there is much disorder of the primse vias, when the disease is attended with habitual costiveness, and any manifestly increased determination of blood to the brain and * See Wardrop's Essays on the Morbid Anatomy of the Eye ; and Frick on Diseases ofthe Eye, by Welbank, p. 150, 2d edit. CL. IV.] NEUROTICA. [ord. II. Gen. I. Spec. XI. Paropsis amaurosis. Antiphlo- gistic practice. Mercury. To be modified according to circum- stances. Aperients, cupping, and leeches. Mercurial altera- tives. Blisters. Tonics. Mercury for cases attended with inter- mitting pain. eyes. This state may be presumed to exist whenever amauro- sis is connected with the suppression of any accustomed dis- charge, as ofthe menses, bleeding from piles, secretion of mat- ter from an old ulcer, &c. The origin of the greater number of cases of amaurosis, that is to say, of those which directly affect the retina or optic nerve, is ascribed by Mr. Lawrence to vascular excitement, to congestion, or even a slow inflammation of the nervous structure constituting the seat of vision. His practice, therefore, in such instances, is at first decidedly anti- phlogistic, comprehending local and general bleeding,purgatives, low diet, &c, afterwards followed up by the free use of mercu- ry, aided with blisters or a seton. This mode of treatment, however, he recommends to be graduated according to the violence ofthe attack, the constitu- tion, age, and strength ofthe individual, and other circumstances. It must not be supposed, he observes, that all amaurotic patients require to be bled and salivated. When we meet with the af- fection in the form of active inflammation of the retina, more especially in young and vigorous individuals of full habit, where there are obvious marks of local vascular congestion and con- stitutional excitement, the antiphlogistic treatment cannot be too active, or too quickly followed up. According to Mr. Lawrence, amaurosis often comes on in a slow and very insidious manner in persons of enfeebled constitution: the organ suffers from ha- bitual excessive exertion, at the same time that the constitution is depressed by residence in confined dwellings, bad air, by sedenta- ry occupations, unwholesome diet, costiveness, and other hurtful influences. In the treatment of a thin, pallid, feeble woman, who had destroyed her health by close confinement to needle- work, less active measures would be required. Emptying the ali- mentary canal, perhaps, taking away a little blood by cupping, or by leeches to the temples, and then using mercury in the alterative manner, with mild aperients, would here be the best plan. Mr. Lawrence recommends a few grains of Plummer's pill to be giv- en every night, or every second night, and the bowels to be kept open with occasional doses of electuary, castor oil, or rhubarb and magnesia. The blue pill, he says, may be taken in combi- nation with aloes, or the compound extract of colocynth. It may be necessary to persevere with the mercury, slowly increasing the dose, until the mouth is slightly affected. A nutritious diet without stimuli, good air and exercise, and repose of the organ, Mr. Lawrence deems important auxiliaries. With these means may be joined a succession of moderate-sized blisters. After mild antiphlogistic means, and the alimentary canal has been cleared, it may be expedient to combine tonics with aperients, as rhu- barb with bark, columba, or cascarilla, and allow a generous diet, with a little porter and wine. Dr. Frick has seen much benefit from mercury or calomel in those cases of incipient amaurosis, which come on with deep seated pain in the head and orbit, more particularly when such pain is found to in- termit.* * On Dise.-ises of the Eye, 2J edit, by Welbank, p. 153. cl. iv.] NERVOUS FUNCTION. [ord. ii. Although modern practitioners place little reliance on the Gen. I. real utility of various local stimulating applications in the treat- Spec. XL ment of amaurosis, and not much more on electricity, galvanism, ParoP»" and several internal medicines, once supposed to have a specific amaurosis' effect in removing blindness, the editor has considered it right Sion". pot to suppress the following remarks delivered by the author, as they bring before us many plans which have occasionally been strongly commended.] Sternutatories demand attention : they are best formed of tur- sternuta beth mineral, with about ten times its proportion of mild snuff, tories. or any other light powder. The vapour of ammonia, ether, or camphor, mixed with hot water, has sometimes also afforded benefit; as has probably the use of moxa frequently repeated, Moxa. so warmly recommended by Baron Larrey. " By this remedy," says he, " not only has the progress of amaurosis been arrested, but in some cases removed, even where the blindness was com- plete."* Professor Beerf is minute in describing the modifications that Rheumatic proceed from plethora, and a morbid state of the digestive or- amaurosis gans; but gives a still more copious detail of that which de- ofBeer- pends upon local rheumatism, and which he hence calls the rheumatic amaurosis. In this he remarks, that the pupil is per- fectly clear, and the iris unalterable, slightly dilated, and thrust a little nearer the nose and the eyebrow than naturally, so as to be in a small degree displaced inwards and upwards. The tears flow on slight occasions, and the light is often troublesome, ac- companied with an aching pain in the eyeball. The movement ofthe eye is impeded, and. more in one direction than in others. This modification rarely proceeds to perfect blindness. The rheumatic form is frequently treated with success, and Diapho- principally by diaphoretics. Beer employs guaiacum and cam- relics- phor combined during the day, and Dover's powder at night; Dover's and with these he has recourse also to blisters, placed in sue- powderwith cession behind the ear, on the temple, and ov^r the eyebrow, blisters- so as to maintain a catenation of counter-irritative actions. Both Stimulants this and the plethoric modification, in which local bleeding is of i,lJ"rioi,s io the utmost benefit, are frequently hurried on to a complete de- dlfitaUonsT velopment of disease, and a total insensibility of the retina by Stimulant stimulants, and particularly by galvanism and electricity. vapours. Where it has followed repelled eruptions, it has also been Setons, occasionally found to yield to setons and blisters, or a rcstora- when useful. tion of the suppressed efflorescence; and, as in other diseases, Theocca- what has sometimes proved the source of its production has sional cause been found its best remedy ; so that the cause has become the in80me cure. Thus it has at times yielded to the violence of a fever, occasional to that of a sudden blow on the head, to a strong light, to a pa- cure in roxysm of convulsions. Electricity, and especially voltaism, 2,,!,e^8•. . has probably been serviceable in some instances; at least, the eclnc,t^ assertions to this effect are very numerous, though in various * Recueil de Memoires de Chirurgie, &c. I'aris, 8vo. 1821. t Lelue von den Augenkrankheit. «fec. vol. iv. 23 178 cl. iv.] NEUROTICA. [ord. n. Gen. I. Spec. XL Paropsis amaurosis. Magnetism, Internal tonics and stimulants. Pulsatilla entitled to farther trial. Euphrasia little enti- tled to the name. Rue. Narcotics. Union of antimonials and blisters. Instance of temporary scintillation from emetics: cases both these have sometimes been altogether unsuccessful, and, as just observed, sometimes highly mischievous. Nor is the magnet without its recommendations, having been applied to the upper part of the spine, while minute bags filled with iron filings were placed on the eyes;* and, in an imperfect case ofthe complaint, Weher conceives he derived benefit from the plan. The chief dependences besides these have been on cam- phor, cajeput, musk, mercury, iron, bark, arnica, and externally the Pulsatilla nigra. Of the arnica or German leopard's bane, Pellier, as well as Collier, speaks warmly. The latter recom- mends it in all nervous atonies, whether general or local. He employed the flowers ofthe plant in decoctionf in the propor- tion of about half an ounce to a pint of the strained liquid, which may be taken in a day or a day and a half. Richter, Schmiick- er, and other German writers declare it to be of no avail. The Pulsatilla is certainly better en-titled to attention. " I would recommend it," says Dr. Cullen, with his usual liberality," to the attention of my countrymen, and particularly to a repetition of trials in that disease so frequently otherwise incurable, the amaurosis. The negative experiments of Bergius and others are not sufficient to discourage all trials, considering that the disease may depend upon different causes, somejof which may yield to remedies though others do not."| Wheft distilled with water it gives forth a terebinthinate substance resembling cam- phor, which necessarily possesses a stimulant, and hence a me- dicinal power. Whence the euphrasia officinalis, or eye-bright, obtained the character it once possessed as a specific in this dis- ease, it is difficult to say. By Hildanus and Lieutaud, however, it was chiefly confined, even in its zenith of popularity, to the amaurosis of old age. Its chief sensible quality is that of being a mild astringent. Rue, which rivalled it at one time, and by Mil- ton is put upon a level with it, has far better pretensions when used externally in the form of a potent infusion; for it unites the properties of volatile pungency and bitterness : both which, as concentratea" in strong chamomile tea, I have occasionally found highly serviceable in an incipient state of this disease pro- duced by weakness ; though, as already remarked, none of these should be employed in several forms ofthe disease. With respect to narcotics, the aconite has been chiefly popu- lar in Germany : it has been strongly recommended by many writers of reputation, and has sometimes been given by gradual augmentation to the amount of a drachm daily.§ Chevillard combined the use of antimonials with blisters; but cold applied externally, and cold bathing as recommended by Warner, is much entitled to our attention. Dr. Powell relates a case of sudden loss of vision, preceded by an acute cephalaea, in which an emetic was found during * YViirkung des Kunstlichen Magnets, &c. p. 24, 25. Hell. v. Nootnaeel I.e.* 22. Eph. Nat. Cur. Dec. ii. Ann. v. Obs. 247. t Prodigious En- largement and Dropsy of the Eye. Dr. Layard. Phil. Trans. 1757-8 vol 1 p 747 X Mat. Med. vol. ii. Part. ii. Chap. v. p. 216. * Beobachtungen und Untersuchungen, &c. band ii. Nuremb. 1767. a cl. iv.] NERVOUS FUNCTION. [ord. ii. 179 the act of vomiting, abruptly to restore sight to the right eye Gen.i. (for both were affected) with a sensation as if a flash of light- Spec XL ning had taken place, but the vision was soon again lost. More Paropsis than a twelvemonth afterwards, the patient returned to emet- amaurosis- ics; when, after the use of the second, the pupils of the eyes and?f recovered the power of dilating and contracting on exposure ^veryof" to light, and preserved it till death, but the power of vision the motory was not restored. During the whole of this case of blindness, power of the the sense of hearing was peculiarly acute.* The discovery of !"s* . Dr. Bock, that a few nervous filaments, appertaining to the sometimes great sympathetic nerve, are thrown off while this nerve is acute. within the cavernous sinus, and entering the orbit unite with Explained. the lenticular ganglion, may account for these remote influen- ces ; the ear, as is frequently the case, sympathizing with the morbid state of the eye either directly or reversely.! Species XII. Paropsis Strabismus.—Squinting. Optic axes of the eyes not coinciding on an object. This disease, in colloquial language now called squinting, was Formerly formerly denominated goggle-eye, whence the word goggles is nam^d still applied to the glasses which are used by persons affected ^[fi„c'ethe with the complaint. The French call these glasses masques a term gog- louchette, literally squinting-guards. The technical term stra-|,les'^tlie bismus is derived from the Greek &c. von. D. A. Carl Bock. Leipsic, 1317. on their 180 CL. IV.] NEUROTICA. [ORD. II. Gen. I. Spec. XII. Paropsis strabismus. obtaining sight. A like want of habit where one eye is naturally stronger than the other, and hence chief- ly or alone trusted to : This inac- cordance of direction constitutes squinting. muscles being never subjected to discipline, the eyeballs roll at random, and wander in every direction. In consequence of which, one of the most difficult tasks to be acquired by such persons, after obtaining sight, is that of keeping their eyes fixed, and giving the same bearing or convergent line to each. And hence, again, they see things double at first, and in a state of great confusion. When one eye is naturally stronger, or of a more favourable focus, or more frequently employed than the other, as among watchmakers and jewellers, the latter, from comparative ne- glect, relapses into an undisciplined state, and less readily obeys the control of the will. Its muscles do not assume the same direction as those of the eye employed ; and if they do, in the two former cases, the object still appears double ; and hence the neglected or weaker eye wanders and stares at one or at various objects, while the eye relied upon is fixed upon some other. And it is this divergence of the optic axes, this inaccordance of direction, or looking at different objects at the same time, that constitutes the present disease.* It is obvious, therefore, that strabismus may have three va- rieties : x Habitualis. Habitual squinting. 0 Atonicus. Atonic squinting. y Organicus. Organic squinting. From a" vitiated habit; or the custom of using one eye and neglecting the other. From debility of the affected eye, whence the sound eye possesses a different focus and power of vision ; and is alone trusted to: in consequence of which the weak or neglected eye insensibly wanders as al- ready stated. From the eye being differently constructed in form or posi- tion.! * When the axes of the eyes of persons who do not squint, and sometimes also of amau- rotic individuals, are directed in different lhies, objects are seen double : squinting per- sons, however, do not see objects double. Yet the principal reason assigned for the sin- gular phenomenon, that the images impressed upon the two eyes excite only one image in the mind, is, that the two images fall upon corresponding points of the retina. The probability therefore is, that, in a squiiuing person, both eyes do not see the object looked at. In many cases, as Sir Everard Home has remarked, "this is pretty evident to a by- stander, who is able to determine, that the direction of one of the eyes differs so much from that of the other, that it is impossible for the rays of light from any object to fall on the retina of both, and therefore, that one. eye dors not see the object. The same thing may be proved in another way. For since a small deviation in the direction of either eye from the axis of vision produces double vision, any greater deviation must have the same effect, only increasing the distance between the two images, till it becomes so great that one eye only is directed to the object. In squinting there is evidently a I™aparHn,,[wtIOn-f'0nlthe,axe8 °f Visl0n than in d0llble vision, and the object does not —Editor u ls therefore not seen by both eyes."— Phil. Trans, vol. Ixxxvii. 1797. mus?rim^!l.1!fthy^theSiu here af,0pte<1 in «xPlanatio» of the manner in which strabis- mus is produced, others have been suggested. M. de la Hire conceived that the defect ci. iv.] NERVOUS FUNCTION. [ord. ii. 181 The first of these varieties constitutes the nystagmus of Dr. Gen. I. Plenck, and its cause is sufficiently obvious. In the second, the Spec. XII. sound eye is alone trusted to, because it is the only eye on * p- Str* which any dependence can be placed; and hence the weak j,abitualis. eye, neglected by the will, wanders insensibly, as in the pre- The nystag- ceding order we have seen, that any one of the mental facul- D™9 °£ ties will wander in like manner under the same want of disci- pline. [It has been ascertained by experiment, that, in indi- £ p- Stra" viduals who have a confirmed squint of this kind, one of the at0I1icus. eyes is too imperfect to see distinctly. Of this, however, the patient is not always conscious, as was evinced in a young lady, whose case is related by Sir Everard Home. Neither she her- self, nor her friends, believed that any defect of the eye exist- ed ; and upon being asked if she saw objects distinctly with her eyes, she said, certainly, but that one was, stronger than the other. To ascertain the truth of this, he covered the strong eye, and gave her a book to read, when, to her astonishment, she found she could not distinguish a letter, or any other near object. More distant objects she could see, but not distinctly : when she looked at a bunch of keys in the door of a bookcase about twelve feet from her, she could see the bunch of keys, but could not tell how many there were. The obscurity of vision in one eye, then, is the cause of this common«species of squinting, and may occasion this irregularity in the following way. The obscure image being so imperfectly formed in the weak eye as to excite little attention in the mind, the use of the eye, and its uniform direction to the same object with the other, may have been neglected from the beginning ; for, as dis- tinct vision was obtained at once by the perfect eye, the end was answered, and therefore fjiere was no necessity for any ex- ertion of the other; or, in the effort to get rid of the confused image, the muscles may have acquired an irregular and unna- tural action. Under either of these circumstances, the eye is directed towards the nose, because, as Sir Everard Home re- marks, this direction is determined by the superior force ofthe adductor muscle.] In the third variety, the difference of form y p. stra or position respects the situation or figure of the one eye com- bismus pared with the other, or of the particular parts of the one eye organ'cus- compared with those of the other: in consequence of which the one is favoured, and the other thrown into disuse. [Dr. Porterfield has pointed out two cases referable to this variety, or rather constituting two distinct varieties themselves. One might ariseflfcpm the more sensible part of the retina not being placed in the axis of the eye, but at\4mie distance from it, on one side or the other ; and that, consequently, not the axis, but this more sensible part of the retina, is turned towards the object on which the axis of the other eye is fixed, so that both axes are not directed to the same point. A case of this description would, of course, be absolutely incurable. Dr. Darwin's ob- servations rather tend to show the possibility of such a form of strabismus; but both this hypothesis, and that of obliquity of the crystalline lens, are mostly considered to have been refuted by Dr. Jurin. Buffon refers the cause of squinting to an inequality in the goodness or in the limits of distinct vision in the two eyes ; a doctrine, the truth of which is at present generally admitted. The exclusive adoption of any one hypothesis will ob- viously not explain all the varieties of suabismus.—Ed. 182 cl. iv.} NEUROTICA. [ord. ii. Gen. I. Spec. XII y P. Stra- bismus organ icus. Mode of treatment. Goggles seldom serviceable. A more effective plan pro- posed. depends upon an oblique position &f the crystalline lens within the eye, by which the image of an external object is refracted out of the line ofthe axis of the eye ; and the other from an oblique position and greater protuberancy of the cornea, pro- ducing a similar effect.*] In this last variety a complete cure is hardly to be expected. In the second it is attended with considerable difficulty; and in the first is rather to be accomplished by what, in mania, we have called moral treatment, than by medicine. A constant and resolute exertion on the part ofthe patient to obtain a command over the weak or irregular eye is of absolute necessity, while the neglected eye itself, if weak, should be strengthened by tonics and gentle stimulants. Goggles, though often recom- mended, are seldom serviceable, and especially to children; for although the sight must hereby be restrained in each eye to a common line, the child will still use the sound eye alone, and leave the irregular eye unemployed. It is a better plan to affix some object near the orbit of the affected eye at such a distance, that it may constantly catch and draw off the pupil from the inner angle to the outer. [If squinting has not been confirmed by long habit,'and one eye be not much worse than the other, Dr. Darwin recommends a piece of gauze, stretched on a circte of whalebone, to cover the best eye some hours every day, so as to reduce distinctness of vision in this eye to a similar degree of imperfection to what exists in the other eye.] But the method that I have myself found by far the most ef- fectual, is to blindfold the sound eye with a blink for a consid- erable part of every day, and thus force the affected eye into use, and a subserviency to the will. I recommend this simple plan most strongly, and especially in the case of children ; and may venture to predict, that it will be sure to succeed in the first variety ofthe disease, that of habit, and frequently in both the others. [The same plan, which was first suggested by Dr. Jurin,t is recommended by Mr. Lawrence in his lectures, who mentions, however, that the squinting eye has sometimes been cured by it, but the opposite one has then become affected. With one or two remarks offered by this eminent practitioner, we shall close this part of the subject. As strabismus, says he, occurs from so many causes, of course, the treatment cannot be uniform. A close investigation, with the view to discover the cause, is a necessary preliminary to any other measures. When this is accomplished, the course of treatment will be obvious ; or we shall see, perhaps, that the defect cannot be Remedied. In the temporary forms of strabismus, arising frdm, momen- tary irritation in the sensorium or alimentary canal, the treat- ment will of course turn upon the removal of the cause ; and when strabismus and double vision occur in the commencement of amaurotic affection, we must endeavour by suitable measures to remove that affection. The squinting, produced from change in the pupil and cornea, will hardly admit of relief. * Edin. Essays, vol. iii. art. xn. + See Smith's Optics, Rem. p. 30. CL. IV.] NERVOUS FUNCTION. [ORD. II. 183 Dr. Darwin mentions a singular case of squinting, in which Gen. I. the patient was equally expert in the use of either eye, but Spec. XII. viewed every object presented to him with only one-eye at a > P. Stra- time, and always with the eye on the side opposite the object, orga'okus. Thus, if the object was presented on his right side, he viewed it with his left eye; and when it was presented on his left side, he viewed it with his right eye. At the same time, Dr. Dar- Singular win found, that he turned the pupil of that eye which was on u"^^^ the same side with the object in such a direction, that the image of the object might fall on that part of the bottom of the eye where the optic nerve enters it, and where it would of course excite no impression ; and this insensible portion of the retina Dr. Darwin ascertained, by some ingenious experiments, to be four times greater in this patient than in • ordinary persons. When an object was held directly before the patient, he turned his head a little to one side, and observed it with but one eye, viz. with that most distant from the object, turning away the other in the manner just mentioned ; and when he became tired of examining'it with that eye, he turned his head the contrary way, and observed it with the other eye alone with equal fa- cility ; but never turned the axes of both eyes on it at the same time. For remedying this curious example, in which there was no defect in either eye, but merely a depraved habit of using both eyes separately, Dr. Darwin says, " a gnomon of thin brass was made to stand over his nose, with a half circle of the same metal to go round his temples : these were covered with black silk ; and by means of a buckle behind his head, and a cross- piece over the crown of his head, this gnomon was managed so as to be worn without any inconvenience, and projected before his nose about tivo inches and a half. By the use of this gno- mon, he soon found it less inconvenient to view all objects with the eye next to them instead ofthe eye opposite to them. " After this habit was weakened by a week's use of the gno- mon, two bits of wood, about the size of a goose-quill, were blackened, all but a quarter of an inch at their summits. These were presented for him to look at, one being held on one side of the extremity of this black gnomon, and the other on the other side of it. As he viewed these, they were gradu- ally brought forwards beyond the gnomon, and then one was concealed behind the other. By these means, in another week, he could bend both his eyes on the same object for half a mi- nute together. " By the practice of this exercise before a glass almost every hour in the day, he became in another week*able to read for a minute together with his eyes both directed on the same ob- jects ; and I have no doubt, if he has patience enough to perse- vere in these efforts, he will in the course of some months overcome this unsightly habit."*] * Phil. Trans, vol. lxviii. p. 86—89. 184 CL. IV.] NEUROTICA. [ord. II. GENUS II. PARACUSIS.—MORBID HEARING. Sense of hearing vitiated or lost. Gen. II. Paracusis is a term of Hippocrates derived from rx^xxow, Origin of " perperam, depravate, vitiose audio.1' The mechanism ofthe termg.ener'C ear }s as complicated as that of the eye, and as admirably adapt- Physiology. et'' *n a^ *ts Parts? to the perfection of the sense which consti- tutes its function. Its lobes, its entrances, its openings, its va- rious drums, its minute and multiplied foramina, its delicate Bones sur- bones, all contribute to one common effect. Even the surround- ^H'Ldo,",g a ™g bones, and, still more than this, the teeth, are in no small the ear, and ■_, ° ' ... ' . . . ' ' . . ,. even the degree auxiliary to the same object, as the experiments of M. teeth, auxi- Perolle, given in the fifth volume of the Turin Transactions, Iiaryto have abundantly established; as they have, also, that bone in general is a far better conductor of sound, than air, alcohol, or water. Hence one We may hence learn one very important use of the four mi- use ofthe nute bones deposited in the posterior chamber of the tympanum, cavity of the ^oss 0I" any one or" which impairs the hearing, and, in some thetympa- instances, has produced total deafness; of which we have a num. . striking proof in the case of a lad, described in the Philosophical Casein Transactions, who'had parted with the incus on one side, and both the incus and malleus on the other, by means of an ulcer- ated sore throat that opened a passage from the fauces into each ear, and through which the bones were discharged. The tympanum, on the boy's recovery, seems not to have lost its vi- bratory power, for he was sensible of violent or sudden sounds, but altogether insensible to conversation, and apparently as deaf in the ear that had only parted with the incus, as in that which had parted with both bones.* Diseases of From the complicated organism of the ear, it follows neces- tft6 eab sarity that, like the eye, it must be subject to a great' variety of an analogy,} diseases ; while many of the diseases of the one sense must to those of bear a striking analogy to those ofthe other. Thus painful and the eye. obtuse hearing and deafness may be well compared with painful Illustrated. anj 0Dtuse vision and blindness. As the eye is at times affected with illusory objects, so is the ear with illusory sounds ; and as, when the optic axes do not harmonize, as in strabismus, the same object may be seen double, so may the same sound be heard double when the action ofthe one ear is inaccordant with that of the other. Sympathy And hence it is»not at all to be wondered at that a peculiar SSrflbe deSree ,of sympathy should exist between thee senses, and the sight and state of the one be frequently affected by that of the other. hiring. Bartholine gives a case in which deafness and blindness alter- Alterualion * Vol. ii. No. 50, 1761. The editor has seen one case, in which a boy, who was reported to have lost all the ossicula of one ear, was not completely deaf from it; though, certainly, his hearing on that side was dull. Sir Astley Cooper is acquainted with another example of the same kind. According to Mr. Mayo, the stapes is so strictly applied to the membrana fenestra; ovalis, that the loss of this bone necessarily produces incurable deafness by injuring the labyrinth. Outlines of Human Physiology, 2nd edit. p. 415, 8vo. Loud. 1828. cl. iv.] NERVOUS FUNCTION. [ord. ii. 185 nated with each other,* and we shall presently have to observe, Gen. II. that a temporary affection of the eyes may sometimes be pro- Paracusis. duced by particular noises. of deafness As the organ of the ear, however, is less exposed than that and bl,nd" of the eye, we are far less acquainted with the immediate seat *' 4, „ c -i j- i wu iL * u • l- l From the ot its diseases, and even with the exact bearing which every depthofthe particular part sustains in the general phenomenon of hearing, organ of It was at one time supposed, that the nicest power of discri- ."%• e . '.r . ' , . r «... seat of do- minating sounds, or, in other words, that accuracy ot distin- ease often guishing, which constitutes what is called a musical ear, is less known seated in the cochlea ; birds, however, whose perception is ex- *rdersc>f1S" quisite, have no cochlea. It has since been conceived by Sir visiou. Everard Home, that it is the membrana tympani in which this Whether fine feeling is peculiarly lodged,t and that it depends upon the the cochlea muscularity of this membrane ; yet the same feeling has re- discrimina- mained, and in a high degree, in persons whose membrana tym- tivepartof pani has been ruptured.J [Mr. Bell does not conceive, that the the organ cochlea, or any part of the organ particularly, conduces to the membrana bestowing of a musical ear, although it is by hearing that we are tympaui? capable of the perceptions of melody and harmony, and of all the charms of music. It would seem, says he, that this depends upon the mind, and is not an operation confined to the organ. It is enjoyed in a very different degree by those, whose simple fa- culty of hearing is equally perfect.] Paracusis as a genus includes the following species: 1. PARACUSIS ACR1S. ACRID HEARING. 2.--------OBTUSA. HARDNESS OF HEARING. 3. ■--------PERVERSA. PERVERSE HEARING. 4. ------•- DUPLICATA. DOUBLE HEARING. 5. - ILLUSORIA. IMAGINARY SOUNDS. 6.--------SURDITAS. DEAFNESS. Species I. Paracusis Acris.—Acrid Hearing. Hearing painfully acute and intolerant of the lowest sounds. This occurs occasionally as an idiopathic affection in nervous Occurs idk> and highly irritable idiosyncrasies, and bears a striking analogy p»H>'cally to that acritude of sight which we have noticed under paropsis ^9yn." lucifuga. It is the hypercousis, or, as it should rather be, the crasies. hyperacusis of M. Itard, who also regards it as an idiopathic af- Hypercousis fection in various cases.§ of ltard" It depends upon a morbid excitement, sometimes of the whole of the auditory organs, but more generally of some particular part, as the tympanum, or the labyrinth, and especially the cochlea, or some of the internal canals. In many instances it seems confined to the branches of the nerve ; and Bonet gives * Epist. Cent. iv. No. 40. + Phil. Trans. Year 1800. X See Bell's Anatomy, vol. iii. p. 180, Lond. 1820; and Buchanan's Physi- ological Illustrations ofthe Organ of Hearing, p. 14, Lond. 1828. i Traite des Maladies de TOreille et de l'Audition, 2 tomes, 8vo. Paris, 1821. VOL. IV. 24 186 CL. IV.] NEUROTICA. [ord. II. Gen II. Spec I. Paracusis acris. Found as a symptom in various diseases. Sensation sometimes intolerably keen. Strikingly illustrated. Singular sympathy with the sense of sight. Remedial process. Causes. an instance of it from the very singular cause of a triple audi- tory nerve formed on either side,* in which case there is suffi- cient ground for its idiopathic origin. It is found more fre- quently, however, as a symptom of ear-ach, head-ach, epilepsy, otitis, cephalitis, and fevers of various kinds. The sensation is sometimes so keen as to render intolerable the whisperings of a mere current of air in a room, or the re- spiration of persons present, while noises before unperceived become highly distressing. I have at this moment before me a most impressive descrip- tion of this effect in a letter from a young lady of about twenty- eight years of age, of an irritable habit, great genius, and a highly cultivated mind, who, about a twelvemonth ago was at- tacked with a cephalitis which proved severe and alarming. The mental powers are rendered more acute, and the external senses, especially those of hearing and seeing, strangely sympa- thize with each other. " You think me," says she, in this let- ter, " unfit for study, but study I must, whether I am fit for it or not, otherwise my mind preys upon itself, and no power can prevent my thinking, which is almost as bad as reading. Last night I was kept awake for some hours by so powerful an ex- citement ofthe brain, that I really thought it would have taken away my senses. The pain is very acute, but 1 do not mind that so much as the distraction which accompanies it. It usual- ly comes on with a most painfully quick hearing. I feel as if the tympanum was stretched so tight as to make the least sound appear almost as loud as thunder; and a loud noise is just as if I received a blow quite to the centre ofthe brain. This really is not imagination but actual sensation. Moreover, a noise af- fects my eyes so much, that I am obliged to darken my room when at any time I am under the necessity of hearing any thing like a noise: a loud sound affects my eyes, and a strong light my ears. They seem to act reciprocally. My head is certainly not so bad, nor any thing like it, as it was at Clifton, but still the sudden attacks I have from over-exertion ofthe mental powers, or upon any other excitement, make me always fearful I shall lose my senses." Injections of warm water, or a few drops of almond oil drop- ped into the ear, will occasionally afford relief. But cold wa- ter, and cold applications about the ear, and even pounded ice where there is no tendency to a periodic rheumatism, by di- rectly inducing torpitude, will at times have a better effect; laudanum may also be introduced in the ear, and a blister be applied to its immediate vicinity. Species II. Paracusis Obtusa.—Hardness of Hearing. Hearing dull and confused; and demanding a clear and modulated articulation. This may proceed from organic defect; from local debility, deafness, In which case it is called nervous deafness ; or from some acci- what. * Sepulchr. Lib. i. Sect. xix. add. Obs. 7. CL. IV.] NERVOUS FUNCTION. [ord. ii. 187 dental obstruction in the external tube or passage, as that of Gen. IT. mucus, wax, sordes, or any other extrinsic body ; or, in the in- Skec ii. ternal or Eustachian tube, from mucus, inflammation, or ulcera- Paracusis tion and its consequences.* It is also found occasionally as a _ usf" . i . • r ■ • i • Found as a symptom or sequel in various fevers, in hemiplegia, apoplexy, gymptom in otitis, lues, and polypous caruncles or concretions in the passage various of the ear; and has followed on drinking cold water during diseases. great heat and perspiration of the body, of which several ex- produced amples are given in the Ephemerides of Natural Curiosities, by imper- Among the cases of organic defect, one of the least common is fr>ra,|n»" atresia, or imperforation: yet AlbucasisT gives us an instance ^ jDsectg. of this, as does BartholineJ and Henckel.§ And among the most singular obstructions of an accidental kind may be mentioned insects and the grub of insects or worms. Bartholine mentions a leech which was once found to have burrowed in the ear; and Walker a small stone, which had unaccountably become lodged there, and was discharged by a fit of sneezing || The cure must depend upon the nature of the cause. All Medical foreign bodies must be carefully removed or destroyed, and the t^eatment• cavity ofthe ear be washed by means of a syringe. Accumula- tions of wax may be softened by oil of almonds and alcohol, which will dissolve whatever resinous part it possesses : and a like inunction will be found the best means of destroying insects. Atonic or nervous deafness will often bid defiance to our utmost exertions, but it will sometimes yield to local stimulants and to- nics; of the former are alcohol, ether, camphorated spirits, es- sential oil of turpentine combined with olive oil, and the tinc- tures ofthe gum-resins, as myrrh, amber, kino, balsam of Tolu, and blisters about the ear; ofthe latter, cold water, and solu- tions of alum, sulphate of zinc, or other metallic salts. [When hardness of hearing depends upon a deficiency of ce- Casesat- rumen, Mr. Buchanan recommends warmth and stimulant appli- lo- cations, Two drops of the subjoined formula!! he advises to be quantity or * That hardness of hearing sometimes depends on deficiency of the ceruminous secre- tion within the meatus auditorius, is a fact of which most surgeons are perfectly aware. It is a cause, however, that does not appear to have received the author's notice. The ceruminous lining ofthe meatus auditorius is regarded by Mr. Buchanan as very essential to perfect hearing; and he has termed it the " ceruminous tubular circle." Without this provision, says he, "the undulations would affect or strike upon various parts ofthe mem- brana tympani irregularly, and produce confused vibratory action. And hence we find, in patients divested of this secretion, almost total inability to partake ofthe pleasure of a conversational party, where the news, politics, or other matters, are discussed by the ge- nerality ofthe company; more especially if an argument ensue, in which a part of the discussion is taken by each individual." Mr. Buchanan compares the effect ofthe " ceru- minous tubular circle," in absorbing what he calls the resilient pulsations of sound, to that ofthe pigmentum nigrum in the eye, which absorbs the superabundant rays of light, and prevents them from being reflected so as to injure the retina, or render vision indistinct.— See Buchanan's Physiological Illustrations of the Organ of Hearing, p. 21. 8vo. Lond. 1828. t Vide Marcell. Donat. Lib. vi. Cap. ii. p. 619. X Hist. Anat. Cent. vi. n. 36. The editor of this work has seen a child which was born entirely destitute of both auricles, and with the places of the meatus auditorii covered by the common integuments. In this case, the hearing was dull, but not annihilated. } N. Anmerk. u. || Observ. Medico-Chirurg. xx. 8vo. 1718. T R Acid. Pyrolign. Sp. jElher. Sulph. 01. Terebinth, a a M. 188 CL. IV.] NEUROTICA. [ord. 11. Gen. ii. applied to the interior parts of the tube every night at bed- Spec. ii. {ime<> and a table-spoonful of the mixture, the composition of Paracusis which is given below,* to be taken at the same time. If the o tusa. patient be costive, the pillulas rhei comp. are also to be pre- of the scribed. When the wax is deficient in quality, or deficient both cerumen. in quantify and quality, Mr. Buchanan, with the view of improv- ing the state of the digestive organs, gives two table-spoonfuls of an infusion of quassia, with rhubarb and magnesia. The pa- tient should reside in a dry airy place; take regular exercise ; use the warm bath at bed-time once or twice a week; and im- mediately after getting into bed take pulv. ipecac, comp. Bj. and hydrarg. submur. gr. ij. Mr. Buchanan also directs the un- derwritten injection! to be used every second or third day. He speaks also favourably of bathing the feet in warm water, and a light nourishing diet, with a glass of port wine after dinner. Sometimes he applies blisters behind the auricle, or uses them and an antimonial embrocation^ alternately.§] Hearing Where hardness of hearing is habitual and cannot be radically trumpet. cured, we can only endeavour to diminish the evil by advising Principle of the use of a hearing trumpet, which is, in fact, an instrument its action. forme(] Up0n the principle of imitating the cavities ofthe laby- rinth of the ear itself, and the object of which is to collect a large body of sonorous tremors, and send them to the tympanum in a concentrated state, by means of a convergent tube, or, in other words, to increase as much as possible the vibratory pow- er of the sound. Now sound is well known to be propagated in straight lines, and hence persons partially deaf will always hear most distinctly when directly opposite the speaker. For the same reason the trumpet itself should be formed as nearly as possible in a straight line; though we are sometimes, for the sake of convenience, obliged to deviate from this direction, and to bend the tube into the segment of a circle, by which some How formed degree of power is always lost. The metal of which the tube mostadvan. is made should be that which is found most sonorous, or, in ageousy. <,ther wonjs? which most completely reflects, instead of absorb- ing, the sound; and while the funnel or larger aperture is as wide as possible, the extreme end of the pipe cannot be too small. M. Itard has found that a parabolical figure has no ad- vantage over a conical or pyramidal tube ; but that the tube is assisted in producing distinctness of sounds by an insertion into it of slips of gold-beater's leaf, at proper distances, in the man- ner of partitions.|| * R Tinct. Colchici 3 lij. Aq. distillat. g vj. t R Acid. Pyrolign. 3 ij. Aq. distillat. 3 vj. M. ft. injectio. X R 01. Sabina;, 3 ss. Antim. Tart. gj. Ung. Cetacei giij.Misce. 8vo.* L0ndTi825Chanan,SlllUStratl0nS0f Ac0UStic Su,Sery» P- 60, et seq. || Trait6 de Maladies de POreillc et de 1'Audition, 2 tomes, Paris, 1821. cl. iv.] NERVOUS FUNCTION. [ord. ii. 189 Species III. Paracusis Perversa.—Perverse Hearing. The ear only sensible to articulate sounds when excited by other and louder sounds intermixed with them. This is a very extraordinary hebetude of the organ, though Gen.II. it has occasionally been met with in most countries. Where it Spec. III. exists, the ear, as in other cases of imperfect hearing, requires Paracusis to be roused, in order to discriminate the articulate sounds ad- ^rve"a' dressed to it, but finds the best excitement to consist in a great yBI00SJ,• and vehement noise of almost any kind.* It consists, according cauieand to Sauvages, who seems to judge rightly concerning it, in a tor- seat ofthe pitude or paresis of some parts ofthe external organ which, in d',eaie- consequence of this additional stimulus, convey the proper sounds addressed to them beyond the membrane of the tympa- num, in the same manner as the drowsy, or those who are slug- gish in waking, do not open their eyes, or admit the light to the retina, unless a strong glare first stimulates the exterior tunics. It seems, however, sometimes to depend upon an obstruction of the Eustachian tubes. Under the influence of this species, it occasionally happens Some that particular sounds or noises prove a better stimulus than sounds others, though equally loud, or even louder; as the music of a better pipe, of a drum, or of several bells ringing at the same time. thaTothers. Holder relates the case of a man who never heard but when he niU8trated. was beating a drum ;| and Sauvages a similar case of a woman who, on this account, always kept a drum in the house, which was constantly played upon while she was conversing with her husband. The latter gives another case of a person who was always deaf except when travelling in a carriage, during which time, from the rattling ofthe wheels, he was perfectly capable of hearing and engaging in conversation. And Stahl gives an instance of like benefit derived from the shrill tones of a pipe.J In ordinary cases of practice, if we can once hit upon astimu- Mode of lus that succeeds in giving temporary tone to a debilitated or- treatment. gan, we can often avail ourselves of it to produce a permanent benefit, and sometimes a complete restoration, by raising or Stimulus of lowering its power, continuing its power for a longer or shorter 8°UBd term of time, or modifying it in some other way, so as to adapt theexi- it to the particular exigency. And it is hence probable, that if gency any of these sonorous stimuli were to be employed medicinally, rtisv Drove and with a due respect to length of time and acuteness of tone, a perfect they might, in some instances, be made the medium of obtain- cure. ing a perfect success. Dr. Birch, indeed, gives an instance of Illustrated. such success in a person who only heard during the ringing of bells; and who, by a permanent use of this stimulus, recovered his hearing altogether.§ Voltaism may here also be employed Voltaism. in many cases with a considerable promise of advantage ; and especially in connexion with the ordinary routine of general General and local tonics and stimulants, as cold, and cold bathing, pun- ai!d ,ocal ' al r stimulants * Feiliz in Richter Chir. Bibl. band ix. p. 555. t Phil. Trans. 1668, No. and tonic1, 26. X Colleg. Casual. N. 7G. v Hist. vol. iv. 190 cl. iv.] NEUROTICA. [ord. n. Gen. II. gent masticatories, and injections, bark, valerian, alone or with Spec. III. ammonia, and a free use of the siliquose and coniferous plants Paracusis perversa. as a part of the common diet. Physiology. Analogous to strabis- mus or squinting. Singular examples. Medical treatment. Buchanan's different view of this case. One case imputed to imperfect action of the radi- ated muscle of the tym. panura of one ear. Species IV. Paracusis Duplicata.—Double Hearing. The action ofthe one ear inaccordant with that of the other; sounds heard doubly, and in different tones or keys. This pravity of hearing depends upon an inaccordance ofthe auditory nerve on the one side with that on the other; so that the same sound produces, on each side, a very different effect, and is consequently heard, not homotonously, or in like tones, but heterotonously, or in separate and unlike. And hence this spe- cies of morbid hearing, as I have already observed, has a con- siderable parallelism with that of strabismus or squinting, in which the optic axis ofthe one eye is not accordant with that of the other, whence the same object is seen double, and often in a different position. Sauvages has given two or three very curi- ous examples of this affection. A musician, while blowing his flute, heard two distinct sounds at every note. The sounds were in different keys, and consequently not in harmony ; and as they were heard simultaneously, the one could not be an echo of the other. On another occasion, he was consulted by a person who for several months had been troubled with a hearing of two distinct voices whenever he was spoken to ; the one at least an octave higher than the other, but not in unison with it, and hence producing a harsh and insupportable discord- ancy. This affection is mostly temporary, and, as proceeding alto- gether from a morbid condition of the auditory nerve, has been cured by blisters and other local stimulants. From not being attended to, however, in due time, it has sometimes assumed a chronic character, when it is removed with great difficulty ; and, in a few instances, it has been connected with a constitu- tional irritability ofthe nervous system, in which case a plan of general tonics must co-operate with local applications. [Mr. Buchanan does not coincide with the author respecting the cause of paracusis duplicata, but ascribes its symptoms to an imperfect secretion of cerumen in only one ear.* In this view ofthe case, nothing more need be said on the treatment, than what has already been stated under the head of paracusis obtusa. If some observations published by Sir Everard Home be correct, double hearing may sometimes arise from another cause, not adverted to by Dr. Good. " An eminent music-master (says he), after catching cold, found a confusion of sounds in his ears. On strict attention, he discovered that the pitch of one ear was half a note lower than than that of the other; and that the percep- tion of a single sound did not reach both ears at the same in- * See Buchanan's Physiological Illustrations ofthe Organ of Hearing, p. 24, Lond, 1828. cl. iv.] NERVOUS FUNCTION. [ord. ii. 191 stant, but seemed as two distinct sounds following each other in Gen.IL quick succession, the last being the lower and weaker. This Spec IV. complaint distressed him for a long time, but he recovered from Paracusis it without any medical aid. In this case (Sir Everard Home ob- duP1,cata- serves) the whole defect appears to have been in the action of the radiated muscle (of the tympanum) exerted neither with the same quickness nor force in one ear as in the other, so that the sound was half a note too low, as well as later in being im- pressed on the organ."* This case seems to be very similar to those above cited from Sauvages. Mr. Buchanan expresses his doubts about the reality of the alleged cause, which he suspects might be a defective state ofthe ceruminous secretion.] Species V. Paracusis Illusoria.—Imaginary Sounds. Internal sense of sounds without external causes. This is in most instances strictly a nervous affection, and Analogous bears a striking analogy to paropsis illusoria, or that illusory or }°Par?ps'" false sight in which unreal objects of various forms, colours, and mostly V other sensible qualities, appear before the eyes. The morbid state nervous is often confined to the auditory nerves, or some ofthe branches a&*c,'0|>; alone ; yet it is not unfrequently the result of a peculiar irritability cause may that extends through the whole ofthe nervous system. And occa- be local or sionally it proceeds from an obstruction of one or both the Eusta- general« chian tubes. M. Itard ascribes it to two other causes; a peculiar SoTtlTD state ofthe blood-vessels, local or general, and an impeded motion obstruction of the air in the tympanal cavity.t [Mr. Buchanan here also dis- °f the agrees with our author, and refers the present species to the Eustachian imperfect secretion of cerumen.J] The sounds, hereby pr6duc- ed, differ greatly in different persons, and sometimes in the very same person at different periods; but it is sufficient to contem- plate them under the three following varieties, all which the French express by the term bourdonnements : » Syrigmus. A sharp, shrill, successive sound. Ringing or tinkling. 0 Susurrus. An acute, continuous, hissing Whizzing. sound. y Bombus. A dull, heavy, intermitting sound. Beating. Heister recommends, in cases arising from a debility of the Medical local nerves, to fumigate the ears with the vapour of a hot vin- treatment. ous infusion of rosemary and lavender; and, where a spasmodic affection of the inner membrane may be supposed to follow such debility, he advises a simultaneous use of diaphoretics internally. If it proceed from an obstruction ofthe Eustachian tubes incon- sequence of spasm or inflammation, the fumes of tobacco drawn * Phil. Trans. 1800. t Traite des Maladies de l'Oreille, et de l'Audi- tion, 2 tomes, 8vo. Paris, 1821. X Physiological Illustrations of the Organ of Hearing, p. 23. 192 cl. iv.] NEUROTICA. [ord. ii. Gen. II. Spec. V. Paracusis illusoria. Chronic cases very difficult of but have disappeared spontane- ously. into the mouth, and forcibly pressed against these tubes by clos- ing the lips and nostrils, and then urgently sniffing the vapours upward to the palate, have often proved serviceable by taking off the irritability, on which the spasmodic or inflammatory ac- tion is dependent. Stimulating the external ear by blisters or aromatic injections has sometimes availed, though not often. Chronic cases are extremely difficult of cure ; though I had lately an elderly lady for a patient, who, after having at differ- ent times suffered from each of these modifications of illusory sounds for several years, and tried every remedy that could be suggested in vain, at length lost the distressing sensation by de- grees, and without the assistance of any medicine.* How differs from the preceding species. et P. Surdi- tas organica. Causes. Sometimes in the outer entrance. Sometimes in the inner or Eusta- chian tube. 0 P. Surdi- tas atonica. Causes. Species VI. Paracusis Surditas.—Deafness. Total inability of hearing or distinguishing sounds. In the preceding species, the sense of hearing is in various ways depraved or impaired ; in the present, it is altogether abolished, and may proceed from causes which offer three dis- tinct varieties of affection : x Organica. From organic defect or impedi- Organic deafness. ment. 0 Atonica. From local debility or relaxa- Atonic deafness. tion. y Paretica. From nervous insensibility. Paretic deafness. The organic defect or impediment may exist in the outer or inner entrance, or in the cavity, of the ear. The outer en- trance has in a few instances been imperforate,! but far more generally blocked up with indurated wax, excrescences, concre- tions, or some other substance. The inner entrance or Eustar chian tube has been sometimes also found imperforate on both sides, but more frequently obliterated by ulceration,^ or closed by the mucous secretion of a catarrh, or the pressure ofthe ton- sils in whatever way morbidly enlarged. If the defect or im- pediment exist in the cavity of the ear, its precise nature can seldom be known during the life of the patient, and if known would rarely admit of a remedy. It often consists of a mal- formation of the helix ; and, as we have already seen under parotitis, in a loss of the articulation or substance of one or more of the tympanal bones. Atonic deafness, or that dependent on local debility or re- laxation, may be superinduced by a chronic cold, abruptly plunging the head into cold water in a heated state, a long ex- posure to loud and deafening noises, or the sudden and unex- *" The treatment suggested by Mr. Buchanan, has already been briefly no- ticed under the head of Paracusis Obtusa. t Cels. De Medicin. lib. vn. c 8. Biichner, Miscell. Phys.-Mcd. p. 318. 1727. X Haller, Elem. Phys. torn. v. p. 286. cl. iv.] NERVOUS FUNCTION. [ord. ii. 193 pected burst of some vehement sound upon the ears,* as that of Gen. II. a cannon or a thunder-clap,t where the constitution is in a state Spec. VI. of great nervous irritability: in which state, moreover, it has 0 P. Surdi- in a few instances been produced by a violent fright.J It has tasat0D'ea- also proceeded from an atony ofthe excretories of the outer ear, Sometimes in consequence of which there has been neither wax, nor mois- jjjhj Mr!*' ture of any kind. And it has followed as a sequel upon various fevers and inflammations, especially cephalitis and otitis, rheu- matic hemicrania, and other nervous head-aches, repelled gout, and repelled cutaneous eruptions. Paretic deafness may be regarded in many cases as nothing P< Surdj. more than an extreme of atonic deafness; and almost all the tasparetica. causes producing the one, when operating with greater violence Causes, or upon a feebler frame, may also produce the other. It has those of the not only been induced suddenly by loud sounds and violent Variety.06 frights, but by a vehement fit of sneezing, and, from sympathy, by the use of powerful sternutatories ;§ the olfactory nerve hereby becoming insentient through all its branches. Deafness has often been transmitted hereditarily; of which Sometimes numerous and unequivocal instances are to be found in Hoff- hereditary. man,|| Morgagni,1F and other writers of established reputation. The most usual causes of total deafness are beyond the power often im- of the medical art to relieve; and hence the disease runs very medicable. generally through the whole period of life. Where the cause is an imperforation of either of the passages, an opening has been often effected with success. Many other impediments, as Treatment of indurated wax, or infarction from inflammation, are in general whencapa- removable still more easily; and some obstructions have been b,»?ft- suddenly carried off by a fall, or other violent concussion ofthe head. The great difficulty, however, is in getting at such im- pediments when they are formed in the tympanal cavity. The perforation of the mastoid process, recommended by Riolanus, Perforation has been practised occasionally with success, and especially by ofthemas- the Swedish anatomists, Jasser and Hagstrcem. But the difScul- toid proce39- ties arc so considerable, that the plan has usually been super- seded by a puncture of the membrane, or by injecting the Eu- Puncture of stachian tube, as first proposed by an unprofessional artist, Guyot *he mem" of Versailles, and since followed up successively by Cleland, ,rfne-. Petit, Douglas, and Wathen. Of late, however, even this has JiJSa^ been dropped ; though now once more revived in France by M. chian tube. Itard,** and in Great Britain by Mr. Buchanan.ft In deafness from atonic relaxation, almost all the stimulant Stimulants and tonic methods, pointed out under the preceding species, and tonics. have been tried in turn, occasionally with palliative success, F"mes of sometimes altogether in vain. The fumes of tobacco sniffed Bniff«l°iip up the Eustachian tubes from the mouth, in the manner de- the Eusta- chian tube. * Schulze, Diss, de Auditus Difficultate, Sect. 23. t Borelli, Observ. Cent. iv. Par. 1656. X EPh- Nat- Cur- Cent- lx- 0bs- 6- i Eph. Nat. Cur. Dec. n. Ann. ix. Obs. 26. || Consult, et Respons. Cent. i. cas. 40. IT De Sed. et Caus. Morb. Epist. xi.vm. Art. 48. ** Ut supra. t+ Engraved Representation ofthe Anatomy of the Human Ear, &c. Hull, 1823. VOL. IV. 25 194 CL. IV.] NEUROTICA. [ORD. II. Gen. II. Spec. VI. Paracusis surditas. Obstruction in these tubes has sometimes ceased sud- denly, or by phenomena, which often become causes. Mode of treatment. Voltaic electricity. Blisters. Solution of nitrate of silver. Chronic ulcer. Case of cine by saliva- tion. Explained. PuDcture of the mem- brana tyin- pani a sub- stitute in i in perfora- tion of the Eustachian tube. Its proper limitation, as opposed to a useless and wanton employ. ment. scribed under the last species, were recommended by Morgag- ni* and many other writers of earlier times, and have occasion- ally been found beneficial in our own day; the spasm or other obstruction of the fine tjibes ceasing of a sudden, and with the sensation of a smart snap that almost startles the patient. And as sight has sometimes been restored in amaurosis by a violent fever or a flash of lightning, so has deafness from atony, ap- proaching to paralysis, been recovered by a like fever or a thunder clap ;f ordinary causes being thus transferred into ex- traordinary modes of cure. Among the stimulants most useful, where the deafness is de- pendent upon debility of the membrane of the tympanum, or the nerve of hearing, have been the aura of voltaic electrici- ty, applied two or three times a day for half an hour or longer each time, and persevered in for many weeks, a series of blis- ters continued for a long period, and a diluted solution of nitrate of silver. Yet a chronic ulcer forming in the ear, and dis- charging plentifully, has often proved still more effectual. Mr. Gordon relates a case of total deafness, produced sud- denly, in a soldier in good health, by plunging overhead into the sea; which, after a long routine of medicines had been tried in vain for three months, yielded to the use of mercury as soon as the mouth began to be affected. A gentle salivation supervened, his hearing was gradually restored, and, in six weeks from its commencement, he returned to his duty per- fectly cured.J The excitement of the salivary glands seems, in this case, to have extended by sympathy to the Eustachian tubes, or whatever other parts of the organ of hearing were diseased. When the Eustachian tubes are imperforate or irrecoverably closed, which may commonly be determined by an absence of that sense of swelling in the ears which otherwise takes place on blowing the nose violently, Riolamus, and afterwards Che- selden, proposed a substitute for the canal by making a small perforation through the membrane of the tympanum; and Sir Astley Cooper has boldly put their recommendation to the test. The artificial opening does not destroy the elasticity of the membrane, and it has hence been occasionally attended with success; and perhaps would be always, if it were to be limited, as M. Itard§ has shown it ought to be, to a permanent obstruc- tion of the Eustachian tube, unaccompanied with inflammation, or any other cause of deafness. And it is from a wanton ap- plication of this remedy to other cases, that it has so often been tried in vain since Sir Astley Cooper's successful sanction. * Epist. Anat. vn. Art. 14. Eph. Nat. Cur. Dec. I. Ann. vi. Obs. 110. t Bresl. Saraml. 1718, p. 1541. J Edin. Med. Com. vol. iii. p. 80. ' 4 Traite des Maladies de TOreille, et de l'Audition, &c. 2 tomes Paris 1821. ' cl. iv.] NERVOUS FUNCTION. [ord. ii. 195 GENUS III. PAROSMIS.—MORBID SMELL. Sense of smell vitiated or lost. This is the parosmia and anosmia of many writers; from Gen. HI. rx$x, " male," and o£a, " olfacio," analogous with paracusis and Synonyms paropsis: anosmia, however, will not include one of its species, and generic and the present termination is preferred on account ofitsanalo- derivation. gy with that of the parallel terms. Under this genus may be arranged the three following species : 1. PAROSMIS ACRIS. ACRID SMELL. 2. -------- ORTUSA. ORTUSE SMELL. 3.--------EXPERS. WANT OF SMELL. Species I. Parosmis Acris.—Acrid Smell. Smell painfully acute or sensible to odours not generally perceived. Generally speaking, the sense of smell in all animals is in Physiology. proportion to the extent of the Schneiderian or olfactory mem- brane with which the nostrils are lined, and over which the branches of the olfactory nerves divaricate and ramify. And hence this membrane is much more extensive in quadrupeds and birds, which chiefly trust to the sense of smell in selecting their food, than in man ; for it ascends considerably higher, and is, for the most part, possessed of numerous folds or duplica- tures. It is hereby the hound distinguishes the peculiar scent thrown forth from the body of the hare, and the domestic dog recognizes and identifies his master from all other indivi- duals. Yet the nerves of smell are not only spread in great abun- olfactory dance over the olfactory membrane of all animals possessing nerves near- such an organ, but they are distributed so near the surface as /nd\ence to be almost naked ;* and hence in every class they are easily stimulated. * Over the whole of the Schneiderian membrane, branches of the fifth nerve are dis- tributed. In the human subject, the first, or olfactory nerve, does not spread so exten- sively, but goes principally to the septum narium and upper turbinated bone. M. Magen- die has ascertained the effect of the separate division of the first and fifth nerves in ani- mals; and has thus more correctly demonstrated how much of the impression received by the nostrils belongs to smell, properly so called, and how much to touch. " It appears that, upon the division of the first nerve, the animal remains as sensible as before to the disagreeable impression of odours which act pungently. A young dog, thus mutilated, appeared conscious of an unpleasant impression when ammonia, acetic acid, oil of laven- der, or Dippel's oil, were held to its nose. On the other hand, after the division of the fifth, the first nerve remaining entire, an animal is not affected by the presence of the substances above-mentioned." But M. Magendie mentions, that a dog which survived the division of the fifth nerve for a considerable period, would, at times, when food was offered to it rolled up in paper, unrol the paper, and expose and eat the food, although, at other times, he appeared to want the power of distinguishing by smelling the presence of objects placed near it. " Pungent odours seem to offend the nose upon the same prin- ciple that they irritate the conjunctiva of the eye ; their acrid impression, without their scent, being perceived when the influence of the first nerve is artificially destroy- ed." The first nerves, therefore, constitute the organ of smell.—See Mayo's Outlines of Physiology, p. 412, 2d edit.; and Magendie's Journ. de Physiol. Exp. torn. iv. p. 173. —Ed. 196 cl. iv.] NEUROTICA. [ord. n. Gen. III. Spjec. i. Parosmis by the finest nromatics impalpably pulverized; and rapidly acting by sympathy, and afford- ing refresh- ment. Hence also the ready and exten- sive effect of fetid odours. Under pe- culiar cir- cumstances the sense becomes exquisitely keen. Said to be keener among savages than civilized na- tions, and why. Sense of smell, like all others, capable of cultivation : more fully relied upon by those who are de- prived of sight or bearing. Striking illustration of this remark. and hourly excited into action, being covered with little more than a layer of bland, insipid mucus, thin at its first separation, but gradually hardening by the access of air into viscid crusts, and which is expressly secreted for the purpose of defending them. From this nearly naked state it is, that they are stimu- lated by aromatics, however finely and impalpably divided ; whence the violent sneezings that take place in many persons in an atmosphere in which only a few particles of sternutato- ries or other acrid olfacients are floating: and hence also the rapidity with which a sympathetic action is excited in the neighbouring parts, or in the system at large, and the refresh- ment which is felt on scenting the pungent vapour of carbonate of ammonia, or vinegar, or the grateful perfume of violets or lavender, in nervous head-aches or fainting-fits. The fetid odours are well known to affect the nostrils quite as poignantly as the pleasant, and to produce quite as extensive a sympathy ; and hence the nausea, and even intestinal looseness, which often follow on inhaling putrid and other offensive effluvia. Under peculiar circumstances, however, the ordinary appara- tus for smell possesses an activity, and sometimes even an in- tolerable keenness, which by no means belongs to it in its natu- ral state. M. Virey, who has written a very learned treatise upon the subject of odours, asserts, that the olfactory sense ex- ists among savages in a far higher degree of activity than among civilized nations, whose faculty of smell is blunted by an habitu- al exposure to strong odours, or an intricate combination of odours, and by the use of high-flavoured foods. And he might have added, that this sense, like every other, is capable of cul- tivation, and of acquiring delicacy of discrimination by use; that savages, many of whom make an approach to the life of quadrupeds, employ it, and trust to it in a similar manner ; and that this is perhaps the chief cause of the difference he has pointed out. It is in like manner relied upon by persons who are de- prived of one or two of the other external senses, as those of sight or hearing, or both : not merely in consequence of more frequent employment, but from the operation of the law we have already pointed out, that where one ofthe external senses is destroyed, or constitutionally wanting, the rest, in most cases, are endowed with an extraordinary degree of energy ; as though the share of sensorial power, naturally belonging to the defect- ive organ, were distributed among the rest, and modified to their respective uses. One of the most interesting examples that I am acquainted with of this transfer of sensorial power is to be found in the history, first given to the public by Mr. Du- gald Stuart, of James Mitchell, a boy born both blind and deaf; and who, having no other senses by which to discover and keep up a connexion with an external world than those of smell touch, and taste, chiefly depended for information on the first' employing it on all occasions, like a domestic dog, in distinguish- ing persons aud things. By this sense, he identified his friends and relatives; and conceived a sudden attachment or dislike to strangers according to the nature of the effluvium that escaped cl. iv.] NERVOUS FUNCTION. [ord. ii. from their skm. « He appeared," says Mr. Wardrop, who has Gen. III. also published an account of him, " to know his relations and Spec. I. intimate friends by smelling them very slightly, and he al once Parosmia detected strangers. It was difficult, however, to ascertain at acri8, what distance he could distinguish people by this sense ; but, trom what I could observe, he appeared to be able to do so at a considerable distance from the object. This was particularly striking when a person entered the room, as he seemed to be aware of such entrance before he could derive information from an/, pther sense than that of smell. When a stranger approach- ed him he eagerly began to touch some part of the body, com- monly taking hold of his arm, which he held near his nose ; and after two or three strong inspirations through the nostrils, he appeared to form a decided opinion concerning him. If it were favourable, he showed a disposition to become more inti- mate, examined more minutely his dress, and expressed, by his countenance, more or less satisfaction ; but if it happened to be unfavourable, he suddenly went off to a distance with expres- sions of carelessness or disgust."* The Journal des Sgavans for 1667 gives a curious history of a Sex, age, monk who pretended to be able to ascertain, by the difference of and ot.her odour alone, the sex and age of a person, whether he were s\"j tote married or single, and the manner of life to which he was ac- ascertain customed. This, as far as the fact extended, may possibly have able by.this been the result of observations grafted upon a stronger natural exqinsTte™ sense than belongs to mankind in general, and is scarcely to be keen. ranked in the list of diseased actions. But, among persons of a Hence often highly nervous or irritable idiosyncrasy, I have met with nu- distrMsinsIy merous instances of an acuteness of smell almost intolerable and particularly distracting to those who laboured under it; which has fairly to persons constituted an idiopathic affection, and sometimes nearly realiz- ?f?-nerv?U8 ed the description ofthe poet, in making its possessors ready at have fainted every moment to beneath the tv e . . . smell of a Die of a rose in aromatic pain. rose ag je. Mr. Pope seems to have written this line as a play of fancy ««ibed by at the time, but the writings of various collectors of medical cu- x'imdes- riosities abundantly show, that he has here described nothing cription more than an occasional and sober fact. Thus M. Orfila gives no'fanciful. us an account of a celebrated painter of Paris, of the name of oNu^1*8 Vincent, who cannot remain in any room where there are roses, correctness. without being in a short time attacked with a violent cephalaea succeeded by fainting ;t and M. Marrigues informs us, that he once knew a surgeon who could not smell at a rose without a sense of suffocation, which subsided as soon as the rose was re- moved from him; as he also knew a lady who lost her voice whenever an odoriferous nosegay was applied to her nostri!s.| We have observed, that a keen stimulation of the olfactory nerves is often productive of a very powerful sympathetic ac- tion in other organs. There are few persons who, on inhaling * History of James Mitchell, a boy born blind and deaf, &c. By James Wardrop, F. R. S. 4to edit. 1813. t Sur les Poisons, tom. ii. Cl. v. sect. 972. % Journ. de Physique, year 1780. 198 CL. IVt] NEUROTICA. [ord. II. Gew. III. the fine particles of black hellebore and colocynth, while in the Spec I. acj 0f being pounded, would not feel their effect on the intes- Parosmis tines by a copious diarrhoea; but where the acuteness of smell exists which constitutes the present disease, whether limited to particular odours, or extending to all odours equally, the sym- pathetic action is sometimes of a very singular description. M. Singular Valtain gives the history of an officer, who was thrown into odour of1 * convulsions and lost his senses by having in his room a basket of pinks: pinks, of which, nevertheless, he was very fond. The flowers were removed, and the windows opened, and, in the course of half an hour, the convulsions ceased, and the patient recovered his speech. Yet, for twelve years afterward, he was never able like effect of to inhale the smell of pinks without fainting.* And M. Orfila the odour of relates the case of a lady of forty-six years of age, of a hale constitution, who could never be present where a decoction of linseed was preparing, without being troubled, in the course of a few minutes afterwards, with a general swelling of the face, followed by fainting and a loss ofthe intellectual faculties ; which symptoms continued for four-and-twenty hours.t Predis- The predisponent cause of the species before us is a nervous ponent or irritable habit. The occasional causes are local irritation present * * ^rom a slight cold, in which the contact of the air alone, as in- species. haled, often produces sneezing; or excoriation of the mucous Occasional membrane ofthe nostrils from the use of sternutatories in those Sometimes not accustomed to them. It is often the result of idiosyncrasy ; a result of and perhaps at times, as in paracusis acris, of a superfluous idwyn distribution of olfactory nerves. As a symptom, it is often found Often found *n ophthalmia and rheumatic hemicrania. asasymp- Where the disease is connected with the habit, the nervous torn in excitement should be diminished by refrigerants and tonics, as diseases. ^e shower-bath, bark, acids, neutral and several ofthe metallic Medical salts. And where it is chiefly local, we may often produce a treatment, transfer of action by blisters in the vicinity ofthe organ ; or re- lax the Schneiderian membrane, and moisten its surface by the vapour of warm water. The sniffing up cold water will also prove serviceable in many instances, by inducing torpitude at first, and additional tone afterwards. Dr. Darwin advises errhines for the first of these purposes, that of exhausting the excitabili- ty and blunting the sense. Species II. Parosmis Obtusa.— Obtuse Smell. Smell dull and imperfectly discriminative. Sometimes This is often a natural defect, but more frequently a conse- a Mturai quenCe of an habitual use of sternutatories, which exhaust, weaken, and torpify the nerves of smell, just as exposure to a strong light weakens and impairs the vision, and sometimes de- FoduSby Str°yS U alt0&cther- To tl»ose unaccustomed to sternutatories, ofsTernuta'6 * H^iena Chirurgicale, p. 26. t Sur les Poisons, loc. citat. toriei. cl. iv.] NERVOUS FUNCTION. [ord. ii. 199 the mildest snuffs will produce such an excitement as is marked Gen. HI. by a long succession of sneezing, which is nothing more than an Spec. II. effort of the remedial power of nature to throw off the offending Parosmia material; while those, who have habituated themselves to snuff for years, can hardly be excited to sneeze by the most violent us ra e • ptarmics. The evil is here so small, that a remedy is seldom sought for Remedies in idiopathic cases; and in sympathetic affections, as when it seldoi!ff proceeds from catarrhs or fevers, it usually, though not always", w|,en sym-' ceases with the cessation of the primary disease. It is found pathetic, also as a symptom in hysteria, syncope, and several species of usuallytem" cephalaea, during which the nostrils are capable of inhaling very pungent, aromatic, and volatile errhines, with no other effect, than that of a pleasing and refreshing excitement. Where the sense of smell is naturally weak, or continues so when after catarrhs or other acute diseases, many of our cephalic snuffs natural, may be reasonably prescribed, and will often succeed in remov- 'eliwed^r ing the hebetude. The best are those formed of the natural cephalic order verticillataB, as rosemary, lavender, and marjoram : if a snuffs. little more stimulus be wanted, these may be intermixed with a proportion of the teucrium Marum; to which, if necessary, a small quantity of asarum may also be added; but pungent er- rhines will be sure to increase instead of diminishing the defect. Species III. Parosmis Expers.— Want of Smell. Total inability of smelling or distinguishing odours. This species is in many instances a sequel ofthe preceding ; Sometimes a for whatever causes operate in producing the former, when sequel ofthe carried to an extreme, or continued for a long period, may also Species'.08 lay a foundation for the latter. But as it often occurs by itself, Sometimes and without any such introduction, it is entitled to be treated of idiopathic. separately. It offers us the two following varieties: x Organica. From natural defect, or accidental Organic want of smell. lesion, injurious to the structure ofthe organ. 0 Paralytica. From local palsy. Paralytic want of smell. The first variety occurs from a connate destitution of olfac- a. p. expers tory nerves, or other structural defect; or from external injuries organica. of various kinds: and is often found as a sequel in ozaenas, fistu- How pro- la lachrymalis, syphilis, small-pox, and porphyra. The second d"ced> is produced by neglected and long continued coryzas, and a per- parainfcT severing indulgence in highly acrid sternutatories. Howd o-' The author once knew a very beautiful and elegant young duced. lady, who had from birth so total a want of smell, as not only to Instance of be incapable of perceiving any difference in the odours of dif- the disease ferent perfumes or flowers, but of sweet and corrupt meats, and romb,rtn* who could inhale very powerful errhines without sneezing. Though this affection seemed to have been connate, and de- 200 cl. iv.] NEUROTICA. [ord. n. Gen. III. pendent upon a natural imperfection ofthe nerves of smell, the <=»■"■ iit £ .-. • . . . ... -rn._ .l:-i---:„« *vhich Spec III. Schneiderian membrane had something ofthe thickening wl Parosmis js ordinarily produced by catarrhs, and the lady always spoke as though under the influence of a slight cold. When this affection is a sequel of local irritation, as from a coryza or catarrh, warm stimulating vapours, as of vinegar or frankincense, are often useful. If produced by syphilis, the fumes of cinnabar may be inhaled by the nostrils; or a sternuta- tory may be used, composed of turbeth mineral and ten times the quantity of any mild and light powder, as orris-root. expers. Mode of treatment Origin ofthe genericterm. Synonyms. Association between the senses of taste and smell. Illustrated. Tongue not the only though the chief orgau of taste. Some ani- mals have a power of taste that have no tongue. Other animals possessing a tongue do not employ it as an organ of taste. Few birds thus employ it. Toucan. GENUS IV. PARAGEUSIS.—MORBID TASTE. Sense of taste vitiated or lost. Parageusis is derived from T*g«, " malS," and ytvu, " gustum praebeo," whence xx^xytvu, and consequently irxgxytvirK. The author has preferred, with Vogel, the present termination to parageusia, as analogous to the names of the preceding genera ofthe order before us. In the senses of taste and smell, there is a considerable asso- ciation. The young lady I have just noticed, who was destitute, or nearly so, ofthe sense of smell, was equally destitute of that of taste, and could not distinguish by this criterion between beef, veal, and pork ; and consequently, in respect to all these, had no preference. The chief organ of taste is the tongue, but this is not the only organ, nor is it absolutely necessary for an existence of the sense. The Philosophical Transactions give us examples of persons who possessed a perfect taste after the tongue had been wholly destroyed ; and Professor Blumenbach, in his Comparative Ana- tomy, affords us a similar example in an adult whom he visited, and who was born without a tongue. Consonant with which, many insects appear to have a faculty of taste, though they have no organ of a tongue ; and among these the gustatory function is supposed by Professor Knoch to be performed by the posterior pair of palpi or feelers. While, on the other hand, there are many animals possessing a tongue, who do not use it as an organ of taste. All birds possess a tongue, for even the pelican, which has been said to be tongueless, has a rudiment of this member ; yet there are but few birds, comparatively, that taste or are able to taste with this organ. Parrots, predaceous and swimming birds are an exception to this remark; for they possess a soft thick tongue, covered with papillae, and moistened with a sali- vary fluid, and select that food which is the most agreeable. Yet, in by far the greater proportion of birds, we do not find the tongue appropriated to this purpose. In many of them in- deed, it is stiff, horny, and destitute of nerves. The tongue of the toucan, though sometimes several inches in length, is scarce- ly two lines broad at its root: it has throughout the appearance of whalebone, and its margins are fibrous. The tongues of the cl. iv.] NERVOUS FUNCTION. [ord. ii. 201 woodpecker and cock of the woods are equally hard and horny : Geh. IV. in themselves, they are short, and in a quiescent state, lie back- Parageusis. ward in the mouth, and are covered with a sort of sheath issuing Wood peck- from the os hyoides or the oesophagus ; but they possess a me- ^^ *jjjjjj, chanism, which renders them extremely extensile, and capable of being thrust forward to a considerable distance. That of the woodpecker is sharp-pointed with barbed sides, and is darted with great rapidity out of the mouth to an extent of some inch- es ; by which means it follows up such insects as the animal is in pursuit of through all their crannies in the bark of trees, sticks them through with its apex, and in this state drags them out for food. The chameleon has a tongue of a somewhat similar kind, Chameleon. which, in like manner, answers the purpose, not of taste, but of preying for food. It is contained in a sheath at the lower part of the mouth, and has its extremity covered with a glutinous secretion. It admits of being projected to the length of six inch- es ; and is used in this manner by the animal in catching its spoil, and especially in catching flies. It is darted from the mouth with wonderful celerity and precision ; and the viscous secretion on its extremity entangles minute animalcules, which constitute another portion of its food. The tongue, when it forms an organ of taste, as in man, is The tongue studded, and especially on its upper surface and lateral edges, ]J[J° ^jf with innumerable nervous papillae issuing from a peculiar mem- taste stud- brane that lies beneath, and has a near resemblance to the skin ded with in other parts, but is softer and more spongy. Its external tunic PaPlllffi: or cuticle is an exquisitely fine epithelium, which is moistened, ^™ fine not by an oily fluid, like that of the surface of the body, but a epithelium. peculiar mucus. We have here, therefore, a more exquisite sense of touch Hence more than on the general skin, whose papillae are not only smaller J™""^ but dry. the papillae There can be no question, also, that the sentient fluid with of the skin; which they are supplied is differently modified from that of the skin ; and hence the provinces of the two senses, though they oc- render. casionally approach each other, are still kept distinct; and the f^git*capa- tongue becomes a discerner of certain qualities which the skin can- ble of dis- not discriminate, as sour, sweet, rough, bitter, salt, and aromatic* ceming ' qualities. * Instead of this hypothesis of a modification of the nervous fluid, modern discoveries teach us rather to seek in the different nerves with which the tongue is supplied for an ex- planation of the cause ofthe peculiar and diversified faculties which it enjoys; as, for in- stance, the power of motion, the power of common sensation or touch, and the power of taste. "In man," as Mr. Mayo has observed, " the apparent sense of taste is the tongue and palate : the same surfaces have an exquisite sense of touch ; and an attentive exam- ination shows, that the latter occupies a larger surface than the former, and is, indeed, the only sense with which the palate is endowed. " Upon the surface of the tongue, again, the. sense of taste is very partially distributed, being restricted to the papillae fungiformes. The largest of these are found upon the dorsum of the tongue, while the smaller and more numerous are situated along the sides and towards the tip of the tongue. They are vascular and erectile, and shoot up when the tongue is touched by a sapid substance." (See Outlines of Human Physiology, p. 406, 2nd edit.) It is clear, however, that if some facts, to which the author of the Study of Medicine has adverted, be correct, either the sense of taste must be more extensive than here represented, or else that, under particular circumstances, other parts than those speci- VOL. IV. 26 202 cl. iv.] NEUROTICA. [ord. ii. Gen. IV. Parageusis. Exact cause of diversity of flavours unknown. Opinion of the Epicu- reans. Explana- tion un- founded. Thus much we know ; but we do not know the cause of that different effect, or, in other words, of that variety of tastes which different substances produce upon the papillae of the tongue, and which constitute their respective flavours. It was supposed by the Epicureans, and the doctrine has descended to the present day, that all this depends upon the geometrical fig- ure of the sapid corpuscles; and particularly so with respect to saline bodies, which are cubic in sea-salt, prismatic in nitre, and equally diversified in vitriol, sugar, and other crystals. It is suf- ficient, however to annul this explanation, to observe, that many crystals of very different forms arc alike insipid ; while others of the same, or nearly the same, shape, possess very different fla- vours ; as also that the flavour in any of them continues the same even where we are able to change the figure ; as, for ex- ample, by rendering common nitre cubical. The cause of fla- vours, therefore, appears to reside in the elementary principles of substances that lie beyond the reach of our senses. But the variable condition of the peculiar covering of the papillae of the tongue, together with the condition of the adjoin- ing organs, which concur in the purpose of the tongue, as also the changeable nature ofthe saliva and ofthe substances lodged in the stomach, all concur in influencing the taste, and giving a character to the flavour. And hence the same flavours do not affect persons of all ages, nor of all temperaments; nor even the same person at all times. In general, whatever contains less salt than the saliva does seems insipid. The spirituous parts of plants are received, in all probability, either into the papillae them- ^.of"^Vr'ie se'ves? or in*° *ne absorbing villi of the tongue ; and hence the rapid refreshment and renovation of strength, not easy to be accounted for otherwise, which these stimulating materials pro- duce even when they are not taken into the stomach. It is from the diversity of flavours, by which nature has dis- tinguished different substances, that animals are taught instinc- tively what is proper for their food : for, speaking generally, no aliment is unhealthy that is of an agreeable taste ; nor is any thing ill tasted that is fit for the food of man. We here take Noaliment no notice of excess, by which the most healthy foods may be unhealthy, rendered prejudicial, nor of mineral preparations, which are Exceptions, not furnished by nature, but prepared by art. And hence the wisdom of Providence incites man to select the nutriment that is best fitted for his subsistence, equally by the pain of hunger, and the pleasure of tasting. Man, however, is often guided by Quadrupeds instruction and example, as well as by his own instinct • but ani- dhcrimmal mals> which are destitute of such collateral aids, and have to ing taste as depend upon their instinct alone, distinguish flavours as we wellassmell have already observed they do smells, with a far nicer accuracy lied must acquire a gustatory power. The ninth pair of nerves, which are distributed to the muscles of the tongue, are merely the nerves of motion ; while those of taste and sen- sation appear to^be fust, the gustatory branch of the ganglionic portion of the third di- vision of the fifth, which is distributed not merely to the muscles of the tongue, out to its mucous surface and to two of the salivary glands; and secondly the p|Z 1 ,1 nerve, which sends branches to the surface of the root of The 3U!^Ed. ^ ^ * Flavour in- fluenced by the state of the tongue and adjoin- ing organs. Whence the came flavours affect differ ent persons differently. quality of being insipid. How the spirituous parts of plants act. Diversity of flavours teaching animals. cl. iv.] NERVOUS FUNCTION. [ord. ii. 203 than mankind ; and admonished by this correct and curious test, Gen. IV. abstain more cautiously than man himself, from eating what would Parageusis. be injurious. And hence herbivorous animals, whose vegetable than man; food grows often intermixed with a great diversity of noxious and heuc« plants, are furnished with much longer papilke and a more deli- SgJifh nu- cate structure ofthe tongue than mankind, as they are endowed tritivefrom also with a more accurate sense of smell; both which, indeed, p°a8n°°°wnen they jointly rely upon for the same purpose. mtermixed" The sense of taste, therefore, which possesses so close an analogy to that of smell, is subject to a similar train of specific diseases, and consequently the genus parageusis must contain the three following species: 1. PARAGEUSIS ACUTA. ACUTE TASTE. OBTUSA. OBTUSE TASTE. EXPERS. WANT OF TASTE. Species I. Parageusis Acuta.—Acute Taste. Taste painfully acute or sensible to savours not generally perceived. The sense of taste, like that of sight, smell, or hearing, is Senseof capable of acquiring a higher degree of accuracy by use; and liveable hence those who are in the habit of tasting wines by this organ, by use: perceive a variety of flavours, or modifications of flavour, which another person, not versed in such trials, is insensible of. We n f Xj 0 also perceive, that the nerves of taste, like those of every other labour. sense, become exhausted, and consequently torpid, by much la- bour and fatigue. And hence the nicest discriminator, after hav- ing tried a variety of wines, spirits, or other pungent savours in quick succession, is far less capable of judging concerning them, and has at last little more than a confused percepfion of gusta- tory excitement. Morbid acuteness of taste, however, varies essentially from Morbid accuracy of taste: for, under particular states of irritation, pun- acuteness of rf c u i i • j i i. .i ' tastedistinct gent savours, of whatever kind, give equal pain to the tongue, from accu. which at the same time is altogether incapable of distinguish- racy of ing between them. taste- This painful acuteness may proceed from two causes: a mor- Causes, bid or excessive sensibility in the nerves of taste, or a deficient m"r!"d .9en' secretion of the peculiar mucus that lubricates the lingual pa- u,e'gusta- pillae ; in consequence of which the latter are exposed in a tory nerves; naked state to whatever stimuli are introduced into the mouth, and a defi. The former is sometimes found, though for the most part only tion of lu- temporarily, in highly nervous and irritable constitutions, and es- bricating pecially during a state of pregnancy ; the latter in certain mor- mucu9> bid conditions ofthe stomach, accompanied with great thirst and a parched tonsrue. Both these causes, however, very fre- Both cau-es r ., . ° , , , .. , ., J . sometimes quently co-exist; as in ulcerated sore throats, or other excona- C3.exist. tions of the mouth, in which the papilla; are in a state of the keenest excitement, while the tongue is sore, either from a de- 204 cl. iv.] NEUROTICA. [ord. ii. Gew. IV. Spec. I. Parageusis acuta. Mucus sometimes acrimonious when secreted. Medical treatment. Emetics. Topical ap- plications. Attention to the primary disease when symp- tomatic. fective secretion of mucus, or from its being carried off by a morbid and augmented action of the absorbents as fast as it is formed. In this state of diseased action, moreover, it not unfrequently happens that the mucus itself is secreted in a morbid condition ; and the palate, instead of being soft and smooth, becomes harsh and rugous or furrowed, exquisitely irritable, and intolerant of the slightest touch or the mildest savours. I have sometimes met with this distressing affection, apparently as an idiopathic ailment, or at least unconnected with any manifest disease of the stomach or any other organ ; and seemingly induced by a rheumatic pain from carious teeth. It is, however, far more frequently a symptom of dyspepsy, porphyra, and chronic sy- philis. In treating this affection, we should, in the first instance, di- rect our attention to the state of the stomach, and clear it of whatever sordes may probably be lodged there. This may sometimes be done by aperients, but it will be the surest way to commence with an emetic. The local symptoms may, in the mean while, be relieved in two ways. First, by changing the nature of the morbid action, or exhausting the accumulated sentient power by acid or as- tringent gargles, or a free use of the coldest water alone ; for which purpose also sage-leaves and acrid bitters have often been employed with advantage. And next, the naked and irri- table tongue may be sheathed with mucilages of various kinds, and thus a substitute be obtained for its natural defence. And, in many cases, both these classes of medicines may be conve- niently united. When the affection is a symptom of some other disease, as in the case of syphilis and scurvy, it can only be cured by curing the primary malady. Carious teeth, if such exist, should be ex- tracted ; and if the palate be rugous or spongy, scarification should be employed. Sometimes idiopathic: and con- nected with obtuseness of smell. Species II. Parageusis Obtusa.— Obtuse Taste. Taste dull and imperfectly discriminative. This species rarely calls for medical attention. It occurs sometimes idiopathically, and seems to be dependent on a de- fective supply of nerves, or nervous influence subservient to the organ of taste. I have seen it under this form in various instances; and, as already observed, have found it connected in a few cases with obtuseness of smell. The patient has not been altogether without taste or smell, but both have been extreme- ly weak and incapable of discrimination. In the case alluded to at the commencement of this species, the individual could dis- tinguish the smell of a rose from that of garlic, and the fla- vour of port wine from that of mountain or madeira; but she could not discriminate between the odour of a rose and that of cl. iv.] NERVOUS FUNCTION. [ord. n. 205 a lily, nor between the taste of beef, veal, or pork, and conse- Gen. IV. quently gave no preference to either of these dishes. Spec* II# As a symptom, this affection occurs in almost all the diseases Parageusis that are accompanied with hebetude of smell, as catarrh, hyste- F !', ria, and several species of cephalgea. quently as a symptom. Species III. Parageusis Expers.— Want of Taste. Total inability of tasting or distinguishing savours. As an utter want of smell is sometimes a natural or congeni- Sometimes tal effect, so in a few instances is an utter want of taste, a»d un- natural and questionably from the same cause, an absolute destitution of ^then* ' nerves or nervous power subservient to the gustatory organ, immedica. This default is altogether immedicable : as is also for the most ble* part the same when a result of palsy, general or local; though t^^"" f here stimulant gargles or masticatories, as mustard-seeds, horse- paisy> and radish, pyrethrum, and camphor, have sometimes succeeded in may admit restoring action to the torpid nerves. When, however, it oc- °fPa!1,a" curs, as it sometimes does, from a long use of tobacco, whe- ther by smoking or chewing, or of other acrid narcotics, these stimulants will be of no use. In fevers, various exanthems, and inflammations, this species A tempora- exists temporarily, partly, perhaps, from a diminished or mor- fy 8y?'Ptom bid production of sensorial power, but chiefly from a conver- complaints. sion of the mucus of the tongue into a dry, hard, or tough and viscid sheath. And where there is much increased heat and action, the epithelium or cuticle of the tongue itself be- comes often peculiarly thickened and coriaceous or leathery. Acids, in the form of gargles, are the pleasantest means of removing this morbid substance, but they will often succeed best if rendered viscid, and converted into a soap by mixing with them a little almond oil, which may at the same time be sweetened with honey. GENUS V. PARAPSIS.—MORBID TOUCH. Sense of touch or general feeling vitiated or lost. Parapsis is derived from the Greek terms, ir«g« and aimfcxit Origin of " perperam tango." The common technical name for the ge- the generic nus is dysesthesia, but not quite correctly; since this word, as ^[f^to we have already had occasion to observe, is also employed to differently express morbid external sensation of any kind, whether of touch, and dis- taste, smell, sight, or hearing : while by Dr. Young it is equally j££jj'e,,([ly applied to one at least of the faculties of the mind, as in dyses- thesia interna, which he characterizes as " a want of memory, or confusion of intellect." This genus embraces three species as follow: 1. PARAPSIS ACUTA. ACUTE SENSE OF TOUCH OR GENE- RAL FEELING. 206 cl. iv.] NEUROTICA. [ord. ii. Gew. V. Parapsis. EXPERS. -- ILLUSORIA. INSENSIBILITY OF TOUCH OR GENE- RAL FEELING. ILLUSORY SENSE OF TOUCH OR GE- NERAL FEELING. [The skin is the principal seat of touch ; though modifica- tions of this sense are said to reside in various mucous surfaces, and in the voluntary muscles. The power of distinguishing with the finest discrimination the tangible properties of bodies is certainly in the hand, and especially in the extremities ofthe fingers. " The nerves," says Mr. Mayo,* " which minister to the sense of touch, are the posterior roots of the spinal nerves, the large division of the fifth, the nervi vagi, and the glosso- pharyngeal nerves. The body, the neck, and occiput, and the limbs, are supplied by the spinal nerves; the face, temples, and fauces, by the fifth ; the pharynx and oesophagus by the nervi vagi and glosso-pharyngeal nerves. It is remarkable, that the nerves of touch have ganglions near their origin."] a. P. acuta teneritudo. Pathology. Different circum- stances un- der which the affection occurs. Feeling of corporeal ease and comfort, on what de- pendent. Species I. Parapsis Acuta.—Acute Sense of Touch. The sense of touch painfully acute or sensible to impressions not generally perceived. This species of morbid sensibility shows itself under almost innumerable modifications ; but the four following are the chief: x Teneritudo. Soreness. 0 Pruritus. Itching. A Ardor. Heat. S Algor. Coldness. In the first variety, or that of soreness, there is a feeling of painful uneasiness or tenderness, local or general, on being touched with a degree of pressure that is usually unaccompa- nied with any troublesome sensation. This is often an idiopa- thic affection; but more generally a symptom or sequel of fe- vers in their accession or first stage, inflammations, or external or internal violence, as strains, bruises, and spasms. It is not always easy to account for this feeling, and perhaps the cause is, in every instance, more complicated than we mio-ht at first be induced to suppose. It occurs where there is disten- tion of the vessels, where there is contraction of them, and where there is neither. Wherever it exists, however, it is a concomitant of debility, and may, in many instances, be regard- ed as the simple pain of debility, the uneasiness of an organ thrown off from its balance of health. The general health of the body depends in a very considerable degree upon the har- monious co-operation of its respective organs; insomuch, in- deed, that this harmony of action, as we had occasion to observe » the Physiological Proem prefixed to the present class, was supposed by a distinguished school of ancient philosophers, and * Outlines of Human Physiology, p. 402, 2nd edit. cl. iv.] NERVOUS FUNCTION. [ord. ii. 207 is still supposed by many physiologists of the present day, to Gen. V. constitute the principle of life itself. Regarded as an universal Spec. I. principle, the hypothesis is unfounded, though in many respects * p- acuta beautiful and plausible. Yet notwithstanding that the life of the teneritudo. animal frame does not altogether depend upon an harmonious co-operation of the whole ofthe organs that enter into its make, much of the comfort of life has such a dependence ; and we trace the same principle in the minutest and comparatively most trivial parts of the animal functions, as manifestly as in the largest and most complicated organs. Where every portion of a member, however subordinate in itself, as a toe or a finger, works well or healthily, there is a feeling of ease and comfort, Feeling of but wherever it works ill or with difficulty, there is a sense of disquiet and disquiet, and, under peculiar circumstances, of tenderness or tenderness soreness. A change in the diameter of a vessel, whether by ^rio"? dilatation or contraction, provided it be moderate and gradual, causes. is accompanied with no uneasy sensation whatever; but if ei- ther be violent or sudden, a feeling of soreness is a certain re- sult. Warmth, gentle friction, and stimulants, as spirits, balsams, Gentle sti- and essential oils, are of general advantage, wherever the kind mulants of tenderness we are now describing occurs, and is unconnected [orD1 the . .,i • a i.- ° ' best remedy. with inflammation. ' ^ The sense of itching, which may be defined a painful tililla- g p. acuta tion, local or general, relieved by rubbing, is commonly a re- pruritus. suit of some mechanical or morbid irritant applied externally or Generally internally to the part affected; though sometimes, unquestiona- prod"ce.d°y ui j j i. i • i .,-,.. <..! r. n i mechanical bly, dependent upon a morbid sensibility of the nerves of feel- or* morbid ing themselves. If the summit of the nerves or their extreme irritants. points be alone touched, the effect is tickling or titillation, as u0metimlsd in the vellication of the skin by a feather; if it descend a little g/nsSbilUyof below the summit, it is accompanied with a vibratory feel which the nerves we call tingling, as when the beard of barley-corns creeps un- ^hamcal observed by us up the arms; and if it reach still deeper, it is stimulants. combined with a sense of piercing, which we call pricking, as Simple when the keen hairs of several species of dolichos or cowhage jJ5kl,.?g" are handled or blown upon the skin by a light breeze. Pricking. In many cases all these modifications of itching are the effect of some acrimonious secretion on the surface ofthe body, or of an acrimonious change in the common matter of perspiration in consequence of its lodging in the cutaneous follicles longer than it should do. The papulous efflorescences we shall have to Morbid ir- treat of under the third order ofthe sixth class will afford abun- ritants. dant examples of both these causes of itching, as they will also of an intolerable itching, apparently produced by, or closely connected with, a morbid sensibility of the cutaneous nerves themselves. For the present we can do nothing more than re- fer generally to various species of exormia, as lichen and pru- rigo ; and of acpyesis, as impetigo and scabies. It is, moreover, highly probable that the disorder called fidgets is sometimes chiefly dependent on a morbid sensibility of the summits or ex- treme ends of the cutaneous nerves. 208 cl. iv.] NEUROTICA. [ord. II. Gen. V. Spec. I. Found ai a symptom in various diseases. y P. acuta ardor. Easy and pleasurable warmth, what. Heat a strong irritant. Mode of action and cause of uneasiness. Operating in a two-fold manner. When an idiopathic affection, how re- lieved. Found also as a symp- tom in various diseases. I P. acuta algor. Cold, a slroog irritant. Mode of ac- tion and cause of uneasiness. Operates in a two-fold manner, re- versely to the process of beat. Where chiefly seated, when an idiopa- thic affec- tion ; and This affection is also found as a very troublesome symptom in pernio and other cutaneous inflammations, as likewise in urtica- ria and other rashes. The sensations of heat and cold may be explained at the same time. An easy and pleasurable warmth depends, in a state of health, upon a moderate temperature of the atmos- phere, which cannot be very accurately laid down, because, from habit or constitution, or some other circumstance, different persons enjoy very different temperatures. Now it is the well known property of heat and cold to disturb the temperature, whatever it may be, that affords ease and comfort to the nerves of feeling; and to produce disquiet as they either raise or de- press it. And this both of them do in two distinct ways. Heat is a strong irritant, and even if it made no change in the bulk of a living organ, or the juxta-position of its particles, like all other irritants it would still excite a troublesome feeling, amounting at length to acute pain, if raised to a considerable range beyond the ordinary scale. But it does, in every instance, excite a change in the bulk of living organs and the juxta-position of their particles; for it enlarges the former in every direction, and only does this by separating the particles from each other; in which forcible and sudden divellication we have a second source of the troublesome and acute sensation which so con- stantly accompanies a temperature when carried very consider- ably above the point of health. Heat, as an idiopathic affection, occurs chiefly in plethoric and irritable habits. In the former it is relieved by blood-let- ting, and evacuants of neutral salts; in the latter by mild dia- phoretics, and afterwards cold bathing and other tonics. As a symptom it is found, also, in the second stage of fever, in inflammation, and entonic empathema. Cold is also a strong irritant, though it acts by the opposite means of heat. When the atmospheric temperature is too high, it is a pleasant and reviving agent, inasmuch as it both reduces the heated medium, and restores the particles of the affected organ from a state of disquieting tenseness to their usual scale of approximation. If the cold be pushed farther, it may go a little beyond this, and still be pleasant and healthful; for the organ or the general system may be in a state of morbid relaxa- tion, and, consequently, in their actual scale of approach, the living particles may be too remote for the purposes of high elas- ticity and vigour. And it is in such a condition as this that cold chiefly shows its stimulant power, and is so generally resorted to as a tonic. But if the agency of cold be carried farther than this, it produces uneasiness to the nerves of feeling by a process precisely the reverse of that we have just shown to be pursued by heat, and consequently in a two-fold manner. First by sink- ing the warmth of the organ, or of the system, below its scale of ease and comfort, and next by forcing the living particles into too close and crowded a state, and not allowing them suf- ficient room for play. Cold, as an idiopathic affection, is chiefly local, and most com- cl. iv.] NERVOUS FUNCTION, [ord. ii. 209 mon to the head and feet. It is temporarily relieved by warmth ' Gen. V. and stimulants, and particularly by the friction of a warm hand ; SpEC«l- and, where it can be used, the exercise of walking. It is per- <»'P'acuta man'ently relieved by the warmer tonics, as sea-bathing and aro- . matic bitters. lieved. Considerable mischief has often been produced by a sudden Mischief of exposure of the feet to severe cold, and especially in delicate a sudden and irritable habits, unused to such applications: as colic, ceph- cokST"6 ulae, catarrh, fevers of various kinds, and, in a podagral diathe- sis, gout. But the application of severe and sudden cold to the head or stomach by drinking ice or cold water, and especially when the individual is heated and perspiring, has been followed with more alarming effects, and even with death itself. Mauri- ceau relates an instance of death produced during baptism, bv applying to the head the water ofthe baptismal font.* But this must be a rare occurrence; while the fatal effects of drinking ice or iced water in a state of heat are innumerable. It is observed by Dr. Fordyce,t and the observation is quoted Singular and called curious by Dr. Darwin, " that those people who have p™;£ke° been confined some time in a very warm atmosphere, as of 120 or 130 degrees of heat, do not feel cold, nor are subject to pale- ness of their skins, on coming into a temperature of 30 or 40 degrees ; which would produce great paleness and painful sensa- tion of coldness in those who had been for some time confined in an atmosphere of only 86 or 90 degrees." The cause is not diffi- Explained. cult of explanation. The sensorial power is exhausted, and the nerves of feeling rendered torpid by a long exposure to a heat of 120 'or 130 degrees, and the turgid capillaries, whose dilatation produces the general blush, lose their power of constriction or collapse; while in a heat of 86 or 90 degrees neither of such effects takes place. Cold, as a symptom, is found in the first stage of fever, in Cold as a syncope, hysteric syspasia, nausea, and atonic empathema; in ^3'^™' all which the affection is general. various diseases. Species II. Parapsis Expers.—Insensibility of Touch or General Feeling. The organ of touch totally impercipient of objects applied to it. Under this species, by some writers denominated amblyaphia, Theambly- . ' i . f 11 • a • aphia of we may mention the two following varieties: 8£ine a Simplex. Confined locally or generally to inters. Numbness. the organ of touch: some- times accompanied with un- easiness. ' 0 Complicata. Complicated with insensibility Complicated insensibility. in several of, or all, the other senses. * Tom. ii. p. 348. t On Simple Fever, p. 163. VOL. iv. 27 210 cl. iv.] NEUROTICA. [ord. n- Gen. V. Spec. II. a. P. expers simplex. How pro* duced occa- sionally. Idiopathic and perma- nent numb- Part affect- ed may be pierced or wounded without paiu. Sometimes local: sometimes general. Singular example. Farther illustration. 0 P. expers complicata. Striking examples. Occasional and local numbness is common to most persons. A tight bandage, or accidental pressure of one limb upon another, by obstructing the communication or activity of the nervous in- fluence, will often produce this, when the limb is commonly and emphatically asserted to be asleep. A very slight motion, how- ever, takes it off, when the irregular transmission of the senso- rial power, on its first return, produces a sense of pricking, as though a ball of needles were in the limb, and pushing in eve- ry direction. Where such numbnesses, however, occur without pressure or any manifest cause, they well deserve watching and resisting by tonics or stimulants, local or general; for they clearly show a tendency to paresis, if not to paralysis. But there are some persons who possess by nature a numb- ness, or privation of the sense of feeling, in particular organs or parts of the surface, which appears to depend on a natural destitution of the nerves of touch wherever such insensibility is to be found. And hence they are able, in such parts of the body, to prick or cut themselves, or to run pins to any depth below the skin without pain. I have seen several striking ex- amples of this peculiar affection.* Sometimes the numbness has been limited to a single limb, but common to the whole of it, as the hand, for example, which at the same time has possessed a full power of motion. Sometimes the insensibility has been universal, or extended over the whole surface. Lamarck re- lates a case, in which this want of feeling was confined to the arm ; but, at the same time, was so complete, that the man who laboured under it had no pain during the progress of a phlegm- on ; and who, on another occasion, in which he broke his arm, felt nothing more than a crash, and merely thought he had broken the spade he was at work with. Dr. Yelloly has des- cribed another interesting case in the third volume of the Me- dico-Chirurgical Transactions. The patient, aged 58, had been first affected in Jamaica about three years before, and the affection had become permanent. " The hands," says Dr. Yel- loly, " up to the wrists, and the feet half-way up the legs, are perfectly insensible to any species of injury, as cutting, pinch- ing, scratching, or burning. The insensibility, however, does not suddenly terminate ; but exists to a certain degree near- ly up to the elbow, and for some distance above the knee. He accidentally put one of his feet, some time ago, into boiling water, but was no otherwise aware of the high temperature, than by finding the whole surface a complete blister on removing it. The extremities are insensible to electrical sparks taken in ev- ery variety of mode." As an example of the second modification, or insensibility in the organ of touch, complicated with insensibility in several other senses, we may mention the following, which Sauvages has copied from the Academy Collections: "The patient, a delicate young man, was suddenly in the morning deprived equally of speech and of the sense of touch, without any as- signable cause or premonition. Punctured and pricked in dif- ferent parts of the body, in his head, neck, back, shoulders, cl. iv.] NERVOUS FUNCTION. [ord. ii. 211 breast, arms, abdomen, he felt nothing whatever, and even Gf.n. V. laughed at the singularity of the phenomenon; as, with the Spec. II. exception of numbness and cutaneous insensibility, he laboured 0 P. expers under no kind of disease. The complaint continued two days, c°inPlicala' and seems to have yielded to venesection." Insensibility of touch, either simple or complicated, is also felt as a symptom in apoplexy, palsy, catalepsy, epilepsy, syspa- sia, and syncope. Where the numbness is complete and constitutional, it lies Found in beyond the reach of medicine; where it is recent and less ex- oneform.or treme, it will often yield to friction alone, or with camphorated va^uY"" oil or spirits ; to heat, especially that of the warm-bath ; ether, complaints. ammonia, and water, and the voltaic stream, or small shocks of Remedia' electricity. treatment. Explana- tion. Species III. Parapsis Illusoria.—Illusory Sense of Touch. Imaginary sense of touch, or general feeling in organs that have no existence. This is the pseudaesthesia of Ploucquet; and is frequently Pseuda:- found among persons that have suffered amputation ; who, for a thesia of long time after the loss of the separated limb, have still a sense plonc>e also cases of neuralgia in various situations, by Dr. Evans, in Edin. Med. Journ. JNo. 79, p. 278.—-Editor. t Tableau des Maladies observers a l'Hotel-Dieu, dans les Snlles de Cliniques, &c. Par L Martinet, Revue Medicale, &<•. 1 "2 1. X Commentatio de Caenesthcsi Dissert. Inaug. Medica.—Auctore C. F. Hubner, 1794. 214 cl. iv.] NEUROTICA. [ord. ii. Gen. VI. Spec. I. Synonyms. Tic dou- loureux, what. Meaning of thewordtic. Symptoms in this spe- cies suffi- ciently in- dicate its seat and nature. Seat and course described. Diagnostics. Line of pain changes as the different branches of nervea are affected. Disease has been mis- taken for Species I. Neuralgia Faciei.—Nerve-ach of the face. Lancinating pains shooting from the region ofthe mouth to the orbit, often to the ear, and over the cheek, palate, teeth, and fauces; with convulsive turitchings ofthe adjoining muscles. This is the trismus maxillaris, or t. dolorificus of M. de Sauva- ges, for it is not necessary to make a distinction between them, as Sauvages himself has done ; by Dr. Fothergill it is denomina- ted dolor crucians faciei. As the French give the name of tic to trismus or locked-jaw, they distinguish this first species of neuralgia, affecting the nerves about the jaw, by the name of tic douloureux, by which term the disease is, perhaps, chiefly known even in our own country in the present day. I shall have occasion to observe more at large, under the genus tris- mus, that the word tic is commonly supposed to be an onoma- topy, or a sound expressive of the action it imports; derived, according to some, from the pungent stroke with which the pain makes its assault,*resembling the bite of an insect; but, according to Sauvages and Soleysel, from the sound made by horses, that are perpetually biting the manger when labouring under this peculiar affection. We do not, however, appear to be acquainted with the real origin ofthe term. From the symptoms by which this complaint is distinguished, it is not difficult to decide concerning both its seat and nature. The character ofthe pain is very peculiar, and its course cor- responds exactly with that ofthe nerves. The second branch ofthe fifth pair is, perhaps, more frequently affected than either the first or the third. But the portio dura of the seventh pair, which is distributed more extensively upon the face, under the name of pes anserina, is more frequently the seat of affection than any ofthe branches ofthe fifth pair seem to be ; which is a matter of no small regret, as it is difficult for any operation to reach this quarter effectually, although it is a difficulty which we shall presently find has in one instance, at least, been en- countered and surmounted. When, however, the disease is seated in the seventh pair of nerves, we can be at no loss to decide concerning it, in consequence of the course and divari- cations ofthe pain, which commences with great acuteness in the fore-part of the cheek towards the mouth and alae of the nose, sometimes spreading as high as the forehead, and ramify- ing in the direction of the ears. At other times, the forehead, temple, and inner angle of the eye on the side affected, and even the ball of the eye itself, form the chief lines of pungent agony, while, from irritation of the lachrymal gland, the eye weeps involuntarily. In this case we may reasonably suspect the disease to be seated in some part of the superior maxillary nerve constituting the second branch of the fifth pair. And it is hence obvious, that the radiation of the pain must vary accord- ing to the nerves or nervous twigs that are affected. The disease has been occasionally mistaken for rheumatism, hemicrania, and tooth-ach: yet the brevity of the paroxysm, cl. iv.] NERVOUS FUNCTION. [ord. ii. 215 the lancinating pungency of the pang, the absence of all intu- Gen. VI. mescence or inflammation, the comparative shallowness, instead Spec. I. of depth, of its seat, and its invariable divarication in the course ^""l8ia ofthe facial nerves or their offsets, will always be sufficient to varA distinguish it from every other kind of pain. others. Of its exciting causes we know but little. It seems some- How distin. times to have been produced by cold, and sometimes by mental guishable. agitation in persons of an irritable temperament. But it has Cause llt,,e been found in the robust as well as in the delicate, in the mid- dle-aged as well as in the old. In a few cases, the irritation Sometimes has been local, of which Mr. Jeffereys has given a very striking local. instance in a young woman who, when only six years old, fell Exempli- down with a tea-cup in her hand, which was hereby broken, one ofthe cheeks lacerated, and a fragment of the tea-cup im- bedded under the skin. The wound healed, though slowly and with difficulty ; the buried fragment of the tea-cup was not no- ticed, and consequently was not extracted. From an early pe- riod a violent nervous pain returned nightly, and one side of the face was paralytic. These dreadful symptoms were en- dured for fourteen years: at the end of which time an incision was made through the cicatrix down upon what was then found to be the edge of a hard substance, and which appeared, when extracted, to be the piece ofthe tea-cup above noticed. From this time the neuralgia and paralysis ceased ; the affected cheek recovered its proper plumpness, and the muscles their due power.* It is possible, as suggested by M. Martinet, that, as a symp- tom, it may sometimes occur in what he calls, and perhaps cor- rectly, an inflammation of the nerves, or a thickening of the neurilemma in some particular organ, of which he has given va- rious examples, accompanied with a reddish or even violet tinge, and studded with minute ecchymoses.j But that this is not the only, or even the ordinary, proximate cause is clear, since, in the cases alluded to, pressure upon the part is intolera- ble, while in idiopathic neuralgia it is commonly consolatory, and considerably diminishes the agony. Andre appears to have been the earliest writer who remark- Nature of ed this painful affection with accuracy ; and he succeeded in re- J^'JJJ^ moving it permanently by applying a caustic to the infra-orbita- 0™ pyin ry or maxillary branch of nerves in one case in which a pre- Andre, and vious division ofthe nerve by the scalpel, as practised by Mare- *}™ked chal, had produced only a temporary cure. Andre, who resided succeMi at Versailles, published his account in 1756, whimsically enough inserting it in a treatise on diseases of the urethra. A few un- satisfactory experiments and operations were given to the pub- lic in the course of the next fifteen years, chiefly by French practitioners, from which little of real value is deducible. In Afterwards 1776, Dr. Fothergill, in the fifth volume of Medical Observa- Jjj.jj^ * Lond. Med. and Phys. Journ. Mar. 1823, p. 199. Fothergill: t Memoire sur l'lnflammation des Nerfs, &c 1824. Also cases by Evans in Edin. Med. Journ. No. 79, p. 282. 216 cl. iv.] NEUROTICA. [ord. n. Gen. VI. Spi:c. I. Ni-uralgia f.icifi. by Tliouret and Pujol; by Mfglin and Cliaus- Bier. Seat of iriit at ion sometimes suspected at the origin of the nerve. Hence ar- senic Iried; and mer. cury, even to salivation. Oil of croton. Bark. Acetic ether. Henbane aud zinc. {Suhcar- bonate of iron. tions and Inquiries, communicated a very full and elaborate de- scription and history ofthe disease : since which time M. Thou- ret and Pujol have each published a valuable paper on the same subject, in the Memoirs of the Society of Medicine of Paris, containing .various cases collected and described with great minuteness ; and we have already adverted to the more recent publications of Dr. Meglin and Professor Chaussier. It has of late been suspected, that in some cases, at least, of this disease, the seat of irritation might be at the origin instead of at the extremity ofthe nerve ; an idea that has arisen from the powerful sympathetic action manifested by the eye and the stomach forming the boundaries ofthe chain, upon which sub- ject we shall have to speak at large when treating ofthe genus entasia in the ensuing order. u The nerves," remarks Dr. Parr, "that supply the eye externally, and the slight connexion ofthe intercostal wilh the brain, are nearly from the same spot in the cerebrum, and it did not seem improbable, in the case al- luded to, that the disease may have really been at the origin of the nerve, although felt as usual at its extremity." Dr. Parr was, in consequence, induced to try arsenic, and in one instance, he tells us, with a decidedly good effect. It is also said to have been since found serviceable in a few other cases. In Mr. Thomas's hands, however, we shall presently perceive that it completely failed. Mercury is also reported to have occasion- ally proved successful, and especially when carried to the ex- tent of salivation ; though in numerous instances it has been tried even to this last effect without any benefit whatever. [Some cases of facial neuralgia have been cured by applying a drop or two ofthe oil of croton to the tongue.* The effect on the nerve was almost instantaneous. Bark, and the present fashionable medicine, the sulphate of quinine,! have also been tried with various results.] When about thirty years ago animal magnetism was a fash- ionable study in France, it was had recourse to for this disease among others, and had its day of favour as a popular remedy.J Of late, however, neuralgia has been attempted to be cured in France by an external use of acetic ether; while in Germany Dr. Meglin has employed piHs composed of the extract of hen- bane, and sublimed oxyde of zinc, and according to his own statement with great success. But, beyond controversy, one of the most valuable medicines that have hitherto been tried, is the subcarbonate of iron, for the first use of which, so far as I know, we are indebted to Mr. Hutchinson,§ who commonly em- ploys it in doses of a drachm three times a day. * Med. Chir. Review, Sept. 1821. t Obs. de Neuralgie sus-orbitaire droite, guene par le sulfate de quinine, par M. Piedagnel. Magendie, Journ. de Physiologie E.xper. torn. ii. p. 124 X Edin. Med. and Surg. Jouru. July, 1823. i Cases of Neuralgia Spasmodica, &c. By B. Hutchinson, &c.8vo. Lond. 1822. Numerous examples ofthe utility of subcarbonate of iron are now on record, aud Dr. Elliotson adduces his testimony in favour of its efficacy in chronic neuralgia. See Med. Chir. Trans, vol. xiii. p. 252. Also Crawford in Me.-l. Chir. Review; Dr. Belcher's case of neuralgic amaurosis, successfully treated by the carbonate of iron. Edin. Med. Journ. No. 86. p. 37.__Ed. cl. iv.] NERVOUS FUNCTION. [ord. ii. 217 [Dr. Borthwick, however, has found the last plan so success- Gen. VI. ful, and his confidence in it is such, that he regards the point Spec. I. now almost settled in practice, " that iron will relieve, if not Neuralgia cure, tic douloureux, (neuralgic affections, generally speaking,) as certainly and as speedily as quicksilver, in particular forms, will relieve and cure the lues venerea." The dose, which he gives in severe cases, is one drachm and a half four times a day.*] The instances of success appear to be very numerous, though this also, like all other medicines, has often failed. But there is another energetic medicine, which has also a fair claim to attention from a very different property—that of subduing the sensibility; and this is prussic acid. Mr. Taylor, of Cricklade, Prussicacid. Wilts, has made repeated trials of this powerful sedative in various cases, and apparently with more rapid relief, than is afforded by the carbonate of iron. He commenced his career with a drop of Scheele's preparation, in twenty-four hours, in divided doses; but as he grew better acquainted with the ef- fects of the medicine, he gave a drop for a dose at first, and then increased the dose to two drops, repeating it three times a day. In one or two instances he has carried the quantity, by a gradual augmentation, to twenty-four drops a day, in the course of a month's use ; and very often to five and six drops a day, by adding a drop to every's day's account.t Time alone must determine, whether the cures thus obtained will prove as permanent as those effected by the tonic power of the subcar- bonate of iron. To induce ease, however, under any circum- stances, and for any period of time, in the midst of so much torment, is an invaluable blessing. In effect, neither narcotics, nor tonics, nor any other class of No medi- medicines that has hitherto been employed, can be in every Jjjj1^"^ case depended upon for a radical cure, though some of them, uJ5™fora and particularly the subcarbonate of iron, are worthy of high radical cure commendation. "My father," says Dr. Perceval of Dublin, in all cases. " in his manuscript comment on the present author's Nosology, Case from was subject to neuralgia faciei for several years, and^ used a Perceval. variety of medicines without relief. He was worse in close damp weather, and much worse when his mind was occupied. At length he had an issue inserted in the nucha, kept his bow- els free with James's analeptic pills, and exchanged a town re- sidence for the country. In this situation he soon threw off the disease, from which he was free for a considerable lime before his death." Change of scene, a transfer of morbid ac- Occasional tion, and a recruited cheerfulness of spirits are valuable auxilia- &£*£" ries in the present as in every other nervous affection ; but I found. much question, whether these aione have ever operated a cure. A spontaneous cure is the work of time alone; and J™*00" time, though often a long and tedious period is requisite, will natura]cure, generally accomplish it, and probably did so in the case befpre if worked * See Edin. Med. Journ. No. 83, p. 297. t Edin. Med. and Surg. Journ. July lfl-3. > vol.. iv. 2f: 218 CL. IV.] NEUROTICA. [ord. II. Gen. VI. Spec. I. Neuralgia faciei. Moxa and cautery. Acupunc- ture. Chief radi- cal cure to be found in a division of the affected nerves. Interesting case related by Darwin. Disease at first mista- ken : and medi- cines tried in vain. Progress of the disease. us. The fact is, that the nervous system in every part, and every ramification, becomes gradually torpefied by excess of action; and as the eyes grow blind and the nostrils inolfacient by strong stimulants applied to them, so the nervous twigs of every kind, after a long series of irritation from the present disease, become exhausted of power and obtuse in feeling: and it is probably by hastening this state, that the most active stimulants, and the warmer tonics, produce whatever benefit is to be ascribed to them. [In the treatment of various cases of neuralgia, Baron Lar- rey was very successful with the moxa, which he repeated the application of according to circumstances. Delpech uses the actual cautery, and, after the separation of the eschar, keeps up a discharge for a long time.] How far acupuncture or needle pricking, the zin-king of the Chinese, which we have already described under chronic rheu- matism, might be useful, has not yet been determined. It has, at least, a fair claim for experiment, before having recourse to a curative attempt by the knife. This radical cure consists in a division of the affected branch- es, provided they can be followed home. Dr. Haighton com- pletely succeeded, some years ago, in a case in which he divi- ded the sub-orbital branch of the fifth pair ; and Mr. Cruickshank and Mr. Thomas more recently in a case of considerable com- plication, and where the affection was evidently not confined to the different branches of any single nerve". This last case is given by Dr. Darwin, whom the patient had intermediately consulted, in the second part of his Zoonomia, and is one of the most interesting sections of the work. The patient, a Mr. Bosworth by name, was between thirty and forty years of age. When he first applied to Dr. Darwin, he complained of much pain about the left cheek-bone. Dr. Darwin suspected the an- trum maxillare might be diseased; and, as the second of the grinding teeth had been lately extracted, directed a perforation into the antrum, which was done, and the wound kept open for two or three days without advantage. Afterwards, by friction about the head and neck with mercurial ungent, he was for a few days copiously salivated, and had another tooth extracted by his own desire, as also an incision made in such direction as to divide the artery near the centre of the ear next the cheek which gave also a chance of dividing a branch of the affected nerve ; but without success. When the pain was exceedingly violent, opiates were administered in large quantity ; bark being used freely in the intervals, but without effect. ' The pain spread in various directions from a point in the left cheek a little before the ear, sometimes to the nose, and fore- part of the lower jaw, and sometimes to the orbit of the eve also affected. It returned on some days many times in an hour, and continued several minutes; during which period, (it is well worth observing, as showing the connexion between an irregular sensitive and an irregular motive power in the same cl. iv.] NERVOUS FUNCTION. [ord. ii. 219 muscles), the patient, says Dr. Darwin, seemed to stretch and Gen. VI. exert his arms, and appeared to have a tendency to epileptic Spec. I. actions, so that his life was rendered miserable. The com- Neuralgia plaint gradually grew worse, and Mr. Bosworth removed to acle1' London for the purpose of again putting himself under Mr. Patient put Cruickshank's care, and of submitting to any operation he "aVof '6 should recommend. The pain was now intolerably acute, and Cruickshank almost unremitting; and opiates afforded him little or no re- ""^ lief, though taken to the quantity of six tea-spoonsful of lauda- num at a time. The operation of dividing the diseased nerve was therefore determined upon. " As the pain," says Mr. Thomas in his letter to Dr. Darwin, after its completion, " was felt more acute in the left ala of the nose, and the upper lip of the same side, we were induced to divide the second branch of the fifth pair of nerves as it passes out at the infra-orbital foramen. He was instantly re- and ope- lieved in the nose and lip ; but towards night the pain from the n}*& "Pon eye to the crown of the head became more acute than ever. ^"J^1" ia Two days after, we were obliged to cut through the first branch passing: out at the supra-orbital foramen : this afforded Fartne.r ,. ,r,., ../. ... £ y-v ,1 * i ,i • operations him the like relief with the first. On the same day the pain subir.ittedto. attacked, with great violence, the lower lip on the left side, and the chin: this circumstance induced the necessity of divid- ing the third branch, passing out at the foramen mentale. Du- ring the whole period, from the first division of the nerves, he had frequent attacks of pain on the side of the tongue ; these, however, disappeared on division of the last nerve. " The patient was evidently bettered by each operation : still the pain was very severe, passing from the ear under the zygoma towards the nose and mouth, and upwards round the orbit. This route proved pretty clearly that the portio dura of the auditory nerve was also affected, at least the uppermost branch of the pes anserina. Before I proceeded," continues Mr. Thomas, " to divide this—Mr. Cruickshank had operated hitherto—I was willing to try the effect of arsenic internally; and he took it in sufficient quantity to excite nausea and verti- go, but without perceiving any good effect. I could now trust only to the knife to alleviate his misery, as the pain round the orbit was become most violent; and therefore intercepted the nerve by an incision across the side of the nose, and also made some smaller incisions about the ala nasi. To divide the great Additional branch lying below the zygomatic process, I found it necessary division of to pass the scalpel through the masseter muscle till it came in contact with the jaw-bone, and then to cut upwards : this re- lieved him as usual. Then the lower branoh was affected, and also divided ; then the middle branch running under the paro- tid gland. In cutting this, the gland was consequently divided into two equal parts, and healed tolerably well after a copious discharge of saliva for several days. " 1 hoped and expected that this last operation would have terminated his sufferings and my difficulties; but the pain still affected the lower lip and side of the nose, and upon coughing, 220 cl. iv.] NEUROTICA. [°RD- "■ Gejv. VI. Spec. I. Neuralgia faciei. and ulti- mate cure. General remarks. or swallowing, his misery was dreadful. This pain could only arise from branches from the second of the fifth pair passing into the cheek, and lying between the pterygoideus internus muscle and the upper part of the lower jaw. The situation of this nerve rendered the operation hazardous, but, after some at- tempts, it was accomplished." This finished the series of ope- rations, and restored the afflicted patient to perfect health. I have dwelt the longer on this interesting case, because it seems to show, first, that there is occasionally no certain cure but in the use of the knife ;* secondly, that a delay in perform- ing the operation only affords time for the disease to spread from one branch of the affected nerve to another, and even to different branches of nerves in a state of contiguity ; and thirdly, that the disease betrays the spasmodic character of the diathesis when minutely watched, even in cases in which this character is most obscure. Dr. Darwin objects properly enough to ar- ranging this disease as a trismus, " since no fixed spasm," says he, " like the locked jaw, exists in this malady." He adds, in- deed, that in the few cases he has witnessed, there has not been any convulsion of the muscles of the face ; but, in Mr. Bos- worth's case, he has expressly noticed the morbid stretching of the arms, and the tendency to epileptic actions. Its proper place, however, seems to be where it is now arranged. Synonym exemplified. Case from which the present spe- cies was first described by the author. Species II. Neuralgia Pedis.—Nerve-ach of the Foot. Racking and lancinating pains ranging about the heel; and tremu- lously shooting in irregular directions towards the ankle and bones ofthe tarsus. This is the neuralgia plantaris of Professor Chaussier: who mentions a very decided case of it, to which Dr. Marino, a phy- sician of Piedmont, had been long subject. It commenced, he tells us, in early life ; was relieved by the mineral waters of Vi- vadio ; and still more by the pressure of a tight bandage. With advancing years it became less severe, the cause of which we have already explained in the preceding species, but never ceas- ed altogether. It alternated with other nervous affections, and was at length complicated with convulsive asthma. In calling the attention of the medical profession to this spe- cies, by introducing it into the volume of Nosology, so long ago as the beginning of 1817, I had my eye directed to a very mark- ed case, which had then lately occurred to me in a clergyman of this metropolis, about forty-five years of age, but otherwise in firm health and cheerful spirits. He had for many years been a victim to it. The paroxysms were short, and of uncertain re- currence, but so acute as nearly to make him faint, and at length compelled him to relinquish the duties of the pulpit, for which, * As this expression may induce young practitioners to promise too much from the operation, the editor deems it right to mention, that the knife has fre- quently failed. cl. iv.] NERVOUS FUNCTION. [ord. ii. 221 from his zeal and eloquence, he was admirably qualified, but G»^- VI> where he had frequently been obliged to break off with great Sp£C- IL abruptness from the unexpected incursion of a fresh paroxysm, ^-[f gla The pain usually extended up the calf of the leg towards the knee, and ramified towards the toes in an opposite direction, and was usually compared by himself to that of scalding verjuice poured over a naked wound. The tibial branches of the popli- teal nerve, and particularly the plantar twigs, seem in this spe- cies to have been the part chiefly affected, though it is probable that some of the offsets from the peroneal branch associated in some instances in the morbid action. Every therapeutic process that the art of medicine in the Curative hands of the most experienced physicians of this metropolis eff?rts ID could devise, was in this case tried in a long and tedious succes- sion in vain. Sometimes external and sometimes internal pre-,, parations, or a tight ligature, appeared to afford a temporary alleviation, and to protract the intervals : but never any thing more. It was in consequence proposed by a surgeon of great Amputation eminence to amputate the leg, which was at one time on the ^^ point of being submitted to, though protested against by the objections present author, on two accounts. First, the uncertainty whe- urged. ther the morbid condition of the nerve might not be seated chiefly in the origin instead of in the extremity of the nerve, in which case, amputation could be of no avail; and secondly, the chance that in process of time the keen sensibility of the affect- ed branches would be worn out and obtunded by the violence of the action. Such was the undecided and miserable condition of tliis patient at the time of noticing his case on the publication of the author's volume of Nosology. Since this period, the prediction that the disease would gradually wear itself out has Cure effect- been completed : the paroxysms are now slight and tolerable, ed by t"ne• and the intervals much longer; and the patient has for nearly a twelvemonth been able to resume the'duties of his profession without any interruption. Species III. Neuralgia Mammae.—Nerve-ach of the Breast. Sharp, lancinating pains divaricating from a fixed point in the breast; and shooting equally down the course of the ribs and of the arm to the elbow; the breast retaining its natural size, complexion and soft- ness. About the year 1820,1 was requested by Mr. Blair to examine illustration a young woman, then eighteen years of age, who, for more than of case on two years, had been subject to a painful disorder of the breast, wnlc1'tl)e that seemed equally to defy all parallel and all mode of treat- ci^sla 8pe ment. On examining into the nature of the symptoms, I found founded. them as described in the preceding definition. The organ was full-formed, soft, and globular, without the slightest degree of inflammation or hardness. When the paroxysm of pain was not Description present, it would bear pressure without inconvenience; but, and progress 222 cl. iv.] NEUROTICA. [ORD. II. Gen. VI. Spec. 111. Neuralgia mammae. ofthe disease. General health unaffected. Prognostics. Course of medical treatment, in every respect unavailing. Failure of nux vomica. during the pain, the whole breast was acutely sensible. The paroxysms returned at first five or six times in the course of the day, and were short and transient: but as the disease became more fixed, it became also more severe and extensive ; for the agonizing fits at length recurred as often as once an hour, and sometimes more frequently : and, from being comparatively con- centrated, the lancinating shoots darted both downward in the course of the circumjacent ribs, and upwards to the axilla, whence they afterwards descended to the elbow, below which I do not know that they proceeded at any time. These fits were at length so frequent aud vehement as to embitter her whole life, and incapacitate her from pursuing any employment; for it frequently happened, that, if she attempted needlework, her fin- gers abruptly dropped the needle a few minutes after taking hold of it, from a mixture of pungent pain and tremulous twitch- ing. The twitching or snatches in the shoulder, for it at length reached to this height, were at one time so considerable as to give the patient an idea, to use her own words, that something was alive there ; while, though the lancinating pain did not de- cend below the elbow, a considerable degree of trepidation reached occasionally to her fingers' ends. Her general health was in the mean time unaffected, and she was regular in men- struation. I had no hesitation in regarding this as a non-descript species of neuralgia; and as little in communicating my fears, that no plan of medicine we could lay down would be more than pal- liative, even if it should prove thus far beneficial, and that we must trust to time alone for a cure, and that obtuseness of sensi- bility, which I have already noticed as a common consequence of high nervous irritation, continued till the organ becomes ex- hausted and torpefied. Every remedial process was, nevertheless, tried in series for the purpose of obtaining relief, if not full success. Bleeding, local and general, frequently and profusely repeated; purga- tives of all kinds ; tonics and antispasmodics of every sort; the hot and cold bath ; electricity and galvanism in every form ; rubefacients, blisters, setons, issues, and whatever else could be suggested, were enlisted into service in succession. But every thing was equally without avail ; nor do 1 know that even a temporary relief was obtained by any of these. Narcotics of all kinds proved impotent: drowsiness, indeed, and a comatose stupor, were hereby in various instances obtained, but the in- terval of wakefulness was as much as ever tormented with the same racking paroxysms. From the powerful influence of nux vomica in many cases of nervous affection, to some of which we shall have the occasion to advert hereafter, I had some hope of producing a slight impression on the nerves affected; but the hope proved illusory : the patient took it in infusion as far as to about eight grains at a dose three or four times a day, till her head was intolerably confused, and every other part became numb, but the paroxysms were intractable. The poor sufferer, whose relations were incapable of afford- cl. iv.] NERVOUS FUNCTION. [ord. ii. 223 concerning case. ing the resources of private practice, tried one dispensary after Gen. VI. another, and at length one ofthe largest hospitals of this metro- Spec. III. polis, without the smallest benefit, and from each was discharg- Neuralgia ed as incurable. About six months since, however, being near- mammae- ly four years from the commencement of the disease at home, ®.,s™s.. , ___i i ; .. i i- • i i n i. i ... diminished and having utterly relinquished all medical means, with the ex- ep0ntane- ception of a seton under the breast, which was not dried up, ously. she began to think herself rather better, and has continued to improve ever since, till a week ago, when her mother came to inform me she was worse again. This intelligence greatly sur- prised me, till I learned that the seton was now quite healed. It has since been opened, and there is a hope of her again im- proving. Thus far was written in the first edition of this work. The Subsequent patient, under the kindness of Sir William Blizard, obtained an inforn^ii°„n entrance into the Margate Sea-bathing Infirmary, and, after five Ju>£r or six weeks' use of the marine-bath, returned home—not in- deed entirely free from pain, but in comfortable ease, and able to resume the use of her needle. About six months afterwards, however, the complaint returned with as much violence as ever, and again the most powerful tonics and antispasmodics were tried in vain. The sub-carbonate of iron, in the fullest doses employed by Mr. Hutchinson, was had recourse to, and steadily persevered in, but to as*little purpose as every other medicine. She has now again returned to the Margate Infirmary, where I hear she has again found benefit. In various cases, however, even in this species, 1 have reason to believe, that the iron has proved as successful as in neuralgia faciei. And Dr. Alderson has given another example, in a very striking instance of mam- mary neuralgia, but in an older and less irritable period of life.* CLASS IV. NEUROTICA. order ni.-mnttkx. DISEASES AFFECTING THE MUSCLES. Irregular action of the muscles or musctdar fibres ; commonly de- nominated spasms. Having, in the Physiological Proem to the present class, General srlanced, as far as our space would allow, at the disputed ques- character of • ' . ., .' <> , • .. i.i-. , .• muscular tion concerning the nature ot muscular irritability, or contracti- fi(,reg ina lity, to adopt the language of Dr. Bostock, and its affinity with massy form. sensorial or nervous influence, it is now only necessary at pre- sent to take a very brief view of the general character and mode of action of musftles as they appear to the naked eye in a *'Cases of Neuralgia Spasmodic:!, <^c. By B. Hutchinson, &c. 8vo. London, 1822. 224 «■■ ,vl NEUROTICA. [ORD. III. Class IV. Ord. III. Cinetica, Effects of muscular action upon muscles themselves. Constitute the cords of the living frame. Approxi- mate the nature of bones, as the latter do of muscles at tlwir extremities. Structure of tendons. Though more com- pact than muscles, often broken by their exertion. Explained. Bones sometimes broken in the same manner. Muscular action pro- duced by a principle peculiar to life: massive form, or in other words, as composed of an almost infi- nite variety of minute fibres. A muscle, thrown into action, increases in absolute weight, in density, and in power of resistance. It is also said to in- crease in absolute bulk, but the experiments upon this subject are contradictory; the middle or belly of the muscle, indeed, is at this time evidently enlarged, but then its length appears to be proportionally diminished. [The ventricular portion of the heart, removed from a large dog immediately after the ani- mal had been hanged, was immersed in warm water, contained in a glass vessel which was closed below with a ground glass stopper, and terminated above in an open vertical tube one third of an inch in diameter. The ventricles continued alter- nately to contract and dilate for a considerable length of time, during which the water stood at the same level in the tube, to- tally unaffected by the varying condition ofthe muscular fibres.*] Muscles constitute the cords, as bones do the levers, ofthe liv- ing frame ; and in most cases the muscles grow tendinous, as the bones do cartilaginous, towards their extremities, by which means the fleshy and the osseous parts ofthe organs of motion become assimilated, and fitted for that insertion of the one struc- ture into the other, upon which their mutual action depends ; the extent and nature of the motion being determined by the nature of the articulation, which is vanied with the nicest skill to answer the purpose intended. Whether, however, the sub- stance of tendons consists of the same fibres as the belly of a muscle, but only in a state of closer approximation, and possessed of finer vessels which do not admit the introduction of red blood, or whether they form a distinct system of fibres, merely attached to those ofthe muscles, is at present undecided. It is certain that tendons possess nothing ofthe peculiar structure of muscles, and seem to be more nearly allied to the simple solid.! It appears singular, at first sight, that the tendinous fibres, which thus seem to be compacted into a firmer and more sub- stantial cord than those of the muscles, should be sometimes broken by muscular exertion, while the muscular fibres remain uninjured; yet this unquestionably depends upon their greater rigidity, and, consequently, inability of yielding to the force by which they are opposed. And hence the bones themselves are sometimes broken in the same manner, as by a violent jerk, or a sudden and spasmodic contraction, of which we shall pre- sently meet with examples, especially in the patella, the ribs, and the arms. The muscles themselves, however, are occa- sionally ruptured by a like irregular violence and excess of power, as the recti abdominis in tetanus, and the gastrocnemii in cramps. Muscular action, then, consists in a mutual attraction and con- centration of the constituent fibres and muscles, in a manner peculiar to living matter; for we cannot,imitate it by any com- * See'Mayo's Anat. and Physiological Commentaries, vol. i. p. 12. . i Sec Dr. Bostock's Elementary System of Physiology, p. 67, 8vo. 1824. cl. iv.] NERVOUS FUNCTION. [ord. hi. 225 bination or action of mechanical fibres. It is not, however, a Class IV. contraction in every dimension, since in this case the muscular 0rd- HI. volume would be diminished ; but, in length only, attended with Cmetica, a proportional increase of bulk, so as to preserve the absolute volume unchanged, or nearly so. It is easy to conceive, from these few remarks, that the force Its force exerted by muscular contraction may be enormous; but by the j^™™".8' mechanical physicians it was calculated in the most extravagant rated by the manner from premises in many instances wholly chimerical, mechanical Thus Borelli estimated the force with which the heart con- P'y^1308, tracts, in order to carry forward the circulation of the blood, to examples of be equal to not less than 180,000lbs. at each contraction ; while miscalcula- Pitcairn, applying the same speculation to the function of di- Uon' gestion, conceived that this process is accomplished by a mus- cular exertion divided equally between the stomach and the auxiliary muscles that surround it, amounting in the stomach alone to the force of U7,088lbs., for which " had he assigned five ounces," says Professor Monro, " he would have been nearer the truth.1'* Yet we do not want these visionary cal- culations to prove the wonderful power possessed by muscular fibres; the facts we have already adverted to, and others we shall have to notice in the course ofthe present order, are suf- ficient to establish their astonishing energy, without having re- course to unfounded hypotheses or exaggerated statements. In general, says Dr. Parr, in a very excellent article upon Law of this subject,? it appears that the force with which a muscle con- "^traction: tracts is in proportion to the number of its fleshy fibres, and the as exhibited extent ofthe surface to which these fibres are attached ; but its in the long degree of contraction, or the extent of its motion, is in propor- ^^Mcles. tion to their length. The limits of contraction differ in the long and in the circular muscles; for the former do not contract more than one third of their length, but the circular fibres of the stomach, which in their utmost dilatation may be expanded to a foot in circumference, may, after much fasting, be reduced to the circle of an inch. It must, however, be added, that in circular muscles no fibres pass completely round; bundles of fibres are collected and end at different points, while some be- gin where others end. Each may, therefore, admit of only a limited contraction, while the dilatation just mentioned may be the sum ofthe whole. The action of muscles never intermits, and is only diminished Action of in the sleeping state ; though, where the sleep is profound and ^8fnfssh°end,y lethargic, the diminution amounts to almost a cessation, except even ;„ in the involuntary organs. When muscles are not exercised (to sleep. use the words of Haller), " the vis insita is very slightly ex- erted ;" but we can still trace its influence by the position which the limbs assume, and discover the relative strength of the antagonizing muscles. Thus we find the flexors stronger than the extensors; for, during sleep, the head falls forward, and the body, legs, arms, and fingers, are slightly bent. The * Homo, Comp. Anat. Pref. p. viii. t Med. Diet, in verb. Musculus. vol. iv. 29 226 cl. iv.] NEUROTICA. [ORD. III. Class IV. OnD. III. Cinetica. VVhy in this state the flexors over- balance the extensors. Illustrated. This doc- trine of use in symptom- atology. Contract- ility widely distinct from elasticity. Compared. Tonicity often uted synony- mously with elasticity. Voluntary or animal muscles as contradis- tinguished from in. voluntary or automatic. Distinctive characters. cause of this additional strength is easily explained ; for the flexors have stronger and more numerous fibres, their insertion is farther from the centre of their motions, and under a larger angle, which must increase when flexion has begun. This su- periority of the flexors bends the fetus in the womb into a round ball. The same superiority of power continues, though in a less degree, after birth, and hence frequent pandiculations are required to give activity and energy to the extensors, which they again lose in advanced age. On awakening from a sound sleep, the same yawnings and stretchings occur from the same cause ; and Bethel fancifully refers the crowing of the cock, and the fluttering of his wings, to a similar purpose. It is al- ways useful in diseases to examine the position of the limbs during sleep, particularly the sleep of children. If they devi- ate from the ordinary degree of flexure to a more straight po- sition, there is generally some irregularity in the state of tone, and of course in the vital influx. The irritability or contractility of a muscle is a very different power from that of elasticity. The latter always depends upon simple re-action, and is never a source of actual energy: it merely restores, in a contrary direction, the force which had been impressed, and the effect which it produces can never be greater than the amount of the cause. But, in muscular con- traction, the mechanical effect produced is infinitely greater than the mechanical cause producing it, as, when the organ of the heart, recently detached from the body just dead, is slightly scratched in its inside by a needle, it will contract so strongly as to force the point of the needle into its substance.* But the chief proof of the difference between the two is, that the ir- ritable power of a muscle is often excited without any mechani- cal cause at all, and from the mere influence of the will, which has no effect upon the simple elasticity of organs. Hence, while contractility belongs to the muscular structure alone, elasticity appertains to many other substances as well, whether animal, vegetable, or even metallic. Muscles also have their elasticity, but the principle is altogether of a different kind, though often confounded with the preceding by modern patho- logists ; and particularly in their use of the term tonicity^, which is often employed with little precision, and frequently means nothing more than this common principle of elasticity, to which indeed it seems directly to be applied by Dr. Cullen. The muscles of the body may be divided into two grand classes, voluntary or animal, and involuntary or automatic. In the former we meet with some that are peculiarly remarkable for strength and continuity of contraction, as the greater part of the round muscles; and others as remarkable for mobility and vacillation, among which we may place most of the long muscles. These properties are strikingly exemplified in a state of disease, and call for particular attention; the muscles cha- * Fordyce, Phil. Trans. 178fS, p. 80. t Bostock, Elein. Syst. oi Physiology, p. IC8, 8vo. 1C24. cl. iv.] NERVOUS FUNCTION. [ord. iii. 227 racterized by mobility presenting examples of atonic or agita- Class IV. tory spasm, while those that are conspicuous for continuity of °RD-II1* action are chiefly subject to rigid or entastic spasm. Cmetica. Continuity of exertion, however, is generally less evident in Continuity the voluntary than in the involuntary muscles, of which last of action in some organs, as the heart, continue their efforts through life JuJ^y0" without intermission ; though all of them relax or remit occa- muscles, sionally or periodically. For this greater permanency and and whence regularity of action they are indebted to the peculiar provision compared which has been made for their supply of nervous power; for with the while the voluntary muscles are furnished in a direct line from supply of the sensorium, whence indeed the close connexion they hold larVmuT with it, the control the will exercises over them, and their ca- des. tenation with the prevailing emotion of the moment, the invo- luntary muscles are dependent chiefly on the intermediate or ganglionic system described in the proem to the present class, and are more remotely connected with the sensorium : they are in consequence far less influenced by the variable impulses of the mental faculties, and are placed beyond the jurisdiction of the will. And hence the tenour of their action is more equable, more permanent, more uninterrupted, and less subject to fatigue or weariness. But as these organs are by no means free from the power of Though injury, or diseased action, they are also subject at times, in com- moSe moo with the voluntary organs, to those abnormal motions which "heiraction are ordinarily denominated spasms : and it is not a little curious still subject to observe the uniform tendency, which different spasmodic af- toabnor- fections manifest towards some organs or functions, rather than "" 'es' towards others. Thus the vital function, in which the heart org^anj and lungs are such prominent agents, is chiefly disturbed by functions palpitation and syncope ; the natural, or that in which the ab- the subjects d. i n , i_ i • j .u of different ommal organs so generally co-operate, by hysterics; and the k;ncis of animal, extending through the range of the voluntary organs, spasmodic by tetanus and epilepsy. In the prosecution of the present or- nlot,0,)S- der, indeed, we shall see that this does not hold universally; A few ex- that epilepsy, for instance, is often a disease rather of the sto- thigeneral mach or intestines, than of any other-organ, and that the heart rule. is sometimes affected with rigid instead of with clonic spasm: but the rule holds generally, and is not essentially shaken by these casual exceptions. Dr. Cullen has contended that, in all spasmodic affections, the Cullen's brain is the actual seat of disease, and that they consist in some doctrine morbid modifications of its energy. " The scope and purpose *'aSd8 of all that he has said," he tells us, " is to establish the general dependupon proposition, that spasmodic affections, whether they arise pri- » morbid marily in the brain or in particular parts, do consist chiefly, and Drain.° "* always in part, in an affection and particular state of the energy ofthe brain : and that the operation of antispasmodic medicines must consist in their correcting this morbid or preternatural state in the energy of the brain, by their correcting either the state of preternatural excitement or collapse, or by obviating the too sudden alteration of these states." 228 cl. iv.] NEUROTICA. [ORD. III. Class IV. Ord. III. Cinetica. Origin of fori its errone- ousness pointed out This proposition seems rather to follow from Dr. Cullen's singular doctrine concerning the mutable condition of the ener- gy of the brain, and the immutable nature of the nervous power, which is propagated from it by vibrations, than from the clear accounted"6 face of facts before us- Spasms, in many instances, are alto- gether local; they are confined to particular muscles, or parti- cular sets of associate muscles, and have no effect on the brain whatever, so as to disturb its energy; of which we have exam- ples in hiccough, priapism,* chorea, and often in palpitation. They depend upon some irritation existing not at the origin but at the extremity of the nerves : and where such is their source, even though the chain of morbid action should at length reach the brain and affect its energy, as in convulsions from teething, epilepsy from worms, or some palpitations from ossific or poly- pous concretions, all the antispasmodics in the world will afford no relief, so long as the local cause of irritation continues to operate; while the moment this is removed, where it is capa- ble of removal, as by the use of a gum-lancet or active anthel- mintics, all the powers of the brain become instantly tranquil- lized ; its faculties are rendered clear, its energy is re-invigor- ated, and its motive power or sensorial energy is distributed in an uninterrupted tenour. The greater number of spasmodic affections, therefore, do not so much depend upon the state of the brain, as of the living fibres that issue from it, and maintain a correspondence with it; for the stream may be vitiated while the fountain is untouched. We have seen, indeed, in the proem to the present class, from the concurrent results of various phy- siological experimenters, that although, while the organ of a brain exists, it exerts a certain influence over the principle of muscular motion, this principle is far less dependent upon the encephalon, than that of general feeling or of the local senses; that it is found abundantly in animals totally destitute of a brain; and that, hence, those possessing a brain may be excited not only into abnormal and spasmodic, but even into a continuation or re-production of regular and natural, motions of various mus- cular organs after the brain-has been separated from the spinal chain, by stimuli applied to this chain, or even by the artificial breath of a pair of bellows. We have seen, also, that the nervous filaments ofthe muscles are of two kinds, sensific and motific, the former proceeding from the cerebellum, or the posterior trunk ofthe spinal chord, to which it gives rise, and the latter from the cerebrum, or an- terior trunk ofthe same double chord ; and as these two sets of filaments do not necessarily concur in the same affection, it is obvious that the muscles of a limb, or of the whole body, may be thrown into the most violent agitation, or the firmest rigidi- ty, without much, or perhaps any degree of painful emotion or Why often increased sensibility. And we can hence readily account for the felt during little complaint that is made by patients upon this subject, on Bevere fits of • tetanus or . * hlR cannot be explained by the action of any muscle, and consequently convulsions. >s not a spasmodic affection.—Ed. Argument farther illustrated Sensific and motific Bhies. Spinal chord double. cl. iv.] NERVOUS FUNCTION. [ord. hi. 229 their being freed from a severe paroxysm of tetanus, convul- Class IV. sion-fit, or hysterics. Ord. hi. The following are the genera of diseases which will be found Cinetica. to appertain to the present order: I. ENTASIA. CONSTRICTIVE SPASM. II. CLONUS. CLONIC SPASM. III. SYNCLONUS. SYNCLONIC SPASM. GENUS I. ENTASIA.—CONSTRICTIVE SPASM. Irregular muscular action producing contraction, rigidity, or both. Entasia is derived from the Greek arxris, " intentio," " ve- Origin of hementia," " rigor," from arum, " intendo." By many nosolo- generic gists the genus is called tonos, or tonus, which is here dropped "tgl,nlecan('-t in favour of the present term, because tonus or tone is employ- explained. ed by physiologists and pathologists in direct opposition to ir- regular vehemence or rigidity, to import a healthy and perfect vigour or energy ofthe muscles ; and by therapeutists to signify medicines capable of producing such or similar effects. The genus entasia includes the following species : 1. ENTASIA PRIAPISMUS. PRIAPISM. LOXIA. WRY-NECff. 3. ■ RHACHYBIA. MUSCULAR DISTORTION OF THE SPINE. 4. ■ ARTICULARIS. MUSCULAR STIFF-JOINT. 5. ------- SYSTREMMA. CRAMP. 6. ------- TRISMUS. LOCKED-JAW. 7. ------- TETANUS. TETANUS. 8. ------- LYSSA. RABIES. CANINE MADNESS. 9. ------- ACROTISMUS. SUPPRESSED PULSE. Species I. Entasia Priapismus.—Priapism. Permanent rigidity and erection of the penis without concupiscence. The specific term is derived from the name of Priapus, the origin of son of Venus and Bacchus, who is usually thus represented in the specific paintings and sculptures, but with a concupiscent feeling. Galen name- applies the term also to females, as importing a rigid elongation ^"c11!*64 of the clitoris without concupiscence. y Spasm is, in all instances, a disease not of vigour, but of de- Peculiarly bility with a high degree of irritability: and there is no case in a disease of which this is more striking, than in the present species. It has Ability- been found occasionally in infancy; but it is far more frequently an attendant upon advanced years. It has sometimes also fol- lowed cold, and especially local cold, clap, dysury, and the use of cantharides. It has at times been a result of free living, and particularly hard drinking. The spasms consist in a stiff and 230 Gen. I. Spec. I. Entasia priapismus. Sometimes chronic. CL. IV.] NEUROTICA. [ord. HI. Cure difficult. permanent contraction of the erectores penis,* unconnected with any stimulus arising from a fulness of the vesiculae semi- nales. Dr. Darwin says he had met with two cases, where the erec- tion, producing a horny hardness, continued two or three weeks without any venereal desire, but not without pain. The easiest attitude was lying upon the back with the knees bent upwards. The corpus cavernosum urethrae at length became soft, and in a day or two the whole rigidity subsided. One of these patients had been a free drinker, had a gutta rosacea on his face, and died suddenly a few months after his recovery from the present complaint. It is singular, that this spasm should sometimes con- tinue after death; at least we have accounts of such cases in Marcellus Donatus and other writers. As the disease is a case of both local and general debility, its cure is in most instances difficult. Antispasmodics and tonics are the only medicines that promise relief, as camphor, opium, bark, warm aromatics, warm-bathing, cold-bathing: but the whole are often tried without effect. [In the case which surgeons most frequently meet with, name- ly, that excited by the irritation of ulcers and excoriations about the glans, or by gonorrhoea attended with chordee, the most effectual treatment is the antiphlogistic, combined with antispas- modics. This is quite inconsistent with the notion of the com- plaint being connected with debility, a notion that has no foun- dation, except the author's hypothesis of the cause of spasm.] Origin of specific term. Causes. Species II. Entasia Loxia.— Wry-Neck. Permanent contraction of the flexor muscles on the right or left side of the neck, drawing the head obliquely in the same direction. The term loxia is derived from the Greek, Ao|*?, " obliquus, tortus;" whence loxarthrus in surgery, an obliquity of a joint of any kind, without spasm or luxation. By the Greeks, however, the term was specially applied to the joints or muscles of the neck. This disease, in its genuine form, proceeds from an excess of muscular action, particularly of the mastoid muscle on the con- tracted side. But we frequently meet with a similar effect from * ^kat the author has fallen into an error in representing priapismus to be a species of constrictive spasm, cannot be doubted ; because erection of the penis is not really produced by the action ofthe erectores muscles, as they are termed, but by the injection and disten- tion ofthe glans, corpus spongiosum urethrae, and corpora cavernosa with blood. " Each of the crura penis gives attachment at its origin to a tolerably strong muscle named the erector penis, probably because, when a power capable of producing the effect indicated by that name was sought by anatomists, this muscle seemed to be their only resource. At present the name appears very ill adapted, since the muscles in question obviously draw the penis downwards and backwards, instead of upwards and against the pubes. Those who explain the erection of the penis by the compression of its vein, should find out a power capable of elevating the organ against the bone, and of carrying it forwards."— (See Rees's Cyclopaedia, art. Generation.) In fact, mechanical pressure of the vein will not produce erection.—Ed. cl. iv.] NERVOUS FUNCTION. [ord. in. 231 two other causes : one in which there is a disparity in the Gen. I. length of the muscles opposed to each other, and consequently Stkc- J1, a permanent contraction on the side on which they are shortest; Entasia and the other in which, from cold or a strain, there is great de- bility or atony on the side affected, and, consequently, an incur- vation of the neck on the opposite side, not from a morbid ex- cess, but an overbalance of action. This species, therefore, offers us the three following va- rieties : x Dispars. From disparity in the length of Natural wry-neck. the muscles opposed to each other. /3lrri tata. From excess of muscular action Spastic wry-neck. on the contracted side. y Atonica. From direct atony of the muscles Atonic wry neck. on the yielding side. The first variety is mostly congenital, though sometimes *E. Loxia produced by severe burns or other injuries. And a like effect dl!1Pars> occasionally issues from a cause that may be noticed in the pre- Most,y sent place, though not connected with a morbid state ofthe mus- Occasional cles,—a displacement of the muscles from an incurvation in the causes. vertebrae of the neck ;* by which, though the antagonist mus- cles be of equal length and power, those on the receding side ofthe neck are kept on a perpetual stretch, while those on the protruding side are in a state of constant relaxation. The other two varieties are commonly the result of cold, or inflammation, ^e. Loxia or a strain ; often by carrying too heavy loads on the head. M. irritata. Boyer gives instances ofthe disease produced by moral causes: yE. Loxia and Wepfer relates the case of a man who had a wry-neck, oc- atonica. casioned by a convulsive action ofthe muscles on one side of the neck, which appeared whenever he was tormented by chagrin, but ceased as soon as he was restored to a state of mental tran- quillity.! The cure must depend upon the nature of the cause. In Mode of colds and strains, warmth, the friction of flannel, and the stimu- treatment- lus of volatile or camphor liniment combined with opium, will be found most serviceable, as tending to diminish pain, and re- store action to the weakened organ. In direct spasms the same process will also frequently be found useful ; but the application of cold water will often answer better. [The editor was lately consulted by a gentleman, whose right sterno-cleido mastoideus muscle is not only affected with permanent and rigid spasm, but has attained a vast increase of bulk and force. Under the di- rection of Dr. Babington, Mr. Brodie, and Mr. C. Bell, the pa- tient has tried various narcotics, ammoniated copper, and differ- ent local applications, without benefit. The editor recommend- ed a seton in the nape ofthe neck, and friction over the muscle * In almost evpry instance, the change in the bones is the consequence of the long-continued action of the preponderating muscle. This doctrine, which is maintained by Jorg, is now generally admitted.—Ed. t Traite dc Maladies Chirurgicales, &c. torn. vii. 8vo. Pari*, 1821. 232 cl. iv.] NEUROTICA. [ord. III. loxia. Gen. I. with camphorated mercurial ointment, with a course of Plum- Spec. ii. mer's pill, combined with hyosciamus and conium, and occasion- Entasis ai purgatives; but the patient has not yet had courage to begin the plan. In this case, the wry-neck is evidently associated with considerable disorder of the nervous system ; and the pa- tient can only lift a glass to his mouth by using both hands for the purpose.] Where the antagonist muscles are of unequal length, the case lies beyond the reach of medical practice, and, if relieved at all, can only be so by a surgical operation. If the cervical vertebrae be incurvated, but the bones sound, the dis- ease may not unfrequently be made to yield to a skilful appli- cation of machinery by the hands of an ingenious surgeon. It sometimes happens, however, that the bones in this case are soft and occasionally carious, and the slightest motion of the head is attended with intolerable pain. Setons have here been found serviceable, with an artificial support of the head ; but this kind of affection is often connected with a constitutional soft- ness of the bones, of which we shall have to treat in the first order of the sixth class, under the head parostia Jlexilis. Various kinds of spinal distortion. distortion as first describ- ed by Pott; scrofulous and produc- ing caries. Rhacbetic source. Species III. Entasia Rhachybia—Muscular Distortion of the Spine. Permanent and lateral curvature ofthe spine, without paralysis ofthe lower limbs : muscles ofthe back emaciated; mostly without soreness upon pressure. Distortion of the spine is produced in various ways; and it is chiefly owing to a want of due attention to this fact, that so much confusion has of late prevailed respecting the real nature of the particular case to be treated, and the particular treatment that ought to be adopted. The disease, under this general name, was first introduced before the public with any considerable degree of notoriety by Mr. Pott, as connected with a palsy of the lower extremities, and as dependent upon a scrofulous diathesis; which at length fixed itself upon some part ofthe vertebral column, softened or rendered carious the bones that became affected, and hereby necessarily produced crookedness, and a morbid pressure upon the right line of the spinal marrow. This is a case that often happens, and a like effect occasion- ally occurs in a very early period of life, from a rhachetic instead of a scrofulous diathesis; though, from the greater facility with which the principle of life is able to adapt itself to deviations from the ordinary laws of health at this latter period than after- wards, a paralysis of the lower extremities is less common, and even the mischiefs incidental to a misformation of the chest less fatal. So that while the disease of a hump-back can rarely take place in puberty or later life, without a serious injury to almost every function, we often find it occur in infancy without making much encroachment on the general health. cl. iv.] NERVOUS FUNCTION. [ord. in. 233 In all cases of this kind, the malady is primarily and idiopa- Gen. I. thically an affection ofthe vertebral bones ; and there is always Spec. III. to the touch a mollescence in their structure, or a manifest sore- ^ntahs'?. ness and ulceration. And, from the peculiar contour ofthe ver- 'lac y l ' tebral column, the distortion is always from within outwards, CHgeg ,|ie forming what has been called an angular, in contradistinction to disease a a lateral curvature. So that the characters of the osseous gib- p""1^ bosity are sufficiently clear and specific. tne bones. But the muscles of the vertebral column, and their append- producing ages, the ligaments and cartilages into which the latter are in- angular dis- serted, are of as much importance to its healthy contour as its opp^"d^0 bones. And hence any morbid affection of these several struc- lateral. tures may as essentially interfere with the natural curve of the Muscular spine, and the well-being of the constitution, as a disease of the ligamentous vertebral bones. Jjj,"', It is possible that these are all affected in particular instances, contortion. sometimes separately, sometimes jointly ;* but there can be no These doubt, that the muscular fibres of the neck, back, and loins, °^ganti those on which all the complicated movements ofthe vertebral affeaeT column depend, and which compose more than three hundred singly, distinct muscles in the whole, are most frequently thus enfeebled sometimes either in part or in their entire range ; though an enfeebled state J™ ^st of any of these organs must produce an inability of preserving frequently the spine in its natural sweep and equilibrium. And where dis- the muscles. tortion proceeds from this cause, the indications are in most in these cases as clear as where it is the result of a diseased condition of cases the the bony structure : for first the morbid curvature, instead of j^rai'0" being from within outwards, takes place laterally, the crooked- alone. ness being manifestly on the right or the left side, according as the muscles on the one side or the other overpower the action of their antagonists; there is little or no soreness upon pressure, unless indeed the bones or their cartilages should ultimately be- come affected from the protracted state ofthe disease ; and the distortion being less abrupt or angular than in the ossific gibbo- sity, the lower limbs are not affected with paralysis. The distinction, therefore, between the osseous and the mus- Distinction cular distortion of the spine is clear and definite; and, so far as ^H^y regards the peculiar character of the curvature, was minutely writers. noticed by the Greek writers, who identified the first by the names of lordosis or cyrtosis, according as this curvature was Lordosis, anterior or posterior, and the second or the lateral curvature by * ^.g the term hybosis, from voos (hijbus), incurvus. It is from this term ^i.518 that the author has derived the name which he has ventured to Hybosis, assign to the present species—rhaciivbia—as an allowable con- what. traction of rhachyhybia, literally spinal inflexion. Swediaur has denominated it, from the same source, hyboma Scoliosis.] The distinction is very accurately pointed out by Mr. Pott, Well di«- who,—while he affirms that " the ligaments and cartilages of Jjri,lp^i{,ed the spine may become the seat of the disorder (scrofula) without y any affection of the vertebrae;" in which case "it sometimes * Copland's Obseivationson the ^pinc, p. IJ. t Tom. ii. p. 740. VOL. IV. 30 234 cl. iv.] NEUROTICA. [ord. 1)1. Gen. I. Spec. III. Entasia rhachybia. Pott's views too often mistaken, and why. Views of Baynlon ; of Wilson; of Lloyd: happens that the whole spine, from the lowest vertebrae of the neck downwards, gives way laterally, forming sometimes one great curve to one side, and sometimes a more irregular figure, producing general crookedness, and deformity of the whole trunk of the body, attended with many marks of ill-health ;"•— yet admits that paralysis of the lower limbs never accompanies cases of this sort, so far as his experience had extended, nor even that untempered and mis-shapen structure of the spine, which occurs at birth or during infancy from a rhachetic soft- ness of the bony material. " I have never," says he, " seen paralytic effect on the legs from a malformation of the spine, however crooked such a malformation might have rendered it, whether such crookedness had been from time of birth, or had come on at any time afterwards during infancy.—None of those strange twists and deviations which the majority of European women get in their shapes from the very absurd custom of dress- ing them in stays during their infancy, and which put them into all directions but the right, ever caused any thing of this kind, however great the deformity might be. The curvature of the spine, which is accompanied by this affection ofthe limbs, (i. e. that which takes place from a diseased condition of the bones themselves subsequently to childhood, and from a supposed scrofulous diathesis), whatever may be its degree or extent, is at first almost always the same ; that is, it is always from within outwards, and seldom or never to either side." Now it has unfortunately happened, that as Mr. Pott's re- marks were written chiefly to explain this last form of spinal dis- tortion, and addressed to the single cause of scrofula, the hints he has given respecting distortions from every other cause have been too often forgotten ; and the moment a young female is found to have a tendency to a vertebral distortion of any kind, it has too generally been taken for granted that the bones were in a diseased state, or on the point of becoming so ; that the pa- tient was labouring under the influence of a strumous diathesis, which was manifesting itself in this quarter; and all the severe measures of caustics or setons, with an undeviating permanent confinement to a hard mattress, or inclined plane, for many weeks or months, which a strumous affection of this kind calls for and fully justifies, has been improvidcntly had recourse to, with a great addition to the sufferings of the patient, and, in many in- stances, no small addition to the actual disease which has been so unhappily misunderstood. Mr. Baynton seems justly chargeable with having adopted this general view of the subject, and extending it indiscriminately to every case. Mr. Wilson, who, though he conceived the disease to originate in a rhachetic rather than a strumous diathesis, and had recourse, as we shall observe presently, to a different mode of treatment, seems to have stretched his parallel hypothesis over the same extent of ground. And Mr. Lloyd, who has lately favour- ed the profession with a valuable work on the same subject, in like manner contemplates every case of spinal distortion as issuing from a common and that a strumous cause ; to which cause also it cl. iv.] NERVOUS FUNCTION. [ord. nf. 23f) has since as uniformly been assigned by Dr. Jarrold.* Mr. Lloyd, Gen. I. correctly indeed, distinguishes between the angular and the lat- Spec III. eral curvature ; and with equal correctness observes that " in Entaria the former there is always some destruction of some portion of rhachybia. the vertebral column, and often, for a considerable time, pro- and Ja^^0,d• gressive destruction of bone, cartilage, and ligament, and the vertebrae undergo precisely the same changes as the extre- mities of other bones in scrofulous diseases of the joints:" while he adds that " in the latter there is no destruction of parts, but merely an alteration of structure;" that " a wasting of the muscles always attends it in a greater or less degree;" and that "it has been supposed by some authors that the cause of the curvature is entirely in the action of the muscles. But al- though," he continues, " this may be and most probably is the immediate cause, I am much more inclined to believe, that the primary cause is in the vertebrae ; that scrofulous action is set up in them, which increases their vascularity, and softens their texture." Here, then, is a distinct recognition of the two forms of mor- General bid distortion of the spine, to which 1 am anxious to direct the admission. attention of the reader: and each of them is allotted its pecu- Two chief liar seat and diacritical signs; the bones with manifest injury ?nd dl*',nct of the bones, and the muscles with manifest injury of the mus- 6pinal cles. The rest is matter of mere hypothesis, and needs not distortion. urge us into a discussion. So obvious and so much more common indeed is muscular, The mus- than osseous distortion of the spine, that other pathologists, cular ,nost ■»- o * common * from this fact chiefly, have contended, that this is the only form and hence of the disease in its commencement. Such was the opinion of by some the late Mr. Grant, of Bath, and such is the opinion of Dr. Dods, '^°^e of the same city, in an interesting tract he has lately published form of on this subject;! while Dr. Harrison refers its origin to the contortion. connecting ligaments of the vertebrae. " These," he observes, Opinion of " get relaxed, and suffer a single vertebrae to become slightly ^DoVg. displaced;" in consequence of which, he adds, "the column of Harrison: loses its natural firmness, other bones begin to press unduly upon seated sole- the surrounding ligaments; they in turn get relaxed and elon- J-onnecthie gated, by which the dislocation is increased, and the distortion ligaments. permanently established. The direction becomes lateral, ante- rior, or posterior, according to circumstances ; but the malady has, in every instance, the same origin, and requires the same mode of cure."J There is much ingenuity in this explanation, and I have no This last doubt, that it is a correct expression of various cases of verte- hypothesis, bral distortion. It chiefly fails, like the osseous hypothesis, in J,' ® ^ too wide a spirit of simplification, and in allowing no other limited. origin in any instance, than that which forms the key-stone of its own pretensions. Admitting the disease to commence in the illustrated. * Inquiry into the Causes of the Curvature of the Spine, with suggestions, &c. 8vo. lfl-4. t Pathological Observations on the Rotated or Contorted Spine, Svo. Lond. lo'iI. X Lond. Med. a:id Phys. Journ. No. cci/xiv. 236 Gen. I. Spec. III. Enta-ia rhachybia. et. iv.] NEUROTICA. [ORD. III. Whence the change that occurs in the relative position of various ver- tebra? or their processes. Subject differently explained : by Harri- son ; by Dods. Double curvature accounted for. Rotation of the vertebrae. connecting ligaments, the associating muscles must soon be in- volved in the mischief; while, if it commence in the latter, the ligaments which unite them to the bones cannot long continue unaffected. So that the question is merely one of primogeni- ture, and imposes little or no difference in the mode of treat- ment. Nay, even the bones themselves, by being irregularly pressed upon, may at length suffer in such parts from increased absorption, become thinner and more spongy, or even ulcerate and grow carious; so as, in process of time, to give a direct proof of osseous or angular contortion, though induced instead of taking the lead. One ofthe chief difficulties, in cases where we have no rea- son to apprehend a morbid state of the bones, consists in ac- counting for the change that seems to take place in the relative position of several of the vertebrae or their processes; and es- pecially in the greater elevation or prominence of their trans- verse processes on one side, while those on the other are scarce- ly perceptible. And it is in truth chiefly to solve this question, that most of the hypotheses of the present day are started in opposition to each other. The idea of an actual dislocation of the vertebral bones, which enters into that of Dr. Harrison, would sufficiently account for the fact, if such a dislocation could be unequivocally shown. But while the change of position does not seem in any instance to amount to a complete extrusion of a vertebrae from its seat of articulation, the ease and quietude with which, under judicious management, it often seems to re- cover its proper position, and to evince its proper shapes, are inconsistent with the phaenomena that accompany a reduction of luxated bones in every other part ofthe body. The explanation therefore has not been felt satisfactorily to a numerous body of pathologists ; and Dr. Dods has hence of- fered us another solution, which is also highly ingenious, and may perhaps in the end be found correct in those cases in which the miscurvature is very considerable, and especially where it becomes double or assumes a sigmoid figure. He supposes, in the first place, that the whole disease in its origin is seated in the extensor muscles of the back, or that part of them to which it is confined: more especially in the quadratus lumborum, sacro-lumbalis, and longissimus dorsi. He supposes, next, that the right hand being habitually more exerted than the left, the effect of such surplus of force, in consequence of our throwing the body towards the left to preserve its centre of gravity, and hence strongly contracting the muscles of this side ofthe spine, must fall in a greater degree upon those muscles, and more dis- pose them " to suffer disorganization and become contracted;" and he hence accounts for the greater frequency of contortion on the right side than on its opposite. He then proceeds to account for the single or double curvature which the contortion effects, by remarking, that the morbidly contracted muscles of the left side, in overcoming the action of the muscles of the right, do not drag the vertebrae forward towards themselves in a direct line, but rotate the vertebra) to which they arc at- CL. IV.] NERVOUS FUNCTION. [ord. m. 237 tached, because of the angles formed, relatively, between the Gen. I. vertebrae and the pelvis (the points of origin and insertion of Spec III. these muscles), and the force of their contraction acting upon Entasia moveable, horizontal, or transverse levers, namely, the trans- rhachybia- verse processes ofthe vertebrae.* Morbid curvation of the spine, therefore, in the opinion of Dr. Effects of Dods, does not consist in an evulsion of separate vertebrae from suchrota- their natural course and position, but in a twist of a great part torycha°8e- or the entire column, by which means the morbid lateral flexure is nothing more, than the natural sigmoid sweep of the verte- bral chain, wrested more or less round to one side, as by the turning of a corkscrew. Whatever displacement is met with in the ribs, or the other bones of the chest, is necessarily a result of this first deviation from the line of health. " All the ribs," he observes, " have a double attachment to the vertebrae ; one, by their heads, to the bodies of them, and the other, by their tubercles to the transverse processes. When the vertebrae, then, are made to rotate upon each other, in the manner described, by the per- manent contraction, and this, for example, to the right side, which is the more frequent direction they take, from the causes noticed, they, by this movement, push out or backwards the heads of the ribs of the left side, and force their sternal ex- tremities considerably forward, because of the quick circular turn which the ribs make between their angles and their points of attachment to the vertebrae, and the very small motion, from such a formation of them, requisite here to produce them. To- gether with this movement of the ribs, which produces the pro- jection of the left side of the chest in front, they are also made, from their double attachment to the vertebrae, to fall down and approximate, or, as it were, overlap each other, at their an- gles. This causes that hollowness or sinking in ofthe left side of the chest behind. The falling down of the ribs here des- cribed appears to me to be in part owing, also, to the per- manent contraction of the sacro-lumbalis muscle, which is in- serted into all their angles. While these movements take place with the ribs on the left side of the body, the very opposite, of necessity, happens to those on the right. By the rotatory movement of the vertebrae, the ribs on the right side have their heads contrary to those on the left, drawn inwards, and their sternal extremities made to recede backward, while their double connexion with the vertebrae causes them, contrary also to those of the left side, to be raised up and separated from each other at their angles. This rising up and separation ofthe ribs at their angles is what produces the projection ofthe right side of the chest behind." From this general change of position, and particularly the Morbid twist of the ribs, Dr. Dods accounts for the unnatural situation situation of of the scapula;, and in many instances of the clavicles and the scapula .11 r ■ ■- i i- .i -i^i ii „ , accounted sternum, with the falling down ot the right shoulder. He ob- ror. * Ut supra, p. 93. 238 cl. iv.] NEUROTICA. [ORD. III. Gew. I. Spec III. Entasia rhachybia. Hypothesis ingenious: but cannot be adopted exclusively. The muscu- lar form of distortion most com- mon in the present day. Explained. Muscular debility the proximate cause. Commence- ment of the disease, where chief- ly found. serves, moreover, that though the contortion of the spine most frequently takes place to the right side, yet that it occasionally takes place to the left; that the whole column is not always moved round, but only a part of it; and that hence, instead^ of a profile of three morbid flexures brought into view, which invariably follows in the former case, we have often a profile of only two : and that where the muscles of both sides of the co- lumn become contracted from position, which sometimes takes place, the greater number of the vertebral joints acquire an ancylosis, and the body is arched backwards. There is much ingenuity through the whole of this explana- tion, which plausibly accounts for that ridgy line of projection so frequently felt on the left side of the loins, when the morbid curvation is on the right, ascending nearly to a level with the spinous processes, while there is not only no such ridge on the opposite side, but even no appearances of the transverse pro- cesses. Upon the hypothesis before us, these processes are conceived to be equally elevated on the one side and depressed on the other, which gives us the two phaenomena of an unnatu- ral and ridgy prominence in the former line, and of an unnatu- ral disappearance in the latter. The hypothesis nevertheless (for at present it cannot be entitled to a higher appellation) re- quires farther elucidation and support; and, after all, can never altogether reach the precise object at which it aims, that of establishing itself at the expense of every other view, and es- pecially of subverting the doctrines of a diseased action of the other moving powers or their appendages, the ligaments ofthe spinal muscles, or the cartilages into which they are inserted; a morbid condition of which is often capable of proof from the very limited area of pain and tenderness to which, on pressure, the disease seems to be confined: to say nothing ofthe affection ofthe vertebral bones themselves, in which, as already observ- ed, spinous distortion sometimes commences, though from a very different source, and in which, even when derived from the source now contemplated, it sometimes terminates. There can be no doubt, however, that the spinal distortion of the present day is a disease far more frequently of the mus- cles and their appendages than of the bones, and is the result of a want of equilibrium between the antagonist forces on the one side and on the other of the vertebral column, as well those of the trunk as of the back ; in consequence of which this column is deranged in its natural sweep, and either twisted or deflected in particular parts, or in its whole length : all the other changes in the general figure, and deviations from the general health, being dependent upon this primary aberration. It is hence a disease of muscular debility or irregular, and hence clonic, action in the fibres of the yielding muscles, and an inability to resist the encroachment that is made on them by their more powerful antagonists. The complaint almost invariably shows itself from the age of puberty to that of mature life, though sometimes later ; and is nearly limited to females, and, among females, to those of deli- cl. iv.] NERVOUS FUNCTION. [ord. hi. 239 cate habits, and who are especially disciplined in the false and Gew. I. foolish rules for obtaining a fine figure. It is hence a perpetu- Spec III. al inmate in our public female schools, and is by no means an Entasia unfrequent attendant upon domestic education. rhachybia. The progress of the disease may be so easily collected from the physiological survey we have already taken, that a few words in addition is all that is necessary to be added. The complaint first shows itself by a general listlessness and Progress. aversion to muscular exertion of any kind, and an unwonted desire- to lounge and loll about. No signs of constitutional dis- ease, however, are as yet manifest; the nights are not disturb- ed, the appetite does not fail, the evacuations are regular, and the pulse unaffected. There is soon afterwards a sense of weariness, and even at times uneasiness, about the back, and especially the loins; and if the muscles of these parts be mi- nutely examined, several of them will give proof of flaccidity and extenuation. If no steps be taken at this time to arrest the disease in its march, or if the steps taken be injudicious or in- adequate, the vertebral column will soon be involved in the morbid action; and especially, as Mr. Ward observes, " on the occurrence of any particular disturbance to the constitution:*" its numerous joints will lose their nicely adjusted poise; they will in various parts be left too loose on the one side, and drag- ged too rigidly on the other; and the elegant contour of the spinal chain will progressively be broken in upon. All the Sequel of other changes, whether upon the general form or the general &ene*?**a'1 health, which progressively take place in the advance of the tional disease, are entirely consecutive upon the symptoms before us, mischief. and may be anticipated by any one. From the morbid contest which is thus continually going on between the antagonist mus- cles, their internal organization must necessarily become great- ly affected, and the growing debility, which is manifest in the contractile and extensile power of their aggregate fibre, will enter into every part of every separate fibril, and affect their vis insita. The debility and irregular action of one muscle will spread by sympathy or association to various others; and from the derangement of the bones of the spine and the chest, the functions of respiration and digestion, and consequently, in a greater or less degree, all the other functions of the body, must be interfered with in their respective powers, so that there is scarcely any other disease but may follow : and the frame will become generally emaciated. As the proximate cause is debility of the extensor mus- Occasional cles of the back or loins on either side, the occasional cause causes- will consist in whatever has a tendency to produce such debili- ty. Too rapid growth is a frequent source of this complaint; Too rapid a casual strain of the muscles on either side is a source not less Sr°wth: common ; chlorosis or any other constitutional weakness may chlorosis: lead to the same effect; and assuredly the use of stiff and gird- * Practical Observations on Distortions of the Spine, Chest, and Limbs, p. 36, 8vo. 1822. 240 cl. iv.] NEUROTICA. [oRD- m. Gew. i. ing stays, or any other part of that fashionable compression which Spec III. is designed, in the school-discipline ofthe present day, to mould Entasia fae forra into a somewhat different and more graceful shape, rhachybia. thgn perhaps the njggar(i hand of nature has intended—such as »Sh(|o1". back-boards, braces, steel-bodices or steel-crutches, spiked col- tbo'd'ay.6 ° lars5 neck-swings, and even education-chairs. The tendency of all these to produce deformity where it does not exist, and to aggravate it where it does, is forcibly pointed out by Dr. Dods; who nevertheless seems to censure, with rather more acrimony than needful, the whole system of school-drilling education, as How far practised in many of our most fashionable establishments. A Jlinemay'be course of discipline for giving grace and elegance to the grow- salutary: ing form, if conducted with judgment, devoid of rigorous com- pression to the expanding organs, and allowing a sufficient al- ternation of relaxation and ease, so far from being injurious to the health and strength of the general frame, has a natural tendency to invigorate it. But the greater frequency of the lateral distortion of the spine in our own day, compared with its apparent range in former times, together with the increased coercion and complication of the plan laid down in many of our fashionable schools for young ladies, seems clearly to indicate, that some part at least of its increased inroad is chargeable to but appears this source : and the following remarks of Mr. Pott upon the toobfaCrain'ed various instruments applied to a growing girl in order to pre- manyr" vent a crooked shape, have a wider claim to attention in the places: present day, than when they were first given to the world. observed b " These?" savs nei " are used witn design to prevent growing observe y c|jj|jren from becoming crooked or mis-shapen; and this they are supposed to do by supporting the back-bone, and by forcing the shoulders unnaturally backwards. The former they can- not do ; and in all cases where the spine is weak, and therefore in- clined to deviate from a right figure, the latter action of these instruments must contribute to, rather than prevent, such devia- tions, as will appear to whoever will, with attention, examine the matter. If, instead of adding to the embarrassment of children's dress by such iron restraints, parents would throw off all of every kind, and thereby give nature an opportunity of exerting her own powers ; and if, in all cases of manifest de- bility, recourse were had to friction, bark, and cold-bathing, with due attention to air, diet, exercise, and rest; the children of the opulent would perhaps stand a chance of being as stout, as straight, and as well shapen as those of the laborious poor." Unculti- The simple fact is, that the system of discipline is carried vatedcom- j0() faFi anj rendered much too complicated; and art, which cultivated should never be more than the hand-maid of nature, is eleva- youth. ted into her tyrant. In rustic life we have health and vigour, and a pretty free use of the limbs and the muscles, because all are left to the impulse of the moment to be exercised without restraint. The country girl rests when she is weary, and in whatever position she chooses or finds easiest; and walks, hops, or runs as her fancy may direct when she has recovered herself; she bends her body, and erects it as she lists, and the cl. iv.] NERVOUS FUNCTION. [ord. hi. 241' flexor and extensor muscles are called into an equal and harmo- Gew. I. nious play. There may be some degree of awkwardness, and Spec. ill. there generally will be, in her attitudes and movements; and Entasia the great scope of female discipline should consist in correct- rhacl)J'bia- ing this. With this it should begin, and with this it should ter- minate, whether our object be directed to giving grace to the uncultivated human figure or the uncultivated brute. We may modify the action of muscles in common use, or even call more into play than are ordinarily exercised, as in various kinds of dancing ; but the moment we employ one set of muscles at the expense of another, keep the extensors on a full stretch from day to day by forbidding the head to stoop, or the back to be bent; and throw the flexors of these organs into disuse and neglect; we destroy the harmony of the frame instead of ad- ding to its elegance ; weaken the muscles that have the dispro- portionate load cast upon them, render the dejected muscles torpid and unpliant; sap the foundation of the general health, and introduce a crookedness of the spine instead of guarding against it. The child of the opulent, while too young to be fettered with a fashionable dress, or drilled into the discipline of our female schools, has usually as much health, and as little tendency to distortion, as the child of the peasant; but let these two, for the ensuing eight or ten years, change places with each other ; let the young heiress of opulence be left at liber- ty, and let the peasant-girl be restrained from her freedom of muscular exertion in play and exercise of every kind ; and, in- stead of this, let her be compelled to sit bolt upright in a high narrow chair with a straight back that hardly allows of any flexion to the sitting muscles, or of any recurvation to the spine; and let the whole of her exercise, instead of irregular play and frolic gaiety, be limited to the staid and measured march of Melancholy in the Penseroso of Milton : With even step and musing gait; to be regularly performed for an hour or two every daj', and to constitute the whole of her corporeal relaxation from month to month, girded moreover, all the while, with the paraphernalia of braces, bodiced stays, and a spiked collar,—and there can be little doubt that, while the child of opulence shall be acquiring all the health and vigour her parents could wish for, though it may be with a colour somewhat too shaded with brown, and an air somewhat less elegant than might be desired, the transplant- ed child of the cottage will exhibit a shape as fine, and a de- meanour as elegant, as fashion can communicate, but at the heavy expense of a languor and relaxation of fibre that no stays or props can compensate, and no improvement of figure can atone for. Surely it is not necessary, in order to acquire all the air and Muscular gracefulness of fashionable life, to banish from the hours of re- amusements creation the old rational amusements of battledore and shuttle- sistenTwltu cock, of tennis, trap-ball, or any other game that calls into ac- grace of tion the bending as well as the extending muscles, gives firm- C6ure' vol, iv. 31 242 cl. iv.] NEUROTICA. L° Gew. I. Spec. 111. Entasia rhachybia. Such should intermix with those in ordinary use. Such the best prevrn. live means. Remedial means. Cupping sometimes necessary. More commonly tonics. Friction and sham- pooing: ness to every organ, and the glow of health to the entire surface. . Such and a thousand similar recreations, varied according 10 the fancy, should enter into the school-drilling of the day, and alternate with the grave procession and the measured dance, for there is no occasion to banish either ; although many ot the more intricate and venturous opera dances, as the Bolero, should be but occasionally and moderately indulged in; since, as has been sufficiently shown by Mr. Shaw, " we have daily opportu- nities of observing, not only the good effects of well-regulated exercise, but also the actual deformity which arises from the disproportionate development that is produced by the undue ex- ertion of particular classes of muscles* It maybe observed," continues the same excellent writer, " that the ligaments of the ankles of some of the most admired dancers are so unnaturally stretched, that, in certain postures, as in the Bolero dance, the tibia nearly touches the floor. So bad, indeed, is the effect oc- casionally produced by a frequent stretching of the ligaments, that the feet of many of them are deformed; for the ligaments, which bind the tarsal and metatarsal bones together, become so much lengthened by dancing and standing on the tips of the toes, that the natural arch of the foot is at length destroy- ed."! Such then are the best preventive means against muscular or ligamentous distortion of the young female frame, and espe- cially of the vertebral column, in conjunction with pure air, plain diet, and well-regulated hours of rest. If, notwithstanding such means, a tendency to crookedness on either side should manifest itself, evidenced by the symptoms already pointed out, no time should be lost in making an accu- rate examination of the spinal chain: and if such tendency should be accompanied with pains about the pelvis and lower extremities, our attention should be particularly directed to the state ofthe vertebra? seated in the centre ofthe different flex- ures of the column, but especially of the lumbar, for it is prob- able, in this case, that one or more of them may be in a state of inflammation. Where this is the case, the usual means of taking off inflam- matory action, and especially depletion, by cupping-glasses, should be instantly had recourse to. But where the cause is debility alone, and a want of equilibrium between antagonist sets of muscles, rest, reclination, general tonics, especially myrrh, steel, and in many cases the sulphate of quinine, sea-bathing, and, in effect, whatever may tend to introduce a greater firmness of fibre and general vigour of constitution, constitute the best plan of treatment. To these should be added a series of friction, and especially of shampooing or manipulation applied down the whole course ofthe spine, and particularly that part of it where the distortion * On the Nature and Ticatinent of Distortions, &c. p. 15. Lond. 8vo. 1823 t lb. p. 17. CL. IV.] NERVOUS FUNCTION. [ord. hi. 243 is most evident: and it may be of advantage, as proposed by Gf.w. I. Dr. Dods, to direct the course of the manipulation in a particu- Spec. ill. lar manner to such transverse processes of the vertebra? as ap- Entasia pear peculiarly elevated, so as artfully, and by insinuation, to rhacl,^ia- assist in restoring them to their proper position. It will also be appiiedwith found expedient in most cases to smear the hand with oil, or dexterity. some other unctuous substance, in order to prevent the friction from irritating or excoriating the skin. Those who ascribe the disease to a strumous diathesis in eve- How treated ry instance, have of course a medical treatment of their own when lieltl adapted to this view of the case. Such is the practice of Dr. !!,as,r"' r i j , . , . , . . ,' ,. mous com- .Jarrold, who has lately written a treatise upon this subject con- plaint. taining many valuable hints, but who limits the seat ofthe mala- dy.to the intervertebral cartilages, as he does its cause to a stru- mous taint. His Materia Medica, therefore, for the present purpose, is nearly restricted to burnt sponge and carbonate of soda. " Conceiving," says he, that " there might be some rela- plan of tion between it and bronchocele, I have made use of similar re- Jarrold: medies."* To which he occasionally adds, when the debility is considerable, twenty drops of nitric acid daily. And with this his alleged simple process he tells us, that he has been so successful in a success. restoration of health, strength, plumpness, and uprightness, that " medical treatment is seldom farther required, unless the appe- tite and digestion be impaired." Not acceding to this causation, I have not tried the plan; which seems here to have been far more successful than in bronchocele itself; even when the more powerful aid of iodine is called into co-operation, which it is singular that Dr. Jarrold does not appear to have had recourse to. To all the confeder- probably ate means, however, of recumbency, friction, shampooing, pure ,ess owi."g air, and occasional exercise, he is peculiarly friendly: and as {{jan'Si,?sirect these have of themselves effected a cure in the hands of various auxiliary other practitioners, it is not improbable, that Dr. Jarrold is far meaus. more indebted to such confederates than he is aware of, and that his auxiliaries have been of more service to him, than his main force. It has been made a question of some importance, which is Position, the best position for a patient to rest in who is labouring uqder the complaint before us, or has a striking tendency to it; as also what is the best formed couch for him to recline upon ? All seem to agree that the couch should be incompressible, Nature of or nearly so, in order that the weight of the body may be equal- couch. ly instead of unequally sustained, and not one part elevated and another depressed; and hence a mattress is judged preferable to a bed, and a plain board is by many esteemed preferable to a mattress. It is also very generally agreed, that the board Inclined or mattress should form an inclining plane, so that the body, p'a'>e, and placed directly on the back, may be kept perpetually on the ^"ion. stretch ; while Dr. Dods maintains, in opposition to this general Curved po- opinion, that the line should be horizontal or even curved, that a "«'<"» Pr°- r ' ' posed by * Inquiry into the Causes ofthe Curvature ofthe Spine, tit supra, p. 119. 244 cl. iv.J NEUROTICA. [ord. hi. Gew. I. Spec. III. Entasia rhachybia. Either may be right or wrong, oc- casionally. Illustrated. Hence ges- tation, pure air, sea- bathing, and general tonics to combine with the preceding position on the back is by no means necessary, and that a posture of extension cannot fail of being injurious, and adding to the strength or extent ofthe disease. Either of these opinions may be right or wrong, according to the nature of the case ; and hence neither of them can be cor- rect as an universal proposition. Ease and refreshment are the great points to be obtained, and whatever couch, or whatever position will give the largest proportion of these, is the couch or the position to be recommended ; whether that of supine exten- sion or relaxed flexure. Dr. Dods, who refers all kinds of lateral distortion to debili- ty ofthe fibres ofthe extensor muscles, proscribes an extended position in every instance ; and, as already observed, recom- mends a curved relaxing couch in its stead, so that the patient may sink into it at his ease, instead of being put upon the stretch. The advice is good so far as the opinion is correct, and the disease is dependent upon debility of the external mus- cles alone ; for here nothing can afford so much ease to the pa- tient as such an indulgence. But it is not to be conceded, that the fibrous structure of these muscles forms the seat of the dis- ease in every case, and consequently the recommendation will not always apply ; for the flexor muscles may be affected, or the debility be seated in the extensor ligaments, or the vertebral cartilages with which they are connected. I have at this mo- ment under my care a lady just of age, who, for four years past, has been labouring under a slight affection of lateral distortion, feeling much more of it whenever she suffers fatigue, or is af- fected in her spirits. A position strictly supine, and somewhat extended, upon a hard mattress or a level floor, is the only pos- ture that affords her ease, and takes off the sense of weight on the spine, and oppression on the chest. She has often tried other positions, but in vain. To this, therefore, she has uni- formly recourse after dinner, and, occasionally, at other times in the day as well. Pure country air has also been of great ser- vice, but above all things sea-bathing. She has just returned from an excursion around the Devonshire coast. The first day's journey, though in a reclined position in an open landaulet, with every attention that could afford ease and accommodation, prov- ed so fatiguing, and produced so much pain in the spine, that it was doubtful whether she would be able to proceed. A better night, however, than was expected, capacitated her for another trial, and the fatigue was considerably less: on the third or fourth day she had an opportunity of beginning to bathe ; and by a daily perseverance in the same was enabled, soon after reach- ing Teignmouth, to engage in long walks, climb its loftiest hills, and enjoy the entire scenery: her appetite became almost un- bounded, and her flagging spirits were restored to vivacity. It is hence perfectly clear, that, while that position and (hat mode of dress are most to be recommended, which afford the highest degree of ease and comfort, gestation, pure air, sea- bathing, and every other kind of tonic, whether external or in- ternal, are also ofthe utmost importance ; and that perfect and cl. iv.] NERVOUS FUNCTION. • [ord. hi. 245 continued rest, in whatever position it be tried, is far less effi- Gew. I. cacious than when interrupted by such motion as can be borne, Spec. III. though with some degree of fatigue, and the other tonic auxili- Entasia aries just adverted to. In extreme cases, indeed, such exercise * ac .y ,a' as is here adverted to should be postponed till the debilitated ^ptednter" and, most probably, irritable organs have lost some part of their rather than disease ; yet the motion of friction or manipulation by a skilful continued: and dexterous hand may still be adverted to, and should supply extreme" its place. cases. Species IV. Entasia Articularis.—Muscular Stiff- Joint. Permanent and rigid contraction of one or more articular muscles or their tendons. The joints of the limbs are as subject to muscular contrac- tions as the neck, and in many instances from like causes: the following are the varieties of affection hereby produced : a Irritata. From excess of action in the muscles Spastic stiff-joint. contracted. 0 Atonica. From direct atony in the yielding Atonic stiff-joint. muscles. y Inusitata. From long confinement or neglect of Chronic stiff-joint. use. Besides the ordinary causes of cold, inflammation, and strains, Causes. by which the first and second variety are produced, the former has sometimes followed a sudden fright.* Freind, also, mentions a case, in which it has been cured by a fright ;t and Baldinger one, in which it disappeared on the revival of a suppressed eruption which had given rise to it.f Rheumatism has often produced it, and particularly the second variety, in the joint of the knee and thigh-bone. In a case of the latter kind, it was successfully attacked by Treatment. Richter§ with a cautery of a cylinder of cotton. In this and the third variety, much benefit is often derived from repeated and long continued friction with a warm hand, or with some stimu- lant balsam or liniment. In an obstinate contraction of the fin- gers succeeding to a fractured arm, Dr. Easo'n relates an in- stance, in which the rigidity suddenly gave way to a pretty smart stroke of electricity after every other mean had failed ; and the patient had the use of his fingers from this time.|| Such exercise, moreover, or exertion of the limb, should be recom- mended as it may bear without fatigue. The cold-bath, as an antispasmodic, has sometimes been serviceable in the first va- riety,H and more frequently, as a tonic, in the second. * Starke, Klin. Instit. p. 32. t Vit. Gabriel. X N. Magazin. band xi. 78. i Chir. Bibl. band x. 219. || Edin. Med. Comment, v. p. U. H In an example of this kind, brought on by a wound of one ofthe fingers, the editor applied a succession of blisters to the back of the hand and wrist; and the patient, a woman residing at Weybridge, was very soon enabled to extend her fingers again. 246 cl. iv.] ' NEUROTICA. [ord. in. Gew. I. Spec IV. Entasia articularis. Chronic stiff-joint often pro- duced from habitual neglect of muscles affected - Explained. Most men exhibit proofs of the third variety, or chronic stiff-joint, from a neglect of using many of their muscular pow- ers : for nearly a fourth part of the voluntary muscles, from be- ing seldom called into full and active exertion, acquire a stiff- ness which does not naturally belong to them ; while many that, by exercise, might have been rendered perfectly pliant and obedient to the will, have lost all mobility, and are of no avail. Tumblers and buffoons are well aware of this fact, and it is principally by a cultivation of these neglected muscles that they are able to assume those outrageous postures and grimaces, and exhibit those feats of agility, which so often amuse and surprise us. It is a like cultivation that gives that measured grace and firmness as well as erect position in walking, by which the sol- dier is distinguished from the clown ; and that enables the mu- sician to run with rapid execution, and the most delicate touch, over keys or finger-holes that call thousands of muscular fibres into play or into quick combinations of action, which in the un- tutored are stiff and immoveable, and cannot be forced into an imitation without the utmost awkwardness and fatigue. Origin of specific name : invented to supersede the barba- rous term crampus. Raptus of the Latins, what. Parts chiefly affected. Causes. In the last case, how produced, especially in the long muscles. Species V. Entasia Systremma.—Cramp. Sudden and rigid contraction and convolution of one or more muscles ofthe body: mostly of the stomach and extremities, vehemently pain- ful, but of short duration. Systremma, literally " contortio, convolutio," " globus," is derived from avar^a, " contorqueo," " convolvo in fascem." Stremma, the primary noun, is an established technical term for " strain, twist, wrench ;" and the author has hence been induc- ed to add the present term to the medical vocabulary in the sense now offered, for the purpose of superseding and getting rid of crampus, which has hitherto been commonly employed, though at the same time commonly reprobated, as a term into- lerably barbarous, derived from the German krampf. The pro- per Latin term is, perhaps, " raptus nervorum ;" whence opis- thotonia or opisthotonus is denominated by the Latin writers " raptus supinus." But raptus is upon the whole of too gene- ral a meaning to be employed on-the present occasion, unless with the inconvenience of another term combined with it. The parts chiefly attacked with cramp are the calves of the legs, the neck, and the stomach. The common causes are sud- den exposure to cold, drinking cold liquids during great heat and perspiration, eating cold cucurbitaceous fruits when the stomach is infirm and incapable of digesting them, the excite- ment of transferred gout and overstretching the muscles ofthe limbs, in which last case it is an excess of re-action produced by the stimulus of too great an extension. Hence many persons are subject to it, and especially those of irritable habits, during the warmth and relaxation of a bed, and particularly towards the morning, when the relaxation is greatest, the accumulation cl. iv.] NERVOUS FUNCTION. [ord. iii. 247 of muscular or irritable power most considerable, and the ex- Gew. I. tensor muscles of the legs are strained to their utmost length to Spec.V. balance the action, which the flexor muscles have gained over Entasia them during sleep. Cold night-air is also a common cause of gyslremraa' cramp, and it is a still more frequent attendant upon swimming, otner . in which we have the two causes united of cold and great mus- craiDp, cular extension. An uneasy position of the muscles is also in How pr0. many cases a sufficient cause of irritation; and hence we often duced in meet with very painful cases of cramp in pregnant women down swimming. the legs, or about the sides, or the hypogastrium. When the hollow or membranous muscles are affected, they Symptoms feel as though they were puckered and drawn to a point; the wh,en the - . . . , r •• i - i , • \. hollow or pain is agonizing, and generally produces a violent perspiration ; membran- and if the stomach be the affected organ, the diaphragm asso- ous muscles ciates in the constriction, and the breathing is short and distress- are affected. ing. If the cramp be seated in the more fleshy muscles, they When the seem to be writhed and twisted into a hard knot; and a knotty "jJSjjJU induration is perceivable to the touch, accompanied with great affected. soreness, which continues for a long time, after the balance of power has been restored. In common cases where the calves ofthe legs are affected, an Mode of excitement ofthe distressed muscles into their usual train of ex- treatment. ertion is found sufficient; and hence most people cure them- selves by suddenly rising into an erect position. I have often produced the same effect, and overcome the re-action without ris- ing, by forcibly stretching out the affected leg by means of other muscles, whose united power overmatches that of the muscle that is contracted. Warm friction with the naked hand, or with camphorated oil or alcohol, will also generally be found to suc- ceed. A forcible exertion of some remote muscles, which thus collects and concentrates the irritable power in another quarter, will also frequently effect a cure; and it is to this principle Vulgar alone, I suppose, we are to refer the benefit which is said to Plan °f arise from squeezing strenuously a roll of brimstone, which ron"f'uga suddenly snaps beneath the hold. The brimstone snaps from brimstone the warmth of the hand applied to it; but its only remedial explained. power consists in affording a something for the hand to grasp vehemently, and thus excite a sudden change of action. Where the stomach is affected, brandy, usquebaugh, ether, or Treatment laudanum afford the speediest means of cure; and it is often where the necessary to combine the laudanum with one or the other ofthe afr^ted.'8 preceding stimulants. Here also the external application of warmth, and diffusible irritants, as hot flannels moistened with the compound camphor liniment, are found in most cases pecu- liarly beneficial. Exciting a transfer of action to the extremi- ties, as by bathing the feet in hot water, or applying mustard sinapisms to them, is frequently of great advantage; as in the use of hot, emollient, and anodyne injections, whose palliative power reaches the seat of spasm by sympathetic diffusion, and often affords considerable quiet. Here, also, the patient should be particularly attentive to his diet and regimen, confining him- self to such viands as are most easy of digestion, and least dis- 248 Gew. I. Spec. V. Entasia systremma. Treatment under preg- nancy. Best pre- ventives. Found also as a symp- tom in many diseases. CL. IV.] NEUROTICA. [ord. III. posed to rouse the stomach to a return of these morbid and anomalous actions; for a habit of recurrence is soon established, which it is difficult to break off. In pregnancy, where the crampy spasms are often migratory and fugitive, the, position should frequently be changed, so as to remove the stimulus of uneasiness by throwing the pressure upon some other set of muscles ; and if the stomach be affected with gout, opium, rhubarb, chalk, or aromatics should be taken on going to rest. The best preventives when the cause is constitutional, are warm tonics, and habituating the affected muscles to as much exercise as their strength will bear : and hence the same forci- ble extension used in swimming, which produces cramp the first or second time of trial, will rarely do so afterwards. Cramp is also found, as a symptom, and as one ofthe severest symptoms of the disease, in various species of colic and cholera ; in which cases, it must be treated according to the methods al- ready pointed out under those respective heads. French synonym. Origin of the techni- cal term. Both the Greek and French terras formerly applied to a different affection; and recently ■o applied by Aker- Species VI. Entasia Trismus—Locked-Jaw. Permanent and rigid fixation of the muscles of the lower jaw. This disease is by the French writers called tic. The tech- nical term is derived from the Greek ry^a, " to gnash or grind the teeth;" which, like the French synonym, is supposed by the lexicographers to be an onomatopy, or a word formed from the sound that takes place in the act of gnashing. In truth it was to a disease, in which morbid gnashing formed a symptom, that both the Greek and French term was originally applied; for the trismus of the old writers consisted, not of a rigid, but a convulsive or agitatory spasm of the lower jaw; an affection comparatively trifling, arid rarely to be met with, and, when 1t does occur, appertaining to the clonus of the present system of nosology, the clonic spasm of authors in general. And the use of trismus or tic to import a state of muscle directly op- posed to that which it first indicated, is another striking proof of the incongruous change which is perpetually occurring in the nomenclature of medicine, for the want of established rules and principles to give fixation and a definite sense to its respective terms. Dr. Akerman is the only writer of reputation I am acquaint- ed with in recent times, who has used trismus in its original in- tention, or rather who has united its original with its modern meaning. For he employs the term generically; and arranges under it the two species of trismus tonicus, being that now under consideration, and trismus clonicus, or the disease it originally denoted. But this arrangement is uncalled for and inconvenient, and has not been received into general use; the term trismus being, with every writer of the present day, limited to the first of these two species alone, notwithstanding the origin of the CL. IV.] NERVOUS FUNCTION. [ord. hi. 249 word. And hence, as it is so generally and completely under- Gew. I. stood, there would be an affectation in changing it for any other.- Spec VI. The Germans call it kinnbakkenzwange, which is precisely Entasia parallel with the locked-jaw of our own tongue. trismus. Dr. Cullen, in the first edition of his Nosology, made trismus Variously and tetanus, our next species, distinct genera; but he altered his *nd »rr«fgu- opinion before the publication of his First Lines, and regarded ranged'hy them as nothing more than degrees or varieties even of the same Cullen: at species. " From the history of the disease," says he, " it will °ne.time a be evident, that there is no room for distinguishing the tetanus, gersuTfrom opisthotonos, and trismus or locked-jaw as different species of trismus, this disease, since they all arise from the same causes, and are w,,,cu w*s almost constantly conjoined in the same person."* In conse- a distinct quence of which, in the later editions of Dr. Cullen's Synopsis, genus: in which the supposed error is attempted to be corrected, the at other disease is introduced with a very singular departure from noso- times ^th logical method ; for, first, tetanus is employed as the term for a va^y 0f * distinct genus, defined " a spastic rigidity of many muscles;" common and next under this generic division are given no species what- 6enu*« ever, but two varieties of degree alone; to the first of which is again applied the name of tetanus, defined " the half or whole of the body affected with spasms," and to the second that of trismus, defined " spastic rigidity chiefly of the lower jaw." Passing by this irregularity of method, the proper view of Proper the subject seems to lie in a middle course; in contemplating P1???,10.? trismus and tetanus, not as distinct genera, or mere varieties of 0f arrange- a single disease, but as distinct species of a common genus ; and ment, each under this view it is contemplated in the present arrangement. *?r^,n^ a Trismus bears the same relation to tetanus as synochus does to gpecies. typhus : the two former, like the two latter, may proceed from Analogy. a common cause and require a similar treatment; and the first may terminate in the last. But trismus, like synochus, may run its course alone, and continue limited to its specific symptoms. And as Dr. Cullen has thought proper to make synochus and typhus distinct genera, he ought at least to have ranked trismus and tetanus as distinct species.j Trismus is found in all ages, sexes, temperaments, and cli- Found mates. In warm climates, however, it occurs far more fre- generally quently than in cold ; and chiefly in the hottest of warm cli- tempera^"*' mates. Dr. Cullen observes, that the middle-aged are most sus- ments and ceptible ofthe disease, men more so than women, and the ro- cliunate*. bust and vigorous than the weakly. Other animals are subject ,n.ot,"!r to this complaint as well as man, particularly parrots; and from well many ofthe causesj that affect the human race. man. These causes, for the most part, are chilliness and damp op- Causes. erating upon the body when heated, and hence sudden vicissi- tudes of heat and cold ; wounds, punctures, lacerations, or other irritations of nerves in any part ofthe body ; whence it has not * Pract. of Phys. Book m. Sect. I. Chap. I. i mcclxvii. t Not- withstanding this mode of reasoning, the editor adopts Dr. Cullen's view. \ Bajon. Abhandlungen von Krankheit. auf der lnsel Cayenne, &c. VOL. IV. 32 as in 250 cl. iv.] NEUROTICA. [ord.hi. Entasia trismus. Gew. i. unfrequently followed on venesection when unskilfully perform- Spec VI. >e(j}* an(j stiU more frequently on amputation, worms or irrita- tion in the stomach and bowels, especially in those of infants. We have thus the three following varieties offered to us, which, however, chiefly differ in symptoms peculiar to the period of life in which the disease is most disposed to show itself, or in the interval between the casual excitement and the spastic ac- tion: a Nascentium. Locked-jaw of infancy. 0 Algidus. Catarrhal locked-jaw. y Traumaticus. Traumatic locked-jaw. Pathologi- cal principle difficult! but attempted to be explained by the author in part, especially the princi- ple of re- mote action between the chief seat ofthe disease and that of primary injury. Analogies. Sympathy of remote organs when united in a common chain of action. Attacking infants during the first fortnight after birth. Occurring at all ages, after ex- posure to cold and damp, es- pecially the dew of the eve- ning, the symptoms usually appearing within two or three days. Occurring as the consequence of a wound, puncture, or ul- cer ; chiefly in hot climates ; and rarely appearing till ten days or a fortnight after local affection. The pathology is highly difficult, if not mysterious, and has hence been purposely avoided by most preceding writers. Dr. Cullen expressly avows that he " cannot in any measure attempt it."t There is one principle, however, to which I have fre- quently had occasion to direct the reader's attention, which will help us in a considerable degree to develope something of its obscurity, and to account more especially for so remote a separation between the seat of primary irritation and that of spasmodic excitement, which constitutes, perhaps, its most em- barrassing feature. The principle I allude to is the sympathy that prevails throughout the whole of any chain of organs, whether continuous or distinct, engaged in a common function, and which is particularly manifest at its extremities; so that let a morbid action commence in whatever part ofthe chain it may, the extremities, in many instances, become the chief seat of distress, and even of danger. We had occasion to notice this law ofthe animal economy when treating of parapsis illusoria, or that imaginary sense of feeling and of acute pain in a limb that has been amputated and is no longer a part of the body which we referred to the principle before us; and farther no- ticed, by way of illustration, the pain often suffered at the glans penis from the mechanical irritation of the neck of the bladder by a calculus. So, irritating the fauces with a feather excites the stomach, and even the diaphragm, to a spasmodic action, and the contents of the organ are rejected. Irritating the ileum, as in ileac passion, produces the same effect upon the stomach * Delaroche, Journ. de Med. torn. xv. p. 2)3. Forestus, Lib. x. Obs. 111. Scbenck, Obs. l. i. N. 250. t Pract. of Phys. Book in. Sect. i. Chap. i. $ mcclxix. CL. IV.] NERVOUS FUNCTION. [ORD. III. 25 1 and oesophagus; at the same time that the other extremity of Gew. I. the canal is attacked with rigid spasm, and consequently with SpKC- VI> obstinate costiveness : while in cholera both extremities are af- Entasia fected in a like way, and we have hence both purging and vom- iting. It is to the same principle we are to ascribe it, that when the surface of the body is suddenly chilled, as on plunging into a cold-bath, the sphincter ofthe bladder becomes irritated, and evacuates the contained urine: and, in treating of marasmus, we had occasion to show, that while, in one of its species, the dis- ease seems to commence in the digestive, and in another in the assimilating organs, constituting the extreme ends of a very long and complicated chain of action, it very generally happens, that, at which end soever the decay commences, the opposite end is very soon affected equally. In a continued chain of nervous fibres, however, this princi- Sympathy pie of sympathy, which induces remote parts, and particularly Pe™£'°f remote extremities, to associate in the same morbid action, is nervoug peculiarly conspicuous. Hence, if a long muscle be lacerated fibres; in any part of its belly, the tendinous terminations are often the and evinced chief seat of suffering. As the ulnar nerve sends off twigs from "Jjjj' jj^, the elbow to supply the fore-arm and fingers, a blow on the in- eitremities. ternal condyle of, the humerus gives a tremulous sensation niustraled* through the fore-arm and hand : and as the ulnar nerve itself is only an offset from a plexus or commissure of the cervical nerves, which also give a large branch to the scapula, a paraly- sis ofthe ring or little finger has sometimes been removed by stimulating the scapular extremity by a caustic applied at the internal angle ofthe scapula. In inflammation of the liver, a severe pain is often felt at the top of the shoulder, and, in pal- pitation ofthe heart, at the left orifice of the stomach. Both these are to be accounted for by recollecting, that the radia- tions ofthe phrenic nerve extend in an upper line to the shoul- der, and in a lower to the diaphragm, which constitutes its ex- treme points ; and that one of its branches passes over the apex of the heart. Now as the under surface of the diaphragm par- ticipates, from its contiguity, in an inflammation of the liver, the top ofthe shoulder suffers, as forming the extreme point ofthe phrenic chain by which these organs are connected ; and as the upper surface ofthe diaphragm is in direct contact with the left and very sensible orifice of the stomach, an uneasiness at the apex ofthe heart becomes the cause of irritation to this orifice in consequence of its connexion with the diaphragm, and hence, of necessity, with the lower branch of the phrenic nerve at its extreme distribution. These remarks apply with particular force to the disease be- This fore us, and many others ofthe same class, with which it has a reasoning close analogy, as tetanus, lyssa, and hemicrania. And although, gjj^ *d from the intricacy of the intersections and decussations with diseases of which various nerves pursue their radiating courses, it isimpos- a like kind. sible for us, in many instances, to determine why one line of connexion suffers while another remains unaffected, yet, in most 252 cl. iv.] NEUROTICA. [ord. III. Gew. I. Spec. VI Entasia trismus. Illustrated in trismus. Illustration applied to the first variety. Illustration applied to the second and third varieties. instances, we may be able, by an accurate survey, to trace the catenation, and hence to obtain some insight into the physiolo- gy of these exquisitely curious and complicated disorders. In mapping the nervous ramifications which give rise to tris- mus or locked-jaw, we must regard the ganglionic system, con- sisting ofthe various branches ofthe intercostal trunk, and the numerous branches which unite with it from the whole line of the spinal marrow, as constituting the centre ; and as, from this centre, we perceive ramifications radiating in every direction to the face, the entire length of the back, the upper and lower limbs, and the thoracic and abdominal viscera, we see a founda- tion laid even by a continuous chain, for an association of re- mote parts and even extreme points in morbid changes, even though we may not be able, satisfactorily perhaps, in any in- stance, to trace out the individual line by which the diseased action is carried forward, and to separate it from other lines with which it is inextricably interwoven. Thus, in the case of trismus nascentium, forming the first variety under the present species, the irritation of the nerves of the stomach, which is very clearly the primary seat of disease in most cases, is propa- gated directly to the central branches of the ganglionic system by the tributary offsets which the stomach receives from it. But we have already observed, that the chief contribution to this grand junction-canal is derived from the intercostal nerve itself. In the first instance, an arm from the trigeminus or fifth pair of nerves, two branches of which radiate upwards, consti- tute the maxillaris superior and maxillaris inferior, and are lost in the muscles of the jaws : so that the upper extremity of the nervous line distributed over the stomach is the nerves of the jaws themselves; while various branches of the fifth occasion- ally unite with the portio dura, or respiratory trunk ofthe sev- enth pair, which divaricates not only to the diaphragm, but over al| the muscles that have the remotest connexion with the respi- ratory system. And hence, agreeably to the law of the animal economy we have just pointed out, the muscles of the jaws, forming this extremity in the chain of morbid action, are the or- gans in which we may expect an irritation of the nerves of the stomach in various instances to manifest itself most strikingly. In like manner we may account for the second and third vari- eties of trismus, or that produced by a chilly dampness, or irri- tative violence applied to the upper or lower extremities: for as these are all supplied by nerves from the vertebral source which, we have already remarked, gives off branches from ev- ery aperture in the spine to the ganglionic system, and as this system, at its upper end, terminates in the maxillary branches ofthe fifth pair of nerves, the muscles into which these nerves are distributed constitute one extreme point of a long chain of nervous action, while those ofthe upper and lower limbs con- stitute the other. And hence the same law, which produces a spastic fixation of these muscles in certain irritations of the sto- mach, may reasonably be expected to operate with a like effect cl. iv.] NERVOUS FUNCTION. [ord. iii. 253 in certain irritations of the upper and lower limbs. And as the Gew. I. intercostal nerve, at its first rise from the common source of it- Spec. VI. self and the maxillary branches, receives also, in its progress, Entasia offsets from the sixth, seventh, eighth, and ninth pairs of cere- tnsmU8, bral nerves, as well as from all the vertebral, and as all these, in consequence of such an interunion and decussation, are send- ing forth branches over the muscles of the back, the chest, and the thorax, there is no difficulty in conceiving, when a rigid spasm has once commenced in the lower jaw, why it should be propagated through any of the muscles appertaining to these parts of the system, or even originate in them from any of the causes that excite locked-jaw, and hence lay a foundation for Illustration tetanus as well as trismus, both as a primary and a secondary eq,,?.,ljrH disease. And I have touched upon this subject now, that we to tetanus! may not have to repeat the present explanation when treating of tetanus in its proper place.* In the simplest state of trismus, indeed, there is some degree of stiffness found at the back of the neck, and even in the ster- num. The disease, in some cases, shows itself with sudden vio- lence, but more usually advances gradually ; till at length the muscles that pull up the jaw become so rigid, and set the teeth so closely together, that they do not admit of the smallest open- ing. In tropical climates, for Dr. Cullen's remark that it is most Peculiarly common to the middle-aged, only applies to the temperate re- common to gions of Europe, children are particularly subject to this com- clims«i«. plaint, and with a few peculiarities which, though producing no Called vol- specific difference, are sufficient to establish a variety. The dis- garly, but ease in this case is vulgarly known by the absurd name of fall- pbs,l!.rdly,f ing of the jaw. It occurs chiefly between the ninth and four- the Jaw.° teenth day from birth ; seldom after the latter period. Without any febrile accession, and often without any perceptible cause whatever, the infant sinks into an unnatural weariness, and drow- Description. siness, attended with frequent yawnings, and with a difficulty, at first slight, of moving the lower jaw ; which last symptom takes place in some instances sooner, in others later. Even while the infant is yet able to open its mouth, there is, occasionally, an in- ability to suck or swallow. By degrees the lower jaw becomes rigid, and totally resists the introduction of food. There is no painful sensation ; but the skin assumes a yellow hue, the eyes appear dull, the spasms often extend over the body, and, in two or three days, the disease proves mortal. The ordinary cause is irritation in the intestinal canal. Hence Ordinary viscid and acrimonious meconium frequently produce it; as worms cause. are said also to do, some months after birth. It seems, moreover, in some instances, to have followed from irritation in tying the navel-string, or its not being properly attended to afterwards ; * See Cloquet, Traite d'Analomie Descriptive. Bock Beschreibung des funften Nervenpaares und seiner Verbindungen mit anderen Nerven, vorzug,- lich mit dem Gangliensysteme. Leips. 1817. The whole of the above hypoth- esis is merely intended to explain the origin and extension of tetanic disorders by the intricate communications of the nerves of different parts ofthe body. Editor. 254 ct-,v«] NEUROTICA. [ORD. III. mus nascen- tium. Disease sometimes Gew. i. in which case, though the stomach may be affected by contigu- Spec. VI. ous sympathy, the disease makes a near approach to the third «E. Tris- or traumatic variety. Yet the appearance ofthe spastic action is as early as where the stomach is primarily affected. In cold and even mountainous countries, this variety is also sometimes found. " I am informed," says Dr. Cullen, " of its found in frequently occurring in the Highlands of Scotland ; but I never mounuhiou. ™et with any instance of it in the low country."* Whether, countries. according to the conjecture of this celebrated writer, it is more • common to some districts than to others, has not been sufficiently determined. " It seems," says he, " to be more frequent in Switzerland than in France." Hot climates, however, constitute its principal domain ; and hence it is not very surprising, that Bajon should place one of its chief residences at Cayenne,! or that Akerman should assert it to be endemic in Guinea. In the second variety ofthe disease, or that proceeding from ,0E. Tris- cold or night dew, the symptoms often appear within a day or mus catar- two after exposure to the exciting cause. It is not common that rhalis. the gpasm extends to the muscles of the chest or back, so as to Description, produce tetanus, though there is often an uneasy sensation at the root of the tongue, with some difficulty in swallowing liquids af- ter their introduction into the mouth; the disease thus making an approach towards lyssa or canine madness in its symptoms, as we have just endeavoured to show that it does in its physiology. According to the observations of Baron Larrey, indeed, this ap- proach is in many instances very considerable ; for he informs us, that on post obituary examinations he has often found the pharynx and oesophagus much contracted, and their internal membranes red, inflamed, and covered with a viscid reddish mu- cus. Dr. Hennen, however, does not place much dependence upon any such appearances; he admits, nevertheless, that they are to be traced occasionally, though he ascribes them more to an increased flow of blood, consequent on increased action, than to any other cause.J In this variety, from the slighter nature of its attack, the pa- tient not unfrequently recovers by skilful medical treatment, and there are unquestionably instances of spontaneous recovery,^ though cases of this kind are very rare. The intellect remains Prognostics, unaffected, there is little quickness of the pulse, sometimes none whatever, and little or no disorder of any kind, though the bow- els are usually very costive. If the patient pass the fourth or fifth day, we may begin to have hopes of him, for the spasmodic constriction will then frequently remit or intermit; but as, even in the last case, it, is apt to return at uncertain intervals, there is still a considerable danger for many days longer. Symptoms When, as in the third variety, the disease proceeds from a appear later nerve irritated by a wound|| or sore, the spasmodic symptoms varieties'? * Loc. chat. } mcclxxxi. t Bajon, Abhandlung. von Krankheit. auf derlnsel Cayenne, &c. Erp. 1781. X Principles of Military Surgery, 246. ♦ Briot, Hist, de la Chirurgie Militaiie en Fiance, &c. 8vo. Besan^on, 1817. j] Trismus traumaticus sometimes follows surgical operations, and very fre- cl. iv.] NERVOUS FUNCTION. [ord. hi. 255 are much later in showing themselves ; and sometimes do not Gew. I. make their appearance till eight or nine days afterwards, occa- Spec VI. sionally, indeed, not at all till the wound is healed. The dis- y E. Tris- ease is more dangerous in proportion to the delay ; the adjoin- ["us trauma" ing muscles ofthe face become more affected, and, as is already observed, the spasms often shoot downward into the back or a°Jtia0re If0" chest, and trismus is complicated with tetanus. The breathing Sore'dan.7 is nasal and abrupt, the accents are interrupted and slow, and gerous. uttered by the same avenue; the muscles ofthe nose, lips, mouth, Description. and the whole of the face are violently dragged and distorted, and the patient sinks from nervous exhaustion and want of nu- triment, the jawbone being set so fast, that it will often break rather than give way to mechanical force. The disease, from this cause, is generally fatal; and we are Thisvariety indebted to the ingenuousness of Sir James M'Grigor and Dr. generally Hennen for a confession that, whatever remedies were employ- f ' ed in the British army, whether in India or in Spain, the mor- tality was nearly the same. But as the treatment of the present Treatment variety and the ensuing species should be founded on a like prin- the 8ame as ciple, we shall reserve this subject till we have entered upon a ^Vrwwved distinct history of the latter. for the close of that sub- ________ ject. Species VII. Entasia Tetanus.—Tetanus. Permanent and rigid fixation of many or all the voluntary muscles; with incurvation of the body, and dyspncea. Tetanus is derived from Tirana, which itself is a derivative Origin oT from rum, " tendo, extendo." Like trismus it is a term com- the specific mon to the early Greek writers, among whom it was used sy- teru1' nonymously with opisthotonus and emprosthotonus, though the two latter were afterwards employed to express two distinct modifications of the disease. From peculiarities in the seat or mode of its attack, this spe- cies offers us the four following varieties: x Anticus. Tetanus of the flexor muscles. Tetanic procurvation. The body rigidly bent for- wards. 0 Dorsalis. Tetanus of the extensor muscles. Tetanic recurvation. The body rigidly bent back- ward. y Lateralis. Tetanus of the lateral muscles. Tetanic transcurvation. The body rigidly bent late- rally. J Erectus. Tetanus of both the posterior Tetanic inflexibility of the and anterior muscles. The body. body rigidly erect. quently lacerated wounds of the fingers, toes, and other tendinous parts. The editor has seen several cases of it brought on by gunshot injuries, amputation, castration, and he knew of one instance in which it was induced by the amputa- tion of a cancerous breast. In warm climates, it occurs from very slight causes and hence is much more frequent in them, than in temperate and cold countries. 256 cl. iv.] NEUROTICA. [ORD. III. Gew. I. Spec VII. Entasia tetanus. Eraproa- tbotouuB, what. Catochus how con- nected with these. More pro* perly a sub. division of carus. General physiologyj already glanced at. Proximate cause. Neurostenia of Berga- maschi. Exciting causes. Terror sometimes a powerful auxiliary to them. The first of these varieties is the emprosthotonus of early writers ; the second the opisthotonus; the third the pleuros- thotonus of authors of a later date ; the fourth the proper te- tanus of Dr. Lionel Clarke and a few others. To these varie- ties it has been usual to add the singular disease called cato- chus; which by Sauvages, Cullen, and various other authori- ties, is regarded as closely connected with this species. It has a near affinity to it unquestionably, and hence, out of deference to concurrent opinions, it was suffered to stand as a variety of tetanus in the first edition of the author's Nosology, but with a note intimating that it seems rather to belong to the genus cards of the fourth order of the present class, and to be a modification of the species ecstasis, under that genus : and as this appears to be its proper place, it will now be found ar- ranged there accordingly. The general physiology, so far as it seems capable of eluci- dation, has been already given under the preceding species \ the proximate cause being that of a peculiar irritation of a cer- tain chain or association of nerves, chiefly operating with the greatest violence at the two extremities of the morbid line. This irritation seems, in many instances, to consist in inflamma- tion ; and hence is made a common cause by many of the most valuable writers of the present day. Professor Frank seems first to have started the idea, and he has been followed in suc- cession by Dr. Saunders of Edinburgh, Dr. Chisholm, Dr. James Thomson, and Dr. Abercrombie, who have been upheld in Italy by M.M. Brera, Rachetti, and Bergamaschi, and in France ]»y M. Esquirol. Bergamaschi* advances, indeed, so far as to maintain, that where wounds themselves, of whatever form, are the remote cause, a neurostenia, as he calls it, or in- flammatory affection of the nerves, is still the proximate cause ; extending itself from the wounded part, by the nervous ex- tremities, to the spinal marrow and the brain, or, vice versd, from the brain to the spinal marrow and principal nerves, and thence to the parts that are subservient to locomotion. Dissec- tion, however, is very far from giving proofs of such inflamma- tory change in every instance ; while in many cases the disease is of too fugitive a character, and makes its seizure or its disap- pearance too rapidly for the more measured progress of inflam- mation. The exciting causes are also for the most part those of tris- mus; though it appears in infancy far less frequently, unless as a concomitant of that disease. Damp and cold, therefore, and simple nervous irritation from wounds or sores in hot climates and crowded hospitals, are the chief sources of its production; and where these accessories exist, terror seems to be a power- ful auxiliary, and has alone, in some instances, been sufficient for its production. " Passion, or terror," says Dr. Hennen, " after wounds and operations, has been known to produce the * Osservazioni Medico-pratiche sul Tetano.—Giornale di Medicina prati- ca del Sig. Cons, e Prof. V. L. Brera. r cl. iv.] NERVOUS FUNCTION. [ord. hi. 257 disease in some ; and sympathy, though a rare cause, in others." Gew. I. It is said also to have been produced by insolation or exposure Spec VII. to the direct rays of the sun,* and has unquestionably followed, Entasia as M. Magendie and numerous other French authors! have tetanus- abundantly shown, from various irritant narcotics, as strychnine, or the active principle of nux vomica, as also from galvanism, when raised to a sufficient power for the purpose. Lateral tetanus is very rarely to be met with, and seems to Lateral te- be rather a chronic than an acute malady. Fernelius, who first tanus pecu- described it,J gives a case in which it occurred annually, but JjjJjJJ1," only in the winter, during which season the patient had two or three paroxysms daily: the head was first attacked with a pe- culiar vibratory feeling, which gradually descended to the neck with a sensation of cold, and by the time it'reached the scapu- la was immediately succeeded by symptoms of opisthotonus, and afterwards of lateral contraction ; during which the mind and external senses were unaffected, but the flexor muscles were so firmly fixed, that no antagonist force of the bystanders was able to overpower the contortion. Nor are the other varieties nearly so frequent as trismus, ex- Description. cept where they form a subsequent part of the general chain The other of morbid action. My observant friend Dr. Hennen confesses, varietiesalso that, during the whole period of his superintending the British {^"i'smu! hospitals in Spain, he never met with but one case of empros- whenstrictly thotonus, and even this he describes as an incurvation that ra- idiopathic ther approached it, than constituted the disease itself. " It was observed," says he, " at the same time and in the same hospital, with the various degrees of trismus : rigid spasms of almost every muscle of the body, and violent periodical convulsions, all from similar injuries to that in which it was produced."§ From the complicated manner, indeed, in which tetanus Tetanus a shows itself, and its anomalous attack upon different sets of peculiarly muscles at the same time, it seems in manv instances to put all ^"^l^r .. . ,. .... />i ■/» • " . . anection 01 the subordinate divisions of classification at defiance. It is, in the muscles. truth, for the most part a mixed disease, affecting various and opposite sets of muscles; and this in many cases so equally, that the spastic action of the flexors, just balancing that of the extensors, "the patient," to adopt the language of Dr. Lionel Clarke, " seems often to be braced between opposite contrac- tions." It is to this form, infleed, that this last very intelligent writer has limited the name of tetanus, as that to which it applies most emphatically. Like Dr. Hennen, he asserts that he had never seen a single case of genuine emprostho- tonus; and that of the other two varieties of which he treats, the opisthotonus and proper tetanus, the former occurs most frequently. In opisthotonus or tetanic recurvation the symptoms some- Tetanic re- curvation. * Pathol. Lib. v. p. 372. t Desportes, Raffenean, Fonquier, Dupuy. X Medical Observations and Inquiries, vol. vi. } Military Surgery, p. 217, 8vo. Edin. 1820. vol. iv. 33 258 cl. iv.] NEUROTICA. [ord. m. Gew. i. times show themselves suddenly, but more commonly advance Spec. vii. s]ovviy and imperceptibly, the patient mistaking the uneasy Entasia stiffness, which he feels about the shoulders and cervical re- e anu*' gion, for a crick in the neck, produced by cold and rheumatism. Description. ^he stjfl-nesSi however, increasing, he finds it impossible to turn his head on either side without turning his body: he can- not open his jaws without pain, and he has some difficulty in swallowing. A spastic and aching traction now suddenly darts at times towards the ensiform cartilage, and thence strikes through to the back, augmenting all the previous symptoms to such a degree, that the patient is no longer able to support himself, and is compelled to take to his bed. The pathogno- monic symptom in this variety is the spasm under the sternum, which is perpetually increasing in vehemence ; and instead of returning, as at first, once in two or three hours, returns now every ten or fifteen minutes. Immediately after which all the host of concomitant contractions renew their violence, and with additional severity : the head is forcibly retracted, and the jaws snap with a fixation that rarely allows them to be afterwards opened wide enough to admit the little finger. This vehe- mence of paroxysm may not, perhaps, last longer than for a few minutes or even seconds; but the spastic action prevails so considerably, even through the intervals, that it is difficult for an attendant to bend the contorted limbs into any thing like an easy or reclined position. The breathing is quick and labori- ous, and the pulse, though calmer and less hurried, small and irregular. The face is sometimes pale, but oftener flushed, the tongue stiff and torpid, but not much furred ; the whole coun- tenance evinces the most marked signs of deep distress, and swallowing is pertinaciously abstained from, as accompanied with great difficulty, and often producing a sudden renewal of the paroxysms. The last stage of the disease is truly pitiable. The spasms return every minute, and scarcely allow a mo- ment's remission. The anterior muscles join in the spastic ac- tion ; but the power of the posterior is still dominant; and hence while every organ is literally on the rack from the se- verity of the antagonism, the spine is more strongly recurvated than ever, and forms an arch over the bed, so that the patient rests only on the back part of the head and on the heels. During the exacerbation of the spasms, the lower extremities, even while they continue rigid, are so violently jerked, that the utmost attention is necessary to prevent the patient from being projected from his bed : and Desportes gives a case in Wstatt wnich botn the tniSh bones were broken from the violent con- been broken traction of the flexor muscles during a momentary remission of from the the extensors ;* similar results to which we shall have occasion violent con- to nolice hereafter. traction of rnL ..... , the flexor f he tongue is in like manner darted spasmodically out ofthe muscles. mouth, and the teeth snapped suddenly and with great force; so that unless a spoon covered with soft rags, or some other in- • Hist, des Maladies de St. Domingue, ii. p. 171. CL. IV.] NERVOUS FUNCTION. [ORD. III. 259 tervening substance, is introduced between the teeth at such Gew. I. periods, the tongue must be miserably bitten and lacerated. Spec VII. The exertion is so laborious, that the patient sweats as in a hot ^a™* bath ; and the heat has in some instances been raised to 110° Fahrenheit. The pulse is at this time small and irregular ; the heart throbs so violently that its palpitations may be seen: the eyes are sometimes watery and languid, but more commonly ri- gid and immoveable in their sockets: the nostrils are drawn upward, and the cheeks backward towards the ears; so that the whole countenance assumes the air of a cynic spasm or sardonic grin, while a limpid or bloody froth bubbles from the lips. There is sometimes delirium, but this is not common : the pa- tient is worn out under this laborious agony in a few hours; though more usually a general convulsion comes to his relief, and he sinks suddenly under its assault. In the erect tetanus, in which there is a balance of spastic Erect action between the anterior and posterior sets of muscles, the tetan"»- progress ofthe disease is not essentially different. The march Description. of the spastic action, however, varies in some degree, as we Spastic have already observed, in almost every instance from trismus action con- to tetanus, and from one modification of tetanus to another: yet "J^ y the course we have now described, is that which chiefly takes place where the disease advances in something of a regular and uninterrupted progress. Its danger and duration are commonly Prognostics. to be estimated from the degree of violence of the incursion. Where this is very severe the patient rarely survives the third day, and is sometimes cut off on the second, or even in six and thirty or four and twenty hours. But, where the attack is less acute, the patient may continue to suffer for a week before he reaches his tragic termination. If he have strength enough to survive the ninth day he commonly recovers, for the paroxysms diminish in violence, the intervals of remission are longer, and the muscles being generally more relaxed, he is able to take a little nourishment. Through the whole period, there is an ob- stinate costiveness, partly from want of food in the stomach, but chiefly from an association of the mouths of the intestinal excernents in the spasmodic constriction. The general principle of cure is far more easily expressed General than carried into execution. It is that of taking off the local ir- jj^jj.0* ritatioo, wherever such exists, and of tranquillizing the nerv- fo|d : to ous erethism of the entire system. The first of these two ob- takeoff jects is of great importance in the locked-jaw or trismus of in- [^.j^3" fants; for by removing the viscid and acrimonious meconium, traD'quj]ii2e or whatever other irritant is lodged in the stomach or bowels, the general we can sometimes effect a speedy cure without any other medi- ^JJjJ^ cine. Castor oil is by far the best aperient on this occasion, and it may be given both by the mouth and in injections. But, The 6rst of if this do not succeed, we should have recourse to powerful JJJ|*^in anodynes; and of these the best by far is opium, which should the locked be administered from three to five drops in a dose, according to jaw of the age of the patient. Musk and the host of antispasmodics mfanU have been tried so often with so little success, that it is not 260 cl. iv.] NEUROTICA. [ORD. III. Gew. I. SrEC VII. Entasia tetanus. Modes of accomplish- ing this object. Treatment of trismus or tetanus from wounds or sores. Spastic action here as much dependent upon con- stitutional as tropical irritability. Great diffi- culty of prognosti- cation. Treatment. Local im- provement, however, often highly favourable: and hence at all times an object of pursuit. How to be attempted. worth while to put the smallest dependence upon them; nor has the warm or cold bath produced effects sufficiently general or decisive to allow us to lose any time in trusting to their ope- ration. They may be employed, however, as auxiliaries ; but our sheet-anchor must be opium, which, if the spastic action have made much advance when we first see the patient, should instantly be employed in conjunction with the prescribed aperi- ent. By taking off the constriction from the intestinal canal, and thus restoring and quickening the peristaltic motion, it may even expedite the dejections. In trismus or tetanus from wounds or sores, the local irrita- tion is not so easily subdued; nor is its removal of so much im- portance, though in no case of small moment. But, generally speaking, the spastic action is, in these instances, as much de- pendent upon constitutional, as upon tropical irritability, and when it has been once excited it will run through its career, whether the local cause continue or not. It is owing chiefly to this fact, that the best and most active plan of cure so often fails of success; and the most cautious practitioners hesitate in their prognostications, whatever be the march of symptoms, for the first four or five days. "From the state ofthe pulse," says Dr. Hennen, " I have derived no clue to either the proper treatment or the probable event: it has, in the cases 1 have met with, been astonishingly unaffected. From the state ofthe skin, 1 have been left equally in the dark. Sweating, which some have imagined critical, I have seen during the whole course ofthe disease, and attended with a most pungent and pe- culiar smell; while, in others, it has never appeared at all: and suppuration, which is generally interrupted, I have seen continue unaffected by the spasms. Even the process of heal- ing, which, it would be reasonable to conclude, should be alto- gether put a stop to, has gone on apparently uninfluenced by the disease : and in the most severe case I ever saw, which oc- curred after a shoulder-joint amputation, sent into Elvas from before the lines of Badajos, the life ofthe patient and the per- fect healing of the wound were terminated on the same day." So powerfully does the constitutional irritability operate in ma- ny cases after the disease has once displayed its hideous fea- tures, and render the local treatment of subordinate importance. In numerous instances, however, a change in the condition of the wound has produced a beneficial result; and hence various means have been resorted to for the purpose of effecting such a change, as local bleeding, anodyne applications to allay the morbid sensibility, resinous, terebinthinate, or mercurial stimu- lants to excite a new action, and amputation of the diseased limb. The first of these three plans is the ordinary mode of practice, and in full plethoric habits it has sometimes proved favourable ; the second plan seems to have been very generally employed by Baron Larrey, who occasionally used stimulants of a far higher power, as penciling the wound with lunar caustic, or an application of the actual cautery. It is upon this princi- ple of counter-irritation that advantage has sometimes been de- cl. iv.] NERVOUS FUNCTION. [ord. hi. 261 rived from needle-puncturing, of which the periodical journals Gew. I. have lately furnished us with various examples:* and, by the Spec VII. French pathologists, from an employment of strychnine or the Entasia active alkaline part of nux vomica, where the disease has not tetanus- been primarily induced by this irritant.! Amputation seems to Needle: have answered in a few cases, if we may give full credit to Su^chninf" those who have chiefly tried and recommended it;J but it is at Amputation best a clumsy and desperate kind of remedy, and, for reasons a c.lu!nsy' already assigned, must be often altogether inefficient if it do not rate remedy add to the constitutional erethism. even when The general treatment has consisted in a free use of opium; conet'jStful' salivation; the hot or cold bath; and wine or ardent spirits, in tional'treat. some instances so far as to produce intoxication. Dr. Cross ment. gives a case in which, after other medicines had been used in Disease has vain, and every hope seemed to fail, the patient was inebriated byTntoxica- with spirits, and kept in this state for ten days, with the result tion. of a perfect recovery.§ A generous use of wine appears to be An exciting almost indispensable, and, considering the ordinary constitution state of regi- in which the disease occurs, the difficulty of supporting: the F1*;"altnost , i .1 , • ■ i • indispensa- system by common means, and the great sensorial exhaustion ble, which is perpetually taking place, it is far from difficult to ex- . . .. plain in what manner H operates beneficially: but intoxication cation a is a frantic experiment, and, where it succeeds once, we have desperate reason to apprehend it would kill in a hundred instances. experiment. The warm and the cold bath have each of them a much bet- ^J1.' *{jf ter claim to attention ; and their votaries are so equally divided, ing. that it is no easy matter to say which is most strongly recom- mended. The latter demands more general strength in the sys- tem, than the former; but neither of them is to be depended upon except as an auxiliary. The cold bath has the authority of Dr. Lind in its favour,|| and has in some instances been tried with success in America.lt Mercury, in various forms, has been had recourse to from a Mercury very early period: and, on the authority of Dr. Stoll, has occa- employed so sionally been used for the purpose of exciting salivation. On salvation.6 what ground it has been carried to this extent, I do not know, except it be that a pretty free flow of saliva from the mouth spontaneously has, by many persons, been regarded as a favour- able sign. The disease, however, does not seem to be accompa- nied with any symptom that can be called critical ; and it is hence probable, that this spontaneous flow of saliva is nothing * London Med. Repos. vol. xx. p. 403. Case furnished by Mr. Finch. t M. Coze, Remarques sur la Nux Vomique, &c. > X Silvester, Med. Obs. and Inq. i. Art. i. White, Med. Obs.^ind Inq. n. Art. xxxiv. Mr. Liston amputated in a case of tetanus from laceration of a branch ofthe median nerve distributed to the thumb ; but, thou^i partial re- lief followed, the patient died. After the operation, it was wished to let the stump bleed for a time ; but not more than eight ounces of blood could be thus obtained, and only one vessel was tied. "Could this arise," says Mr. Lis- ton, "from the coats of the vessels partaking in some measure of the general rigidity and contraction ?'"—See Edin. Med. Journ. No. 79, p. 292.—Editor. i Thomson's Annals of Philosophy. || Essay on Disease's in Hot Cli- mates, p. 257. H Tallman, Amer. Phil. Trans, i. xxi. Cochran, Edin. Med. Com. vol. iii. p. 183. 262 cl. iv.] NEUROTICA. [ORD. III. Gew. I. Spec VII. Entasia tetanus. Treatment. Opium chiefly to be depended upon in every stage and modifi- cation: to be given in very free doses. Exempli- fied. Opium in union with ■udorifics: especially ipecacuan: as given by Latham. more, than a result of the violent action and alternating relax- ation of all the parts about the fauces. Nevertheless, saliva- tion, where it has been accomplished, is said by many writers to have been serviceable, though 1 know of no practitioner who has relied on it alone. And, in reality, such is the rapidity, with which both trismus and tetanus usually march forward, where they have once taken a hold on the system, that we have seldom time to avail ourselves of this mode of cure, were its pretensions still more decisive than they seem to be. It is most successfully employed after copious venesection, and in con- junction with opium. Opium, indeed, in every stage and every variety of both teta- nus and locked-jaw, is the remedy on which we are to place our chief, if not our only dependence; but to give it a full chance of success it should be administered in very free doses, and it is not easy for us to be too free in its use. In the Edin- burgh Medical Commentaries* we have a case, in which five hundred grains were taken within seventeen days, which is about thirty grains a day : and in the Edinburgh Journal! ano- ther case, in which, after smaller doses along with calomel, the practitioner at last gave a drachm of solid opium at one time. This, however, proved too high a dose ; for the induced stupor was accompanied with very laborious respiration, and nearly an extinction ofthe pulse, and the patient was obliged to be roused by stimulants. He recovered ultimately. Yet, in the West In- dies, opium is often carried vgith the most beneficial effects to as great an extent as this, though not at once. Thus Dr. Glos- ter of St. John's, Antigua, gave to a negro, labouring under te- tanus from an exposure to the night air, not less than twenty grains every three hours, in conjunction with musk, cinnabar, and other medicines; and continued it with but little abatement for a term of seventeen clays, in the course of which the pa- tient took five hundred grains of this narcotic. For the first six days, little benefit seemed to be effected; but after this pe- riod the symptoms gradually declined under the same persever- ance in the medicine, and, in thirteen days more, they were so much diminished that no farther assistance was thought neces- sary. If there be any thing which adds to the sedative power of opium in this disease, it is sudorifics, and particularly ipecacuan. And upon this subject, Dr. Latham has given a valuable paper in the Medical Transactions, in which he offers examples of failure in the use of James's powder, when used either alone or in alternation with opium ; but of full success by uniting the two powers of the narcotic and the sudorific, though he after- wards preferred ipecacuan to James's powder, and prescribed it in the form of the compound powder of this name. He gives cases in which he employed this compound in very severe at- tacks, and sometimes in what seemed to be its last stage ofthe disease, with an immediate arrest of its symptoms, and pro- * Vol. i. p. 88. t Edin. Med. and Surg. Journ. No. lxxi. Mr. Barr's case. CL. IV.] NERVOUS FUNCTION. [ord. iii. 263 gressively a perfect restoration to health. His doses consisted of Gew. I. ten grains repeated every three or four hours. In no instance Spec VII. was there any unusual inclination to sleep, how long soever this Entasia treatment was continued, which in one case was for a fortnight: ., j r • i a Treatment nor was there any degree ot sickness, nor any other inconve- nience, except that of a perspiration troublesome from its ex- cess.* It is only necessary to observe farther, that, during the treat- Proper ven- ment either of trismus or tetanus, a very particular attention tilation of should be paid to ventilate the chamber with pure air; and es- ;mp0rtance. pecially to purify the air of close and crowded hospitals, with- out which no plan of treatment in the world can be of any avail. We should also remove, if possible, the costiveness, to ™bebr°_ ' which the bowels are so peculiarly subject, by some gentle ape- i;eved 0r rient: for it sometimes happens, not only in infantile trismus or costiveness tetanus, but in that from obstructed perspiration, or cold and j^f"^*. dampness, that the primary cause of irritation is seated in the bowels; while, whatever accumulation takes place in this quar- ter, during the course ofthe disease, may add to and exacerbate the general erethism. At the same time, nothing can be more hut drastic mischievous, than the drastic purges which practitioners are {J"ghfy mis- apt to give at the commencement of this disease, consisting of chievous. jalap, scammony, and aloes. We have already seen, that the Explained. general excitement is so extreme, that the slightest occasion- al irritation, even that of changing the position of the head, is sometimes sufficient to produce a return of the spasms ; and hence there can be nothing more likely to do it, than the grip- ing effects of such medicines. And it will be far safer to pass by the constipation altogether, than to attempt to remove it by such dangerous means. The best medicine is castor oil, which may be given either by the mouth or in the form of injections; and if this do not succeed, we may employ calomel. But the action of the bowels must only be solicited, and by no means violently excited.t * Med. Transact, vol. iv. art. iv. t The editor freely confesses, that he does not participate in the author's aversion to the employment of strong purgatives in tetanus. While Dr. Good condemns them, we find some other physicians prescribing them in extraordinary doses, and with decided suc- cess. Thus, in an example under Mr. Manifold, of Liverpool, on which Dr. Briggs has of- fered some reflections, half a drachm of calomel, as much scammony, and fifteen grains of gamboge, were given in one dose, followed by a clyster of half an ounce of turpentine, and two drachms of aloes. As these powerful means had produced no effect, two drops of the oil of croton in a little treacle were given in the evening, and at the same time a clys- ter of four ounces of the sulphate of magnesia in a pint of infusion of senna. In less than an hour afterwards a black stool was voided, and relief immediately experienced from the evacuation. By continuing the same active remedies, a cure was effected. (See Edin. Med. Journ. No. 85, p. 277.) Indeed, the oil of croton, owing to its great efficiency in pro- moting stools, promises to be a most valuable medicine in tetanus. Dr. Briggs even main- tains, in direct opposition to Dr. Good, that the principle on which the utility of purga- tives rests in this disorder is that of counter-irritation on the bowels ; a theory, which we need not investigate too deeply, provided the practice be found to answer. Dr. Good describes opium as the sheet-anchor in the treatment; yet, in almost every case, in which the editor has seen this medicine used as the chief or only one, the disease proved fatal. One remedy for tetanus, in favour of which wc have now many facts recorded, is tobacco. Two examples of its efficiency are detailed by Dr. Anderson, of Port Spain, Trinidad.— 264 cl. iv.] NEUROTICA. [ord. III. Species VIII. Entasia Lyssa.—Rabies. Spasmodic constriction of the muscles of the chest; supervening^ to the bite of a rabid animal; usually preceded by a return of pain and inflammation in the bitten part: great restlessness, horror, and hurry of mind. Gew. I. The Greek term for rabies was lyssa : and the antiquity of Spec.VIII. the disease is sufficiently established from its being referred to Antiquity of several times under this name by Homer in his Iliad, who is namePand of perpetually making his Grecian heroes compare Hector to a the disease mad dog, xt/v* Xver runs rapidly from one dog to another, and it may be difficult in cation. many cases to trace the marks of a bite, yet considering that No solid the smallest and most imperceptible scratch of a tooth may be a for'stichan sufficient medium of infection, and that every inoculated dog opinion. adds to the sources from which it may be derived, there is no Whether difficulty in accounting for such rapidity of spread, without as- ™?*g *° * Trolliet, ubi supra. t According to Dr. Barry, "The notion that the hydrophobic poison is absorbed, after the manuer of other substances similarly circumstanced, but that it does not produce its peculiar effects until it has wandered through the penetralia of the animal for forty days or longer, is in direct opposition to all analogy. The experiments which we have witnessed with the vegetable, mineral, and reptile poisons, applied to animals externally, prove that the com- mencement of the symptoms is synchronous with the consummation of absorption, and that their repetition is dependent upon its renewal." (Experimental Researches on the Influence of Atmospheric Pressure upon the Blood in the Veins, &c. p. 151.) However, although the hypothesis rejected by Dr. Barry is said by him to be contrary to all analogy, a somewhat similar one was adopted by John Hunter, and even now generally prevails in relation to syphilis, the constitutional effects of which follow absorption of the virus at very indeter- minate periods, and in a great diversity of forms. Now this absorption is not a conjecture, but often actually proved hy the occurrence of a bubo. The editor, however, merely ad- verts to these circumstances, in order to remind the reader that analogy is not entirely against the hypothesis of the hydrophobic poison being absorbed some time previously to the commencement of the symptoms, and not with the view of denying the correctness of Dr. Barry's conclusion. In hydrophobia it is not improbable, as this gentleman's arguments maintain, that the poison, which is afterwards to affect the constitution, is generated in the wounded part from the germ first deposited there by the tooth of the rabid animal, just as we see happen in variola, vaccinia, and lues itself. But, if the commonly received opinions of syphilis be well founded, its virus is certainly generally absorbed without giving rise to any immediate constitutional effects, and even is sometimes expelled again without such effects ever taking place at all. The assertion of Dr. Marochetti, that the hydrophobic poison is translated to the place on each side of the fraenum of the tongue, where the sub- maxillary salivary ducts terminate, and where it produces vesicles or pustules, will be pre- sently noticed.—Editok. 270 cl. iv.] NEUROTICA. [ord. in. Gew. T. Spec.VIII. Entasia lyssa. ceived with- out a wound or sore : asserted by Heister, aud by Pal- mariud. The effects in these cases ac counted for upon the common law ofthe disease. Proofs offered. Has been sometimes denied that the virus can be prop- agated in any way from the human subject. Contra. dic'ed by experiments of Mmen- die and Bre.-chet. Nervous system the immediate quarter of disturbance: but the effects re- ferred by some writers to the san- guiferous system, and regarded as a lever or an in- flammation. cribing anomalies to the laws hy which it is regulated. Heis- ter, indeed, has given a case of lyssa, in one ofthe foreign col- lections, produced in a man by his having merely put into his mouth the cord hy which the mad dog had been confined: but as in this instance there was probably some ulceration in the mouth at the time, there is nothing marvellous in its produc- tion. Palmarius, in like manner, relates the case of a peasant who, in the last stage of the disease, communicated it to his children in kissing them and taking leave of them.* Yet, un- less we could be certain that there were no cracks or other sores on the lips, and no eruption on the cheeks of these chil- dren, the example affords no proof. I can distinctly state, that I have seen the same intercommu- nication successively repeated between a rabid young man and a young woman to whom he was betrothed, and who could not be restrained from such a token of affection, without any evil consequences ; notwithstanding that the patient was labouring at that time under hydrophobia and all the severest mailc^ of the disease which destroyed him in a few hours afterwards, and had also a perpetual desire to spit his saliva about the room. M. Trolliet asserts, not only that the virus will not permeate a sound skin, but that it is only contained in the frothy matter communicated^ from the lips; and that neither the blood, nor the secretions of any kind are tainted with it, or give rise to the disease, whatever scratch or other injury may be received during dissection. It has, still farther, been doubted whether the virus itself is capable of propagation from the human subject to any animal even by inoculation: but a bold experiment of M. Magendie and M. Breschet has completely settled this question ; for on June 19, 1313, having collected upon a piece of linen a portion ofthe saliva of a rabid man in the last stage of the disease, they inserted it under the skin of two dogs that were in waiting, both of them in good health ; of which one became rabid on the 27th of July, and bit two others, one of which also fell a victim to the disease just a month afterwards The general aggregate ofthe symptoms point forcibly to the nervous system as the immediate quarter of disturbance. Such was the opinion of Morgagni, Cullen, Percival, and Marcet; and such indeed is the common opinion ofthe present day. By ma- ny writers, however, the effects have been rather referred to the sanguiferous system, and regarded as a fever: Mangor de- scribes it as a continued fever,! and Rush and many others as an inflammatory affection ; Bader as a fever sui generis.l Nor is the difficulty in the least degree removed by dissection, for noth- ing can be more at variance than the appearances in different cases. Generally speaking, the fauces and parts adjoinino- ex- hibit redness and inflammatory characters. But while in some instances these are so considerable as to be on the point of o-an- * De Morb. Contngios. p. 266. Paris, 4to. 1518. t Act. Hafn. u. X Vcrsuch ener ucuen Theorir, Szc. CL. IV.] NERVOUS FUNCTION. [ord. in. 271 grene, in others there is no inflammatory appearance whatever. Gen. I. Morgagni has examined and described bodies in both these Spec.VIII. states, ftolfinc gives one or two decided cases of the latter E»tasia sort:* while Feriar notices examples, in which the inflamma- ^s a\ tion ofthe fauces had spread over the whole oesophagus and ex'^nslw?ed, even the stomach ;t and another writer has recorded an in- and inflam- stance, in which it had descended to the ileum, which was in a matoty c 4. i .1 li i appearances state ot gangrene.J In some cases, the encephalon, and even accounted the spinal marrow," have appeared to be as much diseased as for. the fauces ; the vessels turgid ; the plexus choroides blackish ; the ventricles loaded with water: though, in the cases examin- Sometimes ed by M. Magendie, which were confined to dogs, there was no no such ap- appearance of inflammation either in the brain or spine. Some- times the lungs have been inflamed, sometimes the liver, some- times the vagina ; while the blood, according to Sauvages, has been also found in a dissolved state, and, according to Morgagni, in a state highly tenacious and coagulable. From all which we can only conclude that, owing to the violence of the disease, every organ is greatly disturbed, and those the most so that in particular cases are most severely affected. Riedel asserts that, Whether among dogs, a highly offensive fetor of a peculiar character is accompanied thrown forth from every part of the body :§ but I have not *^A"e found this remark confirmed by the veterinary practitioners of fetor our own country ; and it certainly does not apply to mankind, seen* to wilh an exception or two that seem to depend upon some acci- have been dental circumstances; for Wolf informs us, that in one of his pa- *°J^ *^ tients, and a patient that ultimately recovered, the blood stunk some intolerably as it was drawn from n vein; and a patient of Dr. casualty, Vaughan'si cotmdained of a most offensive smell that issued from b,",10t,* ...ii r- i • i -ii i general con- the original wound, but of which no one was sensible except comitant. himself. In like manner, the patient described by Dr. Marcet, towards the close ofthe disease, complained loudly of an intol- erable stench that i-sued from his body generally, but without .being perceived by any other person.|| Dissection in this case produced nothing striking. Dessault, in bis treatise on rabies, tells us that he has often Hypothesis met with numerous minute worms in the heads of those who °f Dessault, have died of this disease ; and he hence regards such animal- ",^1^"^" cules as its cause. But this writer was a slave to the Linnean from ani- hypothesis of invermination, and applied the same cause to sy- malcules. pliilis, which he also supposed to be maintained by a transfer of vermicules from one individual to another: and hence proposed to treat syphilis, lyssa, and itch, as diseases of a like origin, with the common antidote of meicury ; and gives instances of a suc- cess which no one has met with out of his own practice. The cases, however, which he describes had not advanced to the stage of water-dread ; and, in all of them, he thought it prudent to combine with his mercurial inunction cold bathing and Pal- marius's antilyssic powder. * Dissert. Anat. Lib. i. cap. xii. + Medic. Facts and Observations, vol. i. X ^- Act- Nflt- Cur' vo1- iV' 0bs> 2u- ' Act. Acad. Mogunt. Erf. 1757. [| Medico-Chir. Trans. I. 132. 272 ci. iv.] NEUROTICA. [ord. III. Gen. I. Spec.VIII, Entasia lyssa. Whether the local irritation proceed from a dormant seminium, or from universal excitement. Not from the last, as it commonly precedes it and gives rise to it. Variation in feline rabies from canine, by which the disease seems to be rendered somewhat less malig- nant. Hence two distinct forms. et E. Lyssa felina. Example from Morgagni. In tliif case no hydro- phobia, Vander Brock and, after him, Rahn maintain that the return of pain and inflammation to the bitten part, on the onset of the disease, does not occur from any virus which has hitherto been lying dormant there, but from the universal excitement alone. It may be observed, however, in opposition to such an opinion, that this local affection is in most instances a prelude to the gen- eral disease, and forms the punctum saliens from which it is- sues; as though the contagious ferment had remained dormant there, and was at length called into action by some exciting cause. There seems, nevertheless, to be a slight departure from the general character of the disease in a few cases, and particularly in those that are produced by the bite of a rabid cat, whether the latter have originated it, or received it from a rabid dog, as though by a passage through the domestic cat the virus un- dergoes a similar change to that which takes place in the virus of small-pox, when passing through the system of an individual who has previously submitted to the influence of cow-pox : for, upon the whole, the disease appears to evince somewhat less malignity, to be more disposed to intermit, and its spastic-symp- toms, and especially that of water-dread, to be both less fre- quent and less violent: so that in respect to symptoms we may perhaps mark out the two following varieties: x Felina. The spastic symptoms less acute Feline rabies. and frequently intermitting; pro- duced b}' the bite of a rabid cat. 0 Canina. The spastic constriction, for the Canine rabies. most part, extending to the mus- cles of deglutition, which are violently convulsed at the ap- pearance or idea of liquids: produced by the bite of a rabid dog, wolf, or fox. There is a case of feline rabies, if it be rabies, in Morgag- ni, and which is copied from him into Sauvages' Nosology, in which the above distinction is so strongly marked, that the au- thor, in the first edition of his own Nosology, was induced to follow M. de Sauvages' mode of classifying it, and made it, after him, a distinct species, though he deviated from the name un- der which it occurs in this justly celebrated writer, which is that of Anxietas a Morsu.* The history of the enrap-ed cat is not given, nor is it certain that the rage was that of rabies. The master of the animal was attacked and wounded both by ils teeth and claws. The symptoms took place four days after the bile, and were confined to spasms of the chest without hy- drophobia ; nor do these seem to have been of great violence for they are described as " magna praecordiorum anxietas." Local and general bleedings were useless : a frequent repeti- tion of the warm bath afforded relief; but it only yielded to an * Classis vii, Ord. i. v. 6. CL. IV.] NERVOUS FUNCTION. [ord. iii. 273 ephemera with copious sweat. The intervals were lunar : for Gew. I. it returned with the full moon for two years; the bitten part, Spec.VIII. as usual, first becoming highly irritable, and the spasms or ve- <*E. Lyssa hement anxiety of the praecordia supervening, which were now felma' relieved by bleeding. After this period, it returned with *"£ j?", c°n" every fourth full moon for two years more, and then appears to periodical' have ceased. returns, A few instances of intermission, with a return of periodical j^™"™0"18 paroxysms, produced by the bite of a rabid dog, are also to be bitten part, found in the medical collections: of which Dr. Peter's case* and con- affords a striking example, the paroxysm returning for many J^oyfJ^ months afterwards, severely once a fortnight, or at every new . . and full moon, and slightly at the quarters, or in the interven- stances of ing weeks. Selle, indeed, asserts that he has met with an in- periodical stance ofthe same kind of intermission among; doers; and return9 |jave ° ° occurred hence, where the individual recovers, both varieties seem oc- among dogs. casionally to subside in this manner.t And hence Dr. Fothergill has given two cases of unquestionable affec- both varie- tion from feline rabies, produced by the same animal. The cat ties se.em soroetiixies first bit the maid-servant, and afterwards the master of the to terminate house, about the middle of February. The wound inflicted on in this the maid-servant remained open and irritable from the first, I,,anner- and continued to resist every application for many months; it Fothergill's healed, however, at length, and no constitutional symptoms su- g^i""^ pervened. The wound inflicted on the master healed easily affection and in a short time, but in the middle of the ensuing June, f,om feline being four months afterwards, the usual symptoms of lyssa ap- ra ies' peared, yet with comparatively slight and occasional water- ,n t,,e on*j dread ; insomuch that the patient, far from resisting the use of d'ffi^it'to the warm bath, sometimes called for it, expressed a high sense heal. of the comfort it afforded him, and was able at times to dash in the other the water over his head with his own hands. It terminated, the wound however, fatally, and with the usual symptoms of distress.;); easily1 but In the Transactions of the Medical Society of London we death'en- have a highly interesting case of the same kind, which proved sued. equally fatal, in seventy-four days from the time of receiving Farther the injury, and fifty-eight hours from the commencement of the illustrated disease; all the symptoms, moreover, exhibiting less violence Marked case than usually occurs in canine madness, with little or no water- in the Phi- dread, and consequently an ability to drink fluids to the close of losophlcal the disease, though the muscles of deglutition, as well as those tjoDg"ac' of the chest, evinced always some degree of constriction, with occasional exacerbations.§ The patient was a young lady of eighteen years of age ; the attack was made in the month of January, with both claws and teeth, by a domestic cat that was lurking under the bed, and which, though not known to be ill, had for some time before been observed to be wild, and had been roving in the woods. The fate of the aninial is not men- . * Phil. Trans. 1745. IVo. 475. t JN'eue Betrage zur Natur und Arzney- wissenschaft. b. iii. 118. X Med. Observ. and Iuquir. vol. v. i Vol. i. Ait. iv. p. 78, 8vo. 1810. vol. iv. 35 274 cl. iv.] NEUROTICA. [ord. iii. Gew. I. Spec.VIII. * E. Lyssa felina. Exciting cause clear. Little affec- tion of the parts origin- ally injured. Spasms about the throat, hut little water- dread. Fatal ter- mination. 0E. Lyssa railing. Distinctive signs and general de- scription. tioned. The lacerated parts were incised and purposely in- flamed by the application of spirit of turpentine. The wounds healed, and the general health of the patient continued perfect till the beginning of the ensuing April, when she was suddenly frightened by looking out of a window, and seeing a mad dog pursued by a crowding populace. This proved an exciting cause. She instantly expressed alarm, anxiety, and dejection of mind. In the afternoon she complained of an unusual stiff- ness in moving her left arm, and its sense of feeling was im- paired; she discovered an aversion to company; the irritations of noise, heat, and light, were offensive to her; she avoided the fire, and forbade a candle to be brought near her. The rigidity and insensibility of the affected arm seemed to shoot in a line from the middle finger which had been lacerated, and was accompanied with an acute pain which terminated in the glands of the axilla, where she complained of a considerable swelling. Yet neither of the hands (for both had been injured) was affected with discoloration, tension, tumefaction, or any other mark of local injury, though a degree of lividity had been observed upon the lacerated part of the finger a short time before the disease made its appearance. She had a pain- ful constrictive sensation in her chest, and the respiration was interrupted by frequent sighings. The spasmodic symptoms in- creased, and at length the whole system, but especially the lungs, was effected with violent convulsions : the breathing was ex- quisitely laborious, but the paroxysm subsided in about two minutes. Frequent sickness and vomiting followed : the convul- sive spasms about the throat obliged her to gulp what she swal- lowed, and she showed a slight reluctance, but nothing more, to handling a glass goblet. The pulse was 132 strokes in a minute ; the skin was cool, the tongue moist, the bowels open, the thirst urgent, without any tendency to delirium. She was worn out, however, by sensorial exhaustion and distress, and at last expired calmly, at the distance of time from the attack al- ready stated. In the general progress of canine rabies, all the above indi- cations are greatly aggravated, and the mind often participates in the disease and becomes incoherent. Whatever be the ex- citing cause, the wounded part almost always, though not universally so, takes the lead in the train of symptoms, and be- comes uneasy ; the cicatrix looking red or livid, often opening afresh, and oozing forth a little coloured serum, while the limb feels stiff and numb. The patient is next oppressed with anx- iety and depression, and sometimes sinks into a melancholy from which nothing can rouse him. The pulse and general temperature of the skin do not at this time vary much from their natural state. A stiffness and painful constriction are however, felt about the chest and throat; the breathing be- comes difficult, and is interrupted by sobs and deep sighs as the sleep is, if any be obtained, by starts and frightful dreams. Bright colours, a strong light, acute sounds, particularly the sound of water poured from bason to bason, even a simple ag- CL. IV.] NERVOUS FUNCTION. [ord. m. 275 itation of the air by a movement of the bed-curtains, are sour- Gew. I. ces of great disturbance, and will often bring on a paroxysm of Spec.VIII. general convulsions, or aggravate the tetanic constriction. The @E- Lyssa patient is tormented with thirst, but dares not drink; the sight canina' or even idea of liquids making him shudder : his eye is hag- gard, glassy, fixed, and turgid with blood from the violence of the struggle ; his mouth filled with a tenacious saliva, in which we have already shown lurks the secreted and poisonous mi- asm, and he is perpetually endeavouring to hawk it up and spit it away from him in every direction; often desiring those around him to stand aside, as conscious that he might hereby injure them. The sound which is thus made, from the great Sound made oppression he labours under, and from his vehement effort to in the tra. excrete the tough and adhesive phlegm, is often of a very sin- vSheoirot" gular kind; and being sometimes more acute than at others, as effort'to" well as quick and sudden, and also frequently repeated, like terete every other motion of the body, has occasionally, to a warm jJn.Tth.'.Jll" and prepossessed imagination, seemed to be a kind of barking resemblance or yelping. And hence, probably, the vulgar idea that a bark- !° t,,e bark- ine, like that of a dog, is a common symptom of the disease. jf'Jj °f. The restlessness is extreme, and if the patient attempt to lie whence the down and compose himself, he instantly starts up again, and vulgar idea looks wildly round him in unutterable anguish. " On ffoinsr jfJ!1,!rp*'n„ into the room," says Dr. Munckley, describing the case of a barking. patient to whom he had been called, and the author can bear Forcible witness to the accuracy of his very forcible delineation, " we delineation found him sitting up in his bed, with an attendant on each side J,01" ... of him: he was in violent agitation of body; moving himself unckU?7' about with great vehemence as he sat in the bed, and tossing his arms from side to side. On seeing us he bared one of his arms, and, striking it with all his force, he cried out to us with the greatest eagerness to order him to be let blood. His eyes were redder than the day before ; and there was added to the whole look an appearance of horror and despair greatly be- yond what I had ever seen either in madness or in any other kind of delirium." The patient was, nevertheless, " perfectly in his senses at this time, and there was not the least appear- ance of danger of his biting any person near him ; nor, among the variety of motions which he made, was there any which looked like attempting to snap or bite at any thing within his reach: and they who were about him had no apprehension of his doing this."* The patient had at this time reached the third day of the disease, and expired about two hours after Dr. Munckley had left him. There is, however, a considerable difference in many of the fympioms''6 symptoms which characterize the progress of this malady, de- muchdis- rived from difference of age, idiosyncrasy, or some other casu- F?*«*.l° alty, so that it is possible no two cases are in every respect different precisely parallel. The volume of the Medical Transactions cases. from which I have just quoted contains three instances of lyssa Exempli- fied. * Medical Transactions, vol. ii. Art. v. p. 53. 27(i cl. iv.] NEUROTICA. [ord. in- Gen. I. Spec.VIII. 0 E. Lyssa canina. Bitten part sometimes not affect- ed ; yet such affec- tion gener- ally forms the prelude. Commonly the mind never wanders: but the patient is sometimes furious and ungoverna- ble. Pulse rarely much changed from its natural standard. Great varia- tion in the interval between the injury and the incur- sion of the disease. Ordinary interval about six weeks. Course and symptoms often discrepant. This dis- crepancy apparently communicated by different practitioners. In the first, which is Dr. Munckley's, no notice whatever is taken of the original bite, which was both in the hand and cheek, from a favourite lap-dog, and the patient does not seem to have had any return of pain or irritation in these organs. In the second case, which is that of a lad of fifteen years of age, the bite, which was in the leg, was so small that it was scarcely perceptible at the time, and from first to last never gave the least uneasiness.* In the third case, which is that of an adult woman, the disease was preceded by the ordinary prelude of torpor, stiffness, and ting- ling in the bitten part, shooting upwards to the trunk.j In the first case, the patient's mind never wandered to the last moment of life, which is a common character of the disease; in the second and third, both were furiously mad, bit themselves, the bed clothes, and whatever else fell in their way. In all of them, however, there was a severe hydrophobia, and in all of them the pulse did not essentially vary from its common standard. The first died on the third day; the two last recovered; the one under a treatment which consisted principally of opium, and the other under that of salivation ; leaving it therefore doubtful how far the recovery may be ascribed to the natural powers*bf the constitution, and how far to remedies so widely different in their nature. Dr. Marcet's patient did not expire till the sixth day after the appearance of water-dread, and without any affec- tion in the bitten part ;\ and, towards the close of the disease, he sometimes suddenly gulped half a pint of water, or splashed it over his body. There is also, in these three cases, an equal and most singu- lar discrepancy in the interval between the infliction of the wound and the incursion of the disease, or, in the language of Professor Trolliet, its period of incubation. The first interval was about six weeks, which may be regarded as the ordinary term: the second was only five days : the third is not set down with any degree of precision ; the patient is only stated to have been seized " about the time that the second horse died" that had been bitten by the same rabid dog; and hence this interval con- sisted probably of about a fortnight. A like variation in the course of morbid symptoms distin- guishes the series of cases published by Professor Brera, and which took place in the month of November 1804, on the in- cursion of a wolf sufficiently proved to be rabid. Generally the patients showed no desire to bite or otherwise injure persons about them; but, in one instance, such a desire was strikingly prominent. In another case also, though there was a fatal water-dread, there was no flow of saliva. In some, the horror extended to liquids of every kind ; in others, water alone pro- duced it, while wine was drunk with ease.§ This discrepancy seems to depend entirely upon the nature or presence of the predisponent or exciting cause that gives * Medical Transactions, vol. ii. Art. xii. p. 192. t Id. Art. xv. p. 222. X Medico-Chir. Trans. I. p. 152. $ Commentario Clinico per la cura dell' Idrofobia, &c. Mem. Soc. Ital. Scienz. torn. xvii. Modena. cl. iv.] NERVOUS FUNCTION. [ord. hi. 277 energy to the virus, and without which it may lie, as we have Gew. I. already observed, for an almost indeterminable period dormant, Spec.VIII. but undecomposed, and therefore as malignant as when first 0 E. Lyssa generated.* In the three cases just quoted from the Medical czuiaz' Transactions, the lad who was soonest affected seems to have dePen^ent had a strong predisposition to the disease from the first moment, p{-edispo- and which alone became an exciting cause; in the woman, who nent or suffered about a fortnight afterwards, there was probably some e*clUnS CIIUS6. degree of predisposition, but the immediate exciting cause ap- pears to have been over-exertion in walking, for we are told that " she was seized as she was going on an errand on foot, and had walked about two miles." There is a like uncertainty among quadrupeds. We have Alike just taken the interval of ten or twelve days as the common uncertainty term; but, in the instance just referred to, it may have been ^JXupeds; considerably longer. According to Meynall, the disease among common dogs appears from ten days to eight months after the bite. In interval ten Earl Fitzwilliam's hounds, which were bitten June 8, 1791, the °fa™ v< interval varied from six weeks to more than six months; and but has not much less in Mr. Floyer's hounds, as described by Mr. J5**"^" James. It is not therefore to be wondered at, that there should sj™^ eigbt be a great uncertainty among mankind. And hence we find it months. has occurred a week or fortnight after the bite, three weeks, a Hence in month, and sometimes six weeks, and even three months ; after mankiud which last period, however, notwithstanding occasional instances r^j/a"6 to the contrary, the patient is generally considered safe. There week or a are two cases published by Dr. Tracher,! in which the injury fortnight inflicted by the same dog, August 16, 1810, did not produce hy- 0°r L"nsreweee 8 drophobia in either instance till nearly three months afterwards, months: namely, November 3, and November 14, ensuing: and it is the after which more remarkable, that the first case was that of a child under js^enera"^ four years of age, the second that of an old man of seventy- considered three. Both terminated fatally; the former case in six days, saff!- the latter in seven from the onset of the disease. Upon the Illustrated. whole, we may calculate the interval as varying from five or £rec^ab,e six days to as many months, the usual period being about the jnt,';rnvaj. same number of weeks. The academical journals, and monographic writers, never- a tew theless, have numerous instances of the malady appearing after ^sjances^on a bite of many years' standing ; sometimes twelve, eighteen, [no*drigeaSC twenty, and even thirty years; but the evidence is mostly im- occurring perfect. I shall presently, however, have occasion to notice many years * If this doctrine were positively proved, the information would be of high w"nJ"°*.y importance in practice, as justifying the excision of the parts at a very late tj)(jrjt„ period after they have been healed up, when this measure, so indisputably prudent in an early stage, has been neglected. However, whether the virus first inserted lie dormant in the part or not, if the bite be known with certainty to have been inflicted by a rabid animal, the extirpation ofthe bitten parts is advisable also on the other hypothesis, that the virus, though not now actually present itself, may have communicated to the parts a disposition to assume at a subsequent period a specific action, by which the hydrophobic poison will be regenerated, aud subjected to absorption, with all its horrible consequences.— Ed. + Amer. Med. and Phil. Reg. vol. i. p. 457. 278 cl. iv.] NEUROTICA. [ord. iii. Gen. I. Spec. VIII. 0 E. Lyssa canina. Singular case of retardation related by Dr. Bards- ley : giving an interval of twelve years. Trolliet's extensive experience. General train of symptoms. Ordinary interval. Singular extension of intervals. one, in which it occurred and proved fatal more than nine months afterwards: and there is another, communicated by Dr. Bardsley to the Manchester Society, strongly entitled to credit, however difficult it may be to account for the fact, in which the attack did not commence till twelve years after the bite of a dog supposed to be mad. The patient died in the Manchester Infirmary with decided symptoms of the disease. He had been for some time antecedently labouring under great nervous agi- tation and considerable depression of spirits ; and Dr. Bardsley inclined to ascribe it to this cause, rather than to any specific poison lurking in the system. But this is to suppose that lyssa is capable, under particular circumstances, of being generated spontaneously in the human frame, while Dr. Bardsley, as we have already observed, contends that it cannot exist, even among dogs, except by contact.* There are few physicians, whose experience seems to have been so extensive upon this melancholy subject, and so actively followed up by judicious and even original views, and post-obit examinations, as that of Professor Trolliet, to whom I have al- ready adverted. Independently of a variety of single and un- connected cases that had fallen under his care, he gives an ac- count of a ravage committed on not less than twenty-three per- sons, besides cattle and dogs, in the department ofthe lsere in 1807, twelve of whom, for the most part terribly bitten in the face, were conveyed to the Hotel Dieu at Lyons, in which he was clinical professor, and, as such, were placed under his im- mediate care.j The general train of symptoms as the patients became succes- sively affected and died, after an active and judicious treatment of preventive as well as curative means, did not essentially vary from those just related. The local indications mostly, but not always, preceded. The interval, between the bite inflicted by the rabid wolf and the access of disease, varied from a fortnight to five weeks, and the patients uniformly sunk on the second or third day after a clear development of the symptoms. In the preceding year, however, M. Trolliet had a case, produced by the bite of a mad dog, in which the disease did not show itself till five months and a half after the infliction ofthe wound. The patient was a strong, robust man, of thirty years of age, and the dog had died mad in the veterinary school at Lyons soon after the injury. The first symptoms in this case were the usual ones of pain in the bitten part, which gradually extended to the arm and neck. Two days afterwards the patient was sensible of a vapour or aura, which ascended from the abdomen to the head, accompanied with a general uneasiness. The symptom of hydrophobia was manifested on the day ensuing; the deplet- ing plan was, in this instance, followed up with a daring urgen- cy, and the man expired on the evening ofthe same day. * The author overlooks the possibility of mistaking a tetanic affection for lyssa; yet the close approximation, which one disease frequently makes to the other, is acknowledged by all men of experience aud observation.__En. t Nouveaux Traite de la Rage, Observations cliniques, Recherches d'Ana- tomie pathologique, et Doctrine de cette Maladie, &c. 8vo. Lyori, 1820. cl. iv.] NERVOUS FUNCTION. [ord. hi. 279 M. Trolliet's post-obit examinations are numerous, and they Gew. I. uniformly give proof, like the dissections already noticed, of Spec.VIII. extensive mischief in various organs remotely situated from 0 E. Lyssa each other; the chief of which, however, were the mucous canina- membrane of the trachea and bronchiae, and the membranes of P°sl"?DI| the brain, especially the pia mater; all which, in direct repug- \\om. nance to M. Magendie's observations, were infiltrated with red blood, and gave evident proofs of inflammatory action ; while the mucous membrane of the bronchiae and trachea were cover- ed over with a frothy material of a peculiar kind, which M. Trolliet supposes to be the seat or vehicle ofthe specific virus, and which in his opinion is driven forward into the fauces and intermixed with the saliva by each spastic expiration from the chest. The other organs he found affected as follows : the ca- pillary vessels of the lungs were penetrated with a larger quan- tity of blood than ordinarily ; their substance was emphysema- tous, or contained an accumulation of air, as did also the heart and large blood vessels in^me instances. The blood itself was black, uncoagulating, and of an oily appearance. That taken from the veins, during the disease, coagulated into an entire cake without any separation of serum. The mucous mem- branes of the mouth and pharynx were of a pale gray, and lu- bricated by a gentle moisture ; they contained no saliva, nor any frothy material. The most singular fact of the whole is, that " the salivary glands, and the cellular substance which enve- lopes them, afforded not the least vestige of inflammation, nor the slightest alteration in their volume, their colour, or their texture." It is this last circumstance that seems chiefly to have induced Trolliet's M. Trolliet to venture upon a new hypothesis, and to suppose, hypothesis^ that the actual seat of the specific virus is the mucous mem- mate cause brane ofthe bronchiae or lower part of the trachea, rather than of lyssa. the fauces or the salivary glands ; and had these last in every instance been discovered as clear of any manifest morbid ap- pearance as in the dissections of this ingenious pathologist, there would be strong ground for his conjecture : but as we have al- ready seen that, in some cases, there have been found only slight marks of inflammatory action in the bronchiae, while the fauces and oesophagus, and occasionally the stomach and even the ileum, have been so inflamed as to approach a state of gan- grene, much farther investigation is necessary before the old doctrine should fall a sacrifice to the new. The only fact we are at present able to collect from dissections, is a very exten- sive and violent disturbance throughout the entire frame ; some- time fastening chiefly on one set of organs, and sometimes on another. The mode of treatment is a field still perfectly open for Medical trial; for, at this moment, we have no specific remedy, nor any treatment. plan that can be depended upon, after the disease shows itself. Antecedently, indeed, to this period our course is obvious, Prophylac- and particularly if we should be so fortunate as to be consulted l,'c course at the time of the bite : it should consist in endeavouring, by obv,ous- 280 cl. iv.] NEUROTICA. [ord. hi. Gew. I. Spec.VIII, Entasia lyssa. Prophylac- tic treat- ment. The bitten part to be destroyed. Various modes pro- posed. Potential cautery not to be de- pended upon. Excision and actual cautery to be employ- ed jointly. the promptest and most efficacious means, to prevent the spread ofthe disease, by washing the part well and thoroughly at the nearest spring or river at hand, and by extirpating the virus be- fore absorption has taken place. This has been done in various ways; for the lacerated part has been sometimes amputated or dissected out, and at other times totally destroyed by the actual or potential cautery. The actual cautery, by the means of irons heated to whiteness, was first adopted and recommended by Dioscorides,* and afterwards by Van Helmont, Morgagni,! and Stahl: the potential cautery seems to have been proposed as a less terrific mode of operation, and has usually been ac- complished by the means of lapis infernalis or decarbonated soda. It is recommended by Schenck, Pouteau, and Dr. Mose- ley. A notion, however, has obtained, from a very early peri- od, that the irritation produced by a cautery, whether actual or potential, only increases the tendency to absorption ; and Tram- pel has endeavoured to prove this :J on which account Hildanus and Morgagni have advised excisioqpin combination with the cautery : the former proposing to cut out the eschar as soon as it is formed, without letting it remain for a spontaneous separa- tion; and the latter, far more effectually, recommending that inustion should follow the application of the knife, instead of preceding it. Of these three modes of operating, the potential cautery is least to be depended upon; for it is not sufficiently rapid in its action. Of the other two it is, perhaps, of little consequence which is selected, and either of them will generally prove suffi- ciently efficacious alone, if employed early enough to anticipate absorption, and extensively enough to make sure of extirpating or destroying every portion of the bitten part. There is rea- son to believe that, in many instances, this has not been done ; so that Camerarius places as little confidence in the actual cau- tery as in the potential, and Dr. Hamilton almost as little in ex- cision. And hence another reason for employing both means in the manner recommended by Morgagni; in which case we shall find it unnecessary to superadd any of those irritant, exulcerant, or suppurative applications, which have been employed by many practitioners with a view of introducing a fresh local ac- tion, and maintaining a fresh local discharge, and which have chiefly consisted of cantharides, camphor, alliaceous cataplasms, resins, turpentine, or, as Celsus recommends, culinary salt.§ It may likewise be advisable, as proposed by Sir Kenelm Dig- by, and since his time by Dr. Haygarth, to wash the wound again thoroughly with tepid water, or tepid wine and water, be- fore the excision is commenced. M. Portal, however, thinks the application of the cautery, whether actual or potential, may be serviceable long after the wound has been inflicted, and even after it has healed, though he advises its use as early as pos- sible.|| * Lib. vi. t De Sed. etCaus. Morb. Ep. vm. Art. 26. J Beobach- tungen und Erfahrungen, &c. band ii. passim. } De Medicina, Lib. v. Cap. xxvii. i 1. || Memo'nes sur la Mature et le Traitement de plusicurs Maladies, torn. iv. 8vo.« PariF, 1819. cl. iv.] NERVOUS FUNCTION. [ord. in. 281 There is also another, and a very easy, and perhaps a very Gen. I. salutary operation, which I would strenuously recommend from Spec.VIII. the first, even before the process of ablution. I mean that of Entasia applying a tight ligature to the affected part, wherever it will p^pL. admit of such an application, at a short distance above the lace- lactic ration. I have never had an opportunity of trying the benefit treatment. of such a measure in my own practice ; but analogy is altogether A tSgnt in its favour, for it is well known to be one of the most impor- D'e applied! tant steps we can take in confining the poisonous effects of the jts Dene6t rattle-snake and other venomous animals, and of mitigating its from violence by the torpor which follows ; and it has the sanction analogy. of many authorities of deserved credit, as Hacquet, Percival, Vater, Wedel, and Trolliet* Practice If, however, the local plan should prove ineffectual, our cu- loose and * As the editor has already noticed, it is proved, by the ingenious experiments of Dr. Barry, that the commencement of the symptoms produced by vegetable, mineral, and rep- tile poisons, is synchronous with the consummation of absorption, and that their repetition is dependent upon its renewal. The same gentleman has also satisfactorily proved, that ab- sorption does not proceed under a vacuum. In the treatment of the recent bite of a rabid animal, therefore, he recommends, I. The application of a powerful cupping-glass over the wound. This measure, he says, supersedes at once the ligature, ablution, excision, &c. during the period of its application, and for a certain time after its removal.—(See Exp. 5 and 7.) 2. After the cupping-glass has been applied for an hour, at least, the whole of the parts wounded or abraded should be freely dissected out. 3. The cupping-glass should then be immediately re-applied. 4. Dr. Barry recommends the hermetical sealing of the vessels (as his expression is) with the actual cautery. 5. The part should be as little exposed to the contact of the air after the slough comes away, and as soon healed up, as possible.—(See Exper. Researches, &c. p. 149, et seq.) If the bite of a decidedly rabid animal were to be in one of the fingers, to which a cupping-glass could not be ef- fectually applied, immediate amputation of the part would be prudent. The performance of this operation, previously to the commencement of the symptoms, is a very different practice from that of amputating parts after the symptoms have begun. In Guy's Hospital a limb was amputated about a year ago, under the latter circumstances, without the least check being put to the disorder. Unless, however, a limb were bitten in many places, or very deeply in parts not admitting of excision, as through the tarsus or carpus, the editor conceives that amputation would not be warrantable either before or after the accession of the symptoms ; 1st, because the severity ofthe mutilation is too great to be encounter- ed for the prevention of a disorder that is not certain of coming on at all; 2d, Because the above-mentioned proceedings would supersede the necessity for so severe a measure. Ac- cording to Dr. Marochetti, (Magendie, Journ. de Physiol, torn. v. p. 279.) there is only one means of preventing the development of hydrophobia, viz. that of discharging the hydro- phobic poison as soon as it is formed ; and he asserts, that the situation where this takes place is on each side of the frsenum of the tongue, where one or two little vesicles or tu- bercles present themselves. The period when they become manifest, he says, cannot be stated with precision ; but, when they occur, it is commonly between the third and ninth day from the bite. When they are examined with a probe, he remarks, that a fluctuating liquid may be perceived in them, which is, in fact, the hydrophobic poison, and which, if not discharged in twenty-four hours, is generally absorbed, and no vestiges of it remain. When a person has been bit by a rabid animal, Dr. Marochetti examines thefrsnum once or twice every day for forty-two days, and if the vesicles or tubercles do not appear in that time, he considers it certain that the patient has not been infected. When, however, they are seen, he opens thein freely, directs the patient to wash the mouth with a gargle, and applies caustic to the cuts or incisions. Afterwards, he prescribes genista in the form of decoction or powder. With respect to the vesicles or tubercles on each side of the fraenum, M. Magendie apprehends that Dr. Marochetti may have mistaken the natural appearances ofthe orifices of Warton's ducts for the vesicles supposed to contain the hydrophobic virus. Here we see, also, that Marochetti starts an hypothesis which interferes very much with prevailing opinions, already noticed", concerning the long dormant state of the poison in the bitten pari, or the production of a similar poison by the vessels in this part at a late period after the bite, in consequence of the influence of a germ ofthe virus supposed still to con- tinue there. Dr. Marochetti's assertions, however, require confirmation.—Ed. vol. iv. 36 282 cl. iv.] NEUROTICA. [ord. hi. Gen. I. Spec.VIII. Entasia lyssa. Remedial treatment. apparently incongruous when the constitu- tional symptoms appear. Summary of the common intentions of cure. First in- tention : to stimulate and support the vital power. Volatile alkali. Cordial con- fections and theriacas ; pungent aromatics. Second in- tention : to take off supposed inflammato- ry action. Submersion in cold water: recom- mended by Celsus. rative practice, as already observed, is still unfortunately all afloat, and we have neither helm to steer by, nor compass to direct our course. There is, indeed, no disease for which so many remedies have been devised, and none in which the mor- tifying character of vanity of vanities has been so strikingly written on all of them. In the loose and heterogeneous manner in which they have descended to us, they seem indeed to have followed one another, without rational aim or intention of any kind. Yet, if we nicely criticise and arrange them, we shall find that this is not the case. There are four principles, by which physicians appear to have been guided in their respective attentions to this disease. That of stimulating and supporting the vital power, so as to enable it to obtain a triumph in the severe conflict to which it is exposed ; that of suddenly exhausting the system by severe bleedings and purgatives, as believing the disease to be of a highly inflammatory character; that of opposing the poison by the usual antidotes and specifics to which other animal poisons were supposed to yield; and that of regarding the disease as a nervous or spasmodic, instead of an inflammatory affection, and, consequently, as most successfully to be attacked by an antispas- modic course of medicines and regimen. The very popular use of volatile alkali and camphor may, by some, be ascribed to the first of these views, as being pow- ful stimulants; yet, in fact, they were rather employed from different motives, and fall within one or two of the principles of action which yet remain to be considered. But to this class of medicines, designed expressly to support the vital power, and enable nature herself to triumph in so severe a struggle, belong expressly the warm and cordial confections and theri- acas that were at one time in almost universal estimation; as also various kinds of pepper given in great abundance, oil of cajeput, different preparations of tin, copper, and iron, and, in later periods, bark. In direct opposition to this stimulating and tonic plan, was that of suddenly debilitating and exhausting the system, upon the hypothesis that the symptoms of canine rabies were those of violent and rapid inflammation. The practice of applying ice or the coldest water to the head, and of submersion in cold water, belongs mostly to this view of the subject, as used a century ago, though in the time of Celsus it was employed in a much slighter degree to take off the spasm of hydrophobia, and to quench the thirst that accompanied it. " Miserrimum genus morbi; in quo simul aeger, et siti et aquae metu cruciatur: quo oppressis in angusto spes est."* In this almost hopeless state the only remedy (unicum remedium), Celsus continues is to throw the patient instantly, and without warning, into a fish- pond; alternately, if he have no knowledge of swimming, plunging him under the water that he may drink, then raising his head; or forcing him under it if he can swim, and keeping * De Medicina, Lib. v. Cap. xxvu. sect. 2. cl. iv.] NERVOUS FUNCTION. [ord. hi. 283 him below till he is filled with the water; so that the thirst and Gen. I. water-dread may be extinguished at the same time. But there Spec.VIII. is here, continues our author, another danger, lest the body of Entasia the patient, exhausted and worn out by the submersion as well y88a* as by the disease, be thrown into convulsions: to prevent which* ^"{menl. as soon as he is taken out of the pond, he is to be put into warm Second in^ 01'» tention. The bolder practitioners of subsequent times, in pursuing the To besuc- refrigerating plan, were regardless of convulsions, and perse- ""led by vered, at all hazards, in reducing the living power to its last Harmon. ebb ; believing that the nearer they suffocated the patient with- co]d gub] out actually killing him, the greater their chance of success, mersion in Hence Van Helmont kept the wretched sufferer under water till la,ef tjmei the psalm " Miserere" was sung throughout, which, under some perilous choristers, occupied a much longer time than under others ; and, extreme. in the experiments of the Members of the Academie Royale, we illustrated. meet with instances of a still more dangerous pertinacity, though success is said to have accompanied one or two of them. Thus, M. Morin relates the case of a young woman, twenty years old, who, labouring under symptoms of hydrophobia, was plunged into a tub of water with a bushel of salt dissolved in it, and was harassed with repeated dippings till she became insensible and was at the point of death, when she was still left in the tub, sitting against its sides. In this state, we are told, she was at length fortunate enough to recover her senses; when, much to her own astonishment, as well as to that of the by-standers, she found herself capable of looking at the water, and even of drink- ing it without choking.! • With respect to the warm oil-bath, which Celsus recommends Warm oil- in succession to that of coId'Svater, the present author can say, ^lytf "° that, in a single instance to which he was a witness when a young man, it produced no benefit whatever. It was prescribed by a physician in consequence of the recommendation of Celsus, but who certainly had not read him attentively, nor was acquainted with the scope of his reasoning. For, in this case, cold-bathing had not been tried antecedently, and consequently there was no danger of those convulsions for which alone the Roman physi- cian enjoins the use of the oil. The experiment, however, was so far perfect, that the tub was full of oil, and deep enough to reach the patient's chin. In connexion with the cold-bath thus persevered in to suffo- Drastic cation, the reducent or antiphlogistic plan was still farther for- purgatives. warded, at one time, by the use of strong drastic purgatives, of which colocynth was, for a long period, the favourite ;+ and at Profuse ve- other times by a very bold and perilous use of the lancet. nesectiom. Bleeding has lately been revived and carried to the extent of Revived in deliquium by large and rapid depletions, and the operation has daV^resent been repeated almost as long as the powers of life would allow. Dr. Nugent employed it at Bath, in 1753, in one case, and the * Cels. loco citato. t Hist, de l'Academie Royale, Ann. 1709. X Hellot, An de Morsis a Rabido Colocynthis ? Paris, 1676. 284 cl. iv.] NEUROTICA. [ord. m> Gew. I. Spec.VIII. Entasia lyssa. Remedial treatment. Second in- tention. Exemplified patient was restored, but musk and other antispasmodics were largely employed at the same time: and Dr. Schoolbred of Ben- gal has since had two patients who recovered under this process ; hut he employed mercury at the same time, and it is by no means Certain, either from the history ofthe patients, or of the dog by which they were bitten, that the disease was a genuine lyssa. Yet whatever benefit this practice may possess, it has no pre- without any tensions to novelty; for there is not a single course of treatment KoveUy* ever invented f°r this intractable disease that has been for up- wards of a century more extensively tried and re-tried, both moderately and profusely, or excited a warmer controversy upon its merits. Poupart, in 1699, espoused the practice, and gives the case of a woman, who perfectly recovered by bleeding her to deliquium, and afterwards confining her for a year to bread and water.* Berger, in the same year, recommended bleeding, but advised that the blood should be taken from the forehead. In the Bres- law Collections for 1719, is the case of a cow supposed to be rabid, and said to be cured by profuse bleeding. And the Phi- losophical Transactions abound with similar histories, some of them purporting to have been attended with similar success, de- rived from human subjects; but most of them too loosely given, or too undecided in their symptoms, to be in any measure enti- tled to reliance. That of Dr. Hartley and Mr. Sandys was, at one lime, appealed to as demonstrative. It is the case of a groom who was bitten by a dog, supposed to be mad, towards the end of November, and who sickened about the middle of January ensuing; he had an aversion to drink, and was conjec- tured to be labouring under rabies. Venesection was here trust- ed to almost entirely, and every repetition ofthe lancet seemed serviceable : in consequence of which he lost a hundred and twenty ounces of blood in the course of a week, by different de- pletions, which consisted of sixteen or twenty ounces at each time. The man recovered : but few readers will believe him to have been really rabid when they learn, that, although he had an aversion to drink, he swallowed liquids; that his chief symptoms were sickness, trepidation, a faltering speech and memory; and that, through the whole course ofthe disease, he attended, though with some difficulty, to his duty in the stable.t The Edinburgh Medical Commentaries are equally replete with cases in which the same plan of evacuation had been tried- but they are also equally unsatisfactory. Thus, Dr. Tilton in- forms us, that, having heard of the recovery of a patient from the disease before us, who had bled profusely and almost to death, by an accidental fall from a high place, and a division of the temporal artery, he employed venesection freely in a case of his own, drawing off from twenty to thirty ounces at a time and occasionally bleeding to deliquium.J But the symptoms are' here also so doubtful, that the result is of no importance. Additional instances. * Hist, de l'Academie des Sciences, An. 1709. X Vol. vi. p. 432. t Phil. Trans. Year 1737-8. cl. iv.] NERVOUS FUNCTION. [ord. iii. 285 The practice, therefore, has been not uncommon for at least Gen. I. a century and a half; and had it proved as specific as some late SpEc.VIII. reports would induce us to believe, it must have descended to Entasia us with a wider and more confirmed reputation, and formed the R9Sa'd- only course to be relied on. But the misfortune is, that, how- treatmem. ever salutary at times, it has often completely failed in the hands Second in- of unprejudiced and judicious practitioners; and where it has tention. succeeded, it has generally been combined with other means Failure of that have been resorted to at the same time. There is a case phrovKom of failure related by Dr. Pluramer in the Edinburgh Medical itadbcontin- Essays;* but it is not much to be relied on, as not more than uance and twenty ounces of blood were lost at a second and accidental ^cetc9'fic bleeding, and only ten a day or two before by a prescribed vene- section. Mr. Peters, however, who employs profuse and re- peated bleedings, sometimes even to deliquium, had, in his day, so little dependence on them alone, that he uniformly combined this remedy with opium and mithridate, or other cordials; and in the case which he has introduced into the Philosophical Transactions, he ascribes the success, which accompanied his plan, to this combined mode of treatment.f In like manner, Additional Mauchart, as quoted by Biihlmeier, while he advises bleeding, examples. and to an extent proportioned to the length of the interval be- tween the infliction of the wound and the attack ofthe paroxysm (and where the patient is of a melancholy temperament, even to deliquium,) advises, at the same time, that the bitten part be scarified; and when this also has bled till nothing but serum es- capes, that the wound be dressed with mithridate, theriaca, or rue, and a defensive plaster put over it, and that the patient take pills, compounded of mithridate and other materials, to the number of nine every day for nine months, keeping himself in a free perspiration, and cautiously changing his linen. In the case of dogs, venesection, how liberally soever made use Failure of, does not seem to be of much benefit. It has lately been the Proved l,P°n subject of a series of experiments at Paris, under the superin- Magendie tendence of MM. Magendie, Dupuytren, and Breschet, who have and others. carried it to deliquium, but without any success whatever. And hence, though it has unquestionably been serviceable, in many cases, the practice cannot be regarded as a specific. To close the whole, Professor Trolliet has employed vene- And abun- section so extensively, and in such variable proportions, from dantiyprov. single or double bleedings, of sixteen ounces each to not less f^ upon V|_e than seven pounds, by different bleedings in the course of a few ject by hours, and in every instance so entirely without effect, as rea- Trolliet. sonably to put the question at rest for ever. And the more so And the as, in his hands, the bolder the practice, the sooner the patient "'orepiofuse fell a sacrifice to it. We have a striking example of this in the !hJ wjS* case ofthe patient just referred to, whose interval between the fatal issue. infliction ofthe wound and the signs ofthe disease, extended to upwards of five months. Early on the morning in which the hydrophobia first appeared, blood-letting to syncope was pre- * Vol. v. Part ii. t Phil. Traus. 1745, No. 475. 286 cl. iv.] NEUROTICA. [ORD. III. Gew. I. Spec. VIII. Entasia lyssa. Remedial treatment. Second in- tention. Third in- tention : to counteract the poison by general or specific antidotes. Radix Mungo. Acids. Alkalies. Useful in many ani- mal poisons. Eau de luce. scribed, and five pounds were drawn off before this effect was produced. The water-dread returned with the return of recol- lection ; and, at eleven o'clock on the same morning, he was again blooded to the amount of eighteen ounces, when he again fainted. The spasms of the chest and throat became more per- manent. At three o'clock, fourteen ounces more were taken away, when deliquium followed, succeeded by a considerable augmentation of the spasms, in extent as well as in violence. At seven in the evening, the respiration became frothy as well as difficult, the difficulty increased, and the patient expired in a few minutes, about twelve hours only after the commencement of the hydrophobia. The poison of rabies has, by a numerous body of pathologists, been contemplated as of a nature akin to the poison of other venomous animals, and particularly serpents, and consequently best to be opposed by the usual remedies and specifics, to which these are found most effectually to yield. And hence, in the first place, the use of the radix Mungo of Kcempfer (ophiorrhiza Mungos, Linn.), still supposed to be a specific for the bite of the cobra di capello and the rattle-snake. In India and Ceylon, it is used to the present day as an antidote against the bite of the mad dog: Kcempfer highly extols it, and Gremmius, who prac- tised with great reputation at Columbo, employed it very largely. Acids and alkalies belong to the same class of antilyssics. Of the former, Agricola, who was hostile to the depleting system, preferred the muriatic acid, and regarded this as a specific* even when restrained to a topical application. Poppius preferred the sulphuric; but, by far the greater number of practitioners, the acetous was held in most esteem. Many combined this last with butter, and used it both internally and externally : Wedel, with other materials ; " as a cure," says he, " for the bite of a mad dog, let the patient drink vinegar, theriaca, and rue."t The general suffrage, however, was far more considerable in favour of the alkalies, and especially of ammonia. There is some reason for this preference. It is well known that ammo- nia is a valuable medicine, whether applied externally or inter- nally, against a variety of animal poisons. 1 have successfully used it, more or less diluted, in various instances, as a lotion against the sting of wasps and bees, and the bites of gnats and vipers ; and I have seen it of great service in checking the poi- son ofthe rattle-snake, and restraining the extent ofthe inflam- mation. On the continent, and especially in France, the usual form in which ammonia was formerly employed in cases of lyssa, was that ofthe eau de luce, a caustic spirit of ammonia, prepar- ed with quick-lime combined with rectified oil of amber, ren- dered more easily miscible by being rubbed into half its weight of soap. This was in general employed both externally and in- ternally ,J though we have several reports of a successful use of * Chirurg. p. 391. t Exerc. Semiot. Pathol. Cap. 8. % Sage, Erfahrungen, &c. p. 49. Guettard, Memoires sur differentes Parties des Sciences et Arts, p. 122. Paris, 1768. cl. iv.] NERVOUS FUNCTION. [ord. iii. 287 it when confined to an internal trial alone; especially one re- Gew. I. lated by M. Hervet,* and another by M. Rubiere.t SpecVIH. Mercury, from its proving a specific in syphilis, and more es- Entasia pecially from its specific action on the salivary glands, the im- lysw- mediate outlet ofthe poison of rabies, has had a strong claim to ^^e'nt general attention ; and has been very extensively tried in vari- Th;rd ous forms. It was first recommended by Desault of Bourdeaux intention. in 1736, and afterwards very confidently by Dr. James in our Mercury: own country, as a certain cure for man and other animals. He first recom- used it both as a prophylactic at the time of the bite, and an S^Juitb7 antidote at the commencement of the disease. He employed it afterward as well externally as internally; but his favourite form was that freely em- of the turbeth mineral, in the shape of pills. He has published S^esJcb£ a full account of his success with this medicine on Mr. Floyer's externally hounds, after they had made a trial of every other favourite and inter* and fashionable remedy in vain. These dogs, as we have al- "eg^ed*1 ready observed, were affected with a severe hydrophobia, both as a which has been denied by some writers to be a symptom ofthe prophylac- disease as appertaining to quadrupeds. All the hounds, we are anifd"^- told, that were salivated with the mercury, in whatever stage in quadm- of the malady, recovered, and the rest died.j His experiments pedsaswell on mankind are less complete: for they amount to not more as ,n man" than three, and in each of these the medicine was employed as ^^ be a preventive, shortly after the infliction ofthe bite; and hence, produce as the patients never became rabid, we cannot be sure that they »alivaiion. had received the contagion, or. would have had the disease, had His expert- the mercury never been employed. The muriate of the metal men'B.°n was another favourite form, which, by Loisy, was used together incomplete. with inunction. The grand object was to excite a speedy salivation, and main- tain it so long as there was supposed to be any danger; and especially where the administration had been delayed till the De • .. paroxysm had shown itself. Frank, Girtanner, De Moneta, many to be Raymond, and a host of writers upon the subject, deny, not only eitner a that mercury is a specific, but that it has ever produced a cure, *Pecific>or in whatever way it may have been employed. Kaltschmid, on but regard- the contrary, with an unjustifiable confidence, calls it remedium ed °y Ka't- indubium,§ and De Choiseul a methode sure el facile.\\ In the o^ch'-™1 fortieth volume of the Journal de Medecine, there is a relation seulasan in which mercurial inunction seems to have been successful in a on,y and genuine case, and I have heard of one or two other instances c^gia that have occurred in our own country. As diuretics were supposed to possess a strong alexiapharmic Diuretics. power, or that of expurgating the system from animal poisons in general, these have also had their votaries, and been in high reputation, as a remedy for lyssa. Cantharides were kt one Canthar- time the favourite medicine under this head, or some other ide*and other * Journ.de Medecine, torn. lxii. t Id. torn. lxiv. coleoptera. X Phil. Trans, vol. xxxix. Year 1735-6. { Dissertatio de Salivatione Mercuriali, ceu indubio praeservationis et curationis remedio adversus rabiem caninam. Jan. 1760. || Nouvelle Methode, sur et facile, pour le Traitement des Personnes attaquees de la Rage. Paris, 1756. 288 cl. iv.] NEUROTICA. [ord. III. Gen. T. Spec.VIII Entasia lyssa. Remedial treatment. Third intention. Cantharides re-employ- ed by Axter. Ash- coloured liver-wort, or lichen caninus, Linn. Pulvis antilyssus. stimulant insect of the coleopterous order, as the meloe, lytta, or one or two species of scarabaeus; which, like mercury and ammonia, were sometimes taken internally alone, and sometimes applied topically also, to keep up a perpetual irritation. Bo- hadsch tells us gravely, that the disease will always yield to ten cantharides powdered and introduced into the stomach:* Mon- conys, that the powder should be continued from the bite to the time in which we may reasonably expect the symptom of hydro- phobia ; and adds, that this medicine, which was regarded as an arcanum in his day, was a remedy of publicity over all Greece.t He might have extended his theatre; for Egypt was as well acquainted with the general principle of this practice as Greece or Hungary; and it is a positive exhortation of Avicenna, that whatever diuretic may be employed should be carried to its ut- most acrimony, even to the discharge of bloody urine.J M. Axter of Vienna has of late revived the use of cantharides, and tells us, that he has for thirty years employed this medicine with far more success than any other, after having previously made experiments with and been disappointed in the use of all other remedies, as musk, camphor, belladonna, opium, or oil, used in- ternally and externally, and water-bathing. But it does not seem, that he can speak farther than to its supposed prophylac- tic powers, as he does not appear to have tried it in the acute stage ofthe disease.§ The ash.-coloured liver-wort (lichen terrestris cinereus Raii) was another diuretic of great popularity, and which seems at length to have triumphed over the stimulant insects, and to have superseded their use; on which account Linneus changed its trivial name from cinereus to caninus. In our own country, this medicine was at one time peculiarly in vogue. It was given in powder, with an equal quantity of black pepper, a drachm and a half of the two forming the dose for an adult, which was taken for four mornings, fasting, in half-a-pint of warm cow's milk ; the patient, however, was first to lose nine or ten ounces of blood, and afterwards to be dipped in cold water for a month together, early in the morning. And such was the general con- fidence in this plan, or rather in the antilyssic power of which the lichen was supposed to be the most active principle, that its virtues formed one of the most common subjects of eulogy in the Philosophical Transactions at the time when Mr. Dampier introduced it to public notice at an early period of the history of the Royal Society ;|| while, at the earnest solicitation of Dr. Mead, the powder was admitted in the year 1721 into the Lon- don Pharmacopoeia, under the title of pulvis antilyssus; who declares, that, " when united with the previous venesection and subsequent cold-bathing, he had never known it fail of a cure,H though he had used it a thousand times in the course of thirty years' practice." * Posit. Zoolog. in Klinkosch. Diss. Select. t Voyages, i. p. 406. X Lib. iv. Fen. vr. Tr. iv. i Nouv. Biblioth. Germ. Medico-Chirur- gicale. Paris, 1821. || Mechanical Account of Poisons, art. 3. T Chiiurg. parv. Nuriib. &c. 8vo. 1643. ct. iv.] NERVOUS FUNCTION. [ord. hi. 289 How far emetics may be serviceable, general trial has not, Gen. I. perhaps, been sufficient to determine. They have often been Spec.VIII. found capable of relieving spasms ofthe throat, and enabling the Entasia patient to swallow liquids when every other plan has failed. lys8a; They were hence recommended by Agricola, but only, perhaps, ^Jme^ on account of their violence upon a weakened frame, as a sort Tliird of forlorn hope, for he does not advise them till after the third intention. day. Dr. Satterley, however, has given a case in the Medical Emetics: Transactions, which he regards as rabies, in which vomiting formerly was employed from an early period of the disease, and with Dy ^g^d very decided advantage.* But there seems to be a doubt, whe- cola: ther the patient here referred to laboured under genuine lyssa. more ,a,ely He had been bitten three months before by a dog, but the fate w^th" of the dog was not known: the cicatrix betrayed no uneasiness success, but or irritation precursive to the disease, or during its course; the inadoubtful hydrophobia was remittent, or intermittent, so that the patient case* drank liquids at times with tolerable ease; the spastic action ran to a greater extent over the muscular system than usual, so as at one time to produce emprosthotonus; and the patient did not expire till at least a week after the attack: all which are very unusual symptoms in lyssa, and have seldom, if ever, been combined in the same individual. In lyssa, however, the nervous system appears to be that Fourth which is hy far the most severely tried, and to which the dis- jn,ent,on: ease may be most distinctly referred. And hence it is not to be nervous wondered at that antispasmodics and sedatives should also have and spas- been had recourse to very extensively, and obtained a very ™ i/iaritlea general suffrage. In effect, whatever benefit in this disease has byanem- at any time been derived from ammonia, camphor, or cold- ployment bathing, it is more easy to resolve their palliative or remedial °paa9nmodjcs power into the principle of their being active antispasmodics, and seda. than to any other mode of action. The more direct antispas- tives. modics and sedatives, however, employed in this malady were musk, opium, belladonna, nux vomica, tobacco, and stramonium. Stramo- The last has been chiefly tried in India, where three drachms nium: and a half of the leaves, infused in a very large portion of water or other common drink, and swallowed daily for three days in succession after the bite, was, at one time, a very approved and popular remedy. Musk, opium, and belladonna, however, are the antispasmo- Musk: dies which have been chiefly depended upon in Europe. They have sometimes been given in very large doses alone, but more generally in union with other medicines. Cullen seems doubt- little de- ful ofthe powers of either, apparently from not having had suf- {, ndja°gd to ficient opportunities of witnessing the disease, and their effects 0D either. upon it, and hence refers us, in both instances, without ventur- ing upon any decisive opinion of his own, " to the labours of the learned industrious Societe Royale of Paris, who have taken much pains, and employed the most proper means for ascertain- ing the practice in this disease."? With respect to musk, he * Vol. iv. p. 343. t Materia Medica, vol. ii. p. 252. 380. vol. iv. 37 200 CL. IV.] NEUROTICA. [ord. III. Ge\. I. SpecVIII, Entasia lyssa. Medical treatment. Fourth intention. Opium not much more efficacious than musk. Striking in-' stance of its effects by introduction into the circulation. Belladonna in large doses com- bined with mercury. admits, however, that Dr. Johnston has given us two facts that are very much in favour of its power: and " I have," says he, " been informed of an instance, in this country, of some large doses of musk having proved a cure after symptoms of hydro- phobia had come on."* Hilary says, " in these cases it acts as a sudorific;" and Gmelin regarded it as a specific antidote.t Opium, in like manner, when employed alone, was given in large doses, and we have numerous cases on record in which this, like the preceding medicines, is said to have operated a cure.f But unfortunately neither musk nor opium, in whatever quantity employed, has been found successful in general prac- tice. Tode more especially has pointed out the inefficiency of the latter, in the largest doses referred to,§ and Raymond has confirmed his remarks. || But a late experiment of Professor Dupuytren, of the Hotel-Dieu, has given a still more strfking and incontrovertible proof of its utter inefficacy, if not in all cases ofthe disease, in certain states and circumstances. Surlu, a man aged twenty-four, had been bitten by a dog sufficiently proved to be mad, had been cauterized immediately afterwards, and been discharged as supposed to be cured. In about a month from the time ofthe bite, he was attacked with rabies in its se- verest symptoms, and conveyed to the hospital. Opium was the medicine determined upon, and as the constriction of the throat prevented it from being given by the mouth, a gummy solution was injected into the veins, for which the saphaena and cephalic were alternately made use of. Two grains ofthe extract were in this manner thrown in, and the patient was in some degree tranquillized for an hour or two: the dose was doubled towards the evening ofthe same day. It was repeated at intervals, and at length increased to eight grains at a time. The relief it af- forded, however, was never more than temporary, and he ex- pired on the fifth day from the incursion.1T M. Trolliet used it freely in the form of pills, in combination with belladonna ; but in no instance had he reason to boast of his success, though he gave, in some cases, twenty-seven grains of opium, and nine of the extract of belladonna in the course of twenty-four hours. Professor Breda employed the belladonna, but united it with mercury instead of with opium : his doses were carried gradu- ally to a great extent, insomuch that the patients at length took the powdered root of the belladonna, to the amount of three drachms a day; and, in about forty-four or forty-six days, swal- lowed seven ounces and a half of this drug, and ten grains of corrosive sublimate, besides rubbing in some ounces of mercu- rial ointment.** The object was to keep the system, as much as possible, under the influence of mercury, evidenced by pty- alism, and of the narcotic effects of belladonna, so lone as the * Ibid. t Diss, de specifico antidoto novo adversus effectus morsu canis rabidi. Tub. 1750. J Dantzic, Gazette de Sante, 1777, p. 51. § Anna- len, ix. p. 33. || Med. Observ. and Inquiries, vol. v. IT Orfila, Traite des Poisons, &c. The extract of beladonna in solution, and other narcotics, have likewise been injected into the veins without success.__Editor. ** Mem. Soc. Ital. Scienz. torn. xvii. Modena. cl. iv.] NERVOUS FUNCTION. [ord. hi. 291 combination was continued. As a preventive it seems to have Gen. I. been successful: though several #f the patients appear to have Spec.VIII. advanced to the first symptoms of acute affection, having had Entasia some degree of water-dread, and recurring irritation in the bit- Mgdjca| ten parts, the disease did not proceed beyond these initiary treatment. steps. But we have no proof of success from this plan after the Fourth pathognomonic signs had shown themselves. The warm bath intention. was also combined with the above practice." In like manner, Useful as a musk, opium, and belladonna, have been all united; and some- friliTof*" times combined with camphor, oil of amber, inunction with opium and olive ©il,* or bleeding. Musk was also at one time very gene- musk when rally combined with cinnabar, and in this form supposed to be aud^nTted peculiarly efficacious. The famous powder employed by the with other natives of Tonquin, and introduced into this country by Mr. ™eans-. Cobb, on which account it was called pulvis Cobbii or Tunguin- powdeTor ensis, consisted of sixteen grains of musk with fortj'-eight grains pulvis of cinnabar, mixed in a gill of arrack. This, taken at a dose, CoDDU' is said to have thrown the patient into a sound sleep and per- spiration in the course of two or three hours; and where it did not, the dose was repeated till such effect was produced. And this medicine also was regarded as a specific during the short career of its triumph, and a cure was commonly supposed to follow the administration of the medicine. The sedative power of several ofthe preparations of arsenic, Arsenical however, had perhaps a fairer pretension than any of these, and PrePara- especially as, like mercury, it has for ages been employed with decided benefit in Asia in the case of syphilis. Agricola men- tions its use in his day,t but the forms, in which it was then employed, were rude and incommodious, and they do not appear to have been followed with much success. It is to be regret- ted, however, that even in the elegant and manageable form of Dr. Fowler's solution, it has not been found to be more effica- cious. It has of late years been tried internally in various • cases, and particularly, with great skill and in full doses, by Dr. Marcet; but in every trial it has disappointed our hopes. Ap- plied externally, as a preventive, to the bitten parts, Dr. Linke, of Jena, thinks it has succeeded; but as his trials were made on dogs inoculated from the froth of rabid animals after death, no dependence can be placed on them. Under this head I may also observe, that the Prussic acid has Prussicacid. occasionally been had recourse to, but without any apparent benefit. In the form of the distilled water of the prunus Lauro- cerasus, it was not long since made a subject of experiment at Paris by Baron Dupuytren, who injected this fluid into the veins of various dogs, and appears to have done so in one instance into those of a man : but in every case without effecting a cure. There are two or three other remedies, which it is difficult Anomalous to arrange, but which have also acquired a considerable cele- remedies) brity in the cure of lyssa ; and hence it is necessary to notice them. * Vater, Pr. de OleiOlivarum efficacia contra morsum canis rabiosi, expe- riment Dresdee facto, adstructa, Viteb. 1750. t Comment, in Popp. p. 54. 292 cl. iv.] NEUROTICA. [ord. hi. Gen. I. Spec.VIII Entasia lyssa. Medical treatment. Anomalous reu edies. Ormskirk medicine: its basis alkaline. Alyssum or madwort. Other plants. The first is the Ormskirk medicine, so called from its pre- parer, Mr. Hill of Ormskirk,«upposed, for the inventor could not be prevailed upon to publish his secret, to consist of the fol- lowing materials: powder of chalk, half an ounce; Armenian bole, three drachms; alum, ten grains; powder of elecampane root, one drachm ; oil of anise, six drops. The single dose, thus compounded, is to be taken every morning for six times in a glass of water, with a small proportion of fresh milk. If this be the real formula, and the analysis of Dr. Black concurred with that of Dr. Heysham in determining it to be so, the inven- tor seems to have contemplated the specific virus to be an acid, for the basis of this preparation is unquestionably an alkaline earth. And with regard to its occasional efficacy, the latter writer, following the general current of opinion of the day, in- forms us, that this has been so thoroughly established by expe- rience, that there can be no room to doubt it. Dr. Heysham himself, however, admits of various cases in which it failed, while in many instances his successful ones do not afford proofs of an existence ofthe genuine disease.* The second of the anomalous remedies I have just referred to might possibly have been introduced under the head of the common antidotes for the bites of venomous animals; but as it has reputed powers in some degree peculiar to itself, it is best to notice it separately. This is the alyssum, or alysma Planta- go (madwort plantain), of established reputation in America as a specific for the bite of the rattlesnake, where it seems to rival the imprescriptible claims ofthe ophiorrhiza Mungos, though its juice is generally given in combination with that ofthe common horehound—an addition that certainly does not promise much accession to its strength. This species of alyssum has for some ages been a popular remedy for canine madness, especially in the north of Europe : and in a late communication to Sir Walter Farquhar in the Rus- sian tongue, translated and published in Mr. Brande's Journal,] we are told that it still retains its popular sway and reputation over a great part ofthe Russian empire, and that in the gov- ernment of Isola it has never failed of effecting a cure in a sin- gle instance for the last five-and-twenty years. The prepara- tion is simple: the root is reduced to a powder, and the pow- der is to be eaten by being spread over bread and butter. Two or three doses are said to be sufficient in the worst cases, and will be found to cure mad dogs themselves. The butcher's broom (genista tinctoria), and side-leaved scull- cap (Scutellaria laterifolia), have however rivalled the reputa- tion ofthe plantago ; and, in our own day, the first is power- fully recommended by M. Marochetti of Moscow, in the St. Pe- tersburg Miscellauies of Medical Science, as employed with great success in the Ukraine ; and the second by Dr. S. Spal- ding of New-York, who tells us that it has been successful in * Diss. Med. Rabie Canina, 8vo. No. ix. p. 142. t Journal of Sciences and the Arts, cl. iv.] NERVOUS FUNCTION. [ord. in. 293 America in upwards of a thousand cases, not only in men, but Gew. I. in dogs, swine, and oxen. Spec.VIII. The next remedy I have to notice is also of extensive use in Entasia the present day, and comes before us with no mean authority. /."*! Whilst the medical practitioners of the East are pursuing their treatment. plan of abstracting rabid blood from the system, as the surest Anomalous means of curing canine madness, the physicians of Finland have remedies. undertaken to accomplish the same effect by introducing rabid Rabid blood into the morbid frame. In the second number of the blood- Hamburgh Medical Repository, Dr. W. Rithmeister, of Pow- lowsk in Finland, has given an article, in which he has collect- ed a multiplicity of striking cases, and various authorities, in proof that the blood of a rabid animal, when drunk, is a specific against the canine hydrophobia, even where the symptoms are most strongly marked. The rabid wolf-dog, or other quadru- ped, is, for this purpose, killed, and its blood drawn off and col- lected as an antilyssic ptisan. Dr. Rithmeister's communica- tion contains a letter to himself from Dr. Stockmann of White Russia, confirming this account, and stating the practice to be equally common and successful in his own country. I will only add, that a discussion has lately taken place be- Chlorine. tween two Italian physicians of distinguished reputation, Pro- fessor Brugnatelli of Pavia, and Professor Valetta of Milan, upon the virtues of chlorine as an antidote for the disease in question. The former has strongly recommended it,* and the latter has denied that it is of any use ;| in answer, however, to which de- nial, Professor Brugnatelli has adduced various authenticated facts, by which what he calls the specific powers of the chlorine have been established and verified.J [M. Magendie§ conceived, that the sudden production of ple- thora might have the effect of arresting this ungovernable dis- ease, and with this view he injected about a pint of warm water into the veins of a hydrophobic patient; but, though it is al- leged, that the operation relieved for a time the violence of the symptoms, death took place nine days after the experiment.] I have thus endeavoured, upon a subject of so much interest and importance, to put the reader into possession of the general history of the practice that has hitherto prevailed ; and he will at least allow, that if the result be highly unsatisfactory—as most unsatisfactory it is—such conclusion does not result from idleness on the part ofthe medical profession. But how are we to reconcile the clashing and contradictory statements which the present analysis unfolds to us? This is a question of no easy solution. Yet there are many circumstan- ces which ought to be borne in memory, and will, in a certain degree, account for such opposite views and decisions, without rudely impeaching the veracity of any of the experimenters. * Giornale di Fisica, &c. Pavia, Dec. 1816. t Biblioteca Italiana. Gennaj. 1817. X Giornale di Fisica, &c. Pavia, Febbraj. 1817. } Journ. de Physiol. Exper. t. i. p. 44, &c. The expectations once raised by this new method appear to be on the decline.—Editor. 294 «•• iv-] NEUROTICA. [ord. III. Gev. I. Spec.VIII. Entasia lyssa. Medical treatment. Conciliation of clashing opinions and practice. Remedies serviceable in some cases, though not in others. Cases sup- posed to be genuine lyssa not always so: hence some medicines celebrated for cures they never performed. Variable nature of the symptoms in lyssa has often led to deception. Where many per- sons bitten at the same time, the poison not equally applied to all: whence some have been tup. posed to derive a prophy- lactic power from In the first place, it is possible, that the morbid poison itself, like that of plague or intermitting fever, may vary, in its degree of virulence, in certain idiosyncrasies, certain countries, or cer- tain seasons ofthe year: and hence that a medicine, which has proved useless in general practice, may succeed in particular persons, particular places, or at particular periods ; or, if inac- tive in itself, may be employed in so much milder a degree of the disease, that the constitution may be able, in most or many instances, to triumph over it by its own powers alone. it is a just remark of Celsus, that omnis fere morsus habet quoddam virus ;* and we have already given proof, that this is particularly the case when the animal that bites is labouring under the influence of violent rage or other sensorial excite- ment: the symptoms incident upon which produce a severe ef- fect upon the nervous system, and often simulate those of genu- ine lyssa. And hence, there can be little doubt, that these symptoms have often been mistaken for lyssa, and have given a celebrity to the medicines employed for their cure, to which they were never entitled. In various cases, as we have already seen, the disease commences almost coetaneously with the exter- nal injury, or inoculation; in others, not till months or even years afterwards. In some instances, the first symptoms of the disease show themselves in the bitten part, and even this in a very different manner, for there may be a troublesome sense of numbness, or of irritation ; and this irritation maybe confined to the cicatrix, or travel up the limb, and produce acute pain or spastic action: while, in other instances, there is no local affec- tion whatever through the entire progress of the malady. Or- dinarily speaking, hydrophobia, or water-dread, is one of the most common as well as one of the severest symptoms of the disease ; yet there are instances, even where the rabies has ter- minated fatally, in which water-dread has not been once com- plained of. Most commonly again, on an early examination after death, the fauces and parts adjoining are found red and in- flamed; but we have already observed, that Morgagni dissected patients in whom there was no such appearance whatever. And in two bodies, examined after death by Dr. Vaughan, the fau- ces, oesophagus, stomach, diaphragm, and intestines, were all in a natural state. There can be little or no doubt, moreover, where many per- sons are bitten in quick succession by the same rabid animal, that the poison is not equally introduced into all of them. In some cases it may be expended entirely upon the earlier vic- tims, and hence the rest, though bitten, may be free from the virus; while in others, where the teeth have to pass through various foldings of clothes, it is possible that the virus, which still remains, may be wiped off in its passage, and the laceration be nothing more than a clean wound from the first. And in all such cases a sanguine experimenter, without allowing for these circumstances, will be apt to persuade himself, whatever medi- * De Medicinfc, Lib. v. x. cl. iv.] NERVOUS FUNCTION. [ord. hi. 295 cine he makes use of, that the absence ofthe disease is owing Gen\ I. to the efficacy of the plan or the medicine he has prescribed, Spec.VIII. and which he is hence tempted to hold up to the world as an Entasia antidote or specific. lyssa/ Some of these remarks will best explain the very different lament. results ofthe same mode of treatment, in the eleven patients med;cjnM intrusted in 1775 to the care of M. Blaise of Cluny, after having which they been dreadfully bitten and torn by a mad wolf. The principal do DOt remedy was mercurial inunction, though combined with anti- j*.?8?8',- spasmodics. The mercury was carried on in all of them to 0f "everal of salivation, and the treatment continued for above a month, in the above Jhose that lived long enough for this purpose. One died with f«naiks' great horror and water-dread about the twelfth day from the injury, and after the mercury had begun to act. A second per- ished under hydrophobia, furious, and at length comatose, just at the close of a month, his mouth and gums being slightly af- fected by the mercury. A third died nearly six weeks after the commencement of the mercurial plan, having been taken away by his friends on the eighteenth day apparently in a state of do- ing well. The remaining eight, after having exhibited greater or less symptoms of spasmodic affection, but never amounting to hydrophobia, are said to have recovered, and were discharged accordingly ;* but, in a subsequent work, M. Blaise informs us, that even one of these died in a paroxysm of hydrophobia six weeks after his discharge and supposed restoration to health.! In all these cases, the success is ascribed to the action of the Different mercury, and the want of success to some irregularity or other, results of committed by the patient while under medical care. The l1,1?'!??^ . . J r r cases capa- enormities, however, are in general rather far fetched, and not ble of being very convincing. Thus, in the last of the above cases, it is differently ingeniously observed, that the man who had been so long dis- j^.0"" e charged as well, four days only before the symptoms of hydro- phobia appeared on him, had thrust his arm down the throat of an ox which was said to be mad; though no proof is offered that the ox was really mad, nor is it pretended, that even this re- puted mad ox inflicted any bite upon the arm whatever. Who does not see, that, in all these cases, the mercury may have been guiltless of exercising any control? that those who died may have died in consequence of an effective lodgment of the virus in the wound inflicted, and that those who sur- vived may have survived because it obtained no admission to the bitten part ? It is, moreover, highly probable that a spontaneous cure is Rabies occasionally effected by the strength of the constitution, or the sometimes, remedial power of nature alone. The fact appears to be, that cured spon- the disease requires about six or seven days to run through its taneously. course, at the expiration of which period the system seems to be exonerated, by the outlet of the salivary glands, of the poi- son with which it is infested. And hence, if by any means it * MSthode eprouvee pourle Traitement de la Rage. t Hist, de la So- ciete de Medecine, torn. ii. 296 cl. iv.] NEUROTICA. [ord. in. Gen. I. Spec.VIII. Entasia lyssa. Medical treatment. The inac- tivity of the poison, and length of in- terval be- fore it often operates, other occasional causes of deception. Strikingly exemplified. Exciting cause pre- sent though not noticed. Analogous remarks and illustra- tions by Perceval. be able to sustain and carry itself through this period, without being totally exhausted of nervous power in the course of so protracted and prostrating a conflict, it will obtain a triumph over the disease ; and any prescribed medicine, made use of on the occasion, will seem to have effected the cure, and will run away with the credit of having done so, till subsequent in- stances dissolve the charm, and prove beyond contradiction the utter futility of its pretensions. I have already had to observe, that the contagion of lyssa, though highly malignant, is neither very volatile nor very ac- tive, and in every instance, perhaps, requires some exciting or predisponent cause to enable it to take effect: but, as it seems. to be more indecomposible than any other contagion we are acquainted with, it is capable of lying latent and undissolved for months, if not years, till it meets with a cause of this kind. And hence the very long and uncertain interval, which some- times occurs between the attack of the rabid animal and the appearance of rabid symptoms, has often proved another source of deception ; of which we have a singular example in Mr. Nourse's case, related in an early volume of the Philosophical Transactions,* which states, that a lad, who had been bitten in the thumb by a mad dog, took morning and evening for forty days a drachm of the pulvis antilyssus already described, and bathed in the sea for ten days in succession. He was in due time reported to be well, and the cure was altogether ascribed to the specific virtues of the antilyssic powder. He was shortly afterwards cut for the stone, from which also he recovered : nineteen months after which operation, however, he was at- tacked with hydrophobia and the other symptoms of canine madness, and fell a victim to their violence. Had this patient died under the operation of lithotomy, or from any other cir- cumstance in the interval, the virtues of the antilyssic powder would have obtained a complete, and indeed a rational triumph in this instance: and even now there may be a question whe- ther the appearance of the disease was not retarded by the plan pursued, though its specific power can no longer be main- tained for a moment. The occasional exciting cause which, in this instance, at length gave activity to the dormant virus, is not pointed out to us. But it is difficult, if not impossible, to account, without such a cause, for the quickening of the lurk- ing seminium of the poison at this time rather than at any other.t And the following valuable remarks of Dr. Perceval, occurring in his manuscript comment on the author's volume of Nosology, in relation to this subject, are in full illustration of the same opinion. " A wine porter was attended, in Dispensary practice, for a low fever : after a time appeared symptoms of lyssa ; and much * No. 445. t It deserves to be recollected, however, that modern practitioners do not puzzle themselves about the exciting cause in cases where the syphilitic poison first produces constitutional symptoms several weeks or months after the application of the virup, and the formation of a chancre.—Editor. CI.. IV.] NERVOUS FUNCTION. [ord. hi. 297 enquiry elicited the recollection of his having been slightly Gen. I. bitten by a dog six weeks before. In the interval he was con- Spec.VIII. victed of some fraudulent practice in the cellar of his master, Entasia to whom he owed great obligation, and was dismissed with dis- yssa" grace. Anxiety on this event seemed to produce the fever, Treatment. which terminated in lyssa. " Lately an officer in our barracks was bitten by a dog, Farther whose madness being recognized, the bitten part was excised »llustratl0D> immediately. After an undisturbed interval of two months, he was advised to go to England to dissipate the recollection of the accident: there he exercised himself violently in hewing wood; felt pain in the hand which had been bitten; embarked for Ireland ; had symptoms of hydrophobia on board the pack- et, and died soon after his arrival. " I have lately seen a c;ise of hydrophobia treated ineffectu- in which ally by most profuse bleeding and large doses of opium. Here, profuse too, the bitten part was extirpated by caustic within an hour. Jnde/JIIL The patient was a man of steady mind, nor could any occasion- doses of al cause be assigned for bringing the poison into action, except opium of no that a bilious diarrhoea was suddenly checked. use' " From the varying period of attack we might infer, that the The influ* influence of occasional causes is very considerable. In the enceofocca- last patient, hydrophobia supervened exactly five weeks from ™y ™',M the time of the bite ; he lost a hundred and eight ounces of siderable. blood in twelve hours, which sunk him much; violent perspi- ration, and at length delirium, attended the water-dread ; du- ring the last twenty-four hours he swallowed, and recovered his senses; and died slightly convulsed whilst cutting an egg. These cases seem to point out agitation of mind and feverish excitation as powerful occasional causes." In a disease so intricate as lyssa, a very complex treatment Violence is by no means unpardonable : but it may fairly, I think, be p"edx;'°™f questioned, whether the complexity and the energy of the ,oe means means employed to produce a cure may not rather, in some employed instances, have had an opposite effect, and have hastened and ^fy^ne- confirmed a fatal issue. A patient bitten by a mad dog, having times in vain tried and persevered in the use of the Ormskirk medi- proved mis- cine, was next put under the joint care of Dr. Watson and Dr. ch,evou*- Fothergill. Having been bled standing, as long as he could Exempli- stand, he was next immersed in a warm bath, where he was ordered to remain till he again became faint; a clyster of milk and water with a drachm of Dover's powder dissolved in it was injected as soon as he was removed from the bath ; half an ounce of mercurial ointment was at the same time rubbed into the legs and thighs, and three grains of thebaic extract given in the form of pills, two grains being ordered to be continued every hour till he became sleepy. To stand the brunt of a treatment, thus vigorous, would de- mand no ordinary constitution, even without the co-operation of any disease. But that the wretched sufferer should sink (as he did, in a few hours) under the assault of such a malady and such a mode of cure, cannot be matter of surprise. vol. iv. 38 298 «» »v0 NEUROTICA. [ORD. III. Gew. I. Spec.VIII. Entasia lyssa. Treatment. Hence the subject of treatment highly dif- ficult and afflictive. General result and recommend- atory process. No direct specific, and hence what. ever plan is pursued can be palliative only. Poison of lyssa of a peculiar kind, and requires five or six days to be thrown off. Hence the system to be supported generally, and espe- cially the nervous part of it, by cardiacs and diffusi. ble sti- mulants : occasionally by wine and ardent spirits. The whole subject is afflictive, as well in respect to its treatment as its progress. But how, after all, is a young prac- titioner to proceed when he meets with a case of rabies ? This is a most important question ; and the following remarks, submitted with great deference as the result of some little per- sonal experience and no small degree of reflection, are meant to meet it, and to point out the path which, in the present un- settled state of the subject, it may perhaps be most expedient to adopt. From the whole of the preceding survey it is sufficiently clear that we have no direct specific for the cure of the dis- ease ; and, hence, whatever plan we employ must be pallia- tive only. It appears, also, that the disease consists in a poison of a peculiar kind, capable of assimilating some of the animal secretions to its own nature, and that the new matter, or con- tagion, hereby produced, continues to be eliminated for five or six days principally, if not entirely, from the excretories of the salivary glands, as the inflammation of gout unloads itself on the extremities, and the specific matter of exanthems on the surface generally; and that, at the expiration of this period, or as soon as such depuration has been effected, the disease abates, and the patient is restored. It appears, also, that the disease is one of the most dangerous in the whole catalogue of nosology, and that few patients recover from it under any plan of medicine that has ever been devised : but that, never- theless, some patients have recovered under almost every mode of treatment, however incongruous and contradictory to other modes; and, hence, that many cases of restoration must be rather referred to a natural or spontaneous cure, than to the virtue of medicines. In this state of things, it seems reasonable that our first in- tention should consist, as in various other kinds of* animal poi- sons communicated in the same manner, in supporting the sys- tem generally, and the nervous part of it more particularly, so that it may not sink under the violent excitement and augment- ed secretion which the organ of the nerves has to encounter during so perilous a struggle. And it is to this principle we have to resolve all the benefit, which has at any time been found to result from the use of the stimulant theriacas and other cordials of the old practitioners. On this account, ether, am- monia, and camphor, have a strong claim on our attention, and especially the two last, as they may be given in a solid form. All the pungent spices belong to the same class, as cardamom- seeds and capsicum, and may be adverted to as auxiliaries; nor should wine or even ardent spirits be refrained from, if the pa- tient can be induced to swallow them ; moderately through the entire course of the disease, but liberally and profusely as his strength declines. Our grand object must be to keep him alive, and prevent a fatal torpitude in the sensorium for a cer- tain number of days, at any expense of stimulants, or of subse- quent debility. Wine is profusely given with great success in the bite ofthe most venomous serpents ofthe East, and analogy justifies us in proposing it in the present instance. CL. IV.] NERVOUS FUNCTION. [ORD. III. 299 Our next intention should be to diminish, as much as possible, Gen. I. the spastic action of the chest and fauces, and to prevent a re- Spec.VIII. turn of the exacerbations. And to this end as much quiet and Entasia composure as we can possibly procure, under so restless a state i,'ssa' of body, seems imperatively called for, and is far more likely to " be serviceable, than the fatigue of taking the patient repeated- action to be ly out of bed for the purpose of plunging him either into a diminished hot or a cold bath. And though opium has never of itself, per- by.a,9 much i ■ , . ,.11 • ■ i-i i quiet as naps, produced a cure, it seems advisable to try it in liberal possible and doses; and the more so, as several of the cases already ad- a prohi- verted to afford a direct proof, that it is capable, occasionally, b,t,°" °[„„ n i , r J. .. , ' ' . v unnecessary ot producing some degree of tranquillity lor a short period, exertion. In employing it, however, it seems most reasonable, from ana- By seda- logy, to combine it with some diaphoretic, and particularly with lives, and ipecacuan in the form of Dover's powder, since, at all times, "f^3 y the animal frame is most disposed to be quiet and free from ir- combined regular actions when there is a general moisture upon the sur- with some face. In many cases of rabies, such a state of body has been glover's0' found unquestionably favourable; and in one of the instances, powder. already quoted from the Medical Transactions, the benefit was so striking, that the practitioner could not avoid regarding it as critical. It is possible, also, though no great stress can be laid upon this remark, that a part of the virus itself may be hereby eliminated, as in various other cases of animal poisons. To obtain and encourage such elimination should indeed be The morbid our first object, if we had any means of accomplishing it upon be^iTpossi- which we could fully depend. This, however, we have hot; ble, eiimi- but as the quarter to which the virus is directed is the salivary nated from glands, of which, indeed, we have full proof in consequence of ^ J^' the saliva being the fomes of the poison apparently as soon as by means of it becomes elaborated, and as we have a medicine which pos- the faiivary sesses a specific influence on this organ, and is capable of aug- f^ewe of menting its secretion to almost any extent, it seems of the ut- mercury. most importance that, while we endeavour to support the sys- tem, and to allay the nervous irritation, we should endeavour at the same time to quicken the elimination of the morbid mat- ter, by exciting the salivary emunctories, and thus probably also carrying it off in a diluter and less irritant form. It is dif- Ks apparent ficult to withhold one's assent to all the numerous instances of advantage cure, which are so confidently asserted to have followed the use cases're- of mercury carried to the point of free salivation. And hence, solvable without allowing this medicine to be a specific more than any "^jA11^ other, we may indulge a reasonable hope of its forming a good pr auxiliary, and should employ it freely, either externally, inter- nally, or in both modes simultaneously, but with as little dis- turbance to the patient as possible, till a copious ptyalism is the result. Fever, or inflammatory action, does not necessarily belong to Fever.orin lyssa in any stage ; and the present mode of treatment is alto- Jj{""^SJ gether grounded upon this principle. Either, however, may sometimes become incidentally connected with it, from the peculiar state associated: ofthe habit or some other cause. Hence, as a preventive, the 300 cl. iv.] NEUROTICA. [ord. hi. Gen. I. Spec.VIII. Entasia ljssa. Treatment. and hence to beguarded against by gentle nperients : and some- times by a free use of the lancet: Importance of interme- diate pro- cess upon the infliction of the wound. Poison of viper pro- posed as an antidote to that of mad dog. Contagion of canine catarrh said to emancipate dogs from a power of generating rabies : but not of receiving it by contact. Use to be made of this fact if true. bowels should be kept moderately open; and when there is any just apprehension of plethora, or a turgid state of the ves- sels, and particularly ofthe brain, blood should be drawn freely from the arm, and, if necessary, be repeated. We have already seen that such a state of congestion is sometimes produced even at the onset ofthe disease, and is so forcibly felt by the patient himself, that he earnestly entreats the medical attendant to bleed him. Such entreaty should, perhaps, never be urged in vain ; but the bleedings to deliquium, which have of late years been so strongly recommended, are a rash and dangerous practice.* Such, in the doubt and darkness that at present beset us con- cerning the real physiology of lyssa, seems to be the safest and most promising path we can pursue. Our best time for action, however, and almost the only time we can improve, is imme- diately on the infliction of the wound : a tight ligature above which, with the treble precaution of the cupping glass, excis- ion, and cauterization, may in general be regarded as an ef- fectual preventive. 1 do not know, indeed, that the profession is acquainted with any other.! It has, however, been proposed in France, to fight off the poison of lyssa by preoccupying the ground with the poison of a viper, upon the principle of com- bating variolous with vaccine matter: and for this purpose it has been suggested, that the part bitten by a mad dog should be again bitten, a little below the wound, as soon as may be, by a venomous serpent, whose virus, from its greater activity, will, in most cases, be certain of taking the lead, and may, it is pre- sumed, guard the constitution against any subsequent effects from the wound of the mad dog. 1 have not, however, heard that this proposal has ever been carried into effect, and the claim of ingenuity is, most probably, the whole it will ever have to receive. 1 ought not, however, to conclude without noticing one very extraordinary fact in the economy of morbid poisons, and es- pecially of that before us, which I have had confirmed by the testimony of several veterinary practitioners entitled to credit. It is, that no dog who has ever had the distemper, as it is called, which is the canine catarrh or influenza, has been known to become rabid spontaneously, though he is capable of receiving the disease by the bite of another dog. If this be true, for which however, I cannot fully vouch, we have certainly an- other instance of morbid poisons mortally conflicting with each other; and it might be worth trying how far inoculation with the matter of canine catarrh might succeed in protecting a hu- man subject after the infliction of a rabid bite ; though in the * Instead of persevering in these and other plans, which, when allowance is made for the ambiguous nature of many imperfectly reported recoveries and the influence ofthe remedial powers of nature, cannot be said positively to have done effectual good in a single example, practitioners ought, perhaps, to make new experiments on the subject. If we always continuum the same path, we shall never discover the long desired object, namely, a method of treatment which can be depended upon.—Editor. t Dr. Marochetti's prophylactic treatment has already been mentioned.__ Editor. CL. IV.] NERVOUS FUNCTION. [ORD. III. 301 dog, perhaps from a stronger predisposition to rabies, it seems Gen. I. to be impotent. In South America, rabies, as already observed, Spec.VIII. is altogether unknown, and I have hence been anxious to learn, Entasia whether the distemper be unknown there also; and, in answer Z"*' to this enquiry, it has been told me, by several intelligent resi- p0j|alerai' dents in that quarter, that this last disorder is so common and facts in sup- so fatal, that two-thirds of the dogs littered there perish of it port of it. while pups : a remark, which still farther confirms the home- report concerning its influence on rabies, and may partly ex- plain the non-existence ofthe latter on the shores of the Plata. Species IX. Entasia Acrotismus.—Pulselessness. Failure or cessation of the pulse, often accompanied with pain in the epigastrium ; the perception and the voluntary muscles remaining undisturbed. Acrotismus is literally "defect of pulse," from *g«T«j, " pul- Origin of sus," with a primitive x prefixed : whence the technical term the specific crotophus or crotophium, importing " painful pulsation or throb- bing in the temple." Asphyxia is the term employed for this Asphyxia disease by Ploucquet, and would have been used in the present sometimes arrangement, but that it has been long appropriated to import nt^no^Mly. suspended animation or apparent death ; a total cessation, not of the pulse only, but of sense and voluntary motion. This failure or cessation of pulsation sometimes extends over Failure of the whole system, and is sometimes confined to particular parts, j™,^1"",, In every case, it imports an irregularity in the action of the general, heart, or of the vessels that issue from it, and, in most cases, an sometimes irregularity proceeding from local or general weakness, and de- "nite ; pendent upon a spasmodic disposition hereby produced in the debility of muscular tunic of the vessels. Of this last cause, we have a the heart clear proof in the universal chill and paleness that spread over and arteries; the entire surface in the act of fainting or of death, to which Co,in'pCted fainting bears so striking a resemblance. Except, however, in with spas- the agony of dying, the spasmodic constriction for the most part modic dis- soon subsides, and the arteries recover their proper freedom pos" lon# and diameter. Yet this is by no means the case always, for in violent hemorrhages, and especially hemorrhages ofthe womb, the rigidity has sometimes continued for several days, during the whole of which time the heart has seemed merely to pal- pitate, and there has been no pulse whatever. Morgagni re- Exem- lates, from Ramazzini, a case of this kind which extended to p lfaed" four days. The patient was a young man of great strength and activity, even during this suppression. The arteries were as pulseless as the heart; and through the whole period he was quite cold to the touch, and without micturition. On the fourth day he died suddenly.* Examples, indeed, are by no means uncommon, in which the spasm has existed for three,! four, or even five daysj before death. * De Sedibus et Causis Morb. Ep. xlviii. Lugd. Bat. 4to. 1767. t Pathology, p. 25. X Pelargus, Med. Jahngange. band v. p. 23, 302 cl. iv.] NEUROTICA. [ord. III. Other irritations, besides that of weakness, have occasionally led to a like spastic state ofthe arteries. The stimulus of an aneurism of the aorta has produced it in the brachial arteries, so that there has been no pulse in the wrists ;* and gout or some irritation in the stomach has operated in like manner on the ar- terial system to a much greater extent; as has likewise general pressure on the larger thoracic or abdominal organs, from water in the chest or cavity ofthe peritoneum. The cause, however, is not always to be traced, and hence Marcellus Donatus has given an instance, which he tells us was unaccompanied with any disease whatever;! the irritation probably having subsided. Berryatt, in the History of the Academy of Sciences, has fur- nished us with a very singular example of this disease, which was general as well as chronic, and continued through the whole term of life. In all which cases, however, though the heart itself should seem to participate in the pulselessness, we are not to suppose, that it is entirely without any alternation of systole and diastole, but only that its action is indistinct from Weakness or irregularity. In treating of the nature of the pulse in the Physiological Proem to the third class, we observed, that it is in some persons unusually slow, and has been found, as measured by the finger, not more than ten strokes in a minute; and that, in many of these cases, the cause of retardation seems to be a spasticity or want of pliancy in the muscular fibres of the heart or arteries, or both, rather than an actual torpor, which is also an occasional cause. I have never met with any case, in which the ordinary standard of the pulse was not more than ten strokes in a minute ; but I have at this time a patient, of about thirty-six years of age, whose pulse has not exceeded twenty-four or twenty-six strokes, and has often been below these numbers. He is a captain in the Royal Navy, of a sallow complexion and bilious temperament; till of late he enjoyed good health, but, about three years since, was attacked with a fit of atonic apoplexy from which he recovered with difficulty. At an interval of a few weeks from each other, he had several other fits ; on recovering from the last of which he instantly married a young lady to whom he had for some time been en- gaged. He has now been married about fifteen months, has a healthy infant just born, and has had no fit whatever. His spi- rits are good, and he is residing by the sea-side, which situation he finds agrees with him best. Dr. Latham gives a similar example in a merchant whose pulse, though never intermissive, seldom, for ten or twelve * The hypothesis of such a degree of spasm as is here referred to, and supposed to be capable of rendering the large arteries impervious, is one that would not be generally adopted by modern practitioners. Many physiologists, perhaps all the most eminent ones, consider the small arteries as possessing the power of becoming completely constricted by a kind of action that may be sometimes spastic, but a contraction of the arterial trunks in this degree is a position that could not be so well established. In aneurisms of the arch of the aorta, the occasional interruption of the pulse can be explained on a better principle, and one confirmed by dissection ; namely, the manner in which the disease obstructs or breaks the impetus of the blood destined for the upper extremities.—Editor. t Lib. vi. cap. n. p. 620. Gew. I. Spec. IX. Entasia acrotismus. Other irri- tations than that of weakness are some. times causes. Sometimes habitual after the irritation lias sub- sided. In all which cases the heart pro- bably beats. Great re- tardation of the pulse not uncom- mon, some- times amounting to only ten strokes in a minute. Exem- plified. cl. iv.] NERVOUS FUNCTION. [ord. in. 303 years that he had known him, exceeded thirty-two beats in a Gen. I. minute ; occasionally was as slow as twenty-two, and at one time Spec. IX. only seventeen. "I once," says Dr. Latham, " attended him Entasia through a regular fever, when his pulse was not more than sixty, notwithstanding the disease ran on for at least a fortnigiht with a juu3tration. hot and dry skin, white and furred and parched tongue, and oc- casional delirium."* In many of these anomalies, there is not only no perceptible In these pulse, or a very retarded one, but often intermissions more or ™2°m * . fi i • ,i n i i often a want less regular, and occasionally a want of harmony between the of harmony stroke in some of the arteries compared with that in others, in the Reil gives a case in which the heart, the carotids, and the ra- "^^ dial arteries all pulsated differently ;t and Beggi another, in arteries. which the acrotism, or want of pulsation, extended over the en- tire frame, with the exception of the heart, which pulsated violently.^ This species is strikingly exemplified in the biographical ^jj^T sketch of Mr. J. Hunter, drawn up and prefixed to his volume exemplified on Blood and Inflammation by Sir Everard Home. Mr. Hunter, in J. Hun- for the four preceding years, had annually suffered from a fit of f^3^^ the gout in the spring. In the year 1773, this did not return, i;re by and having, on a particular occasion, been greatly affected in Home. his mind, " he was attacked," says Sir Everard Home, " at ten o'clock in the forenoon, with a pain in the stomach, about the pylorus : it was the sensation peculiar to those parts, and be- came so violent that ne tried change of position to procure ease ; he sat down, then walked, laid himself down on the car- pet, then upon chairs, but could find no relief: he took a spoon- ful of tincture of rhubarb, with thirty drops of laudanum, but without the smallest benefit. While he was walking about the room, he cast his eyes on the looking-glass, and observed his countenance to be pale, and his lips white, giving the appearance of a dead man. This alarmed him, and led him to feel for his pulse, but he found none in either arm. He now thought his complaint serious. Several physicians of his acquaintance, Dr. William Hunter, Sir George Baker, Dr. Huck Saunders, and Sir William Fordyce, all came, but could find no pulse : the pain still continued, and he found himself, at times, not breathing. Being afraid of death soon taking place if he did not breathe, he produced the voluntary act of breathing, his working his lungs by the power of the will, the sensitive principle with all its effect on the machine not being in the least affected by the complaint. In this state he continued for three quarters of an hour, in which time frequent attempts were made to feel the pulse, but in vain. However, at last the pain lessened, and the pulse returned, although at first but faintly, and the involuntary breathing began to take place. While in this state, he took Madeira, brandy, ginger, &c, but did not believe them of any service, as the return of health was very gradual. In two hours he was perfectly recovered."§ * .Med. Trans, vol. iv. art. xx. t Memorabilia Clinica, vol. ii. Fase. 1. 6. Hall. 1792. % Opp. Pacchioni. Rom. 4to. 1741. i Sir E. Home's Life of Mr. Hunter, prefixed to the Treatise on Blood, &c. p. xlvi. 304 cl. iv.] NEUROTICA. [ORD. III. Gen. I. Spec. IX. Entasia acrotismus. This case highly ex- traordinary, and striking- ly eluci- dating a close sym- pathy often prevailing between discontinu- ous organs. All such cases com- monly con- nected with a diseased state of the larger ar- teries or viscera, and lead to sud- den death. Exempli' fied. Mode of treatment, where the disease is constitu- tional. When dependent upon a dis« eased state of some one of the larger organs. This is one of the most extraordinary cases on record, con- sidering the extensive group of important functions that were jointly affected, and the total freedom of the rest: and nothing can more strikingly prove, how close is the sympathy that in many instances prevails between discontinuous organs, the chief disease having prevailed in the heart, and the chief pain in the stomach on its upper side. The nature of the pain and the collateral symptoms seem sufficiently to show, that this disease was of a spasmodic kind ; for the deficiency of pulse was subsequent to the pain, and ceased upon its removal, while the deadly paleness of the face gave proof of a constriction of the capillaries. So far as my own experience has extended, such failures of the pulse, whether consisting in a total suspension or a preter- natural retardation, and attended with acute or with very little pain, are dependent upon a diseased state of the larger arte- ries, or the larger viscera ofthe thorax or abdomen, and gene- rally lead to sudden death. The case of the captain of the navy, which I have just related, and which was drawn up while the first edition of this work was in the press, I may now apply to an illustration of this remark; for 1 have since been informed by his sister, that while at Swansea, apparently in as good health as he had ordinarily enjoyed for several years, he was attacked with a fit of apoplexy, which carried him off in less than an hour. Such, too, was the fate of Dr. Latham's pa- tient, for we are told, that " one day, when in complete health, as he then considered himself, he dropped down in the street and expired." And so sudden was the decease of Mr. J. Hunter, that feeling himself unwell while in the course of his professional attendance at St. George's Hospital, he went into an adjoining room, gave a deep groan, and dropped down dead. In all cases of this kind, therefore, the mode of treatment must depend upon the nature of the exciting or pre-disponent cause, as far as we are able to ascertain it. Where the cause is constitutional, a sober, quiet, and regular habit of life, with a due attention to the ingesta and egesta, and particularly to a tranquillized stale of mind, will often enable the valetudinarian to reach his threescore and tenth year with cheerfulness and comfort; but he must content himself with ----the cool sequestered vale of life, and not form a party in its contentions and its glitter, its bustle and k' busy hum." Where the affection appears to be dependent upon a particu- lar state of any one of the larger thoracic or abdominal or- gans, as the heart itself, the lungs, the stomach, or the liver our attention must be specially directed to the nature of the primary disease. And, in these cases, it is often essentially re- lieved by some vicarious irritation, as a seton or issue, a regu- lar fit of the gout, a cutaneous eruption, or a painful attack of piles. During the paroxysm itself, the most powerful and dif- cl. iv.] NERVOUS FUNCTION. [ord. hi. 305 fusive'stimulants should be had recourse to, as brandy, the aro- Gejv. I. matic spirit of ammonia, or of ether, which is still better, and Spec. IX. opium in any of its forms. Entasia Some persons are said to possess a natural power of thus acrot,smus- keeping the heart upon a full stretch, and hereby producing an Jj^ueed"1 universal deficiency of pulsation, and of simulating death. Of spontane- ous Dr. Cleghorn and Dr. Cheyne both give an instance. It ou,,y- should be observed, however, that the individuals died sudden- ly ; and one of them, Colonel Townshend, within a few hours, after having maintained this rigidity of the heart for half an hour, at the expiration of which time he consented to resusci- tate himself, and awoke from the apparent sleep of death. It should hence seem, that the natural energy of the heart sinks gradually, or abruptly, beneath the mischievous exertion, wherever such a power is found to exist. GENUS II. CLONUS. CLONIC SPASM. Forcible agitation of one or more muscles in sudden and irregular snatches. The Greek terms, xAaro? and xXowh, import " agitation, com- Origin of motion, concussion." The clonic or agitatory spasms form two |pr:ingenenc distinct orders in Sauvages, and a single genus in Parr. The first is unnecessarily diffuse ; the second is too restricted. The WW™*- two orders of Sauvages are in the present arrangement redu- ced to two genera, and constitute that immediately before us, and synclonus, or that which immediately follows. Dr. Cullen seems at one time to have had a desire of distinguishing the diseases of both these genera by the name of convulsions ; and of limiting the name of spasms to the permanent contractions, or rigidities of the muscular fibres, produced by spastic action, g and constituting the different species of the preceding genus. " I convulsioo think it convenient," says he, in his First Lines, " to distin- how distin- guish the terms of spasm and convulsion, by applying the for- gjjjj by mer strictly to what has been called the tonic, and the latter to what has been called the clonic spasm." Yet the whole are treated of in his nosological arrangement under the common name of srASMi, and even in his First Lines, notwithstanding this distinction, under that of " spasmodic affections without fe- ver." These spasmodic affections are, indeed, subsequently divided into a new arrangement of " spasmodic affections ofthe animal functions ;—of the vital;—and ofthe natural:" through- out which an attempt is still made to separate the term convul- sion from that of spasm, and apply it to all clonic or agitatory motion of the muscles, while convulsio is, nevertheless, re- tained in the Synopsis, as the technical name of that single species of disease, which is colloquially called convulsion-fit, and not extended to any others. There is doubtless a difficulty in drawing the line between entastic and clonic spasm in many cases, from the mixed nature of the symptoms; but if it be felt vol. iv. 39 306 cl. iv.] NEUROTICA. [ORD. HI. Gen. II. Clonus. Physiologi- cal explana- tion of spasms. Natural flow of nervous power augmented by various stimulants. Mental stimulants. Corporeal stimulants. Uniformity of the flow of nervous energy how interfered with. Production of rigid or entastic spasm. of importance to take terms out of their general meaning, and tie them down to a stricter interpretation, such interpretation should be rigidly adhered to, or some degree of confusion must necessarily ensue. To understand the real nature of the spasms we are now en- tering upon, it may be expedient to recollect, that the nervous power appears to be naturally communicated to parts by mi- nute jets, as it were, or in an undulatory course, like the vi- brations of a musical chord. But the movement is so uniform, and the supply so regular, in a state of health, and where there is no fatigue, that we are not conscious of any discontin- uity of tenour, and can grasp as rigidly and as permanently with a muscle as if there were no relaxation in its supply of power. To prove the nature of the influx, however, nothing more is necessary, than to reduce the muscle from a state of healthy tone to a state of languor, or to wear it down by fa- tigue ; for, in this condition, all the muscles tremble, and the stoutest man is incapable of extending his arm with a small weight in his hand, or even of raising a glass of wine slowly to the mouth, without a manifest, and even a painful oscilla- tion. The flow of the nervous power, in a state of health, is aug- mented by the application of various stimulants, both mental and corporeal. The ordinary mental stimulus is the will, but any other mental faculty, when violently excited, will answer the same purpose, though the action which takes place in con- sequence hereof will, in some degree, be irregular, as proceed- ing from an irregular source, and will in consequence make an approach to the character of spasms ; of which a violent ex- citement of almost any of the passions affords examples suffi- ciently evident, and especially the passions of fear and anger, .under the influence of which it is sometimes found impossible to keep a single limb-still. The ordinary corporeal stimulants are the fluids, which are naturally applied to the motory organs themselves. Thus the air which we breathe becomes a sufficient excitement to the action of the lungs; the flow of the blood from the veins a sufficient excitement to that of the heart; while the descent of the feces maintains the peristaltic motion of the intestinal canal. Where these stimulants are regularly administered, and the organs, to which they are applied, are in a state of health, the alternations of jets and pauses in the flow of the nervous en- ergy, as we have already remarked, are uniform. But in a state of diseased action, this uniformity is destroyed, and in two very different ways : for, first, the nervous energy may rush forward with a force that prohibits all pause or relaxation whatever, and this too in spite of all the power of the will; and we have then a production of rigid or entastic spasms, or those abnormal contractions in different parts of the body, of which the preceding genus furnishes us with abundant exam- ples : and, next, the pauses or relaxations may be too protract- CL. IV.] NERVOUS FUNCTION. [ord. in. 307 ed ; and, in this case, every movement will be performed with Gen. II. a manifest tremor. Where this last is the case, moreover, the Clonus. succeeding jet, from the accumulation of nervous power that necessarily follows upon such a retardation, must at length take place with an inordinate force and hurry; and the movement Production in the voluntary muscles, when attempted to be controlled by °[c°,D™i1c8ive the will, must be irregular, and often strongly marked with ag- °pasni. itation, giving us examples of convulsive or clonic spasm. Mixture 0f And as, moreover, in such a state of the nervous system or of both kinds any part of it, there will often be found a contest between the how pro- retarding and the impelling powers, the spasm will not unfre- duce<1, quently partake of the nature of the two ; the nervous energy, after having been irregularly restrained in its course, will rush forward too impetuously, and for a few moments without any pause; and we shall have either a succession of constrictive and clonic spasms in the same muscle or sets of muscles, or a constrictive spasm in some parts, while we have a clonic spasm in others: and hence, those violent and-ramifying convulsions, which we shall have more particularly to notice under the en- suing genus. A sudden and incidental application of any irritant power Farther whatever to any of the muscular fibres will throw them into an ,lluslratea* irregular action, not only in a morbid state, when they are most prone to such irregularities, but even in a state of health. Hence the involuntary jerk that takes place in all the limbs when a boat, in which we are sailing at full speed, gets aground without our expecting it, or we are assailed unawares with a smart stroke of electricity. Now, whenever a forcible and anomalous movement of this Tendency to kind has once been excited in any chain of muscular fibres what- j|r7r?eguiar ever, there is a strong tendency in them to repeat the same action when movement even from the first; and when, from accident, or a oncepro- continuance of the exciting cause, it has actually been repeated, ~"ce : it forms a habit of recurrence that is often broken off with great esetnabijshed difficulty. Hence the convulsive spasm of the hooping-cough habits of always outlasts the disease itself for some weeks, and is best re- recurrence moved by the introduction of some counter-habit obtained by a "h'ooping- change of residence, atmosphere, and even hours. A palpita- cough: tion of the heart, first occasioned by fright, in an irritable frame, ;n palpita- has in some cases continued for many days afterwards, and in a tion: few instances become chronic. A habit of sneezing has sometimes been produced in the iosneeaing: same manner, and followed an obstinate catarrh ; after which the slightest stimulants, even the sneezing of another person, have been sufficient to call up fresh paroxysms, and, in some cases which I have seen, of very long and troublesome con- tinuance. Hiccough affords us another example of the same tendency iD hiccough. to a recurrence of muscular abnormities. This is usually pro- duced by some irritation in the stomach, not unfrequently that of fulness alone : the irritation is by sympathy communicated to the diaphragm, which is thrown into a clonic spasm, and the 308 CL. IV.] NEUROTICA. [ORD. III. Gen. II. spasm being a few times repeated, the habit becomes so estab- Clonus. lished, as, in many instances, to be broken through with con- siderable difficulty. It is to these physiological laws, that most of the affections we are now about to enter upon, are referrible ; and the con- centrated view we have thus taken of their operation will ren- der it less necessary for us to dwell at much length upon any of them. The genus clonus comprises the six following species : 1. clonus singultus. 2. —— sternutatio. 3. - palpitatio. 4. ■----- nictitatio. 5.-----subsultus. 6. ----- pandiculatio. HICCOUGH. SNEEZING. PALPITATION. TWINKLING OF THE EYELIDS. TWITCHING OF THE TENDONS. STRETCHING. Disease principally seated in the stomach when idiopathic. Remote and exciting causes. Morbid cause some- times seated in other organs than the stomach. Exempli- fied. Species I. Clonus Singultus.—Hiccough. Convulsive catch ofthe respiratory muscles, with sonorous inspiration; iterated at short intervals. Though the spasmodic action in this affection exists chiefly in the diaphragm, the principal seat of the disease is the sto- mach, when strictly idiopathic ; an observation which was long ago made by Hippocrates, and has in recent times been more copiously dwelt upon by Hoffman, but which Mr. Charles Bell has been the first to establish by experiments on the nervous system. " Vomiting," says he, " and hiccough, are actions of the respiratory muscles, excited by irritation of the stomach."* Debility is perhaps the ordinary remote cause, and irrita- bility, or some accidental stimulus, the exciting. Thus excess of food, and especially in a weak stomach, is often a sufficient stimulus : and hence, the frequency [of this complaint among infants. For the same reason, it is occasionally produced by worms, acidity, or bile in the stomach. External pressure on the sto- mach is another exciting cause: and hence it has sometimes followed an incurvation of one or more of the ribs,t or of the ensiform cartilagej of the sternum, produced by violence, and pressing on the coats of this organ. The stomach, however, is not at all times the only organ in which the morbid cause is seated, that excites the diaphragm to this spasmodic action. The liver is frequently to be suspected. " I have often," says Dr. Percival, in his manuscript notes on the volume of Noso- logy, " found hiccough symptomatic of an enlargement or inflam- mation ofthe liver on the upper convex side." It also frequently follows strangulated hernia; and, according to Mr. John Hunter, * Experiments on the Structure and Functions ofthe Nerves. Phil. Trans. 1821, p. 406. + Schenck, Lib. m. Obs. 49, ex Fernelio. X Bonet Sepulchr. Lib. m. Sect. v. Obs. 8, Appex. cl. iv.] NERVOUS FUNCTION. [ord. hi. 309 in numerous instances accompanies local irritation after opera- Gen. II. tions of various kinds. It has sometimes attended the passage Spec- L of a stone in one ofthe ureters.* ^ultus The affection is often very troublesome, but it cures itself in "°®*m ordinary cases, and where the exciting cause is lodged in the ofpten cures stomach ; for the spasmodic action very generally removes the itself, or is accidental irritant; and if not, the disorder usually yields to ea8t'^ined very simple antispasmodics, as a draught of cold water, or a dose of camphor or volatile spirits. Where these have failed, How to be a nervous action of a different kind, and which seems to ope- ^re com- rate by revulsion, has often been found to succeed, such as mon means holding the breath, and thus producing a voluntary spasm of a fail. rigid and opposite kind in the diaphragm; or a violent fit of sneezing. An emeticf will sometimes answer the purpose ; and, still more effectually, a sudden fright, or other emotion of the mind.J If these do not prove sufficient, we must call in the aid of opium; and, in the intervals, have recourse to tonics inter- nal and external, the warm bitters, bark, pure air, exercise, and cold bathing. We have already pointed out the tendency, which these ir- regular actions have to form a habit, and the more so in pro- portion to the general weakness and irritability of the frame ; and hence, indeed, their arising so readily in the later stages of Hiccough typhus and other low fevers, and their continuing to the last jjyjjJJJ. ebb of the living power. low fevers. Even where the constitution is possessed of a tolerable share chronic of vigour, hiccough is too apt to become a chronic and periodi- hiccough. cal affection ; and as the frequency of the spasm is also usually increased with the frequency ofthe series, it has sometimes be- come almost incessant, and defied every kind of medical treat- ment that could be devised. As a chronic affection, it has been Singular known to return at irregular periods from four§ to four and examPe8- twenty years ;|| and as a permanent attack, to continue without ceasing for eight,1T nine,** twelve days,tt and even three months.|J Dr. Parr tells us, that he once knew it continue for a month with scarcely any intermission even at night. " The sleep," says he, " was at last so profound, that the convulsion scarcely awoke the patient." In a few instances, it has proved fatal. Poterius mentions one ;§§ and another, produced by cold beverage, occurs in the Ephemerides of Natural Curiosities.|| || In the Gazette de Sante for 1817, is the case of a young girl, who had been tormented for six months with an almost inces- sant hiccough. It ceased during deglutition, but reappeared immediately afterwards. The sleep was frequeutly disturbed. Baron Dupuytren, on being consulted, after antispasmodics and * Darwin, Zoonom. iv. I. i. 7. t Rigaud, Ergo solvunt Singultum Vomi- tus et Sternutatio ? Paris, 1601. X R'edlin, Lin. Med. 1696, p. 276. •( } Bartholin, Hist. Nat. Cent. n. Hist. 4. || Alberti, Diss. Casus Singul- tus chronici viginti quatuor annoium. Hal. 1743. IT Riedlin, Cent. I. Obs. 15. ** Act. Nat. Cur. vol. v. Obs. 108. tt Tulpius, Lib. iv. cap. 25. it Schenck, Lib. in. Obs. 49, ex Fernelio. ii Cent. ii. Obs xxvii. 11| Eph. Nat. Cur. Dec. in. An. i. Obs. 48. 310 CL. IV.] NEUROTICA. [ord. III. the warm bath had failed, applied an actual cautery to the re- gion of the diaphragm, and the hiccough immediately ceased ; but perhaps terror operated in no slight degree in this mode of cure. Gen. II. Spec. II. Pathology. Has some- times become a serious dis- order. Ordinary causes. But, when severe, usually pro- duced by sympathy with some remote and diseased organ. Origin of the bene diction for- merly be- stowed on sneezing. Tendency in sneezing to call into action other Species II. Clonus Sternutatio.—Sneezing. Irritation ofthe nostrils, producing sudden, violent, and sonorous ex- piration through their channel. Sneezing is a convulsive motion of the respiratory muscles, commonly excited into action by some irritant applied to the inner membrane ofthe nose, and not unfrequently, when so ap- plied, to an extremity of almost any one of the respiratory nerves; in the course of which the air from the lungs is sono- rously forced forward in this direction as the lower jaw is clos- ed at the time. " In sneezing," says Dr. Young, " the soft pa- late seems to be the valve, which, like the glottis in coughing, is suddenly opened, and allows the air to rush on with a great- er velocity than it could have acquired without such an ob- struction."* It is a common and rarely a severe affection in its ordinary course. But, from the habit which irregular actions of the ir- ritable fibres are perpetually apt to assume, as we have already explained, and particularly in a relaxed and mobile state of them, sneezing has occasionally become a serious complaint. Forestus, Horstius, Lancini, and many of the German medical miscellaneous collections, give instances of its having been sometimes both permanent and violent, sometimes periodical, and a few cases wherein it proved fatal; which last termina- tion is confirmed by Morgagni. The Ephemerides Naturae Cu- riosorum contain OBe instance, in which the sneezings continued for three hundred times in a single paroxysm. The ordinary irritants, operating immediately on the mem- brane which lines the interior ofthe nostrils, are sternutatories, a sharp pungent atmosphere, indurated mucus, the acrimonious fluid secreted in a catarrh or measles, or a morbid sensibility of the Schneiderian membrane itself. But the severest cases have usually been produced by sympathy with some remote organ, as an irritable state of the lungs, stomach or bowels. For the same reason, sneezing often accompanies pregnancy and inju- ries on the head, and sometimes the last stages of low fevers. The benediction, formerly bestowed with so much courtesy on the act of sneezing, is said to have been congratulatory on ac- count of its frequent violence ; but we do not seem to be ac- quainted with the real origin of this custom. As sneezing is a symptom of catarrh, if it be repeated for some time with quick succession in an irritable habit that has been frequently affected with catarrh, it will sometimes in the * Med. Literat. p. 107. CL. IV.] NERVOUS FUNCTION. [ord. hi. 311 most singular manner, call sympathetically into action the whole Gew. II. circle of symptoms with which it has formerly been associated, Spec. II. and the patient will seem at once to be labouring under a very Clonus severe cold. An instance of this singular sympathy has occurred ster"u"-atia to me while writing. The patient is a lady of about fifty years lavements of age, in good health, but of a highly nervous temperament, formerly She began to sneeze from some trifling and transient cause, and a9.s°c!*ted having continued to sneeze for five or six times in rapid sue- jiIuBtrated- cession, her eyelids became swollen, her eyes blood-shot and full of tears, her nostrils'discharged a large quantity of acrid serum, her fauces were swollen and irritable, and a tickling and irrepressible cough completed the chain of morbid action. The sneezing at length ceased, and, within a quarter of an hour afterwards, the whole tribe of sympathetic symptoms ceased also. Sneezing, in?its ordinary production, though a convulsive, is Naturally a natural and healthy action, intended to throw off instinctively a healthy from the delicate membrane of the nostrils whatever irritable ^omethnes or offensive material may chance to be lodged there. But troublesome when it proceeds from a morbid cause, or becomes troublesome and 8fv?'e from habit, we should use our endeavours to remove it. That ar°™reqUjrej there is nothing of proper convulsion in sneezing is shown, as removal. Mr. Charles Bell has justly observed, by the admirable adjust- ment of the muscles to the object. A body irritating the glottis will call into simultaneous action the muscles of respiration, so as to throw out the air with a force capable of removing the offending body: but if the irritation be on the membrane ofthe nose, the stream of air is directed differently, and, by the action of sneezing, the irritating particles are removed from these sur- faces. By"the consideration of how many muscles require ad- justment to produce this°change in the direction of the stream of air, we may know, that the action is instinctive, ordered with the utmost accuracy, and very different from convulsion.* When the complaint is idiopathic and acute, or, in other Remedial words, when the Schneiderian membrane is morbidly sensible, |n6gU™uent or stung with some irritant material, it may be relieved by co- cases. piously sniffing warm water up the nostrils, or throwing it up gently with a syringe, or forcing up pellets of lint moistened with opium dissolved in warm water, the pressure of which is sometimes of as much service as the sedative power ofthe fluid itself. If this do not succeed, leeches or cold epithems should be applied to the,nose externally. But a free and spontaneous epistatix, or hemorrhage from the nostrils, effects the best and speediest cure, of which lliedlin has given an instructive in- stance, t Its return has been prevented by blisters to the tem- ples and behind the ears, and frequently sniffing up cold water. It has also been attempted to be cured by pungent sternutato- ries, so that the olfactory nerves may be rendered torpid and even paralyzed by over-exertion ; but this has rarely answer- * Of the Nerves which associate the Muscles of the Chest in the Actions of Breathing, &c. Phil. Trans. 1822, p. 305. t Lin. Med. 1695, p. 148. 312 CL. IV.] NEUROTICA. [ord. III. Gen. II. Spec II. Clonus sternutatio. How to be palliated when the affection is sympa- thetic. ed ; for when once a morbid habit is established, it does not re- quire the primary cause or stimulus for its continuance. When the complaint proceeds from sympathy, the most effec- tual mean of removing it is by ascertaining the state of the re- mote organ with which it associates, and removing the stimulus that gives rise to it. This, however, cannot always be done ; and, in such cases, camphor in free doses will often prove a good palliative, and if this do not succeed, we must have re- course to opium. Discrepant interpreta- tions of different nosologists. Sometimes too con- tracted : sometimes too broad. et C. Palpi- tatio cordis. Throbbing: fluttering. Both pro- ducible by two causes: systole hassh and unpliant: and an Species III. Clonus Palpitatio.—Palpitation. Subsultory vibration ofthe heart or arteries. Palmcjs or palpitatio is used in very different senses by diffe- rent writers. By Cullen and Parr, it is limited to a vehement and irregular motion of the heart alone. By Sauvages and Sa- gar it is applied to an irregular motion " in the region of the heart." By Linneus it is denominated " a subsultory motion of the heart or a bowel—cordis viscerisve ;" and by Vogel is de- fined " a temporary agitation of the heart, a bowel, a muscle, a tendon, or an artery." The first of these views is too contracted, for palpitations, or quick abnormal beats, are felt almost as frequently in many other organs, and particularly those of the epigastric region. Yet, as in these, it seems in every instance, however compli- cated with other symptoms, to depend upon a morbid state of the heart itself, or ofthe arteries which supply them, or are in their vicinity, the definitions that extend palpitations to other organs than the heart and arteries, as separate from these, ap- pear to be as much too loose and out of bounds as the first de- finition is too limited. The view now offered takes a middle course: it contem- plates palpitation as dependent on a diseased action ofthe heart alone, or ofthe larger arteries alone, or ofthe one or the other associating with some organ more or less remote; and hence lays a foundation for the three following varieties: x Cordis. Palpitation of the heart. 0 Arteriosa. Palpitation of the arteries. y Complicata. Complicated or visceral palpitation. The vibratory and irregular action, which we denominate palpitation of the heart, is sometimes sharp and strong, in which case it is called a throbbing of the heart, and sometimes soft and feeble, when it is called a fluttering of this organ. Both may possibly proceed from two distinct causes; the one a morbid irritability of its muscular fibres, or some sudden stimu- lus applied to it, either external or internal, by which its sys- tole becomes harsh and unpliant, and evinces a tendency to a spastic fixation ; and the other an irregular motion of the entire organ of the heart in the pericardium, by which it literally cl. iv.] NERVOUS FUNCTION. [ord. in. 313 strikes against the chest: the cause of which we do not always Gen. II. know, though we see It very frequently occasioned by a sudden Spec. III. and violent emotion of the mind, and have reason to believe, « C. Palpi- that it is often a result of the spastic systole or contraction 0f *all° cordls- the heart which we have just noticed. When, however, the Ir^„"f substance ofthe heart is thus irregularly acted upon, and jerked the organ backward and forward from a cause extrinsic to itself, the palpi- of the heart tation is confined to the pericardium, and the pulse does not p"^-^"" partake ofthe abnormity. The last is, perhaps, the most common proximate cause of as first the palpitation of this organ, and we are indebted to Dr. William g'g^"* Hunter for having first pointed it out to us. The heart, in its Hunter. natural state, lies loose and pendulous in the pericardium: and niustrated. when the blood which it receives is, from an irritation of any kind, thrown with a peculiar jerk into the aorta, the moment it reaches the curvature of this trunk, it encounters so strong a resistance as to produce a very powerful rebound in conse- quence of the aorta being the first point against the spine : the influence of the heart's own action is now, therefore, thrown back upon itself, and this organ, as a result of its being loose and pendulous, is tilted forward against the inside of the chest, between the fifth and sixth ribs on the left.* The rebound of so strong a muscle as the heart, against the Rebound inside of the chest, must depend for its violence upon the vio- ]°™e£D,es lence ofthe jerk with which the blood is spasmodically thrown to be heard! into the aorta ; and this has often been so powerful as to be dis- tinctly heard by by-standers.t Castellus has given an example of this sonorous effect: and Mr. Dundas has observed it in vari- ous cases. "The action of the heart," says the latter, "is and agitate sometimes so very strong as to be distinctly heard, and to agitate the bed- the bed the patient is in so violently, that his pulse has been clotlies- counted by looking at the motions of the curtain of the bed."J The heart has sometimes palpitated with a force so violent as to Has some. dislocate§ or break the ribs,|| for both are stated to have occur- times dis- red on respectable authorities,!! and, in one instance, to rupture f™1^1' its own ventricles.** Upon the wonderful power of the soft the ribs; parts, or rather of the muscles over the bones, when thrown andmptur- into vehement spasmodic action, we had occasion to observe in ^^^ the Physiological Proem to the present order: and hence we have sometimes had examples of the humerus, and other long bones, being broken by a convulsion-fit. A contraction of the left aurico-ventricular opening is sometimes found to produce the phenomenon of a double pulse.jt I have said, that we are not always acquainted with the re- mote or exciting causes of the palpitation of the heart. Violent * See J. Hunter on Blood, p. 146, note. t Castellus, P. Vascus. Exercitat. ad affectus Thoracis. Tr. ix. ToIofo. 1614. 4to. Lettsom, Med. Soc. Lond. vol. i. A Vega, De Art. Med. Lib. in. Cap. 8. X Trans. Medico-Chirm?. Soc. i. 27. i Horstii, ii. 137—139. || Schenck, Observ. 215. ex Fcrnelio. ^ The editor has no doubt ofthe incorrectness of such reports. ** Portal, Memoires de Paris, 1784. tt Hodgson on the Diseases of Arteries and Veins. VOL. IV. 40 314 CL. IV.] NEUROTICA. [ord. III. Gkn. II. Spkc. 111. a. C. Palpi- tatio cordis, Striking example of the first. P.emote causes; chiefly con- sist in a morbid structure of the heart. Exempli- fied. Other causes occa- sionally to be met with. Organic injury. Yet often severe lesion with- out affecting the life. emotion of the mind, as already observed, is a frequent excite- ment, and one or two others have been already indicated. The • first of'these is perhiips the most frequent cause; and hence we can readily admit with M. Corvisart, that palpitation, together with many other diseases of the heart, have been far more fre- quent in France, since the commencement of its late horrible revolution. M. Portal has, indeed, proved this fact by various interesting examples; from which the following may be select- ed, as it is short. A young lady, who had suddenly learned that her husband had been cruelly murdered by a band of the popular ruffians, was instantly seized with a violent palpitation that terminated in a syncope so extreme, that she was supposed to be dead. This apprehension, however, was erroneous. She recovered; but the palpitation continued for many years: and she at length died of water in her chest.* The remote causes are rarely to be discovered till after death, and for the most part seem to consist in a morbid structure of the heart itself, or the pericardium, by which last the muscular walls ofthe heart have either been obstructed in their play, or have had too much liberty of action. The heart has sometimes been found ossified in its general substance, as in the case of Pope Urban the Vlllth ; and more frequently in its valves or its connexion with the aorta. It has sometimes been thickened and has grown to an enormous size, which change of structure has lately been distinguished by the name of hypertrophy, and has been found in one instance of a weight of not less than fourteen pounds.! A case occurred to the present author not long ago in a young lady of fourteen, in whom it reached half this weight, and was the cause of a most distressing palpitation, as well as of a general dropsy. By close confinement and quiet, and the use of elaterium and scarification to carry off the water, she recover- ed an apparently good share of health; but the exercise of dancing, a few months afterwards, produced a recurrence of all the symptoms in a more violent and obstinate degree, and she gradually fell a sacrifice to them. In other cases, the heart has been peculiarly small and con- tracted, chiefly, perhaps, in the disease of tabes, or marasmus; and consequently there has not been a sufficient capacity for the regular influx of venous blood. The space ofthe pericardium has often been morbidly dimin- ished by inflammation, or an undue growth of fat; and hence, again, the heart has been impeded in its proper action; while occasionally it seems to have been filled, or nearly so, with a dropsical fluid. Organic injury from external violence is also a frequent cause of palpitation. Yet it is singular to observe the severity of lesion, which the heart and its appendages will sometimes under- go, when the constitution is sound, without affecting the life. M. Latour, who, during the French war, was first physician to * Memoires sur la Nature et le Traitement de plusieurs Maladies, tome iv. 8vo. Paris, 1819. t Eph. Nat. Cur. Dec. in. Ann. in. Obs. 166. cl. iv.] NERVOUS FUNCTION. [ord. hi. 31-5 the Grand Duke of Berg, attended a soldier who laboured under Gen. II. a tremendous hemorrhage from the breast, produced by a wound Spec III. from a musket that had penetrated this organ. The hemor- * c- Palp«- rhage, however, ceased on the third day, the patient's strength gradually recruited, and suppuration proceeded kindly. It was nevertheless necessary to cut several pieces of fractured rib away; yet the wound cicatrized at the end of three months, and the only inconvenience that remained was a very troublesome palpitation ofthe breast that annoyed him for three years. Six years after the accident, he died of a complaint totally uncon- nected with the wound. His body was opened by M. Mausion, chief surgeon of the hospital at Orleans ; and the ball, which had entered his breast, was found lodging in the right ventricle of the heart, covered over in a great measure by the pericar- dium, and resting on the septum medium.* To these causes may be added a scirrhous or other morbid structure of the lungs, and, perhaps, of the spleen, liver, stomach, or intestinal canal; for it is a frequent accompaniment upon most species of parabysma: and, in these cases, appears as a symptom- atic affection alone. For reasons already assigned, it is also an occasional symptom in hydrothorax; during which it shows it- self in a very violent degree upon mental agitation, especially that produced by fright or vehement rage. We should not, however, be hasty in deciding upon any struc- The real tural affection of Ihe heart, or of any of the larger organs that ™i"ueJelre_n closely associate with it, nor in reality upon any incurable cause stood: and whatever. For it has not unfrequently happened, that a palpi- the disease tation of longstanding, and which has been regarded as of a dan- [^unex- gerous kind, has gradually gone away of its own accord, and left peetedly. us altogether in the dark. Dr. Cullen gives a confirmation of Exemplified this remark in the following very instructive case : " A gentle- fromCulleo. man pretty well advanced in life was frequently attacked with palpitations of his heart, which, by degrees, increased both in frequency and violence, and thus continued for two or three years. As the patient was a man of the profession, he was visit- ed by many physicians, who were very unanimously of opinion, that the disease depended upon an organic affection ofthe heart, and considered it as absolutely incurable. The disease, howev- er, after some years, gradually abated both in its frequency and violence, and at length ceased altogether; and since that time, for the space of seven or eight years, the gentleman has remain- ed in perfect health, without the slightest symptom of his former complaint."! A case precisely similar, and in a professional Confirmed gentleman somewhat beyond the middle of life also, has occur- ^^ red to the present author, with a spontaneous termination equal- praclice. ly as favourable. M. Laennec's ingenious method of mediate aus- cultation by the stethoscope, as we have already explained, will often be found of great importance in the different forms of this species of disease.^ * Diet, des Sciences Medicales, Art. Cns. Rares. t Mat. Med. Part ii. Chap. vm. p. 357. J See vol. iii. Cl. in. Ord. iv. Gen. m. Spec. v. 316 cl. iv.] NEUROTICA. [ord. in. Gen. II. Spec. III. 0 C. Palpi- tatio arte- riosa. Existence of topical irritability in arteries. Yet some- times capa- ble of full proof. Ordinary flow of the blood through the arteries no alternate change. In phleg- monous in- flammation such alter- nate change manifest by the throb- bing : which cannot be derived from the action of the heart. Inflamma- tion only one cause of this subsultory action. The punctu- ality of this abnormal action whence derived. The same alternating spasmodic motion, into which the mus- cular substance of the heart is occasionally thrown by one or other of the causes thus glanced at, seems, at times, to take place in some of the larger arteries, and extends to a greater or less length in proportion to the nature of the cause, or the extent of the morbid irritability, by which they are affected, producing the second variety before us. That a morbid irrita- bility may exist in a part of an artery while the rest is free from any such condition, is easily conceived, since a like partial irrita- bility is often found to exist in organs, in which we are capable of tracing it in the most manifest manner. Yet even in arteries themselves, we can sometimes ascertain the same to the convic- tion of our senses; as for example in the case of phlegmonous inflammation; in which, also, we find it accompanied with the throb, or alternating spasm and relaxation which constitute what is meant by palpitation. In a healthy and ordinary flow of the blood through the arteries, it is very well known, that there is no sensible series of contractions and dilatations whatever; and we have already observed in the Physiological Proem to the third class, that there is no actual change of bulk of any kind, and that it is the pressure of the finger or of some other sub- stance against the side of an artery that alone produces a feeling of pulsation. In a phlegmonous inflammation, however, every one is sensible of a considerable change in this respect; for there is often a very smart and vibratory pulsation while the affected part is in perfect freedom, and no finger is applied to it: and that this is a pulsation, unconnected with the regular pulsa- tion ofthe heart, is perfectly clear, because it is frequently less uniform, rarely, if ever, synchronous with it, and, in most in- stances, twice as rapid. We have here, therefore, a full proof of a local excess of irritability in an arterial tube, and of a palpi- tation, or alternating spasm and relaxation, as its effect.* Yet inflammation is but one cause of this subsultory action, or of the irritability which gives rise to it. With other causes we are not much acquainted; but we have reason to believe them very numerous, and wherever they exist, the artery operated upon will evince the same kind of vibratory throb, though, in general, the stroke will not be found quite so smart as that which takes place in the pulse of a phlegmon. It may appear singular, that this abnormal action, whether of the heart or arteries, should evince so much punctuality in its vibration; but there is often a wonderful tendency to punctuality in all intermissive affections whatever. We see it in hemorrhoidal discharges, in gout, and above all, in intermitting fevers : and, till the cause of such punc- tuality is explained in this last instance, it will be in vain to ex- pect an explanation in the case before us. * The tenor of some of these observations disagrees with the results of cer- tain microscopical observations made on parts in a state of inflammation. Thus, Dr. Thomson, of Edinburgh, in his experiments, was unable to discern any al- ternate expansion and contraction ofthe arteries. The statement about the pulse in an inflamed part not usually coinciding in number and time to the pulse of the left ventricle, is also at variance with other observations.—Ed. cl. iv.] NERVOUS FUNCTION. [ord. hi. 317 In very irritable habits, or, perhaps, where there is a morbid Gen. ii. sensibility through the whole of the sanguiferous system, the Spec. III. palpitation will not unfrequently shoot from one artery to ano- i3 C. Palpi- ther; and one or two cases are given in the Ephemerides of ^osa.3^ Natural Curiosities,* in which it appears to have been univer- paipitation sal. It was so, indeed, in the very irritable organization of that sometimes singularly constituted character J. J. Rousseau, if we may credit sl,00ts [rom the account he gives of himself in relation to this subject: for artery. ° he tells us that, after a peculiar paroxysm of high corporeal ex- „ f citement, he became, all of a sudden, sensible of a pulsation in emplified in every part of his body, which from this time accompanied him J.J.Rous. without intermission : and he adds, that the throbbing was so seau" distinct and strong, that he was often capable of hearing as well as feeling it. The temporal arteries are peculiarly apt to concur in this mi- Palpitation gratory throbbing, and occasionally the carotid; and the throb- °[ th™^"8 bing of both is sometimes synchronous with that of the heart, and poral arte- sometimes successive to it. Mr. Dundas has observed, that this ries, andthe affection of the carotids is most common to persons in the prime carot,d- of life; and that, on dissection, the heart is often found enlarged in its size, but without any increase of muscular power; an as- sertion collaterally supported by the case of the young lady de- scribed under the preceding variety. We here also sometimes meet with polypous concretions, and very generally adhesions to the pericardium. And it is highly curious and interesting to notice the ramifying chain of chain of morbid action, of which the heart sometimes forms the morbid ac first link. I had lately a lady under my care, of delicate consti- singular?" tution and highly nervous habit, in the third month of pregnancy, illustrated. who had for several weeks been uniformly attacked in the even- ing with a violent palpitation in the heart, that continued for nearly an hour or upwards; it was then transferred to the tem- ples, which throbbed with as much violence and for as long a period of time ; vertigo followed with a tendency to deliquium, immediately after which there was a general reaction in the system ; the skin became heated and at first very dry; but the dryness at length yielded to a gentle diaphoresis, which conclud- ed the morbid series; for the patient, at that time becoming tranquil, drooped into a sound and refreshing sleep, and woke free from all these symptoms in the morning. In this case, also, there was a considerable tendency to that universal subsultus or alternating spasm of the arterial system to which we have just adverted : for all the arteries of the extremi- ties pulsated or palpitated whenever accidentally pressed upon by any substance, though it required this additional stimulus to ex- cite the spasmodic action. Arterial palpitation, however, is to be found, though not more Palpitation frequently, still far more alarmingly in the epigastric region, ">theepi- than in the head ; and appears to proceed from some particular regicm. excitement of the aorta, the superior mesenteric, or some branch * Eph. Nat. Cur. Dec. i. Ann. vi.—vir. 318 CL. IV.] NEUROTICA. [ORD. III. Gen. II. Spec. III. 0C. Palpi- tatio arte- riosa. Sometimes resembling an aneurism. Illustrated from Baillie. Often inde- pendent of any disease of the cceliac artery. Its beat has here some resemblance to that of an aneurism of these vessels, and has often been pro- nounced to be such without the slightest foundation, to the great terror of the patient, and consequently to a considerable exacer- bation of the disease. It may, for the most part, be easily dis- tinguished from an aneurism by being destitute of any circum- scribed pulsatory tumour, that can be ascertained by a pressure H?TdJ?tin" °ftne finger; by a smarter vibration in the arterial stroke; and guishable. y,y that degree of irregularity in the return of the stroke by which palpitation is distinguished from pulsation. In some cases, indeed, the line of the affected artery can be distinctly felt and followed up to a considerable length ; and the vibration has oc- casionally been so strong as to be visible to the eye, even at some distance, when the surface of the epigastric region has been exposed to view. "From a good deal of experience upon this subject," says Dr. Baillie, " I am enabled to say, that the increased pulsation of the aorta in the epigastric region, very rarely depends upon any disease of the aorta itself, or of its large whatever in branches in that place ; and that this occurrence is almost con- the aorta, sfantly of very little importance."* This distinguished physiolo- gist tells us, farther, that he has had an opportunity of examin- ing the state ofthe arteries in the epigastric region after death, in two persons who had this pulsation very strongly marked, and who died from other diseases. In both cases, all the arteries were perfectly free from every appearance of diseased structure. He was, also, some years ago, consulted by an old man upon a paralytic affection; who afterwards spoke to him incidentally concerning a palpitation of the kind before us, to which he had been subject for upwards of twenty-five years. The throb, on examination, was distinctly to be felt; and on the patient's first perceiving it, and applying to Sir Caesar Hawkins, Mr. Bromfield, and Dr. Hunter, the two former had declared it to be an aneu- rism, while the latter, more modestly, confessed that he did not know what it was. Dr. Baillie, in the article now alluded to, has imitated the modesty of Dr. Hunter. " It is, perhaps, difficult," says he, " to ascertain, in many instances, the causes of this increased pulsa- tion ofthe aorta in the epigastric region : but, in most cases, it wiil be found to be connected with an imperfect digestion, and an irritable constitution." And hence, whatever may improve the digestion, and render the constitution less irritable, will be of use in mitigating the complaint: and, above all, it will be tained: but found highly serviceable to remove the patient's anxiety on the nTctedwhh subJectt> whenever it can fairly be done.t It is here that M. dyspepsy. Laennec's stethoscope may be employed as a valuable diagnos- tic, and will often enable us, better than any other means, to as- * Med. Trans, iv. xix. t With respect to pulsations in the epigastrium, useful information will be found in A. Burn's work on Diseases of the Heart, Edin. 1R09 ; and in a pub- lication by the late Dr. Albers, of Bremen, entitled Uber Pulsationem im Un- terleibe, 8vo. Bremen, 1803. The subject is also introduced into the editor's Dictionary of Practical Surgery, under the head of Abdominal Pulsations. Hence the cause often difficult to be ascer- Advantage of the ste- thoscope. cl. iv.] NERVOUS FUNCTION. [ord. hi. 319 certain the real nature of the malady; for an account of which Gen. II. the reader may turn to the remarks on phthisis.* Spec III. But the throbbing or pulsatory motion is often communicated y c. Palpi- to other organs than the sanguiferous-vessels, and forms that va- tatiocom- riety of affection, to which we have given the name of compli- P,lcata- cated palpitation. This is clearly dependent, in many cases, juiced upon the vicinity or close connexion of such organs with the by the heart or arteries that form the seat of disease; and it may also vicinity of in other cases be produced, as ingeniously conjectured by Dr. {^"'"heart Young, by an accumulation of fluid in the pericardium or tho- or large rax, which transmits a pulsatory motion from the heart itself to trunks of whatever other organ or surface of a cavity such fluid may artenf : u • ii_ .1/1 , • .11 sometimes reach ; in the same manner as the fluctuation, produced by a perhaps slight blow given to one side of the abdomen, when distended by the with water, is distinctly propagated to the opposite side. In fl[?ctga,Aon,. the case of a middle-aged woman, of a rheumatic habit, labour- cumuiated ing under symptoms of general dropsy,t " a palpitation," he tells in cavities us, " was observed in the right hypochondriac region, and on °Pera'ed the right side ofthe neck, which exhibited a vibratory motion palpitation more rapid and less regular, than that of the pulse felt at the of the heart wrist; and a similar vibration was observable in the heart it- orarlenes- self: the pulsation in the neck was not confined to the jugular I,lust{ate(1 from x ouuff. veins; it was more forcible and extensive, than it could have been, if it had originated from those vessels; and it had more the appearance of a violent throbbing of the carotid artery; although, in the axillary artery, the pulse was comparatively regular and natural." Dr. Young found, nevertheless, upon making a strong pressure on the right side of the neck with a single finger, that the motion of the carotid artery was very perceptible, and totally independent of that of the superficial parts, being precisely synchronous with the pulse at the wrist, although it required considerable attention to distinguish it from the more irregular palpitation. The symptoms, however, of a dropsy of the chest or pericardium in this patient appear to have been obscure; and at the time when the general hydropic en- largement, which had been much reduced in the course of the autumn, began to increase towards the end of October, the pal- pitation was considerably less, as well as the pulsations in the abdomen and neck, though the motion ofthe heart was still flut- tering, the pulse at eighty, intermitting and very irregular. On the death of the patient, which occurred soon afterwards, a con- siderable quantity of fluid was found in the pericardium, in the right cavity of the thorax, and in the ventricles of the brain, but little or none on the left side of the chest: the heart was inconsiderably enlarged, and some of its valves, as also some of those ofthe pulmonary artery, which were much ossified, so that a free passage ofthe blood was impeded. I have said that palpitation is sometimes dependent upon a Palpitation morbid irritability of the sanguiferous system in general. In sometimes J dependent * Vol. iii. Cl. m. Ord. iv. Gen. m. Spec. v. t Med. Trans, vol. v. Art. xvii. 320 cl. iv.] NEUROTICA. [ord. hi. Gen. II. Spec. III. y C. Palpi- tatio com- plicata. upon a general irritability ofthe system. Illustrated in Baleman. Subsultory motion of the heart and arteries sometimes synchro- nous, some- times sepa- rate. Languor insupport- able : and the most powerful stimulants unavailable, some instances, however, we find it rather dependent upon a morbid irritation and debility of the entire frame, and conse- quently connected with a very irregular performance of many, or all the functions of the body. Of this highly complicated slate ofthe disease we have a striking example in Dr. Bate- man's history of himself as given in one of the volumes of the Medico-Chirurgical Transactions,* which he ascribes to a poi- sonous action of mercury employed on his own person copiously in the form of an unguent to relieve an amaurosis of the right eye, and which seems to have produced something of the mer- curial erethism described by Mr. John Fearson,t as taking place in some singular idiosyncrasies, already noticed by us under the head of Syphilis.} In this case, the heart and arteries were equally subject to subsultory and violent motions, sometimes separately, and sometimes synchronously, but inaccordantly as to the number ofthe throbs in a given time, and almost perpetu- ally accompanied with a most distressing sense of languor and sinking. There was also a very irksome cough, an occasional sense of constriction across the region of the diaphragm, and such a difficulty of respiration as to render an erect position at night imperatively necessary. Life was, in this case, unques- tionably a forced state of being, and all the stimuli ofthe exter- nal senses and ofthe will seemed necessary to excite the senso- rial organ to produce a sufficiency of nervous energy for the mere preservation of life. And, hence, during sleep, or as soon as these stimuli were cut off, there was such an increase of lan- guor, irregular action of the heart, and sinking, as though in the act of dying, that it was at times necessary, notwithstanding the extreme drowsiness ofthe patient from a previous and long- continued watchfulness, to interrupt the sleep every two min- utes; since by this time or even sooner, the failure ofthe pulse and the appearance ofthe countenance indicated a supervening deliquium. The powers of the stomach, from the repeated paroxysms ofthe disease, seem to have declined rapidly. Fre- quent supplies of food and cordials, as spiced wine, appeared at first serviceable in warding off the languor; but, at length, nothing but fluids could be taken and retained, without increas- ing the disturbed action ofthe heart. Yet so extreme was the sense of sinking and immediate dissolution, that, on one occasion after a quarter of an hour's sleep, air was importunately de- manded, and three glasses of undiluted brandy were drank in five minutes, without much relief; and afterwards ammonia and ether repeated every ten minutes for two hours; when the paroxysm rapidly declined after a copious discharge of limpid urine. The disease continued a twelvemonth before the pa- tient felt, in any essential degree, amended : and little benefit was derived from medicines of any kind. It is well kn own, how- ever, that this acute pathologist, and excellent man, has since fallen a sacrifice to a return ofthe complaint. * Vol. ix. p. 227. t Observations on the Effects of various Articles of the Materia Medica in Lues Venerea, ch. xii. X Vol. iii. Class in. Order iv. Gen. vi. Spec. ii. cl. iv/j NERVOUS FUNCTION. [ord. hi. 321 In a disease, produced by so great a diversity of causes, often Gen. II. obscure, and very generally complicated with other affections, Spec. III. it is impossible to lay down any one plan of treatment that will Clonus pal apply to every case. Our first endeavour should be to ascer- J" a l0* tain, as far as we may be able, whether the palpitation be idio- r a . pathic or symptomatic ; and if the last, while we endeavour to^[an 0r palliate the present distress, our attention should chiefly be di-weatment. rected to the primary malady. If any other morbid state of the Primary stomach or bowels be suspected, this, as far as possible, should "^cal'*" be removed; and if we have reason to suppose hydrothorax, disease is or any other kind of dropsy, the means, hereafter to be recom- eympto mended for this tribe of complaints, should be resorted to from malic- the first. In pregnancy, the disease will most probably cease upon a cessation of this state of body, and usually, indeed, ceases during the latter months, or after the period of quicken- ing. And, if it seem to be chiefly dependent upon a general ir- ritability of the sanguiferous system, or of the whole constitu- tion, the sedative antispasmodics, tonics, and especially the metallic, quiet of mind as well as of body, regular hours, light meals, pure air, and such exercise as agrees best with the in- dividual, will often prove of essential service and sometimes ef- fect a radical cure. Much of this plan will also be requisite where we have rea- indication son to apprehend some structural affection ofthe heart, or larger where the blood-vessels : and when, from any incidental excitement, the fd'[opathicor irritation is here more than ordinarily troublesome, recourse structural. must be had to narcotics. Opium is by far the best where it agrees with the system : but its secondary effects are often very distressing, and we cannot employ it. In such cases, we must find out, by trial, what is its best succedaneum : the hop, hen- bane, hemlock, and prussic acid, have all been essayed in their turn, and sometimes one has succeeded where the rest have all failed. But, upon the whole, the henbane has answered far . better and more generally under the author's own hands: and, in one or two instances of great obstinacy, he has known it ef- fect a perfect cure, when all the rest had been tried in succes- sion and had totally failed. In Dr. Bateman's case, however, which was peculiarly se- vere and complicated, the henbane, though it seemed service- able at first, taken in doses of from three to five grains of the extract every night, gradually lost its effect even when re- peated three times a night in doses of five grains at a time. The tincture of hop, in doses of thirty drops every six hours, was next tried, but produced no other effect, than a slight drowsiness. Musk seemed most successful in draughts of ten grains each; yet even this was of transient duration, and was abandoned as of no use. Where the palpitation is accompanied with a distressing tendency to deliquium, 1 have occasionally relieved it by camphor pills, with the ammoniated tincture of valerian or the aromatic spirit of ether. The disease has occasionally been carried off by a sudden at- Disease hat tack of some other complaint, as gout, herpes, diuresis, or the sometimes vol. iv. 41 322 cl. iv.] NEUROTICA. [ord. hi. Gen. II. Spec. Ill, Clonus pal- pitatio. Treatment. been carried off by othA complaints^ formation of an abscess : and hence, setons and issues have been recommended, and have occasionally proved serviceable. Za- cutus Lusitanus found the latter produce a radical cure in pal- pitation of the heart, which he ascribed to the rapid healing of some chronic ulcers.* Schenck advises the wearing a bag of aromatics at the pit of the stomach ;t and hence, perhaps, the origin of camphor-bags as a specific for irregularities of the heart of another kind. Common nictitation a natural action for useful pur- poses : especially for the pur- pose of supplying the cornea with mois- ture. Advantage of such supply. Illustrated. Blue shade of light in painting, what. Species IV. Clonus Nictitatio.—Twinkling of the Eyelids. Rapid and vibratory motion ofthe eyelids. To a certain extent, twinkling or winking of the eyes is per- formed every minute without our thinking of it. It is a natural and instinctive action for the purpose of cleansing and moisten- ing the eye-ball, and rendering it better fitted for vision. Dr. Darwin has some ingenious remarks upon this subject. " When the cornea," says he, " becomes too dry, it becomes at the same time less transparent, which is owing to the pores of it being then too large ; so that the particles of light are re- fracted by the edges of each pore instead of passing through it; in the same manner as light is refracted by passing near the edge of a knife. When these pores are filled with water, the cornea becomes again transparent."! Moisture is, indeed, a frequent cause of transparency in various bodies ; and hence, in dying people, whose eyelids are become torpid and do not nictitate, the cornea is sometimes so dry that its want of trans- parency is visible to by-standers. So when white paper is soaked in oil, and its pores filled with this fluid, from an opaque body it becomes transparent, and radiates the light that is thrown upon it: air itself is most transparent when as much moisture is dissolved in it as it will hold ; when void of mois- ture, indeed, it forms a dry mist, which is occasionally met with in the morning, and through which distant objects are seen indistinctly ; while, on the contrary, when distant objects are seen with perfect clearness, it is a sign of rain. In a mist, dis- tant objects are also seen indistinctly ; yet here the moisture is not dissolved in the atmosphere but merely suspended, and formed by the attraction of cohesion into collected spherules. We may hence account for the want of transparency in the air which is seen in tremulous motions over corn-fields on hot sum- mer days, and over brick-kilns, after the flame is extino-uished while the furnace still remains light. It is this dryness and want of transparency in the atmosphere over the summits of hot and arid hills, in a bright unclouded sky, as in Italy, which constitute what is called by the painters the blue shade of light, and which is copied in most pictures of Italian scenery. * Prax. Hist. Lib. vm. Obs. 30. X Zoonom. Cl. i. i. 4. 2. t Lib. ii. Obs. 1216. cl. iv.] NERVOUS FUNCTION. [ord. hi. 323 The ordinary use of nictitation is therefore obvious : but Gen. II. there are many persons, who wink or twinkle their eyes far Spec IV. more frequently than is necessary for the purpose of moistening ^°"t"*;o the cornea, and in whom it forms an unsightly habit. This has Morb;d nic. usually been produced at first by some local irritation, as in- titation how flammation or dust in the eyes, which quickens the natural ac- produced: tion, and, where the stimulus is considerable, renders it irregu- by"l0nm'"y lar and convulsive.- If indeed the stimulus be very vehement, local irrita- the nature of the spasm is changed, and the eyelids, instead of tion: irregularly opening and shutting with great rapidity, become *"{_"^ ' rigidly closed. closes the We have seen, in many of the preceding species of diseases, eyelids with with what ease morbid actions are continued when once intro- "Clonic ** duced into an organ : and hence, when any permanent irrita- spasm. tion of the eye has excited and maintained for some days or weeks a quick repetition of twinkling, this iterative action will often be found to become habitual, and remain after the irrita- tion has subsided. This morbid habit has been sometimes cured by a powerful Morbid nic exertion of the will; but, more generally, by using one eye only j}^10^. at a time, and closing the other : the open eye being employed jered ha- in examining an object for a considerable period with great at- bitual. tention and steadiness. A minute examination of the stars at Remedial night, through a telescope, has a like corrective tendency, and lreatnient- may be employed for the same purpose. Species V. Clonus Subsultus.—Twitchings. Sudden and irregidar snatches of the tendons. This affection is to the tendinous extremities ofthe muscles, Pathology. in which the principle of irritation is often apt to accumulate, what palpitation is to the irritative fibres ofthe heart and arte- ries : and hence, as we have already seen, it is included under the general term of palpitation by Vogel. We witness these starts or twitchings most frequently in ex- Affection treme stages of debility produced by atonic fevers, and espe- !"°SJ B*r*" ciallyjust before the act of dying. They are, in such cases, {"eme stages weak convulsions interruptedly undulating from one limb or of debility. part of a limb to another, too feeble to raise the iimb itself, al- though sufficiently powerful to give slight but transient swellings to the belly of a muscle, and consequently a slight involuntary flickering to its tendons. In the ordinary close of life, they are the precursors of the fatal scene, the harbingers of the dying struggle, and generally indicate that the will has lost its hold, and the power of sensation is rapidly ceasing : thus affording an- other proof, if other proofs were wanting, to those adverted to in the Proem to the present Class, that the irritative fibres are capable of maintaining their function, under particular circum- stances, for a much later period than the organs of perception and sensation, occasionally, indeed, for some hours after the 324 cl. iv.] NEUROTICA. [ord. m. Gen. II. Spec. V. Clonus snbsullus. Why the subsultory motions stronger as the frame becomes weaker. These con- vulsive movements sometimes dependent on local debility, and do not interfere with the ge- neral health. Illustrated from Darwin. Farther illustration. death of every other part of the body. And as debility and ir- ritability often exhibit a joint march, the subsultory motions are apt to become stronger, as the regular motion of the pulse be- comes weaker, and at length work up those agonizing convul- sions, under which the little and loitering flame of life is some- times extinguished instantaneously. Such twitchings of the tendons, however, do not always prove fatal; for they often show themselves where the case is not so extreme : and hence, they may occasionally be allayed by cordials, antispasmodics, and warmer sedatives, and are altogether lost in a favourable turn ofthe disease. It occasionally happens, that the debility, producing these weak convulsive actions, is local and habitual; and in such ca- ses they may be seen to agitate and play over a limb, without any influence on the system generally, and without much injury to the limb itself. Such a state of nervous constitution may be produced by accident, but it is for the most part strictly idiopa- thic ; and there are few practitioners, perhaps, who have not met with examples of it. Dr. Darwin gives us an instance in the following words: " A young lady, about eleven years old, had for five days had a contraction of one muscle in her fore- arm, and another in her arm, which occurred four or five times every minute; the muscles were seen to leap, but without bending the arm. To counteract this new morbid habit, an is- sue was placed over the convulsed muscle of her arm, and an adhesive plaster wrapped tight like a bandage over the whole fore-arm, by which the new motions were immediately destroy- ed, but the means were continued some weeks to prevent a re- turn."* The author has sometimes seen it about one of the shoulders, but the extremities are its most usual seat; and he was lately consulted by a lady of a strikingly irritable habit, who was suddenly attacked with it both in her hands and feet, so as to throw her into a considerable degree of alarm. Upon enquiring into the patient's age and state of health, he was in- formed, that she was between forty and fifty, that menstruation was on the point of leaving her, and had of late appeared very irregularly, and that she had a considerable oppression in her head. The cause was therefore obvious, and the cure was not difficult; for it yielded to a moderate venesection, and an ha- bitual attention to the state of the bowels. Species VI. Clonus Pandiculatio.—Pandiculation. Transient elongation of the extensor muscles, usually ivith deep in- spiration and a sense of lassitude. Why to be This is, perhaps, the slightest modification of spasmodic ac- regarded as tions; but as it often occurs, as in nausea on the first stao-e of .ction*.'"0*1'0 a febrile paroxysm, whether the will consents or not, and is * Zoonomia, Catenation, Sect. xvn. i. 8. cl. iv.] NERVOUS FUNCTION. [ord. hi. 325 frequently and irregularly repeated, it cannot but be regarded Gen. II. as belonging to the present family on many occasions. The Spec VI. muscles chiefly concerned are the extensors of the lower jaw Clonus and of the limbs: the particular kind of pandiculation, to [aat"0#,cu" which the first of these movements gives rise being called oscitancy, yawning, or gaping ; and that produced by the 0scltiJncy» j mL i -i i x Ai ■ i- yawning, or second, stretching. The muscles are excited to this peculiar gaping. action by a general feeling of restlessness or disquiet; and the Stretch;n& spread of the action from one muscle, or set of muscles, to .. another is from that striking sympathy, or tendency to catenate ca„Cg e'ng in like movements, which we so often behold in different parts of the body without being able to explain. It is possible, how- ever, that the synchronous motion of the muscles of the lower jaw and of the limbs, for it is rarely that yawning and stretch- ing do not accompany each other, may be dependent upon the same line of intercourse, by which trismus so often accompa- nies a wound in one of the extremities, and which we have already attempted to illustrate ; the irritant power, in the one case, leading to a fixed or entastic, and, in the other, to a tran- sient and clonic spasm. Pandiculation, considered physiologically, is an instinctive Pathology. exertion to recover a balance of power between the extensor and flexor muscles, in cases in which the former have been en- croached upon and held in subjection by the latter. A very slight survey of the animal frame will show us, that jyaturai the flexor muscles have, in every part, some preponderancy prepon- over the extensors; and that this preponderancy is perpetually deran(cJMjf counteracted by the stimulus of the instinct or of the will. We 0yer the see it from the first stage of life to the last, and most distinctly extensor in those states in which there is most feebleness, and conse- muscles. quently in which the controlling powers are least capable of exercising and maintaining a balance. In the fetus, therefore, Shown in in which the weakness is most pressing, the power of instinct the fetus" is merely rising into existence, and no habit of counterpoise established in the nascent fabric, every limb, and part of every limb capable of bending, undergoes some degree of flexure, and the entire figure is rolled into a ball, as the hedge-hog habitually rolls himself, even after birth. As the fetus, howev- er, increases in size and age, and the powers of instinct, sensa- tion, and volition become more perfect, this general conflex- ure produces occasionally a sense of uneasiness; and hence Pandicu- every parturient mother is sensible of frequent internal move- j?1]"^'™ ments and stretchings of the little limbs of the fetus to take e™trJe the off the uneasiness, by restoring some degree of balance to the balance of antagonist powers. After birth, and during wakefulness, the P0™"- stimulus of the will, directed rather to the extensor than the J0JjeerJ^ flexor muscles, renders the counterpoise complete for all the after birth. purposes for which it may be necessary. But the moment we repose ourselves in sleep, and the will becomes inactive and withdraws its control, the flexor muscles exercise their pre- ponderancy afresh, though in a less degree than in fetal life, since the extensors, from habitual use, have acquired a more 326 cl. iv.] NEUROTICA. [ord. III. Geit. II. Spec VI. Clonus pandicu- latio. Pandicu- lation again used to restore the balance. In all these cases pan- diculation a natural action. How far a morbid and convulsive action. Frequency of recur rence how accounted for. Yawning of indolence and fashionable indulgence. than proportionate increase of power. The preponderancy, however, when long exerted, still produces some degree of disquiet, and hence, occasionally during sleep, and still more vigorously the moment we begin to awake, we instinctively rouse the extensor muscles into action; or, in other words, yawn, stretch the limbs, and breathe deeply, to restore the equipoise that has been lost during unconsciousness. In all these cases, pandiculation is a natural action; it is an effect produced by the will when it is called to the particular state of these two sets of muscles, or by the instinctive or remedial power of nature, which supplies its place, when it is dormant or inattentive, to restore ease to a disquieted organ. But, in an infirm or debilitated condition of the system, it evinces a morbid and convulsive character, and takes place without our being able to prevent it, even when the will uses its utmost effort to resist, instead of to encourage it. How far its repetition may be of use in the shivering fit of an ague, or in a nauseating deliquium of the stomach, it is dif- ficult to say. Yet we are at no loss to account for its frequency of recurrence : for as the whole system is, in such circumstan- ces, thrown into a sudden prostration of strength, the extensor- muscles, in consequence of being naturally weaker than their antagonists, must become soonest exhausted, and give way with a more than ordinary submission to their power. And hence we behold a painful retraction over the whole system, and the preponderancy assumes a rigid and spastic character; and we may fairly conclude, that much of the yawning and stretching, which ensue, is for the purpose of getting rid of the constric- tive spasm, though these counteractions themselves often run, in the attempt, into a spasm of another kind, and become con- vulsive. Yawning and stretching, then, are among the signs of debility and lassitude. And, hence, every one who resigns himself in- gloriously to a life of lassitude and indolence, will be sure to catch these motions, as a part of that general idleness which he covets. And, in this manner, a natural and useful action is con- verted into a morbid habit; and there are loungers to be found in the world, who, though in the prime of life, spend their days as well as their nights in a perpetual routine of these convul- sive movements, over which they have no power; who cannot rise from the sofa without stretching their limbs, nor open their mouths to answer a plain question without gaping in one's face. The disease is here idiopathic and chronic: it may, perhaps, be cured by a permanent exertion ofthe will, and ridicule or hard labour will generally be found the best remedies for calling the will into action. Origin of the generic term. GENUS III. SYNCLONUS.—SFA-CL0A7C SPASM. Tremulous, simultaneous, and chronic agitation of various musclesi especially when excited by the Kill. We have already observed that clonus imports " agitative," or " tremulous motion of the muscles ;" and hence synclonus CL. IV.] NERVOUS FUNCTION. [ord. iii. 327 means necessarily their " multiplied, conjunctive, or compound Gen. III. agitation, or tremulous motion." The term is therefore in- Spec. I. tended to denote a group of diseases more complicated in form, Synclouic of more extensive range, or more connected with the general 8pas£ state ofthe constitution, than those of the preceding genus ; and it runs parallel with the clonici universales of Sauvages, as far as Clonici they can be said correctly to belong to this family. The spe- ^gauvages. cies, included under this genus, will be found to be the follow- ing: 1. SYNCLONUS TREMOR. TREMBLING. 2.---------CHOREA. ST. VlTUS's DANCE. 3.---------BALISMUS. SHAKING PALSY. 4. ■---------RAPHANIA. RAPHANIA. 5.---------BERIBERIA. BARB1ERS. Species I. Synclonus Tremor.—Trembling. Simple tremulous agitation of the head, limbs, or both; mostly on some voluntary exertion. The proximate cause of this disease, is an irregular transmis- proximate sion of irritable power to the motory fibres of the muscles that cause. constitute its seat. It is strictly a disease of nervous debility, Exciting either general or local: debility produced by sudden exhaustion, cause8, as in the case of great muscular fatigue from violent exercise, severe cold, or a vehement exertion of the passions, and par- ticularly the passions of fear and rage ; or debility produced slowly and insensibly by causes of tardy operation, as an injudi- cious use of mercury, lead, opium, or other mineral and nar- cotic poisons ; an habitual excess in hard drinking or sexual commerce ; and, in some idiosyncrasies, an immoderate indul- gence in tea. And, as this disease is a result of debility, it why a con- necessarily occurs as a symptom on the general spasm and pros- comitant of tration of strength that so peculiarly distinguish the accession an ague" ' of an ague-fit, and the interruption of sensorial power that takes place in paralysis. There are some persons, however, in whom the same con- Habitual vulsive action exists habitually, without any morbid state of tremor other organs, or any other inroad upon the general health. I ^"j1™68 once knew a lady, considerably beyond the middle of life, who some organs was strikingly affected with this complaint, insomuch that the ™£°J a°y slightest voluntary exertion of any of the muscles threw the ^g^neral head and arms into as great a tremor as if they had been hung health. upon wires, but who enjoyed at the time, and had for a long illustrated. term of years continued to enjoy, as perfect health as possible in every other respect; was lively, cheerful, animated, possess- ed of brilliant powers of conversation, and able to use a more than ordinary portion of exercise without fatigue. The earlier part of her life had been passed in India, but her constitution did not appear to have suffered from this circum- stance ; and so gradual was the attack of the affection, that 328 «<• iv.] NEUROTICA. [ord. III. Gew. III. Spec. I. Synclonus tremor. Physiology. Tremulous movements often regu- lar and uniform, and under the control of the will. Exempli- fied. Where med- ical treat- ment may be of ad- vantage : and of what it should consist. Balance of easy weights. Shampoo- ing. though she had laboured under it for many years, she could not date its commencement from any given point of time. She at length died at the age of seventy-two or seventy-three, her cor- poreal powers progressively declining, and laying a foundation for a general dropsy, while her mind continued firm to the last. In all cases of this kind, the supply of nervous energy to the motory fibres ofthe affected muscles takes place interruptedly, and where the organ or the constitution is in a state of debility, it is also less abundant as well as less uniform. We have alrea- dy observed, that the nervous energy, (or fluid, as the author preferred calling it) in its natural course, is transmitted only by waves or vibrations, and consequently with an interposing pause or relaxation after every efflux; but that the pause is instanta- neous, and the supply so regular as to answer the purpose of a permanent and continuous tenour. In clonic tremor, the pauses are, however, prolonged, and, for the most part, irregular or untrue to themselves; and the greater the retardation and irregularity, the more marked aud alarming the spasmodic shake. In the case just adverted to, there was no other diseased ac- tion whatever; the nervous power was unquestionably supplied in sufficient abundance, and the pauses, though prolonged, were uniform; and it was singular to observe the influence the will possessed over the affected muscles under these circumstances, and how completely they were still under its control: for, in consequence of the uniformity of the morbid interruptions, and from the force of habit, I have seen this patient, in the midst of a shaking that threatened every moment to overturn whatever she took hold of, raise a cup brimful of tea, or a glass brim- ful of wine to her lips by way of experiment, without spilling a single drop. Where the corporeal health is so little interfered with, as in the present case, a course of medical treatment might, perhaps, do more mischief than benefit. But where the constitution is generally affected, or the muscles that form the seat ofthe con- vulsion are manifestly debilitated, general and local tonics and stimulants may sometimes be tried with advantage, though they frequently fail of producing any good effeets. Sea-bathing and horse-exercise, a generous diet, change of air and scene, may be found useful auxiliaries in the general treatment; and lono-con- tinued and daily friction by a skilful rubber, ammoniacal embro- cations, blisters, setons, and a course of voltaism or electricity offer the best promise, as topical means oPrclAf. The affected' limbs may also be put into a train of gradual exertion for the purpose of obtaining both strength and steadiness: and, to this end, the head or shoulders may be occasionally made to balance an easy weight for a given period of time, and the hands to sus- pend, or carry, a wine-glass or tumbler brimful of water. Here also may be recommended the kneadin«--friction or shampooing of the Egyptians and Turks, which has of late be- come a fashionable refreshment in the watering-placea of ouc cl. iv.] NERVOUS FUNCTION. [ord. hi. 329 own country; and there can be no question, that the pungent Gen. III. and exhilarating essential oils, which are applied to and absorb- SpEC-l- ed by the skin afterwards, add considerably to the general effi- Synclonm cacy. Something like this the French have long been in the reui0r' habit of employing under the name of frictions siches.* The Frictions horse-hair shirts, and periodical flagellations, of the old Fran- seches. ciscan friars would probably be found to answer the same pur- pose. But this is a remedy which is not likely to be revived in the present day, whether from a medical or a moral call. Species II. Synclonus Chorea.—St. Vitus's Dance. Alternately tremulous and jerking motion of the face, legs, and arms, especially when voluntarily called into action ; resembling the grim- aces and gestures of buffoons; usually appearing before puberty. The term chorea, from ^?«f, " chorus," " ccetus saltantium," Specific is comparatively of modern date in its application to the present x™%°a disease; nor is it easy to determine satisfactorily who originally date. employed it. It was first more limitedly denominated chorea sancti viti, under which limitation it occurs in Sydenham, and is still known in popular language, being called, in colloquial English, St. Vitus's Dance, and, in colloquial French, Dance de St. Guy. According to Horstius, the name of St. Vitus's Dance wlj«ee was given to this disease, or, perhaps, more probably to a dis- yit*sh ease possessing some resemblance to it, in consequence of the dance, or cure produced on certain women of disordered mind, upon their Dance de paying a visit to the chapel of St. Vitus, near Ulm, and exercis- l' uy' ing themselves in dancing from morning to night, or till they became exhausted. He adds, that the disease returned annually, and was annually cured by the same means. The marvellous accounts of this dance, as related by old Nature and writers, are amusing from their extravagance. The paroxysm f,^ar^al of dancing, we are told, must be kept up, whatever be the dance length ofthe time, till the patient is either cured or killed ; and described. this", also, whether she be young or old, in a state of virginity or of parturition ; and, in the growing energy of the action, we are Said to further told, that stools, forms, and tables are leaped over with- J^PJJ out difficulty if they happen to be in the way. Felix Plater kept up for gravely tells us, that he knew a woman of Basle, afflicted with a month this complaint, who, on one occasion, danced fojr a month togeth- w er ;t and the writers add generally, that it was hence necessary to hire musicians to play in rotation, as well as various strong sturdy companions to dance with the patients till they could stir neither hand nor foot.J * Ardouin, Essai sur f Usage des Frictions Seches, &c. t De Mentis Alienat. cap. iii. A case, in which a girl, ten years of age, kept up the most extraordinary movements and exercises for five weeks, sometimes lor fifteen hours a day, is related by Dr. Watt. (See Med. Chir. Trans, vol. v.) As Mr. Hunter of Glasgow has truly remarked, it is perhaps the most extraordinary case of the kind on record. (See Edinb. Med. Journ. No. 83. p. 268.)—Ed. \ Paracels. De Morb. Amentium, Tract. I. Schenck, De Mania, Lib. I. vol. iv. 42 ceasing. 330 cl. iv.] NEUROTICA. [ord. m. Gen. III. Spec. II. Syncloous chorea. Recent case approaching to it. Tarantis- mus. Carneva- letto delle doune. Probably synonymous with the seelotyrbe of Galen. Description from Hamilton. A disease of debility, appearing most com- monly among children. Muscles of the face usually attacked first. Afterwards other mus- cles of different kinds. The nearest approach to this kind of gymnastic medicine, which I am acquainted with in modern times, is a singular case of the same disease, described by Mr. Wood in the seventh vo- lume of the Medico-Chirurgical Transactions. The morbid movements were in measured time, and constituted a sort of regular dance as soon as music was struck up, but ceased in- stantly upon a change of one time to another, or upon a more rapid roll of the drum, which was the instrument employed on the occasion, than the morbid movements could keep up with. Advantage was taken of the last part of this very singular in- fluence, and the disease was cured by a perseverance in dis- cordant or too rapid time. This form of the disease appears to have a near relation to the tarantismus of Sauvages, which is the carnevaletto delle donne of Baglivi, all of them probably nothing more than modifications of the present. Linneus, and after him Macbride, from the epithet of sanctus, as applied to chorea, or a belief that such affections are induced by the im- mediate agency of a superior order of beings, have applied to it the name of hieronosos, or " morbus sacer"—a name, however, which, by earlier writers, was appropriated to convulsion-fits. In Galen chorea seems to be included under a disease which he calls scelotyrbe, literally, " cruris turba or perturbatio,"— " commotion of the leg ;" and his description, which is as fol- lows, is extremely accurate. " It is a species of atony or para- lysis, in which a man is incapable of walking straight on, and is turned round to the left when the right leg is put forward, and to the right when the left is put forward, or alternately. Some- times he is incapable of raising the foot, and hence drags it awk- wardly, as those that are climbing up steep cliffs." One of the best general descriptions which have been given us of chorea, is the following of Dr. Hamilton, contained in his valuable treatise on the utility of purgatives: " Chorea Sancti Viti attacks boys and girls indiscriminately; and those chiefly who are of a weak constitution, or whose natural good health and vigour have been impaired by confinement, or by the use of scanty or improper nourishment. It appears most commonly from the eighth to the fourteenth year. 1 saw it in two young women, who were from sixteen to eighteen years of age. The approaches of chorea are slow. A variable and often a raven- ous appetite, loss of usual vivacity and playfulness, a swelling and hardness of the lower belly, and, in general, a constipated state of the bowels, aggravated as the disease advances, and slight, irregular, involuntary motions of different muscles, par- ticularly those ofthe face, which are thought to be the effect of irritation, precede the more violent convulsive motions, which now attract the attention of the friends of the patient. " These convulsive motions vary. The muscles of the ex- tremities and ofthe face, those moving the lower jaw, the head, and the trunk of the body, are, at different times, and in differ- ent instances, affected by it. In this state the patient does not walk steadily; his gait resembles a jumping or starting; he sometimes cannot walk at all, and seems palsied; he cannot cl. iv.] NERVOUS FUNCTION. [ord. hi. 331 perform the common and necessary motions with the affected Gen. III. arms. This convulsive motion is more or less violent; and is Spec. II. constant, except during sleep, when, in most instances, it ceases Synclonus altogether. Although different muscles are sometimes succes- c sively convulsed, yet, in general, the muscles affected in the early part ofthe disease remain so during the course of it. Ar- Articulation ticulation is now impeded, and is frequently completely suspend- a^f0^"" ed. Deglutition is also occasionally performed with difficulty. peded. The eye loSes its lustre and intelligence; the countenance is Patient pale, and expressive of vacancy and langour. These circum- appears stances give the patient a fatuous appearance. Indeed, there is fatuous, and every reason to believe, lhat when the complaint has subsisted n°™o^e for some time, fatuity to a certain extent interrupts the exercise really so. of the mental faculties." Thermaier gives a case in which it was connected with a Sometimes deeply melancholic temperament, and the limbs were in a state has evinced of constant snatching and trepidation :* but this is a rare con- meleaenpcholic comitant; nor is fatuity a constant sequel of it, even in its tempera- most obstinate and chronic form. The present author has met ment a|^ with various instances in which the disease has continued with [reer^"t^on. considerable violence from an early period to old age, without ^.^ making any inroad whatever on the mind, or even spreading not unfre. to any other joints, limbs, or muscles, than those at first affect- quently un- ed. He once knew a man under the habitual influence of this j^™*^ complaint who was a good orator, always reasoning with great diseaseis clearness, and delivering himself with much animation. The violent and movements of his arms were indeed in ungraceful snatches, habitual. and the muscles of the neck frequently evinced a like convul- Hasaccom- sive start, yet not so as to interrupt the flow of his periods, or £™l„ffgpod to abridge his popularity. He knew another person for many ' years severely afflicted with the same complaint, who was an PVA"™JJ excellent musician, public singer, and composer of music; singers. and this, too, notwithstanding that he was blind from birth. The person alluded to is the late Mr. John Printer of the ExemPli- Foundling Hospital. In walking he was always led on account fied. of his blindness, and used a staff on account of the unsteadiness of his steps; but, notwithstanding every exertion, his gesticu- lation was extreme, and so nearly approaching the antics of a buffoon, that it was often difficult for a spectator to suppress laughter. Yet, in singing and playing, he had a perfect com- mand over the muscles of the larynx and of the fingers; his tones were exquisitely clear and finely modulated; but his neck and head curvetted a little occasionally. He died when about sixty years of age, without ever exhibiting any debility of intellect. There is a singular form of this disease, which has been Malleatio, called by some writers malleatio, consisting in a convulsive what. action of one or both hands, which strike the knee like a ham- mer. In this case the hands are usually open, but sometimes clenched. Morgagnif relates a case in which it came on even * Consil. Lib. n. cap. xi. t De Sedibus, &c. x. 16. 332 cl. iv.] NEUROTICA. [ord. hi. Gew. III. Spec. II. Syticlonus chorea. Sometimes connected with hyste- ria. Singular example of these mixed movements. Description. Predispn- nent cause ; chiefly de- in the sound hand, if the finger of the affected one were ex- tended. If the motion be forcibly stopped, the convulsion be- comes afterward still more violent and general. Where the system is disposed to hysteria, the paroxysm is sometimes extremely vehement, and partakes of the constitu- tional diathesis, making an approach to epilepsy, but distin- guished from it by a continuance of consciousness and sensibi- lity. Dr. White of York has given us a striking example of this mixed affection in a lady forty-two years of age, who "had always a very weak system of nerves," and was rendered speechless for an hour or two upon any sudden surprise. In November, he tells us, she was affected with a fresh paroxysm, which, upon being sent for, he describes as follows:—" She complains of a violent pain in the right side of her face, and of universal erratic aches and soreness. There is a scorching heat all over the skin, except from the feet up to the ankles, which are as cold as marble. Pulse not quickened but full ; mouth dry but no great thirst; body costive, which is indeed her natural habit, so as to oblige her to the frequent use of magnesia. She is regular as to the menses, the return of which she expects in five or six days. Appetite good, rather vora- cious ; but her spirits always low after a full meal, especially dinner. Has a violent pain in the loins, which often shifts from hip to hip ; the leg of the aching side being so much af- fected with stupor and numbness, lhat she drags it after her in walking. She falters in her speech at times, but this does not Qontinue long. All the muscles of the body evince convulsive motions; not simultaneously but successively: thus, her face is first violently affected, then her nose, eyelids, and whole head, which is thrown forcibly backward, and often twitched from one side to the other with exquisite pain. From this quarter, the convulsive action removes first into one arm, and then into the other; after which both legs immediately be- came convulsed with violent and incessant motions, and, in this manner, all the external parts of her body are affected by turns. She is all the time perfectly sensible, and knows what limb is going to be attacked next, by a sensation of something running into it from the part already convulsed, which she can- not describe in words: but the foretoken has always been found to be true, though the transition is surprisingly quick. She is easiest in a prone posture. Such," continues Dr. White, " has been her situation upwards of forty-eight hours, with scarce a moment's remission, by which she complains of great and universal soreness. No words can convey an adequate idea of her odd appearance : and I do not in the least wonder, that, in the times of ignorance and superstition, such diseases were as- cribed to supernatural causes and the agency of demons."* Even Dr. White himself applies to it, perhaps in imitation of Sauvages, the name of hieronosos. The predisponent cause of this disease is an irritability of * Edin. Med. Comment, vol. iv. p. 326. cl. iv.] NERVOUS FUNCTION. [ord. iii. 333 the nervous system, chiefly dependent upon debility, and par- Gen. III. ticularly a debility of the stomach and its collatitious organs. Spec. II. Most of the diseases of children are seated in this quarter; and Synclonui it is from it that chorea commonly takes its rise, and shows it- self in an early period of life; the ordinary occasional causes bility of the , . . . J. r . .... ' . , t . \ e stomach and being bad nursing, innutritions diet, accumulated teces, worms, j,scoiiati. or some other intestinal irritant. tious organs. About the age of puberty, there is another kind of general Unkindly irritation that pervades the system: and where this change menstrua- does not take place kindly, which is frequently the case in L*a\svo- weakly habits, the irritation assumes a morbid character, and nent. is exacerbated by a congestive state of the vessels lhat con- stitute its more immediate seat: and chorea takes its rise from this cause. .In effect, where the predisponent cause of an irritable state An irritaile of the nervous system is very active and predominant, a local ^"^"apre. or temporary excitement of any organ, and almost at any pe- disponent: riod of life, will give rise to the convulsive movements of cho- in which rea : and hence we find it so frequently united with an hysteric f0ac8*,a"cite_ diathesis. It has been produced by a fright,* by a wound pene- ment may trating the brain through the orbit ofthe eye,t by an improper produce the use of lead, mercury, and some other metals,f and by suppress- ^"** ed cutaneous eruptions.§ _ citements From this view of the general nature and origin of the dis- various. ease, we can be at no loss to account for the great benefit, Medical which has been derived from a steady course of brisk purging treatment. in recent cases, or those of early life: for this, while it car- First inten- ries off the casual irritation, or unloads the infarcted viscera, tion to seems at the same time to act the part of a revellent, and to £j0/A. prohibit the return of the paroxysm by a new excitement. It tation. may appear perhaps strange to those who have not thought Hence a upon the subject, that where the disease has proceeded from »lea£jrf intestinal irritation, it should also be carried off by intestinal 0°"srk8epu.g_ irritation. But the irritations are of very different kinds : and ing, it is so far from following of necessity, that, because one kind of irritation, applied to a particular organ, excites a particular effect in a remote part, another will do the same, that the con- verse is more commonly true, and that any other kind of irrita- tion, applied to the same organ, by exciting a new action, will be the most effectual way of taking off or preventing such effect. And it is upon this ground alone that we often en- deavour to cure rabies, trismus, and tetanus, by laying open the original wound to a considerable extent, or the application of some new stimulus that may answer the same purpose. * Stoll. Rat. Med. Part m. p. 405. t Geash, Phil. Trans, vol. liii. 1763. X De Haen. Rat. Med. Part in. p. 202. i Wendt, Nachricht von dem Kiankeninstitut zu Erlangen, 1783. What myriads of different diseases are referred to debility, disorder of the stomach and bowels, suppressed eruptions, discharges, &c. Yet, we remain quite in the dark, how the effect is produced ; why it should happen in one indi- vidual, and not in another; and why apparently the same alleged cause should produce in different persons consequences entirely different? The clue to an explanation of these points would convey more information, than the often repeated allusion to debility, disordered stomach, &c—Editor. 3,34 "• iv.] NEUROTICA. [ord. hi. GlEN. III. Spec II. Synclonus chorea. Medical treatment. The parti- cular purga- tive of no great im- portance : but, where worms are suspected, the oil of turpentine preferable. Purgative plan pursued by Syden- ham in con- junction with bleeding: but the last rarely called for. Similar plan useful where the cause is unkindly memtrua- tiou. Blistering the sacrum. \ Secoid in- tention to strengthen the sjstem generally. Antispas- modics. Opium. Tonics and alterants. The principle being a general one, it does not seem of much consequence what purgative is employed, provided it be suffi- ciently powerful; though, where worms are suspected, the es- sential oil of turpentine, from its being a good anthelmintic, as well as a good cathartic, will be found one of the best. It seems, indeed, to have been occasionally serviceable where worms have not been the cause, for Dr. Powell relates a case, in which he completely effected a cure in a girl of seventeen by a single dose of a fluidounce :* and hence its antispasmodic power may at times co-operate with its purgative quality as well as its vermifuge power. Sydenham, who recommended an alternation of bleeding and purging, probably derived far more advantage from the latter, than the former part of his plan: it has been found peculiarly advantageous in the hands of Dr. Hamilton: and Dr. Parr, who ascribes to Sydenham the first hint he obtained upon this sub- ject, affirms, that having pursued the purgative plan with great activity through sixty cases of the disease, which occurred to him in a course of twenty years' practice, he was successful in the whole of these cases except one ; and that in all, but this one, he found the disease yield, not only soon, but with few in- stances of a relapse. There is, therefore, no malady whatever, perhaps, that calls so peremptorily for stimulating the abdominal viscera into in- creased action; and as chorea often precedes puberty, or occurs about this period of life, we have another reason for directing an augmented stimulus to the lower regions ofthe living frame, and rousing into energy the tardy development ofthe sexual or- gans. Even blistering the sacrum at this period of life is often attended with success. Dr. Chisholmt affirms, that he found it so after a total failure of antispasmodics and the purgative plan: and, as his patients were all eighteen years of age or below, the success was probably dependent upon the principle here point- ed out. But it is necessary to attend to the state of the system gene- rally as well as locally, to take off the constitutional weakness and irritability, as well as the topical irritation, and especially where the disorder has acquired a chronic character. And hence other remedies must be had recourse to as well as purga- tives. The German physicians have strongly recommended the use of antispasmodics and sedatives, and especially musk, bella- donna, and foxglove, with a view of allaying the irregular ac- tion, and Dr. Cullen speaks as decidedly of the benefit of opium. J But the advantage derivable from these seems to be merely pal- liative ; and the stimulant tonics and alterants promise a better success. The cuckoo-flower or lady's smock, cardamine pratensis, so common to the meadows of our own country, was at one time * Transact. Medico-Chir. Soc. vol. v. p. fCtt. eases of Tropical Countries, p. 97, 8vo. 10.22. vi. p. 246. t On the Climate and Dis- X Mat. Med. Part n. chap. CL. IV.] NERVOUS FUNCTION. [ord. iii. 335 supposed to be of essential service in the cure of this and vari- Gew. III. ous other spasmodic affections. Michaelis, who is a great advo- SpEC- lo- cate for its use, employed it in the proportion of a drachm eve- Syncionus ry six hours.* But it owed of late its reputation in this country ^!°r]!a', chiefly to the recommendation of Sir George Baker, who pub- treatment. lished five cases of spasmodic diseases, two of them instances of Cardamine chorea, in which he conceived a most decided benefit was ob- pratensis tained from the use of these flowers. In the hands of later prac- strongly re- titioners, however, they have not supported their credit, and byMichaelis have consequently sunk into disuse. The leaves of the Spanish and Sir Geo. or Seville orange-tree, as a stimulant and tonic bitter, are far Baker- more entitled to attention, not only in this, but in various other Seville c i • mi A i ii. orange-tree cases ot convulsive spasm. Iney were first recommended to thefavourite De Haen by Westerhoef, who, as well as Werlhoff, employed remedy of them with considerable success: and they were afterwards in- ^ees^earho'ef troduced by Hoffman, as a valuable ingredient, into his celebrat- and Hoff- ed stomachic elixir; and for the same reason formed a part in man: the composition of Wbyt's stomachic tincture. They were giv- hig to ^. en in the form of decoction, and in that of powder; in the last icelixir. case the dose is from half a drachm to a drachm, three or four times a day. The metallic salts and oxydes have been tried in every form. Metallic At one time, the most popular of these were the flowers of zinc. ^y9dagDd Dr. Gaubius first brought them into reputation, and gave to the ' metal the name of cadmia ; and, according to his statement, they fleers of worked wonders in all clonic affections whatever, chorea, hoop- zinc. ing-cough, hysteria, convulsion, and epilepsy; on which account Cadmiaof they were afterwards employed upon a still larger and more Gaubius. popular scale by the famous empiric Luddemann, under the name of luna FiXATA.f This medicine has, however, by no means Lunafixata. been able to maintain its high character; and even Stoll, who once employed it as a favourite, at length abandoned it as good for nothing, and returned to the belladonna in its stead, which he employed in the form of an extract from the juice of the root; giving it from a sixth to a quarter of a grain every quar- ter of an hour, and, as he affirms, with very great advantage. For the information of practitioners in general, however, it Ammonial- should be noticed, that, when the stomach has reached its full j^0,0^" dose ofthe oxyde of zinc, it will still bear a full dose of ammo- mjxe(jewi,|, niated copper in conjunction with it, by which means the metal- fulldosesof lie power may be very much increased. Thus a delicate stom- °v(le of, • -i. i i i c -i-u c .l zinc, and ach will rarely bear more than two grains ot either ot these tlie st0mscli without nausea ; yet it has been found, that the same stomach still bear it. will continue at ease under a mixed powder of two grains of the former, and two and a half of the latter, at a dose.J The nitrate of silver seems to have been radically successful Silver. in various well-established cases. It has commonly been given in the guise of pills, from one to five or six grains to a dose. * Richtcr, Chirurg. Bibl. b. v. p. 120. t Disfcertatio Merlica inaug. de Zinco. Aut. Jacob. Hart. Lugd. B;it.4to. X Letter from Dr. Ocier to Dr. A. Duncan, Edin. Med. Com. in. p. 1*J1. 336 cl. iv.J NEUROTICA. [ORD. III. Gen. III. Spec. II. Synclonus chorea. Medical treatment. Iron. Arsenic. Different remedies required for different individuals. Illustrated. Musk stated to have been useful after every other medicine had failed. Leeches, shower- bath, and purgatives- fin one very interesting example recorded by Dr. Crampton,* purgatives were very extensively tried, with various other reme- dies ; but the disorder scarcely remitted under any mode of treat- ment, until the nitrate of silver was prescribed. As Dr. Elliotson has observed, iron has been recommended in chorea, among a multitude of vegetable and mineral tonics; but its powers have not been appreciated, or the possibility contem- plated of giving it with advantage when the disorder has been accompanied with head-ach, vertigo, and a degree of paralysis. The facts which this physician has published in favour of the efficacy of the subcarbonate of iron, given every six hours in doses of two scruples and sometimes even of half an ounce, are particularly calculated to recommend it strongly to the notice of medical practitioners as a remedy highly entitled to trial in cho- rea. When the bowels were confined, Dr. Elliotson sometimes gave his patients scammony, calomel, and .other purgatives; but, in some ofthe instances, they were rarely used.?] Another remedy entitled to credit in the present day, is arse- nic ; for it is difficult to resist the evidence from various quar- ters in which it seems not only to have produced benefit, but to have established a perfect cure. [Mr. Martin prescribed it in one case with success; and Mr. Salter, of Pool, found it answer in an instance in which the nitrate of silver, and many other medicines, had failed. It has also been given with advantage by Dr. G. Gregory .J] It is commonly given in the form of the solution ofthe London College, in doses of ten drops to a youth of twelve or fourteen years of age three times a day, increasing the dose as there may be occasion. In this disease, however, as in various others, it will often be found, and the remark is well worth attending to, that different remedies are required for different individuals, even where the cause is obviously the same ; and that what produces no benefit in one case, is highly advantageous in another. Camphor in large doses has succeeded where turpentine or the nitrate of silver has completely failed : and a brisk purgative plan has sometimes an- swered where all the preceding have proved of no use what- ever. It is hence we are to account for Dr. Cullen's peculiar attachment to the bark, which he tells us he has found " remark- ably useful," and prefers to any of the preparations of cqpper, zinc, or iron :§ while Dr. Powell informs us, that in a lady of seventy years of age, of a very irritable habit, attacked for the first time with this complaint in severe paroxysms at night, he found musk, in doses of ten grains every six hours, succeed and produce a cure, when purging, blistering, the ammoniated spirit of amber, nitrate of silver, ammoniated tincture of valerian, cas- tor, muriated tincture of iron, bark, and opium had all failed.|| [In a severe example successfully treated by Dr. Crampton,1T * Trans, ofthe King's and Queen's College of Physicians, vol. iv. p. 111. t See Med. Chir. Trans, vol. xiii. p. 232, et seq. X See Med. Chir. Trans, vol. iv. p. 45, vol. x. p. 218, and vol. ii. p. 299. i Mat. Med. Part ii. Ch. H. p. 112. II Medic. Trans, vol. v. p. 192. Also Maton's Case cured by Musk, p. 188, * Trans, of the King's and Queen's College of Physicians, vol. iv. p. 120. CL. IV.] NERVOUS FUNCTION. [ord hi. 337 where head-ach was a prominent symptom, leeches were re- gen. iii. peatedly applied to the temples, neck, and along the spine, in Spec.1I. succession ; the head shaved ; the shower-bath employed; and ^clonus the action of the bowels regulated. In another case treated by j^JJj^j Mr. Hunter, of Glasgow, a cure was accomplished by rubbing |reatment- antlmonial ointment into the scalp, and along the course of the Antimonial vertebral column.* In an instance recorded by Mr. Stuart, the ointment to patient was cured by the prussic or hydrocyanic acid, preceded ^^JP by purgatives.]! prus«ic add. Voltaism or electricity was warmly recommended by De VoUaiem Haen. Like the preceding remedies, either appears to have andelec. been serviceable in some cases; but they are far outbalanced tricity. by the instances in which they have failed. It is very possible, Gymnastic that, in some instances, a long and punctual discipline ofthe af- ^™ee(,,n fected limbs, where the disease is not very severe, to regular moveraents. and measured movements, may progressively recall them to their wonted order and firmness, as a like discipline of the vo- cal organs in stammering has not unfrequently been found to restore them to a regularity of utterance : and, with this view, as lhat of the gymnastic exercise of dancing, whose movements are all dancing measured with the greatest nicety, and which was so much de- ™n*;P* pended upon in former times, and asserted to have been so sue- boundg- cessful, may be well worthy of attention in the present day, provided it be kept within due bounds, and be not carried to the ridiculous extreme we had occasion to notice a few pages above. Species III. Synclonus Ballismus—Shaking Palsy. Permanent agitation of the head or limbs without voluntary excite- ment ; body bent forward, with a propensity to run and fall head- long ; usually appearing after maturity. This is the scelotyrbe festinans of Professor De Sauvages, Synonyms. and the shaking palsy of Mr. Parkinson.}: The genus Tantaris- mus of Baligvi seems to hold an equal point between ballismus and CHOREA,°and the species usually arranged under it may be resolved into the one or the other, and are done so under the present arrangement. The term Ballismus (pxXX«T[i*) is not used in a medical sense Origin of by the Greek writers, but occurs in Athenajus, and various oth- J^P601 IC er authors, in the literal sense of tripudiatio, or "tripping, ca- pering, curvetting on the toes ;" from 0*xx&, " tripudio, pedi- bus plaudo;" and is hence well designed to express the charac- teristic feature ofthe patient's being thrown involuntarily, when he attempts to walk, "on the toes and fore-part of his feet," to employ the language of Mr. Parkinson, " and impelled, unwil- lingly, to adopt a running pace:'' or, as Dr. Cullen, who has ggj^ * Edin. Med. Journ. No. 83, p. 261. t Op. cit. No. 93, p. 271. jJjJpSj X Essay on the Shaking Palsy. VOL. IV. 43 33a c^- iv0 NEUROTICA. [ord. III. Gen. III. Spec. III. Synclonus ballismus. Distinctive signs. Disease not properly named a palsy. Description from Park- inson. Commence- ment. Progress. Advanced stage. indiscriminately blended this species with the preceding, ex- presses it, to "various fits of leaping and running."* Ballismus, however, though not found in the writings of the Greek physician^, has been long established as a technical term in the medical nomenclature of later times, in which it has been used, with little discrimination, to import almost all or any ot the species that belong to the present genus. Sauvages observes, that while chorea, or seelotyrbe Sancti Viti, attacks the young, ballismus, or seelotyrbe festinans, attacks those in advancing life ; and the remark is founded on a just distinc- tion of the characters of the two diseases; though there are other features also of as striking a peculiarity, and which are here introduced into their respective definitions. Shaking pal- sy, as it is called by Mr. Parkinson, who has adopted the collo- quial name, is by no means a correct designation ; for though in the disease before us there is a weakness of muscular fibre, and a diminution of voluntary power in the parts affected, there is none of that diminution of sensation, by which palsy is generally characterized. Mr. Parkinson's description ofthe disease, how- ever, is the best we have hitherto had, and is as follows : " So imperceptible is the approach of this malady, that the precise period of its commencement is seldom recollected by the patient. A slight sense of weakness with a proneness to trembling, sometimes in the head, but most commonly in the hands or arms, are the first symptoms noticed. These affections gradually increase, and at the period, perhaps, of twelve months from their first being observed, the patient, particularly while walking, bends himself forward. Soon after this, his legs suffer similar "agitations and loss of power with the hands and arms. " As the disease advances, the limbs become less and less ca- pable of executing the dictates of the will, while the unhappy sufferer seldom experiences even a few minutes' suspension of the tremulous agitation: and should it be stopped in one limb by a sudden change of posture, it soon makes its appearance in another. Walking, as it diverts his attention from unpleasant reflections, is a mode of exercise, to which the patient is in gen- eral very partial. Of this temporary mitigation of suffering, however, he is now deprived. When he attempts to advance he is thrown on the toes and fore-part of his feet, and impelled unwillingly to adopt a running pace, in danger of falling on his face at every step. In the more advanced stage ofthe disease, the tremulous motions ofthe limbs occur during sleep, and aug- ment in violence till they awaken the patient in much agitation and alarm. The power of conveying the food to the mouth is impeded, so that he must submit to be fed by others. The torpid bowels require stimulating medicines to excite them into action. Mechanical aid is often necessary to remove the feces from the rectum. The trunk is permanently bowed ; muscular power diminished; mastication and deglutition difficult; and the saliva constantly dribbles from the mouth. The agitation now * Pract. of Phys. Part ii. Book m. Ch. in. Mccd.nr. cl. iv.] NERVOUS FUNCTION. [ord. hi. 339 becomes more vehement and constant; and when exhausted na- Gen. III. ture seizes a small portion of sleep, its violence is such as to Spec III. shake the whole room. The chin is almost immovably bent Synclonus ,. . 1 ,. . , I .1 ballismus. down upon the sternum ; the power ot articulation is lost; the urine and feces are discharged involuntarily, and coma with slight delirium closes the scene." The remote cause is involved in some obscurity. Long ex- Remote posure to damp vapour, by lying from night to night on the bare causes. earth, in a close unventilated prison, seems to have produced it; and possibly other causes of chronic rheumatism : and hence it has frequently supervened on chronic rheumatism itself. Long indulgence in spirituous potation has often given rise to it; and probably any thing that debilitates the nervous power. And on this account miners, and others exposed to the daily exhalation of metallic vapours, and especially those of mercury, are frequent and severe sufferers ; of which Hornung has ad- duced many interesting examples from the quarrymen in Car- niola.* It has also followed worms in the intestines ;| and, in this case, has sometimes assumed a periodical type.]; The part of the nervous organ more immediately affected Seat of the has, also, afforded some ground for controversy. Bonet ascribes fr'^edon' it to a diseased state of some portion of the cerebrum, and has Ce,rebmm> given examples of its being found, on dissection, to contain, in as regarded various quarters, proofs of serum, sanies, and other morbid se- by Bonet. cretions.§ But the misfortune is here, as we have already ob- served in similar appearances after mania, that it is impossible for us to determine whether these diseased fluids give rise to the disease, or the disease to them. And hence Mr. Parkinson JJrPtvJ*Jhe seems to pay no attention to them, at least as a cause, and fixes Ppinal raar. the seat ofthe affection in the cervical part of the spinal mar- row. as re- row, from which he supposes it to shoot up by degrees to the ^"jjjj^j medulla oblongata. We have already shown sufficiently in the Q|iestion ' Physiological Proem to the present Class, that the nervous examined. fibres which ramify over the extremities, whether sensific or motific, originate from the chain ofthe spinal marrow ; and we have also shown, in discussing the diseases of trismus, tetanus, and lyssa, how acutely one extremity of a chain of any kind, and particularly of a continuous fibrous chain, sympathizes with another: and there can be no difficulty, therefore, in conceiv- ing, that wherever the cutaneous ends ofthe nerves of motion are torpified, or otherwise affected by any of the causes just ad- verted to, the vertebral column must itself very seriously par- ;o™ral ticipare in the mischief, and consequently the upper or cervical mu>t par. part of this column ; and that from this point the disease must ticipate in ramify to the brain before the general functions of the system the disease. become affected, as in its latter stages. The remedial process is not very plainly indicated. Vesica- Remedial tories, and other stimulants applied to the neck or even the dor- F0^- sal vertebra?, have appeared useful. A seton or caustic, and tories> * Cista, p. 280. t Commerc. Liter. Nor. 1743, p. b'j. J Act. Nat. Cur. vol. ii. Obs. 143. i Sepul. Lib. i. Sect. xiv. Obs. 7. 9. 340 cl. iv.] NEUROTICA. [ord. III. Gen. III. Spec. III. Synclomis ballismus. Actual cautery. Active purgatives. Subcarbo- nate of iron. Solution of arsenic. Musk. Local stim- ulants. Voltaic trough. Bath waters. especially the actual cautery, as practised so generally in France, might possibly be of more avail applied to different parts ofthe spine. Beyond this an active purgative system, as strongly re- commended by' Riedlin, has certainly been found efficacious ;* and the subcarbonate of iron, the prussic acid, and solution of arsenic, bid as fair for a favourable result here as in the pre- ceding species. Stark tried musk, and carried it to very large doses frequently repeated every day ;t but it does not seem to have produced any decisive success. Friction of the affected extremities resolutely persevered in by a skilful rubber, with stimulant embrocations of camphor or ammonia, should also be tried in an early stage of the disease, and be alternated with the use of the voltaic trough. Here, too, we may expect to derive advantage from a free use of dia- phoretic and alterant apozems, as the decoction of the woods, and especially where the disease is suspected to be of a rheuma- tic origin :—to which may be added a regular course of bathing in the Bath springs. Origin of speciGc name, and cause of the disease as fixed by Linneus. Other sources urged by other writers. Species IV. Synclonus Raphania.—Raphania. Spastic contraction of the joints; with trembling and periodical pains. Of this species we know little or nothing in our own coun- try. It was first described by Linneus, who called it Raphania, from his supposing it to be produced by eating the seeds of the raphania raphanistrum, a wild radish or sharlock that grows in- digenously in our native corn-fields, as well as in the corn-fields of most parts of Europe. By other writers, as Hermann and Camerarius, it has been ascribed to the use of darnel or ryej infested with the spur, or ergot, or some other parasitic plant, which, as we have already observed, is a frequent cause of other very severe complaints, as mildew mortification (gangrcena us- talaginea)§ and erythematous plague (pestis erythematica).\\ All these diseases, however, are so distinct from each other, that though there can be little doubt of their being severally pro- duced by some poisonous material contained in the patient's food, the poison must be of different kinds, and we do not seem to be acquainted with the cause of this difference ; and hence the question has given rise to much controversy, and been dis- cussed with some warmth on the continent; for, while the great- er number of writers refer the disease to the raphania, or spur- red rye (secale cornvtum), many deny that it is produced by either of these,1F and Lentin ascribes it to the honey-dew of various plants,** concerning which we shall have to speak in the fifth volume, under paruria mellita. That it is a vegetable * Lin. Med. 4695, p. 101. t Klinische und Anatomische Bemerkungen. X Abhandlung von der Kriebelkrankheit, &c. Cassell, 1775-8. De Lall. Lolio. temulento. Tubing. 1710. i Vol. iii. in loc. || Id. in )oc. IT Wichmann, Beytrag. zur Geschichte der Kriebelkrankheit. Leips. 1771-8. ** Beobachtungen einiger Krankheiten, &c. cl. iv.] NERVOUS FUNCTION. [ord. hi. 34] poison, however, seems to be admitted by common consent, Gen. III. and it is possible, that the poison is not confined to a single Spec IV. plant. Synclonus That many poisonous plants have a direct tendency to affect ™p '*"'*■, the nervous system and excite entastic or clonic spasm, or a mixture of the two, according to the peculiarity of the poison itself, or of the habit into which it is introduced, we have fre- quently had occasion to notice already, and particularly under the head of eruptive surfeit (colica cibaria effiorescens).* This is particularly the case with several of the deleterious agarics or funguses, some of which seem to operate chiefly on the sen- sific nerves, and produce a general stupor; and others on the motory, and produce palpitations, cramps, or convulsions over the whole system.! It is very probable, therefore, that the cause, ordinarily assigned for the present species of disease, is the true one. There is an excellent paper upon this subject in the Amoeni- Rothman's tates Academicae,"]: furnished by Dr. Rothman, a pupil of Linne- ^j^jjj" us, from which the disease seems to be not unfrequently epide- 't","e3 Aca. mical, and always to commence in the autumn. It is found, demic*. however, only among the lower orders of people, and, in the epidemic referred to, is sufficiently traced to impure admixtures with their grain, and the employment of this vitiated grain in too new a state. Dr. Rothman delineates the disease from ac- tual observation, and does not believe it to be a new malady, Supposed as generally supposed, but thinks he has traced it in the writ- to be of ings of various authors from the year 1596 to 1727; which early date. would establish, moreover, that it has been common to other parts of Europe as well as to Sweden. And in confirmation of this we may observe, that Dr. Mercard§ describes a disease very much resembling raphania that appeared at Stade in the winters of 1771, 1772, which was evidently epidemic, and ac- companied with symptoms of fatuity, or that narcotic effect which many deleterious plants are sure to produce. Dr. Cullen, who has generalized far too much his descrip- Regarded tion of chorea, in his Practice of Physic, seems to have em- b? Cullen bodied this species, as well as the preceding, in the common 0f chorea?8 delineation, and hence, when he tells us that " there have been instances of this disease (chorea) appearing as an epidemic in a certain corner of the country,''!! there can be little doubt, that he alludes to the species before us originating from the cause now assigned, although, without some such interpretation as the present, the passage is not very intelligible. The disease commences with cold chills and lassitude, pain Origin and in the head, and anxiety about the praecordia. These symptoms f^gd'J1,e,aj[# are followed by spasmodic twitchings, and afterwards rigid con- tractions of the limbs or joints, with excruciating pains, often accompanied with fever, coma, or delirium, sense of suffoca- tion, and a difficulty of articulating distinctly. It continues from Close- * Vol. i. p. 211. t See Hcberden, Med. Trans, ii. 218. X Tom- vi' art. cxxin. 1763. } Medicinische, Versiiche. Zweyter Theile 8vo. Leipzig. || Part n. Book in. Chap. in. mcccliii. 342 cl. iv.] NEUROTICA. [ord. hi. Synclonus raphania. Remedial treatment, Gen. III. eleven days to three or four weeks ; and those who die gene- Spec. IV. raUy sink under a diarrhoea or a paroxysm of convulsions. The warm antispasmodics, as valerian, castor, and camphor, appear to have been employed with decisive success. An emetic however, given at the onset of the symptoms, as recom- mended by Henman, would probably cut short the course ofthe disease, and mitigate its violence. This writer advises also blistering or bathing with Dippell's Animal Oil* Camphorated vinegar, as employed by other practitioners, would probably be found a more useful embrocation.! Towards the close of the disease, purple exanthems or ve- sications are said to be sometimes thrown out, which approxi- mate it to mildew-mortification and the erythematic pestis, both which, as we have already observed, have been traced to a similar cause. Origin of generic name. How re- garded by Sauvages. Said to have been known to the Greeks, but not under this name. Term clear- ly of orien- tal origin : Probably the elymon ofthe French brebis. Disease chiefly found on the Malabar coast, in Ceylon, and to the north of Madras. Causes. Species V. Synclonus Beriberia.—Beribery. Barbiers. Spasmodic rigidity of the lower limbs impeding locomotion; often shooting to the chest, and obstructing the respiration and the voice; trembling and painful stupor of the extremities ; general adema- tous intumescence. Bontius seems first to have introduced the term beriberi or beriberia into.medical nomenclature, and tells us it is of orien- tal origin ;J and Sauvages has hence copied it into his list of "nomina barbara, seu nee Grseca, nee Latina." Mangetus af- firms that the disease was known to Erasistratus, but certainly not under this name. Eustathius, however, has &g£eg«, but in the sense of " concha or ostreum," " conch or shell,"—and tells us that it is a term of Indian origin. He might have said, with more propriety, of oriental origin, for it is common both in its primary and duplicate form, -q or tf-Q,1212 or D*H1"Q to the Hebrew, Chaldee, Syriac, and Arabic, in which last it is (berabir), and in all of them is a nomadic term, importing til- lage and its production which is grain, or pasturage, and its production which is sheep, or other cattle ; and hence, proba- bly, the origin of brebis or sheep in the French tongue. The term is said to be applied to this disease in India from the pa- tient's exhibiting, in walking, the weak and tottering step of a sheep that has been over-driven. This disease, though common to various parts of India, is chiefly met with on the Malabar coast and in Ceylon, [and in that tract of country reaching from Madras as far north as Ganjam.§] It seems to be produced by sudden transitions of the atmosphere from dry to damp, and from sultry calms to chilling breezes. In these countries, it attacks both natives * Abhandl. von der Kriebelkrankheit. t Nachricht. von der Kiiebel- krankheit. X Ue Medicina Indorum, Cap. I. i Hamilton in Edin. Med. Chir. Trans, vol. ii. p. 13. cl. iv.] NERVOUS FUNCTION. [ord. hi. 343 and strangers, but particularly the latter during the rainy season, Gen. III. which commences in November and terminates in March; Spec. V. through a great part of which, also, the land winds blow from Synclonus the neighbouring mountains every morning about sun-rise with great coolness; and hence, those who sleep abroad, or without sufficient shelter, are equally exposed to the influence of a penetrating chill and damp. [The instances are comparatively rare, in which it has occurred at a distance from the sea ex- ceeding sixty or seventy miles.] Fresh troops, partly from their being new to the climate, Freshtroops but chiefly from their want of a sufficient degree of caution, P£enc'Pdally very frequently suffer severely from this complaint so long as ' the rainy season continues. Thus we learn from Mr. Christie, fied# that the 72nd regiment was severely attacked with it in the au- tumn of 1797, not many months after its arrival, and continued to suffer from it till the ensuing spring; and that the 80th re- giment, which relieved the 72nd in March, 1797, was equally attacked with it in the ensuing November.* It is however, in Predispo- all such cases, most frequently to be found amongst those who nenU- have previously weakened their constitutions by sedentary habits, or a life of debauchery; and particularly where too free an indulgence in spirits has co-operated with sedentary habits, as among the tailors and shoemakers of a battalion ; who, in order to give them time to work at their respective trades, are often excused from the duties of the field, and, by their double earnings, are enabled to procure a larger quantity of spirits than other men. And we may hence, in some degree, account for Mr. Christie's remark, that, during his stay at Ceylon, he never met with an instance of this complaint in a woman, an officer, or a boy under twenty. The disease commences with a lassitude and painful numb- History and ness of the whole body, the pain sometimes resembling that of ^^ease. formication. The legs and thigs become stiff, the knees are spasmodically retracted, so that the legs are straightened with great difficulty, and instantly relapse into the retracted state, whence the patient is apt to fall if he attempt to walk. In some cases, indeed, the motory and sensific power, instead of being distributed to the muscles of locomotion irregularly, is not distributed at all, and the limbs become paralytic. And even where the spasmodic action exists, it often travels or ex- tends to other parts of the body, and particularly to the chest and the larynx, so that speaking and respiration are conducted with great difficulty. At the same time, the whole of the absorbent system exhi- bits equal proofs of torpitude, the legs first, and afterwards the entire surface ofthe body becomes bloated and cedematous, and all the cavities, particularly those ofthe chest, are progressive- ly loaded with fluid: and hence towards the close of the dis- * "So far as I know (says Mr. Hamilton), there is no instance on record of an individual being attacked with the disease immediately upon his ar- rival in India."—Edin. Med. Chir. Trans, vol. ii. p. 21.—Ed. 344 cl. iv.] NEUROTICA. [ord. hi. Gen. III. ease, where it terminates fatally, the dyspnoea is extreme, and Spec. V. accompanied with an intolerable restlessness and anxiety, and Synclonus constant vomiting ; the muscles are convulsed generally ; while beriberia. the pu|se grarjually sinks, the countenance becomes livid, and the extremities cold. Sometimes Such is the course of the disease as it shows itself at Cey- peculiarly^ jon? w'uere it seems to rage more severely than on the Malabar rapid?31 coast, and where we are told by Mr. Christie, whose account is confirmed by Mr. Colhoun,* that its progress is so rapid, that the patient is often carried off in six, twelve, twenty-four, or thirty-six hours from its onset, though it ordinarily runs on for several weeks. Original Since the first edition of the present work, various impor- communi- tant communiCations have been made to the Army Medical UieTrmy Board upon the subject before us. These, by the kindness of Medical rny eminent friend the Director-General, I have been enabled Board, to examine, and they concur in supporting the general charac- confirming _. , :. , •> . , ' r ° , ° . . «;„„, the preced- ter of the disorder as given above ; as they do also in affirm- ing account, ing, that neither women, officers, nor persons under twenty years of age become the subjects of beribery ; evidently be- cause such individuals are rarely called upon to expose them- selves at night, or to sleep in the open air. Beribery From the complicated nature of the disease, however, and sometimes foe variety of organs that are linked in the general chain or be^modi.0 morbid action, suggestions have often occurred, whether beri- fication of bery be not rather a modification of some other malady, than some other an idiopathic affection ; and especially whether it be not a pe- especia'lly of culiar form of Anasarca deflected from its common course by anasarca. accidental circumstances. The last is more especially the opi- Collier's nion of Mr. Collier, a staff-surgeon of considerable talents and opinion: authority ; and to the same opinion I find Dr. Dwyer inclining, Dwyer's: physician to the forces at Kandy in Ceylon. Yet, after having, in his manuscript report, which is a very valuable document, called it incidentally by the name of acute anasarca, he tells us that, from the great diversity of its symptoms, many cases have been referred to apoplexy, carditis, aneurism, gastritis, which were purely examples of beribery. And he then proceeds as fol- lows : " although allied in many of the symptoms to dropsical affections it is to be considered distinct both in symptoms and treatment."! And to the same effect, a very able inspector of Farrell's. hospitals in the same quarter, Dr. Farrell, who observes as fol- lows: "I cannot help thinking still, notwithstanding the weight of his (Mr. Collier's) authority, that the affection, commonly called beri-beri, is a disease of exhaustion and debility, occur- ring chiefly in persons of intemperate habits, and labouring un- der other maladies." In effect, it is not only a disease of ex- haustion and debility, but of these properties peculiarly applied to the nervous system ; the dropsical and apoplectic symptoms * Essay on the Diseases incident to Indian Seamen or Lascars on long Voyages, by W. Hunter, A.M. &c. + Lord Valentia's Travels, vol. i. p. 318. CL. IV.] NERVOUS FUNCTION. [ORD. III. 345 only taking place secondarily, and as a result of the general Gen. III. weakness. " The more prominent symptoms," observes Dr. SpEc. V. Dwyer, " were numbness of the extremities, muscular power j^"^""™ greatly impaired, walking attended with a considerable degree D™cr7p'*joa of unsteadiness, pain, tottering and weakness of the joints; by Dwyer. such instability of gait as resembles a person walking on his heels ; sometimes paralysis. In the latter stages of the disease, when the thorax becomes affected, increased uneasiness of the epigastrium and vomiting succeed ; dyspnoea and all the symp- toms of hydrothorax." At times the spasmodic action spreads, even from the first, to Spasmodic other organs than the limbs, and produces a very striking effect. JJJJJ^Jy A sergeant ofthe 45th regiment, of sober habits, who seems to exleD,iVe. have nearly recovered from two previous attacks at Kandy strikingly about a year before, and had left the hospital, was suddenly illustrated. seized, April 1, 1822, with "an extreme difficulty of breathing, inability to walk or speak much. The muscles of the fore- head, face, and nose, were in motion at the exertion made to speak or breathe. The corrugations of the latter gave a sharp- ness of countenance very peculiar, but indicative of great dis- tress and anxiety. The countenance soon became livid; the pulsations of the heart were loud and fluttering ; its strokes against the side could not be distinctly counted. He was bled two pounds without much relief. The appearance of this poor man was very affecting. The blood drawn was sizy ; and, upon re-opening a vein from a large orifice, he again bled freely ; but becoming exhausted, it was thought prudent to stop it again. His legs were much swelled, and pitted on pressure. They were covered with small livid spots, as well as other parts of his body, like flea-bites, but much larger. He died in- half an hour afterwards. The thighs and abdomen were but little swell- ed in proportion to his legs, but evidently larger than natural. His arms were emaciated,-and no part (edematous. He appear- ed of stout make." The intumescence of the legs seems to have been a result of General debility from the two prior attacks: but it was nevertheless ex- lhe case pected, that most of the cavities of the body would have given proof of an hydropic affection ; and I have selected this case as one ofthe strongest in support of such an opinion; for, in gene- ral, though water is traced, sometimes in one cavity and some- times in another, yet there is seldom much accumulation, and still more seldom such as to produce oppression. Dr. Dwyer took a minute of sixteen cases, and his remark upon the whole of'these is, " water is usually found in some of the cavities, but the organs vary:" and such an observation is alone sufficient to take beribery out of the list of proper dropsies, whatever other place we may assign to it. An early post-obit examination, however, of the case before PosU**t us showed as follows: " About an ounce of serous straw-co- ^a loured fluid escaped in various ways, on opening the dura ma- ter. Filling up the gyri on the surface of the brain, we ob- served a, gelatinous transparent matter of some tenacity and vol. iv. 44 346 cl.iv.] NEUROTICA. [ord. hi. Gen. III. Spec V. Synclonus beriberia. consistence : it looked like a coating of isinglass. In the ventri- cles there was but very little fluid ; in no other part of the crani- um were indications of pre-existing disease observed." In the thorax there were various adhesions, especially within the pe- ricardium; on opening which, seven ounces of a straw-colour- ed serum were found in it, yet warm. No fluid in the thoracic cavity.—In the abdomen there were few morbid appearances, except in regard to the spleen, which was as large as an ordi- nary sized liver, and weighed three pounds ten ounces. The liver of its usual size, but had a mottled appearance. Only ele- ven ounces of serous or dropsical fluid were found in this cavity* The curative intention is to re-excite the absorbent system and the affected branches of the nerves to a discharge of their proper functions by a process of diaphoretics and stimulants. Squill pills and calomel are chiefly depended on for the latter, and James's powder for the former ; though the compound powder of ipecacuan seems better calculated for the purpose, as containing a sedative admirably adapted for allaying nervous irregularities. On the Malabar coast, it is no uncommon practice to excite perspiration in this complaint by burying the patient in a sand- bath : for which purpose a hole is dug in the sandy soil, into which he is plunged as deep as to his neck, and confined there as long as he can bear the heat of the sand that surrounds him. The strength, throughout the whole, is supported by cordials, and in many instances even by ardent spirits diluted for the pur- pose ; punch is a common drink on this occasion, and the re- freshing and sedative power of the acid entitles it to a prefer- ence. To remove the numbness and pricking or formicative pain from the limbs, friction and stimulant liniments are applied locally, and not unfrequently the legs are plunged into a pedi- luvium. And where the disease assumes an alarming appear- ance, and the spasmodic symptoms are very violent, recourse is had to a hot bath, and the strongest cordials and antispasmodics, as brandy, sulphuric ether, or its aromatic spirit, and laudanum, which it is sometimes found necessary to continue for several weeks. * The morbid appearances, observed by Mr. Hamilton, materially differed from those above described. Upwards of an ounce of serum was effused between the pia mater and tunica arachnoidea ; and, in two or three places, there were dark red-coloured patches, one of which was exceedingly vascular, and extended into the substance of the brain from a quarter to half an inch. There was likewise found considerable effusion in all the ventricles except the fourth. In the base of the cranium, four ounces of fluid tinged with blood were contained. The lungs were much loaded will) dark-coloured blood, and in both cavities ofthe thorax there was extensive effusion. The heart was healthy, nor did the pericardium contain more fluid than usual. Both its external and internal surface, however, exhibited evident marks of inflammation. The diaphragm was also much in- flamed, particularly its right portion. The stomach was healthy. The liver was larger than natural, and gorged with blood, as were also the mesentery and pancreas. The intestines presented nothing remarkable. Traces of congestion were remarked in the spinal marrow. From three to four pounds of fluid were found in ihe cavity of the abdomen, and the cellular texture, nearly all over the body, was anasarcou«. (Edin. Med. Chir. Trans, vol. ii. p. 18.) Mr. Hamilton notices, that the post morttm appearances, described by Mr. Ridley, (Dublin Hospital Reports, vol. ii.) mark the existence, not only of internal, congestion, but of visceral inflammation, in beribery still more decidedly.—Editor. Curative intention. Diaphore- tics and stimulants. Treatment. Sandbalh. Spirituous cordials. Local ap- plications. cl. iv.] NERVOUS FUNCTION. [ord. iii. 347 In convalescence, the patients should be removed, as soon as Gekt. III. may be, to a drier and more equable temperature, and be put Spec. V. upon the ordinary plan of tonics, regular exercise, and nutritive Synclonus diet. In milder cases they generally recover with the shifting ber,beria- ofthe monsoon, which carries off the remote cause of the dis- Treatment ease, and brings a change of temperature home to them. tecent [The evident congestion, noticed by Mr. Hamilton in his dis- regimen. sections, made him resolve to try the effects of blood-letting. Bleeding This was practised freely and Repeatedly, after which twenty a»:1 "ier" grains of calomel and thirty drops of laudanum were exhibited, cury* and the patient's body fumigated with the hydrargyri oxydum cinereum. In an hour and ten minutes, the calomel and lauda- num were repeated. In three hours more, the calomel was given again with six grains of gamboge, and the body was ex- posed again to the fumigation, " which, together with the scru- ple doses of calomel, and friction over the surface ofthe abdo- men-and thighs with the unguentum hydrargyri fortius and li- quor ammonia?, was repeated every three or four hours, until ptyalism was fully established. Every unfavourable symptom then speedily disappeared. Three other cases, treated in the same way, proved equally successful.*] Beribery has not been hitherto described as existing in any Beribery other part ofthe world, and if it should be found it will proba- not describ- bly exhibit a modification of some ofthe symptoms according to f0" as "lst" the quarter in which it appears. I am induced to make this re- where: mark from observing an account! of a very singular spasmodic but a case disease by Dr. Bostock, which evidently belongs to the present of-fae-»v hai genus, and seems to be a variety of the present species assum- occurred in ing a chronic form. The patient, who was in the middle of our own life, was first attacked with achings in the lower limb on one 5°"",!^ side, accompanied with a difficulty and irregularity of motion, by Bostock. which soon spread to the other side, and then gradually to the throat, so as to hinder deglutition, except with great pain and severe exertion : the larynx next became affected so as to pre- vent speech, and afterwards the back of the neck, the muscles affected being the voluntary alone. From the spastic rigidity of the limbs, they were both bent and straightened with a like difficulty. The pricking pain like that of pins, or of a limb awaking from stupor, common to the extremities in beribery, was present here also, though apparently without stupor or oedematous swellings. Yet the intellectual powers were at length affected and weakened; the failure of understanding gradually increasing, but principally showing itself in parox- ysms, during one of which the patient died. No cause of the disease could be traced before death, or by dissection after- wards. * Hamilton in Edin. Med. Chir. Trans, vol. ii. p. 23. t Med. Chir. Trans, vol. ix. art. 1. p. 1. 348 ex.. iv.] NEUROTICA. [ord. IV. CLASS IV. NEUROTICA. Present order as contrasted with the preceding divisions. Origin of ordinal term. order iv.—Sgstatfca. DISEASES AFFECTING SEVERAL OR ALL THE SENSORIAL POWERS SIMULTANEOUSLY. Irritation or inertness ofthe mind extending to the corporeal senses or the muscles ; or of the corporeal senses or the muscles extending to the mind. The sensorial powers are those which are dependent on the sensorium or brain as their instrument or origin; and are three in number, the intellectual, the sensific, and the motory. Thus far we have only contemplated these as they are affected siDgly, or, where more are affected than one, as influencing the rest only secondarily or sympathetically. The diseases of the pre- sent order are of a more complicated origin and nature, and af- fect several or all the sensorial powers conjointly from the first. The order is hence denominated systatica, a Greek compound from ffvwrryiftt, " congredior, consocio." Syncoptica might have been employed, and upon as large a scale, so as to denote in- creased as well as diminished action, itnpellentia as well as con- cidentia ; but this term is usually limited to express maladies of the latter kind, and, consequently, might have produced con- fusion, since the present order, like all the preceding, includes diseases evincing different and even opposite states of action. The genera appertaining to it are the following: I. AGRYPNIA. SLEEPLESSNESS. RESTLESSNESS. ANTIPATHY. HEAD-ACH. DIZZINESS. SYNCOPE. COMATOSE-SPASM. TORPOR. II. DYSPHORIA. 111. ANTIPATHIA. IV. CEPHALjEA. V. DINUS. VI. SYNCOPE. VII. SYSPASIA. VIII. CARUS. Origin of generic term not noticed by Cullen. but generally by his pre- decessors. GENUS I. AGRYPNIA.—SLEEPLESSNESS. Difficulty or inability of obtaining sleep. Agrypnia (xy£V7nix) is a Greek term significant of the English sleeplessness, by which it is here rendered. The affection is not introduced into Dr. Cullen's nosological arrangement, and has consequently been omitted by most nosological writers since his time ; but it occurs in the greater number of those who pre- ceded him; and its claim to be considered as an idiopathic af- fection is as clear as that of most diseases concerning which there is no dispute. CL. IV.] NERVOUS FUNCTION. [ORD. IV. 349 The two following species are embraced by this genus: 1. AGRYPNIA EXCITATA. IRRITATIVE WAKEFULNESS. 2.---------PERTES.EA. CHRONIC WAKEFULNESS. Species I. Agrypnia Excitata.—Irritative Wakefulness. Sleep retarded by mental excitement: listlessness to surrounding objects. On the physiology of sleep and dreaming, we briefly touched Gen. I. under the genus paroniria or sleep-disturbance in the first or- SpEC' *• der of the present class, but the subject is of great extent and complexity, and cannot be followed up into any detailed explana- tion in a work on pathology. At present, therefore, I can only Natural observe, that natural sleep is a natural torpitude of the volun- sleep what, tary organs of the animal frame produced by a general ex- produced. haustion of sensorial power in consequence of an exposure to the common stimulants or exertions of the day. And hence, if such exhaustion do not take place, natural sleep cannot possi- bly ensue, though morbid sleep undoubtedly may as produced by other causes. Now it often happens that, from an energetic bent of the How mind to a particular subject, the sensorial power continues to prevented. be produced, not only in a more than usual quantity, but for a more than usual term of time; and, in consequence of this ad- ditional supply, there is no exhaustion at the ordinary period, and therefore no sleep. Severe grief is often a stimulus of this kind ; during which a morbid redundancy of sensorial power continues, followed by a morbid excitement of the system ge- nerally from day to day, and from night to night, till the frame is worn out by the protracted watchfulness or sensorial ere- thism. And it is astonishing to witness, in various instances, how long the frame will support itself before it is worn out, or the irritation that prevents sleep sufficiently subsides for its re- singular turn, and particularly where the mind is labouring under the examples influence of the depressing passions, or of depressing pain. A of.Protract* hemicrania has kept a person awake for three months,* and a lessness," melancholy or gloom on the spirits, for fourteen months. Overwhelming joy has often a similar effect, though seldom in an equal degree, or for so long a period of time. The mind may also be intensely directed to some peculiar object of study, and the energy ofthe will becomes in this case a like stimulus to the production of a fresh or protracted supply of sensorial * Bartholin. Hist. Anat. Cent. i. Hist. 64. Schenck, Lib. I. Obs. 2.56. The editor once attended a young lady, whose complaints consisted in violent palpitations of the heart, cough, and difficulty of breathing, and who was kept almost constantly awake by her distressing sensations for nearly three months. As sitting up, or the least exertion, aggravated the palpitations, she continually kept her bed. This patient was one of the last visited by Dr. Good, who recommended a trial of hyoscyamus. This medicine, and many others, were tried in vain; but under Dr.Oke and Mr. Taylor, of Farnham, a complete recovery has gradually taken place.—Editor. 350 cl. iv.] NEUROTICA. [ORD. IV. Gen. I. Spec I. Agrypnia excitata. Occasional approxima- tion to aphelxia intenta, or mental ab- straction. Medical treatment. power, so that the usual exhaustion of the nervous system does not take place at the accustomed period. This is peculiarly the case in a pursuit ofthe abstract sciences, or those of a more strictly intellectual nature, as the higher branches of the ma- thematics. Where the determination of the mind to a particular subject is exquisitely intense, whether that subject be a passion or a problem, by far the greater part of the sensorial power is ex- pended at this particular outlet; and consequently the frame at large, with the exception of those organs to which such outlet peculiarly appertains, is so far drawn upon, as a common bank, for a contribution of sensorial power, that it labours under a certain degree of deficiency, and hence a certain degree of tor- pitude, so as to become insensible to the world around it; mak- ing, in this respect, an approach to the state of mind we have already described under the name of aphelxia intenta, or mental ABSTRACTION. The cure of this species of sleeplessness is to be accomplished by allaying the mental excitement by which it is produced. This is best done by recalling the mind from the pursuit that leads it astray, and a free surrender of the will to listlessness and quiet. The perturbation will then subside, the sensorial organs become tranquillized and inactive, and the habit of re- freshing slumber resume its influence. But where this cannot be obtained by the mere exercise of the will, we must call opium or some other narcotic to our aid, which, by its revellent stimu- lus, may coincide with the consent of the will, and produce the exhaustion, and consequently the quiet that is requisite for sleep. Species II. Agrypnia Pertsesa.—Chronic Wakefulness. Sleep retarded by bodily disquiet; attention alive to surrounding objects. Causes. The exhaustion, in which the very essence of natural sleep consists, supposes a perfect quiescence and inactivity ofthe sen- sorial powers. Uneasiness of any kind will become an obstacle ; and, hence, an aching coldness of the extremities or of any other part will prevent it; an uneasy sensation at the stomach or any other part will prevent it; an absence ofthe common pleasura- ble feeling with which we ordinarily prepare ourselves for sleep will prevent it: "And, on this account," as Darwin ob- serves, "if those, who are accustomed to wine at night, take tea instead, they cannot sleep. And the same evil happens from a want of solid food for supper to those who are accustomed to use it; as, in these cases, there is an irksome or dissatisfied feeling in the stomach. And hence, also, too great an anxiety or desire to sleep is another cause of its suspension ; for this, as a mental disquiet, will only add to the corporeal disquiet which has produced it; and, as already observed, the emotions of the mind must be as quiescent as those of the body, and the will, in- cl. iv.] NERVOUS FUNCTION. [ord. iv. 351 stead of commanding or interfering, must tranquilly resign itself Gen. I. to the general intention. Spec. II. Where uneasiness of this kind has been permitted to continue Agrypnia for several nights in succession, the sleeplessness is apt to be- P"1*83* come chronic, and to be converted into a habit. We have hence „°"e^°j0 had examples, as noticed with their appropriate references in chronic the volume of Nosology, in which vigilance or sleeplessness has wakefulnew continued for a month without intermission ;* for six months ;t J°jj*"£ and even for three years.J riods: Mr. Gooch gives us a singular case of a man who never slept, forthe and yet enjoyed a very good state of health till his death, which whole life. happened in the seventy-third year of his age. He had a kind of dozing for about a quarter of an hour once a day, but even that was not sound, though it was all the slumber he was ever known to take.§ The cure of this disease demands a particular attention to its Medical cause; for if we can get rid of the organic disquiet on which it treatment. depends, we shall be pretty sure to succeed in obtaining our object. All irksome chills, and especially those of the feet, should be taken off by a sufficient warmth of clothing; and the Habitual habitual supper, or other indulgence which has hitherto pre- indul" ceded and introduced sleep, should be freely allowed. The lulling sounds of soft and agreeable music, or agreeable Soothing reading, have been tried as concomitants, and not unfrequently music, and with success. And narcotic aromas have at times been had re- reading.6 course to, especially that of the hop, heaped into pillows ; but, h^^ so far as 1 have seen, and I have once or twice witnessed the experiment, with as little efficacy as the pillows of the male fern in cases of rickets, which were once, according to Van Swieten, in equal estimation for this last complaint. A pediluvium, as Pedilu- recommended by Lang,|| will often be found a much better pre- v'um- scription, or any means which will excite that breathing mois- ture which is indicative of general ease. Soft, gentle, and gen- Gentle eral friction, and especially where there is any chill or rigidity friction. upon the limbs, will frequently produce the same effect in a very agreeable way; and this, too, without combining it with the external use of opiates, as proposed by De la Prada,1F and vari- ous other writers.** Mosch was the favourite medicine of Thilenius,tt and hyos- Mosch. cyamus of Stoerck ;|J but a free and exhilarating glass of wine, Hyoscya- as proposed by Fordyce, will often answer much better than mus. either of them. In many cases of disquiet, and particularly in Wine. the stomach and praecordia, it might be well to try the hypo- Hypnotic notic powers of the nutmeg, as warmly recommfnded by Dr. powers of Cullen. We have already noticed this reputed effect in the ie nu meg" East Indies, which Bontius confirmed by his own experience, * Grilling, Cent. iv. Obs. 90. + Panarol, Pentecost, v. Obs. 4. X Plinii lib. v. vii. cap. 51. i Medical and Chirurgical Obser- vations, &c. 8vo. || Epist. xlv. II Journ. de Mede- cine, torn, xxxvi. ** Ansert. Abhandl. b. i. iv. st. 45. tt Medicinische und Chirurgische Bemerkungen, &c. Xt Libellulus quo continuantur Experimenta, &c. 352 cl. iv.] NEUROTICA. [ord. IV. Gen. I. Spec II. Agrypnia pertsesa. Treatment. Opium. Wakeful- ness of old people not strictly a disease. Symptom- atic wake- fulness. and which has since been confirmed by practitioners in Europe. And when taken in a large dose, there can be little doubt of its somnolent virtue. In the case recited by Dr. Cullen in proof of this, the person had swallowed more than two drachms by mis- take, and the effect was a drowsiness, commencing an hour after- wards, which gradually increased to a complete stupor and in- sensibility. After this he was delirious, and continued to be al- ternately stupid and delirious for several hours : but, in six hours from the attack, he was pretty well recovered from every symptom.* Where, however, the morbid habit is too rigidly established to give way to any of these means, we must forcibly break through it by the use of opium, till the habit itself be overcome, when all narcotics should be gradually omitted. The wakefulness, so common to old people, is hardly a dis- ease. They use but little exertion, and hence require but little sleep; and the internal activity is upon a par with the external. A third part of the vessels, perhaps, that took a share in the general energy of the middle of life is obliterated, and the wear and tear of those that remain are much less. The pulse beats feebly; the muscles of respiration are less forcibly distended ; the stomach digests a smaller portion of food, for only a smaller portion is required ; the intellect is less active, the corporeal senses less lively, and a minuter quantity of nervous energy pro- duced by the brain and its dependencies. And hence, though there is far more weakness than in earlier life, there is a less proportionate demand for exertion, and consequently a far smaller necessity for sleep. From such a line of reasoning we may see, why sleeplessness should be found as a symptom in excessive fatigue, violent pain of any kind, inflammation, fevers, and various affections of the brain. GENUS II. DYSPHORIA—RESTLESSNESS. Troublesome and restless uneasiness of the muscles ; increased sensi- bility ; inability of fixing the attention. Synonyms. This is the inquietudo of many authors, which the Greeks ex- pressed by the generic term now chosen, importing, literally, " tolerandi difficultas," " a difficulty of enduring one's self." It does not expressly enter into the classification of Sauvages, nor that of Cullen, but is nearly synonymous with the anxietas of the former, which in the present system becomes a species of this genus. " Molesta sensaito," says Sauvages, " quae ad jacti- tationem cogit, sed quomodo ab affininibus morbis discrepet, di- cant qui experti sunt.'' The genus embraces two species, as exhibiting restlessness or inquietude chiefly confined to the sensific or the irritable fibres; or as dependent upon the state of the mind. * Mat. Med. Part n. ch. v. cl. iv.] NERVOUS FUNCTION. [ord. iv. 353 1. dysphoria simplex. fidgets. 2. -------anxietas, anxiety. Species I. Dysphoria Simplex.—Fidgets. Restlessness general, and accompanied with a perpetual desire of changing the position. This is what we mean by the English colloquial term Fidgets, Gen. II. from fidgety, most probably a corruption of fugitive, though the bPEC- ■ lexicographers have given us no origin of the term. Both im- tj,relg,!"i]00. port restlessness, unsteadiness, and perpetual change of place. qUjai term. The proper Latin term is titubatio; and, indeed, most languages Synonym. have some peculiar term to express this troublesome and irrita- ble sensation, though it has been rarely introduced as a disease into the nosological catalogue. The actual cause seems to consist in an undue accumulation Cause. of sensorial power, which seeks an outlet, so to speak, at every pore, for want of a proper channel of expenditure. Thus ev- illustration. ery one becomes fidgety who is obliged to sit motionless be- neath a long-drawn and tedious story of common-place facts totally destitute of interest: and still more so when he is eagerly waiting, and fully bottled up, as it were, to reply to an argument loaded with sophisms, absurdities, or untruths, and over which he feels to have a complete mastery. So the high-mettled horse is fidgety that, called out, in full caparison, and still restrained in his career, is panting for the race or the battle. " 3o the squirrel, when confined in a cage, feels," as Confirmed Dr. Darwin has ingeniously observed on this disease, which he fJ"om . calls jactitatio, "a restless uneasiness from the accumulation of a,w,n" irritative power in his muscles, which were before in continual and violent exertion from his habit of life, and, in this situation, finds relief by perpetually jumping about his cage to expend a part of his redundant energy. For the same reason, children Farther that are constrained to sit in the same place at school for hours illustrated. together, are liable to acquire a habit of playing with some of the muscles of their face, or hands, or feet, in irregular move- ments which are called tricks, to exhaust a part of the accumu- lated irritability by which they are goaded." In the two last instances, this irritability is simply accumu- lated for want of a proper outlet, and not from inordinate se- cretion. In the two preceding cases, of the restrained horse and the restrained orator, there is added to this simple accumu- lation, for want of disbursement, an accumulation also from inor- dinate excitement. It is this last source alone that can give the present affection How far anything of a morbid character ; and in irritable temperaments J™*^ this is often the case ; for there is a diseased excess of sen- sorial power produced constitutionally, which is apt, on various occasions, to show itself by a perpetual restlessness or jactita- vol. iv. 45 354 Gey. II. Spec. I. Dysphoria simplex. Exciting causes. Remedial treatment. CL. iv.] NEUROTICA. [ord. IV. tion, as troublesome to those who are of the company, as to those who are afflicted with it. v Paulini* observes that worms, and Lentint that atony alone, is a cause; and hundreds of other sources of irksome irritation may be added to these ; one of the most common of which is an obstinate and unconquerable itching like that of prurigo senilis, and especially in a part ofthe body that we cannot conveniently get at to scratch : and hence ascarides in the rectum or puden- dum, into which last organ they have sometimes been found to creep, is a "most distressing, and, in some cases, a maddening cause. A course of cooling purgatives, warm bathing, or increased exercise, will probably be found most serviceable in this ha- rassing complaint; with an attention to the primary disease where it is sympathetic. Where an idiopathic affection, often symp- tomatic. Causes. Alysmus of Hippo- crates. Sometimes accompa. nied with- great ex- citement of the nervous system generally. Medical treatment. Species II. Dysphoria Anxietas.—Anxiety. The restlessness chiefly affecting the prcecordia ; with depression of spirits, and a perpetual desire of locomotion. This species, in persons of an irritable or highly nervous temperament, and especially among those inclined to hysteria or hypochondriacal symptoms, is occasionally to be met with as an idiopathic affection, to which such a temperament gives a pecu- liar predisposition. But we see it more frequently as a feature in the first attack of fevers, in nausea, in various affections of the praecordia, and most powerfully and most distressingly in lyssa or canine madness. It has been ascribed to the want of a free passage for the blood through the heart, in consequence of a polypous concretion or some other obstruction ; to a similar dif- ficulty of its passage through the lungs; and to a constriction of the vena portae, producing a like impediment in the lower belly; and the anxiety has been denominated precordial, pul- monary, or epigastric, according to the part affected, which, however, we cannot always trace out. The complaint is par- ticularly noticed by Hippocrates, who distinguishes it by the name of alysmus (xXvopos), literally, restlessness or inquietude. It has sometimes, and especially in persons of an acutely ir- ritable habit, been accompanied with great excitement of the nervous system generally, and spasmodic action of some or even all the muscles, displaying, according to the idiosyncrasy, the symptoms of chorea, hypochondrias, or lyssa ; and has oc- casionally, as I have reason to believe, been mistaken for lyssa, where the morbid mind has pored incessantly on the recollection of some former scratch or bite of a dog or cat; and, like lyssa, it has sometimes terminated fatally, though by no means with a like rapidity. Where the affection is idiopathic, an emetic will be generally * Lanx. Sat. Dec. n. Obs. 10. t Beobacht. der Epidemischen Krankheiten, p. 47. cl. iv.] NERVOUS FUNCTION. [ord. iv. 355 found to produce the readiest assistance: after this, the warmer antispasmodics, and, if necessary, narcotics msiy be successfully employed, with gentle exercise and a light diet. GENUS III. ANTIPATHIA.—ANTIPATHY. Internal horror at the presence of particular objects or subjects; with great restlessness or deliquium. Antipathia (avriirains, from xnurxfau, " naturalem repugnan- Gew. III. tiam habeo,") does not occur in Swediaur, nor in Dr. Cullen's Origin of classification, but enters into his supplementary catalogue, " Mor- generic borum a nobis omissorum quos omisisse fortassis non oportebat;" *"m* or, as he expresses it, in another place, of diseases which were n^ed'by either forgotten when the arrangement was settled, or for which Cullen: no fit place coufd be found within its limits. It occurs, howev- and other er, in Sauvages, Linneus, Vogel, and Ploucquet, and seems to writers. comprise two species: 1. antipathia sensilis. sensile antipathy. 2.---------insensilis. 1nsensile antipathy. Species I. Antipathia Sensilis.—Sensile Antipathy. Antipathy produced through the medium ofthe external senses. Very singular examples of both species belonging to this ge- Common nus are recorded by the collectors of medical curiosities; while origin and others are of every-day occurrence. Some may be accounted Appearance for from early fright, stories told in the nursery, or that incon- gruous association of ideas in early life, which we had occasion to notice in the Proem to the present class. But many are of difficult solution, and others altogether inexplicable. Under the species before us, we may mention an antipathy Singular produced by the smell of roses, of strawberries, of mint and examples. some other herbs ; by the. sound of music ; or the sight of a drawn sword, which is said to have existed in King James I.; James I. or the rattling of a carriage over a bridge, which continued for some years after mature life in Peter the Great of Russia, who peter t|ie was frightened, while an in-fant, by a fall from a bridge into the Great of water, and who only overcame the antipathy by resolutely ac- Russia. customing himself to the object of disgust. The sight of crabs and lobsters, and, still more frequently, of Other loads and vipers, has produced the same effect. And we have '"stances. a few instances of its being occasioned by what we should much less expect as a cause, the appearance of bread and cheese, or even bread alone.* The object, itself, however, seems to be of little or no importance ; the feeling in most of these cases re- Common suits from an association of such object, whatever it may be, nse and J * progress of * Ephem. Nat. Cur. Dec. 1. Ann. r. Obs. 144, et in Schol. Dec. ill. Ann. tuefeel,nS' in. Obs. 149. 356 cl. iv.] NEUROTICA. [ord. iv. Gen. III. Spec. I. Antipathia sensilis. Sometimes strictly idiopathic. with some painful occurrence in early life, of which it contin- ues to be as much the symbol or expression as letters are of ideas. In many instances, the original occurrence is forgotten, but the impression indelibly remains, and the object recalls the mind to its influence. There is reason to believe, however, that the antipathy is often the result of idiosyncrasy, or some- thing peculiar in the frame-work of the individual constitution. Contrasted with the preceding species. Illustration ofthe species. Produced in some cases by the presence of a cat, though concealed. Examples of this fre- quent and well sup- ported. Disease de- pendent on idiosyn- crasy. How ex- plained by Sauvages. Viverra noctula, or common bat. Remedial treatment Species II. Antipathia Insensilis.—Insensile Antipathy. The antipathy produced through an unknown medium. In the preceding species the feeling of antipathy is excited through the medium of one ofthe external senses, to which the object of antipathy presents itself, or with which it is associated on recollection; for it is the sight, or taste, or smell, or touch, or hearing of such object, or the idea of such sensible impres- sion, that alone calls the antipathy into action. There are some persons, however, that are struck with a peculiar and indescribable kind of horror at the presence of an object, which is unperceived by any of these senses, as soon as it comes within the atmosphere of some unknown influence. The presence of a cat has been often known to produce this ef- fect, under the circumstances now adverted to, or when the ani- mal, though present, has been concealed, and not one of the senses has been alive to its presence. Instances of this kind are to be found in most ofthe collections of medical curiosities, as well as in various other works;* and I have met with seve- ral decided instances in the course of my own practice. The affection, in this case, depends unquestionably upon an extraor- dinary idiosyncrasy ; but by what means such an idiosyncrasy is influenced we know not. Sauvages enquires whether the efflu- vium thrown from the object of aversion into the atmosphere may not, in combining with the fluids of the affected person, produce an irritating and digressing tertium quid, as corrosive sublimate is produced by a combination of mercury with oxymu- riatic acid. The fact, at present, appears inexplicable ; but it is not more singular than the wonderful power so well known to be possessed by the viverra noctula (common or great bat), which renders it conscious of the presence and position of ob- jects when all its senses are muffled, and which enables it, when flying in this state, to avoid them. This extraordinary faculty, to which we adverted in the Proem to the present class, has been called a sixth sense by several naturalists. In all these cases, whether of the preceding or of the pre- sent species, the only means in our power of destroying the anomalous or morbid impression is by introducing a counter- habit; or, in other words, by gradually inuring the sensorium to the influence of the disgustful object. By being familiarized * Eph. Nat. Cur. Dec. n. Ann. n. Obs. 60. Borelli, Cent. iv. Obs. Cl. Emercetanus, Diaetet. Polyhistor. p. 82. CL. IV.] NERVOUS FUNCTION. [ord. iv. 357 with what at first we most shrunk from, our courage becomes Gen. III. hardened, and the painful impression blunted; and sights, and SpecII. sounds, and smells, and the most imminent dangers that could Antipathia not at one time be encountered, or even contemplated with- out fainting, in process of time no more affect us, than the roar of cannon affects the war-horse, or the mountain-tempest the mariner. GENUS IV. CEPHALjEA.—HEAD-ACH. Aching pain in the head; intolerance of light and sound; difficulty of bending the mind to mental operations. Cephaljea (mQxXxix from xs stomach. The last acts, indeed, in a double way; direcjly, as l"^ei withholding the means of sensorial recruit; and, indirectly, from whence the close sympathy that, on all occasions, exists between the derived. two organs. And hence, wherever we meet with cephalaa gravans as a sympathetic affection, and are doubtful to what particular organ to ascribe it, we shall, in most cases, find the stomach affected, and may venture to treat it accordingly. As much of the remedial process, however, which maybe G-r.eral serviceable in any one ofthe species of head-ach before us, may remedial be useful in the rest, it will be most expedient to reserve this Process" subject for the close of the entire genus. Species II. Cephalaea Intensa.— Chronic Head-Ach. Pain vehement, with a sense of tension over the whole head; periodic; often chronic. This species is, perhaps, always dependent upon some local Often from irritation ; and may be produced by many, probably most, ofthe internal irritants noticed at the opening ofthe preceding species : and as defies all not a few of these have a seat in the brain itself, and must re- medical aid, main concealed till disclosed to us by dissection, and would be and why" still beyond our reach if we could ascertain them from the first attack, there is no difficulty in conceiving why this form of head-ach should often defy all medical aid whatever, and run parallel with life itself. Among the external causes, those productive of rheumatism External are, perhaps, the most frequent, as exposing the feet for a long cause>- time to cold and damp, or lying in a damp bed with a small quantity of covering. And as all rheumatic affections, when they become chronic, have a tendency to intermit, and return periodically, we may easily see why the disease before us should do so in many instances. This species may therefore be distinguished by its being Present rather limited to some particular part of the head than extend- species ing over the whole organ; by its remissions or intermissions; ll0vhdJ,Sitin" by the acuteness ofthe pain during the return ofthe paroxysm ; from others. by an intolerance of all motion of the head, far more than of light or sound, both of which, however, are sometimes highly irksome; and by a peculiar feeling of tenseness or constriction over the encephalon, as though its membranes were muscles and spasmodically contracted. This last symptom rarely takes place till the disease has es- Other dis- tablished itself for some time, and seems to indicate a thickening ,inctive of one or more of the tunics of the brain from increased action" syml,toms' produced by a long course of irritation ; a result which has fre- quently been discovered on dissection. Where the affection is 360 cl. iv.] NEUROTICA. [ORD. IV. Gen. IV. Spec I r. Cephalaea intensa. Intervals of ease in cases produced by internal causes, ac- counted for. The ob- struction sometimes very singu- larly car- ried off. Caries or other struc- tural affec- tion of the sutures. Medical treatment. entirely rheumatic, the local pain in the head ceases as soon as a rheumatic pain takes place in any other part of the body. There is, indeed, no great difficulty in accounting for a cessa- tion of pain in this case upon the principle of a transfer of ac- tion. But we find it cease also, or very much remit, not unfre- quently in other cases, in which post-obit examinations have proved the disease to be dependent on local irritation, as some bony protuberance from the interior of the skull, ossification, or calcareous concretions in some parts of the substance of the brain, a.tumour in the pineal gland, or some other portion of the cerebral mass, or an aneurism of the carotid artery; the two last of which are particularly described by Sir Gilbert Blane, as having been detected, after death, in persons who had been long and severely troubled with this modification of cephalsea. To account for the intervals of ease experienced, as in the foregoing instances, while the cause of irritation is permanent and perpetually acting, we must call to our recollection, that most organs, when they have been long exposed to a more than ordinary stimulus, become gradually exhausted and blunted in their sensibility in consequence of such exposure. And hence the pain they are occasionally sensible of, and which returns in irregular paroxysms, is produced by fresh causes of excitement, periodical or incidental, or a serious aggravation of the disease itself. In a few instances, an obstructing material, forming the ex- citing cause, appears to have been carried off, and in one or two very rare cases, by channels whose communications it is pecu- liarly difficult to account for. A caries, or some other disease, affecting a small part of the bony substance of one of the sutures, is a cause noticed by many pathologists ; and this cause has, in some instances, been so obvious, that while the patient has been able to point out the precise spot of pain with his finger, the practitioner has been able to discover a considerable indentation or vacuity, proving that a part of the suture had been absorbed or detached.* A case of this kind is related by Mr. Henry of Manchester.! For the few remarks we shall have to make under the head of medical treatment, it will be most convenient, as already ob- served under the preceding species, to refer to the close of the genus, in order that the plan, proper to be pursued under one species, may be compared with that under another. At present it is only necessary to add farther, that the irritating causes of chronic head-ach we have thus noticed, excite, occasionally, other symptoms than acute pain, and particularly clonic agita- tions ofthe muscular fibres adjoining the seat of pain, not unlike those of neuralgia, and severe and irremediable hemiplegia. * Bonet, Sepulchr. Lib. i. Sect. i. Obs. 92. Morgagni, De Sed. et Caus. Morb. Epist. m. Art. 8. Stalpart van der Weil, Cent. I. N. I. t Mem. Med. Soc. of Loud. vol. i. cl. iv.] NERVOUS FUNCTION. [ord. iv. 361 Species III. Cephalaea Hemicrania.—Megrim. Pain vehement: confined to the forehead, or one side of the head: of- ten periodical. This is, in most cases, a disease of far less importance than Gen. IV. the preceding. Its seat seems to be chiefly in the integuments SpEC-1IL of the head, and its principal symptoms are tenderness on pres- ™nfa7. sure, an obscure redness ofthe skin, and a suffusion ofthe eyes, theintegu- And with these there is frequently a nauseating uneasiness at ments. the stomach, but whether as a cause or a consequence of hemi- Symptoms. crania, it is not easy to determine; it is most probable, indeed, that in some instances it is the one, and in others the other. The disease is most common to persons of delicate health, or Predispo- relaxed habits, and an irritable temperament, and particularly nents- when subject to dyspepsy and hypochondrism. In such persons, all the causes of catarrh and rheumatism are sufficient for its production, as is any thing that disturbs the balance of the cir- culation. And hence it is often a result of cold feet, or the chill that follows a dinner not comfortably digested. Hemicrania frequently assumes a periodical character, in often which case, the pain mostly fixes itself on the same side or the periodical. same part of the head, in some cases being limited to a small disk of the integuments, with little affection of the encephalon, and in others striking deeply into the interior of the head, and down towards the eye, which cannot endure the least glimmer of light. In many instances, its intermissions are perfectly regu- Periods lar, and the paroxysm returns daily at the hour of noon ;* but p0^',™8 more commonly its attacks are produced by some incidental ex- regular: citement, and are consequently of uncertain recurrence. Yet it ""[j®110™" is more frequently found in the afternoon, than in the morning. ™0c"ryta°n So far as I have observed, indeed, it usually takes place in the recurrence. evening during, or soon after, the digestion ofthe dinner, and in persons of the middle age of life who live temperately. In one Yet more instance, in which the disease is still very obstinate, it returns ^7,^° at this hour after an interval of two or three weeks, continues noon than through the whole of the night and the ensuing day, and sub- the morn- sides towards the evening; the paroxysms thus lasting about ,n£* twenty-four hours. In a very active and otherwise healthy man, Illustrated. however, about thirty years of age, who has no apparent disor- der of the stomach or bowels, it commences uniformly before Occasion- breakfast, continues with great violence about six hours, and JJJ^J^ then subsides; leaving intervals of about six weeks or a month. ul0rDing. Species IV. Cephalaea Pulsatilis.—Throbbing Head-ach. Pain pulsaioYy, chiefiy at the temples ; often with sleeplessness, and a sense of drumming in the ears. In discussing the genus palpitation (clonus palpitatio) we en- Pathology. * Schenck, Libr. Obs. 78,79. Zecchii, Consult. M«d. 90, 98. Franc. 1650. vol. rv. 46 362 Gkn. IV. Spec. IV. Cephalaea pulsatilii. et. it.] NEUROTICA. [ORD. IV. Origin. Pulsation often inac- cordant with that of the heart. Sometimes accordant, but still a diseased action. Disease more com- plicated fhan any of the^eet. tered into an explanation of the very curious phaenomenon of the throbbing or beating of the heart, or of a particular artery, or part of an artery, which frequently takes place without anv^con- nexion with the regular systole ofthe circulation, often, indeed, discordantly with it both in time and force : and we endeavoured to show that these anomalies, for the most part, depend upon a peculiarly nervous irritability, and spastic tendency of the mus- cular fibres of the arterial fabric, sometimes limited to the arte- ry, or portion of an artery, in which the palpitation occurs, and sometimes common to the whole arterial system. Whenever any of the preceding species ofthe present genus are grafted upon a constitution of this kind, or at least upon an idiosyncrasy in which one or both the temporal arteries are pos- sessed of this spastic tendency, and are consequently disposed to run into this anomalous contraction and relaxation, we shall have an instance ofthe species before us which commonly originates in this manner. The consequence of which is, that a regular arterial stroke, as though influenced by the systole and diastole of the heart, is often feigned, which has no existence; and a pulsation is produced, which is in no respect synchronous with the movements ofthe heart, and is often half as rapid again. It occurs, not unfrequently, however, that the morbid beat is in perfect accordance with that of the heart; but it is not less a spasmodic action on this account, for in the discussion already adverted to, as well as in the Proem to the third class, we have observed that the arteries, when in a state of health, suffer no alteration in their diameter during the passage of the blood through them, and that their ordinary pulsation is only produced by the pressure of the finger or of some other hard substance against their sides.* The species of head-ach before us, therefore, is to be regard- ed as something of a more compound kind than the rest, in con- sequence of the peculiarity of the constitution in which it oc- curs ; with the exception of which, its causes and history, and, as we shall presently show, mode of treatment, do not essentially differ. Species V. Cephalaea Nauseosa.—Sick Head-ach. Spasmodic This is the spasmodic affection of Dr. Fothergill, who has as- head-ach of cribed it at great length and with much accuracy. As the last Fothergill. Specjes consists of almost any ofthe preceding, set down upon a Pathology. const|tution peculiarly predisposed to irregularity of arterial ac- tion, the present consists of the same set down upon a constitu- * If the doctrine, inculcated by the author and some other eminent medical writers, were unequivocally correct, that an artery can really both dilate and contract itself in an extra- ordinary degree, and this sometimes without any accordance to the action ofthe heart, all the doubt entertained by some distinguished physiologists in relation to the muscularity, not only of the small but of the large arteries, would be removed. That the arteries can under- go a dilatation is certain, for the change is visible in various circumstances, and particularly in inflammation. But Mr. Hunter, Dr. Thomson, and others, could never discern in this cl. iv.] NERVOUS FUNCTION. [ord. iv. 363 tion peculiarly predisposed to irregular action of the intestinal ^tfiMV' canal. In its general symptoms, however, it is chiefly related to E it may become a question how far the use of the trepan has a Effects chance of being serviceable. Vogel gives a case, in which the oftensalu- pain was hereby considerably mitigated,! and Baglivi another, tarv; in which a radical cure was effected.£ But, in this instance, a portion ofthe brain was found in a state of suppuration, and the confined pus hereby obtained a way of escape. Marchetti gives an example of a temporary cure, the head-ach being sus- pended so long as the wound was open, but returning after it was healed.§ And hence, even where no structural cause of ^ui tne irritation has been reached, this operation has sometimes prov- operation, ed serviceable as a revellent. It must, however, be admitted ^o^vw! that it has often been performed without any benefit what- ever^ It is hardly needful to observe, that where cephalaea is evi- Treatment dently a secondary disease, as in plethora, chlorosis, gout, or when a sec neuralgia, our attention must be chiefly directed to the malady °„eary on which it is dependent. Where it appears as a sequel to any suppressed and habitual evacuation, or repelled eruption, the best means of obtaining relief will always be found in restoring the system to its former state; and, where this cannot be done, we must furnish the best substitute we can by some temporary irritation or drain. As a general palliative, strong coffee has often proved service- Coffee often able ; and, where its own sedative virtue is not sufficient, it j"^""^6 forms one of the best vehicles for the administration of lauda- species: an num in doses of eighteen or twenty drops. It diminishes, in excellent some degree, the hypnotic power of the latter, but it counter- ]*^*J°T. acts its distressing secondary effects. When laudanum is inter- 0flen pre.' mixed with strong coffee for the cure of many modifications of venting head-ach, tranquillity and ease are produced, though there n^aca"d may be no sleep : when laudanum, on the contrary, is taken alone, sleep will, perhaps, follow, but is mostly succeeded by nausea and a return of the pain. Hence the Turks and Arabi- ans make strong coffee their common vehicle for opium, from its tendency to counteract the narcotic principle ofthe latter.1T * Hecatost. ii. 67. t Chirurgische und Medic. Beobachtungen, p. 410. X Specim. Quatuor Librorum de fibra motrice et morbosa. i Observ. 36. 38.* || The editor has seen two cases in which the patients lost their lives by submitting to such treatment. IT Phil. Med. and Experimental Es- says. By Thomas Percival, M. D. vol. iii. 368 «. iv.] NEUROTICA. [ORP. IV. Gen. V. By some nosologists made a species of cephal«a ; but impro- perly. Best con- templated as con- taining only a single species. GENUS V. DINUS.—DIZZINESS. Illusory gyration of the person while at rest, or of objects around the person, with hebetude of sensorial powers. The distressing sensation of dinus, a strictly Greek term, oc- curs, in different persons and different circumstances, under very different modifications, or is connected with very different symptoms. It is often united with cephalaea, and hence, by some nosologists, it is made a mere species of this last genus; but there are few practitioners who have not witnessed instan- ces of both, that have commenced, continued, and terminated their career without any interference with each other: and hence Linneus has not only separated them from each other, and regarded them as distinct genera, but has even made scoto- ma, or dizziness with blindness and a tendency to swoon, a dis- tinct genus also. In the author's volume of Nosology, scotoma, with two other forms of dinus, were regarded as separate species. But as, on a fuller consideration ofthe subject, 1 am induced to think, that all these diversities originate from the particular habit or temper- ament of the individual, or the nature of the exciting cause, it will be more correct to reduce them to a single species, and to contemplate the diversities of symptoms and sensations they produce as varieties or modifications alone : and hence, adopt- ing the common name for this purpose, we shall denominate this species i. dinus vertigo. VERTIGO. Pathologi- cal explana- tion hither- to unsatis- factory. Sauvages. Darwin. Herz. Crichton. Species I. Dinus Vertigo.— Vertigo. Dizziness, with a fear of falling. Common as this complaint is, I have not hitherto met with any satisfactory explanation of its cause. Sauvages,* indeed, has entered upon the subject pretty fully, as has Darwint since his time, and CrichtonJ since the time of Darwin ; while, on the continent, it has been investigated with much patience and ingenuity by Dr. Herz of Berlin.§ For the most part, it has been ascribed to a morbid excitement, or increased action in the organ of vision, which is the view taken of it by Sauvages and Darwin, or to " a state of mental confusion arising from too rapid a succession of representations," which is the explanation of Herz and Crichton. That there is, in all instances, some degree of mental con- fusion, may, perhaps, be allowed, and that there is often too rapid a succession of representations with a morbid increase of sensorial action, may be allowed as readily: but if the following * Nosol. Method. Class v hi. Vesanite. X Of Mental Derangement, vol. i. p. 324. Berlin, 1791. t Zoonom. Class iv. n. i. 10. ♦ Versuch iiber der Schwindel. Cli. IV.] NERVOUS FUNCTION. [ORD. IV. 369 remarks be found entitled to attention, and succeed in delineat- Gen. V. ing the real nature of vertigo, it will appear, that the external Spec L senses are only indirectly, if at all, the seat of the morbid ac- t?"J™* ver" tion ; that the energy of these is far more frequently in a state of diseased diminution, than of diseased increase ; and that even a rapid succession of representations is not essential to the sen- sation. We have had frequent occasions of showing, that the nervous New view of power, which supplies the muscular fibres, is communicated, thesunJect- not strictly speaking, in a continuous tenour,-but in minute and successive jets, so that the course of it is alternately broken and renewed by a series of fine and imperceptible oscillations. In a state of health and vigour, this succession of influx and Irritative pause is perfectly regular and uniform, and, hence, whatever communi- movements result from it will partake of the same uniformity, catedtothe and appear to be one continued line of action, instead of a'suc- irritable cessive series. But as soon as ever the harmonious alternation, through which the nervous power is thus supplied, is interfered with, the oscillations become manifest, the apparently uniform current is converted into a tremulous undulation, and the mus- cular exertion to which it gives rise, instead of being seeming- ly one and undivided, is sensibly multiplied into hundreds : of which any person may convince himself on observing a strong and healthy arm extended for a few minutes with a small weight at the end of the fingers, and an arm reduced in strength by a fever, or any previous labour; for while the first maintains an even and uniform line, in the second, this line is broken into perpetual tremors and undulations. That the nervous power, which supplies the muscular fibres, ah other is communicated in this way, there is no doubt; and, as it is nervous highly probable, that all the different kinds of nervous fibres JJed inPa" are fed by a like process, there can be little doubt, also, that gjmiiarway, those which maintain an intercourse between the brain and the ud inject external senses, and even those which belong to the external ^^an'ces senses themselves, are supplied by the same kind of alternating i„ the line pause and flow. And consequently that, as a perfect regularity ofcommu- and uniformity in this alternation is the means of conveying from n,ca ,on, the organ of vision to the sensorium one undivided perception of every single object presented to it, so, an irregularity and From this want of uniformity in the alternating series must confuse and £"**.""- complicate the perceptions, and multiply them into as many as inti,eflow the series of jets themselves consist of, though each perception of thesenti- may, perhaps, be less distinct and perfect than the single per- l^Z"'* ception conveyed in the ordinary course. Thus, in looking and comp|j. through a window, or an eye glass, the objects that pass before cation of us in regular order, pass singly without confusion; but, if this \??™eat*~ order be interrupted by movements, we are not accustomed to, or the objects jerked about, as in a magic lantern, they make us dizzy with their motion, and we see them confusedly and in delusive numbers. 47 VOL. IV. 370 cl. iv.] NEUROTICA. [ORD. IV. Gen. V. Spec. I. Dinus ver- tigo. Hence ver- tigo a clonic action of the nervous fi-res sub- servient to perception. Principle applied to the . phaenoraena of vertigo. Why ob. jects appear to circum- volve, why the patient him' self. Whence illusory sound;, and multiplica- tion of objects. Whence illusory smells and tastes. Vertigo often pres- ent whether there be light or darkness: hence not from in- creased en- ergy in the irritative motions of the organs of In this manner, then, it appears to me, that the increased mo- tion, and apparently rapid succession of representations, is pro- duced in the affection we call vertigo; which, under this expla- nation, is a clonic action of the nervous fibres subservient to perception, in the same manner as the rapid and tumultuous agi- tation of the muscles in tremor, shaking palsy, or epilepsy, are a clonic action of the fibres subservient to voluntary motion. In the last of these affections, we find a considerable difference in the nature and intervals of the clonic movements; for these must depend upon the greater or less degree of interruption which the nervous power sustains in its flow, or upon the pecu- liarly relaxed or spastic state of the nervous fibres themselves, and probably, at times, upon some other cause of which we are totally ignorant. And we have, hence, reason to expect, and do in fact perceive, an equal diversity in the clonic and illusory motions of vertigo; for the objects, or their representations presented to the perception, appear sometimes to circumvolve horizontally from right to left, or perpendicularly from above downwards^or from below upwards, or to be very whimsically changed in their form. And not unfrequently the patient him- self se-ems to be moving as well, and commonly in a contrary direction to the apparent motion ofthe objects. And as the in- termediate nerves, between the other external senses and the brain, seem occasionally to coincide in the same morbid agita- tion, we can easily conceive, how that very common modifica- tion ofthe disease may be produced in which the dizziness is combined with illusory sounds, as of whispering or murmuring, the ringing of bells or bealing of drums, or even the roar of cannon°; for as single objects may, under the influence we are now contemplating, be prodigiously multiplied or magnified, so may single and otherwise almost imperceptible sounds; and es- pecially°where the auditory nerve is itself in a state of high morbid acuteness, during which we have already had occasion to remark, that the gentlest and lightest tones, even the whis- perings of a mere current of air in a room, or the breathing of persons present, is intolerable, while sounds before unperceiv- ed become highly distressing* And in like manner, by an equal irregularity in the supply of the nervous energy, subser- vient to the perceptions of smell and taste, we may account for similar illusions upon these faculties. In many instances, we find the vertigo equally present, wheth- er the patient be in the dark or light, whether the eyes be closed or open ; and we have hence a full proof, that it is not dependent, as Dr. Darwin conceives, upon an increased energy in the irritative motions ofthe organs of vision. In some cases, the representations of objects are very numerous and rapid, but in others far less so, and particularly where the affection is se- vere from the first, or the patient is in a state of constitutional debility; under which circumstances we may conceive the pauses in the flow ofthe nervous power to be more irregular, * See Paracusis aciis, vol. iv. Cl. iv. Ord. n. Gen. n. Spec. I. cl. iv.] NERVOUS FUNCTION. [ord. iv. 371 or of longer duration, than they otherwise would be. In many Gen. y. cases, indeed, the only sensation is that of a buoyant undulation SpEC- *• or swimming, without any succession of representations what- ^°"sver" ever; affording us a proof, that the rapid succession of repre- yX^ ag sentations, described by Dr. Herz, is not more essential to ver- conceived tigo, than the increased energy of Dr. Darwin. by Darwin. But as the disease advances, or, in other words, as the trans- Objects not mission of the nervous power becomes still more interrupted, rJeXdsfs" the representations are confused, indistinct, and rapid in succes- frequently sion, often conjoined with a sense of dimness or darkness, exist- rapid, or ing equally whether the eyes be shut or open, forming a state by "Screwed Hippocrates and the Greek writers generally called scotoma or in number, scotodinus: and as the disease makes a farther progress by a £3™Pf°sed farther interruption ofthe sensorial principle, every power of ^J^*' body and mind augments in languor, till at length sensation, both aj;d scoto> external and internal, fails altogether, the action of the heart diuus what. and the other involuntary organs is enfeebled, and the patient Swooning often an swoons away. effect an(J The great predisponent cause in all these cases, whether of why ' muscular agitation or of vertigo, is nervous debility, or exhaus- Pl.e(iisp0. tion : the exciting causes are whatever has a tendency to dis- nent cause turb the uniformity, with which the nervous power is supplied. °[^^ And, hence, those persons are most subject to both kinds ot af- nerV0Usde-' fection, whose nervous system is constitutionally weak and mo- bility, or bile, or has become debilitated by disease or accident. Hence ™|iaust'0"- dyspeptic patients are peculiarly subject to both these affections ; J*/^ ™y as are those who are faint from sudden and violent evacuations, tl)eseaffec- want of food, or a long course of labour. Hence we meet with tions. it as a frequent and distressing attendant upon those, who have too freely indulged in the pleasures ofthe table, in those ot sexual intercourse, and particularly the gross gratification of self-pollution. And hence, too, we may see why it is so often an accompaniment of cephalaea, as the nervous fibres subservi- ent to the organs of perception are here influenced from con- tiguous, in some cases from continuous, sympathy. The exciting causes we have stated to be whatever has a Exciting tendency to dfsturb Ihe uniformity, with which the nervous c;iu*es: leuucuw «•<-> «»<■""» ---- ......------j^ .. . power is supplied. Of these the chief are motion or exertion ^° to which the strength is not equal, motion to which the system has not been accustomed, or hurried motion whether external °\ a state of great weakness, whether from hunger, hard la- ^kind, bour, hemorrhage, or a protracted fever, even the ordinary mo- exertion t0 tion of gentle walking is more, than the little remaining strength wilich t|ie can support; and the man who tries it trembles in every limb, ^^ » and becomes immediately vertiginous. In like manner, what- J ever be his degree of strength, he will feel vertiginous by ex- ^^ chano-ino-the motion, to which he has been uniformly accus- w|lici, ,he tomed, for one of a different kind, and which he has seldom or system has never engaged in ; aud, hence, the reason of the vertigo that ;°CUI™ ed> accompanies swinging, sailing in a ship, walking in a circle, sit- ting backward in a carnage, or standing on one's head; for the 372 cl. iv.] NEUROTICA. [ord. iv. Gen. V. Spec. I. Dinus ver- tigo. Third kind, hurried or tumultuous motion ex- ternal or internal. Whence vertigo on looking down a precipice or climbing a ladder. uniformity of the external habit has by length of time associated itself with the uniform production of the sensorial power, and the one cannot be interfered with without interfering with the other. And that this is the cause of the dizziness hereby pro- duced is obvious, since as soon as the old habit is overpowered by a new one, or, in other words, as soon as the man has accus- tomed himself to the new action, it may be persevered in with- out any vertiginous sensation whatever. In some persons, this sympathy of association is not so strong as in others, and hence they are not so soon affected : in infants and young children, such a kind of sympathy has rarely commenced, for while their age has not given time for it, they have had so little walking in a straight line, and been accustomed to so much swinging and tossing about in the arms, in every direction, that they are equally prepared for all; and hence can run round a circle, or even circumvolve on their feet, without any feeling of giddiness whatever. For the same reason, hurried, tumultuous, or confused motion of any kind, whether external or internal, has a tendency to produce the same effect; for the current ofthe nervous supply will partake of the agitation, and dizziness be a necessary re- sult. Hence the vertigo that accompanies intoxication, in which, from the inordinate excitement that prevails throughout the system, the regular and uniform supply of the sensorial power is quickened into a confused and disorderly rush. And hence the same effect from congestion, or compression of any kind, as also from a sudden influence of mental emotion, and particularly ofthe depressing passions ; though, in such cases, the uniformi- ty ofthe sensorial principle is interfered with by a check, in- stead of by a rapidity of action; and where the check is con- siderable, as in cases of sudden fright or apprehension, a faint- ing-fit is at once produced without the preceding stages. It is to this cause, exercised indeed in a less degree, that we are to ascribe the dizziness, which is felt on looking down a precipice, climbing a tall ladder, or walking over a very nar- row bridge, with a roaring torrent below ; for, in all these cases, we are conscious of danger, and lose our firmness in our fear. And that such is the real cause is quite obvious from the fact, that those who possess their firmness, and have no apprehen- sion or trembling whatever, have no dizziness; and that we our- selves are able to endure an exposure to the same scenes* yd the same motion with as great a freedom from it, when habit has given us calmness, and we have no longer any apprehen- sion. So the sleep-walker has been known to tread firmly and fearlessly over planks and precipices, the sight of which has whirled all his brains when awake. Vertigo, then, as thus explained, consists in a clonic action of the nervous fibres subservient to the faculty of perception, and lays open to us the three following varieties: « Undulans. Dizziness wilh a sense of swim- Swimming of the head. ming or undulatory motion. Ch. IV.] NERVOUS FUNCTION. [ord, iv. 373 0 Illusoria. Dizziness with dimness of sight, Gen. v. Illusory Vertigo. and imaginary objects before Spec I. the external senses. Dinus ver- y Scotoma. Dizziness with blindness and ten- tlgo' Blind head-ach. dency to swoon ; often suc- Nervous fainting-fit. ceeded by head-ach. Vertigo is not generally an alarming affection, but it is only Vertigo not to be remedied by a particular attention to its cause, and espe- generally an daily the predisposition of the system to a relapse. affection. If we have reason to suspect congestion or extravasation in Mode of the head, bleeding, and especially from the temporal artery, will treatment often afford effectual reHef. I have seen a very severe attack underdlf- /. .. ., , - .1 • ferentcauses ot vertigo cease instantly, as by magic, on opening this artery, an(| circum. although not more than a tea-cup full of blood was drawn from stances. it. Where the stomach has been gorged, an emetic, and after- wards a purgative, will prove most effectual; where the cause, on the contrary, is debility or exhaustion, it is best relieved by cordials and a generous diet; and where it is an idiopathic affec- tion of the nervous system, the warm antispasmodics and tonics, with a tonic regimen, will bid fairest to succeed. Such persons will derive great benefit by a change of air, of scene, and of company ; by visiting the most quiet of our watering-places, cold bathing, and a cold ablution of the head, or of the whole body, every morning. Here also a particular attention should be paid to the state of the bowels, as costiveness is always an exciting cause. During the paroxysm, perfect rest and a re- clined position will be always found necessary; and, where there is a tendency to fainting, stimulant odours may be applied to the nostrils, and ether, ammonia, and the volatile fetids to the stomach in draughts of cold spring water. , GENUS VI. SYNCOPE.—SYNCOPE. Motion of the heart and lungs feeble or imperfect: diminished sensi- bility : inability of utterance. Syncope, from av^virra, " concido," " to fell or cut down," is Origin of a neoteric rather than an antique term. It occurs, indeed, {^nfeneric among the Greek writers, but rather in the description of bat- tles than of diseases. I cannot find who first introduced it into the medical nomenclature. In Hippocrates, the common syno- JfjJjJjJ: m nym is leipopsychia, and in Galen apopsychia: but it answers pocrates.'1*" its purpose, and is, in the present day, so generally established, Apopsychia that there is no kind of necessity for exchanging it. of Galen. Dr. Cullen's definition of the genus is " motus cordis immi- Cullen's de- nutus vel aliquamdiu quiescens." But this is by no means suf- d°'\'°"e'na' ficient; for the heart has been sometimes totally void of motion and why. without syncope, as in acrotismus, and especially in the well known case of Mr. John Hunter, which we have noticed under that division. The leipothymia of Sauvages and other nosolo- Leipothy- gists is only syncope in its first attack or mildest degree. Its ™»<* character is " subitanea et brevis virium dejectio, superstite wauuavtage1' 374 cl. iv.] NEUROTICA. * [ord. IV. Gen. VI. pulsus vigore, et cognoscendi facultate." The pulse is, perhaps, Syncope. always affected in some measure ; but in slight cases it still re- tains a certain degree of power : the perception rarely fails al- together ; but the voke seems to be uniformly lost. The species in some systems of nosology are very numerous, and unnecessarily multiplied. Out of deference to high and established authorities, the author was induced, in his volume of Nosology, to offer five ; but as several of these differ only in cause or some accidental symptom, they may be reduced to the two following, and the accidental differences be regarded as constituting varieties or modifications alone : 1. syncope simplex. swooning. 2. ------ recurrens. fainting-fit. Pathologic- al explana' tion to be collected in a consider- able degree from that already offered un- der vertigo. Additional illustration. To maintain a regular motion in the heart the blood must flow in an equal and uniform stream. Whence swooning in venesection as well when the blood first flows from the punc- ture, as when the ligature is removed. Species I. Syncope Simplex.—Swooning. Occurring suddenly and accidentally, and ceasing without any ten- dency to a recurrence. In vertigo, the defective or irregular action is chiefly confin- ed to the nerves, and particularly to those of perception: in swooning it is sometimes a result of nervous exhaustion, as in cases of exquisite pain or torture, whether of body or of mind, but it more commonly originates in the sanguific or digestive organs, though the sentient participate in the affection. Verti- go, as we have already observed, occasionally terminates in swooning; and, in like manner, swooning is not unfrequently succeeded by vertigo. To maintain the faculty of perception clear and true to the impressions that'are made on the external senses, we endeav- oured to show, under the preceding genus, that the. motion of the nervous power, which connects it with those senses, must be equable and uniform ; and, to maintain the action of the heart in a firm and regular order, it is necessary, that the blood should flow into it in an equal and uniform stream ; for if its volume be altered from any cause, whether of obstruction, surcharge, or deficiency, its motion will be checked and enfeebled, the brain and respiratory organs will participate in the debility, and syncope be a frequent result. And hence we may account for the fainting that frequently takes place on the commencement and sometimes on the close of venesection. On tying the arm for this purpose, a considerable stream of supply is cut off, and ten ounces of blood flow, in perhaps five minutes, into a bason which would otherwise have flowed into the heart in the same period of time. The volume of blood is hence diminished and the heart must collapse or contract itself in proportion. In many habits, this is done with great facility ; but in others and particularly where there is a feeble supply of motific or irrita- tive power, the contraction takes place slowly and irregularly and with a considerable degree of flutter, or, as we have al- ready explained it, clonic spasm; and fainting or a temporary cl. iv.] NERVOUS FUNCTION. [ord. iv. 375 failure of sensation, is the necessary consequence ; during which Gen. VI. the alternating systole is very feeble, and the blood ceases to SpEC-!• flow at the puncture. This effect is ordinarily ascribed to a Syncope loss of the stimulus of distention ; and there may be some degree of truth in such an explanation. But that there is something be- yond this is certain, because, on removing the ligature from the arm, this stimulus is once more obtained ; for the blood, instead of flowing away at the venous orifice, now takes its proper course, and flows back to the heart. Yet we see almost as often a syncope produced at this moment, and consequently by a re- newal of the distention, as by an interruption of it. The fact is, that the heart, which by this time has accommodated itself to the diminished volume of the returning current, has now once more to change its diameter, and to expand itself in pro- portion to the increased measure and momentum of the return- ing tide. And as a change in its diameter produced a syncope in the former case, a change in its diameter in like manner pro- duces it in the latter.* For the same reason, we may see swooning take place when Whence any extensive range of blood-vessels, that have been pressed *w^"nggon upon by any other means, suddenly acquire a power of dilata- large ab- tion, as when a large cavity is formed in the abdomen by the scesses, or process of tapping for. an ascites, or on opening an extensive ?n'd^"ess- abscess in any other quarter.! But the flow of sensorial power from the brain may also be Syncope suddenly exhausted, or checked; and syncope may ensue from ^enota'"6 this source, the action of the heart being diminished not pri- regular sup- marily, but secondarily, or by sympathy with the state of the ply of sen- sensorium. In fainting, from entonic passions or emotions, as a !,°r™eri sudden shock of vehement joy, the sensorial power is perhaps Hence abruptly expended, as also in severe pain.J In fainting, under fainting the influence of the atonic passions, as fear or heart-sick grief, from violent i i i i i ■ i a a mental emo- this power is unquestionably checked in its regular flow, and tions ail(j probably checked also in its production ; as we have reason to severe pain. believe it is where fainting occurs from a repulsion or retroces- sion of gout, exanthems, or various other diseases. And to the Fainting same cause may be referred those cases of swooning, which, in from par- some idiosyncrasies, or indispositions of body, are well known to oclourg in take place on exposure to particular odours, as those of cheese, certain idi- apples, or, as we have already had occasion to observe, of roses, osyucrasies. lilies, and other fragrant plants. Syncope then, in its simplest state, as unconnected with any structural disease of the heart or its adjoining vessels, seems to appear under the following modified forms or varieties : * The explanation, here given, seems very doubtful. The patient often faints about the lime, when the ligature is loosened, or immediately afterwards; but this is, in consequence of the blood, already lost.—Ed. t Meckel, Epist. ad Haller. Script, vol. iii. Eph. Nat. Cur. Dec. n. Ann. v. Obs. 53. X Amat. Lusitan. Cent. n. Cur. r. Plater, Observ. n. p. 431. 376 CL. IV.] NEUROTICA. [ORD. IV. Gen. VI. Spec. I. Syncope simplex. m Inanitionis. Swooning from inanition. /3 Doloris. Swooning from acute pain Pathematica. Swooning from mental emo- tion. Metastatica. Swooninar from metastasis. Degree and duration of the par- oxysm, on what de- pendent. Sometimes apparent death.which may be mis- taken for real. Exempli- fied. Recovery commonly effected without me- dical aid, and why. Process of recovery The swooning produced by fd- tigue, long-fasting, or a sud- den and excessive discharge of any fluid, whether natural or morbid, accompanied with a sense of inanition, and great prostration of strength. Preceded by severe pain or ir- ritation of body, internal, as from poisons, flatulency, or worms ; or external, as from wounds or other injuries. Preceded by an exercise of some sudden and overwhelming passion or emotion. Accompanied with a retroces- sion or repulsion of gout, ex- anthems, or other diseases. The degree and duration of the paroxysm depend upon the peculiarity or the violence of the cause, the extent of the sen- sorial exhaustion, or the nature of the constitution, and hence must greatly differ in different individuals. In some cases it ceases in a few minutes, and the patient, though incapable of speaking, retains enough of perception and sensation to be conscious of his own disorder, and to understand what is passing around him. The pressure and irritation of flatulency in dys- peptic and hypochondriacal habits are often sufficient of them- selves to produce a fainting of this kind. In other cases the general feeling and understanding fail totally, and the pulse is scarcely perceptible. Occasionally, the sensorial power has been totally as well as suddenly exhausted, and the syncope has run into asphyxy, and even proved fatal. Hence, Portal has justly remarked that " we may have ap- parent death from syncope as well as from asphyxy, and that, from not attending to this, we may mistake, and bury the living with the dead. I have seen," he adds, " a man who, after a violent fit of colic, remained for many hours in a state of syn- cope without pulse, with the colour and coldness o'f death, and without any respiratory motion of the chest whatever. After some hours of such apparent death, he passed a bilious concre- tion, and the fainting vanished."* When not assisted by medicine, the system recovers itself by the gradual accumulation of sensorial energy that must ne- cessarily take place, so long as the living principle continues, during such a state of quietism; aided, unquestionably, by the continual action of (he instinctive, or remedial power of na- ture, which is always aiming to repair what is amiss. The process of recovery, however, varies almost as much as that of sinking. Some revive almost immediately, without any incon- 8vo, Memoires sur la Nature et le Traitement de plu&ieurs Maladies, torn. iv. Paris, 1819. cl. iv.] NERVOUS FUNCTION. [ord. iv. 377 venience or sense of weakness whatever; while others im- Gen.VI. prove slowly and almost imperceptibly, and require many hours Spec. I. before they fully regain their self-possession. In various cases, Syncope the head becomes clear as soon as the pulse becomes regular; while, not unfrequently, the recovery is accompanied with a confusion of ideas, vertigo, and head-ach. As this disease is always attended with an irregularity in the Xe,tn1^ be n c i i c v .• aided by now ot nervous power, and some degree ot spasmodic action, me^;cai entastic or clonic, about the heart, the best remedies we can means. have recourse to, during the paroxysm, are antispasmodics and Remedial stimulants; and those which are the most volatile, are the most process. useful. Hence the advantage of admitting a free current of cold air, sprinkling cold water over the face, and pouring a lit- tle of it, if possible, down the throat. And hence, also, the advantage of holding ammonia, the strongest vinegar, or any other pungent odours, to the nostrils. A recumbent position is always advisable, as most favourable to an equable circula- tion of the blood ; and irritating and warming the extremities by the friction of the hand, or the application of rubefacients, will commonly be found to expedite the recovery, upon the prin- ciple we often had occasion to advert to, that, in a chain of or- gans united by sympathy or continuity, an impression, produced on the one extremity, is sure to operate on the other. As soon as the patient is capable of swallowing, some spirituous cordial, as a glass of wine, brandy and water, fetid tincture, or the aro- matic spirit of ammonia or of ether, should be administered ; and the occasional cause should be sedulously avoided in future. Species II. Syncope Recurrens.—Fainting-Fit. Recurring at periods more or less regular ; occasional palpitation of the heart during the intervals ; and unquiet respiration during the paroxysm. This is, in most cases, a far more serious form of syncope Commonlya than the preceding, and is commonly ascribed to some structu- f™'me ^fr,°Ua ral disease of the heart or the large arteries that immediately disease than issue from it, as an ossification ofthe valves, polypous con- the last, as cretions, an enlargement or thickening of the substance of "^tde_ the heart, an accumulation of water in the pericardium, or an upon some aneurism. structural Each of these may possibly be a cause in some instance or "[Xhear't other; and where, during the paroxysm, the breathing, though or ]arger feeble, is anxious and obstructed, the face livid, and the patient arteries. in the midst of the swoon shows a tendency to jactitation, or an uneasiness on one side or on the other; and, more especially still, where no ordinary exciting cause can be assigned, and it has commonly followed some unusual exertion, or hurry of the blood through the lungs, it would be imprudent not to suspect such mischief. vol. iv. 48 378 cl. iv.] NEUROTICA. [oru.it. Gen. VI. Spec. II. Syncope recurrens. But not always so : many cases being from slighter causes. How such causes operate. Periodical ■woonings. Patient's idiosyncrasy to be studi- ed. Remedial treatment. But there are causes of a different and much slighter kind that I cannot avoid believing frequently operate in the produc- tion of recurrent syncope, and that, too, with many of the pe- culiar symptoms just enumerated. And 1 now allude to any ot the ordinary causes of syncope, as set down under the first spe- cies, or any other incidental irritation whatever, occurring in a constitution of great mobility and excitability, or vvhere the heart alone, or in conjunction with the whole arterial system, is peculiarly disposed to that irregular and clonic action, which we have noticed under the species palpitation, and particularly under the first and second varieties. In such a frame of body, any sudden alarm, a longer absti- nence than usual, a fuller dinner than common, unwonted ex- ercise, and a thousand minute excitements of daily occurrence will often succeed in producing a fainting-fit; and especially where a morbid habit of recurrence has been once established, and there is a predisposition to return. Atonic plethora is ano- ther frequent cause in the peculiar constitution we are now considering, and a cause far too liable itself to establish a circle of recurrence, and consequently to give recurrence to the form of syncope before us. There is a singular example of periodic swooning in the Ephemera of Natural Curiosities,* which seems to have been dependent upon this state of body ; and another example, in which it was evidently produced by a re- turn of the term of menstruation, and became its regular har- binger.! In all cases of this kind, therefore, it is ofthe utmost import- ance to study minutely the character ofthe patient's idiosyncra- sy and habit, and not to excite any alarm concerning organic mischief, and thus add another excitement to those which alrea- dy exist, while there is a probability, that the affection may be owing to one or other of these lighter and more manageable causes. In the latter case, tonics, cold bathing, equitation, regular hours and light meals will form the best prescription. Where we are compelled to suspect some organic impediment, or other mischief about the heart, small bleedings that may anticipate the usual time ofthe return, camphor, nitre, hyoscyamus, and what- ever other sedative may be found best to agree with the patient and diminish the rapidity ofthe circulation, will form the most rational medical plan we can devise ; while tranquillity of body and mind, an abstinence from all stimulant foods, and a regular attention to the state ofthe bowels, should form a standard rule for the whole tenour of his life. Origin of the generic term GENUS VII. SYSPASIA.—COMATOSE SPASM. Clonic spasm ; diminished sensibility; inability of utterance. Syspasia, or syspasis, from avona.*, " contraho, convello," lit- * Dec. II. Ann. I. Obs. 10. t Id. Dec. h. Ann. v. Obs. 53. CL. iv.] NERVOUS FUNCTION. [ord. iv. 379 erally imports convulsion in the popular sense of the term, or Gen. VII. in other words, clonus or agitatory spasm, in combination with Syspasia. a greater or less degree of failure of the sensation and the un- derstanding. The term seems wanted as a generic name for the three following diseases, whose symptoms, and, for the most part, mode of treatment, are so accordant, as to establish the propriety of linking them under a common division : 1. syspasia convulsio. convulsion. 2.-------hysteria. hysterics. 3.-------epilepsia. epilepsy. The author has entered so fully into the nature and principle p"11"1^ of clonic or agitatory spasm under the genus clonus, that a very gy g?venun. few remarks will be necessary in explaining the pathology of dercloDus. these three species. They are all of them clonic spasms, as ex- pressed in the definition, but complicated with other morbid af- fections, and particularly with those of the two preceding ge- nera: for, if we combine clonic or synclonic spasm with differ- ent modifications of vertigo or syncope, we shall produce the three species now before us. In explaining the nature of clonic spasm, we noticed the ten- dency there frequently exists, when the uniformity of the flow ofthe sensorial power is once interfered with, to alternations of a hurried and excessive, as well as of a restrained and deficient supply, and consequently to an intermixture of constrictive or entastic spasm with clonic or agitatory, of which palpitation, and various other affections of this kind, afford perspicuous ex- amples. In the diseases immediately before us, the proofs of Distinctive such an intermixture are still more striking; for there is not one g"^01 of them but evinces an union of both descriptions ot spasmodic that apper. action in a high, though not an equal, degree of vehemence, tain to the In convulsion-fit the two kinds of spasm are nearly upon a bal- St- ance, commonly with a retention of some share of both sentient and percipient power. In hysteria, the spastic or entastic action, in its sudden and transient irruptions, is more violent than the clonic, the force exercised at this time is enormous, ami there is also, in many cases, a small retention of sensation and under- standing. In epilepsy, the clonic action is most conspicuous, and the failure of the mental and sentient faculties generally C°Sf'nie'essence of the nervous power, we have repeatedly Pathologic-^ stated that we know nothing; for we can trace it only by its already ad. effects • but we are compelled to conceive it to be formed by va(,ced some particular organ within the animal system, which organ jjphedk^ there can be no difficulty in contemplating as the brain singly, gemi8> or the brain and nerves jointly, which constitute only different Nervous parts of one common apparatus. Admitting this the nervous power, how nower may be produced in excess or in deficiency, orbeimper- acquainled fectly elaborated, and, however produced it may be "regularly ^ble transmitted, as well by precipitation as by interruption Ihe Producible means by which these diseased actions take place, we have al- aml .„ ready touched upon ; and have shown, that the common causes deficiency, 380 cl. iv.] NEUROTICA. [ord. iv. Gen. VII. are sometimes mental, sometimes mechanical, sometimes sym- Syspasia. pathetic, and sometimes chemical, as narcotics and other poisons, by mental, and repelled eruptions. mehanical, Now jt }s jn persons of relaxed or debilitated fibres, that we andchemic-0 fin(1 these exciting causes chiefly operative. For in those of al causes. high health, full vessels, and a firm constitution, however the These circulation may be accelerated, or the nervous power excited, where' ^s rarely that we meet with clonic spasms, or, indeed, spasms chiefly of any kind: or, at least, we meet with a far less tendency to operative. sucn abnormities, than in persons of lax and debilitated fibres, possessing, necessarily, more mobility, or facility of being put into new actions from the very quality of debility itself. Hence the The common predisponent, then, is weakness, particularly of c0 fi'"0" • ^e nervous system ; and the common excitement, irritation. The fioVweTk- peculiar effect must, however, be modified by the idiosyncrasy or ness, espe- peculiarity ofthe constitution, or of collateral circumstances, by ciallyoi the which it may be influenced at the time. And hence the very system.- exciting cause that in one individual may produce hysteria, in and hence another may produce epilepsy, and in a third the more fugitive the different anj jess jmpressive attack of syspasia, as convulsion.* fortius in6" The nature ofthe idiosyncrasy, or, more particularly, of the different individual constitution, is rarely within our control; but the col- mdividuals. ia(erai circumstances are often before us : they constitute the Idiosyncra- . . ,, . ,. 1 i 1 1 r • * sy rarely occasional cause ot the disease, and should iorm a prominent within m«-di- point in our attention to its progress. cal control. There are, perhaps, few more common causes of weakness than tendedves- over-distended vessels; and hence plethora is a frequent occa- ■elsacom- sional cause of each of the diseases belonging to the genus be- Tweaknes- f°re US5 tne sPecies actually produced depending, as just observ- whence ' ed, upon the influence of other circumstances. Thus, if such ple- plethora a thora take place in a young woman of eighteen or nineteen, frequent whose menstrual flux has been accidentally suppressed or re- ncciisional . . , . . , ■ • 1 cause: tarded, it is most probable, if an irregularity in the nervous fits ofhys- system be hereby excited, that such an irregularity will lead to teric«:orof a £t Qf hySteriCSi rather than to one of convulsion or epilepsy, ' since we shall find, as we proceed, that this species of spasm is peculiarly connected with an irritable and especially an orgastic state ofthe genital organs. On the contrary, if the plethora produce chiefly a distention of the vessels ofthe brain, epilepsy is more likely to be the re- sult ; in other words, that form of spasmodic action, in which the sensation and the intellect suffer more severely, than in either of the others. While, if the plethora be general, we have reason to expect, that the spasmodic effect will be gener- or ol" con- al also, or, in other words, take the form of convulsion in which ^!sl0"i no single organ is tried more than another. Yet plethora, in a thora hi^o- Arm and vigorous frame, is seldom found to produce either of bust persons these affections, for the resistance ofthe coats ofthe blood-ves- 'u'emTy sels is ^ere sufficient to counterbalance the impetus ofthe san- produces guineous fluid, and, consequently, to prevent an over-distention. these effects. * Pritchard on Nervous Diseases, p. 139. CL. IV.] NERVOUS FUNCTION. [ord. iv. 381 And hence, again, we see in what manner debility becomes are- Gen.VII. mote or predisponent cause of the diseases under our consider- Syspasia. ation. Plethora, thus acting by over-distention, may be regarded as Plethora in a mechauical stimulus, upon the removal of which, as upon the ^eec|Jam?ceala removal of other mechanical stimuli, the disease will cease, stimulus. Venesection is the most direct means of such removal; but it labours under the inconvenience of being only a temporary remedy. It takes off the occasional cause ; but, by adding to the general debility, it gives strength to the predisposing cause. The more direct mechanical stimulants are sharp-pointed os- More direct sifications formed in the membranes of the brain, or arising ™£™n2, from the internal surface of the cranium ; splinters of a fractur- ed cranium, or the introduction of some wounding instrument. The occasional causes resulting from mental emotions, we have Mental already been called to notice more than once; as also to show, causes- that, while some of these appear to act by instantaneously ex- hausting the sensorial organ of its living principle, others oper- ate by giving a check to the production ofthe sensorial power. These modes of action are indeed opposite, but the result, which is a depletion of the nervous apparatus, is the same. And as, in weakly or relaxed habits, there is in every organ a Why, in greater mobility, or facility of passing from one state of action ^J™^ to another, than in the firm and robust, we see also why the habits, the former should be not only more subject to spasmodic actions j,enr,Peras from mental emotion, but to sudden changes of mental emotion, ™as the and, consequently, to caprice and fickleness of temper. . ^ Species I. Syspasia Convulsio.—Convulsion. Muscular agitation violent; teeth gnashing; hands forcibly clenched: transient. In defining convulsion, most of the nosologists represent the Synonyms. faculties of the mind and the external senses as still sound and unaffected. Sauvages says, "superstite in paroxysmis animte Whether functioaem exercilio." Vogel distinguishes it, « cum integri- P^™ tate sensuum." Dr. Cullen is more exact than either of these. lhe parox. His words are, " musculorum contractio clonica abnormis, citra ysm. soporem;" " an irregular clonic contraction of the muscles, bordering on but short of lethargy." The influence ofthe dis- ease on the sensation and perception varies considerably in dif- ferent cases, but, so far as I have seen, the sensibility is always in some degree diminished, and I have hence ventured to intro- duce this feature into the generic definition as a pathognomonic symptom. • . There are also some other differences that occur in the char- acter ofthe disease in its different attacks, and which have been laid hold of as the ground-work of very numerous subdivisions by many nosologists. For these differences we cannot always account: but in general they will be found to depend upon the 382 cl. iv.] NEUROTICA. [ORD. IV. Gen. VII. Spec. I. Syspasia convulsio. idiosyncrasy, habit, or stage of life in which the disease makes its appearance, and to give rise to the following varieties: x Erratica Migratory convulsion. /S Universalis. General convulsion. y Recurrens. Recurrent convulsion. 3 Ejulans. Shrieking convulsion. i Puerperalis. Puerperal convulsion. £ Infantilis. Infantile convulsion. «»« deformity or some spicular node within the cranium ; and are said by Desessartsj to occur most frequently in those whose skulls are peculiarly large, or, in the language of Morgagni,! nearly cubical in the occipital region. Pressure, however, or congestion in the braiu, from whatever cause, is an occasional source of this complaint. And hence convulsion is a frequent mental result of severe fright, or any other violent agitation of the em010DS: mind. And, like several of the species we have just noticed, it suppressed is a frequent result of some suddenly suppressed natural or ^aec^on8 morbid discharge, or suddenly repelled complaint affecting a lhems> remote organ. It has hence appeared on suppressed menstrua- tion, suppressed flow of milk, leucorrhcea or lochia ; suppressed dysentery,§ the suppressed discharge from an old ulcer,|| re- pelled gout, exanthems, and cutaneous eruptions. The usual causes in pregnancy and infancy have been already noticed. Convulsions are also frequently produced by many of the nar- Narcotic cotic poisons in a certain degree of strength or activity, and a P01*0113. certain state of the constitution. For if the dose be very large, or the system much debilitated at the time, the' irritability will be entirely destroyed, and death will often ensue instantaneous- ly, without any struggle whatever. Thus the distilled water of the leaves or kernels ofthe prunus lauro-cerasus, under different as prunus circumstances, will produce both these effects; as will also the ^ro-ceras- distilled water of the kernels of various other fruits possessing prussic acid, as those of the black cherry and bitter almond- tree ; and hence the prussic acid itself; And we may hereby understand the remark of Sir Hercules Langrishe, that one ounce * Baumes.—Des Convulsions de l'Enfance, de leur Cause, et de leur Traitement, &c. 8vo. Paris, 1789. t Journ. de Med. xlvii. 114. t De Sed. et Caus. Morh. Ep. ix. 9. * Hoefner, Baldinger N. Mag. b. vi. p. 323. || Gruellmann, Diss. Observ. de usu cicutae Goett. 1782. Ephem. Nat. Cur. Dec. in. Ann. ii. Obs. 74. 384 cl. iv.] NEUROTICA. [ord. iv. Gen. VII. of laurel-water will occasion more violent and stronger convul- Spec. I. sions? than five or six ounces. The dose of this water given, ^S. Con- by way of poison, to Sir Theodosius Boughton, was a draught- fa'S"" Phial fnl,> and' consequently, about an ounce and a half. The struggling fit, in this case, began in a minute and a half, or two minutes, after it was swallowed ;* it continued for about ten minutes, when he expired. The spasmodic action, produced by these plants, is chiefly clonic, which, in effect, is the ordinary action with which life ceases: but there are others that render it of a mixed charac- ter, the entastic alternating with the clonic ; and some, in which the rigid or entastic power considerably predominates, as in the upastiente. poisonous juice of the upas tiente, which, though with occa- sional relaxations, fixes the muscles as rigidly as in tetanus, and continues the rigidity till the patient dies. A paroxysm In ordinary cases, however, the mode of attack and the pro- sometimes gresg Qe ^e par0Xysm exhibit a considerable variation. Some- lome^mes times the assault is sudden and without any warning; but, more ushered by generally, there are a few precursive indications, and especial- precursive ]y in patients who are subject to returns of it ; such as a cold- S'6nS' ness in the extremities with a dizziness in the head, and float- ing spectra before the eyes, or a flatulent uneasiness in the bowels, and a tenseness in the left hypochondrium. In other cases, the patient complains of tremors in different muscles, and a cold aura creeping up the back which makes him shiver. Diagnostics The^stroggle itself, I have already said, varies equally in its and descrip- extent and violence, and I may add in its duration. The mus- tion' cles are alternately rigid and relaxed, the teeth gnash, and often bite the tongue, the mouth foams, the eyelids open and shut in perpetual motion, or are stretched upon a full stare, while the protuberant balls roll rapidly in every direction: the whole face is hideously distorted. The force exerted is enor- mous, so as frequently to shake the entire room, and overpower the strength of six or eight attendants. In some instances, it has been so violent as to break a tooth, and even fracture a bonej. When the lungs are much oppressed in the course of the contest, the lips, cheeks, and indeed the entire surface, is dyed with a dark or purple hue. C « ud- ^e paroxysm will sometimes cease in a few minutes, but denly:or occasionally lasts for hours, and, after a short and uncertain continues period of rest, returns again with as much violence as before ; a for hours: ^ . p£cu];ar|y common to puerperal and infantile convulsions. or returns at " r j r r uncertain Great languor commonly succeeds; sometimes head-ach, verti- peiiods. go5 and vomiting, occasionally delirium : but not unfrequently, and especially in infants, there are no secondary symptoms whatever. Medical The treatment of convulsion must apply to the paroxysm treatment itself, and to the state ofthe constitution which gives a tenden- of two kinds, . .. as respecting c)r t(> lts recurrence. the parox- If it proceed from a narcotic or any other poison introduced ysm and the interval. * Guiney's Trial of John Donellan, Esq. for the wilful murder of T. E. A. Boughton, Bart, folio, pp. 18, 19. t Eph. Nat. Cur. Dec. H. Ann. 7. CL. IV.] NERVOUS FUNCTION. [ord. iv. 335 into the stomach, much benefit may often be obtained from the Gen. VII. stomach pump. If the poison be in a liquid form, most of it may Spec I. hereby be withdrawn, while the remainder, or the whole, if it Syspasia be a powder, may be diluted and pumped up afterwards. convulsio. As there is danger from congestion in the brain, venesection yrea ™*n.' is, in most cases, a good measure of caution, and, in many in- generally stances, is absolutely necessary: and hence, where plethora has useful, preceded, and has threatened to become a cause, the disease has often been prevented, and sometimes effectually cured, by a spontaneous hemorrhage from the nose, the ears, or some other organ. But we have often had occasion to observe that, but in par- in weak and relaxed habits, bleeding, if frequently repeated, ticular ha- increases the tendency to plethora; and, on this account, how bi,s ,0 b« necessary soever at the time, it should be employed with eau- with great tion, and persevered in with reluctance. caution. Brisk cathartics introduced into the stomach, if possible, and Cathartics where this cannot be accomplished, in the form of an injection, "'ways use- lower the morbid distention almost as effectually, and in some fuL instances directly remove from the system the principal fomes of the complaint. Emetics are of more doubtful effect: they Emetics: also may, occasionally, carry off the actual cause of irritation, and, by powerfully determining to the surface, make a favoura- ble diversion of action. But, in many cases of debility, they i,aveoften have evidently increased the violence and prolonged the dura- proved in- tion of the fit. In puerperal convulsions, they are strongly dis- jidicious. approved by Dr. Miguel.* The authorities, however, in their favour, are numerous and highly respectable. Le Preuxf strongly recommends them in early infancy: and Hoeffner as- serts, that he has found them highly serviceable where the irritation proceeded from dysentery.J Schenck employed them generally with considerable success, and preferred the prepar- ations of copper, and particularly the verdigris, to any other emetic, from their rapidity of action.§ Antispasmodics are Antispasmo- certainly entitled to our attention, and often succeed in allaying: dlcs of.ten the irregular commotion. Those most commonly resorted to are ammonia, ether, musk, camphor, and valerian. The empy- Empyreu- reumatic oils, both animal and vegetable, seem to have fallen as Inatic0is' much below their proper value in the present day as they were once prized above it. And the same may be observed of the Volatile fe- volatile fetids generally, as fuligo, assafoetida, and chenopodium lJ^*- Vulvaria or stinking arach : the last of which, however, under diunTv'uJ- the older name of atrip lex foctida, seems to have been a favour- varia. ite with Dr. Cullen. It is not very easy to explain the operation of antispasmodics Atriplex of this kind. Dr. Cullen refers it to their volatility alone, and |j?,"!a* hence concludes, that they are useful in proportion as they are 0f opera-0 * volatile; which is, in fact, to regard them in the light of stimu- tion. lants. But, beyond this, they seem to possess a sedative power, which probably resides in their fetor. Where flatulency or * Traite des Convulsions chez les Femmes Enceintes, &c. Paris, 1824. t Diss. An. Convulsionibus recens natorum Vomitoria? Paris, 1765. | Bald- ing. N. Mag. b. vi. 323. i Lib. I. Obs. 244. VOL. IV. 49 386 cl. iv.] NEUROTICA. [ord. iv: Gew. VII. Spec. I. Syspasia convulsio. Treatment. Carmina- tives. Narcotics. Cold and heat. Action of heat. Action of eold. Often useful in infantile convulsions. Illustrated. some other misaffection ofthe stomach is the exciting cause, as is frequently the case in infancy, after opening the bowels, the warmer carminatives of asice, mint, ginger, and cardamoms will often be found sufficient; and where these fail, recourse has been had to opium, hyoscyamus, belladonna, and sometimes St. Ignatius's bean, or M. Wedenberg's favourite medicine in this disease, the extract of stramonium.* Cold and heat have also been very frequently resorted to as powerful antispasmodics, and, in many cases, with considerable success. Heat appears to act by a double power, and espe- cially when combined with moisture, with which it is always most effectual. It both relaxes and stimulates: and is hence admirably calculated to harmonize two alternating and contend- ing states of a morbid rigidity and a morbid mobility, on which the disease depends, and consequently to restore a healthy equi- poise of action. On this account we find warm bathing, and especially in infantile convulsions, of great benefit. It ought not to be forgotten, however, that both effects, as well the stimulating as the relaxing, have a considerable tendency to ex- haust and debilitate, and hence the warm bath must not be fre- quently repeated. The immediate effect of a sudden application of cold, whether by a blast of air, or by an affusion of water, is a general shud- dering, a spasmodic contraction of the entire skin. And hence, where cold, applied in this manner, takes off either clonic or entastic spasm, it is^by a revulsive power; by a transfer ofthe spasmodic action from a particular organ, or set of organs, to the surface of the body generally ; in the same way as blister- ing the neighbourhood of an inflamed organ, takes off the pri- mary inflammation by a transfer of the inflammatory action to the part where the blister is applied. If the cold excite a gene- ral reaction, and the shuddering be succeeded by a glow, it be- comes a direct and very powerful tonic: and, on both these accounts, is a remedy highly worth trying in hysterics, convul- sions, and even those cases of epilepsy, in which a suspicion of some structural cause of irritation within the cranium does not form a bar, by prohibiting every thing that may increase the impetus ofthe blood. In the convulsion-fit of infancy, the affusion of cold water, so far as I have seen, may be much oftener resorted to with per- fect safety, than the fears of mothers will allow ; and be found much more successful in a hot close unventilated nursery, than the more popular description of a warm bath. And where I have not been able to proceed thus far, and the warm bath has been tried repeatedly in vain, I have frequently succeeded by taking the little infant in my arms, and exposing him naked, or nearly naked, for a few moments to the air of the window, thrown open to allow it to blow upon him. The great diminution of sensibility, which prevails at such a time, prevents all danger of catching cold; while, on the contrary, the little patient is Dissertatio Medicade Stramonii usu in Morbis Convulsivis, 4to. Upsalise. CL. IV.] NERVOUS FUNCTION. [ord. iv. 387 usually revived by the sudden rush of the external air, and the Gew. VII. fit, in many cases, ceases instantly. Spec. I. Cold bathing, when not prohibited by any other complaint, Syjpasia will also be found a useful tonic in the intervals of the attacks, coovuls,°' and may conveniently be employed in conjunction with internal Treatment. medicines of the same character.* Of these the metallic salts In the inter- and oxydes are chiefly to be depended upon, and especially bath^n* * those of iron, copper, arsenic, silver, and zinc. Zinc has had ^aii^ by far the greatest number of advocates, and is generally sup- oxydes. posed to have succeeded best in the form of its white oxyde, Zinc Imw ten or twelve grains of which are usually given to an adult in far useful, the course of twenty-four hours. Mr. Dugaud increased the j£nn,1n w ia proportion to fifteen grains ;t and Mr. Bell, at length, prescrib- ed not less than ten grains at a time, repeated three times a day.J [Dr. Brachet joins the extract of henbane with the ox- yde of zinc, giving to children four grains of the former, and two of the latter, in divided doses, one of which is taken every three or four hours.] In the hands of the present author, zinc has proved more salutary in the form of its sulphate, which has not unfrequently succeeded where the oxyde has failed ; the usual proportion which he has employed, being a grain three times a day, given in the emulsion of bitter almonds. Where silver has been made choice of, the usual preparation has been its nitrate, and the dose has begun with a grain given four or five times a-day in the shape of a pill, and gradually increased lo eight or ten grains, or as much as the patient's stomach will bear. The virtue of all these, however, seems considerably im- All im- proved by a combination with camphor, which has often been proved by a found advantageous even alone. " In spasmodic, or convulsive [jjJJJ ™^ affections," says Dr. Cullen, " it has been of service, and even camphor« in epilepsy it has been useful. I have not indeed known an w,hlc'V.g. epilepsy entirely cured by camphor alone; but I have had sev- jjseer||i e'ven eral instances of a paroxysm, which was expected in the course alone. of a night, prevented by a dose of camphor exhibited at bed- time; and even this when the camphor was given alone; but it has been especially useful when given with a dose of cuprum ammoniatum, or the sulphate or the flowers of zinc."§ The vegetable tonics are little to be depended upon. The Vegetable bark recommended by Dr. Home, Sumeire, and many other tonics. distinguished writers, is rarely of use, except where the pa- roxysm is periodical: and the cardamine pratensis (lady-smock), Cardamine sempervivum tectorum (house-leek), and viscus quercus (mistletoe), PrateM»« are hardly worthy of notice in the present day, notwithstand- ing the specific virtues they were supposed to possess former- ly. The cardamine, the eurvftfyor trip* of Dioscorides, is of an- ^j£rj"_m cient celebrity, and, in modern times, has been warmly extolled rides.'unduiy by the commanding authorities of Mr. Ray, Sir George Baker, praiu'ed by high au- * Y. W. Wedel. Liber de Morbis Infantum, cap. xiii. t Edin. Med. thorities. Comment, v. 89. X *d- '• 120» * Medical Transactions, vol. i. art. XIX. 388 cl. iv.] NEUROTICA. [ord. IV. Gew. VII. Spec. I. Syspasia convulsio. Treatment. Sempervi- vum tecto- rum, or house-leek. Viscus quercus, or mistletoe. and Dr. Home ; the second of whom, as was noticed under the head of chorea, declares himself to have succeeded in its use, not only in cases of convulsion, but of all clonic spasms what- ever, and this, too, when almost every other medicine had failed.* The house-leek was employed in the form of an expressed juice intermixed with an equal quantity of spirit of wine, which gives a white coagulum, resembling cream of fine pomatum, that has a weak but penetrating taste, and was supposed, from its ready evaporation, to contain a considera- ble portion of volatile alkaline salt. The mistletoe has rarely been employed in our own country, except by Dr. Home, who thought he found it serviceable ; though it is chiefly indebted for its fame as a specific in convulsions, to the practice and writings of Colbatch.t It has been given in powder, infusion, and extract. Origin of generic term. Usually though not always con- nected with a morbid condition of the uterus. Often con- founded with hypo- chondrism. Distinctive characters. Species II. Syspasia Hysteria.—Hysterics. Convulsive struggling, alternately remitting and exacerbating ; rum- bling in the boivels; sense of suffocation; drowsiness ; urine co- pious and limpid ; temper fickle. Hysteria, from la-rt^x, " the uterus or vulva," or more cor- rectly " viscus posterius vel inferius," evideutly imported, in an early period of medical science, some inisaffection of the womb or other sexual organ: and hence hysteria, among the Greeks and Romans, was also a term by which female midwives were denominated, or those who especially attended to affec- tions of the hysteria or womb. The Latin term uterus, al- though it approaches it in sense and sound, is altogether of a different origin. For this has a direct reference to the use and figure of the uterus as a single organ, and is an immediate derivation from uter, a bag or bottle. With a morbid condition of this organ, indeed, hysteria is in many instances very closely connected, though it is going too far to say, that it is always dependent upon such condition : for we meet with instances occasionally, in which no possible con- nexion can be traced between the disease and the organ ; and sometimes witness it in males as decidedly as in females. It has been contended by various writers, that, in this last case, the disease ought to be called hypochondrism, the hypochon- drias of the present work; and that hysteria and hypochon- drias are merely modifications of a common complaint. No- thing, however, can be more erroneous. These two diseases have often a few similar symptoms, and more particularly those of dyspepsy; but they are strictly distinct maladies, and are characterized by signs that are peculiarly their own. The * Auserl. Abhandl. fur Pract. Aerzte. b. x. 13. t See also Diss, sur la Gui de Chene, Remede Specifique pour les Maladies Convulsives. Paris, 1719. CL. IV.] NERVOUS FUNCTION. [ord. iv. 389 convulsive struggling paroxysms, the sense of a suffocating ball Gew. VII. in the throat, the fickleness of temper, and the copious and Spec. II. limpid urine, which arc pathognomonic of hysteria, have no Syspasia necessary connexion with hypochondrias, and are never found by8te^,a• in this disease when strictly simple and idiopathic. While, on the contrary, the sad and sullen countenance, the dejected spi- rits, and gloomy ideas that characteristically mark hypochon- drias, have as little necessary connexion with hysteria, and are in direct opposition to its ordinary course. Hysteria is strictly a corporeal disease, hypochondrias a mental, though it common- ly originates in corporeal organs, but organs that have a pecu- liar influence upon the mental faculties, and has not established itself till these participate in the morbid action. Hysteria is a disease of the irritative fibres, hypochondrias of the senti- ent ; hysteria is a disease of early life, hypochondrias of a later period. Both, however, are diseases of a highly nervous or excitable temperament, and, as such, may co-exist in the same individual : but so also may vertigo or cephalaea with either of them; which would nevertheless continue to be regarded as distinct diseases, notwithstanding such an incidental conjunction. And hence Mieg,* and various other established writers! upon Hence the the subject, have not incorrectly, though perhaps unnecessari- nvster'a ly, treated of the disorder before us under the two divisions of onviieglag male and female hysteria, hysteria virorum, or masculina, and distinguish- hysteria foeminina. Swediaur, who affirms that men may labour 5d ^r.0?1 ^ Aj il u « u "1l- j foeminina. under the hysteric passion as well as women, arranges this and „ hypochondrism as distinct species of a common genus, to which, kin^iaof with his extravagant fondness for long Greek terms, he has Swediaur. given the name of hyperkinesia. Hysteria, like all other clonic affections, shows itself most Period of frequently in mobile and irritable temperaments, and particu- J,fean^ larly during that period of life in which irritability is at its ^emTio" highest tide, as from the age of puberty to that of thirty-five which hy- years, seldom appearing before the former, and rarely after the ',en? latter of these terms. The common occasional causes of con- appears. vulsion, which we have already described, are also those of Occasional hysteria; and hence, disorder of the stomach, or other ab- causes. dominal organs, mental emotions, plethora, and particularly turgescence of the sexual region, are among the most frequent; on which account, we are told by Forestus,J and Zacutus Lusi- tanus,§ that one of the most common causes of hysteria in males is a retention of semen, as one of its surest cures is an excretion. As every thing, moreover, that disturbs the uniform trans- mission of the nervous energy, or the ordinary diameter of the blood-vessels or cavity of the heart, becomes a powerful irri- tant, we may also see why this disease should occur on debili- * Epistolae ad Hallerum scripts, No. v. + Eph. Nat. Cur. Dec. ii. Ann. iv. Obs. 18. 61. Traite INouveau de Medecine, &c. Lyons, 1684, X Observ. et Curat. Medic. Libr. xxvm. Obs. 29. 33. i De Praxi Admiranda, Libr. H. Obs. 85. 390 CL. IT.] NEUROTICA. [ORD. IV. Gew. VII. Spec. II. Syspasia hysteria. Pathology. Why some- times of a clonic cha- racter and sometimes of a spastic. Hence the last most common to robust con> ■titutions. Paroxysm generally without any previous warning. Signs de- scribed. Commence- ment and progress of paroxysm. Sphincter ani. tating, and especially sudden evacuations, and be at no loss to account for its appearing on excessive as well as on suppressed menstruation, and consequently in leucorrhoea. And as the sexual organs lose much of their orgasm during the period of parturition, we may also see why the disease should attack bar- ren rather than breeding women, particularly young widows, who are cut off from the means of exhaustion they formerly en- joyed ; and, more especially still, those who are constitutionally inclined to that morbid salacity, which has often been called nymphomania, and, in the present work, will be found under the genus LAGNES1S. 1 have already endeavoured to show by what means, in a ha- bit of great nervous irritability, both clonic and entastic or rigid spasms are produced ; and the disposition there frequently exists for them to pass into each other, or to alternate in rapid succession. And we have also seen, that the former is most predominant in laxer, and more mobile, and the latter in firmer and more vigorous constitutions. There is no frame, however, that may not become a prey to spasmodic action of some kind or other, and hence, there is no frame that may not become a prey, under particular circumstances, to the species of spasmo- dic action we are now describing. These circumstances are very generally concealed from us ; but we uniformly perceive, that the rule we have now adverted to holds true ; and that the hysteric spasms will assume more or less of a clonic, or of a spastic character, in proportion as the individual is of a more relaxed or a more vigorous make. And hence the most violent, though the least common, instances of hysteric struggle that oc- cur to us, are in young women of the most robust and masculine constitution. The paroxysm often takes place without any previous warn- ing or manifest excitement whatever, and especially where it has established itself by a frequency of recurrence. Occasion- ally, however, we have a few precursive signs which rarely show themselves in vain : as a sense of nausea or sickness, flatu: lency, palpitation ofthe heart, depression of spirits, and sudden bursts of tears without any assignable cause. The fit soon suc- ceeds with a coldness and shivering over the whole body, a quick fluttering pulse, and an acute feeling of pain in the head, as though a nail were driven into it. The flatulency from the stomach or colon rises in the sensation of a suffocating ball into the throat, and forms what is known by the name of globus hystericus. The convulsive struggle now commences, which in women of very mobile fibres is sometimes very feeble, the re- laxant alternations prevailing over the contractile : but, in other cases, is prodigiously violent, evincing during the contractions a rigidity as firm as in tetanus, and a force that overcomes all opposition. The trunk of the body is twisted backward and forward, the limbs are variously agitated, and the fists are clos- ed so firmly that it is difficult, if not impossible, to open the fingers; and the breast is violently and spasmodically beaten. An equal spasm takes place in the sphincter ani, so that it is c*. iv.] NERVOUS FUNCTION. [ord. iv. often found impracticable to introduce a clyster pipe; andthe Gew. VII. urine discharged, though copious, is colourless. The muscles Spec. II. ofthe chest and trachea are agitated in every way, and hence, Syspasia there is an involuntary utterance of shrieks, screams, laughino-, hystena< and crying, according to the direction the spasm takes, some- ^£1*? times accompanied with, or succeeded by, a most obstinate and screams, distressing tit of hiccough. When the fit ceases, the patient ami. fits of appears to be quite spent, and lies stupid and apparently life- ,swShlDS- less. Yet, in an hour or two, or often much less, she perfectly H,CC0"SU- recovers her strength, and has no other feeling than that of a JonXhe general soreness, and perhaps some degree of pain in the paroxysm. head. It is rarely, indeed, that an hysteric fit becomes danger- ous ; though it has, in a few instances, terminated in epilepsy or insanity. The temper is fickle, and the mind is as unsteady as the mus- Fickleness cles: " and from hence," observes the sagacious Burton, who of temPer- has painted strongly, but from the life, " proceed a brutish kind Des"iption of dotage, troublesome sleep, terrible dreams, a foolish kind of hysteric bashfulness in some, perverse conceits and opinions, dejection tempera- of mind, much discontent, preposterous judgment. They are meDt' apt to loathe, dislike, disdain, to be weary of every object. Each thing almost is tedious to them. They pine away, void of counsel, apt to weep, and tremble, timorous, fearful, sad, and out of all hopes of better fortunes. They take delight in doing nothing for the time, but love to be alone and solitary, though that does them more harm. And thus they are affected so long as this vapour lasteth; but by and by they are as pleasant and merry as ever they were in their lives; they sing, discourse, and laugh, in any good company, upon all occasions. And so by fits it takes them now and then, except the malady be in- veterate, and then it is more frequent, vehement, and conti- nuate. Many of them cannot tell how to express themselves in words, how it holds them, what ails them. You cannot under- stand them, or well tell what to make of their sayings."* The mode of treatment bears so close a resemblance to that Mode of for the preceding species, that it will be unnecessary to eularge treatment. upon it. Pungent applications may be applied to the nostrils, or round the temples, or the face and neck may be sprinkled or dashed with cold water during the paroxysm, and warmth and the friction ofthe hand be applied to the feet. The peris- taltic action ofthe bowels should be increased, which can only be done by stimulant and cathartic injections, if the contraction of the sphincter ani will allow them to pass. Our chief attention, however, should be directed to the in- Chiefly to tervals. And here the first recommendation is, sedulously to bedire.cted avoid every remote or exciting cause. If the menstruation be tervals.11" in a morbid state, this must be corrected as soon as may be, Mif-men- concerning which, however, we shall have to speak in the en- struation to suing class. If plethora be a striking symptom, the lancet should becorrec,e<,« be employed. In robust and vigorous habits, we may bleed ^'h0™- Anat. of Melancholy, Part i. Sec. in. 392 ct. iv.] NEUROTICA. [ord. IV. Gew. VII. Spec. II. Sypasia hysteria. Treatment. Tonics, aro- matics, and antispas- modics. freely and have nothing to fear; but, in loose and relaxed con- stitutions, far more caution is necessary, as has been already explained under convulsio. In this last state of body, tonics should also be had re- course to, and many of the warmer sedatives and antispasmo- dics, as assafcetida, camphor, most of the verticillate plants, and cajeput, which was a favourite remedy with Mieg.* Vale- rian has often proved serviceable, but is rarely prescribed in sufficient quantity to produce any good effect. u It seems," says Dr. Cullen, " to be most useful when given in substance and in larger doses. I have never found much benefit from the infusion in water."t The ammoniated tincture of the London College, however, is an excellent form ; but even here the quantity ofthe root employed should be double what is prescribed. The cinchona may be usefully united with valerian, but does not seem to be of much benefit in this disease by itself. Opium is a doubtful remedy: where the precursive signs are clear, it will often allay the irritation, and thus prove of great value. But it so frequently produces head-ach, and adds to the constipation, that it is rarely trusted to in the present day. When resorted to, it is best combined with camphor.J Where the disease occurs in the bloom of life, and there is reason to apprehend the ordinary orgasm of this age to be in excess, the surest remedy is a happy marriage. Origin of the generic term. By the Latins call- ed morbus comitialis, and why. Species III. Syspasia Epilepsia.—Epilepsy. Falling- Sickness. Spasmodic agitation and distortion, chiefly ofthe muscles of the face, without sensation or consciousness: recurring at periods more or less regular. The Greek physicians gave the name of epilepsy, from tiriXxft^xvoftxt, to the present disease from its " sudden seizure or invasion," which is its direct import: and as the violence of passion or mental emotion, to which the Roman people were accustomed to be worked up in their comitia, or popular assem- blies, from the harangues of their demagogues, was one of the most common exciting causes, it was among the latter denomi- nated morbus comitialis, in the popular language of our own day, " electioneering disease," in reference to the time and oc- casion in which it most frequently occurred ; or, according to Seneca, because, whenever the disease appeared, the comitia were instantly broken up.§ There are many other names, also, by which epilepsy was distinguished in former times ; but it is unnecessary to recount them. * Epist. ad Haller. ut supra, No. v. t Mat. Med. Part ii. Ch. vni. X Sydenham has given a description of a cough dependent on hysteria. In its treatment, lie chiefly depended upon opium ; but, in a case recorded by Dr. Sinclair, powerful cathartics effected a cure, after the failure of bleeding, opi- um, antispasmodics, and various other means. (Edin. Med. Journ. No. 82, p. 38.)—Editor. } De Ira, m. 7. cl. iv.] NERVOUS FUNCTION. [ord. iv. 393 The general pathology of the two preceding species, and Gew. VII. which has been given at some length under the genus clonus, Spec III. will apply to the present: but it is obvious from the symptoms, Syspasia that the muscular power, commonly speaking, though not al- *pi *p?ia' ways, is affected to a less extent, and the sentient and intellec- ,,,%Jcof-7 tual to a much greater; and consequently that the irritative lected from fibres suffer in a smaller degree, than the sensific and percipi- lhat of tlie. 07 r r two preced- ent. ;Dg species. Before we enter upon the history of the disease, it will be convenient to remark, that, from the different modifications un- der which it shows itself, it has been subdivided by many nosolo- gists into very numerous varieties, but that the whole may be reduced to the following : a Cerebralis. Attacking abruptly without any Cerebral epilepsy. evident excitement, except, in a few instances, a slight giddiness. In this case the predisposing cause is external violence or some internal in- jury, misformation or disease of the head. 0 Comitata. Catenating with some morbid Catenating epilepsy. action of a remote part, with the sense of a cold vapour as- cending from it to the head, or some other precursive sign. y Complicata. The limbs fixed and rigid, with Complicate epilepsy. clonic agitation of particular organs. • The causes of epilepsy, like those of the two preceding spe- Cause cies, may be mental or corporeal: but to produce this, rather ™e"t0ar14"d than either of the others, there must be a peculiar diathesis, which seems to depend upon the state of the nervous organ. Where this exists, almost any of the passions or mental emo- tions, when violent, have been found sufficient to occasion a paroxysm, as anger, grief, fright, consternation ; of all which the records of medicine afford abundant examples. In a like diathesis, any kind of corporeal irritability will often become an exciting cause, whether more or less remote from the head it- self; and particularly where it is productive of a preternatural flow of blood into the vessels of the brain. Thus an irritability in the ear from an inflammation, abscess, or some insect or oth- er foreign substance that has accidentally entered into it, or the sudden suppression of a discharge to which it has been subject, has in various instances produced epilepsy. Hildanus* mentions a case in which it followed a considerable degree of irritation, excited in the same organ by the accidental introduction of a small piece of glass. In like manner, an irritable state of the stomach, or intestines, or the liver, from chronic inflammation, * Cent. i. Obs. 4. VOL. IV. 50 394 cl. iv.] NEUROTICA. [ord. IV. Gen. VII. Spec. III. Syspasia epilepsia. Like hyste- ria, often produced by a morbid state of the uterus in an epileptic diathesis. Whether such a dia- thesis exist. Predis. ponent cause most frequently seated in the head. debility, worms, or the presence of substances that do not natu- rally belong to it, has proved a frequent origin. Bartholine gives an instance, in which it supervened upon swallowing pieces of glass,* and Widenfield another upon swallowing a needle.t Confirmed drunkards are peculiarly subject to this complaint. Particular affections ofthe uterus are, in like manner, an oc- casional source of epilepsy, as well as of hysteria: and some- times the latter has run into the former, where the epileptic diathesis has predominated. What this diathesis consists in it is difficult to determine, for it gives no external signs: and hence Dr. Pritchard seems to doubt its existence :J but it is otherwise no easy matter to determine why a like irritation in the uterus should in one woman produce hysteria or convulsions, and in another epilepsy ; examples of which last occur very numerous- ly in all the medical collections of cases.§ Menostation or a suppression or retention ofthe menstrual flux is, perhaps, the most common of this class of causes; and we may hence see, why it should occasionally be excited by a suppression of the lochial discharge. A sudden suppression, indeed, of discharges of almost every kind, natural or morbid, of long continuance in an irritable habit, has occasionally proved a sufficient source of excitement. Hence, also, repelled gout has been a cause, and still more generally repelled eruptions, and exanthems, as itch, various species of ecpyesis, small-pox, and in one instance miliaria.|| Sometimes it has occurred with the regular flow ofthe menses, and been re-excited by every periodical return; for where the peculiar diathesis exists, the slightest stimulus is often sufficient to call forth the disease. In the case before us, however, the 4 periodical discharge is usually accompanied with pain in the loins, or other local distress, as has been justly observed by Professor Osiander.TT Yet the most frequent cause of epilepsy is seated in the head itself; and has been found, on post-obit examinations, to consist in some morbid structure or secretion in the bones, tunics, or substance of this organ, as tubercles, exostoses, caries, apostems, natural misconstruction of the whole, or of particular parts, in- juries from external violence, loose, calcareous earth, hydatids, pus, ichor, and other diseased fluids. Of these, some are pre- disponent, others occasional causes; the former of which will often continue inactive for a long period of time, and, as we have already observed, appertain chiefly to the first or cerebral va- riety. It has been observed also, that in this modification the * Hist. Anat. Cent. v. Hist. 66. t Diss. Obs. Med. Triga. Goett. 1768. X On Nervous Diseases, p. 95, 1822. i Moranus, Apologia de Epilepsia Hysterica, Orthes. 1626, 4to. Schulze, Diss. Casus Hysterico-epileptici Resolutio. Hal. 1736. Eickmeyer, D'i'ss. de Epilepsia Uterina. Ultraj. 1638. II Baraillon, Hist, de l'Acad. Royale de Med. an 1776, p. 220. tT Uber die Entwicklungs-krankheiten in den Bliithen jahren des weiblichen Geschlechts. Theil. I. 58. Gbtting. 1817. CL. IV.] NERVOUS FUNCTION. [ord. iv. 395 disease often makes its attack suddenly, and without any mani- Gen. VII. fest exciting cause. Yet there can be little doubt that, in every SpEC- I,L instance, some occasional cause does exist, though, from its act- Syspasia .. .- .1 . i« ? 1 epilepsia. ing upon a morbid part ot an organ that lies beyond our re- Qr * ^{m search, it entirely eludes all notice. The organ chiefly affect- ly affected. ed, as appears from the numerous and delicate dissections of M. Wenzel, is the cerebellum. He tells us, indeed, that he never opened the body of a single epileptic patient, in which he did not find the cerebellum diseased in some way or other.* But then Dr. Prout, who examined the bodies of numerous epilep- tics in the hospitals of Paris, tells us the same respecting the existence of worms in the intestines;! while "it is proper to Appear. remark," observes Dr. Cook in his essay on Epilepsy, published anceson since the first edition of the present work, " that in some in- Jj""*100 stances, after this disorder, no marks of disease whatever could be found within the cranium, the thorax, the abdomen, or any other part of the body."f So that, however curious in them- selves, it is only in a few cases such morbid appearances can be turned to any account; while some of them may occasionally, perhaps, be effects of the disease rather than its causes. Dr. Lobenstein-LSbel, however, thinks that there ought always to be found some marks of disease or other within the cranium; and there is something humorous in his mode of accounting for their absence. " This is owing," says he, " to an injudicious treatment on the part of the practitioner, or neglect of the pa- tient, by means of which the disease, instead of confining itself to a particular organ, is thrown over the nervous system at large."§ . r The paroxysm in most cases occurs suddenly, and the patient ^™ma^dce" is, so to speak, cut down at once, and loses all sense of percep- progI,.ssof tion and power of motion; so that if he be standing he falls to thepar- the ground with a greater or less degree of convulsion. There ™>mspmje(rree are a few rare instances of some degree of consciousness and orperee£ perception throughout the paroxysm ;|| but the exceptions are tionandcon- few, and by no means enough to disturb the general rule Com- ^Xemain- monly the limbs on one side are more agitated, than those on ing in a few the other. The muscles of the face and eyes are always much rare affected, and throw the countenance into Various and violent dis- instances. tortions. The tongue is thrust out of the mouth, which dis- charges a frothy saliva ; the lower jaw is strongly convulsed ; the teeth gnash violently upon each other; and, as this occurs while the tongue is protruded, the tongue is often wounded most ^Durta/the continuance ofthe fit, there is generally an alter- Cessation of nate remission and exacerbation of the symptoms; though the ™W- whole does not usually last long, and is often of shorter dura- tion than hysteria. On the cessation of the paroxysm, the pa- * Observations sur le Cervclet, et sur les diverses Parties du Cerveau dans les Epileptiques, &c. Mentz. t Medecine eclairee par 1 Observation et SuvertJr. de Corps. Paris, 1804. i On Nervous Diseases vol. „. Part 4 . } Weser und Heilung der Epilepsie, &c. 8vo. Leipsig, 1818. || Bresl. Sammlung. 1724. band. i. p. 436. 396 cl. iv.] NEUROTICA. [ord. iv. Gen. VII. Spec. III. Syspasia epilepsia. « S. Epilep- sia cere- bral is. Sometimes objects appear brighter or larger. Sometimes accompani- ed with local para- lysis. In one in- stance blindness was sudden- ly removed Sometimes the joints have been insuperably contracted. /SS.Epilep siacomitata Aura epileptica. Makes its ascent from all organs whatever. Other singular harbingers. tient remains for some time motionless, quite insensible, and ap- parently in a profound sleep or lethargy. He recovers from this attack sometimes suddenly, but more generally by degrees, yet without any recollection of the sufferings he has under- gone.* [In one example, recorded by Dr. Burnet,t there was consid- erable dyspnoea, and a remarkable slowness of the pulse, which at times did not exceed fourteen strokes in a minute.] Under the first or cerebral variety, or where there is little or no appearance of an occasional cause, and the predisponent cause is supposed to exist in the head, the comatose symptoms, and, indeed, the general mischief to the external as well as to the internal senses, are most striking. Yet the effect is even here very different in different individuals. The optic nerve affords severe proofs of this. Sometimes surrounding objects appear brighter or larger than natural, or both.J Yet, in many cases, the irritability of the nerve or its adjoining muscles has been destroyed, and a paresis, more or less general, has been the result. Hence a perpetual nictitation, strabismus, or blindness, is no unfrequent consequence. Yet, in one instance, a most fortunate and directly opposite effect was produced, for an habitual blindness was removed.§ Where the muscles of speech have suffered in an equal degree, speechlessness has in like manner followed ;|| and, for the same reason, where the joints have been violently affected with a predominancy of rigid over clonic action, they have sunk into an insuperable contrac- tion.1T It is hence not to be wondered at, that the whole system should occasionally be nearly exhausted of its entire stock of sensorial power, and that the paroxysm, as observed by Aretae- us, should terminate in mania, idiotcy, or even death itself; sometimes instantaneously, and, at other times, through the me- dium of a fit of apoplexy.** The warning or precursive symptoms, by which epilepsy is sometimes ushered, have been most common to the second or catenating variety. The most usual sensation is that of the ascent of a cold creeping vapour from some particular part of the body, ofthe nature and cause of which we know nothing, but which has often been called an aura epileptica. This halitus usually ascends from the extremities, but there is no organ from which it has not issued in different individuals, according to ex- amples accumulated by the collectors of medical curiosities; as the feet, the hands, the fingers, the thumb, the great toe, the legs, the arms, the hypochondria, the crown ofthe head. And, in various instances, spots on the face or feet have preceded, and at other times accompanied the paroxysm. We sometimes meet, however, with other harbingers, of * Portal, Mgmoire sur la Nature et le Traitement des plusieurs Maladies, torn. ii.229. t Med. Chir. Trans, vol. xiii. X Bartholin.'Hist. Anat. Cent. in. Hist. 45. N. Saml. Med. Wahrnem p., iv. p. 229. i Ephcm. Nat. Cur. Cent. i. n. Obs. 130. || Hagendorn, Cent. i. Obs. 14. Act. Nat. Cur. vol. i. Obs. 71. IT Horstius, H. p. 90. ** Aretaeus, de Caus. et Sign. Morb. Cent-, i. 4. CL. IV.] NERVOUS FUNCTION. [ord. iv. 397 quite as singular a character, in the other varieties; as a heavi- Gen. VII. ness of the eyes, pain, heat, and sparkling, which; by Sir Clif- SpEC- In- ton Wintringham, were regarded as signs that peculiarly distin- /2S. Epjlep- guish the idiopathic from the symptomatic disease.* Sometimes s,acom,tata- there has been a wild play of phantasms or illusive objects be- fore the sight :t and Portius relates the case of a woman, who was always warned of an approaching fit, by the appearance, as it were, of her own image in a mirror.ij; On many occasions, indeed, as Paulini has rightly observed, there is a peculiar over- flow of spirits, and a tendency to merriment, as though the mind were entirely thrown off its balance.§ Sometimes the patient exhibits sudden starts of running,|| or dancing ;1I occasionally he is strangely talkative ;** and, in one instance, exhibited a new and peculiar talent for singing.tl Vic-D'Azyr relates the case singular of a woman, who had been subject to epileptic fits for twelve case from years, and which at length became as frequent as four or five v,c" zyr' times a day. They always commenced with a peculiar sensa- tion in one leg, near the lower part ofthe gastrocnemius mus- cle. A surgeon, present on one of these accessions, plunged a scalpel into the part affected, which came in contact with a hard body, that he soon cut out, and found to be a dense cartilaginous ganglion, ofthe size of a very large pea, that pressed upon the nerve which he divided. The woman had no return of epilep- sy .\\ We have already noticed a similar cause of irritation and mode of cure in a case of neuralgia faciei; and it is highly pro- bable that, under a slight variation of the nervous erethism in either instance, the one disease would have been substituted for the other. Under the third or complicated variety, while many of the ys. Epilep- limbs are rigidly fixed, almost without relaxation, the muscles JucomPli" of other parts are thrown into the most grotesque and ludicrous g**etiraejJ gesticulations of chorea ; and, if the muscles of the chest be af- accompani- fected in this way, the patient appears in some cases to burst ed with into involuntary fits of laughter from their irregular and clonic ^Jj^j" action.§§ At the same time, such has been the force ofthe spas- tions : tic muscles, as to break one or more teeth, to rupture an artery, explained. or render a vein varicose ; and in one case, at least, to burst lf*£*e the left ventricle of the heart itself.|| || occasionally It has been observed, that the epileptic paroxysm occurs chief- such as to ly at irregular periods, and is for the most part of short duration. Jjj^ek £jj°r There are, however, some instances on record of a singular ex- 0r bones. ception to this rule in both cases. For it has occasionally lasted Has occa- for two or three days, with little or no remission. It has also ^"jjjj" returned at stated times, and with great frequency; with the re- for two or * Ricardi Mead Monita et Prsecepta, permultis notationibus et observa- tionibus illustrata, torn. i. 8vo. t Bartholin. Hist. Anat. Cent. i. Hist. 81. Cent. 11. Hist. 72. Hagendom, Cent. in. Obs. 42. X Medics Consider- ationes Varite. 4 Cent. u. Observ. 13. Bresl. Samml. 1724. band. ii. p. 434. II Boot. De Afl'ectionibus Omissis, cap. vi. Schenck, Obs. I. Lib. ii. p 202. H Chesneau, Lib. I. Cap. iv. Obs. 4. Eph. Nat. Cur. passim. ** Eph. Nat. Cur. Dec. n. Ann. vi. Obs. 229. tt Act. Nat. Cur. vol. v. XX Diet, des Sciences Me'dicales, art. Cas. Rares. i} Eph. Nat. Cur. Dec. I. Ann. in. Obs. 304. || || Johnston, Med. Remarks, ic. vol. ii. three days. 398 cl. iv.] NEUROTICA. [ORD. IV. Gen. VII. Spec III. y S. Epilep- sia compli- cata. Has return- ed six times in a single day. Regularity of return how ac- counted for. Sometimes hereditary and conge- nital. Effects of fright. Paroxysm not unfre- quently takes place on waking in the morn- ing. Explained. Mode of treatment. Intention two-fold: to remove the exciting cause, and allay the habitual irritation. First inten- tion. Venesection when useful. Cathartics: their bene- ficial opera- tion ac- counted for. volution of the morning, or even of the night; in one instance six times in a single day;* and in another, on the revolution of the birth day of each of the patient's parents: t and hence it may occasionally have obeyed lunations, and appeared to be influenc- ed by the phases of the moon,J while running a regular course from some other cause. In a highly nervous temperament it is not difficult to account for such returns; since the dread of its return alone, when it has once established a circle of action, will form a sufficient source of irritation. In a few instances, it seems to have been hereditary,§ and perhaps in an equal num- ber congenital, appearing soon after birth, and mostly produced by a fright of the mother during pregnancy. Hildanus gives an example, in which a fright of this kind was occasioned by the presence of an epileptic patient when suddenly attacked with a paroxysm: || and other medical records contain instances of a like effect on the sudden rush of a hare, or some other animal, against a pregnant woman. Many persons, habitually disposed to epilepsy, are attacked immediately on waking in the morning from a sound sleep, when we may be inclined to think they would be least liable to such a surprise. Dr. Cullen finds a difficulty in explaining this curi- ous fact. But, when we reflect, that epilepsy is a disease of ir- regular action, chiefly in a debilitated system, depending, where there is a confirmed diathesis, upon whatever may disturb the balance of perhaps any of the circulating fluids—and that this balance may be disturbed either by too much as well as too lit- tle excitement;—when we reflect, moreover, that, during sound sleep, there is always taking place a considerable accumulation of sensorial power, and may at times be an excess of it—we shall no longer, I think, be at a loss to account for an adequate Cause of this very singular phenomenon. The general mode of treatment, proposed for the last two diseases, will apply to the present. The two-fold intention is to remove, as far as we are able, the exciting cause, and to allay the habitual irritation ofthe nervous system. Where plethora manifestly exists, we may use venesection with great hopes of success, and, generally speaking, more freely than in hysteria. But here also cathartics will be of considerable avail, and, in the hands of Dr. Hamilton, have been found suffi- cient alone to produce a cure.lf To effect this, they should be used freely and maintained steadily, so as to keep up a perpetu- al counter-irritation in the bowels ; which may act as a revellent against the morbid irritation in any other part, and directly carry off whatever irritating matter may exist in the bowels them- selves. * Tulpius, Lib. I. cap. xi. + Eph. Nat. Cur. Dec. in. Ann. iv. App. 193. X Forest. Lib. x. Obs.60. { Fiid. Hoffm. Diss.de adfectibushrereditariis eorumque origine. Hal. 1699. App. Suppl. ii. 1. p. 523. Abhandlung uber die erblichen Krankheiten, &c. von J. Clund. Rongemont. Frankf. 1794, 8vo. || Cent. m. Obs. 8. f With the purgative plan, free bleeding and a blis- ter to the nape of the neck may often be usefully combined, as in the case re- lated by Mr. Gunn. (See Edin. Med. Journ. No. 90, p. 78.)—Ed. CL. IV.] NERVOUS FUNCTION. [ord. iv. 399 Provided this be accomplished, the particular medicine em- Gen. VII. ployed does not appear to be a matter of great moment. Colo- Spec. HI. cynth, gamboge, sulphate of magnesia, and calomel seem to have Jas;J5|j[j?" been used with almost equally good effects; though in visceral catai congestion the last should never be omitted. If worms be sus- Treatment. peeled, and especially the vermicular ascaris, the rectified oilof'pirst in- turpentine should undoubtedly be allowed a preference. Even tention. where worms are not found to exist, this has often proved high- Oil of tur- fy successful, apparently by the revulsive action it excites. As P™l,ne: a purgative it should be given in ounce or ounce and half doses J^in°steer_ to an adult; but as an alterant in smaller doses repealed daily.* ed under Cold affusion, whether general or confined to the head, has different cir- been rarely tried in our own country, but is strenuously recom- ^l*^' mended by many foreign authorities, as well during the parox- gi°n ysm as in the intervals; particularly by Dr. Lbbenstein-Lbbel. He employs it, indeed, both in an entonic and atonic state ofthe frame, only in the former case premising venesection. Under particular circumstances it may be useful, but it requires great caution; for even this writer prohibits it where the patient is subject to gout, rheumatism, diarrhoea, or nervous trepidations; at the period of menstruation, or any other expected discharge, or on repelled eruptions.! It was probably from its stimulant and cathartic effects alone, Muscus that the muscus agaricus was ever in a high degree of populari- agaricus. ty. It is a reddish mushroom, with a white, thick, and hollow pillar, and a reddish or crimson cup, nearly flat, about six inches in diameter. The dose was from ten to thirty grains of the powder to be taken in vinegar. Its effects, however, are sudo- rific as well as purgative, and, as the former are not wanted, it has been judiciously relinquished for other medicines ofthe same delSS De Haen often employed emetics, and chiefly for the purpose Emetics. of exciting and maintaining a new action, for which purpose he continued them daily for a week or two. His example was fol- lowed at one time, but has long been relinquished.! Externally, stimulants have also been tried, and, in various in- External 1 stances, seem to have been attended with good success. The s imu an s- spine has been rubbed night and morning with different prepara- tions of ammonia, camphor, cantharides, and the antimonial oint- ment ;§ and setons and issues have been applied to different parts of the body, as have also the actual and potential cautery,|| and the moxa. Where the cause of the disease has been suspected * See Dr. Latham, Med. Trans, vol. v. art. xxm. and compare with his Treatise on Diabetes. t Wesen und Heilung der Epilepsie, &c. 8vo. 1318. t Rat. Med. Part v. cap. iv. } 1. Eph. Nat. Cur. Cent. vi. Obs. 58. i See Cieighton on the use of Tartar Emetic Ointment in Epilepsy. (Trans. of the Assoc, of Physicians, Ireland, vol. iv. p. 332 ) This gentleman applied it also to different parts of the body ; and lie noticed, that the eruption, produced by it, is not confined to the spot on which the ointment is rubbed, but mostly appears in very remote parts ; thus proving, lhat its action is in some degree on the constitution.—Ed. || Ab. Heers, Observ. Var. Locher, Observ. Pract. Roekard, Journ. de Med. torn. xxv. p. 46. 400 cl. iv.J NEUROTICA. [ord. iv. Gen. VII. Spec. III. Syspasia epilepsia. Treatment. First inten- tion. Accidental burn of service. Ligature round the limb yield- ing an epi- leptic aura. Sedatives and tonics. Popular use of stramoni- um atone time: especially in Sweden. Its immedi- ate effects. to be seated in the head,* they have been chiefly confined to this organ, but where there has been a manifest aura epileptica, to the limb or other part of the body from which the vapour has seemed to ascend. And there can be no question, that these means have frequently proved serviceable, especially in pre- venting the recurrence of subsequent fits, where a habit of re- turn has been established. The practice is of considerable an- tiquity, for, under some modification or other, it is recommend- ed by Galen, and many other Greek writers. In later times, it has been chiefly employed by Baron Percy! and by M. Gondret. Schenck has examined, at considerable length, the successful and unsuccessful cases which, in his day, had been published upon the use of cauteries.;}; In several instances, an accidental burn has answered the purpose of a surgical escharotic, and fortunately proved a radical cure.§ Professor Zeoffler of Altona, instead of cauterizing the limb from which the epileptic halitus seems to ascend, has ingeniously tied a tight ligature above the part whence the vapour issues, probably upon the ground of the suc- cess, with which it is often attended in the bite of the rattle- snake and other venomous animals, and, in one or two cases, the ligature seems to have proved quite as favourable in the present disease. The general irritability of the nervous system has been at- tempted to be overcome by sedatives and tonics. Of the for- mer, the chief have been camphor, cajeput, valerian, hyoscya- mus, stramonium, opium, and digitalis. Stramonium, like many other medicines, has had a strange alternation of fortune. About a century ago it was esteemed every thing, half a century ago it declined greatly in its reputation, and has of late been once more rising into esteem. Fourteen epileptic patients in the royal hospital at Stockholm were, many years since, treat- ed with pills of stramonium.|| Of these, eight are declared by Dr. Odhelius, in the official report upon this subject, to have been entirely cured, five had their symptoms mitigated, and only one received no relief. The greater number, on first using this remedy, were affected with confusion in their heads, a. I. IO StlVlUUI lliat LUC OOal VJ UIC IU\,ai llllO^lll^ij »"ii"" vuuwv^ x- jjiit jj.-'jr ■«■ biawjv \.i*i-^j which arise from organic derangements within the head, can be exactly ascertained ; and it is not always lhat, when ascertained, they are within the reach of a surgical operation ; yet such cases are on recorH, and one remarkable instance is related by Dr. Rogers of New York. It was a protracted epilepsy, cured by elevating a portion of the os frontis, which had been depressed upon the brain fourteen years.—(See New York Med. and Physical Journ. 1826.) Facts of this kind, and others in which strabismus and other unequivocal signs of affection of the brain take place, are decidedly adverse to Dr. Reid's theory, lhat epilepsy should be ranked amongst those diseases, to which, what he terms, the spinal system is liable.—(Trans, of Assoc, of Physicians, Ireland, vol. iv. p. 355.) That Epilepsy does not always depend upon the state of the spinal cord, is also proved by the morbid changes in the head, frequently revealed by dissections as the cause ofthe disease. That they are not merely consequences, is shown by the fact, that when removable, as in the case advert- ed to, the cure follows. At the same time, what is here stated is by no means intended to controvert Dr. Reid's position, that in epilepsy the medulla spinalis is sometimes found in a morbid state, and may sometimes be concerned in the production of the disease.—Ed. t Pyrotechnie, passim. X Observ. Lib. i. No. 233. i Eph. Nat. Cur. Dec. i. Ann. n. Obs. 9. || Mem. de l'Acad. Royale des Sciences de Stockholme, traduit par M. Ka- ralio, torn. iii. Razoux, Diss. Epist. de Stramonio, &c. CL. IV.] NERVOUS FUNCTION. [ord. iv. 401 dimness in their eyes, and thirst; but these symptoms gradually gen. VII. diminished. Spec. III. Where hyoseyamus has been given, it has been employed Syspasia both in the leaves and seeds : Dr. Parr preferred the latter, and ^>ie^8,a* usually combined the seeds with some aromatics, commencing rea ™en ■ with doses of a grain, and advancing them to four or five io^nUon. grains. [One or two cases, in favour ofthe utility of digitalis, Hyoscya- are recorded* by Mr. Scott of Liverpool.] mus. The tonics employed have been both vegetable and metallic. Vegetable Among the former, the mistletoe of the oak stood at one time tomc»- at the head of the remedies for epilepsy. It was regarded as Mistletoe a specific by Colbatsch,t and most warmly recommended by f"y^°ar Haller and De Haen.J It appears, however, of no importance formerly: from what tree it is taken, for, as a parasite, it flourishes equally on many, and preserves its own peculiarities on all; and from yet without every tree, so far as late experiments have been made, it is reason. equally inefficacious and futile. The leaves of the orange-tree, which have been strongly re- Folia commended§ for epilepsy, are not worth a trial. In plethoric aurantii- habits cinchona will generally do mischief; in the cerebral vari- B*rk «*1* ety it can do little or no good ; and it is only in a relaxed and mo- ° use' bile state of the animal frame, in which any benefit can be ex- pected from it. Mercury has been tried in almost every form and to almost Mercury. every extent; sometimes, indeed, to that of salivation, in which state some practitioners pretend to have found it highly useful. As a general plan, however, this can never be advisable : and Mu- ralt admits, that, in most cases, where it has seemed to answer, it has only restrained the disease, or prolonged the interval, but not effected a radical cure.|| Of the preparations of zinc we took notice under convulsion, Zinc. and the remarks there offered are equally applicable to epilep- sy. Such, however, has been the state of exhausted irritability All its pre. produced by this disease in some instances, that the patient would parationi bear almost any quantity of them. Mr. Johnson of Lancaster gave f™°,n the sulphate of zinc in doses of five grains twice a day at first, quantities. and increased the dose gradually to twelve grains. Theleni- us had previously given eight grains ofthe same daily .11 Arse- Arsenic: nic has of late been chiefly employed in the form of the com- with nickel. mon solution, and as united with nickel, in the compound of an arseniate.** But the preparations of copper and silver have Copper. met with more success than any of the preceding. The best form of the first is that of the cuprum ammoniatum; and the Edinburgh Medical Commentaries are full of cases that afford * See Edin. Med. Journ. No. 90, p. 19. t See' also Abhandlung von dem Missel, und dessen kraft wieder die Epilep- sie, Altenb. 1776. X Rat- Med- Pract. Part vi. p. 317. i Hannes (Christ. Rud.) Epist. de Puero epileptico Foliis Aurantiorum recentibus servato. Leips. 1766. Gesner, Beobachtungen, I. No. 19. The epilepsy was here an effect of terror. || Hippocr. Helvet. p. 247. IT Medicinische und Chirurgische Bemerkungen. Franc. 1789. ** See a valuable article on this and similar medicines in the Edin. Med. and Surg. Journ. No. 19, p. 374. VOL. iv. 51 402 cl. iv.] NEUROTICA [ord. iv. Gew. VII. Spec. III. Syspasia epilepsia. Treatment. Second intention. Pilulae coerulae, Edin. Silver : its nitrate: in a ruder form, of early use. Dark colour on the skin from the use of the nitrate of silver. Employed in pills and in solution. Bpth modes highly serviceable. Exem- plified. proof of its remedial power. The simplest mode of exhibit- ing this medicine is that of pills, as the pilulat ccsrula of the Edinburgh Pharmacopoeia, which is nothing more than ammo- niated copper made into a pilular consistence by means of crumbs of bread. The patient should begin with half a grain of the metallic salt every night, and increase it to double, the quantity if his stomach will bear it. The best, and indeed the common preparation of silver for the purpose before us, is its nitrate. Under a more operose and unscientific form, it was employed as early as the beginning of the seventeenth century by AngelusSala, and afierwards by Boyle and Geoffrey, though for other complaints rather than the pre- sent. Dr. Albers of Bremen has observed, and the remark has since been confirmed by Dr. Roget,* Dr. Badeley,t and numer- ous other practitioners, that the use of this medicine, if perse- vered in, gives a peculiar darkness to the colour of the skin, which remains for many months after its discontinuance, in some cases for upwards of two years.J Dr. Powell has tried the nitrate of silver in St, Bartholomew's Hospital upon a large scale, and in two forms, that of pills and that of solution, the solvent being mint water, which seems best to cover its unpleasant taste. Many of the cases seem to have been strongly marked, and they are givennn a communication to the London College.§ They relate chiefly to young persons of both sexes from nine to fifteen years of age ; in all of whom the me- dicine proved successful, and is said to have operated a perfect cure. The dose at first consisted of not more than half a grain or a grain of the metallic salt, whether in the form of pill or of solution, given usually every four hours, but this was gradually increased to doses of three or four grains taken at the same distance of time: and the increase was still continued till sick- ness or some other inconvenience forbad. It is singular, that while the earlier writers complain very generally of the pur- gative powers of this medicine, and the griping it produces, the modern preparation excites no such effects; not even when it has been carried, as it has occasionally been, to the amount of fifteen grains to a single dose in the shape of pills; though it should be remembered, that few stomachs will bear more than five grains in a dissolved state. Dr. M'Ginnis cf Portsmouth affirms, that he has employed it repeatedly both in recent and chronic cases, without any perceptible effect, in doses of twelve grains: and M. Georget, who, however, does not seem to be much acquainted with its use, has condemned it, as a medicine dangerous to the coats of the stomach'.|| * Trans. Medico-Chir. Soc. vol. vii. p. 290. t See Epichrosis Rcecilia of this Work, vol. v. Cl. vi. Ord. in. Gen. x. Spec. vi. • X On the Effect of Nitrate of Silver, Tians. Medico-Chir. Soc. vol.ix.«p.234. i Med. Trans, vol. iv. art. vin. A case in favour of the nitrate cf silver is related by Dr. Williams, of Liverpool, though many other potent remedies were also employed, as oil of turpentine, blisters, cold washes to the head, sul- phate of zinc, issues, and mercury. (Edin. Med. Journ. No. 85, p. 297.)—Ed. || Phys. de Syst. Nerv. torn. ii. p. 401. cl. iv.] NERVOUS FUNCTION. [ord. iv. 403 Iron, in all its preparations, offers a far less hazardous reme- Gew. VII. dy, and, in some instances, appears to have been attended with Spec III. considerable success. The best form perhaps is that of the sy*pa''.a subcarbonate, in the proportion of a drachm three times, a day, ^'^P913, as already recommended in the case of Neuralgia : and, thus Treat"ient< administered it has occasionally produced a radical cure. fntention. All these tonics seem to operate by taking off the tendency iron. to irregular nervous action, and, consequently, the tendency to Mode by a return ofthe paroxysm, vvhere a habit of recurrence has once which tonics been established ; for, in many instances, such habit alone appears ProdlRCe to be as much an adequate stimulus as a similar habit in inter- ;„ the epi- mittents : and hence, whatever has a tendency to break through leptictem- such a habit must have a beneficial effect; fevers themselves of VerameaU various kinds have often done this,* and especially quartans, the most obstinate of the whole tribe of fevers ; and the above re- mark explains their mode of operation in this respect: it is that of introducing a new circle of actions. But the exciting causes of epilepsy are so numerous, and the Causes and disease itself so complicated, that it would be in vain to expect £™a£. '0ie success in every instance from metallic tonics, or any one de- complicat- scription of medicines whatever. The remodies must often be ecl> that the varied to meet the varying case. And, on this account, it is by „TusT he * no means uncommon to find epilepsy removed by oil of turpen- vaiied to tine or some other purgative, that had obstinately resisted the meet them. most powerful doses of the metallic salts: while, in some in- The disease stances, the disease is altogether irremediable.! i^emedhV able. GENUS VIII. CARUS.— TORPOR. Muscidar immobility ; mental or corporeal torpitude, or both. Carus or xx$os, "sopor cum gravedine," is derived from Origin of **£<*, " the head," being the organ in which the disease is Jjjj^nenc chiefly seated. As employed in the present arrangement, the genus, signified by this term, will readily include the following species:— 1. CARUS ASPHYXIA. ASPHYXY. SUSPENDED ANIMATION. 2. ---- ECSTAS1S. ECSTASY. * Hornung, Cista Medica. Norib. 1625, 4to. Augziige aus dem Tagebuche eines ausii- benden Arztes, &c. 1 Samml. Berl. 1791. t Dr. Reid mentions two modes, in which the convulsions of epilepsy may be stopped. "During the inordinate struggle," says he, "to perform respiration,-the practitioner may abstract some of the force applied to the respiratory organs by attracting the exertion in another direction. Thus, while the hands and arms are violently contracted, if the at- tendants forcibly extend them, and open the fingers, so much exertion is involuntarily made by the patient to oppose this, that the violent operation of the respiratory muscles subsides, the organs fall into their natural train of action, the patient draws a heavy sigh, and the paroxysm is at an end. Any unusual irritation," Dr. Reid adds, " may have this effect." The other mode is to let an assistant press forcibly the soft parts of the abdomen towards the spine with his closed hand. The theoretical explanation of the practice we need not examine, if the plan answer, as Dr. Reid has found it do.—See Trans. of Assoc, of Physicians, Ireland, vol. iv. p. 363-365.—Editor. 404 cl. iv.) NEUROTICA. [ORD. IV. Gew. VIII. Cams. 3. 4. 5. 6. CATALEPSIA. LETHARGUS. APOPLEXIA. PARALYSIS. CATALEPSY. LETHARGY. APOPLEXY. PALSY. Synonyms. Torpor preferred to stupor and sopor, and why. Preferred to insensibili- ty, and why. Extent of the terms cams and torpor, as employed in the pre- sent ar- rangement. Carus, therefore, will be found to embrace under the pre- sent arrangement, a field somewhat more extensive, than that allotted to it by most other writers, so as to include several of the species arranged by Sauvages under his two orders Lei- popsychiae, and Comata; to be nearly synonymous with the Defectivi and Soporosi of Linneus; and still more so with the Adynamiae of Macbride. As a generic sign, the author has preferred the term torpor or torpitude to stupor or sopor, which have hitherto been chiefly made use of for the same purpose; and this on two ac- counts. First, as being of wider signification, since it includes the general idea furnished by both the others: and, secondly, because neither stupor, nor sopor, has been uniformly employ- ed in a determinate sense of any kind. Thus stupor is often, perhaps usually, restrained to mental insensibility or morbid sleep; while Sauvages has explained it as meaning hebetude of the sense of touch, " molestia quae sensum tactus obscurat;" and Linneus, transient sleep of any part with a sense of formi- cation, " sopor transitorius partis alicujus cum sensu formica- tionis." In this place, and indeed generally, Linneus makes sopor combine the two ideas of a cessation of motivity and of feeling; or of irritability and sensibility ; while Cullen objects, and correctly, to this strained extent of the terra, and limits it to the ordinary signification of " sleep, or a sleep-like state." Torpor or torpitude, in the definition of carus now offered, im- ports insensibility, mental or corporeal, in a frame still alive, and actuated, though often imperceptibly, by the vital princi- ple. The term insensibility would not so well answer the pur- pose ; it is of too wide a range, and too loose a meaning, being often predicated of insentient, unorganized matter, that never possessed the principle of life. Carus or torpor, thus explained, will equally apply to all the species we have just enumerated, some of which are very un- common, and a few of which have been supposed doubtful; though, upon the whole, the authorities are in their favour, and they ought neither to be omitted nor merged, as they seem to be by Cullen, in the sweeping name of apoplexy; constituting, in his hands, a genus that includes a variety of distinct, and, in some instances, very different diseases; but which, under his own classification, Dr. Cullen found it difficult to distinguish, or place separately. Species I. Carus Asphyxia.—Suspended Animation. Total suspension of all the mental and corporeal functions. Origin of . _ ... , „ . the specific Asphyxy, from x privative, and >. 130. 192. 412 CL. IV.] NEUROTICA. [ORD. IV. Gen. VIII, Spec. I. *C A- sphyxia suf- focationis. No positive means of determining whether the vital princi. pie be latent or has dropped its connexiou with the body. Farther illustrated. Perspiration and other secretions sometimes produced after death. Explained. an influence on the economy of animals, independently of its action through respiration: and that this influence is probably exerted through the medium of the skin.* And we may hence see why recovery from hanging is more frequent, than from drowning, under like intervals of protraction. Unfortunately, we have no means of determining whether the vital principle lies latent in the body or has utterly dropped its connexion. Want of heat is no more to be relied on, than ces- sation of the pulse or of breathing: for while in submersion, heat, in consequence of its rapid absorption by the surrounding elements, is one of the first properties of life that disappears, whether the patient recover or not; in death from convulsions and various other sudden causes, it often continues for hours, and sometimes even for days after the event, cheating the bystanders with an empty and unfounded hope of a restoration never to take place. The present author was a few years since sent for in haste, to a female domestic of Mr. Salmon of Meck- lenburgh Square, who however died under a convulsion-fit be- fore his arrival. In the evening, nearly twelve hours after- wards, he was again requested to attend, as, notwithstanding the body had been lain out from the first and merely covered with a sheet, it still possessed a considerable degree of warmth. He was sorry to repress a hope which he found fondly and highly cherished, but the symptom was illusive, and the heat gradually disappeared. On the decease of a robust and corpu- lent lady, whom he also attended in Bedford Row, and who died of a spasmodic asthma, this symptom continued, or rather show- ed itself afresh, eight and forty hours after death, so that the author was requested to attend at the time the body was on the point of being put in the coffin. In this case, the heat was pro- duced by putrefaction; for the body was livid and offensive. Bartholine has an example or two of the same kind ; and the Ephemerides, among other cases less marvellous, one in which the heat is said to have continued till the fourth day after death: and which should no doubt fall within the solution just given.! As heat has occasionally maintained itself for hours after death, so also has perspiration. Paullini mentions a case, in which tears flowed from the eyes \\ Riedlin another, in which the eyes themselves recovered their brightness ;§ and Hagen- dorn a third, in which the face swelled and looked red.|| In all these cases, we have proofs of a lingering of the irritable prin- ciple in particular parts after the sentient principle lias totally disappeared. And hence, in a few instances, some of the mus- cles have been thrown into irregular action, the penis has be- come erect,1T the jaws have opened and shut, as though masti- * Memoires sur l'Asphyxie consideree dans les Batraciens. Paris, 1817. Also, De 1'Influences des Agens Physiques sur la Vie, &c. Paris, 8vo. 1824. t Eph. Nat. Cur. Dec. ii. Ann. iv. Obs. 18. J Cent. m. Obs. 10. Franc. 1698, 8vo. i Lin. Med. 1696, p. 203. || Cent. ur. Obs. 46. If Eph. Nat. Cur. Dec. I. Ann. ix. X. Obs. 34. 158. cl. iv.] NERVOUS FUNCTION. [ord. iv. 413 eating ;* and, as is well known, the heart, when dissected from Gew. VIII. the pericardium, has leaped from the table. Spec. I. In attempting a cure of suffocation by submersion, the two * C. A- grand means, by which we are to operate, are those of warmth j^ayt|*n; and inflation of the lungs. The body should be quietly con- Medical' veyed to a warm and dry situation, and rubbed all over with treatment: moderate stimulants, as diluted flower of mustard, or the warm- warmth: er balsams ; while the nostrils are plied with volatile ammonia, J^"1^" °; and the eyes exposed to a strong light. But a restoration of friction and the action of the lungs is chiefly to be aimed at: and for this stimulants. purpose, a full expiration of warm air from the lips of a by- stander, should be repeatedly forced into the patient's mouth, and his nostrils held close to prevent its escape by that channel. Inflation may also be attempted by a pair of common bellows; Means of or, which is far better if it can be readily procured, by a pair inflating the of bellows communicating with a pipe introduced into the larynx, or, as some have recommended, into an aperture made between the rings ofthe trachea. Stimulating injections of acrid purga- Stimulating fives, or camphor, ammonia, and brandy, or other spirits, have "fjections. often been introduced with success into the rectum, and some- times injections of warm air alone : and it would be better that the air introduced into the lungs should be also moderately warm. Besides this active process, it may be possible to con- stimulanti vey some warm and cordial stimulant, as ammonia, or the com- to be con- pound spirit of lavender, into the stomach by means of a syringe; JK,"£b| or tvhat may probably in this case answer better, by a piece of and how. sponge, impregnated with one of these, fixed to the end of a small rod of whalebone. In the Berlin Transactions is recommended the Ventriculi use of a ventriculi excutia, or stomach-brush, to produce internal g^0^01 friction in the same manner. brush, what. There is no family of diseases, in which the internal use of Phosphorus. phosphorus seems to promise more success. The German phy- sicians have employed it very generally in the last ebb ot ty- phous fevers, in apparent death from convulsion,! and in most cases in which the nervous power has been suddenly annihila- ted. It is one of the most powerful stimulants we know, and in asphyxy should be given to the amount of two or three grains for a dose, dissolved in ether. Venesection, and especially that of the jugular vein,+ has Venesection been strenuously recommended by physicians of high anthority ; ™ablej and, wherever there is reason to believe, that the drowning has followed a sudden fit of apoplexy, the recommendation is rational enough, provided it can be practised with effect. But, commonly speaking, it is advice to no purpose, for the blood will not flow; and, in other cases, if it would, such depletion, we have reason to believe, would do more injury by weaken- ing, than good by removing what is erroneously supposed to be congestion. It may occasionally, perhaps, be serviceable as soon * Commerc. Nor. 1732, pp. 82. 90. 173. t De Phosphori, loco Medica- ment! adsumpti, virtute medica, &c. Anat. J. Gabi, Mcntz. X Jo. Wences Nachtigal, Dissertatio de Submersis. Vindobon. 8vo. 414 «• «▼•] NEUROTICA. [ord. iv. Gew. VIII. Spec I. a C. A- sphyxia suf- focationis. Treatment. Sign? of returning life, how to be encouraged. Same treat- ment appli- cable to most ofthe modes of suspended animation. Other direc- tions to be found in Cullen's letter to Cathcart. & C. A- sphyxia mepliitica. Surface of the body mostly pale, aud why. Sometimes combined with apoplectic symptoms, and why. Meaning of choke- damp. By what means the inhaled vapours prove instanta- neously destructive, not very clearly ascertained. as the living powers begin to show themselves, but it is rarely to be tried in the first instance. Returning life is first usually discoverable by the symptoms of sighing, gasping, twitching, or subsultus, slight palpitation, or pul- sation ofthe heart; in effect, by a weak or clonic action in most ofthe organs. Our efforts should here be redoubled, for the feeble spark still requires to be solicited, and nourished into a permanent flame—and has often disappeared from a relaxation of labour. A spoonful or two of warm wine, or wine and water, should now be given by the mouth as soon as the power of swallowing is sufficiently restored; which should be shortly suc- ceeded by a little light, warm, and nourishing food of any kind, with gently laxative clysters, a well-heated bed, and perfect tranquillity. I have dwelt the longer upon this subject, because the gen- eral principles of the remedial treatment, here recommended, apply to most of the other varieties under which asphyxy or suspended animation is to be traced : and the reader, who is de- sirous of following the operative plan into a still minuter detail, will do well to consult Dr. Cullen's letter to Lord Cathcart, the president ofthe Board of Police in Scotland, concerning the re- covery of persons drowned and seemingly dead, an able extract of which is given in the Medical Commentaries of Edinburgh.* We may observe, however, that in attempting the recovery of those who have been hung, and particularly who have inexpert- ly hung themselves, bleeding from the jugulars may be more frequently found necessary, than in attending the drowned, since in the former, as we have very fully observed above, there is a greater tendency to apoplectic symptoms than in the latter: yet, even here, the quantity abstracted needs not be large. In the second variety of asphyxy, or that from an inhalation of irrespirable auras, death in many cases takes place instanta- neously ; and, consequently, for reasons already advanced, the general surface ofthe body, and even the countenance itself, is pale.t Yet as the gas is often in some degree diluted with at- mospheric air, the circulation, and even the breathing are oc- casionally continued for some time in a feeble and imperfect state, and the asphyxy is united with symptoms of apoplexy, or genuine apoplexy takes place, in its stead. In Cornwall and other mining regions, these gases are vulgarly called damps, from the German dampff, " a vapour or exhalation." The direct effect of such gases, when in a concentrated state, is utterly and instantaneously to destroy the irritability and serv- sibility ofthe nervous system, of which we have examples per- petually occurring in persons who incautiously descend foul beer-casks, or the shafts of mines. By what means, however, such exhalations when they have penetrated the lungs become so rapidly communicated to the nervous system as to prove in- stantly destructive, we do not seem to be very well informed. * Vol. iii. p. 243. t Brukser von den Ungewissheit der Kennzeichen des Todes. cl. iv.] NERVOUS FUNCTION. [ord. iv. 415 Absorption would be the most ready way of accounting for it; Gew. VIII. but, till the objections, thrown out by Mr. Ellis against an ab- Spec' !• sorption of oxygen or any other gas by the lungs, and which we £ c- .A" have noticed in the Physiological Proem to our second Class, jfctica. are more satisfactorily replied to, than they appear to have Difficulties been, it is an hypothesis that can hardly be allowed. In the attending case of hanging or drowning, it does not seem to be owing to a the '.W0* direct want of irritability that the heart ceases instantly to con- absorpUon. tract, but, as we have already remarked, to its being deprived of the necessary stimulus, which is no longer afforded by the lungs, however they may act, in providing it. Yet, in the pres- Apparently ent case, there seems to be not only a cessation of action, for a total want of a proper stimulus, but a total abstraction of both sen- absb^_tion sific and motific power: and this as completely in one part of 8ensiGcand the frame as in another. moti6c The gases ofthe description before us, that are found most Power* fatal, are the carbonic acid, hydrogen, nitrogen, and several of d^eterTou* a more compound kind, which are thrown forth from putrefying animal and vegetable substances, and especially from cemete- Deadly ha- ries, on opening fresh graves, in which the process of decom- lit us from position is proceeding rapidly, and the concentrated effluvium Putrefy«>g bursts forth with an intolerable stench. Of the powerful ef- grav fects of this last exhalation, Foiircroy has furnished us with a very particular and striking account from the narration of grave- diggers examined for the purpose : from which it appears, that its instant those who are immediately hanging over a corpse, whose abdomen operation. is accidentally penetrated by a pick-axe, often fall down instantly in a state of senselessness and apparent death, while persons who happen to be at a little distance, and receive the exhala- tion in a form diluted with atmospheric air, are attacked with nausea, vertigo, faintness, and tremors, which continue for some hours. The most common of these gases is the carbonic acid, which Carbonic is chiefly found in the guise of a torpefying vapour in close n^ostsca0sm. rooms where charcoal has been burnt, at the bottom of large mon: where beer-casks, or of wells, and in many natural caverns in the chiefly earth's surface. Its weight prevents it from escaping readily, ° ' even where there is an accession of atmospheric air; and its Dye^g want of smell, when pure, prevents it from being detected oth- weight from erwise than by its effects. As it will not support flame, the com- scaping mon and easiest test, where it is suspected to exist, is that of a and undi- lighted candle, which is well known to be extinguished imme- scerninle diately, if this gas be present in a quantity sufficient to be inju- °y«nell. rious to respiration. Nitrogen and hydrogen, when pure, have probably as little Hf best test 11 1 • • 1 1 x A 11 u- j whether it smell as carbonic acid gas; but they are generally combined wiil support with other gases, sulphur, carbon, or phosphorus. The first, or extin- formerly denominated phlogistic air, and sometimes mofette, is &u_lsh flame- thrown forth largely during the decomposition of animal matter, ^'trogen and in a small degree during that of vegetable matter. Combin- phlogistic ed with hydrogen, it forms ammonia ; 'with oxygen, nitric acid. air. 416 cl. iv.] NEUROTICA. [ord. ir. Gew. VIII. Spec VI. /3C.A- Bphyxia mephitica. Whether it possesses a specific odour. Hydrogene its offensive odour in combination with other materials. How far respirable. Metallic fumes. Fumes of charcoal operate differently according to their degree ofconcentra- tion or other circum- stances- Illustrated. Treatment of this modi- fication of asphyxy. Voltaic electricity, Fourcroy asserts, that it possesses a peculiar and distinct odour resembling that of fishes just beginning to putrefy; but this is probably at all times produced by its combination with other materials. It seems chiefly concerned in giving the greenish colour to parts, and especially muscular parts, in a putrid state. In some gases of this kind, a candle will burn freely. Hydrogen issues also from fecal matter, and, in combination with sulphur, phosphorus, and carbon, produces the chief part of the nauseating and putrid stench thrown forth from decom- posing animal and vegetable substances. It is emitted in a much purer state from the sides of coal and metallic mines, and often exists in considerable abundance without being perceived by the nostrils. If mixed with an equal proportion of oxygen, it may be breathed for about an hour without any great inconvenience. If inhaled beyond this time, or in a more concentrated form, it has a great tendency to occasion the effects we have just noticed, lower the irritability of the animal frame, and induce stupor or an inclination to sleep. The fumes of mercury, lead, and some other metallic substan- ces, when highly concentrated, seem to operate not very dissimi- larly to those of charcoal, and give a check to the mobility of the nervous power at once. The fumes of charcoal are generally inhaled in a diluted form, but they are still highly deleterious and produce asphyxy more or less complete, according to their degree of concentration, and in some cases according to the strength or weakness of frame of those who are exposed to them. We have a striking illustration of this in the case of two persons communicated by Dr. Babing- ton to the Medico-Chirurgical Society, who had gone to bed in a room in which a charcoal fire was kept up through the whole of the night, with the gas of which the surrounding atmosphere was strongly impregnated. According to the principle we have en- deavoured to establish,mwe ought here, from the dilution of the vapour, to expect, that whatever tendency there might be to asphyxy would be united with a tendency to apoplexy. And such we find to have been the fact: for, of these two persons, the younger and less vigorous, a boy of thirteen, died apparently during his sleep, and without commotion: while the elder and more robust, a man of thirty-eight, was found, upon being called in the morning between six and seven, in an apoplectic state, with a swollen, projecting tongue, suffused and prominent eyes, and laborious breathing. The patient, if any degree of sensibility remain, should in this variety be freely exposed to the open air, instead of to an heated atmosphere as in the preceding : and, if he can swallow, acidu- lated liquors should be given him. If insensible, cold water should be dashed on his face; strong vineg;>r, and especially aro- matic vinegar, be rubbed about his nostrils, and held under them, and stimulating clysters be injected as recommended under the first variety. The lungs should be inflated with the warm breath of a healthy man, or, which is belter, with oxygen gas. A proper use of voltaic electricity is also in many instances cl. iv.] NERVOUS FUNCTION. [ord. iv. 417 found highly serviceable. No advantage, however, is likely to Gew.VHI. accrue from passing the electric aura across the chest, directly S*1"5-1- through the heart and lungs, which is a common practice. The 0 c* A" fluid should be transmitted along the channel ofthe nerves, from ^Stka. the seat ofthe phrenic perve in the neck, to the seat ofthe dia- Treatment. phragm or that ofthe par vagum immediately under the sterno- how to be mastoid muscle, and that of the great sympathetic nerve, which applied. send forth branches to the heart.* In Dr. Babington's case, the application of voltaic electricity surprisingly increased the pow- er of the muscles of respiration, but appeared rather to diminish the action of the heart. It was hence used alternately with a forcible inhalation of oxygen gas, and various external stimulants. Venesection was tried, but does not seem to have been .beneficial. The man recovered in a few days. M. Portal recommends a division of the jugular vein, but the Division of blood will rarely flow from any vein, and is still more rarely sue- temhow'far ceeded by any advantage even where it is obtained. And if eve- advisable: ry other remedy fail, he advises bronchotomy, and a scarification hronchoto- of the feet and hands., -Som'"' The sprinkling or dashing of water upon the body seems to _ . be useful on two accounts ; first, from having a tendency to rouse cold water. the vessels on the surface to contract; and next, as affording an opportunity for a disengagement of oxygen. In the third, or electric variety, the whole system appears to y C. A- be not so much rendered inirritable to stimulants, as to be sudden- 8VPnx.'a ly exhausted of its entire stock of nervous power, like a Leyden t,ec " phial upon an application ofthe discharging rod: inconsequence operates. of which the limbs are flexible, the countenance pale, and the blood uncoagulable. The mode in which the electricity is com- Effects alike municated is of little importance ; for, if sufficiently powerful for ,n!""l,ia,R j . .ii.- \ ■ under every the purpose, real or apparent death is instantaneously produced, like degree whether Ihe stroke flow from lightning, an electric battery, or a of intensity, voltaic trough. "J^m Upon plants, on the contrary, we often find a stroke of lightning employed. of the same intensity occasion very different effects in different Operates kinds or branches of the same plant, in consequence ofthe vari- with differ- ety they exhibit as conducting powers. Upon some, it descends ^eerpnctU In without mischief; in others, it exhausts itself on particular parts, plants. which are withered, as though attacked by a hemiplegia. In the betula alba, or common birch, it never runs along the stem, but confines its stroke to the top alone, beating off" the boughs in every direction. In animal life, however, there is also a difference of effect, but if in animals only in proportion to the degree of intensity or the electric pow- the intensity er that attacks the system ; and it is curious to observe the na- effect'differs ture of this effect. Small doses of electricity prove a powerful too. stimulus to the nervous function, increase the flow of sensorial Exemplified. energy, and augment the irritability ofthe muscles: while a vi- olent shock, as we have just seen, exhausts the nervous system * Greg. Consp. Med. Theor. Hiifeland, Diss, usus Ver. Elect, in Asphyxia. Goet. 1783. t Observations sur les EfTets des Vapours Mephytiques sur les Corps de l'Homme, &c. nouv. edit. Paris, 1774. vol. iv. 53 418 cl. iv.] NEUROTICA. [ord. iv. Gen. VIII. instantaneously, carries off the entire stock from the animal fab- SpecI. riC) an(j leaves the muscular fibres flaccid and flagging. This y c* A_ singular result is extended to the blood, and extended to it in effirica. both cases : for its coagulability, or the firmness of its texture, is increased by the application of small doses of electricity, while the shock of lightning, which renders the muscles lax and un- eontracted, renders the blood loose and uncoagulable. It is to this variety of effect that Mr. John Hunter makes a powerful, and certainly a very impressive appeal, in proof that the blood, though a fluid, is actuated by the same living principle as the muscular fibres. Medical The general principle of medical treatment has been laid down treatment. una-er tne fjrst variety. Stimulants of the most active kind should" Electricity j,e resorted to without loss of time : but of all stimulants, that of d^gree'tharf electricity, or voltaism, seems to be especially called for in the what caused present modification of asphyxy. 1 do not know that it has ever theasphyxy. ^en tried to any great extent, in the variety before us, on the Illustrated, hitman subject, but M. Abildgaard has related a few experiments # on other animals that are well worthy of attention. The animals 'chiefly selected were from the poultry-yard, and consisted of cocks and hens. These were first rendered asphyctic, or appa- rently dead, by a strong shock of electricity passed through the head ; and afterwards recovered by another shock passed through from the chest to the back, the animal instantly walking about as if nothing had happened. M. Abildgaard does not say what in- terval he allowed between the shocks thus administered: but he observed, that where no second shock was employed, the appa- rent was converted into real death, for the animal, in no instance, showed any tokens of resuscitation: and he observed farther, that, if the second shock were thrown through the head like the first, instead of from the chest to the back, the same lifelessness con- tinued, and no benefit whatever was produced.* JC. A- 1° frost-bitten asphyxy, or that produced by intense cold, the sphyxia limbs are rigid, and the countenance pale and shrivelled. This algida. variety is always preceded by an insurmountable desire to sleep, Always pre- which the utmost exertion of the will is unable to overpower. Amount" The s,eePis'in most cases> fata,iand becomes the sleep of death.f able desire Captain Cook, in the account he has given of his first voyage tosleep;the r0und the world, has strikingly exemplified this remark in the rngTauT" case of Dr- Solander and Mr. (afterwards Sir Joseph) Banks. Illustrated " Dr. Solander," says he, " who had more than once crossed the from Cap- mountains which divide Sweden from Norway, well knew, that tain Cook's extreme cold, especially when joined with fatigue, produces a oyage. torp0r anc| sleepiness that are almost irresistible; he therefore conjured the company to keep moving, whatever pain it might cost them. ' Whoever sits down,' said he, ' will sleep, and who- ever sleeps will wake no more.' Dr. Solander himself was the first who found the inclination, against which he had warned others, irresistible, and insisted upon being suffered to lie down. * Societatis Med. Havniensis Collectanea, &c. vol. ii. art.Tentamina Elec- tricain Animalibus. t Rhazes ad. Almans. Tract, vi. Cap. V. vn. cl. iv.] NERVOUS FUNCTION. [ord. iv. 419 He soon fell into a profound sleep, from which, however, by the Gen. VIII. exertion of Mr. Banks, he was awakened. Several others of the SpEC-l- party very narrowly escaped; and two of them slept, and perish- * c# -V ed from the cold."* eLctrica. For these symptoms, and their effects, it is easy to accpunt. Effect Cold, so long as the living power is capable of producing a re- explained. action, is one of the most strenuous tonics we are possessed of, and the glow that accompanies the reaction is felt to be pecu- liarly vigorous and elastic. But if it exceed this proportion, and no reaction ensue, the contraction of the vessels on the surface is converted into a rigid spasm, the blood is driven in- to the interior, and the surface must necessarily be pale. In this extremity of temperature, moreover, cold, instead of being a tonic, is one of the most formidable sedatives in animal chemistry: it carries off the heat of the body far more rapidly than it can be recruited, and as effectually exhausts it of all its irritable and sensible power. But such exhaustion, as we have already shown under the genus paroniria, is a cause of stupor or sleep, and a cause so cogent that the will is, in many cases, incapable of resisting it, and falls a prey to its power. In applying remedial means to this modification of asphyxy, Medical great caution is necessary respecting the employment of treatment. warmth ; and particularly where the limbs are peculiarly rigid, and under the influence of frost. In this last case, it will be generally found most advisable, in the first instance, as in frost- bitten limbs, to plunge the body for a few minutes into a bath of cold sea-water or salted water, at the same time that warm air may be breathed into the lungs, and the stomach and rec- tum gently excited by moderate stimulants : for it does not fol- low, that, because the limbs and surface of the body are frozen from frost-bite, the central parts have suffered to the same ex- tent. After a short emersion in sea-water, the body should be taken out, wiped perfectly dry, laid in flannel in a moderate- ly warm room, and submitted to the friction of warm hands, several persons being engaged in this process simultaneously. Species II. Carus Ecstasis.—Ecstasy. Total suspension of sensibility and voluntary motion; mostly ofpien- tal power; pulsation and breathing continuing: muscles rigid: body erect and inflexible. There is so close a connexion between the present and the Many of the ensuing, and, in truth, most of the ensuing species ofthe order ^g con- before us, that they are occasionally apt to run into each other, nected and or to exhibit a few aggregate symptoms. And, on this account, apt to run they have been very differently arranged by different writers. ^J^ Sauvages, and most of the continental nosologists, have regard- eMh[t ag_ ed them as distinct genera. Dr. Mead and Dr. Cullen, as spe- Bregattemg * Hawkesworth's Account of Voyages, vol. ii. p. 46. cl. iv.] NEUROTICA. [o™. iv. Gen. VIII. Spec II. Cams ecstasis. Differently arranged by Sauvages, &c. General physiology. Sensorial powers dif- ferent and differently disturbed : cies or subdivisions of apoplexy, and Dr. Cheyne, as the same of lethargy. Dr. Cooke has treated of them more cursorily than those, who are acquainted with his talents and learning, could wish; and has so far followed Dr. Cullen as to place them, conjointly in a chapter under the head of apoplexy: while Dr. Young, coinciding with the view taken in the pre- sent work, has arranged the whole as a species under the ge- neric name of carus. To understand the nature of their distinctive symptoms, and the reason of their occasional combination, it is necessary to bear in mind the remarks offered in the Physiological Proem to the present class respecting the natural division of the ner- vous ramifications into sensific and motific fibres; since it hap- pens, that some of these diseases are confined to one set, and others to another, while other diseases, again, extend equally to both. And hence, we are able to account for disorders in which the perception or sensibility is abolished, while the irri- tability continues without much interference: or in which there is a disturbed flow or total cessation of the irritable pow- er, with little interference with the percipient, and sometimes also with the sentient, as in some cases of paralysis : or in which there is a disturbance or cessation of all these, with the exception of a partial supply of irritative power to the invol- untary organs. It will also be necessary to recollect, as we have endeavoured to show in many of the preceding pages, and particularly under the genus clonus, that where there is a disturbance of the motific or irritative power, this disturbance chiefly from is of two kinds, one from excess, and one from deficiency ; and excesi and that, jn b0th cases, there is a great irregularity of action, and consequently entastic or rigid, and clonic or agitatory spasms, exhibiting, by their continuation, innumerable modifications. All the divisions of the nervous system, moreover, have a natural tendency to sympathize in the same action, however combined or interchanging ; and hence, in whatever division of it a disease commences, one or more of the other divisions are divisions of peculiarly apt to participate in the affection; and the more so ' as it is not very common for abnormal actions, when once com- municated, to proceed with much order or regularity ; for if trismus and tremor give us examples of such order, tetanus very generally, convulsion-fit, epilepsy, and hysteria furnish proofs of the most capricious alternations of spastic and clonic action, or of their existing in different trains of muscles simul- taneously. These remarks peculiarly apply to ecstasy, the species im- mediately before us, compared with catalepsy or trance, the species that immediately follows. In both, the nervous influ- ence contributory to sensibility and irritability is disturbed in its transmission, or regularity of action, but not equally, nor in the same manner; for while the transmission of the sensific principle seems to be totally suspended, that of the irritable principle continues, though with a striking deviation from the uniform tenour of health. Thus far the two diseases agree. from de- ficiency. General tendency to sympa- thize in different system. These re- marks pe- culiarly applicable to ecstasy compared with catalepsy. How far the tiro agree. CL. IV.] NERVOUS FUNCTION. [ord. iv. 421 They differ in the nature ofthe disturbance ofthe motific Gen. VIII. principle. In ecstasy, this seems to be produced in excess and Spec.II. irregularly accumulated ; in consequence of which the muscles Carus are thrown into a rigid and permanent spasm, not incurvating "s'a8".' the body, as in the different modifications of'tetanus, but main- theyrdiffer. taining it erect from an equal excess of supply to the extensor and flexor muscles. In catalepsy, on the contrary, the motific principle seems to be in deficiency rather than in excess, though it is often irregularly distributed ; and hence, while some mus- cles appear sufficiently supplied, the action of others, even the involuntary ones, is often peculiarly weak. Whence, also, the limbs, instead of resisting external force, yield to it with readi- ness, and assume any position that may be given to them. In both cases, the torpitude of the external senses appears in both the to extend to those ofthe mind ; for the patient, on returning to mind and himself, has no recollection of any train of ideas that occurred "„""" to him during the fit. Yet, we shall find presently that, in a equally few instances, the power of sight and of judging, and perhaps torpid in some other powers, do not seem completely to have failed. genera It deserves, however, to be specially remarked, that both always. these diseases are most common to persons constitutionally dis- Both dis- posed to some mental estrangement, as melancholy or revery, ease? most hypochondrism, or morbid elevation of mind; thus pointing out common to to us the outlet at which the sensorial power is often carried predisposed off: for we have already seen that, under intense revery, the to mental external senses are, for the most part, inactive or torpid to the estrange- impressions of surrounding objects during wakefulness; while cor"ciuSjon the mind is alike dead to every thing but the train of ideas, to be drawn which immediately constitute the subject of the revery. The from l"i,> same tendency to abstraction, though not carried so completely Illustrated. into effect, is often to be found in melancholy, and still more so in that species of alusia which, in the present work, is deno- minated elatio, mental elevation or extravagance, and particu- larly the variety called elatio ecstatica, false inspiration, vi- sionary conceits. If the person labouring'under any of these be attacked at the same time with a general entasia, or rigid tetanus, erecting instead of incurvating the body, he will be thrown into an ecstasy, constituting the present species. And if, instead of an excessive, there be a deficient supply of irri- table power, and consequently a flaccidity or flexibility of the muscles instead of a rigidity, his disease will be a catalepsy, constituting the ensuing species, with this difference alone, that, in most cases of the two diseases before us, the faculties of the mind unite in the torpitude of the senses, instead of giving rise to it. I say, in most cases, and have kept to the same limitation in the specific definition: for if it be true, that one of the causes of both these affections is profound contemplation or attention of mind, or some overwhelming passion, as we are told by many writers, the mind does not seem, in such cases, to be without ideas, nor without them in a very energetic degree. And it is to ecstasis under this modification that, I am inclined to think, 422 cl. iv.] NEUROTICA. [ord. iv. Gen. VIII. Spec. II. Carus ecstasis. Catochus what. Predispo- nent cause of ecstasis. Exciting cause. Remedial intention. Where con- nected with a morbid state of the liver, mercury useful. Interesting case from Chisholm. we should refer the catochus of most of the nosologists, which they arrange in the same order as, and next to tetanus, and de- fine a " general spastic rigidity without sensibility." Ecstasis is of rare occurrence ; its predisponent cause is un- questionably a highly nervous or irritable temperament; the exciting or occasional causes it is not easy, a^all times, to de- termine. For the greater part, they seem to be of a mental character, as profound and long-continued meditation upon sub- jects of great interest and excitement; and terror or other vio- lent emotions of the mind. It seems also to have proceeded, like most of the spasmodic affections already treated of, from various corporeal irritations, and particularly those of the sto- mach and liver, suppressed menstruation, repelled chronic erup- tions, and plethora; and perhaps occasionally, as hinted by the younger M. Pinel,-from an inflammation of the spinal marrow.* The duration of the fit varies, from a few hours to two or three days. The patient rouses as from a sleep, seems languid, and complains of nausea and vertigo ;—evidently showing, that the morbid supply of sensorial power is exhausted, and that the spasm has ceased in consequence of such exhaustion. As the disease evidently consists in a disturbance of the bal- ance of the sensorial power, or in an excessive production of the irritable, but a deficient or suspended production of the sen- sific principle, the curative intention should lead us to aim at a restoration of this balance : and hence the remedial process will run so nearly parallel with that for tetanus, that it is only necessary to refer the reader to the treatment already laid down for that disease. • Where catalepsy is connecfed with a morbid state of the liver, mercury given to ptyalism has often proved highly successful. Dr. Chisholm has given a very interesting case of this kind in a young lady of eighteen of an hysterical diathesis, and in whom the ecstasy, or paroxysm of rigidity, was alternated with par- oxysms of mania. " At the end of ten minutes the patient sud- denly started up in bed, the muscles became at once relaxed, but maniacal distraction of mind instantly succeeded. During the maniacal state* now, it was particularly singular that, al- though she could not articulate a single word, and was evident- ly unconscious of what she did, yet she sung some very beauti- ful airs with a sweetness of tone and correctness of measure extremely interesting and affecting: at the end of ten minutes, her head suddenly and unexpectedly dropped, and she fell back into the state of rigidity."! She finally recovered by the use of mercury. * Journal de Physiologie Experimental, par F. Magendie, D.M. &c. torn. i. Janv. 1821. + Of the Climate and Diseases of Tropical Countries, p. 160, 8vo. Lond. 1822. CL. IV.] NERVOUS FUNCTION. [ORD. IV. 423 Species III. Carus Catalepsia.—Catalepsy. Trance. Total suspension of sensibility and voluntary motion; mostly of men- tal power; pulsation and breathing continuing; muscles flexible : body yielding to, and retaining any given position. This species is chiefly distinguished from the preceding by ^EN,V.I]ITI" the flexibility, instead of inflexibility, of the muscles. The 'FEc' __ ' cause of this difference has been explained under-the preceding tinguished species, and needs not to be repeated in the present place. The from the specific term common to the Greek writers is derived from preceding KxTxXxftZxvonui, " deprehendor," " to be seized or laid hold of," *?e.cl.es" . and alludes to the suddenness of its attack. the specific The predisponent and exciting causes are the same as those name. of ecstasis; and the state of the habit or idiosyncrasy alone Predispo- produces the difference of effect. The countenance is com- nen.t and monly florid, and the eyes open, and apparently fixed intently causes". upon an object, but in most cases without perception. Yet here, Description- as in ecstasis, we sometimes meet with examples, in which one or more of the senses, mental as well as corporeal, do not associ- ate in the general torpitude. So, in paroniria, the sight or hearing continues awake, while the other external senses are plunged in a deep sleep, and, in some cases of paralysis, the sen- tient fibres retain their activity, while those of motion are torpid. The paroxysm commonly attacks without any previous warn- Progress of ing, and closes with sighing or a clonic effort ofthe nervous theparox- power to re-establish its regular flow. Its duration is from a ysm* . few hours, or minutes, to two or three days ; and, according to Durat,on' well established authorities, sometimes for a much longer period. And so completely exhausted of irritable power are some of Wonderful the organs, and even those of involuntary action, that we have „f Sble one example in a foreign journal of forty grains of emetic tar- power. tar having been given without any effect.* The disease, like.the last, is not common. Dr. Cullen never Disease of saw an instance of it, except where it was altogether counter- rence°:CUr" feited, and asserts the same of other practitioners ; which, in and he*nce fact, he offers as an apology for not knowing exactly where to its place arrange it. " Therefore," says he, " from the disease being misarranged seldom, differently described, and almost always feigned, I can y '" eD5 scarcely tell where to place it with certainty; but I am well whoregard- persuaded, that it does not at all differ from the genus apoplexy, ^"won and 1 have hence arranged it as a species of this division." 0f apoplexy. Plethora or pressure ofthe brain may, perhaps, be an occasion- al cause of this, as of most other nervous diseases, in some ha- bits ; but the greater number of cases that have occurred, show very clearly that this disease, in its genuine form, is as distinct from apoplexy as from epilepsy. fnu°nd nice We have said, that both catalepsy and ecstasy are most Ire- ecstasy in quently found in constitutions disposed to mental estrangements, constitu- Dr. Gooch has given a very interesting case in illustration of Jj™'d™' • inn mental * Behrends, Baldingers, N. Magazine, b. ix. 199. estrange- ment. 424 cl. iv.] NEUROTICA. [ord. iv. Gen. VIII Spec III. Carut catalepsia. Striking illustration. From the singularity of its symp- toms often regarded as an impos- ture; yet sometimes wrongfully. Additional illustration. this remark in his paper on puerperal insanity published in the Medical Transactions. The patient was twenty-nine years of age, had been often pregnant, but had only borne one living child ; and was now confined after delivery of a dead child in her seventh month of gestation. " A few days after our first visit," says Dr. Gooch, " we were summoned to observe a remarkable change in her symptoms. The attendants said she was dying, or in a trance. She was lying in bed motionless, and apparently senseless. It had been said, that the pupils were dilated and motionless, and some apprehensions of effusion on the brain had been entertained., But, on coming to examine them closely, it was found, that they readily contracted when the light fell upon them; her eyes were open, but no rising of the chest, no move- ment of the nostrils, no appearance of respiration could be seen ; the only signs of life were her warmth and pulse : the latter was, as we had hitherto observed it, weak, and about 120; her feces and urine were voided in bed. " The trunk of the body was now lifted, so as to form rather an obtuse angle with the limbs (a most uncomfortable posture), and there left with nothing to support it. Thus she continued sitting while we were asking questions and conversing, so that many minutes must have passed. " One arm was now raised, then the other, and where they were left, there they remained ; it was now a curious sight to see her, sitting up in bed, her eyes open, staring lifelessly, her arms outstretched, yet without any visible sign of animation; she was very thin and pallid, and looked like a corpse that had been propped up, and had stiffened in this attitude. We now took her out of bed, placed her upright, and endeavoured to rouse her by calling loudly in her ears, but in vain; she stood up, but as inanimate as a statue ; the slightest push put her off her balance; no exertion was made to regain it; she would have fallen, if-1 had not caught her. " She went into this state three several times : the first time it lasted fourteen hours; the second time, twelve hours; and the third time, nine hours, with waking intervals of two days after the first fit, and one day after the second. After this, the disease resumed the ordinary form of melancholia, and three months from the time of her delivery, she was well enough to resume her domestic duties." From the rarity of the complaint and the singularity of seve- ral of its symptoms, many physicians who have never witnessed an example of it, are too much disposed, like Dr. Cullen, to re- gard it in every case as an imposture. The instance just given is sufficient to clear it from this charge; yet the following from Bonet is added in confirmation. George Grokatski, a Polish soldier, deserted from his regiment in the harvest of the year 1677. He was discovered a few days afterwards, drinking and making merry in a common ale-house. The moment he was apprehended he was so much terrified, that he gave a loud shriek and was immediately deprived of the power of speech. When brought to a court-martial, it was impossible to make cl. iv.] NERVOUS FUNCTION. [ord. iv. him artfculate a word: he was as immovable as a statue, and Gen.VIII. appeared not to be conscious of any thing that was going for- Spec. III. ward. In the prison to which he was conducted, he neither Carus cata" ate nor drank, nor emptied the bowels and the bladder. The leps'3' officers and the priest at first threatened him, but afterwards endeavoured to soothe and calm him ; but all their efforts were in vain. He remained senseless and immovable. His irons were struck off, and he was taken out of the prison, but he did not move. ^ Twenty days and nights were passed in this way, during which he look no kind of nourishment, nor had any natural evacuation. He then gradually sunk and died* The pliability of the muscles to any stimulus that acts upon Singular them is sufficiently evident from both these cases: but it has powerinthe not been generally observed by pathologists, that the force of ^m* the stimulus, which is acting upon them at the time of the at- given posi- tack, continues afterwards, so that the same state of motion or tion or even rest is still maintained. In the case of a schoolboy aged eleven J^o'Tonf years, related by Mr. Stearns,t the paroxysms returned ten Illustrated. times in twenty-four hours, and never exceeded three minutes at a time. And if it commenced while the patient was walking, the same pace was maintained, though without the direction of the mind. The present author was consulted a few years ago Farther on a similar case by a student of Gray's Inn, about nineteen illustration. years of age. Having been attacked with a fit of catalepsy while walking, within a few minutes after having left his cham- bers, he continued his pace insensibly, and without the slightest knowledge of the course he took. As far as he could judge, the paroxysm continued for nearly an hour, through the whole of which time his involuntary walking continued ; at the end of this period, he began a little to recover his recollection and the general use of his external senses. He then found himself in a large street, but did not know how he got there, nor what was its name. Upon enquiry he learned that he was at the farther end of Piccadilly near Hyde Park corner, to which, when he left his chambers, he had no intention of going. He was ex- tremely frightened, very much exhausted, and returned home in a coach. He was not conscious of any particular train of ideas that had passed in his mind during the fit ; but if such there had been, there can be little doubt that, like the visions of a dream, the reminiscence of them would have been com- pletely banished by the terror he felt on first recovering his recollection, and finding himself in a strange place, to which he had been irregularly wandering through a great number of streets without consciousness. He had several slighter attacks antecedently, shorter in duration, and, from his being at rest at the time, unaccompanied with a tendency to perambulate. • In this case, and in all of a similar kind, from the power In similar which the patient seems to possess of avoiding danger, the fa- J:ase?,he culty of the will and of sight, must be in some degree of activi- th^wflUnd ty, however obtunded: bearing a near resemblance to paroniria thesenseof sight must * Medic. Septentrion. lib. I. sect. xvi. Cap. 6. t American Med, Re- ^e ia sorae tester, vol. i. art. vm. vol. iv. 54 426 cl. iv.] NEUROTICA. [ord. IV. Gen.VIII. Spec. III. Cams cata- lepsia, degree of activity. Power of deglutition sometimes preserved. Catoche, what. In other cases an utter inac- ambulans, or sleep-walking, with the exception of the" sudden- ness of the attack. Some pathologists, indeed, have noticed a modification in which the powers of deglutition and digestion continue, as well as those of pulsation and breathing, provided the food be thrust into the mouth. If we were right in ascrib- ing the catochus ofthe ancients to that form of ecstacy in which the mind retains some train of ideas, we shall probably be right also in referring their catoche to this modification of catalepsy ; though Galen seems to have regarded the term as a mere syno- nym of catalepsy, and iEtius adopted his opinion. Instead, however, of most of the involuntary organs being in a joint state of activity, instances have occasionally been known , of an apparent cessation of activity in all of them. A critical thefnvolun- examination ofthe region of the heart will mostly, indeed, give tary organs, proof of a very feeble flutter, and if a clear mirror be applied mKakenfor to the mouth and nostrils, it will generally be found to have a real deatb?1" thin vapour on its face. But even these signs have not always andthesuf- been given: insomuch that the disease has been mistaken for ferer some- real death . an(^ in countrjes where the rite of sepulture takes red^live"" place speedily, it is much to be feared, that the unfortunate Singular ei- sufferer has, in a few instances, been buried alive.* In a case ample of 0f asphyxy of a singular kind, related by M. Pew, the patient, escape. a fernaiGj was peculiarly fortunate in having had her interment postponed for the purpose of ascertaining the cause of her sup- posed death by dissection : for on being submitted to the scal- pel, its first touch brought her to her senses, and threw her into a state of violent agitation, the anatomists being almost as much frightened as herself.t So Diemerbroeck relates a case of a rustic, who was supposed to be dead of the plague, and was laid out for interment. It was by accident three days be- necessityof fore he could be carried to the grave, when, in the act of being UoTinob"- bu^ed, he showed signs of life, recovered, and lived many taining signs years.J Mathaeus, Hildanus, and the collectors of medical curi- ofputrefac- osities are full of stories of this kind: many of them, indeed, loosely related ; but many also possessing every requisite authority for belief: and urging the necessity of waiting for signs of putrefaction before the lid of the coffin is screwed down, or, I should rather say, before the body is removed from its death-bed. We have already observed, that the predisposing and excit- ing causes are the same as those of ecstasy, and that the state those of«" of the habit or idiosyncrasy alone produces the difference of stasy.the effect. This distinction has not been sufficiently attended to difference by pathologists in their mode of treatment: and hence one com- Jmducedby mon plan has been too generally laid down and pursued in ecsta- the habit or sy, fcitalepsy, lethargy, and even apoplexy, the general treat- ment being as much confounded as the diseases themselves. * Pineau, Sur le Danger des Inhumations precipitees. Paris, 1776. t Pratique des Accouchemens, &c. Tozzetti's Raccolta de Teorie, Osser- vazioni e Regole per distinguere e promptemenle dissipare le Asphyssie, a Morte apparente. Fiorenza, 8vo. 1772. X Tractat. de Peste, lib. iv. Hist. 85. Additional illustration Hence the tion before closing the coffin. Predispos- ing and ex- idiosyn crasy cl. iv.] NERVOUS FUNCTION. [ord. iv. 427 'Commonly speaking, copious bleedings and purgings have Gen.VIII. been chiefly trusted to in all of them: and as the present dis- Spec. III. ease, in some cases, arises from plethora, or obstruction, or Cams cata- some irritation of the stomach, it is not to be wondered at that ^.ps'a' this process should sometimes succeed. But, if we have been J/eeaVment. correct in our pathology, if catalepsy be not only a nervous disease, but a disease of nervous debility, in which the sensorial ^ power is disturbed with enfeebled and clonic irregularity, and consequently with a necessary disturbance of the balance of the nervous system, it is perfectly clear, that a reducent treat- A reducent ment, however serviceable in a few cases, cannot be laid down alwayMo as the proper plan to be pursued in general, nor even in any be pursued. case as an advisable practice, farther than it may be called for by the contingency ofthe exciting cause. Stimulants of most kinds will usually be found far more serviceable, particularly in the form of blisters to the head and heart, sinapisms and other rubefacients to the extremities, and injections to the rectum. It is now well known, that the simplest substances, as a solu- Injection or tion of fiftim arabic, or merely warm water infused, to the fo^'g" sub- ■o. ' J . . ' c stances into amount ot not more than an ounce or two, into the current ot tj,e bi00d, the blood by opening a vein, will not only excite the heart to a more violent action, but affect the stomach and intestinal canal with a like increased action by sympathy, producing sickness in the former, and looseness in the latter: and hence Dr. Regnau- dot, in an ingenious inaugural dissertation, has thrown out a hint, well worthy of being followed up, that such a stimulus may probably succeed in rousing the system generally in the present and most ofthe preceding species. Electricity or voltaism, in the manner already recommended, Electricity. may also be tried with a hope of success: and if it be possible Voltaism. to introduce any thing into the stomach by means of a syringe, Diffusible brandy, ether, ammonia, camphor, or even phosphorus, in the to be imro- form and dose already recommended, may be attempted in rota- ducedinto tion. The body in the mean while should be kept warm, with thestomach. a free influx of pure air, and general and persevering friction should often be had recourse to. A steady use of the metallic Metallic tonics should be chiefly confided in after the paroxysm is over. t°ni«- Species IV. Carus Lethargus.—Lethargy. Mental and corporeal torpitude with deep quiet sleep. Lethargy, from the Greek terms M6n and «gyos, " oblivio Origin of pigra," is distinguished from all the preceding species of the |g'remgeneric present genus, by the apparent ease and quietism of the entire Di'• on atony and a disturbed production or balance of the sensorial power, the warm nervine irritants, as musk, camphor, valerian, with blisters, sternutatories, and other stimulants, are the means we should have recourse to. These different processes have been pursued in most ages, The treat- ment hither- * Morgagni, de Sed. et Caus. Morb. Ep. v. 13, 14. Albertino. t Edin. Phil. Trans. 1817. 430 cl. iv.] NEUROTICA. [ord. ir. Gen. VIII. Spec. IV. y C. Leth. argus vigil. Treatment. to too indis- criminate. Plan of Forestus compared with that of Celsus. Both plans consistent with the ex- planation of the authors, but both cannot be right. Where the lethargy is a disease of nervous and especially of general de- bility, a re- ducent plan wrong. Illustrated. but unfortunately they have been pursued indiscriminately : and bleeding, purgatives, and ethers and other diffusible excitants have been employed on like occasions, or even at the same time. Forestus and Dr. Cheyne, who regarded lethargy as chiefly dependent upon plethora or congestion, seem uniformly to have adhered to a reducent plan; and Celsus, who contem- plated it as a nervous affection, equally confines himself to ex- ternal and internal pungents, and advises pepper, euphorbium, castor, and vinegar, with the fumes of burning galbanum or hartshorn applied to the nostrils: as also shaving the head, fo- menting it with a decoction of laurel leaves, or rue, and after- wards applying sinapisms or some other rubefacient epithem. All these are consistent with themselves, how much soever the writers may differ in their view of the proximate cause. Yet, neither line of conduct can be right as a general practice ; and hence other practitioners have occasionally intermixed the two, sometimes incongruously ; and consequently have done less mischief, as at other times they have done less good. That genuine lethargy is, not unfrequently, a strictly nervous affection, and even closely connected with an irregular or de- bilitated state of the mind ; and that a reducent plan is not al- ways calculated to afford it radical relief, however it may give a temporary promise, must, I apprehend, be obvious to most practitioners who have paid a due attention to their own circle of cases; but the following example from Dr. Cooke, bearing a close resemblance in its termination to that already quoted from Mr. Brewster, is peculiarly in point, and ought not to be omitted on the present occasion : " A lady about twenty years of age, who had usually enjoyed very good health, was one morning found in a state of profound but quiet sleep, from which she could not be awakened, although the preceding evening she had gone to bed apparently quite well. Various means had been tried with a view of exciting her from this state, but in vain. Under these circumstances, 1 recommended cupping in the neck; and after she had lost a few ounces of blood in this way, she opened her eyes, perfectly recovered, and remained through the day, quite free from all symptoms of disorder. The next morning, and for several successive mornings, she was found in a similar state, from which she was recovered by the same remedy, no stimulating external applications produc- ing any good effect. As she was considerably weakened by re- peated depletions, it was determined that, on the next recur- rence of the paroxysm, the case should be left to the effects of nature, as long as was consistent with safety. The experiment was tried; and, at the end of about thirty hours, she sponta- neously awoke, apparently refreshed, and wholly unconscious of her protracted sleep. On the future returns of these pa- roxysms, which were frequent, the same plan was adopted, and she awoke after intervals of thirty-six, forty-eight, and, on one occasion, sixty-three hours, without seeming to have suffered from want of food, or otherwise. In the early part of the dis- ease, various means were employed without the smallest ad- cl. iv.] NERVOUS FUNCTION. [ord. iv. 431 vantage, except that, while under the influence of mercury, Gen.VIII. which produced a very severe salivation that lasted more than Spec- iv- a month, she was free from the complaint. For a considerable Carus leth* length of lime, these paroxysms recurred : but at length they arsus" gradually left her; and soon afterwards she became deranged in mind, in which state I believe she still remains."* When, therefore, there are no symptoms leading to a pecu- Treatment liar cause, it will be advisable to bleed by cupping, once or where no twice, but not oftener, to open the bowels and keep them in a U™' state of slight irritation ; to employ blisters or other external peculiar stimulants occasionally, and to have recourse to a repeated use cause. ofthe voltaic trough, sending the line of action from the occi- put down the spine, and varying it to the extremities. In the mean time, if the patient can be made to swallow, we should try the effect of musk, or camphor, with free doses of the me- tallic tonics, of which the sulphate 'of zinc, in doses of a grain, three or four times a day, offers the best prospect of success. Species V. Carus Apoplexia.—Apoplexy. Mental and corporeal torpitude with pulsation and oppressive, mostly stertorous, sleep. There is a considerable difference of opinion among patho- Whether logists whether stertor is a necessary and invariable, or only an stertor be a occasional sign of apoplexy. Sauvages, Linneus, Vogel, Sagar, oronwTc- Forestus,t Kirkland,f Young, and by far the greater number of casional, writers have arranged it as an essential symptom ; and, hence, symptom. the present author was induced to view it in the same light when he published his volume of Nosology. He has since, The disease however, met with one or two cases of atonic apoplexy, in hasoccurred which, although the disease proved fatal, the breathing was at aut|,or no time noisy or stertorous, though uniformly laborious or op- without it: pressive: and he has hence been induced to modify the speci- and hence fie character in the manner it stands at the head ofthe present modification division ; and thus to approximate it to the opinion of Forestus, in the Cullen, and Portal, who do not regard stertor as a necessary in- definition. dex. Dr. Cullen is generally conceived to have omitted this peculiar mark, in consequence of his having included asphyxy and catalepsy under the genus apoplexia, which have no pre- tensions to stertor. But, as we shall have to return to this sub- The subject ject when discussing the different forms or varieties under t°bere- which apoplexy shows itself, I shall only farther observe at hereafter. present, that Dr. Cooke has, with great judgment, steered a judicioua middle course in laying down his own definition, which charac- definition of terizes apoplexy as "• a disease in which the animal functions Cooke. are suspended, while the vital and natural functions continue ; respiration being generally laborious, and frequently attended with stertor."§ * Treatise on Nervous Diseases, vol. i. p. 372. t Lib. x. Obs. 73. X Comment, p. 16. i On Nervous Diseases, vol. i. p. 166. 432 cl. iv.] NEUROTICA. [ord. iv. Gen. VIII. Spec. V. Cams apo- plexia. Apoplexy strictly a disease of the nervous system : and hence makes a near ap- proach to the preced- ing species of cams. Distinctive characters. This view of the subject too limited- Explained. Apoplexy is strictly a disease of the nervous system, depen- dent upon a suspension ofthe sensorial power in almost all its modifications, sentient, percipient, and motory, with the excep- tion of a certain portion which still continues to be supplied to the involuntary organs; the faculties of the mind participating in the torpitude ofthe body. In these respects, it bears a very near approach to the preceding species of carus ; it chiefly dif- fers in its being generally connected with an oppressed state of the vessels ofthe, brain from over-distention or effusion : so ge- nerally, indeed, that apoplexy is, by almost all the writers on the subject, regarded rather as a disease of the sanguineous, than ofthe nervous system ; the morbid action of the latter be- ing supposed to be entirely dependent on that of the former, and consequently only a secondary affection. This view ofthe subject, however, is by far too limited: for although in most cases the more prominent symptoms concur with the appearances on dissection in leading us to com- pression of the brain as the primary cause of the disease, yet we shall find presently, that it has sometimes taken place where no such compression seems to have existed, whilst we have al- ready had occasion to notice a variety of affections of the head attended with forcible and severe compression, as inflammation and dropsy ofthe brain, that have run their entire course with- out any mark of apoplexy whatever: to which should be added that, while in most other diseases or lesions accompanied with compression of the brain, and a suspension of sentient and mo- tory power as a consequence hereof, such suspension ceases almost the moment the compression is removed, when the nerves of feeling and motion, together with the faculties ofthe mind, resume their wonted activity, and evince no tendency to a relapse; in apoplexy, on the contrary, the result is always doubtful; for a palsy of some part or other is a frequent and permanent effect, or the mind suffers in some of its faculties, and a relapse is generally to be apprehended. So that though compression of the brain, and particularly from a morbid stale of the sanguineous and respiratory functions, may be justly regarded as the ordinary efficient cause, there seems to be at the same time some peculiar debility or other diseased condi- tion of the sensorial system to which apoplexy is primarily to be referred, and without which it might not take place ; and which has not been sufficiently adverted to by practitioners. Though there can be no difficulty in our affirming that, wherev- er such a morbid condition exists, compression, from whatever cause, will be sure to produce the disease. We may hence see why advancing age should prove a pre- disposing cause; and account for the statement of Morgagni, who tells that, of thirty cases of apopleptic patients that fell within the reach of his observation, seventeen were above the age of sixty, and only five below that of forty. Hippocrates, on Statemeotof a more general estimate, calculated that apoplexies are chiefly Morgagni. (ftxXtarx) produced between the fortieth and sixtieth year.* Hence obvi ous why advancing age should be a pre- disposing cause, * Aph. Sect. vi. 57. CL. IV.] NERVOUS FUNCTION. [ord. iv. 433 This, indeed, is somewhat earlier than we should expect on the Gen.VIII. ground of advancing age; but when we take into consideration Spec. V. that it is the precise period, in which the mind is most agitated Carus and exhausted with the violent and contending passions of inter- aP°P,ex,a- est, and ambition, and worldly honours, and the blood most fre- ofaSci011 quently determined to the head by this impulse of sudden and crates. irresistible emotions, we shall, perhaps, readily accede to the • Hippocratic aphorism as a general rule. How far apoplexy is occasionally the result of an hereditary Hereditary influence on the frame, it is not easy to ascertain. Forestus, influence Portal, and Wepffer refer to decided instances of such facts with- ^2"^ in their own knowledge; the first, indeed, relates the history of cause. ' a father and his three sons, all of whom died in succession of this disease ; but as the chronology drops with the second gene- ration, it does not descend quite far enough for the purpose. There is great reason, however, for believing that an hereditary tendency does sometimes show itself; and, as this exists without external or manifest signs, it is probably seated in the sensorial system, and constitutes another of the morbid conditions of this system, to which we have referred above, as often giving effect to subordinate causes. There is no difficulty in conceiving how heat may become a Heatapre- predisponent cause, since nothing tends more effectually to disposing quicken the action of the heart, drive the blood forcibly into the explained. aorta, and consequently, overload the vessels of the brain. But cold is said to be a predisponent cause, as well as one that ope- ^f^-9, rates quite as extensively, while the reason of this has not been cause, but at all times very clearly explained. Now as a hot temperature operating acts chiefly upon the sanguiferous system, extreme cold acts entfy and" chiefly -upon the sensorial, benumbs the feeling, weakens the chiefly upon muscular fibres, diminishes the sensorial energy, and conse- tht?»ensorial quently induces, as we have already seen under one ofthe vari- syslein- eties of asphyxy, an unconquerable propensity to sleep. And hence again, in apoplexies produced by severe cold, the prima- ry or predisponent cause is to be sought for in a debilitated state ofthe nervous system. The Greek physicians are perpetually Cold sup- alluding to this cause as one of great frequency, and the expla- posed by nation now given does not essentially vary from that offered by ll'e 9rfek Galen.* If, indeed, the cold be exquisitely intense, carus As- to be a* ' phyxia is more likely to be produced than carus Apoplexia; for cause of we have already observed under the preceding species, that the j?r*a^ very same cause which, operating in a vehement degree, ex- When cites the former, operating less powerfully has often a tendency exquisitely toexci.e.helacter £"_* The other predisponent causes, so far as they have been asphyxy, traced out, are more obvious to the senses, and, for the most an<1 on|y part, more directly referrible to the state of the sanguineous je^dp",.* function ; as plethora, corpulency, and grossness of habit, a apoplexy. short thick neck, and the free use of wines and heavy ferment- Other and ed liquors. Dr. Cheyne, indeed, believes the last to be so com- f^prediT- VOL. IV. posing De Loc. Aff. Lib. hi. cap. vi. causes 55 434 cl. iv.] NEUROTICA. [ord. IV. Gen.VIII. Spec. V. Carus apoplexia. How far a daily use of winn in moderation ma> pre. dispose. The com- mon efficient cause com- pression of the brain. How far there may be any other excit- ing cause, as deter. minable by dissections. The ordinary morbid ap. pearanceu mostly ineffective otherwise than as con- comitants: though they may be sufficient where a strong pre. dispositiou exists. Hence the apoplexy of infants from teething or disorder of thestomaih. As also apoplexy from other remote irritations. Most of these morbid actions and appearances as common to other affections of the sensorial system as to apoplexy. mon a cause, as even to produce the disease without any inordi- nate indulgence whatever: " the daily use, says he, "of wine or spirits will lead a man of a certain age and constitution to apoplexy, as certainly as habitual intoxication."* This may be true as here limited; but then the limitation must be attended to; in which case we are only told in other words, that wherev- er such a kind of sensorial debility exists as that which we have already adverted to, the result of age, or habit, or constitution, one man will be as readily led to apoplexy under a moderate use of wine, as another man destitute of such predisposition will be under a state of habitual intoxication. With this expla- nation, however, a moderate use of wine becomes only an ac- cessory, and not a primary cause. How far there may be any other efficient or exciting causes of apoplexy, than compression of some kind or other, it is diffi- cult to determine, though various cases on record should induce us to suppose there are. Hydatids, tumours of almost every consistency, gelatinous, steatomatous and bony, pus, and indura- tions ofthe membranes, have, in various cases, been discovered on dissection, and are generally supposed to operate by com- pression. But, in many instances, these appearances seem to have been too minute for any such effect; and can only fairly be regarded as concomitants or allied powers—as local irritants, stimulating and exhausting the sensorium, and preparing it for attacks of apoplexy against the accession of some superinduced and occasional cause. Though where there exists already a strong predisposition to the disease from hereditary or any oth- er affection, it is not improbable, that such local irritants may alone be sufficient to perfect the complaint. And we may hence account for that form of apoplexy which is said to proceed from intestinal worms, or some irritation of the stomach, or from teething; and which, consequently, occurs at an early, instead of at a late period of life, and has been especiallj' denominated apoplexia infantum. Other organs, however, besides the teeth and the stomach, seem not unfrequently to have given occasion to apoplectic attacks from irritation, distention, or organic le- sion. Thus, acccording to M. Portal, superinducing tumours and congestions have been found in the neck, in the breast, or in the abdomen; ossifications in the thoracic and ventral aorta, as well as in the arteries ofthe upper and lower extremities, in the superior vena cava, and in the right ventricle and valves of the heart, which has also indicated various other changes.! Most of these morbid actions and appearances, however, are as common to various other affections of the sensorial system as to apoplexy. We have already noticed them in lethargy, con- vulsion, epilepsy, various species of cephalaea, and some forms of insanity : and hence, wherever they become causes at all, it is most probable, that the disease they immediately produce, is regulated by the predisposition of the individual to one, rather than to any other of the above sensorial affections, resulting * Cheyne, p. 146. t Portal, Ch. Resultats de l'Ouvcrture des Corps, p. 329. cl. iv.] NERVOUS FUNCTION. [ord. iv. 435 from family taint, idiosyncrasy, habit, or period of life: and, Gen. VIII. consequently, that the same exciting or occasional cause, which, Spec V. in one person, would produce apoplexy, in a second, would form Cani* . epilepsy, in a third, convulsion, and in a fourth, madness. apop It is highly singular, that this view of the subject should Singular scarcely ever have been attended to by physicians ; and that, ^J*^ ofthe whilst all the writers have pretended to regard apoplexy as a s„bject disorder ofthe nervous system, none of them have suffered such should ideas to enter fairly into their pathology, or in any way what- ^"1^,, ever into their practice: the nervous organ being supposed by attended to: all of them to be in a state of soundness at the time of the ajf either in the tack ; and whatever mischief it suffers to be merely secondary )|f ^"^J™ and consequent upon a morbid state of the blood-vessels, or of ease or some other cause, that as suddenly and effectually interrupts the practice. production and distribution of the sensorial power, as retroce- dent gout, mephitic vapours, or narcotic poisons. Now ail these accidental or effective causes of apoplexy are This point well known to be causes, also, of the other nervous affections farther we have just referred to. But if this be the case, how comes "lvestlSated- it that they should thus vary in their result, and that what in one person, and at one period of life, should produce apoplexy, should in another person, and in another period of life, produce lethargy, palsy, convulsions, or epilepsy ? or that some of them should exist without producing any of these diseases or any Other disease whatever? It is not, perhaps, possible for us to develope the precise condition of the sensorium that leads to any one of these effects, rather than to any other; but that there is such a condition, forming a predisponent or remote cause of the specific disease that shows itself, must, I think, be allowed by every one who seriously considers the subject. Nor is there, in effect, any other means of reconciling the No other discrepant and opposite opinions that have been held concern- v'e* H""> ing the proximate cause of the disease. This we have stated ^pXe'of* to be, for the most part, compression, and especially sanguine- reconciling ous compression. Mr. John Hunter was so strenuously attached various to this cause, that he would allow of no other; M. Rochoux 0p2" has followed his footsteps ;* and if a man died of apoplexy concerning from atonic gout, and without effusion, the former distinguished «»«" prof- it as a disease similar to apoplexy. He regarded apoplexy and ™a e cau8e; palsy as one and the same disease, merely differing in degree : j$™°n ° and he gives us his sentiments very forcibly in the following Hunter: words : " For many years," says he, " I have been particularly compression attentive to those who have been attacked with a paralytic Nation to stroke forming a hemiplegia. I have watched them while the brain alive, that I might have an opportunity to open them when j° *™|* dead: and, in all, I found an injury done to the brain in conse- p^dSg quence of the extravasation of blood.—I must own, I never saw extravasa- one of them which had not an extravasation of blood in the tion' brain, except one, who died of a gouty affection in the brain with symptoms similar to apoplexy.^ * Diet, de Medecine, torn. ii. Paris, 1822. t Treatise on Blood, &c. p. 213. 436 «*• »v0 NEUROTICA.' [ord. IV. Gen. viii. In direct hostility to this hypothesis, many other writers of Spec V. great eminence and experience have contended that compres- Caius sion is no cause whatever, and that an accumulation of blood apoplexia. jn the heaj? ag a prominent symptom in apoplexy, is a doc- Compres- trme^ ratner than a fact. Of this sentiment is Dr. Abercrom- caule'what- bie, who, after examining the question with much ingenuity, ever in the brings himself to the following conclusion: "Upon all these Ser°"utho. groundsi" says he» "l lhink we must admitithat th-e doctrine rities.'and0" of determination to the head is not supported by the principles no such of pathology, and does not accord with the phenomena of apo- tJrminat?oCn P,exy"* M- Serres, however, a physician of considerable to'the'he'ad. distinction in France, and who followed up this subject for many Abercrom- years by a careful examination of the bodies of persons who bie- died of apoplexy and paralysis, both at the HStel Dieu, and the Eiperi- Hopital de la Pitie, has carried his inroad upon the popular hyprthrii doctrine of the day still farther; for he has not only, in his ofSerres. own opinion, completely subverted it, but has endeavoured to establish another doctrine, of a very different character, upon its ruins.t To determine the question, he has gone through a long series of experiments upon the brains of dogs, pigeons, rabbits, and other animals, whose crania were trepanned, their lateral, or longitudinal sinuses laid open, and their brains lace- • Treatise on Apoplexy, &c. p. 19. If, however, we consult a later publication of this distinguished physician and pathologist, we shall find that, whatever may be his opi- nion respecting determination of blood to the head, as a cause of apoplexy, he himself brings forward examples of apoplexy from pressure on the veins in the neck, and a con- sequent distention of the vessels of the brain.—(See Pathological and Practical Research- es on Diseases of the Brain and the Spinal Cord, p. 204, Edin. 1828.) After adverting to cases from strangulation (cases, however, in which the actual suspension of the functions of the brain might be more justly imputed to the transmission of black, or unoxygenated blood to that organ, than to an apoplectic state of it), he notices other examples, "in which persons fall down suddenly in a state of perfect apoplexy, and very speedily re- cover under appropriate treatment, without retaining any trace of so formidable a mala- dy. The apoplectic attack, as it occurs in such examples as these," he says, "must be supposed to depend upon a cause, which acts simply upon the circulating system of the brain, producing there a derangement, which takes place speedily, and is often almost as speedily removed. What the precise nature of that derangement may be, is a point of the utmost difficulty to determine," &c. And again, " the apoplectic attack is generally preceded by symptoms, indicating some derangement of the circulation in the brain."— (p. 205.) Were the editor bold enough to question the accuracy of some parts of Dr. Abcrcrombie's valuable treatise, he should be disposed to say, that this author compre- hends too many different states of disease in his view of apoplexy. Thus his 90th case (p. 212) appears to have been only an example of ascites and hydrothorax, where death was preceded by coma and stertor. But if all diseases, which exhibit coma and stertor a little before their termination, were to be regarded as apoplexies, where would be the limit to this principle of classification ? The editor would also say, that apoplexy might be characterized by the suddenness with which the fit takes place, whether preceded by other ailments, or not, and that no examples ought to be looked upon as apoplexies, in which the coma and loss of sense come on gradually, as they do in the last stage of fever and other disorders. Apoplectic symptoms, as a critical writer observes, are known to arise from various states of the brain or its parts. It is now, says he, regarded as most expedient to restrict the appellation of apoplexy to lhat state ofthe vessels of the brain, in which they are either excessively distended with blood, or in which this fluid has escaped, either by exhalation, or rupture.—(Ed. Med. Journ. No. 90, p. 83.) Dr. Abercrombie s remarks are particularly interesting, however, as proving that apoplexy should not always be ascribed to fulness of the cerebral vessels, or to extravasation, even though some un- known form of derangement ofthe circulation in the brain may exist.—Editor. t Annuaire Medico-Chirurgicale, Aviil, 1820. CL. IV.] NERVOUS FUNCTION. [on©, iv. 437 rated and excavated in various ways, so as to be gorged with Gen. VIII. effused blood, yet, in none of them, did somnolency or any Spec. V. other apoplectic symptom take place. And he hence triumph- Carus antly concludes, that extravasation of blood does not produce aP°P,exia> apoplexy, whether lodged between the cranium and the dura mater, or between the dura mater and the brain : whether the blood occupy the great interlobular scissure, and thus lie upon the corpus callosum ; whether cavities be made in the fore, the back, or the middle part of the hemispheres, or run from the one into the other; or, lastly, whether piercing through the corpus callosum we reach and fill up the ventricles of the brain. " On whatever animal," says he, " we try these ex- periments, whether on birds, rabbits, or dogs, the result is the same, and hence apoplexy in man ought not to be ascribed to such effusions." [" A person (says Dr. Abercrombie), previously in perfect Apoplexy health, falls down suddenly, deprived of sense and motion, and w'tn. spreading sometimes over the limbs, but more generally confin- crneaduii, ed to the muscles of the face; insomuch that, under the first, pupil dilat- the teeth are firmly closed, and deglutition is impeded. And g1' icor where this state exists the pupil is contracted, as in a synizesis, ^,,1,^ sometimes, indeed, almost to a point. This last feature has action. been rarely dwelt upon by pathologists, whether of ancient or PjjPJj *°™' modern times: but it has not escaped the observant eye of my tracted, par- accurate and learned friend Dr. Cooke : "In some instances," ticularly says he, " 1 have seen the pupil contracted almost to a point, ™os*^ed by and a physician of eminence of my acquaintance has likewise observed this appearance ofthe eyes in apoplexy : yet although all writers on the subject mention the dilated pupils, I do not find any one, Aretseus among the ancients, and Dr. Cheyne among the moderns excepted, who has noticed the contracted PUThe paroxysm varies in its duration, from eight to eight and J*™^0* forty hours, and sometimes exceeds this period. Dr. Cooke ysJ quotes from Forestus the case of a woman, who being seized Has extend- with an apoplexy, which he calls fortissima, lay in the fit for ed to rtiree three days, and afterwards recovered. We have already ob- recovery. served, that where it does not prove fatal, it predisposes to a Sequel of relapse, and often terminates in a lesion of some of the mental the disease. faculties, or in a paralysis more or less general; commonly, in- Hemiplegia, deed, in a hemiplegia, which usually takes place on the oppo- J"™?^ site side of the body from that of the brain in which the con- thebody eestion or effusion is found, on examination, to have taken place, from that of " This," says Dr. Baillie, « would seem to show, that the right *£™£te side ofthe body derives its nervous influence from the left side iseffusi0nof of the brain, and the left side of the body its nervous influence blood. from the right side of the brain. It is rarely indeed, if ever, that some of the turgid vessels of the brain are not ruptured in this form of the disease, and consequently produce an effusion of blood into some part of the organ of the brain." And, ac- cording to the same distinguished writer, the part where the rupture most commonly takes place is its medullary substance near the lateral ventricles, some portion of the extravasated fluid often escaping into these cavities.! Atonic apoplexy is the disease of a constitution infirm by na- /3C. Apo- ture or enfeebled by age, intemperance, or over-exertion of Pj™a at0" body or mind. It has more of a purely nervous character, as Aregultof we have already observed, than the preceding variety, and is vascular de- more a result of vascular debility than of vascular surcharge, ™££™ and consequently where effusion of blood is found, as it often is, cuiarsur. in the present form, the vessels have been ruptured, not from charge: habitual distention or vigorous plethora, .but from accidental, vessels* often, indeed, slight causes, that have produced a sudden excite- have been ment and determination to the head beyond what the vascular found rup- * Ibid. p. 174. t Morbid Anat. p. 227. 446 «- »v.] NEUROTICA. [ord. IV. Gew. VIII. walls are capable of sustaining. Hence, a sudden fit of cough- Spec. V. jng or vomiting, a sudden fright, or fit of joy, an immoderate 0C. Apo- fit of laughter,* the jar occasioned by a stumble in walking, or nica'a'at0 a severe jolt in riding, have brought on the present form of tured from aP°P'exy5 an(l w^h so much the more danger as the system their own possesses less of a remedial or rallying power in itself. weakness. In most of the cases the effusion detected after death has, Objection to therefore, been as truly sanguineous as in entonic apoplexy ; sanguineous ana" hence a valid objection to the use of the term sanguineous apoplexy, as descriptive of the entonic form alone. " It is," says M. Por- tal, "an error to believe, that the apoplexy, to which old men Illustrated, are so much subject, is not sanguineous." Daubenton and Le Roy, Members of the Institute, died of this precise kind of the disease at an advanced age : and Zulianus describes a case mark- ed by a pale countenance, and a pulse so weak as scarcely to be felt, which, on examination after death, was found to be an apoplexia vert sanguinea: and another in which, after all the symptoms of what is ordinarily called serous apoplexy had shown themselves, extravasated blood was discovered in the brain without any effusion of serum, or the smallest moisture in the ventricles.! This form It is nevertheless true, that atonic apoplexy is often found often found with an effusion of serum, instead of an effusion of blood, and fusb^of tlie aPParent'y produced by such serous effusion ; and hence, not- serum. withstanding the objections of Dr. Abercrombie, and, in the latter years of his practice, of M. Portal, to serous effusion as a cause at all,+ the experience and reasoning of Boerhaave and Hoffman, and Mead, and Sauvages, and Cullen, must not be abruptly relinquished without far graver proofs than have hith- erto been offered: for if it be a question, as Stoll has made it, whether effused serum, when discovered in the brain of those who have died of apoplexy, be a cause of the disease or an * Aretteus de Sign, et Caus. Diut. Morb. Lib. I. Cap. 7. t See also Burser. De Apoplex. p. 82. Cooke, ut sup. X The following conclusions of Dr. Abercrombie, the editor of this work is disposed to adopt as most consonant to facts: 1. There is a modification of apoplexy, which is fatal without leaving any morbid ap- pearance, that can be discovered in the brain. 2. There is another modification, in which we find serous effusion often in small quantity. 3. The cases, which are referrible to these two classes, are not distinguished from each other by any such diversity of symptoms as can be supposed to indicate any essential difference in their nature. 4. Without any apoplectic symptoms, we find serous effusion in the brain in an equal, or in a greater quantity, than in the cases ofthe second modification. 5. It is therefore probable lhat, in these cases, the effusion was not the cause ofthe apoplectic symptoms. 6. It is probable, that the causes of the first modification depend upon a cause, which is entirely referrible to a derangement of the circulation in the brain distinct from inflammation. 7. It is probable, that the cases of the second modification are, at their commencement, ofthe same nature with those ofthe first; and that the serous effusion is to be considered as the result of that peculiar derangement ofthe circulation, which constitutes the state of simple apoplexy. In short, Dr. Abercrombie considers the serous modification as simple apoplexy terminat- ing by effusion.—(On Diseases ofthe Brain, &c. p. 220.) With respect to the impossibil- ity of detecting any morbid appearances in some cases of apoplexy, we are not to infer from it, that a minute derangement of the structure of the brain, some alteration of its consistence, or some diseased action of its vessels, may not frequently have been concern- ed in the production ofthe disease, though overlooked, or not demonstrable after death.— Editor. CL. IV.] NERVOUS FUNCTION. [ord. iv. 447 effect,* we may apply the same question to effusion of blood. Gek.VHL It is possible, indeed, for effused serum to become occasionally *EC' ' a cause even of entonic apoplexy, or that which, from its symp- pjexjaato^ toms, is ordinarily denominated sanguineous apoplexy; for it is nica. possible for the exhalants of the brain to participate so largely Effused se- in the high vascular excitement by which this form of the dis- rum may ease is characterized, as to secrete an undue proportion of becom^/'eQm effused fluid into any jof its cavities, and thus become as direct tonic apo- a cause of apoplexy as extravasated blood. plexy. This, however, is not what is generally understood by the fexroujnaepo- term serous apoplexy as distinguished from sanguineous, and, in- piexy as deed, ought only to be regarded as an effect of sanguineous dis- commonly tention.t Serous apoplexy, properly, so called, is strictly the "he result of result of a debilitated constitution, and especially of debility ex- a debilitated isting in the excernent vessels of the brain, whether exhalants constitution. or absorbents. I say absorbents, because, although lymphatics have not yet been discovered in this organ, there must be ves- sels of some kind or other to answer their purpose, and the ex- tremities ofthe veins have been supposed thus to act; a suppo- sition which has derived countenance from various experiments of M. Magendie, to which we shall have to advert in the Proem to the sixth class, and which may at least stand as an hypothesis till the proper system of vessels is detected. Hence, atonic apoplexy rarely makes its attack altogether so Hence ato- incontinently as entonic; and is commonly preceded by a few Dicapoplexy warning symptoms. These are often, however, nothing more ^e's'low in than the ordinary precursors of other nervous affections, as ver- its progress tigo, cephalaea, imaginary sounds, a faltering in the speech, a thanentonic. failure in the memory or some other mental faculty, and at length Precursive a sense of drowsiness, and a tendency to clonic spasms. On the 8lgDB". attack of the paroxysm, the patient is as completely prostrated ncursi0D* as in the entonic variety, but the symptoms are less violent, though not on this account less alarming, in consequence of the greater debility of the system. The countenance is here pale or sallow, instead of being flushed, but at the same time full and bloated; the pulse is weak and yielding, sometimes, indeed, not easy to be felt; and the breathing, though always heavy and labori- ous, not always, as we have already observed, noisy or stertorous. If spasms occur, they are uniformly of the convulsive or clonic kind. The duration of the fit varies, and if the patient recover, Duration of he is more liable to a relapse, and more in danger of hemiple- thefitvarier. gia or some other form of paralysis, than in the stronger modifi- cation ofthe disease. From these remarks on the two varieties of apoplexy, we may rjisease un- readily see why this complaint, and its ordinary associate or se- deroneform quel, palsy, should be about equally common to the poor and to orotl,er the rich: for frequent exposure to cold and wet, severe and long nmn to the poor and the * PrEelect. p. 367. t Here, and in the preceding sentence, the author ad- rich. mits one of Dr. Abercrombie's principal conclusions, somewhat differently ex- pressed, namely, lhat serous apoplexy is a consequence of some derangement in the cerebral circulation, though what this derangement maybe, is not defin- ed farther, than that it is unaccompanied with any visible morbid appearances in the brain after death.—Editor. 448 cl. iv.] NEUROTICA. [ORD. IV. Gen.VIII. Spec. V. |8 C. Apo- plexia ato- nica. Illustrated from Blane's tables. Prognostic. Antonicapo- plexy more dangerous thanentonic, and why. In other respects the danger pa- rallel with the violence ofthe symptoms. Favourable signs. Unfavour- able. Acontracted pupil a sign of great dan- ger, and why. Convulsions whether dangerous- protracted exercise, and a diet below what is called for, will of- ten be found to produce the same debilitating effects as ease, in- dolence, luxury, and indulgence at too sumptuous a table. And hence, contrary to what many would expect, Sir Gilbert Blane has observed from accurate tables kept with minute attention and derived from a practice often years in St. Thomas's Hospital, and his private consultations, that " there is a considerably great- er proportion of apoplexies and palsies among the former than among the latter:" or, in other words, that these disorders bear a larger proportion to other diseases among the lower classes, than among those in high life. " Some cases of hemiplegia," says he, " occur in full habits; some in spare and exhausted ha- bits. The former, being most incident to the luxurious and in- dolent, most frequently occur in private practice, and among the upper ranks of life. The latter occur more among the laborious classes, and among such of the rich as are addicted to exhausting pleasures."* In forming our prognostic, a special regard must be had to the peeuliar character of the disease. Generally speaking, atonic apoplexy is more dangerous than entonic, for we have here a more barren field to work upon, and nature herself, or the in- stinctive power of the living frame, has less ability to assist us. As to the rest in either modification, the degree of danger will be generally measured by the violence of the symptoms. Where, under the first variety, the breathing is not much disturbed, the pupil is relaxed, and there is no appearance of spastic action; where the perspiration is easy, the skin warm rather than hot, the bowels are readily kept in a due state of evacuation, and more especially where there is any spontaneous hemorrhage, as from the nose or hemorrhoidal vessels, and of sufficient abun- dance, we may fairly venture to augur favourably. But where the symptoms are directly opposed to these; where the stertor is deep and very loud,t and particularly where it is accompanied with much foaming at the mouth; J where the teeth are firmly clenched, or a spasm has fixed rigidly on the muscles of degluti- tion, and the pupil, instead of being dilated, is contracted to a point, we have little reason to expect a favourable termination. The great hazard resulting from this tendency to spastic ac- tion, and particularly as evidenced in a strongly contracted pupil, is thus forcibly pointed out by Dr. Cooke. " Among the dan- gerous signs in apoplexy, many authors mention a dilated state ofthe pupil ofthe eye: but the contracted pupil, which I con- sider to be a still more dangerous appearance, has been scarcely noticed. 1 am of opinion, that this ought to be reckoned among the very worst symptoms of the disease. I never knew a person recover from apoplexy when the pupil was greatly contracted. My opinion on this subject is confirmed by that of Sir Gilbert Blane and Dr. Temple."§ Dr. Cheyne, in like manner, regards convulsions as a source * Trans. Medico-Chir. Soc. vol. iv. p. 124. X Burser. p. 97. t Dolaeus, p. 144. } Burser. p. 280. cl. iv.] NERVOUS FUNCTION. [ord. iv. 449 of great danger: while M. Portal, on the contrary, thinks they Gen.VIII. sometimes announce a diminution of the morbid cause. The Spec. V. latter reasons from the fact, that when, in living animals, a slight £C. Apo- pressure has been made on the exposed brain, convulsions have {j-"!*310" taken place ; while, if the pressure be increased in power, gene- ral stupor with stertor and difficult respiration have followed in- stead of convulsions; an ingenious conclusion, but not exactly applicable, since in the one case the brain is in a morbid and in the other in a sound state; whence the premises, on which the reasoning is founded, are not parallel.* In the treatment of apoplexy, if we be timely consulted dur- Medical ing the existence of the precursive signs which have been no- treatment. ticed as occasionally taking place, we shall often find it in our Importance power completely to ward off a paroxysm by bleeding, purga- attention to tives, perfect quiet, and, in the entonic variety, a reducent regi- the precur- men. Where, however, the pulse, and other symptoms give aive si8ns- proof of weak vascular action, and nervous debility, the de- B!eedl,ne:h pleting plan should be pursued with caution, and it will be better pursued with to employ cupping-glasses than venesection, and, in some in- caution. stances, to limit ourselves to purgatives alone. Yet, whatever When abso. be the degree of general debility, if the proofs of compression ,utel.y nece?- or distention be clear, as those of drowsiness, vertigo, and a dull apoplexy. pain in the head, it will be as necessary to have recourse to bleeding either locally or generally, as in entonic apoplexy ; for such symptoms will assuredly lead to a fit, unless timely counter- acted and subdued. " In the actual paroxysm of apoplexy," says Dr. Cooke, and I General quote his words because it is impossible to exchange them for direct'oni. better, " the patient should, if possible, be immediately carried into a spacious apartment, into which cool air may be freely admitted. He should be placed in a posture which the least fa- vours determination of blood to the head: all ligatures, especial- ly those about the neck, should be speedily removed, and the legs and feet should be placed in warm water, or rubbed with stimulating applications. These means may be employed in all cases of apoplexy :"f and are consequently equally applicable to both the forms under which we have contemplated the disease. The collateral means to be had recourse to require discrimina- tion, and it will be most convenient to consider them in relation to the actual form, under which the apoplexy presents itself. * The following passage from Dr. Abercrombie's work, in relation to the prognosis, deserves attention.—" From the facts, which have been related, we have seen reason to believe, that there is a modification of apoplexy, which is fatal, without leaving any mor- bid appearance, and which probably depends upon a deranged condition in the circulation in the brain. We have also seen grounds for believing, that the cases, which terminate by effusion, are probably at their commencement in this state of simple apoplexy. We have seen farther, that we have no certain mark, by which we can ascertain the presence of ef- fusion ; and finally we have found, that even extensive extravasation of blood in the brain may be entirely recovered from by the absorption of the coagulum. These considerations give the strongest encouragement to treat the disease in the most active and persevering manner. They teach us, also, not to be influenced in our practice by the hypothetical dis- tinction of apoplexy into sanguineous and serous; and finally, not to be hasty in conclud- ing, that the disease has passed into a state, in which it is no longer the object of active treatment."—Pathol, and Pract. Researches on Dis. ofthe Brain, p. 288. -f Burser. p. 288. VOL. iv. 57 450 c^ !▼•] NEUROTICA. [ORD. IV. Gen.VIII. Spec. V. Carus apoplexia. Treatment. Particular treatment of entonic apoplexy. Copious and repeated bleeding. Timid practice of Hippo- crates. Mischievous influence on later physi- cians-, as Forestus: Heberden: Fothergill. In entonic apoplexy, copious and repeated bleeding seems, prima, facie, to offer the most rapid and effectual remedy we can have recourse to: yet the opinions of the best practitioners, as well in ancient as in modern times, have been strangely at vari- ance upon this subject. Hippocrates, who regarded apoplexy as chiefly dependent upon a weak and pituitous habit, discoun- tenanced the use of the lancet, as adding to the general debility: and even where it is accompanied with symptoms of strong vas- cular action, he discountenanced it equally, from an idea that the case was utterly hopeless. The authority of Hippocrates has had too much influence with physicians in all ages, and has extended its baneful effects to recent times, and, in some in- stances, even to our day. Hence Forestus tells us, that in strong or entonic apoplexy, no courageous plan ought to be attempted, no venesection, no pills: we may, indeed, to please the by- standers, have recourse to the remedia leviora of frictions, and injections, and ligatures round the arms and thighs; " and where," says he, " we have not found these succeed—in ra- tionem sacerdotibus commiserimus." In our own country, the same timid feeling has been particu- larly manifested by Dr. Heberden and Dr. Fothergill, but on grounds somewhat different. These excellent pathologists have chiefly regarded apoplexy as a disease of nervous, rather than of general debility, and have been fearful of adding to this de- bility by abstracting blood, and hereby of almost ensuring hemi- plegia, or some other form of paralysis. Hence Dr. Heberden speaks with great hesitation concerning the practice, rather than with an absolute and general condemnation of it: he ob- serves, which is true enough, that many persons have been in- jured by large and repeated bleedings, and then lays down his rule, not to bleed either in an attack of apoplexy or palsy, if there would have been just objections to taking away blood be- fore the incursion of either.* Dr. Fothergill, however, expresses himself still more decided- ly against bleeding than Dr. Heberden. He suspects that the weakness it occasions checks the natural effort to produce ab- sorption ; and that even the hard and full and irregular pulse, which seems imperatively to call for a very free use ofthe lan- cet, " is often an insufficient guide;" since " it may be that struggle which arises from an exertion of the vires vita to re- store health." And hence, he adds in another place, " I am of opinion that bleeding in apoplexy is, for the most part, injurious, and that we should probably render the most effectual aid by endeavouring, in all cases, to procure a plentiful discharge from the bowels: as by these revulsions, the head is, perhaps, much more effectually relieved from plenitude, and that without weakening or interrupting any other effort of nature to relieve herself, than by venesection."! It is singular lhat in drawing such conclusions from the in- stinctive efforts or remedial power of nature, where a cure has Medical Transactions, i. p. 472. t Works, vol. iii. p. 20G. cl. iv.] NERVOUS FUNCTION. [ord. iv. 451 been effected spontaneously, these distinguished writers have not Gen. VIII. felt more deeply impressed by the salutary effects of sponta- SrKc.V. neous and copious hemorrhages, as from the nose, the lungs, Cams and the hemorrhoidal vessels, which have never perhaps poured aP°P,exia- forth blood freely without operating a cure; and that they have Treatment. not endeavoured to follow these footsteps, as far as they might have done, by substituting an artificial discharge of blood where a natural discharge has not taken place. Other physicians, however, both in ancient and modern times, Bolder have not been equally insensible to this important fact. Galen, practice of though he always hesitated in departing from the practice of °ll!er Hippocrates, ventured to deviate from him upon the point be- Tncientand fore us. Aretaeus, Paulus of iEgina, and Ccelius Aurelianus modem. carried the remedy of bleeding to a still farther extent, and Celsus regarded it as the only mean of effecting a cure.* " The Arabians adopted the practice ofthe ancients, as far as Arabian relates to the employment of blood-letting in the strong apoplexy, practice. and by far the greater number of modern physicians have, in this respect, followed their example. In support of this prac- tice we might adduce the opinion of all who have written on the disease: we might quote from the works of Sydenham, Wepffer, Boerhaave, Van Swieten, Morgagni, Baglivi, Sauvages, Boerhaave, Tissot, Mead, Freind, Pitcairn, Hoffman, Cullen, Portal, Cheyne, Morgagni, and many other eminent modern writers."! As this paragraph Cullem*0' is quoted from Dr. Cooke, it is almost superfluous to add his own Portal, name to the list of those who strenuously recommend blood- Cheyne, letting. Cooke- A question has been made as to the side from which it may On which be most advantageous to take blood. Aretaeus drew it from the side l?lood sound side, wherever this could be distinguished. Valsalva and d^,, most Morgagni recommend the same; as does also Cullen, observing advantage- that " dissections show that congestions producing apoplexy are ous,y# are always on the side not affected."£ Baglivi recommends Mostly re- bleeding from the diseased side, except where blood is abstract- from"'u7ee ed locally. The question appears to be of no great importance: sound side. the grand object in general bleeding is to diminish the quantity By Baglivi and momentum of the circulating fluid, to enable the ruptured frora t,ie vessels to contract with greater facility, and to afford time for 8\fcase an absorption of whatever may have been effused. In entonic apoplexy, general and local bleeding should go Local hand in hand; and the quantity drawn should in every instance bleeding to depend upon the urgency of the symptoms. Dr. Cheyne ad- generad?"*' vises us to begin with abstracting two pounds, and tells us, that xowhat it will often require a loss of six or eight pounds before the dis- extent. ease will give way. Dr. Cullen,'and many other writers, as Morgagni, Valsalva, Temporal and Portal, have recommended, that the opening should be artery. made in the temporal artery or the jugular veins. " In all cases of a full habit," says Dr. Cullen, " and where the disease has * De Medicin. Lib. 111. cap. xxvu. t Cooke, ut supra, 292. X Pract. of Phys. vol. iii. p. 184. 452 c1- Iv0 NEUROTICA. [ord. IV. Gen. VIII Spec V. Cams apoplexia. Treatment. Jugular vein. Opening of the superior longitudinal sinus, pro- posed by Dejean: but discom- mended by Portal and Tenon. , General result. Purgatives. been preceded by marks of a plethoric state, blood-letting is to be immediately employed, and very largely. In my opinion it will be most effectual when the blood is taken from the jugular vein; but if that cannot be done, it may be taken from the arm. The opening of the temporal artery, when a large branch can be opened so as suddenly to pour out a considerable quantity of blood, may also be an effectual remedy; but, in execution, it is more uncertain, and may be inconvenient. It may in some measure be supplied by cupping and scarifying on the temples or hind-head. This, indeed, should seldom be omitted, and these scarifications are always preferable to the application of leeches."* In bleeding from the temporal artery we may safely let the stream flow as long as it will, for in common it will cease before we have obtained enough, and all tight ligatures about the head, or indeed any other part of the body, should be avoided as much as possible. For the same reason Heister advises that, on open- ing the jugular veinj no ligature should be made use of, as the smallest pressure on the part may do harm by interrupting the circulation ofthe blood on the external veins ofthe neck. M. Dejean, of Caen, proposed, not long ago, to the Academy of Sciences, to open the superior longitudinal sinus after raising the bone which covers it, and asserted that he had employed this mode with great success on strangled dogs. M. Portal, and M. Tenon, however, who are appointed commissioners to report on M. Dejean's memoir, agreed that bleeding from the jugular vein is preferable to that from the sinus, as producing the same effect more speedily, and with more facility of restraint when a sufficiency of blood has been taken away. What seems to be the fair result the author will give in the words of Dr. Cooke. " General opinion, then, as well as rea- soning, appears to be very much in favour of free and repeated evacuations of blood, both general and topical, in the strong apoplexy; and I am persuaded that greater advantage may be reasonably expected from this than from any other practice; yet I am very much inclined to think, that it may be, and actu- ally sometimes has been, carried too far. I have seen several cases, and heard of many others, in which very large quantities of blood have been drawn without the smallest perceptible ad- vantage, and with an evident and considerable diminution of the strength ofthe patient."| The next important means to be pursued is that of exciting the bowels by active purgatives. [This, as Dr. Abercrombie justly remarks, is always to be considered a most important and leading point in the treatment; and "though, in arresting the progress of the disease, our first reliance is upon large and re- * Pract. of Phys. vol. iii. p. 182. t The superior utility of opening this vein is questioned by some ofthe best practitioners. As Dr. Abercrombie justly observes, "the only jugular vein that can be opened is the external jugular, which has very little communication with the brain, and consequently bleeding from it is probably much inferior to bleeding from the temporal artery.' (On Dis. of the Brain, p. 289.) X Ut supra, p. 311. cl. iv.] NERVOUS FUNCTION. [ord. iv. 453 peated bleeding, the first decided improvement of the patient Gen.VIII. is generally under the influence of powerful purging."] The Spec« v- particular purgative is of no importance: whatever will ope- Carus rate most speedily and most effectively is what should be pre- aP°Plexia- ferred in the first instance :* and hence a combination of calo- Treatment- mel and extract of jalap will be found among the best: though a free action may afterwards be more conveniently maintained by colocynth or sulphate of magnesia. Dolaeus employed calo- mel so as to excite salivation, from an opinion that all evacua- tions are useful; and he gives an account of several cures he was hereby enabled to effect, and particularly relates the case of a woman, who was in this manner considerably relieved, and died on the cessation of the ptyalism.t The collateral remedies are of less importance, though some Emetics, in of them may add to the general effect. Emetics are of a very entonic doubtful character in the form of the disease before us, though of °a doubt- often highly useful in atonic apoplexy. They have been given ful charac- upon the principle of their producing a sudden prostration of ter: strength, and faintness : but this is a result of nausea rather than of vomiting; and we cannot answer, that the straining will not renew the extravasation, or even rupture a vessel where no rupture has existed.^ Blisters and sinapisms promise but little in this form of the Blisters and disease : they tease and irritate to no purpose when applied to s,naPlsm8- the extremities, and are still more injurious when they are made to cover the scalp; for they effectually prevent the use of epithems of cold water, or vinegar, or pounded ice, which afford a rational chance of producing benefit. Cordials were in high reputation among the Greek practi- Cordials tioners, from a belief that apoplexy is in almost every case the and aljsli* result of a debilitated and pituitous habit: and the custom has ™"scyesv. too generally descended to the present day, even where the ous. ground on which it was founded has been relinquished. Stimu- lants and cordials of all kinds should be sedulously abstained from: and the neutral salts with small doses of the antimonial powder, or any other cutaneous relaxant be employed in their stead : cooling dilute drinks should be freely recommended ; and if we should hereby be enabled to excite a gentle moisture on the skin, it may prove of incalculable advantage. The curative process under our second variety of the dis- Particular ease, or atonic apoplexy, must vary in many points from the 0rfeailt^"t preceding. It is here, if at any time, we should pause, before ap0p°exy. we employ bleeding. Yet, as dissections show us, that even Bleeding here also compression, and that too from an efflux of blood, is demands a very general, and either from blood or serum, almost constant, Pause: J ° but may in * The most efficient purgative is the croton oil; and, as Dr. Abercrombie some cases observes, if the patient cannot swallow, it may be very conveniently intro- be ™Pera" duced into the stomach, suspended in thick gruel or mucilage, through an elas- "veiy caiiea tic gum tube. The operation should be expedited by strong purgative injec- tions. (Op. cit. p. 239.)—Editor. t Dolaeus, p. 149. t Dr. Abercrombie says, " antimonials may occasionally be useful as an aux- iliary, from their known effect in restraining vascular action, provided, in the early stages, they do not occasion vomiting." (On Dis. of the Brain, p. 288.) 454 CI- 1V0 NEUROTICA. [oro. iv. Gen. VIII. Spec V. Carus apoplexia. Treatment. Illustrated. Local bleed- ing mostly to be pre- ferred to general. Purgatives and emetics may be used. As may ex. ternal and internal sti- mulants. With cau- tion. Treatment of apoplexy from excess of drinking, or of narco. tics. —whatever be the degree of constitutional debility, 1 can hard- ly conceive of any case, in which we should be justified in with- holding the lancet or the use of cupping-glasses. The argument stands precisely upon the ground of the expediency of bleed- ing in typhus accompanied with congestion : it is in itself an evil; but it is only employed as a less evil to fight against a greater. With it we may succeed : without it, in either instance, the case is often hopeless. Generally speaking, however, local bleeding will here be preferable to that of the lancet; but cupping should always be preferred to leeches, whose operation is far too slow for the urgency ofthe occasion. The last, however, are recommended by Burserius, and Forestus quotes an instance in which they succeeded by a formidable application over the entire body.* Aretaeus, after abstracting blood by cupping-glasses, recommends also the use of dry cupping between the shoulders, and the re- commendation is highly ingenious and worth attending to.t Purgatives, though less violent than in entonic apoplexy, should in like manner be had recourse to : and as we have less danger to apprehend from the use of emetics, they may be given. They have the triple advantage of freeing the stomach from morbid acrimony, rousing the system generally, and determining from the head to the surface of the body.+ Here also we may use both external and internal stimulants in many cases with considerable success. Ofthe former, ammo- nia, camphor, electricity, and galvanism, rubefacients, and blis- ters may be made choice of in succession, and applied alter- nately to different parts of the body. Of the latter, we should chiefly confine ourselves to the warmer verticillate plants, as lavender, marjoram, and peppermint, or the warmer siliquose, as horse-radish and mustard, or the different forms of ammonia ; yet even of these we are debarred by Dr. Cullen. [In France, nux vomica has been employed; and in Germany, phosphorus. Dr. Abercrombie§ is of opinion, that all stimulants must be used with considerable caution, and that the patient, during their use, should be kept in a very low state by spare living and occa- sional evacuations; and he cannot agree, that the diet in para- lytic cases ought to be nourishing and restorative.] In that peculiar kind of apoplexy, which is sometimes pro- duced by taking immoderate doses of spirits or some narcotic, and especially opium, in which we meet with an almost instan- taneous exhaustion of the nervous power, making a near ap- proach to asphyxy, though with a heavy drowsiness and sterto- rous breathing, the patient should first have his stomach tho- roughly emptied by an emetic of sulphate of copper; he should be generally stimulated by blisters, and kept in a state of per- * Lib. x. Obs. 76. t De Cur. Morb. Acut. i. 4. X After the pathological remarks already delivered on the present disease, it seems that the practice of employing emetics must be attended with some risk of producing a renewal of hemorrhage, or even of occasioning a fresh rupture of the weakened or diseased vessel*.—Editor. $ Pathological and Practical Researches on Diseases of the Brain, p. 298. cl. iv.] NERVOUS FUNCTION. [ord. iv. 455 petual motion by walking or other exercise, so as to prevent Gen. VIH. sleep till the narcotic effect is over. An interesting case of this Spec-v« kind is related by Dr. Marcet.* Carus . After all it should not be forgotten, that apoplexy is in most, ^ perhaps in all cases, not secondarily alone, but primarily a ner- _,. . vous affection, and dependent upon a predisposition to this dis- Val of great order in the sensorium itself, if not upon a morbid condition of importance, it: and that hence the patient, though we should recover him a™ "j6" from the actual fit, will be subject to a recurrence of it. In ramute this view, the interval becomes a period of great importance, attention. and should be as much submitted to a course of remedial treat- ment as the paroxysm itself. After entonic apoplexy, the patient should habitually accus- Intermedi- tom himself to a plain diet, regular exercise, early hours of meals ate *reat- and retirement, and uniform tranquillity of mind: and the state entonic of his bowels should particularly claim his attention. After the apoplexy, atonic variety, the same general plan may be followed with a of atonic like good effect, but the diet may be upon a more liberal al- aP°Ple*y- lowance ; and a course of tonic medicines should form a part of the remedial system. And hence much of the treatment laid down under limosis Dyspepsia! may be pursued here : together with the use of the waters of Bath, Buxton, and Leamington. Species VI. Carus Paralysis.—Palsy. Corporeal torpitude and muscular immobility more or less general, but without somnolency. Palsy is a disease which makes a near approach to apoplexy Relation to in its general nature and symptoms, and is very frequently a apoplexy. result of it. It is, however, still more strictly a nervous affec- Still more tion, and less connected with a morbid state of the sanguife- "p"^a rous or the respiratory organs. In examining it more in detail, affection. we shall find, that sometimes the motory fibres alone are affect- Sometjraes ed in any considerable degree, while the sentient are only ren- exists prin- dered a little more obtuse; sometimes both kinds are equally cipallyin torpid, and sometimes several of the faculties of the mind par- fibre"fory ticipate in the debility, though they are never so completely lost as in apoplexy. The Greek writers contemplated the two diseases under the Apoplexy same view, considering them as closely related to each other, ^j^?7 or, in other words, as species of the same genus. " The an- p]ated a8 cients," says Dr. Cooke, who has accurately gone over the en- different tire ground, and taken nothing upon trust, " very generally ^rm"nof a considered apoplexy and palsy as diseases of the same nature, disease by but different in degree ; apoplexy being an universal palsy, and the Greeks palsy a partial apoplexy. Aretaeus says, apoplexy, paraplegia, paresis, and paralysis, are all of the same kind; consisting in a loss of sensation, of mind, and of motion. Apoplexy is a palsy * Med.-Chir. Trans, vol. i. p. 77. t Vol. i. 456 cl. iv.] NEUROTICA. [ord. iv- Gen. VIII. of the whole body, of sensation, of mind, and of motion. And Spec. VI. 0n this subject Galen, Alexander, Trallianus, iEtius, and Pau- Carus lus JEgineta, agree in opinion with Aretaeus. Hippocrates, paralysis. who^ in various parts 0f his works, speaks of apoplexy, no- where, as far as I know, mentions paralysis; and when he re- fers to this disease, he employs the term apoplexia. Both Aretaeus and Paulus iEgineta represent him as speaking of apo- plexy in the leg. Celsus describes palsy and apoplexy by Paresis how the general terms resolutio nervorum."* It is only necessary far different f0 a^ that paresis and palsy were used sometimes synonymous- from palsy. ^ . and tha^ ^en a distinction was made between them, pare- sis was regarded as only a very slight or imperfect palsy. Whythe Palsy and apoplexy, however, are something more than the two should same disease merely varied in degree; the one, indeed, may begcdted lead to and terminate in the other, but they very often exist disease'"^ separately and without any interference ; and, notwithstanding their general resemblance, are distinguishable by clear and Proper sta- specific symptoms. But if the Greeks approximated them too tion appa- closely, the greater part of the nosologists of modern times, ofnthepre- as Sauvages, Linneus, Vogel, Sagar, Cullen, and Young, have sent work, placed them too remotely, by regarding each as a distinct ge- nus : the proper nosological arrangement seems to be that of co-species, as they are ranked by Dr. Parr, as well as under the system before us. Common The common causes of apoplexy are usually asserted to be causes of those of palsy : and considering how frequently palsy occurs as very fre a sequel of apoplexy, the assertion has much to support it; for quently compression is here also, as well as in apoplexy, a very fre- those of quent cause. Yet as compression does not seem to be the only aaUy com-" cause of apoplexy, it is still less so of palsy in all its modifica- pression- tions, and we shall still more frequently have to resolve the Yet the dis- disease into some of those causes of general, and especially of ease often nervous? debility, which we have already noticed as occasional- froni other ly giving rise to apoplexy, and which we have more particu- causes. larly illustrated under the genus clonus of the preceding or- der. Often in- Palsy is often preceded by many of the precursive signs of troduced by ap0plexy; and it commonly commences slowly and insidiously; ^recursive & gingje jj^ or a part of the bodv being at first troubled with an occasional sense of weakness or numbness, which continues for a short time and then disappears. A single finger is often subject to this token, as is one of the eyes, the tongue, or one side of the face. Nerves The nerves chiefly affected are those subservient to volun- f''i^71\~ tary motion' Dut ^e accompanying nerves of feeling in most oTvoluntary cases participate in the torpitude, though not in an equal de- motion, gree, and sometimes not at all. " I never," says Dr. Cooke, " saw a case of palsy in which sensation was entirely lost:" Action of though such cases seem sometimes to have occurred. The ac- andluS Hon of the involuntary organs, and especially of the heart and little inter- fered with. * Treatise on Nervous Diseases, vol. ii. p. 1. CL. IV.] NERVOUS FUNCTION. [ord. iv. 457 lungs, is but little interfered with, though in a few instances Gen. VIII. something more languid, than in a state of ordinary health. Spec VI. And, in this respect, we perceive a considerable difference be- Carus . tween paralysis and apoplexy, in which last the heart appears Paray> to be always oppressed, and the breathing laborious. The fa- Mind and culties of the mind, however, rarely escape without injury, "^"'ly^es- and especially the memory ; insomuch that not only half the cape injury. vocabulary the patient has been in the habit of using is some- times forgotten, but the exact meaning of those terms that are remembered; so that a senseless succession of words is made use of, instead of intelligible speech, the patient perpetually misusing one word for another, of which we have given vari- ous examples under moria imbecillis, or mental imbecility. And it is hence not to be wondered at, that palsy should occasionally impair all the mental faculties by degrees, and terminate in fatuity or childishness. We have frequently had occasion to observe and to prove by General examples, that, where any one of the external senses is pecu- {^a'rk610* liarly obtuse or deficient, the rest are often found in a more explanatory than ordinary degree of vigour and acuteness, " as though the of many sensorial power were primarily derived from a common source, $ p^gy"1' and the proportions belonging to the organ whose outlet is in- valid, were distributed among the other organs." Something of this law seems to operate in many cases of palsy, and is more and more conspicuous in proportion to the extent of the disease: for, in hemiplegia and paraplegia, the half of the Hence the body that is unaffected has not unfrequently evinced a morbid "^ increase of feeling. Dr. Heberden attended a paralytic per- sometimes son, whose sense of smell became so exquisite, as to furnish evinces a perpetual occasions of disgust and uneasiness: and he mentions j™^eof one case, in which all the senses were exceedingly acute. feeling. It is to this principle we are to resolve it, that where the iu„strated. disease confines itself to the motory nerves of an organ alone, Hence, too, and the sensific are not interfered with, the feeling of the the sensific palsied limb itself is sometimes greatly increased, and some- JJ^JjJ lhe times exacerbated into a sense of formication, or some other fimbsome- troublesome itching. "I have seen several instances," says times pos- Dr. Cooke, " in which paralytic persons have felt very violent j^e"ine" pain in the parts affected, particularly in the shoulder and ° ee ,,,g' arm ;"* and the remark, if necessary, might be confirmed from numerous authorities. Palsy, however, is strictly a disease of nervous debility, and Sometimes where it shows itself extensively, the whole nervous system is J^vou'.06 affected by i*. The consequence of which is, as we have al- system ready shown in treating of entastic, and particularly clonic mi!J^tl7 spasm, that the sensorial power in all its modifications is com- municated irregularly, and its balance perpetually disturbed, so afeto operate upon the mind as well as upon the body : whence some parts are too hot and others too cold, and even the affect- Hfnce!{je b ed limb itself, according to the nature of the affection, and its ^0^mn warmer, * Ut supra, p. 5. vol. iv. 58 458 CL- IT-1 NEUROTICA. [ord. it. Gen. VIII. Spec. VI. Carus paralysis. Bometimes colder than natural. Passions of the mind affected. Illustrated. Affected limbs com- monly sup- posed to te colder than in ordinary health) especially by Earle. By Aber- crombie supposed not 10 be colder. Diversity of opinion reconciled. Subdivision of Pen boom founded on a true physiology; but not quite correctly expressed, limitation or extension to different sets of nerves, will be warmer or colder than in its natural temperature, and will waste away, or retain its ordinary bulk ; while the passions ofthe mind will participate in the same morbid irritability, and evince a change from their constitutional tenour. Persons of the mildest and most placid tempers will often discover gusts of peevishness and irascibility ; and men of the strongest mental powers have been known to weep like children on the slightest occasions. In a few instances, however, an opposite and far more desira- ble alteration has been effected. " I had several years ago," says Dr. Cooke, " an opportunity of seeing an illustration of this remark in the case of a much respected friend. The per- son, to whom I allude, had always, up to an advanced age, shown an irascible and irritable disposition : but, after an attack of palsy, his temper became perfectly placid, and remained so until his death about two years afterwards."* It is the general opinion, that paralytic limbs are uniformly colder than in a state of health : and Mr. Henry Earle has ably supported this opinion upon an extensive scale of examination.! Dr. Abercrombie, on the contrary, in a correspondence upon this subject with Dr. Cooke, gives it as his opinion, that para- lytic parts do not become colder than natural; and adds, " that he had long ago observed, that they are sometimes warmer than sound limbs, but without being able to account for it." The present author has frequently made the same remark, though he has more commonly found them below the ordinary temperature. The facts, therefore, on both sides are correctly stated; and the discrepancy is to be resolved into the nature and extent of the sets of nerves that are immediately affected, whether sensific, motific, or both, and into the disturbed and ir- regular, the hurried or interrupted tenour with which the ner- vous influence is distributed.J The learned Pereboom, who has followed Boerhaave and Heis- ter in attaching himself to the apparently correct doctrine of the Galenic school, that the nerves issuing from the sensorium are'of two distinct sorts, one subservient to sensation, and the other to muscular motion, and has so far accorded with the physiology attempted to be established in the commencement of the present volume, has divided palsy, which he describes as a genus, into three species; a nervous, muscular, and nerveo- muscular ; by the first meaning that form of the disease, in which there is a deprivation of sense without loss of motion; by the second, loss of motion while the sensibility remains; and by the third, loss both of sense and motion.§ The specific names are here at variance with the physiology; for, if it be true, that * On Nervoirs Diseases, vol. iii. p. 12. t Medico. Chirur. Trans, vol. vii. X According to Dr. Abercrombie, paralytic limbs lose, in some degree, that remarkable power, possessed by the living body hi a healthy state, of^e- serving a medium temperature ; and paralytic parts become hotter, or colder, than sound parts, which have been exposed to the same temperature.—(Pa- thol. Researches on the Brain, &c. p. 277.) { Acad. Nat. Cur. Soc. De Paralysi, 8vo. Hornse. ct.iv.] NERVOUS FUNCTION. [ord.it. 459 muscular motion is as dependent upon the nerves as sensation, Gbn. VIII. then, palsy affecting the moving fibres, is as much entitled to be Spec VI. called nervous as palsy affecting the sentient. Nor are the few Carus . cases to be met with of privation of feeling, without loss of mo- P3" ra- tion, strictly speaking, to be regarded as palsies. They are n"ce3U8"riiy rather, as Aretasus has correctly observed, examples of anaes- complicated. thesia, or morbid want ofthe sense of feeling, and as such will be found described in the present system under the name of pa- rapsis expers.* On this account the present author, in his volume of nosolo- Hence a gy, thought it better to follow up, though with a considerable more degree of simplification, the subdivisions of Sauvages and Cul- ''"'P1'1?^ 1 j a. j- \- -iii- ■ . . * .. . subdivision ien, and to distinguish the disease under the three following va- offered in rieties, founded upon the line or locality of affection : the present tr • 1 mi t- ■ rr system of m Hemiplegia. The disease affecting and con- nosology. Hemiplegic palsy. fined to one side of the body. 0 Paraplegia. The disease affecting and con- Paraplegic palsy. fined to the lower part of the body on both sides, or any part below the head. y Particularis. The disease affecting and con- Local palsy. fined to particular limbs. Some nosologists have transferred to this division the local Some local insensibilities and atonies ofthe external senses or parts of them, b"re."81" f as though they were idiopathic affections. It is rarely, howev- the external er, or never, as Aretaeus has justly remarked, that they are not senses not connected with other symptoms and other derangements of such Pp7pe/b? . organs and their respective functions : and hence, they rather this species: belong to the second order ofthe present class, than to paraly- and why. sis in the strict sense of the term. They are anaesthesiae,— vtffot irx£x\vTixoit or •xx^itmi, rather than vx^xXvaui; and in the system before us are arranged accordingly. Hemiplegia, the first ofthe above varieties of palsy, is far * c. Para- most frequently met with as a sequel of apoplexy, and especial- lysis hemi- ly of atonic apoplexy, or that in which the energy of the ner- PleS'a- vous system is peculiarly diminished and irregular. The usual seq^i^f exciting causes of apoplexy are in consequence those of palsy, apoplexy: and need not be enumerated in the present place. In a few in- but some- stances, however, hemiplegia occurs without preceding apo- ,,m.es found plexy; and hence, distinctly proves that pressure, or at least preceding 6uch a pressure as is demanded to produce somnolency, is not apoplexy: essentially necessary.t Mr. John Hunter, as we have already evidencefJ • Class iv. Ord. n. Gen. v. t Dr. Abercrombie's third class of apoplectic cases is that which he terms paralytic. "The leading phaenomenon of this class," he says, "is the paralytic attack without coma, or at least without that complete and permanent coma, which occurs in the former classes." He describes the attack as appearing under various forms; the most common of which is hemiplegia with loss of speech ; but, in some cases, the speech is not affected; while, in other cases, the loss of speech is at first the only symptom. In some cases again, he observes, one limb only is affected, which is most commonly the arm, though sometimes the leg. Numerous other modifications occur, as palsy of one eyelid ; or of the orbicularis muscle; distortion of the eyes; double vision; twisting of the mouth, &c. Loss of the power of swallowing also occurs occasionally, though more rarely in the cases, which do not pass into apoplexy.—(Pathological and Practical Researches on the Diseases 460 cl. iv.] NEUROTICA. [ord. IV. observed, was inclined to think, that pressure from effused blood, was, in every instance, the cause both of this disease and of apo- plexy ; but in allowing, as he has done, that on one occasion at least he was called to a patient who died of a gouty affection of the brain " with symptoms similar to apoplexy," and without any extravasation whatever, he directly yields the point of compres- sion as an universal cause : for if atonic or retrocedent gout may produce apoplexy or palsy without pressure on the brain, so may many other atonic powers, operating as effectively on the sensorium. One ofthe most frequent of these powers is a de- bilitated and paretic state of the liver; and hence those per- sons are peculiarly subject to this variety of palsy, who have spent the earlier part of their lives in an habitual course of in- temperance. Hoffman has particularly noticed this cause ; and Morgagni describes the case of a man advanced in years, who was attacked with jaundice and hemiplegia simultaneously ; the jaundice affecting the hemiplegic side alone, which was the right, and that with so much precision, that the nose was of a deep yellow on the one side, and of its proper colour on the oth- er, which were divided from each other as by a ruled line. Other causes are exposure to the rays of the sun, drinking cold water and bathing in it when heated, repelled eruptions, and chronic rheumatism. As apoplexy has its precursive symptoms occasionally, so also has hemiplegia, and particularly when it is connected with a plethoric habit: for, in this case, the veins ofthe neck and face often appear turgid, there is an obtuse pain in the head, the tongue moves with some difficulty, and particularly on one side, the perception and memory become impaired, and the patient feels a tendency to drivel at one corner of the mouth, rather than at the other. The onset, like that of apoplexy, is at last sudden : and, if the patient be standing, he drops down abruptly on the affected side. The progress of the disease is uncertain ; and depends very much upon the state ofthe nervous system at the time of the attack. If there be no chronic debility, nor other morbid con- dition ofthe sensorium, the patient will sometimes recover en- tirely in a week or even less; but if this system, or some par- ticular part of it, be in an infirm state, he recovers only imper- fectly ; and obtains, perhaps, a thorough or a limited use ofthe lower limb, while the upper remains immovable ; or he is compelled to pass through the remainder of a wretched and ofthe Brain, &c. p. 245. J The following are the morbid conditions specified by Dr. Aber- crombie, as connected with these varieties. 1. Many ofthe cases have a close analogy to simple apoplexy, and after the patient's death, no particular changes in the brain are found, or only an effusion of serum, often in small quantity. 2. Extravasation of blood of small extent. 3. Softening of the cerebral substance. 4. Inflammation and its consequences.— (p. 247.) 5. Induration of a portion of the brain. 6. Empty cysts, from which the ex- travasated blood has been absorbed. 7. Extensive disease of the arteries ofthe brain.— (p. 279.) Some cases, however, depend upon local affection or injury of the nerves; as the palsy of the deltoid muscle, or whole arm, from pressure of the head of the dislocated humerus on the cervical nerves; palsy of one side of the face from an affection ofthe portio durae, brought on by inflammation ofthe ear, or parotid gland, &c.—Editor. Gen. VIII. Spec VI. a. C. Para- lysis hemi- plegia. from the admission of J. Hunter. A debili- tated and paretic state ofthe liver, sometimes a cause. Illustrated. At times accompa- nied with a jaundice of the hemi- plegic side alone. Other causes. Precursive symptoms of hemiplegia. Attack. Progress of the disease. Duration. Result. CL. IV.] NERVOUS FUNCTION. [ord.iv. 461 precarious existence with only one-half of his body subservient Gew. VIII. to his will, the other half being more dead than alive, and with- Spec. VI. ering, perhaps, with a mildew-mortification.* * c- Para- We have stated, that, in this disease, as, indeed, in all others ]££*mi~ accompanied with an atonic disturbance of the nervous energy, proor,'0f there is not only a great irregularity in its supply, but a great irregular and confused disproportion in its distribution to different parts of distribution the body. Dr. Cooket and Dr. AbercrombieJ have collected ^uZ^ numerous and highly interesting examples, in which the sensific or motific nervous influence was either deficient in some parts, or so accumulated in others, that the most capricious and extra- ordinary sensations, or motions, were produced in them. Sauvages gives a case from Conrad Fabricius, of what he Transverse calls transverse hemiplegia, in which the disease was confined hemiplegia to the arm on one side, and the foot on the other : and Ramaz- wtoi. *"*"' zini speaks of a patient whose leg, on one side, had lost its feel- other »in- ing, but retained its power of motion, while the other leg had gular ex- lost its power of motion but retained its feeling.§ In some in- amP,es' stances, indeed, the entire feeling of one side is said,to have been lost, and the entire motivity on the other side ;|| and, in a few rare examples, persons during the paroxysms, and even for Heat from some time afterwards, have felt, on the affected side, a sensa- c0,d. bodiei tion of pungent heat from cold, and especially polished bodies, affected and of painful cold from an application of hot bodies. side: and Where the sensibility is morbidly accumulated in a weak ?f ">,dJ.fron» i • l -i/v ••!•!• ■ 1 hot bodies. limb, as it olten is in hemiplegia, sometimes so much as to give Thi • a painful sense of formication, cold not only excites action, but gular feeling becomes almost as pungent an irritant as an actual cautery; in explained. the correct language ofthe poet —Bores penetrabile frigus adurat.11 And hence, in climbing lofty mountains, as the Alps and the Andes, the traveller frequently finds bis skin more completely blistered from the sharp cold by which he is surrounded, than by an exposure to an equinoctial sun. On the contrary, the morbid halitus or perspiration into which the application of hot bodies often throws a limb, in the same relaxed and debilitated state, produces an unusual sense of coldness in consequence of §•„„, i the evaporation. And we may hence explain the singular case, example. recorded by Dr. Falconer, of a gentleman who, after a paralytic attack, felt his shoes very hot when he first put them on, and * See vol. ii. Cl. Hi. Ord. iv. Gen. XII. Spec. n. t On Nervous Diseas- es, vol. ii. Part i. X Treatise on Apoplexy and Palsy. i De Morb. Artif. 286. See also Heister, Wahrnehmungen, I. 205. For re- ferences to various other facts of this kind, see Abercrombie's Pathol, and Practical Researches on the Diseases ofthe Brain, p. 275. "A gentleman," says he, " who was under the care of Dr. Hay, of Edinburgh, had two paraly- tic attacks at the distance of eight months from each other. In the first, there was perfect loss of feeling, with only partial loss of motion; in the second, there was perfect loss of motion, with only partial loss of feeling," &c. Mr. C. Bell's discoveries certainly tend, as Dr. Abercrombie has observed, to throw light on this curious subject.—Editor. Jj Eph. Nat. Cur. passim. IT Virg. Georg. i. 93. 462 cl. iv.] NEUROTICA. [ord.it. Gew. VIII. Spec. VI. * C. Para- lysis hemi* plegia. Additional illustration. This irregu- lar distribu tion of sensorial power sometimes dangerous. Explained. gradually become cool as they acquired the warmth of his feet; the re-action, and consequent increase of moisture thrown forth from the surface of the feet producing the difference of sen- sation. The case of Dr. Viesseux* is very singular; he was gradu- ally attacked with an imperfect hemiplegia, which at first show- ed its approach by perturbed sensations, and vertigo, with a feeling of sea-sickness, a sight of objects reversed, a difficulty in swallowing liquids, and a total loss of voice, while the pow- ers of the tnind remained unimpaired, so that he could watch all his symptoms. Shortly after this, the whole ofthe right side became utterly insensible, the insensible part being divided from the sensible by a geometrical line running down the body in a vertical direction: and, in about three months more, the insensibility of the right side of the head, accompanied with a debility of all the voluntary muscles, was transferred to the left, the right re-acquiring its antecedent powers; but all the right side, below the head, still continuing to possess its former torpitude. Here, also, there was a very different sense of heat and cold on the opposite sides; for, whilst the left was influenc- ed naturally, the right had the falsified sensation just noticed in Dr. Falconer's case, so that, in getting into a cold bath or a cold bed, the right side had a feeling of heat, while the left side felt cold, as it should do. Hot bodies, in like manner, felt cold to the diseased side, apparently from the cause just stated. And that this was the real cause, seems manifest from the patient's having often a feeling of a cold dew, or of cold water on the surface, and especially over his face, which induced him to wipe himself as if he had been wet. It is, perhaps, more sin- gular that, though plunging his right or affected hand into cold water gave him a sense of lukewarmness, plunging it into boil- ing water gave him a disagreeable sensation, but very different from that of either heat or cold.t This morbid disturbance and irregular distribution of senso- rial power is sometimes productive ofthe most alarming conse- quence ; for, in a hemiplegic state of the bowels, some parts are, in certain cases, so acutely sensible, and others so utterly insensible, that while ordinary purgatives are incapable of ex- citing evacuations from the torpitude and irresponsibility of the palsied parts, they are sufficient to occasion inflammation, and have actually occasioned it in the parts exacerbated by ac- cumulated sensibility, as certain experiments of M. Magendie have sufficiently established. * Med. Chir. Trans, vol. vii. p. 216. t Dr. Abercrombie remarks, that paralysis generally begins in the extreme parts ; but he has seen one patient,'who could write distinctly with his arm supported upon a table, after the arm, from the shoulder to the elbow, was completely paralytic. In a few hours afterwards, the hand was also para- lytic. He also quotes a case, related by M. Velpeau (Archives G6n. 1825,) where the right arm was paralyzed from the shoulder to the middle ofthe fore arm, while the hand was not in the least affected.—(See Pathological Research- es on the Brain, p. 277.) CL. IV.] NERVOUS FUNCTION- [ord. it. 463 It is owing to the same irregular distribution of sensorial Gew. VIII. power, where every department of the nervous system partici- Spec. VI. pates in the diseased state ofthe sensorium, that we sometimes * C. Para- behold hemiplegia, and particularly imperfect hemiplegia, uni- p*egia. """ ted with other affections of the same system. The symptoms nemjpieg^a of hypochondrism are peculiarly apt to associate with it, in hence which case the bravest hero will often lose all his magnanimity, sometimes and sit down and weep like a child : and, in the celebrated nyPoChon- geologist M. de Saussure, we find a still more complicated in- drism and stance of hemiplegia, hypochondrism, and chorea. The dis- other affec- order crept on by imperceptible degrees, and was accompanied nerv0us with various anomalies. Both sides were weakened, but the system. left suffered chiefly ; yet, with the aid of a stick, he could still Exemplified drag forward the left leg. By some unknown means, he had ,n s»"«,'r*. taken up a morbid notion, very common to hypochondriac pa- T^e-J|e^'" tients, ofthe difficulty of passing through a door-way when wide traying not open without being squeezed to death ; and hence, at the very only hypo- time, in which he could cross his room with a tolerably firm b1u°n8^rms™' step, the moment he reached the door, which was of capacious ,ymptom« breadth, and thrown open for his passage, he tottered and pre- of chorea. cipitated his motions with the jerk of a St. Vitus's dance, as though he were preparing for the most perilous leap: yet, as soon as he had accomplished the arduous undertaking, he again became collected, and passed on with comparative ease till he had to encounter another adventure of the same kind, which was sure to try him in the same manner.* Tulpius gives a Sometimes somewhat similar case, in which hemiplegia was united with b""!*d w,th beribery.t Paraplegia or the secoud variety of palsy, has generally 0C. Para- been conceived to depend altogether upon a diseased affection Z™**n~ ofthe spine in its bones, ligaments, or interior, most frequently Cb"efly in the region ofthe loins; in consequence of which the spinal dependent marrow becomes pressed upon, or otherwise injured, inde- uponadis- pendently of any complaint of the brain. That this is a com- p^T"'* mon cause is unquestionable, and a cause that often operates ^0,1" long without external signs: for the vertebral extension of the ways; dura mater may be thickened, or a serous fluid effused, or blood be extravasated within the vertebral cavity ; or a tumour may be formed in some part of it, or the spinal marrow itself may undergo some morbid change. But the best practical observers butoftenest ofthe present day concur in opinion that paraplegia, like hemi- ^""'" plegia, is produced still more frequently by causes operating on t|,e bra,n: the brain, than confined to the spine. Of this opinion is Dr. asaffirine(j Baillie, who ascribes it chieflv to pressure on the brain,| Sir by many of Henry Halford, Sir James Larle, and Mr. Copeland.§ Some ^Jjg. kind of affection of the head, indeed, will commonly be disco- 0f iiie'day". veredfrom the first, if we accurately attend to all the symp- prec|irgive toms ; some degree of pain, or giddiness, or sense of weight or ,jgns. undue drowsiness, or imperfection in the sight. And hence, Causes of hemiplegia. * Medico-Chir. Trans, vol. vii. p. 214. t Lib. iv. Cap. 5. X Trans. Med. vol. vi. Art. n. i Treatise upon the Symptoms and Treatment of the Diseased Spine. 464 «■• iv.] NERVOUS FUNCTION. [ord. it. Gew. VIII. Spec. VI. £ C. Para- lysis para* plegia. May occur at any age, hut chiefly after the middle of life. Occurs often insidiously. Progress of the disease. Termina- tion. Origin and progress when pro- duced by an injured or diseased state ofthe spine, as described by Pott. Curvature of the spine, many of the causes of paraplegia are evidently those of hemi- plegia, operating probably upon a different part of the brain. This form of paralysis may take place at any age, but it is more frequent as we advance beyond the middle of life; and Dr. Baillie has observed, that it occurs oftener in men than in women; for which it is by no means difficult to account, con- sidering the greater hurry and activity of life pursued by the former. The disease, in many instances, makes an insidious ap- proach. There is at first nothing more than a slight numbness in the lower limbs, with an appearance of stiffness or awkward- ness in the motion of the muscles : these symptoms increase by degrees; there is great difficulty in walking, and an inability in preserving a balance ; the aid of a staff or the arm of an as- sistant is next demanded : and the urine is found to flow in a feeble stream, or perhaps involuntarily. The bowels are at first always costive ; but as the sphincter loses its power of con- striction, the motions at length pass off involuntarily. The dis- ease may continue for years, and the patient at last sink from general exhaustion. It sometimes, but rarely, terminates in a recovery.* When an injured or diseased state of the spine is the origin of paraplegia, the complaint shows itself suddenly, or makes its advances insidiously according to the nature of the cause : and for a knowledge of this form of the malady we are chiefly in- debted to Mr. Pott,T who, however, does not think, that it pro- perly belongs to the species paralysis, though there seems no sufficient reason why it should not be so arranged, as in truth it has been by most pathologists from the time of Galen, who seems not only to have understood its nature, but to have con- templated it in this view.J The disease, however, must not be confounded with rhachybia, or distortion of the spine, from de- bility of muscular power, of which we have already treated§ in the present volume. It sometimes happens in hemiplegia, that one or more ver- tebrae have been pushed, by sudden force, a little way out of their proper position ; and, in this case, a considerable degree of numbness, together with less motion in one or both the lower limbs, is almost sure to follow, too often succeeded by a para- lysis of the sphincters of the rectum and bladder, and conse- quently an involuntary discharge of feces and urine : and if the luxation should take place in the dorsal or cervical vertebra;, the organs of digestion may all, more or less, suffer, the respi- ration become affected, and the spine itself exhibit a considera- ble degree of curvature. And the same effects are still more likely to follow, and even to a greater extent and with still more serious mischief, from an idiopathic affection of some part ofthe spinal chain, arising from inflammation, scrofula, rickets, * Practical Essay on the Diseases and Injuries of the Bladder. By Robert Bingham, 1822. t Remarks on that kind of palsy of the lower limbs which is frequently found to accompany a curvature ofthe spine, 8vo. 1788. X De Locis affectis, Lib. iv. cap. vi. i Cl. iv. Ord. in. Gen. i. Spec. 3. cl.iv.] NERVOUS FUNCTION. [ord. iv. 465 mollifaction, or caries; from compression by some effused fluid, Gew. VIII. or a thickening of its external tunic, or even ofthe substance of Spec. VI. the spine itself; of which last M. Portal has given a singular 0 C. Para- example* lysis para- D1C213- In the last case, the disease, for the most part, makes its ap- JL^ found proach slowly, and is often found in weakly and ill-nursed in- in m-nursed fants. Its precursive symptoms are commonly languor, listless- infants. ness, weakness in the knees, and a pale and shrivelled skin. As it advances, there is a difficulty in directing the feet aright when walking, the legs involuntarily cross each other, and the little patient is perpetually stumbling upon level ground, till at length he is incapable of walking at all. In adults, the pro- gress of the disease is more rapid, than in childhood. Like hemiplegia, this variety is sometimes connected with a Connected morbid state ofthe mental powers, and particularly with hypo- ''I'ti^occa- chondrism, and this too where the disease proceeds from an or- gionally ganic lesion of the spine. Dr. Cooke has an instructive case in with a mor- illustration of this, in an officer of the army, aged forty-five, J)',^ mentalf who had for many years been exposed to the hardships of a powers, and military life, particularly to extremes of heat and cold in vari- *ve»» where ous climates. " For two or three years previous to the para- —f^")*" lytic attack, he had complained, that his state of health was de- affected. teriorated, although no precise symptoms of disease could be Instructive pointed out either by himself or by his medical friends. His illustration appetite was good, his bowels regular, though inclined to cos- roni °° e' tiveness, and his usual robust appearance was not diminished. He entertained some fanciful notions respecting the state of his health: and, from some uneasy sensations about the sacrum, he supposed that he had internal hemorrhoids, though no evidence of their existence could be perceived by his physicians, by whom he was considered as hypochondriacal." After having suffered for two or three years, he gradually lost the power of walking without some support for one of his hands. He went to Bath, and had the hot water pumped upon his loins: soon after which he complained of pain in the lumbar region, which was followed by a collection of fluid behind the great trochan- ter of the left side, which burst externally, and was discharged daily, in considerable quantity. The paraplegia was now com- plete: the lower extremities being quite useless: the feces and urine, which, for a considerable time, the patient had with some difficulty retained, came away involuntarily: his strength rapidly wasted; he became much emaciated; and, at the end of three months after his return from Bath, he died ; retaining the use of his senses and his intellectual faculties to almost the last instant of his life.t Where the upper part of the spine is affected, the superior Sensibility limbs are usually divested of mobility or sensibility, or both, j,nd m«bili- while but little disturbance, in a few rare instances, takes place j^ed in the inferior. The most singular example of this sort that where the upper part * Anatornie Medicale, p. 117. ofthe spine t On Nervous Diseases, vol. ii. Part I. p. 4S. IS affected. VOL. IV. 59 466 «■• IV-1 NEUROTICA. [ord. IV. Gew. VIII. Spec VI. 0 C. Para- lysis para- plegia. Singular case from Rullier. Appear- ances on dissection. Mollifaction ofthe spinal marrow. has occurred to the present writer, is contained in a case re- lated by M. Rullier, of Paris * The subject was forty-five years of age, and had evinced a slight rhachetic tendency from infancy, accompanied, as is often the case, with a considerable precocity of intellectual powers; the dorsal portion ofthe ver- tebral column evincing a little distortion, so as to give some de- gree of elevation to the right shoulder; but which did not pro- ceed farther. The patient, from early youth, had indulged himself in every concupiscent indiscretion, and especially in an unbounded and extravagant intercourse with females, which fre- quently reduced nim to a state of exhaustion amounting almost to deliquium. It tvas not, however, till the age of thirty-four, that he first began to perceive any serious difficulty in the movement of his arms, which was soon connected with some degree of pain and swelling in the distorted part ofthe verte- bral chain. The complaint made a rapid progress, and the pa- tient in a short time lost the entire use of these limbs, though their sensibility continued to the last, and appeared to grow morbidly acute, as he would not suffer any one to touch them, on account ofthe pain produced by such contact. He became indeed highly irritable in his temper, but could .walk to a con- siderable distance, enjoyed company and his usual meals, and still retained an immoderate appetency for venereal pleasures, with the fullest means of indulging it. Hectic fever, however, now attacked him with phthisis, and he at length fell a sacrifice to such a host of marshalled evils. On a post-obit examination, the chief organs found to be affected were the lungs, and the spinal marrow at the seat of distortion. The last indeed pre- sented a very singular appearance. From its origin to the fourth pair of cervical nerves, it was quite natural; but from this point, through an extent of six or seven inches in length, the whole substance of the column was reduced to the most diffluent state of mollifaction, like what we have already noticed as sometimes found in the brain ; while below this length, the cord appeared again to be firm and uninjured; a few flakes of medullary matter were alone found in the morbid fluid which had usurped its place, but altogether disorganized and unconnected. And we here, therefore, behold, to adopt M. Magendie's re- marks upon this very marvellous affection, a man enjoying, al- most to his last hour, great moral activity, powerful generative faculties, a free movement of his inferior extremities, and a keen sensibility of the superior; who nevertheless, for an un- certain, but probably a very considerable period, had been des- titute of one third part of the substance of the spinal marrow; and possessed no kind of communication between the cervical and dorsal portions of this cord,t unless we suppose something * London Medical and Physical Journal, July 1822, p. 80. t If this were the fact, the case is undoubtedly exceedingly interesting, in a physiological as well as pathological view. However, as a very slight com- munication between the cervical and dorsal portions ofthe spinal cord might have existed previously to the dissection, and been inadvertently broken in it, a doubt may be entertained upon this material point,—Ed, cl. iv.] NERVOUS FUNCTION. [ord. iv. 467 ofthe sort to have been maintained by means ofthe surround- Gen.VIII. ing membranes ; a supposition, however, which is entirely gra- Spec VI. tuitous,and at most capable of throwing but little light upon the subject. r Local palsy is often produced by the general causes of the vC oara- other varieties probaby operating in a less degree or more iysis'pPartt partially on the brain. We have already seen thaUt frequently culari,. takes the lead of the general affection, and appears for some Often days or weeks antecedently, in an imperfect movement of the Cteld^ tongue, or of one eye or of one side of the mouth, sometimes Lgc'auset ot one or more of the fingers, or of an entire arm. And if, in and some- this incipient state of the disease, proper evacuants, or other "Zl^™' means, be instantly had recourse to, the paralytic tendency may ^ceding De subdued, and the complaint be limited to these local affections, »°™s. and in a very few days be entirely removed. This variety, however, is often the effect of other causes often tending to destroy the irritability of the nervous system, or par- produced by ticular parts of it, such as exposure to certain metallic fumes, or fu'ea • other means of absorbing metallic particles, especially those of SIS?: mercury and lead: and, above all, exposure to keen blasts of a8metallic cold and damp air. This last is, perhaps, the most common fumes; and effective cause of local palsy, and is peculiarly operative, and cold where the limb or organ so exposed is in a state of relaxation damP air- and perspirable moisture, whether from previous exercise, or great heat of the atmosphere. A palsy on one side of the mouth, of the muscles of one eye, of one of the cheeks, of an arm or a leg, is in this manner frequently produced, and be- comes, at times, of very great obstinacy. Occasionally, indeed, the torpitude extends much farther than to a single limb, and various organs are involved in its mischief. "A watchman," Illustrated says Dr. Powell,* " on quitting his duty, after a night of severe cold, was attacked by sudden and violent general pains in his limbs, which soon departed, and left him in a state of universal palsy ofthe muscles of voluntary motion. He had lost all com- mand over the muscles of his limbs or trunk; but the joints were unaltered in their external appearance: they were per- fectly flexible; and it gave him no pain if you moved them in any direction. The sphincters also of the rectum and blad- der had lost their usual powers of retention, and he passed both stools and urine involuntarily and unconsciously. His circula- tion was not affected in any cognizable degree, and his mind re- tained its usual powers. His voice was not lost: the hot bath and other remedies were tried in vain ; he died : but, on ex- amination, there was no congestion, or effusion, or alteration of structure of any kind discoverable." In this case the motific Motific nerves, or those derived from the anterior trunk of the spinal nerves here cord, seem to have been alone affected; and in those slight cliiefl7 palsies, induced by sudden cold or damp, applied to one side of affec,ed: the face, and commonly known by the name of blights, the a8a|.oin nerves that lose their power are branches of the portio dura blights. * Med. Trans, vol. v. p. 195. 468 ci. iv.] NEUROTICA. [ord. iv. Gew. VIII. Spec. VI. Carus paralysis. Medical treatment of palsy. As compres- sion of the brain is a common cause, copi- ous bleeding and purga- tives are often Decenary. But this rule admits of excep- tions. Palsy as dependent as apoplexy upon the two oppo- site states of entony aud atony. Under the first the reducent plau should the respiratory nerve of Mr. Charles Bell, while it is rarely that the twigs of the trigeminus, which commonly accompany them for the purpose of conveying sensation, are united in the mischief. In the treatment of palsy, it is necessary to distinguish between its attack and its confirmation, and as much as possible to ascer- tain the nature of its predisponent and exciting cause. Generally speaking, in hemiplegia, and very frequently in paraplegia, and even in local palsy, the causes of apoplexy are those of the present affection. And as, of these causes, com- pression of the brain has appeared to be by far the most fre- quent in the former disease, so we ought to regard it, and shall generally find it, in the latter. And hence, copious bleeding, and purgatives not only recommend themselves to us from the good effects we have already seen them produce in apoplexy, but from the actual and general advantage, which has been de- rived from them in palsy itself. Mr. John Hunter was so fully convinced ofthe benefit of sanguineous depletion, that he made it his unicum remedium, though he allowed of cathartics sub- ordinate!^. Upon this subject, however, he writes with more force, than discrimination. Referring to the stimulant plan pur- sued by some practitioners, he observes, " this is even carried farther than blistering," to which he also objects: " we hardly see a man taken with all the signs of an apoplexy, where a paralysis in some part takes place, or hemiplegia, but he is im- mediately attacked with cordials, stimulants, electricity, &c. Upon a supposition that it is nervous debility, &c, the poor body is also tortured because it cannot act, the brain not being in a condition to influence the voluntary muscles. We might, with exactly the same propriety, stimulate the fingers, when their muscles are torn to pieces. We ought to bleed at once very largely, especially from the temporal artery, till the pa- tient begins to show signs of recovery, and to continue it till he may begin to become faintish. We should give saline purges freely to diminish impetus, and promote absorption ; then quiet- ness should be enjoined, and as little exercise of body as possi- ble, and especially to avoid coughing and sneezing. Plain food should be directed, and but little of it."* All this is excellent, as a general rule; but the rule must admit of exceptions. In treating of apoplexy, we have noticed it as dependent on two very different and opposite states of the constitution, an entonic and an atonic. And the same diversi- ties of constitution are to be found in paralysis. Now, under the entonic state, there can be no question, and there ought to be no exception: and the boldness of the practice should be regulated by the nature of the exciting cause. Where this is over-eating or intoxication, eighteen or twenty ounces of blood may be taken away, with advantage, at once; in a few hours after, twelve or fifteen ounces more; and the venesection may be repeated a third or even a fourth time, if necessary. Dr. * On Blood and Inflammation, p. 213. CL. IV.] NERVOUS FUNCTION. [ord. iv. 469 Cross pursued this active plan, in the case of a man thirty-five gen. VIII. years old, who became hemiplegic from excess of drinking, and Spec. VI. at the same time gave calomel to the amount of twenty-five Cams grains to a dose, and, in a few days, effected a complete cure.* paralysis. And similar instances of success are to be found in all the writ- Treatment. ers upon the subject. be general Even in atonic apoplexy, it has been observed that venesec- followed up. tion is occasionally necessary; and it may be equally necessary Bleeding in atonic paralysis; for here also effusion may take place both sometimes of blood and serum: of serum, indeed, more frequently from ™cea™y edciency, than from excess of vigour; and of blood, from a aU>nic palsy debilitated state of the vessels, and their greater facility to be as well as in ruptured from slight causes, as a violent fit of coughing or ^"lexy sneezing, of joy or terror. Absorption may not easily take apopex7' place in this state of constitution ; but, emptying the vessels alone will gain space by stimulating them to contract their diameter. I cannot better illustrate this, than by the following case from Dr. Abercrombie: " An old and very poor woman, aged about Strikingly seventy, thin, pale, and withered, having gone out to bring »N«"trated. water from one of the public wells, on the morning of the sec- ond of July 1818, fell down in the street speechless, and com- pletely paralytic on the right side. Nothing was done till about two p.m. when she was found stupid, but not comatose, yet com- pletely speechless and paralytic: her pulse of good strength, and about ninety-six. She was bled to fifteen ounces. Purga- tive medicine was ordered, and cold applications to the head: on the third, she was considerably improved both in speech and motion ; but having become rather worse at night, the bleeding was repeated, and the purgative medicine continued. From this time she improved gradually: at the end of a week she was able to walk with a little assistance, and speak pretty distinctly, and, by the end of another week, she had entirely recovered her former health."! Nothing could be more judicious than Case,and iti this treatment, and the result corresponded with the views ofthe fortunate enlightened practitioner. There can be no doubt that, in this j^"f. . case, a vessel had suddenly been ruptured : the labour in which the patient was occupied was violent, the season was that of the summer, and the temperature probably very hot: the stupor and state of the pulse equally indicated compression of the brain. Thus far bleeding may be allowed, and, indeed, ought to be When imperatively enjoined. But there are some cases, in which it bleeding is altogether a venture, and others in which it is considered on maybe o ' iiT)prop6r all hands to be injurious. Even Mr. Hunter himself recoils andtnis- from the practice, where hemiplegia is apparently a result of chievous. retrocedent gout; and if we follow up the spirit of this for- bearance, we shall be induced to abstain equally in all instances where there is a like diminution of sensorial power—in all in- * Thomson's Annals of Philosophy, No. xliv. p. 121. t Treatise, &c. p. 15. 470 CL- IV-3 NEUROTICA. [ord. IV. Gen. VIII. Spec VI. Carus paralysis. Treatment. Excellent discriinina. tion of 'Cooke. Purging may be indulged with less restraint. The purga- tives should be of the warmer rather than of the colder tribes. Emetics. Practice of Stol). stances of atonic paralysis, let the exciting cause be what it may, where there is no stertor, no stupor, no vertigo; no convul- sion nor other irregular nervous action, and the pulse, instead of being firm, is feeble and intermittent. For it should never be for- gotten that, if many patients have recovered after bleeding, in suspicious circumstances, others have died after it, and probably in consequence of it, while great numbers have derived no benefit whatever. The advice of Dr. Cooke upon this subject is therefore founded on the truest wisdom, and cannot be too extensively committed to memory: " Each individual case must be viewed in all its circumstances, and by a careful considera- tion of them our practice should be regulated. Before we pre- scribe blood-letting in hemiplegia, we must investigate the age, strength, general constitution and habits of the patient, and, above all, the actual symptoms of the disease. In early or even in somewhat advanced life, if plethora and the various symp- toms tending to apoplexy be present, I should not scruple to bleed freely both generally and topically. On the contrary, in great age, debilitated, leuco-phlegmatic habit, dropsical tenden- cy, &c, I should think it right to abstain altogether from this and from every other powerful mode of depletion, unless there be an evident determination to the head, marked by flushing in the countenance, throbbing of the arteries, redness of the eyes."* In purging, we may proceed with less restraint: for even in debilitated and dropsical habits, stimulating the bowels is al- most uniformly beneficial: should there be serous, or even san- guineous effusion, absorption is hereby powerfully promoted ; and if there be none, a beneficial revulsion will often be pro- duced, and the stimulus will always be useful. In a very de- bilitated state of the constitution, however, we should choose the warmer in preference to the colder purgatives; and hence jalap, colocynth, or even aloes in preference to neutral salts: and it will also be serviceable to combine them with some dis- tilled water impregnated with an essential oil, as mint, penny- royal, juniper, or rosemary. If we have strong reason to apprehend a sanguineous effu- sion, emetics ought not to be employed for a few days; but if we have no ground of such suspicion, they cannot be had re- course to too soon. In low or atonic hemiplegia, Stoll first checked the hemiplegia by emetics, and then carried it off by external and local stimulants, as cantharides, in conjunction with pills of gum ammonia, myrrh, and aloes.j Such, under different modifications, is the reducent course it seems proper to pursue in the general train of paralytic attacks when they first make their appearance. If this course succeed, the patient will soon recover, and, with a view of preventing a relapse, an extension of the reducent or * On Nervous Diseases, vol. ii. Part I. p. 141. t Rat. Med. Part it. p. 92. Few of the best modern practitioners ven- ture to prescribe emetics in any examples of paralysis, connected with dis- ease in the head.—Ed. cl. iv.] NERVOUS FUNCTION. [ord. iv. 471 tonic regimen, according to the nature of the case, as we have Gew. VIII. already noticed in the treatment of apoplexy, is all that we Spec. VI. shall have farther to prescribe. Carus But this course may not succeed : the disease may prove ob- Para,y8,s» stinate and become confirmed ; and the practitioner be called Trealment' upon to proceed farther. Having removed, as far as we may be able, all pressure upon Subsequent the sensorium, and so far given an opportunity of healthful play treatment. to its function, our next business is to re-invigorate its general General energy, and extend it to the parts which it has ceased in a great- princiPle to er or less degree to actuate. ^ystfm Stimulants external or internal, or both, have been almost generally. uniformly had recourse to for this purpose : but I cannot avoid Stimutants thinking, that the practice has been too indiscriminate, and, in have been many cases, far too precipitate. We have observed, that, in Hindis? many cases of hemiplegia, there is not only great local inacti- criminately vity, but great irregularity of action ; a tumultuous hurry of a.n°r« active 472 cl. iv.] NEUROTICA. [ord. iv. Geit. VIII. Spec. VI. Carus paralysis. Treatment. and stimu- lant plan to be pursued. External and internal irritants. External stimulants. Their in- tention and effect. The sili- quose and alliaceous rubefacients more useful than blisters. Liquid styrax. Burning moxa or cotton. Striking case from Larrey. Issues, side, or some other extensive part of the body, shows a fixed loss of sense and voluntary motion, while every other part has resumed its healthy function, we may then, with safety, have recourse to the stimulant practice. This will consist of external and internal irritants, and Dr. Cullen has given a long and useful table of both. Of the for- mer, the chief are friction by the hand or a flesh-brush; stim- ulating liniments prepared of the concentrated acids, or the caustic alkalies inviscated in oil or lard to render them less acrid and corrosive ; brine or a strong solution of sea-salt; the essential oils of turpentine, or other terebinthinate substances; and various vegetable acrids, as mustard, garlic, and cantharides or other blistering insects. The object of all these is the same : it is that of acting upon the origin of the nervous chain by stimulating it at its extreme end, and as we have numerous instances of the production of such an effect in a great variety of cases, particularly in those of trismus and lyssa, or canine madness, the principles of which we have endeavoured to elu- cidate under these diseases, we have reason to expect a like influence, and of a beneficial instead of a morbid kind, in the applications before us. Generally speaking, however, the ir- ritation, produced by a use of many of the siliquose and allia- ceous or alkalescent plants, as mustard, horse-radish, and garlic, is more uniformly efficacious than that of cantharides; as the irritation excited is more considerable and of longer duration. Dr. Cullen tells us, that he has reason to believe the use of liquid styrax in the proportion of one part to two of the old black basilicon, a favourite empirical composition, " has been of remarkable service in paralytic cases, and particularly in a debility of the limbs following rickets."* Many practitioners have, for the same purpose, been in the habit of burning moxa, or cotton alone, on different parts of the affected side. Dupuytren employed the former, and Pas- calf the latter; and both, as they tell us, with great advantage. Baron Larrey speaks in terms of high commendation of the first, and especially in spine-cases, or paraplegia. One of his examples is worth relating. The patient had been a sufferer for three years, and had violent and almost permanent pain in the extremities, tremor, emaciation, and sleeplessness; the spinous processes of the dorsal vertebrae projected, and were painful on pressure. The moxas were applied in pairs begin- ning from the tenth and eleventh dorsal vertebras. On the first application all pain was removed; on the second, spontaneous motion was restored; and, after the use of thirty moxas, the patient walked without support.J Others have thought they derived more service from a repeated use of sting-nettles. Some again have employed issues, others setons, others acu- * Mat. Med. Vol. ii. Part ii. Cap. v. The editor has not much faith in the employment of internal stimulants, and believes with Dr. Abercrombie, that the practice is hardly safe, unless accompanied by a low regimen. t Journ. de Mid;-torn. Ixvi. X Recueil de Memoires deChirurgie, &c. 8vo. Paris, 1821. CL. IV.] NERVOUS FUNCTION. [ord. iv. 473 puncture, and others the potential or even the actual cautery. Gen.VIII. This last mode of treatment, however, is best calculated for Spec VJ. that form of hemiplegia produced by a diseased spine. Mr. Caru*' Pott found caustics applied on each side of the spine peculiar- L, ' ly serviceable, and they have been in common employment ev- er since his recommendation of them. cauteries. In the rank of external stimulants, we are to arrange electri- Caustics to city and voltaism. From their well-known and extraordinary ^'{^ty power of re-exciting irritability in the muscular fibres of animals andCVoi- that have been for some time dead, it was very reasonable to taism. suppose, that either of these stimuli might be employed with very great advantage : and accordingly we meet with them in extensive and popular use from the earliest periods of their hav- ing been, if not discovered, at least reduced to scientific man- agement; and have numerous reports of cases in which the former was tried, and in many instances with advantage, rather before the middle ofthe last century.* In several experiments, Variously both have been found highly beneficial; but in various cases, J^ k[\ad also, both have been made use of in vain, and in a few instan- w;ln various ces, with apparent disadvantage ; and those who were at first success. most sanguine of success, gradually lost their confidence in them. The fact seems to be that, even at this late period of trial, A proper we are greatly in the dark upon the subject, and have not learn- aJ^nofeTec- ed to discriminate the exact modifications ofthe disease, or the trie power exact modifications of electric power in which alone this active and of the stimulus may be employed with advantage : for that, in both Jy**"g° the forms, it has been occasionally of very high benefit is by no teems still means to be disputed: and even at times when communicated to be want- by the gymnotus electricus or electric eel itself, of which a singu- IDg' lar example is given in the Haerlem Transactions ;t the pa- tient having recovered the use of the affected side after a hun- dred strokes from the fish. Upon the whole, as it is a direct More appli- stimulus, it appears better adapted to the atonic, than the ento- SJJJJJ^ nic character of paralysis. tonic palsy. The stimulus of hot water alone is often serviceable in local Hot bath- palsy, especially when it has been produced by cold or damp ; ing. and in conjunction with the rubefacients and vesicatories we f^eto bave just enumerated, or with friction to the part affected by iocaj pai,y. means ofthe hand or a flesh-brush, and particularly when aided by terebinthinate or other essential oils, will usually succeed in restoring to the affected muscles their wonted power. But But ;„ he. where the palsy is more extensive, as in hemiplegia and many miplegia, _ cases of paraplegia, it has been more usual to recommend the and °|tena,n stimulus of hot water in conjunction with various active miner- hor&thi*' al corpuscles held in solution hy it; and hence the common re- preferable sort of paralytic patients in our own country to the waters at that arteedm" Bath, Buxton, and Leamington. Hot baths of this kind are also pregna * Memoires de 1'Academie des Sciences, 1749, p. 40. Jallabert, Experience sur l'Electricite. Genev. 1749. t Abhandlungen aus den Schriften der Harlerner und anderer Hollandischen Gesellschaften, band i. p. 109. VOL. IV. 60 474 cl. iv.] NEUROTICA. [ord. IV. Gen. VIII. Spec. VI. Carus paralysis. Treatment. Cold bath- ing : an indirect stimulant. Medical intention. Recom- mended by Cullen. Hence hot mineral baths best adapted to atonic, cold affusion to entonic paralysis. Internal stimulants : proscribed generally by Cullen and J. Hunter: but useful in the atonic form of the disease. Acrid poisons, as arnica montana, rhus vernix, nux vomica. Mode of action and proposed object in their use. Arnica or doronicum first largely recommend- ed byCollin; a direct stimulus ; and, as such, are found more efficacious in pa- ralytics of atonic or dilapidated constitutions, than in those who have suffered from plethoric or entonic fulness, or at least till they have been lowered to the proper standard by a long course of some reducent regimen. Cold bathing is also a stimulant as well as hot bathing, but a stimulant of a different kind, for it acts indirectly instead of di- rectly. The intention, with which it is used, is that of forcibly urging the mouths of the cutaneous vessels into a general entas- tic or rigid spasm in order hereby to excite a general re-action, as in the case of the first and second stages of the ague-fit, and thus to draw the torpid muscles into the common range of as- sociation. Dr. Cullen seems favourable to this practice under a prudent management. " Cold," says he, " applied to the bo- dy for any length of time is always hurtful to paralytic persons: but if it be not very intense, nor the application long continued, and if at the same time the body be capable of a brisk re-action, such an application of cold is a powerful stimulant ofthe whole system, and has often been useful in curing palsy. But if the power of re-action in the body be weak, any application of cold may prove hurtful."* It is hence only necessary to add, that while the hot mineral baths appear best adapted to cases of atonic paralysis, cold affusion or the cold bath may be employed with most promise of success in accidental palsies of the plethoric and the vigorous. The ordinary internal stimulants are the mineral waters we have just adverted to, camphor and other terebinthinate sub- stances, many of the siliquose and alliaceous plants, as mustard, horse-radish, garlic, and onions, and a temperate use of wine : the whole of which, however, are proscribed in all cases by many writers of great eminence, and particularly Dr. Cullen and Mr. John Hunter: and which, if allowed at all, should be confined to the atonic form of paralysis, or never be commenc- ed in any instance of entonic palsy, till the system has been suf- ficiently reduced for the purpose. And where this has been ac- complished, such a class of remedies has often been found of essential service. Independently of these, there is a tribe of medicines entitled also to the name of stiiriulants. I mean several of the acrid poisons, as arnica montana, or leopard's-bane, rhus vernix var- nish-sumach, and strychnos nux vomica. All these excite the nervous system to great agitation and spasmodic action ; and if the dose be increased, violent convulsions, alternating with te- tanus, are sure to ensue : and hence it has been supposed, that they may be rendered effectual in a restoration of motivity to paralytic limbs. The flowers ofthe arnica, or doronicum, as it was once called, were chiefly employed, though sometimes the leaves were preferred. Dr. Collin was much attached to the former in palsies of all kinds, and affirms that he has found them very generally successful. He gave them in an infusion or de- * Pract. of Phys. vol. iv. MCLXVI. p. 190. CL. IV.] NERVOUS FUNCTION. [ORD. IV. 475 coction, in the proportion of from a drachm to half an ounce, Gen.VIII. to a pint of the liquid :* and, from his recommendation, they SpEC*VI* were, at one time, very generally adopted, were countenanced Carus . by Plenck, and Quarin, and experimented upon by Dr. Home.t Jj,r nU The last tried them in six cases, but without much success; and afterwards* they have not been able to maintain their reputation : nor, from \,y p\enck, the violence and uncertainty of their effects, is it worth while and Quarin. to revive them. HtUe'sucl The rhus vernix, or varnish-sumach, is chiefly indebted for by Home. whatever degree of fame it has acquired in paralysis to the re- Rhus vernix commendation of Dr. Fresnoi. The milky juice of this plant is °„J[a^{J"h" so acrid as to blister the hands of those who gather its leaves, Recom - so that they are obliged to wear gloves. The leaves are em- mended by ployed in decoction, and in extract: and appear not only to act F/*8^1'^ powerfully upon the nervous system, but by urine and perspi- ration ; and hence the plant has a claim to be considered as an active promoter of absorption as well as a revellent, which may, perhaps, render it serviceable in some cases of paralysis from serous compression of the brain. Of its benefit in some other diseases of a spasmodic or nervous character, and especially in hooping cough, we have already spoken. Most of the species of the rhus or sumach contain a like pun- Other spe- eent acridity in their milky iuices, and hence several others of cie9 of rhus . . • 11 i i 1 r i l t-» possess a them have occasionally been employed for the same purpose. Dr. fike power. Alderson, of Hull, has of late preferred the leaves ofthe rhus toxi- hence rhus codendrum, poison-sumach, or poison-oak, as it is sometimes, but toxicoden- .111 i • i l ii Li -j r drum, or improperly called : and, in many cases, he has thought it ot con- pojsonous siderable benefit. He commences with half a grain ofthe pow- sumach, dered leaves which he gives three times a day, and gradually g^3"^" increases the dose to four or five grains, till he finds a sense of DyAWerson. tingling produced in the paralytic part, accompanied with some degree of subsultus, or a twitching or convulsive motion. There are other acrid poisons which have a tendency to pro- Other acrid duce strong, entastic or rigid spasm, most of which possess an ^produce intensely bitter principle, and perhaps derive this difference of rigid spasm: effect from the tonic power of this very quality. Of these the asnuxvomi- chief are the strychnos nux vomica, and the ignatia amara. Both caand 'g'»- have hence been employed in paralysis, and the virtues of both tia amara- seem to be nearly alike; the former, however, has of late taken The former the lead upon the recommendation of Dr. Fouquier, ofthe Hos- jj^f*' pital de la Charite at Paris, who has tried it upon a very exten- employedby sive scale, and apparently with a perfect restoration of health Fouquier. in many cases ; and whose success has been authenticated by similar experiments under the superintendence of MM. Magen- die, Husson, Asseiin, and other pathologists. He gives it in the prepara. form of powder, or alcoholic extract: four grains of the first, tion. and two ofthe last are a dose, and may be taken from two to six times a day. He also employs it in ejections. In half an Effects. hour after administration the paralyzed muscles have, in various cases, begun to evince contraction: and, what is peculiarly sin- * Observ. circa Morbos Acutos et Chronicos, torn. v. p. 108. t Clinical Experiments, Histories, &c. Edin. 8vo. 1780. 476 ™. 'v.] NEUROTICA. [ord. IV. Gen. VIII. gular, while a spastic contraction is determined to these, the Spec VI. sound parts remain unimplicated in the action. A frequent ef- Carus feet, unquestionably dependent on the bitter principle of the paralysis. plant, is that of increasing the appetite, and diminishing the Treatment. number 0f tne alvine evacuations when in excess. Sometimes it produces a temulent effect, and occasions stupor and a sense of intoxication, and, when rashly administered, general tetanus with all its train of distressing and frightful symptoms. The most powerful form of this medicine is its alkaline basis, to Strychnine, which the French chemists have lately given the name of strych- nine. It has hitherto been chiefly used through the agency of clysters.* Variable Like all other powerful medicines in their first and indis- remlts. criminate use, the nux vomica appears sometimes to have been highly beneficial, sometimes mischievous, and sometimes to have produced violent effects on the nervous system, without an im- portant change of any other kind. Dr. Cooke has collected a variety of cases, in which it has been tried in our own country as well as in France, and this seems to be the general result. The present author has tried it in various instances, but has never been able, from its tendency to temulency, to proceed much more than half as far as some practitioners have gone, who have gradually advanced it from four grains of the powder Illustration, to twenty-four three or four times a day. In the case of the late E. Sheffield, Esq., of the Polygon, Somer's-Town, mineralo- gist to the estates of the Duke of Devonshire, and who is well known to have been one ofthe best practical geologists of his day, the author commenced with two grains alone of the pow- der given three times daily, as this was a hemiplegia following upon a second fit of atonic apoplexy, with a general debility both of the mental and corporeal powers, the patient being, at the time, rather upwards of sixty years of age. This dose oc- casioned no manifest effect, and on the third day, August 21, 1819, it was gradually increased to six grains. It now produced a powerful sense of intoxication, but with clonic agitation instead of a tetanic spasm, ofthe paralyzed leg and arm, and great heat down the whole ofthe affected side. The powder was contin- ued in this proportion for three or four days, but the stupor and vertigo were so considerable and afflictive that the patient could not be persuaded to proceed with it any longer, and it was in consequence suspended. On the ensuing September 1, he was evidently getting weaker, and recommenced the medicine at his own desire ; the dose was gradually raised from four to six grains three times a-day : the same clonic effect was pro duced with the same sensation of heat through the whole of the affected side, but without a sense of intoxication. The dose was advanced to eight grains, when the head again became af- fected, but without any permanent return of muscular power or sensation in the palsied limbs, or any other effect than a few oc- * Remarques sur la Nux Vomique considered comme Medicament. Par F. M. Coze, &c. Journal Universal des Sciences Medkales. Nov. 1819. cl. iv.] NERVOUS FUNCTION. [ord. iv. 477 casional twitches and involuntary movements. Mr. Sheffield Gen.VIII. could not be persuaded to persevere any farther, and the medi- Spec. VI. cine was abandoned. He continued in the same feeble state for Carus about three months, when he fell a sacrifice to a third apoplec- J*™*"11* tic attack apparently of a much slighter kind. I have stated that this was a case of atonic affection, and Apparent hence, there was no opportunity of giving full play to the pow- t°"bCpUdSe°nl er of the nux vomica. But so far as I have seen, I think we rived from may come to the following conclusions: First, that when only theordinary small doses can be given without seriously affecting the head, nUXCySon^jca> as in cases of great general, or nervous debility, the effect is a clonic instead of an entastic or tetanic spasm. Secondly, that, under this effect, it is not calculated to do any permanent good, and often produces mischief. And thirdly, that it is most ser- viceable in entonic hemiplegia, after the patient has been suffi- ciently reduced from a state of high energetic health, and espe- cially energetic plethora, to a subdued and temperate state of pulse ; in which state, it may very frequently be employed in doses sufficient to excite strong or entonic spasm. Nervous agitation, proportioned to the mode of the disease Henceob- and the strength of the patient, has often been of peculiar ad- Vl0,,s that vantage ; and hence, palsy has occasionally been carried off sud- agjtation in denly by a violent fit of mental emotion, as of anger* or fright,! due pro- of both which the examples are very numerous ; by a stroke of £°tgtl0nf" lightning :| and by fevers.§ Nor can I do otherwise than think, peculiar that one ofthe most rational and efficacious means of cure in advantage: many instances of paralysis, and especially, where no great in- whence the road has been made upon the general strength of the constitu- J^cVrried tion, would be a journey into the Hundreds of Essex or some offsponta- other marshy district, for the purpose of obtaining a sharp at- neously; by tack of a tertian ague, which would most effectually, and I ap- aigs,J[m-knegof prehend at the least expense, give us all the advantage of en- and fever. tastic spasm and re-action that we could wish for. In treating Tertian ofthe tertian intermittent, we observed from Dr. Fordyce, that ague might it has often a tendency to carry off a variety of obstinate and J™^"iihly chronic diseases to which the constitution has been long subject, efficacious, and to restore it to the possession of a better and firmer degree and a jour- ofhealth.|| , . , . . .j L j Hundreds6 In a few cases, hemiplegia is said to have ceased spontane- of Essex. ously by the mere remedial energy of nature ; in one instance, Collateral after ten years' standing, and accompanied with loss of voice.TT opinion of And, in a few cases of paraplegia from external injury to the C^^SU spine, where only one or two vertebrae have in a small degree 0f this hint. been displaced from their proper position, the same instinctive Hemiplegia. Paraplegia * Camerar. Memorab. Cent. v. No. 30. Paulini, Cent. in. Obs. 89. has Schenck, Observ. Lib. i. No. 182. t Diemerbroeck, Observ. et Cur. Med. sometimes Loeffler, Beytrage zur Wundarzneykunst, band i. J Wilkinson's Case of received a Mrs. Winder, 8vo. 17G5. i Act. Nat. Cur. vol. v. Obs. 64. Samml. Medi- natural cinischen Wahrnehmungen, band vi. p. 152. cure. II As the pathology of paralysis shows the very frequent dependence of this disease upon effusion of blood in the head, and certain morbid changes in the brain, and spinal marrow, as causes, the editor has less confidence, than the author, in the scheme here proposed. H Bresl. Samml. 1721, p. 406. S03. 478 «• IV-1 NEUROTICA. [ORD. IV. Gen. VIII. or remedial power has alone produced a cure or greatly allevia- Spe'cVI.' ted the mischief by so far thickening the growth of the bones Cams immediately above and below that the chasm has been filled up, paralysis. an(j a iine 0f support restored. The best artificial means of ob- Treatment. taining- so salutary an action is by a free and laborious process of friction, vellication or shampooing, with such intermediate exertion or exercise as the patient may be able to take.* ►, Palsy. It is only necessary to add farther, that where local palsy has been produced by the fumes or minute divisions of lead or other noxious metals, it is almost always accompanied with symptoms of colica rhachialgia, or painter's colic, and is to be remedied by the treatment already laid down under that disease. * See especially, Shaw on the Nature and Treatment of Distortions to which the Spine and the Bones ofthe Chest are subject. 8vo. 1823, NATIONAL LIBRARY OF NLM 03277131 fl NLM032779318