iWH'iM!'- hlt'i'lf^'.'!:!'1; ;:■;:'■-•.•;• iliiiiiiii yi:;h;:;: ,Ui'- ■ « ■ » • " ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl avian ivnoiivn jnoioiw jo uviiii ivnoiivn inoioiw *o Aaviin ivnoiivn inoioin ART OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL I .avaau ivnoiivn jnoiqiw jo Aivaa n ivnoiivn snoioiw jo iiyiiii ivnoiivn jnoioiw j ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL IIBRARY OF MEDICINE NATIONAL L. avian ivnoiivn iNDioiw 10 xavaan ivnoiivn sndiojw to uvaan ivnoiivn inoiqiw j avian ivnoiivn inidiqiw jo xavaan ivnoiivn jnidiqjw jo Aivaan ivnoiivn inoiqiw t avian ivnoiivn jnidiqsw io Aavaan ivnoiivn jnidiqjw io uyiiii ivnoiivn indiqiw i IRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATION/ Aivian ivnoiivn inidiqjw jo Aivian ivnoiivn jnoiqjw jo Aivian ivnoiivn inijiqi RARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATI0NAI AlViai'1 IVNOIIVN 3NI3IQ3W JO A1V1BI1 IVNOIIVN 3NIDIQ3W JO A1V18I1 IVNOIIVN iNIJIOil Aivaan ivnoiivn JNiDiaaw jo Aivian ivnoiivn inoioiw jo Aivaan ivnoiivn jnoioii -: & l¥VI RARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONA Aivaan ivnoiivn indiqiw jo Aivian ivnoiivn jnidiqjw jo Aivian ivnoiivn jnisiqi PROSPECTUS OF THE LIBRARY OF MEDICINE: CONDUCTED BY ALEXANDER TWEEDIE, M.D. F.R.S., PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL; EDI- TOR OF THE CYCLOPEDIA OF PRACTICAL MEDICINE, &C, WITH THE ASSISTANCE OP NUMEROUS CONTRIBUTORS. The design of this work is to supply the want, generally admit- ted to exist in the medical literature of Great Britain, of a compre- hensive System of Medicine, embodying a condensed, yet ample, view of the present state of the science. This desideratum is more especially felt by the Medical Student, and by many Members of the Profession, who, from their avocations and other circumstances, have not the opportunity of keeping pace with the more recent improvements in the most interesting and useful branch of human knowledge. To supply this deficiency, is the object of The Li- brary of Medicine; and the Editor expresses the hope, that with the assistance with which he has been favored by Contributors, (many of great eminence, and all favorably known to the Public,) he will be enabled to produce a work, which, when completed, will form a Library of general Reference on Theoretical and Prac- tical Medicine, as well as a Series of Text Books for the Medical Student. It is intended to treat of each Department, or Division of Medi- cine, each Series forming a complete Work on the subject treated of, which may be purchased separately at a very moderate price, or it will constitute a Part of The Library of Medicine. This arrangement is made with the view of giving those persons who may wish to possess one or more of the Series, the opportunity of purchasing such Volumes only, and thus avoid the inconvenience • of making a larger addition to their stock of Books than their wants or circumstances may require. Each Treatise will be authenticated by the Name of the Author; and from the care bestowed in the arrangements, it is confidently hoped, that the want of uniformity noticed in works of a similar kind, will be obviated, at least, as far as is compatible with the execution of the work by a numerous body of united Authors. The First Series will comprehend Practical Medicine. The Se- cond Practicnl Surgery. The Third will include Midwifery, the Diseases of Won^en, and the Diseases of Children, &c. 11 ADVERTISEMENT. The other Departments of Medical Science will be treated of in successive Volumes. A work of this description is a greater desideratum in this coun- try than even in Great Britain, from the great number of country practitioners here who have not access to libraries, and whose circuit of practice is so extensive as to afford little leisure for consulting elaborate treatises. To supply it. the republication of the Library has been undertaken and the second volume is now presented to the American medical public. The subsequent volumes will appear in quick succession. * The third volume, which has been received and is now at press, is devoted to the Diseases of the Organs of Respiration, and em- braces the following subjects: — The Diagnosis of Diseases of the Lungs, Laryngitis, Tracheitis or Croup, Laryngismus Stridulus, Nervous Affections of the La- rynx, Acute Catarrh, Bronchitis, Bronchorrhcea, Bronchial Con- gestion, Spasmodic Asthma, Hooping Cough, Strictural Lesions of the Air Tubes, Pleurisy, Pneumothorax, Pleurodynia, Pneu- monia, Pulmonary OZdema, Dilatation of the Air Cells or Pul- monary Emphysema, Tuberculous Disease of the Lungs or Pul- monary Consumption, Malignant Growths in the Lungs, Diseases of the Bronchial Glands by Dr. Williams. The article on Influenza is by Dr. Theophilus Thompson; that on Asphyxia by Dr. Carpenter. > The Diseases of the Organs of the Circulation are by Dr. Joy and include the following articles:—Diseases of the Heart, Ner- vous Palpitation, Syncope, Angina Pectoris, Neuralgia of the Heart, Pericarditis or Inflammation of the External Membrane of the Heart, Endocarditis or Inflammation of the Internal Mem- brane of the Heart, Carditis or Inflammation of the Muscular Substance of the Heart, Hypertrophy of the Heart, Dilatation of the Heart, Partial Dilatation or Real Aneurism of the Heart, Atrophy of the Heart, Changes in the Consistence and Color of the Heart, Morbid Effusions into its Substance, and New Forma- tions, Rupture of the Heart, Polypous Concretions of the Heart, Hydropericardium, Secondary Effusions into the Pericardium, Pneumo-Pericardium and Hydropneumo-Pericardium, Displace- . ment of the Heart, Hernia of the Heart, Malformations of the Heart, Congenital Malformations, Preternatural Communication between the two Sides of the ;eart. The American Publishers invite particular attention to the fact, that each volume is complete in itself and will be sold separate- ly; the acquisition of any one will not, therefore, necessitate the purchase of the others. The whole will, however, form a com- plete Medical Library. Such notes or additions as may seem to be required will be supplied for the subsequent volumes. The first volume contains Dissertations on Fevers, General Pathology and Diseases of the Skin. DISSERTATIONS NERVOUS DISEASES. BY JAMES HOPE, M.D. F.R.S. Physician to St. George's Hospital, &c. J. C. PRICHARD, M.D. F.R.S. M.R.I.A. Corresponding Member of the National Insti- tute of France; Senior Physician to the Bristol Infirmary, &c. JOHN HUGHES BENNETT, M.D. ROBERT H. TAYLOR, M.D. Liverpool. THEOPHILUS THOMSON, M.D. Physician to the Northern Dispensary, &c. EDITED BY ALEXANDER TWEEDIE, M.D. F.R.S. Fellow of the Royal College of Physicians, Physician to the London Fever Hospital and to the Foundling Hospital, &c. WITH AMERICAN NOTES AND ADDITIONS, BY W. W. GERHARD, M.D., Lecturer on Medicine, Physician to the Philadelphia Hospital, Blockley, &c. ..n. Gen/' eoLiriLV-'-'T. 5 PHILADELPHIA: LEA & BLANCHARD. 1840. SYSTEM OF PRACTICAL MEDICINE COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. ARRANGED AND EDITED BY ALEXANDER TWEEDIE, M.D. F.R.S. »# • FELLOW OF THE ROVAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL AND, TO THE FOUNDLING HOSPITAL, ETC. DISEASES OF THE NERVOUS SYSTEM W ■?' PHILADELPHIA: LEA & BLANCHARD 1840. / Entered according to act of Congress, in the year 1840, By LEA & BLANCHARD, In the office of the Clerk of the District Court of the Eastern District of Pennsylvania. Wh Tins X. K. * P. e. COLLINS, Printrn,, H». 1 Lodje Alley. PREFACE. (BY THE AMERICAN EDITOR.) The notes contained in this work are added by the American Editor, with the exception of those marked Author. The large size of this volume made it necessary to restrict these notes to the least possible number, and with the exception of the addi- tions made to the articles Delirium Tremens and Hydrocephalus, they are limited to short explanations of the text. For those on Ophthalmia, the editor is indebted to a medical friend, who has made that disease a subject of particular study. No alterations have been made in the text of the work, with the exception of errors in the spelling of the proper names of authors who are quoted in the work. The manifest injustice of carelessness in this respect is obvious enough; amongst the names which are corrected are those of Dr. Bouillaud and of the American Editor. The high character of the articles contained in this volume will be apparent to the reader. Those which appeared most defective have of course received the largest share of the new matter introduced by the American editor; this will, it is hoped, supply the trifling deficiencies inseparable from the execution of so extended and difficult a task. In the remarks which are added by the American editor to the chapter on Delirium Tremens, it is stated that the alcoholic treatment was required in all severe cases of the disease, and was also eminently successful in the slighter varieties of it. At the same time it is mentioned that it was not at all necessary in Vih PREFACE. mild cases, which would do well under many different modes of treatment or without treatment of any kind. In the manage- ment of the cases admitted into the men's wards of the hospital? no opium was used in the treatment of the disease for a con- siderable time, but it is not meant that all these cases were treated by alcohol; some were treated by emetics, especially ipecacuanha and lobelia, some by antispasmodics, as Hoffman's anodyne, valerian and assafbstida, and others were left to nature; but the alcoholic practice was the most certain and was always relied upon when other remedies failed. This explanation is given, to prevent a misconception of the remarks upon this subject. CONTENTS OF THIS VOLUME. DISEASES OF THE NERVOUS SYSTEM. On the Pathology of the Nervous System. (Dr. Bennett.) Structure and Arrangement of the cineritious and Medullary matter.—Functions of the central Organs of the nervous System.—Cerebral Functions.—Spinal Functions.— Cerebro-spinal Functions.—Pathology of the central Organs of the nervous System. —Nature of the Circulation within the Cranium.—Influence of Pressure and Struc- tural Disorganisation --------13 INFLAMMATION OF THE BRAIN. (Dr. Hope.) Preliminary Observations.—Precursory SymptomsofCerebrallnflammation.—Cerebral Determination and Congestion.—Cerebral Congestion from Debility and Inaction.— Cerebral Irritation, Determination, and Congestion, in Infants and Children.—In- flammation of the Dura Mater.—Meningitis.—Acute Meningitis.—Varieties.—Phre- nitis.—Meningo-cerebritis.—Hydrocephalic.—Anatomical Characters of Meningitis. ChronicMeningilis.—Cerebritis.—Acute general Cerebrilis.—Acute partial Cerebri- tis.—Chronic Cerebritis.—Intermittent Inflammation of the Brain.—Anatomical Cha- racters of Cerebritis.—Softening.—Suppuration and Abscess.—Ulceration.—Indu- ration.—Comparative Frequency of the several Forms of Cerebral Inflammation.— Predisposing Causes.—Diagnosis.—Prognosis.—Treatment of the several Forms of Cerebral Inflammation --------27 HYDROCEPHALUS. (Dr. Bennett.) Explanatory Observations.—Two Forms, acute and chronic.—Symptoms of acute Hy- drocephalus.—Division into Stages or Periods.—Symptoms.—Of the first Stage.—Of the Second stage.—Of the third Stage.—Forms of acute Hydrocephalus.—Gradual or subacute.—Rapid or acute.—Sudden or hyperacute.—Anatomical Characters.— Predisposing Causes.—Exciting Causes.—Diagnosis.—Prognosis.—Treatment 106 Pathology and Pathological relations of the disease. {Dr. Gerhard.) 132 APOPLEXY. (Dr. Bennett.) Definition.—Premonitory Symptoms.—Of the different Forms.—Transient or fugitive. —Sudden or primary.—Ingravescent.—Paraplexy.—Anatomical Characters.—Con- nection of Symptoms with morbid Appearances.—Pathology, or Theory of Apoplexy. —Causes—predisposing—exciting.—Diagnosis.—Prognosis.—Treatment - 136 X CONTENTS. INSANITY. (Dr. Prichard.) Explanation of terms and Enumeration of the different Forms of Insanity.—General or # incoherent Insanity, including Mania and Dementia.—Moral Insanity.—Monomania and Melancholy.—Instinctive Madness, or insane Impulse, including, 1. Homicidal Impulse; 2. Pyromania; 3. Suicide; 4. Other morbid Propensities.—Progress and Terminations.—Anatomical Characters.—Diagnosis.—Causes.—Treatment—reme- dial—moral—Of Hypochondriasis—its Causes, Nature, and Treatment.—Of Puer- peral Insanity and its Treatment ------- 165 DELIRIUM TREMENS. (Dr. Bennett.) History.—Causes.—Symptoms.—Two Forms of the Disease.—Second Form divided into three Stages.—Description of the first—second—and third Stage.—Anatomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment - 225 Varieties.—Staces.—Symptoms.—Complications.—Pathology.—Treatment. (Dr. Ger- hard.) - S - - - ' - - - - - - 237 CEPHALALGIA. (Dr. Bennett.) General Symptoms.—Causes.—Morbid Anatomy and Pathology.—Varieties.—Diag- nosis.—Prognosis.—Treatment ______ '24'J EPILEPSY. (Dr. Bennett.) History.—Symptoms—premonitory—of the Seizure—consecutive.—Duration.— Causes—predisposing — exciting.—Varieties—idiopathic—sympathetic.—Anatomi- cal Characters.—Nature.—Diagnosis.—Prognosis.—Treatment - - 264 CATALEPSY AND ALLIED AFFECTIONS. (Dr. Bennett.) Definition.—Symptoms.—Duration.—Varieties.—Catochus.—Ecstasy.—Lethargy or Cataphora. —Coma. — Causes — predisposing — exciting. — Nature. — Diagnosis.— Prognosis.—Treatment - - - - -- -- 292 SPINAL IRRITATION. (Dr. Bennett.) Explanation of the term Spinal Irritation.—Various anomalous Symptoms.—Predis- posing Causes.—Exciting Causes.—Nature.—Diagnosis.—Prognosis.—Duration.— Treatment --------- 297 SPINAL MENINGITIS. (Dr. Bennett.) Definition.—Symptoms—of the acute Form—of the chronic Form—Causes.—Anato- mical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment - - 304 MYELITIS, or INFLAMMATION OF THE SPINAL CORD. (Dr. Bennett.) Definition.—Symptoms of acute Myelitis—of chronic Myelitis.—Causes.—Anatomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment - 309 HYDRORACHIS. (Dr. Bennett.) Definition.—Congenital Hydrorachis.—Hydrorachis developed after Birth.—Causes. —Anatomical Characters.—Nature.—Diagnosis.—Prognosis.—Treatment - 316 SPINAL APOPLEXY. (Dr. Bennett.) Symptoms.—Causes.—Anatomical Characters.—Nature.—Diagnosis.—Prognosis.__ Treatment - - - - - - _'. _ 324 CHOREA. (Dr. Theophilus Thomson.) Characteristic Symptoms.—Analogous Affections.—Anatomical Characters.__Nature. —Causes.—Diagnosis.—Prognosis.—Treatment - 327 CONTENTS. XI HYSTERIA. (Dr. Theophilus Thomson.) General Observations.—Division into three Forms—regular—irregular—complicated. —Diagnosis.—Prognosis.—Causes.—Nature.—Curative Treatment.—Moral Man- agement and preventive Treatment ----- 344 TETANUS. (Dr. Bennett.) Explanation of the term Tetanus and its Varieties.—Trismus.—Opisthotonos.—Em- prosthotonos.'—Pleurosthotonos.—TrismusNascentium.—General and local.—Acute and chronic.—Idiopathic and symptomatic.—Continued and periodic.—Premonitory Symptoms of Tetanus.—Symptoms of the Paroxysm of Trismus—of Opisthotonos— of Emprosthotonos—of Pleurosthotonos.—Chronic Forms of Tetanus.—Predisposing Causes.—Exciting Causes.—Anatomical Characters.—Nature.—Diagnosis.—Prog- nosis.—Treatment. -------- 367 HYDROPHOBIA. (Dr. Bennett.) Definition.—P ^monitory Symptoms.—Symptoms of the Attack.—Various Modifica- tions observed in the Symptoms in the Human Subject.—Symptoms of Rabies in the Dog.—Predisposing Causes.—Exciting Causes.—Nature.—Anatomical Characters. —Diagnosis.—Prognosis.—Prophylactic or preventive Treatment.—Curative Treat- ment - - - - -- - - - - 390 NEURALGIA. (Dr. Theophilus Thomson.) Definition.—Symptoms.—Varieties.—Diagnosis.—Causes.—Nature.—Treatment 413 PARALYSIS. (Dr. Bennett.) Explanation of the term.—Varieties and Distinctions.—Symptoms.—Mode of Acces- sion.—Description of the various Forms and Varieties of Paralysis.—General Para- lysis.—Hemiplegia.—Paraplegia.—Various Forms of local Paralysis.—Paralysis of particular Muscles.—Strabismus.—Ptosis and Lagophthalmia.—Aphonia.—Paraly- sis of the Face.— Paralysis of a Limb, or particular Muscles of a Limb.—Paralysis of Sensibility.—Amaurosis.—Cophosis.—Anosmia.—Ageustia.—Anaesthesia.—Pa- ralysis of Motion.—Paralysis of the Insane.—Paralysis from metallic Poison.—Mer- curial Palsy.—Lead Palsy.—Paralysis Agitans.—Causes of Paralysis.—Anatomical Characters.—Nature.—Crossed Effect from Lesions above the Medulla Oblongata.— Direct Effect from Lesions below.—Diagnosis.—Seat of the Lesion.—Nature of the Lesion.—Prognosis.—Treatment - - - - - - 431 BARBIERS. (Dr. Bennett.) Symptoms—.Causes.—Morbid Anatomy.—Diagnosis.—Treatment - - 460 INFLAMMATION OF THE EYE. (Dr. Taylor.) General Remarks on Ophthalmic Inflammations and their Classification.—1. Inflamma- tion of the Conjunctiva.—(a) Catarrhal Ophthalmia—Symptoms—'Causes—Diagnosis —Treatment.—(b) Purulent Ophthalmia of Infants—Symptoms—Causes'—Treat- ment.—Of Adults—Symptoms—Causes—Treatment.—(c) Gonorrhoeal Ophthalmia —Symptoms—Causes—Treatment.— (d) Strumous Ophthalmia—Characteristic Symptoms—Causes—Treatment.—(e) Variolous Ophthalmia—Symptoms and Treat- ment.—(f) Morbillous and Scarlatinous Ophthalmia—Symptoms and Treatment.— (g) Erysipelatous Ophthalmia.—II. Inflammation of the Sclerotica—Symptoms and Treatment.—(a) Catarrho-rheumatic Ophthalmia—Symptoms, Causes, and Treat- ment.—III. Inflammation of the Cornea—Symptoms, Causes, and Treatment.—IV. Inflammation of the Iris.—(a) Acute idiopathic Iritis—'Symptoms—Causes—Diagno- sis—Treatment—Varieties.—(b) Syphilitic Iritis—Symptoms, Diagnosis, and Treat- ment.—(c) Rheumatic iritis—diagnostic Symptoms and Treatment.—(d) Arthritic Iritis—Symptoms, Causes, and Treatment.—(e) Strumous Iritis—Characters and Treatment.—V. Inflammation of the Retina—Symptoms of the acute—of the chronic —Causes—Diagnosis—Treatment.—VI. Inflammation of the Choroid—characteristic Symptoms, Causes, and Treatment.—VII. Inflammation of the lining Membrane of the Aqueous Chamber, and of the Lens and its Capsule - 463 Xll CONTENTS. AMAUROSIS. (Dr. Taylor.) Definition.—Idiopathic and Symptomatic.—Symptoms.—Causes.—Diagnosis.—Prog- nosis.—Treatment - - - - - - - - 515 INFLAMMATION OF THE EAR, or OTITIS. (Dr. Bennett.) Definition of Otitis and Otorrhoea.—Acute and chronic Otitis.—Symptoms of acute external Otitis—of acute internal Otitis—of chronic Otitis or Otorrhoea.—Causes.— Anatomical characters.—Diagnosis.—Prognosis.—Treatment of acute externil Oti- tis—ol acute internal Otitis—of chronic Otitis - - - - 527 DISEASES OF THE NERVOUS SYSTEM. General observations on diseases of the nervous system—Structure and ar- rangement of the cineritious and medullary matter.—Functions of the central organs of the nervous system.—Cerebral functions.—Spinal functions— Cerebro-spinal functions.—Pathology of the central organs of the nervous system.—Nature of the circulation within the cranium.—Influence of pres- sure and structural disorganisation. Before entering upon the description of diseases of the ner- vous system, there are certain considerations of a general nature, applicable to the whole class, the discussion of which in this place will prevent much unnecessary repetition. It is evident that, as disease consists in the derangement of those functions the proper performance of which constitutes what is termed health, it is necessary that the physician should be as intimately acquainted with the latter as with the former. To the union of scientific with practical knowledge may be attributed the great advances which have been latterly made in the study of the nervous system; as it is an undoubted fact that the myste- rious functions of this portion of the animal structure have been principally elucidated by the labors of those who have had extensive opportunities of proving the accuracy of their opinions by clinical observation. Indeed it must be obvious that anatomi- cal, physiological, and pathological researches bear a mutual relation to each other; and as experience has shown that, prose- cuted by themselves, they are inadequate to the end in view, modern physiologists unite the results which these have respec- tively elicited, and thus endeavor to correct the numerous fallacies which are likely to result from confining the attention too exclu- sively to the one department or the other. The inquiries that have been carried on in this way have made it necessary to view ' the nervous system in a very different light from that in which it was formerly considered; and that we may place before the reader the present state of knowledge of this subject in as con- densed a manner as possible, we shall, first, consider its general anatomy; secondly, its physiology, and, lastly, its pathology. I. The nervous system is composed of two structures; the gra- nular or gray, and the fibrous or white. The former is more vas- 14 DISEASES OF THE NERVOUS SYSTEM. cular than the latter, a fact fully established by the injections of Ruysch and the microscopical examinations of Lewenhoeck. In the gray matter, according to the researches of Ehrenberg, there is mingled with a soft granular substance a number of minute corpuscles, which are strung on filaments like beads, and which become distinctly fibrous in the neighborhood of the medullary substance. The white matter, on the contrary, is not granular, but tubular, consisting wholly of tubes, which, in the brain and spinal cord, contain a transparent gelatinous fluid. They are from fa to ^fav part of a line in diameter, of an ampullated form arranged in parallel lines; and in the brain are larger towards the base, and in the spinal marrow towards the external surface. The first, second, and auditory nerves consist of similar tubes; but in the spinal nerves generally, the tubes are of a cylindrical form, are larger than the others, and contain a peculiar granular mat- ter, which may be squeezed out of them. The sympathetic nerves are formed of both kinds of tubes; and in the ganglions is superadded the same granular structure as is found in the gray matter of the brain. The gray and white matter are arranged differently in the brain and spinal cord. By the brain we understand all that part of the encephalon situated above the corpora quadrigemina; and here the cineritious substance is placed external to the white, and covers the surface of the cerebral hemispheres, which, by its numerous infractuosities and convolutions, allows a large quan- tity of this material to be contained in a small space. In the spinal cord, however, which includes not only that portion in the vertebral canal, but all that part of the cerebrum below the cor- pora quadrigemina, the gray matter is internal, surrounded by the white—an arrangement which permits the latter to extend in the form of nerves to all parts of the animal frame. In the superior or cranial portion of the cord, the gray matter is collect- ed in masses, as in the corpora striata, thalami nervorum optico- rum, &c, through which medullary fibres pass forming ganglia; but in its inferior or vertebral portion it is continuous, somewhat in the form of the letter X, the prolongations of which constitute its anterior and posterior peaks or cornua. The medullary matter in the spinal cord may be divided into six columns, three being contained in each symmetrical half of the cord. The anterior column includes the part enclosed be- tween the anterior longitudinal groove and the anterior cornu of the gray matter; the middle column is placed between the two lateral cornua of the gray matter, and the posterior column be- tween the posterior cornu of the gray matter and the posterior longitudinal groove. These different columns maintain a uni- form relation to each other in that part of the spinal cord en- closed within the vertebral canal, the fibres of which they are composed being arranged in vertical lines. In the medulla General Observations. 15 oblongata, however, while the greatest number of the fibres in the anterior columns continue upwards through the pons varolii to form the crura cerebri, and ultimately proceed to the cerebral convolutions, some decussate with their fellows on the opposite side, as they approach the corpora pyramidalia; and others, as shown by Mr. Solly, pass outwards below the olivary bodies to join the posterior columns and accompany it into the cerebellum. The middle columns also decussate in the medulla oblongata, as lately shown by Sir Charles Bell, but instead of passing through the corpora striata, traverse the optic thalami, to become expand- ed in the hemispheres. The posterior columns, on the other hand, diverge from each other without any decussation, and pro- ceed upwards and outwards to assist in forming the crura cere- belli, and are lost in the cerebellum. The anterior motiferous roots of the spinal nerves are connected with the anterior columns and anterior peaks of the gray matter, while the posterior or sen- siferous roots are connected with the middle columns and poste- rior peaks of gray matter. The medullary matter in the brain is composed partly of the fibres which are continuous with the columns of the spinal cord, called the diverging fibres, and partly by others which connect them together. Some of these cross those just described transversely, forming the commissures, the corpus callosum, &c, while others run from before backwards, forming the fornix, processus a cerebello ad testes, &c. II. The great difference in structure and peculiar arrangement of the two component portions of the nervous mass lead to the idea that they perform different functions; and it is an opinion held by many physiologists, and daily gaining ground, that the gray matter is the originator of nervous power, while the office of the medullary fibres is to act as conductors, conveying to the cineritious or gray matter the influence of impressions communi- cated to these fibres, and conducting outwards from the gray sub- stance the mental and motive influences to distant organs. Anatomists and physiologists have disputed whether the spinal cord is to be considered as a prolongation of the brain, or the brain as an expansion of the spinal cord; but it is now admitted that, when viewed physiologically, they ought to be regarded as two distinct organs, capable of performing functions independent of each other, although the action of both at the same time gives rise to results which partake of a mixed character. Thus nume- rous facts demonstrate that the brain furnishes the conditions necessary for mental acts, while the spinal cord possesses those essential for the manifestation of motion. We have seen, how- ever, that there is an anatomical connection between the brain and spinal cord, and in their normal state one may influence the other so that the two functions may be called into action simul- taneously, giving rise to results which partake of both, yet re- 16 DISEASES OF THE NERVOUS SYSTEM. semble neither alone. The functions of the central organs of the nervous system, therefore, may be divided into those furnished by the brain, those furnished by the spinal cord, and such as result from the action of both. These may be named the cere- bral, spinal, and cerebro-spinal functions, each of which we shall consider in succession. 1. The brain furnishes the conditions necessary for the mani- festation of the intellectual faculties, properly so called, of the emotions and passions of volition; and is essential to sensation. Taking into consideration what has already been said concerning the offices of the gray and white matter, there are many reasons for supposing that mental acts originate in the former, a supposi- tion which is rendered probable by the following facts:—1. In the animal kingdom generally, a correspondence is observed between the cortical substance, depth of convolutions, &c, and the sagacity of the animal. 2. At birth the cortical substance is very defective, being only marked out by superficial fissures almost confined to the surface of the brain; as this substance increases, the intelligence becomes developed. 3. The results of experiments by Flourens, Rolando and others, have shown that, on slicing away the brain, the animal becomes more dull and stupid in proportion to the quantity of cortical substance removed. 4. Foville, Delaye, Pinel, Grandchamp, Bouillaud and Davidson, by an unusual degree of accuracy in pathological in- vestigation, were generally enabled to detect morbid alterations of the cortical substance in cases of insanity; that is, by employ- ing a degree of care which renders it probable that many cases recorded by writers where no alteration was discovered, de- pended upon the unskilfulness of their attempts to demonstrate it. 5. An observation of the symptoms in those cases in which the structural alteration has been afterwards found to commence at the circumference of the brain and proceed towards the centre, shows that the mental faculties are those among the first affected; whereas in those diseases in which the lesion com- mences at the base of the organ and proceeds towards the cir- cumference, they are affected last. If such be the office of the gray matter, the fibres of the white matter in the brain must serve to conduct the mental impressions made on their extremi- ties; and it may be asked whether the fibres so minutely described by Reil, running transversely, and from before backwards, and which connect anatomically different portions of the cortical substance of the brain, are not subservient to that combination of the intellectual faculties which characterises thought. But whatever opinions are held regarding the office of these two sets of fibres, there can be no doubt that some of the diverging fibres carry the influence caused by volition to the spinal marrow, and others the influence of impressions made on the sensitive nerves General Observations. 17 upwards towards the gray matter. Of the use of these fibres, however, we shall speak when treating of cerebro-spinal actions. 2. The spinal cord furnishes the conditions necessary for com- bined movements; and that the nervous energy requisite for these movements originates in the gray matter, is rendered pro- bable by the following facts:—1. Its universal communication with all motor nerves. 2. Its increased quantity in those portions of the spinal cord from whence issue the large nervous trunks. 3. Its collection in masses at the origin of such nerves in the lower animals as furnish peculiar organs which require a large quantity of nervous power, as in the Triglia Volitans, Raia Tor- pedo, Silurus, &c. In the spinal cord also the white matter serves as a conductor, and is the agent by which not only the influence of impressions made on the nerves reach the gray matter, but by which the changes these occasion there, are trans- mitted outwards to act on the muscles. From the researches of Sir C. Bell, it appears most probable that the first office is per- formed by the fibres which constitute the middle or sensitive columns, and that the last is the peculiar function of the anterior or motor columns. In the present state of our knowledge it is difficult to determine the exact uses of the posterior columns. Before proceeding further, however, it will be necessary to dis- tinguish the different kinds of motion performed by the animal frame from each other. The instruments of all motion in animal bodies, are the muscles, which the researches of Halier have proved to possess a certain property he named irritability, but which has since received the more appropriate name of contractility. This pro- perty, by means of which the muscles are thrown into action on the application of certain stimuli, does not appear to be neces- sarily connected with the nervous system, and hence a class of movements may be induced, independent of the brain or spinal cord. But this property may also be called into action by the influence of stimuli, which may be applied through the medium of the nervous filaments connected with the anterior column of the spinal cord. These stimuli may be classed under two heads, those of volition and mental emotions, and those of chemical or mechanical agents. Thus there are three kinds of movements: —1. Those which depend on the application of a stimulus to the muscular fibre itself, independent of the brain or spinal cord. 2. Those which depend on this stimulus being conveyed to the muscular fibre through the agency of the brain and spinal cord combined. And 3. Those which are called into action only through the medium of the spinal cord. Of the second class we shall speak when considering the cerebro-spinal functions, and here describe only the last or spinal movements. The third class of movements which we have mentioned have been for the most part elucidated and separated from the others 2* IS DISEASES OF THE NERVOUS SYSTEM. by the labors of Dr. M. Hall, who has termed them excito- motory. They include all those co-ordinate motions engaged in the organic functions of the body, such as sucking, swallowing, respiration, the emission of certain sounds, &c; the action ot some of the sphincter muscles, and the abnormal movements constituting convulsions or spasms. These movements result from certain excitations applied to particular organs of the body, and are effected in the following manner:—1. A change (which, for want of a better name, we call an impression) is made upon some of the expanded nervous filaments which are connected with the sensitive columns of the spinal cord either in its vertebral or cranial portion. 2. This impression is conveyed inwards either to the vertebral or cranial portion of the cord. 3. An influence is generated in the cord and transmitted outwards along the filaments connected with the anterior or motor columns. And, 4. This influence stimulates the muscular fibres to contract. Thus sucking in the infant depends, 1. Upon certain impressions having been made on the filaments of the larger root of the fifth pair expanded upon the mucous membrane of the mouth. 2. These impressions are con- veyed by these filaments of the fifth pair to the medulla ob- longata. 3. An influence is there generated, and is transmitted outwards along the motor nerves distributed to certain muscles of the face, throat and chest. 4. This influence stimulates these muscles to contract. In the same manner respiration is habitu- ally performed by certain impressions made principally upon the filaments of the par vagum distributed to the lungs, and to a less extent upon the filaments of the fifth pair, and posterior roots of the other spinal nerves, ramifying on the skin of the face and other parts of the body, while the influence the impressions give rise to in the medulla oblongata is transmitted outwards by the phrenic, intercostal and other motiferous nerves distributed to the respiratory muscles, which are stimulated into simultaneous con- traction. It has been fully ascertained, both from observations made upon anencephalous foetuses of the human species, by experiments upon the lower animals, and by the fact that they continue when the functions of the brain are suspended in dis- ease, that none of the parts of the encephalon above the corpora quadrigemina are necessarily engaged in the performance of these actions, and that the corpora quadrigemina, tuber annulare, medulla oblongata, vertebral portion of the spinal cord, and the various nerves attached to these different parts, are the only por- tions of the nervous system essential to their performance. These movements, however, although essentially spinal, are to a certain degree placed under the dominion of the brain; an apparent con- tradiction, which we shall now proceed to explain. 3. We have previously stated that a third class of functions result from the combined action of the brain and spinal cord. General Observations. 19 We have stated that the function of the brain may be said to consist in furnishing the conditions necessary for intelligence or mental acts—a function which may exist without the power of motion; and that, on the other hand, the spinal cord furnishes the conditions necessary for combined movements, a function which may exist without intelligence. In the one case a certain integrity of the brain is necessary, and in the other a certain in- tegrity of the spinal cord. There are, however, some motions which can only be produced through the agency of the brain, and some mental operations which can only take place through the agency of the spinal cord; and the difficulty of analysing the different motions which occur, and the nature of the mental ope- rations which accompany them, is what hitherto has given rise to so much confusion. We hope, however, that the method we have adopted of considering this subject will in a great degree dispel the obscurity which has hitherto surrounded it. The class of motions which are produced by mental acts are of two kinds:—1. those resulting from an exercise of volition; and, 2. those occasioned by the emotions or passions. When the muscles of the trunk or limbs are thrown into contraction by an act of volition, it is effected in the following manner:—1. The mental act of volition takes place in the brain. 2. This produces an influence which is transmitted downwards along some of the diverging (or in this sense converging) fibres of the brain, the anterior column of the spinal cord, and the nerves leading from it to the muscles to be moved. 3. This influence acts as an ex- citant to the property of contractility inherent in the muscular bundles by which they are called into contraction. Hence if the brain be incapable of performing the mental act of volition, or if the spinal cord be incapable of transmitting the influence it gives rise to, loss of voluntary motion is the result. This, however, may be partial; and then it may not only depend on partial dis- ease of the brain or spinal cord, but on the abnormal condition of one or more nerves which transmit the influence produced, or a loss of the property of contractility in a greater or less number of muscles. As the muscles which perform the excito-motory actions also contract either habitually or occasionally from ihe stimulus of volition, these movements may be considerably con- trolled by the mind. Thus a strong exercise of the will may suppress or diminish their force, while many of them appear to be most perfect after the suspension of the functions of the brain. The mind is also capable of exciting an occasional influence over the muscles of organic life, as is well illustrated by the increased or diminished action of the heart from anger or fear. The par- ticular nerves subservient to these motions, or the manner in which they are produced, is still unknown. We now speak of those mental operations which are excited through the necessary agency of the spinal cord, viz. sensations. 20 DISEASES OF THE NERVOUS SYSTEM. We apply the term sensation to certain changes with which we are familiar, and which are attended with consciousness. Some physiologists have extended this term to various changes not attended with consciousness; but such vagueness of expression cannot be too carefully avoided. When a sensation is created from an impression made upon any of the organs of the body, as wlien the rays of light fall upon the retina, it is effected in the ^ following manner:—1. An impression is produced on the ex-" panded filaments of the optic nerve. 2. The influence of this impression is conveyed by the trunk of the optic nerve to the brain, and carried upwards by means of some of the diverging fibres. 3. Some change is produced in the brain (most probably in the gray matter) of which the mind becomes conscious; or, in other words, a sensation is felt. The property possessed by cer- tain nerves of receiving those impressions which excite sensation, is generally termed sensibility. The impressions so made pass along the sensiferous nerves, and are conveyed upwards to the brain by the middle columns of the spinal marrow; and if we are conscious of these impressions, sensation is produced. This sensation, when once excited, may suggest various circumstances connected with the properties and relations of the objects of the external world, by which the impression is caused; and this con- stitutes perception. For the existence of sensation, therefore, it is necessary, 1. that the expansion of the nervous filaments should possess sensibility; 2. that the fibres in the nerves and spinal marrow should be enabled to transmit impressions; and lastly, that the mind should become conscious of such impressions. It is obvious, therefore, that however we may be led to refer the sensation felt to the extended filaments of the nerves upon which the impression has been made, yet this sensation actually takes place in the brain. As it is only by motion, however, that we are enabled to detect the existence of sensation in others, it was for a long time supposed that the movements in decapitated ani- mals, which often resemble those dictated by volition, were con- nected with sensation. But by adopting this opinion, it is neces- sary to admit two centres of sensation; a view which the writings of Le Gallois tended principally to inculcate, but the fallacy of which is apparent when we metaphysically examine our own thoughts. Every one feels internally convinced that when he is sensible of an impression, he must be conscious of it, and at once sees the absurdity of supposing that an animal can be conscious of an impression, when the brain, in which the intellectual facul- ties reside, is removed. These various actions, therefore, must depend upon circumstances distinct from the possession of sensa- tion and volition, and, as we have before explained, are purely spinal. From what has been said it appears that two sets of medullary fibres are capable of transmitting two nervous influences in dif- General Observations. 21 ferent directions. That originating in the brain from volition is transmitted downivards to the muscles to produce motion, and that originating in the expanded filaments of the nerves is trans- mitted upwards to produce sensation. In connection with this subject it may be necessary to remark, that impressions made upon the different sensiferous nerves are not capable of exciting all the various kinds of sensation indis- criminately. Thus it has been proved that impressions made upon the optic nerve can only excite one kind of sensation—that of light. When the retina is pricked or. torn, a sensation of a flash of light is experienced, but no pain. It has also been shown that although the brain is the seat of sensation, yet its substance may be cut, torn, or burned, without producing any indication of suffering, or any convulsive movement; proving that however capable the medullary fibres may be of transmitting the influence of sensitive impressions, they cannot originate them. It is only when injuries of the encephalon extend down to the cranial por- tion of the spinal cord, that pain or convulsions are excited; proving the difference in function of these two parts of the ence- phalon. From what has preceded it appears that we are enabled phy- siologically to separate with tolerable distinctness the functions of the brain and spinal cord, and in those which depend upon both refer to each the part it respectively performs in their mani- festation. Thus the brain, acting alone furnishes the conditions necessary for intelligence; the spinal cord acting alone furnishes the conditions necessary for the co-ordinate movements necessary to the vital functions; and the brain and spinal cord acting toge- ther furnish the conditions necessary for voluntary motion and sensation. Before concluding this sketch of the physiology of the nervous system, it is necessary to allude more particularly to that class of movements which appear habitually to be independent of nerves, and yet are occasionally influenced through them. We allude to the continued movements of the heart, the peristaltic actions of the stomach and intestines, &c. The Hallerian doctrine concerning muscular contractility ap- pears to be the one most consistent with facts; namely, that this property is inherent in the muscular fibre itself, and is not neces- sarily called into action through the medium of the nervous sys- tem, but only by the application of an appropriate stimulus to the muscular fibres themselves. Thus the blood which flows into the cavities of the heart is the natural and habitual excitant of that organ; while the muscular fibres of the intestines are called into contraction by the direct excitation of the ingesta contained in their interior. The experiments of Le Gallois and Dr. W. Philip, however, have shown that sudden extensive injuries either of the spinal cord or brain destroy the contractility of the 22 DISEASES OF THE NERVOUS SYSTEM. heart, and bring the circulation to a stand; while, on the other hand, both these organs may be removed or gradually destroyed without arresting the heart's action, provided artificial respiration be maintained. It has been further proved by Dr. VY. Philip, that injuries inflicted upon the substance of the brain, though not sufficiently extensive to arrest or even materially impair the con- tractility of the heart, may yet prove rapidly fatal by destroying the functions of the medulla oblongata, and consequently arrest- ing the respiration. It has also been shown that extensive inju- ries inflicted upon any part of the nervous system, as when a limb is severely crushed, will seriously impair the contractility of the heart. These facts, however difficult they may be to explain, are of the greatest value in the study of disease. III. There are certain circumstances in the animal economy which must always be taken into consideration before we attempt to reason correctly on nervous affections. The most important of these is the nature of the circulation within the cranium. The brain is circumstanced very differently from any other organ: in a state of health it entirely fills an unyielding case of bone, by means of which, all atmospheric pressure, or any other disturb- ing cause is prevented, except such as is communicated through the blood-vessels, which enter it. No doubt can exist that the substance of the brain is incompressible by any force that can be conveyed to it from the heart through the arteries; and it is im- possible that the quantity of blood circulating in the vessels can be materially increased, unless something give way to make room for the additional quantity; and in the same manner the amount of blood cannot be diminished unless something enter to supply the place which had become vacant. The quantity of blood, therefore, circulating in the brain in a state of health is always exactly the same, and distributed in certain proportions between the arterial and venous vessels. These views, which have been ably advocated by Dr. Abercrombie, result from the experiments of Kellie, Monro, and Carson, who found that in animals bled to death, although every other part of the body was blanched, the brain alone retained its normal quantity of blood; but when an opening was made into the cranium, so as to place its contents in the same relation to atmospheric pressure as other organs, it became blanched in the same manner. The work of Dr. Abercrombie offers so many arguments in favor of this view as to render it extremely probable that a healthy state of the brain depends, as he expresses it, upon a just proportion of blood being maintained in the arteries and veins distributed through its substance. But when this equilibrium is deranged, it appears evident that pressure is produced on some part of the brain, for, although the organ itself is incompressible, the numerous vessels which traverse it would, under such circumstances, be differently General Observations. 23 acted on; the calibre of some would be diminished, and that of others increased, and the dilatation of the latter would necessarily induce the exercise of an unaccustomed degree of pressure on the nervous tissue with which they were in contact. As far as the explanation of morbid phenomena, therefore, is concerned, the terms " change of circulation within the cranium" and " pressure on the brain" are synonymous, as the one cannot take place without the other. Another circumstance to be alluded to is, that the functions of the brain and spinal cord, although different in their nature and effects, are similarly connected with those portions of the nervous system which furnish the conditions necessary for their manifes- tation. They are all capable of being perverted, increased or diminished by the same external or internal stimuli, or by the same morbid actions. Thus the too long continued application of a stimulus produces irritation; this causes excitement of the part to which it is applied, and the effect is an exaltation of the function dependent on that part. If, on the other hand, instead of irritation, destruction of the part be occasioned, or a certain amount of increased pressure be applied to it, instead of an aug- mentation,a cessation of the particular function will ensue. Irregu- larity of the heart's action, or any thing that tends to disturb the equilibrium of the circulation within the cranium, produces these different effects, and they are more or less marked according to the degree of disturbance occasioned. An increased circulation of blood produces a rapid flow of ideas, sometimes delirium at- tended with tinnitus aurium, and other disturbances of sensation, augmented muscular action, convulsions, &c. If it continue or become greater, profound coma, or an arrestment of these func- tions, follows. A diminished flow of blood is known to occasion similar results; viz. convulsions, various disturbances of sensation, and of the intellect, terminating in syncope or a suspension of the functions of the nervous centres. The intelligence is influenced by exactly the same causes, and becomes disordered from an in- crease or diminution of the natural stimuli. Excesses in diet and in intoxicating drinks produce mania, and a like effect has been occasioned by too scanty an allowance of food. We see, there- fore, that incipient disease or irritation, by means of moderate or partial pressure on any portion of the nervous system, more im- mediately connected with motion, sensibility, and intelligence, produces excitement of that part, followed by an increased or augmented action, but that complete pressure or destruction of the part on which each respectively depends, causes total loss of either. When any portion of the motor or sensitive tracts have been destroyed, paralysis occurs in all the parts furnished by nerves which arise below the injury. This may result from pressure or disease affecting the whole diameter of the tract. As the tracts 24 DISEASES OF THE NERVOUS SYSTEM. diverse within the cranium, there is less liability here for the whole diameter to be involved; hence we meet with cases of large chronic abscess in the cerebral lobes, disease of the corpora striata, &.c, without corresponding disturbance, and with other instances where death has taken place, and, contrary to all ex- pectation, the brain has been found extensively diseased. In these cases large portions of brain have been lost by interstitial absorption, a process to which cerebral substance is liable in com- mon with the other textures, and which prevents the effects of pressure. Thus, if the distension and pressure be gradually ap- plied, the power of accommodating itself to circumstances which the brain so far possesses, will prevent any great disturbance of the functions belonging to the healthy portion, until the disease has reached a certain extent, when its effects are manifested. The functions of the nervous centres, however, are almost invariably destroyed, if sufficient pressure be suddenly applied; and that the pressure is the disturbing cause, is placed beyond doubt by the recovery which takes place on this cause being removed. Should this affect that portion of the tract in which the fibres are con- veyed and concentrated, more fatal results follow; hence the well marked and immediate effect of lesions in the pons varolii and medulla oblongata. It is evident that a knowledge of the above general law is of the utmost importance, more especially when connected with the result of physiological researches. For if the opinions with re- spect to the brain and spinal cord formerly alluded to be correct, much of the obscurity which surrounds this subject will be dis- pelled. At all events, we consider that the present state of ana- tomical, physiological, and pathological knowledge, fully war- rants our adopting such opinions as explanatory of the effects of disease. Here, however, much caution is necessary, for each of these methods of inquiry, as respects the nervous system, is pecu- liarly liable to fallacy. We need not point out "the deceptions which a minute inquiry into the structure and arrangement of the nervous tissue may occasion, or the numerous objections that exist to experiments on the lower animals, especially where the brain is concerned. The post mortem appearances found after death, which are by many considered sufficient to explain functional alterations, are in many cases quite incapable of throwing any light on the symptoms, and, as data for pathological conclusions, are often most fallacious. This will readily be granted by those practically acquainted with the difficulties of distinguishing a natural from an unnatural degree of softness; the impossibility in many cases of determining what amount of vascular congestion is to be denominated a morbid lesion, or in deciding the bounda- ries between the sound and diseased tissue. Again, certain mor- bid conditions may be present during life, and yet leave no traces of their existence after death. Does a knowledge of this fact en- General Observations. 25 able us to deduce the cause from the effects? This may also lead to much error, but, if the conclusions are consonant with the united facts of anatomy, physiology and pathology, this method of reasoning will perhaps enable us to approximate as near the truth as the state of medical science will permit. Congestion within the cranium, for instance, will occasion pressure on the brain as well as a depression of bone, or an extravasation of blood; but who can calculate the amount or extent of such pressure ex- cept by its results? If, therefore, it has been demonstrated that slight pressure causes increased action, and complete pressure loss of function, and if pain, convulsions or delirium, manifesting the former, or loss of sensibility, motion, or consciousness demon- strating the latter, be present, while after death no structural dis- organisation can be discovered that will otherwise account for such symptoms, are we not authorised to conclude that a state of congestion has occasioned partial or complete pressure on those portions of the nervous system which furnish the conditions ne- cessary for intelligence, sensation, and motion? We answer this question in the affirmative, for by such means only is it pos- sible to give a rational explanation of the phenomena of nervous affections. Hence we have been led to divide all nervous dis- eases into four classes, the Cerebral, Cerebro-Spinal, Spinal and Neuro-Spinal, according as the brain, spinal cord, or nerves ap- pear to be either alone or jointly concerned in producing the essential symptoms which distinguish one from the other. < It has been observed by all pathologists, that the same train of symptoms has been caused, not only by different degrees of in- tensity in the same lesion, but by the various lesions to which the nervous centres are liable. Now as the morbid appearances observed after death are so different, although they give rise to the same symptoms during life, we cannot ascribe these to the nature of the organic alteration, but must attribute them to some- thing which all these changes have in common; and it appears to us that they all act in one of two ways, either of which is suf- ficient to produce the morbid phenomena, namely, by pressure, with or without organic change ; or by destruction of the part from disease. Pressure, it has already been stated, is occasioned by a change in the circulation, and, in many cases where organic alterations have been discovered, it is presumable that these do not act merely by their presence, but because they render the nervous centres more liable to be affected by such causes as pro- duce this change in the circulation. Were it possible to regulate pressure or organic change, so that the portion of the brain engaged in the manifestation of the mental faculties might alone be influenced, delirium, coma, and mental derangement might be produced without affecting the sensibility and power of motion. In this case, there would be no disposition to move, but spasmodic action might be induced by the applica- 3 26 DISEASES OF THE NERVOUS SYSTEM. tion of stimuli. In like manner, were it possible to circumscribe pressure or disease to the motor or sensitive tracts, we might cause loss of motion without loss of sensibility, or convulsions and paralysis, while the mental faculties and sensibility remained perfect. In some rare instances this is the case ; but the gradual manner in which the various portions of the brain are lost in each other, together with their proximity and consequent liability to participate in disease, sufficiently explains why, in the generality of cases, impairment of motion, sensibility, and intellect, are more or less produced together. It may be thought by some, that the opinions here advocated are too mechanical, and that we are not warranted in ascribing to pressure so many of the morbid phenomena that are presented. No doubt the activity of the brain is considerably modified by the quality of the blood distributed to it; the tissue also of Which it is composed is liable to structural and constitutional differences like every other. But these circumstances of themselves, how- ever they may predispose to disease, cannot be supposed to pro- duce those marked effects which may be occasioned and dissipated with so much rapidity, or which are confined to one part of the nervous system and not to others. The fact also that tumors and other organic alterations are not liable to any sudden change, while the principal feature of many diseases they are supposed to occasion is their paroxysmal character, renders it highly probable, if not certain, that the more immediate cause must be attributed to some temporary local, or general, congestion of the nervous centres, a pathological condition which may often exist in the living subject, and leave no traces of its existence after death. While, therefore, innumerable facts prove that pressure is capable of producing, all the phenomena, and that this pressure may take place without leaving any appreciable lesion, we conceive our- selves warranted in attributing to this cause and to structural dis- organisation, the generality of those symptoms which distinguish diseases of the nervous system. 27 INFLAMMATION OF THE BRAIN. Preliminary observations.—Precursory symptoms of cerebral inflammation.—■ Cerebral determination and congestion.—Cerebral congestion from debility and inaction.—Cerebral irritation, determination, and congestion, in infants and children.—Inflammation of the dura mater.—Meningitis.—Acute menin- gitis.—Varieties.—Phrenitis.—Meningo-cerebritis.—Hydrocephalic.—Ana- tomical characters of meningitis.—Chronic meningitis.—Cerebritis.—Acute general cerebritis.—Acute partial cerebritis.—Chronic cerebritis.—Inter- mittent inflammation of the brain.—Anatomical characters of cerebritis.— Softening.—Suppuration and abscess.—Ulceration.—Induration.—Compa- rative frequency of the several forms of cerebral inflammation.—Predisposing causes.—Diagnosis.—Prognosis.—Treatment of the several forms of cerebral inflammation. The diseases of the brain are, at the present moment, more obscure than any other great class in the nosology. Twenty years ago, the same was said, and with truth, of the diseases of the lungs and heart; but the elucidation and corroboration of the general symptoms by the physical signs derived from auscultation, percussion, &c, have reversed the proposition, and not only re- deemed these diseases from their obscurity, but actually rendered their diagnosis more precise and certain than that of any other important class. There are no physical signs applicable to the brain; and, from the circumstances in which the organ is placed, it is to be feared that none will ever be discovered. Our diagnosis, therefore, must rest upon physiological and pathological induc- tions ; and, if inductive signs vary much in more simple organs, in consequence of mere variation of circumstances, they must be, and actually are, infinitely more variable and complex in reference to the brain, an organ of great structural complexity, discharging multifarious and most important functions, and connected by the finest relations with all the other parts of the system. Still, phy- siology has done much, and is every day doing more, to dissipate the obscurity of the diseases of the brain; and we may rationally anticipate that our knowledge of them will sooner or later be greatly simplified and extended, though it will never, perhaps, obtain that physical precision and certainty which we enjoy with respect to the diseases of the chest. It is a duty, therefore, con- sidering the importance and extent of the class, to prosecute the investigation with unremitting assiduity and with cheerful antici- 28 INFLAMMATION OF THE BRAIN. pations of the future. Impressed with this feeling, we are dis- posed to encourage every attempt to unravel the several varieties of diseases of the brain, and to assign to each its characteristic symptoms. In doing this, however, we should be jealous of allowing the spirit of generalization to tempt us beyond the boun- daries of well ascertained facts, such a procedure being calculated to retard, rather than accelerate, the progress of science. Precursory symptoms of inflammation of the brain. The precursory symptoms of inflammation of the brain constitute seve- ral groups of affections so troublesome in themselves, so formida- ble in their consequences, and so frequent in their occurrence, that we need no apology for dwelling upon them at considerable length. The subject will be distributed under the several heads of, 1. Cerebral determination.and congestion; 2. Cerebral con- gestion from debility and inanition; 3. Cerebral irritation, determination, and congestion, in infants and children. 1. Cerebral determination and congestion. When blood flows in preternatural quantity to the head, in consequence of increased arterial action, either general or local, the state is designated by the epithet, " cerebral determination," or, popularly, "flow of blood to the head." When the active determination exceeds a certain point, the blood, not being carried off by the veins as rapidly as it is introduced by the arteries, accumulates in the lat- ter system of vessels; probably, we think, with a slight increase of the total amount within the head, and constitutes the state de- nominated, " active cerebral congestion." When, on the con- trary, an accumulation takes place, not from preternatural arterial determination, but either from deficient contractile tone of the cerebral capillary vessels, whence they do not propel their con- tents with sufficient freedom on occasions of ordinary accelera- tion or excitement of the circulation; or from a mechanical im- pediment to the return of the venous blood from the head, as a tight cravat, a tumor in the neck or chest compressing the de- scending veins, valvular disease, dilatation with attenuation, soft- ening, or any other form of obstruction to the circulation through the heart, the state is then denominated " passive congestion " and its seat is principally in the veins and their sinuses. It was formerly supposed that the symptoms connected with these three states of active determination, active or arterial con- gestion, and passive or venous congestion, were dependent on the simple circumstance of an increased quantity of blood existino- in the head. But it was shown by Dr. Kellie, that when animals were bled to death, the head invariably remained as full of blood as natural: whence he inferred that the cranium, on the syphon principle, was always necessarily full of blood, and that, from the assumed incompressibility of its solid contents, it could not admit any additional quantity. Hence, the followers of Dr. Kellie have Determination and Congestion. 29 explained the symptoms of the above diseases on a different prin- ciple ; namely, that when either the arterial or the venous system of vessels is congested, the opposite system is compressed and depleted, whence there results an obstruction to the circulation through the brain, and consequent disturbance of its functions. Though we have reason to suspect that experiment will hereafter prove the brain to be capable of admitting a small additional quantity of blood, we, notwithstanding, entertain no doubt of the general accuracy of the above explanation, as no other equally accounts for all the phenomena. In accordance with this view, then, it may be stated in general terms, 1. That the symptoms of active determination are those of excitement or exaltation of the cerebral functions; since there is increased arterial action, yet not congestion enough to obstruct the circulation and occasion the opposite train of symptoms. 2. That the symptoms of active or arterial congestion are those of depression of the cerebral functions; because, here, the disease has proceeded to the extent of occasioning an obstruction to the circulation through the brain. 3. That the symptoms of passive or venous congestion are likewise those of depression of the cere- bral functions; because, here also, there exists an obstruction to the circulation. Now, the three states in question are often the precursors both of inflammation of the brain, in any of its forms, and of apoplexy and palsy; nor can we always determine, in individual instances, why they conduce to the one rather than to the other; but we think it true, as a general rule, that increased determination, implying augmented arterial action, is equally productive of inflammation and of apoplexy and palsy; while con- gestion, especially the passive form, is more allied to apoplexy and palsy than to inflammation. Sometimes the nature of the exciting cause determines whether the premonitory symptoms shall issue in inflammation or in apoplexy: thus, stooping may occasion apoplexy, while mental excitement may induce inflam- mation. So formidable are these consequences, whether of one kind or the other, that the states conducing to them must be looked upon as serious maladies; and it is important to the stu- dent to know that, in practice, he will encounter an incompara- bly greater number of "determinations" and "congestions"—in other words, of precursory symptoms, than of actual inflamma- tions, apoplexies, and palsies. The symptoms of active determination (and they indicate ex- altation of the cerebral functions) are, tension, or decided head- ache, with throbbing of the temporal arteries, generally increased by the horizontal position; vertigo, especially on stooping; heat of the head, with flushing of the face, blood-shot eyes, and ex- cited or animated countenance; ringing, stunning, or rumbling noises in the ears; impatience of ordinary sounds, as the rustling of silk or paper; impatience of light, with scintillations and other 3* 30 INFLAMMATION OF THE BRAIN. optical illusions; general nervous excitability, so that trifling causes, as unexpectedly meeting a friend, produce agitation, wakefulness and unsound sleep, with dreaming and starting; restlessness and unwonted irritability of temper, occasionally with depression of spirits and undefined dreads; incapability of sustained and vigorous attention; pulse commonly full, though, in the very plethoric, we have often observed it weak and op- pressed. In general, it is slightly accelerated. Not unfrequently there is palpitation, and occasionally angina cordis, leading the patient to imagine that he labors under disease of the heart. Such are the symptoms of active determination. They are identical in their nature with those of the first stage of acute meningitis, being merely less in degree; and it sometimes requires the utmost attention and discrimination to determine when the inflammatory action really commences. For the criteria, the reader is referred forward to the first stage of meningitis. When determination proceeds to active or arterial congestion, or when the disease is originally passive or venous congestion, the symptoms (which now bespeak depression, instead of exalta- tion, of the cerebral functions) are as follows: there may or may not be headache, but there is always a sense of fulness and great weight in the head, the patient sometimes comparing it to a ton of lead, a millstone, &c. This is occasionally attended with a feeling of coldness of the head, and, in severe cases, especially of venous congestion, the temperature is often actually reduced. There is vertigo, sometimes faintness, and more rarely nausea. The eyes are dim and watery and the eyelids purplish; the veins of the forehead are sometimes visibly turgid; the cheeks, nose, ears, and lips, are purplish in the naturally florid, and rather livid in the naturally pale, the intermediate parts being pale and sal- low. The countenance is dull and depressed; the sight is defec- tive, so that the patient can seldom read small print, and there are sometimes dark moats floating before the eyes, double or bick- ering vision, and occasionally transient blindness. The hearing is obtuse, often with rumbling and rushing noises. There is op- pressive drowsiness when awake, and sleep at unusual hours; frequent yawning; dejection and apathy of mind; intellectual sluggishness; confusion of thought, and sometimes momentary unconsciousness; diminution or loss of memory—especially for- getfulness of words, names, and spelling, and the substitution of one name, word or letter, for another; corporeal lassitude; aching of the limbs; and, in severe cases, cramps, twitchings, numbness, formication, paralytic feebleness, with a vacillation and stumbling gait; indistinct, trailing, or hesitating articulation; difficulty or "stiffness" in opening and shutting the eyelids; sometimes tran- sient loss of sensation and voluntary motion. The pulse is weak oppressed, or sluggish (/. e. tardus), often slower than natural' and occasionally unequal. Such are the symptoms of congestion. The whole are not to Determination and Congestion. 31 be expected in every case, and frequent variations in intensity are observable at different times. The more urgent symptoms of diminished sensibility and intellectual power, with the more considerable muscular phenomena, are wont to occur in par- oxysms of a few minutes' or hours' duration only, the patient being comparatively comfortable, though far from well, during the intervals; and these intermissions, with other symptoms,indi- cate that the disease is still congestion, and not yet what may be strictly considered apoplexy—still less, inflammation. The duration of the symptoms of cerebral congestion is very variable. Some patients experience a single attack only; others have attacks at long and irregular intervals, often in connection with some obvious and adequate exciting cause; in some, we have known the attacks recur annually in the spring; in females, we have frequently seen the symptoms return regularly at the catamenial period, during consecutive years, especially when the secretion was scanty and the patient of full habit, or a free liver. In others, again, we have known more or less of the symptoms, with occasional paroxysms, subsist continuously, not only for several months, but even for a series of years, and issue sometimes favor- ably and sometimes the reverse, the result being very much de- pendent on the nature of the causes, whether remedial or not. In females, at the period of catamenial cessation, we have frequently known the symptoms continue from two to six or seven years, and then completely subside. Andral mentions a case in which a man was not exempt from one or other of the symptoms for a single day during thirty years. In the more severe cases, especially the congestive, there gene- rally supervenes, as a consequence of the cerebral affection, a greater or less degree of derangement of the stomach, bowels, and liver, to which, indeed, we have often noticed the patient disposed to ascribe the whole of his symptoms. The truth is, that there subsists an intimate connection between the cerebral and chylopoietic systems, and derangement of either seldom con- tinues long, without more of less disturbance of the other—a fact which will be more fully developed in the article Cephalalgia. The diagnosis between active determination and active or arterial congestion is formed by the symptoms in active determi- nation being those of exaltation of the cerebral functions, the reverse being the case in congestion. When the states are pass- ing into each other, there will be a temporary mixture of the symptoms. It is common for patients subject to determination to experience occasional paroxysms of congestion. Active or arterial congestion is distinguished from passive or venous by the precedence, in almost all cases, of some symptoms of active determination, and often by the intermixture at intervals of sypmtoms of cerebral excitement with those of depression. A plethoric, youthful, and robust state of the patient also favor 32 INFLAMMATION OF THE BRAIN. the diagnosis of active congestion. The converse series of cir- cumstances indicate passive or venous congestion. There are cases, however, in which the two forms are so nearly allied and the circumstances so mixed, that the diagnosis requires the most careful consideration. The diagnosis of active determination from meningitis is formed, as already hinted, by a comparison of the symptoms and causes of the two, to which the reader is referred, as our limits do not here permit the institution of a long comparison. The same may be said of the diagnosis of either variety of congestion from cerebritis and from apoplexy. With regard to the prognosis, active determination is in gene- ral easily curable, unless its predisposing cause be of an organic or otherwise irremediable nature, or unless the patient be intract- able under treatment, especially with respect to diet, regimen, intellectual exertion, and exciting causes in general. Still, the disease is serious; because it may suddenly issue in inflammation or apoplexy, or, if neglected, may lay the foundation of perma- nent cerebral "delicacy," impaired intellectual capacity, and de- rangement of the general health. The prognosis of active and passive congestion is, for the same reason, still less favorable, though the diseases of themselves seldom compromise life. The particular prognosis in individual cases depends much on the predisposing cause. Thus, if it be organic disease of the brain, valvular disease of the heart, a tumor in the chest, or other irre- mediable cause, the ultimate prognosis is unfavorable, and vice versd. The anatomical characters of the subject under consideration are important, though it was formerly little understood. Active determination is never fatal of itself; but, from its occasionally existing at the time when other diseases prove fatal, as fevers, &c., it is ascertained to be attended with increased florid vascu- larity of the brain and its membranes, without any other change except occasionally a little serous effusion, probably an exudation after death from the gorged vessels. But though the effects of active determination are seldom witnessed after death, those of congestion, both active and passive, are not unfrequently seen; for the patient sometimes dies suddenly from the supervention of congestive or "simple" apoplexy, and the morbid appearances, under these circumstances, are only a higher degree of the con- gestive condition which immediately preceded the fit. Further, venous congestion is frequently seen in fatal cases of organic disease of the heart attended with great obstruction to the circu- lation; and in those who die of cold, or of apnoea, whether occa- sioned by drowning, strangulation, diseases closing or greatly obstructing the air passages, opium or other narcotics, tetanus fixing the muscles of respiration, or any other cause of deficient respiration. Determination and Congestion. 33 It may be premised as a fact now fully established, that a pa- tient may die with symptoms of congestion from any of the above causes, yet, after death, not a vestige of any morbid condition in the brain may remain. The refrigeration of the blood, and its accumulation in the great vessels, has removed all appearance of increased vascularity. In the great majority, however, the con- gestion is greater than can be removed by these causes, and preternatural injection consequently remains. Its appearance differs somewhat, according as it is active or passive. Active or arterial congestion is characterised by a rather more florid tint both of the membranes and the cerebral substance, and by less considerable engorgement of the great veins and sinuses. In short, as the congestion commences on the arterial side, it is more in the capillaries and less in the great veins; and this is, without doubt, more decidedly the case during life, because, sub- sequent to dissolution, the arteries, by their tonic contractility, propel the greater part of their contents into the veins. Passive or venous congestion, on the other hand, is characterised by a darker tint of the capillaries and a greater engorgement of the large veins and sinuses, especially when it commences in the latter and is propagated retrograde to the capillaries. In extreme cases, the appearances are exceedingly marked. Thus the scalp, on division, yields a stream of dark blood; the sinuses and large veins are gorged, and an unusual degree of dark ramiform vas- cularity is exhibited by the capillaries of the pia mater. The denuded surface of the hemispheres presents a preternaturaily dark tint, and, when the organ is divided, its substance, both cortical and medullary, especially the former, displays an extraor- dinary degree of dark venous speckling, occasioned by the pre- sence of colored blood in the naturally colorless capillaries; and when this speckling is removed by wiping, it is quickly repro- duced by a new exudation from the divided vessels. In some cases, especially those connected with organic disease of the heart, cyanosis, emphysema, and fatal polypus, the general tint, even of the medullary substance, is so lowered as to be represented on paper by a delicate wash of neutral tint. Dr. Bright has pub- lished a plate exhibiting the darkest tint of this kind that I have witnessed. Serous effusion, in small or moderate quantity, is a frequent associate of congestion, both active and passive; being the natural mode by which, as in ordinary dropsies from obstruction of the circulation, the gorged vessels disburden themselves of their unnatural load. The relief is sometimes so complete, that all appearance of preternatural congestion is entirely removed; and such cases, when fatal, were formerly denominated serous apo- plexy, under the erroneous supposition that the serous effusion was the only morbid phenomenon. Abercrombie showed that it was merely a consequence of previous congestion, and that it 34 INFLAMMATION OF THE BRAIN. was not, as imagined, confined to the aged and debilitated, but incident to all ages and constitutions. The causes, both predisposing and exciting, are identical with those of inflammation of the brain and of apoplexy, to which we refer the reader for details, contenting ourselves here with a brief general enumeration. The predisposing causes are, scrofula, hereditary irritability of the nervous system, early age, advanced age, the sanguine temperament, especially with violent temper or passions; habitually excessive intellectual exertion; stooping pro- fessions, as gardening, which cause atony of the cerebral vessels; previous attacks of determination or congestion leaving similar atony; plethora; hypertrophy of the left ventricle, with or with- out dilatation; obstructions to the circulation through the heart from valvular disease, dilatation or softening; excrescences from the cranium; obliteration or undue contraction of a sinus; tumors in the brain. The exciting causes are, febrile diseases, especially the exanthematous—some of which, particularly variola, scarla- tina and rubeola, may be preceded, as well as followed or at- tended, by the congestive paroxysm; intermittent fever or " masked ague," which may occasion intermittent fits of con- gestion; injuries of the head; irritation or inflammation, acute or chronic, of the mucous membrane of the stomach and bowels— particularly in children; dentition; worms; bilious accumulations —an exceedingly frequent cause of headache, with nausea; sup- pressed natural evacuation, and suddenly or otherwise injudi- ciously checked morbid discharges; immoderate meals; too free and stimulating a diet, especially in the sedentary and naturally plethoric; intoxication; exhaustion from fasting; over-fatigue, &c; atmospheric electricity, as before a thunder storm; a relaxing south-west wind; sudden mental emotion or great intellectual efforts; loud noises; violent corporeal exertions in the predis- posed; the act of stooping; tight ligatures round the neck or trunk; the epileptic fit, of which the subsequent drowsiness pro- ceeds from congestion; hot weather and insolation; still more, cold weather and intense cold; sudden transitions from hot to cold weather, and vice versd; opium, hyoscyamus, belladonna, camphor in large doses, tobacco, strychnia. In the treatment (which it may be proper to state has no reference, in the present section, to cases resulting from debility and inanition, nor to those of children,) the first object should be to relieve the immediate symptoms. Venesection or cupping should be promptly employed, and the practitioner should not be unwarily scared from this important measure by the feeble, slow, and oppressed state of the pulse in congestive cases, especially if occurring in plethoric or otherwise robust subjects; for the pulse generally rises when the cerebral oppression is relieved by the bleeding. As a general rule, from 3xii to xx, drawn in the erect position, will suffice for the first abstraction, the larger Determination and Congestion. 35 quantity being suited for active congestion in young, robust and plethoric subjects; and the smaller for mere determination and congestion in weakly subjects, or of the passive form. Immedi- ately after the first bleeding, the patient should be actively purged. If the congestive symptoms threaten an immediate fit of apoplexy, a strong purgative enema is the most expeditious means. Infus. Sennse Co. gviij, magnes. Sulph. §i, 01. Ricin. |j, and |viij of warm water, will generally suffice. If Infus. Sennae Co. is not at hand, Extr. Coloc. Co. Bij, rubbed up with viij of water, may be substituted. Simultaneously, a full dose of calo- mel and Extr. Coloc. Co. or of croton oil, should be given by the mouth, and should be followed, in two hours, by a black draught repeated, if necessary, so as to procure six or eight copious evac- uations. If immediate relief be not afforded by the first bleed- ing, the speedy immersion of the feet, up to the knees, in hot water rendered stimulant by mustard, and the simultaneous application of an ice-cap on the head, are remedies of great power in protecting the head from apoplexy or inflammation— the former by acting as a derivant, and the latter by constricting the cerebral vessels. If, by the time that the purgatives have freely acted, the congestive symptoms should not be satisfactorily relieved, or even earlier, if they strongly menace an apoplectic paralytic or convulsive fit, 3viij to xii more of blood should be drawn from the nape, temples, or ears, by cupping; a measure which we have generally observed to be more efficient than a second bleeding from the arm. Meanwhile, the head and shoul- ders should be kept well raised, even during the night; the head should be kept cool by an evaporating lotion and the occasional use of ice, and cool fresh air should be freely admitted into the room. By calomel and colocynth, followed by neutral salts, five or six liquid motions should be procured daily for a week or ten days, except in the passive congestion of weakly subjects, for whom two or three motions will suffice. If, however, there be bilious accumulations, mercurial cathartics may be employed even in the latter class of cases, the bile being a far greater irri- tant than the remedy. The diet should not at the utmost exceed white fish, thin broth, and farinaceous articles, for a week or ten days, and, in the plethoric and robust, farinaceous mucilages and bread are sufficient. Thin veal or chicken broth is a bland diluent, highly suitable for bilious cases. The means now detailed will generally succeed in removing the immediate attack of determination or congestion; but, for the eradication of the disease, it is requisite also to dissipate the predisposing cause, and the measures will differ according to its nature. Thus, if general plethora, whether connected with a naturally plethoric tendency, or a too full and stimulant diet, or both, be the exciting cause, the depleting treatment already commenced 36 INFLAMMATION OF THE BRAIN. must be prosecuted in a moderate degree for several weeks, or even months, according to the effect. The blood-letting may require to be repeated to the extent of gviij to xii once, twice, thrice, or more, at intervals of two to six weeks, according to the indications in each case. A few patients feel languid and more confused in the head after the loss of a quantity so small even as that specified. In these cases we have often found the abstrac- tion of two to four ounces of blood, by cupping, round the occiput and ears, once a week or less, produce the desired effect without inconvenience. Probably, a part of the benefit is to be ascribed to the counter-irritant effect of the scarifications. In cases of suppressed bleeding from piles, the application of leeches to the anus sometimes affords more relief than depletion from the head itself; and, in the far more common cases of suppressed cata- menia, occasioning cerebral determinations and congestions, we have often found the application of six or eight leeches to the groins, at each period, not only afford satisfactory relief, but also restore the natural secretion. Together with abstraction of blood, moderate aperients should be employed, so as at first to procure two or three evacuations daily, and afterwards one or two. If the evacuations be dark, offensive, and of green or orange tinge, indicating bilious accumulations, mercurial aperients should be employed with vigor till these appearances have ceased. The patient should long continue on a diet of broth, fish and fowl, and should return to animal food by taking it on alternate days exclusively. It is also highly beneficial to restrict him to as small a quantity of liquids as is consistent with his comfort, as they readily cause vascular repletion, and sometimes, according to our observation, completely counteract the effect of the other means. It is needless to say that all stimulant potations should be interdicted. Active, though not violent, exercise should be enjoined on the plethoric and sedentary, and an immoderate indulgence in sleep should be strongly discountenanced. The head should be kept cool by having the hair closely cut and by sleeping without a nightcap. During convalescence, the habit of washing the head every morning with cold water, or the use of the shower bath, is sometimes eminently useful by giving tone to the cerebral vessels. If hypertrophy of the heart be the predisposing cause of the cerebral affection, active exercise should be rigidly interdicted; and a dangerous mistake in this respect is apt to be made by those who are inattentive to diseases of this organ. On the same principle, mental excitement, and any other cause of acceleration of the circulation, should be carefully avoided. Bleedings to about Ivi every three to six or eight weeks, moderately low diet as meat on alternate days only, mild aperients, and the occa- sional use of digitalis, hyoscyamus, prussic acid, and hop, must be continued with uncompromising regularity for a year or more Determination and Congestion. 37 till the hypertrophy is cured; care being taken that this tranquillis- ing system be not carried so far as to increase the palpitation by inducing anasmia. If the predisposing cause be venous retardation, as from val- vular disease or dilatation of the heart, tumors in the neck, chronic disease of the lungs, &c, after relieving the immediate symptoms of cerebral congestion, the practitioner must turn his attention to curing or palliating the primary diseases as far as is practicable; but it may be remarked, in general terms, that such cases do not admit of considerable depletion. Intermittent headachs from malaria are, in general, readily cured by large doses of quinia, or this combined with arsenic; and, as the patient often becomes anaemic, the strong prepara- tions of iron should be given in the sequel. In obstinate and protracted cases of all kinds, a series of blis- ters, or an issue or seton on the nape, are valuable auxiliaries. In cases attended with dyspeptic and biliary derangement, we have often found that country air, especially of the clear, dry, bracing kind, seemed indispensable to the completion of a cure, the patient always retrograding on a return to town. 2. Congestion from debility and inanition. This affection comprises a much larger number of cases than is commonly sup- posed; and we think that it has been greatly overlooked, imper- fectly understood, or too cursorily noticed, by professed writers on diseases of the head. As its treatment is almost diametrically opposed to that of the preceding varieties, and as it therefore requires to be carefully distinguished from them, we have as- signed to it a separate section, for the purpose of giving it the utmost possible prominence. The patient generally represents himself to labor under a " flow of blood to the head;" a prepossession strongly favored by the frequent " rushing noises" in his ears, and throbbing of the tem- poral arteries: he is therefore astonished and somewhat incredu- lous when informed that his condition is the precise converse of an increased determination; namely, a deficient circulation through the head, dependent on debility and innutrition, and leading, for reasons which will presently be explained, to venous congestion of the organ. The symptoms are a moderate degree of those of congestion which have been already enumerated. They occasionally, how- ever, proceed so far as to occasion, not only numbness, formica- tion, twitching, and paralytic debility of the muscles, but even slight delirium, epileptiform convulsions, and coma. For instance, three patients fell under our care in 1837, who had each experi- enced a single epileptic attack, but who have subsequently been exempt from the malady. This class of cases may easily be recognised by the patient 4 38 INFLAMMATION OF THE BRAIN. being decidedly pale; this character, in the naturally florid, exhi- biting itself on those parts of the face which are properly desti- tute of high color, while the redness on the cheeks is dimmer than natural; by the paleness being attended with loss of flesh in most, and by muscular flabbiness in all; by the pulse being small, weak, and slow, during periods of calmness; but, as the patient is morbidly excitable and nervous, it is readily accelerated by slight causes, and is then attended with the feeling of palpitation; by the headach being referred principally to the courses of the great sinuses, especially where they traverse the occipital bone; by an unusual degree of languor and muscular debility; by the patient probably stating that he had repeatedly been bled, and always felt worse after it; finally, by the existence of some cause of deficient nutrition, as protracted dyspepsia, dribbling piles of old standing, menorrhagia, abortion, leucorrhoea, immoderate lactation, over-exertion, whether mental or corporeal; deficient, innutritious, or unwholesome diet, especially abstinence from animal food, to which females of the higher class are much ad- dicted; damp, confined, dark air; and, in short, any other cause of anasmia. The pathology of this affection has been differently viewed. M. Andral, after citing cases of excessive loss of blood and of ordinary chlorosis, presenting the symptoms characteristic of the various forms of cerebral congestion, expresses his opinion that they are referrible to " a state the entire opposite of congestion; in other words, anasmia." " We must admit," he pursues, " that the brain is disturbed in its functions, because it is not suitably stimulated or nourished by the too poor or too thin blood which the heart sends to it." (Clin. Med. torn. v. p. 300.) This may be partly true; but we venture to think that the able writer quoted has not, in the present instance, arrived at the whole truth. We believe that there is really venous congestion in the cases alluded to, originating, perhaps, in the unfilled state of the arteries, so well manifested by the jerking pulse; whence, as the cranium, on the syphon principle, must necessarily be always full, the veins acquire a predominant degree of repletion, and eventually obstruct the circulation through the organ. The fact of congestion, whatever be the theory, rests on strong evidence. Dr. Kellie found the veins and sinuses of the brain gorged in ani- mals which he had bled to death. M. Andral himself cites a case of fatarcerebral hemorrhage in a patient at La Pitie, who labored under the highest degree of anEemia from uterine hemor- rhage connnected with cancer! Nor is this case by any means solitary. In instances of patients who have died comatose the large veins and sinuses have been found gorged, either with or without serous effusion, while the cerebral substance was remark- ably pale. In a few cases, serous effusion alone has been found- when, as shown by Abercrombie in reference to " serous" ano- Determination and Congestion. 39 plexy, there is the strongest reason to believe that the dropsy was merely a result of previous congestion, which it had entirely removed. Again, the symptoms of anaemic congestion are re- markably relieved by the horizontal position and by stimulants, which promote the afflux of arterial blood to the head, and thus tend to restore the equilibrium of the circulation. This explanation applies to several degrees and aspects of the same affection; and it is desirable to keep these varieties in view, in order that we may clearly discern the analogy which prevails throughout the whole class. Thus, a slight degree of congestion constitutes the never-failing headach of chlorotic females; a higher degree is the form of which we are at present treating; a still higher degree results from more rapid and powerful exhaust- ing agencies, as sudden and excessive loss of blood, profuse diar- rhoea, energetic antiphlogistic treatment for acute inflammations, &c. The latter, when affecting infants and children, has been denominated spurious hydrocephalus, or, more recently, by Drs. Gooch, Hall, Abercrombie, &c, the hydrencephaloid disease; a truly important distinction, as it differs from real, that is, inflam- matory hydrocephalus, no less in treatment than in pathology. As it is often confounded with inflammation of the brain, we' reserve it for consideration in a corollary to that part of our sub- ject, in order that the distinction may be rendered more promi- nent by direct contrast. IVeatment. Congestion from debility and innutrition, if ex- empt from organic or other serious complication, is so easily and promptly curable, that, as the patient is usually in a very dis- tressed condition, the practitioner generally acquires great credit by his cases. Supposing that there be urgent symptoms of cerebral irritation or congestion immediately threatening apoplexy, epilepsy, or inflammation, the legs should be speedily immersed in a foot-bath f(which is improved by mustard); cold may be applied to the head, if it be hot; a strong purgative enema should be administered, and be followed as soon as practicable by an active cathartic by the mouth. Should the symptoms resist and create alarm, the pro- priety of abstracting four to six ounces of blood by cupping or the application of leeches, or, what is still better, by opening the jugular vein, may be considered; for there is no inconsistency in employing a local depletion to relieve a local congestion, even while we are supporting or stimulating the system at large; and we have met with a small proportion of cases in which this treat- ment not only seemed to be indispensable, but was followed by speedy relief. It should, however, be resorted to reluctantly, and with the utmost circumspection, the depletion being suspended, if the abstraction of a small quantity of blood should not answer the object. As a general rule, we prefer relieving the paroxysm on the 40 INFLAMMATION OF THE BRAIN. principle of derivation as now described, this mode being the safest and most scientific. But when the paroxysms come on very fre- quently, and, especially, when they pass speedily into epileptic fits, we have used volatile diffusible stimulants internally, in a great number of cases, with signal success. Liq. Ammoniae in doses of twelve minims, in three ounces of water, or Aq. Menth. Virid. with syrup, we have found beyond comparison the most efficient formula; the epileptic fit, unless of organic origin, seldom failing to be averted by it, provided the medicine be taken at a single draught on the first warning of the attack. On commenc- ing the use of this or any other diffusible stimulant, the practitioner would do well to feel his way with a smaller dose, and personally watching its effects. If favorable, the patient may be entrusted with a draught, to carry constantly on his person, and take on any emergency. Supposing the case not to present any immediately urgent symptoms threatening a fit, after clearing out the alimentary canal, and cleaning the tongue, if furred, by one, two, or more gentle mercurial cathartics, the practitioner may proceed at once to the use of tonics. Animal food, slightly under-dressed, should be given to the extent of at least three to six ounces, twice a day, at breakfast and dinner; an interval of seven or eight hours being interposed, as full meals of animal food are not well assimilated at shorter intervals. The appropriate and never-failing tonic is iron; but, unless the alimentary mucous membrane be in a per- fectly healthy and unirritated condition, we have found it better to premise the use of a draught composed of infusion of cascarilla and sesqui-carbonate of ammonia (gr. v), or something equivalent, thrice a day, for three or four days. If by this time the stomach and bowels have been brought to a satisfactory state, the practi- tioner may proceed at once to iron. He may feel his way for a- day or two by moderate doses, and then proceed as speedily as possible to full quantities. We feel assured that the great utility of iron is overlooked by many, in consequence of its being admi- nistered in too small doses and for too brief a period. After mak- ing special comparative observations on the effects of the several preparations of the metal in a hundred cases each, we have found that the stronger preparations, and full doses, are the most effica- cious, and that the duration of a course should extend over a month at least. No preparation has appeared to us superior in power to the well-known Griffith's Mixture (Mist. Ferri Co.). Of this, ten drachms may be conjoined with from one to three drachms of Decoct. Aloes Co. the latter not only rendering it lighter to the stomach, but insuring one free alvine evacuation daily, which is always necessary to prevent the too stimulant action of iron on the head. It may be given thrice a day, one or two hours after meals, as, on an empty stomach, it occasionally creates nausea. The same preparation in a solid form, namely, the Pil. Ferri Co! Determination and Congestion. 41 may be given in an equivalent dose of gr. x to xv thrice a day, provided the pills be recent and soft. The Pil. Aloes c. Myrr. may be simultaneously used as the aperient. Other efficient prepara- tions are, the Ferri Sesquioxyd. in doses of 3ss to 3iss thrice a day; the Ferri Sulph. in doses of gr. ij to iij, dissolved in a light bitter, thrice a day, and the Tinct. Ferri Sesquichloridi, in doses of Tttxv to 3ss, at similar intervals. These measures should be seconded by much fresh bracing air out of doors, with amusing, but not fatiguing exercise. Whilst they are in operation, the coun- teracting agency of any known predisposing or exciting causes should be suspended to the utmost that is practicable. Chronic hemorrhages, as menorrhagia, bleeding piles, &c. should especially be checked. If the former be merely a passive hemorrhage from anaemia and debility, cold astringent injections and the horizontal position, with the internal tonics already mentioned, will gene- rally suffice for the cure. Bleeding piles may generally be checked by injecting a pint of cold water, with or without an astringent, daily, after the morning evacuation, aloetic aperients being avoid- ed, or so much softened with treacle or soap as to insure their com- plete solution in the upper bowels. If these means fail, the expe- diency of surgical assistance should be promptly ascertained by an examination of the rectum. When there is no special counteracting cause of an intractable nature, the patient is generally well within a period varying from three to six weeks; more commonly the latter. If towards the end of convalescence, and subsequently, after the omission of the iron, aperients should continue to be requisite, those which con- tain a tonic are incomparably the best; as aloes with sulphate of iron, rhubarb with columba, &c; the tonic appearing to increase the peristaltic action.* * The treatment of congestion of the brain should be decidedly anti-phlo- gistic, with bleeding and smart purging in those cases in which there is evi- dence of active excitement, a strong or at least tense pulse, and permanently flushed face. If the pulse be not strong, (we do not mean if it be merely quick and jerking,) or if the flush of the face be very bright in tint, and transient in duration, general bleeding is invariably productive of ultimate mischief. It relieves for a time, but reproduces the tendency to the disease. The same re- marks are applicable to severe purging. The best means of treatment consist in the avoidance of the exciting causes, in repeated cold affusions upon the head, mild counter-irritants, as frequent mustard foot-baths, or dusting the stockings with cayenne pepper and laxatives enjoined with tonics. The re- peated cold affusions as suggested by the author, by means of a stream of cold water, allowed to fall slowly upon the head for several minutes at a time, is one of the most efficacious remedies. The frequent predisposing cause of the disease is a derangement of the alimentary canal; hence an infusion of a drachm of rhubarb with three or four drachms of gentian, and two of the carbonate of 4* 42 INFLAMMATION OF THE BRAIN. 3. Cerebral irritation, determination, and congestion, in infants and children. In infants and children, inflammation of the brain is generally, yet not invariably, ushered in by precur- sory symptoms. To these the attention of the student cannot be too strongly drawn; since, though occasionally arising without obvious cause, they ordinarily constitute that familiar group, com- pounded of derangement of the stomach and bowels, with irrita- tion of the brain, which he will be perpetually witnessing as concomitants of excessive or unsuitable feeding, of dentition, of ascarides or other worms, and of derangement of the liver; a group which the inattentive are apt either to regard as wholly foreign to the brain, or hastily to mistake for confirmed hydroce- phalus. The cerebral symptoms are sometimes those of excite- ment, and sometimes, on the contrary, those of depression; not unfrequently, they are mixed. We shall first sketch the respective classes, and subsequently advert to their nature and causes. Amongst the symptoms of excitement, evincing morbidly ex- alted sensibility of the brain, one of the first circumstances that usually strikes the attention, is, unaccustomed peevishness and restlessness, with indifference to previously amusing objects, and a vacant, abstracted air and expression, as if the little patient were preoccupied by his own uneasy sensations. In infants, the fretfulness is in many instances only to be soothed by perpetual gestation in the nurse's arms. The external senses are inordi- nately affected by ordinary impressions. The hearing is pain- fully alive to every sound; an unexpected touch with the finger, as in feeling the pulse, often causes starting and fretfulness; if the head be directed towards the window or a candle, it is impatiently averted, with frowning and winking; the pupils are frequently, though not always, contracted, in consequence of the sensitiveness of the retina; and the conjunctiva, from increased arterial action in the head, is occasionally injected. Headach is generally expe- rienced, and is by elder children made a subject of complaint, while infants evince it by tossing, rolling, or putting the hand to the head. Wakefulness is a prominent symptom, the child seldom even dozing, and its imperfect slumbers being broken from time to time by starting and crying. Muscular phenomena are not unfrequently manifested: in infants there is a more or less fre- quent clenching of the fist, with the thumb drawn to the inside; a drawing back of the head, with stiffness of the neck; and occa- sodaor potassa, is often an excellent remedy; it is rendered more agreeable to the stomach. The chalybeates are of course best fitted for the anaemic cases. If the repeated attacks of cerebral congestion be treated by blood-letting, as often as they recur, the case is sure to be exasperated, and at last is removed with great difficulty; for the abnormal distribution of the blood is renewed upon the slightest recurrence of a disturbing cause. Determination and Congestion. 43 sionally a drawing back or opisthotonos of the whole spine, with rigid extension of one or both legs. We have even known these phenomena to occur when there were very few other manifest symptoms. In elder children, there is grinding of the teeth dur- ing sleep, distortion of both eyes upwards and outwards, and sometimes squinting. Convulsions are common to all ages. The symptoms of depression, evincing diminished sensibility of the brain, are characterised by the little patient being deficient in animation. Though not asleep, he lies in a drowsy state, indifferent to surrounding objects, occasionally moaning, gaping, and sighing, and irritably fretful if aroused; when more decidedly awake, he is languid, grave, pensive, silent, abstracted, and pee- vish ; any sleep which he obtains is disturbed and unrefreshing; there may or may not be headach, vertigo, confusion. The ex- ternal senses seem obtuse rather than the reverse; the face is often pale and sunk, sometimes with occasional flushes; the gait is feeble, and, when the disease is on the verge of inflammation, the patient, as G'olis remarks, " in stepping forward, raises the foot as if stepping over a threshold—he totters and staggers as if drunk." The two classes of symptoms above described—of excitement and of depression—sometimes coexist in a greater or less degree; in which case exaltation of the external senses is conjoined with the dull drowsy state. Whatever be the aspect of the cerebral symptoms, they are in general attended with more or less of a febrile movement, and of derangement of the alimentary canal. The pulse is accelerated, and it sometimes, especially in the cases attended with drowsiness, already exhibits an incipient degree of that oscillating inequality in speed and strength, which constitutes one of its most charac- teristic features in decided cerebral inflammation. The respira- tion is accelerated in proportion to the pulse, and is sometimes unequal and suspirious, as in confirmed inflammation. The skin is rather hot and dry; the nose and lips are dry and subject to itching, whence the child picks them—a sign often, but incorrectly, considered peculiar to worms. The tongue is white or yellow, often with red papillae at the point and edges, and there is, in dif- ferent degrees, thirst, a defective, voracious, or capricious appetite, nausea, vomiting, and fcetor of the breath. The bowels are either costive, or loose and griped, the excrements in the latter case being almost invariably mucous, and either green, black, or pale, sour and frothy. The abdomen is tumid and tense—often slightly tender on pressure. The duration of the above precursory symptoms may be from a day or two to several weeks; but, sometimes, they are observed for a few hours only, or they do not exist at all, the child being abruptly seized with convulsions, and other marked signs of established inflammation. The immediate cause ox pathology of the affection consists in 44 INFLAMMATION OF THE BRAIN. an irritation of the brain, occasionally arising without any cause that we can detect, and sometimes dependent on the excitement of precocious talents, but far more frequently propagated from the peripheral extremities of the nerves exposed to the primary irritation of teething, derangement of the alimentary mucous membrane, disease of the liver, surfeit, worms, &c. The cerebral irritation, there is every reason to presume, is attended with active determination and congestion of the organ, a state short of inflam- mation, but on the confines of it, and ready to make the transition at any moment, if not adequately checked. Terminations of the precursory symptoms. It is the opinion of some that the class of symptoms denoting excitement is pre- monitory of inflammation of the membranes and surface, while the class denoting depression threatens inflammation of the cere- bral substance and central parts. We have, however, so fre- quently seen each disease follow either class of symptoms, that we should hesitate to venture a diagnosis founded on such grounds. We should rather be disposed to think that the symptoms of ex- citement are dependent on active determination, and those of depression, on the ulterior state of active congestion, while the mixed symptoms are connected with a fluctuation between the two states. On this point, however, there is a want of direct and positive evidence. The character of the inflammation in which the premonitory symptoms issue depends greatly on the constitution, temperament, and general health of the patient. Plethoric children, of florid sanguine temperament and healthy constitution, are apt to be affected with sudden and violent in- flammation, especially of the membranes and cerebral surface, but sometimes of the ventricles and centre's, with or without effusion. This constitutes the "rapid" hydrocephalus of Cheyne, the " tumultuous" of Golis, the " ataxic" of Guersent, and the " in- flammatory" of Hopfengartner:—for writers on hydrocephalus assign this name of a symptom to every cerebral inflammation of children, whether there be " water on the brain " or not. On the other hand, feeble, puny, delicate children, especially those of scrofulous constitutions and belonging to families in which hydro- cephalus has prevailed, usually present the low and protracted form of precursory symptoms and of cerebral inflammation ; the congestive, and subsequently the inflammatory, action being of a much less active kind. This constitutes the "gradual" hydro- cephalus of Cheyne, and the " nervous " of Hopfengartner, because it commences like a low nervous fever, and it is of much more frequent occurrence than the rapid or any other variety. When the constitutional state and powers are modified by ex- isting or late exanthemata, pertussis, fever, &c. precursory symp- toms are rarely distinguishable ; the inflammation either making a sudden burst, or stealing on occultly till it has made dangerous Determination and Congestion. 45 progress. This is the " secondary" hydrocephalus of writers in general; and, when rapidly fatal and attended with serous effu- sion, it constitutes the water-stroke (wasserschlag) of G'olis. If the reader wish to study the precursory symptoms now described in immediate juxta-position with those of actual in- flammation, he is referred forward to the Symptoms of acute Meningitis. Treatment of the precursory symptoms in infants and chil- dren. From the extreme frequency of these symptoms, and the great magnitude of their possible consequences, the treatment is of such importance that we offer no apology for dilating upon it rather beyond our prescribed limits. The very first manifestation of suspicious symptoms ought to arrest as much attention as if inflammation actually existed; for it must not for a moment be forgotten, that the invasion of the latter is sometimes instantane- ous, and in other cases so insidious, as to elude suspicion till the disease has made irreparable progress. If these circumstances be retained constantly in recollection, the treatment for the pre- cursory symptoms will be eminently successful. We have found that scarcely more than two or three cases per cent, have passed into inflammation. The gumsduring dentition demand the first attention. Wherever they are red and tumid, they should instantly be divided by an incision down to the tooth, and sufficiently long to liberate its whole edge: in the case of double teeth, the incision should be crucial, so as to liberate the four corners. We have never found the slightest inconvenience, but greatly the reverse, result from repeating the operation once or even twice a week, if, after its first performance, there was a recurrence of redness and swelling; for the mere circumstance of bleeding the gums often affords immediate and surprising relief. In the employment of scarifica- tion, the practitioner will often find himself opposed by a popular prejudice against a supposed "hardening of the gums" from the operation. They who entertain this notion are unacquainted with the principle on which scarification is practised. The grand source of irritation resides, not in the gum itself, but in the mem- brane immediately investing the tooth, which, formed out of cellular tissue becoming progressively denser and tighter in pro- portion as it is more and more stretched by the enlarging tooth, eventually attains an exquisite degree of painful tension. When once this is fairly divided, it retracts so completely as ever after to be incapable of reuniting. It is the division of this membrane, therefore, which constitutes the great source of relief: if the superincumbent gum heal, any supposed induration of it is of little moment: the part has only to be divided again as often as it becomes inflamed. It is astonishing how much mischief this simple operation will prevent. The stomach should be the next object of attention. If there 46 INFLAMMATION OF THE BRAIN. be reason to suspect that it is charged with a load of undigested food (and this may be apprehended if there is no other assignable cause for a sudden appearance of the precursory symptoms, and still more if any indiscretion in diet can be detected) an emetic should immediately be administered. From r^xx to 3J of Vin. Ipecac, according to the age, may be given every ten minutes to infants under a year old, till vomiting is excited: after a year, the dose may be doubled. The powder is slower in its operation. Tartar emetic sometimes exerts a dangerously sedative influenoe on children under two years of age: later, it may be safely used, but as a mere evacuant it is less certain than ipecacuanha. Glasses of warm water should be perseveringly administered after every act of vomiting, so long as the water is returned with any intermixture of the contents of the stomach. The whole process may be greatly expedited by titillation of the fauces with the finger or a feather. This effectual evacuation of the stomach will, with few exceptions, immediately remove all the symptoms, if they originated merely in a surfeit: still, to make sure, it is well to add an aperient, to scarify the gums, if red, and to reduce the diet for two or three days. Supposing there be no reason to suspect a surfeit, the attention should next be directed to the bowels. They should be com- pletely evacuated with all possible promptitude; for detained faeces, whether indurated or of acrid irritating quality, may alone occasion all the symptoms. A child of aet. 2. may take Rhei Pulv. gr. vi, with Hydrarg. cum Creta gr. iv, or Hydrarg. Chlorid. gr. i vel ij, a lavement of half a pint of warm water, with 01. Ricini gij, being simultaneously administered. In an hour and a half, 01. Ric. siij may be given by the mouth; and, if the body should not have acted freely at the expiration of four hours, the lavement and powder may be repeated. If ascarides be sus- pected, the lavement should contain gij, or iij, of 01. Terebinth. Purif.; and as much may be given, with mucilage, &c, by the mouth, instead of the castor oil. The head, meanwhile, should be kept cool, by interdicting caps, cutting the hair if abundant, allowing a free access of cool fresh air, and applying an evapo- rating lotion if the heat be considerable and the cerebral symp- toms urgent. By this combination of means, the more alarming features of the case will generally be removed in a few hours— so soon, in short, as the medicines have fully acted. If the child be attacked with convulsions, after scarification of the gums, he should, without loss of time, be immersed up to the shoulders' for five to fifteen minutes, according to the age, in a warm bath at 98°, with the trunk in the erect position, and a cold lotion or ice should simultaneously be applied to the head. The bath by dif- fusing the blood over the surface, withdraws it from tfie head while the cold application co-operates by constricting the cerebral vessels. If a warm bath cannot speedily be procured, a thin Determination and Congestion. 47 stream of cold water should be directed from an elevation of two or three feet on the vertex, which will often be attended with immediate success. This remedy, to which Abercrombie is very partial under the present circumstances, is perhaps equally effi- cacious as the warm bath, and certainly more safe; for the bath, if at too high a temperature or continued too long, especially in plethoric children, may be directly detrimental; and we account for this on the supposition that, when the whole blood of the body is expanded, and the circulation accelerated by the heat, the cerebral congestion is increased. The temperature, therefore, and duration of the bath, should always be so regulated as, with the assistance of cold applications, to prevent the face from be- coming flushed. In the case of plethoric children, we should not trust to the bath alone; but should, either previously or during the immersion, draw blood from the jugular vein, or, in infants, by means of leeches. It must be clearly understood that we have hitherto been speaking of acute convulsions, from a state of the brain short of inflammation, yet verging upon it: if the prac- titioner judge that inflammation has actually taken place, the treatment now prescribed must be followed up by that for acute meningitis. Under no circumstances of precursory symptoms should narcotics of any description be employed: though recom- mended by some, our personal experience is strongly opposed to them; they are never necessary, and always dangerous. But though the above means may succeed in removing the urgent symptoms within a day or two, let not the practitioner imagine that he has yet cured his patient. If the bowels have been deranged for some time, as a week or more, we feel certain, from ample observation, that a complete cure is only to be ef- fected by a course of alterative aperients, with antiphlogistic diet and regimen; for such a state of the alimentary mucous mem- brane as that in question—a state of irritation and active conges- tion, not unfrequently passing into inflammation—demands, not Only appropriate treatment, but a certain length of time for its effectual cure. Hydrarg. cum Creta gr. ij, with Cretae Praeparatae gr. iij, should be given every eight hours to infants between one and two years old: under or beyond this age, the dose may be proportionably diminished or increased. For the first three days or so, the bowels should be cleared of morbid secretions and accumulations by 01. Ricini 31, or if necessary 3ij, every morning: afterwards, its administration every second morning is generally sufficient. If, from the first, the bowels be very loose, that is, moved four or five times a day or upwards, the proportion of Creta Praeparata should be increased to gr. v or vi, the dose of castor oil should not, if possible, exceed ^i, or it may be wholly replaced by an emollient lavement; and a warm bath, which has a highly soothing effect on the irritated or inflamed mucous membrane of children, may be employed once or even twice a 48 INFLAMMATION OF THE BRAIN. day. In proportion as the evacuations become less mucous and green, the powder should be less frequently given, as twice, and eventually once a day, a diminution which can ordinarily be commenced within a week. The Hydrarg. cum Creta should be wholly omitted at the end of a fortnight, lest it induce ptyalism; but it may be resumed in three or four days, if required, provided its constitutional effects have not been manifest on the gums. The object and action of the above medicines are as follow:— The Hydrarg. cum Creta is alterative and aperient; the creta praeparata. is useful as an antacid absorbent, which does not form an aperient compound. Some are in the habit of conjoining with them gr. ij to iv of Sodas Carbonas Exsiccatus as an antacid (the dried form being preferred merely because less bulky); but we have satisfied ourselves that, by making an aperient compound, it purges and gripes. Many are in the habit of giving calomel instead of Hydrarg. cum CretS. We do not object to an occa- sional dose, especially in older children, when the body is costive and not likely to yield to Hydr. cum Creta; but we entertain strong objections to it as an habitual purgative or continued alte- rative, because it often occasions violent irritation, inflammation, and occasional invagination—evils which the practitioner erro- neously ascribes to the severity of the disease. One of the great- est improvements, indeed, in the modern treatment of children, consists in the banishment from practice of the immoderate use of calomel, jalap, scammony, and other drastic purgatives, under the circumstances in question; as the disease, though often dis- guised under the inappropriate appellations of infantile remittent fever, worm fever, weaning brash, thrush, &c. is really only va- rious degrees and forms of active congestion and acute or chronic inflammation of the mucous membrane of the alimentary canal, a disease always exasperated by active purging, stimulants, and narcotics, and as constantly relieved by mild antiphlogistic treat- ment and alteratives. The object of the castor oil is to sweep away the morbid and acrid fasces, which are more irritating than the aperient used for their removal: but the latter would also irritate if exhibited in too large and frequent doses: therefore emollient lavements are employed as a soothing auxiliary. In young infants, if magnesia will suffice, it is preferable even to castor oil. Colic pains, indi- cated in infants by sudden screaming and retraction of the le«*s, are seldom experienced in any considerable degree when the above mild treatment is pursued; but they are common when pungent irritating aromatics (as the Pulv. Cretae Co. instead of Creta Praep.) are given, with the mistaken view of obviating them. When violent, they require to be relieved, and we have found no medicine answer this object more safely and effectually than the following prescription of the late Dr. Hooper, employed in the St. Marylebone Infirmary:—R. Magn. Carb 9j Tinct Determination and Congestion. 49 Card. Co. n\xx, Aq. Anethi gss. Of this one or two teaspoonfuls may be given to infants eight months old, once or even twice a day, when there are violent returns of pain. The tincture should be omitted if there be inflammation, or even considerable irrita- tion, of the mucous membrane, indicated by frequent mucous evacuations. Warm fomentation and the warm bath are well known auxiliaries in all cases of colic. Diet, meanwhile, re- quires the most rigorous attention; if this be neglected all other means are unavailing. It should be constantly kept in mind and impressed on those to whom the care of infants and children is intrusted, that unsuitable feeding—giving food too often, solid food too soon, and inappropriate food at all—is the prolific parent of half the maladies of infants and young children. An infant at the breast, affected with the precursory symptoms in question, should be stinted in diet: though suckled at the usual and proper intervals of two and a half, or three hours, (with an interval of five hours during the night,) it should not, as usual, be allowed to satiate itself. If fed by the hand, its diet should be entirely liquid, and should invariably be sucked out of a bottle, through a leather or perforated parchment, yielding it so slowly as to require about three acts of suction for every one of deglutition— a process which, as it is adopted by the infant at the breast, is accordant with nature, and explicable on sound physiological principles. Asses' milk generally agrees best with young in- fants; but, in its absence, two parts of barley-water or of water arrow-root with one of milk, (increased to half as the infant improves,) forms the best substitute. When convalescence is well advanced, and the infant is emaciated, the liquid food may be thickened twice a day by a rusk, pulverized and reduced to jelly by affusion of boiling water, which may afterwards be partly removed by pressure through linen. " Farinaceous" foods are suspicious; as they generally consist of bad arrow-root made worse by adulteration with potatoe-starch, &c. Infants, and children above the age of a year and a half, who, from having double teeth, had previously been allowed to par- take of solid food, should be reduced to a liquid farinaceous and milk diet. The practitioner will find great difficulty in stemming the importunities of friends and nurses to countenance a prema- ture increase of diet before the bowels are restored to a healthy state, the appearance of " weakness" being, to lookers on, the most alarming of all symptoms. Duty as well as common sense requires the medical man to be inflexible. When the infant or child is sufficiently well to go out, it should have abundance of fresh air; and, even in cold weather, this may be permitted to a much greater extent than is commonly imagin- ed, provided the child be sufficiently clothed. There is no species of pampering worse than that which confines a child to the house on a cold day, when a layer of flannel would not only render him 5 50 INFLAMMATION OF THE BRAIN. as independent as the wind which he dares not face, but would protect him from that constant chilliness within doors, the sedative influence of which is even more pernicious than temporary ex- posures without. That young animals do not thrive well, and that they exhibit a great mortality, when unduly exposed to cold, has not only been demonstrated by the direct experiments of M. Edward, but might be proved, in opposition to popular prejudice, by reference to the statistics of the poor, as indeed has been shown by the statistics of M. Quetelet, in reference to about 600,000 cases. Plague, pestilence, and famine, have not perhaps slain more than attempted " case-hardening." But though adequate clothing will enable children and elder infants to go out in most weather, this does not apply to infants under six months old. The mere inhalation of very cold air in severe winter weather is injurious to them, and unless the face be kept covered with a strong double veil, they are safer in warm airy rooms within doors. By the means now indicated, the precursory symptoms of in- flammation of the brain may almost always be averted; and if infants be well managed from the first, such symptoms will com- paratively seldom appear. Early attention to them is especially requisite in families where hydrocephalus has already prevailed, and in instances where a child has received a blow on the head. In conclusion, if the cerebral symptoms should fail to be speedily relieved by the above treatment, the practitioner should examine, and balance with the utmost care, whether he may not resort to bleeding and other antiphlogistic measures, on the assumption that inflammation has actually taken place. This diagnosis is some- times one of the most delicate in the practice of physic. The pathognomonic symptoms are detailed under Diagnosis of In- flammation of the Brain. I. Inflammation of the Dura Mater. This is very rarely a primary or idiopathic affection. Dr. Ab- crombie, for instance, records only a single case of the disease in this form. It is generally secondary, and produced by disease of the cranium extending inwards, or abscess of the brain extending outwards. 1. One of the most common forms of disease of the cranium is dependent on ulceration of the bones of the ear, occurring prin- cipally in scrofulous children subject to a discharge from the ear, or to cutaneous sores around it. The ulcerative process, pene- trating the bones, at length reaches the dura mater, excites chronic inflammation, sometimes implicates the arachnoid and pia mater occasioning meningitis, mostly chronic, and then attacks the brain itself, and occasions abscess. It may be known that the disease commences in the ear by the purulent discharge taking prece- Inflammation of the Dura Mater. 51 dence of the cerebral symptoms. But there is another, though less numerous, class of cases, in which the disease commences in the brain, and, penetrating through the membranes, extends to the ear. These may be known by deep-seated pain and other cere- bral symptoms taking precedence of the purulent discharge from the meatus externus. 2. Disease of the nose, attended with ulceration of the aethmoid bone or frontal sinuses, and a purulent discharge, is another form of disease of the cranium, which may produce Ihe same effects as disease of the ear; and here, likewise, the affection of the nose is occasionally secondary to abscess of the brain. 3. Disease of any other part of the cranium, as, for instance, that resulting from syphilis treated by an excess of mercury, may produce a similar train of consequences; and several instances are on record in which such disease caused inflammation of the longi- tudinal and lateral sinuses, with coagulation of their blood, sup- puration of the coagulum, and fatal suspension of the cerebral circulation. 4. External violence may occasion inflammation of the dura mater by injuring or fracturing the bone. If, however, the blow produce concussion only, it does not follow that the dura mater shall be injured; for experience shows that it is more commonly the cerebral substance itself which suffers: abscess is frequently the result, and it may be seated remotely from the situation of the blow, though usually in one of the lines of direction in which its force has been transmitted through the brain. The symptoms of inflammation of the dura mater are very diversified, in consequence of the affection being variously com- plicated by inflammation of the arachnoid and pia mater and of the substance of the brain itself—complications which may im- part acuteness and activity to the disease in proportion to their nature and extent. As a general rule, however, inflammation of the dura mater is insidious and rather slow in its progress, ex- hibiting the phenomena of partial acute, or even of chronic cere- britis, rather than of meningitis. For instance, when the disease originates in the ear, the patient generally experiences pain, which is for several days regarded merely as an ordinary ear-ach. If discharge of matter, often foetid, take place, the practitioner is disappointed at finding that the pain, so far from being relieved by it, continues unabated, or even increases in violence. The patient becomes oppressed and drowsy, then slightly delirious, often with shivering, and at last comatose. In other cases, there is no discharge of matter; but the patient, after complaining for a day or two of deep-seated pain in the ear, becomes restless and forgetful, lies rolling his head from side to side, or tossing about his arms, and in a short time sinks into coma. In other cases, again, the affection supervenes upon a sudden cessation of a pur- ulent discharge from the ear, perhaps of some standing (such as 52 INFLAMMATION OF THE BRAIN. that which often follows scarlatina), or which may even have subsisted for many years. The sudden disappearance of the dis- charge, in these cases, is followed by pain in the ear; this, by languor and drowsiness, and in a few days by coma. The pulse is in some cases frequent, in others natural, and in others again below the natural standard. (Abercrombie.) When the pulse is quick and the case comes to a fatal termination within a week or two, more or less extensive inflammation of the arachnoid and pia mater may generally be expected; whereas, when there is little fever, and the case is protracted through several weeks, the disease, whether confined to the membranes or implicating the cerebral substance, will generally prove to be local and circum- scribed. The symptoms now described apply equally to inflammation of the dura mater when originating in the nose. Pain in the forehead, with purulent and often most offensive discharge from the nose, sometimes of many weeks' or months' duration, is at length followed by forgetfulness, delirium, and fatal coma, with or without fever and convulsions. When inflammation of the dura mater originates in sponta- neous disease of other parts of the cranium, the symptoms are essentially the same, but in their commencement they are more obscure and doubtful, because there is no discharge or other ex- ternal circumstance affording a clue to the nature of the affection. The difficulty is less when there is any lesion of the scalp, and still less after a blow on the head. From all that has now been said, the practitioner will see the importance of regarding even the slightest ear-ach with suspicious distrust, in reference to its possible consequences, especially if it be attended with an offensive purulent discharge of some dura- tion, indicating deep-seated otitis, and still more if that discharge be suddenly suppressed. He will anxiously guard against in- flammation of the brain, and watch for the first manifestation of cerebral symptoms. The same remarks apply to deep-seated in- flammation of the nose with ozena, "and of the eyeball or socket —an occasional, though more rare, source of inflammation of the dura mater. II. Meningitis. Before entering upon this subject, it is necessary to ascertain ex- plicitly to what membranes this term meningitis properly applies; as, on this point, some writers appear to us to have entertained inaccurate ideas, and to have refined beyond the limits of ascer- tained facts. MM. Lallemand, Parent and Martinet, have described inflam- mation of the membranes of the brain under the designation of arachnitis, contending that it is to the lesion of this membrane Meningitis. 53 that the symptoms are due. We cannot subscribe to this opinion. We believe that the symptoms are referrible, as much, nay pro- bably more, to co-existent inflammation of the pia mater, and, in many instances, of the surface of the brain itself, than to that of the arachnoid membrane alone; and we entertain this opinion, not only from much personal observation, but from an examina- tion of their own cases and many others on record. M. Georget, analysing the cases of MM. Parent and Martinet, says, that in almost the whole the arachnoid membrane was only slightly al- tered, especially if compared with the alterations of the pia mater and brain. For instance, the writers avow that, out of 117 cases, 48 presented alterations of the cerebral substance; also, that the redness of the arachnoid was ordinarily confined to a few points of the convexity or the base. Out of 52 cases, taken without selection out of the whole number, and particularly analysed by Georget, five only presented pus on the free surface of the arach- noid: on the other hand, in 3.2 instances, the pia mater was in- jected, and infiltrated either with blood, or with serous, san- guinolent, sero-purulent, or purulent fluid, even to the bottom of the convolutions; 26 times the brain was softened, particularly or generally; 13 times it was injected and speckled (sable) with blood, or infiltrated with this liquid, or very dense, &c. Again, most of Lallemand's cases of inflammatory softening of the brain are said to be complicated with arachnitis. But what is the arachnitis of which he speaks? It ordinarily consists of injections of the pia mater with blood, its infiltration with serous or puru- lent fluid, and its adhesion to the surface of the brain? Again, of six cases of chronic arachnitis recorded by Bayle, the only alterations of the arachnoid were, that divers points, especially of the convexity, were thickened, opaque, resistent, and whitish; whereas, there was serous effusion into the cavity of the arach- noid or into the ventricles, in all six; adhesion of the arachnoid (he means the pia mater) to the surface of the brain, which was softened so as to tear off with the arachnoid, in five; local altera- tion of an hemisphere, in one; pia mater red, injected, infiltrated with serum, in five; false membrance on the arachnoid, in two. Thus, in five of these six cases of reputed arachnitis, the pia mater was diseased, and in all six the surface of the cerebral sub- stance was seriously injured! Again, we have analysed the 16 cases of meningitis given by Abercrombie, and in all these was disease either of the pia mater, or of the surface or interior of the brain, or of both pia mater and brain; while the lesions of the arachnoid were comparatively insignificant. The cases of Golis, of Morgagni, and many others that we have examined, present much the same results. It, therefore, appears that injection or infiltration with blood, and serous, sero-purulent, purulent, and false membranous effu- sions, are incomparably less frequent and considerable in the 5* 54 INFLAMMATION OF THE BRAIN. arachnoid membrane than in the pia mater; and that disease of these membranes is very frequently accompanied with serious disease of the surface, and often of the interior of the cerebral substance. It is, consequently, a gratuitous assumption, wholly opposed by facts, to say, that the symptoms, in these cases, are wholly, or even principally, referrible to the state of the arach- noid membrane; and it is equally unsupported by facts to say, that arachnitis can be distinguished by symptoms from inflam- mation of the pia mater. For these reasons, we shall treat of the inflammation of these two membranes conjointly under the name of meningitis; and in doing this we are not singular, the same having been done by Abercrombie, Guersent, Quain, Copland, and most other recent writers. Another question arises as to whether meningitis can exist without exciting inflammation, or irritation, of the surface of the brain. We are disposed to think that it cannot; and this opinion is substantiated equally by a consideration of the physiology of the membranes, by morbid anatomy, and by symptoms. The distribution of the blood-vessels to the brain, as has been well pointed out by M. Georget, is peculiar. All other organs are more or less spongy and areolar; their vessels can penetrate them by trunks and branches; they are not enveloped in a vascular membrane like the pia mater; they need it not; the whole of their vascular system exists in their interior. But the brain is not spongy and areolar; no cellular tissue is there discoverable; its vessels cannot penetrate it by trunks and branches, nor even by twigs; they must penetrate it on every side, after having ramified and subdivided ad infinitum, on its whole surface, where they are sustained by cellular tissue, and disposed in a vascular membrane, which forms the immediate and universal envelope of the organ. Hence, as the membranes and the contiguous cerebral substance are supplied by the same vessels, it is impossible that inflamma- tory action occurring in the one should not affect the other, either by an extension of the inflammation itself, or by a propagation of its irritative influence. Now, this is precisely what is demon- strated by morbid anatomy. In the bulk of the case already quoted, it has been seen that the surface of the cerebral substance visibly participated in the inflammation of the membranes, and the increasing accuracy with which post mortem examinations of the brain are now conducted, brings the connection in question more frequently under observation than ever. Enlarged vessels penetrating the cineritious substance are now discerned which were formerly overlooked; and increased redness and softness of that substance are now appreciated as morbid, which were for- merly supposed to be healthy. Symptoms bring us to the same conclusion. There is acute pain, and there is high inflammatory fever, in meningitis, precisely as in inflammation of any other im- portant serous membrane. But this is not all; there is likewise Meningitis. 55 disturbance of the functions of the brain itself; there is perversion or abolition of the intellectual faculties, the external senses and the muscular powers; there is delirium or coma, convulsions or paralysis; and it is principally these morbid phenomena, exhibited by the brain itself, which constitute our indirect or intermediate guides to the detection of inflammation of the membranes; with- out them, it displays itself as little more than a febrile headach. The general truth of what has now been stated is not invalidated by occasional exceptions, occurring more especially in the aged, in whom morbid changes of the membranes are sometimes found after death, though the intellect, the senses, and the muscular powers, had not been materially deranged during life. If, then, the symptoms of meningitis be principally those of disturbed function of the brain, is it possible to distinguish it from inflammation of the brain itself? Dr. Abercrombie, indeed, re- solves this question in the negative. " Our knowledge," says he, " is not sufficiently matured to enable us to say with confi- dence what symptoms indicate inflammation of the substance of the brain, as distinguished from that of its membranes." M. Georget is so strongly of the same opinion that he treats menin- gitis and cerebritis as a single affection. We cannot, however, subscribe to the opinion of these able writers. Observation and numerous post mortem dissections lead us to think that, when extreme cases of the two affections are selected for consideration —when we place, on the one hand, meningitis with the least possible degree of inflammation of the surface of the brain, and on the other, cerebritis not implicating the membranes, the differ- ence between the symptoms is so marked, that the diseases can scarcely fail to be distinguished from each other by a discerning practitioner. But when the two affections co-exist, the one will so far modify the other, as in a great measure to neutralise the characteristic symptoms of each. Yet the compound or interme- diate character of the symptoms in such cases will sometimes indicate even the double affection, and a predominance of the one or the other may occasionally be inferred from the preponderance of its particular symptoms. We are far, however, from suppos- ing that these latter distinctions can be formed with certainty. The utmost length to which it is possible to go, is to establish more or less strong probabilities. Entertaining these views, Ave shall treat meningitis and cerebritis as distinct affections, and en- deavor to point out, under each, the manner in which it is mo- dified by the co-existence of the other. In this way, the com- pound affection, which is of far more frequent occurrence than either in the independent form, will, we think, be rendered more intelligible than if it were treated separately as a distinct variety. In this view we are countenanced by an analogy derived from the lungs. Pleurisy and peripneumony are always treated of separately; whereas, pleuro-peripneumony is not. 56 INFLAMMATION OF THE BRAIN. We now, then, proceed to treat of meningitis, repeating that this term is applied to inflammation of the arachnoid and pia mater conjointly, since the two membranes are almost always simultaneously affected, and the symptoms are not distinguisha- ble during life. Meningitis may be—1. acute, and 2. chronic. 1. Acute Meningitis. The symptoms present varieties, accord- ing to the part of the membranes which is the principal seat of the inflammation; according to its extent, its rapidity, the degree of its complication with cerebritis, the age, and the previous con- stitutional state of the patient. We shall first present the symptoms of the most common form, and subsequently point out the pecu- liar features of the several more important varieties. Precursory symptoms. These, as occurring in infants and children, and likewise in adults, have been already described. When the inflammation actually commences, there is sometimes more or less of a cold stage, indicated by chilliness or decided rigors, with cutis anserina, and paleness; then comes reaction, with fever, and the following symptoms : Symptoms of meningitis of the superior surface of the hemi- spheres. We assume this as the type, because it is the most com- mon form in adult subjects, though it occurs also in children. MM. Parent and Martinet, Guersent, Cheyne, and other practical writers, indicate three stages, presenting different groups of symp- toms. Any one of these stages, however, may be absent under circumstances which we shall explain as we proceed. They may also coalesce or alternate. The first stage is characterised by symptoms of increased cerebral excitement and exalted sensibility, dependent on aug- mented vascular action, short of the degree producing compres- sion; and it must be recollected that in most cases the inflamma- tion, and in all, its irritative influence is propagated to the conti- guous surface of the cerebral substance. The head is attacked with pain of the acute kind, often darting from part to part. It is referred principally to the forehead, temples, vertex, or occiput; and is attended with violent throbbing, felt more especially in the same parts. There is often also a feeling of diffuse tension and constriction around the forehead. The pain, though incessant, sustains exacerbations at brief intervals, which elicit from chil- dren a peculiar scream, well-known to observers as highly cha- racteristic of cerebral inflammation. After uttering this, the child either relapses at once into a drowsy state, in which he grinds and gnashes his teeth, or for a time rotates his head on the pillow, and saws the air with his arms, exclaiming "Oh! my head." The head, in children more especially, always seems heavy, since it falls back, as if by its own weight, when the patient is raised. There is usually vertigo. The head is hot, with diffused redness and more or less turgescence of the face; but sometimes the flush Meningitis—Symptoms. 57 is observed during the paroxysms of pain only, paleness prevail- ing during the intervals. The degree of color depends mainly on the natural complexion of the patient, whether florid or pale, and plethoric or not. In all cases, whether of adults or infants, the countenance presents an anxious expression, indicative of suffering. The eyes are often blood-shot, and there is great im- patience of light, with frowning in infants and children: to avoid it, indeed, the patient generally lies with the eyes shut, and impa- tiently resists every attempt made by the practitioner to raise the eyelid, even during sleep. The pupils are sometimes very much contracted, probably from the great sensibility of the retina, and sometimes they oscillate between contraction and dilatation ; but decided dilatation does not supervene till the next stage, when compression becomes more considerable. The ears are affected with tinnitus, and are so impatient of sound that the noise even of a light step in the room is sometimes intolerable. The mus- cles sometimes present slight twitchings of the face and eyelids; but it is seldom before the second and third stages that we see considerable convulsive paralytic affections. To this, however, there is one important exception in the stomach; for it rarely happens, especially in infants and children, that vomiting does not occur from the first; and it is apt to continue, sometimes at considerable intervals, but in children, often almost incessantly, during this and the following stages. In infants, we have often found it the first suspicious symptom, and therefore think that its cause should always be scrutinised with especial care. That this vomiting is cerebral, and not gastro-enteritic, is proved by the absence of pain and tenderness on pressure in the epigastrium, and of redness of the tongue, unless there happen to be a gastro- enteritic complication. Even in this case the vomiting is not so obstinate and frequent as in the cerebral affection. The mind evinces increased irritability; the manner of the patient being abrupt and hurried, and his answers brief, quick, and impatient. This state is compatible with somnolency, when he is not aroused; and such is particularly the case in children; but in adults the somnolency usual passes into constant wakefulness; and delirium, supervening with more or less rapidity, at length attains a high, and sometimes a furious, degree of violence. The symptoms hitherto detailed are principally connected with the functions of the brain; we now proceed to notice those de- pendent on the symptomatic fever. This fever, as resulting from inflammation of a serous membrane, is more or less violent, ex- cept in aged persons and feeble constitutions. The pulse is fre- quent, and it is usually full and hard, unless the subject be weakly or anaemic, when it is sharp. The respiration is accelerated very much in proportion to the speed of the pulse; but even at this early period, it often begins to exhibit the peculiarity of being irregular and suspirious, and therefore slower than would other- 58 INFLAMMATION OF THE BRAIN. wise accord with the pulse, the long sighs seeming to replace a greater number of brief respirations. Moaning not unfrequently attends the long expirations. The skin is hot and dry; the tongue is whitish, with clamminess and thirst; the bowels, in the gene- rality, are obstinately costive, unless there has been a previous inflammatory diarrhoea, which is not uncommon in children. The evacuations are usually dark and offensive, but " spinage stools" are not, as is supposed by old writers on hydrocephalus, either peculiar to, or characteristic of, cerebral inflammation. The urine is scanty and high colored, and in children, Guersent remarks, it is very sedimentous, from the large proportion of calcareous salts which it contains; as happens, indeed, in all diseases in which they void it seldom. Such are the symptoms of the first stage of meningitis of the upper surface of the hemispheres. Second stage. After the foregoing stage of excitement or ex- alted sensibility has subsisted for a period varying from one to three or four days, it is followed by the opposite condition, or of depression, with diminished sensibility, constituting the second stage. Of this it may be premised, in general terms, that it is more characterised by muscular affections, the convulsive class being dependent on cerebral irritation, which attains its maximum in this stage, and the paralytic class being referrible to cerebral compression, which supervenes a little later. It must be remark- ed, however, that convulsive affections are most [prevalent in inflammation of the base and ventricles of the brain, which in children frequently complicates meningitis of the convexity of the hemispheres. The symptoms of this stage in their order are as follows:—The delirium passes into drowsiness, and eventually into more or less complete coma. Though the headach continue, delirium or coma prevents it from being a subject of complaint, yet children continue to scream and toss the arms, as if instigated by pain. The flushing and heat of the head often continue through a considerable part of this stage, though the rest of the body become chilly, but they eventually give place to paleness, coldness, and sinking of the features. The eyes become morbidly insensible to light; the pupils continue to oscillate between con- traction and dilatation; but, as the coma advances, the dilatation becomes predominant and finally constant, contraction not being excited by the strongest light. Mr. Grainger is of opinion that immobility of the pupil indicates abolition of the "excito-motory" function by compression of the medulla oblongata; but that, when mobility remains, yet the patient is blind, the excito-motory func- tion is perfect, but the sensitive function of the brain abolished. There is strabismus, especially in children, with rolling of the eyeballs, or distortion upwards or outwards, by the tonic action of the superior oblique, or the abducens; there are also double vision and other optical illusions, and sometimes total blindness. The eye itself, as the stage advances, becomes pale, dim, and Meningitis—Symptoms. 59 sunk. Morbid acuteness of hearing is commuted for dulness or deafness. The muscles of the face and limbs are affected with convulsive twitchings and subsultus tendinum; sometimes there are convulsions of one set of muscles and imperfect paralysis of another, and occasionally convulsions and paralysis alternate in the same limb. As coma becomes complete, the convulsive affec- tions are superseded by complete muscular relaxation or paralysis. The pulse, in consequence of cerebral compression or obstructed circulation, not only becomes weak and soft, but it usually, though not invariably, falls to its natural standard or even lower, being at the same time singularly variable in frequency, unequal in force, and liable to great accelerations by any slight exertion, as that of merely being raised in bed. This variability, even many times per minute, is not seen in other diseases, except from tran- sient causes, and is therefore an important and striking character- istic of inflammations of the brain. With this state of the pulse, the respiration also becomes remarkably irregular, unequal, and sighing, the long sigh being sometimes followed by still longer pauses, and these again by a number of brief quick respirations. We have seen fifteen or twenty slow respirations alternate with as many quick gasping ones, with the utmost regularity for hours together, in comatose children; and we imagine that, during the slow respirations, pulmonary congestion takes place, and is re- lieved by the subsequent quick respiration, precisely as we have elsewhere shown to be the case in the last stages of certain dis- eases of the heart. (See Treatise on Diseases of the Heart, by the writer, 3d edit. p. 399.) The temperature is apt to fall in children, if unduly exposed. The tongue becomes dryer and more furred, and the bowels are even more obstinate than before. The excito-motory function being still perfect, deglutition—an act subordinate to this function—is readily, and even greedily, per- formed, when excited by food well introduced by a spoon into the mouth. Such are the symptoms of the second stage, which is usually the longest. It not unfrequently lasts a week; and, in weakly scrofulous children presenting the slow form of inflammation, we have seen it exceed a fortnight. It occasionally happens in chil- dren, that when the collapse of this stage has reached the state of stupor, but not of complete coma, a treacherous amelioration takes place; the stupor diminishes without wholly disappearing, and the child recognises its friends, and even takes an interest in surrounding objects. All the other symptoms appear to sustain a corresponding improvement. The vulgar call this "a lightening up before death." After lasting for a day or two, it is followed by complete coma, with screaming, tossing and rolling of the head, convulsions, paralysis, and death. Third stage. This is little more than an assemblage of the worst symptoms of the preceding stage in their most aggravated 60 INFLAMMATION OF THE BRAIN. form. The coma is profound, and no pain is felt; universal re- laxation or paralysis replaces all previous convulsive movements or spasmodic rigidity of the limbs, face, or jaws; the pupils are widely and immovably dilated, with blindness and deafness. Abolition of the cerebral functions is attended with that of the excito-motory, and as this system of nerves presides over the orifices and sphincters of the body, there is the semi-apert eye, stertor, involuntary discharge of the urine and faeces, and difficulty of deglutition, the'latter act not being excited except by the in- troduction of spoon-meat far back into the fauces, and ultimately not at all. The pulse, lately slow, undergoes a remarkable final acceleration, rising to 140, 160, or even 200, with extreme feeble- ness, but in general with regularity. This is, in fact, the flutter preceding dissolution. The respiration also becomes quick and regular, in accordance with the pulse, but it slackens and some- times becomes more stertorous during the period of dissolution. The tongue is dry and brown; the lips and teeth are coated with fuliginous sordes; the abdomen is tympanitic; the extremities and general surface become cold; the perspirations partake of the same character; the face is sunk and ghastly; and with this as- semblage of mortal symptoms the patient speedily dies. Remarks on the stages. Though the three stages now de- scribed are frequently seen, in acute meningitis, it is still more common to find one or more of them absent or indistinct. The first stage may be absent when, from the rapidity or extent of the inflammation, or the unusual susceptibility of the subject, the disease sets in aruptly, as with a violent and protracted convul- sion, followed by comatose and paralytic symptoms. It may also be absent, or at least escape observation, in aged persons, who are less susceptible of high excitement, and in whom, there- fore, mental confusion and stupor, with convulsive or paralytic affections, often constitute the first indications of the disease. The subsequent occurrence of fever distinguishes it from mere congestion. Weakly youths or adults are occasionally affected in the same manner. Cruvelhier has described several of these cases under the title of "comatose subarachnoid meningitis," effusion of serum and lymph, &c, being usually found under the arachnoid. We regard such cases as the exception to the general rule, and cannot subscribe to the opinion of this author, founded on a limited number of cases, that stupor, gradually increasing to coma, is the pathognomonic character of meningitis of the superior surface of the hemispheres; while acute pain, exaltation of sensibility, high delirium and convulsions are foreign to it. The second stage may be absent or barely discernible, in con- sequence of the great extent and rapidity of the disease hurrying it at once out of the first stage of excitement into the last of com- plete collapse, a violent convulsion not unfrequently occurring during the transition. The third stage may be absent, from Meningitis—Symptoms. 61 violent general convulsions abruptly cutting short the thread of life—an event not unfrequent in children, and which we have several, times witnessed in adults. In some instances, again, the stages, during their transition, partially coalesce, so as simultane- ously to present the phenomena of both; thus violent fever and convulsions may co-exist with stupor and partial paralysis. In other instances, it occasionally happens that there is an alternation of the phenomena of the two first stages, lethargic collapse being repeatedly broken by paroxysms of excitement, till complete coma is fully established. The causes of these irregularities in the stages are, to a certain extent, explained by varieties in the circumstances of the disease, which we now proceed to notice. Varieties of acute meningitis. Of these we shall advert to the most striking appreciable alone. Phrenitis.—When meningitis affects a great extent of the superior surface of both hemispheres, and, still more, if it involve the surface of the brain in the inflammation, and if this occur in a robust adult, the symptoms are apt to be those of violent ex- citement, with furious delirium, followed by rapid sinking and speedy death—this event sometimes taking place within a day or two, especially if accelerated by convulsions, and generally occurring within a week. This constitutes the variety described by old writers under the designation of phrenitis. Robust, healthy children, under the same circumstances as to the locality and extent of the disease, are apt to be suddenly attacked by violent convulsions, more or less speedily followed by coma and death. Whether in adults or children, the post mortem appear- ances frequently do not proceed beyond increased vascularity of the membranes and gray matter of the convolutions, but some- times there are effusions of serum, lymph and pus on the surface, as will presently be explained under the head of morbid anatomy. Meningo-Cerebritis.—Meningitis is sometimes modified by the co-existence not merely of superficial, but of deep and exten- sive cerebritis, constituting what may be denominated meningo- cerebritis.* Here, the disease is altered in its aspect by the peculiar symptoms of cerebritis. What then are these? Not to anticipate fuller explanations to be given under the head Cere- britis, it may be sufficient here to state, that cerebritis is almost always attended with spasmodic contraction of the extremities, alternating with or followed by paralysis, partial or general, and more or less complete, symptoms which are not of ordinary oc- currence in meningitis of the upper surface of the hemispheres; and that these symptoms, together with coma, supervene at an * We employ this term because it is descriptive, and therefore definite. Encephalitis, used by some writers, with the same import, is objectionable, because others, as Pouillaud, &c, apply it to cerebritis.—Author. 6 62 INFLAMMATION OF THE BRAIN. earlier period than in meningitis, because the functions of the brain are more speedily abolished when its interior, as well as its membranes and surface, is affected. Spasmodic and paralytic symptoms are common, it is true, in meningitis of the base and centres of the brain; but here they usually come on late, consti- tuting the second and third stages of what is called hydroce- phalus, as will be shown under the next head. These circum- stances, therefore, if kept in recollection, will generally be suffi- cient to indicate the compound disease, meningo-cerebritis, to the observant and reflecting practitioner. We now proceed to point out the features characteristic of the hydrocephalic variety. When meningitis is confined to a mode- rate extent of the membranes at the base of the brain, or within the ventricles, and is not propagated beyond a moderate extent into the cerebral substance, we have the most perfect type of the group of symptoms which, in this country is commonly denomi- nated acute hydrocephalus. Abercrombie refers them to inflam- mation of the arachnoid membrane of the ventricles and of the contiguous corpus callosum, septum lucidum, and fornix, pro- ducing in some cases softening alone of these parts; in others, effusion alone into the ventricles; and in others again, which is the most common case, both effusion and softening. In the majority of our own cases, we have found, in connection with these changes, more or less vestiges of inflammation of the mem- branes at the base. Parent, Martinet and Rostan, though less definite in their accounts than Abercrombie, have evidently de- scribed the same disease in reference to the same parts. It occurs principally in children; and those of weakly scrofu- lous constitutions are the most liable; but it is also occasionally met with at puberty and afterwards. In consequence of the limited extent of the inflammation, it is apt to run a prolonged course of two or three weeks, sometimes, though not always, exhibiting three distinct and well-defined stages. The symptoms differ from those of meningitis of the superior surface of the hemispheres in the following particulars:—1. They are less characterised by high excitement and irritation; the de- lirium, for instance, being of a quiet kind, rather a confusion of thought, with forgetfulness, than real delirium; and often so slight as not to prevent the patient, when roused, from answering questions coherently, though slowly, and with an evident effort to rally and concentrate his thoughts. This absence of violence from the delirium is perhaps to be explained by the disease not implicating the gray substance of the cerebral hemispheres, which is believed by many physiologists to be the seat of mental power, and therefore, when irritated by inflammation, of violent delirium. 2. The symptoms are more characterised by somno- lency, which is almost continual; by the earlier tendency to more or less complete coma, and by the greater prevalence, in the Meningitis—Symptoms. 63 latter stages, of spasms, tonic and clonic, alternating with partial paralysis, and ultimately superseded by complete muscular relax- ation. These pathognomonic features are ascribable to the dis- ease being seated in the immediate neighborhood of the medulla oblongata and cerebral centres in general; even slight local com- pression of which, either from vascular turgescence or effusion, suffices to occasion somnolency at an early period; while a higher degree not only occasions coma, but, by irritating the excito- motory nerves, induces spasms. When the compression becomes extreme, or the parts disorganised, the spasms are superseded by complete paralysis. Such are the characteristic features of hy- drocephalus. MM. Parent and Martinet have shown that arachnitis at the base of the brain is much more common in infants than in adults, and is characterised by a greater tendency to convulsive affec- tions, and less to delirium; whereas, in adults, inflammation of the membranes occurs more frequently in that portion of them which covers the upper and lateral parts of the hemispheres, and is characterised at first by delirium, to which a soporose state, and at length coma, succeed. It is manifest that in the former part of this comparison, the writers have described hydrocephalus, and in the latter phrenitis. Although, in our opinion, hydroce- phalus is to be regarded only as a modification or variety of cerebral inflammation, and not as an essential or distinct disease, it is proper to state, that a different vieAV is entertained by some pathologists, in so far that while they admit that hydrocephalic effusion originates in inflammation of the membranes or sub- stance of the brain, they think that it may also arise independ- ently of cerebral inflammation in any form or degree. Our limits do not permit us to enter on this question. We return to menin- gitis in general. Duration of acute Meningitis. It has already been made apparent that, from the diversified circumstances of the disease, its duration is, and necessarily must be, very variable. That of fatal cases, dating from the actual attack, without comprising the stage of precursory symptoms, ranges from two to thirty days; but the most frequent period is between one and two weeks. Thus of 42 cases given by Lallemand, 3 died suddenly, 3 very speedily, 16 between the second and seventh days, 12 between the eighth and twelfth days, 7 between the fifteenth and twenty- first, and 1 at the end of two months. Again, of 116 cases by Parent and Martinet, 66 died between the third and eleventh days, 33 between the eleventh and eighteenth, 17 between the eighteenth and thirty-second days. Cases terminating favorably would probably present much the same results, or the average duration might possibly be shorter, but we have not access to a sufficient number of cases to determine the question. Large numbers like the above convey more accurate information than 64 INFLAMMATION OF THE BRAIN. can be derived from smaller numbers, because, in individual cases, the date of the invasion cannot always be ascertained, ambiguous precursory symptoms or the co-existence of other dis- eases, as fever, scarlatina, pertussis, &c, throwing obscurity over the cerebral affections. Abercrombie, in his fourth variety, de- scribes cases occurring principally in young persons towards the age of puberty and upwards, which may run on from two to six weeks, the symptoms being at first febrile, with headach, foul tongue, anorexia, and pulse from 96 to 100. They then present ambiguous exacerbations and remissions until, about the twelfth or fourteenth day, the pulse suddenly falls to the natural standard or below it, while the headach is increased, with an evident ten- dency to stupor. This instantly marks an affection of the head of the most dangerous character, and the patient now lies for several days in a state of considerable stupor, sometimes with convulsions, often with squinting and double vision. The pulse then begins to rise again, and about this time there is frequently a deceitful interval of apparent amendment; sometimes the squinting goes off, and the eye appears quite natural, the stupor is lessened, and the patient appears easy and intelligent, but soon relapses into perfect coma, and dies in three or four days. The duration of the disease is uncertain: it may be drawn out to five or six weeks, or it may be fatal in two or three. Anatomical characters of acute Meningitis. As it is in many cases exceedingly difficult to pronounce whether a given degree of redness in the brain or its membranes is morbid or not,' every source of fallacy ought to be studiously avoided. It is, therefore, incumbent on the student to recollect and take into account that, wholly independent of inflammation, preternatural redness may be occasioned after death—1, by gravitation of blood to the head, when it happens to have lain in a dependent position; and that, even when horizontally placed, redness from gravitation may exist in any part which happens to have been the lowest; 2, by putrefaction causing the blood to transude through the coats of the vessels; 3, by breaking the cranium with a hammer; 4, before death, by retardation of the venous circula- tion, as from organic disease of the heart, pericarditis or endocar- ditis with great obstruction in the organ, polypus, great emphyse- ma, suffocation, death during convulsions or tetanus, &c. It must also be recollected, that if the chest and great vessels be opened before the head, the latter is disgorged, and its redness diminished the moment that the cranium is divided, as the atmospheric pres- sure now acts upon and depletes its vessels, which were kept full on the syphon principle so long as the cranium remained undivided. The morbid appearances presented by the membranes are the same as those of serous membranes in general; namely, redness and effusions of serum, lymph, and pus, the latter either in the Meningitis—Anatomical Characters. 65 liquid or the concrete form. The dura mater is very seldom inflamed, except from external injuries, disease of the pericranium, or deep-seated disease of the ear, the eye, the ethmoid bone, or the frontal sinuses. Disease of any of these parts may penetrate to the dura mater. We then find pus, either liquid or concrete, between the skull and the dura mater, surrounded by a zone of redness both in the dura mater and the bone itself. In other instances, the dura mater is thickened, tumid, or ulcerated, and generally detached from the bone, and on its arachnoid surface, there is a purulent or false membranous deposition, mostly limited, occasionally diffuse. In a few instances of circumscribed accumulations of pus, the dura mater is completely perforated. The arachnoid membrane rarely presents morbid appearances dissociated from the same in the pia mater. To this opinion we are led by personal observation; but the cases of Abercrombie also afford equal data for it, and, in those of Parent and of Mar- tinet, though professedly writers on arachnitis, the lesions of the arachnoid are always confounded with those of the pia mater. The arachnoid is sometimes found finely and minutely injected at a few points of the hemispheres or base, and occasionally within the ventricles, but seldom over a considerable extent in any situation. If the patient has been suddenly carried off in the very earliest stage of inflammation, as by convulsions, the surface of the membrane may also be v unusually dry. More commonly, however, the redness of so fine a membrane disap- pears after death, and we only judge that it has been inflamed by slight thickening and opalescent or milky opacity, observed chiefly on the hemispheres, at the base, and occasionally within the ventricles. When the patient has died in the second or third stages, the free surface of the membrane on the hemispheres, whether injected or not, is found to have effused a fluid most commonly serous; but not unfrequently flocculent and turbid, from an intermixture of lymph or pus. Adherent layers of soft greenish-white false membrane occasionally form on it; but, ac- cording to our observation, they are of rare occurrence in this situation. The arachnoid likewise secretes fluid within the cavi- ties of the ventricles, constituting the effusion of acute hydroce- phalus. In the slow variety of cases, it usually consists of clear serum; in the more acute, it is slightly turbid, from flakes of lymph or a purulent intermixture; but it is exceedingly rare to see either pure pus or false membranous layers within the ven- tricles. The pia mater, from its close connection with the arachnoid by cellular tissue, is, as already stated, almost always simultane- ously inflamed. It is then more or less highly injected, the slighter degrees being merely ramiform, that is, consisting of dis- tinct arborescent vessels, while the higher degrees are uniform, that is, the interstices are so closely filled up, that intervals are no 6* 66 INFLAMMATION OF THE BRAIN. longer distinguishable. This uniform redness may be either patchy or diffuse, the latter bespeaking a higher degree of inflam- mation. Sometimes there are also actual extravasations of blood, commonly indeed after concussions; but we have repeatedly seen them under ordinary circumstances. That such redness is inflam- matory, may be known by its vivid scarlet tint, the injection being arterial; whereas venous congestion presents the darker tint of venous blood. It must not be forgotten that the latter turns scarlet by exposure for a few minutes to the oxygen of the atmosphere. The pia mater secretes serum, lymph, and pus, into the cellular tissue which unites it to the arachnoid mem- brane; and these effusions we have found far more frequent in this situation than in any other. Some ascribe them to the arach- noid; but we understand not on what grounds, the pia mater being superlatively the vascular membrane. If the effusion con- sist of clear serum, it gradually oozes out when the arachnoid is punctured. If the serum be thickish from albumen, instead of oozing out, it is detained in the meshes of the cellular tissue, and presents a gelatinous appearance, like the vitreous humor of the eye. Sometimes it is hazy or opalescent, in which case nothing but the large veins ramifying between the convolutions can be discerned. Sometimes the proportion of lymph and its opacity are greater in every degree up to the point Avhere they constitute opaque, greenish-yellow false membrane, sometimes even a quarter of an inch thick, and more or less widely overspreading the hemispheres and the base. When the effusion consists of pus (which in this situation is as frequently concrete as liquid), a dead yellow that runs along the sinuous interstices of the convolutions. These copious effusions of lymph or pus may widely separate the convolutions, penetrating to their utmost depths. Their most common situations are, the vertex and the base, before and be- hind the crossing of the optic nerves, where the cellular tissue is loose and abundant. The pia mater frequently adheres to the brain, and cannot be detached without lacerating the cerebral substance, which, in such cases, is usually reddened and softened. In scrofulous subjects it is not uncommon to see the pia mater and arachnoid studded with lubercles, varying between the size of pin's heads and peas. Sometimes, by coalescing, they form patches of an inch or more in extent. They follow the mem- branes between the convolutions, and are also found buried in the gray substance, where we have often observed them to be surrounded by a halo of redness—generally connected with an enlarged vessel, ramifying from the pia mater. Their most com- mon situation is along the tract of the falx major, especially oppo- site to the anterior fontanelle if not closed, and at the base. More rarely minute tubercles are found in the white substance of the brain, where they are with difficulty discerned, and therefore often overlooked in consequence of their pale, semi-transparent, Meningitis—Anatomical Characters. 67 yellow tint, contrasting little with the surrounding whiteness. Laennec was one of the first who pointed them out. They may be expected in delicate scrofulous children, who have long been subject to head symptoms, and have finally died of hydrocephalus. 2. Chronic Meningitis. This may either be a "sequel of the acute form, or it may be primarily chronic. In either case it is obscure from the deficiency of fever, and from the absence, in many instances, of any considerable intellectual disturbance, the only symptoms then being, more or less constant headach, mostly with somnolency, convulsive movements, and in children vomit- ing. When, however, the disease affects the membranes of the convexity of the hemispheres, M. Bayle, who has attentively investigated this subject, affirms that delirium and progressive paralysis are its inseparable concomitants. The delirium is at first a mere monomania with intellectual imbecility, and often with sullenness, irascibility, taciturnity, and lofty hallucinations; but, sooner or later, it passes into confirmed mania, and this into idiotcy. The paralysis is at first slight, incomplete, and partial; but, gradually augmenting and encroaching, it ultimately per- vades almost the whole muscular system, renders the gait totter- ing, and finally annihilates the powers of motion. This state is sooner or later aggravated by spasmodic twitchings and rigid contractions of the limbs; epilepsy follows, and not unfrequently terminates in fatal apoplexy. We have frequently witnessed this series of symptoms in patients under our care in the insane wards of the St. Mary-le-bone Infirmary. Duration. This is too indeterminate to admit of being defined. When the chronic, is a sequel of the acute affection, its course has appeared to us shorter than that of the primitively chronic form, often terminating within three or four months; while we have known the chronic, in connection with symptoms of insanity, run on for as many years. Either variety may, with or without assignable cause, suddenly become acute, and hurry rapidly to its fatal termination. Anatomical characters of chronic Meningitis. In cases ter- minating abruptly with symptoms of excitement, we may of course expect to find vascular injection of the membranes and effusions of serum, lymph, or pus ; but, in addition to these, and constitut- ing the characteristic features of the chronic affection, we find the arachnoid membrane in the vicinity of the falx major, thickened, opake, and its unattached surface roughened by small, irregular granulations of a grayish white color, commonly denominated glandulae Pacchioni; but as they are foreign to the healthy con- dition of the membrane, especally in infancy, they are to be re- garded as false membranous products of chronic inflammation. We have in numerous instances found them in scrofulous children, and sometimes in connection with tubercles. We have also seen them follow the line of the coronal suture, when imperfectly 68 INFLAMMATION OF THE BRAIN. united, after the age of two years. The arachnoid membrane thus affected, generally adheres to its reflected layer investing the falx major, especially at the angles of the hemispheres ; and at these points we have frequently noticed the inferior surface of the arachnoid, together with the thickened pia mater, to be adherent to the cerebral substance, while the latter, in some instances, Avas softened or indurated and discolored. We have repeatedly seen a moderate degree of the same appearances in old persons, though, so far as we could ascertain, they had not presented any material disturbance of the cerebral functions during life ; and Ave lately found the same albuminous granulations, though rather softer, together Avith thickening and adhesions, in a gentleman twenty years of age, whose father assured us that, though from his youth upwards every slight ailment Avas accompanied by severe headach, he had not been subject to other more decided cerebral symptoms. He finally died of universal cerebritis slightly involving the membranes, particularly at the base. In the mu- seum of Professor Monro we have seen a large osseous plate, which adhered to the arachnoid membrane, and overspread the greater part of a cerebral hemisphere ; but of the symptoms we are ignorant. From the cases now cited it may be inferred, that slow inflammation may sometimes steal on for years Avithout materially deranging the cerebral functions, and that it may attain the degree of complete ossification, Avithout compromising life. This inference may probably afford indirect grounds for another: namely, that Avhen disease of the membranes does disturb the functions of the brain, as in acute meningitis, the disturbance results from the inflammation, or at least irritation, being pro- pagated to the surface of the brain* itself, a doctrine which Ave have already propounded in the Preliminary Observations to Meningitis. The causes, diagnosis,prognosis, and treatment, of meningitis will be postponed till Ave have treated of cerebritis; when they Avill be considered at once in reference to all the varieties of in- flammation of the brain. III. Cerebritis. By this term we mean inflammation of the' substance of the brain. Let us first contrast its distinctive characters Avith those of meningitis, in order to make the difference as palpable as possible. We have already shoAvn that in meningitis of the con- vexity of the hemispheres, the surface of the brain itself is ahvays irritated and generally inflamed; that the consequent disturbances * This, as already stated, is ascribed by some to the gray substance of the hemispheres being the source of mental power.—Author. Cerebri! is—Sy mptoms. 69 of the functions of the organ are the principal, though indirect, signs of the meningitis; and that these disturbances are charac- terised, as a general rule, by high excitement and irritation, evinced by smart symptomatic fever, headach of the acute kind, great sensibility of the eye and ear, delirium of the more violent kind, and convulsive movements, Avhich, from the usually great extent of the cerebral inflammation, may affect any or all parts of the muscular system simultaneously or in succession, Avithout being restricted to a particular limb or part. Noav, in general cerebritis, no less than in meningitis, the functions of the brain are disturbed, but the disturbance is characterised less by excitement than by depression. Nor is this difficult to understand; for when the substance of the organ is extensively diseased, the abolition of the function speedily overtakes, as it were, and supersedes any excitement existing in the early stage. Accordingly, though the invasion be attended Avith fever, quick full pulse, exalted sensi- bility, &c. as is apt to be the case when general cerebritis is com- plicated Avith meningitis, yet these symptoms of vascular excite- ment are less violent than in pure meningitis of the convexity, and they are promptly replaced by a slow irregular pulse, stupor advancing to coma, and muscular spasms and universal paralytic relaxation. In some cases Ave have seen universal cerebritis Avholly devoid of vascular excitement, and attended Avith a pre- ternaturally sIoav, Aveak', and irregular pulse from first to last. In such instances, Avhen post-mortem examination shows the mem- branes to have been implicated, Ave suspect that they had been attacked only secondarily; for, in certain instances of the kind, we have noticed slight vascular excitement, evinced by heat of the head, Avith quickness of speech, manner, and movements of the eye, to supervene in the mid-career of marked symptoms of depression. " It is not, hoAvever, to be supposed, that convulsions, Avhether in the form of mere twitching, or of violent and general fits, are incompatible Avith symptoms of depression: Ave have repeatedly seen them in general cerebritis, and they may result either from the irritation of coexistent meningitis, or from coun- ter-pressure on the medulla oblongata—the superior extremity of the " true spinal or excito-motary column." Besides convulsions, there may be tonic spasms, that is, rigid contractions of limbs; and it is maintained by Rostan, Lallemand, Bouillaud, and others, that these are peculiar to cerebritis and foreign to meningitis; but their idea appears to extend to the cerebritis of the surface Avhich accompanies meningitis, and it therefore includes the bulk of the cases Avhich we denominate meningitis. However, when the rigid contractions occur in general cerebritis, or in meningo-cere- britis, it is maintained that they are not restricted to a particular limb, side, or part, but affect a variety of parts on both sides at the same time; also, that Avhen the rigid spasms relax, the limb recovers its muscular power and sensibility. 70 INFLAMMATION OF THE BRAIN. Such are the leading peculiarities of general cerebritis; Avhen partial, it is said to be characterised by the circumstances that spasmodic, convulsive, and paralytic affections are more limited to particular limbs, corresponding, it is assumed, Avith particular parts of the brain affected; that the rigid contractions arc perma- nent, Avith loss of voluntary motion, and more or less impaired sensibility; and that they are finally superseded by complete para- lysis. The reason why these symptoms present a more perma- nent and aggravated character in partial cerebritis, appears to us to be, that, in this, the disease can proceed to a greater extent, even to disorganisation, before compromising life, whereas, in general cerebritis, or meningo-cerebritis, the patient necessarily dies or recovers before the inflammation can proceed to a disor- ganising extent; whence the spasmodic contractions are compa- ratively slight and transient. The preliminary observations which Ave have now offered are perhaps sufficient to afford a clue to the otherwise complex and embarrassing symptoms of the several forms of cerebritis, which we now proceed to notice. The disease may be acute, and this may be either general or partial; or it may be chronic, and this is ahvays partial. 1. Acute General Cerebritis. Though general cerebritis, like meningitis, may commence suddenly, it is more commonly usher- ed in by precursory symptoms. These have been already de- scribed under the head of Cerebral Determination and Co?iges- tion. General cerebritis is usually complicated Avith more or less of meningitis, and Ave have already glanced at it as a variety of meningitis, under the denomination of Meningo-Cerebritis. The symptoms of high excitement dependent on the meningitis are greater in proportion as this is more extensive, and takes prece- dence of the cerebritis. Thus, after a rigor, there may be acute and extensive or throbbing headach; flushing, heat, and intu- mescence of the head, intolerance of light and sound, with red- ness of the conjunctivae, staring prominence of the eye-balls, and contraction, with oscillation of the pupils; more or less violent delirium; pulse quick, full, and hard. In connection with these symptoms, the train of muscular phenomena soon come on. Sometimes there are paroxysms of general convulsions, which for the time aggravate all the other symptoms, suddenly raising the pulse to 130, 140, or 150, Avith a corresponding acceleration of the respiration. In a feAV instances, a fit of general convulsions marks the first invasion of the disease. In other cases, instead of general convulsions, there are merely convulsions of individual limbs or muscles, in any or all parts of the body, namely, twitch- ings of the limbs attended with subsultus tendinum, twitchings of the face, rolling of the eyes, tremor, or violent movements of the tongue Avhen protruded, and in children vomiting. In addition to these clonic spasms, there may also be tonic, that is, rigid con- Cerebritis—Symptoms. 71 tractions of the muscles. They often folloAv general convulsions, affect some of the muscles or limbs on one or both sides of the body, occasionally cause strabismus, may change their situations Avithout necessarily leaving paralysis, and may be attended with such pain as to elicit cries on any attempt to extend the limbs, or even to change the posture of the patient. The symptoms hoav enumerated are, from the greater extent of the disease, generally more rapid in their progress than when resulting from mere meningitis. In the space of from twelve to forty or fifty hours, they may be superseded by the stage of coma and collapse, and this may be a result of compression by vascular turgescence alone, before effusion has taken place. Stupor and coma noAV rapidly come on, attended with unconsciousness of pain, and diminished or abolished sensibility of the eye, ear, and other senses. The spasms, both clonic and tonic, are superseded by more or less complete paralysis, or general relaxation. The eye may be distorted from paralysis, instead of the previous tonic spasm, and the eyelids may fall; the pupil is dilated, and the mouth may be drawn awry in consequence of paralysis of one side of the face. The pulse becomes sIoav and irregular, but at last ex- ceedingly rapid and Aveak; or, when the transition from the stage of excitement to that of complete collapse is sudden, this rapid state of the pulse may supervene at once without intermediate sloAvness. Next come relaxation of all the sphincters, the sunk Hyppocratic face, coldness and clammy perspirations of the sur- face, and soon afterAvards the fatal termination. In the majority of cases this eArent occurs Avithin a week, and it may occur even within twelve hours, especially from violent general convulsions. It is very intelligible that so extensive an inflammation should be incompatible Avith any considerable prolongation of life. The dis- ease is seldom found, after death, to have advanced beyond the state of vascular congestion. Such is the usual train of symptoms Avhen meningitis compli- cates the cerebritis. But when the cerebritis takes precedence, becomes general, and only tardily and partially extends to the membranes, the symptoms of excitement may be in a great mea- sure absent. Though the pulse in some instances ranges between 70 and 80, it generally does not exceed its natural standard, but, on the contrary falls below it to 60 or 50, with remarkable varia- tions of the speed several times per minute. At last only, during the moribund period, it may rise to 120, or thence to 160, Avith the usual smallness, Aveakness, and regularity. In connection Avith this slow state of the pulse from the first, to Avhich Ave Avould strongly draAV attention, lest it should throAV the practitioner off his guard, there is acute and deep-seated headach, which patients mostly describe as shooting from the centre to either temple, the eyes, the ears, or the vertex. There is a feeling and look of much oppression, the patient being sullen, and unwilling to be disturbed. 72 INFLAMMATION of the brain. The face is, in general, rather pale, though it may flush occasion- ally, there is sometimes, though by no means always, slight into- lerance of light and sound, Avith contraction of the pupil; occa- sionally there is vomiting. Delirium comes on at an early period, but it i's slight and observed principally Avhile the patient lies in a dozing state, during Avhich he mutters incoherently; yet, Avhen roused, he can talk sensibly, though-often Avith a slow, hesitating, and stupid air, from confusion of thought and remarkable forget- fulness of particular Avords. Occasionally there is an unnaturally quick, stammering accent, a quick movement and winking of the eyes, and a general quickness of demeanor. This delirium may fluctuate in degree from day to day, each amelioration exciting hopes in the practitioner and friends. After subsisting for about five or six days, it passes into more or less coma, Avhich may be fatal in a period varying from tAvelve hours to three or four days. Occasionally the patient is carried off (sometimes by convulsions), though still able to answer questions distinctly till a very short time before death. This series of symptoms has been accurately described by Abercrombie as his fifth variety of inflammation of the brain, but he does not specify the particular lesion Avith Avhich it is connected. We have found such cases present after death universal vascular injection of the cerebral substance, Avith an incipient, and often limited, affection of the membranes, especially at the base. We knoAV not whether a variety added by M. Gendrin is re- ferable to the same cause; but, from its insidiousness, it is highly worthy of attention. It often steals on without headach or fever. There is chiefly observed a Certain obscuration of the mental functions, accompanied by lassitude and an appearance of mental depression. The patient seems scarcely to comprehend Avhat is said to him—asks the same questions several times in succession, and answers questions put to him Avith sloAvness and hesitation. He complains of little beyond a general feeling of being indis- posed; and thus the symptoms creep on gradually, with disturbed sleep and slight rigors, till they pass into slight delirium, and at last into coma; the pulse, Avhich Avas at first not affected, becoming rapid as the disease adArances. 2. Acute Partial Cerebritis. The premonitory symptoms Avhich forebode partial cerebritis more especially, Avhether acute or chronic, are deep-seated, fixed, and protracted pain in one part of the head; numbness, creeping, or tingling, Avith Aveakness, and sometimes Avith pain, in one half of the body, or in one extremity, or a part only of an extremity, even a single finger, or in any other set of muscles; the speech, for instance, is sometimes thick, trailing, stammering, or hesitating; or one or both eyes are dis- torted. The sight and hearing may be impaired or perverted, the memory deteriorated, and the mind occasionally confused. These symptoms, Avith general deterioration of health, may have Cerebritis—Symptoms. 73 been present for Aveeks, months, or even a year or two, and they are often erroneously ascribed to nervousness, dyspepsia, anaemia, gout, &c, Avhich may produce many of a similar kind. Symptoms. The aspect of partial acute cerebritis is so diver- sified, that it is difficult to seize its prominent lineaments. From personal observation, hoAvever, and the examination of many cases, Ave think that, speaking in general terms, the characteristic symptoms are headach, suddenly followed by violent convulsions, either general or partial, Avith or Avithout rigid contractions of the limbs, coma and paralysis finally supervening, and the fever and delirium being throughout of a mild character. The folloAving more particular account of the symptoms Avill, Ave think, apply to a large proportion of cases. After, but some- times Avithout, headach and the other precursory symptoms enu- merated above, the patient is suddenly and unexpectedly seized with violent general convulsions, which may be either imme- diately succeeded by coma, ending fatally in tAvo or three days, or may recur very frequently for a day or tAvo, the patient during the intervals complaining of headach, and may then pass into fatal coma. In these fearfully seA'ere cases, the inflammation may not have affected more than a very limited portion of the cerebral substance, as an inch or tAvo, and it may not have ad- vanced beyond the state of simple inflammatory congestion. The disproportion, therefore, between the violence of the symp- toms and slightness of the structural lesions must be referred either to the intensity and rapidity of the inflammation, (for experience shows that even a slight lesion, if suddenly developed, may create great functional commotion,) or it must be ascribed to the lesion affecting a peculiarly important part of the brain, as the medulla oblongata, or its vicinity. In some cases the pro- gress of the disease is less rapid than in the preceding instances; for the coma completely subsides after ten or tAvelve hours, and the patient proceeds satisfactorily for several days, when there is a sudden return of convulsions folloAved by fatal coma. In still less acute and rapid cases the convulsions, instead of being gene- ral, are hemiplegic, or even confined to a single limb; and some- times there are no convulsions, but an attack of coma, as if from apoplexy, folloAved by permanent tonic spasm; that is, rigid con- traction, mostly Avith pain, of a particular limb or set of muscles. The contracted state, usually that of flexion, is owing to the pre- dominant poAver of the flexor muscles. In a few rare instances tonic and clonic spasms alternate for a time in the same limb, and in other instances we see spasms on one side of the body with paralysis on the other. During the continuance of these states of the muscular system, there may be a degree of intellec- tual confusion, forgetfulness and sluggishness, vision of one or both eyes may be impaired or lost, hearing may be similarly affected, and the pupil may be contracted, or dilated and slug- 7 74 INFLAMMATION OF THE BRAIN. gish. There may be heat of the head, but the fever throughout is very moderate, the pulse seldom rising above 70 or 80, and sometimes remaining at, or falling below, its natural standard. Dissections shoAv that up to this period the disease may not have proceeded to softening; but after the lapse of a few hours, or days, the attacks of comatose insensibility or convulsions recur, and are ultimately folloAved by relaxation of the tonic spasm and complete paralysis, denoting the advance of the disease to soften- ing and disorganisation. The patient dies either in one of the fits, or by gradual sinking. The total duration of such cases may be from five or six days to two or three weeks. If the patient recover, the convalescence may be protracted through several Aveeks. Chronic Cerebritis. This, it has already been stated, is always partial. The inflammation is of a slow and often a scrofulous kind: it begins in a small portion of the brain, and extends only very gradually, sometimes occupying many months in its course, independent of the precursory symptoms before enumerated, which most commonly, yet not invariably, precede. The symp- toms are much the same in their nature as those of the sloAver varieties of acute cerebritis when partial; but they are less in degree, and are irregularly scattered over a longer period. Thus the patient may several times, and at various intervals of weeks or months, be attacked with headach and a comatose fit, or Avith a general convulsion, or a partial spasm, either tonic or clonic, or paralysis, either primary, or consecutive upon the spasmodic affections; and he may recover more or less perfectly from a greater or less number of such attacks. We have seen this occur four or five times over, and it is common for it to occur twice or thrice. During the intervals, the intellectual functions and exter- • nal senses, one or all, are most commonly someAvhat impaired, and the general health is deteriorated. One of the most frequent sequels of the attacks is paralysis, at first perhaps limited to one limb or to any single set of muscles, as those of the eye, whence strabismus; of the face, Avhence distortion; or of the tongue, Avhence difficult articulation. This paralysis sometimes extends from part to part by slow progression, Avhence it has been deno- minated " creeping palsy." Sooner or later neAv attacks of coma or convulsions come on, and may either destroy the patient sud- denly, Avhen the organic lesion may still not have proceeded beyond the first stage, or inflammatory congestion; or they may leave him to linger for a time in a state of a paralytic exhaustion, Avhen the disease is commonly found to have advanced to soften- ing or abscess, though occasionally it presents the opposite state of permanent induration. Chronic cerebritis is a disease of fre- quent occurrence in the loAver classes of society: at least, Ave see a very large proportion of the disease in hospital practice. Its Cerebritis—Anatomical Characters. 75 frequency is probably referrible to intemperate habits, and to neglect of the precursory symptoms. In termittent Inflammation of the Brain. It is a AArell-knoAvn, but too frequently forgotten, fact, that inflammation of various organs may assume an intermittent and periodic character in in- dividuals Avho have either experienced ague at some anterior period, or who live in an atmosphere tainted, even slightly, with efiiuvia from vegetable decomposition as, for instance, along the banks of the Thames, between London and Richmond, a district in which the malaria is so much diluted as rarely to produce overt ague. Inflammations of the brain are subject to the same intermittent character, innumerable instances of Avhich have been recorded by various authors. Thus, in one case by Parent and Martinet, five paroxysms Avith delirium and coma occurred on consecutive evenings, and the last proved fatal: in a second case, four paroxysms occurred at the same hour daily: in a third, five paroxysms occurred at the same hour on alternate days, the apy- rexia being complete in the intervals. After death all presented inflammatory injection of the membranes, Avith purulent effusion, or softening or abscess, of the cerebral substance. These cases were mistaken for pernicious intermittent fevers, and Avere treated merely with quinine. We do not see the difficulty Avhich some have experienced in explaining such cases. It is knoAvn that in- flammation of the brain sometimes steals on so sloAvly and in- sidiously, especially in aged persons and in weakly constitutions, as to produce comparatively slight symptoms, though serious dis- ease be in progress. Supposing intermittent fever to be super- added to such a case, it is intelligible that the intermissions might be exempt from delirium, coma, and any marked degree of fever; whereas, the supervention of the paroxysm, by congesting the brain in common Avith all the other internal organs, Avould fur- nish an additional source of irritation, sufficient to impart an acute character to the cerebral symptoms, and produce delirium, convulsions, and coma. We have more than once Avitnessed this train of phenomena in the pernicious intermittent fevers of Rome, complicated Avith cerebral inflammation; and have seen such cases successfully treated by large doses of quinine every tAvo to four hours, in conjunction Avith antiphlogistic treatment addressed to the head. The explanation now offered is still more intelligible in reference to chronic inflammation of the brain, and it is principally this Avhich presents the intermittent character. It will hereafter be seen that organic disease of the brain may also be intermittent, and that an analogous explanation applies to them. Anatomical Characters of Cerebritis. The substance of the brain, when sliced, presents an increased degree of scarlet dot- ting, the dots being larger, more numerous, and of a more vivid red than natural. The French have compared this to a sprink- 76 INFLAMMATION OF THE BRAIN. ling Avith red sand. There is also an increase of red, hair-like streaks, from vessels cut longitudinally or obliquely. These ap- pearances are occasioned by the injection of naturally colorless capillaries. Moreover, there are small, cloudy, red stains, of various forms, sizes, and depths of color, sometimes as deep as purple or chocolate, which impart a marbled or variegated ap- pearance to the surface of the section. When a number of these smaller stains coalesce, they form large red patches, generally Avith a soft blending circumference. The stains probably result from rupture, before death, of gorged capillary vessels. The in- flamed portion of brain presents, in its earliest stage, a slightly increased degree of firmness, resulting from vascular turgescence; but it is, at the same time, more lacerable than natural. These characters may be scattered in various parts, or they may affect a large continuous extent, even the Avhole brain; and the gray substance, from its greater vascularity, is more subject to them than the white. Thus, of 41 cases by Lallemand, the gray substance was the principal seat of the inflammation in 33, and the white in 8 only. If extensive, the inflammation may be fatal in this early stage of mere vascular congestion, and that too with coma- tose symptoms, erroneously ascribed, by old Avriters, to effusion alone; for tumefaction of the brain from vascular engorgement is no less calculated than effusion to occasion compression. If the inflammation be limited in extent, it commonly passes on to the next stage, that of— Softening. Here the increased firmness is replaced by morbid softness to the touch; a pulpiness is next visible to the eye; and, finally, the softened portion is broken up into a disorganised dif- fluent matter, intermixed Avith remains of cellular and vascular tissues. The color of softening mainly depends on the previous quantity of blood in the part. If it was a deep red colour, the blood is never wholly absorbed; but, mixed with pus, is changed from red to chocolate, and then successively to brown, dirty green, and gray. Some have assigned to this the appellation of " red softening." If the redness was originally slight, the blood is so far absorbed as merely to impart a dirty, greenish tinge to the pale yelloAv color, Avhich results from purulent infiltration, at first appearing in detached points, and then gradually pervading the Avhole diseased portion. To this the epithet, " yelloAv soften- ing," has been assigned. The red and yellow varieties may, of course, coexist in the vicinity of each other. In the midst of softened portions of brain, extravasations of blood are very apt to take place,'in consequence of disorganisation and rupture of con- siderable vessels. They present a number of reddish-black spots, varying from the size of a pin's head to that of a pea, or more. It is important that this be distinctly understood, lest such soften- ing be confounded with that which is merely consecutive to apo- pletic extravasations, instead of being the cause of them. There Cerebritis—Anatomical Characters. 77 is a third variety of softening, which is of a pure blue white, often like curd, or whipped cream, sometimes glistening like satin, and always moistened Avith serum. vThis is sometimes a result of inflammation, and sometimes not. Abercrombie has satisfactorily demonstrated it to be a result of inflammation Avhen preceded by inflammatory symptoms, as those of acute hydro- cephalus, and when accompanied by other anatomical vestiges of inflammation in its immediate vicinity, as softening, abscess, and effusions of lymph, serum, and pus, into the ventricles. The parts in which he has seen this inflammatory Avhite softening are the corpus callosum, the septum lucidum, the fornix, and the cerebral substance immediately surrounding the ventricles. He ascribes it to gangrene, from suspension of the circulation by the intensity of the inflammation. On the contrary, white softening is not inflammatory when it occurs in aged persons, affected with disease of the arteries at the base of the brain, and presenting the symptoms of " creeping palsy." This form has been particu- larly described by Rostan, who, as well as Abercrombie, ascribes it to gangrene from interruption of the circulation by disease of the arteries. Suppuration and Abscess. It has been stated that inflamma- tory softening is attended with a secretion of pus. This appears first in detached globules, which, multiplying, enlarging, and coalescing, eventually form collections or abscesses. The number of these may be one or tAvo, or may amount to five, six, or more; but small collections, contiguous to each other, are apt, as the disease advances, to coalesce by extension, and form larger ab- scesses. Suppuration takes place in the brain as rapidly as in other parenchymatous organs. Laennec states that he has knoAvn it to occur Avithin twenty-four hours. In one of Dr. Abercrom- bie's cases several small abscesses were found after four days' illness. Abscesses, Avhen recent, are circumscribed by the cere- bral substance alone, which being softened, and more or less broken down, forms an irregular, undefined boundary. The pus within the abscess is sometimes pure and of a yelloAv or greenish- yellow color; but in other instances it is mixed Avith shreds and fragments of disorganised brain, diluted Avith a thinner fluid, and discolored by blood, Avhich, in different stages of decomposition, presents various tints of brown, dirty green, and gray. Such are the appearances presented by abscesses if the patient have died Avithin a Aveek or ten days; but if he have survived this period, the abscess gradually becomes lined by a cyst, formed by succes- sive layers of coagulated lymph: the lymph at first appears here and there like cellulo-vascular tissue: a little later it forms a fine soft membrane, which may with care be detached from the cere- bral substance: finally, the membrane presents a distinct organi- sation, and is so firm as to admit of being detached Avith consi- derable facility. Though the first traces of a membrane have 7* 78 INFLAMMATION OF THE BRAIN. been observed at the expiration of a week, three or four gene- rally elapse before it attains the perfect organisation noAV de- scribed. When abscesses are throughout of chronic formation, Avhich is most apt to be the case in scrofulous subjects, or in con- nection with disease of the bones of the cranium, the cyst is Avont to be much thicker, and sometimes to consist of tAvo or more layers, separable from each other. The internal layer we have often observed to present a soft pulpy aspect, not unlike the vil- losity of a mucous membrane; beneath this is a thicker and firmer layer, like indurated lymph or albumen; and externally is a more lax cellulo-vascular tissue, forming the medium of adhesion to the cerebral substance. The pulp Avithin these chronic abscesses is more commonly of a foul, green color, and sometimes it is ex- ceeding fetid, more especially in abscesses connected Avith disease of the ear. The most common seat of abscesses, Avhether acute or chronic, is Avithin the interior of any part of the hemispheres; but there is no portion of the brain which is exempt from them. The cerebellum is less subject to abscess than the cerebrum, and the medulla oblongata still less than either. Abercrombie records the case of a young girl, in whom the left lobe of the cerebellum was entirely converted into a bag of purulent matter of a greenish color and intolerable fetor. The cerebral substance surrounding recent acute abscesses is ahvays found softened; for, in fact, the abscess is the focus of the previous softening: but chronic abscesses often present little or no alteration of the con- tiguous cerebral substance, and hence Ave derive an explanation of the Avell ascertained fact, that such abscesses may, for an in- definite period, be unattended Avith material symptoms; a time however at length arrives, Avhen, either from the enlargement of the abscess, or from its internal changes, or from some external determining cause, the cerebral substance becomes irritated, in- flamed, and softened; in connection Avith which morbid actions, supervene unequivocal symptoms of chronic cerebritis, or at least of a serious organic affection, which proves speedily fatal. When chronic abscesses, by enlargement or extension, reach the surface of the brain, they sometimes, after implicating, or even penetrating, the membranes, occasion disease of the cranium itself. In this manner the petrous portion of the temporal bone and the internal ear have frequently been disorganised, and the same has occasionally happened to the aethmoid bone, the matter of the abscess being not unfrequently evacuated through the ear or the nose. We do not think that abscesses of the brain, like those of external parts, have a tendency to open towards the surface or the ventricles; for the support of the cranium renders the pressure equal in all directions; Avhich is not the case in other parts of the body, where, consequently, abscesses travel in the direction Avhich offers least resistance. Ulceration. By this is meant an erosion, Avith depression, of Cerebritis—Anatomical Characters. 79 one of its surfaces, the ulcer having a rough, irregular base, cov- ered Avholly or in part by soft lymph, sometimes intermixed with blood. The surfaces affected are principally those of the cere- brum, the cerebellum, and the ventricles; but the pons, medulla oblongata, and spinal cord are not exempt. Vascular injection of the pia mater, Avith thickening, and sometimes with erosion, is always found in the vicinity of superficial ulcers; Avhence it is more than probable that it is a result of local inflammation of the pia mater. Softening of the cerebral substance is occasionally found beneath the base of the ulcer, and is most commonly con- fined to the gray substance, but sometimes it penetrates more deeply. The extent of ulcers varies from a line to tAvo or three inches or more, but we have generally found them under an inch. Their depth may amount to an inch, but is more commonly limit- ed to tAvo or three lines. They produce the obscure symptoms of chronic cerebritis. Induration, the converse of softening, is sometimes occasioned by the same cause, namely inflammation. When general, that is, affecting the greater part or the Avhole of the brain, the degree of hardness never exceeds that of brain Avhich has been immersed for some time in dilute nitric acid. The induration is not always equal throughout the Avhole of the parts affected, the central me- dullary parts usually exhibiting a higher degree of it than the gray substance. A section of the indurated portions generally presents increased vascularity in the usual speckled and striated form; yet the reverse is occasionally observed, the brain being preternaturally Avhite. This general induration is usually ascribed to acute inflammation; yet there is reason to believe, that the in- flammation is of a less active kind and of longer duration than that which produces acute softening; for general induration has been observed principally after protracted typhoid fevers, in Avhich inflammation is usually of a low type, and in the insane, who have presented cerebral symptoms of old standing. When indu- ration is partial, Avhich is much more common, it may be as firm as neAV cheese or even Avax, or, if elastic, as fibro-cartilage. The color may either be red, from increased vascularity, or it may re- semble yellow fibrous tissue, or it may be white, from diminished vascularity. Chemical analysis proves that the change is referri- ble to a great increase of albumen. It may affect any part of the brain, but is more common in the interior than in the convolutions of the surface. Its extent is generally limited to one, two, or three inches. It occasionally proceeds to softening. Partial in- duration is always the result of inflammation of the chronic form, giving rise to perverted nutrition, the elementary or nutritive par- ticles of the part affected being harder and more albuminous than natural. It has been Avell pointed out by Abercrombie, that par- tial induration may be the origin of many organic tumors. We may here remark incidentally, and merely for the purpose so INFLAMMATION OF THE BRAIN. of indicating a general analogy, that the spinal cord is subject to inflammatory lesions, identical in their nature with those of the brain; namely, to inflammation of the membranes, Avith thicken- ing and the usual effusions of serum, lymph, and pus, and to soft- ening, suppuration, abscess, ulcer, and induration of the medullary substance. These Avill be more fully considered under Spinal Diseases. Comparative frequency of the several forms of cerebral in- flammation. Inflammation of the dura mater, exclusive of that produced by fractures and other surgical affections, is, perhaps the most rare variety. The phrenitis of old authors, that is, inflam- mation of the membranes and surface of the convexity of the brain, with furious delirium and rapid sinking, is not, according to our observation, a frequent affection in this country; but it is much more common in tropical climates, Avhere inflammations in general are characterised by intensity and rapidity of progress. Inflammation of the central parts of the brain, Avith or Avithout effusion in the ventricles, and not unfrequently conjoined with meningitis at the base or on the hemispheres, occurring princi- pally in children, and running a protracted course of fifteen to thirty days, Avith two or three Avell-marked stages, is an affection Avhich, under the designation of hydrocephalus, is perhaps not surpassed in frequency by any other single variety of cerebral inflammation. General acute cerebritis is rare; partial is pretty common, especially Avith more or less meningitis; chronic partial cerebritis is perhaps equally, or even more, common. Predispositig causes. 1. Scrofula may be mentioned as a pre- disposing cause, since it imparts a proclivity to slow inflamma- tion of the brain, in common with many other organs and tissues of the system. It also predisposes indirectly, by favoring the de- velopment of various chronic diseases, as inflammatory and other derangements of the stomach, boAvels, and liver, worms, otitis, numerous cutaneous eruptions, &c. all of v/hich affections may ope- rate as exciting causes of inflammation of the brain. Hence, it is mainly in delicate, scrofulous children that we witness the sIoav form of hydrocephalus. 2. Hereditary irritability of the nervous system in general, and therefore, of the brain in particular. This, again, obtains principally in the scrofulous. 3. Early age, because the head and cerebral vessels are proportionably larger in the youthful periods of life; also, because infants and children are more subject than adults to irritations, from dentition, Avorms, derange- ments of the stomach, bowels, liver, &c. The most common age, according to Guersent's observations, is from five to fifteen. The tables of MM. Parent and Martinet, indeed, assign the period be- tween fifteen and sixty as the most common; but a fallacy, which they have overlooked, resides in the circumstance, that their cases Avere principally collected in an hospital devoted to adults. Thus, out of 180 cases by these authors and Lallemand, 139, that is, Causes. 81 nearly |ths, Avere above the age of fourteen! The fallacy is self- evident from these numbers alone, as the personal experience of every practitioner Avill satisfy him, that the proportion of cerebral inflammations in children is far from being so small as is here indicated. 4. Advanced age predisposes to partial cerebritis in the subacute and chronic forms; probably because disease of the arteries of the brain is most prevalent at that period of life. 5. The male sex predisposes in adults: thus, of 116 cases by Parent and Martinet, 88, or more than Iths, Avere male. The cause of this probably resides in the fact, that males are more subject to external injuries of the head, to exertions and fatigue, and to every form of dissipation and excess; circumstances which give rise to inflammation not only directly, but indirectly, by exciting disease of the heart and of the arteries of the brain. 6. Preco- cious talent in children, subjecting the brain to inordinate and premature excitement. 7. Habits of immoderate and intellectual exertion in adults, over-stimulating the brain, and causing active determination or congestion, as formerly explained. 8. Sanguine, ardent, and violent temperaments. 9. Plethora, especially if con- nected Avith a large head, short neck, and square frame. 10. Hypertrophy, Avith or without dilatation of the left ventricle, Avhich acts by violently propelling an inordinate quantity of blood into the cerebral arteries. 11. Obstructions in the heart from valvular disease, dilatation, and softening, sometimes, though rarely, produce inflammation, but by a converse mode of opera- tion, namely, by impeding the return of the venous blood from the brain. Exciting causes.—Inflammation of the brain is very rarely a result of the ordinary exciting causes of inflammation in general namely, cold folloAving heat or perspiration and fatigue. In the immense majority of cases it is a secondary or symptomatic affection, as will be perceived from the following numerous list of exciting causes, Avhich cannot be too attentively studied by the young practitioner:— 1. Febrile diseases are by far the most frequent causes, espe- cially continued fever, scarlatina, variola, pertussis, rubeola, ery- sipelas of the head, and other cutaneous diseases of that part. Thus, according to Dr. CraAvford, (Cyc. of Pr. Med. vol. i. p. 309,) of 864 cases of continued fever, in a fever hospital, 602, that is nearly fths, exhibited cerebral symptoms. In scarlatina, inflammation of the brain is apt to come on, frequently in con- nection with inflammatory anasarca, betAveen the tenth and twentieth days after the disappearance of the eruption. The convulsive and comatose symptoms were formerly mistaken for the consequences of mere dropsy affecting the brain, in common Avith the rest of the body. It is noAV hoAvever fully ascertained that the affection is inflammatory, and the patient only to be rescued by prompt and vigorous antiphlogistic treatment, Avith 82 INFLAMMATION OF THE BRAIN. the use of mercury. So rapid are many of the cases connected with this and other cutaneous eruptions, that Gdlis has designated them by the epithet water-stroke (Avasserschlag,) serous effusion, generally turbid from lymph or pus, being commonly found in the ventricles after death. In measles, meningitis and bronchitis are almost the only sources of immediate danger. The inflam- mation appears to be propagated from the nasal mucous mem- brane to the interior of the head. In erysipelas of the head it is propagated by contiguity, and not, as was formerly supposed, by metastasis, that is, a desertion of the external part, and a con- centration on the internal organ; for the inflammation does not necessarily, or even generally, desert the exterior. We suspect, however, that Avhen the external vessels are constricted by cold applications, a vicarious determination is apt to take place to the internal; for Ave have rarely known cerebral inflammation to occur in erysipelas of the head treated Avith Avarm fomentations, but Ave have repeatedly noticed the reverse. In pertussis, the engorgement of the head by the paroxysms of cough, appears to be the determining cause of the cerebral irritation and inflamma- tion. We have known slight convulsions folioav every paroxysm. Gout and acute rheumatism are reputed, but, according to our personal observations, unfrequent, causes of inflammation of the brain. Scarcely less rare are parotitis, nephritis, and testitis.* 2. External injuries of the head, as blows, concussions, Avounds, &c, are much more frequent causes of cerebral inflam- mation than is generally supposed. This is especially the case with young children, in Avhom the fall or blow is overlooked or * Diseases, which are attended with an altered condition of the blood, all more or less directly predispose to meningitis. Of these the most promi- nent are the albuminous disease of the kidneys, and indeed all forms of renal disorder, in which the peculiar secretions of the kidneys are not elimi- nated from the economy; jaundice, whether connected with organic diseases of the liver or not, and the strongly marked inflammatory diathesis which coexists with pneumonia, and is attended by a large proportion of fibrine in the blood. The cerebral inflammations which occur in fevers, may be ascribed in great part to the action of the same cause, we mean the secondary inflammations which occur in the latter stages of continued fever. The most obscure of these secondary cerebral inflammations, are those which occur in jaundice and in the albuminous disease of the kidneys. In these diseases the functional disorder of the brain forms an essential part of the disease, if it be long protracted, or if the alteration of the blood be great; this functional disorder then passes by insensible degrees into a sub-acute form of inflamma- tion, which is not attended by severe symptoms, and is therefore recognised with great difficulty. The symptoms are generally more connected with slow alteration of the intelligence, and the other cerebral functions than active excitement or decided delirium. Causes. S3 forgotten, because two, three, or more weeks may elapse before formidable symptoms make their appearance. Though the patient have recovered from the immediate effects of an injury, it often leaves the brain in an irritable state, and predisposed to inflammation on the application of an exciting cause, hoAV- ever slight. Thus, some are unable for months, or even years, to take wine, spirits, fermented liquors, or even animal food, with impunity. A glass of spirits has often been knoAvn to produce delirium, and we once saAV intoxication occasioned by a basin of broth, after farinaceous diet had been employed for several Aveeks. Under the denomination of external lesions, Ave may range deep-seated inflammation of the ear, the nose and the eye; also syphilitic and other diseases of the cranium subjects on which Ave have already descanted as exciting causes of inflammation of the dura mater especially. We once saAV fatal meningitis (phrenitis) follow the extraction of a tooth Avhile the gum was inflamed. The accidental ligature of considerable nerves about the neck in surgical operations for aneurism, &c, has been knoAvn to produce the same effect. 3. Powerful and frequent exciting causes of cerebral inflam- mation, especially in children, are to be found in various com- plaints Avhich seem to act by propagating to the brain an irritation from the sentient extremities of the nerves of the part affected: for instance, irritation and inflammation of the gums during dentition; the irritative or inflammatory diarrhoea accompanying dentition; the same, in infants and children, independent of den- tition, and often called infantile remittent fever; tabes mesente- rica, marasmus, &c; worms in all their varieties; disease of the liver, and pneumonia in children. Phthisis is added by authors to this class, but we think it rare, as we have never witnessed an instance: perhaps the cerebral inflammation is only a result of the same scrofulous constitution which had generated the pulmo- nary tubercles. 4. Suppressed natural evacuations and morbid discharges con- stitute another class of exciting causes. Amenorrhoea and con- stipation are the most common; the effect of constipation, for instance, in occasioning headache, is notorious. Ischuria renalis, though unfrequent, is one of the most formidable suppres- sions, as coma may supervene in about three days, and prove fatal in a few days more. The ventricles are usually found dis- tended Avith fluid. Bleeding haemorrhoids abruptly checked in plethoric persons, Avithout the substitution of some suitable vica- rious evacuations; entensive chronic ulcers hastily healed under similar circumstances; and chronic cutaneous eruptions, especially about the head, as crusta lactea in children, Avhen prematurely repelled by external applications, are also exciting causes apper- taining to the present class. The Avhole act by exciting vascular plethora of the system in general, and sometimes of the head 84 INFLAMMATION OF THE BRAIN. alone, Avhen that organ happens to be unusually predisposed. The modus operandi is strikingly illustrated by the experiment of injecting Avater into the veins of animals, when delirium and coma are produced, unless the animal have been previously bled. 5. The folloAving exciting causes are direct irritants of the brain:—Habitual intoxication: intense and protracted study; habitual straining of the eye, as by microscopic or telescopic pursuits, and vivid lights; straining of the ear by loud sounds; all the more violent passions of the mind, as rage, grief, anxiety, jealousy, love, hatred; stooping professions, Avhich congest the cerebral vessels—a cause Avhich Ave have noticed especially in gardeners, floor-cloth makers, farriers Avho shoe horses, Avhere the stooping is accompanied by much corporeal exertion. Habitual and violent nervous or bilious headaches, or tic douloureux, oc- casionally become inflammatory; exposure to the direct rays of a hot sun, called insolation, coup-de-soliel, &c, which mostly occa- sions meningitis, but sometimes mania, and sometimes apoplexy, if coporeal exertion attend the exposure. Long endurance of intense cold may also excite meningitis, sometimes Avith most furious delirium, of Avhich many striking instances occurred in the disastrous Russian campaign of Buonaparte. Opium, the effects of Avhich in exciting headache, and even delirium in some constitutions, are familiarly known; but it is comparatiA^ely little knoAvn, though it ought to be notorious, that the most minute doses, often administered secretly by impatient nurses to pacify irritable infants, may be productive of fatal consequences. Hyos- cyamus and belladonna given in excess, particularly, as Golis remarks, for the cure of pertussis; stramonium, strychnia, Avhich Ave have several times known to produce the most alarming con- vulsions and coma; apoplectic extravasations, Ayhich, by irritating the surrounding cerebral substance, excite inflammation and softening; tumors and other organic diseases of the brain, Avhich may act in a similar manner. Diagnosis. We shall first recapitulate the pathognomonic symptoms of inflammation of the brain in general, adding the explanations of them so far as appears to us possible in the pre- sent state of science; for Ave feel confident that a thorough know- ledge of these symptoms is one of the most important elements in the diagnosis ; since it keeps the practitioner's attention alive to the very first indications of cerebral inflammation, often over- looked from inadvertence, and thus leads him to institute a search- ing and jealous inquiry into all the circumstances of the case. We shall, secondly, point out the diagnosis of the several varieties of cerebral inflammation from the diseases Avith Avhich thay may be respectively confounded. I. As the symptoms of inflammation of the brain in general are numerous, and difficult to register in the memory, Ave shall Causes. 85 endeavor to simplify them by adopting, with Abercrombie, an arrangement according to their seats. In the head. Violent headach, Avith throbbing and giddiness, especially if the pain be referred to a particular spot and ahvays in the same part; sense of weight and fulness, or of tension and constriction, tinnitus, stupor, a great propensity to sleep. In many obscure and insidious cases, a constant feeling of giddiness is the only remarkable symptom. The headach, tension, and .throbbing, are referrible to vascular fulness; and the giddiness, droAVsiness, and stupor, to compression of the brain by vascular turgescence or by effusion. It is not generally knoAvn, but we think it a demonstrable fact, that the brain is actually swollen from vascular turgescence during inflammation. This may occasion every de- gree of coma and paralysis from pressure, even in the first stage, the pressure in one part probably occasioning an obstruction to the circulation in another: in the later stages, the pressure may result either from this cause of from effusion in various parts; or the symptoms may result from disorganisation. In the eye. Intolerance of light; unusual contraction or dila- tation of the pupil; squinting; distortion of the eyes outwards; paralysis of the muscles of the eyelids, producing, according to the muscle that is affected, either the shut eye, (ptosis,) or the gaping eye, (lagophthalmia;) transient or permanent blindness, or double vision; objects seen that do not exist; along-sighted person suddenly recovering ordinary vision. The impatience of light is from augmented sensibility; the remaining symptoms are principally from various degrees of com- pression in various situations. It is not, perhaps, positively de- termined, Avhy the pupil is sometimes contracted and sometimes dilated ; and Avhy, in many cases, these conditions rapidly alter- nate. Contraction, hoAvever, in the early stages of inflammation of the brain, appears to depend on irritation of the optic nerve; and dilatation, in the later stages, on its compression, Avhile oscillation between the tAvo probably depends on a fluctuating action of the nerves and muscles of the iris. Strabismus or squint- ing depends on compression, occasioning more or less paralysis of the third or oculi-motor nerve; and it presents different varie- ties, according to the number and situation of the branches im- plicated. Thus, when the eye is distorted imvards, the tonic action of the internal rectus or adductor muscles of the eyeball prevails over that of the opponent muscles, which are paralysed. When the eye is distorted outwards, the abductor muscles sup- plied by the sixth nerve is unaffected, whilst the adductor, sup- plied by the third, is paralysed. The tonic action of the superior oblique, co-operating with that of the abductor, turns the eye upAvards and outAvards. Rolling of the eye is from clonic or intermittent action of the several muscles. Compression of the third nerve is also the cause of the closed eye or ptosis, the leva- 8 S6 INFLAMMATION OF THE BRAIN. tor palpebrae muscle, supplied »by this nerve, being paralysed. The open eye is occasioned by complete paralysis of the seventh nerve, the excito-motory branch of which supplies the orbicularis oculi, Avhich is the sphincter muscle of the eye. This muscle is not paralysed in hemiplegia from pressure restricted to the oppo- site hemisphere; as, for instance, that occasioned by a small extravasation; because the excito-motory branch (which springs from the gray matter of the medulla oblongata) is not compressed; but if the extravasation be near the medulla oblongata, so as to compress it; or if it, or any other cause of pressure in one hemi- sphere, be so considerable as to compress the Avhole brain, the excito-motory branch may participate in the effect, and the orbi- cularis oculi may be more or less paralysed. The common cause, hoAvever, of its paralysis, is compression of the seventh nerve in its course either Avithin or without the cranium; as, for instance, by an internal tumor, by SAvelling of the parotid gland, &c. The open eye, therefore, is independent of cerebral disease in some cases, and dependent on it in others; whereas the closed eye and strabismus are almost ahvays cerebral affections. Blindness, (amaurosis,) transient or permanent, results from compression of the optic nerve by pressure, general or local, within the cranium. hi the ear. Unusual acuteness of hearing, Avith intolerance of sound; great noise in the ears, (tinnitus;) transient attacks of deafness. The acuteness and intolerance proceed from exalted sensibility, and the deafness from compression of the eighth or auditory nerve. The tinnitus may exist in connection with either cause. In the speech. Indistinct or difficult articulation; unusual quickness or unusual sloAvness of speech. Difficult or sIoav arti- culation proceeds from compression of the portio minor of the fifth, distributed to the temporal, masseter, buccinator, and ptery- goid muscles; the portio dura of the seventh, distributed to the external voluntary muscles of the face ; and the lingualis, a volun- tary muscle of the tongue. Unusually quick articulation (which Ave have also observed to be generally hesitating) results from cerebral excitement. We have also noticed quick movements and much Avinking of the eye to be concomitant and very cha- racteristic phenomena. In the pulse. Slowness; remarkable variations in frequency, occurring repeatedly even in the course of a minute. The sIoav- ness proceeds from compression, Avhether that of cerebral tume- faction or of effusion, its effect being, as in apoplexy, to retard the action of the heart. The variability is probably from an irregular transmission of nervous power. SloAvness is a deceptive phenomenon, as it disguises fever; yet, in connection with other cerebral symptoms, it is highly characteristic and suspicious, and it can scarcely be mistaken if accompanied by variability. In the mind. High delirium; transient fits of incoherence; Causes. S7 peculiar confusion of thought; and forgetfulness on particular topics. These proceed from disturbance of the intellectual func- tions of the brain, i. e. memory, attention, judgment, &c. High delirium is generally connected with inflammation of the mem- branes on the surface of the hemispheres, and Avith its acute stage. Some explain this by maintaining that the gray matter of the convolutions is the source of mental power, as the gray matter of spinal cord is of motive power. Hence, in disease of the base and centres of the brain, convulsive and paralytic affec- tions usually precede disturbance of the intellectual functions. In the muscles. Paralytic and convulsive affections, some- times confined to one limb, or even to part of a limb; a state of rigid contraction of particular limbs. Paralysis, Avhen universal, proceeds from general compression, with obstructed circulation, within the cranium, occasioned either by cerebral vascular tume- faction, or by effusion, or both. We see the same in apoplexy, either from extreme extravasation into the substance or ventricles of the brain, or from widely diffused extravasation from the ves- sels of the pia mater on the surface of the hemispheres. Convul- sions, according to Avriters on the true spinal or excito-motory system of nerves, proceed from irritation of this system. When occurring in meningitis of the hemispheres, and before compression may be supposed to have taken place, they are ascribed to irrita- tion transmitted through the nerves distributed to the membranes, as Arnold's recurrent of the fifth. When occurring in meningitis, with copious effusion on the surface; in meningitis of the base or ventricles; or in cerebritis, they are ascribed to pressure irritating the medulla oblongata, corpora striata, &c. Avhich constitute the superior extremity of the true spinal column or gray matter of the cord. Dr. M. Hall states, in substantiation of this vieAv, that in a girl, aet. 13, croup-like convulsions occurred repeatedly, until one day, when the bones of the cranium separated, Avhich put a final period to them. In another case, croup-like convulsions occurred Avhenever the child, affected with spina-bifida, Avas turned so as to press upon the tumor. In the case of an acepha- lous foetus, described by Mr. LaAvrence, convulsion Avas produced by pressing on the medulla oblongata. In a case of meningitis given by Dr. Abercrombie, convulsion was induced by pressure on the anterior fontanelle, which became very prominent. Hy- pertrophy of the brain induces convulsions, unless the cranium groAV Avith the brain. Rigid contraction of limbs is referred to the same source ; for all spasm, whether clonic as in convulsion, or tonic as in rigid contraction, is assumed to depend on the excito-motory system. When either paralysis or spasm is partial, it is connected Avith partial disease, or, in other Avords, with less extensive pressure and irritation Avithin the cranium. We have frequently seen spasm of one side of the body, or of individual muscles, with paralysis of the opposite side, or of other individual 88 INFLAMMATION OF THE BRAIN. muscles; but the coexistence of spasm and complete paralysis in the same muscles is possible, because the excito-motory nerves cannot excite paralysed muscles. Dr. Hall explains the following practical remark of LalLemand on excito-motory principles:—" In inflammation of the arachnoid," says Lallemand "there are spasmodic symptoms without paralysis;" i. e. says Dr. Hall, from irritation Avithout paralysing compression; " in haemorrhagia, sud- den paralysis without spasmodic symptoms;" i. e. from paralys- ing compression rendering spasm impossible; "in inflammation of the substance of the brain, spasmodic symptoms, and sloiv and progressive paralysis;" i. e. from irritation at first, gradually superseded by paralysing compression or disorganisation. In the organs of touch. Diminution or loss of sensibility in a limb, or often in a very small part of a limb, and various morbid conditions of sensation. These phenomena proceed from more or less extensive and complete paralysis of nerves of sensation, and are connected with the same causes as paralysis of the nerves of voluntary motion. Such are the symptoms indicating disturbance of the cerebral functions. The student must not however expect all, or even many, to be simultaneously present; but the existence of one or two should be sufficient to awaken his suspicions. It has been well remarked by Abercrombie, that in this important diagnosis minute attention to the correspondence of the symptoms is of more importance than any particular symptom: thus, the peculiar oppression Avhich accompanies a high degree of fever is familiar to every one, and is not reckoned an unfavorable symptom; the same degree of oppression occurring Avithout fever, or Avith very slight fever, Avould indicate a cerebral affection of the most dan- gerous character. In the same manner, a degree of headach and delirium, Avhich, accompanying a high degree of fever, would be considered as symptomatic; accompanying slight fever, would indicate a dangerous affection of the brain. We now proceed to point out the diagnosis betAveen the several varieties of inflammation of the brain and the diseases with Avhich they may respectively be confounded. These diseases are, mania, continued fever, delirium tremens, apoplexy, active determina- tion and congestion of the brain in various diseases of infancy, exhaustion, and hysterical, neuralgic, rheumatic1 bilious, and dyspeptic headachs. Meningitis of the convexity of the hemispheres, Avith fierce delirium (phrenitis), is distinguished from mania by the more or less complete absence of fever and disturbance of the digestive organs, together Avith the prolonged course, which characterise mania. The diagnosis of meningitis, both superficial and central, from continued fever Avith cerebral disturbances (typhus mitior; fievre nerveuse, ou ataxique essentielle,) is certainly very obscure. The Causes. S9 symptoms of cerebral excitement sometimes commence as early in the fever as in meningitis, but more commonly they are later, not appearing till after the lapse of tAvo or three days or more. The nature of the symptoms may, at the onset, be much the same in both; but the progress of the two affections soon renders mani- fest a remarkable difference betAveen them. The typhus fever is characterised by restlessness in a high degree, by anxiety, low delirium, and spasm, in the form of subsultus tendinum, but sel- dom more; and these symptoms often alternate with intervals of calmness and even of sleep, especially in the morning. In me- ningitis, on the contrary, there is comparatively little restlessness, except in the phrenitic variety, when there is Avild delirium, but not the peculiar restlessness of fever; the muscular symptoms are distinct convulsions, spasmodic rigidity, or paralysis; they occur in connection with a state either of delirium, decided somnolency, or complete coma; and these symptoms are more or less perma- nent, seldom exhibiting intermissions, except occasionally in the earliest stage. The pulse in fever does not fall beloAv its natural standard, display singular fluctuations in frequency, and finally rise to an extreme degree of acceleration before the fatal event- circumstances which are highly characteristic of meningitis; nor is the respiration suspirious and irregular in fever, as in meningitis. Finally, in the later stages of fever there are, a parched, broAvn, crusted tongue, Avith sordes on the teeth; dark, offensive faecal evacuations; tympanitic abdomen; sometimes petechiae; low mut- tering delirium; the supine posture; slipping down in bed; symp- toms Avhich, taken in connection with the absence of the pathogno- monic symptoms of meningitis, render the diagnosis so distinct, that the two diseases can scarcely be confounded. We have seen cases of general cerebritis present symptoms at the onset very like those of low fever; but these may be detected with little difficulty by observing that the headach is more intense and permanent than corresponds with the degree of fever, and that it usually increases in intensity as the pulse falls—a most suspicious circumstance, especially if the pulse also fluctuate and the respiration be suspirious and irregular. Such are the most prominent diagnostic criteria between inflammation of the brain and fever. Delirium tremens is distinguished by the absence of the head- ach; by the peculiar tremors; by the singular hallucinations and spectral illusions, inspiring fear in the patient; by the remarkable wakefulness; by the tractability and unoffensiveness of the deliri- um; by the copious clammy perspiratious; and by the history being that of habitual inebriation: on the contrary, there is ab- sence of the somnolency, coma, convulsive and paralytic affec- tions, and slowness of the pulse, Avhich characterise inflammation of the brain. , Apoplexy is distinguished by its invasion being abrupt, the 90 INFLAMMATION OF THE BRAIN. paralysis sudden and complete, and the course of the disease short and rapid; Avhereas, in partial cerebritis, there are most frequently premonitory symptoms; tonic or clonic spasms generally precede the paralysis, Avhich supervenes more gradually, and the course of the disease is irregular and comparatively slow. It must not, however, be forgotten that, Avhen cerebritis is excited by an apo- plectic extravasation, spasmodic symptoms, with delirium and fever, may folloAv the apoplectic phenomena. Active determination and congestion of the brain in various diseases of infancy, has already been elaborately noticed. In infants under a year old, the diagnosis requires the most scruti- nising attention. " The head hanging over the nurse's shoulders, and the half-closed eyelids," says Cheyne, "are alarming symp- toms; and in no other complaint do we observe the same knitting of the eyebroAvs unaccompanied Avith crying." There is a quiet, vacant, abstracted air in the face, from non-convergence of the pupils, very different from the lively, violent, and varying expres- sion, indicative of acute pain from other causes than cerebral dis- ease. There are no paroxysms of temper, Avith alternate exten- sion and retraction of the legs, as in colic and gripes. If, in addition to these symptoms, there be unusual Avakefulness, or unsound sleep Avith starting and crying, or obstinate screaming Avithout obvious cause; if, while awake, the infant seem drowsy, moan, roll its head restlessly on the pilloAV or the nurse's arm, or keep thrusting it backAvards against the pillow; if there be a shrink- ing and froAvning aversion to light, a contracted or dilated state of the pupil, or disobedience of it to light, and obstinately frequent vomiting not explicable by other causes, we may feel almost cer- tain, in the absence of great and rapid exhausting causes capable of producing some of the same symptoms (the hydrencephaloid disease), that we are dealing Avith the first stage of inflammation. If coma, dilated pupil, blindness, and strabismus, with or even without convulsions or spasms, have taken place, the nature of the case can scarcely be doubted, and the disease has made con- siderable advances. The same diagnostic symptoms are applicable to children above the age of one year, and they are rendered more distinct by the declarations or more intelligible manifestations of the patient with respect to pain, fever, and other circumstances. The most perplexing cases are those in which the cerebral symptoms are unusually masked by great previous exhaustion and emaciation from tubercular disease, dentition, and chronic gastro-enteritic (infantile remittent fever, tabes mesenterica, ma- rasmus). After scarlatina, likeAvise, the utmost attention is requi- site for two or three weeks to detect the very first symptom of inflammation of the brain, which, as already stated, generally supervenes in connection with inflammatory anasarca. The occurrence of severe headach should be regarded with the utmost Meningitis—Prognosis. 91 suspicion, as usually being the earliest sign. If neglected, con- vulsions, coma, and other formidable symptoms rapidly folioav. Worms are distinguished by the transitory nature of the head- ach, vertigo, dilatation of the pupils, convulsions, and vomiting, which they occasionally excite; by the absence of fever, of the sIoav fluctuating pulse, of the unequal suspirious respiration; and by the symptoms not presenting the progressive increase and regu- lar course usually observed in inflammation of the brain. Exhaustion, producing some cerebral phenomena resembling those of hydrocephalus, Avhence it has been called the hydrence- phaloid disease, is distinguishable by coldness and paleness of the surface, in connection with a very quick and feeble pulse, and by the occurrence of these symptoms after the operation of exhaust- ing causes. This important subject will be fully considered in an article appended to the present. The diagnosis of nervous, hysterical, neuralgic, rheumatic, and bilious and dyspeptic headach is so simple, as merely to require in the student a competent knowledge of these several affections. (See Cephalalgia.) Prognosis. Meningitis of the convexity of the hemispheres, though extremely rapid and dangerous if neglected, is perhaps the most tractable form if properly and vigorously treated. In- ternal arachno-cerebritis (hydrocephalus) is less tractable and more fatal. Before it Avas known to be an inflammatory disease, the sufferers died, almost without exception; subsequently, the mortality has amounted to about two-thirds; but, in consequence of improvements in diagnosis and the use of mercury, the propor- tion is noAV undergoing a considerable diminution. Cerebritis is the most dangerous form of cerebral inflammation, in consequence of the facility with which the organ passes into softening and dis- organisation. When chronic, and attended with progressively increasing palsy, complete recovery is exceedingly rare. Success, however, in the treatment of chronic cerebritis is daily on the increase, in consequence of its inflammatory nature being better understood; for formerly, under the supposition that the symptoms were nervous, neuralgic, rheumatic, dyspeptic, or from debility, they Avere treated with tonics, stimulants, and full diet. The general prognosis is more unfavorable, when inflammation of the brain appears during, or shortly after, other serious diseases, especially typhoid fever, the febrile exanthemata, pneumonia, apoplexy, epilepsy, and mania; because, in these maladies, the vital powers are already more or less exhausted, and in some the blood is diseased, Avhence active treatment is less easily borne. The same remarks apply to Aveakly, scrofulous constitutions, espe- cially Avhere several of the family have been affected by hydro- cephalus. The particular prognosis in individual cases is regulated by the symptoms. The following are favorable:—return of natural sleep 92 INFLAMMATION OF THE BRAIN. in contradistinction to somnolent stupor; return of the several secretions; viz. moisture of the tongue, Avith cleaning of its points and edges, and removal of dry sores from the gums and lips; gen- tle perspiration, or at least softness and coolness of the skin; a free secretion of natural urine, and an open manageable state of the boAvels; a simultaneous diminution of the heat of the head; a more equal and regular state of the pulse and respiration; and a corres- ponding amelioration of the other bad symptoms. The earlier this improvement takes place, the more favorable the prognosis; because, in the first stage, or the early part of the second, the dis- ease may not have proceeded beyond vascular turgescence, Avhich, by pressure and interruption of the circulation, is capable of pro- ducing the Avorst symptoms—convulsions, coma, paralysis, &c; yet, as the brain is not disorganised, the vascular congestion is susceptible of removal. An amelioration in the advanced part of the second stage, or later, ought to inspire less sanguine hopes, as effusions of serum, lymph, and pus, may have taken place, and may not admit of absorption; or, if the case be cerebritis, the effect may have been softening—a highly intractable affection. The unfavorable symptoms are, a continuance, notwithstanding suitable treatment of headach, heat, delirium, and Avatchfulness; or of coma, convulsions, strabismus, spasmodic rigidity, palsy, and a sIoav irregular pulse: finally, the mortal symptoms; namely, an exceedingly rapid and feeble pulse; relaxation of all the sphinc- ters, including the orbicularis oculi; singultus, aphonia, dyspha- gia, general muscular relaxation, Avith inability to move; collapsed cadaverous countenance, &c. Of chronic inflammation of the brain, or acute becoming chronic, the prognosis is ahvays doubt- ful, and the friends should be apprised that the disease may induce epilepsy, paralysis, mania, insania, or idiotcy. Treatment of Acute Inflammation of the Brain. The suc- cess of remedies for inflammation of the brain, hoAvever Avell selected, depends mainly on their being adopted at an early pe- riod, and with the utmost vigor that the circumstances authorise. The first twelve hours of an acute case are incomparably more valuable to the practitioner than a much longer period in a sub- sequent stage. The patient, especially if a child, should, during the early stage, be visited at least every tAvo or three hours, as success is surprisingly dependent on close watching. The reme- dies are, blood-letting general and local, active purgatives, cold applications on the head, mercury, and blisters. On these Ave place our reliance: others are merely subsidiary; namely, salines, diaphoretics, refrigerants, tartar emetic, digitalis, colchicum. Bleeding. Venesection should be performed Avhile the patient either stands or sits erect; the blood should Aoav in a full stream, and should not be checked till manifestations of approaching syncope are exhibited. In the more acute cases affecting healthy adults, from tAventy to forty ounces or upAvards will often be Meningitis— Treatment. 93 borne before syncope is induced, as this inflammation imparts to the system great tolerance of biood-letting. On the first symp- toms of reaction, namely, fulness of the pulse with heat and anx- iety, the depletion should be repeated to the verge of syncope a second, or even a third, time, within twelve hours, so as, if pos- sible, to keep doAvn and crush the complaint by preventing the full establishment of reaction. Dr. MaxAvell of Dumfries has carried blood-letting in hydrocephalus to a greater extent than any other individual, with the extraordinary success of curing sixty out of ninety cases! He placed the child in the horizontal posture, opened the jugular vein, closed it from time to time with the finger; so as to obviate syncope, and continued the depletion till the pulse became Avholly imperceptible. Insensibility fol- loAved, and sometimes persisted for several hours. The shock thus given to the circulation is said to have often immediately suspended the disease. Great, hoAvever, as Avas the success of this practice, it is not justifiable; for it is now Avell ascertained that blood-letting cannot safely be carried beyond the point at Avhich syncope Avould occur in the erect posture; that in the horizontal posture it is liable to be carried much farther; that coma, convul- sions, and even sudden death, may occur during the operation; or, if the patient escape the immediate effects, that he may fall into a state of dangerous exhaustion and anaemic debility. After one, tAvo, or three general bleedings, as above described, cupping or leeching, at suitably short intervals, Avill generally prove sufficient to control minor degrees of reaction. After a series of observations, Ave have not found arteriotomy attended Avith advantage, but the reverse; as the subsequent bandaging is injurious by heating the head. Opening the jugular vein is ap- plicable to young children, in Avhom the veins of the arm are so small and indistinct as to render venesection difficult, if not im- practicable. In infants, general bleeding is effected by leeching the hand or foot, the celerity of the discharge being promoted by immersion of the extremity in warm Avater. Paleness of the face is, in them, the indication of faintness, and marks the period when the depletion ought to be suspended. The quantity of blood to be draAvn cannot be specified, but must be regulated by the effect, taken in connection with the constitution, age, and sex, of the individual. It may, however, be stated in general terms, that, in the more active and acute cases, occurring in good constitutions, blood-letting, so long as it is indicated by a recurrence of reaction, may be carried to the utmost limits of the patient's strength; whereas, in sloAver and less active cases, occurring in feeble or scrofulous constitutions, in the aged, and in the course of, or after, other exhausting dis- eases, blood-letting can neither be borne to the same extent, nor does it produce the same good effects. In a large proportion of such cases—for instance, in the slow form of hydrocephalus— 94 INFLAMMATION OF THE BRAIN. cupping and leeching will often produce all the good effects Avhich can be derived from this mode of depletion. They may be prac- tised behind the ears, on the occiput, the nape of the neck, or between the shoulders. In France and Germany, we have seen the arms, the groins, and the feet preferred, Avhere the cerebral inflammation was connected with a suppressed haemorrhoidal or catamenial discharge; but it has appeared to us that, though this mode of procedure is eminently useful for precursory symptoms, direct depletion from the head is more certain and efficacious in actual inflammation. The same objection does not apply to leeching the inside of the nostrils, Avhen the patient has been sub- ject to epistaxis—a favorite practice Avith many German physi- cians. We may finally remark, that though Ave advise blood-let- ting to be carried to the utmost limits of the patient's strength in cases where it is indicated, yet the indications Avill generally cease at so early a period, when mercury is vigorously employed, that the total amount of blood abstracted will commonly be moderate. Cold applications on the head should be employed immedi- ately, the patient lying Avith the head and shoulders Avell raised, and the hair having previously been cut close or shaved. Eva- porating lotions alone are totally inadequate to the object. The most powerful of all methods is the cold dash, that is, a stream of cold Avater, as large as a quill, poured from an elevation of two or three feet on the head of the patient, a basin being held under the chin, and napkins around to prevent splashing. It may be continued for five or ten minutes, or till the patient complain of its being intolerable. It cannot be safely used during decided coma with a feeble pulse, since its sedative influence might over- whelm the poAvers of life. For the same reasons, it must be employed with caution in delicate children and in aged persons. This remedy is eminently suitable for making a decided impres- sion in the first instance: subsequently, if ice is not to be obtained, it may be repeated every two or three hours, or oftener, during the early stages, Avhilst there is heat of head and a good pulse. Evaporating lotions on a single fold of linen should be employed during the intervals, in order to maintain the effect and obviate the violent reaction which the sudden and brief application of intense cold naturally tends to produce. The efficacy of the cold dash may be increased by immersion of the feet in warm Avater, or, Avhat is more convenient, by enveloping them in a blanket Avrung out of hot Avater. The Avater in either case may be ren- dered stimulant by mustard powder. The cold dash, hoAvever, from being inconvenient and fatiguing to the patient, will seldom be used beyond a few times \vhen ice can be procured. This should be pounded, enclosed in a bladder Avithout air, and ap- plied on the head like a cap. Its situation should be changed every minute or tAvo, both to cool every part of the head, and to Meningitis— Treatment. 95 prevent the injurious effects which might result from a too pro- tracted application on one spot. By this mode of procedure its use may be continued for half an hour or more at a time, Avhen, if the Avhole head feel cool, evaporating lotions may be substi- tuted until a return of heat and flushing demands the re-applica- tion of the ice. This agent must be used with the same reserve as the cold dash in feeble constitutions, in the aged, in coma Avith a feeble pulse, and in the advanced stages of the disease. Purgatives. Except Avhen there is a gastro-enteritic compli- cation, active purging during the early stages possesses great efficacy in almost every form of the acute disease, Avhether the constitution be robust or feeble. It frequently happens that bleeding fails to produce its full effects till a free action of the boAvels is established. After the first bleeding, it is Avell to admi- nister at once a strong purgative enema, and simultaneously to give a full dose by the mouth. The purgatives usually selected are calomel, either alone or in combination Avith compound extr. of colocynth, jalap, rhubarb, or scammony; but croton oil is also highly convenient from its certainty, and from the ease Avith which it may be administered to children, even Avhen the stomach rejects all ingesta. As a first dose for an adult Ave should prefer either gr. x or xv of calomel alone, or half that quantity Avith an equal weight of extr. coloc. c. expediting its action by a black draught Avithout tincture, administered after an interval of tAvo hours. From three to five motions daily should afterAvards be obtained by purgative pills at night and a draught in the morn- ing, in case the practitioner entertain a prejudice against the con- stitutional use of mercury. Mercury. We are personally convinced, by careful and unbi- assed observation, of the great power and perfect suitability o this remedy in inflammation of the brain, in common Avith dan- gerous inflammations of vital organs in general. Some postpone its use till after the acute stage, under the supposition that it stimu- lates. Our experience has satisfied us, that danger from this source is imaginary, and that the best effects of the remedy are sacrificed Avhen its employment is delayed, since it is principally by controlling and modifying vascular action in the earliest stage, that subsequent effusions and disorganisation are prevented. We therefore give it at the very onset of the disease, after the first bleeding and administration of a calomel purgative to clear out the alimentary canal. If, hoAvever, the practitioner be called in at an advanced period of the disease, Avhen effusions may have taken place, this is not a reason why he should not still resort to the remedy, since effusions may sometimes be absorbed under its instrumentality, when all other remedies Avould be unavailing. The quantity of calomel at the onset of acute and rapid cases should be equivalent to a grain per hour, exclusive of the first large dose administered as a purgative; and it Avill be less apt to 96 INFLAMMATION OF THE BRAIN. irritate the mucous membrane if two grains be given every two hours, than if four or five grains be administered every four or five hours. In slower cases, and in young children, half or even one third of the quantity may prove sufficient. The object in every case is to affect the gums, or in other Avords the constitu- tion, as promptly as possible. It must be recollected that there is great difficulty in rendering the action of mercury manifest in the gums of very young children; yet it does not follow that the constitution is not affected, the contrary being proved by the dis- ease in many instances giving Avay. It is our habit in all cases to superadd inunction to the use of calomel, in order to obtain the effects of the remedy at a less risk of irritating the bowels than by its internal administration alone. We have never found inconvenient salivation result from infriction of so much as an ounce of Ung. Hydr. Fort, into the thighs and axillae of adults, daily, for two or even three consecutive days: in children, half the quantity may suffice. If calomel should irritate eAren slightly, of Avhich we may judge by its griping, producing mucous stools, and occasioning calls more frequently than three or four times a day, the quantity may be diminished, and each dose given with § ss of Mist. Cretae and gr. 5 to j of Extr. Hyosc, opium being objectionable from its tendency to stimulate the head. If, how- ever, the irritation be at all considerable, the calomel should be at once commuted for Hydr. cum Creta, in doses of at least gr. iij for every j. of calomel, with the addition of Mist. Cretae and Extr. Hyosc. as above directed. If, notwithstanding, the irrita- tion should persist, we must trust to inunction alone, in an in- creased degree, until the boAvels are restored to a calm state by fomentations, poultices, emollient lavements, counter-irritation, liniments, demulcent drinks, &c; after Avhich, it must be left to the discretion of the practitioner, whether to revert or not to the cautious use of Hydrarg. cum Creta. If there be any delicacy of the bowels when the practitioner is first called in, it is better to dispense entirely Avith the use of calomel, and resort at once to the milder preparations of mercury; namely, blue pill, Hydrarg. cum Cret&, or Oxydum Hydrarg. Cinereum, conjoined with small doses of Extr. Hyosc, and free external inunction. During the exhibition of mercury, no succulent vegetables or fruits, and no acid beverages should be allowed; as indulgence in these exposes the patient to an additional chance of gastrointes- tinal irritation. By attention to the precautions now inculcated, Ave have generally succeeded in administering mercury without the injurious effects on the mucous membrane, which constitute, especially Avith continental practitioners, the principal barrier to its general adoption. Even Golis, a decided advocate for mer- cury, is afraid of a larger dose of calomel in hydrocephalus than gr. ss every two hours. Such being the mode of administering mercury, Ave proceed to notice its effects. Meningitis— Treatment. 97 No sooner are the gums sensibly affected than, in the great majority of instances, a distinct amelioration is observed in the symptoms; and, not unfrequently, the amelioration becomes ap- parent even prior to the affection of the gums. The improve- ment may occur within the brief space of 48 hours, suspending the indications for further blood-letting, and thus occasioning that economy with respect to this depletion to which Ave have already alluded. The moment that the improvement has become appa- rent, the dose of mercury may be diminished and the intervals ex- tended; or, if the gums be affected, it may be wholly suspended for a day or tAvo, and resumed again if necessary; the object being, not to excite profuse salivation, but to maintain a mode- rate action of the remedy until the dangerous symptoms have Avholly subsided. If the body should become confined, in con- sequence of this diminution or suspension of the mercury, it may be necessary to resort again to the moderate use of ordinary aperients. Tartar Emetic. This remedy was given in large doses by Laennec with the view of curing inflammation of the brain by its specific effect! Its use, however, on this principle has been almost generally abandoned, even by the French. The objec- tions to large doses are, that they are apt to excite gastro-enteritis, and thus render the internal use of mercury impossible; also, that they sometimes provoke vomiting, by Avhich act the cerebral con- gestion is increased, with a general aggravation of the symptoms. We have not, hoAvever, found the same objections apply to small doses, as gr. £ every three or four hours, and we think that, thus employed, tartar emetic is a useful subordinate auxiliary, by pro- moting diaphoresis and contributing to diminish vascular action. James's powder, another preparation of antimony, is also useful in promoting diaphoresis; and, from its innocuous character, it is very unexceptionable: gr. \ to j may be given with the mercury every two hours. Digitalis. Without denying the poAver of this remedy in low- ering the pulse, Ave entertain the strongest objections to its use in inflammation of the brain. In no disease do the symptoms re- quire to be kept, as far as is practicable, in a simple, uncomplica- ted, and intelligible state; no remedy is so calculated to confuse them as digitalis. The reduction of the pulse which it occasions cannot be discriminated with any degree of certainty from that occasioned by the supervention of pressure in the second stage; for Ave cannot agree Avith some Avriters, 4hat in the case of pres- sure it is distinguishable by a greater sharpness in the beat of the vessel: on the contrary, it is often eminently prolonged and soft, the oppressed pulse of authors, any sharpness that it may acquire being merely the result of anaemia from previous depletion. Again, digitalis is apt to produce vertigo, faintness, and nausea; and how are these symptoms, artificially excited, to be distin- 9 98 INFLAMMATION OF THE BRAIN. guished from the same as results of the cerebral inflammation? If not distinguishable, Ave are deprived of the usual checks, and may carry the remedy to a poisonous extent, while we are at a loss how to act Avith respect to the symptoms themselves, the treatment for digitalis, being by stimulants, and therefore Avidely different from that for inflammation of the brain. Colchicum is a sedative, allaying pain and vascular action; but its operation is uncertain, and it is apt, even in doses so small as W[ xx, three times a day, to excite intractable dysenteric inflam- mation. Considering, therefore, the paramount importance of presenting no impediment to the use of mercury, and taking into account the inadequacy of colchicum to combat so serious an in- flammation as that of the brain, Ave may advantageously dispense Avith its use. Diaphoretics and Refrigerants. We have already remarked that, in the present, as Avell as all other dangerous inflammations, these remedies are, from mere insufficiency, of very secondary value, and should therefore never be allowed to supersede others of more decided and certain efficacy. Tartar emetic na, small doses, James's powder, and ipecacuan, are the most suitable dia- phoretics; as they can do little harm and may contribute to do good. The Liquor Ammoniae Acetatis, is a stimulant diaphore- tic, usually from containing an excess of ammonia; we therefore never use it in important inflammations. Of Refrigerants, nitrate of potass, bitartrate of potass, and neutral saline mixture, are those in common use. The vegetable and mineral acids highly diluted, and the acid fruits, are also supposed to be refrigerant; but Ave have already stated that they are objectionable, as tending to irritate the bowels and interfere with the use of mercury. Even the saline refrigerants may do the same, if insufficiently diluted or too freely administered. Cold or iced Avater is one of the best and least exceptionable refrige- rants. Diuretics are not only objectionable as often nauseating the stomach and leading to polypharmacy, but they are generally superfluous; since, if antiphlogistic treatment with mercury ismot sufficient to cause absorption of the small amount of effusion Avhich, in this disease, suffices to destroy life, that happy result Avill rarely be produced by diuretics. It is principally in other parts, as the pleura, peritoneum, &c, where copious effusion may remain compatibly Avith life, after the inflammation has been more or less completely subdued, that diuretics are of real value; still, when inflammation of the brain is attended with a deficient secretion of urine, squill and nitre may be advantageously super- added to mercury. Blisters. There is scarcely any class of cases in Avhich blisters produce happier effects than in inflammation of the brain, pro- vided they be scientifically employed. In the early stages, they Meningitis— Treatment. 99 are totally unsuitable; since, until blood-letting, purging, mercury, and low diet, have subdued the energy of the phlogistic action, they operate as stimulants, general as well as local, and exaspe- rate, instead of alleviating, the inflammation. In the more ad- vanced stages this danger is no longer to be apprehended, and they are then invaluable. They should be applied of large size, and in quick rapid succession, to the nape, behind the ears, and in severe cases even over the Avhole occiput as high as the vertex. Some shrink from applying them to the head itself. We feel assured, that provided the pulse has been rendered soft and the head cool by adequate antiphlogistic treatment, the Avhole occiput may be enveloped in a blister, not only Avith perfect safety, but often with surprising advantage. We have more than once seen the most profound coma dissipated in twelve hours by this mea- sure. When the vital powers are sinking, blisters and sinapisms applied to the feet, calves, or any other part, are sometimes used as general stimulants to rouse the flagging system. Whenever a patient labors under delirium or coma, so as to be unable to ansAver for himself, the bladder should be sedulously examined by hand every morning and night, and the urine drawn off by catheter, if necessary; nor should stillicidium throAV the practitioner off his guard, since this is compatible with paralysis of the organ from over-distension. Silence, gloom, coolness, and perfect repose are pre-eminently important in this inflammation. Diet. In the first stage, this should consist merely of six or eight ounces of gruel thrice a day, with toast-water at pleasure, or of barley-water alone, taken at pleasure. When the more acute inflammatory symptoms have been subdued, a little panada may be allowed until the approach of convalescence renders a fuller diet admissible. When slow protracted hydrocephalus causes rapidly increasing debility and emaciation, the patient should be'supported by a free alloAvance of beef-tea, mutton- broth, animal jelly, milk, and similar light articles. >.<# Convalescence. The return to an ordinary diet should be made Avith the most cautious and jealous sloAvness, since there is no one cause of relapse of so freqnent occurrence as premature excesses in diet. For very young children, asses' milk, continued for several Aveeks, is one of the lightest and most Avholesome articles. The transition of the patient to his ordinary habits, par- ticularly those of an intellectual nature, should be equally cau- tious and sIoav; since the brain, after inflammation, long continues irritable, and predisposed to a relapse on the application even of the slightest exciting causes. The practitioner, therefore, should continue his attendance on the patient up to a much later period of convalescence than is necessary in most other diseases. Spurious Symptoms of Inflammation of the Brain. The practitioner would be very incompetent to treat so dangerous a sSy,/'s-'ft s* t / <- ri c l ' 100 INFLAMMATION OF THE BRAIN. malady as acute inflammation of the brain if he Avere not tho- roughly aAvare that, at the end of an attack, especially after very active depleting treatment (often unavoidable when mercury is not used,) delirium or coma will sometimes continue, increase, or even come on, from mere exhaustion; and that, if he persisted in the use of evacuating measures, under the erroneous impression that the symptoms resulted from an increase or recurrence of the cerebral inflammation, he would probably kill his patient out- right. A small and rapid pulse, paleness and coldness giving an appearance of exhaustion, and the precedence of exhausting agencies, are the distinctive features of this affection. We shall not anticipate a fuller account of exhaustion subjoined to the present article, as a necessary appendage to inflammation of the brain. At present, it will be sufficient to allude to the treatment. Opium, strong broths, and sometimes Avine, are the remedies; opium allays the cerebral irritation giving rise to delirium, and sometimes immediately produces calmness and refreshing sleep. It may be given in full doses at suitably long intervals, or in small doses at short intervals, if the practitioner Avish cautiously to feel his Avay. Hyoscyamus Avill answer the same purpose, but is less certain than opium. It is seldom before exhaustion, or a tendency to it, supervenes, that narcotics are serviceable in inflammation of the brain. Strong beef-tea should be simultane- ously given, and it is better borne and more efficacious in small doses, as an ounce or two every half-hour or so, than in full quantities at long intervals. Ammonia and camphor are some- times requisite as temporary stimulants; but if the pulse be very small and Aveak, and the exhaustion be evidently great, with a tendency to sinking, wine must be more or less freely given. As much as a wine-glass hourly, for several consecutive hours, has been known to produce the most salutary effects. (Abercrombie.) When, under these circumstances, coma continues obstinate, a large blister over the Avhole occiput Avill sometimes effectually rouse and restore the patient; of which happy result we have Avitnessed several instances. In conclusion: if the practitioner be doubtful Avhether the symptoms be referrible to exhaustion or not, he should commence the above treatment cautiously, watch carefully, and be guided by the result. If the patient improve, he may feel pretty confident that his vieAV is correct, and may prosecute his measures Avith less reserve. If heat, flushing, and acceleration of pulse be induced, he must desist. Treatment of Chronic Cerebritis. The same antiphlogistic measures are requisite as for the acute affection, but they should be less vigorously pursued. During the first stage, or that of excitement, characterised by headach, vertigo, convulsions, or rigid spasms, Avith or Avithout fever, blood-letting, either general or local, should be employed to an extent corresponding Avith the urgency of the symptoms and the poAvers of the constitution. Meningitis— Treatment. 101 Sometimes a single bleeding will suffice; in other cases, two or three repetitions Avithin a day or tAvo are demanded for the re- duction of the immediate symptoms. In this the judgment of the practitioner must be his guide. For subsequent attacks, or exacerbations of the symptoms, which are apt to occur at irre- gular intervals of weeks or months, bleeding must be employed Avith more reserve than in a primary attack, in consequence of the protracted course and exhausting nature of the malady. Still the practitioner must not shrink from an adequate bleeding, if the symptoms of an embarrassed or an impeded cerebral circulation threaten immediate extinction of life. When there is a doubt respecting the propriety of bleeding, small depletions 3ij or iv by cupping around the occiput, at intervals of three or four days to a week, are sometimes attended with very satisfactory results. Together Avith bleeding, either in primary or secondary attacks, the cold dash of ice, and evaporating lotions, may be applied to the head, Avhich, together with the shoulders, should be well raised, while the feet may be immersed in warm water, with or without mustard. After a feAV smart purgatives, the body should be kept moderately open about twice a day by gentle aperients. With respect to the use of mercury, it is less imperatively neces- sary than in acute cases; yet, from having found the chronic affection yield much more readily and certainly under its use, Ave noAV generally employ it from the commencement, exciting, hoAV- ever, only a gentle action, but extending it over a long period, as six Aveeks, tAvo months, or more, if necessary. Blisters, frequently repeated, on the nape of the neck and behind the ears, also setons and issues Avhen the case becomes very protracted, are remedies of great efficacy. The diet should consist of slops and farina- ceous articles in the first stage, and should seldom exceed light broths, fish, and fowl, in the more advanced stages, unless para- lytic relaxation, emaciation, and paleness indicate the superven- tion of suppuration and softening, Avhen the patient must be sup- ported by richer broths or animal diet, and in some instances even by wine, in order to enable nature to maintain, if pos- sible, a reparative process. Great perseverance is often requisite to effect a complete cure of these chronic affections. If the practitioner proceed, unAveaned and undaunted, for many conse- cutive months, his efforts Avill not unfrequently be croAvned with success; but if his patience fail after a feAV weeks, and he be tempted, from the apparently Ioav state of the patient, to put him on full diet, failure and disappointment Avill commonly be the reward of his Avant of firmness. It is scarcely necessary to add, that after recovery the patient should for years, or if necessary even for life, be extremely cautious of exposing himself to any causes of cerebral irritation and excitement. Treatment for Inflammation of the Pericranium. This disease, one of the forms of periostitis, often occasions acute pain 9* 0 102 INFLAMMATION OF THE BRAIN. from tension of so unyielding a membrane, and it is apt to be mistaken for disease Avithin the cranium. The tenderness, how- ever, of the scalp itself on pressure, and the absence of true cerebral symptoms, generally remove all difficulty from the diag- nosis. The treatment consists in dividing the painful part or parts by an incision penetrating completely through the pericra- nium, and repeating it as often as the pain recurs after healing of the incision. We have seen it performed eight or nine times on the same patient with complete success. Cerebral Symptoms from Exhaustion, resembling Inflam- mation of the Brain—the Hydrencephaloid Disease—Spurious Hydrocephalus. It is very important to direct attention to a remarkable affection which produces certain symptoms analogous to those of inflammation of the brain, but depends on a diame- trically opposite cause; for while inflammation is an active hype- raemia, exhaustion, the affection to Avhich Ave allude, is connected with anaemia—a deficiency of blood in general in the system. As to the exact state of the circulation through the brain there is, as already stated, some difference of opinion. When there are throbbing headach, exalted sensibility, delirium, &c, which some- times constitute a first stage of excitement, it is probable that there is increased circulation through the brain, but of a blood too thin and poor suitably to stimulate or otherwise act upon the organ; but when there are coma, depressed sensibility, languor, paleness, and coldness, these symptoms bespeak venous conges- tion of the brain; which condition moreover, Avith or without serous effusion, is usually found after death in such as have sunk under the symptoms in question. It is absolutely necessary that a practitioner treating inflam- mation of the brain should understand this affection, because, as Ave have already stated, it frequently occurs as a consequence of the depleting measures employed to subdue that inflammation, and because a persistence in such measures would inevitably destroy the patient. But the disease, as will presently appear, may also occur independent of inflammation; and in children it so much resembles hydrocephalus, as to have acquired the name of spurious hydrocephalus, an objectionable term, because it is Avholly foreign to hydrocephalus. Nor is the term hydrocepha- loid disease scarcely less objectionable, because the symptoms do not ahvays accord with the category denominated hydrocephalus. The disease in question has been noticed by Dr. Abercrombie, Avho appears to have had the first idea of it, and more fully by Gooch and Hall. We shall describe it as occurring— 1. In infants and young children, principally between the ages of two months and three years. The children are usually delicate and small for their age. The disease is almost invariably traceable to some decided cause of rapid exhaustion, as diarrhoea Spurious Hydrocephalus. 103 from over-feeding, improper food, weaning, dentition, &c, purga- tion injudiciously and immoderately employed to remove the diar- rhoea, Avhich Avas of an irritable or inflammatory nature; leeching or bleeding unnecessarily, commonly in the later periods of in- fancy; operations on very young children. (Travers on Consti- tutional Irritation, p. 139, et seq. 1826.) There is sometimes a preliminary stage of restlessness; irrita- bility of temper; sensitiveness, causing the patient to be startled at any sudden noise, or even by being unexpectedly touched; feverishness, denoted by heat of surface, flushing of the face, and frequent pulse; grinding of the teeth,moaning and sighing during sleep. The symptoms, so far, are nothing more than Avhat are frequently seen as results of diarrhoea with mucous evacuations, flatulence, &c, or of dentition, worms, &c; and they may be, equally, precursors of inflammation of the brain. If the diarrhoea continue, either spontaneously or from the administration of pur- gatives, the state of exhaustion is induced, and presents the fol- lowing symptoms: The infant is found lying on its nurse's arm or lap, unable or unAvilling to raise its head, half asleep, one mo- ment opening its eyes, and the next half-closing them again, with a remarkable expression of languor. The look is vacant, and not attracted by objects unusually interesting to the patient; the pupil is sluggish, and sometimes immovable on the approximation of light; the face is pale and cool or even cold; the lips are Avhite, Avith a livid hue ; the general surface, especially of the extremi- ties, is likeAvise cooler than natural; the pulse becomes very Aveak in addition to its former frequency; the respiration, previously accelerated, now becomes sloAver, irregular, suspirious, and, before death, slightly crepitant or rattling, occasionally with stertor; the voice becomes husky, and there is sometimes a slight husky cough; there may or may not be complete coma. These symptoms, if not arrested, usually terminate fatally in tAvo or three days. The diagnosis from inflammation is easily formed by the quick weak pulse, the paleness, the coldness, and the precedence of exhaust- ing causes. Treatment. The diarrhoea must necessarily be checked; chalk is the best remedy, to Avhich a few drops of laudanum may be added for children above a year old; but beloAV that age even a drop or two may produce poisonous effects. Simultaneously, with the view of counteracting the immediate sinking tendency, five or ten drops of Spiritus Ammoniae Aromat. should be admi- nistered every three or four hours, and in the intervals five to ten drops of brandy, in water-arroAvroot, should be given two, three, or more times, till the sinking tendency appears to cease; if, how- ever, the brandy seem to gripe, it should be replaced by extra doses of Sp. Ammon. Aromat. The milk of a healthy nurse as nutriment is an important auxiliary; in its absence, asses' milk may be employed. So long as the sinking tendency exists, the 104 INFLAMMATION OF THE BRAIN. erect posture, by Avhich it is increased, should be carefully avoided. The coldness of the surface, and especially of the extemities, should be counteracted by keeping the little patient near a warm fire, and promoting the circulation by friction of the limbs Avith flan- nel The room should not be close, as a current of fresh, though Avarm, air is highly reviving, by supplying oxygen to the too venous blood. Coma may" often be promptly dispelled by a sinapism on the nape or occiput, or a blister applied for an hour or two according to the age, and repeating it, if necessary, on a different spot. When the immediate danger of sinking is over, the bowels must be brought into a healthy condition by Hydr. cum Cret£, with additional chalk if they be relaxed, and by a suitable diet of nurse's or asses* milk for infants, and light liquid and farinaceous food for children. 2. In elder children, and more rarely in adults, analogous symptoms may come on in the last stage of diseases of exhaustion; especially tedious and neglected diarrhoea, and inflammation of any organ actively treated. The patient may either become de- lirious in any degree of violence, with a small, feeble, and rapid pulse, and an expression of paleness and exhaustion; or, for a considerable period before death, he may fall into a state of coma, with the face pale, pupils dilated, eyes half open and insensible to light, and the pulse feeble but distinct. This state may con- tinue for a day or tAvo, and either prove fatal or terminate favor- ably under the use of Avine and nourishment. Abercrombie considers this affection to correspond Avith the apoplexia ex inanitione of old writers. It differs from syncope in coming on gradually, in resulting from causes of exhaustion operating for a considerable period, and in continuing for so long a time as a day or two; Avhereas syncope is induced by sudden and temporary causes, and subsides after a few minutes or hours. The treat- ment consists in the free administration of wine and nourishment, diminishing the former in proportion as the symptoms subside. In the comatose cases, we have found a large blister over the whole occiput restore the sensibility of the patient within the space of twelve hours. 3. Profuse haemorrhage is well known to produce symptoms analogous to the above; namely, in the first instance, there is a rapid, jerking pulse, throbbing headach, vertigo, exalted sensi- bility, and occasionally delirium; constituting the state denomi- nated reaction. If this continue unsubdued, or if the haemor- rhage in the first instance exceed a certain point, there may be dilatation of the pupils, blindness, deafness, convulsions, coma and death. The convulsions are spinal, as they have occurred in animals bled to death after the brain had been isolated by dividing the spinal marrow in the neck. In the treatment, the remedies are, opium or hyoscyamus to tranquillise the nervous system when there are symptoms of excitement; good nourish- Spurious Hydrocephalus. 105 ment in the form of strong beef-tea or mutton-broth, to restore fibrine to the blood; Avine or brandy, if there be great feebleness of pulse, coldness, and other indications of a sinking tendency; evaporating lotions on the head, if there be heat Avith violent throbbing headach; and blisters on the nape or occiput, if there be coma. The horizontal position, with the head low should be scrupulously maintained, until the fall of the pulse and the return of pink tint to the complexion, with a corresponding ameliora- tion of the other symptoms, indicate that the sinking tendency has ceased, and that fatal syncope from the erect position is no longer to be dreaded. The immediately urgent symptoms being removed, iron in large doses and a liberal allowance of lightly broiled mutton or beef twice a day, are the all poAverful means of dissipating the anaemia. 4. Starvation produces delirium, &c. on the same principles. The treatment is similar, except that nutriment should be given in very minute quantities and in the liquid form at first, lest, by proving too stimulant, it should excite inflammation of the stomach or brain. This is the origin of the popular notion, that retributive madness visits those who, under the reckless influence of starvation, feed upon their OAvn species. 5. Chlorosis.— The anaemia of young females, Avhen carried to a high degree, sometimes produces, not only violent throbbing headach and exalted sensibility, but even delirium. Of this we have seen several instances. Hyoscyamus, iron and animal food, are the almost never failing remedies. The rapid sketch iioav given will perhaps suffice to shoAV the immense importance of thoroughly understanding cerebral symp- toms from exhaustion—a subject almost unknown till within the last fifteen years, 106 HYDROCEPHALUS. Explanatory observations.—Two forms, acute and chronic.—Symptoms of acute hydrocephalus.—Division into stages or periods.—Symptoms.—Of the first stage.—Of the second stage.—Of the third stage.—Forms of acute hydrocephalus.—Gradual or subacute.—Rapid or acute.—Sudden or hyper- acute.—Anatomical characters.—Predisposing causes.—Exciting causes.— Diagnosis.—Prognosis.—Treatment. The above term (from v'Swp water, and xs$axq, the head) was formerly applied to serous effusions, occurring either in the scalp external to the cranium, beneath the membranes, or into the substance of the brain. It is now, however, used to express the abnormal collection of serous fluid within the cranium: hence the term hydrencephalus (from v$aP, and iyxifaxof, the brain) has been used by various Avriters. The circumstance of the effusion of a certain quantity of serum in the serous cavities Avithin the cranium cannot alone be considered as constituting hydroce- phalus, Magendie having shoAvn that the presence of liquid in these situations is not always a morbid appearance. From the quantity of this fluid varying in different persons, as Avell as from the facility of its absorption after death, no fixed amount can alone enable us to determine the previous existence of disease. This is to be determined either by enlargement of the head, or by there having been Avell-marked cerebral symptoms before death. Hydrocephalus has been described under tAvo forms, the acute and the chronic; and although the exact limits betAveen each cannot invariably be defined, yet as, in general, individual cases can be classed under the one form or the other, these terms are still retained. In this place Ave shall treat only of acute hydro- cephalus; the chronic form Avill be described as one of the varieties of dropsy. Although acute hydrocephalus was known to some of the older writers, it was first accurately described by Dr. Whytt, Avho pub- lished, in 1768, his Observations on Dropsy of the Brain, and gave an excellent account of the symptoms and progress of the affection. Since his time it has been considered as a distinct malady by numerous authors in this and other countries, although there still exists a difference of opinion regarding its nature. Symptoms. In some cases the symptoms are ushered in with hydrocephalus, (Symptoms.) 107 great rapidity and severity, constituting the apoplexia hydroce- phalica of Cullen, and the water-stroke (wasserschlag) of Gblis. In general, however, the invasion is more slow, the symptoms varying in different cases. Many of these have been considered precursory by some Avriters, while by others they have been described as forming the first stage of the disease, under which, in order to prevent repetition, Ave shall enumerate them. For the most part these symptoms only indicate derangement of the nervous system and general health, and are not peculiarly pathognomonic of hydrocephalus. Moreover, they are very liable to be overlooked, especially in children of a scrofulous or unhealthy constitution, in whom they are often confounded with the numerous ailments incidental to strumous children. They may pass off spontaneously, or be removed by appropriate reme- dies, a circumstance much chvelt on by Dr. Yates, Avho considered them premonitory. In all cases, hoAvever, they demand the serious attention of the practitioner; and when there is an un- usual precocity of intellect, or if the child belong to a family pre- disposed to hydrocephalus, their occurrence gives rise to just apprehension. The description of acute hydrocephalus is rendered difficult by its irregular progress, and the want of uniformity in the duration and intensity of the symptoms. These circumstances have led to the establishment of certain stages or periods to mark the progress of the disorder, and to different forms, in order to indicate its intensity and duration. Stages of Acute Hydrocephalus. Whytt described three stages of the disease, each characterised by a peculiar state of the pulse. In the first it is quick, in the second sIoav and irregular, and in the third rapid and feeble. Gblis describes four stages, founded on the presumed pathological conditions present in each; these he denominated the periods of turgescence, inflammation, effusion, and palsy. P. Frank, Conradi, and Rush, notice only tAvo stages; and Cheyne, following the views of Whytt, describes three, but has named them from the changes which occur in the functions of the nervous system. We shall adopt this division, and describe the symptoms under three heads:—1. The period of increased sensibility; 2. that of diminished sensibility; and, 3. that of palsy and convulsions. First stage. The symptoms at the commencement vary con- siderably, and have been referred in some cases to the brain, in others to the alimentary canal or biliary organs, constituting the idiopathic and sympathetic varieties of practical writers. The cerebral symptoms (which may appear sooner or later) are usually indicated by an increase or diminution of the intellectual poAvers—vertigo, which renders the child liable to fall or stumble —droAVsiness—disturbed and unrefreshing sleep, during which there is rolling of the head upon the pilloAV or grinding of the 108 hydrocephalus, (Symptoms.) teeth—slight pain in the head gradually becoming more severe- noises in the ears—increased sensibility to light, Avith contracted pupils and corrugation of the brows. The gait is often unsteady and vacillating, and the child in progression often raises his foot as if stepping over some object. Sometimes there is great feeble- ness of one loAver extremity, and the foot of the affected limb is dragged after the other. The child becomes silent and often irri- table, or indifferent to former objects of interest; sometimes falling into a reverie, from Avhich it aAvakens with a sigh. The intelli- gence, hoAvever, is not seriously affected; though there is often slowness in returning ansAvers, yet they are correctly given. There is occasionally, however, dullness of the countenance and loss of expression in the eyes, Avith a dark line under them, and transient paleness and collapse of the features; sometimes alternate chills and flushes, Avith an unnatural degree of excitability in the whole system, and inability to sit up. The temperature of the surface is increased, the scalp feels hot, and in some cases tender on pressure, Avith Avandering pains in the neck, limbs, or abdomen. The appetite is often defective or capricious, but there is less thirst than the degree of fever would lead us to expect. The nostrils are dry, and the lips cracked; the tongue is slightly furred, and the breath has a faint sickly or fetid odor. Vomiting occurs fre- quently, and is often brought on or increased by the erect posture, or by taking the child out of bed. The epigastric and hypochon- dric regions are sometimes tumid and tender on pressure; but as the disease advances, the abdomen falls in, and becomes flaccid. The bowels are torpid and irregular, and such evacuations as take place are of an unhealthy character, sometimes of a clay-like appearance, or of a pale or dark greenish hue, mixed Avith slimy matter. The urine is sometimes high-colored and diminished in quantity, or turbid, depositing on standing a Avhitish sediment. The pulse at first is little altered, but occasionally it is irregular both in frequency and force. If the above symptoms be Avell- marked, the pulse is accelerated and excitable; but as the succeed- ing stage approaches, its force and frequency diminish. The respiratory organs are sometimes affected; manifested by occa- sional cough, irregular breathing, moaning, and sighing. The cutaneous transpiration is lessened, rendering the skin dry, harsh, and of an unhealthy color. An eruption of minute vesicles has also been occasionally observed in this £tage, or at the commence- ment of the next, by Formey, Golis, Raimauer, Schmalz, and others, principally about the mouth, cheeks, and forehead, the outside of the humerus, and the upper part of the chest. The above symptoms are common to many of the diseases of infancy and young children, and a greater or less number of them may be present two or three Aveeks, or even longer, in a slight degree, Avithout exciting any serious apprehension. It is only when they have resisted ordinary treatment, and gradually in- hydrocephalus, (Symptoms.) 109 crease in intensity, that they are supposed to be the forerunners of acute hydrocephalus. The duration of this stage varies accord- ing to the form of the disease, from a feAV hours to one or two weeks, and in some cases even longer. Second stage. The pulse noAV becomes irregular and of unequal force, decreasing in frequency till it falls to the natural standard, or even beloAV it. It is, however, readily accelerated by any ex- ertion, as sitting in the erect posture, or removal from the bed. The sensibility is also diminished, the restlessness and irritability characteristic of the previous stage giving way to somnolence and stupor, Avith dilatation and immobility of the pupils, squinting, and impaired or double vision. Sometimes, however, as was pointed out by Odier, there are oscillatory movements in the iris, or, if it be dilated, it is sensible to the stimulus of light. The eyes are dull, heavy, and vacant, the countenance pale and collapsed; and, in a feAV cases, it has been observed to be oedematous. The nose is dry, the lips are pale, dry, and cracked. The countenance is expressive of indifference, stupor, or idiotism, which latter may in some measure be ascribed to the dilatation of the pupils. This physiognomical expression, according to Sprengel, is peculiar, and more distinct than in any other disease, and has even been con- sidered by Golis a pathognomonic symptom. The patient now lies in a soporose state, with the eyelids half closed, Avhich is inter- rupted by exclamations or shrill piercing screams. The headach still continues, but the nausea and vomiting diminish, although they are liable to recur if the child is raised up. The appetite sometimes seems to return, and the little patient swalloAvs greedily any food that may be offered. The bowels are still constipated, and faecal evacuations procured Avith difficulty; there is either retention of urine, or it is passed involuntarily; and in some in- stances there is almost total suppression of this excretion. The hands become tremulous, and are frequently raised to the head and back of the neck, or the fingers are employed in picking the nostrils, lips, or hair, or boring into the ears. As the disease ad- vances, progressive emaciation, deep inspirations, hectic flushes on the cheeks, cold extremities, and low delirium, supervene. The duration of this stage varies from four to fifteen days. Third stage. The pulse now becomes more frequent, often rapid, thready, and weak: it has been knoAvn to rise as high as 210 in the minute. Convulsive movements of different kinds also supervene: sometimes there are tAvitchings in the face with vibra- tory motion of the eyeballs; in other cases slight spasmodic move- ments in one or more sets of muscles, or convulsions more or less general. Occasionally there is paralysis of a limb, or of one side of the body, conjoined Avith convulsions in other portions of the muscular system. Sometimes there is greater or less rigidity in the neck or extremities, a symptom Avhich has been more parti- cularly remarked where there has been inflammation of the mem- 10 110 hydrocephalus, (Varieties.) branes at the base of the brain, or of those covering a portion of the spinal cord. The child becomes now either insensible or delirious; he moans or breathes heavily or hurriedly, rolls his head on the pilloAV, grinds his teeth, and Avaves the unpalsied hand Avildly in the air. The cheeks are alternately flushed and pale; the levator palpebral appears paralysed, and drops partially over the eye; the cornea is dim; the conjunctiva injected, and the pupil more and more dilated; the strabismus and collapse of the coun- tenance continue; the lips become livid, and the skin partially covered with profuse perspiration, while in other portions it is dry and burning. At length the extremities become cold; the respiration unequal and stertorous; the pulse more and more weak; and death takes place very often in the midst of convul- sions. This event may occur in a few hours, or not before ten or twelve days after the commencement of the above symptoms. Such is the progress of acute hydrocephalus in its most ordi- nary and inflammatory form. But it must be kept in vieAV, that many cases occur in Avhich the symptoms do not appear in the order now detailed; while some may be absent or only slightly marked, and others prominent and long-continued. Again, in several instances the stages are by no means dis- tinctly separable from each other. Quin and Rush, for example, relate cases which proved fatal in a feAV days, in which there was no evident division into stages, no dislike of light, nothing cha- racteristic in the pulse, no dilatation of the pupils, nor any vio- lence of headach. Sometimes patients regain their consciousness a short time before death, take food, drink without vomiting, swalloAv Avith eagerness, and even participate in amusements— circumstances which often give fallacious hopes of recovery. It is of great importance that the time of appearance and se- verity of the cerebral symptoms, or those referrible to distant organs, constituting the idiopathic or sympathetic varieties of some Avriters, should be attended to in practice, inasmuch as they indicate the primary source of irritation, and the nature of the remedies necessary for its removal. Forms of Acute Hydrocephalus. Dr. Cheyne considered that the disease might be reduced to three forms; which he denomi- nated the gradual, the sudden and violent, and the secondary. Hopfengartner describes the nervous, the inflammatory, and con- secutive, Avhich are obviously nearly the same as those proposed by Cheyne. Gblis speaks of the affection as being acute and hyperacute; Itard and others, as idiopathic and symptomatic; and Brachet, as nervous, inflammatory, and gastric. We shall consider the disease as being, 1st, gradual, or subacute; 2d, rapid, or acute; and, 3d, sudden, or hyperacute. The gradual or subacute form is of frequent occurrence, of longer duration, and is more nearly allied to the chronic affection hydrocephalus, (Varieties.) Ill than the other forms. It is most common between the second and twelfth or fourteenth month of infancy, and commences Avith the sIoav development of the symptoms of the first stage, which are of long continuance, though on their first appearance they are often very obscure, and merely indicative of general derange- ment. After a time, symptoms of the second stage make their appearance; the child seems unable to support the weight of the head, Avhich begins to enlarge, the suture being at the same time slightly separated, by which, if it occur rapidly, the symptoms are sometimes relieved. Some feAV cases have occurred Avhere, Avith the increasing strength of the child, all traces of the affection have gradually disappeared, but more frequently a fatal termina- tion is the result. The symptoms are, for the most part, similar to those previously described, but are of longer continuance. The duration of this form is generally from three to six Aveeks; but if the commencing symptoms are taken into consideration, it is much longer, and so variable as not to be determined. In the rapid or acute form, the first stage, although present, is not so long continued as in the gradual form, and is sometimes overlooked. The severe symptoms make their appearance more abruptly, are attended with more violent excitement of the sys- tem, and at their commencement have often been mistaken for fever with cerebral complication. There is commonly, even at first, considerable excitement; viz. fever Avith slight irregular re- missions, a rapid, small, or hard pulse, furred tongue, severe headach, increased heat and tenderness of the scalp, hot skin, thirst, augmented sensibility, brilliancy of the. eyes, and tender- ness of the abdomen. There is stupor or unwillingness to be moved, alternating with violent screams, and complaints of the head and belly; retching and vomiting are readily induced by changes of position or the erect posture. There is a peculiar despondent, vacant, and heavy expression of the eyes and anxiety of the countenance, accompanied with constipation, diminution of the secretions and excretions, &c. These symptoms become rapidly mingled Avith those characterising the second stage; viz. dilated pupils, strabismus, stupor, diminished frequency of the pulse; and soon pass into the state of collapse Avhich distinguishes the third. Many cases supervene upon other diseases, especially scrofula, painful dentition, infantile remittent, or the eruptive fevers, hooping-cough, &c; and hence these have been called consecutive, metastatic, or secondary; and should the disease commence during the continuance of these affections, its approach is often imperceptible; the early symptoms are not recognised; and it is not until dilatation of the pupil, strabismus, convulsions, or paralysis, and other advanced symptoms supervene, that its true nature is suspected. When it folloAVS scarlatina or measles, the symptoms have been known to commence Avith great febrile excitement; not unfrequently, hoAvever, especially during denti- 112 hydrocephalus, (T^aricties.) tion, weaning, and diarrhoea, there is every symptom of debility or diminished vital action, with a Aveak and rapid pulse. The duration of this form differs considerably, but for the most part it seldom continues longer than three Aveeks, and is often fatal in less time. It is difficult to determine the duration of the con- secutive cases, as the early symptoms are not observed, but when once clearly apparent they usually continue about a Aveek. The sudden or hyperacute form corresponds Avith the apo- plexia hydrocephalica of Cullen, the water-stroke of Gblis, and the hydrocephale apoplectique of Guersent. It usually folloAvs the recession of small-pox, scarlatina, measles, erysipelas, and other acute eruptive diseases, and has sometimes been noticed on the disappearance of the various forms of boAvel affections in children. According to Gblis, however, it is sometimes idiopathic; and Bosc has given cases in Avhich it supervened on paralysis in old persons, after previous attacks of haemorrhagic apoplexy. (Arch. Gin. de Mid. torn, xxii, 1830.) Under such circumstances it constitutes the serous apoplexy of some authors. The first stage in this form of the disease is so slight as almost to escape notice, Avhile the symptoms of the second come on Avith such violence, and so rapidly run into the third, that they can scarcely be distinguished from each other. Death sometimes occurs quickly; Gblis gives a case in which it took place in tAvelve hours, although this event more usually occurs between the second and fourth day. Acute hydrocephalus has been too often supposed to be con- nected with one peculiar state of the vital powers, or induced by one series of morbid actions. Formerly it Avas thought to arise from debility, while in later times it has been considered to depend on inflammation in the brain or its membranes. Obser- vation, hoAvever, demonstrates, that neither of these states are invariably connected Avith the disorder, and that both the one and the other may occasionally induce the disease. In this respect it resembles most affections of the nervous system; and this should be particularly attended to before determining the plan of treatment. The rapid or acute form of the disease is the one most frequently met with, and it is for the most part accom- panied by active fever, and other evidences of increased action in the vital powers. But not unfrequently there is no fever what- ever, the disorder often commencing under circumstances which evince a state of exhaustion, as in many of the consecutive cases, or when it occurs in advanced life. Hence each of the three forms Ave have described may, for practical purposes, be divided into two varieties, the inflammatory and the non-inflammatory. It has also been pointed out by Drs. Gooch, Hall, Abercrombie, and others, that hydrocephalic symptoms are sometimes conse- quent upon Aveaning, protracted diarrhoea, improper or imperfect feeding, and exhausting treatment. The term hydrencephaloid hydrocephalus, (Anatomical Characters.) 113 disease has been introduced to distinguish this class of cases by Dr. M. Hall, Avho remarks, however, that this disorder is often mistaken for hydrocephalus, and that it may be difficult to state the grounds for a just diagnosis betAveen the two affections. The argument adduced, that recovery from hydrencephaloid disease takes place after the exhibition of stimulants and nutritious diet, is in our opinion insufficient to Avarrant the conclusion, that this is a distinct affection, as similar treatment is sometimes indicated in other disorders of the nervous system. Moreover, as there are no differences in the essential nervous symptoms in many cases of acute hydrocephalus, properly so called, and this hydren- cephaloid affection either during life, or in the morbid appear- ances after death, the propriety of such an artificial distinction is questionable. It appears to us that so long as our present ar- rangement of diseases continues, and pathological knowledge is not sufficiently advanced to permit our classifying them on better principles, Ave cannot consider them as distinct affections, but as instances of the same disease occurring in different states of the system. Anatomical characters. The characteristic morbid appear- ance found after death in acute hydrocephalus, is the abnormal accumulation of serous fluid Avithin the cranium. The quantity may be said to be abnormal when it amounts to more than an ounce, although in several cases a less quantity has been discov- ered. The effused serum is sometimes confined, to the arachnoid or sub-arachnoid cavities, constituting the external hydrocephalus of some Avriters. In other cases it is principally in the ventricles and central parts of the brain, forming the internal hydrocepha- lics of the same authors. In the generality of cases, hoAvever, more or less fluid is found in both situations. When the effusion is more particularly connected with the surface of the brain, it is usually found betAveen the arachnoid and pia mater, separating the convolutions from each other. When in the ventricles they are generally enlarged, and sometimes disorganised. The largest quantity is contained in the lateral ventricles, while the posterior horns are generally enlarged, and the anterior portion of the for- nix elevated, so as to cause a free communication betAveen the third and fourth ventricles. The layers of the septum lucidum are also sometimes enlarged, and contain fluid. The serum in some cases is effused into the cellular substance of the choroid plexus, which distends the serous membranes so as to form vesi- cles, which somewhat resemble hydatids, an appearance often seen in the choroid plexus. The aspect of the fluid differs in various cases: in some it is clear, thin, and transparent; some- times destitute of color, or it may have a bluish, greenish, yelloAv or sanguineous tint; in other instances it is more or less opaque, turbid, Avhey-like, or puriform, or of various colors, as noticed by 10* 114 hydrocephalus, (Anatomical Characters.) Morgagni, Baader, and others. Golis hoAvever states, that in simple acute hydrocephalus, uncomplicated Avith inflammation, caries in the ear, or other diseases, he has never seen the fluid discolored; and considers that, in such cases, the reddish tint, mentioned by some Avriters, must have arisen from blood poured out by Avoimded vessels during dissection. Occasionally shreds of coagulable lymph are found floating in the serum effused, as Avell as lining the ventricles, an appearance often seen in the hyperacute form of the disease, or when its course has been rapid. Baillie found the fluid in the ventricles generally clear, and purer than in other cavities of the body. With regard to the nature of the effused fluid it is, in most cases, not coagulable, as noticed by De Haen, Morgagni, Whytt, Watson, Hudson, and Marcet. Baillie, Blackhall, and others, however, were enabled to coagu- late it in some instances. According to Marcet 1000 parts con- sist of 990.80 of water; 1.12 of muco-extractive matter, with a trace of albumen; 6.64 of muriate of soda; 1.24 of subcarbo- nate of soda, with a vestige of an alkaline sulphate; and .20 of phosphate of lime, with traces of phosphate of magnesia and iron. The quantity of fluid has also been found to vary greatly, from one or tAvo teaspoonfuls to eight or ten ounces. The most common quantity is from tAvo to six ounces; this last amount, which Golis has found even in the hyperacute form of the disease, is rarely exceeded. It is rare that an abnormal quantity of fluid exists within the cranium Avithout other appreciable lesions, Avhich in most cases are of an inflammatory nature. Thus, there is sometimes adhe- sion between the scull cap and dura mater, more rarely betAveen the layers of the arachnoid. This latter membrane is not unfre- quently found dry, thickened, and opaque, and when the inflam- mation is severe, the vessels of the sub-arachnoid cellular tissue are very commonly much injected, a lactescent serosity, or sero- gelatinous, or sero-purulent fluid, being at the same time effused. If the inflammation has been very acute, there are occasionally small plates of concrete pus extended in a membranous form over the surface, which Charpentier has once seen traversed by blood- vessels, and consequently organised. When purulent matter is formed between the arachnoid and pia mater, it is most frequently found betAveen the fissures of Sylvius, on the decussation of the optic nerves, in the neighborhood of the infundibulum, and around the cerebellum and commencement of the spinal cord. Some- times the inflammation descends into the vertebral canal, and gives rise to analogous products. The pia mater is often highly injected, having a net-work of florid vessels more or less extended over its surface, occasionally with patches of extravasated blood. It is sometimes more adherent to the brain than natural; in other instances it is more easily separated from it. Rufz, Gerhard, Dance, and Piet, have observed it sprinkled to a greater or less hydrocephalus, (Anatomical Characters.) 115 extent, Avith hard, gray, or yelloAvish semi-transparent granula- tions, Avhich by some have been considered to be the enlarged glands of Pacchioni, by others to be coagulable lymph, or miliary tubercles. We have several times had occasion to observe these bodies in children who have died laboring under meningeal in- flammation, and in every instance tubercles Avere found in other organs. Similar observations have been made by Piet and others, so that it is more than probable that these granulations are miliary tubercles, and that their presence ultimately excites inflammation and its consequences. The substance of the brain in acute hydrocephalus is usually softer than natural, more especially in the central parts; but it sometimes retains its natural firmness. Golis mentions that in one case, in Avhich a small quantity of Avater only was found, the mass of the brain expanded on removing the skull cap; so that a few minutes after, Avhen he attempted to place the portion of the cranium Avhich had been saAvn off over the brain still inclosed within its membranes, the cerebral mass could not be contained Avithin it. Laennec, Dance, and others, have remarked, that in some cases the convolutions have been flattened, apparently from their being pressed against the osseous walls of the cranium. On cutting into the brain it not unfrequently presents more or less indications of congestion, the cut surface being studded with bloody points, but sometimes it is paler and less vascular than usual. In either case it is often mingled with serous infiltration. Cheyne noticed the increased moisture on making sections of the brain, and Golis relates that once, on cutting the hemisphere, a colored serum floAved freely from it; and*that, Avhen the cerebral mass Avas compressed, a reddish fluid exuded as from a sponge. The gray substance of the convolutions is occasionally injected, so as to give an appearance varying from a pale rose to a lively red color. Charpentier states that this lesion frequently escapes the researches of morbid anatomists, but that it is rarely absent Avhen the sub-arachnoid tissue is strongly injected. The white matter in the neighborhood of the ventricles, including the septum lucidum, fornix, and adjacent parts, have been found softened in different degrees, from the slightest Avant of natural consistence to that of cream. The lining membrane of the ventricles also has been found vascular, opaque, or covered by layers of coagu- lable lymph. It is often readily separated from the subjacent cerebral substance, and is sometimes covered with numerous Avhite flocculent filaments, Avhich become very apparent by their floating, when the membrane is placed in Avater. This disor- ganisation has been supposed in many cases to give the fluid its turbid appearance. The plexus choroides is not unfrequently injected, thickened, or covered Avith granulations; sometimes it is pale and discolored, Avith small serous cysts resembling hydatids. Occasionally the septum lucidum is lacerated, establishing a com- 116 hydrocephalus, (Anatomical Characters.) munication betAveen the lateral ventricles. The cellular mem- brane in the structure of the pituitary gland has been found dis- tended Avith serous effusions in the form of little bladders. (Joy.) It must not on the other hand be forgotten, that in some cases, instead of increased vascularity of the brain, it has been found particularly pale, and, Avith the exception of serous effusion, free from every other morbid appearance. This more particularly occurs Avhen the disease arises from debility and exhaustion. Several Avell-marked examples of acute hydrocephalus have been recorded by Abercrombie (Researches on the Brain, fyc. cases 63—66.), Breschet (Journ. de Med. torn. xxix. p. 151.), Bricheteau (Arch. Gen. de Med. 18.24), and Andral (Clin. Med. torn. v. obs. 20—22.); in which, after death, there Avere no traces of inflam- mation either in the membranes or substance of the brain. These are recorded in such a careful manner as fully to establish this fact, and refute the supposition, that in such instances the exami- nations were not made with sufficient accuracy. Various chronic alterations of structure have been also occa- sionally found in the brain, which may have assisted in exciting the disease. Laennec has pointed out the existence of granular tubercles in the cerebrum, cerebellum, and optic thalami, and the coexistence of tumors of a schirrous, encephaloid, or fungoid nature; abscesses, apoplectic cysts, spiculae of carious bone, &c. have been mentioned by others. Coindet has observed, what has since been noticed by Dance and others, that, besides the serous effusion in the ventricles, there was more or less also in the spinal canal. This no doubt is often the case, and is explained by the ready communication which exists between the spinal canal and the serous cavities of the brain. That it is not more frequently seen, arises probably from the spinal canal being seldom carefully examined. Numerous alterations have been found in other organs, which by some Avriters have been considered to be connected with hydrocephalus. Dr. Cheyne has pointed out the frequency of disease in the liver and intestines. The liver has been found enlarged, and adhering to the neighboring parts by organised lymph. Of eleven cases of hydrocephalus examined after death by Dr. A. T. Thomson, traces of inflammation of this organ Avere found in nine, inflammation of the colon in the tenth, and invagi- nation of the jejunum in the remaining one; in four cases also, recorded by Mr. Coke, the liver Avas diseased in three. Tubercles have also been found both on its surface and in its substance, as well as in the splenic, mesenteric glands, and other organs. The mucous membrane of the alimentary canal has been occasionally found more or less inflamed, the glands of Peyer much developed, and different parts of the intestinal canal contracted. In sixteen cases dissected by Dr. Blackhausen of Bremen, the mucous coat of the stomach \vas softened in all, and the internal surface of the hydrocephalus, (Causes.) 117 intestines studded Avith diseased follicles, from Avhich pus escaped. Invagination of the small intestines also has been found by differ- ent authors. Causes. Among the predisposing causes the doctrine of he- reditary predisposition has been strongly advocated by Quin, Odier, P. Frank, Portenschlag, Baader, Golis, and others. That the disease occurs frequently in more than one child of the same family is a matter of common observation. Underwood says he has known six children, born of the same parents, die successively at the age of two years, five of whom Avere examined after death (Diseases of Children, 9th edition, p. 298.); and Dr. Cheyne mentions ten children in one family having died of the disease. Great terror and anxiety on the part of the mother during the last months of pregnancy is placed by Golis among the predispo- sing causes. He states that he, as Avell as other physicians, had an opportunity of observing this when Vienna was bombarded in 1809, as most of the children Avho were born after this catas- trophe Avere seized about ten, twenty, or thirty, days after their birth with convulsions, and died. These views, hoAvever, have never been confirmed by any other authority. Hydrocephalus is more frequent during the period of infancy and childhood than at any other age. This circumstance has been generally attri- buted to the rapid development of the brain, and the great nervous sensibility which then prevails, rendering the economy particularly liable to be acted on by the exciting causes. From the tables of Percival and Bricheteau, it appears that the disease is most com- mon betAveen the second and fifth year, but it is not unfrequent between the fifth and twelfth. Cases, hoAvever, are met with in infants at the breast, and several are recorded by Dance and others betAveen the ages of tAvelve and thirty-one. Dr. Gregory has related a case caused by a fall, at the age of forty. (Ed. Med. and Surg. Journal, Oct. 1834.) It becomes more and more rare, hoAvever, as the individuals approach adult life; but in advanced age it again becomes rather more frequent, deaths from acute hydrocephalus (often called serous apoplexy) being then occasionally met Avith. It has generally been observed, that children Avith large heads and precocious intellects are peculiarly liable to the disease. Underwood, however, says that children Avith large heads do not seem to be more predisposed than others, but the observations of Gardien, Hopfengartner; and Guersent, have confirmed the popular opinion. The peculiarity of sex does not appear to exercise much influence in the production of the disease. LudAvig and Cheyne have thought that, after ten, girls are more liable to it; and, according to Dr. Copland, before that period it is most common in boys. A scrofulous habit powerfully predisposes to the disease, a large proportion of cases occurring in strumous children. This has been especially remarked Avhen the affection has appeared in several members of the same family. IIS hydrocephalus, (Caicses.) Dr. Cheyne considered that to the strumous diathesis must be attributed the hereditary disposition to hydrocephalus, Avhich is so strongly marked in some families. It has also been observed by this author and Sprengel, that hydrocephalus and scrofulous affections are mutually convertible into each other. It is true that hydrocephalus sometimes occurs after the disappearance of scrofulous affections of the glands, joints, or lungs; but there are strong doubts Avhether hydrocephalus has ever induced the latter disorders. Some think that the disease is most frequent in chil- dren Avith a fair skin and hair, pink complexion, and blue eyes; but, according to Cheyne, it is most common in those Avith dark eyes and a dark complexion. It is very often seen in both. The circumstances, hoAvever, Avhich induce arterial or venous cerebral congestion are the most frequent predisposing causes ol hydrocephalus; such as administering spirituous liquors to infants when suckling; the abuse of narcotic remedies, too often employed during infancy; keeping the head too Avarm; a too stimulating diet; violent mental emotion, as terror, anxiety, anger, fear, &c; too much mental exertion in young children; exhausting dis- charges, as from the boAvels, or undue loss of blood; insufficient nutriment; impoverished quality of the nurse's milk; injudicious employment of drastic purgatives or emetics; or, in short, any circumstances Avhich tend to depress the vital poAvers. Irritation in distant organs also appears to predispose to hydro- cephalus, such as that which arises from dentition; worms in the alimentary canal; acute or chronic diseases of the stomach or intestines, or of the biliary organs; enlargement of the mesenteric glands, constipation, &c. Among the other predisposing causes may be noticed previous attacks of cerebral congestion or inflam- mation; or of diseases of the respiratory organs. Hydrocephalus also may form a complication, or become one of the sequelae of infantile remittent or exanthematous fevers, especially scarlatina. It is stated by Itard, that of the two years in which he had re- marked the frequency of acute hydrocephalus, one Avas charac- terised by an epidemic scarlet fever, and the other by an ataxic fever, Avhich particularly affected infants. The circumstances mentioned above, inducing cerebral conges- tion, debility, and irritation, may act also as occasional exciting causes. The suppression of eruptions on the scalp and behind the ears has often been known to occasion the disease. Golis even supposes that the diminished frequency of these eruptions has rendered hydrocephalus more common noAV than formerly. The affection has also been knoAvn to follow falls or bloAvs on the head; the extension of inflammation from the ear; the sudden suppression of chronic evacuations, or accustomed discharges, as from ulcers, cutaneous eruptions, epistaxis, or of the menstrual secretion; carrying heavy loads on the head; jumping and other bodily concussions; hanging by the feet Avith the head down- hydrocephalus, (Diagnosis.) 119 Avards, with other feats performed by rope-dancers, as remarked by Golis, Odier, Hufeland, and others. Rush, Lettsom, Golis, and Coindet, have given cases in which the hydrocephalic symp- toms Avere apparently connected with rheumatism, or Avith in- flammation of the throat, neck, lungs, pleura, peritoneum, or abdominal viscera. Diagnosis. The difficulty of distinguishing hydrocephalus in the very early stage from the various acute infantile diseases is admitted by all practical physicians. In the acute diseases of infancy and childhood, every symptom which indicates cerebral irritation should be carefully noticed, since in the early stages, curative measures have the best chance of being permanently beneficial in arresting the progress of a disease too often formi- dable. Whenever, therefore, infants and young children are observed to be Avakeful both by day and night; to cry for hours together Avithout apparent cause, or disease, that can be discov- ered; if the faecal evacuations be unhealthy, and ordinary treat- ment fail in restoring their natural appearance; and if the urine be at the same time scanty, there is strong suspicion of some affection of the brain, which, if not treated energetically at the onset, may terminate in hydrocephalus. Again, if at any period in the course of an acute disease the child falls into a state of insensibility, Avith rolling of the head on the pilloAV, grinding of the teeth, and screaming, the attention of the practitioner should be instantly directed to the head. Acute hydrocephalus in children not unfrequently resembles some of the various febrile disorders to which they are so liable. From these it may, hoAvever, in general be distinguished by the starting and peculiar scream; the expression of anguish in the countenance Avhen the child is roused; by the constant drowsi- ness; the knitting of the eyebroAvs; the pain in the head, occasion- ally darting through the brain, and rendering the child very cau- tious in moving; by the hands being frequently raised to the head, and the neck being thrown back; frequent and deep sighing; by the irritability of the stomach, increased by the erect posture and by motion; and by the obstinacy of the bowels, and the character of the alvine evacuations. The subsequent progress of the dis- ease soon clears up the doubt, and exhibits its peculiar character. Typhoid fever is rare in children, and Avhen present may be recognised by the supine posture; the absence of acute headach; the Ioav muttering delirium; the dark brown sordes on the teeth and gums; the dark and fetid character of the evacuations; the more equable pulse; and the absence of convulsions or palsy. The febrile affection produced by vermination (denominated ivorm fever by some Avriters) may be distinguished by its irregu- lar course and remissions; by the dull and obscure headach; the pulse being uniformly quick; the senses of sight and hearing unimpaired; the sleep sound; the appetite voracious; the tumidity 120 HYDROCEPHALUS, (PrOgUOSlS.) of the abdomen; the copious and spontaneous alvine evacuations; and the pale and abundant urine. It is often a matter of great difficulty to distinguish hydroce- phalus from infantile remittent fever. Some authors doubt the possibility of an accurate diagnosis in children under five years of age, until the enlarged pupil and coma indicate Avith too great certainty hydrocephalic effusion. In the early stage of hydroce- phalus the prominent signs are the irritability of the stomach; the continued severe headach; aversion to light; droAVsiness; scream- ing in sleep; and evident uneasiness in moving the head, evinced by frequently raising the hand to the head; the contraction and subsequent dilatation of the pupils; the variation in the pulse; the little ayersion to food, which is generally taken readily and with- out reluctance; and by the state of the boAvels, Avhich, though occasionally disordered, are easily acted on. The distinct stages of the disease are also diagnostic of hydrocephalus. In infantile remittent fever, on the other hand, the pulse is quick throughout the course of the disease, never falling below the natural stan- dard; there is seldom vomiting, except as an accidental occur- rence; the appetite for food is lost, and nourishment refused; the belly is tumid from flatulent distension; the nostrils are dry, Avith constant itching of the nose; the bowels are acted on with much difficulty; the evacuations are unhealthy and extremely offensive, and mixed Avith portions of undigested food and shreds of lymph; the exacerbations and remissions of fever are irregular but well- marked, the child during the intervals being often lively and playful. The irritation in the boAvels sometimes induces convul- sions at an early period of the disease, but after the fit, the com- plete restoration of the faculties without permanent palsy, and the preceding symptoms indicate their origin in intestinal irrita- tion. Dr. Joy (Cyc. Prac. Med.) has well remarked, that amidst our efforts to establish a diagnosis in any particular case, we must not forget that diseases are at times, in the language of the older writers, convertible into each other; or that, to use the more modern phrase, complications may arise in their course, and the secondary affection eventually predominates over the original. It is thus that in the course of infantile fever hydrocephalus fre- quently comes on, and often Avith such insidious advances, as altogether to elude observation almost up to the very last mo- ment of its fatal termination. Prognosis. Whytt, Fothergill, and other writers, Avho first described the disease, considered it as uniformly fatal. It is Avell known, however, that cases have recovered even Avhen very unfavorable symptoms, such as strabismus, dilatation of the pupils, blindness, palsy, convulsions, stupor, involuntary evacua- tions, &c, have been present. When detected at an early period, hoAvever, and energetic and judicious treatment ■ has been em- ployed, the comparative number of recoveries has greatly in- HYDROCEPHALUS, (Prognosis.) 121 creased. Of thirty-seven cases recorded by Gblis, five recovered; and that physician, in the course of his extensive practice, has known permanent restoration of health to take place in forty-one instances. Odier says, that at Geneva about eighteen children on an average are annually attacked, of which six, or one third, recover. Of tAventy-eight cases recorded by Mills, seven termi- nated favorably; and of eleven given by Bricheteau, four recov- ered. These facts hold out much encouragement to the practi- tioner, Avhile a knowledge that individuals have recovered when in the last stage of the disease should stimulate him to continue his efforts, although they may be apparently hopeless. In forming our prognosis, great attention should be paid to the circulation. If the pulse from being quick, fall slowly and mode- rately, our opinion of a successful termination Avill be more favor- able than Avhen it becomes suddenly slow. Should the pulse, on the other hand, have been preternaturally slow, a slight increase in its frequency may be considered a propitious circumstance; a rapid and very considerable rise, on the other hand, indicates the commencement of the last stage. Great caution, however, is necessary in prognosticating from the pulse, as many practition- ers have supposed the fall of the pulse a favorable sign, when it proved to be the forerunner of the fatal termination. It has generally been supposed that Avhen effusion has once taken place, the disease is hopeless—an opinion that doubtless has tended to increase its mortality. So long, however, as the general strength is not too much exhausted, the pulse continues steady, and the breathing natural, the most alarming symptoms should not prevent the employment of active remedies. Dr. Copland affirms that the supervention of hurried breathing is the only symptom which should lead us to despair of the case. When the disease appears in children of a previously sound constitution, or after an attack of some acute disorder, its termination is gene- rally more happy than when it occurs in scrofulous or Aveak individuals. The favorable signs are the improved appearance and natural odor of the stools, an increased flow of urine, mucous or watery discharges from the nose, or an abundant perspiration. None of these individually, however, should be depended on; profuse per- spirations, for example, whether partial or general, often precede the fatal termination. In many cases, also, apparent improve- ment is observed, Avhich continues one or two days; but this amendment is often folloAved by a relapse, which proves fatal. Even Avhen the amendment is longer continued, a favorable result cannot be confidently anticipated until the iris recovers its sensibility, the alvine excretions resume their natural odor and appearance, and the other marked symptoms become greatly diminished. Among the unfavorable symptoms may be noticed the acces- 11 122 hydrocephalus, (Treatment.) sion of hydrocephalus in individuals of a Aveak and debilitated constitution; its sIoav progress, so as not to be recognised until far advanced; total insensibility of the retina; dryness of the mouth, lips, and nostrils; great rapidity, smallness, and feebleness of the pulse; hurried respiration; partial sweats, particularly on the neck and back of the head, &c. Treatment. We have already stated that at an early period it is impossible to determine Avhether the symptoms be those of acute hydrocephalus, or of other affections to Avhich they are common. This fortunately is of little consequence in a practical point of vie\v, as the treatment of these symptoms must be guided by the same general principles, Avhatever be the morbid con- ditions which may subsequently arise. There is every reason also to believe, that Avhen the disease is threatened, or Avhen the incipient symptoms have come on, the judicious administration of remedies has often prevented the development of hydrocepha- lus; consequently, it is of great importance that the earliest symp- toms should be properly and actively combated. Sometimes also it becomes a matter of importance to counteract a predisposition to the disease. With this view every means should be adopted to produce regularity in the secretions and excretions in young infants by means of a healthy nurse, and at a later period by strict attention to a proper diet and regimen, combined Avith suf- ficient exercise. As the intellectual poAvers expand, great care should be taken to prevent their being too early exercised, espe- cially in children Avhose mental poAvers are precocious, and recre- ations that demand more bodily than mental exertion should be selected. Should the health become affected, and incipient cere- bral symptoms supervene, attention must be paid to the state of the bowels and cutaneous transpiration. If the former be defi- cient in quantity, or of an unhealthy character, castor oil. Hyd. c. CretS, either alone or combined Avith small doses of rhubarb or jalap, according to the age of the patient, should be given occa- sionally in appropriate doses. If the skin be dry, James's powder, with or Avithout calomel, Avill tend to restore it to its natural state. The various forms of counter-irritation, with the vieAV of exciting an artificial discharge from the nape of the neck, occiput, or upper part of the arm, by means of issues, moxas, or repeated blisters, have also proved highly serviceable in diminishing cerebral symptoms, even in children hereditarily predisposed to the dis- ease. Dr. Cheyne supposed that the disease was more easily guarded against in such families—a circumstance Avhich, if true, Dr. Joy has Avith much reason supposed to depend on the readi- ness Avith Avhich the parents detect the incipient symptoms. As soon as there is reason to suspect the invasion of the disease, the patient should be placed in bed, in a tolerably large chamber, screened from strong daylight, Avell aired, and of moderate tem- perature. The bed should be formed into a slightly inclined hydrocephalus, (Treatment.) ' 123 plane, from which, Avhen necessary, the patient may be sloAvly raised, and gently laid down again. The head ought to be some- what more elevated than the feet, and the bed-clothes not too heavy, but only sufficient to preserve the natural heat. All quick and sudden movements of the patient must be prevented, and in children every thing which is likely to irritate should be carefully avoided. The necessary medicines are to be administered by soothing and persuasion, and every thing approaching to force guarded against as much as possible. The indications in the treatment of acute hydrocephalus, are, 1. To remove all sources of irritation. 2. To equalise the circu- lation Avithin the cranium. 3. To moderate the pain, vomiting, and convulsions, even Avhen the two first indications cannot be accomplished; and, lastly, to support the strength in the advanced stage of the disorder. In endeavoring to equalise the circulation in the brain, it is necessary to take into consideration the constitutional poAvers of the patient, the form of the disease, and the nature of the symp- toms Avhich have preceded, or accompany, the cerebral affection. If the pulse be strong, the head-symptoms Avell-marked, the con- stitution vigorous, blood-letting should be freely employed. Copious venesection is under such circumstances necessary, and in the early stages of the disease has been knoAvn to relieve the pain of the head, reduce the fever, and induce a state of the sys- tem highly favorable to the action of other remedies. Dr. Max- Avell opened the jugular vein, Avhile the patient was in the hori- zontal posture, and stopped the Aoav of blood from time to time with his finger, so as to obtain a considerable quantity of blood before the syncope was induced. This was continued until the pulse could not be felt; and insensibility Avas occasioned. By this bold practice sixty out of ninety cases are said to have recovered. Most of these, hoAvever, Avere instances of cerebral inflammation; and it is impossible to knoAV whether any of them Avould have terminated in effusion. Such severe practice, if indiscriminately employed, is not free from danger; excessive exhaustion, indeed, is well-known to occasion convulsions, and other hydrocephalic symptoms and even produce the very effusion the remedy Avas intended to prevent. Mr. Cooke observed, that Avhenever bleed- ing had been carried to a large extent, although it temporarily relieved the patient's condition, a proportionally larger quantity of fluid Avas effused. (Med. Rep. vol. ii.) Dr. Rush employed this remedy more moderately, and in the same manner as in the treatment of phrenitis. We have previously stated, that, in the early stages, the disorder cannot be distinguished from inflamma- tion, or an active state of congestion; and Avhenever bloodletting is indicated, the same rules Avhich guide the practitioner in the treatment of those pathological states, should govern his conduct in the management of the disease under consideration. The 124 • hydrocephalus, (Treatment.) quantity of blood taken must be regulated by the effect produced upon the pulse, and the general appearance of the patient. In children the diminution of heat and color in the cheeks furnish valuable indications of its effects. It is a safer practical rule to repeat the bleeding should the pulse again rise, than, by a too copious detraction at first, run the risk of producing exhaustion, from Avhich the individual is Avith difficulty restored. This should be more especially taken into consideration when the disease arises in the progress of other acute affections; but when the symptoms depend on primary cerebral inflammation, bloodletting may be employed with greater freedom. It is unnecessary to remark, that this remedy is almost inadmissible in the advanced stage of the affection, though Dr. Cheyne has adduced instances in Avhich even then a moderate bleeding has been useful, espe- cially Avhen pain in the head and vomiting have been prominent symptoms. This physician, hoAvever, does not advocate very active bloodletting at any period of the symptoms; and Drs. Gar- nett and Porter are even hostile to its general abstraction, con- sidering the application of leeches or cupping-glasses to be all that is necessary. This mode of abstracting blood should be trusted to only in the treatment of children under three or four years of age, and even in them should not Avholly be relied on, when the indications for bloodletting are well-marked. Dr. John Clark prefers cupping to leeches, and informs us, as the result of his experience, that although very young children may bear loss of blood to syncope once or twice, they are apt to sink if it be carried beyond this limit. In infants of a year old he thinks the abstraction of three ounces enough; this may be repeated in twelve hours if necessary. This may be considered the standard quantity to be taken at that age, unless peculiar circumstances arise Avhich render it necessary to increase it. When leeches are preferred, it is not material to what situation in the neighborhood of the head they are applied. Kuhn recommends the inner angle of the eye; others have advised the temples, behind the ears, the angle of the jaw, or nape of the neck. It should be kept in mind, that the more early bloodletting is employed, the greater is the chance of its proving beneficial. On the other hand, cases occur in Avhich it should be used Avith extreme caution, especially in the consecutive forms, when the pulse does not appear much increased in force, and the general strength is somewhat reduced. It is positively injurious when the symptoms appear after long-continued diarrhoea, or other causes of exhaustion; and it should never be prescribed when the appearance of the patient and diminished strength of the pulse indicate debility. Cathartics are of great service, especially after bloodletting has been employed, and may be administered freely in most cases in Avhich the latter remedy is indicated. They are useful hydrocephalus, (Treatment.) 125 in all forms and stages of the disease in procuring healthy evacu- ations, and thus removing or preventing the irritation which accumulations in the digestive canal are likely to produce, as Avell as producing derivation from the general mass of blood, but more especially from the vessels of the head, as is shoAvn by the pallor of the face, after the operation of a brisk purgative. In- deed, according to the experience of Abercrombie, the judicious exhibition of purgatives is little, if at all, inferior to bloodletting, in arresting almost every manageable form of cerebral disease. He states, that "although bloodletting is never to be neglected in the earlier stages, more recoveries from head affections of the most alarming aspect take place under very strong purging than under any other mode of treatment." (Diseases of the Brain, p. 153.) Similar testimony to the good effects of this practice is borne by Whytt, Rush, and others. Active purgatives are con- tra-indicated, however, if there is great irritability of the stomach, and mucous membrane of the intestines. If, under such circum- stances, purgatives increase the vomiting and general irritation, or produce watery stools of an unhealthy appearance, their exhi- bition should be postponed, until, by bleeding and other remedies these symptoms have been removed or alleviated. Of the various remedies of this class, calomel has been much employed, with the vieAV of inducing a free biliary secretion. In general it is neces- sary to combine it Avith some other purgative. Gblis prefers toasted jalap, as it does not so readily excite colic pains. Should the calomel produce much intestinal irritation, Dr. A. T. Thom- son recommends the Hyd. c. Creta, Avith poAvdered colchicum. Dr. Cheyne found one or two drachms of magnesia, saturated with lemon juice every two or three hours, sit Avell on the sto- mach, even Avhen it Avas irritable, and to act freely as a purgative in most cases. Elaterium has been employed by Dr. Elliotson, and may be given in the acute forms of the disease, Avhen it is deemed advisable to lower the general powers by acting briskly on the bowels. It is very liable, hoAvever, to produce severe sickness and vomiting, which renders its employment less advisa- ble; and when the stomach is irritable, it should never be thought of. The regular and steady exhibition of calomel at stated in- tervals, longer or shorter according to circumstances—interposing a solution of any of the neutral salts in infusion of senna, so as to insure its free action, will be followed in most instances, by the most beneficial effects. Some prefer the Hydr. c. Creta as a milder preparation: it may be given in combination'with rhubarb, jalap, or scammony. Dr. Abercrombie has found the croton oil eminently successful in evacuating the boAvels, and it has the great advantage of being easily administered; one or tAvo drops smeared on the tongue being generally quickly folioAved by copi- ous Avatery stools. In the non-inflammatory varieties of the disease, and Avhen there is debility, poAverful cathartics should be 11* 126 hydrocephalus, (Treatment.) withheld, and gentle aperients, such as the neutral salts, with senna, rhubarb, &c, employed. Dr. A. T. Thomson says he has found obvious advantage from a long-continued course of the wine of aloes combined with an alkali. When evacuations are procured Avith difficulty, emollient clysters, containing suitable doses of the saline purgatives, or, if there is debility, the turpen- tine enema Avill often prove highly efficacious, and tend much to assist the operation of other cathartics. These preparations also are beneficial when there is irritation in the loAver part of the alimentary canal. Cold applications to the head should also be used in conjunc- tion Avith the above remedies, and in order to permit their more effectual application, the head should be shaved. The most con- venient and effectual mode of applying cold, as Avell as that which causes least trouble, is by means of bladders filled Avith snoAV or pounded ice; but if this cannot readily be procured, cloths dipped in cold Avater, or a refrigerating mixture, should be constantly applied to the shaved head. Evaporating lotions, con- taining spirits of wine and aether, may also be used, or a stream of cold water directed on the head, and continued as long as the heat of the surface remains. This last method is a most poAverful means of subduing cerebral excitement, and applicable to the more violent forms of the affection. Dr. Darwall has knoAvn cases which seemed hopeless, recover by letting water drop in a small stream on the head; and Formey employed it every two hours, for several consecutive days and nights, with the best effects, even Avhen it Avas supposed that effusion had taken place. Abercrombie also strongly recommends its employment, and has found it very successful in the coma of children arising from con- gestion, and in cases attended Avith convulsions. In some in- stances the action is favored by the simultaneous employment of Avarm or tepid pediluvia. Care should be taken, during the employment of the cold applications, that they should not be continued after the increased temperature of the surface has been permanently reduced, as, under such circumstances, they are powerfully sedative, and may, according to Burns and others, produce an alarming state of collapse. The utility of this remedy is best observed in the early stages of the disorder, Avhen the tem- perature of the scalp is increased; and at that period the expe- rience of Rush, Quin, Conradi, Formey, Gblis, and a host of practitioners, has established it as one of great efficacy. Antimonials. Large doses of the tartrate of antimony have, in a few instances, been given after the method of Rasori Avith success. Laennec eured three cases of cerebral affection in this manner; but as the symptoms Avhich occurred Avere not suffi- ciently well-marked to indicate that effusion had taken place, they cannot be considered as decided illustrations of hydroce- phalus. Dr. Mills also gave tolerably large doses of this prepa- hydrocephalus, (Treatment.) 127 ration, Avith a view to relieve the headach and lower the pulse; and, if the stomach Avas irritable, he combined it Avith the tinc- ture of opium. The generality of practitioners, hoAvever, have not derived much benefit from this practice; and Guersent re- marks, that these large doses of antimony have ahvays seemed to him to irritate the intestinal canal, increase the cerebral symp- toms, and aggravate the enteritis, which often coexists with meningitis of the base of the brain. Antimony is now given chiefly as a sudorific, and for this purpose James's poAvder is the preparation chiefly employed. It may be combined with calomel and opium, or Avith cathartics, a mode of administration much recommended by Dr. Cheyne, who considered that by these means the inflammatory action in the brain Avas reduced, while at the same time the abdominal and cutaneous secretions were promoted. Mercury has been extensively employed in hydrocephalus since it Avas first introduced into practice by Dr. Dobson, with the vieAV of subduing inflammation, or favoring absorption Avhen effusion has taken place. NotAvithstanding many practitioners have extolled this remedy, and some cases have appeared to owe their recovery to its administration, there are many doubts whether the good effects which have folloAved its employment are really to be attributed to its use. True it is that in numerous cases no benefit has resulted, although mercury has been given in the most judicious manner, Avhile in others recovery has taken place, although it has not been employed at all. Though mer- cury may be said to be a powerful auxiliary in the treatment of cerebral inflammation, its Avarmest partisans do not trust to it alone; and Avhen the pulse is strong, the fever great, and the inflammatory symptoms Avell-marked, our chief reliance must be placed on bloodletting, cathartics and other antiphlogistic mea- sures. Most practitioners, however, are agreed that it may be beneficially employed to stimulate the absorbent vessels, and numerous cases are recorded in which the effusion, even in chronic hydrocephalus has sensibly diminished under its exhibi- tion. With this object it may be given in the inflammatory variety, after depleting measures have been had recourse to; and in the advanced stage, or Avhen it depends on exhaustion or debility, in combination with opium or hyoscyamus. Different prepara- tions have been recommended. Calomel is the one usually em- ployed in doses of one or two grains repeated every third or fourth hour, until the gums are affected. Dr. Merriman and some others hoAvever, in order to produce the mercurial effect with greater rapidity, have given corrosive sublimate in doses of one sixtieth to one thirtieth of a grain, repeated every four or six hours. In urgent cases the external may be combined with the internal administration, and half a drachm to one drachm of Ung. Hydrargyri rubbed on the thighs, or any portion of the 128 hydrocephalus, (Treatment.) surface three or four times a day. In infants three or four grains of calomel may be rubbed on the gums every three or four hours Avhen it is thought of importance to bring the system rapidly under its effects. Blistered surfaces may also be dressed Avith mercurial ointment, or the mercurial liniment on warm poultices may be applied io them. In Avhatever way mercury is employed the state of the gums, mouth, or tongue, should be carefully noticed, as salivation, if car- ried too far, may induce sloughing of these parts, Avhich is at all times a source of great irritation. Its effects on the boAvels should also be watched, especially Avhen calomel is given: if griping and diarrhoea are occasioned, it must be discontinued, or the Hyd. c. Creta substituted. Golis, Avho considers that the doses generally given in England have occasionally produced fatal enteritis, admi- nisters only half a grain to two grains every tAvo hours, until it produces four or five green slimy stools, or colic, Avhen the medi- cine is discontinued until these effects have ceased. Children under three years of age, hoAvever, are salivated Avith great diffi- culty. Dr. Clarke could never produce it in them, although he he has frequently tried to do so. Golis says also, that, under one year, children bear large doses of calomel without either colic, diarrhoea, or salivation. Should apparent benefit result from the use of mercury, it should not be left off suddenly, but discontinued gradually, by diminishing the dose. Iodine has also been used to facilitate the absorption of the serous fluid, and in some cases Avith success. It appears to act most beneficially Avhen combined with mercury, as in the proto- ioduret of that metal. This may also be used in the form of oint- ment. The binoxide of mercury thus employed, in addition to any absorbent properties it possesses, combines the advantages of counter-irritation; but care must be taken to prevent salivation. Iodine, when combined with diuretics and tonics, has been found useful in assisting their action. Narcotics. Opium has been employed by some physicians in the second and third stages of hydrocephalus to lessen the acute pain in the head, convulsions and irritability of the stomach and intestines, and may be given Avith this vieAV at an early period, when the disease depends on exhaustion and debility uncompli- cated with inflammation. It has often succeeded in effecting this without in any Avay interfering Avith the action of other remedies, or inducing constipation, when moderately employed. At the early part of the second stage, it may be given Avith calomel, James's powder, or the tartrate of antimony, in doses varying from the eighth to the fourth of a grain every four hours. If there is much irritability of the boAvels, it is best administered in the form of Dover's poAvder combined Avith Hyd. c. Creta. Ac- cording to Crampton and Cheyne, contraction of the pupils, fol- loAving the exhibition of this remedy, indicates that it has been hydrocephalus, (Treatment.) 129 pushed sufficiently far. In some cases hyoscyamus may be given with the same vieAV as opium, especially if the latter appear in any Avay to increase the cerebral irritation. Digitalis Avas first employed by Dr. Withering, and has since been used by BroAvn, Whytt, Cheyne, and others, to subdue the excitement of the first stages; and, Avhen effusion has taken place, to favor its absorption. Much uncertainty, hoAvever, prevails regarding its effects, as it is often difficult to determine Avhether the deranged cerebral functions, vomiting, and irregular pulse, be consequent upon the remedy, or the original disease. Dr. Cheyne was of opinion, that when the sIoav irregular pulse of the second stage becomes small and sharp, it is the effect of digitalis, and is readily distinguished from the pulse in hydrocephalus, which is soft and full. He also attempted to draw a distinction betAveen the brain affection arising from the exhibition of digitalis, and that of hydrocephalus, from the vertigo and momentary blindness of the former, and the continued coma of the latter. But it is im- possible to make out these distinctions in practice, and the greatest caution is necessary to guard against the too long continuance of this often poAverful sedative. Dr. Cheyne gave the tincture, com- mencing Avith ten drops, and adding tAvo or three to every succeed- ing dose, which was given at intervals of four hours. His object was to bring the system perfectly under the action of the digitalis in one or tAvo days, and he has given as much as 120 drops a day to a child only four years old. In the first stage this is the best method of administration, but in the second it may be advantage- ously conjoined with squills and other diuretics, as advised by some of the German Avriters. Golis and Merriman recommend half a grain of digitalis in poAvder Avith a grain of calomel every four or six hours. Windelstadt combined it Avith opium, and Kle- ber rubbed it over the scalp Avith Vinum Scillae. Colchicum has been given Avith the same intentions as digitalis, but does not appear to be so efficacious, or to have been so extensively tried. Diuretics have been thought useful auxiliaries Avhen effusion has taken place. Among other remedies of this class, squills, colchicum, Sp. .-Ether. Nit., Sp. J.unip. Co., &c, have been em- ployed. When the stomach is irritable, care should be taken that the vomiting is not increased by the injudicious use of these medi- cines. In some cases they may be advantageously combined Avith opium, and in others Avith restoratives and tonics. Briche- teau and several foreign Avriters warmly recommend squills as the most poAverful diuretic in this disease; but, according to Cop- land, turpentine in the form of enema, or liniment rubbed on the scalp, is the most energetic. Derivatives and counter-irritants have been extensively em- ployed in hydrocephalus, and if judiciously applied are productive of great benefit. They are for the most part only required in the second stage, but have been used in the first Avhen there is little 130 hydrocephalus, (Treatment.) fever, and Avhen there is coldness of the lower extremities. Blis- ters have been most commonly employed as a counter-irritant, although the best period and proper situation for their application has been much disputed. In the first stage of the disease they are contra-indicated if there be much febrile disturbance, restless- ness, or muscular excitement; but should the febrile excitement be moderate, they are best applied at some distance from the head, as between the shoulders, or to the legs or arms. The utility of blisters in the first stage, hoAvever, is at all times much to be dis- trusted, unless the cerebral affection appears to have been induced by disorder of the digestive organs; in Avhich case, should tender- ness exist in the epigastrium, hypochondrium, or other region, a blister may often be applied to the painful part Avith advantage, after the local abstraction of blood. In the second stage, how- ever, they have been much relied on by Rush, Odier, Percival, Cheyne, Hopfengartner, Golis, and others; and many cases haATe been recorded, where great alleviation of the symptoms has fol- io Aved their application to the head or nape of the neck. Several should be applied in succession, or an irritating ointment employed to keep up the derivative effect, especially in the third stage, Avhen there has been great sopor. In young infants they should be re- moved in a few hours, or Avhen redness of the skin has been pro- duced, as in some cases their long-continued application has been followed by fatal sloughing. Sinapisms Avill often answer every indication, and prevent the inconvenience blisters are liable to occasion. Tartar emetic ointment has been found useful as a derivative, and is indicated Avhen the disease supervenes on repelled erup- tions. Moxas, setons, and issues are for the most part too slow in their effects to be much relied on in this disease. The first, hoAvever, were employed by Renault, and the latter are useful as prophylactics. Dr. Merriman gave the Tinct. Lyttae inter- nally with a view of producing strangury, and causing irritation at the neck of the bladder. He administered from five to ten minims every four hours until this effect was produced, and cured three patients by this remedy. This preparation has also been used externally as a rubefacient. The tepid and warm semicupium and pediluvia are often bene- ficial when the extremities are cold, and may be used in con- junction with cold to the head. When there is much febrile ex- citement, and a sthenic state of the constitution, hoAvever, they are contra-indicated. Their good effects are increased by the addition of salt, mustard, and other cutaneous stimulants. The warm bath increases cerebral determination in cases Avhere there is much excitement of the system, but Avhen the disease is con- nected Avith a state of debility, it often tends to relieve the gene- ral irritability, especially in children. The vapor bath has been recommended by Dr. A. Hunter. M. Itard impregnates it Avith hydrocephalus. (Treatment.) 131 vinegar as a means of stimulating the surface, and producing an abundant Aoav of perspiration. He states, that until he intro- duced this practice, all the cases he treated, amounting to seven- teen, perished; but that afterwards he Avas fortunate enough to cure two out of three infants, and in one case the child was in the last stage of the disease, without consciousness and poAver of motion. M. Recamier has employed the cold bath in the first stage Avhen there is much excitement, and it is said Avith success. It may also be useful as a tonic during convalescence. Fomen- tations and frictions to the abdomen, Avhen there is pain in that situation, are also occasionally beneficial. Palliatives and restoratives are to be had recourse to in the latter stages of the complaint, although the disease may appear hopeless. Indeed, cases apparently at the last extremity have recovered, and this should induce the practitioner to continue his efforts to relieA^e distressing symptoms, and support the strength under the most adverse circumstances. Vomiting may be sometimes checked by effervescing draughts, combined with a few drops of laudanum, the application of a sinapism or tur- pentine liniment over the epigastrium, or by emollient clysters containing turpentine. The convulsions have often been sus- pended or somewhat lessened by the cold affusion or turpentine enema. If they are severe, the tobacco enema may be cautiously tried. In the last stage, Avhen the powers are exhausted, gentle stimulants and nourishing broths should be given to support the strength; and the preparations of ammonia, camphor and vale- rian, combined with bitter infusions, may be at the same time ad- ministered. The diet must have reference to the constitutional poAvers. If, as is generally the case, the disease occurs in a sthenic state of the system, an antiphlogistic regimen, consisting chiefly of di- luents, should be enforced during the early stages. When the Arital poAvers, however, are feeble, or the disease depends on ex- haustion, a nourishing diet should be alloAved: in infants the milk of a healthy nurse or asses' milk is necessary. In the collapse of the last stage of the disease the nutriment should consist of beef- tea, Avarm jellies, &c, &c. The convalescence should be care- fully watched, and the patient removed to a pure dry air as early as the strength will permit. The remedies Ave have noticed are the most poAverful means Ave possess for subduing acute hydrocephalus, depending on active congestion or inflammation of the membranes or substance of the brain. We have remarked, hoAvever, that acute hydro- cephalus is occasionally connected with an opposite state of the system, or one of exhaustion and debility: under such circum- stances the circulation Avithin the cranium is to be restored to its natural state, and subsequent effusion prevented by invigorating the general powers. Several writers have noticed the identity 132 hydrocephalus, (Treatment.) of the cerebral symptoms so produced with those of hydrocepha- lus, and have thought that the difference in the constitutional phenomena, and the means necessary to relieve them, to be suffi- cient reasons for treating this affection as a distinct disease, and for giving it a neAV appellation (hydrocephaloid disease). We have, hoAvever, already stated our reasons for considering it to be only a variety of hydrocephalus, and shall noAV describe the plan of treating it. If it occur in very young children, the milk of a strong and healthy nurse is essential, and if the diarrhoea which sometimes precedes the disorder continue, it will be neces- sary to check it by mild astringents, such as preparations of chalk or catechu. Small doses of sal volatile or brandy should be at the same time administered. When the diarrhoea has ceased, the boAvels are to be regulated, if necessary, by small doses of Hyd. c. Creta, magnesia, or castor oil. If there be much irritability, the Avarm bath will be useful; and, should coma supervene, blis- ters or sinapisms should be applied to the nape of the neck. The extremities should be kept Avarm by flannels, and the erect pos- ture avoided. The treatment of these cases in adults and in old persons is described under the head of Apoplexy. The chapter on hydrocephalus is rich in practical views of much interest, and the rules for the treatment of the disease, are as definite as the nature of the subject will admit of. The treatment is based upon the leading idea, that the disease is an inflammatory one, of a sub-acute type; and it is therefore correct; but if we attempt to follow a particular mode of practice, without understanding the natural course of the disease, its complications, or its prog- nosis, we are much embarrassed and often unable to pursue a method which is in itself correct. The erroneous pathology of those who follow the classifica- tion of the author, arises mainly from one circumstance: they regard the effu- sion of serous liquid as an essential character of the disorder, when in fact it is a mere consequence, just as independent of the disease, properly speaking as the effusion of lymph or of purulent matter. It is true, that in the larger proportion of cases, water is effused in an abnormal quantity, either on the surface of the brain or into the ventricles, but it is very often so small in quan- tity, that no apparent effect can be ascribed to it, and in some cases it is totally wanting. The true pathology of the disease, which is generally meant by hydroce- phalus, is simply this:—it is a sub-acute inflammation of the membranes, and often of the substance of the brain, which is more frequent in children, than in adults, and nearly always connected with a deposit of tuberculous granula- tions. The sub-acute inflammation of the membranes, without this turbercu- lous deposit, is so rare, that the exceptions need scarcely be regarded, especially in children. The disease is therefore a tuberculous one, and like all affections of the same class, it is often connected with the same lesion in other parts of the body; that is, the formation of scrofulous or external tubercles, and of pulmonary phthisis. The reason that scrofulous children, or adults laboring HYDROCEPHALUS, (Pathology.) 133 under phthisis should be peculiarly liable to the disease, is readily explained. It is a mere dependence upon the general tuberculous diathesis. The forms of the tuberculous disease which precede its development in the membranes of the brain, vary with the disposition to them, which exists in particular ages of life: thus, in children, the lymphatic ganglia are most frequently affected, and in adults it nearly always follows consumption of the lungs, and then it carries off the patient much before the ordinary termination of the disease. The granulations which are found in the membranes, do not in the large majority of cases, precede the inflammatory affection. If they are of extremely small size, the regularity of form and the proportion, which generally exists between the number of the granulations, and the degree of the inflammation, show, that the same morbid action caused the deposit of the tuberculous sub- stance, and of the ordinary products of inflammation. In many cases the same process occurs simultaneously in other serous membranes, as the pleura and peri- toneum, and the same progress of inflammation and tuberculation takes place. This simultaneous action often occurs in the serous membranes, without those of the brain being involved, and we therefore infer that the disease is the same in both instances, although its seat is different. It is only in exceptional cases, that the larger size and more complete formation of the tubercles authorise us to conclude, that they were deposited previously to the inflamma- tion, and acted merely as exciting bodies in forming its development. This view of the pathology of the disease, is based upon the examination of about forty cases of hydrocephalus, which terminated fatally at the chil- dren's hospital of Paris, in the years 1832 and 1833, including nearly all the cases which were entered the hospital from the epidemic of cholera, in April and May 1832, to the end of the year 1833. These cases were collected into a series by Dr. Rufz and myself, and the joint results of our labors, were pub- lished in the years 1834 and 1835. (American Journal of the Medical Sciences, 1834, and The'se de M. Rufz, Paris, 1835.) Some subsequent re- searches into the same disease as it occurs in adults, were published by me in the American Journal for 1835. The inquiries upon this subject were made by us simultaneously, but not in common, that is, each one observed different patients, and after collecting a considerable number of cases, we arrived at the conclusions, which subsequent experience has confirmed. Our cases were observed in concert from the month of September 1832, but I had commenced a continued series of studies at the hospital several months earlier, and M. Rufz had also noted cases, though not with a view to a regular course of study upon this subject until September. MM. Piet and Constant studied the dis- ease at the same hospital, from the beginning of 1833. It was not known previously to the researches of Dr. Rufz and myself, that the tuberculous character of the disease was any thing but a mere complication. Thus far, the researches of Dance had extended, and it was taught by M. Guersent at the children's hospital, that the granular or (as we now term it, tuberculous menin- gitis,) was a variety of the disease. The physicians and students who had fol- lowed the practice of the children's hospital, had of course become familiar with the fact, that tubercles were occasionally found in the pia mater; and this circumstance, which was well known to M. Constant, as well as to others, led 12 134 hydrocephalus, (Pathology.) a physician who assisted in preparing his notes upon this subject, to claim a priority, which he himself would have been too conscientious to have asserted while living. The difference between the description of the disease as adopted by Dr. Rufz and myself, and that retained in the text of the work is simply this: After we had ascertained the regular coincidence between the intractable variety of the disease, so well known at the children's hospital, and the tuber- culous affections, we classed it amongst them, because it is this common type that renders the disease, when partly formed, as difficult to arrest, as other dis- eases of the same nature, and which furnishes us with the only rational means of prophylaxis, if not of cure. The subsequent observations of others, who have practically studied the same subject, have so fully confirmed our state- ments, that the term tuberculous meningitis, is entering more and more fre- quently into the received nosological arrangements. The symptoms of the disease are accurately described by Dr. Bennett, that is, the symptoms of the acute meningitis, for there is of course no local symp- tom which is referrible to the tuberculous substance. The diagnosis of the dis- ease, as distinguished from other varieties of the sub-acute meningitis, is made in two ways; 1st, by relative frequency of its recurrence, as compared with the varieties of the sub-acute inflammation; 2d, by the evidence of the tuberculous diathesis, as derived from the general constitution and appearance of the patient, as well as the previous existence of a scrofulous or tuberculous disease. The latter is almost always present in adults, who scarcely ever labor under tubercu- lous meningitis, except as a sequel of another disease of the same type; in chil- dren the same direct connection is frequently observed, although in a goodly pro- portion of cases, they previously show no signs of decided ill-health. But when a disease of this peculiar character has appeared, there will remain almost no doubt of the nature of the meningitis. The relative frequency of the disease in children, is the best guide when the collateral evidence fails us. Upon comparing the history of the cerebral diseases of children, which presented the character of idiopathic meningitis, we found of the large number of patients of the age of those admitted into the children's hospital, but two or three cases presented any analogy with the disorder in question. Of course we excluded those cases in which cerebral inflammation occurred, as a mere complication, during the course of an exanthema, or a continued fever, or any other acute dis- ease; in like manner we excluded tumors of the brain, whether resulting from large tubercles which had increased slowly without inflammation, or from any other cause. This distinction must necessarily be admitted in adults, as well as in children, otherwise the diagnosis of the disease would be involved in inextricable confusion. The few exceptional cases that remained were true hydrocephalus, in which there was a chronic effusion of serum within the ventricles, and the rare case of true arachnitis, or inflammation of the free surface of the arachnoid. Hence with children above the age of two years, the mere estimate of probabilities will make the diagnosis nearly cer- tain, for 1 have found that the rule deduced by Dr. Rufz and myself, holds good in private practice, as well as in hospitals, and is quite as true in the United States as in" France. hydrocephalus, (Pathology.) 135 There are, however, usually some more precise signs of the disease, for the symptoms generally increase so regularly and gradually, from simple irritation of the brain, to decided inflammation, that there is little difficulty in distin- guishing the disease from the more common varieties of acute meningitis. It is true, that the tuberculous variety is occasionally more acute, but this is not common, and unless other signs confirm our diagnosis, we may reasonably doubt, in such a case, whether the disease is really of this nature. The effusion of serum, which has given the designation hydrocephalus to this disease, does not produce specific symptoms, unless it takes place in a sufficient degree to abolish the functions of the brain. There is then a gradual loss of muscular power, and of the intelligence, with less spasmodic contrac- tion of the muscles, or active excitement than occurs in the cases in which there is but little effusion. The proportion of serum does not seem to bear any definite relation to the previous state of the patient, or the mode of attack of the disease. As a general rule, it is rather more abundant in young children, than in those who are older. In very young children, that is, those who have not completed their first dentition, the tuberculous meningitis is not common. Their cerebral affec- tions are much more rapid, generally occur during the course of other diseases, as the exanthemata, or from some disorder of the digestive canal, and there- fore they do not present that distinctive character which attends tuberculous meningitis, or other forms of cerebral disease, which pass through a regular series of symptoms. These infantile cerebral disorders, are commonly attend- ed with convulsions, and often terminate in effusions of serum, but rarely of lymph or pus. They are distinguished from the tuberculous disease by these peculiarities, and unless large effusions of serum take place, usually termi- nate in death or recovery in a short time. The treatment recommended by the author for acute hydrocephalus, is very appropriate for the tuberculous meningitis, which is evidently the disease he mainly refers to. If the disease is fully developed, or if it follow an ad- vanced tuberculous disease of another portion of the body, it will almost always terminate fatally. In its earlier stages, the antiphlogistic treatment with re- vulsive baths, is the most appropriate in the second period, a continual dis- charge from blisters behind the ears, which are made to suppurate freely, and the use of mercurials, have been with me the most useful remedies. The inflammations of the serous membranes, which give rise to tuberculous forma- tions, are the only varieties of these diseases in which the good effects of a mercurial treatment are shown. This is the case, with these inflammations, whether they occur in the pleura, peritoneum or membranes of the brain. The prophylactic precautions are at least as important as the treatment, and their beneficial effects are more decided. In children of a scrofulous or tuber- culous constitution, excitement of the brain should be sedulously avoided until the age of 10 or 12 years: after this period, the tendency to tuberculous men- ingitis is much lessened. The constitutional treatment required for a scrofu- lous diathesis, is of course applicable to children threatened with this disease, and if the disease shows itself externally, it is, as a general rule, not prudent to arrest the discharge which usually follows abscess of the glands, or caries of the bones. 136 APOPLEXY. Definition.—Premonitory symptoms.—Of the different forms.—Transient of fugitive.—Sudden or primary.— Ingravescent.— Paraplexy. —Anatomical characters.—Connection of symptoms with morbid appearances.—Patho- logy, or theory, of apoplexy.—Causes.—Predisposing.—Exciting.—Diag- nosis.—Prognosis.—Treatment. By the term apoplexy (derived from djiortXrisam, percutio) is understood a sudden loss of consciousness and volition, the circu- lation and respiration being more or less disturbed. In this sense it has been usually employed by physicians from the days of Hippocrates to the present time. This definition, hoAvever, does not distinguish apoplexy from syncope, concussion of the brain, fracture of the cranium Avith depression, or indeed from any other disease in Avhich there is coma; and, as we shall have occa- sion to point out hereafter, there may be sometimes much diffi- culty in separating it from these affections. The French writers have endeavored to avoid this confusion by limiting the meaning of the word apoplexy to the occurrence of spontaneous haemor- rhage in an organ, and hence the terms apoplexy of the spinal cord, of the lungs, liver, heart, muscles, &c. They are, however, under the necessity of acknowledging, that it is often difficult to discover in the living body, whether any extravasation of blood has taken place, and consequently a person may be laboring under all the symptoms of apoplexy, as it has been described from the most ancient times, and if after death no effusion of blood is discovered within the cranium, we must not apply the term apoplexy to this disease. Some cases also have occurred, Avhere slight cerebral haemorrhage has taken place, and the ordi- nary symptoms of apoplexy have been Avanting: under such circumstances we must admit that the patient has been laboring under the disease, although none of its symptoms have been pre- sent. In the absence, therefore, of any certain signs which indi- cate the lesion which causes apoplexy, Ave consider that the French pathologists have been premature in endeavoring to change the meaning of a Avord so generally employed. Even Avere their ideas correct, it would be better to designate the lesion by its proper name, such as haemorrhage Avithin the cranium, than introduce increased confusion by changing the signification of a Avord which has been used in medicine for a series of ages. apoplexy, (Symptoms.) 137 Hippocrates divided apoplexy into the strong and the iveak; Galen into four varieties, according to the effect produced on the respiration. Most authors consider that, though there is great diversity in the severity of apoplectic seizures, the terms Avhich have been invented to indicate the force of the attack, as weak, strong, or intense, (debilis,fortis,fortissima,) are only compara- tive, and do not convey precise notions to the mind. Cullen distinguishes nine species of apoplexy, the sanguinea, serosa, hydrocephalica, traumatica, venenata, mentalis, cataleptica, and suffocata. This arrangement from the causes bears, hoAV- ever, no relation to the symptoms, or morbid anatomy, and has consequently been rejected by subsequent writers. The terms sanguine and serous, from the nature of the effusion found after death, have been retained by many, and some have adopted the terms nervous and bilious, as giving some idea of the origin of the disease. We shall have occasion to shoAV, however, that neither of these latter distinctions is founded in an extensive knowledge of its pathology. With reference to the state of the vital poAvers, several authors speak of atonic or entonic, active or passive, sthenic or asthenic apoplexy—terms which convey no idea of its nature, although, as indicating opposite states of the system in this disorder, they are founded on truth, and are, therefore, useful with a view to treatment. Other distinctions have arisen from the prominent symptoms; thus, Burserius, Zu- lianus, Sydenham, Hoffman, Tissot, and others, speak of convul- sive, hysteric, and paralytic apoplexy. When no morbid ap- pearance can be detected after death, the term nervous has been applied to it by numerous writers, simple by Abercrombie, and M. Gendrin treats of it under the name of coup de sang. The tAvo last terms, however, have been differently applied by other authors, Avho understand, by simple apoplexy, that the attack is unconnected with any complication; and, by coup de sang, a sudden seizure dependent on congestion of the cerebral vessels. Apoplexy complicated Avith paralysis, has been distinguished by the Avord paraplexy. Galen and Boerhaave employed this term, which has been lately adopted by M. Gendrin. Symptoms. It is very rare that an attack of apoplexy takes place without certain premonitory signs, although in some cases they are too slight or rapid to be noticed. The folloA-ving are those Avhich have been most commonly observed: droAVsiness Avith sense of Aveight in the head; vertigo, especially on leaning forAvards; noises in the ears; some defect in the sense of hearing and of smell; more or less imperfect vision; optical illusions; diffi- culty in reading and distinguishing small objects; numbness of the extremities; itching or formication; pain in the temples or behind the ears, particularly after eating or remaining some time in places of a high temperature. Sometimes there is loss of memory, for- getfulness of Avords, or the substitution of one Avord for another; 138 apoplexy, (Symptoms.) incoherent talking; inability to write, and difficulty of spelling words; spasmodic movements of one or more of the extremities, of the eyelids, or of the muscles of the face; more or less rigidity or contraction of the limbs; fatigue after gentle exercise; unsteadi- ness in Avalking; flushing or unnatural paleness of the counte- nance; turgidity of the veins of the head; haemorrhage from the nose; yawning; vomiting, &c. These symptoms are not peculiar to apoplexy, many of them being also the precursors of acute diseases, of chronic lesions of the brain, or of diseases occasioned by affections of the heart or stomach. As, however, they ahvays indicate a disorder in which the functions of the brain are more or less disturbed, they are not to be overlooked. One or more of these may be present and disappear several times before the apoplectic attack, and occa- sionally they undergo several changes, some being replaced by others. The duration of these premonitory signs is also variable: many months may intervene after their first appearance; while, on the other hand, they may come on only a few minutes before the attack. None are to be relied on more than others, as point- ing out with certainty the nature, intensity, or form of the attack. The order of their appearance is also very various. In several instances the most severe forms of apoplexy have resulted, when the premonitory symptoms have been so unimportant as almost to have escaped attention; while in others a comparatively slight attack has followed well-marked precursory signs. Notwith- standing the difficulty these circumstances occasion, the practi- tioner, if called in at a sufficiently early period, should take much pains in investigating the above symptoms, as, by connecting them with the age, habits, and condition of the patient, he may be led to predict the approaching disease, and, if not able to pre- vent, may at least be prepared to lessen its effects. The symptoms Avhich characterise the attack may assume dif- ferent forms: 1. Transient or Fugitive Apoplexy. In this, the slighter form of the disease, the symptoms generally commence with vertigo and sensation of feebleness; occasionally with retching or vomit- ing. The patient shortly after becomes unconscious, and falls to the ground, appearing as if in a profound sleep; the limbs when lifted fall like inert bodies, and the different senses are more or less insensible to the application of their appropriate stimuli; the pulse is strong, not frequent, sometimes bounding; the face is generally injected, and occasionally appears to be swollen; the eyes are immovable, the conjunctiva injected, and the lips livid; the carotid and temporal arteries beat with much force; the respi- ration is free, deep, and regular. The heat of the skin is gene- rally increased over the head and face, Avhile it is diminished on the other parts of the body. Sometimes, at the commencement of the attack, the face becomes suddenly pale and afterwards apoplexy, (Symptoms.) 130 injected, while the temples are covered Avith perspiration; in other cases the paleness alternates with flushing. The symptoms in this form of apoplexy have various degrees of intensity, and continue for a shorter or longer time. Some- times the patient is affected with giddiness, feels his legs totter, and loses consciousness only for a feAV minutes. In general, however, the duration is about tAvo or three hours, and more rarely the apoplectic symptoms continue ten or twelve hours. Immediately on recovering from the attack, the patient expresses astonishment, feels difficulty in expressing his ideas, and cannot articulate distinctly. These effects soon pass off, but there remain generally for two or three days a sense of pain and heaviness in the head, dulness of the mental faculties, dislike to all kinds of exercise, and droAvsiness. This form of apoplexy is seldom fatal, but has a strong tendency to return, so that a patient may, per- haps, have three or four attacks annually. If frequent, however, they gradually affect the functions of the brain, producing great feebleness of the intellectual faculties, loss of memory, imperfect muscular motion, trembling of the limbs, and dulness of sensi- bility. M. Gendrin relates the case of a man who, during a period of seven years, had tAventy-three apoplectic attacks, Avhich gradually affected his intellect; he died, almost fatuous, of cancer of the stomach. No lesion could be found in the brain or spinal cord. (Traiti Philosophique de Midicine Pratique, 1838.) Hoffmann and other authors speak of intermittent apoplexy, Avhich may be classed Avith the cases uoav under consideration. M. Bailly has noticed it in conjunction with the intermittent fevers of Rome. (Traiti Anatomico-Pathologique des Fievres Intermittentes, Simples et Pernicieuses.) Andral gives a re- markable case of it cured by quinine, and another where after death the spleen was found enlarged. (Clin. Mid.) The occur- rence of vertigo also sometimes accompanied by loss of conscious- ness, is not uncommon in some persons at certain periods of the year, as at the commencement or termination of the autumn and winter. To this form of apoplexy belong, in our opinion, those cases Avhich M. Foville speaks of as constituting a mild species of epilepsy, characterised by loss of consciousness, general in- sensibility, relaxation of the muscles, and vacillation or falling of the trunk. (Diet, de Mid. et Chir. Prat.) There is undoubtedly much analogy betAveen this form of apoplexy and epilepsy, as shown by its tendency to recur and the gradual loss of intelli- gence ; but the distinguishing feature of the latter disease, viz: convulsion, is rarely present. M. Lallemand has pointed out that it is often symptomatic of long-continued seminal emissions, and that the urgency of the cerebral symptoms often causes the ori- ginal malady to be overlooked. (Des Pertes Siminales Involon- t aires.) 2. Sudden or Primary Apoplexy. In the second form the 140 apoplexy, (Symptoms.) patient falls doAvn suddenly, deprived of consciousness and volun- tary motion; the face is generally flushed; the breathing slow, deep, and stertorous; and the pulse usually full, not frequent, or below the natural standard, but occasionally small and weak. Sometimes there is convulsion, or rigidity of the muscles of the extremities; in a few cases there is contraction of the muscles of one side with relaxation of those on the other. Occasionally the attack commences or is accompanied with general convulsions passing into profound coma. In this state the patient may die after an interval varying from a few minutes (Abercrombie) to several days, generally from the first to the fourth day; or a gradual and complete recovery may take place. It is rare, how- ever, that a patient recovers after being perfectly comatose for more than tAvo days. 3. Ingravescent Apoplexy. The third form commences Avith sudden and violent headach, and occasionally momentary loss of consciousness and voluntary motion, from Avhich the patient quickly recovers. The face is pale, there is often a feeling of sickness and faintness, and frequently the patient falls down in a state resembling syncope: sometimes there is a slight convulsion. These symptoms, either Avholly or in part, soon subside, conscious- ness returns, and the patient is able to walk about. The headach hoAvever continues, and is often referred to one side, Avhile the vomiting recurs. The pulse becomes gradually weak and fre- quent, the countenance pale and sunk, and the patient feels de- pressed. After the continuance of this state for a period varying from a few hours to several days, the face becomes flushed, the pulse more strong, and the heat of the skin increased; the patient more and more oppressed, forgetful, and incoherent; slight and afterwards profound coma succeed, and death closes the scene. The cases recorded by Abercrombie show that these changes may occur in fifteen or tAventy minutes, or an interval of a fortnight may occur between the first seizure and the more urgent symp- toms. (Pathological and Practical Researches on Diseases of the Brain.) 4. Paraplexia, or Apoplexy complicated with Paralysis. In the fourth variety a greater or less degree of paralysis, generally hemiplegia, is the characteristic symptom, and this may appear before, during, or after the attack. The first symptom which occurs may be sudden loss of power on one side of the body, with loss of speech, while ,the consciousness remains perfect, or, if lost, it may return. In this situation the patient attempts to express himself by signs. Instead of hemiplegia, the paralysis may be confined to the muscles on one side of the tongue, which deviates to the right or left Avhen it is thrust out of the mouth. In some cases the motor poAver may be enfeebled, and limited to certain parts, as the hand, fore-arm, the foot, &c. In others there is in- sensibility of a part of the integuments joined to paralysis, more apoplexy, (Symptoms.) 141 or less complete, of the arm, hand, leg, or one side of the face: there may be also inability to move the eye or eyelids. Either of these states may pass into apoplexy. When paralysis accom- panies or folloAvs the apoplectic attack, the latter may commence Avith one or more of the premonitory symptoms, Avhich may be of longer or shorter continuance. During the seizure the mouth it often distorted on one side, the limbs are motionless and insen- sible, Avhile those on the other are contracted or slightly convulsed on the application of stimuli. As the apoplexy declines, the paralytic symptoms become more prominent, and paralysis of the orbicularis, distortion of the eyes, twisting of the mouth, palsy of a particular set of muscles or of one or more limbs, of half the trunk or of the face, &c. may remain. At other times there is loss of sensibility in these parts, while the power of motion is perfect, or only enfeebled. In general the speech is either lost or greatly impaired; and the patient, perfectly conscious, attempts to express himself by signs, though very often he is incoherent, unintelligible, and without recollection. The various symptoms now described may disappear in a feAV hours, and the patient perfectly recover. Sometimes the amendment is gradual, the paralysis not disap- pearing for several Aveeks or months; in other cases there is partial recovery only, which afterwards undergoes no further amend- ment, and the patient may continue in this state for an indefinite period, and at length die of another disease or of a new attack. In some instances no amendment takes place after the invasion of the symptoms—he remains speechless and paralytic, confined to his room, in possession of his other faculties, and after many Aveeks or even months sinks exhausted, coma having occasionally supervened a short time before death. The different forms of apoplexy Ave have iioav described not unfrequently pass into each other. Thus it may happen, that after one or more attacks of the first form (fugitive apoplexy), the second, third, or fourth variety may supervene, and many of the symptoms characterising these last may in particular instances be found united. Numerous varieties also occur in individual cases, which differ according to a variety of circumstances, but minute inquiry into the particular symptoms of the case will generally enable the practitioner to attribute the disorder to one or other of the above forms. Besides considering the various symptoms constituting the dis- ease in the aggregate, it is necessary, with a view to a correct and efficient treatment, to pay particular attention to each indi- vidually. The character of the pulse is very variable in apoplexy. It may be strong Avithout frequency; or soft, as in the first or second forms; or it may be firm and irregular, as in the third variety and last stages of the fourth. At the commencement of an attack it may be slow and full, and toAvards the end become feeble and irregular. The character of the pulse, as we shall 142 apoplexy, (Anatomical Characters.) aftenvards have occasion to observe, is important as a guide in the treatment, and often proves a valuable diagnostic. The respiration also is variable; it is often stertorous, although some- times perfectly free even in extreme cases: experience has proved, in opposition to the opinion of some Avriters, that in itself it fur- nishes no indication of the danger of the patient. The color of the countenance is equally uncertain. Flushing or paleness of the countenancchas been supposed to distinguish the sanguineous from the nervous and serous forms of apoplexy. The diagnosis founded on the one condition of the countenance or the other is extremely fallacious, as no constant relation exists between them. The expression of the countenance, as indicating stupor and loss of the mental faculties, is usually Avell-marked. The pupils are generally immovable, especially in violent attacks and towards the latter stages; in some cases, hoAvever, the iris retains more or less of its contractility. The excretions are occasionally dis- charged involuntarily; this generally happens as the disease ap- proaches its fatal termination. Rigidity and contraction of the limbs are often present to a greater or less extent, and come on gradually or suddenly, before, during, and after the attack. We have seen the rigid contraction of one or both limbs on the same side of the body, Avhich had appeared simultaneously with the seizure, diminish in a feAV hours, and appear suddenly in the op- posite, although the apoplectic symptoms had undergone no change. Convulsions are sometimes observed, especially in the third and fourth forms; in the latter they are usually on the side not paralysed. They may be general, or confined to one limb or one side of the body. Occasionally they occur on the same side, and alternate Avith the paralysis; and sometimes there is tetantic rigidity in the same parts. Loss of consciousness, more or less transient, has been generally supposed to be invariable. M. Ro- choux however states, that he has seen a number of cases in Avhich consciousness Avas partially retained during the attack, although an effusion of blood had taken place in the brain. (Diet. de Med. et Chir. Prat. art. Apoplexie.) Sensibility is often destroyed so that pricking or pinching apparently produces no impression. When consciousness is entirely destroyed, however, the application of stimuli to the limbs often causes slight contrac- tions. Paralysis of motion may affect the muscles of the eye, the orbicularis, those of the larynx, tongue, oesophagus, face, neck, arm, leg, or side of the trunk. The muscles of the superior and inferior extremities are most commonly affected, particularly the former; next in frequency are those of the tongue and face, then the neck, and more rarely the larynx and oesophagus. Anatomical characters. The appearance found on the dis- section of individuals who have died of apoplexy are very vari- ous; a fact which has given rise to much speculation regarding apoplexy, (Anatomical Characters.) 143 the true cause of the disease. Five distinct states of the brain have been found after death:—1. The brain has in every respect presented a healthy appearance, the most rigorous and careful examination having failed to discover any morbid change. 2. The vessels of the substance of the brain, or the membranes cov- ering its surface or lining the ventricles, have been found more or less injected with blood. 3. Serous effusion, more or less consi- derable in the cavity of the arachnoid, and in the ventricles of the brain. 4. Extravasation of blood has been discovered either between the membranes, or into different parts of the substance of the brain. 5. A portion of the brain may have undergone the alteration knoAvn by the name of softening, or ramollissement. The four last appearances may be found co-existing. We shall describe each of these lesions in succession:— 1. No appreciable lesion in Fatal Apoplexy. That fatal cases of apoplexy may occur, and leave no appreciable lesion, is a fact now acknowledged by all writers on this disease. Many instances have been recorded by the older authors, as Morgagni, Tissot, Quarin, and Stoll; but, until lately, such instances were attributed to Avant of care during the examination. The cases, however, Avhich have been detailed by Abercrombie, Bright, Cooke, Wilson, Louis, Gendrin, and others, have shown that this can no longer be a matter of dispute. Hildenbrand noticed, that after the apoplectic state of contagious typhus, no morbid ap- pearances could be discovered in the brain. The same symp- toms, moreover, are knoAvn to result from concussion of the brain, death by lightning, extreme cold, and from narcotic poi- sons, Avithout necessarily occasioning any appreciable lesion. To apoplexy, in Avhich no morbid alteration can be discovered after death, different names have been given. Burserius termed it convulsive; Hildenbrand, and others, nervous; Tissot, hysteric; Abercrombie, simple; and M. Gendrin treats of it under the name of coup de sang. 2. Injection of the bloodvessels of the brain or its membranes is often observed, especially combined with the two lesions next to be described. Occasionally, however, it is the only alteration that can be observed, in Avhich case it constitutes a mild form of Avhat has been denominated sanguineous apoplexy. It has been observed in rapidly fatal cases of coup de soleil. Injection of the cerebral vessels, extremely well-marked and occasioning apo- plexy, has been remarked by Andral in persons laboring under phthisis, and in a female affected with cancer of the uterus, Avho . Avas much exhausted in consequence of the frequent haemor- rhages from that organ, proving that it is compatible Avith the anaemic condition. Injection of the membranes of the brain is so common in neAv-born infants, that Billard considered it as a natural rather than morbid state. This vascular injection may be partial or general; it may be confined to a small spot, or more 144 apoplexy, (Anatomical Characters.) or less extended over the organ: indeed, every portion of the cerebral substance is liable to this alteration. It is not unfre- quently seen surrounding the remains of old coagula. 3. Effusion of serum is not unfrequently found after death from apoplexy. The effused fluid is sometimes limpid, or it is turgid, and of a yelloAv or reddish color. The presence of serum Avithin the cavity of the arachnoid, or in the ventricles, is to be attributed to obstruction of the blood, and transudation of the more fluid parts through their coats; and hence the origin of the serum in these cases is the same as in other dropsies. It is sel- dom found without engorgement of the veins and sinuses of the brain, and may take place immediately before or even after death. When the effusion of serum is the chief morbid lesion after fatal cases of apoplexy, it constitutes hyperacute hydroce- phalus—the serous apoplexy of some writers. 4. Extravasation of blood is by far the most common morbid lesion found in persons Avho have died of apoplexy, and consti- tutes the true sanguineous apoplexy of authors. The extrava- sation, which varies in quantity from a few drops to six or seven ounces, may occur between the membranes, in the ventricles, or in the substance of the brain. Dr. Watts has recorded a case cited by Abercrombie, in Avhich, from caries of'the left parietal bone destroying a vessel, extravasation of blood took place be- tAveen the bone and dura mater. The patient was immediately affected Avith hemiplegia of the right side, and died in five days. Effusion of blood may also take place in the cavity of the arachnoid, forming the meningeal apoplexy of M. Serres. In this case it may be diffused over the whole surface of the brain, confined to one hemisphere, or to a small portion of it. The researches made by M. Cruveilhier at La Maternite have shown that apoplexy, connected with this lesion, is the cause of death in one-third of the infants who die shortly after birth. Extravasa- tion of blood into the cavity of the arachnoid is the morbid ap- pearance generally found in these cases; in most instances it is limited to the circumference of the cerebellum, but sometimes covers the cerebral lobes: it rarely occurs in the ventricles, and M. Cruveilhier has never seen it in the substance of the brain or cerebellum. He has observed it in almost all the cases which have been usually considered to be asphyxia, and attributes its production to mechanical causes arising from difficult parturition. (Anat. Pathol, du Corps Humain, liv. xv.) Blood may be extravasated into the lateral, third, and fourth ventricles; it may be found in one cavity only, or in all of them: sometimes the effusion extends into the cavity of the arachnoid, or into the spinal cord. Most frequently the haemorrhage takes place into the substance of the brain, and this may occur in almost every portion of its substance— towards the circumference, near the centre, or at the base. It is most common hear the corpora apoplexy, (Anatomical Characters.) 145 striata and optic thalami, and next in the hemispheres. Of 392 cases of cerebral haemorrhage collected by Andral, 202 occupied at the same time the corpora striata and optic thalami; 61 the corpora striata; 35 the optic thalami; 27 the portion of the hemi- spheres above the centrum ovale of Vieussens; 16 the lateral lobes of the cerebellum; 10 an anterior lobe of the brain; 9 the tuber annulare; 8 the spinal marroAv; 7 a posterior lobe of the brain; 5 the middle lobe of the cerebellum; 3 the cerebral pedun- cles; 1 the peduncles of the cerebellum; 1 the olivary body; and and 1 the pituitary gland. (Anat. Pathol, torn, ii, p. 758.) The haemorrhage may take place from the minute capillaries, or from the larger trunks; in the latter case the symptoms are more severe. Over-distension from any of the exciting causes to be presently mentioned may give rise to cerebral haemorrhage; but sometimes it can be traced to disease of the vessels themselves, as noticed by Morgagni, Lieutaud, Baillie, and other later Avrit- ers. Bouillaud has seen chronic inflammation of the vessels; Morgagni, Mills, and Serres have found them ulcerated; Blane, Hodgson, Serres, Bright, and others, have traced the extravasa- tion to the rupture of small aneurisms; and in old persons it may be caused by their rigidity, or by calcareous deposits in their structure. When the haemorrhage is in the cavity of the arach- noid, it arises from some of the meningeal vessels; when in the lateral ventricles, Morgagni, De Haen, and Hufeland, have traced it to the choroid plexus; and avhen at the base of the brain, the retiform plexus, or the trunk and branches of the basilar and carotid arteries, may furnish it. Sometimes the blood is infiltra- ted into the substance of the brain, the texture being softened; in other instances it forms circumscribed collections and cavities in the cerebral mass. If the patient survive the immediate effects of the cerebral haemorrhage, certain changes take place in the extravasated blood: these changes indicate the length of time such effusions have existed previous to death. If the patient have survived from fourteen to tAventy nays after the extravasation, it has been observed that the fluid parts of the blood have disappeared, and the coagulum has become more firm, and of a dark brownish color. After this it gets more solid, of a fibrous texture, and the red color is gradually lost. In general, at the end of four or five months, all the coagulum has disappeared, and nothing remains but a loose cellular-looking mass of a light reddish color. This process is longer or shorter, according to the size of the coagu- lum, and the constitution of the individual. Moulin found a small portion of the coagulum at the end of a year. Riobe ob- served some blood in a cavity after twenty months, and in two cases found a hard coagulum—the one at the end of two, and the other of three years. The texture in the immediate vicinity of the effused blood also undergoes changes. A yellowish mem- 13 146 apoplexy, (Anatomical Characters.) brane forms, which remains Avhen the coagulum has entirely disappeared, and is often observed to be organised, and to pos- sess numerous bloodvessels. It forms a Avell-defmed cavity, which is either empty, or crossed by bands of the same substance which composes it, uniting the opposite sides. Cruveilhier, Bright, and others, have in some instances seen it reduced to a a dense nucleus, and in others to a linear induration resembling a cicatrix. Dr. Abercrombie, however, states that he has exam- ined such cysts at various periods of their progress, but has seen nothing like an approach to obliteration. Various opinions have been formed as to the formation of this cyst. M. Gendrin thinks that it precedes and is necessary to the absorption. Andral and other French writers state that they have found the cyst full of serum; and M. Rochoux has seen one with the internal surface almost as smooth as that of the ventricles, and moistened by a slight serosity. These facts favor the theory of M. Riobe, that the coagulum is absorbed by the exhalation of a serous fluid from the surrounding membrane, which dissolves a portion of the coagulum, and favors its absorption. A portion of the blood may also be absorbed when it is effused between the membranes, or into the ventricles, but its complete disappearance, under such circumstances, is exceedingly rare. In this case no perfect cyst is formed, but the arachnoid membrane becomes thickened, of a yelloAvish color, and appears to perform its absorbent function. These cysts or cicatrisations are always of the same number as the previous attacks. M. Moulin and Dr. Abercrombie have each found four in one individual, and M. Cruveilhier has seen five. These instances, hoAvever, are very rare. M. Lallemand says he has seen forty cysts, the remains of extravasations, in one individual: there must, hoAvever, be some error connected with this observation. Softening. Dan de la Vauterie, Rochoux, Andral, Lallemand, and others, have recorded many cases of apoplexy connected solely Avith softening of the brain. This lesion presents different appearances. Sometimes it is not distinguished by any change of color; in other cases the part affected may be more pale than natural, and of a dull or bright Avhite. Occasionally the softened part is of a rosy color, more or less intense, arising from increased vascularity, or it may be of a grayish or yellow greenish aspect. When it surrounds an extravasation of blood, it is generally of a dirty red or brownish color, arising from the mixture of this fluid with the altered structure. It varies considerably as to consis- tence: in extreme cases the softened portion of brain is reduced to an almost fluid pulp: but there is every intermediate degree of softening, until it can scarcely be distinguished from the healthy cerebral substance. The change to softening may be sudden, the softened portion filling a cavity apparently dug out in the sub- stance of the organ, or it may be softest in the centre, and gradu- apoplexy, (Anatomical Characters.) 147 ally become more firm until it terminates in healthy brain. Much doubt exists regarding the origin of this alteration. By Lallemand it is supposed ahvays to arise from acute, subacute, or chronic inflammation; and that this may occasionally produce it, is generally acknowledged. Baillie, Abercrombie, and Rostan, have found it under circumstances where no appearances of in- flammation Avere present, particularly in old persons; and in such cases they have considered it analogous to gangrene in other structures. M. Recamier thinks the same species of softening is the result of an alteration sui generis, occasioned by nervous, pernicious, or malignant fever; Avhile Dr. Carswell is of opinion, that its real nature is unknown. When softening occurs around collections of blood, it is supposed by Cruveilhier, Craigie, and some other pathologists, to be the result of the extravasation; Avhile M. Rochoux thinks that it precedes this event, and that it forms a peculiar species of ramollissement, different from that described by MM. Rostan and Lallemand, to Avhich he has given the name of hoemorrhagipare. Some cases, recorded by -M. Durin Fardel (Gaz. Mid. Mai, 183S), seem to favor this view. From the numerous facts, however, Avhich have been published concerning this disputed question, it seems most probable that softening sometimes precedes, and sometimes follows, cerebral haemorrhage. This lesion forms the capillary apoplexy of M. Cruveilhier. Numerous other alterations have been found on the dissection of individuals who have died from apoplexy. The most impor- tant of these are the various changes which occur in the heart and lungs, as the obstruction they occasion in the circulation may produce a state of the brain highly favorable to the production of apoplexy. Thus, thickening of the pericardium, a collection of serous fluid in its cavity, and adhesion between its layers, have been occasionally found. Legallois, Bricheteau, Lallemand, Wat- son, and others, have shoAvn that hypertrophy of the heart is not an unfrequent complication of apoplexy. Dr. Cheyne has pub- lished a case, in Avhich after death the fleshy part of the heart was found converted into fat. (Dub. Hosp. Rep. vol. ii, p. 216.) Thickening and ossification of the. aortic valves also have some- times been observed. The lungs have been found condensed by effused fluid, more or less congested, inflamed, hepatised, or dis- organised by tubercles, melanosis, calcareous concretions, &c. The bronchia have been found thickened, and their mucous linings considerably altered by chronic inflammation. Connection of symptoms icith morbid appearances. It has already been stated, that haemorrhages may occur in almost every part of the brain, and an attempt has been made to connect par- ticular symptoms Avith lesion of certain portions of the cerebral substance. Apoplexy, however, can in very feAV instances either confirm or nullify such physiological or pathological speculations, 148 apoplexy, (Anatomical Characters.) as the morbid changes Avhich occasion it are seldom confined to one portion, but are either Avholly or in part diffused over the organ. Hence, Ave need not be surprised that the theories Avhich have been brought forward should be sometimes apparently sup- ported or opposed by different cases. M. Bouillaud has related many instances Avhere paralysis of the tongue coincided Avith more or less alteration in the anterior lobes of the brain. Pinel, however, has observed paralysis of the tongue, when the anterior lobes Avere not the seat of any lesion; and Rochoux states that he has observed a delirious loquacity Avhen they Avere affected. MM. Cruveilhier, Piorry, Sandras, and Berard, have noticed numerous similar facts. M. Foville considered paralysis of the tongue to be connected Avith injury of the cornu ammonis, Avhile Treviranus believed it to be the seat of the memory of impres- sions on the olfactory nerves. Many observations,. hoAvever, are opposed to these opinions. MM. Serres, Foville, and Pinel Grandchamp suppose, that lesions of the corpora striata are fol- loAved by paralysis of the superior extremities, and those of the thalami by palsy of the inferior. Numerous observations, how- ever, shoAv that this opinion is founded in error, besides that it is opposed to the majority of anatomical, physiological and patho- logical facts. Neither does apoplexy furnish any proof that the gray matter is the seat of intelligence, as stated by MM. Foville, Delaye, and Pinel Grandchamp. Extravasations into the cerebellum are generally fatal, and oc- casion the most formidable attacks. Flourens and Rolando have considered that this portion of the brain is connected with the power of motion; but when it is the seat of haemorrhage, the loss of movement is more readily explained by the pressure ne- cessarily produced on the medulla oblongata. Neither does apoplexy prove that the cerebellum, according to the vieAvs of MM. Foville and Pinel Grandchamp, is in any way related to sensibility. M. Serres maintains Avith Gall and his followers, that injuries to the cerebellum cause disorder of the genital func- tions, particularly erections and seminal emissions in men, and sanguineous discharges from the female. Cruveilhier, Aber- crombie, and other writers, have recorded cases in which no such symptoms occurred, although the cerebellum vvas the seat of large apoplectic effusions; and it is Avell known that they often result from lesions of the spinal cord, Avhen no morbid lesion is found in the cerebellum. The tuber annulare is occasionally the seat of extravasation, notwithstanding its density; and in such cases general paralysis, soon involving the muscles of respiration, and quickly folloAved by death, is usually the result. But if the lesion is of small extent, paralysis on the opposite side sometimes follows, Avhich is invariably permanent if the nervous fibres are torn across. In such cases cysts form in this as in other portions of the brain. apoplexy, (Pathology.) 149 With regard to the morbid changes more immediately connect- ed Avith the different forms of the invasion, it generally results that the more sudden the extravasation, and the larger the quantity of blood effused, the more abrupt and severe is the attack; and, should the patient recover from it, the more serious are the effects. When the blood occupies the base of the cranium, influencing more especially the superior portion of the spinal cord, such as the medulla oblongata, annular protuberance, optic thalami, and corpora striata, sudden death, or more or less complete paralysis, is the result; and hence these parts are usually affected in the fourth variety. In the third form Ave most commonly find softening in the brain near the extravasations of blood, the cerebral substance being discolored and broken doAvn, indicating that in these cases this change had either preceded the attack or folloAved shortly on the effusion. Occasionally it is apparent that a recurrence of the haemorrhage had produced a lacerated opening, communicating either Avith the ventricles or the exterior surface of the brain. The symptoms we have enumerated—first, the pain in the head, and sudden loss of consciousness; secondly, the recovery; and, thirdly, the fatal coma—are apparently connected with these changes. In the second form Ave find effusion of serum or of blood. The for- mer results from congestion of the vessels, Avhich is more or less common to all the forms of apoplexy. It is the only change which exists in the first form, as the attack comes on suddenly, often passes away, and returns at indefinite, or in some cases at regular, periods. Pathology, or Theory, of Apoplexy. We noAV proceed to in- quire into the condition of the brain on Avhich apoplexy strictly depends. We have seen that loss of consciousness, sensation, and voluntary motion, is the chief characteristic of the apoplectic state. We have also seen, that although by far the most common lesion found after death is extravasation of blood within the cranium, this is not necessary to produce the malady, as occasionally only turgescence of the vessels, serous effusion or softening, can be dis- covered, while in some instances no morbid appearances whatever can be detected. In many of these latter cases the symptoms are the same as in the former; and, in the living state, it is often im- possible to tell whether any, or which, of these morbid appear- ances may be found afterdeath. Apoplexy,therefore, though itmay be induced, is not necessarily dependent on any one of the mor- bid lesions described, but on some cause Avhich is common to all its forms; and to all the post mortem appearances which have been found in connection Avith it. In the preliminary observations Ave have already attributed it to pressure, and we entirely agree with Dr. Clutterbuck, in considering that this pressure acts on the blood- vessels, producing interrupted circulation within the cranium. (Cyc. Prac. Med. art. Cerebral Apoplexy.) It must be remem- 13* 150 apoplexy, (Pathology.) bered, however, that sufficient pressure on the brain will ahvays cause interrupted circulation, and the latter Avill always occasion the former; so that, in point of fact, these two expressions, so far as the explanation of apoplexy is concerned, are almost synony- mous. If fracture of the cranium Avith depression of bone occur, coma and perfect apoplexy is produced; and, on elevating the depressed bone, consciousness and the other mental faculties in many cases immediately return. Hence pressure has evidently been applied to the brain, causing loss of its functions, and on remoAdng it they are restored. In the same way, if a bloodvessel is ruptured in the head, blood is poured into the ventricles, or into the substance of the brain, and the same symptoms are occasion- ed. Here surely we are also Avarranted in attributing the apo- plexy to the pressure produced. If the blood is poured from a large vessel, or quickly from a small one, the effect will be sud- den; but a little reflection will shoAV the possibility of the extrava- sation taking place very sloAvly, and in such a manner, that the numerous tubes Avhich everyAvhere traverse the brain may be par- tially compressed, and prevent any pressure on the nervous mass. At other times a small effusion of blood may take place, then cease, and occur at intervals; and in all cases, if it be sudden, pressure will be occasioned, and apoplexy produced more rapidly. But if the haemorrhage be circumscribed, the vessels surrounding it are wholly or partially compressed; and the organ accommodat- ing itself to the foreign body, a free circulation is established, the pressure removed, and the attack disappears. Then commence those changes in the neighborhood of the coagulum necessary for its absorption. Should the extravasation have pressed with suffi- cient force, either directly or indirectly, on the motor tract, or any of the nerves arising from the cranial portion of the spinal cord (which, as has been stated, commences Avith the corpora striata and optic thalami), paralysis will be the result. . It must be ob- vious, however, that in an organ situated like the brain, it is im- possible to define the limits of that space over Avhich the pressure is diffused, as this Avill depend not only on the extent of the extra- vasation, but on the force Avith Avhich the blood is poured out. Hence there are many cases in which no connection can be disco- vered, after death, betAveen the situation or size of the coagulum and the effects produced. Should the pressure be applied in a partial manner to the motor tract, so that some portions of it are not affected, while others are Avholly or slightly so, either partial paralysis or convulsions may occur. The former may be occa- sioned also by softening and disorganisation of the motor tract, and the latter by the irritation of the commencement of this pro- cess. Laceration of the fibres, or the presence of cysts, will readily explain the continuance of paralysis when the apoplectic attack has disappeared. When a coagulum is present, therefore, more or less pressure explains all the phenomena occasioned. apoplexy, (Pathology.) 151 But hoAV are we to attribute apoplexy to pressure in those cases Avhere no morbid lesion can be discovered? When an individual who is intoxicated falls down suddenly Avithout consciousness, we observe the pulse bounding, the countenance flushed, and the heart's action increased—circumstances Avhich occasion distension of the arteries Avithin the cranium, and corresponding compression of the veins. On the other hand, when a person falls down in a state of syncope, the pulse is feeble, the face pallid, and the heart's action depressed or scarcely perceptible—circumstances Avhich indicate an accumulation of blood in the veins, and a proportion- ate diminution in the calibre of the arteries. In either case, ow- ing to the peculiarities of the circulation within the cranium, pressure is exerted on the brain. Hence syncope differs from apoplexy only in the extreme feebleness of the heart's action, the cause producing loss of consciousness, sensation, and motion, being the same in both. Indeed it is sometimes difficult to distinguish these states from each other, the pulse in many cases of apoplexy being small and irregular, Avhile a different treatment is required in such cases from those in which it is strong. Thus, either from increased or diminished action of the heart, pressure on the brain may be produced by over-distension of its vessels Avith arterial or venous blood. After death of course this is not to be detected; the tonic contraction of the arteries is alone sufficient to empty them of their contents, and turgidity of the veins may remain or not according to the symptoms immediately preceding death, and the position in Avhich the body is placed. Obstruction of the circula- tion may occasion effusion of serum in so great a quantity that a portion of it may be detected after death, or this may be so small as to be immediately absorbed Avhen the circumstances Avhich produced it have ceased. Now, in the living state, the congestion may be greater in one portion of the brain than in another; and hence may arise different symptoms in conjunction Avith those of apoplexy, as paralysis or convulsions, according to the situation or nature of the pressure. Such we consider to be the patholo- gical condition of the brain in those cases Avhere no morbid lesion can be discovered after death. When extravasation of blood has taken place, and an apo- plectic cyst has formed, the brain is more liable to a recurrence of the attack, the presence of this, as of other foreign bodies during sudden changes of the circulation, assisting in producing pressure under circumstances that ordinarily Avould not give rise to it. The influence of the circulation is also Avell-marked in certain cases Avhere pressure has been caused primarily by extra- vasation of blood, and Avhere, after the first effects have disap- peared, the consciousness has been restored, evidently in conse- quence of the brain having accommodated itself to the injury. Dr. Abercrombie quotes a case from Dr. Barlow, Avhere a copious extravasation of blood was found extended over the surface of 152 apoplexy, (Predisposing Causes.) the brain, its substance being healthy. In this case coma alter- nated with a return of consciousness and recollection several times before death, which occurred on the sixteenth day after the attack. We have been particular in speaking of the effects of pressure in this place, because we consider it to be the chief agent in the production of all cerebral diseases. With regard to apoplexy it must be remembered that Ave Avere unable to explain its occur- rence in all cases before the researches of Dr. Kellie of Leith Avere made knoAvn, as before his time pathologists had very con- fused ideas concerning the peculiarities of the circulation Avithin the cranium. We need not be surprised, therefore, at some of the older Avriters, such as Kortum, Zuliani, Schiller, Schagger, Hufeland and others, attributing certain cases to a defective state of the nervous poAver, enervation, &c, vague terms Avhich have no meaning. The nervous power is undoubtedly diminished in all cases of apoplexy; the question is, to Avhat it may be attri- buted. All Avriters are under the necessity of allowing, that in the majority of instances pressure produces the disorder; and we have endeavored to adduce arguments for supposing that there are no exceptions to this rule. Predisposing causes. It is generally supposed that males are more liable to apoplexy than females, as their active life exposes them more frequently to the exciting causes. This agrees with the statistical results of M. Falret, who found, that of 2297 apo- plectic cases 1670 occurred in men, and only 627 in women, (cited by Rochoux, Arch. Gen. de Mid. torn, ii, 1836.) No age can be said to be exempt from apoplexy. Of 69 cases of apoplexy col- lected and rigorously analysed by M. Rochoux, there were tAvo betAveen 20 and 30; ten betAveen 30 and 40; seven betAveen 40 and 50; thirteen betAveen 50 and 60; twenty-four between 60 and 70; tAvelve between 70 and 80; and one betAveen 80 and 90. From this it Avould appear that apoplexy is most frequent be- tween the years of 50 and 80. Cases have occurred, however, at a younger age than 20, although these are very rare. Dr. Copland states he has met with the true haemorrhagic apoplexy at 18 years. M. Andral had a case 12 years old. M. Lallemand mentions a case at 3 years, and M. Billard at 3 days. There are some doubts Avhether the tAvo last Avere cases of apoplexy. Mr. GreenhoAv, hoAvever, has recorded a fatal case, from extravasa- tion of blood over the surface of the brain, in a child two years and a half old. (Lond. Med. and Phys. Journ. vol. xlvii, p. 131.) We have already alluded to this affection in new-born infants. Isolated cases have been remarked in persons very old. Cheyne attended a woman Avith apoplexy upAvards of ninety years of age. Hereditary disposition, it must be acknowledged, is occasion- ally a predisposing cause. To no other circumstance can the apoplexy, (Exciting Causes.) 153 succession of apoplexies, that occur among different members of the same family, be ascribed. Portal has observed this in many families; and Forestus, Wepfer, Blane and others, have noticed the same fact. The sanguine temperament appears to be most liable to this disease. Of the 69 cases collected by M. Rochoux, 25 Avere of a sanguine: 21 of a sanguino-bilious: 7 of a bilious: and 16 of a lymphatico-sanguine temperament. A large head, red face, short neck, full chest, corpulent body, activity of the circulation, and general plethora, are usually considered as tend- ing to apoplexy; but observation daily shows that it occurs as frequently in individuals Avho possess a constitution the very reverse of this, and a form of body in no Avay remarkable. Apoplexy has been attributed to a sedentary life, especially in plethoric individuals who live Avell, in Avhom this disease is by no means unfrequent. Want of exercise produces a languor in the venous circulation highly favorable to this affection. Studi- ous habits have been thought to predispose to apoplexy. (Al- berti, Seiz.) Some, however, (Rochoux,) think that the exercise of the mental faculties is a preservative against the disease. The poor appear to be as subject to it as the rich: but in them, as Ave have often had occasion to observe at the Salpetriere in Paris, it is commonly attended with paralysis. Extremes of heat and cold have been thought to favor apo- plectic attacks. Of 134 cases, which fell under the observation of Andral, 50 occurred in December, January and February; 36 in June, July and August; 31 in March, April and May; and 17 in September, October and November. Winter, also, has been shoAvn, from the statistical researches of M. Falret in Paris, to be most conducive to this disease. The same fact has also been observed in Holland during a period of twenty years: and at Turin, from an average of tAventy-five years. (Andral, Clin. Mid.) Of the 69 cases of M. Rochoux, on the other hand, 16 occurred in spring; 19 in summer; 18 in autumn; and 16 in Avinter. Among the other predisposing causes may be noticed an unre- strained indulgence of the passions; laborious employment, espe- cially in the stooping posture; a too free use of Avine or malt liquors; immoderate sexual indulgence; masturbation; involun- tary seminal emissions; the suppression of habitual discharges; influence of other diseases, especially hypertrophy of the heart, and organic alterations in the lungs, obstructed respiration; sleeping Avith the head Ioav, particularly after meals, &c. Exciting causes. Many of the predisposing, when suddenly applied, become also the exciting causes of apoplexy. The im- moderate use of Avine or spirits is often folloAved by an attack of apoplexy. This is one of the most common exciting causes among the poor. The narcotism produced by the various narcotics, such as 154 apoplexy, (Diagnosis.) opium, hyoscyamus, tobacco, stramonium, &c, much resemble an apoplectic seizure. Dr. Copland thinks it more readily pro- duced by monkshood than any other. He mentions the case of a young man Avho had incautiously cheAved some seeds of this plant, Avhich occasioned partial loss of sensibility in the face, fol- loAved by complete apoplexy, from Avhich he recovered Avith dif- ficulty, and with palsy on one side. A large number of persons are seized with this disease, either during or immediately after violent exercise, particularly if they have been unaccustomed to bodily fatigue, or if the exertion has been made Avhile the head has been held in an unusual position. Straining at stool and the act of parturition have been known to induce it. M. Rochoux gives a case of an individual Avho died apoplectic in the act of copulation. Cold long continued, or sud- denly applied, may occasion apoplexy. Instances of the disease Avere numerous in the French army during the retreat from Russia; and the narroAV escape of Dr. Solander, in Terra del Fuego, is also well knoAvn. Heat is a fruitful source of this malady. Exposure to the sun's rays causes the coup de soliel, Avhich is not uncommon, particularly in Italy, where the people are obliged to take off their hats Avhile the long religious proces- sions pass through the streets. The heat of crowded rooms and assemblies has often brought on attacks, and produced some of the premonitory symptoms, even in individuals not liable to apoplexy. Exciting mental emotions, such as joy, anger, grief, consterna- tion, terror, fear, despondency, anxiety, &c, have been known to induce apoplexy. During the period of the French Revolution, this Avas a most fertile cause of the disease. Many other exciting causes may be added to those now specified, such as the presence of tumors, spiculae of bone, and other organic alterations within the cranium; metastasis of other diseases, especially gout and rheumatism; sudden disappearance of the exanthemata; suppres- sion of the menstrual fluid; healing of ulcers, and the stoppage of accustomed discharges; sleeping after meals, particularly if an unusual quantity of food or drink has been taken; violent fits of coughing or sneezing; the undue employment of the Avarm bath; pressure on the umbilical cord during labor; obliteration of the jugular veins by tumors or inflammation of their coats. From the many circumstances now enumerated, it will be generally easy to find some cause to Avhich an attack of apoplexy may be attributed; and, indeed, all those which produce sudden changes of the circulation Avithin the cranium may, in different persons, prove the exciting cause of this disease. Diagnosis. The apoplectic state is readily recognised, and is produced, as Ave have shoAvn, by pressure on the brain. To dis- tinguish, hoAvever, the various circumstances Avhich occasioned it, is often very difficult; as, for example, when an individual falls apoplexy, (Diagnosis.) 155 doAvn suddenly, and no one is acquainted Avith the symptoms which have preceded it. In this case the symptoms may be knoAvn to arise from intoxication from the smell of the breath, and the nature of the contents of the stomach, Avhich may be ex- pelled by vomiting. In general, too, the pulse is more frequent, and the breathing is not stertorous. No great reliance, hoAvever, can be placed upon the presence or absence of these last symp- toms in a diagnostic point of view. Syncope and asphyxia are recognised by such a diminution of the pulse and feebleness of respiration as seldom occurs in apo- plexy. These, together Avith the extreme pallor of the counte- nance in the former, are the chief differences. Apoplexy occa- sioned by injuries of the head, concussion, &c, is not to be distin- guished unless the circumstances under Avhich the attack took place are made knoAvn, or the practitioner is enabled to detect some bruise or laceration of the scalp or fracture of the cranial bones, &c. The coma folloAving epilepsy and hysteria is only to be knoAvn by the previous history in such cases, and the symptoms Avhich have preceded them. In the same manner, when narcotic and deleterious gases occasion apoplexy, no peculiar symptoms point out the origin of the disorder. It may be observed that coma or the apoplectic state is symptomatic in many diseases, and, when present, is only to be distinguished from genuine apoplexy by those symptoms diagnostic of the different maladies Avith Avhich it may be complicated. Attempts have been made to distinguish the various lesions Avhich induce apoplexy by particular symptoms. In the present state of our knoAvledge of the pathology of the nervous system, hoAvever, the diagnostic indications laid doAvn by some authors should be received with caution. Congestion of the cerebral bloodvessels is rarely preceded or followed by paralysis; and if after apoplexy is well established, the symptoms continue to in- crease, or if they gradually diminish Avithout any paralysis being manifested, Ave may in general consider this morbid lesion to have occasioned the attack. Dr. Bright has pointed out the occurrence of a constant or frequently recurring pain over the occiput, often most distinctly referred to that part to which the occipital nerve or a large branch of the second cervical nerve issuing from behind the upper part of the sterno-mastoid muscle is distributed. He considers this symptom may be diagnostic of disease in the coats of the vertebral arteries, and relates a case Avhich supports this opinion. (Guy's Hosp. Rep. vol. i, p. 9.) He also conjectures, that in those cases Avhere disease of the vessels is attended Avith unusual symptoms of lethargy, and the superficial pain in the occiput is less observable, the disease probably has been situated chiefly in the internal carotids and their branches. The vieAvs of this distinguished physician, although they are not supported by 156 apoplexy, (Prognosis.) a sufficient number of facts, are Avorthy of attentive consideration, in order that they may be tested by further observation. Many of the older writers have endeavored to draAV a dis- tinction between the apoplexy connected Avith effusion of serum and that produced by other lesions, and have considered as indi- cations of the former its slow progress Avith vomiting, paleness of the countenance, general discoloration of the surface, cachetic aspect of the individual, slow pulse, &c. Portal, Wepfer, and numerous later observers, have shoAvn that these symptoms can- not be considered as diagnostic of the presence of serum. But Avhen the malady proceeds so sloAvly as to enable us to observe the symptoms, we may usually predict the presence of this fluid by the gradual loss of the special senses, particularly that of sight; feebleness of the mental faculties, and great disposition to sleep; Avhile, at the same time, there is not much disturbance of the general circulation or respiration, and no paralysis. Soften- ing is indicated by a continued pain in the head remaining after the first slight seizure, described under the third form of the dis- ease, Avith partial loss of intelligence, difficulty of speaking, dis- tortion of the mouth, more or less loss of sensibility or motion, and sudden rigid contraction of the arm or leg. This last symp- tom, on Avhich much stress has been laid, cannot be considered alone diagnostic of this lesion, and we have often seen the most experienced French physicians deceived, even Avhen all those above mentioned have been Avell marked. In the fourth form of apoplexy, if paralysis precede the attack, it may depend either upon softening or the extravasation of blood. Partial paralysis, occurring suddenly, is one of the most certain signs of haemor- rhage in the cerebral hemisphere opposite the side affected. If loss of sensibility or motion exist during the attack, it may de- pend upon any of the morbid lesions Avhich occasion apoplexy. But if it remain after the attack has disappeared, it is usually caused by a coagulum pressing, directly or indirectly, on the motor and sensitive columns. Many facts and much observation, hoAvever, are required before Ave shall be enabled to distinguish Avith accuracy in the living subject the precise morbid lesion; for although the above symptoms are undoubtedly often useful in indicating the immediate cause of the apoplectic seizure, the exceptions are sufficiently numerous to render the greatest cau- tion necessary in endeavoring to determine its nature. Prognosis. Apoplexy must always be looked upon as a most dangerous disease. Death may take place almost immediately or at different periods after the seizure. Occasionally, hoAvever, persons have perfectly recovered, and even ultimately died of other diseases. The unfavorable symptoms are laborious, irregular or sterto- rous breathing; difficulty or complete loss of the poAver of deglu- tition; intermittent, irregular or frequent pulse; coldness of the apoplexy, (Treatment.) 157 extremities; cold, clammy or profuse perspiration on the face or temples; immovable pupil; foaming at the mouth; continuance of perfect coma more than twenty-four hours, especially if judi- cious treatment has been employed; involuntary discharges of the urine or faeces; frequent yawning supervening delirium; gene- ral paralysis; frequent attacks of vomiting, &c. The favorable symptoms are, free and natural respiration; easy deglutition; regularity and softness of the pulse; general and moderate perspiration over the body; quick return of the mental faculties after proper treatment; free and conscious alvine and urinary discharges; epistaxis; and the return of any accustomed discharges which may have been suppressed, as the haemorrhoidal, menstrual, &c. Generally speaking, a first attack is less fatal than a second or third, especially in middle aged or young individuals, whereas, in old persons, the prognosis is more unfavorable. In giving an opinion, hoAvever, as to the probability of perfect recovery, even Avhen the attack has disappeared, it is necessary to be very guarded, as a relapse is ahvays to be dreaded, particularly before the tenth day. Treatment. When we consider the various lesions connected with apoplexy, together Avith the different states of the system which accompany them, Ave need not feel surprised that many, and even opposite, methods of treatment have occasionally been successful. Experience has now proved that no exclusive plan of treatment ought to be folioAved, inasmuch as some cases admit of depleting, and others of stimulating, measures. But it is often difficult to distinguish the former from the latter, and under such circumstances, our knowledge of the pathology of this malady, together with the connection between the symptoms and lesions, will occasionally furnish most valuable indications. We have seen that pressure on the brain is the cause of all the forms of apoplexy, and that it may be produced by haemorrhage or by congestion of blood-vessels Avithin the cranium. This latter, in- deed, is almost invariably present, as to it must in general be at- tributed the changes Avhich immediately precede the attack. But Ave have also seen that congestion may occur in opposite states of the system; there may be increased or diminished vital powers, and consequently opposite measures may be necessary in its treatment. The indications in the treatment of^apoplexy are, 1. To prevent the attack by arresting the premonitory symptoms; 2. To remove the apoplectic seizure Avhen it has come on; and, 3. To obviate its effects; and prevent its recurrence. It is of the utmost importance that the earliest indications of the premonitory symptoms should be promptly arrested, since many of the more serious organic changes which have been de- scribed may be prevented, if an energetic plan of treatment be at once adopted. If the symptoms be not urgent, brisk purging, 14 158 apoplexy, (Treatment.) and restricted diet, will often remove the premonitory symptoms, especially in persons of feeble poAvers and languid circulation. If, however, the pulse be full and strong, or the countenance flushed, and the eyes prominent or suffused, bloodletting is the chief remedy to be relied on. General bleeding is usually to be preferred; but in some cases, particularly Avhen the patient is advanced in life, the application of leeches or cupping-glasses is to be preferred. The symptoms generally abate after a moderate bleeding, but the exhibition of a brisk purgative should folloAV the venesection. If, on the contrary, the pulse is Aveak, the coun- tenance sunk or pale, the head cool, &c, restoratives or stimu- lants should be administered; at first small doses, narrowly Avatch- ing their effects on the pulse. In doubtful cases, while neither the countenance or any other symptom offer any therapeutic in- dication, the practitioner should be contented with administering a brisk purgative, and applying cold lotions to the head. Should these remedies someAvhat relieve the symptoms, and not mate- rially diminish the force of the pulse, a small bleeding may be tried, carefully Avatching its effect on the pulse and general symp- toms. But if this plan of treatment produces no benefit, and the pulse becomes weak, the stimulating practice must be cautiously resorted to. Should premonitory symptoms appear shortly after a full meal, especially if much wine has been taken, an emetic should be given; as although the action of this class of remedies undoubt- edly tends to produce momentary congestion of the cerebral ves- sels, the retention of a bulky meal in the stomach may induce more serious consequences. If, hoAvever, the pulse is full and bounding, the countenance much injected, and the general symp- toms be urgent, a large bleeding should in the first instance be premised; Avhen by these means the premonitory symptoms have been removed, it will be necessary to avoid strictly the predis- posing and exciting causes, to regulate carefully the diet, which should consist of the most digestible matters. The state of the secretions should also be duly attended to, and a system of moral and regiminal management rigorously pursued. If the individual have had periodical discharges of blood from the haemorrhoidal vessels, an occasional application of leeches to the anus will be advisable, in conjunction with the other measures. Treatment of the Apoplectic Seizure. Immediately the at- tack occurs every thing should be removed from the neck, and the individual placed in the recumbent posture, Avith his head ^and shoulders raised. If possible the patient should be removed to a large and airy apartment; if not, care should be taken that the room be of a moderate temperature. Orders should imme- diately be given to have hot and cold water in readiness, Avith basins, tOAvels, &c, and such persons only be permitted to remain apoplexy, (Treatment.) 159 in the room as are necessary to afford assistance. The physician is then to ascertain whether consciousness has entirely disap- peared; Avhether the sensibility of the limbs remains, by pinching and tickling the soles of the feet; and whether they are rigid, or retain their natural flaccidity, &c. He should notice the respira- tion, whether it is free, laborious, or stertorous; the state of the pulse, as to its fulness, strength, and regularity; the aspect of the patient should be particularly attended to, Avhether he appears strong, of a full habit, or weak and cachectic; the state of the eyes and pupils should be remarked; the circumstances under which the attack occurred should be ascertained, and whether there have been previous seizures. The practitioner should make him- self acquainted Avith* these particulars as soon as possible, and at once decide upon a plan of treatment. If the pulse, especially at the temporal and carotid arteries, be full and strong, the face flushed and tumid, the respiration natu- ral, and the eyes injected, general bloodletting is indicated. Neither advanced age, emaciation, or the disposition to any other malady, is to be considered as contra-indicating this practice. The extent, however, must be modified according to circumstances. In middle-aged, robust, and plethoric individuals, twenty, thirty, or forty ounces, may be taken at once, and repeated if the symp- toms do not yield, and the pulse retain its character. Should the patient, however, be advanced in life, and of a spare habit, more caution is necessary: from ten to twenty ounces only ought, under such circumstance, to be taken. Morgagni mentions the case of a woman eighty years old, and Cooke that of another seventy-four years of age, both of Avhom recovered from apo- plexy by bleeding. Burserius quotes from Lancisi the case of a very aged man, who Avas freed from impending apoplexy by the spontaneous loss of an immense quantity of blood from the nose. The same practice is to be pursued should the pulse be intermit- tent or irregular, so long as it retains its fulness and force, pro- vided the irregularity or intermission does not result from disease of the heart. The utmost attention should in all cases be paid to the state of the circulation, as indicated by the pulse, because after a time the vigor of the vital actions diminishes; and although such energetic treatment is most judicious at the commencement of an attack, it is by no means to be followed in its more ad- vanced stage. When the disease is preceded or attended by paralysis, it is possible that extravasation of blood may have taken place. In such cases a smaller bloodletting lessens the force of the pulse, and assists the practitioner in forming an opi- nion of the nature of the lesion. In all cases, Avhen the pulse becomes weak during the bleeding, the Aoav of blood should be stopped, and, should it again rise in volume, it may be allowed to floAV again, Avatching the effect on the pulse. Much has been written about the different situations from 160 apoplexy, (Treatment.) Avhich blood ought to be drawn. The consideration, hoAvever, of the peculiar nature of the circulation Avithin the cranium must render it evident, that it is only by producing an effect upon the general mass of the blood, and diminishing the action of the heart in these cases, that the pressure can be removed from the brain. The situation, therefore, from which blood can be drawn with the greatest facility is to be chosen. Bleeding from the arm is the most easy operation, and Avill in general ansAver every pur- pose. If, however, blood cannot readily be obtained in this way, the jugular vein or the temporal artery may be opened. Portal strongly recommends the former; and, Avith Burserius, Morgagni, Valsalva, Friend, Heister, and others, directs that no ligature should be employed, as the smallest pressure on the part may do harm, by interrupting the circulation of the blood in the external veins of the neck. Dr. Abercrombie observes, that the only jugular vein that can be opened is the external, which has little communication with the brain, and that opening the temporal artery is probably more beneficial. Many physicians consider bleeding from the saphena vein most advantageous; and if there is any difficulty in procuring the blood from other situations, this may be tried. The feet should be plunged in Avarm water, to favor its abstraction. Local abstractions of blood are preferable when any doubt exists in the mind of the practitioner regarding the employment of general bloodletting, as in cases in Avhich the symptoms are not strongly marked. Indeed, the same circumstances occasionally occur during the attack, as Ave have mentioned when speaking of the treatment to be adopted Avith a vieAV of preventing the disease; namely, that there maybe no prominent symptoms either of augmented or diminished vascular action; and in such cases it is often difficult to determine Avhether general bloodletting should be had recourse to or not. When local bleeding is deemed advisable, the mastoid process, the nape of the neck, the temples, or betAveen the shoulders, are the situations generally recommended. Some prefer one situation and some another. The operation of cupping being more prompt in its action, it is to be preferred to the application of leeches. If leeches, however, be preferred, they are generally applied to the neck, occiput, and behind the ears. When epistaxis has preceded the attack, Lancisi and Cruveilhier recommended leeches to be applied to the inside of the nostrils, and if the patient has haemor- rhoids, to the margin of the anus. Immediately after the bloodletting, a brisk purgative should be administered. It is often difficult, and even impossible, to admi- nister cathartic medicines by the mouth. Dr. Copland, however, says we may ahvays succeed by mixing ten or fifteen grains of calomel, sometimes Avith the addition of two or three grains of gamboge, with SAveet butter, and placing it upon the root of the apoplexy, (Treatment.) 161 tongue. Two or three drops of croton oil given in the same way, or simply applied to the tongue, are even more efficacious, and may be folloAved in an hour or tAvo by a purgative enema. If necessary, these remedies may be introduced into the stomach, suspended in thick gruel or mucilage, through an elastic gum tube. If no evacuations follow this treatment, its repetition will seldom fail to produce them. It is necessary to give a caution as to the exhibition of calomel, Avhen the patient is unable to swal- low. Dr. Bright mentions that on one occasion having placed a dose of calomel on the tongue it was not swallowed, but remained and produced in a few hours the most alarming ptyalism, during which the tongue was forced out of the mouth, and it Avas neces- sary to scarify the organ deeply before it could be returned within the teeth. (Hosp. Rep. part ii, p. 337.) When dark, greenish- black, offensive stools are discharged, a torpid action of the liver is manifested, and purgatives, conjoined with mercurials, should be given at regular intervals, to keep the bowels open, and sti- mulate this organ to a healthy discharge of bile. Care, hoAvever, must be taken not to excite salivation. Preparations of antimony, and James's poAvder may be given at the same time, or combined with the mercury. In conjunction with these remedies, the hair should be removed, and cold applied to the head, either in the form of affusion, or by folds of linen frequently saturated in a cold solution. A bladder containing pounded ice or snow may be used for the same pur- pose. It has been pointed out by Lallemand that the application of cold to the head acts locally only in diminishing congestion, and does not produce the same depression on the system as when applied generally to the surface. Its beneficial action is increased by Avarm applications to the lower extremities. Bran poultices, if readily procured, will be found an easy and excellent appli- cation. If, after the use of the above remedies, the patient should re- cover his consciousness, he is still to be watched Avith the greatest care; and, should the pulse become weak and soft, slight restora- tives should be given, but with the utmost caution, particularly before the tAvelfth or fourteenth day, as, until this period, the attack is very liable to return. During this time, therefore, the patient must remain in bed, Avith his head and shoulders elevated. The temperature of the room should throughout the period of treatment be moderate, and every circumstance that interferes with the tranquillity of mind or body should be carefully avoided and prevented. The injunction of Morgagni is always to be remembered, namely, to examine the hypogastrium, and remove any accumulation of urine by the catheter. The treatment Ave have now described for apoplexy attended Avith increased vascular action would be highly dangerous at the commencement of an attack, or at a period of a seizure Avhen the 14* 162 apoplexy, (Treatment.) pulse is Aveak, or small and irregular, the temperature of the head not increased, the countenance pallid or sunk, and there is pro- found torpor, with laborious or stertorous breathing. These symptoms indicate a state that demands restoratives and gentle stimulants; such as small doses of Sp. JEther. Sulph. Co., prepa- rations of ammonia, or even wine in small quantities, stimulating purgative injections, Avith turpentine, &c. The application of volatile substances to the nostrils, and sprinkling cold Avater sud- denly on the face, are also useful. The application of cold to the head in cases connected Avith extreme prostration is often beneficial, especially if warm fomentations be at the same time applied to the inferior extremities. Lallemand gives a case in which the pulse Avas scarcely perceptible, even in the carotids; there Avas also general resolution of the limbs, stertorous breath- ing, and a cold clammy sweat on the surface, and yet the indivi- dual recovered under this treatment. (Letlre 2me, obs. 28. p. 297.) The character of the pulse should not be our sole guide to the adoption of stimulating remedies, as it is often Aveak at the com- mencement of an attack that requires bloodletting, and rises sub- sequently; but Avhen taken in conjunction with the other depress- ing symptoms, it is of great value. Blisters to the temples, behind the ears, and to the calves of the legs, are in these cases of advan- tage, while sinapisms, or stimulating frictions, may be at the same time applied to the extremities. When hemiplegia, or any other form of paralysis, has preceded the attack, it is necessary to be very cautious, as it may in general be the effect of extravasation of blood, or of softening; either of Avhich lesions will render the brain peculiarly liable to be acted on by any sudden change in the circulation, by Avhich the patient may be exposed to fresh danger if incautious treatment be adopted. In old persons also much caution is necessary. Purgatives in these cases are decidedly useful, but they should not be so poAV- erful, and are better Avhen combined with medicines of an aro- matic and somewhat stimulating character. Numerous other remedies have been recommended in the treat- ment of apoplectic attacks. The exhibition of emetics has been already alluded to: most physicians consider that they are only useful Avhen we have positive evidence that the attack arises from an over-distension of the stomach, narcotic poisons, or intoxi- cation. In any other case they are not likely to produce any good effect, and may be highly dangerous. Mercury, Ave have already stated, may be useful, administered in the form of calomel, when the biliary secretion is suppressed or diminished. It has been supposed, by some, useful in promoting the absorption of the coagulum, and a slight mercurial course has been recom- mended for this purpose, Avhen all immediate danger from the first symptoms has disappeared. Dr. Prichard, Avhen speaking of hemiplegia, observes, "that those patients in Avhom a slight apoplexy, (Prophylactic Treatment.) 163 degree of ptyalism has been produced, have almost uniformly appeared to him to derive material benefit from it, and their recovery has been more complete than that of others in Avhose cases the same remedy has either not been used or has not been administered to the same extent." Blisters, sinapisms, stimu- lating liniments, and friction, may be used Avhen the pulse is low, and there is evidence of depressed vital action. Setons, issues, and moxas, may be employed Avith the same view, and particu- larly when the attack has been preceded by the drying up of any chronic sore. Dr. Prichard has lately recommended the forma- tion of a long issue, better made by the scalpel than by an escha- rotic, in the direction of the sagittal suture. Sternutatories, elec- tricity, and galvanism, have rarely been found beneficial, and are generally injurious. Means to be adopted with a vieiu of obviating the effects of an Apoplectic Seizure and preventing its return. We have seen that it requires some months before a coagulum can be ab- sorbed, and that occasionally a much longer time is necessary. It is therefore impossible to guarantee the safety of the patient when Ave are led to conclude there has existed an extravasation of blood into the substance of the brain. Even Avhen congestion only has occurred, there is always a great tendency to its return. Under these circumstances the treatment is nearly the same as that recommended for preventing an attack. The patient, in general, should be kept rather low, in order to favor the absorp- tion of the coagulum, and prevent the possibility of its giving rise to any irritation or inflammation in the surrounding substance of the brain. Of the use of mercury we have already spoken; and the preparations of iodine, from their Avell-knoAvn effects in pro- moting the absorbent powers of the system, might also be benefi- cial. The utmost care must be taken to avoid all the predisposing and exciting causes of the disease. The bowels should be kept regular by the use of gentle aperients. Moderate exercise may be allowed, but never to such an extent as to induce fatigue. The necessity of mental tranquillity should be impressed not only on the patient, but on his family and ordinary attendants, so as to prevent the sudden communication of either agreeable or afflict- ing intelligence. A too sedentary life, frequent stooping, and much indulgence in sleep, should be carefully avoided. After an attack of an acute character, when symptoms arise to demand evacuation of blood, occasional small bleedings, low diet, and a course of the natural or artificial purgative Avaters, will be neces- sary. The patient, also, should invariably sleep on a hair mat- tress, with the head and shoulders Avell elevated by a hair pilloAV, and rise early. When the disease is connected Avith diminished vital action, and Ave have no reason to suspect that extravasation of blood, has taken place, a tonic plan of treatment, gentle exer- 164 apoplexy, (Prophylactic Treatment.) cise in the open air daily, nutritious and digestible diet, with such remedies as increase the general tone of the system, should be employed. In those cases of congestive apoplexy, rising second- arily from involuntary seminal emissions, Avhich M. Lallemand has pointed out to the profession, attention must be paid to the primary malady, and the means he recommends adopted, Avith a vieAV to its cure. (Des Pertes Siminales Involontaires.) The treatment of chronic paralysis which follows apoplexy, will be noticed under Paralysis. Notwithstanding there is sometimes a difficulty in deciding as to the nature or even the existence of an organic lesion in cases of apoplexy, we do not think that the pathological anatomy of the disease should be lost sight of, for the therapeutic indications are to a certain extent connected with it, and the prog- nosis is always greatly modified. As stated in the text, the French patholo- gists are disposed to restrict the term apoplexy to the cases in which there is a positive extravasation of blood from the vessels. There are, it is true, some disadvantages in thus limiting the signification of a term which has generally been employed in a much more extended sense, and it is therefore better to modify it, and to speak of these cases as true apoplexy, or as simply cerebral haemorrhage. When a patient is first attacked with apoplectic stupor, there is little or no difference in the symptoms of the attack, whether it depends upon extravasa- tion or congestion of blood, or is a purely functional disorder. But if the stupor diminishes, the case becomes clear, for permanent hemiplegia remains if a clot has been formed. If the hemiplegia be perfect, the patient never recovers the entire use of the paralysed limbs, if it be incomplete, the paraly- sis will cease more or less completely according to the degree of intensity which it may have offered in the commencement. If the extravasation be very small in quantity, there is little or no rupture of the fibres of the brain, and the organ may perfectly recover its integrity. In many of these limited cases of apoplectic palsy, the patient does not lose his consciousness and he may ex- perience few or no symptoms which he refers to the head, for the whole cere- bral circulation may be but little disturbed. This variety of the disease is apt to occur during sleep, and the patient on awaking is surprised to find that he has partially lost the command of the muscles of one side of the body. The rules for the treatment of all cases of apoplectic disease are simple; the circulation of the brain must be relieved when it is congested, by free de- pletion, purging and other revulsive means. "Where the pallor of the com- plexion and the previous disease or feebleness of the patient render it probable that the case is merely one of nervous apoplexy, the best means of treatment are stimulating revulsives, such as terebinthinate injections, and sinapisms; internal stimulants which have any direct action upon the brain should be used with much caution. If decided vascular reaction should occur, the usual means of treatment may be resorted to, but in these cases the blood-let- ting should be chiefly local. 165 INSANITY. Explanation of terms and enumeration of the different forms of insanity.— General or incoherent insanity, including mania and dementia.—Moral in- sanity.—Monomania and melancholy.—Instinctive madness, or insane im- pulse, including, 1. Homicidal impulse; 2. Pyromania; 3. Suicide; 4. Other morbid propensities.—Progress and terminations.—Anatomical char- acters.—Diagnosis.—Causes.—Treatment—remedial— moral.—Of Hypo- chondriasis—its causes, nature, and treatment. Of Puerperal insanity and its treatment. Insanity and madness are precisely synonymous expressions, the former being a term naturalised in our language, and substi- tuted by custom, or used as an equivalent for the old English Avord madness.* Insanity, in a legal acceptation, is synonymous Avith unsoundness of mind, but not strictly so in a medical sense. Mental unsoundness is defined by lawyers to be a condition of the faculties, Avhich renders an. individual incompetent to dis- charge the ordinary duties of life, and to take care of himself and his affairs. Noav it is obvious, that a person laboring under a fit of intoxication, or apoplexy, or under the delirium of fever, or one Avho has fallen into the second childhood of old age, is un- sound of mind, or "insanus," according to this sense of the ex- pression, although he is not a lunatic or madman. The medical or pathological acceptation of the term insanity is, therefore, somewhat different from the meaning Avhich laAvyers affix to the expression of mental unsoundness. It is restricted to that un- soundness Avhich is the result of a particular disease, or rather a particular class of diseases, knoAvn to impair the mental faculties in various ways and in different degrees. The symptoms of these disorders are so complex, that it is impossible to comprehend them all under one definition; and, perhaps, the best substitute that Ave can furnish for such a definition, is to enumerate briefly the several forms or varieties of morbid mental phenomena, which are comprehended under the term insanity, or the corresponding expression—madness. If a person of correct observation goes through an extensive *This word may be recognised in several of the Indo-European lauguages : Madah is madness in Sanskirt; and madayati, he drives mad, or insane. See Professor Wilson's Lexicon, p. 30.—Author. 166 INSANITY. hospital Avhere lunatics of various descriptions are assembled, with the view of noting the principal varieties of madness ; and endeavors, for that purpose, to enter into conversation Avith the inmates, the most essential distinction that he Avill remark in the phenomena presented to him will be the following:—Some of these individuals will appear capable of conversing, and will even express themselves for a time in a manner not strikingly different from that of sane persons; they will make remarks and utter sentences, Avhich, if not perfectly sensible and rational, will be at least intelligible and connected; their thoughts do not appear to be confused; their ideas and expressions are coherent. Other individuals, perhaps an equal number, Avill be found quite inca- pable of reasoning, and often of expressing a single proposition; the thoughts of these last are confused and incoherent; their ideas do not succeed each other according to the usual laAvs of associa- tion or sequence; their sentences are broken by the intrusion of thoughts Avhich croAvd themselves upon the mind, and render it hurried and confused; their conduct displays, in like manner, a want of any distinct purpose or intention; they are incoherent madmen. Many of them are subject to occasional periods of unusual excitement; when their passions are roused, they be- come boisterous and violent. Their minds are agitated by a va- riety of illusions or false impressions, which fill them with anxiety and terror, or with anger and rage : they are then raving mad- men or maniacs; but when this excitement ceases and some de- gree of tranquillity is restored, they return to the ordinary state of calm incoherence, and this incoherence is often the most charac- teristic feature in their psychological state. Insane persons of this latter class are said to labor under general or universal madness. When the disorder is accompanied with illusions and Avith violence, and principally in the early stage, while incoherence is not always so decided as it afterwards be- comes, the disease is termed mania: in the later period it is named dementia, the characteristic of which is a more complete incohe- rence producing fatuity; and at last a total obliteration of the mental faculties. Dementia is the advanced stage or the termina- tion of mania, but the two states are not so distinct as they are by most Avriters represented to be, for there is ahvays some inco- herence in mania, and sometimes this is the only, or the principal feature of the disease, even from its commencement. Maniacs and demented persons, or incoherent lunatics, as they may be termed, collectively constitute half, or more than half, of the inmates of many hospitals for the insane. The other part labor under coherent madness, or what is termed partial insanity. Madmen whose thoughts are coherent, and Avho are capable of expressing themselves in a connected and intelligible manner on many subjects, are a very different class of persons from the in- coherent. Their disorder has been termed by French writers, INSANITY. 167 folie raisonante. The most striking phenomena of their con- dition are not displayed in their Avords but in their conduct; their actions and gesture, and their whole manner of existence, are extraordinary, and different from that of sane persons. On con- versing Avith these persons it is discovered, though occasionally not without a careful investigation, that some of them labor under an illusion as to their personal identity, or some circumstance connected Avith their state or relations; they are insane in reference to a particular idea or a particular train of thoughts, Avhile their notions regarding other subjects are tolerably correct. Persons thus affected are the monomaniacs of modern Avriters. Other individuals in the class above described betray no symptom of unreason; they labor under no illusion Avhatever; their under- standings are not perceptibly deranged; their habits and manners are singular and eccentric; their principal disorder is a perverted and unnatural state of their moral feelings and affections: it con- stitutes what has lately been denominated moral insanity. There is one division of partially deranged persons, whose disorder is termed melancholia; they are sometimes comprehended among the two classes above-mentioned, but their complaint differs from other varieties of partial insanity, by bearing the constant appear- ance of sorroAvful dejection; they are melancholy and miserable. If they have any illusion, it is in harmony with the prevalent tone of their temper and feelings. They fancy themselves lost, damned, hated of all mankind, accused justly or unjustly of flagitious crimes. The disorder of these persons comes under the head of moral insanity or of monomania, according as they are free from illusion, or labor under that characteristic symptom. There is another class of persons Avhose disorder is insanity, and often of a very appalling and dreadful kind, but who are seldom seen in lunatic asylums, or not so often as they ought to be. These individuals are, during the greater part of their time, apparently sane; but they are subject to occasional impulses Avhich drive them to commit or attempt horrible acts, such as homicide, suicide, arson, or other deeds of violence, and occasion- ally of sensual and abnormal depravity. The galloAvs and the gibbet have been, OAving to the ignorance of judges and juries, the destiny of many belonging to this class Avho ought to have been consigned to lunatic asylums. Their state will be described under the head of Instinctive Madness, or Insane Impulse. I. General or Incoherent Insanity, including Mania and Dementia. i. Mania. The onset of mania, or raving madness, is seldom altogether sudden, or without precursory symptoms, Avhich serve to give Avarning of its approach. In acute mania the precursory stage is shorter and less strongly marked than in the other forms 16S insanity. of mental derangement; but, even in this disease, its existence may perhaps ahvays be traced on a careful investigation, and it is in general striking and manifest. It is found on inquiry, or is related by the friends of the patient of their oavii accord, that his conduct has been for days, or for Aveeks, or even for months, singular and different from his usual behaviour. This precursory stage of insanity has been termed by some the period of eccentricity. The patient during this interval between the healthy and natural state of his mind and the decided attack of disease is subject to fits of occasional excitement of passion, accompanied Avith some con- fusion of ideas. He passes days in a state of feverish agitation and general uneasiness; is full of activity, and displays a morbid energy in the pursuits on Avhich he is intent, in Avhich hoAvever he performs nothing, his projects being for the most part trifling and absurd. He loses his appetite or neglects food, passes sleep- less nights, either lying aAvake and fatiguing his mind Avith anxious speculations, or rising often and Avalking to and fro in a state of uneasiness and perturbation. At length his reason is found to be disordered: he appears scarcely to know what he says, talks non- sense, repeats his Avords frequently, is unable to complete the sentences Avhich he begins, and makes ineffectual efforts to recol- lect his thoughts, utters rapid and confused expressions in an impetuous manner, cries, laughs, appears irritable, and prone to anger, though perhaps naturally of mild and sedate temper, is impatient of the most trifling opposition, and absurdly obstinate and capricious, expressing his feelings with an unreasonable degree of warmth and enthusiasm. The morbid state of a person under these circumstances is always apparent to those who surround him, but it is sometimes doubted Avhether he is completely mad, and a proper subject for restraint, until some attempt being made to oppose him and inter- fere Avith his Avild pursuits, he breaks out into a degree of violence Avhich obviously requires coercion; and sometimes, though this is not a constant phenomenon in mania, shoAvs that he has labored under the influence of an unperceived delusion, an insane and absurd impression as to his oAvn person or his relation to others. Attacks of madness frequently come on attended Avith symp- toms of febrile excitement, heat of skin, Avhiteness of the tongue, thirst, and rapidity of pulse. It is often difficult to determine Avhether these phenomena are probably symptoms of the disease, or result from the constant agitation of the patient. Occasionally indeed there are Avell-marked indications of vascular turgescence in the head, and even of a state bordering on phrenitis. "This, as it might be supposed, is most frequently the case Avhen the disease follows causes of strong excitement, such as a fit of intoxication, or exposure to the heat of the sun, or some injury of the head. In females mania frequently makes its approach Avith hysterical symptoms,asAvithparoxysmsofsobbing,crying,laughing, attended insanity, (Mania and Dementia.) 169 with a sense of suffocation and with a suspension of conscious- ness. When the disease is fully developed the state of the patient is manifest. He sometimes breaks out into a fit of raving mad- ness, in Avhich anger is the predominant feeling, and this is directed against his nearest relations or most affectionate friends, who are under the necessity of exercising restraint and resisting his absurd attempts, and who have perhaps threatened to put him into con- finement, or have perhaps carried the proposal into effect. As the disorder approaches its highest pitch, the current of ideas becomes more and more turbid; the thoughts and feelings are expressed with cries and ejaculations, and with agitation displayed in the manner and countenance, with violent and irregular move- ments and gestures; the internal sentiments, or feelings, so absorb the attention, that the patient becomes almost unconscious of external impressions. Many individuals abandon all regard to cleanliness and decency, and become filthy and disgusting in the extreme. All the functions of the body are in these circumstances of the disease affected: the boAvels are irregular, the tongue is furred, the skin cold and clammy, the patient excretes saliva mixed Avith mucus, his features become haggard and maniacal, and his eyes watery and suffused. In some instances the counte- nance of lhe individual is so much altered in expression, that his nearest relatives scarcely recognise him. The symptoms of madness often vary according to. the predo- minance of particular emotions or feelings in the natural disposi- tion of the patient; and the individual character of the disease is in some measure determined by the mental habits and tempera- ment. But this is not uniformly the fact. Sometimes the mildest and most gentle persons become violent and abusive, and deli- cate females of modest and retired habits utter the most obscene expressions in a manner surprising to those who had been pre- viously acquainted Avith them. Many appear completely out of themselves, if such an expression may be used, and as if pos- sessed by an evil spirit suggesting thoughts and feelings foreign to their nature and to the habit and tenor of their minds. Mania as well as monomania is a disease affecting the passions, and it often appears to consist principally in the morbid exaltation of feelings. In some, anger, in others joy or sorrow, is the preva- lent state of the mind. Cases of this description are sometimes supposed to be examples of monomania; but this is an error, since, by the term monomania, it is intended to designate partial insanity, or a form of mental disease in which the patient is capable of reasoning calmly and coherently on subjects uncon- nected with a particular train of thought, or with some single hallucination or illusion. In acute mania it sometimes happens that a particular impression predominates for a time and occupies the mind to the exclusion of all other thoughts and feelings; but then there is no coherence; the ideas are hurried and confused on 15 170 insanity, (Mania and Dementia!) every attempt to express them; and it is often observed that the impression is changed after an interval of quiet, or a short period of sleep, and that some different train of ideas noAV occupies the mind, having a similar relation to the preArailing state of the feel- ings. Those maniacs who are agitated by terror, fancy at one time that they are about to be devoured by wild beasts, at ano- ther that they are surrounded by devils, or about to be hanged or droAvned. The period of greatest intensity in Avhich acute mania assumes its completely developed form, has been termed by Chiaruggi the second stage. This Avriter, Avhose graphical delineation of mad- ness has been much celebrated, and has been cited by Avriters in various languages, has thus described the confined period of rav- ing madness:—" In the second stage anger, violence, and the loss of reason, manifest themselves in their greatest intensity; shriek- ing, roaring, raging, abusive expressions and conduct toAvards the dearest friends and the nearest relations, Avho are now looked upon as the bitterest enemies. The patient tears his clothes to tatters, destroys and breaks in pieces Avhatever comes in his way. A striking and characteristic circumstance is the propensity to go quite naked. Whoever touches the patient is abused or struck by him; strange confused ideas and absurd prejudices occupy the mind. Stillness soon follows, or a murmuring sound, as if the patient were alone; on the other hand, Avhen he is alone, talking and gesticulating as if he Avere in company. If such individuals are confined and tied during the height of their paroxysms, for their own security or that of others, nothing can be compared to the truly satanical expression Avhich their countenances display. In this state, they throAV hastily away, with cries and shrieks, all the food presented to them except fluids, which thirst compels them to receive. When after some days hunger begins to be felt, they swalloAv every thing with brutal greediness; they even devour, as it has often been observed, their oAvn excrements, Avhich, black and offensive, escape from them in great quantity, or smear with them clothes, beds, and walls. Notwithstanding his constant exertion of mind and body, the muscular strength of the patient seems daily to increase; he is able to break the strong- est bonds and even chains; his limbs seem to acquire a remarka- ble nimbleness and pliability, and a singular aptitude of perform- ing movements and actions'Avhich appear almost supernatural." Chiaruggi saAV a Avoman, Avho, clothed in a straight Avaistcoat and laced doAvn in her bed like a child in a cradle, dreAv out her limbs from this double confinement Avith the greatest nimbleness and pliancy. Bold, hoAvever, and impudent as such patients are, yet they are according to common observation, although not Avithout exception, easily daunted by a strong threatening voice, by the sight of stocks, by close yet harmless restraint. After their violence has expended itself, they become still and gloomy; ap- insanity, (Mania and Dementia.) 171 pear to be reflecting or brooding over something concealed; but they break out again, before it can be anticipated, into a new storm of rage. At length comes on the third stage. A real ces- sation of violent paroxysms now ensues, exhaustion, sleep, though unquiet, disturbed by fearful dreams. The pulse is small, the aspect of the Avhole body squalid, the countenance pallid and meagre. The patient is obdurately silent, or sings and laughs in a strange manner, or chatters Avith incessant volubility. These uncertain intervals, Avhich often put on the appearance of fatuity, are frequently interrupted by new but short renewals of violence. Memory, for the most part, remains unimpaired through all the stages, and, during the highest intensity of the disease, the senses appear to acquire an unusual degree of acuteness and suscepti- bility. A patient Avho had recovered described to Chiaruggi all the scenes of his Avild reverie and long-continued mental pertur- bation. It has often been remarked, that maniacal patients of this description are never attacked by any epidemic, and are sel- dom affected by any contagious malady.* As Mead and many other writers have observed, even consumptive disorders, drop- sies, and other chronic maladies, have disappeared on the acces- sion of violent insanity. When patients are not freed from the disease after a succession of attacks, Avhich come on like so many paroxysms of fever, one or another of the folloAving events ensues—either the powers of mind are exhausted to that degree that the disease subsides into a permanent fatuity; or this appear- ance of fatuity is only a space of calmness interposed betAveen relapses of violent madness, which now and then break out, like the eruptions of a volcano, after a long period of repose; or the patient falls into a state of melancholy, or of complete mental confusion; or, finally, his madness becomes chronic, and he scarcely recovers from this condition, in Avhich sense and under- standing appear to be lost in incoherence. Chiaruggi saAV a Avoman who had sat during tAventy-five years on a stone-floor in a fearfully demented state, beating the ground Avith her chains Avithout ceasing, night or day. It appears that attacks of acute mania often attain their utmost degree of intensity, and begin to decline and undergo a remission, or a species of imperfect crisis, at a period of no long duration after the first appearance of severe symptoms. It is the opinion * As a general rule this is correct, but with some epidemics the contrary is true: maniacs and lunatics in general are particularly subject to dysentery and generally suffer with a severe and dangerous form of the disorder. Consump- tion is also very apt to occur in lunatics, whatever may be the form of their insanity, but it is more frequent in lypemaniacs than any'others. If the dis- ease had appeared previously to the occurrence of the insanity, it is probable that authors are correct in stating that the progress of the disorder is retarded. 172 insanity, {Mania and Dementia.) of M. Esquirol, that such a change may generally, or at least frequently, be perceived to take place within the course of a month, from the commencement of an acute attack. Certain it is, that, in the generality of cases, the symptoms of extreme vio- lence subside in a greater or less degree, and that intervals of at least comparative quietness are perceived. Such a remission is sometimes a prelude to gradual recovery; at others it is folloAved by a milder but protracted derangement, breaking out into occa- sional exacerbations, and terminating in a permanent obliteration of the faculties. This last condition is commonly called fatuity, or dementia. n. Dementia. Insane persons often survive for many years the permanent loss of reason. Some continue very long to dis- play nearly the same phenomena of mental disorder, with alter- nations of increased and subsiding violence; but the generality, if no recovery or lucid interval take place, sink gradually into a state of fatuity or decay of the mental faculties, Avhich French writers after Pinel have denominated dimence. English Avriters have translated this term into dementia, meaning, to distinguish by it, that peculiar form of mental Aveakness Avhich is the conse- quence of insanity and other diseases of the brain, as distin- guished from that fatuity or imbecility which is connate or origi- nal. The term fatuity would answer the purpose equally well, if its meaning were restricted. It is important to distinguish this kind of acquired fatuity from primary or congenital idiotism, since mistakes have often been made, especially by laAvyers, from ignorance of the nature of these morbid states, or inattention to the characters which distinguish them. The approach of dementia or fatuity is indicated by an increased degree of incoherence in the ideas of the insane. At the first attack of general madness there is always a Avant of order and connection in the ideas or thoughts, Avhich may be observed not to follow each other in their usual trains of sequence. This may be resolved into a failure, in greater or less degree, of the power exercised by the will over the trains of ideas. It is evident when a lunatic begins to talk, that he cannot call up and arrange his ideas and expressions as he was Avont to do; his thoughts imme- diately wander, nearly as the thoughts of a man considered to be of sane mind are observed to do, when, his attention being defec- tive, some casual association, such as the double meaning of a word or a coincidence in sound, is sufficient to make him forget what he was going to say, and diverge to something quite foreign to his purpose. This appears to "be one of the essential characters of the mental disorder Avhich constitutes madness, or at least ge- neral mania. An increase of this defect indicates the approach of dementia. At the same time the emotions become less vivid and definite—the feelings more obtuse. The state of dementia when insanity, (Mania and Dementia.) 173 fully developed is characterised by " an unceasing current of un- connected thoughts and evanescent emotions." Pinel has given the folioAving definition of it:—"Idees incoherentes entre elles, et sans aucun rapport avec les objets exterieurs."—"Une mobilite turbulente et incoercible, line succession rapide et comme insta- nanee d'idees qui semblent naitre et pustuler dans Pentendement sans aucune impression faite sur les sens, un flux et reflux conti- nuel et ridicule d'objets chimeriques qui se choquent, s'alternent, se detruisent les unes les autres sans aucune intermission et sans aucun rapport entre eux, le meme concours incoherent mais calme d'affections morales, de sentimens de joie, de tristesse, de colere, qui naissent fortuitement, et disparaissent de meme, sans laisser aucune trace, et sans avoir aucune correspondance avec les im- pressions des objets externes: tel est le caractere fondamental de la ddmence dont je parle." This state of mental decay, or of destruction of mental poAver, has been confounded Avith idiotism, Avhich in all its degrees and modifications is a very different affection. The distinction, Avhich is a very important one, has not ahvays been kept.in view by writers on disorders of the mind, and even in the works of Pinel we find it sometimes overlooked. M. Esquirol has the merit of having drawn more accurately the line of discrimination. He refers to dementia all the cases of effete or obliterated intellect, which are the results of maniacal or other diseases, and are inci- dent to persons originally possessed of sound faculties, and in- cludes those defects only under idiotism which are original or congenital. "The imbecile," he observes, "have never possessed the faculties of the understanding in a state sufficiently developed for the display of reason. The victim of dementia was once en- dowed with them, but has lost this possession. The former lives neither in the past nor the future; the latter has some thoughts of times past, reminiscences which excite in him occasional gleams of hope. Imbecile persons, in their habits and manner of exist- ence, display the semblance of childhood; the conduct, the acts of the demented preserve the characteristics of consistent age, and bear the impress derived from the anterior state of the individual. Idiots and cretins have never possessed memory, judgment, sen- timents; scarcely do they present, in some instances, indications of the animal instincts, and their external conformation plainly indi- cates that they were not organised to be capable of thought." In the author's work on insanity four stages of dementia are distinguished, each of which is characterised by peculiar pheno- mena. Some practical advantages, with respect to legal arrange- ments for the insane, and the calculation of a probable event, may, in many instances, arise from this distinction. Each of these four degrees of dementia is susceptible of an appropriate designation, derived from the most remarkable of the phenomena displayed by it, and the terms will be found useful in assisting the memory, 15* 174 insanity, (Mania and Dementia.) and rendering the notions, especially of jurymen in inquests of lunacy, more precise and positive. The first stage of dementia is that of forgetfulness or impaired memory. It is characterised by the momentary obliteration of recent impressions, while the memory retains a comparatively firm hold of ideas laid up in its recesses from times long past; the poAver of reasoning within the sphere of distinct recollection is not remarkably impaired; and the faculty of judgment is exercised in a sound manner Avhen the attention can be sufficiently roused. The disease of incoherence approaches most gradually and slowly when it comes on as the symptom and accompaniment of old age: it is in such instances that its several degrees are most clearly re- cognised and distinguished. It is particularly in this modification of dementia that the commencement and sIoav advances of the first stage can be most distinctly traced. It seems to begin with dulness of perception or apprehension. The organs of sense are not so perfect in advanced age as in the more healthy and vigor- ous periods of life; sensation is not so acute, but it is rather in the subsequent recognition which the mind makes of the ideas pre- sented to it, than in sensation itself, that the defect chiefly lies. Perception indeed takes place, but the impression is momentarily evanescent. The individual sees and hears; he replies to ques- tions, but his attention is so little excited, that he speedily forgets what he has said, and repeats the same remark or inquiries after a few minutes. At the same time ideas long ago impressed upon the mind remain nearly in their original freshness, and are capa- ble of being called up whenever the attention is directed towards them. Sensation produced by present objects are so slight, and the notions connected with them so confused and indistinct, that the individual affected scarcely knows Avhere he is, yet he recog- nises Avithout difficulty persons with Avhom he has long been acquainted; and if questioned respecting his former life he will often give pertinent and sensible replies. The disorder of his mind consists, not in defective memory of the past, but in the incapacity for attention and for receiving the influence of present external agencies, Avhich in a different state of the cerebral organi- sation would have produced a stronger effect upon the sensorium, or seat of sensation and perception. It has been said, that in senile decay the phenomena of incoherence in the first degree are most distinctly marked. Traits of the same description may, how- ever, be observed in other cases of dementia. The memory of those who labor under this disease in the early stage, from what- ever cause, and in Avhatever period of life it may haAre arisen, is like that of aged persons, more tenacious of long-past than of recent events; the latter make so feeble an impression that it is speedily obliterated. In such persons all the powers of the mind are greatly Aveakened; they have no aptitude to any train of thought or action; and they are quite unable to fulfil the duties of insanity, (Mania and Dementia.) 175 their business or profession; they cannot combine a variety of considerations in order to arrive at any practical conclusion; can- not enter into any affairs of importance, or comprehend any con- tinued conversation; all their discourse is marked by diffuseness and incoherence. The second stage of dementia is characterised by a total loss of the reasoning faculty: the energy of the will over the train of thoughts is impaired to such a degree as to deprive the individual of all control over his associated ideas, and render him incapable of any effort of the mind, or of carrying on the series of thoughts to the end of a sentence or proposition. He hears a question, apprehends sometimes its meaning, and attempts to answer, but before he has uttered the half of his reply his mind becomes con- fused and beAvildered; some accidental suggestion turns aside the current of his ideas, Avhich are too loosely associated to remain coherent, and his expressions become consequently absurd and irrelevant. It is sometimes easy to observe the point at Avhich the intention of the speaker ceases to direct his Avords, and at which the ideas are drawn aside into a different course. The individual begins to talk of one thing, and before he has spoken half a minute he has wandered into subjects so remote from it, that some care is required to trace the links by Avhich his thoughts have reached the point at Avhich they are found. This degree of incoherence is generally to be observed as a prelude to a more severe and complete form, Avhich will be next described. Until the mind has passed into the more advanced stage, glimmerings of sense and reason are displayed; the indiA'idual affixes some meaning to his words, though he soon forgets it. The memory is not entirely lost, though much impaired, its defects resembling in kind those of senile memory, but exceeding them in degree. Many individuals in this state of dementia know and remember their friends or relatives, but seldom display signs of emotion or sensibility on being visited by them. Not a few even in this state are capable of being employed in mechanical occupations. Females knit or sew, or perform any work with their hands to which they had been previously habituated; and men draw, or write letters or sentences, in Avhich, hoAvever, their imbecility is generally conspicuous. Some patients have occasional periods of greater excitement, in which the symptoms of a more active stage of madness resume their prevalence. The third stage of dementia, or that of incomprehension, is cha- racterised by a total inability to comprehend the meaning of any question, or proposition, hoAvever simple. If the attention can be ever so slightly roused, the reply attempted is ahvays so re- mote from the subject, as plainly to indicate that the question has not been understood. This may be termed the instinctive stage of dementia. Reason being entirely lost, and the instinctive or mechanical principles of action still remaining in vigor, the latter 176 insanity, (Mania and Dementia.) display themselves more remarkably. The demented person in this degree is the creature of instinct and habit. Bodily force and activity survive, and are often remarkably displayed, and assume the appearance of trick or habit. Some jump, or run to and fro, or Avalk round perpetually in a circle. Some dance and sing, and vociferate frequently. Many talk incessantly in the most unmeaning jargon; others pass their time in muttering half sentences and broken expressions, in which it is scarcely possible to discover any link of connection, or if any association can be traced, it is of the most trivial kind, and depending on a word, or on some sensible object, Avhich for a moment attracts a degree of attention. Many on the other hand sit in silence with a tranquil look, sometimes Avith a vacant smile or unmeaning stare, and scarcely pronounce a syllable for Aveeks, months, or even for years. A feAV remain crouched in a particular posture, appa- rently nneasy and painful, but if placed in a different manner by those Avho have the care of them, they soon resume their habitual position. Many demented persons croAvd round a stranger who happens to visit a lunatic asylum, having just enough intelligence to perceive something neAV. Some have a propensity to adorn themselves in a strange manner; they take any thing that hap- pens to be in their way, and append it to their dress, Avhich is singular and ridiculous. In the fourth stage of dementia (inappetency—loss of instinct) even the animal instincts are lost. The miserable victim of dis- ease has merely organic or physical existence; he appears scarcely conscious of life; has neither desires nor aversions; and is unable to obey the calls of nature. Scarcely any exhibition of human suffering can be more deeply affecting than the aspect of a group of lunatics reduced to the last stages of fatuity. Sometimes an individual may be seen always standing erect and immovable, with his head and neck bent almost at right angles to his trunk, his eyes fixed upon the ground, never appearing by any move- ment or gesture to be conscious of external impressions, or even of his own existence. Another sits on a rocking-chair, which she agitates to and fro, and throws her limbs into the most un- couth positions, at the same time chaunting or yelling a dissonant song, only capable of expressing a total inanity of ideas and feelings. Many sit constantly still, with their chins resting upon their breasts, their eyes and mouth half open, unconscious of hunger and thirst, and almost destitute of the feelings which belong to merely physical life; they would never rise, or lie doAvn, were they not placed in bed. A great proportion of the patients Avho are reduced to this degree of fatuity are found to have lost the use of their limbs in a greater or less degree by partial or general paralysis. This state is not hoAvever always uniform; some of them have comparatively lucid intervals, in Avhich nature seems to make an effort to light up the mind and insanity, (Moral Insanity.) 177 recall lost impressions and ideas. A patient who had been seve- ral years in the same state, sitting all day in a wooden elbowed chair, with his chin hanging over his breast, apparantly hardly conscious of existence, who would not eat if food were not put into his mouth, appeared occasionally to rouse himself, and for a short time to recover an unusual degree of animation. At such periods he would sometimes read a chapter in the Bible Avith a clear voice and a distinct and intelligible articulation. Such oc- casional variations in the state of demented persons are not unfre- quent. They are capable of being raised by favorable influences from a loAver degree of their disease into one Avhich is above it in the scale. II. Moral Insanity. Moral insanity, though a Avell-marked and frequently occurring form of mental derangement, Avas first recognised and described by the Avriter in the Cyc. of Pract. Med., and afterwards in his work, entitled, Treatise on Insanity* It is there defined as consisting in "a morbid perversion of the feelings, affections and active poAvers, without any illusion or erroneous conviction im- pressed Upon the understanding." In the above Avork it is thus described—" There are many individuals living at large, and not entirely separated from society, who are affected in a certain degree by this modification of insanity. They are reputed per- sons of singular, wayward and eccentric character. An attentive observer may often recognise something remarkable in their manner of existence, Avhich leads him to entertain doubts of their entire sanity; and circumstances are sometimes discovered on inquiry, which assist in determining his opinion. In many instances it is found, that there is an hereditary tendency to mad- ness in the family, or that several relatives of the person affected have labored under diseases of the brain. The individual him- * Dr. Ray, an American writer on the medical jurisprudence of insanity, who has cited the above passages, observes that Pinel was the first writer who distinctly recognised the existence of moral insanity. Pinel, who termed the affection which he described, Emportement manieque sans delire and Manie sans delire, had in view only one particular aspect of moral insanity, viz. that which will be described under the designation of Instinctive Madness, or Insane Impulse. M. Esquirol, who in his late excellent work has translated a great part of the series of cases given in the Treatise on Insanity above cited as exemplifying this disease, has observed that the moral derangement, designated by the term used at the head of this section, is very different from the instinc- tive madness of Pinel: they are both forms of insanity without lesion of the understanding, or at least without illusion and the belief of unreal facts..— Author. 17S insanity, (Moral Insanity.) self is discovered, in a former period of life, to have sustained an attack of madness of a decided character. His temper and dis- position are found, on inquiry, to have undergone a change, to be not Avhat they Avere previously to a certain time; he has be- come an altered man; and this difference has perhaps been noted from the period when he sustained some reverse of fortune which deeply affected him, or since the loss of some beloved relative. In other instances the alteration in his character has ensued im- mediately on some severe shock Avhich his bodily constitution has undergone. This has either been a disorder affecting the head, a slight attack of paralysis, a fit of epilepsy, or some fever or inflammatory disorder, Avhich has produced a perceptible change in the habitual state of the constitution. In some cases the alteration in temper and habits has been gradual and imper- ceptible; and it seems only to have consisted in an exaltation or increase of peculiarities, Avhich were ahvays more or less natural or habitual." " Individuals laboring under this disorder are capa- ble of reasoning or supporting an argument on any subject within their sphere of knoAvledge that may be presented to them; and they often display great ingenuity in giving reasons for their eccentric conduct, and in accounting for and justifying the state of moral feeling under which they appear to exist. In one sense, indeed, their intellectual faculties may be termed unsound; but it is in the same sense in Avhich persons under the influence of strong passions may be generally said to have their judgment warped, and the sane or healthy exercise of their understandings impeded. They think and act under the influence of strongly excited feel- ings; and a person sane is, under such circumstances, proverbially liable to error both in judgment and conduct." Moral insanity is, as has been observed, by no means rare. In a report of the lunatic hospital for the state of NeAV England it is observed by the Avriter, Dr. Woodward, Avho has examined the records of the hospital Avith a view to this particular inquiry, that at least one fourth of the lunatics committed by the courts (of that state) belong strictly to the class Avhose disorder is moral insanity. This however comprehends, and perhaps chiefly consists of, cases referrible to the head of Instinctive Insanity, or Insane Im- pulse. For a series of characteristic examples of moral insanity the reader is referred to the author's Treatise on Insanity. It has been objected against the admission of moral insanity as a form of mental derangement that, by recognising the existence of insanity Avithout illusion, we lose sight of the only tangible and clearly marked boundary between eccentricity and madness. Modern laAvyers and Avriters on medical jurisprudence have laid down the dogma, that illusion or hallucination is essential to men- tal derangement, and a criterion of its existence. The late Sir John Nicholl in a celebrated decision insisted strongly on this dis- insanity, (Moral Insanity.) 179 tinction, Avhich he illustrated in a very able, lucid, and to many satisfactory, manner; he showed that his opinion derived support from the decisions of former laAvyers, among whom Avere Lord Coke and Lord Hale. He likeAvise cited the evidence of Dr. Bat- tie and Dr. F. Willis, and he might have adduced many other authorities directly to the point from among the medical writers of this and other countries. But the decisions of courts of justice, and even the opinions of the most learned laAvyers and physicians, cannot impose laAvs on nature, or on the physical constitution of man. There is a modification of insanity Avithout illusion, or the be- lief of any unreal or imaginary fact, Avhich consists merely in moral perversion; and the existence of this morbid state is now beginning to be universally recognised, though formerly denied; and the matter of fact being such, it is to no purpose to pretermit all notice of it in legal provisions for the care of the insane, and for the protection of those Avho are of sound mind. It has been said, that an admission of the existence of moral insanity as above defined, confounds madness with eccentricity; and that persons whose character is harmless and merely singular and eccentric, Avill be liable to the allegation of mental derangement, and may be deprived, Avithout any sufficient cause, of their liberty and civil rights. But this is founded on a misconception of the nature and foundation of proceedings in all inquiries concerning the ex- istence of insanity. The question which jurors have to determine in such investigations is, not whether the individual brought under their cognisance is, according to any abstract or settled definition, affected Avith insanity, but Avhether his mental state is individually such as to render him an unfit person to be at large and to be entrusted with the care of himself and his property. It is impor- tant to be aAvare of the general fact, that persons are liable to fall into a state in which they may lose this capability through the effect of disease, (namely, that termed moral insanity), Avithout displaying those phenomena Avhich were heretofore reckoned essential to madness; but Avhether in each particular case the per- son affected is in the predicament above-mentioned is to be deter- mined by evidence. Be his eccentricity ever so great, and ever so strikingly and undoubtedly morbid, or the consequence of dis- ease affecting his brain or nervous system, still there will be no plea for putting him under confinement, or taking from him the care of his property, unless it can be shoAvn that other persons, or himself, are likely to suffer in body or estate from his odd manner of conducting himself. IfhoAvever Ave are obliged to discuss the question, Avhether eccentricity is in general allied to madness, and. even a modification of that state or not, there is no doubt that the decision Avould be in the affirmative. It is Avell-knoAvn that per- sons who have been decidedly insane, or Avho have labored under one of the usually recognised forms of madness, often remain ec- 180 insanity, (Moral Insanity.). centric during life, after their reputed recovery: others are eccen- tric for an indefinite period beforehand, and their eccentricity is a precursory state to declared madness. Monomaniacs, Avho are considered, insane only on one particular point, are often eccentric in the whole of their conduct. Moreover, it may very commonly be observed, that in families in which many individuals have dis- played symptoms of decided insanity, some others are only eccen- tric, and are reputed to be such through life. We shall conclude Avhat we have to say upon the subject of moral insanity for the present by enumerating briefly the most characteristic features of that disorder. 1, A state of excitement. Periods of excitement, often lasting for months, alternate Avith others of corresponding depression. Sometimes the excitement is permanent, or it lasts until the pa- tient returns gradually into his usual and healthy state, without any interval of an opposite condition. An unusual degree of hilarity and joyous excitement is, in many instances, the most character- istic difference betAveen the morbid and the healthy state of the person affected. The excitement of moral insanity is very similar to that which is produced in many persons by intoxication: they even describe their feelings after recovery as precisely analogous to those of persons half-drunk or slightly under the influence of strong liquors. It is probable that a state of the brain is induced by morbid causes nearly bordering on that condition to Avhich alcohol or Avine gives rise under ordinary circumstances. 2. Absence of reserve. Nothing is more striking in cases of moral insanity, than a total absence of that prudential or decent reserve or circumspection which in various degrees is habitual to most persons, especially in the Avell-educated, in their sane and natural state. The insane feel no repugnance to expose all their thoughts and feelings. It seems never to occur to them, that any thing should be concealed, because the open avoAval and exposure is unbecoming. They ofeen talk loudly and coarsely to perfect strangers about their family affairs, their property, and their feel- ings towards their nearest relatives; complain of ill-treatment from one, and testify the most unbounded affection to another, which is liable to be reversed on the slightest caprice, and expose their inmost thoughts to every person indifferently. 3. Garrulity is another feature of their disorder. Many enter into long stories always relating to themselves; their narratives are often very characteristic, and display in a most curious man- ner the singular state of their mind and feelings. Their memory is often surprisingly accurate, even in the most trifling particulars; they make long digressions, and explain the motives which influ- ence them, or by which they profess to have been influenced, in their most singular and absurd actions, and generally Avith a vieAV to account for their conduct, and make it appear more reasonable insanity, (Moral Insanity.) 181 or more like that of other men. Some lose themselves in long digressions. 4- The propensity to make extravagant purchases is often very striking in moral insanity. The particulars of some cases of mental disorders in which this feature was very remarkably dis- played, are detailed in the author's Avork already alluded to. A farmer Avho Avas affected Avith the same disease, used to go to the markets, and fairs, and sales, in the neighboring counties, and make great purchases of live stock; he Avould buy household fur- niture, carriages, horses, Avithout any rational intention or pros- pect of disposing of them. The Avriter has seen a lady Avhose disorder showed itself in a similar Avay. She used to go to jew- ellers' shops, and make purchases of the most expensive trinkets and ornaments Avithout end. Her extravagance and disposition to run in debt Avas such, that it was the main inducement with her family to sue for a Avrit; she was declared of unsound mind, and ordered to be put under control. This person labored under no illusion or hallucination: her moral feelings Avere in disorder. 5. A total disregard of veracity and of moral obligations in general is a feature of this form of mental disorder. Persons Avho profess no disregard of religion, display a perfect want of any moral control over their conduct; they tell gratuitously the most palpable falsehoods, and have no regard whatever to the morality of their actions. 6. An irresistible propensity to drinking fermented and other intoxicating liquors is often the result of moral insanity, and one of the principal characteristics of particular cases. The state of the individual after this indulgence becomes changed into that of a raving maniac; and what characterises it and distinguishes it from the ordinary effects of drunkenness is its permanence. A day or a night will suffice for the recovery of a drunkard from the immediate effects of his debauch; but an insane person, whose disorder is produced or aggravated by a similar cause, is often weeks or even months before he returns to his previous condition. A very small quantity of wine often gives rise in such persons to unusual excitement; the disturbance Avhich it occasions is both greater and of longer duration than in healthy persons. 7. Perfect selfishness marks all the conduct of the morally in- sane. They are generally indifferent to the feelings of others, and only consult in every thing their own personal gratification, and particularly the gratification of their bodily appetites. 8- A dislike towards relations and friends formerly beloved, and even the objects of their warmest affection, is well-knoAvn to be a feature of madness, and it belongs particularly to moral in- sanity. Husbands and wives conceive aversion and repugnance, Avho had always displayed in the same state the greatest fond- ness and tenderness. Mothers dislike their children, or are per- 16 182 insanity, (Moral Insanity.) fectly indifferent to them, and pass months Avithout making any inquiry about them. 9. A proneness to suspicion is often very manifest; the most triflin? circumstance is often sufficient to give rise to a train of for- midable apprehensions Avhich the insane person harbors, and over which he broods, until he comes at length to believe them as matters of fact; the disorder then passes into monomania. No- thing is more common in morally insane persons than a dread of being poisoned. It is an unfavorable symptom, and marks a tendency in the disorder to become converted into monomania, or acute melancholy dejection. 10. Melancholy (sorrroAvful dejection of mind, or loAvness of spirits), without any erroneous belief, or the conviction of any un- real fact impressed upon the understanding, is a form of moral insanity, inasmuch as the disorder extends not beyond the moral feelings and sentiments, and the disposition of the mind Avith respect to hope and fear; it affects not the intellect, Avhich remains unclouded. Persons in this state have no relish for the enjoy- ments of life; they express no feelings of consolation or happiness in the prospect of a future existence; they vieAV every thing through a medium of gloom. Many individuals thus affected labor under bodily ailments, to Avhich they generally ascribe a greater part of their sufferings than these ailments can account for: they complain of loss of appetite, a burning heat in the stomach, constipation of the boAvels, and dull oppressive pains in the head, accompanied in females with disordered menstruation. The countenance indicates anxiety or dejection; the complexion is pale or salloAV; sometimes there is a sense of fulness or oppres- sion in the head, which impedes thought, and a torpor and gene- ral lassitude, which deprives the patient of all inclination to bodily exercise. They never go abroad, but remain, unless compelled to move, moping and silent in their beds or in their chambers; give up their usual employments; neglect their domestic and social duties; become indifferent towards the objects of their most ten- der affections; dislike society and the intercourse even of their nearest friends; complain of their OAvn incompetency to exertion and to fulfil the duties of life; and appear to feel existence itself an intolerable burden—a state of mind Avhich indicates danger of a termination by suicide. We have seen several individuals affect- ed Avith the symptoms above described Avhich have lasted for months, sometimes for years, and have then disappeared entirely for a considerable time, but have returned at intervals Avithout any discoverable cause. In some the intermediate space of time has been passed in perfect health; the person affected has per- formed all his duties Avith the same energy and good spirits as before the first attack. In others the period of depression has alternated Avith one of unusual excitement. So long as this disordered state of mind is accompanied by no insanity, (Monomania.) 183 illusion, Avhile there is no unreason, the patient labors under a form of moral insanity which may be termed simple melancholy. When after long brooding over the sources of distress, and indulg- ing the imagination in trains of thought which are in harmony with the temper of the mind, some illusory phantom has impressed itself upon the belief, the disorder must be considered as having passed into monomania. III. Monomania. Partial insanity was until lately termed melancholia, an ex- pression Avhich originated from a hypothetical notion respecting the cause of the disease. It was defined to be a form of insanity in which a single false notion is impressed on the understanding, the mind being otherwise unclouded, so that the insane person is still capable of reasoning correctly though on false premises. As partial insanity is not always of a sorrowful or melancholy char- acter, Esquirol has proposed the term monomania as a designa- tion for those forms of the disease to Avhich the description par- ticularly applies, and this expression has got into general use. I shall adopt it as a designation for those cases of insanity in Avhich the patient is coherent and capable of conversing and reasoning on most subjects, but labors under some particular illusion or hallucination, and as comprehending instances, not only of cheer- ful illusion but also those attended with sorrowful dejection. The latter are still classed by some under the head of melancohlia, for which M. Esquirol substitutes " lypemania," meaning madness attended with grief; but as the same essential character belongs to both kinds, I see no reason for separating them. M. Esquirol, in his late excellent work on insanity, gives some reasons for including cases of moral insanity under the head of monomania. With great deference to this justly celebrated phy- sician we venture to observe, that the term monomania does not appear applicable to a disorder which is not characterised by any particular error or delusion, but involves a perversion of the whole moral character of the individual, his affections, senti- ments, feelings, inclinations, and which displays itself in a change of all his usual habits. We may likewise remark, that if moral insanity really exists, it is expedient that it should be distinctly recognised, and that the fact should be generally proved, that a form of mental derangement is occasionally found, in Avhich, though the understanding is impressed with no erroneous con- viction, the state of the individual may yet require some pruden- tial interference. Cases are on record which fully correspond with the psycholo- gical definition of monomania. Individuals who have continued to display great ability and aptitude in all affairs and in the busi- ness connected Avith their professions, Avho have conducted them- 184 insanity, (iMonomania.) selves Avith propriety in all the relations of life, have yet been known to labor under some insane illusion, like the madman of Argos, Avho, Avhen he used to see visionary performances in a theatre, Avas yet " comis in uxorem, posset qui ignoscere servis." One of the most remarkable instances of this description was that of Baron SAvedenborg, Avho is said to have held an official ap- pointment under the Swedish sovereign, the duties of Avhich he continued to perform, though laboring under an illusory notion that he ever and anon saAV and conversed with prophets and kings of the Old Testament, or Avith the saints and apostles of the NeAV. Cases which ansAver so fully to the definition of monomania are, however, extremely rare; generally the mind is otherwise disordered and weakened, though the characteristic allusion is ahvays the most striking phenomenon; the moral affections and feelings are likewise in a perverted state. Some ruling passion seems to have entire possession of the mind, and the hallucination is in harmony Avith it, and seems to have had its origin in the intense excitement of the predominant feeling: this is ahvays a selfish desire or apprehension, and the illusory ideas relate to the personal state and circumstances of the individual. M. Leuret terms monomania le dilire des passions. This excellent writer has given the details of several cases which strongly exemplify the preceding remark, and which should be read by those Avho are desirous of studying the nature of monomania. The particular desire or aversion Avhich occupies the mind seems to excite the imagination to such a pitch, that a fantastical idea at length takes hold of the belief. The illusory notions are often vague and fluctuating, but have relation to the same senti- ment. Those Avho fancy themselves persons of great distinction often change their titles—a king to-day is an emperor to-morroAv; the subjects of dread Avhich the melancholic contemplates are not ahvays the same. The misanthrope Avho has sustained injuries from all his friends, complains perpetually of new grievances; the affronts Avhich he imagines to-day that he has suffered are not those of yesterday. It is by dint of brooding over the imagi- nary Avrong that he fixes it in his mind, and ultimately in his belief. " Monomania," says M. Esquirol, "is, in its ground-work, a disorder of the feelings, the study of this affection is inseparable from the knoAvledge of our passions: it is in the heart that it has its real seat, and there Ave must study to discover the hidden cause and its different aspects and varieties. How many cases of monomania are produced in disappointments in love, by fear, by vanity, by Avounded self-love, or mortified ambition? This dis- order manifests all the phenomena Avhich characterise the pas- sions; the madness of the monomaniac is exclusive, fixed, and permanent, like the idea Avhich occupies the mind absorbed by some strong emotion." insanity, (Monomania.) 185 f" The last-mentioned writer, in his recent work on mental alien- ation, has made some excellent observations on the nature of monomania. " It has long ago been said, that insanity is the disease of civilisation: this might have been observed Avith truth in regard to monomania; indeed, monomania increases in pro- portion to the advancement of civilisation; it borroAvs its character from the different stages of society: it is superstitious and erotic in the infancy of society, as it still is in countries where civilisation has made little progress; while, in a more cultivated period, it takes its character from pride, scepticism, ambition, the passion of gaming, despair, suicide. There has been no epoch Avhich has not been remarkable for instances of monomania impressed with the intellectual and moral character of the particular period." The condition of modern society, as M. Esquirol remarks, has modified the causes and the characters of monomania; and this disease returns under neAV forms. With the weakening of reli- gious convictions, demonomania and superstitious madness have disappeared. The influence of religion over the conduct of the people being Aveakened, in order to keep men in obedience go- vernments have had recourse to police, since Avhich time it is the police Avhich haunts weak imaginations. Asylums are filled Avith monomaniacs who, fearing this authority, have gone mad upon the subject, and believe that they are constantly pursued. The same monomaniac Avho formerly would have gone mad upon magic, Avitchcraft, or hell, raves noAV upon being threatened, pur- sued, and imprisoned, by the agents of the police. The political convulsions of France produced a great number of monomaniacs, excited and characterised by the events which singularised each epoch of the revolution. In 1791 there was at Versailles a pro- digious number of suicides. Pinel relates, that an enthusiastic admirer of Danton having heard him accused, became mad, and was sent to Bicetre. The death of the king and his unfortunate family created a great number of monomaniacs: the trial of Mo- reau, the death of the Duke d'Enghien caused many. When the pope came into France, religious ideas were excited; and there were a number of superstitious maniacs, Avho disappeared after a time. At the period Avhen the emperor peopled Europe with new kings, there were in France numerous monomaniacs, who fancied themselves emperors or kings, empresses or queens. The war in Spain, the conscription, conquests, and defeats, produced their peculiar mental diseases. It is a fact, that there are in dif- ferent lunatic asylums many individuals who believe themselves to be the dauphin of France, and destined to the throne. Every observation confirms the fact, that the state of society exercises a great influence upon the production and character of monomania. Melancholia, or that variety of partial insanity in which the predominant sentiment is grief and. despondency—a sentiment 16* 1S6 insanity, (i\[onomania.) which conjures up corresponding ideas and illusions, though it comes Avithin the same general definition—is a strongly marked, and, in many respects, a very different disorder from the cheerful madness of the lively monomaniac. The external aspect of the melancholic is striking, and symptomatic of his mental state. He is generally thin and emaciated, Avith a pale salloAV complexion, sometimes a red patch on the cheek, or the tip of the nose; the hair is often straight and black, the skin cold and clammy, the look fixed and motionless, turned towards the ground, or gazing as if into distant space, expressing absence of thought, or some- times by quiet and furtive glances indicating that suspicion or fear is uppermost in the mind. M. Esquirol has described this disorder in the most graphical manner. The concentration of feelings and thoughts renders the actions of the melancholic uniform and slow; he dislikes all kinds of motion, passes his days in solitude and idleness; he sits habitually Avith his hands crossed, or if erect, inactive, Avith his arms hang- ing doAvn; if he walks, it is with slowness and apprehension, as if he had some danger to avoid, or else he Avalks with precipita- tion, and ahvays in the same direction, as if his mind was deeply engaged. There are some who tear their hands, the extremities of their fingers, and destroy the nails. Tormented by grief or fear, the ear and eye constantly on the watch, the lypemaniac, says M. Esquirol, has no rest by day, nor sleep by night. The secretions are scanty or suppressed. Some melancholies obstinately refuse all kinds of nourishment; some have been knoAvn to have passed many days Avithout eating although very hungry, prevented by hallucinations and illusions which produced chimerical fears. One dreads poison, another dishonor; one wishes to do penance, while another thinks that if he eats he brings his relatives or friends into difficulty; and there are some Avho hope to get rid of life and their torments by abstaining from all nourishment. A lunatic has sustained absti- nence during thirteen and twenty days, and longer. When the repugnance to eat has been overcome, most melancholies are less sorrowful and dejected. The pulse is generally sIoav and Aveak: sometimes it is very hard, and a kind of trembling of the artery is felt under the finger; the skin is arid, of a dry heat, and often burning. Melancholies seldom sleep; restlessness, fear, terror, jealousy, and hallucina- tions, keep them aAvake; if they become droAvsy, as soon as their eyes are shut they see a thousand phantoms which terrify them; if they sleep, their rest is interrupted and agitated by dreams. Sometimes they awake, starting up with the nightmare, or from dreams Avhich have brought before them the objects Avhich have caused or kept up their delirium. Many, after a good night, are more melancholy and restless; some believe that they never shall gat to the end of the day, and are better as night approaches; t insanity, (Monomania.) 187 Avhile others feel their restlessness increase towards night—they dread darkness and solitude, fear lying awake, or the terrors accompanying sleep. The secretions present remarkable disorders in melancholies; the urine is abundant, clear, and limpid; sometimes it is scanty and turbid. Some melancholies, for various motives, retain their urine for several days. The case is related of a patient who Avould not pass his water, fearing to deluge the Avorld, and who Avas at length only prevailed upon to do so in order to extinguish a fire that was raised on purpose. M. Esquirol has observed that melancholia presents in the assemblage of symptoms tAvo Avell-marked distinctions. Some lypemaniacs are very irritable and extremely excitable; every thing makes a most lively impression upon them; the slightest causes produce the most painful effects; the most ordinary and simple events appear to them new and singular phenomena, ordained expressly to torment and injure them. Cold, heat, rain, Avind, affect them Avith horror and grief; noises distress, and make them tremble; if any thing displeases them, they repulse it with rudeness and obstinacy; if their food is not what they relish, their repugnance often causes nausea and vomitings. All their feel- ings, thoughts, and actions, are forced and exaggerated. This extreme susceptibility causes them to be continually meeting Avith fresh objects and occasions of distress; thus, both day and night, they are constantly on the watch; they are ahvays in mo- tion, in search of their enemies and the cause of their sufferings; and they relate to every person Avho comes in their Avay their misfortunes, fears, and despair. Sometimes the mind is so ab- sorbed in one single idea, that sensation seems to have abandoned the bodily organs; the body is incapable of any impression; and this one subject absorbs the attention, and suspends the exercise of all the intellectual functions. The motionless state of the body, the rigidity of the features, obstinate silence, betrays the deplorable state of the intellect and the affections. In this state of distressing excitement of feelings, melancholies are not only inaccessible to every impression foreign to the object of their delusion, but they are also quite unreasonable, because they receive false impressions. An 'abyss separates them, they say, from the exterior Avorld. "I hear, I see, I feel," some melancholies have said, " but I am not as I formerly Avas; objects do not come to me; they do not identify themselves with my being; a thick cloud, a veil, changes the color and the aspect of bodies; the most polished surfaces appear to me rough with bris- tles," &c. External objects not having their natural relation, distress, astonish, and alarm them. They have illusions of the senses—hallucinations; they associate together ideas the most 1SS insanity, (Insane Impulse.) dissimilar and most absurd; and hence spring convictions more or less contrary to common sense, unjust prejudices, fear, horror, or grief. The feelings modify the ideas, the hopes, the determinations, of the most sensible men. Melancholy feelings thus affect a par- tial lesion of the understanding. The whole intellectual life of a person suffering under melancholy delirium, is impressed with the character of his feelings. The mountaineer cannot bear to be absent from the place Avhich gave him birth; he pines aAvay and dies, unless he is restored to his paternal soil. A person Avho fears the pursuits of justice, alarmed and terrified, dreading to be arrested every instant, fancies he is surrounded by agents of police, and even sees them among his friends and relations. IV. Of Instinctive Madness, or Insane Impulse. It has been truly observed by Esquirol, that the disorder which Pinel described under the epithet of Manie sans dilire, and Avhich is here termed instinctive "madness, or insane impulse, is in some respects a different affection from that Avhich has been designated moral insanity. It may be considered as a variety of moral in- sanity, but it is very distinct from the disorder of the feelings and moral affections above described, as pervading the whole mind and perverting the moral character of the individual. In this instinctive madness the understanding is unclouded, as it is in moral insanity: there is no hallucination or illusion; but in the former state it has not been observed, that the affections and moral sentiments and the feelings are universally in that intense exaltation which belongs to most cases of moral insanity. The will is occasionally under the influence of a disordered impulse, which suddenly drives the person affected to the perpetration of acts of the most revolting kind, and to the commission of Avhat he has no motive. This impulse is instinctive; it is irresistible; and its gratification is unaccompanied for the most part by any organic or mental pleasure; it is unlike the gratification of physi- cal appetites, and equally unlike that of hatred and revenge. Individuals who have felt the approaches of this disorder have been known to take precautions against themselves; they have warned their Avives and children to escape from Avithin their reach till the paroxysm shall have subsided. i. Homicidal Impulse. Among the varieties of insane im- pulse there is none that better characterises the nature of this deplorable affection than the homicidal impulse. It Avas first described by Pinel, and considered by him to be (as noAV gene- rally admitted) an instinctive impulse without delirium. M. Es- quirol in the Dictionnaire des Sciences Medicates, art. Manie, insanity, (Insane Impulse.) 189 attempted a different explanation of the cases supposed to be of this description, which at that time were knoAvn to have oc- curred. In his late Avork (Traiti sur VAliination,) and previ- ously in a dissertation appended to the translation of Hoff bauer's Psychologie in ihren Hauptanwendungen auf Rechtspflege, this Avriter has very candidly admitted that he has been brought, by the cogent evidence of facts, to a different opinion. He now declares that numerous and Avell-authenticated cases have de- monstrated the fact, that Avhile some madmen commit homicide under the influence of delirium or of illusions, while others per- petrate similar acts Avith premeditation and design, influenced by an intense feeling of malevolence, Avhich may be a part of the general perversion of their moral feelings, there is a third class who are neither under illusion nor moral perversion, if Ave inquire into the general state of their affections and moral feelings, and Avho are driven to commit homicide by a sudden and merely blind and instinctive impulse, Avithout motive, Avithout conscious- ness of the nature of the act. The following instances are related by M. Esquirol in his late Avork:—" A female, ten days after her delivery, felt herself all at once, and Avithout any motive, agi- tated with the desire of cutting her infant's throat. The mother of four children is involuntarily impelled to destroy them, and the only Avay of escaping such a misfortune is by deserting her house. A nursemaid Avas seized with an irresistible desire to rip open the infant committed to her care every time she undressed it to put it to bed. A mother attempts to cut the throats of those of her children 'whom she loves with the greatest tenderness. A female at the period of menstruation experiences the desire of killing her husband and her children, and the desire is strongest Avhen she sees them asleep. A gentleman read a neAvspaper in which were related the details of a murder of a child; the next night he awoke, starting from his sleep, with the intent to kill his Avife. A female who cut off the head of a neigh- bor's child was brought to judgment; the trial Avas very much talked of, and produced in imitation a great number of homi- cidal attempts Avithout delirium. In this last series of facts the intellect, moral affections, and the Avill, are annihilated. What then is this terrible disease, Avhich, mocking the sweetest feelings of existence, drives a man to the violation of the most sacred laAvs of nature, and impels him to kill his felloAV-creature —to destroy the persons dearest to him. The miserable victim of disease does not attempt to reason before he commits the mur- der, and at the time he is not actuated by any passion or by any motive, but is instinctively driven to the commission of the crime. A husband kills a wife whom he tenderly loves, a father the son that is most dear to him, and a mother her nursing babe. This phenomenon could not take place without admitting the total suspension of all intelligence, of all moral sensibility, and of all 190 insanity, (Insane Impulse.) will. The folloAving is a good illustration:—A gentleman, thirty- two years of age, tall, rather thin, of a nervous temperament, and amiable character, had received a good education, and cultivated the arts; he had been ill Avith a cerebral affection, but had been recovered from it for some months. He Avent to Paris, and for tAvo months conducted himself in the most regular manner. One day he Avent to the Palais de Justice, and entering into the hall of the Pas Perdus, he threw himself upon a lawyer and seized him by the throat; he was arrested, and conducted to prison, and committed to my care the very day of the event. On my first visit, the next day, he Avas calm, tranquil, Avithout anger or resentment, and had slept Avell all night; and the same day he painted a portrait. He recollected perfectly Avell what had hap- pened the evening before at the Palais de Justice, and spoke of it with great coolness; but he had no recollection of the motives nor the circumstances of his action, and felt no regret for it: he replied to my questions Avith politeness, without dissimulation, and Avith the accent of truth. < I went to the Palais de Justice, as I might have gone any Avhere else, to the Palais Royal or the Tuilleries, Avithout plan or intention; and so far from having any resentment toAvards the laAvyer, he Avas perfectly unknoAvn to me, and I never had any kind of business with any lawyer, and I cannot explain how such a disaster could have happened; it might have taken place any where else, and I might have seized upon any other individual.' On my observing to him, that a sudden attack of disease might explain this action, ' You may explain it as you like,' he replied; ' I do not feel ill; nor can I give any reason for the event." During three months Avhich this gentleman passed under my care, he was never insane for an instant, never delirious, and never committed an absurd ac- tion; he Avas polite, obliging to every body, amused himself Avith painting and reading serious books." Many facts might be collected which sufficiently prove the connection of this formidable mental disorder Avith physical con- ditions, or Avith a morbid state of the bodily constitution. Among these is the circumstance, that such insane impulses have been noted as occurring in persons subject to epilepsy. One case has been recorded by Pinel, in which the homicidal propensity was observed to break out after symptoms of gastric disorder. Nasse and other Avriters have mentioned facts, which indicate that a similar excitement is particularly incident to persons Avho labor under hypertrophy of the heart: the connection of the phenomena is in this last instance easy to be understood. M. Esquirol has given a remarkable case in illustration of the dependence of in- stinctive madness on congestion in the brain. 2. Insane Impulse to burn (Pyromanie of M. Marc). An- other form of instinctive madness is the impulse to burn or set fire to houses, churches, beds, &c. So many instances of this de- insanity, (Insane Impulse.) 191 scription have occurred, that the disorder has received a distinc- tive name, that of pyromania, given by M. Marc, Avho first wrote on the subject. Tavo or three cases of this kind are alluded to in the Avriter's Treatise on Insanity. Arson, as it is termed, has been perpeirated by lunatics labor- ing under illusion, who fancied themselves commissioned by an angel, or to have received a divine command. Such was the man Avho burnt the Minster at York. These are not cases of the description noAV considered. The conclusion of M. Esquirol, Avho has examined the evidence of facts bearing on this subject, is as folloAvs:—" Among incendiaries Avho are insane, or whose minds are Aveakened, some have hallucinations; but the greater part obey an impulse more or less strong, and are hurried on by motives more or less plausible; but these patients are not deprived of the faculty of reasoning. There are facts Avhich show that some incendiaries are moved by an instinctive impule, indepen- dent of their Avill. And it is this fact Avhich places this last variety in the manie sans dilire of Pinel, and Avhich 1 call mono- manie sans dilire, because the action of burning is neither the result of passion, nor of delirium, nor of Avant of reason." The connection of this disorder of propensity with corporeal derangement is illustrated by a case recorded by the same writer, in Avhich a strong incendiary impulse appeared to be the conse- quence of epilepsy, or to have been connected with that disorder. 3. Suicide. The propensity to self-destruction is another phe- nomenon, which in some instances belongs to the class of morbid affections now under consideration, namely, to that of instinctive impulses; in which it would almost appear that volition takes place Avithout motive, or at least without deliberation. It must, however, be admitted, that suicide is often connected with other forms of insanity. M. Falret, who has Avritten an able and very celebrated Avork on suicide, has perhaps erred in treating it as one distinct and specific form of insanity. We shall find reason to conclude that suicide is caused by various morbid states of the mind, or by different modifications of mental derangement. But is suicide always the result of insanity in some one of its modi- fications? Some have maintained the affirmative. A perversion of the strongest instinct, or active principles impressed on the mind, that of self-preservation, seems to be so great a deviation from the natural state of the feelings and of human desires, that it Avould imply something nearly bordering on insanity. Never- theless, it must be admitted, that suicide has often been perpe- trated by persons Avho cannot be considered to have been, in any proper sense of the word, insane. Hoav many persons destroy themselves under the influence of enthusiasm, or some false reli- gion, as in the processions of the Hindoos, where four or five hundred fanatics are often crushed under the Avheels of the car of Juggernaut in a single festival. At Rome, as every one knoAvs, 192 insanity, (Insane Impulse.) suicide was the general consequence, among the nobles, of falling under the displeasure of the emperor; and in China,* no manda- rin or public officer, Avho falls into disgrace, thinks of any other termination of his career. At Ceos, the country of Simonides, it was the custom to commit suicide Avhen any man attained the age of sixty years, and it Avas deemed shameful to survive the period Avhich rendered him unable to serve his country and the commoiiAvealth. These and similar facts are sufficient to prove, that suicide exists independently of mental disease, and as the result of moral causes Avhich exert their influence on the whole community. The same inference arises from the history of par- ticular cases of suicide, in Avhich it appears that the act has been sometimes premeditated, and the result of motives Avell-Aveighed —of moral determination of the will; and at others has been committed under the influence of some strong passion or motive, which although it may have perverted the understanding, or have deprived reason of its due influence over the mind, as other violent passions are apt to do, is yet not to be confounded with insanity. The same inference arises from cases, of Avhich there are many on record, of suicide committed by more than one in- dividual conjointly, and Avith a similar and common purpose. Two or more persons cannot be supposed to have been seized at the same moment Avith a similar insane impulse. Cases of suicide depending on insanity may be referred to three divisions, in each of Avhich the nature of the action in a psycho- logical point of view is different from that of other forms. (a) Suicide takes place in cases of suicidal melancholy Avithout illusion or any erroneous notion. We have known instances in Avhich persons Avho had shoAvn no other indication of mental de- rangement than gloom, taciturnity, or continual expressions of grief, distress, and inward misery, at length destroy themselves by shooting themselves, or jumping out of a AvindoAv. In these individuals there Avas no unreason. They must have known the moral nature of the act committed by them. Their disorder Avas merely one of the feelings and sentiments, and left the under- standing unimpaired. Many have sunk into this state, Avhile all the circumstances of their outward state Avere such as are most likely to make life happy and desirable. Suicide under such conditions has been committed generally by persons Avhose education has been faulty, whose minds have agitated by violent passions, or wholly engrossed by Avordly pur- suits, and broken by disappointments; never by those Avho have obtained the consolations of religion. (b) Suicide is in many instances a result of some morbid illusion. These cases belong to monomania Avith melancholy dejection; * See the translations of Chinese plays in Duhalde, in which the fre- quency of suicide is quite ridiculous.—Author. insanity, (Insane Impulse.) 193 and they illustrate strongly the nature of that disease, in the power which the illusory idea exercises over the mind, the obstinate adhesion with which the lunatic holds to his morbid persuasion and unhappy resolve, and his indifference to the sufferings Avhich he experiences in the accomplishment of his purpose. (c) None of the cases of suicide above noted come properly within the description of instinctive madness or insane impulse, or excited propensity to certain acts Avithout motive or design. None of the acts of self-destruction which originate from the states of mind referrible to melancholy dejection, either with or without illusion, Avill bear a comparison Avith the acts of homicide de- scribed in the preceding pages; but there are other cases of sui- cide, Avhich appear to be strictly analogous to those of instinctive homicide. This remark most obviously applies to cases of suicide accompanied, or immediately preceded, by homicide, of Avhich many have been reported on unquestionable authority. Persons apparently in sound health, both of body and mind, have been seized, as if possessed by an evil spirit, with an unaccountable impulse to destroy some of their friends or relative's, and at the same time themselves. A lady Avhose case Avas reported in the public journals in 1835, after having throAvn four of her children into a well jumped into it. She had previously sent a poisoned cake to another child Avho was absent. M. Falret and other writers have reported a number of cases in Avhich these strange and horrible propensities were developed simultaneously, and which leave no room for doubt as to the psychological character of either action. Instances have occurred in which persons, occupied Avith the desire of self-destruction, or longing for death, have committed homicide in order to obtain their end without dying by their OAvn hands. Dreading the guilt of suicide, or rather the punishment Avhich they believed to be its consequence in a future life, they have committed murder in the hope of obtaining absolution pre- viously to their death by the hands of the executioner. Such instances cannot be numerous, since they imply conditions Avhich are not often found in combination. Various as are the states of mental disorder which precede suicide, there are yet so many physical conditions Avith which it is connected, as to establish the conclusion, that it often depends on disease, or on physical states of the constitution, and even afford some countenance to the opinion maintained by M. Falret, that it is a specific mental disorder on the manifestation of one. Suicide is often connected Avith bodily disease, manifested either during life, or by necroscopy. It is Avell-known that some females have displayed a strong propensity to suicide at the periods of the catamenia. Individuals who have manifested this propensity are known to have labored under hypochondriacal and dyspeptics ymptoms, cardialgia, flatu- 17 194 insanity, (Insane Impulse.) lent or neuralgic pains in the bowels: they are generally of the melancholic or atrabilious temperament, or display the external appearances of the constitution, Avhich is designated by that term, Avhich appearances indicate a certain morbid state described in medical Avorks. The general state of health is seldom unimpaired in persons who make attempts to destroy themselves. It is well- known that the pellagre endemical to Lombardy, a disease affect- ing primarily the digestive organs, and displaying its external effects on the skin, gives rise to a strong propension to suicide. M. Esquirol was assured by Professor Tomassini, that one third at the least of the persons affected Avith this disease commit sui- cide; and some Italian physicians affirmed the proportion to reach to one half. Necroscopy has displayed a variety of phenomena in the bodies of persons who have been the victims of suicide. And although these phenomena are not constant, the frequent discovery of some or others of them in such bodies indicates their connection Avith the propensity displayed. In the head we usually look, in the first place, for phenomena connected Avith forms of mental derangement. Gall Avas of opinion that the skulls of self-murderers are thick and dense. Esquirol declares that he possesses in his collection many skulls which are negative of this opinion. " I have sought," says this excellent observer, " in many heads to find some general fact in the proportions of the different diameters, and could obtain no result. I possess skulls of suicides, of Avhich the antero-posterior diameter is very long, Avhile in others this diameter is nearly equal to the lateral one; so that in one case the head was very long, and in the other almost spherical." There is nothing constant in the phenomena presented by the brain in these cases, either in respect to original conformation, or the marks of internal and supervening disorganisation. Osiander regarded lesions of the heart and inflammations of the abdominal viscera as the causes of suicide. Disorders of the heart have been found frequently by Alberti of Gottingen, and by Corvisart. M. Esquirol has found the transverse colon out of its natural position, and lying in a perpendicular direction towards the pubis, a phenomenon noted in other modifications of insanity. This writer concludes that there is nothing constant or uniform in the phenomena of suicide in necroscopy. The same conclusion Avas obtained by M. Leuret as the result of sixteen dissections. (Diet, de Mid. et Chir. Prat., art. Suicide.) The predisposing and occasional causes of suicide indicate the connection of this propensity with physical conditions. Those Avho have committed suicide, according to universal testimony, have generally been members of families predisposed to insanity. Dr. Rush has reported a remarkable case coinciding with this series of observations. Two young officers Avho distinguished insanity, (Insane Impulse.) 195 themselves in the revolutionary war of America Avere twins: they Avere so much alike, that feAV persons could distinguish them: both Avere of cheerful dispositions, and happy in their families, connections, and fortune. Both committed suicide about the same period, Avhen they Avere in different parts of the country: they had been dejected for some days before. The mother of these young men was insane; and two of their sisters were for some years harassed by temptations to suicide.* The influence of season is perceptible in the frequency of suicide. It is a vulgar opinion that the gloomy months of autumn give rise to the depression of spirits which foster this propensity. This is an error. The effect of season is entirely physical, since in the hottest and brightest months of the year suicide chiefly occurs. This general fact has been established by the averages of Fodere and Duglas at Marseilles, and by the observations of Dupuytren and M. Esquirol at Paris. The Avriter last mentioned found the number of suicidal attempts in the Salpetriere during six years as folloAvs:—In the winter, trimestre of January, 42; spring, trimestre of April, 58; summer, trimestre of July, 61; autumn, trimestre of October, 31; making 73 cases in the winter and autumn, and 119 in the spring and summer. In hot seasons they are most frequent. This was observed at Mansfield by Sydenham long ago, and recently at Stuttgard, at Rouen, and in the Valais. Suicide has been committed more frequently by males than by females, in the proportion of three to one; and the most numerous cases have occurred betAveen the ages of twenty and thirty. The preceding summary contains the principal facts knoAvn in relation to suicide. It is evident that this horrible catastrophe is the result of various causes: sometimes of national customs, erro- neous notions, and of imitation: in other instances it is a deliberate act, in which the will, according to the ordinary laAvs of human action, is influenced by motives, and is determined after delibera- tion: in some cases it results from moral dejection and tedium of life, Avhich may be considered as a form of moral insanity: in another class of instances insane illusion has perverted the under- standing; and, lastly, it is sometimes the result of an immediate and spontaneous impulse, analogous to that which produces the most fearful and appalling cases of homicide. Physical circum- stances, however, give a predisposition to the act in most of these examples. 4. Some other manifestations of morbid propensity are occa- sionally observed, Avhich appear to be, in the nature of that de- viation from the healthy state Avhich they display, analogous to the facts above described. As the recognition of these is impor- * Medical Inquiries and Observations upon Diseases of the Mind. Phila- delphia, 1812. Esquirol, sur 1'Alienation, torn. i. p. 580.—Author. 196 insanity, (Insane Impulse.) tant in a medico-legal point of vieAV, Ave shall briefly describe, or allude to, them. Instances of a propensity to steal Avhich Avas Avholly irresistible, are said to have occurred. " There are persons," says Dr. Rush, " Avho are moral to the highest degree as to certain duties, but who nevertheless lie under the influence of some one vice. In one instance a Avoman \vas exemplary in her obedience to every command of the moral law except one—she could not refrain from stealing. What made this vice more remarkable was, that she was in easy circumstances, and not addicted to extravagance in any thing. Such Avas the propensity to this vice, that Avhen she could lay her hands on nothing more valuable, she would often at the table of a friend fill her pockets secretly with bread. She both confessed and lamented her crime." What is most to our purpose is the fact, that this propensity is proved to be depending on a morbid state of the brain. In the first place it is connected with other indications of insanity; it sometimes folloAVs and sometimes precedes, at other accompanies mania. Pinel says, " It is a matter of common observation, that persons Avho in their lucid intervals are considered models of probity, yet cannot during the paroxysm refrain from stealing and cheating." Fodere re- lates the case of a female servant in his OAvn family, Avho could not help stealing secretly from himself and others articles even of trifling value, though she Avas intelligent, modest, and religious; and was all the Avhile conscious of, and admitted the turpitude of her actions. He placed her in a hospital considering her insane, and after apparent restoration, and a long trial, he again took her into his service. Gradually, in spite of herself, the instinct again mastered her; and, in the midst of an incessant struggle between her vicious propensity on the one hand, and a conscientious horror of her condition on the other, she was suddenly attacked with mania, and died in one of its paroxysms. Injuries of the head, which often occasion mental derangement under other forms, also give rise to this particular symptom, which is occasionally an in- sulated one. Acrel, who is cited by Ray, mentions the case of a young man, Avho, after receiving a severe wound on the temple for Avhich he was trepanned, manifested an invincible propensity to steal, Avhich Avas quite contrary to his ordinary disposition. After committing several larcenies he was imprisoned, and would have been punished according to laAv, had not Acrel de- clared him insane, and attributed his unfortunate propensity to a disorder of the brain. Abnormal erotic propensities have given rise to a series of phe- nomena in human actions Avhich have been considered to belong to the province of the moralist, or the enacter of penal chastise- ment, rather than to that of the medical philosopher. That this opinion has been founded in error we are fully convinced; and Ave doubt not that the time will come, when the very names o. insanity, (Progress and Terminations.) 197 many offences against decorum, now considered as punishable crimes, Avill be erased from the statute-book; and when persons now liable to be sentenced to the pillory or the galloAVS, will be treated as lunatics. It Avould be superfluous to enlarge upon this topic, Avhich belongs to jurisprudence rather than to a practical work like the present. The public are not yet prepared for en- tering upon it without prejudice. Progress and terminations. Insanity, as it is Avell known, is either continued, or intermittent and recurrent. It is the opinion of M. Esquirol, who has devoted his attention perhaps longer and more closely than any other individual living to the phenomena of insanity, that attacks of continued madness have regular stages of progress, which are in general perceptible and distinctly marked; the first is an acute period, Avith concom- itant symptoms of disorder in the physical health, the second one of chronic or presisting madness, exempt, for the most part, from any such symptoms; and the third is the period of decline in the disease, and of approaching recovery. Intermittent or recurrent madness has very various intervals, and these are sometimes regular and at other times irregular. The same season of the year, the same moral or physical causes produce a return of mental derangement of a similar kind and duration as the preceding attack. More frequently the recurrence is at various periods, and the form of madness changes at succes- sive reneAvals of derangement. The returns of disease are some- times announced by headach, want of sleep, loss of appetite, or by voracity, constipation, pains in the bowels; some patients ex- perience vivid dreams, presentiments, excitement of the imagina- tion ; they display excessive loquacity, great bodily restlessness and activity. Madness is complicated with various cerebral disorders, such as paralysis, convulsions, epilepsy, hypochondriasis, and hysteria. Such complications greatly affect the prognosis. M. Esquirol maintains the doctrine of critical terminations of madness, and gives a variety of examples to show, that the disease has ceased speedily on the supervention of other diseases, on sudden sponta- neous evacuations of different kinds. According to the results obtained by the same writer from a comparison of various dates, it appears that the absolute number of complete recoveries in cases of insanity is about one in 3, and varies from one in 4 to one in 2, the difference depending on the circumstances connected Avith various establishments, such as their local situation, the nature of the cases admissible into them respectively, and the treatment to Avhich the patients are subject- ed. In the treatise on insanity before cited, statements have been collected from a considerable number of hospitals for lunatics, proving that many of the returns from establishments in England 17* 198 insanity, (Progress and Terminations.) afford a more favorable result than that Avhich M. Esquirol has obtained in France. Thus, in the Retreat near York it appears, that of 334 cases admitted 168 have terminated in recovery; in the county asylum at Gloucester the proportion of recoveries, Avithout taking into account a considerable number which after- wards took place among those dismissed as relieved and on trial, is here very great, viz. 234 in 516, which approaches nearly to one half of the total number admitted—a circumstance the more striking as no selection is used in the admission, lunatics of all descriptions being reckoned fit objects to receive the benefits re- sulting from this excellent establishment. The prognosis is much less favorable in cases of insanity com^ plicated with other diseases of the brain, and is almost uniformly unfortunate Avhen epilepsy and paralysis coexist with mental de- rangement. The paralysis of the insane is of a peculiar charac- ter. It is in fact a disease distinct in its phenomena from other modifications of paralysis, .which was not knoAvn to medical ob- servers until it Avas described by Esquirol and Calmeil. The first symptoms of this deplorable disease are perceptible in imperfect articulation or muffled speech ; by and bye a tottering vacillating gait announces that it has reached the nerves of the lower ex- tremities ; all locomotive power is afterAvards lost, and the patient perishes within a year or tAvo from the commencement of the paralysed state, after losing successively all the powers of animal life. The period of the disease, is of the greatest importance in regard to prognosis. Out of 2005 cases considered as curable ones in the Salpetriere we are informed by M. Esquirol that 604 were cured in the first year, 497 in the second, 86 in the third, and 41 in the seven succeeding years. Hence it is concluded, that the mean duration of cases of insanity, which terminate in recovery, is short of one year; and that, after the third year, the probability of cure is scarcely more than that of one in 30. However, there is perhaps no period the length of which renders recovery entire- ly hopeless. Pinel and Esquirol have given statements, from Avhich we learn that this event has taken place after the disease has lasted twenty-three or even twenty-five years; and if it can happen after the disease has continued so long, there can be no reason for asserting it to be impossible after any period. Age occasions some difference in the prognosis: from tAventy- five to thirty is the period of life at Avhich the greatest number of recoveries has taken place. From the forty-fifth year to the end of life the probability of recovery gradually diminishes. Sex is also a circumstance to be taken into the account. Ac- cording to the researches of Esquirol, a greater number of females than of males recover. Anatomical characters. As insanity, uncomplicated with insanity, (Anatomical Characters.) 199 other diseases, is not fatal in any great proportion of cases, ma- niacs generally fall victims to complaints remotely, or not at all, connected with mental derangement. Some live to an advanced age, and wear out the vitality of the bodily fabric just like those Avho have retained their reason to the last moments of life. "Maniacs," says M. Esquirol, " do not die in consequence of the cerebral affection which was the immediate cause of insanity. They perish " in typhoid or ataxico-cerebral fevers, phthisis pul- monalis, epilepsiform convulsions, and accidental complaints." Dissection displays the phenomena connected with these adventi- tious disorders, and very many of these phenomena have been mistaken for the causes of insanity. Maniacs who have died ac- cidentally, have furnished no indications of disease. M. Esquirol says, " We had at the Salpetriere a young Avoman, twenty-four years of age, who Avas in a state of recent furious madness, free from all complication of disease: she Avas killed by one of her companions. The pupils Avho assisted at the opening of the body Avere equally surprised Avith myself not to find any lesion ofithe brain, or of the meninges." It happens that the brain and the meninges are without lesion, although patients have lived maniacs for many years. The nature, the extent, and the seat of the le- sions, is not in accordance with the violence and duration of the delirium. When authors have met with lesions of the brain, or of the membranes, they have observed during life an irregularity in the poAvers of motion, paralysis, or convulsions. If Ave were to follow with attention the steps of the disease, we might, by the symptoms Avhich soon become complicated, assign the exact pe- riod at Avhich such lesion begins. On the other hand, hoAV many organic lesions of the brain, or of the meninges, have escaped the most attentive observation ? When a long-continued mania ex- ists, even to the last hours of life, may not a,general weakness dispose to local inflammation ? May not the symptoms of me- ningitis, of sanguineous congestion, of cephalitis, and of encepha- litic lesions, that are observed on the opening of a body, belong, to the epiphenomena Avhich precede death ? Has any one taken the pains to distinguish the phenomena Avhich belong to simple, from those of complicated, insanity ? It is certain that there have been maniacs in Avhom no cerebral lesion has been found. Some insane persons are suddenly cured; others live ten, twenty, or thirty years, notAvithstanding the organic lesion of one of the or- gans most essential to life. Fits of intermitting madness cease spontaneously. To what conclusion do Ave then arrive ? that pa- thological anatomy, notwithstanding the very important works of MM. Foville, Calmeil, Bayle, and Guislain, has not yet made us acquainted Avith the organic cause of madness. Thirty years ago I Avould willingly have written upon the pathological cause of insanity; I Avould not now attempt so difficult a task, there is still so much uncertainty and contradiction in the results of the exa- 200 insanity, (Anatomical Characters.) mination of the bodies of mad persons: but recent researches lead me to hope that more positive, clear, and satisfactory notions may be obtained." Necroscopical researches into the causes of insanity began with Bonetus and Morgagni. Late writers have accumulated a vast mass of observations on this subject, the principal heads of Avhich Avill be found in the Treatise on Insanity : their researches have been principally directed to the brain and its coverings. M. Es- quirol hoAvever found, at the Salpetriere, that secondary organic lesions of the thoracic and abdominal viscera Avere the most fre- quent phenomena discoverable after death. Of 176 females Avho died of melancholia, the phenomena of pulmonary phthisis Avere found in the bodies of 62, organic lesions of the heart in 16, the results of chronic inflammation in the abdomen in 32. Only six appeared to have died from disease of the brain, namely, under the symptoms and with the lesions of the encephalon proper to apoplexy. (Op. cit., torn, i, p. 443.) The same writer informs us, on the other hand, that the results of examinations at Charen- ton afforded a very different result. Morbid changes of the brain and its coverings Avere in that hospital more frequent than those of the thoracic and abdominal viscera. He attributes the differ- ence in these observations to the fact, that at Charenton the pa- tients are all males, Avho are much more subject to general para- lysis (paralysie des aliinis) than females. Here the disorder of madness was complicated with an additional disease, Avhich had its seat and left its vestiges in the encephalon. M. Georget has summed up the morbid changes Avhich he con- sidered as authentically connected with madness, and his recapit- ulation may be looked upon as a tolerably complete statement of the result of anatomical researches into this subject up to the time Avhen his Avork on insanity, and the article contributed by him to the Dictionnaire de Medecine, Avere published. The folioAving are the principal points:—" Irregular conformation of the cranium, the prominences of which are developed irregularly, those of the right side being generally larger than those of the left; some skulls having the lateral diameter of equal extent with the antero-poste- rior, and the cavities of the base irregular in extent; some skulls (one in twenty) thickened partially or generally, more frequently the bones hard, Avhite Avithout diploe, resembling ivory; some very light. Dura mater rarely changed; sometimes adherent to the skull, thickened, containing deposits of bone. Arachnoid dis- playing in places additional laminae of a red or gray color; some- times thickened, but smooth. Pia mater injected or thickened, and infiltrated with serum, giving at first the appearance of gela- tinous deposit. Volume of the brain sometimes less than the ca- vity of the cranium seems to require. Some brains very hard, cut Avith difficulty, the Avhite substance glutinous, elastic, and suf- fering distension; more frequently the brain is soft, the gray mat- insanity, (Anatomical Characters.) 201 ter being pale and yellowish, and the white substance discolored, of a dirty Avhite, the color and consistence of these portions al- most confounded. The convolutions separated by serosity, and the pia mater thickened. Interior caArities of the brain appearing in some instances very large, in others small, often filled with a serous fluid, remarkably clear and limpid; plexus choroides exsan- gueous, containing hydatiform vesicles. Partial softenings of the brain, erosions, ulcerations of the surface of the ventricles. Cere- bellum generally softer than the cerebrum, sometimes partially softened. Mesocephalon, medulla oblongata, and medulla spi- nalis, rarely displaying morbid changes of structure." Considerable additions have been made to the morbid anatomy of the brain in cases of insanity since the time of M. Georget. These researches have been conducted chiefly by MM. Bayle, Calmeil, Lallemand, Foville, and Bouillaud. The two former have principally directed their attention to the history of general paralysis; and the pathological details given by them have refe- rence to this disease, Avhich may be termed an adventitious one; but Avhich is so frequently connected Avith insanity, that its super- vention cannot be looked upon as a matter of mere contingency. M. Calmeil's observations resolve themselves into the general conclusion, that unequivocal signs of chronic inflammation of the brain exist in almost every case of this disease complicated Avith insanity. Some of the morbid appearances Avhich M. Calmeil considered as proper to the disease, which he terms paralysie des aliinis, are connected by M. Foville with insanity, and are regarded by that Avriter as ultimate results of that disease in its protracted stage, when the brain having long been disordered in function, and es- pecially in the state of the vascular apparatus, passes into a de- gree of disorganisation, no longer compatible with the continued preservation of even physical life. The changes Avhich the differ- ent parts of the encephalon undergo, according to M. Foville, re- solve themselves into the signs of recent inflammatory action in acute cases, and the well-known results of long-continued inflam- mation in chronic and inveterate examples of the same disease. He has noted in the former the chief morbid signs in the gray substance of the brain: such are a red color, uniform, and very intense; numerous mottled spots, varying from a bright to a violet red, bloody points; minute extravasations of blood; diminished consistence in the thickness of the cortical substance, coincident Avith a slight increase of consistence in its surface; dilatation of the vessels, and resistance of their parietes. In acute cases M. Foville has never observed adhesions of the membranes to the cortical substance. Such adhesions are very frequent in chronic cases; and hence, as he conjectures, may be explained the curable nature of recent maniacal affections, and the hopeless and incu- 202 insanitv, (Anatomical Characters.) rable state of those patients who have long labored under in- sanity. The chronic changes of the cortical substance are, increased firmness and density of the superficial part, extending to no great depth, but uniform, and constituting a distinct lamina or layer of hardened consistence, Avhich, torn off, leaves a red, soft, mam- millated bed of softened cortical substance beneath. The volume of the convolutions remains natural, or is less than natural, owing to a real atrophy, or to the existence of lacunae, Avhich are the results of a minute extravasation. This morbid change often extends to three or four convolutions on each side of the sagittal suture, a chasm filled with serosity, often occupying the place of the absorbed cerebral substance. Coexistent Avith this state of the encephalon is that species of atrophy of the cranium in Avhich the diploe disappears, leaving a superficial depression on the head. Another morbid state of the cortical substance is that of an uniform and red ramollissement, Avhich is a change very dis- tinguishable from that above described. ■The changes of the Avhite substance, principally its preter- natural hardness and unusual whiteness, resolve themselves, in M. Foville's opinion, into adhesions between the cerebral fibres and the deposition of additional matter, the results of chronic in- flammation. It is Avell known to those Avho have studied the works of late anatomists on the structure of the brain, that M. Foville has attempted to demonstrate in the organisation of the cerebral mass the existence of distinct planes of medullary sub- stance, superimposed one upon another, and connected in the healthy state by means of a very fine cellular tissue. These planes, thus easily separable in the healthy state, become closely adherent in long continued cases of madness. M. Foville repeats the observation made by many Avriters, that the brains of lunatics are so full of serous fluids, that an abun- dant serosity Aoavs from the surface of incisions. He likewise observes the presence of small serous cavities, from the size of a millet-seed to that of a nut. This Avas first noted by M. Esquirol. It is the appearance Avhich the late Dr. Sims has more recently described as the spontaneous cure of ramollissement. The sec- tion of a brain thus perforated is compared to that of a porous cheese. By M. Foville these cavities are supposed to be the relics of extravasation. Perhaps the opinion of Dr. Sims will be allowed to be the most probable, that they are the results of soft- enings of the brain. It must be carefully noted, that these changes in the Avhite substance do not belong to insanity, separately existing and un- complicated with paralysis. In persons affected Avith the para- lysie des alienis, they are almost universal. They are likewise found in the brains of old men, Avhose voluntary movements insanity, (Diagnosis.) 203 have become uncertain and vacillating, but more in lunatics Avhose muscular poAvers had remained unimpaired. The changes in the membranes observed by M. Foville may be referred, in like manner, to the various results of meningitis: they are thickenings and adhesions of the dura mater, injections of the pia mater, and opacity and increased density of the arachnoid. The pathological results deduced from these observations are, that morbid changes in the cortical substance are directly con- nected Avith intellectual derangement, and those of the Avhite substance Avith disorders of the motive powers. These opinions coincide generally Avith those of the most accurate morbid anato- mists of recent times. It must be observed, that all such changes in the brain and the membranes resolve themselves into the well known results of inflammation and increased vascular action. Diseases in the thorax are often traced in cases of mental de- rangement. Hypertrophy of the heart is a phenomenon of fre- quent occurrence. M. Georget declares, that in more than three fourths of the bodies of insane persons examined by him there had existed organic disease of the lungs, such as chronic pneu- monia, or phthisical degenerations. He says, that phthisis is the cause of death in more than half of the maniacs who die in the Salpetriere. Cavernous excavations are found in the lungs of numerous patients, who, during life (unless the fact has been ascertained by auscultation,) are never known to labor under pulmonary disease. Of abdominal diseases in insane persons the most frequent is gastro-enteritic inflammation. This has been discovered in a considerable proportion of bodies of persons affected with mental derangement. One of the most remarkable changes in the necroscopy of in- sane persons is displacement of the transverse colon. This was observed by M. Esquirol in 33 out of 168 cases of melancholia. The change consisted in an altered position of the intestine, which instead of traversing the abdomen, was turned into a perpen- dicular direction, and precipitated behind the pubes. A similar phenomenon has been noticed by Bergmann, Nasse and Guislain. Organic diseases of the liver are of very rare occurrence in connection Avith insanity. Diagnosis. It is well known that the diagnosis of insanity is often surrounded Avith difficulties. Some of them are important Avith respect to medical jurisprudence; others in a practical point of vieAV. The question whether insanity exists or not, Avill turn on different considerations, or Ave must apply our attention to different Avays of solving it in the several forms of the disease. Monomania is the most clearly defined of all the forms of insanity, and the only source of perplexity that occurs, Avhen an attempt to ascertain its presence depends on the difficulty of 204 insanity, (Diagnosis.) discovering the actual state of mind of the person supposed to be affected. Monomaniacs generally betray their illusion when questioned in relation to it, or Avhen the subject is mentioned with Avhich it is connected; but there are some Avho have artifice enough to conceal their morbid impressions, and will evade any question made to them Avith a view to the discovery, or Avill even deny what they at the same time believe. This is the fact, especially Avhen they have been repeatedly examined on the points in question, when their replies have led to the continuance of confinement from Avhich they are desirous of being set free. It is on this ground sometimes almost impossible to convince a jury of the real state of a lunatic; and the physician can only convince himself by the testimony of others in Avhose presence the patient has been less guarded, and by such confirmatory cir- cumstances as repeated opportunities of observing the party may enable him to ascertain. It Avill afford much help in these inquiries to be aware of the fact that persons Avho labor under illusion are, for the most part, eccentric in their conduct in general, and are morally insane; and that the supervention of some illusory opinion on a previously existent derangement of the habits and moral feelings is the general character of monomania. The existence of moral insanity is more difficult to determine. The various considerations which must be taken into the account by those Avho are called upon to decide as to the existence of this form of mental derangement, are summed up in the description of that disease; and Ave can add nothing to Avhat is there said, except the remark, that it is unnecessary in legal investigations to go accurately into the question on the negative side. It must be proved before any proceedings against an alleged lunatic can be taken, and before he can be declared of unsound mind, not merely that he labors under a degree of moral insanity, but that his state is individually such as to render him incapable of man- aging his affairs, and unfit to be entrusted even Avith the care of his own personal security. The diagnosis of instinctive madness, or of insane impulse from crime, the object of moral punishment, is a most difficult and at the same time an important investigation. In the Treatise on Insanity the grounds on which a decision on this question must in particular cases principally depend are stated, and to that Avork we must refer for more ample details. The diagnosis of mania, or of raving madness and delirium, is the only point which remains to be considered. Mania may be distinguished in general from the delirium of fever by the absence of that typhoid state Avhich accompanies the latter affection. We have seen several patients laboring under febrile delirium Avho Avere supposed to be maniacal, through in- attention to this simple rule of diagnosis. There are, however, insanity, (Causes.) 205 some instances of very acute raving mania, in which from the violent and long-continued agitation, symptoms supervene Avhich resemble those of fever. The history of the case Avill generally be sufficient to remove doubt on this subject. Mania, on its first attack, may easily be recognised. The state of the cerebral func- tions is likeAvise different. The perceptive faculty is seldom so much impaired in mania as in febrile delirium. Maniacs see, hear, and perceive correctly, although they talk incoherently; their senses are not obtended or obscured as are those of a patient in febrile delirium; they have not the tremulous agitation and muscular Aveakness Avhich generally exist in the latter disorder. There are instances, however, in Avhich perception and the mus- cular powers are unimpaired in delirium, or in Avhich the patient makes at least powerful efforts, and perceives the objects Avhich surround him. A patient in the Bristol Infirmary once jumped suddenly from his bed, being alarmed by a clap of thunder, and sprang up Avith astonishing strength and agility over the bed- steads in the ward to a AvindoAV nearly eighteen feet from the ground, from Avhich he made his exit before any body could lay hold of him. He held himself up on the outside of the building by the sill of the windoAV, and was taken doAvn from a great height. He afterAvards recovered from his fever, and shoAved not the slightest symptom of mania. Patients in fever often rave in a way Avhich indicates that they are under illusion as to the places where they are, and mistake the persons who surround them. An apprehension is often entertained by their relatives that they are maniacal; but the history of the case, and an attention to the pre- ceding remarks on the different states of the sensorium in mania and in delirium, will generally suffice for an easy and satisfactory discrimination. The diagnosis of mania and delirium tremens is important, and sometimes more difficult than that of madness and febrile delirium. The history of the case must be taken into consideration; but the same habits of drunkenness leading to both diseases, this is not always sufficient. The state of the sensorium is the chief ground of discrimination. Patients in delirium tremens have seldom or never clear and accurate perceptions; their organs of sense are affected by the disease; they fancy themselves to be surrounded by fiends or spectres, or gnaAved by rats; their muscular power is greatly impaired; they are vveak and tremulous, Avhile even in the most violent paroxysm or mania the person affected sees and hears distinctly, and is strong and active in his limbs. Causes. It is usual to divide the causes of insanity, as of other diseases, into predisposing and exciting. 1. The most important of the predisposing causes is a certain constitutional state, either derived from ancestry, or originating in the organisation of individuals, Avhich renders persons in whom 18 206 insanity, (Causes.) it exists liable to be affected by mental derangement Avhen sub- jected to particular moral or physical agencies. Without such predisposition, or natural liability, the same external causes Avill not give rise to the like effect. When it exists in a very intense degree, the operation of slight causes is sufficient to bring about the result. This condition of body is in general not to be dis- covered by any external indications; it is not known to exist until the morbid process has actually taken place, or at least not till it has commenced. In the reports of hospitals for the insane in France, the cases which are attributed to hereditary predisposition bear a consider- able proportion to the entire number of admissions. In a report drawn up M. Esquirol of admissions into the Salpetriere, in 361 the disease was traced to various physical causes; in 105 it was ascribed to hereditary predisposition. In M. Esquirol's private establishment, where only the better class of patients are received, the last mentioned class amounts to 150, Avhile all other moral causes are stated at 120. In a similar report from the Maison Royal de Charenton, in 256 the disease was produced by physi- cal causes, of which 93 come under the head of hereditary pre- disposition; and, in 150, by moral causes. This may suffice for the present to furnish some idea of the proportional numbers, but it cannot be considered that the extent of this physical influence has been ascertained. The information obtained at the admis- sion of patients from the lower orders of society is often imperfect, and it is probably to be ascribed to this circumstance, that the proportion of hereditary cases is so much greater in the return from Esquirol's private establishment than it is at the Salpetriere, or even at Charenton. Age and sex are to be mentioned among the predisposing con- ditions of insanity, or of other constitutional disorders. With re- spect to age, it appears from some of the dates collected by M. Esquirol, 1st, That the maximum of admissions, the cases being classed according to ages, is from thirty to thirty-five years of age; 2d, That the number in the three preceding periods of five years remain stationary. Between the ages of fifty and fifty-five years the number of admissions is less considerable. After fifty-five years the admissions decrease rapidly in both sexes, although the females are rather more numerous. These results are correct with respect to the absolute number of admissions, but on comparing the admissions Avith the general population of each age, we acquire the knoAvledge that, as age advances, the brain is deteriorated, and the intellectual faculties are weakened or extinguished. To make a strict deduction of the absolute number of lunatics relatively to their ages, it is not enough to state numerically the admissions betAveen thirty and forty years of age; it is necessary to search out and to know the number of lunatics compared with that of the population in each age. insanity, (Causes.) 207 For this reason Ave have stated the ages of 12,869 lunatics, observed at Bicetre, at Salpetriere, and at Charenton; we have classed these 12,869 individuals according to their ages, and Ave have reduced them to a geometrical scale, thus displaying at one view the number of lunatics in each age. This same proceeding has been followed Avith regard to ten millions of individuals from the general population, classed according to their age, in order to show the proportionable numbers proper to each epoch of life. The Annuaire du Bureau des Longitudes has served for the basis of this Avork, which has been effected by Dr. Leuret. The absolute population diminishes according to the ages of men: this diminution is gradual, and operates in the proportion very nearly of twenty to thirty-five years; it is greater from thirty-five to forty-five; more decided from forty-five to sixty; very rapid after sixty or sixty-five. From this epoch until the last stages of disease, this diminution operates regularly, and almost in a geometrical progression. The frequency of madness compared with the ages of men does not ahvays follow the same law as the general population, it offers very singular anomalies, although it goes on increasing. Thus as a man advances in years he is more exposed to the causes which excite insanity, but Avith different chances, relatively to age. There are a smaller number of insane persons from twenty to thirty years of age, compared with the population of that epoch of life; there are more from thirty to forty years, although the population is diminished; and, nevertheless, the number of madmen is less, compared with the population in the folloAving ages; from forty to forty-five years the population is diminished, and the relative number of lunatics increases in pro- portion to this very diminution; it is the same from forty-five to fifty years. The relative increase in the number of lunatics is more marked still from fifty to fifty-five years; from seventy to seventy-five, and from seventy-five to eighty the number of luna- tics, compared with the population, is enormous. This is the age of senile dementia. Thus although it is numerically, and in a manner absolutely, true, that there are a greater number of lunatics from the ages of thirty to forty years than before or after this period of life, we shall be deceived if Ave draw the conclusion, that it is the age in Avhich men are most prone to insanity, since relatively to the general population there are feAver persons insane from tAventy to thirty years of age than after that period. The same Avriter has computed the relative frequency of mad- ness with regard to the sexes. It seems from his computation, that in 76,000 persons affected with insanity, the proportion of males to females Avas nearly as thirty-seven to thirty-eight, and this Araries in different countries and under different circumstances. 20S insanity, (Causes.) The proportion varies but little from that of the tAvo sexes in the general population. 2. In the reports obtained from different quarters, relative to the exciting causes of insanity, there is infinite variety. So much is left to the private judgment of persons Avho make the entries in different hospitals, that the statements are likely to be affected by various prejudices, or preconceived opinions. We have been assured by M. Guerry, Avhose extensive researches in statistics are universally knoAvn, that he could obtain no satisfac- tory information on the relative frequency of insanity produced by physical and moral causes. In some countries the reports at- tributed by far the greatest proportion of cases to physical, and in others to moral causes, Avithout any difference of circumstances that can account for such a variety in the statements. The French Avriters, to whom Ave are indebted for so many important addi- tions to the information previously obtained Avith regard to the nature and causes of insanity in its different modifications, attri- bute by far the greatest influence to moral causes. In a memoir presented by M. Esquirol to the Society of Medicine (now the Royal Academy), in 1818, it Avas stated that cases of madness occasioned by moral causes are, to those resulting from physical causes, in the proportion of four to one. The calculations of M. Pinel amounted nearly to the same conclusion. According to M. Georget, it was an observation almost proverbial in the Sal- petriere, " qu'on perd la tete par les revolutions de l'esprit." He says, " the first question that M. Pinel puts to a new patient who still preserves some remains of intelligence is,' Have you under- gone any vexation or disappointment?' ■ Seldom is the reply in the negative." " It is," continues the same writer, " in the age in which the mind is most susceptible of strong feelings, in which the passions are excited by the strongest interests, that madness is principally displayed. Children, calm and Avithout anxiety, incapable of long and extensive combinations of thought, not yet initiated into the troubles of life, and old men, Avhom the now vanishing illusions of their preceding age and their increasing physical and moral Aveakness render indifferent as to events, are but rarely affected. The same remark applies to persons Avho, in their constitution, approach to the character of children or of old men." Among moral causes by far the most influential, as it appears from these reports, are reverses of fortune, misery (meaning poverty), and domestic griefs or cares; next to these are disap- pointments in love; then " devotion exaltee." It must be remem- bered that these reports relate to the lunatic hospitals in a catholic country.* * In the Treatise on Insanity the reader will find a collection of facts in- tended to illustrate the nature of what is termed " Religious Insanity," and insanity, (Treatment.) 209 Among physical causes, or those so termed, vicious indulgences are by far the most frequent and poAverful in their influence. Drunkenness (especially dram-drinking) is, among the loAver orders, the cause of madness in a great proportion of cases. Li- bertinism and immoral habits come next in order; and it would appear that the derangement produced by these causes and espe- cially that occasioned by masturbation, is of a severe form, and more apt to degenerate speedily into dementia than those occa- sioned by any other causes whatever. Blows on the head, sup- pression of evacuations or of eruptive disorders, insolation, and other accidental complaints affecting the. brain and tending to in- duce inflammation of that organ, are causes of inferior moment in respect to the proportional number of cases produced by them. The collective number of such cases is hoAvever considerable. Treatment. The treatment of insanity has generally been divided into the remedial and moral:— 1. Remedial treatment. Insanity is a disease of the brain, or the result of a state of that organ Avhich is different from its usual condition. To remove this condition, or to change it into the healthy state, is the first suggestion that occurs to the mind of the physician who is called to treat a case of madness. Two pre- liminary inquiries immediately present themselves. The first is, in what the diseased state of the brain consists, and what is the precise deviation from the healthy condition that has taken place? the second is, can that morbid change be reversed, or is is to be obviated by remedial means? On the first of these questions pathological anatomy has thrown some light, though it has not fully solved the problem. There seems on the whole to be abundant proof, that the state of the brain in madness is one closely allied to inflammation, and per- haps Ave may venture to say, certainly constituting inflammation in some parts of the encephalon, and principally in the cortical or cineritious substance of the brain. In cases of general paralysis it is manifest, from the researches of Calmeil and Foville, that inflammation of the Avhite substance is superadded. The general inference, as to the inflammatory nature of the cerebral disease subsisting in madness, is confirmed by pathological observations on the physical causes which often give rise to insanity, such as the use of ardent spirits, exposure to heat, injuries of the head, metastasis of cutaneous diseases, suppression of habitual evacua- tions. That excessive intellectual exertion or agitation of the feelings should give rise to the same result is in strict accordance its relative frequency in different countries, catholic and protestant. The other moral causes belong to the influence of different passions; but the sum total of cases produced by the latter bears a very small proportion to those which are classed under the heads above mentioned.—Author. IS* 210 insanity, (Treatment.) with this pathological conclusion; since excessive action in any or°un is, under ordinary circumstances, folio Aved by inflammatory disease. From these considerations Ave are led to infer, that the state of the brain in madness is nearly allied to that Avhich con- stitutes inflammation. That this is a condition often within reach of remedies is well known. The important question is, Avhether experience sanctions the use of ordinary antiphlogistic measures in cases of insanity. We shall begin with considering the propriety of bleeding as a remedy for madness. The testimony of practical authors is so contradictory on the question, that it is quite impossible to reconcile them. We shall be very brief in adverting to the controversy. M. Foville is one of the most strenuous advocates of the pro- priety of copious bleeding as a remedy for insanity; he recom- mends it not only for the pathological considerations above ad- verted to, but also on practical grounds. M. Foville Avas for some years physician to a very large lunatic hospital, that of St. Yon, in the department of the LoAver Seine, and consequently has had extensive opportunities of forming a practical opinion. Dr. Rush and Dr. Haslam, both of great authority as practical writers, and likely to form a correct judgment as to facts submit- ted to their observation, and who had both very extensive expe- rience in hospitals devoted to the care of the insane, are decided in recommending the abstraction of blood as the principal remedy in madness. Dr. Haslam says, that bleeding is the most benefi- cial remedy that has been employed in this disease, and that it is equally so in melancholic as in maniacal cases. The quantity of blood to be taken must, as he says, depend on circumstances. He recommends that it be taken from the head by cupping: eight to ten ounces may be draAvn at first, and the operation repeated as circumstances may require; this hoAvever is rather indefinite. He adds, that Avhen a stupid state has succeeded to one of high ex- citement, bleeding is contra-indicated. Dr. Rush recommends much larger bleedings than those advised by Dr. Haslam. He speaks of having taken 200 ounces in less than tAvo months, and begins by taking from twenty to forty ounces from a patient stand- ing erect, in order to produce syncope. In opposition to these Ave must state the opinion of the cele- brated French Avriters, Pinel and Esquirol, who condemn the prac- tice of bleeding entirely, and declare it to be their opinion founded on their experience, which has been very extensive, that bleeding is not only useless in cases of insanity, but most pernicious, and tends to bring on a state of hopeless dementia. In the Gloucester County Lunatic Asylum, under the care of Dr. Shute and Mr. Hitch, where, as we have seen, a highly fa- vorable result is obtained in the average number of recoveries, and the practice of which hospital may be cited as eminently sue- insanity, (Treatment.) 211 cessful, bleeding is never performed. Cases in Avhich a state of high excitement would induce many practitioners to prescribe copious bleedings, are treated Avith stimulants and a full diet. The result is favorable: there are, as we have seen, very numerous re- coveries; and, what is remarkable, sudden attacks of apoplexy, paralysis, or other affections depending on vascular repletion, such as many persons Avould auspicate from the practice here pursued, have not been known to occur. From what has been said it Avill be apparent, that we are not to regard bleeding as a general and indispensable remedy in the treatment of insanity, or to expect from it those decided and un- questionable benefits Avhich arise from the adoption of the same measure in cases of inflammation of the joints or thoracic and ab- dominal viscera. It must be remembered, that the cases admitted into asylums are often not very recent: in many instances they have been beforehand subjected to depletion. We therefore can- not consider the negative evidence resulting from the practice of the Gloucester Lunatic Asylum, or from that which has been adopted in hospitals under the care of M. Esquirol, as fully con- clusive against the use of the lancet in cases of recent mania. It must in particular instances be left to the judgment of an expe- rienced and skilful practitioner, to discriminate the cases which require bleeding from those in Avhich that remedy is inadmissible. A general rule, hoAvever desirable, is not to be obtained; but some suggestion may be useful as to the particular phenomena Avhich furnish an indication. As contra-indications to the employment of evacuant remedies, but especially bloodletting in insanity, the folloAving considerations deserve attention:—weakness and irritability with feeble poAvers —symptoms approximating to delirium tremens—frequent com- pressible pulse with throbbings, without strength of the carotids, and feeble circulation in the extremities—clammy cold skin, espe- cially of the hands and feet—profuse though Avarm perspirations —tremulous tongue or voice—tremor of the limbs. Such symp- toms accompanying mania should make the practitioner cautious in employing depletive measures, though they do not always pre- clude the topical abstraction of blood. In puerperal mania blood- letting is rarely admissible. The beneficial effects derivable from the abstraction of blood may be promoted in cases which allow of its adoption; and in cases Avhich preclude the use of this measure, the same purpose may be in some degree attained by the aid of other means partly general, and in part locally applied. Of the first class are antiphlogistic medicines, or those which produce relaxation of the vascular action, as Cullen would have said, of vascular tension. When a full hard pulse, hot and dry skin, coexist Avith maniacal excitement, no class of remedies is more indicated than nauseative medicines. Many recommend 212 insanity, (Treatment.) the infusion of digitalis. We have generally found that tartarised antimony Avill ansAver all the purposes for which digitalis has been adopted, and that it is more speedy in the effect, and much more manageable, if such a term be alloAved. Tavo or three grains of tartarised antimony given every three hours, Avith the addition of a small quantity of opium, in order to prevent its speedy rejec- tion by the stomach, Avill in many cases bring about in a short time a general relaxation, free perspiration, a soft pulse, and a cooler skin. If constipation has existed, purgatives should be given at the same time, such as scammony and calomel. The stomach often rejects the dose, but not till it has remained a suffi- cient time to excite the action of the bowels. Shaving the head and keeping it covered with an ice cap, and the application of cold Avater and the various means of refrigera- tion, have an important effect. The most efficacious Avay of ap- plying cold to the head is that practised by M. Foville, of directing a stream of cold water through a flexible pipe directly on the head. The most violent and refractory patients are easily quieted by this method. When frequently repeated and folloAved by the conti- nued application of cold lotions, Avhile the feet are kept warm, it is an useful auxiliary to the means of reducing inflammation of the brain or its membranes. Counter-irritation is in some instances of great value. Setons and issues have been tried in numberless instances. General ex- perience condemns their use in mania. They occasion much irri- tation and no benefit. Blisters are more successful, as the irritation is of short duration, and the discharge is of service. If there is no unusual heat upon the scalp, it is better to apply them over the vertex, or to cover at first the anterior and afterAvards the poste- rior half of the head by a blister, Avhich is to be speedily removed after the skin has become inflamed. This remedy is strongly indi- cated in cases attended Avith stupor. Stupor amounting to de- mentia, and constituting one modification of that state, has been most successfully treated by an issue formed in the scalp over the sagittal sutures. A most important resource for tranquillising the system, and bringing back the healthy condition of the brain, is the use of opium. There are few disorders in which so much benefit is de- rived from this remedy as'in cases of insanity. While the skin is hot and dry, and the pulse full and hard, it is injurious; but Avhen relaxation has been induced by the means above suggested, opium may be safely given. Sometimes a large dose^s two or three grains given at once, Avill answer the end of procuring sound and refreshing sleep. A better method in general is to prescribe ten grains of Dover's powder, with or without tartar emetic, every third or fourth hour until sleep is induced. After sound sleep thus induced it is often found that the disease is almost cured. The attempt to cure madness by restoring through the imme- insanity, (Treatment.) 213 diate agency of remedies the healthy condition of the diseased organ, viz. the brain, has its application chiefly to the early stages, and to the more acute cases of insanity, and especially of mania. In cases of sloAver development or of a chronic form, and in the advanced stages of the most acute attacks, the means above de- scribed can only be adopted on a more limited scale, which Avill require discretion and practical judgment. In later periods of insanity, and in the more chronic cases, the principal indications are to support and promote the physical health of the patient, and at the same time to mitigate the disor- der which affects the mental powers. As we have seen that death is occasioned by diseases affecting the organs of physical life, our attention must be directed, and it often may be directed effectually, to the prevention or removal of them. The restoration of phy- sical health very often produces relief and even cure of the disor- der of the mind. The latter is so associated Avith the former, that this gives way after the restoration of bodily health. It is Avell- known to every person Avho has had the care of lunatics, that Avhen patients are brought to them, as they often are, from their private dAvellings, or from madhouses, where they have been suf- fered to fall through neglect into a state of squalid cachexia, and are fed Avith wholesome and nutritious diet, and the casual com- plaints Avhich may have befallen them, Avhether affecting the ab- dominal or thoracic viscera, are relieved or cured by judicious means, the mental disorder often gives Avay at the same time. Care must be taken to restore the general health, to ascertain and remove any morbid affections of the digestive organs, the func- tions of Avhich must be regulated by appropriate remedies. The subcutaneous circulation must be promoted by warm bathing, friction, Avarm clothing, a warm atmosphere, and such bodily ex- ercise as the state of the patient admits. Exercise in the fresh air, a nourishing diet, consisting of animal and farinaceous food, malt liquors and some wine, and occasionally the use of vegetable tonics and bitter astringents with carbonates of potass and ammo- nia, are to be prescribed according to the particular indications of circumstances. In females the catamenia should be restored when deficient, if that can be done by remedies. At the same time the condition of the mind Avill require parti- cular care, and this brings us to the subject of the moral treatment of insanity. 2. Moral treatment. The moral treatment of the insane de- pends on the principle of removing from their presence all objects Avhich are calculated to excite and foster their morbid feelings, and to surround them with circumstances of which the tendency is to withdraAV their attention from such feelings and ideas, and induce a return to natural and healthy habits of mind. It is Avith a vieAV to this mdication in part that medical writers recommend 214 insanity, (Treatment.) the removal of insane persons from their homes and from society, and, what is by long custom generally connected with such a proceeding, the shutting them up in asylums kept for the recep- tion of lunatics. The propriety of secluding insane persons in such hospitals requires to be treated both as a medical and as a legal or medico- legal question. Legislators have provided for the arrest of insane persons who disturb or endanger the public tranquility; they have ordained the confinement of such individuals in receptacles Avhich are appropriated to their detention, and have enacted a suspen- sion of the rights which those Avho are sane possess, and can alone with propriety exercise in disposing of persons and property ac- cording to their inclinations. Of all these arrangements the main- tenance of public order is the principal object, and the second is the preservation of the property belonging to the lunatic and the interest of his family. It belongs to medical jurisprudence to determine under Avhat circumstances such proceedings are re- quired for the objects above mentioned: the inquiry comprehends what are termed medico-legal discussions. Our present engage- ment is Avith a consideration strictly medical, viz: under what conditions and in Avhat manner confinement or seclusion is re- quired in order to promote the recovery of insane persons ? M. Esquirol has long devoted his attention to this subject, and in his various writings, published from time to time, has recapi- tulated the arguments on which he has founded the opinions first expressed by him more than twenty years ago. In his last work, in Avhich he has embodied the results of his long and extensive experience, the same question has been more fully investigated. As it is one with regard to Avhich it is of consequence to have the authority of so great a Avriter, in order to determine fully the conviction of medical students and practitioners, and give them that confidence Avhich is sometimes necessary in order that they may be qualified to contend with particular prejudices, and even with public opinion, Ave beg to refer to M. Esquirol's Avork. It must be observed, that all ^hese arguments for the seclusion of the insane are of partial application, though they are by no means equally applicable to all the forms and modifications of insanity. Maniacs who require to be confined in their beds and treated as delirious persons during the acute stage of their dis- order, cannot be removed from their houses, or would derive no benefit from such removal. In the advanced period, seclusion, and even some coercion, is absolutely requisite for insane persons of this class. All the reasons urged in favor of separation apply to monomaniacs and those who labor under moral insanity, and it is particularly in these instances of the disease that confinement in asylums becomes necessary. With regard to melancholia it may happen occasionally that removal from home aggravates the dejection and sorrow with which the mind is already over- insanity, (Treatment.) 215 Avhelmed: the result is generally othenvise, great benefit arising in many cases of melancholia from placing the patient in an asy- lum Avhere there is a judicious selection and classification of the inmates. The company of eccentric but cheerful persons tends powerfully to abstract them from the subject of their gloomy thoughts, and excite reflection on the fallacious nature of their own morbid impressions. If there is any propensity to self-de- struction, or if the degree of melancholy dejection is so great as to point out the danger and probability of such attempts, it is the more obviously and imperatively necessary to have recourse to confinement, no degree of vigilance that can be exercised in pri- vate dwellings will suffice for security against such calamities. We have knoAvn several lunatics who, contrary to the advice repeatedly given, Avere kept at home or in private lodgings, under the care of keepers procured from lunatic asylums, and Avho con- trived to elude the most vigilant watching and destroy themselves. When the patient is misanthropic and malicious, he Avill find some means of gratifying his revenge if not confined and kept from the opportunities of committing injury; and this can only be obtained safely in an asylum. A considerable proportion of the inmates of most lunatic asy- lums are demented persons, or those who have become incoherent and fatuous. Such persons are very nearly in the condition of old men in the state commonly termed second childhood. There is nothing in the nature of their disease which renders confine- ment necessary or advisable on their OAvn account, and it is only Avith regard to convenience that it can be recommended. Many retain only a merely physical existence, and to them it can be of little consequence, provided that their bodily comfort is cared for, whether they live at home or in a madhouse; but there are others Avho have at times glimpses of reason and momentary returns to a natural state of their feelings. There are many considerations which ought to induce families to keep such individuals at home and take care of them in their own dwellings, but they are gene- rally reckoned among madmen: the change in their state from insanity to dementia is unknown to their relatives, Avho are too ignorant to comprehend the nature of such an alteration in the disorder, and they remain for life and die in lunatic asylums. It must be observed, that in well-regulated houses of this description, many of the inmates, though in the state just alluded to, are, on the Avhole, more comfortable than they Avould be under the care of their own relatives; and this remark includes nearly all who belong to the loAver or poorer classes. It is the opinion of M. Esquirol, that patients Avho become convalescent are often?removed too soon from lunatic asylums, and that this is especially the case in England. So strong a pre- disposition to the disease appears to remain for some time after its apparent cure, that convalescent patients are known to under- 216 ' insanity, (Treatment.) go relapses, Avhen excited by such emotions as they are almost sure to experience as soon as they are at large, and can only be protected from by seclusion continued as long as this extreme susceptibility remains. M. Pinel has given some important re- marks upon this subject, Avhich we shall briefly abstract, lie observes that any sudden alarm, transport of anger or of grief; that intemperance, hot Aveather, or even a sudden change from a state of confinement and constraint to liberty, is liable to produce in convalescent lunatics a disturbance of which they Avould not be susceptible in other circumstances, and to reneAV the attacks of mania Avhen the habit has not been long suspended; that some convalescent patients who have been taken aAvay too soon by their friends have suffered relapses, and have been v obliged to return several times to the hospitals. Every available method should be adopted for Avithdrawing the attention of insane persons from their morbid impressions. Exer- cise by Avalking or riding in the open air, during as great a portion of the day as the strength of individuals will support the fatigue resulting from it, is often of great service. We have known in- stances in Avhich both insane persons and hypochondriacs have been greatly improved by adopting this rule, and systematically adhering to it. Long Avalks in fields or Avoods, in company Avith a suitable guardian, have aided principally in the restoration of health in some instances in Avhich the relatives of patients have refused to send them to a lunatic asylum. All establishments of this description ought to be provided Avith the means of affording regular employment, in the open air, to such patients as can be induced to undertake it. Gardening and various agricultural works should as much as possible employ their time at stated pe- riods of the day; and by system and judicious management many of the inmates of these asylums may be brought into the habit of devoting themselves mechanically to such occupations. It is said that a farmer in Scotland once obtained a high reputation for the cure of mental diseases. He employed lunatics on his farm, made them Avork in tillage, fastened thein to his plough, and by degrees brought the most violent to a state of quietness and submission. M. Fodere cites Avith commendation Dr. Wendt's account of the lunatic asylums at Copenhagen, and some others in the North of Europe recently established or improved. In these hospitals Ave are informed that all arrangements for instruction are on the best contrived plan; and that the principle of gentleness in the treatment of the patients is carried further than elseAvhere. " All violent means of repression are proscribed, such as chains, the ro- tatory machine, solitary confinement, harshness of manner, and forced abstinence; lunatics are treated in such a manner as to spare them as much as possible the conviction of their real state." It may be doubted whether this is always advisable. " Patients Avhose attacks abate in violence are admitted to the society of the insanity, (Hypochondriasis.) 217 director, take their meals with him; they are aliowecf free inter- course and society among themselves, and care is taken to furnish them all such occupations as are consistent Avith their habits and education. The men are occupied either with military exercises, or they cut Avood, or cultivate the soil; the women Avash linen, and knit, spin, sew. Both sexes are taught geography, draAving, and music. On Sundays," says Dr. Wendt, " they are alloAved to play cards, billiards, and in some asylums are made to act co- medies. Convalescents have the use of a library and reading- room, Avhere the public journals are put into their hands." Fe- male patients and men of sedentary habits should be engaged as much as possible in some regular occupation. This rule is fol- lowed with great advantage in some of the hospitals for lunatics in France, where the females occupy their time in embroidery and Avorking in various Avays. It is found, as before mentioned, that even in the early stages of dementia it is not impossible to induce such patients to work steadily at some merely mechanical employment. Such habits mitigate the disease, and at least its manifestations, and in many cases they tend strongly to promote recovery. V. Hypochondriasis. Hypochondriasis, or the hypochondriac' malady (or the vapors, as it is vulgarly called), is often supposed to be merely symptom- atic of difficult digestion. Disorders of the different viscera and of the functions of physical life are in a very curious manner con- nected with states of the mind. It is a well-known fact, that dys- peptic and flatulent persons are generally subject to loAvness of spirits. Nephralgic diseases are accompanied Avith an anxious fretful state of mind, beyond what can be explained by reference to actual sufferings of the patient, to pain or irritation in the kid- neys or bladder. Phthisical patients are ahvays sanguine of re- covery, and in good spirits generally, and cheerful to the last. A proneness to violent emotions and passions is remarked as symp- tomatic of organic diseases of the heart. Slight cases of hypo- chondriasis might be referred to this explanation; but the disease is of a graver nature, and the more severe examples pass into un- doubted insanity. Hypochondriasis is in fact a modification of insanity. Every medical practitioner is Avell acquainted Avith hypochon- driasis in its ordinary form. It is Avell -characterised by Sagar:— " Desperant aegri de sua valetudine recuperanda ob ruetus, bor- borygmos, palpitationes, tremorem precordiorum, fugaces verti- gines, flatulentiam. Hinc persuasi fatum lethale sibi imminere, omnia symptomata et minimas mutationes in corpore suo scrupu- lose observant, narrant et describunt medicis, suisque querelis 19 218 insanity, (Hypochondriasis.) alios mox et alios defatigant, ingenio caeterum et appetitu pollen- tes." Patients laboring under hypochondriasis often complain of severe pains in the hypochondria, Avhence the name of the dis- ease. They often refer their uneasiness chiefly to the left hypo- chondrium, where there is in reality considerable fulness and in- duration; in some instances there is considerable enlargement of the abdomen, Avith a degree of hardness and a feeling of consoli- dation, Avhich excite suspicion of some organic disease. The tongue is generally clean, or covered with a slight broAvn coat; the stomach is the seat of every symptom of disordered action; the appetite is often irregular, sometimes voracious, and hardly to be satisfied, though more frequently there is a total want of inclina- tion to eat and even a loathing of food; after eating the patient ge- nerally complains of a sense of Aveight and uneasiness in the sto- mach; sometimes this amounts to very severe pain, Avhich recurs at a short interval after every meal, and eructation, cardialgia, or a sense of burning heat at the extremity of the oesophagus, ensue, and, after a long time, Avind is expelled in large quantities, Avith a sense of cramp succeeding the effort; sometimes viscid mucus is brought up with half-digested food, and a fluid so strongly acid as to corrugate the throat and set the teeth on edge. In other cases nausea prevails almost constantly, and prevents the patient from taking sufficient food for supporting strength; Avhen a small por- tion is swallowed it produces great irritation in the system, head- ach, pulsation in the epigastrium, and flushing in the face; occa- sionally these symptoms are relieved by vomiting. The patient experiences severe pains through different parts of the abdomen, Avhich he describes as burning, twisting, tearing, and distending, the bowels, seizing suddenly different parts of the alimentary ca- nal. He feels a momentary relief Avhen wind is expelled, but the sense of distension soon returns. Besides complaints referred to the abdomen, morbid feelings are experienced in different parts of the body, and more especially in the head. Patients complain of violent pains in the forehead and temples, sometimes in the occiput, of severe and distressing headach, with intolerance of light. In more frequent cases they experience, not pain but some indescribable sensations, Avhich are more difficult to endure than the most severe pain; a sense of in- tolerable pressure on the top of the head threatens, at every mo- ment, to extinguish consciousness and life itself; the head is as if squeezed in a vice, the scalp is drawn tight, and the eyes are felt as if starting out of the sockets: these sensations alternate with vertigo, or a feeling of giddiness; the eyes sparkle, twinkle, or grow dim; vision is impaired; it is impossible to look at a book, or to direct the eyes for a moment to any near object, Avithout expe- riencing a sense of confusion; there is a noise in the ears like the ringing of bells, bursting, boiling of tea-kettles, rushing of water, insanity, (Hypochondriasis.) 219 the sound of a steam-engine, strange voices, sudden cracklings, whizzings. The power of attention is destroyed, at least the pa- tient is persuaded that such is the fact, though, Avhen aroused by any sudden intrusion from his tale of sufferings, he is as lively and as acute as ever; he cannot think—his ideas are confused. Sometimes he fancies that his understanding is utterly destroyed, that he shall become insane and die in a madhouse. The suscep- tibility to all impressions on the senses is morbidly increased. Light, sounds, noises, are intolerable. During the actual presence of the disease the physical func- tions are more or less affected. Digestion is performed in the most imperfect manner; flatulence and gastralgia are constantly prevalent; the tongue is furred and often brown and dry; the skin is cold, clammy; the body becomes, sooner or later, emaciated. Causes. Attacks of hypochondriasis are chiefly occasioned by causes acting on the nervous system. It is stated by M. Louyer de Villermay, that, in twenty-tAvo cases of this disease out of thirty-six, it Avas occasioned by moral affections of a painful nature, by Avhich Ave are to understand, causes giving rise to to mental distress; in eight cases out of the same number it Avas occasioned by too close application to study; in two it arose from fright or sudden alarm; in two it folloAved an immediate transi- tion from a state of life requiring great activity to one of ease and leisure. These facts are favorable to the opinion, that hypo- chondriasis is a primary disorder of the nervous system; a con- clusion Avhich has been adopted and supported with much ingenuity by M. Georget. This writer considers the disease in question to be one of the brain, excited by the influence of moral agents, or by those causes Avhich act in a hurtful manner on the mind, and through that medium on the brain. He observes, in support of this opinion, that hypochondriasis is most common, in the higher classes of society, among persons occupied in official and diplomatic business, or devoted to literary pursuits. " Eng- land," he adds, "is perhaps the country Avhere this species of nervous disease chiefly abounds: this is principally owing to the prodigious activity of mind which exists in that country; to the miseries Avhich are contingent on the great development of in- dustry; to fortunes rapidly acquired in commerce by a number of individuals, who subsequently pass their whole lives without employment in excesses of every description. In many cases of hypochondriasis the symptoms refer them- selves principally to the state of the heart, the action of which is often so violent or irregular and interrupted as to excite sus- picion, even in the mind of the medical attendant, indeed, of organic disease. Many individuals have been subjected, in such cases, to rigor- ous antiphlogistic treatment, under the supposition that there existed organic disease of the heart. 220 insanity, (Hypochondriasis.) This error can scarcely be committed by those Avho are practi- cally familiar Avith the healthy, as contradistinguished from the morbid, sounds of the heart. Nature. Various opinions have been maintained respecting the seat and nature of hypochondriasis. Broussais maintains Avith some modification the opinion, formerly general, that its primary seat is in the stomach and small intestines, in the form of chronic gastro-enteritis. M. Georget has contended, Avith greater success, that it has its origin in the brain. We cannot, indeed, othenvise account for the variation in the phenomena. At one time the chest, at another the abdomen, is the local seat of pain, or of an indescribable uneasiness; and, in fact, often the principal manifestation of the disease. This could hardly be the case if the primary seat of disorder Avere in the stomach and intestinal canal; but it is quite intelligible if the disease is in the brain. Hypochondriasis, like insanity, is often recurrent. Persons Avill give up all their occupations, and banish themselves from society, or pass their time in bed for some months, and then , Avithout any apparent reason suddenly revive, resume their Avonted cheerfulness and vivacity, and will remain, perhaps for years, free from all symptoms of their disorder, and then Avithout any apparent cause, fall again into the same state. Treatment. Remedies which tend to restore the physical functions to a healthy state, and principally those which relieve dyspeptic complaints, are sometimes of use in palliating the dis- tressing complaints of the hypochondriac; but the only effectual relief is obtained by removing him from the causes which have oppressed his mind and nervous system. All practical Avriters are agreed in recommending travelling, change of scene, and all the means of diverting the attention. Places resorted to for the use of mineral Avaters are much frequented by patients laboring under this disease. There is no particular method of treatment by medicine that has been found invariably advantageous, and yet there are few cases in which the physician will fail, by attentive observation of symptoms and their obvious suggestions, to afford some relief to the patient. The Avhole class of nervines and anti-dyspeptics are constantly put in requisition every day in the treatment of hypo- chondriasis. Ammonia, camphor, ether, assafoetida, galbanum, myrrh in different mixtures and preparations, are not Avithout their use. Warm purgatives are, perhaps, of all other remedies the most frequently approved. When there are any signs of chronic gastro-enteritis, leeches must be applied to the abdomen and epigastrium; but such cases are in very small proportion. If the chief complaints are in the head, which is the fact in one third of the cases occurring in this country, leeches behind the ears, folio Aved by blisters to the occiput, are sometimes found to insanity, (Puerperal Insanity.) 221 afford temporary relief; but the majority of patients do not bear much abstraction of blood, or remedies which lessen the vigor of the general system or of the circulation. The due regulation of the bowels by a course of mild alterative aperients, followed by preparations of light bitters, and strict adherence to a mild nutri- tious diet, Avith daily exercise, especially horse exercise if it can be obtained, should be enforced on all nervous or hypochondriac persons. VI. Puerperal Insanity. The term puerperal madness is given by medical authors to any species of mental derangement incident to Avomen, either during pregnancy or soon after delivery, or during the period of nursing. The Avhole constitution of females is so much affected by either of these conditions, and the functions of physical life must be so much disturbed and put out of the usual course during their continuance, that the state of the animal system must also be modified, and any morbid predisposition is likely to be, under such circumstances, occasionally brought into action. But the states of constitution during pregnancy and lactation are very different from that of the puerperal period, and the charac- ters of mental disorder which are displayed at these times are also different. It is therefore improper to comprehend all the affec- tions described under one designation and in full; such a pro- ceeding is likely to lead to error, both in treatment and in prog- nosis. This mistake was avoided by Sauvages, who distinguished two kinds of insanity incident to females, terming one Para- phrosyne Puerperarum, and the other Mania Lactia. The former, only, is properly termed puerperal madness. This disease generally comes on Avithin a feAV days of delivery. The facts furnished by M. Esquirol, from the registers of the Salpetriere, are the most authentic source of information as to the period of the attack. We learn from them that 92 females, laboring under puerperal madness, were admitted into that hos- pital during four years. Of these 16 became disordered between the first and the fourth day; 21 from the fifth to the fifteenth day, a period which generally includes the cessation of the lochia; 17 from the sixteenth to the sixtieth day; 19 from the sixtieth to the tAvelfth month of suckling; and 19 after the Aveaning of their infants. The two last of these classes must be considered as belonging to the mania lactia, rather than to paraphrosyne puer- perarum. It seems, from these facts, that puerperal madness takes place chiefly about the time when the secretion of milk is set up, and from that period till after the cessation of the lochia. It depends on the irritation which the system undergoes owing to these pro- cesses, the influence of Avhich is severely felt under the condition 19* 222 insanity, (Puerperal Insanity.) of unusual weakness and excitability, resulting from the circum- stances of the time. Cases of puerperal derangement occurring, as Ave have said, within a few days, or generally Avithin a fortnight or three Aveeks after delivery, have the form of acute mania, distinguishable by no particular feature from the ordinary appearance of that disease. Such an attack is often the effect of too early elation or excite- ment, or of some imprudence in diet, or of circumstances Avhich give rise to emotion or disturb the mind: in other instances it comes on independently of any external or occasional cause that can be ascertained. It is ushered in by a sleepless, restless, anxious state, some- times accompanied by febrile symptoms, accelerated pulse, pains in the head, intolerance of light and of sounds. The signs of derangement in the mind are sudden in their appearance, and become at once decidedly manifest. Great excitement of feelings, loud talking, vehement expressions, Avandering of thoughts, inco- herence, are the usual phenomena. The secretion of milk, if it has commenced, becomes in general suppressed; the lochia com- monly cease; the skin becomes hot and dry, and the patient com- plains of thirst, and has a total Avant of appetite. It is the general opinion of practical writers, that the chief dan- ger in cases of puerperal mania is that of speedy dissolution, and that if the patient survives a period of not long duration, the recovery of a sane and lucid state of mind may be expected as a matter of ordinary experience. The records of hospitals do not bear out this opinion. Of the 92 cases mentioned by M. Esqui- rol, 31 proved to be incurable, or became instances of permanent madness. According to Haslam, out of 85 similar cases admit- ted at Bethlem Hospital, only 50 Avere recovered, leaving 35 as the number of incurables. Dr. BurroAvs mentions 57 cases, of which 35 terminated in recovery, and 11 Avere incurable. Dr. Gooch appears to have been much more fortunate. He says, that of the many patients about Avhom he was consulted, he only knew two Avho remained, after many years, in a state of derange- ment, and one of them had been so before her marriage. This statement would have been more satisfactory, if the author had specified the number of cases. We may, however, conclude, that the proportion of recoveries among Dr. Gooch's patients was much greater than that which occurred under the observation of Esquirol and Haslam; and perhaps the different circumstances of puerperal females in public hospitals, especially in such ones as old Bethlem and the Salpetriere (though we do not mean to be so unjust to our French neighbors as to compare these establish- ments,) and in the houses of opulent persons, may be sufficient to account for the great diversity of these results. Puerperal mania is generally considered to be a disease dan- gerous to life, and such, indeed it appears to have been under the insanity, (Treatment..) 223 hands of practitioners, Avhose sphere of observation has been chiefly in the wealthy classes of society. We might reasonably suppose that the mortality Avould be much greater in the loAver orders: yet, while 11 patients out of 57 treated by Dr. Burrows, died, 6 cases only out of 92 recorded in the Salpetriere Avere fatal, according to the statement of M. Esquirol. According to Hunter and Gooch those patients who have acute febrile symptoms, and especially a very rapid pulse, generally die. The indications of danger are, for the most part, precisely those Avhich denote great exhaustion of the system, and debility accompanied with considerable excitement. It may well be conceived that the risk is greatly enhanced, when, under simi- lar circumstances, the case has been treated on erroneous princi- ples. It is by no means an unfrequent occurrence to hear medi- cal practitioners speak of a rapid pulse and great excitement, both in the animal and physical functions, as calling for antiphlo- gistic remedies, and especially the use of the lancet; and many a patient laboring under puerperal mania has perhaps been sacri- ficed to this error of judgment. The disease is one of indirect debility, and is perhaps analogous in some of its pathological con- ditions to instances of delirium tremens or delirium traumaticum, and to some forms of febrile delirium, those namely in which the pulse is small, weak, and rapid, and the skin relaxed. A mode- rate and judicious use of stimuli, and especially of opium, is in these instances productive of the greatest advantage, Avhile an opposite method almost certainly leads to a calamitous result. Treatment. In the majority of cases of puerperal madness to which medical practitioners are called, they find the symptoms of debility and exhaustion already present. When this is the case to a considerable degree, the first and principal object must be to recruit the physical energy, to maintain the circulation of blood in a state sufficiently active for the due performance of the vital functions, and to procure sleep. A certain quantity of wine or brandy, perhaps an ounce of the latter, should be given every hour or every second hour, or even more frequently, according to the emergency of the case, and strong broth should be admin- istered in the intervals between the doses of stimuli. In cases of extreme weakness and agitation, tincture of opium may be ad- ministered occasionally in brandy. When the warmth of the skin has been restored, the use of powerful stimuli should be laid aside, and that of opium continued. Ten grains of the pulv. ipec. comp. however, repeated every third or fourth hour, till sleep shall have ensued, will often be followed, after a feAV doses, by a period of great rest and a return towards tranquillity. When these objects have been attained in a due degree, or even at first if there be no alarming state of weakness tending to preclude such remedies, it is often found that small benefit arises from the use of antimonial emetics, followed by mercurial purgatives; and these 224 insanity, (Treatment.) are so much the more requisite when signs are present, such as a furred tongue, fetid breath, a discolored skin, and dark and offensive evacuations, Avhich indicate a disordered state of the alimentary canal. Such a condition of the intestines is a frequent accompaniment, and probably no unusual exciting cause of the disease and its removal is attended Avith a salutary change. Such remedies should be repeated occasionally, according to the strength and circumstances of the patient, and followed by opi- ates in tolerably full doses. Heat of the scalp, flushings of the face, and pains in the head, may sometimes appear to preclude the use of opium, or to ren- der it at least a doubtful remedy. In such instances it is advise- able to shave the head and apply cold lotions, or an ice cap; and if the arteries are full and pulsate strongly, and the strength of the patient admits of it, to apply some leeches to the temples, previously to the administration of opiates. A full dose of opium, viz., two or even three grains, may often be given at once with advantage. Sometimes half a grain of the muriate of morphia may be preferable. We have generally found repeated doses of Dover's powder more successful, such as ten grains every third or fourth hour, until sleep ensues. In cases of great exhaustion, other stimulants and tonics may be added to the use of wine and alcohol, which, however, are the most efficacious and important. Carbonate of ammonia with camphor may be given every third hour in doses of six or eight grains, if the subcutaneous circulation is defective, and the extre- mities are cold. Sulphate of quinine, with mineral acids in con- siderable doses, Avill be of service, if the skin is relaxed and there is a disposition to free and copious exudation. 225 DELIRIUM TREMENS. History.—Causes.—Symptoms.—Two forms of the disease.—Second form divided into three stages.—Description of the first—second—and third stage. —Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treatment. This disease is distinguished from the delirium so common in febrile, inflammatory, and other maladies, by the peculiar nature of the illusions, accompanied by tremor of the hands and limbs, Avakefulness, and frequency of pulse. It has been denomi- nated Brain Fever by Pearson and Armstrong; Delirium ebriositatis by Blake; Mania a potu by Snowden and Carter; Oenomania by Rayer; la Folie des ivrognes, Dilire tremblant, by many French writers; Phrenesia potatorum, Delirium ebrietatis potatorum, and many other names, by German au- thors; and Delirium tremifaciens by Copland. Though these and numerous other synonyms are derived from the prominent symptoms or supposed seat of the disorder, they are all inappli- cable to many cases, and hence Ave shall retain the term delirium tremens, which, though it is not entirely free from objection, is universally understood; and, since its first introduction by Dr. Sutton, has been generally employed to designate the disease. Indeed, it is only since the tracts of this writer were published in 1S13, that delirium tremens has been considered a peculiar affec- tion, although there is sufficient evidence, as pointed out by Dr. Blake (Treatise on Delirum Tremens), that cases of it were treated by Hippocrates; and Calmeil remarks that, according to Aristotle, Denis the Tyrant had an attack of drunkenness which lasted twenty-four days. It has also been thought to constitute a large proportion of the cases denominated " Demonomania" by the Avriters of the sixteenth and seventeenth centuries, and it was described by Stoll under the name of "Phrenzy," in 1778, as pointed out by Dr. Forget of Strasbourg. Even before the Avork of Dr. Sutton appeared, it Avas treated of as a distinct affection by Drs. Pearson, M'Whirter, and Armstrong, in essays on this sub- ject, and by Drs. Saunders and Colles in their lectures. At pre- sent it is universally considered as a specific disease, and although the numerous observations Avhich have been made regarding it, have throAvn little light on its pathology, we shall endeavor to give a succinct account of its known causes, symptoms, and treatment. 226 delirium tremens, (Causes.) Causes. It is of great consequence that the causes of delirium tremens should be ascertained, as a knoAvledge of the different agents and circumstances Avhich produce it materially influences the treatment. Among the predisposing causes, the excessive use of alcoholic fluids is by far the most common, and hence it is frequent in countries Avhere spirits are cheap, as in America, and in many of our colonies: it has been more frequently observed, also, on coasts Avhere smuggling is extensively carried on. It may folloAv a fit of intoxication, or the habitual use of spirituous liquors in small quantities (popularly termed tippling), Avithout occasioning Avhat may be denominated confirmed drunkenness: hence distillers, retail dealers in spirituous liquors, men employed in bottling wines or spirits, and all persons who from the nature of their occupation have facilities of obtaining Avine or ardent spirits, are frequently affected. Even an over indulgence in beer has brought on the disease. The continued use of narcotic drugs also poAver- fully predisposes to delirium tremens. Thus, habitually taking opium, or the drugged beverages of the East, may induce a state of the constitution favorable to the production of this malady. We have seen it follow the use of beer in which Coculus Indicus had been infused by an unprincipled breAver; and it is probable that the presence of the poison, not only in this but in other cases, has tended to the production of the disease. Great mental exertion, continued for a long time Avithout suffi- cient sleep, has been observed to be one of the predisposing causes of delirium tremens. Dr. J. Johnson has met Avith it in young ladies, whose mental powers had been exhausted by intense or prolonged study. Excessive venereal indulgences, masturba- tion, different febrile affections, and other circumstances which diminish the general strength, act also as predisposing causes. According to Bang, Lind, and Rayer, the affection is most com- mon between the age of thirty and fifty; but Guldberg, from an analysis of 173 cases, found it most frequent betAveen forty and fifty. In England, both males and females are found to be equally liable to the disorder. Bang however found, that in 456 cases, only 10 Avere females; and of 176 cases seen by Rayer, 7 only were females. The difference in these observations can only be reconciled by supposing (and this we believe to be the fact), that in England, and more especially in London, females of the lower orders indulge to a great extent in the use of ardent spirits. Ac- cording to Guldberg, twice as many cases occur in May as in any other month; but Bang considers the disease to be just as frequent in June and July. Their united observations tend to show, how- ever, that the disorder is most common in summer. Delirium tremens has often been observed in individuals of a weak constitution and irritable temperament; but, on the other hand, it is not unfrequent in strong, robust, and plethoric indi- delirium tremens, (Symptoms.) 221 viduals. Even in these latter however, as, for instance, among the porters of London, it may be questioned whether the strength is not more apparent than real, and that before the disease ap- pears, a state of debility has been induced by the quantity of beer and spirits they consume. Numerous observations tend to shoAV that delirium tremens is most common in individuals of a Aveak and depraved habit of body. We have been informed by Mr. Atherstone, Avho has practised some time at the Cape of Good Hope, that he has observed the disease most common in such native tribes as are idle, sedentary, and possess little physical power, rather than in such as are industrious, engaged in field exercised, and warlike. Hence it is frequent among the Bushmen and Hottentots, but rare among the Caffres. This observation is in favor of what Ave have just stated. Exciting causes. The principal exciting cause is the too sud- den abstraction or diminution of the alcoholic or other stimuli to Avhich the individual has been accustomed. Thus soldiers or sailors deprived of their usual quantity of spirits have often been attacked; drunkards rendered unwell, meeting with accidents, or throAvn into prison, and put upon Ioav diet; opium-eaters, obliged by circumstances to relinquish their habit, are frequently the sub- jects of this malady. It may be directly induced by potations of spirituous liquors, and then it may exist with, or follow, intoxica- tion and a protracted debauch. In habitual drinkers, also, slight symptoms are often observed every morning until recourse is had to the usual stimulus. Another exciting cause is the shock given to the system by Avounds and operations. The state thus occa- sioned is exactly the same as that produced by the sudden depri- vation of the accustomed stimuli. The disorder arising from this cause has been denominated by Dupuytren, Avho first called the attention of the Profession to it, delirium traumaticum. In several cases, also, it appears to result from great mental depres- sion or despondency, particularly in young men leading a life of debauchery. We have seen it in such individuals folloAving acute feelings of shame, especially after receiving urgent and kind re- monstrances from their friends. Lastly, the disease may super- vene on typhus fever, scarlatina, erysipelas of the scalp, pneumo- nia, acute rheumatism, and various other acute disorders. Symptoms. Delirium tremens, like most affections of the nervous system, may be connected Avith an increased or diminished action of the vital poAvers. To the latter condition, however, the term delirium tremens is usually applied; the former being con- sidered by most authors only a modification of the disease. On the other hand, in this as in other nervous diseases, cases some- times occur of a character so complex as to make it difficult to determine Avhether they belong to the one or the other; but as it is of great importance with a vieAV to treatment, that a distinction should be made between them, and as the symptoms of each are, 238 delirium tremens, (Symptoms.) with these exceptions, sufficiently constant to render their diagno- sis a matter of no great difficulty, we shall consider delirium tremens as occurring under tAvo distinct forms. The first form appears during the progress of a protracted de- bauch, or shortly after a fit of intoxication, or an excessive use of opium and other stimuli. It is characterised by delirium Avith great irritability, often much violence, and sometimes vomiting and convulsions. The head is hot; the face flushed; the eyes bloodshot, or injected and suffused; the countenance expresses a degree of wildness and fury; the tongue is dry or cracked, and red at the point and edges; the pulse is frequent, full, or hard; the skin dry; in the intervals of delirium the intelligence is con- fused; there is often, but not ahvays, trembling of the hands and sometimes of the whole body, Avith constant wakefulness, or short restless slumbers Avhich afford no relief. These symptoms gra- dually pass into coma, and sometimes there are convulsions before death. It generally happens, hoAvever, that if appropriate treat- ment be employed, the patient recovers, as a first or even second attack is rarely fatal. Occasionally it passes into the second or third stage of the form next to be described, especially if the dis- ease has been mistaken, and depleting remedies have been car- ried too far. The second form is that which is generally denominated the true delirium tremens; and with the view of rendering the de- scription as accurate as possible, we shall, after Dr. Blake and other writers, divide it into three stages. The commencement of the first stage is announced by symp- toms of general debility: the countenance and general habits of the patient undergo a remarkable change; he is dejected, restless, and melancholic, sighs frequently, and complains of oppression of the praecordia; the sleep is short, and disturbed by painful dreams, on rising in the morning there is fatigue and weakness, slight fever, with loss of appetite, loathing of food, nauseous taste in the mouth, feeling of sickness, sometimes vomiting and cramps of the extremities; the tongue is moist, sometimes furred and tremulous; the bowels are generally open, although occasionally costive; the pulse is sIoav, soft, and easily compressible, often feeble and irregular; the hands and feet are cold and clammy; there is excessive perspiration from trifling exertion, generally vertigo and confusion of ideas, and sometimes, though not ahvays in this stage, trembling of the hands. These symptoms may come on very gradually in habitual drinkers, when many of them are apparent in the morning, and disappear after a dose of the accustomed stimulus. Generally, however, they come on more abruptly from two to nine days after a debauch, and have been considered by some authors as the premonitory symptoms of the disorder. In the young they seldom continue longer than a few days, but in the old and more confirmed drunkard their continu- delirium tremens, (Symptoms.) 229 ance may be extended to a much longer time. If the malady is treated in a judicious manner in this stage, the cure is readily effected; and by prudent conduct on the part of the patient, any further serious invasions may be prevented. In the second stage the vertigo and confusion of ideas are more marked, and the aberration of mind is more serious. The coun- tenance of the patient has a strange and Avild aspect; there is great abruptness and precipitation in all his movements; his steps are uncertain, his hands tremble, and it is Avith the greatest diffi- culty, he can perform the most simple office for himself. There is great nervous irritability, watchfulness, and Avandering of the mind, Avhich latter symptom often assumes the form of complete alienation, generally of a melancholy kind; he cannot bear re- straint, and, if imposed, Avill use violence to overcome it, although there is no malignity, and he is easily governed; he almost al- ways takes any remedies offered to him, and occasionally recog- nises such relations and friends as may be near him. As the disease continues, the patient becomes covered Avith a clammy SAveat of a disagreeable odor; he is entirely deprived of sleep; the tongue becomes more foul; the tremor of the hands is inces- sant in severe cases, passing into rigid spasms of the Avhole body, the bowels are often confined, the stools being dark and offensive, and the urine scanty; the pulse is small and soft (according to Copland, ranging between 100 and 120); the pupils are generally contracted, but Avithout intolerance of light; the patient exhibits great loquacity, and as the mind becomes more alienated, he imagines he beholds frightful images; sometimes he fancies himself a prey to Avicked spirits, who conspire to take away his life, or that he is surrounded by assassins, and is constantly endeavoring to escape from his imaginary enemies; on some occasions he believes that rats, mice, and other animals are continually run- ning over him, or that he is threatened by demons, black angels, &c. Indeed countless absurdities, sometimes of the most extra- ordinary nature, occupy the mind of the sufferer, Avhich, having all the appearance of realities, influence his conduct and conver- sation. These symptoms may remain three or four days, and during that period may be subject to various remissions, in Avhich the individual appears exhausted from his previous efforts. Re- covery is ahvays ushered in by a sound sleep, Avhich frequently continues twenty-four hours, and has occasionally extended to thirty-eight. A sleep of six or eight hours, however, has been folloAved by recovery; but should this not supervene, sooner or later the next stage is constituted. The third stage is characterised by depression of the vital powers, and a state of collapse which somewhat resembles that in the last stage of typhus. Sometimes the patient dies almost suddenly in convulsions, or there is a short interval of calm, and then violent delirium, during Avhich there is violent struggling, 20 230 delirium tremens, (Anatomical Characters.) and great perspiration immediately before death. In general, hoAvever, the fatal symptoms come on more gradually, and may be known by coldness of the hands and feet, sloAvly extending over the surface; by the pulse rising in frequency, becoming in some cases too quick to be numbered, and often thready and scarcely perceptible; by the increasing tremor of the hands, occa- sionally attended by trembling of the Avhole body; by the hands, feet, and more or less of the surface being covered Avith perspira- tion, Avhich exhales a peculiar smell, someAvhat betAveen a vinous and alliaceous odor, as pointed out by Dr. Hodgkin; by the coun- tenance becoming pale and anxious, the pupils contracted; the tongue deeply furred, brownish in the centre and tOAvards the root, with incessant talking, and great irritability; subsultus ten- dinum; constant Ioav muttering delirium, Avhich before death passes into coma and convulsions. In some rare cases the third stage is only marked by tranquility, Avhich precedes sleep, when recovery almost always occurs. It must be admitted that this division into stages is arbitary, and that cases seldom occur Avrfich present all the symptoms in the order they have been described. Sometimes a few of them may be absent, while in others various modifications may take place. The intensity of the disease also may differ; in some being so remarkably slight, as scarcely to be distinguished from simple nervous tremor, Avhile in others the second stage may be very violent, and approach somewhat that of the first form. It rarely happens that the physician has an opportunity of witness- ing the disease in its first stage, as the symptoms in general are not thought sufficiently important to demand medical interference, and in many cases, particularly those which occur after a de- bauch, they are not observed, the malady commencing Avith the second stage. The general duration of delirium tremens is three or four days, but it occasionally continues longer, even when the disease is Avell manifested. When the first stage is prolonged, and the course of the disorder is gradual, Ave can understand that it may continue for several Aveeks; but when it is accompanied with the more violent symptoms, they are rarely present more than four days, though in some instances they have been pro- longed to six. Anatomical characters. The appearances Avhich have been discovered on dissection of those Avho have died while laboring under the disease, are by no means uniform. Sometimes con- gestion has been found; sometimes effusion of serum in the ven- tricles, and in the cavity of the arachnoid; in many cases no morbid appearance Avhatever can be detected. Guldberg found a deposit of lymph between the membranes of the brain a com- mon appearance, and an injected state of the arachnoid is not un- frequent. In a case of delirium tremens examined by M. Calmeil, delirium tremens, (Anatomical Characters.) 231 the cortical substance was found of a slight violet tint; the me- dulla oblongata, to a level with the third and fourth ventricles, was softened, and of a rose tint. In a man who died comatose four days after he was admitted into the hospital in a state of drunkenness, and Avith other symptoms resembling delirium tre- mens, Morgagni reports (Letter 14—258), that there Avere fibri- nous concretions in the sinuses of the dura mater; the arachnoid was injected, and the pia mater infiltrated with serosity; there was much serum in the lateral ventricles, and the base of the brain Avas softer than in its natural state. These morbid appearances may be considered accidental, and only show that they may be occasionally found connected with this as with other diseases of the nervous system. The internal surface of the stomach in some cases presents an appearance of chronic gastritis, the villi being ef- faced, and the mucous membrane thickened or softened. The liver has occasionally been found enlarged, granulated, and of a yelloAv faAvn color, or more or less altered by the fatty degeneration. These appearances are accidental, but may explain peculiar symptoms in different cases. Nature. It is a disputed question whether delirium tremens depends on arachnitis or cerebral congestion. In the first form we observe that the cerebral symptoms are connected with in- creased vascular excitement, Avhile in the second the vital actions are depressed, so that this disease, like congestive cephalalgia, apoplexy, and other nervous affections, may depend upon the same pathological condition of the brain, although the states of the system connected with it are Avidely different. The conges- tion is in the one case of an arterial, and in the other of a venous character, and both, by producing partial pressure and augment- ed action, may give rise to cerebral symptoms of the same kind: we are consequently induced in the majority of cases to refer the symptoms to congestion, although Ave do not mean to deny that in some instances inflammation may have existed, as shoAvn by the occasional discovery of coagulable lymph after death. What influence the action of the alcoholic poison has upon the system is as yet a matter of conjecture. It is natural to conclude, that the peculiar symptoms Avhich distinguish this disease from the other kinds of delirium, are caused by some impression upon the nervous mass. In various animals poisoned with spirit by Dr. Percy, he Avas enabled to procure alcohol from the brain after death, as Avell as from the brain of an individual Avho died from excessive drinking. It may be inferred from the numerous experiments he has performed, that alcohol has a tendency to ac- cumulate in the brain and liver. But how far this circumstance, if true, may explain the symptoms of delirium tremens, is un- known. It is probable that the alcohol was contained in the blood or serum effused; and when other poisons are taken (opium, for example), a portion of it may be contained in the fluids. But 232 delirium tremens, (Diagnosis.) Avhether eA^en then it acts directly by stimulating the nervous » mass, or indirectly by rendering the whole system morbidly irri- table, cannot be determined. At present our knowledge is spec- ulative, and Ave conclude this unsatisfactory subject by acknow- ledging our ignorance, and impressing the necessity of further investigation. Diagnosis. The two forms of delirium tremens may in gene- eral be readily distinguished from each other, especially when the previous history of the case is knoAvn. The first is recognised by its coming on shortly after a fit of intoxication, or a dose of opium; by the pulse becoming strong and full, the head and skin hot, the face flushed, the eyes injected, the tongue dry; by the violent de- lirium and constant confusion of ideas, and strongly marked vas- cular excitement of the system. The second form, on the other hand, is knoAvn by its being usually the result of habitual stimu- lation ; by the pulse being small and quick, the extremities cold; by the delirium being in general unaccompanied by violence; by the confusion of ideas being only occasional; and by the depress- ed vascular action. It is often difficult to distinguish the first form from phrenitis. If, however, the symptoms arise soon after intoxication, and the trembling of the hands be present, these cir- cumstances should induce suspicions in the mind of the practition- er. The latter symptom, however, may not exist, and the only dis- tinction is the knowledge that the fever, impatience of light noise, turgescence of the eyes, and flushing of the face, are not so violent in delirium tremens as in phrenitis; that in the latter headach is a leading symptom, Avhereas in the former it is rarely observed. The second and third stage of the second form is readily distin- guished from phrenitis by the quick and small pulse, the moist state of the tongue, tremor of the hands, desire of change, pale countenance, damp and relaxed skin, partial preservation of in- telligence, giving intelligent answers to questions, &c. The same circumstances combined Avith the previous history will readily distinguish delirium tremens from febrile delirium. Delirium tremens is Avith great difficulty distinguished from some form of mania, especially Avhen there is no trembling. The mental aberration may be distinguished from that of ordinary in- sanity by its being changeable, and not confined to any particu- lar train of ideas. In mania rational answers are never given, and the symptoms increase on the approach of daylight, Avhile in delirium tremens they are augmented at night; the patient gen- erally becomes more tractable under mild expostulation. The expression of countenance, also, in these tAvo diseases is very dif- ferent, and may be readily distinguished by an experienced eye. It must be acknoAvledged, hoAvever, that the diagnosis is often very difficult, and all doubtful cases should be carefully Avatched for several days, and every means taken to learn the previous his- tory before forming a decided opinion. delirium tremens, (Treatment.) 233 Prognosis. The first or second attack is rarely fatal; its fre- quent occurrence, hoAvever, Aveakens the system; and, if there have been repeated attacks, the prognosis should be guarded. In old persons, also, of Aveak constitution, the occurrence of this disease must be looked upon as more serious than Avhen it occurs in the middle-aged and strong, or in young persons. Dr. Ware of Boston considers that the disorder runs a certain course, and terminates in death or recovery, Avithout in any Avay being influ- enced by remedies. Whether this be true or not, our prognosis must be guided in a great degree by the apparent strength, age, and previous habits of the patient, whatever be the treatment pursued. The unfavorable symptoms are subsultus tendinum; coldness of the whole surface, with clammy SAveats; non-uniform- ity in the contraction of the pupils; great frequency and threadi- ness of the pulse; brown and dry tongue, &c. The favorable signs are, sound sleep ; diminution of pulse, and gradual abate- ment of the delirium and other symptoms. Treatment. From what has been said of the symptoms and pathology of the different forms of delirium tremens, it will be evident that they require tAvo distinct modes of treatment. The necessity of establishing tAvo forms Avill now become apparent as a guide to practice, inasmuch as some physicians have treated successfully this disease by one line of treatment, while others have been equally fortunate by adopting an opposite one. This contradiction evidently arises from their not having distinguished the two forms under Avhich the disorder may occur, a circum- stance that at the same time reconciles the conflicting opinions, and points out how such discrepancies are in future to be avoided. In the first form of delirium tremens, if the pulse be strong, the head hot, the face flushed, and there be much violence, we must relieve the congestion of the brain by general or local bleeding. Care must be taken to watch the effect of the loss of blood on the pulse, as it will be found that in many cases the abstraction of a few ounces Avill accomplish all that is necessary. Unless the in- dications for bleeding, therefore, are very Avell marked, it will be better to combat the increased action by other means. Active purgatives are in this point of vieAV of great service, and may be repeated with safety. They should be mixed Avith the volatile oils and preparations of ammonia or of aromatics, in order to guard against any sudden depression. , Injections also should con- tain, in addition to any purgative medicines that may be found necessary, a portion of assafcetida, turpentine, and other stimula- ting drugs. Cold may be applied to the head in the form of affu- sion, or by an evaporating lotion frequently applied. If the skin is dry and hot, sponging the surface of the body with tepid water Avill produce much relief. Antimonials, given in nauseating doses frequently repeated, Avill also powerfully conduce to diminish the vascular excitement; on which the symptoms depend. 20* 234 delirium tremens, (Treatment.) When the disease comes on during a debauch, or shortly after, and there is reason to believe the stomach contains alcoholic fluids, emetics should be prescribed, or if necessary the stomach pump may be introduced. The same measures should be adopt- ed when the disease arises from an over dose of a narcotic drug. When, hoAvever, the symptoms have existed for some time, these remedies should not be employed, as their action tends to favor the cerebral congestion that may already exist. In the first stage of the second form, the symptoms generally yield to the administration of opium, in small frequently repeated doses. Ten drops of the solution of muriate, acetate, or meconate of morphia, laudanum, or Battely's sedative solution, may be given every tAvo hours in camphor mixture. Camphor and am- monia in larger doses, or sulphuric sether and the aromatic spirits of ammonia, may be mixed Avith the opiates if the depression ap- pear to be great. Should there be nausea or vomiting, the two last remedies, or effervescing draughts combined with the opiates, may be used. These remedies may also be given in the form of injection; opium mixed Avith camphor, assafcetida, and other stimulating drugs in appropriate doses, being thrown up the large bowels. Care must be taken, Avhile this plan of treatment is adopted, to keep the boAvels well open, in order that the opium administered may not produce costiveness, and because the accu- mulation of faecal matters in the intestines will undoubtedly aug- ment, and aggravate the symptoms. Dr. Copland even considers, that concretions of vitiated bile in the gall bladder and hepatic ducts, have favored the supervention of the malady. He has observed dark, offensive, bilious evacuations after cathartics have been repeatedly administered, even in cases Avhere the boAvels had been relaxed. The administration of purgatives, indeed, is by most Avriters considered of great importance, and Ave should therefore, at as early a period as possible, administer active ape- rients combined Avith aromatics and opiates, as above recom- mended. Tavo or three drops of croton oil made into an emulsion, with one or tAvo drachms of the Mist. Guaiaci, and fifteen or twenty drops of laudanum, folloAved in two or three hours by an enema, Avith assafcetida or turpentine, Avill generally in a short time pro- duce one or more copious discharges. Dr. Copland recommends a bolus, consisting of ten grains of calomel, Avith as much cam- phor, and a grain of opium in conserve of roses, followed by a warm stomachic and aperient draught, and in an hour or two by an enema. Either of these will sufficiently unload the boAvels, and it may be necessary to repeat them Avhile the opiates and stimulants are employed, especially if, from the appearance of the stools, there be any probability of the biliary secretion being ob- structed. Though the use of the accustomed stimulus ought never to be relied on as a means of cure Avhen the depression is extreme, and delirium tremens, (Treatment.) 235 there is great exhaustion, especially in old and habitual drunk- ards, or opium-eaters, moderate quantities may be alloAved, in conjunction with tonics and aromatics. The quantity should after a time be gradually diminished, but the effect of this diminution should be Avatched. In some cases the warm bath is serviceable in inducing tranquility; its beneficial effects, hoAveA^er, are more marked in the next stage. Blisters to the head and nape of the neck have been recommended; it is only, hoAvever, in constitu- tions much depraved and debilitated, that they can be employed with propriety. The above treatment judiciously employed and modified according to the age and strength of the patient, will in the majority of cases prevent the further progress of the disease, induce sleep, and restore the individual to perfect health. The treatment of the second stage, which is most frequently met Avith in practice, is to be conducted on the same general prin- ciples as the first. Purgatives are to be employed even more actively; and the first object of the physician, if not called in until the disease is advanced, should be to evacuate the bowels by the means before recommended. The principal indications in this stage are, to remove the irritability and to procure sleep; and Avith this vieAV opium is to be given in full doses, either alone or in conjunction with camphor and ammonia. One or two grains repeated every three or four hours, or four and five grains given at bedtime, Avill in general be sufficient. Much larger, and even enormous doses (ten to twenty grains of solid opium every two hours), hoAvever, have been recommended by Drs. BroAvn, Jack- son, and other American physicians; but it is very probable that all the good effects of Avhich opium is susceptible are produced by the doses Ave have mentioned; and that, if much larger quantities are given, they tend to produce convulsions; paralysis, and coma, Avhich, as remarked by Dr. Wright of Baltimore, may readily be mistaken for the fatal symptoms of the disease. Many cases occur undoubtedly, Avhich require larger, and some Avill do well Avith smaller doses, so that the physician must use the remedy according to the effect it produces, and the circumstances of the case. If small doses are employed, it will be useful to increase the quantity at night, and to favor sleep by removing the light, and guarding against every interrupting cause. We have seen several cases in which half a drachm of laudanum had been given every two hours, for tAvo, three, or even four days; and Avhen, on increasing the dose in the evening to four grains of solid opium, and enforcing absolute tranquillity in the room, sleep, folloAved by recovery, was induced. Sometimes the stomach is very irritable, and the medicine is rejected by vomiting. In this case a small quantity of sulphuric aether, or of Sp. Ammon. Co. Avith water, or the effervescing draughts, may form the vehicle for its administra- tion; it may also be given in the form of injection. When any ten- dency to sleep is manifested, great care must be taken bv the at- 236 delirium tremens, (Treatment.) tendants to favor it as much as possible; and should the slumber appear to be disturbed, or the patient Avake up alarmed, a small quantity of Avarm negus, or mulled Avine, should be given Avith a moderate dose of laudanum, Avhich will often induce long and refreshing sleep. The doses of opium should then be discontinu- ed. When there is much debility, Avith a frequent small pulse, as is often the case in old persons and confirmed drunkards Avith broken constitutions, the opium should be combined Avith a mode- rate quantity of Avine, or the accustomed stimulus, which when the more urgent symptoms have disappeared, should be gradually diminished. The same kind of treatment is necessary in the delirium tremens occurring after Avounds and operations. An injection containing fifteen or tAventy drops of laudanum was considered by Dupuy- tren highly serviceable in cases of delirium traumaticum. But Avhen the pulse is increased, the skin hot, Avith sense of weight or heavy pain in the head, and symptoms of increased vascular action, it may be necessary to employ some of the depleting measures recommended for the first form of the disease, viz. local bloodletting, cold to the head, active purgatives, antimonials, &c. Great caution, however, is necessary not to carry their employ- ment too far. In this stage the Avarm bath at the temperature of 90° will often relieve the patient, and assist in procuring sleep. Other remedies have been recommended, some of Avhich may be tried either alone, or conjoined Avith those already mentioned— hyoscyamus, digitalis, hydrocyanic acid, musk, ox-gall, &c. It will rarely be found, however, that these succeed Avhen the others have failed. It will be necessary to subdue any violence or indisposition to confinement that may be exhibited. We should endeavor to do this by a firm and temperate line of conduct, rather than by coer- cive measures; and Avhenever the wishes of the patient are rea- sonable, and do not lead to injurious consequences, they should be gratified. It must be remembered, however, that danger may result to the individual, or to others, by placing too much confi- dence in him, and at no time should the patient be left alone, or under circumstances where there are no ready means of control- ling the violent paroxysms. In hospitals it may be necessary to apply the straight Avaistcoat, but in private practice it will be suf- ficient that proper attendants sit by the bed night and day, pre- pared to act on any emergency. In the third stage all remedies will in general be useless, as the exhaustion which characterises it is usually too great to be re- lieved, and when it comes on after the judicious use of remedies in the second period, the case may be looked upon as hopeless. Should the former treatment, however, have been improper or inefficient, it is still possible to produce a change for the better. With this vieAV, large doses of stimulants, such as ether, ammo- delirium tremens. 237 nia, camphor, &c, should be given, the hair should be removed, and a blister applied to the scalp or nape of the neck, and a sina- pism to the epigastrium. Stimulants and cordials, in extreme cases, should at the same time be administered, and stimulating liniments, Avith mercurials, rubbed upon the inside of the thighs. If there be not too much exhaustion, the Avarm bath may be employed, and indeed every measure that can stimulate the sink- ing vital poAvers, remove the congestion in the brain, and favor the absorption of serum that may probably be effused. During the course of the disease, the patient generally feels no disposition to eat, and very often loathes all kinds of food. Light nourishment, hoAvever, should be offered occasionally; it may consist of arrow-root, tapioca, sago, &c, mixed with a little brandy or wine. During the convalescence, the diet should be nutritive but light, Avith a small quantity of porter or Avine, ac- cording to the previous habits of the patient. The state of the secretions and excretions should be regulated, if necessary, by appropriate medicines, and the tone of the stomach improved by tonics. Every opportunity should be seized of pointing out to the indi- vidual the evil consequences of an indulgence in those habits which have brought on the disease, although experience has proved that the most convincing arguments and earnest repre- sentations seldom produce the desired effect. Delirium tremens is still a common disease in the United States, although the improvement in the habits of the people is gradually rendering it less fre- quent. The cheapness of spirits and the comparative pecuniary comfort of our population, place the means of indulgence in intoxicating drinks within the reach of all classes, and render delirium tremens a much more frequent disease than it is in countries where either distilled spirits are difficult to pro- cure, or the habits of the people prevent their indulgence in them. It is for this reason that the disease has attracted so much attention amongst the phy- sicians of this country. In common with others I have been obliged to make it a subject of investigation, and my position as a medical attendant upon the principal institutions of Philadelphia for a period of nine years, afforded me an extensive field for the study of the disease, and has enabled me to settle some points of practice which have had an important influence on the mortality of the disease. The distinction generally admitted by writers as to the origin of the disease, is a correct one: there are two distinct modes of origin;—in one which is the more simple form, the disease begins after complete abstinence from spirits, and in the other the patient continues his habits of intemperance until the dis- order breaks out, or until some derangement of an important organ produces an attack of disease which prevents him from indulging longer in his habitual beverage. 1. Common Delirium Tremens. This variety appears a few days, or even the 238 delirium tremens. next day after a fit of drinking, whether it has been carried to the extent of a decided debauch or not, or it may occur in individuals who are simply tipplers, that is, accustomed to drink from two to six or eight glasses of spirits daily, or from a gill to a pint. The patients who are affected with this disorder in private practice, belong for the most part to the latter class, and are taken with the disease when ill health or a surgical injury has suddenly obliged them to give up their habitual stimulants. The attack is generally more mild in those who are accustomed to this less degree of stimulation, than when it directly follows a fit of intemperance. The disorder is usually divided by authors into three stages which are not always clearly separated one from another. The distinction is, however, per- fectly well founded, and the symptoms of each period are more definite in this disease than in most others. The division is extremely convenient, for the prog- nosis and treatment of the disorder are extremely different in its several stages, and a disease which is almost always curable at the beginning, be- comes in the advanced stage extremely intractable. (a) First Stage. This is well known amongst drunkards as the horrors.- a term which expresses the aspect of the patient, which is that of extreme anxiety and agitation, and the distressing feelings of fear which the patient experiences. This anxious alarming expression, is one of the most character- istic symptoms of the disease, and with the tremor which is equally remarka- ble, it constitutes the only pathognomonic character. The tremor extends to the whole muscular system, but as it may be to a certain extent restrained by a voluntary effort of the will, or by supporting the weaker muscles of the limbs against the trunk, it is sometimes not very obvious unless the patient is directed to put out his tougue, or to hold up his hands, where it is at once perceived. The restlessness and tremor are the most frequent and important symptoms of the first stage of the disorder, but are by no means the only ones; the others, however, are only accessary or secondary, and vary with each pa- tient. As a general rule, the pulse is feeble and frequent, the mind is unable to direct itself long to any single subject, and the pupils are slightly con- tracted. The complexion is extremely variable; it is often pale if the patient has not been long addicted to intemperance, but in the majority of cases it retains the usual tint of the drunkard's countenance. The appetite fails, the bowels are often constipated, and there is generally more or less thirst. In this stage of the complaint, the restlessness continues throughout the night, and of course the patient is unable to sleep: sometimes, the sleeplessness is the first symptom of the disease, but in the majority of cases it attends the restlessness, and is strictly proportioned to it. The agitation may gradually subside and the patient recover or the disease may pass into the next 6tage. (b) The second stage of the complaint presents the same symptoms as the first, but in an exaggerated degree, the tremors, restlessness, and insomnia are increased, and the appetite is more completely destroyed. The pupils are more contracted; if, however, the patient has not taken opium, the contraction of the pupils is never very great. The distinctive symptom of the second stage, is the illusions which at first occur only at night, when the patient is left alone, and in the dark. These hallucinations are perfectly under the con- delirium tremens. 239 trol of the understanding when the courage of the patient is revived by light and society; he is then perfectly aware of their nature, and will often laugh at his own fancies. The illusions are not confined to the night, if this stage become more confirmed, but they still remain perfectly under the control of the will and of the intelligence; if the disease continue, the illusions become more and more frequent, and cease to be recognised by the patient, that is, they are completely confounded with real objects. The attention may still be directed to surrounding objects and the patient is capable of answering ordinary questions with perfect correctness, if he is addressed in a sharp decided tone of voice, and there is no incoherence in his answers, so long as his attention can be commanded. These illusions are nearly always of an alarming kind and are as varied in their nature, as the objects which happen to be most familiar to the patient; devils, guns, fire, serpents, and the like are the most common objects of his fear. At other times he feels a vague dread that his life will be taken, and earnestly entreats that it may be spared. These illusions are so well characterised, that they have always been regarded as the essential character of true delirium tremens; this is nearly but not abso- lutely correct, for in some cases, the tremors are not attended with illusions, but on the contrary, the mind of the patient is almost clear, and the disease may prove fatal, although no illusions present themselves, by the occurrence of convulsions or sudden insensibility. Still in the regular simple variety, of which I am now treating, the illusions may be regarded as a constant symp- tom. The other symptoms of the second stage are not pathognomonic, and with the exception of the countenance which retains the same restless ex- pression as in the first stage, are not even characteristic. The pulse is fre- quent, and generally small, the frequency evidently depends rather upon the extreme agitation of the patient than any regular connection between the state of the circulation and the disease. The appetite rarely returns during this stage, although this is sometimes the case; the tongue is generally furred, but rarely dry. The skin remains moist throughout this stage, and if the efforts of the patient to escape from confinement be constant, or if his agitation be very great, the sweat is often very profuse. This sweat is of a different cha- racter from that which generally occurs during the third stage of the disorder, and seems to be strictly dependent upon the constant exercise which the agi- tation of the patient obliges him to take. The second stage may gradually decline, and the patient fall asleep, and recover; or it may pass into the next stage. Sleep is nothing but the indication of the recovery; it follows rather than precedes the decline of symptoms. The insomnia arises from the extreme nervous disturbance which is the essential elementof the disease, and although the fatigue of the patient may be extreme, he is still altogether unable to sleep. Let the nervous agitation be quieted by any means, and sleep will immediately follow, and will finally complete the restoration. This is the true rationale of the close connection between sleep and recovery, which has certainly been misunderstood, and has led to erroneous deductions as to the treatment of the disease. If the disease be completely removed, the patient will sleep for a long time, and will generally awake perfectly restored. In some cases, however, the recovery after prolonged sleep is not complete, butthedis- 240 DELIRIUM TREMENS. ease recurs again, and is not completely cured until a day or two afterwards. If the prolonged sleep occur naturally, it is always productive of great relief to the patient, but if it be forced by the operation of narcotics in large doses, instead of conducing to recovery, it will sometimes end fatally, and the pa- tient may then die without awaking. A short sleep of one, two, or three hours is refreshing, but is not usually followed by immediate recovery, although it affords an evidence of the gradual decline of the disease. If delirium tremens be well treated, or if the disease be essentially mild, but few cases pass beyond the second stage; recovery taking place without difficulty. (c) The third stage is attended, like the others, with a symptom which is characteristic; that is, incoherence. The illusions either cease, or they are no longer connected, the patient passing from one object to the other with great rapidity, and not reasoning correctly or connectedly, upon the images which are presented to his mind. He becomes feeble, but is, at the same time, ex- tremely agitated, and can only be retained in bed by the constant watchfulness of an attendant, or by straps or bandages. The sweat becomes profuse, the skin sometimes cold, at others warm, and pupils greatly contracted. The con- traction sometimes ceases before death, and may be succeeded by a morbid dilatation, if there be much serous effusion upon the brain. The senses be- come gradually more and more obtuse, from the first appearance of incoherence; the patient generally loses his power of attention, and can with great difficulty be induced to direct his attention to surrounding objects, and as the disease advances, he becomes completely comatose, and generally lies in a state of insensibility for some time before death. The pulse gradually fails during this period, and the patient often presents symptoms of nervous distur- bance, which are very analogous to those which take place in cases of typhus fever, such as subsultus, spasmodic tremors of the muscles generally, and mut- tering delirium. By adopting this division, and basing the distinctive characters of the dif- ferent stages, upon the mental disturbance which occurs in each of them, a clearer idea may be formed of the character of the disease. If the third stage is reached, the chances of recovery, of course, are extremely small. But the disease will sometimes terminate fatally without going thus far; those cases which I have seen of this sudden termination, were, for the most part, treated by high doses of opium; I have also seen it occur where little or no active remedies had been given, very soon after the entrance of a patient into a hos- pital, and after the emetic practice. The sudden termination, of the disease, is not therefore dependent upon any uniform method of practice. These sudden deaths are more frequent in the second variety, when they are generally preceded by convulsions; these, however, sometimes occur in the milder form. 2. The second variety of delirium tremens occurs during a debauch, and patients actually intoxicated are often admitted into the Philadelphia hospital, laboring under this disease. The individuals who suffer with this form, are attacked with it after very high stimulation. That is, the stimulation is ex- tremely great, either because the quantity of spirits is very large, or the patient is extremely susceptible of the effects of alcohol. There is in this variety of the disease, a singular union of the directly exciting action of alcohol upon the brain, DELIRIUM TREMENS. 241 with the debilitating effects of a diminished stimulation. The apparent con- tradiction is in many cases easily accounted for; the stomach in these patients is gradually enfeebled and will not receive, or at least retain the accustomed quantity of spirit, and the nervous tremor therefore supervenes: if the stomach becomes again capable of acting upon the alcohol, the tremors are not arrested, although positive intoxication is sometimes brought on. The disorder consists then of two distinct parts; one is the ordinary form of delirium tremens, which is but slightly modified, and the other is the vascular congestion or inflamma- tion which is directly caused by the alcoholic excitement. If there is simply congestion, the face is flushed and the eyes often injected, but the color is of a dark and not a bright red tint, the intelligence is dull, and the whole counte- nance indicates nearly an apopletic stupidity. These cases are extremely apt to terminate in convulsive fits, which sometimes do not differ from ordinary apo- plexy of the simple congestive form, and in other cases resemble an epileptic attack much more closely than apoplexy. If the fits are frequently renewed, the disease will either terminate fatally in the paroxysm, or coma may come on more slowly, and the disorder merely assume the form of the third stage of delirium tremens. When convulsions take place, the ordinary course of the disease is often singularly modified and its stages greatly shortened. If the excitement be of a more active inflammatory form, the delirium will assume the characters of ordinary meningitis, and the symptoms of the delirium tremens be gradually merged in them; or the reverse may take place, and the inflammatory symptoms abate and be followed by those of this disease. This variety is neither as frequent nor as dangerous as the congestive form. It must not be confounded with true meningitis or cerebritis, which occasionally occurs in drunkards, especially those who have been exposed to the ordinary causes of cerebral inflammation, as blows on the head received during their debauch, or the heat of a summer sun. This mistake can scarcely take place with those who are accustomed to the disease, but it might occur with prac- titioners who are not familiar with delirium tremens. Complications. It is evident, that delirium tremens is a well characterised disease, with its own peculiar symptoms, but it may present numerous com- plications. These may be either acute or chronic disorders of the viscera. The fevers .properly speaking, rarely complicate delirium tremens, unless they are of the milder forms, such as the ordinary intermittent or remittent, for a severe continued fever comes on gradually, and either prevents the formation of delirium tremens, or it replaces the symptoms by its own peculiar pheno- mena. The ordinary complications are the vascular congestions or inflamma- tions. These follow the prevailing epidemic constitution of the season, or are caused directly by the action of the alcohol. Thus in summer, dysentery and diarrhoea are extremely frequent, while in winter pneumonia is a common and a very grave complication. In a few cases gangrene of the lungs has occurred during the course of the disease; this was particularly frequent in the winter of 1828-9, when I observed a large number of cases of gangrene at the Phila- delphia Hospital. The complications which arise directly from the alcoholic stimulation, are cerebral inflammation or congestions; and gastric disorders, either inflammatory, or the reverse; and various affections of the liver, especially 21 242 DELIRIUM TREMENS. the fatty enlargement. Individuals laboring under phthisis or other chronic dis- eases, especially hypertrophy of the heart, are sometimes the subjects of delirium tremens. These complications do not in general obscure the symptoms of delirium tremens, except those disorders connected with the brain. The latter occur for the most part in the second form of the disease. Diagnosis. The diagnosis of the disease is formed from the previous habits of the patient, as well as his present symptoms, and is in general easy; it becomes difficult only when a cerebral disorder more or less similar to delirium tremens occurs in drunkards. The distinguishing characters are the tremors, the peculiar and changing character of the illusions; the sweats and the restless alarmed countenance. The pulse and the other secondary symptoms of the disease are of little value for the diagnosis. The accidental inflammations are readily distinguished by one who is accustomed carefully to examine the con- dition of the viscera, otherwise they may often escape notice. This is espe- cially the case with the thoracic inflammations, which are singularly obscure in all cases in which the brain is much disturbed, for the functional signs of these affections then cease or become very slight. Prognosis. The prognosis of the disease depends greatly upon the treat- ment. If it be treated according to the plan which is here presented, it is almost invariably favorable. Should fatal cases occur, they may be ascribed to some unforeseen cause, or some accidental complication which is not to be looked for in the ordinary course of the disease. If the disorder be left to itself, mild cases wear themselves out and terminate favorably, although the suffering of the patient is far from inconsiderable; severe cases pass into the advanced stages of the disease, and are apt to terminate fatally. Other methods of treatment modify the prognosis. The disease is, therefore, much more variable in this respect than those disorders which are less amenable to therapeutics. Anatomical characters. These are not necessarily connected with those of either congestion or inflammation. The brain may be in either of these states but it is as a purely accidental complication. The most frequent anatomical character is an unusual moistness of the whole brain, serum seems diffused through it, and follows every cut of the scalpel, and is at the same time ef- fused beneath the arachnoid, and contained in undue proportion in the ven- tricles. Even this appearance I do not regard as necessarily connected with the disease, but I am disposed to refer it in part at least, to the slow approach of death and to the labored condition of both circulation and respiration, which generally precedes it. If this view be correct, the disease must be classed amongst those purely functional disorders of the nervous system which are connected with no regular anatomical lesion; this opinion is confirmed by the history of the symptoms. Treatment. Of the various other remedies employed in the treatment of delirium tremens, opiates have probably received the most attention, I for- merly used these remedies in almost every case, though not in as large doses as some of my brethren; but when I was a resident physician at the Philadelphia hospital, we were directed to give opium in very large doses—frequently as much as four grains every two or three hours, until sleep was procured. The patients, for the most part, got well under this treatment; but in. estimating DELIRIUM TREMENS. 243 the value of a particular plan of treatment, we ought to consider the propor- tional success of this and other plans. A comparison of this sort will prove that opium is not the most effective remedy in delirium tremens. In conjunction with this remedy, certain hygienic regulations were also enforced at the time to which I have alluded. The patients were locked up in cells, and if very disorderly, that is in every severe case, they were confined in a straight jacket, or retained in bed with gloves and straps. The practice of the hospital has never been to give opium to the exclusion of other remedies; it was always the custom to use cups and cold applications to the head, purgatives and various other remedies, when they seemed neces- sary. From time to time a change would be made in the practice, and the affection would either be treated upon empirical grounds, or in accordance with the varying symptoms, or the emetic practice would be pursued. But the plan of treatment, by opiates and confinement, is the one that was almost universally practised in Philadelphia several years ago, with variable results. In ray own practice I have gradually diminished the quantity of opium which I formerly gave, and for some time past have not used it at all. Instead of it, I have relied upon the stimulant treatment which is followed in some parts of New England, and from timeto time has been much resorted to in the Philadelphia hospital; that is, the use of stimulating remedies, particu- larly alcoholic liquors. These articles I first employed in conjunction with opium, or prescribed them without opiates, in two different conditions; 1st, in the slighter cases, or those of incipient delirium tremens; or, 2dly, in the severe cases where opium had been exhibited but was followed by distress of mind and stupor. But at present I use them singly. This treatmeut has diminished the mortality of the disease, and rendered it almost always curable. The change which I have adopted in the hygienic rules, has also contributed very decidedly to this result. Instead of confining the patients, I let them walk about and enjoy the company of others as much as they choose: merely taking care that some one should be near them to prevent accidents. I was led to this change by observing that the hallucinations which attend the disorder were more dis- tressing when the patients were in a state of confinement than when they were allowed to walk about as much as they wished. As I have already remarked, they are capable of controlling these hallucinations, until the intellect is en- tirely powerless; and they can do so the more easily when they are surrounded by objects which may serve to engage their attention. Confinement always irritates them, and increases their ravings, so that the third stage, in which the intellect is completely destroyed, is apt to be brought on more speedily. I have very often tested this by a simple experiment; a man who was confined . to his bed by a straight jacket or something of the kind, I have frequently directed to be dressed, have soothed him by conversation, and after requiring a promise that he would conduct himself with propriety, I have very seldom found reason to be dissatisfied with the result. On the contrary, the disease would almost invariably become milder, and the necessity of confinement cease. It is true that confinement is often necessary at night, from the impos- sibility of always providing a sufficient number of attendants. I therefore (with the exception just stated) allow the patient to have full liberty, the only 244 DELIRIUM TREMENS. restraint being the presence of the keeper: sometimes also I direct them to be set at work, which serves still farther to distract their attention. The proportional mortality under the two plans of treatment which I have detailed, is represented in the following summary, comprising the number of cases treated amongst the men for the space of 5$ years—that is, from the 20th of May, 1834, to the 13th of November, 1839. The whole number of cases admitted for delirium tremens, or intemperance, which was expected to termi- nate in delirium tremens, was 1241. Of these, there were 1198 whites, and only 43 men of color. Of the whole number, 708 were decided cases of de- lirium tremens, 60 were slight cases, and 430 cases of mere intemperance. Of the latter, some terminated in decided delirium tremens, and others proved fatal from diseases (such as pneumonia) contracted during the fit of drunken- ness, for which they had been sent to the lunatic asylum. So that this class furnishes a considerable number of bad cases. Of the whole number, 121 cases proved fatal; that is, a fraction less than one in ten. In the first year, from May, 1834, to May, 1835, the number of admissions was 141; of these, 18 died; that is, rather more than one in eight. In the second year the number of cases was 211, the deaths 24, or a little more than one in nine. The third year, in 301 cases there were 47 deaths, a much larger proportion than in preceding years, one in 6 19-47ths, but depending upon an accidenal cause; that is, the occurrence of an epidemic of typhus, which attacked many of the debauched subjects of intemperance: some of them were sent to the lunatic asylum as laboring merely under the effects of intem- perance, and could not be afterwards removed to the proper ward. In the fourth year, beginning May, 1837, of 206 cases, 19 only proved fatal, that is about one in eleven. This was a decided amelioration, and coincides precisely with the epoch at which the change of practice was introduced. In the fifth year the mortality went on diminishing, and was less than one in twenty-six; or of 274 cases, 9 only were fatal; and amongst these cases, the mortality was certainly greatest in those which were treated chiefly ac- cording to the method formerly pursued at the hospital. Finally, in the months, ending November, 1839, the mortality Was only one in 33f, that is, 4 cases out of 135; and of these four, one entered mori- bund, and was not, therefore, treated in the hospital; another had inflicted upon himself several fractures and other injuries, by leaping from a third story window, in a fit of delirium tremens, previously to his entrance. The others, it is believed, were also complicated cases. The preceding summary of the results of the treatment, is extracted from a lecture which I delivered at the Philadelphia Hospital, in December, 1839. The results of the treatment for the last year, up to the present time, (Octo- ber, 1840,) have been still more satisfactory. The number of cases of the sequelae of intoxication, and of delirium tremens in the three stages, admitted into the men's wards of the Philadelphia Hospital from October 12, 1839, to October 12, 1840, is 223. Of these, 61 were classed under the head of intoxi- cation or its immediate sequelae, some of them passing into delirium tremens. If we exclude the whole of these 61 cases, there remain 162 cases of decided delirium tremens; of these, 87 were admitted in the first stage, 73 in the DELIRIUM TREMENS. 245 second, and 2 in the third: 160 cases recovered, and one remained con- valescent, who is since well. (Oct. 16.) One only proved fatal: this patient was admitted in the third stage of the disease, and died in a few hours after his entrance; he had been treated with opium, and a box of pills which he was taking, were sent to the hospital with him. Of course, this apparent exception confirms the general conclusion, that the disease terminates favorably in every instance, when treated according to the method recommended. The proof must, therefore, be conclusive if all the circumstances surround- ing the patient remain the same. These have remained precisely as they for- merly were, with the exception of the difference in the management and treat- ment of the patients. The superintend ant is the same, the resident physicians in whose immediate charge the patients remain, are of the same average edu- cation and experience, and the other circumstances connected with the disease remain unchanged. The inference is, therefore, rigorously deduced, that the former method of treatment yielded an average mortality, which varied but little in different years; while the treatment now pursued, is followed by a mortality which may be regarded as a mere cypher. The single fatal case which has occurred amongst the list of 162 patients admitted, depending on other causes, and the progressive decline of the proportionate mortality keep- ing pace with the change of the treatment. If, therefore, evidence of this nature be rejected, or if the facts which were not observed by one person alone, but by a large number, or if a practice which was not carried out by a single resident physician, but by a succession of a large number, be rejected as wanting due confirmation, it is very clear, that the common rules of obser- vation, and the conclusions which, under the ordinary circumstances, would be regarded as beyond cavil, must fail when applied to medicine. This, of course, involves a contradiction, that few would be willing to admit, at least, to avow. The treatment substituted for the former practice was conducted according to the following general plan:—If a patient entered in a state of intoxication, whether he was laboring under the early symptoms of delirium tremens or not, an emetic was always prescribed; the best for this purpose is either a sim- ple diluent drink, such as chamomile tea, or warm water, or a dose of ipeca- cuanha. After the operation of the emetic, the patient was generally tranquil for a time, and sometimes fell asleep. On his awaking, the symptoms of deli- rium tremens presented themselves, if his debauch had been protracted. If it had lasted only for a few days, the disturbance of the nervous system was limited to a slight agitation, or tremors; many such cases occur and terminate in a day or two. If the disease pass into regular delirium tremens, the treatment does not differ from that pursued in those cases, in which the disease is deve- loped previously to the admission of the patient. The object is then to remove the disorder of the nervous system which fol- lows the excessive use of ardent spirits, by a milder excitement which may gradually terminate in recovery. For this purpose, the best remedy is alco- hol, that is, some form of distilled spirits; in our hospital that employed is the cheaper kind of brandy. Of this, an ounce may be given every three or four hours, if the case be a slight one; if the tremors are more severe, or if the dis- ease is advanced to the second stage, two ounces should be given every four 21* 246 DELIRIUM TREMENS. hours, or one ounce once in every two hours. It is very rarely necessary to exceed this quantity in cases which are brought under treatment during the first, or early in the second stage. There are some cases which require for a short time larger doses: there are those in which the disease is either of itseif more severe, or in which the patient has been in the habit of using enormous quantities of alcoholic stimulus. It is then often necessary to administer the brandy in doses of two ounces every two hours, but these doses are rarely required for more than a single day. In a few cases where the depression is extreme, it becomes necessary to increase the dose even beyond this amount. In two instances at least, the quantity was not less than two ounces every hour for three or four doses; there were, however, extreme cases, of a class which I have never known to recover under ordinary methods of treatment. The rationale of this practice is evident enough; the excessive stimulation to which these patients have been long subjected is not only followed by a subsequent depression, but is attended with an extreme disorder of the ner- vous system, which constitutes the essential character of the disease. The stimulating practice relieves this irritability for a time by substituting its own peculiar action and when administered in these doses, which are never suffi- cient to intoxicate, the subsequent depression may be completely avoided. Of course, no practitioner who feels a proper regard for his patient, or for his own character, would allow the patient or his friends to increase the quantity of alcoholic stimulants to such a degree as to run the slightest risk of producing these intoxicating effects. The quantity must vary according to the suscepti- bility of the patient; if this has been nearly destroyed by excesses, the quan- tity of alcohol which is necessary to produce a given effect, must of course be greater than in those cases, in which it is still but little impaired. The dose should always be as small as possible, for if the quantity necessary to tran- quillise the patient be exceeded, it acts as an irritant, and produces injurious consequences. I am perfectly aware that the alcoholic stimulants are not absolutely neces- sary for the majority of cases of delirium tremens; a variety of methods will cure the disease, or it will in the greater number of cases get well of itself, like all diseases which have a self-limited duration. I wish merely to state what is incontestibly proved by the documents, that the stimulant practice offers a suc- cessful result, which may be looked for with a certainty which is almost ab- solute, and that this method of treatment has the advantage of being applica- ble to the worst cases; in the milder ones the only question is, whether it unites the advantages of curing the patient " safely, quickly, and agreeably;" of this no one who has witnessed the horrible sufferings of the patients who labor under delirium tremens and their speedy alleviation by this treatment can entertain a doubt. The difficulty which will arise in the minds of many, is of a different kind: many physicians will hesitate on moral considerations, from a dread of either seeming to give countenance to the habit of spirit drinking, or from a dislike to administer a poison which has itself caused the disease. This for a long time caused me to use this mode of treatment with extreme reluctance, and to restrict its employment to those cases in which it seemed indispensably neces- sary, but the results were so incontestible, and the diminution of the mortality DELIRIUM TREMENS. 247 so evident, that I could not avoid adopting a method which has hitherto in- sured the safety of the patient, under circumstances in which it would other- wise have been placed in extreme hazard. If the probability of a recurrence of the disease were increased, it would still be a matter of doubt whether a phy- sician should hesitate; but there is no reason for believing that there is an in- creased danger of a relapse. At least the examination of the register of the hospital proves that such is not the case. If the patient return to his former associates before the disease is completely passed, that is, before the restless- ness is removed; a relapse into habits of intemperance is almost imme- diate; but if all remains of the disease be completely removed, the remem- brance of the attack and its accompanying horrors, will in general preserve the patient, for a time, from a renewal of his vicious habits. A complete abandonment of them is unfortunately not common, and is scarcely practicable without an entire abstinence from intoxicating drinks. Although the treatment of the disease by alcoholic stimulants is so univer- sally successful, something more is required to insure their favorable results; that is, a judicious management of the complications which are so frequent in the disorder. Their treatment in general does not interfere with that of the delirium tremens, for in drunkards the constant habit of stimulation renders the system almost insensible to ordinary excitants. If the complication be inflammatory, venesection is occasionally advisable, but free local depletion by cupping, and the application of counter-irritants are absolutely necessary. This is particularly the case with the inflammations of the thorax and brain; if the latter organ be attacked, revulsive foot baths and cold applications to the head should be constantly kept up. Although an active congestion of the brain, which requires these antiphologistic means, does not constitute an insuperable objection to the use of stimulants, these remedies should always be given in the least possible dose, and be immediately discontinued if the symptoms of the delirium tremens abate. If there is gastritis, ice and iced water should be given, and the stimulant discontinued as soon as possible. Many of our cases were of this complicated kind, but the mortality was not increased by them. Still the gravity of the prognosis is much increased, and they must occasionally prove fatal. In recommending the stimulant treatment as on the whole the safest, espe- cially in cases which cannot be carefully watched, I do not mean to assert that other methods of treatment will not be equally successful with extraor- dinary care, but I am fuliy convinced that no method is so safe and so prac- ticable both in severe and in slight cases, especially if they cannot receive more than the ordinary attention which a physician in large practice can give them. But a physician, who is convinced of the propriety of the course, may leave a mild case to itself with the certainty that it will wear itself out, or he may adopt some other form of practice. Of these the two which are most used in this city are the methods by opiates and by emetics. As to the former, notwithstanding the predilection I once had for it, I would restrict the use of opiates to two different circumstances; one is the cases of delirium tremens which follow surgical accidents, in which the attack is often slight, hut where rest is essential. In these cases I would at present, give opium with stimulants, either the anti-spasmodics or the alcoholic stimulants. 24S DELIRIUM TREMENS. But the opium should be given in moderate doses, as thirty or forty drops of laudanum, repeated at intervals of two, three or four hours. There is another case in which opium is useful, though I have not found it strictly necessary; that is, at the close of the disease when the symptoms have subsided, either naturally or by the aid of treatment, but the patient remains restless and sleeps badly; a single dose of 10 or 12 grains of Dover's powder, or 25 or 30 drops of laudanum, given at night, will then often hasten the recovery. There are also times during the course of the disease in which the patient is disposed to sleep but composes himself with difficulty, in which the same treatment will produce good effects. I do not object to opium given in this way to assist nature, I object only to relying upon it as the remedy by which sleep may be forced, to use a common expression. The emetic treatment is in like manner often a successful one, and in the milder cases of the disease which occur after a forced abstinence from the habitual use of spirits, it is found to be successful. It was much relied upon by Dr. Klapp of this city, who contributed greatly to its introduction. The ex- planation which I give of the action of emetics, differs from that admitted by Dr. Klapp, who supposes that they act chiefly upon the stomach. It is their general, not their local action, which seems to me the most beneficial; the languor and relaxation which follows vomiting, calms the nervous agitation and disposes to a healthful sleep. If the vegetable emetics be prescribed, there is little danger following their use; but in patients who have had the facilities of indulging freely in large quantities of ardent spirits, that is, the drunkards belonging to those classes of society who are in comparatively easy circumstances, these remedies are attended with danger, and I have not found, as a general rule, that they are equally certain of producing a speedy cure as the stimulant practice. In recommending alcoholic stimulants as the most certain remedy, I do not exclude anti-spasmodics and the different stimulants. These may be substi- tuted in many cases for the former remedies, or they may be given in combina- tion with them. The best are Hoffman's anodyne, assafcetida either in milk or tincture, capsicum and valerian. The simple infusion of valerian is an excel- lent calmant in these cases. Capsicum is best fitted to those cases in which theTe is much nausea with a sensation of sinking at the stomach, while there are few or no evidences of inflammation. It may be given in pills of one or two grains repeated every two hours, or in a larger quantity if the article be of feeble strength. Tonics are also of great benefit in many stages of the disease. In the treatment which I have recommended, I am aware that I do not agree with some of my professional brethren, for whom I entertain the highest respect. In common with them I had my own repugnance for it to overcome; but the evidence of its effects has been of a nature, which I could not refuse to admit. I lay no claim, of course, to originality in advising a method which has been long used, other than what results from settling its value upon a more definite basis than has yet been done. It is possible that other methods may prove equally successful; for the disease tends to a natural recovery, and this termination may be favored in many ways, but the results which I have given for the past year are upon so large a scale, that they clearly prove that no method can yield a more successful result. 249 CEPHALALGIA. General symptoms.—Causes.—Morbid anatomy and pathology.—Varieties.— Diagnosis.—Prognosis.—Treatment. The term Cephalalgia (from x^aTw}, caput, and, a%yo{, dolor) simply implies pain in the head. In its various forms it is, perhaps, one of the most frequent maladies to. Avhich humanity is subject, and often constitutes a disease of the most distressing and fatal kind. This affection appears under so many forms, is produced by such a number of causes, is in its nature so variable, and is connected Avith such different morbid lesions, that a perfect knowledge of it, Avith a vieAV to treatment,'is obtained with the utmost difficulty. Indeed, as has been Avell-observed, " there is no disorder Avhich tries the science, experience, powers of obser- vation, and acumen of the physician more than this does, and there is none that requires a more precise estimate of the patho- logical conditions on which it depends, as a basis for safe and successful indications of cure." (Copland.) This, indeed, Avill be evident when we reflect that it is not only a disease sui generis, but one of the most common symptoms of numerous others; that a knowledge of its pathology involves an acquaintance Avith the Avhole morbid anatomy of the brain, and that the indications it furnishes for an accurate diagnosis in diseases of this organ gene- rally are of primary and essential importance. The characters and symptoms of headach are very variable, but demand great attention Avith a view to the proper treatment. As regards intensity, the pain may be so slight as scarcely to be noticed, and may vary in this respect, until it becomes so severe as to render the patient almost maniacal. In its situation it may be apparently near the surface, or deepseated. Sometimes the pain is diffused, so that it can be ascribed to no particular place, or it may occupy only a part more or less circumscribed, such as the forehead, temples, occiput, or vertex. When limited to one side of the head, it is denominated hemicrania, and vulgarly megrim; Avhen confined to a small spot, so that it can be covered Avith the finger, clavus; when under the eyebroAvs, suborbital; when in the ear, otalgia, &c. In character it may be described as dull, heavy, indistinct, numbing, pricking, compressive, con- strictive, tensive, acute, tearing, splitting or bursting, darting, lancinating, plunging, cutting, gnaAving, boring, throbbing, &c. 250 cephalalgia, (Symptotns.) Some persons state that the head appears to be breaking open, others, that the pain resembles continued strokes on the cranium made Avith a hammer, or as if Avedges or nails were driven into the brain. In its approach, headach may be sudden or gradual, in duration variable, from a few minutes to several years, and in the latter case may be continued, remittent, or intermittent. It may be accompanied by several abnormal sensations, such as giddiness, a feeling of sinking and dread of falling, coldness in the head, sleepiness, stupor, or, on the other hand, great wakefulness. There are often various noises in the head, as Avhistling, humming, ringing, buzzing, drumming and detonations; different affections of sight, as ocular spectra, muscse volantes, dimness, black spots, bright rings, sparks, &c; and more or less obtuseness of taste and odors. General sensibility may be augmented, so that the slightest contact causes groat agony; the scalp, in particular, is often excessively tender to the touch. Sometimes it is diminished or partially destroyed. The muscular system may be affected Avith fatigue, prostration of strength, soreness, shivering, pain in dif- ferent regions, sometimes cramps, pricking, or there may be con- vulsions and more or less paralysis. The intelligence is often affected. The patient may be hypochondriacal, and have his usual spirits depressed. There is melancholy and moroseness; he is indifferent to circumstances Avhich, if in good health, he Avould have thought important, and incapable of using mental exertion. He may seek repose, silence, solitude and obscurity, 'or, on the other hand, society, noise, music, and active occupa- tions. The collateral symptoms should also be attended to. The face is sometimes hot, flushed, and swelled, or pale, cold, livid, and sunk; the eyes may feel heavy or painful, and appear injected or suffused; one or more of the teeth are occasionally painful; the skin of the cranium or forehead may be hot and more or less injected; sometimes there is discharge from the ear, and occasion- ally tenderness on pressing the cervical vertebrae. Sometimes the circulation is increased, the temporal and carotid arteries beating with violence; at others, the pulse is small, hard, and Aveak, and the veins of the head and neck occasionally swollen. There may be thirst, loss of appetite, and disgust for food; acidity and flatu- lence of the stomach; eructations, nausea, and vomiting. The urine may be pale and clear, or loaded, depositing a copious sedi- ment. The bowels are often costive and deficient in biliary secretion, the skin dry or unusually moist, &c. Causes. Women are more liable to headach than men, on account of their having a higher degree of nervous irritability and delicacy of constitution. Their sedentary life also, and the great changes produced in the system by the flow of the men- strual fluid, particularly if it be retarded, increased or diminished, render them peculiarly predisposed to this malady. Some phy- cephalalgia, (Causes.) 251 sicians, as Georget and Calmeil, suppose headach to be hereditary and that it may be transmitted by the father or the mother for several generations. We know nothing certain, however, regard- ing this point. The other causes which predispose to Cephalalgia, are a too early or long continued use of the mental faculties; unrestrained indulgence in the passions; mental anxieties; too eager pursuit of business, or of gain; full living, and a conse- quent state of plethora; or, on the other hand, an insufficient diet and anaemia; the scorbutic diathesis; depressing circumstances; pregnancy; indolence; indulgence in bad; neglect of exercise in the open air; wearing a large quantity of hair; intestinal Avorms; abuse of mercurials; the presence of other maladies, as rheuma- tism, gout, syphilis, &c; obstacles to the free course of the circu- lation from morbid alterations, in the heart, aorta, lungs or other organs; venereal excesses; masturbation; involuntary seminal emissions, &c. The exciting causes are numerous; such are the abuse of vinous or spirituous liquors, sometimes coffee; errors in diet, especially too great a quantity or variety of food, especially of indigestible, rich or heavy articles; inspiration of deleterious gases, fumes of charcoal, miasmata, mephitic vapors, impure air of croAvded or insufficiently ventilated rooms; odors of various substances, particularly turpentine and oil paint; sleeping in apartments containing plants in floAver; suppression of accustomed discharges, as epistaxis, the menstrual secretion, or haemorrhoidal flux; losses of blood; spontaneous or artificial leucorrhoea; supine posture Avith the head Ioav; a tight cravat, or straight corset; sud- den vicissitudes of temperature, or of the weather, especially by northerly or' easterly winds; abrupt changes in the electrical states of the air; prolonged or excessive lactation; Ioav diet and prolonged fasting; the various depressing passions, as alarm, fear, grief, anxiety of mind; want of sleep; inordinate mental or phy- sical exertion; use of tobacco, digitalis, opium, belladonna, aco- nitum and other narcotic drugs, especially in certain idiosyncracies or in large or unaccustomed doses; caries or irritation of the teeth and gums; costiveness or constipation; the irritation of morbid secretions and faecal matters retained in the boAvels; exposure to cold and humidity or to currents of air; uncovering the head Avhen in a state of perspiration; exposure to the sun; damp or insufficient clothing. Finally, headach may be symptomatic of other diseases, as of fever, phrenitis, coryza, congestion of the lungs, hypertrophy of the heart, the presence of Avorms, inflam- mation, various diseases of the eye, &c. Morbid Anatomy and Pathology. Cephalalgia may be oc- casioned by every species of change to which the structure of the brain is liable, and consequently its morbid anatomy compre- hends a knoAvledge of all the abnormal alterations Avhich have been found in this organ. On the dissection of individuals Avho have died laboring under the most distressing headachs, have g52 cephalalgia, (Causes.) been found worms in the frontal sinus; caries of the ethmoid and other bones of the cranium; collections of pus in the nasal cavi- ties; fibrous tumors formed in the dura mater, together with ossifications in different portions of that membrane; serous effu- sions into the ventricles and cavity of the.arachnoid; indurations and softening of the substance of the brain; encysted abscesses, hydatids and apoplectic cicatrices in the cerebral lobes or cerebel- lum; different kinds of tumors occupying various portions of the organ, as the tuberculous, cancerous, albuminous, steatomatous, &c, and lastly, greater o#less congestion of the vessels. Nume- rous instances also have occurred Avhere no morbid change could be detected, and yet the pain has been very intense. Under any circumstances it is difficult to explain in Avhat manner headach is produced, the brain having been disorganised to an immense extent by large chronic abscesses when no material suffering has been occasioned, and when even cerebral lesion Avas not sus- pected; Avhile the results of numerous experiments on animals, as Avell as the infliction of severe wounds on the human bram, have shoAvn that the structure of the cerebral lobes and cerebel- lum is not endoAved with sensibility. The slow progress, how- ever, of some morbid growths is well calculated to obviate irrita- tion, inasmuch as the brain becomes accommodated to them, its structure is gradually absorbed to make room for their develop- ment, and the circulation is carried on in the healthy portion without any material derangement. Thus in tAventy cases of fungus of the dura mater published by Louis (Mim. de VAcad. Roy. de Chir. t. 5,) there were only three with cerebral symp- toms of any kind; and chronic abscesses, cysts, hydatids, exos- toses, &c, have often arrived at an enormous size Avithout having produced any serious alteration in the functions of the brain. But these evidently render the organ more disposed to sudden alterations in its circulation, as is manifested by the sudden and rapid effects occasioned, whenever any cause excites or diminishes the heart's action. Some morbid changes, hoAvever, appear to produce a greater irritating effect than others, such as cancer, encephaloid and malignant tumors of the nervous structure and acute softening. The pain accompanying these is more pro- longed, deep-seated, and of a peculiar character. The pain itself is generally referred to the external surface of the head, and often appears to the patient connected with the bones, a fact Avhich MM. Jolly, Georget and Calmeil, explain by supposing that in this, as in other parts of the system, impressions are attributed to the extremities of the nervous fibres. Numerous observations have established the fact, that headach and a greater or less disturbance of the functions of the brain, is often accompanied by more or less derangement of other organs, as the stomach, heart, liver, uterus, &c; and diseases in these last often apparently occasion affection of the first. This has been cephalalgia, (Varieties.) 253 generally attributed to sympathy, a term, hoAvever, by which Ave can only express that the altered functions of one organ coincide tvith the deranged functions of another, without any obvious cause. As our knoAvledge of pathology increases, the number of these sympathetic diseases diminishes; and although much difficulty attends the investigation, Avhen connected with headach we anticipate that at some future period more precise ideas will be entertained of its pathology. At present it may be considered a law in the animal economy, that pain cannot be produced unless the animal is conscious of the application of a stimulus producing irritating impressions on a portion of the nervous sys- tem; that a certain degree of pressure is capable of producing this irritation, which may exist Avithout causing any structural alteration; and that consequently, Avhen no organic change can be discovered, headach is ahvays occasioned by pressure, Avhich probably arises from local congestions of blood, although the causes tending to these, or the means by Avhich they are pro- duced, are yet unknoAvn. On the other hand, Avhy the stomach, heart, liver, uterus, &c, should be affected from diseased brain, is even more difficult to explain. We know that a certain connec- tion exists between these viscera and the centre of the nervous system; but why in some cases one should be acted on in pre- ference to another is inexplicable. The numerous theories Avhich have been formed regarding the functions of the sympathetic system of nerves by no means remove the difficulty. Did we even adopt the theory regarding the influence of the ganglial nerves over the bloodvessels, Ave are still at a loss to account for the production of functional changes in one organ, independent of or unconnected Avith others. We may indeed suppose, that an irritation exists at the origin of the par vagum which is capa- ble of explaining some of the symptoms, as gastralgia, nausea, vomiting, loss of appetite, &c; and we consider it much more probable, that these nerves furnish the communication which exists between the brain and stomach than the sympathetic. But Avhy should the respiratory system in these cases escape? Are we to imagine the morbid alteration limited only to those fibres which are distributed to the stomach, Avhile those going to the lungs are unaffected? Mature consideration of this subject has hoAvever convinced us that, in the present state of science, no positive opinion can be given concerning these points. Varieties. An arrangement of the different forms of headach is, as has been stated, of great importance with a view to treat- ment. For this purpose, however, while we regard the symp- toms as being the chief point to be attended to, it is of equal importance not to lose sight of the pathology of this affection, in order that it may be reduced, if possible, to the general laws 254 cephalalgia, (Varieties.) which govern all the operations of the nervous system. Neither pathological nor semeiological principles, hoAvever, can in this case guide us alone, and we are, therefore, under the necessity of arranging the different varieties according to both, as far as they are known and distinct. Without entering then into a criticism on the different classifications of headachs, we consider that, in a pathological point of vieAV, and for practical purposes, this disease may be divided into seven varieties: 1. The congestive, from congestion occasioned by increased or diminished vital action of the heart and bloodvessels. 2. The inflammatory, from inflam- mation in the membranes or substance of- the brain. 3. The sympathetic, from disorder of the digestive, biliary, uterine, uri- nary, and other organs. 4. The organic, from structural change of the bones of the cranium, membranes, or substance of the brain. 5. The neuralgic, from affection of the nerves distributed to the integuments. 6. The metastatic, from the metastasis of disorders; and, 7. The intermittent, occurring at stated periods. We shall notice each of these in succession. Congestive headach. It is very probable that every species of headach, except the organic and neuralgic, depends upon a greater or less degree of congestion of the vessels of the brain. The variety which we are noAV considering is characterised by the congestion being primarily cerebral, and unconnected with any other affection. It must be remembered that this patholo- gical state may be produced in the brain by an increase or dimi- nution of those vital actions by Avhich the equilibrium of the circulation Avithin the cranium is maintained; and hence all those causes which diminish and increase the action of the heart and bloodvessels may induce it. The headach depending upon de- pressing causes, and accompanied by general irritability of the system, is the nervous headach of some authors, and the conges- tion in these cases, if increased, may determine to syncope; but, when connected with increased action, the congestion if continued may occasion apoplexy. We shall have an opportunity, under the head of Treatment, of alluding to the great importance of attending to the two different kinds of congestive headach. The cerebral symptoms in both will be found to be nearly the same; thus the pain may be acute, lancinating, or attended with a sense of heaviness; there is vertigo; and the sight is dim or impaired, dark spots or meshes move before the eyes; there is occasionally buzz- ing, ringing, and humming noises in the ears, and other affections of the special senses. The other symptoms, however, are much opposed; thus the pulse may be small and Aveak, or full and strong; the face pale and sunk, or flushed and tumid, &c; other symptoms may be present, arising from more or less derangement of other organs, of which we have already spoken. Inflammatory headach. This variety of headach arises from inflammation of the membranes or substance of the brain, and cephalalgia, (Varieties.) 255 the symptoms are those Avhich characterise those affections, to the description of which we refer. Sympathetic headach. By this term must be understood head- ach apparently depending on disease or derangement in the func- tions of another organ. Pathologically it cannot be separated from the congestive variety, but in this case it is secondary. If the stomach is deranged, and nausea or vomiting is a prominent symptom, it has received the name of sick headach; if the liver or biliary apparatus is affected, it has been called bilious headach; if it accompanies indigestion, it is known by the name of dyspeptic headach. It may also be connected with derangements of the uterine and urinary organs. When headach coincides with de- rangements in other viscera, it is often difficult to discover the primary affection. It frequently happens in practice that reme- dies are directed to cure disorders of the stomach as if it Avere the primary malady, although it may have been produced by organic disease of the brain. Sufficient attention has not been paid to this point, although of the greatest importance, as some remedies prescribed for a stomach affection, as for instance eme- • tics, Avould be highly dangerous did any structural change exist in the brain. We shall again allude to this subject under the head of Diagnosis and Treatment. Organic headach. We have already stated that this variety may be occasioned by any of the numerous alterations to which the bones of the cranium and the membranes or structure of the brain are liable, and that there is much difference between the results occasioned by a slow or rapid formation of these. When the brain is the seat of the morbid structure, the pain is fixed to one place, more continued and deep-seated, although intermissions •are not uncommon, and sometimes it remits without being en- tirely absent. It often produces derangement of the stomach, but without any apparent cause connected with that viscus itself. If the pain is occasioned by disease of the cranial bones, it is con- fined to one spot, and appears more superficial: if the periosteum be affected, its character, according to Dr. Binder, is tensive. The advanced stages of tumors and other alterations in the brain are marked by convulsions, neuralgic pains, paralysis, and affections of general and special sensibility. Neuralgic headach. For information on this variety the reader is referred to Neuralgia. Metastatic headach. This variety is usually observed in persons of a rheumatic and gouty diathesis. The rheumatic headach is simply rheumatism affecting the aponeurosis of the occipito-fron- talis and temporal muscles. It depends upon the same causes and is cured by the same means as rheumatism in general. It is rarely, however, present before this disease has been manifested in some other part of the body. The arthritic headach is not uncommon in individuals of a gouty diathesis, particularly if they 256 cephalalgia, (Diagnosis.) have neglected the means necessary for developing a confirmed paroxysm. It is often very dangerous, and may be occasioned by a metastasis of gout to the brain, although in some instances it is premonitory of a regular attack. If not removed, it may terminate in apoplexy. Intermittent headach. This form of the disease attacks persons subject to periodic fevers. It may return daily, or even twice in the course of tAventy-four hours, for a certain time, or assume a tertian or quartan type. It may be limited to a half or smaller portion of the head. When the brows are especially affected, it is called brow ague. The character of the pain is often neuralgic. It is most common in spring and autumn; prevails in damp and marshy districts: and is caused by exposure to cold, terrestrial exhalations, &c. Diagnosis. We are persuaded that, generally speaking, very little care is taken to distinguish the different varieties of headach, although in treating nervous diseases this is the most important subject that can occupy the attention of the practitioner, as it often indicates the nature of the malady, influences his prognosis, and directs his treatment. Some of the varieties are readily dis- tinguished; others, hoAvever, are determined Avith more difficulty, and in certain cases require the greatest patience and power of observation on the part of the physician. The congestive headach may be knoAvn by the occasional ver- tigo and a sense of fulness or weight in the head. The pain is acute, or dull, throbbing or gravitating, not fixed to one spot or long continued. It comes on gradually, reaches its highest inten- sity, and then slowly declines. These changes are often very quick and not observed. In some cases the pain is relieved by the horizontal, in others by the upright posture: it is often pro- duced by stooping, sleeping Avith the head low, Avearing a tight neckerchief, stays, &c. We have said that this variety may be divided into two kinds, distinguished by the debilitated or ple- thoric state of the system. The first is recognised by the feeble- ness of the pulse, paleness of the countenance, chlorotic habit, general irritability, by its occurring in females, or, when it occurs in males, it is often the indication of dissipated habits, and ex- haustion of the constitutional poAvers. In the second kind, on the contrary, the pulse is full, there are symptoms of repletion and plethora, and this form is generally met Avith in males or in persons of either sex habituated to full living. The congestive variety of headach is generally more severe either in the morning or in the evening; and, in order to be distinguished, should be carefully compared Avith the diagnostic symptoms of the other varieties. The inflammatory headach is distinguished by the strong pulse, heat of surface and general fever, flushed countenance, suf- fusion of the eyes, and sometimes intolerance of light. The pain cephalalgia, (Diagnosis.) 251 is very acute and throbbing, accompanied Avith a pulsating noise in the ears or temples. The patient is excited, restless, watchful, and irritable: in the more advanced stage convulsions and delirium appear, accompanied by symptoms which indicate inflammation of the brain and its membranes. It is of great importance to distinguish sympathetic headach, especially from the organic. When it depends upon derangement of the stomach, liver, or alimentary canal, it may be known by the foul state of the tongue, and improper performance of the diges- tive functions. The pain is often diffused over the head, but sometimes more circumscribed, usually affecting in such cases the forehead or one temple, particularly the left. In character it is either dull, heavy, or oppressive, or acute, sharp, and darting. The headach is usually present when the patient wakes in the morning, and in slight cases generally disappears after breakfast, or even earlier. In general there is little appetite in the morning, and the too frequent practice of having recourse to alcoholic sti- mulus, from its often giving temporary relief, increases the affec- tion. If there is nausea, the headach generally continues till vo- miting takes place, when the remains of an indigested meal, or ingesta mixed with bile of a yellowish or greenish color, is dis- charged, to the great relief of the patient, after Avhich the symp- toms disappear for a time, a circumstance that does not take place in the organic headach. The sensation attending the vomiting is also very different, being often preceded by unpleasant taste in the mouth, eructations, and flatulence. In general it returns the same day, and runs a similar course for some time, until the diet is properly regulated, and purgatives have been taken. Some- times it follows a principal meal, particularly if any indigestible substances have been indulged in. Many idiosyncracies exist in this respect, the headach in some being invariably occasioned when certain articles of food have been inadvertently indulged in. The headach occasionally comes on at a certain period, perhaps two, three, or four hours after a meal; and in this instance, ac- cording to Drs. Warren and Paris, it arises from irritation of the duodenum. In all these cases the pulse is generally slow and weak, sometimes frequent and small; the tongue is white or yel- low, more densely furred tOAvards the root; and the bowels usu- ally costive. The group of symptoms now detailed will suffi- ciently distinguish dyspeptic and bilious headach. The cephalal- gia to which hypochondriacs are subject, is generally to be refer- red to the same variety. In Avomen, headach is often combined with hysteria, and depends upon some derangement in the ute- rine system. In this case, it is often confined to a small spot, and in its character resembles a nail pressing upon or driven into the brain. The attention of the physician should here be directed to the menstrual discharge, Avhich Avill generally be found irregular, painful, scanty, or excessive. Leucorrhoea also, combined with 22* 258 cephalalgia, (Diagnosis.) flatulence and more or less disorder of the alimentary canal, may be present. It is remarked by Jolly (Diet, de Mid. et Chir. Prat.), that cephalalgia arising from disorder of the uterine function is generally confined to the sinciput, a diagnostic symptom, how- ever, that requires confirmation. Headach is also symptomatic of shock or mental impression. In such cases there is a sense of weight or pain in the head and sleeplessness, and often a disposi- tion to suicide; according to the observation of M. Barbier, of Amiens, the pain is generally in the occipital region. It is often of consequence to distinguish this kind of headach, which it is dif- ficult to do, without being informed that some circumstance has occurred which has produced an effect on. the mind; and with a view to diagnosis, inquiry on this point should be made. Head- ach may also arise from a host of other disorders, to which it may readily be attributed, as worms in the intestines, calculi in the kidneys, ureters, or bladder, inflammation of the spinal cord, &c. The organic headach is in the early stages with great difficulty distinguished from the other varieties. A careful examination, hoAvever, into the history of the case, will enable the observing physician to learn that the pain often occurs in paroxysms Avith- out any apparent cause, and at irregular periods; that Avhen pre- sent, it is increased by conversation and active occupations, and relieved by solitude, tranquillity, and absolute repose. It is in no way alleviated by any particular position the patient assumes, but often increased on stooping, or turning the head suddenly. The character of the pain is lancinating, or darting, apparently confined to one spot, and, if the bones are affected, is increased by pres- sure. If there be vomiting, it may be distinguished from that Avhich accompanies dyspeptic headach, by its being apparently independent of any error in diet or affection of the stomach, and by its occurring when the pain is most violent, and not producing any material relief. In the advanced stages it may usually be re- cognised by the continuance and severity of the pain, by spasmo- dic twitching, greater or less imperfection or total destruction of one or other of the senses, paralysis, &c. A very cautious diag- nosis should be given in the first stage of this variety, until the patient has been observed some time; the increasing number and severity of the attacks noticed, and its permanent effect on the functions of motion and sensation carefully attended to. The neuralgic headach is readily known by the intensity of the pain, and its shooting or plunging character, following the course of the nerve, but sometimes confined to one spot. It is of short duration, and comes on in violent paroxysms, leaving inter- missions which are sometimes considerable. Although, in this form, the digestive organs are often deranged, it may readily be distinguished from the sympathetic headach by the above charac- ters. The metastatic headach includes two varieties:—1. Rheuma- cephalalgia, (Prognosis.) 259 tic headach may be known by the severe aching pain, occupying the scalp, increased on applying pressure, or on the slightest move- ment of the muscles connected with it. It is generally increased in the evening, and is sometimes associated Avith the inflamma- tory or congestive headachs. 2. The arthritic form occurs in persons of a gouty diathesis. The pain is severe and attended Avith a sense of heat or burning, great tenderness and increased heat of the scalp, flushed countenance, confusion of thought and loss of memory, vertigo, dimness of sight, intolerance of noises, and most of the cerebral symptoms which characterise the severe forms of the congestive and inflammatory varieties. There are also furred tongue, flatulence, costiveness, unhealthy stools, and other symptoms of derangement in the digestive functions, toge- ther Avith scanty high-colored urine, Avhich deposits a copious red- dish sediment. The history of the case hoAvever, and its connec- tion with some of the forms of gout, Avill readily distinguish it. The intermittent headach is analogous to the neuralgic, and is distinguished by the regularity of the paroxysms. The pain is often excruciating, and is usually dependent upon the same causes that produce intermittent fever. The prognosis of headach entirely depends upon the accuracy of the diagnosis. In all organic affections of the brain the result is generally fatal, although, if the symptoms are developed sloAvly, this may be deferred for several years, especially if judicious treat- ment be pursued. In cases of this variety, therefore, the progno- sis will always be unfavorable, particularly if more or less loss of motion, sensation, and intelligence, be the principal symptoms. A cautious opinion is necessary when the bones of the cranium appear to be the seat of organic change. In the congestive va- riety, the prognosis will depend on the constitutional state of the patient. Generally speaking, hoAvever, these cases are not fatal unless symptoms of an apoplectic tendency supervene. Much caution is necessary in giving a prognosis in the inflammatory and metastatic varieties: the arthritic, in particular, is an affection demanding a very guarded opinion; the prognosis in the sympa- thetic variety will depend upon the extent to Avhich disease af- fects those organs primarily disordered. If recent, and no organic disease be present in any particular viscus, a favorable prognosis may be confidently givem An opinion, however, should be of- fered with caution, when the stomach, heart, liver, kidney, &c. are the seat of structural alterations. The neuralgic and inter- mittent headachs generally admit of a favorable prognosis; the former, however, if it occurs in elderly persons of a debilitated con- stitution, may render any other malady under which they may incidentally labor more dangerous. Treatment. No doubt can exist that the treatment of cepha- lalgia, generally speaking, has been conducted on principles which partake too much of empiricism, and that purgatives and other 260 cephalalgia, (Treatment.) remedies Avhich act on the primae viae have been too indiscrimi- nately employed. A study of the pathology of this affection, Iioav- ever, must convince the practitioner that headach may depend upon states of the system directly opposed to each other; that occasionally it is complicated Avith, or seems to form, part of other maladies, and that consequently its treatment must be varied ac- cording to the morbid conditions present, and the organs prima- rily affected. With this view a diagnosis of the variety described is absolutely essential. The congestive headach will demand two opposite kinds of treatment, according as it is connected Avith increased or dimin- ished action, or, in other words, with plethora or anaemia. If cephalalgia occurs in persons of a plethoric habit of body, who are accustomed to a full diet, and take little exercise, and in whom the pulse is full and of good strength, general bloodletting is indi- cated, the extent of which is to be guided by the age and consti- tution of the patient. In strong and middle-aged persons, it should be continued until a marked effect on the pulse is pro- duced. This should be followed by active purgatives, and anti- phlogistic diet. Cold affusions on the head are also useful, com- bined with warm and stimulating applications to the feet. In elderly persons, or when the pulse and general appearance do not indicate the more active method of general depletion, the ap- plication of cupping-glasses to the temples, behind the ears, occi- put, or nape of the neck, Avill often be sufficient to remove the vertigo and other distressing symptoms; leeches may be applied with the same view. The above means rarely fail in removing the complaint, and the endeavors of the practitioner should then be directed to prevent its recurrence. This is to be accomplished by enforcing a light, abstemious, and easily digestible diet; pro- moting the secretions and excretions by exercise in the open air, and, if necessary, by aperient medicines, or by a course of the natural or artificial purgative waters. The hair should be cut short, and care taken to sleep with the head and shoulders Avell- elevated. The occasional use of the shower-bath will also be heneficial; and, in some cases, blisters behind the ears, over the temples, and at the nape of the neck, or the tartar emetic ointment and other derivatives have been employed with advantage. When too close mental application is connected Avith the causes inducing the complaint, the former should be restricted or entirely broken off, and the mind relieved by travelling, light reading, and active exercise in the country, while the measures recommended for lessening the congestion, according to the age and constitution of the patient, should be resorted to. Slight attacks of this form of the disease are very common, and are in general removed by a spirit lotion applied to the forehead, an aperient, exercise in the open air, cheerful conversation, or any circumstance that distracts the attention. Sternutatories also are often instantaneously use- cephalalgia, (Treatment.) 261 ful in light cases, by procuring defluxion from the Schneiderian membrane. Should the congestive headach, however, be connected with an opposite state of the system, and symptoms of debility be present, then a stimulating and tonic line of treatment is to be adopted, which must be influenced by the state of exhaustion to which the patient is reduced. If this be extreme, much caution is necessary, as irritative fever is, in such cases, readily induced, particularly in females. Small and frequently repeated doses of the Sp. Ammon. c Tr. Lavend., or alkaline carbonates with some bitter infusion, Avill improve the state of the system and increase the appetite. The diet should be nourishing, at the same time light and digesti- ble, and a glass of good wine may be taken during dinner. In this variety of headach, the bowels should be rigorously attended to. They Avill generally be found torpid, requiring stimulation by the resinous purgatives mixed Avith the aromatic roots and barks. These remedies will often be successful in ordinary cases, but if the disease continues, and there is much restlessness and watch- ing at night, small doses of anodynes and hypnotics may be given. A pill, containing Ext. Hyos. and Pil. Hyd. aa gr. iv, may be taken at bedtime, and in the morning a draught, consisting of Dec. Aloes Co. 3ss, Spir. Ammon. Co. 3ss, Inf. Aur. Co. 3vj. This prescription may be repeated several successive nights, or every other night, as occasion may require. The other anodynes and more powerful tonics may also be administered if necessary, particularly camphor, the muriate and nitrate of morphia, qui- nine, preparations of iron, valerian, assafoetida, &c. Inflammatory headach demands active bloodletting and anti- phlogistic treatment. (See Inflammation of the Brain). Sympathetic headach. The treatment of this variety of head- ach must be directed to the cure or alleviation of those maladies on which it depends. The dyspeptic headach of authors is bene- fitted by all those means adapted to prevent indigestion; and with this view a light diet, regular exercise in the open air, aperients combined Avith tonics, and such remedies as promote the regu- larity of the excretions and secretions, are indicated. In some few cases leeches to the pit of the stomach, and a rigorous anti- phlogistic diet, have been found useful, especially when the dys- pepsia depends on chronic inflammation of the stomach. Should nausea be present, and we are sure that it is in no way connected with organic change in the brain, an emetic of ipecacuanha or tartrate of antimony, followed by copious draughts of Avarm Avater, or chamomile tea, so as to favor its action, "will often tem- porarily remove the nausea and cure the headach. For this pur- pose small doses of the neutral salts Avill be useful, such as the sulphate of magnesia, tartrate of soda, particularly in the form of Seidlitz poAvders, in combination Avith carminatives. They should be taken every morning, and followed by exercise, to fa- 262 cephalalgia, (Treatment.) vor their operation. Other purgative preparations may be em- ployed Avith the above, if necessary; such as the compound rhu- barb or colocynth pills, one or more of which may be taken on alternate nights. The patient must be guarded in his regimen, avoiding repletion and indigestible substances. The amusements of a watering-place, and a course of the ferruginous or aperient mineral Avaters, according to circumstances, will assist in produc- ing a cure. Should the headach come on after dinner, two or three of the pills, composed of rhubarb, aloes, soap, and ginger, in equal proportions (generally denominated the dinner pill), will often tend to its removal. When cephalalgia is connected with any derangement of the biliary functions (constituting the bilious headach), in addition to the general treatment above pointed out, it is proper to combine with the purgatives, such medicines as have a special action on the liver. For this purpose, calomel or the blue pill may be mix- ed Avith the purgative pill masses, and given in moderate doses, according to the strength of the patient and circumstances of the case. It will be right at the commencement of the treatment to procure several copious stools, and afterwards give small altera- tive doses of the mercurial preparations, so as to keep up a regu- lar action on the bowels and liver. The purgative action may be assisted, if necessary, by doses of aloes, gamboge, compound in- fusion of senna, and other remedies of the same class, combined with the alkaline subcarbonate and neutral salts. These latter Avill prove particularly useful when there is an acid taste in the mouth, or eructations. If any pain exist in the neighborhood of the liver, increased by pressure on the substance of the organ, and the pulse is accelerated and strong, general or local bleeding is indicated, together with antiphlogistic remedies. If gall-stones, or masses of indurated bile, block up the hepatic or biliary ducts, a diluent diet, with demulcents, cooling drinks, and an alterative mercurial course, should be prescribed. Much care sho.uld be taken in such cases to examine the abdomen, and remove collec- tions of faeces in the large intestines by emollient or purgative in- jections. The treatment noAV recommended for the dyspeptic and bilious headachs will, in general, be also adapted to the affection occurring in hypochondriacs, combined with the other means ap- plicable to the treatment of that malady. When headach follows the suppression of cutaneous eruptions, diaphoretics and the warm and vapor baths are to be employed. If it arise from disorder of the uterine functions, removing the original affection is the only means of permanently remedying the cephalalgia. The same may be said when it is connected with disorder of the urinary or other organs. When the teeth are decayed, extraction is necessary, or the application of reme- dies which alleviate the pain, as opium, creasote, &c. The hysteric headach is to be combated by the use of tonics, cephalalgia, (Treatment.) 263 antispasmodics, and purgatives, if necessary, according to the age and constitution of the patient. All the therapeutic remedies useful for removing the general nervous derangement tend to relieve the cephalalgia. (See Treatment of Hysteria.) Organic headach. When we have reason to believe organic change exists in the substance of the brain, and that it is not far advanced, absolute tranquillity and the horizontal posture are necessary elements in the treatment. With this should be com- bined, first, general and local bloodletting, purgatives, and an antiphlogistic diet, according to the age and powers of the indi- vidual. This should be followed by various derivatives, as blis- ters over the temples, behind the ears, to the occiput and nape of the neck, frequently repeated, and dressed by stimulating oint- ments, in order to keep up a long discharge. Issues, setons, and the moxae, may be used for the same purpose. The secretions and excretions are also to be carefully watched, and their healthy state promoted as much as possible by appropriate remedies. If vomiting is a frequent symptom, this should be relieved by some effervescing drink, or hydrocyanic acid, both of Avhich have often been useful in temporarily alleviating the distress occasioned by it. When the system has been brought low by the above treat- ment, a mild mercurial course may be tried, Avith a vieAV of pro- curing absorption, or the different preparations of this drug Avith iodine. In general, however, therapeutic remedies only alleviate the symptoms, and by no means prevent the progress of the dis- ease. In the advanced stage, characterised by more or less para- lysis, loss of the special senses, and of general sensibility, all reme- dies are in general useless, and we can only lessen the distressing pain so often present by opiates and soothing remedies. When the bones are affected by a syphilitic taint in the system, remedies adapted to the cure of that malady are to be employed. If caries exist, the usual surgical treatment is to be followed. In active in- flammation of the periosteum or bone beneath it, art incision through the periosteum to the bone is often folloAved by speedy relief. The metastatic headach, including the rheumatic and arthri- tic, together Avith the neuralgic and intermittent varieties, are to be treated in the same manner as the diseases of which they usually form a part. Although the various remedies to Avhich we have alluded have often been found useful in certain headachs, there is great diffi- culty in applying them to those cases Avhich are capable of being benefitted by each respectively. Idiosyncracy in different indi- viduals also often baffles our investigation of the exact effect of a particular drug. In obstinate cases, therefore, Ave should vary the different medicines and applications, so that, Avithout depart- ing from the general principles Avhich have been detailed, we may give the patient the benefit of all such means as the present state of our therapeutic knowledge, and the experience of others, teach us may possibly be successful. 264 / EPILEPSY. History.—Symptoms—premonitory—of the seizure—consecutive.—Duration. —Causes—predisposing—exciting.—Varieties—idiopathic—sympathetic. —Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treatment. The term epilepsy (itti^ia, Irta^i, from trtaappava, to seize or attack) is applied to a disease in which there is sudden loss of consciousness and sensibility, with convulsion of the voluntary muscles, accompanied and followed by coma; these symptoms occurring in paroxysms. This disease has been described by the oldest medical Avriters, many of whom considered it to be induced by supernatural agency. Hence many of the names Avhich it has received, as morbus sacer, scelestus, demoniacus, deificus, divi- nus, &c. Although Hippocrates attempted to combat the absurd opinions regarding its origin, he retained the first of these names. Since his time it has received numerous appellations. It is the morbus Herculeus of Aristotle; lunaticus of Aretaeus; comitialis of Pliny; sacer and major of Celsus; convivalis of Plautus; son- ticus of Aulus Gellius; carducus of Paracelsus; analepsia of Riverius, &c. In France it is vulgarly called mat de terre, mat de Saint Jean, haut mat, &c; and Avith us falling sickness. Symptoms. We shall divide the symptoms of epilepsy into those Avhich precede, constitute, and folloAV the attack. Premonitory symptoms. Georget says, that the premonitory symptoms do not occur in more than five cases in a hundred (Diet, de Mid. Epilepsie); but according to the statistical re- searches of M. Beau, they are observed in about half the attacks that take place. (Arch. Gin. de Mid., torn, ii.) The folloAving are the premonitory symptoms which haAre most frequently been noticed: pain in the head—dimness or temporary loss of sight— optical illusions—double or partial vision—strabismus—vertigo— drowsiness—noises in the ears—disagreeable odors.—morbid per- ception of flavors—violent sneezing—hiccough—frequent yawn- ing—flushing or unusual paleness of the face—anxiety of the countenance—increased size of the pupils, or alternate contrac- tions and dilatations, Avith trembling of the iris—feeling of cold- ness or of emptiness in the head—perversion of character—loss of recollection—confusion of ideas—frightful dreams—disturbed sleep—feeling of increased strength—loathing of food, or great voracity and increased appetite—vomiting and eructations—in- epilepsy, (Symptoms.) 265 voluntary evacuation of the excretions—increased sensibility of the surface—sensation of pricking or formication in the arms, legs, back, &c.—cramps—unsteady gait—desire of motion—im- pulse to run forwards, or to turn round, &c. A premonitory symptom peculiar to epilepsy is named the aura epileptica. It consists in a sensation of coldness, warmth, pain or itching, pro- ceeding from the toes, legs, thighs, hands, arms, uterus, abdomen, stomach, breast, face, or head. If it commence in the extremities, it proceeds up the limb affected towards the head, and when it arrives there or ceases, the paroxysm begins. Sometimes it stops at the epigastrium. It is seldom that more than two or three of the above symp- toms are present at a time, but they occasionally change in the same individual. When they are felt, the patient is aware of the approaching attack, and seeks to avoid it by the use of such remedies as experience dictates. Sometimes, however, the pre- monitory symptoms are either so severe, or occasion so much irritability in the individual, that he drinks Avine or other liquors with a view of favoring the attack and bringing it on as soon as possible. Symptoms of the seizure. The commencement of the seizure is generally characterised by the utterance of a scream or exclama- tion, immediately after which the individual falls to the ground violently convulsed. In forty-eight cases mentioned by M. Beau, in Avhich the cry occurred at the commencement of the attack, there Avere no premonitory symptoms in thirty-eight. He thinks, therefore, that this symptom should be considered as an expres- sion of surprise on the part of the patient, and not as properly belonging to the attack. (Arch. Gin. de Mid. torn, ii.) Occasion- ally the convulsions occur before the fall, or various singular movements immediately precede it, as running fonvard or turn- ing round. One of Esquirol's cases kept turning round for seve- ral minutes, and another ran as fast as possible some distance before falling. Foville describes a case in which, after screaming, the patient took several quick pirouettes, and convulsively made numerous signs of the cross. Sometimes the patients take seve- ral short leaps resembling dancing, described by Fabricius as the epilepsia saltator; and Dr. Reid says, that he has often seen patients hop five or six times on both feet, with their bodies per- fectly rigid, before they fell. (Trans, of Assoc, of Phys. in Ire- land, vol. iv.) These various states are not unfrequently fol- lowed by more or less tetanic rigidity before the accession of the convulsions, and in some cases the cry, the fall, and the convul- sions, succeed almost immediately each other, or appear instan- taneously. Consciousness is entirely suspended, the most pain- ful application failing to produce any sensation. In severe attacks (the grand mat of the French) the hair becomes erect; the fore- head contracted and wrinkled, the eyebroAVS drawn down and ap- 23 266 epilepsy, (Symptoms.) proaching each other, or agitated; the eyes are prominent, some- times fixed and drawn upAvards, or rolling in the orbits; the pupils are contracted, dilated, or natural, but the motions of the iris are slow or entirely abolished; the eyelids are sometimes alternately elevated and draAvn doAvn, or half shut or open; the face is tumid, red, livid, or ecchymosed; the Countenance much distorted; the lips either contracted, elongated, pushed forwards, or drawn backAvards; the inferior maxilla is either draAvn strongly against the superior, or the jaAVS are Avide asunder; the teeth are some- times forcibly gnashed or ground together, and have been broken by the violence of this action; according to Van Swieten, it has even produced dislocation of the jaAV. The tongue is thrust out of the mouth, is swollen, livid, and more or less lacerated by the spasmodic action of the maxilla; the vessels of the head and neck are much distended; the carotids beat Avith great force; the head executes rotary movements, or is carried forwards and backAvards, or to the right and left sides alternately, and sometimes it is spas- modically fixed in one position that differs in various persons; the neck is often rigid; the trunk is either twisted in different Avays, or rests tetanically fixed; the extremities are violently tossed about, Avhile the arms strike against the chest, and the hands and fingers perform continued motions of flexion and extension, and the thumbs are permanently flexed, and the toes incurvated. The former of these symptoms has been thought by some character- istic of epilepsy. The convulsions are usually of a tonic character, the muscular contractions being more prolonged than the relaxations, and sometimes one side of the body is more affected by them'than the other, Avhile the face is drawn to the right or left side. The res- piration is at first performed Avith difficulty, as if a load was placed upon the thorax, and soon becomes quick, short, and irregular. The air entering the lungs is almost immediately ex- pired mixed Avith a mucous fluid, sometimes tinged with blood, which is thus rendered frothy as it flows from the mouth. If it enter the trachea, a suffocating rale is produced, and the contrac- tions of the muscles of the larynx are increased, so that partial asphyxia is occasioned. The pulse, at first small, becomes fre- quent, hard, irregular, and sometimes imperceptible; the action of the heart is tumultuous and violent, and that of the carotids increased; sometimes there is erection of the penis and emission of semen or of the prostatic fluid; occasionally involuntary dis- charge of the urine and faeces, the latter often accompanied with flatus; the skin is bathed Avith perspiration, and sometimes there is a discharge of blood from the nose, and in a feAV rare cases from the ears. After a certain time these severe symptoms diminish; the convulsions gradually cease; vomiting or eructations some- times occur; the patient takes a few deep inspirations, and the movements of the chest by degrees become natural; the pulse be- epilepsy, (Symptoms.) 267 comes full, soft, and regular; the distortion and discoloration of the face disappear; the eyes resume their natural aspect; and after a period of stupor, more or less continued, consciousness returns, and the patient appears as if awoke out of a deep sleep, without the slightest recollection of what has passed. A feeling of great fatigue, and sometimes of pain in the neck or occiput, is com- plained of; and there is an irresistible desire for sleep, from Avhich the individual generally awakes in a natural state. Sometimes, hoAvever, the eyes remain squinting, fixed or haggard, and the pupil temporarily enlarged, Avith faltering of the speech, weakness of one or more limbs, and general disinclination to exertion, These symptoms gradually disappear, and the patient is restored to apparent health. The duration of the paroxysm is very variable: generally speaking, it is from five to fifteen minutes: sometimes, however, it may be momentary, and in other cases it continues for several hours. Dr. Copland states he has seen it last more than four hours, and in one case seven hours, the seizure consisting of tAvo fits Avith an indistinct interval of soporose exhaustion. The fre- quency of the attack is also variable; it may return many times in a day, every day or tAvo, or once a Aveek, fortnight, month, six months, every year or even longer, with occasional vertigo only in the intervals. The accessions in some persons recur at deter- minate periods, and take place at a certain time every year, month, week, or day. When it is monthly, the day of attack often coincides Avith a new or full moon, but by no means in a regular manner, and in females it is often apparently connected Avith the increased activity of the uterine functions. At other times the paroxysms appear irregularly, and there may be several attacks, with short intervals, folloAved by an interval of some duration. In some persons the seizure takes place during the day, at others during the night, or only during sleep, in Avhich latter case the patients are only aware of the attack on Avaking in the morning. In such cases the epileptic attack seldom occurs during the day. The severity of the epileptic paroxysm varies from the slightest convulsion or spasmodic movement to the more violent and frightful seizure. When the attacks are habitually slight, the malady is named by the French petit mat, or ipilepsie vertige. If the consciousness is lost only for a few moments, the eyes and features become spasmodically fixed, but the patient, on recovering, continues the discourse he may be engaged in at the time of its occurrence. In some cases consciousness is not entirely lost, the individual retaining a confused recollection of what passed during the paroxysm; in others the loss of consciousness is ac- companied by slight spasms, rigidity or convulsions of a feAV mus- cles only, or of one or more limbs, which may continue a minute or tAvo; Avhile, in othftr instances, the patient does not fall to the ground, although the mental faculties may have been momen- 268 epilepsy, (Symptoms.) tarily abolished. These slight epileptic seizures may continue for years without any change, or they may gradually increase in severity, and usher in the more confirmed attack. Not unfre- quently they alternate with the more perfect paroxysms, the one ' or the other being more frequent. In 206 cases of this kind col- lected by M. Beau, the slight fits were more frequent than the severe in 115, and less frequent in 27, equally frequent in 45, and undetermined in 19. Symptoms which follow the attack. We have noticed some of the effects Avhich supervene on the abatement of the paroxysm; there are others, however, Avhich appear and continue for a longer or a shorter time. Thus a severe fit maybe followed by con- vulsions or irregular movements, more or less complete palsy or hallucinations of mind, sometimes accompanied with a kind of ecstasy, and continuing for a few hours or several days. The intelligence may be affected in different ways; there may be delirium, loss of memory, frightful dreams, watchfulness, deaf- ness, dimness of sight or spectral images of uncertain duration. Sometimes, after the attack, epileptics are seized Avith a fury, which requires restraint. This state has been denominated mania ipileptica or epileptic delirium, and usually continues from one to three days. Various accidents occasionally occur during the fit, which may require surgical aid. Thus, patients may fracture bones, receive contused or other Avounds, or they may fall into the fire or into water, or be precipitated from a Avindow or scaffold. The long continned or frequent repetitions of the attacks occa- sion a peculiar physiognomy, which is at once recognised by an experienced eye. The features become enlarged and coarse, the inferior eyelids swollen, the lips thick, the eyes full or vacillating, the pupils dilated, the cheeks pale, certain muscles of the face convulsed, and the countenance assumes an expression of va- cancy, Avhile the finest features become plain. Epileptics have a peculiar gait; the arms and legs waste, and the body sometimes becomes fat, or in other cases emaciated, and ultimately they become either deformed and paralytic, or the limbs are power- fully contracted. The intelligence gradually becomes Aveak, the sensations obscured, and at length complete alienation of mind is established. Generally speaking, when the fits are severe, or even if slight and frequently repeated, these latter effects are to be dreaded. Esquirol and Foville have observed that they occur more frequently after the ipilepsie vertige ox petit mat. Some- times the patient has fits of melancholy alternating with mania, either of which states may terminate in perfect imbecility. It occasionally, although rarely, happens, as noticed by Dr. Cheyne, that epileptic persons preserve their intellects to a very old age. The frequent complication of epilepsy A^jith mental alienation is shoAvn by the result of 385 cases collected by MM. Esquirol epilepsy, (Causes.) 269 and Calmeil. Of these 46 had hysteria, 12 monomania, 30 mania, 145 dementia; 34 Avere furious, 8 idiotic, 50 generally reasonable, but subject to loss of memory, or extravagant ideas; some had slight delirium, and all a tendency to dementia; and in the remaining 60 the intelligence was perfect. The termination in mania is apparently little influenced by the mildness or severity of the epileptic attack, the most violent paroxysms sometimes leaving the patient sane, whilst the slightest have been followed by dementia. Epileptics are much addicted to venery and to onanism, Avhich frequently induce the disease, and favor its con- tinuance. The duration of epilepsy is most uncertain, and depends upon the cause, constitution and habits of the patient. In young per- sons it may cease at puberty, or it may continue for a series of years. The individual may die during a violent fit, immediately after it, or from its effects, or death may be caused by the super- vention of other consecutive diseases, generally some form of cerebral disease, or from others quite unconnected with it. Causes. Before the age of seven years the influence of sex is not apparent, but after that age epilepsy is most common in females. On the 31st of December, 1831, there were 162 male epileptics at the Bicetre, and 389 female epileptics at the Sal- petriere. J. Frank found that of 75 patients 40 were females. The greater proportion of females is to be accounted for by the increased irritability of their nervous system. Of 66 cases in which the period of menstruation was ascertained by MM. Bouchet and Casauveilh, in 38 the seizure happened before, and in 28 after, its occurrence. Epilepsy may occur at all ages; it is, hoAvever, most frequent in infancy and childhood, more rare in adults, and seldom met Avith in old age. The period of puberty seems favorable to its development from the changes which take place in the constitution: and when it existed previously, it often disappears about this period. In 69 cases given by MM. Bouchet and Casauveilh, epilepsy was manifested from birth to the age of 5 years in 18 (9 of these were congenital,) from 5 to 10 years in 11, from 10 to 15 years in 11, from 15 to 20 in 10, from 20 to 25 in 5, from 25 to 30 in 4, from 35 to 40 in 2, from 40 to 45 in 1, from 45 to 50 in 2, and from 50 to 60 in 1. Nearly the same results Avere obtained from the more extended observations of M. Beau, who out of 232 cases found 17 Avere congenital, 18 determined in infancy at an age unknoAvn. from birth to 6 years it commenced in 22, from 6 to 12 in 43, from 12 to 16 in 49, from 16 to 20 in 17, from 20 to 30 in 29, from 30 to 40 in 12, from 40 to 50 in 15, from 50 to 60 in 4, and from 6 to 61 in 1; in 9 cases the age was not ascertained. Hereditary disposition has been considered as poAverfully predisposing to epilepsy. Zacutus Lusitanus, Stahl, Hoffman, Saillant, Maisonneuve and others, cite numerous examples sufficient to prove this. In 110 cases, 23* 270 epilepsy, (Causes.) where the necessary inquiries Avere made by MM. Bouchet and Casauveilh, 31 Avere hereditary. Esquirol considers, from the results of the inquiries he made at the Salpetriere, that it is more commonly transmitted by the father than the mother, Avhich is contrary to what takes place in madness. Congenital formation in some cases occasions this disease, particularly Avhen the cra- nium is unnaturally elevated or depressed in particular parts, or otherAvise ill-formed. No particular habits of life or tempera- ment are exempt from this disease, although it is more common in some than in others. Foville considers it is more prevalent in the poorer classes, and Copland agrees with him. Ancient as Avell as more recent observers have noticed the frequency of its occurrence in persons of a plethoric habit of body, and Dr. Cooke remarks, that all the cases he has seen have taken place in those of the sanguine temperament. No doubt can exist, however, that it is often met with in individuals of feeble poAvers, and that the numerous causes Avhich tend to depress the vital actions poAverfully predispose to epilepsy. Thus, it is common in per- sons of a cachectic habit of body, originating in scorbutic, scrofu- lous, syphilitic or rachitic affections, or from ill-regulated and improper diet. Esquirol has noticed its frequency in persons of a melancholic temperament. Great excitation or depression of the mental powers, as fear, terror, grief, anxiety, joy, anger, indignation, &c, predispose to this disease. The observations of Hibread tend to show that celibacy may also prove a predis- posing cause. On the 31st of December, 1813, he found in the Bicetre 162 male epileptics, of whom 119 were unmarried, 33 married, 7 widows, and one had been divorced. Particular climates have been thought by some to favor the production of epilepsy; it is certainly more prevalent in some countries than in others, more especially Italy, France, Poland, and some parts of Germany. This circumstance may be more correctly attributed to moral causes, particularly to onanism and premature venereal indulgences. The plica Polonica has been thought by Frank and De la Fontaine to be a predisposing cause of epilepsy. Season does not appear to exercise any influence on its produc- tion, as in the large receptacles for epileptics in Paris no differ- ence is observed at any particular period of the year. Hippo- crates and Tissot, however, considered it more common in spring. The occurrence of one attack produces a state of the system which poAverfully predisposes to subsequent seizures. Among the other predisposing causes may be enumerated peculiarity of constitution or idiosyncrasy; improper nutrition, arising in the infant state from an impaired quality of the milk furnished by the nurse; the presence of the meconium; intestinal worms; errors in diet; irritation of dentition^ injuries of the head; ligatures and bandages on the head or neck; insolations; abuse of vinous or alcoholic liquors; organic alterations in the bones epilepsy, (Causes.) 271 of the cranium and vertebral column, or in the membranes or substance of the brain and spinal cord, &c. The exciting causes are numerous, and may be divided into two classes:—1. Those which act directly on the brain and spinal cord; and, 2. Those Avhich act indirectly. Of the first class, injuries are common exciting causes of epi- lepsy, arising from falls or bloAvs on the head, producing fracture of the cranium, or vertebrae, and consequent pressure on the brain or spinal cord, or contusion and concussion. Morbid changes in the nervous substance, or the membranes and bones which cover it, as inflammation, tumors, indurations, softening, &c, of the former and caries or exostosis of the latter may also induce the disease. The numerous circumstances producing congestion, hoAvever, are by far the most frequent exciting causes, as the immoderate use of fermented or distilled liquors; excessive exercise; fatiguing exertions; strained position; suppression of the catamenia, otto- rhoea, purulent discharges, and other accustomed evacuations; checked transpiration; metastasis of gout or rheumatism to the head; sudden disappearance of porrigo, psora, herpes, and other eruptions; exposure to a high temperature, especially to the rays of the sun; impure air and crowded assemblies; exposure to cold; atmospheric vicissitudes; disagreeable odors; recollection of par- ticular events; excessive haemorrhage; bloodletting unnecessarily employed or carried too far; menorrhagia, excessive masturbation or venereal indulgence; inordinate exciting or depressing affec- tions of the mind, as joy, indignation, anger, terror, fear, grief, anxiety, intense mental exertion, disappointment, nostalgia, &c; Avatchfulness, frightful dreams, prolonged wakefulness, effect of certain dramatic performances, turning round rapidly, &c. To the second class may belong difficult or painful dentition; foreign substances in the ear; the presence of the meconium; indu- rated faeces; mucous, acrid, and foreign substances in the alimen- tary canal; calculi in the kidneys, ureters, or bladder; narcotic and other poisons; pregnancy and other causes of uterine irritation, &c. It may also occur as a complication of measles, scarlatina, small-pox, and other eruptive disorders in children. There are some exciting causes that cannot be comprehended under either of the above classes. Thus, numerous instances are given by Baglivi, Boerhaave, Lettsom, Duncan, and others, in Avhich imitation, or witnessing a paroxysm, has brought on an attack. To the same cause, probably, may be ascribed its having occurred epidemically in the free school of Bickfeld in Germany, as recorded by Dr. Meyer. Boys and girls were taught together; only the latter, however, Avere affected; the girls were approach- ing the age of puberty, and of a highly excitable temperament. On one morning; two epileptic girls having experienced a parox- ysm, in less than half an hour more than twenty others Avere similarly affected. (Brit, and For. Med. Rev., October, 1838.) 272 efilepsy, (Varieties.) Galen, Aretaeus, Riverius, Hoffman, Stahl, and many other Avri- ters, consider that there is some relation between the paroxysms and the periods of neAV and full moon. Esquirol, hoAvever, states, that in the number of epileptics he has seen together, he has never observed the accessions more frequent at one phase of the moon than at another. Lamotte speaks of a woman who had been pregnant eight times, Avith five girls and three boys, and had epi- leptic attacks only when pregnant with boys. In conclusion it may be remarked, that, of all the exciting causes that have been enumerated, fear and terror appear to be the most frequent; next, fits of passion, distress of mind, and venereal excesses. Varieties. The division of epilepsy generally adopted into idiopathic and sympathetic appears to be the most useful for prac- tical purposes. The former implies that the disease arises prima- rily in the brain or spinal cord; the latter, that the exciting cause originates in remote organs. In this sense these terms are syno- nymous Avith those of centric and eccentric employed by Dr. Mar- shall Hall. Another point of great importance to be attended to is, that either idiopathic or sympathetic epilepsy may be connect- ed Avith an increased or diminished action of the vital powers, and that consequently a very different line of treatment is to be pursued in cases belonging to the former or to the latter. Idiopathic or primary epilepsy is induced by all those causes we have enumerated which act directly upon the brain or spinal cord. Idiopathic epilepsy, attended with increased vascular action, occurs generally in persons of a sanguine and plethoric habit, Avho have lived generously, and Avhose general appearance indicates a full habit of body. The premonitory symptems are usually head- ach, vertigo, noises in the ears, dimness of sight, &c., and full strong pulse. During the paroxysm the face is red, tumid, or livid; the respiration, at first interrupted, becomes difficult and stertorous; the convulsions in general are not violent or long con- tinued, and the stupor which follows is long and profound. In the interval, vertigo, headach, and the occasional occurrence of the other premonitory symptoms, are common. This variety of the disease has a tendency to terminate in, or to be compli- cated with, apoplexy. Idiopathic epilepsy connected with diminished vital action, on the other hand, appears for the most part in individuals of weak constitution, Avho are supported on insufficient diet, or in persons in whom the, bodily functions are exhausted by continued labor under depressing circumstances, or who have_ been addicted to masturbation and venereal indulgences. The premonitory symp- toms are unusual depression; increased irritability; nausea or vo- mititing, or fainting, accompanied Avith a weak, small, and acce- lerated pulse. During the paroxysm the countenance is not so full and livid as in the variety just described, the respiration is epilepsy, (Varieties.) 273 less difficult, the convulsions more violent and longer continued, and the subsequent stupor comparatively slight. During the interval the face is pale and salloAV, the pulse small and Aveak, and there is evidence of general depression. This variety has a tendency to terminate in insanity or mental imbecility. It must be remembered that cases occur, Avhich are Avith diffi- culty ascribed to one or other of the above varieties. In general, however, they are readily distinguished, the most common being that Avith increased vascular action. Some authors endeavor to draAV a distinction between cerebral and spinal epilepsy; but a consideration of the general pathology of nenrous diseases must show that this can have no proper foundation, as the malady ne- cessarily consists in the derangement of the functions of both. The convulsions must be attributed to irritation of the spinal cord, and the loss of consciousness to pressure on the brain. The only difference between them, therefore, Avill be found to consist in the increased degree of stupor when the brain is the organ principally affected, and the more severe convulsions Avhen the exciting cause more especially influences the spinal cord. Sympathetic or secondary epilepsy is brought on by all those causes Ave have enumerated which act indirectly on the brain and spinal cord. This species of the disease, Avhile it is also connected with an increased or diminished energy of the vital powers, cha- racterised by the symptoms above described, is principally depen- dent on diseased action or disordered function in other organs. Hence affections of the circulating, digestive, biliary, urinary, and generative organs may occasion attacks of epilepsy, and give rise to so many varieties of the disorder. Sympathetic epilepsv con- nected Avith disease of the heart has been noticed by Morgagni, Lancisi, Gould, Greding, Reid, and other Avriters, Avho have point- ed out, that in these cases the attacks are preceded or accompa- nied by irregularity or intermission in the heart's action. Syncope is also a frequent symptom, and in cases thus complicated, the epileptic paroxysm is often brought on by mental emotions. This variety is generally associated Avith a depressed state of the sys- tem. Sympathetic epilepsy arising from irritation in the digestive organs has received the name of epilepsia stomachica, gastrica, enterica, verminosa. When the stomach is affected, one or more of the folioAving symptoms may be observed: cardialgia; nausea; eructations; vomiting; increased, capricious, or diminished appe- tite; loaded tongue; disagreeable breath; acid or bitter taste in the mouth; torpid boAvels, and various dyspeptic symptoms. They are for the most part associated with a state of vascular excite- ment. When the intestines are the seat of irritation, many of the above symptoms may be present, sometimes accompanied Avith pain in the abdomen, attended either \vith constipation, or with diarrhoea, arising from accumulation of acrid secretions or indu- rated faeces, and portions of undigested food. In children the dis- 274 epilepsy, (Anatomical Characters.) ease is often brought on by the irritation of dentition during the first or second period; in the latter case the disease is occasionally severe and of long duration. The presence of Avorms, especially the tape and lumbricoid varieties, in the intestines, is also a fre- quent cause of convulsions in children. In these cases, the usual symptoms of the presence of worms are observed: viz. craving, voracious, and unnatural appetite; costiveness, alternating with diarrhoea; the appearance of the stools being unhealthy; tumid abdomen; picking the nose, great restlessness, &c. When epilepsy is connected with irritation in the biliary organs, it may be sus- pected from the salloAv or jaundiced appearance of the face or skin. If there be pain, fulness or tenderness in the region of the liver, Avith flatulence, occasional hiccough, vomiting of yellow or greenish bile, light or clay appearance of the stools, &c, we may in general ascribe the origin of the disease to a morbid condition of the liver. During the paroxysm the respiration is often inter- rupted, and the diaphragm moves with difficulty, and is apparently draAvn downwards. Obstructions in the biliary ducts from gall- stones, or other causes, may also induce this variety. Sympa- thetic epilepsy may arise from irritation in the urinary and gene- rative organs. Thus, calculi in the kidneys, ureters, bladder, or stricture of the urethra, may prove exciting causes. We have already alluded to the influence of masturbation in the male and female, or of disordered uterine functions in the latter, as exciting causes of the disease. This last forms the epilepsia uterina, hys- teria, nervosa, &c. of authors, and has been ably treated by Dr. Prichard, Avho has recorded several cases of this variety of the disease. It generally appears about the menstrual period, and is most common towards the approach of, or soon after, puberty. It may also arise from difficult, obstructed, suppressed, or exces- sive menstruation, or indeed from any cause producing irritation of the uterus or genital organs in general. Convulsions are also frequently met with in connection Avith pregnancy and parturition. Lastly, epilepsy may be connected with irritation in the skin and external organs of the body. Numerous cases have been report- ed by authors, in which epilepsy has apparently been induced by the appearance or disappearance of cutaneous eruptions, ulcers, cicatrices, tumors, wounds, &c, and which have been cured by their removal. It must be evident, that attention to these sympathetic varieties is of the utmost importance with a view to the proper treatment of the disease, as by removing the irritation which is the exciting cause, the disorder is in many cases relieved or disappears Avith it. Anatomical characters. All the various morbid alterations to which the brain and spinal cord are liable, have been found in persons Avho have fallen victims to epilepsy. When an individual dies, who has for a short time been laboring under this disease, epilepsy, (Anatomical Characters.) 275 uncomplicated with any other nervous affection, no appreciable lesion can be discovered. If death takes place during a paroxysm, more or less congestion of the brain is often found. If the disease be of longer standing, and is connected with mental aberration, there is generally considerable dilatation of the bloodvessels, accompanying an indurated or softened state of the white matter of the brain, affecting either its Avhole substance or particular parts of it. There are also irregularities in the surface of the gray matter, arising from chronic inflammation, with adhesions to the membranes Avhich cover it, as has been shoAvn by Morgagni, Foville, Bouchet, and Casauveilh. It often presents a marbled appearance and a rosy tint, dipping more or less into its substance, and is sometimes increased or diminished in consistence. Such are the appearances most generally found; but in particu- lar cases, other alterations have been described by authors, and thought to have some relation to the disease. It has been re- marked, for example, by Leduc and Lorry, that the bones of the cranium are generally thickened in epileptics, and the sutures more or less effaced. Dr. Bright gives the delineation of a case, in Avhich the anterior portions of the cranium Avere thickened nearly half an inch, and Bontius found on one occasion the occipi- tal bone nine lines thick. Zacchias saw the interior table of the same bone destroyed by caries. Exostosis and caries have been frequently found in the bones at the base of the cranium, and prolongation or alteration in direction of the processes in the same situation, by the Wenzels, Greding, Neumann, Sims, and others. Dr. S. Palmer has furnished us Avith several cases observed and examined by him in lhe Edinburgh Poor-house, where the sphe- noid bone was more or less thickened, the posterior clynoid pro- cesses elongated, or various spicula of bone growing from the base of the cranium. The membranes, also, are often thickened, and contain osseous points, spicula, or tumors of different forms. Esquirol, on opening an epileptic, aged twenty-three, found an osseous ovoid tumor adhering to the internal surface of the dura mater, eight lines in diameter, depressing the superior convolu- tions of the brain. We have seen in the possession of M. Magen- die, the preparation of a brain taken from an epileptic, Avhose intelligence Avas perfect during the intervals, although two tumors groAving from the dura mater had considerably pressed upon both anterior cerebral lobes. One, on the left side, Avas the size of a Avalnut, and had hollo Aved out for itself a portion of the nervous mass; Avhile the other, on the right side, was much larger, and intimately connected Avith the substance of the brain, so that its exact extent could not be ascertained. The sinuses and vessels of the brain are often turgid Avith blood, their coats containing fibrous and osseous secretions. Small bony points in its sub- stance are so common, as to be considered a natural rather than a morbid occurrence. Greding has found it softened in twenty- 276 epilepsy, (Anatomical Characters.) five epileptics. The pineal gland has been found more or less changed by Baillie, Soemmering, the Wenzels, and Greding. The pituitary gland has been found more or less altered by the Wenzels, Greding, Neumann, Sims, and others. The Wenzels in particular have directed much attention to the changes in this substance, which they have ahvays found altered in epileptic cases. In twenty epileptics they discovered it enlarged in seven; containing a yellow solid or pulverulent matter in ten; and a thick viscous fluid in five. It often showed traces of inflammation, although there was no other alteration in the brain or meninges. In the substance of the brain have been found scirrhous, tubercu- lous, fibrous, osseous, or encysted tumors; extravastions of blood; abscesses, &c. Morgagni, Greding, Meckel, Boerhaave, and others, have found the brain indurated and even callous, and in many cases softened. Serum has been effused into the lateral ventricles, and the plexus choroides has been found enlarged, injected, and containing serous cysts. Most of the morbid changes we have mentioned as connected Avith the brain have also been discovered in the spinal cord. M. Esquirol, assisted by M. Amussat, found that, in ten epileptics Avho died at the Salpetriere between the 1st of February and the 1st of June, there Avere nine Avith lesion of the cord or its cover- ings, the most common appearance being concretions in the arachnoid membrane. M. Gendrin has discovered tubercles in the superior part of the cord in several epileptics; and in one case M. Andral fouftd the cervical portion indurated. In the sympathetic varieties of the disease, numerous lesions of the viscera and other structures of the body have also been dis- covered. In the cardiac variety, a greater or less number of the alterations to which the heart is liable, are found, such as water in the pericardium; hypertrophy or atrophy of the substance of the organ; dilatation of the cavities; obstruction in the aorta or pulmonary orifices. Various diseases of the lungs may occur in individual epileptics. The numerous morbid changes Avhich take place in the stomach or digestive tube; intestinal Avorms; enlarge- ment, inflammation, abscesses, and other lesions of the liver; dis- eases of the kidneys or bladder, or calculi in these organs; ulcera- tion or other morbid alterations in the uterus and genital organs of the male and female; tumors and inflammation in the course of the nerves; wounds, cicatrices, ulcerations, eruptions, &c. on the surface; and indeed almost every morbid alteration which the various tissues undergo, have been found in epileptic cases. Nature. Epilepsy is characterised by two distinct morbid phenomena, namely, loss of consciousness and convulsions. Whatever be the nature of the connection between intelligence and nervous matter, all physiologists are agreed, that the cerebral lobes furnish the conditions necessary for its manifestation. Nu- merous facts and experiments also demonstrate that motion epilepsy, (Anatomical Characters.) 277 depends upon the tractus motorius of the spinal cord, and that combined movements may be attributed to its being acted on by the stimulus of volition on the one hand, and that of mechanical irritation on the other. In epilepsy there is a loss of the first function and increase of the second, and consequently we regard this as a cerebro-spinal disease, the functions both of the cerebrum and spinal marrow being necessarily deranged. Foville asks how it happens in epilepsy, Avhen consciousness and sensation are abolished, that motion should be so much increased. The fact is, this is the circumstance which constitutes epilepsy. If the functions of the brain alone were increased or diminished, there Avould be delirium or apoplexy; if those of the spinal cord, convulsions or paralysis. In the disease we are considering, however, the functions of the brain are lost, while those of the spinal cordf are increased; and although in this, as in all nervous diseases, numerous modifications occur, by Avhich, in different cases, it more or less approximates to other disorders of the same class, these circumstances may be considered the distinguishing characteristics of this affection. What is the lesion Avhich occasions these effects ? A consider- ation of the different alterations usually discovered after death, renders it evident that they cannot be attributed to them, although it is reasonable to suppose, that when spiculae of bone or other morbid structures directly irritate the motor columns, or some part of the brain, they may predispose to convulsions. But that this is not the sole cause, is evident from the occasional occur- rence only of the attack, Avhile such morbid structures are con- stant. If a spicula of bone occasioned the convulsions, they Avould continue so long as it Avas present; and supposing that this or other limited fixed lesion could produce either the loss of con- sciousness or increased motion, Ave cannot suppose it capable of annihilating one function and exciting another at the same time. These different organic alterations, therefore, can only act by rendering the brain more liable to sudden changes of the circula- tion Avithin the nervous structure ; and considering that epilepsy is usually found in individuals either of plethoric or debilitated constitution, that the attacks are excited by causes influencing the circulation, and that, Avhen death occurs during a paroxysm, in- creased turgidity of the cerebral vessels is invariably found, we are at once led to the conclusion, that Ave must attribute to cere- bral congestion a necessary part in the production of the disease. That there is cerebral congestion during the attack is generally admitted, but it is still disputed whether it be the cause or the effect. It is stated by Foville, that Ave cannot refer the phenom- ena to congestion, inasmuch as the paroxysm ceases when the congestion is at its height, as manifested by flushing of the face, turgescence of the exterior parts of the head, tension of the jugu- 24 278 epilepsy, (Anatomical Characters.) lars, &c. But the continuation of such symptoms a short time after the decline of the paroxysm, by no means proves that Avhen this takes place the congestion of the brain is most intense; on the contrary, as it precedes their appearance, so its diminution must occur before their disappearance, for it is only Avhen there is obstruction of the circulation Avithin the cranium, that the blood is diverted into the external vessels; and the effect so produced must be most intense Avhen the cause begins to diminish. Be- sides, congestion is the only morbid state which can produce the results. Thus, it may be partial or general, and more intense in one portion than another; and in the introductory remarks, and when speaking of apoplexy, Ave have alluded to the fact, that slight,pressure causes increased action, and intense pressure, dimi- nution or loss of action. The substance of the brain itself is in- compressible by any force which can reach it from the heart, but the caliber of the numerous tubes which traverse it may be in- creased or diminished. This, of course, may occur unequally, giving rise to different degrees of pressure; and hence Ave can understand how congestion may occasion in one case apoplexy, in another paralysis, in a third convulsions, &c. according to its seat and intensity. Thus, in epilepsy, the cerebral lobes probably undergo such a degree of pressure as Avould cause temporary loss of intelligence, Avhile the cranial portion of the spinal cord is only affected to such an extent as to occasion convulsions. The ten- dency of the paroxysm to return is not peculiar to it, but to all congestive diseases; and we can readily comprehend how a cer- tain set of vessels, being once preternaturally dilated, are more disposed than others to become so again. The repetitions of the attack will of course lead to permanent organic lesions, as dilata- tion of the vessels, induration of the brain, &c. and gradually to continued disorder in the functions of the organ. The spinal symptoms may be caused either by direct or indi- rect irritation of the cord acting on the tractus motorious. The former is induced by congestion of the brain, or other morbid changes acting on the cranial or vertebral portion of the cord, and the latter by stimuli affecting the extremities of the nerves. The researches of Hall and Muller have shown that all convulsions are spinal, and that, when occasioned by irritation in distant or- gans, they depend upon a reflex function in the spinal cord. In epilepsy they must necessarily be independent of sensation, as consciousness and mental acts are abolished. In the sympathetic varieties of the disease, there can be little doubt that convulsions are so caused originally, because many cases have been cured by the removal of the source of such irritation. It is not, however, simply convulsions that constitute epilepsy, but a loss of con- sciousness combined Avith them; and the influence of cerebral con- gestion is at once determined by contrasting their violence and extent after the fall, with the spasms or irregular movements Avhich epilepsy, (Diagnosis.) 279 precede it. Hence, Avhatever the exciting cause may be, Avhether the motor column be irritated directly or indirectly, and the stim- ulus producing this be situated in the brain, spinal cord, or nerves, it is to cerebral congestion alone, acting on the two former, that the phenomena which constitute the epileptic paroxysm can be referred. Diagnosis. Epilepsy in its severe form is readily distinguish- ed from every other disease. It may, hoAvever, be so modified as somewhat to resemble, during the attack, other nervous affec- tions. Hysteria has often been mistaken for epilepsy, from which it may be discriminated by the presence of the globus hystericus and borborygmi, while the sensibility and consciousness are little, if at all, affected. The characters of the convulsions are some- what different, being more uniform and clonic; the features are less injected, and not so distorted; and the attack is not folloAved by sopor and fatigue. In the interval the history of the case, and the presence of other hysterical symptoms, in general indicate the nature of the convulsive attacks. Occasionally, however, epilepsy is complicated with hysteria in females, and the paroxysms pecu- liar to each may alternate, or partake of the characters of both. The loss of consciousness distinguishes the epileptic fits from the others in some cases, although very often no difference whatever can be discovered between them. Dr. M. Hall has pointed out, that in epilepsy the larynx is usually closed, Avith forcible expira- tory efforts, Avhile in hysteria it is open, with heaving, sighing, breathing. It is often very difficult to distinguish the convulsions in children from epilepsy, especially at an early age; hence ob- servation of the case for some time is always necessary before the diagnosis is pronounced. In general hoavever, Avhen not epileptic, the paroxysms are irregular, more frequent and continued; and the convulsions are of a clonic character. There is also more or less fever, dislike of food, thirst, watchfulness, or droAvsiness. The convulsions are most common at the periods of dentition, and cease Avhen the irritation this process occasioned is removed. Epilepsy is distinguished from apoplexy by the character of the convulsions, the limited continuance of the attack, and the history of the case during the interval. From all other diseases it is re- cognised by the occurrence of a scream; the preceding loss of consciousness, accompanied by tonic convulsions, Avhich are im- mediately folloAved by sopor and a sense of fatigue, and, as the malady becomes chronic, by mental aberration. Real may be detected from feigned epilepsy during the paroxysm by the sud- den application of any substance causing great irritation. If sen- sibility is manifested, we may consider the individual an impostor. The diagnostic symptoms characterising the different varieties of epilepsy are easily distinguished by referring to the description given of them. Prognosis. The opinion of the practitioner may be required 2S0 epilepsy, (Prognosis.) regarding the probable danger of the fit, the period of its return, or the curability of the disease. Epilepsy seldom proves fatal during the attack. This result, hoAvever, is most to be apprehended in individuals of a plethoric and sanguine constitution, in Avhom extravasation of blood Avithin the cranium may take place. The long continuance of coma is to be looked upon in an unfavorable light. When, also, symptoms of organic disease in the brain exist, as deep-seated, fixed, and in- tense pain; partial or total loss of vision, or of the other special senses; vigilance; paralysis, &c, the attack will probably be at- tended Avith fatal consequences. In young persons the paroxysm seldom indicates any immediate danger, unless from accidental circumstances, as injuries of thethead, &c, or from situations Avhere the patient may be at the time of seizure, as on the banks of a river, high-road, an open Avindow, near a fire, &c. The paroxysms recur more frequently in the idiopathic than in the sympathetic form. If the disease be hereditary, and there be marked alteration in the form of the cranium, or if organic lesion have taken place in the brain or spinal marrow, frequent recur- rence of the fits may be expected. Of the sympathetic varieties, the paroxysms are most common when the heart is affected, Avhile the intervals are more considerable Avhen the disease arises from irritation in the digestive, urinary, or uterine organs. An opinion regarding the curability of the disease should al- ways be very guarded, the most experienced physicians having acknoAvledged that it is one of the most obstinate maladies they are called upon to treat; indeed, by some it is considered to be in- curable. The idiopathic form of the disease is always to be con- sidered less curable than the sympathetic; and Avhen there is evi- dence of organic alterations in the brain or spinal cord, and when paralysis or insanity continues during the intervals, very little hope can be entertained of restoring the patient to health. The same may be said if the disease be decidedly hereditary, or if there be any marked change in the form of the cranium. The affection is more curable before the age of puberty, and often dis- appears during the changes produced in the system at that pe- riod; but should they continue, it is a proof that the disease is more firmly fixed in the system. When the general health is much impaired by masturbation or venereal indulgences, or is associated Avith a scorbutic, syphilitic, scrofulous, or rachitic dia- thesis, the disease is generally obstinate, although it occasionally disappears on abandoning the improper practices which occasion it, or by removing the malady Avith which it is complicated, and improving the general tone of the system. Treatment. The treatment of epilepsy should have reference, 1. to the seizure, with a vieAV of lessening its violence or guarding against injury; and 2. to the disease, with a vieAV of diminishing the frequency of the paroxysms, or preventing their return. epilepsy, (Treatment.) 2S1 ]. Treatment of the seizure. Immediately on the occurrence of an epileptic fit, all ligatures should be removed, and the head and shoulders supported in an elevated position. When preceded by the aura epileptica, a tight band should be placed just above the part where the sensation is experienced; in some cases this has been knoAvn to prevent the attack. If it take place in a house, the patient should be laid on a bed, and air freely admitted into the apartment. A cork, or a piece of soft wood in the form of a wedge, should be introduced between the teeth as soon as possi- ble, in order that the tongue may not be lacerated, and the vio- lence of the struggles gently restrained, so as to prevent any in- jury to the individual. As a general rule, no further interference is necessary or even useful, more particularly if the practitioner is unacquainted with the constitution and previous history of the patient. Stimulating the nostrils, or attempts to make the indi- vidual swallow, are injurious. But if it be a first attack, and if there have not been previous symptoms of diminished vital ac- tion, or if he be decidedly of a plethoric constitution and san- guineous temperament, bloodletting may be resorted to with ad- vantage. This remedy is also useful when the attack supervenes during the puerperal state. Cold affusion on the head is benefi- cial under the same circumstances, and should be continued for some time, so as to produce a depressing effect. It must not be * persevered in, however, when the heat of the scalp and force of the pulse is diminished. The above remedies may be employed, also, during the sopor which continues after the convulsions have ceased, if there be much heat of the head, a strong pulse, turgid countenance, and other signs of congestion in the brain connected with increased vascular action. But it must be remembered that they are dangerous Avhen the disease is connected with an oppo- site state of the system. Dr. Copland relates two cases where in- discriminate bloodletting increased the frequency and severity of the attacks. Stimulating purgative injections, particularly such as contain turpentine and camphor, may be used in most varieties of the disease Avith benefit. Many efforts have been made to shorten the attack. Dr. F. Hawkins thinks filling the patient's mouth with common salt use- ful for this purpose. Dr. Reid says, that " pressing the cold hand of an assistant forcibly on the soft part of the abdomen towards the spine; Avhile the patient is firmly supported on the back, with the head and shoulders raised," diminishes the duration of the seizure. Frank thinks the same effect is occasioned by placing a piece of cold metal in the hands; and Dr. Copland has seen appa- rent benefit from a similar application to the nape of the neck, or occiput. The plan of Dr. HaAvkins may induce suffocation, and is therefore dangerous, but the others recommended may be tried when the fit appears unusually long, although in most cases they will be found to produce no influence on the convulsions. 24* 282 epilepsy, (Treatment.) 2. Treatment of the disease. From Avhat has been said Avhen describing the different varieties of epilepsy, it Avill be evident that, as the disease may be connected Avith a plethoric or asthenic state of the system, or as it may arise from primary disease of the brain, or from various sympathetic irritations, the treatment must depend on the nature of, and circumstances connected with, each individual case. A successful result of curative measures, there- fore, Avill materially depend upon our being able to refer the par- ticular case to its appropriate species and variety. With this view, the practitioner should make minute inquiries into the his- tory of the case, especially as to the cause of the original and sub- sequent attacks; the existence of premonitory symptoms; frequen- cy of the paroxysms, and the effects Avhich have appeared to fol- low. He should pay great attention to the constitution, mode of life, and habits of the individual, to the state of the circulation, and whether any recent or chronic malady, or other source of irri- tation, exist in any part of the system. The imagination has a powerful influence both in relieving and augmenting many of the forms of epilepsy, especially in females, and to this may be attributed many of the astonishing cures boast- ed of by charlatans. A knowledge of this fact should induce the practitioner to gain the confidence of the patient, by inspiring in him a moderate degree of hope, indulging to a certain extent the Aveakness to which he may be subject, adopting a decided and calm manner, and guarding against a too great appearance of mystery on the one hand, and unnecessary communicativeness on the other. In many cases the moral treatment is as important as the physical, and great tact is often necessary to prevent the gloom, melancholy, or despair, with which many epileptics are affected. Bodily and mental exercise skilfully varied, so that nei- ther fatigue nor ennui shall be occasioned, is of great service as a means of abstracting the mind from the disease. Sudden changes in remedies have often been known to prevent an attack for a long time, and if managed judiciously, a succession of different medicines at proper intervals may in some cases, by rendering the attacks less frequent, tend much to obviate their recurrence. Care, hoAvever, must be taken to guard against disappointment, by not raising the expectations too high. In the treatment of idiopathic epilepsy connected with in- creased vascular action—a variety of the disease more common than any other in Britain—depleting remedies are indicated to a greater or less extent according to circumstances. If the heat of the head be great, the countenance flushed, the pulse slow and strong, bloodletting is necessary, folio Aved by cold affusion on the head. The extent to which the bleeding should be carried must be regulated by the effect it produces on the pulse. If the vascu- lar excitement be moderate, the topical abstraction of blood from the occiput, nape of the neck, or in the course of the spine, by cup- epilepsy, (Treatment.) 283 ping or leeches, may be substituted. Active purgatives, by the mouth or in the form of injection, Avill assist in lessening the gene- ral excitement, and Avith this vieAV the more powerful cathartics should be employed, as croton oil, elaterium, gamboge, scammo- ny, jalap, &c, until several copious stools are procured. Having by these means someAvhat reduced the general excitement, our endeavors should be directed to preventing its return. With this view, occasional topical bleedings by cupping or leeches, repeated according to circumstances, should be employed; and if the at- tacks are at all of a periodic nature, the abstraction should be made a short time before they are expected to appear. The sho\ver bath, or the affusion of cold Avater on the head daily, is of great service; blisters, setons, issues, and moxas, behind the ears or to the occiput, should also be used so as to keep up a constant discharge, or the antimonial ointment rubbed over the nape of the neck, occiput, or spine, so as to bring out and keep up a copious eruption of pustules. Antimonial preparations have a powerful effect in reducing vascular action, and when this variety is Avell-marked, the patient should undergo a course of James's powder, after the manner re- commended by Dr. Cheyne. According to this experienced phy- sician, the patient should begin Avith a very moderate dose, not more than two or three grains at bedtime, Avhich ought to be in- creased by half a grain every night, until some sensible effect upon the stomach, bowels, or skin, is produced. Should the stomach be affected with sickness, the dose must be lessened by one grain on the folloAving night. By the addition of a feAV grains of rhu- barb, a larger quantity of James's poAvder may be administered than the stomach could otherwise bear. If the skin be softened, or the bowels affected, the dose should not be further increased, but it must be repeated every night for a considerable time. In several instances, eighteen or twenty grains have been taken for a considerable period without inconvenience. (Dub. Hosp. Rep., vol. i, p. 315.) Attention must be paid to the regularity of the alvine excretions, and occasional purgatives or injections adminis- tered in order to insure this result, and Avith a view of assisting the other depletory measures. It is of great importance that the diet should be low, and that the patient should abstain from ani- mal food, and fermented or spirituous liquors. All mental agita- tion and violent exercise should be avoided, the bedroom kept at a moderate temperature; the patient should sleep on a firm mat- tress, Avith the head and shoulders well-elevated, and sleep should not be prolonged more than seven hours. The general treatment of idiopathic epilepsy connected with diminished vascular action, is directly the reverse of that just de- scribed, the obje'ct being to remove inanition, and by gentle stimu- lants and tonics to increase the tone of the system. A knoAvledge of the causes Avhich have induced the epileptic seizure is here 284 epilepsy, (Treatment.) necessary, as it will be in vain to attempt to obviate the disease so long as its source is unsuspected or unknoAvn. Thus a knoAV- ledge of the individual being subject to exhausting discharges: living upon a scanty diet, or not sufficiently nutritive; Avorking in manufactories under depressed circumstances, in an unhealthy situation, or at too early an age, indulging in the vicious practice of onanism or excessive venereal pleasures, &c, is of importance. It should not be forgotten, also, that the system may be so reduced by bloodletting and antiphlogistics, as to render an invigorating line of treatment necessary. If the pulse be quick and feeble, if there be great irritability, and the patient appear much exhausted, gentle stimulants should be administered occasionally, such, for example, as the aromatic spirits of ammonia; Tr. Card. Co., Tr. Cinch. Co., &c, conjoined or alternated with tonics, as the sul- phates of iron, copper, zinc, or quinine, or any of the bitter infu- sions. The diet should be nutritive and of easy digestion, and a moderate meal, taken three or four times a day. Evacuations from the alimentary canal should be obtained regularly by sto- machic laxatives; such as rhubarb, cream of tartar, the neutral salts, or castor oil, combined Avith aromatics and compound pur- gative tinctures. Violent purgatives should be avoided. If there are occasional sensations of lightness or emptiness in the head, sponging the forehead and scalp with cold Avater, or if the patient be not too Aveak, a daily use of the shoAver bath is useful. The application of cold in these cases should not be continued, but applied suddenly, and for a short time, so as to produce a stimu- lating reaction. Friction of the surface of the body Avith coarse towels, or the flesh brush, is beneficial after the shower bath, or shampooing, if the patient be not too much exhausted. Dr. Cheyne strongly recommends walking and exercise in the open air, as a powerful means of promoting digestion and improv- ing the muscular strength. Care, however, must be taken that fatigue is not produced. When the spine appears to be debili- tated, the same general treatment is necessary; but the cold affu- sions, blisters, and other local remedies, should be applied over the diseased part. If there is reason to suspect that the disease has been induced by masturbation in either sex, the impropriety and danger of the practice ought to be forcibly pointed out to the individual, who should be Avatched, and not alloAved to sleep alone. Cold affusion, night and morning, on the genitals and in the course of the spine, or sea bathing, together with tonics, exer- cise, and a nutritive but not stimulating diet, should be employed. The patient should rise early, sleep on a firm mattress, avoid crowded assemblies and heated rooms, and have the mind con- stantly engaged in some pursuit. Should the disease proceed from sexual indulgement, or from addiction to intoxicating liquors, both should be imperatively forbidden. In these cases, in addi- tion to the general means already pointed out for remedying de- epilepsy, (Treatment.) 285 bility, the Liquor Potassae, or alkaline carbonates, should be given in combination with bitter infusions. The muriate of morphia, or extract of henbane or of lettuce, combined Avith camphor, Avill lessen the general irritability. When epilepsy is connected Avith scrofula, alteratives should be conjoined with the tonics, such as small doses of the chloride or the bichloride of mercury, the blue pill, hydriodate of potass, soduret of iron, &c, or the mercurial and iodine preparations may be given on alternate nights. If the ma- lady be complicated with syphilis, scurvy, or other cachectic affec- tions, the appropriate treatment for these disorders must be em- ployed. Esquirol cites two cases in Avhich epilepsy disappeared Avhen the syphilis with which it Avas associated Avas cured by mercury. Although idiopathic epilepsy generally belongs to one or other of the two forms described, cases are sometimes met with Avhich cannot be attributed to either, inasmuch as the state of the vascu- lar system and general strength does not appear to be above or beloAv the natural standard; Avhile, at the same time, no symptoms are present Avhich can be referred to functional derangement of any particular organ. In these cases stimulating purgatives may be given, Avith cold affusion on the head, or the shower bath and occasional topical bleedings, when symptoms occur to require this practice, from the occiput or nape of the neck. Exercise in the open air, by Avalking or in a carriage, travelling, frequent change of air, light farinaceous diet, avoiding fermented and spi- rituous liquors, are beneficial. Some cases may require a more nutritive diet, with the exhibition of the mineral and vegetable tonics, occasional dry cupping, and the application of blisters or tartar emetic ointment to the occiput and spine. Great care should be taken not to excite the passions, and to overcome the mental depression which is often great in these cases. The moral treat- ment formerly alluded to must not be overlooked. The indications in the treatment of sympathetic epilepsy are, first to remove the disorder which is the primary cause of the epileptic disease, and then to combat the tendency to its return, which the system may have acquired. In epilepsy connected Avith disease or disorder of the heart, a cure is seldom accom- plished. It is often difficult to determine whether the cardiac affection is the cause or effect of epilepsy. Organic disease of the heart, especially hypertrophy of the left ventricle, is frequently complicated with cerebral disease; on the other hand, frequent epileptic attacks, by their effect on the centre of the circulation, may gradually occasion disease of the heart. In either case it Avill be necessary to diminish the heart's action by appropriate remedies, Avhile at the same time attention is paid to the general or constitutional poAvers, or to any local disease with which the cardiac or cerebral affection may be complicated. If there be plethora, and the quantity of blood in the body seems above the 286 epilepsy, (Treatment.) natural standard, local depletions by leeches or cupping, fol- lowed by derivatives, as setons, issues, tartar emetic ointments, or a succession of blisters over the precordial region, ought to be employed. These remedies should be combined Avith active purgatives, a low diet, antimonials, and the treatment pointed out for diminishing excessive vascular action. But Avhen, as is generally the case, the cardiac epilepsy is associated with a de- pressed state of the system, the exhibition of tonics and a nutri- tive diet, with counter-irritation over the region of the heart should be adopted. When pallor and a feeling of syncope pre- cede the attack, or palpitation of the heart is experienced, an antispasmodic draught should be administered. All agitation of the mind should be carefully avoided, and any pulmonary in- flammation or congestion that may appear combated by local bleeding, derivatives, and general antiphlogistic measures, Avhich, however, should have strict reference to the constitution or poAV- ers of the individual. Epilepsy connected with irritation in the digestive organs is the most common variety of the sympathetic form of the disease. When there is nausea, eructations, vomiting, and other symp- toms indicating that the stomach is disordered, the exhibition of an emetic is often advantageous. Digestion being generally im- perfectly performed, laxatives combined Avith tonics are neces- sary; such as the compound colocynth, galbanum or rhubarb pill combined or alternated Avith quinine, nux vomica, the prepara- tions of bark or bitters. The mineral tonics, as the sulphates of zinc, iron, or copper, nitrate of silver, Mist. Ferri. Comp. are often useful. When there is a bitter taste in the mouth, and the biliary secretion appears more or less disordered, mercurial preparations should be combined Avith the above remedies. If there be an acid taste, the alkaline carbonates, in conjunction Avith the infu sions of gentian, quassia, orange-peel, &c, often remove this un- pleasant symptom. Pains in the abdomen, depending on costive- ness or on an accumulation in the alimentary canal, may be removed by laxative injections, combined Avith, or folloAved by, opiates, stimulants, or antispasmodics, as the case may require. When epilepsy is connected with dentition, the gums should be freely divided every third or fourth day, and the fever subdued by gentle saline laxatives, antimonials, and Ioav diet. If it depend on the presence of worms, they are to be expelled from the intes- tines by purgative anthelmintics, administered both by the mouth and by enemata. If the appetite be voracious, it must be com- bated by improving the tone of the stomach by the mineral and vegetable tonics, combined with occasional laxatives. The careful regulation of the diet is of the utmost importance in this variety of the disease; generally speaking, it should be nutritious, but of light and easy digestion. The meals should be taken three or four times a day, not much eaten at a time, and epilepsy, (Treatment.) 287 that Avell masticated. All fermented and spirituous liquors should be avoided. Exercise short of fatigue in the open air, travelling and change of scene, also assist in removing the morbid condition on Avhich the epilepsy depends. A short time spent at one of the fashionable watering-places, drinking the chalybeate or pur- gative waters, is often beneficial. The remedies above recom- mended must ahvays be prescribed Avith reference to the state of plethora or anaemia that may exist. In the former, active purga- tives may be ventured on, while stimulants should be avoided, and a modified antiphlogistic plan of treatment pursued; whereas, in the latter state, Avhich is more commonly associated with this variety, occasional gentle laxatives, with tonics, antispasmodics, slight stimulants, and a nutritious diet employed. To epilepsy connected with irritation in the biliary organs, a similar plan of treatment is applicable. When, however, there appears to be a deficiency of the biliary secretion, the blue pill, or calomel combined Avith laxatives, should be given occasion- ally to stimulate the liver to a proper performance of its function. If there be symptoms of acute or chronic inflammation of the liver, general or local bloodletting, blisters, and other derivatives, should be employed, according to the severity and nature of the symptom. Should the liver be enlarged, or there be obstruction in the biliary ducts from indurated bile or gall-stones, deobstru- ent purgatives, preparations of mercury and of iodine, combined Avith depleting, stimulating, or tonic remedies, should be em- ployed according to the symptoms and the constitutional powers. The curative treatment of epilepsy connected Avith irritation or disorder in the urinary or generative organs, must have refe- rence to the nature of the local disease; disorders of the urinary organs are a much less common cause of epilepsy than that aris- ing from irritation of the genital organs, and when they exist, must be removed if possible by medical or surgical means. In females, affections of the uterus are intimately connected with the production and communication of epilepsy; hence, the manner in which the functions of that organ are performed should always be particularly inquired into. The treatment of this form should have strict reference to the state of the constitutional poAvers. Thus, if the habit is full and.strong, and the catamenia suppressed or diminished, general bloodletting may be employed, or leeches applied to the inside of the thighs, or to the neighborhood of the vulva; Avhile the hip bath, emmenagogues, and other remedies usually employed to favor the flow of the menstrual fluid, are exhibited. Dr. Prichard recommends the warm bath, conjoined Avith bleeding, in these cases, the effects of Avhich are to be pro- moted and maintained by fomentations to the feet and to the lower part of the abdomen, by means of moderate Avarmth and by frequent draughts of Avarm diluent drinks. Anodynes and hypnotics will tend to remove pain and sleeplessness if present. 288 epilepsy, (Treatment.) If there be much irritation or evidence of hysteria, the latter remedies also should be employed in conjunction Avith cooling saline purgatives and antispasmodics. If the patient be chlorotic, or the catamenia be irregular or profuse, a stimulating and tonic plan of treatment is necessary. As has been remarked by Stahl, Hoffman, and others, marriage has sometimes removed the com- plaint. If the fits generally appear before the menstrual period, the application of leeches to the vulva, or the Avarm bath, Avith the judicious administration of purgatives, especially the castor oil and turpentine enema, may occasionally avert or render them less frequent. But if they follow the flow of the menses, tonics and the application of cold to the genitals, and such remedies as diminish the amount of the discharge, may produce the same effect. Should epileptic fits occur about the period of the cata- menia, without any diminution or increase in the amount of the discharge, a small bleeding will probably be beneficial. In such cases, Dr. Prichard has remarked, the flow of the menses appears to be deficient Avith respect to the particular habit of the patient, although not remarkably scanty in proportion to what is observed in other individuals. When the attacks appear in girls before the age of puberty, antiphlogistic measures or strengthening reme- dies must be employed according to the constitution of the pa- tient, and emmenagogues, and such remedies as favor the appear- ance of the catamenia, administered. In both sexes, Avherever masturbation is detected or suspected, the means formerly de- scribed should be employed. When epilepsy is connected Avith irritation in the skin or external organs of the body, it must be treated constitutionally in the same manner as the other varities. The local disorder must, if possible, be removed, or the irritation it produces dimi- nished. The cutaneous diseases Avith which the epilepsy is com- plicated, must be treated in a manner appropriated to the par- ticular affection. Although it sometimes happens that epilepsy is cured by removing the local disease Avhich has occasioned it, the practi- tioner must not be too sanguine as to a permanent recovery, as it unfortunately often happens that, the system acquires a pre- disposition to the affection Avhich may thus continue in an idio- pathic form after all local irritation has been removed. This has been remarked with regard to the disease Avhen connected Avith uterine affections by Maisonneuve, and the remark is applicable to all the other varieties. More or less disorder in different organs also may supervene on epilepsy Avhich was originally idiopathic, and care must be taken, while directing our remedies Avith a view of curing the former, not to neglect the constitutional and moral treatment. In the advanced stages of the disease, when paralysis or mental alienation has supervened, although we must abandon all hopes of cure, Ave should endeavor to ameliorate epilepsy, (Treatment.) 289 the severity of the attacks, and lessen their frequency. With this view the constitutional and moral treatment already described should be followed, and every thing that skill and humanity can suggest for alleviating the condition of the individuals, employed. If apoplexy supervene, the treatment recommended for that dis- ease should be adopted. In the treatment of a disease Avhich too generally bids defiance to the best directed efforts, it is not surprising that various reme- dies should have been had recourse to, even on empirical or unascertained principles. We shall mention a feAV medicines which have been thus occasionally administered. Phosphorus has been given, but is generally considered a dangerous medicine. Strychnine has been found useful in some chronic cases, compli- cated Avith paralysis. Electricity and galvanism haAre been occa- sionally successful, but they should only be employed when there is marked evidence of depression, and even under such circum- stances they have by no means proved of such benefit as to lead to great confidence in their efficacy. Tonics have been extensively administered, and, as has been shown, are directly indicated whenever the disease arises from, or is associated with, a depressed state of the vital poAvers. They have been principally depended on after the use of bloodletting and other active measures, and in many instances have been advantageously combined with local depletion. Of the mineral remedies of this class, the nitrate of silver has of late years at- tracted much attention, and its occasional success has been attested by Drs. Wilson, Sims, Baillie, Roget, J. Johnson, Lombard and others. It is usually given in substance in the form of pill made Avith bread crumb. A pill containing half a grain is to be given every night and morning, and the dose is to be gradually increased to five or six grains in the course of the day. In general, a long continued trial of the medicine is necessary. There is, however, a great disadvantage in the employment of nitrate of silver, in the circumstance of its producing in some individuals, a dark, per- manent discoloration of the skin, as observed by Drs. Roget, J. Johnson and Vetch. This forms a powerful objection to its use. When employed, therefore, it should not be too long continued at one time. An eruption of small pustules on the surface of the body has been observed to folloAV its employment by Simentini and Copland, Avhich the latter thinks should be looked upon as a favorable circumstance. Several other mineral tonics, as the preparations of iron, cop- per, zinc, arsenic, bismuth, &c.,have been employed with varied success by various Avriters, especially the sulphate of zinc. They may be used either alone or combined with other remedies. The vegetable tonics, especially quinine, the different preparations of cinchona, gentian and the other bitter roots, barks and herbs have likeAvise been occasionally prescribed. 25 290 epilepsy, (Treatment.) Cold and salt water bathing are beneficial as tonics, but they should be avoided when dreaded or disliked by the patient, as this alone has often been knoAvn to bring on an attack. Narcotices and anodynes, especially belladonna, opium, hyos- cyamus and stramonium, are beneficial Avhen epilepsy occurs in individuals of a nervous and irritable temperament, or Avhen the attacks have been occasioned by fear or mental affections. They should only be given when the disease is connected Avith a de- pressed state of the system, and under such circumstances have been useful adjuncts to other remedies. As a principal means of cure, they have been found of little service, and are only bene- ficial in relieving pain, tremors, or great excitement during the intervals. Tobacco has been used in the form of clysters as a vermifuge, and conium was employed by Stoerck in the scrofu- lous complication of the disorder. Digitalis has been found ser- viceable in the cardiac variety, when the action of the heart is increased and readily excited by mental emotions. Alteratives have been employed with the vieAV of correcting the disposition to the attacks. Mercury has been given Avith this object, but unless the disease is complicated with some of the secondary forms of syphilis, or there is derangement of the biliary functions, it has not hitherto been very successful. The absorbent properties have been thought beneficial in removing serous effu- sions or other lesions in the coverings or substance of the brain or spinal marroAv, and it may be employed for this purpose, although in epilepsy no great success ought to be expected from its employment. The preparations of iodine Avith mercury or iron may be administered Avith greater hopes of success when the disease is associated with scrofula. It should be remembered that these remedies are contra-indicated when there is much vascular excitement, and should at all times be given with caution. Derivatives have often been found of great service. The use of the actual cautery, moxas, setons, issues, antimonial ointment, &c, has been attended Avith the best effects in cases connected with a plethoric constitution. Whenever the disease has also been attended by the drying up or disappearance of an old ulcer, fistula, eruption, &c, they are directly indicated. They should in general be applied to the nape of the neck or occiput when the cerebral symptoms are Avell marked, and on each side of the spinal column when the convulsions are unusually violent or long continued. Andral and some physicians advise their appli- cation to the limbs, particularly Avhen the fit has been preceded by an aura. Numerous other remedies have been administered, the action of which is not determined. Among these indigo has lately been introduced, and from some trials made by the physicians of the Charite Hospital at Berlin, may be prescribed Avith advantage in idiopathic epilepsy, or Avhen the disease is uncomplicated Avith epilepsy, (Treatment.) 291 any organic lesion. Large doses are necessary, and the remedy should be continued for three or four months. An ounce, or even more, has been given daily, combined with tonics or Avith Dover's powder, to guard against diarrhoea. Dr. Roth has treated 31 cases, of Avhom 9 males and 5 females were cured, 11 relieved, while in 6 there was no amendment. (Brit, and For. Med. Rev., vol. ii, p. 244.)* Surgical operations have in desperate cases been resorted to. Trephining the cranium has in a feAV cases been successful Avhen circumscribed injury or disease of the bone was well marked, and in one case tying the common carotid arteries was followed by temporary relief. (Trans, of Med. and Phys. Soc. of Cal- cutta, vol. vi, p. 390.) It is perhaps unnecessary to say, that such operations, particularly the latter, can be warrantable only in very extreme cases. * I have used indigo in a number of cases, but in much smaller doses; generally not more than a drachm or two in a dose was taken readily by the patients. It proved useful in averting the paroxysm, but did not appear to produce any permanent benefit. A combination of sage, ginger and other aro- matics given in rather large doses, is a remedy of which Dr. Otto of this city recommended; of course, he did not profess to explain its action; it seemed to act as a stimulant to the stomach, and like others of the class, was of tempo- rary benefit. 292 CATALEPSY AND ALLIED AFFECTIONS. Definition.— Symptoms.—Duration.—Varieties.—Catochus.—Ecstasy.—Le- thargy or cataphora.—Coma.—Causes, predisposing, exciting.—Nature.— Diagnosis.—Prognosis.—Treatment. By catalepsy (derived from xa^a^^a seizure, from xata%ay.6avu, to seize) is understood a sudden loss of consciousness and volition, the patient retaining during the attack the same position in Avhich he happens to be at its commencement, or in which he may be placed during its continuance. This disease is so rare, that some physicians, and among others Cullen, imagined that it was always feigned. Its occasional occurrence is, however, now well esta- blished. Symptoms. In general the cataleptic seizure is not preceded by any premonitory signs; occasionally there is lassitude, confu- sion of mind, headach, hallucinations, palpitations, vertigo, tin- nitus aurium, yaAvning, stiffness in the neck, pain and slight spasms in the limbs. During the attack the patient is fixed and immovable as a statue, retaining the same expression of countenance and posture of the body as at the time of the seizure; the face is sometimes pale, sometimes slightly suffused; the eyes open or shut, but always fixed; the pupils usually dilated, but contractile from the stimulus of a strong light; the pulse generally quick and small, but sometimes sIoav and strong, while the action of the carotids is increased; the respiration is generally unaffected, but noAV and then quickened or embarrassed; the temperature of the surface is unequal, the head being hot, and the extremities cold; con- sciousness and sensibility are entirely suspended, the most pow- erful stimuli failing to produce their accustomed effects; the vo- luntary muscles are passively contracted, and slightly rigid, but readily yield to the application of a counterbalancing power. Thus, the head, neck, and limbs, may be placed in any posture in Avhich they are permanently maintained so long as the fit continues, although such posture may be one which, in the na- tural state, is very painful, and could only be continued a short time. Bouillaud has noticed that, on raising the limbs of cata- leptics, they appear light, as if the patient assisted in the move- ment; but on depressing them there is a certain resistance to be catalepsy, (Symptoms.) 293 overcome. (Diet, de Med. et Chir. Prat.) The evacuations are either suppressed, or passed involuntarily. The duration of this state may be only a few minutes, but it may extend to several hours, or even days. This last occurrence is exceedingly rare. The symptoms or fits may recur at irregular intervals of days or months, or several times in a day. In a case related by Mr. Stearns (Amer. Med. Reg., vol. i,) there were ten fits in the twenty-fours, and in another by M. Bouvier (cited in NouveauxElimens de Therapeutique de MAlibert,torn, ii,) there were more than a hundred accessions in the same space of time, there being a few minutes of interval only between each. The recovery is generally instantaneous, accompanied by sighing, but sometimes it is followed by a more or less confusion of mind, headach, pain in the praecordia, and a sense of fatigue or uneasi- ness. The patient has no recollection of what has passed during the attack, and continues any occupation in which he had been engaged, or pursues the same train of thought as if nothing had happened. According to some Avriters, the sentence which was broken off by a sudden seizure, is taken up immediately on reco- very from the paroxysms. Such is the perfect form of catalepsy; but there are various modifications which have received different names. The con- sciousness may be only partially suspended, occasionally it re- mains perfect, while the slightest muscular movement cannot be exerted. This state has been called catochus, an instance of which has been given by Dr. Fitzpatrick (Duncan's Medical Commentaries, vol. x,) in a Avoman, who was on the point of being buried alive, and felt all the horrors of seeing her own body prepared for interment. Similar cases are related by Pew, Dei- merbroeck, Hildanus, and others. Occasionally voluntary motion is not entirely destroyed, the patient being able to move a hand or limb. In some cases deglutition may be excited by putting food into the mouth. When all consciousness and volition have disappeared, while the mind is in a state of excitement, the affec- tion is termed by nosologists ecstasy. By this term, however, Dr. Good understood a loss of consciousness and volition, accom- panied by such great muscular rigidity, that the limbs cannot be moved as in catalepsy. The term, hoAvever, is usually applied to the former group of symptoms, which may be accompanied either by muscular contraction or relaxation. During the ecstatic attack the patient remains standing or sitting in a position expressive of great excitement, the eyes are immova- bly fixed, and impassioned expressions, fervent prayers, or absurd exclamations are uttered. Sometimes the individual sings with great pathos and expression. Chisholm relates a case in which this last symptom was present in a young female, in Avhom it alter- nated with mania. Dr. Copland Avas consulted about another in Avhom the disease was connected Avith hysteria; this patient sung 25* 294 catalepsy, (Causes.) and composed long doggerel strains. It is probable that the faculty peculiar to the Italian Improvisatori is sometimes associ- ated with a morbid state similar to that now described. When consciousness and voluntary motion only are suspended, and a state resembling sleep is present, from which it differs by being more prolonged, the affection is termed lethargy, and by some writers cataphora. The same state, Avhen more profound, is denominated coma. This last affection, (coma,) however, is more properly cerebral than cerebro-spinal. A frequent recur- rence of cataleptic or ecstatic fits may terminate in more severe affections, as epilepsy, apoplexy, mania, or confirmed insanity. In general they are complicated Avith hysteria, and sometimes with mania or epilepsy. Causes. Catalepsy has appeared in both sexes, but females are much more predisposed to the disease than males, especially such as have a tendency to hysteria, melancholy, hypocondriasis, or mania. The affection may occur from the age of five years to that of advanced life. It is rare, however, before puberty and in old age. Cold has been thought by some to predispose to catalepsy; there are doubts, however, whether the cases recorded by Forestius and Sprengel, apparently caused by this agent, were true instances of catalepsy. The passions, if long-continued and violent, are the most predisposing causes both of catalepsy and ecstasy; such as intense sorroAv, unrequited affection, great anxi- ety, &c. Religious contemplations, particular trains of thought, especially those of an exciting description, too great mental appli- cation, excessive venereal indulgences, masturbation, frequent miscarriages, painful parturition, predispose to this affection, and Avhatever tends to debilitate the system or augment nervous irri- tation. The passions, when intense, act as exciting causes of this disease, also strong mental emotions, as terror, fright, anger, suppressed rage, indignation, and domestic inquietude; great mental application; ungratified desires, particularly that of love; religious enthusiasm; irritation of worms in the alimentary canal; disorder of the uterine functions; repulsion of eruptions; suppres- sion of the menstrual or other discharges; sudden noise; fatigue; un- accustomed exercise; onanism, &c. Catalepsy is stated to have been induced in a girl, by taking aAvay during a meal a choice morsel Avhich she much desired. (Pinel, Nosographie Philosophique.) Tulp saw a young man become cataleptic on receiving the news that his marriage was broken off with a female that he loved pas- sionately. Jolly has seen it occur in a lady during the celebration of mass, on the elevation of the Host; and Dionis gives another someAvhat similar instance of a monk Avho was performing the ceremony. (Dissert, sur la Mort Subite et sur la Catalepsie.) Nature. As few individuals have died laboring under cata- lepsy or its allied affections, Ave know little of its morbid anatomy. In such as have been examined, either no unnatural appearances catalepsy, (Diagnosis.) 295 have been discovered, or such as in no Avay throw any light upon the peculiarities of the disease. Were we to reason from the ana- logy betAveen this and other nervous affections, we should attri- bute the loss of consciousness and volition to congestion of the brain, as we observe the same causes Avhich occasion this patho- logical condition in other affections, produce also catalepsy. But the muscular phenomena are Avholly inexplicable from any knoAvn result of irritation. In catalepsy the general tone of the muscular system appears increased Avithout intermissions, and as Ave have reason to suppose that this vital property is immediately dependent upon the spinal marrow, we may Avith great probabi- lity refer the peculiar phenomena to some alteration in that por- tion of the nervous system. Further than this, the present state of science Avill not allow us to go. We deem it unnecessary to discuss the views of M. Petitin and others, who believe in the transmission of the senses. Diagnosis. Complete catalepsy is readily distinguished from all other diseases by the peculiar muscular phenomena described. But Avhen these are not well marked, and Avhen the circulation and respiration are performed either feebly or Avith undue vigor, it may be mistaken for death, syncope, or asphyxia in the one case, or apoplexy in the other. It may be distinguished from death by applying the ear or stethoscope to the precordial region, as the action of the heart, though diminished, must still continue. The condensation of the breath on a mirror held over the mouth will also assist in enabling us to detect it. The temperature of the body, state of the eyes and of the sphincters, mode of attack and previous knowledge of the case, may also guide us in our di- agnosis. If the slightest doubt exist, there should be decided evi- dence of putrefaction before inhumation be allowed. Syncope may be known by the flexibility of the limbs, and the diminished action of the circulation and respiration. In asphyxia there is not only flexibility of the limbs, but a deep color of the lips and coun- tenance, circumstances Avhich sufficiently indicate it. Apoplexy is distinguished by the flexible limbs, and occasional congestion of the head and face, stertorous breathing, and occasional para- lysis. We have already detailed the symptoms by which catalepsy may be known from ecstasy and lethargy. Ecstasy may be mis- taken for somnambulism; but in the latter state the countenance of the individual is dull and inanimate, and in the former highly excited. Catalepsy in its imperfect forms, as well as ecstasy, has often been feigned with a view of escaping the naval or military service, or to obtain notoriety. The detection of these impostures must depend upon the acumen of the practitioner, and such ex- periments as the nature of the case may dictate to him. Prognosis. Catalepsy is seldom dangerous, though it was thought so by Sennert, Vogel, and Boerha'ave. Fatal cases, hoAV- 296 catalepsy, (Treatment.) ever, have been, recorded by Lieutaud, Holier, and Ab Heors, but in general this event only occurs when it is complicated Avith some more serious malady. Pinel gives a case that terminated in apo- plexy, and Rostan another which proved fatal from inflammation of the lungs. Treatment. When there is evidence of plethora, Avith flushed face, quick pulse, hurried breathing, and heat of skin, general bloodletting is indicated, which may be folloAved, if necessary, by cupping on the back of the neck, or between the shoulders. If there be pains or uneasiness in the spine, the local abstraction of blood from the neighborhood of the affected part by cupping or leeches is advisable. At the same time cold should be applied to the head, and active purgatives administered. If the catamenia be suppressed or irregular, cupping between the shoulders, the hip bath, and purgatives, should be employed. Cheyne recom- mends aloetic, and Dedier hydragogue cathartics in these cases, with which antispasmodics and injections containing turpentine may be combined. If the attack be induced by the suppression of an accustomed discharge, or by the repulsion of a cutaneous eruption, in addition to the above general remedies, issues, setons, blisters, or the tartar emetic ointment should be employed, so as to produce a drain from, or irritation on, the surface similar to that which existed before the seizure. In the intervals of the fits, the diet of the patient should be restricted; he should rise early, and use daily exercise short of fatigue. Wine, spirituous and fermented liquors, should be abstained from, and every cause of excitement, Avhether mental or physical, carefully avoided. But when, as is most commonly the case, the disease is con- nected with an opposite state of the system, and there is paleness of the countenance, cool skin, weak pulse, feeble respiration, and other evidences of depressed vital action, tonics, antispasmodics, and stimulants with gentle aperients are indicated. During the intervals a nourishing and easily digestible diet should be alloAved, and change of air, the shower bath, or sea bathing, regular exer- cise and agreeable mental occupations recommended. Any com- plication, as of hysteria, mania, epilepsy, &c. that may exist, must be treated on the principles recommended for the management of those diseases. When the biliary secretion is deranged, the gen- tle administration of mercurials is requisite. Should there be the appearance of death, artificial respiration, Avarmth to the surface, and the other remedies usually adopted in such cases must be ac- tively resorted to. When the disease becomes chronic, counter- irritants applied to the occiput and spine are useful. Moral treat- ment is also essentially necessary; the passions, ideas, and medita- tions, which may have occasioned the disease, should be broken off or counteracted as much as possible. 297 U"' SPINAL IRRITATION. Explanation of the term spinal irritation.—Various anomalous symptoms.— Predisposing causes.—Exciting causes.—Nature.—Diagnosis.—Prognosis. —Duration.—Treatment. This term has been used to designate an affection usually charac- terised by pain in the back, either induced or increased by pres- sure of the spinous processes of the vertebrae, accompanied by neuralgic and hysteric symptoms of a nature so variable as to simulate almost every form of disease to Avhich the body is liable. Spinal irritation ought to be considered rather as an effect of dis- ease, than as a malady sui generis, but as the subject is of the highest practical importance, it is proper to direct attention to it by giving a detail of its phenomena in this place. Various forms of this affection have been described as cases of neuralgia, and termed thoracic, epigastric, or intestinal, accord- ing to the locality of the pain, by practical writers, especially Ni- cod (Nouv. Journ. de Mid. Chir. et Pharm., torn, iii, p. 247. 1818), Teale (On Neuralgic Diseases), and Brown (Glas. Med. Journ., 1828). They have been described in connection Avith hysteria by Tate (Treatise on Hysteria). The disorder has been called spinal irritation by Parrish (Amer. Journ. of the Med. Sci- ences, 1832), DarAvall (Midland Med. and Surg. Rep. 1829), Griffin (On Functional Affections of the Spinal Cord, $c), Entz (Rust's Magazin fiir die Gesammelte Heilkunde, 1836), and Ollivier (Sur la Moelle 'Epiniere, 3d edit.) The term spinal irritation, although objectionable in many points of view, has been generally received, and is therefore retained in this place. Symptoms. When it is remembered that the spinal cord fur- nishes directly or indirectly nerves to every organ in the body, the numerous symptoms which may be produced by the increased, diminished, or perverted functions of one or more of these may be readily imagined. Hence the phenomena this affection presents differ according to the extent, seat, and intensity of this irritation, and are so greatly diversified as to prevent the possibility of giving a description Avhich would be applicable even to the majority of cases. The only means Ave can think of for conveying a general idea of this disorder, is by referring to the different forms of hys- teria, neuralgia, and chronic rheumatism. A combination of the 298 spinal irritation, (Symptoms.) symptoms occasionally presented by all three, constitutes spinal irritation. The only constant symptom is more or less pain on pressing the spinous processes of the vertebrae. It may be confined to one spot, or be more or less diffused over the spinal column, pointing out the extent of the spinal irritation. In many cases the patient is unconscious of any thing wrong in the back, often denies the existence of pain in that situation, and refers all the uneasiness to the ultimate distribution of the nerves arising from the part. Sometimes there is a dull constant pain, which is over- looked, and thought to be Avholly unconnected Avith the local complaint. When pressure, however, is made on the affected part, the pain in the back is increased, and not unfrequently the patient starts as if an electric shock had been received, or falls into a state of syncope. The seat of pain generally corresponds with the origin of the nerves ramifying on the organs, or portion of the surface complained of, although in some instances, as stated by Griffin, the morbid changes in the cord appear somewhat more extensive than the external tenderness. The local pain is often produced or increased by lifting heavy weights, or twisting the body, and has often been excited by jerks or slight concus- sions Avhen Avalking.* In conjunction with the spinal tenderness there may be neu- ralgic pains, more or less diffuse, over different parts of the sur- face, diminished sensibility, convulsions, or paralysis; and as the functions of the different viscera and organs of the body are often impaired, various diseases, are.simulated. Thus Avomen suffer neuralgic pains sometimes in the right, but more commonly on the left side, beneath the mamma; sometimes, again, the breast itself is more especially affected, constituting the irritable mamma of Sir A. Cooper. In other cases there is a feeling of numbness, as pointed out by Dr. Brown of Glasgow, or of constriction round the thorax, as if a walnut or other hard substance Avere pressed within a tight belt. Occasionally the affection commences with pain in the occiput, and rheumatic sensations in the neck and shoulders, several cases of which are given by Mr. Teale of Leeds. At other times, instead of neuralgic pains, there is a sense * The pain is not always present; at least not in all cases in which applica- tions to the spinous processes of vertebrae, which nearly correspond with organs which are the seat of functional disorder or of neuralgic pains, are sometimes more beneficial than any other treatment. This is often the case with neuralgic pains near the left nipple, whether they occur in children or in adults, and with some forms of dyspepsia. These neuralgic pains in males frequently follow intermittent fever. The success of these applications is, however, much less certain in these cases than in those in which the vertebrae are tender on pressure. spinal irritation, (Symptoms.) 299 of numbness in the hands or feet, extending more or less over the extremities. We have seen a case where the only symptom was excessive coldness in the hands and fingers, that often amounted to actual pain, and prevented the individual from seAV- ing, and carrying on her usual employments. If the spinal irri- tation be more severe, the internal organs participate, and the symptoms produced vary according to the portion of the cord that is affected. When the spinal tenderness is confined to the cervical portion, there may be headach; loss of voice; neuralgic pains in the face and gums; trismus; various disorders of vision, as ocular spectra, muscae volantes, night blindness, &c; more or less deafness, or confused sounds in the ears; diminished or perverted sensation of taste and smell; dysphagia; paralysis of the tongue; sickness; vomiting; loss of appetite, inordinate hunger or thirst; pain at the stomach; pyrosis; difficult breathing, cough, irregularity of the pulse; palpitations; disposition to syncope; paralysis of one or both arms, sometimes confined to the fingers, hands, arms, or shoulders; increased sensibility or numbness in those situations; pricking, formication, &c. Although these symptoms may have coincided at different times Avith cervical tenderness, it is evident that many of them, more particularly such as affect the special senses, arise from irritation of the cranial portion of the cord. When vertigo or delirium is present in such cases, it is probable that the brain itself is more or less affected. When the irritation is in the dorsal region, the palpitations of the heart and dyspnoea are more marked; there is sometimes dry cough; pleurodynia; pain under the clavicles, in the shoulders and superior extremi- ties; sense of constriction in the thorax, often like a tight band; neuralgic pains in the side; diminished sensibility in the breast and epigastrium; more or less derangement in the digestive or- gans, &c. When it is situated in the lumbar portion, the symp- toms are, pain in the parietes of the abdomen, hypogastrium, loins, and genito-urinary apparatus; symptoms resembling gravel in the kidneys, ureters, or bladder; irritable uterus; cramps and increased sensibility, or palsy more or less complete in the in- ferior extremities. When the spinal irritation is more diffused, there is an admix- ture or combination of the above symptoms. Hence the occa- sional difficulty experienced in tracing the various undefined symptcftns to their true source. Cases of angina pectoris, asthma, different forms of neuralgia and hysteria, spasmodic croup, con- vulsions, hydrophobia, epilepsy, tetanus, chorea, paralysis, spas- modic colic, diarrhoea, cholera, irritable bladder, &c, are recorded by Griffin, all of Avhich have been connected with the spinal irri- tation, and disappeared on its departure. It often happens that the spinal tenderness shifts its position, Avhen the other symptoms change also. A remarkable case is detailed by Griffin of a young 300 spinal irritation, (Causes.) lady, in Avhom the symptoms successively assumed the appear- ances of organic lesion of the lungs, heart, and abdominal viscera, together Avith an endless variety of other complaints of a neural- gic, asthmatic, epileptic, cataleptic, and paralytic nature. Indeed the singular changes the disease undergoes, render it impossible to obtain a perfect knoAvledge of its numerous forms, Avithout studying in detail the extraordinary cases Avhich have been re- corded of it. Causes. Women are much more predisposed to this complaint than men, and young girls more than married Avomen. Of 248 cases given by Griffin, 26 Avere males, 49 married Avomen, and 73 girls. In a table of 154 cases (given in the same work), Ave have determined that one occurred at the age of 4 years, that there were 7 betAveen the age of 10 and 15; 18 between 15 and 20; 31 between 20 and 25; 15 betAveen 25 and 30; 17 between 30 and 35; 18 between 35 and 40; 14 betAveen 40 and 45; 12 betAveen 45 and 50; 7 between 50 and 55; 3 between 55 and 60; 5 between 60 and 65; and 6 Avhose ages are not recorded. This disorder, therefore, is most frequent between the ages of fifteen and fifty—the menstrual period of Avomen. Spinal irrita- tion has been observed in every habit and constitution—in the full and plethoric, as well as in those Avho are spare and delicate. In almost all, however, who have been affected, somewhat of the nervous temperament has been remarked, or at all events a peculiar excitability of the system. The most common exciting causes are uterine disorder; exposure to cold and moisture; dys- pepsia, worms, and other sources of irritation in the alimentary canal; affections of the liver, mental emotions; erysipelatous, rheumatic and eruptive fevers; local injuries, &c. Nature. As spinal irritation uncomplicated with other disease rarely terminates fatally, the exact anatomical characters of this affection are unknoAvn. There can be little doubt, however, that in the majority of cases the symptoms are referrible to a state of congestion of the spinal cord„or its investing membranes. Lud- wig and J. P. Frank have alluded to the effects of spinal conges- tion, and the anatomical circumstances which favor its occurrence. The latter, in particular, has pointed out the absence of valves in the spinal vessels, together with their peculiar distribution on the surface of the cord. Their anatomical structure and arrange- ment render them peculiarly liable to congestion, as the venous blood must ascend in opposition to gravity. They grre also equally pressed on by the cerebro-spinal fluid in a state of health, and any cause Avhich tends to increase or diminish its normal quantity, may readily be conceived to produce venous conges- tion. Hence, derangements in the menstrual functions, and the various causes which have been mentioned, frequently occasion dorsal and lumbar pains, Avith other symptoms of spinal irritation. The vessels being principally superficial, unless very much di- spinal irritation, (Diagnosis.) 301 lated, occasion only partial pressure, and consequently increased action followed by the principal phenomena of this affection, viz. neuralgic pains. That motion is not so commonly increased or diminished, may be attributed to the relation of the cord Avith the osseous walls Avhich surround it, as pointed out by Ollivier, for the anterior columns are almost immediately applied to the bone, while the posterior are five or six lines distant from it. Inde- pendent of any positive evidence, therefore, it may be said that the theory of congestion is fully capable of explaining the phe- nomena, and is the morbid condition which of all others Ave should expect to follow the known causes of the disorder. On the other hand Ave cannot, with some authors, suppose it to be chronic inflammation, for the changeable nature of the affection, and its sudden appearance and disappearance, are opposed to such an opinion. With regard to the spinal tenderness, it has been well pointed out by Mr. Locock (Edin. Med. and. Surg. Journ., No. 136), that " an inspection of the vertebral column in an anatomical subject Avill show at once how impossible it is to press the cord or the nerves going from it, in the slightest degree." We cannot think Avith him, however, that "tenderness of the spinal marrow is a sign of little value," as numerous cases prove that there is a connection between the situation of the local ten- derness and other symptoms, while local treatment has dissipated the disorder, when remedies directed to the removal of its more remote effects have failed. No doubt the spinal irritation is in itself only a symptom, although one Avhich indicates with tolera- ble certainty the origin of the malady, and as our pathological knoAvledge improves, there is every reason to suppose that this vieAV of its pathology will be generally admitted. Diagnosis. It is remarked by the Messrs. Griffin, that there does not appear to be any complaint to which the human frame is liable, Avhether inflammatory or otherwise, Avhich may not occasionally be imitated in disturbed states of the cord, and hence it is a prolific source of those complaints called hysterical or ner- vous. The same authors have given the following diagnostic symptoms, by which it may be distinguished from organic dis- ease:—1. The pain or disorder of any particular organ being altogether out of proportion to the constitutional disturbance. 2. The complaints, Avhatever they may be, usually relieved by the recumbent position, always increased by lifting weights, bending. stooping, or twisting the spine; and among the poorer classes, often consequent to the labor of carrying heavy loads, as in draw- ing Avater, manure, &c. 3. The existence of tenderness at that part of the spine which corresponds with the suffering organ. 4. The disposition to a sudden transference of the diseased action from one organ or part to another, or the occurrence of hysterical symptoms in affections apparently acute. (Opus cit. p. 214.) Attention to the four circumstances above enumerated, will gene- 26 302 spinal irritation, (Treatment.) rally enable the practitioner to identify this disorder. It may readily be mistaken for disease of the vertebral bones, as there is not unfrequently an apparent prominence of the vertebrae, where the tenderness is felt. As such an error may lead to very distress- ing consequences, it will be well to enumerate the circumstances which distinguish the one from the other. In vertebral disease the prominence is angular, and depends on displacement of the bones or curvature: in spinal irritation it is round, and is occa- sioned by slight SAvelling of the liagaments or coverings of the spine: in diseased vertebra there are seldom hysterical symptoms in young females, Avhereas they are common in spinal irritation. Disease of the vertebra is most common in young persons of a strumous constitution, Avhereas spinal irritation is most frequent in adults. Lastly, complete paralysis is common in vertebral dis- ease, rare in spinal irritation, and in the latter, the general health is not so much affected. Prognosis. The prognosis in spinal irritation is always favor- able, as there is every reason to believe that the mere state of irritation uncomplicated with a more serious morbid lesion has never proved fatal. When there is any other coexisting disease, the prognosis of course is the same as that of the particular affec- tion with which the spinal irritation is complicated. The duration of the symptoms is very variable, and may con- tinue from a single day to three or four years. A case is given by Griffin Avhere it continued four years and a half; according to whose experience, a quick and irritable pulse and furred tongue are indications of an obstinate and troublesome attack. Treatment. The various and often contradictory symptoms induced by spinal irritation, render its diagnosis and treatment difficult and uncertain. Numerous facts, indeed, attest that indi- viduals have long labored under rheumatic, neuralgic, and hys- terical complaints, during which they have suffered the greatest tortures, although they have been relieved in a few days by treat- ment directed locally to the spine. Whatever difficulties, there- fore, may exist in drawing a line of demarcation between the effects of spinal irritation and numerous other disorders, notwith- standing the obscurity that rests on the precise nature of the morbid change Avhich produces it, the great practical utility to be derived from its study is unquestioned. So fully are Ave impressed with its importance, that we consider that in all cases of neuralgia, rheumatism, and hysteria, the spine should be examined; Avhile, perhaps, there is scarcely afunctional disorder to Avhich the young female is liable, which may not occasionally be found connected Avith spinal irritation. We have often had an opportunity of observing the manner in Avhich numerous disorders have been traced to this source, and feel assured that if practitioners in gene- ral Avould pay greater attention to this complication, many of the extraordinary and anomalous cases which are at present the spinal irritation, (Treatment.) 303 cause of great embarrassment in practice, might terminate in the speedy relief of the patient, and increased credit of the physician. It must not be supposed, however, that the difficulty terminates, even Avhen the disease is found to be connected with spinal irrita- tion, for experience has demonstrated that this is in itself not unfrequently a secondary effect, produced by the disordered func- tions of other organs. The first object of the medical attendant, therefore, should be to determine Avhether the affection is idiopa- thic or sympathetic, acute or chronic. When the disorder is idiopathic, our attention must be directed to the restoration of the general health of the patient, and an antiphlogistic or tonic line of treatment determined on according to the circumstances of the case. Accordingly, the application of leeches, or cupping over the spine where there is tenderness, or stimulants and counter-irritants, should be employed, according to the general strength of the patient, and the acute or chronic nature of the disease. In many cases the loss of blood by leeches has been sufficient to remove the symptoms; in others counter- irritation, as by blistering or the tartar emetic ointment, has suc- ceeded.* The latter is particularly recommended by Mr. Tate, and may be used with every hope of benefit. But when the affection is sympathetic, as is generally the case, in addition to the above means, the origin of the malady is to be anxiously sought after, and remedies administered Avhich are calculated to remove it. By far the most common cause in females is derangement in the menstrual discharge, and, under such circumstances, the endeavors of the medical attendant should be directed to promote the due performance of this function. If there be irritation in, or improper action of, the digestive or biliary organs, the disordered states hould be combated by appropriate remedies. Every medi- cine employed should have reference to the state of the system, and constitutional powers of the individual, and a low or nourishing diet prescribed accordingly. In persons of an irritable tempera- ment, change of air, exercise, congenial society, and all methods of distraction, should be recommended. In chronic cases, the disease is often very intractable, but if it have been previously treated in an injudicious manner, much may be effected by the above means. If there be much pain or watchfulness, anodynes are useful: hyoscyamus and belladonna should be preferred, opium often increases the irritability. In other respects the treatment should be conducted on the principles laid down under Hysteria and Neuralgia, with Avhich disorders spinal irritation is almost inseparably connected. * There are milder counter-irritants which are adapted to many cases. Such as the repeated application of mustard poultices, every night or every second night; they should be made much diluted, in order to be borne for a long time, or frictions with croton oil, or a stimulating liniment made with the oil of turpentine, olive, and some stimulating essential oil also act very well. 304 SPINAL MENINGITIS. Definition.—Symptoms.—of the acute form—of the chronic form.—Causes.— Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treatment. Inflammation in the membranes investing the spinal cord is an affection which exists very rarely without accompanying dis- ease in the substance of the cord, or in the membranes of the brain. Occasionally, however, it occurs alone, and appears to be as readily distinguished from inflammation of the substance of the cord (myelitis) as cerebral meningitis is from cerebritis. Obser- vation has shoAvn that there are no signs by Avhich it is possible to distinguish inflammation of the membranes of the spinal cord, that is, inflammation of the dura mater from that of the pia ma- ter, although Prefessor Albers of Bonn has attempted to do so. (Journalfur Chirurgie und Augenheilkunde, vol. xix, chap. 3). The symptoms, therefore, must be considered common to inflam- mation of both these membranes. Symptoms. Acute spinal meningitis generally commences with sensation of weight and fatigue in the limbs, often attended with constipation, and occasionally Avith dysuria, or even re- tention of urine. These symptoms are followed by pain in the back, more or less severe, most commonly in the lumbar region, Avhich is at first of a dull description, but becomes rapidly more acute, and extends to the limbs; the pain is sometimes lancina- ting, arising from a fixed point in the back; in other cases it is not so concentrated or severe when the patient is at rest, but is greatly in- creased by the slightest motion, a circumstance that often gives rise to the impression, that the affection is rheumatism. According to Ollivier, the pain is not augmented by pressure; sometimes it is con- tinued; occasionally there are complete remissions, and the patient almost always avoids muscular motion, from the fear of increas- ing it. On the occurrence of the pain, there is often a sense of constriction in the neck, back, or loins, according as the mem- brane is inflamed to either of those situations. As the disease advances, there are convulsive contractions of the neck and pos- terior part of the trunk; sometimes there is complete opisthotonos, or a considerable degree of rigidity in the muscles of the back, in which occasionally those of the limbs participate. These move- ments may come on without any apparent cause, but they are most frequently excited by change of position. In other in- spinal meningitis, (Causes.) 305 stances, there is trismus or convulsions, or rigidity of the extremi- ties, with pain throughout their Avhole extent. Paralysis of mo- tion is mentioned as a symptom by some authors; but there is every reason to believe that in these cases the cord itself is affect- ed. The respiration is laborious or hurried; the pulse, at first natural, becomes rapid, small, and feeble; while the motions of the heart are strong and frequent: these symptoms are generally accompanied with hot skin, thirst, and loaded urine. When the tetanic spasms are intermittent, there is generally abundant per- spiration, which becomes more profuse as the disease advances toAvards a fatal termination. At a later period, the pulse becomes smaller and more irregular; the tongue and mouth dry; the faeces and urine are passed involuntarily; the dyspnoea is more urgent; and drowsiness, delirium, convulsions, Avith increase of the tetanic spasms, passing into coma, precede the fatal issue. The progress of these symptoms is usually rapid, if not check- ed by proper treatment, although its duration varies according to the intensity and extent of the inflammation. It is generally fatal from the fifth to the fifteenth day. Some cases, however, have been recorded by Ollivier, which have been fatal as early as the fourth, and others Avhich have been prolonged to the twentieth or thirtieth day. In chronic meningitis of the spinal cord, the symptoms are de- veloped more slowly. They consist generally at first of obscure dorsal pains, Avith a sensation of constraint and fatigue in the limbs; sometimes there is morbidly acute sensibility of the cuta- neous surface; occasionally pain in the bowels, Avhich is often so severe as to be considered and treated as the primary disease: sometimes there is palpitation of the heart, with dyspnoea, and other anomalous symptoms, so that the spinal disease is very apt to be overlooked. The pain in the back in some instances be- comes suddenly increased, or there are distinct remissions or even intermissions; in others it becomes acute, and the patient is carried off with the same symptoms as characterise the last stage of the acute form just described. In both varieties there is usually more or less rigidity of the limbs, with contraction. Poletti has given a case, where, from contractions of the cervical muscles, the head Avas draAvn forcibly down to the right shoulder six months before death. (Ann. Univ. de Mid. de Omodei, Nov. 1825). M. Olli- vier has observed, that eschars on the sacrum are not so common in this as in other spinal diseases of long standing. Causes. The causes of this affection are often very obscure, and in some cases not discoverable. All mechanical injuries are capable of producing the disease, as fractures and dislocations of the vertebrae ; violent blows and contusions on the spine, or con- cussion from falls on the feet and on the nates: it may also su- pervene on cerebral meningitis, the inflammation apparently ex- tending to the membranes of the spinal cord. Suppression of the 306 spinal meningitis, (Anatomical Characters.) menses, haemorrhoidal haemorrhages, and of accustomed dis- charges; chilliness of the body, and sudden changes of heat and cold, have sometimes been supposed to have occasioned it. Cases are given by Ollivier and Bergamaschi, where it followed violent efforts to lift heavy weights. Lastly, individuals subject to rheu- matism have been found peculiarly predisposed to this disease. Anatomical characters. After acute meningitis of the spinal cord, the membranes are usually injected, the red color being more or less intense, and principally confined to the pia mater, while the arachnoid is rendered opaque by the thickening of the cellular tissue contiguous to it. No vessels have yet been found in this membrane, and consequently the red appearance it often presents arises from an injection of the tissue below it. These signs of inflammatory action are generally found throughout the Avhole extent of the spinal cord, although sometimes they are more or less circumscribed or limited to spots, an a>ppearance usu- ally found when inflammation has been the result of mechanical injury to the bones. When the dura mater is laid open, there is often effusion of yelloAvish Avhite lymph, giving the cord, as point- ed out by Ollivier, an appearance of enlargement and density. It is ahvays thicker posteriorly than anteriorly, this thickening be- ing sometimes conjoined with a collection of sero-pundent fluid; occasionally there is effusion of pus, but, as noticed by Ollivier, it is rarely found in the cavity of the arachnoid, but generally between that membrane and the pia mater. J. Frank has shoAvn that dropsy of the cord may result from acute inflammation of its membranes. The dura mater is sometimes injected and more or less thickened. Professor Albers of Bonn has seen it of a cinnabar color in tAvo cases, accompanied with serous and purulent effusions. (Mim. cit.) Ollivier. Lallemand, and Bergamaschi, have found serous fluid accumulated between it and the bones. Constant has ob- served pus in the same situation. (Gaz. Mid., 1835, p. 74, 75.) In chronic meningitis, besides one or more of the above ap- pearances, there is generally adhesion of the arachnoid to the pia or dura mater, and not unfrequently cartilaginous plates, gene- rally small and numerous, in the arachnoid, between it and the pia mater. It is very rare that any of the above signs of inflam- mation are confined to the membranes of the cord in general, they are found likewise in those of the brain, or in the substance of the spinal marrow. Nature. The symptoms of this affection are readily explained by the morbid appearances discovered after death. The inflam- mation produces irritation and the symptoms of increased action which follow. Paralysis, when present, is to be attributed to pressure on the spinal cord, which not uncommonly participates in the inflammatory action, constituting meningo-myelitis. (See Myelitis and Hydrorachis.) spinal meningitis, (Treatment.) 307 Diagnosis. According to Ollivier, inflammation of the men- inges is to be distinguished from inflammation of the structure of the cord (myelitis), by the acute pain in the back, increased by motion only, and by the tetanic rigidity of the muscles, while in the latter (myelitis), the pain is augmented on pressure, with diminution of sensibility, with more or less paralysis. Apoplexy of the spinal cord is recognised by the sudden occur- rence of vertebral pain, tetanic rigidity, convulsions or paralysis. The pain is increased on pressure, which is not the case in men- ingitis. In some cases there are no tetanic spasms, the pain is fixed and not liable to remission, while the general sensibility is often diminished. Cerebral meningitis is distinguished by the headach, delirium, injected countenance, intolerance of light and sounds, intense thirst, and general symptoms of fever. Chronic spinal meningi- tis is known by the sIoav progress of the symptoms, the intelli- gence being unimpaired. In the early stage it is with great diffi- culty diagnosed from rheumatism, and in many cases it cannot be distinguished until the more urgent symptoms appear. Its prin- cipal character is tetanic rigidity, whereas in chronic myelitis there is more or less paralysis. Prognosis. Spinal meningitis must always be looked upon as a most dangerous disease; by some authors it has been considered incurable. J. Frank, however, has published a case that was cured by antiphlogistic remedies (Prax. Med., vol. v, p. 76), and Ollivier has found thickening of the spinal membranes in an epi- leptic, who died of some other disease. We have seen an in- stance of acute spinal meningitis under the care of M. Cruveilhier at Bthe Salpetriere, which completely recovered. These cases, hoAvever, are exceedingly rare; and Avhen the malady is fairly established, the prognosis is always most unfavorable, if not fatal. Treatment. In the acute form, general and local bleeding is obviously indicated, and should be vigorously employed, so as to produce a marked effect on the pulse, especially if the patient is strong and of a plethoric constitution. Leeches or cupping- glasses should, Avith or without venesection, be applied over the part which is the principal seat of pain. M. Goss recommends deep incisions on each side of the spinous processes, with a view of opening the veins that communicate Avith the spinal cord (Des Maladies Rheumatoides, p. 231); Ave have no proof, hoAvever, of the benefits of this severe treatment. Purgative injections, containing a large quantity of fluid, should be given occasionally; purgatives by the mouth, especially such as are of a drastic nature, being contra-indicated, on account of the straining, during their operation, increasing the pain and tetanic spasms. Ollivier advises the cold affusion, or the application of ice to the spinal column, Avhich he says ought to be as beneficial in spinal as in cerebral meningitis; no facts, however, are given in support of 308 spinal meningitis, (Treatment.) this opinion. Warm pediluvia are beneficial, and should be con- ' tinued some time, care being taken to support the patient in an inclined position, and to prevent, as much as possible, all unneces- sary motion. The catheter should be introduced three or four times a day, to prevent accumulation of urine, and the conse- quent decomposition this fluid is liable to undergo in the bladder when long retained. Antimonials are hazardous, from their lia- bility to occasion vomiting. If acute pain continue after the em- ployment of the above means, anodynes and hypnotics may be given to relieve it and procure sleep. Absolute rest in the hori- zontal posture is essentially necessary. A severe antophlogistic diet must be rigorously persevered in. In the chronic form of the disease, cupping in the neighborhood of the seat of the pain may be occasionally employed, followed by counter-irritation, extending over a greater or less surface according to the severity of the symptoms. With this vieAV, moxas, issues, setons, tartar emetic ointment, or the actual cautery, may be employed, so as to keep up a constant irritation and discharge from the part. Blisters are objectionable, as in some cases they occasion strangury and increase the general irritation. From numerous instances we have seen of the effects produced by the actual cautery in diminishing chronic inflammation, Ave are convinced that it is not only the most efficient, but, on the Avhole, the least painful mode of applying counter-irritation. The pain, though severe for a time, is not long continued, and on this account, is less in the ag- gregate than that occasioned by other kinds. In the hands of Professor Syme of Edinburgh, it has frequently succeeded in curing chronic inflammation of the joints, when all other means had failed; and in two cases of chronic spinal meningitis, oc- casioned by diseased vertebrae, Ave have seen it produce a com- plete cure. The triangular cautery of Rust should be applied, at a white, or an intense red heat, for two or three inches on each side of the spine, where the pain is most intense, so as to produce a deep eschar. When the slough separates, water dressing is all that is necessary. The cold or tepid sea-water douche, or a weak saline solution, poured from a jug or tea-kettle over the spinal column, may be also employed. Absolute rest in the horizontal posture is also necessary in this form of the disease, and great attention should be paid to the daily change of cushions and air-pillows, so that the formation of sores on the sacrum and back may be prevented as much as pos- sible. 309 MYELITIS, OR INFLAMMATION OF THE SPINAL CORD. Definition. —Symptoms of acute myelitis—of chronic myelitis,—Causes.— Anatomical characters.—Nature.—Diagnosis.—Prognosis.—Treatment. By this term (from (tvabs, medulla spinalis) is understood in- flammation of the spinal cord. The disease has received various names from different authors. It is called notamyelitis, by F. Hildenbrandt; spinitis, by several French Avriters; rachialgitis, by Brera and J. Frank; mielitide stenica, by Bergamaschi, &c. The two last authors, hoAvever, have not distinguished this affec- tion from spinal meningitis. The term myelitis, first used by Harles (Dissert. Inaug. Mid. de Myelitide, Erlangen, 1814), and subsequently adopted by Khloss (Dissert, de Myelitide, Halle, 1820), Ollivier, Andral, and others, is the best, and the one most commonly used. Symptoms. The symptoms of acute myelitis vary considera- bly, according to—1. The period and intensity of the disease; 2. The portions of the cord inflamed; and 3. The extent to Avhich it may be complicated with spinal meningitis. 1. If the inflammation is not very severe, the first symptoms are numbness and a sensation of cold in the fingers or toes, ac- companied with pain and difficulty of moving them. These symptoms gradually affect the upper and lower extremities, and extend to the trunk. Sometimes there is obscure pain in the course of particular nerves; formication; feebleness of the muscles or a kind of subsultus; constipation; retention of urine; affections of the heart; and more or less derangement in the functions of other internal organs, which are often thought to be the primary diseases, Avhile the state of the spinal marrow is overlooked. Under these circumstances, firm pressure or percussion applied to the spinous processes successively, or passing a sponge saturated Avith hot Avater along the spine, (as recommended by Mr. Cope- land,) will generally detect the seat of the disease. If the inflam- mation be more active and intense, the disease commences with partial or general convulsions Avithout numbness, while acute pain is felt in the back, extending along the course of the nerves. Sometimes the convulsions are clonic, and in some instances of the tonic character, but there are strong reasons for supposing, that, if there be tetanic rigidity, the meninges are also affected. 310 myelitis, (Symptoms.) As the disease advances, and disorganisation occurs, there is paralysis, Avith diminution or complete loss of sensibility. The bowels are generally costive, and the urine is either retained or passed involuntarily; the latter generally occurring during con- vulsions. Sometimes the paralysis commences in the inferior extremities, and gradually proceeds upAvards, until all the respi- ratory muscles become affected, and the patient dies asphyxiated. Occasionally, but more rarely, the paralysis appears first in the superior, and subsequently in the inferior, extremities; in some cases it is confined to one side of the body only, or to a single ex- tremity. In general, motion and sensibility are lost together, but sometimes the one is paralysed Avithout the other. Not unfre- quently, paralysis appears first on one side of the body, and then on the other; or one foot, leg, hand, or arm, may be affected, ac- cording to the situation or extent of the disease. The different paralytic phenomena are treated of more at length under Para- lysis. 2. The general symptoms above detailed are liable to greater or less alteration, according as the inflammation is seated in the cra- nial, cervical, dorsal, or lumbar portion of the cord. When the cranial portion of the cord is affected, the patient experiences a sense of pricking, and of formication in one or more of the limbs; deep-seated headach; greater or less affection of the special senses, as obscurity or loss of sight, hearing, or smell: sometimes there is delirium; trismus, or convulsions; grinding of the teeth; red and dry tongue; difficulty of swalloAving; vomiting; embarrassment, or loss of speech; frequent and convulsive respi- ration: in some instances, symptoms resembling hydrophobia have been observed, or irregularity in the heart's action and in the pulse; hemiplegia, or other form of paralysis. As the fatal stage advances, the prostration increases; the pulse becomes more fee- ble; the dyspnoea increased; and the excretions are passed invo- luntarily. When the cervical portion of the cord is the seat of inflamma- tion, the symptoms are—difficulty of deglutition; impossibility of supporting the head (Vogel); acute pain in the back of the neck; difficult and hurried breathing, the functions of respiration being principally carried on by the contractions of the diaphragm; palpi- tations; frequent hard pulse; pricking sensations in the fingers or hands; paralysis of the superior or inferior extremities, sometimes of the former only, gradually extending to the muscles of the trunk; and before death, the usual symptoms of failure of the vital powers. When the superior part of the dorsal portion of the cord is the seat of the disease, there is pain in the dorsal region; convulsive movements of the trunk; palsy of the arms and lower extremities; short and laborious perspiration, principally carried on by the ex- ternal respiratory muscles; palpitation, or tumultuous and irregu- lar actions of the heart, &c. myelitis, (Symptoms.) 311 When the lumbar portion, or lower part of the dorsal region is affected, Avhich is the most common seat of the disease, besides a greater or less number of the above symptoms, the loss of motion and sensibility in the inferior extremities is more marked; there are deep and severe pains in the loAver part of the back; pain in the abdomen, resembling colic; convulsive contractions of the ab- dominal parietes; sensation of tightness above the pelvis, as if con- stricted with a band or cord. Paralysis of the bladder and sphinc- ter ani also is a prominent, as well as one of the earliest symptoms. 3. When myelitis is complicated with spinal meningitis, con- stituting meningo-myelitis, the symptoms above described are conjoined with those characterising inflammation of the mem- branes, such as increased pain on the slightest motion, and more or less tetanic rigidity. The inflammation in these cases is often of greater extent, and the pain is not confined to a circumscribed spot. There are also not unfrequently febrile symptoms, the pulse being quick, strong, and irregular, the skin hot, the tongue foul and dry, and the respiration laborious and frequent. Abercrombie (case 147), J. Frank, Bergamaschi, and others, have confounded cases of this affection with myelitis or simple inflammation of the cord. The duration of acute myelitis is variable, usually proving fatal from the fifth to the tenth day. Cases are not uncommon where this event has occurred on the third or fourth, and a feAV are re- corded Avhere death has taken place in fifteen or twenty hours. The symptoms are more intense, and the disease more rapidly fatal, when the dorsal portion of the cord is affected, a fact observ- ed by Mr. Earle (Phil. Trans., 1822) and by Ollivier, and attri- buted Avith much reason by the former to the small size of the cord in this situation. The symptoms of chronic myelitis are essentially the same as those which characterise the acute; they come on, however, more slowly, and at the commencement are more obscure and difficult of detection. In many cases, long before any pain is complained of in the back, there is a feeling of numbness, pricking, formica- tion, loss of strength, or other obscure symptoms in the fingers, hands, toes, legs, thighs, and other parts of the muscular system. Sometimes there is increased sensibility in these parts. When pain occurs in the back, it is often for a long time considered to be rheumatism, and is generally mistaken for lumbago or sciatica. The numbness and Aveakness are generally greater on getting up in the morning, and are often lessened by exercise; the poAver of motion and muscular strength being also temporarily increased, a circumstance ascribed by Ollivier (vol. ii, p. 427,) to a state of congestion which is favored by long repose, and in some measure dissipated by increasing the activity of the circulation. The gait of persons affected Avith chronic myelitis is peculiar, and thus de- scribed by Ollivier:—" Each foot is lifted from the ground Avith 312 myelitis, (Causes.) difficulty, and in the effort Avhich the individual makes to do this and carry it forward, the trunk is first straightened, and then throAvn back, as if to counterbalance the Aveight of the inferior extremity, Avhich vacillates involuntarily before it is again placed to the ground. Sometimes the point of the foot is drawn down- wards, and is more or less dragged on the ground before it is lift- ed, while, in other instances, it is raised quickly, and at the same time thrown outwards." When there is incomplete paralysis of the fore-arm and hand, objects are obscurely felt, seized with dif- ficulty, and readily fall from the patient's grasp. Complete para- lysis is slow in its approach, and is often limited for a long time to one or even to a portion of the extremities, which gradually becomes rigid, and is extended with difficulty and pain. Some- times there is no rigidity or contraction, but slight pain in the affected limb on motion, or on pressing the hand on the course of the nerves. In the paralysed parts there is often a perceptible diminution of temperature, and an absence of cutaneous transpi- ration, rendering the skin dry and scaly. In many cases the heart is much affected, the strength of its contractions being increased and its action tumultuous, Avhile the pulse is Aveak and irregular. In others there is difficulty of breathing, and the patient is fre- quently almost suffocated. Ollivier considers that this disease is often the cause of idiopathic asthma. There are occasionally symptoms resembling those of angina pectoris, the paroxysms being in some instances preceded by pain and numbness, extend- ing from the arms to the chest, and in others from the chest to the arms. There is often colic pain, with contractions of the abdo- men; cramps in the stomach; painful spasms of the abdominal parietes; sometimes a sensation of constriction, as if a cord was tied tightly round the trunk, with the knot over the spine. There is almost always constipation and retention of urine, Avhich, as the disease advances, is changed into inability to retain the excre- tions. In the generality of cases, large eschars and sloughs form on the back, under the exhausting discharges from which the pa- tient sinks. The intelligence is unaffected throughout, unless the brain participates in the disease. The duration of chronic myelitis is generally from one to four years, the immediate cause of death being most generally ex- hausting discharges from large sores in the sacrum. Some, how- ever, die of gradually increasing debility Avithout these sores; and in others death has been occasioned by a true asphyxia. Indivi- duals have existed under this affection for fifteen or twenty years, Avith perfect preservation of the intelligence. Causes. Myelitis (to Avhich males appear to be more liable than females) may be occasioned by falls and blows on the verte- bral column; fractures and displacements of the vertebrae; altera- tions in the bones and ligaments by caries, scrofula, or rachitis. It has been observed by Ribes to follow rheumatism (Diet, des myelitis, (Anatomical Characters.) 313 Sciences Mid., art. Vertebrae); and by J. P. Frank (De Curan- dis Hom.Morb. Epitome, vol. x,p.50, 51.) and Ollivier, cerebral meningitis, pneumonia, and inflammation of the digestive organs. It may also be caused by sudden changes of temperature, and long exposure to cold and tempestuous Aveather. Great fatigue and excessive muscular exertion have produced it. MM. Dupuy and Bouley have pointed out its frequent occurrence in the lum- bar region of horses subjected to much labor. It has followed also excessive venereal indulgences. Hourtet gives a case where it depended on the venereal disease, and disappeared Avhen the original affection was cured. (Mem. de I'Acad. Roy. de Chir., torn, iv, p. 141.) In a great number of cases, however, myelitis cannot be attributed to any apparent cause. Anatomical characters. It is rare that death takes place in the early stages of inflammation of the spinal cord; but there is every reason to believe, from the analogy of its structure Avith that of the brain, that it presents the same appearances as the lat- ter organ. Mr. Stafford describes it Avhen occurring after inju- ries of the spine as being redder than natural, presenting bloody points Avhen cut into, Avhich, as Dr. Todd has remarked, implies that he has seen the lesion in its early stage. In general, hoAV- ever, the results of inflammation are discovered; such as softening, induration, and suppuration. Softening may exist in any portion of the spinal cord, but it is most common in the lumbar region, and next in the cervical. It presents the same characters that we have described as belonging to softening of the brain, and there are the same doubts in many cases regarding its inflammatory origin. In some instances it occupies only the posterior columns, in others the anterior, but in general, as remarked by Ollivier, the central portions are most affected, though there is obviously much difficulty in establishing Avhether it is ever confined to the gray matter, as that Avriter supposes to be not unfrequently the case. Sometimes the Avhole thickness of the cord is destroyed and re duced to a thickish fluid or pulp; in which no traces of nervous matter can be discovered; in other cases it is only partially de- stroyed, and fibres of medullary matter can be traced through the softened mass; or Avith more or less softening, the cord has been found flattened by pressure; for example, by. an exostosis. (Jan- son, Compte Rendu du Grand Hotel Dieu de Lyon, 1822.) In- duration is also sometimes met with, most generally in chronic cases, although Bouillaud considers it is a change that often pre- cedes softening. (Sur VEncephalite.) Occasionally, when the cord is indurated, it is also atrophied. Hutin relates a case of chronic myelitis, Avhere the cord Avas indurated and atrophied, so that it exactly resembled a ligamentous cord. (Nouvelle Bib. Mid., an 1S23, torn, i, p. 24.) Sometimes the volume of the cord is increased, as noticed by Bergamaschi, Portal, Laennec, Aber- 27 314 myelitis, (Anatomical Characters.) crombie, Ollivier, Andral, Hutin, and others. In some instances the induration is connected Avith increased vascular action in the part and neighboring structures, as pointed out by Bergamaschi and Portal; in others it is deprived of all coloring matter, resem- bling the Avhite of egg, as remarked by Esquirol and the younger Pinel. In a case by Somenkalb, of induration of the cord, it Avas hypertrophied in the cervical region, the remaining portion being in a state of atrophy. (Corns Zeitschrift fur Natur und Jfcil- kunde, torn, i, p. 5, 2d year.) Suppuration in the spinal cord is a result of inflammation, Avhich is very rarely met Avith. Velpeau met Avith two distinct abscesses, one in the right, the other in the left column; the former three inches long, and two or three lines in diameter; the latter one inch long, and one line in diameter. (Riv. Med. 1826.) In a case published by Mr. Hart, of Dublin, the spinal cord Avas enlarged in size. On cutting it open, thick purulent matter, Avhich Avas contained in a cyst, flowed out, occu- pying the centre of the spinal marrow, extending from the first to the eleventh dorsal vertebra; its diameter Avas about four lines. (Dub. Hosp. Rep., vol. v.) Dr. Carswell has seen two abscesses in the cord; one on the right side, five inches long and a line in diameter, and another on the left side, an inch long. (Carswell, Path. Ana t.) Nature. In the greater number of cases the morbid appear- ances readily explain the symptoms, according to the general laws of the pathology of nervous diseases formerly alluded to in the preliminary observations, the early inflammation producing irri- tation, and causing pain, convulsions, and other symptoms of in- creased action, Avhile the loss of motion and sensibility are in pro- portion to the amount of pressure on, or destruction of, the differ- ent affected portions of the cord. The great majority of the cases also are in perfect accordance Avith our knoAvledge of anatomy, and the numerous experiments performed on animals. Some hoAvever have occurred, in which, Avhen the cervical portion of the cord only has been affected, there has been palsy in the supe- rior extremities above, while the inferior have remained in their natural state, readily obeying the influence of volition; on the other hand, the lower limbs have been affected Avhile the upper have remained unaffected. These instances are rare, and are only to be explained by supposing that the feAV fibres not impli- cated in the organic lesion are capable of performing their usual office of conductors—a supposition perfectly consistent with our knoAvledge of the special and independent endowment of nervous fibres. Regarding the feAV cases Avhich have been recorded, in which total destruction of the spinal marrow is said to have oc- curred, without in any way deranging sensibility or voluntary motion in the lower extremities—a result equally opposed to all our anatomical, physiological, and pathological knowledge, we perfectly agree Avith the opinion expressed by M. Bouillaud, viz: myelitis, (Treatment.) 315 that it is probable the observers of these cases have committed some error, either in the observation of the symptoms, or in the description of the morbid alterations. (Diet, de Mid. et de Chir. Prat., art. Myelite.) This point is discussed more fully under Paralysis. Diagnosis. We have already explained how myelitis is to be distinguished from spinal meningitis Avhen treating of the last named disease, the leading symptoms in the first being paralysis and loss of sensibility, and in the latter tetanic rigidity and in- creased sensibility. In the advanced period of the chronic form, the disease of the cord generally becomes complicated with spinal meningitis, and there is perfect paralysis, with rigidity and con- traction. Meningo-myelitis is recognised, in the acute stage, by the combination of tetanic rigidity, paralysis, and pain, with more or less fever. The progress, of the symptoms distinguishes mye- litis from spinal apoplexy, in Avhich latter the effects are sudden. In some cases there is great difficulty in detecting the early stage of the chronic form of the disease from rheumatism, and occasion- ally it is impossible, unless paralysis is present; but if, on percus- sing or pressing on the spinous processes, or passing a sponge sa- turated with hot Avater down the vertebral column, increased pain is complained of in a particular part of the spine, we may con- clude that there is some affection of the cord or its membranes. This method will likewise assist in distinguishing the part of the cord affected. Prognosis. Acute myelitis generally terminates fatally, pro- bably because the symptoms in the early inflammatory stage are confounded Avith rheumatism, or other affections, and are treated inefficiently. When disorganisation has taken place, we have every reason to believe the disorder to be incurable. The disease is most rapidly fatal Avhen the lesion involves the respiratory nerves. Life is usually prolonged when the lumbar region is affected, although the observations of Calmeil have shoAvn that, even in this case, death may occur quickly. The chronic form may be successfully combated in the early stages. MM. Ollivier and Latour (Mim. de la Soc. Med. d'Emul, torn, vi, p. 92,) have reported several cases of cure after the disease had existed several months. We have seen one case of Avell-marked acute meningo- myelitis recover, and another is reported by Dr. Ruse of Baltimore. (American Medical Recorder, July, 1825.) Treatment. The treatment of myelitis, both in its acute and chronic forms, is exactly the same as that recommended for spinal meningitis; and Ave have nothing to add to what has been there stated. With regard to the value of certain remedies which have been recommended for the cure of paralysis, in the chronic form of the disease, such as strychnine, galvanism, electricity, &c, this subject is discussed in the observations on the treatment of Paralysis. 316 HYDRORACHIS. Definition.—Congenital hydrorachis.—Hydrorachis developed after birth.— Causes. — Anatomical characters. — Nature. — Diagnosis. — Prognosis.— Treatment. This term (from vSwp, aqua, and pdxn, spina) is applied to ab- normal collections of fluid Avithin the spinal column, Avhether congenital or occurring after birth. Magendie has pointed out, that in the healthy state there is always a certain quantity of fluid in the subarachnoid cavity of the spinal canal, which is absorbed soon after death. Whenever, therefore, a considerable quantity of this fluid is discovered tAventy-four hours after death, we may consider it morbid, and resulting from previous disease of the brain or spinal marrow. On account of the free communication betAveen the arachnoid and subarachnoid cavities of the spinal cord and the brain, it is often difficult to determine whether hydrorachis occurs primarily from the membranes of the one or the other, but if the seat of effusion be between the dura mater and osseous covering, there can be no doubt (as observed by Abercrombie) that it is spinal only. Congenital hydrorachis in the foetus or new-born infant is always associated either with hydrocephalus or spina bifida. When connected Avith the former, all the symptoms of Avater in the head are present; Avhen hydrorachis is complicated Avith spina bifida, there are certain local and general symptoms which indi- cate the affection. These Ave proceed to enumerate. " On examining the spine, one or more tumors containing fluid are found, situated immediately over the deficiency in the verte- bra, most commonly the lumbar, this affection being seldom met with in the dorsal and sacral, and still more rarely in the cervical region. When the disease occurs in the latter situation, there is generally separation also of the cranial bones. There may be one or more distinct tumors in the cervical, dorsal, or lumbar regions, or, if the Avhole spine is bifid, one tumor may occupy all three regions, being proportionate in length to the number of malformed vertebrae. Feiliz gives a case in Avhich all the spinous processes Avere deficient, and the tumor occupied the whole length of the spine. (Richter, Chir. Bibl., band 9, p. 185.) In magnitude it varies from the size of a hazel nut to that of an adult head, and is usually of a globular or ovoid shape, but sometimes pyriform, hydrorachis, (Symptoms.) 317 semilunar, or flat, Avith either a large base or a narrow neck. In a case by Brewerton, it was bi-lobed. (Edin. Med. and Surg. Journ., July, 1820.) To the touch it is either tense or flaccid, according to the position of the infant; for as there is always a free communication between the cavity of the tumor and that of the spine, and generally with the cranium; it is more distended Avhen the infant is in such a position as Avill alloAv the fluid to gravitate tOAvards it. By gradual pressure, also, its bulk may be diminished, and if small, all the contents may be thus forced into the spinal or cranial cavity, stupor being often produced from the pressure on the brain. In some cases, as noticed by Cruveilhier, the tumor expands during expiration, and sinks during inspiration, but he Avas unable to observe movements synchronous with those of the pulse. (Anat. Descrip., torn, iv, p. 564.) The coverings of the tumor may present various appearances, Avhich have been divided by Billard into three varieties. In the first, the integu- ments covering the tumor are in a healthy and uninflamed state; in the second, the skin is thin and discolored, sometimes Avith exudations of a sero-sanguineous fluid, indicating the approaching rupture of the parietes of tumor; in the third variety, the tumor has burst, the effused fluid escaping through a fine ulcerated per- foration, surrounded by a red, rugous, and unequal elevation of the skin. Of these, the first is the most uncommon and the least dangerous. In seven cases observed by Billard, tAvo Avere born with the skin covering the tumor in the healthy state. Spina bifida sometimes coexists Avith other malformations, as of the urinary or genital organs; Avith imperforate anus; malformation in the digestive canal, &c. The constitutional symptoms of this affection present no remark- able difference from those of other spinal diseases. Infants after birth are generally emaciated and feeble. There is more or less paralysis of the loAver extremities, sometimes connected Avith oedema, occasional convulsions, inability to take the breast, resolu- tion of the sphincters, difficulty of breathing, which, as the disease approaches its fatal termination, becomes stertorous. The infant becomes gradually more and more exhausted, its cries Aveaker, the extremities cold, the pulse excessively quick and feeble; and convulsions or coma, more frequently the former, precede death. These symptoms bear a relation to the state of the tumor, being less urgent if it is small, and if there be no opening. In the latter case, if the aperture be minute, no distressing symptoms may appear for sometime, though a certain quantity of fluid is con- tinually discharging, or may be pressed out. In this way, several pints have been removed. Very often, hoAvever, the nature of the fluid becomes altered, and from being colorless and limpid gets turbid, more or less purulent, and sometimes foetid. The exhaustion of the little patient is proportionate to the quantity 27* 318 hydrorachis, (Symptoms.) and purulent character of the discharge. These effects are the result of inflammation of the meninges, Avhich sooner or later comes on and destroys the infant. Of the seven cases observed by Billard, he found traces of spinal meningitis in five. If the tumor be large, and burst suddenly, and a large aperture after- wards form, death occurs more quickly, generally preceded by convulsions. This event has taken place in utero Avithout having been immediately fatal. Duges has given a case Avhere there was a large scar in the sacro-lumbar region, covering a mem- branous substance, by Avhich the vertebral canal was not very firmly closed. The child perished six Aveeks after birth. Hydrorachis developed after birth. Cases have been recorded by Frank and Reydellet, Avhere tumors Avith an aperture in the spinal canal have occurred after birth. Such cases, however, are very rare, and when the bones of the column are perfectly formed, no tumor is produced except in the sacral region, which is naturally open. Morgagni gives a case from Genga (epist. 12, sect. 9,), of hydrocephalus following a blow on the head, in which a tumor appeared at the coccyx. This was opened, and the head dimin- ished in size as the fluid was evacuated. What further proved the communication between the fluid in the head and that within the tumor, was, that on pressing the cranium it escaped Avith impetuosity. Tumors may also be produced by acephalocysts, and the escape of fluid between the vertebral laminae; cases of which are given by Ollivier. Hydrorachis developed after birth is generally symptomatic of spinal congestion or meningitis, and may be associated with, or depend upon, hydrocephalus. It is characterised by pain in the back, extending a greater or less distance; paralysis of the loAver extremities, with numbness or complete loss of sensibility; some- times oedema of the legs and feet, or gangrene of the toes; parox- ysms of convulsions or tremors have been occasionally observed (Bonnet. Sepulchretum, tom. i, p. 305, 307); and resolution of all the limbs, involuntary stools and urine, laborious respiration becoming stertorous before death. If hydrocephalus, as is generally the case, accompany the spinal disease, all the symptoms of the former affection are combined. Itard gives a case of hydrocephalus, in which, on ice being applied to the head, the cerebral symptoms disappeared, and complete paraplegia folloAved, apparently from the changed position of the effused fluid. Dr. Graves speaks of a case in which, Avhen the patient was lying doAvn, the loAver extremities could be moved with a certain degree of force, but when the individual stood erect, he could not place one leg before the other. Ollivier attributes this to the presence of serous effusion, which, when the patient was in the latter position, pressed with greater force on the lum- bar portion of the cord. When the seat of effusion is between the dura mater, and the bony walls of the vertebral column, as in hydrorachis, (Anatomical Characters.) 319 cases given by Bergamaschi, Ollivier, Abercrombie, and Lalle- mand, the same general symptoms are present. Causes. The causes of congenital hydrorachis have been sup- posed to depend remotely on constitutional disorder in the mother, as syphilis, scrofula, scurvy, or rickets; violent mental emotions, excessive venereal indulgences during pregnancy; concussions or other injuries affecting the mother, and imagined to act upon the foetus in utero, &c. There is no proof, however, that any of these circumstances bear any relation to the presence of hydrorachis in the foetus. The immediate causes are organic changes in the placenta or umbilical cord, producing more or less interrupted circulation and subsequent serous effusion into the spinal cord; in- flammation of the membranes of the cord, or of the brain, &c. Hoffman imagined that pressure on the head during parturition sometimes squeezed the fluid into the spinal canal. (Miscel. Nat. Cur., obs. 208.) In the majority of cases, hoAvever, the occur- rence of hydrorachis cannot be traced to any cause. The nume- rous theories brought forward to explain spina bifida, it is unne- cessary to discuss. The causes of hydrorachis, Avhen developed after birth, are of course the same as those Avhich produce the disease Avith which it is complicated, or on which it depends, as hydrocephalus, spinal meningitis, &c. Anatomical characters. The characteristic appearance found after death in hydrorachis is the abnormal collection of serous fluid, the presence of which is generally associated with morbid alteration of the neighboring tissues, such as detailed in the de- scription of spinal meningitis and myelitis. It may, however, be the only morbid appearance present. Duges gives the case of a man who died Avith paraplegia, in Avhom no other morbid lesion could be found except an effusion of serosity in the sacro-lumbar region, that gave the dura mater the appearance of an intestine filled Avith Avater. (Diet, de Med. et Chir. Prat., art. Hydrora- chis.) The fluid is sometimes limpid, often turbid, flocculent, or mixed with pus. In the latter case it is the result of meningitis or ulceration of the tumor. Its color may be of a light yellow, green, or black tint, and often more or less sanguineous. The amount of the effusion differs considerably from a slight accumu- lation of serosity, to such a quantity as fully distends the mem- branes, occupying the whole of the spinal canal pressing on the brain or communicating with a fluid in the cavity of the cranium. M. Montault found 14 ounces in the first situation alone. (Journ. Hebdom., August, 1833.) .It may exist in three situations:—1. between the pia mater and the arachnoid membrane, the seat of the cephalo-spinal fluid of Magendie; 2. in the arachnoid cavity; and, 3. betAveen the dura mater and bony walls of the vertebral column. When the fluid collects in the two first situations, it generally, but not ahvays, communicates freely Avith the ventri- 320 hydrorachis, (Anatomical Characters.) cles, and the arachnoid cavity Avithin the cranium. In tAvo in- stances Billard observed that the effusion into the cranium, and that into the vertebral canal, Avas different in color, shoAving that they Avere perfectly distinct, and in one of these the fluid in the fourth ventricle Avas retained by a firm reddish membrane, Avhich formed a cul-de-sac beloAV its inferior angle, interrupting all com- munication with the subarachnoid cavity. (Billard, 3d edit. obs. 69.) Two other cases have been reported by M. Lediberder. (Arch. Gin. de Mid., torn, v, 2d series, p. 39.) Cruveilhier has seen a similar membrane to that described by Billard in a case of hydrocephalus, where the fluid was prevented from entering the spinal canal. (Anat. Pathol., liv. xv.) In the third situation it is impossible any communication can exist Avith the brain, on account of the adhesion of the dura mater to the margin of the foramen magnum. It must not be forgotten that a serous fluid may be effused into the substance of the cord. In a case given by Portal there was a cavity in the cord extending to the fourth dorsal vertebra, large enough to admit a common quill, distended with serous fluid, and communicating Avith the ventricles. The serous cysts which are occasionally developed in the cord or mem- branes, if small, cannot be said to constitute hydrorachis, any more than similar cysts in the brain or its membranes constitute hydrocephalus. In congenital hydrorachis combined with spina bifida there are deficiencies in the vertebra, Avhich Fleischmann has divided into three classes:—the first comprehends division of the whole verte- bra, body as well as processes; the second, imperfect develop- ment of the lateral arches only; and the third, development Avith- out union of the lateral arches. (De Vitiis Congenitis, circa Thoracem et Abdomen. Erlangae.) The first and third of these are rarely met with. The anatomical character of the tumor also varies, its walls being sometimes natural, composed of skin, dura mater, and one layer of the arachnoid or both, according as the fluid is situated in the arachnoid or subarachnoid cavity; in other cases its parietes are more or less diseased, being inflamed, thickened, ulcerated, gangrenous, covered with fungous groAVths or tufts of hair. In these cases, also, the spinal cord may be more or less affected, its substance being, according to Meckel, either softened, reduced to a pulp, diminished in size, divided into tAvo parts, or expanded into a membrane; according to the observations of Ollivier, however, these alterations are not common. The cord is often preternaturally long, owing, as Ollivier thinks, to the ad- hesion betAveen it and the Avater of the lumbar tumor fixing it permanently at a point of the spinal canal where it ought only to have remained temporarily. More rarely the substance of the cord is entirely wanting; the membranes, according to Otto, hav- ing fallen together, and being usually slit at one or more places, or they are more or less degenerated, and adherent to each other, hydrorachis, (Prognosis.) 321 forming sometimes a closed sac filled with lymph. Morgagni cites cases from Tulpius, Lechel, and Alpinus, Avho saw the nerves floating in the aqueous tumor. (De Sed. et Cans., epist. 13.) This has also been seen by Ollivier and Cruveilhier. Mr. Stafford has described the nerves as distributed on the inside of the tumor in Avhich they terminated, and where occasionally they formed a nervous network. (Injuries and Diseases of the Spine, p. 21, et seq.) Nature. The pathology of hydrorachis will ahvays be found in perfect accordance Avith that of other spinal diseases, and with the facts stated in the general observations. As the palsy which accompanies hydrorachis is explained under Paralysis, it is un- necessary to discuss the subject here. Diagnosis. In the congenital form, when combined with spina bifida, the situation of the tumor, and the effects of pres- sure, Avill readily detect the nature of the disease. When at birth or at a later period it is complicated with hydrocephalus, it is distinguished by the peculiar symptoms of that disease. In these cases, however, in addition to the cerebral symptoms, those de- noting lesion of the spinal cord, as convulsions, paralysis of the extremities, rectum, and bladder, are more marked. When it is the result of spinal meningitis, myelitis, or meningo-myelitis, the peculiar symptoms of those maladies are observed. We are not aAvare of any symptom Avhich may be considered as diagnostic of hydrorachis in an idiopathic form, unless the circumstance noticed by Dr. Graves, formerly alluded to, may be so considered. We have seen two cases of incomplete paraplegia, in which the patients could move the inferior extremities much more readily in bed than Avhen supported in the erect position. As these indi- viduals are still living, it is impossible to say Avhether this de- pends upon the gravitation of fluid in the spinal canal; very little attention has hitherto been paid to this point. Prognosis. The prognosis in hydrorachis must ahvays be very unfavorable. In the congenital form, Avhen connected with spina bifida, it is not necessarily fatal, many cases having been recorded that existed several years, and in these death Avas appa- rently unconnected with this affection. Individuals have been found in Avhom this disease was complicated Avith spina bifida— by Bonn at 10 years; by Martini at 11 years; Paletta and Acrel at 17 years; by Henderson at 18 years; by Copland at 19 years; by Warner, Hochstetter, and S. Cooper at 21 years; by Camper at 28 years; by CoAvper at 30 years; and Ollivier cites a case by Swagermann, Avho saAV it in an individual 50 years old. (Olli- vier vol. i, p. 227, 3d edit.) Generally speaking, however, the larger the size of the tumor, and the greater the destruction of the°cord or brain, the greater is the danger, and this is increased when there is sloughing or gangrene. When the tumor bursts, the patient generally dies quickly in convulsions. Ollivier says, 822 hydrorachis, (Treatment.) that once only in such a case a cure has folloAved. The death takes place more rapidly if the laceration in the tumor be large, or inflammation attacks its walls. When other malformations are combined with the disease, it is unnecessary to say the case is more hopeless. Treatment. The treatment of congenital hydrorachis Avith spina bifida may be considered as radical or palliative. The radical treatment is very hazardous, and in the majority of cases has hastened the fatal result. Sir A. Cooper has cured tAvo cases by repeated small punctures. Probart another (Lan- cet, No. 186,) and Rosette and MM. Robert one each. (Arch. Gin. de Mid., tom. xvii, p. 280, and tom. xviii, p. 102.) In the tAvo last cases the inferior extremities Avere completely paralysed, proving that this circumstance does not contra-indicate the per- formance of the operation. Experience has shown that the sud- den bursting of the tumor almost always produces death, by occasioning spinal meningitis; and consequently, Avhenever it presents an inflamed appearance at any point, and is apparently about to break, a puncture should be made Avith a small cataract knife, at the most depending part of the tumor, and the fluid gently squeezed out. Before the pressure is removed, the orifice should be covered Avith a piece of adhesive plaster, in order to favor union by the first intention, and a bandage applied so as to occasion gentle pressure, and support the Avails of the tumor. After a time this may be repeated if necessary, and the treat- ment conducted nearly on the principles recommended by Mr. Abernethy for psoas abscess. All other radical methods of cure, such as the ligature, setons, &c, are incompatible and dangerous. Except under the circumstances Ave have alluded to, the pal- liative treatment should always be employed. Compression Avas proposed by Mr. Abernethy, Avith a vieAV of supplying the defi- ciency in the spinal canal, and giving support to the part. Sir A. Cooper applied a plaster of Paris mould to the tumor, to effect this. In Avhatever manner pressure is applied, care must always be taken that it is gradual, for if it be sudden, or carried too far, convulsions or paralysis will be the consequence. Although this practice is undoubtedly useful, it may be questioned Avhether the local application be the principal means of cure. Most probably the improvement in the general health, by strengthening the sys- tem, increasing the activity of the circulation, and thus prevent- ing local congestion, which tends to keep up or increase the amount of serous effusion, must be the chief indication of treat- ment in this disease. While, therefore, gentle pressure on the tumor, either by bandages, plaster of Paris, or a discutient plas- ter, is employed, great pains should be taken to increase the general tone of the system, and apply such remedies as Avill induce absorption of the fluid, and prevent its tendency to in- crease. With this vieAV, change of air to a dry situation in the hydrorachis, (Treatment.) 323 country ought to be recommended, and a healthy Avet nurse em- ployed. Small doses of the Hydrarg. c. Creta, or one or two grains of calomel, according to the age of the child, should be given every other morning for two or three Aveeks. The prepa- rations of iodine may also be administered Avith a view of pro- curing absorption, or the nurse may undergo a course of this medicine. Small blisters applied above the tumor, in the course of the spine, so as to cause a rubefacient effect only, may be em- ployed frequently. Extreme caution, hoAvever, is necessary, that vesication is not produced, as in infants, particularly those of a Aveak constitution, sloughing and farther exhaustion may be oc- casioned. Great attention must be paid to the regularity of the alvine discharges, and gentle aperients given to insure this if necessary. The child should be Avarmly clothed, and carried out frequently in the open air when the Aveather is fine. When hydrorachis is associated Avith hydrocephalus, or with congestion, or inflammation of the spinal cord or its membranes, the treatment recommended for those affections should be em- ployed. The same measures are to be employed Avhen the dis- ease is developed after birth, the remedies having reference to the age of the patient and the stage of the disease. There is a form of spinal disease which follows intermittent fever, that seems to be of the nature of that described in the text, as the hydrorachis of adults. I have not had an opportunity of examining cases of this disease, at least not in its early stages, but the sudden appearance of this disorder, the moderate degree of pain, and the comparatively rapid development and exten- sion of the paralysis from the lower to the upper extremities, seem to prove that a liquid must be rapidly secreted in the spinal sheath. The acuteness of the symptoms and their rapid increase, if much motion be allowed, indicate that the disease is of an inflammatory nature. This sub-acute inflammation is a more frequent attendant upon intermittents in some years than in others, but it arises from causes which are totally unknown. The best means of treating the disease are, rest, frequent cupping to the spine, and repeated blistering: purgatives are also most useful aids, but are less essential than the other remedies which I have just mentioned. These cases, if carefully managed will, in general, terminate favorably, though the disorder is sometimes quite intractable, and may prove rapidly fatal. 324 SPINAL APOPLEXY. Symptoms.—Causes.—Anatomical characters.—Nature.—Diagnosis.— Prognosis.—Treatment. Although there are some doubts as to the propriety of apply- ing the Avord apoplexy to haemorrhage into any tissue, its general use has induced us to adopt it to express the spontaneous extra- vasation of blood into the spinal canal, either betAveen the mem- branes or into the substance of the cord. Symptoms. We have noticed, when speaking of cerebral apoplexy, the symptoms denoting haemorrhage into the cranial por- tion of the cord. But spontaneous effusion of blood into the cer- vical, dorsal, or lumbar portions is an occurrence of extreme rarity, and its history is consequently very defective. We have every reason to suppose, hoAvever, that haemorrhage Avill give rise to the same effects as destruction of these parts by accident or disease, and that they Avill be more sudden and well-marked, according to the violence and the extent of the effusion. s The cases recorded by Abercrombie, Chevalier, Stroud, Cruveilhier, Monod, Grisolle, Gaultier de Chaubry, and others, show that the attack is ahvays characterised by acute and sudden pain in the back, corresponding Avith the seat of effusion. Sometimes there are precursory symptoms of shivering, and slight dorsal pains, which have been mistaken for rheumatism. In some instances, there is sudden paralysis in one or more of the extremities beloAV the seat of pain; in others, the paralysis comes on gradually, and is preceded by pain in the portion of the spine corresponding with the supposed seat of the haemorrhage. The other symptoms which have been observed are similar to those Ave have noticed when treating of myelitis affecting the cervical, dorsal, or lumbar portion of the cord. Eschars are often formed on the sacrum before death; the sphincters are paralysed, and the respiration becomes gradually more and more laborious; in the case of M. Grisolle, there was nausea Avith sense of suffocation, and in that of M. Cruveilhier vomiting of black blood before the fatal termi- nation. In the case of M. Monod, pus and blood were mingled with the urine, and in that of Abercrombie there was tetanic rigidity and convulsion. In this last case, hoAvever, the spinal marroAv Avas not changed in structure, the haemorrhage having occurred between the dura mater and bones. There is in general spinal apoplexy, (Diagnosis.) 325 no fever, the pulse is not affected, and the intelligence remains perfect to the last. Causes. Effusion of blood into the spinal canal may result from blows, falls, contusions, fractures, and other kinds of direct violence. Spontaneous apoplexy of the cord has been observed to folloAV Avhen the individual has remained some time in the sit- ting posture, from lifting a heavy weight, and as a consequence of rheumatism, cerebral apoplexy, and myelitis. Anatomical characters. The haemorrhage in spinal apoplexy appears to be occasioned by the same causes that produce it in the brain. It may form circumscribed extravasations in the sub- stance of the cord, as in cases recorded by Hutin, Cruveilhier, and Stroud. In such circumstances a cyst forms, and the blood effused undergoes exactly the same changes we have described in cerebral apoplexy. In some instances it is combined Avith softening (Gaultier and Grisolle), Avhen the nervous substance is more or less broken up and' mixed with the extravasation. The gray matter appears most liable to this alteration. Haemor- rhage may also occur in the subarachnoid or arachnoid cavity, or between the dura mater and bony Avails of the canal, as in the case given by Dr. Abercrombie. The effusion may be referred to haemorrhage occurring in the brain, which is forced into the spinal canal/or to rupture of some bloodvessel in the adjacent structures, to Avhich only, in the latter case, it can be attributed. Nature. The pathology is perfectly consistent Avith the known functions of the spinal cord. The amount and seat of the para- lysis is attributable to the degree of pressure or disorganisation occasioned, and the portion more immediately affected. The study of the recorded cases also shows that the changes after the attack are proportionate to the alterations occurring in the extra- vasation. The occurrence of convulsions in Dr. Abercrombie's case, in which the effusion was exterior to the dura mater, thus occasioning partial pressure, illustrates Avell the influence of this cause in producing excited action. This symptom has not been observed, when the extravasation has affected the substance of the cord directly. In Dr. Stroud's case, circumscribed effusion of blood took place on the left side of the cord, producing first hemi- " plegia of the same side of the body, and afterwards paraplegia. (Bright's Reports, vol. ii, p. 339.) Diagnosis. The diagnosis of this disease is very obscure, as our observation of it is as yet insufficient to enable us to indicate its peculiarities; the premonitory symptoms, hoAvever, have been confounded with rheumatism, from Avhich it can only be distin- guished by the progress of the case. In general, the sudden and acute pain distinguishes it from other spinal affections, and when the spinal marroAV is the seat of the haemorrhage, there is no con- vulsion or tetanus. 28 326 spinal apoplexy, (Treatment.) Prognosis. The case of Cruveilhier, in Avhich the patient lived five years after the first attack, proves that this disease is not always speedily fatal. In the majority of cases, hoAvever, the greatest danger is to be apprehended. Treatment. In the treatment of spinal apoplexy, absolute rest, in order to prevent any recurrence of the extravasation, and to favor the absorption of effused blood, is the chief element. Bleeding should be employed if there be no signs of prostration, but not to any great extent, as the symptoms do not indicate active vascular excitement. The diet should be low, and great attention paid to the alvine evacuations, which are to be regu- lated by injections, active purgatives being as much as possible avoided. The state of the urinary bladder should be inquired into daily, and, if necessary, the urine drawn off by the catheter. Counter-irritants are obviously useless. Care should be taken to prevent the eschars, which are likely to form on the sacrum and back, by placing the patient on the hydrostatic bed, or by adjust- ing cushions and air-pillows so as to prevent loog continued pressure on any part. 327 CHOREA. Characteristic symptoms.—Analogous affections.—Anatomical characters.— Nature—Causes.—Diagnosis—Prognosis.—Treatment. The disease to Avhich the name of Chorea is most commonly applied, and to which it Avas first restricted by Chaussieur is cha- racterised by incomplete subserviency of the muscles of voluntary motion to the will, rendering their actions irregular, tremulous, and often ludicrous. It occurs most frequently in the female sex, and in general betAveen the ages of eight and fifteen. The de- signations, " St. Vitus's dance" and dance of St. Guy," became popular in consequence of the practice which formerly prevailed among the subjects of similar affections, to repair annually to a chapel at Ulm in Swabia dedicated to the saint, called by the Germans St. Weit, and by the French St. Guy; Avho, having suf- fered from the complaint in his lifetime, was supposed to be re- warded with the poAver of curing it after his death. It is probable that, from the influence of sympathy, a temporary aggravation of the complaint Avas produced in so large an assemblage of sub- jects, but it is said that they afterAvards remained for a year free from the malady. * In chorea the muscular disorder may either be general, affect- ing the extremities, trunk, and face, or partial and confined to the face or neck, or to one extremity. It occurs for the most part in persons of a Aveak constitution, either natural or acquired, and is commonly preceded by derangement of the organic functions, indicated by variable appetite, tumid abdomen, constipated bowels, and impaired vivacity. The convulsive motions are preceded by slight irregular twitchings of the muscles of the face, Avhich may easily be mistaken for voluntary grimaces. In the progress of the complaint the irregular action becomes more in- tense, and implicates a greater number of muscles; those of the extremities, of the lower jaAV, or of the head and trunk, being at different times affected. The patient does not walk steadily, but moves irregularly from side to side, or proceeds by jumps or starts; one foot is rather dragged than lifted, and the movements of the arms resemble the gesticulations of players. As the com- plaint increases, the patient seems as if palsied, and becomes un- able to walk or to perform the necessary movements of the arms. In extreme cases deglutition is difficult, and articulation inter- 32S chorea, (Symptoms—Varieties.) rupted, so as to produce stuttering; the mouth is distorted, and saliva drivels from it. Different muscles may be successively convulsed, but those first affected usually continue involved throughout the whole course of the disorder. In severe cases the irregular actions are never suspended ex- cepting during sleep, and may even continue irrespective of this condition. They may be continuous, intermittent, or remittent; and are increased by observation, contradiction, or any irritating cause, and especially by any attempt forcibly to restrain them. The eye loses its lustre and intelligence. The liability to cause- less emotions, and the disposition to concealment characteristic of hysteria, are often present; the mind becomes capricious and irritable, and there is a tendency to take alarm or to Aveep at the slightest cause. The disease Avhen long protracted may induce fatuity, epilepsy, or hemiplegia, or may terminate in marasmus. Chorea in the female is frequently associated Avith deranged uterine function, sometimes with chlorosis, but perhaps more frequently with amenorrhoea. Hysterical symptoms are in gene- ral superadded Avhen the disease occurs about the time of puberty. At this period chorea may be superseded by hysteria, Avhich at a later period may in turn give place to neuralgia, the susceptibility to these diseases seeming to depend on a similar condition of the nervous system, modified by different periods of life. Serous effu- sions, especially into the arachnoid and pericardium, sometimes attend protracted cases. The complication Avith rheumatic affec- tions of the muscles, pericardium and spine, has been Avell eluci- dated by Dr. Copland, as well as by Drs. Prichard, Roeser and Bright. Various cutaneous eruptions, of Avhich urticaria and roseola, are the most frequent, may be associated with chorea; but sinde the irregular movements may either precede, attend or folloAV the eruption, we must consider the phenomena, not as in the relation of cause and effect, but rather as results of the same state of the nervous centre. It is however probable that the eruptive condi- tion tends to moderate the spasmodic disorder. In the disorder to which Ave noAV limit the name of chorea, the will is properly exerted, but is only partially efficient. The analogous affections to Avhich the term has been occasionally applied, consist chiefly in energetic and often measured actions of the muscles, under the influence of a morbidly excited will. Such appears to be the nature of the original chorea of the Ger- ^ mans, of Tarantism, and of Leaping ague. Sometimes, how- ever, the muscular disturbance seems independent of the will, and unassociated with consciousness, and differs from convulsion only in the orderly nature of the motions. Cases of rotation of the Avhole or part of the body, of malleation, and of irresistible propulsion forwards or backwards, belong to this class. The phenomena Avhich have occasionally occurred under the excite- chorea, (Symptoms—Varieties.) 329 ment of religious enthusiasm, although in the first instance re- sulting from mental impressions, often become involuntary in their progress. I. In the first class of analogous affections Ave may specify the following examples:— 1. The original chorea consisting of inordinate and almost supernatural muscular exertions, depending on a mental impulse and excited by imitation or by music, the measure of which seemed to regulate the movement. Felix Platerus mentions a woman of Basil Avho danced for a month; and it appears from the accounts of Horstius and others, that, the complaint Avas apt to recur annually, and that those affected Avould continue dancing when under the influence of music, for an incredibly long period, until at length exhausted by their exertions. (De Mentis Alien., vol. i, p. 15.) Later writers have referred to the affection under the names of Epilepsia saltatoria and Morbus saltatorius. The first distinctly recorded manifestation of such a malady occurred, a. d. 1027, near Bernberg, on St. John's Day; a festival during Avhich it was customary, perhaps in imitation of Baccha- lian rites, to kindle the nodfyr, and to dance around or through it with various frantic gestures. There is reason to believe that these performances sometimes gave origin to the disorder in question. For several centuries after this period the affection was occasionally witnessed. The excitement produced by de- structive epidemics and other calamities, and the superstitious ceremonies of Popery, probably contributed to its prevalence. In St. John's dance, as Avell as in that of St. Vitus, and in the affection next to be described, a tympanic state of abdomen was a frequent symptom. 2. Tarantism (sometimes designated Tarantulismus, Chorea Sancti Valentini, Choreomania, Dsemonomania, Melancholia saltans, fyc.) in every important particular resembling the affec- tion last described. A feAV hours after being bitten by the poison- ous spider called Tarantula, the patients fell doAvn senseless and motionless, Avith difficult respiration and heavy sighing. As these symptoms subsided, they appeared desponding and melan- choly, frequented churchyards and solitary places, evinced a capricious fancy for particular colors, and sometimes appeared to have an irresistible propensity to roll themselves in the dirt. At the sound of suitable music they began to move first the fingers, then the hands, feet, and successively other parts of the body, and then sighing and dancing threw themselves into every va- riety of violent and fantastic gesture. Sauvages says, " Those who are stung die in a little time Avithout the present assistance of music, all other remedies giving no relief." Those affected were capricious as to tune, and required the notes to be run over Avith the greatest quickness. This quickness of sound, called 28* 330 chorea, (Symptoms—Varieties.) tarantella, afforded a test for the detection of those Avho feigned the disease, a practice, according to Baglivi, common among the women of Apulia, Avhen they wished to be indulged in music and dancing. If they were satisfied Avith sIoav musical move- ments the deception was at once discovered. An instance of convulsive disorder resembling tarantism, produced by the bite of a spider, and cured by music, is related in the New York Medical Repository. 3. The Leaping ague of the Scotch Avriters, characterised by increased efficiency, but depraved direction of the will, pro- ducing an irresistible propensity to dance, tumble and run about in a fantastic manner, often with far more than the natural vigor, activity and precision. The subjects of the malady, after some pain of the head and lower part of the back, become affected Avith bodily distortion. They leap in a remarkable manner, climbing or springing from the floors to the rafters of cottages, and swinging by or whirling around them. This state is often accompanied Avith a disposition to secrete any thing Avithin their reach. In the Edinburgh Medical and Surgical Journal there is an account of a girl affected Avith this complaint, Avho also exhibited a remarkable inclination to commence sentences Avith the last Avord, and often put the last letter of a Avord foremost. In writing she Avould proceed from right to left, placing the last word and the last letter first; often Avith great rapidity, and apparently Avithout consideration. In the treatment of this case, purgatives proved useless; opiates sometimes prevented a paroxysm, but did not permanently relieve. Locked jaAv of eight days' duration folloAved the use of a shower bath, and the symptoms did not return. Some cases of periodical jumping and shrieking, related by Armstrong, folioAving pertussis, and considered epileptic, pro- bably belonged to the same class of affections. At the close of the seventeenth century, a case in some respects resembling those above described occurred at Edinburgh, and an account of it was published with the title, A True Narrative of the Sufferitigs of a Voting Girl, who was strangely molested by Evil Spirits and their Instruments. A commission from the king Avas appointed to inquire Into it, and seven persons were in consequence committed to the flames for witchcraft. (Ediu. Med. Com. vol. ix.) II. The second class includes those analogous affections in which the movements are systematic, but involuntary; viz. mal- leation, rotation and propulsion in various directions. 1. The affection to Avhich the term Malleatio has been applied, examples of Avhich have been described by Morgagni, Dr. Craw- ford, and other Avriters, consists in an apparently irresistible dis- position to beat the knees with the hands as with a hammer. The action is regular but involuntary, and occurs in paroxysms. chorea, (Symptoms— Varieties.) 331 2. Instances have occasionally occurred of involuntary rotatory motion of the Avhole or part of the body. For example, rotation of the head has been observed by Drs. Conolly and Crawford, and Mr. Hunter has related a case in Avhich rotation of the head and trunk occurred, and Avas relieved by the application of tartar emetic ointment to the scalp and spine. Under the name of chorea Dr. Watt has related the case of a girl ten years of age, who, after suffering from vomiting and excruciating headach, evinced a singular propensity to turn round on her feet like a spinning-top. On the subsidence of the affection (in about a month) the head Avas aggravated, and the muscles of the neck Avere partially paralysed. After this, paroxysms occurred daily, in which she placed herself across the bed, and rolled rapidly on her side, from one end to the other. About sixty rotations Avere accomplished in a minute. They Avere not checked by the affu- sion of cold Avater; indeed, when placed in the shalloAV bed of a river, the girl kept up the .motion, although at the risk of being drowned. In about five weeks a different movement Avas sub- stituted, namely, that of approximating the head and heels, raising the trunk, and then falling forcibly on the back. These motions continued to characterise the affection for five weeks, when they Avere succeeded by a propensity to stand on the head, to raise the feet perpendicularly, and then fall as if dead; these evolutions Avere performed more than tAvelve times a minute for fifteen hours daily. The malady did not yield to blisters, setons, local depletion, emetics and cathartics, Avhich were successively employed, but disappeared after a spontaneous diarrhoea. 3, Propulsion, either forwards, backwards, or in zigzags, has occasionally occurred. M. Piedagnel has given an instance of a man Avho sometimes went out and Avalked fonvards till he Avas exhausted and obliged to be carried home in a litter (Magendie's Physiology, by Milligan,p. 189); and Dr. Laurent, of Versailles, has related a counter part to this case, in a girl irresistibly propelled backwards Avith such violence, as to sustain considerable injury. Drs. Dufour and Rennes (Arch. Gin.; Lond. Med. and Surg. Journ., June, 1832) have related examples of zigzag movements occurring in persons addicted to intoxication, who had previously suffered from bronchitis. The phenomena Avere at first mistaken for those of drunkenness, but yielded to the use of opium. Mr. Kinder Wood has recorded a most interesting example, in which the phenomena of the original chorea were associated with malleation, rotation, propulsion, and leaping ague. It occurred in a woman whose nervous susceptibility Avas probably increased by prolonging lactation for fourteen months, the catamenia having appeared during the latter three months. At first she suffered from pains of the face, which Avere relieved by a liniment of opium and ammonia; twinkling of the eye, motions of the legs, and rotation of the arms, succeeded. The palms of the hands 332 chorea, (Symptoms—Varieties.) were beat upon the thighs, and the feet upon the ground; the backs of the Avrists Avere struck frequently against each other; at other times the middle fingers being extended inwards, struck the palm of the opposite hand, and so alternately with almost incon- ceivable quickness. The affection of the eyelids Avas usually succeeded by headach of short duration, Avith sickness and vomit- ing. On some occasions she would move up and down, or from side to side on her chair, and then springing on her feet, leap and jump, or be propelled forwards. Sometimes she would go into every corner of the room, striking the furniture. She Avould fre- quently dance on one leg, holding the other in the hand. In the course of the complaint it Avas observed, that the bloAvs on the furniture were in musical time, and the involuntary actions, as they Avere considered, changed to a measured step. Although ordinarily an inexpert dancer she Avould on these occasions move about elegantly as in a minuet. It was ascertained that there Avas ahvays a tune in her mind impelling her to the movements. When this tune Avas performed on the drum, she ran up to the instru- ment and danced with great activity and apparent delight, but the movements were ahvays stopped by rolling the drum. Al- though yielding, as it seemed, unavoidably to the desire of danc- ing, she always wished for the rolling of the drum, that the muscular excitement might be checked; for, till a neAV inpression was made by a change of measure, the morbid desire prevailed over the rational Avill. As occurs in tarantism, the motions always commenced in the fingers and then extended to other parts of the body, and became more frequent as their duration lessened. On the day the motion ceased, diffused patches of a bright red eruption came out near the elboAvs, and continued for three days. The catamenia afterAvards appeared, and health seemed established. In five weeks, however, the muscular move- ments recurred, and the eruption appeared on the arms. This attack lasted about ten days. Five Aveeks afterwards the affec- tion returned for the third time, but assumed a more spasmodic character; when laid doAvn the patient turned involuntarily on her back, and the muscles of the neck Avere so affected as to force back the head and occasion dyspnoea. On this occasion no relief was obtained from music, but a cure was effected by bleeding. The previous attacks had been treated with aperients, tonics, and anodynes; and it is Avorthy of notice, that in each instance the most decided improvement succeeded the use of calomel and jalap. The catamenial function was suspended at the time of the malady, but had been previously regular. III. The convulsive disorder which has sometimes occurred in religious assemblies, and has occasionally prevailed as an epi- demic, is usually accompanied Avith shouting, singing, dancing, laughing, and coughing, Avith irregular exacerbations and remis- chorea, (Anatomical Characters.) 233 sions. During a remission, shaking hands Avith, or even looking at a person affected Avith the complaint, will excite a paroxysm. The seizure is at first violent and convulsive, and continues even on lying down, but after a time becomes chronic, and more closely resembles chorea. The phenomena have been well described by Dr. Robertson, as they occurred among a sect of enthusiasts in Tennessee and Kentucky, in the year 1800. (Inaug. Essay on Chorea St. Viti, 1805.) A similar affection occurred in a congregation at Cam- buslang, in the year 1742. The movements, Avhich Avere at first voluntary, became spasmodic, the muscles of the neck and upper extremities were convulsed, and the sufferers were throAvn down and agitated Avith motions like those of a live fish upon land. Anatomical characters. The opinions of authors regarding the morbid anatomy of chorea are extremely various, and the descriptions of occasional appearances serve chiefly to prove that there is not necessarily any structural change. Dr. Clutterbuck considers the disease dependent on inflammation of the brain; Drs. Coxe and Patterson on turgescence of its vessels with ten- dency to hydrocephalus. Roeser and Willan have found serum in the ventricles. Monod refers the malady to hypertrophy and injection of the brain and spinal cord; Hutin to hypertrophy and hardening of the anterior part of the spinal cord. Changes in the membranes of this part, such as the effusion of turbid serum or lymph, or the formation of bony plates, have been described as occasional phenomena by Drs. Copland, Prichard, Aliprandi, and Bright; and ecchymosis of the membranes, with a pulpy state of the medulla spinalis, Avas detected in a case related by Dr. Keir of Moscoav. (Edin. Med. and Surg. Journ., No. cxxii, p. 93.) Dr. Serres having found, in one case, a tumor pressing on the corpora quadrigemina, in tAvo instances inflammation of these parts, and in another example sanguineous effusion, is disposed to refer the disease to a morbid condition of these organs. Dr. Brown discovered a concretion in the medullary substance of the left hemisphere of the brain. In Dr. HaAvkins's case there Avas increased vascularity of the uterus, Avith concretions in the pan- creas, omentum, and mesentery. Duges, Ollivier, Rufz, Gerhard,* Hache, Rostan, LaAvrence, and many other pathologists have, hoAvever, searched in vain for any morbid changes which could be regarded as necessarily connected with the disease; and it is evident that many of the appearances above described must be * The case cited by the author was that of a young girl of nine or ten years of age, who died purely of the disease, that is, worn out by the excessive and continued movement. No lesion whatever could be detected in the brain or spinal marrow, although I examined those organs with the most scrupulous attention. It is cited in the memoir of Dr. Rufz. (Archives Generates.) 334 chorea, (Anatomical Characters.) considered simple coincidences; whilst others, as Drs. Patterson and Percival have observed in reference to hydrocephalus, must be vieAved rather as effects than causes of the complaint. Since the scalpel fails to reveal the seat of the malady, Ave must have recourse to the light Avhich physiological investigations may throw on the inquiry. There is considerable evidence in favor of the opinion, that the stimulus of the Avill passes from the brain through the spinal cord to the voluntary muscles; and the conclusion Avhich Magendie has deduced from his experiments, namely, that the will passes through, the hemispheres of the cerebrum, and that the direct cause of motion is in the medulla spinalis, is at least plausible. The disturbance of harmony between the part which supplies and that Avhich conveys the stimulus of the will to the muscles, must be sufficient to produce the irregular movements of chorea; and this harmony may probably be interrupted by derangement, Avhether structural or functional, of any part inter- vening between the cerebral hemispheres and the portion of the spinal cord from Avhich the nerves of the affected muscles proceed. The frequency Avith Avhich, in extreme cases, change of structure of the cerebro-spinal axis has been observed, is favorable to this vieAV, since long-continued functional derangement, although it does not necessarily occasion organic change, will frequently pro- duce that result. There is direct experiment in support of this explanation of the cases of propulsion forwards and backAvards, and of rotation, which have been above described as in some respects analogous to chorea. Magendie found, that Avhen the corpora striata were removed, the animals operated on darted irresistibly forward; and that, when injury was inflicted on the cerebellum or medulla oblongata, they receded. (Op. cit., p. 187,202.) The experi- ments of Serres, Flourens, and Rolando, are favorable to the same conclusion. When the peduncles of the cerebellum were divided, rotation took place tOAvards the side cut; and vertical sections of the cerebellum, or pons varolii, produced the same effect, Avhich Avas ahvays most decided in proportion as the in- jury was near to the peduncle, the movement being to the right or left, according as the incision was right or left of the mesial line. Lesions of the medulla oblongata, where it approaches the external part of the anterior pyramid, occasioned a rotatory movement; but, on cutting through the spinal cord behind the occipital bone, the motions became involuntary and irregular. In connection Avith these inquiries it may be interesting to men- tion, that effusion, into the ventricles, pressing upon the corpora striata, has been constantly found in horses affected Avith inability to go back. The physiology of the nervous system is not sufficiently ad- vanced to enable us to fix the locality of its individual functions; allowing their full Aveight to the experiments and observations chorea, (Causes.) 335 Avhich have been referred to, we are not authorised, with Serres, to limit the seat of chorea to the corpora quadrigemina or striata, or with Bouillaud and Magendie to the cerebellum. Cases of rotation may probably depend on derangement affect- ing the pons varolii, medulla oblongata, or the peduncles of the cerebellum; propulsion forwards on an altered state of the cor- pora striata, and backwards on morbid condition of the cerebel- lum: but the correct exercise, yet inefficient poAver, of will, Avhich characterises true chorea, seems rather to indicate an affection either of the spinal cord, or of some part closely approximating to it. Tarantism and the chorea of the Germans may probably consist Avith integrity of functions of these parts. The muscles in those affections accurately obey the stimulus of the will Avhich exists in excess, possibly from excitement of some part of the sensorium, more directly connected Avith the mind, perhaps indi- dividual faculties of the mind, inasmuch as they are associated Avith material structure, may possess a poAver of stimulating to action analogous to will; and which, in contradistinction to the rational Avill, may be termed instinctive. The morbid excitement of this power rendering it uncontrolla- ble by the judgment, may occasion some of the irresistible actions present in affections analogous to chorea, and may also produce some of the phenomena of monomania, to which, indeed, these maladies seem closely allied. Nature. Galen and Mead considered the disease a modifica- tion of palsy; Sydenham regarded it as a convulsive disorder, occasioned by a humor affecting the nerves; Baumes and Pinel attributed it to a combination of convulsion and palsy; Sauvages, Cullen, and many others, have referred it to a state of general debility, and consequent mobility of the system; others, among Avhom Drs. Parr and Hamilton may be particularly mentioned, consider that the derangement of the muscular actions arises from sympathy Avith disorder of the digestive functions. Chorea may doubtless occasionally arise from a morbid condi- tion of the cerebro-spinal axis or its membranes, sometimes in- duced by the excitement of mental impressions or moral emo- tions; but the peculiar irritation of the nervous system essential to the malady, seems to be generally associated Avith, and proba- bly dependent upon, disorder of the organic functions, which, acting on a susceptible nervous system by means of the ganglio- nic nerves, may sympathetically interrupt the functions of those parts Avhich convey to the muscles the stimulus of the will. Causes. When derangement of the bowels occurs in young subjects of susceptible nervous system, almost any powerful im- pression, either on the mind or the body, may be sufficient to ex- cite the disease. Among mental causes, jealousy, envy, anger, disappointment, anxiety, and excited imagination, may be men- tioned, but fright is generally alloAved to be the most frequent. 336 chorea, (Caicses.) A majority of the cases related by Dr. Reeves, Mr. Bcdingfield, Dr. Bright, and others, are referrible to this cause; and its in- fluence in producing chorea cannot be denied, notAvithstanding the contrary opinion of Guersent, Avho argues that the liability to be easily alarmed is a characteristic of the morbid condition, rather than the cause, of the malady. The disease is occasion- ally induced by the irritation accompanying the second dentition. Mechanical injuries (Med. Chir. Rev. vol. ii, p. 569), especially of the head (Edin. Med. and Surg. Journ., vol. ix, p. 123; and Med. and Phys. Journ., vol. xv, p. 127), and through the orbit (Phil. Trans., vol. Iiii), suppressed eruptions, the healing of ulcers, extension of rheumatism to the spinal membranes, Avorms and intestinal accumulations, and the influence of fever or other previous disease, are among the causes enumerated by authors of repute. Dr. Marshall has detailed a case resembling chorea, apparently produced by lightning. The symptoms Avere much aggravated by pressure at certain points of the spine. The ex- ample is of peculiar interest in connection Avith the evidence ad- duced in Dr. Marshall's Avork, of the occasional production of softening of the spinal cord by lightning. It also serves to illus- trate some milder examples of the disease, which Avere relieved by treatment applied to the spine. All the causes of constitutional debility, Avhether hereditary or acquired, are favorable to the production of chorea; but premature excitement, either of the intellectual faculties or moral feelings, sedentary employments, innutritious diet, and impure air, may be especially mentioned. Females are much more liable to the affection than males. The proportion in Dr. Reeves's cases Avas 57 to 27; in Dr. Manson's, 53 to 19; in those of M. Rufz, 138 to 51: from these statements, and from the recorded experience of Heberden, Frank, Elliotson, and Copland, the liability of the sexes may be calculated as in the proportion of 3 to 1. The time of life in Avhich the disease is most common is from the period of second dentition to puberty; but instances have occurred as early as the fifth year, and the disease has been known to exist from infancy. No age, however, seems to be absolutely exempt, Dr. Copland having Avitnessed the disorder in a man above fifty years of age, Dr. Powell, in a woman, aetat. seventy, after epi- lepsy, and M. Bouteille associated Avith hemiplegia in a Avoman, aetat. eighty. The complaint appears to be little influenced by atmospheric changes; but Rufz, Duges, Blache, and Spangen- burg, consider it most common in summer. There is reason to believe that it is very rare in the southern hemisphere, M. Ro- choux not having witnessed any example in Guadaloupe, Chervin in the Antilles, nor Danste in the course of thirty years' practice in Martinique. Imitation has little influence in the production of the disorder. In the Hopital des Enfans, Blache never wit- nessed its production by this cause. chorea, (Treatment.) 337 Diagnosis. The characteristic partial dependence of the ir- regular muscular motions on the will, is sufficient to distinguish chorea from most other disorders. In convulsions, Avhether. epi- leptic or hysterical, the movements are more violent, and are en- tirely independent of the will. In paralysis agitans, a disease for the most part of later life, the agitation is more constant, more limited, and is devoid of ludicrous character. The tremor pro- duced by mercury has a greater resemblance to chorea, but is accompanied Avith a peculiar quick catching. In cases combining the phenomena of chorea and hysteria, attention to the history and attendant circumstances will enable us to analyse the symp- toms as far as is essential for practical purposes. The prognosis is generally favorable, chorea being scarcely ever fatal, and becoming dangerous only when associated with, or merging in, any more formidable disease, such as epilepsy, dropsical effusion into the serous cavities, paralysis, or change of structure of the brain or spinal cord. Dr. Elliotson observes, that when the disorder is confined to the muscles of one arm or of the head, and especially Avhen occurring in the adult, he has never seen it cured. Since the susceptibility of the nervous system is less in the adult than in the child, the probability of the existence of important organic lesion is greater Avhen the disease occurs in advanced life, especially if the limited nature of the malady implies a local seat. Treatment. Cases Avhich are not very severe, frequently yield to almost any plan Avhich, Avithout impairing the strength, pro- duces a decided effect on the system. Hence it is easy to explain the diversity of remedies recommended by different practitioners; Dr. Bardsley senior mentions, that in the Manchester Infirmary, notwithstanding the variety of treatment adopted by successive practitioners, an incurable case had not presented itself in the course of thirty-three years. Still the duration of the complaint, and the facility with Avhich it is remedied, will often in a great degree depend on the judicious adaptation of treatment. A case, for example, may be cured in two or three Aveeks by suitable treatment, Avhich, under less appropriate management, would be protracted for several months. The general abstraction of blood has been adopted by those who considered the disease congestive or inflammatory, and has been sanctioned chiefly by M. Bouteille, Lisfranc, and Dr. Clut- terbuck, Avho repeats the bleeding at intervals of a feAV days. Serres, considering the disease to depend on congestion or some other morbid state of the corpora quadrigemina, applied leeches and counter-irritation to the upper part of the spine. Dr. Watt speaks favorably of bleeding, but Cullen and Armstrong found it frequently injurious. The purgative plan has been adopted chiefly by Whytt, Hamil- 29 333 chorea, (Treatment.) ton, Cheyne, Guersent, and Chapman, and by a large proportion of the most successful practitioners. Dr. Hamilton generally cured the disease by these means alone in ten days or a fortnight. The purgatives which have been most employed are aloes, senna, calomel, scammony, and jalap, but probably sufficient discrimina- tion has not always been exercised in the selection of the individual remedy. Of the vegetable tonics employed in the treatment of this com- plaint may be mentioned cinchona bark, as particularly recom- mended by Cullen, Mahon, and Werlhoff; the flowers of the cardamine pratensis by Sir George Baker and Michaelis; the powder infusion or decoction of Seville orange-tree leaves by Haen and Engelhard. Among the metallic tonics may be enumerated, the oxide of zinc, Avhich Avas considered a specific by Mr. Bedingfield, and is favorably noticed by Dr. CraAvford: many of the German authors commend its poAvers, but Stoll has not observed any advantage from its use. The sulphate of zinc is much employed by Dr. Bright, and is preferred to the oxide by Dr. Copland. The latter author confirms the statement Of Dr. Odier of Geneva, that the addition of two grains of ammoniuret of copper to each dose of the oxide of zinc, prevents that remedy from irritating the stomach. The nitrate of silver, Avhich Avas recommended by Frank, Uwins, and Crampton. Fowler's arsenical solution, in doses of three minims, gradually increased to ten, three times a day, has been advantageously employed by Mr. Martin and Dr. Gregory. But the use of arsenic is sometimes productive of injurious effects, an objection which applies also to sulphate of copper and nitrate of silver. Of all tonics iron is perhaps the safest and most efficacious. Dr. Elliotson's experience leads him to confide in the remedy without the previous use of purgatives. He prefers the sesqui- oxide in doses of from half a drachm to half an ounce, but some- times administers from one to four grains of the sulphate. Cold-plunging Avas the method constantly employed by Dupuy- tren; his plan Avas to immerse the patient suddenly five times in twenty minutes: this treatment continued for a fortnight, or at most a month, generally cured. Dr. Hamilton was accustomed to adopt this measure previous to his employment of the purga- tive plan; but attributes bad consequences to its use. It is difficult to suppose that a disease, associated with so much organic de- rangement, could be removed by the shock of the cold bath without the risk of superinducing some other malady. The use of cold affusion or the shower bath, the patient standing in warm water, is not liable to the same objection. Extract of belladonna in doses of a sixth to a quarter of a grain was administered by Stoll, who at the same time employed an antispasmodic liniment Avith great advantage. Valerian is recom- mended by. Bouteille and Guersent, assafcetida by Bayle and chorea, (Treatment.) 339 Jadelot, musk by Bardsley, and a combination of gamphor and extract of henbane by Dr. Bright. Among internal counter-irritants may be specified spirits of turpentine, first prescribed in this disease by Dr. Copland, a solu- tion of tartar emetic by Ferran, large doses of the same remedy (from four to eight grains) by Breschet, and emetics by Laennec. External counter-irritants, such as blisters, setons, and issues, have been employed by many practitioners, and by others tartar emetic ointments, or plasters to the scalp and spine; and Chrestien ad- vises aromatic embrocations. Galvanism, recommended by Meyreaux, and electricity, first introduced as a remedy by De Haen, appear to act as counter- irritants. The application of electricity often produces an erup- tion of the nature of lichen urticatus. This agent seems especially efficacious in cases associated with defective catamenial secretion, and has been lately employed by Dr. Addison with considerable success. The above enumeration is not intended to imply, that the authors referred to confided exclusively in the remedies Avhich they particularly sanctioned, since many of them Avere accustomed to combine and vary resources according to the peculiarities of individual cases. If the opinion be correct, that the disease usually depends on nervous mobility, associated Avith derangement of the digestive organs, whether we regard these conditions in the relation of cause and effect, or as simultaneous expressions of the same dis- eased state, it is equally obvious that tAvo indications are presented, viz. the correction of the morbid state of the digestive organs, and the removal of the nervous susceptibility. The relative degrees of these two conditions doubtless vary. Probably the nervous affectibility is less in Scotland than in England; and from this circumstance we may derive an explanation of the fact, that Dr. Hamilton found purgatives adequate for the cure of the cases which fell under his management, Avhilst the same mode of treatment has often failed in England. Dr. James Johnson tried purgatives alone without success in cases Avhich afterwards yielded to the administration of oxide of zinc Avith alteratives and antispas- modics. Of twenty cases treated by Dr. Bardsley on the purgative plan only fourteen were cured, and the average duration of the treat- ment Avas more than six Aveeks. Of twenty cases treated by purgatives for a time, and afterwards by antispasmodics, the whole Avere cured in an average period of less than a month. Dr. Bardsley tried the uncombined antispasmodic treatment, selecting remedies of acknoAvledged power, such as camphor, opium, valerian, ether, and musk. He gave a fair trial to the tonic method, employing the sulphate and the carbonate of iron, the ammoniurets of copper and of iron, oxide of zinc, nitrate of 340 chorea, (Treatment.) silver, and arsenical solution. He also had recourse to iodine, strychnia, electricity, the shoAver bath, tartar emetic ointment and blisters to the spine; and he derived from his experiments the conclusion, that no single plan of treatment Avas entitled to con- fidence, and that the combination of purgatives and antispasmo- dics Avas the best. The principle of combination Avas also countenanced by Syden- ham. His method was to employ purgatives, tonics, and anti- spasmodics; and although he perhaps carried depletion to too great an extent, in other respects it is probable that his treatment has not been much improved by subseqnent practitioners. We are strongly impressed Avith the desirableness of commencing the treatment Avith purgatives. UnderAvood has indeed objected to the opinions of Parr and Hamilton, that if the intestinal irritation which they assume exist, it is dangerous to increase it by the em- ployment of purgatives; but Avhatever may be said of the theo- retical explanation, the advantage of commencing the treatment of chorea Avith purgatives may be considered established. Dr. Bright, Avho seems to disparage the purgative plan, em- ploys chiefly calomel, scammony, and senna, and Dr. Bardsley aloetics; but Dr. Hamilton rarely omitted occasional doses of calomel Avith jalap; and Ave believe that when this combination is not contra-indicated, it is the most efficacious in the treatment of chorea, freely emulging the biliary ducts without producing much irritation. The advantage derived appears to be propor- tioned not to the quantity of scybalae passed, or to the amount of irritation induced, but rather to the production of free secretion without concomitant irritation. The indications in the management of chorea are, 1. To ascer- tain the existence of any congestion or irritation of the cerebro- spinal axis, and if such a condition be found to exist, to relieve it by moderate local depletion; 2. To act freely on the bowels by suitable purgatives; and 3. To administer remedies calculated to invigorate the frame, and thus to diminish nervous susceptibility, and increase the energy of the digestive function. 1. In some cases of chorea, although by no means a large pro- portion, various symptoms, such as pain and heat of head, throb- bing of the carotid or temporal arteries, suffusion of the eyes, ten- derness at the back of the neck or other parts of the spinal column, and excitement of mind, indicate congestion or inflammation of the cerebro-spinal axis or its membranes. In such instances the abstraction of blood cannot safely be dispensed with, and should be succeeded by counter-irritation, and the application of cooling lotions to the head and of Avarmth to the extremities. The state of the pulse will materially assist us in determining the extent to which the abstraction of blood may be carried. Unless the pulse possesses some degree of incompressibility; the application even of a few leeches will often be productive of eventual injury; and chorea, (Treatment.) 341 it is better to deplete less than the urgency of the symptoms may* appear to indicate, trusting to the use of purgatives, which, if not alone sufficient, prove most important auxiliaries in correcting the condition above described. All excitement of the senses must be as much as possible avoided, light and noise being excluded; the mental faculties must be suffered to rest, and moral emotions be restrained. 2. In the simple form of the disease, the judicious employment of purgatives is sufficient materially to moderate the symptoms; we are accustomed to confide chiefly in occasional doses of calo- mel and jalap, followed in a few hours by castor oil, and repeated at intervals of two or three days. Spirit of turpentine will some- times prove a valuable auxiliary, especially when there is reason to suspect the presence of Avorms in the intestinal canal. The num- ber of doses of calomel and jalap must be regulated partly by the appearance of the intestinal evacuations, partly by the effect pro- duced on the muscular disorder, and on the general health. While the evacuations continue scybalous and fetid, the repetition of the calomel is usually indicated; but Avhen the secretions become natural, the occasional employment of milder aperients, such as castor oil, or a combination of the infusions of gentian and senna, may be substituted. Sometimes the irregular muscular actions disappear in less than a fortnight, under the use of purgatives; at other times the symptoms are temporarily relieved, but after a few days recur or increase. Under such circumstances Ave have immediate recourse to the tonic plan, Avhich indeed may often be commenced after the first or second dose of purgatives. 3. In cases characterised by general debility, tonics may be required almost from the commencement of the treatment; and feAV cases occur in this country, in which they are not eventually required to render the cure rapid and permanent. The diversity of opinions regarding the most effectual tonic has been already noticed. Dr. Bright prefers sulphate of zinc, especially in cases produced by fright, in doses of from one to ten grains; in patients of weak and irritable habit, nitrate of silver combined Avith aloes and myrrh may be suitable: but we have rarely met with instan- ces of which the indications were not readily fulfilled either by the sesquioxide of iron or the sulphate of quinine; each of Avhich medicines has occasionally succeeded after the failure of the other. In cases characterised by general laxity of fibre, or by decided intermissions, quinine has appeared to be most effectual. In the majority of instances however, especially in those accom- panied with deficient energy of circulation, or in which undue re- pletion has been employed, iron has far surpassed all other tonics. Dr. Elliotson finds that it may be continued notwithstanding the presence of headach and paralysis, and there seems to be scarcely any limit to the quantity which may be administered. Mr. 29* 342 chorea, (Treatment.) Maclure has detailed the case of a little girl who took more than thirty pounds in a few months Avith advantage. In many instances ten or fifteen grains in treacle or syrup of orange-peel, given three times a day, will accomplish the object; sometimes it is necessary to increase the dose to several drachms. Valerian and calumba may occasionally be given with advan- tage combined with iron and an aromatic. By some practitioners antispasmodics have been considered essential, and they must not be despised as auxiliaries; but we consider them rather as pallia- tives than remedies, and repose more confidence in the perma- nency of cures accomplished chiefly by the agency of purgatives and tonics. Dr. Bardsley recommends musk and camphor, in doses of four grains each every four hours, and every evening an enema containing twenty or thirty drops of laudanum in four ounces of assafcetida mixture. The tendency of laudanum to produce constipation and cerebral congestion is an objection to its frequent use, and the object may probably be as effectually obtained by a combination of camphor and extract of henbane. The sulphur bath is very generally used at Paris in these com- plaints: Baudelocque has found it almost invariably efficacious. The poAver of the remedy in improA'ing the condition of the capil- lary circulation, regulating the bowels, and augmenting the gene- ral vigor, render it Avell deserving of greater attention than it has yet received from the Profession in England. Treatment of complicated states. Chorea in the female is so frequently associated with amenorrhoea, that it has been referred by Bouteille to a puberty difficult to establish. In such instances a combination of Pil. Galbani Co. Avith Pil. Aloes et Myrrhae forms a suitable medicine. If proofs of congestion be present, leeches may be applied to the upper part of the thighs or to the back; if there be deficient tone, or a state of anaemia, the Tinct. Ferri Muriatis, or some other preparation of iron is indicated. In cases accompanied Avith chlorosis, a combination of iodine Avith iron is singularly efficacious. A draught containing from five to ten grains of carbonate of iron, and from five to ten drops of tinc- ture of iodine, may be given twice or thrice a day; or if the bowels be too irritable to bear internal stimulants, the transmission of electrical shocks through the pelvis will sometimes accomplish the object. Complications Avith disease of the heart and pericardium, or of the spinal cord and its membranes, require careful treatment: if of an inflammatory nature, Avell-regulated depletion and counter- irritation must be employed; if there be rheumatism, without inflammation, ammoniated tincture of guaiacum, with serpentaria and camphor, will be appropriate. Cod liver oil may be given to patients Avho can tolerate the remedy. Incases combined with paralysis,or with stuttering, especially when occurring in adults, and exciting suspicions of effusion chorea, (Treatment.) 343 under the arachnoid, the use of iodine has sometimes produced gratifying results. The iodide of potassium when pure, in doses of from three to five grains judiciously administered, is a safe and powerful remedy. In some cases a course of mercury may be required. It is obvious that in the treatment of the disorder, as well as in the management of convalescence, the general habits of mind and body, and the regulation of diet, demand especial care. The shower bath, and subsequently sea bathing, are useful tonics, especially when folio Aved by friction of the skin. Mineral Avaters adapted to the peculiarities of the individual case may be employed Avith advantage—Pyrmont, Spa, Tonbridge, and other chalybeates, being Avell adapted to the pallid and leucophlegmatic; Ems to cases characterised chiefly by irritation; and Carlsbad perhaps more especially to instances of the disease associated with the strumous habit. Free exercise in country air is very desirable, and the use of the skipping rope, horse exercise, or other sports accustoming the muscles to prompt and accurate subserviency to the will, should not be neglected.* * The use of warm sulphur baths, made by dissolving the sulphuret of potassa, was introduced by Dr. Baudelocque at the children's hospital of Paris, and the practice was found to be very successful. No other remedy was used. In private practice, these baths are inconvenient, but they will sometimes be useful as an adjuvant to other modes of treatment. 344 HYSTERIA. General observations.—Division into three forms—regular—irregular—compli- cated.—Diagnosis.—Prognosis.—Causes.—Nature.—Curative treatment.— Moral management and preventive treatment. The term Hysteria, although established by long usage, seems to have been generally employed with more than ordinary vague- ness too often characteristic of attempts to designate disease. It is also liable to the objection of suggesting a theory of the com- plaint, which is extremely questionable; yet as attempts to substi- tute other titles have not been more successful, we might readily submit to the etymological inaccuracy of the appellation, if it ansAvered the useful purpose of conveying to the minds of medical men the idea of a certain and definite series of phenomena. Un- fortunately, however, the idea attached to the name by various practitioners is almost as varied as the phenomena themselves; and the word Hysteria owes perhaps much of its popularity to the convenience Avith which it may be employed to cover our ignorance, and to furnish a receptacle for those cases Avhich, in the present state of our knoAvledge, cannot easily be referred to any distinct place in the nosological arrangement. It must be allowed that the progress of pathology has not materially tended to curtail these cases, but it is on that account the more important to endeavor to fix their limit, and to assist the student in their recognition. The peculiarities of individual constitution occasion varieties in the phenomena of most complaints, which render it extremely difficult to frame definitions accurately representing their essential characteristics. It cannot, therefore, be deemed surprising that a disease, pre-eminent in the irregularity and va- riety of its symptoms, should defy all attempts at rigid definition, although a description of its principal phenomena may be given sufficiently specific for practical purposes. The phenomena of the hysterical paroxysm are Avell known; but those who are prone to such attacks are often subject to other affections, naturally referred to the same predisposition. A similar condition not unfrequently exists in some who rarely or never present the more prominent phenomena; and Ave there- fore find it necessary to treat of the disease, not merely as an assemblage of certain characteristic symptoms, but also as a ge- neral condition disposing to the production of various analogous hysteria, (Regular.) 345 disorders, when suitable exciting causes are presented. We may, therefore, describe hysteria as a peculiar nervous susceptibility, leading to the production of symptoms remarkable for the capri- ciousness of their character, the changeableness of their seat, and the suddenness of their accession and subsidence, the function of nutrition being seldom interfered Avith, notwithstanding their se- verity and long continuance. The mental condition of hysterical females is generally modified, and often distinguished by sensitive feelings, sudden impulses, and fickle temper. Sufficiently Avell- marked cases of the disorder have occurred in men, under the influence of sexual restraint or of depressing passions; but it more especially appertains to women, whose originally susceptible ner- vous system has been rendered more than naturally mobile by an injudicious system of education: and it is from the age of puberty to the cessation of the catamenial function that the greatest liabi- lity to the malady is observable. The difficulty of conveying an idea of the varied phenomena of hysteria Avill perhaps be diminished by describing the disease under three forms: the regular, the irregular, and the compli- cated. This division will best enable us to exhibit the characte- ristic features of the malady, although when we come to the subject of treatment, it will be necessary to modify the arrange- ment. 1. Regular Hysteria. The regular form may be distinguished by its strikingly paroxysmal character. The patient does not necessarily present any symptoms of habitual disorder, but is liable, under the influence of slight exciting causes, physical or mental, and sometimes without any appreciable cause, to sudden attacks of a spasmodic nature. After feelings of general uneasi- ness, and perhaps headach, cramp, or stiffness about the throat, and a vacant stare, or irregular movement of the eyeball, a sen- sation as of a ball is felt in the left iliac region, Avhich, rising up- Avard to the throat, produces the feeling called globus hystericus, sometimes followed by a violent fit of laughter, alternating with Aveeping, and in milder cases the patient quickly returns to her usual state. In more severe seizures there is great mental and bodily agitation, oppression of chest, dyspnoea, palpitation, and incapability of utterance. The sufferer falls down, and beats her breast or the pit of her stomach, in Avhich situation there is often violent pain. The breathing is slow and laborious; the abdomen extremely distended and flatulent. Sometimes the patient strikes her head, tears her hair, and attempts to bite her arms, or even the person Avho may be near her. The limbs are either motion- less or convulsed; and the body is perhaps supported on the heels and back of the head. The violence of the contortions may oc- casionally intermit, and be again renewed, but after considerable eructation, vehement expiration, and.perhaps sobbing or laughing, the patient comes to herself, often retaining, but not generally 346 hysteria, (Irregular.) acknowledging, a recollection of much that has passed during the paroxysm, but complaining of fatigue, and sometimes suffering , from temporary paralysis of the bladder, arms, or other muscles either of voluntary or involuntary motion. Frequently there is a copious excretion of limpid urine. In some instances the fit lasts for several hours, and, instead of the usual favorable termi- nation, passes into a state of coma, or of syncope, rather peculiar in its character, and sometimes so closely resembling death as to have led to serious mistakes. Those who are liable to attacks of regular hysteria, usually possess a susceptibility, which renders them prone to hurried breathing, or to sighing, sobbing, or laughing, under the influence of ordinary emotion, and they are, for the most part, apt to pursue objects with ardor, and to exaggerate grievances. The more severe paroxysms chiefly occur Avhen the catamenia are sus- pended, the boAvels torpid, or the digestion deranged. Those who have been long subject to these attacks frequently have ten- derness at the sides of some of the vertebrae, which, however, is seldom suspected by the patient, and only discovered by a close examination. When the complaint has continued for many years unchecked, the nervous system becomes more seriously affected, and para- plegia, weakened memory, or even mania, may ensue. 2. Irregular Hysteria. The irregular form of hysteria may exist Avithout the occurrence of decided paroxysms. The pheno- mena which it presents are indescribably various. There is scarcely any part the function of which it may not disturb, so as to excite the suspicion of organic disease: but the rapidity with which the morbid condition is transferred from one part of the system to another, and the marked disproportion between the symptoms, are generally sufficient to indicate the real nature of the malady, although there is probably no class of cases in which errors of diagnosis are so frequent. The most constant symptom is pain under the left mamma, confined to a small space, and not necessarily increased by a deep inspiration. Sleep is generally disturbed; there is great suscepti- bility to impressions, Avhether bodily or mental, and generally a liability to palpitation, spasmodic cough, flatulent colic, tender- ness of skin, or to neuralgia of a peculiar character. A few of the more marked phenomena require particular notice. Hyste- rical headach is sometimes fixed to one spot, particularly of the forehead, over one eye, producing the sensation as of a nail driven into the part; hence called clavus hystericus; at other times it may affect the Avhole head, and be attended with tenderness of the scalp, intolerance of light or sound, and other symptoms of phrenitis. This state is often associated Avith an irritable condi- tion of the uterus; it is not removed by the remedies of indiges- tion, but is generally relieved by nervine medicines. hysteria, (Irregular?) 347 The subjects of irregular hysteria generally evince much capri- ciousness, inconstancy, and irritability, and are sometimes liable to temporary delirium, presenting a very peculiar character, intermediate between somnambulism and mania. One patient will hide her head under the bed-clothes and shun observation; another will employ outrageous language, and endeavor to injure those who approach her, to destroy children, or to commit sui- cide; a third will sing, or repeat words in some language with which she is not ordinarily familiar, but of which, under this par- ticular state, she seems to possess a vivid recollection. The hysterical condition sometimes produces dysphagia. It is not necessarily spasmodic, but may depend on defective action of the voluntary muscles. The difficulty of swallowing is some- times so great as to excite suspicions of hydrophobia. The oppo- site condition of remarkable avidity for swalloAving has been observed. In the Dublin Medical Journal, vol. iii, an interest- ing example is related by Dr. Graves, in which any attempt to interrupt the process of swallowing Avas followed by hysterical convulsions. The oesophagus is sometimes so remarkably sensi- tive, that the introduction of a probang is sufficient to produce a decided hysterical paroxysm. (Bright's Medical Reports, vol. ii, p. 257.) Sydenham observes that hysterical patients often spit a thin saliva for many weeks, as if produced by Mercury: the same phenomenon has been noticed by Mauriceau, Stoll, Rowley, and Darwin. Dr. Graves thinks it is secreted from the fauces. In some hysterical subjects we have observed the tongue covered with a profuse thick secretion resembling cretaceous mixture. The laryngeal muscles may be either in a state of irritation, or of deficient power. The former state not unfrequently occurs in young hysterical females, producing in some instances spasmodic closure of the glottis; in others fits of loud convulsive cough, often followed by stridulous inspiration and threatened suffocation. The attack generally comes on in the evening; it may last two or three hours, and close with a common hysterical fit, or with syn- cope or convulsions, but is never fatal. The intervals of healthy respiration, the absence of fever, of pain on swallowing, or of tenderness on pressure, distinguish this affection, when simple, from chronic laryngitis; but in some instances the tAvo disorders exist together. Hysterical cough may be hard, loud, and solitary, producing hurried breathing, palpitation, and perspiration, and is sometimes folloAved by a long sonorous expiration, not unlike the howling of a dog. At other times the paroxysm consists of short, rapid, tearing coughings, producing great distress and exhaustion. Mental emotion is a frequent cause of these affections; and it is worthy of notice that, of three cases of this character mentioned by Dr. William Stokes, one on dissection exhibited proofs of 348 hysteria, (Irregular.) meningitis; and the phenomena of the other tAvo furnished strong grounds for suspecting a similar condition. (Treatise on the Diseases of the Chest, p. 266.) Loss of voice may occur at the catamenial period from mental emotion, or from slight intestinal irritation. It comes on and ceases very suddenly, often Avithout evident cause. Any great excitement sometimes restores the poAver of articulation for a time, but on its cessation the voice is again reduced to a whisper. Hiccough is occasionally among the phenomena of irregular hysteria, or an exclamation resembling the latter half of hiccough, which Ave have knoAvn to continue without intermission for many days and nights. Palpitation of the heart, characterised by extreme violence, and by the slight nature of the causes which induce it, is no uncom- mon occurrence. Bellows' sound, in the region of the aorta, is sometimes produced in such patients by mental emotion; but its irregularity and want of persistency soon betray its nervous origin. The stomach is, in some instances, peculiarly irritable, reject- ing a large portion of every thing taken into it. The vomiting is not much influenced by the nature of the diet, and is often accom- plished with very little effort. It generally occurs soon after tak- ing food, but may sometimes be controlled by a powerful effort of the will, and it is remarkable how long it may continue, with- out materially impairing nutrition. Spasm of the abdominal muscles producing a hard and knotted surface is occasionally observed. Tympanitic distension of the abdomen may proceed to such a degree, as to cause the patient, if immersed, to float on Avater; and, through neglect of the simple expedient of percussion, has been mistaken for ascites. This state probably depends some- times on partial paralysis of the intestinal muscles; sometimes on secretion of gas. The gas thus produced, in a case of hysteria, was analysed by Dr. Osborne, and found to consist of carbonic acid gas with a slight proportion of nitrogen, hydrogen, and car- buretted hydrogen. Hysterical ischuria is more frequent than is generally supposed, being often overlooked by the practitioner, or concealed by the patient. It sometimes depends on deficient secretion, at other times on defective action of the will. In the former case the affection is not relieved by the catheter, and in the latter is ren- dered more obstinate by its use. There is a form of neuralgia Avhich may justly be considered hysterical. It comes on suddenly, is generally attended Avith puffiness and tenderness of the skin, and often with alternate heat and chilliness of the part affected, and is peculiarly apt to migrate from one place to another. The pain under the left hysteria, (Complicated.) 349 breast, which may almost be considered pathognomonic, more particularly of irregular hysteria, is probably of a neuralgic cha- racter. The joints enjoy no immunity from the all-pervading influence of the disorder, but are liable to be affected Avith morbid sensi- bility or severe pain. The hip and knee joints are the most fre- quent seats of the complaint; and in the latter the inner side, and apparently the branches, of the anterior tibial nerve. Serious local disease is too often suspected, and sound limbs have some- times been sacrificed to this mistake. With a vieAV to diagnosis, it may be observed, that pinching the skin gives as much pain as pressure on the joint; that examination gives less pain, if attention is directed to other objects; and that there is no wasting of the limb, or painful starting in sleep. To enforce the importance of such discrimination, it will be sufficient to quote the remarkable statement of Sir Benjamin Brodie—" I do not hesitate to declare, that among the higher classes of society at least four-fifths of the female patients who are commonly supposed to labor under dis- eases of the joints, labor under hysteria and nothing else." The voluntary muscles may be affected in different degrees of violence or extent. One or more muscles is sometimes attacked Avith paralysis, as complete, Avhile it lasts, as that Avhich arises from softening or compression of the spinal cord. At other times there is periodical or permanent contraction of the limbs; or a condition Avhich has been denominated " leaping ague," charac- terised by a remarkable propensity to skip, swing, dance, and jump, in a degree to Avhich the powers of the patient, in the natu- ral state, would be unequal. Various perverted sensations, such as inordinate hunger and thirst, might here be noticed, but the catalogue of symptoms is already sufficiently voluminous. We have known the majority of those above described to occur successively in the same indi- vidual, but a very few, if Avell defined, will be sufficient to autho- rise our referring them to that remarkable disorder Avhich has defied " all systems of nosology, all doctrines of pathology, and all kinds of remedy except time." 3. Complicated Hysteria. When the other diseases attack persons of hysterical contitution, the symptoms of the two com- plaints may be so blended, that the more important malady may be modified or even masked. Such a complication may increase the formidable aspect of the principal disease, Avithout necessarily augmenting the danger, although it may eventually augment ex- isting disorder by promoting inflammatory action at the extremi- ties of irritated nerves. Common continued fever is often ushered in by hysterical phe- nomena, which may also indeed occur during its course, espe- cially in the form of croupy breathing, spasmodic action of the abdominal and respiratory muscles, fits of laughing and crying, 30 350 hysteria, (Diagnosis.) &c. During convalescence from fever, such phenomena may appear in males as Avell as in females, and are probably in part dependent on debility. When hysterical complications attend the latter period of phthisis, or of other chronic diseases, the pain of head, throbbing of the carotids, and excitement of the imagi- nation, by which they are often characterised, may induce an apprehension of phrenitis; but free depletion rather aggravates than relieves the symptoms. To attempt a description of all the ■various complications of hysteria Avould, hoAvever, be a vain and useless task. Diagnosis. There are few disorders Avhich hysteria does not occasionally simulate; but the variety, changeableness, and in- congruity of the symptoms; theirregularity of their course, and the rapid alternations of violent derangement, and of a nearly natural state with which they are attended, generally disclose to the observant practitioner the true nature of the malady. When accompanied with spasmodic phenomena the disease may be mistaken for epilepsy, and in its chronic form for hypochon- driasis. The genuine epileptic paroxysm is generally sudden, making its onset with a shrill cry; the eyeballs are distorted; the pupils dilated; the teeth ground against one another, or closed upon the tongue, Avhieh is protruded from the mouth; the face is swollen, discolored, or ghastly, and the larynx spasmodically closed, occa- sioning ineffectual efforts at expiration. The fit is folloAved by heavy sleep, and on Avaking the patient does not recollect what has happened. The countenance of those Avho have suffered long from the complaint, becomes dull and inexpressive. The hyste- rical paroxysm seldom occurs in the streets, and is characterised by laughing, crying, and the sensation of globus; the muscles of the face and the pupils of the eyes remain nearly in their natural state; the respiration is heaving and sighing. After the fit the patient has more or less recollection of what has passed; and although disposed for quiet, seldom falls into profound sleep. There is in general no evidence of organic disease, and the ha- bitual physiognomy is restless or lively. A combination of the two conditions may, however, occur. In epileptic hysteria the patient laughs on one side, and the eyeballs are distorted. In hysterical epilepsy the fits are more frequent than in pure epi- lepsy, and are more apt to be produced by mental emotion. Hypochondriasis and hysteria have been regarded as identical by various authors, particularly by Lepois, Highmore, Sylvius, Sydenham,'Boerhaave, Van SAvieten, and Whytt; but the more ancient opinion of their diversity, supported by Hippocrates, Cel- sus, Galen, and Aretaeus, has been in later times sufficiently esta- blished by numerous writers, among whom Willis, Hoffmann, Sauvages, Cullen, Pujol, Louyer-Villermay, Georget, and Brachet, hold a conspicuous place. The last mentioned author regards hysteria, (Causes.) 351 hysteria as a spasmodic affection of the cerebral nerves, and hy- pochondriasis as a morbid condition of the ganglionic nerves, but it is very questionable, whether the present state of physiological knowledge authorises such theoretical refinement. It may be sufficient to mention, that hypochondriasis is characterised by a false direction of the moral energy, and is generally associated with inactivity, a concentration of interest upon self, and a dispo- sition to have recourse to a great variety of medical practitioners. Hysteria is accompanied with vicious innervation, fitful activity, and often with a lively interest in the welfare of others, and with confidence in the usual medical attendant. The former disorder is marked by sullen countenance, gloomy ideas, and dejected spirits; the latter by a restless animated expression, convulsive paroxysms, and fickle temper. We must, hoAvever, remember, that the two diseases are not incompatible, and that hysterical hypochondriacism does occasionally occur. The circumstances Avhich may assist in distinguishing various isolated affections incidental to irregular hysteria from organic diseases of the same parts have been already noticed; it must be here noticed, that the coma of hysteria may be distinguished from apoplexy by the variableness of the pulse, and the occasional intervention of symptoms inconsistent with compression of the brain. The tenderness of abdomen present in some hysterial cases may be distinguished from peritonitis by its superficial cha- racter, and by the absence of the sinking or yielding physiognomy Avhich serious disease of that part usually produces. The con- currence of regular pulse with violent pain, or of irregular pulse Avith slight symptoms, and the presence of other and Avell knoAvn hysterical phenomena, rarely fail to elucidate the real nature of the disorder, however alarming it may at first sight appear. Lay- cock mentions plumpness of the form, large mammae, and dark areolae, as characteristic of the hysterical diathesis, and Avhen these circumstances are present they certainly merit attention. Causes. Dubois has advanced the opinion, that hysteria is an exaggeration of the sanguineo-nervous temperament. (Hist. Philos. de VHypochondrie et de VHysteric) Persons possessing that constitution are doubtless particularly prone to the disease; but a certain mobility or affectibility of the nervous system seems also necessary. Parents who are gouty, epileptic, or in any Ayay sickly, are most apt to engender this condition in their offspring; but the conduct of early life may also remarkably conduce to its development. The various emotions resulting from social life, rendered more frequent and intense by civilisation, and the exer- cise of the sensations rather than of the active powers incidental to the same state, appear to increase the general susceptibility of the nervous sytem. From the influence of luxury, indolence, and sentimental reading, the hysterical habit is becoming a com- mon characteristic of the female inhabitants of towns, and gaining 352 hysteria, (Nature.) increased prevalence among our country population. In like manner females who have been long enured to an active hardy life, when removed to the mansions of the opulent, often acquire the hysterical susceptibility. The causes of plethora sometimes induce a liability to hysteria in nervous habits, and particularly to the convulsive form of the complaint; but the disposition is more frequently produced by the causes of debility, such as a sedentary life, attacks of fever, excessive evacuations, or the long continued use of sedative, depletory, or irritating remedies. Nature. The question regarding the intimate nature of hys- teria is one of peculiar difficulty, rather increased than diminished by a reference to its literary history. Hippocrates adopting the opinion of Pythagoras and Plato, that the uterus was an animal, referred the phenomena of hysteria to the wanderings of this ani- mal to the head, throat, liver, and limbs. Aretaeus embraced the same absurd doctrine. Galen refuted the notion of the move- ments of the organ, but agreed in making it the seat of the disease, and iEtius illustrated the view of Galen. The theory of Hippo- crates Avas afterwards revived by Holler and Duret, to be again confuted by Baillou, who substituted, for the movements of the uterus, a chilling malignant humor arising from the same source. The principal vieAvs Avhich have since been entertained by authors may be arranged as folloAVs:—1. Hysteria has been re- ferred to a morbid condition of the uterine nerves by Cullen, Pinel, Lieutaud, Louyer-Villermay, and Foville, &c, and to chronic inflammation of the uterus by Pujol. 2. A morbid con- dition of the stomach Avith imperfect digestion, producing, acord- ing to Cheyne and Parry, acid humors, and, in the opinion of Pitcairne, imperfectly concocted blood, affecting the brain through the arteries, and to gastro-enteric inflammation by Broussais. 3. Congestion of the lungs and heart by Highmore, and of the vena portae by Stahl. 4. A morbid condition of the nervous system generally by Dumoulin, Loob, Pomme, Lorry, Whytt, Tissot, Boerhaave, Hoffmann, Sauvages, Andral, and numerous other writers. 5. A morbid condition of the brain or cerebral nerves by Lepois, Willis, Barbeyrac, Georget, and Brachet. A morbid condition of the spinal cord by several recent authors, and of the ganglionic system by Van Swieten, Lobstein, and Willis. Amard ascribes hysteria to disorder of the loAver portion of the spinal cord. Frank, M. Colson, Drs. Bradley, BroAvn, Darwall, Griffin, and Marshall, refer it to a more or less general irritation of the same organ; and Tate, to spinal irritation connected Avith irregular or defective catamenia. The information afforded by morbid anatomy respecting hys- teria being almost entirely of a negative character, affords us but little assistance in the attempt to determine its essential nature. Villermay has quoted cases from Diemerbroeck, Vesalius, and Morgagni, to prove the frequent coexistence of disease of the hysteria, (Nature.) 353 ovaries. Georget has endeavored to connect the phenomena with changes in the brain, and Broussais with morbid appearances in the intestinal canal; but no sufficient evidence has yet been ad- duced to prove the dependence of hysteria on any structural change, and we are therefore left to form our opinion chiefly from analogy. Extensive disordered action may be considered as a change of vital properties; and since life is not monopolised by any one of the organs or structures, but diffused through them all, we must avoid the error of hastily limiting disease to single organs, Avhich may perhaps be affected only as parts of the whole. At the same time the evidence adduced by Geoffroy St. Hilaire and Serres, to show that the development of the body has a remarkable refer- ence to the nervous system, and the instances continually pre- senting themselves in which various functional disturbances are produced by causes acting directly on the nervous centre, authorise the suspicion that a disorder, characterised by peculiar nervous susceptibility, depends on a morbid condition of this particular system; and although physiology does not at present enable us to fix precisely the functions of individual parts of the nervous system, yet a remarkable analogy may be traced between the effects produced by indisputable changes in the cerebro-spinal axis and the phenomena of the disease under review. We believe Avith Dr. Marshall Hall, that the spinal cord is " the axis of a system of excito-motory nerves, which is the peculiar seat of ac- tion of certain diseases, and of certain causes and remedies of disease;" and although the nature of such actions may be inap- preciable, there are various considerations Avhich give force to the opinion that they constitute the essential source of hysterical disorder. Injuries and diseases of the spinal cord often produce effects resembling the phenomena of hysteria. Krimer found the urine become limpid when the cord Avas divided in the dorsal or lum- bar region; Chausset observed loss of voice produced in dogs by division of the cord in the neck; and Nasse noticed the same re- sult from its division in cats and rabbits. Inflammation or disorganisation of the cervical, portion of the cord often produces vomiting, impaired deglutition, sensitiveness of the oesophagus, or interrupted respiration; and a similar con- dition of the cervical or dorsal region may occasion convulsions or palsy of the muscles of the trunk; and it is a natural conclusion that phenomena similar in kind, though less permanent and less severe, may result from functional disturbance of the same parts. This opinion derives strong confirmation from the case recorded by Dr. Billing, of a man aged twenty-eight, Avho having strained his spine by falling Avith a heavy load, suffered afterwards from globus hystericus and palpitation. (Lancet, vol. iv, p. 426.) Various hysterical symptoms are often associated with puffiness 30* 354 hysteria, (Nature.) of the integuments, and a peculiar sensitiveness of the cutaneous nerves of some part of the spine, and may often be increased by pressure at the sides of the vertebrae. We have observed this condition in connection with painful affections of various parts, difficult deglutition, cough, eructation, colic, and fainting, Such symptoms are frequently relieved by local treatment directed to particular parts of the spine. It is true that some phenomena illustrative of hysteria may be produced by irritation of the sympathetic ganglia: for example, contraction of the intestines from irritation of the splanchnic gan- glia or coeliac plexus, as proved by Volkmann and others; but this fact is not inconsistent Avith the explanation proposed, since there is reason to believe that the brain and spinal cord are the chief sources of power to the organic nerves, and the reflex action of the sympathetic is most readily excited by irritation of the cerebro-spinal. It is highly probable that interference Avith that part of the nervous axis more directly connected Avith the eighth pair is the condition most essential to the production of the characteristic phenomena of hysteria, the parts supplied by this pair being so remarkably influenced by the disorder, and its lesion, from Avhat- ever cause, being productive of analogous changes of function. Brachet found the sensation of hunger, Avhich is apt to be mor- bidly felt in hysteria, suspended by the division of the par vagum; and Gendrin has related an interesting case of cough of a de- cidedly hysterical character produced by exposure of this nerve to the atmosphere, in consequence of opening a neighboring ab- scess, Avhich subsided as soon as a cicatrix perfectly closed the wound. In order to appreciate the important relations of this nerve, Ave must remember its communication with the corpora restiformia, the corpora olivaria, and Avith those fibres of the cor- pora pyramidalia, Avhich pass into the cerebellum: Ave may thus trace its influence on sensation and respiration; and if the vieAvs of Gall and Spurzheim be true, Ave may even derive an explana- tion of its relation to sexual conditions through the cerebellum. If the opinions of Bellingeri be correct, we can readily understand how increased, perverted, or impaired sensations or motions of various parts may be produced, according as different portions of the gray or Avhite matter are most affected; and we may refer interference Avith the state of the rectum or bladder to a similar disturbance of the lateral strands of the medulla spinalis. The close connection of the different parts of the cerebro-spinal axis, and the ready transference of congestion or irritation from one part to another; will readily explain the mutability of hysterical symptoms; and Ave thus reduce to a simple and connected ar- rangement the " disorderly heap of phenomena," of which the disease has been defined to consist. Dr. Conolly is of opinion that causes productive of irritation in hysteria, (Nature.) 355 various viscera may occasion the nervousdisturbance producing hysteria; but Dr. Copland thinks it essential, that the nervous or vascular condition of the sexual organs should first be affected. It seems difficult, however, to reconcile the doctrine, that the uterine system is necessarily concerned in the production of hysteria, with the fact, that the disorder may coexist Avith every appreciable variety in the condition of this system, with monor- rhagia or amenorrhoea, Avith inflammation in various degrees, or Avithout any disturbance at all. The existence of a special irri- tation seems scarcely consistent Avith such a variety; and when the function of an organ is unaltered, there is no ground for sup- posing it disordered. The occurrence of all the characteristic phenomena in men is fatal to the uterine hypothesis. Napoleon in his boyhood is said to have had a fit of hysteria from Avoimded pride. Dr. Ferrear (Me- dical Histories and Reflections) relates the case of a young man affected with globus hystericus and apparent insensibility, yet re- taining consciousness, and Avho was treated successfully Avith an emetic, antispasmodics, and afterwards tonics. In the Edin. Med. and Surg. Journ., vol. xi, there is an account of a strong, healthy man who had alternate laughing and crying, and inability to speak, from a feeling of something in the throat. If additional evidence be required of the occasional occnrrence of hysteria in men, Ave might refer to the statements of Lepois, Willis, Whytt, Sydenham, Hoffman, Trotter, Cullen, Watson, Georget, Conolly, Billing, and even of Villermay; and although some of the cases described by these Avriters may seem referrible to sexual condi- tions, there are many which are not capable of such an explana- tion. Several have fallen under the observation of the author in children of each sex, and in adults under circumstances of debility or mental depression, which cannot be referred to such causes; and it cannot be denied that treatment applied to other parts will often effect a cure Avithout changing the condition of the sexual organs. At the same time it is readily allowed that, OAving to its great nervous endoAvment, the uterus must be fully as competent as other organs to produce sympathetic disturbance of the nervous centre; and it is equally natural to conclude, that an organ pos- sessing such intimate associations Avith that centre must be pecu- liarly liable to be affected by its derangements: and hence it will often be a problem in such cases, Avhether the uterus is primarily or secondarily concerned. In his very instructive work on local nervous affections, Sir Benjamin Brodie has attributed the susceptibility to their occur- rence to imperfect development of the nervous system; but since of all parts of the body the nervous system is perhaps that Avhich least frequently exhibits marks of insufficient development; since it often contributes by its derangements to the disorganisation of other parts, and yet survives the ruins it has caused; and since in 356 hysteria, (Treatment.) maladies of a nervous character its actions are rather perverted than enfeebled, and more frequently exalted than deficient, Avhilst the susceptibility to them is greatest in youth, and diminished by the progress of age, this opinion, notAvithstanding the deserved eminence of its author, seems to be questionable. When the condition of the nervous system above described ex- ists, a very slight excitement will be sufficient to induce hysterical symptoms. Among these, emotions of mind of whatever kind, as of grief, joy, unrequited affection, jealousy, disappointment, or surprise, are conspicuous. The force of imitation is also very re- markable. Dr. Mead supported the popular opinion, that the fits we're peculiarly liable to occur about the time of new and full moon. . Fanciful as such an opinion may be, Ave are not perhaps authorised entirely to repudiate statements regarding lunar influ- ence on the animal frame. The opinion that electrical agency may affect nervous subjects is gaining ground, and has the de- cided support of Rostan. The principal exciting cause, hoAvever, is irritation in some important organ; and since the association of hysteria Avith such conditions is the most important circumstance in reference to treatment, it will be found desirable to adopt a cor- responding division of the malady as the basis of a more simple and available arrangement of practical remarks. Treatment. During a paroxysm of hysteria it is important to adopt such measures as may be necessary to prevent the patient from sustaining injury during the violence of the struggles. Any tight clothing about the neck or Avaist should be loosened. Cold water may be sprinkled on the face, and stimulating scents ap- plied to the nostrils. If the patient can SAvalloAV, a dose of ether, foetid spirit of ammonia, or tincture of valerian, may be adminis- tered, or an enema of assafcetida, turpentine, or of iced water, which is recommended by Professor Chiappa as peculiarly effec- tual in arresting the fit. Some modifications of treatment are re- quired even during the paroxysm, by peculiarities of the indivi- dual case; and in the intervals they are more especially requisite according to the varieties of aspect Avhich this Protean malady assumes; but it is hoped that an arrangement may be introduced, by means of which the principles of treatment may be simply ex- pounded and readily applied. If the vieAV which has noAV been offered be correct, namely, that the essence of hysteria consists in a peculiar disorder of some portion of the nervous centre Avhich may produce the symptoms, either spontaneously under ordinary influences, or by irritation communicated from other organs, Ave obtain a division of the disorder into the idiopathic and the sym- pathetic. It is probable that the brain cannot produce the symp- toms except through the medium of the spinal cord, yet, as these parts are so closely connected, Ave shall combine them in our vieAV of the idiopathic form of hysteria, and consider it a cerebro-spinal disease. hysteria, (Treatment.) 357 Sympathetic hysteria may probably be produced by disorder of any organ, since even a Avound of the finger may occasion it; but as its principal sources are the intestines and the uterus, we shall embody our remarks on the treatment of the disorder under the divisions of intestinal and uterine. Idiopathic Hysteria. In this form there is no evidence of dis- order of any organ except the cerebro-spinal axis, but the condi- tions of this part may vary in different cases, so as to require a corresponding modification of treatment, The principal diversity regards the state of the circulation; and it is therefore convenient to subdivide this form into, 1. the congestive, either with general plethora or local determination of blood, and 2. the atonic. 1. The congestive variety of idiopathic hysteria often depends on a state of general plethora. This condition is apt to occur in those Avho are Avell nourished, and lead a sedentary life. It gene- rally assumes the form Avhich, in the preceding arrangement, has been described as regular hysteria, and is characterised by violent paroxysms occurring most commonly just before the return of the catamenial period. The convulsions are often severe, the face flushed, the arteries of the neck and head throbbing, the conjunc- tival vessels distended. In some cases fatal coma has followed these attacks. This, therefore, is the form of hysteria in Avhich depletion is generally safe, and sometimes necessary. During the paroxysm, bleeding or cupping between the shoulders Avill be desirable. Cold should be applied to the head, and if stimulants be administered, the ammoniated tincture of valerian should be given rather than brandy. The purgative plan must be subse- quently adopted. A dose of calomel with jalap or colycinth should be promptly administered, followed by a more or less con- tinued use of saline purgatives combined Avith senna. The occa- sional repetition of the calomel may be requisite. Late hours, hot rooms, and feather-beds must be avoided, the diet must be light and unstimulating, and exercise on foot must be enforced. As in this form of the disease the paroxysms are generally ushered in Avith headach, cupping on the first occurrence of that symptom Avill often avert the attack; but it will be important, by an assi- duous attention to diet and medicine, to obviate the necessity of a very large abstraction of blood. Other cases are associated with local congestion rather than general plethora, and require much care in their investigation and treatment. When the brain is chiefly affected, there may be headach and flushing of the face. One part of the head may be hotter than another: there may be occasional delirium, or some peculiar form of temporary monoma- nia, as a disposition to destroy children or to commit suicide. The sudden occurrence of the symptoms, their temporary and variable character, their dependence in many instances on moral excite- ment, and their association with other hysterical phenomena, will enable the practitioner to distinguish them from cases of chronic 358 hysteria, (Treatment.) derangement. The patient sometimes lies unconscious of all around her, Avith torpor of the senses, or even with dilated pupils: but in addition to other modes of distinguishing this from the hy- drocephalic or apoplectic states, it may be mentioned that the countenance retains more intellectual expression than in those dis- orders. In these, instances leeching, or cupping moderately em- ployed, are often advantageous, or if the strength seems unequal to the abstraction of blood, dry cupping will sometimes answer the purpose. Five or six glasses applied to the nape of the neck, and retained there for ten or fifteen minutes, will often avert the hysterical fit, if employed as soon as headach or other symptoms indicate its approach. Turpentine is a useful remedy. A drachm suspended in mucilage, with the addition of a few drops of tinc- ture of capsicum, may be administered three times a day, or seve- ral drachms combined with castor oil may be introduced as an enema. Great attention must be paid to the regulation of the bowels and to the promotion of a free catamenial secretion. When local congestion about the spinal cord exists, there will in most instances be found puffiness and tenderness of the part affected. The tenderness probably depends on a sympathetic condition of the cutaneous nerves, for the spinal cord is too Avell protected to be directly influenced by external pressure. A large proportion of cases of irregular hysteria are associated with this condition, particularly those characterised by spasmodic closure of the glottis, spasmodic cough, dysphagia, palpitation, hiccough, and vomiting. These phenomena are faithfully de- scribed and instructively illustrated in Griffin's Avork (On Func- tional Affections of the Spinal Cord). Dr. Griffin even supposes that there is a special relation between the organs affected and certain parts of the cord: thus, that palpitation, vomiting, inordi- nate hunger and thirst, epigastric pulsation, and cough depend on affections of the cervical region; disorders of the stomach and colon, loss of voice, pain in the chest and arms, on those of the dorsal region; whilst irritation of the lumbar portion produces affections of the hip joint, colic, menorrhagia, ischuria, constipation, or paralysis of the legs. Such a relation may, no doubt, often be observed; but considering the close connection of the different parts of the spinal cord, we need not be surprised to find frequent deviations from the rule. Much caution is required in the treat- ment of these affections, the hysterical susceptibility of the cerebro- spinal system being associated Avith a peculiar sensitiveness to any disturbance of the balance of circulation, Avhether on the side of excess or of deficiency. When the strength has been good, we have repeatedly witnessed great advantage from the applica- tion of a few leeches to the tender part of the spine, and subse- quently from counter-irritation by blisters or tartar emetic oint- ment; and have known a case of vomiting, apparently hysterical, of two years' duration, yield in a few days to this simple treat- hysteria' (Treatment.) 359 ment. In cases associated Avith isolated affection of the spinal cord, two blisters, one on each side of the part, are the best counter- irritants: Avhen the affection is more extensive and chronic, anti- monial ointment is probably more effectual. Palpitation of the heart and teasing cough may often be relieved by the same means. The cough is temporarily relieved by antispasmodics, as ether; more completely by a combination of ammoniacum and prussic acid; but counter-irritation can rarely be omitted, and sometimes a slight course of mercury is essential. In cases of spasmodic closure of the glottis, cold Avater should be throAvn on the face, and ammoniacal salts applied to the nos- trils. The fauces and pharynx may be tickled with a feather or with the forefinger, the retching, and consequent expiration thus induced, engage the laryngeal in one combined act Avith the other respiratory muscles, and the spasm of the glottis is thus overcome. In the epileptic form of hysteria with spasmodic closure of the jaw, we may often succeed in opening the mouth by firmly com- pressing the muscles attached to the hyoid bone. Mr. Laycock supports this recommendation by mentioning a case of spasm of the glottis in an adult male, in-which inspiration immediately folloAved pressure of the thyroid cartilage. (Med. Gaz., 1838.) If this method fail, the object may sometimes be accomplished by forcibly overcoming the tetanic flexion of the forearm and fingers. The relief thus obtaiued may be temporary, but it gives an op- portunity for the administration of valerian or assafcetida. Hys- terical hiccough is occasionally relieved by the same measures which prove useful in cases of cough and palpitation: one case hoAvever, of a severe character, which had lasted for Aveeks, and continued during sleep, resisted this method, but was cured by a blister to the epigastrium. In the class of cases under revieAV the author has given a trial to veratria in the form of unguents, but it has not appeared so effectual a counter-irritant as the tartar emetic ointment. When a tympanitic state of abdomen appears to depend on the condition of the spinal cord, turpentine is often useful; and when this remedy has failed, alum in considerable doses has accomplished a cure. Dr. Abercrombie has referred to some interesting cases, probably of this class, in which the application of galvanism proved remarkably efficacious. This agent is per- haps peculiarly suitable when the tympanic condition depends on partial paralysis of the muscular coat of the bowels. In all cases of this class it is essential to obviate hepatic congestion, and to prevent intestinal accumulation. The long-continued use of a * stimulating embrocation rubbed freely along the whole course of the spine is a valuable auxiliary; and when the more urgent symptoms are removed, exercise, whether on horseback or on foot, tends to lessen the morbid susceptibility, and probably the disposition to congestion. In most hysterical cases the long-con- 360 hysteria, (Treatment.) tinued use of mercury is greatly to be deprecated, although occa- sionally necessary, as in the treatment of some cases of obstinate barking cough. To the class of cases depending on spinal congestion may probably be referred many instances of diminished poAver of voli- tion, some of A\mich also folloAV mechanical injuries of the spine. In these cases medical treatment accomplishes little, but some sudden moral excitement seems occasionally adequate to rouse the volun- tary power, and to transmit its influences to the muscles. It is chiefly on these cases that alleged miracles, such as those of Prince Hohenlohe, have been wrought. 2. The atonic variety of idiopathic hysteria is most frequently witnessed in patients Avho, on account of some severe disease, have undergone free depletion, or taken mercury to excess; as, for example, in the course of treatment required for the rapid ulceration of the cornea; and it is interesting to observe, that the change to the tonic plan is generally as useful to the local com- plaint, as it is essential to the control of the hysterical malady. In some of these instances tenderness occurs in the spine, but it generally exists also in other parts of the body. It is aggravated by leeching, Avhich may even be followed by paralysis. It is not uncommon to Avitness great cerebral excitement, sleeplessness, throbbing of the carotid and temporal arteries, and intolerance of light and sound. Such cases are sometimes unhappily mistaken for phrenitis; but the sudden changes in the severity of the symp- toms—the pulse not being characteristic of alarming local disease —the existence of other hysterical complaints, as tympanic abdo- men, urgent pain of various parts, particularly under the left mamma, and the production of the disorder by some mental ex- citement—soon disclose its true nature. The mistake is, hoAvever, too often committed, and is of serious consequence, since injudi- cious depletion aggravates all the symptoms, and may even pro- duce permanent mania, whilst it ahvays retards, and sometimes prevents, ultimate recovery. On the other hand the application of cold to the head, the use of mild anodynes, such as camphor with extract of henbane, or, if they fail, morphia, Avith perfect quietness, soon dispose to rest; after Avhich the nitrate of silver, in half-grain doses, exerts a most favorable influence on the mor- bid sensibility. Should the debility continue long, and the symp- toms assume an intermittent character, the sulphate of quinine Avill be found a valuable auxiliary; or if there be pallor, Avith neuralgic symptoms, the sesquioxide of iron. Some of the chaly- 0 beate mineral waters, as the Eger, Pyrmont, or Spa, and exercise in dry country air, will materially promote the recovery of strength. The use of the shower bath is an important auxiliary to the tonic plan, its influence on the cutaneous nerves producing a most favorabte effect on the nervous centre. Secondary or sympathetic hysteria is generally associated with hysteria, (Treatment.) 361 derangement of the intestines or the uterus, to which parts it will therefore be necessary to direct the chief attention. We cannot be surprised that impressions made on the delicate extensive plexuses of the intestines should poAverfully affect the nervous centre. A striking example of the poAver of such impressions in producing hysterical symptoms is given by Brachet. On tAvo different occa- sions, at intervals of nine months, a Avoman, who had never be- fore exhibited any phenomena of the disease, took food Avhich, without her knowledge, contained cheese, and each time fell into an hysterical paroxysm, which Avas relieved only by vomiting. The symptoms exhibited, and the treatment required, in hysteria from intestinal derangement, vary according to the peculiar nature of that derangement. For practical purposes it will be sufficient to consider it as associated with intestinal irritation, or with in- testinal torpor. The first class of cases, those arising from intestinal irritation, often partake of an inflammatory character; the abdomen is dis- tended and rather tender; pain is felt after taking food, especially when of an indigestible kind; the tongue presents large red pa- pillae, and there is much thirst. Eruptions arise on the skin from slight causes; sleep is much disturbed: any indigestible substance detained in the stomach, such as cheese or potato, will occasion- ally produce terrific palpitation of the heart. Intense gastrodynia occurring in paroxysms, particularly in the morning, is not un- common. The hysterical phenomena attending this condition are exceedingly irregular. Perhaps the most usual indications are attacks of violent headach, strong and variable emotions, and a disposition to laughter, or excessive Aveeping on slight occasions. In these cases if the tenderness of stomach be considerable, leeches are in the first instance necessary; afterwards great benefit is de- rived from cooling saline medicines combined with hydrocyanic acid. If there be much flatulence, and especially if the urine (which is very common) appears muddy, a few drops of Sp. Ether Nitr. may be added to each dose Avith advantage. The catame- nia are apt, in these cases, to be profuse, and accompanied with much pain of back and head. These symptoms are materially relieved by rest, and small doses of Liquor Ammon. Acet. Aloe- tic and all irritating purgatives must be carefully avoided. Cas- tor oil is almost the only aperient Avhich can be borne. When the paroxysms of palpitation and flatulent colic are urgent, the assafcetida enema Avill often give relief. Morphia sprinkled on a blistered surface, applied to the praecordial region, will often quiet the heart, and soothe the stomach. Stimulants of every kind should, as far as possible, be avoided, since the temporary relief afforded by them does not compensate for the prolonged suffering which the subinflammatory state of the digestive organs, thereby induced, is calculated to occasion. The diet must be regulated with great care. In the attacks of gastrodynia which occasion- 31 362 hysteria, (Treatment.) ally attend or folloAV the condition just described, Ave have found great benefit from the use of small doses of sulphate and sesqui- carbonate of soda combined Avith an aromatic. In some instances there is no evidence of general irritation; the tongue is perhaps pale. The symptoms are almost limited to the stomach, Avhich rejects food; and the occasional occurrence of glo- bus is the chief indication of hysteria. The epigastrium may be tender, but the feeling after taking food is one of oppression ra- ther than of pain. In these cases hydrocyanic acid is a remedy of great value, but is better combined with mucilaginous mixture than Avith salines. A few leeches, followed by counter-irritation, and a strict adherence for a time to farinaceous diet, shortly change the character of the complaint. The sickness attending this state of stomach, Avhen not removed by prussic acid, is some- times curable by creasote, but the remedy is too stimulating for indiscriminate use, and the nitrate of silver Avould often be prefer- able. Globus, palpitation, and the hysterical condition of mind, are occasionally accompanied by haemorrhoids. In these cases he- patic congestion is generally present. The mercurial pill in half- grain doses, continued for some time, is useful; and if paroxysms of flatulent colic occur, a combination of valerian and opium. 2. Hysteria associated Avith intestinal torpor is generally ob- served in those who lead a sedentary life, and whose constitution is by no means delicate. A constipated state of boAvels is Avell known to disturb the functions of other parts, to weaken the organic energy, and to predispose to hysteria, which, Avhen com- bined Avith this state, generally assumes the regular form. Here it is obvious that a judicious purgative plan is strongly indicated; and an emetic of ipecacuanha will frequently prevent a threatened paroxysm. This variety is usually complicated with amenor- rhcea, and the remarks made under that complication Avill bear more or less application to the present one. The second leading division of the sympathetic disease is that connected with uterine derangement, and in a practical point of vieAV there are three important conditions Avith Avhich it may be associated, namely, menorrhagia, defective menstruation, and leu- corrhcea. 1. Hysteria accompanied with menorrhagia is particularly apt to occur in those who have had frequent miscarriages. When there is reason to believe that the complaint is passive, and that the hysterical affection is dependent on the debility thus induced, it is necessary to check the discharge by means of sulphuric acid or alum. The acetate of lead may perhaps have a more decided effect, but we have observed a greater tendency to colic from its use in hysterical persons than in others. If there is general or local irritation, sulphate of magnesia dissolved in infusion of roses will be useful; and during the catamenial period, cooling saline hysteria, (Treatment.) 363 medicines, especially the acetate of ammonia, should be employed. Dry air, rest, and freedom from excitement, are essential to the cure. 2. When hysteria is associated with defective menstruation, some of its most decided and prominent features are presented; and this variety of the disease has therefore attracted peculiar notice. Tate has even restricted the term hysteria to this class. The catamenial secretion is scanty, irregular, or unnatural in ap- pearance. The patient does not generally complain of pain in the back, but on examination the spine is almost ahvays found tender, especially near the six upper dorsal vertebrae, Avith head- ach, aching of the loins and legs, and pain under the left breast. The bowels are commonly confined, the tongue is furred, and the pulse variable. Stupor, palpitation of the heart, and suspended respiration, are occasional phenomena. Hysteria thus associated usually exhibits a remarkable influence on the motor system of nerves. The paroxysm is decidedly convulsive, and contractions of the limbs may occur, especially at the catamenial period. Cases of hysterical catalepsy, chorea, and paralysis, are generally refer- rible to this division. In the treatment of this variety the restoration of the catame- nial secretion to its natural state is important, but not alone suffi- cient to effect recovery, since, especially Avhen this depraved cata- menial condition has been produced by mental causes, the atten- dant hysteria Avill often remain after the uterine function is re-es- tablished. Unless the patient is very delicate, cupping or leeching the tender part of the spine will be expedient, and in some cases bleeding is necessary. Subsequently counter-irritation by means of antimonial ointment, and active purgatives, Avith Avhich, if the face be pale and the circulation languid, iron may be combined, constitute the leading points of treatment. When the catamenial period approaches, especially if indicated by pain of back, head- ach, and general uneasiness, a few leeches to the labia or thighs, and the mustard pediluvium, will promote its occurrence. A single dose of calomel, digitalis, and aloes, followed by an active aperient, as recommended by Dr. A. T. Thomson, and subse- quently the use of pills of aloes and myrrh Avith galbanum, once or tAvice daily, poAverfully contribute to re-establish the uterine action. The transmission of electrical shocks through the pelvis has considerable efficacy in correcting flatulence, promoting alvine evacuation, and exciting the catamenial function. During conva- lescence, active exercise and the use of the shoAver bath are requi- site, and the general principles of treatment Avhich have been re- peatedly proposed must be duly observed. 3. The last variety of sympathetic hysteria, namely, that asso- ciated Avith leucorrhoea, or depending on chronic uterine irritation, is one of great importance, owing to its frequent occurrence and its liability to be overlooked. The sufferer complains of debility, 364 hysteria, (Treatment.) her movements are languid and her spirits depressed, and she weeps on slight occasions, but makes no specific complaint. The appetite is bad, and the tongue is often fissured, the clefts being filled with a viscid secretion. Globus hystericus occurs from time to time, with tenderness of loins and sacrum, pain under the left mamma, neuralgic affections in the region of the stomach, along the margin of the ribs, on the right side, or throughout the abdomen generally, and often a flatulent state of the bowels, especially of the colon. The usual causes are, active exertion during the catamenial period, mental anxiety, or undue excite- ment, sometimes incidental to matrimony. In these chronic uterine affections the urine generally deposits the triple phos- phates, while in the more acute and regular forms it is watery and contains little urea. The treatment which Ave have found most effectual is a dose of mercurial pill and extract of hemlock, folloAved by castor oil Avith tincture of henbane, and afterwards saline medicines com- bined with prussic acid, tincture of henbane, and spirit of nitric ether. The frequent use of mercury, even in small doses, is to be deprecated, as it increases the irritability of the system; but an occasional dose relieves congestion and improves the secretions. After a time astringent lotions may be used, such as the Liq. Aluminis Comp. Sexual excitement must be avoided, and every measure employed which is calculated to strengthen without stim- ulating. The use of tonics must not be rashly or hastily adopted. Chalybeates are generally too exciting, and even quinine cannot ahvays be borne. The sulphate of zinc is occasionally useful; and in some instances, especially Avhen there is a catamenial de- ficiency, the artificial Kissingen water, prepared at the German Spa at Brighton, is of remarkable service in relieving from the sensation of Aveight after food, correcting the tendency to flatulent colic, and regulating the uterine function. It removes local con- gestion, especially of the uterus, and is peculiarly adapted to de- rangement of this organ associated Avith fibrinous catamenia. The affection of abdomen attending this form of the malady sometimes greatly resembles peritonitis, but superficial is as pain- ful as firm pressure. The countenance is less anxious and dis- tressed than in peritonitis, and the variable and diffused character of hysteria is easily recognised. Sometimes, hoAvever, there is sufficient uterine inflammation associated Avith this state to au- thorise a single bleeding, though the effect must be carefully watched, and undue depletion avoided. Most of the neuralgic affections Avhich Ave have seen associated with hysteria have been on the left side. For the relief of pain under the left mamma, between the cartilages of the fifth, sixth, and seventh ribs, and Avhich appears to be of this character, Mr. Tate and Dr. O'Beirne place great dependence on tartar emetic ointment rubbed over that portion of the spine which supplies hysteria, (Treatment.) 365 this part with nerves, and Dr. Copland has found benefit from the moistened inner bark of mezereon Avorn for some time, so as to produce a superficial sore. The sesquioxide of iron is often ser- viceable after the other symptoms of irritation have subsided, but its efficacy is much promoted, in many cases, by the previous application of leeches. The painful affection of the abdomen may sometimes be relieved by a warm flannel dipped in spirits of tur- pentine. A careful observer cannot mistake for hepatic disease, the shifting and uncertain pain in the right hypochondrium Avhich often attends this variety of hysterical complaint. When neural- gia of the uterus itself is present, according to Lisfranc, the cervix is tender, and possesses the form and size characteristic of the second month of pregnancy. Hysterical affections of the joints, Avhich have been so Avell described by Sir Benjamin Brodie, are frequently but not invaria- bly associated Avith the same variety. In some cases those of the knee so closely resemble in the symptoms ulceration of the carti- lages, that it requires much time and care to form a correct diag- nosis; but in hysterical affections the limb is often extended, whereas in diseases of the cartilages it is usually bent; in addition to Avhich, the previous history of the case Avill frequently solve the problem. In these cases blistering is in general useless, and confinement injurious. The belladonna plaster is less useful in this than in other forms of hysterical neuralgia. Sir Benjamin Brodie has found the pain palliated by a tepid lotion, consisting of equal parts of Sp. Rosmarini and Mistura Camphorae; and Avhen the limb is liable to alternate heat and cold, by a cold spir- itous lotion during the hot fit, and during the cold one by a Avors- ted stocking covered with oiled silk, so as to confine the heat and perspiration. The intermittent character of the symptoms indi- cates the administration of the sulphate of quinine. Marriage has been by some authors recommended as a remedy for hysteria; but the preceding remarks will shoAV that it is quite as likely to aggravate the complaint as to cure it: and where it does prove a remedy, it is probably rather by satisfying the affec- tions of the heart. Hysteria frequently occurs in persons of a gouty constitution, by Avhich it is someAvhat modified; and in these cases colchicum merits a trial. Those Avho have long suffered from hysterical complaints, have frequently a tedious convalescence, Avith various distressing affec- tions of the stomach, nerves, mind, &c; but provided the recovery is progressive, it is better not to interfere too actively. Exercise, country air, and useful occupations, gradually restore the health; and in the absence of any distinct indications of treatment, the advice of Sydenham is peculiarly valuable, " If you cannot do good, do nothing." In the moral management of hysteria it is important to tem- 31* 366 hysteria, (Treatment.) per kindness with firmness, and to avoid a parade of sympathy. A due intercourse Avith society, which diverts without exciting, is desirable. It is of great importance to remember that hysteri- cal susceptibility is perhaps, in a majority of instances, the result of injudicious management in early life. The many excellent works published of late years on the subject of physical education, are already attracting deserved attention and contributing to cor- rect this evil; nevertheless, in the upper ranks of society, young females are still pampered Avith stimulating food, and injured by modes of dress Avhich unduly compress the most important vis- cera. Too much time is still devoted to sedentary employments, and the perusal of the Avorks of fiction is too often substituted for solid attainments, by Avhich a fondness for injurious excitements is naturally promoted, instead of a salutary habit of self-control. It was never intended by Providence that every woman should be a musician or a painter, but it was undoubtedly designed that she should cultivate those substantial qualities of sense and tem- per which give permanence and freshness to the charms of do- mestic life. During early youth, the mind must not be alloAved to outstrip the body; exercise and fresh air strengthen both, and in favorable Aveather the house should often be regarded rather as a retreat than as a dAvelling-place. 367 TETANUS. Explanation of the term tetanus and its varieties.—Trismus.—Opisthotonos. —Emprosthotonos.—Pleurosthotonos.—Trismus nascentium__General and local—Acute and chronic.—Idiopathic and symptomatic—Continued and periodic—Premonitory symptoms of tetanus.—Symptoms of the paroxysm of trismus, of opisthotonos, of emprosthotonos, of pleurosthotonos.—Chro- nic forms of tetanus.—Predisposing causes.—Exciting causes.—Anatomical characters—Nature—Diagnosis.—Prognosis.—Treatment. This term (derived from tdva, to stretch) denotes a disease, the principal characteristic of which is tonic spasm of a certain num- ber of muscles. Some authors have restricted its meaning to that form in which, by the muscular spasm, the trunk is kept perfectly straight, and employ other terms to designate the disease when any particular set of muscles are more especially affected. Thus, if the muscles which raise the loAver jaw be in a state of contrac- tion, it has been denominated trismus, (from tplfa, to gnash;) if those attached posteriorly to the spine be affected, so as to draw the body backAvards, opisthotonos, (from oituseev, backAvards;) if the muscles of the neck and abdomen be contracted anteriorly, in such a manner that the trunk is inclined foY\va.rds,emprosthotonos, (from eprtpoadsv, forwards;) and if the muscles are affected late- rally, so that, the body is curved sideAvays, pleurosthotonos, (from 7tuvp6o6sv, sideAvays.) In all these forms, however, the disease is essentially, the same, and at present the above terms are only used to express the distortion or particular posture produced. When it occurs in infants it is called trismus nascentium. Some Avriters divide tetanus into general, Avhen the whole muscular system is affected; and local, when there is rigidity of one or several muscles, as in cramp, priapism, &c. Tetanus has also been distinguished, as regards its duration, into acute and chronic? though the limits Avhere the one terminates, and the other begins, have not been fixed. Two varieties have also been established, the idiopathic and symptomatic; the former arising from causes acting directly on the nervous system, the latter from the irritation in other organs being propagated indirectly to the nervous cen- tres. Thus tetanus following Avounds (termed traumatic) be- longs to the latter variety. It has also been divided into the con- tinued and periodic: in the former the rigidity does not disappear entirely, but the symptoms sometimes suddenly increase; in the 368 tetanus, (Symptoms.) latter there are complete intervals or interruptions of the tetanic rigidity—the symptoms in some cases recurring at stated or fixed periods. The continued forms are ahvays acute or subacute, the periodic ahvays chronic. Dance has recorded four cases of the latter variety. (Diet, de Med. et Chir. Prat.) Hufeland has also seen a case that for years returned at regular periods, Avhich lasted eight hours. (Manuel de Med. Prat, par Jour dan, p. 234.) Symptoms. The symptoms of tetanus vary according to the severity and duration of the disease, and the particular set of muscles affected. It sometimes comes on suddenly, Avithout any signs to indicate its approach. In general, however, one or more of the folloAving premonitory symptoms have been observed, viz: sadness; languor; unusual melancholy and depression; unAvilling- ness to speak or move; restlessness or uneasiness; watchfulness; headach; yawning; loss of appetite; bitter taste in the mouth; foul tongue; constipation; unpleasant sensation about the praecordia; pains in the back; a dry tumid skin; unusual extension of the limbs during sleep, and sometimes a strange sensation of terror. According to Larrey, traumatic tetanus is announced by deep pains in the Avounded part, extending to the spine, and in some cases twitchings of the limb have been observed to precede the attack. The above symptoms are, hoAvever, common to many disor- ders; but in chronic cases of an epileptic character, Avhere a dis- tinct interval more or less prolonged takes place between the paroxysms, one or more of the above signs indicate Avith tolerable certainty an approaching attack. The tetanic symptoms may be said to commence with a feeling of stiffness in the muscles of the jaws, throat, or neck, attended with difficulty of swallowing. There is a constraint in flexing or rotating the head, and in opening the jaAVs. In general this latter symptom, or the trismus, comes on gradually, accompanied with uneasiness or pain in the muscles affected, when the inferior maxilla is by degrees draAvn against the superior, and at length so firmly closed that it is impossible to separate them. Sometimes, hoAvever, this occurs suddenly, and the jaws are violently snapped together, and remain firmly clenched. Violent and acute pain is noAV felt below the sternum, sometimes of a darting or stabbing character, extending to the spine, or there is a sense of traction or constriction in this situation. If the rigidity extend to the muscles of the trunk and extremities, the complete paroxysm is manifested. At this time the face is sometimes pale, but*usually flushed, the veins being full and prominent; the broAvs are con- tracted; the skin covering the forehead corrugated; the eyes fixed and prominent; sometimes suffused with tears; the pupils station- ary, generally contracted, but sometimes dilated; the alae of the nose elevated, and the nostrils expanded; the angles of the mouth drawn outwards and upAvards, sometimes doAvmvards, so as to tetanus, (Symptoms.) 369 produce the most frightful risus sardonicus; the tongue fixed and immovable, and the whole countenance expresses the greatest pain and anxiety. Sometimes a frothy saliva is squeezed out betAveen the teeth, and flows from the mouth; in other cases the tongue is thrust forwards and lacerated, givine rise to considera- ble haemorrhage. The larynx is raised; the articulation indistinct and painful; sometimes the power of articulation is lost, all attempts to speak apparently aggravating the paroxysm. The muscles generally are tense, rigid, and often feel as hard as a board; the shoulders are draAvn forwards, and the trunk and ex- tremities firmly fixed in various positions, afterAvards to be de- scribed, or violently thrown about by occasional momentary re- laxations, followed by sudden muscular contractions of longer or shorter continuance. The respiration is hurried, and performed with great difficulty and anguish, presenting to the spectator one of the most distressing forms of dyspnoea. The patient often feels great thirst, but all attempts at swallowing produce extreme agony, and spasms of the muscles of deglutition; symptoms allied to those of hydrophobia being thus occasionally produced. The pulse at the commencement is full and hard, but gradually be- comes feeble and frequent, sometimes intermittent or irregular, according to the continuance and severity of the attack. The temperature of the skin is increased, and the surface covered with a profuse perspiration, which in certain instances is confined to the face and chest. Occasionally the urine is expelled with vio- lence, but sometimes there is retention. The sphincter ani in ge- neral is firmly closed, but in some cases the faeces have been expelled involuntarily. In the midst of all these sufferings the intelligence is unaffected—a circumstance Avhich increases the distress with Avhich the bystander must naturally regard them. Such are the general symptoms Avhich characterise the parox- ysm in its severe acute form; but there is considerable variation, according to the peculiar class of muscles more especially affected. When the disease is confined to the levators of the lower jaAV, constituting trismus, some time may elapse before other muscles become affected; in this state the malady may disappear, or it may prove fatal. When the disorder, hoAvever, is more severe or advanced, trismus supervenes, which may be considered only as a mild or partial form of the general disease. Opisthotonos is occasioned by the posterior muscles of the spine being powerfully contracted, the effect of Avhich is to draw back either the head and neck alone, or to curve the trunk into the form of an arch, the body resting only on the occiput and sacrum, or on the vertex of the head and heels, if the lower extremities be affected. The force and suddenness with which this is produced, is sometimes sufficient to throw the patient out of bed. Fournier Pescay has seen dislocation of the second cervical vertebrae, and Desportes, 370 tetanus, (Symptoms.) fracture of the thigh bones from the excessive muscular action. Larrey and Curling also relate cases in Avhich one of the recto- abdominalis muscles Avas ruptured. Emprosthotonos is produced by the muscles on the anterior part of the body being most pow- fully contracted, so that the head is flexed upon the breast, the thighs on the abdomen, and the trunk curved forwards. In severe cases the head and knees approach each other, the arms are flexed, and the hands sometimes clasped together. According to Larrey the legs are rigid and flexed upon the thighs, but Aretaeus describes them as being extended. Emprosthotonos, hoAvever, is a very rare form of tetanus, and it is to the experience of Larrey in mo- dern times we are chiefly indebted for its description. In pleu- rosthotonos, the neck and trunk is curved toAvards one side: this form is so rare, that some Avriters have doubted its existence. Occasionally the whole body is perfectly rigid and straight, no particular set of muscles apparently being more affected than another. To this state some physicians consider the term tetanus ought to be restricted. The dreadful symptoms described may terminate in death, or they may gradually cease, and the patient return to his natural condition, or to a comparative state of ease. In the former case the various symptoms increase in intensity: the dyspnoea becomes more urgent; an agonising sense of suffocation is felt; the per- spiration becomes cold and clammy; the pulse thready or imper- ceptible; a frothy, bloody mucus escapes abundantly from the mouth; the countenance assumes a livid hue; the spasms increase in frequency, and are reneAved by the slightest attempt to move or swalloAV, or by any trivial circumstance, such as opening the door, a draught of air, &c. ; delirium sometimes supervenes, and the patient sinks either asphyxiated or exhausted from the efforts and pain of the paroxysm. Sometimes the individual dies sud- denly after an amelioration of the symptoms. When the disease terminates favorably, the rigidity gradually lessens, the spasms are less frequent, the respiration becomes more free, and the pulse natural; and although there is for some time a feeling of stiffness or soreness in the muscles,' the patient gradually returns to the state in which he Avas before the seizure. The duration of acute tetanus varies. A case is recorded of a negro, who, having scratched his hand Avith a piece of broken plate, died of tetanus in a quarter of an hour. (Rees's Cyc. art. Tetanus.) The fatal termination usually takes place from the fourth to the eighth day, but cases have been reported Avhich continued to the fourteenth and even to the twentieth day. (Morgagni.) On the other hand the recovery is generally slow. Of 58 cases collected by Curling, Avhich terminated successfully, 8 recovered in a Aveek; 3, in 10 days; 4, in a fortnight; 4, in three Aveeks; 15, in a month; 4, in 5 weeks; 8, in 6 Aveeks; 3, in 8 Aveeks; 3, in 2 months; and tetanus, (Symptoms.) 371 2 so late as 3 months. Greater or less rigidity of certain muscles may remain for many months, and in some cases a peculiarly aged character is given to the countenance. The chronic form of tetanus is characterised by the same symp- toms, but they come on more gradually, and there are sometimes shorter or longer intervals between the paroxysms for several months or even years. There does not seem to be any very clear division between the acute and chronic forms. Dr. Symonds thinks a subacute form should be constituted, including those cases which are of mild character, but which do not continue long enough to be designated chronic. But hoAvever we multiply the divisions, intermediate cases will ahvays be found, Avhich no ar- bitrary classification can comprehend. Many of the symptoms are liable to various modifications in particular cases, or at different periods of the disorder. The muscular system, as Ave have stated, may be so affected as to produce trismus, opisthotonos, emprosthotonos, or pleurosthoto- nos. Cramp also is a slight modification of the disease, and during the paroxysm all the muscles are more or less spasmodi- cally affected. The contraction of the pectorals draw the shoulders forAvard, and the rigidity of the respiratory muscles prevent the free motion of the chest. In trismus, although the jaAV is closed, the anterior muscles of the neck appear hard and contracted, and in opisthotonos the Avails of the abdomen are stretched, and feel as hard as a board, showing that the peculiar distortion produced is not the effect of a particular set of muscles only being affected, but that their power is increased, or that they are acted on to a greater degree than others. The muscles of deglutition are pecu- liarly liable to be excited on the slightest contact, producing ina- bility or difficulty of swallowing, and in severe cases horror of fluids, and symptoms resembling those of hydrophobia. In some instances it has been observed that the cremasters participate in the disease and draAV up the testes. The eyeball is ahvays fixed, and sometimes from irregular action of its muscles drawn imvards. During sleep the muscles are relaxed, and it has been observed in many cases that, during the whole course ^of the disease, those of the fingers have not been affected. The voluntary muscles principally suffer, though several authors are of opinion that the involuntary are also occasionally affected. It must be evident, however, that tetanic spasm of the heart, diaphragm, &c, must soon be folloAved by death; and although certain symptoms indi- cate that they are in some Avay or other acted on, the manner in which they are affected is unknown. The sensibility to touch is not increased in tetanus, but in many cases the slightest contact, or even noise, is sufficient during the remission to bring on the spasms. The pain experienced in par- ticular muscles is sometimes very great, especially in those which have been injured by a wound. In a case however given by Sir 372 tetanus, (Causes.) G. Blane (Obs. on Diseases of Seamen) a pleasurable tingling sensation Avas experienced. In almost every instance of tetanus, great pain is felt in the praecordial region or below the sternum, Avhich has been denominated by Dr. Chalmers the pathognomonic symptoms of tetanus. It is described as being of a dragging nature, occurring suddenly, and darting toAvards the back, and not increased by pressure. In some cases it appears early in the disease; in others at a later period, and is attributed to the dia- phragm partaking in the general spasm. The intelligence is in the great majority of cases clear and un- changed. Some instances are recorded hoAvever (and Ave have seen a remarkable one of this kind), in Avhich the consciousness was completely lost. Under such circumstances the disease may be called epileptiform. The pulse in tetanus varies according to the stage of the dis- ease. Morrison, Hennen, Macgregor, and others, have noticed that it was not much affected. In the early stage there is no re- markable acceleration; but during the spasms, it is somewhat quickened; and as the disease approaches its fatal termination, it becomes weak, frequent and thready. Dr. Parry thought that the patient was safe if the pulse did not exceed 110 beats on the fourth or fifth day. No dependence hoAvever can be placed on this symptom as a prognostic, many cases having died when the pulse Avas more slow, while others have -recovered Avhen it Avas more frequent. The temperature of the surface is generally in- creased, and sometimes the skin feels hot. M. Prevost of Geneva had a case in whom the temperature at the axilla was 110° (Fah- renheit), and Dr. Bright another, in Avhom it Avas 105°. The cutaneous transpiration is increased, Avhich may be attributed to the violent muscular exertion into which the patient is involun- tarily thrown. Sometimes there is a slight miliary eruption. There is occasionally fever, more commonly in idiopathic cases, but sometimes also Avhen it arises from wounds: many Avriters hoAvever, who have seen much of the disease, have never ob- served this. The tongue is moist at the commencement, but becomes'dry as the disease proceeds. Constipation is almost an uniform symptom in tetanus: this has been attributed to many causes, as spasm of the muscular coat.of the intestines, excessive cutaneous transpiration, pressure of the diaphragm and abdomi- nal muscles, loss of the voluntary poAver necessary for defaecation, the use of opium, and other constipating remedies, &c. Reten- tion of urine occurs occasionally, and in such cases there is much difficulty in introducing a catheter, from the spasmodic action of the muscles at the neck of the bladder. The urine is generally high-colored and scanty. Causes. Men are more liable to tetanus than females, a cir- cumstance Avhich is accounted for by the former being more exposed to the exciting causes of the disease. Tetanus is com- tetanus, (Causes.) 373 mon in early infancy; the term trismus nascentium has been given to the disease, Avhen it occurs at this epoch of life. After this period, hoAvever, it occurs most frequently between the ages of ten and fifty. Extensive observation has shoAvn that it is very rare in advanced life, although Aretaeus thought it readily deve- loped in old persons. It is a Avell-established fact, that notAvithstanding tetanus may occur in all climates, it is most common in those of an elevated temperature, and more frequent when the season is hottest. Army and navy surgeons, Avho have practised in the East and West Indies, have proved this, although Ave possess no statistics which enable us to speak decidedly as to its proportionate fre- quency. Moist situations also predispose to the disease. In the French hospitals at Cairo, Avhich Avere erected on ground subject to the periodic inundation of the Nile, it Avas very frequent. It is said also to be more common in marshy situations and coun- tries bordering upon the sea, than in dry and elevated places far from the coast. The strong, robust, and athletic, have been noticed as being more liable to the disease than Aveak persons, or those in ill health. It is also more common in individuals of a nervous, than in those of a lymphatic temperament. Campet, Dazille, and Anderson, have noticed that tetanus is much more common among the negroes than among the Avhite population, a circum- stance Avhich has by some been imputed to an inherent predispo- sition, and by others to their more frequent exposure to the ex- citing causes. Insufficient nutriment, close and ill-ventilated habitations,^mcleanliness, and neglect of the boAvels, powerfully predispose to this disease. Drs. M'Arthur and Dickson have shoAvn, that since these evils have been remedied, a marked diminution in the frequency of the disorder has occurred in the West India department of the navy. The most frequent exciting causes of tetanus are external inju- ries, and it appears that the most unimportant superficial abra- sion, and the most serious operation may give rise to the disease. It has been occasioned by a bite on the finger from a tame spar- roAV (Morgagni); the stroke of a Avhip lash under the eye, although the skin Avas not broken (Reid, on Tetanus and Hy- drophobia); a fish bone sticking in the pharynx (Larrey, Mim. Chir. Mil., tom. i, p. 254); a seton in the chest (Andral, Clin. Med., tom. iv, p. 445); the stroke of a cane on the neck and hand (Morgan, on Tetanus, p. 6); flagellation; extraction of a tooth (Edin. Med. and Surg. Journ., vol. xv); cupping; venesection, &c. It has also folloAved severe fractures, lacerations, contusions, punctures, amputations, excision of the ( mamma, tying arteries, gun-shot Avounds, castration, injection for hydrocele, &c. An instance is related Avhere it followed the bite of a horse in the arm (Boyer, tom. i, p. 2S7), and another in which it was occa- 32 374 tetanus, (Causes.) sioned by stretching a nerve. (Swan, on the Nerves, p. 541.) A wound in any part of the body may produce tetanus, although it has been observed more frequently from injuries of the extre- mities, than from similar injuries of the head or trunk. In 12S cases of traumatic tetanus, collected by Mr. Curling (Essay on Tetanus), the wounds occurred on some part of the loAver extre- mities in 64, and on the upper extremities in 46, and of these the feet and toes Avere the seat of injury in 35, and the hands and fingers in 34. Dr. Hennen observed it most frequently after wounds of the elboAV and knee, and others when the thumb or great toe was injured. Some authors have noticed a peculiar state of the wounds in connection Avith tetanus. Rush remarked that they Avere always free from inflammation (Med. Inquiries, vol. i;) Larrey, that they Avere either dry, or covered Avith a thin serous exudation; and Fournier Pescay describes them as being pale, livid, sometimes co- vered with an ichorous secretion. (Diet, des Sc. Mid.,tom.lv.) Sir J. Macgregor and Dr. Hennen, hoAvever, after great experience in this disease, conclude that there is no relation betAveen the state of the Avound and the occurrence of tetanus. They have seen it occasioned by all descriptions of sores, healthy and sloughing, incised and lacerated, simple and complicated. Neither does its accession produce any alteration in the wound, or retard its pro- gress towards a cure; and in many cases it has been completely healed and forgotten before the occurrence of the tetanic symp- toms. Dr. Elliotson observes that the disease has sometimes declined and ceased, Avhile the wound every day grew Avorse and worse. * The interval between the infliction of the injury and the com- mencement of tetanus differs considerably. In a case related by Dr. Robison, (Rees's Cyc, art. Tetanus,) it followed immedi- ately; the longest period on record is ten weeks; the case is de- tailed by Mr. Ward. (Facts establishing the Efficacy of Opiate Friction in Spasmodic and Febrile Diseases, fyc, 1809.) In the 128 cases of traumatic tetanus collected by Mr. Curling, it appeared from the fourth to the fourteenth day in 81, and this is the most common period of its occurrence. The time after Avhich an individual may be considered safe from tetanus Avhen he has received an injury, is undecided, and has been differently stated by authors. Fournier Pescay says he has seen it occur after a month. Sir J. Macgregor never witnessed an interval longer than tAventy-two days, and Sir B. Brodie longer than seventeen. Larrey thought that in Egypt the French soldiers were safe after the sixteenth day. Exposure to cold and damp is a frequent exciting cause of tetanus, independent of any other circumstance. Numerous cases are related of individuals being affected after sleeping dur- ing the night in the open air, particularly in tropical climates, tetanus, (Causes.) 375 where the deAV is abundant, and the nights cold. Hennen and Larrey have noticed its occurrence in Egypt, when the nights Avere chilly and rainy, and when the troops Avere exposed to cold and moist breezes from the sea. Sudden changes ef temperature have in like manner been noticed by the last-named authors, and by Dazille, Campet, and Rush. The latter Avriter informs us, that Avhile no case occurred among the soldiers who had passed a Avinter in Rhode Island in 1781, it Avas frequent in some troops neAvly arrived from the West Indies. Begin states, that after the battle of Muskowa, although the heat Avas very intense, no cases of tetanus occurred; whereas, after the battle of Dresden, Avhen moist and cold weather succeeded a great elevation of tempera- ture, it Avas common. Dr. Chalmers gives a case where it Avas brought on by sudden change of weather in a man Avho slept Avithout his night-cap. Going into the external air from the heated atmosphere of a ball-room has also occasioned it. Four- nier Pescay gives two instances Avhere it followed the action of cold Avater on the body when in a state of perspiration, and one where it arose from exposure to the' north Avind, Avhen the indi- vidual labored under fever. Intestinal irritation has occasioned the disorder: the presence of worms is one of its most frequent causes. Laurent (Mim. Chir. sur le Tetanos, 1797), considered this almost the only cause of the disease; and in addition to the cases he has related, others have been recorded by Morgagni, Stoll, Fournier Pescay, O'Beirne, and others, Avhere tetanus Avas apparently produced by vermination. It may also be occasioned by any other disorder of the digestive organs arising from. improper food, irritating sub- stances in the stomach or intestines, indurated faeces, &c. In infants an acrimonious state or retention of the meconium is a frequent cause, as well as irritation produced by the milk of the nurse. Among the other exciting causes of tetanus have been observed great fatigue; terror; mental anguish; abortion; suppressed perspi- ration; cessation of the lochia, and other habitual discharges; intoxication; variola, typhus fever, gastric inflammation, and other acute diseases; retrocession of cutaneous disorders; lacera- tions and ulceration of the navel string; difficult and painful den- tition; ulceration of the gums; irritation from the appearance of the dens sapientiae; insolation; indigestion; constipation; rheuma- tism; hysteria; large doses of strychnine, mix vomica, &c. It should be observed, that in many cases it is extremely diffi- cult to determine the exciting cause, inasmuch as one or more of those Ave have enumerated may exist in the same individual, and in some instances the disease may probably be occasioned by their conjoined effect. Thus it has been noticed by almost every wri- ter that tetanus is more frequent Avhen individuals suffering from 376 tetanus, (Anatomical Characters.) external injuries are also exposed to cold moist weather, or to sud- den changes of temperature. The occurrence of fear and mental anguish under the same circumstances has often been thought by Hennen to occasion it. We can also readily understand that in- testinal irritation or other causes may prove exciting causes, and that it may be attributed to an accidental scratch received before the accession of the symptoms. Hence many of those cases Avhich are reported to have folio Aved Avounds several Aveeks after they have been received may have arisen from other causes of irrita- tion, connected Avith the internal organs; and, on the other hand, it is possible that the wound Avhich occasioned the disease may be overlooked. Anatomical Characters. The morbid appearances found in those who have died laboring under tetanus are very various. Not unfrequently no morbid lesion Avhatever can be discovered to Avhich the symptoms can be referred. With a view to illus- trate the pathology of the disease, Ave shall describe the morbid alterations that have been observed, 1. in the brain and its mem- branes; 2. in the spinal cord and its membranes; 3. in the nerves; and 4. in other parts of the system. 1. Numerous cases have been reported in which the vascularity of the brain and its membranes was increased, the sinuses gorged with blood, the pia mater more or less injected, and the arachnoid cavity and ventricles more or less distended by serous effusion. These appearances have been occasionally observed by authors, Avho have had much opportunity of investigating the morbid ana- tomy of tetanus. Dr. Bright found an incysted abscess the size of a large nutmeg in the substance of the middle lobe of the brain (Hospital Reports, case 39), and Bouillaud several tubercles, one of Avhich was as large as an egg, in the right hemisphere (sur VEncephalite). Generally speaking, the substance of the brain is found healthy. 2. Alterations in the spinal cord and its membranes are by far the most common appearances found after tetanus, and in such cases there have generally been traces of spinal meningitis. These instances are too numerous to be spoken of individually. Several have been recorded by Reid, Kennedy, Brayne, and others in Britain; Larrey, Broussais, Magendie, Recamier, Ollivier, and others, in France; Bergamaschi, Brera, Bellingeri, Uralli, Poggi, in Italy; and Frank, Funk, &c. in Germany. Thomson (Phys. Obs. on the Topography, &c. Philadelphia, 1818), and Goelis (Salz. Mid. Chir. Zeitung, 1815), have observed the same ap- pearances in infants Avho have died of trismus nascentium. In some cases the inflammatory appearances were more or less dif- fused over the spinal cord, and in others recorded by Ollivier, Pelletier, and Curling, they Avere limited to particular portions of tetanus, (Anatomical Characters.) 377 it. Burserius found a large quantity of viscid yellow serum under the outer covering of the medulla spinalis. Ollivier discovered in the dorsal region of a child a red, consistent fluid in the cellular texture, betAveen the dura mater of the cord and walls of the spi- nal column, with serous effusion Avithin the membranes, and an albuminous concretion covering four inches of the medulla of the cord. Bellingeri gives a case Avhere blood was effused in the cel- lular tissue, exterior to the dura mater. Poggi and Combette, in addition to evidence of spinal meningitis, have observed softening confined to the anterior columns of the cord. Bony and cartila- ginous deposits have been occasionally found in the membranes covering the spinal marroAv after tetanus. In some instances, on the other hand, no morbid appearances have been detected either in the cord or its membranes. 3, In traumatic tetanus, the nerves in the neighborhood of the wound have often been found more or less injured, or to have undergone morbid alterations. In certain cases they have been contused, lacerated, partially divided, irritated by spicula of bone, or other foreign substances included in ligatures placed on arte- ries, or participating in the inflammation of the surrounding tex- tures. In the latter case, the appearances have differed according as the inflammatory action Avas acute or chronic; injection, more or less intense, and softening being evidence of the former, and thickening, induration, and discoloration of the latter. Lobstein (De Nervi Sympathetici, p. 152), and Andral.(Clin. Med., tom. i, p. 49), have observed signs of inflammation or redness in the semilunar ganglion, and Swan (Diseases of the Ne?'ves) has often seen the ganglia of the sympathetic system in general considera- bly injected—an appearance which has been occasionally ob- served by other authors. 4. Dupuytren found in an individual who died of opisthotonos the muscles gorged with blood and lacerated. Larrey and Cur- ling give cases where one of the recti abdominis muscles Avas torn across. The pharynx and cesophagus Avere often seen by Larrey contracted, and their mucous membranes red, inflamed, and co- vered with a viscid reddish mucus. The large papillae at the root of the tongue have occasionally been found thickened, and the mucous lining of the larynx injected and covered with frothy mucus. Andral gives a case where unequivocal marks of gastri- tis were discovered, and M'Arthur found in four cases inflamma- tion of the alimentary canal, Avith a peculiar yellow matter cover- ing the mucous membrane of the stomach and cesophagus, Avhich in one case effervesced on being exposed to the external air. Worms have been discovered in the intestinal canal by Sauvages, Laurent, Larrey, O'Beirne, and others. The last Avriter states that distension of the caecum and colon is a constant pathological appearance. In a case related by Mr. HoAvship the heart Avas 378 tetanus, (Nature.) much indurated, and presented considerable resistance to the knife.* Nature. Numerous theories have been advanced to explain the different phenomena observed in tetanus, but as none of them appear to have been deduced from a sufficiently extended series of observations, they have been rejected as inapplicable to the end in vieAV. We are unacquainted Avith any series of facts Avhich explain Avhy in some cases there should be trismus alone, and in others opisthotonos or emprosthotonos, although in some feAV cases the increased vascularity of the spinal cord and its mem- branes have been circumscribed so as to involve more particularly the origin of those nerves Avhich are distributed to the muscles especially acted on. These cases, hoAvever, are very rare, and observation has shown that in the majority of instances no such limited lesion can be discovered. That the motor portion of the fifth pair is morbidly stimulated in trismus, is highly probable, because Ave observe the muscles to Avhich it is distributed are those principally affected. But the proximate cause producing the irri- tation is not always discovered after death. Larrey thought that emprosthotonos or opisthotonos Avas occasioned according as the wound injured the nerves on the anterior or posterior part of the body, and that if the nerves in both situations were Avounded, complete tetanus Avas established. Numerous facts, however, prove that there is no relation between the situation of the Avound and the form of the disease. Bellengheri has brought fonvard an elaborate theory Avhich consists in attributing to the cerebral he- mispheres the poAver of producing one kind of motion, and to the cerebellum that of producing another. He considers that the for- mer presides over flexion and adduction, and the latter over ex- tension and abduction. This is Avhat he denominates "nervous antagonism," by which he thinks all motions throughout the body are governed. Thus, according to this author, opisthotonos or spasmodic extension depends on some irritation or disease of the cerebellum and posterior columns of the spinal cord; Avhile in em- prosthotonos or spasmodic flexion, the hemispheres and anterior spinal columns are more particularly affected. These views, though they have been maintained with great ingenuity, are not only opposed to the physiology of the nervous system established by Sir C. Bell, but to the majority of pathological facts Avith Avhich we are acquainted. * As in the majority of cases no morbid lesion can be discovered, and as the alterations when they exist are extremely slight and irregular, it is very clear that no structural lesion is connected with tetanus. The alterations of tissue are purely accidental. I have examined with great attention the brain and spinal marrow of ten or twelve subjects, dead of tetanus, and could not detect any lesion which seemed to have the slightest influence upon the production of the symptoms. tetanus, (Nature.) . 379 It has been stated in the general observations, that irritation of any part of the nervous substance Avill increase the function dependent on the part irritated. In tetanus, the intelligence and general sensibilty are affected, while the characteristic symptom of the disorder is referrible to an augmentation of motor influence. We are therefore led to conclude, that irritation of the tractus motorius is a pathological condition necessary for the production of tetanus. . Partial pressure, it is Avell known, is capable of pro- ducing irritation, Avhether applied to the spinal cord alone, in the course, or to the extremities of a nerve, and we find that morbid alteration or injury of either has been knoAvn to induce tetanus. The present state of science, hoAvever, does not enable us to indi- cate Avhat particular morbid lesion occasions this irritation, Avhich, with a vieAV to treatment, is a point of primary importance. When treating of spinal meningitis, we have seen that muscular rigidity is a diagnostic symptom of that disease, and the dissection of individuals who have died laboring under tetanus has shown, that a vascular state of the membranes of the cord is by far the most common morbid lesion discovered. In many cases, hoAV- ever, no appearance of inflammation or increased vascularity is to be discovered; and it has been thought by some, that these appearances are rather the effects than the cause of the disease. HoAvever Ave may speculate on this point, proofs are Avanted to establish the correctness of either opinion; but as we knoAV that congestion of the bloodvessels Surrounding the cord will occasion partial pressure, and consequently irritation, although it may not leave any traces of its existence after death, it seems reasonable to suppose that such a state more frequently precedes than folioavs the tetanic spasms. Pelletier and Bergamaschi attributed the disease to inflamma- tion of the nerves of the part injured, extending to the spinal cord; and Mr. Swan having found the ganglia of the sympathetic sys- tem of nerves preternaturally injected, thinks that the various predisposing and exciting causes produced disorder of the digestive organs, Avhich was communicated by the ganglionic nerves to the other parts of the nervous system. Either of these views are fully capable of explaining hoAV in certain cases irritation may be induced in the spinal marroAV; but observation does not warrant us in considering either one or the other the true cause of the dis- ease. Indeed modern researches have not revealed to us what is the nature of the morbid lesion Avhich gives rise to the irritation, and whether it be allied to inflammation or congestion is equally unknown. It should be observed that tetanus rarely follows the infliction of a wound immediately, that its occurrence bears no relation to the severity or extent of the injury, and that it cannot be produced artificially, except by the administration of poisons containing strychnia or brucia. These facts lead to the inference that, besides 3S0 tetanus, (Diagnosis.) the local injury, there is a peculiar state of the system hitherto unknoAvn and unexplained, Avhich favors the production of teta- nus, inasmuch as mechanical irritation of the motor tract, or of a nerve, does not produce tonic spasm, but convulsion. We have also been satisfied from experiments on the frog, that strychnia acts through the medium of the circulation, and not by direct in- fluence on the nerves to which they are applied. A similar con- clusion has been arrived at by other experimentalists. It appears therefore that the great point with regard to the pathology of tetanus, is to dertermine the essential distinction between tonic spasm and clonic convulsion, and the agents which induce the one or the other. The exciting causes Avhich occasion the first, including Avounds, the presence of Avorms, and other sources of irritation, much more frequently give rise to the second. To Avhat are Ave to attribute the different result? No ansAver can be given to this question: it is evidently better there- fore to abstain from hypothesis, acknoAvledge our ignorance of the subject, and recommend it as a subject of experimental in- vestigation. Diagnosis. Tetanus is readily distinguished from other mala- dies, by the continued muscular rigidity often suddenly increasing, the distortion of the countenance, and the peculiar pain at the scrobiculus cordis. It has been sometimes closely simulated by hysteria; but the latter disorder is general in females, while tetanus, as has been shoAvn, is most common in males. In hys- teria also the globus hystericus, the absence of distortion of the face, and the dissimilar exciting causes, are sufficient to indicate the disease. We have stated that sometimes in tetanus there is difficulty of SAvalloAving and horror of liquids. Hydrophobia, however, may be distinguished from these cases by the absence of continued rigidity, and the nature of the spasms Avhich are clonic and of short duration. In general also there is great ex- citement, and a peculiar anxious expression of countenance very different from the distortion in tetanus. It is scarcely possible to confound this disease with any other. It is of great importance to discriminate Avhether tetanus arises spontaneously, or is the effect of poisons containing strychnia. This, however, is very difficult, as the symptoms are identically the same. If the poison be taken internally, there may be signs of unusual irritation in the digestive organs. The sudden occur- rence of the disease in its acute form, Avhen the individual has not received any Avound, or been exposed to cold and moisture or sudden changes of temperature, are circumstances that should excite suspicion, the truth of which can only be confirmed, during the life of the patient, by strong collateral evidence. Care should be taken to distinguish the trismus arising from local causes, as inflammatory affections about the face and throat, tumors at the base of the ja\v, rheumatism of the temporal and masseter mus- tetanus, (Treatment.) 381 cles, or the local inflammation arising from the administration of mercury. Prognosis. The prognosis is more unfavorable in the traumatic than in the idopathic form of tetanus. The danger must also depend on the violence and frequency of the spasms, and the ex- tent to Avhich the muscular system is affected. The great fatality of traumatic tetanus is spoken of by all Avho have had extensive opportunities of Avitnessing the disease. Sir J. Macgregor, Avho saw several hundred cases in the campaigns of Spain and Portu- gal, witnessed very few recoveries, and Dr. O'Beirne did not see a single recovery out of 200 cases Avhich came under his observa- tion. Hennen, Dickson, Morgan, and others also allude to the uniform fatality of the disease in its acute traumatic form. Several instances of cure hoAvever have been recorded. Sir G. Blane mentions that of twenty cases which occurred in the West Indies, after the action of April, 1782, three recovered. Of thirteen cases Avitnessed by Mr. Dickinson, surgeon at Grenada, four Avere cured, and many other instances are recorded by various authors. The idiopathic form is not so dangerous as the acute, but the recoveries bear no proportion to the deaths. The trismus nascen- tium of infants is uniformly fatal. The favorable circumstances are, a long interval between the occurrence of the exciting cause and the accession of the disorder; the sIoav progress of the disease, and the patient surviving beyond the fourth day; the muscular spasms not being general, frequent, or severe; the respiration easy, and the pulse natural. The unfavorable symptoms are, quick accession; general spasms and rigidity; rapid progress of the affection; violent paroxysms occurring frequently; urgent dyspnoea; rapid, thready, and im- perceptible pulse; inability to SAvallow; cold and clammy perspi- ration; livid countenance; delirium, &c. Treatment. When our ignorance of the pathology of tetanus is taken into consideration, we need not feel surprised that the treatment has in the generality of cases been strictly empirical. Neither need Ave Avonder that, while the most opposite remedies have been occasionally employed with apparent success, they have each in turn been rejected as unworthy of confidence. Not unfrequently several plans of treatment even opposed to each other have been employed in the same case, and such frequent changes made, that should the patient recover, it is impossible to determine Avhich remedy has produced the beneficial result. 1. Treatment of idiopathic tetanus. In idiopathic tetanus attention should be paid to the constitution of the individual, and especially to the state of the vascular system, in order that the principles of treatment may be duly regulated. As a general rule, if the pulse is full and hard, the system ple- thoric, the tongue foul and dry, the individual of a strong constitu- tion, the skin hot, or other symptoms indicate increased vascular 382 tetanus, (Treatment.) excitement, general or local bloodletting, or if the symptoms be urgent, both general and local bleeding should be employed. This treatment is evidently indicated if there be pain in the back, or other symptoms of inflammation in the spinal cord or its mem- branes. At the same time acute purgatives should be adminis- tered in order to remove all sources of irritation from the alimen- tary canal, and repeated if necessary, so as to procure copious evacuations. These means will generally lessen the force of the spasms Avhen tetanus is connected Avith increased vascular action, which is not uncommon in the idiopathic tetanus. If the spasms continue after these measures have been adopted, sedatives in full doses should be administered. The cold affusion or the cold bath has sometimes been beneficial. If, notAvithstanding these means diligently employed and a restricted diet, the symptoms continue, and the disease become chronic, occasional cupping and counter-irritants on the spine should be employed; in short, a treat- ment adopted somewhat similar to that recommended for chronic spinal meningitis. If, however, at the commencement of the disease, the patient be feeble and of a weak constitution, or spare habit, with a quick and small pulse, pallid face, and evidence of diminished vascular action, a tonic and stimulating plan of treatment should be had recourse to, combined Avith sedatives, if the spasms be severe; a generous diet should be allowed, the boAvels kept regular if neces- sary by purgatives with aromatics, and other remedies of a stimu- lating and tonic kind employed. When the symptoms assume the form of trismus, a Avedge of soft wood should be placed between the teeth, in order to prevent perfect closure of the jaAvs, and during the progress of the disease every kind of irritation that may occasion an increase or return of the spasms should be carefully guarded against. By adopting a method of treatment on the general principles laid doAvn, we con- sider that the practitioner will best guard himself against the charge of empiricism, and by steadily pursuing it, will at the same time be most likely to overcome this formidable disease. 2. Treatment of symptomatic Tetanus. When we reflect on the numerous trivial injuries Avhich the body may occasionally receive, and to which perhaps the attention is not drawn until the accession of the tetanic symptoms; Avhen moreover the numerous sources of irritation that may exist in other organs, and more especially in the alimentary canal, are considered, it seems very probable that many cases Avhich have been reported as idiopathic are only symptomatic of some disorder which has been entirely overlooked. Mr. Mitchell (Med. Chir. Trans., vol. v, p. 25.) relates a case in Avhich tetanic spasms of the tongue and muscles of the face were removed by abstracting some carious teeth, and he alludes to a similar instance, Avhich occurred under the care of Dr. Thomas. We saAV under the care of Dr. Graham, in the tetanus, (Treatment.) 383 Royal Infirmary of Edinburgh, a man affected Avith opisthotonos of an epileptic form, there being loss of consciousness during the paroxysm. In the fit the Avhole body Avas powerfully draAvn backAvards, perfectly rigid, and formed an arch which rested only on the head and heels. Dr. Graham discovered that the dens sapientiae on one side had not room enough to descend. The next tooth Avas extracted, and the spasms for a time entirely disap- peared. We have since heard that the attacks returned, but that after undergoing a variety of treatment he recovered. Aware, therefore, that the disease may not only be occasioned, but in cer- tain instances kept up, or rendered more severe by local irritation, the utmost pains should be taken to discover its source, and every effort employed, not only to obviate its effects, but remove its cause. If the suppression of the lochia, leucorxhoea, or other chronic discharges have preceded the attack, Ave should endeavor to promote their return, or establish some artificial drain in the neighborhood, Avhile any disposition to plethora or increased vas- cular action should be combatted by local or general bloodletting. If there are any symptoms of Avorms, acute vermifuge remedies should be given both by the mouth and in clyster. A case of poAverful trismus, Avith spasms of the face and abdominal muscles, is related by Dr. E. Phillips, Avhich was relieved immediately by an injection of half an ounce of turpentine with yolk of egg. The following morning there was a copious stool, in which a Avorm Avas discovered, and the patient got well. (Med. Chir. Trans., vol. vi, p. 65.) If the disease can be traced to checked perspira- tion, diaphoretics are indicated. Wounds however are the most frequent cause of symptomatic tetanus, and should in all cases be carefully examined, Avith the object of ascertaining Avhether there be any foreign body, in order that it may be at once removed.- Whenever the symptoms appear a short time after the reception of a Avound, and there can be no doubt that the Avound is the exciting cause of the disease, all ner- vous communication between it and the spinal marroAv should be cut off as soon as possible. It is a singular fact, that this practice, Avhich our knowledge of pathology and physiology shows to be necessary, and likely to be successful, has only (as far as medical records go) been performed four or five times, but in all these with perfect success. In a case related by Dr. Murray (Trans, of Med. and Phys. Soc. of Calcutta) occasioned by a wound in the left foot, the posterior tibial nerve Avas divided, and although the patient could not articulate distinctly before, from the closure of the jaAvs, he immediately opened his mouth with an exclamation, and expressed himself as being benefited. He rapidly recovered. Amputation has also been employed Avith varying success: sur- geons hoAvever generally condemn this severe proceeding, except Avhen the parts are much lacerated. Should the tetanic symptoms be advanced, it is inadmissible; and as the indication for Avhich it 3S4 tetanus, (Treatment.) is employed can be answered by dividing the nerves going to the injured part, it may appear extraordinary that it has ever been had recourse to. It should also be kept in mind, that the disease having been once called into action, often continues independently of its local origin. While therefore our attention is directed to the exciting cause, Ave must pursue the constitutional treatment on the principles already laid down. The numerous remedies Avhich have been recommended in the treatment of this disease have tended to produce great perplexity. Much however may possibly be attributed to the indiscriminate mariner Avith Avhich our most poAverful medicines have been em- ployed, and to the total absence of any principle in their adminis- tration. So far from considering our resources as insufficient, Ave consider they ^re fully capable of fulfilling all the indications, If used Avith perseverance and judgment. The sudden and asto- nishing cures that have been occasionally produced, Avhen by accident a particular therapeutic remedy has been rightly admi- nistered, prove that our present want of success is not to be attri- buted to the inefficacy of the remedies employed, but to our igno- rance of those symptoms in the patient Avhich should direct their application. A few remarks, therefore, on the individual reme- dies that have been resorted to may not be inappropriate. Bloodletting is indicated in those cases which are are attended with increased vascular excitement, and Avhenever there are evi- dences of inflammation in the spinal cord or its membranes. Un- der such circumstances, it generally diminishes the force of the spasms. In a case Avhere the pulse Avas full and strong, beating 140 in the minute, Mr. Earle repeatedly bled the patient, and there was remission of the spasms after every venesection. Wine and porter, however, Avere given to him by the friends, and he died. Vascular depletion has been carried to an extreme extent by some practitioners. From fourteen to fifteen pounds of blood were abstracted by M. Pelletier with success in a feAV days. (Rev. Med., 1827.) In one case Avhich recovered, M. Lisfranc bled eight times, and applied 792 leeches over the spine. (Diet, de Mid. et Chir. Prat., art. Tetanus.) In a case of severe opisthoto- nos published by M. Larrey (Mem. de Mid. et de Chir. Mili- taire, tom. xxxiv,) in the acute stage, Avhich lasted tAvelve days, he bled four times, and applied 120 leeches to the spine Avith a like result: M. Carron of Lyons has cured four out of five cases by the same means. In such cases as indicate bleeding, Avhen the malady is acute, as often occurs in traumatic tetanus," venesection should be pushed to such an extent as to produce a marked effect on the system, while leeches are applied to the spine. Purgatives, opium, and other remedies, should be afterwards administered; and Avhen all symptoms of increased vascular excitement have disappeared, the collapse is to be obviated by tonics and stimu- lants. tetanus, (Treatment.) 3S5 Purgatives are of great utility in all forms of tetanus, Avith the vieAV of removing any source of irritation that may exist in the intestines. Drastic purgatives should be avoided, as instead of removing irritation they often induce it. When vascular excite- ment exists, this class of remedies may be used freely, so as to produce copious evacuations, and thus promote the effect of other antiphlogistic measures. For this purpose the more active pur- gatives, such as jalap, gamboge, scammony, &c, may be given. When the poAvers are depressed, croton or castor oil Avith turpen- tine or camphor, both by the mouth and by injection, is best adapted. Turpentine is especially beneficial whenever there are worms in the intestines, and as they often prove the source of irritation, without the patient being aAvare of the cause, an enema, consisting of an ounce of oil of turpentine with a sufficient quan- tity of gruel, or formed into an emulsion of yolk of egg, should be one of the first remedies employed. The constipation is oc- casionally very obstinate in tetanus, and purgatives have been given in very large doses, before any evacuation could be pro- cured. Dr. Briggs has recorded an extraordinary case of this kind (Edin. Med. and Surg. Journ., vol, v, p. 141), in Avhich, in forty-eight hours, the patient took 210 grains of scammony, 89 grains of gamboge, an ounce and four scruples of jalap, two pounds and a half of infusion of senna, and eight grains of calo- mel, Avith decided benefit. If the sphincter be spasmodically closed, so as to prevent the free passage of the faeces, an injection of the infusion of tobacco will for a time diminish the contraction, and tend also to relieve the excited state of the nervous system. When constipation is great, the tobacco enema may be tried, as the purgatives given may possibly produce the desired effect during the temporary relaxation induced by the action of the tobacco. At all times purgatives should be among the first reme- dies exhibited, as very little impression can be made upon the disease, until the boAvels are freely opened. The action of other remedies is also favored by a free state of the alimentary canal, which should be maintained during the Avhole progress of the disease. It sometimes happens that it is difficult to give medi- cines by the mouth, from the powerful closure of the jaAvs. In general, however, one or two drops of croton oil mixed Avith a little butter can be inserted between the teeth, but if this cannot be effected, we must have recourse to clysters. Sedatives have been extensively employed in this disease Avith a view of lessening the irritation and pain that exists. Opium has been given in enormous doses, without producing its accustomed effects on the system. Mr. Abernethy found 30 drachms of undissolved opium in the stomach of an individual Avho died of tetanus; 20 grains of this substance has been given every three hours for several days. According to Begin, M. Blaise administered in ten days, 4 pounds, 7 oz., and 6 drachms 33 386 tetanus, (Treatment.) of laudanum, and 6 oz., 4 drachms, and 45 grains of solid opium. Numerous other cases have been recorded where inordinate doses of this drug have been administered. Yet, although our expe- rience of this medicine has been greater than that of any other, it has been so indiscriminately employed, both alone and in com- bination with other measures, that great uncertainty prevails re- garding its value. On the whole it seems to have been more beneficial in idiopathic than in symptomatic tetanus. Its use has been advocated by Larrey, and opposed by Fournier Pescay, Rush, and Macgregor. Extensive experience, moreover, has shoAvn that it is a remedy in no Avay to be depended on, while we are unacquainted Avith any particular indications that should render its use more applicable in one case than in another. There does not appear to be any necessity for administering the extra- vagantly large doses so often recommended, and Avhen employed, one or tAvo grains should be given every hour, and this quantity doubled in six hours, if no good effect be produced. In the form of laudanum the minute division favors its operation; from one to tAvo drachms may be given every hour, this quantity being also doubled in six hours if necessary. It may also be given in the form of enema, in half an ounce to tAvo ounces of the tinc- ture, or from 10 to 30 grains of solid opium. The preparations of morphia have not yet been extensively tried in this disease, though there is every probability that they Avill prove of as much service as opium, if not greater. M. Lambert has used it suc- cessfully in two cases by the endermic method, and M. Carioli has cured a case of traumatic tetanus in this way: the intense sedative action produced by tobacco has led to its administration in tetanus, and its effect seems to be more powerful and decided than that of opium in lessening nervous irritation, diminishing the force of the pulse, producing nausea, perspiration, and some- times sleep. Dr. O'Beirne administered it in the form of enema, consisting of a scruple of the leaves infused in eight ounces of Avater, with the effect of at once producing relaxation of the muscles. On discontinuing the remedy, the spasms returned, but on resuming its use, amelioration again took place. From this time the enema was repeated two or three times a day, some- times oftener, and continued for eighteen days. The patient com- pletely recovered. (Dub. Hosp. Rep., voL iii.) Dr. Anderson, in addition to a decoction of the fresh leaves used as an enema, employed it in the form of bath. Of five cases treated in this way, four recovered. (Med. Chir. Trans, of Edin. vols, i and ii) Several other cases have been recorded in which its bene- ficial effects have been well marked in tetanus, and so far as our present experience of it has extended, it appears to be the most efficient remedy of this class. The best form of administration is that of enema, of the strength used by Dr. O'Beirne, which should be repeated sufficiently often to keep the system under its tetanus, (Treatment.) 387 influence. Care must be taken not to increase the dose too sud- denly, as such prostration may be occasioned as to prove fatal. At all times a most distressing feeling of sinking and depression is induced. It should be remembered also, that some individuals are more susceptible than others to its effects, and that sailors and persons addicted to its use require a larger dose. Antimony from its Avell known depressing effect has been em- ployed in cases where vascular excitement is well marked. Its tendency to occasion vomiting is a powerful objection to its use, an effect Avhich often aggravates the disease, and increases the severity of the spasms. Mr. Liston speaks of a case in which it was successful (Lancet, 1834-5), and another is recorded by Mr. Woodward (Dub. Journ., 1835). Hydrocyanic acid has been recommended by Mr. Ward of Gloucester (Obs. on Tetanus, 1835), Avho gave a drop and a half of it every half hour to a girl laboring under the disease, Avho ultimately recovered. We have very little experience of this remedy, and its sedative action is by no means so certain or manageable as that of opium or tobacco. Digitalis, stramonium, belladonna, hyosciamus, and conium, have been tried, and found comparatively inert. The effects of the cold affusion are very similar to those of tobacco, namely, great prostration and temporary relaxation of the muscles. It has been strongly recommended by Drs. Wright, Currie, and Rush, who thought it a tonic remedy, and several cases have been recorded in Avhich it has been the apparent means of recovery. Three in particular related by Dr. Doue (Nouv. Bibl. Mid., March, 1818), shoAvs its beneficial action when energetically employed. In other instances, hoAvever, it has failed, and in a few has occasioned sudden death. Dr. Elliot- son gives an instance, and Mr. Morgan relates another, in Avhich the patient, on being plunged into the cold bath, died imme- diately. The most powerful effect is produced by pouring several buckets of cold water from a considerable height over the indi- vidual, in a continued stream. Syncope is often produced by these means, so that stimulants should be at hand, and the patient, after being Aviped dry, placed in Avarm blankets. As he recovers, the stimulants should be discontinued, and, if the spasms return, the cold affusion repeated. A less poAverful effect is produced by plunging the patient into the cold bath, or dashing cold water on the body. In the present state of our knoAvledge cold appears, when properly applied, to be one of the most active and useful agents Ave possess. It has been most beneficial in the idiopathic forms of the disease. Tonics and stimulants have been recommended by Drs. Wright, Currie, Rush, Bright, and others; and Avhenever there are signs of debility, either at the commencement or in the course of the disease, they are directly indicated. Rush gave Avine and bark liberally 388 tetanus, (Treatment.) Avith occasional success. In a remarkable case given by Dr. Cur- rie (Med. Rep. vol. i, p. 148,) the patient took 140 bottles of Madeira wine in less than a month, taking generally every twenty-four hours four or five bottles with tAvo gallons of strong broth, some ale and brandy, and two drachms and a half of laud- anum. Laudanum and ether embrocations with the tepid bath Avere also used. The recovery Avas slow. Spirits, wine, and ale, may be given in large quantities without producing their accus- tomed effects, although Dr. Cross is reported, when other medi- cines had failed, to have kept the patient for ten days in a state of intoxication Avith spirits, and, singular to relate, with the result of a perfect recovery. (Good's Study of Med., vol. iii, p. 268.) Fournier Pescay recommends musk, which he has used Avith success in doses of 10 or 12 grains every hour. Mr. S. Cooper however states, that 120 grains Avere given to a young girl in the space of tAvelve hours without producing any benefit. (Surg. Diet., art. Tetanus.) Fournier Pescay gives some cases Avhich were cured by M. Francois Avith ammonia. Carbonate of iron has been employed by Dr. Elliotson from an analogy he considers to exist betAveen this disease and hysteria and chorea. (Med. Chir. Trans., vol. xv, p. 161.) Recovery took place in tAvo cases out of three. Dr. Dehayne of Wolverhampton gave a pound daily, and the patient got well. A larger dose than tAvo drachms appears unnecessary, and in acute cases the remedy is inadmissihle on account of the time necessary for its effects to be manifested. Quinine has also been given extensively in conjunc- tion Avith stimulants and tonics. Dr. Bright has published a case that terminated successfully, in Avhich in the course of tAventy days the patient took two ounces of the sulphate of quinine, and drank daily from fourteen to twenty ounces of wine, besides taking brandy and(ammonia. (Guy's Hospital Reports, vol. i, p. 111.) In this as well as in the generality of cases where a tonic and stimu- lating line of treatment has been pursued, opium Avas also given, so that it is impossible to knoAv Avhether the recovery is attribu- table to any one particular remedy, or to the combined treat- ment. Preparations of zinc and iron and other tonics have been recommended. Sudorifics are indicated in chronic cases when the disease arises from any sudden check to the perspiration. The vapor bath has been recommended by Dr. Marsh (Dub. Hosp. Rep., vol. iv, p. 567,) Avho has given tAvo cases which recovered apparently by its use. We have seen a case successfully treated in this Avay by M. Sanson at La Pitie, and other instances are recorded. (Journ. Heb. de Mid., 1828.) Its trial has not been very extensive; for as it is necessary to keep the patient in the bath for a long time, its use seems inadmissible in acute cases. The Avarm bath may be useful in chronic cases, as it relieves the rigidity and uneasi- ness Avhich is sometimes present. In acute tetanus it is of little tetanus, (Treatment.) 389 service, and instances are recorded where it produced sudden death. It is highly spoken of by Bajon, Chalmers, and Boyer. Fournier Pescay and Stutz used medicated baths containing the deutoxide of potassium and lime, combined with the internal ad- ministration of opium. Dr. Latham recommended Dover's poAV- der, Avhich in some cases has also been beneficial. A diaphoretic treatment, Avith small doses of opium gradually increased, and alkaline baths, has proved successful in the hands of M. Fritz of Prague. Among the other remedies which have been employed, mer- cury has been extensively given, although on what principle it is difficult to explain; for although it tends to lessen inflammation, and sometimes acts as a stimulant, we possess better and more poAverful remedies for these purposes. Whenever success has attended the use of this mineral, it has been combined Avith opium or some other remedy, so that it is impossible to speak decidedly as to its effects. Mr. Curling has seen two cases where the ptyalism it occasioned, produced great suffering, and in which the patients were compelled to keep their lips constantly open with their fingers, in order to prevent the suffocating paroxysms consequent upon attempting to sAvallow the saliva. Camphor, from its combined narcotic and stimulant, properties, may be given in some cases with benefit, particularly in the form of enema. Combined with opium it is much praised by Larry. Colchicum has been given with partial success by Drs. Smith and Dufresnoy, combined with opium. Injection into the veins of a watery solution of opium and stramonium has been employed by MM. Percy and Laurent. Dazille recommends ether. Counter- irritants applied to the spine are beneficial in chronic cases. M. Cruveilhier apparently cured a patient in whom the hiccough and spasms Avere very distressing, by constant pressure on the abdo- men. (Riv. Mid. Avril, 1824.) Other remedies have been re- commended and occasionally tried, such as phosphorus, electricity, strychnine, acupuncture, &c, but Ave have no proof of their effi- cacy. In all cases of tetanus the diet should be light, consisting of soups, gruel, &c. It should be antiphlogistic when there are symptoms of excitement, and nourishing when the vital powers are depressed. It is not always easy to give the patient sufficient nourishment, as sometimes the teeth are so firmly closed, that no substance Avhatever can be introduced: in other instances all attempts to swallow bring on the most violent spasms. In the former case, liquid food may be introduced into the stomach through a tube passed into the stomach by the nostrils, and in the latter the spasmodic action should be overcome by tobacco injec- tions, and advantage taken of the period of prostration to give food. Articles of nourishment may also be thrown into the intes- tines by the svringe. 33* 390 HYDROPHOBIA. Definition of the disease.—Premonitory symptoms.—Symptoms of the attack. —Various modifications observed in the symptoms in the human subject.— Symptoms of rabies in the dog.— Predisposing causes.—Exciting causes.— Nature. —Anatomical characters. —Diagnosis. —Prognosis.—Prophylactic or preventive treatment.—Curative treatment. The disease termed hydrophobia (from vSap, Avater, and $680$, fear) is characterised by spasms of the muscles of the pharynx and chest; difficulty of drinking, and dread of fluids; great rest- lessness, and mental inquietude. From the circumstance that water is not the only substance which causes dread, it has been denominated hygrophobia with a view of indicating the inability to SAvalloAv any kind of liquid; phobodipsia, to express the presence of thirst, with the dread of liquids; aerophobia, or dread of air; pantaphobia, dread of all things. As these various terms allude to a symptom which is only occasionally present, they are in no respect preferable to that of hydrophobia. Some modern authors have called it rabies, rabies canina, or rage; but these denominations imply delirium, or a furious state of mind, Avhich is rarely observed, and the word canina is evidently useless, as the malady is occasioned not only by the bites of dogs, but of cats, wolves, and other animals. The disease is called lyssa in the nosology of Dr. Good, from xiaaa, a word used by the Greeks to express madness in dogs; but rabies in these animals differs from hydrophobia in the human subject. The French have endeavored to establish tAvo diseases, according as the symptoms are produced by the bite of a rabid animal, or by other causes. The former they call la rage, and the latter hydrophobic But the symptoms and treatment in both are iden- tical, and, as far as our present knowledge extends, their nature is the same. We do not therefore consider that any of the terms which have been proposed are at all preferable to that of hydro- phobia, although undoubtedly it is not free from objection; but there is scarcely a disorder which does not undergo modifications in different individuals; and, as Dr. Bardsley has stated, "feAV rational physicians expect to find the history of a disease con- densed into a sort of essence in its name." As moreover not- withstanding the various alterations which have been proposed, the term hydrophobia has been generally employed for a series hydrophobia, (Symptoms.) 391 of ages, and is still almost universally adopted, we shall retain it to express the group of symptoms above detailed, from whatever cause they proceed, as well as when the disease undoubtedly arises from the bite of a rabid animal. Symptoms. Some authors have divided the disease into peri- ods or stages, denoted by the appearance of certain symptoms. As such divisions, however, are purely arbitrary, and lead to no practical utility, we shall describe, 1. The premonitory symp- toms; and, 2. Those which constitute the attack. 1, When the disease, as is generally the case, arises from the bite of a rabid animal, the most marked premonitory symptom is pain in or round the bitten part, Avhich often resembles that caused by rheumatism, and sometimes attended Avith itching. The nature of the pain is liable to variations, being more or less acute; sometimes there is a feeling of torpor, stiffness, tingling, heat or coldness, Avhich does not amount to actual suffering. The pain extends gradually along the course of the nerves, and if the hand be the part bitten, shoots to the forearm, arm, or shoulder, and sometimes to the muscles of the neck; or, if the injury be in the leg, to the thigh, hip, or loins. In some cases, the pain does not arise in the wound, but in a part near the trunk, as the shoul- der or hip; the cicatrix swells, inflames, becomes red or livid, and occasionally, after it has cicatrised, opens, discharging an ichorous matter. Sometimes the pain shoots from the Avound to the region of the heart, and now and then darting pains are felt in various parts of the body. Callisen (Syst. Chir. Hodiern, vol. i, p. 595,) Marcet, and Babington, have observed that these pains follow the course of the nerves, and never irritate or produce inflammation in the absorbent glands or A^essels. The local symptoms detailed are often accompanied by desire of solitude, uiiAvillingness to ansAver questions, dull despair, and other signs of mental depression; but more generally the intellectual faculties are not at all altered; not unfrequently, indeed, the imagination is more fertile, the memory stronger, the patient's conversation animated, both the mental and bodily poAvers displaying unusual activity. In some cases, on the other hand, there is intolerance of light, Avith dilatation of the pupil, contracted eyebroAVS, and tumid face; or wandering pains in the neck, trunk, or limbs; pain, or a sense of heaviness in the head; restlessness, drowsiness, and disturbed sleep; occasionally sighing, momentary flushes and rigors, slight febrile symptoms, loathing of food, loss of appetite, nausea, vomiting, constipation, pains in the abdomen, &c. These premonitory symptoms are not peculiar to hydrophobia; but Avhen one or more occur after an individual has been bitten by a dog, there is just cause for alarm. The symptoms do not follow any order which can indicate an approaching attack of hydrophobia; pain in the Avoimded part being felt by one patient, melancholy by another, or intolerance of light by a third; on the 392 hydrophobia, (Symptoms.) other hand, every one of these have been absent in certain cases. . The duration of the premonitory symptoms is, in general, from four to six days; cases, hoAvever, have occurred, in which they existed tAvo or three days only. 2. Symptoms of the disease. Hydrophobia may be considered established Avhen there is a peculiar constriction about the throat, which, at the commencement, is usually slight. It frequently resembles a feeling of stiffness, gradually extending towards the root of the tongue and thyroid cartilage, and is often accompa- nied with pain. The patient experiences difficulty of swalloAV- ing, especially fluids; and all endeavors to accomplish this are apparently prevented by sobbing, or deep catching sighs. At the same time the liquid contained in any vessel held in the hand, is generally either spilt on the ground or violently jerked to a dis- tance. These symptoms are usually of short duration, but often leave in the mind of the patient a continual dread of water or other fluids, so that even the idea of drinking induces their return. Deglutition gradually becomes more and more difficult, until at length, any attempt to SAvallow, particularly liquids, produces violent spasm of the muscles of the pharynx and larynx, and occasionally of those of the face, the patient, being, at the same time, throAvn into a state of the greatest agitation and alarm. The horror of fluids is often such that any circumstance which can lead to the idea of drinking, as the splashing or running of water, the sight of jugs or glasses, the rattling of earthenware, the noise of a pump, or even the mention of any kind of beverage, is often sufficient to occasion a recurrence of the spasms. As the disease advances, the irritability becomes greater, the spasms are more frequent and prolonged, and though generally confined to a limited number of muscles, occasionally the whole muscular sys- tem is affected, and such is the morbid sensibility, that the spasms may be excited by various trifling causes, as a current of air, opening a door or windoAV, a strong light, looking at a polished surface, &c. In the interval of the paroxysms, there is an unusual degree of debility. As the spasms increase in frequency, the respiration becomes more uneasy, and often interrupted by occasional deep inspirations or sighs; some individuals scream loudly from slight causes. To these succeed flatulent eructations, often vomiting, urgent thirst, sense of obstruction in the throat, increased secre- tion of saliva, intense headach, and acute pain, either in the epi- gastrium or throughout the whole course of the spine, particu- larly in the cervical portion. The state of the patient is noAV very distressing; the countenance expresses the utmost anxiety and alarm; the eyebroAvs are contracted; the eyes staring and glassy, giving a peculiar wild expression; there is intolerance of light, and of sounds; the speech is abrupt and rapid; the angles of the hydrophobia, (Symptoms.) 393 mouth are draAvn slightly upAvards, giving the countenance an expression someAvhat approaching the risus sardonicus; the face is sometimes pale, often flushed or covered Avith large irregular ruddy spots; the saliva is secreted abundantly, and ejected repeat- edly and with considerable force; the heat of the skin is in gene- ral natural, but occasionally increased; the pulse is quick, and of variable strength; and the respiration, although in some cases not much affected, is usually hurried and laborious. In the midst of so much suffering, the intelligence remains perfect, and the pa- tient retains his consciousness. These aggravated symptoms may be established a few hours after the commencement of the dis- ease, but in genera] are not fully developed before the second day. The disorder noAV progresses rapidly; the patient experi- ences a burning heat and dryness in the throat; and the attempts to relieve this by drinks produce severe convulsions of the whole body, in which the patient appears on the point of suffocation. The spasms appear to come on spontaneously, or to be produced by the most trivial causes, as touching the surface, or the hairs of the head; the saliva becomes thick, viscid, and adhesive; it accu- mulates about the glottis, increasing the irritation in the throat; and, in the efforts the patient makes to remove it, rapid reiterated noises are produced, Avhich have been supposed by the vulgar to resemble the bark of a dog. The voice is hoarse; the feeling of thirst, and sometimes of hunger, the pain in the stomach and ten- sion of the praecordia, become more urgent, and the eructations more frequent; vomiting of a yelloAv, greenish, glairy, or grumous fluid succeeds, the abdomen being, at the same time, distended, or sometimes retracted and drawn towards the spine. As the fatal issue approaches, there is general and incessant tremor; the convulsions are increased in frequency and violence; the sense of suffocation is more urgent; and from the difficulty of expelling the saliva, it collects in the mouth, and Aoavs over the lips; the pulse becomes small, irregular, feeble, and rapid; the patient evinces great terror, or lapses into a state of Avild delirium; hic- cough and rapid breathing succeed, followed by gradual ex- haustion; and at length the patient dies in an intense paroxysm. Sometimes a temporary calm takes place before death, Avhich, hoAvever, is only the precursor to a fatal return of the spasms; occasionally, the unfortunate sufferer expires in perfect tran- quillity. The duration of the hydrophobic symptoms is in general from tAvo to three days; but cases are recorded in which they have been prolonged to eight or nine days. The disease has also been knoAvn to be fatal in thirty-six hours. Such is the general progress of this dreadful disease; but almost every one of the above symptoms occasionally undergo modifica- tions. The dread of Avater and liquids has ahvays been consid- ered the most remarkable symptom of the disorder, and apparent- 394 hydrophobia, (Symptoms.) ly arises from a conviction the patient entertains, that every attempt to swalloAV will produce the greatest suffering. Though there is difficulty in swallowing any thing, it has been observed that the deglutition of solids does not occasion such distress as that of liquids—a circumstance which has been attributed to the greater surface of the pharynx, Avith which the latter, in the act of deglutition, are brought into contact. Some individuals have reso- lutely determined to swallow water, and have only been prevent- ed by the violent pharyngeal spasms which the contact of the liquid occasioned; others, who have retained an insuperable aversion to water, have been able to drink easily red wine, or broth. M. Cayol attended a young girl laboring under this disease, Avho had no great dread of liquids, though she disliked them, and Avas not absolutely unable to SAvallow them, notAvithstanding there Avas great difficulty in the effort. Dr. Bright and others have recorded cases in Avhich there was no abhorrence of fluids, but only a dis- inclination to SAvallow, or to alloAV any thing to approach the mouth. In the course of the disease, this symptom undergoes remissions, not unfrequently before death. Occasionally, also, there is complete intermission, during which the patient drinks with tolerable comfort. The mental faculties are generally observed to be altered, but in what the alteration consists it is often difficult to determine. The consciousness and reasoning poAvers usually remain perfect in the midst of the most dreadful sufferings; but there is evidently mental excitement, manifested by increased loquacity, and cir- cumstantial explanations, unusual and uncalled for on the part of the individual. There is often great tendency to take alarm from trival causes, to form suspicions Avithout adequate motives, and an extraordinary susceptibility to circumstances associated Avith the idea of drinking. These symptoms are liable to various alterations in different individuals; in some cases they have been altogether absent, the mind having been little disturbed from the commencement to the termination of the disease. Furious delir- ium is rarely present, and then only during violent paroxysms or towards the close of the disease. But there is often, even soon after the commencement of the symptoms, muttering, unconnect- ed talking, and hallucinations of mind, although, when spoken to, the patient gives rational answers. The mental faculties also evidently exercise considerable influence over the other symptoms, which have been observed to be more or less distressing and urgent, according to the weakness or strength of the patient's intellect. The sensibility, both general and special, may be greatly in- creased. There is always great pain in the throat, sometimes in the thyroid gland, and occasionally in the neck and spinal column. This increases as the spasms become more violent; and when the symptoms are intense, there is usually excruciating pain in the hydrophobia, (Symptoms.) 395 chest and epigastrium. Though in most instances patients betray great dread of being touched, and regard with aversion the ap- proach of individuals, particularly strangers, the sense to touch remains unaltered: sometimes a sense of tickling is produced by contact. In other instances the sense of touch is very acute, and great uneasiness is often occasioned by the contact of the lightest body, or by currents of cold or heated air. In a case described by Magendie, touching the hair induced a recurrence of the spasms; and in another by Dr. Powell, the same effect Avas pro- duced by a fly settling on the face. It has been noticed that the sensibility to light is also morbidly increased; hence daylight, burning objects, brilliant colors, and polished surfaces, often pro- duce great distress and a return of the paroxysms. The hearing is also very acute, and noises that cannot be distinguished by others, are occasionally complained of. A patient treated by Ma- gendie heard distinctly, during the paroxysms, though born deaf and dumb. Disagreeable odors also are sometimes perceived, which are inappreciable to others. It almost always happens however, that, towards the end of the disease, the different senses become more or less obtuse, and even entirely lost. The muscular system is variously affected. The disease essen- tially consists in a spasm of the pharyngeal or laryngeal muscles, of greater or less intensity, occasioning the difficulty of deglutition, particularly of liquids, Avhich forms the prominent symptom of the disorder. Occasionally the spasms appear to commence by rigidity and stiffness at the root of the tongue. Inspection of the throat in some cases detects turgescenee and other signs of in- flammation about the fauces, but in others nothing morbid can be seen. In the intervals there is not unfrequently unnatural activity, and occasionally a desire to perform certain motions, as leaping upwards, running backwards, climbing, &c. Towards the termination of the disease, the hands and legs are thrown about convulsively, and sometimes the spasms resemble those of tetanus, the trunk being drawn backwards. In a case given by Dr. J. Johnson, the sphincter ani was so firmly constricted by spasm, that poAverful efforts to pass a clyster-pipe failed. In some cases the spasms are accompanied by priapism, contraction of the cremasters, and involuntary seminal emissions; in others, towards the termination, paraplegia, hemiplegia, or general par- alysis, supervene. The pulse is generally accelerated, but of va- riable strength. At a late period it becomes quick (sometimes 150 in the minute,) weak, Aviry, and irregular. The respiration is differently affected in various stages of the disease. At the commencement the breathing is convulsive, or the patient sighs deeply; or there are sobs, occasioned by efforts to swallow, or by terror. As the paroxysms become more intense, the respiration is difficult and laborious, so that suffocation is often threatened. During the remissions the breathing becomes more easy, but 396 hvdrophobia, (Symptoms.) sometimes interrupted by frequent sighs and sobs every fourth or fifth inspiration. The skin is not unfrequently covered Avith a profuse perspiration, but sometimes it is hot and dry, occasionally harsh, Avhile the heat is not increased; in one or two cases it has been observed livid. The excretions are not particularly affected; occasionally there is great constipation. In general there is no alteration in the urine; in some few cases it has been observed to be scanty, and of a pale greenish or lemon color; in others high- colored. ToAvards the termination of the disorder, both faeces and urine are often passed involuntarily. The mouth is usually filled with saliva, Avhich at first frothy, becomes gradually so thick and tenacious as to adhere to the lips. The tongue is sometimes moist, and more or less furred. Nausea is a frequent symptom, and in the fatal forms of the disease there is not unfrequently vomiting of a yelloAv, greenish, glairy or grumous fluid, resembling coffee-grounds. Symptoms of rabies in the dog. As every practitioner, parti- cularly in the country, is liable occasionally to be called on to determine Avhether a dog is rabid, Ave shall give the principal symptoms of rabies in this animal, referring to Avorks of veteri- nary medicine for more ample details, and especially to the treatise of Mr. Youatt on this subject. It is necessary at the commence- ment to remove from the mind an idea Avhich is very general, viz: that the disease in quadrupeds is similar to hydrophobia in man. Many persons suppose that, as the animal does not evince any dread of water, or appear Avild and furious, it is not in a rabid state, and have consequently been lulled into dangerous security. The first symptom observed in the dog is a change in his usual habits; in some there is a disposition to pick up straAvs, rags, bits of paper, or any small objects; in others, licking cold surfaces, as iron, stones, &c, or different parts of other dogs that may be do- mesticated with him. Sometimes the dog becomes attached to animals formerly regarded with indifference, but more generally an antipathy to strange dogs and cats is early observed, particu- larly to cats. It becomes lonely and irritable; is less eager for food, or neglects it, but is evidently thirsty: there is sometimes redness and Avatering of the eyes; the ears and tail droop, and his look is suspicious and haggard. In a short time the respira- tion becomes difficult; sometimes there is vomiting, and saliva flows from the mouth, Avhich soon assumes the form of viscid foam. The rabid dog noAV shows great irritability, with dispo- sition to bite other animals, but is still obedient to the voice of its master; and though seldom, unless enraged, attacking the human subject, occasionally flies at every creature it meets. Holding up a stick or whip invariably excites great fury, and never intimi- dates. In the advanced stages of the malady, the breathing be- comes more laborious, and death takes place during strong con- vulsions. hydrophobia, (Causes.) 397 In the lower animals there is no dread of water; the dog, although unable to swalloAV, flies to it with eagerness; and all other quadrupeds in the rabid state, Avith perhaps an occasional exception in the horse, drink with ease and with increased avi- dity. (Youatt.) In most instances, also, there is not the savage fury which persons in general expect to find, but rather a snap- pish irritability. In many instances, however, the most furiously rabid animals are obedient to the master's control. Causes. Whether there be any particular predisposing causes of hydrophobia is at present a matter of great doubt, inasmuch as it has attacked individuals of both sexes, at all ages, and in all seasons and climates. Neither has any particular constitution, habit of body, diet, or other circumstances, been found incompa- tible with the manifestation of the disease. It has undoubtedly been more common in some countries than in others, and in these countries more frequent at particular periods. The loAver classes also have been more frequently affected. These circumstances, however, do not appear to be connected Avith any inherent pre- disposition in the human frame, but are owing to accidental oc- currences, such as the greater prevalence of rabies among dogs, or other animals, in particular countries, and at different seasons, Avhile the laboring classes are necessarily more exposed. In the absence of positive knowledge on this subject, therefore, we do not consider ourselves Avarranted in entering into a consideration of Avhat some have considered predisposing causes of hydro- phobia. Of the exciting causes the introduction into the system of the saliva of rabid animals is by far the most frequent. Though it has been generally thought that the hydrophobic poison can be introduced only by the medium of a wound inflicted by the bite of a rabid animal, yet, according to Portal, Matthieu, Gill- man, and others, the disease may be developed Avhen the mucous membrane has been exposed to the action of the virus. That inoculation is necessary to the production of hydrophobia, is established by the folioAving facts: 1. The same phenomena hav- ing been knoAvn to follow the bite of dogs from the earliest ages. 2. The similarity of the symptoms in different persons who have been bitten by the same rabid animal. 3. The more frequent occurrence of the disease in those Avho have received the bite on uncovered parts, as the hands and face; and, 4. By experimental proofs that the introduction of the saliva of a rabid animal into the system of a healthy quadruped will produce the same disease. Magendie and Breschet induced rabies in the dog by inoculating the animal Avith the saliva of a hydrophobic man. We consider it unnecessary to allude to particular examples, with a vieAV of proving the above statements. That the bite of a mad dog Avill occasion hydrophobia has been universally believed for a series 34 398 HYDROPHOBIA, (CauSCS.) of ages—a belief that the careful observations and scientific re- searches of modern times have tended to confirm. We consider it, hoAvever, incontestibly proved, that other causes are capable of producing hydrophobia, attended Avith symptoms exactly resembling those occasioned by the bite of a rabid animal. Pinel relates the case of a young soldier Avho, disliking the mili- tary profession, secluded himself. His comrades, attributing this to coAvardice, entered at midnight into his chamber, beating the charge on the drum, and crying that the Austrians had passed the Rhine. He Avas immediately seized with convulsions, ac- companied Avith a sensation of burning and constriction in the throat, dread of liquids, and expectoration of a copious frothy saliva. In the morning the horror of fluids and burning pain in the throat were more intense, accompanied with a sense of Aveight in the head, hurried and irregular respiration, intermittent feeble pulse, and intolerance of light, but without alteration in the intel- lectual functions. He Avas certain that he had never been bitten by any animal. The symptoms increased, and he died. The examination presented nothing extraordinary. A quantity of mucus only was found in the throat. (Pinel, Nosog. Phil., tom. lii, p. 145,4th edit.) The minute details of this case, correspond- ing Avith the principal symptoms described as constituting hydro- phobia, Avere identical Avith those of hydrophobia arising from inoculation. In Hufeland's Journal (December, 1839) there is a similar case, from the bite of a dog received five Aveeks before the symptoms appeared. The dog was perfectly healthy, and remained so after the individual bitten had died laboring under the most dreadful form of hydrophobia. A Avell-reported case, occasioned by great fatigue during a hot day, is also recorded, in which all the symptoms of hydrophobia were Avell marked: it terminated fatally. (Journ. des Savans, Aout, 1757, p. 81.) In others, horror of Avater, and symptoms resembling hydrophobia, have folloAved rheumatic and inflammatory affections, exanthe- matous fevers, cerebral lesions, suppression of habitual discharges, some kinds of poisons, &c. (Diet, des Sciences Mid, art. Hydro- phobie.) Many of these cases no doubt are not sufficiently well detailed to demonstrate satisfactorily that the disease was in every respect identical Avith hydrophobia; but a sufficient number exist to prove that it has not unfrequently occurred independently of hysteric, epileptic, or tetanic complication. It may then be consi- dered perfectly established, that hydrophobia is the result of a peculiar poison with which the system may be inoculated, but that it may also be occasioned by other causes, especially poAV- erful mental impressions. These facts have led to much dispute; some thinking that the state of the mind induces the disease, because the symptoms come on some time after the local injury, and are preceded by evident signs of mental disturbance. Others affirm that it can only be HYDROPHOBIA, (Causes.) 399 produced by the hydrophobic virus, and that the supposed terror may have originated in some bite which had been forgotten. A third class adopt neither of these vieAvs, but consider one cause or the other as producing distinct diseases; the one they denomi- nate hydrophobia, and the other " La rage." That inoculation is alone sufficient to produce the disorder, is proved by its having been thus occasioned in infants, horses, asses, &c, in which the force of imagination cannot be supposed to operate. Five cases also are reported by Mr. Hewit to have occurred in natives of the East Indies Avho were bitten by a jackal, and who had never heard of the disease, or had even a suspicion of its nature. (Med. Chir. Trans., vol. xiii.) On the other hand there is every reason to suppose, that the disease may occur solely from mental dis- turbance, or the other causes to Avhich we have alluded. We see no reason, therefore, for adopting any exclusive vieAV of the origin of hydrophobia, or for considering diseases distinct because their exciting causes are different. Many fevers and eruptive disorders may arise spontaneously, or be the result of contagion. Tetanus, it is knoAvn, may be produced by exposure to cold, or it may succeed to wounds, or the introduction of poisons, such as strychnine for example. In like manner paralysis may be occa- sioned by a poison, (lead,) as Avell as by mental emotions or other causes. Epilepsy, and numerous other diseases, may arise from causes widely different, and yet, as far as our means of observa- tion extend, the disease occasioned is identically the same. Such we consider to be the case with hydrophobia. It has been re- marked with regard to tetanus and other affections, that the influ- ence of a wound, combined Avith that of exposure to cold and bad weather, or terror, has a greater effect in the production of the disorder than when one of these causes acts alone. The same is the case Avith hydrophobia; the bite of a rabid animal is more liable to produce the malady in individuals who are impressed with a horror and dread of its effects, than in those Avho do not experience any imaginary fears. We have observed that in some years, when the public prints industriously circulate an account of the dreadful symptoms of hydrophobia, and the means neces- sary to guard against their appearance, cases soon become very frequent; and, although this may undoubtedly be attributed to other causes, it is not improbable that the moral effects thus produced may favor the production of the disease. The accession of the symptoms may take place at different pe- riods after the reception of the bite. Mr. S. Cooper states, that of 131 cases none of the patients became ill before the eleventh day after the bite, and only 3 before the eighteenth. Of 15 cases men- tioned by Troilliet, 7 were attacked betAveen the fourteenth and thirtieth days; 5 between the thirtieth and fortieth days; 2 a little after that period; and 1 after fourteen Aveeks. (Obs. Chir. sur la Rage.) The most general period is betAveen the twentieth and 400 hydrophobia, (Anatomical Characters.) fortieth davs, but cases are mentioned by Marestan, Astruc, Wil- loughby, and others, in Avhich it occurred two, three, and six days after the bite. On the other hand, numerous instances are record- ed in Avhich several months have elapsed. Dr. J. Vaughan men- tions an interval of nine months; Mead of eleven months; and Bauheir and Boissiere of a year; Brown and Adams fifteen months (Trans. Med. and Phys. Soc. of Calcutta); Nourse of nineteen months; R. Lentilius of three years (Cooper's Diet., art. Hydro- phobia); and Lusitanus, four years. (De Prax. Admir., lib. iii, obs. 87.) Dr. S. Bardsley gives a case that occurred twelve years after a bite had been received (Manchester Memoirs, vol. iv.); and others are recorded Avhere it is said to have appeared after an interval of eighteen, twenty, and even thirty years. (Diet, des Sciences Mid., art. Rage.) We cannot however suppose, that in any of these latter cases the bite Avas the exciting cause of the disease, though it is difficult to determine Avhat is the latest period at Avhich the virus may be supposed capable of producing the disorder. Dr. J. Hunter considers seventeen months, and Dr. Hamilton nineteen months, as the longest possible interval. (On Hydrop., vol. i, p. 115.) Dr. J. L. Bardsley thinks two years constitute the limit. (Cyc. of Pract. Med., art. Hydrophobia.) We may observe, hoAvever, that even these periods appear to be very long for a poison to lurk in the system without producing any effect; and knowing that mental disturbance is capable of pro- ducing the disease, there must always be great doubts whether or not such cases were produced by the former or the latter cause. When hydrophobia is occasioned by mental impressions, the in- terval is not so long. The premonitory symptoms commence at once, and last from one to five days, and occasionally the disease is declared immediately. This is the only important distinction betAveen spontaneous hydrophobia and that occurring from inocu- lation; but no nosologist would be warranted in founding a distinc- tion on a circumstance, which in all diseases, and in this more especially, is so uncertain. Anatomical characters. In this, as in other diseases of the nervous system, no uniform appearances have been presented after death. The brain has, in several instances, presented signs of conges- tion. The sinuses and vessels of the membranes have been ob- served considerably injected, and more or less effusion of serum found in the ventricles, and in the arachnoid and subarachnoid cavities. These appearances were found in six cases dissected by Troilliet (Sur la Rage), who also observed the surface of the ce* rebrum studded with scarlet points, and the plexus choroides of a brown color, and gorged with blood. In tAvo cases, blood was extravasated toAvards the base of the brain in large quantity; and in others there existed a plexus of vessels somewhat injected, hydrophobia, (Anatomical Characters.) 401 surrounding the origin of the optic and pneumo-gastric nerves. In five cases inspected by Dr. J. L. Bardsley (Cyc. of Pract. Med.), three presented traces of considerable cerebral vascularity; in the fourth there was only slight turgescence of the vessels of the pia mater, and rather more distension than usual of the cho- roid plexus; in the fifth the brain Avas natural. Dr. Marshall and other Avriters have also shown the frequent existence of conges- tion Avithin the cranium. In some cases the substance of the organ has been found someAvhat softened, and in one or tAvo in- stances rather indurated. Bony depositions have been occasion- ally met with in different parts of the dura mater and arachnoid. On the other hand, Van Swieten, Bonetus, Lieutaud, and others, have seen cases Avhere, after death, no alteration could be detect- ed in the brain. The spinal cord has often been found to exhibit signs of con- gestion. Instances of this kind have been reported by Salin, Brera, Saunders, Reid, Troilliet, Ribes, Ollivier, Goodrich, and others. Dr. A. T. Thomson has recorded a case in which the spinal cord was covered Avith blood, and its vessels turgid. (Med. Chir. Trans., vol. xiii.) M. Mathey found a quantity of serum Avithin the spinal canal. (Journ. Gin. de Mid., tom. liv, p. 279.) In a case by M. Clot, cited by Ollivier, the cellular tissue which sur- rounded the cervical portion of the cord Avas very red, and infil- trated with a large quantity of blood. Its substance also, at this part, was intensely inflamed, contrasting strongly with the Avhite- ness of the dorsal and lumbar portions. Ollivier has found soft- ening in the inferior portion of the dorsal region in an individual Avho died of the disease. In a case by Dr. Bright also (Hasp. Rep., case 285), the whole substance of the cord Avas found softened for a quarter of an inch in the same situation. A case is given in Johnson's Med. Chir. Rev., 1817, in Avhich the principal marks of disease were in the coverings of the pons varolii, medulla oblon- gata, and upper part of the spinal cord. These parts formed one crust of inflammation, most intense on the spinal cord. Similar lesions have been found in the loAver animals by Dupuy and Bar- thelemy. Dr. Bright tells us, that in one case examined at St. Thomas's Hospital, small plates of bone were found in the arach- noid of the spinal cord. In several instances, however, no morbid appearances Avhatever could be detected in the spinal marrow. M. Gendrin, in particular, says he has examined many cases of hydrophobia, and never could discover any disease in the spinal cord or nervous ganglia. (Transl. of Abercrombie on the Brain, p. 578.) The pharynx and oesophagus, to Avhich the most prominent symptoms of the disorder are referred, ha\re often been found dis- eased. Sauvages, Rossi, Rush, Gorci, Ribes, Bardsley, and others, have found marks of inflammation in one or other of these situa- tions, and sometimes in both. Dr. Powell found the oesophagus 34* 402 hydrophobia, (Nature.) covered by a thin layer of coagulable lymph, an appearance also seen by OldknoAv, Ballingall, and Ferrier. Dr. J. L. Bardsley in one case discovered in the oesophagus a membrane lying closely within the orifice without filling up the cavity. When inflated by the bloAvpipe, it assumed a tubular appearance. He consi- dered it a portion of the internal membrane of the oesophagus. In other cases, however, no morbid change could be discovered in these parts, or they Avere only covered by a frothy mucus. In the six cases dissected by Troilliet the mouth and fauces were of a pale grayish color, and no signs of inflammation existed in the pharynx. The lungs have often been found somewhat engorged Avith blood, and of a deep red color. This occurred in all the six cases examined by Troilliet, as well as in those observed by Morgagni, Portal, OldknoAv, Ballingall, Marshall, and numerous other Avriters. The larynx, trachea, and bronchia, have presented traces of inflammation, and been found lined with a thick, Avhite, frothy mucus by Faure, Troilliet, Rush, Ribes, Lalonette, and others. The extent and intensity of this inflammation appear from the dissections that have been made to be proportionate to the violence of the dyspnoea. In two cases by Troilliet, gelatinous clots Avere found in the heart and large vessels, but the greater portion of the blood was black and fluid, as in subjects who have died of asphyxia. The mucous membrane of the stomach and small intestines have been found more or less inflamed by Morgagni, PoAvell, Old- know, Ballingall, and others. Dupuytren found the former almost gangrenous. The salivary glands have occasionally been found enlarged and very vascular. Numerous alterations and dis- placements of the other viscera have been reported by different authors, which Ave have reason to believe Avere accidental. It should also be understood, that some individuals have died of hydrophobia, in whom no alterations whatever, either in the nervous, circulatory, respiratory, or digestive symptoms, have been found. ( Vaughan, Fabbroni, &cc.) Nature. The essential symptoms of this disorder are sufficient to demonstrate that it is dependent on some pathological condi- tion of the nervous system, but in Avhat this consists we are wholly ignorant. Some have thought it must be attributed to inflammation of the pharynx or cesophagus, others to congestion or inflammation of the brain, while a third class have considered it dependent on some irritation of the spinal marroAV. These veiws, hoAvever, have been drawn from a very limited number of observations, in which particular morbid alterations have led to the theories maintained. But the variety of appearances pre- sented on dissection, and the occasional absence of one or the other, or all of them in particular cases, sufficiently proves that morbid anatomy is as yet unable to furnish us with a sufficiently hydrophobia, (Diagnosis.) 403 extended series of facts from which we can deduce any positive conclusions as to the nature or seat of hydrophobia. Did we in- deed, infer the cause from the effects, Ave might Avith some show of reason attribute the disease to more or less pressure upon the eighth pair of nerves. A careful perusal of the experiments made upon this nerve by physiologists, and particularly by Dr. John Reid of Edinburgh (Edin. Med. and Surg. Journ., No. cxxxiv), will show that congestion of the membranes at the base of the brain, producing more or less pressure upon the origin of these nerves, is capable of explaining all the phenomena the disorder presents, viz. spasms of the pharynx, accompanied with pain ex- tending to those of the larynx and lower part of the face, dyspnoea, secretion of frothy mucus, pain in the back of the neck, chest, or epigastrium, nausea, vomiting, &c; while the other symptoms, such as the excited mental faculties, delirium, increased sensi- bility, &c, may be ascribed to the participation of the cerebrum, the fifth and other nerves, in the morbid action. Had we space to follow this theory, we could satisfactorily shoAV that it is sup- ported by more anatomical, physiological, and pathological facts, than any other, and fully agrees Avith the researches of the accu- rate experimenter to whom Ave have above alluded. If attention during post mortem examinations in cases of hydrophobia were more particularly directed toAvards this view of the subject, we might be able to speak with certainty regarding it. On this point, however, the present state of science has only furnished us with conjecture, The same may be said of other questions con- nected with the pathology of this disease, such as the origin of the virus; the changes it undergoes after the bite, and before the commencement of the premonitory symptoms; Avhether it pro- duces its effects directly or indirectly, by absorption or otherwise; Avhether the disease is communicable by man, when it arises from other causes besides inoculation, &c. These interesting questions have been fully discussed by various authors, without any posi- tive results having been arrived at, a circumstance which in some degree reconciles us to the necessity imposed upon us by our limits, of not entering into their consideration. Diagnosis. Hydrophobia, when perfectly developed, presents such peculiarities as readily distinguish it from all other disorders. The bite of a rabid animal may have healed up, however, and have been forgotten long before the appearance of the premoni- tory symptoms, and under such circumstances these may be mis- taken for melancholy and hypochondriasis. The rapid progress of hydrophobia, and the manifestation of the characteristic symp- toms of the disorder, such as difficulty of deglutition, dread of water, &c, will soon clear up any doubts that may exist. Many Avriters have pointed out the similarity between hydro- phobia and tetanus, and undoubtedly they resemble each other in many particulars. In general, however, the spasms in the 404 HYDROPHOBIA, (PrOgHOStS.) former are clonic, of short duration, and followed by distinct in- tervals; in the latter they are tonic, of longer or shorter duration, with remissions only. In hydrophobia the pharynx and root of the tongue are the parts first complained of, and the mouth opens and shuts readily. In tetanus there is almost ahvays pain and stiffness in the muscles of the jaAVs, which gradually become fixed and closed. Thirst, vomiting, and febrile symptoms, are common in hydrophobia, rare in tetanus. In the first also the mind is unusally excited from the beginning, in the latter it is rarely altered, and then only toAvards the termination. A knoAvledge of these circumstances can rarely fail in detecting hydrophobia from tetanus, even when it arises independently of a bite. It must not be denied, hoAvever, that instances have occasionally occurred, in which the diagnosis has been very difficult. Cases are recorded arising from the bite of a rabid animal, in which, together with all the symptoms of hydrophobia, there Avas tetanic rigidity of the muscles with complete opisthotonos. On the other hand, traumatic tetanus may exist, with constriction of the throat, horror of liquids, increased sensibility, abundant flow of saliva, and all the symptoms of hydrophobia. Such instances, however, are very rare, and are only to be detected by taking into con- sideration the causes, period of accession, and progress of the symptoms. Hydrophobia may be confounded with some rare forms of hysteria. The history of the case, presence of the globus, borbo- rygmi, absence of increased salivary secretion, &c, Avill distinguish it. Hydrophobia from inoculation is known by the traces of a bite the local symptoms connected with it, and the accession from the twentieth to the fortieth day, Avhile in that arising from other causes there is no wound, and there are no local symptoms. Prognosis. Hydrophobia must be considered as one of the most fatal diseases to which the human subject is liable, and by some authors has been thought invariably to terminate in death. Several cases, however, caused by inoculation, are recorded, in which all the symptoms have been present, and yet recovery has taken place. Hydrophobia induced by the bites of rabid animals is much more fatal than that arising from other causes. It has been thought by some that Avild animals inflict more dangerous injuries than those which are domesticated, a circumstance which, if true, may be attributed, not to any greater intensity of the virus, but the deeper Avounds such animals inflict, and the more perfect inoculation thus occasioned. Wolves also, Avith regard to which this remark has principally been made, usually fly at the face, while dogs bite through the clothes. Others, however, maintain, that small wounds are more dangerous than large, as in the former the flow of blood is not great, and does not wash away the virus Avhich is deposited. The proportion which the occurrence of hydrophobia bears to hydrophobia, (Treatment.) 405 the number of persons bitten is unknoAvn. Mr. J. Hunter has stated that on one occasion a dog bit twenty persons, of whom only one became affected Avith the disease. In 1780 at Senlis, a dog bit fifteen persons, of whom three afterwards died of hydro- phobia. At Brives seventeen persons Avere bit by a wolf: of these ten died. Of twenty-three others bit by a she-wolf, thirteen died. (Troilliet.) The chances of escape ought never to be relied on, as no doubt can exist that the individual who has been bitten by a rabid animal incurs great risk, and the prognosis must always be more unfavorable when no preventive measures have been employed, than when excision or cauterisation has been had recourse to. Treatment. A survey of the causes which occasion hydro- phobia, as well as the symptoms of the disease when it is fully established, shoAvs that the treatment should be divided into the prophylactic or preventive, and curative. 1. Prophylactic treatment. As we shall afterwards have occasion to observe, medicine has little control over the disease when once fully established: the prevention of the disease is con- sequently the principal means of escaping the extreme suffering and dreadful death Avhich hydrophobia in general occasions. It fortunately happens that we are Avith tolerable certainty enabled to guard against the invasion of the disease when an individual has been bitten by a rabid animal, and Ave think it may be truly stated, that every person Avho has once witnessed the disorder would cheerfully submit to any temporary pain, to give even the chance of being relieved from its horrors. Of all methods the complete excision of the bitten parts, and the immediate applica- tion of some poAverful caustic to the raw surface, is that which undoubtedly merits the greatest confidence. When this cannot be done immediately from want of instruments or necessary assistance, the Avound should be perseveringly washed with tepid water. Dr. Haygarth recommends a continued stream of Avater from the spout of a tea-kettle, held up at a considerable distance, to be directed upon its surface. Excision, however, is to be had recourse to as soon as possible, and great care should be taken that the operation is performed effectually, and every portion ex- posed to the animal's teeth entirely removed. It is stated that on one occasion Mr. Hunter, after examining the piece cut out, thought he had removed all that Avas necessary, but on exploring the surface of the wound he found a hollow had been left which had been exposed to the dog's teeth, and which could only have been discovered after the operation. (Trans, of Med. Soc.) This circumstance indicates not only free excision, but a careful ex- amination of the wound afterAvards. Many practitioners think that caustic is alone sufficient to destroy the virus, and various remedies of this class have been recommended, as the actual cautery, the nitric, sulphuric, and hydrochloric acids, potassa fusa, 406 hydrophobia, (Treatment.) nitrate of silver, butter of antimony, &c. Mr. Youatt prefers the nitrate of silver, as it produces a hard, dry, and insoluble eschar, whereas most of the others produce a soft or fluid mass in contact Avith the skin in Avhich the virus is suspended, so that re-inocula- tion may be accomplished. He considers the lunar caustic also, when sharpened to a point, may be applied Avith more certainty to every recess and sinuosity of the wound. He has operated in this Avay on 400 persons, and on himself four times after bites from dogs decidedly rabid, and the disease has not appeared. He recommends also that, after the part has been destroyed by the caustic, the Avound should be healed speedily, in the mildest man- ner. In this respect he is opposed to the practice advised by several German physicians, who, by the application of stimulating substances, keep up a state of suppuration for some time. L. M. Axter, senior surgeon at Vienna, applies a blister over the Avound, and afterAvards dresses it Avith Pulv. Lyttae, or some stimulating lotion, for six weeks. He gives also a grain of Pulv. Lyttae and six grains of Cane. Ocul. internally for six days. During a period of twenty-seven years, no patient thus treated had been brought back to the hospital laboring under the disease. Dr. Hausbrand of Braimsberg employs general bleeding, and makes deep scarifi- cations of the Avound, Avhich he washes Avith salt and water, after favoring the Aoav of blood as much as possible. He then applies an ointment of Ung. Basilicum and Pulv. Lyttae, so as to keep up a discharge for three months. He also gives camphor and opium internally for the first three days. Eleven persons bitten by dogs actually rabid escaped after this treatment. Dr. Wendt of Breslau, besides'keeping up for six weeks suppuration in the wound by means of Pulv. Lyttae and irritating applications, em- ployed mercury internally, so as to produce salivation: 180 per- sons were admitted into the Breslau hospital, of Avhom half had been bitten by rabid dogs, or supposed to be so, and two only died. All these methods of treatment are infinitely more painful and not so effectual as excision of the part, which Ave consider ought invariably to be done, Avhenever the situation of the bite will allow of it; and if not, the nitrate of silver, as recommended by Mr. Youatt, should be Avell-applied, and the Avound enlarged if necessary, in order to allow the cauterisation of any sinus or recess on its surface. The application of a small cupping-glass over the bitten part has been recommended by Dr. Barry, and after excision this practice may be useful. Dr. Good advises the application of a tight ligature a short distance above the laceration, which may also be used. Amputation has been thought Avar- rantable in some cases by Mr. S. Cooper, when a limb has been so severely lacerated, that complete excision of the parts is almost impossible or very dangerous. In cases Avhere the smaller bones have been injured, this operation should be performed. Dr. Marochetti considers that the rabid virus appears in the hydrophobia, (Treatment.) 407 form of small pustules under the tongue, at each side of the frae- num, from the third to the ninth day, and that the prophylactic treatment essentially consists in opening and cauterising them within twenty-four hours after their formation. He also advises that the mouth should be Avashed Avith a decoction of the genista tinctoria, of Avhich the patient should drink a pint and a half every day for six weeks. (Hufeland's Journal, March, 1824.) In addition to several cases reported by himself, this plan has ap- parently succeeded in some cases given by Salvatori and Rossi. In ten cases however, in Avhich this treatment Avas adopted by Majistal, five died, which is a very large proportion: probably more Avould not have been affected if nothing had been done. When these pustules are present, it will be well, as a precaution- ary measure, to open and cauterise them, but in numerous cases which have been carefully examined they could not be found. It has been supposed that the extremities of Warton's ducts have not unfrequently been mistaken for them. Washing the wound Avith oxymuriatic acid has been recommended by Wendelstadt and Brugnatelli, and for a short time this remedy was much thought of, but it soon fell into neglect. A case mentioned by Dr. Johnson died of the disease, although excision Avas practised seventy hours after the infliction of the bite, and the wound washed with oxymuriatic acid. It has been supposed by Dr. A. T. Thomson, that the virus remains latent in the wound, and produces no evil effect until a peculiar state of the constitution favors its action. It is of course impossible to determine the truth of this theory, but the practical point to be derived from it is, that excision, even some time after the bite has been inflicted, may be useful. Jolly tells us that M. Recamier opened the cicatrices which were tumefied in an indi- vidual who had been bitten by a rabid animal fifteen days before, and cauterised them with the crystallised nitrate of mercury. Baths and diaphoretics were also employed, and the patient escaped the disorder, while another person Avho had been bitten by the same rabid animal, at the same time, perished from hydro- phobia. A case is related by Professor Rush, where excision Avas performed thirty-one days after the bite, even after the hydro- phobic symptoms had appeared, and still the patient's life was saved. Dr. Harder relates a case in which, five months after the bite, and eight weeks after excision, hydrophobia appeared, but another excision and cauterisation saved the child. In two weeks the symptoms again returned, and a pale and painful excrescence formed in the bottom of the wound. This was excised, the nitrate of silver applied, and recovery took place. (Petersburgh Med. Trans., vol. i, p. 170.) These are undoubtedly strong cases in favor of excision or the cautery, some time after the reception of the bite. The longest period at which it may be prudent to have recourse to such a proceeding is undetermined; but we should 408 hydrophobia, (Treatment.) not hesitate to advise it any time before the fortieth day, if the animal was proved to have been rabid. The cases above alluded to also render it Avarrantable to excise the part Avhenever pain or swelling commences in the wound. KnoAving that mental agitation is a powerful exciting cause of the disorder, particularly Avhen the individual is aware that the animal from Avhich the bite has been received is in a rabid state, every means should be taken to tranquillise the mind, and remove imaginary terror. If an individual has been bitten by a dog sup- posed to be rabid, but which is not so, the animal should be ex- hibited to the sufferer; but if it have been destroyed under the unfounded apprehension, it will be well to cauterise the Avound, and use the same methods as if the animal had been decidedly rabid. Experience has sufficiently proved that all internal remedies, with a view of preventing the accession of the disease, are un- Avorthy of confidence. Considerable doubts must always exist even with regard to the utility of local prophylactic treatment, so long as the great majority of individuals bitten escape without remedies of any kind having been applied, though there are few physicians who would not recommend, and feAV prudent indi- viduals Avho would not submit to it. 2. Curative treatment. The result of experience has proved, that no mode of treatment hitherto adopted is capable of arresting the disease when once fully established. A few cases of recovery indeed have taken place, but the remedies which Avere supposed to have affected these, have failed so frequently in other instances, that it may be doubted whether such recoveries are to be attribu- ted to the power of medicine. Of this the reader will judge from the following account of the effects which various therapeutic means have produced. Sedatives have been most extensively tried with a view of overcoming the nervous excitement. Opium in particular has been largely given, and in all forms without success. Dr. Vaughan gave 57 grains in fourteen hours, besides half an ounce of laud- anum in an injection, and Dr. Babington gave 180 grains in eleven hours. (Med. Records and Researches, p. 121.) Both cases died. Dupuytren injected the gummy extract with the like ill success. Dr. Booth recommended that 24 minims of the solution of acetate of morphia mixed with 3 ij of distilled water should be introduced into the cephalic vein, and repeated at intervals of ten minutes if no effect was observed. (On Hydrophobia.) Dr. Brundreth tried this plan, but with only temporary alleviation. (Edin. Med. and Surg. Journ., No. lxxxii.) In another case Dr. J. L. Bardsley did not find it produce any benefit whatever. Dr. Ward advises opium frictions, which in some instances have occasioned temporary abatement of the spasms. Schmidt, Rich- ter, Munch, and Brera, have administered belladonna, but unsuc- hydrophobia, (Treatment.) 409 sessfully, when the disease has been perfectly established. The latter Avriter prescribed it in combination Avith mercury to the ex- tent of 3hj of the powdered root daily, and has published several cases in which it appeared to prevent the attack, even Avhen the early symptoms of the disease Avere present. (Mem. Soc. Ital. Scienza Mod., tom. xvii.) In the hands of other physicians, hoAvever, it has entirely failed. Prussic acid produced only tem- porary relief in Dr. A. T. Thomson's case, and in several other in- stances it has been found inert. Tobacco Avas used by Mr. Sawrey Avith advantage, and has been found beneficial in relieving the spasms of the muscles of the throat. As we have observed in the treatment of tetanus, it is a most powerful means of overcoming extreme nervous excitement, and seems Avorthy of further trial. An infusion of Bj of the leaves in ^viij of water, given in the form of enema, is the best method of administration. Cold affusion, energetically applied, is a powerful sedative, and has been em- ployed, though Avith temporary benefit only. In a case given by Dr. Bardsley, it relieved the burning heat of the skin. Stramo- nium, acetate of lead, Avarm baths, &c. have been used Avithout success. Bloodletting has been recommended by Mead, Boerha'ave, Poupart, Fothergill, Nugent, and others; and has been performed to a great extent with occasional success. Dr. Innes took 116 ounces in four days: this large bleeding produced the greatest possible degree of prostration, but the patient recovered. (Med. Essays and Obs., Edin. vol. i.) Symon (Edin. Med. and Surg. Journ., vol. ix, p. 24.) Shoolbred (Ibid., p. 30.) Wynne (Par- ticulars of the successful Treatment of a Case of Hydrophobia, fyc.) Burton (Phil. Mag. Aug. 1805), and Vogelsang (Med. Repos., vol. iv, p. 500), bled to fainting Avith great success. Dr. Shoolbred recommends that the venesection should be performed in an early stage of the disease, and from a large orifice. Other instances are recorded, in Avhich this treatment Avas followed by recovery; but in others it has failed in preventing the fatal ter- mination. Rutherford, Parry, Bosquillon, and Troilliet, have used bloodletting without beneficial result; the latter even thinks that the cases spoken of by Shoolbred Avere not cases of hydrophobia; and Mr. S. Cooper and Dr. J. L. Bardsley appear to coincide in this opinion. From the published results of this plan of treat- ment hoAvever, Avhen employed at an early stage of the disorder, it appears to have been more beneficial than any other; and in certain cases, Avhere the vascular excitement is much increased, and the constitution robust, may be adopted with every hope of success. Stimulants and tonics have been given with a view of support- ing the system against the prostrating effects of the spasms. Dr. Good Avas of opinion that the disease Avears itself out in six or seven davs, and that if the constitution can be supported beyond 35 410 hydrophobia, (Treatment.) that time, the patient Avill recover. For this purpose, the different preparations of ammonia, camphor, assafcetida, castor, and other stimulants, have been largely employed. M usk has been thought by some to be useful, and may be given in large doses combined with opium and belladonna. It can, hoAvever, in no way be de- pended on; Avhen conjoined Avith cinnabar, and abont four ounces of arrack, it forms the Pulv. Cobbii or Turgiensis, Avhich had a short-lived reputation for the cure of this malady. Electricity and galvanism have been employed occasionally, Avith temporary benefit. Strychnia and the nitrous oxide gas Avere given in a case by Dr. Bardsley, but Avith little apparent effect. Carbonate of iron has been administered by Dr. Elliotson, and the mineral tonics by Dr. Bright, but Avithout effect. The latter also recommends diffusible stimuli, and an injection of the Tinct. Ferri Mur. into the rectum. Acids, particularly the oxy- muriatic and acetic, have been used and recommended, both as preventive and curative remedies, by Previtati, Agliatelli, Ancelli, Narcissi, and Brugnatelli (Giornale de Fiscia, 1821.) Nitrate of silver, plunging in the sea, hydrochlorine, sulphate of quinine; tur- pentine, and other remedies of this class, have been given, and found useless. Mercury has been extensively employed by numerous practi- tioners. It was first recommended by Dessault, and afterAvards by James, Kaltschmid, Du Choisel, Andry, Sebig, Kbnigsdorfer, Walther, and others. Its beneficial effects are wholly denied by Frank, Girtanner, De Moneta, Raymond and several other Avriters, and experience has proved it has little power in controlling the symptoms. Arsenic has been given by Dr. Marcet, combined with opium and iron, Avithout benefit. Of sudorfic remedies, sweating by means of heated air has been recommended, but the time necessary to produce any effect on the system by these means is apparently hostile to its use. Diu- retics have been highly extolled, especially cantharides, Avhich has been employed for many ages in this disorder, and has been much praised as a prophylactic, by Axter of Vienna. Emetics have been occasionally given. Dr. Satterly thought them advantageous in a case in Avhich they Avere employed by him. (Med. Trans, of the Coll. of Phys., vol. iv.) Purgatives should be given to procure the necessary alvine discharges, but do not appear to have been much relied on by practitioners. Injection of warm water into the veins has been tried by Ma- gendie, from his having observed nervous debility produced in animals Avhich had been subjected to it, and that the fluid parts of the blood were diminished by the impossibility of taking fluids, and the great cutaneous and pulmonary transpiration. A pint of water heated to 30° Reaumur Avas injected into the arm of a man laboring under advanced and violent hydrophobia. Immediately after the operation the patient became tranquil, and the pulse fell hydrophobia, (Treatment.) 411 in twenty minutes from 150 to 80. The spasms ceased, and the individual drank a glass of Avater without difficulty. He conti- nued to improve until the fifth day,- when SAvellings and acute pains in the wrists, knees, and elbows, appeared, and an abscess formed in the leg, occasioned by the broken points of tAvo lancets, which remained in the foot, from former unsuccessful efforts to bleed. He died on the ninth day; The sAvollen joints were found filled Avith pus, and it is probable these secondary purulent depo- sits Avere the cause of death. Dr. Pearson recommended the in- jection of warm water in small quantities, impregnated Avith nar- cotic substances, into the veins, in order to relieve the spasms Avhich prevent deglutition, folloAved up by cathartics, antispasmo- dics, the mineral and vegetable tonics, and sponging the body with cold Avater and vinegar. Tracheotomy has been proposed by Mr. Mayo as an expedient in this disease. Dr. Hunter speaks of tAvo cases benefitted by running. Several other remedies, supposed to act as specifics, have been employed. The ash-colored liverAVort Avas formerly so popular, as to be admitted into the London Pharmacopoeia of 1721, under the name of Pulvis Antilyssus. The thalictrum flavum and angustifolium, and the delphinum consolida, are plants Avhich were considered specific in some parts of Russia. (Med. Repos., vol. ii, p. 153.) The guaco juice has been recommended by Sir Robert Kerr, but has been found inert in several cases. In Ame- rica, the sartellaria laterifolia has been extolled by Dr. Spalding. The bite of a viper has been tried in some cases, Avith the idea that the venom of this animal Avould counteract the rabid virus. (Diet, des Sciences Mid.) The alysma plantago, ophiorrhiza mungos, genista tinctoria, have been praised, as Avell as phospho- rated water, soap lees, and other remedies, which are iioav aban- doned. In the midst of so many remedies Avhich have been lauded by partisans, and in turn found to be useless—with a knoAvledge that the most powerful drugs are apparently inert—overAvhelmed Avith the sad conviction that the learning and talents of the most expe- rienced and energetic physicians have utterly failed in arresting the progress of this dreadful malady, the practitioner, Avhen called upon to act, must still respond to the aAvful question—What is to be done? It is in such a situation only that he can experience the benefit of having studied the Avhole train of nervous diseases, of being able to detect and appreciate the analogies and dissimi- larities which exist between each respectively, and of having de- duced from the whole such general principles, as Avill enable him to act conscientiously in every case, as far as the present state of the art will permit. In hydrophobia, therefore, as in tetanus, and several other nervous disorders, no exclusive line of treatment should be followed. If the patient exhibit signs of plethora, be 412 hydrophobia, (Treatment.) strong, of a vigorous constitution, and there be symptoms of in- creased vascular excitement, venesection, cupping, or the appli- cation of leeches to the occiput or back of the neck, and antiphlo- gistic remedies should be actively employed, so as to make an impression upon the nervous system. But if there be evidence of anaemia, and general depression of the vital powers, stimulants and tonics are indicated, and should be used energetically. With a vieAV of overcoming the spasms, the tobacco enema, or cold af- fusion, may be had recourse to according to circumstances; and the same kind of treatment should be persevered in, as has been recommended for acute tetanus. (See Tetanus.) 413 NEURALGIA. Definition.—Symptoms.—Varieties.—Diagnosis.—Causes.—Nature.— Treatment. The term Neuralgia (derived from vevpov, a nerve, and c&yoj, pain), is applied to a painful affection in the course of a nerve, not necessarily referrible to inflammation or to any appreciable organic change. The pain is in some instances confined to the trunk of a nerve, in others extends to the branches, and occasion- ally proceeds from the branches to the trunk. It is sudden in its onset, often commencing Avith, rather than acquiring by degrees, its full intensity. The patient is usually at a loss for Avords fully to describe the suffering, but often speaks of it as shooting, stab- bing, or scalding. The pain is in most instances aggravated by a slight touch, but relieved by firm pressure. It may be intermit- tent, remittent, or without a distinct interval. Intermission is a more frequent characteristic than is usually supposed, and it com- monly attends neuralgia from mechanical injury. The attack is often ushered in by numbness, or a sensation of creeping or prick- ing in the part affected; and its cessation may be preceded by itching. Exalted sensibility of the part, muscular agitation, cramp, and even tetanic stiffness, may folloAV. The phenomena are in some degree diversified according to the peculiar function of the suffering organ. In the intervals betAveen the paroxysms, a sen- sation of obtuse pain or numbness may be experienced, or there may be perfect freedom from all uneasy feeling. The accessions gradually become more and more violent, and the intermissions less defined, till at last the patient enjoys no immunity from suf- fering, except Avhen under the stupefying influence of sedatives. A severe case of this description probably occasions the greatest degree of anguish to Avhich the human body is liable; and in its full extent of duration and intensity, is perhaps " beyond the en- durance of human fortitude." Hippocrates and Galen appear to have confounded tic doulou- reux with toothach, and to have described other neuralgic affec- tions as varieties of gout and rheumatism. Andre, in 1756, in a work on a very different subject, introduced remarks showing his knoAvledge of their separate character. Cotunnius, in 1770, spe- cified the discriminating marks betAveen gout and sciatica, and described Avith considerable accuracy the cubito-digital variety of 35* 414 neuralgia, (Symptoms.) neuralgia. His observations were folloAved by those of Fother- gill, Pujol, Thouret, and Fortsmann on tic douloureux. But the vieAVS entertained of the affection Avere very incomplete until Chaussier, in 1802, first introduced the name neuralgia, accurately described the disorder as affecting the nervous cords, and gave a faithful account of several varieties. Since the publication of Chaussier's remarks, the disease has attracted a degree of atten- tion, in some degree commensurate Avith its importance. It is noAV generally allowed not to be limited to any particular part of the body; and evidence is continually accumulating in support of the opinion of M. Jolly, that as wherever there is blood there may be inflammation, so wherever there is a nerve, there may be neuralgia. We cannot deny even to the ganglionic system of nerves, a liability to exalted sensibility. Cruveilhier has shoAvn by experiment, that spasmodic cough may be produced by irrita- tion of the pneumogastric nerve. Various affections, such as asthma, dyspnoea, pertussis, and nervous vomiting, have been re- ferred to a similar condition by Pinel, Delens, Bland, and Lob- stein. Laennec attributed angina pectoris to a similar source. Legond has written an interesting monograph on colica pictonum, describing it as a neuralgic affection of the sympathetic nerve. Gastrodynia, and various analogous disorders, have also been traced to a similar condition by Teale, Marshall, Griffin, and others, in our own country. On these interesting subjects it may be sufficient to mention, that such affections of ganglionic nerves are generally attended with altered or increased secretion of asso- ciated organs; that they are more frequent in Avomen; and that the exacerbations, according to Jolly, instead of occurring, as in ordinary neuralgia, chiefly in the evening, appear at night or early in the morning. There is no reason to believe, that any of the nerves of the cerebro-spinal system, from the root to the rami- fications, enjoy immunity from neuralgia. A severe variety of headach (termed cerebralgia) appears to depend on a neuralgic condition of the membranes of the brain. A similar state of the membranes of the spinal cord occasionally exists, and may be associated Avith alterations of the voice, spasm of the cesophagus, cough, dyspnoea, vomiting, colic, cramp, &c. (Nouv. Biblioth. Mid., 1827. Gassaud and Costa.) The subcutaneous nerves, especially those of parts provided Avith numerous muscles, are, hoAvever, most subject to the disease; and the most frequent seat of the intense form is the head and face, in consequence of the number and sensitiveness of the nerves in this situation, as well as their superficial arrangement, and per- haps, also, from their intimate connection Avith tlie sympathetic, and consequent susceptibility of impression from conditions of the abdominal viscera. Bell and Shaw have questioned the liability of the portio dura to neuralgia, but there is reason to believe that its branches are occasionally affected, although much less frequent- neuralgia, (Symptoms.) 415 ly than those of the fifth pair of nerves. In forty cases related by Bellingheri, thirty-eight affected the fifth pair; only two the portio dura. It is the third branch of the fifth pair which is most liable to this distressing complaint in its most intense form; and to this variety, from the suddenness of its onset, the term tic douloureux was originally given by Andre. It constitutes the dolor faciei of FothergiU and Fortsmann, the dolor faciei typico charactere of Siebold, the neuralgia facialis of Chaussier, neuralgia spasmo- dica of Kerrison. It is denominated trismus clonicus by Acka- mann, trismus dolorificus by Sauvages, hemicrania idiopathica by Darwin, rhumatismus canerosushj Vogel, febris topica by Van Swieten, ophthalmodynia periodica by Plenck, and by others prosopalgia, dolor faciei atrox, Src. When the supraor- bital branch is affected, Ave generally find redness, sensibility, and pain of the eye, shedding of tears*, sAvelling of the veins, and throbbing of the arteries in the neighborhood. The attack gene- rally comes on in the evening, and lasts most of the night: some- times the affection is confined to the eyeball, constituting a severe variety of neuralgia, Avhich has been Avell described by Mr. Mid- dlemore: the pain is usually intermittent. There is great intole- rance of light, especially during the paroxysms, and the pupil is in most cases contracted. When the suborbital nerve suffers, the pain may. be confined to the eyelid, or it may extend to the dental branch, involving the maxillary sinus, palate, base of the tongue, and side of the face, and through the communications of this nerve Avith the portia dura, convulsive actions of the lid, cheeks, and upper lip, may be produced. Shedding of tears and excretion of nasal mucus are common accompaniments!, but sometimes these parts are remarkably dry. When the maxillary branch is the seat chiefly implicated, the teeth or their sockets, the sides of the tongue, the lips, and chin, suffer. This is said to be the least regular in its progress of all the varieties of facial neuralgia, and to affect the right more frequently than the left side. When associated Avith trismus, or with lateral distortion of the face, the disorder may be more obstinate, but the pain is generally less severe. Sometimes the complaint is limited to a single nervous tAvig, as to the labial, dental, or palpebral; but in other instances it extends to the neighboring parts: it is gene- rally confined to one side, but sometimes attacks both sides toge- ther, or passes alternately from one side to the other. In all these varieties the first attacks of pain may be so slight as * It is remarkable that cases which have involved the lachrymal glands often leave a liability to shed tfears even during sleep and in the absence of emotion.—Author. | Dr. Macculloch on one occasion observed a pint of mucus to distil from the nostrils in a short space of time.—Author. 416 neuralgia, (Symj)toms.) io attract little attention, but their severity gradually increases. The duration of the paroxysm may be only a feAV seconds, and seldom exceeds a minute. Sometimes repeated attacks occur in a feAV minutes, at other times the intervals are considerable. The suddenness of the pain stops abruptly any conversation in which the patient may be engaged; and rocking in his chair, or writhing with anguish, he places his hand on the face, which he beats, rubs, or presses. He knits the broAV, compresses the eyelids, draws up the lips into a sardonic grin, and fears either to speak or to masticate. When the complaint has been long protracted the appetite fails, a feverish state arises, the patient obtains no rest, except under the influence of opiates, and sometimes becomes de- lirious from the violence of the pain. The affection described by Itard under the name of Otalgia, and Avhich is peculiarly apt to occur in infants and in children shedding the first set of teeth, evidently belongs to this class of disorders, differing from otitis in the lancinating and intermittent character of the pain and the absence of fever. The paroxysm is frequently accompanied with deafness, and, when existing in adults, otalgia often associated with facial neuralgia. The cervical nerves have been occasionally affected with this disorder, in consequence of injury occasioned either by the appli- cation of leeches (Nouv. Bibl. Mid., 1827,) or from a Avound re- ceived in the operation of opening the jugular vein. Of the intercostal nerves, that Avhich runs betAveen the eighth and ninth ribs is most liable to suffer, particularly in Avomen. A neuralgic condition of the lumbamerves, constituting one of the most important varieties of lumbago, has been denominated ilio- scrotal and spermatic: the anus, spermatic cord, scrotum, and ure- ter, are the parts chiefly affected, and in Avomen the vulva: the cubito-digital variety of neuralgia described by Cotugno and Chaussier is the most frequent to Avhich the upper extremities are subject. The pain passes between the olecranon and tubercle of the humerus, and runs doAvn to the fore-finger and to that adjoin- ing. The femoro-popliteal (commonly called sciatica) is perhaps the most common, and the best known. The pain sometimes seems to arise from the ischiatic notch; at other times from the origin of the sacral nerves, some of the divisions of Avhich it follows. It is particularly liable to occur in pregnant Avomen, in consequence of the pressure of the gravid uterus. Neuralgia of the plantar nerve has been knoAvn to alternate Avith that of the facial. These varieties have been mentioned as among the most fre- quent affections of single nerves, and it is unnecessary farther to extend the enumeration. Parenchymatous, muscular, and membranous structures are also liable to be affected. Hepatalgia and hysteralgia may be mentioned as examples of neuralgia of parenchymatous tissue. neuralgia, (Symptoms.) 417 The bruised feeling attending fever, and the muscular pains de- pending on atmospheric vicissitudes, are examples of muscular neuralgia. To the membranous variety may be referred some intensely painful affections of the pleura and peritoneum, occa- sional examples of Avandering gout, and not a few of the affec- tions of the periosteum, often attributed to syphilis or mercury. Neuralgic affections of the joints might be noticed as instances of membranous neuralgia, but they occur most frequently in persons subject to hysteria, and have therefore been described in the dis- sertation on that complaint. Some intermittent affections of the nostrils, bronchial tubes, and conjunctive membranes, as Avell as of the urethra, may be arranged in the same division. A tertian variety affecting the last mentioned part, has been described by Professor Fulci. Neuralgia of the rectum occasionally occurs: in a case described by Busche, it existed only during the first three months of pregnancy. A neuralgic condition .of the skin may present itself, sometimes as a symptom of internal disease, at other times as a primary disorder. The " epidemie de Paris," Avhich occurred in the spring of 1828, and Avhichis described by Chomel in the Journal Hebdomodaire, No. ix, affords a remarkable example of cutaneous neuralgia: it began in persons previously healthy, Avith sensations of pricking, severe pain, and acute sensi- bility of the integuments of the hands and feet; subsequently the sensibility of the affected parts was diminished or abolished, but in most instances Avas gradually and spontaneously restored. Herpes and other eruptions are occasionally preceded by pain of a neuralgic character. Glandular organs sometimes suffer severely from the com- plaint. The liability of the lachrymal gland to the malady has been already noticed. Sir A. Cooper has accurately described neuralgia of the mamma, under the designation of " the irritable breast." It is almost confined to patients betAveen the age of fifteen and thirty. Sometimes both breasts are affected, at other times only part of one. In cases of long duration, the gland is sometimes slightly enlarged, but in most instances is not visibly , altered. The pain darts like electricity into the part, shoots to the axilla, shoulder, inner side of the elbow and fingers, or passes by the sides of the body to the hip. There are alternate feelings of heat and cold in the part. The patient is unable to rest on the side affected, and the Aveight of the breast sometimes occa- sions intense pain. One or more lobes are exquisitely tender, and very severe pain, often of some hours' duration, is produced by handling them. Vomiting is sometimes induced by sympathetic disturbance of the stomach. The complaint may continue for months or years Avithout intermission. An interesting example of neuralgia of the kidneys has been described by Dr. Macculloch. It assumed an intermittent cha- 418 neuralgia, (Diagnosis.) racter, and the secretion of urine during the fit Avas more abun- dant than in diabetes. When the testis is affected Avith neuralgia, some part of that organ, or of the epididymis, is exquisitely tender, so as to oblige the patient to rest in the recumbent posture, and on the side opposite to that affected. The increase of pain produced by pres- sure or motion, sometimes continues for a considerable time after- Avards. Sympathetic vomiting is sometimes excited by the vio- lence of the pain. A variety of neuralgia depending on a small tumor involving the nervous structure has been remarked by Camper (Demonst. Anat. Pathol., lib. i), Cheselden and Bisset (Mem. of Med. Soc. of Loud., vol. iii; Med. Facts and Obs., vol. vi), but was first fully described by Mr. William Wood (Edin. Med. and Surg. Journ., vol. viii), under the denomination of "painful subcutane- ous tubercle." -The pain occurs in paroxysms, lasting from ten minutes to two hours, gradually increasing in severity, and leav- ing a bruised feeling. The pain is increased by changes of atmo- sphere. It is also produced, or, if previously existing, is much aggravated by pressure. The complaint is most common in Avomen, and in a case related by Dr. Bisset, Avas invariably more severe during pregnancy. Angina pectoris is probably a neuralgic affection of some of the cardiac nerves, sometimes arising from mechanical irritation, occasioned by organic disease of the heart or its vessels; but this subject is still involved in uncertainty. It may be questioned, Avhether any of the affections which have been designated Gastralgia and Enteralgia can be strictly considered neuralgic. Diagnosis. The exquisite form of neuralgia is readily distin- guished from every other malady by the nature of the pain, and by the suddenness of its onset. In less severe attacks, the situa- tion of the pain in the course of a nerve is generally sufficiently characteristic. In neuritis there is decided tenderness on firm pressure, with heat, redness, and other signs of inflammation, and Avithout the sensation of coldness, so common in neuralgia. It is, hoAvever, important to remember, that inflammation of a nerve may occasionally precede or accompany neuralgia. The pain produced by otitis is less lancinating and intermittent than that of otalgia, and is not relieved by the introduction of anodynes into the ear. The pain of common toothach is more constant, is increased by touching with a metallic instrument, and is often attended with SAvelling of the gums. But it must not be forgotten, that the neuralgic variety of toothach is by no means uncommon: it may attend or alternate with other forms of neuralgia, is produced by the same causes, and resembles them in the nature of the pain. The pain of rheumatism is usually neuralgia, (Nature.) 419 gnawing, pungent, continuous, or remittent, while that of neural- gia is lancinating or thrilling, periodical, and often relieved by pressure. Causes. Among the predisposing causes may be mentioned the nervous temperament, adult age, residence in marshy coun- tries, intellectual exertion, moral emotions, and long continued watching. Dr. Baillie and others agree, that the disease has lately become more frequent than formerly; and although a more accurate diagnosis, by separating the disease from rheumatism, may have conduced to the apparent increase of frequency, yet there is good reason to believe, that the anxieties associated Avith a state of progressive civilisation have increased the prevalence of these affections. The question, AArhether one sex be more sub- ject than the other to this disorder, must be considered as unde- termined, Andre, Baillie, Samuel FothergiU, Sauvages, and Bar- nard, considering it more frequent in men, while Pujol, John FothergiU, and Hutchinson, regard it as more common in Avomen. The observations of Thouret, however, strongly support the for- mer opinion. He examined the question with considerable care, and found, that of the cases Avhich fell under his observation, the proportion of men to that of Avomen suffering from the complaint was as two to one. The disease may be induced by any cause Avhich deranges the digestive organs, or which disturbs the balance of the circulation. Long fasting, or free bleeding for the cure of inflammation, maybe followed by a paroxysm; occasion- ally, the opposite condition of plethora may produce it. Of the exciting causes most commonly enumerated, viz., blows, fright, suppression of sanguineous discharges, currents of cold air and-damp, the last is probably the most efficient. Of forty cases described by Bellingheri, tAvo Avere attributed to fright, two to wounds, tAvo to suppressed .discharges, and thirty-four to damp. All the forms of the complaint prevail most in spring, and during easterly Avinds. Neuralgic ophthalmia is most frequently met with in places where intermittents are common: it is, for example, prevalent on the coasts of the Mediterranean, at Tri- poli, and on the shores of Barbary, at Rome, Naples, and Flo- rence, and at Valentia and Albatera. In connection with the relation existing between neuralgia and toothach, it may be inte- resting to mention the observation of Captain Smyth at Villa Cidro in Sardinia, that the women who cultivate the marshy plain are noted for bad teeth, Avhile those of the men who reside on the mountains are remarkably sound. Haemorrhoids and stricture of the urethra sometimes induce a liability to neuralgic affections, particularly of the lower extremities. Nature. The opinion of Cabanis and of many of the ancients, that the disorder depends upon an arrest of the nervous fluid, although founded on an assumption, has the support of many of the moderns, and is not Avithout plausibility. Whatever may be 420 neuralgia, (Nature.) the nature of the nervous influence, its proportionate distribution among the organs of sensation, motion, and intelligence, seems to be essential to the healthy state. Many phenomena are most readily explicable on the supposition of a change in the direction of the nervous energy. It is, perhaps, through the intervention of such a change, that pain and convulsion tend to counteract each other, Avhile delirium and drunkenness may suspend both; but Ave pass from these speculative vieAvs to notice the apprecia- ble lesions Avhich have been found associated Avith the disease. Cotunnius, Dr. Sayer, and others, have observed a gelatinous secretion under the neurilemma of affected nerves. Cirillo at- tached importance to thickening of this structure; a condition Avhich Avas also observed by Mr. Earle in the portion of the ulnar nerve, Avhich he removed in a case of neuralgia of the arm. Such appearances must, hoAvever, be alloAved to be only occasional, probably dependent on long-continued disease, and more fre- quently associated with rheumatic affections than Avith true neu- ralgia. Enlargement of the vessels of affected nerves is a much more frequent occurrence. It Avas described as an accompaniment of the complaint by Bichat and Van de Keer, and, during the late war, Avas frequently detected in those Avho had suffered from sciatica. It is probable that in cases of shorter continuance, such a condition may have existed, but have disappeared after death. We have often observed venous congestion' about superficial nerves, affected Avith neuralgia. The necessity for a balance between the arterial and venous system to preserve the healthy condition of nerves, and the fact that these affections are often relieved by warmth, are favorable to the opinion that this con- gestive state may frequently exist. At the same time it must be acknoAvledged, that such a state does not appear essential, since in cases of long duration, examined after death by distinguished pathologists, such as Chaussier, Desault, Cooper, Andral, and Rousset, the nerve has been found in appearance perfectly healthy. In several instances some irritating cause has been discovered betAveen the part to Avhich the pain is referred and the nervous centre. A case of fourteen years' duration is described by Mr. Jeffries, depending on irritation from a piece of china imbedded in the face, and which Avas immediately cured by the removal of the foreign body. Sir H. Halford, in his interesting essay on tic douloureux, has related a case produced by exostosis arising from a sound tooth, and has referred to cases in Avhich disease of bony canals through Avhich nerves pass, or spiculae of bone pressing upon nerves, have been associated Avith neuralgia. In an exam- ple of tic douloureux, Avhich occurred at the Richmond Hospital in Dublin, the gasserian ganglion Avas fibro-cartilaginous, and as large as a nutmeg. In some instances the irritation is communi- neuralgia, (Treatment.) 421 cated from distant nerves by sympathy, as in the case described by Mr. LaAvrence, in which neuralgia of the thumb was occa- sioned by the pressure of a pivot tooth on the nerve of an old fang. Various causes of irritation affecting any part of the cerebro- spinal axis seem capable of producing the complaint. Dr. Mar- shall has related some remarkable instances, in which aneurism of the aorta had occasioned absorption of the bodies of some of the vertebrae, and produced pressure on the spinal cord, but with- out occasioning any observable change in its structure. In one of these cases, in Avhich the arch of the aorta was affected, and the bodies of the fifth, sixth, and seventh dorsal vertebrae were absorbed, the patient frequently suffered from a sensation, as though struck forcibly with the fist or by an electrical shock on the fifth, sixth, and seventh ribs of the left side, and afterwards felt as if burnt in that situation Avith a hot iron. In another case, in Avhich the descending aorta Avas affected, similar shocks, fol- loAved by a burning sensation, were experienced to the left of the linea alba. It is Avorthy of notice, that, in both these patients, drawing a silk handkerchief, hoAvever lightly, over the affected parts from the mesial to the dorsal aspect, occasioned intense agony, whilst draAving the handkerchief in the opposite direction was not attended Avith suffering. Several other practitioners, particularly Player, BroAvn, and Teale, have traced an important connection between a morbid state of the spinal cord and various neuralgic affections; and we have witnessed some remarkable phenomena resulting from bloAvs upon the back, favorable to the same vieAV. In some of these cases there was an alternation of neuralgia with cutaneous eruptions of a scaly character. Alter- nation of the complaint Avith herpes has been noticed by Dr. Bright (Reports of Medical Cases), in a case of intercostal neu- ralgia, and by M. Jolly in the cubito-digital variety (Diet, de Mid. et Chir.); and M. Recamier mentions tAvo cases of sciatica in Avhich zona appeared, but in four days entirely vanished. This is not the place to adduce evidence of connection betAveen certain cutaneous eruptions and affections of the spinal cord; but it may be advanced as a plausible opinion, that when there is disorder of many parts in succession, there is some focus of irritation, and it is reasonable to suspect the medulla spinalis as the great medium of metastasis. Although the researches of pathologists have failed to prove that any organic change is necessarily con- cerned, yet we feel authorised to conclude, that some cause directly interfering Avith the functions of the brain or spinal cord, is gene- rally present in neuralgia, and that the causes of the complaint commonly exert their influence through the medium of these organs. ^Treatment. Few parts of the records of medical practice are more unsatisfactory than those which relate to the treatment of 36 422 neuralgia, (Treatment.) this distressing affection. The long list of remedies, alternately recommended and discarded, furnishes a forcible evidence of their inefficacy. External applications of every kind, tar, cantharides, and even the smoking entrails of live pigeons, have been suc- cessively employed. The internal use of every variety of ano- dyne and of numerous metallic salts, has led to repeated disap- pointment. Lentin honestly confesses, that of fourteen cases Avhich he treated, he did not succeed in curing one. Dr. Baillie observes, that he has known medicine produce an intermission of some months or even a year, and the division of a nerve sus- pend the complaint for tAvo years, but that he had not Avitnessed a case of permanent cure; and Dr. FothergiU closes his melan- choly list of unsuccessful remedies Avith the remark, that Ave must look to the influence of moral agencies. Dr. FothergiU's obser- vations on the subject of magnetism, a measure adopted in his day in the treatment of neuralgia, may not be Avithout interest at the present time. His Avords are, " In some few cases Avhere the disease was recent, and the pain slight, the use of magnetism cer- tainly procured ease, but merely, I should conceive, by forcibly acting upon the imagination like the modern tractors and all such absurdities with Avhich the credulity of the public is daily gulled and deservedly duped. Indeed, it is much safer and more pru- dent to ease people of their superabundant cash with a patent, than to dive into their pockets Avithout one: the one practice is attended Avith riches and honor, the other with infamy and dis- grace." It must be acknoAvledged that the power of the imagi- nation over the complaint is often considerable. Dr. Macculloch, for example, has related a case which the gibberish of an old woman charmed aAvay, after the failure of arsenic. Although, from the effect of modern improvements, the disease is noAV found often to yield to scientific treatment, yet Ave have too frequently to deplore the inefficacy of remedies. There can be no doubt that the probability of successful treat- ment must in a great degree depend on the accuracy with which we discriminate the peculiarities of the individual case, and adapt our remedies to them. With a vieAV to this object, it will be im- portant to distinguish the disease into the idiopathic and the sym- pathetic forms; the first depending on a primary derangement of some part of the nervous system, the second on derangement of some other organ. In every instance it is important to examine the parts in the neighborhood of affected nerves, and also to investigate the con- dition of the spinal cord. If any part of the spine be found par- ticularly tender, it Avill generally be expedient to abstract a little blood from the neighborhood, and subsequently to employ coun- ter-irritation by means of blisters or tartar emetic ointment. If there be pain of head, flushed cheeks, and dizziness, the loss of blood Avill be desirable; and this measure will often convert neuralgia, (Treatment.) 423 irregular into regular neuralgia. Mr. Teale has related many Cases, some of considerable severity, in which this plan proved remarkably efficacious. We have adopted the same treatment with similar success, and have occasionally derived great advan- tage from the subsequent use of spirit of turpentine in doses of 3j tAvice or thrice a dayv especially in cases in which psoriasis had also existed. This treatment proved rapidly efficient in a case of hysteralgia of some years' duration, recurring daily in severe paroxysms, in which tenderness and puffiness, previously unsus- pected, afterwards ascertained to have been produced by a bloAV, existed over the upper lumbar vertebrae. When concurrent causes of irritation are removed, such as constipation of the bowels and torpor of the liver, it will be important to ascertain whether the attacks partake of an intermittent character. Should this be the case, whether the pain be superficial or deeply seated, attended or unaccompanied with fever, sulphate of quinine will be found the most effectual remedy. It may be advantageously combined with anodynes: those of a milder character, as the tinc- ture of henbane, occasionally prove sufficient, and should first be tried; but if they prove inefficient, the sedative solution of opium, or the black drop, should be subsituted. Dr. Bardsley prefers the acetate of morphia to all other preparations of opium, and has related several cases of neuralgia cured by that remedy alone. (Hospital Facts and Observations.) Small doses of quinine often prove adequate to the relief of the symptoms, but they sometimes require to be increased even to the extent of a scruple or half a drachm several times a day. An interesting case illus- trative of this fact, and having a manifest relation to intermittent fever, is described by Sir B. Brodie in one of his lectures on ner- vous affections. In cases not characterised by distinct intermissions, the sesqui- oxide of iron is a more suitable remedy, and is perhaps peculiarly efficacious when there is a deficiency in circulating energy. There is probably no medicine, the claims of which to attention in the treatment of common neuralgic affections are founded on so many recorded instances of success; and the liberal manner in which Mr. Hutchinson published his observations on the subject, affords one of the many examples of disinterested devotion to the public welfare of which the Medical Profession may be justly proud. In some instances a dose of ten or fifteen grains several times a day will be found sufficient; in others the quantity may be increased even to half an ounce for a dose. We are disposed to consider arsenic as inferior both to quinine and iron in the scale of remedies for neuralgia, and to regard it as less safe and less effectual; it will, however, occasionally succeed after the failure of those medicines, where Ave Avish to produce an altera- tive effect rather than to make a strong impression on the system. The pills of Meglin require some notice in consequence of the 424 neuralgia, (Treatment.) importance attached to them by some French physicians. They consist of equal parts of oxide of zinc, powdered valerian, and extract of henbane. Meglin in one case gave forty pills night and morning; but in others only three could be borne twice a day. Many instances of their successful employment are recorded in the French periodicals. (Journ. de Mid, et Pharm., t. xxii, xxvii; Biblioth. Mid., t. xlviii.) Considerable expectations were once entertained from the trial of strychnia; it has, hoAvever, been given to the extent of producing subsultus tendinum Avithout any relief to the symptoms. Anodynes must be regarded rather as remedies of a symptom, than of a disease; Ave have rarely found them productive of more than temporary advantage, although we have reason to think that belladonna deserves a careful trial, and, if Avell-prepared, may prove of considerable value, the Liquor Belladonnae (Battley) having occasionally appeared to be pro- ductive of permanent benefit. Extract of stramonium, in doses of from half a grain to two grains three times a day, has sometimes given relief, but at other times it has been carried to the extent of producing narcotism Avithout any advantage. (Med. Chir. Rev., vol. xxii, p. 72.) Dr. Fott (Lon. Med. and Phys. Journ., Sept. 1832) has employed the tincture with good effect in doses of fifteen minims every three hours. Mr. LaAvrence prefers conium to all other narco- tics in this complaint (Med. Chir. Rev., vol. xxii, p. 565); and other authors have recommended extract of aconite. There can be little doubt that the preparations of opium are decidedly the most entitled to reliance, and Avhen introduced into the rectum they are at once more safe and efficacions than when administer- ed by the mouth. The mineral Avaters are entitled to great at- tention as remedies in this complaint, and the Carlsbad has been the most frequently successful. It appears not only to correct the condition of the liver and other digestive organs, but also to im- prove the state of the nervous structure: many obstinate cases have recovered under its use. It is scarcely necessary to observe, that the advantages of the water may now be secured at the Ger- man Spa at Brighton, almost as effectually as at the natural spring. The experiments of Flourens, showing the production of congestion of different parts of the nervous system by different remedies, encourage us to hope that means may eventually be discovered, of acting on the nervous functions without disturbing other processes. External applications of various kinds have been strongly re- commended. Mr. Scott sometimes employs a combination of mercurial ointment, and tartarised antimony—in other cases an ointment of iodide of mercury; but the irritation produced by these applications is considerable, and the benefit derived doubt- ful. Blisters have been occasionally applied, but the opinion of Heberden, that they are calculated to aggravate superficial neu- neuralgia, (Treatment.) 425 ralgia, is supported by recent experience, and their employment is now almost confined to the treatment of sciatica. The appli- cation for a few minutes of lint dipped in strong solution of am- monia, covered so as to prevent evaporation, is recommended by Dr. James Johnson. The production of pustules by means of friction Avith croton oil has been occasionally useful, as, for ex- ample, in some cases of sciatica related by Andral. The application of the moxa proved useful to patients treated by Dr. Duncan and others in this country, and also by several French practitioners. Most of these cases, however, Avere affec- tions of the sacro-ischiatic nerve. In ordinary neuralgia little could be expected from the remedy unless severe spinal irritation Avere present, and the moxa be applied near the affected part of the back. Electricity has been occasionally recommended, but Dr. Mac- culloch tried it in vain for many years, notwithstanding all the facilities afforded for the experiment by a military hospital. During the last thirty years, the Indian practice of acupuncture has been sometimes adopted in this country; and Dr. Osborne (Dub. Med. Journ., vol. xii), who regards the disease under con- sideration as a modification of paralysis, has made many experi- ments on the subject, Avhich lead him to be sanguine respecting the efficacy of this measure in many cases of neuralgia, and to consider it as the most valuable addition made of late years to European practice. In sciatica, Dr. Osborne rarely found acu- pucture fail to relieve, excepting in cases in which, from the ag- gravation of the pain on coughing, there was reason to apprehend disease of the theca vertebralis or in the pelvis. The experiment is perfectly safe, since it appears from the experiments of Cloquet, Bretonneau, and Carraco, that well-tempered sewing needles may be thrust Avith impunity through any structure of the body, through the liver, lungs, intestines, or arteries. Various external applications of a soothing character have been used with uncertain advantage. Distilled cherry-laurel-Avater has been occasionally found an efficacious lotion. Dr. L. Broglia del Persica has given an account of its successful employment in ten cases. (Annali Univers. di Mid., 1832.) Its use is perfectly safe and easy, and it deserves a more extended trial. The ap- plication most depended on by many of the French practitioners, is the cyanuret of potassium: it Avas particularly recommended by Buttigny, Roubiquet, Villaumy, and Bally; and Lombard of Ge- neva has given a favorable report of its virtues. He sometimes employs an ointment containing from tAvo to five grains of the cyanuret to the ounce of lard, but prefers a lotion containing from one to four grains in an ounce of water. He considers it ineffi- cient in sciatica, and in neuralgic cases complicated Avith inflam- mation. The few experiments made Avith the remedy in this 36* 426 neuralgia, (Treatment.) country have not prepossessed practitioners Avith any very strong opinion of its efficacy. A lotion composed of equal parts of prussic acid and solution of acetate of lead is sometimes useful, and, in the less exquisite cases, relief may often be derived from a solution of extract of belladonna, or of opium in camphorated oil. Sprinkling half a grain or a grain of morphia on a blistered surface is often found productive of great relief; but caution must be observed in the employment of a remedy, Avhich, even Avhen applied in the en- dermic method, is capable of producing a very powerful effect upon the system. Some French physicians have introduced the remedy by inoculation into the affected part Avith advantage: it may be mentioned, as an interesting result of this procedure, that a tubercle surrounded by an areola is formed upon each puncture. The application of steam by means of a suitable apparatus to the part affected is strongly recommended by Dr. Macculloch, who has found it invariably alleviate and often remove pain. We have made occasional trials of veratria ointment, and con- cur Avith those Avho believe it to be an application of little value in neuralgic complaints. We entertain, however, a different opinion of aconitine, having found it, in the proportion of one or tAvo grains to two drachms of lard, peculiarly effectual in arresting the pain in several instances of cubito-digital and frontal neural- gia. Some cases illustrative of its utility, have also been narrated by Mr. Skey, (Med. Gaz., Nov. 1836,) the one of nine, the other of eight years' duration. Although Ave cannot expect any local application to effect a radical cure, yet the arrest of pain has ad- vantages beyond those of mere temporary relief. Pain increases the sensibility of a nerve; the sooner, therefore, the habit can be overcome, the greater is the success likely to be produced by measures adapted to the constitutional condition. The practice originally recommended by Galen, of dividing nerves or amputating limbs affected with neuralgia, after the failure of remedies, although on a few occasions successful, as in the cases treated by Kelson, Cooper, Thomas, and Cruickshanks, derives no support either from philosophical reasoning, or from the average results of the experiment. Some very affecting cases are recorded, in which a succession of amputations was resorted to in vain. Whilst, on the other hand, instances in which a proposed operation has been deferred, have spontaneously reco- vered. When, as often occurs, many parts are involved in the com- plaint, the presumption for its constitutional origin is strong; and the disease being in common instances so often connected Avith the condition of the nervous centre, Ave can readily understand that, although a severe operation may by the violence of the shock suspend the affection, yet that is not a measure calculated to insure permanent relief. neuralgia, (Treatment.) 427 Treatment of Sympathetic Neuralgia. The most important of the causes of sympathetic neuralgia are derangements of the digestive organs, hysteria, and rheumatism. 1. A slight degree of gastric or intestinal irritation in persons of nervous temperament, will sometimes prove sufficient to induce neuralgic affections, which in the commencement may be slight and variable in their seat, occurring sometimes in a tooth or in the face, at other times in an extremity, and recurring under the influence of any cause which depresses the strength or disturbs the stomach, as fatigue, anxiety, fasting, or injudicious diet. The tongue in such cases often presents elevated red papillae; flatulent distension of the abdomen is apt to occur after food, especially if digestion be interfered with by anxiety or study. These cases require mild and careful treatment. Powerful remedies, whether of the purgative or tonic class, aggravate the local as well as the general irritability, while opiates give only temporary relief, and add the inconvenience of their own effects to the original malady. A considerable proportion of such cases, neglected or violently treated, gradually assume the exquisite form, and become un- manageable; but if, on the contrary, the diet be judiciously regu- lated, and be nourishing, unstimulating, and taken at regular intervals; if the powers be husbanded, and a due proportion of sleep insured; if acidity be corrected by small doses of soda or magnesia; and if other symptoms, as they arise, be met with prompt and mild measures, the neuralgic tendency will generally be overcome. In paroxysms of pain, associated with the condition just de- scribed, even after the failure of laudanum, Ave have known decided relief produced in a few minutes by the administration of tAvo or three grains of carbonate of soda. The importance of these facts is here peculiarly insisted on, because the habits of medical education are perhaps calculated to engender a bias in favor of the employment of powerful remedies. In the manage- ment of acute inflammatory diseases, such a bias may be safe and useful; but in the treatment of nervous affections, Avhich constitute an increasing proportion of the cases which fall under our care, the secret of success Avill probably be found rather in the accurate adjustment of mild measures, than in the bold adop- tion of heroic plans. In the instances above referred to, the suc- cessive employment of quinine, arsenic, mercury, iron, and other powerful medicines, too often produces an almost incurable con- dition of the intestinal mucous membrane, while the original disorder remains unmitigated; and the administration of opium for the purpose of temporary relief becoming more frequent and excessive, an alternation of torment and torpor constitutes the remainder of a life, at last terminated by apoplexy, the production of Avhich these measures may accelerate. Doubtless the vacilla- tion of patients impelled by the urgent desire for immediate relief 428 neuralgia, (Treatment.) frequently to change their medical attendant, by depriving any one plan of treatment of a fair trial, materially contributes to these lamentable results. A more confirmed derangement of the digestive organs, at- tended Avith depraved hepatic secretion, and a deposit in the urine of the brickish red sediment of purpurate of soda, is some- times connected Avith neuralgic maladies. There is not necessa- rily any peculiarity in the nature of the pain in this or any other variety of symptomatic neuralgia, but Avhen depending on chronic disturbance of the digestive organs, the complaint perhaps affects some situations more than others, especially the head, shoulders, and hypochondriac regions, the treatment of these cases resolves itself into the careful adoption of measures adapted to the peculiar form of indigestion. But the occasional use of mercurial pill, followed by a combination of bitters and aperients, will generally prove useful; and when there is much nervous pain of the head, a combination of valerian and iron Avill sometimes give relief. In other instances, in which the derangement of the digestive organs is more protracted and severe, the urine deposits the Avhite earthy sediment of the triple phosphates, and the general strength is extremely reduced, a complete, change of scene and habits will often be found essential. The diet may be as generous as the digestive functions will admit; and wine, though generally inex- pedient, will sometimes be desirable. Mr. Carmichael, who suf- fered severely from this form of the complaint, in the interesting detail of his OAvn case, mentions having derived benefit from the use'" of the Lafitte and Chateau Margaux claret. He also had recourse to the baths of St. Sauveur and Bareges, Avhich are Avell deserving of a trial.* Active exercise must not be ventured on too soon. In cases characterised by torpor, rather than irritability of the intestines, a decided impression by means of purgatives Avill sometimes prove useful. In support of this opinion it may be mentioned, that Sir Charles Bell administered small and re- peated doses of croton oil in several obstinate examples of neu- ralgia Avith great success. When the disease has been seated in the hip or scrotum, he has frequently observed a scalding sensa- tion of the lower extremities exceedingly like what is often felt during the passage of a purgative through the intestines; and he has always regarded this symptom as a sufficient indication that the source of the complaint is in the boAvels. 2. The second division of sympathetic neuralgia, namely, the hysterical, most frequently affects the intercostal nerves, especially on the left side, the hip and thigh, and the inner part of the knee * Some of the effects of the internal use of the Bareges water may be obtained by taking in the morning 60 grains of tartarised soda and 20 of the bicarbonate with 2 of sulphate of iron, in a pint of warm water.—Author. neuralgia, (Treatment.) 429 joint. This subject having been already treated of in the article Hysteria, does not noAV require a lengthened notice. It will be sufficient to mention that the treatment consists chiefly in the correction of uterine irritation, the improvement of the constitu- tional condition, and the local application of belledonna or other soothing remedies. In some of these varieties the sesquioxide of iron possesses considerable efficacy, but its use sometimes requires the preliminary application of leeches to subdue local congestion. 3. Rheumatic neuralgia is apt to occur in gouty or rheumatic subjects after exposure to Avet; the pain is induced by slight ex- ercise, and is dull, aching, or gnawing, rather than stabbing or plunging. In these instances there is reason to believe that the neurilema is more or less affected. If the attack be acute, cup- ping or bleeding will be necessary, folloAved by the use of anti- mony, colchicum, and purgatives. Plasters of opium or bella- donna may be advantageously applied, and an occasional night dose of calomel combined Avith James's poAvder, guaiacum, nitrate of potash, and opium, followed by an aperient in the morning, ^ will sometimes prove singularly efficacious. If the complaint be decidedly intermittent, quinine will be found almost a specific. In the chronic form, especially if benfitted by the application of Avarmth, the administration of turpentine will sometimes give relief; but the ammoniated tincture of guaiacum, in doses of from twenty drops to two drachms every four hours, is probably the most efficacious remedy. Stimulating applications containing mustard, pepper, or salt, the hot douche, sulphuretted baths, and especially those of St. Sauveur and Bareges, may be had recourse to with advantage. In this form of neuralgia, acu- puncture is often surprisingly efficacious. These cases are re- markably influenced by the state of the mind, Avhich must there- fore receive a due share of attention. Neuralgic complaints have occasionally occurred, apparently produced by syphilitic exostosis, and Avhich yielded to mercury. Dr. Corkindale administered this mineral with success in a case in which this origin Avas suspected. The late Dr. Warren Avas indeed accustomed to treat most cases of neuralgia with blue pill combined Avith extract of belladonna; but though the mercurial plan has occasionally succeeded, yet as a general rule it may be stated, that except in instances depending on a syphilitic origin, the continued use of mercury is more likely to increase the ner- vous irritability than to cure the complaint. Dr. RoAvland mentions having derived great benefit from the application of nitrate of silver to the vesicles in cases of neuralgia depending on herpes. When the complaint is produced by the irritation of old cicatrices, he applies the same remedy to the cicatrix, and also insulates it from the surrounding skin by a cir- cle of the caustic. It is Avorthy of notice, that Avhen the insulation is incomplete, the pain, although checked in its usual course, 430 neuralgia, (Treatment.) shoots through the opening and attacks the neighboring parts. (On Neuralgia.) In neuralgia of the urethra, the occasional introduction of a bougie constitutes the most effectual treatment. In neuralgia depending on subcutaneous tubercle the local application of bel- ladonna often gives considerable relief, but the only effectual remedy is excision. The application of caustic has been tried, but with unsatisfactory results; and the sore produced has proved difficult to heal. 431 PARALYSIS. Explanation of the term.—Varieties and distinctions.—Symptoms.—Mode of accession.—Description of the various forms and varieties of paralysis.— General paralysis.—Hemiplegia.—Paraplegia.—Various forms of local paralysis.—Paralysis of particular muscles.—Strabismus.—Ptosis and lagophthalmia.—Aphonia.—Paralysis of the face.—Paralysis of a limb, or particular muscles of a limb.—Paralysis of sensibility.—Amaurosis.—Co- phosis.—Anosmia.—Ageustia.—Anesthesia.—Paralysis of motion—Para- lysis of the insane.—Paralysis from metallic poison.—Mercurial palsy.— Lead palsy.—Paralysis agitans.—Causes of paralysis.—Anatomical cha- racters.—Nature.—Crossed effect from lesions above the medulla oblongata. —Direct effect from lesions below.—Diagnosis.—Seat of the lesion.—Na- ture of the lesion.—Prognosis.—Treatment. By paralysis (from napd^vaii, dissolutio, resolulio) is understood a diminution or loss of motion and sensibility in one or more parts of the body. By the older writers it was confounded with apo- plexy, Avith which it is often complicated, but they are quite dis- tinct and independent of each other. Varieties and distinctions. It unusually happens that both motion and sensibility are affected together; but the one may be lost or diminished, while the other is unimpaired. Hence the necessity of distinguishing paralysis of motion from paralysis of sensibility. The former is called acinesia (from axwqola), the latter anaethesia (from ava^Orjata). All paralytic affections, then, may be divided into two classes:—the first including those in Avhich both motion and sensibility are affected; the second, those in which the one or the other only is lost or diminished. We propose to denominate the former perfect, and the latter imperfect paralysis. Again, the paralysis may be general or partial, as it affects the whole body or only a portion of it. Partial paralysis is divided into hemiplegia, (from ^>kjdj, dimidius, and n-h^om, per- cutio), when it is limited to the lateral half of the body; and into paraplegia (from rtopd aug., and rc^oou), when it is confined to the inferior half of the body. The term local paralysis has been applied Avhen a smaller portion of the body, as a limb, a foot, a hand, or a finger, becomes affected. As regards intensity or de- gree, paralysis may be complete or incomplete. With respect to its cause, it is spoken of as being idiopathic, when arising from mental emotions, exposure to cold, &c; or symptomatic, Avhen 432 paralysis, (Varieties.) occasioned by any other malady. The propriety of using the former term is very doubtful, as every form of paralysis is symp- tomatic; although in all cases the nature of the morbid lesion on which it depends is not knoAvn. When produced by lead, mer- cury, arsenic, and other poisons, the term venenata has been usually adopted. Paralysis may he fixed or movable, continued or intermittent. Some nosologists describe an exanthematic, febrile, plethoric, serous, bilious paralysis, &c; but these terms are little used in the present day, being mere designations of causes. When treating of apoplexy, congestive and organic, cephalalgia, myelitis, &c, Ave have enumerated the symptoms which precede paralysis. We consider it unnecessary, therefore, to say any thing here of premonitory signs. Paralysis has been observed more frequently on the left than on the right side, Avhich has been attributed to the greater Aveak- ness of the former, and the comparatively little exercise to Avhich it is subjected. It is also more common in the loAver than in the upper extremities. In Avhatever part of the body paralysis ap- pears, it may be perfect or imperfect, complete or incomplete. Sometimes there is a greater loss of mobility than of sensibility, or the reverse takes place, and every gradation may occur from the most trifling loss of either to the complete abolition of both. When different parts on the same or opposite sides of the body are affected, as the legs, arms, &c, the paralysis may be more complete or perfect in one place than in another. In hemiplegia, the arm or the leg may be most completely paralysed, and in paraplegia one leg more than the other. In local paralysis also, as of the leg or arm only, an individual may have perfect and complete paralysis in the fingers or hands, toes or feet, while in the forearm or leg the paralysis is incomplete or imperfect. Paralysed parts present different appearances. They are gene- rally pale, livid, and flaccid; sometimes cedematous. In certain cases they are covered Avith copious perspiration, which is occa- sionally of a viscous or greasy nature, and in others, Avhile the perspiration is abundant on all other parts of the body, there is no perceptible moisture in those which are paralysed. The tempera- ture is sometimes increased, as remarked by Dr. Abercrombie, or it may be diminished, as observed by Mr. Earle and others, a circumstance which the former Avriter has attributed to their losing the property Avhich healthy parts possess of retaining a medium temperature, while they readily acquire that to which they may be exposed. There is often more or less rigidity of the muscles in paralysed limbs, and the joints are usually in a state of flexion. Sometimes they can be readily extended, but it is often necessary to overcome more or less resistance in doing this. In old persons, if the disease has existed some time, the joints often become flexed, and almost immovable. Though in a large proportion of cases, there is impaired motion and sensibility in paralysed parts, they paralysis, (Varieties.) 433 are occasionally painful, the pain being of a tingling, pricking, dull, acute, or even lancinating character. It may also shift from one paralysed part to another, and may be continued, remittent, or intermittent. The muscles in such cases often appear to be the seat of this pain, as it is not increased by slight contact, but by pressure. A peculiar sensibility in paralysed parts is a subject which has lately attracted some attention. In a case of complete paralysis of the extremities, detailed by Dr. Elliot of Carlisle (Lancet, 1837-8, vol. ii, p. 77), spasmodic actions were occasioned on irritating the parts. We have often seen in limbs Avhich Avere paralysed, muscular motions excited by pricking or pinching the skin, and especially by tickling the sole of the foot, although the utmost voluntary efforts of the individual were unable to produce the slightest movement. But in such cases there has always been some slight feeling, and we have never observed these movements when the patient has been Avholly unconscious of the application of stimuli to the affected part. We have no doubt, however, that spasmodic actions may be occasioned in paralysed limbs by the application of stimuli, independent of sensation, although their occurrence in the human subject must be considered one of great rarity. It has been stated that the circulation in paralysed is more lan- guid than in healthy limbs, and that the pulsations of the arteries are diminished. Whether this is universally the case maybe doubted, but some observations to which we shall presently refer, show that it frequently happens. In a longer or shorter time, paralysed parts diminish in volume, become thin, and afterwards sensibly atrophied; which is another proof of diminished circula- tion. It sometimes happens that, Avhile the tissues are really atrophied, a greater or less effusion into the cellular substance may give the part an appearance of enlargement. When one or both of the inferior extremities are affected Avith incomplete paralysis, so that with the assistance of a stick or crutch the patient is enabled to Avalk, progression is made in a peculiar manner. This is very well seen when one limb only is affected. In such cases the knee of the paralysed extremity is flexed, the heel elevated, while the toes, turned outwards, scrape the floor. There is great difficulty in lifting up the limb and placing it before the other: in doing this, the foot is throAvn outwards, and the patient then sets it doAvn Avith the knee perfectly straight. The difficulty of walking and the above symptoms are increased as the paralysis becomes more complete, and are often alone suffi- cient to distinguish the paralytic affection. When chronic paralysis affects the muscular system, and more especially the lower extremities, interfering with the muscular motion, and consequently the proper exercise of the affected parts, the general health is gradually impaired. The skin becomes pale 37 434 paralysis, (Varieties.) and flaccid, and the muscles soft. In general, the respiratory or digestive organs are little affected, unless the muscles more par- ticularly connected Avith these functions are paralysed. Occasion- ally, however, the appetite is increased, which sometimes leads the patient into various excesses. The circulation also is usually undisturbed, though palpitations of the heart, and a frequent, feeble, or irregular pulse are noAV and then observed. The nutri- tive functions are imperfectly formed: hence, most persons labor- ing under paralysis, becomes thin. The intelligence is sometimes unaffected to the last, though frequently it is impaired; and the memory is more or less enfeebled. The speech is often thick and confused, and occasionally particular words or names cannot be remembered, or one word is substituted for another. Some para- lytics become gradually idiotic, others have their natural character totally changed, and become timid and suspicious, or peevish, irritable, and irascible: mild and placid persons shoAV signs of antipathy, or break out in paroxysms of anger; in other instances, individuals Avho were previously noted for courage and vigor of mind, shed tears from the most trifling causes, and often without any apparent motive. In the advanced stage of paralysis, but more especially when the mental poAvers have suffered, the coun- tenance very frequently assumes an expression of stupidity. The manner in Avhich paralysis comes on is important, with respect to proper vieAVs of treatment. The principal points to be observed are, Avhether it occur suddenly or gradually, with or without premonitory symptoms, as a knowledge of these circunu stances is necessary to enable the practitioner to form a correct diagnosis of the morbid lesion which is the primary cause of the disease. Paralysis may take place suddenly from cerebral or spinal apoplexy, in Avhich case all the phenomena Ave have de- tailed in describing those diseases are observed. A local form of palsy may be suddenly induced by strong pressure on a limb or a single nerve, by a tight ligature, a fracture, luxation, circum- scribed effusions of blood, or various kinds of Avounds, dividing the nerves, &c. Paralysis of one or more parts of the body may occur in various Avays. The patient may suddenly and unexpectedly become hemiplegic or paraplegic, or affected with some form of local paralysis at first, in a very trifling degree. There may be only Aveakness in the part, sometimes accompanied or succeeded by tingling, or a degree of numbness and impaired motion. The individual cannot perhaps stand or walk so firmly as before, or there is an awkwardness in moving one hand, or objects are less firmly grasped by it than by the other. On touching bodies he can- not feel distinctly by means of the hand affected, the sensation produced being often compared to that felt by examining sub- stances Avith the hand covered with a leather glove. The obscure sensibility and difficulty of movement may remain stationary for paralysis, (General Paralysis.) 435 some time, and then gradually or perhaps suddenly increase, until complete paralysis is manifested. In some cases the numbness first appears in a small circum- scribed part, as in one toe or finger, and gradually extends up the limbs, often involving in its progress other parts of the body; it may thus commence in the eyelid; spread over one or both sides of the face, and thus suddenly appear in the fingers, arms, toes, or legs. This is denominated by many Avriters creeping palsy. In this manner local or general paralysis, hemiplegia, or paraplegia, may be permanently produced according to the extent to Avhich this creeping affection may proceed. Again, local paralysis has often been caused by the gradual increase of tumors, Avhich press on particular nerves. Lastly, a few cases have occurred in Avhich the upper parts of the arm have been paralysed, Avhile the hand was unaffected. (Velpeau, Arch. Gen. de Med., 1835; Aber- crombie, on the brain, 8?c.) 1. General paralysis, properly so called, or total loss of sen- sibility and motion throughout the system, cannot take place without extinction of life. This term therefore is only applied to paralysis of the four extremities, Avhether any other parts of the body are affected or not. General paralysis, like the other forms, may come on suddenly, or gradually. In the former case it is either the result of extensive extravasation of blood, or disloca- tion and fracture of the bones pressing on the cranial or cervical portions of the spinal cord. When it occurs gradually, it usually commences in the toes or fingers, and extends by degrees over the body. In middle-aged or old persons laboring under this form of the disease, the change in their natural disposition is often well-marked. The intelligence also in general becomes sooner or later impaired. We saw lately an old Avoman affected Avith general paralysis, and unable to utter a Avord or make the slightest sign, betray no indication of intelligence, except by excessive weeping when she was asked questions or even looked at. In this form of palsy loss of motion is usually more marked than that of sensibility, indeed it is very rare that in general paralysis the sense of feeling is entirely abolished. M. Defermon has given a case in Avhich the intelligence Avas perfect, but the sensibility was Avholly destroyed, except in a small patch on the right cheek, by tracing letters on which his friends Avere enabled to hold inter- course Avith him. The motion also of every part of the body was lost, Avith the exception of the muscular apparatus of the tongue, and of the organs of deglutition and respiration. (Bullitin des Sciences Mid., vol. xiii, p. 6.) Another remarkable case is given by Mr. Davies Gilbert, of a girl Avho had lived to the age of seventeen years Avithout general sensibility or voluntary motion. She Avas blind, deaf and dumb, and betrayed no evidence of in- telligence, except such as was manifested by a feeble cry Avhen she wanted food, and a certain appearance of satisfaction while 436 paralysis, (Hemiplegia.) she was eating fruits and confectionary. On a post mortem exami- nation of this case, the tensorium and dura mater lining the base of the cranium were deficient, the latter being replaced by a thin semitransparent membrane very lax and irregular. All the nerves Avere firm and healthy. The paralysis in this case must be as- cribed to the pressure to Avhich the nerves Avere subjected from the mass of the brain before they entered their separate foramina. (Edin. Med. and Surg. Journ., Jan. 1828.) 2. Hemiplegia. This term is used to denote paralysis of one side of the body, or at least of one upper and loAver extremity. When the arm of one side and the leg of the other is affected, the term transverse paralysis Avas applied by Sauvages. Hemiplegia is the most frequent form of palsy, and has been more commonly observed on the left than on the right side. It is often limited exactly to one half of the body, the median line forming the boun- dary betAveen the sound and affected side. With a view of ex- plaining this, Bordeu and Bichat supposed that the tAvo halves of the human body Avere endoAved Avith a separate existence, and possessed a life peculiar to each. The regular distribution of the spinal nerves hoAvever offers the true explanation. Hemiplegia may come on suddenly without any previous indisposition, or it may be preceded by several of the premonitory symptoms before alluded to, as cephalalgia, twitchings of the muscles, more or less fever, &c. In the former case it often precedes an apoplectic sei- zure, and on the other hand frequently folloAvs that disease. In- deed, the morbid lesions in the brain, Avhich produce apoplexy, most frequently occasion also hemiplegia, Avhich becomes well- marked on the return of consciousness, and is more or less per- manent. Sometimes hemiplegia comes on gradually; local para- lysis is perhaps first manifested in the toes, foot, leg, fingers or hand, which slowly extends until the lateral half of the body is affected. More frequently, however, it appears suddenly and un- expectedly, so that very often individuals enjoying perfect health, and performing their usual avocations, are struck Avith complete paralysis of one side of the body. Occasionally there are spasms in the affected side, from Avhich circumstance the disease has been denominated by Sauvages spasmodic, by other nosologists hys- terical hemiplegia. It is generally only a modification of hyste- ria. In incomplete hemiplegia, the gait of the patient has in a remarkable degree the peculiar characters before described, and the arm of the affected side is usually drawn to the trunk, the fingers, arm, and forearm being more or less rigid and in the state of flexion. Intermittent hemiplegia has been seen by Sauvages, Torti, Morgagni, Cullen, Larrey, Elliotson, and others. In gene- ral it is one of the anomalous forms of intermittent fever. 3. Paraplegia has been differently defined by different writers. Hippocrates confounded it Avith apoplexy. Aretaeus understood by it partial paralysis; Boerhaave and Van Swieten, palsy of a paralysis, (Paraplegia.) 437 parts of the body below the neck. Mr. Earle proposed, as a defi- nition of paraplegia, " a paralytic affection of both sides of the body, whether that be partial or general, in opposition to hemi- plegia, in Avhich the affection is confined to one side." The ma- jority of writers, however, have used this term to express para- lysis of the inferior half of the body, or at least of the two lower extremities, in which sense Ave shall employ it. Paraplegia may commence in the same manner as other forms of palsy, but most frequently begins Avith weakness and numb- ness of the inferior extremities, sense of Aveight and slight pain in the feet, extending a greater or less distance up the legs. The patient has a tendency to trip on slight occasions, and complains of fatigue after little exertion. As the disease advances, the ne- cessity for support increases, until at length the power of walking is lost. Sooner or later paralysis of the bladder and rectum su- pervenes, occasioning incontinence of the faeces and urine, though sometimes at first there is retention of the latter, which after a time is discharged involuntarily. In paraplegia, the urine is particu- larly liable to deposit calculous formations, as pointed out by Dupuytren, who observed catheters left in the bladders of para- plegics become quickly covered with calculous incrustation. Sometimes the paraplegia is accompanied Avith cerebral symp- toms, as cephalalgia, vertigo, dimness of sight, diminution or com- plete loss of the special senses, &c; in other cases there are evi- dences of spinal irritation or disease, evinced by tenderness on pressing or percussing one or more of the vertebrae, pain on stoop- ing, alteration of the form of the spine, projection of one or more of the vertebrae, &c. Not unfrequently there is much flatulency of the bowels. When this form of palsy is complete, there is per- fect loss of sensibility and motion in the lower extremities, with paralysis of the bladder and rectum, so that the individual is obliged to remain in the horizontal posture; sloughs are particu- larly liable to form on the sacrum, and the exhausting discharge which follows generally accelerates the patient's death. Brachet of Lyons observed, that in these cases the uterus lost the poAverof contracting, and that it was always necessary to deliver paraplegic pregnant Avomen with the forceps, a statement hoAvever denied by Andral, who has seen, natural labor occur in a case of complete paraplegia. When paraplegia is not of very long standing, Ave find, as in hemiplegia, occasional spasms in the muscles of the lower limbs. Sometimes there is more or less permanent rigidity and contraction of the flexor muscles, so that the extremities are bent; occasionally the extensors have been at the same time simi- larly affected, and thus the limbs have been kept extended. Dr. Todd alludes to a case in Avhich the extensor muscles were spas- modically contracted; there Avas no poAver of flexing the loAver limbs, but if at the request of the patient they Avere placed in the state of flexion after the lapse of a short interval, they Avere, by 37* 438 paralysis, (Local Paralysis.) short and successive tAvitchings of the extensor muscles, gradually brought back to the state of extension. (Cyc. ofPract. Med., art. Paralysis.) In old chronic cases the muscles become atrophied, and the joints rigid. 4. Local paralysis implies loss of motion, and sensibility in some part of the body of small extent; and although frequently only the commencement of a more general affection, it is sometimes permanent: Avhen thus limited it constitutes a modification of palsy. Paralysis of particular muscles generally arises from division of, or pressure on, the nerves, Avhich are distributed to them. Thus dislocation of the head of the humerus pressing on the cir- cumflex nerve produces palsy of the deltoid. The serratus mag- nus anticus muscle maybe paralysed by injury of, or pressure on, the posterior thoracic nerve, as in cases recorded by Gendrin and by Velpeau. (Anat. Chir., vol. i, p. 303.) Dr. Stokes has point- ed out probable paralysis of the intercostal muscles and diaphragm, in connection with hydro-thorax and diseased liver. (Dub. Journ., No. xxv. The sternomastoid muscle also may be affected, giving rise to symptoms like those of wry neck. Strabismus is occasioned by palsy of one or more muscles of the eyeball. Palsy of the eyelids occasions tAvo paralytic affec- tions, ptosis and lagophthalmia; which are treated of at great length in works on ophthalmic surgery. In the former, the eye- lids are partially or completely closed, in the latter they are kept permanently open. The muscles concerned in the act of degluti- tion are occasionally paralysed, as in a case related by Mr. Hun- ter. (Trans, of Soc. for the Improv. of Med. Knowl., vol. i.) But it is a very rare affection, except in hysteria, in Avhich dis- ease dysphagia is occasionally observed. (See Hysteria.) Du- puytren has given a case in which an hydatid pressing on the ninth nerve caused paralysis and atrophy of one side of the tongue. (Lecons Orates.) Aphonia may be caused in three Avays; by paralysis of the muscles of the larynx, of those of the face, or of the tongue. When the muscles of the face are paralysed, the individual can speak by supporting the cheeks with the hands. The power over the motion of the tongue may be lost for a time only, and after- wards suddenly return. Sometimes certain movements only are abolished or performed with difficulty, while in other respects the actions are natural. In incomplete paralysis of the tongue, when protruded from the mouth it is sometimes straight, some- times drawn towards the sound, in other cases towards the para- lysed side. Various explanations of the latter occurrence have been given. Lallemand ascribes it to the action of the genio- glossus muscle of the unaffected side drawing the base of the tongue forwards, and turning the apex towards the opposite side. Others attribute it to the stylo-glossus bringing the base toAvards its OAvn side, and turning the apex toAvards the opposite, by a swivel kind of movement. Cruveilhier considers, that, when the paralysis, (Local Paralysis.) 439 tongue is thrust fonvard, it inclines toAvards that side on which there is the most feeble resistance. The above forms of partial paralysis rarely occur by them- selves, and are more generally met with when one side of the body or face is affected. Paralysis of the face. This form of paralysis is the effect of pressure or injury of the portio dura and fifth pair of nerves. In perfect paralysis of the face, the loss of motion is produced by lesions of the portio dura and motor branch of the fifth, and loss of sensibility by lesions of the sensitive portions of the latter nerve. The symptoms vary according as one or other of these is more immediately affected. If the fifth nerve only is the seat of disease, in addition to more or less loss of sensibility of the parts to which its branches are distributed, the motions of the jaAV on the affected side are im- paired. Mastication is impeded in consequence of palsy of those muscles Avhich subject the morsel to the action of the teeth; and from the impaired grinding motion of the jaws, the individual can only chew on the sound side, while in performing this act the action of the masseter and temporal muscles of the affected side is more or less imperfect. There is still command over the fea- tures however, and no distortion of the countenance, or loss of expression. The jaw is in some cases a little depressed, but this almost disappears when the patient smiles or laughs. This form of paralysis may exist alone, but is usually combined with hemi- plegia. The loss of sensibility is referable to a morbid condition of the ganglionic division of the fifth, and loss of mobility to the non-ganglionic portion. It is very rare that one is affected with- out the other. M. Serres has recorded a case where the gasse- rian ganglion only Avas diseased, occasioning loss of general sen- sibility on one side of the face, without impairment of mobility. (Arch. Gin. de Mid., tom. v, p. 629.) When the portio dura is affected, the general sensibility remains intact, while the muscles of the face to which its branches are distributed are paralysed. The aspect of the face differs according as the muscles are in a state of repose or activity. In the former case, all expression is lost in the paralysed part; the tAvo sides of the face are not symmetrical, and when viewed by themselves, apparently belong to different individuals. The fea- tures generally are dragged toAvards the sound side; the labial commissure of the paralysed part is drawn rather doAvnwards, and is brought nearer the median line; the mouth is oblique, and its centre does not correspond to the axis of the body. The paralysed half of the face is a little more prominent than the sound one, which is Avrinkled, contracted, and concealed behind the other, Avhen viewed in profile. The paralysed side also ap- pears broader than the sound one, while the eyelids are opened Avide, and the eye appears more voluminous than its fellow. 440 paralysis, (Local Paralysis.) When, on the other hand, the individual speaks, laughs, cries, sneezes, or coughs, the deformity of the countenance is much increased, the mouth and features remaining perfectly motionless on the paralysed side, while on the other they appear thrown into inordinate action. The muscles moving the jaAVs, however, which are supplied by the motor portion of the fifth, are still obe- dient to volition; mastication is readily performed, and the patient can hold solid bodies betAveen the teeth. The cheek on the affected side is flaccid, it sAvells at the moment of expiration, and especially when the patient wishes to Moav or pronounce a word Avith emphasis. The lips are paralysed, and the saliva and aliments sometimes escape from the mouth on the palsied side. The pronunciation of vowels, as the o for example, Avhich re- quires the intervention of the lips, is imperfect. The labial con- sonants, as b and p, are very imperfectly articulated. Lastly, the patient has difficulty in spitting out his saliva, or directing it to any given point at a distance from his mouth. Occasionally the patient is enabled to articulate Avith tolerable freedom, by'sup- porting the paralysed cheek Avith his hand. Lagophthalmia is frequently observed in this variety of palsy, exposing the eye to constant irritation, and often producing ophthalmia. When the disease is of long standing the affected muscles are often Avasted, giving a peculiar expression to the countenance, which an expe- rienced eye readily recognises. It is rare that the lesions are confined to the fifth or seventh pair of nerves; in general, the symptoms characterising disease of the one and the other are conjoined, although both nerves are seldom equally affected. It usually happens that the affection appears first in the one and then in the other, and that when the muscles on Avhich the nerves of the first ramify are completely paralysed, the muscles supplied by the second are partially affect- ed. In these cases also the paralysis is often accompanied with neuralgia of a very distressing and acute description. We have lately seen a case of paralysis of the left side of the face, in which the eyebrows, chin, and all the parts furnished by the first and third branches of the fifth nerve, Avere completely paralysed and perfectly insensible, while the cheek, left ala of the nose, and parts supplied by the second branch, Avere extremely painful, and the slightest touch caused intense agony. Paralysis of a limb, or of particular muscles of a limb, is not uncommon, arising from causes affecting the nerves by Avhich it is supplied. Dr. Healy has described it appearing suddenly in the hand and forearm, during sleep, Avhich he attributes to the head resting on the arm, and compressing the nerves. (Dub. Hosp. Rep.) Dr. DarAvail has seen paralysis of the deltoid mus- cles attached to the scapula and humerus folloAV the lifting of heavy Aveights. It often extends to the whole extremity, and apparently arises from the nerves being injured by the exertion paralysis, (Of Sensibility.) 441 and straining employed. Sometimes the extensors, in other instances the flexors only, are affected. Occasionally, as noticed by Sir C. Bell, there is only paralysis of the fingers, so that the poAver of writing is either lost, or the letters are Avritten zigzag. In the same Avay, by injuries or diseases of the different nervous branches, the muscles, or sets of muscles they supply, in either of the extremities, may become paralysed. In general, however, Avhen palsy occurs in the hands or feet, it is the precursor of mere general paralysis. 5. Paralysis of sensibility, both special and general, may occur, the muscular motion being perfect or only impaired. Amaurosis. The disease is termed amaurosis (from apavpos, obscure), when the retina loses its sensibility to the rays of light. We must refer to Amaurosis and to works on ophthalmic sur- gery for a description of this affection, as our limits preclude us from treating so important a subject in this place. Cophosis (from ^w^oj, deaf), is used to express deafness, or in- sensibility to the impressions of sounds. It may be caused by compression or structural disease of the auditory nerve; oblitera- tion or obstruction of the canals and passages of the auditory, apparatus, &c. Anosmia (from A, privative, and 6^, smell), or insensibility to odors, is sometimes congenital. Cases of this kind have been met with by Good, Todd, Pressat (Thise, 1837), and others. When it is the result of disease, it is occasioned by pressure on, or organic alterations of, the brain, involving the olfactory nerves and ethmoid bone. More commonly it follows alterations in the Schneiderian membrane, of an inflammatory or congestive nature, as in coryza. Ageustia (from 6\ privative, and ytvatbs, taste), or loss of taste, is occasioned by insensibility of the nerve or nerves, which have been termed gustatory; but Avhat those nervous branches so en- doAved really are, is a point still disputed by physiologists. Chew- ing tobacco or other narcotics, smoking, a thick fur on the tongue, as in the various forms of acute as Avell as chronic diseases, may more or less impede or destroy the taste. Ansesthesia (from d privative, and ataerje^, sensibility.) In per- fect paralysis there is loss of general sensibility, or that of touch, as well as loss of motion. But when the sensibility is lost or diminished, while motion remains perfect or nearly so, the affec- tion is denominated anaesthesia. This may be complete or in- complete, general or partial. Good, YeUoAvly, Earle, Bell, Andral, Ollivier, and others, have recorded cases of complete anaesthesia. In these instances the part affected is insensible to the most poAverful stimuli, or to the most severe injuries. Phlegmonous , abscesses, the formation of blisters from the application of heat, wounds of different kinds, fractures, &c, have occurred without causing the slighest pain. Mr. Liston removed the metatarsal 442 paralysis, (Of Sensibility.) bone of the little toe from a gentleman who did not experience the slightest pain during the operation; sensibility was nearly if not altogether lost, Avhile that of motion Avas so entire as to enable him to use his hands in carving his food, in writing, holding the reins on horseback, &c. (Med. and Surg. Journ., vol. xxxi, p. 292.) A similar case is related by Mr. Reid. (Idem, April, 1829.) Such cases, hoAvever, are very rare. A singular case is recorded (Med. Chir. Trans., vol. ii, p. 217), in Avhich the left side of the head Avas insensible, while the sensibility of the right was perfect; in the left side of the body, and in the left extremi- ties, also, the sensibility was diminished. The right side was quite insensible to touch, but the impressions of heat and cold produced sensations directly opposite to those experienced in health. Instances are recorded in Avhich, although the anaesthesia was general, a small spot on the surface retained its sensibility. In a case related by Ollivier, this spot was situated on the hip, and in another, by Andral, on the cheek. In general, hoAvever, the disorder is partial. Andral has observed the loss of sensibility confined to five or six round spots on the surface, of the size of a crown-piece,the surrounding skin being perfectly natural. (Clin. Med.) It may also be limited to different parts of the face, to a limb, one side of the body, &c. Muscular motions, under* such circumstances, can apparently only be performed by the indi- vidual fixing all the attention he can command on the perform- ance of the required muscular effort. In Dr. YelloAvly's case the patient could hold objects so long as her eyes Avere directed to them; but the moment her attention was othenvise directed, they fell from her grasp. When the face is so affected Avith anaes- thesia, that a portion of the lips only is involved, the individual on drinking from any vessel invariably feels as if the margin Avas broken. It has been observed, that the mucous membranes con- tinuous with the common integuments affected, not unfrequently lose more or less of the general or special sensibility, Avith Avhich they are in their healthy state endowed. Hence the conjunctiva becomes insensible and inflamed, the inflammation in some cases being so severe as to destroy vision, from the application of irri- tating bodies of Avhich the patient is unconscious. The Schneide- rian membrane is sometimes similarly affected, and the sense of smell destroyed. Occasionally there is deafness, and in many cases loss of taste results from the want of general sensibility in the mouth. In the same manner when anaesthesia attacks the abdomen and loAver extremities, the introduction of a catheter into the urethra causes no pain, and the urine iioAvs from the bladder, and faeces from the rectum, Avithout the consciousness of the individual. Anaesthesia may come on suddenly or gradually. In the latter case there is sometimes a sensation, as if fine sand were inter- posed between the skin and the object touched, or as if the former paralysis, (Of Motion and of the Insane.) 443 were covered Avith Avoollen or other kinds of stuff, or it some- times commences with pricking or formication. In either case the insensibility may remain stationary for an uncertain period, and then disappear, or gradually increase, until complete anaes- thesia is produced. The duration of this affection is variable. It may continue for a short period only, or for several years: in the former case it may return unexpectedly. M. Guest has given an account of the dis- ease as it appeared epidemically in Paris, in the summer and autumn of 1828. (Arch. Gin. de. Mid., October, 1828.) 6. Paralysis of motion generally accompanies loss of sen- sibility, but may occur without the sensibility being at all im- paired. We are not aAvare of any recorded case, however, in which the voluntary motion was completely abolished, Avhile the sensibility in the motionless part Avas perfect. Dr. Ley has described the case of a young Avoman, who after delivery became affected Avith loss of motion on one side of the body, and loss of sensibility on the other. She Avould hold the child to one breast as long as she looked at it, but on the attention being abstracted, there was danger of her dropping the infant. On this side she could not feel the application of the child's mouth to the nipple, though she could see it sucking; on the other side feeling was intense, but she was unable to hold the child to the breast. A someAvhat similar case is given by Dr. Bright. (Case 271.) Not unfrequently paralysis of motion alone is a sequel of perfect para- lysis, the sensibility gradually returns, having the poAver of motion more or less affected. The accession of paralysis of motion may be sudden or gradual. Sometimes a certain degree of rigidity is present in the paralysed part, and the limbs are somewhat flexed; in other cases they are perfectly flaccid and poAverless. Loss of motion is occasionally preceded by spasms and pain, more or less violent and severe; and not unfrequently the sensibility is morbidly increased. Mr. Travers relates the case of a man Avho, after an injury of the back by a fall, felt the most agonising pain in the lower extremi- ties from the slightest touch: to use his own Avords, " Avhen any one even Avalks by his bedside, it is just as if a number of razors were cutting him down to the bone." (A further Inquiry into Constitutional Irritation, p. 358, 359.) Dr. Abercrombie also relates a case in Avhich, conjoined Avith loss of motion in the arm, the sensibility Avas so increased, that the least breath of cold air brought on convulsions. The sensibility of the part also may be more or less perverted, giving rise to sensations of pricking, ting- ling, or formication; hot bodies may be mistaken for cold, or cold bodies for hot. 7, A peculiar form of paralysis occurs in the alienated, which has been described with great care by Calmeil (De la Paralysie considerie chez les Aliinis), and also by Dr. Prichard (Treatise 444 paralysis, (From Metallic Poisons.) on Insanity). It may precede insanity, a circumstance, hoAV- ever, which is very rare, or take place at the same time which is not common, or, as is generally the case, it may appear at a longer or shorter interval after alienation has been established. It is a kind of creeping palsy, but presents the peculiarity of ap- pearing first in the tongue.* The Avhole course of the affection has been divided into three stages. In the first the movements of the tongue are embarrassed, and this increases until the pro- nunciation of Avords, which is at first difficult and performed with effort, becomes impossible. In the second stage the paralysis extends to the extremities, most commonly the inferior commen- cing by a degree of weakness, dragging of one limb, &c, and gradually increases in intensity, and at the same time extends to the superior extremities and other parts of the body. In some the paralysis is permanent, but in others motion has been known to return under the influence of passion, or strong mental emo- tions. When all poAver of locomotion has ceased, the third stage is established, and the disease then gradually affects the functions of organic life. The bladder and sphincter ani are paralysed, and if the affection is not complicated with other organic lesions, Avhich may terminate life, the individual dies from general ex- haustion, palsy of the muscles of deglutition, or those of respira- tion, producing asphyxia. The sensibility is very slightly affected in this form of paralysis. The paralysis of the alienated now described is very common in Paris, and has been observed more so at Charenton, where patients in an elevated class of society are treated, than at the Bicetre, which is an institution for the poor. It is most frequent between the ages of thirty-tAvo and fifty, being rare before and after that period. It is seldom that an insane person with para- lysis lives more than four or five years; but Calmeil says, that " such individuals have the chance of existing for thirteen years." 8. Paralysis from metallic poisons presents peculiarities that require notice. Mercurial palsy. This form of paralysis is liable to attack artificers in quicksilver, gilders of toys, buttons, glass-platers, ba- rometer-makers, &c. It generally comes on gradually, although in some cases its appearance is sudden. The arms are the parts generally first affected, and the individual has less control over them than usual. Sometimes he experiences a sense of Aveak- ness; occasionally slight convulsive tAvitchings, followed by a con- tinued state of tremor, Avhich gradually extends to the legs, and, in some cases, to the whole body. All muscular movement is now so impaired, that any kind of combined motion is imperfectly performed. Thus articulation, mastication, and loco-motion, are * Sometimes in the lower extremities; but at first it requires a good deal of experience to detect it. paralysis, (Paralysis Agitans.) 445 performed with difficulty, and the use of the hands is almost en- tirely lost. Occasionally the muscular movements are so violent as to resemble convulsions. In some cases the patient suffers from abdominal pains; the whole body has a broAvn tint, the skin is dry; there is restlessness and delirium, with more or less derange- ment of the general health. There is no disorder of the respira- tion, impaired digestion, or colic; and, except in chronic cases, no Avasting. Mental emotions and efforts to control the muscles almost invariably increase the inability and tremors. Lead palsy. Plumbers, glaziers, painters in oil and Avater- colors, type-founders, color-grinders, and Avorkers in the different preparations of this metal necessary for manufactures and the arts, are liable to be affected with palsy. It usually accompanies or follows colica pictonum, but may exist independently of that affec- tion. It has been rarely observed in the inferior extremities, the hands being generally affected, though the palsy sometimes ex- tends to the forearm. Lead palsy commences by a feeling of Aveakness in the fingers, Avhich soon extends to the Avrists, beyond Avhich it seldom passes, although there is often pain in the shoul- ders, arms, and forearms; Avhich resemble rheumatism. The Avrist, according to Dr. Pemberton, is remarkably flaccid and loose. The patient cannot grasp any thing Avith firmness, and, as the disease advances, he cannot use the hands. The fingers are bent, and cannot be extended voluntarily; there is no rigidity, however, as they can readily be straightened by force, and assume their natural position Avhen the arms hang doAvn.* In general there is little diminution of sensibility in the skin. Christison and Bright have noticed the occasional Avasting of the paralysed parts. Paralysis from arsenic, given in poisonous doses, has been observed by De Haen, Murray, Falconer, Christison, and others. It generally occurs in the extremities, and may be complete or incomplete. Dr. Christison observes, "on the whole, local palsy appears to be the most frequent of the secondary effects of arse- nic." (Treatise on Poisons, 3d edit. p. 184.) 9. Paralysis agitans. A peculiar form of palsy, termed para- lysis agitans, has been minutely described by Mr. Parkinson. Its approach is very gradual, and characterised by Aveakness and trembling, Avhich usually commences in the hands and arms, but occasionally in the head, and by slow degrees extends over the Avhole body. At length the trembling becomes incessant, and Avhen the patient attempts to advance, " he is throAvn on the toes and fore part of the feet, and impelled unwillingly to adopt a run- ning pace, being in danger of falling on his face at every step." * The peculiarity of this form is that the extensors are much more affected than the flexor muscles: The latter remain strong for a long time after the patient is completely unable.to straighten the hand. 38 446 paralysis, (Causes.) When the disease is advanced, the shaking continues during sleep; the patient cannot carry food to the mouth; there is consti- pation; mastication and deglutition are performed with difficulty; the agitation at length becomes so violent as to prevent sleep; the body is bent fonvard, and the chin bent upon the sternum; articu- lation is impaired or entirely lost; the urine and faeces pass invo- luntarily; and "coma, Avith slight delirium, closes the scene." (Parkinson on the Shaking Palsy.) This affection, Avhich is rare, is distinguished from mercurial palsy, delirium tremens, chorea, and nervous tremor, by the agitation continuing Avhen the limb is supported, and the peculiar gait of the patient—a symptom Avhich has been thought by some, pathognomonic. Causes. Paralysis is more common in men than in Avomen, and less frequent in youth than in infancy and adult age. It is one of the most frequent disorders of old persons. It is much oftener observed in persons of a feeble constitution, and in those who lead a sedentary life; Avhile those of the sanguinous and ner- vous temperaments are said to be more predisposed to the affec- tion than others. Particular trades favor the production of certain forms of paralysis; thus, as we have noticed, the disease occasion- ally occurs in house-painters, plumbers, workers in the different preparations of lead, glaziers of earthemvare, miners, ornamental and Avater-color painters, looking-glass and barometer-makers, &c. From the appendix attached to Dr. Cook's Avork, palsy ap- pears to be rare among soldiers. Mental labor and luxurious habits of living also predispose to paralysis, much more than a sober and active ltfe, or one requiring much exercise in the open air. The exciting causes may be divided into, 1. Those Avhich affect the brain or spinal cord; and, 2. Those Avhich influence the nerves in their course, or at ^heir extremities. 1. The causes Avhich more particularly influence the brain and spinal cord are those Avhich produce pressure on, or destruction of, the nervous matter. Hence blows, falls, fractures, or other injuries affecting the skull and vertebral column, occasioning either concussion or depression of bone; osseous, fibrous, encepha- loid, hydatid, tuberculous, or other tumors pressing on the ner- vous mass, or disorganising its substance; alterations of the bones and ligaments of the spine by caries, scrofula, or rachitis; atrophy, or agenesia, of the nervous centres; inflammation of the brain, and its consequences, as suppuration, softening, induration, &c, and indeed every kind of lesion to Avhichthe brain and spinal cord are liable, are exciting causes of paralysis. Any circumstance produ- cing congestion, whether arterial or venous, may induce paralysis, —as the various mental motions, joy, anger, grief, terror, anxiety, &c, exposure to cold or heat, sudden changes in the temperature of the Aveather, intemperance, fatiguing occupations and strained positions, constipation and affections of the boAvels, metastasis of paralysis, (Anatomical Characters.) 447 gout or rheumatism, diseases of the heart, sudden disappearance of the eruptive fevers, suppression of the lochia or menstrual dis- charge, cicatrisation of old ulcers, sudden check to the perspiration or accustomed discharges, as the haemorrhoidal, epistaxis, &c, ex- cessive venereal indulgences, &c. Paralysis has also been known to follow tying the carotid artery. 2. The causes Avhich act especially on the nerves are, inflam- mation and thickening of the different membranes at the point Avhere they leave the cranium, or vertebral canal; disease of their investing neurilemma, or of the nerves themselves; various tu- mors situated in their course, in Avhich they may be involved, as aneurisms, osseous, fibrous, encysted, and other kinds of morbid groAvths, abscesses, effusions of blood, contusions, &c; fractures or spiculae of bone, or luxations producing pressure on one or more of the nerves; various kinds of wounds, or incisions by Avhich they are divided; ligatures throAvn round them in tying an artery, &c. Paralysis may result from exposure of a part of the surface to a piercing wind, or to cold, from the influence of this agent on the extremities of the nerves of the part. Some causes act in an obscure manner; thus the influence of metallic poisons, as lead, mercury, and arsenic, in producing palsy, has not been explained. Paralysis has folloAved the inha- lation of certain fumes. Stoll says he has seen hemiplegia pro- duced by the fumes of charcoal, (Rat. Med. p. 7,) and Bosquillon by the vapors of quicklime and mephitic air. Anatomical characters. Every kind of alteration to Avhich the nervous system is liable, has at different times been found on the dissection of persons Avho have died paralytic. On the other hand, many cases, both of local and general paralysis, have been examined after death, Avithout any morbid lesion Avhatever hav- ing been discovered. To enter into the morbid anatomy of para- lysis, however, is only to repeat what has been stated, Avhen describing the diseases of which it is symptomatic. Thus the membranes and substance of the brain have been found more or less vascular, presenting traces of acute or chronic inflammation, or extravasations of blood, effusion of serum, softening, induration, abscesses, ulcerations, different kinds of tumors, apoplectic cysts, &c. (See Inflammation of the Brain, Apoplexy, &c.) It has been observed also to folloAV an imperfect development, or " age- nesia," of the nervous centres, and Avasting or atrophy of the same parts. We have often seen the corpora striata atrophied in old persons, in Avhom no other morbid alterations could be discovered, and are inclined to think that this is a more common lesion in old paralytics than is generally supposed. In a case of hemiplegia, mentioned by Mr. O'Halloran, a considerable quan- tity of the right hemisphere had sloughed out, producing a "fright- ful cavern." (Injuries of the Head.) The membranes and sub- 448 paralysis, (Nature.) stance of the spinal cord have been found to present all the appearances described under Epilepsy, Spinal Meningitis, Myelitis, Hydrorachis, and Spinal Apoplexy. Caries of the A-ertebrae, as described by Pott, is sometimes found, and more or less displacement of the bones, from relaxation of the ligaments. The nerves have been discovered more or less injected, and of a deep-red or violet color. They have been found occasionally enlarged by Pinel, Rostan, and Cazauvielh, but are more gene- rally atrophied. They have also been disorganised by suppura- tion, softening, and complication Avith various morbid groAVths. Sometimes the nervous tissue has been indurated, and in a few cases has totally disappeared, leaving the sheath filled Avith fluid. The sheath may be thickened, causing more or less pressure on the nerve it encloses. A knowledge of the alterations occasion- ally discovered in the nerves, is only to be obtained by studying individually the numerous cases recorded by different authors, to Avhose Avorks Ave must refer, especially to those of Bell, Aber- crombie, Shaw, and others. Changes of structure in other parts of the body have been found, but such alterations are for the most part accidental. Inflamma- tion and thickening of the membranes of the brain and spinal cord, which are not unfrequent, are capable of explaining nume- rous cases of paralysis. Changes in the bloodvessels also have been thought capable of producing local paralysis, as in cases related by Abercrombie, Rostan, Storey, Graves, Stokes, and others. In these there was more or less disease of the vessels leading to the part, ossification of their coats and obstruction of their calibre from coagula of blood. Andral mentions the case of a child Avho Avas subject to momentary paralysis of the volun- tary muscles, in Avhom the superior longitudinal sinus Avas trans- formed into a hard cord, and the veins entering into it filled with coagulated blood. The muscles of paralysed limbs have some- times been found degenerated into fat, especially in scorbutic individuals. Nature. If some parts of the nervous system be the origin of nervous poAver, Avhile others serve to conduct it, paralysis may be induced by any circumstances Avhich diminish or prevent its evolution or transmission. Disease in the gray matter of the spinal cord may destroy the first, and injury of the medullary matter, or nerves, the second property; and the extent of the paralysis will be greater or less, according as the morbid lesion involves the origin of a greater or less number of nerves, or, what amounts to the same thing, cuts off their intercourse Avith the brain. Hence congestion, inflammation and its results, or the different kinds of morbid growths, may occasion paralysis by pressing upon the nervous mass, so as to prevent the exercise of its proper functions; or the same result may be produced by de- generation and destruction of the nervous tissue, cutting off its paralysis, (Nature.) 449 communication with the brain, the source of volition. Under the head of Apoplexy Ave have explained how pressure or disorgani- sation, when they occur in the brain and cranial portion of the spinal cord, may cause paralysis; and, Avhen speaking of spinal irritation, Ave have alluded to the influence of congestion on the vertebral portion, in Avhich also morbid growths, and other changes of structure, Avill necessarily interfere Avith its functions. In order, hoAvever, to understand the pathology of paralysis, it it will be necessary to give an outline of the different laAvs by which the cranial and vertebral portions of the cord appear to be governed. It has long been a matter of observation, that disease on one side of the brain causes paralysis on the opposite side of the body —an effect Avhich modern pathologists attribute to the decussation of fibres in the medulla oblongata. For a long time, however, this decussation Avas supposed to be confined to the anterior columns only; but although in this Avay the crossed paralysis of motion might be explained, it did not account for paralysis of sensibility following the same law: but Sir C. Bell has lately shoAvn that the middle columns decussate as Avell as the anterior, which fully accounts for the crossed action of both. (On the Ner- vous System, 3d edit. p. 211, et seq.) It has been moreover ob- jected, 1. that lesions of the cerebellum also produce a crossed effect, although this portion of the nervous system is situated above the point of decussation; and, 2. that paralysis of the face folloAvs the same laAV, and arises from morbid changes of the opposite side of the brain, although the nerves distributed to it also arise above the decussation. In reply to the first objection it may be remarked, that the dissections of Mr. Solly have de- monstrated numerous fibres running between the spinal cord, below the corpus olivare and the cerebellum, which, he has no doubt, actually decussate Avith their felloAvs of the opposite side, forming in fact part of the apparatus of decussation, though he has not yet positively ascertained that fact. (On the Human Brain, p. 155.) This discovery at least establishes a direct com- munication betAveen the cerebellum and the spinal cord in the immediate neighborhood of the decussation, and is an answer to the first objection. With reference to the second, Sir C. Bell has also shown that the fifth pair of nerves arise beloAV the decussa- tion; and Mr. Solly has traced one of the origins of the portio dura from the fibres he has described, Avhich run between the spinal cord and cerebellum: thus the sensitive and motor branches of the face ought to folioav the same laAV as the other spinal nerves, Avhich is consonant with Avhat actually takes place. These dis- sections are in accordance Avith numerous pathological observa- tions on record, and appear to us capable of explaining the ob- scurity Avith Avhich this subject has been hitherto enveloped. 38* 450 paralysis, (Nature.) Cases have been recorded, hoAvever, in which paralysis has occurred on the same side as the lesions of the brain. Mr. Hilton, in a paper read before the Royal Society, 1837-8, has lately sIioavii a disposition of fibres in the decussation, Avhich he thinks explains this exception to the general laAV. But there are strong reasons for doubting whether disease in the brain ever causes a direct influence. Of the many thousand cases of cerebral hemor- rhage, softening, tumors, &c, Avhich have occurred, Ave are only acquainted Avith tAventy-one, in which paralysis is said to have resulted from disease in the same side of the brain; and on ana- lysis, of these more than half are imperfect and doubtful, and should consequently be rejected. As instances, therefore, of this occurrence are so feAV, may Ave not consider that the paralysis even in them was produced in the usual manner, and that the morbid lesion had no reference to the complaint? Numerous instances have occurred, of abscesses, softening, and other morbid changes having been found after death, but in Avhich there Avas no paralysis during life; and a still greater number are on record, in Avhich there Avas Avell-marked paralysis during life, but no appre- ciable change in the structures after death. It is by no means improbable, therefore, as paralysis may be induced Avithout leav- ing any traces, that in these few cases it Avas caused by unknoAvn changes in the opposite hemisphere of the brain; and, as is some- times the case, that the lesion found in the hemisphere of the paralysed .side had produced no effect. Such, we think, is the most probable explanation of these exceptional cases, although the question does not admit of a positive solution. In the vertebral portion of the spinal cord, lesions produce not a crossed, but a direct, influence; and it may be stated as a gene- ral rule, that, Avhenever structural disorganisation, or morbid conditions, interrupt its functions, all the parts furnished by nerves arising beneath the lesion, are affected. Hence the para- lysis Avill be more general, the nearer the lesion of the cord is to the brain. But it sometimes happens, that in the former, as in the latter portion of the nervous system, disease gradually pro- ceeds to a considerable extent, causing more or less disorganisa- tion, while such fibres as may remain unaffected, appear suffi- cient to carry on the necessary functions. Some cases have been recorded, hoAvever, in Avhich the individuals have had voluntary movements of the loAver extremities up to the moment of their death, and yet, on examination, the spinal cord has been found entirely destroyed. Every one accustomed to pathological ex- aminations, must receive with distrust accounts of such observa- tions, knowing hoAV soon this portion of the nervous system may in certain cases become softened after death, and the injuries it is likely to receive in opening the vertebral canal, particularly in France, where the hammer is used to a most umvarrantable extent. A strict analysis of these cases will show, that there is paralysis, (Nature.) 451 no absolute proof that the cord Avas entirely destroyed during life. In the celebrated case of Desault (Journ. de Chir. de Desault, tom. iv, p. 437,) the appearance of the parts is not described: it is merely stated, " the spinal marroAv was totally divided;" and the the movements Avhich took place are thus narrated:—He Avas in a continual agitation, and moved the pelvis and inferior ex- tremities even to the last." In all this there is nothing decided. May not the movements have been excito-motory? Was the altered structure well-observed? The case of M. Rullier (Journ. de Physiol., 1823) has been also frequently alluded to in connec- tion with, this question. It Avas that of a gentleman who had complete and perfect paralysis of the arms, Avithout loss of sensi- bility and motion in the inferior extremities; he remained in this state six years, and died of pectoral complaints. Dr. Abercrom- bie alluding to the case states, that a portion of the cord, six inches in length, occupying two thirds of the cervical portion and part of the dorsal, Avas entirely diffluent; so that, before the membranes were opened, it moved upAvards and downwards like a fluid. The posterior roots of the nerves of this portion preserved their nervous matter to their junction to the mem- branes of the cord; but in the anterior roots it Avas destroyed, and they Avere reduced to an empty neurilemma. (Abercrombie, p. 350, 3d edit.) This Avriter mentions that the anterior columns Avere completely destroyed, and others in alluding to the case have thought a portion of the cord Avas entirely disorganised. The case itself is headed, Disappearance (Disparilion) of the Nervous Substance of the Spinal Marrow in the Superior Third of the Dorsal Portion (Ollivier, 3d edit, vol. ii, p. 368), and yet, in the details of the dissection it is stated, " On voyait a peine, vers la partie anterieure de cette portion alteree, les cordons medullaires en rapport avec les racines correspondantes des nerfs spinaux;" and again, " Cette alteration etait beaucoup moins sensible lorsqu'on regardait la molle par sa face ant6rieure," &c. From this it would appear that certain continuous fibres still existed in the anterior columns, although they Avere seen Avith difficulty, but that there could be no doubt many existed in the posterior. The persistence of voluntary motion and sensibility in the inferior extremities under such circumstances, when the disease too was chronic, is in no Avay surprising. Instances have also been recorded, in Avhich balls have tra- versed the vertebral column; or sAvords have been thrust into the neck, Avhich are said to have entirely cut across the spinal cord; or, as asserted by Velpeau, that the vertebrae have been found in a state of caries, Avithout being folloAved by paralysis. We cannot here enter into the analysis of these cases, but those Avho choose to do so will readily come to the conclusion, that no positive proof exists that the cord Avas Avholly destroyed during 452 paralysis, (Diagnosis.) life. On the other hand, Avithout throAving any doubts on the accuracy of the observations Avhich have been made, may Ave not consider that the complete destruction Avhich has been de- scribed, is in some degree a post mortem appearance caused by partial softening of the cord, mixing, after death, perhaps, with the serous fluid always present? Is it not probable that the necessary violence in opening the vertebral canal may have broken across the fibres, Avhich during life Avere entire? Again, may not the movements described in many cases have been excito-motory? At all events Ave consider that, in the present state of science, such vieAvs are much more rational than to sup- pose that the influence of volition can leap over four or five inches of disorganised spinal cord in order to reach the inferior extremities, or that impressions made on the latter can be com- municated to the brain by other channels than the nervous system. Diagnosis. Paralysis cannot readily be confounded with any other disease. It may, hoAvever, be complicated with insanity, or with the febrile, scrofulous, scorbutic, rheumatic and other diseased states of the system. The diagnosis of the lesion causing the paralysis is often ob- scure, and in many cases impossible. The most experienced physicians have occasionally committed the greatest errors, in attributing before death the affection to lesion of some particular part of the brain or spinal cord. In the case of an old woman Avho had hemiplegia of the right side, after momentary loss of consciousness, and Avho Avas found in the street unable to rise, Ave heard one of the most distinguished and experienced physi- cians for the treatment of cerebral disorders in Paris, publicly diagnose, " softening or extravasation of blood in the neighbor- hood of the left ventricle, or haemorrhage into the arachnoid cavity on the left side." On opening the cranium after death, neither of the three morbid conditions he had predicted Avas found, but a number of circumscribed, shallow softenings con- fined to the gray matter, distributed over the whole periphery of the brain, varying in size from a pea to a sixpence. This un- doubtedly is a rare case, but illustrates the difficulties Avhich attend the diagnosis, and we are of opinion that there is no physician Avho has had much experience in paralytic cases, that has not met Avith similar instances. At the same time, by a care- ful observation of the symptoms with, a knowledge of the history of the case, Ave are enabled in most instances to indicate with tolerable certainty the morbid lesion that exists. The symptoms Avhich more particularly indicate the situation of the morbid lesions are fully detailed in the articles, Inflam- mation of the Brain, Apoplexy, Myelitis, Spinal Irrita- tion, &c. It must be remembered, hoAvever, that the cranial portion of the cord may not only be affected directly by destruc- paralysis, (Diagnosis.) 453 tion or effusion of blood, but indirectly by congestion, haemor- rhage or other morbid alterations occurring in the substance of the hemispheres. Hence general paralysis may depend upon some cerebral lesion producing pressure upon the cranial portion of the cord, in the same manner as Avhen that or the cervical portion of the spinal marroAv is directly affected. The tAvo former may be distinguished by the presence of cerebral symp- toms, such as headach and Arertigo, derangement of the special senses, &c; and the latter by the absence of these symptoms, pain in the neck, spinal tenderness, &c. Hemiplegia almost ahvays depends, as has been already re- marked, on some lesion in the opposite hemisphere of the brain to the side affected; sometimes, hoAvever, it is produced by altera- tions of one side of the spinal cord. The former may be diag- nosticated by the cerebral symptoms above alluded to, especially those mentioned under the fourth form of apoplexy, and the latter by those characterising spinal disease. Paraplegia in general depends upon affections of the spinal cord, but as shown by Dr. Baillie and others, may arise from changes Avithin the cranium. These latter may be knoAvn by vertigo, cephalalgia, diminution or loss in the special senses, and such symptoms as Ave have described under the heads of conges- tive and organic cephalalgia. Mr. Earle has pointed out the means of distinguishing paraplegia depending on caries of the vertebrae, from that caused by debility in the muscles of the back, inducing slight curvature. In the former the curve is angular; in the latter round, in the shape of a half-hoop. " If a person Avith such an incurvated state of the spine be placed on a horizontal plane, the back Avill immediately and spontaneously be restored to its proper form, Avithout causing any pain or distressing symp- toms, Avhich Avould certainly be produced by any attempt at any extension of a diseased spine." (Med. Chir. Trans., vol. xiii, p. 52.) .This is important, as curvature Avith paralysis is not unfre- quently seen in Aveak children, and has often been mistaken for diseased spine. In local paralysis depending upon lesion of the nerves, those symptoms Avhich characterise cerebral or spinal disease are absent: there will seldom be difficulty in detecting the part injured, if tu- mors, Avounds, fractures, &c. exist. The previous occupation of the patient will indicate the paralysis arising from metallic poisons. In order to distinguish partial paralysis of the face, arising from affections of the portio dura, or branches of the fifth pair, Ave refer to Avhat has already been said concerning these forms of local palsy. When the ganglionic portion of the latter nerve is the seat of disease, disorganisation of the eye has been observed to take place, as in cases recorded by Alison, Stanley, and Serres. Care also must be taken not to attribute paralysis of the face de- 454 paralysis, (Prognosis.) pending upon disease in the portio dura, to changes occurring Avithin the cranium, although cephalalgia, and a greater or less number of cerebral symptoms, may be complicated Avith it. Another important point in the diagnosis is to determine the nature of the morbid lesion. In the present state of pathological knowledge, Ave have no diagnostic symptoms which indicate an invariable connection betAveen the paralysis and morbid lesion on which it depends. In many cases, however, extravasation of blood is to be distinguished by the suddenness and intensity of the paralysis. If there be hemiplegia Avith loss of consciousness, Ave may predict haemorrhage Avithin the cranium in the hemisphere opposite to the affected side. Sudden pain in the back, and loss of motion in the parts beloAV it, indicate extravasation of blood into the spinal canal. (See Apoplexy and Spinal Apoplexy.) When paralysis arises from softening, according to Lallemand, there is more or less contraction. This is by no means invariably the case, many instances having been recorded, Avhere no such symptom Avas manifested; and on the other hand, from the obser- vation of many cases at the Salpetriere in Paris, we are inclined to think it is equally common in cerebral haemorrhage. The pa- ralysis from softening occurs generally less quickly than that re- sulting from haemorrhage; in some cases, however, it is equally sudden, and then it is impossible to draAV any distinction between the two lesions. Paralysis from tumors is generally knoAvn by its sIoav progress and circumscribed nature. The diagnosis of tubercles in the brain and spinal cord has been made in a few cases at the Hop. des Enfans Malades, in children of a scrofulous diathesis, in whom they are most common betAveen the age of tAvo and eight years (see Dr. Hennis Green, on Cere- bral Tubercle in Children; Lancet, vol. i, 1838-9, p. 755), and are very rarely met Avith after the age of twelve.. Cancer in the nervous centres has also been diagnosed, when individuals have suffered under the disease in other parts ,of the system. Contrary to what has been observed respecting tuber- cle, cancer is rare before the age of tAventy, and most common betAveen that of thirty and sixty. We have merely alluded to this subject because the nature of the morbid lesion is not made the subject of diagnosis to such an extent as its importance deserves. For the symptoms of paraly- sis arising from other lesions, Ave must refer to the articles Inflam- mation of the brain, Hydrocephalus, SriNAL Irritation, Hydrorachis, &c, &c. Prognosis. The danger of paralysis is in proportion as it is more or less general and complete. The difficulty of cure in- creases as the malady becomes more chronic. The prognosis in general must be governed by the diagnosis the practitioner is en- abled to make of the seat and nature of the morbid lesion. If this be situated in the brain, or near the origin of the eighth pair of paralysis, (Treatment.) 455 nerves, the prognosis will be very unfavorable. The same may be said if active inflammation exist in the spinal cord, causing pa- raplegia and involuntary discharges of urine and faeces. On the other hand, local paralysis, independent of disease in the nervous centres, although it may occasion great suffering and inconve- nience, is rarely of immediate danger, and in such cases death generally takes place from the secondary effects on the constitu- tion. Very severe cases of paralysis,/hoAvever, have recovered, and the individuals have lived a long time Avithout illness, and ultimately died of other disorders. Professor Ferguson of Edin- burgh had hemiplegia at the age of fifty years, and by antiphlo- gistic treatment got well in a few months. He remained ever after free from the disease, and died at the age of ninety-three. (Edin. Med. Chir. Trans., vol. vii, p. 230.) Such cases, how- ever, are rare. Dr. Cooke says, " I do not recollect more than one or tAvo cases of a complete restoration, both of sensation and motion, in the Avhole side of a person who had been affected Avith a perfect hemiplegia;" and this agrees with the general experi- ence of physicians. The prognosis of paraplegia will entirely depend on the nature and situation of the morbid lesion Avhich causes it, and the ex- tent to Avhich the affected parts have been involved. If it comes on gradually and is chronic, it may exist for years before death, an event which may be ultimately caused by other diseases, or by exhaustion from the sloughs, Avhich are liable to form on the sacrum. Should the neck of the bladder and sphincter ani have lost their functions, the prognosis Avill be more unfavorable than when the faeces and urine pass voluntarily. The prognosis in local paralysis varies according to circum- stances. If it depend upon division or morbid destruction of the nerves going to the part, the disorder is incurable, but when they are compressed only, the continuance of the paralysis will depend upon the greater or less facility of removing the compressing cause. The paralysis from lead and mercury is, generally speak- ing, curable, although some cases have resisted every kind of treatment. The longer the individual has been exposed to the poison, and the more complete and extended the disorder, the more unfavorable should be the opinion as to the result. Treatment. As paralysis is only the effect of some morbid lesion acting directly or indirectly on some part of the nervous system, our treatment must have reference to the pathological conditions on Avhich it depends. The means of combating con- gestion, inflammation, structural disorganisation and other altera- tions, of Avhich paralysis is occasionally symptomatic, have al- ready been fully treated of in several articles to Avhich we refer. (See Apoplexy, Inflammation of the Brain, Hydrocepha- lus, and Spinal Diseases.) In this place, therefore, we shall 456 paralysis, (Treatment.) only describe the treatment of paralysis in its chronic form, or Avhen it is purely local. When paralysis is chronic, the indications are, 1; to remove the morbid conditions on Avhich it depends, by such means as act on the system generally; and 2, by a stimulating line of treatment directed to the paralysed part, endeavor to excite the nervous branches to a due performance of their functions. With a vieAV of condensing Avhat Ave have to state on this subject, Ave must remark, that the same treatment applies to all forms of paralysis, the various remedies being in general the same, although differ- ent parts of the system are affected. Whenever any particular exceptions occur, they Avill be mentioned. The general treatment of chronic paralysis must depend upon the age and constitution of the individual. If plethora be present, Avith the usual signs of increased vascular action, the diet should be Ioav and of a digestible nature. But when there are evidences of debility, light nutritious food should be taken, combined AA-ith tonics and moderate stimulants, such as a glass or tAvo of wine at dinner. In all cases the secretions and excretions are to be regularly attended to, and solicited, if necessary, by medicines, the strength of Avhich must have reference to the state of the constitutional powers. Moderate exercise in a carriage, or so managed as to call into action the paralysed limbs, may be per- mitted according to circumstances. In local paralysis of the arms and hands, alternately elevating and depressing a Aveight suspended on a Avheel, Avhich weight is gradually increased, has been found beneficial. When the legs and feet are affected, walking, short of fatigue, with such support as may be necessary, is the best exercise. Paralytics should never expose themselves to bad weather, or to sudden changes of temperature, and flannel should be Avorn next the skin. The propriety of change of air and scene, visiting some of the retired Avatering places, different kinds of amusements, mental or corporeal, and various other remedial means, must depend upon the nature of the case and the discretion of the practitioner. The second indication is to be fulfilled by the use of such sti- mulants as act more particularly on the paralysed parts. These remedies, judiciously employed, have often succeeded in remov- ing the disorder, but for the most part are only applicable Avhen all danger from increased action of the vital powers has ceased. We shall mention such as have obtained reputation in this class of disorders. With a view of stimulating the nervous extremities, and rous- ing them to a proper performance of their functions, frictions by the hand or flesh-brush, stimulating liniments of turpentine, tinct. lyttae, croton oil, and the concentrated acids or alkalies, mixed with oil or lard, strong saline solutions, &c, have been used with paralysis, (Treatment.) 457 occasional benefit. In hemiplegia, when applied to the scalp on the side of the head opposite to the paralysis, they may be useful in facilitating the absorption of the coagulum. Sinapisms, blis- ters, issues, and setons, have been applied to the neighborhood of the supposed injury, and are indicated when paralysis follows the drying up of any old sore. In chronic paraplegia this line of treatment over the vertebral column, is the most powerful means we can employ. Pott recommended caustics on each side of the spine, and they have been used since his time with great success. Larrey, Dupuytren, and others, have employed the moxa in the same situation Avith much benefit, and the actual cautery is per- haps one of the most poAverful and useful remedies of this class. Counter-irritation produced by the tartar emetic ointment, or the powder sprinkled on the blistered surface, has been followed by considerable relief. The Acetum Lyttae, employed in this Avay, has been found a useful and cleanly application in local para- lysis of the face. Electricity and galvanism have been extensively employed. A paralytic individual is said to have been cured when on board a vessel Avhich was struck several times by lightning, and ano- ther instance of recovery is stated to have followed a hundred strokes of the Gymnotus electricus. A case of hemiplegia cured by a thunderbolt striking the house in which the patient rested, is reported. (Arch. Gin. de Med., tom. ii, 1836.) No doubt this is an agent Avhich, properly and judiciously employed is of great service in local and partial paralysis, but great caution is neces- sary in its application. It has been found beneficial in numerous cases, since it Avas first introduced for the treatment of this dis- order by M. Jalabert in 1747, but, in a host of others, has pro- duced no amendment, and has latterly fallen into undeserved neglect. The reason of this may, in a great measure, be attri- buted to the insufficiency and improper state of the apparatus often employed. From many trials we have seen made of this remedy, it appears that the method of passing shocks through the part is not so beneficial as insulating the patient, and drawing sparks from the affected surface. In this manner, many cases Avhich have come under our notice have been perfectly cured by an electrising quack, and a great number of others much relieved; but the apparatus was very large, of great poAver, and kept in the most perfect order. The stimulating effects of this remedy, hoAvever, may be injurious in plethoric states of the system, attended Avith vertigo. In such cases antiphlogistic medicines should be given, with a view of diminishing the vascular excite- ment, before having recourse to it, and care should be taken not to continue its application Avhen symptoms of cerebral or spinal irritation appears. It is also dangerous after recent apoplectic attacks from haemorrhage, and should not be used until suffi- cient time has elapsed for the coagulum to be absorbed. 458 paral\*sis, (Treatment.) Galvanism also has been used in several cases Avith great suc- cess, and by some is preferred to electricity. Dr. J. L. Bardsley, in particular, has highly recommended its use, and has given cases in Avhich its beneficial operation Avas very manifest. The same precautions must be attended to in the use of this remedy, as in that of electricity. Dr. Castana has cured a great number of patients laboring under facial hemiplegia by galvanism, and applies it by placing the positive wire inside the lips and cheeks, and the negative wire externally on the face in the course of the nerves. (Journ. des Connais. Mid. Chir., Dec. 1S35.) It results from the researches of Pichonniere, confirmed by the observations of Bottu-Desmortiens, that galvanism excited by certain acids, as the nitric, produces more pain than when others are employed, as the sulphuric. (Bottu-Desmortiens, These, 1834, No. ccclxv.) Both electricity and galvanism have been found most useful in the various forms of paralysis, arising from exposure to cold, metallic poisons, and in cases unconnected Avith structural disor- ganisation. They have been found beneficial, also, in certain cases of amaurosis, cophosis, and aphonia, and may be conjoined with the administration of other remedies. In partial paralysis of the face, electro-puncturation has been found beneficial by Pichonniere, Bally, and Montault. The lat- ter cured a severe case of this description, Avith neuralgia of the portio dura of the same side, by inserting a needle through the nerve at its exit from the stylo-mastoid foramen, and four others in the course of its principal branches, and transmitting from the former to the latter a number of shocks once a day, from a pile of thirty couples. Strychnia and brucia. Various remedies, Avhich OAve their activity to the presence of these alkaloids, have been given with success in several cases. Dr. Alderson of Hull recommended the rhus toxicodendron, M. Fouquier the nux vomica. The arnica montana, or leopard's bane, rhus vernix, or varnish-sumach, and Ignatia amara, or St. Ignatius's bean, &c, have also been given. The alkaloids themselves are noAV generally used, as the doses may be better regulated. Andral, from comparative trials has established that six grains of brucia are equal to a quarter of one grain of pure strychnia. This drug acts as a powerful stimulus to the muscular system, and especially on paralysed parts, a cir- cumstance Dr. M. Hall attributes to the augmented irritability in such parts. It produces involuntary contractions in the muscles affected, and in large doses general spasms of a tetanic nature, delirium, and death. It is seldom met with pure, and its strength consequently varies. The twelfth to an eighth of a grain should be taken for a dose in the form of pills, which is to be cautiously increased. Dr. A. T. Thomson recommends the acetate as a pre- ferable preparation, which is readily procured by dissolving one grain of the alkaloid in a fluid drachm of distilled vinegar. Six paralysis, (Treatment.) 459 minims should be given at first; this dose to be gradually in- creased until the tetanic tAvitchings appear. If there be irrita- bility of the stomach, preventing the internal administration of the preparation, strychnia in poAvder may be sprinkled on a de- nuded surface in double the dose given by the mouth. It is ahvays necessary to produce twitchings and slight spasms of the paralysed parts, before any benefit can be expected, and in seve- ral cases the restoration has been found proportionate to the severity of these. Numerous instances have been recorded in the British and Foreign Journals, in which strychnia given in this way has been beneficial. Dr. J. L. Bardsley mentions tAventy- three cases of paralysis, in the majority of which this remedy was undoubtedly beneficial. (Hosp. Facts and Observ.) Brucia acts in the same manner, but is not so poAverful. Half a grain may be used at first, Avhich may be increased to two grains tAvice a day. It should ahvays be remembered that these medicines are uncertain in their action, and should not be given indiscrimi- nately. They are contra-indicated if there be cerebral or spinal irritation, and have been found most useful in paralysis Avhich is purely local, and independent of irritation, as in palsy connected Avith metallic poisoning and rheumatism, although they have been occasionally beneficial in hemiplegia and paraplegia. They should, however, be employed with the utmost caution, and not resorted to till other means have failed. The Avarm bath is beneficial in many cases of partial paralysis especially hemiplegia. The Bath waters have been much extoll- ed; and their moderate use, conjoined with other remedies, may be serviceable. Care must be taken, however, that they are not used too long, or too frequently, as under such circumstances they are apt to prove relaxing. The cold bath has been employed, and is spoken favorably of, by Cullen. The same cautions are necessary in its use, as we have just mentioned with respect to the Avarm bath, as when long continued, or too cold, it is a poAV- erful sedative. It is consequently inadmissible in persons of a debilitated constitution. Such individuals derive more benefit from the tepid bath, the temperature of Avhich should be gradually loAvered as the general strength of the patient improves. The vapor bath has been found very useful in the paralysis from lead complicated with colic. Opium and hyoscyamus may be given in some forms of para- lysis attended Avith much pain, Avhen there are no severe cerebral symptoms. In partial paralysis of the face, attended Avith dis- tressing pricking or lancinating pains, Ave have seen opium plas- ters applied over the parts, where the affected nerves come out on the face, often useful. These remedies may also be given inter- nally in such cases, to relieve the wathchfulness which is often harassing. 460 / BARBIERS. Symptoms.—Causes.—Morbid Anatomy.—Diagnosis.—Treatment. This disease was first described by Bontius (De Medicina Indo- rum), but is better known to the Profession from the observations of Dr. Clark (On the Diseases ivhich prevail in long voyages in Hot Countries, fyc, vol. i), and Mr. Marshall (Notes on the Medical Typography of Ceylon, fyc.) These writers have sepa- rated the affection from Beriberi, Avith which it has been con- founded even by Good, and shown that while the latter is a disorder allied to the dropsies, that of which we iioav treat is purely nervous. Symptoms. The disease usually commences with more or less lassitude and pricking pain, or sensation of formication in the muscles of both lower extremities, accompanied with numbness, tremors, and irregular spasmodic movements during locomotion. Occasionally the forearms and hands are similarly affected, and in some cases the spasmodic action extends to the muscles of the larynx and chest, so that speaking and respiration are performed with great difficulty. As the disease advances, the inferior ex- tremities become more and more rigid, the knees are spasmodi- cally bent, so that the legs are straightened with much difficulty, and instantly relapsed into the flexed position Avhen the effort ceases. These symptoms are increased on standing or walking, these efforts rendering the performance of both unsteady, and at length the patient is incapable of performing either without sup- port. After a time the upper extremities become similarly affected, and inactivity, great torpor, and loss of sound sleep are complained of: the numbness in the affected limbs noAV increases, till at length they become completely paralytic, much emaciated and contracted, and lose their natural temperature. The general health also suffers; there is loss of appetitite, indigestion, wasting, and general sinking of the vital poAvers; the pulse latterly be- comes weak, thready or fluttering, and death takes place, appa- rently from a gradual decay of the contractility of the muscular fibre. The above description refers to the severest form of the disease, but more frequently the symptoms are much milder: the affec- tion is essentially chronic, and generally continues several months, and sometimes years. barbiers, (Diagnosis.) 461 Causes. This disease is common in several parts of India, but chiefly in Ceylon, and on the Malabar coast. It occurs most frequently in Europeans, and those generally are attacked Avho are exposed to the land Avinds, and are intemperate in their habits. (Lind.) Wright describes it as most prevalent toAvards the end of the rainy season, when the night temperature is many degrees lower than that of the day. (Edin. Med. and Surg. Journ., vol. xli, p. 235.) Mr. Marshall states that late comers are more liable than long residents, and that he never noticed it among the inhabitants of the island. Much contradiction, Iioav- ever, prevails regarding the various circumstances Avhich may induce the disease, and a complete memoir on this subject, deri- ved from actual observation, is still a desideratum. As far as our present knoAvledge however extends, the causes appear to be, " cold and moisture applied to the body; intoxication, irregulari- ties and excesses consequent upon inebriety; violent exercise in the sun; lying doAvn in the open air during the heat of the day; exposure to the cold chilling dews of the night, or sleeping Avhen thus exposed; suddenly obstructed perspiration by currents of air; long fasting, and whatever exhausts the energies of life." (Copland.) The morbid anatomy of this disease, and consequently its pa- thology, is very imperfect. It appears hoAvever to be a species of palsy, affecting more especially the contractility of the muscles, and the functions of the nerves distributed to them. Whether this is to be attributed to morbid changes occurring in the spinal cord, or in the extremities of the nerves themselves, Ave knoAV not: at the commencement, the disease often resembles chronic rheu- matism, and at a later period, paralysis from the poison of lead. Diagnosis. Barbiers may be distinguished from all other diseases by the sIoav and continual progress of the tremors, spasms, rigidity and contraction of both inferior extremities, Avith more or less paralysis. Such hoAvever is the endless variety of nervous affections, and the almost imperceptible differences Avhich sometimes exist betAveen the exceptional cases of one disorder and those of another, that it is occasionally difficult to say, Avhat (nosolosically speaking) is the disease under which certain pa- tients labor. Thus Dr. Bostock has recorded a case occurring in Eneland, in which the symptoms very much resemble those now described; and Dr. Copland says, that for several years he has been occasionally consulted by a patient, whose complaints are very nearly the same as those Avhich constitute barbiers. In the countries, hoAvever, Avhere the disease is common, the only malady Avith which it is likely to be confounded is beriberi; barbiers may be distinguished by its being essentially chronic, presenting phenomena of a nervous nature, and terminating in death slowly from inanition, Avhilst beriberi is an acute affection: and although there may be nervous symptoms, it is principally characterised 462 barbiers, (Treatment.) by general oedema, dyspnoea, and the suddenness of its fatal ter- mination, often with symptoms of asphyxia. The treatment of this disease is in every respect similar to that recommended for lead palsy, and creeping paralysis with debility, and we have nothing further to add to what has been recommended in the article Paralysis. 463 INFLAMMATION OF THE EYE. General remarks on ophthalmic inflammations and their classification.—I. In* flammation of the conjunctiva.—(a) Catarrhal ophthalmia—symptoms—■ causes—diagnosis—treatment.—(b) Purulent ophthalmia of infants—symp- toms—causes—treatment. Of adults—symptoms—causes—treatment.—(c) Gonnorrhoeal ophthalmia—symptoms—causes—treament.—(d) Strumous ophthalmia—characteristic sypmtoms—causes—treatment.—(e) Variolous ophthalmia—symptoms and treatment.—(f) Morbillous and scarlatinous ophthalmia—symptoms and treatment.—(g) Erysipelatous ophthalmia.— II. Inflammation of the sclerotica—symptoms and treatment.—(a) Catarrho- rheumatic ophthalmia—symptoms, causes, and treatment.—III. Inflamma- tion of the cornea—symptoms, causes, and treatment.—IV. Inflammation of the iris.—(a) Acute idiopathic iritis—symptoms—causes—diagnosis—treat- ment—varieties.—(b) Syphilitic iritis—symptoms, diagnosis, and treatment. —(c) Rheumatic iritis—diagnostic symptoms and treament.—(d) Arthritic iritis—symptoms, causes, and treatment.—(e) Strumous iritis—characters and treament.—V. Inflammation of the retina—symptoms of the acute—of the chronic—causes—diagnosis—treatment.—VI. Inflammation of the cho- roid—characteristic symptoms, causes, and treatment.—VII. Inflammation of the lining membrane of the aqueous chamber, and of the lens and its capsule. The eye is a very complex organ, exhibiting in its structure almost every tissue of which the body is composed, besides several peculiar to itself, as the cornea, the iris, the choroid, and the retina. From the varied character of its component parts two inferences may be drawn, viz. its liability to many different diseases, and its possession of a wide range of sympathies, through Avhich its vital phenomena may be variously influenced. Its diseases therefore are more or less identical with those of the other organised tissues, and the same principles of treatment are applicable to both. Dr. Mackenzie has very justly remarked, that the knoAvledge of the inflammatory diseases of the eye has been greatly retarded by the practice of confounding them all under the name of ophthalmia, and thus overlooking both the seat of the disease and the peculiar nature of the inflammation. The consequence of thus vieAving all those diseases Avithout dis- crimination, has been a method of treating them equally prepos- terous. We find, for example, that the remedies which in the course of a few days are sufficient completely to remove inflam- 464 INFLAMMATION OF THE EYE. mation of the conjunctiva, only aggravate inflammation of the sclerotica or iris, Avhile the plan of treatment Avhich speedily cures sclerotitis or iritis, if trusted to in conjunctivitis, would expose the eve to almost certain destruction. (Pract. Treat, on Dis. of the Dye.) The symptoms of the ophthalmia generally may be considered under two heads—the objective, or those Avhich Ave ascertain by the direct exercise of our senses, and the subjective, or those Avhich Ave gather from the testimony of the patient. Among the former, the increased vascularity of the part is a condition gene- rally well marked; and as the arrangement of the bloodvessels is peculiar, and generally constant in different species of ophthalmia, it forms an indication of much value in their diagnosis. A simple inspection of their appearance is frequently sufficient to denote the nature and seat of the malady, without the necessity of a single interrogation. Four different arrangements of the blood- vessels have been enumerated—the reticular, the zonular, the fascicular, and the varicous. The first and third are chiefly seated in" the conjunctiva, and are characteristic of diseases of that membrane; the second and fourth belong to the fibrous tex- tures, and are most strongly marked in inflammation of the sclerotica and the deeper tissues of the eyeball. Although per- fectly distinct from each other, tAvo or more maybe combined, as in the compound ophthalmiae. The appearance of the secretion from the eyes should also be attended to, as it differs Avidely in inflam- mation of the mucous and fibrous tissues. Under the second head of symptoms, or the subjective, the nature of the pain is a distinctive mark of some moment in some forms of ophthalmiae. Thus in inflammation of the conjunctiva it is of a sandy character, superficial, and felt most during the day; while in inflammation of the sclerotica, iris, and fibrous textures generally, it is deep-seated, pulsative, and strikingly nocturnal, affecting the circumorbital region as much as the eye itself; commencing soon after sunset, it increases in violence till after midnight, and abates towards morning. Ophthalmiae, at- tended by the conjunctival or sandy pain, are generally curable by external applications: those accompanied by the pulsatory circumorbital pain ahvays require depletion. With regard to the classification of ophthalmic inflammations, the most simple and practical appears to be according to the structure in Avhich they are seated. This we propose to adopt, following very nearly that given by Dr. Mackenzie in his Treatise on Diseases of the Eye. I. Inflammation of the Conjunctiva. (a) Catarrhal Ophthalmia. There are three ophthalmiae, Dr. Mackenzie observes, which INFLAMMATION OF THE EYE. 465 are frequently excited, especially in adults, by atmospheric influ- ences, viz. the catarrhal, the rheumatic, and the catarrho-rheu- matic. The first of these is puro-mucous or blennorrhoeal in- flammation of the conjunctiva; the second, an affection of the fibrous sclerotica; Avhile in the third, both the conjunctiva and sclerotica are attacked, the symptoms of catarrhal being united to those of rheumatic ophthalmia. (Op. cit., p. 399.) Symptoms. Catarrhal ophthalmia generally commences with redness and itching of the palpebral conjunctiva, a feeling of stiff- ness in the eyes,,and some degree of lachrymation and intolerance of light, which is succeeded by pricking pain, accompanied with a sensation as of sand or some other foreign body beneath the upper eyelids. The intolerance of light (photophobia) subsides as the disease advances; but the overfloAv of tears often continues, probably from the swelling of the lachrymal passages presenting a mechanical obstacle to their transmission.* The vascularity,t which first appears on the conjunctiva of the lids, and in slight cases does not extend beyond it, presents itself in the form of irregular clusters of tortuous vessels of a bright scarlet color, which may be traced advancing from the palpebral and posterior surface of the globe toAvards the cornea. As the disease is de- veloped, they gradually assume the reticular arrangement, forming a general netAvork over the Avhole globe. These vessels are quite superficial, and can easily be moved upon the subjacent textures by pressure with the finger, or motion of the lids. Patches of extravasated blood are sometimes observed beneath the conjunc- tiva, or even a pretty general but slight ecchymosis: slight ©ede- matous swelling of the conjunctiva is occasionally observed, but never any thing like true chemosis. The conjunctival secretion is increased in quantity, and becomes opaque and puriform;^ * There exists no photophobia so long as the ophthalmia is simply catarrhal and uncombined with sclerotitis, and the tears, the passage of which through their natural channel is only mechanically obstructed, are not increased in quantity or acrimony. Photophobia and lachrymation are almost pathognomonic of rheumatismal ophthalmia. f The vascularity of the lids is marked rather by a uniform velvety redness, intermixed frequently with granulations, while that of the ocular conjunctiva is regular in its arrangement, composed of trunks emanating from the angle of reflexion of the mucous membrane, running tortuously in radii torwards the cornea and bifurcating before reaching this membrane so as to leave a space of a line around it free from injection. ^ When the secretion is puriform, the cornea may become affected by the conversion of its external laminae into a pulpy matter. When granulations crowd upon the cornea it is frequently the seat of an interlaminar deposit of pus; and finally when the granulations persist for a long time, the friction to which the cornea is subjected in the movements of the eyelids may produce a vascular keratitis (pannus). 466 INFLAMMATION OF THE EYE. sometimes, hoAvever, it retains its natural transparency, imparting an appearance of unusual moistness to the eyes, and to the patient a sensation of glueyness. The eyelids are united in the morning by the formation of crusts upon the cilia, of a yelloAv color. Vision is someAvhat disturbed by the mucosities Avhich descend upon, and sometimes obstinately adhere to, the cornea. Besides the local symptoms just enumerated, Jungken of Berlin and Mr. LaAvrence mention the occasional appearance at the edge of the cornea of small vesicles or pustules filled Avith yelloAv lymph, which burst, leaving roundaphthous ulcers of a harmless character. By Dr. Mackenzie this symptom is considered as distinctive of a variety of strumous ophthalmia. When the local symptoms are mild, there is no constitutional disturbance: but in severe cases, and especially Avhen accompanied Avith the consentaneous affec- tion of other portions of the mucous surfaces, the usual symptoms of pyrexia are developed: Avhen headach is present, it is generally felt across the forehead; sometimes it does not amount to more than a sensation of weight in the situation of the frontal sinuses. The symptoms are generally of a remittent character, becoming milder during the day, and returning Avith increased severity towards evening. Causes. Exposure to the vicissitudes of the atmosphere; the irritation caused by a glare of reflected light, or by the presence of foreign matters, as dust, &c, in the eye; over-exertion of the organ by reading or writing to a late hour of the night; and, generally speaking, all those influences, Avhether atmospherical or otherwise, by Avhich inflammation of mucous surfaces is usually excited, may be enumerated as the occasional causes of catarrhal ophthalmia. Instances are not Avanting, both in this country and on the Continent, in which this disease appears to have prevailed epidemically over considerable districts. Its endemic existence is of still more frequent occurrence. Besides its origin from atmospherical influences, some authors are of opinion that it is decidedly contagious, especially in those cases in Avhich the discharge is distinctly puriform; and that the conveyance of the matter by the fingers, nails, &c. to a sound eye, " Avill excite a conjunctivitis still more severe, more distinctly puriform, and more dangerous in its effects upon the cornea, than was the original ophthalmia." (Mackenzie, Pract. Treat., p. 403.) We have certainly observed some facts Avhich tend to con- firm the opinion of its being propagable by contact. Diagnosis. From rheumatic ophthalmia, or inflammation of the fibrous membrane of the sclerotica, the catarrhal is distin- guished by the absence of circumorbital pain and intolerance of light, by the predominance of the mucopurulent over the lachry- mal secretion, and by the position, color, and arrangement of the bloodvessels, Avhich form a striking contrast in these respects to the pinky hue and deep-seated, parallel, radiated course of those ob- INFLAMMATION OF THE EYE. 467 served in sclerotitis. We frequently find these diseases combined, Avhen the symptoms present a mingled assemblage of those pecu- liar to each, although one or other generally predominates. (See Catarrho-rheumatic Ophthalmia.) Occurring in individuals of a strumous habit, catarrhal ophthalmia presents various modifica- tions, for an account of which Ave must refer to the description of strumous inflammation of the eyes. " From purulent ophthalmia it is distinguished by its much milder character; yet the two affections approximate, especially when Ave compare the severest catarrhal with the mildest puru- lent inflammation; the difference is rather in degree than kind, unless it be established, which it is not at present, that the latter always is, and the former ahvays is not, contagious." (Lawrence, Treat, on the Dis. of the Eye, p. 155.) Treatment. If the patient is young and plethoric, the local symptoms severe, and the general febrile disturbance considerable, venesection may be necessary, followed by cupping or the appli- cation of leeches, and perhaps scarification of the conjunctiva. The leeches should be placed in the hollow of the temple, over the cheek bone, or upon the side of the nose over the angular vein, and not upon the lids. Scarification of the conjunctiva ought to be performed by making one or tAvo deep incisions with a lancet, the point of which is rounded off, the Avhole length of the inner surface of either eye-lid; a considerable discharge of blood will take place, and by proper management of the lids it will continue to floAV for some time. The bowels should be well cleared by one or two doses of a brisk purgative, and the action of the skin promoted by the use of warm pediluvia and diaphoretic medi- cines, as Dover's poAvder, the Liq. Ammon. Acetat. or tartar- emetic in small doses. Abstinence from animal food and fer- mented liquors should be enjoined, and the action of the bowels should be maintained by occasional doses of the neutral salts. If the Aveather be fine the patient may be permitted to go out, and if the light be found to irritate the eyes, a broad pasteboard shade, covered Avith green silk or calico, should be worn. With regard to local applications, a variety have been proposed, both astringent and soothing, and either cold or tepid. During the acute stage, a mild tepid application is generally the most agreeable to the feelings of the patient, and most in accordance Avith what common sense Avould dictate. We may use for this purpose, either Avarm water or decoction of poppy-heads, which should be applied by means of a piece of flannel or soft sponge Avrung out of the liquid and held beneath the eye, in order that it may be enveloped in the steam. Any mild unctuous substance, as the Ung. Cetac. or cold cream, should be introduced between the lids at night, to prevent their adherence during sleep. Some practitioners make use of highly stimulating applications from the very commencement of the disease, the propriety of Avhich is 468 INFLAMMATION OF THE EYE. very questionable, Avhen the inflammatory symptoms are at all severe. Others, among Avhom is Dr. Mackenzie, rely upon a local treatment of a moderately stimulating character, combined Avith measures of general and local depletion. As a collyrium he employs a solution of gr. j of the bichloride of mercury Avith gr. vj of the hydrochlorate of ammonia in'§ viij of water, to be used tepid several times daily. The sandy pain is relieved and the inflammation abated, by dropping into the eye, once or oftener daily as circumstances may require, a solution of gr. iv of nitrate of silver in g j of distilled Avater; and the bulk of a grain of hemp- seed of an ointment containing gr. iss of red precipitate to 3} should be smeared along the edges of the palpebrae at bedtime.* If the disease manifests a tendency to become chronic, a blister applied to the nape or behind the ears, and kept open, Avill prove serviceable. The condition of the internal surface of the lids should be frequently examined; if rough and sarcomatous, it will be necessary to scarify the lining membrane and touch it lightly with the solid sulphate of copper or nitrate of silver. While we are of opinion, that general remedies in this disease are by no means to be relied upon, and that great evil frequently results from their exclusive employment, we believe that there are many local applications which may be used with nearly equal advantage. The solution of alum and of the various metallic salts have each their advocates, and in the hands of judicious practitioners have each succeeded in effecting a cure. With regard to the treatment recommended by Dr. Mackenzie, we can con- fidently testify to the success Avhich attends it both in his practice and our own. (b) Purulent Ophthalmia. Purulent ophthalmia occurs under three different forms, which are yet essentially the same disease; the tAvo first distinguished only by circumstances arising out of the age of the patient, the last (gonorrhceal ophthalmia) presenting some peculiarities Avhich are perhaps referrible to the specific nature of the cause. (See Lawrence's Treatise,]). 163.) Purulent Ophthalmia of Infants. This form generally com- mences on the third day after birth, although it may occur a few days later, and during the first stage is confined to the mucous lining of the palpebrae. The edges of the lids are observed to adhere firmly by a hardened secretion, and presents a redder ap- pearance than natural, especially toAvards the angles. If the lids are separated, a drop of thick white fluid escapes from betAveen them, and on everting them Ave find the conjunctival lining red *We learn that compression, so valuable an antiphilogistic in acute inflam- mation of other organs, has lately been employed by Velpeau in the treatment of ophthalmia, with very favorable results. INFLAMMATION OF THE EYE. 469 and villous, while that investing the globe is natural. During the second stage there is progress in all the symptoms: the SAvelling and vascularity of the conjunctiva increases; the purulent secretion becomes copious, firmly uniting the edges of the lids, collecting beneath them, or oozing out in considerable quantity Avhen they are separated, and the palpebral integuments assume a dark red hue. The child keeps its head constantly averted from the light and its eyes shut, if they are not already closed by the tumefac- tion of the lids. The chemotic swelling of the conjunctiva, pressed upon by the orbicularis muscle, causes eversion of either or both lids, Avhich may be permanent, or only occasional during a fit of crying, or on attempting an examination of the affected organ. The discharge from the eyes, though generally of a yelloAv color, may present a greenish hue in unhealthy children; sometimes it is ichorous or mixed Avifh blood, or Avhitish in appearance. The disease may continue in this state for eight days or even longer, Avithout any injury to the transparent parts, further than a slight haze of the cornea. About the twelfth day purulent infiltration of the cornea is liable to occur, and that membrane gives way by ulceration, either in a spot of circumscribed dimensions, or throughout its whole extent, so that on examining the eye after the occurrence of this untOAvard accident, Ave may find merely a small penetrating ulcer with a hernia of the iris, or the Avhole cornea destroyed and the humors prolapsed through the pupil. The other injuries to vision consequent upon this ophthalmia are, opacity of the cornea from interstitial deposit either into the con- junctival layer or into its substance, producing a loss of transpa- rency varying in degree from a thin bluish gray film to complete opacity, and limited to a circumscribed portion, or including the Avhole extent of the cornea. Adhesion of the iris to the cornea, constituting Avhat is termed " synechia anterior," may also occur; and finally a central opacity seated in the anterior hemisphere of the capsule of the lens, generally about the size of a small pin's head, is a not unfrequent result of this ophthalmia. Both eyes are usually attacked, either simultaneously or Avith an interval of several days. The constitutional symptoms accompanying the complaint are, restlessness, loss of sleep, a loaded tongue, and dis- ordered bowels; if it is neglected, feebleness and emaciation fre- quently result from the prolonged irritation. Prognosis. Though purulent ophthalmia be very manageable in its early stages, in the advanced it assumes a serious character, especially if neglected or mismanaged. The issue, therefore, de- pends on many circumstances. If the cornea still retain its trans- parency, hoAvever violent the inflammation and profuse the dis- charge, the sight will be preserved, although the cure may be tedious if the disease has been allowed to establish itself. Opa- city from thickening of the corneal conjunctiva will disappear completely, but superficial ulceration of the cornea, or morbid de- 40 470 INFLAMMATION OF THE EYE. position in its substance, will lead to the production of opacities more or less injurious to vision; and if purulent infiltration has taken place, the organ may be destroyed and vision permanently lost. Protrusion of the iris through a penetrating ulcer of the cornea Avill occasion a permanent alteration in the form of the pupil; and should this occur in the axis of vision, total loss of sight may result from the pupillary margin of the iris becoming engaged in the aperture: in such cases vision may perhaps be restored in after life by an operation for artificial pupil. If there is central capsular opacity, the probability is that it Avill remain unaltered, and though vision may improve by the expansion of the pupil as the child advances to maturity, permanent shortsightedness may be occasioned. Causes. Authors agree in referring this complaint, in the ma- jority of instances, to the inoculation of the conjunctiva during parturition with leucorrhoeal, gonorrhceal, or some other morbid discharges: * its occurrence, however, in the offspring of appa- rently healthy mothers Avho deny the existence of vaginal dis- charge in any form, must leave the source of the disease, in such cases at least, doubtful, and hence its contagious origin still re- mains open to dispute. Simple catarrhal ophthalmia may, hoAV- ever, possibly degenerate into this form of disease under the influ- ence of various causes which tend to impart to it a degree of ma- lignancy. Treatment. Before proceeding to the employment of curative means, it is of great importance that we should ascertain distinctly the actual condition of the affected organ, and especially the pro- gress Avhich the inflammation has made with reference to the transparent parts. This of course can only be satisfactorily accom- plished by separating the lids and exposing the cornea, an opera- tion which is frequently rendered very difficult by the state of the parts and the restlessness of the little patient. Nevertheless, when it can be accomplished without the exercise of undue violence, it ought to be attempted, and by adopting the following suggestions of Dr. Mackenzie we shall generally succeed:—Let the surgeon, after spreading a tOAvel upon his knees, receive between them the head of the infant, which the nurse, sitting opposite and a little to one side of him, supports across her lap. On attempting to sepa- rate the lids by drawing at the skin, eversion almost invariably takes place from the contraction of the orbicularis muscle upon the swollen conjunctiva; Ave must therefore place the the points of the * Sichel considers the cases arising from inoculation as exceptional. The real causes are difficult to trace; it frequently exists endemically in Hospitals where children are crowded together—but it also as frequently occurs sporadi- cally, generally at periods when catarrhal affections are prevalent, probably from the same causes, as it commences with all the anatomical symptoms of catarrhal ophthalmia. INFLAMMATION OF THE EYE. 471 fingers against the anterior edges of the tarsi, and press them firmly but gently backwards over the globe. If we fail in obtain- ing a vieAV of the cornea, we must rest satisfied Avith Avhat infor- mation can be obtained from the external condition of the lids and the nature of the discharge Avhich issues from beneath them. In the acute stage of the disease if there is bright redness and swelling of the ocular conjunctiva, and especially if the cornea is hazy or in a doubtful condition, it will be necessary to abstract blood from the part; and even Avhen we cannot see the eye itself, if the palpebrae are much swollen and of a bright red externally, local depletion is not less advisable. It may be effected by scari- fication of the inflamed membrane, or, what is better, the appli- cation of a single leech to the upper eyelid: from the vascularity of the skin it will bleed freely, and this is generally followed by marked diminution of the inflammatory symptoms. One leech is generally sufficient, or at most tAvo, even in robust children. The boAvels should be opened with castor oil or magnesia, Avhich may be repeated occasionally. When the tongue is white and the in- flammation active, a grain or tAvo of calomel may be given once or oftener as required; small doses repeated daily are often very beneficial. Counter-irritation by blistering has been recommend- ed, but unless absolutely necessary, it is better to avoid it in in- fants. The eyes should be frequently bathed Avith tepid water, gently separating the lids and removing the purulent matter Avith a bit of soft sponge; the upper and loAver lid are alternately to be everted and wiped clean; if the former remains everted, it may be easily replaced by compressing the swollen conjunctiva and bring- ing doAvn the edge of the lid. A little cold cream or fresh butter should be smeared along the edges of the tarsi to prevent their adhesion, and consequent dilatation of the palpebrae by the accu- mulated discharge. Having subdued the violence of the inflam- matory symptoms by the use of antiphlogistic means, Ave must have recourse to astringents, Avhich may be used with more safety and advantage in this ophthalmia than in any other. For this purpose we may employ the bichloride of mercury collyrium already mentioned, or a solution of gr. iv of alum, which may be gradually increased to gr. x, in 3j of Avater. With either of these washes the eyes ought to be bathed three or four times in the tAventy-four hours, and the fluid injected with a syringe between the palpebrae. As it is advisable to vary the stimulant occasion- ally, the solution of the nitrate of silver (gr. iv to Ij of Avater) should be applied daily Avith a large camel's hair pencil to the whole surface of the inflamed conjunctiva, after cleaning it as already directed. When disorganisation of the cornea is threatened, and the con- stitutional symptoms indicate debility, the system must be sup- ported by tonics, as quinine, in doses of gr. ss twice or thrice daily, If the conjunctiva continues in a relaxed condition during 472 INFLAMMATION OF THE EYE. the decline of the disease, we may touch it daily with the Vin. Opii; or if it presents a sarcomatous or granular appearance, strong nitrate of silver ointment or the solid caustic may be ap- plied. Mr. Guthrie employs an ointment consisting of ten grains of nitrate of silver in an ounce of axunge from the very first. Its application in the acute stage of this or any other ophthalmic inflammation must be attended with great pain, and Ave are not aware of any particular advantage which it possesses over the treatment just recommended. With the exception of Mr. Guthrie himself, Ave do not find any author of experience Avho seems to favor its application, unless in the chronic stage, Avhen a power- ful stimulant is universally allowed to be beneficial. As the purulent discharge in this disease is highly contagious, those in attendance on the child should be made aware of the fact, and cautioned against Avhatever might, favor its communication to themselves or others. Purulent Ophthalmia of Adults. This form, knoAvn also by the name of Egyptian Ophthalmia, Avhen severe, is a most for- midable disease, sudden in its attack, rapid and often uncontrolla- ble in its progress, and destructive in its effects, varying in degree from a slight affection of the conjunctiva of the lids to an intense inflammation of all the structures of the eyeball, and frequently terminating in ulceration and rupture of the cornea, Avith destruc- tion of vision. It generally affects both eyes, though not simul- taneously, and commences Avith an itching uneasiness in the con- junctiva of the lids, or a sudden sensation, as of a particle of sand lodged betAveen the eyelids and globe: next morning the palpebrae are found to be adhering, and the lining membrane is highly vascular and greatly SAVollen. The discharge is profuse; at first mucous it speedily becomes purulent, collecting in considerable quantity in the interstices of the tumefied membrance, and es- caping abundantly from betAveen the eyelids, irritating and exco- riating the skin of the cheeks over Avhich it flows. The sAvelling of the conjunctiva continues to increase, and in severe cases is raised by the inflammatory oedema in the form of pale red, soft elevations, or chemosis, round the cornea, so as at times com- pletely to overlap and conceal it, producing excessive distention of the palpebrae, or protruding from between them and causing eversion. The pain varies in degree, according to the textures which are involved; if the conjunctiva alone suffers, it is incon- siderable, but when the deeper and firmer tissues are attacked, it becomes almost insupportable. It is felt chiefly in the neighbor- hood of the orbit, and is of an aching, pulsative character, subject to remissions and exercabations of variable duration. There is sometimes hemicrania, accompanied with an agonising sense of tension in the eye; in other instances the whole head is affected. The presence of light during the paroxysm does not appear to aggravate the pain. With local suffering of such severity, Ave INFLAMMATION OF THE EYE. 473 find some degree of constitutional sympathy in the form of fever, and the general health is at times much impaired by the pro- longed irritation. A characteristic of the disease is its tendency to relapse. When the inflammation has apparently expended its strength, it may be again rekindled and rage with increased violence. Rupture of the cornea, which sometimes occurs during a paroxysm of pain at variable periods from the commencement of the disease, may afford a temporary relief to suffering; but this is not always the case, as sometimes it does- not put a termination to the dis- ease, and scarcely even checks its progress. If resolution takes place, the inflammation may issue in the production of various morbid conditions of the eye and its appendages, as vascular thickening of the palpebral conjunctiva with enlargement of its mucous papillae,commonly called "granular conjunctiva," opacity, ulceration, sloughing, or staphyloma of the cornea, or prolapse of the iris.* The inflammation may subside into a chronic form, charac- terised by a thin gleety discharge, a moderate degree of pain, and a vascnlar condition of the corneal conjunctiva, dependent upon the rough and thickened state of the lining membrane of the upper lid, by which vision is materially abridged, or even totally destroyed. From this chronic form the disease readily passes again into an active state, under the influence of various exciting causes. Causes. The opinion of authors is divided as to Avhether this disease is merely an aggravated form of common catarrhal oph- thalmia, or whether it arises from a specific contagion, produced in warmer climates and imported into this country: the Aveight of evidence is certainly in favor of the former opinion. HoAvever originating, there can be little doubt that Avhen it occurs in cir- cumstances favorable for the development of contagious disease, it presents that character, and is capable of being propagated by contact from one individual to another, acquiring additional viru- lence from the circumstances which at first favored its origin. That it may also be communicated by miasmata conveyed through the air from the eyes of those infected with the disease, is asserted by Muller, denied by Dr. Vetch (Pract. Treat., p. 179), and considered doubtful by Dr. Mackenzie (Pract. Treat., p. 419), who remarks that " in every instance in Avhich this oph- thalmia has spread through a regiment, school, or family, there has been a suspicion of actual contact by means of the fingers of the patients, or of the towels or other utensils Avhich they used in common." " In practice," says Mr. LaAvrence, " it is the safest * The granulations generally occur at a very early period of the disease, increase in number and size, and collect in groups in different portions of the conjunctiva, and remain even after the subsidence of the inflammation. 40* 474 INFLAMMATION OF THE EYE. course to proceed upon the notion of the complaint being conta- gious; and, acting upon that notion, to prohibit the use of the same sponges, utensils, or linen, or any other thing capable of communicating the disease from one to the other, just as if the contagious nature Avere decidedly proved." Treatment. On this subject Mr. Lawrence remarks (Treatise, p. 211), "there are in short, two points to be kept in mind in treating acute purulent ophthalmia—first, to check inflammation by antiphlogistic means, and then to employ astringents: if Ave proceed on this plan, Ave shall prevent that chronic thickening and granulation, Avhich are so obstinate and troublesome." To proceed on these principles, if the patient is robust and plethoric, and there is much deep-seated and circumorbital pain with chemosis of the conjunctiva, general bleeding should be prac- tised. Venesection is preferable to arteriotomy, and equally effectual. The quantity abstracted ought in all cases to be such as will produce a decided effect upon the disease. Dr. Vetch strongly recommends that the blood be alloAved to flow till deliquium animi is produced. (P. 206.) We must be cautious, however, not to carry this practice too far, as the disease cannot be cured by it alone: the patient's strength may be so reduced, as materially to favor disorganisation in the textures of the eye. After vene- section, blood may be abstracted locally by cupping or leeches. In severe cases from tAventy to thirty of the latter may be applied round the eye, avoiding to place them upon the lids: this addi- tional depletion should folloAV the general bloodletting by about two hours. If the symptoms continue unabated, or have in- creased in severity, the venesection may be repeated in tAventy- four or thirty-six hours. Scarification of the swollen conjunctiva of the globe and eye- lids with deep incisions is strongly recommended by Dr. Mac- kenzie, Avho regards it as one of the most effectual methods of combating this disease, the copious bleeding Avhich ensues tend- ing greatly to allay the symptoms. Mr. Lawrence disapproves of scarifications in cases of acute ophthalmia, as tending to aug- ment the local irritation. Walther advises the excision of large portions of the chemosed membrane after general bleeding has been premised, Avhile Sanson recommends its entire removal, and the cauterisation of the bleeding surface with lunar caustic in substance. The boAvels should be freely moved by mercurial purgatives, which may afterAvards be exchanged for milder aperients. Rest, and a strict antiphlogistic regimen should be. enjoined. In mild cases leeching and cupping will probably suffice, with the exhi- bition of purgatives, which ought not in any case to be neglected, from the powerful sympathetic influence which they exert upon the conjunctiva. As soon as the active inflammation has been subdued, diaphoretics may be prescribed, as a full dose of Dover's INFLAMMATION OF THE EYE. 475 poAvder at bedtime, accompanied Avith warm pediluvia and dilu- ents. There is a difference of opinion as to the free employment of mercury in this disease. Rust recommends its exhibition Avhen the inflammation is advancing unchecked despite of antiphlogistic measures. Mr. Lawrence states, that his experience corresponds with that of Vetch and Walther, Avho have seen salivation pro- duced in many instances without the smallest advantage. Dr. Mackenzie considers the exhibition of calomel and opium, pre- ceded by general bleeding, as very useful in severe cases attended with nocturnal circumorbital pain, and advises it to be given in the proportion of gr. ij of the former and gr. i to gr. j of the latter every two hours, thrice a day, or only at bedtime, as the case may require, till the mouth is affected. Counter-irritation is of the greatest service; after depletion a suppurating surface should be opened by blistering upon the nape or behind the ears. The local treatment ought to partake both of a soothing and stimulant character, but the protracted use of the one, or the pre- mature employment of the other, is equally injurious. Cold ap- plications to the inflamed organ have been recommended by high authorities, as of great utility in reducing the vascular action. If perseveringly employed, on the first appearance of the disease, no doubt this may be the case; but Avhen the inflammation is fully developed, the feelings of the patient must be generally against them. Mr. Travers decidedly prefers a tepid application in the painfully acute stage of inflammation, an opinion in which we concur. Considerable benefit is sometimes derived from ex- posing the eye to the vapor of hot water and laudanum, and the temples may be rubbed with warm laudanum before the noctur- nal attack of circumorbital pain sets in. The purulent discharge should be frequently and carefully removed from the eyes with the bichloride of mercury collyrium used tepid, and injected over the Avhole conjunctival surface by means of a syringe. Dr. Vetch recommends very strongly an infusion of tobacco, in the propor- tion of 3ij of the leaves to 3 viij of water, and the undiluted Liquor Plumbi Diacetatis, as collyria in this stage of the disease. (Op. cit.,o. .211.) Some mild application should be applied to the edges of the eyelids at bedtime. When the acute inflammatory symptoms have been subdued, the treatment must be changed, and astringents of greater activity employed: the gr. iv solution of the nitrate of silver is one of the best, and ought be dropped into the eye every five or six hours, or whenever the raw painful feeling is reneAved: in the intervals the bichloride of mercury collyrium may be continued, or a solution of alum (gr. ix to gr. x in Ij of water.) The red precipitate, or the citrine ointment, Avhich is highly recommended by Sir P. Macgregor, may now be substituted for the milder applications previously used. Mr. Briggs employs the 01. Terebinth, introduced betAveen the lids, as an effectual means of checking the profuse discharge: he ap- 476 INFLAMMATION OF THE EYE. plies it in minute quantities Avith a camel's hair pencil, afterAvards bathing the eye with cold Avater till the heat and uneasiness produced are allayed. In employing astringents it is necessary closely to Avatch their effects, discontinuing their use, and having recourse again to antiphlogistic measures upon any reneAval of the inflammation and pain. With change of local treatment may be conjoined better diet, exposure of the eye to light, and exer- cise in the open air. Dr. Vetch and Mr. Murray speak highly of the good effects of exercise in the open air upon the soldiers affected Avith this disease, even during the existence of chemosis and purulent discharge. As the state of the pupil frequently cannot be ascertained during the progress of this disease, the extract of belladonna ought to be rubbed into the forehead or temples to dilate it, and prevent those abnormal adhesions of the iris which, though com- paratively rare in any of the puro-mucous ophthalmiae, occasion- ally take place to the cornea from a penetrating ulcer. Evacuation of the aqueous humor by puncturing the cornea has been suggested as a means of relieving the intense pain of the eye and head, and preventing the rupture of that membrane. Sir P. Macgregor, who performed it in twenty-three cases, speaks very favorably of its good effects. If ulcers form upon the cor- nea, they must be touched with the lunar caustic pencil sharpened to a point. This practice is especially useful Avhen a portion of iris protrudes through the ulcer. Spreading ulceration of the cornea attended with debility will require a decided tonic and stimulating treatment, viz: good diet with porter or wine, quinine, and local astringents. (Lawrence, p. 211.) The Vin. Opii is an excellent application in the relaxed condition of the conjunctiva, which frequently remains after the acute inflammatory symptoms have disappeared, and the puriform discharge has ceased. Be- sides the plan of treatment above recommended, and which in general Ave should consider the safest and the best, it has been proposed by some authors of experience and merit, to cut short the disease at the commencement by the free use of powerful astringents; and certainly their testimony goes far to establish the utility of this practice Avhile the disease is confined to the mucous lining of the palpebrae, or is just beginning to spread to the conjunctiva of the globe. Dr. Ridgway employed the gr. x solution of the nitrate of silver, to which Dr. O'Halloran added the use of the sulphate of copper in substance, which he freely applied to the inner surface of the eyelids, not only in the early stage of the disease, but also when the purulent discharge and chemosis Avere fully established. Mr. Guthrie's nitrate of silver ointment may be employed for the same purpose; but if we deemed it advisable in any case to adopt this mode of treatment, we should certainly prefer the lunar caustic pencil rapidly passed ^over the diseased membrane to any other form of stimulant. INFLAMMATION OF THE EYE. 477 (c) Gonorrheal Ophthalmia. Having already given a detailed account of purulent ophthal- mia in the adult, Ave shall now describe at length the symp- toms or consequences of this disease, which differs from that referred to rather in origin and degree than in kind. The vehe- mence of its attack, and the rapidity Avith which it runs its brief but destructive course, render gonorrhoea!, ophthalmia decidedly the most dangerous inflammation to Avhich the eye is subject, and fortunately it is one of the most rare. The symptoms are those of ordinary purulent ophthalmia in the highest degree of development, intense general external red- ness, great vascular congestion, chemosis and SAvelling of the lids, and profuse yelloAv discharge. The palpebral and ocular conjunctiva are generally attacked simultaneously, and to this membrane the inflammation is at first confined, but speedily ex- tends to the cornea and fibrous tissues of the eyeball, this being marked by severe and agonising pain of the globe, orbit, and head, accompanied Avith general febrile disturbance. Such a combination of symptoms indicates the most imminent danger to the organ; and indeed, if the inflammation has spread beyond the mucous membrane, Ave can scarcely expect by any treatment to arrest completely its destructive course. From the excessive swelling and eversion of the lids and the great chemosis, it is frequently impossible to ascertain the precise condition of the cornea. When the pain is intense, Ave may suspect its implication in the disease; but sometimes that symptom is very slight in de- gree, or even entirely absent. The symptoms are by no means of equal severity throughout the progress of the disease, being generally aggravated as the inflammation advances from the yielding membrane of the palpabrae to the denser textures of the globe. The principal disorganising changes to be apprehended are thus concisely stated by Mr. Lawrence: "The immediate effects of this inflammation upon the cornea are sloughing, sup- puration, ulceration, and interstitial deposition, Avhile the conse- quences to Avhich these changes lead more remotely are, escape of the humors and collapse of the globe, obliteration of the ante- rior chamber and flattening of the eye, staphyloma, prolapsus iridis, obliteration of the pupil, corneal opacity, and anterior ad- hesion of the iris.". (P. 220.) Causes. Gonorrhceal ophthalmia has been referred, 1. to the inoculation of the conjunctiva Avith the matter of gonorrhoea; 2. to metastasis of the inflammation from the mucous lining of the urethra to the analogous tissue of the eye. WTith reference to the first, the cases related or referred to by Messrs. Allan (Syst. of Path, and Oper. Surg., vol. i, p. 153), Mackenzie (op. cit.,o. 43S), and Lawrence (op. cit., p. 227), sufficiently establish in our opinion the possibility of its being thus communicated. With re- 478 INFLAMMATION OF THE EYE. gard to the opinion of its metastatic origin, it is probably errone- ous: the testimony of observation is certainly against its occur- rence. In none of the cases observed by Mr. LaAvrence, in Avhich this ophthalmia coexisted with or supervened upon gonorrhoea, was the urethral discharge stopped; and although generally less- ened in quantity, it continued in some instances Avith little dimi- nution; while, on the other hand, the sudden suppression of go- norrhoea! discharge, Avhen effected by surgical means, is not succeeded by inflammation of the eyes. Treatment. The antiphlogistic plan in all its details has been carried to its utmost extent in this disease, and with very varia- ble success, in some instances proving effectual for the preserva- tion of sight, while in others it has as signally failed, and indeed, " in many cases the result must be unfavorable whatever plan is adopted; because, from the rapidity and violence of the disorder, irreparable mischief has been done before assistance is demanded." It has been proposed to cut short the disease in its early stage by the application of strong astringents and escharotics, as the gr. x solution, or the ointment of the nitrate of silver. From the fre- quent failure of the antiphlogistic mode of treatment this method is worthy of a trial in favorable cases, as Avhen the inflammation has not yet extended beyond the conjunctiva; and even Avhen the cornea is affected, from the generally unfavorable termination of such cases under any plan of treatment, Mr. LaAvrence thinks that these local measures might still be tried, bloodletting being pre- mised or accompanying their application. (P. 230.) If antiphlogistic measures are determined upon, they must be vigorously pursued to be of any service. Provided the cornea is still uninjured, in a doubtful condition, or only partially sloughed, Ave may hope by copious and repeated venesection to preserve its integrity in the former case, or some degree of vision at least in the latter. If suppuration and sloughing to any extent has taken place, such activity of treatment is unnecessary, though moderate depletion may still be requisite. In some cases general bleeding is demanded for the mere relief of the intense suffering attendant upon the disorganisation of the denser tissues of the eyeball Avith- out any reference to the preservation of sight. Having thus checked the extreme violence of the inflammatory action, the local abstraction of blood by leeches, scarification, or excision of a portion of the chemosed membrane, will probably suffice for the removal of the slight remaining symptoms. The bowels must be freely moved by active purgatives, and their due action, as Avell as that of the skin, maintained by appropriate means: a low diet and rest will complete all that is necessary in the treatment of the acute stage of this disease. Dr. Mackenzie recommends the employment of calomel and opium, as in conta- gious ophthalmia: counter-irritation may be resorted to as an aux- iliary means, antiphlogistic measures having been premised. The INFLAMMATION OF THE EYE. 479 eyes should be frequently bathed with the bichloride of mercury collyrium to remove the discharge, and the edge of the lid smear- ed Avith some mild unctuous substance. When the inflammation has been completely checked, leaving the patient pale and weak from the effects of the previous treatment, it may be sometimes necessary to give general tonics, as quinine, and employ astrin- gents locally, though Mr. LaAvrence thinks such measures are rarely required. Mr. Travers, on the other hand, recommends a careful but prompt exhibition of tonics, Avith the use of astringent lotions, in this stage of the disease. The best astringent applica- tions are, the alum or nitrate of silver solutions formerly mention- ed, Avith which may be combined the use of the red precipitate ointment. Ulcers of the cornea may be touched Avith the lunar caustic pencil. Besides the severe form of disease above sketched, Mr. Law- rence describes (p. 232) a gonorhoeal inflammation of the con- junctiva, comparatively mild in its symptoms, and much less dan- gerous in its results; it readily yields to the astringent plan of treatment, rarely requiring antiphlogistic measures, unless in pa- tients of a full habit.* (d) Strumous Ophthalmia. Strumous ophthalmia is peculiarly a disease of childhood, nine tenths of the cases of inflammatory affections of the eyes in young subjects being of this nature. It seldom attacks infants previous to weaning; from that period to puberty is the season of life Avhen it most frequently appears. It rarely occurs however in adults, unless they have previously suffered from the disease.t Strumous ophthalmia has its primary and essential seat in the conjunctiva and Meibomian glands, although it may secondarily extend to the tissue of the sclerotica and iris. It is characterised by moderate vascularity of the conjunctiva, a copious lachrymal * All these various forms of ophthalmia are regarded by Sichel as of the catar- rhal type, and are collected together under the general term " Blenorrhoie Ophthalmia." Purulent ophthalmia, both in adults and children, and Egyp- tian ophthalmia, he considers as identical in their nature, only more oj less modified by the circumstances which preside over their formation and march, and by the age of the individuals attacked. Even gonorrheal ophthalmia, much as it differs by the nature of its cause from the others, differs very little in its symptoms, march, and duration. He proposes to distinguish by the word blenorrhoie the milder forms of these ophthalmiae. While the term ble- norrhagic will indicate those in which the symptoms are not acute. f Sichel admits another primary seat for strumous ophthalmia—the cornea, producing a scrofulous keratitis, not vascular. Our author treats also of this p. 316. 4S0 INFLAMMATION OF THE EYE. secretion, and a degree of intolerance of light Avhich is quite dis- proportioned to the urgency of the concomitant symptoms. The palpebrae are firmly closed by the spasmodic action of the orbicularis, and the child seems to be unable to open its eyes by the light of day, even when Avilling; or if it does succeed by a con- vulsive effort, the cornea is immediately rolled upAvards beneath the margin of the tarsus, so as to be completely hid from view; an effect which equally folio avs the forcible separation of the lids, and renders an examination of the cornea a matter of no small diffi- culty. Were Ave to estimate the severity of the other symptoms by the degree of intolerance of light,* we should frequently be sur- prised, on quickly separating the lids, to find the eye nearly natu- ral in appearance. We mention the quick separation of the lids, because an exposure of a few seconds to the light is sufficient to cause copious injection of the conjunctiva, and an appearance of vascularity which it Avould not otherAvise present; a source of fal- lacy in estimating the amount of inflammatory action present, which it is well to be aAvare of. The vessels observed upon the conjunctiva, and sometimes con- fined to the inner surface of the palpebrae, generally of a someAvhat dusky hue, are either single, or arranged in fasciculi, and direct their course to the margin of the cornea, over Avhich they pass, terminating toAvards its centre. At the extremities of these ves- sels, small phlyctenulae or pimples, containing a clear or yelloAvish fluid, are formed, Avhich speedily burst, and give place to a small round funnel-shaped ulcer. These phlyctenulae are also observed upon the sclerotica, and very frequently at the line of its junction * This is a mistake made by almost all authors who do not distinguish be- tween simple strumous ophthalmia and scrofulo-rheumatismal ophthalmia, in which the sclerotica is involved, as long as the affection is simple, it is con- fined to the conjunctiva, and the injection is peculiar, composed of vessels of tolerable size, slightly tortuous, united in groups, generally at the inner or outer margin of the eye, ordinarily constituting a triangle, the base of which almost touches the circumference of the cornea, without however passing be- yond it. Beneath this injection the sclerotica is seen of its natural whiteness. As the affection advances these groups of vessels spread out so as to cover a greater surface, appear dilated, of a deep red? and intermixed with veins; but still so long as the disease is confined to the conjunctiva, no matter what may be its degree, there is not the slightest epiphora or photophobia; nor unless there is complication, is there increased mucous secretion—in a word, the epi- phora and photophobia depend upon a rheumatismal complication, while the increased mucous discharge depends upon a catarrhal complication. There is, however, in the most simple form of strumous ophthalmia, a spasmodic con- traction of the eyelids. It must be recollected, then, that the description here given combines the symptoms of scrofulous ophthalmia, scrofulo-catarrhal oph- thalmia, and scrofulo-rheumatismal ophthalmia. INFLAMMATION OF THE EYE. 481 with the cornea; they vary both as to number and size, being ge- nerally smallest upon the cornea. The degree of pain is generally moderate while the eyes are shaded from the light. When the inflammatory symptoms are active it is considerable, especially during the night. The secre- tion from the eyes is evidently of an acrid nature, from the irrita- tion it occasions in the nostrils and upon the integuments of the face, Avhich become red and inflamed, and are sometimes affected with a pustular eruption. The foregoing local symptoms are at- tended with a disordered condition of the stomach and bowels; the tongue is foul; the breath often fetid, and the evacuations of an unhealthy character. The temper becomes irritable and fret- ful, and this tends to prolong the disease. ToAvards evening, especially after sunset, there is a considera- ble remission in the symptoms, which have been aggravated dur- ing the day; a phenomenon which is not observed in any of the other forms of ophthalmia. Both eyes are usually affected, though not in an equal degree; or the disease may commence in one and pass to the other, or attack them alternately. The strumous diathesis is further indicated by various morbid appearances in other parts of the body, some of them evidently produced by the acrid secretion from the eyes, others apparently originating in the general unhealthy condition of the system. From the insidious nature of this form of inflammation, and the frequent absence of any prominent symptom, the most serious organic changes may have taken place in the transparent tex- tures of the eye, tending materially to abridge, or even totally destroy vision, before Ave are aware of the danger Avith which they are threatened. The organic changes most to be apprehended are, ulceration of the cornea, and the deposition of opaque matter in its sub- stance. The phlyctenulae Avhich we have already described as forming upon this membrane may be absorbed, and the remaining opacity be entirely removed, or a transparent dimple of the cornea may be left, which is long in filling up. In other cases the opacity is observed to extend itself, and red vessels run into it, forming what is named " vascular speck," which is a very troublesome symptom. More frequently the phlyctenulae burst, and form, ulcers which may be superficial and considerable in extent, but are generally deep and infundibili-form. This change is usually preceded by the appearance of red vessels running to the phlyc- tenulae, a symptom indicative of much danger to the eye, from the frequency Avith Avhich the ulcer penetrates to the anterior chamber, causing protrusion of the iris, and subsequent adhesion of that membrane to the cornea. The ulcer, when healed, leaves an opaque permanent cicatrix, which however may be in some 41 482 INFLAMMATION OF THE EYE. degree lessened by contraction upon itself, or by the groAvth of the patient. If several phlyctenulae coexist upon the cornea, they may unite previous to bursting, infiltrating their contents into the substance of the cornea, and forming a species of onyx, which is sometimes observed at the edge of the cornea, inde- pendently of this cause. It frequently happens, that Avhile the entire thickness of the corneal substance has been penetrated by an ulcer, the lining membrane of the aqueous chamber still remains entire, and by the pressure of the contained humors is protruded through the opening in the form of a small vesicle, forming what is termed " hernia corneae." Should this give Avay, as generally happens, the aqueous humor escapes, the iris is prolapsed, and a dense opaque cicatrix is the result. If the corneal ulcer has been of considerable size, and the iris , extensively prolapsed, the pseudo-cornea which has been formed over the protruded portion of iris, sometimes gives way before the pressure of the humors, forming a partial staphyloma. A general protrusion of the whole cornea may take place from the same cause, Avhen its texture has become Aveakened by inflam- matory action, and the iris is adherent to its posterior surface. The transparency of the cornea may be further impaired by interstitial deposit, or the ramification of red vessels in its con- junctival layer forming a vascular net-work, which has been named "pannus." The inflammation may be propagated from the cornea to the sclerotica and iris, and may even extend to the deeper-seated structures, producing serious organic changes of the internal parts, especially when the disease is of long standing, and has frequently renewed its attacks. The globe may be en- larged by an increased secretion of the humors, a degree of hydrophthalmia being thus produced; while in other cases it is observed to be dwarfish and atrophic, apparently the result of interrupted nutrition. Frequent and long-continued attacks of strumous ophthalmia generally leave the eyes in an imperfect condition, and predis- posed to become amaurotic, under the influence of causes which would not have similarly affected them in other circumstances. Dr. Mackenzie (p. 469) describes, under the name of Pustular Ophthalmia, another form of strumous inflammation of the eye, which differs in several respects from that which we have just described. The subjects of it are generally children of a some- what advanced age, or young adults. It is not attended with danger to the transparent textures of the eye, and readily yields to a very simple mode of treatment. As its name indicates, it is characterised by the formation of pustules, generally of consider- able size, filled with an opaque yellow matter, and usually seated a line or two distant from the margin of the cornea: they burst and are converted into broad elevated ulcers. The vascularity INFLAMMATION OF THE EYE. 483 of the conjunctiva is fasicular and confined to the vicinity of the pustules. Sometimes it is pretty general over the surface, and accompanied Avith conjunctival ecchymosis. This ophthalmia is often combined Avith catarrhal conjunctivitis. The intolerance of light is generally moderate in degree, sometimes wholly absent; and we never observe the spasmodic contraction of the lids so frequently attendant upon the ordinary form of strumous inflam- mation of the eyes. Causes. This form of ophthalmia, as its name implies, occurs in individuals of scrofulous diathesis, in whom the morbid pre- disposition may be called into action by various causes, as the use of umvholesome food, excess or irregularity of diet, resi- dence in bad air, and neglect of exercise; to which may be added exposure to cold and wet, teething, over-exertion of the eyes, the presence of irritating bodies in the folds of the conjunctiva, slight blows, &c; and it is a not unfrequent sequela of exanthe- matous fevers and hooping eough. Treatment. Originating as this disease unquestionably does in an unhealthy condition of the system, Ave cannot expect that any mode of treatment Avill prove effectual for its cure, Avhich is not in a great measure directed to the improving and confirming of the general health. Unless this ultimate object is kept con- stantly in vieAV, and perseveringly aimed at, the most appropriate local treatment will prove altogether unavailing. As strumous ophthalmia is almost invariably attended Avith an unhealthy condition of the digestive organs, our first care must be to restore and insure the due performance of their functions. It will be necessary to administer purgatives, and those too of an active nature even in young children: large quantities of morbid faeculent matter are thus frequently removed; and a brisk purge, several times repeated, Avill in some instances suffice to effect a cure. The purgative plan of treatment has been recommended as especially useful Avhen the ophthalmia is accompanied Avith an impetiginous eruption over the body; but we must be cautious not to carry it too far, from the debility which may ensue. After thoroughly clearing the bowels of their unhealthy secretions, Ave may exhibit mild alteratives. In some cases attended Avith heat of skin, a quick pulse, and a foul tongue, Ave may commence the treatment more advantageously with an emetic, and afterAvards small doses of tartar-emetic (to children fa to TV of a grain) thrice a-day. Antimony combined with the sulphate of mag- nesia, and administered so as to keep up a state of nausea and catharsis, is a mode of treatment well adapted to acute cases in adults. Bloodletting, either general or local, is seldom requisite, and intolerance of light alone is not to be recorded as an indication either for its employment or repetition. If there be considerable redness and pain of the eye with general fever, leeches must be 484 INFLAMMATION OF THE EYE. applied. It may be necessary to repeat them frequently, if the local symptoms continue urgent, and the constitution will bear the depletion; though it must be borne in mind that depletion alone will not effect a cure, and Ave may often as effectually sub- due the disease, Avhile Ave save our patient's strength, by the exhibition of tartar-emetic. Repeated bleedings, to the neglect of other means, are highly pernicious; tending to increase the irritability of the affected organ, and by reducing the patient's strength, to render the transparent textures of the eye more sus- ceptible of destructive changes. Tonics are peculiarly useful in this disease, from their effects in removing the constitutional debility upon Avhich it in a great measure depends. After the alimentary canal has been suffi- ciently cleared by the exhibition of purgatives, Ave may com- mence their use; and the di-sulphate of quinine seems to be the most eligible form. Dr. Mackenzie, who has used it extensively, says, " In most of the little patients to whom I have administered sulphate of quinine, it has acted like a charm, abating commonly in a feAV days the excessive intolerance of light and profuse epiphora, promoting the absorption of phlyctenulae, and hasten- ing the cicatrisation of ulcers of the cornea." (P. 460.) A health- ful condition of the skin should be promoted by the use of the tepid bath, or daily ablution of the body Avith tepid salt Avater, followed by gentle friction. The temperature of the Avater may be gradually reduced, till the cold plunge, or shoAver-bath, can be borne Avith advantage. Among constitutional remedies Ave ought not to omit to men- tion the marked benefit Avhich is frequently derived from change of air, especially by the removal from the impure atmosphere of a large town to the more salubrious air of the country. Mercury or its preparations, though usually administered in this disease for their purgative effects are sometimes employed Avith other intentions. Their deleterious influence however upon strumous habits, should deter us from their exhibition, except as purgatives or alteratives, unless imperatively demanded, as to arrest disorganisation of the transparent textures of the eye. In these circumstances, calomel and opium may be given till the gums are affected, or the Hydrarg. c. Creta, either singly or com- bined with James's poAvder, or the Pulv. Ipecac. Comp. Counter-irritation is highly beneficial, and is often effectual in speedily removing the intolerance of light. Its mode of applica- tion is a matter of some difficulty in very young subjects, and re- quires to be conducted with caution. If we prefer a blister, it ought to be applied betAveen the shoulders or behind the ears, and should be removed in six or eight hours at farthest: it is safer to repeat the application after a short interval, than to keep up a discharge by the use of irritating ointments. The position of the child during sleep is a matter of some moment: it ought on no INFLAMMATION OF THE EYE. 485 account to be permitted to lie burying its face in the pillows; nor, unless absolutely necessary, should it be alio wed ^to remain in bed during the day. Local remedies. Scarification of the conjunctiva of the lids has been recommended, especially in chronic cases, and mav sometimes be employed Avith advantage. Warm fomentations are employed with much advantage when the symptoms are at all severe, affording much relief to the photophobia and spasm of the lids. A bit of flannel, or soft sponge, wrung out of a decoc- tion of poppyheads, or chamomile flowers, or an infusion of opium, may be applied to the eyes as hot as it can be borne; or they may be exposed to the vapor of laudanum, or of a vinous solution of belladonna, raised by mingling it in a cupful of hot water: warm bread and water poultices during the night are sometimes beneficial. When the symptoms are moderate and the attack recent, evap- orating or slightly stimulating lotions are frequently effectual in removing the complaint. The solution of a grain of the bichloride of mercury in 3 viij of simple or rose water, is as useful a form as any: it should be employed tepid to bathe the eyes several times daily. In severe attacks, Avhen the acute inflammatory symptoms have been subdued by the treatment already pointed out, stimuli of considerable strength may be applied to the surface of the eye with decided benefit. The most useful are the gr. iv solution of the nitrate of silver, the red precipitate ointment, and the Vinum Opii. They have a marked effect in diminishing the irritability of the organ, in promoting the healing of ulcers of the cornea, and in dispersing the opacities which these may have occasioned The red precipitate ointment should be introduced betAveen the lids at bedtime every night, or every second night; and any other stimulant Avhich is selected ought to be regularly applied once a day, or every tAvo days. When large ulcers exist upon the cornea, a stronger solution of nitrate of silver than that mentioned above may be applied di- rectly to their surface with a camel's hair brush, or the lunar caustic pencil filed to a sharp point may be employed. The lat- ter is especially useful in deeply penetrating corneal ulcers, or when there is protrusion of the iris from the anterior chamber having been opened. The prolapsed portion may be touched with it every second or third day. In deep central ulceration of the cornea, the extract of bella- donna should be smeared over the eyebroAV, or an. ointment con- taining this substance rubbed into the temple and forehead: its effect in dilating the pupil is sometimes sufficient to free the iris, even Avhen involved in an ulcer of the cornea. The eyes should be protected from the light by the use of a broad green shade, and guardians of children ought to be cautioned against binding 41* 486 INFLAMMATION OF THE EYE. up their eyes Avith handkerchiefs, a common and most pernicious practice. It is not necessary to confine the patient to a dark room, exposure to the air when the Aveather is fine being deci- dedly beneficial. In cases of "vascular speck," the removal of a portion of the enlarged vessels Avhich supply it, is one of the most effectual means of arresting its progress. With regard to the treatment of the pustular form of strumous ophthalmia, a few words will suffice. The pustules or ulcers should be touched daily with solid caustic, or a strong solution of nitrate of silver, and the eyes bathed Avith the bichloride of mer- cury collyrium. After the exhibition of a few smart purges, it has been recommended to give chalybeates, as the sesquioxide of iron, in the dose of from gr. x to xx thrice daily: we have seldom found this necessary, the disease yielding readily to stimulating local applications. (e) Variolous Ophthalmia. The sympathy Avhich is observed to exist between the skin and the mucous membranes in a state of health, is equally exhibited in their morbid conditions; and in no instance is it more strongly marked'than in the exanthemata, in all of which the eye is apt to suffer, sometimes very severely. Previous to the introduction of vaccination, variolous inflammation of the conjunctiva Avas a frequent cause of serious injury to vision, or even of its complete destruction. The variolous pustules may be confined to the in- teguments of the palpebrae, or they may be developed on any part of the conjunctiva of the eye; constituting true variolous ophthalmia. When they occupy the former situation, and are numerous as in the confluent form of the disease, they are at- tended with great swelling of the lids, by which the eyes are completely closed; while the augmented conjunctival and Meibo- mian secretions being confined by the incrustations which bind together the cilia, tend to increase the irritation of the organ and the patient's suffering. As the disease subsides these more im- mediate effects of the inflammation may pass away and the eye escape uninjured, though Ave more frequently find that both the eye and the lachrymal apparatus have materially suffered. Among the changes of structure usually resulting from the formation of pustules upon the palpebrae, may be enumerated complete destruction or an abnormal position of the cilia, un- sightly marks upon the tarsi, irregularity of their edges, or super- ficial ulcerations and excoriations with an irritable condition, which from slight causes is apt to pass into chronic ophthalmia of a very obstinate character. Chronic inflammation of the lachrymal sac and strumous inflammation of the conjunctiva are also frequent consequences of small-pox. True variolous ophthalmia is characterised by the formation INFLAMMATION OF THE EYE. 4S7 upon the conjunctiva of the pustules peculiar to this disease: they may be seated in any part of the membrane, though the greatest danger is to be apprehended from their developement upon the corneal layer. The disease is essentially the same on the cornea as on the skin, though in the former case its effects are serious and destructive, while in the latter they are compara- tively insignificant. From the great tumefaction of the lids, it is frequently impossible to ascertain by inspection the actual condi- tion of the eye; but if there is pain of the globe aggravated by motion or exposure to light, a feeling of dryness and stiff'ness of the eye with a sensation as of sand in it, and increased lachryma- tion and discharge, Ave may infer the existence of acute variolous inflammation, and consequently imminent danger to Adsion. If the above symptoms are absent, the disease is probably confined to the palpebrae. The pustules of the palpebral conjunctiva are small and of a yellowish color. Upon the cornea they commence by small whitish points, which gradually become elevated and yelloAv. The suppuration extends to the substance of the cornea, and a pointed elevated pustule is formed, Avhich is sometimes succeeded by onyx. The inflammation may extend to the deeper tissues of the eye. Total or partial loss of sight will result from these disorganising processes. Suppuration or sloughing of the cornea is followed by a greater or less degree of opacity, which may or may not be attended with synechia anterior. Prolapse of the iris, or staphy- loma, Avill folloAV penetrating ulcers, and in severe cases almost the Avhole of the cornea may be destroyed by purulent infiltra- tion and ulceration. Should the eyes escape during the early stages of variola, they are still liable to become the seat of a pustular eruption during the decline of the disease in other parts of the body: from this circumstance it has been named, "secondary variolous ophthal- mia." The period of its attack varies from two to six Aveeks after the apparent termination of the primary complaint, with Avhich it is identical in character; and though milder in degree, it is still not unattended with danger to vision. One or more pustules may form on the cornea, their development being accom- plished in the manner already described, and accompanied with redness of the sclerotic coat, lachrymation, pain, and increased sen- sibility to light. This form of the disease seldom terminates in destruction of the cornea. The matter of the pustules is either entirely absorbed, leaving no trace of the disease; or ulceration takes place, and opacities varying in degree are the result. The injury to vision is often less serious than the aspect of the disease in its early stages would lead us to anticipate. Treatment. When the eruption is limited to the integument of the eyelids, besides placing the patient in a moderate tempera- ture and upon a cooling regimen, vvith the use of tepid ablutions, 488 INFLAMMATION OF THE EYE. we may adopt some local measures to moderate the irritation occasioned by the pustules. The face should be covered Avith a soft cloth spread with some mild cerate, or fomented frequently with chamomile decoction, or tepid milk and water. When the pustules are matured their contents may be evacuated by pricking them, and the succeeding incrustation removed, after being Avell- softened Avith some unctuous application, or tepid wash. M. Serres recommends the pustules to be opened and thoroughly cauterised with the solid nitrate of silver. (Traiti de V Ophthal- mic, #c. par J. Sichel, p. 460.) In true variolous ophthalmia, when the pustules have extended to the conjunctiva of the lids and globe and to the cornea, active antiphlogistic measures seem alone to afford any chance of saving the organ, but unfortunately these are not ahvays admissible. If the propriety of general bleeding is questionable, local depletion by leeches to the temples or behind the ears may be resorted to with advantage, and followed by a blister if necessary. Mercu- rial purgatives should also be freely administered. From the SAVollen condition of the palpebrae it is frequently impracticable to make any application to the inflamed conjunctiva; but the ex- ternal surface may be bathed frequently Avith poppy decoction or tepid Avater, and the edges of the lids smeared Avith cold cream after removing the incrustations. As soon as the state of the parts will admit of it, a Aveak solution of nitrate of silver or diluted Vin. Opii should be injected betAveen the lids. In the treatment of the secondary form of the disease, the ex- hibition of tartar-emetic has been recommended as tending to abate the inflammation, and promote the absorption of the pus- tules and onyx. Leeches and blisters may also be required. When the acute inflammatory symptoms have been subdued, quinine may be given Avith advantage. Undiluted Vin. Opii should be applied once daily to the conjunctiva, and belladonna smeared over the eyebrow as a precautionary measure to keep the pupil dilated. M. Serres recommends the adoption of his mode of treatment for pustules seated upon the cornea, as well as for those upon the integuments of the lids. (f) Morbillous and Scarlatinous Ophthalmia. The ophthalmia Avhich usually accompanies measles and scar- latina is neither so severe in its nature, nor so injurious in its con- sequences, as that attendant upon variola; bearing the same rela- tion to the latter in degree which is observed to exist betAveen the cutaneous inflammations in these several exanthemata. The conjunctiva, participating in the morbid condition of the cutaneous circulation, exhibits some degree of redness accompa- nied with intolerance of light, slight pain, and increased lachrymal discharge. The cornea sometimes becomes the seat of phlyctenulae, ulcers, or onyx, especially in scrofulous subjects, and indeed it is INFLAMMATION OF THE EYE. 4S9 difficult to distinguish this form of inflammation from ordinary strumous ophthalmia till the eruption appears. In weakly chil- dren, or from the neglect of proper treatment, ulceration of the cornea and staphyloma have sometimes resulted from the ophthal- mia attendant upon measies, and Mr. Lawrence has observed the same occurrence in that accompanying scarlatina. Opacities of the capsule of the lens, and affections of the iris, have been ob- served in some rare cases to ensue from scarlatinous ophthalmia. Treatment. Active treatment is not required in these ophthal- miae. The eyes should be frequently bathed Avith some cooling wash and protected from the light. The patient ought to be freely purged, and if the symptoms are unusually severe, a few leeches may be applied to the temples, followed by a blister be- hind the ear or to the neck. The nitrate of silver solution and the di-sulphate of quinia will be found highly useful Avhen the acute symptoms have yielded. (g) Erysipelatous Ophthalmia. Inflammation of the eyes from the extension of erysipelas of the face to the conjunctiva is frequently observed, but idiopathic erysipelatous inflammation of the conjunctiva, a form of ophthal- mia described by some authors, is of rare occurrence. It is chiefly characterised by the elevation of the ocular conjunctiva in the form of vesicles round the cornea, which are of a soft con- sisitence and yelloAvish red color; the natural secretions of the part are augmented, and there is some degree of pain; the disease seems disposed to subside of itself, and does not demand any treatment beyond the puncture of the vesicles, and the exhibition of an aperient and diaphoretic. It is chiefly observed in individuals of cachectic habit, and may be caused by atmospherical changes, slight bloAVs, and the stings of insects.* II. Inflammation of the Sclerotica. Rheumatic Ophthalmia, or, as it has been termed, Sclerotitis atmospherica, may be denned to be an inflammation of the sclerotica and surrounding fibrous tissues of the orbit: it rarely exists alone, being either accompanied from the first, or speedily folloAved, by a degree of inflammation of the conjunctiva. The iris and cornea suffer to a certain extent, though, unless from neglect or mistreatment, serious change of structure in either is not usually observed. * The conjunctiva rather offers a general appearance of infiltration, with a confluent pale yellowish or reddish injection; the secretions are scarcely aug- mented; there is no intolerance of light or injury to vision, and the pain seems to be confined to a disagreeable sensation of prickling, or tension owing to the swelling of the conjunctiva and its projecting between the lids. 490 inflammation of the eye. Symptoms. There is general bright redness of the globe of the eye, specially developed round the cornea, toAvards the mar- gin of which the radiated sclerotic vessels may be observed advancing, and along Avith those derived from the conjunctiva, passing over it to the extent of about half a line, forming a fine vascular Avreath, encircling the cornea either wholly or in part, and in Avhich all the vessels are observed to terminate Avith sharp points, and at an equal height; none pass beyond it, the rest of the cornea remaining free. This arrangement and mode of ter- mination of the vessels is considered by Jiingken to be character- istic of Rheumatic Sclerotitis. (Lehre von den Augen Krank- heiten, p. 231.) As the inflammation extends to the lining membrane of the aqueous chamber, the cornea becomes hazy;* the iris loses its lustre, and sometimes changes in color; its movements are slug- gish, and the pupil is somewhat contracted, as may easily be ascertained Avhen only one eye is affected, by comparing it with the other. Vision is of course impaired to a greater or less degree. Intolerance of light is ahvays present, but varies in amount according to the severity of the other symptoms. The lachrymal secretion is considerable in quantity, and Aoavs periodi- cally from the eye. The pain felt in the globe of the eye is of a stinging, darting character, accompanied Avith a sensation of ful- ness and pressure. It extends also to the orbit and forehead, temple, cheek, and generally in the course of the branches of the fifth pair of nerves distributed to the face. The pain is much increased by warmth, and is sometimes of a pulsatory character, or consists chiefly in an agonising, wearing-out sensation. It continues till the disease is subdued, varying, however, in degree, increasing in severity towards sunset, attaining its maximum about midnight, and abating towards morning: it entirely pre- vents sleep, and is a cause of so much distress to the patient, that he never fails particularly to mention it. Along Avith these symp- toms fever is present to a greater or less degree. Causes. This form of ophthalmia is more rarely met Avith in children and old persons, than in those of a robust constitution and of middle age, the same exciting causes probably originating at different periods of life different forms of ophthalmia. It may * Sometimes instead of affecting the deepest laminae of the cornea producing this hazy appearance, rheumatismal ophthalmia implicates the more superfi- cial layers, in giving rise to the formation of a small phlyctena which does not appear supplied by the sclerotic vessels, which bursts, leaving a small ulcer; the cicatrix of the ulcer, however, is not productive of opacity, but leaves a small facet cut out of the cornea; the hazy appearance of the cornea ascribed to an extension of the disease to the lining membrane of the eye, is in fact attributable generally, to the involvement of the deeper layers of the cornea itself as is clearly proved by microscopic examination. (Vide Sichel, p. 262.) INFLAMMATION OF THE EYE. 491 occur in those who have never suffered from rheumatism in other parts of the body, and under any circumstances is said to be ahvays a primary affection, never metastatic. Both eyes are seldom simultaneously attacked; when it does happen, one is generally more seriously affected than the other. Those who have suffered once from this disease, are very liable to be again attacked. Diagnosis. Besides the diversity of their seats, inflammation of the sclerotic coat is easily distinguished from the corresponding affection of the conjunctiva, by the following diagnostic marks: The redness in inflammation of the sclerotica is deep-seated, and forms a radiated zone around, and upon the margin of the cor- nea; in that of the conjunctiva it is superficial and reticulated, and frequently accompanied with subconjunctival patches of ecchymosis. The secretion from the eye in the former (scleroti- tis) is lachrymal, in the latter it is mucous. The pain attendant upon sclerotica is generally severe, deep-seated, and frequently pulsative; it is especially felt over the orbit, and is aggravated from sunset to sunrise. In inflammation of the conjunctiva, the pain is comparatively slight; it is felt upon the surface of the con- junctiva, imparting a sensation as of sand beneath the eyelid; it seldom extends to the head, and is felt most in the morning Avhen the eyes begin to be moved. In inflammation of the sclerotica there is ahvays intolerance of light, varying in degree according to the severity of the other symptoms; in that of the conjunctiva, though slightly observed in the early stage of the disease, it dis- appears as the other symptoms become developed. The cornea, moreover, is dull and hazy in the former; in the latter it preserves its natural appearance. If the inflammation has advanced to the iris, symptoms of iritis will be superadded to those already men- tioned. Treatment. Venesection is generally necessary in all cases of rheumatic ophthalmia. With a full strong pulse and a foul tongue, we may take fifteen or tAventy ounces of blood, to be fol- loAved by the application of leeches in considerable numbers to the forehead or temple. The circumorbital pain is generally much relieved by the depletion; but should it still continue with a hard pulse, we must repeat the venesection; and this may be several times required before the symptoms entirely yield. After clearing the boAvels Avith a smart purgative, four grains of calomel and one of opium ought to be given every night, or they may be exhibited in smaller doses at intervals during the day. The effect of this combination in relieving the circumorbi- tal pain is very marked; but as it is not given Avith a view to produce salivation, Ave are to be guided in its administration rather by the effect produced upon the disease, than upon the system. It is seldom, however, productive of decided benefit till the mouth is made slightly sore. Occasional laxatives should be 492 INFLAMMATION OF THE EYE. administered, to obviate the constipating effects of the opium; but active purgatives are to be avoided, as tending to interfere Avith the due action of the mercurial. The vinum colchici has been recommended, either alone or in combination with a purgati\re. If employed singly, it ought to be given in the dose of 3] or giss every four or six hours till some decisive effect is observed. When thus exhibited, its effects must be closely Avatched. Warm opiate frictions on the temple and forehead are useful in averting or relieving the nocturnal paroxysms of pain. Lau- danum alone, or combined Avith the extract of belladonna, may be used for this purpose, and ought to be applied about an hour previous to the expected occurrence of the attack. Equal parts of laudanum and Tr. Cantharides form a good liniment in chro- nic cases. Blisters are frequently found beneficial. The iris should be kept under the influence of belladonna dur- ing the Avhole course of the disease. Applications to the eye in the form of collyria are of little ser- vice; those of a stimulating character are decidedly hurtful in the early stages. Tepid water may be recommended as at least harmless. The vinum opii, either pure or in a diluted state, "will be found useful, after the acute inflammatory symptoms have been removed, and little more remains than a lingering redness and morbid irritability of the organ. At this period of the dis- ease, general tonic medicines are sometimes advisable, as small doses of the disulphate of quina, or of the mineral acids. Dr. Mackenzie recommends the arsenical solution in old mis-treated cases, in doses of from eight to twelve drops three times daily. (a) Catarrho-Rheumatic Ophthalmia. To describe this disease merely as a complication of the former with a catarrhal affection of the conjunctiva, would not, in our opinion, be sufficient; its frequent occurrence and the serious organic changes Avhich it often occasions in the structure of the eye, entitle it to a separate consideration. Symptoms. We have the sandy pain and muco-purulent secretion, characteristic of conjunctival inflammation, co-existing with the circumorbital uneasiness,lachrymal discharge, and intole- rance of light observed in sclerotitis. The latter affection is generally the more severe of the two. Beneath the reticular arrangement of the conjunctival vessels may be observed the zonular disposition of those appertaining to the sclerotica, at least Avhen not concealed by inflammatory oede- ma of the submucous cellular tissue, a not unfrequent accompa- niment of the acute stage of the disease. The discharge from the inflamed organ is moderate in quantity, and from its com- pound nature is seldom opaque; imparting a moist appearance and slippery feeling to the palpebrae, the edges of Avhich are INFLAMMATION OF THE EYE. 493 generally found adhering in the morning from incrustations of the Meibomian secretion, and their external surface is occasion- ally red and swollen. The photophobia and lachrymation, which are considerable throughout the course of the disease, become more marked when the inflammation has extended to the struc- ture of the cornea. Structural changes in the cornea in the form of ulceration, or deposition of pus in its substance, are what is most to be appre- hended; and these are symptoms of such frequent occurrence, that if the disease has been allowed to run on unchecked during eight or ten days, Ave may expect to meet with one or both of these consequences, especially in patients of advanced years. The ulceration is peculiar in this respect, that it tends to spread over the surface of the cornea, rather than to penetrate deep into its substance. The ulcer is generally of an irregular figure, with a transparent and uneven surface, someAvhat resembling an abra- sion of the conjunctival covering of the cornea, or as if a portion of its substance had been hacked off with a cutting instrument. The deposition of pus in the substance of the cornea, constituting what is termed onyx, is a symptom still more alarming Avith re- ference to the eventual preservation of vision. It is usually ob- served first at the loAver edge of the cornea, from whence, gradu- ally extending upAvards, it may involve half the diameter of that membrane. The pus thus deposited is rarely absorbed, being generally evacuated externally through an ulcer which forms over its centre. Very frequently the ulcerative process extends iirwards through the posterior layers of the cornea, giving vent to the aqueous humor and producing prolapse of the iris, which terminates in general or partial staphyloma. Hypopion, or the deposition of pus in the anterior aqueous chamber, is sometimes observed to accompany the formation of onyx; or it may result from the contents of the onyx being pri- marily discharged into this cavity through the posterior wall of the cornea, this membrane ultimately giving Avay through its entire thickness. While these changes of structure are proceed- ing in the cornea, the iris becomes altered in color,* and sluggish in its movements; lymph is effused into the pupil, which is now observed to be hazy and contracted, and at last may be entirely closed. Febrile symptoms indicate the sympathetic affection of the constitution. * When the iris becomes involved, in addition to the ordinary symptoms of iritis, there is one which is peculiar, and, although not of constant occurrence, may he considered, when it exists, as pathognomonic of rheumatismal or arthritic iritis; viz: an ov.il form of the pupil, of which the greater diameter Corresponds With the vertical axis of the eye. 42 494 INFLAMMATION OF THE EYE. Sleep is prevented by the nocturnal accession of pain, and the patient's sufferings are frequently aggravated by the co-existence of catarrhal affections of other portions of the mucous membrane. Beer attributed rheumatic ophthalmia to the effects of currents of cold air, Avhile he supposed the catarrhal form of the disease to originate from a similar impression of a foul atmosphere. The disease in question may possibly arise from the co-existence of these causes, a combination often to be met Avith in the damp and ill-ventilated dwellings of the poor. The subjects of it are generally persons advanced beyond the meridian of life; it is more rarely observed in the middle-aged or young, and we have never seen it in children. Treatment. As Ave have here the co-existence of tAvo distinct diseases, our treatment must be equally of a tAvofold nature, being directed both against the sclerotic and conjunctival part of the affection. With regard to the former, those means must be employed which have already been recommended under the head of rheu- matic ophthalmia. The accompanying conjunctivitis is to be treated by the usual local applications, mentioned under the head of that disease, although it will be prudent to postpone their employment till the acute symptoms of the sclerotic affection have yielded; the gr. iv solution of the nitrate of silver may be dropped into the eye several times daily, or the Vin. Opii either pure or diluted. The red precipitate ointment should be smeared upon the edges of the palpebrae at bedtime, and a solution of gr. j of the Hydrarg Bi- chlor. in Iviij of water used tepid, as a collyrium, three or four times a day. The rheumatic symptoms are generally the first to yield, the catarrhal persisting for some days longer; in other instances, the circumorbital pain continues to linger after the conjunctivitis has disappeared. Dr. Mackenzie dissuades from any attempt being made to evacuate the contents of an onyx by incising the cornea; stating that, in every case in Avhich he has adopted this measure, partial or total staphyloma has resulted. (Practical Treatise, p. 488.)* * We cannot conclude the subject of ophthalmia without referring to a peculiar form of this disease, not described by the author, generally connected with visceral derangement, and an obstruction in the venous circulation, andjhence designated by the German ophthalmologists as " abdominal or ar- thritic or venous ophthalmia." The character of the injection is in this form pathognomonic, and evidently attributable to a venous congestion of the eye, dependent on a general cause of a like nature. Hence the affection is not confined to the conjunctiva and sclerotica, but bears principally upon those tissues which most abound in the venous capillaries, particularly the choroid and its dependencies. INFLAMMATION OF THE EYE. 495 III. Inflammation of the Cornea. Inflammation of the cornea, attacking different portions of its tissues, has been already described, as occurring in several of the ophthalmiae. The disease Avhich Ave are about to consider is, at its origin, apparently seated in the parenchyma of the cornea, although it gradually spreads to its other tissues, and sometimes even extends throughout the various textures of the eyeball. Occurring generally in individuals of a strumous habit, it partakes The conjunctiva presents a few large, almost varicose vessels, bifurcating twice and anastomosing by arcade around the cornea, very distinct when not complicated with catarrhal ophthalmia, but still recognisable, even when this complication exists. Beneath this, and partially masked by it in some cases, is to be seen the specific injection of the sclerotica, composed of vessels forming a zone around the cornea, resembling somewhat the rheumatismal zone, but differing from this latter in being of a deeper color, bifurcating and anastomos- ing before reaching the circumference of the cornea, from which they are separated by a bluish circle, (arcus arthriticus of Beer—venous circle of Sichel.) This circle, constituting the pathognomonic symptoms to which we wish to direct attention, being probably due to a corresponding engorgement of the canal of Fontana, which canal is in reality a sinus receiving the veins of the iris, and must consequently participate in the general congestion, or due possibly in those cases where the venous circle is incomplete, to an inflammatory swelling of the ciliary body which separates the fibres of the sclerotica in certain points, and renders this membrane so diaphonous, that a change in the color of the subjacent tissue becomes visible through it. The cornea, as in all cases of affection of the sclerotica, particularly when combined with derangement of the choroid, may offer an interlaminar effusion. This is sometimes followed by a circumscribed, oval ulceration, with irregular edges, which itself often presents a pelvurulent or cretacious appearance prior to its cicatrisation. We have already mentioned that the congestion bore principally upon those tissues most abundantly supplied with veins; in corroboration of this the iris is always affected, and the changes which occur in it are peculiar, in addition to the dull, dirty color ordinarily assumed by this membrane when diseased, its tissue becomes more attenuated, and the pigmentum disappearing in certain points, gives to it a marbled appearance, exhibiting itself in patches of a grayish, bluish, or pearly color, contrasting with those parts of the iris where the pigmentum is still retained. The pupil also when not adherent to the capsule of the lens is perpendicularly or more frequently transversely oval. But if the iris is affected, so a fortiori is the choroid and the consequent disor- ganisation of this membrane, frequently gives rise to a series of symptoms, the mechanism of which is not generally well described by authors, but which constitute a new disease called Glaucoma, better designated by the term Chro nic Choroiditis; the consideration of which will be found in the notes to the chapter on Choroiditis. 496 INFLAMMATION OF THE EYE. of the chronic character of scrofulous disease, and seems therefore entitled to the distinctive appellation of Strumous Corncitis. Symptoms. The usual subjects of its attacks are individuals betAveen the ages of eight and eighteen years. It generally com- mences sloAvly and insidiously, the cornea loses its natural bril- liancy,* and becomes dull and hazy, its surface appearing as if covered with fine dust, or resembling glass which has been breathed upon. In a more advanced stage, attended with in- creased opacity, the cornea frequently appears covered Avith minute depressions, such as might be produced by dotting its surface Avith the point of a pin; sometimes they are of greater depth, resembling under a magnifying lens numerous small ulcers aggregated together. The fine vessels of the conjunctiva and sclerotica become injected with red blood; those of the latter membrane, which is the principal seat of increased vascular action, are arranged in radii round the cornea, and present a carmine hue. The edge of the cornea is sometimes partially encircled by a ring of minute vessels, of a broAvnish red color; occasionally they are arranged in patches slightly elevated, Avith a regularly defined margin, and bearing a close resemblance to spots of ec- chymosis. Examined Avith a strong magnifying power, they are seen to be composed of numerous small vessels, Avhich are straight and parallel Avith each other. Single vessels are observed to pass over the corneal epidermis and ramify upon it; sometimes they are so numerous as to form a vascular net work covering the entire surface, and giving rise to the appearance which has been named " Pannus." Besides the general haze of the cornea, there is a marked ten- dency to the deposition in its substance of an opaque white mat- ter, which is sometimes confined to circumscribed spots, with intervening transparent portions, giving the cornea a mottled appearance. These spots occasionally assume a yellowish hue, as if pus had been deposited; but they rarely ulcerate, and deep ulceration is scarcely ever seen. In other instances the deposition is more general; commencing at the centre it spreads toAvards the circumference, producing dense opacity of the whole surface, of a uniform dirty Avhite color. At this stage of the disease, the cornea, Avhen examined laterally,is seen to be increased in volume, and its texture appears as if softened. Inflammation of the cornea, when of some standing, is usually accompanied Avith an increased secretion of the aqueous humor, producing a change of figure in the cornea, which becomes more convex than natural. Sometimes the Avhole globe assumes a * Mackenzie and Velpeau speak of a sea-green color of the cornea, as atten- dant upon its inflammation; this appearance is not mentioned by other authors, and its existence is positively denied by Sichel. INFLAMMATION OF THE EYE. 497 somewhat conical form, the thinning of the sclerotica anteriorly permitting it to give Avay beneath the pressure of the recti mus- cles; thus constituting, to a certain extent, staphyloma of the cor- pus ciliare. Dilatation of the pupil Avith some degree of amaurosis has been observed. In other cases, the inflammation has spread to the iris, producing contraction of the pupil, and adhesion to the cap- sule of the lens. From the opaque condition of the cornea, it is frequently very difficult to ascertain the precise state of the in- ternal structures. Much assistance may be derived in such cir- cumstances from dilating the pupil with belladonna, and concen- trating the light upon it by means of a large double convex lens. The intolerance of light is generally moderate in degree, though in some instances it is very great, and accompanied Avith lachry- mation. Considerable pain* Avith a sense of pressure or tension in the eye, and pain in the forehead, are frequent symptoms in the early stages. The pain is sometimes acute, coming on in paroxysms; but in the chronic state it is slight, especially after the Avhole cornea has became opaque. The prognosis is rather unfavorable, although from the early age of the patients Avho are usually the subjects of this affection, surprising reco\Teries certainly take place. Treatment. Judging from the apparent chronic character of the inflammation and the trivial amount of pain usually attending it, Ave might suppose that depletion Avas seldom indicated; the local abstraction of blood, hoAvever, is productive of the best effects in the early stage of the disease. If there be severe pain in the eye and forehead, the propriety of antiphlogistic measures is sufficiently obvious; it may even be necessary to bleed from the arm. The local depletion ought to be repeated occasionally, care being taken not to reduce too much the strength of the patient. Purgatives and emetics should be employed as recommended under the head of Strumous Ophthalmia. The exhibition of small doses of the potassio-tartrate of anti- mony, in combination Avith the disulphate of quinia, is highly beneficial, and more effective than either given singly. In cases of moderate severity, the disulphate of quinia alone exercises an equally marked, though less speedily developed control, over this disease as it does over scrupulous inflammation of the conjunc- tiva. In cases accompanied Avith much general debility, it may be prescribed from the first. * When the keratitis is pure and uncomplicated there is neither photophobia or increased secretion, pain rarely exists, but vision is impaired according to the degree of opacity, from a slight cloudiness to complete blindness; it must be borne in mind that the description above given includes not only simple corneitis but its complications. 42* 498 INFLAMMATION OF THE EYE. When the symptoms of active inflammation are urgent, and opacity of the cornea is rapidly progressing, these remedies alone cannot be relied upon. Having checked the severity of the in- flammatory symptoms, Ave must have recourse at once to the exhibition of calomel* and opium, so as to affect the mouth; the beneficial operation is evidenced by the contraction of the dilated corneal vessels, and the gradual absorption of the opaque deposit, the process of clearing beginning at the circumference, and ad- vancing towards the centre. The use of mercury from the first is especially required when the iris participates in the inflamma- tion. Counter-irritation ought not to be neglected, as it is fre- quently productive of great benefit. The pain and intolerance of light may be alleviated by the use of warm anodyne fomentations. Stimulating applications to the eye ought on no account to be employed till the acute symptoms have been subdued. When had recourse to, the stimulant ought to be frequently varied; the pupil should be kept under the in- fluence of belladonna, not only Avhen there are evident symptoms of iritis present, but also Avhen its existence is merely suspected. The treatment adopted must be persevered in for a considerable length of time, even although no good effects are immediately observed. The progress of recovery will be much accelerated by the beneficial influence of pure air aad moderate exercise. Evacuation of the aqueous humor by puncturing the cornea has been proposed as a means of relieving the sense of distension occasioned by the increased secretion of that fluid. The practice is highly recommended by Jiingken of Berlin and other conti- nental oculists, also by Mr. Wardrop in this country, who has employed it frequently Avith advantage in different inflammatory affections of the globe. (Med. Chir. Trans., vol. iv.) Mr. Law- rence, on the other hand, speaks less favorably of the operation. IV. Inflammation of the Iris. We have already had occasion to notice this disease as occur- ring in the course of several of the ophthalmiae which have their primary seat in the external tunics of the eyeball. We shall now consider it both as an idiopathic affection, and as it occurs sympathetically, in certain peculiar conditions of the system. Iritis, from whatever cause it originates, is recognised by cer- * The propriety of employing mercury with a view to its constitutional effect in affections of the cornea tending to the disorganisation of this membrane is very doubtful; it is absolutely proscribed by Sichel in cases where suppu- ration may be anticipated, on the very fair grounds that so far from tending to arrest the suppurative process, it actually solicits it by its antiplastic pro- perties. The treatment should be energetically antiphlogistic. inflammation of the eye. 499 tain general indications, some of Avhich it exhibits in common with other ophthalmiae, and some are peculiar to itself. Among the former may be enumerated: 1. Zonular redness of the sclero- tica, composed of numerous vessels surrounding the cornea, and running in parallel radii towards its edge: 2. Adhesions of the iris, and chiefly of its pupillary margin, to the capsule of the lens, and in some rare cases to the posterior surface of the cornea: 3. Effusion of coagulable lymph into the anterior or posterior cham- bers, and sometimes into both: 4. Imperfection of vision, varying in degree from mere dimness to total blindness: 5. Pain in the eye, and nocturnal circumorbital pain. Among the latter, or those which may be considered as pecu- liarly characteristic of iritis, are—1. Loss of brilliancy and change of color in the iris, from its natural hue to that which might be produced by mingling the color of the red vessels or the effused lymph Avith its original tint; thus, a light-colored iris becomes greenish or yellowish, the blue is converted into a green, or, if dark-colored, it presents a reddish tinge: 2. Structural change in the iris, manifested by the obliteration of its naturally fibrous texture, and the formation of tubercles or abscesses in its sub- stance: 3. Contraction and immobility of the pupil. The co- existence of these three last mentioned symptoms is pathogno- monic of inflammation of the substance of the iris only, the first and third being equally characteristic of inflammation confined to the serous covering of that membrane. All of the symptoms above mentioned, in either division, are not invariably present in every single case of iritis: thus, there may be total absence of pain whether in the eye or head, no effusion of lymph, nor any abnormal adhesions, or morbid depo- sition in the substance of the iris. In some cases complicated Avith amaurosis, the pupil, instead of being contracted, is dilated; still these are the exceptions: in general, a sufficient number of symptoms is present, to enable us to determine with precision the nature of the disease. As inflammation of the iris may occur in two apparently different structures of the same membrane, viz. the serous covering and the parenchyma or proper substance, it is hence distinguished into "iritis serosa," and "parenchymatosa;', the former is most frequently observed as attendant upon stru- mous ophthalmia, the latter in cases of venereal origin. Iritis may present itself either in an acute or chronic form, to Avhich some authors have added a third, or sub-acute degree. We shall first describe in detail the usual symptoms and effects of acute idiopathic iritis, leaving for after consideration the modifi- cations Avhich it may undergo in degree, and the peculiarities which distinguish it Avhen occurring sympathetically., (a) Acute Idiopathic Iritis. Symptoms. A vascular, radiated band is formed round the 500 inflammation of the eve. circumference of the cornea, consisting of hair-like, parallel, straight vessels, Avhich terminate abruptly at the edge of this membrane, appearing to sink through the sclerotica as they pass to the iris. The redness is at first confined to the immediate neighborhood of the cornea, the circumference of the globe being comparatively clear; but as the disease advances, the increased action extends to the vessels of the conjunctiva, the Avhole surface of the eye assuming a fiery redness Avhich often masks for a time the zonular sclerotic injection. The radiated zone continues, however, so long as the disease lasts, varying in intensity and completeness, according to the degree and extent to which the iris is inflamed. The naturally brilliant surface of the iris becomes dull and muddy in appearance,* and the beautiful fibrous arrangement of its internal structure is rendered indistinct, or is destroyed; Avhile from the increased vascularity of the membrane or the effusion of lymph, its original hue is exchanged for one of a darker shade. These changes commencing in, and in some instances for a time confined to, the edge of the pupil, gradually extend outAvards to the ciliary margin of the iris. The effusion of coagulable lymph may take place upon either surface of the iris, or into its substance. It may form a thin layer of variable extent upon its anterior surface, producing discolora- tion, slight irregularity, and a villous appearance of the part; this form of deposit, though generally confined to the smaller circle of the iris, is attended Avith dimness and change of color of the an- nulus major. , The lymph is sometimes deposited in masses of a reddish yel- Ioav color, varying both in size and number, and seated at the edge of the pupil, or upon any part of the anterior surface of the iris. Sometimes it is so profuse in quantity as to fill the anterior chamber. Suppuration and true abscess of the iris may occur. The mem- brane appears to sAvell, and bulges fonvard toAvards the cornea, becoming puckered and irregular; one or more minute yelloAvish points appear upon its surface, indicating the seat of the abscess, Avhich bursts, and pours its contents into the anterior chamber, forming hypopion. The shreds of the cyst are often visible for some days hanging from the surface of the iris. Hypopion may * In simple serous iritis, the fundamental color of the iris is not changed, but is modified by the interposition of a pale grayish coat, which gives a dull appearance to the membrane; while in simple parenchymatous iritis, the fun- damental color is absolutely changed for another color. Thus, in serous iritis a blue iris remains blue, and a brown iris remains brown; but the color in both remains dull: while in parenchymatous iritis, a blue iris becomes green, and a brown iris, reddish. INFLAMMATION of the eye. 501 also occur from direct effusion of lymph, sometimes mingled with blood, into the anterior chamber. Effusion of lymph may also take place upon the posterior surface of the iris or uvea, and upon the margin of the pupil, in the former case uniting the iris to the anterior capsule of the lens, in the latter obscuring the natural transparency of the pupil by the intervention of a thin film of lymph, or even completely blocking it up Avith an opake mass. Lymph may be effused in such quantity into the posterior chamber as to make its way through the pupil, or produce tumor of the sclerotica, or even pass through that coat and protrude be- neath the conjunctiva. From the yellowish appearance of the tumor thus occasioned, such cases have been mistaken for exam- ples of general suppuration of the globe; a consequence Avhich Mr. LaAvrence remarks he has never observed to result from iritis in any form. (Op. cit. p. 287.) Effusion into the substance of the iris, with discoloration of this membrane and thickening of the pupillary margin, are generally the first changes observed, and usually occur together, but in very violent cases, effusion of lymph may take place simultaneously in each of the situations indicated. The movements of the iris, Avhich at first are rendered sluggish and limited by the interstitial effu- sion, become at last wholly suspended; an effect which is further promoted by the existence of abnormal adhesions. The pupil is observed to contract as the disease *advances, to become dull, cloudy, and irregular, and sometimes altered in situation from the causes just mentioned. Its edge is thickened and retracted towards the capsule of the lens, and presents a villous or spongy appear- ance. As many morbid phenomena tend to prove the existence of an intimate vascular connection between the sclerotica, cornea, and iris, Ave are not surprised to find haziness of the cornea, Avhich is at first general and slight; but if the inflammation is severe, or of long continuance, circumscribed capacities of greater density may be formed. Pain is rather a variable symptom: sometimes it is of a burning tensive character, felt deep in the globe and over the orbit, ex- tending: also to the bones of the temple and cheek; it is aggravated during" the night, and totally prevents sleep. In other instances it is slight, or entirely absent, even in cases attended Avith exten- sive disorganisation. Dimness of sight is an early consequence of iritis, and may be gradually increased, until a mere perception of light and shadoAv remains. In very acute cases there is a considerable degree of fever pre- sent, which hoAvever is variable. If not checked, the inflamma- tion gradually spreads from the pupillary margin of the iris to its external border, and from thence to the corpus ciliare, and the deeper-seated structures of the choroid and retina, attended Avith great increase of the local suffering, and marked by the sensation of flashes of light, and the gradual extinction of the power of vi- 502 INFLAMMATION OF THE EVE. sion. The inflammatory action also extends to the cornea and other external tunics, until at last it may involve every tissue of the eyeball. The structural changes most frequently observed are the fol- loAving: the iris presenting a dull leaden hue, and completely altered in structure, bulges forAvard in the form of a convex pro- tuberance with a puckered surface, the result either of thickening of its texture or the pressure of an increased secretion behind it. The cornea is either clear, or opake in various degrees, and vision is irrecoverably lost, as inflammation capable of effecting such alterations of structure generally extends to the retina. The pu- pillary margin of the iris may be attached by various points of its circumference to the capsule of the lens by means of slender threads of lymph, Avhich hoAvever admit of some degree of motion. Alteration of the pupil in figure does not interfere Avith perfect vision; and even its reduction in size to a mere pin-hole is not productive of any material inconvenience provided it is clear. In some instances, the pupil is entirely closed, and the iris adherent to an opake mass of lymph Avhich has been effused behind it, pro- ducing the condition termed "atresia iridis perfecta," in which case vision is lost. In other instances Ave find the pupil still open and only partially occupied by the effused lymph, which may be situated either in the centre of the aperture, leaving the iris free, or on one side Avith the iris adhering to it, and producing displace- ment of the pupil from its natural position. This has been term- ed " atresia iridis imperfecta:" vision is impaired to a greater or less degree, but is often susceptible of improvement by the use of belladonna to dilate the pupil. If lymph has been effused to such an extent as to cause tumors of the sclerotica, although it may be absorbed as the inflammation declines, the internal structures have generally suffered so much injury that the globe becomes flaccid and atrophic. For some time after the disease has ceased, and especially if the attack has been severe and protracted from mismanagement, the eye continues Aveak, morbidly sensitive to external influences, and prone to relapse from slight exciting causes. Iritis may present itself in a chronic form, arising imperceptibly and attended with so little pain and redness, as not to attract the patient's attention, and yet proceeding by the effusion of lymph to the gradual diminution, or even total destruction of vision. If confined to one eye the injury may only be discovered accident- ally, by the patient closing the sound one. BetAveen this very obscure form of the disease, and the severe and Avell-marked af- fection which we have already described, various degrees may be observed, varying in the prominence of their symptoms, the amount of injury Avhich they inflict, and the facility Avith Avhich they yield to treatment. Causes. Among these may be enumerated direct injuries to INFLAMMATION OF THE EYE. 503 the eye, Avhether occurring accidentally or inflicted during the per- formance of surgical operations, as in the extraction of cataract, or the formation of artificial pupil. Over-exertion of the eyes, or atmospherical influences, are sufficient to give rise to this disease in some individuals, especially in those of strumous habit, or who exhibit that unhealthy condition of the system observed in gout, rheumatism, or secondary syphilitic affections. The occurrence of iritis has been ascribed by some writers, either wholly or in part, to the use of mercury. That its undue employment may predispose an individual to iritis, as well as to inflammatory affec- tions of other textures, may be admitted; Avhile we are far from thinking that there is sufficient evidence to establish the relation of cause and effect between the judicious use of this medicine and the disease in question. Mr. LaAvrence (Treatise on the Vene- real Diseases of the Eye, p. 165,) remarks that he has seen no instance of iritis of any kind, in which there appeared to him rea- son for ascribing the complaint to this cause. A similar testi- mony is given by Mr. Rose, Dr. John Thomson, and Dr. Eckstrom of Stockholm, as quoted by Mr. LaAvrence. Diagnosis. The rheumatic and catarrho-rheumatic forms of ophthalmia and iritis may be confounded with each other; and indeed the former diseases are seldom observed to exist without the latter being present in some degree. The mistake would not however be of much importance at first as regards treatment, similar and equally active measures being required in the same form of each of these affections. From corneitis, Avith Avhich it has several symptoms in common, it may be distinguished by the opacity of the cornea, Avhich exists to a much greater degree in the former affection than is ever observed in iritis, presenting a peculiar mottled and striated appearance, with red vessels occa- sionally ramifying upon its surface. The state of the iris and pupil, Avhen it can be ascertained, will frequently assist us in deciding upon the individual or combined existence of these dis- eases. If the pupil is of the natural size, and the motions of the iris free, the case is one of simple corneitis; if on the other hand, the pupil is contracted and fixed, iritis is undoubtedly present. Retinitis exhibits the same appearance of external inflamma- tion and gradual closure of the pupil observed in iritis, but is more sudden in its attack, and runs its course with greater ra- pidity; the local suffering is more intense, and vision in every degree is extinguished at an earlier period of the disease. Recovery may be considered hopeless, when along with change of color in the Avhole iris, and a contracted and opaque pupil, there is great external vascularity, severe, deep-seated pain, and total insensibility to light. Treatment. To subdue the inflammatory action, to arrest the effusion of lymph and promote the absorption of Avhat has been already deposited, and to preserve the natural condition of 504 INFLAMMATION OF THE EYE. the pupil, are the three principal indications to be fulfilled in the treatment of this disease. We must seek to accomplish them by the employment of antiphlogistic measures, mercury and belladonna. General and local depletion must be at once resorted to, and pursued with vigor, Avhen there is reason to apprehend an ex- tension of the inflammation from the iris to the deeper tissues of the eye. The bloodletting should be repeated till the disease gives way. The boAvels must be freely moved by mercurial purgatives followed by saline aperients, the potassio-tartrate of antimony in nauseating doses, Ioav diet and rest, not merely of the inflamed organ, but of the whole body—a circumstance of much importance in the treatment of the internal ophthalmiae. In cases of less severity, the local abstraction of blood by leeches and cupping will probably suffice; although venesection is often to be recommended, even when the disease does not pre- sent a very acute character. Having thus arrested the inflam- matory action, we must proceed at once to the exhibition of mercury; without which Ave shall rarely succeed in checking, and still less in removing, those alterations of structure, Avhich result from the deposition of lymph in the pupil and texture of the iris. The best form, generally speaking, is that of calomel with opium, in the proportion of from gr. ij to gr. iv of the former, with from gr. % to gr. \ or more, of the latter, every eight, six or four hours as the case may require. With regard to the extent to Avhich the employment of mer- cury should be carried, it is in general sufficient to affect the mouth. In some cases full salivation rapidly produced, acts like a charm in carrying off the disease; the medicine may then be intermitted and its effects allowed to subside. In cases of a chronic character, it is generally necessary to keep up a moderate degree of mercurial action for some time; this is more frequently required in relapses, and cases where the patient has been pre- viously affected, than in first attacks. The question has been frequently discussed, Avhether iritis can be cured without mer- cury, and variously replied to: we have no hesitation in saying that it can; but it is much more likely in such circumstances to prove injurious to vision, from the persistence of those structural changes which this medicine only is adequate to remove. As regards the sufficiency of mercury Avhen employed alone, to effect the cure of iritis, it is no doubt possible, and the disease has frequently been thus treated; but generally speaking, the practice is not to be recommended, and the exhibition of mercury unpreceded or accompanied by depletion has unquestionably been productive of serious injury to the affected organ. Mr. Lawrence states, that " iritis generally, and the syphilitic form of the complaint particularly, Avill be most advantageously treated by the successive or combined employment of antiphlogistic INFLAMMATION OF THE EYE. 505 means and mercury; that this plan will give the quickest relief, will most effectually arrest the inflammation, restoring the iris to its healthy structure and functions, and will afford the best secu- rity against the return of the disease." (Op. cit., p. 307.) The exhibition of mercury will often prove beneficial even after every symptom of active inflammation has passed aAvay, and those effects alone remain, which we might suppose to be per- manent; in such circumstances, its action ought to be slowly excited and maintained during several weeks. Mercury has also been employed locally, to relieve the circumorbital pain, which is frequently productive of so much suffering. For this purpose, from gr. viij to gr. x of the Ung. Hydr. Fort, combined with gr. ij or more of powdered opium, ought to be well rubbed into the temple or forehead at night, previous to the occurrence of the paroxysm. To prevent the contraction of the pupil, the extract of bella- donna should be smeared over the eyebrow once in the twenty- four hours. The employment of belladonna in this manner, during the acute stage of iritis, has been objected to, from its occasional effect in tearing asunder the adhesions between the iris and capsule of the lens, leaving portions of the uvea perma- nently fixed upon the capsule. Although it cannot be denied that this does sometimes happen, it will be of rare occurrence if suitable depletory measures have been premised. When the acute inflammatory symptoms are removed, a filtered aqueous solution dropped upon the conjunctiva may be substituted for the extract applied to the skin. The continued use of this remedy in one or other form, even for months, is frequently advantageous, producing gradual dilatation of the contracted pupil, and elongation of the filaments of lymph which bind the iris to the capsule of the lens. Counter-irritation by blisters, though not admissible in the acute stage of the disease, is of essential service at a later period. Local applications in the form of collyria are unnecessary; those of a tepid soothing nature are productive of little benefit, and stimulating washes are decidedly injurious while any acute symp- toms remain. Mr. Carmichael of Dublin has recommended oil of turpentine as a remedy in iritis; he was led to employ it from the observation of its good effects in peritonitis, in Avhich a mem- brane, presenting some analogies both in its healthy and morbid conditions to the iris, is the seat of inflammation. It is not pro- posed as a general substitute for mercury, but as an active and effectual remedy, applicable in circumstances in Avhich from idiosyncrasy, debility, or other causes, the former is inadmissible. He employs the folloAving formula:—B. 01. Terebinth. Rectif. Ij; Vitell. Unius Ovi; tere simul, et adde gradatim Mist. Amygd. liv; Syrupi Aurantii 3ij; Tr. Lavand. Comp. 3iv; 01. Cinnamomi gtt. iij vel iv. Misce. Sumant coch. magna ij ter in die. Mr. Guthrie 43 506 INFLAMMATION OF THE EVE. reports favorably of its effects in some instances, while in others it was either of little service, or completely failed. Mr. LaAv- rence has had no experience of it; and although Ave have not given it a fair trial, Ave should advise its employment in cases in which the use of mercury is contra-indicated. (b) Syphilitic Iritis. The iritis which occurs in a constitution infected with the venereal poison, is a sympathetic affection, Avhich closely resem- bles the idiopathic form in its leading features, and yet differs from it in presenting some peculiarities. It is the most frequent form of iritis, and a secondary symptom of the venereal infection as distinctly marked as any other. It sometimes occurs alone, but more frequently presents itself in combination Avith other morbid evidences of the constitutional taint; and like other mem- bers of the family of early secondary symptoms, may appear be- fore the primary disorder is cured. Conformably to the cause of syphilitic affections in general, it is slow and insidious in its early stages, but as it is developed, may prove rapidly and extensively destructive. It is rarely observed as a symptom of syphilis in infants. Mr. Lawrence, whose experience in this disease has been very great, says, that only two instances of the kind have come under his observation. (Op. cit., p. 317.) Syphilitic iritis may occur either in an acute or chronic form, is distinguished in these different degrees by the general symp- toms already enumerated. Two circumstances have been men- tioned, as peculiarly characteristic of the syphilitic form of the affec- tion,—viz. displacement of the pupil, upAvards and inwards, towards the root of the nose; and the effusion of lymph in masses, or in the form of tubercles, upon the surface of the iris. With regard to the first phenomenon, its occurrence appears to be acci- dental, and may be referred to the peculiar position of the adhe- sions betAveen the pupillary margin of the iris and the capsule of the lens. Dr. Mackenzie attributes it to an affection of the ciliary or iridal nerves, and states that he has observed it to occur in chronic rheumatic iritis, and still more frequently in choroiditis, unattended by inflammation of the iris. (Op. cit., p. 513.) Tubercles upon the iris are certainly rare to be met Avith, except in syphilitic cases; they are of a reddish brown color, Avith an irregular surface, and may grow from any part of the membrane, sometimes attaining such a size as to compress it and fill the anterior chamber. They ultimately suppurate, pouring their contents into this cavity; and from the pupillary margin being generally adherent in such cir- cumstances to the anterior capsule of the lens, the gradual con- traction of the remaining cyst may detach the iris from the ciliary ligament, or cause laceration or absorption of its fibres, thus pro- ducing a permanent false pupil. In addition to the above circum- stances, a cinnamon color of the sclerotic zone, minute brown INFLAMMATION OF THE EYE. 507 spots upon the cornea, and nocturnal circumorbital pain, have been mentioned as diagnostic distinctions of syphilitic iritis; they are certainly corroborating evidences when taken in conjunction with other symptoms, but are not peculiar to this form of inflam- mation. Diagnosis. There is no single symptom which can be relied upon as pathognomonic of syphilitic iritis; but in the generality of cases its existence may be clearly inferred from the combination of several, taken in connection with the previous occurrence or actual presence of syphilitic affections in other parts of the body. Mr. Lawrence observes, "although the effusion of reddish, brownish, or browish-yelloAV lymph on the iris in the adult, clearly shows the case to be venereal, I have seen analogous appearances in several instances both of young children and infants, in Avhom no suspicion of syphilis could be entertained. (Op. cit., p. 319.) The treatment already recommended under the head of Idio- pathic Iritis is equally applicable to the syphilitic variety. (c) Rheumatic Iritis. Judging from the descriptions which have been given of this disease, and we especially refer to that of Dr. Mackenzie (op. cit., p. 505. et seq.), we are unable to discover wherein it essentially differs from idiopathic iritis. It is apparently the same in its symptoms, mode of progress and effects; is produced by many similar causes, and yields to the same mode of treatment. The distinction which might be drawn from the circumstance of its occurrence with an unsound condition of the system, is one Avhich does not always hold good, as it may occur in individuals Avho have never exhibited any other evidence of their possessing a rheumatic diathesis. Like rheumatic affections in general, thisform of iritis is said to be frequently excited by atmospherical changes, and is very apt to reneAv its attack; it has not been observed to be metastatic. The modifications of treatment which have been recommended apply chiefly to the minor details, and do not at all affect the general principles already laid doAvn. The disulphate of quinia is frequently beneficial, but ought by no means to be relied upon singly, and still less ought it to supersede the exhibition of calomel and opium, in the circumstances and manner already noticed under the head of idiopathic iritis. The patient ought to be especially careful aganist exposing himself to sudden alterations of temperature. Dry warmth, applied to the eye by means of compresses of old linen heated at the fire, is frequently productive of benefit, and tepid fomentations with some narcotic decoction, as poppyheads, belladonna, or tobacco, may be employed; the parts being afterwards carefully dried and the heated compress replaced. Counter-irritation is especially useful; this may \fe effected in a minor degree, by adding an equal quantity of the 50S INFLAMMATION OF THE EYE. Tinct. Lyttae to the laudanum Avith which the temples are rubbed. Vin. Opii dropped into the eyes is useful in the decline of the disease. (d) Arthritic Iritis. The arthritic inflammation of the Germans, whether identical or not with the gouty inflammation, properly so called, as observed in this country, does not manifest itself exclusively in the first or plethoric period, of gout, when the patient's digestive poAvers con- tinue unimpaired; but occurs equally, and perhaps more frequent- ly, " in the second or asthenic period of the disease, when repeated attacks have produced debility and dyspepsia." (Mackenzie, op. cit., p. 527.) Although the disease we are about to describe originates in and is limited to the iris, it is also developed in the sequel of a more extended and destructive inflammatory condition of the internal textures of the eyeball, apparently of a gouty character.* Arthritic iritis generally presents itself in an acute form, and exhibits the usual objective symptoms of inflammation of that membrane; distinguished, however, by several peculiarities: thus, the sclerotic redness is of a purplish hue, and the vessels com- posing it stop short within a line or so of the margin of the cornea, the intervening space being occupied by a narrow ring of a bluish white color, which is sometimes incomplete, being developed only towards the angles of the eye. The sclerotica itself presents a dirty grayish violet color while the visible bloodvessels passing across it from the recti muscles are frequently varicous. The palpebrae are red and slightly SAVollen, and small masses of a whitish foam are observed to collect upon their edges and at the inner canthus. As the disease advances, the iris begins to exhibit symptoms of change of structure, becoming dull and discolored: the pupil retains its natural position, but is contracted, and the iris is united by one or more points of adhesion to the capsule of the lens; there is considerable intolerance of light and lachryma- tion. The pain, which is sometimes the earliest symptom, is at first of a peculiar tingling character, felt in the neighborhood of the eye and upon the integuments of the face; but extending by degrees to the eye and orbit, the side of the head, and the jaw, it becomes proportionally increased in severity. The pain is fre- quently periodical in its attacks, but is always aggravated during the night; the constitutional symptoms are of a febrile character and vision is considerably impaired. After having continued for * This general morbid condition Beer includes under the head of" Arthritic Iritis;" while Mr. Lawrence, more correctly in our opinion, describes it under the title of " Arthritic Inflammation of the internal Tunics," of which the iritic affection is only one of many consequences.—Author. INFLAMMATION OF THE EYE. 509 some time, the disease may gradually decline, the symptoms wholly disappear, and vision be completely restored, although the iris remains united by Avhitish adhesions to the capsule of the lens. The inflammation is very prone to return, and such relapses may occur frequently without occasioning any serious injury to the organ. But as effusion of lymph takes place during each attack, the pupil in general is gradually contracted, and at last entirely filled with an opaque adventitious membrane, sight being wholly lost, although the texture of the iris may have undergone but slight alteration. The pupil is sometimes closed by one severe attack, or contracted and filled with a densely opaque mass. Arthritic inflammation, when severe and long-continued, may produce complete disorganisation, with puckering and tubercular projection of the iris, and extinction of sight. Caitses. The disease in question appears to arise spontaneously, without any assignable cause besides that which exists in the state of the constitution, and perhaps in the condition of the diges- tive organs. In such circumstances, the ordinary ophthalmiae are apt to degenerate into this form. Treatment. We shall notice the treatment only in so far as it differs from that recommended under the head of Idiopathic Iritis. HoAvever objected to by some writers, apparently on speculative grounds, we need not hesitate to deplete, both gene- rally and locally, in robust and plethoric individuals; and even in older persons, whose strength has been reduced by previous gouty attacks, the abstraction of blood is apparently equally necessary, when active local disease is combined Avith much febrile action. After depletion and the exhibition of mercurial purgatives, the Tr. of Colchicum may be given with advantage, either alone or combined with a purgative. Although the employment of mer- cury, to the extent of producing salivation, is neither necessary nor beneficial, an alterative course may be prescribed Avith much advantage, and continued in some cases during Aveeks or months. The sesquioxide of iron has been given Avith benefit in some cases, in Avhich depletion and mercury had been employed with- out advantage. The disulphate of quinia, in combination with Fowler's solution, is also worthy of a trial. Abstinence from stimulating articles of food and drink ought to be enjoined. Counter-irritation is of great service after the urgent inflammatory symptoms have been subdued. Tepid anodyne fomentations, or preferably, dry Avarmth as recommended in the preceding section, are the best local applications. Friction with opiates upon the temple and forehead will moderate the severity of the periodical attacks of pain, and ought to be employed every evening previous to the time of their expected recurrence. To correct the relaxed and Aveakened condition of the bloodvessels of the eye, and remove the preternatural sensibility which gene- rally remains after the acute inflammatory symptoms have dis- 510 INFLAMMATION OF THE EA'E. appeared, Ave may employ some local tonic. The Germans re- commend for this purpose" Avearing over the eye small linen bags filled Avith dried aromatic plants: probably the gentle stimulus communicated by the exhalation of their volatile particles may be of service. Friction round the orbit with some stimulating fluid has been employed beneficially with the same design, and even stimulating applications to the conjunctival surface itself. But of one and all of these local remedies it may be remarked, that Ave must be cautious in having recourse to them, while any inflammatory symptom continues to linger in the affected organ. (e) Strumous Iritis. Strumous iritis is sometimes observed to exist as a primary affection, but much more frequently occurs in consequence of the extension of this kind of inflammation from the external tunics to the deeper textures of the eyeball. Occurring generally in a chronic form, with mild symptoms, and being preceded and ac- companied by structural changes in the cornea Avhich obscure our view of the internal parts, its existence may be entirely unsus- pected. After continuing for a length of time Avithout making much progress, it may ultimately extend and produce disorgani- sation of the neighboring tissues, terminating in amaurosis and atrophy of the globe. Iritis occurring in very young persons may ahvays be suspected as of this character, from the compara- tive rarity of its other forms at this period of life. Like strumous inflammation of the external tunics, it is an obstinate affection, and less amenable to treatment than the other species of iritis. The treatment, Avith the exception of certain modifications suited to the peculiar nature and seat of the disease, as the omis- sion of local stimuli, and the application of belladonna to the eye- brow, does not differ in any essential particular from that recom- mended under the head of Strumous Ophthalmia. V. Inflammation of the Retina. Simple idiopathic retinitis is comparatively a rare disease, at least in this country, although as a sympathetic affection it fre- quently occurs in the course of other ophthalmiae, whether exter- nal or internal. From the peculiar position of the retina, by which it is con- cealed from immediate observation, as Avell as from its functional importance, the symptoms by Avhich we are enabled to recognise retinitis are chiefly of a physiological character. There is acute deep-seated pain in the globe extending to the eye-broAV, great intolerance of light, and the appearance of shining spectra of various forms, Avith gradual diminution of the poAver of vision. The iris is motionless, and the pupil greatly contracted, while the whole globe is exceedingly sensible to the slightest touch or INFLAMMATION of the eye. 511 movement. All of these symptoms are frequently developed, before a dull general redness of the sclerotica makes its appear- ance. The disease is attended with great febrile excitement; and the excessive pain of the eye and head is frequently followed by delirium and other symptoms of phrenitis; for which indeed it may be mistaken, as the characteristic symptoms of the ophthal- mia are not ahvays very obvious. Acute retinitis is rapid in its progress, and tends, if neglected, to pass into general inflamma- tion of the internal textures, accompanied with photopsia, che- mosis of the conjunctiva, discoloration of the iris, deposition of coagulable lymph in the pupil, and finally purulent effusion into the anterior chamber, which may increase to such an extent as to cause rupture of the cornea, and destruction of the eyeball. Chronic inflammation of the retina, or as it is vulgarly termed " weakness of sight," is an affection much more frequently to be met with than the acute form of the disease above described. It is characterised by intolerance of light varying in degree, imper- fection of vision, the appearance of "muscae volitantes:" and other ocular spectra, and a sensation of dryness in the mucous mem brane of the eyes and nostrils; by degrees the pupil becomes con- tracted, and the iris motionless. Morbid sensibility of the parts supplied by the fifth pair of nerves is sometimes observed to ac- company this disease; thus the slightest touch in the neighbor- hood of the eye is followed by pain of some duration. Causes. Acute retinitis may be produced by sudden jand vivid flashes of light, or by exposure to the continued influence of light and heat, as from large fires: hence it is frequently met Avith in cooks, and certain classes of artizans whose occupations neces- sarily subject them to these stimuli. Reflected light seems to be more pernicious to the retina than that Avhich falls upon it directly from a luminous object; hence the deleterions effects of the glare from snow in northern regions, or from the burning sands of southern latitudes. Simple retinitis, however severe, does not usually pass into general inflammation of the globe unless from neglect, or Avhen it occurs in individuals specially predisposed from some peculiarity of constitution, or accidental condition of the system. The chronic form of the disease is generally observed in per- sons whose occupations require continued exercise of the eyes upon minute objects, whether brightly or imperfectly illumina- ted;* for in either case the eye is overstrained, though the modus operandi of the exciting cause may be different. Thus watch- makers, tailors, milliners, engravers, printers, and those who fatigue their eyes much in reading and writing by artificial light, are frequently the subjects of this affection. Probably the con- * Tailors frequently complain of dark-colored work as being especially injurious to the eyes.—Author. 512 INFLAMMATION OF THE EYE. strained and stooping posture required in these and some other trades, may contribute to its occurrence, by inducing a congested condition of the vessels of the head. It is not unfrequently met with in those addicted to the excessive use of ardent spirits, and perhaps from the reason just mentioned. Onanism has also been assigned as a cause, Avhether justly or not we cannot say. Diagnosis. Occurring in a chronic form it is very apt to puzzle the young practitioner, who is frequently misled by the patient's complaints of " Aveakness of sight," to apply stimulants when he ought to deplete. The history of the origin and progress of the complaint, taken in connection with the temperament of the pa- tient and his habits of life, will in general suffice to clear up the diagnosis. In all doubtful cases, great caution ought to be shown in the employment of stimuli, whether general or local. Treatment. Copious bloodletting is to be employed, followed by the application of leeches round the eye in considerable num- bers, till the inflammatory symptoms are relieved. After clearing the bowels, calomel and opium should be given so as rapidly to affect the mouth. (See cases related by Mr. Lawrence, ch. xviii, of Treatise, p. 323.) The extract of belladonna ought to be smeared over the eyebrow, and perfect rest both of the body and of the eyes must be enjoined, with abstinence and the exclusion of light. Counter-irritation may be had recourse to after the em- ployment of more effective remedies. If general inflammation of the globe takes place with suppuration, a poultice is to be ap- plied; but the cornea is not to be opened while the contained pus is small in quantity, as it may possibly be absorbed under the combined influence of mercury and counter-irritation. Beer re- commends the repeated application of the vinum opii to the eye in this condition, and states that under the use of this remedy, along with the exhibition of opium and sometimes cinchona, he has witnessed the complete disappearance of depositions of pus in the anterior chamber. Should the matter collect in such quantity as to fill the anterior chamber, or be accumulated at a greater dis- tance from the surface, it must be evacuated by incising the cornea with an extraction knife, or by making a section of the sclerotica parallel to and a little behind the edge of the cornea. In these circumstances the natural appearance and structure of the eyeball are destroyed, and it becomes either flattened anteriorly or staphy- lomatous. With regard to the treatment of retinitis in its chronic form— avoiding the use of all stimulant applications, Ave must have re- course to moderate depletion by leeching, Avhich may be repeated as the occasion demands, along Avith the exhibition of purgatives and the moderate use of mercury and counter-irritation. The eyes ought to be shaded from the light, and exposure to the ex- citing causes of the disease as much as possible avoided. Inat- tention to this last named and apparently very obvious particular, INFLAMMATION OF THE EYE. 513 either from neglect or necessity, is frequently an occasion of the protraction of the disease, despite of the most judicious treatment. VI. Inflammation of the Choroid. Inflammation of the choroid (choroiditis) is minutely described by Dr. Mackenzie as an independent disease, while Mr. Law- rence regards it rather as one link in a chain of morbid effects resulting from general inflammation of the internal tunics. Al- though the inflammatory action in its early stages may possibly be limited to the texture of the choroid, it speedily extends to the neighboring tissues, producing various forms of disorganisation by Avhich the disease is recognised rather than by any sign of vascular action. One of the earliest objective symptoms is the formation of a blue zone round the cornea, of variable breadth and completeness, produced by thinning of the sclerotica, which is succeeded by the protrusion of small tumors of a dark bluish color, and varying in number, size, and position. A watery effusion is gradually formed between the choroid and retina, producing absorption of the vitreous humor, and compressing the latter membrane into a cord- like substance, Avhich simulates the appearance of deep-seated cataract or malignant tumor of the optic nerve. Changes in the pupil are frequently observed, consisting in dis- placement, contraction or dilatation, and immobility, with narrow- ing of the iris toAvards the affected portion of choroid. The cornea presents opacities of various forms and degree; from Avhich cause alone vision may be materially impaired. Great enlargement of the globe sometimes succeeds to these changes, followed by inflammation and suppuration, or fungous growths, rendering the extirpation of the organ necessary. The disease is generally attended with considerable pain and intole- rance of light, and the appearance of various morbid and optical phenomena referrible to the condition of the retina or the neigh- boring tissues. In some cases these symptoms afford the earliest indications of the disease. Blindness may ensue before the dis- ease has apparently made much progress; and on the other hand there may be enlargement and discoloration of the Avhole globe with tolerable vision. The constitutional symptoms are inconsi- derable, especially in the early stages; but the digestive organs are frequently deranged from the first. The causes of choroiditis are involved in much obscurity; those to Avhich it has been referred are equally productive of other forms of ophthalmia. It is a disease of adult years, more frequent in females than in males, and in those of a strumous habit than the reverse. In children it occurs only as a consequence of injury. The treatment consists in the employment of profuse and re- peated bloodletting, both general and local, in the early stages, 514 INFLAMMATION OF THE EYE. with the use of mercury, in the first instance as a purgative, and afterwards as an alterative. The continuance of the medicine till the mouth is affected, does not appear to be productive of any decided benefit. The warm bath will be found of much service, and tonics are sometimes productive of benefit after depletion. The arsenite of potass has beeh recommended as exerting a marked influence over several of the symptoms; it may be given in the dose of fa of a grain thrice daily, and gradually increased. Counter-irritation by means of the tartar-emetic eruption is useful. Puncture of the sclerotica and choroid to evacuate the contained fluid, may be resorted to Avhen there is a tendency to choroid" sta- phyloma; it generally relieves the sensation of tension and pres- sure in the eye, and may be repeated Aveekly, or at longer inter- vals. A choroid staphyloma sometimes requires to be removed, from the inconvenience occasioned by its size and prominence; the most projecting portion is generally cut away, and the rest of the eyeball left VII. Inflammation of the Lining Membrane of the Aqueous Chamber, and of the Lens and its Capsule. These diseases having been described by different writers upon ophthalmology, demand only a passing notice. They are of rare occurrence, and the latter affection at least little amenable to treat- ment; they are consequently comparatively unimportant; and from the difficulties attending the diagnosis, they are not likely to be recognised, unless by those who have made the diseases of the eye a special object of study. It is therefore sufficient to refer to the works of Wardrop (Morbid Anatomy of the Human Eye, 2d edit. vol. ii, p. 6.), Mackenzie (Practical Treatise, 2d edit. p. 552), and Walther (essay on The Diseases of the Crystalline Lens, and the Formation of Cataract, in his Abhandlungen aus dem Gebiete der Praktischen Medicin. Landshut, 1810), for a detailed account of these affections. 515 / AMAUROSIS. Definition.—Idiopathic and symptomatic.—Symptoms.—Causes.—Diagnosis, —Prognosis.—Treatment. The term Amaurosis (derived from d^avpow, to obscure or darken,) is applied to those diseases of the eye in which there is partial or complete loss of vision from impaired sensibility of the retina. It is synonymous with gutta serena, which has been given to the disease from the erroneous idea, that the enlarged pupil, Avhich is often one of its symptoms, is a dark fluid that intercepts the rays of light: hence also the name cataracta nigra. Amblyopia (from d/tSxi.?, dull; and o^j, vision) is applied to the slighter forms of the disease, in which, though objects can be seen, they are imperfectly distinguished. Some writers describe, as a complicated form of this disease, various structural changes of the internal textures of the globe, which ultimately affect the retina, and in which, therefore, impaired vision or total loss of sight occurs as a symptom: but we agree with Mr. LaAvrence in deeming it better to limit the term amaurosis to the instances in which the disease has commenced in, and been originally con- fined to, the nervous structure. (Treatise on the Dis. of the Eye, p. 490.) Much confusion has been produced by the indiscrimi- nate and inaccurate use of the terms functional and organic, which when thus opposed to each other, as if expressive of tAvo distinct and essentially different conditions of disease, are far from conveying any clear or definite ideas. The following remarks of Mr. Lawrence upon this point are so pertinent, that Ave quote them at length: " The state of an organ necessary to the correct execution of its function, is a living not a dead condition; it requires not merely a certain organisation as we find it after death, but a supply of healthy blood in a certain quantity, a natural state of nervous influence and sympathy, and perhaps other circumstances not clearly understood. " If all these condi- tions are combined, can we consider it possible that the function should be disordered or interrupted? If one or more should be altered or wanting, can the disease be properly regarded as sim- ply functional?" "Since then the epithets organic and func- tional are indefinite, being employed in different senses by differ- ent persons; since they do not denote generally well ascertained and clearly understood conditions of parts; and since the situation 516 amaurosis, (Symptoms.) of the nervous apparatus of sight renders it impossible for us to knoAV its exact state in most instances, I consider this distinction of amaurosis to be of no practical utility, but from its vagueness rather calculated to mislead." (Op. cit., p. 489-90.) While agreeing fully with these observations, we Avould not be misun- derstood as denying the principle contained in the distinctions above referred to, hoAvever we may question the propriety of the mode in which it has been applied. Looking at the amaurotic affections generally, two great classes into which they naturally divide themselves are clearly distinguishable;—viz., those dependent upon primary disease of some portion of nervous apparatus of vision, as the retina, optic nerve or brain; and those arising secondarily and sympatheti- cally from disease in other, and perhaps distant parts of the sys- tem. To the former of these classes, the name of the idiopathic may be given; to the latter, that of the sympathetic or sympto- matic. We do not enter upon a consideration of the analogies or differences in the actual condition of the visual structures in these tAvo classes of disease, inasmuch as such an attempt would be in a great measure conjectural, nor do we affirm that the line of demarcation can, in every case, be clearly drawn betAveen them; but, generally speaking, they are sufficiently discriminated from each other by the differences in their symptoms, the nature of the prognosis which they suggest, and the treatment which they demand. Dissociated from names which only tend to mis- lead, we consider the distinction to be of great practical utility, and propose to adopt it in the sequel of this paper. With reference to its duration, amaurosis has been divided into the incipient or recent, and the inveterate or confirmed. In degree, it may be partial or imperfect, and complete;* Avhile in regard to persistence, it has been distinguished as continued and intermittent, the latter being periodical or irregular. Amaurosis is said to affect females more frequently than males, and dark- colored eyes rather than the lighter shades. The disease may attack one or both eyes; in the former case, generally extending after a time to the other also; and in the latter instance, present- ing differences in degree in each organ. Symptoms. In detailing generally the symptoms, whether of idiopathic or sympathetic amaurosis, Ave shall arrange them under the heads of the objective and the subjective, or those which Ave recognise by the direct exercise of our senses, and those which Ave ascertain from the testimony of the patient. Each of these classes ought to be separately investigated, and if, * The term "complete" ought to be restricted to cases in which the patient has entirely lost the perception of light. It is not so, however, by all writers. —Author. amaurosis, (Symptoms.) 517 as frequently happens, one eye exhibits differences in the cha- racter and progress of the disease from the other, the history of each must be individually considered. We notice the objective symptoms in the order in Avhich they Avould probably engage the attention of a watchful observer. 1. The air and gait of an amaurotic patient is frequently peculiar. If the disease is imper- fect, or even if complete, provided it is limited to one eye, the above-mentioned circumstances may not present any thing unu- sual; but when both eyes are affected, and vision is reduced to a mere perception of light and shadow, there is an uncertainty in the movements of the individual, and a vacancy in the expres- sion of his countenance, which is altogether characteristic of the disease. 2. The eyeballs are frequently affected Avith oscillatory movements, or they are completely fixed, or from want of har- mony in the action of the recti muscles, strabismus varying in form and degree is the consequence. The motions of the palpe- brae also may be Avholly suspended, or imperfectly or irregularly performed. The globe of the eye must be examined as to its color, prominence, size, form, and consistence. The sclerotica seldom exhibits a healthy appearance, being either yellowish or of a leaden hue, or loaded Avith varicous vessels. The eye may be unusually prominent, hard, and tense, or sunk and atrophic, and soft and yielding to the touch; in these circumstances it is sometimes flattened on one or more sides by the pressure of the recti muscles. 3. The pupil may exhibit changes in its form, dimensions, position, and mobility; being irregular, dilated, or contracted, inclining towards some portion of the circumference of the iris, and either sluggish in its movements or completely fixed. In some instances, the pupil retains its natural mobility, although vision is much impaired or even Avholly extinct; and in cases where one eye only is amaurotic, the movements of the iris in the sound organ are participated in by.that of the diseased: hence the precaution recommended in such circumstances of closing the sound eye, while examining the condition of the other.* 4. The appearance and condition of the humors of the eye are points of much importance. They may exhibit changes in their transparency, indicated by the appearance behind the pupil of the greenish yelloAv opacity, termed glaucoma; or they may be altered in consistence, the globe feeling softer than natu- ral, an effect Avhich may result either from the partial absorption of its fluid contents, or from the breaking doAvn of the membra- * Dr. Mackenzie has suggested, in explanation of this interesting pheno- menon, the possibility, in such cases, of the brain or optic nerves being dis- eased posterior to the communication which takes place between the latter and the third pair, upon the maintenance of which, in its normal state, the motions of the iris depend. The theory appears to be highly plausible.—Author. 44 518 amaurosis, (Symptoms.) nous septa by means of which the figure and position of the vitreous humor is maintained. Changes in the deep-seated tis- sues, of a more marked and definite character, may also be ex- hibited.* 5. The marks of injuries about the head and face, whe- ther old or recent, ought to be observed and inquired into, espe- cially such as from their appearance and position were likely to affect directly or indirectly the superficial branches of the fifth pair of nerves, or any portion of the optic apparatus. 6. As amau- rosis is not limited to any period oflife, habit of body or pursuit; the age, the general aspect, the physical and moral constitution, and the profession of the patient, ought to be carefully noted and inquired into, as tending to throAV much light upon the causes of the disease, and the mode of treatment which it demands. Subjective symptoms. Of these, the most prominent is the impaired vision, which presents every variety in degree and rate of progress, as Avell as in the periods and circumstances in Avhich it occurs. It may be sudden and complete, or gradual in its de- velopment, slowly advancing to the entire destruction of sight, or remaining stationary after reaching a certain point. It may be constant, or occur at irregular intervals, or at certain fixed periods, assuming the form of hemeralopia or nyctalopia. It may come on Avithout any assignable cause, or succeed to the con- tinued exercise of the eyes upon minute objects. In some cases, the obscurity extends to the whole field of vision, Avhile in others it is limited to a portion or portions; thus, in reading print, the patient either sees the whole page indistinctly, or he loses sight of a word or letter here and there. In other instances, one half only of any object is seen ("visus dimidiatus," "hemiopia"), or certain portions of it, or every object appears double ("visus duplicatus," " diplopia"). Some rare examples of double vision with one eye have been observed. Some patients see best what- ever is situated obliquely to them, others what is directly in front: some can only distinguish objects Avhich are at rest, others those which are in motion; or all objects are observed as if disfigured and distorted in various ways. In some instances, vision as- sumes a myopic, in others a presbyopic form. Some persons see best in dark and cloudy weather, others in bright sunshine. In some instances, vision is most perfect in the morning, after the rest of night, Avhen the stomach is empty or the diet restricted; in others, it is much improved by taking food and stimulating drinks. * The dilatation of the pupil by means of belladonna, though not always practicable in cases of amaurosis, ought to be attempted, especially when it is accompanied with deep-seated opacity. The degree of susceptibility to its influence still retained by the iris is thereby exhibited; and if the pupil dilates, the nature of the opacity is of course more easily ascertained.—Author. amaurosis, (Symptoms.) 519 False impressions constitute an important item in this class of symptoms, and are either persistent or occasional. In appearance, they may be luminous or dark-colored, and are either general over the field of vision, or limited to particular portions. Those of a bright color are sometimes only perceptible to the patient Avhen in the dark; in other instances, they are seen both during the day and night, assuming various forms, as of a sea of molten gold, or globes of fire or stars, which are either at rest or in mo- tion, or they resemble flashes and sparks of fire Avhich seem to dart from the eye. In some cases, all objects are seen as if bor- dered with prismatic colors, or the patient becomes unable to distinguish certain hues which formerly he could easily recognise. The dark-colored phenomena appear in the form of a general cloud or net-work, or of specks apparently floating in the air, which are either solitary or numerous, and seem to rise and fall with the movements of the eye. Sometimes they resemble mem- branous films, or chains and coils and numerous other figures equally diversified and fanciful. The sensibility of the eye to light varies in different cases; generally it is much diminished, but in some instances it is greatly augmented, giving an unnatural clearness and brightness to sur- rounding objects (oxyopia), or causing so much pain and un- easiness that the patient is unable to bear the ordinary light of day. A sensation of dryness in the mucous membrane of the eyes and nostrils is a not unfrequent attendant upon amaurosis. Pain limited to the eyes, or extending to the head and face, is observed in the majority of amaurotic cases. It may be constant, intermittent, or periodic. Its character, degree, and the extent over which it is felt, ought to be inquired into; also, the circum- stances which tend to relieve or aggravate it, Avhether accom- panied with vertigo, tinnitus aurium, nausea, a disposition to sleep, or Avakefulness. Dulness of one or more of the senses sometimes exists, with failure of memory, and inability to exert certain r other of the intellectual faculties. The history of the patient's general health, and especially of any prevous attacks of disease, ought to be made a particular subject of inquiry, as tend- ing to unfold the causes Avhich may have remotely and indirectly prepared the way for his present affection. Other points for in- vestigation arising out of the peculiarities of each individual case, will readily suggest themselves to every reflecting mind. Beer describes, under the name of "Amaurotic Cat's-eye," a peculiar and rare affection of the organ, attended with impaired vision, immobility of the iris, and an opalescent reflection from the pupil and bottom of the eye. Mr. LaAvrence relates three cases of this disease (Treatise,?. 564-5), all of which occurred in young persons, and states, that in his experience it has always proceeded to complete loss of sight. The appearance presented 520 amaurosis, (Causes.) by the pupil renders it probable that the disease is dependent upon structural changes in the choroid and retina, with the pre- cise nature of Avhich we are still unacquainted. Dr. Mackenzie adverts to another condition of the eye, also attended with loss of sight, but differing from the former, in presenting an opaline reflection apparently from the anterior capsule of the lens. In one case affecting both eyes, at the patient's request, he intro- duced a cataract needle through the cornea and pupil, but found no trace of the lens; a profuse discharge of watery fluid folloAved the puncture, and when the cornea healed, the glittering reflection was observed as before. (Pract. Treat, p. 834.) Causes. The predisposing causes of amaurosis do not differ essentially from those Avhich may give rise to disease in any other texture of the eye or organ of the body. It has been observed, in some rare instances, to be congenital, and is hereditary more frequently than cataract, according to Beer, who mentions the case of a family in which it prevailed among the females during three generations. (Lehre von den Augen Krankheiten, vol. ii, p. 442.) Whatever tends to depress and exhaust the vital powers may prove a predisposing cause of amaurosis; as chronic dis- charges of any kind, immoderate venery, or onanism, protracted lactation, the long-continued influence of depressing passions, in- anition, and some poisons. Frequent and long-continued attacks of strumous ophthalmia in childhood have been observed to render the individual very liable to amaurosis in after years, from the influence of slight exciting causes. The period of life unquestionably exercises some influence in its production, for although occurring at all ages, it is more frequent in those of mature years, and has been remarked to occur especially about the period of the cessation of the catamenia in females, and the corresponding age in males. Among the direct or exciting causes of amaurosis may be enumerated over-exertion of the eyes, or their protracted occupa- tion upon minute objects, or exposure to bright light and intense heat; hence the frequency of the disease among certain classes of artizans, Avho are necessarily subjected to the influence of such stimuli. A single exposure to one or other of these causes has sufficed in some instances to produce loss of vision; but in general this result is gradually developed, appearing to flow from con- tinued over-excitement of the organ. Injuries from mechanical violence, inflicted upon the retina, optic nerve, or brain; or dis- eases of these parts, whether consisting in simple congestion or a deficient supply of red blood, or in more serious structural changes,* either originating in these tissues themselves, or pro- * It was ingeniously conjectured by Mr. Ware, and has since been con- firmed by observation, that dilatation of the anterior portion of the " circulus amaurosis, (Diagnosis.) 521 duced by the pressure of morbid growths in neighboring textures, are frequent causes of amaurosis in some of its most intractable forms. It may also originate from injuries done to the branches of the fifth pair of nerves, or even from mere irritation of these parts, as by a carious tooth,* &c. Violent mental emotions, the effects of lightning, and the rays of a tropical sun, may be men- tioned as occasional causes. Amaurosis has also been ascribed to the cessation of inordinate or habitual secretions, and by some writers to the retrocession of eruptive diseases. Derangement of the hepatic system, or continued irritation of the stomach and in- testinal canal, the existence of pregnancy, and some diseases of the puerperal state, are among the principal causes of amaurosis in its sympathetic forms. In conclusion of this part of the sub- ject, it may be remarked, that amaurosis is rarely the effect of any single cause; most frequently it is tracable to the combined operation of several, differing perhaps widely from each other, and exerting their influence during a protracted period. Diagnosis. Impaired vision, whether recent or of long standing, if unaccompanied with opacity in the cornea or behind the pupil, cannot be confounded with any other disease. To distinguish amaurosis from glaucoma is seldom required from the frequency with Avhich they occur together, nor is it practically needful, as the same treatment is in general applicable to both. Amaurosis in its early stages, Avhen combined Avith glaucoma, may be mis- taken for incipient cataract, but the folloAving points of difference will serve to distinguish them:—In glaucomatous amaurosis the opacity is of a greenish yelloAv hue, deep-seated, and surrounded apparently by a transparent circle, and most obvious on looking directly into the pupil. The opacity in cataract is of a milk and water tint, appearing immediately behind the pupil, by the mar- gin of which it is bounded, and is equally visible in Avhatever direction the eye is examined. In posterior capsular cataract, the opacity is also deep-seated, and presents the concave surface frequently observed in glaucoma; but it differs from it in exhib- iting striae radiating from a central point, whereas the opacity in glaucoma is ahvays uniform. In glaucomatous amaurosis the consistence of the eyeball is generally firmer than natural, a cir- cumstance not observed in cataract. The progress of glaucoma- tous amaurosis is usually slow, both as regards the increase of arteriosus," or of the central artery of the optic nerve, might sometimes be the cause of amaurosis. (See Chir. Obs., vol. ii, p, 428, and Mackenzie's Pract. Treatise, pp. 946, 947.)—Author. * An interesting case of this kind is detailed in the Arch. Gen. de Med., tom. xxiii, p. 261, in which the amaurosis depended upon the irritation caused by a minute splinter of wood which had penetrated through the fang of a decayed tooth.—Author. 44* 522 amaurosis, (Diagnosis.) opacity and the declension of vision; the latter symptom may in- deed remain stationary for years. In cataract, vision declines rapidly, and always bears a fixed ratio to the amount of opacity. The pupil in glaucomatous amaurosis is generally sluggish, if not dilated and motionless; whereas in cataract it retains its nat- ural mobility. Glaucomatous amaurosis is frequently preceded and accompanied by pain and various other uneasy sensations in the eye and head, and by derangement of the functions of other organs, as of the stomach and bowels: the motions of the palpe- brae and of the globe may be imperfect or abnormal; there may be ptosis or strabismus, &c. The formation of cataract is not in general attended with any of these circumstances.* Other dis- tinctions have been enumerated, derived from the nature and ap- pearance of the optical phenomena Avhich are visible to the patient, and from the circumstance and direction in which his vision is most perfect; but as they are not pathognomonic of either disease, they cannot be relied upon. Should the amaurosis be combined Avith cataract, the difficulty of the diagnosis is of course augmented; but a careful observation and comparison of the symptoms of each disease will in general suffice to establish it, and if not, the growing opacity of the lens will in due time render it evident. In cases of amaurotic cat's-eye, the shining metallic appearance behind the pupil might possibly be mistaken for fungus nematodes. For the distinguishing circumstances, we must refer to descriptions of this disease given elsewhere. (See Lawrence's Treatise, p. 616.) With regard to the discrimination of the different forms of amaurosis, a careful consideration of the history of each case and of the peculiar combination of symptoms which it presents, will in the majority of instances serve to distinguish the idiopathic from the sympathetic disease. No characteristic signs can be pointed out by Avhich they may be certainly recognised. A sim- ilar remark may be applied to the diagnosis of amaurotic affec- tions of an asthenic character, and those dependent upon incura- ble structural changes, the distinction between which, from its great practical importance, must by all means be made, although often beset with difficulties. * In doubtful cases of this description we have employed the aid of artificial light to assist in determining the diagnosis, as ingeniously suggested by Pro- fessor Sanson, senior. It is certainly useful in furnishing negative evidence at least; for where the inverted image of the candle is observed, we may confidently affirm the non-existence of opacity in the posterior capsule of the lens, or in the layers of its substance immediately adjoining. For an account of this interesting phenomenon, and its application to diagnosis of opacities behind the pupil, see "Remarks on Lenticular Glaucoma," by Dr. Mackenzie in London Med. Gaz., April 14, 1838.—Author. amaurosis, (Treatment.) 523 Prognosis. There are tAvo points \vh\ch,primdfacie, ought ma- terially to influence our prognosis, viz. the duration of the disease, and the degree in Avhich vision is impaired. Sudden attacks at- tended Avith urgent symptoms of disturbed vascular action, and whether accompanied by paralysis or not, are more favorable than those which come on gradually without any strongly mark- ed indication, one amaurotic and paralytic symptom by degrees succeeding to another. By energetic measures, we may hope to relieve such cases as the former, while in the latter Ave have to fear the developement of morbid growths, or other serious struc- tural changes within the cranium. If the retina is quite insensi- ble, the prognosis is certainly unfavorable, although cases are re- corded, in which vision was restored after nearly total blindness of several days' duration. (Lawrence, op. cit., p. 324, 325.) Should the insensibility continue Avithout improvement during a feAV weeks, the case may be considered as hopeless. Great al- teration in the size, form, and mobility of the pupil, with preter- natural hardness or softness of the globe and glaucoma, is unfa- vorable, as indicating disease of the nervous apparatus of vision, or of the internal textures of the eye, which is probably incurable. The prognosis is favorable in the sympathetic forms of amau- rosis; as we may generally anticipate a return to the healthy condition of the function, Avhere the disease upon which the im- paired vision is dependent admits of alleviation or cure. In cases where one eye alone is affected, our prognosis must be extended to the healthy as well as to the diseased organ; for from the in- timate sympathy existing between them, it rarely happens that one is attacked without the other participating in the affection at a period more or less remote. Hence active treatment must fre- quently be adopted and pursued, not as a curative, but as a pre- ventive measure. Treatment. Amaurosis being accompanied in a large ma- jority of instances Avith symptoms of inflammation or congestion in the nervous apparatus of vision, antiphlogistic measures are frequently required, varying in kind and degree according to the age and constitution of the patient and the urgency of the indi- cations. Referring to what has been already said in a former article, regarding the treatment of retinitis, Avhich in an acute or chronic form is a fertile source of idiopathic amaurosis, it will suffice at present to observe that when the patient is young and plethoric and the inflammatory symptoms active, depletion, both local and general, must be practised, with the free exhibition of purgatives, and the employment of counter-irritation. Should these measures fail in producing the desired effect, recourse must be had to mercury, Avhich from its influence in controlling inflam- mation in other textures, analogy Avould suggest, and practice confirms, as being equally useful in the present instance. Calo- mel and opium ought therefore to be given till the mouth is 524 amaurosis, (Treatment.) affected; and, generally speaking, the influence of this remedy upon the system ought to be maintained during several weeks, to insure all the benefit which it is capable of affording. If the antiphlogistic treatment and mercury equally fail, little more re- mains to be done: measures ought to be taken to promote the general health, the maintenance of which may possibly operate beneficially upon the diminished poAvers of vision. The effect of counter-irritation, by means of a succession of blisters, may also be tried. In cases of a more chronic character, occurring, as we every day witness, in combination Avith a debilitated constitution and disor- dered general health, such activity of treatment Avould be highly prejudicial. Topical bleeding however may still be requisite, the indication for which, as well as for general depletion in other instances, is to be derived, not from the condition of the system, but of the part. In such instances as the above, although mer- cury is to be employed chiefly as an alterative, considerable bene- fit is frequently derived from the continuance and gradual increase of the dose, till the mouth is slightly affected. The employment of counter-irritation must not be omitted; repose of the organ should be enjoined, and the use of tonics, both dietetical and me- dicinal, is often a useful auxiliary. In cases attended Avith symp- toms of cerebral congestion of long standing, along with topical bleeding and the exhibition of purgatives, we have derived consi- derable benefit from the insertion of a seton in the neck. The amaurotic affections Avhich we have termed sympathetic or symp- tomatic, being in general dependent upon a disordered condition of the stomach and bowels, arising from the presence of irritating matters or some other cause, whether temporary or permanent, the state of these organs must be especially attended to. The emetic and "resolvent"* plan, as proposed and practised by Richter, Schmucker, and Scarpa (Pract. Obs. on Dis. of the Eye, p. 486), might be supposed to be peculiarly applicable in such circumstances; but Messrs. Lawrence and Travers, both of Avhom have given it a fair trial, concur in stating that they have never derived any benefit from its employment. The latter remarks (Synopsis of the Dis. of the Eye,o. 310.), that "the cases of gas- tric disorder to which it is especially applicable, are most benefited by a long-continued course of the blue pill, with gentle saline pur- gatives and bitter tonics." It must be admitted, however, that many of the temporary amaurotic affections, especially of children, are speedily relieved, if not entirely removed, by an emetic, suc- ceeded or not, as the case may require, by a feAV brisk purgatives. * The " resolvent pills," which formed an important item in the scheme, consist of a farrago of drugs, and fifteen of them are directed to be taken three times a day for some weeks. amaurosis, (Treatment.) 525 Where amaurosis can be traced to general debility of the sys- tem, induced as is sometimes the case, by protracted lactation, or the abuse of other natural secretions, the indications of cure are so obvious, as to require no additional comment. Various powerful stimuli have at different times been employed in the treatment of amaurosis, on the supposition that the disease might be dependent upon a diminished energy or want of tone in some portion of the nervous apparatus of vision. Of one and all of these remedies it may be affirmed, that their indiscriminate use has been productive of much evil, and that in the early stages of the disease, accompanied with symptoms of local inflammation, they are wholly inadmissible. Where no such objection exists, and the concurrent symptoms appear to indicate a condition of diminished nervous energy, we see no objection to a judicious trial of their powers, although the ill-success which, generally speaking, has hitherto attended the experiment, does not warrant us in building much upon their efficacy. Mr. Hey of Leeds (Med. obs. and Enq., vol. v,) and the late Mr. Ware (op. cit., vol. ii, p. 409), have related cases which sufficiently attest the occa- sional benefit of electricity; while Messrs. Travers (op. cit., p. 309), and LaAvrence (op. cit., p. 543), concur in stating that they have never Avitnessed any good effect from its employment, or that of galvanism, although repeatedly tried in cases of a favor- able description. Mr. Tyrrell's (Cyc. of Pract. Surg., p. 105) testimony is nearly to the same effect. Strychnine has been much employed in the treatment of amau- rosis since its first proposal by Dr. Shortt. (Edin. Med. and Surg. Journ., vol. xxxiv.) The cases which he has published show very clearly the immediate benefit which may result from its exhibition, Avhile the doubts Avhich he expresses as to the per- manency of these effects, has been only too amply confirmed by the subsequent experience of others. Dr. Shortt recommends the strychnine in instances Avhere the symptoms are apparently de- pendent upon simple Avant of poAver or atony of the nervous struc- ture, or Avhen a congested condition of the capillaries of the retina, unattended Avith vascular excitement, may be supposed to exist. In such circumstances, we should not hesitate to employ it after the failure of other and more certain remedies. The most effica- cious mode of applying the remedy is to dust it upon a blistered surface, from which the cuticle has been removed, over the eye- brow or upon the temple; commencing Avith one sixth of a grain and increasing the quantity daily, till the constitution is sensibly affected, as indicated by headach, pricking pains over the body, or tremors, Avhen it should be discontinued, and on resuming its use, the dose should ahvays be considerably diminished., Mr. Tyrrell (op. cit.) observes, that he has made trial of strychnine m cases apparently the most appropriate for its use, and has pre- scribed the remedy in various ways, both internally and exter- 526 amaurosis, (Treatment.) nally, continuing it till the involuntary muscular contractions Avere frightful; but Avithout meeting with a single instance of benefit from its employment. Dr. Mackenzie (op. cit. p. 916) states, that he has never witnessed any remarkable effect Avhich could fairly be attributed to the strychnine. We have ourselves fre- quently made use of it, and still more frequently witnessed its em- ployment in the practice of Mr. Morgan in Guy's Hospital; and Ave are unable to recall even one instance in Avhich it proved perma- nently beneficial, although temporary improvement of vision to a remarkable degree Avas sometimes produced. The testimony of the above mentioned authors, as being the most competent judges of the merits of this remedy, ought to deter the less expe- rienced from its indiscriminate employment, and caution them against buoying up the unfortunate subjects of incurable amau- rotic disease with hopes of returning vision, which are only des- tined to be cruelly disappointed. Stimulating applications to the eyes and nostrils, in the form of vapors and snuffs, have been recommended; and from the sym- pathy which exists betAveen the branches of the trigeminal nerve and the retina, they may possibly be of service in cases where a stimulus is required. On the same principle, a succession of small blisters to the neighborhood of the orbit has been productive of benefit in some instances. Amaurosis succeeding to wounds of the frontal or other branches of the fifth pair of nerves, has been in some instances cured by a complete division of the injured twig; generally hoAvever the operation has failed to relieve. Bel- ladonna, given internally or rubbed upon the surface, is some- times productive of benefit in such cases, and they occasionally undergo a spontaneous improvement. We purposely abstain from mentioning many other remedies Avhich have been proposed in the treatment of amaurosis, inasmuch as experience has demon- strated their total inefficacy. 527 l INFLAMMATION OF THE EAR; OR, OTITIS. Definition of otitis and otorrhoea.—Acute and chronic otitis.—Symptoms of acute external otitis—of acute internal otitis—of chronic otitis or otorrhoea. —Causes.—Anatomical characters.—Diagnosis.—Prognosis.—Treatment of acute external otitis—of acute internal otitis—of chronic otitis. The term Otitis (from oCj, 15*65, the ear) is applied to inflamma- tion of one or more of the parts Avhich constitute the organs of hearing. From the pain which frequently accompanies the dis- ease, some writers denominate it otalgia, from ovj, J>t6s, and a%yot, pain), while, by most authors, the chronic form has been called otorrhoea (from ols wt-oj, and £|«, to flow,) on account of the dis- charge by Avhich it is characterised. This disease was very imperfectly described, before M. Itard gave an excellent account of it in his work (Sur les Maladies des Oreilles, c/c), published in 1821. The researches of Saunders, Abercrombie, and Pilcher, in England; of Lallemand, Andral, and Deleau, in France; and of P. Frank, Lincke, and Kramer, in Ger- many, have tended still further to clear up the obscurity in Avhich it was formerly involved. These writers have shown that a knoAV- ledge of auric medicine can only be acquired by those Avho are acquainted with the general laws which regulate disease through- out the animal economy. Otitis has been divided into the acute and chronic, the distinc- tion being founded on its severity and duration. Acute otitis has been subdivided into the external and internal; the former includ- ing inflammation, more or less general, of the meatus auditorius externus and membrana tympani; the latter, inflammation of the tympanum and Eustachian tube. Symptoms of Acute External Otitis. This form generally commences with an unpleasant sensation or slight pain in the au- ditory canal, resembling that occasioned by the presence of a foreign body in the ear; in other cases, it is of a burning or itching nature. This gradually increases, until there is acute, occasion- ally lancinating, pain, sometimes of a dull, heavy, dragging, and tearing character, increased on pressure; by the motions of the loAver jaw, or by the contact of cold air and hot fluids. The hear- ing is confused or impaired, and accompanied by whistling, buz- zing, ringing, or roaring sounds, intermittent or constant. The membrane lining the meatus is red, and generally more or less 528 otitis, (Symptoms.) SAVollen. At a period varying from a feAV hours to three or four days from the commencement of these symptoms, a thin, limpid, or sanguinolent discharge, gradually becoming more consistent, and of a Avhitish, yellowish, or puriform appearance, takes place from the meatus. In some cases, Dr. Kramer has described the tumefaction of this stage to be so great as scarcely to permit a knitting needle to be introduced, and in other cases as affecting only one side of the meatus, forming a kind of elevation which extends irregularly along the cavity, and also affects the mem- brana tympani. The lining membrane is usually covered with pimples, filled either with a serous or purulent fluid; some of which having burst, leave ulcerations that continue to furnish the discharge, or crusts which more or less block up the cavity of the meatus. The discharge is occasionally inodorous, but more fre- quently fetid, and sometimes so acrid as to produce considerable irritation in the parts over which it Aoavs. Granulations often form, resembling excrescences of polypi, of a soft, spongy, and very red appearance, and covered Avith a copious muco-purulent secretion: these granulations bleed from the slightest touch, but sometimes they have a broad base, are hard, insensible, of a pale red color, and bleed little or not at all. In cases in which the membrana tympani appears to be primarily affected, it is more or less red, rough, swollen, and opake, and sometimes covered Avith small projecting glands or follicles. Occasionally, also, bundles of vessels may be seen in it, and the point of the handle of the malleus cannot be distinguished. As the discharge becomes abun- dant, the pain usually decreases, unless the inflammation extend to the internal ear. The consistence of the matter discharged may undergo changes several times in the course of a week or even in a day. Sometimes it stops suddenly from the accumulation of crusts having caused a mechanical and temporary obstruction. As the inflammation declines, however, it often becomes thicker. and presents the color, consistence, and even odor, of caseous matter. (Hard.) The discharge now gradually diminishes, and gives place to a more than usually abundant secretion of wax, sometimes accompanied by a serous exudation from behind the ear. Itard remarks, that now and then perforation of the carti- laginous portion of the external ear takes place, Avhereby a fistu- lous communication is established, connecting the cavity of the meatus with the cellular substance which unites the cartilage and the bone. In tAvo or three days, broad, dry, cuticular scales are thrown off, and a tenacious cerumen, of a bright or dark brown color, is secreted, Avhich is mixed up with cuticular scales, adher- ing firmly to the walls of the meatus, which is thus completely stopped up. Acute internal otitis usually commences with acute deep- seated pain in the interior of either ear, rarely in both, accompa- by more or less general headach or hemicrania, rapidly increasing otitis, (Symptoms.) 529 in severity, Avith Avhistling, clanging, loud, or beating metallic noises, and a sense of bursting or distension. Mastication and sudden noises or motions of the head augment the symptoms. The pain in the head may be violent, lancinating, or compressive, fixed or undefined. Some patients complain of insupportable heaviness in the head, and others think that the cranium will burst open. The pulse is hard and frequent, the skin hot, the counte- nance anxious, the eyes injected and sensible to light, the tongue furred, the taste vitiated, the appetite lost, with febrile excitement. At night, there is loss of sleep, great restlessness, sometimes deli- rium, and in children convulsions. Occasionally there is an un- pleasant itching at the bottom of the throat, towards the orifice of the Eustachian tube, Avith swelling of the tonsils. An examina- tion of the external ear exhibits nothing abnormal. These symp- toms, if actively combated at the commencement, may, in tAvo or three days, partially subside; the pain diminishes in intensity; the loud noises in the ear give Avay to violent hissing, the taste and appetite return; and the febrile symptoms gradually disappear. The hissing or buzzing noises with indistinct hearing usually con- tinue three or four Aveeks. But should the inflammation not thus terminate in resolution, perfect deafness is occasioned in the affected ear; the fever conti- nues, and sometimes assumes a nervous or typhoid type, attended with much exhaustion; Avhile the local inflammation gives rise to products Avhich accumulate in the cavity of the tympanum, and at length force a passage toAvards the external surface. These products may be discharged, 1. by the meatus externus, from per- foration of the membrana tympani; 2. into the throat, through the Eustachian tube; and 3. through a fistulous opening in the mas- toid process. The first is by far the most common, its frequency to that of the second, according to Itard, being ten to one. The discharge of matter establishes, according to some authors, the second stage of the disease. When this takes place by perfo- ration of the membrana tympani, it occurs suddenly, generally about a week after the commencement of the symptoms; a large quantity of matter being discharged, sometimes mixed Avith bloody streaks, as if an abscess had burst. The acute symptoms then generally diminish, and the patient experiences considerable re- lief, so long as the Aoav of matter is abundant and unimpeded. Sometimes, hoAvever,it is obstructed, either by its concreting and filling up the perforation in the membrana tympani—by causing inflammation and tumefaction in the external meatus—or by ac- cumulating and getting incrusted in that part of the ear. In either case, the acute symptoms are likely to return, unless the obstruc- tion is removed. A communication is now established between the posterior fauces and the external auditory passage, if, as is rarely the case, the Eustachian tube be not obstructed. This may be proved by causing the patient to expire forcibly Avhile the mouth 45 530 otitis, (Symptoms.) and nose are shut. By this act, bubbles of air, mixed with fluid, escape from the meatus; or if the flame of a candle be placed be- fore the external passage, it receives an evident impulse. AVhen the matter is discharged through the Eustachian tube into the fauces, it may take place suddenly or gradually. In the former case, a sensation is felt as if an abscess in one of the ton- sils had burst; there is sudden expectoration of a muco-puriform, or purulent matter, sometimes of a disagreeable taste, and recur- ring in smaller quantities at uncertain intervals. In the latter case, the accumulated matter is discharged into the throat in small quantities, and brought up in the form of thick, tenacious, and sometimes bloody sputa, Avhich is detached from the fauces with much difficulty, especially in the morning. Under such circum- stances, the lining membrane of the Eustachian tube, by partici- pating in the inflammation, may be partially obstructed. Not unfrequently, also, the discharge of matter by tickling and irritat- ing the glottis, produces a very unpleasant cough, a symptom which may induce the superficial practitioner to overlook its real cause. When the discharge takes place through a perforation in the mastoid process, it is an evidence of the inflammation having extended to the membrane lining the cells in that portion of the bone, and the formation of an abscess behind the ear. This is a rare termination of the acute otitis, and has been observed most frequently in those cases Avhich supervene on the decline of acute affections. (Hard.) It usually degenerates into the chronic form of the disease, and will be described more particularly under that head. The symptoms Avhich folloAV the discharge of matter differ ac- cording to the morbid alterations which have occurred in the internal ear. Thus the hearing is either entirely lost, remains impaired, or is recovered, in proportion to the nature and extent of the morbid lesions to be afterwards noticed. The symptoms usually lose their severity before a month has elapsed, at the ter- mination of Avhich period, if they have not disappeared, the dis- ease may usually be considered chronic, and otorrhoea is esta- blished. Sometimes, however, the symptoms increase in inten- sity—there are rigors, spasmodic phenomena, more or less marked, with greater or less rigidity of the muscular system; the restless- ness and agitation at night continue, Avhich, with delirium, at length appear during the day. There is sometimes more or less paralysis and coma, followed by death. Sometimes otorrhoea does not occur; the pain becomes apparently deep-seated; the patient is melancholy and dull, notices nothing, moves his head backAvards and fonvards, holding it between his hands, and at last falls into a comatose state, and dies. Deleau and Kramer describe a form of internal otitis, which the latter considers to be occasioned by inflammation of the mucous otitis, (Symptoms.) 531 membrane, as contra-distinguished from that of the cellular tissue and periosteum. The lining membrane of the cavity of the tym- panum being fibro-mucous, at once a mucous membrane and periosteum, it may be doubted how far this distinction is borne out by anatomy. Several facts, hoAvever, indicate that this mem- brane may be the seat of a peculiar inflammation, resembling the blenorrhoeal of some other mucous membranes, in Avhich the violent symptoms above described are absent, and the principal lesion consists in impaired hearing from accumulation in the cavity of the tympanum, and the patient complains of a sensa- tion of fulness and heaviness in the ear without pain; the hearing is always more or less dull, and nothing can be discovered in the external auditory canal. The only signs of this lesion are drawn from various kinds of auscultatory phenomena produced by inject- ing air into the internal ear. These will be more fully noticed under the head of Diagnosis. These symptoms are generally subacute, but become chronic, and Mr. Pilcher is of opinion that they not unfrequently lead to acute internal otitis. (On the Ear, p. 206.) Inflammation of the internal ear may arise secondarily from the extension of disease in the Eustachian tube, from its lining membrane participating in the inflammation of the throat in angina, or from the extension of ulceration and other affections in the region of the throat. In this case, the patient may com- plain of momentary deafness, Avithout its having been preceded by acute symptoms in the ear. This temporary deafness may be of longer or shorter duration, Avith intervals of perfect hearing. The patient sometimes hears his oavii voice worse than that of others, and occasionally has a crackling, gurgling, or detonating sensation in the throat leading to the ear. The blenorrhoeal form of internal otitis, also, is very liable to be complicated Avith stric- ture of the Eustachian tube, occasioned by an acute or subacute inflammation of its lining membrane. In all such cases, a cor- rect idea of the state of the parts is only to be obtained by means of injections and catheterism through the guttural orifice of the tube, as recommended by Deleau, Kramer, and Pilcher. Chronic otitis, usually termed otorrhoea, is often a termina- tion of acute otitis, although it may also be a primary disease; and the discharge from the ear be established without pain, or other prominent symptom. This form of the disease is more frequently met with than the acute, and the long continued escape of matter in many cases, Avithout injuriously affecting the organs essential to life, is probably the principal reason Avhy it has been regarded with so little attention. Chronic, like acute otitis, may be confined to the external or internal ear. It rarely happens, hoAvever, if its progress be not checked, from Avhatever part the disease originally proceeds, that it does not sooner or later extend from the one to the other by 532 otitis, (Symptoms.) perforation of the membrana tympani. Itard, and the generality Of authors, have divided otorrhoea into the mucous and purulent, but that distinctions should not be drawn merely from the character of the discharge is further shoAvn by recent microscopic observa- tions, and more particularly from the researches of Haenle (Uber Eiter und Schleim. Berlin, 1838), Avho has demonstrated that it is utterly impossible to distinguish the fluids secreted from inflamed tissues into mucous and purulent. The point of real importance to determine is, Avhether the inflammation be confined to the membranes lining the auditory passages, or Avhether it be com- bined with caries of the bone, or complicated Avith lesions of the brain. With a vieAV of directing attention more especially to these points, Ave shall consider chronic otitis as occurring, 1, Avith inflammation only of the membranes lining the various passages of the ear; 2, with caries of the bone; and, 3, Avith cerebral dis- ease. 1. Chronic otitis limited to the membranes may be confined to the external ear, and be the result of acute otitis, or be induced by vegetations, thickening of the lining membrane, herpetic erup- tions, or other chronic lesions of the lining membrane of the meatus externus. It is most common in children of a scrofulous constitution; apparently depends upon the general morbid affec- tion inherent in the system, and disappears when this is removed by change of diet or residence, on the attainment of puberty, or by other circumstances Avhich produce a radical change in the economy. The hearing is more or less impaired, according to the greater or less degree of obstruction in the meatus, either by the accumulation of matter, groAvth of vegetations, or thickening of the lining membrane of the meatus or membrana tympani. The matter itself varies in color, odor, and consistence, in the course of the disease. The quantity discharged also varies at different times, although in general it bears a relation to the ex- tent of the inflammation. In the majority of cases, a perforation is made sooner or later in the membrana tympani, and thus the disease involves the in- ternal ear. Under such circumstances, the hearing becomes more and more dull, according to the extent of the injury inflicted on the membrana tympani and chain of bones connected with it. No other marked symptoms, hoAvever, occur so long as there is no impediment to the flow of matter. Sometimes this is-suddenly arrested, and then acute symptoms generally supervene; such as severe pain in the ear, fever, more or less violent headach, and other cerebral symptoms, which either disappear on the re-estab- lishment of the discharge, or by their continuance prove destruc- tive to life. Sometimes the suppression of the otorrhoea is fol- lowed by other disorders; such as affections of the eyes, porrigi- nous eruptions on the scalp, SAvelling of the lymphatic glands of the neck, &c. Itard has once seen tumefaction of the testicle in a otitis, (Symptoms.) 533 young man from this cause; Lallemand also has observed the otorrhoea alternate with accessions of rheumatism, catarrh of the bladder, leucorrhoea, &c. The affection called by Roche otite chronique seche, and by Pilcher ery thematic otitis, and Avhich has also been described by Mr. Earle {Med. Chir. Trans, vol. x), is not, in our opinion, an inflammatory disease, but depends upon a perverted secretion of the lining membrane, which occasions a morbid deposit, similar to that formed in the muguet of French Avriters. The duration of chronic otitis limited to the membranes varies infinitely; it may continue for many years Avithout producing any serious result. In some very rare cases, the otorrhoea gradu- ally diminishes, and at length wholly disappears, without pro- ducing any unpleasant result, but more frequently even this spontaneous cessation of the disease occasions a greater or less degree of deafness. This may arise from extensive lesions of the membrana tympani; thickening or stricture of the external meatus; loss of the tympanal bones, or complete obliteration of the external passage, from adhesion of its Avails; in Avhich case total loss of hearing is the invariable result. Even these termi- nations may be considered comparatively favorable, as in the majority of cases the discharge having accumulated more or less in the cavity of the tympanum, at length becomes acrid, induces ulceration and denudation of the membranes, and ultimately caries of the surrounding bone. 2. Chronic otitis complicated ivith caries of bone may be either the result of acute or chronic inflammation limited to the membranes, or it may, although more rarely, be the primary disease. In the external ear, it usually arises from inflammation of the periosteum, as pointed out by Kramer. A tumor forms toAvards the base of the external meatus, Avithout pain or other inconvenience, except deafness to a greater or less extent. When the abscess opens, an ichorous fetid fluid is discharged, the deaf- ness is diminished, as long as the passage is clear. The discharge may thus continue for years, but if exfoliation take place, the ulcerated part begins to heal, this process being accompanied by a great tendency to narrowing or obliteration of the meatus. When the bones of the internal ear are diseased, the matter evacuated, instead of retaining the usual yellow color and con- sistence of healthy pus, becomes thin, of a grayish or dirty color and more or less sanguinolent; it exhales a peculiar, sometimes very fetid odor, similar to that generated by carious bones, and frequently stains a silver probe of a brown or violet hue. Some- times the acrimony of the discharge irritates the lobule of the ear and other parts Avith which it comes in contact, and occasions more or less swelling of those parts. As the disease advances, the discharge becomes mixed with small fragments of bone. In these cases, the patient feels a dull pain in the ear, Avhich extends 45* . 534 otitis, (Symptoms.) to a greater or less extent over the side of the head, Avith more or less impaired hearing. The mastoid process is the part most frequently affected; a dull pain, increased on pressure, being felt. In some cases, the skin Avhich covers it becomes reddish, slightly swollen, and the seat of a purulent deposition or abscess, Avhich is not accompanied by any acute pain. The skin subsequently becomes of a reddish broAvn or violet color, more and more thin, and at length ulcerates, giving exit to the sanious discharge above described. A fistulous communication now exists betAveen the external surface behind the ear and the cavity of the tympanum, through the mastoid process, the cellular structure of which is perforated, destroyed to a greater or less extent, and infiltrated with matter. On introducing a probe, the naked rough bone may be readily detected, and in several cases the instrument penetrates Avith facility into the mastoid cells, and even into the cavity of the tympanum. If the membrana tympani be rup- tured, a fluid injected through the external opening escapes by the external meatus, and occasionally by the Eustachian tube. Sometimes the discharge from the fistula alternates Avith that from the auditory canal, or should it be suppressed, the pheno- mena formerly alluded to may be- induced. Occasionally, the pus penetrates betAveen the muscles attached to the mastoid pro- cess, and the abscess opens low down in the neck. Under such circumstances, it is very liable to be mistaken for an ordinary scrofulous tumor, and the ear affection to be overlooked. When on the other hand, the caries of the mastoid process takes place Avith still greater sloAvness, its cellular structure becomes degene- rated and broken doAvn, and escapes through the meatus externus with the sanious discharge, while its rounded form gradually dis- appears, Avithout the soft parts covering it being affected: hence Lallemand considers it important, in all cases of chronic otitis, to compare the volume of the two mastoid processes. Sometimes the matter collects in the mastoid cells, and after gradually excavating the bone at length finds its way through the Eustachian tube. In such cases, in addition to the dull pain, increased on pressing the mastoid process, there is a continual noise in the ear, resembling that made by a windmill, a Avaterfall or unpleasant Avhistling, which deprives the patient of sleep. The hearing at length becomes more and more obscure, or is entirely lost, although in some cases it has returned, and again disappeared at intervals; the noises also may increase or diminish in intensity; these symptoms, together with the loss of hearing, apparently depending upon the mixture of air and pus in the Eustachian tube, and the plenitude or vacuity of this cavity. The patient has sometimes a bitter taste in the mouth, with nausea and vomiting. Occasionally, he is suddenly seized Avith cough, and expectorates a sanious purulent matter, mixed with bloody streaks; a symptom which is very liable to appear in the otitis, (Symptoms.) 535 morning. Whatever food is taken has a nauseous, disgusting taste; the appetite is lost; the patient becomes melancholic, emaciates and loses strength everyday. These symptoms are referable to the caries of the bone and the sanio-puriform dis- charge dropping into the fauces, although they have often been mistaken and attributed to some affection of the stomach or lungs. The caries however extends; involves the other osseous parts of the organs of hearing; perforates the dura mater, and affects the brain, even in some cases before its real nature is suspected. The petrous portion of the temporal bone, Avhich encloses the semicircular canals, is the portion next most likely to be affected; and Avhen this occurs, the destructive process is very liable to be communicated to the brain, giving rise to the symp- toms to be presently described. Sometimes the caries follows the aqueduct of Fallopius, probably by the opening Avhich gives passage to the chorda tympani, and then the patient experiences acute pains in the ear, spasmodic contractions of the muscles of the face on the side affected, terminating in paralysis. Lalle- mand has met with five cases of this kind, in Avhich the phe- nomena were to be attributed to the facial nerve having partici- pated in the structural disorganisation, and others are recorded by Berard. The caries may also follow the aqueduct of the cochlea, and more rarely the internal auditory canal. It seldom happens, hoAvever, that, when caries is once established, its progress is limited to one direction. The same causes Avhich occasion it in one situation may induce it in others, and hence the Avhole of the mastoid process and petrous portion may be destroyed. Lallemand cites a case from Beaugrand, in Avhich the mastoid, coronoid and styloid processes were destroyed by caries, as Avell as the glenoid cavity of the first vertebrae, the odontoid process of the second, and the inferior part of the occi- pital bone. He says he has seen a similar case, in Avhich the head Avas inclined on the shoulder of the affected side, with in- complete paralysis of the superior extremities, painful SAvelling of the neck, &c, (Lettre iv, p. 222.) The duration of chronic otitis with caries may vary from a few months to several years, during which period the symptoms may differ according to the passage by which the matter is discharged. This may take place in the same patient sometimes by the external meatus, sometimes by a fistulous opening, at others by the Eustachian tube giving rise to the different effects we have noticed. 3. Chronic otitis complicated with cerebral disease is analo- gous to the cerebral otorrhoea of M. Itard, Avhich he divided into the primitive and consecutive; the former, according to him, commencing in the brain and extending to the ear, Avhile the latter commences in the ear and extends to the brain. The valuable researches of Lallemand, however, have made it very problematical Avhether the cases described by Itard and others as 536 otitis, (Symptoms.) primary otorrhoea, are not in point of fact consecutive to chronic disease in the bone, in Avhich the cerebral affection is the first circumstance Avhich attracts the attention of the patient and practitioner. In all these cases, caries of the petrous portion of the temporal bone is found, and it is evidently more likely that this should be the cause of the cerebral inflammation or abscess in its neighborhood than that inflammation should have existed a long time Avithout prominent symptoms, pus have slowly formed and produced perforation in the hardest and thickest of the cranial bones. It is Avorthy of remark, also, as rendering the latter opinion still more improbable, that Avhile cerebral abscesses do not produce perforation in the softer bones Avhich form the walls of the cranium, so they seldom communicate Avith the in- terior of the ear by means of the meatus auditorius internus. Whichever theory be adopted, it is important to knoAV that the cerebral symptoms may occur previously to any discharge from or other prominent symptom in, the ear, and, on the other hand, may supervene on chronic otitis of longer or shorter standing. In this sense, therefore, the terms primary and consecutive may be used. In either case, the symptoms are, obstinate headach, at first obtuse, afterAvards lancinating and severe; sense of weight in the head; redness of the eyes; pain at the base of the orbit; sometimes convulsive contractions in the muscles of the face; tension or slight swelling of the scalp; sensation of constriction in the cranium, as if it were not large enough to contain the brain; sometimes lesions of the intellectual faculties, especially of the memory; hard and frequent pulse; loss of appetite; wakeful- ness, rigors, general fever, increased at night; furred tongue, fetid breath, increased Avasting, general collapse, anxiety of the countenance, delirium, continual moaning, contracted or dilated pupils, strabismus, convulsions, rigidity of the muscular system or palsy, coma and death. These symptoms, Avhich vary accord- ing to the seat and intensity of the cerebral disease, are of the same nature, and follow the same progress, as inflammation of the brain and its membranes. When the discharge from the ear has preceded the cerebral symptoms enumerated above, it is generally diminished before they appear; when, on the other hand, they appear consecutively, the membrana tympani is sometimes ruptured, and a considerable quantity of matter escapes from the external meatus. Under such circumstances, the cerebral symptoms are for a time alleviated, and Itard has seen tAvo cases Avhich terminated in recovery after this occur- rence. In the majority of instances, hoAvever, they return, and continue until the death of the patient. Sometimes, when cere- bral disease supervenes on long-continued chronic otitis, the fatal event is more gradual; hectic fever supervenes, which by degrees destroys the constitution, and the individual sinks exhausted. It may also happen in otorrhoea accompanied by occasional head- otitis, (Anatomical Characters.) 537 ach, that muscular contractions or coma may come on suddenly, and either prove quickly fatal, or hemiplegia may be the result: in which case, an apoplectic attack generally sooner or later closes the scene. Causes. Otitis has been observed rather more frequently before than after puberty, but both sexes appear equally liable to it. (Lallemand.) The causes Avhich more especially predispose to the affection are a plethoric state of the body, or the scrofulous and gouty diathesis (Kramer); the period of dentition, the syphi- litic poison, previous attacks, and diseases of the throat, pharynx, and oesophagus. The disease may be excited by a rapid current of air acting on the head, or by exposing it uncovered to a cold atmosphere, especially during perspiration, or immediately after removal of the hair, imprudent bathing, the introduction of foreign bodies into the ear, injury of the external meatus by pricking or cutting instruments, caustic applications, stings of insects, irritating salves or drops, &c, the employment of galvanism or of electricity di- rected towards the ear for the cure of deafness (Roche); irritating injections into the auditory canal, the sudden disappearance of ophthalmia, the suppression of chronic discharges, the extension of scrofulous, syphilitic, herpetic, or porriginous diseases of the skin to the ear. It is likeAvise frequently one of the sequels of exan- thematous fevers, more especially variola, erysipelas, and scarla- tina, or of diseases of the throat and pharynx, &c. It has also been apparently occasioned by the irritation of carious teeth, cleft palate, congestive disorders of the brain, and injuries of the head. It must, however, be stated, that otitis has come on without any obvious exciting cause. Anatomical characters. At an early period of the disease, the lining membrane of the auditory passages is injected and red- dened, and the vascular congestion most frequently causes it in a greater or less degree of tumefaction, producing more or less obliteration of the canal. Pimples are often seen covering the membrane; these are sometimes feAV in number but of large size; in other cases they are very small, resembling millet grains sprin- kled over the walls of the meatus. The lining of the external meatus in some cases strongly resembles inflamed mucous mem- brane, the secretion covering it being similar in appearance to that furnished by inflamed mucous membrane in other parts of the body; hence the secretion presents different appearances, according to the intensity and character of the inflammation. These appearances, as stated by Kramer, vary according to the tissues principally affected, if the glandular structure of the in- vesting integument of the external meatus be inflamed, the dis- charge is of a catarrhal nature; if it be the cellular tissue of this passage, the fluid is of a phlegmonous purulent character. Not 538 otitis, (Anatomical Characters.) unfrequently the inflammation in the lining membrane gives rise to unequal SAvelling of its structure, giving the appearance of excrescences of polypi; these are either soft, spongy, or of a bright red color, vesicular, bleeding on every touch, sensitive, covered with a copious mucous secretion, pedunculated or globular; in other cases, they have a broad basis, almost as hard as cartilage, or even as bone; insensible, bleeding little or not at all, and rather of a pale red color. (Kramer.) Occasionally, but more rarely, true abscesses form in the external meatus, sometimes giving issue to pure pus, or to a degenerated sanious discharge. In the latter case, inflammation of the periosteum has taken place, folloAved by caries in the neighboring bone, as pointed out by Kramer; sometimes a membranous or albuminous exudation forms on the surface of the canal, similar to that observed in the mouth, and Avhich has been described by the French under the name of muguet. Occasionally the thickening of the membrane is so great as entirely to obstruct the canal; the obstruction has also been occasioned by a species of septum originating in elongation or diseased growth of the cutis, as in a case of Maunoir's quoted by Saunders; on the laceration of which, hearing returned. Ob- struction of the canal is also very likely to folloAV the contraction of the ulcer after exfoliation of bone. The membrana tympani has been found Avholly destroyed or more or less perforated and injured; it is not unfrequently opaque and thickened; sometimes as hard as cartilage. Saunders had a preparation in which half this membrane had been destroyed as far as the manubrium of the malleus, around Avhich the cutis of the meatus had grown and joined the lining of the tympanum. (On the Ear, p. 69.) The lining membrane of the Eustachian tube undergoes similar alter- ations, producing stricture or obliteration; its calibre may also be lessened or obstructed, from being involved, or pressed upon, by different SAvellings or tumors in its neighborhood. The cartilages may also be affected, even in the acute form of the disease. Andral has found the cartilage of the external mea- tus softened and perforated in individuals Avho have labored under otitis only fifteen days. Sometimes the perforation of the carti- lage is produced from Avithout imvards, by an abscess formed between the mastoid process, the angle of the jaw, and hollow of the ear. It has also folloAved suppuration in one of the parotids, the pus, first formed in the granular structure of the gland, finding its Avay into the external meatus by a fistula of its cartilaginous walls. Lesion of the osseous structure is one of the most serious results of the disease. The tympanal bones are generally those Avhich are first affected, and they either escape through the perforated membrana tympani, the articulations and membranes which con- nect them together being destroyed, or, as rarely occurs, they become anchylosed. In'the former case, of the four tympanal otitis, (Anatomical Characters.) 539 bones, the two outermost, the malleus and the incus, or these with the orbicularis only, may be detached and expelled, while the stapes is left behind; or it may happen that the suppuration has affected the base of the stapes and the membrane connecting it to the fenestra ovalis. The vestibule is thus exposed, and the water it contains escapes. (Ed. Med. and Surg. Journ.,vol. xix, p. 92, 93.) The other osseous textures connected Avith the organs of hearing are the different portions of the temporal bone. The hollo av parts of the bone are lined by a thin membrane, which is continuous, and thus inflammation in one part of it is liable to extend to the others: hence caries of the osseous structure follows certain directions, which bear a relation to the different canals that perforate it. The communication of the mastoid cells with the cavity of the tympanum is much more direct than with the labyrinth; and its soft structure, and the extent of the membrane which traverses it, render this portion of the bone especially liable to disease. It is occasioned by the destruction of the thin periosteum, the denudation of the bone, folloAved by suppuration of its cellular tissue, while the matter is discharged in the various ways previously described. After having destroyed the mastoid cells, the caries often extends to the petrous portion of the bone, most frequently that part Avhich contains the semicircular canals. The superior semicircular canal is separated from the cavity of the cranium by a very thin but compact plate of bone; hence the reason of the communication of the caries with the membranes of the brain being almost ahvays at the superior and anterior surface of the bone, as remarked by Itard and Lallemand. The morbid alterations found in the brain and its membranes are analogous to those described under Inflammation oe the Brain. The dura mater only may be diseased; in Avhich case a portion, for the most part corresponding to a carious spot in the bone below it, is inflamed and thickened, or spongy, disorganised, or ulcerated, and in most cases detached from the bone. Occa- sionally, on lifting it from the petrous portion of the temporal, black spots are found on its external surface, which cover similar discolorations in the bone. This degeneration, and the other morbid changes just noticed, may be confined to the dura mater, or may have extended to the arachnoid, and involved, to a greater or less extent, the latter membrane. Pus is frequently found ex- travasated between the dura mater and bone, or between the former and the arachnoid membrane; sometimes there is effusion of false membrane in the latter situation: both these products have been occasionally found to extend more or less over the surface of the brain or cerebellum, or along the tentorium. Some- times the alterations in the membranes are connected Avith soften- ing or with an abscess in the brain, the latter not unfrequently encysted, and communicating Avith the cavities in the internal ear. Such alterations may or may not be more or less connected with 540 otitis, (Diagnosis.) injection of the cerebral substance, effusion of fluid into the ven- tricles or arachnoid cavity, and other signs of acute inflammation. Morgagni, Itard, Abercrombie, Lallemand, Brodie, O'Brien, Pil- cher, and others, relate several cases Avhere the cerebrum or cere- bellum has been the seat of large abscesses, in some of which the matter was of a green color and fetid odor. Diagnosis. An accurate diagnosis of the various forms of otitis can only be arrived at by a careful inspection of the organ. The examination of the external ear is readily accomplished in its normal state, by inclining the patient's head to the opposite side, directing the ear to the sun or a strong light, and converting the curved passage of the meatus into a straight one, by drawing the auricle upwards and outAvards, whilst the tragus is pressed outAvards. When, howe\rer, the external ear is the seat of morbid changes, it will be necessary for this purpose to use a speculum, such as is recommended by Kramer, by Avhich, with the aid of sun-light, or that reflected from a mirror, the membrana tympani and meatus may be minutely examined. The examination of the internal ear, with a view to diagnosis, was practised by Sabatier, Wathen, Douglas, Saissy, Itard, and others, by means of metallic tubes introduced into the guttural orifice of the Eustachian tube, and injections of tepid Avater; the sensations thus produced formed the basis of diagnosis in several cases. Of late years, the mode of exploring the internal ear has been much improved by introducing air instead of Avater, the idea of which first originated with Cleland, and has since been exten- sively practised by Deleau and Kramer. The latter authors, especially Deleau, have by these means applied with great success and ingenuity the principles of auscultation to the investigation of diseases of the internal ear. For the purpose of operating, Deleau recommends that an elastic catheter be introduced into the Eusta- chian tube, although Kramer considers that the usual inflexible metallic instrument in general use answers every purpose. The following are the directions for proceeding with the investigation given by Kramer, air having been previously compressed in an appropriate apparatus. " After the catheter has been introduced into the Eustachian tube, and fixed by means of the frontlet, the patient is placed close to a table, on which he leans the elboAV next to it, and in this position he holds with the hand of that side the pipe of the air-press previously filled Avith compressed air. The operator then introduces the metal beak of the pipe into the funnel-shaped dilatation of the catheter; applies his ear close to that which is under examination; opens the cock of the machine; and listens to the sound made by the air rushing into the middle ear: when the Eustachian tube and cavity of the tympanum are perfectly free and open, the air Aoavs in strokes without interrup- tion, and Avith an audible shock against the membrana tympani. When the first shock of so strong a stream of air is over, or if it otitis, (Diagnosis.) 541 be not very violent, we hear, during the continuance of the streaming in of the air, a blowing and rustling in the ear of the patient, which appears to issue out of the auditory passage, and to fill his ear in its Avhole extent." The variations from this sound are morbid, and furnish indications, more or less distinct, of diseased changes in the organ, although, in order to judge of these correctly, it is necessary to pay attention to the force with which the air enters, and be somewhat skilful in the manipulation of the necessary instruments. Deleau has denominated these sounds bruit de pluie, bruit de pavilion, bruit de la caisse, fyc, to dis- tinguish which great experience is required. For a more parti- cular account of them, however, we must refer to his Avork (Mim. sur le Catheterisme de la Trompe d'Eustache.) If the air douche does not penetrate into the cavity of the tympanum, it will be necessary to explore the Eustachian tube by means of catgut bougies. It is proper to state, however, that such modes of inves- tigating diseases of an organ of such delicate and minute structure can be with safety undertaken by those only who are intimately acquainted Avith minute anatomy. The different forms and varieties of otitis may for the most part be readily diagnosed by uniting the above means of investigation with a study of the symptoms presented by each. External is recognised from internal acute otitis—1. by ocular examination of the external meatus; when, in the former, the appearances previously described will be observed, Avhile in the latter there is nothing abnormal; 2. by the discharge in the former occurring from three to thirty-six hours after the commencement of the symptoms, and increasing gradually, while in the latter, it seldom appears before the sixth day, and then takes place suddenly from the external auditory canal, or either suddenly or gradually into the throat. When describing external otitis, we gave the diagnostic signs Avhich, according to Kramer, distinguish the different kinds of in- flammation from each other. Primary inflammation of the mem- brana tympani may be distinguished in the acute stage by the red, swollen, and opaque appearance it presents; and at a later period by its being thickened, perforated, and giving rise to a purulent discharge, or being more or less covered Avith fungous excrescences. It may be knoAvn from internal otitis by the above appearances at the commencement of the disease, and the milder nature of the symptoms. Kramer is of opinion that this primary inflammation of the membrana tympani constitutes the disorder generally termed ear-ach, and has been mistaken for pure nervous otalgia. Mr. Pilcher also points out the importance of distinguish- ing inflammation of this membrane, as the introduction of opium and other narcotics, Avhich will benefit pure neuralgia, will here increase the excitement (p. 178), it is only to be detected by ex- amination. The blennorrhoeal inflammation of the internal ear 46 542 otitis, (Diagnosis.) is to be distinguished from the other varieties of otitis by dullness of hearing, Avithout pain or any discharge from the external meatus, and the presence of a gurgling mucous noise (bruit muceux) on the introduction of the air-douche into the cavity of the tympanum. Inflammation of the lining membrane of the Eustachian tube may be suspected from the occurrence of deafness to a greater or less extent, Avith irritations in the throat, Avithout pain in the ear unless it be complicated Avith some of the other varieties of the disease. It can only be positively diagnosed by using the catheter, which will also determine the amount of con- striction or obliteration in the tube. In the chronic form of the disease, it is important to determine whether the membranes alone are affected, or Avhether the bones are also involved. In the former case, the matter is of a yellow- ish purulent appearance, more or less abundant, and of greater or less consistence; in the latter it is ahvays thin, grayish, or of a dirty color, more or less sanguinolent, staining a silver probe, and exhaling a peculiar odor, generally denominated carious. It is also sometimes mixed Avith small bony fragments, the irre- gular form, and rough surfaces of which, render them easily dis- tinguishable from the small bones of the ear. In some cases, examination of the external canal will enable the practitioner to see the denuded bone. It is of great importance, Avith a view to prognosis, to deter- mine Avhether the stapes is present or absent, which can only be done Avith certainty Avhen the membrana tympani is absent. This is not easy, " on account of the obliquity of the cavity, and of the little bone presenting only its small head, being deeply seated, and throAvn into shade by the projecting promontory. A little glistening spot may, however, generally be recognised above the anterior part of the promontory, which is the head of the ossiculum, Avhereas, were it absent, a dark spot Avould occupy that point." (Pilcher, p. 273.) Caries of the mastoid process may be suspected when, in con- junction Avith the peculiar discharge, there is a fixed dull pain in that portion of the temporal bone, increased on pressure. When a fistula exists, examination with a probe will remove all doubt. It is important to distinguish the congestive symptomatic ce- phalalgia, occurring in the course of otitis supervening on the suppression of the discharge, from the headach and cerebral symptoms symptomatic of inflammation of the brain or its mem- branes, either primary or consecutive. This is only to be effected by inquiring carefully into the history of the case. In the former, there is deep-seated throbbing pain in the middle of one side of the head, Avith great tenderness of the scalp; in the latter, there is a sense of constriction, Avithout tenderness of the scalp, Avhile the fever, delirium, injection of the face and conjunctiva, are more intense than in the former, and the increase of the symptoms at otitis, (Prognosis.) 543 night, and exacerbations are not so well marked. It must be ' remembered, also, that inflammation is more liable to occur in conjunction with caries of the bone, than when otitis is limited to the membranes. On the Avhole, hoAvever, it must be confessed that the diagnosis is by no means easy at the commencement, although at a later period, should there be convulsions, paraly- sis, rigidity, or coma, it will be comparatively less difficult. The symptomatic headach from otitis may be distinguished from the other varieties of cephalalgia by the severe pains in the ear, and the violent noises which are heard in the affected organ; symptoms Avhich are increased on mastication and sudden noises. The fever, restlessness, and delirium, if present, are always in- creased at night. Irritation in the throat, and swelling of the tonsils, combined Avith the above signs, will throw further light upon the diagnosis. In all cases, the ear and throat should be carefully examined, as otherwise, from the ignorance of the patient and his friends of the connection between the head affec- tion and local disease, the latter may be entirely overlooked, and a line of treatment adopted which will increase rather than diminish the affection. Prognosis. All discharges from the ear, more especially if chronic, should be looked upon in a very serious light, inasmuch as they not only tend to destroy the sense of hearing, but are lia- ble to induce structural alterations in the brain and its mem- branes. The opinion we may form of the disease, therefore, will have reference to two points; first, the influence it may produce on the sense of hearing; secondly, the greater or less amount of danger, as regards the life of the patient. The prognosis, as to the curability or alleviation of the deaf- ness, Avhich may exist to a greater or less extent, Avill be derived from the history of the case, examination of the organ, and the symptoms Avhich indicate in a negative manner that the disease has not extend-d to the tympano-vestibular membrane and the labyrinth. Examination of the external ear, by the means pre- viously detailed, will determine whether the deafness depends upon some mechanical obstruction in the auditory passages, or upon the destruction of those parts essentially concerned in the function of hearing. In the first'case, the prognosis will be favo- rable, if the obstruction be caused by the accumulation of pus, wax, crusts, &c, or growths which are susceptible of being removed or perforated; and unfavorable, when incurable stric- tures, or callous cartilaginous growths have permanently dimi- nished or obstructed the calibre of the external meatus or Eusta- chian tube. In the second case, the practitioner must endeavor to ascertain whether any or all of the tympanal bones have been discharged. If the stapes still adheres to the membrane of the fenestra ovalis, hearing may be only impaired, from a defi- ciency in the conducting apparatus, and sonorous vibrations may 544 otitis, (Treatment.) still be conveyed distinctly to the labyrinth, by the solid parts of the head. If the stapes, hoAvever, have come aAvay, it is proba- ble that the vestibule is laid open, the sac eroded, and the Avater it contains in a healthy state has escaped. This is attended Avith irreparable deafness in the organ, as the nervous apparatus necessary to receive the impressions of sounds, and conveying the influence they produce to the brain, will then be so injured as to have lost its function. In the former case, the ticking of a watch is distinctly heard Avhen placed between the teeth, and there is every reason to assure the patient that much may be done to improve his condition by a judicious treatment. When the labyrinth, and consequently the sentient part of the organ, has been destroyed, it is better to inform the patient at once that the deafness is incurable, than to make vain attempts to ameliorate his situation. Treatment of Acute External Otitis. The local means neces- sary in this variety of the disease are for the most part such only as are capable of removing irritation from the external canal; as the application of poultices and the injection of tepid and emollient fluids. For this purpose, Kramer recommended a syringe three inches long, which contains an ounce and a half of Avater, and is furnished, anteriorly, Avith a pipe three quarters of an inch long, having an opening wide enough to give passage to a strong stream of Avater. The introduction of other substance into the meatus, as camphor Avrapped up in cotton, recommended by Itard, or narcotic tinctures and preparations, as advised by some other authors, are more injurious than beneficial. Should the external meatus feel hot and burning, Avith swelling of its lining membrane, Avarm fomentations should be assiduously applied to the ear and side of the head affected, and at the same time a number of leeches behind the auricle. This treatment should be combined Avith the administration of purgatives, antimonials, pediluvia, and antiphlogistic remedies, which should be em- ployed Avith greater or less activity, according to the severity of the symptoms. Derivatives may also be applied to the nape of the neck or behind the ear. With this vieAV, Kramer much pre- fers the tartar-emetic ointment rubbed on the mastoid process to blisters, which he thinks are only useful in circumscribed inflam- mations of the meatus or membrana tympani. If there is much redness in the auditory passage, without vesicles, or if the mem- brana tympani be the chief seat of the inflammation, Kramer recommends injections containing the acetate of lead; and for this purpose uses a solution varying from one to ten grains of the salt to an ounce of Avater, Avhich should be used two or three times a day. If there be great SAvelling, and redness of the ex- ternal meatus, with fever (phlegmonous inflammation) of Kra- mer), endeavors must be made by general or local bleeding, and other suitable antiphlogistic remedies, with a rigorous die , to otitis, (Treatment.) 545 induce resolution. Should these not succeed, hoAvever, and an abscess form, its suppuration must be favored as much as possi- ble by warm emollient poultices, applied night and day, until the tumor bursts, and they should be persisted in, combined Avith Avarm fomentations and injections, if the pain continue. If the discharge at a subsequent period become offensive or fetid, a feAV drops of pyrolignous acid or of chloride of lime to an ounce of water is to be employed as a lotion. As soon as the first acute symptoms have subsided, the atten- tion of the practitioner should be directed to the removal of the cause of the disease. If it depend on the extension of porrigi- nous, herpetic, or exanthematous affections, the remedies applica- ble to the cure of the original diseases should be employed and perseveringly continued, in conjunction with the local means above described. Fungous growths should be removed, if pos- sible, torn Avholly from their attachments, and the bases touched with caustic, care being taken, hoAvever, that this does not occa- sion too much irritation. When the excrescences in the ear are hard, with a broad base, Kramer has found incisions and caute- ries useless, and considers them incurable. When insects enter the canal, a little fresh olive oil is to be dropped in, for the pur- pose of killing them, after Avhich they may be easily Avashed out, or removed by the forceps. When foreign bodies have got into the ear, they must be removed by appropriate surgical means, care having been first taken to subdue the inflammation, if it have proceeded so far as to render the canal too sensitive to bear the contact, of any instrument. As the disease becomes more chronic, and all fever and local pain disappear^ slight astringent injections maybe used, and their strength cautiously increased, in the manner to be described in the treatment of chronic otitis. In all cases, hoAvever, these should be immediately suppressed if they induce the slightest irritation, or threaten a return of the disorder. Our chief reliance must at this period be placed on improving the general functions, especially those of the stomach and bowels, change of air, and such means as promote the healthy action of the different organs in the economy. 2. Treatment of Acute Internal Otitis. The acute internal otitis requires more active treatment than the external form; general depletion should be employed to a greater extent, so as to make a marked impression on the system. It will be generally necessary to employ afterAvards cupping or the repeated applica- tion of leeches behind the ear, should the local pain continue. At the same time, an active purgative should be administered, and after its operation, antimonials every three or four hours, so as to keep up a state of nausea, and prevent a return of the general excitement. These remedies, if employed at an early period, Avill eenerally afford considerable abatement of the symptoms. 46* 546 otitis, (Treatment.) Indeed, a large general bleeding alone has been often known to cut short the disease. On the second or third day after this treat- ment has been pursued, should the acute symptoms be evidently diminished, a blister may be applied behind the ear or at the nape of the neck. But should these means from having been employed too late, or from other causes, not induce resolution of the acute symptoms at the end of four or five days, and the suffer- ings of the patient be undiminished; if there be throbbing pain, with a bursting sensation in the ear, general headach and delirium, we may infer that suppuration has taken place. Under such cir- cumstances, ulceration will for the most part take place sponta- neously in the membrana tympani, and the discharge of matter will in most cases be immediately folloAved by considerable relief. * Should this not occur, hoAvever, before the sixth or seventh day, it is desirable that the membrana tympani, should be punctured, as the long confinement of matter in the cavity, mixed more or less with air, may, from its being insinuated into the mastoid cells, give rise to caries, or at all events induce a spontaneous lacera- tion of the membrana tympani, that may be highly injurious. The evacuation of the matter, whether spontaneous or artificial, should be immediately folloAved by the injection of tepid fluids, in order to favor its discharge. The practitioner should then be careful in preventing any obstruction to its free exit by the use of tepid and emollient injections tAvo or three times a day. The patient, also, should be directed to sleep on the affected side of the head, in order that the matter may not accumulate in the cavity of the ex- ternal or internal ear. In ail cases, the throat should be exam- ined, and if there is swelling or irritation in the tonsils or posterior fauces, gargles, containing the suborate of soda, the nitrate of potass, or the hydrochlorate of ammonia should be used; or such as are more astringent, formed of the decoction and tincture of bark, muriatic acid, &c. These gargles should be employed in such a manner as to strike with violence the affected part, in order to remove, as much as possible, any concreted matter Avhich may adhere to the throat, and obstruct the extremity of the Eusta- chian tube. Itard recommends that the vapor of warm water should be inspired and expired with force, while the mouth and nostrils are shut. It is rare, however, that by such means ob- struction is overcome; recourse must therefore be had to aqueous injections, as advised by Saissy, Itard, and others. The air- douche is preferred and practised by Deleau and Kramer. Should these not succeed, catheterism, performed by a skilful operator, may be attempted; and if the tube be found completely closed from disease, further efforts will tend rather to increase than diminish the evil. It will be proper, also, that such general measures as are calculated to assist in removing the disease be at the same time adopted. Itard speaks favorably of sternuta- tories, but their utility is very questionable, and if the patient is otitis, (Treatment.) 547 liable to headachs, they are dangerous. As the affection becomes chronic, the remedies, to be advised under that form of the disease are to be employed. With a vieAV of relieving the blennorrhceal form of internal otitis, recourse must be had to the air-douche. If a small mucous rale is heard on applying the ear to that of the patient, during the streaming in of the air, followed by a material improvement in the power of hearing, which is readily ascertained by the watch, it should be used daily; and if the mucous rale changes to a gurgr ling sound, and the patient's hearing becomes more distinct after each sitting, there is every hope of curing the disease. Should no sound be heard, however, or no improvement in the sense of hearing take place after the fourth sitting, Kramer lays it down as a rule that the attempt should not be persisted in. Injection of fluids, as Avarm water, or a saline solution, has also been em- ployed, but those in general are not so beneficial as the air- douche. In this variety of the disease, also, catheterism of the Eustachian tube may be often necessary. 3. Treatment of Chronic Otitis. The difficulty of curing chronic otitis will be in proportion to the length of time it has been established, and the amount of destruction produced in the membranous or osseous structures of the organs of hearing. Be- fore commencing the treatment, the practitioner should pay con- siderable attention in all cases to the appearance of the discharge, and examine with care the external auditory canal, the parts sur- rounding the concha, the region of the mastoid process, and the interior of the mouth, soft palate, and amygdalae. In all endea- vors, moreover, to cure or alleviate the disease, it should never be forgotten that, when the malady has existed some time, the system becomes habituated to the discharge, and that, in propor- tion as the disease assumes a more chronic character, the greater is the danger from hastily suppressing it. In cases of long stand- ing, the utmost caution is necessary to avoid the serious com- plaints that are apt to follow when the discharge suddenly lessens or disappears. The general treatment is of great consequence, and should be steadily continued, in order to place the system generally in such a state as to favor the action of local remedies. If the affection have been induced or be kept up by chronic eruptions in the neigh- borhood of the ear, the use of warm or medicated baths, change of air, the internal exhibition of sulphur, mercurials, antimonials, sarsaparilla, and other alteratives should be employed. When the disease is connected with a syphilitic taint, the line of treat- ment necessary for treating the original affection should be adopted. When it is connected with scrofula, the preparations of iodine, such as the ioduret of iron, or the proto-ioduret of mer- cury, may be used alone, or in combination Avith the infusion or decoction of cinchona, or preparations containing quinine, tartar- 548 otitis, (Treatment.) ised iron, and other tonics. In some cases, it is of importance, by a nutritious diet, combined Avith exercise, judiciously regula- ted, to prevent the quantity of the discharge from producing a depressing effect on the system, while precautions should be taken to prevent the head, ears, or feet, from being exposed to cold, or changes of temperature. At the same time, vinous and spiritu- ous liquors should be abstained from, and all stimulating articles of diet that may prove a source of irritation to the digestive organs carefully avoided. The local treatment should be at first confined merely to the introduction of tepid Avater injections, until the practitioner, after a use of the remedies above mentioned, is assured of the general good state of the patient's health. This treatment should be per- sisted in for some time, at least four or five months in cases of old standing; although, when the disease is comparatively recent, the-treatment by injections, to be noticed immediately, may be at once adopted. If there is a spongy condition of the external meatus, tents of lint, dipped in a solution of the acetate of lead, may be introduced into the passage, as recommended by Kramer, the pressure of which is useful in producing a disappearance of the excrescences. Should the discharge at any time become con- siderably diminished, or cease suddenly, every effort should be made to induce its return, especially should it be followed by cerebral or other serious symptoms. For this purpose, Avarm fomentations to the ear, and hot poultices, should be applied. Itard recommends the application of a loaf Avhich has just left the oven, the crust on the side Avhich is applied to the ear having been previously cut off. These means will in the majority of instances succeed. If, after the adoption of general treatment for some months, with the use of emollient injections once or twice a day, the discharge remains stationary, and especially if it have gradually diminished Avithout any previous acute symptoms, the practitioner may proceed to lessen the discharge, and cure the chronic morbid action by resorting to a more active local treatment. Itard recommends that this should be accomplished with great caution, a maxim that in our opinion it is of the greatest conse- quence to attend to, as an attempt to hurry the cure, and induce a too sudden diminution of the discharge, may not only induce metastasis, but delay the recovery, and render it again necessary to go through a preparatory treatment. In several cases which have come under our observation, where this advice was not suf- ficiently attended to, Ave have seen acute symptoms come on, which in some were followed by caries, and the Avorst effects of the disease. We have observed also, that not a feAV patients laboring under otorrhoea have attributed their most serious com- plaints to the application of a blister or seton. On the other hand, when the medical attendant considers that attempts to check the discharge, and diminish the morbid action producing it, may be otitis, (Treatment.) 549 tried without danger, he should exchange the tepid and emollient injections for those which are astringent in the mildest degree, and such as are more and more powerful should be successively and cautiously used. A weak and tepid infusion of chamomile flowers or rose leaves should be employed to commence with, and continued several weeks, and the strength of these may then be gradually increased, rather than have recourse to stronger astringents. After a time such injections may be used cold, and subsequently a weak solution of the sulphate of zinc, or acetate of lead, may be employed, and its strength increased by degrees. Solutions of alum and nitrate of silver may also be employed. Months, however, should be occupied in this treatment, and the greatest care taken not to hurry on the cure, either from impa- tience on the part of the patient, or want of resolution on that of the practitioner. Whenever the discharge diminishes too ab- ruptly, the astringent injections should be for a time suspended; and should it cease suddenly, care must be taken to solicit its return by the methods previously mentioned, more especially if there should be the slightest threatening of acute symptoms. When this has been difficult, Itard has succeeded in one case by the use of the warm bath for three hours, and in another by ap- plying a large cupping glass, so as to embrace all the concha and external ear. If, at the end of five or six months, the discharge has nearly ceased, and the patient suffers from no unpleasant symptoms, a small blister behind the ear or at the nape of the neck may be employed, and in a feAV days replaced by a larger one. At this period of the treatment we have found derivatives useful in completing the cure. Injections may be introduced not only through the external meatus, but through the Eustachian tube. When the practitioner, however, has not been accus- tomed to this mode of operating, he had better inject by the former opening, as otherAvise he is very likely to bring on acute symptoms. If by the means noAV recommended the discharge should after a time permanently cease, a little cotton should be Avorn in the ear for a short time, in order that the parts may recover their tone. This must be Avorn continually if total deafness be the re- sult of the disease; but if this be only partial, and the membrana tympani is not wholly destroyed, recourse may be had to such mechanical contrivances as are best suited to assist audition. If on the other hand the disease proves inveterate, and no benefit is derived from astringent injections, combined Avith appropriate general treatment, the efforts of the practitioner must be directed to keeping the parts clean, and favoring the discharge by emol- lient and simple injections. By attention on the part of the patient, although the disease cannot be cured, its destructive pro- gress and termination in caries may be prevented. Dr. Burne alludes to the case of a woman seventy years of age, Avho 550 otitis, (TreatmeJit.) had been affected with otorrhoea from both ears, and deafness, since she had the scarlet fever in childhood, and Avho by the daily injection of Avarm Avater had preserved the organs from further disorganiation. (Cyc. Pract. Med.) We have laid great stress on the necessity, in chronic otitis, of acting cautiously and sloAvly, especially Avhen it extends to the tympanum, being convinced that many of the inveterate cases met with in practice result from the ill-directed and hasty efforts made to effect a speedy cure of the disease by the injudicious use of too astringent injections, and the early employment of blisters, setons, &c. In otitis with caries the same general treatment is to be fol- lowed as has been described, more particular attention being given to support the strength by tonics, antiseptics, and a nutri- tious diet. Should the discharge issue from the external meatus the same tepid and emollient injections should be frequently used, and every thing that obstructs the escape of matter carefully re- moved. If the matter is fetid, or of a disagreeable odor, a few drops of pyrolignous acid or chloride of lime, in an ounce of water, used as an injection, will correct it. A probe should be cautiously introduced, and if loose pieces of bone are felt slightly attached, their separation should be favored as much as possible by slight pressure with the instrument, or if they can be reached Avith the forceps, extracted Avithout force. When caries affects the external meatus, and the diseased bone exfoliates, the healing of the ulcer is very liable to be 'followed by obliteration of the passage. Kramer recommends that Avhen the parts shoAV a ten- dency to close, touching the edges Avith lunar caustic is the best means of keeping them open. If the parts are already closed, they should be opened by incision, and the caustic employed to prevent re-adhesion. Hearing, however, usually remains more or less dull, partly because the natural form of the meatus is lost, and partly because the membrana tympani has participated in the inflammation. If a dull fixed pain have existed some time in the mastoid process, and the skin covering it become SAVollen and discolored, Ave should not Avait and alloAv an abscess to form, Avhereby much time is lost, and the caries rendered more exten- sive, but cut down on the bone at once, enlarge any small open- ing that may exist in it, so as to permit the free escape of matter, and inject directly tepid Avater into the cells of the mastoid pro- cess. An opening even may be made in the bone, by a proper instrument, if the operator is convinced of the presence of matter in the mastoid cells. When, hoAvever, the matter points in the neck above the clavicle, the abscess should not be opened, as by so doing a troublesome fistula Avould be produced, and there Avould be no means of acting directly on the diseased part. In these cases Ave should use as early as possible such means as are most likely to cause absorption in the abscess, and by the methods otitis, (Treatment.) 551 previously detailed endeavor to promote a free discharge from the external meatus. The caries of the petrous portion of the bone can only be treated by emollient injections, until the dis- eased portion of the bone separates. To promote this, an appro- priate general treatment is of great importance, in addition to Avhich Itard directs frictions on the scalp, the head to be shaved and covered constantly Avith a gummed silk cap. Subsequently astringent injections may be employed as formerly noticed: some authors have recommended irritating and even caustic injections into the external meatus, to favor the separation of the carious bone, but Kramer, with Avhose experience our own coincides, states that they should be avoided. When there is any evidence that the disease has extended to the cavity of the cranium, absolute rest is necessary, and none but the mildest injections should be employed to favor the flow of matter from the ear. If the patient be of good strength, and the symptoms of cerebral inflammation be Avell pronounced, active bloodletting and antiphlogistics are indicated. Purgatives are especially useful in this case, both as a means of removing irritation from the alimentary canal, and from their acting as a derivative. We have already alluded to the difficulty of distin- guishing such cases, and they are often very embarrassing to the practitioner. If, as is very likely to happen, he is called in to treat the cerebral symptoms, he may overlook the local disease, and use depleting measures to an extent, that may afterwards, when the discharge returns, or becomes established, prove dan- gerous from having too much exhausted the poAvers of the patient. Dr. Burne states that he was once called in to a case that had been viewed and treated as idiopathic phrenitis, when he dis- covered a large abscess presenting behind the ear; it was opened and discharged a quantity of most offensive pus. The patient Avas relieved, but she sunk from the copious bloodlettings that had been practised. (Cyclop, of Pract. Med.) More generally hoAvever this unfortunate termination of the disease supervenes on a long-standing otitis Avith caries, Avhen the patient is more or less enfeebled by the continued discharge, or by the local irrita- tion having for a length of time acted on a constitution originally scrofulous or delicate. Under such circumstances the cerebral disease fhust be combated by derivatives, such as blisters or the tartar-emetic ointment applied to the scalp or nape of the neck, Avhile the excretions are to be properly regulated, and tonics, a nutritious diet, and such means employed as may support the sinking poAvers of the patient. ..^2615® r * xJt -s '^ t x/^ x *v=- w jo Aivian ivnoiivn 'xisifliw jo Aivaan ivnoiivn iNOioiw jo Aivian ivnoiivn jni: a\ i *^/ i V^1 My i \>\ i Hy \ s Al LIBRARY OF MEDICINE NATIONAL IIBRARY OF MEDICINE NATIONAL IIBRARY OF MEDICINE NAT * Cri W y"\. » XV T» r- Aivaan ivnoiivn inoiojw jo Aivian ivnoiivn inoioiw jo Aivian ivnoiivn Jnioiojw : iSFv n ? y i^fj ~. asrL ? o * mu - a*i?» n ? y j ^/ ; Aivian ivnoiivn 2 n i d i a 3 w jo ai v aa n i v no i 1 v n jn i 3 io 3 w jo ai v 1a n t vn o u v n inoiqiw !VN i RARY OF MEDI CINE N A T I O N A I L I B R A R Y O F M E D I C I N E N A T I O N A I L I B R A R Y 0 F M E D I C I N E NATIONAL NATIONAL LIBRARY OF MEDICINE NLM D3E7flQfi5 h NLM032780856