74 NLM 0055=11370 M ^ * * V"- . ! t?:'•*■•;■' ■ m NATIONAL LIBRARY OF MEDICINE Washington,D.C. 38 •~r & PI NLM005596704 DISEASES OF THE NERVOUS SYSTEM: BEING A TREATISE ON SPASMODIC, PARALYTIC, NEURALGIC AND MENTAL AFFECTIONS. For the use of Students and Practitioners of Medicine. BY ., CHARLES PORTER HART, M.D., HONORARY MEMBER OF THE COLLEGE OF PHYSICIANS AND Sl'RGEONS OF MICHIGAN ; AUTHOR OF "REPERTORY TO THE NEW REMEDIES," " HOMOEOPATHIC OPHTHALMIC PRACTICE," " DISEASES OF THE BRAIN," ETC. ; ASSISTANT EDITOR OF THE AMERICAN HOMOEOPATHIC OBSERVER; FORMERLY SI7RGEON-IN-CHARGE OF THE SURGICAL WARDS, CHIEF SURGEON TO THE EYE DEPARTMENT, AND PRESIDENT OF THE BOARD OF MEDICAL EXAMINERS OF BROWN , '"" "J GENERAL HOSPITAL, U. S. A., '.. ETC., ETC., ETC. x\ '/; WITH AMPLE CLINICAL ILLUSTRATIONS. BOERICKE & TAFEL, NEW YORK : PHILADELPHIA : 145 Grand Street. 1011 Arch Street. TPUBNER & CO., Lcdgate Hill, London. HOMOEOPATHIC PUBLISHING CO., No. 2 Finsbury Circus, London. 1881. H325J Copyright, 1881, by BOERICKE <5^ TAFEL. PREFACE. The chief functions of the cerebro-spinal nervous system are motion, sensation and mental action. The consideration of these functions constitutes the subject-matter of the present volume. Many of the diseases we have described are now known to depend upon organic changes in the nerve centres, and therefore, so far as their pathology is concerned, can no longer be regarded as purely functional; but the pathology of a disease and the disease itself, are two very different things, although, singularly enough, they have been, and still are, frequently confounded with each other. If perversion of function is a disease, then all the diseases described in this volume are functional, though some, and perhaps all of them, have an organic basis. The paralysis arising from structural changes in the nerve centres is just as much disease as the structural changes themselves, though the pathology of the former can only be understood by a knowledge of the latter. We have not hesitated, therefore, to include under this title even such disorders as " Progressive Bulbar Paralysis," since the only objection that can be urged against it is purely tech- nical. For if there is any meaning in the term, then all spas- modic, paralytic, neuralgic and mental affections are func- tional, whether organic alterations are associated with them or not. In fact, we might go further, and assert, as many do, that disease is always functional—that there is no such thing IV PREFACE. as disease entity. This is not the place to discuss this subject, but it is certain that the converse of the proposition admits of no question, namely: that functional derangement is always and everywhere, disease; and hence, that our classification of nervous disorders, however much it may conflict with the no- tions of those who hold to a material basis for disease, is not, strictly, any too comprehensive. We do not object, however, to the current view of pathologists on this subject, for, even if it serves no other purpose than that of elucidating the history and development of diseased action, it is not without great benefit to medical science. For this reason, we have endeav- ored to bestow upon this branch of our subject all the care and attention which its importance demands. In order to render the work more practical, the author, availing himself of the large amount of clinical material at his command, has selected for illustration such cases as seem to him to be best adapted for that purpose. Hence, in lieu of the mere synopsis usually given, which is often too meagre to furnish the practitioner with a correct picture of either the disease or its treatment, care has. been taken to give all the more important clinical illustrations in sufficient detail to ob- viate any such objection. It has been well said, that the char- acter of a man may generally be known by the coat he wears; and we think the simile holds good with reference to clinical illustrations of disease. If complete, they bring disease, before the, student and practitioner in the same vivid and practical manner, as does the study of it at the bedside of the patient. And as the sight of an object will be likely to convey a better idea of it than the most labored description, so will a well- worded clinical illustration be apt to make a better and deeper impression upon the mind of the reader. In the preparation of this manual, the author has steadily kept in mind the requirements of both students and practi- PREFACE. V tioners of medicine. He has sought information from every source within his reach, and has spared no pains to bring the work up to the present advanced state of the science. The medical journals of this country and of Europe have not only been freely laid under contribution, but have been diligently searched for such newly-discovered and accurately-recorded facts, as pertain to nervous diseases, in the hope, that, while far from exhausting the class of subjects of which it treats, the work may meet the every-day wants of the profession, and at the same time prove useful as a text-book for students. For the material thus furnished, the author has endeavored to give proper credit in the body of the work. Charles P. Hart. Wyoming, Ohio, March, 1881. CONTENTS. PAGE PREFACE ............. 3 PART I. Physiology of the Cerebro-Spinal Centres, CHAPTER I. General Remarks on Nervous Diseases. Meaning of the term 'functional,' as applied to nervous diseases—Classes so called —Organic and histological changes—Our inability to detect them, no proof of their non-existence—Opinion of C. Hanfield Jones—Atrophy of nerve-tissue —Anstie on neuralgia—A knowledge of nerve-lesions of the highest import- ance in the interpretation of functional phenomena, .... 9 CHAPTER II. Functions of the Cerebral Cortex and Lobes. Hitzig and Fritsch's experiments—Motor and sensorial areas—Petrina's observa- tions upon cerebral tumors—Nothnagel and Ferrier's experiments—Longet's investigations—Loss of power from destruction of nerve-centres not always permanent—Flouren's law of vicarious action—Niemeyer's theory of collateral oedema—Tumors of the convexity—Motory centres in the ape—Hitzig and Stark's observations—Tumors in the anterior lobes—Bernhart's observations —Lateral, vertical and posterior lobes—Scholz's observations—Lesions of the right hemisphere generally more serious than those of the left—True seat of aphasia—Double perceptions—Researches of Eckhard, Lemoigne and Lus- sane,.............11 CHAPTER III. Functions of the Cerebral Ganglia. Longet on the corpora striata—Tremor and chorea produced by minute emboli— Effects of tumors, pressure and faradization—Crossed paralysis, loss of con- sciousness, convulsions, psychical and intellectual disturbances, tremor, chorea vm contents. and amblyopia—Lesions of the thalami optici—Effects similar to those of the striated bodies, but not so marked—Sclerose en plaques—Longet on their re- moval—Effects of faradization, tumors, abscesses and hemorrhage in the optic thalami—Charcot and Veyssiere's researches on these ganglia—Injury of the peclunculus cerebri—Charcot's researches—Crossed paralysis and vaso-motory disturbances—Paralysis of the bladder-Lesions of upper and lower part of the crura cerebri—Ocular disturbances, vertigo and unilateral position of body and bulbi—Lesions of the pituary body—Mental disturbances and diabetes mellitus—Cerebellar disease—Incoordination of muscular movements—Cere- bellar paralysis—Sexual excitement—Ferrier on the function of coordination —Diseases affecting the tnbercula quadrigemina—Crossed effect upon vision — True optic ganglia, but function not limited to vision—Emotional expression —Faradization produces complex movements and peculiar cries—Epileptic moaning—Inhibitory centre of reflex action—Lesions of the pons Varolii— Crossed paralysis and coma—Influence on speech, .... 16 CHAPTER IV. Functions of the Medulla Oblongata and Spinal Coed. Crossed action of fibres—Labio-glosso-laryngeal paralysis—The respiratory centre —Spasm of the glottis—Marshall Hall's theory of reflex action—Dr. Meryon on this theory—Dr. Schuetz on the etiology of infantile convulsions—Seelig- muller's case of paralysis and atrophy—Wernich on the etiology of eclamp- tiform convulsions—Brown-Sequard and Westphal's experiments on guinea pigs—Researches of Billroth and Briond—Hecker's case—Apostoli on ataxia locomotrice and grey degeneration of the posterior columns of the cord— Subsidiary vaso-motor centres in the cord—Schiff on vicarious interchange of functions of the cord—Different centres for the lower sphincters, . . 21 PART II. Derangement of the Motor Function. SECTION I. Spasmodic Disorders. CHAPTER I. Convulsions. Convulsions—Meaning of the word—Tonic and clonic spasm—Limitation of the terms—The two synonymous, ....... 27 X. Infantile Convulsions. How divided—Centric or sympathetic c.—Eccentrio or reflex c.—Secondarv or sympathetic c.—Predisposing causes—Heredity—Nervous susceptibility__ contents. ix General debility—Exciting causes—Cerebro-spinal traumata—Irritation of peripheric nerves - Errors in diet—Dentition—Helminthiasis—Burns, blis- ters, etc.—Genito-urinary irritation—Rectal croup—Diarrhcea—Peculiar causes—Acute exanthemata—Anaemia— Symptoms—Prognosis — Results- Treatment—General t.—Prophylactic t.—Medical t.—Illustrations—Com- pression of the carotids,..........28 2. Convulsions of the New-Born. Very rare in this climate—Great Britain and Ireland—Rice plantations—Causes —Inflammation and ulceration of the umbilicus—Cerebro-spinal hemorrhage —Symptoms—Prognosis and treatment,......46 3. Convulsions of Adults. Two classes, puerperal and non-puerperal—The former connected with the puer- peral state—Other varieties,.........48 (1.) Puerperal Convulsions. During pregnancy—During labor—After labor—Causes—Predisposing c.—Effi- cient c.—Exceptional c.—Symptoms—Prognosis—Treatment—Artificial de- livery—Me Jical treatment—Clinical illustrations, .... 48 (2.) Non-puerperal Convulsions. Ursemic c.—Cholaemic c.—C. from inanition—Hydrsemic c.—Treatment—General t.—Medical t.—Synopsis of t.—Illustrations,......56 CHAPTER II. Epilepsy. Meaning of the term—History—Demoniac possession—General description—Epi- leptic aura—Paroxysm—Grand mal and petit mal—Other varieties—Thal- amic e.—Cortical e.—Vaso-motory e.—Reflex e.—Results—Causes—Predis- posing c.—Exciting c.—Efficient c.—Constitutional c.—Syphilitic epilepsy —Differential diagnosis—Treatment—During the fit—Between the fits— Synopsis of t.—Medical t.—Clinical indications and illustrations, . . 61 CHAPTER III. Hystero-Epilepsy. Hysteria a form of mental derangement—Not to be confounded with the reflex phenomena constituting the fit—Hystero-epilepsy—History of the disease— Meaning of the term—Subjects of the disease—Symptoms—Diagnosis—Com- pression of the ovaries—Temperature—Causes—Pathology—Treatment— Cannabis indica,........... 75 CHAPTER IV. Chorea. Meaning of the term—Chorea magna and minor—C a disease of childhood— Symptoms—Hemichorea—G. paralytica—Post-paralytic c.—Differentiation— X contents. Causes—Cerebral and spinal c—Prognosis—Treatment—Antero-lateral and posterior spinal anaemia—Ice-bags—Electricity—Clinical indications ana il- lustrations, ..........' CHAPTER V. Tetanus. Forms and varieties—Trismus nascentium—Traumatic tetanus—Symptoms—Te- tanic rigidity—Temperature—Sudden death—Influence of age and sex—Of cold—Rheumatic tetanus—Sympathetic t— Blood poisoning—Pathology- Prognosis—Treatment—Sweating process—Illustrative cases, . . 102 CHAPTER VI. Hydrophobia. Definition—History—In dogs and man—Symptoms—Stage of delitescence—Of recrudescence—Of spasm—Etiology—Is h. a disease of the imagination?— Does it ever occur spontaneously in man?—Susceptibility of the human sub- ject to the poison—Pathology—Rabies in the dog, symptoms of—Treatment — Russian steam baths—Liquor ammoniae and cedron as prophylactics — Clinical indications and illustrations—Faradization and galvanism, . 118 CHAPTER VII. Catalepsy. Definition—Symptoms—Suspended animation—Causes—Most frequently met with in hysterical subjects—Pathology—No constant morbid alterations met with —Treatment -Faradization—Clinical indications and illustrative cases, 130 SECTION II. Paralytic Disorders. CHAPTER I. Paralysis in General. Definition of paralysis—Generally a symptom of cerebral or spinal disease— Hemiplegia—Paraplegia—Complete p.—Partial or incomplete p.—Paresis— Akinesia—Anaesthesia—Causes—Heredity,...... 134 CHAPTER II. Hemiplegia. Paralytic stroke—Symptoms—Etiology, pathology, etc.—Corpus striatum hemor- rhage—Softening produced by an embolus or thrombus—Facial palsy__Differ- entiation—Burns—Tobacco—Syphilis—Treatment—Galvanism and faradiza- tion—Clinical indications and illustrations,......J3g CONTEXTS. xi CHAPTER III. Paraplegia. Definition—Most frequent cause, myelitis—Hemi-paraplegia—Paresis—Sensibility and pain—Spinal epilepsy—Paralysis of the bladder—Hyperesthesia and anaesthesia—Bedsores and cystitis—Local gangrene—Impaired nutrition— Cold abscesses—Decubitus and progressive muscular atrophy—Hydrorachis acquisita—Paraplegia epidemica—Pathology, etiology, etc.—Softening and abscess—Sclerosis—Treatment—Convulsions—Faradization, galvanism and baths—Clinical indications and illustrative cases,.....142 CHAPTER IV. Infantile Spinal Paralysis. Essential paralysis of childhood—Pathology—Symptoms—Prognosis—Fatty de- generation — Causes—Treatment—Electricity — Bathing—Clinical indica- tions,.............154 CHAPTER V. Facial Paralysis. A variety of peripheral paralysis—An affection of the portio dura—Symptoms— Parts affected—Diagnosis—Fifth nerve—Third nerve—Prognosis—Pathology —Causes—Treatment—Electricity—Other external measures—Shampooing —Clinical indications and illustrations,.......158 CHAPTER VI. Diphtheritic Paralysis. History—Hippocrates, Aretseus and Bretonneau—Two forms of the disease- Symptoms—Prognosis—Etiology and Pathology—Microphites—Anatomical lesions — Treatment—Electricity — Clinical indications and illustrative cases,.............164 CHAPTER VII. Progressive Bulbar Paralysis. History—Duchenne, Trousseau, Charcot, Kussmaul, Joffroy and Hammond— Symptoms—Diagnosis—Facial paralysis—Ordinary paralysis—General p. of the insane—Progressive muscular p.—Aphasia—Prognosis—Etiology and pathology—Chronic sclerosing myelitis—Treatment—Plumbum, . .168 CHAPTER VIII. General Paralysis of the Insane. Its nature—Symptoms—"Mania de grandeur"—Causes—Pathology—Chronic en- cephalitis—Prognosis—Treatment—Clinical indications and illustrations, 173 Xll CONTENTS. CHAPTER IX. Progressive Muscular Atrophy. Not a m-uscular but a spinal affection—Symptoms—Atrophy of the voluntary muscles—In children, pseudo-hypertrophy—Causes—Heredity—Pathology— Myopathic and neuropathic theories—Prognosis—Treatment—Faradization and galvanism—Remedies, indications and illustrations, . . . 179 CHAPTER X. Progressive Locomotor Ataxy. Reasons for including this disease among paralytic disorders—History—Symp- toms—Duchenne's three stages—Hyperesthesia and anaesthesia—Incoordina- tion—Diagnosis—Causes—Syphilis and tobacco—Pathology —Posterior spinal atrophy and sclerosis—Prognosis—Treatment—Electricity—Lukewarm baths —Remedies, clinical indications and illustrative cases, .... 184 CHAPTER XI. Paralysis Agitans. Symptoms — Tremor—Paralysis — Muscular contractions — Diagnosis — Tremor senilis—T. mercurialis—T. saturninus—T. potatorum—T. simplex—Multiple sclerosis—Etiology, pathology, etc.—Treatment—Faradization and galvanism —Remedies, clinical indications and illustrations,.....195 CHAPTER XII. Scrivener's Palsy. Symptoms—A peculiar form of local spasm—Diagnosis—Etiology, pathology, etc. —Treatment—Galvanism—Massage—Stimulating baths and embrocations— Remedies and indications,.........201 CHAPTER XIII. Aphasia. Meaning of the term—Varieties—History and description—Agraphia—Transitorv form—Connection with right-sided hemiplegia—Etiology, patholo°v etc.__ Treatment—Syphilis—Congestion—Anaemia—Epilepsy—Clinical indications and illustrations,......... 205 CHAPTER XIV. Paralytic Aphonia. Derivation and meaning of the term—Symptoms—Etiology, pathology etc__ Diagnosis—Prognosis—Treatment—Electricity—Massage—Remedies, clini- cal indications and cases,....... 014 CONTENTS. Xlll PART III. Derangement of the Sensory Function. CHAPTER I. Neuralgia. Meaning of the term—Symptoms—Periodical neuralgia—Paresthesia— Sensitive- ness to pressure —Varieties—Causes — Heredity — Diagnosis — Prognosis — Treatment,............219 CHAPTER II. Hemicrania. Synonyms -Symptoms—Megrim—Causes—Influence of sex and heredity—Diag- nosis—Tender points of Valleix—Prognosis—Pathology—Two forms of the affection—Spasm and paralysis of the vessels—Treatment—Clinical indica- tions and illustrations,..........223 CHAPTER III. Neuralgia Trigemini. Synonyms—Varieties—Symptoms—Sensitive points—Causes—Heredity—Diag- nosis—Pathology—Prognosis—Treatment—Remedies, clinical indications and illustrative cases — Local treatment —Electricity —Nerve-stretching — Galvanism—Chloral hydrate,........237 CHAPTER IV Intercostal Neuralgia. Pleurodynia—Symptoms—Tender points—Mastodynia—Etiology, pathology, etc. Herpes zoster—Diagnosis—Mistakes in—Prognosis—Treatment—Galvanism and faradization—Remedies, indications and clinical illustrations, . 249 CHAPTER V. Sciatica. Parts affected—Symptoms—Tender points of Valleix—Glossy skin—Eczema- Atrophy and paralysis —Causes —Pathology —Temperature —Diagnosis- Prognosis—Treatment—Fatty food—Galvanism—Artificial warmth—Elec- tricity—Acupuncture and electro-puncture—Nerve-stretching—Clinical in- dications and illustrative cases,......• • 257 CHAPTER VI. Angina Pectoris. Synonyms—Definitions—Symptoms—Crampoide form—Spinal or syncopal form —Recurrent form—Causes—Pathology—Suppressed neuralgia—Prognosis— XIV CONTENTS. Treatment—Amy 1 nitrite—Skim-milk—Galvanism—Remedies, clinical in- dications and illustrations,.........269 CHAPTER VII. Gastralgia. Neuralgia of the stomach—Symptoms—Secondary phenomena—Pyrosis—Causes —Dyspepsia—Tobacco—Tea and coffee—Diagnosis—Treatment—Fomenta- tions—Galvanism—Remedies, indications and clinical cases, . . 283 CHAPTER VIII. Neuralgia of the Female Genital Organs. Vaginodynia—Symptoms—Hysteralgia—Symptoms—Ovaralgia—Compression of the ovaries—Hysteria—Symptoms—Causes—Prognosis—Treatment—Fara- dization and galvanism—Vaginal douche—Remedies, clinical indications and illustrations,............293 CHAPTER IX. Spinal Irritation. Definition—Symptoms—Their diversity and changeableness—Causes—Mostly confined to adult females—Pathology—Anaemia of the cord—Diagnosis— Differentiation—Prognosis—Treatment—Galvanism—Clinical illustrations and indications,...........301 PART IV. Derangement of the Mental Function. SECTION I. Moral Disorders. CHAPTER I. Hysteria. Definition—Hysterical knee—Nature—Carnomania—Cases illustrating its mental nature—Symptoms—The hysteric fit:—Mental symptoms—Diagnosis__Hys- terical hemoptoe—Causes—Prognosis—Treatment—Remedies, clinical in- dications and illustrations, . . . . . . . t ,311 CHAPTER II. Hypochondriasis. Its nature—Symptoms—Causes—Prognosis—Treatment—Remedies indications and clinical cases,...........324 CONTENTS. XV CHAPTER III. Melancholia. Definition — Symptoms — Varieties—Causes—Heredity — Treatment—Clinical illustrations and indications,.........332 CHAPTER IV. Moral Insanity. Definition, history and symptoms—Etiology, diagnosis, etc.—Pathology—Treat- ment—Illustrative cases,.........339 SECTION II. Intellectual Disorders. CHAPTER I. Mania. Different forms of insanity—Symptoms—Temperature—Puerperal mania—Causes —Heredity—Moral and physical causes—Pathology—Cerebral irritation, excitement and depression—Diagnosis—Hallucination—Want of motive— Absence of volition—Prognosis—Structural changes—Duration, etc.—Treat- ment—Asylums—Home treatment—Private treatment—Medical treatment— Remedies, indications and illustrations, ...... 34N CHAPTER II. Dementia. Definition—Symptoms—Causes—Prognosis—Pathology—Treatment — Remedies, etc.,..............376 CHAPTER III. Cerebral Exhaustion. Brain-work and its effects—Symptoms—Causes—Treatment—Diet—Exercise — Rest—Sleep—Change—Medical Treatment—Clinical indications and illus- trations, .............3X0 CHAPTER IV. Delirium Tremens. Definition—Symptoms—Causes—Anatomical appearances—Pathology—Prognosis Treatment—Confinement—Exhaustion—Blanket-bath—Medical treatment— Remedies, indications and illustrative cases,......3S'l A TREATISE ON FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. PART I. PHYSIOLOGY OF THE CEREBRO-SPINAL CENTRES. CHAPTER I. GENERAL REMARKS ON NERVOUS DISEASES. The term "functional," as applied to disease, has long been used to denote simple derangement of what is known as the animal and organic functions, or actions, in contradistinction to those diseases which arise from a change in the structure or position of parts. In this sense it is very doubtful whether there is, strictly speaking, any such thing as a purely func- tional disease of the nervous system. The diseases so called, embracing neuralgic, spasmodic, paralytic and mental affec- tions, are known to depend in many instances on organic or histological changes in the cerebro-spinal, or other portion of the nervous system; and it is highly probable, therefore, that all nervous diseases, even the neuralgias, are connected, either directly or indirectly, with such changes. The fact that tissue-alterations are not always discernable, is no proof to the contrary, since an abnormal irritation, even when indicative 10 NERVOUS DISEASES. of molecular changes, may become a normal one by persistent repetition. Indeed, such an acquired tolerance of ordinary causes of irritation, would seem to be sufficient proof of the existence of such changes. " It seems to me a vain dispute whether in strict accuracy there are, or are not, any such dis- orders. The probability is that there are not; that in all mor- bid action the cells and fibres of the organs undergo some molecular change from their perfectly normal condition. It is, however, perfectly certain that there are very grave disor- ders in which the most careful scrutiny fails to detect any ac- tual change, in which complete recovery is perfectly possible, and in which the 'juvantia' are such as operate more in modi- fying the power of the organs than in their texture."—C. Han- field Jones. Atrophy of the nerve-tissue, first clearly demonstrated by Romberg, is a well-established fact in pathology. This sub- ject has been most successfully studied in connection with atrophy of the optic nerve, where the amblyopic and amau- rotic conditions are seen to keep pace with the pathological changes on which they depend. This form of nerve degener- ation is now so frequently met with, that, as Dr. Anstie says of neuralgia, "most probably in all cases there is either atro- phy, or a tendency to it, in the root of the principal nerve or in the central grey matter with which it comes in closest con- nection." As we approach the great nerve-centres, the lesions become more pronounced, and the functional disturbances depending on them are therefore, as a general rule, more marked, and also more frequent. As these lesions and their effects on the nervous system have of late been carefully investigated, and, moreover, as they furnish a ready key to the solution of a great variety of functional phenomena, or what has heretofore gen- erally been regarded as such, we shall devote a brief chapter or two to their consideration. CEREBRAL CORTEX AND LOBES. 11 CHAPTER II. FUNCTIONS OF THE CEREBRAL CORTEX AND LOBES. \Ve are chiefly indebted to the labors of Hitzig and Fritsch for our present knowledge of the cortical functions of the brain. These observers established, by a series of carefully conducted electrical experiments, the fact that there are true motor cen- tres in the cerebral cortex; that the motor and sensorial cen- tres are differently located; and that there are definite areas governing the movements of certain parts in animals, some of which, though in close contact with each other, exhibit differ- ent functions. These results are found to agree in many in- stances with clinical observations made within the last few years, especially those upon tumors by Dr. Petrina, the dis- turbances caused by superficial abscesses, and the circum- scribed destruction of motor centres by cauterization of small portions of the cineritious substance with chromic acid by Xothnagel, or with the actual cautery by IVrrier. They are, however, in direct conflict with the previous investigations of Longet, who found that the hemispheres throughout their whole extent were entirely destitute of both sensibility and excitability, so that both the white and grey substance could be lacerated, burned or crushed without exciting any convulsive movement, or any apparent sensation. We shall therefore content ourselves with presenting a brief summary of their observations, merely remarking, that the loss of power caused by the destruction of nervous centres has not always proved permanent, a circumstance sought to be explained by Flou- ren's law of supplementary or vicarious action, or else by Nie- meyer's theory of a collateral oedema, extending to the motory 12 NERVOUS DISEASES. centres, and causing an arterial anaemia of the opposite hemi- sphere. According to Dr. Petrina, the growth of tumors, even of the convexity, so excites the other nervous ganglia as to give rise to isolated crossed clonic spasms, but never to perfect hemiplegia; consciousness is also mostly preserved. In these cases there is likewise long-continued headache, considerable vertigo and nervous irritability, with circumscribed disturbances of sensi- bility, amblyopia, and altered hearing.—Zeitschr.fi. Horn. Klin,, 19,77. Hitzig, experimenting on the cortical part of the brain of an ape, the surface of which closely resembles that of man, determined the fact that, in apes at least, the motory centres for the upper and lower extremities, and also for the head, are situated in the cortex of the anterior cerebral convolution, in- asmuch as electric irritation of certain points at that place causes different movements of those parts. This is apparently confirmed by an observation communicated by Hitzig in rela- tion to an abscess in the lower half of the right central con- volution, which, was attended with spasm and pains in the left side of the face, showing that the point whence the irritation of the facialis takes place, is nearly the same in the ape and man, namely, that part of the anterior central convolution, whence the second frontal convolution turns forward and a little downward.—(Arch.fi. Psych., Ill, 2.) Hitzig's observation is also confirmed by a case recorded by Dr. Carl Stark, in which a cyst was found somewhat behind the centre of the right and left first frontal convolution, and another at the root of the first right and left frontal convolu- tion. There was also a third cyst, of the size of a walnut, on the upper part of the right sulcus prsecentralis. The root of the second frontal convolution, and the lower part of the ante- rior central convolution were, from pressure of the cyst, greatlv atrophied and only half their normal size. In this case there was progressive general paralysis, trembling of the facial mus- cles, and, as the paralysis of the left facialis became more and more decided, nearly all the muscles supplied by the motorv branches of the trigeminus, namely, the masseter and pteri- CEREBRAL CORTEX AND LOBES. 13 goides. At one time both bulbi were spasmodically rolled in- wards, and in that position made short twitching movements from right to left; that is, clonic and tonic spasm of the left external rectus and of the right internal rectus.—(Berlin. Klin. Wchschrifit, 33, 1874.) Tumors in the anterior lobes, according to Dr. Patrina, mostly cause frontal pains, with intellectual and psychical alterations and abnormalities, and with or without partial chorea, paresis, or, more rarely, hemiplegia. There is no dis- turbance of sensibility, but there may be general convulsions, rarely attended with loss of consciousness; sight, smell and hearing are also disturbed.—(Zeitsclir.fi. Horn. Klin., 19, 77.) In a case of paresis of the right side of the body, Dr. Bernhart found the left lobe of the forehead and vertex hypersemic, caused by many small emboli. The lobulus supra-marginalis was hyperaemic and changed in structure.—(Arch. fi. Psych., IV, 698.) A tumor in the lateral part of the right vertical lobe pro- duced, according to Bernhart, sudden and transient paresis of the left arm after an interval of apparent health. There was also spasm, slight of the left lower extremity, the left side of the face being last attacked. He also found neoplasmata in the cortex of the vertical lobe, especially in the superior lateral and median part of the posterior central convolution, to pro- duce paretic debility of the extremities of the left side, especi- ally of the arm, and spasms of the muscles of the right side (muse, orbic. palp., corr., front,, of the nose and mouth, sterno- cleido-mast., platysma, biceps, supin., and extensor dig., flexors of the right hand and fingers). Aneurysm a at the place of union of the lowrer temporal convolution, he found to produce paralysis of the left hand, followed by amelioration and sud- den death. The aneurysma burst, and the sudden diffuse ex- travasation of blood explains the sudden death.—(Loc. cit.) Patrina says that tumors of the vertical lobes give rise to disturbances of sight, of cutaneous sensations and frontal head- ache; but the most important symptom is crossed hemiplegia, often sudden; aphasia is frequent, with left-sidecl disturbance of the island of Reil; convulsions general only when the tumor 14 NERVOUS DISEASES. is large. The same authority also found tumors of the poste- rior lobes to produce crossed paresis, partial paralysis of the oculo-motorius on the same side, convulsions, and disturbances of the senses, intelligence and sensibility.—(Zeitschr. fi. Horn. Klin., 19, 77.) Dr. Scholz, of Bremen, details a case of cerebral abscess. attended with aphasia, paralysis of the left oculo-motorius, and left-sided hemiplegia. The abscess found its way through the sagittal suture, and was opened with a lancet. The aphasia and paralysis of the oculo-motorius proves the seat of the ab- scess to have been in the third left convolution. The occur- rence of hemiplegia on the same side is accounted for by Xier- meyer, in such cases, by supposing the existence of a collateral oedema, extending to the motory centres, with swelling and stasis in the capillaries of the opposite hemisphere.—(Berlin. Klin. Wchschrifit, 42, 1872.) These cases appear to confirm the fact, noticed by others. that, as a general rule, lesions of the right hemisphere are more serious in their effects than lesions of the left hemisphere. Thus, it has been observed that tonic convulsions are more frequent when the right side of the brain is implicated. Para- lyzed muscles generally suffer to a greater extent from failure of nutrition, when the right hemisphere is the affected part. Hysterical paralysis, conjugated deviation of the eyes, and other functional abnormalities are more common, when the right side of the brain is the seat of disease. On the other hand, the different forms of aphasia are due to disease located in the left hemisphere. Nothing is now better established than that amnesic, ataxic and agraphic aphasia are the result in most cases, of embolism of the left middle cerebral artery about the island of Reil, or of some injury of the left middle cerebral lobe on its lateral and inferior part.—(LuczHeivicz.) This, however, is contrary to the opinion of Brown-ISequard who says, "Injuries and lesions of the left side induce greater alterations of the mind, more especially in those faculties con- nected with speech, but not connected with aphasia." Dr. Julius Feasen records a case of periodically returning hemicrania, attended with double perceptions; the latter phe- CEREBRAL CORTEX AND LOBES. 15 nomena depending on congestion, from relaxation of the vaso- moters of the affected side, attacking one hemisphere, while the other hemisphere remained normal. The double percep- tions, he thinks, are caused by the incongruous function of the two hemispheres; in one hemisphere, with its normally acting function, the perception is also normal; in the other hemi- sphere, irritated by the afflux of blood, the perception pales; both perceptions do not become united as in the normal state, but the more imperfect one follows the perfect one, as it were, as a reminiscence; hence the double perception of the same subject,—(Arch.fi. Psych., IV, 547.) It thus appears that, while there is a general agreement as to the results of stimulation and lesion of different portions of the cerebral cortex and lobes, there are obvious reasons for the opinions of those who contend that the effects observed are in reality due to stimulation or lesion of the medullary fibres, leading from the cineritious substance to the central ganglia, or else a more direct action upon the ganglia them- selves. Eckhard has traced one of these excitable fibres for the front leg down to the corpus striatum; while MM. Le- moigne and Lussana point to the fact that mechanical stimula- tion does not excite the so-called cortical centres, and that galvanization and faradization are also generally ineffectual when the animal is fully under the influence of an amesthetic, as well as immediately after death. This view appears to be confirmed by the fact, already mentioned, that the motor pa- ralysis observed after destruction of the cortical centres, is neither complete nor permanent, like that which attends de- struction of the lower motor centres. Dr. Brown-Se'quard goes still further, and asserts, as the result of his experiments and researches, that the same symptoms may present from lesions in any part of the brain, and consequently, that there are no special or circumscribed centres in the cerebrum for any func- tion. "Each alleged function of the brain," he says, "may re- main after the destruction of what is considered its centre." He therefore concludes that the symptoms depend, not upon a direct lesion of the cerebral tissue, or of any circumscribed centre, but upon a loss or perversion of function from distant irritation. 16 NERVOUS DISEASES. CHAPTER III. FUNCTIONS OF THE CEREBRAL GANGLIA. 1. Corpora Striata.—Notwithstanding the fact that these ganglia are situated directly in the track of the prolonged anterior fibres of the spinal cord, Longet declares that irrita- tion of these parts does not excite the slightest convulsive movement in the muscles below. More recent experiments, however, fail to confirm this observation, for there is reason to believe that irritation of the motor tracts of the corpora striata not only excite convulsions, in some instances, but give rise to the involuntary muscular movements of tremor and chorea; minute emboli, composed chiefly of white corpuscles, having been found in these cases in the smaller vessels in this region of the brain. According to Patrina, tumors of the corpora striata produce total hemiplegia, loss of consciousness, convul- sions, psychical and intellectual disturbances, tremor, chorea and amblyopia. Pressure on this part is followed with great uniformity by crossed paralysis, with facial paralysis on the injured side; sensibility, on the contrary, is not generally much impaired. Apoplectic pressure in the corpora striata produces at most secondary amaurosis.—(Psych. Cadralbl., No. 2, 1873.) Faradization of these ganglia produce tonic contractions of the muscles of the face, neck, trunk and limbs. \Yhen the electrode is applied to one corpus striatum, the contractions are unilateral, with predominance of the flexors over the ex- tensor muscles; there is also produced a condition of pleuro- sthotonus, the body being bent to the opposite side. 2. Thalami Optici.—Lesions of these parts sometimes pro- CEREBRAL GANGLIA. 17 duce general convulsions and sensory disturbances, according as the destruction is in the fibres to the optic tract or corp. genic. med.; in the one case there may be paralysis of the opticus, changes of the pupils, nystagmus and exophthalmos; in the other, vaso-motory disturbances, such as considerable differences in the temperature, cyanosis, circumscribed red^ ness; large tumors have caused psychico-intellectual disturb- ance and retarded speech.—(Patrina, loc. cit.) The paralysis is not so great in this lesion as in that of the corpora striata, the paresis consisting more in a general weakness of the body, with less-marked facial paralysis, and diminished sensation of the corresponding side. Sclerose en plaques of the optic thalami produces either amblyopia or amaurosis.—(Apostoli, loc. cit.) According to Longet, the optic thalami have a peculiar crossed action upon the voluntary movements; for if both thalami are removed in the rabbit, the animal is still capable of stand- ing and moving about, but if only one thalamus is removed, the animal falls immediately upon the opposite side. This want of balance, however, is probably simply due to the paresis above described. The optic thalami are not sensibly affected by faradization. Tumors, abscesses or hemorrhage into the posterior part of the thalamus may produce hemiplegia, hemi-ansesthesia, crossed amblyopia and impaired articulation; but these symptoms are not the direct result of the lesion, but of the pressure thereby exercised upon the internal capsule of the nucleus lentiformis. Charcot and Veyssiere have shown that lesions of the anterior part of this capsule produce simple motor hemiplegia, while lesions of the posterior portion give rise to hemi-ansesthetic hemiplegia. 3. Pcduaculus Cerebri.—According to Charcot, injury to the posterior third of the pedunculus cerebri, from thrombosis of the art. fossae Sylvii, results in crossed paralysis and an- esthesia of the extremities, with paresis of the opposite side of the face.—(Med. JScuigl-., May, 1877.) Tumors of this part cause high-graded vaso-motory disturbances and anomalies of tem- perature; early simultaneous paralysis of the oculo-motorius; palsy of the bladder; crossed paresis and disturbance of sen- 18 NERVOUS DISEASES. sibility; intelligence not deeply disturbed, but often the senses, especially that of sight; forced movements and anomalies of position on the side opposite the tumor.—(Zeitchr. fi. Horn. K lin., 19, 77.) 4. Crura Cerebri—Crossed paralysis if the lower part is affected, together with loss of sensation if the upper part is in- volved. Ptosis, divergent strabismus, protruded bulbi and dilated pupil indicate paralysis of the third nerve of the same side, the lesion occurring at the lower and inner side of the crus cerebri. Tumors of this part produce unilateral position of the body; forced lateral position, rotation about the axis of the body; unilateral position of the bulbi; vacillating gait, with tendency to fall over to one side; frequent disturbance of the senses, vertigo and headache.—(Patrina, loc. cit.) 5. Pituitary Body.—Extreme sleepiness, loss of memory, mental apathy, slow speech, amblyopia, amaurosis and other disturbances of the senses, paralysis of the oculo-motorius, headache, high-graded diabetes mcllitus. 6. Cerebellum.—Hemiplegia, with absence of facial and lin- gual palsy, indicates cerebellar disease. Sudden lesion of the crus cerebelli gives rise to conjugate deviation of the eves, the one turned downwards and inwards, looking towards the seat of lesion, and the eye turned upwards and outwards, look- ing from the seat of disease. In cerebellar paralysis, the lesion is on the same side of the body as the paralyzed limb, and the lower extremity is generally more affected than the upper. Lesions of the middle lobe are said to cause excitement of the sexual apparatus in both sexes. This is probably due, not to any direct relation between the cerebellum and the sexual appetite, but simply to pressure, exerted upon the posterior surface of the medulla and pons. Tumors of the cerebellum frequently cause occipital headache, manifestations of motorv irritation, marked inco-ordination of muscular movement dis- turbance of the senses, strabismus convergens, and crossed paresis; tliere is also diminished electrical reaction on the sound side of the body.—(Zeitsclir.fi. Horn. Klin,, 19, 77.) Destruction of the anterior portion of the middle lobe of the cerebellum causes a tendency to fall forward; of the posterior portion, to fall backward; and of the lateral lobes, to fall CEREBRAL GANGLIA. 19 sideways; while pathological irritation or faradization of those parts appears to excite such muscular movements as would counteract this tendency and enable the animal to maintain his equilibrium. This function of co-ordination, however, is, according to Ferrier, shared in common with the optic thalami and pons Varolii, which with the cerebellum appear to form a combined mechanism, incapable of being separated without producing a disorder of function. 7. Tubcrcula Quadrigcmina.—These bodies are the true optic ganglia; they give origin to the optic nerves, and if de- stroyed, or if the nerves are divided at any point between the retina and tubercles, complete blindness is the result. Diseases affecting the central fibres of one optic tract will in- jure or destroy the sight of the opposite side, and vice versa. If the optic commissure be affected, both eyes will suffer. Dis- ease seated between the tubercles and cerebrum will not affect the vision, except by pressure exerted upon the latter, as it is by the tubercles alone that the impression of light is perceived. The geniculate bodies are so closely connected with the tuber- cles, that syphilitic, cancerous or inflammatory neoplasmata, apoplectic affusions, cysts, abscesses, or any morbid state of the hemispheres, pressing upon the corpora geniculata, quadri- gemina or optic tract, will produce amblyopia or amaurosis; the same is true of encephalitic diffusa, producing softening of these bodies.—(Psych. Centralbl., No. 2, 1873.) But the functions of the corpora quadrigemina are by no means limited to vision. They exert a marked influence in the expression of the emotions, such as fear, terror, joy, etc.; and when subjected to .faradization, they produce complex movements of all the muscles, especially of those concerned in locomotion and the preservation of the normal attitude. Fara- dization of these parts in animals causes them to utter peculiar cries or moans, rendering it highly probable that the protracted moaning sometimes heard during the epileptic seizure, is due to morbid irritation of these bodies. Setchenow has demon- strated the fact that a mild chemical irritation of these bodies exerts a retarding influence upon the reflex action of the spinal cord, so that a comparatively long interval is made to elapse between an impression and the reflex movement caused 20 NERVOUS DISEASES. by it, while a more powerful irritation abolishes reflex action altogether. This, therefore, is no doubt the inhibitory centre of reflex action, and accounts for the well-known fact, that we are often able, by the strong exercise of our will-power, to pre- vent or greatly diminish the extent of reflex movements. 8. Pons Varolii.—Lesions of the pons produce no general convulsions; disease of one side causes crossed paralysis; when both sides are affected, both sides of the body are para- lyzed and a deep comatose state exists. The fibres of the pons decussate in such a manner that both sides of the face may be paralyzed and only the left side of the body. Lesion of the lower part of the right side will paralyze the same side of the face and the opposite side of the body: if the sensory fibres of the fifth nerve should happen to be implicated, there will also be loss of sensation on the same side of the face. When the sixth nerve is involved we have convergent strabismus, which may coexist with facial paralysis of the injured side, and loss of sensation on the opposite side, the latter resulting from the crossing over of sensory fibres of the fifth nerve to the seat of lesion. Hyperesthesia and anaesthesia of the parts to which the sensory fibres of the fifth nerve are distributed, may also occur. Apoplexy of the central parts of the pons will be fol- lowed by coma, general paralysis, contracted pupils, indistinct articulation, difficulty of swallowing, etc. Tumors in the pons produce characteristic electrical reaction in the paralyzed fa- cials, disappearance of the electro-muscular contractility for the galvanic current, and simultaneous diminished galvanic irritability of the facial branches (Pctrina). Tumors in the pons also give rise to vertigo, and vaso-motory troubles, alter- nated hemiplegia, paralysis of the external recti, paresis of the lingual muscles, anaesthesia, dysphagia, disturbances of sight and of the other senses, of the trigeminus; sometimes there will be crossed sensory disturbances between the trunk and one-half the face, as above described.—(Zeitschr fi Bom Klin 19, 77.) The effect produced by lesions of the pons Ararolii on speech is due to paresis, and not to their influence on intelligent lan- guage, the articulation being so indistinct and clumsy as often- times to render the words nearly or quite unintelligible. MEDULLA OBLONGATA AND SPINAL CORD. 21 CHAPTER IV. FUNCTIONS OF THE MEDULLA OBLONGATA AND SPINAL CORD. The medulla oblongata connects the spinal cord with the brain in such a manner that each half of the latter exercises its peculiar influences over the opposite side of the body. This is owing to the decussation of the motor conductors of the cord in the anterior pyramids. The medulla gives origin to the facial, glosso-pharyngeal pneumogastric, and spinal accessory nerves, the roots of which sometimes become atrophied, giving rise to the affection called labio-glosso-laryngeal paralysis, the characteristic symptoms of which are, an inability to keep the lips closed, constant flowing of saliva from the half open mouth, paralysis of the tongue, loss of speech, dysphagia, difficult res- piration, and great prostration. The respiratory centre is seated in the apex of the fourth ventricle, at the point of the calamus scriptorius. Irritation of this part produces sudden rigidity of the respiratory mus- cles of the neck, chest and diaphragm. In this condition all access of air to the lungs is cut off, and, unless quickly relieved, results fatally. Dr. Marshall Hall regards spasm of the glottis as " an exci- tation of the true spinal or excito-motory system. 22 NERVOUS DISEASES. It originates in: I.—1. The trifacial in teething.. 2. The pneumogastric, in over-, or improperly-fed in- fants. 3. The spinal nerves, in constipation, intestinal disor- der, or catharsis. These act through the me- dium of II.— The spinal marrow, and HI.—1. The inferior or recurrent laryngeal, the constrictor of the larynx. 2. The irdercostals and diaphragmatic, the motors of, res- piration." In a similar manner, Dr. Mcryon "accounts for those strange and mysterious sympathies by virtue of which the different parts of the body are maintained in a state of mutual depend- ence, and by means of which a disturbed condition of one or- gan produces impressions on the other, and, it may be, distant parts of the system. What, for instance, but this kind of af- finity, can occasion the contracted brow in severe headache, the dilated nostrils in painful affections of the chest, or the raised upper lip, stretched over the gums, in great suffering of the abdomen. These, and others far more important phenom- ena, were interpreted by the thoughtful experiments of Dr. Marshall Hall, who first taught us that they are dependent on diffusions of excitement, not by the nerve primarily affected, which acts only as a conductor of sensation to the nervous centre, but by the nervous centre itself, on which the primary impression impinges, and from which it is reflected."—(Pract. and Path, Research, on the Var. Forms ofi Pared.) Dr. Scheutz, of Prague, in his remarks on the etiology of in- fantile convulsions, speaking of meningitis basilaris, and its accompanying hydrocephalus acutus, says: "The chief seat of this exudation is on the fascicles of cellular tissue between the pia and arachnoidea inside of the both-sided hilus cerebri from the chiasma nerv. opt. to the pons and medulla oblon- gata. Hence the inflammation spreads to the fossa? sylon and the longitudinal fissure of the hemispheres, to the blood ves- sels and ependyma of the ventricles, especially the lateral ones MEDULLA OBLONGATA AND SPINAL CORD. 23 and thus causes the acute hydrocephalus. By its extension the oculo-motorius, trochlearis, abducens, trigeminus, facialis, acus- ticus, glosso-pharyngeus, vagus, and accessorius Willisii are drawn in, producing the characteristic symptoms, as the posi- tion of the eye during and after the attack, the squinting, the vomiting, the cry hydrocephalique, especially the contraction of the muscles of the neck, and teaching us the deposition of exudations and of granulated tubercles around the nerves coming out from the base of the brain." Seeligm'dller describes a disease in a girl, twenty-four years old, which began a few years before with difficulty of swallow- ing, and ended in paralysis and atrophy of both sterno-cleido- mastoidei and cucullares; paralytic symptoms at the vellum palati and at the larynx; pulse 90 and over; there was also atrophy and paralytic weakness of the upper extremities, es- pecially on the left side. Such a pathological state corre- sponds to the anatomical condition which Burchard and Heil- derhain found about the course of the fibres of the internal ramus of the accessorius after its union with the vagus; and it is well known that the cucullaris and sterno-cleido-mastoi- deus are supplied by the ramus externus. These studies clearly show that the nervous pharyngeus contains nearly exclusively fibres of the accessorius, the nerv. laryng. sup., only a few on the ram. muse crico-thyroidei, the nerv. laryng. inf. s. recurrens, and the rami cardinea exclusively fibres of the accessorius. Physiological experiments perfectly agree with it, as they constantly prove the dependence of the laryn- geal muscles on the accessorius. The disease in question is a steadily progressing disease of the medulla oblongata and of the cervical cord, running its course slowly, from above down- wards. It began in the ramus inter, of the accessorius, and finally attacked the motory nerves of the upper extremities, especially of the left side, a process allowing only the most unfavorable prognosis.—(Arch.fi. Psych., III., 2.) Dr. Wernich, in giving the etiology of eclamptiform par- oxysms, says:—"It is Avell known that during pregnancy eclamptiform convulsions may set in without any albuminuria. Schroeder reports fifty such cases in his work on Midwifery. 24 NERVOUS DISEASES. In two cases which came under my observation, albuminuria was also absent, and the patient complained especially about a numb sensation, prickling, at times severe pains and para- lytic weakness in the lower extremities. Most authors consider its cause a pressure on the plexus ischiadicus in the pelvis. Brown-Sequard and Westphal, in their experiments on guinea-pigs, showed that epileptiform convulsions could be produced at any time on these animals. By dividing one-half of the spinal cord or one nervous ischiaticus, and pinching the face on the same side (irritation of an epileptigonous zone), a paroxysm can be produced, which in all its points is very sim- ilar to an epileptic fit. Other lesions of nerves produce the same effect, as Billroth and Briond have shown, and we must therefore look out for such an epileptigonous zone. Westphal demonstrated that we must make our experiments for that purpose on different parts of the body. In the case before us we have to inquire, if the sexual organs do not contain such peripheric nervous regions, by the irritation of which the vaso-motory and spasmodic centres, already morbidly affected, are put into action. Many accoucheurs report cases arising through exploration of the uterus. Heker reports a case where eclampsia set in during scarification of the labia majora. I saw one case where, in a woman who never had an epileptic fit, a well-characterized eclamptiform convulsion set in after an intro-uterine injection. We see, therefore, no reason why we may not in some cases of eclamptic fits consider such epileptogonous zones existing in the sexual organs, especially in all such cases where no albu- minuria is present."—(Bed. Klin. Wschfit., 42, 1872.) Finally, Dr. Apostoli refers one form of organic amblyopia and amaurosis to ataxia locomotrice and grey degeneration of the posterior columns of the spinal cord. According to the same authority, amblyopia and amaurosis sympathetica arises by reflex action, mostly from the trigeminus (neuralgia, even irritation or dentition, foreign bodies in the teeth, caries den- talis); helmenthiasis and pregnancy may also cause sympa- thetic amaurosis.—(Psychl. Centrbl., No. 2, 1873.) Numerous other cases of this kind might be cited but we MEDULLA OBLONGATA AND SPINAL CORD. 25 have given enough to show the various causes operating to disturb the healthy action of the nervous system, as well as afford an explanation of the mechanism by which impressions made on one part of the system may spend their force, and produce great functional disturbance, or loss of power, in another. Further illustrations, therefore, will be reserved for their appropriate place in subsequent chapters of the work. In order to render our remarks on the physiology of the spinal cord more complete, we will add, that while the chief vaso-motor centre is situated in the medulla oblongata, there are subsidiary or minor centres throughout the whole length of the cord. The cervical portion of the cord contains a centre which appears to regulate the production of animal heat, for when this portion of the cord is crushed or deeply injured, the thermometer, after the effects of the shock have subsided, runs up to 105° F., and shortly after death frequently reaches 110° F. Budge describes the cilio-spinal centre as situated between the last cervical and sixth dorsal vertebrae. Faradization of this region produces dilatation of the pupil through the cervical sympathetic nerve, which influences the dilating fibres of the iris. On the other hand, destruction of this portion of the cord is followed by contraction of the pupil, because now the iris is under the exclusive control of its circular fibres. Schiff contends for what is called "vicarious interchange of functions" in the spinal cord. He bases his argument upon the fact, that after the spine has been injured its function is sometimes re- stored before the anatomical lesion has been repaired. This, however, does not apply to the posterior columns, injury to which permanently destroys the tactile sense, without possi- bility of recovery. Moreover, we know from abundant clinical experience, that although portions of the spinal cord may be regenerated in frogs and some of the" lower animals, as shown by Brown-Sequard and others, such regeneration of tissue does not take place in man, and if recovery from severe pathological injuries ever occurs, it is extremely rare and imperfect, The chief centre for the movements of the lower sphincters is situated in the lumbar portion of the cord; but a curious cir- 2 26 NERVOUS DISEASES. cumstance is, that while relaxation of the urinary sphincter commonly occurs without relaxation of the sphincter ani, the reverse is not true. The lumbar centre, however, is not the only one for the bladder, since, as we have seen, faradization of the pedunculi cerebri and restiform bodies likewise causes contraction of the detrusor and evacuation of the viscus.— (Althaus.) CONVULSIONS. 27 PART II. DERANGEMENT OF THE MOTOR FUNCTION. SECTION I. SPASMODIC DISORDERS. CHAPTER I. CONVULSIONS. Convulsions is a word generally used to denote a condition characterized by violent spasmodic contraction of the muscles, sensibility and voluntary motion being for the time suspended. The term is applicable to both tonic and clonic spasm of the muscular tissues, but is usually confined to diseases character- ized by violent involuntary contractions, with alternate relax- ations of muscles which usually act only under the influence of the will. For the sake of distinction, the term spasm is sometimes used to designate the inordinate action of the in- voluntary muscles, the word "convulsions" being more par- ticularly reserved to denote the irregular contraction of the voluntary muscles; but in ordinary language the two terms are synonymous, being commonly used to designate diseases characterized by violent alternate contractions of the voluntary muscles, attended with complete or partial loss of conscious- ness, and constituting the class of nervous disorders which form the subject of the present chapter. 28 nervous diseases. 1. Infantile Convulsions. For the purposes of description and study, convulsions may be divided into three distinct classes, namely, (1) those con- nected with disease of the brain or spinal marrow, called centric, or symptomatic; (2) those arising from peripheric irrita- tion, such as dentition, worms, etc., called eccentric, or reflex; and (3) those depending upon the quality or quantity of the blood circulating in the system, or in some particular part, called secondary, or sympathetic. Convulsions occur under the greatest possible variety of circumstances, as regards age, constitutional condition, sanitary surroundings, hereditary influences, or whatever else may be supposed to affect the general health of the patient. Although the disease is most common among the poorer classes, or among feeble and impoverished children, it is nevertheless often met with in well-fed infants of apparently robust con- stitutions and perfect health. Causes.—The chief predisposing causes of infantile convul- sions are, heredity, nervous susceptibility and general weakness. 1. Heredity.—An hereditary predisposition has often been observed. It is no unusual thing to find the children of epileptic parents peculiarly subject to convulsive fits. Bouchat mentions a family of ten children, all of whom had convulsions during infancy; one of them married and had ten children of his own, nine of whom were subject to convulsions. 2. Nervous Susceptibility.—The nervous system in infancy and childhood is peculiarly impressible, irrespective of he- reditary influence. The infant organization is such that it feels more sensibly at this period the influence of disturbing causes upon it. Not only so, but some children are naturally more susceptible to the various causes of irritation, more " nervous " as we say, than others. Whether this predisposition is hereditary or acquired, cannot always be determined. Some attribute it to impressions made upon the mother during gestation; while others believe it to be the natural result of their individual organization. Whatever may be the reason such children are more impressible than others to even ordi- CONVULSIONS. 29 nary influences; they are unusually excitable, restless, and apt to start suddenly when spoken to, or when a noise is made in their hearing. I once knew a child, now grown to manhood, who, to use the language of the mother, was never quiet since he was born. During infancy and early childhood this boy was thrown into convulsions from the slightest cause. 3. Cenercd Debility.—Children naturally healthy sometimes acquire a predisposition to the disease, by being subjected to the operation of debilitating influences, such as impure air, insufficient or unwholesome diet, etc. If the state of debility thus induced can be effectually overcome, there is generally no difficulty in getting rid of the convulsions; otherwise such children remain liable to a repetition of the attacks on being exposed to any of the exciting causes of the disease. The exciting causes are very various, and often apparently very trivial. Thus, the irritation of a feather, or the prick of a pin, may be sufficient to provoke convulsions in cases where a strong predisposition to them exists. 1. Centric, or symptomatic convulsions may result from any inflammatory or organic disease of the brain or spinal marrow, such as meningitis basilaris, with its accompanying acute hydrocephalus; tuberculosis, cerebri; inflammation and soft- ening of the brain or cord; tumors, abscesses, hemorrhagic extravasations, or any other form of cerebro-spinal traumata. 2. Eccentric, or reflex convulsions constitute the great majority of cases, particularly among children. They are due to any irritation of the peripheric nerves capable of exciting them by reflex action. Of this nature are the numerous cases arising from dentition, errors of diet, helminthiasis, burns, genito- urinary irritation, rectal croup, denudation of peripheric nerves, retention of the meconium, diarrhoea, exposure, espe- cially to severe cold, or mechanical irritation of the skin or mucous membrane. Some of these causes are of sufficient importance to merit special attention. (1.) Errors in Diet.—Under this head we include all un- suitable and indigestible forms of nourishment, whether it be the mother's milk, artificial food, or such indigestible and ir- ritating substances as children of every age are liable to swal- 30 NERVOUS DISEASES. low. It is well known that the mother's milk does not always agree with the child; and Soemmering mentions the singular case of a woman whose milk agreed perfectly with her own babe, but always caused convulsions in others. Nearly every physician of experience has met with a number of cases, in which the mother's or nurse's milk has been so changed by sudden fright or grief, as not only to disagree with the child, but in some instances to cause convulsions. A case has just occurred in my own practice, in which a nurse, on being ac- cused by the mistress of the house with dishonesty, was thrown into such a violent fit of anger, that, for more than a week afterwards, the child on being nursed was immediately thrown into spasms. "Artificial food," if it disagrees, is also liable to produce con- vulsions. This is particularly apt to be the case if the food is too rich, or difficult of digestion, and especially if the stomach is overloaded, or has become weakened by the ex- hibition of Soothing Syrups, Batesman's Drop<. Godfrey's Cor- dial, paragoric, or other opiate preparations. After weaning, children often fill their stomachs with the most unwholesome and indigestible articles, such as unripe fruit, nuts, raisins, berries, and the like, and as a consequence, some hours afterwards convulsions sometimes supervene. In these cases the offending cause is generally in the small in- testine, and nothing but its removal, by copious evacuations, will re-establish the health. (2.) Dentition.—In explanation of the curious fact that, while the period of the first dentition is marked with frequent con- vulsive attacks, the second dentition is peculiarly exempt from any such phenomena, Dr. Sehuetz, of Prague, says:—"Exam- ining the physiological process of dentition, we find that the steadily consolidating dental pulp gradually absorbs the gums covering it, but where the gum takes on a nearly cartilaginous quality, it prevents the development and the growth of the tooth outwardly; the tooth presses therefore on the pulp of the permanent tooth, which again presses on the nerves, and such a pressure may suffice in certain cases to produce painful sensations and their reflex motions in the form of convulsions CONVULSIONS. 31 Incisions at the edges of the gums are therefore generally re- commended. By holding on to such an explanation, we easily understand why there are no convulsions in second dentition, passing off without subjective symptoms and without pain; here the new tooth produces a tergo-resorption of the root of the milk-tooth, pushing outward the rootless crown; a counter- pressure docs not take place, the milk-tooth becomes loose and is easily removed. But where the milk-tooth after the absorp- tion of the root is tightly held in its place, the permanent tooth pushes its way outward, before or behind the milk-tooth, and keeps this false position, till the milk-tooth falls out or is artificially removed." This explanation is satisfactory enough as far as it goes, but no doubt the tender age of the infant during the first dentition has much to do with its sensitiveness to refiex irritation, as we find that convulsions occur from other causes much more frequently during this period and among nervous, sensitive children, than they do at a more ad- vanced age, or among the more quiet and phlegmatic. (3.) Helminthiasis.—Although the irritation arising from the presence of intestinal worms is, as a general rule, less likely to excite convulsions than is commonly supposed, nevertheless that worms are an occasional cause of their occur- rence, cannot be doubted. In these cases the concomitant symptoms of verminous irritation are always present and serve to identify the cause, even when there is no ocular proof of their existence. It is interesting to note, in such cases, how speedily the convulsions yield to the indicated remedy. (4.) Burns, Blisters, etc,—Extensive denudations of peri- pheric nerves, whether produced by burns, blisters or other agencies, frequently cause convulsions, especially in young subjects. We often witness in the adult, under these circum- stances, merely a nervous chill; but children, being as a rule much more susceptible to nervous impressions, are often thrown into convulsions by such lesions. Hence the neces- sity in such cases of immediately protecting the exposed sur- face by an artificial skin or covering. (5.) Genito-Urinary Irritation.—I have lately met with two cases of convulsions in male infants, arising apparently 32 NERVOUS DISEASES. from undue retention of urine. The latter was passed with great difficulty, and often, when the bladder was unduly dis- tended, dribbled away in small quantities at a time, instead of being passed in the usual manner at regular intervals. A careful investigation showed that the partial retention was the result of congenital phymosis. The convulsions ceased to re- turn immediately after the obstruction was removed. In some of these cases the convulsions appear to arise from the irritation caused by the retention of the sebaceous secretion of the part, rather than from urinary irritation or cystic distension. (6.) Rectal Croup.—Dr. Schuetz mentions two cases caused by rectal croup. "The children were taken with high fever, pains all through the colon, and discharges of bloody slime with tenesmus. Suddenly severe general convulsions set in, during which the discharges were more frequent, consisting of membranous patches of different size, mixed with green or reddish mucus and faces. Improvement began, when urina- tion became copious, the urine being muddy, yellowish-white, containing one-fourth albumen and numerous phosphates." (7.) Diarrhoea.—This is a frequent cause of infantile convul- sions. Whenever the irritation reaches a certain hight, in sensitive subjects, convulsions are very apt to set in; hence they are of frequent occurrence in the summer-complaint of children, cholera infantum and enteritis. In many of these cases cerebral irritation, as evinced by sleepiness, stupor or coma, precedes the attack; but in other cases the convulsions occur without any such evidence of centric irritation, and are probably due to irritation, arising from the pathological state of the intestinal mucous membrane. (8.) Peculiar Causes.—We have already mentioned the fact that convulsions may sometimes result from the retention of meconium. Brachet mentions a case which was due to a worm in the meatus auditorius; and I have recently seen reported, in one of our medical journals, a case of spasm of the throat caused by a feather in the rectum. In these, as in all other cases of mechanical irritation, the removal of the offending substance permanently subdues the disease. 3. Sympathetic convulsions, or those depending upon the CONVULSIONS. 33 quantity or quality of the blood circulating in the great nervous centres, are also of frequent occurrence and often fatal. To this class belong the convulsions that so frequently usher in (1.) The Acute ExantJtemata.—As prodromes of the acute ex- anthemata, convulsions are most common in scarlatina and measles, and they occasionally occur in variola. "The con- vulsions most frequently appear suddenly, when the child is apparently as well as ever, or only after a short feeling of ill- ness; they are never observed at the bight of the exanthema, and sometimes after the first convulsion the eruption comes out in full bloom. Neither the severe febrile symptoms nor the high temperature of the body can be its cause, as both symptoms are absent at the appearance of convulsions and which disappear as soon as the disease localizes itself, as soon as the eruption breaks out. It is yet an hypothesis if the con- vulsions take the place of the chill, so often observed as the precursor of acute diseases, and it is the more questionable, as convulsions are the exceptions. Others suppose, that the ap- pearance of convulsions depends on the quantity of the un- known agent producing the eruption, but we might reply again, that convulsions are only seen in rare cases, that most intense exanthemata appear without such forerunners and vice versa—that convulsions also happen in light cases. We suppose, that in all such cases the cause lies in a greater irri- tability of the nervous system."—(Schuetz) Doubtless there is a greater degree of irritability than ordinary in these cases, and this will suffice to explain why the same cause fails to ex- cite convulsions in every case of acute exanthema, but it fails to account for the cause itself. It is generally conceded that these diseases are due to the influence of some specific poison upon the system, and if so, it must spend its force, either pri- marily or secondarily, upon the nervous system. Now, if the irritation thus excited is sufficient to produce convulsions in the more susceptible patients, the cause, though not fully ex- plained, is at least satisfactorily accounted for. (2.) Anirmia.—This is a much more frequent cause of convul- sions than is generally supposed. Most authors appear to re- 34 NERVOUS DISEASES. gard hyperemia as the principal cause of the phenomena; but while partial congestions, especially those of the brain and spinal cord, are doubtless in some instances the immediate forerunners of convulsions, general or partial amentia, on the other hand, is without doubt the prevalent condition existing at the time of the paroxysm. Thus, a distinguished patholo- gist, speaking of eclampsia, says: "A vascular spasm, starting from the vaso-motor center, rapidly becomes general, and pro- duces cerebral anaemia; thus causing an obstruction to the re- ciprocal reactions which transpire between the blood and the brain. This circulatory disturbance gives rise to loss of con- sciousness and acts, on the other hand, as a powerful stimulus of the center of convulsive movements situated in the pons Varolii and medulla oblongata."—{Rosenthal) Many of the cases occurring in the course of. long-continued diarrhoea, cholera infantum, etc., are anaemic cases, as shown by the sunken face, pale lips, hoarse voice, cool extremities, and small and filiform pulse. Symptoms.—In most cases the convulsions are preceded by premonitory symptoms. The child is either dull and fe- verish, or restless and irritable, indisposed to play, and of a cross, obstinate, and whining disposition. It frequently starts in its sleep, especially when touched, grinds its teeth together, and breathes in an unequal and irregular manner. Individ- ual muscles become spasmodically affected; the eyes squint, or turn obliquely in their sockets, the mouth is twisted in a peculiar manner, so as to give the features a sort of sardonic look, the ankles and wrists are bent, and the thumbs are turned inward. When nursing it suddenly relinquishes the nipple, cries out without any apparent cause, and in some in- stances gasps for breath. In other cases, especially when it constitutes the initiatory symptom of an acute disease, the paroxysm breaks out without any warning. The child is seized in a state of perfect health perhaps in its sleep, or at the breaking out of an exanthema. The features become greatly distorted, the eyes stare and roll spasmodically upwards, the muscles of the face twitch and jerk irregularly, the jaws are forcibly closed, or else work in a CONVULSIONS. 35 grinding manner, froth issues from the mouth, and the respi- ration is short, oppressed, and attended with a hissing sound. At the same time the body and limbs are tossed wildly about, the abdomen is distended, and the extremities flexed and rigid —the lower less so than the upper. The face is almost always more or less bloated, and of a bluish-red appearance, but some- times it is pale, corpse-like and sunken. During the hight of the convulsions there is not the least trace of consciousness or sensibility; but after the paroxysm has lasted a longer or shorter period, according to its severity, the convulsions cease, sensibility partially returns, and the child falls into a deep slumber, from which it awakes apparently fully restored. The above sketch, though brief, is a fair picture of an ordinary attack. But the paroxysms vary very much in dif- ferent cases. Sometimes the attack is so light as only to affect the muscles of the face, but generally those of the trunk and extremities soon become involved. If the attack is violent, the internal muscles also become implicated, the urine and faeces being passed unconsciously. The fit varies in duration from a few seconds, in some cases, to several minutes or hours in others; sometimes lasting as long as ten or twelve hours. Wheirconvulsions usher in the eruptive fevers, there are gen- erally no premonitory symptoms, but the attack sets in sud- denly, attended with more or less evidences of fever, and often also of head trouble. Sometimes the convulsion is partial, affecting perhaps only one side of the head, or even a single set of muscles, as those of the eye or face, or there may be only a few involuntary movements of the extremities, or of the fingers and toes. Par- tial convulsions may or may not be attended with rigor, mo- mentary unconsciousness, etc. Such cases, however, should never, be underrated, as they not unfrequently prove to be the precursors of very severe attacks. This is especially the case if, instead of a momentary unconsciousness, or perhaps none at all, there should be a deep comatose state, accompanied or not with convulsive twitchings in the place of convulsions, as this betokens serious disease of the brain or of its meninges. The attack, however light, is seldom limited to a single 36 NERVOUS DISEASES. paroxysm. Not only does there remain a tendency to relapses, but one paroxysm generally follows another, at longer or shorter intervals, increasing or decreasing in violence accord- ing to circumstances. The whole duration of the attack varies according to the constitution, susceptibility and general con- dition of the patient, the influence of treatment, and other modifying circumstances; but altogether it is very indefinite. Prognosis.—Simon attaches great importance to a large flow of urine, as announcing the termination of a prolonged attack of convulsions. With regard to general prognosis, he considers eclampsia attacks to be not serious. To give a prog- nosis in special cases, one must have definite facts to go upon. As a rule, convulsions at the outset of fevers are not serious, while those at the end are almost always fatal. Similarly with whooping-cough, and in all cases where the cause of the con- vulsions lies in the vitiation of the blood, the gravity of the prognosis increases with the close following of the convulsions one upon the other, and generally is in proportion to the in- tensity of the attack. Baehr, on the contrary, regards the prog- nosis as always rather doubtful. "Age is an important con- sideration; the younger the patients, the more readily they succumb to the attack, more particularly infants at the breast. In hereditary cases, the prognosis is decidedly unfavorable. Convulsions setting in at the commencement of the invasion of some acute disease, are scarcely ever dangerous. On the contrary, if the convulsions set in during the course of the disease, they almost always justify the most serious appre- hensions: they generally mean death. The clanger is greatest in the case of robust and corpulent children." Results.—More or less serious consequences may follow recovery, or rather partial recovery, in these cases. Ixehr very properly says "it is a question, in such cases, whether, such permanently remaining consequences of the attack do not rather originate in some cerebral disease which was likewise the primary cause of the attack. Among such consequences we number paralysis of the muscles of the eyes, less frequently of the muscles of the back, idiocy, or only a certain de<>ree of backwardness in the development of the mental faculties ac- CONVULSIONS. 37 companied with an unusual degree of nervous irritability." ()ther authors mention, as consequences of convulsions in chil- dren, chorea, chronic epilepsy, pains in the limbs, aphonia, deafness, ecchymoses, rupture of the tendons, fractures, dislo- cations, and even curvature of the bones; but the most common sequela is paralysis, or rather a paresis of certain muscles, espe- cially those of the face and-limbs, more particularly those of the eyes, eyelids, mouth and lower extremities; the former causing some degree of squint, and the latter an insecurity in walking or running. Treatment.—Too much stress cannot be laid upon the importance of removing the cause, whenever it is possible. As we have seen, many cases depend upon a sympathy with the digestive organs, and this should be removed by selecting a nurse whose milk will better agree with the infant, or, if weaned, with such articles of diet as are known to be most suitable in such cases. In some instances, an exclusive milk diet has been found sufficient to cure the disease; and I re- cently treated a case where nothing was found to agree with the infant but "condensed milk." It should be borne in mind, in this connection, that food that will cause convulsions in one child may be perfectly harmless to another, and vice versa. Irritation of the bowels is another prolific cause of con- vulsions in children. In such cases, of course, medicine will be of little avail unless specially directed to this particular point. There may be ansemia or hypersemia of the brain, and the cerebral condition may be the proximate cause of the attack; but if the exciting cause be irritation of. the bowels, whether in the form of diarrhoea, cholera infantum, enteritis, verminous irritation, or catarrhal congestion, nothing but the removal of the latter affection will permanently arrest the paroxysms. Nothing could seem to be plainer or more self-evident than this fact, and yet I have known physicians to prescribe Bella- donna day in and day out in such cases, when there was no other reason for giving it than the evidence of cerebral hypere- mia (?) manifested by sleepiness, and the clinical reputation of the remedy for convulsions. Dentition is a cause the effects of which can be ameliorated, 38 NERVOUS DISEASES. though not permanently removed. If fever is excited, it should be allayed by appropriate remedies, of which there is generally none better than Gelsemium. If vomiting occurs, and there is no watery diarrhoea, it is a suspicious cerebral symptom, and Gelsemium or Belladonna will probably do the most good; but if accompanied with a watery diarrhoea, Ipecacuanha or Mer- curius, either singly or in alternation, will be the most appro- priate. As for lancing the gums, though condemned by Bsehr, I have many times seen the simple and harmless operation relieve, not only the convulsive attacks, but the accompanying fever and diarrhoea. Baehr says it may retard the liberation of the tooth in consequence of the formation of cicatrices. This is not sound reasoning. It is evident that the tooth will cut through an inelastic substance, especially if unorganized, much quicker and easier than it will through one whose elas- ticity or sponginess is such that it cannot yield to the cutting process until it has become stretched by the advancing tooth to its utmost limit. What is known as "irritative fever," whether caused by worms, cold, or errors of diet, is an occasional cause of convul- sions, and should be treated by the indicated remedies. In the great majority of cases, Saidonine or Cina, with or without Mercurius, will speedily remove the fever, and with it the con- vulsions. Convulsions caused by sudden denudation of peripheric nerves by burns, blisters, etc., may be relieved by immediately producing an artificial skin over the exposed surface. For this purpose, Schuetz. forms a coating of coagulated albumen, by thoroughly pencilling the broken surface with a saturated solution of Argentum nitratum. We have found nothing bet- ter for this purpose than an application of equal parts of col- lodion and castor oil. This forms an impermeable and elas- tic covering that is not apt to crack, and is very suitable for small surfaces. If, however, the trauma is very extensive it is better to use carbolated vasoline and cotton wool in the usual manner of treating burns, as it will be likely to occa- sion less shock to the system. Convulsions arising from the irritation excited by the pres- CONVULSIONS. 39 ence of foreign bodies, as in the case of a worm in the mea- tus auditorius, or of a feather in the rectum, will require, of course, the immediate-removal of the offending substance. Sometimes this will be nothing more than a stray pin from the child's clothing, or crude ingesta in some portion of the prima viae. During the paroxysm, all the clothing liable to compress vital parts, such as the neck and chest, should be loosened, and plenty of fresh air admitted into the room. If dentition, cerebral congestion, or irritation of the intestinal mucous membrane, is the exciting cause, a warm bath, at a tempera- ture of about 98° Fahr., may be at once administered, as it tends powerfully to draw the blood away from the affected parts, and also to relieve the brain. But if the convulsions coincide with the eruptive stage of an exanthema, and especi- ally if the blood be very impure, as in malignant scarlatina, this will be found to be a very hazardous experiment, as I have never known it under such circumstances to be success- ful. In these cases the eruption has been found upon the surfaces of the cerebro-spinal meninges, and a more powerful agent, such as ice to the spine and head, is required to dis- lodge it. In ordinary cases, however, it is sufficient to cool the head by the application of a damp cloth frequently changed. Prophylactic Treatment.—Mothers and nurses should guard against becoming violently excited or over-heated, as at such times the milk is very unsuitable for the child, and even poisonous. Too frequent nursing or feeding is also deleterious, especially at night. The mother should therefore guard against this, by laying a proper restraint upon the child's de- sires, accustoming it to regular hours, not only in the matter of feeding, but in everything calculated to have an injurious effect upon the nervous system. Hence, very young children should never be rocked violently in a cradle, or jerked about in the nurse's arms, but should be allowed to remain as much as possible in a quiet recumbent position, until the muscular system is sufficiently developed to bear the strain of a more erect position. Of course, it is not only right, but de- 40 NERVOUS DISEASES. sirable, to endeavor to harden the system within reasonable bounds, but this should be done with the greatest possible care, especially if there is any predisposition to the disease. Above all things, the character and amount of clothing should be carefully regulated, so that the child may always be com- fortably clothed, without ever becoming over-heated on the one hand, or the temperature too much lowered on the other; especially should the child's head not be allowed to become too wrarm by an excess, or the feet too cold by a deficiency of covering. Medical Treatment.—Belladonna.—Most physicians look upon this remedy as a specific in infantile convulsions, espe- cially when accompanied with cerebral congestion. Bsehr says "it is without doubt the main remedy for eclampsia; most cases will be found to come within the curative range of this drug. It is particularly indicated in the case of robust and corpulent children with unmistakable symptoms of cerebral congestion. The symptoms of eclampsia occur in almost every case of poisoning with Belladonna, and demonstrate with re- markable accuracy the truth of the principle of similarity as a therapeutic maxim; for it will seldom happen that a second at- tack of convulsions will occur after the administration of Bel- ladonna." Illustration. 1.—Patient, set. 6, had the measles for three clays. Has now fright; wild delirium; sees visions; talks; tosses about; springs up in bed; has not slept for three nights; great prostration. Rhus3, every two hours. Afternoon, better, evening, worse. Furious delirium; rage; strikes; his father could scarcely hold him, and shortly he went into a spasm. Belladonna200, and in half an hour the child slept; better next day.—Dr. J. R. Temple. Illus. 2.—This case had a previous history. About a year ago I was called to see a little girl, about 6 years old, who was in a severe general convulsion, which lasted three hours. Pre- scribed Belladonna30. She remained unconscious all night but next day was conscious, and got well gradually. I learned that the convulsion came on with severe headache which was accompanied with constant gagging and swallowing, as CONVULSIONS. 41 though there was something in the throat that needed remov- ing. March 19, 1877, I was called to see the same child, who presented the same symptoms, with the addition of throbbing carotids and flushed face. The child seemed stupid, and it was with difficulty that she could be induced to answer ques- tions, and when she did it was with a jerk. These symptoms, together with our previous experience, led us to expect another spasm. I gave six pellets from the same vial of Belladonna, on her tongue, and sat by her for a half hour. This was all she needed. Before the end of the half hour she opened her eyes and told me that her head felt better, and she wished to sit up. There was diminished throbbing of the carotids, and less flush on the face. She got no more medicine.—Dr. C. W. Boyce. Gelsemium.—This remedy is equal to Belladonna in most cases. The symptoms specially calling for it, are:—Much ner- vous excitement, or else a stupid comatose condition, from which the child is aroused with difficulty; pain, often severe, in the back of the head and neck; cerebral hyperemia during dentition; child constantly boring its head into the pillow; cramps and spasm of the extremities, or of individual muscles; eneuresis at night, from weakness of the sphincter. Ilhis. 3.—October 8th, 1870, was hastily summoned to Mrs. N's infant, aged eight months. Child had already had three convulsions in rapid succession. Cause, irritation of teething. Child lay in a deep stupor; had passed faeces and urine uncon- sciously; occasional twitches of the flexor muscles of the fingers and toes; head hot, face pale, and extremities cold. Prescribed Gelsemium, lxdil., fifteen drops in half a glass of water, one teaspoonful every half hour, until consciousness should return, then every three hours only. Child had no more convulsions.—Hart. Ilhis. 4.—Called from church to see Mrs. W's child, aged eighteen months. Convulsions appeared to originate in cere- bral congestion. Tendency inherited. Child was very much excited; would strike at and attempt to bite its mother; pupils somewhat contracted; eyes staring; head hot and face flushed; gave Gelsemium as in previous case with the most satisfactory 3 42 NERVOUS DISEASES. results. Recommended the mother to keep the medicine on hand, and to give it whenever there were any premonitory symptoms of convulsions. She has since informed me that a single drop of the medicine (ixdil.) has always been sufficient to allay them.—Idem, Opium.—This remedy is indicated when the convulsions are caused by fright, or when accompanied by trembling of the body and limbs, tossing of the arms and legs, and shrill cries; also when there is lethargy with loss of consciousness, heavy breathing, and accelerated but feeble pulse; also when there is distension of the abdomen, difficult micturition and con- stipation. Illus. 5.—I was called about midnight to see a male child, about twenty months old, who, as far as parental knowledge extended, was quite well until near midnight, when the child waked up, apparently frightened, crying and screaming, at the full extent of its lungs; absolutely refusing all consolatory measures, and finally spasms broke forth in the midst of ex- treme tossing and restlessness. It jerked from head to foot, and threw its head back as far as possible, with upturned eyes, open mouth and quivering chin; legs and arms spread. This spasm was over when I reached the bedside. The child went from spasm to sleep; or rather, the spasm terminated in sleep—a heavy, gutteral breathing, with an occasional, pro- longed sigh; tremulous limbs, hard abdomen, and feeble, quick pulse, were the most prominent features present. After a half hour of this tiresome sleep, the child roused, screaming, tossing and trembling of head and limbs, with short, sudden jerks of the flexor muscles, and lapsed at once into a hard, ir- regularly developed spasm, with all the characteristics of the first. I at once gave Opium, SOth dil., every ten minutes. The spasm was a short one, sleep natural, and the babe recov- ered without any more spasms.—Dr. 0. P. Baer. Calcarea.—Convulsions occurring in scrofulous children especially when there are great disturbances of the circulation congestion of blood to the head, hands and feet cr0 to sleep bloated abdomen, white constipated stools, excessive peevish- ness, great muscular weakness, and frequent trembling of the limbs. CONVULSIONS. 43 Illus. 6.—Convulsions of little boy with light complexion and blue eyes; stools white as chalk; belly like a big pump- kin; croupy. Prescribed Calcarea carb.m; no more convul- sions.—Dr. Ilaivley. Camphor brom,—This remedy is particularly indicated in cases where there is a condition of cerebral anaemia, as in cholera infantum. Dr. Hammond recommends it for infantile convulsions due to the irritation of teething. He gives it in one grain doses every hour. Two children, aged respectively fifteen and eighteen months, required, one of them three, and the other but two doses, to effect a cure. It is especially ser- viceable in cases occurring in.the course of cholera infantum. Illus. 7.—R. R., aet. 15 months, vomiting of milk and drinks; temperature 105°; pulse 168; copious, watery, odorless evacu- ations, sixty within 24 hours; skin on thighs hung wrinkled and loose; constant unquenchable "thirst; rolling of head; coma vigil; has had two severe spasms. Camphor brom.,lxt x, 1 gr. every fifteen minutes till improvement. Improvement slight in 24 hours, but quite marked in 4 illustrate this particular class:—"II. Schneider, set. 23, soldier, received three months ago a bayonet-wound in the left upper arm. The bone was not injured, but the ner- vous medianus was, so that he suffered from complete paialysis and high-graded anaesthesia in the range of this nerve. Shortly after receiving this injury, severe neuralgic pnins and paresthesia of the hand and fingers set in; the external wound healed quickly, but about three weeks afterwards frequent clonic twitching appeared in the left arm, and four weeks later for the first time a perfect epileptic attack. Since then the shaking spasms of the arms, as well as the general uncon- scious epileptic attacks, returned three or four times a week. The epileptic attack is ushered in by a clonic spasm of the left arm, beginning in the finders and rapidly spreading upwards. There is no heredity in this case, nor did this soldier ever suffer before from any nervous disorder." Results.—The ultimate consequences to the patient depend upon both the frequency and the severity of the attack; al- though the former seems to influence the gravity of the result more than the latter, since it is found that, as a general rule, severe paroxysms at distant intervals arc less harmful than frequently repeated attacks, even of the petit mal. Sooner or later the epileptic, whose mental condition is always more or less depressed and gloomy, loses his memory, his intellect and 66 NERVOUS DISEASES. judgment become impaired, and he is gradually reduced to a state of imbecility; or he is seized, after oft-repeated and severe attacks, with insanity, sometimes assuming the form of acute mania, at others that of monomania. Occasionally the disease is attended with paralysis, or some other manifestation of organic change in the brain. Causes.—1. Predisposing causes: The most common pre- disposing cause is heredity. Not only do epileptics frequently beget epileptic children, but the hereditary tendency is also manifested by what is called the convertibility of nervous diseases. Thus, a choreic patient may have an epileptic child, and vice versa. The same is true of all nervous diseases. The hereditary tendency to the transmission of epilepsy, or of a morbid state closely resembling it, is well illustrated by the experiments of Brown-Secfuard upon guinea-pigs. This cele- brated physiologist, by the division of certain portions of the spinal cord, not only excited epileptiform convulsions, but the artificial disease thus produced continued long after the pri- mary effects of the injury had ceased, and in some cases was transmitted to. the offspring, becoming, like the natural disease in riian, hereditary. Another predisposing cause of the dis- ease, apparently, is malformation of the brain. This seems evident from the fact that epilepsy is most frequently met with in confirmed lunatics and idiots. 2. Exciting causes.—The exciting causes are numerous. The most common are: self-abuse, or any undue excitement of the nervous or sexual systems, amenorrhcea, fright, dentition, ver- minous irritation, especially that caused by ticnia, the sudden suppression of cutaneous eruptions or of purulent otorrheea, plethora, and the sight of other epileptics. " In one hundred and two cases treated by Dr. Hammond, in which evidence was received, the epilepsy originated from the following causes:— Over ineutal exertion................. ny Venereal excesses...... .......... ■■- Menstrual derangement................ IP Anxiety and grief................... lf) Indigestion.............,....... ,. Dentition....................... The remaining twenty-eight originated in frights, blows, sunstrokes, fevers, etc." EPILEPSY. 67 3. Efficient causes.—The chief efficient causes of epilepsy are such as produce cerebral irritation, namely, adventitious growths in the brain, inter-cranial tumors, blood-poisons, such as lead or absinthe, affecting the brain, etc. Whether true epilepsy can arise from such injuries, was for a long time a question still undecided, for, as Prof. Berger says, all cases must be excluded where, in consequence of severe palpable lesions, such as fracture of the brain, epileptic spasms set in as a mere symptom of the trauma. If the diseased state is chronic, and the inter-paroxysmal state free from traumatic symptoms, the case should be regarded as one of epilepsy. 4. Constitutional causes.—Under this head we include those conditions which some pathologists rank as special forms of epilepsy, such as the syphilitic. Such cases are not, of course, idiopathic, in the proper sense of that word, since, in the lan- guage of Schuetz, it is characteristic of pure epilepsy that no material or tangible cause can be shown for that disease, and whenever we find such a cause it determines our diagnosis, and the epileptic fits are only concomitant manifestations. By syphilitic epilepsy, according to Prof. Berger, we do not understand a case where, in the course of cerebral syphilis, epileptic convulsions are observed, but that syphilitic cerebral affection where, for a length of time, the epileptic spasms, without complication from other cerebral manifestations, offer the sole symptoms of the disease, and thus the picture of a common idiopathic epilepsy is falsely presented to us. In their monograph on "Syphilitic Nervous Disorders," Gios and Lancereaux report fourteen cases of syphilitic epilepsy, where during the whole course of the disease no other symptoms of a material cerebral lesion were observed. A cure followed in every case where anti-syphilitic treatment was employed, and the persistence of the cure could be shown years afterwards. Trousse.-iu and Pidoux report a remarkable case of a gentleman who was treated for years by the most celebrated physicians of London and Paris for his epilepsy, but so far without results. Anti-syphilitic treatment was then tried ; the epilepsy disappeared, and even after twelve ye.irs the cure could be considered permanent. Haubner describes as a peculiar form of syphilitic epilepsy the following group of symptoms:—Mental disturbance with epilepsy, imperfect paralysis, and a ter- minal, short, comatose state. In the midst of apparent health an epileptic attack suddenly sets in, followed after intervals by new ones, till finally other symptoms are observed. The epilepsy sometimes remains for a long time the only symptom. According to Fournier, epilepsy is a frequent symptom of cerebral syphilis, and appears mostly as epilepsia gravior. Though there are hardly any differential points from common epilepsy, we may regard syphilis as the cause of the disease where, immediately after the attack, transitory paralysis of an extremity, of half of 68 NERVOUS DISEASES. the body, or only of the fare is observed, or where the paroxysm remains imper- fect, partial, unilateial (hemispasm); in some cases even consciousness remains. Gros and Lancereaux consider the headache, preceding the fit for a longer or shorter time, as of importance, and Buyard leads our attention to the circum- scribed prodromal headache. Charcot describes a case where the fit was always ushered in by an exacerbation of a pain steadily localized at the right parietal bone, whereas the convulsions occurred on the left side of the body. Other au- thors report similar cases ; though in some of them the prodromal fixed headache and the spasms were on one and the same side. Still, says Berger, we must not forget that interparoxysmal headache is a frequent symptom also of idiopathic epilepsy. Fournier therefore lays great stress on the totality of the symptoms observed during the whole course of the disease. We find, in contradistinction to pure epilepsy, after more or less time, intervallary symptoms, such as head- ache, vertigo, sleeplessness, at first transitory then persisting, paralysis, neuritis optica, etc.; in other words, syphilitic epilepsy characterizes itself in its course as symptomatic, a pseudo-epilepsy, the clinical expression of a permanent cerebral lesion. Berger asks whether it is possible to diagnose syphilitic epilepsy at a time when the above-mentioned criteria are yet absent or unobserved. The age of the patient may throw some light on this question, for whereas idiopathic epilepsy de- velops itself preponderatingly during first and second childhood, the beginning of syphilitic epilepsy is only observed during manhood. In none of the cases ob- served by Gros and Lancereaux was the patient epileptic from childhood; in all of them the first paroxysm appeared at an age when it is only exceptionally ob- served in common epilepsy, and Fournier puts it therefore as an axiom that epi- lepsy, the first attack of which appears during manhood, should excite the sus- picion of syphilis as its cause. Where in a given case the usual causes of epi- lepsy, such as heredity, alcoholismus, trauma, etc., are wanting, and where sus- picion of syphilis is justified, and where the epileptic fit evinces the characters of partial, hemiplegic epilepsy, we may consider ourselves nearly certain in our diagnosis, whether at the time other manifestations of syphilis are present or not. With hardly any exception syphilitic epilepsy appears only several years after the primary infection, (one to eight years and over), and most authorities con- sider it a symptom of tertiary syphilis.* In brief, then, we have the following points of differential diagnosis: Syphilitic epilpesy occurs in patients who have not had epilepsy in early life, and who have reached the age of at least thirty years; the disease is frequently associated with or is followed by some form of paralysis, generally partial; the attacks are fre- quently preceded by headache, likewise partial, and the convulsions occur often, that is, many in quick succession, the interval between the series of attacks being comparatively long; the periods of quietude, however, are not free from headache or other nervous symptoms, which exist and often become aggravated; conditions contrary to what usually obtain in idiopathic epilepsy. Treatment.—It must be confessed that the medical treat- ment of epilepsy, whether by allopathic or homoeopathic thera- * Zeitschrift fuer Pract. Med., July, 1878. EPILEPSY. 69 peutics, is on the whole anything but reliable or satisfactory. True, very many cases of genuine epilepsy have been cured, and doubtless a much larger number would have yielded, had the treatment been persisted in for a sufficient length of time; but our eleemosynary institutions bear ample evidence of the fact, that a large proportion of such patients never re- cover, even under the most favorable circumstances. Regard- ing all such cases, therefore, as proper subjects for even pallia- tive treatment, we shall not attempt to confine ourselves here to the strict application of our therapeutic law, but shall en- deavor to give a fair, but brief resume of the best clinical experi- ence of both schools. During the fit.—The patient should be placed in a comforta- ble position, and, if practicable, on a bed or lounge, with the head slightly elevated, and all portions of the clothing that interfere with the respiration or circulation, removed or loos- ened ; fresh air should be freely supplied to the patient, his tongue should be protected by placing a piece of cork or a small pad between the molar teeth, and, if exposed to the glare of the sun, a black silk handkerchief or cloth should be placed lightly over the face. Beyond this nothing should be done, except what maybe necessary to guard the patient from injury during the period of unconsciousness that usually follows the attack, and which should be allowed to pass undisturbed. Between the fits.—During the interval between the fits, an en- deavor should be made to discover and remove, if possible, the condition which is the essential element of the disease, namely, the efficient cause; and if this is found to be of such a nature as not to admit of removal, then the exciting cause, if it can be ascertained, should be carefully guarded against or re- moved; and such preventive or palliative measures should be made use of as ma}' be best calculated to diminish the fre- quency and severity of the attacks. At the same time the in- dicated remedy, which if it does not prevent will in most cases mitigate the severity of the succeeding paroxysms, should always be given; and as this, even when rightly chosen, will in most cases require to be given during a period of several months, unusual care should be observed in making the selec- tion. 70 NERVOUS DISEASES. Synopsis of Treatment.—Amm. brom., Bellad., Hydr. ac, Ignat., Kali brom.; recent eases—Arg. nitr., Arson., Cupr. ac.,. Cupr. am., Ferrum, Calcar., Bufo, Cocc. ind., Sulphur, Zincum; chronic cases—China, Ferrum, Phosphor., Phos. ac, Sulph. ac; from self-abuse, excessive sexual indulgence, etc.—Aeon., Opium; from fright, the former when there is fever—Artem. vulg., Cina, Santon., Teuc; from verminous irritation—Bellad., Chamom., Gelsem.; from dentition—Kali iod., Merc corr., Nitr. ac; syphi- litic epilepsy—Chloral hydr., Kali brom.; petit mal.—Arnic, Amyl. nitr., Agar., Ourar., Cann. ind., Cicut, Glonoin, Hvosc, Plumbum, Staphis., Stramon., Zizia, Tereb.; remedies which have been used successfully in some cases. Belladonna.—Previous to the attack, headache, throbbing in the temples, dilated pupils, intolerance of light, redness of the face, and other symptoms of congestion of the head. During the intervals, anxiety, fear of imaginary things, disturbed sleep, vertigo when in motion or at rest, congestion of the face, burning dryness of the eyes, peevishness, twitching and jerk- ing during sleep, Illus. 21.—Young man, set. 22, has suffered with epilepsy seven years; the attacks return every week or ten days, and are preceded by headache, throbbing in the temples, intoler- ance of light, dilated pupils and vertigo. During the intervals there is redness of the face, vertigo when in motion or stoop- ing, constant fear of falling, restlessness at night, anxiety, fear of doing something wrong. Cause unknown; father was a monomaniac, but free from epilepsy, and sane on all subjects but one, jealousy. Had been treated both allopathically and homceopathically, for four years without benefit. Exacted a promise that I should have at least one year in which to effect a cure. Gave Belladonna200, night and morning, for one month with slight improvement; less headache and paroxysms some- what less frequent, but patient peevish and impatient. Chanced to Ignatia30, to be taken in the same manner; in three weeks' time, patient as bad as ever. Returned to Belladonna, 200th dil., and gave it without interruption for the next nine months with the result of affecting an apparent cure. The paroxysms gradually diminished in frequency and severity, until about EPILEPSY. 71 three months ago they ceased altogether. During the last five weeks the patient has taken no medicines whatever, has had no return of the fits, and appears well.—Dr. R. T. Lootze. Illus. 22.—Boy, set. 12. The attacks, which return every week, are preceded by headache and throbbing in the temples. He has had epilepsy for the last four years. Cause unknown. Belladonna3, every night and morning, has effected a complete cure.—Dr. Bojanus. Cannabis indica.—Headache, especially through the temples, with vertigo; glimmering before the eyes, redness of the con- junctiva, noises in the ears, head feels as though it would burst; great exaltation of spirits, and of bodily and mental vigor. Illus. 23.—Mrs.----, set. 56, has suffered from epilepsy for forty years. Her treatment during this period was something ■ wonderful. She had one unfailing premonition of an approaching at- tack, which was a feeling of extraordinary mental and physi- cal vigor—an almost ecstatic exaltation of all the powers of mind and body. Her account of this premonitory condition reminded me of my own sensations when taking Haschish, as I once did for experiment. I prescribed Cannabis indica, there- fore, about one-tenth of a drop at a dose, every hour when she felt "exalted." It is now nearly three years since she com- menced the use of the remedy, and she has had but one slight seizure during that time, whereas before taking the Cannabis, she had about thirty annually.—Dr. R. A. Poster. Staphysagria.—Great sensitiveness of the mind and nervous system; vertigo, vanishing of the ideas, anxiety with tearful- ness; headache as if the brain were compressed; great weak- ness, with spasmodic drawings and twitchings in the muscles; tendency to paralysis; bad effects of masturbation or excessive sexual indulgence. Illus. 24.—G. M., set. 60. For fifteen years has had epilepti- form convulsions with loss of consciousness; retraction of thumbs, and foam at the mouth; attacks every one or two months. Cause, had been unjustly accused of infidelity. Gave Staph i/sagria'M), every morning. Five years have passed without a return.—Dr. Cigliuno. 72 NERVOUS DISEASES. Opium.—Convulsions caused by fright, or where the mental functions are specially affected; it has also been strongly recommended for cases where the fits occur during sleep; pupils dilated, eyes only half closed. Illus. 25.—Subject, a little girl, who had been afflicted with the disease for a number of years. Both allopathic and homoe- opathic treatment had been tried, but as yet without any beneficial result. I found my patient with all the symptoms of epilepsy; great convulsive movements, with foaming at the mouth, etc. During the fit the child kept its ewes only half open; it would neither close them tightly, nor would it any more than half open them. Learning that the child had, previous to the attack, been frightened by a large dog, I prescribed. O/mort*00. The patient, after taking the medicine, went to sleep and slept all day, and has not had any return of the attacks. It has now been almost three months, and. before it never passed a week without them.—Dr. H. Reynolds. Kali bromatum.—This remedy is now extensively employed by both schools. It cannot be denied that, in the majority of cases, if judiciously and perseveringly used, it diminishes the severity of the attacks, lessens their frequency, and in many cases effects a complete cure. According to Dr. Riedel, of Ber- lin, it so contracts the small vessels as to diminish the reflex activity in the nerve-centres, and so reduces both sensibility and muscular irritability. Its effects are most striking in recent cases. In the usual large doses in which it is given (grs. x to xx ter die.,) it is not suited for attacks of the petit mal; though I have verified Dr. Hammond's observation in such cases, the symptoms disappearing on suspending the use of the remedy. It is probably the best palliative remedy that we have, espe- cially in traumatic cases, in which it often proves curative. Ulus. 26.—M. H., set. 13. At intervals of seven, ten and fifteen days, is attacked, usually at four o'clock, a.m., with epileptic spasms. At fourteen the catamenia appeared, and it was hoped that this change would put an end to the attacks; but they still continued to return, without mitigation or change of time. Stramonium, Cuprum aceticum, and electricity, were all tried, but without producing any permanent benefit. I EPILEPSY. 73 then prescribed Kali bromatum, two drachms to half a pint of water, a dessertspoonful three times daily. The relief being greater than at any previous time, she was given three grain doses, three times a day at first, then increased until she took ten grains at one dose, all the time improving. Hoping the doses might be lessened, I began to diminish them, but it would not do, and ten and twelve grain doses were henceforth given until the case was entirely cured, which was in about six months. No ill effects have resulted, and the patient has remained well eight months. She is now eighteen years old, and appears perfectly healthy.—Dr. E. G. Cook, Kali iodatum.—This remedy is especially adapted to syphi- litic cases, in which it has wrought many notable cures; it has also proved curative in some recent cases of pure epilepsy, and ameliorative in some chronic ones. Four years ago I succeeded in curing a case of petit mal, of traumatic origin, in a boy four- teen years of age, on which I was unable to make any lasting impression with any other remedy. Kali bromatum seerned to do some good, so far as lessening the frequency and severity of the paroxysms, which were of daily occurrence, but they were not permanently interrupted until I had given Kali iodatum, 1 x dil., for about ten days, when they ceased altogether, and have not returned. Illus. 27.—E. F., set. 11, fell down stairs and struck his head. He became immediately unconscious, although no lesion could be observed, except a swelling around his left eye. This unconsciousness lasted full four wTeeks, and when he awoke the faculty of speech was found greatly diminished; no paraly- sis of face or of the extremities was present. Three months afterwards, the patient appeared well enough to re-enter school. Towards evening the boy showed a congested face from mental excitation, but he never complained of headache or vertigo. About two and a half years after the fall the first epileptic fit appeared, after a little more than the usual mental strain. Since then he has had many fits at longer or shorter intervals. Prsecordial anguish, dullness of head, vertigo, heaviness of the tongue precede the attack, then absolute coma and convulsions. During the intervals the patient is perfectly healthy, never 5 74 NERVOUS DISEASES. complains of headache, but is irritated and easily angered. Kali bromatum and Atropine failed, but Kali iodatum steadily given for three months, has kept the fits away for the last eight months.—Profi. C Berger. Amyl nitrite.—It has been conclusively proven that the in- halation of the nitrite of amyl during the epileptic aura will, in most cases, prevent the further development of the paroxysm. It is not yet decided whether it is capable, of itself, of curing epileptic convulsions, but experience shows, that after the inhalation of a few drops, two or three times, the blood circu- lates more rapidly, the face, neck and head are flushed, the pulse becomes fuller and quicker, and the convulsions almost instantly cease and do not return again for many hours. In connection with Atropine and Kali bromatum, the convulsions have been prevented for several months.—Dr. J. Muximowitsch. HYSTERO-EPILEPSY. 73 CHAPTER III. HYSTERO-EPILEPSY. The most diverse views are now entertained regarding the nature, the cause, and even the very existence of hysteria. Schuetz, whose monograph on Convulsions has, perhaps, no superior in any language, says "hysteria and hypochondria disappear from the text-books of our age, and live only in the memory of the laity and old fogy practitioners. In former times, all manifestations standing in connection with morbid states, disturbances, or irritation of the uterine system, were denoted by the same general name of hysterical states, without making any very exact examination of the uterus and its adnexa; it was considered characteristic of hysteria that it had no characteristic symptoms, and that it may manifest itself in ever so many diverse ways, and the uterus must be somehow complicated with it." On the contrary, Dr. Reynolds, whose views on this point coincide with those of the majority, and whose definition of the disease is perhaps one of the best that can be given, says: "The hysteric state is essentially one of mental perturbation, and it is brought into existence, if not inherited, by those conditions which are most active in pro- ducing disorder of the mind—in the male sex by worry, anxi- ety, overwork, late hours, accidental injuries, and dissipation; in the female sex by vexatious emotions, want of sympathy or success, disappointed or concealed affection, want of occupation, fear, and morbid conditions or supposed morbid conditions of the reproductive system. ... It would appear that the nutri- tion of the whole nervous system is changed, but that change is of such a kind that it passes beyond our power of recognition, 76 NERVOUS DISEASES. except in its physiological or pathological effects. A\ e cannot see degeneration of tissue here, or too rapid metamorphosis there, but we can witness the effects of such morbid processes in movement in secretion and nutrition, and we observe some of the ultimate results of such changes in emotion and sensa- , tion." We differentiate, therefore, between hysteria, properly so called, which we regard chiefly as a form of mental derange- ment, and the nervous or reflex phenomena constituting the so-called hysterical fit; the latter being for the most part a convulsive affection, and an accidental or incidental accom- paniment or complication of the former. Consequently, we have placed hysteria, where we think it more properly belongs. under the head of " Moral Disorders;" and shall here treat of only one of its many protean forms or phases—namely, that now commonly designated as b^stero-epilepsy. History.—We are indebted chiefly to M. Charcot, whose ex- tensive experience in La Salpietriere fully qualifies him to speak authoritatively on the subject, for a clear and satisfac- tory description and diagnosis of hystero-epilepsy. His views regarding the genuineness and distinctive character of the af- fection have also been confirmed by other French observers, especially MM. Dubois, Briquet and Tissot; so that the opinion of those who deny its existence, or the possibility of a satis- factory differentiation between it and hysteria on the one hand or epilepsy on the other, and whose field for observation is known to be comparatively limited, appears to be entitled to but little weight. That both epilepsy and hysteria, as distinct diseases, may for a time coexist in the same patient, has long been admitted. The cases are not infrequent in which those suffering from chronic epilepsy have been attacked with some form of hys- teria, which, instead of superceding the original disease, has only added to the sufferings of the patient. On the other hand, the instances are still more common, where epilepsy has set in, and run its usual course, in well-known subjects of hys- teria, without the latter interfering in the least degree with its development or progress. Such cases are both interesting and HYSTERO-EPILEPSY. 77 instructive, but are not included in the disease at present under consideration. The term hystero-epilepsy is applied only to those cases in which the paroxysms consist of both hysterical and epileptic symptoms combined, and not to those in which hysteria and epilepsy are associated as distinct diseases, each being charac- terized by its own peculiar symptoms. In the former the par- oxysms resemble those of true epilepsy, and yet they possess features of such a distinctive character as to admit of ready recognition by those to whom the characteristic symptoms are familiar. As we should expect, the women most prone to hystero- epilepsy are those who are likewise most subject to attacks of ordinary hysteria, namely, such as are of a highly emotional nature, of exalted impressionability, and full of romantic no- tions; girls addicted to novel reading, whose passions have been unduly excited, and chiefly at the expense of their phy- sical well-being; women whose nervous systems are not well- balanced, whose minds have not been properly cultivated, and who, perhaps, have inherited a trace of insanity or of moral obliquity; those in short whose mental equilibrium, without being actually upset, is nevertheless weak, unstable and easily disturbed. In addition to this, there is in most cases a Aveak- ened condition of the sexual organs, and especially an irritable state of the ovaries, one or both of Avhich are always implicated, the left more frequently than the right. This hyper-sensitive- ness of the ovaries may result either from self-abuse, excessive sexual indulgence, menstrual irregularities, or any cause cap- able of producing ovarian congestion. In Avhatever Avay ex- cited, it is highly probable that these organs act as reflex centres of the disease. Symptoms.—The initial symptoms are usually of an epilep- tic character; but the aura, instead of being seated in the head or extremities, is always abdominal. It is also of longer dura- tion than the epileptic aura, occupies chiefly the epigastrium, and never takes the form of vertigo. Warned of the ap- proaching fit, the patient appears greatly alarmed, turns pale, utters a characteristic cry, and falls unconscious to the ground. 78 NERVOUS DISEASES. The tonic stage now sets in, exhibiting many of the features of ordinary epilepsy. The face becomes livid and swollen, the features horribly distorted, the jaws locked, and the mouth and lips covered with bloody foam; at the same time, the limbs become rigid and almost immovable, being subject only to slight oscillations, which are chiefly unilateral. After a time this tonic rigidity suddenly gives way, the muscular sys- tem becomes relaxed, and the patient sinks into a state of pro- found coma, accompanied with heavy and stertorous breathing. So far the paroxysm exhibits the type of genuine epilepsy; but now comes the hysterical phase of the disease, the appear- ance of which is coincident with the clonic stage. And as the tonic stage differs from the corresponding stage of epilepsy chiefly by being more out-spoken, more tetanic as it were, so the clonic stage is pre-eminently hysterical. In this, it is ap- parent that the muscular movements are intentional; though varied and eccentric, they are expressive of the passions which at the moment occupy the mind of the patient. Now they show her to be actuated by the most intense hatred; now love fills her bosom and dictates every movement; now fear haunts her mind, and she shrinks from the objects of her terror; and now joy lights up her countenance, and beams in every feat- ure. At last the storm of passion breaks forth in all its fury; the patient lives entirely in a creation of her own fancy; the moral nature seems shaken to its very foundation, and modesty, prudence and self-interest no longer control her actions. The storm of passion sweeps over her soul like a hurricane; all that is beautiful, and anon all that is hideous and revolting, is realized in her imagination and mirrored in her actions, which at one time express the higher and at another the loAver passions of her nature. Thus, having undergone, as it were, every imaginable experience in the heavens above or the in- fernal regions below, she returns, with violent sobs, into the world of consciousness and reality. Diagnosis.—Although hystero-epilepsy is a rare form of disease in this country, it is doubtless more common than our medical statistics indicate. I have myself met with no less than three Avell-marked cases, one of which was diagnosed as HYSTERO-EPILEPSY. 79 epilepsy by one consulting physician, and as hysteria by two others. In fact, it has hitherto generally been the practice to call all cases hysterical that displayed to any extent hysterical features; the greater the diversity in the symptoms, so far as similating other diseases was concerned, being regarded as especially characteristic of that affection. Hence, what have appeared to be merely different phases of the disease, have generally been characterized as epileptiform hysteria, chorea- form hysteria, apoplectiform hysteria, and so on, according as it assumed either one or another of these various types. This distinction, however, though sufficiently coirjct for the great majority of hysteriaform cases met with in general practice, is not at all precise when applied to the disease under considera- tion. This will be evident from the following points in the differential diagnosis between epilepsy and hystero-epilepsy: 1. Hystero-epilepsy differs from pure epilepsy in never, even when of many years' duration, leading to dementia; the intellect always remains unimpaired by the disease. 2. The epileptic group of symptoms is never complete, and never appears in connection with, or under the form of, the petit mal; it never assumes the form of vertigo epileptique. 3. Compression of the ovaries always modifies the attack, and sometimes completely arrests it; effects which are never produced in true epilepsy. 4. As in hysteria proper, the general state of health is not often seriously affected: and even when a great number of paroxysms happen in rapid succession, fatal consequences very rarely ensue. Indeed, in ordinary cases, not even nutrition is apt to suffer to any great extent. Thus, one patient referred to by M. Charcot had the disease in its severest form for forty years, and another had no less than two hundred paroxysms within twenty-four hours, and yet survived the attack. 5. When, after a long series of fits, a thermometrical com- parison is made between the two diseases, a marked difference of temperature is observed. In hystero-epilepsy, even when the series of paroxysms lasts for months, the thermometer never registers above 38.5° C. In true epilepsy, on the con- trary, under similar circumstances, the thermometer rises 80 NERVOUS DISEASES. considerably higher than this, even when the disease is not complicated with apoplectic or meningetic congestion, in Avhich latter case the thermometer still continues to rise, until it may indicate a fatal termination. Causes.—The predisposing causes are such as undermine the constitution and vitiate the mind, such as an aimless course of life, faulty education, hereditary tendency, etc. The exciting causes are late hours, nervous exhaustion, mental depression, deficient nourishment, adverse hygienic conditions, or any agency calculated to irritate, overstimulate, or exhaust the genital organs and functions, or lower the vitality of the system. The essential or efficient cause is a diseased state of the sexual apparatus, especially of the ovaries. Pathology.—Although a diseased state of the ovaries un- doubtedly exists in these cases, as shown by the invariable effect produced by their compression, no reliable pathological change has yet been demonstrated, either in these or in any other organs; enough, however, has been established to render it highly probable that the ovaries constitute the centres of reflex irritation whence originate the cerebral and spinal symptoms. The blood also may be more or less depraved, as in ordinary hysteria, but this point has not yet been fully established. Treatment.—Hitherto these cases have been chiefly treated by the allopathic practitioners into whose hands they have mostly fallen; consequently, homoeopathy has as yet but little to offer on this subject in a clinical point of view. In old- school hands the result, so far as regards cure, has invariably been unfavorable; but knowing the great superiority of our treatment in nervous diseases generally, we may reasonably expect, by a strict adherence to the homoeopathic principle in its treatment, to present a more favorable report. The most important point, doubtless, is, first of all, to seek to improve both the moral and physical condition of the patient. The dimin- ished vitality should, if possible, be raised to the normal stand- ard by suitable hygienic treatment, and the power of self-control should be aided and strengthened by proper advice and disci- pline, the observance of regular and correct habits, and the HYSTERO-EPILEPSY. 81 administration of such remedies as have a specially tonic and healthful action on the sexual organs. As the field of curative action in these cases is very unfavor- able, partly by reason of the nature of the disease, and partly by the fact that the neuroses often become habitual, and there- fore particularly obstinate to remedial influences, especial care should be taken, before selecting a remedy, to find out all the important antecedents in the case, such as whether the parents are perfectly healthy, whether they have ever been similarly afflicted or have suffered from any form of mental derange- ment, or whether the patient herself has been affected with any nervous disease prior to the present attack; in other words the prescription should be based upon the entire obtainable history of the case, and upon the totality of the symptoms, both sub- jective and objective. We have already referred to the beneficial effects produced by compression of the ovaries. Dr. Chairon claims that such compression so excites the reflex sympathies of the epiglottis and of the larynx, as to produce the globus hystericus, dys- phagia, etc., which pertain to fits of hysteria. From this it appears that ovarian compression is truly homoeopathic to the premonitory symptoms of the disease. Moreover, Charcot and Bourneville have obtained the best results by the application of the ice-bag compress for several hours a day on the ovarian region. The hystero-epileptic attacks decreased and the gen- eral health improved. Whenever there is an ovarian aura, the breaking out of the fit can be prevented.* Amyl nitrite.—In hystero-epilepsy, even Avhen there is not a complete cure, very great improvement may be obtained by the use of this remedy. In a very severe case, in which the paroxysms were nearly an hour long, and which had proved rebellious to ice compresses, inhalation of chloroform, etc., the inhalations of five drops of the nitrite of amyl gave complete relief. A second attack was cut short in the same manner, and the patient was cured by this and other nervines.—Dr. J. Maximowitsch, * Med. Cent. Zeit., 36, 1877. 82 NERVOUS DISEASES. Cannabis indica.—This is the remedy from AA'hich we obtained the best results in the three cases above referred to. We used the third decimal dilution, five drops in half a glass of water, giving a teaspoonful three times a day. We administered the remedy during the week immediately before and after the menstrual flow, and omitted it during the remainder of the intermenstrual period. One case was apparently cured, the patient remaining free from attack for more than two years. The others have been greatly benefited, the paroxysms having become much less frequent and severe. Perhaps, if the medi- cine had been used higher, the result in these cases would have been more satisfactory. As it is, the remedy is the compeer of any that has been tried, and I hope it will be faithfully tested in this class of cases whenever opportunity offers, as its patho- genesis presents a perfect picture of the disease, and fully war- rants us in expecting the happiest results from its faithful and judicious employment. CHOREA. 83 CHAPTER IV. CHOKEA. The derivation of the word chorea is the same as that of our English, or rather anglicized Latin term chorus, both words having originally the same signification—namely, that of a company of singers and dancers. By modern writers it is used to denote the disease called "St. Vitus' Dance," a spasmodic affection of the voluntary muscles, characterized by the pecu- liar irregularity, permanence, and partly voluntary nature of the motions. German writers make two distinct forms— namely, chorea magna, or Germanorum, and chorea minor, or Anglorum; but as the difference between them is probably only one of degree, we shall describe them both under one and the same heading. It is proper to remark, however, that Von Ziemssen does not regard chorea magna as a form or modifica- tion of true chorea, but "as a degenerate form of hysteria, the causes of the latter playing the chief part in its production, and in exaggerating the simulated spasms to the form of chorea magna." Chorea is pre-eminently a disease of childhood, occurring for the most part between the ages of six and sixteen, most frequently between the tenth and fourteenth years. Although it is a rare thing for it to occur earlier than the sixth, or later than the sixteenth year of age, it is sometimes met with during infancy and also during mature life. In the latter case it is most apt to oc'cur in individuals of a tuberculous constitution, or in those whose blood is otherwise depraved. Symptoms.—Sydenham's description of the ordinary form of chorea is so graphic, and at the same time so accurate, that 84 NERVOUS DISEASES. we shall make no apology for quoting it. He says it is " a spe- cies of convulsion which for the most part attacks boys or girls, from the tenth year to puberty. It first announces itself by a kind of halting, or rather instability of one leg, which the pa- tient drags after him, as idiots do. Afterwards it shows itself in the hand of the same side, which, when applied to the chest, or any other part of the body, cannot be retained in the same situation by the patient even for a moment, but is twisted about from one place to another, however much he strives to prevent it. If a full vessel be given him to drink from, before he can bring it to his mouth he exhibits a thousand gesticula- tions, like a mountebank; for as he cannot carry the cup in a straight line to his lips, the hand being diverted by the spasm, he tips it from side to side for some time, until at length, by good fortune, approaching it nearer to his lips, he jerks the liquor suddenly into his mouth and drinks it with eagerness, as if the poor creature were merely performing a feat to excite the laughter of by-standers." In some cases the spasmodic action is so intense that the patient finds it utterly impossible to execute any voluntary movement. As a consequence, he is unable to either dress or feed himself, and has to be cared for like an infant. Although unable to walk or even to stand, he is never still, but is thrown and jerked about in a most violent manner. He is not safe even in bed, but is liable to be thrown out at any moment. This gives rise to bruises and abrasions of the skin, and in some cases to broken bones; eczematous eruptions are also met with, caused partly by the incessant rubbing and attrition, partly by neglect or want of cleanliness, and partly by the lack of inervation attending the disease. In the majority of cases, however, the disease is much milder, and these consequences do not ensue. The patient is able to perform most voluntary movements, but only in an aAvkAvard and imperfect manner. This arises not from the want of power to execute the movements, but to their being interrupted by spasms; and these are not unfrequently increased in violence by the very efforts of the patient to subdue them. When gen- eral, all the muscles of the body may be effected, except the CHOREA. 85 muscles of the external ear, and the sphincters of the bladder and rectum. When partial, they are either limited to the muscles of one side of the body (hemichorea), or to particular groups of muscles. Those of the face are especially implicated, producing in turn every conceivable variety of physiognomical expression. At one moment the patient laughs, then frowns, winks, squints, grins, darts out his tongue, twists his nose or his jaws to one side, and all in such a rapid and grotesque manner as generally to excite the humor rather than the sym- pathy of observers. When the musles of the neck are involved, the head moves up and down or from side to side in an equally ludicrous manner, the movements being of a tortuous char- acter, arising from the attempt on the part of the patient to counteract them. Speech is generally rendered quite unintel- ligible, owing to the respiratory and laryngeal muscles being implicated. The respiration is also unequal and irregular, showing that the diaphragm and abdominal muscles are affected. Other forms or varieties also occur, one of the most inter- esting of which is that called hemichorea, before referred to. In this the disease, or rather the spasmodic movements, are confined to one side of the body, generally the left; this is also the side which, as a rule, is most severely affected in bi-lateral chorea. Of the Avhole number of cases of hemichorea that I have treated, or that have come under my notice in public and private practice, over seventy per cent, have been of the left side. Another form of the disease is that known as chorea paralytica. These are generally cases of hemiplegia, in which the paralyzed muscles are affected with the irregular movements of chorea. Sometimes the disorderly movements set in after the paralysis, constituting post-paralytic chorea. Such cases are closely allied to the affection termed paralysis agitans. Dr. Bastian says of these cases:—"These choreic movements are not to be con- founded with occasional attacks of tonic spasm, occurring in the arm especially, of certain hemiplegic patients who are also subject to unilateral convulsions. Such an attack may exist alone, or it may at other times prove merely the first stage of 86 NERVOUS DISEASES. a complete fit, with unilateral convulsions and loss of con- sciousness. The alliance of such spasms is distinctly with the epileptoid condition, whereas the alliance of the more con- tinuous twitchings or clonic spasm, to which we are now more especially referring, is as distinctly with the choreic state. In fact, just as a unilateral chorea may give place to a unilateral paralysis, so may a hemiplegic condition as it disappears favor the manifestation of one-sided tremor, or of an abortive hemi- chorea." Differentiation.—One of the most characteristic features of chorea is the inco-ordination of movements. In chorea magna the co-ordinative disturbances appear to originate in certain centres of irritation, and are transmitted centrifugally from the cells of the cerebral cortex to the affected muscles. Hence the spasmodic movements are limited to certain groups of muscles, corresponding to the centres of irritation, and are more irregular, more uncertain, and more paroxysmal, than in chorea minor. In the latter the movements are to a greater or less degree continuous, except at night, when they generally subside; in chorea magna, on the contrary, the paroxysms are just as liable to occur during sleep as when the patient is awake. Again, in chorea magna the muscular movements are not only paroxysmal in character, but are usually preceded by prodromata affecting both the motor and sensory systems, and also the physical functions. These prodromata, however, or what are considered as such, are often only imperfectly developed phenomena of the same general character as those constituting the paroxysm itself. In these cases we may have, in addition to the peculiar spasmodic movements, pare- sis, amesthesia, analgesia, ecstacy, and cataleptic or tetanic convulsions. In milder cases the psychical phenomena are not so pronounced, although in most cases the special senses are more or less affected, and there may also exist a loss of consciousness. Others are characterized by hallucinations of the senses, and especially the sense of sight; or the faculties of the intellect or of memory may be disturbed or impaired. Mental disturbances have also been observed in chorea minor but as a general rule there is not much disturbance of con- CHOREA. 87 sciousness in this form of the affection. The motor system is the one chiefly implicated, and when the cranial nerves are irritated, may affect the speech. Von Ziemssen, speaking of chorea of the laryngeal muscles, says that by means of the laryngoscope we may " watch the restlessness of the laryngeal muscles, the twitching contractions of the closers, openers, and tensors of the cords." Dilatation of the pupils has been ob- served in some cases, and when binocular indicates serious lesion of the brain; generally, however, it is a reflex symptom, arising simply from irritation of the sympathetic; from dis- order of the digestive organs, spinal irritation, or helminthiasis. Causes.—The chief predisposing causes are age and sex. Although not limited to childhood, the disease, as already stated, is much the most frequent between the ages of six and sixteen. Previous to puberty, or rather to the congestive period immediately preceding it—that is to say, before the age of nine or ten years in girls, and fourteen or fifteen in boys—both sexes appear to be equally liable to the disease; but after that period it is more apt to occur in the female sex. The exciting causes are mostly such as give rise to ordinary convulsions, such as fright and other mental emotions, the second dentition, verminous irritation, onanism, derangement of the menstrual functions, anaemia, rheumatism, and " ocular contagion"—that is, the liability of susceptible persons to con- tract the disease by seeing or imitating it in others. This im- itative propensity, if we may so call it, shows that the disease in some of its forms is closely allied to hysteria. In fact, cho- reic patients generally possess the " nervous " temperament to a high degree, having in most instances inherited it. The essential causes of chorea are more obscure. The same lesions are found in hemichorea as in epileptic hemispasms and in hemiplegia—namely, venous congestion of the brain and cord, meningeal hemorrhages, softening of the cord, and inflammatory thickenings of the spinal nerves. Hence Ave find the same groups of muscles affected in hemichorea as in hemi- spasms. The frequently unilateral form of the disease, and its occasional association with hemiplegia, have been regarded by the majority of British observers, especially Drs. Todd, Rey- 88 NERVOUS DISEASES. nolds, Parks and Mackenzie, as establishing the cerebral origin of the disease; on the contrary, MM. Carville, Chauveau, and other French authorities, have endeavored to show that the brain is not in any way implicated in the disease, but that it is due exclusively to histological changes in the posterior horns of the grey matter in the centre of the spinal cord. Perhaps some light may be thrown upon this important ques- tion by considering the nature of the relation which rheu- matism sustains to chorea. Romberg, Grisolle, and others, consider rheumatism and rheumatic affections of the heart as merely accidental complications of chorea; but M. Rogers is of a very different opinion. He says:—"The coincidence of chorea and rheumatism is so common a fact, that it ought to be regarded as a pathological law, just as much as the coinci- dence of heart disease and rheumatism." This statement is confirmed by the observations of the late Dr. Hughes, of Guy's Hospital, who found that out of 104 carefully observed cases, only 15 wrere free from cardiac murmur and had not suffered from rheumatism. That the cardiac murmur was due to rheu- matic endocarditis, is shown by the fact that out of 14 fatal cases of chorea recorded by this observer, 11 cases exhibited vege- tations upon the cardiac valves. Dr. Kirke's experience, also, led him to the conclusion that chorea was connected with chronic mitral disease of the heart, depending upon or asso- ciated with rheumatism. The theory is, that portions of the fibrinous vegetations or granules deposited upon the cardiac valves are washed off, while soft and easily disintegrated, and carried into the circulation, and thus find their way as micro- scopic emboli into the capillary vessels of the cerebral tissue, giving rise to lesions that interfere more or less with the nutri- tion of the brain. Now, if this theory is correct, we can easily understand that individuals so affected would be much more liable to be brought under the influence of the exciting causes of the disease, and thus account for the frequency with which the two affections are found to be associated. But it seems to me that this explanation is somewhat remote, as well as hypo- thetical, especially as the very existence of the supposed emboli remains to be demonstrated; and that a more simple and CHOREA. 89 satisfactory explanation of the connection in question may be found in the pulmonary and cerebro-spinal congestion arising from mitral insufficiency. It is freely admitted that much disease may exist on the left side of the heart without giving rise to urgent symptoms; but such patients are known to be often troubled with dreams and other forms of mental disturb- ance, and it is therefore reasonable to suppose that the cerebral and spinal motory centres may be sufficiently irritated by it to giAre rise to the spasmodic movements of chorea. But although chorea is often of cerebral origin, it is very far from being exclusively so. Dr. Elischer mentions the case of a woman, aged 22, who had attacks of chorea at the ages of eight and sixteen. She became pregnant when nineteen years old, and at the sixth month of her pregnancy the chorea re- turned and lasted up to her confinement, which was normal. She afterwards became pregnant again, and the choreic motions returned at the fifth month with great severity. Such cases are rare, but not exceptional. Dr. Pratt, at a meeting of the Phila. Obstet. Soc, reported a similar case, and a number of others are on record. These cases are very difficult to manage, and if not relieved by the coming on of labor, are apt to prove fatal. Any disturbance of the reproductive system may give rise to the reflex phenomena of chorea, as well as pregnancy. Dr. Goewey reports the case of a girl of twelve years of age, in whom the muscular movements became so violent that she had to be tied in bed and watched day and night for fear of injuring herself. The movements did not cease during sleep, and were so violent as to render her helpless. She had to be fed, and sometimes it was impossible for her even to masticate her food. Two years afterwards, when the function of men- struation was established, she recovered her health. These cases show that the spinal cord may sometimes be the chief seat of irritation, and this is fully confirmed by the ana- tomical lesions discovered after death. In the case first men- tioned there were diffuse changes, affecting not only the thalamus opticus, corpus striatum, the insula and claustruim but also granular proliferation in the connective tissue of the 6 90 NERVOUS DISEASES. peripheral nerves and along the vessels ofi the spinal cord. This agrees with the observation of Rokitansky, Avho also found proliferation of connective tissue in the cord. Cruveilhier, in addition to softening of the occipital convolutions of the left cerebral hemisphere, found sclerosis ofi the posterior columns ofi the spinal cord. Dr. Delamater reports an interesting case due to anaemia of the antero-lateral columns of the spinal cord. The character- istic symptoms were: "Considerable pain, burning and aching in the spine, better from rest; great tenderness to slight press- ure over the spinous processes in cervical and dorsal regions ; not much tenderness or pain from percussion over the spine; no special cutaneous hypersesthesia; hands and arms paretic." The case yielded permanently to the valerianate of strychnia, 3x trit., given in two grain doses four times a day, during a period of eight weeks. Injury to the conducting power of the nerves is an occasional cause of chorea. Dr. Cranch reports a case of hemichorea from accidental nerve-stretching. The patient, \\Those health was perfect in every other respect, raised herself on her elbow when lying, and felt something " crack." The condition lasted nearly three months. According to Dr. Foster, "a few years ago an eastern physi- cian announced as his belief, that the origin of chorea, in a large number of cases, could be traced to a faulty condition of the eyes. He examined specially the eyes of a considerable nu mber of such patients, and found in nearly every one some- thing abnormal in the refraction. In some cases the muscular inco-ordination was benefited by the wearing of glasses, though in others it had no effect." These cases, however, were no doubt cerebral. The motor-nerves of the eye are intimately connected with branches of the fifth and sympathetic nerves, and hence "it is not difficult to comprehend how any great strain or irritation of the organ of vision may be reflected to other parts of the head and give rise to disturbance there." Not only so, but the deep origin of the fifth nerve has been traced to, and found to be connected with, the pyramidal body and lateral column of the cord, the fibres of which are directly CHOREA. 91 in the tract of the corpus striatum, which is supposed to be the chief centre of choreic movements. (See Part I, Chap. III.) Prognosis.—Death from chorea is rare, and therefore the prognosis is generally favorable. When it does occur, it is al- most always from some fatal complication, such as endocarditis and pericarditis, myelitis, meningitis and encephalitis. It may, however, result from the great intensity of the disease. In such cases the symptoms are violent from the very beginning; the patient can get no rest day or night, but is fairly "worn out" by incessant muscular movements and sleeplessness. Cases which first occur after puberty are generally much more difficult to manage than those that set in early. As a general rule, the disease is quite amenable to treatment, and some even get well without any treatment. Spontaneous recoveries, however, can only take place in very recent, simple and un- complicated cases, in which the cause is of an accidental or temporary character. Treatment.—Most cases of reflex chorea will yield readily to the removal of the exciting causes; and as these are far the most numerous, we should, as a general rule, pay more atten- tion to hygienic measures, and the invigoration of the general health, than to the mere administration of medicine. The great majority of choreic patients are anaemic and debilitated; some have been deprived by poverty of a sufficiency of good Avholesome food; others have been overworked, either bodily or mentally; while not a few have become debilitated by bad social habits, such as a sedentary life, late hours, and unhealthy stimulation of the nervous, digestive and repro- ductive systems. These causes are all capable of being re- moved, and are of such importance in the treatment that they should never be overlooked or neglected. Moral influences, also, should be brought to bear upon the disease, especially when it does not appear to arise from any tangible or remov- able cause. The patient should, if necessary, be placed under the care of an intelligent, firm, and not too-sympathizing guardian. He should be taught to control his muscles as much as possible, not by force, but by the exercise of the will. He should be removed from all emotional or other excitement, 92 NERVOUS DISEASES. and not permitted to associate with patients similarly afflicted; neither should his mind be allowed to dwell upon the disease. These measures alone are often found to be productive of great benefit. Cases arising from spinal irritation (antero-lateral and pos- terior spinal anaemia) are generally greatly benefited by certain external applications to the spine, especially Ice-bags and the Ether-spray. The former are recommended by Dr. Hamilton, Avho allows them to remain ten minutes at a time. I have found the same remedy equally beneficial when applied to the head, in cases where the intense headache and flushed face indicated cerebral congestion. The pounded ice is best applied in a hog's bladder half filled with water, with a folded towel intervening between it and the head. When Ether is used, the spray may be thrown upon the naked back, from occiput to sacrum, as recommended by Dr. Hammond, for ten minutes each day, using for the purpose any ordinary spraying instru- ment, such as Richardson's. From ten to twenty such appli- cations are usually sufficient to effect a cure in uncomplicated cases. When the brain or medulla oblongata are implicated, the spray should be chiefly directed upon the cervical portion of the spine. I have in some cases obtained excellent results by applying to the tender portions of the spine, where such existed, a strip of cloth saturated with a strong preparation of the fluid extract of Cimicifuga, and covered Avith oil silk. Two years ago I treated successfully a case of this kind, in this man- ner, in a lady, aged 46, whose attack set in during the meno- pause, and which resisted every other form of treatment I could think of. Under its use the spinal tenderness and irri- tation gradually diminished, and in three weeks from the time the first application was made she was well. Electricity is an agent highly spoken of by some authorities, as Benedict, Meyer, Duchenne, Remak, Butler, Rosenthal, and others. Benedict says that out of twenty cases treated by him with the constant galvanic current, not one failed to recover. On the other hand, such authorities as Hammond, Reynolds, Von Ziemssen, and others, esteem it of but little value in the treatment of chorea. CHOREA. 93 Medical Treatment.—Agaricus.—Chorea of cerebral origin, with congestion to the head, dilated pupils, flushed face, twitch- ings of the voluntary muscles when awake, but quiet when asleep. Illus. 28.—Clara R., set. 13, of scrofulous maternity, slight frame, no sign of developing womanhood, but of uniformly good health. First complained of feeling tired in right arm and leg; Avould frequently drop her fork when carrying it to her mouth; right leg would sometimes give way in walking. After this condition had lasted several days, there began to be twitching on the right side of the face; she then lost control of the glottis and tongue; could not speak intelligibly, or swallow without great difficulty, especially liquids. After this the con- vulsive movements became general, progressing steadily from bad to Avorse, till head and limbs were in constant motion; appliances necessary to keep patient in bed. The pupils Avere dilated, there Avere flashes of heat to the head, tenderness from pressure on the last cervical and first dorsal vertebrae, bowels constipated, appetite good. After faithfully trying Bellad., Nux vom., Coccul., Ignat., Cimicif., Stramon., Hyosc, Amm. brom., in the order named, without benefit, and the patient had become so reduced as to suggest a fatal termination, hav- ing passed an involuntary stool, I added fifteen drops of Agari- cus to two ounces of water, and ordered a dessertspoonful every half hour. Next day she was better, and I ordered the third dilution every four hours. Continuing to improve, the next day the Agaricus was given every eight hours. In four days from the first dose of Agaricus the twitchings ceased and did not return.—Dr. H. B. Bagley. Cansticum.—Chorea in scrofulous constitutions, especially where there is a tendency to aphonia, or other paralytic conditions. Illus. 29.—M. D., set. 9, had a fall when about two years of age. This resulted in a white swelling, the left knee became anchylosed, and the leg atrophied. About two years ago the lad had an attack of chorea, from which he recovered. About three months since, the disease set in again, involving both sides of the body, but worse on the right side; the speech 94 NERVOUS DISEASES. was also affected. Canst.200, four times a day. Improvement began within one AAreek, when the movements were confined to the right side. After another Aveek's treatment, the sounds of the heart were found to be not quite normal, and he was given Caust2m. This was the last prescription, and, so far as I have ever learned, the chorea was permanently cured.—Dr. H B- Fellows. Cimicifiuga.—Rheumatic cases, where the whole body is in constant motion, with loss of speech, or where the menses are suppressed by cold; also in cases resulting from spinal irrita- tion, or where the menstrual functions are deranged, or where the chorea is worse at the menstrual period; also in "cardiac chorea," characterized by irregular, tumultuous and strange movements of the heart, aggravated by emotions, and subsid- ing during sleep. Dins. 30.—Ruth, set. 17, of a weakly, "nervous" constitution; took cold by falling into the water while skating; menses stopped upon her four months ago; choreic movements set in on the left side three weeks ago, and have remained mostly confined to that side; patient greatly troubled by palpitation of the heart. Prescribed Cimicifiuga d, fifteen drops in half a glass of water, teaspoonful three times a day. Menses appeared in five days from the commencement of treatment, and the choreic symptoms immediately ceased; no return.—Hart. Belladonna.—Cerebral chorea where hypersemia exists; also in reflex chorea excited by dentition or pregnancy. Constant agitation, with inability to remain erect; moaning and grating of the teeth; difficult deglutition; uncertain gait; trembling of the tongue; anaesthesia of the fingers; convulsive move- ments of the lips; incontinence of urine. Illus. 31.—Child, set. 5, attacked twenty clays ago with choreic movements of both sides of the body; voice hoarse and indis- tinct; paralysis of throat and legs; constipation; incontinence of urine; restlessness worse at night, with tetanic convulsions- Belladonna, 6th dil., six drops in a glass of Avater, a teaspoonful every four hours, so benefited the patient that he slept two hours the first night, and on the second night the convulsions ceased. The remedy was continued at intervals of a month, and Avas followed by a complete cure.—Dr. P. Bandeau. CHOREA. 95 Hyoscyamus.—Choreic movements with imbecility, or dul- ness of comprehension; derangement of the stomach, with anorexia; variable appetite, weak, perverted or voracious; convulsive twitchings, aggravated by eating; disposition to laugh and perform foolish actions. Illus. 32.—Alfred H., set. 7, had been treated allopathically for three months, taking cod-liver oil, Fowler's solution, etc. Complexion fair, blue eyes, light hair, unusually tall and deli- cate for his age, had never been very strong. Noticed that he had a voracious appetite, eating greedily and hastily twice as much as he ought to eat. He was extremely restless, wander- ing from one place to another. Dull of comprehension, seemed stupid, difficult to make him understand and reply to ques- tions. At times his face presented an idiotic expression; AA7ould have spells of laughing, which evidently he could not control. He had also contracted the habit of playing with his genital organs. The jactitations were principally confined to the muscles of the face, eyelids, left arm and side. Worse during and after meals. After regulating the diet, I prescribed, as the nearest similium, Hyoscyamus*, four doses per day. For the first ten days there was no very perceptible improvement; after that he commenced improving, and at the end of six weeks I discontinued the medicine. Five months have elapsed and there has not been the slightest return of the jactitations, and I consider the cure completed.—Dr. G. A.-Goewey. Stramonium.—Twitching of the muscles in different parts of the body, and especially when they act crosswise, as the arm of one side and the leg of the other; choreic movements greatest when awake; deglutition difficult; not disposed to talk, or unable to talk; silly or emotional laughing, singing or acting. Illus. 33.—A girl, set. 10, came under my care, pale, ansemic,, slender, unable to study much; was attacked with fever, fol- loAved by chorea; could not walk or speak; tongue swollen, protruding; constant twisting of the hands, feet and mouth, all producing an idiotic appearance. She entirely recovered in a few weeks, the curative agent being Stramonium. I have used this remedy with equal success in hereditary cases devel- oped in the progress of acute diseases.—Dr. I. S. White. 96 NERVOUS DISEASES. Phosphoric acid.—Great weakness and prostration; jactitation of the muscles, especially in the lower limbs; aphonia from paralysis of the laryngeal muscles; urine milky-looking and loaded with phosphates; great weakness of the extremities, ac- companied with ansesthesia. Illus. 34.—Chorea in a girl of ten years. For some time she had allowed things to fall out of her hands, cups, plates, etc., which the parents attributed to carelessness, and for which they scolded her. Gradually the spasms set in with increasing violence. Every part of the body, from the head to the feet- •became affected. The convulsions were frightful to behold- The patient had to be strapped to her bed. She was scarcely able to swallow a drop of liquid. The spasms lasted uninter- ruptedly day and night. She was utterly unable to articulate a single word. I had been trying various remedies without success, when I examined her urine and found it loaded with albumen (phosphates?). She was noAV placed upon the officinal Phosphoric acid, beginning with five-drop doses, three times a day, and gradually increasing the dose; after taking the acid for six weeks, she was completely restored to health.—Dr. C. I- Hempel. Simaruba.—Choreic movements resulting from irritation of the genital organs. Illus. 35.—Post coitum, irregular and uncontrollable move- ments of the left upper and lower extremities, and of some portions of the face, manifested by grimaces and contortions of different kinds; these symptoms lasted from fifteen to twenty minutes; she could not speak without stammering, and her respiration was ATery much affected; she also had involuntary discharge of urine and fseces at times during the attack.— Proving of Simaruba cedron, as reported by Dr. S. A. Tones. Natrum mur.—Raue advises this remedy in chronic cases of chorea, occurring after fright or suppression of eruptions on the face; paroxysms of jumping high up without taking notice of the things around him, thus sometimes injuring himself; or; jerkings of the right side of the head. The remedy is espe- cially indicated in anaemic and chlorotic cases, attended with thirst and fever. CHOREA. 97 Ulus. 36.—Hannah S., set. 7, has suffered from general choreic movements and contortions for over tAvo years. When about four and a half years of age she was frightened by a cow, since Avhich time she has been under allopathic treatment for chorea. She is very pale, delicate and anaemic; drinks a great deal of water, which is gulped down in small quantities at a time; the child is feverish, tongue white, mouth frequently sore. Nine weeks ago I placed her upon Natrum mur200, three doses per day. For two weeks there was no apparent improvement. She then began to have some control over her actions, the jerkings, especially on the left side, became less severe, and the pallor of her cheeks and lips began to disappear. She has taken no other remedy and is now entirely well.—Hart. Strychn /c—The Valerianate of Strychnia has proved curative in some cases of chorea, especially in those caused by spinal irritation. The indications are: burning and aching in the spine, with tenderness and pressure over some of the spinous processes; ameliorated by rest. Ulus. 37.—Lelia W., set. 12; slight, rather tall, dark hair and eyes; nervous temperament. Always had poor health; had large scrofulous swellings when fourteen months old, and pneumonia Avhen four years of age; at five years had an attack of intermittent fever, which was cured in two or three months, except that after it, for several years, had continually flashes of heat and cold, all over the body. At eight years of age was attacked with chorea of entire body, sudden twitching, jerking motions of hands and legs, and some grimaces from contraction of the muscles of the face. Contractions not very severe, and quiet during sleep. Has steadily grown worse, and now has attacks of loss of speech, lasting fifteen or twenty minutes; also, at times, Avill lose consciousness for a few seconds or possibly a couple of minutes; considerable pain, burning and aching in the spine, better from rest; great tenderness to slight press- ure over the spinous processes in cervical and dorsal regions; hands and arms paretic. Gave Valerianate ofi Strychn ia, 3x trit., a two grain powder four times a day, with a quart of milk per day in addition to the ordinary diet. This treatment was con- tinued for a period of eight weeks, with gradual improvement 98 NERVOUS DISEASES. from the start. She is now well and has been for the last five months. Case recorded as cured.—Dr. N. B. Delamater. Tarantula.—The special indications for this remedy, accord- ing to Lilienthal, are: choreic movements of the right arm and left leg especially, the involuntary movements continuing during sleep. Illus. 38.—Chorea in a boy, the head, right arm and hand affected, the head draAvn downward; involuntary micturition. Tarantula30, cured in tAvo months.—Dr. L. Gaudy, Brussels. Ulus. 39.—Involuntary muscular mo\^ements, irregular and disorderly, limited to the left arm and leg, or to one of them— very seldom the left arm and right leg—with grimaces of the mouth. Cured by Tarantula, 12th and 200tli— Dr. F. Fir mat, Spain. Cuprum met.—Bsehr says this remedy has in his hands cured most cases of chorea. He says it is more suitable to chorea minor than chorea magna, the former very rarely continuing under its use longer than three or four weeks. Illus. 40.—A man, set. 70, Avas attacked with involuntary movements in the arms, which afterwards extended to the legs. The spasms, though violent, Avere modified during sleep, but did not entirely cease. After vainly trying other remedies for three months, he Avas cured in six weeks by Cuprum, lx dil.— Dr. J. Drummond. Silicea.—Symptoms of ATerminous irritation, especially such as arise from the presence of ascarides in the rectum; distorted eyes, pale face, canine hunger, irritation of the nostrils, consti- pation, oedema of the face and extremities, great thirst, sleep disturbed by frightful dreams, spasms. Illus. 41.—W. B., set. 5, is reported to have had spasms occa- sionally, during two years past, and but five to seven days apart, during the past month; is pale, unconscious, with up- turned eyes. The fit is preceded by violent hunger; he throws his head backward incessantly; picks nose; has pinworms (formerly painful constipation); craves sours; the eves and legs twitch before midnight; has pain throughout the left side; likes to have his back rubbed; carotid and inguinal glands swell; arms and legs oedematous; pallid, swollen face; trunk CHOREA. 99 emaciated; green, yelloAV catarrh, offensive; thirst unrelieved; mutters in sleep; talks about God; the heart sounds irregular; prolonged systole, with loud murmur left of sternum. Silicea200, dry, cured.—Dr. C. F. Nichols. Veratrum viride.—This remedy appears to be indicated in those cases Avhere the convulsive action is of the most severe character; the more nearly they resemble eclampsia, the more prompt and effective the remedy. It has cured many cases of chorea magna, of Avhich the folloAving is a fair sample. Illus. 42.—A child, at. 12, had been confined to bed for three weeks, and had been under treatment for about six weeks, first for worms, and subsequently for chorea. It is not in the power of language to convey a proper conception of the truly pitiable state in Avhich I found the child. It had slept none, neither taken any nourishment for days. It was evidently dying from exhaustion and inanition. The muscular commo- tion was Auolent, universal, and unaffected by sleep; the lips Avere embossed Avith foam, worked up by a continued champ- ing of the teeth. One drop of the tincture of Veratrum viride Avas administered every hour. In twenty-four hours I had the gratification to see the symptoms greatly improved; the muscles Avere much quieter, and the child could swalloAv Avith- out difficulty. At the end of the fourth day all convulsi\re action had ceased.—Dr. J. Terry. Zincnm sulph,—Dr. T. C. Williams reports the following case cured by this remedy: "A young girl, set. 15, had been complaining of involuntary and irregular movements of the muscles for three or four months before I saAv her. She had had all kinds of treatment and chalybeates of many schools, and even from no school, and hoav had come to me a most horrible picture of humanity. Her Avhole trunk, her facial muscles, and all her limbs kept a con- tinuous dancing movement, so that she Avas unable to eat, Avalk or lie. She Avas finally given up by her physicians and friends to die. To this, though she had suffered long, she would not submit. Remembering that this disease often occurs before puberty, we Avould not give her up to this sad fate. Among the many remedies used in this disease, Ave selected 100 NERVOUS DISEASES. Zincum sulphuricum200, and gave no other. We gave it at first tAvo or three hours apart. She commenced to improATe; and after ten or fifteen days more we gave it tAvice in twenty-four hours. She still continued to improve, and after four or five weeks we gave it once in twenty-four. She is now, after a lapse. of six months, well and able to attend to her business in a carpet factory, where she is compelled to control her movements, and is normal as to her periodical change." For the sake of completeness, we will, agreeably to our plan, append a few illustrations of what may properly be called old- school therapeutics. Illus. 43.—Eserin.—According to Dr. Bouchut, Eserin dimin- ishes the muscular contractility of the small A^essels. He gives Eserin or its sulphate in the dose of 3—5 milligrammes three or four times a day, hypodermically, and someAvhat stronger per os; but then on an empty stomach. The spasmodic move- ments diminish during its action, afterwards also during the intervals between one dose and another, and after ten. days the cure is finished. Gastric troubles, sometimes even a transient paralysis of the diaphragm follows, Avhich is remedied by ad- ministering 5 milligr. subcutaneously. Its action is more cer- tain Avith hypodermic injections than per os.—Bullet, de Therap., 24, 1875. Illus. 44.—Congenital chorea.—Dr. Franz Heller relates the folloAving case: A woman who Avas someAvhat anaemic, but otherwise in fair health, Avas delivered of a male child about the middle of the eighth month. The child appeared Aveak and pale, and the anterior fontanelle Avas much depressed. Almost immediately after birth it became affected by clonic spasms, affecting the muscles of the head, trunk and limbs equally. The motions consisted of frequent extensions and flexions both of trunk and limbs, rolling of the eyes, contortions of the face, and protrusion and drawing in of the tongue. They were quite continuous, except during sleep, or when the child was in a bath. During light sleep they persisted in a minor degree, and continued even when the child was drinking. The infant was fed artificially, but rapidly increased in weight and strength. Chloral was given twice a day, and had a beneficial effect in CHOREA. 101 diminishing the violence of the chorea, and procuring long remissions, but the movements did not entirely cease until the child was two months old.— Wiener Medizinische Wochenschrifit. Illus. 45.— Chronic chorea.—A woman, set. 46, who-for six years suffered from chorea, who had not been able to walk for a year, and Avas tormented by such incessant and violent movements, that they threw her out of her bed, and who was also unable to sleep, had administered to her as high as 120 centigrammes of the Bromide of Camphor. Her sleep became calmer, she remained quietly in her bed, could walk a little, and often remained fifteen or tAventy minutes undisturbed by choreic movements. In the same hospital (Salpetriere), a woman, set. 22, was attacked by violent chorea, with hysterical vomiting. The dose given Avas first forty, and then sixty centigrammes, daily. Her cure Avas rapid.—Dr. Bourneville (Progres Medical). Illus. 46.—Bromide of Potassium: A very severe case of chorea, occurring in a Avoman at the eighth month of pregnancy— symptoms not given—cured in eight days by thirty to forty grains a day.—(Drs. Gubler and Dumord.) 102 NERVOUS DISEASES. CHAPTER V. TETANUS. Tetanus, derived from a Greek Avord signifying " I stretch," is a disease characterized by a painful and lasting contraction of the AToluntary muscles and diaphragm, alternating with irregular intervals of incomplete relaxation, or of semi-clonic spasm. The disease is often referred to by names employed to distinguish certain marked conditions resulting from the tonic contraction of the muscles; as, first, trismus or lock-jaw, where there is a rigid closure of the jaws; second, opisthotonus, where the head is drawn backAvards so that the body is bent in the form of an arch; third, emprothotonus, where it is curved in the opposite direction; fourth, pleurosthotonus, Avhere the body is curved laterally; and fifth, orthotonus, Avhere it remains straight. The last three conditions are very rarely met with in practice. Tetanus is usually divided by systematic writers into (1) the traumatic, (2) the rheumatic, (3). the toxic, and (4) the sympedlictic. The first three are sometimes called symptomatic, to distinguish them from the last, which embraces all cases arising from fright, or from peripheral irritation in internal organs, such as worms, fissure of the rectum, pneumonia, pericarditis, etc These Avill be noticed more at length hereafter. The great majority of cases are of traumatic origin, and may result from any wound, however trivial, that irritates or im- plicates any portion of the peripheral nervous system. In infants, it is sometimes due to the irritation arising from the separation of the umbilical cord, and is then called trismus nascentium; but as the affection so named is rarely of trau- TETANUS. 103 matic origin, and most frequently takes the form of eclampsia, we have described it under the head of Convulsions (v. Eclampsia Neonatorum,, Chap. I). Although tetanus may be caused by injuries that do not produce a breach of surface, it is certain that, in the great majority of cases, it is excited by a avouikI of some kind; and it Avill generally be found that a nervous filament has been torn or ruptured. Thus, in a case of tetanus that has just occurred in my practice, where a boy had run the dried stub of a Aveed into the leg just above the external malleolus, it was found that the external saphenous nerve and the accompanying vein had both been lacerated. The kind of injury, as avcII as its situation, has much to do Avith the occurrence of tetanus in adults. Contused, punctured, and lacerated wounds, such as are caused by gunshot, burns, rusty nails, etc., are far more apt to give rise to it than clean cuts and thrusts; yet it sometimes follows surgical operations, such as amputations, the ligature of arteries, and even the ex- traction of teeth. On the other hand, the most formidable operations and the most frightful injuries, such as o\Tariotomy, the crushing of machinery, and the mutilations of the battle- field, have'generally escaped this fearful complication. Expe- rience shoAVS that AA'Ounds of the hands and feet, especially of the extremities of the fingers and toes, and also the injury of tendons and nerves, are more liable to cause tetanus than those of other parts. Yet, as remarked by Erichson, it cannot well be supposed to be OAving to the tendons and fascia that abound there, as it is seldom, if ever, met with after operations for tenot- omy, which are so commonly practiced on the feet. It is my belief that the affection is due, in almost every instance, to injury of some kind inflicted upon some portion of the peri- pheral nervous system; and that the injury generally involves one or more minute nervous twigs, the laceration of Avhich is the immediate cause of the spasm. The time between the receipt of the injury and the setting in of the disease, varies from a feAV hours to as many months. Baron Larry says that after the battle of Boutzen, where the wounded were left exposed to severe cold during the night, he 104 NERVOUS DISEASES. found on the following morning that more than one hundred wrere seized Avith tetanus. In hot climates it occurs, as a rule* much more speedily than in temperate ones. Thus, a negro in the West Indies is said to have perished of tetanus Avithin fifteen minutes after scratching his finger Avith a piece of china. On the other hand it has occurred as late as the fifth month, and long after the wound has become cicatrized. In most cases, however, it appears within eight or ten days of the re- ceipt of the injury; and when it runs its usual course, termi- nates fatally Avithin two or three days. Symptoms.—The disease may set in gradually or suddenly. Occasionally it is preceded by more or less uneasiness, depres- sion of spirits, and fear on the part of the patient; he is seized Avith an unaccountable sense of danger, which is sometimes augmented by a disturbed state of the digestive organs, or by nervous pains and twitchings in the Avounded limb. In other cases it comes on so gradually and imperceptibly, that the pa- tient is not aAvare of his danger until he experiences a feeling of stiffness in the neck or about the jaws; the immobility of the lower jaAv being a symptom that more quickly attracts at- tention at the outset of the disease than any other. It is a singular fact that the spasm does not commence in the injured part; but, hoAvever remote may be the situation of the wound, it always first appears in the muscles supplied by the facial or motor branch of the seventh nerve. The stiffness in the back of the neck, and the unusual rigidity of the jaws, are accom- panied with more or less difficulty of swallowing, showing that the muscles of the pharynx are also affected. At this time the symptoms, though characteristic, are not severe; the patient is still able to open his mouth, but not widely, OAving to the mus- cles about the temples, neck and jaAv feeling stiff and somewhat rigid; but soon other muscles become implicated, and those about the jaws, as the masseter and temporal, become perma- nently rigid from tonic spasms, so that the jaws are immovably closed. This condition has given to the disease the familiar name of lock-jaw. What is called the "risus sardonicus" now sets in; the countenance appears terror-stricken, and assumes an indescribable expression of mental and bodily anguish • the TETANUS. 105 eyebroAATs are elevated, the eyes staring, the angles of the mouth depressed, and the features so distorted and immovable as to give the patient a peculiarly aged appearance, heightened as it generally is by the pallor Avhich at this time overspreads the countenance. As the disease reaches its height, it is marked by tonic spasms of the voluntary muscles, of the most violent and pain- ful character. In this condition the muscles become as hard and rigid as boards, and the limbs are often as stiff as though they Avere frozen. At times the tetanic rigidity partially gives way, the paroxysm assuming more or less the form of clonic convulsions, jerking and twisting the patient about in the most violent manner. These spasms are much shorter, but propor- tionally more intense, than the former; and they alternate with periods of comparative relaxation. The spasms are generally extremely painful, the pain being the same in kind as that Avhich attends ordinary cramp of the ex- tremities, but much more severe. It is said that the tonic con- tractions are less painful than the clonic seizures, and that even the latter are not always painful; but as a general rule the con- vulsive paroxysms are attended with the most fearful suffering, the patient dreading their occurrence aboA'e everything else. At first they are slight, and happen only at distant intervals; but as the disease progresses the}* increase in frequency and violence, until finally they occur every ten or fifteen minutes, and sometimes oftener. They become more frequent where the disease is about to terminate fatally, and rice versa. Most authors assert that in very severe cases muscular fibres have been ruptured, the teeth broken, joints dislocated, and even bones fractured; but such effects, if they ever happen, are of very rare occurrence; I have never witnessed any of them. During: the state of tetanic rigidity, the muscles of the trunk are implicated, more particularly the extensors of the spine. This gives rise to one of the most common forms of distortion, that of opisthotonus, in which the neck and trunk are bent backwards into an arch, so that the body rests on the occiput and sacrum. In this condition the chest is arched forwards, whilst the cavity of the abdomen is apparently distended. At / 106 NERVOUS DISEASES. a later period the epigastrium is dravni in, the belly being hard and flattened, and the chest expanded. Forward and lateral curvatures of the spine seldom occur. The permanent contraction of the abdominal muscles, by preventing the descent of the diaphragm, cuts off the supply of air to the lungs, whilst the rigidity of the thoracic muscles con- tribute still more to embarrass the respiration, by interfering with the act of expiration. The consequence is, the lungs and bronchi become congested, mucus accumulates in the air-pas- sages, and the patient, unable to relieve himself by coughing or by drawing a full breath, is in danger of actual suffocation. This danger will be still farther increased if, as sometimes oc- curs, spasm of the glottis sets in; for then the air in the lungs remains wholly unchanged, and if not speedily relieved the pa- tient will necessarily die asphyxiated. Tracheotomy has been tried in these cases, but without any decided benefit, the patient being unable to free the air-passages of the obstructing mucus. Constipation and retention of urine are troublesome symp- toms, resulting from spasm of the lower sphincters and the ri- gidity of the abdominal muscles. It is said that the Avarm bath will overcome the retention of urine, but the faeces can only be brought away b}7 enemata. The muscles of the extremities are generally the last, as well as the least, to be affected; and those of the upper are less in- fluenced by >spasm than the loAver, especially the hands and wrists, which frequently escape altogether. For some reason, the extensor muscles are more liable to be affected by tonic spasm than the flexors. Tetanic rigidity occurs only during the period of consciousness; when sleep occurs muscular relax- ation takes place, but Avhether as cause or effect is not fully de- termined; probably, hoAvever, it is the latter, as the same thing occurs when the patient is under the influence of an anaesthetic The convulsive paroxysms are peculiar, inasmuch as they closely resemble those produced by strychnia. They are not only predominantly tonic in their character, but they occur, or are reproduced, by every new influence, however slight, Avhich acts as an irritant on the reflex system of nerves. Thus, any sudden noise, such as approaching footsteps, or the open- TETANUS. 107 ing or shutting of a door, an accidental touch of the person, and even intentional movements, such as an attempt to swal- low or speak, are often sufficient to excite them. Althaus says "this is evidently owing to convulsibility of the medullary centre, for the movements are co-ordinated, and the heart's action is generally interfered with. The inhibitory centres of reflex action in the corpora quadrigemina, however, do not under these circumstances invariably lose their controlling influence altogether; for if the patient's attention is drawn to a sentient impression just previous to its occurrence, he is often able to suppress the attack." Although there is no fever, except in cases complicated with inflammation, the pulse is gradually quickened, rising to 90, 120, and, towards the end, even to 180 per minute. It is also rendered more frequent during the convulsive paroxysm, but becomes slower again after it is over. During the latter stages of the disease the pulse becomes very frequent, small and irregular, owing in a measure to vasomotor irritation. In consequence of this the blood-vessels, it is said, are sometimes so contracted by spasm, that amputation, which has occa- sionally been resorted to for the cure of tetanus, has been per- formed without the loss of a single drop of blood. . The temperature of the surface generally corresponds pretty well with the frequency of the pulse, though at first there is a fall of heat, but it soon begins to rise, and continues to increase even for some time after death. The temperature rises at each successive paroxysm, until at the close the thermometer may register as high as 112° F. The subsequent rise is supposed to be due to the rapid coagulation of myosene in the muscular tissue. The cutaneous surface is usually covered with perspiration, which is often very profuse, especially after violent paroxysms. As a consequence, a miliary eruption (sudamina) is apt to be developed. The other secretions are generally diminished, especially the urine, which is usually scanty, high colored, and deposits on standing a large amount of urates. The intellectual faculties are not affected, except in rare instances, until the close of the disease, when the mind may 108 NERVOUS DISEASES. begin to wander, as in any other fatal affection. When deli- rium sets in early, it should be regarded as a very dangerous symptom. 1 Insomnia and restlessness generally attend the disease, owing partly, no doubt, to the excess of pain, and partly to dyspn.ca and anxiety. The sufferings of the patient are also increased by hunger and thirst, especially the latter, which is rendered all the more excessive by the profuse sweats that generally accompany the attack. ' It was formerly thought where death took place from sudden arrest of the heart's action, that it was in consequence of car- diac exhaustion; but it is now believed to be due to irritation of the root of the pneumogastric nerve in the medulla ob- longata, That it is not due to overexertion of the organ, is evident from the fact that, notwithstanding the violence of the spasms, they are not attended with the sense of fatigue that results from great muscular exertion under the exercise of the will. It is scarcely necessary to state that the above-mentioned phenomena are not all present in every case of tetanus. The disease assumes every degree of violence, from a slight and temporary stiffness of the neck and jaws, up to those terrible paroxysms in which the whole system of voluntary muscles is involved. The course of the disease also differs in different cases. In some the progress is uninterrupted from first to last; in others the symptoms remit from time to time; and in the most favorable cases they often become intermittent. The duration of the disease is equally variable. The great majority of cases terminate fatally before the fifth day; very few live beyond the fourteenth day, and when they do they generally recover. Causes.—That a constitutional predisposition of some kind is requisite for the production of tetanus, in many cases, appears from the fact that only a comparatively small number of those exposed to the exciting causes are attacked by the disease. But whether this predisposition consists in a depraved state of health, such as results from bad hygienic conditions, or from other causes, is not yet settled. It is certain, however, that TETANUS. 109 age and sex favor its production, the greatest mortality being in the male sex, and between the ages of five and forty-five years. If Ave include eclampsia neonatorum, Ave find it to be of frequent occurrence1 among new-born infants, especially in hot climates. With this exception, it is comparati\*ely rare in children under four or five years of age. It is also rare in ad- vanced life. As regards sex, only about twenty per cent, of all cases are females. This is chiefly OAving, it is supposed, to the circumstance that females are less exposed to injury than males; at least Ave find traumatic tetanus to occur much more frequently among men than women. The exciting causes correspond to the classification before mentioned, namely, traumatic, rheumatic, toxic and sympathetic. Of these the traumatic is much the most frequent and impor- tant; but as it has already been sufficiently considered, little more need be said under this head. Cold is a potent agent in exciting an outbreak of tetanus among the Avounded. We have already referred to its effect upon the soldiers left exposed on the battle-field of Boutzen. Military surgeons agree that a cold night succeeded by a hot day is most apt to excite the disease, and that the vanquished are more liable to be attacked than the conquerors; but whether this results from the mental depression consequent on defeat, or from receiving less care at the hands of the surgeons and nurses, is not certain; probably, however, both these circumstances in- fluence the result. Rheumatic tetanus generally comes from exposure to cold and clamp. Sleeping on the cold, damp ground, or living in Ioav, damp situations, are the usual causes of this form, Avhich is generally very slight, being limited to a feeling of stiffness about the neck and jaws; but, like other forms of the disease, when fully developed it is severe and dangerous to life. This is said to be especially the case in tropical countries, where it is most prevalent, and where a cold bath, or the drinking of very cold Avater, when perspiring, is apt to produce it. What is called toxic tetanus is excited by such agents as strychnia, brucia, mephitic gases, etc. We have already de- scribed a case of this kind under the head of eclampsia toxica, 110 NERVOUS DISEASES. Avhere it more properly belongs (v. Illus. 19). The symptoms produced by these poisons do not exactly correspond Avith those of true tetanus, there being less permanency of the muscular rigidity and a predominance of coiiATulsiAre action. Sympathetic tetanus is that form of the affection resulting from such causes as fright, intestinal worms, ulcers of the rec- tum, urinary calculi, a dead foetus in the uterus, pleurisy, peri- carditis, enteritis, etc. Such cases are undoubtedly rare, but they have been witnessed by too many competent observers to be altogether discredited. The efficient cause of tetanus, according to Dr. Clarke, is "a morbid condition of the peripheral nerves, by which the excitability of the cord is increased, cither reflexly, by action of the bloodvessels excited by those nerves, or by extension of the state of irritation along the nerves to the substance of the cord itself. The grey matter of the cord then becomes unduly excitable, from the hypersemic state of its bloodvessels, Avith the exudations and disintegrations resulting therefrom. Other observers have thought tetanus due to blood-poisoning, the spasms resulting from certain changes in the muscles, Avhich were owing to the poisoned state of the blood. Romberg's the- ory of increased reflex excitability of the cord does not explain all the occurrences in tetanus, although it amply accounts for the symptoms of strychnia-poisoning. In cases of injury to the upper portion of the spine or the head, there is most prob- ably a direct pathological effect produced upon the con- vulsible centre in the medulla. In other cases, Avhere the injury is more peripheral, there is direct transmission of the irritation of the sensitient nerves by neuritis aseendens; and finally, Avhere no such changes are discovered in the peripheral nerves, avc must assume that the peripheral irritation is re- flected to the vasomotor centres in the medulla oblongata, and perhaps also in the spinal cord. That the medulla generally suffers is shoAvn by the affection of the jaw, tongue and phar- ynx, the motor nerves of which have their roots in that organ; and also by the tetanic convulsion showing the character of co-ordination."—(Althaus.) Pathology.—Rokitansky, Benedict, Dickinson, Clarke, and TETANUS. Ill others, have described various lesions of the cord in tetanus, some or all of which may or may not be the true cause of the disease. If they are not the effects of the functional excite- ment of the cord, as believed by Dr. Clarke, then tetanus can no longer be considered a purely functional disorder. The former observers discovered proliferation of connective tissue between the white matter of the cord, destruction of nerve- cells, fatty and amylaceous degeneration, disorganization of the cord by abnormal deposits, hypersemia of the anterior cells, and granular transformation. Leyden, however, showed that some of these changes were only apparent, being due to the mode of investigation pursued, and that the others.were far from being constant. But Dr. Clarke discovered unmis- takable lesions in the six cases examined by him. Some of these were similar to those already noticed, especially hyperse- mia, effusion and granular degeneration; but the chief altera- tion was one of softening, extending in streaks and irregular areas of disintegration in the grey substance of the cord, from the origin of the second cervical nerves through the cervical enlargement, the lower portion of which exhibited, chiefly in the neighborhood of the canal, marked disorganization, vary- ing from a condition of softening to one of complete solution. The same appearances were discovered in the dorsal and lum- bar portions of the cord, in the former of which were also found extensive extravasations of blood extending along the entire lateral part of the grey substance, and alternating with small areas of disintegration. As already stated, Dr. Clarke does not attribute these changes to functional excitement of the cord, because they chiefly occur Avhere the nerve-cells are scanty, Avhilst the cells which give origin to the motor nerve- roots remain unaltered. He therefore refers the lesions in question to disease of the bloodvessels, which are usually found to be more or less dilated and disintegrated. Neither does he think they can be the cause of the spasms, because they are found also in cases of paralysis. Hence, as before stated, he attributes the disease to the morbid condition of the peripheral nerves, Avhich, as shown by Lepelletier, are affected by neuritis ascendens, or by traces of inflammation, thickening and dis- 112 NERVOUS DISEASES. organization in the affected nerves. In protracted cases the muscles are often in a state of fatty degeneration, besides being more or less lacerated, anaemic, and infiltrated Avith minute extravasations of blood. Prognosis.—The prognosis in Avell-developed cases is almost uniformly bad; though if it occurs after ten days from the re- ceipt of the injury, or if the symptoms continue beyond two Avecks Avithout resulting fatally, the chances of ultimate recov- ery are favorable. The most fatal cases are those Avhich occur in the puerperal state. Such as are attended Avith frequent convulsive seizures are generally fatal, the patient either dying during a fit from asphyxia, or sinking into such a state of utter prostration, delirium and coma, as to bid defiance to all treat- ment. Paralysis of certain muscles of the extremities, and also of those supplied by the portio dura, is apt to remain after recovery, which is ahvays gradual and more or less protracted. The paralysis of the portio dura is supposed to be due to ascend- ing neuritis, and that of the extremities to a like condition observed by Dr. Clarke in the cord. Treatment.—The only accessory measures deemed Avorthy of mention, aside from the necessary surgical procedures, are ice-bags or hot-water-bags to the spine, and protracted sAveat- ing. The former are said to have afforded relief in some cases, and the occasional benefit from the latter is well illustrated by a case treated in Mr. Wagstaffe's clinic, in 1877. A covered frame-work was adjusted to the bed, and hot air passed inside by means of a tube connected with a heated cylinder. The temperature Avas raised to 140° F., and maintained for rather more than three-quarters of an hour, by which time the pa- tient became faint. The head Avas co\rered during this time Avith blankets, leaving him only breathing room through them to the external air. He continued to SAveat profusely for about two hours after the bath, and during this time Avas covered Avith blankets. The sweating Avas repeated in the evening; and this treatment, by morning and evening sweating, av;:s persevered in for twenty-three days, after Avhich time it Avas only necessary to use it once a day for a week.—(Brit. Med. Jour., Oct. 20th, 1877). TETANUS. 113 Belladonna.—Stiffness of the jaAA's, Avith convulsive move- ments, dilated pupils, difficult deglutition, lancinating pains, staring eyes, spasmodic respiration, restlessness, involuntary discharges, insomnia, cerebral and spinal hypersemia. Illus. 47.—A man, set. 60, trod upon a nail two weeks ago; jaws now closely locked, deglutition difficult, flexor muscles cramped, abdomen tense and rigid; sudden noises, a touch, or an attempt to move, speak, or drink, would excite a spasm. The affected limb Avas considerably swollen. The Avound healed, leaving only a tender, dark spot, from which, on being reopened, issued a few drops of dark blood. Bacon was applied locally, and Belladonna™ given internally; in three days the patient Avas entirely relieved.—Dr. A. Angell. Cicuta virosu.—Trismus, Avith spasms of the oesophagus, pale- ness of the face, rigidity of the affected muscles; whitish ulcers on the border of the tongue. Illus. 48.—C. M., set. 12, run a nail in the bottom of his foot. In a week the wound healed and no evidence of disease was manifest for two Aveeks, Avhen the rectus muscle of the abdo- men became rigid, soon folloAved by contraction of the muscles of the leg on the side of the Avound. In a few days there was trismus, and a full developed case of tetanus. Treatment: Cicatrix and surrounding tissues of the Avound cauterized deeply. We gave at different times: Bellad., Nux vom., Ilyosc, Aeon., etc. My prognosis was unfaA7orable, as the case AA7as severe and no evidence of improvement by the treatment. The symp- toms Avere : trismus; legs and arms flexed and rigid; abdomen distended and rigid; spasms every half hour: edges of the tongue, as far as could be seen, covered Avith v\Tnte ulcers; spasms of the oesophagus; paleness of the face during the spasm; spasms of a tonic character. Cicuta virosa, 3d dil., AA7as now prescribed, chiefly on the strength of the last four symptoms. An improvement Avas ob- served within twelve hours, Avhich continued until he Avas per- fectly well.—Dr. S. R. lleehvith. Gelsemium.—Stiffness of the jaAvs; pain and stiffness in the back of the neck; spasmodic sensation in the pharynx and 114 NERVOUS DISEASES. oesophagus, \vith difficulty of swalloAving; constrictive pain about the chest, with difficulty of breathing; dilatation of the pupils; cramps in the legs; involuntary discharges of ia'ces and urine; convulsiATe action of the voluntary muscles. Illus. 49.—B. S., aged 13, run the stub of a dried Aveed into his left leg just above the ankle, lacerating the external saphe- nous vein and nerve. Wound Avas treated by the parents with bacon; it suppurated freely and finally healed, with the ex- ception of a small fistulous opening, which, owing to the ob- jections to the use of the knife, was treated by injections of iodine. On the third day of this treatment—the ninth after the accident—stiffness of the jaws and neck set in, with diffi- culty of SAArallowing, moderate fewer, some headache, a coated tongue, and darting pains in the wounded leg. Prescribed an emollient poultice to the sore, and gaye Bellad., 3d dil., every hour. Next day Avorse; jaAvs tightly locked; abdominal mus- cles rigid; head bent backAA'ard and deeply buried in the pil- low ; pupils dilated; eyes staring; pulse hard, 96; breathing irregular and hissing; extensor muscles of the limbs con- tracted, hard and rigid; fistulous opening puffed and tender; wounded limb jerks and twitches Avhenever it is touched. Laid open the fistula, Avith a curved history, to the extent of three inches in the course of the affected nerve and vein, and reapplied the poultice. Prescribed Gelsemium ft, gtts. xv, to half a glass of Avater, a teaspoonful every hour. Next day much better: pulse 7o, soft; no opisthotonus or trismus, but some soreness about the neck and jaAvs. Continued the treat- ment during the next three days, but at more distant intervals. Patient made a good recovery and in two weeks attended school.—Hart. Physostigma.—Paralysis preceded by twitching or trembling of the muscles; dilatation of the pupils; syncope or tendency to fainting; trembling convulsive action of the respiratory muscles; alternate dilatation and contraction of the pupils, the former corresponding with the period of spasm and the latter with the period of quiescence. Illus. 50.—Feb. 3d, 1877, was called to attend a man who had fallen head first from a heavily-loaded wagon, one of the wheels TETANUS. 115 of Avhich passed across his face, producing a severe scalp Avound, extending across the entire occipital region and partially tear- ing off the right ear. The man, Avho Avas in a cold and semi- conscious condition, Avas evidently laboring under a severe con- cussion and shock of the brain. On visiting the patient four days after the accident, I found he had passed a very restless night; had muttering delirium; escape of blood and pus from the nostrils and mouth so copious as to threaten to suffocate him, exciting a spasmodic cough, folloAved by severe tetanic spasms and marked opisthotonus, Avhich hoav extended as far as the heels, most apparent Avhen induced by paroxysms of coughing. Between these periods there was a more quiescent state. Resp. 28; pulse 130; temp. 104°. The planta fascia and toes of both feet, tendo achilles and gastrocnemius muscle very contracted and tense, especi- ally during the spasms; involuntary emissions of urine; con- traction and dilatation of the pupil of the uninjured eye, the former corresponding with the period of quiescence and the latter with the period of spasm. Prescribed Physostigma, 6th trit., one grain eArery t\vo hours. Ordered also hot water to the spine by means of Chapman's Spinal Bag, to be rencAved every forty minutes. These applications seemed to alleviate and quiet doAvn the spasms. Patient gradually improved under this treatment, so that two days afterwards the pulse Avas down to 100, temperature 90° and respiration normal. Remedy to be giATen only once in four hours Avhen awake. Patient continued to improve under proper surgical treatment, and on March loth Avas able to resume his usual duties. I have noticed the symptom, alternate contraction and dilata- tion ofi the pupil, in three former cases of traumatic tetanus, all of which were cured by the internal administration of Calabar Bean.—Dr. C H Von Tagen. Tetanus is such a fatal disease, that Ave deem it our duty to append the most approved allopathic treatment. Illus. 51.—Amyl nitrite,—The case Ave are about to record is the first in which Amyl nitrite has been used alone and success- fully, and its action observed. It was first given on the sixth dav after the accident, and about forty hours after tetanus first 116 NERVOUS DISEASES. set in. Before the three drops had half evaporated, the heart's action became more quiet, and continued to become more so at each subsequent inhalation. Towards the close of the treat- ment the pulse Avas doAvn to about 80, although six days after he had ceased to inhale five drops tAvice daily, the heart's action Avas 132 and tumultuous. Gasping and yaAvning Avas produced at each inhalation, and a marked improvement Avas at once manifested in all his symptoms. Ten clays after the inhalations Avere resumed he had another spasm, and the dose Avas then increased to five drops twice daily. Four days after- Avards the supply of Amyl gave out in the hospital and Avas not replaced until two days afterwards. During this time he greAV rapidly Avorse; the opisthotonus and the risus sardonicus both returned, and his pulse and temperature rose rapidly. On recommencing the inhalations he felt better almost imme- diately, and from that time progressed steadily to complete re- covery. The remedy Avas discontinued on the forty-sixth day after the first dose Avas administered, the patient appearing as avcII in every respect as before the attack, except haA'ing a feel- ing of Aveakness.—Philad'a Med. Times. Illus. 52.— Calabar Bean—H. W., set. 47, a gardener, received a wound between the thumb and index finger, from the cut end of a laurel bush branch. The AA7ound, Avhich Avas about half an inch deep, was carefully cleansed and kept open for a fortnight. Two days after its closure tetanus set in, and five days later he Avas admitted into St. George's Hospital, under the care of Dr. Dickinson and Mr. Pollock. At that time he Avas in a condition of opisthotonus, and spasmodic contractions of the muscles of the neck and face, lasting about five seconds, occurred ten or tAvelve times a day. He Avas first put on tAvel\7e grains each of chloral hydrate and bromide of potassium, with temporary improvement. Three days after admission, how- ever, he Avas much Averse, the spasms recurring five or six times a minute. One-eighth of a grain of extract of Calabar bean was injected subcutaneously every hour for eight successive hours, after which the spasms occurred at intervals of about tAvo minutes, and were less severe. He felt easier and slept some. Tavo days after this the injections were given every TETANUS. H7 hour and a half, alternately with a pill containing one-sixth of a grain of the extract. A few hours after, the pills and in- jections were repeated every two hours. Tavo days later, the improvement still continuing, the injection was increased to one-fourth of a grain. The next day the treatment was dis- continued for five hours, but as the spasms became more fre- quent, it was resumed as before. On the following day the spasms did not occur, except when the fauces were tickled, and the injection was given only every four hours. One week afterwards there was a slight return of spasm. At the expira- tion of another week the spasms ceased altogether, but the patient continued to have some pains in the back for the next three weeks, and his legs were still weak and stiff when, just two months after entering the hospital, he was sent to the con- valescent home. He was seen some months afterwards in good health.—(Lancet.) Illus. 53.— Chloral hydr. and Potass, brom.—A boy, set. 14, Avas seized with traumatic tetanus. Ten grains of chloral hydr. with tAventy grains of bromide ofi potassium, in solution, Avere given every three hours, and on the next clay every two hours. All kinds of delusions ensued. The most marked amelioration of the symptoms was manifested on the third day after taking the medicine. The patient took 1140 grains of chloral in six- teen days, Avith the result of the spasms leaving him in eighteen days from the date of the seizure.—(Dr. J. Carruthers.) 118 NERVOUS DISEASES. CHAPTER VI. HYDROPHOBIA. Hydrophobia is a spasmodic disease produced by inoculation with the poison of a rabid animal. The poison generally enters the system through a Avound made by a mad dog, or from the contact of its saliva Avith an abraided surface. History.—Rabies, or the hydrophobia of dogs, has been known from the earliest times. It is true, no allusion is made to it in the Scriptures, but that may be readily accounted for by the fact, that the disease has never existed in either Syria or Fgypt. On the other hand, canine madness Avas Avell knoAvn to Homer, Avho, in the eighth, ninth and thirteenth books of the Iliad, not only expressly mentions it, but very appropri- ately applies it to Hector's indiscriminate slaughter of his enemies. Human hydrophobia was well known to Democritus, the friend and contemporary of Hippocrates; it is also referred to in the works of Polybius and Aristotle, although the latter, singularly enough, did not believe that the disease could be communicated from animals to man. "Dogs," says he, "are subject to madness, cynanche, and a sort of gout, or lameness. The first of these diseases renders them rabid or furious, and all the animals which they bite become equally affected Avith madness, Avith the exception of man. The malady occasions the death of the dogs affected, and of every animal that is bit- ten by another animal, excepting man." Not to dAvell upon this part of the subject, it is sufficient to say, that the disease has been very accurately described, and much learned specu- lation on the subject indulged in, by the best medical authors, from the days of Aristotle down to the present time. HYDROPHOBIA. 119 ■ Symptoms.—The majority of systematic writers divide the disease into three periods: first, the stage of delitescence, second, the stage of recrudescence, and third, the stage of spasm. First stage, or delitescence.—This stage is not usually marked by any very prominent symptoms. The Avound, which seldom involves any extensive laceration, generally heals readily, leaving a cicatrix which presents nothing remarkable or pecu- liar in its appearance. Sometimes more or less pain is felt in the cicatrix for a considerable period after the wound has healed, but as this is liable to occur in the seat of all wounds of like character, whether simple or specific, it cannot be re- garded as characteristic of this affection. Occasionally a slight fever sets in soon after the accident, and continues until the breaking-out of the hydrophobia, Avhich in these cases super- venes Avithin a feAV clays. Generally, however, the period of delitescense is rarely less than six weeks, or greater than two years. In the majority of cases, nothing unusual is noticed in the appearance or demeanor of the patient, during the time Avhich intervenes between the healing of the bite and the second stage. It is true, the subject of the Avound, apprehensive of danger, sometimes betrays more or less anxiety in his coun- tenance, besides being retired, gloomy, and perhaps someAvhat irritable; but as such symptoms Avould be likely to result from simple consciousness of the peril already incurred by the acci- dent, they cannot properly be regarded as having any other significance. Second stage, or recrudescence.—The patient now experiences more or less pain or uneasiness at the seat of the wound. The cicatrix itches or tingles; twinges of pain are felt in it, or dart from it along the affected limb; sometimes there is a feeling of stiffness or deadness in the part, as though partially para- lyzed; or the cicatrix may become red, swollen, and even liATid; and sometimes it reopens, and discharges a peculiar ichor. As recrudescence adA'ances, the morbid sensations extend from the original seat of injury tOAvards the trunk. These pains always appear to follow the course of the nerves, and are espe- cially apt to shoot from the wound to the region of the heart. These symptoms generally set in only tAvo or three days before 120 NERVOUS DISEASES. the appearance of the spasm; it is rare for them to occur more than a Aveek before hydrophobia supervenes. Third, or spasmodic stage.—As compared with this stage, the preceding ones present the appearance of quiescence; hence the group of symptoms constituting this stage is generally re- garded as representing the entire disease known as hydrophobia. In strict accuracy, however, this is but the closing stage of the malady; and were it always so regarded in practice, perhaps greater success would attend its treatment. However this may be, seeing that the paroxysmal stage is that to which the attention of the physician is chiefly directed, it is not strange that he should come to regard it as the only essential part of the disease. Within a few hours or days after the occurrence of the local irritation, during Avhich time the. patient experiences a sense of uneasiness and anxiety, attended with chills and heat, gid- diness and a general feeling of illness, the special symptoms of the disease begin to manifest themselves. The most constant and characteristic of them may be conveniently arranged under three heads:—1. Spasm ofi the muscles ofi the throat and chest. When the disease fairly sets in, the patient experiences pain and stiffness about the neck and throat, and when he attempts to SAvallow fluids, he finds himself utterly unable to do so; this, with the added consciousness of the aAvful nature of his disease, excites a horror of all liquids, and constitutes the most distinguishing feature of the malady. Even the mere sight or sound of fluids Avill frequently bring on a par- oxysm of choking and sobbing; and so will the reflection of a mirror, or of any object having the appearance of a liquid, the idea of Avhich is immediately associated in the mind of the patient Avith his inability to SAvallow fluids, and re-excites the spasms that cause him so much mental and bodily suffering. —2. Extreme sensibility ofi the surface ofi the body. Thus, a gust of Avind across the face, a touch of the fingers, or the slightest cutaneous irritation, is sufficient to bring on a paroxysm.— 3. Modid distress and agitation. The patient labors under the most extreme nervous excitement, groAving out of the terrific circumstances in which he is placed. His feelings are neces- HYDROPHOBIA. 121 sarily wrought up to the highest pitch, and he imagines, per- haps, that he is about to be smothered or strangled, if not by the disease, at least by his attendants, whose rough manners and excitement are frequently but illy calculated to allay his suspicions. To these symptoms may be added a remarkable feeling of buoyancy, or sense of bodily lightness; an intoler- able thirst, every attempt to allay which by drinking provokes a new and more severe paroxysm of convulsions, which often involve every muscle of the body; the secretion of a remark- ably viscid saliva, which itself tends to excite the convulsive fits ; vomitings of greenish or dark-colored matter ; distension of the stomach and bowels with gases; great pain in the region of the diaphragm ; restlessness, fever, and exhaustion. As the paroxysms increase in violence and frequency, the face be- comes livid, the muscles tremble, and when at length the sys- tem becomes completely exhausted, a more prolonged par- oxysm ends the unequal struggle. Causes.— It seems strange that the etiology of a disease Avhich has been observed for thousands of years, should still remain unsettled; yet there are those who, even at this day, claim that hydrophobia is purely a disease of the imagination ; that the fears of the patient are the only cause of the par- oxysms ; and that inoculation Avith an animal poison, or the virus of Rabies, has nothing Avhatever to do Avith it. This is no iicav notion. Aurelianus, Avho wrote nearly seventeen hundred years ago, says in his treatise on hydrophobia, that many intelligent persons of different ages and countries have utterly denied the existence of hydrophobia, except as a man- iacal affection, deriving its sole origin from the imagination of the patient. But if this be so, how, Ave ask, are Ave to account for its occurrence among mere infants, avIio cannot possibly labor under any such mental impression. Others again are delirious or idiotic; persons Avhose mental terror, if they haATe any, is neither constant, nor likely to be any greater on one subject than another. To these unanswerable objections may be added the general course of the disease, namely, that the characteristic symptoms usually folloAv very soon after the patient has been bitten by an animal laboring under a similar 8 122 NERVOUS DISEASES. affection ; that the affected persons always groAV worse, and finally die before the end of a Aveek; and that the same group of symptoms are rarely preceded by any other cause. These considerations force upon us the conclusion that, as stated by Dr. Bardsley, "there is at least one form of hydrophobia of Avhich the only constant knoAvn antecedent is the bite of a rabid animal; and this, therefore, in the present state of our knoAvledge, Ave are compelled to consider the cause till another is shown." On the other hand, it must be confessed that in- stances occasionally occur, in Avhich hydrophobia, or a disease closely resembling it, appears to be communicated by a non- rabid animal. Thus, Dr. Moritz related to the St. Petersburg Med. Society the case of a boy, who died with Avell-marked symptoms of hydrophobia, six Aveeks after being bitten by a dog, the dog, up to the time of the boy's death, never haAring exhibited any signs of rabies. A similar case was communi- cated to him by a colleague, of a boy who also died hydro- phobic after being bitten by a cat, the cat remaining, to all appearances, well. Dr. Severin had also met with a case of a child dying, who had been bitten by a dog that continued well. He had inoculated rabbits with saliva, blood and pus taken from this child, without producing any results.—(Meriocl sensibility also be- comes impaired. The extremities are affected Avith numbness, together with prickling sensations, and a certain degree of an;csthesia. The patient suffers more or less from headache and vertigo, appears depressed or dull of comprehension, and answers questions in a drawling and indistinct manner. Death generally occurs from nervous exhaustion, preceded by pul- monary hypostasis or oedema, and a condition of marasmus folloAved by delirium and coma. Diagnosis.—Paralysis agitans is so often confounded Avith other tremors, that Ave here present the differential diagnosis, as given by Prof. Ohoostek, at length: 1. Tremor senilis begins on the head, and then attacks the lips, the tongue, and far later the extremities; it is a symptom of senility, and Ave never see there the paretic states character- istic of paralysis agitans. 2. Tremor mercur talis.—Etiology; chronic stomatitis, etc.; paralysis of rectum and bladder, which is never observed in paralysis agitans. 3. Tremor scttarninus.—Etiology; bluish-grey edge of the gums, dingy coloring of the skin, nervous disturbances, lead- colic, paralytic state of the extensors of the upper extremities, epileptiform and eclamptic states, amaurosis. 4. Tremor potatorum.—Etiology; the tongue is easily at- tacked; it appears early in the morning with an empty stom- ach, and is diminished by taking the usual stimulant; chronic gastric and bronchial catarrh, amblyopia, even amaurosis, finally delirium tremens. 5. "Tremor simplex, called by Sanders Dystcria agitans, appears in younger persons, and is never found in combination with paretic states, nor with contraction, propulsion or retropulsion. 6. Multiple sclerosis.—It is a symptom of youth, whereas pa- ralysis agitans hardly ever sets in before forty years. Tremor only appears in sclerosis when motions are intended—for ex- ample, when the patient wishes to carry the spoon to the mouth; in paralysis agitans, on the contrary, the tremor is 198 NERVOUS DISEASES. also observed during perfect rest; it may be increased from an intention to motion, or from mental excitement, but ceases Avhen the part affected is supported. In paralysis agitans, the tremor begins in the upper extremities, or in the hand, and progresses; but rarely attacks the neck or trunk. In sclerosis, the head is first attacked, and then the neck. In paralysis agitans, debility of the affected parts is soon added to the tremors, Avhereas in sclerosis the tremor is added to an already existing paralysis, showing itself as paraplegia, hemiplegia, as crosswise paralysis (facialis of one side, extremities of the other), or finally as paralysis glosso-labio-pharyngea. Sensibility is not dulled in paralysis agitans, Avhereas in several cases of sclerosis, dulness of several parts—for example, in the tri- geminus—has been observed. Cephalic symptoms are never absent in paralysis agitans; vertigo, on the contrary, is observed early in most cases of sclerosis; also headache, and sometimes sleeplessness. Nor does paralysis agitans shoAV any disturb- ances of the organs of sense; whereas in sclerosis, nystagmus is frequent, also dilatation of the pupils, strabismus, disturb- ances of hearing, tasting, or smelling. In sclerosis we also meet an irregular beat of the heart, palpitations, alternately frequent and slow pulse, paresis of the rectum and bladder, vomiting; whereas, in paralysis agitans no symptoms of the cir- culation, or of the abdominal organs, are sIioavii. In paralysis agitans Ave meet slight stammering only from Avord-motions; in sclerosis it may become a monotonous speech at first, and end in raphonia. In paralysis agitans the flexors of the upper extremities are especially attacked, Avhereas in sclerosis the pa- ralyzed muscles, especially the extensors of the loAver extremi- ties, are attacked by tonic spasms; Avhere the upper extremities are in spasmodic action, Ave find them in close proximity to the trunk. The affected extremities show in sclerosis the symp- toms of spinal epilepsy, as soon as they are passively bent or become affected by other stimuli, which is not the case in pa- ralysis agitans. Etiology, Pathology, etc.—Paralysis agitans is chiefly a disease of advanced life; only exceptionally does it occur at an earlier age than fifty years. It is more frequent in men PARALYSIS AGITANS. 199 than in women, in about the proportion of two to one. Anxi- ety, grief, losses in business, severe mental shocks, hard labor, bodily deprivations and injuries, appear to be the chief causes in its production. Nothing is definitely known as to the pa- thology of the disease, no constant lesion having been found in connection with it. Fcav, if any, cases of the malady ever entirely recover. Treatment.—AVe have but little to offer in the way of treat- ment. Electricity, either in the form of faradization or galvanism, has in some instances appeared to produce temporary benefit- and if methodically and perseveringly applied may, under favorable circumstances, prove curative. The internal reme- dies which have hitherto yielded the best results, are: Camphor bromatum, Ilyoscyamus, Mercurius, Plumbum, and Tarantula. Camphor brom.—The most that can be claimed for the bromides in the treatment of paralysis agitans, is, that in moderate doses they are capable of moderating the violence of the disease and ameliorating the condition of the patient. For this purpose, the Camphor bromide, in closes varying from one and a half to fifteen grains daily, appears to be the most efficient. Illus. 84.—Three women in the Salpetriere, under the care of M. Charcot, of the respective ages of fifty, sixty, and sixty- seven years, were attacked by paralysis agitans and pronounced incurable. They took from tAventy centigrammes to one gramme (three to fifteen grains) of the Bromide ofi Camphor, daily, in quantities varying from one to ten dragees, in progres- sive doses. A marked amendment followed.—M. Bournevillc. Tarantula.—The pathogenesis of this remedy sIioavs it to be the true similimum of this disease, and therefore Ave are not surprised that it proved curative in the following case: Illus. 85.—Mrs. K., xt. 61, of strong constitution, but has seen a great deal of trouble during her life. Menstruation ceased at the age of fifty-two. In 1863 she suffered from severe pains in the left arm, so that she could not put her hands to her head, which left some trembling of the hand, which became aggravated by every mental trouble. In 1870 a fire broke out in her neighborhood, frightening her dreadfully, 200 NERVOUS DISEASES. and since then the trembling has increased and iioav affects all her extremities. During the siege of Paris, she Avas ex- posed to all the disagreeable situations incident to the Avar, and no wonder that her disease increased Upon her. The pains became so intense that she could not rest during the night, and the itching and craAvling on her left leg obliged her to rise and to walk about during the night. Simple baths aggraArated the pains, and the only place where she felt some- what comfortable Avas in the fresh air, even during the night. Hospital and private practice exhausted itself in vain to give her relief. Thus she came in my hands to try homoeopathy as a last resource. AVe found intelligence and memory con- siderably diminished; trembling, pricking, and much sensation in the phalanges of the hands and feet, so that she was unable to perform any fine Avork. Motobility and sensibility unaltered; neither paralysis, anaesthesia nor hyperesthesia. The head trembled just as the left foot and arm, and a slight tremor could be perceived on the tongue when she opened her mouth. She could only sleep for a feAV minutes, as the pains woke her up in spite of her sleepiness, and this Avant of rest told fear- fully on her. No appetite, chronic constipation, a stool could only be forced by enemata. Since her menopause she had acne in the face; the ophthalmoscope shoAved a sligJit hyperse- mia of the retina, and an analysis of the urine only revealed an excess of uric acid, showing itself by rhomboidal crystals. AVe gave her for some time Bellad., Nux vom., Iodine, Secale, Croton, Avithout any relief, when further studies led us to Tareudula, which Ave gave in the twelfth dilution in water, a tablespoonful every three hours. Under its influence sleep returned to her, gradually the violent trembling diminished, and after a steady treatment for six months with the same remedy Ave could pronounce the patient perfectly cured—Dr. Cramoisey (Bulletin de la Societe Med. J font, de Paris). scrivener's palsy. 201 CHAPTER NIL SCRIVENER'S PALSY. Scrivener's palsy, or writer's cramp, is a peculiar kind of spasm, affecting the muscles of the thumb, index and middle fingers. It is not confined exclusively to writers, but affects telegraphers, engravers, musicians, painters, sewing women, milk maids, and others, Avhose occupations are such as to greatly cramp and fatigue the affected muscles. Symptoms.—The disease manifests itself by uncontrollable movements in the thumb, index and middle fingers, excited by any attempt to Avrite, paint, or seAv, so that the pen or other instrument is no longer under the direction of the patient, but moves about in an irregular and unsteady manner, producing very different results from those intended by the operator. "The more," says Romberg, "the patient persists in his at- tempt, the more the difficulty of using his pen increases; and to the visible and sensible contractions of the muscles of the thumb, contractions of the forearm, and even of the upper arm, are often superadded. Abnormal sensations, especially of a sense of Aveight and constriction of the hand, or of pain extending from the upper arm to the back, are occasionally present. It is diagnostic of these attacks, that they are in- stantly arrested Avhen the individual ceases Avriting; and that the hand is capable of every other combination of moATements and exertions." The disease generally sets in gradually, but Dr. Hamilton reports a case Avhich occurred immediately after finishing a large extent of copying. Although authors, clergy- men, and other professional men avIio have considerable Avrit- ing to perform, are subject to the complaint, it is much more 13 202 NERVOUS DISEASES. common among clerks, book-keepers and copyists, whose occu- pations are such as to admit of little or no rest to the over- worked muscles. Of the twenty-three cases reported by Hamil- ton, fourteen, or nearly two-thirds of the whole number, avcic clerks, four Avere laAA7yers and musicians, and the remaining five included a clergyman, an engraver, a stenographer, a type-setter and a cigar-maker. Other observers have met Avith similar results. Thus, of the one hundred and twenty-five cases reported by Beard, only about seventeen per cent, were professional men; all the rest Avere clerks, book-keepers, mer- chants, copyists and agents. Those who write carelessly are, as Ave should expect them to be, less subject to the complaint than those who Avrite carefully and plainly. The disease evi- dently consists in overworking certain muscles in a certain Avay; in other Avords, it is a special form of fatigue. AVhen the patient attempts to use the fingers in any other manner, or for any other purpose than that which brought on the spasm, he generally meets Avith no difficulty. This shows that it is not simple paralysis that causes the trouble, but rather the ir- regular and spasmodic contractions excited by fatigue or over- Avork. The final result, hoAvever, is the same, as the patient eventually becomes, so far as the particular occupation that caused it is concerned, perfectly helpless. Diagnosis.—The symptoms of this disease are so peculiar, that there would appear to be but little danger of mistaking it for any other complaint. Paralysis saturninus bears some resemblance to the disease, but in lead poisoning the paralysis generally affects a greater number of muscles, and is also more complete. Moreover, in drop-hand the patient usually has control over the index finger. Progressive muscular atrophy often commences in the thumb, but the atrophy precedes the paralysis, whereas in the disease under consideration, the re- verse is the case; the paralysis, if it exists, precedes the atrophy. Local paralysis from other causes, such as cold or exposure, may be distinguished by careful attention to the symptoms. Etiology, Pathology, etc.—The disease is chiefly confined to the male sex, and to the middle period of life; in short, to those whose occupations are such as to predispose them to the scrivener's palsy. 203 disease. There can be but little doubt, therefore, that the ex- cessive use of the affected muscles is the chief, if not the essen- tial cause in its production. Still, the etiology of the com- plaint is not fully made out, as thousands of people constantly pursue the occupations that are supposed to give rise to it, without ever suffering any such consequences. Perhaps he- redity may act as a predisposing cause, as 'the disease has been known to occur in different members of the same family. As to its pathology, nothing is definitely known. Hammond and others are of the opinion that the disease is of central origin, and due to disorder of the motor cells, but the evidence of this is not conclusive. Others regard the disease as purely local, affecting only the muscles and nerves. The prognosis, accord- ing to Romberg, is bad, especially in all confirmed and long- standing cases, but in the early stages it is undoubtedly cura- ble. Mr. Solly describes several cases where judicious treat- ment, combined with absolute rest of the affected muscles, led to the most satisfactory results. Treatment.—Entire cessation of writing, or of the particu- lar employment that has led to the complaint, is essential to recovery. It is true, some patients avoid the necessity of giv- ing up their occupations entirely, by making use of such me- chanical appliances as will relieve the strain upon the affected muscles, and this, if effective, may be regarded as equivalent to the required rest. Thus, book-keepers and other penmen, by making use of the "ring pen-holder" may be able to guide the pen successfully Avithout holding it in the usual way. Others learn to" write with the left hand, and thus relieve the affected member until a cure is effected; but as there is a strong tendency in such cases for the disease to attack this hand also, it would be better not to employ it in this manner. Galvanism and massage have proved of considerable value in incipient cases, and so have stimulating baths and embrocations. Stromniever applied the principle of tenotomy to the cure of this affection, and in one case with complete success, the pa- tient being able to resume his writing in two weeks after the subcutaneous division of the tendon of the long flexor of the thumb. Dieffenbach, however, performed the same operation several times Avithout success. 204 NERVOUS diseases. Of the following list of internal remedies, Avhich has been recommended for writer's cramp, three have been credited with a cure, namely, Arnica, Gelsemium and Strychnia: Arnica, Belladonna, Causticum, Gelsemium, Nux vomica, dlhus tox., Ruta, Secale, Silicea, Stramonium, Staphysagria and Zincurn, Arnica.—This remedy is specially indicated Avhen the spasm is due to fatigue or overexertion. It is also indicated on gene- ral principals as a remedy for cramp, and also for paralytic conditions. Illus. 86.—Thos. S., book-keeper, set. 34, was obliged to relin- quish his position in consequence of a cramping of the thumb and first tAvo fingers of his right hand, whenever he attempted to write. For the previous sixteen months he had been con- stantly engaged in waiting up and posting three sets of books, Avhich had occupied all' his time during that period, from seven in the morning until ten at night. For the last sixty days he has been under allopathic treatment, which has consisted in the daily application of electricity, rubbing in hartshorn liniment, and taking an internal remedy having a bitter taste, probably Strychnia. As he appeared to get no better under this treat- ment, he thought he would try homoeopathy, although, as he stated, he had no faith in it. I placed him at once upon Arnica, 12th dil., enjoined absolute rest of the affected mem- ber, and gave him a first decimal dilution of Arnica to use twice a day as an embrocation, with instructions to apply it in such a manner as to obtain the benefits of massage. I in- tended, also, if necessary, to employ galvanism, but it Avas not required. In about three weeks of the above treatment he began to mend, and in four months after taking the first dose of Arnica, he was able to resume his labors as an accountant. He was recommended to frequently change the size of his pen- holders, generally using those that were large and light, to rest the tired muscles as much as possible, and at all events, at least three times a day, and to knead the hands and fingers thoroughly every day, by way of prevention. Three years have since elapsed, and he has complained of no further trou- ble, except that the fingers sometimes get stiff and tire easily. —Hart. aphasia. 205 CHAPTER XIII. APHASIA. The term aphasia, which is derived from the Greek a, not, and cv/./7jc, speech, is used to denote that state of the nervous system in which the patient has lost the power of expressing his thoughts in intelligent language. It was formerly called aphonia, from a, not, and ."> Prescribed Sanguinaria200, six pellets night and morning, for a week. Eight months afterwards patient reported relief from the first dose, during the week complete relief, and from that time until now, not a vestige of the old complaint has shown itself.—Dr. J. P. Mills. Illus. 106.—Dr. Mills regards Avhat he calls "sun headaches," that is, those increasing in violence Avith the sun's ascent, de- creasing as it declines, Avhen preceded by scanty urine and pass off attended by profuse flow of clear urine, as indicating Sangui- naria, and the urine symptom as its keynote, giving the follow- ing case as an additional illustration: Mr. AV., railroad engi- neer, was taken early in the morning with headache and nausea, the symptoms increasing hour by hour. At 4 p.m. the pain and distress had reached such a height that, fearing "brain feA7er," 1 was summoned. I found the patient on the bed groaning and Avrithing in agony, face very reel, head hot, injected eyes, sensitive to light. The arteries about the head and in the scalp Avere distended like whip-cords, the blood coursing through them at a furious rate, giving a sensation to the head as if the scalp and temples were alive Avith irrepres- sible pulsations. The pain Avas over the whole head; parox- ysms of retching occurred every feAV minutes, Avith such vio- lence that I feared rupture-of bloodvessels. I prescribed Bell., Glon., and Bry. in succession, but Avithout benefit, not think- ing at first of Sanguinaria, though I was aware that the head- aches passed off with free flow of clear urine, and that he, being an engineer, would be subject to kidney trouble. At midnight a messenger came, saying that Mr. AV. Avas wildly delirious, Avith no abatement of symptoms. I sent Sangui- nariam, to be given in Avater every half hour. Fifteen minutes after the first dose, symptoms began to abate; in an hour and a half, he fell into a quiet slumber for a little time, awaking quite relieved from the acute pain, but an intense soreness continued for two or three days, Avhich compelled him to keep quiet or to walk with great circumspection.—Idem. tfepia,—Hemicrania of a tonic character, caused by mental emotions, especially vexation, and attended with nausea, lo 234 NERVOUS DISEASES. vomiting, rigor, pale face and flying heat, Ameliorated by pressure, sleep and darkness. Periodicity is a marked symp- tom, especially in the female sex, to which this remedy is specially adapted. Illus. 107.—Mrs. L., of a nervo-sanguine temperament, had for several years a headache recurring every Saturday; she sometimes thought it came from the noise of her children w7ho were home from school on that day, but so sure as Satur- day came the headache returned; the pain was of a boring, pressing character from Avithin outwards, and was attended Avith nausea and vomiting; binding the head up tightly re- lieved it somewhat, and if she could get a good sleep would wake up much better. Sepia cured.—Dr. G. M. Ockfiord. Spigelia.—Periodical headache, generally confined to the right temple, or to the left eye and left temple, pulsating, darting or boring, commencing every morning AA'ith the rising of the sun, reaching its height at midday, and gradually de- clining till the sun sets, and accompanied Avith pale face, nausea and vomiting. Aggravated by motion, stooping, noise, thinking, or mental emotion. Illus. 108.—Miss T----, set. 36, had suffered from periodical attacks of left-sided hemicrania for upAvards of nine years. The attacks set in early eA7ery summer, and continued to recur regularly about every tAvo weeks, lasting each time about three days, and compelling her during that time to exclude herself from society. The paroxysms, which set in just after sunrise in the morning, were of the most violent character, causing severe pulsating pains in the left temple and eye, and reaching their greatest intensity about noon, Avhen they avc re attended with vomiting and retching, after which they gradually de- clined, and at sunset gave place to anxious and disturbed sleep. The slightest motion or noise greatly aggravated the headache; even the movement of the eyes would increase it. After the paroxysms subsided the scalp felt sore to the touch, and the brain confused. After trying two or three other remedies without any marked benefit, I placed her upon Spigelia30, five pellets every night and morning for one Aveek. HEMICRANIA. 235 No more paroxysms occurred until July of the following year, after several Aveeks anxiety, and attendance on a very sick brother. I again prescribed the same remedy in the same manner, and for the same length of time, since which she has been entirely free of headache, a period of more than four years.—Hart. Sulphate ofi Nickel.—This remedy is indicated in periodical headaches attended with a sense of great fulness, heat and stupefaction, setting in on rising, and increasing until noon, with vertigo and nausea. Illus. 109.—A woman suffered from distressing periodical headaches every t\vo Aveeks, lasting three or four days. The pain Avas most acute at the root of the nose, and extended to the vertex and through the temples. She had some nausea but no vomiting. The distress Avas so great that she lay and groaned in anguish. After prescribing Cuprum, Ignatia, Sepia, Calcarea and Sulphur Avithout any apparent benefit, I gave her two-grain doses of the Sulphate of Nickle, 3x trit., every day, Avhich suspended the paroxysms four months—a respite she had not enjoyed for ten years.—Dr. A. E. Small. Veratrum.—Headaches attended with great anxiety, fear, cold feeling, small, rapid, intermitting or slow pulse, nausea, and sometimes A'omiting. The headache is occasionally at- tended by a sensation of Avarmth and coldness at the same time on the seal}), and sensitiveness of the hairs. There is sometimes cold sweats on the forehead, weakness, faintness, and profuse micturition. The attacks are generally nocturnal. Ulus. 110.—An inveterate case of chronic nocturnal headache, attended Avith draAving pains in both arms and frequent micturition; the attacks come on in the afternoon and con- tinue into the night, the pain getting better toAvards morning; the patient is able to be about the house in the forenoon. Cured with Veratrum album*00.—Dr. Barrows. Illus. 111.—Airs. 0., set. 27, has been a martyr to nocturnal headaches ever since she Avas thirteen years of age. They do not appear to observe any other form of periodicity, coming and going at irregular intervals, but ahvays setting in just 236 NERVOUS DISEASES. after dark, and going off about three o'clock in the morning. They attack chiefly the left side of the head, and are attended with violent throbbing or beating, heat of the scalp, burning of the face, and vertigo and nausea on rising or sitting up. They are greatly aggravated by motion, mental excitement, and the erect position, and are always Avorse previous to, and at the menstrual period. Veratrum30, night and morning, for six Aveeks, effected a complete cure.—Dr. T. S. Strong. NEURALGIA TRIGEMINI. 237 CHAPTER III. NEURALGIA TRIGEMINI. Neuralgia of the trigeminus, or fifth nerve, is variously knoAvn as tic-douloureaux, facial neuralgia, prosopalgia, and fiaceache. It is not only the most common, but, Avith perhaps one exception, the most severe form of neuralgia. This susceptibility is partly due, no doubt, to the superficial relations of the nerve and its branches, and partly to the fact that most of its rami- fications pass through very small and unyielding foramina. The disease may implicate one, or all three branches of the nerve. Most frequently it is the superior maxillary, or mid- dle branch of the trigeminus, that is affected. AVhen the pain is felt only in the terminal twigs of this branch, in the vicinity of the infra-orbital foramen, it is called infira-orbital neuralgia. At other times some portion of the ophthalmic division of the trifacial nerA7e is affected, constituting one of the sub-varieties of facial neuralgia, knoAvn as orbital, supra-orbital and ciliary neuralgia. AVhen the dental branches of the superior and in- ferior maxillary divisions of the nerve are implicated, we have dental neuralgia or odontalgia. Symptoms.—Facial neuralgia generally occurs in parox- ysms of greater or less frequency, the attacks sometimes follow- ing each other in rapid succession, and at others separated by intervals of considerable length. The pains, Avhich are gen- erally sudden, and of a shooting, lancinating and jerking char- acter, are not apt to be very violent to begin with, but they gradually increase in intensity until the paroxysm reaches its height, when they become so intolerable that the patient is often unable to'suppress his cries. They follow the course of 238 NERVOUS DISEASES. the nerves, and sometimes extend, by means of the connect- ing tAvig given off by the trigeminus after its passage through the parotid gland, to the branches of the portio dura. They may also, by implicating the opposite branches, extend to the other side of the face. AVhen the ophthalmic division is af- fected, the pain is generally first felt in the terminal branches near the supra-orbital foramen, or else in the trunk of the nerve at the bottom of the orbit. At a later period, the ciliary nerves become irritated, producing redness of the conjunctiva and lids, Avith perhaps more or less ciliary injection, pain, pho- tophobia, lachrymation and SAvelling. The motor nerves of the face frequently become involved, causing the muscles sup- plied by them to twitch and jerk convulsively; and in some cases more or less spasmodic action occurs in more distant parts—the result, probably, of reflex action caused by the se- verit}7 of the pain. The irritability of the affected nerves some- times becomes so great, that talking, sneezing and chewing, or even currents of cold air, etc., will renew the attacks. The tender points of A^alleix are the supra-orbital notch, the inner angle of the orbit, the junction of the nasal bone Avith the car- tilage of the nose, the mental foramen, and a spot immediately in front of the ear. Tliere is sometimes considerable constitu- tional disturbance associated Avith this form of neuralgia, espe- cially when the ciliary nerves are implicated, as shown by loss of appetite, coated tongue, pains in the back, scanty and high colored urine, constipation, etc. The duration of the dis- ease, is very uncertain. AVhen it depends on miasmatic influ- ences it is more or less periodical and transient; in other cases it is apt to become continuous, subject only to daily exacerba- tions and remissions, the former usually occurring at night, and the latter in the morning. Causes-—The etiology of this affection is often very obscure. Sometimes the attack is excited by such agencies as Avounds, decayed teeth, cold, rheumatism, syphilis, poisonous cosmetics, suppression of cutaneous eruptions, the sudden arrest of accus- tomed discharges, etc.; and occasionally it can be traced to tumors or bony growths pressing upon the trunks of the af- fected nerves; but in very many cases no definite cause can NEURALGIA TRIGEMINI. 239 be discovered. Probably cold is the chief exciting cause, though there can be but little doubt that the disease is greatly aggravated, if not primarily induced, by such agencies as ex- cess in venery, the immoderate use of tea, coffee and tobacco, the abuse of stimukiting beverages, high living, late hours, severe mental and bodily exertion, mental emotions, and whatever is capable of lowering the tone of the nervous sys- tem. Whether sex predisposes to the disease is not certain, but as it exerts a marked influence in most forms of nervous disease, it is probably not without influence in this. There is no doubt, hoAvever, as to the effect of heredity in favoring its occurrence, the disease often appearing in different members of the same family, and in conjunction with other nervous af- fections, especially hysteria. Diagnosis.—Neuralgia trigemini is liable to be confounded Avith rheumatism and hemicrania. From the former it may be distinguished by the character and severity of the pains, by the shortness of the paroxysms, and by the attacks being excited by such causes as a sudden jar or touch. From hemi- crania it may be known by the transient and darting character of the pains, and by their corresponding accurately with the course and distribution of the nerves. Many cases of hemi- crania, however, have their starting point, as Ave ha\7e seen, in the supra-orbital branch of the trigeminus; but these, instead of being confined to the trifacial nerve, soon extend over the scalp, and, by involving the sympathetic, give rise to vaso- motor and sensory disturbances peculiar to that affection. Pathology.—Not much is knoAvn regarding the pathology of facial neuralgia. In some cases the affected nerves have been found more or less red and inflamed, but quite as often the most diligent search has failed to reveal anything ab- normal about them. There is no doubt, however, that the sympathetic is sometimes at fault, for in no other way can Ave explain such symptoms as contraction of the pupils, conjunc- tival injection, chemosis, and other ocular disturbances, flush- ing of the face, and the constitutional derangement sometimes met with; but it is not certain whether these disturbances are primary or only secondary phenomena; in other words, Avhether 210 NERVOUS DISEASES. the changes Avhich take place in the sympathetic system are secondary to the trifacial disturbances, or vice versa. Prognosis.—This disease, Avhile not directly destructive of life, is sometimes so exceedingly severe and obstinate as to threaten to Avear out the constitution of the patient, by under- mining the general health, rendering the mind feeble, and the nervous system extremely sensitive and irritable. The chances of cure, in any case, depend upon whether the cause is, or is not removable. In the former case, as when the disease arises from cold, malarious influences, bad habits, or nervous debility, it will generally yield to the rightly-selected remedy ; but when the affection depends upon organic changes, such as tumors, exostoses, and other structural alterations, it is very likely to prove permanent. At best, the patient is apt to suffer more or less from the complaint as long as he lives. Treatment.—On the subject of treatment the author* has elsewhere said : "It folloAvs from the purely subjective character and limited range of the symptoms, that the treatment of pro- sopalgia needs to be conducted Avith special reference to the cause. Hence it becomes necessary, first of all, to institute a careful scrutiny into the general state of the patient's health, his habits and surroundings, traveling, as it Avere, beyond the boundaries of the symptomatic indications, in order to ascer- tain, if possible, the true cause of the malady. In this Avay the prescriber is enabled to make his anatomical, physiological and pathological knowledge contribute, not only to the diag- nosis, but, in a large proportion of cases, to the cure of this obscure, obstinate and very painful disease. Even with all the light Avhich can be thrown upon it in this manner, the prac- titioner will often have great difficulty in selecting a suitable remedy, and Avill as frequently be disappointed; but it is evi- dent that in no other way, in many cases, can there be any reasonable hope of success. Thus directed, hoAvever, the symp- tomatic indications are generally sufficiently definite to suggest the proper remedy; and, as a consequence, homoeopathy has produced many brilliant cures in the domain of this opprobium medicorum of the old school." * Practice of Medicine, p. 96. NEURALGIA TRIGEMINI. 241 Aconitia.—This remedy is indicated, according to Prof. Cubler, in every variety of trigeminal neuralgia. He says he has never known a neuralgia of the fifth pair, even tic-doulou- reaux, to resist it. It, however, appears to be most effective in the congestive forms, or where it arises from cold or suppressed perspiration. Illus. 112.—Some years ago, a patient who had long been the victim of obstinate trifacial neuralgia, had all the affected nerves excised by Nelaton. The operation only gave temporary relief, and the patient declared she would commit suicide. By the advice of Debout, Aconitia was tried, and after five milli- grammes had been taken she was permanently relieved. In another patient, who had suffered agonies night and day, six milligrammes completely dissipated the disease.—Prof. Gubler. Agnus castus.—This remedy is specially indicated in infra- orbital neuralgia, particularly if the pain is of a pressive, tensive character, or like a blow, and is relieved by hard pressure. Illus. 113.—Aliss S. E., set. 40, large and.fleshy, has suffered for more than tAvo months past with pressing pains at the bridge of the nose, as if it were pinched in a vice. The pains come on suddenly, " like a flash of lightning," and often cause her to scream out. They are more severe upon the left side of the nose, and extend, modified in intensity, along the under margin of the left orbit, and are relieved by pressing the seat of pain hard Avith the fingers, when they disappear gradually, leaving a continual sensation of discomfort in the parts. She also has many momentary-neuralgic pains in various parts of the body, coming and going Avithout regularity. The infra- orbital pain, though generally of a pressive character, is at times like a severe bloAv, followed by a crawling, scalded feel- ing, or as if cold Avater were running doAvn. There is some painful fulness and pulsating under the left eye, but no swell- ing. Patient fears a cancer, or some other "horrible disease." Agnus castus200 Avas sent her, with directions to take a dose night and morning. This speedily dissipated the pain, and, although more than a year has since elapsed, there has been no return of it—Dr. C W. Butler. Argentum nit.—Prosopalgia frontalcs, Avhen the pains are of 242 NERVOUS DISEASES. a sudden and rending character, extend into the orbit, and the eyeball feels as though it would be pressed out; face pale, sight impaired, and the affected parts more or less anaesthetic. Illus. 114.—Anna Buden, set. 50, a hard working widow, says that after taking cold she Avas seized by a violent, tearing, lightning-like pain in the right eyebroAV, Avhich extended to the point of the nose and into the orbit, so that it felt as if the eyeball Avould be crowded out, then over the right side of the forehead, radiating over the Arertex to the occiput. The par- oxysms appeared irregularly, sometimes at night, sometimes during the day, and left a feeling of numbness in the affected parts, and her ability to see at a distance Avas impaired. The pains occurred several times a day, so that she Avas unable to earn her living. She Avas admitted to the hospital of nuns in Prague, and Avas treated for six Aveeks Avithout any improve- ment of her sufferings. Aftenvards she AA'as transferred to the Imperial Hospital, Avhere she remained tAvo or three Aveeks. She then returned to her home in the country for the benefit of the country air. Here she remained for a long time, but as the attacks increased in violence she at last consulted me. Discovering that Argentum nitricum corresponded to the entire case, even to the color of her face, I gave her Arg. nit.4, four drops in twelve powders, to be taken night and morning. After they Avere used, the pain ceased altogether, but two months afterwards a slight relapse occurred, when a repetition of the Arg. nit. Avas sufficient to complete the cure. Years have passed since that time, and she labors as formerly, but has had no return of the disease.—Dr. W. Heyerbcrger. Atropix sulphas.—This remedy is often useful Avhen Bella- donna is indicated, but foils to relieve. Illus. 115.—W. M., a young man of great physical endurance and of regular habits, Avas taken Avith a terrible pain in the right eye, running up into the temple. The face became flushed and the eyes looked Avild, but the pain disappeared about noon, and did not return until the next day at 9 a.m. Belladonna* Avas prescribed every hour. The following day the attack came on earlier, Avas more severe and lasted longer. Belladonna tinct., in half drop doses every hour. The next NEURALGIA TRIGEMINI. 243 day the attack lasted until evening, and was accompanied by twitching of the muscles of the face, intolerance of light and noise, tongue yellow. Belladonna200, one dose every two hours. Next day worse. Patient insists on taking quinine. Gave him six powders of the third trituration. No improvement; patient thoroughly discouraged. Gave him one powder of Atropim sulphas, 3d dec. trit., dissolved in four ounces of water, a teaspoonful to be taken every hour. The second dose brought amelioration, and the next dose absolute relief, Avith- out return of the symptom.—Dr. H. R. Arndt. The above case is given for what it is worth. NotAvithstand- ing my confidence in the doctor's judgment, I strongly sus- pect it was the Chinin. sulphas3 that did the work, and the Atropia got all the credit. It is astonishing how little of the cinchona, salt is necessary to cure some cases of intermittent neuralgia, especially when the periodicity arises from malar- ious influences. It is strange, also, that there should be so much prejudice in our school against the use of quinine in these cases, when, if there is any truth in the liomoopatliic law, or any force in the experiments instituted by Hahne- mann, and which were to so great a degree instrumental in establishing his faith in the homoeopathic dogma, it is one of the best, if not the best remedy in all such cases. Belladonna.—Intermittent neuralgia affecting the right side of the face, Avorse in the afternoon and evening, and aggra- vated by motion, light and noise. The pains are of a cutting or throbbing character, and frequently extend into the eye and temple, or into the ear. Illus. 116.—The patient has been affected about three months every year, for the past eleven years, Avith daily intermitting neuralgia of the right side of the face, eye and temporal region, the pains commencing at 12 m. and continuing until 6 p.m., or else coming on at 6 p.m. and continuing until 12 p.m., the rest of the twenty-four hours being entirely free from pain; the sight of the right eye Avas obscured, as though looking through a fog. Two doses of Belkulonna3 effected a complete cure.— Dr. Noble. Bisnudhum.—Bismuth is specially indicated in facial neu- 244 NERVOUS DISEASES. ralgia Avhen the pains are of a burning charavter, occur in the morning, are aggravated by Avarmth, and are situated in the forehead and eyes, especially in the right eye. Illus. 117.—A lady, set. 25, had facial neuralgia of some weeks duration. AVas Avorse in the morning. The pain Avas burn- ing, excruciating, and greatly aggravated by warmth. The only relief that could be obtained Avas by holding cold Avater in the mouth and moving about. Several remedies Avere used Avithout any good results, and the patient Avas growing Avorse. Bismuthum200 Avas then given with almost instantaneous relief, and with permanent benefit, as there Avas no further pain for upAvards of three years after it had been administered.—Dr. G. M. Ockfiord. Bryonia.—-General facial neuralgia or tic douloureaux, the pains of a sharp, darting, stitching character, and extending to the teeth; aggravated by stooping, noise, light, and moving the jaw. Illus. 118.—Mrs. P. had suffered for six years with tic dou- • loureaux, and had "suffered many things of many physicians." All her teeth on the left side, upper jaAv, Avere sacrificed, and still no cure Avas effected. At this time the pain Avas most acute, and she found herself obliged to remain in her oavii room, refusing to speak to her children or take food for days together. The motion necessary to speak or eat, aggravated the pain to such a degree that tears floAved freely. One pow- der of Bryonia alba gave so much relief that she joined her family and took a full meal Avithin two hours. Her symptoms continued to improve, and she found herself quite free from pain. After taking a feAv more doses of Bryonia she was dis- charged.—Dr. E. C. Beckwith. Ignatia.—This remedy is indicated in supra-orbital neural- gia of the left side, especially Avhen it is of a hysterical charac- ter, or excited by grief or fright; also in well-marked inter- mittent cases, occurring in Avomen of a mild and amiable dis- position. Illus. 119.—For several years past, during the spring months, Airs. P----, a large, amiable, and benevolent woman, has suf- fered with supra-orbital neuralgia, of an intermittent type. NEURALGIA TRIGEMINI. 245 Every day, at 9 a.m., a severe pain seized her just above the left orbit, of a tearing and pressive character, which extended into the nose and eye, and reached its height in about three hours. After 12 m. it would gradually diminish, and at 3 p.m. would be entirely gone. A thin nasal discharge accompanied the decline of the pain and seemed to give relief. After try- ing several remedies without benefit, I studied up the case, and concluded to give Ignatia. Accordingly, I prescribed the thirtieth dilution of this remedy three times a day. After taking the medicine in this way for about a Aveek, the pain suddenly ceased and has never returned.;;—Hart. Iris vers.—A lolent shooting and cutting pains in the tempo- ral region, extending into the eyes and teeth. The remedy is specially indicated if the pain is seated over the left supercili- ary ridge, or is accompanied by nausea or conjunctival redness. Illus. 120.—Airs. T., set. 42, mother of five children. Has been suffering from neuralgia in the left temporal region, extending down the ramus of the lower jaw into the teeth; pain sharp and cutting; health otherwise normal, and sleep good, except when disturbed by these neuralgic pains. Prescribed Iris vers6, ten pellets, number thirty, four times per day. Cured.—Dr. W. S. Mullins. Kalmiu.—Sharp rending or stinging pains in one or all the branches of the fifth pair of nerves, and extending into the neck, temples, and teeth; ameliorated by cold, aggravated by Avarmth. Illus. 121.—AVas called to treat a case of facial neuralgia in a lady, the attacks coming on in the evening, gradually increas- ing in severity, and lasting all night. The pain commenced in the neck, Avent to the top of the head, then to the temples and right side of the face; the parts were tender to the touch; pain sharp, shooting and twitching, sometimes sudden, in spots; relieved by cold, aggravated by heat; teeth sound but tender. Kalmia relieved, after Bellad., Coloc, Pulsat., Nux vom., Arsen., Spigel. and Carbo veg. had failed.—Dr. Ball. Lachesis.—Neuralgic pains seated in the supra-orbital nerve of either side, of a sharp and lancinating, or dull and heavy character, and associated with great sensitiveness of the sur- 246 NERVOUS DISEASES. face. It is more especially indicated if there is spinal tender- ness or aching also. Illus. 122.—Air. A., set, 40, has a very severe pain, commenc- ing in the inner canthus of the right eye and extending up- Avard and outward in a half circle just above the superciliary ridge. The pain is dull, heavy, and so severe as to disable him for all work; commences at 9 a. m., and goes off in the afternoon; the skin is extremely sensitive to the touch; the pain had located about a week. Luchcsis30, two doses, Avere pre- scribed. The folloAving day the pain Avas very slight, and has never returned, but the following day there appeared a pain in the small of the back,,Avorse after sleeping, similar to a rheu- matic trouble Avhich he had six years ago, and Avhich Avas re- lieved at that time with liniments. Gave Sac. lac, and all symptoms soon disappeared.—Dr. Howard. Mezereum.—Left-sided facial neuralgia, extending from o\7er the eye to the eyeball, cheek, teeth, neck and shoulder; lach- rymation, conjunctiva injected; parts sensitive to the touch; aggravated by Avarmth. Illus. 123.—II. G., a stout, healthy-looking negro man, came to my office, seeking relief from a severe supra-orbital neural- gia, left side, beginning regularly at 9 a. m., increasing in se- verity until noon, and then subsiding gradually until near 4 p. m., Avhen the pain entirely ceased. He had suffered in this manner daily for about a Aveek, using only cold compresses as a palliative. The pain Avas intense, and yet it seemed to extend only along the supra-orbital ridge to the temple, the patient being aide to cover the Avhole extent of. the pain Avith the points of two fingers. The patient Avas in good health ex- cepting the periodical neuralgia.. After prescribing Aeon., Arsen., Bellad., Gelsem. and Spigel., at different times, Avithout success, I made a more careful study of the case. The only symptoms from Avhich to select a remedy Avere: supra-orbital pain, at times extending into the left eye, causing a flow of tears, beginning at 9 a. m., increasing until 12 m., and decreas- ing gradually until 4 p. m., leaving the patient perfectly free from pain or soreness; left eye injected; pain of a heavy, ach- ing character. Finding that the symptoms of Mezereum cov- NEURALGIA TRIGEMINI. 247 ered the case, excepting the periodicity, I prescribed the first decimal preparation, and permanently cured the case.—Dr. J. W. Wince, Sepia.—Aching, draAving, or tearing pains in the face, nose and temples, worse in the left side and at night, extending to the teeth, vertex and occiput, especially when caused by ex- posure to cold; the pains frequently extend to the ear, and are aggravated or renewed by either warmth or cold; especially suited to delicate, sensitive females, particularly when the menstrual function is disturbed. Illus. 124.—A young lady, set. 21, after getting heated, drove at night in a carriage, and, the windows being open, was chilled. Tavo days later she got violent pains in the teeth, that became intolerable at night, The pains spread from the teeth through the upper jaw and the temples of both sides, but Avere worse in the left side, and went to the top and back of the head. Tavo carious teeth Avere extracted Avithout reliev- ing the pain. Avhich became worse. Peruvian bark Avas given in large doses, causing the pains to increase greatly in inten- sity. Seeking my advice, I gave two doses of Sepia3, after which the pain completely disappeared.—Dr. Ileyberger. Local Treatment.—Facial neuralgia is often greatly ame- liorated, and sometimes cured, by certain kinds of local treat- ment, even after internal remedies have failed to relieve. This is especially the case Avith electricity and the ucav operation of nerve-stretching. The former, in the form of galvanism, is fre- quently of great benefit during the paroxysms, sometimes relieA'ing the most intense suffering at a single sitting. The sponge of one of the poles of the battery, Avell-saturatcd, should be applied over the affected nerves, and that of the other at any convenient distance outside of the painful spot. The current, which should be very light at first, Avill be most effective in subduing the pain, by being gradually increased until a slight burning sensation is produced. It should not be continued over five or ten minutes at one sitting, nor should the application be made oftcner than once or twice a day, except in chronic cases. Nerve-stretching is now an approved and highly successful 248 NERVOUS DISEASES. mode of treating obstinate cases, especially Avhen the tissues surrounding the painful nerve are swollen or hypertrophied. The affected nerve having been laid bare, is pulled backAvard and fonvard Avith sufficient force to liberate it from any inflammatory or other form of compression Avhich may be interfering with or exalting its function. The paresis that generally folloAvs the operation soon Avears off, and the patient may then find himself permanently cured. The supra-orbital nerve has been repeatedly operated on in this manner, and Avith the most gratifying success. Chloral hydrate has been used Avith considerable benefit as a local remedy, in some instances, Avhere other measures have failed to give relief. One mode of application is, to saturate folds of lint, of the proper size, Avith a solution composed of about five drachms of the chloral to a pint of water, to Avhich a small quantity of glycerine is sometimes added. These folds, after being brought into close contact with the affected parts, are then C0A7ered with three or four layers of lint, or spongio-piline, wrung out of hot water and covered Avith oil- silk. Another mode of applying the remedy is, to make an intimate mixture of equal parts of chloral-hydrate and cam- phor, which produces a clear fluid, and then to paint the mixture lightly over the painful part and allow it to dry. Dr. Lenox Browne states, in one of the English journals, that he has employed it in this manner, and induced others to do so, and that in every case it has afforded great, and, in some instances, instantaneous relief. It never blisters, though it may occasion a tingling sensation of the skin. Aconitia and Atropine may be applied in a similar'manner. Dr. Holcombe says that two or three grains of the first centesimal trituration of atropine, dissolved in a cup of water, and rubbed into the painful parts with a soft rag, will soon mitigate the sufferings of the patient, INTERCOSTAL NEURALGIA. 249 CHAPTER IAT. INTERCOSTAL NEURALGIA. Intercostal, or, as it is sometimes termed, dorso-intercostal neuralgia, is a hypersesthetic or painful condition of the sen- sory fibres of one or more of the twelve pairs of dorsal ner\7es. It is frequently confounded Avith pleurodynia, but the latter is not seated in the nerves, but in the muscles; in other words, it is a myalgia of the intercostal muscles. Symptoms.—It is important, in order to distinguish the disease from pleurodynia or rheumatism, to bear in mind the tender points to be found in most cases of true intercostal neuralgia. These sensitive points are located in three differ- ent places, namely, close to the vertebral column, or over the spinous processes of the vertebrae corresponding to the affected nerves; in the middle of the intercostal space, about half way between the spine and sternum; and at a small spot in front or by the side of the sternum. The pain, Avhich is generally confined to the left side, and to only one or two of the inter- costal nerves, seldom sets in Avith much intensity, but, like other forms of neuralgia, becomes more and more severe as the disease progresses. It commonly affects the nerves between the fifth and ninth ribs, and is of a shooting, tearing, or jerk- ing character. As the pain passes off, it always leaves a stinging or burning sensation behind it. The pains are aggra- vated by every considerable movement of the spine or thorax, owing to the tender spots above mentioned, and from Avhich they appear to radiate. These tender points are so sensitive, that the patient is very apt to draw attention to them, es- pecially if the practitioner attempts to percuss the chest. A 16 250 NERVOUS DISEASES. characteristic circumstance is, that while moderate pressure over these points is not avcII borne, hard pressure is endured without much trouble. This will serve to distinguish the tenderness from that of inflammation, to which, at first sight, it seems to bear considerable resemblance; it may also be distinguished by the absence of fever. The disease is usually very obstinate, and may last for years, and even for life. It is chiefly confined to females, with whom it often as- sumes the form of Mastodynia, or neuralgia of the mammary gland. This form of the disease may be distinguished from every other affection of the breasts, by its having no direct, or causative connection with pregnancy, or Avith nursing or weaning, though it is fre- quently aggravated by being associated with these conditions. The painful sensations are generally due to mammary conges- tion, arising from the establishment, periodical recurrence, or derangement of the menstrual function, and hence is most fre- quently observed in girls at the age of pubescence, or period- ically in full-grown girls and Avomen betAveen pubescence and the critical age. In girls, the pains are draAving, stitching, or throbbing; or there may be only a tingling or prickling sen- sation in the sAvollen and sensitive breasts. Sometimes the mammae are so sensitive, not only in growing girls but in married Avomen, that the least pressure or.friction is unbear- able; even the Aveight or jarring of the distended organs is painful. This hypersesthesia of the breasts often continues until the reproductive organs undergo a change in consequence of marriage, and sometimes reappears at every menstrual period during life. It may even extend to other parts of the body, particularly to the uterus, pudendum and stomach. Another variety of mastodynia arises from traumatic or con- stitutional causes. The pains, Avhich come on in paroxysms, are lancinating, rending, boring or drawing, and are ahvays worse at the monthly periods; they are also aggravated by pressure. This variety, if it continues for any considerable length of time, is apt to result in the formation of mammary neuromata, which can often be felt as smooth rounded tuber- cles, of the size of hazelnuts, beneath the skin. INTERCOSTAL NEURALGIA. 251 Etiology, Pathology, etc.—AA7c have already stated that intercostal neuralgia chiefly attacks females, and tnat it very rarely occurs prior to the age of pubescence, or subsequent to the climacteric period. As a general rule, it is impossible to refer it to any special or definite cause, though it frequently follows an attack of herpes zoster, shoAving that an intimate relation exists betAveen these tAvo affections. Occasionally, in- stead of the eruption preceding the neuralgia, the two diseases appear together; and still more rarely, the neuralgia precedes the appearance of the eruption. Mastodynia is common in chlorotic, ansemic, and hysterical conditions of the system, and hence these conditions are generally regarded as predisposing causes; but, as before stated, menstrual disorders, especially metrorrhagia, and other Avasting discharges, such as metror- rhagia and leucorrhcea, are no doubt the chief exciting causes of the trouble. The disease is sometimes associated Avith spinal irritation, angina pectoris, and certain constitutional disorders, such as tuberculosis and syphilis. Illus. 125.—As illustrative of the symptomatology, etiology and pathology of mastodynia, avc give the folloAving instructive example from Sehulze : "A woman, a>t. 26, entered the hospital at Lteidelberg on account of torturing pains in both mammae. She states that she Avas confined about three years ago, labor and puerperium normal; nursed the child for six Aveeks, dur- ing Avhich the milk Avas abundant, Avhen.it suddenly ceased on account of grief. The menses Avere irregular, sometimes stop- ping for six months or even a year. Of late, menstruation had been regular, but the last time it Avas scanty and lasted only a couple of days. Seven months before entering the hospital, she suddenly felt as though milk was being secreted, just as she formerly felt when nursing. On pressing the mamma she was astonished to see exuding from the nipple a milk-white yellowish fluid. During the next feAV days the sensation of tension increased, and shortly afterwards the breasts became so painful that the patient was unable to lie on the left side. At first there were free intervals, but now she could only speak of remissions and exacerbations. After four weeks more of suffering, the neuralgia began to tell on the patient, she be- 252 NERVOUS DISEASES. came unable to work, even knitting increased the pain; some- times, also, she complained of vertigo and headache. Exami- nation revealed moderate anaemia, perhaps some chlorosis; the mammae were pendulous and somewhat flabby, and the ma- millse normal. Palpation revealed nothing abnormal, nowhere painful tubercula; moderately strong pressure was well borne, and on pressing the nipples a few drops of yellowish-white fluid was discharged, which microscopically corresponded to colostrum. Sensitiveness to pressure was observed on the spi- nous processes of the second to the tenth dorsal vertebra). In the left fourth intercostal space there was pain on pressure opposite the arch of the rib; pressure on the eighth to tenth dorsal vertebrae caused the pain to radiate toward the right mamma. Examination of the genital organs revealed a mode- rate fluor albus; the mucous membrane of the os uteri redder than normal; uterus otherwise healthy. The patient remained in the hospital nine months, and was subjected to every form of allopathic treatment, up to intoxication by Atropia, but Avithout obtaining more than a mere temporary improvement. Only electricity gave some relief during the first few Aveeks of its application, but after a time the faradic as well as the gal- vanic current ceased to have more than a momentary influence. —Berlin Med. Klin, Wochenschrifit. Diagnosis.—There can be no difficulty in correctly diagnos- ing .intercostal neuralgia, provided due attention is paid to the symptoms, and especially to the tender points characteristic of the disease. Nevertheless, mistakes have often been made in the diagnosis, chiefly from a want of proper care in examining the patient. Thus, Prof. Janeway states* that within a single month he had seen three cases of severe organic disease mis- taken for intercostal neuralgia. The first had been treated for six months for intercostal and cervico-brachial neuralgia, which on examination was found to be due to an aneurism pressing up behind the innominate artery. Another had Potts' disease of the spine, but had been treated for months for intercostal neuralgia and disordered liver, the pain being in the lower intercostal nerves, and particularly on the right * Hosp. Gaz., Oct., 1879, p. 486. INTERCOSTAL NEURALGIA. 25:, side. An examination of the back revealed a marked angular projection in the loAver dorsal spine. Such gross mistakes are altogether inexcusable, and for the honor of our school I am glad to knoAV that we are not responsible for them, if avc Avere, Ave should never hear the last of it! They serve to teach us, however, the importance of making a thorough examination in all cases, and when this is done, there Avill be no danger of ever mistaking the nature of the complaint. Prognosis.—Intercostal neuralgia is often a A7ery obstinate affection, especially Avhen it takes the form of mastodynia. It is sometimes combined Avith spinal irritation, Avhich appears in such cases to be the primary cause of the trouble; at least the neuralgia Avill not yield until the spinal disease is removed. In fact, as a general rule, the duration of the disease is deter- mined by the continuance of the essential causes. The prog- nosis, therefore, will generally depend upon the curability of the disordered or dyscrasic state of the system that constitutes the efficient cause of the affection. Treatment.—Electricity is often one of the most effective means of relieving the neuralgic pains, and sometimes it is the onby one that will do any good. The galvanic current should first be employed, and if this fails, or ceases to produce any beneficial effect, then faradization should be tried. For the best means of applying electricity, and other local remedies, see the preceding chapter. The medicines Avhich have so far yielded the best results in this form of neuralgia, are: Arsenicum, Cimicifiuga, Pulsatilla, Phytolacca, Rhus tox. and Mezereum. For hypersesthesia of the mammae, the chief remedies are: Belladonna, Baryta, Bismuth, Calcarea, Cimicifiuga, Caulophyllum, Cminm, Nuxvom., Phytolacca, Pulsatilla, Sepia, Sabina and Spigelia; the two latter, more es- pecially, when the painful sensations affect the nipples. AVhen the pains result from constitutional causes, the treat- ment, in order to be successful, must be specially directed to such conditions. Thus, anaemia will probably require Arseni- cum or China for its removal; chlorosis will demand the per- sistent administration of Ferrum; tuberculous patients will need Phosphorus or Iodine; and the syphilitic form will be likely to yield only to Mercurius or Kali iodatum. 254 NERVOUS DISEASES. AVe have already expressed the opinion, that this form of neuralgia is generally of a reflex nature, and due to uterine irritation. AVe have come to this conclusion, partly from the other morbid phenomena usually associated Avith it, and partly from the marked benefit generally derived from the adminis- tration of uterine remedies, especially Cimicifiuga. AVe know of no internal remedy that will compare Avith the latter in point of efficiency in most cases. Moreover, Ave find that these vieAvs are sustained by the obseiwations of others. Dr. Hale says: "For those obstinate pains in the left side, Avhich females so often complain of, this remedy is as nearly a specific as any- thing can be. Dr. Simpson, in a paper on the diagnosis of uterine diseases, mentions these 'sympathetic pains in differ- ent and distant parts of the body,' Avhich are really reflex pains or neuralgias, caused by uterine irritation. Among these re- flex pains are: 'pain in one or both mamma?,' 'pain under the left mammae and upon the edges of the rib on that side,' pain in some of the vertebrae of the back, etc. For all these reflex pains, when dependent on uterine disorder, there is no more useful remedy than Cimicifiuga. But it is peculiarly useful for the 'pain under the left mamma.' It occurs more commonly in unmarried females, and- is probably as frequent in cases of uterine affections, as pain in the shoulder is in hepatic affec- tions. The pain is sometimes diffused along the side, but more usually it is limited to a small spot not larger than a half dol- lar. Dr. Simpson used the Cimicifuga in some severe and ob- stinate cases, and the pain rapidly subsided under its use." Phytolacca is another remedy of very great value in these cases. Excepting Cimicifuga, avc know of no medicine so reli- able as this in subduing the neuralgic pains, especially those affecting the mammary gland. It has the advantage, too, of being a superior constitutional remedy in many of these cases, especially adapted to rheumatic, scorbutic and syphilitic sub- jects. It is generally acknowledged to be a remedy of great poAver in subduing the pains of mastitis, and Ave claim for it equal efficacy in many cases of mastodynia. AVhen the pain is accompanied with sAvelling and engorgement of the mam- mary gland, this remedy will be found to be a specific. INTERCOSTAL NEURALGIA. 255 Illus. 126.—Airs. K., set. 26, of a very nervous organization, enjoyed a fair degree of health up to the age of twenty-two, when she became affected Avith exophthalmic bronchocele, which reduced her to a mere shadow. After about three months treatment of this disease, for Avhich she took Iodine* and Bromine30, I succeeded in curing her, and in the course of a few months she became fleshy and the very picture of health. Three years ago she married, and in due time she gave birth to a healthy boy. She nursed the babe until he Avas a year old, during Avhich, and for several months after weaning it, her health remained unimpaired. About eight months ago she began to haA'e pains in her left breast, of a sharp, lancinat- ing character, accompanied with swelling, hardness, and great sensitiveness of the upper portion of the gland. Shortly after- vvards the right mamma became affected in a similar manner. At the same time the exophthalmic trouble began again to shoAV itself. The mastodynia at last became so severe as to deprive her of all rest, She declined rapidly in flesh and strength, became exceedingly nervous and loAv-spirited, and entirely lost her appetite. Up to this time no effective treat- ment had been instituted. As I had treated her successfully in her former trouble, I Avas again-sent for, a distance of some three hundred miles. I found her an object of commiseration to all avIio saw her. Feeble and attenuated, she lay, or rather tossed upon her bed in a paroxysm of intense agony. So great Avas her suffering and restlessness, that it was with difficulty that I could make the necessary examination. I found the mammae swollen, hard, nodulated, and extremely painful to the touch, the nipple especially so. The pains radiated from the latter to all parts of the gland, and also to the spine, which was extremely sensitive to pressure, particularly over the spinous processes of the eighth, ninth and tenth dorsal verte- brae. The pain was Averse at night, and Avas greatly increased by every movement of the spinal column, but the pains were so severe during the latter part of the day and the forepart of the night, that she was unable to remain quiet. I ordered a poultice of fresh Phytolacca radix, roasted, to be applied to both mammse, and a teaspoonful of Phytolacca, lx dil., in water, to 256 NERVOUS DISEASES. be given every half hour until better. Two hours afterwards she was in a heavy sleep, the first sound sleep she had had for many weeks. I remained with her during the next thirty-six hours, and she had no more severe pains. The treatment was continued, at intervals, during the next two Aveeks, when noth- ing but spinal tenderness remaining, I prescribed Cimicifiuga, 3x dil., three times a day internally, and the fluid extract of the same, in water, as a local application to the sensitive verte- brae. This completed the cure, and she has had no return of the complaint.—Hart. SCIATICA. 257 CHAPTER V. SCIATICA. Scicdica, also sometimes called ischias, or fiemero-popliteal neu- ralgia, is a hypersesthesia of the sciatic nerve. It is not only one of the most common, but, owing to the size and situation of the nen7e, one of the most distressing forms of neuralgia. The parts affected are those supplied by the great sciatic nerve and its posterior cutaneous branches, namely, the hinder surface of the thigh, leg and foot. Sometimes other su- perficial nerves are secondarily affected, particularly the sa- phenous, but this is not common. Symptoms.—The disease generally commences gradually, with symptoms resembling those of a slight attack of rheuma- tism ; the pain being constant, of a severe aching character, and somewhat remittent. It is situated mostly about the hip, and in the course of the nerve, seldom extending upwards, but often downwards, sometimes as far as the foot. The pain is not confined to the course of the sciatic nerve, but is frequently felt at the inner side of the knee joint, as in morbus coxae. Anstie says of this pain, " The extremely severe pain at the in- ternal aspect of the knee joint, which is such a common symp- tom in morbus coxae, is evidently a reflex neuralgia of the long saphenous nerve, the ultimate irritation being situated in the branches of the obturator nerves which supply the hip joints. For some reason unexplained, this happens in a considerable number of cases of sciatica." These pains are intermittent in- stead of remittent, and occur in paroxysms, with intervals of more or less aching and burning between them. Sometimes the pains become so violent as to rival in intensity all other 258 NERVOUS DISEASES. forms of suffering. Last Avinter I attended a gentleman, pre- viously in good health, Avho was suddenly seized Avith such in- tense pain in the right hip and thigh, as to cause him to faint away. He said it appeared to him like a stroke of lightning tearing its Avay through the hip joint and doAvn the limb. These terrible pains occurred on an average once or twice a day during the course of his sickness, Avith others of a less severe character between, so that he must have fainted twenty- five or thirty times during his three Aveeks illness. Involun- tary muscular contractions, of a tonic character, also sometimes occur, and add greatly to the sufferings of the patient. The pains are almost ahvays Avorse at night, or Avhen thej)atient is warm in bed; they are also increased by lying upon or ex- tending the affected limb. As a consequence of this, the pa- tient generally keeps the diseased limb someAvhat flexed, and avoids moving it as much as possible, so that in the course of time it is apt to become more or less atrophied from non-use. The points most sensitive to pressure are generally situated at the sacro-iliac articulation, the sciatic notch, and just behind the great trochanter. Other tender points are sometimes found along the course of the nerve, particularly at the back of the thigh, over the head of the fibula, and at the external malleo- lus. The sesthesiometer sIioavs that after the disease has ex- isted some time, the general sensibility of the surface of the affected limb is considerably diminished; and sometimes the temperature, also, is more or less lowered. The hair bulbs near the distribution of the affected nerve, are sometimes stim- ulated to such a degree as to throw out a dense groAvth of hair, the number of hairs becoming multiplied, and the older ones hypertrophied. This phenomenon is most frequently ob- served in traumatic cases. Another peculiar symptom occas- ionally noticed in traumatic lesions of the sciatic nerve, par- ticularly those caused by gun shot Avounds, is a glossy condi- tion of the skin. I met with a number of these cases in the surgical Avards of Brown Hospital during the late war. The affected surface is red, shines as though it had been var- nished, and is entirely devoid of hair. This condition, which is the opposite of that just mentioned, is probably due to the SCIATICA. 259 diminished circulation and nutrition arising from the injury of the nerves. The dorsum of the foot is especially apt to suffer in this manner, as avcII as from two other peculiar symptoms sometimes observed in these cases, namely, severe burning pain and an eruption of eczema. These symptoms are all clearly traceable to the same cause, diminished nervous influ- ence. In chronic cases, in addition to atrophy, it is no un- common thing for paralysis to gradually set in. Even when paralysis does not occur, there may be such a shortening of the tendons as to cause more or less permanent flexure of the limb, and thus render it almost useless as an instrument of locomotion. The disease attacks but one limb at a time, a fact of some importance in a diagnostic point of view. Sciatica antica, or neuralgia of the anterior crural nerve, is a much rarer as Avell as less seA7ere form of the affection. Causes.—Exposure to cold and excessive physical exertion are the two principal causes of the disease. This will account, in a great degree, for the fact that the disease is much more common among men than Avomen, although as a general rule Avomen are more subject to neuralgic affections than men. It Avill also account for the fact that sciatica is an affection of adult life. Common as the disease is, it is rarely met with under the age of twenty. This is all the more remarkable, as debility and general Aveakness strongly predispose to the dis- ease. The explanation appears to be, that men are more sub- ject than Avomen and children to hard labor and out-door exposure. That poor health and general debility predispose to its occurrence, cannot be doubted. Hence, Avhatever favors this condition, Avhether it be insufficient or improper nourish- ment, impure air, sedentary habits, Avasting discharges, or ex- cessive sexual indulgence, will also act as a predisposing cause. The efficient causes are equally numerous. Sometimes, in surgical or traumatic cases, one or more fibres of the injured nerve become entangled in the cicatrix, or the latter may be so situated as to press injuriously upon the nerve, and so give rise to the affection. In the same way, neuromata, subcuta- neous tubercles, enlarged lymphatic glands, aneurisms, hernia, and other morbid enlargements, by pressing upon the affected 260 NERVOUS DISEASES. nerve, or interfering with its nutrition, may be the proximate cause of the trouble. Even intra-pelvic enlargements, such as result from pregnancy, constipation, ovarian engorgement, etc., have been known to produce it, by pressing upon the sacral plexus of nerves, as in the following case: Illus. 127.—Mrs. Ezra Jolint, a French Avoman, set. 23, mother of one child, had been under treatment for about tAAro years for sciatica of the right lower extremity, with only partial and temporaiy relief. After carefully noting the symptoms, I diag- nosed congestion of right ovary, together with chronic disease of the uterus. The metroscope, together Avith the necessary manipulations, having confirmed my previous vieAvs, I at once set about treating her for the above lesions, and as these dis- appeared, the sciatica and attendant lameness also disappeared, and have not yet returned, uoav five months.—Dr. A. I. Sawyer. Pathology.—AVhen we say that nothing is definitely known concerning the special pathology of this disease, we but express the general conviction of the profession thereupon. Theories more or less plausible have, it is true, been promulgated from time to time, but none of them have been sustained by suffi- cient eA7idence to entitle them to be regarded as anything more than ingenious explanations of the morbid phenomena. Thus, Dr. Thompson accounts for the atrophy and pain of many cases of sciatica, by referring them to vaso-motor irritation mainly, and not to mere affection of the nerve trunk. Hence he says he has "always commenced the treatment of these cases, Avhere atrophy and rigidity are present, with measures directed towards remedying this supposed lesion. To do this, we begin with attempts to blunt or paralyze the irritant-sensor impression, which is the starting-point of the Avhole trouble; for, so long as it persists, so long will it be reflected through the ganglia it reaches, upon the motor filaments which proceed from them to regulate the calibre of arteries. It was, therefore, for this purpose, and not for curing his sciatica, that avc ordered the subcutaneous injection of Morphia and Atropia together for this patient, After every such injection, the limb would groAV one or two degrees warmer, thus indicating a return, for the time being, of blood, from corresponding relaxations of the SCIATICA. 261 arteries. But, by themselves, these neurotics would have proved totally inadequate, for like all other real neurotics, their effects are transient, and hence, in a feAV hours, you Avill note the arte- ries contracting again, and the coldness and rigidity returning as before." Noav, avc admit that this reasoning is quite plausi- ble, and the treatment based upon it to a certain extent suc- cessful ; but avc account for the phenomena in a totally different Avay, and upon a principle the application of which in practice is productive of much more permanent and satisfactory results. AVe believe that the temperature, and consequently the tone, of the affected parts, is loAvered, not by central, but by peri- pheral influences, the chief of Avhich, as already stated, are cold and exposure. Consequently, that treatment Avill, as a gen- eral rule, prove most successful, which tends most directly and permanently to raise the temperature of the affected limb— that is to say, by increasing the nutrition. Hence the best re- sults have hitherto been reached in these cases by a heating diet, especially of one consisting largely of fiat; by such local treatment as is calculated to accelerate the circulation, such as galvanism, acupuncture, electro-puncture, etc.; and by such inter- nal remedies as most permanently stimulate the superficial capillaries, such as Arsenicum, Colocyuth and Sulphur. AVe shall refer to this matter again under the head of treatment. Diagnosis.—This disease is most liable to be mistaken for rheumatism and inflammation seated in and about the hip joint. To avoid this, the practitioner should make a thorough physical examination of the patient, noting the presence or absence of the tender points of ATalleix, already mentioned, the presence or absence of fever and deformity, the absence or presence of pain when the head of the femur is pressed against the acetabulum, the rounded or flattened appearance of the hip, the elongation or shortening of the limb, the position of the foot, the mode of carrying the leg, the paroxysmal charac- ter of the pain, the general condition of the health, and all the circumstances that go to establish the presence or absence of inflammation, either acute or chronic, in the hip joint and surrounding parts. It is well, also, to bear in mind the fact before stated, that sciatica never attacks both limbs at once. 262 NERVOUS DISEASES. Prognosis —The prognosis in acute cases is generally favor- able. The same is also true of chronic cases Avhere the cause can be removed. On the contrary, there are some cases Avhich will tax both the skill and patience of the practitioner to effect any lasting improvement. This is especially the case Avhere atrophy and contraction have taken place to any considerable degree. Yet even cases of this kind have sometimes yielded to homoeopathic treatment, at least to such an extent as to render the patient comparatively comfortable, and the affected limb more or less useful. Treatment.—Under the head of pathology Ave have indi- cated the principle the observance of Avhich, in treatment, we deem of paramount importance in these cases. Whatever the practitioner may think of the theory itself, (and it is of no con- sequence except so far as it may influence his treatment,) I can assure him from long experience, that its adoption in practice Avill be found to yield the most gratifying results. The first thing to do, of course, after carefully diagnosing the case, is, if possible, to remove the cause. The next is to raise the tempera- ture of the affected limb, by such means as will bring the sur- face to a normal standard and keep it there. This is not to be accomplished by such stimulants as Avhisky, brandy, etc., nor by superfluous wrappings, as such treatment will be likely to OArerstimulate the circulation, and thus increase the suffer- ings of the patient. The practitioner should bear in mind that the general circulation is not usually at fault; the trouble is chiefly in the cutaneous and peripheral capillaries of the af- fected limb, and nowhere else. Hence fat food, Avhich tends to increase, not only the animal heat, but the nutrition of the subcutaneous tissues; the regular and methodical application of the galvanic current, Avhich has a similar effect; and the in- ternal administration of such remedies as have a stimulating effect upon the superficial capillaries, Avill in most cases prove permanently beneficial. It is a singular fact, and one that has attracted the attention of Anstie, Radcliffe and others, that this class of patients generally avoid all kinds of fat food—a fact Avhich in my opinion has much to do, in many eases, with the origin and obstinacy of the disease. It was only last win- SCIATICA. 263 ter that I treated successfully one of the severest cases I ever witnessed—the one already referred to, in which the patient often fainted from the severity of the pain—chiefly by insist- ing on the regular use of a diet consisting of fat meat, milk, butter, cream, eggs, and other food of like character. If, owing to the condition of the stomach, or other cause, the patient is unable or unwilling to conform to such a dietary, then it will be advisable to place him upon cod-liver oil, or some other oleaginous preparation, by Avhich the object sought to be at- tained may be accomplished. From Avhat has been said, it will naturally be inferred that artificial warmth must be very beneficial in these cases. Applied heat is indeed a valuable adjuvant in the treatment, provided it be rightly managed. But in order to prove soothing to the highly irritated nerves, it is necessary that it should not be so great as to raise the general circulation above par, nor even that of the affected limb. The simple fact already mentioned, that patients often dread going to bed because the Avarmth of the bed is apt to aggravate their sufferings, should admonish us not in any way to over-stimulate the circulation. Bearing this in mind, then, Ave may state emphatically, that there is often no more soothing and quieting agent to be found in these cases than simple Avarm water, the contact of which, at about the temperature of the blood, tends not only to restore the cir- culation of the limb to a healthy condition, but to allay neiwous irritation, and relax the muscular contraction resulting from it- For this purpose, flannel cloths, wrung out of warm water, and applied with Avarm dry ones over them, will often prove of great service; but a much better and handier mode of apply- ing moist heat in these cases, is by means of Chapman's rubber bags, Avhich can be readily applied to the lumbar region and hip, or laid alongside of the affected limb, as circumstances may from time to time require. By far the most efficient application, however, in these cases, is electricity, especially in the form of galvanism. Faradization, though it may prove beneficial in some instances, is not as a rule the best mode of applying the remedy. Indeed, it may well be doubted Avhether it has not done more harm than good 264 NERVOUS DISEASES. in this class of cases. The reason is, because the interrupted current is a stimulant of sensation as avcII as of motion. This renders it Avell adapted to paralysis and anaesthesia, but not to hypersesthesia. On the other, hand, galvanism promotes or- ganic nutrition, without stimulating the nerves of sensation, and hence is not only calculated to relieve the pain, but to effect a permanent cure. By applying the anode over the sacral plexus of nerves, or behind the great trochanter, and the cathode over the posterior part of the thigh, or in the pop- liteal space, increasing the current very gradually until it be- comes perceptible to the patient, but Avithout causing any pain, and repeating the applications more or less frequently accord- ing to the severity of the case, the best results will be obtained. As a rule, the applications should not be continued longer than about ten minutes at a time. Acupuncture and electro-puncture hare also proven curative in some cases, and are Avorthy of trial Avhen other measures fail in giving permanent relief. Dr. Hammond says of the latter: "I have several times succeeded in breaking up a paroxysm of intense sciatica, and effectually curing the patient, by a single application, but usually several are required. I have never witnessed the least untoAvard result from the use of galvanism in this way." He introduces the.needles in the following man- ner: "The needles should be insulated except at their points, and then, being attached to handles which can be brought into communication with the battery, are rapidly passed with a rotary motion down to the nerve. I generally select a point at the upper part of the posterior aspect of the thigh for one, and a point two or three inches below for the other." Nerve-stretching is another approved method of treating these cases, as in the following case: Illus. 128.—A patient had suffered for many years with severe sciatica, for the treatment of which huge doses of morphia had been used, until there was no relief when not under the influ- ence of narcotics. The sciatic nerve having been laid bare, it was pulled backward and forward, forcibly, Avith from eight to ten pounds pressure. The wound healed well, the pain was lost, and some paresis followed; the paresis wore off, and some SCIATICA. 265 pain was felt in the loAver part of the leg, but there Avas no re- turn of the sciatica, and the patient was able to resume Avork. —Dr. Rye, Aconite.—This remedy is indicated in recent cases, especially if there is much febrile irritation, great restlessness, and severe shooting pains, darting from the hip to the ankle. Illus. 129.—A. C, set. 45, nervo-sanguine temperament, and • rheumatic constitution, became "chilled through" by standing at the polls at the November election, 1876. AVas called to see him November 21st, and found that on attempting to rise in the morning, he experienced such severe pain in his back and hip as to bring on an attack of syncope. He complained of intense pain and soreness, extending from the left natis to the knee, Avith occasional but very severe pains darting from the left sacral plexus of nerves to the ankle joint. There Avas some fever, but not much SAvelling or redness; tongue coated with a thin white fur. Aconite3, ten or fifteen drops in half a glass of water, a teaspoonful every hour, and the diluted tincture as a liniment, hot, whenever the pains became excessh7e, effected a complete cure in about three Aveeks, no other remedy than Aconite having been employed in the case—Hart. Allium cepa.—This remedy, according to Prof. Helmuth, has been found almost a specific for "neuralgia of the stump," or Avhen the pain arises from the nerve having become embedded in the cicatrix. Illus. 130.—I was once called in consultation to Jersey City, to see a man suffering from neuralgia of the stump, following a thigh amputation made about three months previous. The wound had completely healed and the cicatrix looked healthy, yet he suffered intensely from sciatica. He had taken many remedies Avhich act upon the ner\7ous system, including Mor- phia, Avithout relief. Fie was a great smoker, and as he stooped one day to light his pipe from a sera}) of a French newspaper, he read of a case of neuralgia of the stump Avhich had been cured by eating onions. He immediately procured three large ones and ate them. Fie continued this treatment for several days and Avas able to sleep every night. Then his physician, Dr. Shelton, thought of trying Allium cepa, and prescribed the 17 266 NERVOUS DISEASES. tincture Avith almost the same effect, which was continued until the cure was completed.—Dr. Wm. Tod Helmuth. Arsenicum,—This remedy comes as near being a specific for sciatica as any remedy can come. It is especially adapted to chronic cases, particularly such as are characterized by period- icity, burning pains, and great restlessness. Illus. 131.—Mrs. C, wife and mother, set. 50, full habit, leuco- phlegmatic temperament, with tendency to rheumatic ailments, suffered from an occasional sciatica for tAventy-five years, fol- lowing an allopathic treatment for intermittent fever. Had been treated by numerous doctors, and had tried all the domes- tic remedies ever beared of, Avithout-relief. Symptoms: A severe burning ache, commencing in sacral region, and folloAV- ing the course of the great sacro-sciatic nerve down the ex- tremity to the foot; relieved by motion; Avorse at night, often obliging the patient to rise and Avalk the floor for relief; seiz- ures lasting two or three weeks at a time. Arsenicum30, a dose every night for a month, cured. No return in two years.—Dr. Morrow. Bryonia.—This remedy is indicated in acute attacks, especi- ally-in rheumatic constitutions, or when caused by cold, with sharp, stitching or shooting pains, and aggraA'ated at night or by the least motion. Illus. 132.—A woman who had suffered from sciatic pains previous to pregnancy, but who had been relieved of them dur- ing the floAv that followed a miscarriage, again suffered from them Avith increased violence after the Aoav had ceased. The patient was not able to stand or sit for a moment, but had to be carried, whenever she Avas moved from one room to another. The pains were always Avorse at night, and Avere aggravated by the least motion. Prescribed Bryonia30, which rapidly and per- manently cured her.—Dr. J. H. Frost. Colocynthis.—This is one of the best known remedies for sciatica, especially when it is of a rheumatic type, or when the pains are of a shooting, tearing character, and are aggravated by the least motion, or are Avorse at night and when warm in bed. Ulus. 133.—Mrs. A., "fat, fair, and forty," has suffered for the SCIATICA. 267 last three Aveeks from excruciating pains in her left knee. She has shooting pains in the knee, sometimes lacerating, running from the hip inwardly down to the knee, aggravated by the least attempt to move the leg; walking or standing on it is impossible; the nights are sleepless, especially in bed, where the feathers over and under her (an abominable German fashion) drive her nearly mad, and she passes therefore most of the time on a sofa, Dr. F., of the old school, has treated her from the very beginning, with internal and external medication, but Avithout giving her any relief; even the much vaunted Morphia failed. Knee not much tumefied, pale, and Avithout more than normal heat. Tongue white, no appetite nor thirst, lower limbs feel heavy, not much pain as long as she keeps quiet, but the least motion produces it, and it becomes worse at every renewed attempt to walk; shooting in the knee Avith every attempt to walk; sleeplessness; chilliness, etc. Colocynthis200, a few pellets in half a tumbler of Avater, dessertspoonful every two hours. That night she slept like a trooper. Next day placebo in water, patient able to walk about the room ; another good night, more placebo; my attend- ance ceased, and she remains well to date.—Dr. S. Lilienthal. Guaiacum.—Rheumatic and hereditary cases; chronic cases attended Avith tonic contraction of the muscles and great exhaustion. Illus. 134.—I have cured several severe cases of sciatica during the last two years with drop doses of Guaiacum officinale17". One case, occurring in a middle aged lady, Avas most severe; continued unmitigated for some three months. It seemed to be hereditary, as two older brothers had suffered from it very much. This case yielded in a few days to the Guaiacum.—Dr. E. H Drake. Ignatia.—This remedy is more particularly indicated in cases occurring in nervous females, especially when preceded or accompanied by chilliness or shivering. Illus. 135.—A woman attacked with sciatica suffered with pains of an acute, tearing, digging, boring character; these pains last from an hour to an hour and a half, and then slowly disappear. The attacks, which are preceded by intense cold- 268 NERVOUS DISEASES. ness and shiA7ering, occur both day and night, but are Avorse at night, so that she is obliged to get up and walk the room. Ignatia1* was given in two drop doses every three hours, and in two days the pain was all gone.—Dr. Nankivill. Polygonum puuctatum.—Pains of an electric-like character, occurring in flashes, reminding one of the aurora borealis; sensation in the thigh and leg as of galvanic shocks. Illus. 136.—N. C, set. 60, had been treated for several days for sciatica, Avhen he remarked the pains put him in mind of the aurora borealis. That evening, in looking over Hale's work, I saAV this peculiar symptom under Polygonum; I at once sent a few powders, and afterwards received a note report- ing immediate and permanent cure.—Dr. Alexander R. Shaw. Rhus tox.—This is one of our most reliable remedies in cases complicated Avith rheumatism, or Avhen aggravated by damp, heavy Avcather, or by standing, Avalking, or any motion of the affected limb. Illus. 137.—Air. R., set. about 55, very obese, but generally healthy. Had sciatica, Avith tenderness about the knee-joint; pain constant when awake, or when Avalking or moving the limb; disability so great that he could rise from bed or chair only with great care and effort. Business, that of cutting in a clothing house, and required to stand on the feet the Avhole day. Difficulty had existed about three years. Rhus tox.2c. Pain remoA7ed within two Aveeks. The improvement has con- tinued for. two months.—Dr. E. II. Peck, Sulphur.—This remedy should be thought of in all very obstinate cases, especially Avhere the capillary circulation is very weak, and the general tone of the system much loAvered. It is also specially adapted to cases arising from the sudden suppression of urticaria, or any other form of cutaneous erup- tion, and also Avhen complicated Avith hemorrhoids, constipa- tion, etc. Illus. 138.—One of the most obstinate cases of sciatica that I ever knew, and which resisted every known remedy and mode of treatment, Avas at last cured with Sulpluu200.—Dr. 0. H. Maun, ANOINA PECTORIS. 269 CHAPTER VI. ANGINA PECTORIS. Angina pectoris, or breast-pang, also called stenocardia and neuralgia of the heart, is a disease characterized by severe par- oxysms of pain and sense of constriction, beginning in the region of the sternum, or deep in the chest, and extending to the left shoulder and arm. This definition is sufficiently com- prehensive to include the majority of cases, but inasmuch as the name has been applied to a great variety of organic and functional disturbances of the heart, some of which haA7e no essential connection Avith the disease, it needs to be understood as embracing the folioAving groups of Symptoms.—Klapka* makes three distinct forms of the affection. The first is "stenocardia Avith venous stasis, and is characterized by palpitation of the heart produced by Avalking in the open air, and Avhich is increased in proportion as one continues to Avalk. A remarkable thing is, that these patients can Avalk for hours together in a close room Avithout experi- encing the least inconvenience. AVhen going into the open air and attempting to walk, they feel a pressure at the middle of the sternum; as they advance a few steps, dyspnoea and palpi- tation of the heart occur; pulsation is felt all through the body, and especially in the carotid and temporal arteries; the face and ears become deep red, and if the unhappy patient forces himself to continue Avalking, he risks being stricken with apoplexy." The second form of stenocardia is the gastralgic or crampoide. "The patients experience not only sternal pressure and dysp- * Rev. Horn. Beige. 270 NERVOUS DISEASES. ncea when they walk, but also a continued pressure at the pit of the stomach; that pressure which appears to act from Avith- out inward, producing a sensation as if there Avere a ball at the epigastrium; there are empty eructations, great precordial anguish, a paralytic pain in the left arm, the neck, and nape of the neck. These symptoms indicate that the cardiac plexus is attacked, and that from here the malady extends to the gastric plexus, the brachial plexus, and even the cervical plexus. An attack of asthma may occur, which puts the pa- tient in great anguish. In the first form—venous stasis—it is interference with.the circulation which occupies the chief role. In this form, on the contrary, there is disturbance of nervous function. In the first apoplexy is to be feared; in the second a fatal paralysis of the heart may occur." The third is "the spinal or syncopal form. At the same time with the spinal pressure and dyspnoea, is felt a pressure between the shoulders Avhich corresponds to the sternal pressure; it is as if the thorax were held by an iron band; the patient is pale, weak, and trembling with anguish; he has a small, irregular, intermittent pulse, is often covered with cold sweat, and threatens to fall in a faint. This variety is most often observed in those who have become thin after having been corpulent, in persons whose health is impaired in consequence of grief, reverses, or as the result of excessive venereal indulgence; al- most always such patients are emaciated, have little muscular force, are pale and cold. AVhile walking, even in a close apart- ment, they are seized with dyspnoea and asthma, because mo- tion brings about that thoracic constriction of Avhich we have just spoken; they are better at rest, because motion reneAvs the oppression. AVith some of these patients, particularly those who have been given to venereal excesses, it is the painful pressure at the back which predominates, and extends toAvards the sternum ; the accessions of dyspnoea and asthma occur later. By physical exploration, one discovers dilatation of the right ventricle, feeble impulse of the heart, no abnormal sounds, but irregular and intermitting beats; often the appetite is im- paired, the urine diminished; there is a tendency to dropsical swellings. Here there is cardiac debility rather than fatty ANGINA PECTORIS. 271 degeneration; paralysis of the heart is not so much to be feared as in the preceding forms, but symptoms occur which depend upon feebleness of the'heart and circulation—hypersemia, venous stasis, dropsy, etc." To these avc add a fourth form, often met Avith in practice, Avhich may be denominated the intermittent or recurrent. Like the gastralgic or "crampoide" form, it arises from disturbance of nervous function, but it differs from it in being free from gastric derangement, and in the intermittancy of the cardiac disturbances. The following case will best illustrate this form of the disorder. Illus. 139.—Mr. C, set. 30, bilious temperament, came to my office complaining of severe pain; described as being "sharp," in the region of the heart, and with occasionally violent palpi- tation. The action of the heart Avas spasmodic; that is, there were regular pulsations that were normal; these were followed, at irregular intervals, by a tumultuous action, attended with a sound and an impulse against the walls of the chest, as if the heart AA'as turning in the pericardium. The pulse varied from eighty to eighty-five. The patient had not been able to lie down to sleep night or day for six months, in consequence of asthma. In examinations of the chest, I could not discover any disease, either organic or functional, of the heart, and he tells me that he never had any pain in that region before.— Dr. C. D. Clawson. Here Ave see the cardiac plexus is temporarily disturbed, but there is no extension of the disease to the brachial or gastric plexuses, simply because the disturbing cause, Avhatever it may be, is not constant or powerful enough to produce it. These cases are frequently met Avith in females, and are ahvays aggravated by emotional excitement; yet they are by no means of a hysterical nature, as they do not occur in the hys- terical constitution, but in subjects whose nervous system is otherwise normal. Can it be that the disturbance'is due to a temporary withdrawal of the restraining influence of the me- dulla oblongata through the pneumogastric nerve, or is it due to excitation of the sympathetic fibres which pass from the me- dulla oblongata down the spinal cord, and reach the heart 272 NERVOUS DISEASES. through the lower cervical and first dorsal ganglia of the sym- pathetic? This form is to be carefully distinguished from those due to organic disease of the heart, in Avhich the pulse-beat may at one moment be normal, and at others faster or slower than usual. In this the pain remains confined to the precor- dial region, and the disturbance of the heart is purely func- tional. In this form the paroxysm sets in suddenly, and dis- appears also suddenly, but its duration is very variable, some- times lasting only a few minutes or seconds, at others continu- ing, in an intermittent manner, for an hour or more. In the latter case, there is apt to be considerable dyspnoea associated with it, and not unfrequently it supervenes upon an attack of asthma. In the other forms of the disease, the paroxysms may or may not set in suddenly, though the latter is gener- ally the case. In these forms, the pain is not confined to the region of the heart, but radiates to the sides of the chest, and the arms, especially the left arm, sometimes to the nape of "the neck, and occasionally to the right arm, and even to the loAver extremities. The paroxysms, as a rule, not only begin and end suddenly, but they generally commence at once in all their intensity, and terminate in the same abrupt manner. The cessation of the paroxysm, however, does not always restore the patient to perfect health. On the contrary, as in other nervous affections, especially such as are compli- cated Avith other disorders, there is almost ahvavs more or less debility and sleeplessness remaining for a time, and not un- frequently a more protracted period of cardiac weakness and oppression. In most cases, hoAvever, the intervals are quite free from all morbid symptoms, and the patient's health is such as to completely allay the apprehensions excited by each renewal of the paroxysms. Causes.—The disease occurs much more frequently among males than females, and is mostly confined to persons above forty years of age. The subjects of the disease are generally such as are, or have been, corpulent, or inclined to corpulency, and belong to the upper classes in society. AVhatever Aveak- ens, or greatly depresses the neiwous system, predisposes to the disease. Hence, the excessive use of tobacco, venereal ex- ANGINA PECTORIS. 273 cesses, spermatorrhoea, etc., are found to aggravate, and, in some instances, to cause the disease. One of the worst cases I ever had to treat Avas in a German who Avas eternally smok- ing. I told him he Avould suddenly die if he did not quit the practice, and Avhen he ceased to smoke he had no more par- oxysms. It is so frequently associated with organic diseases of the heart, especially' Avith atheroma or ossification of the coronary arteries, that these have come to be generally re- garded as the essential causes of the disease; but, as Ave have shoAvn, the disease is sometimes met with independent of such changes, and therefore cannot be regarded as necessarily origi- nating in such disorganizations. It cannot be denied, how- e\7er, that cardiac embarrassment, Avhether arising from ner- vous debility, A-alvular obstruction, fatty degeneration, vascular stenosis, or pulmonary congestion, is the chief exciting cause of the malady, as it is in most cases the remote, if not the proximate, cause of death. Pathology.—NotAvithstanding the fact that organic lesions of the heart are almost ahvays associated with angina pectoris, the symptoms are such as to require the disease to be placed among the neuroses, and such is now the usual classification. Flint, Anstie, Laennec, Eulenberg, Trousseau and others, sub- stantially agree in regarding the disease as essentially a neu- ralgia, Avhile Romberg, Friedrich, Klapka and others, believe it to be a hypersesthesia of the cardiac plexus. AVe believe that the spinal system of nerves is primarily, and the sympa- thetic system secondarily, involved in these cases; and that the neuralgia or spasm is a reflex symptom, generally of pe- ripheral, but sometimes of central origin. The sources of pe- ripheral irritation are found in suppressed neuralgias, in the various organic lesions of the h.eart, and in bronchial, pulmo- nary, and abdominal congestions; the central are chiefly, if not wholly, confined to the various forms of spinal irritation. The following ease of suppressed neuralgia will illustrate this re- flex action. Illus. 140.—A little girl, set. 3, was taken with toothache, which Avas borne a day or two; the mother, after trying several remedies in vain, took the child to a dentist and had 274 NERVOUS DISEASES. the tooth extracted. That night, or the next day, the patient was attacked Avith a severe neuralgic pain in the heart. I was then called to her, and although the acute pain was relieved in a reasonable time, a dull pain and serious disturbance of the action of the heart followed, until, in a short time, the aortic valves became thickened, so that the bellows murmur was very marked, the heart's action violent, and ended in a most serious enlargement of that organ, Avhich has not been fully relieved to this day, now some ten or eleven years, though she has been under treatment for it most of that time. And to show the full bearing of the case and its lesson, it should be stated, that this child had neArer previously had the slightest pain or disturbance in the heart, never had the least sem- blance of rheumatism to account for such a result, for nothing of the kind existed in either branch of the family, back to and including all four of the grandparents. The pain or irritation was simply reflected to the nerves of the heart, and resulted in its enlargement, on the Avell-knoAvn principle that any serious disturbance causes thickening of the aortic A'alves, and con- tinued violent action of the heart must inevitably enlarge it.— Dr. R. R Gregg. Prognosis.—Patients sometimes have but a single attack, but as a general rule, one paroxysm follows another sit shorter and shorter intervals, until finally they become very frequent and severe; and as the danger is generally in proportion to the severity of the attack, the patient is liable, sooner or later, to die of the complaint. This result, however, is generally con- fined to cases complicated by organic disease of the heart, the fatal issue arising, probably, from cardiac paralysis, in conse- quence, as Flint supposes, of distention of the ventricular cavi- ties from an excessive accumulation of blood Avithin them. The functional forms of the malady, on the other hand, are emi- nently curable, and will generally yield to appropriate treat- ment as readily as any other form of nervous disease. Treatment.—Having given Klapka's three-fold division of the disease, Ave shall first give his treatment as adapted to these principal forms of the affection, and then our usual repertory of illustrative cases. ANGINA PECTORIS. 275 Against the first form—stenocardia, with venous stasis— Klapka prescribed for several years Belladonna and Glonoine, because he had in view only the cerebral congestion. He ob- tained, he says, only partial success. He Avas able to moderate for a time the venous stasis, but it recurred later, and he Avas forced to seek another medicine Avhich would bring about a more durable amelioration. lie perceived, he says, that ve- nous stasis was dependent upon the palpitation of the heart; that the more violent this became, the more the dyspnoea and thoracic constriction were augmented. AVhen the cardiac movements became moderate, the intensity of the other symp- toms Avas diminished. It Avas this that led him to try, about four years ago, Aurum mur.3, a medicine the success of which, he says, surpassed all his hopes. After a few doses, the palpi- tation of the heart, the thoracic constriction, the dyspnoea and symptoms of venous stasis, Avere diminished to that degree that the patient could take long Avalks in the open air Avithout in- convenience. Even Avhen there Avere already attacks of asthma and dilatation of the heart present, it has caused, he says, so great amelioration, that he is able to say that Aurum mur. has specific action in this malady as certain as Spigelia in endo- carditis. All the symptoms enumerated in the description of this form of the disease, are found in the pathogenesis of this drug, and this will account for the success attending the use of this medicine. He prescribes Aurum mur.3x, two doses a day, and when its use is likely to be prolonged, he administers concurrently Glonoine3, in order that the patient may not ha- bituate himself to the action of the gold, its action being ex- hausted by too long use. AVith reference to the second, or crampoide form of steno- cardia, he says: "Agaricus muscarius is as powerful in the gas- tralgic form as gold is in the first form of the affection. It relieves and prevents even cases the most severe accompanied by attacks of asthma. After a feAV doses, a greater part of the symptoms grow better, and the patient is free from them for quite a time." He employs the third decimal dilution of this remedy, two doses a day, diminishing the dose as amelioration occurs. It is not well, he says, to employ it for too long a time, 276 NERVOUS diseases. as the organism becomes accustomed to it. It is necessary, from time to time, to gh'e an intercurrent remedy; he em- ploys for' this purpose Kali cctrb.6, the action of which is an- alogous to the first, This alternation, he says, is not ahvays necessary, one of these two medicines, according to the case, often sufficing for a cure. There are patients, however, who, instead of Kali curb., ought to make use of Carbo veg., Laduca vir., or Lycopodium, according as tympanites, pressure upon the vertebral column, or difficulty in urinating, are the predomi- nant symptoms. But Agaricus, he says, remains the principal remedy, and it alone is able to give good results.- AVe iioav come to the spinal or syncopal form. Two doses a day of Sambucus1 is, according to Klapka, the remedy for this form of the malady, when it is accompanied by marasmus and some spermatorrhoea. Often, he says, at the end of a few days avc notice a diminution of the pressure upon the sternum and between the shoulders, of the dyspnoea, and even of the asthma- tic attacks. As an alternate medicine he employs Phosphorus*, same dose, Avhen the symptoms of pressure are felt at the side of the sternum; but Avhen these manifest themselves chiefly between the shoulders, he gives the preference to Petroleuin3^ Fie changes the medicine every eight or twelve days. He says he has sometimes employed Avith success in these cases Kali curb.6 as an alternate medicine. AVhen there is marasmus, he considers the employment of Chinin. sulph.1, tAvo or three doses a day, as indispensable. As, however, its action is not pro- found, only symptomatic, he finds it necessary to employ other medicines at the same time, especially if asthmatic attacks pre- dominate, such as Phosphorus, Cuprum, Ipecac, Vend., etc. Against the dropsy, cyanosis, and symptoms of A'enous hyper- semia, he makes use of Arsenicum3, or Lachesis3, or Chinin. ar- senicos1. Nux vom.3 and Carbo veg.6, he says, may be used ad- A'antageously for the Avant of appetite and abdominal dis- tention. As the regimen he prescribes is judicious, A\7e append it: "There occurs frequently a Aveakness in consequence of dis- turbed circulation; the use of restoratives then becomes neces- sary, in order to stimulate the contractility of the heart—two ANGINA PECTORIS. 277 or three spoonfuls of malaga, of madeira, or of port, Avhich the patient should ahvays have at hand in case of necessity. The food should be free from fats. As a drink, Veau rougie (1 part Avine, 3 parts Avater). Should there be disgust for solid food, soups Avith eggs and farinaceous articles in small quantities may be given according to desire, but always Veau rougie. Beer, Avhich develops intestinal gases, should be proscribed. Often the patients experience Aveakness of the limbs and require frictions. I always prescribe in such cases, for external use, the same remedies that I am using internally, dissolved in alcohol or brandy." The alcoholic stimulants above recommended, and also brandy and ether, which Avere formerly much used in this country as restoratives in these cases, are noAV almost entirely superseded by' Amyl nitrite, a small vial of Avhich is usually kept on hand by the victims of angina pectoris, for immediate use. Ringer in his "Therapeutics" speaks of this remedy in these cases as folloAvs: "Dr. Brunton first employed Nitrite of Amyl in angina pectoris Avith signal success, and found it more effective than any other remedy in this painful and dangerous disease. During an attack, his patient suffered from throbbing of the heart and carotids as high as the cars, Avith severe pre- cordial pain extending to the right arm. The usual character- istic 'sense of impending death' Avas absent, The pulse Avas slightly quickened, and the sphygmographic tracing became modified, for as Dr. Brunton states, 'as the pain increased the curve, became lower, both the ascent and descent more gradual, and dichrotism disappeared. This form of curve clearly in- dicates that the arterial tension is much increased, and can, I think, be due only to contraction of the small systemic vessels,' The increased tension first led Dr. Brunton to employ Nitrite of Amyl. In the case in question, he considers that the attack consisted of spasmodic contraction of some, if not all, of the small systemic and pulmonary vessels, Avhich state of arterial tension gave way on inhaling the Nitrite, and the pain then disappeared. On the recurrence of an attack, the patient in- haled the Nitrite of Amyl, and always obtained instantaneous relief. 278 NERVOUS DISEASES. Dr. Anstie reports a Avell-marked case of angina greatly relieved by this treatment. He says, 'The first sniff produced, after an interval of a few seconds, the characteristic flushing of the face, and sense of fulness of the head; the heart gave one strong beat, and then he passed from the state of agony to one of perfect repose and peace, and at his usual bed-time slept naturally. This experience has, I am happy to say, been repeated on several occasions, and with this fortunate result; that so confident now is the patient of being able to cut short the paroxysm, that he has discarded all use of ether, and greatly reduced his allowance of stimulants.' Dr. Talfourd Jones also finds it very useful in angina. Indeed, in most cases no other remedy affords so much relief. As might be expected, it is not uniformly successful. Thus, in one case. due, as Ave discovered after death, to aneurism of the heart immediately below the aortic valve, an inhalation always arrested the pain, but it returned after a few seconds or minutes, even if the administration were several times re- peated, and Avas as severe and lasting as when no Amyl Avas used. In another case, Avhilst it gave great relief, always arresting the paroxysm, it took ten minutes to effect this, and Avas in no Avay superior to a full dose of ether, which the patient preferred, as the Amyl produced so much giddiness and sensation of fulness in the head. In three other cases, however, it proved strikingly successful. In one desperate case, the slightest exertion brought on intense pain; but by the aid of Amyl, the patient could always at once cut short the attack, so that now he can Avalk several miles, though he is obliged during his journey to employ the Amyl several times. It has appeared to me, that by at once checking the paroxysm, attacks come on less frequently and less severely, and after a time a much smaller quantity suffices to control the pain; so that Amyl really contributes to the prolonged relief of these unhappy patients." AVe will add, that the most convenient way to administer the remedy, is, to add a few drops to a small vial containing cotton-wool, and have the patient inhale it by holding the mouth of the vial to the nostrils a second or two, whenever required. ANGINA PECTORIS. 270 In cases of fatty degeneration, obesity, etc., skim milk Avill probably prove beneficial, as in the folloAving instance: Illus. 141.—A lady who was subject to angina pectoris, and who suffered from great dyspnoea on the slightest exertion, but in whom no valvular disease of the heart could be detected to account for it, nor any other cause whatever, except fatty degeneration, Avhich avc had good reason to believe had com- menced in the heart and elseAvhere in the muscular system, was recommended to make use of an exclusive skim milk diet. Our patient had long indulged in an excessively fatty diet and sedentary habits, and she was in a state of great obesity. The skim milk diet Avas strictly adhered to for several months, and Avith a marvellously good effect. The symptoms of angina pectoris soon began to subside, and ultimately disappeared altogether, AArhile the obesity was remarkably diminished, and the patient enabled to enjoy exercise freely and without incon- venience.—Dr. A. S. Dunk in, Electricity.—The beneficial effect of galvanism in some of these cases, is well shown in the following case: Illus. 142.—Air. C, set. about 45, farmer, large, robust, power- fully built man, sanguine temperament, ahvays an acth'e, energetic worker, and never was sick a day in his life until about two years ago. At that time he was attacked with a severe neuralgic pain in his left breast. The pain remained constant, but was aggravated by any exertion, sometimes coming on in the most excruciating paroxysms. The location of the pain varied from the left supra-clavicular to the epigas- tric and left hypochondriac regions, sometimes running down the left arm. Nothing abnormal in the sounds and action of the heart, except during the paroxysms of pain, at which times it was somewhat irregular. The frequency of the paroxysms gradually increased from one in two or three weeks, to one every two or three days, and sometimes oftener. Dura- tion about two hours. The case, AA'hich had previously been treated allopathically without benefit, came under my treat- ment four months ago. I prescribed Aconite30, three times a day, and an application of electricity twice a week. I used the galvanic current, placing the positive pole at the cervical region, 2S0 NERVOUS DISEASES. and with the negative pole treated the chest and epigastric region. Duration of treatment twenty minutes. Intensity of current sufficient to cause a considerable'burning sensation and rubefaction of the skin. Improvement was rapid from the first. The pain, Avhich had been constant for nearly two years, was instantly relieved by the electrical treatment. The paroxysms became less frequent and much less severe. For the last month he has not felt the slightest touch of it, and has been engaged in his regular farming pursuits.—Dr. F. S. Adams. Aconite.—Aconite is indicated in acute cases, especially in rheumatic patients, or when preceded by rheumatic pains in other parts. AVhether the Aconite Avas of any particular benefit in the above case, is someAvhat doubtful; but there can be no question as to its curative action in the folloAving example: Illus. 143.—A young man complained of stitches at the apex of the heart, Avith pains extending to the left arm; palpitation on moving. He had previously suffered from rheumatism; pulse intermittent, small and hard. Aconite2, a few doses, removed the symptoms.—Dr. E. M. Hale. Cimicifiuga,—This remedy is also indicated in rheumatic subjects, but appears also to be equally adapted to cases of pure neuralgia, of Avhich the following instance furnishes a striking illustration: Illus. 144.—A Avoman, set. 55, ten years past her climacteric, plethoric, subject to neuralgia, dropsical for years, presented the folloAving symptoms: Flas just been relieved of a general dropsical condition by Apocynum.cannab. During the pres- ence of the anasarca, she suffered much from cardiac oppres- sion and palpitation, which I supposed to be due to hydro- pericardium. But on the subsidence of the dropsy the heart symptoms became worse instead of better. I then learned that she once had "neuralgia of the heart"—so called by her physi- cian. Several times a day she is now attacked with intense pain in the region of the heart, great anxiety, livid or purple color of the face; cold perspiration on the hands; numbness of the Avhole body, especially the arms. The heart's action seems suspended by a sudden spasm, during the persistence ANGINA PECTORIS. 281 of which she cannot make the slightest motion, but sits upright, with a look of intense agony impressed on every feature. She says the heart's action ceases suddenly, then a feeling as of impending suffocation sets in, the head is forcibly draAvn back- ward by the cervical muscles, and she becomes finally uncon- scious. AVhen she arouses, it is with palpitation of the heart, numbness of the arms, pain down the left arm into the hand, and a sense of complete exhaustion. I did not see her until after she had had several attacks. Arsenicum3 was first pre- scribed, and Avas taken for two days—no better. Nux vom.3 for two days—no improvement; then Naja30 for tAvo days. Under the last remedy she grew worse. I then visited her. On physical examination, the heart's action appeared to be normal, pulse regular, but soft and quick. There Avas no water in the pericardium, and the heart was not hypertrophied. Cimicifuga1' was prescribed, five drops every hour for six hours, then every tAvo hours. She had a severe attack just before taking the remedy, and two slight attacks after the first dose. Ten days afterwards I Avas informed that there had been no recurrence of the paroxysms.—Idem. Hepar sulph.—This remedy is specially indicated in cases Avhich have resulted from the sudden suppression of cutane- ous eruptions, as in the folloAving instance: Illus. 145.—Mrs. D., set. 30, nervo-sanguine temperament, housewife, Avorks haid, has been a sufferer from angina pecto- ris for the last two years. It seems, from the history of the case, to be the result of suppressed erysipelas, of the phlegmo: nous variety. She was ahvays subject to erysipelas, and two years ago Avas cured of it by external washes. She has had this pain in her heart ever since; never had it before. She also complains of great heat and dryness of the oesophagus, from the stomach to the mouth. She is likewise troubled by apprehensions, continual fear and anxiety. Hepar sulph3, every morning, cured her in tAvo Aveeks.—Dr. S. M. Fowler. Kali curb— This, it will be remembered, is one of Klapka's remedies for the gastralgic form of angina pectoris. Its cura- tive virtues in such cases are well illustrated by the following: Illus. 146.—Mrs. T., set, 48, nervo-bilious temperament, house- 18 282 NERVOUS DISEASES. wife, has been suffering since the change of life (about three years) from irregularly repeated paroxysms of most excrutiat- ing pains in the region of the heart. A sudden start will gen- erally induce palpitation, and it is ahvays aggravated three or four hours after a meal, more particularly if the meal has been a hearty one. Bowels are regular, food digests Avell and seems to be properly assimilated, and never distresses her at or soon after a meal; but the aggravation of the heart symptoms after four hours, induces her to nearly starve herself. At the time of making my first examination, she at as comparatively com- fortable, and physical exploration reArealed nothing abnormal. Has some muscular rheumatism. There is a dirty yellowish appearance of the skin, and in spots a dry, branny eruption, most on feet and legs. But the great trouble is the pain in the heart. Has taken much medicine. For the rheumatism, erup- tion and pain, I found Rhus tax., Arsenicum and Aconite all well indicated, and I determined to try them all, if necessary. Be- gan with Aconite3 every two hours for three days. Report, "a little better." Chive Rhus3 every two hours. Report the same. Gave Arsenicum four times a day. Towards night of the se- cond day I was sent for in great haste; my patient was much worse. I found her suffering fearfully, complaining of " such awful stitches." A stitch would catch her and "take her breath " for a moment, and then she Avould scream so as to be heard across the street. "Stitches" being the most character- istic symptom, I gave Kali carb. From the very first dose my patient began to improve, and has been well since, about six months. She has had a little fluttering, or tendency to palpi- tation, two or three times since, which Avere entirely removed by Lilium tig.—Idem. GASTRALGIA. 283 CHAPTER VII. GASTRALGIA. Gasfralgia, a term-Avhich, like its congener, gastrodynia, sim- ply signifies gastric pain, is a neurosis of the stomach, charac- terized by severe pain seated in or about that viscus, and un- complicated by any other morbid sensation in the part; in other Avords, it is a true neuralgia of the stomach. Symptoms.—As the symptoms of gastralgia do not occur in any Avell defined order, or with any regularity, it will be best to vieAV them as separate phenomena, of which one or or more, besides the pain, may or may not be present in any particular case. The chief symptom is the pain, Avhich is always present during the paroxysm, and is of a burning, gnawing, boring, lancinating, tearing, stabbing, cramping, or twisting character; in fact, the pains, Avhile they are generally sharp and severe, may be of every variety of form and degree of intensity, from a simple stitch up to the most intense agony. It is not always easy to determine Avhether the pains are seated in the stomach itself, or in one or more of the nervous plexuses situated in its immediate vicinity, neither is it of much con- sequence in a practical point of vieAv; it is sufficient to know that the pains are of a neuralgic character, and are located in the region of the stomach. As in other neuralgic affections, the pains are generally progressive, being at first compara- tively mild; but after exciting, or otherwise affecting, the organ, producing eructations and a feeling of depression and sinking at the pit of the stomach, they suddenly increase in severity, often to such a degree as to cause the patient to cry out, and even to writhe in agony. They occur in paroxysms of varia- 284 NERVOUS DISEASES. ble length, and separated by intervals of greater or less dura- tion, Avhich may or may not be free from gastric uneasiness. Generally, the intervals between the paroxysms are character- ized by a sense of weakness at the pit of the stomach; and sometimes there is a dull, ill-defined aching or hea\7iness re- maining after the pains have ceased, due probably to conges- tion. The pains are usually relieved by hard pressure, whilst slight or moderate pressure generally aggraA7ates them. This will ser\7e to distinguish them from the pains of acute gastri- tis, which are ahvays aggravated by hard pressure. The pains are sometimes excited, and at others relieved, by eating, in Avhich respect they resemble those caused by dyspepsia. They may remain confined to the neighborhood of the stomach, or they may radiate towards some other part of the body, as the chest, back or abdomen. The paroxysms are not apt to occur with any well marked periodicity, though such is not always the case, some occurring regularly every morning or evening, others soon after meals or at a certain hour of the night; but generally they happen at irregular hours, apparently excited by some transient and uncertain cause, such as mental emo- tion, fatigue, or indiscretion in eating. The secondary phenomena are as variable as the pains. Most, if not all of them, are accidental symptoms of some other disorder of the stomach, of which the neuralgia is sometimes the cause and sometimes the effect. Of these, the most com- mon is vomiting, which, unless it occurs soon after eating, is apt to take the form of pyrosis, or waterbrash. It generally occurs at or near the termination of the paroxysm, of which in most cases it is probably the result. Another common effect or accompaniment of the neurosis, is an excessive accumula- tion of gases in the stomach. These so distend the viscus, that the patient is often compelled to loosen his clothing, or else to relieve himself by belching. Other derangements of the stom- ach also occur during the intervals, such as nausea, morbid appetite, heartburn, etc.; and although, as a general rule, these are merely secondary phenomena, Avhen present they add not a little to the misery of the patient. In addition to these gastric disturbances, there is apt to be more or less derange- GASTRALGIA. 285 ment of other organs, such as dyspnoea, palpitation of the heart, colic, etc. These sympathetic nervous disturbances, like those before mentioned, are by no means constant; for it is no uncommon thing for the patient to be as free from them during the interval between the paroxysms, as he ever is in health. Mental depression, almost amounting to despair, is a common accompaniment of the attack, but this generally lasts only until the pain subsides. The disease sometimes succeeds, or alternates with, other forms of neuralgia, especially trigemi- nal. A female patient of mine, hoav under treatment, avIio last week had a carious tooth extracted for the purpose of reliev- ing an attack of facial neuralgia, to Avhich she had long been subject, has since suffered from daily paroxysms of gastralgia; the disease having been apparently translated from the mid- dle branch of the fifth pair to the nerves of the stomach. Causes.—The disease is much more frequent among females than males, especially such as are ansemic and hysterical; in- deed, the affection seldom attacks the strong and robust of either sex. Hence, anxiety, debility, and what is called the nervous constitution, predispose to the disease. The exciting causes are such as tend to Aveaken the system, such as hemorrhages, leu- corrhcea, over-lactation, self-abuse, excessive venery, sperma- torrhoea, etc. For this reason, also, dyspepsia is a common cause, from which the disease needs to be carefully distin- guished, as it is very apt to be confounded with it, especially if, as sometimes happens, the two diseases coexist. Spinal irritation is sometimes associated with it, though this is not always easy to determine, as the spinal tenderness may be the same in both cases. Tobacco smoking, or the excessive use of tobacco in any form, is one of the most frequent causes of the disease in men. My son, who was formerly in the tobacco trade, was compelled to relinquish the business, on account of the frequency of such attacks. The folloAving is a striking illustration of its pernicious influence: Illus. 147.—Dr. Teste, after excessive smoking during a rail- way journey, observed slight shootings in the hypochondria. One part of the abdomen was more swollen than usual; the other side, which was the seat of a dull pain, little increased 286 NERVOUS DISEASES. by pressure, was, as it Avere, paralyzed; on touching it, my hands alone experienced the perception of the contact. Some difficulty in speaking, in consequence of an unusual feeling of congestion, not only of the tongue, but also of the buccal and maxillary muscles, Avhich, Avhen I attempted to speak, were affected with a sort of nervous trembling. On sitting doAvn to a plate of soup, I had scarcely swallowed half a dozen spoonfuls when a sudden, acute', indescribable, horrible pain, forced me to scream out. The spoon dropped from my.hand, and I fell back upon my chair, pale as death, bathed in cold perspiration, panting, and apparently at the last gasp. My hands clenched over my stomach alone indicated the seat of pain. I Avas fomented Avith hot towels; this gave me much relief. Sud- denly the paroxysm diminished perceptibly; it was extin- guished like a sound in space; it is going—it is gone. I felt my pulse; it was never calmer. I pressed my stomach and belly strongly; they Avere scarcely tender. A quarter of an hour aftenvards I again took a feAV mouthfuls; this was too much, a hundred times too much. The pain returned; it Avas terrible. During the night, these paroxysms came on, at first every twenty or thirty minutes. The interval between them increased toAvards morning. They lasted from one to three minutes, during Avhich the pain AA7ould have caused me to scream again, Avithout the most violent effort over myself. They Avere attended neither by nausea nor by real colic, nor did they cause the boAvels to move nor the urine to Aoav ; but they constantly produced a copious perspiration, Avhich gen- erally marked the end of the fit. For many days afterwards, a few puffs of a cigar were sufficient to reproduce the acute and characteristic pain in the epigastrium, and other symptoms.— Br. Jour. Horn. XVII, 233. Not a feAV cases of the disease are also due to the abuse of coffee and green tea. Ulus. 148.—Some years before the Avar, I Avas called to an old woman, living in one of the small towns of Indiana, Avho was supposed be in her death agony. Every few moments she would give an unearthly scream, double herself up in bed, press her hands to her stomach, and in a feAV minutes throAv herself GASTRALGIA. 287 back exhausted and apparently unconscious. Her grand- daughter, who was present, said that she had been complain- ing for two or three days of transient stitching pains in the region of the stomach, which gradually greAV worse, until soon after supper that evening they suddenly assumed their present severity. I questioned her closely as to her grandmother's habits, having a strong suspicion that she was addicted to the excessive use of some narcotic, such as chewing>opium, smok- ing, or something of that kind, practices not uncommon in the back-country. I failed, however, to elicit any such informa- tion, and Avas about to abandon the investigation, when the emetic, which I had given under the impression that the stomach contained indigestible matter, began to act, and to my surprise I found that she had thrown up a black, sooty-looking fluid, having the odor of strong tea. I then learned that she was not only in the habit of drinking nothing but tea, but that she made it of unusual strength, that she drank it about six times a clay, and that she Avas also in the'practice of cheAving the leaves. On calling upon her the next day, I found that her nerves were completely unstrung, and that she trembled as though she had the shaking palsy. She said that she had never had but one such attack before, and that was after get- ting a fresh supply of tea, of which she partook in great ex- cess, as in the present instance. I told her if she did not abandon its intemperate use she would soon die of its effects, but the Avarning made but a temporary impression, as she Avas soon using it again as freely as ever, and the next Avinter she died in a paroxysm, Avhich, as described to me by her attend- ing physician, I am satisfied Avas nothing else than neuralgia of the stomach, caused by the excessive use of green tea — Hart. Diagnosis.—This disease is liable to be confounded with inflammation, cancer and perforating ulcer of the stomach, dyspepsia, and the passage of biliary calculi. It may be dis- tinguished from acute gastritis, by the absence of the fever, the persistent vomiting, the sensith7eness to hard pressure, the uninterrupted course, and the great prostration which belong- only to the inflammatory affection. Carcinoma may be known 288 NERVOUS DISEASES. by the emaciation and steady character of the pain Avhich characterize that disease. In perforating ulcer, the painfulncss and sensitiveness to pressure are much more circumscribed, being generally limited to the seat of the ulcer. The other diseases, also, are best distinguished by the symptoms peculiar to each. Treatment.—AVarm applications, especially fomentations, to the region of the stomach, generally promote the comfort of the patient, and are sometimes sufficient of themselves to re- lieA7e the most severe paroxysms. Sinapisms, and other rube- facient applications, are not usually required, though there can be no objection to using them in case the fomentations fail to relieve. Galvanism, hoAvewer, is the most efficient applica- tion that can be made, and should be applied agreeably to the directions already given in the preceding chapters (q. v.). The internal remedies chiefly relied upon in this affection, are Argentum, Arsenicum, Carbo veg., Ignatia, Nux com., and Veratrum. Other remedies sometimes required, are Belladonna, Bismuthum, Calcarea, Chamomilla, China, Cocculus, Coffea, Colo- cynth, Ferrum, Lycopodium, Opium, Platina, Plumbum, Pulsa- tilla, Sepia, Stetphysagria, Stannum, and Sulphur; in other Avords, the proper medicine in these, as in all other cases, is the spe- cially indicated remedy, as regards not only the local but the constitutional condition. Argentum nit.—This remedy is best suited to cases of severe cardialgia attended Avith heartburn, Avhich is aggravated or excited by eating, and Avhich seems to depend upon an irrita- ble state of the nerves of the stomach proper. Illus. 149.—A young man, set. 20, suffered from severe car- dialgia, which Avas worse Avhen moving, better Avhen lying or sitting, but sometimes Avent off Avhen he took violent exercise and got into perspiration. The pain, which Avas excited by eating, was as if a stone lay in the stomach. The appetite Avas good. He Avas soon cured by Argentum nit.3, a dose three times a day.—Dr. Mossa. Arsenicum..—Acute burning pains, accompanied by great restlessness, nervous excitability, coldness of the extremities, palpitation of the heart, and nightly exacerbations. GASTRALGIA. 289 Illus. 150.—Airs. S. (!., set. 37, spare habit, extremely nervous and sensitive, after several days attendance upon a sick friend, Avas suddenly seized about one o'clock at night, with a terrible burning, tearing pain at the pit of the stomach, which would sometimes extend up\A7ards under the sternum and at others Avould shoot towards the right side. The pains occurred in paroxysms lasting several minutes, and Avere so severe as to arrest the breathing and cause a cold perspiration to appear on the forehead. The paroxysms passed off about six o'clock, a.m., with eructations of Avind, after which she experienced great depression and exhaustion. The next night she had another similar attack, more severe if possible than the first. It Avas during this paroxysm that I Avas sent for. I found the tongue clean and the pulse but little excited, but the sufferings of the patient were indescribable. I ordered flannels wrung out of hot Avater to be applied to the region of the stomach and frequently changed, and prescribed Arsenicum6, fifteen drops in half a glass of Avater, of AA7hich she was to take a des- sertspoonful every hour for six doses, then three times a day until permanently relieved. A few Aveeks afterwards I met her upon the street, and she informed me that she had had no trouble with her stomach since the night I prescribed for her. —Dr. A. du Quinn. Belladonna.—Pressing, draAving, clutching, or cutting pains in the stomach extending to the back, Avith nausea, thirst and vomiting, aggravated by drinking Avater or by motion; ameli- orated by eating. Illus. 151.—Miss A., set. 21; has had gastralgia for many years. The pains are dull and aching or gnawing, with a sensation of weight in the stomach. The pains extend through to the spine between the shoulders, which ache as if fatigued. The pains are worse when fasting. Belladonna30 cured this case in five weeks; but I find that the 200th cures cases with these characteristics, especially where the pains ex- tend to the spine, more promptly and permanently than when a lower potency is used.—Dr. P. P. Wells. Carbo veg.—This remedy is best suited to cases complicated with hysteria or dyspepsia, especially if there is a hypersemic 290 NERVOUS DISEASES. and irritable condition of the lining membrane of the stomach present. Illus. 152.—Air. L. G., set. 47, of nervous temperament and active business habits, has complained for the last seven years of dyspepsia, for which he has been physiced, sweated and dieted in every possible manner, but all to no purpose. He feels well enough for three or four months, then an attack comes on lasting several weeks, and then gradually disappears. He Avas just beginning to suffer when my aid AA'as sought. He feels well enough in the forenoon, and till about three p.m., when Avaterbrash sets in with thirst for cold water, the stomach becomes bloated and burning pains are there, partially relieved by eructation; but the pains do not cease till, sometime in the evening, he-throws up large quantities of watery mucus tinged with bile, when relief follows. Fie never throws up food; bowels and sleep perfectly regular. Ardent spirits and tobacco disa- gree Avith him, and he gave up their use several years ago. AVishing to show off smart, I prescribed (like a fool) Arsenicum3, off hand. But superficial prescribing Avill not do; the poAvders failed to have any effect, and I was obliged to study up the case. I found in Allen, under Carbo veg., all his symptoms, and tAvehre powders of the sixtieth potency broke up the attack en- tirely in less than a Aveek and there has been no return, though formerly every attack lasted from four to six Aveeks;—Dr. S. Lilienthal. Ulus. 153.—Ella B., set. 16, daughter of parents well advanced in years. Nervo-sanguine temperament; light hair and eyes. In January last, during her indisposition, she suffered an exposure Avhich resulted in suppressio mensium. AVas treated allopathically for about three months, Avhen I Avas called in, to prescribe for the folioAving symptoms: Repeated and often- recurring attacks of the most distressing gastralgia, attended at times with more or less palpitation; sensation of ball rising from stomach to throat; sensation of choking, amounting to actual strangulation, when she would faint clear away. This was folloAved by almost entire freedom from pain until the next attack. BoAvels constipated, menses for tAvo periods normal. Gave Pulsatilla, Nux vom. and Asafcetida at differ- GASTRALGIA. 291 ent times, Avith varying effect, under Avhich she graclually improved, except the gastralgia, Avhich Avas finally and per- manently relieved by Carbo veg.6.—S. M F., La Mode, la. China,—Gastralgia, attended Avith great chilliness or cold- ness, constant feeling of Aveariness and debility, sour eructa- tions, heartburn, bloated abdomen, palpitation of the heart; pains aggravated or excited by mental emotions, cold, eating, or at night. Illus. 154.—Miss E. R., set. 20, pale and ansemic, has been a sufferer from occasional attacks of gastralgia for more than four years. The pains, which are of a cramping and cutting character, gradually increase in intensity until they become unbearable. They are attended Avith a chilly, cold feeling, palpitation of the heart, acid risings in the throat, and some- times, at the close of the paroxysm, a very sour watery fluid is ejected by vomiting. The attacks generally occur in the latter part of the day or late in the evening, and are most apt to be excited by fatigue or long-continued exertions. Prescribed Chimt3x, in trituration, a powder three times a day. TAventy powders were taken, since Avhich she has had no more attacks, a period of OArer sixteen months.—Hart. Nux vom.—Jahr ad\7ises to commence treatment of all cases of gastralgia Avith Nux in males and Ignatia in females, unless there are special indications calling for other remedies. It is eminently adapted to the tobacco form of gastric neurosis, as exemplified by the folloAving case: Illus. 155.—J. E. J., a young man set. 24, and a confirmed devotee of tobacco, smoked three times in succession, while he lay in bed reading. He became suddenly nauseated, and soon vomited freely. The next morning he had a pain in the stomach, as if he had "swallowed something which was too large." He could hardly cat breakfast, deglution gave him so much pain. He points to the epigastrium when locating the pain. He says it is as if at a certain spot the bolus was forced through too small an opening, and when the food is once in the stomach, it occasions a "bursting" or distensive pain. Fluids occasion a similiar pain, but not so intense. Warm drinks occasion less suffering than cold, while swallow- 292 NERA'OUS DISEASES. ing, but their presence in the stomach someA\7hat alleviates the bursting pain. He also observes, on taking a full inspira- tion, a stitch-like, sharp, but not acute pain, Avhich extends from the epigastrium directly backAvards to the spine. This sensation feels as if it Avould be relieved by an eructation, but it is not, AVhen I saw him, twenty-four hours afterwards, he Avas afraid to eat or drink, because of the pain. He has never had anything like this before; all that he ever noticed from the use of tobacco was a sense of sinking at the epigastrium. Tavo powders of Nux vomica, lx trit., a grain each, enabled him to eat a meal Avithout pain on the folloAving day.—Dr. S. A. Jones. Vcrcttrum alb.—This remedy is particularly adapted to those cases in Avhich the cceliac plexus and sympathetic are involved, the pain passing directly backwards and upwards in the course of that nerve. The pains increase and subside gradually, and are attended Avith marked coldness of the extremities. Illus. 156.—Sarah, set. 54, for a year has had attacks of pain in the epigastrium; pain comes on gradually, first in the region of the stomach, from Avhich it radiates upAA'ards and to both sides, reaching to the back between the loAvest point of the shoulder-blades; it increases in violence till it becomes agon- izing, then gradually subsides. As the pain conies on, she shakes with cold, and the hands and feet are cold. Veratrum3, cured in a week.—Dr. Bayes. NEURALGIA OF THE FEMALE GENITAL ORGANS. 293 CHAPTER VIII. NEURALGIA OF THE FEMALE GENITAL ORGANS. Neuralgic affections of the female genital organs, whether we consider them in an etiological, pathological, or therapeut- ical point of vieAV, are so closely allied to each other, that is to say, their sympathetic relations are so intimate, that we deem it advisable to treat of them in the same connection. 1. Vaginodynia.—Neuralgia of the vagina may be either pri- mary or secondary. The primary symptoms are generally local, but the vaginal irritation may extend to the other geni- tal organs, causing secondary neuralgia of the uterus and ovar- ies. In the same manner, neuralgia of the uterus may extend to the vagina, and thus produce secondary vaginodynia. The local symptoms consist chiefly in a condition of painful hyper- sesthesia, in which coition is exceedingly painful, or else in a peculiar tingling or itching, Avhich may be either painful or pleasurable—painful when not relieved by scratching or rub- bing, and pleasurable or voluptuous when thus treated. This titillation, when slight, may be borne Avithout much incon- venience, or Avithout giving rise to any unpleasant conse- quences; but when excessive, or when aggravated by external Avarmth or irritation, it causes an irresistible desire to scratch or rub the affected parts, which, though it may for a time seem to relieve the unbearable itching, and even excite pleasurable sensations, increases the already abnormal AA'armth, and thus adds fuel to the fire already existing. As a consequence, the parts become preternaturally dry, the sexual appetite is ex- cited, the cheeks appear flushed, the eyes sparkle, and the nervous system is in a state of intense erethism. If not mod- 294 NERVOUS DISEASES. erated by sexual intercourse, and she endeaArors to bear her trouble Avithout resorting to friction, she becomes irritable, feverish and eccentric; but if, on the contrary, the sexual pas- sion is encouraged, she either becomes nymphomaniac, or the erethism and hypersesthesia are relieved by the escape of an albuminous discharge from the vaginal glandulse, Avhich leaA7es the patient weak, pale, exhausted and sullen. In some cases the irritation extends to the uterus and ovaries, hysteria or hystero-epilepsy is induced, and the morbid excitement is re- lieved, for the time being, by a convulsive paroxysm. 2. Hysteralgia.—Neuralgia of the uterus consists, for the most part, of A'arious painful sensations incident to the men- strual period. They may occur immediately before, during, or soon after menstruation, constituting the various forms of dysmenorrhcea. Uterine pains occurring between, and re- mote from, the menstrual periods, are generally due to some other disorder of the sexual organs, and are at most only cases of secondary neuralgia. In pure uterine neuralgia, there is no appearance of congestion, inflammation, or malposition of the organ; neither are the pains due to occlusion or narrow- ing of the outlets: but they occur in paroxysms, like other forms of neuralgia, are easily excited, occur for the most part in an- semic, hysterical and neuralgic subjects, and frequently alter- nate Avith neuralgia in other parts of the system. The pains are of every imaginable form and degree, being at times burn- ing, drawing, pressing, cramping, cutting, stabbing, shooting, tearing and griping. They arc mostly felt in the hypogastric region, just above the symphisis pubis; but they may also ex- tend to the vagina and ovaries, and even to the bladder and rectum. AVhen very severe, they may take the form of labor- pains; or they may spread to or from more remote parts, espe- cially the umbilicus, the lumbar region and the thighs. AVhen they reach their height, they not unfrequently cause nausea and vomiting, followed by coldness and depression. In other cases, the pulse becomes somewhat excited, and is attended with headache, a flushed face, thirst, and more or less oppres- sion of the chest. Other secondary symptoms also sometimes occur, such as palpitation of the heart, clavus and globus hys- NEURALGIA OF THE FEMALE GENITAL ORGANS. 295 tericus, dysphagia, aphonia, dyspnoea, muscular spasm or atony, and all the symptoms usually denominated hysterical. 3. Ovaralgia.—Neuralgia of the ovaries is so frequently met with in the subjects of hysteria, as to be almost identified with that disease. Indeed, as Ave have already stated under the head of " hystero-epilepsy " (q. v.), Dr. Chairon, by simple compres- sion of these organs, Avas able to produce at pleasure the most characteristic symptoms of hysteria. Moreover, Charcot has shoAvn that the convulsive attacks of hystero-epilepsy itself can be instantly subdued by compression of the ovaries. "You may," he says, "by removing the compression and again ap- plying it, stop the seizure or allow it to recur as often almost as you like." In these cases of ovarian hyperesthesia, there is frequently more or less anaesthesia, the affected ovary being on the same side as the anaesthesia. Charcot tells us that when both ovaries are affected, the anaesthesia is general. The reflex character of the pain, in many instances, is well illus- trated by the folloAving case : Illus. 157.—I prescribed for about two years for a case Avhich seemed to be neuralgia of the left ovary. It would be benefited for a brief period only, and then return with renewed intensity. Neither homoeopathic specifics for the symptoms, nor general tonics and constitutional remedies, did any permanent good. Several months ago, the lady had all the teeth and old roots extracted from the upper jaAv, to have a full plate inserted. From that very day, the pain in the left hypogastrium dis- appeared, and has never returned. The. remoteness of this reflected irritation is remarkable. I can only explain it on the theory, that the spinal centres Avhich control uterine func- tions, Avere in a morbid and excitable state, for the patient was not free from uterine disease. That state, howe\7er, Avas not sufficient of itself to produce ovarian neuralgia—but a super- added irritation from above, passing doAvn the spinal column, produced the pain as soon as it struck the morbidly sensiti\7e centres.— Dr. W. H. Holcombe. Dr. Budin, Chef de Clinique d'Accouchements, calls atten- tion* to a vivid pain which is sometimes produced during the * Progres Medical, No. 9. 296 NERVOUS DISEASES. latter months of pregnancy, and during labor, by a very mod- erate amount of pressure made on the abdomen by the ends of the index and meclius fingers. The pain is sometimes so sharp that it causes exclamations, or tears to start in the eye. It never occurs spontaneously, and its production is confined to the vicinity of a line draAvn from the umbilicus to the ante- rior superior spine of the ilium, sometimes a little above, and sometimes below this line, and at a distance varying from ten to fifteen centimetres from the umbilicus. At the seat of this pain so excited, may be felt a movable body resembling the ovary in shape and size. Its presence is most frequently felt on the left side, the existence of a resisting surface—usually the back of the foetus—being necessary in order for the body to be felt and the pain to be excited. Sometimes this can only be done during the contraction of the uterus. Dr. Budin thinks it possible that the "ovarian pain" has been confounded Avith certain neuralgias Avhich several authors have termed rheumatism of the uterus, and Avith the pain sometimes caused by the pressure of the head on the uterine Avail. None of the Avomen upon whom this tenderness had been produced Avere hysterical. Causes.—The \7arious forms of neuralgia peculiar to females, are most frequent in individuals, of sensitive dispositions, especially such as possess the nervous Or hysterical constitu- tion. The exciting causes, Avhich are partly psychical and partly physical, are such as are calculated to excite and maintain a constant irritation of the female sexual organs, such as amorous conversation and reading, dallying Avith male companions, dancing "round dances," libidinous friction of the parts, onanism, incomplete or excessive sexual intercourse, and Avhatever is calculated to produce congestion or nervous erethism of the genital organs. In many cases, the disease is secondary to pathological conditions in the uterus or elseAvhere, especially to the A'arious forms of uterine displacement, struc- tural lesion and chronic engorgement, spinal disease, etc. Prognosis.—The prognosis is good Avhcnever the exciting causes can be permanently removed, but unfortunately these causes are generally most pronounced, and most difficult to NEURALGIA OF THE FEMALE GENITAL ORGANS. 297 reach, in those in AAdiom the predisposing causes are also the strongest. Hence, instead of being able to diminish the latter, the practitioner often finds that he has to contend Avith an additional one, in the shape of a "bad habit of action," to Avhich the nervous system has become accustomed. However, the similarly-acting remedy, if well chosen, Avill generally eifect a satisfactory cure, even in the most difficult cases, pro- vided due attention be paid to the removal of the exciting cause, and the correction or avoidance of all pernicious habits. Treatment.—In these, as in other forms of neuralgia, electricity, either in the shape of galvanism or faradization, is one of the most efficient agents Ave can employ. The inter- rupted current should only be used in those cases in Avhich the constant or gah'aiiic current fails to give relief; and when applied directly to the uterus, the vaginal electrode should be insulated. The current should ahvays be Aveak, especially at first, and in no case should it excite pain. The vaginal douche is a fa\rorite mode of applying remedies locally to the vagina and uterus. A drachm of the fluid extract of •Cimicifiuga or Caulophyllum to half a pint of tepid Avater, injected night and morning, or, in cases of dysmenor- rhoea, just before the commencement of the menstrual period, Avill often prevent the return of the paroxysm at that time, and greatly ameliorate it Avhen present. Even a simple Avarm- Avater douche Avill sometimes give great relief, as will also warm fomentations to the hypogastric region. The leading remedies for neuralgia of the vagina are: Bella- donna, Calcarea, Ferrum acet. and mur., Graphites, Hyoscyamus, Mrcurius, Natrum mur., Nux vom., Phosphorus, Platina, Stramo- nium, Sulphur and Zincum met. The chief remedies for uterine neuralgia are: Aconite, Belladonna, Gelsemium, Cimicifiuga; Caulophyllum., Magnesia mur., Hypericumperfi. and Veratrum vir. For ovaralgia, Ave give Aconite, Ammonium mur., Atropia, Bella- donna, Cimicifiuga, Colocynth, Lilium, Kali brom., Lycopodium, Naja, Viburuam op., Nunth.oxylu.rn and Zincum vol., according to the special indications. Aconitum napel 1 These remedies, either singly or com- Ammonium mur. ) bined, are indicated when the neuralgic 19 298 NERVOUS DISEASES. symptoms are attended Avith swelling and tenderness of the OA'.aries, quick pulse, and a feverish state of the system. Illus. 158.—Dr. J. Marengo Curran details several cases of ovarian neuralgia, which he treated successfully with the above medicine, after the unavailing use of the ordinary allo- pathic treatment. The symptoms presented by the six cases were, in the aggregate, as follows: Pain, dull and aching, or violent and unendurable, in one or the other iliac region, extending along the anterior surface and inner side of the thigh, and attended with swelling and tenderness of the ovary, high, quick inflammatory pulse, dysuria and loss of sleep. In some of the cases the pain Avas chronic, that is, it lasted all through the month, and got worse at the menstrual periods. In other cases the attacks Avere violent, acute, and had rather the appearance of ovaritis.—Dr. E. M. Hale. Atropia.—This remedy may be given in ovarian neuralgia in cases Avhere Belladonna is indicated and fails to relieve, or where the character and severity of the pains are such as to demand speedy relief. Illus. 159.—Mrs. L., set. 40, mother of seven children. With each of her other children, beginning about the third month, she would suffer with the most excruciating pains in the region of the left ovary, of a cutting or draAving nature, extorting screams from her, and causing her to bend over to that side; the pains Avere so severe that she said they Avere unbearable. After continuing in the ovary for aAvhile, the head AA'as attacked, which Avould develop spasms of a hystero-epileptic nature. She had previously been treated for them with chloroform and chlorate of potash, but without avail. I began the treat- ment with 4 to 10 globules of Atropia, three times every four hours, until the symptoms abated. She had no more attacks. —Dr. W. H Blakeley. Belladonna.—This remedy is specially indicated in ovarian neuralgia, in cases where the attack is excited by sudden con- gestion, occurs in paroxysms, and is attended with violent thirst, nausea and vomiting. Illus. 160.—Mrs. AV., confined three months ago; lochial dis- charge suddenly ceased a fortnight after confinement; since NEURALGIA OF THE FEMALE GENITAL ORGANS. 299 that time she suffers intense agony Avith intermittent neuralgia of the right ovary; violent clawing, griping pains, causing constant exclamations for tAventy-four hours at a time Avithout interruption; at length the pains ceased entirely, but invari- ably returned Avith reneAA'ed vigor; much thirst and vomiting during the pain, Avhich occurs day or night; for two'months and a half took much laxative and other medicine, as well as opium in abundance. Belladonna200, in water, every tAvo hours, cured in a week, and she has remained Avell since, a period of tAvo years.—Dr. Wesselhafit, Cimicifuga.—Cimicifuga and its active principle, Macrotine, is indicated in o\7aralgia in all cases where there is severe pain in the head and back; also in dysmenorrhceic cases, or Avhere the pains are increased at the menstrual period. Ulus. 161.—Miss C. S., set. 23. Face pale, hands and feet cold, hand tremulous; complains of great pain and soreness in a small spot, just left of spine in lumbar region; this pain fre- quently passes forAvard, through the left ovary and dovA'n the thigh to the knee; severe pain in the head, extending from orbital region to vertex; no appetite, nausea even after small quantity of food; is losing flesh very rapidly, and feels ex- hausted and very irritable; the pain in the back is intolerable at night, and all symptoms increased at menstrual period; menses regular and normal in appearance. Examination re- vealed marked tenderness of left ovary, but no uterine dis- placement. Macrotine1* gave relief in less than forty-eight hours. This condition not being permanent, the sixth decimal of the same drug Avas given, and patient soon restored to health, with no return of the pain, even at the menstrual period.— Dr. May Ho wells. Tarantula.—This remedy is indicated in hysterical constitu- tions, when the pains are of a spasmodic, cramping character, attended Avith nervous excitability, anxiety, restlessness, cardiac oppression, weeping, and discharge of urine. Illus. 162.—After a fall; hardness, swelling and tenderness in the hypogastric region and in the uterus, which was the seat of burning and cramping pains radiating to the hips, groins thighs, and particularly on the left side, the pains were so ex- 300 NERVOUS DISEASES. cruciating that she Avas obliged to scream, constantly and des- perately, and were greatly increased during defecation, or Avhen excited by it; sanguineous leucorrhcea; constant desire to pass urine, which was clear but difficult to void, passing drop by drop with burning pain. Tongue dry, thirst, pulse small, pale face, desire to constantly move the legs, prsecordial anxiety, sadness, weeping and fear of death. Conium12 greatly relieved, but Tarantula12 had to be given to complete the cure. —Dr. F. Fir mat, Spain. Ustilago mctdis.—This remedy is indicated in ovarian irrita- tion arising from dysmenorrhcea, or vice versa; also in ovaral- gia occurring at or near the climacteric period. Ulus. 163.—Ovarian irritation in a lady past the critical age. Airs. N., set. 54; nervous temperament; has a constant pain in left ovary passing down the hip, so severe that she has to limp \A7hen walking; the pains are sharp, and at times pass cIoavii the leg with great rapidity; every few days has quite a savcII- ing in the left groin; cannot bear pressure over the ovary; bowels regular and otherwise Avell. Tavo prescriptions of Usti- lago, 15th dil., lasting a week at a time, gave her perfect relief. —Dr. W. H Burt. Xanthoxylum.—This remedy, according to Dr. Cullis, is more especially indicated in females of spare habit, nervous temper- ament, and delicate organization. Illus. 164.—Airs. D., set. 26, spare habit, scrofulous diathesis; had suffered for years from dysmenorrhcea. Her sufferings Avere so great, that she would be confined to her bed for two or three days. She had tried all sorts of treatment, but Avith- out any relief. She came under my care saying the only Avay she could live through her menstrual period was to drink whisky, or gin, until she was intoxicated. For several months I treated her with the usual remedies, but Avithout any benefi- cial result. I then gave her Ncudhoxylum, 3d decimal; this completely cured her. She was extravagant of her praises of this remedy. It has never failed to relieve her.—Dr. Cullis. SPINAL IRRITATION. 301 CHAPTER IX. SPINAL IRRITATION. Spinal irritation, or, as it is sometimes called, spinal neuralgia, is a disease characterized by a hypersesthetic or morbidly sen- sitive condition of a greater or less portion of the spinal col- umn, and by sentient and motor disturbances in one or more of the organs and parts to Avhich the nerves proceeding from the affected portion of the spine are distributed. Symptoms.—The symptoms, which are perhaps more di- A7ersified than in any other form of disease, vary according to the particular portion of the spine affected; the only symptom common to all cases being the tenderness upon pressure on one or more of the spinous processess of the vertebrae. In mak- ing a careful examination of the spine in these cases, we may find either a general tenderness along the whole or a large portion of the vertebral column, or, as is most commonly the case, we may find the tenderness limited to a very feAV of the vertebrae, one or two of Avhich are generally more sensitive to pressure than the others. The degree of tenderness also var- ies greatly, sometimes requiring considerable pressure to de- velop it, while in other cases the patient will shrink at the lightest touch. I have knoAvn the sensitiveness to be so great, that a very moderate degree of pressure A\7ould cause the pa- tient to scream out as though cut Avith a knife; and cases are sometimes met Avith in which nausea or vomiting, syncope, and even convulsions, are excited by any external pressure, however slight. The tenderness is usually most marked in the dorsal region; and many cases are attended with no pain or uneasiness except in that portion of the spine. Sometimes 302 NERVOUS DISEASES. there is an intense aching at the seat of lesion; and occasion- ally pains shoot from it anteriorly, or dowiiAvard into the lower extremities; but in most cases, no pain is experienced except when pressure is made on the affected portion of the spine, so that the real nature of the disease is liable to be overlooked, unless the attention'of the practitioner is drawn in that direc- tion by the peculiar character of the general symptoms. These, as we have said, are of the most diversified nature. They may be divided into groups corresponding to the particular part of the spine affected, the functions of those organs usually show- ing signs of disturbance, the nerves of which are connected, either directly or indirectly, Avith the seat of lesion. Thus, pressure upon, or irritation of the cervical region causes head- ache, vertigo, sleeplessness, loss of memory, disordered A'ision, facial neuralgia, soreness of the scalp, deep orbital and cir- cum-orbital pains, ulceration of the cornea and other trophic changes, hallucinations of sight and hearing, nausea, vomiting, dyspmea and other respiratory troubles, palpitation of the heart, and all such disorders as arise from irritation of the pneumogastric nerve and its connections. AAlien the affection is seated loAver down in the cord, Ave may have any or all the disturbances to which the respiratory, circulatory, digestive and sexual functions are subject, such as violent laryngeal cough, spasm of the glottis, distressing dyspnoea, angina pec- toris, gastralgia, neuralgia of the liver, colic, ovaralgia, hyster- algia, amenorrhcea, urinary troubles, hypersesthesia, anaesthe- sia, convulsions, paralysis, and in fact almost every functional disorder. "In short," to use the expressive language of AVood, "there is scarcely a single morbid sensation or perversion of function, occurring in any part of the body beneath the head, which may not originate in spinal irritation; and, in all cases in which the course of any existing disorder of this kind is ob- scure, it should be sought for in the spine." The disease often lasts for years, but is frequently attended by remissions and exacerbations, the latter of Avhich are apt to assume such a different phase from the preceding ones, as to be mistaken for a fresh attack, and even for an entirely new disease. The following case will illustrate the diversity and change- SPINAL IRRITATION. 303 ableness of the symptoms of spinal irritation, as well as the danger of mistaking it for some other form of disease. Ulus. 165.—Airs. AV., set. 37, has had prolapsus uteri, leucor- rhcea, ulceration of cervix uteri, and a general relaxed condi- tion of the uterine system, for about twelve years. She has a good deal of spinal irritation, pain in the lumbo-sacral and cervical regions, and headache. She has had gastritis, and very frequently, in fact most of the time, has been troubled Avith a burning in the epigastrium, pulsation in the epigastric region about one and a half inches to the left of the median line, roughness and raAvness of the throat, tongue also red and raw. She had a chill the evening previous to my being called. Found her with a high fever, intense headache, pain in the back and limbs, yelloAv coated tongue, severe burning in the epigastrium, Avith tenderness on pressure, and diarrhoea. The next day I found her up, no fever, slight headache, tongue clean, no diarrhoea, but the burning and tenderness continued, Avith inability to keep food in her stomach without nausea and some regurgitations. Treated her for a week Avithout any fur- ther improvement, the burning in the stomach still being a prominent symptom, pain in the cervical and lumbo-sacral regions, intense headache, mostly in the occiput, tongue red, raAV, and Avith a moist Avhite coating. She now had another chill, lasting nearly an hour, but no fever folloAved. The symptoms during the next three days were: severe burning in the stomach, inability to retain anything upon it except a lit- tle cold Avater, faintness, pulse Aveak and wiry, at times almost imperceptible, then full and strong, but not above 80, pulsation in the epigastric region, very distressing, worse by lying on her right side. Severe pain in the cervical and lumbo-sacral re- gions of the spine, would flinch on slight pressure, numbness of extremities, mostly on left side, jerking of left side of body, confined principally to left shoulder, arm and eye. Turning in of left eyeball, left eye injected, red and watery, a sensation of falling, as if she Avould drop asleep, sleepiness, yet inability to sleep, if she would get partially asleep she would rouse up with a jerk, moving the whole body in bed, intense pain and pulsation in the occiput at the base of the brain. Stool loose, 304 NERVOUS DISEASES. then natural, tongue red at the tip and edges, Avith thick Avhite coating in the centre. The next three or four days her pulse ranged from 80 to 140, which I attributed to gastritis, result- ing mainly from excessive irritability of the spinal centre, her uterine difficulties being the primary cause. Dr. AVilliams, a brother of the patient, was noAV summoned by telegraph. He examined the patient and pronounced the case one of typhoid fever, and another physician, a former pupil of his, agreed with him. I Avas finally discharged because I could not agree Avith Dr. AV., in calling it typhoid fever, all the pathognomonic signs of Avhich were Avanting.—Dr. J. Cutwater. Causes.—The disease is mostly confined to females betAveen the ages of puberty and the climaxis. This shows that, as a general rule, it is related, either directly or indirectly, to the female sexual system and functions; for although the disease is sometimes met Avith in children and in men, it is not only far less frequent in them, but also much less extensive and se- vere. Moreover, it is almost always associated Avith uterine disorders, or with sexual excesses, and loss of vital fluids, such as menorrhagia, metrorrhagia, leucorrhcea, over-lactation, though it may arise in either sex from debilitating causes. Hence, anaemia, exhausting diseases, hemorrhages, spermator- rhoea, and onanism are also exciting causes. Pathology.—The pathology of spinal irritation has long been a mooted question, and cannot even yet be considered settled. The most opposite views have been, and still are, held on this subject. Hammond is positive that the disease is due to anaemia of the posterior columns of the cord. Hamil- ton thinks the symptoms may be owing either to an ansemic or hypersemic condition of the cord. There are two or three facts Avhich appear to furnish strong presumptive evidence in favor of the ansemic theory. 1. The disease is almost entirely confined to ansemic, debilitated and poorly-nourished subjects. 2. Tonics and good nourishing diet ahvays benefit the patient. 3. AVhatever depresses or has a debilitating influence on the patient, aggravates the disease. Diagnosis.—The fact that spinal irritation is frequently mistaken for some other disease, shows that the diagnosis is SPINAL IRRITATION. 305 sometimes very difficult. There is one pathognomonic symp- tom, hoAvever, upon Avhich we can generally depend, namely, spinal tenderness; but unless this symptom is very pro- nounced, Ave cannot always be certain that spinal irritation is the cause of the trouble. Caries of the spine is also attended by this symptom; but as this disease usually commences in childhood, is confined to scrofulous subjects, and is marked by the characteristic spinal prominence and constitutional symptoms, there will be little danger of confounding it with the disease under consideration. Spinal congestion may be distinguished from irritation by the aching produced Avhen a sponge dipped in hot Avater is passed over the spine. In spinal congestion, also, there is more or less anaesthesia, numbness and formication, instead of hypersesthesia, as in spinal irrita- tion. In spinal meningitis the spinal symptoms are similar to those of spinal irritation, but the hypersesthesia and pain on motion are much more acute, and, except in chronic cases, attended Avith rapidly fatal consequences. In chronic myelitis tliere may or may not be spinal tenderness, but instead of hypersesthesia there is generally anaesthesia; moreover, the muscular contractions are painful, and there is ahvays com- plete paralysis, followed by atrophy, conditions which dO not occur in spinal irritation. The folloAving is Prof. Leyden's differentiation* between spinal irritation after Aveakening agencies and tabes dorsalis: "A nervous debility frequently deA7elops itself after severe typhus, \-ariola, diphtheria, after intermittens and malarious cachexia, after hemorrhages, after too protracted lactation, after long-continued and excessive mental labors, etc., increased by hypersesthesia and muscular weakness in the small of the back, Avith pain on pressure on some spinal processes. DraAv- ing pains in the extremities, running along the intercostal spaces to the epigastrium with oppression will be soon added to it; then an unhappy state of mind, off and on sleeplessness, dulness of the head, and the patients usually fear the begin- ning of tabes dorsalis. Leyden differentiates these symptoms of spinal irritation from those of tabes dorsalis, and, speaking *Leyden, Spinal Diseases, Vol. II. 306 NERVOUS DISEASES. of the frequent seminal losses, which are so often, and we believe justly, blamed for them, he remarks that there can be no doubt Avhatever, that the greater part of the symptoms emanating from seminal losses offers not the picture of organic spinal disease, but rather a nervous debility Avith spinal symptoms. Such patients look pale and cachectic, but after all appear Avell nourished and their muscles show no flabbiness. They complain of muscular weakness, especially in the lower extremities, a kind of paretic state, but which never leads to paralysis. They soon become tired, cannot stand much exer- tion, but after all their muscular strength is good, their walk firm and precise; still they complain more or less of a sensa- tion of insecurity and of staggering, of formications, running down the back to the posterior part of the thighs, and down the legs. In the feet they haAre a sensation of numbness; a kind of anaesthesia. More rarely we find migrating neuralgic pains; more frequently, difficulties in urinating and deficating; apparently impotence. Then headache, vertigo, dulness of the head, surring of the ears, palpitation, etc., are added to it, and especially hypochondriasis, constantly nurtured by the dread of the tabes dorsalis and increased by self-reproaches. Thus the patients seek advise of their physician in the cer- tainty already of a final death from tabes dorsalis; but the Avhole course shows that there is no organic spinal disease. Lallamand, in his Avork on spermatorrhoea, decidedly denies the severity of such cases, and never Avitnessed a fatal issue. AVhen Hippocrates mentions that tabetic patients succumb to consumption, he only means that acute pulmonary phthisis, to Avhich young people with a hereditary disposition are liable in consequence of sexual excesses. Genuine palsies, corres- ponding to a severe spinal disease, have never been observed, but only such symptoms, already mentioned, corresponding to nervous debility reducible to an irritatio medullise spinalis from excessive sexual stimulation." Prognosis.—The prognosis is generally good, as the causes are such as to admit of being removed or corrected. It is necessary, however, that the patient cooperate with the physi- cian, not only so far as abstaining from every pernicious and debilitating practice is concerned, but by a steady adherence SPINAL IRRITATION. 307 to the prescribed treatment and regimen. Thus aided, the physician can, in most cases, promise the patient speedy relief, and, if the treatment is faithfully and perseveringly followed up, an ultimate cure. Treatment.—The treatment, both internal and general, should be especially directed towards the improvement of the patient's general health, the condition of which, as we have shoAvn, is in most cases both the predisposing and the efficient cause of the whole trouble. This calls for the removal, not only of such exciting causes as leucorrhcea, over-nursing, hemorrhage, diarrhoea, spermatorrhoea, or other drain on the system, but a toning up of it by means of good nourishing diet, pure fresh country air, out-door exercise, change of scene, bathing, SAvimming, coasting, sleighing, romping; in short, a complete change of habit, and of those hygienic conditions which originated, and, if permitted to continue, will promote the disease. AA"e cannot be too emphatic on this subject; indeed, we have no hesitation in saying, that unless the patient's habits and surroundings can be completely changed, the mode of life revolutionized, and the weakened machinery got out of the ruts in which it has fixed itself, all other treat- ment, however appropriate, will be liable to fail. At the same time, nothing should be said calculated to discourage the patient. On the contrary, many cases will require the best hygienic mental as Avell as physical treatment, cheering up the patient being of the utmost importance. The best local application is electricity. One pole of the galvanic current should be placed over the tender vertebrae, and the other at some other point. The current should be applied regularly once or tAvice a day, but not continued longer than from five to fifteen minutes at any one time. It is more especially indicated when neuralgic pains are present, which are generally quickly relieved by it. Other stimulating and rubefacient external applications are more or less serviceable, such as sponging with mustard and Avater, salt and water, Avhisky and Avater, etc.; also frictions along the spine with the flesh brush, hair gloves, or coarse crash towels. It would be manifestly impossible even to name, much more give the indications of all the remedies to be employed in the 308 NERVOUS DISEASES. treatment of so Protean a form of disease as spinal irritation. Their appropriateness can only be determined by a careful and systematic study of the case and of the Materia Aledica. The folio wins list embraces the names of most of the remedies Avhich haAre been recommended: Aconite, Agaricus, Atropine, Belladonna, Calcarea carb. and iod., Calcis hypophos., Chamomilla, China, Cimicifuga, Colocynth, Gelsemium, Hypericum, Nuja, Nux vom., lyhosphorus, Rhus tox., Santonine, Scutellaria, Secale cor., Sil- icea, Sulphur, Strychnia phos., Tarantula, Tellurium, Veratrum vir., Zincum met. Cimicifiuga.—This remedy is particularly indicated in cases arising from uterine disorders, especially Avhere there is much pain in the*dorso-lumbar region and head, Avith Aveakness of the lower extremities, worse at the menstrual period and on taking cold. Illus. 166.—Airs. B., set. 42, mother of six children, has suf- fered more or less from spinal irritation since a miscarriage, Avhich took place about eight years ago. Her greatest trouble is a severe aching pain in the lower part of the back and in the occiput, with occasional shooting pains in the chest, and great weakness, almost amounting to paralysis of the loAver extremi- ties. She is ahvays worse at and near the menstrual period and from cold. The pains are aggraA'ated by movement, and most of the time she is compelled to lie quiet upon the bed or lounge. She is ansemic, and her general health is quite poor. The spine is very sensitive to pressure in the dorso-lumbar re- gion, especially over the spinous processes of the tAvelfth dor- sal and first lumbar vertebrae. Prescribed Cimicifiuga lx dil., twenty drops in half a glass of water, a teaspoonful three times a day, and a warm lotion, consisting of the fluid extract of the same remedy and water, one part of the former to three of the latter, to be applied to the tender portion of the spine every morning and evening. This treatment Avas continued until the patient Avas able to keep on her feet the Avhole day without inconvenience, a period of about three Aveeks, Avhen she Avas sent to the seashore, where she remained the rest of the season, taking the baths and inhaling the sea breezes. She returned perfectly well, and has remained so up to the present time, now about three years.—Hart. SPINAL IRRITATION. 309 Strychnia phos.—Strychnia and phosphorus are tAvo of the most powerful remedies that avc have for the disease, and, as is Avell known, both of them are capable of producing spinal amemia and tenderness. AVhere other remedies fail to relieA'e, this double-headed remedy, as Dr. AVilde calls it, should be thought of. Illus. 167.—Aliss----, set. 24, has been complaining of ach- ing and Aveakness in the spine for the last four months. Dur- ing that time she has been under homoeopathic treatment, but Avith no appreciable benefit, and has been compelled to lie on a couch during the day, because Avalking, or even standing, aggravates the spinal pain so much. On examining the spine, it Avas found to be perfectly straight and free from curvature, but there was tenderness on pressure and percussion over the spinous processes of two of the middle dorsal vertebrae. The pain is sometimes burning in character, but chiefly aching, extending frequently to the front of the chest, causing a feel- ing of uneasiness and nausea. The catamenial flow is regular and lasts five days, the discharge being dark and often clotted. Leucorrhcea generally present in the intervals. The digestive organs are but little affected; some flatulent distention after food sometimes occurs, the tongue being moderately clean. The boAvels are regular, but the patient has suffered from ex- ternal hemorrhoids almost from a child. The hemorrhoids do not bleed, nor cause any pain. The patient sleeps very badly, and has difficulty in getting to sleep. She suffers from cold feet, Avhich are often covered Avith clammy perspiration, and also perspires in the hands and axillae. This Avas the condition of the patient Avhen I first saAV her, and she con- tinued to suffer, in a greater or less degree, from the above symptoms for two months, Avhilst under my care. During this time she took Agaricus, Arsenicum, Cimicifiuga, Gelsemium, Ignatia, Lachesis, Nux vom., Sepia, Sulphur. Some mild hydro- pathic treatment Avas also recommended, in the shape of spinal Avashes and sitz-baths, but, it being winter time, and the pa- tient evincing so little reactive power, this part of the curative treatment was postponed. As the result has proved, it was a postponement sine die. To enumerate all the medicines the 310 NERVOUS DISEASES. patient took during the four months before she came into my hands, would be but to specify a goodly proportion of our Materia Medica. All treatment having hitherto proved un- availing, the mother began to despair of her daughter's recov- ery, and the daughter herself began to Aveary of taking medi- cine. At this crisis I dreAv a bow at a venture, and prescribed Strychnia phos., 3x trit, a dose to be taken twice a day. This double-headed arrow (if I may so term it) fortunately hit the mark. Improvement began to shoAv itself in the ability of the patient to walk with less pain, and, after steadily taking this medicine for five weeks, she could go up and doAvn stairs, and take short walks out of doors with comparative ease. For six months the patient had been unable to eA7en Avalk across the room without increase of pain in the spine. AVith this ac- cession of locomotory power, the pain in the spine diminished, as did the other symptoms, with the exception of the hemor- rhoids. These, hoAvever, were present before the spinal irrita- tion set in. The last report I had of my patient Avas that she continued in good health.—Dr. F. G. S. Wilde. Tarantula.—This remedy is indicated Avhen the antero-late- ral tracts of the cord are implicated, as manifested by spas- modic pains, muscular contractions, clonic convulsions, trem- blings, general chilliness, etc. Illus. 168.—The characteristic symptoms of her case Avere: Excessive hypersesthesia; a slight touch along the spine pro- vokes spasmodic pains in the chest, and indescribable distress in the cardiac region; at times the heart feels as if tAvisted over; an intense pricking headache, as from thousands of needles; the body burned all over; headache better by rub- bing it against the pillow; she trembled so she could hardly talk. Cured by Tarantula200.—Dr. E. A. Farrington. AVe might multiply illustrations without number, but they AA-ould be of but little value, on account of the multiplicity and varying character of the symptoms. As said before, spinal irritation is a disease which above all others needs to be indi- vidualized with the greatest precision, both as respects the symptoms of the patient and of the remedy. This, of course, will .require study, but that study will often be reAvarcled by the most brilliant cures. HYSTERIA. 311 PART IV. DERANGEMENT OF THE MENTAL FUNCTION. SECTION I. MORAL DISORDERS. CHAPTER I. HYSTERIA. Hysteria, a term derived from a Greek word signifying "the womb," is used to denote a disease characterized by various mental disturbances and hallucinations, and often attended by functional derangements of the nervous system of the most diverse character. This definition is perhaps as good as any that can be given, and yet it falls far short of comprehending all the phenomena met with in the various types of the dis- ease. The fact is, there is not an abnormal sensation or per- version of function that may not at times be associated with this affection; nay, more, even physical changes of the most surprising character may be symptomatically connected Avith it. Thus, I was once called to treat a lady's knee, which had every appearance of being highly inflamed. It was greatly swollen, red, hot, and extremely sensitive to the touch. Ob- serving that it had been repeatedly cupped, during former at- tacks, I obtained a sufficient history of the case to prevent an error in diagnosis. This woman, the surface of whose body 312 NERVOUS DISEASES. contained, by actual count, no less than nine hundred and sixty scarificator scars, had been a victim of hysteria for more than tAventy years. During that time, the Avhole armamentarium of old school medicine and surgery had been tried upon her in vain; and no wonder, for her ailments were so numerous as to baffle all medical nomenclature even to name, including as they did the symptomatology of apoplexy, epilepsy, chorea, neuralgia, catalepsy, aphonia, laryngitis, pleurisy, asthma, phthisis, haemoptysis, dyspepsia, gastralgia, gastritis, diabetes, metritis, hysteralgia, spinal irritation, dropsy, heart disease, pregnancy, cancer, paralysis, and the d—1 knows what! At one moment she AArould apparently be at death's door, and at the next, nothing the matter could be discovered Avith her. So it was in this instance. Divining from her past history the true nature of the case, I prescribed Cocculus30, and at my next visit, six hours afterwards, she Avas well. Nature.—Schuetz, who refers the phenomena of hysteria chiefly to qualitative changes in the constitution of the blood, says: "In former times, all manifestations standing in con- nection with morbid states, disturbances or irritation of the uterine system, Avere denoted by the same general name of hysterical states, Avithout making any very exact examination of the uterus and its adnexa; it was considered characteristic of hysteria, that it had no characteristic symptom, and that it may manifest itself in so many diverse Avays, and the uterus must be somehoAv complicated Avith it. But now-a-days a strict examination of every organ is required, and avc must find out Avhether Ave have to do Avith a primary diseased state of a cer- tain organ, and whether all the other organs are relatively sound, or whether the morbid symptoms have to be ascribed to other factors." That the disorder of the nervous system to which the name hysteria is generally applied, is a disease of the mind; that "it is born in the imagination, and nurtured by fancies Avhich grow morbid from a low state of the nervous system, and, sud- denly becoming master of the situation, assumes its realm upon the lightest pretext, and holds high carnival with the motors and affections," is a fact so universally recognized at the present HYSTERIA. 313 time, that feAV e\'en of the best informed are Avilling to have the term hysteria applied to their ailments. So sensitive are the majority on this subject, that Dr. C. F. Taylor has invented the Avord carnomania—insanity of the flesh—to designate those cases in Avhich, he says, the symptoms are real, and not im- aginary. This, hoAvever, Ave think is altogether unnecessary, so far as accuracy is concerned. The symptoms in all cases are real, but the conditions generally denoted by them are not. AVhen a patient presenting hysteriform symptoms, exhibits diseased conditions corresponding to the symptoms, then the malady can no longer be regarded as hysteria, but the actual disease, Avhate\'er it may be, represented by the symptoms. Hence the significance of Schuetz's remark, that "hysteria and hypochondriasis disappear from the text-books of our age, and live only in the memory of the laity and old-fogy practitioners." That hysteria depends entirely on morbid conditions of the imagination, and should be treated as such, is, Ave think, clearly shown by such cases as the following: Illus. 169.—A lady Avho refused to consult Avith us until a promise Avas made that Ave Avould implicitly belieA'e Avhat she said, affirmed that there Avas something in her which looked exactly like the yolk of an egg; and so long as it stayed in the region of her liA'er or stomach, she didn't mind it, but that ' sometimes it Avorked up to the throat, Avhich nearly choked her; and at other times wended its way up to the right or left shoulder, where it caused so much pain, that she was obliged to call aid to rub it back to its kennel. She Avas so sure of the reality of this, that she Avas Avilling to declare under oath that it "pushed the skin out," and that she had often moved it with her hand. A few closes of Ignatia cured her permanently, and not for a month did Ave assure her that her egg-yolk was a myth.—Dr. A. K----. Illus. 170.—An unmarried lady, with perfect generative organs, was subject to severe convulsions, sometimes crying, sometimes laughing, and closing with spasmodic muscular contractions. Medicine seemed valueless, and finally a teaspoonful of pepper was ordered for the next attack, with the assurance that she would have a remedy-indeed. AVhen the accepted time ar- 20 314 NERVOUS DISEASES. rived, an attendant administered the dose—the fire and anger produced by this peculiar method of appropriating condiments, proved effectual. She had but one more light attack, which the sight of the cruet cut short.—Idem. Illus. 171.—A widow lady, Avho had suffered with this dire disease for some years, in connection with prolapsus, Avas suddenly left impecunious. AVhen she learned that her relatives would not allow her to visit their homes on account of her fits, they almost immediately left her, and her trouble Avas there- after limited to the prolapsus.—Idem, Illus. 172.—The patient was a young lady Avho came to the doctor from Rhode Island for treatment. She had been in bed for months. The medical experience of her oavu state had been exhausted. Dr. AV. A. Hammond advised a longer con- tinuance in bed. Dr. Mitchell made three visits before he began treatment. The peculiarities of the case Avere spinal weakness and an inability to straighten the loAver extremities. At his fourth visit the doctor requested his patient to straighten her limbs. "But I can't." "But you can. Are they never straightened at night?" "Yes, Doctor. No one ever asked me that question before." The legs were straightened Avith but little difficulty. "Now, be kind enough to sit up." "But that is impossible; I have not been able to do it for tAvo years." " You are able now. Please sit up." Patient sat up. "Bring her Avrapper, hose and slippers and put them on; put on a necktie; belt her waist. Now I Avish you to stand." The patient now began to cry. "Good morning," said the doctor, taking his hat. "AVhere are you going, Doctor?" "I am going aAvay. I never attend patients who do not obey me." "Come back, Doctor; I will obey you." "Then please stand up." She stood up. "But, Doctor, it makes me so dizzy." "I expected it; take my arm." She took his arm. He led her slowly out of the room, down stairs and out of doors. She returned without aid, and did not go to bed again. She Avas cured. This is given as a sample of Dr. AVeir Mitchell's method of treating hysteria. He is never unkind, never rough, but inflexible, quick in manner, decided in speech, yet gentle and exceedingly polite.—Boston Med. and Surg. Jour. HYSTERIA. 315 Symptoms.—AA7e shall not attempt to give all, or even the greater part, of the so-called symptoms of hysteria; as it is only necessary to bear in mind that the disease simulates almost every known affection. There are a fe\v characteristic symp- toms and conditions, the existence of which should lead us, in the absence of any discoverable lesions, to suspect the existence of this disease. Of this character are those constituting what is called the hysteric fit. This frequently sets in by the patient screaming out, or making an unintelligible noise with her mouth, and then falling to the ground in an apparently un- conscious state; the trunk and limbs then become strongly convulsed. " The head," says AVatson, " is generally thrown backAvards, and the throat projects; the face is flushed; the eyelids are closed and tremulous; the nostrils distended; the jaAvs often firmly shut; but tliere is no distortion of the counte- nance. If the hands are left at liberty, she will often strike her breast repeatedly and quickly, or carry her fingers to her throat, as if to remove some oppression tliere; or she will sometimes tear her hair, or rend her clothes, or attempt to bite those about her. After a short time, this violent agitation is calmed; but the patient lies panting, and trembling, and starting at the slightest noise or the gentlest touch; or some- times she remains motionless during the remission, with a fixed eye, till all at once the convulsive movements are re- neAved; and this alternation of spasm and quiet will go On for a space of time that varies considerably in different cases; and the Avhole attack frequently terminates in an explosion of tears, and sobs, and convulsive laughter." During the parox- ysm, the patient complains of a peculiar sensation knoA\7n as the globus hystericus. It is usually described as a ball rolling about in the abdomen, then rising to the region of the stomach, and aftenvards to the throat, Avhere she feels as though she Avas choked. The patient is troubled more or less Avith bor- borrygmi and flatulency; and towards the close of the fit, or soon after it is over, she generally passes a large quantity of pale limpid urine. In most cases the fit resembles epilepsy, but differs from it, according to Marshall Hall, chiefly in the larynx never being entirely closed, while in epilepsy it is 316 NERVOUS DISEASES. closed. This explains how it is, that in the former the respi- ration is heaving and sighing, Avhile in the latter the patient makes violent, but ineffectual efforts to respire. The mental symptoms, however, are the ones Avhich are usually the most characteristic. If Ave observe the general de- meanor of the patient, Ave shall find her to be fitful and capri- cious. She is alive to every trivial impression, and commonly has a thousand notions, the most absurd or trifling of which she defends with the obstinacy and seriousness of the most important. The opposition Avhich such views are apt to en- counter from her friends, renders her extremely sensitive and suspicious, and finally ends in leaving her a prey to melan- choly and depression of spirits. At the same time, perhaps, she exhibits an artificial cheerfulness in striking contrast to her real feelings, and Avhich is well calculated to deceive the most penetrating observer. Such is a picture of the mental condition of some of the lower grades of hysteria; in the higher degrees the mental derangement is more marked. The de- pression may be so great as to seriously threaten the sanity of the patient; Avhile in most cases the temper is extremely irri- table, and in some cases violent. At the same time, strange as it may appear, the Avill-power is often quite lost, as Ave have seen in Illus. 172. It is, hoAvever, capable of being excited, and to such an extent as to arrest the paroxysm. As a general rule, it is only necessary to anger the patient, to accomplish in a moment what no amount of medicine could effect. Notwith- standing the deficiency of the Avill-power, the general Aveakness of the nervous system renders the patient hypersensitive. She complains of a thousand unpleasant sensations and impres- sions, both internal and external, Avhich a healthy individual would not notice; and these impressions are often the opposite of what others experience. Agreeable odors are to her re- pulsive, and repulsive ones are agreeable. The appetite and taste are so perverted, that she not unfrequently selects the most unsuitable, and even the most unpalatable articles of food for her diet. Her likes and dislikes, of every kind, are equally unreasonable and unaccountable. Her best friends she often regards as her Avorst enemies. Sometimes she seems HYSTERIA. 317 insensible to pain, thrusting needles into her flesh, or endeav- oring to excite attention and sympathy in some other equally strange Avay. In short, so far as the phenomena of hysteria are concerned, although they vary in. every conceivable man- ner, the whole may be summed up in the one phrase, perversion of function. Diagnosis.—A disease that simulates at times almost every knoAvn malady, is of course very liable to be mistaken for some other affection. Dr. Buck mentions three cases which came under his notice in a single year, Avhich had been treated for congesth'e chills and heart disease, Avhich Avere found, on care- ful investigation, to be simply hysteria. I Avas once called in consultation to a case of hysterical coma, which the family physician pronounced to be apoplexy. The patient had fallen in Avhat appeared to be an apoplectic fit, and Avhen I saw her she Avas unconscious, Avith stertorous breathing and insensi- bility. I Avas satisfied the case Avas one of simple hysteria, first, because the patient Avas a buxom German girl of eighteen; 2d, because there Avas no paralysis; and, 3d, because she had a few hours before, when exhausted and over-heated' by Avashing, hung out the clothes in her bare feet, Avhen the ground was covered with snoAV. I recommended cold to the head, Avarmth to the feet, the interrupted current to the uterus per vagina, and hot fomentations to the hypogastric region. The next day the menses appeared, relieving her at once of all her unfavor- able symptoms. The superficiality, so to speak, of the symptoms, is often suf- ficient of itself to establish a correct diagnosis; but if not, then the physician owes it to himself, as well as to his patient, to make a thorough examination, and so, by the principle of ex- clusion, determine the real nature of the disease. The follow- ing instance shows, not only the necessity of adopting this plan in all doubtful cases, but how careful physicians ought to be not to destroy a life's happiness by a wrong diagnosis, and a mischievous prognosis founded upon it. Illus. 173.—A young lady, set. 20, engaged to be married, suf- fered from hysterical fits, and, in shorter or longer intervals, from hemoptce. The most celebrated physicians of Naples pre- 318 NERVOUS DISEASES. scribed the usual remedies without any benefit, and therefore advised the breaking off of the engagement. I could only find in the right apex slight rattling murmurs, but all other mani- festations of tuberculosis were wanting, and therefore advised marriage as the best, the only remedy necessary for a cure. As heredity was impossible in this case, and as there never were any febrile symptoms during the hemoptce, and during every interval physical examination proved an entire absence of any chest disease, and as other hysterical symptoms were present, I considered the hemoptce a mere vasomotery disturbance, and urged matrimony. My advice was followed, pregnancy followed soon, and the young mother now enjoys the very best of health. In another case, a regular blue-stocking of a wo- man was attacked with hysteric hemoptce, and here also phy- sical examination revealed a total absence of any tuberculous infiltration. She also married, and that was the last of her hemoptce.—Dr. Franco. Causes.—The fact that hysteria is almost exclusively con- fined to the female sex, and that it occurs only during adult life, shows that it is very closely related to the sexual sphere of woman, and hence it is not at all strange that it should have received the name by which it is generally known. Alore- over, as Ave have already stated in a previous chapter, Dr. Chairon has been able, by compressing the ovaries, to so ex- cite the reflex sympathies of the epiglottis and of the larynx, as to produce the globus hystericus, dysphagia, etc., which per- tain to fits of hysteria. These facts, however, only serve to shoAv the reflex excitability of the nervous system, and the controlling influence which the uterine organs and functions are capable of exerting upon it. Says Dr. Reynolds:* "The hysteric state is essentially one of mental perturbation, and it is brought into existence, if not inherited, by those conditions which are most active in producing disorder of the mind—in the male sex by worry, anxiety, overwork, late hours, acci- dental injuries, and dissipation; in the female sex by vexa- tious emotions, want of sympathy or success, fever, and mor- * Sys. of Med. vol ii., p. 98. HYSTERIA. 319 bid conditions, or supposed morbid conditions, of the reproduc- tive system." Such are some of the exciting causes, but the chief predisposing cause is debility. AVhen the blood is im- poverished, or defective in either quality or quantity, the nerve- centres are in a favorable state for its production, for at such a time any irritation, even the most trivial, may excite the re- flex phenomena characteristic of the disease. Hence it is that woman, Avhose organization is not only more delicate than that of man, but Avhose nervous system is constantly exposed to derangement by uterine disorders, is much more liable to the disease than her male companion. Other causes of the disease are faulty education and modes of life, and all agencies tending to produce debility, such as loss of vital fluids, defi- cient nourishment, impure air, etc. Prognosis.—If the disease be of long standing, the prog- nosis, so far as a radical cure is concerned, is very unfavorable. If, however, it can be clearly traced to poverty or paucity of blood, and there are no established habits to be overcome, the chances of cure are much better. If the patient is young, in good health otherwise, and the mental symptoms predominate, the physician may reasonably hope, by the timely exercise of his own will and firmness, to so excite and sustain the will- power of his patient, as to be able to effect a speedy and lasting cure; but if, on the contrary, his patient is somewhat adA'anced in life, and has suffered from a long continuance of the disease, and especially if there are pernicious habits and mental and moral obliquity to contend with, his task is well nigh as difficult as was that of cleansing the Augean stables. However, as the following cases will show, some of the most unpromising- cases of hysteria have yielded to suitable hygienic treatment and the homoeopathic remedy. Treatment.—If there is any disease that calls for a stricter' individualization, and a closer study of the Alateria Aledica, than others, that disease is hysteria. Instead, therefore, of giving a long list of remedies, not one of which, perhaps, would be appropriate to the case in hand, we shall simply present a few of the most noted and reliable of them by way of illustration. 320 NERVOUS DISEASES. Anacardium.—AVhere the mental symptoms predominate; also Avhen there is pain in the stomach or about the heart. Illus. 174.—Airs. V., pregnant, primipara; had morning sick- ness; relieved Avhile eating and for some time after eating; subject to a form of hysteria, in Avhich there was pain and disturbance about the heart—cardialgia. All relieved by Anacardium200.—Dr. II. Noah Martin. Belladonna.—Belladonna is indicated in cases where the paroxysms occur at the menstrual period, Avhich is painful, and attended with severe frontal headache; aggravated by motion, noise and light. Illus. 175.—Miss G, set. 16, nervo-sanguine temperament, light brown hair, blue eyes. For four months she has had violent attacks of hysteria at the menstrual period, requiring the care of several persons to keep her in bed and from injuring herself. Has been treated allopathically Avithout benefit. Alenses scanty and painful; sensitiveness, Avith feeling of fulness and pain through the hypogastrium, Avhen going up or cIoavii stairs. Disturbed sleep, melancholy, and aversion to seeing any one, with hypersesthesia of all the organs of special sense. Frequent headache, with pressing pain in the forehead over the eyes, and inability to keep the eyes open in strong light. Symptoms ameliorated by darkening the room. Bella- donna30 every three hours. Fi\7e days afterwards, much better; eight days after, well. Alenses returned at the next period Avith but little pain and no hysteria.—Dr. 31 II. Slosson. Gelsemium.—This is an admirable remedy for acute cases of pure hysteria, especially when resulting from, or connected with, a sudden stoppage of the menses from cold or fright, or when occurring in highly sensitive organizations. Illus. 176.—Airs. L., set. 22, married three months; is a deli- cate, fair haired blonde. Has suffered occasionally from dysmenorrhcea, generally the result of cold, accompanied by violent attacks of hysteria. For two hours she has, with short intervals of quiet, been strongly convulsed, requiring two persons to hold her in bed, and passing off Avith alternate paroxysms of laughing and crying. Has passed an enormous quantity of pale lemon-colored urine. lias been forced by HYSTERIA. 321 her old-school nurse to take large quantities of nauseous teas, but Avithout the least benefit, greatly to the surprise and disgust of the nurse. I prescribed Gelsemium, lx dil., in water, every fifteen minutes, until relieved. After taking six doses she Avent to sleep, and aAvoke two hours afterwards sound and in her right mind.—Dr. Samuel Pritchard. Ignatia.—This remedy is regarded by many as a specific for all forms of hysteria. It is specially indicated AA7hen there is a hysterical predisposition, or Avhere the attack is caused by fright; and also Avhere there is a predominance of the mental symptoms. Illus. 177.—Airs.----, set. 20, has had good health hitherto, Avith the exception of some hysterical manifestations; has never had a child, but is pregnant. I found her in bed Avith labor pains Avhich had existed for several hours; some hemor- rhage; the day before had been frightened by a rat jumping into her lap; afterwards trembling. I Avas struck by the posi- tion in Avhich she laid; she Avas lying on her back Avithout a pilloAV, and the lower end of the mattress elevated. On in- quiring her reasons for her strange position, she said that her pains AA7ere better in that position. Taking her hysterical pre- disposition in consideration, and her fright followed by trem- bling, I gave her Ignatia30 in Avater. After three hours I re- turned, found her lying in bed with a_ pillow under her head. The pains had ceased almost instantly; the hemorrhage Avas also controlled. She has done avcII.—Dr. A. McNeil. Illus. 178.—Aliss Alary S., set. 2o, complexion dark. AAras called to this lady at midnight. On entering the parlor, I found her on the floor, Avhere four attendants were in the act of holding her, to prevent the infliction of personal injury to herself. The sudden approach of the attack, and the frequency of the paroxysms, had prevented the removal to her sleeping apartment. I was informed that twelve convulsions had fol- lowed in quick succession, for the preceding three hours, con- sciousness not having returned between the spasms. Between the clenched teeth I forced a dose of a water mixture of Igna- tia30, when relaxation immediately followed, and a moment later, a request to be permitted to rise from the floor, and soon 322 NERVOUS DISEASES. after she retired to her room. But a few more doses of the remedy, the patient sleeping the greater part of the night, hav- ing no recurrence of the convulsions.—Dr. G. B. Cornell. Lachesis.—Hypersensitiveness and extreme irritabiltiy of the nervous system; trembling; great depression of spirits; bodily Aveakness and languor; aggravation by harsh Avords, excite- ment and sleep. Illus. 179.—Airs. H., set. about 23, nursing her second child, having been under allopathic treatment for some months Avith- out benefit, called on me for help. Secretion and excretion were normal; appetite good. But she complained of being nervous, aching all over Avith hysterical spells of trembling; inability to move, work, or sleep, with very dark forebodings of the future. Any news, or excitement, or harsh Avord, aggra- vated her troubles. I ordered her to wean the child and have no intercourse Avith her husband. Gave Belladonna, Ignatia and some other medicines without permanent benefit. I now got another symptom—occasional aggravation, not always, after sleep. I gave Lachesis2m mornings and nights. She made a rapid reco\7ery on the last prescription, and remains Avell, now two months.—Dr. Bahrenburg. Lycopodium.—Tonic muscular contractions, or cramp-like pains in the limbs, with extreme Aveakness and tremor; epi- leptiform convulsions, Avith weeping mood; pain in the urethra, with scanty urine. Illus. 180.—A lady suffering from an attack of hysteria, had a severe spasm of opisthotonus, causing some anxiety, until I learned that her urination Avas very scanty—none at all, in fact, for hours; during the paroxysms, she shut her teeth very tightly together, grinding them every now and then. The spasms remained entirely tonic. Lycopodium stopped the spasms all day. After a slight one at night, four doses of Opium were given, and Lycopodium resumed. No more spasms.—--Dr. G. E. Shipman. Tarantula.—The indications for this remedy are the multi- form and ever shifting character of the symptoms. The ner- vous system is in the highest possible state of excitement, one group of symptoms giving place to another in rapid succes- sion. HYSTERIA. 323 Illus. 181.—The attacks commenced by spells of yawning and irregular breathing; these were followed by muscular contrac- tions of every sort; fixed look, lasting for several minutes, fol- lowed by Avild shrieks, and this folloAved by continued coma; the Avhole scene varied, from time to time, by hysterical par- oxysms of laughing and crying. I have never witnessed more astounding and complicated hysterical phenomena in my life. Epilepsy, catalepsy, chorea, tetanus, hydrophobia, apoplexy, ecstacy, somnambulism, spinal irritation, and ordinary hys- teria all seemed to lnwe a hand in producing the constantly shifting panorama of symptoms. The patient, Avho at the end of a month's treatment was Avorse instead of better, Avas cured in two days by Tarantula200.—Dr. W. H. Holcombe. 324 NERVOUS DISEASES. . CHAPTER II. HYPOCHONDRIASIS. Hypochondriasis—so called from its supposed relation to the hypochondriac regions—is a disease of the mental sphere, characterized by a peculiar form of hallucination, which causes the patient to believe that he is suffering from certain organic diseases when he is not. It bears a similar relation to the male sex that hysteria does to the female, there being no disorder of the intellect, nor any physical changes sufficient to account for the sufferings of which the patient complains. Symptoms.—This disease, like hysteria, presents itself under such a variety of forms, that it Avould be next to impossible to so arrange the symptoms as to correctly represent any consid- erable number of cases. AVe shall therefore give the first place to the mental symptoms, as being not only the most important, but the only ones that can be considered characteristic. The patient's mind is, to a greater or less extent, ahvays engrossed by false impressions concerning the state of his OAvn health. He dAvells upon sensations Avhich in many cases may be real, and proceed from actual alterations of structure or function, but they are so exalted and misinterpreted as to convey wrong and exaggerated impressions. In the majority of cases, Iioav- ever, there are no changes present, except such as are pro- duced by the abnormal mental condition of the patient; but the mind is so attentively fixed upon the state of the system, that natural sensations attract attention, and become so inten- sified by being dAvelt upon, that they come to be regarded as morbid, and at last the unhappy individual makes himself truly wretched by giving a loose rein to his Aveak and disor- HYPOCHONDRIASIS. 32.5 dered fancy. He noAV becomes greatly depressed in spirit, is easily discouraged, ahvays gloomy, and frequently in ill-hu- mor. His sensations, Avhich before were natural or but slightly exalted, are now morbid, and are interpreted by him as some serious disease, which is constantly assuming a neAv form. He enlightens himself after his OAvn fashion by hunting up cases similar to his OAvn, and becomes so A'ersed in medical lore, that he knows much more about his disease than his physician or any one else; making him impatient of contradiction, taci- turn, full of distrust, melancholy, lazy and miserable. At the same time, he neA7er despairs of being cured, having strong faith in treatment, Avhich makes him a plague to his medical attendant. He is ahvays discovering neAv symptoms, the re- sult of functional disturbances arising from the progress of his complaint, Avhich at first Avas a form of pseudo-dyspepsia, giv- ing rise to more or less flatulence, irregular appetite, coated tongue, offensive breath, and, in some cases, to heartburn and constipation. After a time, other organs become functionally disturbed. The lh7er becomes torpid, or fails to act, and diarr- hoea folloAA'S. The system becomes still more disturbed ; there is palpitation of the heart, frequent flushes of heat, rush of blood to the head, vertigo, chilliness, syncope. Any or all of these symptoms may belong to a particular case, and these are generally increased by the constant drugging and physicing which the patient delights to undergo. The irritation and disturbance set up by these processes, together Avith the anxiety and torment caused by the patient's mental condition, sooner or later produce marked impairment of the digestive and as- similative functions, and that which began as a mental dis- order, is at last complicated with organic lesions of greater or less significance. Causes —Heredity is an important factor in many cases of hypochondriasis. The disease is often met with in individu- als, the near or remote ancestors of whom exhibit traces of in- sanity, epilepsy, or some other seA'ere nervous disorder. The disease occurs chiefly during middle life, and among those Avho are harrassed by anxiety, in consequence of losses, or fail- ure to provide for dependent relatives; or else among those 326 NERVOUS DISEASES. who, reared in affluence and indolence, are not only sufferers from chronic ennui, but from a consciousness that life is to them a failure. To these causes may be added such agencies as tend to Aveaken and impair the integrity of the nervous sys- tem, such as severe mental shocks, late hours, dissipation, gas- tric disturbances, sexual excesses, onanism, syphilis, long-con- tinued ill-health, etc. AVhile these are the ordinary causes of hypochondriasis, it should not be forgotten that organic dis- eases of the stomach and liver are apt to give rise to similar symptoms, and therefore such symptoms should in every case be carefully examined into and weighed. Prognosis.—The prognosis is favorable in all cases where the patient's habits and mode of life can be changed for the better. Owing, however, to the fickle disposition of the pa- tient, it is not always easy to enforce the necessary regulations, and where this is the case, a successful termination cannot be safely predicted. The same is true Avhere the assimilative func- tions have become greatly impaired, especially if onanism or sexual excesses are at the bottom of the trouble. It is rarely the case, however, that the disease gains such headway as to endanger the citadel of life. Treatment.—To minister successfully to a mind diseased often requires moral, rather than medical treatment; and in no case can such treatment be safely neglected. In fact, the administration of medicines, however needful and salutary they may be in themselves, may so encourage the hypo- chondriac in his false belief, as to do more harm than good. The chief aim, therefore, should be, to impart vigor of body and cheerfulness of spirit to the patient, and this may often be best effected by such healthful physical exercises as, while they help digestion and divert the mind of the patient from his oavii troubles, will furnish an adequate motive for his ex- ertions, and produce little or no fatigue. Sometimes this may be done by engaging the hypochondriac in Avorks of bene- volence and charity, such as require the personal attention and attendance of the patient. In other cases, some profitable and healthful employment, by improving the pecuniary cir- cumstances of the patient, Avill most contribute to his recovery. HYPOCHONDRIASIS. 327 A third class, enfeebled by a life of seclusion, but naturally fond of sport, may need a course of out-door exercises, such as gardening, horse-back riding, etc. In short, the physician should take into consideration all the circumstances and con- ditions of the patient, and prescribe accordingly. Having done what he can to promote the general welfare of his pa- tient, he should next make a careful study of the symptoms, with the view of prescribing such medicines as the disordered functions require. These he will be likely to find in the follow- ing list: Anacardium, Arsenicum, Asafcetida, Aurum, Calcarea, Cannabis ind., China, Cimicifuga, Conium, Ignatia, Mercurius, Nutrum mur., JSux vom., Petroleum, Pledina, Pulsatilla, Sepia, Stannum, Staphysagria, Sulphur. Asafidida.—Hypochondriasis attended with flatulence, tor- por of the liver, indigestion, constipation, loose cough and great depression of spirits. Ulus. 182.—T. S., a man, ret. about 45, Avho had run through a large fortune by early dissipation, and who had an interest- ing family, consisting of a Avife and four children, had for twelve years suffered from hypochondriasis and the abuse of medicine. I knew something of the history of his case pre- vious to his applying to me for treatment, as it had been a standing subject of conversation among the medical fraternity for a long period. The principal symptoms were: great de- pression of spirits, flatulence, torpid action of the stomach and liver, constipation. The patient had convinced himself that his internal organs, to use his OAvn language, "were sloAvly undergoing liquifaction." Upon this subject he Avas quite fluent, supporting his views by a number of ingenious argu- ments. But when I questioned him closely as to his symp- toms, he was averse to answering. AA^ishing to sound his mental condition more fully by throwing him off his guard, I told him I did not think there was anything the matter with him. "Nothing the matter!" said he; "look here." And suiting the action to the AA7orcls, he thrust his fist under his left false ribs, producing a swashing sound, loud enough to be heard across the street. "Nothing the matter; I should think not!" And with the rapidity of a churn-dasher, he continued 328 NERVOUS DISEASES. to ply his neAv A7ocation Avith an energy which a Heenan might have envied. The sounds thus produced Avere a series of ex- plosions, somewhat resembling the rapid beating of Avaves upon the shore. I attempted to explain to him hoAv the sounds Avere produced, but he only replied by a more vigorous demonstration of his fist upon the mixture of wind and Avater, as if to revenge himself on his tormentor, and prove to me that I had made a false diagnosis. Seeing that he Avas fully convinced of the truth of his theory, I deemed it best to humor the conceit, and prescribed two-grain sugar-coated pills of Asafcetida, three times a day. This prescription was steadily adhered to for about two weeks, Avhen the quantity had to be reduced on account of diarrhoea. He was now ordered to take the medicine only once a day, in the morning. Under this treatment, in connection with suitable out-door exercise, he made a good recovery, and is now a healthy and successful business man.—Hart. Aurum.—This remedy is best suited to male subjects, espe- cially such as have a loathing of life, or a suicidal tendency; they are extremely melancholy, fearful, taciturn and sullen. Its sphere also embraces religious melancholy, with vertigo, anaemia and vascular and nervous depression. Illus. 183.—In the spring of 1868, Air. G., set. 21, Avas married. In June his mother came to me and said she believed G. Avas becoming deranged. She Avas greatly alarmed about him, and said he had not appeared natural for some time, even before he Avas married; but she had thought it Avas from contemplating marriage, and leaving home, and going into business for himself. He Avas nervous, restless, sometimes cheerful, but more often excitable, angry and passionate Avith- out cause. He was naturally mild, gentle and cheerful. Pie could not set himself to work, could not attend to his business, could do nothing satisfactory if he tried to do it, He Avas taken home to his parents and I visited him there. In a long conversation with him alone, I gradually drew from him a confession; the idea possessed him that his case Avas hopeless, that he was himself the cause of all his troubles (self-pollution), and that he should never be any better until, as he said, "my HYPOCHONDRIASIS. 329 blood flows." I gave him Nux; but he grew worse, more excitable and passionate, sleepless and uneasy; disliked to see anybody; would hide if he saw any one coining. One day his mother saw him in the pantry with the butcher knife, feeling its edge. She courageously demanded the knife, and he reluc- tantly gave it up; was very angry. He then went for his father's razor, but she managed to get hold of it first; foiled again, he was terribly angry, and threatened all sorts of things. At this time I made another visit, and learning these facts, I gave him Aurum 6x trit. He had to be Avatched continuously. In a feAV days he became more quiet, not so excitable, slept better, improved every way, and rapidly. He soon lost all desire for suicide. In six weeks he was well, and returned to his business.—Dr. J. L. Gage. Cannabis Ltd.—Strange illusions concerning one's health; great depression of spirits, amounting to despair, with appre- hension of approaching death; constantly studying his own symptoms, and theorizing about them; religious melancholy; depraved appetite, Avith pain in the stomach, flatulency, and cold extremities. Illus. 184.—H. R. M., set. 51, married, has led an idle but not vicious life. About seven years ago he became deeply religious, since Avhich time he has exhibited a state of religious melan- choly; his former life of idleness so works upon his conscience, as to excite in his mind constant apprehensions of speedy death. He is also a prey to morbid fancies concerning his health. He is troubled with flatulence, coldness, alternating with flushes of heat, vertigo, ravenous appetite, and great uneasiness in his stomach. He imagines that there is a tumor growing in his stomach, and no amount of argument Avill convince him to the contrary. About four months ago, a violent storm devastated a farm belonging to his Avife, demol- ishing the barn, and destroying the trees, fences and crops, and causing a loss of several hundred dollars. Since the storm his disease has made sad haA7oc Avith both his mind and body. He is noAV convinced that Providence is against him, and that he will soon be called to answer for an idle and misspent life. He sits in his room Avringing his hands and brooding over his 21 330 NERVOUS DISEASES. coming fate. He has grown very thin, trembles at every word that is spoken in is hearing, and suffers at irregular periods Avith nervous paroxysms, attended Avith chilliness and cramps in his stomach. For several months his bowels have been obstinately constipated. Ordered that he should be taken out to ride daily, whether he wanted to go or not; and prescribed Cannabis Ind3x, a powder every three hours until better, then less and less frequently, p. r. n. This treatment Avas continued during the entire summer, Avith the effect of restoring him to his right mind, and to a fair degree of health. He afterwards visited Rome, with apparent benefit to both his moral and physical condition, and now, tAA7o years afterwards, is in the enjoyment of a remarkable degree of activity and vigor.—Dr. B. Stiga. Nux Vom.—This remedy, according to Bsehr, "holds the first rank among anti-hypochondriac medicines. It corre- sponds most completely to all the symptoms of the digestive apparatus, to their appearance after a meal, to the disposition to gaseous flatulence and to constipation. Other circumstances of great moment are: the origin of the hypochondria from sed- entary habit, deficient exercise Avith rich living and excessive mental etertions; use of stimulants in order to keep aAvake at night; moreover, the excitability of the temper Avhich enduces an ebulition of anger from the least provocation; continual cloudiness of the head, with more or less prominent signs of cerebral congestion, more particularly in the case of patients who are fond of wine and good eating." Its special sphere is material hypochondria. Staunum.—AVe give below Hartmann's estimate of this rem- edy: "Stannum frequently has a marvellous effect in vari- ous spasmodic hypochondriac ailments, which mostly origi- nate in the ganglionic system. By Avalking about the patient is greatly relieved, whereas his distress returns again in a state of rest, which he would like very much to indulge in, owing to his feeling continually weak and weary, both mentally and physically; this makes him sad and melancholy, and he often feels so discouraged that he could almost weep. If with these symptoms are associated a stupefying, pressing distress in the HYPOCHONDRIASIS. 331 brain, as if the skull were in a vice, or other abnormal sensa- tions in the brain, illusions of hearing, distress in the stomach, Avith regular appetite, feeling of emptiness in the abdomen, constipation, exhausting night sweats, etc., the patient feels in the highest degree miserable, and by exaggerating his ail- ments, renders life disagreeable to those around him. It is to this kind of hypochondria that Stan nam will be found to cor- respond, and Avhere it will ahvays be found effective." Staphysagria.—This remedy, according to Berjeau, may be employed Avhen there is hypochondria resulting from mastur- bation, " Avith great taciturnity, constant uneasiness as to the state of one's health; anxious imagination; imaginary fears; queer notions, that expose the patient to the suspicion of be- ing thought crazy; great deficiency of animal heat, and ten- dency to take cold; or when the memory is Aveak and con- fused, and there is giddiness and sleepiness; the eyes are deep sunken, red and lustreless; the hair falls off; there is gnawing toothache, and caries of the teeth, Avhich are very brittle; a dry cough, aggravated frequently after eating, and indigestion at- tended with great flatulence, the stools being dry and lumpy. The urine is of a deep red or yellow color, Avith brick dust sedi- ment; there is continual loss of prostatic fluid, and the sexual desire is impaired; the penis is relaxed with dull and contu- sive pain in the testicles." This remedy takes high rank in all cases of hypochondriasis attended Avith seminal emissions, weakness of the lower extremities, and great prostration of mind and body, the result of having led a dissolute life. 332 NERVOUS DISEASES. CHAPTER III. MELANCHOLIA. Melancholia may be defined to be a form of mental disorder, characterized by excessive gloom, despondency and apprehen- sion. There is little or no disorder of the intellect, but the emotion is disproportioned to the cause, and often associated with a suicidal tendency. The disease is not peculiar to either sex, as in hysteria or hypochondriasis, but is common to both sexes, and to all ages abo\7e infancy. Symptoms.—In the young, the disease is apt to assume the form of hypochondriasis. The subjects of it cherish certain impressions concerning their personal or physical appearance and condition, until it renders them morbidly sensitive- and unhappy. They concentrate their thoughts upon themselves, until they come to believe that they are wanting in health or comliness, or that they are laboring under some fatal dis- ease, that is slowly but surely sapping the fountain of life, and that death Avill soon overtake them. This form of melancholy has already been described under the head of hypochondriasis (q. v.). In middle life, the patient, whether poor or rich, is often haunted by a dread of poverty and want. He feels weak and unable to cope v\7ith the Avorld, or Avith the circumstances in which he is placed, and so yields to depression and gloom. He is a moral coAvard, unable to take care of himself, being de- spondent, taciturn, fearful, Avithout confidence in himself, una- ble to extricate himself from fancied debts and obligations, ac- cusing himself of peculations, tormented by self-accusations, depressed by grief, and sometimes so overcome by his morbid views of life, and of his business and social relations, as to be MELANCHOLIA. QOO OOO driven by a sudden impulse to suicide, or other violent con- duct. In this condition the mind is AA'edded to its avoc; neither reason nor consolation is acceptable, and sympathy is often A'iolently rejected. As old age approaches, the disease, though met with at every period of life, is more apt to assume the form of religious melancholy. The -patient is overcome by remorse and anxiety, often wringing his hands in despair, and sobbing in the greatest distress, Avithout any apparent cause. In other cases there is a settled state of apathy and gloom, the continuance of Avhich is almost certain, sooner or later, to end in a more intense degree of mental alienation, if not in acute mania. Illus. 185.—A mechanic, set. 50, came into my office and gave the folloAving narrative: About fifteen years ago he had a fit of the blues, caused by false insinuations. His Avife is a monthly nurse, and thus frequently from home. A neighbor remarked that it Avould be better for a woman to take care of her oavh household than to labor for others. From that moment he imagined that he lost the love of his wife, became gloomy and desponding. Two years ago he remained at home, while his Avife attended to her duties and the children Avere gone. He went to church after a Avhile, heard mass, but not feeling well, Avent home and to bed. At 3 p.m., feeling better, he dressed, took a Avalk, played nine-pins with some friends, and drank some wine, after which he felt like being intoxicated, and had to be brought home. His Avife prepared the family supper. Suddenly he Avas attacked by mania, broke and de- stroyed everything he could lay his hands on, tore his Avife's hat to shreds, and finally attacked his Avife Avith the intention of strangling her. Fortunately she escaped. A feAV days after- wards, becoming rational, he consulted the doctor. Patient looked well, had no pain, only during his melancholic fits a kind of Aveariness in the epigastric region, Avith nausea, No buzzing in the ears; hearing and sight perfectly normal; mo- tory or sensory disturbances he never felt; his speech Avas in- telligent, and he never Avas given to drink. His sleep had been for some time restless and unsatisfactory. Traveling from home, in genial companionship, Avas the remedy advised. Dr. Chatelain. oo4 NERVOUS DISEASES. Such mental disturbances, hoAvever, cannot long exist Avith- out deranging the bodily functions. Hence avc generally find, in different cases, more or less anorexia, headache, sleepless- ness, dilatation of the pupils, pallor of the lips and face, red- ness of the tongue, weakness and irregularity of the heart's ac- tion, tremulousness, abolition of the virile powers, suspension of the uterine functions, etc. In chronic cases, the surface is dry, cold, shriveled and insensible; the eyes are sunk in tueir sockets; the lips parched and thin; the muscles wasted; the body emaciated; the frame bent and tottering; and the gene- ral aspect of the patient one of premature old age. Causes.—Heredity is the chief predisposing cause, the seeds of the malady being found, not only in different branches of the same family, but to a greater or less extent in those who inherit the same temperament. The physical state Avith which nearly all cases are associated, is anaemia; but Avhether the latter sustains the relation of cause or effect, will admit of question. Certain it is, that poAverful moral emotions, asso- ciated Avith great mental depression, will, if long continued, derange the digestive and assimilath'e functions, and lead to inanition and exhaustion. On the contrary, Avhen there is a strong predisposition to the disease, there is no doubt but that defective blood nutrition, especially if coupled with other ex- citing causes, is capable of exciting the disease. Such excit- ing causes may be found in self-abuse, dissipation, late hours, defective alimentation, impure air, or indulgence in habits which interfere in any way Avith assimilation. Treatment.—The preliminary remarks made under the head of treatment, in the last chapter, should be consulted. The most essential point is, to adopt such measures as Avill impart vigor to both mind and body. Hence, cheerful society, fre- quent visits to friends and relatives, new scenery, and objects and subjects calculated to please and divert the mind, with pure air, good food, and regular habits and exercise, are of the utmost importance. AVhenever practicable, the patient should be advised to travel, in company with a lively and sensible companion. Illus. 186.—AVas called to M. C, who for several months has MELANCHOLIA. 33-) been in a melancholy mood, especially tormenting during the morning hours, yet easily conquered by a Avalk or visit to friends. The patient is sixty years old, a well-to-do farmer, and of a very kind and generous character. Nearly a year afterwards he takes a Avalk, Avithout anything strange being- noticed by his Avife. He perambulates the village and takes the road to a little lake close by. He meets several friends, Avho salute him, but he fails to respond to their salutations. Arrived at the borders of the lake, he goes into the Avater and . sits down on a stone, and quenches his thirst by drinking the Avater with his hand. At the approach of a boat, he slides down into the water and disappears. After some time, the boatmen succeed in recovering his body, but it took a Avhole hour to restore animation. He felt greatly astonished to find himself in bed, and could not recollect anything about it, and Avhen it Avas told him in all its minutiae he felt struck with horror. He could not imagine how he, so firm in his religious principles, should think to commit suicide, and assured his family and friends that he neA'er harbored such a criminal thought. Lie was advised to travel, in company Avith a friend, and returned after a feAV Aveeks, in the best of humor, and his melancholy has left him entirely.—Dr. Chatelain. In addition to the remedies mentioned under hypochondriasis (q. v.), the folloAving have been recommended: Agnus castas, Amyl nitrite, Ambra, Belladonna, Helleborus, Iodine, Kali brom., Opium, Phosphorus, Plumbum, \rercdrum, Amyl nitrite,—According to Dr. Hoesterman, this remedy is curative if inhaled two to four times a day, four to five drops for thirty-five to forty seconds, till symptoms of hyperemia appear; dilatation of the blood vessels still continues after the inhalation is interrupted, advising us to be careful in ansemic persons, or in such as early suffer from congestions; the symp- toms disappear in from three-quarters to one minute; the physical changes correspond to those of an increase of blood; the eye becomes full of lustre, features more lively, the ob- struction to a rapid flow of ideas ceases, and the patient feels more comfortable. All these symptoms correspond to those which a fever produces in a melancholic patient; and as a 336 NERVOUS DISEASES. fever cures a melancholy, so does the inhalation of Amyl nitrite. The sphygmograph shoAvs that it changes the slow pulse into a quick and feverish one.—Psych, Centrbl. 1, 1873. Cimicifiuga.—This remedy is particularly adapted to puer- peral melancholia, especially when attended with great depres- sion, suspiciousness, and apprehensh7eness. Illus. 187.—Mrs. B. set. 33, dark hair and eyes, Avas confined six months ago Avith her fourth child. Three months before this period she became the subject of idle gossip Avhich greatly worried her. Soon after confinement she became melancholy. She imagined that the Avhole world was against her, and that she Avould become insane and be sent to an asylum. She would sit and rock continually, crying and sobbing, feeling perfectly helpless, and satisfied that her condition Avas beyond the reach of medical skill. This state of affairs continued six months under allopathic treatment before the case came into my hands. Her boAvels were costive, tongue furred, and there Avas tenderness on pressure over the dorsal and lumbar spine. She had been "unwell" but once since her confinement three months before. No other uterine symptoms. Milk normal, and she was nursing the child. Tavo Aveeks treatment Avith Ignatia made the bowels more regular, but effected no other improve- ment. I noAV prescribed Cimicifiuga 6, fh7e drops three times daily. Rapid improvement folloAved, the patient resuming control of her affairs. In tAvo months she reported well, but still needed an occasional dose of Cimicifuga. Four months have since elapsed and she remains Avell.—Dr. A. F. Stobbs. Helleborus nig. \ Melancholy, Avith pale, sunken countenance, Nux vomica. J sIoav pulse, lack of appetite, constipation, great depression of spirits, obstinate silence, involuntary sigh- ing and moaning. Illus. 188.—Airs. P., set. 63, a small, thin, sallow, and anxious- looking person of highly-nervous temperament, has been observed during the last feAV days to be extremely irritable and despondent, having been sleepless and restless for several Aveeks back. She refuses her food, saying always, "Rather give it to the children, Ave can't afford so much," but has been seen to take a mouthful or tAvo occasionally when she thought MELANCHOLIA. 337 she was not observed. She thinks they are living very ex- travagantly, although in reality the household expenses are not increased. Instead of being kind and affectionate toAvard her grandchildren, she is easily irritated by them, and dispenses more blows than she formerly did kisses. She takes no interest in household affairs, as Avas her wont, is very suspicious, par- ticularly of the servants, and Avill not go out of doors. During the last two nights she moaned a great deal, and scarcely slept at all. AVhen asked the reason of her strange behavior, she only shakes her head and Avecps. Lately she has been reading Harvey's "Meditations among the Tombs," several books of sermons, and other depressing literature, over which she had been frequently seen sobbing and moaning. After hearing this account the patient was sent for. She was led reluctantly into the room, and, Avithout looking at me, sank into an easy chair, where she sat crouched up, silent, the very picture of despair, and every now and then giving quick glances of fright and suspicion toAvards me and the door, as though she were some, dejected prisoner. Nothing would induce her to enter into conversation. She only said she Avas very unhappy, and that it was wrong to be so. I could detect no physical signs of disease. The bowels were constipated. After advising the removal of all depressing influences, I prescribed Nux vom.30, TflJ every four hours. Two days after, Avhen I made my next visit, she was in bed. Her daughter reported that she had been much better till 2.30 this morning, Avhen she awoke with a start, having dreamed that the Avhole family Avere to be dead in the morning. She raved to me about some great calamity Avhich was going to befall them, but Avhat it Avas she Avould not tell. I noticed noAV Iioav emaciated she Avas, and learned that she had been Avasting aAvav for several months. No improvement except that her boAvels had acted comfortably. One week later, I learned that she had had many ups and downs, from comparative cheerfulness to the depths of despair. Very morose and dull to-day, sus- picious about her clothes, and talks vaguely about taking a long journey. She Avould not speak to me, or ansAver any questions, but incoherently muttered about something hang- 338 NER\70US DISEASES. ing over her, and moaned all the Avhile. Helleborus niger™, tn.j ; Nux vom.30, Tfl.j, alternate every tAvo hours. This appears to have had the desired effect, for Avhen I called a week later, she pleaded hard to stop all medicine, as she felt "quite well," but I advised the continuance of Hellebore, one dose at night, and of Nux one dose in the morning. I have since heard, from time to time, that Airs. P. continues "all right."—Dr. Samuel Brown, England. Veratrum alb.—Great anxiety, despondency and despair; distrusts every one; cold sweat all over; moaning during sleep; frightful dreams; tearfulness, Avith tendency to start; frequent eructations. Illus. 189.—An 0A7erseer who considered himself firmly estab- lished, found himself suddenly dismissed. From that moment a profound melancholy settled on him; he would only endure the presence of his daughter, and Avould only take food from her. Complained constantly of his dismissal, and gave him- self up to despair. Veratrum album cured in twenty days.— Dr. Dulac Illus. 190.—Miss 0. G., set. 28, sanguino-nervous tempera- ment, very intelligent, was sadly disappointed in love. A law- yer of some reputation had paid her marked attention for sev- eral years, and she Avas about to be married to him, Avhen he abandoned her and took up Avith a much inferior woman, whom he finally made his Avife. After his abandonment she became melancholy, and Avas seldom seen by her friends, though naturally very fond of society. But it Avas not until after the marriage occurred that she completely broke cIoavii; she then distrusted every one; would start Avhen any Avould approach her; her eyes Avandcred constantly about; would fre- quently break out all over with sweat, then burn with fever; her sleep Avas constantly disturbed Avith frightful dreams, and •attended Avith loud moaning; she ate but very little, and Avas troubled Avith frequent eructations; she became greatly emaci- ated, the shadow of her former self. Prescribed Veratrum3, every 3 hours; cured.—Dr. Matchowitch, MORAL INSANITY. 339 CHAPTER IAr. MORAL INSANITY. By moral insanity we understand that form of mental aliena- tion characterized by a perversion of the moral feelings, pas- sions and emotions, the intellectual faculties remaining un- impaired. It may manifest itself either by an unfounded suspicion, jealousy or hatred of others, especially of those to Avhom the individual Avas previously attached; by the exhibi- tion of an excitable, cruel and reckless disposition.; or by the commission of acts, not only contrary to reason, but to the Avell- knoAvn character and disposition of the patient. History and Symptoms.—Although Pinel called attention to this disease as early as the first year of the present century, and numerous authors have since Avritten upon it, there are still those Avho doubt its existence, or Avho claim, at least, that insanity never exists in an individual Avithout more or less disturbance of the intellect. Numberless cases, hoAvever, haA'e been observed, in which there Avas not only no appearance of intellectual aberration, no hallucination, illusion or delusion, but Avhere the individual could reason just as well as he ever reasoned; in fact, the reasoning powers, instead of being Aveak- ened, appeared to have been sharpened. Yet these persons were undoubtedly insane. They were compelled by an irre- sistible impulse to commit acts contrary to their reason and natural disposition. The man who is a thief to-day was the honest man of yesterday. He Avho yesterday Avas kind and af- fectionate, Avhose feelings Avould have been shocked at the sight of cruelty or suffering, is the murderer of to-day. The sober man is suddenly transformed into a drunkard, the chaste man 340 NERVOUS DISEASES. into the lewd, the generous into the avaricious, and so on. This is not moral depravity. The man has lost his moral equilibrium; he is morally insane. The disease, hoAvever, does not ahA7ays, nor even generally, commence in this sudden manner. For years, and even for a Avjiole life time, it may not pass beyond the stage of melan- choly or eccentricity. And in most cases, for a considerable period previous to its full development, the patient is apt to appear unduly elated or depressed. In the former case, though he may mingle in society, and even transact business like other men, he acts hastily and Avithout deliberation, is imprudent in his transactions, making large purchases, undertaking vast en- terprises, entering into wild speculations, and living in a state of high mental excitement. In the other form there is great mental depression. The patient suffers from hypochondriasis or melancholy. He is taciturn, gloomy, and disposed to set a low value unon life, especially his own. He has no ambition, and sees nothing but want and misery staring him in the face. He retires within himself, or shuts himself up in his room, becoming unsocial, solitary and dejected. As the disease ad- vances, the patient becomes exceedingly irritable. The most trifling matters will excite his anger, and the least opposition will often throw him into an ungovernable rage. Pie then commits acts which clearly shoAv him to be insane. After his anger subsides, he may regret and even apologize for them, but under similar circumstances he will do them again. At such times he entirely loses control of himself. Nothing is too cruel, vile or horrid for him to perpetrate. He may be par- tially restrained by public opinion, or by fear of personal con- sequences, but if these are not sufficiently poAverful or have lost their influence over him, he may sIioav himself for the time to be little better than a fiend. In Avhatever Avay his passions are excited, he noAV gives full sway to them, delighting in the in- fliction of pain, in coarse ribaldry, in expressions of hate and revenge, in disregard for the feelings of others, in indecent behavior, in extreme selfishness, and in the most flagrant breaches of propriety. Such indulgences grow upon him, until at last he ceases to have any regard for public opinion, and MORAL INSANITY. 341 acts which before were only committed occasionally and at home, or under great mental excitement, noAV become habitual, and of public occurrence and notoriety. At last he throws aAvay all restraint. Blasphemy, open lewdness, theft, drunken- ness, rioting, attest the complete subA'ersion of the moral sense, and the patient is finally declared to be morally insane. It had been better for both the patient and society, had his in- sanity been recognized at an earlier period. In all cases of moral insanity there is more or less disorder of the physical functions. In those cases in Avhich the mind is depressed, there is a torpid state of the general system. The circulation is Aveak, the pulse slow and feeble, the surface cold and clammy, the extremities cold, the boAA'els constipated, the appetite impaired, and sometimes almost abolished. As a consequence, there is emaciation, Avith a corresponding loss of strength. AVhen the passions are greatly excited, there is gen- erally more or less fever, accompanied with headache, sleep- lessness, flushed face, coated tongue, thirst, loss of appetite, scanty and high-colored urine, and constipation. In chronic cases the capillary circulation is deficient, the surface being cold, the extremities cold, and the body weak and emaciated. Etiology, Diagnosis, etc.—The chief cause of this, as of every other form of insanity, is hereditary transmission. Of this there is not a shadoAv of doubt. So true is it, that in most cases it becomes the chief factor in determining the diagnosis. On this point Dr. HoAvard, in his lecture on "Man's Aloral Re- sponsibility," says: "You Avill hrvariably find that the vic- tim is the offspring of parents Avho, if not actually morally in- sane, are Avhat is called very eccentric, and you are sure to find that some of their progenitors Avere actually mad. To find out this fact is a very important proof of hereditary trans- mission of moral insanity; but this generally is a very difficult task to execute. It is extraordinary, but nevertheless true, that the very last thing that any one will admit is that there was ever insanity in their family, and generally it is only in some accidental way that the discovery is made. The heredi- tary morally insane are more impetuous, there is less hesita- tion about them, they execute more rapidly; when there is the 342 NERVOUS DISEASES. impulse to kill they do kill, or attempt it Avithout any hesita- tion; Avhen the impulse is to commit suicide they generally succeed, and if saved at the first attempt, they will go at it again and again, till they do succeed, differing from the other form where the patient is very often cured of the desire, when saved in the first instance—so is it with all the other impulses. I have also remarked, that the hereditary morally insane, when their impulse is to drink they never can be cured of the desire; and Avhen they drink they do not get drunk like other men, but for the time being they become regular maniacs. The morally insane from accidental circumstances are generally curable. The morally insane from inheritance are incurable. They may be relieved and discharged from an asylum, but they always turn up again." Pathology.—A\ nether caused by hereditary transmission or physical disease, there is in both cases some abnormal con- dition of the moral portion of the nervous centre. Pathology shoAVS that, as the intellectual functions are not disturbed, the disease must be seated in the cells of the cortical portion of either the lateral and posterior portions of the cerebrum, or in those of the cortical portion of the cerebellum and medulla oblongata. The former is probably the true seat of the malady, as disease or irritation occurring in the cerebellum and medulla oblongata produces a Avant of controlling poAver, or Avhat is sometimes called insanity of the muscles. On this subject Alaudsley, one of the leading authorities on moral insanity, says: "When an organism is out of harmony with the circumstances in which it should live, by reason of internal derangement, its tendencies are to self-extinction, which it would often reach quickly if it were not carefully guarded from the destructive action of its perverted affinities. Persist- ent suicidal impulse marks the replacement of the self-con- servative, by a similar self-destructive impulse. The impulse to burn, to steal, to kill, are in like manner, occasional symp- toms of deranged nerve-element, and have nothing in their nature more exceptional or surprising than other insane impulses." Treatment.—According to Dr. Earl, one of the most dis- MORAL INSANITY. 343 tinguished alienist physicians of the old school, "the medical treatment of the insane is governed, as in all other diseases, by the general condition or the special symptoms in each indi- vidual case, the primary object in view being to restore the physical health to its normal standard, in the hope that the body being sound, the manifestations of the mind will be so." Fortunately, homoeopathy offers something better than this for a diseased mind. The mental symptoms of our Materia Aleclica are a vast store-house from which Ave may select the required remedy, and experience has sIioavii that Avhen administered agreeably to the homoeopathic laAv of similars, our medicines are just as effective in the cure of mental, as they are in the relief of physical disorders. The remedies usually required in the treatment of this form of mental derangement, have already been given under the heads of hypochondriasis and melancholia (q. a7.) It only remains to add a few cases by Avay of illustration. Belladonna.—This remedy is indicated in all cases Avhere there is marked cerebral congestion, or determination of blood to the head; the face is red and bloated; there is melancholy, with anguish of mind; or there is great irritability; the patient flies into a violent rage, Avith little or no provocation; he sud- denly screams out, and claps his hands or his head; he is very restless, especially at night, keeping every one in the house awake by his noise and craziness; his manners are foolish, talking, laughing, howling, jumping, singing senseless songs, making lascivious advances, weeping at the slightest provoca- tion, overturning and destroying the furniture, tearing his clothes into shreds, disposed to quarrel Avithout cause, and in many other ways showing that the moral faculties are disor- dered, and that the patient is not responsible for his actions. Illus. 191.—Air. E. II., set. 38, married, father of six children, merchant; has ahvays been troubled with rush of blood to the head, and once had brain fever with wild delirium; has always been of an over-bearing, irascible temperament and disposi- tion; easily provoked, violent, suspicious, selfish and vindic- tive. His wife left him three years after marriage, on account of his violent conduct towards her, fearing for her life, but was afterwards induced to return and live with him again, in con- 344 NERVOUS DISEASES. sequence of his passionate protestations of love and promises of reform. His father Avas a A'ery passionate man, and Avas twice arrested and placed under bonds to keep the peace. Since the attack of meningitis above referred to, his conduct has been more violent and eccentric than before; he complains much of his head; is frequently thirsty and feverish; his hair has nearly all come out, leaving the Avhole top of his head bald; and for the last six months he has been a constant tor- ment to his family and neighbors, both day and night. He Avill frequently get up in the middle of the night and pump, and pump and pump, without any apparent object; except to annoy his family. He long ago retired from business, or rather, business retired from him, no one caring to deal with so selfish, capricious and passionate a man. Since then he passes the tedium vitse by interference Avith everybody else's business, and Avould be constantly fighting Avith his neighbors if they did not purposely avoid him. He has several times been knoAvn to take his gun and a large sack, and on pretense of hunting, go to some out-of-the-way country place, kill a large number of the hens and chickens, and bring home the sack full, leaving the others dead on the place. Once on re- turning from such a raid, he discovered the approach of the OAvner, and fearing detection he secreted the sack of fowls in a ravine, Avhere they were allowed to remain and rot. About a month before I was called, he drove his family all out of the house, bolting himself in, and it AA7as several days before they Avere allowed to return. After that'they were in constant fear of their lives, and finally, not having his breakfast ready just at the moment he Avanted it, he overturned the stove, struck his Avife a violent Woav with his fist, and, escaping to the avoocIs, did not return for nearly a Aveek afterAvards. It Avas on this occasion that I was consulted as to the proper course to pursue; Avhether to treat him privately at home, or send him to an asylum, to Avhich the family Avas naturally averse. After hearing the above history and examining the patient, I recommended that a trial be made of homoeopathic treatment, and if that failed, then to send him to the asylum. I found the patient with a hot head, red face, restless eyes, MORAL INSANITY. 345 very loquacious, yet with his reasoning poAvers intact; not at- tempting to defend his conduct, but regretting that he Avas so easily angered, and complained greatly of his head, which he said always pained him. I prescribed Belladonna30, a dose every three hours until the head should be relieved, then every night and morning only. He Avas to have a Avatchful, e\7en-tempered and judicious attendant; and to live chiefly upon fruits, A7egetables and farinaceous diet, Avith little or no animal food. This course Avas steadily pursued for upwards of a year, Avhen the patient's health and conduct were such as to warrant the removal of all restraint and supervision; and I am happy to say, that during the last fourteen months his life has been most exemplary, and all that could be desired.— Dr. Boudet. Ignatia,—Excessive grief over losses real or imaginary; great depression of spirits, with disposition to be alone; tearfulness and timidity, alternating with great boldness and rashness; easily angered, but quickly pacified; extremely anxious and hurried; changeable disposition, yet frequently engrossed by one idea; inconstant, irresolute and impatient; sleep disturbed by dreams; moaning and groaning during sleep; headache, coldness of the extremities and constipation; insane impulse. Illus. 192.—Mrs. F., set. 24, mother of one child; has always been of a retiring and melancholic disposition, yet A'ery affec- tionate; last year her mother died, since which she has been very gloomy and depressed; she is naturally very timid, and always had to send for some one to scare aAvay a coav that might happen to be in her path, or to kill a chicken; recently she has become very bold and irritable, and her pet dog hav- ing playfully jumped upon her lap, she seized a stick and killed it, since which she has been constantly haunted with a desire to kill her child. She knows it is wrong to harbor such a thought for a moment, and has several times placed the child in its cradle and fled to her mother, crying and wringing her hands, in consequence of the sudden and overpowering char- acter of the impulse. Her mother, who is very religious, gen- erally reads her a chapter out of the Bible, prays with her, and after lecturing her upon the sin of entertaining any such 22 346 NERVOUS DISEASES. thoughts, sends her back to her home calm and apparently in her right mind. A few weeks ago she ceased rocking and singing to the child, and upon its crying, suddenly seized it and dashed it upon the hearth, breaking one of its arms. She then ran into the Avood-shed to procure the axe, Avith the view of killing it, but suddenly changing her mind, she dashed off to her mother, Aveeping and moaning as usual. Her mother, on finding to Avhat length she had gone in carrying out her •murderous idea, consulted me as to Avhat had best be done with her. I advised her to take her to her own home, to take her child from her and give it to a wet nurse to be cared for, not letting the mother see it except in her presence, and to place the mother under medical treatment. This Avas done. Ignatia12, a dose three times a day. AA7hat with the removal of the child, the occupation of the mind with new ideas, the daily rides in the open country, and the beneficial effects of the medicine, the patient soon became cheerful and happy, her features lost their thin and Avorn expression, the blood circu- lated healthily in her veins, and in less than a month she could converse calmly and rationally about her condition, ex- pressing no longer any fear of injuring her child, and greatly mortified over Avhat had already occurred. For prudential reasons, she was not allowed the care of the child until it Avas weaned, some four months subsequently, but she returned to her own home Avith one of her sisters as a companion, and from that day to this she has exhibited no trace of mental de- rangement. She does her OAvn work, feeds and dresses her child, plays with it, and cannot bear to have it out of her sight—Dr. Julius Ramsey. Stramonium—This remedy is indicated in subjects of a changeable disposition, easily excited or depressed, full of whimsical notions, disposed to undertake rash enterprises, restless, fretful and inconstant; or else melancholy, indifferent to business, weary of life, and stupid. The symptoms often present the strangest contrariety; love, hate, fear, rage, laughter, moaning, loquacity, taciturnity, occurring without order and in quick succession; no stability of mind or character; face swollen and red; eyes glistening; manner hurried and fitful. MORAL INSANITY. 347 Illus. 193.—S. S., set. 46, clergyman. This man, until he was over forty years of age, Avas most exemplary in his deportment, and an ornament to his profession. He was meek, abstemious, quiet, cheerful, sociable, sensible, fond of his home and family, devoted to his calling, and every way consistent. At the age of forty-one, after a protracted series of meetings in Avhich he took part, and which resulted in several accessions to his church, his conduct suddenly changed. He became fretful and low spirited, often expressed himself as weary of life, secluded himself in his study, and could hardly be induced to see his most intimate friends and parishioners. This condition lasted about four months, Avhen he suddenly lost his melan- choly mood, and became lively and cheerful again, but full of odd schemes and absurd projects. He sent a thousand or more letters to young men throughout the country, offering to edu- cate them for the ministry, and for them to apply in person at a certain date. AVhen the time arrived, over three hundred applicants presented themselves, and had to be temporarily provided for, to the no small annoyance and inconvenience of his family and friends. AVhen remonstrated with for his visionary scheme, he flew into a violent rage, attacked his Avife and daughter with a cane, and Avould undoubtedly have killed them, or done them some great bodily harm, had he not been secured. His conduct Avas so different from the former tenor of his life, that all Avho examined him were convinced of his insanity, although his reasoning was sound, and he always gave clear and distinct ansAvers to all questions. Being the family physician, I enjoined rest, sufficient restraint to prevent mischief, exercise in the open air, cheerful companion- ship and conversation, and a dose twice a day of Stramonium30. Gradual improvement took place, his mind became more tranquil, and in a few weeks he resumed his pastoral relations, and has since manifested no impropriety in his conduct.—Dr. Abel Moore. 348 NERVOUS DISEASES. SECTION II. INTELLECTUAL DISORDERS. CHAPTER I. MANIA. Mania is that form of insanity characterized by disorder of the intellect and general delirium. As it is the most common form of insanity, or rather, the form Avith which ordinary observers are most familiar, the terms "mania" and "insanity" are often used synonymously to signify disorder of the mind, without any very clear idea of the mental conditions denoted by them. By insanity we understand a disease of the brain in Avhich the faculties of the mind are disturbed, so that they no longer act in a healthy or normal manner. AVhen the disturbance is confined to the moral faculties, the disease is termed moral insanity (q. v.) AVhen the intellectual faculties are involved, and throAvn into a state of exaltation and perver- sion, so that the individual is delirious, turbulent, and unre- strained by reason, the disorder is called mania, from [j.av>a, madness. When the intellectual derangement, instead of being general, is limited to a single object, or class of ideas, it constitutes monomania, as homicidal monomania, religious monomania, etc. Another distinction frequently made is founded upon the physical condition of the individual. Thus, Avhen complicated with epilepsy, it is called epileptic mania; when associated Avith parturition, puerperal mania, etc. Symptoms.—In acute mania, just previous to the full de- MANIA. 340 velopment of the disease, the patient's thoughts and feelings are observed to be exaggerated. This exaltation is at first only occasional, but shortly it becomes more and more manifest; those objects which Avere formerly regarded Avith a quiet affec- tion being treated with the most extravagant fondness, while those that simply caused dissatisfaction, are regarded Avith ex- treme displeasure and anger. As the excitement increases, the individual becomes more and more restless and impulsive, hastily and causelessly abandoning his employments, wander- ing from one thing to another, and never quiet. The patient's unnatural appearance and demeanor hoav begin to attract at- tention. At times he appears greatly excited, and his eyes, which are often more or less injected, have a strange, wild expression about them. He is no longer like himself. He neglects his family and business, loses his memory, has fre- quent fits of passion, and suffers from headache and sleepless- ness. 'At last he becomes delirious. Sometimes the delirium, instead of being constant, alternates with reason, but the com- mission of absurd and extravagant acts is frequent. The de- lirium increases, becomes general, and actual raving occurs. The madness is now extreme. The patient's movements, Avhich are angry, violent and destructive, are often accompanied with shouting, singing, jabbering and howling. During these at- tacks of Avild frenzy, the head is hot, and the eyes injected, • brilliant and fixed. At the same time, the general circulation, contrary to what might be expected, is not perceptibly in- creased; for out of two hundred and twenty-two cases examined by Jacobi, only twenty-three presented any evidence of fever, and in these it was attributable to hectic and other causes not connected with mania. Indeed, the pulse seldom affords any guidance in this disorder. This, however, does not appear to be the case with the temperature. On this point, Dr. S. R. Beckwith says: " AVhile I have not observed long enough to attain a well-established fact, each case of mania in our hospital lias an aggravation of maniacal symptoms just in proportion to the rise of temperature, and as it falls the mental symptoms are less. The thermometer does more; it, like a barometer, indicates an approaching storm or foretells fair weather. A 350 NERVOUS DISEASES. patient Avith acute mania Avalks about the room quietly, giving no disturbance to anyone; his temperature is found rising, and unless he is controlled by treatment, a period of violence is certain to ensue, and will continue as long as the temperature remains high." In consequence of his incessant and violent physical exertions, loss of sleep and frequent rejection of food, the maniac soon becomes weak and emaciated, his cheeks and eyes hollow, the skin discolored, the blood deficient in fibrine, and, if allowed to progress and become chronic, may terminate in epilepsy, dementia and paralysis. The symptoms that pre- cede and accompany paralysis of the insane, have already been given under that head. Those peculiar to puerperal mania, which begins Avith restlessness, insomnia and severe pain in the head, are, either a diminution or arrest of the lacteal secre- tion, suppression of the lochial discharge, fever, thickly furred tongue, hot dry skin, full quick pulse, profound debility (espe- cially in patients Avho have suffered from excessive hemor- rhage), the most intense delirium and outrageous paroxysms of frenzy and madness. From this it will be seen that the chief distinction between puerperal and other forms of mania, is in the fever that attends the puerperal form. This, hoAvever, is not the most common variety of the disease. Most cases of puerperal mania are accompanied by only a very moderate disturbance of the circulation, so that there is often no greater difference between them in this respect, than there is in the mental symptoms, of which Dr. Gooch has remarked, that "if a physician Avas taken into the chamber of a patient whose mind had become deranged from lying-in or nursing, he could not tell from the mere condition of the mind that the disease had originated in these causes." The febrile cases are those Avhich generally occur soon after child-birth, and are cases of true mania; Avhile the disorder Avhich affects women exhausted by suckling, is generally much milder, and is most commonly associated with melancholy, or that state of mental depression observed in women Avhose strength is reduced by anaemia, hemorrhage, etc. Causes.—The principal predisposing cause of mania is he- redity. The tendency to the disease is undoubtedly derived) MANIA. o-)l in most cases, from the patient's ancestors. The vicious and criminal classes inevitably propagate their kind, producing offspring of similar inclinations. On this point, Dr. Butler, Asst. Phys. N.'Y. State Horn. Insane Asylum, says: "That this is one of the most potent causes of mental disease cannot be questioned. Statistics of every age and every country shoAv the same universal law. Although varying in their opinions, as to its importance, still every author upon this subject, from the earliest times to the present, has agreed in ascribing to he- redity, a large proportion of the cases which have come under his knowledge. That perfectly accurate statistics cannot be obtained, is evident from the too frequent ignorance of ances- tral history, or a desire to conceal the truth when known. A very great difference evidently exists in the prevalency of this cause in different countries, as shown by our most reliable au- thorities." The Germans assign by far the largest number to this cause. Dr. E. T. AVilkins, in his " Report of Insanity and Insane Asy- lums," says: "Dr. Kceppe,the intelligent director and physi- cian-in-chief, of the celebrated asylum at Halle, in Prussian Saxony, informed us that eighty per cent, of those committed to his asylum were from hereditary causes; and that this Avas in accord Avith the experience of the superintendents of other asylums in Germany." Although as much labor has not been given to the collection of statistics in the United States, yet there is no doubt, that a large proportion of the cases of insanity here are due to inherit- ance, as the exciting or predisposing cause. In the tabu- lated reports, for over thirty years, of the New York State Asy- lum at Utica, of over ten thousand cases, we find over thirty per cent, of the cases due to this cause. Upon this subject, Dr. Brigham, the first superintendent of this asylum, says: "There is nothing in connection with the study of insanity more de- serving of attention, than the tendency of this disease to be transmitted to offspring; the fact is most unquestionable, that it has more influence in producing that disease than all other causes combined." Dr. Gray, at present and for many years, superintendent of the same institution, adhere* to the same 352 NERVOUS DISEASES. opinion. He says: "In reality, there is little doubt, that in- herited disease is much the most powerful agent in the pro- duction of insanity that can be assigned. This transmission is traceable in one-third of all the cases admitted, and in still other cases the type and character of the mental disease are such as to impress the conviction that it is inherited." Although the per cent, assigned by some American Avriters is much lower, Ave find that in most cases they have regarded heredity as a predisposing cause, mentioning in their reports only prox- imate causes. The testimony of such authorities as Drs. Brig- ham and Gray, founded upon so many cases, can be relied upon as a fair statement of the general heredity of insanity in the United States. The peculiar tenacity with which any mental unsoundness seems to cling to certain families, is indeed wonderful. AVe find children, through two and three generations, suffering under the same burden as their fathers, Avhether subject to any exciting cause or not, their insanity seeming to be merely tli2 brand of the race to which they belong. In almost every work upon insanity, Ave find cited many remarkable cases of this kind. The following are taken from the Case Book of the N. Y. State Horn. Asylum for the Insane: Mr. H. H., for past four years insane, alternating between melancholia and mania; mother died in an asylum; only brother committed suicide.; Mrs. Susan S., melancholia. Mother suffered from mania; died insane; maternal aunt insane; father and sister com- mitted suicide. Airs. E. H., mania. Father, brother, sister, uncle and cousin, insane. Charles B., epileptic. A lot her, grandfather, great-grandfa- ther, maternal uncle, and several cousins, insane. Charles B., deaf mute, melancholia. Mother and her sister iioav inmates of the asylum; two other maternal aunts have been insane; two sisters and one brother, deaf mutes; cousin on father's side, deaf mute. The cases cited are fair samples of hundreds, Avhich could easily be collected, in Avhom the insane neurosis, transmitted MANIA. 606 through a smaller or greater number of ancestors, has in them reached its culmination. The effect of this unfortunate inheritance falls not upon the insane alone. Hours and days of agony, weeks and months of suffering and embarassment, years of resil and imaginary ills, reveal its influence in the sufferers from neuralgia, chorea and hysteria. Xor does this taint confine itself to those ordinarily recog- nized as diseased. Destroying in one his reason; in another of the same family, leaving his senses intact, it blunts and perverts his moral nature, and plunges him into a course of sin and crime. Those avIio have our criminal classes in charge, and have made their lives and history a study, are becoming more and more convinced that many of their crimes are crimes of inheritance. Descending from epileptic or insane, in a large proportion of cases, they bear in their general ap- pearance marks of their criminal proclivities. Maudsley, speaking of this class, says: " Crime is a sort of outlet in AA7hich their unsound tendencies are discharged; they Avould go mad if they Avere not criminals, and they do not go mad because they arc criminals. AVandering over the country a pest to hiAA'-abiding citizens, filling our jails, Avork-houses, and prisons through their lives, they are continually doing penance for their inherited propensities." The liability to development of inherited disease is greatest at the period of puberty and adolescence. On this subject Dr. T. S. Coulston* remarks: "The period of greatest danger of insanity in Scotland is that of adolescence. The ratio of in- sane to sane, at different ages, is as follows: twenty years and under, one to twenty-one thousand nine hundred; over twenty, one to three hundred and four. The period of greatest fre- quency is from thirty-five to fifty-five. 'Speaking generally, therefore, insanity in its worst forms is not a disease of youth or puberty, but of middle and advanced life.' Yet the figures show that any predisposition to insanity is apt to show itself about the time of puberty." This statement is confirmed by * Edinburgh Med. Jour., July, 1880. 354 NERVOUS DISEASES. the observations of Althaus, who found that the mortality* from insanity in England and AVales, in 1847, began to in- crease at puberty, from which period it steadily and rapidly advanced until the age of thirty-five to forty, when it began to fluctuate, but did not reach its highest points until the ages of fifty and sixty-five, after which it rapidly declined. Sex does not appear to have much influence in causing the disease. The prevalent opinion that there are more insane females than males, is controverted by the fact, that during the year 1878, in forty-eight asylums in this country and Canada, there were admitted fourteen thousand, eight hundred and eighty-nine males and thirteen thousand, two hundred and fifty-two females.f The disease can in some cases be traced to moral, and in others to physical causes. Of the former, the most frequent are: sudden fright, immoderate grief, disappointed love, intense religious excitement, blighted ambition, pecuniary losses, and excessive intellectual exertion. Among the physical causes, the most common are: masturbation, sexual excesses, the abuse of tobacco, alcohol, opium, chloral, bromide of potassium, mer- cury and other drugs, the retrocession of erysipelas, scarlatina and other exanthemata, epilepsy, sunstroke, and Avounds, tumors, abscesses, adhesions, cicatrices and traumatic injuries of the head. The influence of the latter in producing insanity, is shoAvn by the fact that Dr. Kceppe' extirpated the cicatrix in seven cases, where the patients Avere inmates of the lunatic asylum, and amelioration followed in all cases, a perfect cure in most of them 4 Pathology.—Under the head of "paralysis of the insane," Ave have given the substance of all that is definitely knoAvn regarding the pathology of insanity. In these cases Ave have seen that, in addition to the above-mentioned physical changes in the brain, there is degeneration of the cerebral nerve-cells, * This authority does not give the ratio of insane to sane, at different ages, bat as the mortality from insanity generally correspond; with the prevalence of the disease, the ratios at different ages must be about the same. f Dr. H. S Talcott, Med. Direc. N. Y. State Horn. Ins. Asyl. X Deutsch. Arch.f. Med. XIV. B. MANIA. 3o5 producing condensation and atrophy of the grey substance, increased Aveight, diminished volume, and chronic inflamma- tion with softening. In other cases, amounting only to about nine per cent, of the Avhole number, no lesion of the brain can be discovered. In those instances in which no physical changes can be detected, the symptoms may be accounted for in one of three Avays: first, by cerebral irritation; second, by cerebral excitement; and, third, by cerebral depression. Cere- bral irritation may result from a variety of causes, such as anaemia, general debility, sexual abuses, dissipation, anxiety, worry, excessive mental exertion, overwork, loss of sleep, dis- order of the digestive, hepatic or uterine organs, etc. This condition is believed to be the prevailing one in those cases in Avhich no physical alterations exist. The majority of cases are associated Avith anaemia and general debility, and although sleeplessness, AA'hich generally results from an increased flow of blood to the brain, is one of the most constant symptoms of the disorder, it may be readily accounted for by vaso-motor paresis, the result of debility and exhaustion. But if simple irritation Avill produce disorder of the mind, Ave can easily understand how cerebral exciUment, Avhich is induced in some cases by the same causes and in others by active congestion and inflammation, may give rise to similar disturbances. That cerebral hyperaemia and inflammation will produce men- tal excitement, insomnia and delirium, is Avell known. To cause monomania, it is only necessary for the irritation, con- gestion or inflammation to be. limited to a single organ of the brain, instead of involving the whole structure. Moreover, as increased functional activity in any organ or part causes an increased Aoav of blood to that part, should the action be vio- lent and long-continued it will give rise to hypersemia, and in many cases to inflammation. In this way, doubtless, insanity is often induced, especially in those predisposed to the disease. The third condition that favors mental derangement, is cerebral depression. This condition may result from the same or simi- lar, but more powerfully acting agencies, to those we have enumerated as inducing cerebral irritation, more especially, anaemia, general debility, the depressing emotions, venous con- 356 NERVOUS DISEASES. gestion, the abuse of alcohol, chloral, tobacco, opium and other narcotic poisons. From this vicAv of the subject, Ave conclude that insanity is in all cases an actual morbid condition of the nervous centre, or of a particular portion of it, and that the mental disturbance is the result of that morbid state, Avhether any perceptible anatomical lesions exist in the brain or not. At least, it is not too much to assert, that physical alterations probably do exist in all cases, as mal-functionation of the fac- ulties implies as much. But these material alterations may be, and no doubt frequently are, merely molecular, and result from disturbances in the physiological process of nutrition. In order to become pathological, they must of course pass the physiological limit, whateA7er that may be; and that the pro- cess of regeneration is thus affected in these cases, we have no other means of knoAving, than by the psychical manifestations themselves. Insanity may perhaps be fully developed by a mere functional disturbance of the parts, but it is safe to as- sume, Avhat, indeed, may be regarded as an established law in all vital processes, that excess or deficiency of function, if per- manent, is conclusive evidence of organic change. Hence, the apparent absence of lesions, in many cases of insanity, is no proof that it is not due to physical causes. EA7en with our in- adequate means of demonstration, Balfour, who analyzed seven hundred post-mortems, found tissue alterations in ninety-one per cent, of his cases. These alterations consisted, as before stated, in thickening, opacity, adhesion, effusion and softening —all results of inflammation. It may therefore, Ave think, be laid down as an established fact, that insanity is an actual mor- bid condition of the brain itself, and not a mere functional dis- turbance Avithout physical disease, as it was formerly regarded. Diagnosis.—In ordinary cases of mania, the characteristic features of the disease are sufficiently Avell-marked to enable one at a glance to recognize its true nature; but tliere are many instances of mental alienation, occupying, as it Avere, the bor- derland between sanity and insanity, in which the diagnosis is not so easily determined. In all doubtful cases, avc should make a thorough examination of the patient, paying particular attention to the following points: 1st, as to the presence or ab- MANIA. 357 sence of hallucination, illusion or delusion. In the first of these the.perceptions are false and have no material basis; in the second, Avhile the impressions themselves are real, the percep- tion or estimate of them is distorted, the intelligence being misled as to their real nature; and in the third, the impres- sions are not only false, but are based on false premises. 2d, as to the presence or absence of an adequate motive, The motive may be true or false—that is, it may or it may not have a ma- terial basis—but in either case, if the intelligence is affected to such an extent as to constitute insanity, tliere Avill probably be a Avant of correspondence between the motive and the act. The reasoning powers being perverted, the reasoning itself is illogical, and not in accordance Avith that of the normal mind. 3d, as to the presence or absence of volition. In almost every case of insanity, the Avill-power is more or less impaired. It is evident that, if perception and reason are both defective, voli- tion must be also, since our A'oluntary acts are based upon them. AVe obtain our knowledge of objects or events through the faculty of perception, avc exercise our intellectual faculties in reasoning upon them, and then we act upon them through the operation of the will. Hence, if the former is imperfect, the latter, Avhich is the ultimate step in the mental process, must also be imperfect. There are many other facts and cir- cumstances which bear upon the subject, but these are the most important, and all-sufficient to determine the diagnosis. Prognosis.—AVe may say, in a general Avay, that, if taken in time, the great majority of cases of insanity are curable. This is especially the case with acute mania when simple and uncomplicated. The probable result in any particular case depends on the following circumstances: 1st, heredity. If the patient has inherited the disease, the chances of recovery are much less than they Avould be if the disease was altogether acquired. Nevertheless, such patients sometimes recover, and even remain well afterwards, but they are ahvays liable to re- lapse. 2d, structural changes. The prognosis is more influenced by the condition of the cerebral tissue, than by any other cir- cumstance. It is not ahvays possible, however, to determine Avith certainty Avhen structural lesions have occurred, but their 358 NERVOUS DISEASES. existence may always be inferred \A7hen symptoms of inflam- mation exist, and also in chronic cases. 3d, duration. .The matter of time is ahvays an important element in these cases, for the reason that structural alterations frequently depend upon it. Statistics shoAV that the great majority of recoveries take place during the first year, and that comparatively few oc- cur after that period. 4th, causes. Psychical causes are supposed to be more serious in their consequences than physical ones; nevertheless, the prognosis is very unfavorable Avhen the dis- ease results from onanism, sexual excesses, intemperance, in- juries of the brain, anaemia, or general debility. It is also very bad Avhen complicated with epilepsy or tuberculosis. Puerperal mania, attended with fever, is almost ahvays fatal; but Avhen not thus complicated the subjects of it generally recover. As in other diseases, Avhenever the exciting or efficient cause can be removed, the mental disturbance will be likely to subside, provided the habits of the patient are not such as to prolong the malady. Treatment.—The first question Ave have to consider under this head is, Avhether the patient should be sent to an asylum for treatment, or whether he A\7ould stand a better chance for recovery if the treatment were conducted at home. In order to determine this question, we must take into consideration the manner in Avhich our asylums are at present managed. On this subject, Dr. Samuel AVorcester, in a paper read before the Massachusetts Homoeopathic Medical Society, says: " In judging as to the merits of the present system of asylum man- agement, we should ascertain how far it succeeds in attaining its main objects, viz.: curing speedily and pleasantly such cases as are curable; and guarding comfortably and humanely the incurable chronic insane. AVe also have a right to de- mand that the proportion of those cured shall increase as Ave advance in civilization, and in our knowledge of the curative effects of medicine. But on applying this test, Avhat do Ave find? Does any larger proportion of the insane permanently recover than formerly ? The mean average of recoveries and deaths in the State Hospitals of New England, for the ten years ending in 1870, is as folloAvs: percentage of recoveries 32.14; MANIA. 359 of deaths, 10.25. A very extended and careful analysis of asylum statistics, made by Dr. EdAv. Jarvis some years ago, shows that of every one hundred patients treated, forty-two re- cover, eight die, and the remaining fifty continue in a state of mental invalidism. This, however, presents no better results than Avere attained years before, when the modern system first came in vogue. Dr. Thurman gives a table showing the his- tory of two hundred and tAventy-four persons Avho died at, or after discharge from, the Ncav York Retreat, from 179(j to 1840, and he says: "In round numbers, then, of ten persons at- tacked by insanity, fh'e recover, and five die sooner or later during the attack. Of the five avIio recover, not more than two remain well during the rest of their lives, the other three sustain subsequent attacks, during which at least two of them die." AVe are justified, then, in saying, that, judged by the re- sults, the progress in modern medical science has not been fol- lowed by a corresponding improvement in treating the insane; and indeed it is questionable Avhether the present percentage of lasting cures is as great as during the first ten or twenty years of the "humane" system; when our asylums Avere man- aged by such men as Hahnemann, in Germany, Conolly, Gard- ner Hill and Tuke, in England, Esquirol and Pinel, in France, and Bell, FoAverden, AVoodward, Earle, Ray and Kirkbride, in this country. It is commonly supposed that patients in an asylum receive some special medical and moral treatment, which the superin- tendent is peculiarly qualified to give by virtue of his special training; and perhaps you picture him making his rounds as does the visiting staff in other hospitals, carefully inquiring and examining into the physical and mental symptoms pe- culiar to each case, and directing the appropriate medical and moral treatment. Let us see what Dr. Earle says upon this point, in his report of the Northampton Hospital, where he had four hundred patients under the care of himself and one as- sistant medical officer. "At eight o'clock in summer, and nine in winter, the regular daily medical visit is begun. The superintendent and assistant physician make it in company, three, sometimes four, times in the week, the latter making it 360 NERVOUS DISEASES. alone the other days. It is expected that in nearly all the halls, the patients Avill be collected as much as possible into one part of the hall, generally the 'bay'; the object of this is two-fold; first discipline, from the practice of self-control by the patients; and secondly the saA'ing of time and steps to the physician; for, even Avith this grouping, the visit generally occupies tAvo hours, often tA\'o hours and a half, and is more fatiguing than a Avalk of six miles." "Fortunate are the phy- sicians if they have been permitted to complete their visit un- disturbed by calls to other duty, for not unfrequently one of them is summoned a\vay by a Avant in some other department, or by some persons on a visit to a relative among the patients." So frequent are such interruptions, that I might safely say, that in some of the large hospitals there are Avards not visited, and patients not seen, by the superintendent for days and even weeks at a time; and all the information he has of such pa- tients he obtains from the supervising attendants or the as- sistant physicians. Is it not very evident that the knoAvledge of the patient, upon which the superintendent is supposed to base his treatment, must be very superficial and defective. Let us noAV quote from their reports, and show Avhat the medi- cal treatment consists in, and I will again quote Dr. Earle, who is one of the most distinguished of American alienists. He says: "The medical treatment is governed, as in all other diseases, by the general condition or the special symptoms in each individual case, the primary object in vieAV being to re- store the physical health to its normal standard, in the hope that the body being sound, the manifestations of the mind will be so. Insanity at the present time, whatever it might have been in the past, is a disease Avhich has its origin in debility, or an exhaustion of brain power and nervous energy; hence stimulants and tonics are necessary to a large extent in its treatment. It is often accompanied by excitement and loss of sleep, and frequently sedatives, anti-spasmodies and sopo- rifics are of marked utility. In its acute forms the liver is very frequently, even, perhaps, in a large majority of cases, implicated, requiring the use of chologagues. Not unfre- quently there is a depraved and perverted condition of the MANIA. 361 system generally, Avhich can only be removed by the adminis- tration of alteratives. This brief epitome comprehends nearly the Avhole of the therapeutics of insanity." The so-called moral treatment is no better. Dr. Earle truly says: "The insane generally act from the same motives, and are governed by the same agencies and inffuences.as other men. The patients should be treated as far as possible as if they Avere not insane." But hoAv are they treated? "They are marshalled out and ordered in at exact hours; they are compelled, forced, confined, locked up, tied up like refractory sheep, at a signal of disobedience, and their life is that of the inmates of a House of Correction or of a Reform school. And yet many of them are gentlemen of education, refinement, position; and ladies Avho have perhaps adorned the most fastidious society. Many of them still retain the mark, bearing and tone of their character and positions. They have, in the overthrow of their ordinary faculties, lost none of their native dignity or grace. They are here as in their former conditions, beloved and respected by many, yet what allowance is made for them by the administration of this 'moral treatment?' The same fiat that goes forth to bind the reins tighter for the rebel- lious or riotous patient, the same watch that keeps close upon the moA7ements of the sly and cunning eA7ader, are not varied to suit this or that shade of the disease, but the rule falls alike upon all. It is no respecter of persons or of types. Thus it may be imagined how much this class of patients must suffer, how dearly they must pay the penalty of their vague disease. The more the patient is deprived of his senses, the less of this mental suffering he will have to endure. The more he is himself, the more does self suffer."* AVith reference to home treatment and its comparative \7alue, the following views, from the ready pen of Dr. E. R. Eggleston, are worthy of consideration. The importance of the subject must be our apology for making such long quotations as are contained in this and the preceding extracts. "If I express my belief that a very large majority of cases are curable, and * Behind the Bars. 23 362 NERVOUS DISEASES. that the cure can be accomplished at the home of the patient, more surely and speedily than at any asylum, public or pri- vate, it is at once seen that insanity comes within the province of the humblest practitioner, and likewise, if it is true, forcibly brings home to him his responsibility. AY hose eyes should be keener to mark its beginnings, whose tongue more ready to warn of the approaching danger, Avhose brain better furnished to supply the means to avert the calamity, whose heart more open to the confidence of the enfeebled mind, than the family physician? How is the oversight of a 'superintendent' Avho, in these days, is degraded to a mere office hunter, to be superior? AY hat means of diagnosis or treatment are at the command of a 'physician-in-charge,' that are not at our disposal also? In what respects is the management of these unfortunates by 'overseers,' 'matrons,' 'keepers,' etc., so superior to that which might be carried out by fathers, mothers, husbands or Avives? And yet Ave advise, nay urge, that tenderly nurtured women, Avho, many of them, are keenly sensitive to their calamity, shall be throAvn into a prison, professedly for treatment, where the best boasted curative means are enforced restraint and fear of punishment! A\ no dares to deny his responsibility? It is, then, on account of the negligence or ignorance of physicians that cases are allowed to progress from small be- ginnings to the stage of confirmation, when the fact is recog- nized that the person is certainly crazy, and something must be done. Here it is that our responsibility for public opinion is most manifest. Instead of directing the current of sentiment with all the strength of a large and humane mind, avc too readily drift with the vicious stream that long habit has set in motion. In a given case, perhaps friends A and B are con- sulted—perhaps it is Dr. C—really it makes no difference which, for the advice is precisely the same: "send her off!" By all means, send her off, because, Aveak Avcman as she is, there are monstrous possibilities for danger in her. Stout-hearted, pro- tecting men propose it; trembling, tearful, sympathizing Avo- men urge it; awe-stricken, open-eyed children echo it; the doctor gravely bows his head to sanction it—send her off! From the view of the patient there is nothing to consider. Her wishes are but trifles; her dreads but bug-bears; her plead- MANIA. 363 ings but empty A7aporing; her prayers and tears but maniacal rage. Sensible of her misfortune, deploring it, struggling against it, no strong arm is extended to sustain her, but in- stead, relations, friends and doctor conspire; she is victimized by a pleasure-trip and left Avithin the Avails of an asylum to rage and rave, curse God and man—as well she may! Such humane methods are the beginning of the process of cure; months and years of fear, deprivation and maltreatment at the hands of brutal keepers is a continuation of it; and finally, a cage in a retreat for incurables is the end of it. The relations having performed a solemn duty, mourn' as for the dead; the friends add one more to the uncanny legends of the neighbor- hood; the doctor adds a plume for having treated a case of in- sanity—but his tell-tale case-book, which in another case may describe Avith labored particularity a diminutive ulcer, bears opposite this unfortunate's name the comprehensive description, "crazy." Barbarous, is the only proper designation for such treatment, and among barbarians should it only be tolerated."* This, perhaps, is a little too high-colored, at least so far as some of our asylums are concerned, but yet it cannot be denied that private treatment is best for the patient whenever prac- ticable. Unfortunately, many cases occur in families in Avhich poverty, or some other insuperable obstacle, Avill ahvays pre- vent the carrying out of such measures, however necessary they may be in a medical or humanitarian point of view; but we have no hesitation in expressing the conviction, founded upon personal observation and experience, that a much larger per- centage of cures can be made at home, and especially under homoeopathic treatment, than is made even in our best con- ducted asylums. And yet insane asylums are a necessity, and would be, if rightly managed, a very great blessing, both to the community at large, and to them for whose safety and well- being they are designed. It is to be hoped that the time is not far distant when public opinion will demand such a reform in the management of this class of our public institutions, as will secure to their unfortunate inmates the best medical, moral and hygienic treatment. * "Insanity; its Medico-Social Relations." 364 NERVOUS DISEASES. Private Treatment.—By private treatment avc do not mean complete seclusion, such as asylums afford, neither do Ave mean home treatment, in the sense of being treated in one's own family, surrounded by children and servants, and where no efficient restraint can Avell be exercised; but we mean that the patient should be remo\red from his own house, to one where the surroundings are such as to lead him to forget his malady, or at least to so occupy his mind by neAv objects as to divert it from the old, and not to call up, by sight or otherwise, any of those objects and influences Avhich occasioned, or are liable to aggravate his disorder. Aloreover, such removal will in many cases act beneficially, by rendering the patient more disposed to submit to the authority of his attendant, than would be the case if he remained where he Avas accustomed to haA7e his own way. His attendant should be a person of great self-control, discretion, kindness and watchfulness. His Avatchfulness, while unremitting, should not be obtrush7e, but on the con- trary, should be exercised in such a manner as not to attract the patient's attention. At the same time, he should ne\7er be negligent of his duty, remembering that his patient's Avelfare is entrusted entirely to his keeping. Moral rather than phy- sical restraint should be employed, the patient being at all times encouraged to exercise his oavu self-control. In case physical force needs to be employed, in order to secure the pa- tient's safety, it should be exercised with great firmness and discretion, and Avith as little violence as may be needed to se- cure the desired end. The folloAA'ing mode of managing the mental excitement of the insane avc regard as highly judic- ious, and far preferable to that ordinarily employed: "Dr. S. Rabon discards all narcotics, especially morphine and chloral. Just as every febrile affection demands perfect rest in bed, so he considers such a rest of the maniac a sine quo non. Mani- acs Avho, when up, tear everything to pieces and become dan- gerous, are soon quieted down in their beds; the patients be- come used to their situation, and tliere Avas never any ill effect from the horizontal position. Some patients had to be kept in bed for over a year, and they were not the worse for it. AYhere sleeplessness prevails, a tepid bath for about half an hour in MANIA. 365 the evening is to be recommended, Avith cold compresses to the head, Avhenever there is any congestion to that part. A cold douche does injury, and might only exceptionally be used as a means of punishment, In many cases, maniacs are brought into the ■asylum with a small, weak pulse and a mis- erable state of liealth. Here a strengthening diet and a glass of good wine sometimes works wonders. Maniacs who destroy everything and run about stark naked, are brought into an isolated room, where there is plenty of sea-weed kept for their use, and they are allowed to treat it ad libitum, and may sleep on it at night, for even if they should feel cold, they can roll themselves into it. Good food and plenty of it is the great se- cret of successful treatment. Any patient who is able and Avilling to work, ought to work for his own benefit, and as re- ward there are to be frequent occasions, like concerts, theatri- cals, dances, which reunite the lunatic with the outer world."* All depressing agencies, of Avhatever nature, should be studiously avoided. The cerebral irritation, congestion and inflammation of maniacs are all associated with, and in many cases are due to, an ansemic or debilitated state of the system, and instead of such patients being benefited by a sedative mode of treatment, such as Ioav diet, the cold bath and nar- cotics, they require the very opposite. A threatened attack of mania may frequently be prevented by the administration of a warm bath, stimulants, and a generous diet. For the same reason, everything about the patient should be made as cheer- ful as the circumstances of the case will admit. The room that he ordinarily occupies should be light and Avell ventil- ated, and ornamented with pictures, flowers, and everything calculated to gratify the innocent tastes of the patient. AVhen he has so far recovered his health as to admit of employment and recreation, he should be provided with such as will occupy both his hands and his mind, so that the latter Avill not react upon itself. The mind should also be strengthened, by gradu- ally directing the attention of the patient to former objects and associations. This, hoAvever, must be done gradually and * Bed. Klin. Wchschrift, June, 1876. 306 NERVOUS DISEASES. with great caution, as the mind remains Aveak for a consider- able period after apparent recovery has taken place, and an untimely allusion, or any sudden shock, may be sufficient to arrest recovery. • Medical Treatment.—AVe are indebted chiefly to Dr. N. B. Delamater for the folloAving excellent resume of the therapeu- tics of mania. A few clinical cases will be interspersed, by way of illustration. 1. Belladonna, Cantharis, Hyoscyamus, Stramonium, ATer- atrum alb. 2. Agaricus mus., Arsenicum, Cannabis, Crocus, Cuprum acet., Kali, Lycopodium, Lachesis, Mercurius, Phosphorus, Se- cale corn. 3. Aconite, Anacardium, Camphor, Conium, Moschus, Nat- rum, Nitric acid, Nux vom., Platina, Plumbum, Tartar emet. The first set of these remedies is most useful in acute mania. Most of the second and third class are suitable in chronic mania. Antagonistic States of the Mind. Anacardium.—AVhen the patient seems to have two opposite wills. Is inclined to laugh AA'hen he ought to be serious, and does not incline to laugh Avhen tempted by ludicrous things. Sepia.—AVhen he imagines things he does not want to im- agine; uses wrong expressions, knoAving them to be wrong; proposes to himself things contrary to his intentions ; is in con- tradiction with himself; has paroxysms of laughter and Aveep- ing in alternation, Avithout either resulting from a correspond- ing frame of mind. Phosphorus.—AVhen the patient laughs- against his oavh in- clination, which is very sad. Capsicum annA—AVhen he is merry, but nevertheless in- Staphysagria. J clines to get angry and be quarrelsome. Antipathies. Conium,—AVhen the patient is inclined to dislike every one who passes him; would like to lay hold of them and abuse them. mania. 367 Cicu.ta.—AVhen he abhors all mankind; hates their follies and seeks solitude. Aurum.—AVhen many persons are offensive to him. Ammonium mur.—A\Tien there are involuntary antipathies to certain persons. Calcarea curb.—AVhen there is aversion to most men. Apathy. Antimonium cmd.—AVhen the patient is completely apathetic; does not leave her bed; does not speak; desires neither to eat or drink, but eats readily what is offered and feels hungry. Argentum nit.—AVhen there is apathy with great debility and tremulous weakness. Gay Mania. The principal remedies are: 1. Aurum, Belladonna, Crocus, Lycopodium, Platina, Opium, Stramonium, Veratrum alb. 2. Aconite, Anacardium, Cuprum met., Hyoscyamus, Lache- sis, Natrum mur., Nux moschata, Phosphorus, Phosphoric acid. Belladonna.—A merry craziness Avith laughing and singing; tries to compose songs, and sings merry but senseless tunes, or whistles occasionally, but refuses either to eat or drink, or sings or hums different airs, or smiles a long Avhile to him- self, or is disposed to sing or whistle, Avith frequent bursts of laughter, or is wild and Avantonly merry, Avith inclination to quarrel without cause, or Avill tear off clothes, run out into the street, partially or wholly naked, gesticulating in a strange manner, crying, laughing, muttering, and demanding foolish things. Cicuta.—AVhen heated while asleep, Avakes, jumps out of bed, dances, and does all sorts of foolish things, clasps her hands, etc. Cuprum,—Sings merry songs. Hyoscyamus.—Dances, laughs in an absent manner, makes ridiculous gesticulations like a clown, and performs funny tricks like a monkey. Opium.—When the patient's mirth and bliss increase until he becomes irrational. 368 NERVOUS DISEASES. Stramonium.—AVhen in ecstacy and beside himself, when filled with pleasant fancies, expresses his Avishes by signs, and runs about for some clays exceedingly busy with his fancies and quite cheerful; or Avhen he dances, gesticulates, laughs and sings, or has paroxysms of constant talking, or breaks out into low laughter, or violent rage. Illus. 194.—Mrs. C. Avas delivered, June 23d, of a dead child, after a protracted and very difficult labor. She had shoAvn signs of mental weakness before and during labor, and at its close Avas extremely A'iolent. Chloral and morphine Avere pre- scribed by the allopathic physician in charge of the case. AVhen I first saw her, June 27th, she Avas suffering from acute mania, and exhibited the following symptoms: She Avas sit- ting on her knees in bed, moving arms, hands, feet and body in every direction, in the quick, nerArous manner so character- istic of lunatics. Accompanying this Avas a constant stream of talk, interspersed Avith an occasional maniacal yell, Avhile her eyes Avere Avide open, Avith pupils dilated. There AA-as no fever, the temperature being normal, Avhile the pulse Avas slightly accelerated on account of the intense excitement, There was no abdominal tenderness, and the discharge was normal. She Avas extremely violent almost all of the time, and obtained scarcely any sleep previous to my attendance, although under the influence of powerful narcotics all the time. Her appetite was good, boAvcls regular, and the urinary secretion normal in all respects. The predisposing cause of the insanity existed undoubtedly prior to labor. I judge so from the fact that she had a great deal of domestic trouble, and there was an hereditary tendency to such a condition. The exciting cause Avas the nervous shock depending upon labor, for she informs me positively that she remembers noth- ing from the time she felt the first labor pain, until she com- pletely recovered her reason, July 10th. The treatment was Stramonium 2x, given p. r. n. Improvement began at once, and on July 10th she Avas perfectly sane, and has remained so ever since.—Dr. P. P. Casseday. MANIA. 369 Mania avith Fear. Aconite.—Acute mania attended Avith fear, despondency and apprehensions of future calamity; anxious lamentations, accom- panied by disheartening apprehensions; anxiety attended AA'ith heat of the face and head, palpitation of the heart, and coldness of the extremities; apprehensions of approaching death. Illus. 195.—Mrs. E., set. about 30, actress, became restless, depressed, and possessed by delusions. Some three months be- fore, while nursing a very sick child of her brother's, it fell from the cradle and subsequently died. AVhen mania appeared, her most constant delusion was that "she had killed some one, and the officers of the hiAV Avere after her." She also said she Avas very Avicked and would die in a feAV hours; Avanted to see her friends first. She was constantly trying to cry, but the lachrymal font Avas dry—a symptom peculiar to the insane. On arrival, I found her with hot head and face, cold hands, pulse about 112, and the above delusions very acth'e; little appetite, costive, imploring protection from something dread- ful, she kneAV not Avhat, and under forcible restraint by her friends. She had the appearance of being terribly frightened. Prescribed Veratrum alb.20 Called early in the afternoon and found no improvement. Husband insisted upon something being given to cause sleep, as she had slept very little for two Aveeks. B. Opium20, Avith a request to call at office and get some tincture if she did not sleep by 8 p.m. Heard no more from the patient until calling the next day at noon. Found she had slept nearly all night. But the delusions were the same as before. On account of the fear she had that some cal- amity would overtake her, I prescribed Aconite*m. Called the next day, and found that after tAvo powders had been taken, the gloomy forebodings began to disappear; and in a few hours she became rational, calm, self-possessed, and laughter and good cheer took the place of moaning. During the night she Avas awakened by the ringing of the fire-bells, and was subject to the delusions again for a few hours, but in the morning was quite rational, and was able to shed tears for the first time in two Aveeks. More than a month has since elapsed, and there has been no tendency to relapse.—Dr. E. H. Peck. 370 NERVOUS DISEASES. Mania with Fury. Belladonna. 1—Acute mania attended with congestion of the Gelsemium. J brain; head hot, face flushed, eyes red and pro- truding, extremities cold, or cold and hot alternately, wild de- meanor. Illus. 196.—Airs. D., set. 27; has for years been subject to se- vere spells of rush of blood to the head, Avith temporary in- sanity. Arery Avild and entirely uncontrollable, except by force at the time. Her father died insane. She has been subject to pro- fuse blood-letting by allopathic family physician, Avhich would immediately relieve the congestion, but after a longer or shorter time Avould return again. She applied to me Avith face flushed, head hot, and every indication of severe spell coming on, and demanded to be bled for relief, but I per- suaded her to try a few powders first, and prescribed Bella- donna2'1, Avhich in a Arery short time removed the congestion, and for the first time at such attacks and much to her aston- ishment she escaped her insane fit. Since then she invariably takes Bellad. on the least return of threatening head symptoms, and has entirely escaped her insane spells for several years.— Dr. IF. M. Haines. Illus. 197.—Miss M., set, 16, after suffering for several Aveeks Avith melancholia, suddenly developed acute mania. After severe allopathic treatment, under Avhich she greAV worse, she had paroxysms of frenzy. Eyes red, protruding and ghastly ; hair dishevelled and Avild demeanor; talking and singing al- ternately; hands, feet and head, alternately hot and cold; tongue much coated; bowels constipated and appetite capri- cious. Gelsemium every hour cured in less than three weeks.— Hart. Cuprum.—Alania attended with full quick pulse, red and in- flamed eyes, wild looks, incoherent speech and rage, every pa- roxysm terminating in perspiration. Opium.—Furious mania Avith distortion of the features, swelling of head and face, protruding and congested eyes, bluish redness and swelling of the lips, paroxysms of rage, with rolling on the floor and threats against his own relatives, whom he does not seem to recognize. MANIA. 371 Ilyoscyamns.—Alternately ludicrous, solemn or furious; dresses in some fantastic way, as in a priest's gOAvn over his shirt AA'ith fur boots; wants to go to church in this guise in or- der to preach or officiate at mass, and ferociously attacks all who try to oppose him ; desires to go naked. Illus. 198.—About a year and a half ago, there was admitted to the Insane Asylum at Memphis, an Irishman, named Flaherty, a most violent and viciously disposed subject. He was'as belligerent as any frequenter of "Donnybrook Fair" among his countrymen, and had succeeded in disabling two men before he AA'as safely lodged in the Institution. He Avould wear no clothes, and amused himself by tearing such garments as he had, into tatters, and then binding the strips about his body, until he presented a zebra-like appearance. He became so noisy and violent, that it was found necessary to confine him in the strong room, and hamper his movements still further by means of the straight jacket. This Avas his condition for Aveeks, and he was certainly one of the most unpromising cases I ever saw, Remembering Dr. Guernsey's characteristic of Hyoscyamus: "the patient wants to go naked," I suggested to my colleague, Dr. Allen, Physician to the Asy- lum, a trial of this remedy. It was given in the 200th potency, tAvo or three doses in as many da} s, and then allowed to act undisturbed. A perceptible mitigation of the symptoms took place during the first week. At the end of the second week, the patient manifested no dislike to wearing clothing, and he was allowed the range of the ward with the other patients. He turned out to be naturally one of the mildest and quietest of men, and, in seven or eight weeks, was discharged thor- oughly cured.—Dr. Lucius Morse Tarantula— Restlessness of the hands and legs, constant movement, cannot remain in one place; restlessness, great and constant heat about the epigastrium; disposition to joke and laugh and play tricks, with impulsive movements. Sud- den foxlike and destructive efforts, requiring the utmost vigilance to prevent damages, followed by laughter and then apologies. All the symptoms relieved by music. Illus. 199.—Miss M., set. 27, a confirmed dyspeptic, while in a 372 NERVOUS DISEASES. highly nervous state from too close application to study, Avas operated upon for cataract by absorption. This Avas followed by great nervous depression and prostration, Avith occasional symptoms of mental aberration. After being treated several months for uterine disease, Avithout mental improvement, she was placed under my care, Avith the following symptoms: Restless, changeable, full of wants, sleepless; violent, screams, sings, bites, and throws things, destructive. Use Camirole and give Belladoanetlia, one dose. Next day, no better; violent; soils the bed with urine; furious. Cave IIyoseyamus3m, one dose. Next day, no better; sings loud and continuously, Avith laughter. Clave Stramonium150, one dose. FolloAving day, no improvement; no sleep for five days. In addition to the above symptoms, Avith thirst, she Avould suddenly spring out of bed, breaking and destroying Avhatever she could get hold of. This was done so quickly that it Avas almost impossible, with two attendants, to restrain her, unless she was kept bound. Gave her Tarantula100™- (Swan); fifteen minutes after, she Avas asleep, and continued in a quiet sleep tw7o days; then she aroused for a short time, Avith screaming. Gave her one dose of Tarantula10™; soon after, sleep, with catalepsy, for three hours, after Avhich, quiet sleep until the next day; she then aroused, was semi-conscious, and got up to void her urine and faeces, Avhich had previously been voided in bed. In the evening she recognized and kissed her mother, and then went to sleep again. She took but three more doses of the medicine, at intervals varying from three to ten days, chiefly for neuralgic symptoms, and continued to improve until, tAvo months after- wards, her only remaining troubles were her old complaints, dyspepsia and Avant of vision.—Dr. G. F. Foote. Religious Mania. Lach,esis.—Supposes himself doomed to eternal punishment. Stramonium,—Kneels down, stretches his hands out with pious look, starts up from the least opposition Avith Avild cries and A'iolent gestures. Aurum.—He imagines he is irretrievably lost, with depres- sion of spirits, with shouts and screams. mania. 373 Baryta,—He has all sorts of sad notions about future destiny, deems himself utterly lost. Crocus.—Gloomy, sad mood, with great anxiety about the future; fickle, changeable disposition; cheerfulness, mirth, joy, sadness, despair, all folloAV each other in rapid succession. Illus. 200.—Mary 0., set. 20, returned from boarding school greatly depressed in spirits, and complaining of sleeplessness and headache; her parents noticed that her naturally lively and gay disposition had undergone a complete change; she was now gloomy, and anxious about her future state, convers- ing much Avith her mother and pastor about it, stating to the latter that she expected to be finally lost. This condition of melancholia continued about eight weeks, during which there Avere short periods of gaiety and mirth, when her parents thought she Avas much better, and would soon be well; but just when their hopes were the highest she Avould suddenly relapse into a state of great gloom and despondency. At last a paroxysm of acute mania set in, attended with furious rage and disposition to bite. This state of excitement occurred every evening, and subsided toAvards morning, Avhen there was observed to be great prostration, accompanied with a ten- dency to laugh. After a careful study of the case, I concluded to give Cmcus30, three doses one hour apart, then placebo. Next evening she was quiet and rational, and remained so afterwards. Insomnia and pain in the neck and occiput con- tinued to trouble her, however, for several days, and did not disappear until I gave her a dose of Gelsemium3, after which she was able to resume her studies.—Dr. lames O'Leary. Suicidal Mania. Arsenicum.—Great indifference to life, inclination toward suicide. A\irum.—Excessive desire for water, with melancholy, no- tion that he was not intended for this world; anxiety amount- ing to a desire to commit suicide, attended with derange- ment and cramps in stomach and bowels. Illus. 201.—A woman, set. 30, was brought to the asylum, the leading characteristic of whose insanity was desire to commit 371 NERVOUS DISEASES. self-destruction. She had been rescued from hanging, caught as she Avas in the act of throwing herself from an upper -win- dow, but had succeeded in beating and bruising herself in a most distressing manner. This patient received Aurum 200th, three doses, Avhich promptly removed the suicidal mania, and though her case was of long standing, she Avas discharged cured, three months after her admission.—Dr. Lucius Morse. Belladonna.—Distaste for life Avith desire for death; Avishes some one to kill him; attempts to jump out of the windoAV, al- ternating with paroxysms of fury. Carbo veg.—Despair with weeping, everything seems clothed in darkest colors; inclination to suicide, Avith irritability, de- sire for death because he thinks he is most unfortunate. Nux vomica.—Inclination to commit suicide, Avith palpitation of heart and great anxiety; morose and taciturn; disposed to quarrel if disturbed; desire for death, because his agony of mind allows him no repose, because present pain and misfor- tune seem insupportable to him. Sepia.—Discouragement Avith absolute despair, attended AA'ith moroseness; distaste for life in an extreme degree, because he thinks he cannot endure his pitiable condition, and that he Avill be irretrievably lost if he continues to live. Alumina.—When he sees blood or a knife, he is seized AA'ith a multitude of terrible ideas, attended Avith an inclination to kill himself, although he has a horror of suicide. China.—Indicated where there is distaste for life, with mel- ancholy, anxiety and feverish heat, Avhich drives him to his bed, though he dreads to carry it into execution. Mercurius sol,—Disgust for life, from want of courage to meet trials and mortification, or desire for death, from an insupport- able dislike for every person and thing, even those which are most loved. Nitric acid.—Disgust for life, although one is afraid to die, prosperous, Avhen there is a disgust for life because the Avhole world seems gloomy and terrible, tears alone bring relief, and are followed by the most extreme apathy. Platina.—Distaste for life as if one was not suited to the world as it is, attended with great agony about the heart, fear MANIA. 375 of dying and depression of spirits. Disgust for the whole Avorld Avith inclination to weep. Pulsatilla.—Disposition to suicide, with fear of death and silent anguish; weeping mood and great depression of spirits; disgusted Avith everything, and yet tremulous with anguish, as if death Avas near. Rhus toxicoden.—Disposition to suicide, Avith dread of the future and Avant of confidence in himself; inexpressible an- guish, with restlessness, anxiety, apprehensiveness and painful uneasiness about the heart. Staphysagria.—Desire for death from an hypochondriacal in- difference to everything; disgust for life from anxiety and dis- gusting thoughts. Sulphur.—Disgust for life from discouragement and sadness, and from a feeling of being exceedingly unhappy. Zincum met.—Desponding, sad, sullen and peevish; indiffer- ent to life, with a desire to die; he moans from chagrin, and is exceedingly loAV-spirited, irritable and debilitated. 376 NERVOUS DISEASES. CHAPTER II. DEMENTIA. Dementia is a term used to denote a partial or total loss of the mental faculties. In its complete form it resembles idiocy, but differs from it in the circumstance that in the latter there never has been a development of intellect, Avhile in dementia there is a loss, more or less complete, of previous intelligence. In dementia there is a gradual decay of the mental faculties, Avithout complication with either melancholia or mania. This definition, however, only applies to the disease as an original affection. When it succeeds mania or monomania, paroxysms of A'iolence Avill occasionally occur, but these are mere surface ebullitions or transitory perturbations of a disease Avhich has subsided. The general state of the mind is one of calmness and apathy, the result of mental imbecility; or,in the express- ive language of M. Georget, it is one of forgetfulness of the past, Avith a total indifference as to the present and future. Symptoms.—The disease first shows itself, as a general rule, by failure of the memory. The most familiar Avords ancl names are not only soon forgotten, but they are frequently misapplied. Remote events, which have made a deeper impression on the mind than the more recent, are frequently recalled, the patient liA'ing over again, as it were, his past experiences. Thus, he speaks of having lately participated in scenes which transpired long ago, of meeting acquaintances long since dead, ancl so on. There is generally no marked deficiency of ideas at this stage, but there is loss of mental poAver, Avith confusion of ideas, in- accuracy of expression, more or less hesitancy of utterance, and a gradual loss of reasoning poAver. AVords and sentences DEMENTIA. o—fj arc misplaced and misapplied, sentences inverted, and the grammatical order constantly violated. Ideas and phrases which the patient has long been accustomed to use, may, it is true, be employed in a more or less orderly and sensible way; but the mind is incapable of reasoning in such a manner as to lead to a logical conclusion. The moral faculties undergo a similar decay. The patient exhibits little or no feeling for the joys or sorroAvs of others, friends are seen Avithout emotion, his sympathies are blunted, his desires selfish and narroAv, and he manifests general indifference to all but his former ruling pas- sions, such as avarice or ambition, Avhich to some extent may still influence his conduct. In this state the demented are capable of being employed in occupations Avhich require little or no thought, such as sewing or knitting; and they may even write letters and sentences, but the latter will generally betray their imbecility. AVhen not thus employed, they are quiet ancl inacth'e, taking little notice of what is going on around them, but frequently smiling or singing in an idiotic sort of Avay, without any apparent reason. As the disease advances, they become more and more imbecile, until, in the course of time, their minds become a perfect blank. Their mental capacity is now beloAV that of the brute, since they are without its instincts. They remain sitting or crouching in one position hour after hour, alike insensible of their physical necessities or lack of comfort. They eat only Avhen food is placed before them, or when fed by others; are inattentive to personal cleanliness and decency; and Avhen spoken to, stare at the speaker in a vacant and meaningless manner. Such patients, however, are not always sombre looking, but laugh or smile in a weak, sickly way, which, like the vacant and puzzled look and lustreless eye, equally betrays the vacuity of mind. At last they sink into the state of complete amentia, in which they pass a mere vegetative existence, and present a degree of mental degrada- tion almost surpassing belief. Standing or sitting immovable, their bodies bent forward and their eyes fixed upon the floor, never appearing to be conscious even of their own existence, thcv present a spectacle deeply affecting to every sensitive mind. Comparatively few reach this state of mental vacuity 21 378 NERVOUS DISEASES. without having lost the use of their limbs by paralysis, as al- ready described under the head of "paralysis of the insane" (q: v.). The physical health of these unfortunates is often tol- erably good. The} sleep Avell, have good appetites, are often plump, ancl, if previously thin ancl emaciated, not unfrequently recover their flesh as the disease advances. Such, however, is not the case with the strength; but, as the countenance gra- dually loses its expression, the strength declines, muscular tremor sets in, the gait becomes uncertain and tottering, and finally gives place to the paralytic condition before mentioned. Causes.—The predisposing and remote causes are the same as already mentioned under melancholia and mania (q. v.). Other causes are: Old age and senile decay, brain exhaustion, fever, sunstroke, etc. Prognosis.—The prognosis, as might be expected, is exceed- ingly bad. In cases preceded by mania, the improvement of the physical health without a corresponding amelioration of the mental condition, is of the most unfavorable omen. Some rare cases of recovery, however, are said to have occurred, espe- cially among young subjects, after seA'ere attacks of fever or acute mania. Pinel informs us that many young persons, Avho had passed several years or months at the Bicetre in a state of complete dementia, had had their reason restored to them in this manner, though as a general rule such attacks are fatal to lunatics. Such accidental recoveries can only take place dur- ing the stage of dementia; after complete amentia has set in the case is altogether hopeless. Pathology.—The anatomico-pathological condition is one of diffuse interstitial inflammation of the great nervous centres, Avhich leads sooner or later to destruction of ganglion cells and atrophy of the nervous structures. Tliere is thickening and adhesion of the dura mater, an oedematous state of the pia mater, and an effusion of serum over the middle and posterior lobes of the brain. The pia is discolored and thickened, and adheres to the surface of the brain Avith such tenacity as to tear the cineritious substance on attempting to separate it. The convolutions are Avasted, especially those of the anterior lobes, which are changed into an inert mass by degeneration DEMENTIA. 370 and destruction of the ganglionic cells, the formation of amy- laceous bodies, and hypertrophy of the connective tissue ele- ments, which condenses ancl indurates it. The bloodvessels undergo calcareous degeneration, and their sheaths, according to Dr. Lockhart Clarke, are enlarged from atrophy of the cere- bral tissue, and contain granules of haematoidine. The ven- tricles are dilated, the medullary matter softened, and the central ganglia shrunken and puckered. The weight of the brain is often found reduced to two pounds, and even less. Such extensive degenerative changes, however, are only found in cases of complete dementia; lesser degrees of the affection being, as a rule, attended with similar but less marked altera- tions. In the earlier stages they are chiefly confined to the eA'idences of inflammation above noted, such as effusion, adhe- sion, thickening, etc.; while the degenerative changes and Avasting belong mostly to the latter stage. Indeed, the degn e of imbecility is generally pretty accurately measured by the amount of atrophy and destruction of ganglion cells which the cerebral nerve-centres have undergone. Treatment.—On this point little can be said. The same careful tending and nursing are required as in infancy, the Aveakness and helplessness being equally great. Although a cure is not to be expected, medicines are often of the greatest utility. Such remedies as Arsenicum, Acidum nitr. and phosph., Carbo veg., China, Digitalis, Phosphorus, Nux vom. Podophyllin, etc., are frequently required to render the patient more comfortable, and to prolong his life; Avhile during the earlier stages, the decay of the mental faculties may be greatly retarded, and in some cases arrested, by Anacardium, Ignatia, Nux vom., Phosphoric acid, etc., the selection being determined strictly according to the symptoms presented by the patient at the time of prescribing. 380 NERVOUS DISEASES. CHAPTER III. CEREBRAL EXHAUSTION. Cerebral exhaustion, or brainfag, is a species of mental de- bility resulting from o\7ertasking the faculties of the mind. In these days of severe competition, not only our business men, but our academic and collegiate youth, our scholars and our professional men, are all struggling to attain to the fore- most rank in their several callings, and in the attempt to reach it, often make shipwreck, not only of their hopes, but of their minds, by exertions which prematurely exhaust their nervous resources. Brain-work is not unhealthy, provided it is not carried to excess, and is not attended by constant Avorry and anxiety. On the contrary, it is, under favorable circumstances, as healthy an occupation as any out-door employment; but such is the intense application, anxiety and responsibility involved in the present pursuit after Avealth, station and fame, the constant worry it produces, the tremendous strain on the mental faculties, coupled Avith the continual violation of the plainest and best-established rules of hygiene, that it is no wonder the mental powers soon become exhausted. For be it remembered, it is not simple brain-work that causes the mis- chief, if it were, the Germans, Avho surpass us all in intellectual achievments, would be a nation of sufferers from cerebral neurasthenia; but it is excitement, anxiety, and mental dis- tress that cause the disease. AVere Ave to return to the quiet life and labor of our forefathers, such consequences Avould not ensue, nor would we as a nation be half as prone as avc are to other nervous disorders. The English nation from which Ave sprung, are more sensible in this respect than their fast-living, CEREBRAL EXHAUSTION. 3S1 brain-exhausting American cousins, and they doubtless reap the benefit of their moderation in greater mental and physical possibilities. Symptoms.—The initial stage is marked by excitability, frequent loss of temper, and a disposition to Aveep at trifling causes. The Avithdrawal of nerve-force manifests itself, also, by sleeplessness; frequent attacks of neuralgia; susceptibility to atmospheric influences, especially cold; palpitation of the heart, particularly after exertion; headache; loss of memory; loss of appetite; cutaneous eruptions, especially eczema and acne; heaviness and paralytic weakness of the lower extremi- ties; backache, AA'ith creeping sensations along the spine; epileptiform conditions of the nerves, and sometimes transitory coma. Doss of virile power is a prominent symptom, and the one generally first noticed by the patient. At a more advanced stage, the disease verges upon insanity. The patient loses all control over his moral faculties; he becomes melancholy; iras- cible; given to hobbies; self-Avilled; and is very apt, if tem- perate, to become addicted to the use of intoxicating liquors, for Avhich he has a morbid craving. An examination of the urine of such patients, Avill show that the disease is attended with a copious discharge of phosphates. This waste is soon followed by profuse night sweats, and great debility. If not arrested, the disease will lead to emaciation and premature old ase, if not to suicide. Causes.—These have been sufficiently noticed in our intro- ductory remarks. The chief cause is over-work, coupled with anxiety, fast-living, and unhealthy competition. Treatment.—Hygienic measures are of the first importance. The chief of these are rest, and a radical change of scene, diet and habits. On this subject, Dr. Radcliffe, in his "Croonian lectures," gives the folloAving sensible advice: "Dirt.__A properly mixed diet is best in the generality of cases. The present practice of urging persons at all weakly, especially children, to eat as much meat as they can, may have not a little to do in developing many nervous disorders, and in deranging the health in many other ways besides—perhaps in causing liver and kidney and other glandular disease by overtaxing the eliminating powers of these organs. 382 NERVOUS DISEASES. Exercise.—Too much Avalking may be one cause of a break- down in health,, in Avhich little or no progress is made towards recovery until the patient begins to economize his strength in standing quite as much as in Avalking, perhaps more. It would often seem as if the amount of vital power at the dis- posal of the individual did not alloAv of much head-work and much leg-work together, though quite sufficient to allow of a fair amount of either singly; and that, under these circum- stances, if the head-work must be done, it is expedient to avoid Avalking exercise rather than to seek opportunities for taking it, and often to settle down in an easy-chair and have a.nap than to Avalk at all. It is a common thing for a person suffer- ing from cerebral exhaustion to find that he cannot stand or walk except for a short time, and that, if he persists, he soon becomes faint and breathless and unable to talk, though com- paratively fresh and Avell before. It is also a common thing, in such a case, for Avalking exercise, hoAvever moderately indulged in, to be folloAved by inability to keep the thoughts to the point, or by distressing drowsiness or actual sleep; the walking, in short, having brought on head-symptoms Avhich Avere not present previously. In very many cases, the persistence in Avalking and standing, Avhen rest is rather needed, has had much to do, not only Avith bringing on and keeping up a state of cerebral exhaustion, but with pushing matters to the crisis of hemiplegia. Brain-work.—In regard to heacl-Avork, rest may be too much insisted upon in cerebral exhaustion and in other cases of the kind. AVhat is AA'anted generally, even at the beginning, is, not that work should be given up altogether, even for a short time, but that it should be moderated in amount, or changed. It is a grave mistake to let the mind lie fallow, even for a short time, not only in the particular case under consideration, but in all cases Avhere head-symptoms have to be dealt Avith— in epilepsy, for example, no less than in cerebral exhaustion. Of course this notion may be carried too fan Undoubtedly harm may be done by pressing the necessity for Avork too strongly; but, practically, this danger will prove to be small in comparison with that of letting the mind lie falloAV. CEREBRAL EXHAUSTION. 383 Sleep.—With regard to sleep, the recumbent position has obviously very much to do. with it. Undoubtedly sleep may occur in the sitting posture, and even Avhile standing, but these cases are exceptional. It is certain, also, that sleep in bed is, as a rule, sounder Avith a Ioav pilloAv than with a high one. If, then, there be a state of wakefulness at night, the head should be kept low; if on the contrary, there is undue sleepiness, the head should be kept high. The degree of sleep, and the amount of it, may be regulated by simply taking care that the head is in the right position. If prolonged recum- bency is a necessary part of the treatment, the tendency to sleep too much during the day and too little at night may be thus corrected. By raising the head in the day-time, the patient remains aAvake sufficiently to be able to sleep at night; by depressing the head at bed-time, the conditions are ren- dered more favorable to sleep during the night; and, as a rule, sleep is to be conciliated in this way without the help of narcotics." Change.—But after all, as stated in the outset, many cases AA'ill fail to yield satisfactorily until a radical change of scene, temperature, atmosphere, diet and habit is brought to bear upon the mind and body of the patient. The tendency is for the mind, as well as the body, to become greatly depressed, and in this state will react upon itself by continual worry and anxiety, unless occupied by new thoughts and associations. As long as the patient remains surrounded by the same objects, there is nothing to change the current of his thoughts, and so he sits and broods over his condition, until he works his mind into a state of feverish excitement, as wearing upon it, if not more so, than the most intense application to study or business. A total change of scene, therefore, is often called for in these cases, even when there is no. other reason for making it. But too high or too low a temperature is prejudical in cases of ce- rebral exhaustion, especially the latter, and no amount of clothing, or of artificial heat, will compensate for too great a reduction in the temperature of the atmosphere. AVhen the nervous system is greatly weakened, the patient is as sensitive to extreme atmospheric changes as a thermometer, and a cor- 384 NERVOUS DISEASES. responding degree of nervous depression is sure to result from them. The patient, therefore, should, if possible, go north in summer and south in winter, in company Avith a congenial companion, so that the mind may be diverted and exhilarated by ucav scenes and associations, and the nervous system re- lieved of all unnecessary strain. Illus. 202.—Reuben M., set. 34, broker and speculator, had become broken down by a variety of causes. In addition to his OAvn affairs, after nursing his father through a long and fatal illness, he was called upon to attend to his extensive busi- ness, a large cotton manufactory, Avhich was left in a very unsat- isfactory state. In addition to this, his only son was stricken down with typhoid fever, and although his life was spared, his father passed many sleepless and anxious nights on his account. For the last three months and a half he had been under allo- pathic treatment, all the time getting Avorse, and when I Avas called to take charge of the case, his condition was as follows: Anaemia, wakefulness, great Aveakness and prostration, feeling of exhaustion in the chest, considerable pallor of the face and hands, emaciation, loss of appetite, constipation, palpitation of the heart, great depression of spirit, solitary, taciturn, irritable, suffering with profuse night-sAveats, followed by chilliness. Pulse 90; temperature 96°. For the night-SAveats, chilliness and general Aveakness, he had been taking, for about two weeks quinine and aromatic sulphuric acid. I placed him on Phos- phoric acid, lx dil., fifteen drops in a tumbler of water, a tea- spoonful three times a day. This put an immediate stop to the night-sweats, and they did not return. The urine Avas found loaded Avith phosphates, which did not perceptibly di- minish under anv treatment that Avas tried, including; Phos- phor., Calc. hypophos., Pier, ac, Flyosc, Arnic. As a conse- quence, the patient, though relieved of his annoying night- sweats, chilliness, etc., gradually greAV Aveaker and more de- pressed in spirits; and as the Aveather Avas extremely cold, it was determined to send him south for a change of scene, cli- mate and habit, His cousin accompanied him; ancl as he had received the most benefit from the Phosphoric acid, he continued to take it during his trip, but took no other medicine. After CEREBRAL EXHAUSTION. 385 spending about six weeks in Florida, he traveled by easy stages through the Gulf States, and when he returned to his home in June, after an absence of about five and a half months, he Avas well, and able to resume his business.—Hart. Medical Treatment.—The remedies Avhich have proved most beneficial in cerebral exhaustion are: Erythroxylon coca, Calcis hypophos., Ignatia, Nux vomica, Picric acid, Phosphoric acid, Phosphorus, Secale cor., Pulsatilla, Arnica, Rhus tox., Zinc phosphide. Arnica.—A\Teak, pale, nervous individuals, suffering from a general sinking of strength, and a disposition to faint: drowsi- ness during the day, but Avakefulness during the night, or until two or three o'clock in the morning; irritable, peevish and dis- posed to be quarrelsome; greatly depressed in spirit, and fear- ful that he Avill never recover his health; loss of appetite, Avith a bad taste, desire for sour things, and a repugnance to meat; nausea, and empty or offensive eructations; feeling- of exhaus- tion in the chest; pain in the small of the back; yelloAvish urine, filled Avith phosphates; trembling in the lower extremi- ties, with great weakness and prostration. Calcis hypophos.—Nervous prostration, Avith depression of spirits; profuse night-sweats; pale, wan and emaciated counte- nance; loss of virile power; habitual coldness and venous con- gestion of the extremities from debility; sleeplessness, loss of appetite and emaciation. En/throxylon coca.—Sleeplessness and disinclination to Avork or move; mental depression, with anxiety and palpitation of the heart; pale lips ancl gums, with quivering of the lips; loss of appetite, constipation with abdominal distention; oppres- sion of breathing arising from debility; eruptions in various parts of the body of eczema and acne; fainting fits from ner- vous Aveakness; general debility, the least exertion is attended with fatigue. Illus. 203.—A gentleman consulted me last March, by letter, about his hearing, for Avhich I recommended an infusion of Cora, in case the 3d tincture gave no relief. On the 2d of August, following, he replied: "I delayed answering your letter until I had given the Coca a fair trial. I got some leaves and 386 NERVOUS DISEASES. made an infusion, putting twelve to twenty leaves in a small teapot, -with about a breakfast cup and a half of boiling Avater, allowing it to infuse for some fifteen minutes. This I took morning and evening, and still take it instead of tea, ancl for about three months the effect has been something Avonderful; from being depressed and very low spirited, easily tired, I can now walk any length of time Avithout feeling fatigue. Before taking the Coca my nerves seemed so unstrung, that Avhen I read a pathetic tale I could not refrain from becoming very much affected, although I tried hard to overcome the absurd feeling. Now I am quite myself again. October 22d.—I continue to take the Coca for breakfast and tea Avithout milk or sugar; it has done me a Avorld of good, and I feel myself up to any amount of work, although I have just turned fifty-eight. I attribute all this to the Coca. For breakfast I take a plate of oatmeal porridge, and then the Coca with an egg, or some cold meat or bacon, Avith toast Avithout butter. AVe dine at half-past two. I take mutton or beef, no potatoes, and very few vegetables, and sometimes fish before, a light pudding after, but no pastry, nor cheese, nor soup, as these seem to affect my hearing.—Dr. Tuthill Massy. Ignatia.—Sleeplessness; apprehension; disposed to weep from the most trifling causes; Aveakness of memory; alternate excitement and depression; pale, sunken face, or alternate red- ness and paleness; loss of appetite; feeling of repletion after swallowing the'first mouthful; complete absence of the sexual desire; oppression of the chest and breathing from Aveakness> especially after midnight; palpitation of the heart after eating, or in the morning; coldness of the extremities, Avith heaviness and Aveakness. Nux vomica,—Irritability of temper, headache, AvakefulnesS) constipation, and bilious derangement. Phosphoric acid.—Profuse night-sAveats, followed by chilli- ness; cold sweats during the day, or on the least exertion! falling of the hair; great fatigue on exertion; loss of virile power; general debility, with feeling of extreme weakness and ■ prostration. Phosphorus.—This remedy, either in the form of food or CEREBRAL EXHAUSTION. 387 medicine, is essential to cure in most cases. The chief indica- tion is an excess of phosphates in the urine, slioAving that the brain is deprived of its phosphorus. As it requires to be given in a Ioav form, it should be taken immediately after eat- ing, in order to avoid irritating the stomach. Picric acid.—Great chilliness, followed by cold, clammy sweat; general lassitude, Avith great muscular Aveakness; chilliness, coldness of the feet, and heaviness and Aveakness of the extremities; profound debility, Avith speedy exhaustion from the slightest exertion; excess of phosphates in the urine. Pulsatilla.—Gloomy and melancholy, Avith constant disposi- tion to Aveep; anxiety, apprehension and irresoluteness; pale face, or redness alternating with paleness; want of appetite, Avith bad taste in the mouth, and coated tongue; unsteadiness and weakness of the loAver extremities, with heaviness; espe- cially adapted to sensitive females Avhose monthly periods have become deranged. Rhus tox.—Restless anxiety and apprehension, accompanied with uneasiness about the heart, or pain in the small of the back; complete loss of appetite for any kind of food; cutaneous eruptions, especially eczema and acne; heaviness and weari- ness of the loAver extremities, with general debility. Secale cor.—AA'akefulness at night, or restless sleep, with heavy dreams; great depression of spirits, Avith sadness and anxiety; difficulty of thinking and talking; hardness of hear- ing, Avith humming and roaring in the ears; cheeks pale and sunken; aversion to food, \A7ith nausea and eructations; anx- ious and difficult respiration, the result of nervous debility; Aveakness of the loAver extremities, with numbness, insensibility and coldness; cold sweat, attended with chilliness and slow, weak pulse. Zinc phosphide.—The indications for the employment of this remedy, according to Hale, are: "brain-fag of business men who become haggard, pale, sleepless, and suffer from de- pression of spirits and causeless worry." According to Ham- mond, who first introduced the remedy, it removes the debility, mental depression and paralysis following attacks of cerebral. congestion or apoplexy. 388 NERVOUS DISEASES. Illus. 204.—J. B. AIcK., merchant, about forty years of age, nervo-bilious temperament. For five or six years he had suf- fered from extreme nervousness, affecting his head mostly, and upper part of spinal column; pain sometimes in his neck and back part of the head; then again in his temples, as if some- thing Avas pressing in from one side to the other on the brain; vertigo or dizziness ahvays present; weak digestion, torpid liArer; hands and feet always cold; one of the most distressing symptoms, that of fear; he Avas constantly oppressed Avith an indescribable anxiety, or indefinable fear—fear of something, he knew not Avhat; Avas easily startled. A prominent feature of the case avos, that a recumbent position ahvays relieved the vertigo and improved the other symptoms. This is but the outline of a series of unpleasant symptoms that medicine had failed to relieve. In February I put him on Zinc pltosphidc3; and under date of April 12, he writes: "So much better I have discontinued the medicine."—Dr. J. A. Young. Illus. 205.—Maurice ('., al. 34, merchant, broke doAvn from mental anxiety attending an effort to prevent an assignment in 1874. For ten or tweh7e weeks he had not slept more than one hour out of every twenty-four, and Avould frequently lie awake the whole night. He Avas troubled Avith headache, and vertigo, great depression of spirits, dread of something about to happen, excessive nervousness, loss of appetite, bitter taste in the mouth, genital organs relaxed and flabby, coldness of the hands and feet, great Aveakness and feeling of insecurity Avhen standing, and sometimes when sitting, great heaviness and Aveakness in the lower extremities, oppression of the chest and difficulty of breathing after the least exertion, inability to grasp an object Avith any firmness, and an equal inability to think consecutively and to any purpose. Other remedies, in- cluding Nux vomica, Ignatia, Phosphorus, Phosphoric acid, and Strychnia, having failed to relieve him, I placed him upon the Phosphide ofi Zinc3, three times a day, with the hap- piest effect. In about five weeks from the time that he took the first dose of the medicine, he was well enough to resume business, and he has remained Avell since, a period of over four years.—Dr. Francis Temple. DELIRIUM TREMENS. 389 CHAPTER IY. DELIRIUM TREMENS. Delirium tremens, or, as the disease is sometimes termed, delir- ium potatorum or ebriosornm, is a form of delirium resulting from the habitual use, or rather, abuse of alcoholic liquors; and is so called from the muscular tremors that accompany it. The delirium is of a muttering, hallucinary, stirring, anxious, apprehensi\7e kind; and the tremors, though general, are chiefly confined to the hands and tongue, the latter being especially observable Avhen protruded. The disease should not be confounded Avith inebriation, or an ordinary fit of in- toxication; much less, Avith dipsomenvia, or a morbid craving for intoxicating drinks, which is a species of moral insanity (q. v.). Prior to the year 1860, the disease Avas generally classed among the neuroses, but it has since become the fash- ion to rank it among zymotic diseases; as, hoAvever, it is much more a nervous than a zymotic disorder, we shall treat of it as such. Symptoms.—In most cases the attack is preceded by symp- toms of chronic alcoholism, the principal of which' are: wake- fulness, dulness of intellect or mental stupor, and loss of natu- ral appetite, especially for solid food. These precursory symp- toms, it will be observed, are not peculiar to delirium tremens, being common to many other affections, especially those impli- cating the cerebral functions. Hence, they are of but little value in a diagnostic point of view, except as they are weighed in connection with the individual's habits. These symptoms may continue for a considerable period before the delirium sets in and when it does, it is manifested by an increase of the 390 NERVOUS DISEASES. same symptoms; the patient experiencing an utter loathing of food, Avant of mental control, and complete loss of sleep. This condition produces a restless, irritable state of the mind and body, Avhich soon reaches an extreme degree. The hands and tongue become tremulous, and the excitement is heightened by the patient making constant but ineffectual attempts to occupy himself, in consequence of the incessant agitation and alarm under which he labors. His mind is filled Avith various pain- ful delusions, concerning his friends and others, Avhom he thinks are plotting mischief against him; and this is increased by spectral illusions and imaginary horrors, in Avhich he sees snakes, beetles and rats SAvarming about the room and in his clothing, ready to devour him, and which he is constantly try- ing to drive away, or from which he makes frantic efforts to escape. Even in his more quiet moments he is restless, con- stantly changing his position, and visibly trembling, often de- claring that strangers are present, or are lying in concealment, ready to attack him. He is, however, generally, easily pacified, and may be induced to remain quiet for a considerable period, by such measures as are calculated to insure confidence. He is evidently in mortal dread of some enemy, either appearing or disappearing to his mental vision, and this, with the depri- vation of sleep and nourishment, give him a pale, weak, and worn appearance. The tremor, which affects the hands and upper extremities generally, is in most cases incessant, but sometimes, especially in young and otherwise healthy subjects, it is almost entirely Avanting. The skin is cold and clammy, the boAvels costive, the urine scanty and loaded with urates, and there is pain and sense of constriction in the region of the liver. The carotid arteries throb with violence, but the radial pulse is small and weak, varying in frequency from 90 to 120. The eyes are red and injected, the tongue foul, and the appe- tite entirely lost. After this condition has lasted two or three days, a state of exhaustion sets in, which either terminates in a tranquil sleep, or ends in collapse and death. Tliere is a natural tendency for the disorder to terminate in sleep at the expiration of the period mentioned, and this sleep being criti- cal, the patient awakens from it convalescent, though still weak and exhausted. DELIRIUM TREMENS. 391 Causes.—It is now a well-established fact, that delirium tremens is a toxological condition, the direct result of the poi- soning of the nervous centres by an accumulation of alcohol in the system, in consequence of the continued abuse of stimu- lants, and not, as Avas formerly supposed, a disease of exhaus- tion or irritation, resulting from its sudden Avithdrawal or diminution. Its effects upon both man and animals have been carefully studied, and its poisonous qualities clearly demon- strated. If a toxic dose is giA7cn to a dog or other animal, it loses control over its muscular movements, exhibiting at first the usual symptoms of intoxication. It walks in an uncertain and irregular manner, as though its movements Avere no longer under the control of its own Avill. After a time the hind-legs become paralyzed, the fore-legs preserving, to some extent, their activity. The general sensibility diminishes, and soon the animal can neither feel nor see. After this the respiration fails, and finally the circulation ceases—life becoming extinct. The effects of alcohol upon man are only too well known. That it acts upon the brain through the medium of the circu- lation, AA-as not clearly demonstrated until 1800. In that year, MAI. Lallemande, Perrin, and Duroy, of France, published an elaborate work, entitled: Du Rdlc de VAlcohol et des Anesthes- iques dans V Organism, which received the prize from the acad- emy of sciences. In this work, Avhich abounds in careful and Avell-managed experiments, it is conclusively shoAvn, that "al- cohol stays for a time in the blood, that it exercises a direct and primary action on the nervous centres, Avhose functions it modifies, perverts, or abolishes, according to the dose; that neither in the blood nor in the expired air are any traces to be found of its transformation or destruction; that it accumulates in the nervous centres, and in the liver; and that it is finally discharged from the system by the ordinary channels of elimi- nation." (Op. cit,, p. 580). So far from carbonic acid being one of its final products, as Avas formerly thought, these authors show that it causes a diminished exhalation of that gas. The alcohol, Avhen it has entered the blood, is diffused over the whole system, remains, apparently, during different periods in different organs and parts, and begins almost immediately to 392 , NERVOUS DISEASES. escape; and if as much as eighty grammes of spirit of wine is taken, the urine passed some hours afterwards yields by dis- tillation an amount of alcohol capable of burning; and the elimination by this channel continues for sixteen hours or more. The elimination through the lungs continues for about half this period. These authors believe that the skin is the chief excreting organ, but they have no data for showing how long the process is continued. They show that when a quan- tity of Avine, equivalent to thirty grammes of alcohol, has been taken, its presence may be readily detected in the blood, the urine, the expired air, and the cutaneous exhalation in the course of half an hour after it has been taken. In animals destroyed Avhen intoxicated, the brain and liver are found to yield, Aveight for Aveight, considerably more alcohol than the blood. It is thus seen that alcohol, by accumulating in the system, acts, more especially, upon the nervous centres, giving rise to the symptoms of chronic alcoholism, and finally to de- lirium tremens. In the light of the above facts, avc can easily understand how much the danger is increased, by the almost total absti- nence from food, Avhich those addicted to the use of alcoholic stimulants are inclined to practice, in consequence of the loss of appetite produced by them, and the loathing they have during the seizure for every form of solid food. On this sub- ject Sir James Paget says: "So long as a man keeps up both eating and drinking he is in little risk of delirium tremens. Either Avhen he suddenly leaves off eating and takes to drink- ing, or when he gradually diminishes his food and increases his drink, he is in the greatest danger of that disease. So that we come to this—which may seem paradoxical and immoral too—that a man who both eats and drinks too much, is in less danger than a man who commits only one of those excesses. The double fault is less mischievous than the single; the eat- ing counteracts the harm that Avould ensue from the drinking. If we look about in society Ave may see this very plainly. There are still many persons habitually engaged in too great eating and drinking, doing both to excess; and they are in danger of breaking down in various defects of digestion and DELIRIUM TREMENS. 393 the consequent disturbances, but they are in no danger of de- lirium tremens. The people Avho are in that danger, and show the evil effects of drinking in the most marked form, are they Avho drink largely and eat little." Anatomical Appearances.—In death from acute alco- holism, according to Althaus, a strong alcoholic smell is ob- served in the cavities of the body ancl in the muscles. The liver, spleen and kidneys are hypersemic, the mucous mem- brane of the pharynx, oesophagus, stomach, small intestines, and bronchial tubes is red and injected. The membranes and substance of the spinal cord and brain are hypersemic, the left ventricle and arteries empty, the right side of the heart, the large veins ancl the tissue of the lungs contain a very large quantity of dark fluid blood. The brain is firm and white, and in the ventricles a quantity of serum is found, which smells strongly of alcohol. In chronic cases are often super- added, sclerosis of the cerebro-spinal centres, in cases attended with imbecility, insanity and paralysis during life; chronic catarrh of the bronchial tubes, Avhich is sometimes combined with emphysema, and has during life gh7en rise to asthma ancl other respiratory troubles; enlargement of the liver, granular degeneration and cirrhosis of that organ; atheromatous disease of the heart and arteries, and lastly the atrophic form of Bright's disease of the kidneys. The blood has been found charged Avith fat, so that the serum appears milky-Avhite, and loses this color when treated with ether, slioAving that it is not due to particles of albumen or Avhite blood-globules.* Pathology.—Since the year 1854, Avhen Dr. Peddie, of Edinburgh, published his facts and arguments in opposition to the fallacious notions then held as to the nature of delirium tremens, the views of physicians regarding the pathology of the disease may be said to have undergone a complete revolu- tion. The general belief at that time was, that the disease was the result of temporary absence from drinking, whereby the system was deprived of its accustomed stimulus. Dr. Pecldie has shown, both by analogy and by direct evidence. * Althaus on Dis. of the Nerv. Sys., pp. 134, 278. 25 394 NERVOUS DISEASES. that this is not the case. "Mercurial fumes, when long in- haled, produce a form of shaking palsy, known as the tremble- ment mercuriel of the French pathologists. Now, in this as Avell as in lead-poisoning, a cure can only be effected by re- moval from the poisonous atmosphere and occupation ; other- Avise the symptoms hourly increase, until tremors are followed by sleeplessness, delirium, and ultimately coma. Thus it is Avith alcoholic stimulants in the production of delirium tre- mens. In those of a nervous irritable disposition, the effect of a certain length of indulgence is to induce this condition, and beyond that stage, a small quantity of alcoholic stimulus will keep up and deepen the effect Avhich, previously, a large dose would not do, or, in a less sensitive organization, could not do. Thus is explained the very common, but erroneous statement, made in regard to an individual affected with delir- ium tremens, that although for a considerable time he had sys- tematically indulged in considerable quantities of wine, spirits ancl other alcoholic liquors, yet for a Aveek or two he had drunk very sparingly, and, Avithin the last few days, little or none; in fact, that he was now suffering from the withdraAval of his Avonted stimulus. All this seems plausible, but the statement rather should have been that, although consuming large quan- tities of drink at one time, he had found latterly a smaller quantity affect him; that he then reduced still further the amount, but experienced an equal if not greater constitutional effect therefrom; and thus, from day to clay, reduction Avas forced on him by his own sensations of gastric irritation, ner- vous excitement and muscular debility—these feelings being, in fact, nothing more nor less than the premonitory symptoms of an attack of delirium tremens, and just what might be looked for on the vieAv that alcohol is in such instances a cum- ulative poison, and the exciting as Avell as the predisposing cause of the affection. Another erroneous notion, long held, Avas, that the disease is of frequent occurrence in habitual drunkards. But the experience derived from large prison- houses sIioavs, that while fully three-fourths of the criminals committed belong to the intemperate classes, no bad effects are observed from the sudden Avithdrawal of the Avonted stimuli, and the substitution of prison-fare." DELIRIUM TREMENS. 39.5 Prognosis.—According to Dr. Aitken and other authorities the greatest number die of delirium tremens between the ages of tAventy and forty years, the largest mortality rate being be- tween twenty and thirty, when it amounts to about twenty per cent. It is difficult to tell what influence sex has on the oc- currence of the disease, some observers denying that the dis- ease ever occurs in women ; but the reports of the Registrar- General show that-in England and'Wales the rate of female mortality from delirium tremens for the period of twenty-five years preceding 1870, was in the proportion of one woman to eight men. This is believed to be a much higher rate for women than occurs in any other country. Althaus says that in Italy and some other European countries, the disease is never seen in them. In Norway and Sweden it is stated to be one Avoman to one hundred and seventy men; and in Germany and France it is only exceptionally seen in Avomen, by practi- tioners of the largest experience. Dr. Aitken gives the rate of mortality in the East Indian hospitals as nearly twenty-five men to one woman. Dr. Althaus deduces a very singular conclusion from his sta- tistics on the subject. He says: "As the number of deaths from delirium tremens is known to correspond closely with the amount of strong alcoholic drinks consumed altogether by a population, it appears very significant that hondon, AA'here nervous diseases are at a comparatively Ioav ebb, should con- sume proportionately so much more alcohol than Wales, Avhere these maladies are so singularly rife. The question, therefore, naturally presents itself, whether the consumption of strong alcoholic drinks is really always prejudicial for the nervous system, as has been, perhaps, too sweepingly asserted by many well-intentioned men of late years; Avhether whisky is really the 'devil in disguise;' and whether alcohol does not, in many instances, of course only when taken in moderation, act as a 'preservative against the invasion ofi diseases ofi the nervous system." Now, it seems to me that this is very superficial reasoning. It is all on the 'post hoc ergo propter hoc' principle. It makes no allowance for other influences, arising from local or cli- matic differences, to say nothing of constitutional or other 396 NERVOUS DISEASES. causes. We know that heredity has more to do Avith the pre- valence of nerA'ous affections than any other etiological influ- ence; and it is certainly jumping at conclusions, to infer that, because the ratio of nervous diseases to the consumption of alcoholic liquors is much less in London than in Wales, there- fore it exerts a preservative influence against their invasion. Are there no other habits peculiar to the denizens of London, that Avill exhibit an equal difference of ratios? If so, then such habit or habits, whatever they may be, must exert, pari passu, the same preservati\7e power that is claimed for alco- holic stimulants! Perhaps the good people of London drink more 'pure mountain water' from the river Thames than their unfortunate neighbors over the border; then why not attribute the salutary influence to that!—is not the reasoning the same? Or we might go back to the disease itself, and say, that as they suffer more from delirium tremens, it must have a beneficial effect in Avarding off other nervous diseases! It is hardly logi- cal, therefore, for the doctor to qualify his statement as he has done, by saying that alcoholic stimulants "should be taken in moderation in order to act as a preservative against the inva- sion of diseases of the nervous system." Treatment.—Proper hygienic treatment is of the first im- portance. During the stage of excitement, fear is one of the most prominent symptoms; and experience shows that con- finement is certain to increase it. No more restraint, therefore, should be exercised than is necessary to prevent accidents. "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 to prevent accidents. I was led to this change by observing that the hallucinations which attend the disorder Avere more distressing when the pa- tients were in a state of confinement than when they were al- lowed to walk about as much as they wished. As I have already remarked, they are capable of controlling these hallucinations, until the intellect is entirely destroyed; and they can do so the more easily when they are surrounded by objects which serve to engage their attention. Confinement always irritates them, and increases their ravings, so that the stage of ex- DELIRIUM TREMENS. 397 haustion, in Avhich the intellect is entirely destroyed, is apt to be brought on very speedily. I have very often tested this by a simple experiment. A man who was confined to his bed by a strait 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 w7ould almost invariably become milder, and the necessity of confinement cease. I therefore allow the patient to have full liberty, the only restraint being the presence of the keeper; sometimes, also, I direct them to be set at Avork, which serves still farther to distract their attention."—Gerhard. The chief danger to be apprehended and guarded against is exhaustion; hence care should be taken to support the strength of the patient by nutritious, easily-digestible food, in a fluid form, such as beef or mutton soup, or, if this is too heavy for the stomach, beef tea, coca, Avarm milk, egg-emulsion, etc. Sometimes a cup of Avarm coffee is both soothing to the nerves and supporting to the system. Aitken recommends Cayenne pepper. " The stimulus of such a spice as Cayenne pepper, given in soup, on the atonic stomach, will have a favorable influence on absorption." The folloAving case shows that it is capable, also, of acting as a curative remedy: Illus. 206.—An habitual drunkard of great capacity, having already suffered from many atta3ks of delirium tremens, after long abstinence from food, subsisting entirely during the in- terval upon liquors, of Avhich he took a great variety and an incredible quantity, Avas attacked with a very severe form of delirium tremens. The prostration Avas extreme, the tremor excessive, but the delirium bland, the chief hallucination being that the ceiling was about to fall and crush him, rendering it necessary for him to jump from the bed and hop around the room with as great activity as his weak condition would alloAv. His tongue Avas heavily coated, pulse small and irregular, skin moist, the forehead being- constantly bedewed with a cold, clammv sweat. His voice Avas feeble, husky and tremulous; he had had no sleep for three nights. The treatment was 398 NERVOUS DISEASES. directed principally to sustaining his strength, but all efforts to obtain sleep were for fifty-two hours unavailing. At the end of this time two boluses, each containing one scruple of Cayenne pepper, Avere given, and within two hours the patient Avas quietly sleeping; the skin, feet, and hands, for the first time, being warm. After fourteen hours of quiet sleep, he aAvoke with a desire for something to eat, and from this made a fair recovery.—Dr. Reed, Jr. The elimination of the poison from the system should be encouraged by hot or cold baths, according to the reacth7e power of the constitution. Sometimes the wet-pack may prove serviceable. If there is much prostration, the blanket-bath Avill best promote perspiration, besides being the safest. This con- sists in wrapping the patient in a blanket wrung out of hot Avater, over which are Avrapped three or four dry blankets, the patient being allowed to remain in them for a half hour or more. The effect of this bath is often materially increased by giving the patient a tumbler of cold water previous to the re- moval of the coverings. After the latter are taken off, the sur- face of the body should be well rubbed Avith warm towels, not only for the purpose of drying the patient, but to obtain the benefit of the friction, which is not inconsiderable. Medical Treatment.—The following are the leading reme- dies for this affection: Antimonium tart., Arsenicum, Bella- donna, the Bromides, especially Camphor brom. and Kali brom., Cannabis ind., Capsicum, Cimicifuga, Cypripedium, Digitalis, Gelsemium, Hyoscyamus, Nux vomica, Opium, Scutellaria, Solanum, Strammonium. Chloral hydrate is sometimes a useful remedy as a palliative, and to quiet the patient when he is so violent that he will not take regular doses of medicine, for fear of being poisoned {Brown). In such cases, a full close (grs. xx—xl,) rubbed up with equal parts of simple syrup and Balsam of Peru, given at bed-time, will often pro- duce a good night's sleep, from Avhich the patient will aAvake greatly refreshed. Antimonium tart.—This remedy, either singly or in alterna- tion with Opium, is invaluable in cases of high delirium attended with obstinate sleeplessness, especially in low states DELIRIUM TREMENS. 399 of the system, and when there is a febrile movement of the circulation. Illus. 207.—J. C, set. 43, canal-boatman, had been drinking hard for several Aveeks, but for the past two weeks had been endeavoring to reform, being under religious conviction. On the night preceding my being called, he had come to my house late at night, attended by his daughter, but not finding me up he sat upon the step an hour or so, and then returned to his home, being too timid or too undecided, it seems, to arouse me. On reaching his house I found him in a fearful delirium, running about the room in his night-clothes, ancl throwing the pillows at the demons he imagined were trying to seize him and drag him cIoavii to-hell. His eyes Avere red and injected, the forehead Avas covered with cold perspiration, and the hand trembled so that I could scarcely manage to count the pulse, Avhich was about 96, quick and irritable. I found that he had neither eaten nor slept for more than a Aveek. His Avife Avas ill with consumption in an adjoining room, and her coughing appeared to greatly annoy him. xVfter quieting him as much as possible, by assuring him that I AA-ould keep off the devils that were after him, I got him back to bed, and gave him a dose of Antimonium tart.3* in poAvder, Avhich Avas repeated every fifteen minutes until he slept, Avhich he did after having taken four doses. The next morning I still found him sleeping quietly, and did not disturb him. He awoke about noon, and his daughter gave, as advised, a bowl of mutton broth with barley. I saw him again in the evening, and found him quite rational, but very weak and prostrated. His pulse A\7as 84, and considerably fuller and stronger. He made a speedy recovery, having taken no medi- cine except the four doses of tartar-emetic.—Hart. Arsenicum.—Hughes recommends this remedy AA7hen there are muscular tremors and great prostration, AA'ith nervous de- rangement and gastritis. Other indications are: fear, Avith great anguish and sweat, dread of ghosts, of thieA7es, or of death, and especially of vermin crawling about the bed. Illus. 208.—We remember a case of delirium tremens where the patient complained of vermin crawling over his bed and 1 mds. Arsenicum30, cured him entirely.—Dr. C. J. H.mpel. 400 NERVOUS DISEASES. Camphora bromata.—Hale recommends this remedy in cases of cerebral anaemia. He says of the following case, "there may have been congestion of the brain in the beginning, but it could not very well have been present after the patient had SAvallowed one hundred grains of bromide of soda. In fact, the symptoms which existed Avhen the Camphor bromide Avas given were those of cerebral anaemia, a condition in which five grains of the drug would be likely to have a good effect." Illus. 209.—Delirium tremens in a large man of plethoric habits. Symptoms: great cerebral congestion, tremulousness and great jactitation of the limbs; conversation muttering and incoherent; pulse full and soft; no sleep for several nights; 100 grains Bromide of Sodium did not cause sleep; five grains Monobromicle camphor caused sleep Avithin half an hour; he slept over twelve hours; afterwards the same dose at night caused good sleep, and relief of all the other symptoms.* Gelsemium.—Dr. E. A. Lodge Avas, I believe, the first one to direct the attention of the profession to this medicine as a remedy for obstinate sleeplessness. Dr. W. J. Blakely says it produced a thirty hours sleep in delirium tremens after mor- phia had failed. The indications are: great nervous excite- ment, headache, fear and Avakefulness. Illus. 210.—Henry W., aet. 34, sent for me August 20th, at 2 p.m. I found him watched by a male nurse, and displaying all the symptoms of delirium tremens, though his mind had so far retained its self control that he ansAvered my questions rationally. He had been drinking Avhisky, and had not been able to sleep for ten successive nights. I left Gelsemium tinct- ure, in the proportion of two to three drops for a dose, to be given every hour, and visited him again at 9 p.m. After I had left him, he had struggled in bed Avith the attendant, and kicked off the footboard, all the Avhile, of course, calling for more Avhisky, Avhich I had strictly forbidden. But after the second dose of Gelsemium he slept for four hours, and aAvoke in a gentle perspiration, feeling and seeming much calmer. Some light food Avas given, and he slept nearly the whole of that Hale's Therapeutics, 4th ed. p. 80. DELIRIUM TREMENS. 401 night. The next morning he dressed himself and came to my office, when I gave him, observing that the drunkards' dyspep- sia Avas noAV the chief trouble, Nux vom.1, and earnestly begged him to drop all stimulants.—Dr. J. M Moore. Kali brom.—Hale says of this remedy: "The first or irrita- tive stage of delirium tremens is ordinarily treated by five to ten grains of Bromide repeated every two or three hours; but the face must be flushed, eves red, pulse quick and hard, AA7ith delirium of active type and horrid illusions. If the face is cold and pale, pulse Aveak and thready, Digitalis is the proper remedy. I haAre found these two medicines, aided by Cimi- cifuga31 or Hyoscyamus1*, to control all cases of that fearful malady." Illus. 211.—C. C, laboring under his fourth attack of delirium tremens, under the care of a Doctor avIio had treated him AA'ith Opium and Digitalis, having passed seven nights without sleep. On visiting him on the morning of the eighth day, I found him quietly brushing the vermin from his clothing, and occasionally ordering the nurses to clear the room from the strange animals which AA7ere in every corner, and under every chair. His pulse was fair, tongue but lightly coated, skin moist and warm, appetite good, face someAvhat flushed. The attack, and all former ones, had commenced with severe ver- tigo. His eyes AA'ere injected, boAvels loose, owing to purgatives. I ordered rest from all medicines, strong soup, and oysters with an abundance of Cayenne pepper through the day; at eight o'clock at night I administered one drachm of Kali brom., to be followed if necessary every hour by one-half that quantity. The dose had to be repeated but once, a quiet sleep being ob- tained for twelve hours.—Dr. Read, Jr. Nux vomica.—-This remedy is specially indicated during the forming stage, and also during convalescence. It has likeAvise proved curative in cases where the system was overwhelmed by the alcoholic poison, as in the following case: Illus. 212.—A stout young man had drunk thirty-nine glasses of whisky on a wager in one night. We found him cold, and the skin dry and husky, like parchment. He felt numb all over. Pulse scarcely perceptible. He was in great agony of 402 NERVOUS DISEASES. mind, and expected to be utterly paralyzed. He AA'as unable to sustain his own Aveight. I gave him six globules of Nux vomica30, in half a cup of \A7ater, a dessertspoonful every five minutes. The patient sank visibly under this treatment. Being satisfied that Nux vom. was his remedy, I hoav mixed five drops of the strong tincture in six tablespoonfuls of water, of which mixture I gave him a dessertspoonful every five minutes. After the second dose he began to perspire. The perspiration seemed to be pure alcohol; he was literally drenched with al- cohol. He had to be changed seven times during the night; next morning he felt quite well, except a little Aveak.—Dr. Chas. J. Hempel. Many other remedies have been used successfully in this disease, but none has given me more satisfaction than our in- digenous plant, Scutellaria lateriflora, Avhich, when practicable, I prefer to give in the form of an infusion of the fresh plant, a cup or two of Avhich is usually folloAved by a calm sleep, from which the patient generally awakes convalescent. No one remedy, hoAvever, will suit all, or even the majority of these cases, the successful treatment of Avhich, like that of nervous diseases generally, will be best promoted by a close observance of the golden rule of legitimate therapeutics, namely, the strict individualization of every case. INDEX. For the symptoms, diagnosis, prognosis, etiology, pathology, and treatment of any particular disease, look under those heads, instead of under the name of the disease. Abscess, cerebral, effects of, 12, 14; in para- plegia, 144 ; in hemiplegia, 14. Acid, picroticum in locomotor ataxy, 193. Aconite in facial paralysis, 161 ; in sciatica, 26.5; in angina pectoris, 280 ; in ovaralgia, 297 ; in mania, 369. Aconitia in facial neuralgia, 241. Acupuncture in sciatica, 264. Agaricus in chorea, 93 ; in angina pectoris, 275. Age and sex, influence of, in chorea, 87 ; in tetanus, ins. Agnus castus in neuralgia trigemini, 241. Agraphia, 205, 207. Aitken, Dr , on delirium tremens, 395; on hydrophobia, 123. Akinnesia, 134. Alalia, 85. Albuminuria in eclamptiform convulsions, 50. Alcoholism, chronic, 3S9 ; acute, 393. Allium cepa in neuralgia of the stump, 265. Alluminnm met. in infantile spinal paralysis, 156. Althaus, Dr., on paralysis of the insane, 175 ; on progressive muscular atrophy, 181 ; on paralysis agitans, 196; on delirium trem- ens, 395; on the lower sphincters, 26; on tetanus, 110. Amaurosis, 18, 19; secondary, 16; sympa- thetic, 24. Amblyopia, 18,19 ; crossed, 17 ; sympathetica, 24. Amimia, 207. Ammonia, liquid, in hydrophobia, 125. Ammonisemia, 50, 57. Ammonium mur. in ovaralgia, 297. Amyl nitrite in epilepsy, 74; in hystero-epi- lepsy, 81 ; in tetanus. 115 ; in hemicrania, 226; in angina pectoris, 277; in melan- cholia, 335. Anacardium in hysteria, 320; in bulbar pa- ralysis, 171. Analgesia, 86. Anarthria, 85. Aueurysma, 13. „.,-,„■, Anremia, 11,33; partial, 34 ; of spinal cord, 90. Anaesthesia, 17, 20, 86; of extremities, 17;. crossed, 20 ; hemi-, 17. Angina pectoris. 269 ; remedies for, 27o-282. Animal heat, centre regulating the, 2o. Anstie, Dr., on neuralgia, 10; on sciatica,2o7, 262. Antimonium tart, in diphtheritic paralysis, 166 ; in delirium tremens, 398. Apathy, mental, 18. Ape, motory centre in the, 12. Aphasia, 13, 14, 205 ; amnesic, 205, 207 ; atac- tic, 205, 207 ; transitory, 20S; seat of, 14, 206 ; remedies for, 210. Aphemia, 205. Aphonia, paralytic, 214 ; remedies for, 218. Apoplexy, 16, 19, 20, 52. Apostoli, Dr., on the optic thalami, 17 ; on the spinal cord, 24. Aranea diadema in catalepsy, 133. Argentum nit. in locomotor ataxy, 193, 194; in facial neuralgi<#! 241 ; in gastralgia, 288. Aristotle on hydrophobia, IIS. Arnica in eclampsia neonatorum, 48 ; in hemi- plegia, 139 ; in paraplegia, 150 ; in facial paralysis, 162 ; in infantile paralysis, 156 ; in writer's palsy, 204; in brain exhaus- tion, 385. Arsenicum in sciatica, 266 ; in gastralgia, 288 ; in delirium tremens, 399. Arteria fosssc Sylvii, thrombosis of, 17. Articulation, impaired, 17, 20, S5. Asafcetida in hypochondriasis, 327. Asylums for the insane, 359. Ataxy, locomotor, 184. Atrophy of nerve-tissue, 10; of paralysed muscles, 179 ; in sciatica, 258. Atropia in facial neuralgia, 242, 24S; in ovar- ian neuralgia, 298. Aura epileptica, 61. Aurelianus on hydrophobia, 121. Aurum in hypochondriasis, 328 ; in mania, 373; in angina pectoris, 275. Balfour on insanity, 356. Bamberger on aphonia, 216. Baraduc on thrombosis, 138. Bardsley, Dr., on hypochondria, 122. Baryta in hemiplegia, 141. Bastion, Dr , on post-paralytic chorea, 85. Bathing in paralysis, 156. Baths, lukewarm, in locomotor ataxy, 192; steam, in hydrophobia, 128; stimulating, in scrivener's palsy, 203. Bzehr, Dr., on convulsions, 36. Beard, Dr., on writer's palsy, 202. Beckwith, Dr., on mania, 349. Bedsores, 144. 404 INDEX. • Belladonna in convulsions, 38, 40, 48, 53 ; in epilepsy, 70; in chorea, 94; in tetanus, 113; in hydrophobia, 126; in paraplegia, 150; in infantile paralysis, 156; in facial paralysis. 162; in bulbar paralysis, 172; in paralysis of the insane, 178; in hemi- crania, 227 ; in facial neuralgia, 243 ; in eastralgia, 289; in ovaralgia, 298; in hysteria, 320 ; in moral insanity, 343 ; in mania, 370; iu angina pectoris, 275. Benedict, Prof., on tetanus, 110; on locomo- tor ataxy, 191 ; on chorea, 92. Berger, Prof , on epilepsy, 64, 65, 67. Bernard on aphonia, 215. Bernhart on cerebral neoplasmata, 13; on paresis of the right side, 13. Billroth and Briond's researches, 24. Bismuth in facial neuralgia, 243. Bladder, paralysis of the, 17, 143 ; nerve-cen- tres for the lower sphincters, 26. Blanket-bath in delirium tremens, 398. Blood-poisoning in tetanus, 110. Bockhammer, Dr., on paraplegia epidemica, 145. Bouilland, M., on the seat of language, 205. Bouchat, M., on infantile convulsions, 28. Boutzen, battle of, tetanus after the, 103. Brachet on convulsions, 32 Brain-fag, 3S0 ; remedies for, 385. Brain-work, 382. Breast pang, 269. Briquet, M , on hysteria, 76. Brigham, Dr., on insanity, 351. Broca, M., on the seat of language, 206. Bromine in hemicrania, 227. Brown-Sequard on Guinea pigs, 23 ; on cere- bral lesions and nerve-centres, 14, 15, 25. Bryonia in hemicrania, 228; in facial neural- gia, 244 ; in sciatica, 266. Budge on the cilio-spinal centre, 25. Budin, Dr., on abdominal pressure, 54. Buhl, Dr , on diphtheritic paralysis, 166. Buisson, Dr., on hydrophobia, 125,128. Bulbi, protruded, 17, 18. Burchard and Heilderhain, 23. Burns, blisters, etc., 31, 38, 138. Butler, Dr., on chorea, 92 ; on insanity, 351. Calcarea in convulsions, 43; in paraplegia, 152; in hemicrania, 22S. Calcis hypophos in brain-fag, 38). Camphorabrom. in convulsions, 43 ; in chorea, ll'l; in paralysis agitans, 199; in delir- ium tremens, 4"0. Cannabis Ind. in epilepsy, 71; in hystero- epilepsy, 83 ; in catalepsy, 133; in hypo- chondriasis, 329. Carbo-veg iu gastralgia, 289 ; in angina pec- toris, 276. Carville, M., on chorea, 88. Cardiac exhaustion in tetanus, 107. Carnomania, 313. Carotids, compression of the, 45. Catalepsy, 86, 130 ; remedies for, 133. Causticum in chorea, 93 ; in hemiplegia, 141 ; in paraplegia, 151; in facial paralysis, 163 ; in aphonia, 218. Cayenne pepper in delirium tremens, 397. Cedron in hydrophobia, 126. Centres, cerebro-spinal, physiology of, 9,11. Cephalalgia periodica, 223. Cerebellar paralysis, 18. Cerebellum, functions of, 18 ; faradization and destruction of middle lobe, 19. Cerebral exhaustion, 380 ; remedies for, 385. Cerebral cortex and lobes, functions of, 11. Cerebro-spinal meningitis, 146 Chairon, Dr.. on compression of the ovaries, 81. Change of habits, etc., 383, 80, 307. Charcot on the optic thalamus, 17 ; on the pedunculus cerebri, 17; on syphilitic epilepsy, 6S ; on hystero-epilepsy, 76; on thrombosis, 138 ; on bulbar paralysis, 168. Chauveau, M., on chorea, 88. China in gastralgia, 291. Chininum sulph. iu facial neuralgia, 243. Cholwmic convulsions, 57. Choostek, Prof., on paralysis agitans, 197. Chloral in convulsions, 60 ; in chorea, 100 ; in tetanus, 117 ; in prosopalgia, 248. Chorea, 83 ; paralytica, 85 ; complications of, 88; reflex c, S7 ; congenital c, 85; reme- dies for, 92-101. Chorea and tremor, 16, 90. Cicuta in tetanus, 113. Ciliary neuralgia, 237. Cilio-spinal centre, 25. Cimicifuga in chorea, 92, 94; in intercostal neuralgia, 251, 256; in angina pectoris, 280 ; in ovaralgia, 229 ; in spinal irritation, 30S ; in melancholia, 336. Clarke, Dr., on tetanus, 110, 111; on dementia, 379. Coca in cerebral exhaustion, 385. Cocculus in infantile spinal paralysis, 156. Cohen on eclampsia uteri, 51. Collateral (edema, theory of, 12. Cold, influence of, in tetanus, 109. Collins, Dr., on convulsions of new-born, 46. Colocynthis in sciatica, 266. Coma, 20, 52 Compression of carotids, 45 ; of ovaries, 81. Conium in hemiplegia, 141. Convexity, tumors of the, 12. Convulsions, general, 27, 48 ; eclamptiform, 23, 27; infantile, 28; partial, 27; centric, 28, 29 ; symptomatic, 28, 29 ; eccentric, 28, 29 ; reflex, 28, 29; secondary, 28, 32 ; sympa- thetic, 28, 32; of the new-born, 46; of adults, 48; puerperal, 48; non-puerperal, 56; ansemic, 56; choloemic, 57 ; from in- anition, 58 ; hydrsemic, 58 ; epileptic, 24, 61. Corpus striatum hemorrhage, 136, 137. Corpora striata, functions of, 16; faradization of, 16; tumors of, 16. Cortex, cerebral, centres in the, 11, 15 ; effects of their destruction, 11, 15 ; tumors of, 11. Cortical epilepsy, 64. Coordination, function of, 18, S6, 185-188. Coulston, Dr., on insanity, 353. Crocus in mania, 373. Croup, rectal, 32. Crura cerebri, functions of the, 18. Crus cerebelli, lesions of, 18. Cruveilhier, M , on chorea, 90. Cuprum in convulsions, 54 ; in chorea, 98. Cyanosis, 17. Cyclamen in hemicVania, 229. Cyst, cerebral, effects of, 12. Cystitis, 143. Dax, M., on the seat of language, 206. Dejerine on diphtheritic paralvsis, 166. Delirium tremens, 389 ; anatomical appearan- ces in, 393 ; mortality in, 395; remedies for, 398. Delitescence in hydrophobia, 119. Delusion, 357 Dementia, 376 ; remedies for, 379 ; paralytica, 173. Dental neuralgia, 237. Dentition, 30, 38. Depression, cerebral, 355. Detmold's wire hook, 161. Diabetes mellitus, 18. Diagnosis of syphilitic epilepsy, 68; of hystero- epilepsy, 78; of chorea, 85; of facial pa- ralysis, 137, 159 ; of bulbar paralysis, 170 ; INDEX. 405 of locomotor ataxy, 188; of paralysis agitans, 197 ; of writer's palsy, 202; of paralytic aphonia, 216; of neuralgia, 222; of hemicrania, 225; of facial neuralgia, 23*; of intercostal neuralgia, 249, 252 ; of sciatica, 261 ; of gastralgia, 287 ; of spinal irritation, 304; of hysteria, 317 ; of moral insanity, 341; of mania, 356. Diarrhoea, 32, 37. Dickinson, Dr , on tetanus, 110. Dieffeubach, M., on scrivener's palsy, 203. Diet, errors in, 29 ; iu brain-fag, 381 ; water, 58. Diphtheritic paralysis, 164 ; remedies for, 166. Dipsomania., 389 Diseases, functional, 9. Double perception, 14, Dubois on hystero-epilepsy, 76. Du Bois Raymond on hemicrania, 225. Duchenne, M., on chorea, 92; on progressive bulbar paralysis, 171; on locomotor ataxy, 184, 185. Duchenne's disease, 168. Dulcamara in infantile spinal paralysis, 156. Dupuytren on thrombosis, 138. Dysteria agitans, 197. Earl, Dr., on insanity, 359, 360, 361. Eccentric convulsions, 28, 29. Eckard's researches, 15. Eclampsia, 27, 4S ; infantalis, 2S ; neonatorum, 46, .->.-); parturitium, 4S ; toxica, 58. Ecstacy. S6. Eggleston, Dr., on home-treatment of the in- sane, 361. Electricity in chorea, 92 ; in hemiplegia, 138 ; in infantile spinal paralysis, 155 ; in facial paralysis, 160; in diphtheritic paralysis, 166; in bulbar p , 171 ; in muscular atro- phy, 1S2; in locomotor ataxy, 191; in pa- ralysis agitans, 199 ; in paralytic aphonia, 216 ; iu hemicrania, 226 ; iu prosopalgia, 247; in sciatica, 263 ; in intercostal neu- ralgia, 253; in angina pectoris, 279; in hydrophobia, 128; in catalepsy, 132; in neuralgia of the female geuital organs, 297; in spinal irritation, 307. Electro-puncture iu sciatica, 261, 264; in neu- ralgia of female genital organs, 297 ; in spiual irritation, 3o7. Emboli, cerebral, in chorea, 16 ; in hemiplegia, 136 ; of left middle cerebral artery, 14,137, 208; Bemhart's observations on, 13. Emprosthotonus, 102. Epilepsy, 61; cortical, 64; vaso-motory, 64; thahnic, 63; reflex, 65; syphilitic, 67; remedies for, 70; zones, 24. Erb, Prof., on paresthesia, 220; on tendon- reflex, 183 Erich sou, Dr , on tetanus, 103. Eserin in chorea, 100. Esmarch on locomotor ataxy, 193. Essential paralysis of infancy, 154. Ether-sprav in chorea, 92 Etiology of infantile convulsions, 28; of con- vulsions of the new-born, '46 ; of puerperal c , 50; of epileptic c, 66; ot hystero-epi- lepsy. 80; of chorea, 87 ; of tetanus, 108; of hydrophobia, 121; of catalepsy, 131; of paralysis, 135; of hemiplegia, 136; of paraplegia, 147; of infantile spinal pa- ralysis, 155 ; of facial paralysis, 160; of diphtheritic p., 165; of bulbar p., 170; of p of insane, 175; of muscular atrophy, lso ; of locomotor ataxy, 190 ; of paralysis agitans, liiS; of scrivener's palsy, 2<>2; of aphasia, 2 >8 ; of paralytic aphonia, 2l;>; of neuralgia, 221; of hemicrania, 224; of neuralgia trigemini, 238; of intercostal n 251 ; of mastodynia, 251 ; of sciatica, 2o9; of angina pectoris, 272 ; of gastralgia, 285 ; of female genital organs, 296 ; of spinal irritation, 304; of hysteria, 31S; of hypo- chondriasis, 325; of melancholia, 334; of mor.il insanity, 341 ; of mania, 330; of de- mentia, 37S ; of mental exhaustion, 380; of delirium tremens, 391. Eulenburg, Prof., on muscular atrophy, 179. Eulenmeyer on locomotor ataxy, 193. Euphorbia in hydrophobia, 127. Exanthemata, 33. Excitement, cerebral, 355. Exercise in cerebral exhaustion, 382. Exhaustion, cerebral, 380 ; remedies for, 385. Exophthalmos, 17, 18. Eyes, conjugated deviation of, 14, 18; diseases of, in choica, 90. Face-ache, 237. Facial neuralgia, 237 ; remedies for, 241-247; facial paralysis, 137,158 ; remedies for, 162. Falling sickness, 61. Fall, tendency to, in different directions, 18, 19. Faradization in hydrophobia,, 128; in cata- lepsy, 132; in hemiplegia, 138; in in- fantile spinal paralysis, 155 ; in diph- theritic p., 166 ; in muscular atrophy, 182 ; in locomotor ataxy, 192 ; in sciatica, 263 : in paralysis agitans, 199; in paralytic aphonia, 217 ; in neuralgia of female geni- tal organs, 297. Fatty food in sciatica, 261, 262; fatty degener- ation of muscles, 155, 179. Favez, M., on compression of the carotids, 46. Feason on double perception, 14. Female genital organs, neuralgia of, 293; remedies for. 297. Femero-popliteal neuralgia, 257. Ferrier's researches, 11 ; on function of coor- dination, 19 Fever, irritative, 38. Fibrillary twitching, 180. Flexibilitas coerea, 130. Flouren's th ory of vicarious action, 11. Fomentations in gastralgia, 288. Food, artificial, 30 ; uuwholesome, 30, 39. Foreign bodies, irritation from, 39. Fournier on syphilitic epilepsy, 6S. Frerichs on choloemic convulsions, 57. Friedreich, Prof., on muscular atrophy, 179. Fritsch's experiments on the cerebral cortex, 11. Functional diseases, key to, 10; meaning of the term, 9. Gait, vacillating, 18. Gall, Dr., on the seat of language, 205. Galvanism in chorea, 92 ; in hydrophobia, 128 ; in hemiplegia, 138 ; in facial paralysis, 160 ; in infantile spinal p., 155 ; iu diphtheritic p., 166; in progressive muscular atrophy, 182; in locomotor ataxy, 192; in paralysis agitans, 199 ; in writer's palsy, 203; in paralytic aphonia, 216; in prosopalgia, 247; in intercostal neuralgia, 253 : in sciatica, 261, 263 ; iu angina pectoris, 279 ; in gastralgia, 288; in neuralgia of the female genital organs, 297 ; in spinal irri- tation, 307 Ganglia, cerebral, functions of, 16 ; excited by tumors, 11 ; by cortical stimulation, 15. Gangrene, local, in paraplegia, 144. Gastralgia, 283 ; remedies for, 288. Gelsemium in convulsions, 41, 54; in tetanus, 113 ; in paraplegia, 151 ; in infantile spinal paralysis, 156; in facial p., 161; iu dipth- theritic p , 167 ; in paralytic aphonia, 218 ; in hemicrania, 229; in hysteria, 320; in mania, -S7o ; in delirium tremens, 400. General debility, 29. 406 INDEX. General paralysis of the insane, 173 ; remedies for, 176-178. Geniculate bodies, function of, 19. Georget, M., on dementia, 376. Gerhard, Dr., on confinement in delirium tremens, 396. Gerhard on paralysis of vocal cords, 216; on paralytic aphonia, 216, 217. Globus hystericus, 315. Glonoine in convulsions, 44; in paralysis of the insane, 176; iu angina pectoris, 275. Gooch, Dr., on puerperal mania, 350. Grand mal and petit mal, 63. Gray, Dr., on insanity, 351. Grisolle on chorea, 88. Gros and Lancereaux on syphilitic epilepsy ,69. Guaiacum in sciatica,.267. Gubler on diphtheritic paralysis, 166. Gums, lancing of the, 38. Habits, change of, 80, 307, 383. Hair, changes in the, in neuralgia, 221. Hall, Dr. Marshall, on the excito-motory sys- tem of nerves, 21; on hysteria, 315. Hallucination, 357. Hamilton, Dr., on chorea, 92; on facial pa- ralysis, 159 ; on scrivener's palsy, 201. Hammond, Dr., on Kali brom., 72; on chorea, 92; on bulbar paralysis, 168; on sciatica, 264 ; on writer's palsy, 2o3 ; on thalmic epilepsy, 63. Haubner on syphilitic epilepsy, 68. Hajmatoidine in vascular sheaths, 379. Headache, 12, 13; occipital, 18; frontal, 13. Hearing, disturbances of, 12. Heart disease in chorea, 88. Heker on eclampsia, 24. Helleborus in melancholia, 336. Helminthiasis, 31. Hemi-anresthesia, 17. Hemichorea, 85, 90. Hemicrania, 223 ; remedies for, 227-235. Hoiuiparaplegia, 142. Hemiplegia, 16, 17, 18, 136 ; remedies for, 141. Hemispasms, 17. Hepar s. c. in angina pectoris, 281. Hereditv, 28, 66, 80, 221, 224, 238, 325, 351, 357, 396. Hippocrates on epilepsy, 61; on diphtheritic paralysis, 164. Hitzig's experiments, 11, 12. Homer on rabies, 118. Home treatment of insane, 361. Hughes, Dr , on chorea, 88; on bulbar pa- ralysis, 171. Hydraulic convulsions, 58. Hydrophobia, 118; history of, 118; mental origin of, 122 ; remedies for, 126. Hydrorachis acquisita, 145. Hygienic treatment, 307. Hyoscyamus in chorea, 95 ; in mania, 371. Hyperemia, 34. Hyperesthesia, 20, 143. Hypochondriasis, 324; remedies for, 327. Hysteralgia, 294; remedies for, 297. Hysteria, 75, 311; nature of, 76, 312; remedies for, Hystero-epilepsy, 75. Ice-bags in chorea, 92 ; inhystero-epilepsy, 81 ; in tetanus, ] 12. Ignatia in facial neuralgia, 244 ; in sciatica, 267; in hysteria, 321; in moral insanity, 345; in mental exhaustion,.386. Illusion, 357. Inanitiou, convulsions from, 58. Incoordination, of muscular movements, 18, 86, 1S5-D8; in speech, 21. ' Infantile convulsions, 28 ; remedies for, 38-45 inf. spinal paralysis, 154; remedies for, 156 Infra-orbital neuralgia, 237. Inhibitory centre, 20, 107. Insane, treatment of the, 358, 361, 364, 366-375. Insomnia in tetanus, 108. Intellectual disorders, 348. Intercostal neuralgia, 249 ; remedies for, 253. Iris iu hemicrania, 229 ; in facial neuralgia, 245 Irritation, genito-urinary, 31; cerebral, 12-16, 355 ; tolerance of, 10. Ischias, 257. Janeway, Prof., on intercostal neuralgia, 252. Jarvis, Dr., on mania, 359. Joffroy, M., on prog, bulbar paralysis, 168 Jones, C. Haufield, on functional nervous diseases, 10. Kali bich. in hemicrania, 230, Kali brom. in convulsions, 55 ; in epilepsy, 72 ; in chorea, 101 ; in tetanus, 117 ; in aphasia, 210 ; in paralytic aphonia, 217 ; in delirium tremens, 401. Kali carb. in angina pectoris, 281, 276. Kali chloricum in facial paralysis, 162 Kali iod. in epilepsy, 73; in hemiplegia, 141; in facial paralysis, 163 ; in paralysis of insane, 177; in locomotor ataxy, 194; in paralytic aphonia, 117; in aphasia, 213. Kalmia in facial neuralgia, 245. Karl Pauli on locomotor ataxy, 192. Koeppe, Dr., on mania, 351, 354. Kirke, Dr., on chorea, SS. Kiwisch on puerperal convulsions, 50. Klapka on angina pectoris, 269, 274. Knee, hysterical, 311; phenomena of the, 189. Kudnow, Prof., on hydrophobia, 123. Kussmaul, Prof., on bulbar paralysis, 168; on "verbal deafness and blindness," 207. Labio-glosso-pharyngeal paralysis, 168. Lachesis in facial neuralgia, 245 ; in hysteria, 322. Lallemande,Perrin and Duray, MM., on alco- holic poisoning, 391. Langenbach on locomotor ataxy, 192. Lardois on vasomotory epilepsy, 64. Larry, Baron, on tetanus, 103. Lasegue, Prof., on locomoter ataxy, 186. Lemoigne and Lusana's observations, 15. Lapelletier, M., on neuritis ascendens, 105. Letzerich on diphtheritic paralysis, 165. Leyden, Prof., on tetanus, 111; on spinal irritation, 305. Lithates, 107. Lobes, cerebral, functions of, 11; anterior, tumors of, 13; vertical, lesions of, 13. Lobulus supramarginalis, 13. Lockjaw, 104. Locomotor ataxy, 184; remedies for, 193. Longet, M., on corpora striata, 16; on the cerebral hemispheres, 11 ; on optic thai- ami, 17. Luczkiewicz on embolus of middle cerebral artery, 14: on agraphia, 14, 207. Lycopodium iu hysteria, 322 ; in angina pec- toris, 276. Mackenzie, Dr., on chorea. 88. Maingault on diphtheritic paralysis, 165. Mania, 34S ; remedies for, 366-375 ; ." mania de grandeur," 349. Massaire in writer's palsy, 203; in paralytic aphonia., 217. Mastodynia, 250; remedies for, 253. Maudsley, Dr., on insanity, 353. Medulla oblongata, functions of, 21. Megrim, 223. INDEX. 407 Melancholia, 332 ; remedies for, 335. Memory, loss of, 18. Meningitis, cerebro-spinal, 146; basilaris, 22. Mental function, derangement of, 311; lesions affecting, 378. Mercurius in ursemic convulsions, 60; in hemi- plegia, 140; in facial paralysis, 163. Meryon, Dr., on reflex symptoms, 22. Meyer, Prof., on chorea, 92; on paralysis of the insane, 175, 176. Mezereum in facial neuralgia, 246. Microphites, 165. Migraine, 223. Mitchell, Dr. Weir, on hysteria, 314. Mollendorf on hemicrania, 226. Monomania, 348 Moral disorders, 311; moral insanity, 339; remedies for, 343. Mortality in tetanus, 108. Motor function, derangement of, 27; motor cen- tres in cerebral cortex, 11, 15. Multiple sclerosis, 195, 197. Muscular-movements, incoordination of, 18, 86, 185-188. Myelitis, 171, 176, 305. Natrum mur. in chorea, 96; in hemicrania, 230. Neoplasmata, cerebral, effects of, 13, 19. Nerve-stretching iu locomotor ataxy, 192; in prosopalgia, 247; in sciatica, 264; acci- dental, 90. Nerve-tissue, atrophy of, 10. Nervous susceptibility, 28. Neuralgia, 10, 219 ; varieties of, 221 ; facial, 227; of the heart, 269; periodical, 220; suppressed, 273. Neuromata, mammary, 250. Neurosthenia, cerebral, 3S0. Niemeyer's theory of collateral oedema, 12. Nothnagel on the cerebral cortex, 11; on vaso- motory epilepsy, 64. ■ Nucleus lentiformis, capsule of, pressure on, 17 ; lesions of, 17. Nutrition in paraplegia, 144. Nux vomica in convulsions, 60 ; in infantile paralysis, 157; in gastralgia, 291; in hy- pochondriasis, 330; in melancholia, 336; in mental exhaustion, 3S6; in delirium tremens, 401. Nystagmus, 13, 17. Ocular muscles, disturbances of, 20; spasm of, 13. Oculo-motorius, paralysis of the, 14, 17, 18. Odontalgia, 237. Oi'itel, Dr., on diphtheritic paralysis, 166. Ollivier on paralytic aphonia, 217. Opisthotonus, 47, 54, 102, 105, 115. Opium in convulsions, 42 ; in epilepsy, 72 ; in hemiplegia, 141. Optic thalami, functions of, 16; sclerose en plaques, 17 ; faradization of, 17. Orbital neuralgia, 223. Organic changes in nervous diseases, 9, 356. Orthotonus, lu2. Osborn, Dr., on aphasia, 206. Ovaraltria, 295 ; remedies for, 297. Ovaries, compression of, in hystero-epilepsy, 79, 81 ; Dr. Chairon on, 81. Payet, Sir James, on delirium tremens, 392. Pahs v. local, 134; lateral, 134; facial, 137; wasting, 179 ; writers, 201. See Paralysis. Paralysis, 12, 134 ; corpora striata p., 16 ; thai- ami optici p., 17; of the bladder, 17, 143; crossed, 20; facial, 20, 16 ; hysterical, 14; of the oculo-motorius, 18; p. agitaus, 195; remedies for, 199 ; infantile spiual p., 154 ; remedies for, 156; labio-glosso-pharyngeal p., 21,168 ; progressive general p., 12,173 ; p. of the rectum, 143. Paralytic aphonia, 124; p. disorders, 134; p. stroke, 136. Paraplegia, 134, 142; epidemic, 145; reflex, 147 ; remedies for, 148, 150. Paresthesia, 220. Paresis, 13, 14, 17, 20, 86, 134, 142. Parks, Dr., on chorea, 88. Pathology of hystero-epilepsy, 80; of chorea, S9 ; of tetanus. 111 ; of hydrophobia, 123 ; of catalepsy, 132 ; of hemiplegia, 137 ; of paraplegia, 146 ; of infantile spinal p., 154 ; of facial paralysis, 160 ; of diphtheritic, p., 166; of progressive bulbar p., 171 ; of p. of the insane, 175; of muscular atrophy, 180 ; of locomotor ataxy, 190 ; of paralysis agitans, 199; of writer's palsy, 203; of aphasia, 208 ; of paralytic aphonia, 215 ; of hemicrania, 225 ; of prosopalgia, 239 ; of intercostal neuralgia, 251; of mastodynia, 251; of sciatica, 260; of angina pectoris, 273 ; of spinal irritation, 304 ; of moral in- sanity, 342, of mania, 354; of dementia, 378 ; of delirium tremens, 393. Patrina, Dr., on cerebral tumors, 11, 12, 13. Peddie, Dr., on delirium tremens, 393. Pedunculus cerebri, functions of, 17. Peripheral paralysis, 158. Petit mal, 63, 73. Phosphates, 381. Phosphoric acid in chorea, 96. Phosphorus in paraplegia, 152; in infantile paralysis, 157; in wasting palsy, 182: in aphasia, 212 ; in mental exhaustion, 386 ; in angina pectoris, 276. Philepaux on paralytic aphonia, 217. Phymosis, congenital, 32. Physiology of the nervous centres, 9. Physostigma in convulsions, 43 ; in tetanus, 114, 116. Phytolacca in mastodynia, 254. Picric acid in mental exhaustion, 387. Pinel on dementia, 378. Pituary body, functions of the, 18. Pleurodynia, 249. Pleurosthotouus, 102. Plumbum in locomotor ataxy, 193 : in infantile paralysis, 157 ; in bulbar p., 172. Polygonum punctatum in sciatica, 26S. Polymyositis, chronic, 179. Pons A'arolii, functions of, 20. Post-paralytic chorea, 85. Preguaucy, convulsions during, 49 ; in cho- rea, 87. Private treatment of insane, 364. Prognosis in infantile convulsions, 36; in c. of the Tiew-born, 48 ; in puerperal c, 52: in chorea, 91 ; in epilepsy, 65 ; in paraplegia, 147; iu tetanus, 112; in facial paralysis, 159; in infantile spinal p., 154 ; in bulbar p., 170; in p. of the insane, 176 ; in diphtheritic p., 165; iu muscular atrophy, 181 ; in locomotor ataxy, 191 ; in paralysis agitans, 199 ; in writer's palsy, 203 ; in aphasia, 209 ; in paralytic aphonia, 216 ; in neuralgia, 222 ; in hemicrania, 225 ; in facial neural- gia, 240; iu intercostal n., 253 : in sciatica, 262 ; in angina pectoris, 274 ; in neuralgia of the female genital organs, 296 : iu spinai irritation, 306 ; in hysteria, 319 : in hypo- chondriasis, 326 ; in mania, 357 ; in de- mentia, 378; in delirium tremens, 395. Progressive bulbar paralysis, 168; remedies for, 172; p. paralysis of the insane, 173; p. muscular atrophy( 179 ; remedies for, 182; p. locomotor ataxy, 184; remedies for, 193. Prosopalgia, 237. 408 INDEX. Ptosis, 18. Puerperal convulsions, 48; remedies for, 54; p. mania, 368. Pulsatillainjiemicrania,231 ; in brain-fag, 3S7. Pupils, changes in the, 17, 173; contracted, 20, 25 ; dilated, 18, 25, 87 ; unequal, 173. Rabies, 124. Rabon, Dr., on treatment of the insane, 364. Radclirfe, Dr., on mental exhaustion, 381; on sciatica, 262. Recrudescence in hydrophobia, 119. Rectal croup, 32. Rectum, paralysis of the, 143. Redness, circumscribed, 17. Reflex convulsions, 28, 29 ; r. chorea, 87 ; r. paraplegia, 147 ; r. aphonia, 215. Reil, Island of, lesions near the, 13, 14, 206. Remak on chorea, 92 ; on locomotor ataxy, 191. Respiratory centre, 21. Reynolds, Dr., on hysteria, 75, 318; on chorea, 88, 92. Rheumatic tetanus, 102, 109. Rheumatism in chorea, 88. Rhus tox. in sciatica, 268 ; in brain-fag, 387. Riedel on Kali brom., 72. Roebuck on paralytic aphonia, 217. Rogers, M., on chorea, 8S. Rokitausky on chorea, 90; on tetanus, 110. Romberg on atrophy of nerve-tissue, 10 ; on chorea, S8 ; on facial paralysis, 159 ; on locomotor ataxy, 190, 191; on scrivener's palsy, 201, 203 ; on tetanus, 110. Rosenstein on anssmia, 51. Rosenthal on eclampsia, 34 ; on chorea, 92. Rotation of the body, 18. Sanguinaria in hemicrania, 232. Savage and Sayer on paralysis agitans, 196. Scanzoni on puerperal convulsions, 50. Schiff, Prof., on the spinal cord, 25. Schroeder on eclamptiform convulsions, 23. Schuetz on infantile convulsions, 22, 33; on dentition, 30 ; on rectal croup, 32 ; on con- vulsions of the new-born, 46 ; on puerperal c, 5o ; on c. of adults, 58 ; on hysteria, 75, 312, 313. Sciatica, 257 ; remedies for, 264-268. Sclerose en plaques of optic thalami, 17. Scolz, Dr., on cerebral abscess, 14. Scrivener's palsy, 2ol ; remedies for, 204. Scutellaria in hydrophobia, 127 ; in delirium tremens, 402 ; in catalepsy, 133. Secale in mental exhaustion, 387 ; in infantile paralysis, 157. Secondary convulsions, 28, 32. Sedillot on paralytic aphonia, 216. Seelignuiller on the nervous accessorius, 23 Soemmering ou nursing infants, 29. Senses, disturbances of the, 13, 18. Sensibility, disturbances of, 13, 17. Sensory function, derangement of the, 219. Sepia in hemicrania, 233 ; in prosopalgia, 247. Sequin, Dr.; on hemiplegia, 2<>8. Setscheuow, M., on the tubercula quadri- gemina, 19. Severin, Dr., on hydrophobia, 122. Sex, influence of, 76, S7, 131, 170, 202, 224, 238, 259, 272, 283, 354, 395. Sexual appetite, 18. Shaking palsy, 195. Shampooing in facial paralysis, 161 ; in infan- tile p., 156. Sick-headache, 223. Silicea in chorea, 98. Simaruba in chorea, 96. Simon, M., on convulsions, 36. Skim-milk in angina pectoris, 279. Skiu, glossy, in sciatica, 258. Sleep, 383. Sleepiness, 18. . Solly on writer's palsy, 203. Spasm, 28, 105 ; of extremities, 13, 106 ; of the glottis, 21, io6; of the lower sphincters, 106. Spasmodic diseases, 27. Spasms, crossed clonic, 12 ; tonic, 105. Speech, retarded, 171, 8; impaired, 85. Sphyucter centres, 26. Spicgelberg, Prof., on the cause of puerperal convulsions, 50. Spigelia in hemicrania, 234. Spinal cord, functions of the, 21; inhibitory action of, 20 ; Marshall Hall's theory of, 21 ; sclerosis of, 90, 184, 146; epilepsy of, 143; hemorrhage of, 145; hemiplegia, spinal, 142 ; softening of, 146 ; irritatiou of, 301, 303 ; remedies for, 3o8 ; neuralgia of, 301; granular proliferation of, 89. Stannum in hypochondriasis, 330; in infantile paralysis, 157. Staphysagria in epilepsy, 71; in hypochon- driasis, 331. Stark, Carl, observations of, 12. Steam-bath in hydrophobia, 125, 128. Stenocardia, 269 ; crampoide, form of, 269 ; syncopal, 270 ; recurrent, 271. Strabismus, convergent, 20 ; divergent, 18. Stramonium in convulsions, 55 ; in chorea, 95 ; in mania. 368; in aphasia, 211 ; in moral insanity, 346. Stroinmeyer on writer's palsy, 203. Structural changes, 9. Strychnia in chorea, 97 ; in wasting palsy, 182. Strychnia phos. in spinal irritation, 309. Stump, neuralgia of the, 265. Sudamina in tetanus, 107. Sulphur in sciatica, 268. Supra-orbital neuralgia, 237. Suppressed neuralgia, 273. Suspended animation, 130. Sweating in tetanus, 112. Sydenham on chorea, 83. Sympathetic tetanus, 110 ; convulsions, 28, 39. Symptomatic convulsions, 28, 29 : tetanus, 110. Symptoms of infantile convulsions, 34; of c. of the new-born, 47; of puerperal c, 51 : of epileptic c, 61 ; of hystero-epilepsy, 77 ; of chorea. 83; of tetanus, 104; of hydro- phobia, 119 ; of rabies, 124 ; of catalepsy, 130 ; of hemiplegia, 136 ; of infantile spinal paralysis, 154; of facial p., 158 : of diph- theritic p., 164 ; of bulbar p., 168 ; of p. of the insane, 173 ; of muscular atrophy, 179 : of locomotor ataxy, 1S5 ; of paralysis agi- tans, 195; of scrivener's palsy, 201: of aphasia, 205 ; of paralytic aphonia, 214 : of neuralgia, 219 ; of hemicrania, 223 ; of n. trigemini, 237 ; of intercostal n., 249 ; of mastodynia, 250 ; of sciatica, 257 ; of angina pectoris, 269 ; of gastralgia, 283 ; of spinal irritation, 301 ; of hysteria, 315 ; of hypo- chondriasis, 324 ; of melancholia, 332 : of moral insanity, 339 ; of mania, 348 : of dementia, 376 ; of brain fag, 381 ; of deli- rium tremens, 3S9. Syphilis in hemiplegia, 137 ; in paraplegia, 147 ; in epilepsy, 67. Tabes dorsalis, 184, 305. Tamisier on tobacco in hemiplegia, 13S: in paraplegia, 147 ; in locomotor ataxy, loo. Tanner, Dr., on water-diet, 58. Tarantula in chorea, 98 ; iu paralysis agitans, 199 ; in hysteralgia, 299 ; in spinal irrita- tiou, 310; in hysteria, 322 ; in mania, 371. Tea and coffee, abuse of, 286. Temperature, anomalies of, 17 ; rise of, in hystero-epilepsy, 79; in tetanus, 107: in mania, 349 ; in sciatica, diminution of, 258., INDEX. 409 Tenotomy in writer's palsy, 203. Teste, Dr., on the effects of tobacco, 285. Tetanus, 102 ; traumatic, 103; remedies for, 113; toxic, 102, 109 ; sympathetic, 110. Thalamic epilepsy, 63. Thalami optici, functions of, 17; anterior and posterior parts of, 17 ; faradization of, 17 ; sclerose en plaques, 17. Thompson, Dr., on sciatica, 260. Thrombosis of arteria fossae Sylvii, 17,13S ; in hemiplegia, 136, 137 ; iu aphasia, 138; caused by burns, 138. Thurman, Dr., on insanity, 359. Tic-douloureux, 221, 237. Tissot on hystoro-epilopsv, 76. Tissue alterations. 9, 350." Tobacco in hemiplegia, 138 ; in paraplegia, 147 ; in locomotor ataxy, 190 ; in gastralgia, 285. Todd, Dr., on chorea, 87 ; on locomotor ataxy, 1S4. Tracheotomy in tetanus, 106. Traube and Rosensstein on anaemia, 51. Treatment of infantile convulsions, 37; of c. of the new-born, 48; of puerperal c, 52; of non-puerperal c, 59; of epileptic c, US ; of hystero-epilepsy, 80 ; of chorea, 91 ; of tetanus, 112; of hydrophobia, 124; of cat- alepsy, 132; of hemiplegia, 138; of para- plegia, 147; of infantile spinal paralysis, 155; of facial p., 160; of diphtheritic p., 166; of bulbar p., 171 ; of p. of the insane, 176; of muscular atrophy, 182; of locomo- tor ataxy, 191; of paralysis agitans, 199; of scriveuer's palsy, 203 ; of aphasia, 209 ; of paralytic aphonia, 216 ; of neuralgia, of hemicrania, 226 ; of facial neuralgia, 240 ; of intercostal n., 253 ; of sciatica, 262 ; of angina pectoris, 274 ; of gastralgia, 288 ; of neuralgia of female genital organs, 297 ; of spinal irritation, 307 ; of hysteria, 319 ; of hypochondriasis, 326 ; of melancholia, 334 ; of moral insanity, 342 ; of mania, 358 ; of dementia, 379 ; of cerebral exhaustion, 3sl, 385; of delirium tremens, 396, 398. Tremor senilis, 197; t. mercurialis, 197, 394; saturninus, 197 ; simplex, 197 ; potatorum, 197, 380. Trismus, 102, 104; t. nascentium, 102, 46. 55. Trousseau, Prof., on diphtheritic paralysis, 165; on progressive bulbar paralysis, 168: on locomotor ataxy, 186, 187. Tubercula quadrigemina, functions of, 19; diseases affecting, 19 ; faradization of, 19. Tumors, cerebral, 11; of the convexity, 12 ; of frontal lobes, 13 ; of vertical lobes, 13: of posterior lobes, 14 ; of cerebral ganglia, 16, 18, 20. Underwood, Dr., on convulsions of the new- born, 46. Unilateral effects of lesions, 11-21, 136. Urates, 107. Ustilago madis in ovaralgia, 300. Uterus, neuralgia of, 294 ; remedies for, 294. Vaginal douche, 297. A'aginodynia, 293 ; remedies for, 297. A7alleix, tender points of, 225, 238, 249, 261. A'asomotor centres, 25; disturbances of, 17, 2o, 64 ; irritation of, 64. 260. A'elpeau on puerperal convulsions, 49. A'eratrum album in hemicrania, 235 ; in gas- tralgia, 292 ; in melancholia, 338; v. viride in convulsions, 45 ; in chorea, 99. Verneuil on thrombosis, 138. Vertebra;, injury of, 142, 146, 305. Vertigo, 12, 18-20 ; v. epileptique, 63. A'eyssiere on the optic thalami, 17. A'icarious action, Flouren's law of, 12. Vision, disturbance of, 17-19 ; destruction of, 16, 19, 24. . Volition, 357. Von Graefe on diphtheritic paralysis, 165. Von Ziemssen on chorea, 83, 92 ; on paralytic aphonia, 215; on chorea of laryngeal mus- cles, 87. Vulpian, M., on hemiplegia, 138; on diphthe- ritic paralysis, 166. Warmth, artificial, in sciatica, 263. Wasting palsy, 179. AVater-diet, 58. Watson, Dr., on hysteria, 315. Wernich on eclamptiform convulsions, 23. Westphal on guinea pigs, 23; on the "phe- nomena of the knee," 189. Wet-pack in delirium tremens, 39S; in in- fantile paralysis, 156. Worcester, Dr., on insanity, 3.38. Writer's cramp, 210. Xanthoxylum in dysmenorrhcea, 300. Youatt on hydrophobia, 123, 125 ; on rabies in the dog, 124. Ziemssen, Prof., on chorea, 83, 87, 92; on c. of laryngeal muscles, 87 ; on paralytic apho- nia, 215. Zinc phosphide in locomotor ataxy, 194 ; in brain fag, 3S7; z. sulph. in chorea, 99. Zones, epileptigonous, 24. BOERICKE & TAFEL'S HOMEOPATHIC PUBLICATIONS. ALLEN, DR. T. F. The Encyclopedia of Pure Materia Medica; a Record of the Positive Effects of Drugs upon the Healthy Human Organism. With contributions from Dr. Richard Hughes, of England; Dr. C. Hering, of Philadelphia; Dr. Carroll Dunham, of JSTeAV York; Dr. Adolph Lippe, of Philadelphia, and others. X volumes. Price bound in cloth, 8(30.00; in half morocco or sheep, . . . $70 00 This is the most complete and extensive work on Materia Medica ever attempted in the history of medicine—a work to which the homoeopathic practitioner may turn AA'ith the certainty of finding the Avhole pathogenetic record of any remedy ever used in homoeopathy, the record of Avhich being published either in bookform or in journals. The volumes average about 640 pages each. ALLEN, DR. T. F. A General Symptom Register of the Homoe- opathic Materia Medica. By Timothy P. Allen, M.D., Author of the Encyclopaedia of Pure Materia Medica. 1340 pages in one large volume. Price in eloth, $12.00; in sheep or half morocco, . $14 00 This Index to the Encyclopaedia of Materia Medica is at the same time the best arranged and most complete .Repertory e\7er attempted. Its inge- nious selection and arrangement of different kinds of type greatly facilitate its use. ANGELL, DR. H. 0. A Treatise on Diseases of the Eye; for the Use of Students and Practitioners. By Henry C. Angell, M.D.. Professor of Ophthalmology in the Boston University School of Medicine, etc., etc. Fifth edition, enlarged and illustrated. 343 pages. 12mo. Cloth,............$3 00 The fifth edition of this standard work has just been issued from the press, and shows that the whole work has been thoroughly revised and brought up to the latest dates in ophthal- mology. Exquisite clear photographic illustrations have been added, and an exposition given of the dioptric or metric system, as applied to lenses for spectacles. DAEHR, DR. B. The Science of Therapeutics according to the Principles of Homoeopathy. Translated and enriched Avith numerous additions from Kafka and other sources, by C. J. Hempel, M.D. Two volumes. 1387 pages,.........$9 Op' "In short Dr. Baehr has presented us with the results of his observations at th-* bedside rather than of his researches in the study. It is this which renders his work valuable and which at the same time accounts for his occasional imperfections. We know 2 BOERICKE of no work of the kind in homoeopathic literature where the suggestions for the choice of medicines are given in a fresher or clearer manner, or in one better calculated to interest and inform the practitioner. We have only to add that the two volumes are highly credit- able to the publishers. The type is good, the paper good, and the binding excellent."— Monthly Homoeopathic Review. BECKER, DR. A. C. Dentition, according to some of the best and latest German authorities. 82 pages. l2mo. Cloth,. 50 cts. BECKER, DR. A. C. Diseases of the Eye, treated homceopathi- cally. From the German. 77 pages. 12mo. Cloth, . . 50 cts. BELL, DR. JAMES B. The Homoeopathic Therapeutics of Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera In- fantum, and all other loose evacuations of the bowels. 168 pages. Bound in Muslin. 12mo. Cloth,.....$1 00 This little book had a very large sale, and but few physicians' offices will be found with- out it. The work was, without exception, very highly commended by the homoeopathic press. BERJEAU, J. PH. The Homoeopathic Treatment of Syphilis, Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised, with numerous additions, by J. H. P. Frost, M.D. 256 pages. 12mo. Cloth,.......... . . $1 50 "This work is unmistakably the production of a practical man. It is short, pithy, and contains a vast deal of sound practical instruction. The diseases are briefly described ; the directions for treatment are succinct and summary. It is a book which might with profit be consulted by all practitioners of homoeopathy."—North American Journal. BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi- cines. 383 pages,.........$1 25 Interleaved with Avriting paper. Half morocco,. . . . $2 25 We quote from the author's preface: " It has been my aim, throughout, to arrange in as concise form as possible, the leading symptoms of all well-established provings. To accomplish this, I have compared Lippe's Mat. Med.; the Symptomen-Codex ; Jahr's Epitome; Bcenninghausen's Therapeutic Pocket- Book, and Hale's New Remedies." BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- pathic Medicine, Alphabetically and Nosologically arranged, Avhich may be used as the Physicians' Vade-mecum, the Travellers' Medical Com- panion, or the Family Physician. Containing the Principal Remedies for the most important Diseases; Sj-mptoms, Sensations, Characteristics of Diseases, etc.; Avith the Principal Pathogenetic Effects of the Medi- cines on the most important Organs and Functions of the Body, together Avith Diagnosis, Explanation of Technical Terms, Directions for the selec- tion and Exhibition of Remedies, Rules of Diet, etc. Compiled from the best Homoeopathic authorities. Third edition. 352 pages. 18mo. Cloth,......... . . . $1 50 BUTLER, JOHN. A Text-Book of Electro-Therapeutics and Electro-Surgery, for the Use of Students and General Prac- titioners. By John Butler, M.D., L.R.C.P.E., L.R.C.S.I., etc., etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3 00 " Butler's work gives with exceptional thoroughness all details of the latest researches on HOMOEOPATHIC PUBLICATIONS. 3 Electricity, which powerful agent has a great future, and rightly demands our most earnest consideration. But Homoeo.pathia especially must hail with delight the advent from out the ranks of her apostles of a writer of John Butler's ability. His book will also find a large circle of non-homoeopathic readers, since it does not conflict with the tenets of any therapeutic sect, and particular care has been bestowed on the technical part of electro- therapeia."—Homozopathische Rundschau. DAKE, DR. WM. C. Pathology and Treatment of Diphtheria. By Win. C. Dake, M.D.,of Xashville, Tenn. 55 pages. 8vo. Paper, 50 cts. This interesting monograph Avas enlarged from a paper read at the Third Annual Meeting of the Homoeopathic Society of Tennessee, held at Mem- phis, September 19, J 877. It gives a report of one hundred and seventy-six cases treated during a period of eleA7en months. It Avell repays a careful perusal. DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science of Therapeutics. A collection of papers elucidating and illustrating the principles of homoeopathy. 529 pages. 8vo. Cloth, . . $3 00 Half morocco,.......... $4 00 "After reading this work no one will attempt to justify the practice of alternation of remedies. It is simply the lazy man's expedient to escape close thinking or 6o cover his ignorance. The one remedy alone can be accurate and scientific; a second or third only complicates and spoils the case, and will inevitably ruin a good reputation. But to come to more practical matters, more than one-half of this volume is devoted to a careful analysis of various drug-provings. It teaches us Materia Medica after a new fashion, so that a fool can understand, not only the full measure of usefulness, but also the limitations which surround the drug. . . . We ought to give an illustration of his method of analysis, but space forbids. Wc can only urge the thoughtful and studious to obtain the book, which they will esteem as second only to the Organon in its philosophy and learning."—The American Homoeopathist. DUNHAM, CARROLL, A.M., M.D. Lectures on Materia Medica. 858 pages. 8\7o. Cloth,........$5 00 Half morocco,..........$6 00 . . . " Vol. I is adorned with a most perfect likenpss of Dr. Dunham, upon which stranger and friend will gaze with pleasure. To one skilled in the science of physiognomy there will be seen the unmistakable impress of the great soul that looked so long and stead- fastly out of its fair windows. But our readers will be chiefly concerned with the contents of these two books. They are even better than their embellishments. Thev are chiefly such lectures on Materia Medica as Dr. Dunham alone knew how to write. They are pre- ceded quite naturally by introductory lectures, which he was accustomed to deliver to his classes on general therapeutics, on rules which should guide us in studying drugs, and on the therapeutic law. At the close of Vol. II we have several papers of great interest, but the most important fact of all is that we have here over fifty of our leading remedies pre- sented in a method which belonged peculiarly to the author, as one of the most successful teachers our school has yet produced. . . . Blessed will be the library they adorn, and wise the man or woman into whose mind their light shall shine."—Cincinnati Medical Ad- vance. EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3 50 The author brought here together in an admirable and comprehensive arrangement everything published to date on the subject in the Avhole homoeopathic literature, besides embodying his own abundant personal ex- perience. The contents, divided into eight pares, are arranged as folloAvs: Part I. Treats on Menstruation and Dysmenorrhcea; Part II. Menor- rhagia • Part III. Amenorrhea; Part IV. Abortion and Miscarriage; Part V. 4 BOERICKE & TAFEL'S Metrorrhagia; Part VI. Fluor albus; Part VII. Lochia; and Part VIII. General Concomitants. No work as complete as this, on the subject, was ever before attempted, and Ave feel assured that it will meet with great favor by the profession. " The book is a counterpart of Bell on Diarrhoea, and Dunham on Whooping-cough. Synthetics, Diagnosis and Pathology are left out as not coming within the scope of the work. The author in his preface says: Kennedies and their symptoms are left out, and the symp- toms and their remedies have received sole attention—that is what the busy practitioner wants. The work is one of the essentials in a library ."—American Observer. " A most exhaustive treatise, admirably arranged, covering all that is known of therapeu- tics in this important department."—Homazopathic Times. GUERNSEY, DR. H. N. The Application of the Principles and Practice of Homoeopathy to Obstetrics and the Disorders Pe- culiar to Women and Young Children. By Henry N. Guernsey M.D., Professor of Obstetrics and Diseases of Women and Children in the Homoeopathic Medical College of Pennsylvania, etc., etc. With numerous Illustrations. Third edition, revised, enlarged, and greatly improved. 1004 pages. 8vo. Half morocco,......$8 00 This standard work, with the numerous improvements and additions, is the most com- plete and comprehensible work on the subject in the English language. Of the previous editions, almost four thousand copies are in the hands of the profession, and of this third edition a goodly number have already been taken up. There are few other professional works that can boast of a like popularity, and with all new improvements and experiences diligently collected and faithfully incorporated into each successive edition, this favorite work will retain its hold on the high esteem it is held in by the profession, for years to come. It is superfluous to add that it was and is used from its first appearance as a text-book at the homoeopathic colleges. GUERNSEY, DR. E. Homoeopathic Domestic Practice. With Full Descriptions to the Dose to each single Case. Containing also Chapters on Anatomy, Physiology, Hygiene, and an abridged Materia Medica. Tenth enlarged, revised, and improved edition. 653 pages. Half leather,..........$2 50 GUERNSEY, DR. W. E. The Traveller's Medical Repertory and Family Adviser for the Homoeopathic Treatment of Acute Diseases. 36 pages. Cloth,.......30 cts. This little work has been arranged with a view to represent in as compact a manner as possible all the diseases—or rather disorders—which the non-professional would attempt to prescribe for, it being intended only for the treatment of simple or acute diseases, or to allay the suffering in maladies of a more serious nature until a homoeopathic practitioner can be summoned. HAHNEMANN, DR. S. The Lesser Writings of. Collected and Translated by R. E. Dudgeon, M.D. With a Preface and ISTotes by E. Marcy, M.D. With a Steel Engraving of Hahnemann from the statue of Steinhauser. 784 pages. Half bound,.....$3 00 This valuable Avork contains a large number of Essays, of great interest to laymen as well as medical men, upon Diet, the Prevention of Diseases, Ventilation of Dwellings, etc. As many of these papers were written before the discovery of the homoeopathic theory of cure, the reader will be enabled ir peruse in this volume the ideas of a gigantic intellect when di- rected to subjects of general and practical interest. HOMCEOPATHIC PUBLICATIONS. 5 HAHNEMANN, DR. S. Organon of the Art of Healing. By Samuel Hahnemann. Aude Sapere. Fifth American edition, translated from the Fifth German edition, by C. Wesselhceft, M.D. 214 pages. 8vo. Cloth,...........$1 75 This fifth edition of " Hahnemann Organon " has a history. So many complaints were made again and again of the incorrectness and cumber- some style of former and existing editions to the publishers, that, yielding to the pressure, they promised to destroy the plates of the fourth edition, and to bring out an entire re-translation in 1876, the Centennial year. After due consideration, and on the Avarm recommendation of Dr. Constantine Hering and others, the task of making this re-translation Avas confided to Dr. C. Wesselhceft, and the result of years of labor is noAV before the pro- fession, Avho will be best able themselves to judge how well he succeeded in acquitting himself of the difficult task. " To insure a correct rendition of the text of the author, they (the publishers) selected as his translator Dr. Conrad Wesselhceft, of Boston, an educated physician in every respect, and from his youth up perfectly familiar with the English and German languages, than whom no better selection could have been made." "That he has made, as he himself de- clares, ' an entirely new and independent translation of the whole work,' a careful compari- son of the various paragraphs, notes, etc., with those contained in previous editions, gives abundant evidence; and while he has, so far as was possible, adhered strictly to the letter of Hahnemann's text, he has at the same time given a pleasantly flowing rendition that avoids the harshness of a strictly literal translation."—Hahnemannian Monthly. HALE, DR. E. M. Lectures on Diseases of the Heart. In Three Parts. Part I. Functional Disorders of the Heart. Part II. Inflamma- tory Affections of the Heart. Part III. Organic Diseases of the Heart. Second enlarged edition printing. HALE, DR. E. M. Materia Medica and Special Therapeutics of the New Remedies. Fourth edition, revised and enlarged. In two Volumes. Vol. I. Special Symptomatology. With new Botanical and Pharmaco- logical Notes. 672 pages. Cloth,......$5 00 Vol. II. Special Therapeutics. With Illustrative Clinical Cases. 900 pages. Second enlarged edition. Cloth, . . . . $5 00 K B — Same in half morocco, per Volume, . . . . $6 00 " Dr Hale's work on New Remedies is one both well known and much appreciated on this side of the \tlantic For many medicines of considerable value we are indebted to his re- searches In the present edition, the symptoms produced by the drug investigated, and those which thev have been observed to cure, are separated from the clinical observations, bv which the former have been confirmed. That this volume contains a very large amount of invaluable information is incontestable, and that every effort has been made to secure both fulness of detail and accuracy of statement, is apparent throughout. For these reasons we can confidently commend Dr. Hale's fourth edition of his well-known work on the *cw Rmedies to our homoeopathic colleagues "-Monlhlij'Homoeopathic Renew. .... •^Wedonot hesitate to say that by these publications Dr. Hale rendered an inestimable • V i, m„„Qti,v nnd thereby to the art of medicine. ' The school of Hahnemann m e\eiy couimj credit for having in this fourth edition corrected the mistake fmV I thPthird one had been taxed rather severely, by restoring in Vol. II the 'special fherlpeudcs/ Stead of the 'characteristics' of the third edition."-^/* Journal of Ho- motopathj. 6 BOERICKE & TAFEL'S HALE, DR. E. M. The Medical, Surgical, and Hygienic Treat- ment of Diseases of Women, especially those causing Sterility, the Disorders and Accidents of Pregnancy, and Painful and Difficult Labor. By Edwin 31. Hale, M.D., Professor of Materia Medica and Therapeutics in the Chicago Homoeopathic College, etc., etc. Second enlarged edition. 378 pages. 8vo. Cloth, . . . $2 50 " This new work embodies the observations and experience of the author during twenty-five years of active and extensive practice, and is designed to supplement rather than supersede kindred works. The arrangement of the subjects treated is methodical and convenient; the introduction containing an article inserted by permission of Dr. Jackson, of Chicago, the author upon the ovular and ovulation theory of menstruation, which contains all the obser- vations of practical importance known on this subject to date. The diseases causing sterility are fully described, and the medical, surgical, and hygienic treatment pointed out. The more generally employed medicines are enumerated, but their special or specific indications are unfortunately omitted. The general practitioner will find a great many valuable things for his daily rounds, and cannot afford to do without the book. The great reputation and ability of the author are sufficient to recommend the work, and to guarantee an appreciative reception and large sale."—Hahnemannian Monthly. HAYWARD, DR. JOHN W. Taking Cold (the Cause of half our Diseases): Its Nature, Causes, Prevention and Cure; its frequency as a Cause of other Disease, and the Diseases of which it is the Cause, with their Diagnosis and Treatment, Fifth edition, enlarged and improved. London, 1875. 188 pages. 18mo. Cloth,............50 cts. We quote from the author's preface: "This Essay was originally published under the conviction that, by attention to the di- rections it contains, persons may not only very frequently avoid taking cold, but may them- selves frequently cure a cold at the onset, and thereby prevent the development of many of those serious diseases that would otherwise follow. The favorable reception it has met with is a sufficient testimony that it has been found useful." HELMUTH, DR. W. T. A System of Surgery. Illustrated with 568 Engravings on Wood. By Wm. Tod Helmuth, M.D. Third edition. 1000 pages. Sheep,.........$8 50 This third edition of Dr. ITelmuth's great work is already in appearance a great improve- ment over the old edition, it being well printed on fine paper, and well bound. By increas- ing the size of the page, decreasing the size of type, and setting up solid, fully one-half more printed matter is given than in the previous edition, albeit there are over 200 pages less. And while the old edition, bound in sheep, was sold at §11.50 by its publishers, this im- proved third edition is now furnished at'83 less, or for $8.50. The author brought the work fully up to date, and for an enumeration of some of the more important improvements, we cannot do better than to refer to Dr. Helmuth's own Preface. HEMPEL, DR. C. J. The Science of Homoeopathy; or, A Critical and Synthetical Index of the Doctrines of the Homoeopathic School. Second edition. 180 pages. Large 8vo. Cloth, . . . $1 75 HEMPEL, DR. C. J., and DR. J. BEAKLEY. Homoeopathic Theory and Practice. With the Homoeopathic Treatment of Surgi- cal Diseases, designed for Students and Practitioners of Medicine, and as a Guide for an intelligent public generally. Fourth edition. 1100 pages,............$3 00 HOMCEOPATIIIC PUBLICATIONS. 7 HERING, DR. C. Condensed Materia Medica. Second edition. More condensed, revised, enlarged, and improved, . . . $7 00 In February, 1877, we were able to announce the completion of Hering's Condensed Ma- teria Medica. The work, as was to be expected, was bought up with avidity by the profes- sion, and already in the Fall of 1878 the author set to work perfecting a second and im- proved edition. By still more condensing many of the remedies, a number of new ones co'ild be added witliout much increasing the size and the price of the work. This new edition is now ready for the profession, and will be the standard work par excellence for the practitioner's daily reference. HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- pathic Drugs. Translated from the German by Paul TieTtze, M.D., of Philadelphia. 576 pages. 8\7o. Cloth, . . . . $3 50 This work, but shortly issued, is already meeting with a large sale and an appreciative reception. It differs from most works of its class in these respects: 1. That the symptomatic outlines of the various drugs are based exclusively upon the "pathogenetic" results of provings. 2. That the anatomico-physiological arrangement of the symptoms renders easier the understanding and survey of the provings. 3. That the pathogenetic pictures drawn of most of the drugs, gives the reader a clearer idea, and a more exact impression of the action of the various remedies. Each remedy is introduced with a brief account of its preparation, duration of actionk and antidotes. HILDEBRANDT, PROF. H. Catarrh of the Female Sexual Organs. Translated Avith the addition of the Homoeopathic Treatment, by S. Lilienthal, M.D.,........30 cts. HOLCOMBE, DR. W. H. Yellow Fever and its Homoeopathic Treatment,..........10 cts. HOLCOMBE, DR. W. H. What is Homoeopathy? A new expo- sition of great truth. 28 pages. 8vo. Paper cover, per doz., $1.25, 15 cts. " Prove all things, hold fast that which is good."—St. Paul. HOLCOMBE, DR. W. H. How I became a Homoeopath. 28 pages. 8vo. Paper cover, per dozen, 81.25, . . . -15 cts. HOLCOMBE, DR. W. H. Special Report of the Homoeopathic Yellow Fever Commission, ordered by the American Institute of Homoeopathy for presentation to Congress. 32 pages. 8vo. Paper, per 100, 84.00,..........Sets. This Eeport written in Dr. Holcombe's masterly manner, is one of the best campaign documents for homoeopathy. The statistics must convince the most skeptical, and every homoeopathic practitioner should feel in duty bound to aid in securing its widest possible circulation. HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veterina- rian) * <>r> Plain Directions for the Homoeopathic Treatment of the most Common Ailments of Fowls, Ducks, Geese, Turkeys, and Pigeons, based on the author's large experience, and compiled from the most reliable sources by Dr. Fr. Schroter. Translated from the German. 84 pages. 12mo. ' Cloth,..........50 Cts. w -mnorted hundreds of copies of this work in the original German for our customers, j IrJUe srood satisfaction, we thought it advisable to give it an English dress, so as to and as it g* j]g ^ ^ bli(j generally. The little work sells very fast, and our readers make it a, ^^ haye an opportunity to draw the attention of their patrons to it. 8 BOERICKE & TAFEL's HOMOEOPATHIC COOKERY. Second edition. With additions by a Lady of an American Homoeopathic Physician. Designed chiefly for the Use of such Persons as are under Homoeopathic Treatment. 176 pages,.............50 cts. HUGHES, DR. R. Manual of Pharmacodynamics. 500 pages. American reprint out of print. See list of British books. HUGHES, DR. R. Manual of Therapeutics. 540 pages. American reprint out of print. See list of British books. HULL'S JAHR. A New Manual of Homoeopathic Practice, Edited, with Annotations and Additions, by F. G. Snelltng, M.D. Sixth American edition. With an Apj>endix of the NeAv Remedies, by C. J. Hempel, M.D. 2 vols. 2076 pages,......$9 00 The first volume, containing the symptomatology, gives the complete pathogenesis of two hundred and eighty-seven remedies, besides a large number of new remedies are added by Dr. Hempel, in the appendix. The second volume contains an admirably arranged Keper- torv. Each chapter is accompanied by copious clinical remark's and the concomitant symp- toms of the chief remedies for the malady treated of, thus importing a mass of information, rendering the work indispensable to every student and practitioner of medicine. JAHR, DR. G. H. G. Therapeutic Guide; the most Important Re- sults of more than Forty Years' Practice. With Personal Observations regarding the truly reliable and practically verified Curative Indications in actual cases of disease. Translated, Avith Notes and New Remedies, by C. J. Hempel, M.D. 546 pages,......$3 00 " A\7ith this characteristically long title, the veteran and indefatigable Jahr gives us another volume of homoeopathies. Besides the explanation of its purport contained in the title itself, the author's preface still further sets forth its distinctive aim. It is intended, he says, as a 'guide to beginners, where I only indicate the most important and decisive points for the selection of a remedy, and where I do not offer anything but what my own individual experience, during a practice of forty years, has enabled me to verify as absolutely decisive in choosing the proper remedy.' The reader will easily comprehend that, in carrying out this plan, I had rigidly to exclude all cases concerning which I had no experience of my own to offer.....We are bound to say that the book itself is agreeable, chatty, and full of practical observation. It may be read straight through with interest, and referred to in the treatment of particular cases with advantage."—British Journal of Homoeopathy. JAHR, DR. G. H. G. Clinical Guide, or Pocket Repertory for the Treatment of Acute and Chronic Diseases.. Translated by C. J. Hempel, M.D. Second American reA7ised and enlarged edition. From the third German edition, enriched by the addition of the NeAv Remedies. By S. Lilienthal, M.D. 624 pages. 12mo. Half mo- rocco, ........ .... $2 50 " To those of our readers who have used the old edition, nothing need be said to induce them to procure a copy of the new. To others, however, we feel free to state that as a volume of ready reference to lie on the office desk, or be used at the bedside, it is very valu- able, and will save many tedious and distracting hunts through the symptomen codex. The typographical execution of the book is excellent."—Hahnemannian Monthly. JAHR, DR. G. H. G. The Homoeopathic Treatment of Diseases of Females and Infants at the Breast. Translated from the French by C. J. Hempel, M.D. 422 pages. Half leather, . . . $2 00 This work deserves the most careful attention on the part of homoeopathic practitioners. The diseases to which the female organism is subject are described with the most minute correctness, and the treatment is likewise indicated with a care that would seem to defy criticism. No one can fail to study this work but with profit and pleasure. HOMOEOPATHIC PUBLICATIONS. 9 JAHR, DR. G. H. G. Diseases of the Skin; or, Alphabetical Reper- tory of the Skin Symptoms, and External Alterations of Substance, to- gether Avith the Morbid Phenomena observed in the Glandular, Osseous, Mucous, and Circulatory Symptoms. Arranged Avith Pathological Re- marks on Diseases of the Skin. Edited by C. J. Hempel, M.D. 515 pages. 12mo. Cloth, ..........$1 50 JAHR, DR. G. H. G. The Venereal Diseases, their Pathological Nature, Correct Diagnosis, and Homoeopathic Treatment. Prepared in accordance with the author's oavii, as well as Avith the expe- rience of other physicians, and accompanied Avith critical discussions. Translated, Avith numerous and important additions, from the works of other authors, and from his OAvn experience. By C. J. Hempel, M.D. 428 pages. 8vo. Cloth, . . • . . . . . . $3 00 This is the most elaborate treatise on the subject in print. The work is divided into four divisions, of which the first treats on Primary Forms of Venereal Diseases, in four chapters: On the Venereal Phenomena in general; the Different Forms of Gonorrhoea; the Various Forms of Chancre; and other Primary Forms of Syphilis. The second division, on Second- ary Forms of Syphilis, treats in three chapters, of Secondary Svphilis generally; Syphilitic Cutaneous Affections, and Intermediate Forms of Svphilis. The third division: General Pathological Observations on Syphilis and its course generally, in three chapters; Patho- logical Nature and Origin of Syphilis; on Venereal Contagia; General Development, Course, and Termination of Syphilis. The fourth division: General Therapeutic Observa- tions on the Treatment of Syphilis; General Diagnostic Remarks; General Therapeutic Observations; Pharmaco-dynamic Observations, and Addenda. INDEX to the first eighteen volumes of the North American Journal of Homoeopathy. Paper. ........$2 00 JONES, DR. SAMUEL A. The Grounds of Homoeopathic Faith. Three Lectures, delivered at the request of Matriculates of the Depart- ment of Medicine and Surgery (Old School) of the University of Michi- gan. By Samuel A. Jones, M.D., Professor of Materia Medica, Thera- peutics, and Experimental Pathogenesy in the Homoeopathic Medical College of the University of Michigan, etc., etc. 92 pages. 12mo. Cloth, per dozen, $3; per hundred, 820,......30 cts. Lecture first is on The Law of Similars ; its Claim to be a Science in that it Enables Perver- sion. Lecture second, The Single Remedy a Necessity of Science. Lecture third, The Mini- mum Dose an Inevitable Sequence. A fourth Lecture, on The Dynamization Theory, was to have finished the course, but was prevented by the approach of final examinations, the prepa- ration for which left no time for hearing evening lectures. The Lectures are issued in a con- venient size for the coat-pocket; and as an earnest testimony to the truth, we believe they will find their way into many a homoeopathic household. JOHNSON, DR. I. D. Therapeutic Key; or Practical Guide for the Homoeopathic Treatment of Acute Diseases. Third edition. 312 pages. Bound in linen,..........$1 50 Bound in flexible cover, . . ........$2 00 This has been one of the best selling works on our shelves; more copies being in circula- tion of this than of any two other professional works put together. It is safe to say that there are but few homoeopathic practitioners in this country but have one or more copies of this little remembrancer in their possession. JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- si o-ned for the use of Families and Private Individuals. 494 pages. cfoth, . .......... $2 00 10 BOERICKE & TAFEL'S This is the latest work on Domestic Practice issued, and the well and favorably known author has surpassed himself. In his book fifty-six remedies are introduced for internal ap- plication, and four for external use. The work consists of two parts, Part I is subdivided into seventeen chapters, each being devoted to a special part of the body, or to a peculiar class of disease. Part II contains a short and concise Materia Medica, i. e., gives the symptoms peculiar to each remedy. The whole is carefully written with a view of avoiding technical terms as much as possible, thus insuring its comprehension by any person of ordi- nary intelligence. A complete set of remedies in vials holding over fifty doses each, is fur- nished for £7, or in vials holding over one hundred doses each for $10, or book and case complete for ^9 or $12 respectively. Address orders to Boericke & Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. JOSLIN, DR. B. F. Principles of Homoeopathy. In a Series of Lectures. 185 pages. 12mo. Cloth,.....60 cts. JOSLIN, DR. £. F. Homoeopathic Treatment of Epidemic Cholera. Third edition, with additions. 252 pages. 12mo. Cloth, 75 cts. This work offers the advantage of a threefold arrangement of the principal medicines, viz., with reference, I—to the varieties of cholera; II—to its stages; and III—to its symptoms as arranged in repertories. These last will give the work a permanent value in treating the more frequent complaints of summer. LAURIE AND McCLATCH^Y. The Homoeopathic Domestic Medicine. By Joseph Laurie, M.D. Ninth American, from the TAventy- first English edition. Edited and revised, with numerous and important additions, and the introduction of the new remedies. By R.J. McClatchey, M.D. 1044 pages. ^ 8vo. Half morocco, . . . . . $5 00 " AVe do, not hesitate to indorse the claims made by the publishers, that this is the most complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- eases extant. This handsome volume of nearly eleven hundred pages is divided into six parts. Fart one is introductory, and is almost faultless. It gives the most complete and exact directions for the maintenance of health, and of the method of investigating the con- dition of the sick, and of discriminating between different diseases. It is written in the most lucid style, and is above all things wonderfully free from technicalities. Part two treats of symptoms, character, distinctions, and treatment of general diseases, together with a chap- ter on casualties. Part three takes up diseases peculiar to women. Part four is devoted to the disorders of infancy and childhood. Part five gives the characteristic symptoms of the medicines referred to in the body of the work, while Part six introduces the repertory."—. Hahnemannian Monthly. "Of the usefulness of this work in cases where no educated homoeopathic physician is within reach, there can be no question. There is no doubt that domestic homoeopathy has done much to make the science known; it has also saved lives in emergencies. The prac- tice has never been so well presented to the public as in this excellent volume."—New Eng. Med. Gazette. A complete set of remedies of one hundred and four vials, containing over fifty doses each, is furnished for $12, put up in an elegant mahogany case. A similar set in vials containing over one hundred doses each, is furnished for $18, or book and case complete for 817 or S23 respectively. Address orders to Boericke & Tafel's Pharmacies at New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S. Lilienthal, M.D., Editor of Xorth American Journal of Homoeopathy, Professor of Clinical Medicine and Psychology in the New York Homoeo- pathic Medical College, and Professor of Theory and Practice in the New York College Hospital for "Women, etc. Second edition. 8vo, $5 00 Half morocco,..........$6 00 " Certainly no one in our ranks is so well qualified for this work as he who has done it, and in considering the work done, we must have a true conception of the proper sphere of HOMOEOPATHIC PUBLICATIONS. 11 such a work. For the fresh graduate, this book will be invaluable, and to all such we un- hesitatingly and very earnestly commend it. To the older one, who says he has no use for this book, we have nothing to say. lie is a good one to avoid when well, and to dread when ill. We also hope that he is severely an unicum."—Prof. Sam. A. Jones in American Homoz- opalhist. . . . It is an extraordinary useful book, and those who add it to their library will never feel regret, for we are not saying too mucli in pronouncing it the best work on therapeu- tics in homoeopathic for any other) literature. A\rith this under one elbow, and Bering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner can refute Neimayer's too confident assertion, ' I declare it idle to hope for a time when a medical pre- scription should be the simple resultant of known quantities.' Doctor, by all means buy Lilienthal's Homoeopathic Therapeutics. It contains a mine of wealth."—Prof. Chas. Qatchel in Ibid. LILIENTHAL, DR. S. A Treatise on Diseases of the Skin. A neAv edition in preparation for the press. LUTZE, DR. A. Manual of Homoeopathic Theory and Practice. designed for the use of Physicians and Families. Translated from the German, with additions by C. J. Hempel, M.D. From the sixtieth thousand of the German edition. 750 pages. 8vo. Half leather,...........$2 50 This work, from the pen of the late Dr. Lutze, has the largest circulation of any homoeo- pathic work in Germany, no less than sixty thousand copies having been sold. The intro- duction, occupying over fifty pages, contains the question of dose, and rules for examining the patient, and diet; the next sixty pages contain a condensed pathogenesis of the remedies treated of in the work; the description and treatment of diseases occupy four hundred and eighteen pages, and the whole concludes with one hundred and seventy-three pages of reper- tory and a copious index, thus forming a concise and complete work on theory and practice. MALAN, H. Family Guide to the Administration of Homoeo- pathic Remedies. 112 pages. 32mo. Cloth, . . . 30 cts. MANUAL OF HOMOEOPATHIC VETERINARY PRACTICE. Designed for all kinds of Domestic Animals and Fowls, prescribing their proper treatment when injured or diseased, and their particular care and general management in health. Second and enlarged edition. 684 pages. 8vo. Half morocco,.........$5 00 "In order to rightlv estimate the value and comprehensiveness of this great work, the reader should compare it, as we have clone, with the best of those already before the public. In size fulness, and practical value it is head and shoulders above the very best of them, while in many most important disorders it is far superior tothem altogether, containing, as it does recent forms of disease of which they make no mention."—Hahnemannian Monthly. MARSDEN, DR. J. H. Handbook of Practical Midwifery, with full instructions for the Homoeopathic Treatment of the Dis- eases of Pregnancy, and the Accidents and Diseases incident to Labor and the Puerperal State. By J. H. Marsden, A.M., M.D. 315 pages. Cloth, . • • • • . • ... $2 25. " It is seldom we have perused a textbook with such entire satisfaction as this. The author has certainly succeeded in his design of furnishing the student and young practitioner, within as narrow limits as possible, all necessary instruction in practical midwifery. The orb shows on every page extended research and thorough practical knowledge. The style "*■ clear the array of facts unique, and the deductions judicious and practical. AVe are par- f larlV pleased with his discussion of the management of labor, and the management of ^her and child immediately after the birth, but much is left open to the common-sense "d practical judgment of the attendant in peculiar and individual cases."—Homoeopathic Times. 12 BOERICKE & TAFEL'S MILLARD, DR. H. B. The Climate and Statistics of Consump- tion. Read before the American Geographical and Statistical Society. With extensive additions by the author. 108 pages. Cloth, . 75 cts. MOHR, DR. CHARLES. The Incompatible Remedies of the Homoeopathic Materia Medica. By Charles Mohr, M.D., Lecturer of Homoeopathic Pharmaceutics, Hahnemann Medical College, Philadel- phia. (A paper read before the Homoeopathic Medical Society of the County of Philadelphia) Pamphlet, in paper cover, . . 10 cts. This is an interesting paper, which will well repay perusal and study. It gives a list of fifty-seven remedies and their incompatibles, diligently collated from the best-known sources. MORGAN, DR. W. The Homoeopathic Treatment of Indiges- tion, Constipation, and Haemorrhoids. Edited with Notes and Annotations by A. E. Small, M 1> 166 pages 12mo. Cloth, 60 cts. Diseases resulting from irregularity or debility of the digestive organs are so frequent in their occurrence, that scarcely a family can be found in which one or more of its members are not sufferers thereby. The present work gives in a concise manner the hygienic meas- ures as well as the medical treatment that should be observed, calculated not only to obviate the necessity of recourse to dangerous palliatives, tut to promote a complete restoration of health. MORGAN, DR. W. The Textbook for Domestic Practice; being plain and concise directions for the Administration of Homoeopathic Medicines in Simple Ailments. 191 pages. 32mo. Cloth, . 50 cts. This is a concise and short treatise on the most common ailments, printed in convenient siz£ for the pocket; a veritable traveller's companion. A complete set of thirty remedies, in vials holding over fifty doses each, is furnished for $4.50, in stout mahogany case; or same set in vials holding over one hundred doses each, for SG.50; or book and case complete for $5 or $7 respectively. Address orders to Boericke & Tafel's Pharmacies, New York, Philadelphia, Baltimore, Chicago, New Orleans, or San Francisco. MURE, DR. B. Materia Medica; or, Provings of the Principal Ani- mal and Vegetable Poisons of the Brazilian Empire, and their Application in the Treatment of Diseases. Translated from the French, and arranged according to Hahnemann's Method, by C. J. Hempel, M.D. 220 pages. 12mo. Cloth,..........$1 00 Thisvolume, from the pen of the celebrated Dr. Mure, of Rio Janeiro, contains the patho- genesis of thirty-two remedies, a number of which have been jused in general practice ever since the appearance of the work. A faithful wood-cut of the plant or animal treated of ac- companies each pathogenesis. NEIDHARD, DR. C. On the Universality of the Homoeopathic Law of Cure,..........30 cts. NEW PROVINGS of Cistus Canadensis, Cobaltum, Zingiber, and Mer- curius Proto-lodatus. 96 pages. Paper,.....75 cts. NORTH AMERICAN JOURNAL OF HOMCEOPATHY. Pub- lished quarterly on the first days of August. November, February, and May. Edited by S. Lilienthal, M.D. Vol. X, New Series, commenced in August, 1879. Subscription price per volume, in advance, . $4 00 Complete sets of the first tAventy-seven volumes, in half morocco binding, including Index to the first eighteen volumes, . . . $90 00 Index to the first eighteen volumes.......$2 00 HOMCEOPATHIC PUBLICATIONS. 13 OEHME, DR. F. G. Therapeutics of Diphtheritis. A Compilation and Critical Review of the German and American Homoeopathic Litera- ture. Second enlarged edition. 84 pages. Paper, . . . 60 cts. Same, in cloth,..........75 cts. "This pamphlet contains the best compilation of reliable testimony relative to diphtheria that has appeared from the pen of any member of our school."— Ohio Medical and Surgical Reporter. '"Although he claims nothing more for his book than that it is a compilation, with 'criti- cal reviews,' he has done his work so well and thoroughly as to merit all praise."—Hahne- mannian Monthly. " Dr. Oehme's little book will be worth many times its price to any one who has to treat this terrible disease."—British Journal of Homoeopathy. " It is the best monograph we have yet seen on diphtheria."—Cincinnati Medical Advance. PETERS, DR. J. C. A Complete Treatise on Headaches and Diseases of the Head. I. The Nature and Treatment of Headaches. II. The Nature and Treatment of Apoplexy. III. The Nature and ' Treatment of Mental Derangement. IV. The Nature and Treatment of Irritation, Congestion, and Inflammation of the Brain and its Membranes. Based on Th. J. Riickert's Clinical Experiences in Homoeopathy. 586 pages. Half leather,.........$2 50 PETERS, DR. J. 0. A Treatise on Apoplexy. With an Appendix on Softening of the Brain and Paralysis. Based on Th. J. Riickert's Clinica iExperiences in Homoeopathy. 164 pages.* 8vo. Cloth, $1 00 PETERS, DR. J. C. The Diseases of Females and Married Fe- males. Second edition. Two parts in one volume. 356 pages Cloth,............$1 50 PETERS, DR. J. C. The Diseases of Married Females. Disorders of Pregnancy, Parturition, and Lactation. 196 pages. 8vo. Cloth, $1 00 PETERS, DR. J. 0. A Treatise on the Principal Diseases of the Eyes. Based on Th. J. Riickert's Clinical Experiences in Homoeopath}7. 291 pages. 8vo. Cloth,........$1 50 PETERS, DR. J. C. A Treatise on the Inflammatory and Organic Diseases Of the Brain. Based on Th. J. Riickert's Clinical Experi- ences in Homoeopathy. 156 pages. 8vo. Cloth, . . . $1 00 PETERS, DR. J. C. A Treatise on Nervous Derangement and Mental Disorders. Based on Th. J. Riickert's Clinical Experiences in Homoeopathy. 104 pages. 8vo. Cloth,.....$1 00 PHYSICIAN'S VISITING LIST AND POCKET REPERTORY, THE HOMCEOPATHIC. By Robert Faulkner, M.D. Second edition,......., . • . $2 00 " Dr. Faulkner's Visiting List is well adapted to render the details of daily work more perfectly recorded than any book prepared for the same purpose with which we have hitherto met It commences with Almanacs for 1877 and 1878; then follow an obstetric calendar; a list of Poisons and their Antidotes; an account of Marshall Hall's ready method in As- phyxia- a Repertory of between sixty and seventy pages ; pages marked for general memo- randa ; Vaccination Records ; Record of Deaths; Nurses; Friends and others; Obstetric 14 BOERICKE & TAFEL'S Record, which is especially complete; and finally, pages ruled to keep notes of daily visits, and also spaces marked for name of the medicine ordered on each day. The plan devised is so simple, so efficient, and so clear, that we illustrate it on a scale just half the size of the original (here follows illustration). The list is not divided into special months, but its use may be as easily commenced in the middle of the year as at the beginning. We heartily recommend Faulkner's List to our colleagues who may be now making preparations for the duties