COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00033251 N^^^ I Columbia ©nibergitp in tfje Citp of iSeto gorfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/nerveprostrationOOroos NERVE PROSTRATION AND OTHER FUNCTIONAL DISORDERS OF DAILY LIFE. NERVE PROSTRATION AND OTHER FUNCTIONAL DISORDERS OF DAILY LIFE. BY ROBSON ROOSE, M.D., F.C.S. Fellow of the Royal College of Physicians in Edinburgh ; Author of " Gout and its Relations, to Diseases of the Liver AND Kidneys," "Wear and Tear of London Life," ETC., ETC. NEW YORK WILLIAM WOOD AND COMPANY 1888- New Yokk William Wood and Company. PREFACE. In placing this work before the profession, I venture to make a few remarks by way of explanation. While fully recognizing the important services rendered to medical science by recent pathological discoveries, I feel convinced that the distinction between functional and structural dis- orders is one which is not yet obliterated. Some sanguine observers think that the term " functional " will soon be expunged from medical nomenclature, on the ground that every disturbance of function must be due to change of structure. Even admitting the validity, though by no means capable of demonstration, of this latter statement, it does not follow that the change should always be of such a character as to be discoverable by the aid of any instrument whatever. I regard the condition termed ''neurasthenia," or *' nerve- prostration," as a typical example of functional disorders ; and in addition to those complaints which fairly belong to the same category, I have included, a few others in which slight and temporary changes are seen to occur in the tissues, because under suitable treatment they rapidly pass away, leaving no trace of their previous existence, beyond a certain weakness which shows itself in liability to recur- rences of the same morbid state. PRUFAGi:. Functional disorders constitute a large proportion of the ailments which come before the physician in daily practice, and I hope that a clear and comprehensive account of them may prove acceptable to the profession. While not neglect- ing to make myself acquainted with the views of others, throughout the work my aim has been to utilize the experience acquired in the course of a somewhat extensive practice. 45, Hill Street, Berkeley Square, W. June, 1888. CONTENTS. INTRODUCTION. Functional Disorders in General. Functional and Organic Diseases, Definition of— Not to be regarded as two Distinct Classes— Many Diseases thought to be Functional now known to be Organic — Derangement of Function in the absence of recognizable Alterations of Structure — Increase and Diminution of Excitability— Cardiac Functional Disorder— Neuroses properly so-called — Epilepsy and Chorea as examples of Neuroses — Absence of constant Structural Lesions in Epilepsy— Dr. Brown-Sequard's Views The Pathogeny of Chorea — No constant Structural Altera- tions— Dr. Sturges' Views — Chorea a Functional Disorder — The causes of Functional Derangements— Heredity— Neuropathic Pre- disposition—Education—Physical and Mental Causes— Excessive use of Stimulants— Cold— Pathological Changes in other Organs— Blood-poisons, as Syphilis and Gout— Disorders of Visual Accom- modation and Refraction as causes of Nervous Disturbances— Dr. Stevens' Views —Characters of Functional Nervous Disorders as distinguished from those of Organic Origin 1-23 SECTION I. FUNCTIONAL DISOEDFES OF TSF NFEVOUS SYSTFM. CHAPTER I. Nerve Prostration — Neurasthenia— Nervous Debility. Nerve Prostration — Synonyms and meaning of Term— Nature and Varieties— Prevalence of Nerve-prostration in England and in the United States -Causes— Dr. Beard's Views— Hereditary Predisposi- tion—Training and Habits of Young Subjects— Influence of School- viii CONTENTS. work and Competitive Examinations — Symptoms of Neurasthenia — Symptoms connected with the Motor Faculties — Disorders of the Sensory Faculties— Spinal Pain — Neuralgia — Disorders of Special Senses — Vaso-motor Disturbances — Disorders of the Circulatory, Respiratory, and Digestive Organs — Symptoms referable to the Kidneys and the Organs of Generation — Signs of Mental Disorder — Disorders of Sleep — Duration of the Symptoms of Neurasthenia — Prognosis and Diagnosis — Treatment — Relief of the Sleeplessness — Freedom from Mental Exertion — Amusements and Exercise — Diet —Avoidance of Tobacco and Excess in Stimulants — -Tonics and Bathing — Electricity — The Weir-Mitchell System — Rest, Isolation, Excessive Feeding, Massage, and Employment of Electricity — Cases in which Indicated — Details of Treatment — Duration of Treatment and Results, with Illustrative Cases — Cautions as to Adoption of Treatment in Cases of Organic Disease and of Mental Dis- order 25-55 CHAPTER II. Neurasthenia Spinalis — Spinal Irritation. Neurasthenia Spinalis, a Functional Disorder — Its Presumed Nature — Spinal Irritation — Causes of Spinal Neurasthenia — Symptoms — Causes of Spinal Irritation— Symptoms — Principal Differences between Spinal Neurasthenia and Irritation — Diagnosis and Course of the two Conditions — Their Treatment — Dr. Brown-Sequard's Method of Treating Spinal Irritation ... ... ... Z^-^9. CHAPTER III. Sleeplessness. Sleeplessness in Nervous Disorders — Conditions requisite for Normal Sleep — Causes of Sleeplessness— Vascular Excitement — Presence of Imperfectly Oxidized Materials in the Blood — Indigestion — Anxiety and Excitement — Cold and Heat — Sleeplessness in Elderly Persons — External Causes of Sleeplessness — Want of Exercise — Treatment of Sleeplessness — Importance of Ascertaining Cause — Question of Diet — Treatment of Gouty Subjects— Hypnotics for Cases Due to Anxiety — Various Plans for Dealing with Different Cases 70-80 CONTENTS. ix CHAPTER IV. Hysteria. Hysteria, Definition of the Term — Historical Notices and Geographical Distribution — Causes — Age and Hereditary Predisposition to Nervous Disorders — The Uterine Theory of Hysteria — Local Irritation and the State of the General Health — Exciting Causes of the Paroxysms — Morbid States of System, as in Gout — Symptoms of Hysteria, their Great Variety — Signs of Mental Perversion- -Alterations of the Moral Character— Peculiarities of the Symptoms — The Hysterical Paroxysms — Hystero-Epilepsy, Symptoms and Peculiar Features of the Attacks — Other Forms of Motor Disorder — Paresis — Permanent Contraction and Rigidity of Muscles and Limbs — Disorders of Sen- sation, Hyperaesthesia, the Clavus Hystericus and Neuralgia — Anaesthesia, its Forms — Disorders of the Special Senses — Disorders of the Function of Digestion — of Respiration-r-of the Circulation — of Secretion — The Urine — Course, Duration, and Results of Hysteria — Prognosis — Diagnosis — Treatment, Prophylactic, Curative, and Symptomatic — Removal of Young Subjects from Home Influences Attention to Uterine Complaints and to General Condition — Treat- ment of Mental Disorders — Hygienic Measures — Medicines — Relief of Prominent Symptoms — Treatment During the Paroxysm — of the Complications — Metallo-Therapeutics — Galvanism and Faradism — The Weir-Mitchell System — Hydropathic Treatment ... "81-128 CHAPTER V. Epilepsy. Epilepsy, Definition and Forms of — Historical Notices and Geographical Distribution of the Disorder— Causes — Influence of Hereditary Pre- disposition — Date of First Attacks — Drunkenness — Sexual Excesses — Lesions of the Nervous System — Dr. Brown-Se'quard's Experi- ments — Reflex Epilepsy — Ocular Defects as a Cause of Epilepsy — Dr. Stevens' Views — Exciting Causes — Epilepsy and Gout— ]Morbid Anatomy and Pathology — No Special Lesion^ — Seat of the Disorder — The Epileptic Change — Dr. Hughlings-Jackson's Views — Dr. Brown-Sequard's Views — Symptoms of the Paroxysm — The Pheno- mena in Detail — The Milder Forms of Epilepsy — Irregular Forms — CONTENTS. The Epileptoid States — Reflex Epilepsy — Jacksonian Epilepsy — The Course of the Disorder — Mental Symptoms — Diagnosis — Epilepsy Distinguished from Apoplexy, Syncope, Hysteria, and Infantile Con- vulsions — Prognosis — Treatment — During the Intervals — Hygienic Measures— Medicines — The Bromides, Atropine, Zinc, Silver, Vegetable Tonics and Antispasmodics — Empirical Remedies — Electricity — Hydrotherapeutics — Treatment During the Paroxysm 129-167 CHAPTER VI. Chorea — St. Vitus' Dance. Chorea, Historical Notices, Definition and Geographical Distribution of the Disorder — Causes — Hereditary Predisposition — Imitation — Age and Sex — Mental Excitement — Reflex Causes — Ocular Disorders, Dr. Stevens' Views — Connection between Rheumatism and Chorea — Nature of Chorea — Drs. Broadbent, Kirkes, and Dickinson's Views — Dr. Striimpell's Opinion that Chorea is a Functional Dis- order — Symptoms — Evidences of Mental Disorder — Differences in Severity — Analysis of Prominent Symptoms — Duration of the Disorder — Prognosis, Diagnosis, and Treatment — Necessity of Inquiring into Cause — Specific Remedies, as Arsenic, Zinc, and Strychnine, Cold to the Spine, Chloral — Isolation from other Children 168-186 CHAPTER VII. Neuralgia. Pain, its Nature — Sensory and Tactile Nerves, their End-Organs, Fibres, and Nerve-Centres — Varieties of Pain — Essential Features of Neuralgia — Cause of Neuralgic Pain — Changes in Nerve-Centres — Atrophy of Posterior Roots — Vaso-motor Disorder — Predisposing Causes of Neuralgia, Hereditary Predisposition, Debility, Age, Sex — Exciting Causes, Cold and Damp, Injuries, Pressure on Nerves, Constitutional Disorders, Gout, Diabetes, Syphilis, and Malarious Fevers — Symptoms, Peculiarities and Duration of the Pain, Remis- sions, Intermissions, and Recurrences — Locality of the Pain as a Guide to the Cause — Pain Extending Centripetally and also Radiat- CONTENTS. \ng along the Course of Neighbouring Nerves — Points Douloureux — Cutaneous Hyperaesthesia and Anaesthesia — Motor Disorder — Vaso-Motor Disturbances and Disorders of Secretion and Nutrition — Eruptions of Herpes and Erythema — Effects of Neuralgia — Diagnosis — Treatment — Discovery of Cause — Symptomatic Treat- ment — Quinine, Arsenic, Salicylate of Sodium, Iodide of Potassium — Anodynes, Morphine and Atropine — Liniments — Counter-Irrita- tion — Electricity — Various Tonic Remedies — Neurotomy and Neu- rectomy — Summary of Treatment ... ... ... 187-216 CHAPTER VIII. Various Forms of Neuralgia. I. Neuralgia of the Trigeminus — Tic Douloureux. — II. Inter- costal Neuralgia. — III. Sciatica. I. Causes of Tic Douloureux — Symptoms — Pain— Duration and Fre- quency of the Attacks— rExciting Causes — Tw^o Kinds of Pain — Motor Disorder — Spasm of the Facial Muscles-^ Vaso-Motor and Trophic Disturbances — Neuro- Paralytic Ophthalmia — Disorder of General Health — Neuralgia of the Supra-Orbital Branch — Neuralgia of the Supra- and Inframaxillary Divisions — Two Stages often observed in Facial Neuralgia — Diagnosis — Treatment — Causal and Constitutional — Electricity — Anodynes, Morphine, Gelsemium — Specific Remedies, Quinine, Arsenic, Iron, Ammonium Chloride — Liniments — Counter Irritation — Neurotomy — Neurectomy — Nerve- Stretching. II. Intercostal Neuralgia, Causes and Symptoms — Points Douloureux — Complications and Course — Diagnosis — Irritable Breast or Masto- dynia — Symptoms and Differential Diagnosis — Treatment of Inter- costal Neuralgia and of Mastodynia. III. Sciatica, its Frequency and Causes — Symptoms, their" Nature and Variety — Points Douloureux — State of the Muscles — Vaso-Motor and Trophic Symptoms — Sugar sometimes found in the Urine — Electrical Conditions of the Affected Parts — Course and Duration of Sciatica — Diagnosis — Prognosis — Treatment — Question as to Causation — Rheumatism — Iodide of Potassium — Blisters — Hypo- dermic Injections of Morphine and Atropine — Electricity — Flying CONTENTS. Blisters — Acupuncture — Hot Baths — Warm Applications — The Scotch Douche — Hot Sand-Baths — Massage — Nerve-Stretching 317-259 CHAPTER IX. Articular Neuroses — Neuralgia of the Joints. Nature and Pathogeny of Neuralgia of the Joints — Predisposing and Ex- citing Causes — Symptoms — Cutaneous Hyperaesthesia — Position of the Limb— Joints usually Affected — Course and Progress of Neu- ralgia of Joints- — Diagnosis — Anaesthesia often Necessary — Mental Condition of the Patient — Results of Application of Bandages, etc. — Exaggerated Patellar Reflex in Hysterical Contraction of the Knee- joints — Pain in Knee an Occasional Symptom of Hip-Joint Disease — Treatment, Constitutional and Local — Massage, Douches, Baths, etc. — Electricity — Use of the Limb to be Recommended 260-267 CHAPTER X. Headache. Pain in Head often Symptomatic — Associated with Cerebral Hyperaemia, Active and Passive— Causes and Consequences — Anaemic Headache — Symptoms — Headaches in Neurasthenia and Nervous Subjects Generally — Sympathetic Headache — Indigestion as a Cause of Headache — Rheumatic and Gouty Headache — Headache due to Intemperance — Headache in Hysterical Subjects — Pains in the Head due to Syphilis — Headache due to Disorders of the Refractive Apparatus of the Eye — Diagnosis of Headache — Treatment of the Hyperaemic and Anaemic Forms — Remedies for Neurasthenic and Rheumatic Cases — Empirical Treatment ... ... 268-281 CHAPTER XI. Hemicrania — Migraine — Megrim. Frequency of Hemicrania — Its Prominent Features — Premonitory Sym- ptoms — Symptoms of the Attack — Phenomena indicative of Vaso- Motor Disturbance — Tv^'o Forms — Disorders of Vision — Periodicity of Migraine — Length of Paroxysms — Causes of Migraine — Sex, Age, Hereditary Tendency, Gouty Predisposition — Exciting Causes — CONTENTS. xiii Anxiety, Over-exertion, Impressions on Certain Nerves of Special Sense, Derangement of Stomach, Relation of Gastric Symptoms to Migraine, Insomnia — Pathogeny of INIigraine — The Spastic Form — Pain due to Spasm of the Muscular Coat of the Vessels — Fluctua- tions in the Supply of Arterial Blood as Causes of Irritation — Dr. Liveing's Theory of the Irregular Accumulation and Discharge of Nerve Force — Migraine thought by some to be only a Variety of Trigeminal Neuralgia — Diagnosis — Prognosis — Treatment — A Course of Quinine — Aperients — The Iodides with the Alkaline Car- bonates for Gouty Subjects — Strychnine, Arsenic, Oxide of Zinc, and Nitrate of Silver, Attention to Diet and Habits — Question with regard to Stimulants, Sleep, and Exercise — Change of Air and Scene — Precautionary Measures when a Paroxysm is Threatening — Rest, Darkness, and Warmth — Stimulants, Nux Vomica, Sodium Bicarbonate — Antipyrin — Treatment during the Attack — Darkness and Quiet, Cold to the Head, and Warm'th to the Feet — Amyl Nitrite — Ergot — Cannabis Indica — Chloral — Morphine — Caffeine and Guarana — Galvanism ... ... ... ... 282-304 CHAPTER XII. Vertigo — Giddiness. Vertigo as a Symptom of Organic Diseases of the Nervous System — In Diseases of the Stomach and Liver — In Affections of the Eyes and Ears — In Debility and Anaemia, and Functional Disorders of the Nervous System — Toxic Forms as in Gout — Definition and Kinds of Vertigo — Gastric Vertigo, Symptoms and Treatment — Ocular Vertigo — Aural Vertigo — Vertigo of Anaemia, Neurasthenia, Hys- teria, Epilepsy, and Hemicrania — Vertigo in Gouty Subjects 305-319 CHAPTER XIII. Writer's Cramp and Allied Disorders. Writer's Cramp, Peculiarities of — Persons Most Prone to Suffer — Patho- logy — Symptoms, Three Forms : Spastic, Tremulous, and Paralytic — Mixed Forms — Allied Disorders — Diagnosis — Treatment — Rest — Wolff's Method — Galvanism — Attention to General Health — Local Measures — Counter-irritation — ^Mechanical Appliances 320-329 xiv CONTENTS. CHAPTER XIV. Facial Paralysis. Forms of Functional Paralysis — Rheumatic Paralysis — Paralysis of the Facial Nerve, due to Cold and other Influences — Symptoms, Subjec- tive and Objective — Loss of the Sense of Taste — Auditory Symptoms — Electrical Reactions of the Paralyzed Parts — Diagnosis of Facial Paralysis — Determination of the Site of the Lesion — Prognosis — Treatment 330-340 CHAPTER Xy. Hypochondriasis. Hypochondriasis, Definition and Forms— Causes — Hereditary Predis- position — Habits of Life — Gout — Abdominal and Sexual Disorders — Subsidiary Causes — Symptoms — Influence of Attention — Mental Disorder — Illusions — Disorders of Sensation — Disorders of Motion — Impotence — Vaso-Motor Disturbances — Course and Prognosis — Diagnosis — Treatment — Existing Ailments to be Attended to — Gouty Cases — Rest and Recreation — Change of Air and Scene, and Suitable Occupation ... ... ... .. ... 341-351 SECTION II. FUNCTIONAL DISORDERS OF TSF ORGANS OF CIRCULATION. INTRODUCTORY CHAPTER. Peculiar Features of Functional Disorders of the Heart — Difference between Functional and Organic Affections — Symptoms of Func- tional Disorders, Either the Movements or the Sensations of the Organ Affected — Disturbances of Rhythm — Causes of Functional Disorder of the Heart — Predisposing Causes— Dr. Shapter's Classifi- cation — Symptoms often Accompanying Palpitation — Diminished Impulse Associated with Depression and Anxiety — Necessity of Examination into Habits and Circumstances — Inorganic Murmurs CONTENTS. — Cases of Cardiac Exhaustion — Dr. Hartshorne's Experience — The Irritable Heart — Study of the Cardiac Nervous Apparatus — The Intra-Cardiac Ganglia — The Pneumogastric Nerves — Cardiac Sen- sory Fibres — The Sympathetic Nerve — The Depressor Fibres of the Vagus — Summary of the Circumstances Afifecting the Frequency of the Heart's Action ... ... ... ... '.,. .353-372 CHAPTER II. Palpitation of the Heakt. Cardiac Palpitation, Description of — General Symptoms — Alteration in Sounds of Heart and in Pulse — Condition of the Respiration and of the Features — Subjective Sensations — Duration of Attacks — Causes of Palpitation — Nervous and Toxic Causes — Exhaustion — Reflex Irritation — Exciting Causes — Diagnosis — Prognosis — Treatment — Relief of Paroxysms and Prevention of Recurrence — Position, Cold to Chest, Medicines — Treatment of Nervous ^Subjects — Treatment of Palpitation Due to Indigestion and Gout — During the Intervals — Various Points to be Attended to... ... ... ... 373-387 CHAPTER III. Syncope — Swoonjng — Faintness. Syncope, Definition and Symptoms — Incomplete Attacks or Faintness — — Duration of Attacks — Causes, the Nervous System, the State of the Heart, the Condition of the Blood — Impressions on the Nervous System — Direct Effects on the Heart — Mechanical Causes, Poisons —Syncope Resulting from Loss or Deficiency of Blood — Mixed Cases — Duration of Attacks — Syncope Distinguished from Epilepsy, Apoplexy, Shock, Concussion, and Poisoning — Prolonged Syncope — Prognosis — Treatment — Restoration of Action of Heart, and Supply of Blood to the Brain ... ... ... ... ... 388-400 CHAPTER IV. Neurasthenia of the Heart. Weakness of the Heart in Neurasthenia — Symptoms — Palpitation, Pain, and Sleeplessness — Hypochondriasis — Special Cardiac Symptoms — Periodicity Sometimes Noticed — Causes of Cardiac Neurasthenia — Prognosis and Treatment ... ... ... ... 401-406 xvL CONTENTS. CHAPTER V. Angina Pectoris — Neuralgia of the Heart. Angina Pectoris, Definition of — Peculiarities and Symptoms of the Attacks — The Cardiac Pain and Pulsations — Sounds of the Heart — Respiratory Symptoms and Expression of Countenance — Pains in the Shoulder and Arms — Indications of Vaso-Motor Disorder — Measures Adopted by Patients to Relieve Distress — Results of Attack and State of Health in the Intervals — Causes of a Fatal Termina- tion — Causes of Angina, Essential and Symptomatic — Influence of Tobacco Smoking — Lesions Found after Death in some Cases — Nature of the Disorder — The Nervous Apparatus of the Heart — Three Sources, the Cardiac Ganglia, the Pneumogastric, and the Sympathetic — Vaso-Motor Angina Pectoris — Diagnosis — Prognosis — Treatment, Relief of Attacks and During Intervals — Subcutane- ous Injection of Morphine — Inhalations of Nitrite of Amyl — Nitro- Glycerine Internally — Stimulants — Hygienic Measures — Arsenic — Treatment of Gouty Subjects „.. ... ... i.. 407-423 SECTION III. FUNCTIONAL DISORDERS OF THE RESPIRATORY ORGANS. INTRODUCTORY CHAPTER. Functional Disorders of Respiration — Nerves of Sensation or Motion Implicated — Disorders of the Voice — Hoarseness — Aphonia and its Causes — Laryngeal Growths, Catarrhal Swelling, Paralysis of the Laryngeal Muscles, Hysteria, Anaemia — Dysphonia Clericorum — Insufficient Stream of Air — Treatment of Hoarseness and Aphonia — Inhalations — Tonics — Mineral Waters — Faradism — Anaesthesia and Hyperaesthesia of the Respiratory, Nerves — Neuralgia of the Larynx — Treatment — Nervous Cough — Symptoms — Causes — Con- nection between Cough and Affections of the Ear — Treatment 425-438 CONTENTS. CHAPTER II. Laryngismus Stridulus — Laryngeal Asthma. Laryngismus Stridulus — Nature and Causes — Age, Rickets and Scrofula, Heredity, Malnutrition — Exciting Causes of Attacks — Symptoms of a Paroxysm — Spasm of Larynx — Carpopedal Contractions, Eclamp- sia — Anatomical Changes — Theories as to Nature of Complaint — Sir M. Mackenzie's Views — Diagnosis — Prognosis — Treatment, Prophylactic and During Attacks — Chloroform, Musk, Purgatives, Bromide of Potassium, etc. ... •... ... ... 439-447 CHAPTER III. Asthma. Asthma, Meaning of Term — Causes — Age, Constitutional Conditions, Weather, and Climate — Idiopathic and Symptomatic Asthma — Bronchial and Nasal Affections — Dust and Emanations of Various Kinds — Abdominal Disorders — Renal Affections — Asthma and Gout — Symptoms of Asthma— Objective Symptoms During an Attack — Pathogeny, — Sequelse— Diagnosis — Prognosis — Treatment during the Paroxysm, Narcotics and Antispasmodics — During the Intervals — Removal of Causes — Inhalation of Oxygen and of Condensed Air — Change of Air — Treatment of Gouty Cases — Purgatives — Alkalies — Iodide of Potassium^ — Electricity ... ... ... 448-471 CHAPTER IV. Hay-Asthma — Hay-Fever. Hay-Asthma, Questions as to its Nature — General Description — First Recognized by Dr. Bostock — Causes, Predisposing and Exciting — The Pollen of Grasses, and of Various Cereals — Dr. Blackley's Ex- periments — Symptoms — Affections of the Nose, Eyes, and Throat — Cough and Difficulty of Breathing — Appearances of the Affected Parts — Diagnosis — Treatment — Prophylactic and Curative 472-480 CONTIJNTS. SECTION IV. FUNCTIONAL DISORDERS OF TSE ORGANS OF DIGESTION. INTRODUCTORY CHAPTER. Varieties of Functional Disorders now to be Discussed — Affections of the Stomach, Intestines, and Liver — Their Peculiarities and Causes — Errors in Diet — Excess of Nitrogenous Food — Kidney Affections as a Secondary Result — Deficient Supply of Nitrogenous Materials — Bread as a Food — Influence of the Tannin of Tea on Salivary Diges- tion — Effects of Improper Food — Peculiarities in Certain Individuals — Effects of Nervous Exhaustion — Spasm of the Stomach and In- testines — Spasm of the CEsophagus — Perversion of Gastric and In- testinal Secretion — Effects of Nervous Influence — Hepatic and Pancreatic Secretion — Effects of Nervous Influence on Intestinal Movements — Effects of Alterations in the Blood Supply — Enumera- tion of the Symptoms of Functional Disorders of the Stomach and Intestines ... ... ... ... ... ... ... 481-494 CHAPTER II. Dyspepsia — Indigestion. Functions of Stomach and Intestines — Mechanical Actions and Chemical Changes Therein — Meaning of Term Dyspepsia — Relations with Catarrh — The Vascular Apparatus of the Stomach — Strong and Weak Digestions — Causes of Dyspepsia — Faults Connected with the Diet — Use of Fluids, Alcohol, Tobacco — Positions of the Body, Exertion after Meals, Nervous Excitement, Disorders of Stomach — Anatomical Changes in Catarrh — Symptoms of Acute Dyspepsia — Chronic Forms — Influence on the Mental Condition — Results of Repeated Attacks — Matters Ejected from the Stomach — Formation of Organic Acids — Increase of Salivary Secretion — Pyrosis — Constipation — Diarrhoea — The Urine and Skin — General Condi- tion of the Patient— Cardiac Symptoms — Vertigo — Course and Duration — Diagnosis — Prognosis — Treatment of Acute Attacks — Rest — An Emetic — Alkalies — Laxatives — Treatment of Chronic Forms — Attention to Diet — The State of the Teeth — Articles of Diet CONTENTS. xix Suitable — Fluids — Milk Diet — Treatment of Constipation, Laxa- tives Suitable — Aloes, Cascara, .Salines — Stronger Purgatives — Hygienic Measures as Change of Air, Exercise, Baths — Medicines such as Acids, Alkalies, Bismuth, and Charcoal — Treatment of Irritative Dyspepsia — Arsenic, Ipecacuanha — Question of Health- Resorts 495-534 CHAPTER III. Nervous Dyspepsia and Perverted Appetite. ■Causes of Nervous Dyspepsia — Symptoms — Gastric and Nervous Troubles — Diagnosis — Treatment — Diet and Regimen — Exercise — Drugs, Quinine, Arsenic, and Belladonna — The Weir-Mitchell Treat- ment as for Neurasthenia — Perversion of Appetite — Appetite Ab- normally Increased — Symptoms and Causes — Treatment — Diminu- tion and Loss of Appetite or Anorexia — Case and Treatment — Depraved Appetite — Symptoms and Treatment ... 53.5-545 CHAPTER IV. Gastralgia — Gastrodynia"— Cardialgia. Pain in the Stomach as a Definite Complaint — Causes — Conditions under which it Occurs — Gastralgia in Gouty Subjects — In Loco- motor Ataxy — Of Reflex Origin — Due to Rena! Disease^ Symptoms — Duration and Exciting Causes of Paroxysms — Spasmodic Form of Gastralgia — Diagnosis, from Intercostal Neuralgia, Myalgia, Colic, Peritonitis, Gall-stones, etc., and from Gastric Disorders, as Ulcer, Cancer, and Catarrh — Prognosis and Treatment — Laxatives — Quinine — Arsenic — Alkalies — Ipecacuanha — Morphine, Strych- nine, Chloral, Electricity — Treatment of Gouty Cases ... 546-559 CHAPTER V. Nervous Vomiting and Eructations. Phenomena of Vomiting — Nervous Vomiting — Reflex Causes — Mental Impressions — Organic Nervous Lesions^Peripheral Irritation — Dis- orders of the Abdominal Organs — Disorders of the Sexual Organs — Toxic Causes — Symptoms of Nervous Vomiting — Diagnosis and CONTENTS. Prognosis — Treatment, Causal and Symptomatic — Ice, Anodynes^ Cocaine, Bromide of Potassium, etc. — Nervous Eructations — Sym- ptoms — Sources of the Gas — Case of Nervous Eructations — Treat- ment ... ... ... ... ... ... ... 560-571 CHAPTER VI. Enteralgia — Colic — Neuralgia Mesent erica. Colic, Definition and Causes — Irritating Articles of Food — Gaseous Dis- tension of the Abdomen — Drastic Purgatives — Lead and Copper — Colic as a Symptom of Nervous Disorders, and in Connection with Gout and Rheumatism — Colic due to Cold — Symptoms of Colic — Diagnosis — Prognosis — Other Horms of Colic — Neuralgia of the Bowels — Nervous Diarrhoea — Treatment — Aromatics and Stimu- lants — Warmth Locally — Opiates — Ipecacuanha — Purgatives — Enemata — Morphine Hypodermically — Treatment of Gouty and Rheumatic Cases — Treatment of Neuralgia of the Bowels — Ano- dynes, Tonics, Improvement of General Health, etc. ... 572-587 CHAPTER VII. Constipation. Prevalence of Constipation — Causes, Age, Sex, Occupation, Want of Exercise, Neglect — Too Little Fluid in Diet — Normal Action of Bowels — Contents of Faeces — Defaecation — Consequences of Consti- pation—Chlorosis—Other Causes of Constipation and Disorders with which Associated — Surgical Causes — Habitual Constipation, Influence of Drastic Purgatives —Insufficiency and Improper Quality of Food — Diagnosis — Treatment of Constipation — Of Occasional Attacks — Castor Oil, Salines, Rhubarb, Calomel and Senna— Ene- mata — Faradism — Treatment of Chronic Constipation — Attention to Habits — Necessity of Daily Visit to the Closet— Regulation of Diet — Fruits and Vegetables, Fluids — Laxatives, Aloes and Cascara — Castor Oil, Senna, and Bitter Tonics — Nux Vomica — Salines, Mineral Waters, Friedrichshall, Rubinat-Condal, etc. — Carlsbad Salts— Hepatic Stimulants as Podophyllin, Iridin, Euonymin, and Leptandrin — Nitro-Muriatic Acid — Belladonna — Enemata, their Drawbacks — Other Remedies — Caution as to Use of Laxatives 588-613 CONTENTS. Xxi CHAPTER VIII. Diarrhoea. Diarrhcea, Conditions for its Production — Causes, Food, Cold, Mental Excitement, Summer Diarrhoea — Diarrhoea Accompanying Intes- tinal Lesions and Various Morbid Conditions — Persons most Subject to Attacks — Anatomical Appearances — Symptoms in Adults — In- fluence on General Condition — Severe Attacks — Diagnosis — Treat- ment, Question as to Arresting Discharges — Sometimes Desirable to Facilitate them — Castor Oil, Sulphate of Sodium, Rhubarb, and Calomel — For Checking Diarrhoea, Opium, Aromatics and Astrin- gents, Camphor, Warmth, Stimulants — Chronic Diarrhcea — Diet and Regimen — Rest — Diarrhoea in Children — Causes of Frequency — Disorders of Digestion — Complications — ^Treatment, Cautions as to Use of Opiates — Warm Baths, Stimulants, Flannel to Surface — Diet— Enemata of Warm Water — Calomel — Cautions as to Exces- sive Feeding — Chronic Diarrhcea — Diet, Flannel and Warmth — Grey Powder, Vegetable Astringents, Chalk, Bismuth, Perchloride of Mercury, Arsenic, Iron ... ... ... ... 614-633 CHAPTER IX. Functional Disorders of the Liver. Functions of Liver— Secretion of Bile, Formation of Glycogen and Meta- bolic Processes — Functional Disorders — Hepatalgia — Circulatory Disorder — Hyperasmia, Causes and Symptoms — Treatment — Bilious- ness and a Bilious Attack — Causes and Treatment — Disorders of the Secretory Function — The Saliva as a Test — Excessive Secretion of Bile — Symptoms and Treatment — Diminished Secretion of Bile — Symptoms and Treatment — Vitiated Secretion of Bile — Symptoms and Treatment — Disorders of the Metabolic Processes — Evidence that Urea is Formed in the Liver — Lithaemia as a Result of Func- tional Hepatic Disorder — Symptoms, Causes, and Treatment — Albu- minuria in these Cases — Its Causes, Import, and Treatment — Cutaneous Affections in Lithaemia and their Treatment 634-661 NERVE PROSTRATION AND OTHER FUNCTIONAL DISORDERS OF • DAILY LIFE. INTRODUCTION. FUNCTIONAL DISORDERS IN GENERAL. Functional and Organic Diseases, Definition of — Not to be REGARDED AS TWO DiSTINCT CLASSES MaNY DISEASES THOUGHT TO BE Functional now known to be Organic — Derangement of Function in the absence of recognizable Alterations of Structure — Increase and Diminution of Excitability — Cardiac Functional Disorder — Neuroses properly so-called — Epilepsy and Chorea as examples of Neuroses — Absence of constant Structural Lesions in Epilepsy — Dr. Brown- Sequard's Views — The Pathogeny of Chorea — No constant Structural Alterations — Dr. Sturges' Views — Chorea a Functional Disorder — The causes of Functional Derange- ments—Heredity — Neuropathic Predisposition — Education — Physical and Mental Causes — Excessive use of Stimulants — Cold — Pathological Changes in other Organs — Blood- poisons, as Syphilis and Gout- — Disorders of Visual Accommo- DATJON and Refraction as causes of Nervous Distu-rbances — Dr. Stevens' Views — Characters of Functional Nervous Dis- orders as distinguished from those of Organic Origin. In the various attempts to classify diseases, the terms '^ structural " or " orcranic " on the one hand, and '^ functional ^' on the other, have always found a place. Their general meaning is obvious ; the former term being applied to diseases in which the affected part is the seat of alterations more or less easily demonstrable, I 2 FUNCTIONAL AND ORGANIC DISORDERS. while a " functional " disease or disorder is one which depends on an unnatural or irregular action of a part, unconnected with any apparent injury to its structure. The conditions embraced by these descriptions are there- fore contrasted_, and the belief was once prevalent that a distinct line of demarcation existed between the two classes. No separation of this kind can_, however_, be made. The progress of discovery has indeed effected a great change in the relative numbers of the diseases thus classified,, and many disorders formerly believed to be functional are now known to be organic. In no department of pathology has this change been more marked than in disorders of the nervous system. During the last quarter of a century many of these affections have been transferred from the " functional ^^ to the " organic '' class, and the progress thus made justifies the hope that the former class will become less and less numerous as time goes on. It is sufficient to cite a recent and striking example. Not many years ago the disorder known as infantile paralysis was described as '' essential/' i.e., '^'"functional." It has, however, been shown by microscopical examination that in this disease the spinal cord and its nerves are the seat of a variety of lesions, such as atrophy of the anterior DYNAMIC DERANQJEMJENTS OF NERVE-CENTRES. 3 cornua and of the anterior columns, and granular dis- integration and atrophy of the anterior nerve-roots. Other instances might be adduced to show that in all probability disorders still regarded as functional are really dependent upon structural changes which our pre- sent means of observation are insufficient to enable us to detect. It may, however, be doubted whether we shall ever be able to discover the actual anatomical con- ditions of those innumerable forms of perverted function which in themselves constitute so many of the disorders of every-day life. When describing the condition of any organ, and still more, when attempting to define its range and modes of action, we must often be puzzled to determine the point at which health ends and disease begins. In the state of every part, and in the perfor- mance of everv function, there are considerable differ- ences within the limits of health, and changes which, if permanent, would constitute disease, may be so transient as not to merit such a designation. In the case of slight and temporary nervous disorders, it may well be imagined that there is a dynamic derangement of the nerve-centres, or some change in their Intimate being or mode of action, without any recognized alteration of the nervous tissue. It may easily be supposed that, under 4 JEXCITABILITY INCHJEASJED OR DIMINISHED. such circumstances_, a piece of nervous mechanism should act in an abnormal manner_, and that the per- verted action should be accompanied by other signs of disorder. Excitability is the common property of alJ living parts, and is an essential condition of life. It is obviously susceptible of considerable variation in degree or extent, without going beyond or falling short of the limits of health. The other vital endowments of the tissues, e.g., the assimilatory property and sensibility, are also capable of similar variations. Under the influence of various causes, the excitability or any other property may be so increased or diminished as to cause uneasiness to the individual and to modify the performance of the functions of the part especially affected. Such a condition, if of brief duration, does not necessarily constitute disease, even if the alteration in the function appear to' be considerable. This state- ment may be illustrated by a consideration of the eflfects produced by heat and cold. These agents often cause either increase or diminution of function as well as pain- ful impressions; but if these disappear on removal of the cause, and no permanent alteration results, the con- dition which was temporarily set up can hardly be regarded as one of disease. FUNCTIONAL CARDIAC DISORDER. $ That considerable alteration in the action of a part may occur in the absence of structural change is abun- dantly evidenced in the case of the heart ; and in certain conditions of this organ we have the most striking examples of another fact, viz., that functional disorder long-continued may end in structural lesion. While it is true that cardiac hypertrophy most often proceeds from increase of resistance to the onward flow of the blood, cases are sometimes seen in which the enlarge- ment is a result of increased cardiac action without any augmentation of resistance. The action of the heart is accelerated by excitement of all kinds, and the resultant phenomena are due to the abnormal activity of a normal function. As Niemeyer states, '' in many persons suffer- ing from cardiac hypertrophy we are forced to assume the existence of an exalted irritability, an erythism of the nervous system, particularly of the nerves of the heart, so that trifling causes serve to excite and strengthen its action.''"' In cases such as these the increased cardiac action, at first purely functional, sets up after long continuance a decided structural change. It is, however, in connection with the nervous system that the large majority of functional disorders are found to exist, and to this class of aflections the term 6 IJPILEFSY AN EXAMPLE OF THE NEUROSES. '^neurosis" has been applied. It is quite true that in many fatal cases of these disorders structural changes of various kinds have been discovered, but the relations which such changes bear to the symptoms are matters of the greatest uncertainty. The great variety in the alterations as regards their seat, character, and intensity often renders it impossible to connect them with the symptoms in any definite manner. Two well-known nervous disorders, epilepsy and chorea, furnish abundant evidence in proof of this statement. With regard to epilepsy, Dr. Brown-Sequard states that ^' nothing has resulted froin the efforts that have been made to establish the theory that epilepsy depends on disease in any part having a special name in the nervous centres. The so- called seat of epilepsy has been successively placed in the cerebellum, the cornu Ammonis, the pons Varolii, the convolutions of the brain, etc. There is just as much reason to place that seat in those parts as there would be to place it in the mucous membrane of the bowels or the sole of the foot, or in any peripheric part of the nervous system where an irritation is found caus- ing epilepsy. In cases such as these last, as well as in the preceding, an irritation starts from the place where we find an organic lesion and proceeds to nerve-cells in CHOREA AN EXAMPLE OF THE NEUROSES. 7 the base of the brain^ and in the upper part of the cord, or in one of these parts alone. Through this irritation those nerve-cells have their nutrition altered, and after a time they acquire that morbid excitability which is the essence of epilepsy. We do not think it will ever be possible to recognize what cells are altered, as it is quite likely that the change in them is more dynamical than physical, and that no more microscopic differences could be detected between two of them, one normal and the other possessing great morbid reflex power, than there are visible differences between two pieces of magnet — one poor, the other rich in magnetic power?' It is of course admitted that in cases of epilepsy lesions are often found within the cranium which have set up the irrita- tion in the nervous centres, while other changes are the consequences of the oft-repeated paroxysms. The im- portant fact remains that no special lesion is constantly present. The pathogeny of chorea is, if possible, still more obscure than that of epilepsy. To give a detailed account of the various theories that have been advanced, and of the morbid conditions that have been found in connection with chorea, would be beyond the scope of this chapter, and for information on these topics the 8 CSORJEA AN EXAMPLE OF THE NEUROSES. reader is referred to subsequent pages. It is here only necessary to mention some of the morbid appearances that have been described in order to show the difficulties of reconciling any of them with the clinical manifesta- tions of the disorder. The embolic theory of chorea, first advanced in 1852 by Dr. Kirkes, has gained much acceptance of late years. Before that date, and from the early part of this century^ the disorder was supposed to be closely connected with rheumatism, a view which was further supported by the frequent existence of a cardiac murmur. The presence of warty vegetations on the valves of the heart, so commonly found in fatal cases of chorea, suggested the embolic theory. Dr. Hughlings Jackson thinks that '^ the direct pathological state leading to instability of grey matter, producing choreal movements, is increased quantity of blood in the periphery of the capillary district embolized." The main seat of such lesions is fixed in the corpus striatum. Another authority on chorea, Dr. Dickinson, in his examination of seven fatal cases of the disorder was unable to detect any signs of embolism. On the other hand, he found that both the brain and spinal cord were affected, and that the changes were all connected with vascular disturbance. The parts of the brain most CKOUBA AN EXAMPLE OF THE NEUROSES. 9 decidedly implicated were those lying ^^ between the base and the floor of the lateral ventricles in the track of the middle cerebral arteries ; " in the cord no region was •exempt. In all parts the first visible change appeared to be " injection or distension of the arteries succeeded by extrusion of their contents, to the irritation and injury of the surrounding tissue/^ It is unnecessary to refer to accounts of other morbid appearances discovered in fatal cases of chorea, for with reference to all of them it may t)e stated that they cannot be presumed to underlie even severe choreic manifesta- tions which come on suddenly, and quickly disappear under suitable treatment. With regard to embolism, it has been clearly pointed out by Dr. Sturges, in his excel- lent work on chorea, that this process, so far as our knowledge of it extends, does not produce symptoms similar to those of the disorder under consideration. The symptoms of cerebral embolism are vertigo, pain in the head, faintness or sickness, more or less complete hemiplegia, and impairment of sensation ; the course of the disease is usually from bad to worse, recovery is never complete, and the symptoms characteristic of the •first attack are apt to recur. When minute arteries are affected. Dr. Sturges points out that in addition " there lo CSOTITIA A FUNCTIONAL BISORDER. is often active delirium_, high temperature, and a train of symptoms, rapidly fatal, which resemble most specific fever.^^ It is almost needless to say that symptoms such as these offer the strongest possible contrast to those of chorea. Additional evidence against the embolic theory is supplied by the fact that microscopic emboli have been very rarely found in fatal cases of the disease. The anatomical theories of chorea being thus insuffi- cient to account for the symptoms, we may ask, with Dr. Sturges, whether the affection may not " be looked upon as a functional disorder, which is as much beyond the reach of anatomical demonstration as are the various passions and emotions which, like it, distort and coerce the body in a great variety of ways ? " There is much to be said in favour of this view, and the following are the principal arguments adduced by the author referred to. The limbs are affected in chorea in the order of' their use as intelligent instruments, and not as they would upon any assumption of injury or irritation of a motor centre. The untaught muscles and those that have never been employed as agents of intelligence never suffer from chorea, while the more complex the muscular employment, the greater the liability to suffer.. CHORJEA A FUNCTIONAL DISORDEH. ii There is therefore in chorea the withdrawal or impair- ment of controlling power over certain parts of the frame ; the education of the muscles concerned is arrested " by some nervous shock which renders them useless and unruly^ while the operation of the will^ no longer sufficing to regulate the limbs_, tends rather to disfigure the movements it seeks to arrest.'^ Chorea consists of an exaggeration of those muscular move- ments which are constantly taking place, and especially in children who have not as yet acquired the power of governing the actions of their muscles. The irregular movements are most marked in the face, arms, and hands, for the muscles of those parts are mainly employed as agents of intelligence, and when the con- trolling power of the brain or higher centres is lessened or removed, as a result of shock or otherwise, fuller play is given to the power of the lower centres. The mis- movements are but an exaggeration of those which are natural to the age of the child ; a mere restlessness devoid of character or rhythm. '^^But when chorea comes to the adult, his fixed habits of moving will impart to the disorder a distinct method ; the affected limbs, that is to say, are jerked about in a manner that may be described." As additional evidence in support 12 CAUSES OF FUNCTIONAL NERVOUS DISORDERS. of the functional hypothesis of chorea, Dr. Sturges refers to the frequent recurrence of the symptoms until adult life is reached; the starting-place of the move- mentSj this often being situated in those muscles most directly beset or embarrassed, and to the most common immediate causes of the disorder. To these arguments may be added the fact that the movements are some- times originated as a result of imitation^ and may thus spread through a school. Having thus endeavoured to show that functional dis- order may exist in the absence of discoverable change of structure, it remains to consider the causes and general characters of functional affections, especially of those of the nervous system. The discovery of the cause in a case of this nature is a matter of the highest impor- tance_, for the obvious reason that it constitutes the only safe guide to a rational and successful treatment. When structural changes have taken place, the discovery of the cause, though always desirable, is less likely to be followed by satisfactory results. Hereditary predisposition plays a very considerable part in the causation of functional nervous disorders, and aids greatly in perpetuating attacks which have been excited by influences of the most diverse kinds. Thus, hi: RED IT A R Y PREDISP OSITION. ^ ^ to take chorea again as an example, in many cases its symptoms are obviously caused by fright or mental excitement which they immediately follow. Their con- tinuance long after the exciting cause has disappeared must be due to some peculiarity in the nervous organi- zation, and in children thus affected with chorea hereditary predisposition to nervous disorder will generally be traceable. Sometimes the same disease is handed down ; in other instances another form of dis- order appears in the descendants. Epilepsy is thus often transmitted from father to son, and this feature of the disorder is very clearly exhibited by Dr. Brown- Sequard's experiments, in which the progeny of guinea- pigs artificially rendered epileptic suffered in the same manner. In the second class we meet with examples such as this : an epileptic father begets a son who suffers from chorea, and one or more children of the latter display symptoms of idiocy. The phenomena of atavism are often witnessed in connection with nervous disorders. Families in whom histories of this character are dis- coverable are said to possess a neuropathic predisposi- tion, that is to say, their members come into the w^orld possessing a greater or less tendency towards affections 1 4 CAUSES OF FUNCTIONAL NERVOUS DISORDERS. of the nervous system. Wherein such a tendency consists is a question that cannot be answered in precise terms. We may assume an abnormal increase of irrita- biUty, a diminished power of resisting external influences, or lastly excessive elasticity of the vascular walls and a consequent tendency to hypersemia. In dealing with cases of nervous disorder, and especially in forming a prognosis, it is a matter of great importance to determine whether a neuropathic pre- disposition is present or not. To establish its presence, it is not indeed necessary to discover a history of such typical nervous disorders as are described in text-books ; evidence of marked peculiarities of psychical character may be all that is forthcoming and may yet be sufficient. Another factor of considerable importance is the intensi- fication which almost any kind of tendency to nervous disorder derives from being common to both parents, as measured by the results too often witnessed from the marriage of persons nearly related to each other and subject to the same taint. The influence of alcoholic excesses on the part of one or both parents is daily becoming more and more recognized in connection with nervous disorders in the offspring. It is also highly probable that drunkenness at the time of impregnation JSBUCATION AND EARLY TRAINING. 15 is not without influence on the nervous system of the foetus. The hereditary constitution is^ however^ liable to con- siderable modification from external influences^ both such as directly affect the physical conditions and such as act through the consciousness. In the latter category the roost potent factors are those which are connected with education. The influence of the early training upon the causation of nervous disorder on the one hand^ and upon its prevention on the other_, can scarcely be over-estimated. One point deserves special attention. The first thing that a child ought to learn is to obey ; for if this lesson be neglected the power of self-govern- ment is likely never to be acquiredj and the passions will remain unchecked. The vaso-motor system of nerves is highly excitable in childhood, and the indul- gence of every unchecked passion causes hypersemia of the brain and distension of the cerebral vessels. Fre- quent repetition leads to paresis of the muscular coat of the vessels and more or less permanent dilatation. Results of this character are often due to continuous mental strain and to sexual excesses. In the course of time another factor comes into play. The inhibitory centres in the brain, from w^ant of exercise^ lose their •I 6 CAUSES OF FUNCTIONAL NERVOUS DISORDERS. functional capacity^ so that a very slight cause suffices. to induce cerebral hyperaemia, which at last becomes habitual. With reference to physical and mental causes of nervous disorders_, I venture to quote what I have else- where written on this subject. "Every age is charac- terized by the presence or prevalence of special disorders of health, which have a more or less obvious causation. At the present day ' want of tone' is the characteristic feature of disorders in general, and in none is it more obvious than in those which peculiarly affect official and professional men working at high pressure. As might be expected, the signs of this want of tone, or weakness of the nervous system, vary in different persons," but the condition itself is mainly due to excessive wear and tear of body and mind. At the present day almost everything has to be done at high pressure; we strive to emulate the rapidity of the telegraph and the steam engine. " Incessant struggles to get on, trampling, crushing, elbowing, and treading on each other's heels, are manifest symptoms of the present phase of indus- trial progress. Even in our recreations there are evi- dences of a similar spirit." Thus ith> -• ns that man- of our contemporaries fall out of the race with only CA USES OF FUNCTIONAL NEE VO US DISORDERS. 1 7 shattered nerves and weakened bodies as results of their ill-regulated efforts. Over-strain of the heart is another modern disorder traceable to the same causes_, and this is due to mental as well as to bodily over-exertion. The influence of sexual excesses in producing and perpetua- ting nervous disorders^ and in lowering the tone of the system^ can scarcely be over-estimated. The immoderate use of stimulants is another fertile cause of nervous disorders, and it greatly aids the opera- tion of other factors. Alcohol, tobacco, coffee, and tea are often taken in excess in order to enable a man to con- tinue the struggle. These agents stimulate the nervous system and enable it to get through an abnormal amount of work, but as excitement is necessarily followed by debility the total result of the repeated stimulations is simply a lessening of power. With regard to other agents, such as morphine and chloroform, which are used to deaden sensibility and to drown care, there is, unfortunately, too much reason to believe that their employment is becoming more and more common. We are often inclined to attribute nervous disorders to the operation of cold, and sometimes for the reason *hat no other c 'i«^'^, is sufficiently obvious. As a matter oi tact, there is a close connection between exposure to 2, 1 8 CA USES OF FUNCTIONAL NFE VO US BISORDFRS. cold and certain nervous affections, but the statements of patients on this point should always be carefully sifted. There is no doubt that neuralgia is often pro- voked by exposure to draughts of air^ and that the most common form of facial paralysis owns a similar causa- tion. In our endeavours to discover the cause of functional nervous disorder we must not forget the influence of irritation conducted from distant parts^ and of patho- logical changes in other organs. It is only in com- paratively recent times that we have learnt to recognize the fact that injuries of peripheral nerves may set up changes, probably of an inflammatory character, which extend to the central organs and cause serious lesions. In persons with a neuropathic predisposition_, e.g., to epilepsy, very slight injuries may suffice to produce paroxysms. In a similar manner pathological irritation of peripheral portions of the nervous system, and par- ticularly such irritation as is liable to occur in the digestive and sexual organs, not unfrequently gives rise to, and invariably exaggerates, many nervous affections ; for example, hysteria and hypochondriasis. Not only changes in distant organs, but changes in the blood itself may be the cause of nervous affections ; it is only CA US:ES of functional NER VO us disorders. 19 necessary to mention the common effects of anaemia and of various exhausting diseases as examples of this kind. Nem'algic affections are often the results of exposure to malarious influences^ and according to the statements of some writers are closely associated with that condition of system which predisposes to pulmonary consump- tion. Among blood-poisons affecting the nervous-system, syphilis occupies a very prominent place. Its morbid products are liable to be deposited in the brain_, spinal cord, and peripheral nerves ; such deposit may give rise to symptoms of the most severe type, and these may not show themselves until many years have elapsed since infection. The possibility of syphilis being at the root of a given nervous disorder should always be borne in mind. Many cases with a syphilitic history are more amenable to treatment, and admit of a more favourable prognosis than others in which no such taint can be traced. The gouty diathesis is another, and a potent cause of nervous disorders ; in fact, the term *' nervous gout " has been applied to the entire class of irregular gouty manifestations. ^*^ Nervous affections of this character occur especially in women, and in individuals generally of a nervous temperament and 20 CA USES OF FUNCTIONAL NFR VO US DISORDERS. descended from gouty ancestors. In some families the male members a.re the victims of acute gout_, while the females suffer from neuralgia in various forms^ head- ache/' &c. Facial neuralgia, hemicrania_, and sciatica sometimes alternate with attacks of articular gout, and such grave nervous disorders as epilepsy and insanity are, in not a few cases, of gouty origin.* Reflex irritation has been already alluded to as a cause of nervous disorders, and Dr. Stevens, of New York, has endeavoured to show that the neuropathic pre- disposition may consist simply of a local irritation due to '^some peculiarity of anatomical structure or of physiological adaptations, which is inconsistent with the most regular and easy performance of the function of a part or parts." As a frequent cause of physiological disturbance, Dr. Stevens refers to the difficulties often attending the functions of accommodating and of adjusting the eyes in the act of vision, or irritations arising from the nerves involved in these processes. A single condition, viz., hypermetropia, may be selected as an example. The continued and unnatural tension of * For further details on the connection between gout and disorders of the nervous system the reader is referred to my work on " Gout and its Helations to Diseases of the Liver and Kidneys," Chapter V. CA USES OF FUNCTIONAL NER VO US BISORDFRS. 2 1 the ciliary muscle becomes at length a source of much weariness^ and the hypermetropic eye is never at rest except when closed. There is also another and a greater difficulty connected with this condition of the eyes. For perfect vision " the degree of accommodation of the eyes singly and of the convergence of the optic axes must be in harmony. For if the accommodation be fixed for one point while the convergence is for a point of greater or less proximity^ there must result an absence of perfect definition^ or the presence of double images. A pair of normal eyes accommodated for a given distance will converge for the same distance." In the hypermetropic eye^ " continual compromising adjustments must be made and great nervous perplexity and disappointed nervous action must occur, for no sooner is one part of the adjustment corrected than the other is wrong." The sensations of pain and weariness characteristic of hypermetropia are due to the nervous perplexity even more than to the actual strain of the muscles; and Dr. Stevens cites many instances to prove that this condition of things continued through many years may constitute a permanent source of nervous irritation. Astigmatism and myopia are other causes of nervous perplexity and n'ritation, and the practical value of this theory of many 22 FUNCTIONAL NERVOUS DISORDERS. forms of nervous disorder is substantiated by the good results obtained from correcting the ocular defects by means of glasses. Dr. Stevens cites cases of neuralgia, migraine^ chorea,, and epilepsy in which the patients exhibited ocular defects of the kinds just described. Ordinary treatment proved of little or no avail ; but in many of the cases considerable relief or even a complete cure resulted from attention to the eyes and removal of ocular disturbances. Further reference to ocular defects as a cause of nervous disorders will be found in subsequent chapters. A few general remarks on the characters of functional nervous disorders^ as distinguished from those of organic origin, will conclude this part of my subject. Functional nervous disorders occur in all conditions of the general health, though many of them are especially associated with debility ; there are great variations in the intensity of the symptoms ; the attacks are wont to recurat regular or irregular intervals, during which the health is often perfectly good. In organic disorders the principal symptoms remain per- manent, and variations in their intensity are slowly developed. A sudden improvement, or even a rapid cure, is not unfrequent in functional disorders; such changes FUXCTIOXAL NEBVOUS BISOHBERS. 23 are exceedingly rare in organic diseases of the nervous system. These latter are often accompanied by certain symptoms of irritation of conductors of sensitive impressions and of trophic and secretory nerve fibres, as evinced by various abnormal sensations and altera- tions of nutrition and secretion of the skin and mucous membranes. In functional nervous disorders, with the exception of some forms of neuralgia, these changes are of rare occurrence. Such general features as pain, spasm, and local paralyses may be very severe, but, if organic disease can be excluded, they rarely cause much anxiety as to the ultimate issue. Save in hysterical cases, the bladder and rectum are very rarely involved in functional nervous disorders, and even in hysterical paraplegia the functions of these organs may be normally discharged. The application of electricity sometimes enables us to distinguish between functional and organic disease ; the use of this agent will be described in the remarks on the diagnosis of the special disorders. SECTION I. FUNGTIOISIAL DISORDERS OF THE NERVOUS SYSTEM, ■ CHAPTER L NERVE PROSTRATION— NEURASTHENIA— NERVOUS DEBILITY. Nerve Prostration — Synonyms and meaning of Term — Nature and Varieties — Prevalence of Nerve-prostration in England AND IN the United States — Causes — Dr. BeXrd's Views — Hereditary Predisposition— Training and Habits of Young Subjects — Influence of Schoolwork and Competitive Examinations — Symptoms of Neurasthenia — Symptoms con- nected with the Motor Faculties — Disorders of the Sen- sory Faculties — Spinal Pain — Neuralgia — Disorders of Special Senses — Vaso-motor Disturbances — Disorders of THE Circulatory, Respiratory, and Digestive Organs — Symptoms referable to the Kidney's and the Organs of Generation — Signs of Mental Disorder — Disorders of Sleep — Duration of the Symptoms of Neurasthenia — Prog- nosis and DiAGNiJSis — Treatment — Relief of the Sleepless- ness — Freedom from Mental Exertion — Ajiusements and Exercise — Diet — Avoidance of Tobacco and Excess in Stimulants — Tonics and Bathing — Electricity — The Weir- 26 F0R2IS OF NFRVE PROSTRATION. IMiTCHELL System — Rest, Isolation, Excessive Feeding,. Massage, and Employment of Electricity — Cases in which Indicated — Details of Treatment— Duration of Treatment AND Results, with Illustrative Cases — Cautions as to Adoption of Treatment in Cases of Organic Disease and OF Mental Disorder. Neurasthenia or nerve-prostration is a constitutional neurosis^ affecting the whole system. The term has many other synonyms, e.g., nervousness^ nervous debiHty, nervous exhaustion, spinal irritation, &c. It denotes a condition in which weakness of the nervous apparatus is associated with undue irritability ; excite^ ment and fatigue are produced by causes which in a normal state of things would not be followed by these effects. In one series of cases the manifestations of irritability and weakness appear mainly in the action of the cerebral centres, and we refer them to functional disorder of the brain. In another series the spinal cord appears to be mainly implicated; and there is yet a third class in which the symptoms indicate disorder in both these 2;reat nervous centres. Nothing; is known as to the anatomical changes, if any, which underlie the symptoms. These latter are by no means of modern origination ; but under the various influences of our nineteenth century civilization they have become very CA USJES OF NER VU PR OS TRA TION. 2 7 common^ and in not a few cases very serious. Here^ in England^ and especially in our large cities, instances daily come to the knowledge of the physician ; but it would seem that for frequency of occurrence and severity of type the United States at present enjoy an unenviable reputation. One of their physicians^ Dr. G. M. Beard, has given us an exhaustive description, drawn from his great experience, of this complaint. With regard to the causes of neurasthenia, it may be stated that they are" those of nervous depression in general. Dr. Beard asserts that the inhabitants of the United States are the most nervous people in the w^orld. In order to exhibit in a graphic manner the causes of American nervousness, he makes use of the following algebraical formula: — Civilization in general + Ameri- can civilization (a young and rapidly growing nation with religious, municipal, and social freedom) + an exhausting climate (the extremes of heat, cold, and dryness) + a nervous diathesis (the result of the above- mentioned factors) + immoderate mental and bodily exertion, or excessive proneness to be swayed by in- clinations and passions = neurasthenia or nervous exhaustion. Similar causes are common enough in England, and especially in the large cities; probably 28 CAUSES OF NERVE PROSTRATION. London contains as many instances of neurasthenia as any American city. The excitement connected with politics^ business, Stock Exchange speculation, and various forms of gambling is nowhere more intense, and is daily becoming more and more widely spread. '^Wear and tear^^ are in excess, while ^' rest and repair" are becoming more and more difficult. We can, therefore, sum up all that can be said as to the causes of neurasthenia by stating that they are in the main as follows : — Severe and prolonged excitement and mental strain ; an insufficient amount of rest and sleep, often coupled with improper and insufficient food ; excesses of all kinds, and especially indulgence in alcohol .and tobacco. The patients are often of a nervous tem- perament, and are the subjects of hereditary pre- disposition to nervous disorder, and this latter is one of the most powerful factors in the production of neu- rasthenia. In persons with a family history of diseases of the nervous system the condition most often noticed is one of undue liability to disturbance, which may show itself in several forms. If among the ancestors of a given patient there have been instances of epilepsy, hysteria, insanity, tendency to excess in alcohol, and the like, the result may be the development of any of CA USES OF NER VE PR OSTRA TION. 29 these malaclies_, and not at all necessarily a reproduction of the original disorder. In all cases of neurasthenia inquiry should be made as to the existence of any morbid tendency. There can be no doubt as to the influence of the training and habits of young people upon the production of neurasthenia, and especially in those cases in which there is any hereditary tendency to nervous disorder. Such a tendency often shows itself in very early life, and such children are of poor muscular development, easily excited and soon fatigued, unstable in their wishes and inclinations, apt to sleep badly, not unfrequently subject to night-terrors, and peculiarly liable to convul- sions and delirium upon the supervention of any febrile disorder. They are, however, generally precocious, able to outstrip their contemporaries, and learn easily ; some of them, thus early in life, show signs of moral insanity in a mild form. Lying, stealing, cruelty to other children and to animals, marked insubordination and various acts of mischief appear to have special attractions for such children, and to mark them out as peculiar. These tendencies may be subdued by proper discipline and treatment ; but, if neglected, they result not only in fixed habits, but in other serious perversions 30 CAUSES OF NERVE PROSTRATION. of the moral faculties. I have recently had under my care a young lady, aged 17, whose father became insane from overwork. After considerable nervous prostration, lasting for some weeks, marked sym- ptoms of hysteria and melancholia became developed. Much improvement has taken place under the influence of kindly discipline, cheerful society, good food, and tonics. In not a few cases school-work is potent for evil in the development of neurasthenia among the young. It is only necessary to point to the struggles engendered by the competition everywhere in vogue at the present time j to the so-called " cramming " with all its unwhole- some accessories, and to the anxiety, loss of sleep, and disappointment which are so often superadded to the results of extraordinary efforts. The prevalence of headache and of disorders of vision among the young of both sexes is a measure of the evil which is growing up in our midst. I have seen several cases, in both sexes, in which neurasthenia was purely the result of over-fatigue engendered by competitive examinations at school. We are also told that In America the "social engagements " of the pupils add not a little to the pressure imposed upon them by their studies. SYMPTOMS OF NEURASTHENIA. 31 The prominent symptoms of neurasthenia usually •show themselves in early middle-age ; by that time the various causes have generally been at work long enough to produce their effect. Much^ of course, depends upon the constitution, habits, and surroundings of the indi- vidual. The accession of the symptoms is liable to be hastened by the outbreak of some febrile or other dis- order which, even in fairly vigorous persons, is wont to leave a condition of debility in its train. Symptoms connected with the motor faculties. These are often the first to appear, and may exist alone for some time. The most prominent symptom is muscular debility, indicative of weakness and exhaustion of the nervous system. Such patients are apt to feel tired even on rising from their beds, and a feeling of pain in the legs is often superadded to that of languor. These sensations are aggravated by exercise ; a painful feeling of fatigue is easily induced. Some patients find that even the effort involved in writing a few lines causes more or less discomfort, and that this feelino- becomes so marked that perseverance is all but impossible. Others find that a painful sense of fatigue comes on after a short walk, and that aching and stiffness in the limbs, lasting perhaps for several days, are the penalty 32 S YMF TOMS OF NF UMA STEJENIA . for the slightest degree of over-exertion. The weakness of the museles is often still more elearly demonstrated by uncertainty of their action^ less frequently by tremulous movements_, and, in exceptional cases, by true paralyses. Convulsive twitchings of muscles and of muscular fibres are not unfrequent in the subjects of neurasthenia ; and chorea-like movements are often noticed in the muscles of the face, and especially in those about the mouth. The face is seldom at rest,, and a proneness to laugh is occasionally observed. Some of these patients complain of painful cramps in the legs at night. Palpitation of the heart is very common. A case presenting several of the features just described has recently come under my notice. I was called in hj a medical friend to see a gentleman aged forty-four^ in whom, after a long period of anxiety, very marked and troublesome symptoms of neurasthenia had become developed. There was considerable mental depression,, and muscular action was perverted and uncertain. On starting to walk, a few steps would be correctly made; then the movements would become tremulous and the muscles of the legs would twitch so violently that the patient fell unless means of support were at hand. SYMPTOMS OF NHURASTHENIA. S3 These attacks were wont speedily to pass off and to be followed by convulsive twitchings of the muscles of the face. The disorder of the sensory faculties shows itself in hypersesthesia and various other forms of disordered sensation indicative of excessive irritability of the sensory nerves and nerve-centres. Hyperaesthetic spots can often be detected on various parts of the body^ and the skin is more sensitive than usual to contact with hot and cold water and solid substances in general. I have seen several cases in whom these disorders of sensation were well marked. In the case of a lady who had had several children in quick succession there was acute suffering from tender spots or points in the intercostal and lumbar regions^ and the skin of the chest and back would occasionally become so tender that contact with her silk vest proved almost unbear- able. Such patients often experience actual pain, especially in the head and back and along the spine. Pain in this last-mentioned situation, both spontaneous and excited by pressure, is the predominant symptom in "spinal irritation/^ a form of neurasthenia, which will be described in a subsequent chapter, though for the sake of completeness its prominent features will now be mentioned. The pain is most often confined to 3 34 SYMPTOMS OF NEURASTHENIA. a certain spot ; but it may be diffused over the spine. It is aggravated by pressure and by pinching up the skin, and by movements of various kinds. When the cervical region is affected the seventh spinous process is generally the most sensitive. When the pain is felt in the dorsal vertebrae there are often attacks of difficulty of breathing, which are also liable to be induced when pressure is made over the painful spot. In some cases not only pain, but nausea and faintness are caused by pressure over one or more vertebrae. The pain is some- times felt low down in the lumbar and sacral regions, and is then much increased by walking and standing. In all cases the pain is apt to change its place, and may disappear from time to time. Various forms of neuralgia are apt to occur in neuras- thenic patients, the pain being remarkably obstinate and simulating that due to serious disorder of the nervous centres. In some of these patients the pain is of a migratory character, and in the course of time affects most of the regions of the body. Other forms of disordered sensation are not uncommon, e.g., chilliness, a feeling as if cold water were running down the back, numbness of the legs and arms, tingling and itching in various parts, especially about the genital organs. Signs of disorder of the organs of special sense are- SYMPTOMS OF NEURASTHENIA. 35 noticed in some cases. A peculiarly dull look is associated with redness of the conjunctivae, due to sleep- lessness. The pupils are dilated, but move freely; sometimes inequality is noticed. Intolerance of light, exposure to which causes headache, weakness of vision, and muscae volitantes and flashes of light before the eyes are not uncommon. Hearing is sometimes preter- naturally acute, and subjective sensations of buzzing, ringing or pulsations in the ears are frequently experi- enced. The rushing sound of the blood during in- creased cardiac action is very troublesome and alarm- ing to some of these patients. Giddiness is a common symptom. Symptoms indicative of vaso-motor disorder are of constant occurrence in the subjects of neurasthenia. Many of them are annoyed by the blushes which are involuntarily provoked on the slightest occasions. On the other hand, some of these patients become pale and faint when excited or alarmed ; and even when the head and face are hot, the hands and feet are apt to be cold and clammy. I am now attending a gentleman full of courage and energy and yet liable to outbreaks of cold, clammy perspiration during important interviews and even on the receipt of a letter containing unexpected intelligence. Other symptoms belonging to this class 36 SYMPTOMS OF NEURASTHENIA. are indicative of disordered action of the heart, and these are wont to supervene very suddenly and to excite much anxiety. The slightest mental or bodily exertion causes a great increase in the frequency of the pulse with distressing palpitation as a frequent accompani- ment. The rushing of blood to the head and the throbbing of the vessels in the neck are much dreaded by the patient. Abdominal pulsation is not unfrequent, and a similar sensation is sometimes experienced over the greater part of the body. Further reference will be made to the cardiac symptoms in the chapters on neuroses of the heart. The organs of respiration are less commonly affected, hut they sometimes exhibit manifest evidences of dis- ordered function. There are certain changes in the voice which Dr. Beard regards as characteristic; words are pronounced in a low tone and hesitating manner ; any special effort to express thoughts causes dryness of the mouth and throaty and this in its turn renders speaking impossible. Nervous cough is another symptom of this character, and one which annoys and alarms the patient. It is apt to be very troublesome at night, and the loss of rest thus caused tends still further to reduce the strength. In such cases a suspicion SYMPTOMS OF NEURASTHENIA. 37 of consumption is often excited. In a case of this kindj occurring in a young lady, an intractable cough had been very frequent at intervals during two years. It was undoubtedly due to nervous irritation, and dis- appeared after a few days' treatment with quinine, bromide of potassium, and hydrobromic acid. A desire for air is sometimes noticed in these patients. When indoors they complain of a feeling as though they were being stifled, and sit before an open window in order to obtain relief. Disorders of the digestive oro;ans are very common in neurasthenic subjects, and occur in various forms. Indigestion is sometimes the first symptom, and its manifestations are almost endless in number. Loss of appetite, pain, and a sensation of fulness in the epi- gastrium, eructations, vomiting, flatulent distension, obstinate constipation, alternating with diarrhoea, in which the food passes through the bowels but slightly changed, are the most prominent symptoms referable to the stomach and bowels. Nervous dyspepsia is charac- terized by its sudden appearance and rapid subsidence ; by its alternating with other nervous symptoms, and by the relief afforded by sedatives and by articles of food which would increase the symptoms of gastric catarrh. 38 SYMPTOMS OF NEURASTHENIA. It is a remarkable fact that in some cases of this kind the appearance of the patients is that of good health, and their nutrition seems to be unaffected. In another class the evidences of ill-health are unmistakable, in spite of a fair appetite and a good supply of nourishing food. The urinary secretion varies, but it generally presents some abnormality. Sometimes it is scanty, high- coloured, and deposits urates ; in other cases it is pale and deposits oxalate of lime or the amorphous phos- phates ; in others, again, it is abundant and contains traces of sugar. Symptoms referable to the organs of generation are seldom absent. In men, these take the form of nocturnal emissions and impotence, while women are apt to suffer from various disorders of menstruation. In order to complete this sketch of the symptoms of neurasthenia some account must be given of those evidences of psychical disorder which are rarely absent. In one class of cases these symptoms appear to pre- dominate, inasmuch as the patients constantly dwell upon them in conversation and show by their actions and manners the influences by which they are swayed. Such symptoms as apathy, hopelessness, morbid excita- SYMPTOMS OF NEURASTHENIA. 39 bility and irritability, groundless anxiety and fear, indifference and want of resolution are, if not charac- teristic of neurasthenia, at least seldom dissociated from it. The various kinds of morbid dread are among the most striking of the mental phenomena. Some patients fear to be alone, others have a horror of societv and of certain localities; others again are in constant fear of being attacked by disease, while in another class there is a constant but undefined dread of impending danger or misery. Some bf these patients are averse to remain in rooms with windows and doors closed ; others are in perpetual fear of being injured by lightning or some convulsion of nature. Hallucinations and illusions are rare in these cases, and some of the patients are fully aware of the groundless nature of their fears. Intense excitement and anxiety about the merest trifles are other common symptoms indicative of perverted action of the sensorium. In almost every form of nervous disorder, disturbed sleep, often amounting to utter sleeplessness, is very generally observed, and it tends, perhaps, more than any- thing else to exaggerate all the other symptoms. In some cases the patients remain awake for hours after going to bed ; in others, they fall asleep easily, but wake 40 SYMPTOMS OF NEURASTHENIA. in an hour or so and continue in that condition till it is time to get up. Even the sleep that is obtained is apt to be troubled by dreams and nightmare, and the patients rise from their beds more languid and tired than when they sought them. In some patients the sleep is abnormally profound, but the patients are so little refreshed by it that they remain drowsy and lethargic during the day, unable to attend to business, and faUing fast asleep after making the slightest effort. The memory is apt to be affected in many cases of neurasthenia, and the patients are much worried at finding that after read- ing a short paragraph in a book or newspaper they fail to remember its contents. In som.e cases arithmetical calculations, previously quite easy, appear impossible; any attempt of this character is followed by confusion, headache, swimming before the eyes, and other troubles. It need hardly be said that all the above-mentioned symptoms of neurasthenia are never met with in a single patient ; the manner in which they are grouped and distributed varies to an almost unlimited extent. The symptoms of neurasthenia may last for an indefinite time, and in slight cases are apt to subside and recur at irregular intervals. In more severe cases the condition, in the absence of proper care and treat- DIAGNOSIS OF NJEUR ASTHENIA. 41 ment, gradually becomes \vorse_, and is a source of much ■anxiety to the patient and his friends. Here, again, improvements and relapses are wont to alternate, and it is difficult to forecast the duration of the symptoms. The condition is not serious so far as danger to life is concerned, but it may be the starting-point of grave nervous disease. When an obvious cause is discover- able and capable of removal, a hopeful prognosis may be given. It is, of course, necessary to take into considera- tion the state of the patient, the surrounding circum- stances, and the duration of the symptoms. Diagnosis. This is sometimes easy, especially when a causal connection can be established between the symptoms and their antecedents, but in other cases it can be made only per viam exclusionis, and by carefully watching the patient and noticing the effect of treat- ment. In some severe cerebral diseases, e.g., tumours, the symptoms closely resemble those of neurasthenia. The recognition of the temperament of the patient will sometimes aid the dia2:nosis. The duration of the symptoms and the occurrence of relapses and improve- ments are other points of importance. In some respects the symptoms resemble those of hysteria, but there are decided differences between the two conditions. The 42 TRJEATMBNT OF NEURASTHENIA. sudden appearance of the phenomena, their rapid sub- sidence^ and the manner in which they are excited are sufficient to distinguish hysteria from neurasthenia. The former is liable to assume the more serious aspect, inasmuch as paralyses and spasmodic attacks are prone to occur j but severe cases of neurasthenia would appear to be connected with graver states of disorder of the nervous system. Treatment. Provided that no organic disease is dis- coverable after careful examination (and I am treating only of such cases), the physician should do his utmost to comfort and reassure his patient at the same time that he impresses upon him the necessity of obeying all injunctions. The patient^s fears must be allayed, though it will be often difficult to do this, especially in hypochondriacal cases. The physician must frequently see his patient and assure himself that his prescriptions are attended to in all respects. In cases in which sleeplessness is a marked symptom, and is evidently causing great distress, it is necessary to deal with it at once before attending to the general condition. Much caution must, however, be used in the employment of hypnotics. We may choose between chloral and the bromides, and a combination of these remedies is oftea TEJEA THE NT OF 3^Z URA S THJENIA . 43 better than either taken singly. Twenty grains of bromide of ammonium with fifteen of chloral may be given every night for three or four nights. If the effect be satisfactory the medicines should be discontinued, or given for a few nights in half doses. The production of sleep greatly assists the action, of other remedies. Freedom from mental exertion is the next point of importance^ though it is often necessary to find some employment for the mind. The brain will not suddenly take rest ; trains of action set going in the cerebrum refuse to come to a full stop^ and the best thing to be done is to divert the cerebral activity into other channels. How to effect this object^ depends, of course, upon the individuality of the patient ; but some real amusement (in the true sense of the word) should be carefully sought for. The patient's tastes must be consulted, and they will often guide the physician in selecting the best forms of recreation. The same remark holds good of bodily exercise. Patients even of weak muscular power are apt to think that violent exercise will cure their nervousness. This idea is, of course, a mistaken one, and should not be allowed to be acted upon. The exer- cise should be strictly proportioned to the strength and should never be such as to cause fatigue. Short walks,. 44 TREATMENT OF NEURASTHENIA. carriage exercise^ riding on horseback, boating, etc., will find their appropriate uses. A change to fresh air, either in the country or by the seaside, or in mountainous -districts, will always be beneficial, and it is hardly neces- sary to add that all causes of debility should be carefully avoided. In phlegmatic subjects, with fair muscular development, exercise is often an important part of the treatment. Besides the forms above recommended, some kinds of easy gymnastics may be had recourse to ; Dr. Zander's instruments are very suitable for such cases. The diet also demands very careful attention. The majority of the patients are thin and anaemic, with poor appetites and weak power of digestion. The condition of the stomach must be improved by tonics of various kinds, of which nux vomica is generally the most useful. The tincture should be given in small doses (ntv-x) about half-an-hour before each meal. The food should be of an easily digestible nature, and it is well to provide these patients with a diet-sheet telling them what they may eat and what they must abstain from. Mutton and beef, white fish, game, chicken and eggs, butter, milk, good bread, and green vegetables well cooked, will con- •Stitute the principal articles of diet. Late dinners TREA T3IE NT OF NE UFA STRENIA . 45 should be avoided ; the principal meal should be taken at 2 p.m., and a light supper at seven o'clock. Where loss of flesh has been a marked symptom, increase of weight is one of the best indications of recovery. Tobacco-smoking should be forbidden, especially in cases in which the symptoms are attributable to excess in this respect. Extreme caution is required in recom- mending alcoholic drinks ; if allowed, they should never be taken except with food. A glass or two of sound sherry, claret, or Burgundy will be serviceable in most cases, and particularly when the digestion is feeble and the appetite poor. A little brandy or whisky, well diluted, may also be given at bedtime; it often aids in procuring sleep. With regard to drugs, tonics, of course, are generally indicated ; nux vomica has been already alluded to ; quinine and coca wine or pastils are likely to be useful, and various preparations of iron are indicated in anaemic cases. Cod-liver oil is one of the best roborants that we possess j if tolerated by the stomach it will almost cer- tainly do good in these cases. The hypophosphites (in various combinations) are medicines of great efficacy in some cases of nerve-prostration. When oxaluria is pre- sent the nitromuriatic acid is the best remedy ; it should 46 TBEATIIENT OF NEURASTHENIA. be combined with nux vomica and the tinctures of hen- bane and hops. Mild laxatives and regulation of the diet -should suffice for the relief of constipation if present. Strong purgatives are quite out of place, and the patient should be warned against the use of those aperients which are so freely advertised. The skin should be carefully at- tended to ; few of these patients can bear a cold bath^ but a tepid bath, or sponging with tepid water^ should never be neglected. If the patient can be sent to the seaside, a warm salt-water bath taken daily will constitute an excellent tonic. As in many other nervous ailments, electricity has been often used in the treatment of neurasthenia, and in not a few cases with very good results. For this purpose the galvanic current of moderate strength may be applied to the spine for about ten minutes daily. General faradization is another method; the patient, stripped of his clothes, places both feet on a large flat electrode, while the other conductor, covered with a sponge, is applied to various parts of the body. It has also been recommended that the physician should take the second electrode in one hand and apply the other to the patient's body. The faradic brush may likewise be applied along the spine and to the extremities ; it will TREATMENT OF NEURASTHENIA. 47 be found especially serviceable when there are symptoms •of spinal irritation. The electric bath presents another method of using electricity. In a somewhat large class of neurasthenic subjects a mode of treatment introduced and perfected by Dr. Weir Mitchell is followed by the happiest results. The main elements of this method, as described by its author^ are entire rest and excessive feeding, rendered possible by passive exercise obtained through the steady use of massage and electricity. This treatment is especially suitable for anaemic women with little or no appetite, always tired, spending their days in bed or on a sofa, and with no power of volition or action. Various hysterical manifestations and more or less spinal tender- ness are often present in these cases. Such a condition sometimes follows a season of trial or prolonged anxiety, or it may be due to some severe illness, from which the patient has never entirely recovered. In another class of cases there has been some local uterine disorder, the symptoms of which remain, though the affection itself has been cured. In all such patients it frequently hap- pens that stimulants, opiates, and the bromides have been tried, but only with the result of aggravating all the symptoms. 48 TRBA THE NT OF NE URA STHENIA . . Dr. Mitchell describes another class of cases for whom the treatment is equally suitable. In these the principal symptoms are loss of flesh and colour, various aches and pains, but no organic disease, and no indica- tions of hysteria. All that clearly appears is that the patient is considerably below the normal standard of health. Such cases, as well as the more severe ones just mentioned, are hard to cure. Tonics of all kinds are of little, if any, value. The treatment must be directed towards increasing the weight of the body (and notably the quantity of fat), and the number of red blood-corpuscles. If these objects can be effected the disorders of the stomach, bowels, and uterus will rapidly subside. Dr. Mitchell sums up his directions thus : — ^^ Alter the moral atmosphere, add to the weight, and fill the vessels with red blood."" The principal details of this treatment are as fol- lows : — 1. The patient must be isolated from her friends^ and placed in the charge of a trustworthy nurse. This seclusion is absolutely necessary for emotional women fond of dwelling upon their ailments, exaggerating everything that they really suffer in order to gain sym- pathy and indulgence, and to whom a state of ill-health TREATMENT OF NEURASTSENIA. 49 has become perfectly natLiral. Isolation is less necessary for feeble anaemic women whose loss of vitality is due to obvious causeSj such as over-work or prolonged anxiety. 2. The patient must be kept at rest, which to be effective should be absolute_, and continued for six weeks or two months. Occupation should be provided for the mind, and for this purpose the patient should be read aloud to for several hours daily^ but all sources of excitement should be carefully guarded against. Dr. Mitchell points out that nervous and anaemic women take kindly to the absolute rest. The day is filled up with the massage, the use of the galvanic battery, the administration of food, and the doctor's visits, and by the fifth or sixth day a feeling of ease is generally experienced. The patient must not leave her bed for any purpose whatever; all excreta should be passed while she is lying down. There are many moral benefits attached to this enforced rest and isolation. The patient is not allowed to discuss her symptoms, save with her medical attendant, and she cannot fail to profit by the substitution of quiet and order and simple diet, with absence of drugs, for irregular hours, frequent use of remedies, and the too often mischievous sym- 4 50 TREATMENT OF FEUMASTHENIA. pathy of her immediate friends. Such absolute rest would, however, be attended by various untoward con- sequences and difficulties, and steps have to be taken to counteract these. The muscles require to be exercised, for if not the circulation will become feeble, the appetite will fall oiF, and the digestion will suffer. 3. To avert the consequences just mentioned the muscles should be thoroughly shampooed in order to produce tissue waste. Before commencing this process the patient should be placed en milk diet for a few days j the rubber should then be instructed to shampoo the muscles of the limbs^ thorax, and abdomen twice daily, at first for half-an-hour, and by degrees for an hour or an hour-and-a-half each time. After these rubbings the patient at first feels somewhat exhausted, but when they have been practised for a few days a pleasant feeling of lassitude is all that is experienced. Either galvanism or faradism is had recourse to in order to improve the nutrition of the muscles, and to stimulate the cutaneous circulation. Either current may be used for about twenty minutes twice or three times a day. The rubbings. and the galvanism produce a considerable amount of waste of the muscles thus exercised, and this has to be compensated by excessive feeding. TREATMENT OF NEURASTHENIA. 4. As a matter of course in prescribing the diet the condition and previous history of the patient have to be borne in mind. Following Dr. Weir Mitchell, we begin with milk, which is especially suitable wherever anaemia and obesity are combined. As much as two quarts may be given daily to begin with, and this diet generally relieves all the symptoms of indigestion. In from four to seven days some light solid food may be given with breakfast, and then a mutton chop as midday dinner, and bread and butter thrice a day. About the tenth day, supposing that the rubbing and galvanism have been properly applied, three full meals should be taken daily with three or four pints of milk. One or two ounces of malt extract «should be o;iven before each meal. At the close of the first week it is well to supplement the diet still further by giving one pound of beef daily in the form of raw soup. Stimulants are not desirable, and should, as a general rule, be avoided. If^ however, they have hitherto been taken in strict modera- tion a small quantity may be allowed without dis- advantage. This enormous amount of food, associated as it is with the exercise involved in the rubbings, seldom causes any gastric or intestinal troubles. The usual results are increase of appetite, assimilation of 52 TREATMEls^T OF NEURASTHENIA. increased quantity of nourishment^ and a rapid growth of flesh. If symptoms of indigestion should occur, the substitution of milk diet for a day or two will generally be sufficient to relieve them. When the treatment has been continued for a suffi- cient length of time the patient should not be allowed to get up and stand on her feet too suddenly. She should first sit up in bed for a few minutes at a time, then take food in a sitting posture^ and then, after a day or two, be allowed to sit in a chair. If these pre- cautions be neglected and the patient attempt to walk about or even to stand without previous preparation, she is almost certain to be troubled by attacks of giddiness and palpitation of the heart.. At the end of ten or twelve weeks she should still spend three or four hours in bed daily, and for some time afterwards should make a rule of lying down and resting after exercise, which should be taken with the utmost care. It is seldom necessary to administer -any medicines; but in highly anaemic cases the solution of dialysed iron may be given with advantage. Should the bowels be- come constipated, recourse should be had to mild laxa- tives. When the patient sits up. Dr. Mitchell recom- mends that she should take one-thirtieth of a grain of TSIJATMEJVT OF NEURASTEENIA. 53 Strychnine thrice daily. As a matter of course, the room in which the treatment is carried out should be large and well ventilated. In properly selected cases the course of treatment as above described yields the happiest results. The symp- toms rapidly disappear, flesh and strength are gained, and within a few weeks or months the patient is restored to complete health. Several of such cases have lately been under my care. As examples, I may cite three cases of hysteria with malnutrition in women, two over thirty years of age, and bedridden for many months previous to my being called in. Case A, age 32, un- married, bedridden for fifteen months, and weighing seven stone four pounds. After seven weeks' treat- ment she had increased 22 pounds in weight, and was thenceforward able to walk and resume her ordinary habits of life. Case B, age 34, married J 5 years ago^ and had one child, age 14. The death of the latter, after a short acute illness, was soon followed by the development of hysterical and neurasthenic symptoms in the mother. She became emaciated and bedridden, her weight falling from 11 stone 12 pounds to eight stone two pounds. She practically recovered her health after eight weeks' treatment, and was able to 54 TRJEATMUNT OF NHUEASTEENIA. walk and resume her ordinary habits of life, though sub- ject to occasional fits of despondency. She gained 21 pounds in weight during the treatment. Case C was that of a young lady, age 19, who had been overworked at school. When I first saw her she had been bed- ridden for three months^ and had become reduced from nine stone ten pounds to seven stone nine pounds. She was full of fancies, and at times her mind wan- dered. Her weight rose to ten stone, and she made a perfect recovery after six weeks^ treatment. One or two points have to be carefully borne in mind in connection with the Weir Mitchell treatment of neurasthenia. The attention of the profession has lately been called to them by Dr. Playfair. In the first place the method is unsuitable for cases in which organic lesions exist : its employment for such would be harm- ful^ and would raise hopes which would assuredly be disappointed. An accurate diagnosis is therefore an essential preliminary, and no pains should be spared to determine the nature of the case. It is, however, quite true, as pointed out by Dr. Playfair, that obscure cases from time to time occur, the real nature of which can be determined only' by the effects of treatment. In another class of cases, viz., in those in which there are TIiJEAT3IJSNT OF NEURASTHENIA. 55 marked evidences of mental disorder, the method is in- appHcable as a general rule. In hysterical cases there may be much difficulty in deciding as to the nature of symptoms of mental perversion, and a cautious trial of the method may sometimes be advisable. The last point to be attended to is that the method, to be effec- tive, must be carried out in its entirety. If, for instance, the patient be allowed to get up from time to time, to receive friends, to read, do needlework, or otherwise employ herself, a satisfactory result cannot be antici- pated. CHAPTER II. NEURASTHENIA SPINALIS— SPINAL IRRITATION. Neurasthenia Spinalis, a Functional Disorder — Its Presumed Nature — Spinal Irritation — Causes of Spinal Neuras- thenia — Symptoms — Causes of Spinal Irritation — Symptoms — Principal Differences between Spinal Neurasthenia and Irritation — Diagnosis and Course of the two Conditions — Their Treatment — Dr. Brown-Sequard's Method of Treating Spinal Irritation. It was stated in the preceding chapter that symptoms of cerebral neurasthenia are often associated with various indications of spinal disorder^ which were briefly described. In a somewhat numerous class of caseSj however, the cerebral symptoms are either almost or entirely wanting, while those referable to the spinal cord are especially prominent, and constitute the whole of the complaint. The symptoms referred to may legitimately be attributed to functional disorder, inas- much as the objective indications of organic lesions in the cord are not discoverable; and the development, course, and frequent curability of the symptoms further tend to support the belief that no decided anatomical changes exist in any part of the nervous system. SPINAL NEURASTHENIA AND IRRITATION. 57 As to the condition of the cord in these cases, we can •only hazard a guess that there is either some derange- ment in the nervous mechanism, some change in its molecular state and action, or some disorder of the •circulation due to abnormal vaso-motor action, and interfering with nutrition. A persistent condition of anaemia is scarcely probable. Some authorities have supposed that the symptoms of spinal neurasthenia might possibly be due to functional disorder of the -cerebellum. Whatever may be the actual condition of the implicated parts,, the symptoms require careful study, inasmuch as they are liable to be attributed to the presence of grave lesions. The symptoms in these cases of functional disorder of the spine may be classified under two heads: (i) Those in which debility is the prominent feature, and (2) those in which the sensory nerves of the spine are in a state of morbid excitability indicated by severe pain and tenderness. To the former group the term sp'mal neurasthenia may be conveniently applied, while the latter constitutes the disorder known as spinal irrita- tion. It is impossible, however, to draw a very strict line of demarcation between the two classes, as cases often occur in which weakness and pain- are combined s8 SPINAL njeurasthi:nia. in varying proportions. In the description which follows an attempt will be made to point out the similarities and the differences that exist between the two conditions; they will first be described separately and then compared. . SPINAXi NBURASTHIESNZA is more common in males than in females^ and the patients are generally- young adults or in early middle-age. Hereditary predis- position to nervous disorders is sometimes traceable* The exciting causes are over-fatigue of all kinds, sexual excesses^ undue indulgence in alcohol and tobacco^ late hours_, and insufficient rest. Sexual excesses are the most potent as well as the most common of these causeSj and their effect is, of course, heightened by the simultaneous operation of ajiy of the remainder. In some cases the onset of the symptoms is traceable to previous severe illness, and it not unfrequently happens that slight injuries to the spine are followed by symp- toms closely resembling those about to be described. The symptoms of spinal neurasthenia are for the most part gradual in their mode of invasion, and, for some time after their commencement, indefinite in -character. The first is usually a feeling of undue weari-^ ness after moderate or even slight exertion, such as a SPINAL NEURASTSBNIA. 59 short walk. The patient finds that his legs especially- soon get tired_, and by degrees he becomes conscious of the fact that exercise is no longer a source of enjoyment. If, as is sometimes the case, he tries to get rid of this feeling by ^' walking it off/' he is soon made aware of his mistake. A disagreeable sensation of pain and stiffness in the muscles and joints is added to the debility, and these symptoms are out of all proportion to the exercise taken. The pain is apt to become localized in the back and loins^ it is of a dull, heavy character^, and is sometimes associated with a sensation of heat in those parts. There is seldom any decided tenderness along the spine. The extremities, and es- pecially the feet, are generally cold and numb, and even when the patient is at rest pains like those of neuralgia are often felt in those parts. Loss of sleep is another symptom common in these patients, and when present it greatly aggravates the feelings of debility, and the patient's appearance rapidly becomes altered for the worse. When, on the other hand, a fair amount of sleep is obtained, no such alteration may be observed. Gastric and intestinal disorders are often superadded, though they seldom become very prominent. The appetite may remain good, and indeed may become 6o SPINAL IRRITATION. almost voracious, but the digestion goes on slowly and is often attended with more or less pain. Constipa- tion is generally present. Palpitation of the heart, giddiness, and a feeling of weight in the head are less commonly noticed. After the symptoms have existed for some time the patient is liable to fall into a desponding, hypochondriacal condition. In the male subject, involuntary seminal emissions and loss of sexual power are often complained of. SPINAIi IRRITATION is far more common in females than in males, and the majority of the patients are between fifteen and thirty years of age. Hereditary tendency to neurotic disorder can often be ascertained. The exciting causes are anaemia, however produced; Jactation unduly prolonged ; insufficient and improper food ; over-fatigue (especially in persons unused to much exertion) ; insufficient rest; excessive sexual intercourse; slight injuries to the spine; carrying heavy weights, etc. Marked symptoms of spinal irritation are sometimes noticed in women who for weeks or months have been engaged in nursing, and have paid little or no attention to their own comfort and requirements. Besides the above-mentioned causes, mor-bid states of the mucous membranes may, as pointed out by Dr. Quain, give rise to spinal pain and SFIXAL IREITATIOK. 6i tenderness. Thus pain in the cervical spine sometimes attends congestion of the pharynx ; pain and tender- ness in the dorsal region are common in cases of gastric disorder, while the lumbar and sacral regions are apt to be affected in diseased states of the intestinal mucous membrane and of the urinary and genital organs. Hysterical patients often complain of tender- ness and pain along the spine, and are especially prone to aggravate any abnormal sensation of this kind, how- ever slight, by keeping the attention fixed upon it, and investing it with the gravest importance. It is well known that subjective sensations may be actually called into existence by fixing the attention on parts of the body, and bv the belief in the existence of objective causes for such sensations. The symptoms of spinal irritation are of a multiform character. It would appear, indeed, as if almost any derangement of function in parts of the body supplied w'ith nerves from the spinal cord might originate from spinal irritation. The tenderness on pressure is, how- ever, the only essential symptom; those w^hich are superadded vary in character and severity in almost every case. The tenderness is elicited by making careful pressure over the spinous processes ; its most 62 SPINAL IRRITATION. common seat is the middle and lower part of the dorsal region, but it may be discovered in almost any part of the spine. It may be confined to one or two or several vertebrae, or diffused over the entire column. The tenderness is sometimes slight, but more often ex- quisitely keen_, so that the least touch causes un- easiness, and firm pressure sets up excruciating pain. In some patients, nausea and faintness accompany the pain thus caused. A far less common symptom is spontaneous pain in the spine; when present it may correspond with the tender spot, or may be felt else- where. The skin for some distance around the tender part is often morbidly sensitive; neuralgic pains are common in various parts of the body and in the abdomen. Various other abnormal sensations, such as tingling, itching, feelings of cold, etc., are sometimes complained of; loss of sensation is rarely noticed. Indications of motor disorder are generall} present though they are seldom very marked. They appear in the form of lassitude after exertion and weakness of the muscles of the limbs, sometimes amounting to paresis. In rare cases there are fibrillary twitchings, and even cloaic spasms of various muscles, producing movements like those of chorea. A state of fixed contraction of SPINAL IRRITATION. 63 the muscles of the fore-arm^ remaining even during sleep^ has been noticed in some cases. Coldness of the hands and feet, and flushing of the face, alternating with paleness, are indications of vaso-motor disorder, and are usually prominent symptoms. Other signs of functional disorders often accompany spinal irritation. The most noticeable of these are difficult deglutition, morbid appetite, excessive thirst, copious eructations, vomiting, palpitation of the heart, dyspnoea, a spas- modic cough, spasm or irritability of the bladder, with frequent and copious discharge of pale urine, spasm of the sphincter ani, uterine and ovarian pains, and menstrual irregularities. One or other of these symp- toms may become so severe as to demand special atten- tion ; the varieties which occur in a given case depend upon the localization of the disorder in the spine. Indefinite symptoms of psychical disorder are met with in some cases. Irritability and restlessness, dis- turbed sleep, and decided insomnia are the most common features of this character. The principal differences between spinal neurasthenia and spinal irritation would appear to be as follows : The former is most common in males; the predominant symptoms are those of debility, no marked tenderness 64 SPINAL NEURASTHIINIA AND IBRITATION. in the spine^ no special abnormal sensations except, neuralgic pains ; in the male subject, disorder of the generative organs ; indigestion, and constipation often present. Spinal irritation is most common in females under thirty years of age, tenderness in some portion of the spinal column is the principal symptom ; neuralgic pains and abnormal sensations are frequent ; general weakness, symptoms of disordered action of the thoracic and abdominal organs are more or less commonly present. The diagnosis of spinal neurasthenia is to be inade chiefly per v'lam exclusionis. There are no evidences of anv organic lesion of the spine, and the condition of the limbs is one of weakness only, not of paralysis. The electrical reactions of the nerves and muscles are normal, and there is no tenderness on pressure over any of the nerve-trunks. Exaggerated tendon-reflexes are noticed in some cases, but this symptom is not per- sistent. The diagnosis of spinal irritation is less easily madcy inasmuch as the account given by the patient is apt to be misleading. This complaint is frequently met with in hysterical subjects, and in such cases it is by no means easy to discover the amount of pain that is TBEATMENT OF SPINAL NEURASTHENIA. 65 really felt. A little observation will, however, show that evidences of organic disease are entirely absent. Pain and tenderness in some portion of the spine are common symptoms of meningeal inflammation, but in this latter affection there is always more or less fever and such other indications of serious mischief, as reten- tion of urine and faeces and paresis or decided paralysis of the limbs. In reference to diagnosis, it must be admitted that cases presenting the symptoms of spinal irritation are not unfrequently placed in the category of hysteria. In like manner spinal neurasthenia, with symptoms of dyspepsia, is often regarded as a form of indigestion; and when the patient is decidedly hypochon- driacal, the nomenclature of the affection depends upon the view taken by the physician. The course of the two affections under consideration is almost invariably chronic; improvements alternate with relapses, and even under the most favourable cir- cumstances and judicious treatment the symptoms may last for months or even years. The prognosis, however, is almost always favourable, provided that the necessary remedies be adopted. The treatment of spinal neurasthenia consists first in the careful avoidance of all causes likely to produce 5 66 TEBATMENT OF SPINAL NBUMASTHENIA. debility, and secondly in the adoption of measures calcu- lated to improve the general health. Rest of body and mind is absolutely essential, and excesses of all kinds must be scrupulously interdicted. As in many other affections of the nervous system, a proper amount of sleep is of the highest importance ; in the absence of this desideratum, little or no progress will be made. Sleeplessness and the various methods of dealing with it will be discussed in a succeeding chapter ; it is suffi- cient here to say that in. these cases of neurasthenia narcotics must be used with the greatest caution. They are often indispensable, but patients are only too apt to continue their use until a so-called " habit '^ results, and the end is worse than the beginning. For procuring sleep the physician has to choose between morphine, chloral_, and the bromides, and a combination of the three drugs in small doses sometimes acts better than any one of them given singly. On the whole the bromides are the safest, but their use most not be prolonged. If they fail, a little chloral should be added, and the morphine held in reserve, to be tried if necessary. The diet should be generous and easily digestible ; stimu- lants in moderation should be allowed according to cir- cumstances. Burton ale is one of the best, and among TSjEATMENT of spinal inniTATION. 67 wines sound Burgundy is perhaps the most suitable. Fresh air^ either in a good country district or at the sea- side, will greatly assist all other remedies ; and when the patient has gained a little strength mountain-air is likely to be of service. The skin should be properly attended to; tepid baths and even cold sponge-baths are to be advised according to circumstances. With regard to drugs^ tonics of various kinds are always indicated. Iron, quinine_, and strychnine are the most potent remedies of this character, and may be given separately or in combination. The treatment of spinal irritation resembles in general details that of neurasthenia, but certain local measures require to be superadded. It is necessary to relieve the pain and tenderness, and for this purpose the subcu- taneous injection of morphine or atropine is most efficacious. It should, however, be reserved for severe cases; the anodyne liniments (opium, belladonna, aconite, and chloroform), variously combined, will suffice to relieve lesser degrees of pain, and should be first tried in all cases. Should the local use of the anodynes prove unsuccessful, counter-irritants may next be thought of. When the pain is confined to two or three vertebrae, a small blister (about the size of half- 68 TREATMENT OF SPINAL IRRITATION. a-crown) may be applied over the transverse processes on each side. It is sometimes necessary to apply several blisters in succession over new portions of skin ; but it is undesirable to produce more than slight vesica- tion. The application of croton-oil or tartar emetic ointment is not to be recommended. Sometimes a rubefacient liniment will answer as well as blistering, and Liniment. Sinapis Comp. may be used for the former purpose. Ice applied in one of Dr. Chapman's bags for a few minutes daily will sometimes prove suc- cessful after other means have failed. When the tenderness and pain are not localized^ but more or less diffused over the whole spine, the application of the actual cautery in the manner recommended by Dr. Brown-Sequard is often followed by the best results. It would, however, be difficult to use the cautery to a highly nervous patient, though the amount of pain it causes is really quite insignificant. Unless marked hyperaesthesia exists, a little burning or tingling sensation, lasting for a few minutes, is all that is generally complained of. The Paquelin cautery is a very convenient instrument for the purpose, and Dr. Brown- Sequard's rules for its application should be closely observed. They are as follows : A small instrument should be selected and TRIEATMENT OF SPINAL IRRITATION. 69 raised to a white heat ; it should be drawn firmly, but very quickly, over the skin for two or three inches on each side of the spine, making several linear cauteriza- tions parallel to each other. It is well to begin in the cervical region, and to repeat the operation daily or every other day until the whole length of the spine has thus been treated. Some eight or ten applications will thus be re- quired. If the cautery be properly used, the result will be that the superficial layers of' the epidermis become dry and yellowish; vesication should never be produced. This plan of treatment is adapted for severe cases, and if carried out as above directed will yield excellent results. In cases in which the spinal symptoms form part of the phenomena of hysteria and there are marked evi- dences of profound nervous exhaustion, the plan of treatment known as Weir Mitchell's, and described in a previous chapter (see p. 47), is well worthy of adoption. Every care should be taken in the diagnosis, for, as already stated, the treatment referred to is not suitable for any form of organic disease. CHAPTER III. SLEEPLESSNESS. Sleeplessness in Nervous Disorders — Conditions requisite for Normal Sleep — Causes of Sleeplessness — Vascular Excite- ment — Phesence of Imperfectly Oxidized Materials in the Blood — Indigestion — Anxiety and Excitement — Cold and Heat — Sleeplessness in Elderly Persons — External Causes OF Sleeplessness — Want of Exercise — Treatment of Sleep- lessness — Importance of Ascertaining Cause — Question of Diet — Treatment of Gouty Subjects — Hypnotics for Cases Due to Anxiety — ^Various Plans for Dealing with Different Cases. Sleeplessness in varying degrees is a common symptom of nervous disorders, and when present decidedly aggra- vates the patient's condition. On the other hand, rest of body and mind is a most important part of the treat- ment of all affections of the nervous system, and par- ticularly of those which exhibit the symptoms of neu- rasthenia. This latter affection has been described in the preceding chapters, and the present would appear to be a fitting place for discussing the causes and treat- ment of sleeplessness. There is another reason why this symptom deserves to be separately described. At the SLEEPLESSNESS. 71 present day physicians have to deal with not a few cases in which wakefuhiess or sleeplessness seems to constitute the whole of the disorder; they are^ at all events, the symptoms for which advice is sought. The amount of sleep necessary for individuals in health varies within certain limits, but for adults 7 to 8 hours may be said to be the average. Some persons require more, while others can do withless^ though it is certain that injury often follows protracted mental activity carried on with perhaps only 4 or 5 hours rest daily. A periodical suspension of the activity of the brain and its ganglia is a necessary condition for their repair. During sleep a diminished supply of blood is received by the brain_, and the movement of the blood in the vessels is less rapid than during the waking hours. Dr. Hughlings Jackson has observed that during sleep the optic disc is whiter in colour, the arteries smaller, the veins somewhat larger, and the neighbour- ing portion of the retina more anaemic. Unless this comparatively anaemic condition of the brain exists, normal sleep is impossible. The causes of sleeplessness are many and various^ but vascular excitement is the result which most of them produce. Thus, in many cases the immoderate use of 72 CA USJES OF SLBEPLFSSNUSS. alcohol, coffee^ tea^ or tobacco is a direct preventive of sleep. Another, and a common cause of sleeplessness, is the accumulation in the blood of imperfectly oxidized materials. This condition is frequent in gouty subjects, and especially in those whose kidneys are affected. The cardiac hypertrophy, so common in these cases, is asso- ciated >A'ith excessive tension in the cerebral arteries. The effect of an attack of indigestion in preventing sleep is well known ; it is produced in a two-fold manner, a distended stomach interferes with the heart's action, and imperfectly assimilated products present in the blood cause cerebral hyperaemia and probably irritate the cerebral cells. Sleep is often prevented by anxiety or excitement. At the present day, when so many, either from choice or necessity, spend their time in passing from one form of excitement to another, when such an enormous amount of work or play has to be got through in a limited number of hours, it is not to be wondered at that sleeplessness is so common a trouble, or that specifics for its relief should be so eagerly sought after and so recklessly employed. In some cases compara- tively slight causes are sufficient to render the individual sleepless, and especially if they operate late in the day. CAUSES OF SLEEPLESSNESS. 7^ I have now a gentleman, aged 47^ under my care^ in whom sleeplessness is invariably caused by the receipt of an important letter or telegram during the evening. If such news be received earlier in the dav there are no ill effects. Sleeplessness is sometimes induced by the discomfort arising from cold. In winter time persons leaving a warm room where^ perhaps for an hour or two pre- viously, they had scarcely been able to keep their eyes open, sometimes find themselves quite unable to sleep on going to bed in a room without a fire. The warmth of the sitting-room relaxed the skin, caused its blood- vessels to become filled, and produced an opposite state of things in the brain. The cold of the bed-room reversed these conditions, and if the difference between the two temperatures be very great, perhaps 20 degrees or more, the waking state may be prolonged for hours. Great heat, again, may prevent sleep ; in this case the supply of blood to the brain is increased, owing to the more frequent action of the heart. Sleeplessness is sometimes a great trouble to elderly persons, in whom the smaller cerebral arteries are in a state of degeneration. The elasticity of the vessels is 74 C^ USES OF SLEEPLESSNESS. much diminished, and they remain in a more or less dilated state. It is almost unnecessary to add that pain of any kind may keep a person awake the whole night through. Persons are often rendered wakeful or sleepless by external causes, such as too much light or noise; both act as direct stimulants, whereas silence and darkness have a calming and soothing influence, and predispose to sleep. In some cases, however, monotonous noises tend decidedly to produce sleep ; the ticking of a clock, and the sound of distant waters are usually favourable in this respect. Much, however, depends upon habit ; many persons would lie awake for hours if a loud ticking clock were introduced into their room, and to most the noise of a water-mill would be unbearable ; whereas persons accustomed to these sounds will find themselves unable to sleep when the noises are no longer present. In some cases of sleeplessness the question arises, whether the sleep has been earned ? Have the muscles or the brain been so exercised that sleep is demanded for their restoration ? A person can hardly expect that refreshing sleep should come at night-fall after passing the day in an easy-chair, listlessly turning over the leaves of a novel ora newspaper. Exercise is necessary. TREATMENT OF SLEEPLESSNESS. 75 and not a few persons who complain of sleeplessness and take various drugs to make themselves drowsy must be well aware that exercise of any real kind is almost unknowai to them. In dealing with a case in which sleeplessness is a prominent symptom,, and in urgent need of relief, every attempt should be made to ascertain the cause. It is too much the fashion to give narcotics as a matter of course; these should never be used unless other means fail." Remembering that vascular excitement is the condition w^hich obtains in most cases of sleepless- ness the physician should trace this to its real cause. If it be due to indigestion^ the treatment is obvious. The state of the stomach and bowels should be care- fully attended tOj and suitable diet and time for meals prescribed. Inquiries should be made as to the patient's occupation, especially as to whether sufficient exercise is taken^ and the manner in which the evenings are spent. If it be discovered that a somewhat heavy meal is taken late in the evening by way of dinner^ and the patient goes to rest with an overloaded stomachy it is obvious that a decided alteration is required*. The evening meal must be a- light one, consisting of very little meat, and taken three hours before bedtime. Any 76 TEJEATMENT OF SLSjEP'LFSSNJSSS. excess as regards alcohol or tobacco must be, of course^ strictly interdicted. In the treatment of sleeplessness occurring in patients of the gouty diathesis the regulation of the diet is again all-important. It is well to supply such patients (and, indeed, many others) with printed diet rules. For some time past I have been in the habit of employing a set of forms on which the hours for meals and the articles that may be taken and those that must be avoided are clearly specified. I am constantly meeting with such cases ; careful attention to diet invariably gives relief. Next to diet, exercise, fresh air, and attention to the functions of the skin and bowels are the principal points to be thought of. A course of saline purgatives, e.g., Carlsbad salts, is often the best remedy for gouty in- somnia. Other purgatives, as colocynth or rhubarb, with a little blue pill, are likewise suitable, and if these remedies fail to relieve the sleeplessness the bromides may be tried, but their use should not be persevered with. Cases in which sleep is prevented by anxiety or excitement are often very difficult to deal with. The cause, perhaps, cannot be removed, and it is necessary to relieve the symptom. Hypnotics of some kind are TREATMENT OF SLEEPLESSNESS. 77 indispensable for such cases^ and the choice generally lies between opium, or some one of its preparations, chloral, and the bromides. Each of these has its drawbacks ; opium checks all the secretions except that of the skin and produces constipation and dys- pepsia. Chloral is apt to weaken the heart_, and when taken regularly for any length of time it sometimes produces great depression, irritability, and even a suicidal tendency. The drawbacks connected with the bromides are of a much less decided character. For sleepless- ness due to mental caused, a combination of chloral, with bromide of potassium or ammonium, often acts satisfactorily. Fifteen grains of each of these drugs should be given at bedtime, and repeated, if necessary, for several nights. After two or three doses have been taken, and have afforded relief, it is well to discontinue the medicines for a night or two, so as to see whether a fair amount of sleep can be obtained without them. If, on the other hand, the sleeplessness continues in spite of the drugs, either the dose should be increased or some pre- paration of opium should be added to the mixture. One of the best is nepenthe in doses of fifteen or twenty minims, and a combination of the three drugs sometimes acts better than any one of them separately. If constipation 78 TRJEATMJENT OF SLEEPLESSNESS. occur^ it should be remedied by aloes. As in all other cases of sleeplessness^ directions must be given on such points as diet, exercise, avoidance of all unnecessary excitement, etc. Such measures as a dark and quiet room, not too hot, but raised, if necessary, to a suitable temperature, a comfortable bed, and other details, to be found in a subsequent paragraph, will always repay attention. The sleeplessness which results from cold or from cold feet is for the most part easily relieved. A fire in the bedroom will bring the temperature to the necessary height, say from ^j'^ to 60°, and there are several ways in which the feet can be kept warm. Sleeping socks, hot water bottles, and wrapping the feet in a piece of flannel are the ordinary means of this description. Sponging the feet with cold water and subsequent friction is another useful remedy. Sleeplessness caused by heat is best dealt with by cold or tepid sponging of the body before going to bed; and cold applications to the forehead, retained while the patient is lying down, will often induce sleep in hot weather. In some hot countries sleep is often induced in native children by allowing a tiny stream of water to fall upon the fore- head 'j under the soothing and cooling influence of the teeatmi:nt of sleeplessness. 79 water children will sleep placidly for hours while their mothers are at work. The sleeplessness of elderly people can generally be relieved by the bromides^ combined with henbane. The precaution as to warmth is very necessary in these cases. Eczema is sometimes a very troublesome complication, especially as the . itching is made worse by a high temperature. Under these circumstances the resources of the physician are liable to be severely taxed ; one remedy after another has to be tried until the right one is met with. • Sponging the body with vinegar and water before going to bed is sometimes efficacious ; zinc ointment^ boric acid ointment^ and white pre- cipitate ointment are all likely to be useful. Sleepless- ness in anaemic persons is best combated by a liberal diet, ironj and stimulants ; for the generality of these cases oatmeal biscuits with some hot wane and water or spirits and water are the best sleeping draughts. * There are a few other points of universal applicability in dealing with sleeplessness. Strong light acts as a mental excitant and checks sleep ; on the other handj darkness, especially when accompanied by silence, has a calming effect, and disposes to sleep. Brushing and combing the hair has a sedative effect^ 'So te]satmi:nt of sljeeplessnuss. and is resorted to by some patients. Some of the popular measures recommended for inducing sleep are more apt to produce the opposite result. Among these may be mentioned the mental repetition of numbers^ or lines of poetry^ attempts at mental calculation^ and the picturing to the imagination of a field of waving corn, or of a number of animals — such as sheep — rush- ing in single file through a gateway. A more efficacious plan is to get out of bed and drink a little cold water, or bathe the face and neck, or remain at the bedside until a sensation of chilliness is experienced. An old- fashioned remedy for sleeplessness was a pillow of hops, on which the patient placed his head. The benefit said to have been obtained from it by George III., for whom it was prescribed by Dr. Willis in 1787, brought it into very general use. ^ CHAPTER IV. HYSTERIA. " Hysteria, Definition of the Term — Historical Notices and Geographical Distribution — Causes — Age and Hereditary Predisposition to Nervous Disorders — The Uterine Theory OF Hysteria — Local Irritation and the State of the General Health — Exciting Causes of the Paroxysms — Morbid States of System, as in Gout — Symptoms of Hysteria, their Great Variety — Signs of Mental Perversion — Altera- tions of the Moral Character — Peculiarities of the Symptoms — The Hysterical Paroxysms — Hystero-Epilepsy, Symptoms and Peculiar Features of the Attacks — Other Forms of Motor Disorder — Paresis — Permanent Contrac- tion AND Rigidity of Muscles and Limbs — Disorders of Sensation, Hyperesthesia, the Clavus Hystericus and Neu- ralgia — An.'esthesia, its Forms — Disorders of the Special Senses — Disorders of the Function of Digestion — of Respi- ration — OF the Circulation — of Secretion — The Urine — Course, Duration, and Results of Hysteria — Prognosis — Diagnosis — Treatment, Prophylactic, Curative, and Sympto- matic — Removal of Young Subjects from Home Influences — Attention to Uterine Complaints and to General Condition — Treatment of Mental Disorders — Hygienic Measures — Medicines — Relief of Prominent Symptoms — Treatment During the Paroxysm — of the Complications — Metallo- Therapeutics — Galvanism and Faradism — The Weir Mitchell System — Hydropathic Treatment. 82 SYSTERIA. Hysteria consists of a group of symptoms, occurring mainly in females,, and indicative of functional dis- turbance of the nervous system in general. It is characterized by evidences of mental perversion, and by disorders, more or less marked in different cases, of all the functions of the body. The term ^''hysteria'' implies the idea of a close connection between the symptoms thus designated and the uterus ; but how- ever close this relationship may be in some cases, there are many others in which it cannot be shown to exist. Moreover, the fact that symptoms of hysteria are some- times witnessed in male subjects proves that the oc- currence of the disorder is not necessarily dependent on the state of the organ from which the term is derived. According to Dr. Hirsch,* hysteria is remarkable among the neuroses for its frequency and generality of diffusion at all times and in all parts of the world. It is described in the very oldest Brahminical writings and by the Greek and Arabian physicians, some of whom regarded it as the effect of spasmodic contrac- tions of the uterus or of displacement of that organ, * " Handbook of Geographical and Historical Pathology," New Syd. Sec. Transl., Vol. III., p. 516. GEOGRAFRICAL DISTRIBUTION OF HYSTERIA. 83 this latter condition being supposed to account for the sensation long known as the ^^ globus hystericus." Others thought it was due to retention of the menstrual blood or of the semen. These and similar views pre- vailed until the beginning of the iSth century, when the idea was first propounded that hysteria, like epilepsy, was an affection of the brain. Sydenham considered hysteria to be the most frequent of all chronic diseases, and stated that, though most common in women, it was sometimes seen in men ; hence uterine disorders could not be its real cause, but its origin must be sought in an affection of the nervous system. Later on another English writer. Dr. Whytt, asserted that hysteria was often dependent on uterine disorder, but might occur in its absence, and that it w^as really due to "a too great delicacy and sensibility of the nervous system." With regard to its geographical distribution, hysteria would appear to be a common disorder in many parts of the world. It is found in the Arctic latitudes of the Eastern Hemisphere ; it is said to be common in Central Europe, and especially frequent in the southern parts of that continent. In Turkey it is reported to be '^ the heritage of women and the scourge of men.^' So far 84 CAUSES OF HYSTERIA. as is known, Asiatic women are much less liable to the complaint ; it is very rare indeed among the Hindoos. On the other hand, in parts of Africa, e.g., the Cape,. Mauritius, and Madagascar, Egypt and Tunis, hysteria is said to be unusually common. In the Western Hemi- sphere it is, as might be expected, '^ very prevalent among women of the upper classes in the United States, par- ticularly in the South /^ It is also common in Mexico^ and Brazil and among the Creole women of the West Indies. Causes. It has been already stated that hysteria is almost entirely confined to the female sex. Males very rarely present symptoms that can justly be described as hysterical, though some French authors assert that one case of hysteria occurs among males to every twenty among females ! The first symptoms of hysteria are- wont to appear at the time of puberty ; but in not a few cases they show themselves even at an earlier period, though not in a very marked form. In the large majority of hysterical subjects the symptoms are developed before the 2^oth year ; in a smaller propor- tion they come on between 0,0 and 30. After the latter age, and until the menopause, the proclivity becomes gradually lessened. Symptoms are occasionally CAUSES OF HYSTSRIA. 85 developed in women during "the change of Hfe;^' but this once passed immunity is the ahnost universal rule. Hereditary predisposition to nervous disorders plays a ■conspicuous part in the causation of hysteria^ and the predisposition thus derived is too often fostered by constant association with the affected parent and by defective education and training. A mother subject to hysteria is a bad example to daughters, and is generally incapable of adopting any measures calculated to lessen the inherited tendency. Other circumstances often tend to confirm the predisposition. Sedentary habits^ idle- ness, indulgence in sleep, vicious practices, and that pre- ■ mature development of the emotional side of a girPs nature which often follows excessive devotion to sensa- tional literature are potent factors of this character. The uterine theory of hysteria has been already referred to. There is no doubt that local disorders of the genital organs often take a considerable share in the causation of hysteria. Malpositions of the uterus, erosions or ulceration of the os or cervix, and other chronic sources of irritation are capable of producing and perpetuating hysterical symptoms, especially in the subjects of hereditary predisposition. The connection is demonstrated by the fact that the symptoms often 86 CAUSES OF HYSTERIA. subside after the local disorder has been cured. The relationship is still further evidenced by the frequency with which hysterical attacks are wont to occur during pregnancy and at the catamenial periods. The con- dition of the ovaries is also connected with the disorder. In many cases pressure over these organs causes severe pain or even an acute attack. In hysterical males it is alleged that symptoms may be induced by compressing the testicles. Unsatisfied sexual desire has been thought to be a cause of hysteria. Be this as it may^ it is certain that hysterical symptoms are common and severe arhong the victims of sexual excesses. In the case of women living in a state of celibacy there is often much in their surroundings tending to produce emotional disorder ; the want of congenial occupation^ a feeling of loneliness and neglect, disappointment^ vexations^ and anxiety as to the future^ these and many other circum- stances tend to produce an unhealthy state of mind which is a primary condition for the development of hysteria. Irritation of other parts besides the sexual organs may induce symptoms of hysteria. Thus they are sometimes noticed to occur after injuries, and to show themselves most prominently in the affected part. CAUSES OF HYSTERIA. 87 Hemianaesthesia has been known to set in after a fall in which one side was slightly injured ; a bruised finger has been followed by paralysis of the upper extremity. Neuroses of joints, a common symptom in hysterical subjects,, are often attributable to previous injury. The development of hysteria is more or less favoured by all circumstances tending to impair the general health. Thus the debility of convalescence from ex- hausting diseases, such as fevers, pneumonia, etc., and the anaemic state in general predispose to attacks. Hysterical symptoms are sometimes witnessed in children, the subjects of latent tuberculosis. Of the exciting causes of the paroxysms anything capable of strongly impressing the nervous system is by far the most active. The first attack is liable to be induced by mental shocks of various kinds, e.g., terror, anger, grief, or even surprise, and when the hysterical condition has been established, slight causes of this kind will suflfice to provoke a paroxysm. The imitative impulse is another powerful exciting cause ; the sight of one woman in hysterical convulsions has often induced similar paroxysms in others who had previously shown no signs of the disorder. Epidemics of hysteria form one of the most curious chapters in geographical and SYMPTOMS OF HYSTJERIA. historical pathology. With regard to various morbid states of the system_, as causes of the affection, there is much reason for believing that hysterical symptoms in middle-aged women are sometimes referable to the presence of the gouty diathesis, and are to be classed among the irregular gouty manifestations. It is easily conceivable that the accumulation of sodium-urate in the blood, acting as an irritant to the nervous system, should give rise to attacks in those in any way pre- disposed to them. Symptoms. It is well nigh impossible to give a suc- cinct and connected account of the protean manifesta- tions of hysteria. The most striking symptoms occur simultaneously or in quick succession, constituting the hysterical paroxysm ; but there are various other phe- nomena incident to the complaint, many of them closely simulating real and serious affections. In typical cases signs of mental perversion are usually the first to appear, and these are followed by paroxysms and other motor, sensory, and sympathetic disturbances of the most varied kind, and grouped together in every con- ceivable manner. The greatest possible differences exist in the symptoms presented by hysterical patients; in some they are so slight as to be scarcely recognizable,' SYMPTOMS OF-EYSTERIA. 89 m others the convulsive paroxysms are of the most violent character^ and various other phenomena are scarcely less marked. Moreover^ the same patient may exhibit very different symptoms at different times. In order to give as clear an account as possible, I propose to consider first the signs of mental perversion so common in hysteria ; secondly^ the paroxysmal attacks and other motor disorders ; and thirdly,, the symptoms indicating disturbances of sensation^ digestion, respira- tion, circulation, and secretion. I. The signs of mental perversion vary in kind and degree, but the majority of them point to a disordered state of the emotions. In the most common form of the complaint there is at the commencement an exaggeration of ordinary emotional excitement ; for example, laughter and crying are induced by very slight causes, are repressed with difficulty and recur on the slightest provocation. Lowness of spirits is another common symptom. Without any assignable reason, or for one which is totally inadequate, the patient will remain for hours or even for days in a depressed, listless state, which perhaps suddenly passes off, to be succeeded by the normal condition, or by symptoms the reverse of those so recently exhibited. Any peculiarities 90 SYMPTOMS OF HYSTJEEIA. of temper §.re apt to become emphasized ; impatience, capriciousnesSj and irritability make themselves un- pleasantly manifest. The slightest cause may be sufficient to excite a paroxysm of anger, which cannot be allayed, and soon passes into a convulsive attack. Alterations of the moral character are very common, and are among the most painful features of the com- plaint. Some patients become listless and indifferent, caring little or nothing for what is going on around them ; others become inquisitive, fussy, and morbidly anxious for others. More often, however, the patient's attention is concentrated upon herself; she makes the most of any little ailments or discomforts, recapitulates them to her friends, and loses her temper or falls into a paroxysm if anyone ventures to question the accuracy of her statements. Whims of the most varied kind are invented from time to time ; those who point out their absurdity are regarded as enemies. By degrees the patient may get into such a state of obstinacy as to cling with the utmost firmness to any idea that she has formed with regard to her own condition. Attempts to convince her of her error only make her worse ; if she can find a sympathetic listener, there is no limit to her delight. It is obvious that these and similar manifesta- STMPTOJ^S OF HYSTERIA. 91 tions approach, if they do not pass, '^ the borderlands of msanity;" and it is often very difficult to determine whether the latter condition has been reached. In a large number of hysterical subjects a marked tendency to deceive others is one of the most pro- minent features, and stories of the most extraordinary character are invented by the patients for this purpose. The state of the urinary and genital organs is a very common topic for their complaints ; retention or even suppression of urine is often asserted to exist; frag- ments are shown, alleged to have been passed from the bladder, or urine is declared to have been ejected from the stomach. Some hysterical patients take great pains to injure themselves in various ways, and profess the most complete ignorance of the cause of a wound thus made. As to the motives which induce them to per- form these acts of deception, some patients wish to become objects of notoriety, to have their cases talked about by as large a circle as possible; others desire to attract commiseration and sympathy, and others, again, are influenced by motives of pruriency. There are still other modes in which the mental disorder is exhibited. Sometimes the patients are obstinately silent, refuse to answer the simplest ques- 92 TEE HYSTERIC AL' PAROXYSM. tions, and shut themselves up in their rooms so as to be able to indulge their propensity. The silence may be succeeded by a fit of volubility^ in which the strangest and most improbable stories are told. When this volubility is a prominent feature in the complaint, those who are compelled to associate with the patient are in a most unenviable position. The symptoms as above described often display this peculiarity, that they come on at intervals between which the condition of the patient appears to be per- fectly rational and normal. In some cases the patients know when the symptoms are threatening^ and assert that they make a prodigious effort to check their onset. Partial success is sometimes attained in this direction, but the power of self-control generally becomes less and less, while that of the emotions steadily increases until the patient is unable to resist even the slightest impulse. When this stage is reached, the patient can scarcely be regarded as responsible for her actions. II. Though a greater or less degree of mental perver- ;sion is to be found in most hysterical subjects, there is a somewhat numerous class in which such symptoms never attract much attention, as compared with those which constitute the hysterical paroxysm. This is THE HYSTERICAL PAROXYSM. 9.^ characterized by violent convulsions of a tetanic or epileptic character, induced by various kinds of stimuli, and especially by anything which appeals to the emotions. These paroxysms are wont to occur at irregular intervals ; in some patients they are the chief, if not the only, signs of disorder; in others^ they are merely the prominent features of the protean com- plaint. The paroxysm may come on suddenly, without any premonitory symptoms j or it may be preceded by some of the symptoms of mental disorder, already in- dicated, or by various distressing sensations, e.g., pres- sure at the epigastrium or in the chest, or a feeling as if a ball were rising from the abdomen to the throat. Then perhaps a vacant stare, or rolling movements of the eyes, lasting for a few seconds, are followed by a loud scream; the patient falls to the ground, or finds her way to a sofa, throws her limbs about and twists her body in various directions, sometimes tries to tear her hair and strikes herself, though without doing any serious injury. "While these movements are going on the patient often shrieks or cries or laughs, or perhaps raves about some one whose presence or memory has excited the paroxysm. After lasting for a variable 94 TSi: HYSTERICAL PAROXYSM, period (in some cases only a few minutes^ in others half-an-hour or more) the convulsions subside^ a flood of tears, a fit of laughter, or a confused mixture of laughing and crying affords the necessary relief, and the patient is gradually restored to her usual condition. After long-continued and severe convulsions the patient is apt to fall into a lethargic state, as if quite exhausted, or even to go to sleep for some hours. The convulsions present innumerable variations j sometimes only an arm or leg is flexed or extended at irregular intervals ; sometimes every muscle of the body appears to be in action, and the united force of several persons is insufficient to restrain the patient. In some cases the convulsions alternate v^ith, or are replaced by tonic spasms ; one or more limbs are firmly contracted, or the body assumes the form of an arch as in cases of poisoning by strychnine. In severe and exceptional cases (which belong to the category of hystero-epilepsy) the consciousness is entirely- lost during the height of the paroxysm ; but more often the patient is, to some extent at least, aware of what is going on, her appear- ance showing that she is alive to the absurdity of her performances. The paroxysms usually occur at very irregular ETSTER O-EPILEPSY. 95 intervals ; they may recur daily or not until weeks or even months have elapsed. Their frequency depends greatly upon the surroundings of the patient and the condition of her nervous system. In some cases the attacks come on at the monthly periods, and they are usually most severe at these times. It is worthy of note, as showing the resemblance between hysteria and other forms of nervous disorder, that the patient often feels decidedly better after a severe paroxysm, the ex- plosion apparently relieving the overburdened nervous system. The term hystero-epilepsy is applied to designate severe convulsive attacks exactly similar to the paroxysms of epilepsy, but occurring in hysterical subjects, and to be classed among the phenomena of hysteria. The con- dition has been regarded as a combination of the two disorders, sometimes the one, and sometimes the other assuming the greater prominence. The symptoms are, however, best interpreted by adopting Charcot's view, that in these cases hysteria alone, is present, and that it takes on the semblance of epilepsy. A typical attack of hystero-epilepsy is generally pre- ceded for some days by various uncomfortable feelings, such as loss of appetite, nausea or vomiting, headache," 96 SYSTES 0-EFIZJEFS T. etc. Some patients are unusually quiet and taciturn^ others excited and noisy. If hemianaesthesia be present, it becomes more marked and is apt to spread to the other side of the body. Finally the aura is felt^ beginning in the epigastrium or in the iliac regions ; it lasts for some time, and the patient is therefore generally able to seek a place of safety before the convulsions come on. These begin as in true epilepsy ; the patient screams, turns pale, becomes unconscious and falls if standing. The body and limbs become perfectly rigid. In some cases the body is arched upwards like a bridge,, and rests only upon the feet and head. The rigidity, according to Charcot, is seldom followed by the clonic convulsions, not very extensive, but most marked on one side of the body, as in true epilepsy. On the other hand, the limbs and the entire body are violently con- torted j the patient makes the strangest gesticulations and assumes extraordinary postures. Delirium then super- venes, during which the patient has horrible visions, as of animals or thieves attacking her, of fire and the like. She raves furiously, or shouts, or screams as if in imminent danger. The termination of the attack is ushered in by tears and laughter, and after these have subsided the patient is apt to remain for some time in a SYSTERO-EPILEPSY. 97 State of melancholia, with hallucinations, and some- times painful contractures of various joints. During the convulsions the tongue may be bitten, and bloody foam may, therefore, appear at the mouth. The paroxysm lasts on an average about a quarter of an hour; it may recur again and again at short intervals, the attacks in this way extending over several hours or ev^en days. According to Charcot, the paroxysms are distinguish- able from true epilepsy by the fact that they can be modified or sometimes even arrested by compression of the ovary. Moreover, in hystero-epilepsy the tempera- ture never lises above 101*3° F. ; whereas, after a series of true epileptic fits a height of 105*8° F. may be attained, and may continue for some time. There is another and a most important difference between the two affections ; attacks of hystero-epilepsy may follow each other in rapid succession at the rate of a hundred or more in the twenty-four hours, and yet the patient's general state may be but little affected. Oft-recurring paroxysms of true epilepsy with the accompanying high temperature would place the sufferer in a very critical position. It is only in very rare instances that death has occurred as a result of hystero-epilepsy. 7 98 SYSTERICAL PARALYSIS. III. In addition to the convulsive movements, various other forms of motor disturbance are liable to occur in hysterical subjects. Paresis of the extremities is a somewhat frequent phenomenon, and presents many degrees of intensity. In some cases there is only a feeling of weight and immobility, but this suffices to make the patient believe that she has lost the use of her limbs. Such patients may remain in bed or on a sofa for months or years, or until some startling incident, or a physician, who understands the nature of the case, restores the powers of motion. In other cases the motor power is slightly diminished, while- in a third class it is very considerably reduced ; the patient may be able to move the legs while lying in bed, but can neither stand nor walk. Complete paralysis is very rare indeed, except in connection with secondary changes in the cord. In cases of hysterical paralysis the electrical excita- bility of the muscles and nerves remains undiminished ; but the electro-cutaneous and the electro-muscular sensi- bility are generally more or less reduced. Cutaneous anaesthesia is usually associated with paralysis, and is apt to become converted into the opposite condition after the application of the interrupted current. Other HYSTERICAL PARALYSIS. 99 peculiarities are connected with hysterical paralysis; rapid improvement sometimes takes place, to be followed sooner or later by a return to the former condition. Very slight causes, especially those of an emotional character, are sufficient to increase the weakness ; a woman able to walk with comparative ease may be suddenly seized with paralysis which lasts for days or weeks, and then as suddenly passes off. In some cases the paralysis changes its seat ; first the arm, then the leg suffers, or weakness on the right side is followed by paralysis of the left. Hemiplegia and paraplegia are the most common forms; the upper extremities are less often affected. Paralysis of some of the laryngeal muscles is not uncommon; it gives rise to aphonia, which may come on suddenly, last for a time, and then subside. These attacks of paralysis occur in some cases after the hysterical paroxysms, but in others they supervene independently of any marked explosions. In the latter class the most common immediate cause is sudden shock, or a fit of anger, or anything that appeals to the emotional susceptibilities of the patient. Violent muscular exertion has been known to be followed by paralysis, and in other cases this latter symptom has loo SYSTERICAL CONTRACTION. come on after the sudden subsidence of various hysterical manifestations. Hysterical hemiplegia when rapidly developed closely simulates the result of cerebral haemorrhage; but differs from it in the fact that con- sciousness is preserved and neither the tongue nor the face is affected. Rigidity is also a common symptom of the functional disorder. The onset of paralysis is by no means always sudden ; in not a few cases it seems to grow, as it were^ out of ordinary muscular weakness. Nothing definite can be said as to the duration of these paralyses ; they may go on for months,, or years, or even for life ; and recovery may take place suddenly or very gradually. Complete restoration is the rule, but in cases of long standing the wasting of the muscles from disuse may be very great, and de- generation may become developed. Under such cir- cumstances perfect recovery of the use of the limbs cannot be anticipated. Permanent contraction and rigidity of muscles and limbs are not unfrequent in hysterical subjects, and may either supervene upon paralytic conditions or may occur independently of them. The rigidity, in some cases, affects one side of the body ; in others, the legs are fixed in various positions ; while in a third class one HYSTERICAL CONTRACTION. loi or more muscles of the face, neck, or extremities are firmly contracted. The distortions of the foot are apt to simulate the various forms of talipes. These con- tractions are not always spontaneous ; they sometimes follow slight injuries to the part. Hysterical contrac- tions of single joints are often very troublesome to deal with. The knee is most liable to be thus affected, and next in order of frequency come the hip-joint, the wrist_, the foot, and the shoulder. In some cases the contrac- tion takes place suddenly ; it is always attended with severe pain, which according to the patient's description closely resembles that of severe inflammation of a joint. The suffering, however, does not prevent sleep ; it is, moreover, not increased by firm pressure, though a slight touch may be described as causing intense agony. The ordinary signs of inflammation of a joint, e,g.j heat, redness, and swelling, are altogether absent. The joint remains immovably fixed ; the patient asserts that she cannot alter its position, and she resists any attempt to do so on the part of the nurse or physician. When the patient is placed under the influence of an anaesthetic the contraction disappears, but the limb returns to its old position when consciousness is re- gained. These contractions may last for months or I02 BISOEBEES OF SENSATION. even years, and then suddenly subside in a manner apparently spontaneous. Excitement of various kinds has beeii known to cure these patients. In some cases the disappearance is final ; in others the contraction recurs. IV. Disorders of sensation are among the most important phenomena of hysteria, and appear in two principal forms of varying degrees — [a) hyperaesthesia, and {h) anaesthesia. The hypersesthesia may show itself in almost any part of the body, but some portions, e.g. J the hypogastric, iliac, and epigastric regions, are especially liable to be thus affected. Many hysterical patients complain of a dull, aching pain in the hypo- gastrium, and in one or both iliac regions, increased by slight pressure, but sometimes diminished or abolished when pressure is firmly and steadily applied. The seat of this sensation may be either in the abdominal muscles or in the ovaries. Pain referable to the latter organs may constitute the principal complaint of an hysterical subject, and in such cases even the slightest touch may provoke the severest paroxysms. The epigastrium is likewise often the seat of painful sen- sations, localized in the skin, abdominal muscles or stomach ; pressure aggravates the pain and may pro- THE CLAVUS HYSTERICUS. 103 duce hysterical paroxysms. Severe pain in the stomach is generally accompanied by such other symptoms as vomiting, loss of appetite, or aversion for ordinary food, and in some cases the condition becomes so severe as to give rise to suspicion of gastric ulcer. Colic is another abdominal ■ affection frequent in hysterical subjects; the accumulation of gas in the intestines is sometimes enormous. Of the pains and aches which beset hysterical subjects, a form of headache is one of the most common. It is well known under the name of clavus hystericus. The pain is fixed in one spot, generally over the eye; it is described by the patient as though a red-hot nail were being driven into the head, and there is sometimes increased temperature around the painful spot. In other cases the sensation is said to be that of intense cold ; in others, again, the pain is diffused over the head, or takes the form of hemicrania. Equally common as the headache are pain and tenderness in the spinal column; the group of symptoms known as spinal irritation is, indeed, most fully developed in hysterical subjects. Pains in various muscles are of frequent occurrence, the sensation not following the course of the nerves, but diffused among the muscular fibres. Every form of I04 SYSTJEEICAL HTPER^STHJESIA. pain is increased when the patient^s attention is directed to the part. The hyperaesthesia is sometimes quite superficial, involving the skin alone, and either extending over lar^e areas or confined to small patches. In the former case the weight of the clothes may be pronounced un- bearable. The condition termed ancesthesia dolorosa is sometimes noticed in these patients ; the sense of touch is abolished, that of pain considerably heightened. The external organs of generation are apt to be very sensitive, but the skin of the breast is the most common seat of the cutaneous hyperaesthesia. This, in some cases, is so severe and obstinate as to give rise to suspicions of cancer; especially when, as sometimes happens, small hard nodules are discoverable in the gland. Neuralgic pains of all kinds are very frequent in hysterical subjects; the intercostal spaces and the joints being the parts most often affected. The hyperaesthesia not unfrequently affects the organs of special sense; the patient complains that she cannot bear an ordinary amount of light, and that she is distressed by the slightest sound. There is, of course, often much exaggeration in these and similar statements ; the auditory nerves of the patient are never inconvenienced by the noises she herself makes. HYSTERICAL ANESTHESIA. 105 The opposite condition of anaesthesia has attracted ■considerable attention of late years ; it has been found to be one of the most common symptoms of hysteria. It may affect only the skin and mucous membranes, but in most cases the muscles are also involved. Hemianaesthesia is the most common form^ and the left side is more frequently affected than the right. The symptoms closely resemble those due to cerebral haemor- rhage; sight, hearing, taste, and smell are unilaterally "involved. In nearly all these cases the sense of pain is lessened, or even abolished, and less frequently the sense of temperature is similarly disturbed. There is no doubt as to the reality of the loss ; the skin may be pricked, or pinched, or heat mav be applied to it without the patient's knowledge, provided that her eyes are covered. The anaesthesia usually comes on after a paroxysm ; it may last only a few hours, or may continue for weeks or months. The temperature of the anaesthetic portions is always lowered, and the skin is usually whiter than natural. The loss of sensation is sometimes confined to a few small areas, and may then be easily overlooked. The organs of special sense are occasionally implicated in these cases of anaesthesia; thus, various derangements of sight, hearing, smell, and taste are sometimes noticeable. Of the disorders io6 DIS0Et)BR8 OF DIGESTION. of vision, intermittent colour-blindness^ either complete or incomplete^ is the most remarkable. Other patients- assert that articles of food, well known to be sapid, are tasteless or the converse ; others, again, that they are unable to distinguish odours. Subjective gustatory and olfactory sensations are sometimes complained of» Deafness is less common, but tinnitus aurium and other subjective auditory sensations are seldom absent in well-marked cases of hysteria. V. Disorders of the function of digestion are very common in hysterical subjects, and assume various forms. The symptom known as the globus hystericus is probably due to spasmodic contraction of the oeso- phagus and intestines. The patients are wont to state that they feel, as it were, a ball rising from the epigas- trium toward the throat, where it remains, and causes a distressing sensation as if a foreign body were actually there, or as though the throat were compressed by a cord or by fingers. Some patients assert that they are unable to swallow, and this inability may continue until symptoms of inanition become pro- minent. The stomach is liable to show various indica- tions of disorder. Obstinate longing for strange articles of food, loss of appetite, flatulence, pain, and vomiting, DISORBEES OF DIGESTION. 107 sometimes excessive, and continuing for lengthened periods, are among the most prominent of these symptoms. The vomiting, which is due to spasmodic contraction of the muscles of the stomach and oesopha- gus, occurs in severe cases every time food is taken, and the efforts continue even when the stomach is com- pletely emptied. It is often a matter for surprise that these patients, ejecting nearly all the food they take, should yet appear to be well-nourished, or at all events show no marked signs of wasting. The explanation, however, is supplied by the facts that little or no exercise is taken, metabolism goes on very slowly, and the contents of the bowels are retained for considerable periods. This explanation will also serve to account for those cases in which vomiting is absent, but the amount of food actually taken seems insufficient to support life. As a matter of course the statements of the patients with regard to their food can rarely be depended upon; the tendency to deceive is often manifested in this particular. The stories of complete and pro- longed fasting have been proved to be utter fabrications ; the patients may stoutly refuse to take food, but they always manage to find some means of obtaining it. Besides the constipation, other symptoms of abdominal io8 DISORBJEES OF RESPIRATION. disorder are collections of gases in the intestines^ and colicky pains. The distension is sometimes enormous, and such as to resemble pregnancy and various tumours, and the rumbling noises, which the patient is unable to check, greatly add to her discomfort. VI. Disorders of respiration are less frequent than those of digestion, but some of them are occasionally prominent. One of the most troublesome is a dry, hard cough, which is apt to worry the patient all day, but fortunately ceases at night. In not a few cases this cough gives rise to the suspicion of phthisis, in which, however, the nights are usually the worst. Painful feelings in the larynx are not uncommon ; and the voice may be quite suppressed or so modified as to be unrecognizable. Uncontrollable hiccough is some- times a very prominent and disagreeable symptom, especially when the patient voluntarily adds to the ex- plosive noises. Laboured breathing, yawning, sneez- ing, and sighing are other symptoms of this character, and in some cases precede the convulsive paroxysms. VII. Symptoms of disorder of the circulation are always met with in hysterical subjects. More or less violent palpitation is very frequent, is induced by very slight causes, and may last for hours or even days. DISORDERS OF CIRCULATION. lo^ The heart's action is sometimes irregular, sometimes attended with severe neuralgic pain ; in anaemic cases a bellows murmur is frequently audible. Epigastric pulsation is an occasional symptom, and one which greatly alarms the patient. The pulse is subject to many variations ; but is usually more frequent than natural ; the state of the cutaneous circulation changes rapidly from time to time, the skin being sometimes pale, and sometimes turgid with blood. The abnormal excitability of the vaso-motor centres is shown by other symptoms, such as marked coldness of the feet and hands, which are often covered wath a copious per- spiration ; a sensation of heat over the head, particularly along the course of the sagittal suture, and accompanied by real elevation of temperature. In chronic cases of hysteria the face is often the seat of various eruptions. When anaesthesia exists, the affected parts are apt to be cold and anemic. Under an opposite condition, patches of congestion sometimes give rise to haemor- rhage not only from the skin, but also from internal organs. Such haemorrhage, e.g., from the stomach, is to be regarded as vicarious when it occurs at the menstrual periods. Blood is sometimes discharged from the bowels ; but the patient's account of symptoms of this character is always to be received with caution. no DISOSDi:SS OF SECSETION. VIII. Various disorders of secretion are common phenomena in hysterical subjects, and among these, functional derangements of the urinarv oroans are often prominent. The discharge of a large quantity of pale urine generally takes place after a paroxysm, and in some patients after excitement of any kind. On the other hand, the secretion may be dcticient in quantity, or almost if not quite suppressed. This partial sup- pression may last for an indefinite period, during which a liuid more or less resembling urine is discharged from the stomach. In some cases urea has been detected in the vomited matters; but statements of this kind must always be received with caution. xV much more common symptom is retention of urine, due either to spasm of the neck of the bladder or to paralysis of the detrusor urina\ In not a few cases the retention is a purely voluntary act. Irritation of the bladder, shown by constant desire to pass water, is a very troublesome symptom in many hysterical patients. If the habit of frequent micturition be indulged in the bladder soon becomes intolerant of its contents. Other secretions are less frequently disordered ; but in some cases the liver becomes inactive, and the biliary secretion is lessened. Pale stools, constipation, and symptoms of melancholia are the ordinary results. COURSE OF HYSTERIA. m In comparatively rare cases the breasts become swollen and even a little milk is secreted during the attacks. One of the most extraordinary facts connected with hysteria is that, notwithstanding the many and various disorders, the patient^s general health often remains good, and the nutritive functions appear to be properly dis- charged, even when the amount of food taken is very small indeed. Course^ Duration, and Results. Hysteria is in almost all cases a chronic affection, and unattended by any danger to life ; once developed, some of its manifesta- tions may recur at intervals during the life-time of the patient. In rare instances, after a few acute paroxysms, combated by suitable measures, the disorder comes to an end. The differences in its course depend in great degree upon the psychical condition of the patient and the circumstances and influences by which she is sur- rounded. In the early stages much improvement can generally be effected by judicious treatment persever- ingly carried out. In chronic cases, e.g., those in which the symptoms have been manifested during twelve months or more, complete recovery is decidedly uncommon. ^Even in favourable cases the morbid excitability of the nervous system is apt to betray itself 112 FMO GNOSIS OF SYS TIE RI A . under the influence of very slight causes, and recurrence of the symptoms, perhaps at very long intervals, is the ordinary rule. The symptoms, however, generally become milder and less frequent with advancing years. There are certain forms of hysteria which merge gradually into moral insanity, or monomania, and other varieties of mental unsoundness. With regard to other results of the complaint, in rare instances the patients sink into a low anaemic state and die from inanition and exhaustion. Death has also occurred from suffo- cation during the paroxysm, but in such cases some of the phenomena of epilepsy are generally superadded to those of hysteria. Prognosis. Hysteria very rarely involves any danger to life, though it often causes much trouble and anxiety to the patient and her friends. When the symptoms begin early, and do not subside at puberty or after marriage, they are apt to last for life; when they first show themselves during the third decade they are more likely to disappear eventually. When dependent on slight lesions of the genital organs the symptoms usually subside after the cure of the local disorder. Weak anaemic subjects presenting symptoms of hysteria are more amenable to treatment than full DIAGNOSIS OF HYSTERIA. 113 blooded, vigorous women. Hysteria may terminate (1) in complete and permanent recovery ; (2) in recovery fo;' a time, to be followed by a return of some of the symptoms ; (3) the complaint may merge into de- cided insanity or the patient may become phthisical. In the absence of complications_, death is a very rare termination. A few hysterical subjects have been allowed to starve themselves to death^ and others have died from dyspnoea during a paroxysm. Such instances are^ however,. quite exceptional. Diagnosis. Epilepsy is the affection W\Xh which the paroxysms of hysteria are most liable to be confounded, and it is sometimes a little difficult hastily to determine the real nature of the symptoms in a given case. The distinction is, however, of extreme importance in view of the gravity of epilepsy and the often trivial character of hysteria. When the two disorders coexist the symptoms of epilepsy may be very prominent, but the manner in which the attack comes on and subsides is generally sufficient to guide the diagnosis. The principal features which distinguish the hysterical paroxysms from those of epilepsy are as follows : — In the former, unless as the result of shock, the paroxysm is not sudden, but comes on after other symptoms have shown 8 114 DIAGNOSIS OF HYSTERIA. themselves; the premonitory cry or scream is less common ; when the patient fal]s_, a chair or sofa is usually at hand to receive her ; the features are seldom distorted, the tongue is not bitten ; the pupils react to the influence of light; respiration never ceases, and the face, though red, does not become livid ; laughing, sobbing, and perhaps talking go on continuously, or at intervals ; and throughout the paroxysm there are evidences of a concealed will, and in not a few cases an unmistakable degree of consciousness ; the subsidence of the paroxysm is not followed by coma. In epilepsy the attack comes on suddenly; the patient usually utters a loud cry; the features are much distorted, the tongue is often bitten; the pupils are insensible to light ; respiration ceases at intervals, and the face is livid and turgid ; the convul- sions are less extensive, but injuries often result; the patient does not laugh, cry, or talk, but is absolutely unconscious from the beginning, and a comatose state follows the paroxysm. In hysteria the convulsions may be extremely violent, and may go on for hours, but they are more or less under the control of the patient, and can often be arrested, inasmuch as some degree of consciousness is preserved. In epilepsy consciousness is lost, and the patient has no control over the convul- DIAGNOSIS OF HYSTERIA. i rg sive movements, which are generally of short duration. The differences between hystero-epilepsy and true epileptic convulsions have been already mentioned (see page 97). The distinction of hysterical hemianaesthesiafrom loss of sensation due to cerebral lesions is a matter of considerable importance. In the former condition an account of other hysterical symptoms will rarely fail to be elicited on careful inquiry, and the hemianaesthesia is never permanent, though it may last for long periods. Moreover, the symptoms may from time to time dis- appear and then recur. Such changes are, of course, never observed in organic hemianaesthesia. It has been stated that derangements of the special senses accompanying hemianaesthesia are indicative of hys- teria. This, however, is not correct, for in hemianaes- thesia, due to organic causes, similar derangements are occasionally observed. Nerve-prostration or '^neurasthenia^' more or less resembles hysteria in some of its features. The two disorders may coexist; the former, indeed, is a pre- disposing cause of the latter, but either may be present alone. In neurasthenia, convulsions, paroxysmal attacks, the globus hystericus, and other symptoms of local ii6 DIAGNOSIS OF HYSTERIA. spasm are absent; there is never any decided amount of anaesthesia; the patients generally have a weak and depressed look, and their condition neither fluctuates from time to time nor improves in the absence of proper remedial measures. In hysteria^ on the other hand, the paroxysms are generally prominent symptoms; anaes- thesia is common ; the patients frequently appear strong,, healthy, and full of energy ; the condition varies greatly, and often changes in the most unexpected manner, and complete recovery may take place^ with or without treatment. The effects of sub-acute myelitis of the anterior cornua of the spinal cord more or less resemble the symptoms of hysterical paraplegia. The chief points of distinction are as follows : — In hysteria the patellar reflex is retained and sometimes exaggerated; the electro-muscular contractility is either normal or only slightly diminished ; the reaction of degeneration is never observed ; there is no interference with micturition and defaecation; the temperature of the limbs is not much reduced, and bed-sores are not liable to form. In polio-myelitis the patellar reflex is diminished or lost; the reaction of degeneration can always be detected > the functions of the bladder and rectum are interfered TREA TMENT OF HYSTERIA. 1 1 7 with j the temperature of the limbs is reduced and bed- sores are common. Other differences between oro^anic paralyses and those of hysterical origin have been already referred to (see page 98). Treatment. Three classes of remedial measures are required in the treatment of hysteria : first, those which are of a prophylactic character ; secondly, those which are calculated to cure the disease ; and, thirdly, those which are required for the cure or relief of the prominent symptoms. 1. In all cases of hysteria minute inquiry should be made into the family history of the patient. If, as is usually the case, there be an inherited tendency towards nervous affections, the symptoms mav be expected to prove much more obstinate than when such tendency is absent. When hysterical manifestations appear in a young girl whose mother is, or has been, similarly affected, there can be no doubt as to the plan which ought to be pursued. The child should be removed from its home and placed under proper care and treat- ment. Kind, but firm, management ; plain, but nutri- tious, diet; plenty of exercise in the open air; regular hours; tepid or cold baths; attention to all the bodily functions, and mental occupation of an interesting but ii8 tri:atment of hysteria. not irksome character, will afford the best chance of eradicating the seeds of the nervous disorder. Excite- ment, whether in the form of work or play^ should be scrupulously interdicted. These measures act by im- proving the general state of nutrition of the nervous system and lessening its excitability, and they are applicable to all cases of hysteria in young subjects. 2. The measures calculated to cure the disease re- quire to be considered at some length. In the first place, every endeavour should be made to ascertain the cause, and to deal with it as completely as possible. If there be symptoms of uterine disorder a proper examina- tion should be made and the necessary treatment adopted for the cure of any lesion or displacement that may be detected. Great caution is, however, necessary with regard to an examination in all these cases ; it should never be undertaken unless there are the strongest reasons for anticipating that benefit will result. On the other hand, it is bad practice to allow an hysterical patient to suffer continuously from symp- toms of a displaced uterus without suggesting an examination. It is useless to prescribe tonics, anti- spasmodics, and the like, while the local cause of the disorder remains in full operation. TREA TMENT OF SYSTERIA . 119 The general condition of the patient is the next point for consideration. Hysteria is not connected with any one state of the general health j some hysterical patients are weak and anaemic_, others are robust and plethoric. For the former^ rest^ tonic treatment and regimen are of course indicated ; the latter will be benefited by purga- tives, a reduced diet, and plenty of exercise. Saline purgatives,, e.g., sodium or magnesium sulphate, are generally suitable for these patients, and the salts may be conveniently given in the form of the Carlsbad waters. The springs of Marienbad and of Kissingen are also serviceable. The treatment of the mental condition of the patient is of the highest importance, but much difficulty is often encountered in this particular. The physician should endeavour to gain the confidence of his patient; he should assure her that he quite understands her ail- ment, and that her recovery is certain if his directions are properly attended to. Notwithstanding the ex- aggeration which is so prominent a feature of this com- plaint, it must always be borne in mind that much of the suffering is real, and not imaginary. It seldom answers to treat the patient harshly ; to tell her that her ailments are non-existent and that she is shamming I20 TMI:ATMENT OF HYSTERIA. is almost certain to make her worse ; she broods over and exaggerates her troubles^ and probably develops new symptoms. On the other hand^ nothing can be more mischievous for the patient than to treat her as though she were as ill as she believes herself to be; the adop- tion of this course by well-intentioned but misguided friends and relatives may constitute a serious obstacle to the efforts of the physician. Hence it is that in many cases the most effectual plan of cure is to change the circumstances under which the patient is placed, and to bring a fresh set of influences to bear upon her. Such a plan is not always feasible, and in mild cases it can scarcely be regarded as necessary. For these latter, after due inquiry has been made into all the circum- stances which may have contributed towards the develop- ment of the symptoms, the measures described on page 117 should be sedulously adopted. What the patient should do and what she must not do should be very clearly specified. All causes of emotional excitement, and especially the reading of sensational literature, so mischievous to many girls, must be absolutely shunned. Equal care should be taken in the selection of amuse- ments and occupation_, the great object being to divert or repress emotional excitement, to induce the patient TREATMENT OF HYSTERIA. 121 to interest herself in rational and useful tasks, and to strengthen the power of the mind and the control of the will. Having thus attended to the mental features •of the disorder^ the hygienic remedies may be applied with every prospect of success. With regard to drugs_, tonics, anti-spasmodics, seda- tives, and stimulants may be required as adjuvants, or as special remedies in certain cases. Among tonics, quinine, iron, the salts of zinc and of copper may be given with the view of lessening the irritability of the nervous system. Among anti-spasmodics must be mentioned the old remedies, asafoetida and valerian, aromatic spirit of ammonia and camphor. These are sometimes useful in the treatment of the milder symp- toms. Something has to be given, if only to relieve the anxiety of the patient and her friends ; and medicines which appeal strongly to the nerves of taste and smell serve to occupy her attention and to divert it from herself. Sedatives, anodynes, and narcotics are often necessary in dealing with hysteria; but their use requires great caution. The bromides are the best remedies of the sedative class; they are especially indicated for cases in which the symptoms of motor disorder are very prominent. Anodynes are often required for the relief 122 TEJEATMENT OF HYSTERIA. of pain, and narcotics to produce sleep ; for the former purpose opium and its various preparations^ henbane, and cannabis indicaare the best remedies ; for the latter the bromides, chloral, butyl chloral, and opium are at the disposal of the physician. As a general rule opium should be avoided in hysterical cases. It must always be borne in mind that the symptoms for which it is adapted are liable to frequent recurrences which would necessitate increased doses. Moreover, in many hys- terical subjects opium is apt to produce an effect quite opposite to that which is desired ; instead of calming^ the patient it often causes great excitement. It may, however, be absolutely necessary, e.g., for the relief of severe neuralgic pain. Under such circumstances the subcutaneous injection of morphia will probably be the best method of employing the drug; but the applica- tion of the remedy must never be entrusted to the patient or her friends. 3. For the relief of prominent symptoms remedies and measures of the most varied kind are liable to be required. During a convulsive paroxysm the patient should be placed in a recumbent position, with her dress loosened, especially about the neck ; if necessary, enough restraint should be employed to prevent her from injur- TREATMENT OF SYSTERIA. 12.^ ing herself. To rouse the patient,, and to make her exercise such power of self-control as she possesses, cold water may be dashed over the face and neck, and further treatment of this kind should be promised when- ever exaggeration is manifest. To fulfil a similar pur- pose it is often sufficient to apply irritant substances to the nostrils ; the vapour of burnt feathers is an old remedy of this class, but smelling-salts are equally efficacious and more convenient. If the patient can swallow^, a little ether, ammonia, and asafoetida may be administered; but, as a general rule, it is better not to give medicines by the mouth until the movements have finally subsided. Difficulty of swallowing, with irrita- .tion of the throat and larynx, is likely to be set up and to aggravate the paroxysm. In adult patients, when, as sometimes happens, the convulsions subside and recur at short intervals, and the condition threatens to be indefinitely protracted, the administration of a turpentine enema will generally be found the best means of arresting the symptoms. Another method, which has lately been recommended for the same pur- pose, is that of making firm and sustained pressure by applying the hands over one or both ovaries. In some cases the convulsions immediately cease when pressure 124 TREATMENT OF HYSTERIA. is applied^ but the effect may be only transient. Inhala- tions of chloroform or ether may be cautiously tried when the convulsions are very severe. It is not necessary to induce complete insensibility; as the convulsions become less violent, the patient will probably fall into a quiet, sleepy state of some hours' duration. In addition to the free use of cold water to the head and neck it is sometimes advisable to adopt other measures likelv to produce a decided effect on the patient^s mind. Thus the physician may assert in a very emphatic manner that unless the symptoms cease at once, or that if they recur, it will be necessary to shave •the head and apply a blister, or to adopt some other disagreeable measures. Even when the patient appears to be insensible a remark of this kind will often be appreciated and produce a good effect. When scissors are asked for, for cutting the hair^ as a preliminary to the shaving process, an improvement will generally be noticed. If in a very severe case these or similar measures prove successful it must not be hastily assumed that all the symptoms have been counterfeited. The presentation of a powerful motive for restraining the paroxysms and the sedative influence of fear are sufficient to counterbalance the reflex excitability of the TREATMENT OF HYSTERIA. 125 automatic centres, and the forc£ of the will, previously in abeyance, is set free to act in the necessary direc- tion. The treatment of the other prominent symptoms of hysteria does not require a very lengthy description. The derangements of the stomach and intestines, the palpitation, cough, urinary disorders, etc., must be treated on general principles, due attention being paid to the condition underlying the various manifestations. The hyperaesthesia, which is often so great a trouble, is best treated by full doses of the bromides, massage, and the application of the galvanic current; for anaesthesia, faradism and the metallo-therapeutic treatment is likely to yield the best results. The treatment of hysterical anaesthesia and other syixptoms by the application of metals to the surface of the body has attracted considerable attention of late. The method was known and practised in early times, and has recently been experimented upon by Charcot, who was led to investigate the subject by the reputed successes of a certain Dr. Burg, in Paris. In dealing with a case of anaesthesia, various metals have to be tried in order to discover the particular one to which the patient is sensitive. A piece of the metal in the 126 TREATMIENT OF HYSTERIA. form of a disk is then applied to the skin of the anaesthetic part, and kept in position for about twenty minutes. If the plan succeeds it will be found that the normal sensibility is restored in the immediate neighbourhood of the disk^ and that the improvement gradually spreads until restoration is complete. In a similar manner it is alleged that colour-blindness and other disorders of special senses may be cured by apply- ing the disks to the skin in the neighbourhood of the affected part. Disks of gold are said to be efficacious in the largest number of cases ; but in some more benefit results from the use of silver^ zinc, or copper. In order to strengthen the action of the metal it is re- commended that one of its soluble salts should be given internally for a shorter or longer period. Thus, if the patient prove sensitive to gold the chloride of that metal and sodium is administered daily, and the same plan is adopted with silver, zinc, copper, etc. It is not a little curious that similar effects have been produced by the application of disks of wood and other non- metallic substances. It is impossible to do more than speculate as to the manner in which the effects are pro- duced. Some assert that the metals themselves exercise a specific influence, or that they generate electric cur- tri:atment of hysteria. 127 rents, but this theory is scarcely tenable in view of the similar effects alleged to have been produced by non- metallic substances. It is more probable that such applications produce their effect by directing the atten- tion of the sufferer to the affected part, and by keeping: alive and stimulating the expectation of the cure. In hysterical patients it is scarcely possible to assign any •limit to the influence of " expectant attention."" Another remarkable phenomenon has been reported as resulting in some cases from the application of the metals ; the hemianaesthesia has disappeared from the affected side and transferred itself to the other half of the body which was previously normal. For paralyses of hysterical origin galvanism and faradism are the chief remedies; the latter is especially indicated whenever there are any signs of muscular atrophy. These forms of paralysis are apt to prove very obstinate, but unless connected with some oro"anic ■cause the symptoms in not a few cases disappear suddenly and spontaneously. It is in many of these cases that the Weir Mitchell system of treatment acts satisfactorily. Full particulars with reference to this plan of treating the worst forms of hysteria will be found in the chapter on Neurasthenia. In its principal 1 28 TREA T3IENT OF SYS TERIA . details it may be described as consisting of seclusion^ rest, high feeding, massage, and electricity. It yields, according to Dr. Playfair,* the most satisfactory results in the thoroughly broken-down and bedridden cases. " It is my experience that the worse the case is the more easy and certain is the cure, and the only dis- appointments I have had have been in dubious, half and half cases." It would seem that for hysterical patients whose appearance is that of good health some hydropathic form of treatment is more suitable. If the patient can be induced to take them, cold shower-baths sometimes produce an excellent tonic effect ; moreover, the " bracing up of the mind to the shock of the cold shower-bath is a capital exercise for the W'Cak-willed power of the hysterical patient.^^ To obtain the full benefit of hydropathic treatment it is often desirable to remove the patient from her home and place her in an institution where the necessary appliances are available. The discipline, the diet, and the close personal super- vision are all helpful adjuncts to the cure. * " The Systematic Treatment of Nerve Prostration and Hysteria,' P-S- CHAPTER V. EPILEPSY. Epilepsy, Definition and Forms of — Historical Notices and Geographical Distribution of the Disorder — Causes — In- fluence of Hereditary Predisposition — Date of First Attacks— Drunkenness - Sexual Excesses — Lesions of the Nervous System — Dr. Brown-Sequard's Experiments — Reflex Epilepsy — Ocular Defects as a Cause of Epilepsy — Dr. Stevens' Views — Exciting Causes — Epilepsy and Gout — Morbid Anatomy and Pathology — No Sp'icial Lesion — Seat OF the Disorder — The Epileptic Change — Dr. Hughlings- Jackson's Views — Dr. Brown-Sequard's Views — Symptoms of the Paroxysm — The Phenomena in Detail — The Milder Forms of Epilepsy— Irregular Forms — The Epileptoid States — Reflex Epilepsy — Jacksonian Epilepsy — The Course OF the Disorder — Mental Symptoms — Diagnosis — Epilepsy Distinguished from Apoplexy, Syncope, Hysteria, and In- fantile Convulsions — Prognosis — Treatment — During the Intervals— Hygienic Measures — Medicines — The Bromides, Atropine, Zinc, Silver, Vegetable Tonics; and Anti- spasmodics — Empirical Remedies — Electricity — H yd rot her a- PEUTics — Treatment During the Paroxy'sm. Epilepsy is a chronic nervous affection, without known anatomical basis_, and characterized by attacks of loss of consciousness, which in typical cases are associated with general or partial convulsions of a more or less 9 I30 FORMS OF FPILFPSY. violent character. This combination of phenomena is regarded as constituting '^ true epilepsy/' the haiit mal of the French writers ; but there are many other anomalous and milder forms of the disorder in which motor symptoms are absent. These constitute the petit mal of the French, the " abortive epilepsy " of English writers. The term ^' epileptoid " is applied to conditions of a still more anomalous character, and observed in persons of a distinctly epileptic tendency. Such symptoms as migraine, vertigo, syncope, halluci- nations, and other indications of nervous disorder oc- curring periodically and paroxysmally in persons of this description have been thus classified. Epilepsy has been known from very early times. Dr. Hirsch says: "Of all the diseases included in the group • of neuroses none shows a prevalence so general in time and place as epilepsy ; none is so constant a presence in the morbid life of humanity ; none has so markedly the ubiquitous character." The affection is very common even in Arctic latitudes ; in central and southern Europe its average frequency is said to be about I or 1*5 per 1,000. Its geographical distribution and relative frequency are uninfluenced by conditions of climate and soil. According to the authority already CA USJES OF U PILE PS F. 1 3 r quoted, epilepsy is as frequent in tropical and sub- tropical countries as in cold and temperate latitudes. ^' Peculiarities of race and nation have no influence whatsoever on the occurrence of epilepsy ; " the same types of the disorder are to be found everywhere; the natives of New Zealand are the only race for whom immunity has ever been claimed. The causes of epilepsy are of a very indefinite char- acter, and their respective values cannot be accurately estimated. As a predisposing cause heredity is the most important. It is often noticed that among the children of an epileptic parent one or more exhibit symptoms of the disease. In another set of cases a history of some other nervous disorder is all that can be ascertained^ and in both classes it sometimes happens that the immediate progeny escape and that their descendants suffer. Habitual drunkenness in the parents is a predisposing cause of epilepsy in their descendants; it has also been stated that children be- gotten by a father in a state of intoxication are very liable to become epileptic. Besides nervous disorder, other morbid conditions in the parents contribute towards the production of epilepsy in the offspring. Of these the most important are : exhaustion from ex- CAUSES OF EPILEPSY. cesses, sexual or otherwise ; nearasthenia resulting from excessive mental labour ; a low state of system from want of proper nourishment ; anaemia, rickets, and scrofula. Epilepsy is not unfrequent in women hereditarily predisposed to gout. . When the hereditary predisposition exists the dis- order generally manifests itself before the twentieth year. In such cases it is often noticed that the patients have suffered from convulsions in early life. First attacks are most frequent during the period of puberty ; seventy-five per cent, of all cases occur in persons under twenty years of age. When epilepsy appears for the first time after that age has been reached the disorder is not to be attributed to here- ditary predisposition alone. In liability to suffer there is little, if any difference between the sexes. With regard to other causes, epilepsy may doubtless be acquired ; certain influences appear to be capable of inducing the epileptic change or condition in the nervous system, while other influences, of a more de- finite character, are capable of provoking an attack. Drunkenness plays a decided part in the production of epilepsy, and some intoxicating agents appear to be more powerful than others in this respect. In France CAUSES OF BPILJEFSY. 133 epileptic attacks are often traceable to the use of absinthe ; symptoms closely resembling those observed in man have been produced in dogs by the continued administration of this fluid. Sexual excesses and mas- turbation are supposed to explain the occurrence of epilepsy in a somewhat numerous class of cases. It is, however, probable that the influence of these causes has been over-estimated. If it were as great as some authorities have imagined, epilepsy would be a much more common disorder than it really is. Many epileptics practise masturbation ; but the vice may be regarded as the consequence rather than the cause of the disorder. Syphilis is^ beyond doubt, an occasional cause of epilepsy, and should always be suspected when in a male subject the first attack occurs after the twentieth year. In some cases of epilepsy a causal connection can be shown to exist between certain lesions affecting various parts of the nervous system and the develop- ment of the epileptic change. Such cases are especially interesting from the light they throw upon the patho- geny of the disease. The symptoms are, moreover^ closely analogous to those which can be artificially produced in animals. About thirty years ago Dr. 134 CAUSES OF EPILEPSY. Brown-Sequard showed that epileptic attacks could be induced in guinea-pigs by injuring certain portions of the nervous system — the spinal cord^ the medulla oblongata^ the cerebral peduncles, and the corpora quad- rigemina — and even by section of one or both sciatic nerves. In from four to six weeks after the injury epileptic attacks occurred either spontaneously or as a result of irritating the cheek and the antero-lateral region of the neck_, supplied by the fifth and the occipital nerves. This so-called " epileptogenous zone" is on the same side as the injury, except when the cerebral peduncle is affected ; it is then on the opposite side. The epileptic state can also be produced in guinea-pigs by giving them a succession of slight blows on the head. General convulsions are caused^ but soon subside, and the animal appears to be in a normal condition. In about six weeks it is found that irritation of the face and neck, as before mentioned, induces an attack of epilepsy. It is worthy of note that the progeny of such guinea-pigs often suffer from epileptic convulsions, and that when both parents have been ex- perimented upon, few, if any, of the offspring escape. In other experiments epileptic convulsions were pro- duced by removing the cortical centre for the anterior CAUSES OF EFILEPSY 135 extremity, and also by applying a strong faradic current to the cerebral cortex on one side. These experiments serve to explain the causation of epilepsy in those cases in which the disorder is con- sequent upon lesions of nerves and nerve-centres. In the case of injury to peripheral nerves the local irrita- tion induces by degrees central changes which con- stitute the epileptic state. Many cases are on record in which permanent irritation to a nerve, caused by the presence of some foreign body, e.g., a fragment of glass, has induced convulsive attacks, which ceased after the removal of the offending substance. In like manner the irritation has been known to spread from cicatrices in which small branches of nerves were included. The cessation of the symptoms after removal of the cicatrix was sufficiently indicative of their origin. The term "^ reflex epilepsy " is applicable to all these cases and likewise to those in which irritation is presumed to spread from disease situated in various parts of the body. Injury of the brain from external violence has been known to give rise to symptoms of epilepsy. It is probable that in young subjects the complaint is sometimes attributable to overlooked or forgotten causes of this character. 136 CAUSES OF i:piljefsy. When, however^ due allowance has been made for the influence of heredity, injuries and other causes, there still remain manv cases whose origin cannot be discovered. The artificial production of epileptic symptoms by rapidly depriving the brain of arterial blood would seem to indicate that a condition of cerebral anaemia is at least one requisite for the development of the complaint. It is found that when the supply of blood to the brain is cut off or reduced to a minimum coma and general epileptic convulsions are produced, and that these symptoms cease when the blood-supply is re-established. The phenomena are probably due to some change in the nutrition of the cells. They are not the result of diminished pressure, inasmuch as removal of the cerebro-spinal fluid does not cause convulsions. It has further been proved by experiment that irrita- tion of certain peripheral sensory nerves produces reflex contraction of the cerebral arteries, anaemia, and epileptic convulsions. Dr. Stevens, of New York, asserts that certain ocular defects play a considerable part in the production of an epileptic tendency in young subjects. He reports that an examination of ocular conditions in 144 cases of epilepsy demonstrated the CA USE S OF E PILE PS T. , 3 7 existence of refractive anomalies in a far greater pro- portion than that which exists among children in general. Insufficiency of the motor muscles of the eyes was also discovered. The results of treatment served to confirm the supposition that epileptic in- fluences might arise from ocular' defects. Of twenty- nine cases treated by supplying proper glasses all but two were either cured or considerably improved. A reference to the exciting causes of epileptic attacks will conclude this part of the subject. In some patients the attacks are apparently spontaneous ; in others they result from mental excitement of various kinds. The first attack is sometimes induced by fright^ and the same cause often induces paroxysms in persons subject to the complaint. Sexual causes have some influence in producing an attack; thus in women the occurrence of the complaint has often been observed to coincide with the menstrual periods^ and with pregnancy. In both sexes attacks have been known to occur during sexual intercourse. Disorders of the stomach_, intes- tinal worms^ diseases of the ear^ and irritation from disease of various parts of the body are sufficient to excite paroxysms when once the epileptic change has become established. In another class of cases the 138 PATHOLOGY OF EPILJEPS Y. attacks supervene upon such affections as scarlet fever, measles, whooping cough, small-pox, and diphtheria. In some patients epilepsy would appear to be connected with gout, the convulsive attacks either ceasing or becoming much milder after the development of acute symptoms in the toe. It has been already stated that epilepsy is not unfrequent in women hereditarily pre- disposed to gout. In these cases the attacks are doubt- less excited by the accumulation of sodium urate in the blood, and the consequent irritation and spasm of the cerebral vessels. It has been alleged that epileptic seizures have sometimes occurred from imitation, children, and girls especially, having been attacked by the complaint while merely witnessing the convulsive paroxysms in others. Such a result might follow in a person hereditarily predisposed to the complaint, but in the absence of such tendency such a causation of true epilepsy is at least very improbable. Morbid anatomy and pathology. The most carefully - conducted post-mortem examinations have revealed nothing that can explain the pathology of epilepsy ; they only show that the disorder does not depend upon any special lesion of the brain. In some cases no change whatever has been discovered ; in others the PA TROL OGY OF i: FILE PS Y. 1 39 autopsy has revealed thickening and induration of the bones of the skull, opacity _, thickening, and adhesions of the cerebral membranes^ effusions into the ventricles^ induration of the grey and vi^hite substance. All these may be regarded as consequences of the oft-recurring hyperaemia during the convulsive attacks. Various alterations in the shape of the skull have been noticed in a few cases, and regarded of aetiological importance. Of these perhaps the most interesting is defective symmetry of the cramum_, as a result of imperfect development of one-half of it. This condition has been observed in persons subject to epilepsy from early childhood. In the majority the defect has been found on the left side, and it is interesting to notice that in these patients there were evidences of general want of development of the right side of the body, and that the convulsions commenced and were most violent on that side. The capillary dilatation in the medulla oblongata detected in some cases of epilepsy cannot be regarded as having any definite relation to the disorder. It has been noticed in non-epileptic cases_, and is probably a secondary result, and due to the attacks of congestion. Until within the last few years the pons Varolii and the medulla oblongata were looked upon as the parts I40 FATHOLOaY OF EPILEPSY. especially implicated in the production of epilepsy ; but according to the view most in favour at the present day the seat of the disorder is to be found in the corte^x cerebri. The principal facts adduced in support of the first-mentioned view are as follows : — The pons Varolii contains the spasm-centre, a mass of ganglion cells, reflex irritation of which causes contraction of all the muscles of the body, even of those which are supplied by cerebral nerves. The medulla oblongata contains the chief vaso-motor centre, irritation of which causes con- traction of the muscular coat of the arteries, especially of those of the brain. The characteristic symptoms of the epileptic attack, the loss of consciousness and con- vulsions, can be evoked by irritation of these centres. The former symptom results from the anaemic state of the brain suddenly produced by the constriction of the vessels. The abortive attacks, in which there is loss of consciousness without convulsions, are explained by supposing that only the vaso-motor centre is irritated ; and when convulsions occur without loss of conscious- ness the spasm-centre alone is supposed to be affected. In order to explain the condition of the brain in epilepsy it is assumed that some portions of it, notably the pons Varolii and the medulla oblongata, are in a PA THOL a Y OF JEPILEPS Y. 141 State of abnormally increased irritability — the so-called " epileptic change." I'he attack results when the activity of the nerve-centres situated in these parts is called into play by appropriate stimuli. It is doubtful whether both centres are acted upon at once or whether the vaso-motor centre is first irritated^ the spasm-centre being secondarily affected by the resulting anaemia. This latter condition soon gives place to venous con- gestion, and the continuance of the insensibility and the convulsive movements is to be explained by the fact that the amount of oxygen in the cerebral blood is much below the normal amount. The condition of the cerebral veins is clearly indicated by the marked cyanosis, which is due in great measure to compression of the jugular veins by the spasmodically-contracted muscles of the neck. According to Dr. Hughlings-Jackson's view the epileptic attack originates in the cerebral cortex, which contains motor, and probably also vaso-motor, centres. As a result of disturbance of equilibrium, a violent dis- charge of the nervous force accumulated in the ganglion cells suddenly takes place. If the motor centres are stimulated by pathological processes the convulsions begin in the corresponding groups of muscles, and often 142 FA TMOL OGY OF FFILFPS Y. extend to the limb of the opposite side, and thence to the muscles generally. The abolition of consciousness results from the temporary exhaustion of the ganglion cells which follows the discharge. That an epileptic attack may originate in the cerebral cortex has been conclusively proved by experiments. If the cortical areas for both limbs on one side of an animal be removed, the epileptic attacks which subsequently occur are limited to the muscles of the head and face on both sides. In another and still more demonstrative experiment general convulsions were caused in a dog by continuous irritation of a portion of the cortex. The irritated portion was then removed by means of a horizontal incision, when the convulsions immediately ceased. Moreover, during an epileptic attack artificially produced in a dog, the motor area of one extremity can be excised with the effect of excluding this limb from the attack, while the convulsions continue in the remainder of the body. According to Dr. Brown-Sequard, the theory that epilepsy depends on disease of any special part of the nervous centres has not been established. He thinks that the true seat of epilepsy is to be found in nerve- cells capable of producing morbid reflex muscular con- PATHOLOGY OF EPILEPSY. 143 tractions_, and that these cells are located chiefly in the base of the brain. Epileptiform convulsions can^ how- ever, take place after the removal of the brain, cerebellum, pons Varolii, and a portion of the medulla oblongata. It would, therefore, appear that the spinal cord has a share in the production of epileptiform convulsions, " and as we know that it can in man, as well as in animals, arrest the activity of the brain under some stimulation, we may easily admit that it may help in producing in man an arrest of cerebral activity during a fit of €pilepsy.^^ We know nothing with regard to the anatomical character of the changes in epilepsv, whether located in the cortex cerebri or in the basal ganglia. When we speak of the pathological irritability of the affected centres we use words which convey little meaning. The authority just quoted does not think that alterations in the cells will ever be detected. " It is quite likely that the change in them is more dynamical than physical, and that no more microscopic differences could be detected between two of them, one normal and the other possessing great morbid reflex power, than there are visible differences between two pieces of magnet — one poor, the other rich in magnetic power." 144 SYMPTOMS OF EPILEPSY. With regard to the kind of irritant which excites the activity of the nerve-centres our notions are but vague. In cases of reflex epilepsy the irritation of a sensory nerve may well be the cause of the movements ; while mental impressions produce excitement in the cerebral cortex^ and this is communicated to the cells in the base of the brain and in the upper part of the cord. Symptoms. The phenomena of a typical epileptic fit are as follows : — After certain precursory abnormal sensations, or suddenly without any premonition what- ever^ the patient turns pale^ utters a loud cry, loses consciousness, and falls down, one side or the whole of the body becomes rigid, and the breathing ceases for some seconds. Then the colour of the face changes, it becomes red, and finally purplish ; the eyeballs start from their sockets, and clonic, sometimes unilateral convul- sions of the muscles take place; the contents of the bladder and bowels are often evacuated. The move- ments continue for several minutes, and then gradually abate ; the blueness of the face passes off, the limbs become flaccid, and consciousness returns either at once or after an interval of stupor or coma. When this latter condition has passed off the patient usually complains of headache^ weariness, and soreness of the SYMPTOMS OF EPILEPSY. 145 limbs : he has no recollection of the incidents of the attack. Some of the phenomena require to be examined more ill detail. The premonitory symptoms differ con- siderably in their character and duration. Sometimes the patient is conscious of various alterations of his usual state of feeling, or of confusion of thou2:htj or of failure of memory. At the present time I am treating a patient who is thus warned of an impending attack. In other cases giddiness, headache, drowsiness, and a feeling of fulness in the head are complained of. Various disorders of the special senses, tingling in different parts of the body, and nausea are occasionally experienced. Some patients are able to predict that an attack is coming on. In others the warning is very short, perhaps just sufficient to afford opportunity for the patient to place himself on a sofa or chair. The phenomenon termed the aura epilepiica occurs in a small proportion of cases. It consists of strange sensations, e.g., as of a stream of cold water falling on the skin. This may begin in any part of the body, and it gradually spreads to the head, when loss of consciousness takes place. Tlie aura may last for several seconds, or even for some minutes. When the 10 146 SYMPTOMS OF EPILIJPSY. attack is at its height consciousness is completely abolished^ and the severest injuries are unfelt by the patient. At the same time the reflex excitability is much reduced; and in some cases altogether in abey- ance. The eyelids do not close when the cornea is touched; neither do the pupils contract on exposure to strong light. Injuries are not unfrequently received during the fall and the subsequent convulsions. The tongue^ which is protruded from the mouthy is often badly hurt between the teeth. Owing first to the rigidity, and afterwards to the irregular contractions of the rauscleS; respiration is imperfect, and performed with difficulty; the glottis is contracted, and the lungs are not fully distended. The struggles for breath and the movements of the lower jaw cause the air to be' mixed with saliva and the mucus of the mouthy and\ white or bloody foam often appears at the lips. The first stage of the attack, that of tonic spasm, is always the shortest. It never lasts for more than a minute, and is sometimes over in a few seconds. The clonic convulsions have a longer duration; they may go on for several hours, but their average length is from ten to fifteen minutes. The urine passed after their subsidence sometimes contains albumen and hyaline casts. The frequency of the attacks varies considerably. Daily SYMPTOMS OF EPILEPSY. 147 occurrences are observed in some cases ; in others a year^ or even several years_, elapse between the par- oxysms. A rapid succession of attacks during several days or weeks, follov/ed by a complete immunity for a lengthened period, is not unfrequent. Definite period- icity is very rarely observed except in women, in whom the attacks sometimes coincide with the menstrual periods. In most cases there is an absence of regularity, and the attacks come on quite unexpectedly. It is somewhat difficult to give a succinct account of the milder forms of epilepsy. They are manifested by occasional attacks in which consciousness is either completely lost or much diminished, but power over the muscles is generally so far retained that co-ordinate movements can still be accomplished. The spasmodic element is wanting, or is represented only by a few twitches. The symptoms exhibited differ greatly in different patients. The unconsciousness may last for a few seconds, or for several minutes. Recently, in consultation with Dr. Hughlings-Jackson, I saw a patient in whom the unconsciousness lasted only a few seconds, and sev^eral similar cases in persons of both sexes have come under my notice. During its con- tinuance automatic actions, e.g., walking, painting, etc.^ may still be performed. In other cases the patient 148 IRREGULAR FORMS OF JEPILEPSY. Stops suddenly when talking, stares vacantly for a few moments, and then finishes his sentence without any further difficulty. If these and similar slight attacks occur when the patient is sitting or lying down they may pass off almost without notice. In cases of a more severe form the loss of consciousness is complete and more prolonged. The patient falls down, perhaps when walking, and remains unconscious for several minutes. Giddiness is sometimes complained of, especially when the loss of consciousness is not complete. Partial convulsions, as of a few muscles of the face, arm, or hand/ are noticed in some cases. Attacks as above described are included under the term '' epilepsy " for the following reasons : — They sometimes precede the more severe paroxysms, and sometimes alternate with them. They are often ushered in by the precursory symptoms of the graver attacks, and are followed in some cases by drowsiness and stupor. Moreover, as regards severity of symptoms, epilepsy presents innumerable grades between the mildest and the most violent, and the various "abor- tive " forms of the disorder pass by imperceptible degrees into the pronounced type. Other irregular forms of attack are sometimes noticed. It occasionally happens that the convulsions IB RE G ULA R FORMS OF FPILEPS Y. 1 49 are somewhat violent_, while consciousness and sen- sation arc but very slightly affected. On the other hand^ the convulsions may be absent^ their place being taken by co-ordinate movements of walking or running. In a case recently brought to my notice^ a young man, who suffered from ordinary epileptic attacks of a very severe character^ would sometimes in a state of un- consciousness rush out of the house and run up and down the main street of the village until he fell from exhaustion. In other cases the paroxysms are from time to time replaced by various forms of mental disorder. These symptoms, when of a severe type, resemble those of acute mania. Like the convulsive attack, they come on suddenly, and after their sub- sidence the patient has no recollection of what has occurred. Conditions of this kind sometimes follow the paroxysm, and the mental affection may last for several days. In a less marked form, the utmost variety may be presented by the symptoms. Acts of senseless violence, acts indicative of mental confusion, of complete disregard of decency, etc., would appear in some cases to replace the convulsive paroxysms. After the accomplishment of the acts the patients are ignorant of what has occurred, and express more or less surprise when the details are related to them. I50 i:pili:ptoid states. A full description of the so-called epileptoid states would transgress the limits which the author has prescribed for himself. To classify the conditions thus designated would be a task of much difficulty, more especially as authors are by no means agreed as to the boundaries of the definition. Nothnagel's explanation is as follows : " Those states should be regarded as epileptoid, i.e., as caused by a central epileptic change, in which symptoms show themselves paroxysmally, for the development of which the same physiological pro- cesses, according to our present knowledge, should, or at any rate may be assumed, as produce (when deve- loped in greater intensity or extent) the usual epileptic attacks. . . . The certainty as to whether the case be one of genuine epilepsy or not is to be gathered from the occurrence, sooner or later, of real paroxysms in place of or alternating with these questionable seizures." The main clinical features of the epileptoid states are attacks of giddiness and abnormal sensations of various kinds, which when associated with corresponding mental symptoms more or less closely resemble the phenomena* of hysteria and hypochondriasis. Such conditions may easily pass into real mental disorder, paroxysms of which take the place of the convulsive BE FLEX E PILE PS 1'. 151 attacks. The attacks of giddiness are the most characteristic. Nothnagel cites the case of a clergy- maiij in whom frequently recurring attacks of vertigo, extending over some years_, were succeeded by others in which there was complete loss of consciousness and muscular rigidity. Other cases recorded by the same author presented totally different symptoms_, e.g., obscuration of the visual fields the supervention of a kind of dreamy condition_, lasting for some time, during which sight and hearing were more or less disturbed, and hallucinations of the most varied kind. The paroxysmal character of these phenomena, and their occurrence in persons exhibiting from time to time other symptoms more commonly referred to epilepsy are regarded as sufficient reasons for connecting them with this disease. There are certain forms of epilepsy which yet remain to be noticed. The most important of these are: epilepsy of reflex origin and the so-called '^Jack- sonian " epilepsy. The condition termed hystero- epilepsy has been already described in the chapter on hysteria. The term reflex epilepsy is applied to those forms of the disorder in which some anatomical lesion of the 152 J A CKS ONI A N JEPILi:PS Y. peripheral nerves has caused the development of the symptoms. The course of events in a case of this kind is somewhat as follows : The patient receives an injury, such as a wound on any part of the body, but in most cases on one of the extremities. Healing takes place, and perhaps nothing more is thought of the wound j after an indefinite interval painful sensations are experienced in the cicatrix, and twitchings in the neighbouring muscles begin to be noticed. In some recorded cases a feeling of numbness preceded the twitchings. These movements become more and more troublesome, and extend in an upward direction to other muscles. The feelins; of discomfort likewise spreads towards the head, and finally provokes an attack of epilepsy. This recurs from time to time, and can generally be excited by irritating the cicatrix. It is in these cases that a paroxysm can sometimes be averted by applying a ligature or tourniquet to the limb above the cicatrix, whence the epileptic aura proceeds. That secondary form of the disorder which has been termed '' Jacksonian epilepsy " is connected with the presence of lesions in the cerebral cortex. The convul- sions occur on the opposite side of the body, and may be limited to certain groups of muscles, to a limb, to the COURSJE OF EPILEPSY. 153 head or neck. After each attack a paretic condition is apt to be set up in the affected muscles; this at first is of a temporary character^ but it sooner or later becomes permanent^ and finally merges into complete paralysis. The convulsive movements come on at very uncertain intervals^ and they may be altogether absent for long periods. They are generally unattended by loss of con- sciousness^ and this symptom, when present, is less marked than in cases of typical epilepsy. The course of the disorder varies greatly in different cases. It is generally chronic, and not a few epileptic patients live to a somewhat advanced age, without exhibiting any material impairment of their bodily or mental faculties. Even the frequency and severity of the paroxysms are not of such ominous import as was formerly supposed. Only in very rare cases do the paroxysms terminate fatally in consequence of cerebral haemorrhage or from apnoea. The majority of fatal cases are caused by accidents of various kinds, to which epileptics are peculiarly liable. Accidental death from fallino^ into fire or water or from a hei2;ht is not an un- frequent occurrence. In about forty per cent, of all cases of epilepsy, indi- cations of mental disorder sooner or later exhibit them- 154 MJENTAL DISORDER IN I:PIL:EPSY. selves. After these have appeared the patient's con- dition invariably becomes worse and worse. For some time the general health between the convulsive attacks may appear to be perfectly good, and a very close • examination maybe required to discover any signs of derangement. Constant pain in the head, a feeling of confusion, inability to fix the attention continuously on any given subject, and frequent muscular twitchings are the most common evidences of incipient deterioration. Certain mental peculiarities are likewise apt to become prominent. In some patients, without obvious cause, excitement alternates with depression; marked obsti- nacy and capriciousness are sometimes exhibited j in other cases the memory becomes deficient, and mental exertion is felt to be more and more irksome. As time goes on, the signs of deterioration become more obvious ; not only are the paroxysms more frequent, but the condition during the intervals changes for the worse. All the intellectual powers become more or less im- paired. In some cases violent attacks of mania con- stitute the prevailing feature; in others the patient relapses into a state of dementia. Under such circum- stances the features and manner of the patient are con- siderably changed, and the animal propensities are DIAGNOSIS OF EPILEPSY. 155 wont to become \^ery prominent. A condition of imbecility is the last stage of the disorder, and^ in the absence of organic disease in the chest or abdomen^ may continue for many years. Diagnosis. The affections with which epilepsy is likely to be confounded are apoplexy, syncope from cardiac weakness, hysteria, and convulsions occurring in children. An ordinary epileptic attack can be easily distin- guished from apoplexy. The violent convulsions of the former contrast strongly with the motionless phase of the latter. ' When, however, the paroxysm is over and profound coma has supervened, there may be some difficulty in distinguishing between the two conditions, especially when the previous history cannot be obtained. The appearance of foam mixed with blood about the mouth, the absence of paralysis and of stertorous breathing are usually sufficient to determine the diag- nosis, but it may be necessary to watch the case for some little time before coming to a positive conclusion. Attacks of faintness may be mistaken for epilepsy. In the former, however, the loss of consciousness is, as a general rule, not sudden, but gradual, and preceded by a feeling of depression or nausea. There are no con- 1 5 6 DIA GNOSIS OF E PILE PS Y. vulsions^ and no involuntary discharges^ and the patient after recovery feels anxious and giddy^ but not lethargic. His condition^ moreover, is relieved by stimulants. Until thoroughly recovered his face continues pale. The diagnosis between epilepsy and hysteria has been given in a previous chapter (see p. 113). It is only necessary to add that it has become more difficult to distinguish between the two affections since we have learnt to recognize hystero-epilepsy as a connecting link between them. The loss of consciousness was thought to be characteristic of epilepsy, but this may also occur in the mixed disorder. The abolition of reflex movements points decidedly to epilepsy, but the latter may exist in the absence of this symptom. The more any given attack differs from the typical form^ the greater the difficulty of diagnosis. Convulsions in children, whether arising from intes- tinal irritation or other similar cause, or occurring ■during the course of a febrile affection, may so closely resemble epilepsy as to be incapable of being distin- guished from it. If the convulsions passed away after the removal of the cause, it would be unnecessary to refer them to the state in question, but if they recurred from time to time, the child's health being good in the PEOGNOSIS OF EPILEPSY. 157 interval, they might justly be classified as epileptic. Whether the ^' epileptic change ^' had taken place or not could be determined only by the subsequent history of the case. Epilepsy is occasionally feigned_, and a clever impostor who has carefully studied its most striking phenomena may easily deceive all but a well -practised observer. There are, however, certain symptoms u^hich cannot be counterfeited, viz., the initial pallor of the face, the dilatation of the pupil, the insensibility of the eye to light, the changes in the pulse, and the ultimate pur- plish or livid hue of the face. In a real epileptic patient there are often marks of injury on the face or hands, resulting from falls in previous attacks, and likewise scars on the tongue. The impostor generally chooses a convenient place for falling, and his attacks always occur in the presence of others. He sometimes produces the foam at the mouth by means of a piece of soap. A London policeman has been known to expose the counterfeiter by wrenching open his mouth and re- moving the source of the foam. Frognos'is. Epilepsy is a very serious disease, and rarely admits of a favourable prognosis. The abortive attacks are less amenable to treatment than the ordinary 158 Fit O GNOSIS OF FFILFFSY. type of the complaint. As a general rule it may be stated that permanent recovery takes place in about five per cent, of all cases. It is^ however^ often possible to reduce the severity and frequency of the attacks by proper treatment, but the improvement is generally of temporary character. In not a few cases the progress of the disease appears to be unchecked by any remedies. When a marked hereditary tendency is present, either to the disease itself or to other forms of nervous dis- order, the prognosis is always very unfavourable. In the absence of any such tendencies, and when the attacks occur in a patient under 20 who appears per- fectly well during the intervals, there is much room for hope that recovery may take place. The longer the complaint continues the more likely is it to prove irremediable. Recovery is almost out of the question if the mind has become impaired, or if any symptoms of paralysis are present. As in other forms of nervous disorder, it not unfrequently happens that a change in the treatment is attended with apparent benefit, and the same result often follows any change for the better in the patient's surroundings. The mental condition of the patient always exerts more or less influence on the progress of the complaint. TREATMENT OF EPILEPSY. 159 Treatment. In dealing with a case of epilepsy every endeavour shoidd be made to discover any possible cause of the' disorder. Remedies should not be used in a haphazard fashion, but the state of the system and any irregularity of function should be carefully observed. Subject to these general provisions the treatment divides itself into that which is required in the intervals and that which is adapted to the paroxysms. Cases of reflex epilepsy are sometimes very amenable to treat- ment. The removal of cicatrices, includins: fibrils of nerves^ which formed the starting-point of the aura^ has been followed by the happiest results. In another class of cases a cure has been effected by the operation of trephining, whereby diseased portions of the skull, exostoses, or spicula of bone were removed. As a matter of course improvement is not an invariable result even where the cause of the disease has thus been re- moved ; the changes in the central organs set up bv the irritation at the periphery are apt to become permanent and independent of the lesion w hich originally produced them. The lesson to be drawn from the success which has been obtained in such cases is that every epileptic patient should be very carefully examined in order to learn whether any peripheral causes of irritation, such i6o te:eatmi:nt of epilepsy. as cicatrices, exostoses,, necrosed bone, etc., are dis- coverable. The examination should not be confined to the superficial parts, but should extend to all the organs of the body, and especially to the lungs, stomach, ovaries, and uterus. The general state of the patient should next be con- sidered, and any deviation from the healthy condition should be remedied as far as possible. If the patient be plethoric, saline purgatives and a restricted diet are indicated. Anaemic cases will be benefited by iron, quinine, a nutritious diet, and a general tonic regimen. The condition of the digestive organs should receive especial attention ; constipation in particular should be corrected by appropriate remedies. Symptoms of gastric catarrh when present will require alkalies and vegetable bitters, and the possibility of tape-worm being the exciting cause of the attacks should not be forgotten. In the treatment of confirmed epilepsy the regulation of the diet and of the patient's general habits is of the utmost importance. The rules to be laid down in these particulars must, of course, be adapted to each individual case; only general principles can here be given. In the first place excesses of every kind must be abandoned. The diet should be nutritious and non-stimulating; TREA TMENT OF E PILE PS Y. 1 6 1 especial attention should be paid to the quantity of animal food, for, as a general rule^ the attacks becoine more frequent when articles of this description are too largely used. Some patients are improved by a diet consisting principally of vegetables and milk. Regular and moderate occupation, exercise short of fatigue, early hours, in fact, hygienic measures of all kinds, are indispensable for the satisfactory treatment of an epileptic patient ; if they cannot be secured drugs will prove of little or no avail. An enormous number of remedies have been recom- mended for epilepsy, but the reputation acquired by most of them has been only of a temporary character. A.t the present day the bromide of potassium is the remedy which yields the best results; it is, however, sometimes useless, but it always deserv^es a thorouc^h trial, for though it may fail to cure the disease it will generally cause more or less improvement. Diminished frequency of the paroxysms and improvement in the mental condition of the patient are results which are often witnessed. To afford any prospect of success it must be given in full doses, viz., from one up to three or even four drachms per day. A convenient method of exhibiting it is to dissolve it in seltzer-water II i62 TREATMENT OF BPILEPSY. or niilk_, and sometimes it is better tolerated by the stomach if taken with some bitter infusion and a few grains of bicarbonate of potassium. Concentrated solutions of these large doses should never be employed^ as they are apt to irritate the stomach. To obtain the full effects of the drug it should be given for two or three months ; if no improvement take place its administration should be stopped. It must not be forgotten that prolonged use of the bromide of potas- sium is apt to be followed by very untoward results, such as a condition of utter passiveness, lethargy, and inability to perform any mental operations. If there be any appearance of these symptoms the use of the drug should be disconthiued, and we may then have recourse to atropine. This powerful drug should be given in doses commencing with the yj^^ of a grain, gradually increased up to -gV, or even ^q. The quantity prescribed should be administered in a single dose at bed-time, and slowly increased, week by week, until the maximum is reached. This is to be continued for a fortnight, and then steadily reduced to the minimum dose. This plan of treatment may be persevered in for a year or more, the patient, of course, being very care- fully watched during the whole time, and the medicine stopped on the appearance of any toxic symptoms. TREATMJENT OF JEPILBPST. 163 Other remedies used for epilepsy require only a brief notice. The oxide of zinc_, nitrate of silver, and the ammonio-sulphate of copper, although much lauded from time to time by various authorities, would seem to possess little, if any, real efficacy. They may, how- ever, be tried if the bromide and atropine prove useless. They are supposed to strengthen the nervous system, and to lessen abnormal excitability. The nitrate of silver is given in doses of one-quarter or one-third of a grain three times a day, to be gradually increased to one or even two grains. It is best administered in a pill, with kaolin ointment as an excipient. The risk of permanent discoloration of the skin should always be borne in mind; the remedy should never be con- tinued longer than six weeks or two months without an intermission of an equal length. The oxide of zinc, to be of any use, must be given in large doses, but these are not always tolerated by the stomach. From two grains at first, three times a day, in the form of a pill, the dose may be increased up to ten, fifteen, or even twenty grains' in the absence of marked gastric symptoms. The sulphate of copper is given in doses of from half-a-grain to two grains, and the ammoniated copper in doses of from one to five grains. The latter drug is said to be more efficacious in adults than in 1 64 t:ri:a tment of i:filjep8 y. children; the reverse holds good with regard to zinc. It is also said to be more suitable for torpid^ phlegmatic persons than for those of an irritable, nervous tempera- ment. Many vegetable remedies have been employed in the treatment of epilepsy ; some for their tonic, others for their antispasmodic properties, and others, again, have been given quite empirically. Of the vege- table tonics quinine is worthy of trial when the attacks assume a decidedly periodical form ; it may also be given with the view of improving the digestion. Among the antispasmodics valerian is one of the oldest reme- dies. Its real efficacy may be doubted ; yet it would appear to possess some power of lessening nervous excitability. In some experiments made a few years ago upon frogs the administration of oil of valerian (gr. -\) was found to produce a quiet and apathetic state, followed by complete stupor. Reflex irritability was considerably diminished, and the change appeared to depend upon an influence affecting the spinal cord, as well as the spasm-centres in the brain. The drug would seem to be best adapted for cases of hystero- epilepsy ; its infusion will also serve as a vehicle for the bromide of potassium. Of the purely empirical remedies it is sufficient to mention the cotyledon TREATMENT OF EPILEPSY. 165 umbilicus, indigo, sumbul, and artemisia vulgaris. These and many other drugs are said to have effected improvement, and even cures in some cases. It is probable that any change for the better, observed after their use, has been due mainly to the influence of novelty or hope on the mind of the patient, and to alterations in his manner of living enjoined by the physician when prescribing the drugs. Electricity in various forms has, of course, been tried for epilepsy, and cures are said to have been effected. We know nothing of the special conditions for which electricity would be likely to be serviceable, but it may be tried as an auxiliary to other means. A galvanic current of moderate strength is employed ; the electrodes are placed one on each side of the upper part of the back of the neck^ or over the course of the cervical sympathetic nerves. Currents may also be sent through the cranium; and whenever a decided aura follows the course of a nerve, it has been recommended to apply the electrodes to the surface in relation therewith. . Hydro-therapeutic treatment may sometimes be advan- tageously conjoined with other remedies for epilepsy. The patient should, as Nothnagel recommends, be sent to an institution where the treatment can be methodi- 1(66 TREATMENT OF EPILEPSY. cally carried out for six or eight weeks^ or even longer. It must, of course, be carefully adapted to the condition of the patient ; violent douches to the head and spine should be prohibited. Whenever there is great nervous excitement tepid or warm baths may take the place of more decided measures. In cases in which there is pain or tenderness along the spine the application of Dr. Chapman's ice-bags is likely to be serviceable. Little treatment Is generally required during the paroxysm. In cases attended with the epileptic aura it has been recommended to apply a ligature or a tourni- quet to the limb, and some patients, when time will' allow, are able to avert a paroxysm by inhaling ammonia and other nervine stimulants, or by taking a draught of cold water. In the Fractitioner for October, t868. Dr. Buzzard has recorded several cases, w^hich show that when a marked local sensation precedes an attack, the fits may be diminished, and sometimes even cured by apply- ing a narrow blister round the limb above the starting- point of the aura. The Inhalation of amyl-nitrlte would- seem to be a rational means of keeping off the attack In cases in which there is sufficient warning of Its approach, and whenever decided pallor of the face is the first sym- ptom. . During the paroxysm Itself the patient should be TREATMENT OF EPILEPSY. 167 placed on his back^ with his head somewhat raised ; the clothes should be loosened, especially about the neck and trunk, fresh air should be freely admitted, and a piece of soft wood or cork placed between the teeth in order to prevent the tongue from being bitten. The convulsive movements should be so far restrained as to keep the patient from injuring himself. Toward the end of the attack the mucus which may have accumulated about the mouth should be wiped off. In the majority of cases the attack spontaneously subsides in a few minutes, and the patient falls into a deep sleep. If the convulsions recur and a high temperature exists, cup- ping to the back of the neck, or even the abstraction of a few ounces of blood from the arm, would seem to be the best treatment. For very violent and oft-repeated paroxysms the inhalation of chloroform should be care- fully tried, or twenty grains of chloral hydrate may be administered in an enema. CHAPTER VI. CHOREA— ST. VITUS' DANCE. Chorea, Historical Notices, Definition and Geographical Dis- tribution OF the Disorder — Causes — Hereditary Predis- position — Imitation — Age and Sex— Mental Excitement — Reflex Causes — Ocular Disorders, Dr. Stevens' Views — Connection between Rheumatism and Chorea — Nature of Chorea — Drs. Broadbent, Kirkes, and Dickinson's Views — Dr. Strumpell's Opinion that Chorea is a Functional Disorder — Symptoms — Evidences of Mental Disorder — Differences in Severity — Analysis of Prominent Symptoms — Duration of the Disorder — Prognosis, Diagnosis, and Treatment — Necessity of Inquiring into Cause — Specific Remedies, as Arsenic, Zinc, and Strychnine — Cold to the Spine — Chloral — Isolation from other Children. Chorea is in many respects one of the most interest- ing disorders which the physician has to study. The name was originally given to the epidemic of dancing madness which appeared in the 14th and 15th centuries in some parts of Western Germany^ because the move- ments were supposed to be cured by the help of St. Vitus, called " Guy "" in France^ and " Veit " in Germany. The same word (chorea) was subsequently used by Sydenham to describe the spasmodic disorder now universally known under that name 3 and after- NOTICES OF CHOREA. 169 wards a distinction began to be made between the chorea Germanorum^ or chorea magna^ as it was called, and chorea Anglorum, or minor. The two disorders thus grouped under a common name are completely distinct, and have really nothing in common. At the present day, when epidemics of the dancing mania are unknown, the term chorea signifies a nervous affection characterized by incoherent action of the muscles. It may be more fully defined as a convul- sive disorder, most often occurring in early life, and marked by irregular non-rhythmical contractions of the voluntary muscles, at first usually of one side of the body, but afterwards becoming general; the face and arm are niore frequently affected than the leg. There is no loss of consciousness, but the will is incapable of pre- venting the movements, which, however, cease duri no- sleep. As time goes on the affected muscles become enfeebled, the sensibility is sometimes diminished, and there is often impairment of some special sense. We have no means of judging whether this disorder existed in ancient times ; the works of the earlier writers contain no descriptions which can be applied exclusively to chorea. The affection was well known in the i8th century, and often described by medical 17© CAUSES OF CHOREA. writers throughout Europe. With regard to its geo- graphical distribution^ chorea is, like many other affec- tions of the nervous system, a disorder of civilized life^ Scarcely any part of the world is altogether free from it, but it is far less common in tropical countries than in the temperate zones. It is said to be about equally distributed in the temperate portions of Europe and America; to be very rare indeed in the East and West Indies, and almost unknown in China. The causes of chorea are many in number and various in character. Hereditary predisposition to nervous dis- orders is a very Important factor, and the frequency with which it can be traced is a measure of the relation- ship which exists between many affections of the nervous system. Epilepsy or hysteria in the parents predisposes, the children to chorea. It must, however, be re- membered that when several children of the same family suffer, the development of the symptoms may be due to imitation. Small epidemics, indeed, have been known to arise in institutions for children after a case of chorea had been admitted. Under such circum- stances the complaint very quickly spreads, and its. progress can be checked only by separation. In these respects it is analogous to hysteria. With regard to age and sex, the majority of cases occur between the CAUSES OF CHOREA. ages of 6 and 15; the disorder is more common in girls than in boys_, the proportion being three of the former to two of the latter. The complaint is more often met with in towns than in country places, and among children of the poor than among those of the rich. A very common predisposing cause is debility, especially when due to neglect and want of proper food. Chorea very seldom occurs for the first time in persons over 20 years of age. Among the direct causes the most potent is some form of mental excitement, such as fright or a severe shock. Many cases are on record in which the symptoms have followed immediately upon some sudden alarm. Last year I treated a patient in whom the attack was induced by shock consequent on being run away with in a carriage. Other causes are of a reflex nature, e.g., worms in the intestines, painful affec- tions of the mouth or teeth, and disorders of the genital functions. I am now attending a woman, aged 28, in whom a retroverted womb seems to be the cause of the attack. Symptoms occasionally appear in pregnant women, and subside after delivery. As illustrating the manifold character of reflex causes, it may be mentioned that hemichorea has been known to be associated with fissure of the anus. The movements completely ceased after the fissure had been cured by operation. 1/2 CAUSES OF C SORE A. Dr. Stevens^ of New York, has recently attempted to show that chorea is emphatically a nervous disorder depending upon ocular conditions. He has found that the majority of cases of chorea occur among hyper- metropic children who are attending school, and that the widely dilated pupils^ which constitute a very characteristic feature of chorea, become normal when the complaint passes away. When hyper-metropic children are put to any "^work where a very marked and continued effort to maintain accommodation is re- quired_, the ciliary muscle experiences fatigue^ and finally exhaustion, its action is considerably enfeebled, and with it the action of the sphincter pupillae. The widely dilated pupil is the signal which tired nature gives as a warning to discontinue over-work of the exhausted muscles. If the signal passes unheeded the whole nervous system surrenders.^' Dr. Stevens' experience leads him to believe that cases which occur without any relation to ocular troubles are rare exceptions to a very general rule. In ii8 cases of chorea occurring in private practice simple hyper-metropia existed in 78, and astigmatism with other complications in nearly all the remaining cases. I have seen several patients in whom the chorea depended upon ocular abnormalities of these kinds. CHOBEA AND RHEUMATISM. The connection between acute rheumatism and chorea is one of the most interesting features of the latter complaint. Some writers, indeed, go so far as to declare that chorea is always of rheumatic origin, while others assert that rheumatism, heart disease, and chorea are only different phases of one and the same disease, and that these affections may occur in any order of sequence. Chorea is often preceded by an attack of acute rheumatism or by less severe pains of a rheumatic character; and the connection is still further evidenced . by the fact that a history of rheumatism can sometimes be traced in the parents of choreic children. It is, however, going too far to say that rheumatism in any form is a necessary precursor of chorea. Very widely differeat views are held as to the nature of chorea, but within the last few years considerable light has been thrown upon the pathology of at least some of its forms. More or less serious lesions can be found in fatal cases, especially when the complaint has been preceded by rheumatism ; the difficulty is to account for mild cases which rapidly recover under the influence of good food and fresh air. There is apparentlv much truth in Dr. Broadbent's view that chorea is a symptom rather than a disease, and that the charac- teristic movements are in relation with the seat of the 174 PATHOLOGY OF CHOREA. morbid change rather than with its nature. " The seat of the disturbance is the corpus striatum^ its character probably different in different cases ; bat the anatomical condition cannot amount to actual breach of structure, since that is known to give rise to hemiplegia, while it must obviously be of a kind to impair the functional vigour of the ganglia/^ Nearly forty years ago the late Dr. Kirkes reported a series of cases of fatal chorea, in which on post-mortem examination inflammatory changes were found in the cardiac valves. In a large proportion of these patients there was no history of rheumatism, and in a few of them no cardiac murmurs had been audible during life. Dr. Kirkes advanced the view that the disorder of the nervous centres in chorea is due to the action of the inflammatory products of the endocardium. In this way the embolic theory of chorea originated, and it has now gained pretty general acceptance. In several recorded cases vegetations on the mitral valve were associated with embolisms in the corpus striatum and thalamus opticus. Various other lesions have been found ; the most important of these are interstitial development of connective tissue in the nervous centres ; hyperemia of the brain and spinal cord ; serous effusion and extravasation of blood in the spinal canal. Accord- PATHOLOGY OF CEOREA. 175 ing to another view of the pathology of chorea, the morbid processes are of a diffused character^ and not confined to any special part or parts of the nervous centres. The alterations found in the spinal cord and even in the peripheral nerves in some cases are held to support this theory. Dr. Dickinson examined a number of cases and found many small arteries of the brain and cord much dilated_, the change being especially marked in the optic thalamus and corpus striatum. Minute extravasations were also visible_, but emboli were not detected. Dr. Hughlings Jackson supports the embolic theory; on the other hand Dr. Striimpell^ of Leipsic^ states that this theory is destitute of proof, and is even improbable. He regards chorea as a ^' neurosis," that is_, a disease which produces functional disturbances for which an anatomical basis is at present unknown. The account just given of the changes found in fatal cases of chorea^ and of the theories as to the nature of the disease, will suffice to show the uncertainty which exists on this latter subject. It is evident that very different causes must be at work in severe as compared with mild cases. r76 SYMPTOMS OF CHOREA. Irritative processes and capillary embolisms may account for the former class ; for the latter some other explanation must be found. The rapid subsidence of the convulsive movements would seem to be in- compatible with the presence of organic lesions. At present it seems impossible to do more than assume the existence of nutritive disorder in the brain. Such disturbance may depend upon hyperaemia, with stagna- tion of blood in the capillaries, or with a form of thrombosis, due to accumulation of masses of white corpuscles. When chorea follows directly upon shock vaso-motor disturbance may be presumed to exist, with contraction followed by dilatation of vessels as a result. When, lastly, the movements seem to be reflex in character (as in the chorea of pregnancy), it must be assumed that the irritation is propagated from the peripheral nerves to the spinal cord and brain. Evidence in support of the view that chorea is essentially a functional disorder will be found in the introductory, chapter of this work. Symptoms. In the majority of cases the choreic movements are preceded by symptoms indicative of dis- order of the general health. Fretfulness, irritability, capriciousness, indifference, inattention, etc., are SYMFTOMS OF CHOREA. 177 noticed in a child who had previously exhibited none of these traits. The appetite fails, the sleep is disturbed, the child is disinclined for exertion, avoids his companions, and seems weak and ailing. These symptoms are not invariably noticed, thev are, of course, absent in cases of chorea supervening on fright, or following closely an attack of acute rheumatism. After these symptoais have continued perhaps for some weeks the choreic movements begin to be noticed. There is first a general restlessness and uneasiness ; the parents are apt to say that the child has the " fidgets ; '^ he moves about aimlessly, and seems awkward and clumsy in his actions. If he be attending school his inattention and carelessness are complained of; it is perhaps noticed that his handwriting is w^orse than usual. At home the child is sometimes punished for carelessness during meals, he drops things from his hand, upsets his cup, makes grimaces, and seems not to heed any remonstrances. At this stage there is generally no suspicion as to the real nature of the case. Before long, however, definite convulsive movements occur. The twitchings usually begin in the hand and arm, and thence extend to the shoulder^ face, and other parts SYMPTOMS OF CHOREA. of the body. In most cases they are at first limited to one side^ the left being more frequently affected than the right ; but sooner or later the affection extends to the other side of the body. The twitchings exhibit every variety of force and character ; the fingers are often suddenly flexed^ the forearm is alternately pronated and supinated, and these movements are combined in every possible way^ so that the limb assumes the most unnatural positions. Many muscles of the neck and face are similarly affected_, the head is jerked about, and the mouth, nostrils, and eyebrows are contorted in various directions. All the movements are exaggerated when the patient knows that he is under observation, and especially when he is told to do anything. He is able to perform the action, but he does it hastily, and executes many unnecessary movements. When the twitchings extend to the leg the limb is moved in various directions while the child is sitting or lying down. When he walks he finds that he has imperfect control over the limb ; it becomes difficult for him to move in a straight line. One step is taken rapidly, and another slowly, and the steps vary in length and direction. In the early stages of the complaint the patients often endeavour to disguise the convulsive movements SYMPTOMS OF CHOREA. i>jiy by voluntarily making others in a similar direction. If, however, the case goes from bad to worse voluntary movements gradually become impossible ; the patient can do nothing for himself, but has to be dressed and undressed, fed, and otherwise attended to. Continuous speaking becomes more and more difficult, and at last impossible ; owing to inco-ordination of the muscles of the lips and tongue the words are jerked out and cut short. There is often some amount of aphonia,, due to implication of the muscles of the larynx^ In the large majority of cases the movements cease during sleep, which, however, is often restless and disturbed by dreams. Evidences of mental disorder are noticeable in many ■cases of chorea. The irritability and excitement which characterize the early stages are apt to become more and more decided ; but later on these symptoms are succeeded by others indicative of depression and mental weakness. The face wears a decidedly fatuous aspect, or a look of utter despondency. Studies have to be given up; the child may completely forget all that he had previously acquired, and appear to be little better than an idiot. In severe cases in adults the patient may become maniacal. In chorea, as in many other nervous affections, ,8o SYMPTOMS OF CJIOHJEA. there are great differences in the character and intensity of the symptoms in different cases. In the mildest forms there are only slight twitchings of the muscles of the face^ shrugging of the shoulders^ or perhaps some irregular movements of the hands. In severe cases the convulsive movements may extend to the whole of the body, and be so violent as to make it very difficult to keep the patient in bed. Between these two extremes there are many various degrees of severity. The more prominent symptoms require a somewhat closer analysis. The motor disorders are twofold, and take the form of spontaneous convulsions and subse- quently of inco-ordinate movements which result from the patient's attempts to perform common actions. When, for instance, he wishes to hold out his hand, the limb makes a series of movements more or less wide of the mark before the purpose is accomplished. In other cases common voluntary movements are effected in a manner which is almost normal, whereas the more automatic actions, such as grasping and retain- ing an object, walking, sewing, writing, etc., are accom- panied by marked choreic movements. The convulsive twitchings do not seem to cause fatigue, but as time goes on a general weakness becomes developed, and SYMPTOMS OF CHOREA. i8i loss of power iii oae side^ to a greater or less extent, is often observed. When there are evidences of real paralysis the existence of organic lesions in the brain may, of course, be inferred. The galvanic excitability is generally increased, especially on the affected side in cases of hemichorea. With regard to disorders of sensation, there may be some amount of anaesthesia in one or more limbs, and pain may result from severe spasms. In some cases points douloureux can be detected on pressure along the spine, and on the large nerve-trunks of the extremities. Evidences of derano-ements of the organs of circula- tion are often present. The pulse is usually frequent and sometimes irregular owing to the spasmodic con- tractions of the muscles. Murmurs of various kinds are audible in many cases; mitral systolic is most common in those connected with rheumatism; in. anaemic subjects a systolic murmur may be heard at the base, gradually to disappear as recovery proceeds. In cases of chorea of average severity the disorder lasts from six weeks to three months. Its course, how- ever, is seldom uninterrupted ; exacerbations are apt to occur, and relapses are not unfrequent even after a recovery supposed to be complete. Under favourable i82 DIAGNOSIS OF CHOREA. circumstances the symptoms gradually subside; the movements of the legs become less and less marked^ then those of the arms, and lastly those of the face. In many cases contortions of the features are noticed for weeks or months after the other symptoms have ceased. In children the prognosis is generally favour- able^ complete recovery is the rule_, and sequelae of any kind are seldom observed. An incurable condition of dementia may_, however, supervene, and certain muscles may become permanently weak and atrophied. In fatal cases, which, unless the disorder supervenes on acute rheumatism, are very rare, death is generally caused by exhaustion due to the severity and continu- ance of the paroxysms. In adults the disorder always runs a very chronic course, and it terminates fatally in a large proportion of the cases. About 30 per cent, of cases of chorea occurring in pregnant women end in death. Diagnosis. In the majority of cases, chorea is easily distinguished. The movements may be mistaken for those which characterize disseminated sclerosis, but this affection occurs mostly in adults and is rare in children. Moreover, in sclerosis the movements consist of fine TREATMENT OF CHOREA. 183 rhythmical tremors ; in chorea they are much more ex- tensive^ and of a jerky character. In doubtful cases the course of the disorder under treatment will aid the diagnosis. Treatment. Slight cases of chorea often recover under the influence of good food_, a proper amount of rest^ change of air and scene, and moderate exercise^ and these and all other measures calculated to improve the general health should be adopted as far as pos- sible. Every endeavour should be made to ascertain the cause of the attack, or the circumstances under which it originated. If the condition be one of anaemia and debility, cod- liver oil and iron are especially indicated ; if worms be suspected, suitable anthelmintics should be administered; and any existing disorder of the generative organs should be carefully inquired into and treated. Ordinary routine treatment should not be adopted until a thorough ex- amination has been made with the view of discovering a local source of irritation. When chorea occurs in a child attending school the eyes should be carefully examined. If hypermetropia, asthenopia, or astigmatism be found to exist a general tonic regimen should be adopted, and suitable glasses prescribed. Absolute rest of mind must i84 TBEATMENT OF CHOREA. be enjoined; and no lessons of any kind are to be thought of until the choreic symptoms have completely disap- peared, and a decided improvement has taken place in the general health. In cases of chorea following rheu- matism, iodide of potassium with alkalies and cinchona is likely to be serviceable, and cod-liver oil may be given at the same time. When all possible causes have been dealt with as far as possible, it is time to have recourse to certain drugs which have a beneficial action on the symptoms. Arsenic is the most generally efficacious, and Fowler's Solution is the most convenient form for its adminis- tration. From three to ten minims may be given in a little peppermint water or infusion of orange three times a day after meals. It is well to begin with a small dose, and gradually to increase the quantity taken by adding one minim to each dose every four or five days. Sym- ptoms of gastric disorder must, of course, be watched for; if the appetite fall off, if there be pain in the stomach or frequent eructations, either the dose must be diminished or the medicine altogether omitted until the gastric symptoms have disappeared. Sulphate of zinc is another remedy of this kind, but is less efficacious. It is given in doses of a grain two TREATMENT OF CHOREA. 185 or three times a day_, and these are gradually increased by successive additions, until thirty or forty grains are taken daily. Strychnine, as recommended by Trousseau^ may be tried if arsenic fails. Iron has been already mentioned ; it may be combined with arsenic^ especially in ^anaemic cases. With regard to external remedies, cold applied to the spine is sometimes very efficacious in lessening the fre- quency and extent of the movements. The ether spray or an ice-bag may be employed. The latter should be kept in position for about ten minutes daily, or the spray may be applied to the upper part of the spine for a somewhat shorter time. As measures of a tonic character, sponge baths, with tepid or cold salt water, followed by friction, are useful auxiliaries. Shower-baths are sometimes recommended, but are seldom advisable on account of the alarm they are likely to cause. When the convulsive movements are very severe, and so continuous as to deprive the patient of rest, narcotic remedies must be tried. Chief among these is chloro- form, but the relief it affords is only temporary. Chloral hydrate is another remedy of this kind ; to be of any use it must be given in full doses. Its action is more pro- 1 86 TREATMENT OF CHOREA. longed than that of chloroform, and it has a very decided effect upon the convulsive movements. While the patient is under its influence attempts should be made to administer nourishing food. The bromides and the preparations of opium have a far less potent influence in arresting!; the movements. As a matter of course, in all severe cases great care should be taken to prevent the patient from injuring himself. He must be kept in bed and constantly watched. There is one other point to be attended to in connec- tion with the treatment of chorea. In view of the liability of the disorder to spread from imitation, the patient should, as far as possible, be kept away from other children. CHAPTER Vir. NEURALGIA. Pain, its Nature — Sensory and Tactile Nerves, their End- Organs, Fibres, and Nerve-Centres — Varieties of Pain — Essential Features of Neuralgia — Cause of Neuralgic Pain — Changes in Nerve-Centres — Atrophy of Posterior Roots — Vaso-motor Disorder — Predisposing Causes of Neu- ralgia, Hereditary Predisposition, Debility, Age, Sex — Exciting Causes, Cold and Damp, Injuries, Pressure on Nerves, Constitutional Disorders, Gout, Diabetes, Syphilis, and Malarious Fevers — Symptoms, Peculiarities and Du- ration of the Pain, Remissions, Intermissions, and Re- currences — Locality of the Pain as a Guide to the Cause — Pain Extending Centripetally and also Radiating Along the Course of Neighbouring 'Nerves — Points Douloureux — Cutaneous HyperjEsthesia and Anesthesia — Motor Disorder — Vaso-Motor Disturbances and Disorders of Secretion and Nutrition-t-Eruptions of Herpes and Erythema — Effects. OF Neuralgia — Diagnosis — Treatment — Discovery of Cause — Symptomatic Treatment — Quinine, Arsenic, Salicylate OF Sodium, Iodide of Potassium — Anodynes, Morphine and Atropine — Liniments — Counter -Irritation — Electricity — Various Tonic Remedies — Neurotomy and Neurectomy — - Summary of Treatment. Pain may be defined as a peculiar form of common sensation^ provoked by the action of relatively strong stimuli on sensorv nerves. According: to the most i88 NJEURALGIA. recent physiological doctrines, the sensory nerve trunks contain two functionally different kinds of nerve fibres, viz., those which convey impressions of pain, and those which administer to tactile impressions; with the latter group the sensations of temperature and pressure are associated. Landois states that the sensory and tactile nerves have in all probability different end-organs and fibres, and that they have also special perceptive nerve- centres in the brain, although this is not definitely proved. In support of these views he cites among others the following facts, (i). Tactile sensations are absent from all internal viscera ; impressions of pain alone are discharged from these organs. (2). The con- duction channels of the tactile and sensory nerves are in different parts of the spinal cord. Tactile impres- sions are conveyed through the posterior columns of the same side, while painful impressions are conducted through the grey matter, and some of the conducting fibres pass from one side of the cord to the other. (3). A small portion of the grey matter, if left undivided, suffices to conduct painful impressions; if the division be complete the conduction does not take place, but provided that the posterior columns are uninjured tactile impressions are still transmitted. Thus one CHAMACTEBISTICS OF NEURALGIA. 189 sensation may be abolished while the other is retained. The irradiation of painful impressions, so often noticed, is explained by the fact that they are conducted by the whole of the grey matter. Several varieties or qualities of pain are more or less distinguishable from each othery and are often described by such epithets as '' burning/' " piercing/' '' cutting:/' "boring/' "pricking/' "splitting/' "dull/' "heavy/.' etc. The use of these terms implies that there is something superadded to the peculiar sensation of pain. Thus when the hand is exposed to intense heat the sense of temperature is appealed to, and a definite quality is assigned to the pain ; in like manner, when a needle is thrust into the finger the sense of touch is affected, and a form of pain distinguishable from other kinds is experienced. The general meaning of the term neuralgia is sufficiently obvious^ though it is not easy to suggest a precise definition. Its essential features may, however, be thus described : — I. Neuralgia is characterized by paroxysmal attacks of more or less violent pain, coming on either at regular or irregular intervals and of uncertain duration, and pre- senting complete intermissions or decided remissions. igo THEORIZES OF CAUSATION OF PAIN. 2. The pain extends over distinct areas supplied by sensory nerves^ and is likewise felt in the course of the nerve trunks. 3. The attacks of pain come on spontaneously^ or as a result of slight irritation. 4. There is no discoverable lesion of any organ situated within the region which is the seat of the pain. 5. The attacks are not followed by any general symptoms. The various ways in which pain may be provoked are only too well known^ but the actual cause of neuralgic pain is still a matter of speculation. According to a somewhat plausible theory this prominent symptom is due to a chemical process or change acting upon the nervous system. Experiments have proved that irrita- tion of a nerve is followed by elevation of temperature in the nerve-substance, and a change in its chemical re- action. Lactic acid and acid sodium phosphate are formed^ so that the reaction in the nerve- trunks, previously alkaline, becomes at least neutral, while in the nerve-centre the reaction may be distinctly acid. These changes, however, are only of a temporary charac- ter ; the acid products are soon neutralized by the alkalies of the blood, and are absorbed and removed. Granted, THEORIES OF CAUSATION OF PAIN. 191 however, that this explanation be the correct one, the manner in which the chemical results of the irritation act upon the nerves remains unknown. The periodicity of the attacks may be accounted for in a manner analogous to that by which the same peculiaritv of other processes is explained. The inspiratory'act, for example, is provoked by the poverty of the blood in oxygen. The respiratory centre is stimulated when the blood has lost a certain amount of this gas, and con- tains an increased amount of carbonic acid. In neuralgia the attacks are excited when sufficient quantities of the irritating materials have become accumulated. At first and for some time neutrali- zation is effected as above described, and the attacks cease ; but after a while, as a result of fatigue of the vaso-motor apparatus, neutralization and absorption are less rapidly effected, and the attacks increase in dura- tion and severity. After a time central changes take place, and these have a tendency to become permanent. It is these chano-es in the nervous centres which are concerned in the production of the pain. In neuralgia of a mixed nerve, if onlv the trunk were affected, motor phenomena would show themselves, but this com- plication is not always observed. The irradiation of 192 TEEORIJES OF CAUSATION OF PAIN. the pain along branches of other nerves is likewise a proof of the existence of central changes. This theory of the causation of pain has much to recommend it^ but it has not as yet been supported either by experimental or pathological evidence. In one case of tic douloureux recorded by Billroth atrophy of the nucleus of the fifth nerve was found combined with dilatation of the vessels. Other theories of neuralgic pain deserve a brief notice. The late Dr. Anstie considered that neuralgia was due to atrophy, or to processes leading to atrophy, of the posterior roots of the spinal nerves or of the grey substance connected with them. He supposed that certain cells and groups of fibres were, so to speak, congenitally loci m'moris resistentice, under the in- fluence of such agents as exposure to cold, injuries, mental shocks, alcoholic excesses, as likewise during puberty, pregnancy, and senile disordersof nutrition. It is supposed that these and similar causes tend still further to damage cells and fibres originally weak, and ultimatelv produce a condition of atrophy. Very little pathological evidence has, however, been adduced in support of this theory ; on the other hand, in some cases of neuralgia of spinal origin the roots of the nerves and the grey THEORIES OF CAUSATION OF PAIN. 193 substance of the cord were found quite normal, whereas the posterior columns showed, very decided appearances of irritative changes. The fact that neuralgic svmptoms are common in the earlv stages of locomotor ataxy would appear to indicate that in addition to the roots and the grev substance the posterior columns may be implicated in the causation of neuralgic pains. According to another view_, atrophy of the nerves^ due to inflammatory processes, renders them liable to violent attacks of pain_, the original seat of the lesion in the majority of neuralgias being within the vertebral canal or in the cranium. Inflammatory affections of the mem- branes of the cord and brain, slight in extent and otherwise dev^oid of symptoms, are the principal lesions of this char- acter. In the origination of these excentric neuralgiae_, the vaso-motor nerves play a prominent part, inasmuch as they supply the mechanism which produces an attack of pain_, even in central aflections. Local disorder of circulation at the seat of pain is the result of the action of these nerves. The same vaso-motor mechanism can likewise be called into action at the periphery by causes acting there, with results similar to those due to central changes. Primary irritation of the posterior roots, caused by local anaemia, hypersemia, etc., may, bv reflex action 13 194 CAUSES OF NEURALGIA. upon the vaso-motor fibres, which accompany the anterior roots, play a conspicuous part in the produc- tion of excentric neuralgia. Without discussing these theories any further it is sufficient to remark that vaso-motor changes would seem to furnish a clue to many of the symptoms of neuralgia. The predisposing and exciting causes of neuralgia are of various kinds. The first-named class includes (i) a nervous constitution, for the most part of hereditary origin ; {%) debility ; (3) age, and (4) sex. Neuralgia is especially liable to occur in persons who suffer from other nervous affections and in those with a family history of such disorders as epilepsy, hysteria, etc. It is also common in anaemic and debilitated subjects generally, and especially in those whose strength has been reduced by over-exertion, bodily or mental, excesses of all kinds, etc. Neuralgia is an affection of adult life ; but it sometimes occurs in old age, though rarely in children. Some forms, notably tic douloureux, are more common in women ; others, such as sciatica, are more frequent in men. Among the exciting causes of neuralgia cold and damp and exposure to draughts occupy the first place. CA USUS OF NE URAL GIA . 1 95 We have no certain knowledge as to the manner in which cold acts upon a nerve_, but it is generally sup- posed that slight anatomical changes of an inflammatory character are induced. Other causes of neuralofia are injuries of various kinds^ the presence of foreign bodies and morbid growths in the neighbourhood of the nerves ; and diseases of the bones and periosteum, especially of that lining canals through which the nerve passes. Pressure upon nerves, however, does not aKvays give rise to neuralgia. Various constitutional disorders, e.g., gout, diabetes, syphilis, and malarious fevers, often play an important part in the production of neuralgia. The influence of malaria in this respect is often well-marked, the attacks coming on at regular intervals, and curable only by large doses of quinine. We are quite in the dark as to the manner in which the malarious poison affects the nerves. Climatic con- ditions, e.g., rapid changes of temperature, with excess of moisture in the air, determine the prevalence of neu- ralgia in many parts of the world. Neuralgic pains occurring in gouty subjects may be attributed to the direct influence of the uric acid upon the nervous tissue, but why certain nerv^es are usually affected while others escape is a mystery which appears to defy solution ,()6 SYMPTOMS OF NEUEALGIA. In some patients of gouty habit the pain is felt in the course of those nerves \vhich_, from their position, are most exposed to the influence of cold and damp. Analogous to these cases of constitutional neuralgia are those in which the symptom is traceable to the presence of lead, copper, or mercury in the system. Some forms of neuralgia are evidently of reflex origin ; thus diseases of the uterus often excite neuralgic pains in the lower limbs, and even in the face and head. Symptows. Neuralgic pains may be classified under two heads ; when due to obvious causes they are known as symptomatic ; when no cause can be ascertained the term essential is used. As instances of sym- ptomatic neuralgia may be mentioned the severe shoot- ing pains characteristic of vertebral caries, and of aneurisms in general ; in these cases the pain is assumed to be due to inflammation or pressure. In essential neuralgia no such causes are discoverable, and we are too ready to assume that they do not exist. On the other hand, analogy would lead to the inference that severe and continuous pain is always connected with changes either in the nerves or nerve-centres, and the term essential, as applied to neuralgia, should be only provisionally used. Subject to this proviso, a SYMPTOMS OF NEURALaiA. 197 description will first be given of the general symptoms of neural o;ia, and the various local affections of this character will next be discussed. Neuralgic attacks are most frequently preceded by symptoms indicative of irritation of the cutaneous sensory nerves supplied to the part. These prodromal symptoms take various forms^ e.g.^ sensations of itch- ing, tingling, cold_, warmth_, pressure, tension, etc. After these have lasted a variable time pain supervenes and rapidly increases till the maximum intensity is reached. In some cases of neuralgia prodromal sym- ptoms are almost or altogether absent; the attacks come on without anv w^arninsf. A common feature of neu- ralgic pain is the lightning-like rapidity with which it shoots through the affected part; it starts, as it were, from a centre, and radiates in various directions to certain points from which it appears to return to its seat of origin. At the height of its intensity it is often described as well nigh unbearable ; its special peculiari- ties are further designated by such epithets as '' prick- ing," ''' tearing,^^ ''Mourning," '^^ boring," and similar terms. The duration of the pain varies ; in many cases after remaining at the same degree of intensity for a few seconds or minutes a remission occurs, or even a com- 198 SYMPTOMS OF NJEURALGIA. plete intermission. This interval again varies in dura- tion ; it may last only a few seconds^ when the pain recurs with its former intensity. In another class of cases the pain continues for hours or even for several days, with temporary remissions. Even when very severe, and apparently at its height, lightning-like shocks of still greater intensity are often experienced. Recurrences are wont to occur either at regular or irregular intervals ; and between the attacks the patient is either quite free from pain or complains only of a feeling of soreness or bruising, which, though it may be severe, is lightly regarded when compared with the previous agony. The locality of the neuralgic pain may, to some extent at least, be a guide to its origin. Thus gouty neuralgia most frequently appears in the form of hemicrania; and other forms, notably sciatica and facial neuralgia, some- times alternate with articular gout. Mr. Hutchinson thinks that a gouty origin may be assigned to neuralgic attacks taking the form of sharp explosions of lightning- like pains over the parietal bones, and occurring in quick succession, but unaccompanied by tenderness on pressure. As I have stated in my work on Gout, " such attacks are sometimes to be traced to indulgence in wine and animal SYMPTOMS OF NEURALGIA. 199 food j they are relieved by purgatives and alkalies. We may assume that the pain is due to hyperaemia and oedema of the neurilemma,, but why only certain branches of a nerve should be affected as a result of the constitu- tional disorder is a question that cannot be solved/' Neuralgia due to syphilis may affect almost any sensory nerve ; in the early part of the secondary stage pain in the scalp^ from the ears to the vertex^ and extending over a space two inches in widths is comparatively frequent. Facial and occipital neuralgia and sciatica are also common in the secondary stage^ and severe intercostal neuralgia has been noticed in a few cases. In neuralgia it frequently happens that the pain is felt not only in the parts supplied by the peripheral expansion of the nerve, but in the nerve-trunk itself. Thus in neuralgia of the fifth pair the pain often shoots along the course of the affected branch, usually in a centrifugal direction though sometimes towards the nerve-centres. In the latter case there is generally some tenderness on pressure over the course of the nerve, a symptom which may be regarded as indica- tive of neuritis. The sheaths of the nerves are supplied with special nerve-fibres, and are thus endowed with sensibility. The tenderness is probablv due to irritation 200 SYMPTOMS OF NEURALGIA. of these nerves, which are the channels for the conduc- tion of painful impressions. Radiation along the course of neighbouring nerves is sometimes noticed in connection with neuralgic attacks. Thus in facial neuralgia affecting one branch of the fifth, pain is occasionally felt in another branch, in the occipital or cervical nerves, or even in some branch of the brachial plexus. In other cases the pain affects a branch of the fifth on the opposite side of the face. In like manner in intercostal neuralgia branches of the brachial plexus are sometimes affected ; abdominal neuralgias are some- times complicated by pains in the thigh, while other vis- ceral neuralgias are frequently associated with pain in the cutaneous nerves, either of the superjacent surface or at some distance from the affected part. Such radiation is especially apt to occur when the pain is at its height, and is explainable by the fact, already referred to, that the whole of the grey matter of the spinal cord serves for the conduction of painful impressions, the effect of which is in proportion to their intensity. Radiated pain of this character may be described as reflex neuralgia; examples of it are not unfrequently met with in persons with hereditary predisposition to nervous diseases. Certain other phenomena are often prominently P OINTS DOULO UR:E UX. ' 201 associated with neuralgic attacks ; those most fre- quently noticed are the so-called points douloureux, the cutaneous hyperaesthesia and hypaesthesia and symptoms of vaso-motor disorder. Nearly fifty years ago atten- tion was called by Valleix to the fact that in neuralgia affecting superficial nerves it is often possible to detect certain spots which during the attack are exquisitely painful on pressure. These spots are always to be found in the course of the nerve-trunk_, or of its prin- cipal branches, and generally correspond with bony foramina and openings in fibrous structures through which nerves pass. The area of tenderness is usually small and well defined, but in some cases a large por- tion of the trunk of the affected nerve is equally sensi- tive to pressure. The tenderness is most marked when the pain is at its height, and is either reduced to a minimum or is altogether absent during the intervals between the neuralgic attacks. These points douloureux are not discoverable in all cases of neuralgia ; it is indeed often noticed that the pain is relieved by firm pressure over the nerve, but aggravated by a gentle touch. Spontaneous pain is rarely felt at these points, even during a severe attack, and this apparent anomaly is due to the fact that the integument covering the 202 SYMPTOMS OF NEURALGIA. affected nerve is often supplied by nerves unaffected by the cause of the pain. For the discovery of the points douloureux pressure is always necessary. It has been supposed that the pain thus elicited is due to the existence of local circumscribed lesions, of an inflam- matory character^ in the course of the nerve, such lesions being either at the painful spots or between them and the nervous centres. Some amount of cutaneous hyperaesthesia is a frequent concomitant of neuralgia and especially in the early stages; as time goes on the sensitiveness of the skin is apt to become reduced, though not to any great extent. A similar change is sometimes observable in the sensations of temperature, pressure, and locality. The anaesthesia is usually restricted to the part supplied by the affected nerve; but it sometimes extends beyond this limit. Pain of a non-neuralgic character is oc- casionally followed by one or more of these forms of perverted sensibility, but they are more often observed in connection with neuralgia. Disorders of motor nerves are not unfrequently as- sociated with neuralgic pain, and the connection between the two affections may be either direct or reflex. In neuralgia of mixed nerves the motor fibres S TMPTOMS OF NE URA L GIA . 203 are liable to suffer from the same causes which act upon the sensory nerves. Hence the pain may be. accom- panied by symptoms of irritation^ such as fibrillary twitchings, or even clonic spasm of muscles_, and sub- sequently by loss of power_, seldom amounting to paralysis. Symptoms of irritation may be also of reflex origin ; thus the convulsive form is sometimes super- added to tic douloureux_, and this is due to reflex irrita- tion of the facial nerve_, following upon the irritation of branches of the fifth. In some cases of neuralgia the cardiac and respiratory movements are aflTected by reflex action. Evidences of vaso-motor disorder are commonly ob- served in various forms of neuralgia. Thus at the be- ginning of the attack there is usually excitement^ and later on paralysis, as indicated by contraction and sub- sequent dilatation of the blood-vessels. In many attacks of tic douloureux the face^ conjunctiva and mucous membrane of the nose are at first pale and afterwards flushed. Even the gums are sometimes aflected in a similar manner. In sciatica the skin of the leg^ especially about the heel, is sometimes observed to be reddened when the pain is at its height. Evidences of disorders of secretion and uutrition come 204 SYMPTOMS OF NEURALGIA. next in point of frequency. Daring neuralgic attacks it is often noticed that the saliva is increased, that the tears and nasal mucus flow freely; and the secretion of milk^ perspiration, and urine has been observed to become more abundant. The nutrition of the affected part not imfrequently suffers in chronic cases^ the changes being most prominent in the hair_, skin, and mucous membrane. In cases of supra-orbital neuralgia single hairs, or even patches of hair, sometimes lose their colour and become white; a similar change has, indeed, been observed during an attack, the hair regaining its normal colour after the pain had subsided. • Sometimes the hair falls out; in rare cases it grows more freely and becomes thick and coarse. Changes in the skin itself are likewise common; sometimes there is copious deposit of pigment, more often the skin and subcutaneous tissue are atrophied, and the muscles are apt to be similarly affected in cases of neuralgia of the limbs. The changes in the mucous membranes are, of course, less frequently observed, but in neuralgia of the fifth pair there is often increased growth of the epithelium of the mouth, and especially over the tongue on the affected side. Other forms of disorder are liable to appear in the integument, the most marked of these being an eruption SYMPTOMS OF NEURALGIA. 205 of herpes. This, in some cases, is very peculiar ; the course of the affected nerve is marked out by a red streak upon which groups of small vesicles become developed ; these contain a clear watery fluid, which afterwards becomes cloudy and then dries up. The crusts thus formed drop off, leaving reddened patches, but some- times small ulcers. The association, however^ of neu- ralgia with herpes is by no means constant; for, as is well known, the eruption often occurs without anv accompanying pain beyond a little smarting. When the association exists the pain and the eruption mav appear together ; but more frequently the latter precedes the former. The most marked form of herpes is seen in connection with intercostal neuralgia. Patches of erythema and even erysipelas are some- times noticed along the course of nerves affected with neuralgia, and the redness may extend for some distance on either side. A very decided attack of facial erysipelas has been known to supervene during the course of facial neuralgia, the attacks of which ceased to trouble the patient after the erysipelas had subsided. Pemphigus and urticaria are less frequent, and their occurrence may be taken as evidences of neuritis. The condition known as ^' glossy skin " is sometimes witnessed under 2o6 DIAGNOSIS OF NEURALGIA. similar circumstances. The skin is thin^ smooth^ shin- ing and reddened^ and looks as though it had been stretched. Repeated attacks of neuralgia often produce a very serious effect upon the general health of the patient in consequence of the severity of the pain, the loss of sleepj and of appetite. A condition of profound melan- cholia is set up in some patients. The attacks are the more trying inasmuch as in many cases there is no security for the sufferers that they will be free from them for any length of time : the intervals of freedom are for the most part irregular and uncertain, and owing to the depression which is set up the pain becomes more and more intolerable as time goes on. Its severity and duration are, of course, influenced by the nature of its cause and other circumstances. The younger the patient, the more likely is the pain to be relieved or cured by remedies ; in old people, especially if debilitated, neuralgia is generally very obstinate. Diagnosis. The diagnosis of neuralgia is for the most part easy. The apparently spontaneous acces- sion of the pain, its intermittent character, its cor- respondence with the course of certain large nerves, along which painful spots may often be detected on JDIA GNOSIS OF NE URA LGIA. pressure, are the main points to be attended to. The cause and exact seat of the neuralgia are much more difficult to determine. It is important to decide whether the cause be peripheral or central. In the former case the evidences of vaso-motor disorder and of paralysis (should any such exist) will be confined to the parts adjoining the affected nerve. Neuralgia of central origin is inconstant in locality_, apt to wander from place to place_, lancinating in character, and often appears to be deeply seated^, whereas in the peripheral form the pain follows the course of a more or less superficial nerve. Neuralgia of central orio-in is a common symptom of some cerebral and spinal dis- orders, e.g., of tumours of the brain and of locomotor ataxy. It is important also to distinguish cases of neuralgia due to neuritis from those in which inflammation of the nerve is presumably absent. In all cases complete intermission of pain is evidence against neuritis ; continuous pains (even with paroxysmal exacerbations) are in favour of it_, and in an especial degree wdien associated with other phenomena. The presence of trophic disorders in the hair, nails, or skin is in favour of neuritis, and so likewise is early 2o8 TBEATMIJNT OF NEURALaiA. anaesthesia, appearing in the course of a few days. Swellino; of the affected nerve is another si2;n of inflam- mation, but it does not occur in every case^ and is often not to be felt, on account of the concealed position of the nerve. It is, moreover, probable that the appear- ance of herpes zoster along the course of a sensory or mixed nerve is evidence of neuritis, generally of an acute character. In cases of long-protracted neuritis a time may come when the spontaneous pain and the pain elicited on pressure may both disappear, owing to complete destruction of the nerve-fibres resulting from the perineuritis or neuritic processes. Treatment. A description will first be given of the treatment of neuralgia in general ; the remedies more especially suitable for the various forms of this com- plaint will be mentioned in the ensuing chapters. Having ascertained that any given case is one of true neuralgia, every attempt should be made to ascertain whether there be any obvious cause of the pain, i.e., whether there be any tumour or foreign body or aneurism pressing upon or irritating the nerve. Inquiry should also be made for evidences of constitutional disorder, e.g., gout, diabetes, syphilis, etc. In women, evidences of hysteria should be sought for and noted. If the TRJEATMJENT OF NEURALGIA. 209 attacks recur at regular intervals inquiry should be made as to whether the patient has ever been exposed to malarious influences, and a similar question should be put with regard to lead and mercurv in cases in which there is any reason to suspect the influence of these metals. In manv cases of neuralgia the cause remains un- discovered even after the most careful investigation, and the treatment of the symptom is all that can be attempted. For this purpose we have a host of remedies at our disposal ; some of these will now be mentioned_, but their special uses will be described in the chapter on the various forms of neuralgia. Of all medicines quinine is the one most generally serviceable ; in cases due to malaria it often acts like a charm. In other cases also its good effects are often no less re- markable. It should be given in large doses (grains v-xx), and its effects watched. EiBcacious as it fre- quently is in tic, it is seldom of any avail in sciatica. If there be headache the quinine mav be advantageously combined with half- drachm doses of dilute hydrobromic acid. Arsenic may be tried if quinine fails; it is best given in the form of Fowler''s solution (nj, v-x) three times a dav after meals. If there be an\ history of 14 2 1 o TRUA TMjENT of NF URAL GIA . rheumatism the salicylate of sodium may be tried in doses of about twenty grains every four or six hours. A syphilitic history will indicate iodide of potassium, and neuralgia occurring in gouty subjects will often yield to purgatives, alkalies, and colchicum. If the in- fluence of lead be suspected, iodide of potassium and purgatives should, of course, be tried. Anodynes of various kinds are the main remedies in the symptomatic treatment of neuralgia, morphine being the one most commonly used. It is best administered subcutaneously, the dose being proportioned to the severity of the pain, but half a grain of the acetate should be regarded as the maximum. It is not necessary to make the injection close to the painful spot; the arm or the forearm is generally the most convenient place. Relief is almost invariably experienced, and in some cases the pain disappears after one or two injections. Morphine thus administered is less likely to affect the head and organs of digestion than when given by the mouth ; but patients are occasionally met with who can take the drug in the latter way without discomfort, whereas a hypodermic injection produces most distress- ing head- symptoms. There is a serious drawback con- nected with the use of morphine in severe and chronic TREA TMJENT OF NEURALGIA. 211 caseSj inasmuch as larger and larger doses are required for the relief of the pain ; the so-called morphine-habit is not unfrequently induced^ and attended with conse- quences of a very distressing nature. Under no circum- stances should a patient be allowed to inject the anodyne himself. It is sometimes advantageous to add a minute quantity (gr. i^o'tV) of the sulphate of atropine to each dose of the morphine used for injection. I have found this combination most serviceable ; the atropine coun- teracts the unpleasant effects of the morphine on the head and stomach. For external application anodynes may be used in a great variety of forms^ but it is only slisrht cases of neuralo;ia that are thus benefited. The liniments of aconite, belladonna, and opium, either separately or combined, may be thus used, and a little chloroform liniment may be added with advantage. These and other anodynes may also be used in the form of ointment. Aconitine and atropine are powerful remedies thus applied, and veratrine does good in some cases. The local application of butyl-chloral is sometimes very efficacious in facial neuralgia. In cases in which there are evidences of neuritis, that is when the affected parts, and especially the trunks of the nerves, are very tender on pressure, counter-irrita- 212 TRIIATMJENT OF NEURALGIA. tion is often serviceable. For comparatively slight cases we may employ a small mustard plaister, or the com- pound liniment of mustard^ or the tincture or liniment of iodine ; but these remedies are better adapted to remove the soreness and aching which often remain after the subsidence of the acute pain. For cutting short an attack, if neuritis be suspected, it is better to apply blistering liquid along the course of the nerve. When the pain is diffused, and affects any part other than the face, the use of Corrigan's firing irons is often attended with the most satisfactory results. If properly applied, the heated iron causes no pain. In some cases of neuralgia it is sufficient to apply counter-irritation at some distance from the seat of the pain ; thus, in tic douloureux, relief is sometimes experienced from a blister placed behind the ear, or even at the back of the neck. In the list of local remedies electricity occupies a prominent place. Its application often relieves the pain in a marked degree, though we can only speculate as to the manner in which it acts. It is often useful in cases in which it exerts no influence on the cause of the symptom, and in essential neuralgias it is often de- cidedly curative. Opinions differ as to the best method TRJEATMENT OF NEURALGIA. 213 of applying it, and if it be wished to give electricity a thorough trial in any given case each form should be tried in succession if others fail. In all cases mild currents should be first tried^ and the strength gradually increased if necessary. The good effects are sometimes speedily manifested. In other cases several applications are required, while in a third class no relief is procured. It is hardly possible to foretell the result with accuracy- in any case of neuralgia, but the remedy is always worth a trial. The induced current is applied by placing one rheophore in the patient^s hand or on any convenient part of the body^ and drawing the other over the course of the affected nerve. The wire brush is also useful for the latter purpose, and a current of medium strength should be used. When the constant or galvanic current is selected, the anode or positive pole should be placed upon the affected nerve or painful spot and moved gently over it. The negative pole is placed in the patient^s hand, and the strength of the current should be gradually raised. Another plan is to keep both rheophores in close contact with the skin over the affected nerve. When a long nerve, such as the sciatic, is the seat of pain, the positive pole should be applied over the spine and the negative over some portion of the course of the nerve. 214 TEJSATMENT OF NEURALGIA. It may either be kept firmly in one position or moved to and fro over the seat of pain. Other remedies used in the treatment of neuralgia vi^ill be mentioned in the chapter dealing with the various forms of the complaint. It v^ill suffice for the present to enumerate phosphorus and the hypo-phosphites; iron^ which is almost always useful in anaemic subjects ; gelsemium ; the bromides ; chloral^ etc. The only other methods of dealing with neuralgia which require notice are of a surgical character^ viz., diyision of the affected nerve (neurotomy) and excision of a portion (neurectomy). Very satisfactory results are sometimes attained by these means_, but they should never be resorted to until all other plans have failed. Neurotomy is most successful when some source of irritation which cannot be removed exists at the periphery, but it has been known to succeed in neuralgias apparently of central origin. Neurotomy may be performed subcutaneously, but there is this drawback to the operation, that even if successful at the time, the nerve is apt to unite and the pain to recur. Neurectomy prevents this recurrence, but cannot, of course, be performed subcutaneously, and to be efficient may involve considerable separation of the parts. TBEATMJENT bF NEURALGIA. 215 Nerve-Stretching is another surgical procedure some- times successful. It is impossible to explain the manner in which forcible stretching of the nerve pro- duces its good effects, but it has been suggested that in rheumatic or gouty cases the operation breaks up or overcomes some deposit which has taken place in the nerve sheath. The treatment of neuralgia in general as given in the preceding paragraphs may be thus briefly summarized. All sources of irritation should be carefully searched for and dealt with according to circumstances, and every, endeavour should be made to find out the cause of the attack. Relief of the pain is the next indication, and for this purpose anodynes are geaerally necessary. Electricity should then be tried, and likewise such potent remedies as quinine, iron, arsenic, bromide of potassium, etc. The general health of the patient almost invariably requires special attention. The surgical operations are the last resource, but they must not be regarded as altogether desperate remedies, inasmuch as they have proved markedly successful in not a few cases. Much may be done to prevent the recurrence of attacks, especially when the symptoms have been com- 2i6 TRIIATMENT OF NEURALGIA. paratively mild. Tonic treatment of all kinds is generally indicated. Good nutritious food taken at proper intervals, removal of the patient from an un- healthy locality, exercise according to capacity^ warm or cold baths are all likely to be serviceable. As a matter of course, the patient should avoid exposure to cold, over-exertion, and excesses of all kinds. CHAPTER VIII. VARIOUS FORMS OF NEURALGIA. I. NEURALGIA OF THE TRIGEMINUS— TIC DOULOUREUX. —II. INTERCOSTAL NEURALGIA.— III. SCIATICA. I. Causes of Tic Docloureux — Symptoms — Pain — Duration and Frequency of the Attacks — Exciting Causes — Two Kinds OF Pain — Motor Disorder — Spasm of the Facial Muscles — Vaso-Motor and Trophic Disturbances — Neuro-Paralytic Ophthalmia — Disorder of General Health — Neuralgia of the Supra-Orbital Branch — Neuralgia of the Supra- and, Inframaxillary Divisions — Two Stages often observed in Facial Neuralgia — Diagnosis — Treatment — Causal and Constitutional — Electricity — Anodynes, Morphine, Gel- semium — Specific Remedies, Quinine, Arsenic, Iron, Am- monium Chloride — Liniments — Counter Irritation — Neu- rotomy — Neurectomy — Nerve-Stretching. II. Intercostal Neuralgia, Causes and Symptoms — Points Dou- loureux — Complications and Course — Diagnosis — Irritable Breast or Mastodynia — Symptoms and Differential Diag- nosis — Treatment of Intercostal Neuralgia and of Mas- todynia. •III. Sciatica, its Frequency and Causes — Symptoms, their Nature AND Variety — Points Douloureux — State of the Muscles — Vaso-Motor and Trophic Symptoms — Sugar sometimes found IN THE Urine — Electrical Conditions of the Affected Parts — Course and Duration of Sciatica — Diagnosis — Prognosis — Treatment — Question as to Causation — Rheu- matism — Iodide of Potassium — Blisters — Hypodermic In- jections of Morphine and Atropine — Electricity — Flying Blisters — Acupuncture — Hot Baths — Warm Applications — The Scotch Douche — Hot Sand-Baths — Massage — Nerve- Stretching. 2i8 FACIAL NEURALaiA. The most frequent form of neuralgia is that in which the fifth pair of nerves is affected. In the last century the complaint was described by Fothergill as " painful affection of the nerves of the face." All three divisions of the nerve are liable to be affected ; but attacks are more common in the ophthalmic and superior maxillary than in the inferior maxillary branch. The pain is almost always unilateral. The comparative frequency with which this nerve is attacked is probably due to the fact that its branches pass through bony canals and are liable to irritation or compression as results of periostitis_, exostoses, caries, and other processes.. Peripheral irritation is a still more obvious cause, and marked instances of this character are those in which the pain is due to a carious tooth or to exposure to cold. Wounds of the face of various kinds and the lodgment of foreign bodies are occasional causes, and they may act either upon the peripheral expansion of the nerves or upon small branches. Lesions within the cranium, e.g., tumours at the base of the skull, and aneurisms, are still rarer causes of neuralgia, and in this category may likewise be included diseases of the nasal fossae, frontal sinuses, and of the tympanum. The majority of the above-mentioned causes are of an obvious character^ but there are many cases of tic CAUSES OF FACIAL NEURALGIA. 219 douloureux in which there is no evidence of any anatomical lesion. Syphilis, rheumatism, and gout may be mentioned as constitutional causes; and like- wise anaemia and chlorosis and conditions of debility in general.. The possibility of syphilis as a cause of neuralgia should always be borne in mind. I have lately been consulted by a gentleman, aged 49, a martyr to facial and general neuralgia, which had been altogether uninfluenced by quinine and other tonics. On inquiry I discovered that the patient had had syphilis thirty years previously. I prescribed the iodides and small doses of mercury, and in seventeen days the patient was quite free from pain, and since that time he has had no return of the symptoms. Exposure to malarious influences is another potent cause, and in a few cases exces- sive use of the eyes has been followed by neuralgia of the fifth nerve. The complaint is very rare in children and not common in young adults, unless in connection with carious teeth ; the patients are generally middle- aged or elderly, and females are more often attacked than males. It should never be forgotten that con- ditions and disorders of organs far distant from the seat of pain may be the actual cause of the symptom. Thus tic douloureux is sometimes associated with obstinate constipation, and ceases at once when the 2 20 SYMPTOMS OF FA CIA L NE URA LGIA. latter condition is relieved. There are other instances of a similar character^ e.g., those in which the pain occurs in persons suffering from disorders of the uterus, bladder_, bowels, etc., and lasts until these causes have been satisfactorily dealt with. Symptoms. In neuralgia of the fifth pair the pain is of a more severe character than in any other form. Its outbreak is often preceded by various abnormal sensa- tions, such as formication, burning, soreness, tension, etc., and sometimes by fibrillary twitching. The paroxysms of pain are liable to come on spontaneously ; but speaking and eating are very apt to provoke them. In severe cases the patient appears to be struck down by the pain ; he places his hand against his face and expresses the intensity of his sufferings by gestures and signs. The pain, indeed, according to the subsequent statements of many patients, transcends description; it is compared to that caused by a hot iron^ a knife, a gimlet, etc. The pain is liable to shoot along other nerves, e.g., the occipital, and sometimes to the shoulder and clavicle. During the intervals there is usually at first more or less hypersesthesia, but after- wards anaesthesia in the area of distribution of the affected nerve. An eruption of herpes sometimes pre- cedes the loss of sensation. SYMPTOMS OF FACIAL NEURALGIA. 221 The attacks vary considerably as regards their dura- tion and frequency. The acute pain may last for a few s'econds or for several minutes^ or even for some hours. When thus protracted^ the intensity of the pain is less than in the shorter attacks^ but lightning-like seizures of great severity are apt to occur at short intervals. In some cases many attacks occur durins;; the twentv-four hours ; in others the pain comes on daily or every other day^ or at still longer and irregular intervals, and there are innumerable varieties in this respect. Most patients can recognize two kinds of pain : the one continuous and the other paroxysmal. When the muscular spasms come on, the continuous pain ceases, but the agony during the paroxysms is very great. Sometimes the shocks are so frequent as to be almost continuous; they are only momentarily interrupted by exhaustion of the nerve. The most trifling; causes suffice to induce attacks in some patients, such as speaking, eating, a touch upon the face, combing the hair, changes of temperature, exposure to a draught, etc. I occasionally see an elderly lady who has been afflicted with tic douloureux for many years, and in v/hom a paroxysm is induced when she is suddenly addressed. In another case a paroxysm comes on when the eyes are exposed to a strong light, either sunlight or artificial. Very 222 SYMPTOMS OF FACIAL NFURALGIA. often indeed the attacks come on spontaneously, i.e., without obvious causation. In some patients mental excitement is enough to cause an attack. Unless due to syphilis, the pain is usually less troublesome at night. In warm summer weather the patient may remain free from pain ; the attacks are generally more severe and common in the winter and in damp weather. Even when pain is absent there are often abnormal sensa- tions in the area of distribution of the affected nerve. Symptoms indicative of motor disorder are often present in the form of convulsive spasms of the muscles supplied by the facial nerve. These generally precede the attack, increase in degree and extent when the pain is at its height, and subside during remission. It is sometimes noticed that the convulsions do not occur until the pain has existed for several days or weeks. In severe cases the muscular movements may resemble those of convulsive tic. Sometimes the muscles of visual accommodation are similarly affected, and spasms, both tonic and clonic, of the muscles of mastication (supplied by the motor branch of the fifth) are occa- sionally observed. These, however, are far less common than similar affections of the muscles supplied by the facial nerve, and this fact would seem to indicate that the nuclei of origin of the sensory portion of the fifth are SYMPTOMS OF FACIAL NEURALGIA. 223 more closely connected with the nuclei of the facial than with those of the motor branch. Vaso -motor disorder shows itself by redness and swelling of the affected side of the face during the attack; the eye is often suffused, and the gums swollen. Tears may flow down the cheek_, and the salivary and nasal secretions are apt to be increased in amount. These latter symptoms may remain for some time after the pain has subsided. Symptoms indicative of trophic disorder are frequent results in chronic cases. Some- times the face remains swollen^ and the features are enlarged on the affected side. An eruption of herpes is a frequent complication ; a streak of the integument becomes swollen and reddened_, and is covered with groups of tiny vesicles. A similar appearance is some- times seen on the conjunctiva covering the cornea_, and the result of such an eruption may be permanent opacity of the latter structure, and even destructive inflammation has been known to supervene. Another very serious lesion of this character is the so-called Jieuro-paralytic ophihahnia, which takes the form of an ulcerative keratitis generally in the lower part of the cornea^ and sometimes leads to purulent disintegration of the eyeball. It is doubtful whether this affection is the direct result of disordered nutrition. It seems more 224 SYMPTOMS OF FACIAL NEUEALaiA. probable that it is due to mechanical causes and irritants of the presence of which the patient is unconscious, owing to the loss of sensibility. It may be that the condition of the nerve lessens the capacity of the part for resisting irritation. Deafness sometimes occurs in connection with facial neuvalgia, and subsides w^hen the pain is relieved. A very common phenomenon is loss of colour of the hair, especially of the eyebrows. In the intervals the hair that grows is generally normal in colour, but sometimes the entire hair remains perma- nently white or grey. The general health always suffers in cases of severe tic douloureux. The pain and loss of sleep are apt to cause great depression of spirits and irritability. A condition of profound melancholia sometimes sets in, and not a few of such patients seek relief from morphine and alcohol, both of which, but particularly the latter, tend eventually to aggravate the neuralgia, besides caus- ing their own deleterious effects. Having given this general description of tic doulou- reux, it seems desirable to indicate the peculiarities of the symptoms connected with neuralgia of each of the three divisions of the nerve. The supra-orbital branch of the ophthalmic division is the one most frequently attacked. The pain sometimes SYMPTOMS OF FACIAL NEURALGIA. 22; takes theform of ciliary neuralgia, and occurs in combina- tion with such symptoms as spasm of the eyelids, intole- rance of light, and profuse lachrymation. Neuralgia with these symptoms is not uncommon in scrofulous children. Catarrh of the frontal sinuses is another cause of neu- ralgia of this branch. The pain is probably due to the pressure of the accumulated secretion upon the nerves dis- tributed to t?he membrane lining the sinuses. In this form the pain may extend from the eyelids to the vertex, down- wards to the tip of the nose and laterally to the temple. Pressure over the supra- orbital foramen will elicit pain, and other points douloureux may generally be detected , on the side of the nose and on the upper eyelid. When the second division of the nerve is affected the pain is usually felt in the infra-orbital branch, and pressure over the foramen of the same name causes severe pain. Other points douloureux are to be found over the malar bone, and on the upper lip, and the alveolar process of the superior maxillary bone. In old people this latter part is sometimes the seat of verv severe pain, due to irritation of the nerve from deposit of bony substance. The palatine and naso-palatine branches are seldom the seat of neuralgia. In neuralgia of the inferior maxillary nerve the pain 15 226 C0UR8:E OF FACIAL NEURALGIA. is usually felt in the inferior dental branchy and the internal opening of the inferior dental canal and the mental foramen are the ordiwdiVy points douloureux. The auriculo-temporal branch is less commonly affected. This branch supplies the meatus auditorius and the articulation of the jaw, and a painful point may be found over the temporal bone. Only in very rare instances is the lingual branch the seat of neuralgia. The symptoms are acute pain or a sensation of pins and needles at the tip of the tongue. Salivation is a prominent symptom in neuralgia of the inferior maxillary nerve. In such cases one side of the tongue is often thickly coated, and there may be irregular movements of the muscles of mastication and also of the tongue itself. It rarely happens that all the three divisions of the nerve are simultaneously affected, but whenever this is the case the points douloureux are to be found in a line from above downwards, viz., at the supra-orbital notch, and the infra-orbital and mental foramina. The uncertain course which neuralgia takes has been already alluded toj but it not unfrequently happens that at least two stages can be recognized. In the first, there is more or less severe continuous pain with frequent exacerbations, during which muscular twitch- COURSE OF FACIAL NEURALGIA, 227 ings come on. After a while the continuous pain sub- sides, but the severity and frequency of the paroxysnis ' remain as before. Later on, however, the latter become less frequent, and are no longer spontaneous, but occur only as the result of movements, or of bring- ing something into contact with the face. In the absence of these causes of excitement the patient enjoys immunity from pain, and shows no signs of the suffering which characterized the previous period. This phase of the disorder may last for some weeks, and pre- cede the complete cure; its supervention shows that the hyperaesthesia of the affected nerves is so slight as to be insufficient to cause spontaneous pain. It still, however, exists, though in a latent condition, and rises to such a degree as to cause pain when either movement or contact with a foreign body sets up the slightest amount of excitement. Speaking and eating are both liable to cause acute suffering; the swallowing of fluids is accomplished with less pain, but the contact of a glass, cup, etc., with the lips is almost certain to pro- duce a paroxysm. As time goes on, it is found, per- haps almost suddenly, that paroxysms are no longer provoked as above described ; perhaps a little tingling is all that remains, but this, too, disappears in the course of time. 228 tm:eatment of facial neubalgia. Diagnosis. This is for the most part easily made^ the distinguishing points being [a) the paroxysmal and spon- taneous character of the pain^ and the facility with which it is excited by slight causes; [h] its correspondence with the trunks or branches of large nerves^ and (c) the existence of points douloureux. Pain in the head and face may likewise be due to inflammatory affections of the bones or periosteum, to. inflammation of the tem- poro-maxillary articulation, etc., but such cases are easily, distinguishable from those of neuralgia. It is important to determine whether the cause of the pain is situated within or outside the cranium. As a general rule implication of several or many branches of the nerve is indicative of a central origin, while the restriction of the pain to one or two branches points rather to a peripheral cause. The determination of the cause, how- ever, of cases in which several branches are aflTected may be very difficult ; absolute incurability is, perhaps, the only indubitable sign of an intracranial cause. Neuralgia affecting simultaneously all three divisions of the nerve is by no means necessarily of central origin. Treatment. The general principles of the treatment of neuralgia have already been described (see page 208). Every attempt should be made to discover the cause. When the lower part of the face is the seat of the pain TREATMENT OF FACIAL NEURALGIA, 229 carious teeth will often be found, and these should be removed or otherwise dealt with. When the teeth are not carious^ and painful only during the attacks, it is useless to remove them. When there is a history of syphilis or of exposure to malaria, iodide of potassium and quinine are respectively indicated. Affections of the tympanum should be remembered as possible causes of facial neural2:ia, and likewise catarrh of the frontal sinuses in cases where the supra-orbital branch is the seat of pain. The catarrh may be relieved by a nasal douche of tepid water, containing gr. v of Sod. Bicarb, and Ammon. Chlorid. to 5 j, and by restoring the com- munication between the nose and the frontal sinuses, the pressure on the nerves will be lessened, aud the pain will subside. I have seen many cases much benefited by these measures. When the neuralgia appears to be connected with constitutional conditions, such as various forms of debility, the preparations of quinine and iron will be of marked service. When, on the other hand, there are symptoms of plethora and of cerebral hyperaemia, saline purgatives are indicated, and may be given in the form of the various mineral waters, e.g.. Fried richshall^ Marienbad, etc. For the direct treatment of tic douloureux, we have at 230 TBUA TMENT OF FA CIAL NF URALaiA. our command electricity in various forms, and certain anodynes and so-called specific remedies. Surgical aid may also be sought for cases otherwise intractable. The continuous current is generally to be preferred to the induced ; its application is more efficacious, and causes less pain. The negative pole should be pressed against the back of the neck, and the positive applied to the various painful points for from two to five minutes, the strength of the current being gradually increased. In severe cases two applications may be made daily, and it is sometimes of advantage to apply the current to the sympathetic in the neck. The effi- cacy of galvanism is sometimes very marked in cases of recent origin, and sometimes even old-standing cases, which have resisted all other methods of treatment, are relieved or cured by this remedy. If it fails, the induced current may be tried. A well-moistened sponge elec- trode is placed on a painful spot;, and the other at the back of the neck, while the secondary current is gradually brought into operation. Of remedies belonging to the anodyne class, morphine is the most useful, and is best administered subcu- taneously. Large doses are often required to produce any effect upon the pain. The butyl-chloral is another TREA TMENT OF FA CIA L NF URA L GIA . 231 valuable remedy ; about three grains should be given in a pill with mucilage of tragacanth every two hours up to six or eight doses_, if required. Gelsemium has an almost specific action in some cases ; it is given in the form of the tincture rrt x-xx every hour or two hours. There are^ unfortunately, no special indications for its use ', but it seems to be more efficacious when the second and third divisions are affected than in neuralgia of the ophthalmic division. Aconitine may be used hypodermically, in doses of nt j-iv of a solution contain- ing gr. j in 5 iv of distilled water with a little sulphuric acid. As specific remedies we may choose between quinine^ salicylate of sodium, arsenic, and iron. When- ever periodicity is a feature of the attacks, quinine in full doses (gr. x-xv) should be given several hours before the pain usually comes on. It may be ad- vantageously combined with the hydrobromic acid. For similar cases the salicylate of sodium may be employed in doses of thirty or forty grains. Arsenic comes next in efficacy and should be tried whenever quinine and the salicylate fail. Fowler^s solution should be given in doses of from nxv-x three times a day. Iron is most generally useful whenever there is marked anaemia, but 2.32 teieatmi:nt of facial neuralgia. it sometimes does good when the latter is not a prominent symptom. Chloride of ammonium in doses of gr. xx-xxx^ several times a day, is also recommended. Anodyne remedies, applied externally, are sometimes useful as palliatives. A stick of menthol, the liniments of aconite, belladonna, opium, and chloroform are available for this purpose. Counter-irritation, by means of blisters at the back of the neck or behind the ears, sometimes affords relief. When all other measures have failed to afford relief, and the pain renders the patient's life very miserable, operative treatment may be had recourse to in the form either of neurotomy, or simple division of the nerve, neurectomy, or excision of a portion, or nerve-stretch- ing. Of these neurectomy yields the best results. Before performing either this operation or simple incision, it is desirable to ascertain as far as possible the existence and position of any local cause for the neuralgia, for to be successful the operation must be performed on the central side of any such spot. In nerve-stretching we are able to act from the periphery upon the more central portions of the nerve ; but this operation in cases of facial neuralgia has seldom been followed by satisfactory results. With regard to neu- INTERCOSTAL NEURALGIA. 233 rectomy, it has been noticed that after an operation on one division of the nerve another division has become the seat of very severe pain. II. Intercostal Neuralgia. This is the name given to neuralgic pain affecting the nerves in some of the intercostal spaces ; it is most frequently felt on the left side^ and in the spaces from the fifth to the ninth downwards. It rarely occurs on both sides_, or in a single space ; generally two or three neighbouring nerves are affected at the same time. The reason for the left side being more commonly affected is said to be that the venous blood of its lower inter- costal spaces passes by a more circuitous route into the vena cava, viz., by the small vena azygos. This form of neuralgia is most frequent in persons between twenty and forty years of age, and is much more common in women than in men, but I have seen several cases of severe intercostal neuralgia in male subjects. It is especially apt to occur in those who sit closely at work and take little exercise, but it is also noticed in persons living under different conditions, viz., in those whose rest and food are alike deficient. Certain constitutional disorders predispose to intercostal neuralgia, and among them may be mentioned syphilis, gout, and anaemia. 234 SYMPTOMS OF INTERCOSTAL NEURALGIA. especially when due to prolonged lactation, or to chronic gastric catarrh. In some instances the pain may be traced to exposure to cold. Local affections, such as injuries to the ribs^ caries and morbid growths, diseases of the pleurae and lungSj especially tuberculosis, disorders of the liver, affections of the spinal cord and its membranes, are all likely to cause pain in the inter- costal spaces, though not necessarily of a purely neuralgic character. There is a close connection between affections of the uterus and ovaries and neuralgia in the intercostal spaces. In some patients suffering from profuse menstruation the pain invariably comes on during the monthly periods, and ceases with the discharge. In cases, too, of dysmenorrhoea, dependent upon stenosis of the cervical canal, intercostal neuralgia is sometimes present, and is cured by dilating the cervix. Pain in the intercostal spaces is a common symptom of spinal irritation. The affection termed '' irritable breast '^ is a form of intercostal neuralgia, the pain being localized in one or other of those organs. This complaint occurs almost exclusively in young women, and is apt to. complicate hysteria and various uterine disorders. Symptoms. The pain is felt in the course of the SYMPTOMS OF INTERCOSTAL NEURALGIA. 235 nerves affected, and may be either continuous or paroxysmal in character. In the former case there are generally sharper twinges at irregular intervals ; there is often some amount of cutaneous hypersesthesia in the aiFected region, and pressure over the spinous processes of the corresponding vertebrs sometimes produces severe pain. Sometimes the pain is confined to one or more points^ and these are usually in the axillary lines or just below the breasts. Tender points are frequently discoverable in one or more of the following situa- tions : — T. Over the spot where the nerve escapes from the intervertebral foramen. 2. At a point midway between the vertebral column and the sternum, where the superficial branches are given off. 3. Near the sternum, or further down at the edge of the rectus muscle, where the nerve ends in cutaneous branches. The pain is aggravated by movements of various kinds, and especially by coughing and sneezing. Difficulty of breathing is sometimes complained of; the patient finds that full inspirations increase the pain or cause a paroxysm. In not a few cases the affected nerves are very sensitive to pressure throughout the whole length of the intercostal spaces; sometim.es, indeed, the slightest touch causes the side to be forcibly retracted. 236 SYMPTOMS OF INTERCOSTAL NEURALGIA. On the other hand^ it may happen that firm pressure relieves or even removes the pain for a time. Irradiation of the pain towards the back and to the scapula is of frequent occurrence_, and the arm and breast are also liable to be affected. The second intercostal nerve . communicates with the internal cutaneous nerve of the arm, and several of these nerves send lateral branches to the breast. Frequency of respiration sometimes occurs in connection with inter- costal neuralgia, and painful attacks of palpitation of the heart are occasionally associated with this latter affection. I have recently had under my care a man, age ^8, of gouty habit and family history, suffering from occasional paroxysms of intercostal neuralgia. These were accompanied by severe burning pain in the cardiac region, anid palpitation of the heart. The patient went from one physician to another, fully convinced that he had heart disease and angina pectoris. All his symptoms disappeared under iodide of potassium, gr. v, t.d., flying blisters, and a carefully regulated diet. It would seem probable that through reflex action such local attacks of pain may not only influence the function, but by degrees produce altei'ations in the structure of the heart. DIAGNOSIS OF INTERCOSTAL NEURALGIA. 237 With regard to complications, herpes zoster is the one most frequently observed. It is notj of course, to be regarded as the cause of the neuralgia, inasmuch as the latter may exist alone^ and often precedes the eruption by several weeks. On the other hand, the herpes may appear along the course of one or more intercostal nerves without any accompanying pain, and this is generally seen in children. In old people the herpes is apt to precede the neuralgia, which continues after the sores, left by the eruption, have healed, and is often extremely obstinate. Nothing can be definitely asserted with regard to the course of intercostal neuralgia. It is always tedious and sometimes very protracted : patients are apt to become very anxious, and often imagine that some severe disease of the lungs or breast is the cause of the pain. The prognosis is therefore not very favourable, and the older the patient the more obstinate the com- plaint. Diagjmsis. The points to be determined are : ist, whether we have a case of intercostal neuralgia to deal with ; and, 2ndly, the cause of the suffering. With regard to the first point, the pain might be due to pleurisy, but careful examination with the stethoscope 238 MASTODYNIA. will prevent any such mistake. In so-called rheumatism of the muscles of the chest the parts will be very sensi- tive to pressure. When the heart itself is the seat of the pain, the latter will be felt principally in the pre- cordial region^ and will be accompanied by evidences of weakness (small pulse, feeble heart sounds), and great irritability of the organ. In all cases the ribs should be very carefully examined in order to determine the presence or absence of fracture, caries, or periostitis. The vertebral column, too, should not be neglected, for incipient caries often gives rise to intercostal pain, which if felt mainly in the front of the thorax may be attributed to the heart, lungs, or stomach. By passing the finger backwards along the affected intercostal spaces a sensitive spot will be detected near the verte- bral column. Irritable breast or mastodynia is an affection of the anterior cutaneous branches of the upper intercostal nerves, and the supra-clavicular branches of the fourth cervical nerve are also liable to be implicated. It is one of the most obstinate and painful forms of neuralgia, and the pain is apt to radiate to the arm and neck. The attacks may last for several hours, and be separated from each other by only short intermissions MASTODYNIA. 239 or remissions. In some of these cases the spinous processes of the last cervical and first dorsal vertebrae are very tender on pressure, and^ as a general rule, the whole breast is more or less acutely sensitive. Even contact with the clothes is sometimes almost unbear- able. Movement of the arm increases the pain, which is accompanied by a sensation of weight in the breast. The causes of mastodynia are very obscure ; the affec- tion is most common in young girls at the time of puberty, and up to twenty-five or thirty years of age; it is rare in women of middle age. When it occurs in these latter subjects it is sometimes due to hyperlactation, and under these circumstances the left breast is generally affected. The complaint is not unfrequently associated with disorders of menstruation, but it likewise occurs in the absence of any such complication. Local causes, such as injuries of various kinds, are sometimes assigned for the occurrence of the symptoms, but the relation- ship is for the most part doubtful. It often happens that careful examination of the dand will detect one or more small hard nodules, very sensitive to pressure, and varying in size from that of a pea to that of a hazel-nut. Nothing is positively known as to the nature of these swellings, and they have been supposed 240 TREATMJENT OF INTERCOSTAL NEURALGIA. to be neurornata or tubercula dolorosa of the nerves of the breast. Their size and tenderness are both increased at the commencement of menstruation. They are by no. means always present in these cases of mastodynia ; pain and tenderness of equal severity may exist in their absence. The differential diagnosis in cases of mastodynia mav present some difficulties ; but careful observation will serve to decide the nature of the case. The pain re- sembles that of malignant disease, and the existence of hard nodules tends to corroborate the fears of the patient and her friends. In malignant disease, however;? the growth always increases in size with more or less rapidity j it never remains circumscribed, and^ of course^ never disappears, as is often the case with the growths under consideration. Smal>and deeply-seated abscesses mav be mistaken for these tumours of mastodynia, but their course soon reveals their true nature. The sensi- tiveness of the part in neuralgia of the breast is char- acteristic j it is more marked than in any other affection of the gland. In the treatment of intercostal neuralgia the part should be carefully examined, in order that any existing local cause may not be neglected. Attention should TREATMENT OF INTERCOSTAL NEURALGIA. 241 next be paid to constitutional conditions^ e.g., syphilis and gout, and to the presence of any hepatic, uterine, or other abdominal disorder. All these will require appropriate treatment. Whenever symptoms of anaemia or chlorosis are present, tonics of all kinds, and especi- ally iron, are indicated. When amenorrhoea exists aloes is likely to be suitable, and may be combined with the iron. It seldom happens that general treatment of any kind is sufficient to cure intercostal neuralgia. Measures designed to relieve the pain are almost always indis- pensable. Of these the most efficacious is the hypo- dermic injection of morphine, though its results are for the most part only temporary. Other anodynes, e.g., aconite, belladonna, and chloroform, may be applied locally as liniments. If these measures fail to relieve, electricity should be tried; and, first, the continuous current, the positive pole being applied close to the vertebrae and the negative to the lower border of the ribs in the affected spaces. The induced current may be ap- plied in the form of the faradic brush. In very obstinate cases blisters are likely to be serviceable. Herpes zoster is rather a favourable complication than otherwise, for the pain generally subsides when the blisters left by the vesicles heal up. For mastodynia it is often necessary 16 242 SCIATICA. to try one remedy after another until a suitable one is met with. As a general rule, the pain is relieved by warmth and by bandaging the breast. A stream of warm water should be allowed to play upon the painful spot for fifteen minutes twice a day, and after carefully drying the skin belladonna liniment should be applied, and afterwards cotton-wool and a bandage. Electricity may likewise be tried in the form of the faradic brush or the constant current. If the latter, the negative pole is placed on the vertebral column over any sensitive spot, and the other pole applied to the breast. In all cases the general health should be attended to, and the patient's mind diverted as far as possible from her ailment. A short course of the bromides is likely to be serviceable; it will tend to lessen the hyperaesthesia in the gland, as well as general irritability. III. Sciatica. Next to tic douloureux, sciatica is the most common form of neuralgia, and it has this peculiarity, that the pain is felt mainly in the trunk of the nerve, and either not at all or in a less degree in its branches of distribu- tion. The frequency of the affection is due to the exposed and superficial position of the nerve ; but it would appear that in many cases the mischief is seated CAUSES OF SCIATICA: 243 in the surrounding parts rather than in the nerve itself. The term is somewhat loosely used; it has, for in- stance, been pointed out by Mr. Hutchinson that inflammatory affections of the hip-joint are the real cause of the symptoms in some cases of supposed sciatica. The affection is important, not only because of the pain — often very severe — but also because of the incapacity for movement which results therefrom. With regard to the causation of sciatica, the com- plaint is sometimes directly traceable to the influence of cold and moisture. Standing in cold water, sitting on damp grass, or on cold stones, or wet seats are common causes of an attack. Injuries to the hip or thigh, and continuous pressure upon " the nerve, caused, e.g., by sitting on a hard seat, are sometimes, though less often, followed by similar consequences. After difficult labours and the use of instruments for delivery, a troublesome attack of sciatica has been known to supervene, as a result of pressure upon the nerve in the pelvis. The growth of tumours, either within or external to the pelvis, may produce the same effect. Some cases are attributable to over-exertion of the lower limbs, as in walking or climbing and in working machines with the foot. Constitutional disorders, notably syphilis and 244 G^ USES OF S CIA TIC A . gout, predispose to sciatica; and in the former of these gummatous growths are sometimes found in connection with the nerve. The presence of hard faecal masses in the colon and rectum, and dilatation and congestion of the veins of the pelvis^ are common causes of sciatica. Many of these veins are destitute of valves, and are especially liable to periodical attacks of congestion in various disordered conditions of the abdominal organs, notably the liver. The connection between sciatica and abdominal affections has long been recognized^ and the venous plethora is the connecting link. Constipation often precedes an attack, which is relieved when the former condition is removed. In some cases of sciatica the venous stasis extends to the affected limb^ the veins of which from the foot upwards are enlarged and varicose. As might be expected^ -sciatica is more common in winter than in summer^ and the majority of the patients are of the male sex. The complaint is rare before puberty^ and generally occurs in patients over thirty years of age. Conditions of anaemia do not seem to predispose to it^ as is the case with facial and intercostal neuralgia. The complaint is sometimes met with in persons suffering from the effects of mercury and those SYMPTOMS OF SCIATICA. 245 of lead^ but the brachial neives are more prone to be affected in these cases. Pain alonsr the course of the o sciatic nerves is not unfrequent in diseases of the vertebrce and of the spinal cord. The prominent symptom of sciatica is the pain which extends over the greater portion of the course of the sciatic nerve. It is rarely confined to one portion, though it may be_, and often is, more severe at the back of the thigh than in the leg or foot. There are generally some premonitory symptoms^ such as numbness, tingling, or slight and transient pain along the course of the nerve. The pain often begins at the sides of the vertebral column, where it takes the form of lumbago ; it thence gradually spreads downwards to the thigh, leg, and foot. In exceptional cases the pain begins below and spreads upwards. The pain is sometimes con- tinuous, sometimes paroxysmal, with intervals of immunity. It is usually worse at night, and is variously described by patients as of a burning, piercing, screwing, or stinging character. The attacks often come on spontaneously, but are almost invariably excited by movements of the liinb and pressure. The course of the nerve is sometimes exquisitely tender. In severe cases, owing to the paiii which is caused. 246 SYMPTOMS OF SCIATICA. inovement of the limb is impossible; in slighter forms the patient walks with his knee bent. The pain is almost always worse on attempting to move the limb after it has been kept for some time in one position. Coughing and sneezing are apt to provoke a severe paroxysm. The attacks are not attended with pyrexia. The symptoms are not always so acute as those- above described. In some cases the pain is not such as to confine the patient to his bed, or to prevent him from following his occupation. A sensation of aching or soreness in the back of the thigh and a feeling of stiffness are the principal symptoms_, and these vary in degree from time to time^ last for an indefinite period, and never become very severe. In the acute form, on the other hand, the pain is often of an intense character,, and, especially when occurring in a person unaccustomed to suffering, is apt to produce great mental distress. The extension of the pain along the various branches- of the nerve varies much in different cases. From the back of the thigh the pain may spread either to the internal or external popliteal branches. Sometimes the calf of the leg is the seat of acute pain ; while in other cases the plantar branches of the posterior tibial nerve are especially affected. Moreover, the pain is apt to- SYMPTOMS OF SCIATICA. 247 shift its seat from time to time, without altogether leaving the spot in which it first appeared. The left leg is somewhat more frequently attacked than the right, but the difference in the liability is not very great. In a small proportion of cases both legs are affected . With regard to the existence of points douloureux these are generally to be detected in cases of sciatica. The most important is situated near the posterior superior spine of the ilium ; another is between the tuberosity of the ischium and the trochanter major. Others are to be found behind the head of the fibula and behind the malleoli. Pressure in the middle line of the popliteal space also frequently causes pain. In some cases there is increased sensitiveness on pressure diffused over the back of the limb, and with this some amount of diminution of tactile sensibility and of the temperature sense is apt to be associated. In some cases the sense of temperature is perceptibly heightened. Such a patient, standing with his back to the fire, finds the warmth unbearable on the affected side. The muscles of the limb and the vaso-motor and trophic nerves seldom remain unaffected in cases of sciatica. The flexor muscles of the thiofh and the 248 SYMPTOMS OF SCIATICA. muscles of the leg are stiff and tense, and motion is difficult, even when the pain is not of itself sufficient to prohibit it. This condition of the muscles can be observed when subjecting the limb to passive move- ments, and it is apt to remain for some time after the acute symptoms have subsided. The gait of the patient is often peculiar; he walks with the knee bent, and the pelvis on the aff^ected side lower than on the other. In this position extension of the muscles is avoided, and the nerve and its main branches are not liable to be compressed. In chronic cases this position^ unless steps be taken to remedy it^ is likely to become per- manent and to cause more or less lameness. Spasms of the muscles of the calf and fibrillary twitchings of the flexor muscles of the thigh are sometimes observed. With regard to the vaso-motor and trophic symptoms, these vary in character in difl^erent cases and at diff^srent periods in the same patient. The temperature of the leg and foot on the affected side is sometimes increased, sometimes diminished ; the colour may be either pale, or there may be patches of redness or diffused colora- tion ; the secretion from the skin is either increased or diminished. The surface is sometimes dry and brittle ; in other cases it is moist, and the foot SYMPTOMS OF SCIATICA. 249 especially is covered with copious perspiration. It is curious that two such opposite conditions should occur in the same affection. In some cases after the com- plaint has existed for a few weeks decided atrophy of the muscles supplied by the sciatic nerve sets in. In these cases neuritis most probably exists. On the other hand^ hypertrophy of the muscles has sometimes been noticed. Other evidences of disorder of the trophic nerves are sometimes supplied by the occurrence of various forms of eruption^ e.g., erythema^ erysipelas, herpes_, etc. A remarkable symptom, probably indicative of disorder of vaso-motor nerves, is sometimes noticed in connection with sciatica ; the urine is found to contain a small amount of sugar. The condition is usually transient, subsiding as the pain ceases to be trouble- some. The complication has been observed in cases in which the sciatica was a symptom of some spinal affection ; but it has also been noticed in simple cases, due probably to venous hyperaemia within the abdomen, and particularly in the portal circulation. I have recently attended three cases in which this symptom was present. In cases of sciatica certain changes are sometimes 250 COURSE OF SCIATICA. __ • ■ . — noticed in the electrical condition of the affected parts, especially when evidences of disordered nutrition are in any way prominent. The faradic contractility of the muscles is diminished ; the cutaneous sensibility is at first increased, but afterwards lessened. The reaction to galvanism varies; in cases due to neuritis the ex- citability is at first increased and afterwards much diminished. The course and duration of sciatica are liable to great variations. The pains generally disappear in the same order in which they came on, remaining in the lower parts of the limb for some time after they have ceased in the thigh. In some cases the last symptom is some amount of ancesthesia dolorosa of the toes. During the course of the complaint the pain is apt to radiate along other nerves ; sometimes the other side is affected,, sometimes an arm. Lumbago is likewise a frequent complication. The course of the complaint is of an in- definite character ; it usually extends to several weeks,, in spite of treatment ; sometimes it lasts for several months, or even years. In cases due to cold, recovery is the rule ; but when the cause is a pelvic tumour the sciatica is persistent. In all severe cases more or less weakness and wasting of the limb may be expected ta DIAGNOSIS OF SCIATICA. 251 remain for some time after the paiu has ceased. Re- lapses are very prone to occur^ but instances are not unfrequent in which, after many weeks of very severe sufferings there is complete immunity from further attacks. Diagnosis. This is for the most part easily made, but mistakes sometimes occur. In sciatica the pain follows the course of the nerve^ and is not dependent on muscular action. The lightning-like pains of loco- motor ataxy more or less resemble those of sciatica ; but the absence of patellar reflex is characteristic of the former affection. Sciatica is most apt to be con- founded with disease of the hip-joint. In the latter the pain produced in the part by movement^ the shortening of the limb_, and the position it generally assumes, are the points to be contrasted with the main features of sciatica. The history of the case will also aid the diagnosis, and the same remark applies to cases in which a paretic state of the limb has given rise to a suspicion of paralysis. In sacro-iliac disease, in which there is often severe pain in the thigh, the patients are alwavs voung, and a careful examination will detect the source of the mischief. Besides the affections already mentioned, it must be remembered that pain along the 252 TRIIATMENT OF SCIATICA. course of the sciatic nerves is a frequent symptom of pelvic tumours^ aneurisms^ etc. Dr. Buzzard has pointed out that myalgia of the flexor muscles of the thigh, and muscular rheumatism in the same muscles, closely resemble sciatica. They differ from it^ however, in the fact that the pain is situated especially at the points of attachment of the muscles, and is not spon- taneous, but is felt only when the muscles are in action. The prognosis is favourable in the majority of cases of sciatica. When the attack is directly^ traceable to an obvious cause, e.g., exposure to cold and damp, prompt treatment generally yields the happiest results. Even chronic cases are almost always amenable to treatment, though relapses are prone to occur; and for some time after the pain has subsided there is often more or less discomfort in the limb and a feeling of weakness. The affected limb soon becomes tired, and weeks or even months may elapse before it recovers its normal con- dition. In cases dependent upon serious lesions in the pelvis, the prognosis is, of course, of a different cha- racter. The treatment is more satisfactory than that of most other forms of neuralgia, and local remedies are often of signal service. A vast number of means tri:atment of sciatica. 253 have been recommended, and the difficulty is to select the one most appropriate. The first step is to endeavour to ascertain the cause, and for this pur- pose the affected limb must be carefully examined in order to discover whether there are any local affec- tions connected with the nerve or its branches. Should such exist the question of their removal by operation will have to be entertained. The general condition of the patient is the next point to be studied. If there be evidences of congestion of the pelvic veins, or of the portal system, purgatives are especially indicated^ and of these the sulphates of sodium and magnesium are the most appropriate. Carlsbad salts form a very suitable combination, more particularly for gouty subjects in whom an attack of'sciatica is likely to be due to hepatic congestion. In such cases two or three grains of blue pill should be given at bed-time for three or four nights, and a dose of the salts in the morning. The bowels should be thoroughly cleared out, but drastic purgatives are to be avoided. Salines will also be found suitable for non-gouty cases in whom constipation is a pro- minent symptom, but other purgatives, such as extract of aloes and castor oil, mav also be used. In rheumatic subjects, iodide of potassium or sodium 2 54 TREATMENT OF SCIATICA. will probably be found the best remedy, doses of from fiv^e to ten grains three times a day being usually suffi- cient. It is well to add a little bicarbonate to the iodide, and the disagreeable effects which the latter some- times produces may frequently be prevented by giving three or four minims of tincture of belladonna with each dose. Another way of administering the iodide is to give it in seltzer- water. Where there is great pain I have prescribed salicylate of sodium in doses of 20 grains every four or six hours with much benefit. Blisters are also particularly indicated in this class of cases, and the best method of using them is to apply the liquor epispasticus over circular spots about two inches in diameter down the course of the nerve. If there be marked tenderness at any one spot the blister should be made at some little distance from it. When the acute attack has subsided warm baths are almost always serviceable. In anaemic and chlorotic subjects tonics such as iron and quinine are invariably required in addition to local remedies. For cases in which there is a history of syphilis a course of the iodides will be found efficacious. Much may be done by way of palliation in all cases of sciatica, and the hypodermic injection of morphine is probably the most potent remedy of this class that TREATMENT OF SCIATICA. 255 we possess. It is advisable, and generally practicable, to make the injections close to the seat of the acutest pains, for the morphine has a local as well as a general anodyne action. If the morphine fail to giv^e relief, or if it produce distressing head-symptoms, atropine may be tried, gr. -^^ for each injection. For some cases a combination of the two drugs acts satisfactorily. The atropine counteracts the unpleasant effects of the morphine upon the head and stomach. Electricity is sometimes valuable for the relief of sciatica; but its action in this respect is very un- certain, and therefore it is impossible to foretell its effects in any given case. In recent attacks the continu- ous current sometimes produces marked beneficial effects. Dr. Buzzard, in an excellent paper on Sciatica, which appeared in the Practitioner for February, 1877, states that the application is most hopeful in those cases of sciatica which are not dependent upon obvious causes of peripheral irritation, but that it may be useful in cases belonging to the latter class. Dr. Buzzard gives the following rules for the application of the constant current for the relief of sciatica. From 20 to 40 cells are required, but when used the strength of the current should be gradually increased ; the sponge rheophores should be of laro;e size and thorou2:hlv saturated with 256 TREATMENT OF SCIATICA. warm salt and water. Each sitting should occupy from 10 to 15 minutes_, and during the application the rheo- phores should not be lifted from the skin ; before they are removed the current should be gradually reduced to zero. Unless this precaution be taken, more or less shock will be caused when the current is interrupted. There are three modes in which the constant current can be applied : — 1. The rheophore connected with the positive pole is applied to the upper part of the sacrum on the aflfected side, while the other rheophore may be either attached to the ankle or placed in a tub of warm salt and water in which the patient immerses his foot. • 2. ^'^ Two sponge rheophores are applied firmly at a distance of three or four inches apart to the posterior and upper part of the thigh_, and, that distance being preserved between them, they are made to slide slowly down, following the track of the nerve." A smaller number of cells must be employed than in the pre- ceding method. 3. The rheophore connected with the negative pole is applied to the upper part of the sacrum, and the positive rheophore is moved over the course of the nerve, stopping for a minute or two over the most painful spots. Dr. Buzzard states that the second TREATMENT OF SCIATICA. 257 method of application is theoretically the best, as beins; specially calculated to remove the irritability of the sciatic nerve near its origin. The sitting should be repeated daily ; the use of electricity does not preclude the use of morphine hypodermically. The induction current is far less serviceable as a general rule, but it may be tried if other remedies fail. It is most suitable for those cases in which the svm- ptoms are those of muscular rheumatism. The electric brush should be drawn along the coarse of the nerve and its branches ; slight diminution of the pain is usually all that can be expected. At a later period, however, after the pains have subsided and the limb remains weak and stiff, faradization of the muscles with moistened rheo- phores is often very efficacious. The use of this form of electricity may also be combined with the hypodermic injections of morphine. Blisters have been already alluded to as especially suitable for rheumatic cases, but they are often advisable in the absence of this constitutional disorder. It is not by any means necessary to make a large raw surface ; flying blisters are the most suitable, and they may be applied along the course of the nerve and its branches, or over any existing tender spot in the spinal column. 17 258 TREATMENT OF SCIATICA. Acupuncture is probably but little practised at the present time, yet it would appear to possess a certain amount of efficacy. The rationale of its action can only be guessed at; it may be that it acts as a counter- irritant. It is not to be wondered at that baths of all kinds should be warmly recommended as remedies for sciatica^ and in chronic cases they are sometimes beneficial, inasmuch as they help to remove lingering pain and stiffness. Ordinary water, heated to the requisite temperature, is probably as useful as any of the natural hot springs. The constant temperature of the latter is, however, an advantage. When baths cannot be ob- tained, or are unsuitable for the patient, warm applica- tions applied to the limb often give relief. The so-called Scotch douche is reported to have proved efficacious in several severe cases. In using it the temperature of the water is gradually increased -to the maximum that the patient can bear, and a cold douche is then substituted for the hot one. This treatment can be applied twice a day. Hot sand-baths are a very old remedy, but, like douches, they are to be found, only in special estabhsh- ments ; they would appear to be suitable for subacute and chronic cases. The same remark applies to massage. TREATMENT OF SCIATICA. 259 from which great benefit may be expected when the limb has become weakened and reduced in size after a severe attack. In a few cases of obstinate sciatica nerve-stretching has been practised with success. All other remedies should, of course_, be tried before suggesting an opera- tion of this character. CHAPTER IX. ARTICULAR NEUROSES— NEURALGIA OF THE JOINTS. Nature and Pathogeny of Neuralgia of the Joints — Predisposing AND Exciting Causes — Symptoms — Cutaneous HYPERiESTHESiA — Position of the Limb — Joints usually Affected — Course and Progress of Neuralgia of Joints — Diagnosis — Anaesthesia OFTEN Necessary — Mental Condition of the Patient — Results of Application of Bandages, etc. — Exaggerated Patellar Reflex in Hysterical Contraction of the Knee- Joints — Pain in Knee an Occasional Symptom of Hip-Joint Disease — Treatment, Constitutional and Local — Massage, Douches, Baths, etc. — Electricity — Use of the Limb to be Recommended. This affection was first described by Sir Benjamin Brodie in 1822^ but some light has been thrown upon its nature bv subsequent investigations. Neuralgia of the joints is a painful affection^ w hich has its seat in the sensory nerves supplying the articular capsule^ the fibrous lio-aments, the skin, and the neis^hbourino; tissues. The pain is not confined to a single nerve and its dis- tribution, for a joint is supplied by branches of several nerv^es ; the hip-joint, for example, is supplied by the sciatic, crural, and obturator nerves, while branches of the external and internal popliteal, tibial, crural, and NEURALGIA OF THE JOINTS. 261 obturator ramify in and around the knee-joint. A rare form of neurosis of the joints is due to vaso-motor disorder. An experiment recently made explains, to some extent^ the pathogeny of articular neuralgia. After a lateral section of the spinal cord, involving Flechsig's direct cerebellar paths of the lateral column_, the joints as well as the skin of the injured side were observed to be hyperaesthetic, and it may therefore be that changes in the spinal cord, obviously of a slight and temporary nature, are the causes of neuralgia of the joints. This theory is supported by the fact that various symptoms of spinal disorder are frequent in hysterical women, who are the most common sufferers from these joint- affections. Neuralgia of the joints is rare in male subjects; it is almost peculiar to women of a nervous temperament and belonging to the upper classes. Many of the patients are decidedly hysterical, and are the subjects of various disorders of the urinary and genital organs. Various conditions of anaemia and exhausting diseases, such as typhoid, are predisposing causes of these joint-affections. The majority of patients, however, attribute their suffer- ing to injury or to over-exertion of the joint. In some cases the pain is due to irregular distribution of pressure 262 SYMPTOMS OF NFURALQIA OF THF JOINTS. within the joints such as may be caused by wearing shoes with high heels, and in other instances the neuralgia is the remains of some inflammatory affection, due, perhapSj to a trifling injury. Symptoms, The knee or the hip-joint is almost always affected, and the principal symptom is the pain, invariably described as very severe ; it may be limited to the joint, or may also extend from it in various direc- tions. Keeping the limb at rest by no means always diminishes the pain; the patients sometimes assert that they are better when moving about. Exacerbations are common, and occur irregularly. Sometimes they are provoked by excitement, and sometimes by attempts to move the limb. As a rule they are most troublesome in the latter part of the day. It very rarely happens that the night's rest is disturbed by pain, and the complaint is thus distinguished from inflammatory affections. Pressure upon the joint and the surround- ing parts usually excites great pain. The spots near the hip especially sensitive to pressure are just behind the great trochanter and below Poupart's ligament, while the inner side of the knee is the most sensitive part of that articulation. The attempt to take up a fold of skin between the fingers is also liable SYMPTOMS OF NEURALGIA OF THE JOINTS. 263 to cause great pain. The most striking feature con- nected with the affection is the contrast presented be- tween the subjective symptoms and the absence of any tano:ible or visible chang-es in the ioint. Anv sweUino- that may exist 'is generally due to local applications, fomentations, etc. In most cases the patients assert that the limb is weak, they less commonly complain of twitchings, and it is worthy of notice that the limb is usually kept in an extended position, whereas it is flexed when the joint is inflamed. There are sometimes evidences of vaso-motor disorder, such as redness and increase of temperature, and an eruption resembling urticaria has occasionally been noticed. As already mentioned, in the large majority of cases the knee or the hip is the joint affected; but in- stances of the complaint in the hand, foot, shoulder, and elbow have been placed on record. In the vertebral column, too, articular neuralgia would seem to occur, and to simulate grave affections. As a general rule the pain occurs in one joint only; when two or more are implicated, and especially if they be symmetrically placed, the complaint is probably of a central origin. With regard to its course and progress, neuralgia of a joint usually develops gradually. In some cases, how- 264 DIAGNOSIS OF NEURALGIA OF THE JOINTS. ever_, the patients assert that the pain came on suddenly after shock, excitement, etc. The complaint generally runs a very tedious course; the attention, not only of the patient, but also of her friends, is apt to be concen- trated upon the painful joint, with the result of magnify- ing the suffering. In such cases it will often be noticed that when the patient's attention is in any way diverted the joint-troubles are forgotten. The pain, indeed, has been known to disappear altogether after some sudden^ violent emotion. On the other hand, it not unfrequently happens that the patient keeps her bed for months or years, receiving, it may be, temporary relief from remedies, but never exhibiting any real improvement. The tendency is for the limb to become weaker, and the joint more stiff. Diagnosis. The diagnosis of nervous affections of joints is in not a few cases a very difficult task, especi- ally in the early stages, and whenever there is any history of previous injury, however slight and unim- portant. The examination should be very carefully made, and it is often useful to place the patient under the influence of an anaesthetic. If a joint which has for some time been rigidly fixed then becomes free, there can be little doubt then as to the real condition of DIAGNOSIS OF NEUSALGIA OF THE JOINTS. 265 things ; but it is generally advisable to make several ex- aminations, and it is often necessary to keep the patient under observation for some time before arriving at a positive conclusion. There are generally no physical changes^ and no evidences of impaired health. The psychical condition of the patient will occasionally help the diagnosis, and if treatment be adopted it will gene- rally be observed that remedies which would relieve a real affection of a joint will only increase the symptoms in a neurotic disorder. It has, for instance, been found that the application of bandages to a knee-joint affected with neuralgia, and their retention for several weeks, have served only to make matters worse. In cases of hysterical contraction of the knee-joint the state of the patellar reflex should always be examined ; it will gene- rally be found to be exaggerated. In a case recently under my notice, that of a married woman, aged 47, who had been bedridden for a year with hysterical con- traction of the knee-joint and other ailments, the knee jerked out immediately the patellar reflex was tested. A similar result was obtained in another case, the patient being a young woman, aged 26, who had been bedridden for four months. It must not be forgotten that in young subjects obstinate pain in the knee is 266 TREATMENT OF NEURALGIA OF TEE JOINTS. sometimes the first symptom of disease of the hip-joint, and that the same symptom is present in cases of genu valgum, which is not always bi-lateral. Treatment. Having decided that the case is one of neuralgia of the joint, the general condition of the patient has first to be considered. If there be evidences of anaemia or debility tonic treatment of all kinds is indicated, and may by itself cure the complaint. Any disorder of the digestive or genital organs must be carefully treated, and above all things it is necessary to divert the patient's attention from the joint, and to caution the friends from talking seriously about it. The patient should be assured that she will get quite well if she will only cany out a few simple injunctions. The remedies to be prescribed are massage, carefully con- ducted, douches of tepid water, active and passive move- ments, frictions and baths, especially of salt water. These remedies, persevered in for several weeks, may prove sufficient, but if not there are others which may be tried, and among them electricity is likely to be the most serviceable. The constant current is the best, and it is especially useful whenever any points can be detected which are decidedly painful on pressure. The elec- trodes should correspond with the size of these spots,. TREATMENT OF NEURALGIA OF THE JOINTS. 267 against which they should be pressed^ the strength of the current being gradually increased to the maximum that the patient can bear. Before withdrawing the elec- trodes the strength is gradually decreased. In cases in which the neuralgia of the joint is associated with tenderness over one or more vertebrae^ it is sometimes useful to apply the electrodes to the latter. If the galvanic current fail to relieve^ faradism may be tried, the moist electrodes being applied as before to the painful spots. The wire brush applied in this way is likely to prove serviceable in mild cases. Liniments, bandages, poultices, etc., are always to be avoided. The patient must be encouraged to use the limb and to walk about, -however difficult the movement may appear. CHAPTER X. HEADACHE. Pain in Head often Symptomatic — Associated with Cerebral Hyperjemia, Active and Passive — Causes and Consequences — Anemic Headache — Symptoms — Headaches in Neurasthenia and Nervous Subjects Generally — Sympathetic Headache^ — Indigestion as a Cause of Headache — Rheumatic and Gouty Headache — Headache due to Intemperance — Headache in Hysterical Subjects — Pains in the Head due to Syphilis — Headache due to Disorders of the Refractive Apparatus of the Eye — Diagnosis of Headache — Treatment of the Hyperjemic and Anemic Forms — Remedies for Neurasthenic AND Rheumatic Cases — Empirical Treatment. Pain in the head is a very common symptom of many disorders, but it Ukewise often occurs idiopathically_, and constitutes the complaint for which the patient seeks relief. As a symptom_, it is rarely absent in febrile disorders ; in typhus it is often the first indication of an attack; it is prominent in inflammatory affections of the bones of the cranium and their coverings_, as in periostitis^ syphilitic or otherwise. Headache is a marked symptom of inflammation within the cranium and of tumours of the brain and its membranes. It is sometimes very troublesome in severe nasal catarrh. FORMS OF SF ABAC HE. 269 implicating especially the frontal sinuses ; and, lastly, it is not unfrcquent in affections of the eye and ear. A special form of headache, migraine or hemicrania, will be separately described. In the present chapter it is proposed to consider those headaches which, not con- nected with acute local or general disorder, are due to a variety of causes not always very obvious, and com- paratively insignificant when contrasted with the result they produce. The pain is sometimes diffused over more or less of the head ; it may, on the other hand, be principally felt in the forehead, occiput, vertex, or temples. Sometimes it is localized in a very small area, as in clavus hystericus. The character of the pain varies with the condition with which it is associated. Thus, when there is active hypersemia, it is described as throhhing, and a similar sensation is experienced in anaemia when the vessels are dilated. In passive hyperaemia, the sensation is that of pressure; in rheumatic cases the pain is of a pricking or tearing character. In degree of severity the pain of headache varies greatly ; it may be only so slight as to be scarcely regarded, or so severe as to be described as unbearable. In idiopathic cases the pain is wont to occur periodically; it is rarely con- 27© FORMS OF SFABACSF. tinaous, except in cases of anaemia. Whenever it comes on at definite intervals, and at the same hour, it may generally be regarded as of a neuralgic character. For purposes of consideration headaches may be divided into classes, according as they are associated v^^ith vascular or nervous symptoms. The former may be either those of increased or of diminished blood-supply, and this first category may again be subdivided into those in which the hypersemia is active and those in which it is passive. In headache due to active hyperaemia of the cerebral vessels the condition is manifested by the state of face and eyes, which are red and hot. The temporal arteries are prominent and pulsate freely -, the carotids are full and tense ; the pain is increased on stooping and lower- ing the head, and relieved by the opposite postures ; the patient complains of giddiness, noises in the ears, and black specks and flashes of light before the eyes. This condition is not unfrequently observed after indulgence in alcohol and as a result of excitement of various kinds. When oft repeated, the enlargement of the vessels is apt to become permanent, as a result of paralysis of the vaso-constrictor nerves. The headache then persists, becoming more severe under any form of excitement. FORMS OF HIE AD A CHE. 271 This kind of headache is not anfrequent as the result of excessive brain-work, and the symptoms associated with it may closely resemble those of chronic and severe cerebral congestion. If neglected, the consequences are apt to become very serious j sleeplessness is always present, and its effect is to exaggerate all the symptoms. Vomiting, attacks resembling apoplexy and attended by transient loss of speech, are not uncommon, and the complaint at this stage proves very intractable. Headache, associated with passive hyperaemia, is a common symptom of diseases in which the escape of blood from the veins of the skull is impeded. Hence it is frequently met with in diseases of the heart, and in cases in which cervical tumours, glandular or otherwise^ press upon the veins of the neck. Headache is very common in conditions of anaemia, and great care is necessary lest any mistake should be made in the diagnosis, and, consequently, in the treat- ment. In these patients, although the cheeks may be flushed, the conjunctivae and gums are pale, a venous hum can be heard in the neck, and the headache is diminished when the patient is m the recumbent posi- tion. The sensation in the head is described as if the skull were forcibly compressed. There is likewise a 272 FORMS OF SF ABAC HE. feeling of throbbing and beating within the cranium^ and giddiness and humming in the ears are often very troublesome. Marked cases of this kind are often seen in women, as a result of prolonged lactation. Headaches in which nervous symptoms predominate are also very common^ and are seen especially in the subjects of neurasthenia. These form a large class at the present day^ and include brain-workers of all kinds^ men of business, speculators^ and others whose nervous system is continually under a high degree of tension. The complaint is also common in women as a result of anxiety and mental and bodily strain. The prominent symptom is that of weight or pressure felt generally at the vertex, and with this other symptoms of neuras- thenia^ as described in the chapter devoted to that sub- ject, are always associated. In some cases there is more or less hypersemia, generally unilateral, of the cerebral vessels, and such patients often suffer from sleeplessness and various forms of indigestion. Mental disorder is a marked feature in these cases ; listlessness and aversion to work of any kind alternate with fits of irritability or depression, which latter sometimes amounts to melancholia. Some forms of headache may justly be regarded as FORMS OF HEAD AC RE. 273 sympathetic in character, the most marked of these being that which not unfrequently accompanies acute attacks of indigestion. The connection between the headache and the state of the stomach is shown bv the fact that the former is greatly reheved, or perhaps com- pletely subsides, when vomiting takes place. Headaches o'f this class are often associated wath excess of acid in the stomach, presumably due to fermentation. In these cases the exhibition of a full dose of sodium carbonate sometimes acts like a charm. Other forms of headache belonging to this category are those which occur in women suffering from uterine disorders. Rheumatic and gouty subjects are prone to suffer from headache. In the former, attacks frequently come on after exposure to cold draughts ; the pain is situated in the scalp^ which is likewise tender on pressure. It is always relieved by warmth. In gouty subjects, the headache takes the form either of mig-raine, which is very common, or of sharp explosions of lightning-like pains over the parietal bones, occurring in quick succes- sion, but unaccompanied by tenderness on pressure. Such attacks are sometimes to be traced' to indulgence in wine and animal food ; they are relieved by purgatives and alkalies. In other patients of this class it is found 18 274 FORMS OF HFABACHF. that the articular attacks,, at one time very frequent, either cease or become less marked, but are succeeded by headache, sleeplessness, vertigo, dizziness, and other symptoms of nervous disorder. The symptoms in these cases resemble those produced by the action of certain poisons which require a brief notice. Headache due to indulgence in alcoholic liquors has been already mentioned, and in chronic cases results, in some degree at least, from the action of the poison upon the stomach and liver. A small dose of opium affects some persons in a similar manner; and to the same category belong those forms of severe headache which are associated with uraemia, chronic lead-poison- ing, etc. The headache which is so prominent a feature in many hysterical subjects has been described in the chapter on hysteria. One form of headache, viz., that connected with syphilis, deserves a brief notice, if only because its nature is apt to be overlooked, and the treatment correspondingly misdirected. Pain in the head often accompanies an outbreak of secondary symptoms, and is wont to persist after the fever has subsided and the eruption is fully out. The seat of the pain is usually FORMS OF HFADACRF. 275 over the vertex^ but sometimes at the occiput and in the base of the skull. The pain is more or less continuous, but exacerbates at night; it is sometimes very violent, and associated with great mental excitement, or even delirium. It may be due to periosteal . inflamma- tion or intracranial mischief, which latter sometimes supervenes in the early stages of syphilis, i.e.. within the first or second year. When called upon to treat acute headache in young male adults, the possibility of syphilis should always be kept in mind. The presence of enlarged glands in the neck and groins will establish the diagnosis. Headache due to syphilis may occur many years after the primary disorder. I occasionally treat a case of this nature. The patient suffers at intervals from severe headache and neuralgic pains, which are always relieved by large doses of the iodides. There is, lastly, one important form of headache which must not be passed over, though hitherto but little attention has been paid to it. In not a few cases headache of a more or less severe character is due to disorders of the refractive apparatus of the eye. As might be expected, this form resists all ordinary routine treatment; but yields at once when the proper measures 276 st:adacji:e fbom visual disoebehs. are adopted. The attention of the profession was par- ticularly directed to this form of headache some years ago by Mr. Briidenell Carter^ who met with a case in which a wrong diagnosis had caused much anxiety and a useless and expensive course of treatment. A young man studying at Oxford was attacked by severe head- symptoms^ which were attributed to disease of the brain. A sea-voyage was ordered and taken, but caused no change in the symptoms. On examining the eyes with the ophthalmoscope, Mr. Carter found the patient to be myopic; glasses were ordered^ and a few weeks afterwards all the head-symptoms had disappeared. Two years afterwards the condition was reported as quite satisfactory. Several cases of a like nature have been lately reported,* such conditions as simple and ^compound hypermetropic and myopic astigmatism being discovered on examination. Besides the attacks of headache, such patients often complain of giddiness, faintness, indigestion in various forms, languor, sleep- lessness, and debility, all of which symptoms are * See paper by Mr. T. H. Bickerton, on " Headache due to Errors of the Refractive Media of the Eye," Lancet, August 13, 1887. See also Dr. Stevens' work on " Functional Nervous Affections," p. 35. DIAaNOSIS OF HEADACHE. 277 relieved or cured by the use of suitable glasses. There can be no doubt as to the part which errors of refraction play in the causation of many cases of headache. The account just given of the various forms of head- , ache will sufficiently indicate the great variety of con- ditions under which the affection may arise. Neuralgia' affectins: the head and mi2;raine are to be distinp:uished from headache in general ; in the former the pain follows the course of certain nerves, branches of the fifth or the occipital; in migraine the pain is one of a series of symptoms. In all cases of headache every attempt should be made to ascertain the cause" of the pain and the conditions with which it is associated. Attention should, therefore, be paid to the head itself, the eyes and nose, the organs of circulation and diges- tion, the state of the urine, etc. The history of the attack should likewise be inquired into; the seat of the pain, the frequency of its occurrence; the presence or absence of febrile symptoms and of concomitant dis- order in other parts are the main points to be attended to. In all cases of severe headache, and especially in those for which it is difficult to assign an obvious cause, the ophthalmoscope should be used, and at the same time the urine should be carefully examined for albumen 2 78 TREA TMI:NT OF SUA DA CHE. and casts of the tubes. Severe and persistent headache is a frequent symptom of cerebral tumours, and is not uncommon in advanced renal disease. In the former, optic neuritis is almost invariably present in one or other of its stages; in Bright's disease, evidences of albuminuric retinitis, such as haemorrhages, diffuse opacity and swelling of the retina, small whitish spots of degeneration, inflammation, and atrophy of the retina and nerve, are discoverable in a large proportion of cases. Treatment. Every case of headache requires to be made a separate study in order that the treatment may be properly directed, In chronic cases with evidences of cerebral hypersemia, the diet should be restricted ; stimulants should be forbidden, and tea and coffee taken in great moderation. In very severe attacks, a few leeches behind the ears or to the temples will serve to relieve the pain ; and in chronic and less severe cases a blister at the back of the neck, or even a mustard plaster, will be found efficacious. Cold applications to the head are always grateful to the patient j^ cold affusion may be practised, or an indiarubber bag filled, with iced water may be placed upon the head. Saline purgatives are usually indicated, and sometimes it is necessary to TREATMENT OF HEADACHE. 279 aid their effect by a preliminary dose of calomel or com- pound colocynth pill. Various mineral waters are suitable for these cases^ and especially those of Carlsbad, Marienbad, Friederichshall_, Hunyadi Janos, and Rubi- nat Condal. For gouty subjects in whom the headache is apt to be accompanied by symptoms of gastric catarrh, fermentation and acidity, the Carlsbad and Marienbad waters are especially suitable. The bromides may be required to relieve pain and to cahn excitement, but their use should not be too long continued. Galvanism applied to the sympathetic nerve in the neck is some- times useful. For this purpose the cathode should be applied to the inner border of the sterno-mastoid muscle, the anode being held in the hand ; the circuit can be interrupted by alternately removing and replacing the anode. When the active symptoms have subsided, and in slight cases, tonics are generally suitable; the nitro- muriatic acid, nux vomica, and henbane, form an appro- priate combination. In opposite conditions of the system, viz., those con- nected with anaemia, tonics are indicated, and especially the various preparations of iron and quinine. Arsenic and strychnine are also sometimes suitable for these cases. 28o TEUATMIJNT OF SBABACHE. Headaches occurring in cases of neurasthenia are often very difficult to treat. Rest is one main element in the treatment, and change of air to a suitable locality will often do more good than medicines. Anaemia must be dealt with as above indicated. In some cases a com- bination of quinine with hydrobroraic acid proves very serviceable. Bromide of potassium is useful to procure sleep;, and morphine may be used hypodermically for the same purpose. Moderate exercise^ plain nutritious diet, with a few glasses of good wine (Burgundy is one of the best), and tepid baths will do much to improve the general health. A course of strychnine is likely to be beneficial. For rheumatic headache, alkalies and warm applica- tions are indicated, and a few doses of iodide of potas- sium will often cause the pain to subside. This last- named drug is especially indicated in syphilitic cases, and if the pain does not yield a course of mercury is always desirable. The treatment of headache due to sympathy with other organs is that of the original affection. That of headache connected with errors of refraction is simply the use of appropriate spectacles. In cases in which, after thorough investigation, the tri:atmjEnt of sfadacsf. 281 cause remains obscure, and the indications for treatment are therefore doubtful, such remedies as caffeine^ guarana^ the bromides, butyl-chloral, and gelsemium, may be tried. If periodicity be a feature of the attacks, and particularly if there be any history of exposure to malaria, quinine should be given in full doses. Anodynes applied locally will also help to relieve the pain. The most suitable for use are the liniments of opium, aconite, and bella- donna, either separately or mixed, and to any of these a little chloroform liniment may be added with advantage. CHAPTER XL HEMICRANIA.— MIGRAINE.— MEGRIM. Frequency of Hemicrania — Its prominent features — Premonitory Symptoms — Symptoms of the Attack — Phenomena ' indica- tive OF Vaso-motor Disturbance — Two Forms — Disorders of Vision — Periodicity of Migraine — Length of Paroxysms — Causes of Migraine — Sex, Age, Hereditary Tendency, Gouty Predisposition — Exciting Causes — Anxiety, Over- exertion, Impressions on Certain Nerves of Special Sense, Derangement of Stomach, Relation of Gastric Symptoms, to Migraine, Insomnia — Pathogeny of Migraine — The Spastic form — Pain due to Spasm of the Muscular Coat of the Vessels — Fluctuations in the Supply of Arterial Blood as Causes of Irritation — Dr. Liveing's Theory of the Irregular Accumulation and Discharge of Nerve Force — Migraine thought by some to be only a Variety of Trigeminal Neu- ralgia — Diagnosis — Prognosis — Treatment — A Course of Quinine — Aperients — The Iodides with the Alkaline Car-. BONATES FOR GoUTY SUBJECTS — STRYCHNINE, ArSENIC, OxIDE OF Zinc, and Nitrate of Silver — Attention to Diet and Habits — Question with regard to Stimulants, Sleep, and Exercise — Change of Air and Scene — Precautionary Measures when a Paroxysm is Threatening — Rest, Darkness, and Warmth — Stimulants, Nux Vomica, Sodium Bicarbonate — Antipyrin — Treatment during the Attack — Darkness and Quiet, Cold to the Head, and Warmth to the Feet — Amyl Nitrite — Ergot — Cannabis Indica — Chloral — Morphine — Caffeine and Guar AN A — Galvanism. This form of headache is very common, and causes more suffering and incapacity for work than could well be MIGRAINE. 28.^ imagined by those who have had no personal experience of the complaint. There are, moreover, many obscure points connected with its pathogeny, and it is often very intractable ; for these and other reasons this affection is worthy of minute consideration. Hemicrania is characterized by paroxysmal attacks of pain, on one or other side of the head, of apparently spontaneous origin, and very generally accompanied by vaso-motor disturbances, upon which the principal symptom seems to depend. The left side is more frequently affected than the right, but the pain is not restricted to either side in any given case, sometimes one side being affected, sometimes the other. Various modifications are observed in this respect ; for instance, the attacks may come on in the left side for months or even -years, and afterwards affect the right half of the head for a time and then become irregular. Even when this alternation has become established the pain is usually more severe on one side than on the other. In some instances in which the pain is truly unilateral there is some amount of uneasiness felt on the other side. As a general rule attacks of migraine are preceded by certain prodromal symptoms, the nature and duration 284 MIGRAINE. of which vary In different cases and in different attacks. For a period varying from half-an-hour to perhaps three or four hours before the pain comes on the patient complains of discomfort or a feeling of pressure in the head, of fatigue and disinclination towards exertion^ of depression of spirits_, etc. In some cases there is incessant yawning, frequent sneezing, and a feeling of chilliness; nausea and vomiting are also sometimes present. Flashes of light before the eyes^ black spots, indistinct vision or hemiopsia, and noises in the ears are other subjective phenomena which are often noticed. Sometimes the patient finds the pain present on waking, as in a case which I attended in consultation with Sir W. Jenner j sometimes the attacks occur in the even- ing, after a day of more or less uneasiness. The pain never comes on suddenly and without warning, as in attacks of true neuralgia ; it is not uniformly diffused over the head, but is felt acutely in one spot, generally over the inner angle of the eye. It may, however, spread thence to the frontal region in general, and in some attacks the side of the head is more or less painful. The character of the pain is variously described by patients, and probably varies in different cases and in different attacks ; it is therefore spoken of as heavy, SYMPTOMS OF MIGRAINE. 285 dull, boring, piercing, splitting, etc. Some patients complain of a feeling of tension, as if the head would burst. Certain of the prodromal symptoms remain and even become aggravated during the attacks ; thus nausea and vomiting are often very distressing, and some of the ocular and auditory symptoms are prone to increase. In a large proportion of cases of migraine the paroxysms are attended by circulatory phenomena in- dicative of vaso-motor disturbance, and these symptoms occur in two principal forms. In the first of these during the attack the painful side is pale and shrunken, the pupil dilated, the temporal artery hard and tense, and the ear is pale and cold. The pain is increased by coughing and stooping, and at each pulsation of the temporal artery. Compression of the carotid tends rather to increase the pain than otherwise. There is often an augmented flow of thick saliva. After an interval, which varies much in diflferent cases, an opposite condition becomes established. The face becomes red and full, the ear is hot, the eye is injected, and the pupil often becomes contracted. Other sym- ptoms which are liable to occur are palpitation of the heart with increased frequency of the pulse, sensation 286 SYMPTOMS OF MiaRAINF. of heat over the body, yomiting, and secretion of limpid urine. The vomiting and retching are apt to be peculiarly distressing in young subjects ; as age ad- vances these symptoms generally become less prominent. At the close of some attacks diarrhoea occasionally sets in. I am now attending a lady, aged 34, who always has diarrhoea after the attacks. In the second form, when the attack is at its height, the face and ear on the affected side are hot, red, and swollen, the eye injected, the pupil contracted, and the lachrymal secretion profuse. Sometimes the upper lid feels stiff and difficult to raise; the temporal artery and sometimes the carotid are dilated and pulsate freely. The pain is diminished by pressure over the carotid. The pulse is less frequent than normal, and the radial artery feels small and contracted ; but these are not constant phenomena. In some few cases ophthalmo- scopic examination reveals dilatation of the central vessels of the retina, tortuosity of the veins, dilatation of the choroidal vessels, and a dusky appearance of the back of the eye. There is nothing characteristic about these appearances, for in some cases ophthalmoscopic examination has yielded negative results. As the attack passes off the above-mentioned symptoms SYMPTOMS OF MIGRAINJE. 287 gradually subside. One curious feature in connection with these phenomena is that they sometimes occur in alternate attacks in the same patient. Moreover^ certain symptoms of the one form are sometimes associated with those of the other type. In yet another class of cases of migraine the vaso-motor symptoms are either altogether absent^ or so slight as to be scarcely observable, and whatever may be the type of the dis- order^ the changes in the size of the pupil are by no means constant. The disorders of sight require a more detailed notice, inasmuch as they constitute a marked feature of a cer- tain proportion of cases. They present two forms, viz., partial or complete loss, or indistinctness, of vision in a portion of the visual field, and certain spectral appear- ances. The extent to which vision is interfered with varies in different cases. If the obliteration be centric more or less of the page of a book will be unnoticed when the patient attempts to read. If it be eccentric, that is, not corresponding with the macula lutea, several words or letters will be found to disappear. Some patients describe a general dimness of vision, coming on in paroxysms, with intervals in which the sight is com- paratively unaffected. The spectral appearances are less 288 SYMPTOMS OF MIGRAINE. frequently noticed ; flashes of light are perhaps the most common. Some patients describe a kind of ghmmer- ing, as though surrounding objects were in a state of oscillation; others have noticed in addition luminous lines forming zigzags and circles, surrounding either the objects looked at or the darkened portions of the visual field. The disorders of vision^ whatever form they may assume, rarely last for more than an hour unless the patient happens to be travelling by road or rail when the attack comes on. In that case the visual troubles are liable to become more severe, and they may continue until the journey is completed. Periodicity is a characteristic of migraine, and is well- marked in not a few cases, the attacks recurring with extraordinary regularity at weekly, fortnightly, or other definite intervals. During such intervals the patients are completely free from pain, but many of them find that an attack is liable at any time to supervene as a result of such causes as over-fatigue, excitement, anxiety, exposure to cold, and indigestion. The paroxysms vary in length in different cases, but they generally subside within twenty-four hours. Some patients are fortunate enough to escape with only a few hours' suffering. If the attack commences at noon, or at any time after- CA USES OF MIGRAINE. 289 wardsj it generally reaches its acme before bed-time ; the patient then is apt to fall into a heavy sleep^ from which he awakes, whether in the night or early morning, free from pain. There are, however, exceptions to this ruJe, for in a small proportion of sufferers the attacks last for several days, the pain becoming remittent, but not subsiding altogether. This form of migraine is naturally a very distressing one; while the attack lasts all kinds of exertion are utterly distasteful, if not impos- sible. Those who, under such circumstances, have to attend to the slightest duties are much to be pitied. . The causes of migraine are of a very varied character and will require to be discussed at some length. The effect of certain factors as predisposing causes is beyond a doubt; and among these the chief are sex, age, and hereditary influence. The female sex furnishes the largest contingent of sufferers, and in this respect, migraine is comparable with tic douloureux. The first appearance of the attacks often coincides with that of the menstrual process, and they are wont to cease after the menopause; their severity and frequency are in- creased by menstrual irregularities. With regard to age, the attacks generally appear before adult life is reached ; it has indeed been stated that they rarely, if 19 290 CAUSES OF 3IIGRAINJE. ever^ occur for the first time in persons over twenty- five years of age^ but this statement is far from being correct. In the large majority of cases, migraine first shows itself at the period of puberty ; but where there is decided hereditary predisposition the attacks may come on at a much earlier age. In these latter cases^ the time of their appearance probably depends upon the manner in which the child is brought up. A too early or too close application to studies is beyond all doubt a potent factor in the early development, of the com- plaint. A decided hereditary tendency can often be shown to exist in cases of migraine^ the occurrence of the com- plaint being traceable through several generations. It is moreover a fact of considerable interest that the com- plaint is apt to occur in children whose progenitors have suffered from other forms of nervous disorders, e.g., epilepsy, hysteria, neuralgia, and various mental de- rangements. When the hereditary predisposition to nervous affections is very strongly marked in one or both parents, it is sometimes noticed that one child may suffer from migraine, while others are the subjects of epilepsy, hysteria, or neuralgia. A gouty family history is a predisposing cause of migraine. In my CAUSES OF MIGRAINE. 291 work on Gout* I have drawn attention to the frequent coincidence of nervous affections with the presence of the gouty diathesis. In some famiHes acute gout shows itself in the male members, while the females suffer from neuralgia in various forms, and especially from migraine. These nervous disorders likewise are wont to alternate with acute attacks of gout, and some- times take the place of the latter. Dr. Liveing thinks that migraine, whatever form it may assume, is very frequently connected with the gouty diathesis, and that it is occasionally replaced by fits of regular gout. With regard to other predisposing causes^ there is little definitely known. The complaint exists among all classes of society, but on the whole it is probably most frequent among students and brain-workers in general. A chronic condition of anaemia also seems to be a predisposing cause. Much more can be said with regard to exciting causes of the attacks. Excitement, anxiety, worry, over-exer- tion, whether mental or bodily, will often cause an attack j impressions on the nerves of special sense, whether caused by disagreeable odours, exposure of the * " Gout and its Relations to Diseases of the Liver and Kidneys," 5th edit,, p. 93. 292 CAUSES OF MIGRAINE. eyes to strong lights protracted use of the eyes, a visit to a picture gallery, attendance at a concert, may have a similar effect. Many patients know exactly the kind of penalty they will have to pay for any mild kind of enjoy- ment which makes. a decided impression on the nervous system. Derangement of the stomach is not unfre- quently regarded as a cause of migraine, as it is a common accompaniment of the attacks. This view is doubtless correct with regard to a certain proportion of eases, but it more often happens that the gastric troubles result from the nervous disorder. In the experience of some patients the ingestion of food at a time when there are slight warnings of an attack is sufficient to provoke its onset, whereas if no food be taken the symptoms will usually disappear. This experience is similar to that which warns most sufferers to keep as quiet as possible and in a darkened room when an attack is sup- posed to be impending. The condition of some patients as regards sleep is closelv associated with the occurrence of the attacks. In some persons subject to migraine a sleepless night is almost invariably followed by the well-known prodromal symptoms ; in others no such effect is observable. Dr. Wilks has noticed the close relation between headache and sleepiness. Some of PATHOGENY OF MIGRAINE, 293 his patients have stated that a short nap after dinner is followed by a wakeful and comfortable evening, but that without such rest they are drowsy and lethargic. If in this latter condition they seek their bed they sleep heavily and wake with a headache. Others have noticed that " if after a walk or exertion they have felt tired and sleepy_, and_, fearing the accustomed headache, have taken a cup of coffee or tea to counteract the sleepiness, they have escaped the attack." Dr. Wilks thinks that these facts indicate a close connection between sleeping and headache; in the latter, however, there are generally indications of cerebral hyperaemia, whereas there is every reason to suppose that an opposite condition prevails during sleep. The influence of menstrual disorders, both .as predisposing and exciting causes, has been already noticed. The pathogeny of migraine is confessedly very obscure, but it is obvious that the attacks are in some way connected with local or general disorder- of the cir- culation. Whatever the condition of the affected parts may be, it is, to say the least, highly improbable that it corresponds with that which lies at the bottom of facial neuralgia, which differs fj'om migraine in so many respects. The spastic form of the disorder, viz., that 294 -P-^ THO GJENY OF MIGRA INE. in which the vessels of the affected half are more or less contracted^ may be regarded as due to irritation of the cervical sympathetic, whilst the opposite condition, that of vascular dilatation^ is caused by paralysis of the same nerve. This, however_, is no real explanation, for although the phenomena may be due to anaemia and hyperaemia respectively, we are still in the dark as to the antecedent cause of the changes in the vaso-motor system. The seat of the pain is also a doubtful point, but it seems probable that the dura mater, the pia miater, and the sensory layers of the cortex are the parts affected. The fifth nerve supplies several branches to the dura mater; the pia mater is supplied from the vertebral and carotid plexus, and also from several of the cerebral nerves, especially the fifth pair. According to one theory, the pain is due to spasm of the muscular coat of the vessels ; it is therefore regarded as similar in its origin to the pain attendant upon spasmodic con- tractions whether of the striped muscular fibres, e.g., of the legs, or of the unstriped fibres of the bowels or uterus. This theory, however, does not account for the pain in the opposite class of cases, or those in which the vessels are dilated. According to another theory, the fluctuations in the supply of arterial blood as PATHOGJENY OF MIGRAINE. 295 observed in the two opposite conditions of anaemia and hyperaemia set up irritation of sensory nerves in any or all of the following parts — the skin_, the pericranium, the cerebral membranes, and the sensory portions of the cortex. Such irritation is the cause of the pain, and that it should be produced by two such opposite conditions as anaemia and hyperaemia is no more ex- traordinary than the origination of epileptiform con- vulsions under equally diverse states of the vascular system. The other symptoms of migraine_, e.g., the cutaneous hyperaesthesia^ the disorders of the nerves of special sense, the nausea and vomiting, and the copious secretions which often accompany some portion of the attack^ may in like manner be referred to periodical fluctuations in the quantity of blood contained in the peripheral arteries, or in the cerebral centres of the nerves supplying the affected parts. A theory of migraine, advanced by Dr. Liveing, must not be omitted. This author classes migraine with several other paroxysmal affections, e.g.^ epilepsy, infan- tile convulsions, ague, and gout, and regards them as nerve-storms. He considers that " the fundamental cause of all neuroses is to be found not in any irrita- tion of the visceral or cutaneous periphery, nor in any 296 PATHOGENY OF MiaRAINE. disorder or irregularity of the circulation^ but in a pri- mary and often hereditary vice or morbid disposition of the nervous system itself; this consists in a tendency on the part of the nervous centres to the irregular ac- cumulation and discharge of nerve-force. The im- mediate antecedent of an attack is a condition of unstable equilibrium and gradually accumulating tension in the parts of the nervous system more immediately concerned, while the paroxysm itself may be likened to a storm by which this condition is dispersed_, and the equilibrium for a time restored." As supporting this theory. Dr. Liveing insists upon the paroxysmal and explosive character of the symptoms, the intermittent nature of the disorder, the tendency to recurrence with healthy intervals^ the nature and variety of the exciting causes, and other considerations. The seat of the dis- order is considered to be " the sensory tract, and the ganglia of the sensory nerves, from the optic thalamus above to the nucleus of the vagus below. ^' The storm begins in the optic thalamus, and passes from above downwards, or from before backwards in the sensory tract.* * See Dr. Liveing's work on " Megrim, Sick Headache, and some Allied Disorders," p. 336, et. seq. DIAGNOSIS OF MIGRAINE. 297 Such are the principal theories as to the nature of migraine. The view supported by the late Dr. Anstie, and by some at the present day, that the disorder is merely a variety of trigeminal neuralgia must, I think, be regarded as untenable. • The diagnosis of migraine can seldom present any difficulty, in spite of the variations of the symptoms in different cases. The pain differs from that of true neuralgia, for it does not come on suddenly, or take the form of darts or shocks separated by intervals of freedom. Moreover, it does not follow the course of a nerve; the supra-orbital region and the posterior part of the roof of the orbit are the commonest seats of pain. Tender points are not discoverable. The heat and throbbing of the affected side are also characteristic symptoms, while the vomiting and the evidences of con- stitutional disorder are never observed in connection with tic douloureux. The frequent termination of the attack in a heavy sleep is another distinguishing feature of migraine. The so-called clavus hystericus probably resembles the pain experienced in many cases of migraine, but the two conditions are not likely to be confounded. Migraine, however, may, of course, occur in hysterical subjects. 298 TREATMENT OF MIGRAINE. The prognosis is favourable as regards any danger to life^ and in some cases the attacks appear to exert a beneficial effect, inasmuch as the dread of their occur- rence tends to restrain patients from various excesses to which so unpleasant a penalty is attached. In a large proportion of cases patients find themselves less liable to attacks as they advance in life, and the symptoms become less marked. Much depends upon the circum- stances and habits of life of the patient, inasmuch as under favourable surroundings, and with the exercise of a little common sense, measures can be adopted to ward off the attacks, or at least to render them more tolerable. Treatment. Migraine is often a very intractable affection, owing in a great measure to the difficulty or impossibility of altering the conditions with which it is associated. Much may be done for the relief of patients who are both able and willing to carry out a definite line of regimen and treatment, but there are not many sufferers from migraine who can be included in such a category. Patients come to look upon it as a necessary evil, and comparatively few of them seek and act upon medical advice, except as regards some medicine for the relief of the pain. There are a few drugs which, taken TEE A TMENT OF MIGHAINE. 299 when a paroxysm is threatening, diminish its intensity, but their action is variable and not to be depended upon in all cases. In order to afford any permanent relief the state of the patient's general health must receive minute attention, and any existing cachexia must be dealt with as far as possible. In the majority of cases tonic treatment is indicated, and a course of quinine and iron sometimes yields very beneficial results, especially where there are evidences of anaemia. The quinine should be given about an hour before meals, and the iron immediately after them. If constipation be present, or result from the iron, a little extract of aloes should be given with the quinine. Under the use of these remedies I have known the attacks to cease for several months in a young man who had for many years been subject to almost weekly recurrences. Strychnine, arsenic, oxide of zinc, and nitrate of silver, given for a considerable time, have all been found more or less efficacious in diminishing the frequency of the attacks. In women, any existing menstrual irregulari- ties should receive careful attention. In cases of migraine with a gouty family history, I have witnessed much relief from a combination of the iodides with alkaline carbonates and nux vomica. 300 TREATMENT OF MIGRAINE. As a matter of course, in all cases of migraine the diet and general habits of the patient are points of much importance. The food should be nourishing, easily digestible, moderate in quantity, taken leisurely and at regular intervals. The evening meal should always be a light one. Tea and coffee may be allowed, but always in moderation, and with regard to alcoholic drinks, excess must, of course, be prohibited, but small quan- tities of those preferred by the patient may be allowed if taken with meals. Sleep is another important con- sideration, and patients should be advised to make every effort to secure a proper amount. Exercise must not be neglected; its form and duration 'must be regu- lated by the patient's circumstances, always remember- ing that over-exertion is likely to be as mischievous as the opposite condition. The functions of the skin must likewise be attended to. A prolonged change of air and scene appears in some cases to be remarkably beneficial. A friend of mine who had suffered severely in England for many years was completely free from attacks during a six years' sojourn in India. Some patients have found relief while staying at various watering-places, but the effect seems to be of a transi- tory character. TREATMENT OF MIGRAINE. 301 When the sensations of the patient warn him that an attack is imminent, there are a few measures which, if adopted, may either prevent a paroxysm or lessen its severity. Chief among these is rest, either in the sitting or the horizontal position, in a darkened room, and absolute quiet. If, as often happens, the patient is chilly and his feet decidedly cold_, warmth, applied either by means of a hot bottle or bv sitting near a fire, will be found, not only grateful, but of much assistance in warding off the attack. Some patients find that a small quantity of stimulant helps to shorten this stage. The most useful drug is nux vomica; the best way to take it is to mix 10 or 15 minims of the tincture with an ounce of water, and to sip the mixture slowlv. In some persons the effect of this remedy, especially when combined with the measures just adverted to, is very satisfactory. A full dose of sodium bicarbonate acts well in some cases, presumably in those in which the presence of much free acid in the stomach is the exciting cause of the attack. If any of these measures afford even slight relief, the maintenance of the recum- bent position will often induce sleep, from which the patient awakes almost or altogether free from discom- fort. 302 TREATMENT OF MIGRAINE. A remedy named antipyrin has lately been recom- mended for the relief of migraine. A single dose of from lo to 15 grains will sometimes cut short an im- pending attack. I have witnessed this result in several cases. Should the first dose fail to relieve, a second and even a third dose may be given at intervals of twenty minutes. Given in smaller doses for several days after an attack it is said to prevent recurrences. It must not be forgotten that even a few grains of antipyrin sometimes cause sickness and other un- pleasant symptoms (see Lancet ^ Feb. 25, 1888). When the attack is at its height^ anything that is likely to relieve the pain is readily welcomed by the patient. In not a few cases, however^ experience has taught him that little or nothing can be done in this direction. The horizontal posture, a dark room, and perfect quiet appear to be the most effectual palliatives, and to these may be added the application of cold when the throbbing and the hot stage are present. An ice-bag placed on the forehead lessens the intensity of the pain. If, as often happens, the feet are cold, a hot water bottle will also be useful. But few patients would care to place their feet in warm water owing to the change of position that would be requisite. Some patients TREATMENT OF MIGRAINE. 303 find that heat or a mustard plaster applied to the back of the neck affords relief; and compression of the carotid on the affected side is sometimes resorted to for the same purpose. Various drugs are used with more or less advantage in different cases. When there is evidence of vascular spasm, inhalations of amyl nitrite are likely to be serviceable. From two to four drops may be inhaled from a handkerchief, and where the remedy has a good effect much relief is rapidly obtained. In the opposite condition of the vessels, ergot in some form has been found useful. It may be administered either in pills, in doses of three or four grains, or else injected hypodermically (eight to ten minims of the Pharmacopoeia injection). Cannabis indica appears to benefit some patients; from ten to fifteen minims of the tincture maybe given every two hours until relief is obtained. Bromide of potassium and chloral hydrate will assist other patients. The chloral is best given in a full dose (of 25 or 30 grains), and if it produce sleep the patient will generally awake therefrom refreshed and free from pain. Butyl-chloral hydrate is recommended by some authorities, the dose being five or six grains every three or four hours. The hpyodermic injection of morphine is another remedy of this class, but it is less 304 TREATMENT OF MIGRAINE. efficacious than chloral, and \s, moreover, quite unsuit- able for cases in which the attack has been excited by gastric or hepatic derangement. There are two drugs, viz., caffeine and guarana, which appear to have a really marvellous effect in some cases. Unfortunately their action is very uncertain upon different patients : some persons find them utterly useless. They are, however, always worthy of a trial. About 20 grains of guarana should be given when the attack is coming on, and followed, if necessary, by a second dose an hour afterwards. Under similar circumstances citrate of caffeine may be tried in doses of from eight to ten grains. As a matter of course galvanism has been tried, both as a prophylactic and as a palliative during attacks : in the latter capacity it sometimes gives relief. A weak current must be used, one pole being placed on each mastoid process. If it be wished to galvanize the sym- pathetic nerve, one pole is placed behind and below the angle of the jaw, while the other pole is held in the hand. When the symptoms are referable to vascular dilatation, the negative pole should be applied to the neck, while the positive is held in the hand ; and when the opposite condition exists the position of the poles should be reversed. CHAPTER XII. VERTIGO— GIDDINESS. Vertigo as a Symptom of Organic Diseases of the Nervous System — In Diseases of the Stomach and Liver — In Affec- tions OF the Eyes and Ears — In Debility^ and Anemia, and Functional Disorders of the Nervous System — Toxic Forms AS IN Gout — Definition and Kinds of Vertigo — Gastric Vertigo, Symptoms and Treatment — Ocular Vertigo — Aural Vertigo — Vertigo of Anemia, Neurasthenia, Hysteria. Epilepsy, and Hemicrania — Vertigo in Gouty Subjects. Vertigo is a common and often a prominent symptom of many organic diseases of the central nervous system, e.g., of tumours of the cerebrum, cerebellum^ crura cerebri, and pons Varolii. It also occurs in connection with disorders of the stomach and liver -, as a result of certain affections of the eyes and ears ; in association with post-nasal catarrh ; in states of debility and anaemia ; and as an effect of various functional disorders of the nervous system. There are also toxic forms of vertigo, examples of wdiich are seen in some cases of lithsemia, and likewise as a result of alcohol^ tobacco, and various other drugs. In a few rare cases in which 20 3o6 FORMS OF VERTIGO. giddiness is a prominent symptom, no other abnormal condition can be detected. At the present time I have a patient under my care, a gentleman aged ^^, in whom vertigo is the only symptom, while its cause remains obscure. The term vertigo implies a sense of defective equilibration, accompanied by a feeling of false impres- sions as to the relations and motions of surrounding objects, or of the movements of the body, or of the brain itself. In the most common type of vertigo, surrounding objects appear to be in motion ; sometimes they seem to be revolving round the sufferer, sometimes to be coming towards him, or to be changing their positions and to stand at abnormal angles to each other. In another form the surrounding objects are at rest, while the patient himself appears to be in motion. In a third form the symptom is sometimes described as a " swimming of the head ; " the contents of the cranium seem to be revolving. Vertigo, especially in its graver forms, seldom exists alone; it is often accompanied by a feeling of nausea or even by vomit- ins:, by noises in the ears, confusion of thought, and sometimes even by slight loss of consciousness. The various conditions with which vertigo is associated will FORMS OF rEUTlGO. 307 be first pointed out, and afterwards the pathology of the symptom will be discussed. A common form of vertigo is associated with disorder of the stomach and liver. Men of middle ao'e, who take an insufficient amount of exercise and eat hurriedly, are the most common sufferers. In some of these cases, exercise after a meal will bring on an attack. There are other persons, in whom, owing to a curious idiosyncrasy, an attack of nausea and vertigo is the invariable result of eating certain articles of food, e.g.^ shell-fish and eggs. I have m.et with several examples of this character. When such articles are taken, they cause intense irritation of the stomach, with nausea, sickness, and vertigo, all of which symptoms pass off after the offending matters are ejected. In ordinary cases the vertigo comes on after a hearty meal. The stomach becomes distended, there is pain, heat, or uneasiness in the head, buzzing or other noises in the ears, eructations, perhaps of an acid character, palpita- tion, and vertigo. This last condition varies in degree, and is not unfrequently so severe as to create alarm. All the surrounding objects seem to be in motion ; the patient, on attempting to walk, reels as though he were intoxicated; sometimes there is double vision, flashes of 3o8 GASTRIC VERTIGO. light before the eyes^ confusion of ideas^ and great un- easiness. In some cases, but not in all, the giddiness passes oflT, or is lessened when the patient lies down. These symptoms may last for several hours ; but they almost invariably cease after free vomiting. The ejected matters are often intensely acid ; but sometimes bitter and yellowish. In less marked cases there is only nausea and retching as gastric symptoms, and these, with the vertigo, slowly subside. The attacks, what- ever form they may assume, are very apt to recur, and in some patients a condition of giddiness becomes estab- lished, and lasts almost indefinitely, the sensation being aggravated by movements, by mental efforts, and by impressions on the nerves of special sense. In none of these cases is there any loss of consciousness, and if sensory hallucinations are present, they are not made worse when the head is lowered, as is the case when they are dependent on cerebral hyperaemia. The treatment of gastric vertigo consists first in attention to the diet. The food should be of a simple and digestible character, taken at proper intervals, and without undue haste. Excesses of all kinds are, of course, to be avoided ; beer, pastry, and other substances liable to engender flatulence should be forbidden. In OCULAR VERTIGO. 309 an acute attack, coming on soon after a meal, if there be nausea and retching, an emetic, such as mustard, sulphate of zinc, or ipecacuanha, should be given and followed by a draught of lukewarm water. If the bowels are confined a purgative draught of rhubarb, magnesia, and soda should be "given a few hours after the emetic has acted. A course of vegetable bitters with alkalies will help to ward off attacks for the future. Trousseau recommends a cup of infusion of quassia every morning, and a little soda, chalk, and magnesia at bedtime and after each of the two principal meals. Nux vomica is also likely to be serviceable; ntv-x may be given before meals. When the liver appears to be at fault, purgatives are usually indicated, and the Carlsbad salts and the Rubinat Condal water are suitable for such cases. In the more chronic forms, in addition to purgatives, a course of dilute nitro-muriatic acid with nux vomica and henbane will probably afford relief. Attention to the diet is all-important. Vertigo from ocular causes generally depends upon paralysis of the external rectus muscle of one eye. Diplopia is caused thereby, and is associated with con- fusion of vision, and these symptoms with the giddiness may become so severe that the patient fears to walk 3IO OCULAR VERTIGO. alone in the streets. Loss of power of the internal recti muscles is another cause of vertigo^ and this con- dition is not unfrequent in persons whose daily occupa- tion involves the continuous use of the eyes at reading distance. In maintaining the necessary convergence of the visual lines the internal recti become strained and gradually insufficient; prolonged use of the eyes causes aching pain and confusion of vision, with headache and a feeling of giddiness. All these symptoms become aggravated if the patient's health fail from any cause/or if any special strain be put upon the eyes. On the other handj after regt_, change of air_, and a general tonic treatment the vertigo and the other symptoms are always less troublesome. Astigmatism and asthenopia from defective accommodation are less frequent causes of vertigo. In connection with ocular defects it is worthy of notice that even when slight they may induce and greatly exaggerate giddiness^ due primarily to gastric or aural causes. In persons liable to these latter forms of vertigo the use even of normal eyes is liable to cause or increase the giddiness. The treatment of vertigo due to ocular causes con- sists in remedying the defect in the eyes, either by suit- able glasses or by operation. AURAL VERTIGO. 311 Aural vertigo_, to which much attention has been paid since its pathology was explained by Meniere in 1860^ is to be regarded as the effect of irritation of the nerves of the semicircular canals. The vertigo is associated with auditory sensations of a severe character. The acute attacks are generally preceded by pain in one ear, deafness_, and more or less discharge, and occasionally by sensations of chilliness ; but in some cases they come on suddenly and without any warning. The patient feels giddy and sick^ and is conscious of a loud_, buzzing, whistling, or cracking noise in one ear; the face becomes covered with a cold perspiration, and in rare cases sensa- tion and power of motion are almost completely abolished. In an ordinary attack consciousness is not impaired and movement is possible, though not in a straight line. This condition was very marked in a case I saw recently in consultation with Dr. Woakes. Neighbour- ing objects appear to oscillate or to revolve round the patient; he reels or totters as though the ground were moving under his feet; and sometimes he is conscious of an irresistible tendency to keep turning in the same direction. The impulse is from right to left when the right ear is affected, and vice versa. These symptoms may last for a few seconds only, or may continue for 312 AURAL VERTIGO. several hours, and they sometimes pass off after free vomiting. The patient may then feel quite well, or may still complain of uneasiness about the head, especially on movement. Diminution or loss of hearing is commonly noticed after the first attack, when the latter has occurred without any premonitory symptoms. In some patients the giddiness and noises in the ears are almost habitual^ becoming worse at intervals. In ordinary cases the giddiness and im- pairment of hearing are the only remaining troubles, and the former may soon pass off; but in more severe and complicated cases there are clonic spasms of the muscles of the face, involuntary movements of the limbs, causing the patient to run forwards or fall in various directions. I have a patient suffering from aural disease, in whom the noises continue for months and then stop suddenly, and cease altogether for several weeks, again to recur. Once established, the attacks of aural vertigo are apt to recur at uncertain intervals, and their incidence has no relation to the state of the digestion. If the deafness becomes com- plete, cessation of the attacks is the general rule. Aural vertigo is liable to be mistaken for giddiness, the result of cerebral congestion. In this latter condition AURAL VERTIGO. 313 there are frequently intervals of decided loss of con- sciousnesSj from which recovery is gradual and tedious, so that mental confusion and embarrassment may last for some time. Deafness is, however, absent, and the prodromal symptoms are more often visual than auditory illusions. Loss of consciousness is charac- teristic of epileptic vertigo; on recovery the epileptic patient has no knowledge of what has gone before^ and there is no impairment of hearing. Recent experiments have served to explain the pathology of auditory vertigo. Section or injury of the semicircular canals of the labyrinth produces a feeling of giddiness and consequent disturbances of equilibrium. A normal condition of the labyrinth is necessary for the maintenance of the balancing power. According to Dr. Ferrier^ this portion of the ear seems to regulate the state of the equilibrium of the individual and to preside over co-ordination. Dr. Crum Brown suggests that the sense of rotation has a special peri- pheral organ_, a bram-centre, and a connecting sensory nerve. All experimenters agree that the labyrinth is a special organ of this character; the irritation is •conveyed by the auditory nerve to the centre, with the result of producing anaemia of certain parts of the .SI 4 • AVUAL I'ERTIGO. brain. The vertigo_, reelings and other symptoms are held to depend upon the last-mentioned condition. Irritation of the external and middle ear will sometimes produce vertigo. Thus the injection of cold water into the meatus and the presence of foreign bodies are occasional causes of the condition, while in the middle ear inflammatory processes and obstruction of the Eustachian tube may lead to a similar result. In the treatment of aural vertigo^ the ear should be examined in the hope that a removable cause may be discovered. Hardened wax and foreign bodies should, of course^ be removed, and obstruction in the Eustachian tube must be dealt with by inflating the tympanum, as- tringent applications to the pharynx, and, if necessary, by passing the Eustachian catheter. Labyrinthine vertigo, is much less amenable to treatment. The most useful remedy during the intervals is quinine in large doses, e.g., gr. x-xv daily, combined with dilute hydrobromic acid, and continued for three or four weeks. The bromides, in full doses, are sometimes useful in severe attacks, and the addition of morphine may also be tried. For chronic cases, counter-irritation over the mastoid process is likely to prove serviceable. Attention should be paid to any gastric derangement, for in the subjects. AURAL I'ERTIGO. 315 of aural vertigo, disorder of the stomach is liable to provoke an attack. It must not be forgotten that when the deafness becomes complete and permanent^ the ver- tiginous attacks generally cease. Dr. Woakes* has pointed out that the condition of the Eustachian tubes in post-nasal catarrh^ of which indigestion is a frequent concomitant^ exerts a marked influence on the induction of the so-called stomach vertigo. The result of the obstruction of the tubes is retraction of the drum- membrane, "in consequence of • the external atmospheric pressure not bemg counter- balanced by the column of air behind it, which should be constantly renewed by the automatic action of the Eustachian tubes upon the respired air. This function being in abeyance the air is excluded from the tympanic cavitv and hence the greater or less degree of collapse of the drum-heads. With this the ossicles are also pressed inwards, and through the medium of the stapes exert a slightly increased degree of tension upon the intra-Iabyrinthine fluid, which constitutes a predispos- ing cause of vertigo. Now the subjects of chronic * " On Post-Nasal Catarrh and Diseases of the Nose causing Deaf- ness," p. 52. 3i6 VERTIGO AND BEBILITY. catarrh are particularly prone to attacks of vertigo, which attacks are frequently initiated in the primce viceJ' In various conditions of debility, as anaemia and neurasthenia, more or less severe vertigo is a some- what common symptom. It always attends copious losses of blood, and is felt by the patient before actual syncope comes on. In ordinary anaemia and in chlorosis, patients often complain of giddiness especially on exertion. There is seldom any difficulty in recognizing these condi- tions, and the main question in diagnosis relates to the cause. This, of course, must be discovered and dealt with, and the giddiness and the other cerebral symptoms will then subside. In neurasthenic subjects, vertigo is seldom very severe, though it may continue for some time and cause great distress to the patient. It is always aggravated by the gastric and hepatic disorders and the sleeplessness, all of which are common com- plaints in these subjects. As a symptom, vertigo is apt to be most prominent in those cases of neurasthenia which are mainly due to sexual excesses. It is worse when the patient assumes the erect position, and while he is walking there is a distressing sense of unsteadi- ness. There is no deafness, and noises in the ears are rarely complained of; the vertigo is aggravated by VERTIGO AND NERVOUS DISORDERS. 317 mental efforts of various kinds, and by prolonged use of the eyes. The treatment is, of course, that of the condition of which the vertigo is only a symptom. Avoidance of the cause is indispensable to a cure. Among functional nervous disorders, besides those already mentioned, hysteria, epilepsy, and hemicrania count vertigo among their symptoms. Dr. Weir Mitchell states that he has "^seen hysterical girls with deafness, tinnitus and a great development of equili- bria! disturbance, in whom the disease passed away without leaving a trace behind it.^' He adds that vertigo in such cases does not exclude the presence of true aural, optic, or gastric dizziness, which is then apt to become the starting-point of a long train of hysterical disorders. In epileptic cases the attack may be ushered in or replaced by a feeling of giddiness. Epileptic vertigo is always accompanied by unconsciousness, and often by various motor phenomena and some of the other ordinary symptoms of the typical epileptic paroxysm. The vertiginous fee]ine;s in an attack of migrraine are seldom severe, unless the patient happen to be travellina: during the attack. The giddiness may precede or accompany the pain in the head, and it is often marked when the gastric symptoms are prominent, and subsides 3i8 VERTIGO AND GOUT. after free vomiting. There is neither deafness nor noise in the ear; bat various ocular symptoms of migraine are generally associated with the giddiness. The treat- ment of these forms of vertigo is, of course, that of the conditions with which they are associated. Vertigo is somewhat frequent in gouty subjects, and in some of these cases it forms one of a group of symptoms which alternate with or occasionally replace the articular inflammation. Under such circumstances it is apt to be accompanied by headache, disturbed sjeep, flatulence, and other signs of gastric disorder. It is probably due to the presence of lithic acid and other imperfectly oxidized substances in the blood, and not unfrequently to the presence of undigested and irritating articles of food in the stomach and bowels. The treat- ment is that of gouty dyspepsia ; the diet must be carefully regulated; excess of animal food and indiges- tible articles must be strictly forbidden; stimulants, if allowed at all, should be prescribed in definite and small quantities, to be taken only with meals ; exercise and attention to the state of the skin should be carefully insisted on. By way of medicines, purgatives are generally indicated, and these may be taken in the form of such mineral waters as Friedrichshall, ^sculap, VERTIGO AND GOUT. . 319 Hunyadi Janos^ or the Rubinat-Condal. When there are marked symptoms of gastric catarrh^ such as fer- mentation and acid eructations^ Carlsbad water is preferable. Should the function of the liver appear to be imperfectly performed^ small doses of calomel or blue pill, either alone or in combination with colocynth or rhubarb^ m.ay be given from time to time. Various other hepatic stimulants and alteratives,, as podophyllin^ euonymin, iridin, and leptandrin, are available for use in chronic cases. When the urine 'contains much free acid, a course of alkalies with bitter tonics is likely to be serviceable. Vertigo in cases of gastric disorder is explained by the close .relation which exists between the nuclei of origin of the pneumogastric and auditory nerves ; the irritation is propagated from the former to the. latter. In lithaemia the giddiness is presumably due to the irritating effect of the lithic acid upon the cerebral vessels, and the consequent disturbance of the circulation. CHAPTER XIII. WRITER'S CRAMP AND ALLIED DISORDERS. Writer's Cramp, Peculiarities of — Persons Most Prone to Suffer — Pathology — Symptoms, Three Forms: Spastic, Tremulous, and Paralytic — Mixed Forms — Allied Disorders Diagnosis — Treatment -^ Rest — Wolff's Method — Gal- vanism — Attention to General Health — Local Measures — Counter-irritation — Mechanical Appliances. The condition termed writer's cramp is the most common example of a class of peculiar disorders of motion. These affections present one feature which is common to them all, namely, that certain actions, pre- viously accomplished with perfect ease, are rendered diffi- cult or even impossible in consequence of cramp or other disordered form of muscular action, whereas other kinds of movement are performed by the same muscles with- out difficulty or discomfort. As a matter oF course, the upper extremity, and particularly the hands and fingers, are most liable to be thus affected, inasmuch as these parts have more work thrown on them. The cases in which the lower extremities are affected are compara- tively few in number. WRITER'S CRAMP. 321 Writer's e ramp occurs almost exclusively in persons whose avocations require them to write for many hours daily. The majority of the sufferers are those who are compelled to write a good legible hand and overtax their muscles. It is said that bad writers and authors for the most part escape ; copyists have to bear the burden. Weakly subjects with a predisposition to nervous affec- tions are most liable to be attacked^ and when the symptoms have appeared they are apt to be aggravated by excesses of all kinds, and in fact by anything which tends to lower the tone of the nervous system. In a few cases the symptoms have been noticed to appear after an injury to the hand; their development is^ doubtless, often promoted by the use of hard steel pens, a thin and rigid penholder, and by the adoption of a cramped and confined position when writing. The fear and anxiety lest the disorder should prevent the sufferer from gaining a living will also tend to accelerate the progress of the symptoms. Nothing definite can be stated with regard to the pathology of this affection. The symptoms indicate disordered co-ordination, and, as Dr. Poore has pointed out, such disorder would be produced by " the failure of one muscle, however small, which had been taught by 11 322 SYMPTOMS OF WRITER'S CRAMP. years of laborious education to act in harmony with many others for the accomphshing of a compHcated and dehcate act." It has been thought by some that degenerative changes take place in the spinal cord_, and this opinion is supported by the fact that faradisation of the hands has no effect upon the symptoms. More- over, if the left hand is used to supply the place of the right it is soon apt to become affected in asimilar manner. It may be that slight inflammatory changes are set up in the peripheral nerves, and that the process gradually advances towards the nerve-centres. Symptoms. These are of a typical character, inas- much as they occur only when an attempt is made to use the pen. They begin gradually and insidiously ; there is at first a sense of discomfort in the hand and arm generally, and the guidance of the pen seems to be difficult. As time goes on the symptoms become more marked, and after a few letters or words are written the hand becomes stiff, or painful, or both at the same time. In the most common form of the affection the thumb and index finger are thrown into a state of tonic spasm soon after the patient attempts to write, and it is obvious that certain muscles, or groups of muscles, are spasmodically contracted. In some cases the thumb is SYMPTOMS OF WRITER'S CRAMP. 323 drawn across the palm, and thus pressed against the pen; in others the index finger is firmly extended; while in a third class extension of the thumb is added to that of the forefinger, so that it is impossible to hold the pen in the ordinary manner. In very severe cases the hand is drawn to the ulnar side owing to spasm of the flexor and extensor carpi ulnaris. It less frequently happens that the pronators and supinators are affected; in very rare cases the muscles of the shoulder are spas- modically contracted. When the hand is affected, as above described, writing becomes very difficulty and the letters are apt to be unequal and distorted, and separated from each other by irregular strokes. In a second form of the disorder, immediately the patient attempts to write, the hand, and perhaps the entire arm, begin to tremble, the movements become worse as the patient endeavours to overcome them, and •legible writing is, of course, impossible. In the third, or paralytic form, the hand and arm feel weak and pain- ful after a few words or lines have been written; if writing be persevered in, the hand at last is felt to have lost its strength, and it rests for some time on the paper in order to recover itself. As a general rule other movements can be performed without difficulty by the 324 SYMPTOMS OF WRITER'S CRAMP. affected hand, and no discomfort is felt exctj t when writing; but as time goes on the muscles at the back of the forearm are liable to continue painful, especially when called into action for any purpose. The pain may also extend to the nerves on the inner side of the arm and to the shoulder. These three forms of writer^s cramp may be combined in various ways; tremulous movements are often super- added to the spasm. Various manoeuvres are adopted by patients in order to overcome their difficulties ; they often try holding the pen in a different way, and for a time they may find relief, but at last the different muscles called into play become similarly affected. Writing from the wrist alone, or even from the shoulder, is often, for a time at least, efficacious, and patients always find that they can write more comfort- ably with a pencil than with a pen. A feeling of tired- ness is common to all the patients, but it is especially marked in those who suffer from the spastic form of the disorder. They are apt to make enormous efforts in order to overcome their difficulties. The pain already described may extend from the shoulder to the spine, and the lower cervical and upper dorsal vertebrae are not unfrequently tender on pressure. An eruption of DIAGNOSIS OF WRITER'S CRAMP. 325 eczema, with severe tingling at the back of the forearm, has been noticed in some cases. The electrical excita- bility of the affected muscles is generally normal, but it may be somewhat increased. When the pain and stiffness have become marked, the handwriting is, of course, considerably altered ; the letters are stiff, angular, and ill-formed. The complaint is a very obstinate one; a complete cure can be expected only in slight cases. The chronic and severe forms may, however, be considerably relieved by treatment. Some patients learn to use the left hand, but this, as before stated, is apt to become similarly affected. I have a patient who has learnt to write with his left hand, and by using the hands alternately has prevented a recurrence of the attack. With reference to disorders allied to writer's cramp it is only necessary to mention their names. The most common instances are as follows : Piano- and violin- players' cramp, telegraphists' cramp, and tailors' cramp. In the lower extremities analogous symptoms are occa- sionally witnessed in ballet-dancers and in girls working treadle sewinsf-machines. The diagnosis of writer's cramp is almost always easily made. It is only necessary to remember that 326 TEJEATMJENT OF WRITER'S CRAMP. difficulties in writing are sometimes the first symptom of chorea. Treatment. Rest of the affected part is all-important^ and for mild cases may be all that is necessary. It must, however_, be continued for weeks or even months, and when the patient recommences writing he should do very little at a time/ adopt a comfortable position, wear a glove on his hand, use a large soft cork pen- holder and an easy pen. In severe cases something more than rest is required, and systematic massage would appear to have yielded very favourable results in the hands of specialists. The method employed, with a considerable amount of success, by J. Wolif, is as follows: — (i) Twice or three times daily, the patient is directed to move his fingers, hands, forearms, and arms in all possible direc- tions, the muscles '^ being made to contract from six to twelve times with considerable force and with a pause after each movement, the whole exercise not exceeding thirty minutes." (2) The movements are made as before, but '^each one is arrested by another person in a steady and regular manner; this may be repeated as often as the active exercise. Massage is practised daily for about twenty minutes, beginning at TBIIATMIINT OF WRITER'S CRAMP. 327 the periphery ; percussion of the muscles is considered an essential part of the massage. Combined with these are peculiar lessons in pen-prehension and writing."* Dr. Lewis cites the experience of Theodor Stein^ according to whom, out of 277 cases thus treated, 157 were cured, 22 improved, .while q8 remained un- improved. The total number comprised cases of writers', pianists', telegraphers', and knitters' cramp. In a considerable number of patients, much improve- ment has also been effected by the use of galvanism, the application of which, however, must be adapted to each particular case. As a general rule weak currents alone are necessary, and violent contractions of the muscles and long sittings are to be avoided. In one method the anode is applied to the spinous processes of the lower cervical and upper dorsal vertebrae, while the cathode is placed over the affected muscles or their nerves. The poles are not to be moved about, but should be kept in position for about ten minutes, and the treatment may be repeated either daily or every other day. In another method, the anode is placed as before, over the lower cervical or upper dorsal vertebrae. * " Neural Disorders of Writers and Artisans," by Dr. M. J. Lewis, in Vol. V. of " Pepper's System of Practical Medicine.'' 328 TRI:ATMENT of WRITER'S CRAMP. and the cathode in the depression between the angle of the lower jaw and the sterno-cleido-mastoid muscle. A mild current should be used, it should not be suddenly broken, and the sitting should not exceed five minutes. When, as not unfrequently happens, one or more spinous processes are tender to the touch, the application of the anode will generally relieve this symptom and produce a corresponding improvement in the state of the arm. The faradic current is not to be recommended in these cases of writer's cramp except, perhaps, in the paretic forms, and after the spastic sym- ptoms have entirely disappeared. In these cases the nutrition of the muscles may be promoted by the cautious use of the induced current. One electrode should be placed over the affected muscles, and the other on the patient^s chest ; a weak current just enough to cause contraction of the muscles is all that is required, and the application should not be continued for more than five minutes. In all cases of writer's cramp the state of the general health should be inquired into and improved as far as pos- sible. Anaemia should be combated by iron, quinine, and the hypophosphites ; if nervous irritability, anxiety, and sleeplessness are prominent symptoms, a short course tei:atmjent of writer's cramp. 329 •of the bromides, in combination with the tonic remedies, is likely to be serviceable. Pain in the arm should be relieved by belladonna and chloroform liniment. Some authorities recommend the hypodermic injection of atropine (gr. -^) for cases in which tonic contraction is a marked feature. When pain extends up the inner side of the arm it is probably due to neuritis, and should be treated by the application of flying blisters to the neighbourhood of the painful spots. In very severe cases it may be better to apply the Paquelin cautery to the skin. The instrument must be at a white heat, and very quickly and firmly drawn along the course of the affected nerves. If properly applied, vesication will not be produced ; only the superficial layer of skin becomes dry and brown. The length of the cauterized surface need not exceed a couple of inches, and the application should be repeated from time to time on fresh portions of skin. Various mechanical appliances have been devised for enabling the subjects of writer's cramp to continue their avocation to some extent. Such appliances act by making another set of muscles perform the work. They are of questionable efficacy inasmuch as the sym- ptoms are apt to become developed in the muscles whose vicarious action is solicited. CHAPTER XIV. FACIAL PARALYSIS. Forms of Functional Paralysis — Rheumatic Paralysis — Paraly- sis OF THE Facial Nerve, due to Cold and other Influ- ences — Symptoms, Subjective and Objective — Loss of the Sense of Taste — Auditory Symptoms — Electrical Reactions of the Paralyzed Parts — Diagnosis of Facial Paralysis — Determination of the Site of the Lesion — Prognosis — Treatment. The term functional is applied to those forms of paralysisj the cause of which is either obscure or altogether unknown. Thus under this heading may be grouped the paralyses met with in chronic poisoning by lead and mercury ; those which are observed as sequelae of febrile affections, such as diphtheria, dysen- tery, and intermittent fever; the paralyses of reflex origin, and those which occur in hysterical cases. With the exception of the last, all these forms are compara- tively rare, but another form more often met with, and vaguely termed rheumatic^ may be included in the cate- gory of functional paralyses, inasmuch as the anatomical condition of the affected nerve is unknown. The most common example of rheumatic paralysis is that which CAUSES OF FACIAL PARALYSIS. 331 involves the facial nerve, which, from its superficial and exposed position, is especially liable to be influenced by changes of temperature. The paralysis referred to is almost always unilateral ; facial diplegia is a symptom of bulbar paralysis, and is rarely, if ever, seen as a con- sequence of cold. In the majority of cases exposure to cold, especially in the form of a cold wind, is the exciting; cause of facial paralysis. Persons in good health are liable to be thus attacked after sitting at an open window, for example, of a railway carriage. A decided current of air is not absolutely necessary, inasmuch as remaining in a damp place, as in a new house with imperfectly dried w^alls, has been known to produce it. It is also stated that violent emotions, as terror, grief, or anger, have been the only assignable causes in some cases. Nothing is definitely known as to the nature of the anatomical change which takes place. It may be sup- posed that there is slight inflammatory swelling, followed by exudation in the sheath of the nerve. When this process takes place within the aqueduct of Fallopius the results will be more marked than when the peripheral part of the nerve is affected. According to another theory the cold affects the sensory nerves of the skin. 332 CAUSES OF FACIAL PARALYSIS. and the paralysis is due to reflex inhibitory influence. When the loss of power follows violent emotional excitement^ the nuclei at the origin of the facial nerve must be paralyzed by an influence transmitted to them from the higher cerebral centres. It is necessary to say a few words on the other causes of facial paralysis. The severest forms are ob- served in cases of caries of the temporal bone in which the nerve maybe completely destroyed. Simple catarrh of the tympanum may, however, cause facial paralysis. Owing to the near proximity of the two structures, inflammation may easily extend from the one to the other. Wounds are a not unfrequent cause of facial paralysis, and inflammatory swellings in the neighbour- hood of the parotid gland, and glandular and other tumours near the stylomastoid foramen may produce the same result. Another category includes those causes which are intracranial, and of these the most common are tumours and periosteal growths, especially those of -a syphilitic nature at the base of the skull. Intracerebral lesions, affecting the facial nuclei in the medulla oblongata, or the motor centres in the cerebral cortex, are other causes of facial paralysis. Patients are generally made aware of the occurrence SYMPTOMS OF FACIAL PARALYSIS. S33 of facial paralysis by finding that fluids taken into the mouth have a tendency to escape on one side, and that solid morsels, after mastication, remain between the gums and the cheek. Pain on the affected side, due to implication of the fifth nerve, is rarely experienced, but there is often a feeling of stiffness. When the paralysis has come on slowly, e.g., several days after exposure to cold, the patients are sometimes conscious of some loss of taste, as well as of deafness and noises in the ear of the affected side as premonitory symptoms. When the paralysis is complete, that is, when all the branches of the nerves are involved, the objective symptoms are very distinct. The surface of the face is drawn towards the sound side ; on the paralyzed side the folds and wrinkles are obliterated and the face therefore presents a smooth appearance, the angle of the mouth is lower than normal, the nostril does not rise in inspiration, but sinks owing to the pressure of the atmosphere. The objective symptoms become much more marked when the patient attempts to use the muscles of the face, as in laughing, crying, making grimaces, etc. On the paralyzed side no wrinkles are then seen on the forehead ; the closure of the eye is incomplete ; the eyeball is rolled upwards, so that only 334 SYMPTOMS OF FACIAL PAMALYSIS. . the sclerotic is seen; the angle of the mouth cannot be drawn toward the ear; the lips cannot be moved in any direction^ and when the patient endeavours to whistle the difference becomes very obvious. When he laughs or cries the mouth is opened only on the sound side. Moreover, the eyelids do not blink, the eye remains open and conjunctivitis is apt to be set up^ the tears do not find their way into the lachrymal canal, but course downwards over the cheek. The patient finds it difficult to pronounce the labial consonants, and in speaking the affected side of the face remains flat. The paralysis is sometimes found to affect one side of the soft palate and uvula. Partial loss of taste is frequently met with in these cases of facial paralysis. The lingual nerve is the nerve of taste for the anterior part of the tongue,, and it owes this endowment to the chorda tympani nerve. This nerve leaves the facial within the aqueduct of Fallopius, passes across the membrana tympani to emerge at the Glaserian fissure_, and finally unites with the lingual nerve. If the facial be affected before giving off this branch, the fibres of the chorda tympani will become involved and, as a result, there will be loss or diminu- tion of the sense of taste on the anterior two-thirds of SYMPTOMS OF FACIAL PARALYSIS. 335 the tongue. This loss, if not noticed by the patient, may be detected by placing a few grains of salt, or a drop or two of vinegar, or of some bitter tincture on the surface of the tongue. Dryness of the mouth on the affected side is observed in some cases, and this is due to implication of those fibres of the chorda tympani which supply the parotid gland. x\uditory troubles are more common; they may be due to disease of the tympanum, and in that case would take the form of deafness ; or they may appear as excessive acuteness of hearing, a condition presumably due to paralysis of the stapedius muscle which is supplied by a branch of the facial. When the action of this muscle is in abey- ance, the stapes becomes somewhat loose, so that all impulses from the tympanum act upon it more vigor- ously, and, as a result, more considerable vibrations take place in the fluid of the internal ear. In these cases of facial paralysis there is no loss of sensation on the affected side. When the complaint is of peripheral origin reflex movements are not excited on touching the conjunctiv^a or on irritating the skin of the face. Signs of trophic disorder are rare, but they are sometimes noticed in severe and chronic cases, when they take the form of atrophy of the affected cheek. 336 SYMPTOMS OF FACIAL PARALYSIS. The electrical condition of the muscles is of great importance with regard to diagnosis and prognosis. The electrical excitability is diminished in cases in which the facial paralysis is a symptom of lesion of the medulla oblongata ; but it is not affected in the paralysis which is associated with ordinary hemiplegia. Cases of rheumatic facial paralysis may be divided into three classes according to the electrical reactions which are presented. 1. In the slight forms the electrical irritability is normal^ or only very little increased; the prognosis is favourable_, the paralysis usually subsiding within a week or ten days. 2. In more severe cases the muscles at first show increased irritability to both faradism and galvanism; gradually^ however_, the effect of the former becomes less and less^ while that of galvanism is preserved and may be even still more exaggerated. The irritability of the nerve to both forms is diminished^ but not entirely lost. Severe degenerative changes have not as yet set in; the prognosis is not unfavourable; the paralysis may subside in four or five weeks. 3. In very severe forms the reaction of degeneration is pronounced. The symptoms then are: diminution BIA GNOSIS OF FA CIAL PA BALYSIS. 337 or complete loss of the faradlc and galvanic excitability of the nerve ; loss of the faradic excitability of the muscles : quantitative increase and qualitative changes of the gal- vanic and increase of the mechanical irritability of the muscles. The prognosis is unfavourable ; but after several months the paralysis may subside, leaving behind it some amount of stiffness and contraction of the muscles. The diagnosis of facial paralysis is for the most part easily made. In severe cases the condition is detected at once; the want of symmetry in the face is quite evident. In slight cases the change is rendered per- ceptible when the patient attempts to use the muscles of expression^ and when he purses up his lips as if to whistle. It is a point of great importance to determine whether the symptoms are due to a peripheral or to a central cause ; in the former case all the branches of the nerve are equally involved. The paralysis affects the branches distributed to the forehead and eyelids, whereas these parts remain free in cerebral cases. The reaction of degeneration and the absence of reflexes are additional indications of a peripheral origin. In cerebral cases the electrical excitability and the reflexes are preserved, while other symptoms due to the paralysis of other cerebral nerves are always present. 22 338 PR6gN0SI8 OF FACIAL PARALYSIS. A consideration of the course and anatomy of the facial nerve enables us to discover the site of the lesion in peripheral cases. Thus^ when the nerve is affected outside the aqueduct of Fallopius, paralysis of the muscles of the face is the only result ; the muscles of the external ear will be paralyzed when the lesion extends into the aqueduct^ but not as far as the origin of the chorda tympani. When the lesion is between the chorda tympani and the nerve which supplies the stapedius muscle, in addition to paralysis of the facial muscles, there will be some loss of taste and perhaps diminution of the salivary secretion. If the lesion is between the nerve to the stapedius and the geniculate ganglion there will be abnormal acuteness of hearing, to which will be added paralysis of the velum palati if the neighbourhood of the ganglion be involved. Lastly, if the lesion be situated above the geniculate ganglion there will be the disorders just mentioned^ but no dimi- nution of taste. The hearing may be interfered with, as the lesion will probably affect the auditory nerve. In most cases of rheumatic facial paralysis the prognosis is good, but the symptoms may last for a considerable time : I have seen several cases of this kind. Troublesome sequelae are sometimes ob- TREA T 211: NT OF FA CIA L PARAL YSIS. 339 served ; some of the facial muscles become con- tracted and rigid ; the zygomatici are especially liable to be thus affected, and this rigidity is sometimes associated with spasmodic contractions of the orbicu- laris palpebrarum, and of various muscles about the mouth. In non-rheumatic cases the prognosis depends on the nature of the lesion ; in cerebral hemiplegia the facial symptoms are usually the first to disappear, but in syphilitic cases they are apt to be very obstinate. The muscles of the forehead and about the eye usually recover before those of the mouth. Some amount of disfigurement^ observable when the patient laughs, sometimes persists after the disappearance of other 'symptoms. For the proper treatment of facial paralysis every attempt should be made to discover the cause. If due to cold, hot fomentations should be assiduously applied to the side of the head and face; purgatives are generally useful, and some iodide of potassium with alkalies may be given for a few days. The patient, of course, must be kept warm and quiet. In cases in which there is a history of syphilis the iodides in full doses are especially indicated, and mercury should be given if these fail to cause improvement. By way of 340 TREATMENT OF FACIAL PARALYSIS. expediting the cure the muscles should be carefully faradized ; it sometimes happens that an improvement is manifested after one such application. In severe cases, and whenever the nmscles will not respond to faradism_, the galvanic current should be used ; the positive pole being placed in the auricular fossa^ while the negative pole is applied over the individual muscles. The strength of the current must be carefully graduated, and should never be more than sufficient to produce distinct contraction. It is sometimes advantageous to make alternate applications of galvanism and faradism. In severe cases the treatment may have to be continued for several months, and when no improvement becomes visible it is best to discontinue the applications for three or four weeks, and then to renew them. During this interval the patient should be instructed to rub and knead the muscles. When contraction has taken place electricity should not be applied to those muscles, but rubbing and kneading alone should be practised. For obstinate cases of paralysis^ in which electricity has been applied without avail, the subcutaneous injection of strychnine may be carefully tried. From gr. 3-V-2V ^^ the nitrate of strychnine may be thus employed. CHAPTER XV. HYPOCHONDRIASIS. Hypochondriasjs, Definition and Forms — Causes — Hereditary Predisposition — Habits of Life — Gout — Abdominal anu Sexual Disorders — Subsidiary Causes — Symptoms — Influence OF Attention — Mental Disorder — Illusions — Disorders of Sensation — Disorders of Motion — Impotence — Vaso-^Iotor Disturbances — Course and Prognosis — Diagnosis — Treat- ment — Existing Ailments to be Attended to — Gouty Cases — Rest and Recreation — Change of Air and Scene, and Suitable Occupation. Hypochondriasis necessarily occupies an indefinite place in the category of nervous disorders. In some cases the symptoms are so distinct^ severe, and perma- nent as to place the existence of mental unsoundness beyond all doubt; in others the patients could not with fairness be described as insane. Tn other words, the hypochondriacal state is sometimes on the one, some- times on the other side of the line which separates the neuroses from the mental disorders properly so-called. It may be defined as a form of mental depression in which the attention of the patient is principallv or con- stantly directed to the state of his body or mind. The 342 CAUSES OF STPOCSONDSIASIS. organ or part which is the seat of painful sensations may be really diseased^ and under such circumstances the condition is sometimes termed ^' hypochondria cum materia/^ while the v^^ords '' hypochondria sine materia " are used to describe cases in which no disease can be recognized. Hypochondriasis is most common in men of middle age; hereditary predisposition to nervous disorder is often traceable ; and effeminate habits and easy circum- stances favour the development of the complaint. An out-door life tends to ward off hypochondriasis; studi- ous, sedentary habits_, combined as they often are with insufficient exercise, have a directly opposite effect. An outbreak of the symptoms may be produced by mental agitation or mental fatigue, by witnessing disease in others, and by indulging in a habit only too common in these days, viz., that of reading medical works adapted to the popular understanding. Among patho- logical conditions often associated with hypochondriasis^ functional disorder of the abdominal organs occupies the first place. Congestion of the liver and haemorr- hoids are sometimes associated with hypochondriasis ; I have recently seen a marked case of this character in consultation with Mr. Alfred Cooper. The patient had SYMPTOMS OF HYPOCHONDRIASIS. 343 suffered from piles for years^ and was the victim of profound hypochondriasis. His mental condition rapidly improved after Mr. Cooper had successfully operated upon the haemorrhoids. A gouty habit of body predisposes to hypochondriasis^ which^ in some cases, is cut short when an acute attack of gout supervenes. Next in frequency come various affections of the sexual organs^ often more imaginary than real_, always exagger- ated by the amount of attention devoted to them, and in not a few^ cases by the study of obscene literature. Not a few male hypochondriacs believe themselves to be suffering from spermatorrhoea. As subsidiary causes of hypochondriasis must be mentioned severe diseases and their sequelae, the immoderate use of tea, coffee, and tobacco_, especially the last-named. Hypochon- driasis may be associated with any organic lesion, and the latter may be discoverable only on post-mortem examination. Nothing is known of the seat and nature of the mental disorder. In the majority of cases of hypochondriasis, the symptoms become gradually developed. Given a ten- dency to mental depression, the slightest disorder of any part of the body, or the most trifling indication thereof, is regarded as a matter of the highest import- 344 SYMPTOMS OF HFPOCHONDRIASIS. ance, and the gloomiest apprehensions are excited. The attention becomes closely fixed upon the sensations which emanate from the affected part, with the result of aggravating any existing lesion, and even of induc- ing real disorder in organs previously sound. The influence of attention upon the action of the heart is often manifested in these cases; when the conscious- ness is directed to it, its contractions are quickened or otherwise disturbed. When pain is complained of and the attention is centred on the part, the conductivity of the nerve fibres is augmented, so that very slight irrita- tion gives rise to marked sensations. A vicious circle becomes thus established ; weak peripheral irritation produces a severe effect on nerv^e-centres which are abnormally sensitive; the impressions are thence trans- mitted to other peripheral nerves with increase of the excitement and irritability, and corresponding aggrava- tion of the mental state of the patient. The symptoms of the mental disorder are lowness of spirits, uneasiness, profound anxiety, and marked irrita- bility. In severe cases the patient's own feelings occupy his attention to the exclusion of everything else; he becomes egotistical to the [last degree. The intelligence may seem to be impaired, for the hypo- SYMPTOMS OF MTPOCEONDRIASIS. 345 chondriac engrossed in his own thoughts is incapable of that degree of mental effort which would enable him to understand the thoughts and feelings of others. This condition is often permanent, and no further change takes place^ but if the patient is not satisfied with the natural explanation of his troubles and attributes them to impossible or supernatural influences, the condition is one of true monomania. In some cases the illusions are connected with per- ception. The patient hears imaginary noises, or has visions_, and sees persons or things which are non- existent. For some time he may recognize the true nature of his perceptions^ and may laugh at them as absurd j if, on the other hand, he believes them to be real, and acts on such belief, he is obviously of unsound mind. In rare cases the patient fears to touch certain objects or persons under the idea that some maleficent influence proceeds from them. Some hypochondriacs are very inquisitive, and are constantly investigating the causes of things. They do not propose real problems, but ask useless questions, e.g., why any given article has such and such a name, or why its shape is not other than it is, etc. Disorders of sensation are always present in hypo- 346 SY3IPT0MS OF SYPOCSONBJRIASIS. chondriacal subjects^ and constitute indeed the ground- work of their complaints. Any internal organ may be the seat of peculiar sensations,, increasing in severity until they amount to severe pain. The most common seats of suffering are the chest and abdomen, especially under the false ribs, the locality from u'hich the name of the affection is derived. Uneasiness or pain in the epigastrium, pains in the head, especially about the occiput, and perverted sensations in various parts of the body are always present in different degrees. Anaes- thesia is less common, and when present is usually confined to limited areas. Disorders of motion are far less common, but in ■ some cases there are obvious fibrillary twitchings of various muscles, and these may extend and cause cramp. In rare cases the pharyngeal muscles and some of the muscles of respiration are prone to spasmodic contraction, probably under the influence of some dominant idea. Some hypochondriacs suffer from the group of sym- ptoms termed " agoraphobia,-'-' but these, of course, are in no way peculiar to them. In the commonest form of this condition the patient finds it impossible to cross an open space, for when he attempts to do so he is stopped by a sensation of sinking and weakness, which is PEOGNOSIS OF SYPOCHONDBIASIS. 347 accompanied by a feeling of pressure in the cliest, palpitation of the hearty and pallor of the countenance. The feeling of powerlessness subsides if the slightest help is rendered^ or even if the patient imagines that assistance is forthcoming. The symptoms are_, how- ever, liable to be very troublesome, and are often permanent in these cases. Male hypochondriacs are often impotent, the loss of pauper depending on mental causes, and increased by ineffectual attempts at coition. Any form of true paralysis of the voluntary muscles is very rare; but, on the other hand, defective action of the muscular coat of the intestines, as shown by constipation, is one of the commonest symptoms. The feet and hands are often cold, and the secretions of the liver, stomach, and bowels are always more or less disordered, as results, it may be presumed, of vaso-motor disturbance. When a condition of hypochondriasis suddenly supervenes, it is generally traceable to some specific cause, and most of these cases admit of a favourable prognosis. As a general rule, however, the complaint is gradually and slowly developed, and pursues a chronic course, seldom exhibiting any permanent improvement. The symptoms may, however, remit 348 BIA GNOSIS OF JEYP C SON DEI A SIS. from time to time, the patient during these intervals appearing almost or quite free from his troubles. A fatal termination is of rare occurrence as an immediate consequence of hypochondriasis, but the power of resisting injurious influences is much diminished, and the patient is especially liable to be attacked by various diseases, and notably by those of an infectious character. Suicide is seldom attempted by hypochondriacs unless a condition of melancholia has supervened. The prognosis is unfavourable in cases w^ith hereditary predisposition to nervous disorders^ and when the symptoms appear in early life. Hypochondriacal insanity is quite incurable. Hypochondriacal symptoms, even of a grave character, have been observed to cease on the superven- tion of an acute attack of illness. The diagnosis of hypochondriasis is for the most part easily made. The patient should be very carefully ^examined in order to ascertain whether there are any material grounds for his beliefs and statements. Hypo- chondriasis in some respects resembles melancholia, but there are marked differences between typical examples of the two conditions. The hypochondriac is always dwelling upon his symptoms, and constantly talks about his health. He is quite willing to use remedies. TRUA TMUNT OF SYP CRONDEIA SIS. 349 and goes from one medical adviser to another, and listens with eagerness to any new suggestion. He has no wish to cut short his troubles by suicide, even when he imagines they must have a fatal termination. In melancholia the patient is often taciturn, and seldom communicative on the subject of his troubles. He is always despondent, and rarely" discusses any methods which might relieve his symptoms, for he considers them to be incurable. Melancholic patients often evince a strong tendency to suicide. The satisfactory treatment of a case of hypochon- driasis requires a considerable amount of tact and patience on the part of the physician. He must spare no endeavour to gain the patient's confidence; he must not deny the subjective reality of the suffering while he explains the want or insufficiency of any objective basis. The patient must, of course, be carefully examined, and it is well to let the first examination be thorough and complete, so as to be able to say that nothing has been overlooked. Any obvious source of trouble must be carefully dealt with; any symptoms of indigestion will require appropriate treatment. Consti- pation often exists in these cases, and invariably aggra- vates the general condition. It should be dealt with 3'50 TREATMENT OF HFPOCHONBEIASIS. by attention to diet and exercise^ and if purgatives are required aloes will generally be found the most suit- able. A combination of extract of aloes^ quinine^ and extract of belladonna is well adapted for these cases; moderate and regular action of the bowels is all that is necessary. In cases with a history of gout, a course of alkalies with bitter tonics, combined with purgatives^ is likely to be serviceable. Exercise, a moderate diet, and attention to the state of the skin are especially neces- sary for these cases. A course of iron will be useful where there are evidences of anaemia. When all possible causes of the disorder have been attended to, treatment of a more general character should be adopted, and it should be prescribed immedi- ately in those cases in which there are no objective indications. When the condition is due to overwork, or appears to be associated with the opposite condition, viz., lack of suitable employment, the treatment is obvious. Patients belonging to the former class require rest and recreation, while the lazy and indolent should be encouraged to follow a better way of life. In either case change of scene, as obtained in foreign travel, and exercise are the means most likely to be successful. The recreation must be adapted to the individual; if the TEH A TMENT OF HYP O CHONDEIA SIS. 3 5 1 muscular strength be good and the thoracic organs sound, a sojourn for some time in a mountainous dis- trict, where the hmbs can be exercised in pure air, and where all the surroundings are conducive to health and vigour, will yield good results in many cases of hypo- chondriasis. Dyspeptic symptoms will speedily vanish, and the mind will throw off the cloud which had oppressed it. Any outdoor recreation which interests the patient will help him to get rid of his nervous troubles. The same advice should be given to the idle and indolent hypochondriac ; employment of some kind should be found for him, and if he can be induced to take an active interest in some work of charity he may be regarded as having taken a very important step towards recovery. As soon as he begins to feel for others and to interest himself in them his own troubles will begin to disappear. In advanced cases of hypo- chondriasis, with more or less decided delusions, it is advisable to place the patient in a well-managed institu- tion. SECTION II. FUNCTIONAL DISORDERS OF THE ORGANS OF CIRCULATION. INTRODUCTORY CHAPTER. Peculiar Features of Functional Disorders of the Heart — Difference Between Functional and Organic Affections — Symptoms of Functional Disorders, Either the Movements or the Sensations of the Organ Affected — Disturbances of Rhythm — Causes of Functional Disorder of the Heart — Predisposing Causes — Dr. Shapter's Classification — Sym- ptoms often Accompanying Palpitation — Diminished Impulse Associated with Depression and Anxiety' — Necessity of Examination into Habits and Circumstances — Inorganic Murmurs — Cases of Cardiac Exhaustion — Dr. Hartshorne's Experience — The Irritable Heart — Study of the Cardiac Nervous Apparatus — The Intra-Cardiac Ganglia — The Pneumogastric Nerves — Cardiac Sensory Fibres — The Sym- pathetic Nerve — The Depressor Fibres of the Vagus — Summary of the Circumstances Affecting the Frequency of the Heart's Action. Functional disorders of the heart are of frequent occurrence, and, owing to the importance of the organ, they are often the source of much inconvenience, dis- tresSj and even danger. The symptoms to which they give rise are identical with some of those which are the ^3 354 FUNCTIONAL CARDIAC DISORDERS. result of organic affectioiis_, and they are apt to cause much anxiety and apprehension on the part of the patient^ lest he may be suffering from incurable disease. There is another peculiarity about the symptoms, viz., that those of functional disorder may supervene from time to time in cases in which organic disease exists, without any necessary mutual dependence. A correct diagnosis is, therefore, of great importance, both for the satisfaction of the patient and for determining the treat- ment to be pursued. The duty of the physician is to ascertain the circumstances that are incompatible with the idea of mere functional disorder, and, secondly, those which are quite compatible with it. The following are the principal features of a general character, which serve to distinguish the two classes of disorders. I. In purely functional cardiac disorders, the sym- ptoms, whether serious or the reverse, are never constant for any length of time. In organic cases this con- stancy is the rule, though the severity of the symptoms necessarily varies very considerably from time to time. When, therefore, the signs of cardiac disorder are always discoverable, the idea of a functional origin must be excluded. FUNCTIONAL CARDIAC DISORDERS. 355 2. When symptoms become developed in other organs as a secondary result of the cardiac disorders^ we may be sure that organic derangement is present. Among other symptoms of such import are oedema, ascites, venous congestion, pulmonary haemorrhage, and albu- minuria. As a matter of course, increased dulness on percussion, and murmurs of certain kinds, especially when persistent and not occurring in anaemic subjects, are indicative of structural changes. Murmurs due to functional causes will be afterwards referred to. 3. The effect of exercise sometimes serves to dis- tinguish functional from organic disorders. As a general rule, the symptoms of the latter are aggravated by move- ment, especially if violent; in' functional disorders in general this effect is by no means constant, and is some- times altogether absent. In anaemic cases, however, movement is very apt to induce and to aggravate palpi- tation, while rest and quiet have a contrary effect. The discovery of the exciting cause may aid in explaining the nature of the disease, and if the symptoms cease when the cause is removed, the inference is unavoidable that they are of a functional nature. Thus the immoderate use of alcohol, tea, and tobacco is a potent cause of palpitation, which often ceases when the habits are dis- 356 FUNCTIONAL CABBIAC DISORDERS. continued. Under such circumstances there could be little doubt as to the nature of the symptom. The symptoms of functional disorders of the heart appear as alterations either in the movements or the sensations of the organ. Derangement of movement takes two principal forms. In the first of these the heart is excited or irritated, and beats more strongly and frequently than natural ; this condition is included under the term palpitation. In the second form, of which syncope or faintness is the type, the heart either beats feebly or almost ceases to act. Of cardiac disorders of sensation, angina pectoris, or neuralgia of the heart, includes all the symptoms of functional affection in which pain is a prominent feature, and this latter may be associated with decreased or in- creased action of the organ. In most of these func- tional disorders motor and sensory disturbances are variously combined. Disturbances of rhythm in the forms of intermissions and irregularity are not unfre- quent symptoms of functional disorders. Intermission IS mostly of functional origin ; irregularity is sometimes observed in dyspepsia, but is more often associated with organic mitral disease. With regard to their causa- tion in general, it may be stated that functional dis- FUNCTIONAL CARDIAC DISORDERS. 357 turbances of the heart's action may be caused by any- thing which interferes with the normal development or character of its muscular walls or the healthy condition of the blood passing through it, or by interference, direct or indirect, with the functional activity of its nervous supply. The muscular contraction and expansion of the heart, together with the regularity of its beat or rhythm, depend upon the agency of the cardiac ganglia, the sympathetic and pneumogastric nerves, and these, together with the muscular walls, require for their normal action an adequate supply of healthy blood. The action of the heart may be indirectly disturbed by reflex action through the nervous system, as in dyspepsia, intestinal irritation^ and mental emotion, and may be directly affected through the passage of blood either too rich or too poor in fibrine and red corpuscles. All such conditions may cause palpitation or irregular action, accompanied, or not, by a bruit. Errors in diet, excessive smoking, over-exertion, and mental shock are amongst the most frequent exciting causes of functional disturbances of the heart. Dr. Shapter classifies the predisposing causes as follows: — " (i). Those conditions acting through or upon the nervous system, such as the general exhaus- 3S8 FUNCTIONAL CABJDIAC DISOEDEES. tion of the nervous systein, all forms of reflex irrita- tion, venereal excesses, vain longings, purposeless occupations and amusements, protracted mental exer- cise, abstinence from adequate repose, etc. (2). Those conditions acting upon the general blood supply of the body, and consequently affecting the special blood sup- ply of the heart, such as the turgid and plethoric states of gross feeders, depraved states caused by bad and de- ficient diet, and all forms of blood disorders, as anaemia, gout, scurvy, etc. To these may be added the special tem- perament and personal peculiarities of the individual." * When palpitation and disturbance are caused by over- action and increased impulse of the heart in nervous or plethoric subjects, other symptoms are often superadded, such as giddiness, rushing of blood to the head, violent pulsation of the carotids, a feeling of choking and faintness, vi^ith clammy hands and cold perspiration, and there is frequently irregularity of the heart's action, with, in neurotic patients, an occasional reduplication of the second sound, which seems peculiar to these cases. These effects are usually the result of venereal excesses, errors in diet, or too little out-door exercise, * " Functional Disorders of the Heart." — " Quain's Diet, of Medicine.''' FUNCTIONAL CARDIAC DISORDERS. 359 and when associated with an irregular action of the heart it is very difficult to make the patient take com- fort and believe that he is not the victim of organic disease, especially should the system be further depressed by praecordial pain. When the heart's action is affected, and there is diminished impulse with no sign of organic change, the symptoms are evidenced by much depression and mental anxiety. Faintness is often experienced, and there may be flatulence or other symptoms of dyspepsia. In a case recently under my care, the patient, a gentle- man aged 42, of sedentary habits, had suffered for some months from irregular action of the heart, together with occasional attacks of palpitation. During these paroxysms there was much praecordial pain and a sense of impending death ; his hands, feet, and body generally became cold and clammy, and the forehead was bedewed with cold perspiration. These paroxysms would last from five minutes to two hours, and occurred at intervals of 10 to 20 days, and alw'ays were induced by smoking or sexual intercourse. Some months ago I had a similar case under my care. The subject was a boy, aged 14, who had at an early age contracted the habit of masturbation. The symptoms in this case, though 360 FUNCTIONAL CAJRDIAC DISORDERS. much less urgent, were none the less marked. The practical lesson to be drawn from these and similar cases is the absolute necessity of getting a candid and complete history of the habits of life and surroundings of the patient before prescribing any special form of treatment. Functional disturbances of the heart are frequently associated,, as before mentioned, with inorganic bruits or murmurs. They are basic and always sys- tolic, the sounds being generally conducted in the course of the great vessels ; they are rarely heard at the apex. Murmurs of this character occur especially in chlorosis and anaemia^ and are accompanied usually by palpitation, which may persist after the bruit has ceased to be evident. In 50 cases of both sexes which I have noted, 12 had continued palpitation for some months after the bruit had ceased ; nine of these cases were young girls or women of more or less hysterical character^ but the remaining three were in men leading sedentary and a*nxious lives, not given to dietetic or venereal license. I see many cases of both sexes, and of every variety of age, who present these murmurs, all of which are wont to disappear more or less readily under treatment, leaving no morbid results whatever. FUNCTIONAL CARDIAC BISOEDERS. 361 Cardiac exhaustion often occurs as a result of worry, overwork, late hours, or deficient nourishment, and is characterized by a weakened impulse with a rapid pulse. In these cases the slightest exertion causes increased rapidity and breathlessness, but without any evidence of valvular disease. Dr. Hartshorne says :* "In U.S. General Hospitals during the Civil War, under my own observation, as well as that of other practitioners, quite •a number of cases of soldiers were presented who were rendered unfit for duty by heart symptoms, and yet without signs of valvular or other organic disease. Careful investigation of these satisfied me that the condition was one of muscular exhaustion of the heart." The same author says, " Heart starvation is probably (in people who are underfed, overworked, or suffering from worry) often overlooked or mistaken for fatty degeneration of the heart?"* My experience entirely coincides with the opinion expressed by Dr. Hartshorne; I have seen many cases of the irritahle heart justly so named by Da Costa. I may mention one instance. I was consulted by a medical man who had had much physical exertion in a * *' Essentials of Medicine," 5 th Ed., p. 253. 362 THE NERVES OF THE HEART. parochial practice in a hilly district and had many home worries ; the evidence was conclusive in my opinion that his cardiac derangement was due to muscular exhaustion. Time, rest in a bracing air, with a nutri- tious dietary, is in such cases all that is required for apparently complete restoration to health. Fothergill says that palpitation is the evidence of muscular inability. Neuroses of the heart is the term Niemeyer applies "to these forms of perversion of its action or abnormity of its sensations which, without depending upon any structural change, arise either without perceptible cause or else upon occasions which in most persons would not give rise to any functional disturbance." In order to understand some portion of the mechanism of cardiac neuroses, it is necessary to inquire into the sources whence the heart derives its nerves. A very simple experiment proves that the rhythmical move- ments depend upon the presence of ganglia situated within the heart itself, for when the organ is removed from the body, or when all the nerves passing to it are divided, regular contractions go on for some time. This phenomenon is best seen in the heart of a fish or turtle ; contractions go on for hours after removal, and THE NERVES OF THE HEART. 3(^7, even when they appear to have ceased they may 1)e excited by touching the surface with the point of a needle. Moreover^ the fact that a regularly-pulsating heart has been found in anencephalic monsters proves that this organ is not exclusively or essentially depen- dent upon the central nervous system for the continu- ance of its rhythmical movements. In addition, .however^ to the rhythmical movements of the heart, it is a matter of common observation that its action is influenced by impressions which reach it from without^ e.g., from the brain, abdominal viscera, and limbs, and these impressions are conveyed to it by the pneumogas- tric and sympathetic nerves. The heart contains many automatic centres which are connected with each other by nervous fibres. The dominating centre, according to Landois, lies in. the auricles, and hence the regular progressive movement usually starts from them. The same author states that the auricular centres seem to be more excitable thgn those of the ventricle; that all stimuli of moderate strength applied directly to the heart increase the frequency of the rhythmical heart-beats, whereas stronger stimuli cause a diminution, and possibly paralysis. Another important point is that the heart 364 TSJE NI^RVES OF THE HEART. may be excited from Its internal surface, and that very weak stimuli suffice to produce this effect. A supply of blood or other similar fluid holding nutritive materials in solution is necessary for the contractions. It would appear that the presence of ganglia is not absolutely necessary for rhythmical pulsation, inasmuch as the latter takes place in parts of the heart devoid of these structures, and direct stimulation of the muscular fibres, may cause the movements. The ganglia are, however, much more excitable than the heart itself, and we must assume that they preside over the rhythmical movements. It must be mentioned that, according to some obser- vers, the heart contains certain ganglia which exercise an inhibitory or restraining influence. The influence of the pneumogastric nerve has been much disputed, but the main questions relating to its action may be regarded as settled. Experiments clearly prove that irritation of the pneumogastric nerve weakens ■oi* suspends the motor influence, through which other nervous mechanism causes the contractions of the heart. The action of the vagus is, therefore, of an inhibitory, paralyzing character ; the fibres charged with this office run originally in the spinal accessory nerve. When the fibres of this latter have been removed from the jugular TEE NERVES OF THE HEART. 365 foramen^ and a few clays suffered to elapse, the nervous fibres supplied to the vagus in that position undergo degeneration at their peripheral extremities^ and are incapable of being excited ; it is then found that irrita- tion of the vagus on that side has no effect upon the frequency of the cardiac pulsations^ and certainly does not arrest them. When a magneto-electric current is applied to the medulla oblongata^ the hearths action,, after a few pulsa- tionSj comes to a complete standstill ; and this condition remains until^as a result of the tetanizing, or exhaustion or destruction of irritability of the nervous channels^ the action of the heart is restored. The pneumogastric nerves are the channels which conduct the inhibitory influence from the medulla oblongata, for if one of these be divided, and the peripheral end be galvanized^ the hearths action is arrested in diastole. Irritation of one nerve is sufficient for this effect to be produced^ and not only the number but the force of the pulsations is diminished ; and the arrest of the hearths action is some- times brought about not by increasing the pause be- tween the pulsations^ but by lessening the degree of the contractions. The consequent diminution of blood- pressure in the arteries will thus have a two-fold origin. 366 THE NERVES OF THE HEART. Division of the pneumogastric nerve is followed by permanent increase in the number of the heart's pulsa- tions and simultaneous elevation of the blood pressure throughout the arterial system^ and the amount of work done by the heart is^ therefore, increased. The same result is witnessed when both spinal accessory nerves are removed from the base of the skull, and no further effect is produced by subsequent division of the vagus. It isj therefore, clear that those fibres of this nerve,, whose irritation causes arrest of the heart's action, are the same as those whose paralysis leads to an opposite result, viz., to increased frequency and stretigth of action. In addition to being the channel for inhibitory in- fluences, the pneumogastric furnishes sensory fibres to , the heart. These form a plexus beneath the pericardium; when their central portions are irritated, the heart's action is retarded and the arterial blood-pressure is increased. In the natural state, the sensitiveness of the heart is extremely slight; signs of pain are seldom elicited when the organ is mechanically irritated. No reflex movements follow irritation after both vagi are divided ; but if one be left intact, movements of this character are found to be produced. The third class of nerves connected with the heart THE NERVES OF TSE HEART. 367 are those through whose instrumentaHty its action is accelerated. These are centrifugal fibres_, and when excited, they increase the number of the pulsations by from 30 to 70 per cent._, and thus act as the antagonists of the inhibitory nerves just described. Some of these pass^ however_, with these latter in the cervical portions. of both vagi, but a still larger supply is derived from the branches of the first thoracic ganglion of the sympathetic,, and these take their course to the heart partly as independent fibres and partly in connection with branches of the vagus. The sympathetic in the neck sometimes gives oflF similar fibres. The larger portion of these accelerating nerves pass downwards from the medulla oblongata through the cervical and dorsal spinal cord, and thence to the thoracic sym- pathetic^ and finally to the cardiac plexus. The course described by these nerves is therefore loop-shaped, the majority pass downwards in the spinal cord and up- wards in the sympathetic. Those fewer fibres which pass with the vagus and the cervical sympathetic do not form such loops, but they probably have the same origin as the others. These nerves, by means of vv^hich the action of the heart is accelerated^ are not, as a general rule, in any 368 THE NERVES OF THE HEART. way under the influence of the will ; but some persons possess the power of voluntarily rendering the heart's action more frequent. Such a result is often produced involuntarily under the influence of emotional causes, and is due less to diminished action of the pneumogas- trics than to excitement of the "cerebral centres of the accelerating nerves. These nerves and their centres are said to be less easily excited and less readily exhausted than all other nerves^ and this difference is very marked when they are contrasted with the vagus. Their ex- citement increases the force as well as the frequency of the heart's contractions. There is yet_, in some animals at leasts a fourth set of nerves, by means of which the action of the heart is influenced. These are the so-called depressor fibres of the vagus, and in rabbits are derived from the superior laryngeal nerve and are sometimes increased by a second branch from the vagus itself and then join the cardiac plexus. Excitement of these nerves is followed by considerable diminution of the blood- pressure in the arteries, and this is not the result of an impulse directed centrifugally towards the heart, but of one transmitted in a central direction to the medulla oblongata. The diminution in pressure is THE NERVES OF THE HEART. 369 caused when an induced current is applied to the central end of the divided nerve, but no such result follows the application to the peripheral extremity. In order to explain this curious phenomenon it is assumed that in a reflex manner the depressor fibres lessen or abolish the power of the vaso-constrictor nerves, and especially of those of the abdominal viscera^ and bring about the diminution of blood-pressure in the arteries by facilitating the escape of the blood into the capillaries and veins. Irritation of the central portion of these nerves excites the vagus centre in the medulla oblongata, and diminished frequency of the cardiac contractions is the result^ which, however, ceases when both vagi are divided below the origin of the depressor nerves. It is doubtful whether this second reflex action of the depressors, which they share with many sensory nerves of the skin and viscera, is peculiar to them, or whether it is derived from other sensory nerves which are as- sociated with them. The following extract from Dr. Carpenter's " Prin- ciples of Human Physiology '^ gives a short summary of the circumstances affecting the frequency of the heart's action. '^^ The heart not only possesses an internal system of ganglia and nerves, by which its 370 TRE NERVES OF THE HEART. movements can be maintained and regulated for some time after excision from the body, but it is also under the control of centres situated in the medulla oblongata, and, as there is reason for believing that there are both •accelerating and inhibitory centres in the heart and in the medulla^ it is obvious that great difficulty must exist in determining the cause of any particular varia- tion in the frequency of its beats that may be observed. We have^ however, evidence that the heart may be influenced — "A. By conditions affecting the intra-cardiac motor ganglia which may be (i) excited and the frequency of the pulsations increased ; (a) by heat; [h) by mechanical, chemical, and electrical excitation; (c) by increased blood-pressure, which is essentially a mechanical irritant; [d) by various poisons ; or (3) depressed, and the pulsa- tions lowered ; (a) by cold ; {h) by diminished blood- pressure ; [c) by certain poisons, as chloral. "B. By conditions affecting the intra-ca^-diac inkihitory ganglia, these being stimulated, and the heart slowed or stopped in diastole by certain poisons (muscarin), and paralyzed by others. '' C. By conditions affecting the intra-cardiac acceler- ator ganglia leading to increased frequency of action. THE NERVES OF THE HEART. 371 At present these cannot be satisfactorily distinguished from those affecting the intra-cardiac motor ganglia. '' D. By conditions affecting the cardiac inhibitory centres in the medulla oblongata, snch as increased blood-pressure^ which acts directly upon them, or by irritation of the depressor nerve, or of various other sensory nerves which act upon them in a reflex manner, or by the actions of poisons (digitalis), all of which excite these centres and cause slowing of the heart's action. ''^E. By certain conditions affecting the accelerator centres in the medulla, as diminished* blood- pressure, mental processes, the action of poisons. They may also probably be excited in a reflex manner. It will be seen from the above that certain conditions, increased blood-pressure, for example, exert a double action on the cardiac nerves. On the one hand, it excites the heart to increased frequency of action by direct irritation of its motor ganglia through filaments distributed to the endocardium; on the other hand, it stimulates the vagal centres in the medulla and thus causes slowing of the heart, the actual result in any given case bein"" dependent upon the preponderating influence of the cardiac motor or medullary inhibitory centres. Usually 572 TEE NERVES OF THE HEART. the medullary centres are strongest^ and increased blood-pressure causes slowing of the heart; but if the vagi be divided so that they can no longer act upon the heart, increased blood-pressure stimulates the heart to more rapid action/' CHAPTER II. PALPITATION OF THE HEART. Cardiac Palpitation, Description of — General Symptoms — Alter- ation IN Sounds of Heart and in Pulse — Condition of the Respiration and of the Features — Subjective Sensations — Duration of Attacks — Causes of Palpitation — Nervous and Toxic Causes — Exhaustion — Reflex Irritation — Exciting Causes — Diagnosis — Prognosis — Treatment — Relief of Paroxysms and Prevention of Recurrence — Position, Cold to Chest, Medicines — Treatment of Nervous Subjects — Treat- ment of Palpitation Due to Indigestion and Gout — During the Intervals — Various Points to be Attended to. This term is used to signify attacks in which the heart beats with increased frequency^ and generally with in- creased force. Pulsations of this kind are often excited in a perfectly healthy individual by incidents and amotions of every-day life, and under such circum- stances they are, of course, not to be considered as morbid. It is only when the attacks of palpitation are very frequent or very easily excited that they constitute disorder. They are, of course, a common symptom of organic cardiac lesions, but they are still more frequent when no such changes exist. Attacks of palpitation 374 SYMPTOMS OF PALPITATION. alternate with the normal movements; they may last for a few minutes or for some hours. The frequency with which they occur varies greatly ; in some cases scarcely a day passes without one or more j in others there may be weeks' or months between the attacks. A severe attack of palpitation is often ushered in by peculiar sensations in the cardiac region. The patient experiences a feeling of indescribable discomfort ; the heart appears to be beating irregularly and with diffi- culty_, or as if it could go on no longer^ or there may be a feeling as if something had given way in the heart. During the attack the sensations of distress and oppres- sion continue, and difficulty of breathing is often superadded. The countenance is indicative of the feel- ings of the patient ; the forehead may be covered with cold perspiration. Faintness is sometimes experienced, and headache, noises in the ears, and a feeling of giddi- ness are not unfrequent. In some cases of palpitation, with irregularity of action, the patients complain of pain in the post-occipital region, where the arteries enter the skull, and occurring at the time of the cardiac intermissions. On examining the heart during an attack of palpita- tion its action is found to be tumultuous, abnormally SYMPTOMS OF PALPITATION. 375 frequent^ and perceptible over a large surface. If the attack lasts for any time^ irregularity is generally observed, and the sounds of the heart undergo various modifications. The first sound often has a metallic tone, and can be heard at some distance from the chest. The second sound is sometimes so faint that it may appear to be absent; this change results from the in- sufficient quantity of blood contained in the aorta and pulmonary artery; it is more and more marked in proportion to the rapidity of the movements. Some- times the pauses between the sounds of the heart become equalized_, so that the comparatively long interval which follows the second sound is very much shortened. The carotids pulsate violently, and on placing a stethoscope over them a systolic murmur is frequently audible. When the attacks of palpitation last for any time swelling and pulsation in the veins of the neck are generally perceptible. The pulse at the wrist is frequent, hard, and full, less often soft and small, but irregularity is usually noticeable. With regard to frequency, it is difficult to assign any limits; as many as 200 pulsations have been counted in the minute. In examining a pulse of this character it is well to count by fives, and then to add 376 SYMPTOMS OF PALPITATION. these up ; by this plan mistakes are less likely to happen than if the attempt be made to count by consecutive numbers. It is also well to estimate the number of the heart's contractions by means of auscultation^ for during such rapid movements of the heart the pulse-wave will not alwavs extend to the radial arteries, and hence it happens that the pulse there is often intermittent. In attacks of palpitation the respiration is generally impeded, the patients complaining of the sensation of want of breath. The breathing is frequent and irregular, and liable to be interrupted by deep and sighing inspira- tions. This difficulty of breathing is aggravated when the patient lies down, but is relieved by raising the thorax, or by adopting a sitting posture. In severe attacks speaking becomes difficult, and the voice may be reduced to a whisper. Sometimes there is difficulty in swallowing, and pain in the stomach with swelling of the abdomen. The features are always disfigured; the face is red and generally covered with perspiration ; more rarely the face and extremities are cold, moist, pale, or livid. Elevation of temperature is generally observed. The duration of the attack varies. In some cases it passes off almost suddenly ; in others it subsides very CA USES OF PA LP IT A TION. .3 7 7 gradually. After its disappearance the patients feel very anxious lest it should recur. Sudden subsidence of the attack is sometimes associated with vomiting, eructations, or free action of the bowels. It is worthy of note that there are some cases of palpitation of the heart in which the symptoms are almost entirely subjective. The. patient relates many of the details as given above, but no objective disorder is decidedly manifested. Careful examination may, how- ever, detect some irregularity of the pulse during the attacks. Attacks of palpitation of the heart may be induced by a great variety of causes, the majority of these acting on the nervous system. The attempt has been made to divide these causes into several categories according as the pneumogastric nerve, the sympathetic, the brain, or the spinal cord is the seat of excitement. Such a classification is, however, scarcely possible, but in a general way it may be stated that in most cases of palpitation the condition is that of paralysis of the inhibitory nerve fibres of the heart, which are supplied by the pneumogastric, and less commonly one of irritation of the excito-motor nerves from the sym- pathetic. For clinical purposes it is convenient to 378 CAUSES OF PALPITATION. divide attacks of palpitation into two classes^ the first containing those that are due to nervous causes, and the second, those in which toxic matters are present in the blood. Nervous causes of palpitation, the results of the con- dition of the cerebrum, are of every-day occurrence, and are typified by the various forms of emotional excite- ment caused by joy, grief, shock, anxiety, and the like. The effect of the imagination in producing palpitation is sometimes very marked ; medical students, for example, in studying diseases of the heart for the first time, often suffer from tumultuous and irregular action of the organ in question, and imagine that they are the subjects of heart disease. I am acquainted with many medical practitioners of nervous temperament, who, as a result of hard work, suffer from attacks of palpitation and intermittency of the heart's action, and think themselves the victims of organic disease. All the symptoms, however, subside after a few days' rest and change. Some persons have the power of volun- tarily increasing the frequency of the heart's contrac- tions. Nervous palpitation is, of course, a common symptom both of organic and of functional nervous disorders. CAUSES OF PALPITATION. 379. Thus it often occurs in connection with congestion, haemorrhage, softenings, and tumours of the brain and spinal cord. Tumours in the neck may cause attacks of palpitation by interfering with the pneumogastric or sympathetic nerv^es. In a case recorded by myself in the Archives of Laryngology , Vol.. ii._, No. 3, a bony growth from the last cervical vertebra was the cause of attacks of palpitation and of spasm in the throat. Various conditions of exhaustion are especially apt to be accompanied by palpitation of the heart ; thus attacks are common in cases of hysteria, spinal irritation, and neurasthenia. They are also frequent results of mental strain, of excesses of all kinds, of chlorosis, of loss of blood, and of severe and exhausting diseases. Persons who work for many hours in small and ill-ventilated rooms and take an insufficient amount of nourishment frequently suffer from palpitation. Reflex irritation is a common and important cause of palpitation. It is a matter of every-day experience that attacks are often due to a disordered state of the stomach, either a mere temporary indigestion, or a more permanent and serious condition. I have met with several cases in whom palpitation and signs of 38o CAUSES OF PALPITATION. violent cardiac disturbance^ occurring during the night, and waking the patients from their sleep, were caused by two or three glasses of cheap sour claret taken at dinner. In some persons certain articles of food, even when taken in moderation^ are sufficient to induce an attack. In all these cases the pneumogastric is the nerve through which the irritation is propagated. Other causes of a reflex nature are constipation, worms in the intestines, and haemorrhoids ; in the latter case the attacks are wont to come on after the cessation of haemorrhage. In the case of a gentleman whom I have been recently attending the attacks of palpitation have quite ceased since he has undergone a successful opera- tion for the radical cure of piles. Disorders of the uteru.s and ovaries are especially liable to cause palpitation and other symptoms of hysteria, and attacks are some- times observed in connection with renal calculi. Attacks of palpitation due to toxic causes are very frequently seen. Thus they often follow the immoderate and even the moderate use of alcohol, tobacco, tea, and coffee. Certain peculiarities are sometimes observed ; thus I have met with several cases of middle-aged men and women in whom severe palpitation, with an intermittent pulse, was always caused by taking a cup CAUSES OF PALPITATION. 381 of tea in the early morning. When cocoa was substituted there were no such effects, and the tea could be taken at other times in the day without causing dis- comfort. The palpitation in gouty subjects is due in the first place to irritation^ propagated from the stomach, and, secondly, to the presence of an abnormal amount of uric acid, which acts as a direct irritant to the heart. Palpitation of the heart occurs in persons of all ages. In children it is most common during the educational period, and is due to immoderate application to studies^ ambition, and anxiety. Other causes, such as debility, indigestion, and worms, are often present. In all cases the attacks are wont to come on spontaneously; some- times, indeed, they occur when the patient is in bed and arouse him from a deep sleep. In other cases they are the direct and immediate consequences of bodily or mental exertion. I have recently attended a gentleman, aged 45, married {with a family, and not given to sexual excesses), in whom palpitation always occurs after four or five hours' continuous mental work, but not before that time, and ceases when the occupa- tion is relinquished. Among other causes of attacks may be mentioned intestinal disorders, menstrual irregularities, exposure to cold, or to heat, and the like. 382 DIAGNOSIS OF PALPITATION. Some persons have an attack of palpitation if they lie on their left side. The diagnosis of palpitation of the heart is seldom a matter of much difficulty. Bearing in mind the fact that similar attacks often occur in cases of organic disease^ the actual condition of the heart is the point to be determined. Valvular diseases will_, of course, be accom- panied by the peculiar murmurs, but abnormal sounds are not infrequent in nervous palpitation during a severe attack. The murmur is, however, always systolic in character, and is never associated with signs of dilata- tion and hypertrophy. In chlorotic and anaemic cases a permanent systolic murmur is often present, but the detection of the bruit de diable and the improvement which almost invariably takes place under treatment will indicate the nature of the case. Pericarditis is often accompanied with severe attacks of palpitation, but the cause of the symptoms can hardly be mistaken. . The prognosis, of course, depends upon the cause of the symptom ; in many cases not only can the attacks be relieved, but their recurrence can be prevented by appropriate treatment. In cases in which the cause cannot be dealt with more. or less amelioration can almost always be promised, but the patients are apt to TREATMENT OF PALPITATION. 383 become very low-spirited and even hypochondriacal. However distressing the attacks may be^ a fatal termina- tion need scarcely ever be apprehended in the absence of organic disease. In elderly subjects_, however^ with degeneration of the cerebral arteries, there is risk of rupture of vessels and haemorrhage during attacks of palpitation. The heart itself is liable to become affected in the course of time_, as a result of the over-exertion. Hypertrophy of the organ is generally due to the exist- ence of obstruction^, either in the valves or in the vessels, but in a less numerous class of cases hyper- trophy is the result of increased cardiac action without increased resistance. Niemeyer's statement on this subject has been already referred to. ^^ In many per- sons we are forced to assume the existence of an exalted irritability, an erythism of the nervous system, particularly of the nerves of the heart, so that trifling causes serve to excite and strengthen its action.''- Treatment. In the treatment of persons subject to attacks of palpitation of the heart there are two princi- pal objects to be fulfilled; the first being to relieve or cut short the paroxysms, and the second to prevent their recurrence. To afford relief during attacks the patient should be placed in a semi-recumbent posture. 384 TREATMENT OF PALPITATION. with the chest raised and the clothes loosened about the neck and chest; fresh air should be freely admitted. In some cases relief is obtained by the application of cold to the chest_, or by sucking pieces of ice. Pres- sure on the sympathetic and pneumogastric in the neck and on certain spots in the abdomen has been known to cut short attacks. With regard to medicines^ the subcutaneous injec- tion of morphine often has the effect of relieving palpitation, but its use requires caution. Other reme- dies of the same character, such as chloral_, tincture of henbane, aether, and belladonna are also efficacious, but there are no special indications for their use. In cases in which the palpitation is the result of shock, a full dose of the bromide of ammonium will generally allay the discomfort. In nervous, hysterical, and hypochondriacal subjects, relief will often be afforded by the nervine stimulants, as asafcetida and valerian, camphor, and preparations of ammonia and aether. Aromatics combined with antacids are sometimes useful, inasmuch as they help the expul- sion of flatus and correct acidity. With this view a teaspoonful of the compound tincture of lavender, or of the compound spirit of horse-radish, may be given TREATMENT OF PALPITATION. 385 in combination with half the quantity of aromatic spirit of ammonia. When an overloaded stomach is suspected to be the cause of the attack, an emetic dose of ipecacuanha will be the best remedy. The hypodermic injection of gr. xV of the hydrochlorate of apomorphine may be used instead. For attacks of palpitation in gouty sub- jects, emetics are not advisable unless there be ineffec- tual attempts to vomit. An alkaline draught with a little aether will serve to quiet the heart. In order to prevent the recurrence of the paroxysms, the treatment must be directed towards the removal of the cause or modifying its operation. Hygienic measures of all kinds must first be thought of. Thus the diet must be easily digestible and adapted in quantity to the patient^s condition. Distension of the stomach and excesses of all kinds^ especially in the direction of alcoholic drinks, tea, coffee, and tobacco must be scrupulously avoided ; moderate exercise in the open air and attention to the skin will tend to lessen the irrita- bility of the nervous centres. Constipation, if present, must be dealt with by laxatives and mild purgatives. "With regard to medicines having a specific action on the heart, digitalis and the bromide of potassium are 25 SS6 TEJEATMUNT OF PALPITATION. likely to be serviceable, either separately or in combina- tion. The digitalis should be given in small doses (ttt v-x of the tincture) three times a day, and the effects carefully u^atched. The bromide of potassium may in debilitated cases be combined with a little citrate of iron and ammonia. When the attacks come on at night it is well to apply some belladonna liniment to the left side of the chest before going to bed. Should there be praecordial pain, chloroform liniment, sprinkled on spongio-piline, and applied to the surface for half-an- hour, will generally give relief. In many cases of palpitation, without obvious cause, change of air, especially to the seaside, will prove very advantageous. The place selected should be one that is sheltered from high winds, with level walks, and at no great altitude above the sea. For palpitation occurring in anaemic subjects, the preparations of iron are always useful. The carbonate is one of the best, and quinine or other bitter tonics may be given at the same time. When the patient is nervous as well as anaemic, and irregularity of the heart's action accompanies the palpitation, I have seen very good effects from small doses of arsenious acid and digitalis, taken in the form of a pill, two or three times TREATMENT OF PALPITATION. 387 a day, for five or six weeks^ under careful medical observation. When the disturbance of the heart's action occurs in persons suffering from haemorrhoids the condition of the liver will require attention, and purgatives are generally indicated. The question of a radical cure of the haemorrhoids must also be con- sidered. If there be uterine disorders, as evinced by irregular or suppressed menstruation_, special treatment will be requisite. Hot foot-baths may be tried to re- store the menstrual discharge, and purgatives are generally indicated. The treatment of palpitation in gouty subjects is that of the uric acid diathesis. It may be briefly summed up as follows : careful attention to the diet, and to the state of the skin; avoidance of stimulants and excesses of all kinds; purgatives and alkalies with tonics. A short course of digitalis will generally be useful in these cases. CHAPTER IIL SYNCOPE— SWOONING— FAINTNESS. Syncope, Definition and Symptoms- — Incomplete Attacks or Faintness — Duration of Attacks — Causes, the Nervous System, the State of the Heart, the Condition of the Blood — Impressions on the Nervous System — Direct Effects on the Heart — Mechanical Causes, Poisons — Syncope Resulting from loss or Deficiency of Blood — Mixed Cases — Duration of Attacks — Syncope Distinguished from Epilepsy, Apoplexy, Shock, Concussion, and Poisoning — Prolonged Syncope — Prognosis — Treatment — Restoration of Action of Heart, AND Supply of Blood to the Brain. Syncope is the term used to express a" condition due to diminution or temporary arrest of the heart's action_, and characterized by more or less complete suspension of consciousness and of respiration^ and usually attended by depression of the temperature of the body. It may be briefly described as inhibitory paralysis of the heart. The condition may come on suddenly, but is more often preceded by a feeling of nausea, sinking" in the epigastrium, giddiness, weakness, and loss of balancing power, some disorder of vision and mental confusion, noises in the ears, paleness of the surface. SYMPTOMS OF SYNCOPE. 389 and chilliness. When the syncope is complete^ the consciousness is entirely suspended^ the muscles are relaxed^ the face is deathly pale and cold^ the pulse is imperceptible^ and respiration ceases or occurs only at long intervals. Convulsions are apt to occur in cases of syncope due to haemorrhage. On examining the chest, only the first sound can- be heard, and this is much weakened; the second sound may be quite inaudible. This condition lasts a variable time, and the first signs of recovery are a renewal of the respiration and movements of the limbs. After a few deep in- spirations, the pulse becomes perceptible, the colour slou'ly returns to the face and lips, and consciousness is gradually regained. In less marked instances the loss of consciousness is incomplete, and the respiration is not suspended, but becomes superficial and irregular. The pulse can be felt, and the heart sounds are audible, but much weakened. The patient complains of sinking, giddi- ness, and nausea, and strives to adopt the recumbent position. This state in its various grades is described as faintness, and is of very common occurrence. The duration of syncope varies ; in the slighter degrees the sensations may last for considerable periods. 590 CAUSIJS OF SYNCOPIJ. alternately diminishing and increasing in intensity until they completely pass off. In complete syncope the duration seldom extends beyond a minute or two, unless the case has a fatal termination. The patient may, however, lie for hours in a semi-conscious con- dition, afraid to move lest the worst symptoms should recur, but the pulse will be perceptible and the heart sounds more or less audible. These serious attacks, when connected with organic disease of the heart, may recur again and again until a fatal issue takes place. The causes of syncope are many and various in kind ; they all act by disturbing and interfering with the action of the heart. The majority affect the organ through the nervous system ; in another class the state of the heart itself is the cause of the attacks. Various conditions of the blood likewise contribute towards the causation of syncope, and in some cases several causes co-operate in producing an attack. Many causes of syncope act on the heart through the nervous system, and of these violent shocks are the most frequent. Under this heading we may include the effects of injuries to the brain or other parts, and of sudden and excruciating pain, of offensive or fearful sights, of alarm, or of exciting or depressing intelli- CAUSES OF SFNCOFE. 391 gence. In some cases the same effect is produced upon the heart by less severe impressions on the nerv^ous system, such, for example, as result from certain op- pressive odours, slight irritation of the stomach, want of food, the condition of other internal organs, such as the uterus, kidneys, and liver. A draught of cold water, taken when the body is hot and perspiring, and especi- ally if likewise exhausted after exercise, has been known to produce fatal syncope. Persons differ greatly as regards their liability to syncope. In nervous women attacks are somewhat common. Many of the heroines of the novels written in the last century were remarkable for their proneness to faint under the influence of surprise or excitement. Very slight causes are sometimes suffi- cient to induce attacks of syncope. Manv years ago, when I had to perform a large number of vaccinations, many adults, who came to be revaccinated used to faint under the slight operation. Several medical friends have informed me that they have met with similar experiences. The state of the heart often contributes towards the production of an attack of syncope. Thus the symptom is very common in many organic diseases, and especially in aortic stenosis and fatty degeneration. In women the 392 CAVSJES OF SYNCOPE. heart's action is often seriously interfered with by tight lacing. Other causes acting directly upon the heart are a high temperature, and certain powerful drugs, as tobacco, digitalis, hydrocyanic acid, and chloroform. To these may be added attacks of neuralgia of the heart, the metastasis of gouty inflammation, and the presence of air in the hearths cavities. The most frequent cause of syncope is loss or deficiency of blood, whether due to haemorrhage or to a slower process whereby the blood is robbed of some of its constituents. The effect is produced chiefly through the brain, and is often suddenly developed in cases of loss of blood. When the supply of blood to the brain is deficient, the consequences are seen throughout the body, and especially in the muscular system. When a person is in the erect position the loss of blood neces- sary to produce fainting is much less .than in the. recumbent posture. Hence it not unfrequently happens that a patient, already weak from deficiency of blood, faints suddenly on attempting to rise up in bed ; the lesson to be learnt from such experience is, of course, obvious. The loss requisite to produce faintness varies in different individuals and in different states of the system. The more rapidly the blood is lost, the less the DURATION OF SYNCOPE. 393 quantity necessary to produce an effect. Profuse dis- charges^ as in cholera and diarrhoea, will lead to the same results, and the sudden removal of pressure, causing a rapid removal of blood from one part of the body to another, will also cause faintness. This may be sometimes seen after the operation of tapping the abdomen, unless proper care has been taken to keep up the pressure by means of a bandage. As an illustration of a parallel character, I have known faintness to occur from the abrupt discharge of a large quantity of wind from the stomach, following oppressive distension of that orean. A marked case of this nature has recently been published by Dr. Goodridge {Lancet, April 21, 1888). In many attacks of syncope several of the causes above described co-operate in the production of the result. Thus in anaemic subjects, the effect of shock or grief is aided by the weakened condition of the heart and the deficiency in the quantity and quality of the blood. Also in cases in which there is organic cardiac disease, an attack of syncope may be easily induced bv slight causes, and particularly by gastric distension. The duration of attacks of syncope has been already alluded to; it may extend to some seconds or minutes. 394 DIAGNOSIS OF SYNCOPE. in rare cases the condition^ with various modifications, continues for hours. Incomplete attacks, i.e., those in which the consciousness is not entirely lost, are the most common ; several of these sometimes follow each other, with intervals of partial recovery.. Except in cases of organic disease of the he?irt and in syncope due to haemorrhage, complete recovery is the rule, though for some time after the attack the patient may feel anxious and giddy. In cases in which the symptoms are prolonged for many hours, a condition of apparent death is established ; consciousness is completely lost, while pulse and respiration are both imperceptible. Very careful auscultation will, however, detect a slight sound over the heart. Attacks of syncope require to be distinguished from other conditions attended by loss of consciousness, and mainly from epilepsy, apoplexy, the symptoms of shock, of concussion of the brain, and of poisoning by various substances. In epilepsy, the loss of con- sciousness is sudden in its onset, and is frequently accompanied by tonic spasm, succeeded by convulsive movements. The change in colour which the face undergoes from pallor to lividity is a distinguishing " feature of epilepsy as compared with syncope. Apoplexy DIAGNOSIS OF SYNCOPE. 395 is sometimes ushered in with an attack of syncope, the patient becoming faint and collapsed_, with pale face^ cold damp skin_, frequent, feeble and irregular pulse, nausea, and vomiting. These symptoms are soon followed by insensibility and coma. Paralysis also supervenes, and its presence is sufficient to explain the nature of the case. During the continuance of the coma the insensibility is profound, the face is flushed and the. skin moist, the pulse is slow, full, and hard, and the respiration stertorous. All these sym- ptoms are sufficient to distinguish the attack from one of syncope. The symptoms of syncope are often the result of shock, but in cases of the latter kind consciousness is less interfered with, and may be almost completely pre- served. Tn pure shock of a severe character the patient is at first stunned, but gradually he becomes more or less aware of what is going on, and is able to answer questions, and this state of partial recovery may con- tinue indefinitely. In shock with excitement the movements of the patient are sufficient to distinguish the symptoms from those of syncope. In the collapse due to cerebral concussion the insensibility is seldom quite complete. The pupils are dilated, and in other 396 DIAGNOSIS OF SYNC OFF. respects the symptoms resemble those of syncope. The collapse may last for some hours when the pulse becomes full, the skin relaxed and hot_, and the face flushed. A condition of drowsiness then supervenes. Loss of consciousness results from the operation of several poisons_, especially of those of the narcotic class. With regard to all these, however, the history of the symptoms will be enough to distinguish them from those of syncope. In opium poisoning, moreover, the face is suffused, the skin warm, the breathing slow and deep, and the pupils are contracted. In the later stages the surface becomes cold, and the face is pale and cyanotic. In alcoholic coma the pulse is slow and laboured, and the breathing is stertorous. In profound insensibility due to chloroform the breathing is apt to become stertorous, while the face is generally suffused ; the pulse may remain unaffected. Pallor of the counte- nance is a symptom showing that an excessive quantity of the anaesthetic has been given; it denotes a condition of syncope from failure of the heart's action. In cases of prolonged syncope, with pulse and respira- tion imperceptible, the appearances may very closely re- semble those of death. The heart should be very care- fully examined, and the temperature should be taken in TREATMENT OF SYNCOPE. 397 the rectura. The setting-in of rigor mortis will, of course, determine the real nature of the symptoms, but in the absence of this conclusive sign of death, it may be difficult to express a positive opinion. The prognosis in cases of syncope will, of course, mainly depend upon the cause of the symptoms ; it is generally favourable unless the syncope depends upon organic disease or profuse hemorrhage. The facility and rapidity with which treatment is obtainable may, in severe cases, turn the scale in a favourable direction. In the case of severe shocks to the nervous system, and the syncope which is apt to follow slight exertion in debilitated subjects, much will depend upon the state of the patient and the gravity of his previous condition. In ordinary cases of partial syncope, or faintness, due to heat, fear, or excitement, or to impressions on the nerves of special sense, the attacks generally pass off in a few minutes if proper treatment is adopted ; but thev are very liable to recur, either speedily or after a lon2:er interval. In cases of organic disease of the heart suc- cessive attacks of syncope are often noticed. Treatment. In dealing with a case of syncope we have to endeavour to restore the action of the heart and to supply as much blood as possible to the brain. The 398 THEATIIJENT OF SYNCOPB. second indication can be fulfilled while remedies to act on the heart are being sent for. The patient should be placed on the back in a horizontal position, with the head as low as or even lower than the rest of the body. This simple measure often serves to cut short an attack; a patient subject to faintness instinctively seeks the recumbent position when he feels any of the pre- monitory symptoms. In severe cases, as after excessive h3emorrhage_, it is necessary to maintain the horizontal position for some time^ and to be very careful in rising from it. At the same time that this position is adopted all pressure from tight articles of dress should be carefully removed from the neck, chest, and abdomen; pure, fresh air should be freely admitted, for which purpose the windows and doors should be thrown open and persons should be prevented from crowding round the patient. If haemorrhage be the cause of the attack, and is still going on, measures must be adopted to arrest it. All the above-mentioned steps should be taken as rapidly as possible. Measures should also be employed to restore the action of the heart, and for this purpose smelling salts should be applied to the nostrils, and diffusible stimu- lants should be given. A little spirit of ammonia. TR'EATMENT OF SYNCOPE. 399 brandvj or eau de Cologne are those which are generally at hand. Sprinkling cold water on the face is also use- fulj inasmuch as it incites respiratory efforts by which the irritability of the cardio-inhibitory centre is much lessened. A still greater effect in this direction is produced by the act of swallowing; sipping cold water acts as a powerful cardiac stimulant,, and in most cases of syncope recovery is not long delayed after the patient is able to swallow. If, however, this power be still in abeyance, a stimulant enema should be injected into the rectum, or aether may be administered subcutaneously. If these measures fail^ the limbs should be firmly and energetically rubbed in an upward direction, and warm applications should be applied to the body, while ammonia is held to the nostrils. When the syncope is the result of an overloaded stomach, it will be well to administer an emetic of mustard and warm water, with the addition, if necessary, of a little ipecacuanha. I have seen three cases, in elderly persons, of syncope from an overloaded stomach ; life was apparently saved by the prompt administration of an emetic. In cases in which the attack has resulted from a draught of cold water taken while the body was heated, the patient, if able to swallow, should take a full 4O0 TEJEATMjENT OF SYNCOPJE. dose of compound spirit of aether with hot brandy and water, and in cases of complete unconsciousness^ these remedies may be administered by means of the stomach pump or in an enema. At the same time, hot fomenta- tions with a httle turpentine, or a mustard plaister, should be applied to the epigastrium. As a matter of course, in syncope the result of serious haemorrhage the question of transfusion will have to be considered. In all cases, after the attack has been recovered from, great care is necessary in order to prevent a recurrence; the erect position should be gradually assumed and exertion abstained from until sufficient rest and nourish- ment have been taken to restore the nervous energy reo-ulatinff the heart's action. In cases in which the o o attack has been due to distension of the stomach, the production of this condition must be prevented by appropriate diet and medicines. Food should be taken in small quantities, and articles likely to engender flatu- lence should be rigorously forbidden. CHAPTER IV. NEURASTHENIA OF THE HEART. Weakness of the Heart in Neurasthenia — Symptoms — Palpita- tion, Pain, and Sleeplessness- — Hypochondriasis — Special Cardiac Symptoms — Periodicity Sometimes Noticed — Causes OF Cardiac Neurasthenia — Prognosis and Treatment. The influence of the nervous system upon the move- ments of the heart accounts for the frequency with which symptoms of cardiac disorder occur among the subjects of neurasthenia. Weakness of the heart's action and excessive excitabihty are the predominant features, and are apt to give rise to the suspicion of organic disease. In typical cases, however, there are no valvular or pericardial lesions, though there are some- times grounds for suspecting that a slight degree of fattv degeneration may exist. It is impossible to do more than speculate as to the nature and seat of the nerv^ous disorder. The cardiac ganglia, the sympathetic system, the medulla oblongata, and the pneumogastric nerves may all be implicated. The special symptoms connected with the heart may 26 402 SYMPTOMS OF CARDIAC NEURASTSENIA. be the first to appear, but it more commonly happens that they set in at a later stage. They are more frequent in men than in women. Palpitation and pain in the precordial region are first complained of, and appear to aggravate the already existing weakness. Attacks of faintness are prone to occur, and obstinate sleeplessness is invariably associated with the cardiac symptoms. Severe attacks of hypochondriasis, profound melan- cholia, incapacity for mental exertion, sometimes to such an extent as to suggest softening of the brain, are observed in some cases. The hands and feet are cold and moist, the face and lips are either pale or bluish ; numbness and formication are occasionally present in various parts. The special cardiac symptoms are a small and infre- quent pulse, weakness of the heart's impulse, and faintness of the sounds. In some of these cases the number of the pulsations is as low as 40 in a minute; ' after a meal it may rise to 50 or perhaps 60 if stimu- .lants are taken, but it seldom goes beyond the latter number. In severe cases intermittency of the pulse and symptoms resembling those of angina pectoris may occur from time to time. For some months past I have had under my care a young man aged 27, with- SYMPTOMS OF CARDIAC NEURASTHENIA. 40.-, out any sign of organic disease_, but who after a day's hunting invariably suffers from pain in the cardiac region with an intermittent pulse. I advised him to relinquish hunting, and he has since had no return of the pain in the chest_, while his pulse has kept quite normal. A curious periodicity is sometimes observed in the occurrence of the syniptoms. The heart may act normally for some hours, the patient continuing his occupation and being either quite or comparatively free from any feeling of discomfort. At a certain time of the day_, however, perhaps towards evening, the sym- ptoms begin to show themselves ; there is a sensation of pain and oppression in the cardiac region, and the heart is felt to be acting irregularly. All these symptoms become aggravated if work is persisted in, but they subside under the influence of rest. They recur from time to time under similar circumstances ; it would seem as if the nervous mechanism of the heart would permit of a certain definite amount of physical or mental exertion and would work smoothly for a limited period, but no longer. Many instances of this kind have come under my notice. Undue excitability is always superadded to the weakness of the hearths action ; palpitation and pain are set up by very slight 404 TSUATMIJNT OF CARDIAC NEURASTHENIA. causes. Few of these patients can take a cup of coffee or tea without suffering for it. It is very necessary in these cases of cardiac neuras- thenia to inquire particularly into the habits of the patient in order to discover the exciting causes of the symptoms. It will generally be found that some form of excess is the source of the mischief. Alcohol and tobacco^ abuse of sexual intercourse, prolonged mental exertion, an insufficient amount of sleep, worry, and anxiety are the most frequent contributaries. In the absence ot treatment the symptoms are always chronic, and may continue for some years. They are not dangerous to life, but should the patient be attacked by any severe disease his chances of recovery are decidedly lessened. Acute bronchitis, pneumonia, and any form of fever may easily be fatal in this weakened condition of the heart. The treatment consists first and foremost in the avoidance of the causes (and of all excesses in par- ticular), and, secondly, in the adoption of all measures calculated to improve the general health. The physician should lay down definite rules for the guidance of the patient in all such matters as diet, exercise, occupation, rest, etc. The food must be of a decidedly nutritious TREATMENT OF CARDIAC NEURASTHENIA. 40.S character^ not too bulky and not such as to distend the stomach and engender flatulence. Mutton and beef, game, chicken_, eggs, and white fish may be allowed ; green vegetables are suitable, but potatoes and farina- ceous food in general should be taken very sparingly. Some of these patients are unable to digest bread ; it causes great distension of the stomach and much dis- comfort. Toast is more suitable ; but sometimes it will be found advisable to forbid the use of bread altogether, and let the patient take plain biscuits instead. Tea and coffee must be interdicted ; cocoa is well adapted for these cases. The nibs should be reduced to a coarse powder and boiled gently for three hours; the liquor is then strained, and when cold the fat is skimmed off. Thus made, the decoction will keep good for two or three days ; it is warmed up for use as required. Great moderation as regards stimulants is, of course, required. If the patient will submit, it is some- times well to try the eii^ects of abstinence ; but for most cases a little sound claret or burgundy, or weak whisky and water (not more than two ounces of the spirit in twenty-four hours, and taken only with meals), will do good rather than harm. Tobacco must be strictly for- bidden. A proper amount of sleep is all-important, 4o6 THEATMENT OF CARDIAC NJEURASTRENIA. and whenever symptoms of fatigue come on during the day the patient should discontinue his occupation and lie down for an hour or two. Warm baths occasionally (to be always followed by rest) ; change of air to the sea- side, or other suitable locality^ and the administration of suitable tonics^ as described in the chapter on neuras- thenia, constitute the remainder of the treatment. CHAPTER V. ANGINA PECTORIS— NEURALGIA OF THE HEART, Angina Pectoris, Definition of — Peculiarities and Symptoms of THE Attacks — The Cardiac Pain and Pulsations — Sounds of the Heart — Respiratory Symptoms and Expression of Countenance — Pains in the Shoulder and Arm — Indications OF Vaso-Motor Disorder — Measures Adopted by Patients TO Relieve Distress — Results of Attack and State of Health in the Intervals — Causes of a Fatal Termination — Causes of Angina, Essential and Symptomatic — Influence OF Tobacco Smoking — Lesions Found after Death in some Cases — Nature of the Disorder — The Nervous Apparatus of the Heart — Three Sources, the Cardiac Ganglia, the Pneumogastric, and the Sympathetic^Vaso-Motor Angina Pectoris — Diagnosis — Prognosis — Treatment, Relief of Attacks and During Intervals — Subcutaneous Injection of Morphine — Inhalations of Nitrite of Amyl — Nitro- glycerine Internally — Stimulants — Hygienic Measures — Arsenic — Treatment of Gouty Subjects. Angina pectoris is by no means a common affection, but inasmuch as cases sometimes occur in which no organic lesion is discoverable, and as the symptoms have not been shown to depend upon any specific altera- tion, the complaint must be included in the category of functional disorders of the heart. The affection is characterized by attacks of pain which begins in the 4o8 SYMPTOMS OF ANGINA PECTORIS. cardiac region and extends along the course of various nerves. Alterations in the movements of the heart and in the force of its contractions are almost always asso- ciated with the pain. Attacks of angina pectoris are wont to occur in the absence of any obvious cause. Sometimes they come on just as the patient is going to sleep, or they serve to rouse him after a normal sleep of some hours. In the case of a married lady whom I have lately attended^ the attacks, hitherto three in number, have invariably come on just as the patient was falling asleep. In other cases the attacks occur irregularly, and are, per- haps, traceable to such antecedents as exposure to cold, bodily or mental exertion, indigestion, and the like. The attacks may last only for a few minutes, or they may be prolonged for hours. In rare cases the sensa- tions persist with remissions only for several days. With regard to their recurrence there may be months or even years of freedom, while in other cases attacks come on daily, or even several times a day. As a general rule, the attacks become more frequent and more severe as time goes on. They generally occur without any premonitory symptoms, but in some cases they are preceded by vertigo, noises in the ears, ocular SYMPTOMS OF ANGINA PECTORIS. 409 spectra, uausea_, difficulty of swallowing, chilliness, and various other uncomfortable sensations. The strongest possible epithets are used by the patients to describe the character of the pain which is felt beneath the lower half of the sternum and in the region of the left nipple. It is said to be of a pricking, burning;;, borins; character, as if a hot iron were beinor driven into the chest, or as if the heart were being torn t)ut of it; in other cases the sensation is one of pressure and constriction. A sensation of impending dissolution is always superadded. The objective symptoms are also likewise prominent ; the heart beats tumultuously and with greatly-increased frequency and strength. The first sound is accompanied by a metallic ringing; the pulse at the wrist is hard, but inter- mittent. An opposite condition of the hearths action, viz., diminished frequency and strength, with a weak pulse, is less frequently noticed. Respiratory troubles are always associated with the symptoms just described. There is an intense feeling of want of air in the chest, but the inspirations are irregular, superficial, jerking, and sighing, and suffoca- tion appears imminent. These " symptoms are due to reflex action, resulting from the cardiac pain, for 41 o SYMPTOMS OF ANGINA FJECTOmS. there is no disease of the respiratory organs, and by a strong effort of the will the patients can take deep and regular inspirations. The expression of the countenance indicates the patient's sufferings in an unmistakable manner; the features are distorted and pale, and the face is covered with cold perspiration. Neuralgic pains, due presumably to irradiation, are almost always felt along the course of various nerves. The region of the shoulder and the left arm are the parts most commonly affected, but sometimes the suffering is coiifined to the back and inner side of the arm which is supplied by the internal cutaneous nerve. In other cases the pain reaches to the forearm, follow- ing the course and distribution of the ulnar nerve. The patients generally complain of a sense of numbness and stiffness in the arm, and sometimes of formication, and these feelings may persist long after the pain has abated. The pain in the arm is sometimes a pre- monitory symptom, and not unfrequently the part is the seat of severe cutaneous hyperaesthesia. It rarely happens that the pain affects both arms or the right arm alone, but it often extends to the left side of the neck. Pain in the face is rare, but uncomfortable sensations are often felt in the upper part of the thorax, SYMPTOMS OF ANGII^A PECTORIS. 4rr and the nipple is sometimes very painful and tender on pressure. In exceptional cases pain radiates to the back, and likewise over the abdomen and dov^nwards to the leo-s. I have v^itnessed one attack in an old man in which the pain extended behind the left shoulder- blade down the left arm, and was also felt in the left iliac fossa. Indications of spasm are witnessed in many cases ; thuS;, swallowing is often difficult, while vomiting, difficulty of speaking, hiccough, and epilepti- form convulsions are not unfrequent. Indications of vaso-motor disorder are always pre- sent. The extremities are pale and marked with livid discolorations, while their temperature is lower than normal. These phenomena are attributable to spasm of the minute cutaneous vessels, and are occasionally so decided as to give rise to the supposition that the nervous disorder is not of a secondary character, but that the vaso-motor changes are the primary factors, and that they precede and cause the attacks of cardiac pain. Cases such as these have been described as vaso- motor angina pectoris, and are explained by supposing that the spasm in the cutaneous arteries raises the blood- pressure in the aorta, and causes the alterations in the heart's action. 412 SYMPTOMS OF ANGINA PECTORIS. When an attack of angina is impending, most patients know by experience that they will be relieved by fresh air, and they consequently hurry to a window or out of the house. As a general rule they find that the erect posture serves to mitigate their sufferings ; besides this they often seize the nearest object and press it against the chest, or they clasp the left side of the thorax with their hands. When the attack is at its height, the slightest noise or disturbance worries the patient, whereas he is relieved by quiet and a darkened room. The urine passed after an attack is pale, watery, and copious in quantity. If a paroxysm lasts for some time the patient may become quite prostrate, or even completely unconscious; the respiration almost ceases, the pulse is imperceptible and the heart sounds scarcely audible, so that the patient is reduced to a condition of apparent death. Sometimes the attack passes off suddenly ; in other cases it subsides after eructation, vomiting, or diarrhoea ; copious expectoration has been observed in a few instances. In the intervals between the attacks, the majority of the patients feel comparatively or even quite well, but they are always disturbed by fear that recurrences may CAUSES OF ANGINA PECTORIS. 413. take place. If organic lesions be present, their symptoms will be more or less troublesome. The first attack of angina is sometimes fatal_, as in the case of the late Dr. Arnold, of Rugby ; on the other hand, attacks may continue to recur during many years and without much apparent injury to the general health. In fatal cases death generally occurs from paralysis of the heart ; rupture of the organ and cerebral haemorrhage have been occasionally observed. Some patients gradually fall into a low cachectic state, and eventually die. Sudden death under the influence of strong emotion has been recorded in a few subjects of angina pectoris. Nothing definite can be stated with regard to the causes of angina pectoris. The complaint is much more common in males than in females, and the majority of the sufferers are over fifty years of age. Hereditary predisposition is sometimes traceable, as in Dr. Arnold's case ; in other instances there is a family history of other nervous disorders. Rheumatism, gout, and excesses in alcohol and tobacco play a more or less active part in the causation of angina pectoris. Certain it is that in some cases the attacks cease when tobacco- smoking is given up, and recur on resumption of the habit. The complaint is said to be more common in 414 CAUSJES OF ANaiNA PJECTORIS. well-to-do persons^ leading sedentary lives^ and dis- posed to obesity. It is much more frequent in cold than in warm climates. In endeavouring to trace the disorder to its cause, it is well to divide the cases into two groups, the first of which embraces those in which no organic lesion is discoverable, and the second those in which certain organs are manifestly diseased. To the first class the term " essential " has been applied ; it includes not more than five per cent, of the total number of cases. Among the most prominent causes which have been assigned for cases of this kind are exposure to cold, mental excitement, and excessive indulgence in alcohol and tobacco. With regard to -cold, it may be supposed to contribute at least towards the causation of vaso- motor angina pectoris, examples of which are usually seen in cold and damp climates when the weather is very severe. In cases of symptomatic angina, the most common changes found after death are those which affect the organs of the circulation, such as atheromatous degenera- tion in the aorta and coronary arteries, aneurism of the aorta, and insufficiency of the aortic valves. Angina is a less fiequent accompaniment of mitral disease and PATHOGJENY OF ANGINA PECTORIS. 41 f; fatty degeneration and of pericardial adhesions. Gout and rheumatism seem to play an important part in the production of the disorder. As of purely reflex origin, symptoms of angina have been observed in diseases of the kidney, liver_, and uterus, and in a case of stone in the bladder. Many attempts have been' made to explain the symptoms and nature of angina pectoris. With regard to the chano;es found in the heart and in the blood- vessels^ it cannot be regarded as certain that these are the cause of the attacks, for hundreds of patients suffering from diseases of the heart never exhibit any symptoms of angina pectoris. On the other hand, in some fatal cases of the disorder no morbid changes whatever have been discovered in the ors:ans of circulation. If we regard the symptoms as the result of disordered innervation^, it is well to inquire as to the changes that have been discovered in the nervous apparatus of the heart. There are, unfortunately, but few accounts giving trustworthy details. Pressure on the cardiac branches of the pneumogastric by enlarged bronchial glands, and increased vascularity and hyperplasia of the connective tissue of the cardiac plexus have been noticed in a few cases. The most important changes are those which 4ib FATHOGENY OF ANGINA PECTORIS. have been discovered in the cardiac gangUa themselves. These organs in one case^ in which during Ufe there were symptoms of angina pectoris, were found to be in a state of hyperaemia with interstitial inflammation and increased growth of connective tissue; some of the gangHa were destroyed, and the interstitial tissue was infiltrated with calcareous matter. The physiological explanation of paroxysms of angina is extremely difficult on account of the complex manner in which the heart is supplied with nerves. It has been pointed out in the introductory chapter (see page 0^62) that this supply is derived from three sources : in the first place there are the ganglia in the substance of the heart itself; and these are independent centres of nerve force. In the second place there are the branches of the pneumogastric, which regulate the action of the heart ; and, lastly, there are the branches of the sympa- thetic, which, with those just mentioned, .form the highly complicated cardiac plexus. It cannot be wondered at that many symptoms of disorder of this plexus should fail to correspond with those of experi- ments made upon the vagus and upon the sympathetic. It has been proved that the cardiac ganglia can be irritated or paralyzed by solutions of various substances PATHOGENY OF ANGINA PECTORIS. 417 brought into contact with the endocardium ; and it may be inferred that a similar result might follow alterations in the quantity or quality of the blood. If the ganglia are irritated the heart's action is increased and accele- rated ; if they are paralyzed an opposite condition of things is set up, and may go as far as to amount to suspension of the heart's action. Such a condition might, therefore, result from narrowing or closure of the coronary arteries which supply blood to the ganglia. It can easily be ima2:ined that in atheromatous degrenera- tion of the aorta and in disease of the aortic valves the blood supply of these ganglia might be much diminished, or even temporarily cut off. The pneumogastric nerve may be affected either directly or by reflex action. Stimulation of the cardiac branches may be produced by irritation of the abdominal organs, as in the experiment of Goltz, of tapping the intestines. In cases of angina, provoked by indiges- tion, the irritation is propagated by the sympathetic nerves through the cervical spinal cord to the pneumo- gastric. The result is diminished frequency of the heart's action, amounting, perhaps, to temporary sus- pension, with impediments to intonation and to swallow- ing. The pain, which is likewise present, is due to 37 4i8 PATHOGENY OF ANGINA PECTORIS. irritation of the sensory fibres which are .contained in both the vagus and the sympathetic. The extension of the pain to the shoulders and arms is due to the connec- tions which these nerves form with the brachial plexus. The last set of nerves to be considered in connection with this affection of the heart are those derived from the sympathetic system. Irritation of these nerves accelerates the heart's action. In vaso-motor angina pectoris increased force of the cardiac contractions is requisite in order to overcome the obstacles in the peripheral vessels. The forced contractions give rise to pain analogous to that felt in the calves of the legs_, and in some disordered states of the uterus. The paroxysm of angina comes to an end as soon as the spasm of the cutaneous vessels has been relieved by warmth or other- wise, and an impediment to the free circulation of blood no longer exists. It has been supposed that congenital weakness of the cardiac nerve-centres exists in some cases, and that in others a weakened condition may result from immoderate muscular or mental exercise. Attacks of angina have been observed for the first time in persons who, after recovery from serious illness, have overtaxed their strength^ and in others who have been reduced by mental strain or want of sleep. TREATMENT OF ANGINA PECTORIS. 419 The diagnosis of angina pectoris is for the most part easily inade^ the distinguishing feature being the severe paroxysmal pain in the cardiac region. The attacks can scarcely be mistaken for those of ordinary palpita- tion or of asthma_, or hysteria. It is_, of course, im- portant to determine whether there be any organic affection of the heart or vessels. These should always be carefully examined, and if the physician sees the patient during an attack, he can scarcely make a mis- take as to the nature of the symptoms. The prognosis is always more or less unfavourable. If an organic lesion be present^ its nature will determine the opinion of the physician^ but even in the absence of any such change angina is always a serious com- plaint, and may either cause sudden death or may wear out the patient by the frequency and severity of the attacks.. The vaso-motor form and those in which the affection is connected with some abdominal disorder, or with excess in alcohol or tobacco, admit of a somewhat more favourable prognosis. The treatment of angina pectoris resolves itself into a consideration of the measures to be taken to r^^lieve an attack, and of those best adapted to prevent recurrences. When a paroxysm of angina is threatening, the patient 420 TBEATMEJs^T OF ANGINA PECTORIS. should be placed in a qulet^airy room, with the windows open, but somewhat darkened ; and the clothes about the neck and chest should be loosened. Most patients find that a sitting posture affords most relief. Sucking ice tends to mitigate the distress, and cold applications to the prsecordia are generally grateful to the patient. As a general rule in all cases of functional disorder of the heart, attended bv palpitation and irregular action^ it is of great importance that the physician should gain the confidence of the patient by assuring him that he has no organic disease, and that the attack will yield to treatment. With regard to medicines, the subcutaneous injection of gr. ^ of morphine will sometimes speedily relieve all the symptoms, but the practice is not without risk in cases of fatty degeneration of the heart. The same remark applies to the use of chloroform and aether, the former of which has been known to cause epileptiform attacks, followed by severe collapse. Inhalations of the nitrite of amyl are often very efficacious, and they are especially suitable for cases in which there is coldness and pallor of the skin or livid discoloration, symptoms due to spasm of the cutaneous vessels. The remedy may be used by dropping niv on a handkerchief, and allowing TRI:ATMENT of angina pectoris. 42 t the patient to inhale it until the face becomes red and there is a feeling of pulsation in the head. It is well to let the patient have the nitrite enclosed in capsules, each containing three minims and encased in cotton wool and silk. When used the glass capsule is broken, the liquid soaks the cotton wool and silk cover, and "ht or smell of food caused secretion (Landois). With regard to the effect of nervous influence upon the secretion of bile, very little appears, to be known, and the results of experiments are con- tradictory. It has, however, been proved that dilatation of the abdominal vessels, such as follows section of the splanchnics or of the spinal cord, is followed by an increased flow of bile, while irritation of the cord has opposite effects on the vessels and secretion respectively. Still less is known as to the effect of nervous in- fluence upon the pancreatic secretion. The latter is INFLUENCE OF NERVES ON SECRETION. 491 excited bv direct stimulation oF the (jland itself, and bv irritating portions of the medulla oblongata; while it is lessened or suppressed by stimulation of the central extremity of the vagus, and by irritating other sensory nerves, as the crural and sciatic. How far the nervous system is concerned in connection with intestinal secretion is a matter of complete uncertainty. On the other hand the influence of nerves on the intestinal movements is very considerable, and has, to some extent at least, been ascertained. The intestinal canal contains an automatic motor centre w^ithin its walls, between the lonsfitudinal and circular muscular fibres. When this plexus is unafl^ected by any stimulus the movements of the intestines cease; when food passes from the stomach into the bowels peristaltic contrac- tions of a reflex nature at once be2:in. The effect of the food is heightened by the condition of the blood- vessels ; when these latter are turg^id with blood the irritability of the nervo-muscular apparatus is consider- ably increased, so that slight stimuli produce a com- paratively strong effect. Venous congestion causes increased peristalsis ; and the active movements of the intestines, which often occur as the result of mental excitement, are due to derangements of the circulation. 492 INFLUENCE OF NERVES ON INTESTINES. The continuous application of strong stimuli causes complete paralysis of the intestine, as is seen in acute peritonitis and enteritis. The movements of the small intestines are increased by stimulating the vagus; the splanchnic, on the other hand_, is an inhibitory nerve^ at least to some extent, but when the blood in the capillaries becomes venous, stimulation of this nerve increases the movements. The splanchnics are the vaso-motor nerves of the abdominal viscera; when they are irritated all the intestinal vessels, which contain muscular fibres in their walls, contract; when they are divided the vessels dilate, and anaemia consequently results in the other parts of the body. . The splanchnic is also the sensory nerve of the intestine, and as such, under certain circumstances, it may give rise to extremely painful sensations. The effects of alterations in the blood-supply have been incidentally alluded to in preceding paragraphs ; but changes in the quality of the blood also play a certain part in the causation of disorders of the abdo- minal organs. Blood in which some of the normal constituents are defective will not yield proper secretions, and thus the food will be liable to be imperfectly acted FUNCTIOXAL DISORDERS OF DIGESTION. 493 upon. In this way a vicious circle readily becomes established^ inasmuch as the secretions themselves are dependent on the pabulum which the blood receives through the instrumentality of the assimilating organs. In like manner^ when the blood is overloaded with impurities^ the secretions derived from it cannot fail to be abnormal in many respects. • With regard to the symptoms of functional disorders of the stomach and intestines^ these will be fully described and their significance pointed out in succeeding"^ chapters. They may be briefly recapitulated and sum- marized as those which are referable to the affected organ, and those which make themselves felt in other parts. In the former category will be included such symptoms as derangements of appetite, perverted sensa- tions, flatulence and eructation, nausea and vomiting, constipation and diarrhoea. A numerous category of symptoms are connected with other organs. The kidneys have been already alluded to. They are often the first to suffer, and cutaneous affections are frequentlv superadded. The action of the heart is generally inter- fered with; palpitation and intermittency are conmion symptoms of dyspepsia. Even the lungs occasionally become affected ; dyspnoea and attacks of asthma are 494 FUNCTIONAL DISORDERS OF DIGESTION. sometimes traeeable to the state of the stomach. The nervous system especially suffers in another class of cases^ the symptoms exhibited being more marked in this portion of the organism than in the abdominal viscera themselves. Headache, vertigo, depression of spirits, irritability, incapacity for mental exertion, sleeplessness, hypochondriasis, and many forms of neuralgia often owe their origin to functional disorders of the stomach, liver, or intestines. Nutrition also is affected in not a few of these cases, the patients be- coming thin, ansemic, and debilitated, and these sym- ptoms are sometimes so prominent as to give rise to the suspicion of serious organic disease. It only remains to add that patients who have long suffered from the effects of these functional disorders are especially prone to fall victims to attacks of infectious diseases. Tuberculosis, for example, is often preceded by indi- cations of gastric and intestinal disorder. No reference has been made to the symptoms of hepatic functional disorders; they are of an important character, and require to be discussed in a separate chapter. CHAPTER II. DYSPEPSIA— INDIGESTION. Functions of Stomach and Intestines — Mechanical Actions and Chemical Changes Therein — Meaning of Term Dyspepsia — Relations with Catarrh — The Vascular Apparatus of the Stomach — Strong and Weak Digestions — Causes of Dyspepsia ■ — Faults Connected with the Diet — Use of Fluids, Alcohol, Tobacco— Positions of the Body, Exertion after Meals, Nervous Excitement, Disorders of Stomach — Anatomical Changes in Catarrh — Symptoms of Acute Dyspepsia — Chronic Forms — Influence on the Mental Condition — Results of Re- peated Ai tacks — ^ilATTERS Ejected from the Stomach — For- mation OF Organic Acids — Increase of Salivary Secretion — Pyrosis— Constipation — Diarrhcea — The Urine and Skin — General Condition of the Patient — Cardiac Symptoms — Vertigj — Course and Duration — Diagnosis — Prognosis — Treatment of Acute Attacks — Rest — An Emetic — Alkalies — Laxatives — Treatment of Chronic Forms — Attention to Diet — The State of the Teeth — Articles of Diet Suitable — Fluids — Milk Diet — Treatment of Constipation, Laxatives Suitable — Aloes, Cascara, Salines — Stronger Purgatives — Hygienic Measures as Change of Air, Exercise, Baths — Medicines such as Acids, Alkalies, Bismuth, and Charcoal — Treatment of Irritative Dyspepsia — Arsenic, Ipecacuanha — Question of Health-Resorts. The stomach and the intestinal canal have a doable task to perform. They have to act mechanically upon the materials which are introduced into them, and they 496 DEFINITION OF DYSPEPSIA. are the seat of not a few chemical processes, set up by the secretions of glands which form an important part of their structure, or whose excretory ducts open into their cavities. The chemical changes are intimately connected with the mechanical action of the parts con- cerned, for they are altered in various ways when the food introduced into any portion of the digestive canal is detained for too long or for too short a time. Patho- logical disorder of the movements of the intestines is, therefore, generally associated with disorder of diges- tion, and when the chemical processes are at fault the imperfectly-prepared materials influence the mechanical, action of the viscera. As a general rule, functional alterations involve a large portion of the digestive tube; they remain con- fined to one spot only when the irritation is comparatively slight. Disorders of the stomach and bowels are, there- fore, frequently associated ; it rarely happens that the one is affected without the other being; more or less implicated. The term dyspepsia is used to describe functional disorders in which the stomach is principally involved, and is contrasted with those changes designated by the word catarrh which are of an inflammatory nature, and DYSPEPSIA AND GASTRIC CATARRH. 497 affect the surface, or at least the mucous membrane, principally. No such sharp line of demarcation can, however_, be drawn between the two conditions, for experience teaches us that the difference is only one of degree, and that many of the transitional stages are not to be separated from each other. Long- continued indigestion invariably leads to catarrh, just as the latter, sooner or later, involves the former. The relations between these two processes may be easily traced. If undigested materials remain in the stomach, they undergo fermentative and putrefactive changes, with, as a result, the formation of substances, e,g., butyric and acetic acids, which are especially qualified to provoke inflammation. A similar result may follow the operation of a very different cause. When the stomach contains food, mental excitement may check the secretion of gastric juice and the move- ments of the organ, and may thus produce catarrh. This, however, is a less common cause. Individual peculiarities, dependent upon a variety of circumstances, tend to increase or lessen the susceptibility of the gastric mucous membrane. The epithelium of the stomach and intestines and the number and activity of the glands vary in different subjects, as we find to 3^ 498 WEAK AND STRONG DIGESTIONS. be the case with correspondmg portions of the cutaneous integument. As contributing to the production of functional dis- order, we must not forget to mention the irritability of the vascular apparatus of the stomach, and the manner in which it responds to the influence of the nervous system. Other elements in the calculation are the power of resistance possessed by the cellular structures and the tissues which they compose ; and, lastly, the quantity and condition of the muscular coat of the stomach and intestines. It is only by assuming the existence of differences in the powers of these parts that we are able to explain how it is that one individual can, without apparent difficulty, eat and digest substances which would upset another person for hours or days. The terms '' weak " and " strong ^' applied to stomachs may not be very scientificj but they serve to express differences which undoubtedly exist. It is easy to explain the fre- .quent association of disorders of the stomach with those of the intestines. When any irritating ingesta are not rejected by the stomach they pass into the intestine, where they excite increased peristaltic action, and possibly diarrhoea. If, however, they remain in CAUSES OF DYSPEPSIA. 499 the intestine, and are not rendered innocuous by the various secretions which there become blended with theiTij they will at all events cause irritation, and possibly inflammation of the bowels. Irresfularities and disorders of disrestion are due to a great variety of causes, some of them being connected with the mechanical movements of the parts, and others with the necessary chemical processes. It is important to bear both factors in mind when treating a case of indigestion. The causes of indigestion may be grouped under the following heads : — T. Food of an unsuitable character and imperfectly prepared. — The object of the cook's art is to render food pleasant to the palate and fit for digestion. If the first object be accomplished the second is apt to be regarded as comparatively immaterial. If the palate be pleased, and fashionable tastes be gratified, other con- siderations are neglected. It must be admitted that some amount of improvement has taken place of late years in England ; we have learnt that a reduction in the quantity of nitrogenous food is not only practicable, but very beneficial in. a large majority of cases. There is, however, much still that is faulty; too much S'oo CAUSES OF DY8PI:PSIA. authority is still left to the palate, with little considera- tion for the powers of the stomach. 2. Improper intervals between meals. — Two faults may be included in this category, the one being much more common than the other^ Indigestion is some- times caused by eating too frequently ; the stomach is never allowed to be at rest; but a far more frequent source of mischief is the long interval that busy men especially are apt to allow between meals. This is certainly the case with reference to the modern dinner and the hour at which it is taken. Many a man works hard all day, takes little, if anything, at luncheon, and does not sit down to dinner till eight or half-past eight. His nervous system is too much exhausted to be able to supply the force requisite for digestion. 3. Insufficient division and preparation of the food while in the mouth. — This is a very common cause of indigestion ; persons whose thoughts are fully occupied, either with work or play, are apt to think that the time spent in eating is wasted, and meals are got through as quickly as possible. It is true that common propriety necessitates the use of a knife, but this implement is employed as seldom as possible, the teeth do little or nothing, and the aid of saliva is almost refused : the CAUSES OF JDTSPIEPSIA. 501 food is swallowed^ but not eaten. Immoderate eaters often sin against themselves in the manner just described; some of them, indeed_, never seem to use the muscles of mastication. Persons with defective teeth unwittingly offend in a similar manner. There is another source of mischief connected with bolting the food ; it is apt to reach the stomach while still at a very high temperature, and to disorder the secretory action of the glands by the irritation it creates. 4. The drinking of a large quantity of fluid at a low temperature is a potent cause of indigestion. Too much stress cannot be laid upon this fact ; persons are far too apt, especially during hot weather, to take immoderate quantities of iced fluids during meals. The symptoms, in some cases, quickly follow their cause ; the cold applied to the lining membrane of the stomach converts its hyperaemic state to one of anaemia, and cannot fail to disorder the muscular movements of the organ. It is true that the feeling of exhaustion, and likewise of hunger, is allayed by the cold fluid, but the stomach has to pay the penalty. 5. The use of strong alcoholic fluids, especially when these are taken upon an empty stomach.-^ — .The operation of this cause is universally recognized ; the 502 CAUSjES OF DTSPUPSIA. worst use to which stimulants can be put is to take them between meals j they irritate the stomach, set up hypersemia in portions of its mucous membrane, and cause increased secretion of mucus, which acts as a ferment. They are, moreover, speedily absorbed and conveyed to the liver, whose function they disturb, and in whose tissues they produce serious alterations. Besides causing local changes, alcohol, after acting as a stimulus, depresses the nervous system and thus interferes with digestion, and the fermentation which some alcoholic liquors undergo in the stomach is a source of further mischief. 6. The use of strong tobacco comes next in order as a cause of indigestion, the mischief being proportionate to the strength and other peculiarities of the narcotic. The dryness in the mouth and throat, doubtless, extends to the stomach, and if the saliva be ejected starchy articles of food will be insufficiently prepared for digestion. 7. Constrained positions of the body and tightly fitting clothes may contribute to the causation of dys- pepsia by interfering with themovements of the stomach and bowels. Tight lacing among women comes under this head, and among the lower classes, the stooping CAUSES OF DYSPEPSIA. 503 posture adopted by tailors and shoemakers^ and also by some clerks^ is a fertile source of indigestion. 8. Exertion after a full meal. For digestion to be properly accomplished the organs at work must receive a sufficient supply of blood. This process is^ how- ever, obstructed if the activity of other portions of the body simultaneously claims an increased supply of that fluid. Thus it is that active mental or bodily exertion im- mediately after meals checks digestion_, for it causes the blood to be diverted into other channels. On the other hand, deep sleep is almost always prejudicial, for it lessens the excitability of the nervous system in general and retards the circulation. There is, however^ some diflference in opinion with regard to the desirability of an after-dinner nap. Those who advocate it cite the example of animals, but these gorge themselves with food, and are heavy and drowsy in consequence. A short rest is, however, different from lethargic sleep, and often appears to do good. Severe brain-work after dinner is certainly mischievous, and should always be forbidden : the interval between a late meal and bed- time should be devoted to recreation and amusement. 9. Nervous excitement is another cause of indiges- tion. It is well known that during such a condition 504 CAUSES OF DYSPEPSIA. the want of food is scarcely felt, and that when a meal is taken discomfort is very apt to be created. Nervous exhaustion, already alluded to in a previous paragraph, is another cause of this character. A man may feel terribly in want of food after a hard day^s work, but he has little or no power of digestion left. If, as is often the case under such circumstances, he eats freely and rapidly when opportunity occurs, one form of dis- comfort is speedily exchanged for another. 10. The last cause of indigestion which requires notice is that which is- connected with diseases ot various kinds. Disorders of the stomach and bowels, febrile affections, and severe diseases of all kinds are accompanied by more or less decided symptoms of indigestion, due to the fact that the stomach is in- sufficiently supplied with blood, and also to the distur- bances in the nervous system. Acute dyspepsia, uncomplicated by organic disease, leaves no traces discoverable after death. We know, from observations on animals and on persons with gastric fistula, the changes which the mucous mem- brane undergoes during digestion, but these disappear after death. The indications of gastric catarrh are often visible, and take the form of marked hyperaemia. SYMPTOMS OF DYSPEPSIA. 505 sometimes associated with extravasation of blood in points or patches. The mucous membrane is swollen^ covered with a tenacious adherent layer of mucus and epithelial cells of various kinds ; sometimes the deeper seated vessels show signs of inflammation. The evidences of chronic dyspepsia or catarrh are often seen in the dead body ; they consist mainly of atrophy of the mucous membrane, and of the submucous con- nective tissue. Thickening of the connective tissue^ with deposits of pigment and destruction of the glands, and either hypertrophy or atrophy of the muscular fibres are frequently discoverable. The symptoms of an acute attack of dyspepsia are of a marked character_, but they vary with the cause and with the individual. In the most common form there is nausea and eructations^ with increased secretion of saliva, and followed by retching and vomiting, by means of which the contents of the stomach are sooner or later discharged. Sometimes a portion of the fluid matters contained in the duodenum is also ejected ; the greenish colour and bitter taste indicate the presence of bile. If the matters vomited have been but a short time in the stomach, the other symptoms will soon pass off"; disorder of the intestines will either be very 5o6 SYMPTOMS OF DYSPEPSIA, slight or altogether absent. On the other hand^ under opposite conditions, diarrhoea is very apt to be set up. Persons differ very considerably in their proneness to vomit ; as a general rule^ other things being equal, an irritable stomach affords a better protection against the bad effects of ingested materials than one which is less sensitive. When the vomiting is over, but little dis- comfort may remain beyond a transient feeling of exhaustion. When, however, severe irritation has been set up the suffering may be proportionately great. There is, for example, great pain in the stomach, with intense and persistent nausea, and even after the organ is empty the patient may be greatly distressed by efforts at retching, during which a little mucus or bile maybe ejected. Diarrhoea is likely to set in, accompanied by colicky pains, and the whole of the abdomen is tender on pressure. The tongue is swollen and thickly coated, there is severe prostration and headache; food of all kinds is regarded with loathing, but water is often taken ravenously only to be rejected immediately. There is no elevation of temperature; the pulse, if altered at all, is less frequent than usual. These symptoms last for a variable period, sometimes for several hours, and they may subside from time to time, and again recur. 5 YMF TOMS OF JD YSPEPSIA . 507 Chronic forms of indigestion are much more common than the acute type; they make up, indeed, no small proportion of the ills to which flesh is heir. Whatever be the character of the discomforts, their development is a more or less chronic process. In very many cases the first evidence of disorder is denoted by the patient's becoming aware of the fact that .he possesses a stomach. He is apt to find this out after substantial, though by no means necessarily immoderate meals. The dis- covery is associated with the desire to loosen the clothes round the lower part of the chest, inasmuch as the pressure seems to be the cause of the discomfort. In all but the slightest attacks, further symptoms are superadded, and take the form of eructations, first of gaseous matters, and then of particles of food, the taste of which is perceptible some hours after it has been swallowed, a feeling of heat in the throat and stomach, with increase of saliva. These may be the only symptoms, and they may recur more or less frequently during long periods. Retching and vomiting are, however, often superadded. The bowels, too, are apt to become irregular in their action ; sometimes there is constipation, and sometimes diarrhoea, especially after eating. All these symptoms may go on for years without apparent influence upon the patient's health. So8 SYMPTOMS OF DTSPFFSIA. Unless much pain be likewise present, they are often unheeded. A careful person will notice that the symptoms are liable to be provoked by sundry articles of food, and he will abstain from them^ or take them only in great moderation. It is only a select few, however, who can exercise such restraint, more espe- cially if the food to be avoided is of a highly palatable character. If the warnings given by the stomach be neglected a variety of ill consequences sooner or later make themselves felt. The mental condition shows signs of change; application to study becomes difficult, ideas soon get confused and do not flow readily, the temper becomes irritable, the patient feels either depressed or excited, and takes pessimistic views of things in general. All the^e symptoms are aggravated by constipation, which so often accompanies dyspepsia, and in not a few cases a condition of melancholia or hypochondriasis supervenes. In chronic cases, in which, owing to their frequent repetition, the symptoms have reached a high degree of severity, the condition of the patient is far more serious. There is loss of appetite, which may so far be described as complete, inasmuch as whatever is taken has to be forced down, and these attempts are followed by a SYMPTOMS OF DYSPEPSIA. 509 feeling of weight and pain, which may amount to cardialgia. A burning sensation at the back of the throatj attended by retching_, eructations of acrid matters, vomiting, and constipation, alternating with diarrhoea, and such like symptoms, are more or less troublesome in different cases. The abdomen is at first generally prominent, but later on it is apt to be retracted. The passage of flatus from the lower bowel is often a prominent symptom. There are disagreeable tastes in the mouth, and the breath has an unpleasant, and sometimes even putrid odour, which is especially marked whenever the mouth and teeth are not kept clean. The emaciation which sets in is a measure of the serious disorder of nutrition. Certain of the symptoms require to be considered somewhat more in detail. An examination of the matters ejected from the stomach demonstrates the presence of acetic and butyric acids, which are the products of the fermentation of amylaceous substances. Carbonic acid is sometimes present in large quantities, and is derived from the same source. The products of the decomposi- tion of albuminous substances can be detected in some cases, and among these sulphuretted hydrogen is the most common ; it may become absorbed and cause 5IO SYMPTOMS OF DYSPEPSIA. symptoms of poisoning. The idea has for a long time been prevalent that the symptoms of mental depres- sion^ so common in cases of dyspepsia, are attributable to the absorption of the products of putrefactive decomposition, and this notion is supported by the knowledge recently obtained of the properties of the ptomaines. The formation of the organic acids in the stomach prevents the preparation and solution of albuminous matters, and the acids, moreover, act as direct irritants. In dyspeptic cases the quantity of hydrochloric acid in the gastric juice is generally much diminished, and the conversion of albumen into peptone is therefore limited. The pepsine, also, is less than the normal amount, but is generally sufficient for the digestion of albumen, though the process may be a very tedious one. The accumulation of peptones leads to a similar result, and the delay thus caused is further increased by the in- ordinate secretion of mucus and the less frequent and ^ active movements of the stomach, which retard absorp- tion, and the passage of its contents into the duodenum. Under such circumstances^ and bearing in mind the fact that excitants of putrefaction readily gain access to the stomach with the food that is swallowed, it is no wonder that this process so often becomes developed. P YE OS IS AS A SYMPTOM OF DYSPEPSIA. 511 The salivary secretion is often much changed in cases of dyspepsia. It is generally increased as a result of reflex action set up by the abnormally acid state of the stomach. If swallowed it may produce vomiting, especially if, as often happens, much air be mixed with it. The term pyrosis is applied to describe a profuse flow of saliva and consequent discharge from the mouth of a clear fluid, often occurring in the course of acid dyspepsia. The discharge is attended with more or less cramp in the stomach, and both are paroxysmal, \ but there is no ejection of the contents of the stomach. Sir W. Roberts, who has carefully studied this sym- ptom, states that the '^ gush of saliva is something tremendous, often greater than incessant swallowing efforts can dispose of, and the surplus flows out abun- dantly from the mouth. ... A paroxysm of this kind only occurs during the presence of surplus acid in the stomach.-" In gastric catarrh occurring in drunkards, the quantity of saliva swallowed during the night is sometimes so great that its presence can be detected by chemical tests in the matters vomited in the morning. With regard to the other abdominal symptoms the constipation is due in some measure to the fact that an abnormally small quantity of food passes into the intestines, and the result is aided by the diminished S 1 2 S YMPTOMS OF B YSPHPSIA . energy of the peristaltic action. The food remains for lengthened periods in the large intestine^ and loses much of its watery constituents. The attacks of diarrhoea are the consequence of catarrh of the colon, which in its turn is produced by the presence of faecal masses. The attacks may, however, be due to irritation of the small intestines, the result of the passage into them of imperfectly digested matters from the stomach. The abdominal tenderness which often accompanies dyspepsia may be due to irritation of the peritoneum, caused by distension of the intestines, or possibly to the accumulation of the products of retrogressive meta- morphosis. The circulation of the blood through the abdominal organs is more or less retarded ; the sensi- tiveness to pressure extends over the whole abdomen, or at least over large portions of it, and the pain is everywhere of the same character, and cannot be localized in any one organ. Spontaneous pain in the back and loins is also a common symptom. The condition of the urine varies in different cases, and in the same patient at different times. The secre- tion often contains a disproportionate quantity of urates, which are deposited on standing, and oxalate of lime and deposits of the amorphous phosphate of lime . Calomel — For Checking Diarrhcea, Opium, Aromatics and Astringents, Camphor, Warmth, Stimulants — Chronic Diarrhcea — Diet and Regimen — Rest — Diarrhcea in Chil- dren — Causes of Frequency — Disorders of Digestion — Com- plications — Treatment, Cautions as to use of Opiates — Warm Baths, Stimulants, Flannel to Surface—Diet — Ene- MATA OF Warm Water — Calomel — Cautions as to Excessive Feeding — Chronic Diarrhcea — Diet, Flannel and Warmth — Grey Powder, Vegetable Astringents, Chalk, Bismuth, Perchloride of Mercury, Arsenic, Iron, Diarrhcea, owing to its frequency, occupies a promi- nent place among the functional disorders of the abdo- men ; it is also a common symptom of many organic lesions of the abdominal viscera. The term is used to signify discharges from the bowel more fluid and usually more abundant than those of health. Three CAUSES OF DIARRH(EA. 615 conditions are necessary for the production of diarrhoea : (1) increased peristaltic action, (2) free communication between the upper portions of the intestines and the lower end of the bowel, and (3) the presence of contents capable of being propelled along the canal. The following are the principal causes of diarrhoea : — I. The passage of substances from the stomach into the intestines, capable of accelerating the peristaltic movements of the latter, either with or witht)ut the pro- duction of inflammation. Articles of diet of this character have been already described in the chapter on Indigestion, and the fact must be borne in mind that peristaltic movements of the stomach thus induced may be propagated thence to the intestines, and cause movements of a similar character along the entire tract. Thus it is that in some persons a little cold water taken fasting in the early morning, is sufficient to produce free action of the bowels. Under pathological condi- tions, in which the excitability of the parts is increased^ such propagation of movement is often witnessed under the operation of comparatively slight stimuli. Cases in which the irritation proceeds from the stomach must be distinguished from those in which the intestines form 6i6 CAUSES OF BIARRHCEA. the Starting-point ; but it often happens that both parts a?e implicated. A distinction must also be drawn between such materials as cause inflammation as well as diarrhoea and those which do not induce the former ; in this last category may be placed many articles of food ; fluids, especially water, and laxative medicines of a non-irritating kind. Z. Another common cause of diarrhoea is exposure to cold, and particularly when the abdomen itself is thus acted upon. The manner in which the effect is produced is by no means certain^ but the sequence of the two events is often beyond doubt. Many persons are liable to diarrhoea after exposure to cold, and espe- cially if damp be combined with the cold. In such cases it is generally said that the alimentary canal is a locus minoris resistentice. It may be that the diarrhoea is the result of transudation into the intestines, taking place as a consequence of paralysis of the vaso-motor nerves. Cold often acts very energetically after previous exposure to heat, and especially when the body is per- spiring freely. 3. In a less numerous class, diarrhoea is apt to set in suddenly as a result of nervous excitement, e.g., terror or anxiety, the stomach being sometimes aflfected at the CA USES OF DIA RRR(EA . 617 same time, as shown bv eructations and vomitino". This form is not uncommon in hysterical patients. 4. Another category embraces those forms of summer and autumnal diarrhoea^ the cause of which is doubtful, but is probably of an infectious nature: the stomach is often disordered at the same time. Diarrhoea induced by any of the above-mentioned causes is rapidly developed and of an acute character. Under proper treatment it may quickly subside, and such is the general rule in subjects otherwise healthy. It may, however, become a chronic disorder, liable to exacerbations. Diarrhoea of this latter type frequently occurs in association with disorders of nutrition and various pathological lesions or other circumstances which prevent the restoration of a healthy action. Intestinal lesions and disorders are by no means always attended by diarrhoea, and therefore must be regarded as only a predisposing cause thereof. As a matter of fact they produce the result in question by setting up a condition of catarrh in the intestines; if they fail in this respect, severe disorders, such as extensive ulceration, may exist without diarrhoea. The latter invariably accompanies catarrhal 6i8 CAUSES OF JDIAERSCEA. inflammation of the colon, and is apt to become very- marked as the complaint continues. The intestinal lesions and various conditions often accompanied by diarrhoea are as follows : — I. Ulceration occurring in the course of specific infectious disorders, such as typhoid fever, dysentery, and intestinal tuberculosis. ^. Disordered movement of the blood in the intes- tines, such as results from obstruction to the flow in the vena portae. This condition exists in those diseases of the liver which produce compression of the capillary system of the or^an, and in cases in which the intes- tines are agglutinated together as a consequence of chronic peritonitis. Congestion of the intestinal veins is also liable to occur in those cardiac and pulmonary disorders in which the flow of blood from the inferior cava is impeded. Faecal obstruction is another obstacle of a mechanical kind to the flow of blood, and it may produce symptoms of diarrhoea by causing intestinal catarrh. 3. Attacks of diarrhoea are common symptoms of such constitutional disorders as rickets and scrofula. There is one condition of the bowels, viz., amyloid CAUSES OF DIARRECEA. 619 degeneration, of which diarrhoea is a marked symptom. Once set up, it is apt to b.e almost uncontrollable, and continues until death. Besides the infectious disorders above mentioned which are localized in the bowels^ and are always attended by diarrhoea, there are other infectious com- plaints which are often similarly accompanied. Thus, various septic processes, such as occur in puerperal fever and disorders of a different character, viz., scarlet fever and uraemia, are not unfrequently attended with discharges from the bowels. It is probable that a portion of the virus acts upon the intestinal mucous membrane, and is thus got rid of; evacuations of this character may sometimes be regarded as favourable. In fatal cases, however, various lesions are discoverable in the intestines, such as indications of catarrh, extra- vasations of blood in the mucous and submucous coats, and even ulcers'as a result of necrosis. In non- fatal cases the diarrhoea may be regarded as of a func- tional character. Persons of all ages are liable to suffer from diarrhoea, but the complaint is especially frequent among infants under two years old. This frequency is due in part, though not altogether, to bad feeding. There are great 620 SYMPTOMS OF BIARRRGEA. differences among individuals with regard to liability to attack. The same cause which affects one person will be harmless to others. As a general rule weakly subjects are prone to suffer^ and the complaint in such subjects, once set up, is apt to be violent and obstinate. The anatomical changes in cases of diarrhoea can be disposed of in a few words. In many cases little or nothing is discoverable, for signs of congestion often subside after death. In other cases there is more or less catarrh, with production of much mucus and detachment of epithelium; infiltration of the connective tissue with fluid and cells. In chronic cases atrophy of the mucous membrane is often observed. When the diarrhoea has been associated with specific disorders the changes peculiar to these latter will, of course, be noticeable. In describing the symptoms and treatment of diar- rhoea it is well to make a distinction between the com- plaint as it occurs in adults and those forms of it which are common in children. Important differences exist in several particulars. In adult cases an attack of acute diarrhoea usually begins with a feeling of uneasiness in the abdomen, which soon amounts to pain of a griping character. SYMPTOMS OF BIARRHCEA. bii Rumbling sounds are caused in the abdomen, which becomes somewhat distended. A desire to defaecate is then experienced^ and is soon felt to be uncontrollable. Evacuation takes place with some force; fluid and gaseous matters are dischar2;ed with the more solid faeces, and the stool is often frothy. After the motion the abdominal pain and uneasiness are relieved, and perhaps quite subside, but there is often a feeling of insecurity, warranted by a speedy return of the colicky pains and discharge of faeces. When the lower part of the large intestine is especially implicated, tenesmus is a common symptom. Passage of the motions does not bring relief, the patient is worried by the feeling that something remains in the rectum, and he makes strain- ing efforts to get rid of it. He may even feel that he scarcely dares to leave the closet or night-chair; his efforts sometimes cause more or less prolapsus of the rectum, with aggravation of his troubles. The matters discharged are at first pulpy, with the appearance and odour of faeces. Gradually they become more liquid, and eventually non-faeculent, consisting of fluid matters containing much mucus, and more or less coloured with bile. In some cases diarrhoea sets in with two or three loose watery motions in rapid succession, the disturb- 62 2 SYMPTOMS OF BIARRHCEA. ance then subsiding and stools of natural consistence making their appearance. Diarrhoeal discharges are sometimes unattended by pain, but as a general rule they are preceded by the sensations above described. Sometimes painful and painless discharges alternate in the same patient. The presence or absence of pain is no indication of the special form of disorder present. When the attack is due to irritating ingesta, pain of a griping character is seldom absent. In ulceration of the bowel it is also a common symptom^ and is accompanied by tenderness on pressure. Unless of a very slight character an attack of diarrhoea is seldom without influence on the general condition of the patient. Thirst is often experienced as a result of the withdrawal of fluid from the system. The urinary secretion is lessened, its colour becomes deeper, its specific gravity is increased, and a sediment composed of urates is apt to be deposited when the urine gets cold. More or less weakness and depression are experienced by the patient, and his appearance is altered for the worse. There is generally some loss of appetite, even when the stomach is not involved in the attack. TREATMENT OF DIABRHCEA. 623 After very frequent stools and copious discharges, resulting in the abstraction of much fluid from the tissues, the patient's appearance may closely resemble that which is seen in cases of cholera : the prostration is intense; the features are sunken so that even a young patient looks aged ; the skin is cold ; the pulse small and frequent; there are. muscular twitchings, suppression of urine and diminution of temperature. In children general convulsions are sometimes caused by diarrhoea; adults often become listless and apathetic. After serious attacks, recovery is a tedious process ; and in aged and weakly subjects death is not uncommon. Chronic diarrhoea invariably leads to more or less serious disorder of nutrition, as shown by the loss of flesh and anaemia which steadily progress while the abdominal symptoms are liable to variations. Diarrhoea much aggravates the effects of other exhaust- ing diseases. The diagnosis of diarrhoea can never present any difficulty, and the discovery of the cause, which is all- important as regards treatment, is generally easy. The first question for the physician to decide is whether it is desirable to check the peristaltic action upon which the diarrhoea depends, and the decision must be guided 624 TRTIATM^NT OF DIARRIKEA. by the conditions present in any given case. If the patient's life is in jeopardy by reason of the number and profuseness of the evacuations^ there can be no doubt as to the course to be pursued ; but in the absence of such danger, the question will arise whether the removal of irritating matters from the intestine will not be the most rational way of curing the diarrhoea. Such a question may have to be solved not only when dealing with cases of diarrhoea due to irritating ingesta, but also with those in which the discharges aid in removing from the body the infectious materials of such disorders as typhoid fever, septicaemia^ and the like. In these latter cases the course to be pursued depends upon the condition of the patient, and the frequency and amount of the discharges. When irritating ingesta are present their removal is always desirable, and this is best effected by the use of castor oil, a mild, non-irritating purgative. The sulphate of sodium is another suitable remedy for this purpose ; it should be given in half- ounce doses, dissolved in half-a-pint of warm water. It should not, however, be given to weakly subjects, nor to cases in which the discharges have been very profuse and fluid in character. Rhubarb is another excellent remedy for these cases ; the dose is about TREATMENT OF DIARRHCEA. 621 gr. X, and it may be advantageously combined with so(la_, magnesia, and carminatives. When the stomach is in an irritable condition, and would reject either castor oil or rhubarb, a full dose of calomel (gr. v-x for adults) will prove the best remedy. It quickly removes all offending materials^ without causing much depression, and it likewise tends to check vomiting. When it is deemed- desirable to check the peristaltic action of the bowels and thus arrest diarrhcea, opium is the best remedy at our command. The drug may be given either in the solid form or in that of the tincture^ and small doses are to be preferred to large ones. It is most conveniently administered by the mouth ; but for severe cases the most efficacious way of using opium is the introduction of suppositories containing about a grain of the extract. One of these may be employed after each relaxed motion, and two or three are usually sufficient. An enema containing laudanum is less efficacious; even a small quantity of fluid is apt to irritate the rectum. When uneasiness of the stomach is coupled with that of the intestines_, a few drops of laudanum combined with such aromatics as Tinct. Card. Co._, or Tinct. Lavandulae, or Pulv. Cretse 40 626 TREATMENT OF DIARRHCEA. Aromat., will be found efficacious. In so-called " sum- mer diarrhoea" it is well to combine some bitter astringent with the opium, and tincture of cinchona is very suitable for this purpose. The same combination (using tinct. opii, nx iij-v) mav be continued during convalescence ; given before meals, it serves to lessen the irritability of the stomach and to check abnormal peristaltic action. Astringents of various kinds, e.g., catechu, kino, <'-allic acid, acetate of lead, dilute sulphuric acid, chalk, and sulphate of copper are often employed in cases of diarrhoea; they are suitable mainly for the chronic forms. Those which contain tannin should not be