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CONTRIBUTIONS TO THE PATHOLOGY AND TREATMENT OF FUNCTIONAL NERVOUS DISORDERS.
6 bibulous material over the lips. But the observations of M. Pasteur with regard to the effect of atmospheric atoms in causing decomposition, which haveled to Professor Lister’s treatment of wounds and abscesses, now established in Glasgow and Edinburgh, and certainly the most important improvement in surgical practice of recent times, has led to a complete revolution of ideas on the subject. In cases of bruise, fracture, dislocation, and even operations of tenotomy, large quantities of blood are frequently effused more or less deeply under the integuments without causing any bad effect, and quickly disappear by means of absorption. How, then, does it happen that blood collected in the cavity of a wound should be productive of so much mischief ? It can only do so, as Mr. Lister has shown, through the decomposing influence of atmospheric air, loaded with its myriads of organic atoms, and, therefore, if protected from this agency, would be no more hurtful than in the circumstances just mentioned. He has accordingly found, as stated in the preceding numbers of thisjournal, that wounds of the most formidable character may be divested of all their alarming features by means of carbolic acid, applied so as to prevent the impure air from entering. This remarkable fact has led me to consider the expediency of resorting more frequently than heretofore to the use of ’’torsion" for the suppression of haemorrhage. Ever since this method was proposed by the late M. Amussat I have employed it in wounds of the cheek and lips, and also occasionally in more serious operations, to let my pupils see that it was quite effectual, but have been prevented from adopting it for general use, by fearing that the absence of ligatures, which serve as conductors of the discharge, would increase the risk of blood or serum being pent up in the cavity. Feeling now happily relieved from any apprehension of evil being thus produced, I think "torsion" may in many, if not in all cases, be employed with advantage, instead of the ligature. In order to perform the process effectually, it is necessary that the artery should be seized by catch-forceps, and twisted until they become loose. It has been alleged that such a liberty with the vessel must cause it to slough, and thus disturb the adhesive action. But as this objection is altogether theoretical and contradicted by experience, it is unworthy of notice. In illustration of what has been said, the two following cases may be mentioned as sufficient to substantiate the facts1st. That torsion effectually restrains the haemorrhage of ordinary-sized arteries. 2nd. That its action upon them does not prevent union by the first intention. 3rd. That protection from the air prevents decomposition of the blood. CASE 1. -On the 27th of May I amputated the middle finger of a young woman in the hospital at the metacarpal joint for disease of three years’ standing, and arrested the bleeding by torsion of the arteries, which were three in number. A mixture of carbolic acid and linseed oil, in the proportion of one to five, having then been freely applied to the surface of the wound, I tied the adjoining fingers together so as to retain the cut edges in contact, and placed over them a piece of lint soaked in the carbolic mixture. The result at the end of three days was complete and perfect union without any discharge of matter. CASE 2.-On the llth of June Mr. Annandale removed a tumour from the chest of a male patient by an incision ten inches in length, and employed the torsion for five arteries, two of which were of considerable size. He then applied the carbolic mixture freely to the wound, brought its edges together by silver sutures, and covered them with lint soaked in the protective fluid. Three days afterwards I saw the wound soundly healed without a drop of matter. The following case is sufficient to prove-if proof were wanting-that ligatures do not prevent primary union beyond the extent which they occupy. CASE 3.-On the llth of June a young man was admitted into the hospital on account of a large brachial aneurism, the size of an orange, at the bend of his elbow, which had resulted from the thrust of a file two months before the time of application. I laid open the sac to its full extent, removed the. blood and coagulum, tied the humeral artery on both sides of the orifice, twisted a small vessel that bled, rinsed out the cavity with the carbolic mixture, and applied a piece of lint soaked in it on the wound. There did not follow the slightest local or constitutional disturbance; and complete adhesion took place, except at the small point where the ligatures lay, from which a few drops of pus were discharged. On the fifth day some
one
that
of the ligatures came out, and on the sixth the other ; on the seventh day the recovery might be regarded
so as
perfect. Edinburgh, June, 1867.
CONTRIBUTIONS TO THE
PATHOLOGY AND TREATMENT OF FUNCTIONAL NERVOUS DISORDERS. BY C. HANDFIELD
JONES, M.B. CANTAB., F.R.S.,
PHYSICIAN TO ST.
MARY’S
HOSPITAL.
THE ANALOGY BETWEEN CENTRAL AND PERIPHERAL NERVOUS DISORDER.
IT is admitted now on all hands, I believe, that in dealing with disease the physician has to eschew as far as possible the notion that its several manifestations are to be regarded as so many separate entities, each more or less completely diverse from the other. The progress of knowledge leads us rather to believe that a few great causes of morbid action are in operation, which, by reason of the original differences of the systems on which they act, and of the different parts in different persons which more readily succumb to their power, produce very different results, at least in outward show-viz., the so-called diseases. These often are found much more really similar than they seem to be on a cursory examination. On the present occasion I wish to make an attempt to point out a rapprocliement, which it seems to me may be instituted between certain nervous disorders commonly regarded as peripheral, and others which, beyond doubt, are central. I will relate as briefly as may be a few instances, in which the exist. ence of such a connexion appears to me very probable. CASE 1.-J. A , aged thirty-six, married, had served as a soldier in Bengal, where he had several times had fever and ague. His present disorder, when he was admitted July 14th, was severe neuralgia affecting the right temple, which resisted quinine in five-grain doses, given at first every third, and afterwards every second hour, and continued altogether eleven days; but yielded to arsenic in doses of one-twentieth of a grain three times a day, and large repeated doses of extract of belladonna, of which he took about twenty grains in the first three days. About the middle of August he ceased attendance, and went to Ireland. He returned in the course of the following October (I saw him on the 20th), when he stated that he had remained quite free from the neuralgia, but had had several fits of epileptic character, in one of which he fell into the fire, and burnt his arm rather smartly. Before his visit to Ireland he had never suffered from epilepsy. His head felt heavy, dropped, and he had difficulty in holding it up. He was treated with iodide of potass and bark, and improved somewhat. The interval between the two attacks he had while under my observation was four weeks. It seems to me a reasonable supposition that in this instance the epilepsy was the equivalent of the neuralgia, both being probably the results of the malarious influence he had been exposed to in India, and which had there confined its injurious effects chiefly to the sympathetic nerves and centres. In my work on Functional Nervous Disorders, p. 298, I have related the case of a lady who had very severe facial neuralgia. As this yielded to quinine in full doses she got attacks of hysteria, with partial syncope, only relieved by stimulants in large quantities. The attacks were paroxysmal, and came on at exactly the same hour as the neuralgia had; they were attended also with shivering. Under the continued use of quinine, with arsenic, they ceased. Here it appears that as the disorder ceased in the fifth nerve and its tertiary centre (Simon), it developed itself in a higher-seated one-viz., the emotional, whether that be the corpora quadrigemina and adjacent grey matter, or a part of the hemispheres. I have published elsewhere the case of a medical man who for several days suffered severely with vertigo of obscure origin. It continued to plague him in spite of sundry remedies, when one morning there came on, in addition to the former malady, a fit of brow ague. For this he took quinine, and speedily was cured both of the vertigo and of the neuralgia. Can we doubt that both morbid actions were of the same kind, differing only in their locale ?
7 The following interesting history has been kindly given me and trembling." Some remedies were administered with adby Dr. Palmer, who has contributed several valuable papers to vantage, but the malady rather seemed to pass by than to be THE LANCET:cured. By the middle of July she was a good deal better. CASE 2.-A clergyman, aged sixty-four, had, eight or nine The neuralgia did not return after the attack in 1863 ; only years before coming under observation, an attack of melan- once during the existence of the melancholia she mentioned cholia, which ceased after two years, leaving him quite well. having some dead feeling in the hands and feet. It may, of The veins of the left leg had been varicose a long time, and on course, be that the occurrence of the melancholia had no relaone occasion they had given rise to troublesome heat and itch- tion to the two previous attacks of neuralgia ; but I think the ing. By the aid of a bandage and aperients he had no annoy- view is more probable that the maladies were essentially ance from them for some years, until about October, 1859. the same morbid action variously localised, because neuralgia After a few weeks one or two small ulcers formed, around which is so notoriously prone to relapses; it had recurred once in erythema was set up; and by the end of the year pruriginous this instance, and might reasonably be expected to do so again. itching had increased so much that his condition was really Besides the state of a nerve affected with numbness and pain distressing. He described the suffering as intolerable, pre- really has much analogy with that of a paretic and melancholic cluding sleep, or rest of mind or body. The only relief ob- brain. I may allude here, as having a connexion with this subject, tained was from keeping the leg enveloped in lint soaked in strong infusion of tobacco, to which was added opium or to the fact that patients suffering with delirium tremens, or hydrocyanic acid. His mind all the while was perfectly sound. approaching the verge of it, are not unfrequently attacked by One morning in the beginning of February a hasty message epileptic fits. I have met with such instances myself. The was brought that the patient had gone out of his mind. On observation seems to me interesting from our present point of arriving, Dr. Palmer found him mildly excited and irrational view as marking a connexion between the derangement of the in his talk, but the prurigo was gone. The evening before he neurine of the hemispheres and that of the excitable districts; had been itching as usual; this morning the skin was only a and, further, as suggesting that the different manifestations of little red, and he said it was quite well. He gradually became disordered action in the two cases are rather referable to difmelancholic, and has so remained to the present day. The ferences of locale than of the nature of the morbid condition. Hyperaesthesia of the hemispheres seems to conditionate deliprurigo has never returned. Agreeing as I do with Romberg, that nerve disorder- rium ; hyperaesthesia of the excitable districts, epilepsy. On the essence of prurigo, it appears to me that this view it becomes easy to understand how epileptic convulhyperaesthesia-is the reading of this case must be, that a metastasis of the mor- sions may be the prelude to epileptic mania. Just as derangebid condition of the cutaneous nerves of the legs took place to ment of the vital actions may extend or shift from a nerve or the nerve-tissue of the hemispheres, where the disorder in- its tertiary to a higher centre, so it may also from one of these duced expressed itself by symptoms corresponding to the func- higher centres to another. tions of its new location and the quality of the morbid action. This subject has been recently handled with his well-known Whether an actual materies morbi was transferred from the ability by Griesinger, in the Arch. f. Heilk2cnde, 1866, p. 345; peripheral to the central parts is not material; the essential and his observations are so much to my purpose, and so impoint is that one neurosis was the equivalent of the other. portant, that I shall not apologise for extracting them entire. The following case, related to me by Dr. Headlam Greenhow, After remarking that there are insane patients in whom various is very similar. A young man, convalescent from typhoid dysaesthesiae felt all over the frame excite a condition of general fever, got extreme hyperaesthesia of the legs, and subsequently mental or psychical unrest and irritability, feelings of alarm maniacal delirium, during which the hyperassthesia disappeared, and corresponding illusory ideas, and that these phenomena, but returned as the delirium ceased under the use of morphia. at least in the earlier stages, are dependent on the morbid senHere, again, delirium, or we may say cerebral hyperassthesia, sations, and do not occur in their absence, he proceeds as fol" In other cases, true ordinary neuralgias are the was evidently the equivalent of cutaneous hyperassthesia. lows : I have recorded elsewhere the case of a man subject to rheu- immediate exciting cause of psychical derangement. These matism, quite temperate, who, when admitted, had severe I cases do not appear to me to be remarkably rare, although supra-orbital pain, but was quite rational. Shortly after, he they have as yet attracted no attention. During the previous became extremely delirious, requiring restraint, and remainedI winter I treated a gentleman, in whom a bilateral occipital so for more than twenty-four hours, until a prolonged cold neuralgia formed the prelude to deep melancholic depression. douche to the head was administered. He sank about twenty- ’, In the Policlinic during the past year several instances occurred, four hours later, and at the post-mortem the brain was found I, which exhibited the process in great simplicity, and were, therepale and shrunken, and bathed in much subarachnoid fluid. ’, fore, very instructive. [The histories are givein a note, which In this instance, acute asthenic delirium seems to have been ’, I introduce here.] A woman, aged forty, had for many years a the equivalent of rheumatic neuralgia. right-side neuralgia in the first branch of the fifth, and in the Andral relates (" Clinique Méd.," p. 88) the case of a female occipital nerve, which was said to have originated from a aged thirty-five, who suffered for some time with tic douloureux variolous roseola (Blatter-rose). During the last two years of the face. The neuralgic pains suddenly ceased, but were new phenomena have occurred. The pains begin at the bottom succeeded by a violent pain of head and by a giddiness so in- of the orbit; then a veil seems to be drawn over the head. If tense that the patient could no longer stand up. After the now, during the attack of pain, the patient shuts her eyes, she latter symptoms had lasted two hours, a copious flux of serous sees all imaginable absurd shapes, and hermind is filled withirrafluid took place from the nose, and when it ceased all disorder tional thoughts; she sees persons walking and running, gardens, was at an end. Again we remark the exchange of a peripheral &c., of which she was not thinking before. Here and there she sees also frightful objects, as skeletons; sometimes also she has disorder, a neuralgia, for a central-viz., vertigo. CASE 3.-M. S-,aged forty-nine, a cook, came under my a feeling as if she were falling, and a sense of alarm as if somecare on Nov. 26th, 1863, suffering with neuralgic affection of thing was to be done to her, or as if she had done something. the hands and arms, which was worse at night; she was woke In another case in the Charité, a girl, aged eighteen, had reup at times with numbness and acute pain in these parts. The peated attacks of mental confusion, deep depression, and erotic left arm had suffered badly in the same way three years before. excitement, which invariably commenced with a left supraAt night her eyelids felt heavy as lead; there was, in fact, orbital neuralgia. The attacks of psychical disorder lasted actual ptosis, so that she had to raise her lids with her fingers from ten to fourteen days, and were followed by a remissionif she wished to open them. Her pulse was weak; urine period of from two to three weeks’ duration. After the relanatural. Over-exertion made her worse. She was intolerant tion between the paroxysms and the neuralgia had been disof quinine. With various remedies of a modified tonic kind tinctly made out on three or four occasioits, Fowler’s solushe got well, or nearly so, and remained in very fair case until tion was given during the interval, and no recurrence of the March, 1865. I saw her again at the end of May. She was malady took place. A man, aged forty-five, without herethen in a decided state of melancholia. For a long time she ditary predisposition, had for about a year a burning had had sleepless nights; the irritation of her brain was worse sensation between the shoulders; this increases, and is sucat night, one gloomy thought succeeding another. She had ceeded by a very violent neuralgia in the right half of the face, feelings of great depression, with suicidal tendency, both night especially in the lower jaw, which lasts almost four weeks; at and day; some days being better, others worse. Her aspect the same time, the patient is observed to be remarkably talkawas morose and unhappy. She tried to shake off her gloomy tive, and after eight days there occurs a violent outbreak of thoughts, but could not. About thirteen days later my report mania, with violent acts and magnificent delirious ideas. A is-,Says she does not know what she is doing at times, gets remission soon ensued, in which the patient communicated to quite lost; when she is in this state she seems to forget all us that during the existence of the neuralgia he had perceived about cooking ; is extremely depressed ; has fits of shaking an invincible psychical excitement: it had occurred to him -
8 that his son was going to be killed, and he himself poisoned by The maniacal excitement was repeatedly the physician, &c. preceded by an increased sense of burning in the region of the shoulders. [The text now continues.] One case especially has been the subject of the most lively interest to me, and the
These are instances in which the morbid nervous action is either situated in the peripheral nerves, or at any rate does not extend higher than the associated tertiary centres. Mania, delirium ferox, many cases of bypochondriasis, of hysteria, and epilepsy, afford instances in which a quite similar disorder The other seems to affect the primary or secondary centres. type is anaesthesia, which may show itself peripherally, as analgesia, loss of tactile faculty, or of appreciation of temperature or of electricity. Its peripheral character is very apparent, when, as is not uncommon, it affects tracts of definite extent not corresponding to the distribution of a single or several nerves, and does not affect the subjacent muscles. Centrally anaesthesia may be traced in states of melancholia, of low muttering delirium, of hydrencephaloid coma, and probably in many cases of pernicious ague with coma. Lastly, I would say that hyperaesthesia and anaesthesia, appear to be essentially due to primary changes in the nervous the results of various poisons, miasms, or imponderable influences. Not that I would affirm the hyperassthetic or anaesthetic conditions of the nervous tissue to be always inde. pendent of hyperasmia or anaemia ; but I would express as strongly as possible my conviction that, the amount of bloodsupply remaining constant, the quality of nervous action may vary extremely, and vicp- versa. Green-street, 1867.
patient, who is a dear relative, has furnished me with an admirable report of the symptoms, such as can rarely be procured. The original disorder was a neuralgia of the left fifth nerve. After great psychical excitement one day, a paroxysm supervened, which immediately changed into a condition of vehement distress (angst). From that time the neuralgic attacks assumed a peculiar character. After they had lasted some time, the pain vanished and a comfortable feeling ensued. This was followed by sensations of distress, a special feature of which was that the patient had not room enough, that everything around him was getting narrower and converging towards him; the walls appeared to be closing together round him, and the ceiling to be sinking down. If he was in the street, he appeared to be entering into a cul de sac, while enormous crowds of persons were all pressing towards him. The distress slowly increases, until some external or uprising thought affects him keenly; then the condition is rapidly intensified, and the distress reaches its destined culmination. Circularly-so the patient expresses himself-around these first conceptions there spread themselves in all directions masses of new conceptions; an infinite number of concurrent circumstances are introduced with prodigious rapidity; he is compelled to dispute with imaginary CLINICAL REMARKS AT UNIVERSITY beings respecting these conceptions; the forms of relatives or COLLEGE HOSPITAL. well-known persons appear to him, but all distorted and with the most hateful expression of countenance. Often an irreBY GRAILY HEWITT, M.D., F.R.C.P., sistible impulse to run forward comes over him, and he is no PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AT UNIVERSITY longer master of himself. He feels himself obliged to dwell COLLEGE, AND OBSTETRIC PHYSICIAN TO THE HOSPITAL. fixedly on a thought, and is distressed that he cannot resist it: to think the contrary is impossible. The subjects of the ideas are entirely of a dark and frightful nature : his own EXCESSIVE LACTATION AND ITS EFFECTS. reprobation; suspicion of those about him; an impulse to preMANY suffering from the effects of excessive laccipitate himself from a height, or to jump upon vehicles rapidly tation patients themselves in the out-patients’ room. I propose present passingby. Sometimes he finds decided relief and calm in breaking some object to pieces; it seems as if thereby the to notice some of the facts relating to these cases, and to offer bands which hamper him were broken. As the respiration some remarks on the bearings of the whole subject-an imbecomes easy and free, the frightfully torturing paroxysm conone from whatever point of view we regard it. cludes. For a time, most relief was afforded by chloroform; portant The process of lactation constitutes a great drain on the but this means gradually failed. After long unavailing trials of different remedies, I succeeded in abolishing the neuralgia, system. A woman in health and of good constitution will and therewith the cerebral distress, by making the patient suckle her child, and for some considerable time, without snuff-up a strong narcotic solution into the nostril of the experiencing any bad effects ; but, under other circumstances, affected side. Even this, however, did not accomplish a per- this long-continued supply of food to the infant is productive manent cure. of " very injurious-and not seldom lasting-effects on the body In these examples we become acquainted with remarkable facts relative to a form of insanity most closely connected with and mind of the individual. The ability to carry on the process of lactation varying very neuralgia, a dysthymia neuralgica ; but the mechanism of the connexion is not the same in all instances. In the last case considerably, the symptoms due to over-lactation set in at the psychical derangement appears only as a sequel, as a kind very different periods in different cases. Thus, of eight outof transformation of the neuralgic attack, which has itself patients of the hospital, and whose cases have been taken at already passed by, just in the same way as we often see an random as illustrations, in one the patient applied for relief at attack of psychical disorder occur after the termination of an tive weeks, in a second at two months, in a third at two paroxysm. In the first, and probably to some extent months, in a fourth at three months after the birth of the also in the second and third instances, the pain itself more child; in the remaining four cases the women had suckled directly provoked the psychical disorder. This is not at all their children for periods respectively of five, thirteen, fourthe result of its intensity; but as a neuralgia may excite co- teen, and nineteen months. These figures give roughly some sensations in other parts of the body (reflected pains), so here, idea of the time when symptoms calling for medical aid are by exciting parts of the brain which are not at all involved in observed. The actual symptoms of excessive lactation are next to be the neuralgia itself, it excites co-ideas of a morbid kind. These have not the least connexion, as regards their matter (inhalt), considered. The account which follows is an abstract of the with the pain, but range over quite a different field, being notes referring to these eight cases. One of the most constant symptoms is the presence of an called forth by the irritation which the pain produces on certain parts of the brain." aching pain in the back; often pain is felt across the shoulders The foregoing observations of the German physician need no atid on the top of the head or forehead. Great pallidity of the comment from me. I will only remarli, in concluding this skin is generally observed. A marked symptom is want of sleep ; the patient will often tell you she has had no sleep for paper1. That the study and appreciation of the different kinds a week, or, when she does sleep, that she is awakened by and qualities of morbid nervous action seem to be of fully as frightful dreams. There is marked and great debility. The much importance as any necroscopic examination. The latter appearance and expression of the face is peculiar in these cases, must always present to us chiefly the vltiniate results of morbid sometimes remarkably so ; it conveys an idea of intense bodily processes, which have been going on often for a very long prostration. The mental changes are worthy of special note. There is period, and can reveal to us very little of the actual nature of almost constantly extreme depression of spirits; the patient the processes themselves. 2. Amid the manifold varieties of morbid nervous action, feels as if she had lost all life and energy ; she is desponding there seem to be two principal types, which we meet with both and miserable. We have before us, in fact, symptoms which in the peripheral and central districts. One of these, hyper- are the possible precursors of a malady of great gravity-viz., aesthesia, displays itself in many familiar examples, as the so- puerperal mania. Aberration of mind may occur in connexion called hysterical breast, the irritable testis, the photophobic with or as a result of the exercise of the uterine parturient eye, the exquisitely sensitive uterus or stomach, and so on. functions at two periods-viz., as the immediate result of the
tissue,
impression
epileptic
one
that
of the ligatures came out, and on the sixth the other ; on the seventh day the recovery might be regarded
so as
perfect. Edinburgh, June, 1867.
CONTRIBUTIONS TO THE
PATHOLOGY AND TREATMENT OF FUNCTIONAL NERVOUS DISORDERS. BY C. HANDFIELD
JONES, M.B. CANTAB., F.R.S.,
PHYSICIAN TO ST.
MARY’S
HOSPITAL.
THE ANALOGY BETWEEN CENTRAL AND PERIPHERAL NERVOUS DISORDER.
IT is admitted now on all hands, I believe, that in dealing with disease the physician has to eschew as far as possible the notion that its several manifestations are to be regarded as so many separate entities, each more or less completely diverse from the other. The progress of knowledge leads us rather to believe that a few great causes of morbid action are in operation, which, by reason of the original differences of the systems on which they act, and of the different parts in different persons which more readily succumb to their power, produce very different results, at least in outward show-viz., the so-called diseases. These often are found much more really similar than they seem to be on a cursory examination. On the present occasion I wish to make an attempt to point out a rapprocliement, which it seems to me may be instituted between certain nervous disorders commonly regarded as peripheral, and others which, beyond doubt, are central. I will relate as briefly as may be a few instances, in which the exist. ence of such a connexion appears to me very probable. CASE 1.-J. A , aged thirty-six, married, had served as a soldier in Bengal, where he had several times had fever and ague. His present disorder, when he was admitted July 14th, was severe neuralgia affecting the right temple, which resisted quinine in five-grain doses, given at first every third, and afterwards every second hour, and continued altogether eleven days; but yielded to arsenic in doses of one-twentieth of a grain three times a day, and large repeated doses of extract of belladonna, of which he took about twenty grains in the first three days. About the middle of August he ceased attendance, and went to Ireland. He returned in the course of the following October (I saw him on the 20th), when he stated that he had remained quite free from the neuralgia, but had had several fits of epileptic character, in one of which he fell into the fire, and burnt his arm rather smartly. Before his visit to Ireland he had never suffered from epilepsy. His head felt heavy, dropped, and he had difficulty in holding it up. He was treated with iodide of potass and bark, and improved somewhat. The interval between the two attacks he had while under my observation was four weeks. It seems to me a reasonable supposition that in this instance the epilepsy was the equivalent of the neuralgia, both being probably the results of the malarious influence he had been exposed to in India, and which had there confined its injurious effects chiefly to the sympathetic nerves and centres. In my work on Functional Nervous Disorders, p. 298, I have related the case of a lady who had very severe facial neuralgia. As this yielded to quinine in full doses she got attacks of hysteria, with partial syncope, only relieved by stimulants in large quantities. The attacks were paroxysmal, and came on at exactly the same hour as the neuralgia had; they were attended also with shivering. Under the continued use of quinine, with arsenic, they ceased. Here it appears that as the disorder ceased in the fifth nerve and its tertiary centre (Simon), it developed itself in a higher-seated one-viz., the emotional, whether that be the corpora quadrigemina and adjacent grey matter, or a part of the hemispheres. I have published elsewhere the case of a medical man who for several days suffered severely with vertigo of obscure origin. It continued to plague him in spite of sundry remedies, when one morning there came on, in addition to the former malady, a fit of brow ague. For this he took quinine, and speedily was cured both of the vertigo and of the neuralgia. Can we doubt that both morbid actions were of the same kind, differing only in their locale ?
7 The following interesting history has been kindly given me and trembling." Some remedies were administered with adby Dr. Palmer, who has contributed several valuable papers to vantage, but the malady rather seemed to pass by than to be THE LANCET:cured. By the middle of July she was a good deal better. CASE 2.-A clergyman, aged sixty-four, had, eight or nine The neuralgia did not return after the attack in 1863 ; only years before coming under observation, an attack of melan- once during the existence of the melancholia she mentioned cholia, which ceased after two years, leaving him quite well. having some dead feeling in the hands and feet. It may, of The veins of the left leg had been varicose a long time, and on course, be that the occurrence of the melancholia had no relaone occasion they had given rise to troublesome heat and itch- tion to the two previous attacks of neuralgia ; but I think the ing. By the aid of a bandage and aperients he had no annoy- view is more probable that the maladies were essentially ance from them for some years, until about October, 1859. the same morbid action variously localised, because neuralgia After a few weeks one or two small ulcers formed, around which is so notoriously prone to relapses; it had recurred once in erythema was set up; and by the end of the year pruriginous this instance, and might reasonably be expected to do so again. itching had increased so much that his condition was really Besides the state of a nerve affected with numbness and pain distressing. He described the suffering as intolerable, pre- really has much analogy with that of a paretic and melancholic cluding sleep, or rest of mind or body. The only relief ob- brain. I may allude here, as having a connexion with this subject, tained was from keeping the leg enveloped in lint soaked in strong infusion of tobacco, to which was added opium or to the fact that patients suffering with delirium tremens, or hydrocyanic acid. His mind all the while was perfectly sound. approaching the verge of it, are not unfrequently attacked by One morning in the beginning of February a hasty message epileptic fits. I have met with such instances myself. The was brought that the patient had gone out of his mind. On observation seems to me interesting from our present point of arriving, Dr. Palmer found him mildly excited and irrational view as marking a connexion between the derangement of the in his talk, but the prurigo was gone. The evening before he neurine of the hemispheres and that of the excitable districts; had been itching as usual; this morning the skin was only a and, further, as suggesting that the different manifestations of little red, and he said it was quite well. He gradually became disordered action in the two cases are rather referable to difmelancholic, and has so remained to the present day. The ferences of locale than of the nature of the morbid condition. Hyperaesthesia of the hemispheres seems to conditionate deliprurigo has never returned. Agreeing as I do with Romberg, that nerve disorder- rium ; hyperaesthesia of the excitable districts, epilepsy. On the essence of prurigo, it appears to me that this view it becomes easy to understand how epileptic convulhyperaesthesia-is the reading of this case must be, that a metastasis of the mor- sions may be the prelude to epileptic mania. Just as derangebid condition of the cutaneous nerves of the legs took place to ment of the vital actions may extend or shift from a nerve or the nerve-tissue of the hemispheres, where the disorder in- its tertiary to a higher centre, so it may also from one of these duced expressed itself by symptoms corresponding to the func- higher centres to another. tions of its new location and the quality of the morbid action. This subject has been recently handled with his well-known Whether an actual materies morbi was transferred from the ability by Griesinger, in the Arch. f. Heilk2cnde, 1866, p. 345; peripheral to the central parts is not material; the essential and his observations are so much to my purpose, and so impoint is that one neurosis was the equivalent of the other. portant, that I shall not apologise for extracting them entire. The following case, related to me by Dr. Headlam Greenhow, After remarking that there are insane patients in whom various is very similar. A young man, convalescent from typhoid dysaesthesiae felt all over the frame excite a condition of general fever, got extreme hyperaesthesia of the legs, and subsequently mental or psychical unrest and irritability, feelings of alarm maniacal delirium, during which the hyperassthesia disappeared, and corresponding illusory ideas, and that these phenomena, but returned as the delirium ceased under the use of morphia. at least in the earlier stages, are dependent on the morbid senHere, again, delirium, or we may say cerebral hyperassthesia, sations, and do not occur in their absence, he proceeds as fol" In other cases, true ordinary neuralgias are the was evidently the equivalent of cutaneous hyperassthesia. lows : I have recorded elsewhere the case of a man subject to rheu- immediate exciting cause of psychical derangement. These matism, quite temperate, who, when admitted, had severe I cases do not appear to me to be remarkably rare, although supra-orbital pain, but was quite rational. Shortly after, he they have as yet attracted no attention. During the previous became extremely delirious, requiring restraint, and remainedI winter I treated a gentleman, in whom a bilateral occipital so for more than twenty-four hours, until a prolonged cold neuralgia formed the prelude to deep melancholic depression. douche to the head was administered. He sank about twenty- ’, In the Policlinic during the past year several instances occurred, four hours later, and at the post-mortem the brain was found I, which exhibited the process in great simplicity, and were, therepale and shrunken, and bathed in much subarachnoid fluid. ’, fore, very instructive. [The histories are givein a note, which In this instance, acute asthenic delirium seems to have been ’, I introduce here.] A woman, aged forty, had for many years a the equivalent of rheumatic neuralgia. right-side neuralgia in the first branch of the fifth, and in the Andral relates (" Clinique Méd.," p. 88) the case of a female occipital nerve, which was said to have originated from a aged thirty-five, who suffered for some time with tic douloureux variolous roseola (Blatter-rose). During the last two years of the face. The neuralgic pains suddenly ceased, but were new phenomena have occurred. The pains begin at the bottom succeeded by a violent pain of head and by a giddiness so in- of the orbit; then a veil seems to be drawn over the head. If tense that the patient could no longer stand up. After the now, during the attack of pain, the patient shuts her eyes, she latter symptoms had lasted two hours, a copious flux of serous sees all imaginable absurd shapes, and hermind is filled withirrafluid took place from the nose, and when it ceased all disorder tional thoughts; she sees persons walking and running, gardens, was at an end. Again we remark the exchange of a peripheral &c., of which she was not thinking before. Here and there she sees also frightful objects, as skeletons; sometimes also she has disorder, a neuralgia, for a central-viz., vertigo. CASE 3.-M. S-,aged forty-nine, a cook, came under my a feeling as if she were falling, and a sense of alarm as if somecare on Nov. 26th, 1863, suffering with neuralgic affection of thing was to be done to her, or as if she had done something. the hands and arms, which was worse at night; she was woke In another case in the Charité, a girl, aged eighteen, had reup at times with numbness and acute pain in these parts. The peated attacks of mental confusion, deep depression, and erotic left arm had suffered badly in the same way three years before. excitement, which invariably commenced with a left supraAt night her eyelids felt heavy as lead; there was, in fact, orbital neuralgia. The attacks of psychical disorder lasted actual ptosis, so that she had to raise her lids with her fingers from ten to fourteen days, and were followed by a remissionif she wished to open them. Her pulse was weak; urine period of from two to three weeks’ duration. After the relanatural. Over-exertion made her worse. She was intolerant tion between the paroxysms and the neuralgia had been disof quinine. With various remedies of a modified tonic kind tinctly made out on three or four occasioits, Fowler’s solushe got well, or nearly so, and remained in very fair case until tion was given during the interval, and no recurrence of the March, 1865. I saw her again at the end of May. She was malady took place. A man, aged forty-five, without herethen in a decided state of melancholia. For a long time she ditary predisposition, had for about a year a burning had had sleepless nights; the irritation of her brain was worse sensation between the shoulders; this increases, and is sucat night, one gloomy thought succeeding another. She had ceeded by a very violent neuralgia in the right half of the face, feelings of great depression, with suicidal tendency, both night especially in the lower jaw, which lasts almost four weeks; at and day; some days being better, others worse. Her aspect the same time, the patient is observed to be remarkably talkawas morose and unhappy. She tried to shake off her gloomy tive, and after eight days there occurs a violent outbreak of thoughts, but could not. About thirteen days later my report mania, with violent acts and magnificent delirious ideas. A is-,Says she does not know what she is doing at times, gets remission soon ensued, in which the patient communicated to quite lost; when she is in this state she seems to forget all us that during the existence of the neuralgia he had perceived about cooking ; is extremely depressed ; has fits of shaking an invincible psychical excitement: it had occurred to him -
8 that his son was going to be killed, and he himself poisoned by The maniacal excitement was repeatedly the physician, &c. preceded by an increased sense of burning in the region of the shoulders. [The text now continues.] One case especially has been the subject of the most lively interest to me, and the
These are instances in which the morbid nervous action is either situated in the peripheral nerves, or at any rate does not extend higher than the associated tertiary centres. Mania, delirium ferox, many cases of bypochondriasis, of hysteria, and epilepsy, afford instances in which a quite similar disorder The other seems to affect the primary or secondary centres. type is anaesthesia, which may show itself peripherally, as analgesia, loss of tactile faculty, or of appreciation of temperature or of electricity. Its peripheral character is very apparent, when, as is not uncommon, it affects tracts of definite extent not corresponding to the distribution of a single or several nerves, and does not affect the subjacent muscles. Centrally anaesthesia may be traced in states of melancholia, of low muttering delirium, of hydrencephaloid coma, and probably in many cases of pernicious ague with coma. Lastly, I would say that hyperaesthesia and anaesthesia, appear to be essentially due to primary changes in the nervous the results of various poisons, miasms, or imponderable influences. Not that I would affirm the hyperassthetic or anaesthetic conditions of the nervous tissue to be always inde. pendent of hyperasmia or anaemia ; but I would express as strongly as possible my conviction that, the amount of bloodsupply remaining constant, the quality of nervous action may vary extremely, and vicp- versa. Green-street, 1867.
patient, who is a dear relative, has furnished me with an admirable report of the symptoms, such as can rarely be procured. The original disorder was a neuralgia of the left fifth nerve. After great psychical excitement one day, a paroxysm supervened, which immediately changed into a condition of vehement distress (angst). From that time the neuralgic attacks assumed a peculiar character. After they had lasted some time, the pain vanished and a comfortable feeling ensued. This was followed by sensations of distress, a special feature of which was that the patient had not room enough, that everything around him was getting narrower and converging towards him; the walls appeared to be closing together round him, and the ceiling to be sinking down. If he was in the street, he appeared to be entering into a cul de sac, while enormous crowds of persons were all pressing towards him. The distress slowly increases, until some external or uprising thought affects him keenly; then the condition is rapidly intensified, and the distress reaches its destined culmination. Circularly-so the patient expresses himself-around these first conceptions there spread themselves in all directions masses of new conceptions; an infinite number of concurrent circumstances are introduced with prodigious rapidity; he is compelled to dispute with imaginary CLINICAL REMARKS AT UNIVERSITY beings respecting these conceptions; the forms of relatives or COLLEGE HOSPITAL. well-known persons appear to him, but all distorted and with the most hateful expression of countenance. Often an irreBY GRAILY HEWITT, M.D., F.R.C.P., sistible impulse to run forward comes over him, and he is no PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AT UNIVERSITY longer master of himself. He feels himself obliged to dwell COLLEGE, AND OBSTETRIC PHYSICIAN TO THE HOSPITAL. fixedly on a thought, and is distressed that he cannot resist it: to think the contrary is impossible. The subjects of the ideas are entirely of a dark and frightful nature : his own EXCESSIVE LACTATION AND ITS EFFECTS. reprobation; suspicion of those about him; an impulse to preMANY suffering from the effects of excessive laccipitate himself from a height, or to jump upon vehicles rapidly tation patients themselves in the out-patients’ room. I propose present passingby. Sometimes he finds decided relief and calm in breaking some object to pieces; it seems as if thereby the to notice some of the facts relating to these cases, and to offer bands which hamper him were broken. As the respiration some remarks on the bearings of the whole subject-an imbecomes easy and free, the frightfully torturing paroxysm conone from whatever point of view we regard it. cludes. For a time, most relief was afforded by chloroform; portant The process of lactation constitutes a great drain on the but this means gradually failed. After long unavailing trials of different remedies, I succeeded in abolishing the neuralgia, system. A woman in health and of good constitution will and therewith the cerebral distress, by making the patient suckle her child, and for some considerable time, without snuff-up a strong narcotic solution into the nostril of the experiencing any bad effects ; but, under other circumstances, affected side. Even this, however, did not accomplish a per- this long-continued supply of food to the infant is productive manent cure. of " very injurious-and not seldom lasting-effects on the body In these examples we become acquainted with remarkable facts relative to a form of insanity most closely connected with and mind of the individual. The ability to carry on the process of lactation varying very neuralgia, a dysthymia neuralgica ; but the mechanism of the connexion is not the same in all instances. In the last case considerably, the symptoms due to over-lactation set in at the psychical derangement appears only as a sequel, as a kind very different periods in different cases. Thus, of eight outof transformation of the neuralgic attack, which has itself patients of the hospital, and whose cases have been taken at already passed by, just in the same way as we often see an random as illustrations, in one the patient applied for relief at attack of psychical disorder occur after the termination of an tive weeks, in a second at two months, in a third at two paroxysm. In the first, and probably to some extent months, in a fourth at three months after the birth of the also in the second and third instances, the pain itself more child; in the remaining four cases the women had suckled directly provoked the psychical disorder. This is not at all their children for periods respectively of five, thirteen, fourthe result of its intensity; but as a neuralgia may excite co- teen, and nineteen months. These figures give roughly some sensations in other parts of the body (reflected pains), so here, idea of the time when symptoms calling for medical aid are by exciting parts of the brain which are not at all involved in observed. The actual symptoms of excessive lactation are next to be the neuralgia itself, it excites co-ideas of a morbid kind. These have not the least connexion, as regards their matter (inhalt), considered. The account which follows is an abstract of the with the pain, but range over quite a different field, being notes referring to these eight cases. One of the most constant symptoms is the presence of an called forth by the irritation which the pain produces on certain parts of the brain." aching pain in the back; often pain is felt across the shoulders The foregoing observations of the German physician need no atid on the top of the head or forehead. Great pallidity of the comment from me. I will only remarli, in concluding this skin is generally observed. A marked symptom is want of sleep ; the patient will often tell you she has had no sleep for paper1. That the study and appreciation of the different kinds a week, or, when she does sleep, that she is awakened by and qualities of morbid nervous action seem to be of fully as frightful dreams. There is marked and great debility. The much importance as any necroscopic examination. The latter appearance and expression of the face is peculiar in these cases, must always present to us chiefly the vltiniate results of morbid sometimes remarkably so ; it conveys an idea of intense bodily processes, which have been going on often for a very long prostration. The mental changes are worthy of special note. There is period, and can reveal to us very little of the actual nature of almost constantly extreme depression of spirits; the patient the processes themselves. 2. Amid the manifold varieties of morbid nervous action, feels as if she had lost all life and energy ; she is desponding there seem to be two principal types, which we meet with both and miserable. We have before us, in fact, symptoms which in the peripheral and central districts. One of these, hyper- are the possible precursors of a malady of great gravity-viz., aesthesia, displays itself in many familiar examples, as the so- puerperal mania. Aberration of mind may occur in connexion called hysterical breast, the irritable testis, the photophobic with or as a result of the exercise of the uterine parturient eye, the exquisitely sensitive uterus or stomach, and so on. functions at two periods-viz., as the immediate result of the
tissue,
impression
epileptic