••r^:.'- v«r Columbia (Hnitier^itp intlieCitpoflrttigork College of ^t)P2(ician£f anb ^urgeong Hibrarp ^•^- \y':r.' .• f^"^>; •> NERVE PROSTRATION AND OTHER FUNCTIONAL. DISORDERS OF DAILY LIFE. Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/nerveprostration1891roos NERVE PROSTRATION AND OTHER FUNCTIONAL DISORDERS OF DAILY LIFE ROBSON ROOSE, M.D., LL.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," "leprosy AND ITS TREATMENT," " WEAU AND TEAR OF LONDON LIFE," ETC., ETC. SECOND EDITION LONDON H. K. LEWIS, 136 GOWER STREET London : H. K. Lewis, 136, Gowkr Street. -J ■f.J PREFACE TO THE SECOND EDITION. From the rapid exhaustion of the First Edition of this Work, which has now been out of print for some time, its author feels justified in concluding that his account of functional disorders has been favourably received by the profession. In the preparation of a Second Edition, each chapter has been carefully examined, and while some portions have been condensed, others (notably the chapters dealing with Neurasthenia) have been considerably amplified. It has also been thought desirable to give a description of various toxic neuroses, viz.. those due to alcohol, opium, etc., and to supplement the section on Disorders of the Abdominal Organs by adding a chapter on Corpulence. Throughout the work the paragraphs referring to treatment have been very carefully revised; and reference has been made to all remedies which the Author's own experience has proved to be useful. With these prefatory remarks, the work is offered a second time to the profession, in the hope that it may merit a favour- able judgment. The Author refers with pleasure to the fact that one portion of his work, viz., that dealing with Disorders of the Circulation, has been translated into German by Dr. Krakauer. 45, Hill Street, Berkeley Square, W. October, i8gi. PREFACE TO THE FIRST EDITION. 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. PREFACE. 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 neglecting 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 Dis- tinct Classes — Many Diseases thought to be Functional now known to be Organic — Derangement of Function in the absence of recognizable Altera- tions 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 Derangements — Heredity — Neuro- pathic 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 Accommodation and Refraction as causes of Nervous Disturbances — Dr. Stevens' Views — Characters of Functional Nervous Disorders as distinguished from those of Organic Origin .......... 1-2 1 SECTION I. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. CHAPTER I. NERVE PROSTRATION— NEURASTHENIA— NERVOUS DEBILITY. Nerve Prostration— Synonyms and Meaning of Term — Nature and Varieties — Prevalence of Nerve I'rostration in England and in the United States — Causes — Dr. Beard's Views — Neurasthenia and Lithamia — Hereditary Predisposition — Training and Habits of Young Subjects— Sexual Excesses CONTENTS. — Influence of Schoolwork and Competitive Examinations — Symptoms of Neurasthenia — Symptoms connected with the Cerebrum — Disorders of the Sensory Faculties— Spinal Pain — Neuralgia — Disorders of Special Senses — Various Kinds of Morbid Dread — Insomnia — Symptoms connected with the Motor Faculties — Vaso-Motor Disturbances — Disorders of the Circula- tory, Respiratory, and Digestive Organs- — Symptoms Referable to the Kidneys and the Organs of Generation — Peculiarities of the Symptoms of Neurasthenia — Diagnosis and Prognosis — Consequences — Treatment — Re- lief of the Sleeplessness — Electricity — Question as to Isolation — Freedom from Mental Exertion — Amusements and Exercise — Changes of Air and Scene — Travelling — Diet —Avoidance of Tobacco and Excess in Stimulants. — Sedatives and Tonics — Hydrothetapeutics in Various Forms — Electricity — The Weir Mitchell System — Rest, Isolation, Excessive Feeding, Massage, and Employment of Electricity — Cases in which Indicated — Details of Treat- ment — Duration of Treatment and Results, with Illustrative Cases — Cautions as to Adoption of Treatment in Cases of Organic Disease and. Mental Disorder — Drawbacks connected with the Weir Mitchell Plan 22-87- CHAPTER II. NEURASTHENIA SPINALIS— SPINAL IRRITATION. Neurasthenia Spinalis, a Functional Disorder — Its Piesumed 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 Treat-- ment — Dr. Brown-Sequard's Method of Treating Spinal Iriitation 88-102. CHAPTER III. SLEEPLESSNESS. Sleeplessness in Nervous Disorders — Conditions requisite for Normal Sleepr— Causes of Sleeplessness — Vascular Excitement— Sleeplessness in Neuras- thenia — Presence of Imperfictly Oxidized Materials in the Blood — Indiges- tion — 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 — Chloral, the Bromides, Paraldehyde, Sulphonal, Urethane, ttc. — Various Plans for Dealing with Different Cases — Electricity — Hypnotism 103-120 CONTENTS. CHAPTER IV. HYSTERIA. Hysteria, Definition of tlie Term — Historical Notices and Geographical Distribu- tion- -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 Sensation, Hypersesthesia, the Clavus Hystericus and Neuralgia — Anaesthesia, its Forms — Disorders of the Special Senses — Disorders of the Function of Digestion — of Respiration — 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 — Treatment of Mental Disorders — Hygienic Measures — Medicines — Relief of Prominent Symptoms — Treatment During the Paroxysm — of the Complications — Metallo-Therapeutics — Hypnotism — Galvanism and Faradism — The Weir Mitchell System — Hydropathic Treatment .......... 121-163 CHAPTER V. EPILEPSY. Epilepsy, Definition and Forms of — Historical Notices and Geographical Distri- bution of the Disorder — Causes — Influence of Hereditary Predisposition — Date of First Attacks — Drunkenness — Sexual Excesses — Lesions of the Nervous System — Dr. Brown-Se'quard's Experiments- -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-Se'quard'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 Infantile Convulsions — Prognosis — Treatment — During the Intervals — Hygienic Measures — CONTEIfTS. Medicines — The Bromides, Atropine, Zinc, Silver, Vegetable Tonics and Anti-spasmodics — Empirical Remedies — Electricity — Hydrotherapeutics — Treatment During the Paroxysm ...... 164-197 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 Disorder — Symptoms — Evidences of Mental Dis- order — 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 — The Good Results of Prolonged Sleep — Hypnotism — Isolation from other Children 198-214 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, Here- ditary 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, Remissions, Intermissions, and Recurrences — Locality of the Pain as a Guide to the Cause — Pain Extending Centri- petally and also Radiating along the Course of Neighbouring Nerves — Points Douloureux — Cutaneous Hyperaesthesia and Anaesthesia — Motor Disorder — Vaso-Motor Disturbances and Disorders of Secretion and Nutri- tion — Eruption 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 — Counttr-Irritation — Electricity — Various Tonic Remedies — Neurotomy and Neurectomy — Summary of Treatment 215-238 CONTENTS. CHAPTER VIII. VARIOUS FORMS OF NEURALGIA, I. NEURALGIA OF THE TRIGEMINUS— TIC DOULOUREUX— II. INTERCOSTAL NEURALGIA.— III. SCIATICA. I. Causes of Tic Douloureux — 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, Gelsemium — Specific Remedies, Quinine, Arsenic, Iron, Ammonium Chloride — Liniments — Counter-Irritation — Neurotomy — Neurectomy — Nerve-Stretching 239-253 II. Intercostal Neuralgia, Causes and Symptoms — Points Douloureux — Com- plications and Course — Diagnosis — Irritable Breast or Mastodynia — Sym- ptoms and Differential Diagnosis — Treatment of Intercostal Neuralgia and of Mastodynia .......... 253-261 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 — Prog- nosis — Treatment — Question as to Causation — Rheumatism — Iodide of Potassium- -Blisters — Hypodermic Injections of Morphine and Atropine — Electricity — Flying Blisters— Acupuncture — Hot Baths — Warm Applica- tions — The Scotch Douche — Hot Sand-Baths — Massage — Nerve-Stretching 261-275 CHAPTER IX. ARTICULAR NEUROSES— NEURALGIA OF THE JOINTS. Nature and Pathogeny of Neuralgia of the Joints — Predisposing and Exciting Causes — Symptoms — Cutaneous Hyperaesthesia — 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 CONTENTS. Local — Massage, Douches, Baths, etc. — Electricity — Use of the Limb to be Recommended ......... 276-282 CHAPTER X. HEADACHE. Pain in the 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 — Head- ache in Hysterical Subjects — Pairs 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 28,^294 CHAPTER XI. HEMICRANIA.— MIGRAINE.— MfilGRIM. Frequency of Hemicrania — Its Prominent Features — Premonitory Symptoms — Symptoms of the Attack — Phenomena indicative of Vaso-Motor Distur- bance — 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, Impres- sions on Certain Nerves of Special Sense, Derangement of Stomach, Rela- tion 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 Irrita- tion — Dr. Liveing's Theory of the Irregular Accumulation and Discharge of Nerve Force — Migraine thought by some to be only a Variety of Trige- minal Neuralgia — Diagnosis — Prognosis — Treatment — A Course of Quinine — Aperients — The Iodides with the Alkaline Carbonates for Gouty Subjects — Strychnine, Arsenic, Oxide of Zinc, and Nitiate 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 Guarana — Galvanism .....•.• 295-315 CONTENTS. CHAPTER XII. VERTIGO— GIDDINESS. Vertigo as a SympLom 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, Hysteria, Epilepsy, and Hemicrania — Vertigo in Gouty Subjects ....... 316-329 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 — Galvanism — Attention to General Health — Lccal Measures — Counter- irritation — Mechanical Appliances ...... 330-338 CHAPTER XIV. FACIAL PARALYSIS. Forms of Functional Paralysis — Rheumatic Paralysis — Paralysis of the Facial Nerve, due to Cold and other Influences — Symptoms, Subjective and Objective — Loss of the Sense of "^Faste — Auditory Symptoms — Electrical Reactions of the Paralyzed Parts — Diagnosis of Facial Paralysis — Deter- mination of the Site of the Lesion — Prognosis — Treatment . 339-348 CHAPTER XV. HYPOCHONDRIASIS, (Hypochondriasis, Definition and Forms — Causes — Hereditary Predisposition — 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 .... 349-358 CHAPTER XVI. TOXIC NEUROSES. Alcoholism — Results, Course, and Treatment — The Morphine Habit — Results and Treatment — The Chloral Habit — Ether-Drinking . , 359-382 CONTENTS. SECTION II. FUNCTIONAL DISORDERS OF THE ORGANS OF CIRCULATION. INTRODUCTORY CHAPTER. Peculiar Features of Functional Disorders of the Heart — Differences Between Functional and Organic Affections — Symptoms of Functional Disorders, Movements or Sensations of the Organ Affected — Disturbances of Rhythm — Causes of Functional Disorder of the Heart — Predisposing Causes — Dr. Shapter's Classification — Symptoms 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 Irri- table Heart— Study of the Cardiac Nervous Apparatus — The Intra-Cardiac Ganglia — The Pneumogastric Nerves — Cardiac Sensory Fibres — The Sympathetic Nerve — The Depressor Fibres of the Vagus — Summary of the Circumstances Affecting the Frequency of the Heart's Action 383-398 CHAPTER II. PALPITATION OF THE HEART. 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 — Treat- ment of Nervous Subjects — Treatment of Palpitation Due to Imligestiori and Gout — During the Intervals — Various Points to be Attended to 399-4H CHAPTER III. SYNCOPE— SWOONING— FAINTNESS. Syncope, Definition and Symptoms — Incomplete Attacks or Faintness — Dura- tion of Attacks — Causes, the Nervous System, the State of the Heait, the Condition of the Blood — Impressions on the Nervous System — Direct Effects on the Heart — Mechanical Causes, Poisons — Syncope Resulting CONTENTii. from Loss or Deficiency of Blood — Mixed Cases — Duration of Attacks — Syncope Distinguished from Epilepsy, Apoplexy, Shock, Concussions, and Poisoning — Prolonged Syncope — Prognosis — Treatment — Restoration of Action of Heart, and Supply of Blood to the Brain . . . 412-422 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 — Cases due to Alcohol — Prognosis and Treatment ...... 423-428 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 — Prog- nosis — Treatment, Relief of Attacks and During Intervals — Subcutaneous Injection of Morphine — Inhalations of Nitrite of A myl—Nitro- Glycerine Internally — Stimulants — Hygienic Measures — Arsenic — Treatment of Gouty Subjects ......... 429-443 SECTION III. FUNCTIONAL DISORDERS OF THE RESPIRA TOR Y ORGANS. INTRODUCTORY CHAPTER. Functional Disorders of Respiration — Nerves of Sensation or Motion Implicated — Disorders of the Voice — Hoarseness — Aphonia and its Causes — Laryn- geal Growths, Catarrhal Swelling, Paralysis of the Laryngeal Muscles CONTENTS. 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 — Connection between Cough and Affections of the Ear — Treatment ......... 444-455 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, Eclampsia — 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 456-463 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 — Sequelae — Diagnosis — Prognosis — Treatment During the Paroxysm, Narcotics and Anti- spasmodics — During the Intervals — Removal of Causes— Inhalation of Oxygen and of Condensed Air — Change of Air — Treatment of Gouty Cases — Purgatives — Alkalicrs — Iodide of Potassium — Electricity. . 464-484 CHAPTER IV. HAY-ASTHMA— HAY-FEVER. Hay-Asthma, Questions as to its Nature — General Description — First Recog- nized by Dr. Bostock — Causes, Predisposing and Exciting — The Pollen of Grasses, and of Various Cereals — Dr. Blackley's Experiments — Symptoms — Affections of the Nose, Eyes, and Throat — Cough and Difficulty of Breathing — Appearances of the Affected Parts — Diagnosis — 'IVcatment, Prophylactic and Curative ....... 485-492 CONTENTS. SECTION IV. FUNCTIONAL DISORDERS OF THE 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 ia 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 Digestion — Effects of Improper Food — Peculiarities in Certain Individuals — Effects of Nervous Exhaustion — Spasm of the Stomach and Intestines — Spasm of the CEsophagus — Perversion of Gastric and Intestinal Secretion — Effects of Nervous Influence- — Hepatic and Pancreatic Secretion — Effects of Nervous Influence on Intestinal Movements — Effects of Alterations in the Blood Supply — Enumeration of the Symptoms of Functional Disorders of the Stomach, and Intestines .......... 493-504 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 Condition 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 Suitable— Fluids— Milk Diet— Treatment of Constipation — Laxatives — Aloes, Cascara, Salines — Stronger Purgatives — Hygienic Measures as Change of Air, Exercise, Baths, Medicines such as. coy TENTS. Acids, Alkalies, Bismuth, and Charcoal — Treatment of Irritative Dyspepsia — Arsenic, Ipecacuanha — Question of Health-Resorts . . 505-539 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 Treatment as for Neuras- thenia — Perversion of Appetite — Appetite Abnormally Increased — Symptoms and Causes — Treatment — Diminution and Loss of Appetite or Anorexia — Case and Treatment — Depraved Appetite — Symptoms ami Treatment S4C-549 CHAPTER IV. GASTRALGIA— GASTRODYMA— CARDIALGIA. Pain in the Stomach as a Definite Complaint — Causes — Conditions under which it Occurs — Gastralgia in Gouty Subjects — In Locomotor Ataxy — Of Reflex Origin — Due to Renal Disease — Symptoms — Duration and Exciting Causes of Paroxysms — Spasmodic Form of Gastralgia — Diag- nosis, from Intercostal Neuralgia, Myalgia, Colic, Peritonitis, Gallstones, etc., and from Gastric Disorders, as Ulcer, Cancer, and Catarrh — Prognosis and Treatment — Laxatives — Quinine — Arsenic — Alkalies — Ipecacuanha — Morphine, Strychnine, Chloral, Electricity — Treatment of Gouty Cases 550-561 CHAPTER V. NERVOUS VOMITING AND ERUCTATIONS. Phenomena of Vomiting — Nervous Vomiting — Reflex Causes — Mental Impres- sions — Organic Nervous Lesions — Perijiheral Irritations — Disorders of the Abdominal Organs — Disorders of the Sexual Organs — Toxic Causes — Symptoms of Nervous Vomiting — Diagnosis and Prognosis — Treatment, Causal and Symptomatic — Ice, Anodynes, Cocaine, Bromide of Potassium, etc. — Nervous Eructations — Symptoms — Sources of the Gas — Case of Nervous Eructations — Treatment ...... 562-57 i CHAPTER VI. ENTERALGIA— COLIC— NEURALGIA MESENTERICA. Colic, Definition and Causes — Irritating Articles of Food — Gaseous Distension of the Abdomen — Drastic Purgatives — Lead and Cojiper— Colic as a Symptom of Nervous Disorders, and in connection with Gout and Rheumatism — CONTENTS. Colic due to Cold— Symptoms of Colic — Diagnosis — Prognosis — Other Forms of Colic — Neuralgia of the Bowels — Nervous Diarrhoea — Treatment — Aromatios and Stimulants — Warmth Locally — Opiates — Ipecacuanha — Purgatives — Enemata — Morphine Hypodermically — Treatment of Gouty and Rheumatic Cases — Treatment of Neuralgia of the Bowels — Anodynes, Tonics, Improvement of General Health, etc, ... . . 572-584 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 — Defecation — Consequences of Constipation — Chlorosis — Other Causes of Constipation and Disorders with which it is Associated — Surgical Causes — Habitual Constipation, Influence of Drastic Purgatives — In- sufficiency and Improiier Quality of Food — Diagnosis — Treatment of Constipation — Of Occasional Attacks — Castor Oil, Salines, Rhubarb, Calomel, and Senna — Enemata— Faradism — Treatment of Chronic Consti- pation — 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, Iriilin, Euonymin, and Leptandrin — Nitro-Muriatic Acid-^Belladonna — Enemata, their Drawbacks — Other Remedies — Caution as to LFse of Laxatives — Massage . . 585-607 CHAPTER VIII. DIARRHCEA. Diarrhoea, Conditions for its Production — Causes, Food, Cold, Mental Excite- ment, Summer Diarrhoea — Diarrhcea Accompanying Intestinal Lesions and Various Morbid Conditions — Persons most Subject to Attacks — Anatomical Appearances — Symptoms in Adults — Influence on General Condition — Severe Attacks — Diagnosis — Treatment, Question as to Arrest- ing Discharges — Sometimes Desirable to Facilitate them — Castor Oil, Sulphate of Sodium, Rhubarb, and Calomel- — For Checking Diarrhcea, Opium, Aromatics and Astringents, Camphor, Warmth, Stimulants — Chronic Diarrhoea — 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 Sur- face — Diet — Enemata of Warm Water — Calomel — Cautions as to Exces- CONTJEXTS. sive Feeding — Chronic Diarrhcea — Diet, Flannel and Warmth — Grey- Powder, Vegetable Astringents, Chalk, Bismuth, Perchloride of Mercury, Arsenic, Iron .......... 608-625 CHAPTER IX. CORPULENCE— OBESITY. Meaning of the Term — Causes — Manner of Production — Anatomical Appear- ances — Symptoms — Two Kinds of Corpulence — Diagnosis and Prognosis — Treatment — General Principles - Methods suggested by Banting, Ebstein, and Oertel .......... 626-639 CHAPTER X. FUNCTIONAL DISORDERS OF THE LIVER. Functions of Liver — Secretion of Bile, Formation of Glycogen and Metabolic Processes — Functional Disorders — Hepatalgia — Circulatory Disorder — Hyperaemia, Causes and Symptoms — Treatment — Biliousness and a Bilious Attack — Causes and Treatment — Disorders of the Secretory Function — The Saliva as a Test — Excessive Secretion of Bile — Symptoms and Treat- ment — 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 Functional Hepatic Disorder — Symptoms, Causes, and Treat- ment — Albuminuria in these Cases — Its Causes, Import, and Treatment — Cutaneous Affections in Lithaemia and their Treatment . . 640-663 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 DIMINU- TION OF Excitability — Cardiac Functional Disorder — Neuroses PROPERLY SO-CALLED EpiLEPSY AND ChOREA AS EXAMPLES OF NeL'ROSES — Absence of constant Structural Lesions in Epilepsy — Dr. Brown- ShguARD's Views — The Pathogeny of Chorea — No constant Struc- tural Alterations — Dr. Sturges' Views — Chorea a Functional Disorder — The causes of Functional Derangements — 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 Accommodation and Refraction as causes of Nervous Disturbances — Dr. Stevens' Views — Characters of Functional Nervous Disorders as distinguished from those of Organic Origin. In the various attempts to classify diseases, the terms "structural" or "organic" on the one hand, and "func- tional" on the other, have always found a place. Their general meaning is obvious ; the former term being applied B 2 FUNCTIONAL AND ORGANIC DISORDERS. to diseases in which the affected part is the seat of altera- tions more or less easily demonstrable, while a " func- tional '' 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 therefore contrasted, and the belief was once prevalent that a distinct line of demarcation existed between the two classes. No separa- tion 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 k)ioivn to be organic. In no department of pathology has this chanee 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 micro- scopical 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 cornua and of the anterior columns, and granular disintegration and atrophy of the anterior nerve-roots. FUNCTIONAL AND ORGANIC DISORDERS. Other instances might be adduced to show that in all probability disorders still regarded as functional are really dependent upon structural changes which our present means of observation are insufficient to enable us to detect. The discoveries hitherto made have caused some authorities to deny the occurrence of functional disease. They believe that " if the inquiry were carried far enough we should discover some morbid change to account for every disorder or complaint, even the slightest." They cannot imagine how any of the vital processes should fail to be carried on naturally, so long as every part of the body retains an absolutely normal structure. But, as Dr. Hilton Fagge expressed it, " it is fallacious to assume that things are impossible, because, when submitted to the scrutiny of our faculties, they seem to be inconceivable. The question is not whether an effect can arise without a cause, but whether the cause must necessarily be of one kind, because we know of no other kinds." It may, indeed, be doubted whether we shall ever be able to discover the actual anatomical conditions of those innumerable forms of per- verted function which in themselves constitute so many of the disorders of every-day life, and which cause so much pain and discomfort. 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 (wery part, and in the performance of everv 4 EXCITABILITY 11^ CREASED OR DIMINISHED. function, there are considerable differences within the limits of heahh, 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 ac-tion, without any recognized alteration of the nervous tissue. It may easily be supposed that, under such circumstances, a piece of nervous mechanism should act in an abnormal manner, and that the perverted action should be accompanied b}' other signs of disorder. Excitability is the common property of all 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 per- formance 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 statement may be illus- trated by a consideration of the effects produced by heat and cold. These agents often cause either increase ur EXAMPLES OF FUNCTIONAL CHANGES. 5 diminution of function as well as painful impressions ; but if these disappear on removal of the cause, and no permanent alteration results, the condition which was . temporarily set up can hardly be regarded as one of disease. Muscular fatigue constitutes another example of the same character. The term implies that condition of diminished capacity for work which is produced in a muscle by prolonged activity, and is due partly to con- sumption of contractile elements and partly to the accumulation of those products of decomposition which are formed during the activity of the muscle. After a time the condition, as a general rule, completely passes away ; but after excessive exertion it may be indefinitely prolonged. Nerves and nerve-centres are liable to be similarly affected, and it is not unlikely that many neuroses are thus caused. That considerable alteration in the action of a part may occur in the absence of structural change is abundantly evidenced in the case of the heart ; and in certain con- ditions 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 resist- ance to the onward flow of the blood, cases are sometimes seen in which the enlargement 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 6 i: PILE PS r AN EXAMPLE OF THE NE US OSES. abnormal activity of a normal function. As Niemeyer states, " in many persons suffering from cardiac hyper- trophy 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 hrst 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 affections the term " 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 con- nect 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 from the efforts that iiave 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 scat of epilepsy has been succes- sively placed in the cerebellum, the cornu Ammonis, the pons Varolii, the convolutions of the brain, etc. There is CHOREA AN JEXAMPLi: OF THE NEUROSES. 7 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 causing 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 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 differ- ences 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 irritation in the nervous centres, while other changes are the consequences of the oft-repeated paroxysms. The important 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 APPEARANCES FOUND IN CHOREA. 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 reader is referred to sub- sequent 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 manifestations of the disorder. The embolic theory of chorea, first advanced in 1S52 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. IJr. 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 fix(;d in the corpus striatum. Another authority on chorea, Dr. Dickinson, in his examination of seven fatal cases of the disorder was unable to d(;tect 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 decidedly implicated were those lying " between the base APPEARANCES FOUND IN CHOREA. 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 be 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 excellent 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 sick- ness, 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 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 con- trast to those of chorea. Additional evidence against the 10 CHOliEA A FUNCTIONAL DISORDEli. 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 insufficient to account for the symptoms, we may ask, with Dr. Sturges, whether the affection may not "be looked upon as a func- tional 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 intelli- gence never suffer from chorea, while the more complex the muscular employment, the greater the liability to suffer. There is therefore in chorea the withdrawal or impairment 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 movements which are constantly taking place, and especially in children who have not as yet CHOREA A FUNCTIONAL DISORDER. 11 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 controlling 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 mismovements 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 im[)art 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 of the functional hypothesis of chorea. Dr. Sturges refers to the frequent recurrence of the symptoms until adult life is reached ; to the starting- place of the movements, 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 sometimes 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 12 CAUSES OF FUNCTIONAL NFUVOUS DISORDERS. of this nature is a matter of the highest importance, 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. Pathology is often said to be the proper basis of thera- peutics; and this assertion is correct, provided that the former term be held to include not merely morbid anatomy, but the best attainable knowledge of the origin, course, and termination of the disease (Fagge). It must be admitted that the treatment of patients is often independent of theoretical views as to the exact nature of the affections ; the object in many cases is to rectify function, and thus to diminish suffering, to prolong life, and make it more com- fortable. 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, 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 continuance long after the exciting cause lias disappeared must be due to some pecu- liarity in the nervous organization, 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 HEREDITARY PREDlt^FOkilTWN. 13 disorder 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 predisposition,, that is to say, their members come into the world possess- ing a greater or less tendency towards afTections 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 irritability, a diminished power of resisting external influences, or lastly excessive elasticity of the vascular walls and a consequent tendency to hyperaemia. 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 predisposition is present or not. To establish its presence, it is not indeed necessary to discover a history of such typical nervous dis- orders as are described in text-books; evidence of marked peculiarities of psychical character may be all that is forth- 14 CAUSES OF FUNCTIONAL NERVOUS DISORDERS. coming and may yet be sufficient. Another factor of considerable importance is the intensification which almost any kind of tendency to nervous disorder derives from being common to both parents, as measured by the results too often witnessed of 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 im- pregnation 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 most potent factors are those which are connected with educa- tion. The influence of the early training upon the causation of nervous disorder on the one hand, and upon its pre- vention 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 tin; power of self-government is likely never to be acquired, and the j)assions will remain unchecked. The vaso-motor system of nerves is highly excitable in child- hood, and the indulgence of every unchecked passion causes hypememia of the brain and distension of the CAUSES OF FUNCTIONAL NERVOUS DISORDERS. 15 cerebral vessels. Frequent 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 con- tinuous mental strain and to sexual excesses. In the course of time another factor comes into play. The inhibitory centres in the brain, from want of exercise, lose their 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 elsewhere written on this subject. "Every age is characterized 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 industrial progress. Even in our recreations 10 .CAUHEiS OF FUNCTIONAL NERVOUS D/SOIiJDERS. there are evidences of a similar spirit." Thus it happens that many of our contemporaries fall out of the race with only 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 perpetuating nervous disorders, and in lowering the tone of the system, can scarcely be over-estimated. The imt)ioderate 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 continue the struggle. These agents stimulate the nervous system and enable it to get tlirough an abnormal amount of work, but as excitement is necessarily followed by debility the total result of the repeated stimulations is simply a lessen- ing of power. With regard to other agents, such as mor- phine 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 ta the operation of cold, and sometimes for the reason that no other cause is sufificiently obvious. As a matter of fact, there is a close connection between exposure to cold and certain nervous affections, but the statements of patients CAUSES OF FUNCTIONAL NERVOUS DISORDERS. 17 on this point should always be carefully sifted. There is no doubt that neuralgia is often provoked by exposure to draughts of air, and that the most common form of facial paralysis owns a similar causation. In our endeavours to discover the cause of functional nervous disorder we must not forget the influence of irrita- tion conducted from distant parts, and of pathological changes i?i other organs. It is only in comparatively 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 neuro- pathic predisposition, e.g., to epilepsy, disorder of the stomach, worms in the intestines, and very slight injuries may suffice to produce paroxysms. In a similar manner pathological irritation of peripheral portions of the nervous system, and particularly such irritation as is liable to occur in the digestive and sexual organs, not unfiequently gives rise to, and invariably exaggerates, other 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 necessary to mention the common effects of anaemia and of various exhausting diseases as examples of this kind. Neuralgic affections are often the results of exposure to malarious influences, and according to the statements of some writers are closely associated with that condi- C 18 CAUSES OF FUNCTIONAL NFRVOUS DISORDERS. tion 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 descended from gouty ancestors. In some families the male members are the victims of acute gout, while the females suffer from neuralgia in various forms, headache," etc. 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.* * For furilier details on the connection between gout and disorders of the nervous system the reader is referred to my work on " Gout and its K<.lations to Diseases of the Liver and Kidneys,'' Chajjler V. CAUSES OF FUNCTLONAL NERVOUS DISORDERS. 19 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 predisposition 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, maybe selected as an example. The continued and unnatural tension of 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 con- verge 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 20 CAUSES OF FUNCTIONAL NERVOUS UISORDE ItS. 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 irritation, and the practical value of this theorv of many 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 epilepsv, 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 tunctional nervous disorders, as distinguished from those of organic origin, will conclude this part of the 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 recur at regular or irregular intervals, during which the health is CHARACTERISTICS OF NERVOUS JJISORUERS. 21 often perfectly good. In organic disorders the principal :symptoms remain permanent, and variations in their intensity are slowly developed. A sudden improvement, •or even a rapid cure, is not unfrequent in functional dis- orders ; such changes are exceedingly rare in organic •diseases of the nervous system. These latter are often accompanied by certain symptoms of irritation of conduc- tors of sensitive impressions and of trophic and secretory nerve fibres, as evinced by various abnormal sensations .and alterations of nutrition and secretion of the skin and mucous membranes. In functional nervous disorders, with the exception of some forms of neuralgia, these latter •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. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. CHAPTER I. NEKVE-rKOS'lUATION— NEURASTHENIA -NERVOUS DEBII.II V. NrcnvE-PiiosTRATioN — Synonyms and Meaning of Tehm — Natukf. ani> Varieties — Pkevai.ence of Nervk-Prostration in England ani> in THE Uniteo States — Causes — Dr. Beard's Views — Neurasthenia AND LiTii.T.M lA — Hereditary Predisposition — Training and IIahits OF Young Subjects — Sexual Excesses — Influence of Sciiooi.work AND Competitive Examinations— Symptoms of Neurasthenia — Symptoms connected with the Cerebrum — Disorders of the Sensory Faculties — Spinal Pain — Neuralgia — Disorders of Special Senses — Various Kinds of MonniD Dread — Insomnia- Symptoms CONNECTED WITH THE MoTOR FACULTIES VaSO-MotOU DISTURBANCES — Disorders of the Circulatory, Respiratory, and Digestive Organs — Symptoms Referable to the Kidneys and the Organs of Generation — Peculiarities ok the Symptoms or Neurasthenia — Diagnosis and I'rognosis — Consequences — Treatment — Relief of the Sleeplessness — Electricity— Question as to Is)i.ation — Freedom from Mental Exertion — Amusements and Exercise — Changes of Air and Scene — Travelling — Diet — Avoidance of Tobacco and Excess in Stimulants — Sedatives and Tonics — Hvdrotiierapeutics in Varioi's Forms — Electricity- — The Weir Mitchell System — Rest, Isdlation, Excessive Feeding, Massage,. AND Employment of Electricity — Cases in which Indicated — NERVE-PROSTRATION. 23 Details of Treatment — Duuation of Treatment and Results, WITH Illustrative Casks — Cautions as to Adoption of Treatment IN Cases of Organic Disease and Mental Disordicr — Drawbacks connected with the Weir Mitchell Plan. Neurasthenia or nerve-prostration is a constitutional neurosis, affecting the whole system. The term has many- other synonyms, e.g., nerv^ousness, general debility, nervous debility, nervous exhaustion, spinal weakness, spinal irrita- tion, etc. It denotes a condition in which weakness of the nervous apparatus is associated with undue irritability ; excitement 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 dis- order 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 great nervous centres. Neurasthenia is often associated with various chronic disorders ; but still more frequently such complications are absent. It is a predisposing cause of hysteria, chorea, insanity, and other nervous affections ; but for the most part exists independently, and without inducing any such consequences. 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 nine- 24 CAUSES OF NERVE-PROSTRATION. teenth century civilization they have become very common, and in not a few ca'^es very serious, by reason of the suffer- ing and incapacity with which they are associated. 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 reputa- tion. One of their physicians. Dr. G. M. Beard, has given us an exhaustive description, drawn from his great experi- ence, of this complaint. Causes. — With regard to the causes of neurasthenia, it may be stated ihat 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 world. In all the Northern and Eastern States sufferers from neurasthenia "are to be found in nearly every brain-working household." In order to exhibit in a graphic manner the causes of American nervousness, he makes use of the following algebraical formula : — Civilization in general -f American 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 proncness to be swayed by inclinations and passions = neurasthenia or nervous exhaustion. Similar causes are common enough in England, and especially in CAUSES OF NERVE-PROSTRATION. 25 the large cities ; probably London contains as many in- stances 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. The condition known as lithsemia is not unfrequently associated with some of the symptoms of nervous exhaus- tion, e.g., depression, loss of mental power, irritability, constipation, cold hands and feet, heaviness of the head, etc. ; and hence it has b( en supposed that neurasthenia may sometimes be caused by excess of uric acid in the blood. The two conditions may doubtless co-exist, each tending to aggravate the other ; but there is a marked dis- tinction between them, and they are by no means neces- sarily associated. The treatment of the two affections is, of course, very different. 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, anxiety, and mental strain ; an insufficient amount of rest and sleep, often coupled with improper and insufficient food ; prolonged exposure to severe heat ; excesses of all kinds, and especially indulgence in alcohol and tobacco. In a smaller, but probably increasing number of cases, the symptoms are due to the abuse of narcotic and sedative 26 CA USES OF NE R TE-P R OSTRA TION. drugs, and especially of morphine and cocaine. The patients are often of a nervous temperament, and are the subjects of he7'cditary predisposition to nervous disorder, and this latter is one of the most powerful factors in the production of neurasthenia. Even when hereditary predis- position clearly exists, the symptoms not unfrequently remain latent until fanned into activity by some serious trouble or bodily or mental strain, whose effects would have passed away had no such tendency existed. Heredity also makes itself felt in the obstinate character it imparts to the symptoms and in the frequent relapses. 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 io excess in alcohol, and the like, the result may be the development of any of these maladies, 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. 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 symptoms of hysteria and melancholia became developed. Much im- provement has taken place under the influence of kindly discipline, cheerful society, good food, and tonics. CA USES OF NER VE- I'M OS TRA TION. 27 There can be no doubt as to the influence of the training and habits of young people upon the production of neuras- thenia, 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 convulsions 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, stealings cruelty to other children and to animals, marked insubordi- nation 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 may result not only in fixed habits, but in other serious perversions of the moral faculties. Sexual excesses are a potent cause of neurasthenia, and especially in young subjects. Still more mischievous in this respect is the habit of masturbation, which almost invariably tends to a reduction of the mental and bodily vigour. Loss of capacity for continuous exertion, impair- ment of memory and diminution of energy are the earliest results, and these are apt to become aggravated by fore 28 CAUSi:S OF NERVE-PROSTRATION. bodings of grave and even incurable consequences. Self- reproach and recourse to quack remedies (while the habit perhaps is still practised) too often serve to complete the mental and bodily downfall. In not a few cases school-ivork 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 every v/here in vogue at the present time ; to the so-called ''cramming" with all its unwholesome acces- sories, and to the anxiety, loss of sleep, and disappointment which are so often superadded to the results of extra- ordinary efforts. The prevalence of headache and of dis- orders 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 neuras- thenia was purely the result of over-fatigue brought on by competitive examinations at school. We are told that in America the "social engagements" of the pupils add not a little to the pressure imposed upon them by their studies. Neurasthenia is most common among the upper classes, and among those persons who depend for their livelihood upon the exertion of their mental faculties. It is not found to any very great extent in charitable institutions, and is quite rare among that class for whom such institutions are organized (Beard). Reference has been made to the prevalence of neuras- thenia in America. According to Prof. Ziemssen, the CAUSES OF NERVK-I'ROST RATION. 2* Semitic race is decidedly predisposed to the development of this complaint. A general neurotic tendency is pre- valent among the Jewish people, notwithstanding their capacity for work and the patience and energy they so- often display. They are easily affected by misfortunes, and neurasthenic symptoms are apt to appear suddenly^ assuming the form of intense mental depression. The same authority stales that neurasthenia is very common in. Russia, especially among the upper classes. The prominent symptoms of neurasthenia usually show themselves in earlv middle-age ; by that time the various causes have generally been at work long enough to produce their effect. Dr. Beard states that they are most common between the ages of fifteen and fifty ; they are rare, and of a different character at the extremes of life. It may, there- fore, be assumed that an intimate relation exists between neurasthenia and the reproductive system. Much, of course, depends upon the constitution, habits, and sur- roundings of the individual. The accession of the sym- ptoms is liable to be hastened by the outbreak of some febrile or other disorder, which even in a fairly vigorous person is wont to leave a condition of debility in its train. The clinical symptoms of neurasthenia are peculiarly liable to variations in kind and degree. In mild cases there may be only slight weakness of one portion of the nervous system ; in severe types the condition is one of general and profound exhaustion, and between these ex- ,30 SYMPTOM H OF yiillVE-PROST RATION. tremes innumerable gradations exist. Almost any great nervous centre may become affected, either alone or in combination with others, and the protean character of the malady is not more remarkable than the changes which it sometimes undergoes in one and the same patient. The onset of the symptoms is almost always gradual, although in some cases they appear to be very rapidly developed. In such instances it will generally be found that the pre- monitory symptoms have been altogether ov(?rlooked, or their import mistaken. Symptoms. — In order to present a complete account of the symptoms of neurasthenia, it is necessary to divide them into groups, according to the portions of the nervous system which are peculiarly affected. " Neurasthenia attacks, or is liable to attack, all functions and organs." The first group contains those symptoms which are refer- able to disorder of the brain, and take the form of psychical changes. The second comprises symptoms pointing to implication of the s])inal system ; these will be considered in a subse([ucnt chapter. The third category includes those symptoms whic.h are manifested chiefly in the thoracic and abdominal organs. It must, however, be clearly understood that symptoms belonging to all these classes are liable to occur in th(' same patient. I. Symptoms connected with the cerebrum. — Incapacity for mental effort , as shown by inability to concentrate the attention in the manner desired, is a decidedly frequent SYMPTOMS OF NEItrE-PROSTRATION. 31 symptom. It appears in many forms, sometimes being of a general character, and sometimes noticed especially in connection with the patient's employment. Thus in the case of an accountant suffering from nervous exhaustion due to overwork, arithmetical calculations, previously quite easy, are found to be impossible ; any attempt of this character results in mental confusion, headache, a sensation of swimming before the eyes, and other troubles. A clergyman finds himself quite unable to compose a sermon ; he makes repeated efforts, but the mind wanders away from the subject, and refuses to remain fixed upon it. Some patients are much annoyed at finding that after reading a short paragraph in a book or newspaper they fail to remember its contents. They imagine that the fault lies in the memory, but the inability is due rather to a want •of perception. In yet another class of cases, the mental impairment is shown by the speedy exhaustion of the faculty of attention. The patient sets himself about his task, and for a short time all goes well ; soon, however, that which at first was easy is found to be difficult and irksome, and the work has to be relinquished, notwith- standing an intense desire for its accomplishment. Mental irritability is another symptom often associated with those above described; it is only too likely to be their direct consequence. The patient is vexed at discovering that a task formerly pleasant and easily accomplished has become difficult or even impossible, and he exhibits his 32 SYMPTOMS OF NERVK-PliOSTRATWN. annoyance in a variety of ways. He is either silent and reserved, and broods over his troubles, or he dwells upon them in conversation, and shows by his action and manners the influences by which he is swayed. He becomes excited and anxious about the merest trifles, which at a former time he would have scorned to notice. Anything that affects him in any way is liable to be misconstrued, and converted into a cause of irritation, anxiety, or distress. In not a few of these cases the condition becomes aggra- vated by the means foolishly adopted for its relief. The jjatient finds that a little alcohol effects for the time a greater or less improvement ; under its influence his faculties become clearer, and his mental energy is increased. Even if he have some knowledge of the almost certain con- sequences, he is apt to put aside his forebodings, and to flatter himself that no permanent harm i'^ likely to result.. Sometimes the individual regards himself as the victim of cruel necessity ; the work has to be done, and stimulants alone will enabh; him to do it. I'ndcr such circumstances the almost invariable result is a terrible anfl rapid increase of the symptoms of cert^bral exhaustion. Morphine is sometimes taken for a like ])urpose ; but in a far larger jjropcjrtion of cases this drug is used to drive away irrita- bilitv and to procure sleep. The jjosition becomes mani- festly worse, and less capable of being remedied, when both alcohol and morphine are employed for the relief of t erebral neurasthenia. SYMPTOMS OF NERVE-PROSTRATION. 33 Together with the symptoms above described, sufferers from cerebral neurasthenia are apt to complain of disorder of the sensory faculties^ showing itself in hypersesthesia, and various other alterations indicative of excessive irrita- bility of the sensory nerves and nerve-centres. Hyperaes- thetic spots can often be detected on various parts of the body, and the whole cutaneous surface is sometimes more sensitive than usual to contact with hot and cold water and solid substances in general. I have seen several patients 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 occa- sionally become so tender that contact with her silk vest proved almost unbearable. Such patients often experience actual pain, especially in the head and back and along the spine. Pain in this last-mentioned situation, both spon- taneous and excited by pressure, is the preaominant 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 conhned to 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 D 34 SI' MP TO MS OF NERVE-FIIOSTRATIOJS. 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 vertebra?. The pain is sometimes 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. Perhaps more common than actual pain is a sensation of fulness, tension, or prcss2ire, either diffused over the head or confined to certain parts, such as the vertex and occiput. Decided tenderness of the scalp sometimes exists so that acute pain is caused by brushing the hair. Dr. Beard states that a tender spot is often found over the eyebrow and in the left temple. It is most common in patients subject to migraine, and any sudden jar is liable to cause temporary pain, as though the head itself had been struck. These symptoms are generally intermittent or remittent in character, and are prone to be induced by mental effort, excitement of various kinds, and bodily fatigue. Sick headache is closely allied to this group of symptoms, and the attacks are in some cases the most prominent features of the complaint. Occasionally, as Dr. Beard observes, they may be regarded as a safety-valve, inasmuch as they necessitate rest, and may thus prevent other and more serious affections. SYMPTOMS OF NFRrE-FROSTRATION. 35 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 migra- tory 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 more or less commonly observed. A peculiarly dull look, ■expressive of debility, is apt to be associated with the red- ness of the conjunctivae, due to sleeplessness. The pupils are generally dilated, but move freely ; sometimes in- equality is noticed. Intolerance of light, exposure to which causes headache ; weakness of vision ; ntuscas volitantes and flashes of light before the eyes are not un- common. The neurasthenic asthenopia is a source of great distress to the patient ; it would seem to be of a purely functional character, for no definite change can be detected on examination. Attempts to use the eyes, as in writing or reading, but more especially in the former, cause painful sensations in the eye-balls, and after a little while the print or writing becomes indistinct or blurred. A feeling of heat in the eyes is often associated with the weakness of vision ; the conjunctivas are congested, as if 36 S IMPTOMS OF NJER VE-PR OS TRA TION. irritated by the presence of some foreign body. In neurasthenia due to sexual excesses, this form of asthe- nopia is sometimes a very prominent symptom. Not a few examples are to be found among candidates for our various examinations, and many rejections are doubtless traceable to this cause. Other troublesome symptoms are connected with the organ of hearing. This sense is sometimes preternaturally acute, and subjective sensations of buzzing, ringing, or pulsations in the ears are frequently experienced. The rushing sound of the blood during increased cardiac action, or when lying in bed at night, is very troublesome and alarming to some of these patients ; and all these subjective phenomena tend still further to impair the mental powers. Tinnitus is, of course, a frequent sym- ptom in many forms of ear disease, and whenever it is complained of the ear and throat should be carefully examined. Whatever may be the actual condition of the various parts of the organ of hearing, tinnitus would appear to be always connected with some modification of the " pressure equilibrium " of the ear. This result is pro- duced by the two opposite conditions of hyperaemia and anaemia. In neurasthenic patients with no discoverable aural lesion, the tinnitus is presumably due to decrease in the blood-pressure. In cases of chlorosis and in persons reduced by severe ha--morrhage, noises in the cars arc very common. SYMPTOMS OF NERVE-FROSTRATION. 37 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 society 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 of these patients are averse to remain in rooms with doors and windows closed ; others are in per- petual fear of sustaining some injury, as by lightning or some convulsion of nature. Hallucinations and illusions are rare in all these cases, and many of the patients are fully aware of the groundless nature of their fears. These morbid fears vary considerably in degree, and are connected with many objects. On this account various terms are used to define them. One of the most common is that described as agoraphobia, or fear of places. This expression is, however, used to cover several varieties of morbid fear. Some patients thus affected dread to cross open squares or wide streets ; but the fear generally vanishes when they are aided by the arm of a companion. In other instances this fear of places is associated with the recollection of some unpleasant incident. The patient, for example, dreads to revisit the spot where the symptom was first experienced. In another phase of morbid fear the sufferers dread to mingle with a crowd. If they venture to go to a theatre or to a concert they must obtain a seat near a door, so that they may leave without 38 SYMPTOMS OF NERVE-^ROSTRATIO^\ difficulty when the feeling comes over them. Another condition is entirely opposite to that just described ; the patients are so much alarmed at being alone that they dare not leave the house without a companion. Some of these persons find it intolerable to travel alone in a railway carriage. Another common symptom of this character is the morbid fear which is experienced on ascending a height. This is by no means confined to neurasthenic subjects, but it is often strongly marked in such cases. Even at a very slight elevation, and when there is no real danger, such persons become giddy, and feel as though they should fall,^ or as though they must throw themselves over. An indefinite fear of their fellow men is another phase, per- haps less often met with, though Dr. Beard states that in not a few instances this fear of man is so severe as to compel patients altogether to relinquish business. " I know a number of cases where men of strong muscles, and having the appearance of great physical strength, have been compelled, through this symptom alone, to withdraw from the occupations in which they were en- gaged. They could not face men, deal with them, per- suade them to buy and sell, or have any influence over them. They dreaded to meet a human being." This form of morbid fear is often accompanied by aversion of the eyes and face, and hanging down of the head. Some of these patients, if l(,'ft to themselves, would re- SYMPTOMS OF NERVE-PROSTRATION. 39 main within doors for weeks or months at a time, perhaps stealing out occasionally at night, so as to avoid all chance of recognition. In another class of cases the morbid dread has reference to natural phenomena, such as storms, lightning, earth- quakes, etc. ; a fear of contamination from dust or dirt is another phase which is sometimes noticed. Morbid fear of diseases, and especially of infectious complaints, is sometimes a prominent and a very annoying symptom. This phase of the disorder closely resembles hypochon- driasis, which, indeed, is regarded by some authorities as a decided indication of neurasthenia. The differences between the two conditions will be noticed under the heading of Diagnosis. It seems unnecessary to refer to other phases of morbid fear; those which are most common and most important have been already alluded to. All may be regarded as symptomatic of functional disorder ; they are not of the nature of delusions, for the patients are quite conscious that their fears are groundless, and are ready to adopt any plan of treatment recommended by their medical adviser. The morbid fear is rarely an isolated phenomenon, but is generally associated with such symptoms as dizziness, pain, or a feeling of sinking at the pit of the stomach, flushing of the face, perspiration of the hands, dilated pupils, insomnia, etc. But whatever may be the character of the concomitant symptoms, the morbid fear, as a 40 SYMPTOMS OF NEJiJ'E-PROSTRATION. general rule, far outweighs them in the patient's esti- mate. Insomnia is frequently associated with morbid fears, and is sometimes their direct consequence. The feeling of alarm keeps the patient awake, or so blends with his dreams that sleep is taken only in brief snatches. Palpita- tion of the heart, sensations of flushing, and cutaneous irritation, a feeling which can only be described as one of fidgetiness, or inability to keep still, are often super- added to the morbid dread, and tend to make sleep impossible. These symptoms are, of course, not peculiar to neurasthenia ; they are provoked in many healthy persons, as a result of excessive mental strain or anxiety. In such cases, however, they are wont to subside after removal of the cause, which is easily discoverable. In a neurasthenic subject the symptoms are quite dispropor- tionate to the exciting cause, which, indeed, as a general rule, has no real existence. Disturbed sleep is, however, very common in neuras- thenic patients who are quite free from any morbid sensation of dread. The disturbance, indeed, may amount practically to utter sleeplessness, and it tends, perhaps more than anything else, to aggravate all the other symptoms. Examples of this condition arc common among men who have overtaxed their brains f(jr lengthened periods, and, at the same time, have been more or less irregular in tlu'ir habits of life. In some of SYMPTOMS OF NERVE-PllOSTliATION. 41 these cases the patients remain awake for hours after going to bed ; in others, they fall asleep easily, but wake in an hour or so, and continue in that condition, perhaps, until it is time to rise. Even the sleep that is obtained is apt to be disturbed by dreams and nightmare, and the patients are wont to assert that they leave their beds more languid and tired than when they sought them. This latter effect is doubtless experienced by some of these patients, but there are others who are capable of sustained and severe mental exertion for long periods, and with no apparent exaggeration of their general condition, in spite of the fact that they never obtain more than three or four hours' sleep. As time goes on, however, fresh signs of failing strength make their appearance, and unless the insomnia be promptly attended to and overcome the neurasthenia will assume a very serious type. Re- ference will again be made to these cases in the chapter on Insomnia. A symptom of an opposite character, viz., drowsiness, is sometimes very troublesome, but it is far less frequent than insomnia. Patients sometimes describe their sleep at night as abnormally profound, but complain that they are so little refreshed by it that they remain drowsy and lethargic during the day, unable to attend to business, and falling asleep after making the slightest effort. Sustained attention becomes impossible, even if the drowsiness is not succeeded by positive sleep. Dr. Beard was probably 42 SYMPTOMS OF NERVE-PROSTRATION. right in thinking that this condition is not necessarily associated with cerebral anaemia. Symptoms connected with the motor faculties. These are occasionally 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 nerv^ous 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 discom- fort, and that this feeling becomes so marked that persever- ance 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 for the slightest degree of over-exerlion. The weakness of the muscles is often still more clearly demon- strated by uncertainty of their action, less frequently by tremulous movements, and, in exceptional cases, by true paralyses. In many cases of neurasthenia evidence of muscular debility is altogether wanting. The patients may seem to be languid, but are able to take long walks, and are temporarily benefited thereby. Convulsive twitch- ings of muscles and of muscular fibres are not unfrequent, and chorea-like movements are sometimes noticed in the muscles of the face, and especially in those about the ,S' r3IF TOMS OF NER VE-PR OSTRA TION. AS- 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, and of convulsive action of the intercostal and abdominal muscles. 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 by a medical friend to see a gentleman aged forty-four, in whom, after a long period of anxiety, very marked and trouble- some 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. These attacks were wont speedily to pass off and to be followed by convulsive twitchings of the muscles of the face. Symptoms indicative of vaso-motor disorder are of con- stant occurrence in the subjects of neurasthenia, many of whom are much annoyed by the blushes which are involun- tarily 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 have recently been attending a gentleman full of courage and energy, and yet liable to outbreaks of cold, clammy 44 SYMPTOMS OF NEIlVE-PEOSTliATION. perspiration during important interviews, and even on the receipt of a letter containing unexpected intelligence. The blushing sometimes extends not merely over the face, but also to the ears, neck and other parts of the body. In marked cases, it is apt to be accompanied by twitching of some of the facial muscles, confusion of thought, and stammering when the attempt is made to speak. Of course, it is only when blushing is excessive and occurs in the absence of a sufficient cause that it is to be regarded as indicative of neurasthenia. Occasionally the redness is unilateral and associated with obvious pulsation of the superficial arteries, and sometimes the opposite conditions of redness and pallor rapidly alternate. Hereditary predisposition is traceable in some of these cases; even in early childhood there is sometimes a marked tendency to blush on the slightest provocation. The tendency increases with age, and the habit is liable to become a source of much incon- venience and distress. A curious phenomenon is notice- able in some of the cases ; a sudden shock, such as would cause most persons to become pale, instantly produces redness of the face and neck. The effect of mental exer- tion, on the other hand, is rather to lessen than to increase the redness. A feeling of anxiety, with increased force and frequency of the heart's action, generally co-exists with the cutaneous symptom. Abnormal perspiration is another symptom belonging to this category ; it is often associated with morbid blushing. SYMPTOMS OF NEllVE-PltOSTllATlON. 45- The hands are the part usually affected ; emotion or excite- ment causes a profuse perspiration to break out over the palms. Dr. Beard records a case in which periodicity was clearly observable, the perspiration recurring twice daily. In another instance, " the slightest emotion would instantly saturate the hands as thoroughly as dipping them in a pail of water. The effort to shake hands is sufficient to produce this effect." In another class of cases, the increase of perspiration is exhibited mainly on one side of the head, and this condition is sometimes accompanied by other nervous phenomena, e.g., redness of the face on that side and contracted pupil. The phenomena may not be limited to the face, for cases have been noticed in which the increased sweating affected the whole of one side of the body. II. Symptoms m.anifested in the thoracic and abdominal organs. — Other symptoms connected with the circulation are indicative of disordered action of the heart, and these are wont to come on very suddenly and to produce much anxiety. As a result of emotion or excitement, even of the slightest kind, or of bodily exertion (and, in some cases,, when no such causes are traceable), the heart's action becomes very quick, frequent, and intermittent, and the change is accompanied by much distress and a variety of uncomfortable or painful sensations in the thorax and head. The pulsations of the heart are distinctly felt by the patient,, and are attended with more or less severe pain in the region 46 SYMPTOMS OF ^ERVE-PROSTRATIOJS. of ihe apex. The patients are apt to describe their sensa- tions in emphatic terms, e.g., a. feeling of "tearing" or *' twisting " with every contraction, or as though the heart were forcing itself up towards the neck. The rush of blood to the head, the throbbing of the cervical vessels, and the noises in the ears are much dreaded. Pulsation in the abdomen is a not unfrequent symptom, and a similar sensation is sometimes experienced over the greater part of the body. In some cases, the attacks are aggravated by giddiness, nausea, and a sudden feeling of exhaustion as if death itself were impending. It is difficult to persuade such patients that there is no organic disease, although they are conscious of the fact that all the symptoms are wont to disappear under favourable conditions, and especially such as pleasantly influence the mind. When the attacks are very severe, they form the gravest symptoms of neuras- thenia. I'hey will be somewhat more minutely discussed in the chapters on Neuroses of the Heart. The respiratory organs are less commonly affected, but they sometimes exhibit manifest evidences of disordered function. There are certain changes in tlie voice which Dr. Beard regards as characteristic; the chief peculiarities are its " softness, faintness, want of courage, and clearness of tone. A neurasthenic sufferer may have the muscles of an athlete, yet speak in a voice which in quality and volume of sound suggests the beginning of convalescence from a sc-vere fev(;r." In many nervous patients words are SYMPTOMS OF NJiltVE-P HOST RATION. 17 pronounced in a low tone and hesitating manner ; any special effort to express thought causes dryness of the mouth and throat, and this in its turn renders speaking more and more difficult. 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 of consumption is often excited. In a case of this kind, 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 disappeared after a few days' treatment with quinine, bromide of potassium, and hydrobromic acid. An intense desire for air is sometimes noticed in these patients. When indoors they complain of feeling as though they were being stifled, and sit before an open window in order to obtain relief. Disorders of the stomach and bowels are very common in neurasthenic subjects, and occur in various forms. In some cases indigestion is the first symptom, and some time may elapse before other complaints are superadded. Its manifestations are almost endless. Loss or perversion of appetite, discomfort or pain in the epigastrium, of various kinds and degrees, flatulent distension, eructa- tions, nausea, and vomiting are the most prominent symptoms referable to the stomach. The dyspepsia is characterized by its sudden and casual onset and rapid 48 Si'MFTuMS OF NElirE-FROSTRATlON. subsidence ; by its association with other nervous sym- ptoms ; and by the relief afforded by sedatives and by articles of food which would aggravate the symptoms of gastric catarrh. Dr. Beard states that " in nervous dyspepsia the patients feel worse when the stomach is empty and are relieved by eating. Patients of this class have the greatest distress before meals, or when a meal is long delayed; even over-eating is a relief to them." This description is certainly true of some cases ; but in others the symptoms come on after eating, though, perhaps, not until several hours have elapsed. The appetite is generally capricious ; it is sometimes excessive or voracious. The patient's descriptions of the quantity of food taken are often very inaccurate and misleading. Assertions to the effect that the appetite is entirely gone, and that only a few mouthfuls of food are taken in the twenty-four hours, should never be accepted in the absence of corroborative testimony. Capriciousness of appetite is sometimes very marked, and the ingenuity of friends is severely taxed in the effort to provide sufficient nourishment for the patient. The; symptoms not unfrequently undergo a decided change for the better, when the j)atient's mind is plea- santly occupied. Thus, when alone or with dull com- panions, food of any kind may l)e simply repulsive, and, if taken, may induce a host of painful sensations. But the same food, taken in the company of congenial associates,. S Y3IPT0MS OF NER VE-PROST.RA TION. 49 may be not only enjoyed by the palate, but digested with ease and comfort. This experience has been found to hold good even in regard to food which persons with normal gastric powers would regard as indigestible. The beneficial effects of change of air and scene, in the cases under discussion, are, to a large extent, due to the altered mental impressions. It is a somewhat remarkable fact that in many neuras- thenic cases, wath dyspepsia as a prominent symptom, the appearance is that of good health, and nutrition seems to be unaffected. When, however, the gastric symptoms are very severe and cause the patient to abstain from food, evidence of ill-health soon becomes unmistakeable. When vomiting frequently occurs and the bowels are obstinately constipated, the symptoms are likely to give rise to a suspicion of cancer of the stomach. But the absence of any objective symptom, the history of the case and the improvement which follows suitable treatment will serve to demonstrate the true nature of the malady. Flatulent distension of the bowels and constipation are often associated with the gastric derangements, and cause much discomfort. Some of the gases are doubtless derived from the contents of the intestine, by fermenta- tion; but it is not impossible that a secretion of gas from the blood sometimes takes place. The distension of the bowels diminishes the contractility of the muscular coat, and hence the gases are retained. From experiments on E 50 SYMPTOM fS OF NERVE-PllOSTRATLON. animals, Professor Ziemssen has shown that, after long- continued and excessive distension, not only motor im- pulses from the automatic centres, but even electric currents produce no effect on the calibre of the intestines. No gas is expelled, although there may be no obstacle to its passage. Only after a portion has been absorbed and the tension has become reduced does the automatic impulse make itself felt : at first the movement is very slight and irregular, occurring, perhaps, only once in a minute. Neurasthenic patients often complain of pain or discomfort in the back, below the shoulder-blades, at points corresponding with the transverse colon and especially with its flexure on each side. C onstipation aggravates the discomfort ; the retained faeces and secretions undergo decomposition, by which more gases are produced, while the absorption of effete material exerts a pernicious influence upon the body and mind of the patient. Closely connected with disorders of digestion is the early and rapid decay of the teeth, which Dr. Beard electric excitability of nerve and muscle is in no way modified. A neurasthenic patient may be regarded as an example DTA GNOSIS OF NER VE-PROSTRA TION. 55 of hypochondriasis, and the two disorders may, of course, co-exist, but there are essential differences between them. In the latter, the sufferers reason incorrectly as to the cause and gravity of their symptoms, and refuse to be persuaded that their fears are groundless. Any discussion on these points is only too apt to make them still more alarmed and uncomfortable. In neurasthenia, on the other hand, the patients may exaggerate the importance of their symptoms, and attribute them to an impossible cause. They are, how- ever, quite willing to be set right ; and, once convinced of their error, their suspicions may altogether vanish. A morbid dread of disease is, however, an occasional symptom of neurasthenia, and when present the patient is justly regarded as hypochondriacal. The symptoms of neurasthenia sometimes resemble those of hysteria, but there are decided differences between the two conditions. In the latter, the symptoms are wont to appear and subside rapidly, the paroxysms being often well-marked. They are rarely witnessed in males ; they continue for an indefinite time, and are not necessarily accompanied by signs of physical debility. Hysteria is liable to assume the more serious aspect, inasmuch as paralysis and spasmodic attacks are often prominent symptoms ; but severe forms of neurasthenia would appear to be connected with graver states of disorder of the nervous system. There are some points in common between neurasthenia 56. 'PROGNOSIS OF yJSRTE-PROSTRATION. and the debility due to anaemia, but the two conditions are not identical. In the former, the patients are not necessarily pale and bloodless ; they are, indeed, sometimes plethoric. There are no cardiac murmurs. They often complain of insomnia and mental depression, and of incapacity for mental effort. Anaemia, moreover, is frequently associated with organic lesions, and physical exhaustion, breathlessness, and faintness in various degrees are the symptoms which distress the patient. The differences between cerebral and spinal neuras- thenia will be described in the next chapter. It is sufficient here to mention the principal distinction, viz., that in the cerebral disorder physical exertion is, in many cases, not only possible, but enjoyed by the patient. In spinal neurasthenia, all the symptoms are liable to be aggravated by exercise, and in proportion to its amount and severity. It must, of course, be remembered that the two conditions are not unfrequently associated. Prognosis. — The symptoms of neurasthenia may last for an indefinite time; in slight cases they are apt to sub- side and recur at uncertain intervals. \\\ the more severe forms, unless proper care and treatment are employed, the condition, in most cases, gradually becomes worse, and causes much anxiety to the patient and friends. Here again improvements and relapses are wont to alternate, and nothing definite can be stated as to the probable duration of the complaint. The condition is not serious so FItOGNOSIS OF NERVE-PROSTRATION. 57 far as danger to life is concerned ; but it may prove to be the starting-point of grave nervous diseases. Many of the symptoms are capable of prompt relief; thus the sleepless- ness, which is liable to become habitual, often yields to properly directed treatment. Marked hereditary, predis- position to nervous affections causes the prognosis to be somewhat unfavourable ; such cases are often severe and obstinate. When an obvious cause exists and is capable of removal, a hopeful prognosis may be given. It is, of course, necessary to take into consideration the general state of the patient, the surrounding circumstances, and the duration of the symptoms. With regard to the possible consequences of neuras- thenia, the complaint, as already mentioned, may be followed by some definite chronic form of nervous disease ; but such cases are decidedly exceptional. Myelitis, multiple sclerosis, ataxy, and muscular atrophy are some- times preceded by certain of the symptoms of neurasthenia, and especially by those of the spinal form. As a general rule, however, even severe and chronic cases of neuras- thenia recover under suitable treatment. Mental disorder, in the forms of melancholia, hysteria, and hystero-epilepsy, was regarded by Dr. Beard as a not uncommon sequence of neurasthenia, and the same authority considered that the frequency and increase of inebriety and of the opium habit were in large measure traceable to the increasing " nervousness " of the age. The feeling of debility or 58 TREATMENT OF NERVE-PROSTRATION. prostration gives rise to an irresistible desire for stimulants, while the mental depression and hopelessness, or perhaps the neuralgia, excite a craving for opium. When either habit has become established, the prognosis is, of course, very serious. Treatment. — It is a comparatively easy task to lay down the general principles of the treatment of neurasthenia ; but it is often very difficult to apply such principles to individual cases. The condition is that of weakness of the nerve-centres ; but this is not all, their irritability is at the same time greatly increased. In a general way, therefore, the treatment should be directed towards strengthening and soothing the nervous system. Minute inquiry must be made into the history of the complaint, the mode in which the symptoms have become developed, and the patient's manner of life, especially with regard to occupation, mental and moral conditions, diet and exercise. Provided that no organic disease is discoverable 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 pre- scriptions are attended to in all respects. In cases in which sleeplessness is a marked symptom, and is evidently causing TREATMEIST OF NERVE-PROSTMATION. 5{> 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 and seda- tives. The former constitute a somewhat numerous class, and the selection of a suitable hypnotic agent is often a matter of difficulty. The list includes opium and its pre- parations, chloral, the bromides, chloralamide, paraldehyde, sulphonal, and urethane. Of these, the bromides and chloral are, perhaps, the most serviceable, and a combination of these remedies is often better than either taken alone.. They should, however, be withheld, unless the physician feels confident that the patient is really suffering from insomnia. It is then best to give a full dose, say twenty grains of the bromide of ammonium and fifteen of chloral^ every second, third, or fourth night, according to circum- stances, the object being to secure to the patient several hours of sound continuous sleep. For less severe cases I frequently order the three bromides, seven grains of each^ with half-a-drachm of aromatic spirit of ammonia, or the bromide of ammonium, with eight or ten grains of chloral. If the effect be satisfactory, the medicines should be given at longer intervals, or in smaller doses. The production of sleep greatly assists the action of other remedies, but hypnotics of any kind should be regarded as exceptional auxiliaries, to be employed only in emergencies and to be discontinued as soon as circumstances will permit. When the insomnia is principally due to pain, morphine €0 TREATMEST OF NERVE-PROSTRATION. in small doses should be cautiously tried ; it may be given either alone or in combination with chloral and bromide of ammonium. The danger of inducing a craving for the drug must always be borne in mind. Chloralamide would seem to possess anodyne as well as hypnotic properties, and, given in doses of 20-40 grains, it often subdues the insomnia of neurasthenic patients. Its hypnotic action is certain and rapid, and it seldom causes headache or gastric disorder ; it appears to have no depressing effect on the heart's action, and the sleep it causes is sound and refreshing. Another remedy of this cXz-SS, paraldehyde, is, perhaps, less suitable for neurasthenic subjects. It is not so reliable as the hypnotics already mentioned; it has a disagreeable smell and taste, and sometimes causes gastric irritation. It is, however, occasionally useful in cases of insomnia, with accompanying mental depression, and may be tried if the other remedies fail ; the taste may be disguised by administering the drug in the form of an elixir, with rectified spirit, oil of cinnamon, and oil of bitter orange, or the ffuid may be enclosed in capsules. 1 he dose is from 30 to 60 minims. Sulplional is a valuable hypnotic, but its action is somewhat uncertain, and in full doses of 30 to 40 grains, it is apt to cause prolonged drowsiness, and likewise more or less giddinc^ss and inco-ordination of gait, some- times lasting throughout the day following its administration. I frequently prescribe it for the insomnia of over-worked, but otherwise apparently healthy men, in doses of 10 to 15 TREATMENT OF NERVE-PIWSTRATION. 61 grains, in a cachet at bed-time, washed down with a little water, and repeated in three hours if necessary. Tetronal is allied to sulphonal, but is said to be more powerful. Urethanc is another new remedy belonging to the class of hypnotics ; it is said to produce normal sleep and not to affect the heart. I sometimes order it in lo or 15 grain doses for the insomnia of elderly people. The action of all these and of other hypnotic agents will again be discussed in the chapter on Insomnia. Dr. A. D. Rockwell, of New York, strongly recommends the employment of electricity for the insomnia which is so frequently associated with neurasthenia. He states that general faradization sometimes succeeds, but that the galvanic current more commonly proves efficacious. The effects are not only temporary, but permanent ; the imme- diate relief is decidedly great, the permanent improvement is developed gradually and slowly, and results from the general influence of the electricity upon the system. The method of application is as follows : — A large metal electrode (covered with a smooth layer of absorbent cotton, with a second covering of chamois leather) is placed over the solar plexus, while a second large electrode of fine sponge is applied over the cilio-spinal centre, i.e., the lower cervical portion of the cord and the region of the first to the third dorsal vertebra. An ascending current is used, and, beginning with a few cells, the number is to be gradually increased without interruption until a current-strength of «!' THE A TMEjS T of NE It VE-PR OSTJiA TION. sixty milliamperes is reached. The application is to be continued for eight or ten minutes, and the current is then gradually decreased to zero. In one case thus treated the patient, who tor six months had been compelled to take either bromide or chloral, slept six hours after the first application ; and on the second night, after similar treat- jnent, for seven hours. The galvanism was applied nearly •every day for a month, and afterwards the patient slept jjerfectly well without any further treatment. In all cases of neurasthenia, save those of a compara- tively mild character, it is important to determine whether systematic treatment can be properly carried out in the patient's own home, or whether isolation from friends is imperatively necessary. As a general rule, the latter course should be adopted only when the symptoms are of a severe ml)le those of acute mania. Like the convulsive attack, lhc\- conic on suddenlv, and after their subsidence the patient has no recollection of what has occurred. Conditions of this kind sometimes follow the jjaroxysm, and the mental affection ma\- last for EFILEPTOIB STATES. 181 several clays. 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 accomplish- ment of the acts the patients are ignorant of what has occurred, and express more or less surprise when the details are related to them. 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 processes, according to our present know- ledge, should, or at any rate may be assumed, as produce (when developed in greater intensity or extent) the usual epileptic attacks. . . . The certainty as to whether the case he 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 182 SEFLEX EPILEPSY. 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 attacks. The attacks of giddiness are the most characteristic. Nothnagel cites the case of a clergyman, 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 field, 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 " Jacksonian " 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 peripheral nerves has caused the development of the symptoms. The course of events in a case of this kind is somewhat as JACKSONIAN EPILEPSY. 183 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. HeaHng takes place, and perhaps nothing more is thought of the wound ; 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 feeling 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 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 per- manent, 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 184 COURSE OF EPILEPSY. are generally unattended by loss of consciousness, and this symptom, when present, is less marked than in cases of typical epilepsy. Course and Results. — The course of the disorder varies greatly in diflferent cases. It is generally chronic, and not a few epileptic patients live to a somewhat ad- vanced 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 apncea. The majority of fatal cases are caused by accidents of \arious kinds, to which epileptics are peculiarly liable. Accidental death from falling into fire or water or from a height is not an unfrequent occur- rence. in about fortv per cent, of all cases of epilepsy, indica- tions of mental disorder sooner or later exhibit themselves. After these have appeared the patient's condition in^•ariably 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 may be required to discover any signs of derangement. Constant pain in the head, a feeling of confusion, inability to fix the attention continuously on any gi\en subject, and frequent muscular twitchings are the most common evidences of incipient deterioration. Certain mental peculiarities are DIAGNOSIS OF EPILEPSY. 185 likewise apt to become prominent. In some patients, with- out obvious cause, excitement alternates with depression ; marked obstinacy and capriciousness are sometimes ex- hibited; 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 impaired. In some cases violent attacks of mania constitute the prevail- ing feature ; in others the patient relapses into a state of dementia. Under such circumstances the features and manner of the patient are considerably changed, and the animal propensities are wont to become very 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 weak- ness, hysteria, and convulsions occurring in children. An ordinary epileptic attack can be easily distinguished 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 distinguish- ing between the two conditions, especially when the pre- vious history cannot be obtained. The appearance of foam 186 DIAGXaSIS OF EPILEPSY. mixed with blood about the mouth, the absence of paralysis and of stertorous breathing are usually sufficient to deter- mine the diagnosis, but it may be necessarv to watch the case for some little time before coming to a positive con- clusion. Attacks of faintness mav 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 conv'ulsions, and no involuntan,- discharges, and the patient after recovery feels anxious and giddy, but not lethargic. His condition, moreover, is relieved bv stimulants. Until thoroughly recovered his face continues pale. The diagnosis between epilepsy and hysteria has been given in a previous chapter (see p. 148). It is only neces- sary to add that it has become more difficult to distinguish between the two affections since we have learnt to recog- nize 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 frorfl intestinal irritation or other similar cause, or occurring during the course of a febrile affection, may so closely resemble PROGSOSIS OF EPILEPSY. 18" epilepsy as to be incapable of being distinguished 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 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 obser\-er. There are. however, certain symptoms which cannot be counterfeited, viz., the initial pallor of the face, the dilatation of the pupil. the insensibility of the eve to light, the changes in the pulse, and the ultimate purplish 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 counter- feiter by wrenching open his mouth and removing the source of the foam. Prognosis. — Epilepsv is a very serious disease, and rarely admits of a favourable prognosis. The abortive attacks are less amenable to treatment than the ordinary 188 TREATMENT OF EPILEPSY. type of the complaint. As a general rule it may be stated that permanent recovery takes place in about live 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 a 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 disorder, 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 perfectly well during the intervals, there is much room for hope that recovery may take place. The longer the com- plaint 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 surround- ings. The mental condition of the patient always exerts more or less influence on the progress of the complaint. Treatment. — In dealing with a case of epilepsy every endeavour should bi' made to discover any possible cause of the disorder. ReuK-dies should not be used in a haphazard fashion, but the state of the system and any irregularity of function should be carefully observed. TREATMENT OF EPILEPSY. 189 Subject to these general provisions the treatment divides itself into that which is required in the intervals and that which is adapted to the /^rc'Arj'j'/wjr. Cases of reflex epilepsy are sometimes very amenable to treatment. The removal of cicatrices, including 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 been removed; the changes in the central organs set up by the irritation at the periphery are apt to become permanent, and independent of the lesion which 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 as cicatrices, exostoses, necrosed bone, etc., are discoverable. 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 healthv 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 bv iron, 190 TEEATMENT OF EPILEPSY. cjumine, a nutritious diet, and a general tonic regimen. Any existing ocular troubles should be corrected as far as possible. The condition of the digestive organs should receive special 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 young subjects with evidences of rickets, good milk with entire wheaten flour should form a large portion of the diet, while cod-liver oil and the syrup of the phosphate of iron should be administered for lengthened periods. 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 par- ticulars must, of course, be adapted to each indivi- dual case ; only general principles can here be given. In the first place excesses of every kind must be aban- doned. The diet should be nutritious and non-stimulating ; especial attention should be paid to the quantity of animal food, for, as a general rule, the attacks become more frequent when articles of this description are too largely used. Some patients are improved by a diet consisting principally of vegetables diu/ milk. P^very attempt should be made to secure a projx-r amount of sleej) for e])ilcptic patients. Night seizures may be warded off lo some extent by using high pillows, and sleeplessness should be relieved TREATMENT OF EPILEPSF. 191 by a combination of the bromides with chloral. Regular and moderate occupation, exercise short of fatigue, early hours, in fact, hygienic measures of all kinds, are indispens- able 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. At the present day the bromide of potassium is the remedy which yields the best results ; it is, however, sometimes useless, but it always deserves a thorough 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 or milk, and sometimes it is better tolerated by the stomach if taken with some bitter infusion and a few grains of bicar- bonate 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 drup it should be given for two or three months ; if no improve- ment take place its administration should be stopped. If the attacks be checked, the dose maybe cautiously reduced; but the remedy should be continued for some months after 192 TREATMENT OF EPILEPSY. the last fit. It must not be forgotten that prolonged use of the bromide of potassium is apt to be followed not only bv eruptions of acne, but 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 dis- continued, and we may then have recourse to atropine. This powerful drug should be given in doses commencing with the- yi^ of a grain, gradually increased up to ^L or even -^L. 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 con- tinued 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 carefullv watched during the whole time, and the medicine stopped on the appearance^ of any toxic symptoms. For epilepsv occurring in young children a combination of chloral hydrate with the bromide of potassium is some- times efficacious. To a child a year old, two grains of the former with five of the latter ma)- hv given every four or six hours, until the tendency is subdued. Dietetic and hygienic measures should of course be adoj)tetl at the same time. Calabar bean in doses of gr. yV of the extract twice or three times a day may be tried if the chloral and bromide fail to relieve. If there be any reason to suspect the ojxration of syjihiiis, whether in an adult or a child,. TREATMENT OF EPILEPSY. 193 iodide of potassium, should be given in full doses ; it may, of course, be combined with the bromide. A few other drugs have lately been recommended for epilepsy, and some of them deserve a brief notice. The action of the bromides may sometimes be aided by digitalis and cannabis indica ; the former is likely to be serviceable when the heart's action is tumultuous and irregular. Can- nabis relieves undue excitability, and is also useful when headache is a prominent symptom after the paroxysms. Antipyrin is said to produce good effects when the attacks occur at the menstrual periods, and are apparently pro- voked by menstruation ; and also when the patients are subject to neuralgia and migraine. Antifehrin is reported to yield good results when the bromides and other remedies have failed. It must be given continuously for several months, in doses of from two to six grains, twice or three times a day, the effects being carefully watched. Borax has recently been recommended for the relief of epilepsy. It appears to be far inferior to the bromides ; but it is worthy of a trial when the latter fail or are badly borne. The dose ranges from seven to 60 grains three times a day, the larger doses being reached by gradual increases. In some cases, though not in all, borax seems to check the nocturnal paroxysms rather than those that occur by day. Tincture of Simulo is another new remedy which appears to have some effect on epileptic patients ; but it is less potent than the bromides. O 194 TREATMENT OF EPILEPSY. Other and older remedies used for epilepsy require to be mentioned. The oxide of zinc, nitrate of silver, and the ammonia-sulphate of copper, although much lauded from time to time by various authorities, would seem to possess little, if any, real efficacy. They may, however, be tried if the bromides and other drugs 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 continued 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 children ; the reverse holds good with regard to zinc. It is also said to be more suitable for torpid, phleg- matic persons than for those of an irritable, nervous temperament. Many vegetable remedies have been employed in the TEEATMJENT OF EPILEPSY. 195 treatment of epilepsy ; some for their tonic, others for their antispasmodic properties, and others, again, have been given quite empirically. Of the vegetable 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 remedies.' Its real efficacy may be doubted ; yet it would appear to possess some power of lessening nervous excitability. In some experi- ments 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 iinibilicus, indigo, siunbulj 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 prescrib- ing the drugs. ■ Electricity in various forms has, of course, been tried for epilepsy, and cures are said to have been effected. We 196 TREATMENT OF EPILEPSY. 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 methodically 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 in the way of treatment is generally required during the paroxys}n. In cases attended with the epileptic aura it has been recommended to apply a ligature or a tourniquet to the limb, and some patients, when time will allow, arc able to avert a paroxysm by inhaling ammonia TREATMENT OF EPILEPSY. 197 and other nervine stimulants, or by taking a draught of cold water. In the Practitioner for October, 1868, Dr. Buzzard has recorded several cases, which show that when a marked local sensation precedes an attack, the fits maybe diminished, and sometimes even cured by applying a narrow blister round the limb above the starting-point of the aura. The inhalation of amyl nitrite 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 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. If the convulsions recur and a high temperature exist, cupping 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 carefully 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 Distribu- tion OF THE Disorder — Causes — Hereditary Predisposition — Imitation — Aue 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 or Mental Disorder — Differences in Severity — Analysis of Pro- minent Symptoms —Duration of the Disorder — Prognosis, Diag- nosis, and Treatment — Necessity of Inquiring into Cause — Specific Remedies, as Arsenic, Zinc, and Strychnine — Cold to THE Spine — Chloral— The Good Results of Prolonged Sleep — Hypnotism — Isolation from other Children. Chorea is in many respects one of the most interesting disorders which the physician has to study. The name was originally given to the epidemics of dancing madness which appeared in the 14th and 15th centuries in some parts of Western Germany, because the movements 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 ; and afterwards a distinction began to be made between the chorea Gcrmnnorum, or chorea magna, as it was called, and chorea Ano^loriim, or minor. NOTICjES of CRORHA. 199 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 convulsive 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 more frequently affected than the leg. There is no loss of consciousness, but the will is incapable of preventing the movements, which, however, cease during 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 writers through- out Europe. With regard to its geographical distribution, chorea is, like many other affections 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 temperate zones. It is said to be 200 CAUSES OF C ROBE A. 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. Causes. — The causes of chorea are many in number and various in character. Hereditary predisposition to nervous disorders is a very important factor, and the frequency with which it can be traced is a measure of the relationship which exists between many affections of the nervous system. Chorea is sometimes distinctly hereditary and then affects adults chiefly, or does not come until middle life is reached (Huntington's Chorea), Epilepsy or hysteria in the parents predisposes the children to chorea. It must, however, be remembered 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 circumstances 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 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. Unless there be a distinct hereditary tendency, chorea very seldom occurs for the first time in persons over 20 years of age. The com- plaint is more often met with in towns than in country places, and among children of the poor than among those CAUSES OF CHOREA. 201 of the rich. A very common predisposing cause is debility, especially when due to neglect and want of proper food. Among the direct causes the most potent is some form of mental excitement, such z.s fright or a severe shock. Many cases are on record in which the symptoms have followed immediately upon some sudden alarm. A few years ago 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 affections of the mouth or teeth, and disorders of the genital functions. In one case under my care, that of a woman aged 28, a retroverted womb seemed 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. Dr. Stevens, of New York, has recently attempted to show that chorea is emphatically a nervous disorder depending upon ocular conditions (see page ig). 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 accommo- 202 CAUSES OF CHOREA. dation is required, 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 was associated with ocular abnormalities of these kinds. It must, however, be mentioned that many ophthalmic surgeons are decidedly opposed to Dr. Stevens' views, and deny that any appreciable number of nervous disorders are due to muscular insufficiency or to errors of refraction. The connection between acute rheujuatism 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 affec- tions 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 FATEOLOGY OF CHOREA. 203 iurther 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. In the reports of 439 cases, collected by Dr. Stephen Mackenzie, there was a previous history of rheumatism in about a quarter of the number. Pathology. — Very widely different views are held as to the nature of chorea, but within the last few years consider- able 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 pre- ceded by rheumatism ; the difficulty is to account for mild cases which rapidly recover under the influence of good food and fresh air. There is apparently much truth in Dr. Broad- bent's view that chorea is a symptom rather than a disease, and that the characteristic movements are in relation with the seat of the morbid change rather than with its nature. " The seat of the disturbance is the corpus striatum, its character probably different in different cases ; but 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 examina- tion inflammatory changes were found in the cardiac valves. 204 PATHOLOGY OF CHOREA. 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 endo- cardium. 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 ; hyperaemia of the brain and spinal cord ; serous effusion and extravasation of blood in the spinal canal. According 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 PATHOLOGY OF CHOREA. 205 theory is destitute of proof, and is even improbable. He regards chorea as a " neurosis," that is, a disease which pro- duces functional disturbances for which an anatomical basis is at present unknown. This account 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. 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 incompatible with the existence of organic lesions. At present it seems impos- sible to do more than assume the existence of nutritive disorder in the brain. Such disturbance may depend upon hypersemia, with stagnation 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. 206 SYMPTOMS OF CSOREA. Symptoms. — In the majority of cases the choreic move- ments are preceded by symptoms indicative of disorder of the general health. Fretfulness, irritability, capriciousness, indifference, inattention, etc., are 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, they are, of course, absent in cases of chorea supervening on fright, or following closely an attack of acute rheumatism. After these symptoms have continued perhaps for some weeks the choreic 7nove?nents 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 worse 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 tvvitchings usually begin in the hand and arm, and thence extend to the shoulder, face, and other parts of the body. In most cases they are at first limited to one side. SYMPTOMS OF CHOREA. 207 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 ex- tend 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 by volun- tarily 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 208 SYMPTOMS OF CSOBEA. more and more difificult, 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, 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 difificult to keep the patient in bed. Between these two extremes there are many various degrees of severity. SYMPTOMS OF CHOREA. 209 The more projninenf sympto?ns require a somewhat closer analysis. The motor disorders are twofold, and take the form of spontaneous convulsions and subsequently 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 volun- tary movements are effected in a manner which is almost normal, whereas the more automatic actions, such as grasping and retaining an object, walking, sewing, writing, etc., are accompanied by marked choreic movements. The convulsive twitchings do not seem to cause fatigue, but as time goes on a general weakness becomes developed, and loss of power in one 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 hemi-chorea. 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 derangements of the organs of circulation are often present. The pulse is usually frequent and sometimes irregular owing to the spasmodic contractions P 210 SYMPTOMS OF CEOEEA. 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. Duration, Course, and Prognosis. — In cases of chorea of average severity the disorder lasts from six weeks to three months. Its course, however, is seldom uninterrupted ; exacerbations are apt to occur, and relapses are not unfrequent even after a recovery supposed to be complete. Under favourable 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 favourable, 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 continuance of the paroxysms. In adults the disorder always runs a very chronic course, and it terminates fatally in a large propor- tion of the cases. About 30 per cent, of cases of chorea occurring in pregnant women end in death. TREATMENT OF CHOREA. 211 In hereditary chorea the prognosis is very unfavourable ; improvement may occur from time to time, but recovery seldom, if ever, takes place. 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 rhythmical tremors ; in chorea they are much more exten- sive, and of a jerky character. In doubtful cases the course of the disorder under treatment will aid the diag- nosis. 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 possible. 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 care- fully inquired into and treated. Ordinary routine treatment should not be adopted until a thorough examination has been made with the view of discovering a local source of irritation. When chorea occurs in a child attending school 212 TREATMENT OF CHOREA. 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 tnijid must be enjoined, and no lessons of any kind are to be thought of until the choreic symptoms have completely disappeared, and a decided improvement has taken place in the general health. In cases of chorea following rheumatism, iodide of potassium with alkalies and cinchona is likely to be serviceable, and cod-liver oil maybe given at the same time. When all probable 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 administration. From three to ten, or even twenty, 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. Symptoms 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 or three times a day, and these are gradually increased by succes- sive additions, until thirty or forty grains are taken daily. TREATMENT OF CHOREA. 213 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 frequency 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. The production of sleep is a very important matter in the treatment of severe chorea, and when the convulsive move- ments are very severe, and so continuous as to deprive the patient of rest, sedative and narcotic remedies must be tried. Chief among these is chloroform, 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 prolonged than that of chloroform, and it has a very decided effect upon the convulsive move- ments. 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. In very severe cases, with symptoms of imminent 214 TRI^ATMENT OF CHOREA. exhaustion, and when arsenical and other forms of treat- ment have failed, recourse may be had to chloral , which should be given every six or eight hours, and in gradually increasing doses. For a child about ten years of age the dose at first should be five grains, and this may be cautiously increased until, if necessary, from forty to sixty grains are given in the twenty-four hours. Other hypnotics, such as sulphonal and chloralainide, administered in suit- able doses for several days or weeks, are reported to have proved efficacious. 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 con- stantly watched. Hypnotism, as practised by Dr. Bernheim and others, has proved efficacious in the treatment of chorea, but, for the most part, in mild cases and in those which resulted from imitation. The method has also succeeded in relieving movements consecutive to chorea, and causing difficulty in writing. Several cases of this nature are recorded in Dr. Bernheim's work. In one case of intense general chorea^ of four weeks' duration, improvement began after the first stances of suggestion, and after three or four weeks' treatment but few traces remained of the symptoms. There is one other point to be attended to in connection 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 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-Cen- tres — Atrophy of Posterior Roots — Vaso-motor Disorder — Pre- disposing 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, Remissions, Intermissions, and Recurrences — Locality of the Pain as a Guide to the Cause — Pain Extending Centripetally and also Radiating along the Course of Neighbour- ing Nerves — Points Douloureux — Cutaneous Hyperesthesia and Anesthesia — Motor Disorder — Vaso-Motor Disturbances and Dis- orders OF Secretion and Nutrition — Eruption of Herpes and Erythema — Effects of Neuralgia — Diagnosis — Treatment — Dis- covery of Cause — Symptomatic Treatment — Quinine, Arsenic, Sali- cylate of Sodium, Iodide of Potassium — -Anodynes, Morphine and Atropine — Liniments — Counter-Irritation— Electricity — Various Tonic Remedies — Neurotomy and Neurectomy — Summary of Treat- ment. Pain may be defined as a peculiar form of common sensa- tion, provoked by the action of relatively strong stimuli on sensory nerves. According to the most recent physiologi- cal doctrines, the sensory nerve trunks contain two func- tionally different kinds of nerve fibres, viz., those which convey impressions of pain (or sensory nerves in the 216 NEURALGIA. narrower meaning of the term), 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 conduction channels of the tactile and sensory nerves are in different parts of the spinal cord. Tactile impressions 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). Under pathological conditions, and under the action of narcotics, the one sensation may be suppressed 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 other, 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 some- thing superadded to the peculiar sensation of pain. Thus THEORIES OF CAUSATION OF PAIN. 217 when the hand is exposed to intense heat the sense of temperature is appealed to, and a definite quahty 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 presenting complete intermissions or decided remissions. 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, except perhaps those of exhaustion. 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 218 TSJEORIES OF CAUSATION OF PAIN. chemical process or change acting upon the nervous system. Experiments have proved that irritation of a nerve is followed by elevation of temperature in the nerve-substance, and a change in its chemical reaction. 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 character ; the acid products are soon neutralized by the alkalies of the blood, and are absorbed and removed. Granted, 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 ta that by which the same peculiarity of other processes is explained. In neuralgia the attacks are excited when, sufficient quantities of the irritating materials have become accumulated. At first and for some time neutralization 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 duration and severity. After a time central changes take place, and these have a tendency to become permanent. It is these changes in the nervous centres which are concerned in the production of the pain. In neuralgia of a mixed nerve, if only the trunk were affected, motor phenomena would show themselves. THEORIES OF CAUSATION OF PAIN. 219 but this complication is not always observed. The irradiation of the pain along branches of other nerves is likewise a proof of the existence of central changes. Another theory of neuralgic pain deserves 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 con- nected with them. He supposed that certain cells and groups of fibres were, so to speak, congenitally loci minoris resistentise, under the influence of such agents as exposure to cold, injuries, mental shocks, alcoholic excesses, as like- wise during puberty, pregnancy, and senile disorders of nutrition. These and similar causes may be supposed still further to damage cells and fibres originally weak, and ultimately to produce a condition of atrophy. Very little pathological evidence has, however, been cited 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 substance of the cord were found quite normal, whereas the posterior columns showed very decided appearances of irritative changes. The fact that neuralgic symptoms are common in the early stages of locomotor ataxy would appear to indicate that the posterior columns may be implicated in the causation of neuralgic pains. 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. 220 CA USES OF NE URAL GIA . Causes. — The predisposing and exciting causes of neuralgia are of various kinds. The lirst-named class includes (i) a nervous constitution, for the most part of hereditary origin ; (2) 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 excitijig causes of neuralgia, cold and damp and exposure to draughts occupy the iirst place. We have no certain knowledge as to the manner in which cold acts upon a nerve, but it is generally supposed that slight anatomical changes of an inflammatory character are induced. Other causes of neuralgia 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 always give rise to neuralgia. Various constitutional disorders, e.g., gout, diabetes, SYMPTOMS OF NEURALGIA. 221 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 being 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 conditions, e.g., rapid changes of temperature, with excess of moisture in the air, determine the prevalence of neuralgia 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. 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. Symptoms. — Neuralgic pains may be classified under two heads ; when due to obvious causes they are known as syinptomatic ; when no cause can be ascertained the term essential is used. As instances of syfnptomatic neuralgia may.be mentioned the severe shooting 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 dis- coverable, and we are too ready to assume that they do not 222 SYMPTOMS OF NEUEALGIA. exist. On the other hand, analogy would lead to the inference that severe and continuous pain is always con- nected 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 de- scription will first be given of the general symptoms of neuralgia, and the various local affections of this character will next be discussed. Neuralgic attacks are 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 itching, 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 symptoms are almost or altogether absent ; the attacks come on without any warning. A common feature of neuralgic 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 peculiarities are further desig- nated by such epithets as " pricking," " tearing," "burning," "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 SYMPTOMS OF NEURALGIA. 223 remission occurs, or even a complete intermission. This interval again varies in duration ; 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. Re- currences 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 sore- ness 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 food ; 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 constitutional disorder 224 SYMPTOMS OF NEURALGIA. is a question that cannot be solved." In some patients of gouty habit the pain is felt in the course of those nerves which, from their position, are most exposed to the influence of cold and damp. 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 width, is compara- tively frequent. Facial and occipital neuralgia and sciatica are also common in the secondary stage, and severe inter- costal 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 direc- tion, 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 re- garded as indicative of neuritis. The sheaths of the nerves are supplied with special nerve-fibres, and are thus en- dowed with sensibility. The tenderness is probably due ta irritation of these nerves, which are the channels for the conduction 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 ;S' YMPTOMS OF NEURALGIA. 225 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 sometimes complicated by pains in the thigh, while other visceral 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 char- acter may be described as reflex neuralgia ; examples of it are not uncommon in persons with hereditary predisposi- tion to nervous diseases. Certain other phenomena are often prominently asso- ciated with neuralgic attacks ; those most frequently noticed are the so-caW&d points do2ilotc7^eii-x,t\\e. cutaneous hyperaes- thesia and hypaesthesia and symptoms of vaso-motor dis- order. Fifty years ago attention 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 principal branches, and generally correspond with Q 226 SYMPTOMS OF NJEURALGIA. 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 portion of the trunk of the affected nerve is equally sensitive 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 donloia-eux 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. Spontayieoiis 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 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. Some amount of cutaneous hyperassthesia 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 occasionally followed by one or more of these forms of perverted sensibility, but they are more often observed in connection with neuralgia. SYMPTOMS OF NEURALGIA. 227 Disorders of motor nerves are not unfrequently asso- ciated with neuralgic pain, and the connection between the two affections may be either direct or reflex. In neuralgia of mixed nerves the motor fibres are liable to suffer from the same causes which act upon the sensory nerves. Hence the pain may be accompanied by symptoms of irritation, such as fibrillary twitchings, or even clonic spasm of muscles, and subsequently by loss of power, seldom amounting to paralysis. Symptoms of irritation may be also of reflex origin ; thus, owing to reflex irrita- tion of the facial nerve, the convulsive form is sometimes superadded to tic douloureux. In some cases of neuralgia the cardiac and respiratory movements are affected by reflex action. Evidences of vaso-motor disorder a.ve commonly observed in various forms of neuralgia. Thus at the beginning of the attack there is usually excitement, and later on paralysis, as indicated by contraction and subsequent 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 affected 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 nutritioyi come next in point of frequency. During neuralgic attacks it is 228 SYMPTOMS OF NEUBALGIA. often noticed that the saliva is increased, that the tears and nasal mucus flow freely, and the secretion of milk, perspira- tion, and urine has been observed to become more abun- dant. The nutrition of the affected part not unfrequently 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 ; some- times 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 mcuth, 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 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 SYMPTOMS OF NEURALGIA. 229 cloudy and then dries up. The crusts thus formed drop off, leaving reddened patches, but sometimes small ulcers. The association, however, of neuralgia with herpes is by no means constant ; for, as is well known, the eruption often occurs without- any accompanying pain beyond a little smarting. When the association exists the pain and the eruption may appear together ; but more frequently the latter precedes the former. The most characteristic form of herpes is seen in connection with intercostal neuralgia. Patches of erythe?na and even erysipelas are sometimes 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 similar circumstances. The skin is thin, smooth, shining 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 sleep and of appetite. A condition of profound melancholia is set up in some patients. The attacks are the more trying inasmuch as in 230 DIAGNOSIS OF NEURALGIA. 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 accession of the pain, its intermittent character, its correspondence with the course of certain large nerves, along which painful spots may often be detected on pressure, are the main points to be attended to. The cause and the 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 super- ficial nerve. Neuralgia of central origin is a common symptom of some cerebral and spinal disorders, e.g., of tumours of the brain and of locomotor ataxy. TREATMENT OF NEURALGIA. 231 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 especially when associated with other phenomena. The presence of trophic disorders in the hair, nails, or skin is in favour of neuritis ; so likewise is early anaesthesia, appearing in the course of a few days. Swelling of the affected nerve is another sign of inflammation, 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, more- over, probable that the appearance 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 both disappear, owing to complete destruction of the nerve fibres. 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 complaint will be mentioned in the ensuing chapters. Having ascer- tained 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 con- stitutional disorder, e.g., gout, diabetes, syphilis, etc. In 232 TREATMJENT OF NEURALGIA. women, evidences of hysteria should be sought for and noted. If the 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 mercury in cases in which there is any reason to suspect the influence of these metals. In many cases of neuralgia the cause remains undis- covered 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 remarkable. It should be given in large doses (grains v-xx), and its effects watched. Efficacious as it frequently is in tic, it is seldom of any avail in sciatica. If there be headache the quinine may 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 {\\\ v-x) three times a day after meals. For neuralgia, affecting various regions successively or simultaneously, the following combination often proves serviceable: R. Liquor. Arsenicalis \\\_ xx ; Potass. Bromid. 5! ; Ouininae Sulph. gr. tri:atment of neuralgia. 233 xii; Liq. Strychnin. r\\ xvi ; Acid. Hydrobromic. Dil. 3i ; Syrup. Aurantii 5ss; Aquam ad jviii. An eighth part twice or three times a day after food. If there be any history of rheumatism the salicylate of sodium may be tried in doses of from ten to twenty grains every four or six hours. In these cases I sometimes combine it with the bromide of ammonium, and order ten grains of each with TH, XX Sp. Ammon. Aromat. twice or three times in twenty- four hours. The tincture of cimicifiiga, in doses of five minims every hour, often relieves neuralgia of a rheumatic character, and is especially useful when the complaint is associated with uterine disorders. Chloride of ammonium in full doses (gr. xv-xxx) relieves many forms of neuralgia ; it may be given with milk or with liquid extract of liquorice. Phosphorus sometimes acts very satisfactorily in facial neuralgia and pleurodynia. A syphilitic history will indicate iodide of potassium^ and neuralgia occurring in gouty subjects will often yield to purgatives, alkalies, and colchicum. If the influence 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, jnorphijie being the one most commonly used. It is best administered subcu- taneously, 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 234 TREATMENT OF NEUHALGIA. 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 distressing head-symptoms. There is a serious drawback connected with the use of morphine in severe and chronic cases, 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 consequences of a very distressing nature. Under no circumstances should a patient be allowed to inject the anodyne himself. It is sometimes advantageous to add a minute quantity (gr. y^-jf) °^ ^^^ sulphate of atropine to each dose of the morphine used for injection. I have found this combination most serviceable ; the atropine counteracts the unpleasant effects of the morphine on the head and stomach. Antipyrin relieves pain in some cases of facial neuralgia and neuralgic headache. I give it in seven grain doses, combined with an equal quantity of bromide of potassium^ every four or six hours. For external applica- tion anodynes may be used in a great variety of forms, but it is only slight cases of neuralgia that are thus benefited. The liniments of acoitite^ belladonna, and opium, either TREATMENT OF NEURALGIA. 235 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. Aconite and atropine are powerful remedies thus applied, and veratrine does good in some cases. The local application of butyl-chloral and menthol is sometimes very efificacious 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-irritatioti is often serviceable. For comparatively slight cases we may employ a small mustard plaister, or the compound 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^rm^ 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 236 TREATMENT OF NEURALGIA. 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 decidedly curative. Opinions differ as to the best method 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 current is selected, the negative pole is placed in the patient's hand, while the positive pole is applied to the affected nerve or painful spot and moved gently over it ; 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 TREATMENT OF NEURALGIA. 237 some portion of the course of the nerve. 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 will be mentioned in the chapter dealing with the various forms of the complaint. It will suffice for the present to enumerate the hypophosphites ; iroUj 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., division 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 irremovable source of irritation 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 draw- back to the operation, that 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 efificient may involve considerable separation of the parts. Nerve-stretching is another surgical procedure sometimes successful. It is impossible to explain the manner in which forcible stretching of the nerve produces its good effects, but it has been suggested that in rheumatic 238 TREATMENT OF NEURALGIA. 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 generally 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 comparatively mild. Tonic treatment of all kinds is generally indicated. Good nutritious food taken at proper intervals, removal of the patient from an unhealthy locality, exercise according to capacity, warm or cold baths are all likely to be service- able. 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— IL INTERCOSTAL NEURALGIA.— III. SCIATICA. I. Causes of Tic Douloureux — 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-Paralvtic 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 Mastodynia — Symptoms and Differential Diagnosis — Treatment OF Intercostal 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 — Hypodermic Injections of Morphine and Atropine — Electricity — Flying Blisters — Acupuncture — Hot Baths — Warm Applications — The Scotch Douche — Hot Sand-Baths — Massage — Nerve-Stretching. The most frequent form of neuralgia is that in which the fifth pair of nerves is affected. All three divisions of the nerve are liable to suffer; but attacks are more common in 240 CAUSES OF FACIAL NEUltALGIA. 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 com- pression 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 and the lodgment of foreign bodies are occasional causes which 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 t/c douloureux in which there is no evidence of any anatomical lesion. Syphilis, rheumatism, and gout may be mentioned as constitutional causes ; and likewise 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 S YMF TOMS OF FA CIA L NE URAL GIA. 241 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 conditions 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 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 out- break is often preceded by various abnormal sensations, 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 R 242 SYMPTOMS OF FACIAL NEURALGIA. 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 afterwards anaesthesia in the area of distribution of the affected nerve. An eruption of herpes sometimes precedes the loss of sensation. The attacks vary considerably as regards their duration ^Xidi frequency. The acute pain may last for a few seconds 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 during the twenty-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 momen- tarily interrupted by exhaustion of the nerve. The most SYMPTOMS OF FACIAL NEURALGIA. 243 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 whom 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 often indeed the attacks come on spontaneously, i.e., without obvious causation. In some patients mental excite- ment 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 sensations in the area of distribu- tion of the affected nerve. Symptoms indicative of motor disorder 2x& 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 2U S YMPTOMS OF FA CIA L NE URALGIA. muscles of mastication (supplied by the motor branch of the fifth) are occasionally 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 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 ; the salivary and nasal secretions are apt to be increased in amount, and these latter symptoms may remain for some time after the pain has subsided. Symptoms indicative of trophic disorder ■^x(t frequent results in chronic cases. Sometimes 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 sometimes 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 ncuro-paralytic ophthalmiay which lakes 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 SYMPTOMS OF FACIAL NFURALGIA. 245 whether this affection is the direct result of disordered nutrition. It seems more 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 neuralgia, and subsides when 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 permanently 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 causing their own deleterious effects. Having given this general description of tic douloureux, it seems desirable to indicate the peculiarities of the symptoms connected with neuralgia of each of the three divisions of the nerve. The sup7'-a-orhital branch of the ophthalmic division is the one most frequently attacked. The pain sometimes takes the form of ciliary neuralgia, and occurs in combina- 246 SYMPTOMS OF FACIAL NFUl^ALGIA. tion with such symptoms as spasm of the eyelids, intolerance of light, and profuse lachrymation. Neuralgia with these symptoms is not uncommon in scrofulous children. Catarrh of the frontal sinuses is another cause of neuralgia of this branch. The pain is probably due to the pressure of the accumulated secretion upon the nerves distributed to the membrane lining the sinuses. In this form the pain may extend from the eyelids to the vertex, downwards to the tip of the nose and laterally to the temple. Pressure over the supra-orbital foramen will elicit pain, and other points doiilouretix 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 very severe pain, due to irritation of the nerve from deposit of bony substance. The palatine and naso- palatine branches arc seldom the seat of neuralgia. In neuralgia of the inferior maxillary nerve the pain is usually felt in the inferior dental branch, and the internal opening of the inferior dental canal and the mental foramen are the ordinary points douloureux. The auriculo-temporal branch is less commonly affected. This branch supplies the meatus auditorius and the articulation of the jaw, and a SYMPTOMS OF FACIAL NEURALGIA. 247 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 to ; 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 twitchings come on. After a while the continuous pain subsides, but the severity and frequency of the paroxysms remain as before. Later on, however, the latter become less frequent, and are no longer spontaneous, but occur only as the result of move- ments, or of bringing 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- 248 DIAGNOSIS OF FACIAL NEURALGIA. 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 excite- ment. 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 produce a paroxysm. As time goes on, it is found, perhaps 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. 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 ; [b) 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 temporo- maxillary articulation, etc., but such cases are easily dis- tinguishable 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 TREA TMENT OF FA CIA L NEURALGIA. 249 central origin, while the restriction of the pain to one or two branches points rather to a peripheral cause. The determination of the cause, however, of cases in which several branches are affected may be very difficult ; absolute incurability is, perhaps, the only indubitable sign of an intracranial cause. Neuralgia affecting simultane- ously 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 231). Every attempt should be made to discover the cause. When the lower part of the face is the seat of the pain ■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 neuralgia, 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 5J, and by restoring the communication between the nose and the frontal sinuses, the pressure on the nerves will be lessened, and the pain will subside. I have seen many cases much benefited by these measures. 250 TREA TMENT OF FA CIA L NF UEA L GIA. When the neuralgia appears to be connected with con- stitutional 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., Friedrichshall, Marienbad, etc. For the direct treatment of tic douloureux, we have at 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 galvanic current is generally to be preferred to the induced ; its application is more efficacious, and causes less pain. Four to eight cells being employed, the negative pole should be pressed against the back of the neck, and the positive applied to the various painful spots for from two to five minutes. Some form of rheostat is de- sirable in order to prevent shock ; in its absence, care should be taken to increase and to lower the strength gradually on applying and withdrawing the current. 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 efficacy 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 TREATMENT OF FACIAL NEURALGIA. 251 electrode 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 anody7ie class, morphine is the most useful, and is best administered subcutaneously. Large doses are often required to produce any effect upon the pain. The butyl-chloral is another 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. Gelsejniujji has an almost specific action in some cases ; it is given in the form of the tincture 7)1. x-xx every hour or two hours, until three or four doses have been taken. There are, unfortunately, no special indica- tions 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 hypo- dermically, in doses of nx j-iv of a solution containing 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. Whenever perio- dicity 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 advantageously combined with the hydrobromic acid. For similar cases the salicylate of sodium may be employed in doses of thirty or forty grains. When there is no marked periodicity, quinine may be given in smaller doses (gr. iii-v) with Liq. Morphin. Hydroch. 252 TREATMENT OF FACIAL NEURALGIA. (lit xx-xxx) every four or six hours. Arsetiic comes next in efficacy, and should be tried whenever quinine and the salicylate fail. Fowler's solution should be given in doses of from 111^ v-x three times a day. When debility is a pro- minent symptom, it is well to \.xy pliosplwrus, in doses of gr. 3\^-3^y, thrice daily. Iron is most generally useful whenever there is marked anaemia, but it sometimes does good when the latter is not a prominent symptom. Anti- pyrin is another remedy which is sometimes efficacious. It may be given in seven grain doses, with an equal quantity of the bromide, every four or six hours. Chloride of ammonium in doses of gr. xx-xxx, several times a day, is also recommended. Anodyne remedies, applied ex- ternally, are sometimes useful as palliatives. A stick of menthol, an alcoholic solution (i in lo), 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 does good. 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-stretching. Of these neurectomy yields the best results. Before performing either this operation or simple incision, it is desirable to ascertain as far as possible ihe existence and position of INTERCOSTAL NEUBALGIA. 253 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 neurectomy, 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 fre- quently 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 neigh- bouring 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 intercostal 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, 254 SYMPTOMS OF INTERCOSTAL NEURALGIA. 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, especially when due to prolonged lacta- tion, 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 lungs, especially tuberculosis, disorders of the liver, affections of the spinal cord and its membranes, all are likely to cause pain in the intercostal 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. Tiiis 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 nerves affected, and may be either continuous or SYMFTOMS OF INTERCOSTAL NEURALGIA. 255 paroxysmal in character. In the former case there are generally sharper twinges at irregular intervals ; there is often some amount of cutaneous hyperaesthesia in the affected region, and pressure over the spinous processes of the corresponding vertebrae 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 discover- able in one or more of the following situations: — i. 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 move- ments 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 ; sometimes, indeed, the slightest touch causes the side to be forcibly retracted. 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 256 SYMPTOMS OF INTERCOSTAL NEURALGIA. 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 intercostal 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 28, of gouty habit and family history, suffering from occasional paroxysms of intercostal neuralgia. These were accompanied by severe burning pain in the cardiac region, and 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 dis- appeared 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 alterations in the structure of the heart. With regard to complications, herpes zoster is the one most frequently observed. It is not, 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, DIAGNOSIS OF INTERCOSTAL NEURALGIA. 1^1 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 complaint. Diagnosis. — 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 will prevent any such mistake. In so-called rheumatism of the muscles of the chest the parts will be very sensitive to pressure. When the heart itself is the seat of the pain, the latter will be felt principally in the precordial 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 vertebral column. S 258 DIAGNOSIS OF INTERCOSTAL NEURALGIA. Irritable breast or inastody7iia is an affection of the anterior cutaneous branches of the upper intercostal nerves, and 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 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 sensi- tive. Even contact with the clothes is sometimes almost unbearable. 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 affection 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 unfrcquently 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 relationship is for the most part doubtful. It often happens that careful examina- tion of the gland will detect one or more small hard nodules, TREATMENT OF INTERCOSTAL NEURALGIA. 259 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 sup- posed to be neuromata 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 differe7ttial diagnosis in cases of mastodynia may present some difficulties ; but careful observation will serve to decide the nature of the case. The pain resembles 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; it never remains circum- scribed, and, of course, never disappears, as is often the case with the growths under consideration. Small and deeply-seated abscesses may be mistaken for these tumours of mastodynia, but their course soon reveals their true nature. The sensitiveness of the part in neuralgia of the breast is characteristic ; it is more marked than in any other .affection of the gland. Treatment. — 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 next be paid to constitutional conditions, e.g., 260 TREATMENT OF INTERCOSTAL NEURALGIA. 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 especially iron, are indicated. The combination of arsenic with quinine and strychnine (see page 232) is likely to prove serviceable. When amenorrhoea exists aloes is likely to- be suitable, and mav 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 indispensable. Of these the most efficacious is the hypodermic 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. A pig- ment composed of equal parts of chloral hydrate and camphor, or of chloral and menthol, forms a good applica- tion. If these measures fail to relieve, electricity should be tried ; and, first, the continuous current, the positive pole being applied close to the vertebrce and the negative to the lower border of the ribs in the affected spaces. The mduced current may be applied in the form of the faradic brush. In very obstinate cases blisters are likely to be serviceable. Herpes zoster is rather a favourable compli- cation than otherwise, for the pain generally subsides when the blisters left by the vesicles heal up. For mastodynia it is often necessary to try one remedy after another until a SCIATICA. 261 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 care- fully 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 distribution. The frequency of the affection is due to the exposed and superficial posi- tion of the nerve ; but it would appear that in many cases the mischief is seated in the surrounding parts rather than in the nerve itself. The term is somewhat loosely used ; it has, for instance, 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. 262 CAUSES OF 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. Causes. — Sciatica 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 gout, predispose to sciatica ; and in the former of these gummatous growths are some- times 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 SYMFTOMS OF SCIATICA. 263 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. Con- ditions 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 of lead, but the brachial nerves are more prone to be affected in these cases. Pain along the course of the sciatic nerves is not unfrequent in diseases of the vertebrae and of the spinal cord. Symptoms. — 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 264 SYMPTOMS OF SCIATICA. the pain begins below and spreads upwards. The pain is sometimes continuous, 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 spon- taneously, but are almost invariably excited by movements of the limb and pressure. The course of the nerve is some- times exquisitely tender. In severe cases, owing to the pain which is caused, movement 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 sometime in one position. Cough- ing 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 aj)t 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 SYMPTOMS OF SCIATICA. 265 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 shift its seat from time to time, without altogether leaving the spot in which it tirst 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 other 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 fiexor muscles of the thigh and the muscles of the leg are stiff and tense, and motion is difficult, even when the pain is not of itself 266 SYMPTOMS OF SCIATICA. 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 affected 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 permanent 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 different cases and at different periods in the same patient. The temperature of the leg and foot on the affected side is sometimes increased, some- times diminished ; the colour may be either pale, or there may be patches of redness or diffused coloration ; 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 especially is covered with copious perspiration. It is curious that two such opposite condi- tions should occur in the same affection. In some cases after the complaint 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 SYMPTOMS OF SCIATICA. 267 hand, hypertrophy of the muscles has sometimes been noticed. Other evidences of disorders of the trophic nerves are sometimes suppHed by the occurrence of various forms of eruption, e.g., erythema, eysipelas, 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 troublesome. 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 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 excitability 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 thev have ceased in the 268 DIAGNOSIS OF SCIATICA. thigh. In some cases the last symptom is some amount of anaesthesia 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 indefinite character ; it usually ex- tends 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 to remain for some time after the pain has ceased. Re- lapses are very prone to occur, but instances are not un- frequent in which, after many weeks of very severe suffer- ing, 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 locomotor 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 confounded 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 TREATMENT OF SCIATICA. 269' 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 always young, and a careful examination will detect the source of the mischief. Besides the affections already men- tioned, it must be remembered that pain along the 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 espe- cially at the points of attachment of the muscles, and is not spontaneous, but is felt only when the muscles are in action. Prognosis. — This 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 condition. In cases dependent upon serious lesions in the pelvis, the prognosis is, of course, of a different character. Treatment. — Sciatica generally yields to properly directed treatment, and local remedies are often of signal 270 TREATMENT OF SCIATICA. service. Avast number of means 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 purpose the affected limb must be carefully examined in order to discover whether there are any local affections 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 appro- priate. 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 arc to be avoided. Salines will also be found suitable for non-gouty cases in whom consti- pation is a prominent symptom, but other purgatives, such as extract of aloes and castor oil, may also be used. in rheumatic subjects, iodide of potassium or sodium will probably be found the best remedy, doses of from five to ten grains thr(X" times a day being usually sufficient. It is well to add a little bicarbonate to the iodide, and the dis- agreeable effects which the latter sometimes produces may treatmi:nt of sciatica. 271 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 sometimes prescribe 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 quijiine 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 tnorphine is pro- bably the most potent remedy of this class that 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 give relief, or if it produce distress- ing 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. The 272 TBEATMEST OF SCIATICA. hypodermic injection of a solution (i per cent.) of osmic acid is recommended by Dr. Cohen, of Philadelphia. Ten minims are used at first, and the quantity is to be gradually increased to thirty minims. Electricity is sometimes valuable for the relief of sciatica r but its action in this respect is very uncertain, and therefore it is impossible to foretell its effects in any given case. In recent attacks the continuous 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 follow- ing rules for the application of the constant current for the relief of sciatica. P>om 20 to 40 cells are required, but when used the strength of the current should be gradually increased ; the sponge rheophores should be of large size and thoroughlv saturated with warm salt and water. Each sitting should occupy from 10 to 15 minutes, and during the a])p]ication the rheophores should not be lifted from the skin; before they are rt;moved the current should be graduallv reduced to zero. Unless this precaution be taken, more or less shock will be caused when the current is interru])ted. There are three modes in whi( h the constant current can l)e applied : — TREAT3IENT OF SCIATICA. 273 1. The rheophore connected with the positive pole is applied to the upper part of the sacrum on the affected 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 dis- tance 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, follow- ing the track of the nerve." A smaller number of cells must be employed than in the preceding 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 method of application is theoretically the best, as being 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 symptoms are those of muscular rheumatism. The electric brush should be drawn along the course 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 T 274 TRISATME^T OF SCIATICA. and the limb remains weak and stiff, faradization of the muscles with moistened rheophores is often very efficaci- ous. The use of this form of electricity may also be com- bined with the hypodermic injections of morphine. Various anodynes in the form of liniments may be applied externally. The mixture of menthol with chloral hydrate forms a good application. One of the best anodynes is the chloride of methyl used as a spray for a few seconds along the course of the nerve. Attention has lately been called to an old method of treating sciatica by enveloping the limb in flowers of sulphur: the latter is poured upon the limb as a bandage is wound about it, and the whole covered with oiled silk. Blisters have been already alluded to as especially suit- able 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 exist- ing tender spot in the spinal column. Acupuncture is pro- bably 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 TllEATMJiNT OF SCIATICA. 275 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 obtained, or are unsuitable for the patient, warm applications 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 tempera- ture of the water is gradually increased to the maximum that the patient can bear, and a cold douche is then sub- stituted 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 establish- ments ; they would appear to be suitable for subacute and chronic cases. The same remark applies to massage, 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 operation of this character. CHAPTER IX. ARTICULAR NEUROSES— NEURALGIA OF THE JOINTS. Nature and Pathogkny of Neuralgia of the Joints — Phedisposing AND Exciting Causes — Symptoms — Cutaneous Hyper/fstiiesia — Position of the Limb — Joints usually Affected — Course and Progress or Neuralgia of Joints — Diagnosis — Anesthesia often Necessary — Mental Condithjn of the Patient — Results of Appli- cation OF Bandages, etc. — Exaggerated Patellar Reflex in Hysterical Contraction of the Knee-J(jints — Pain in Knee an Occasional Symptom of Hip-Joint Disease — Treatment, Constitu- tional AND Local —Massage, Douches, Baths, etc. — .Electricity — Use of the Limb to be RECf)MMENDED. This affection \\as iirst described by Sir Benjamin Brodie in 1822, but some light has been thrown upon its nature by subsequent investigations. Neuralgia of the joints is a painful affection, which has its seat in the sensory nerves supplying the articular capsule, the fibrous ligaments, the skin, and the neighbouring tissues. The pain is not con- fined to a single nerve and its distribution, for a joint is supplied by branches of several nerves ; 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 obturator ramify in and around the knee-joint. A rare form of neurosis of th(^ joints is due to vaso-motor disorder. An experiment n-cc-ntly made SYMPTOMS OF NEURALGIA OF THE JOINTS. 277 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 w^ell 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 dis- orders 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 suffering to injury or to over-exertion of the joint. In some cases the pain is due to irregular distribution of pressure within the joint, such as may be caused by wearing shoes with high heels, and in other instances the neuralgia is the remains of some inflam- matory affection, due, perhaps, to a trifling injury. Symptoms. — The knee or the hip-joint is almost always the part 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 directions. 278 SYMPTOMS OF NEURALGIA OF THE JOINTS. 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 either irregularly or at the menstrual periods. Sometimes they are provoked by excitement, and some- times 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 surrounding parts usually excites great pain; but in some cases a slight touch seems to cause more suffering than decided manipu- lations. 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 to cause great pain. The most striking feature connected with the affection is the contrast presented between the subjective symptoms and the absence of any tangible or visible changes in the joint. Any swelling 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 tvvitrhings, 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 red- SYMPTOMS OF NEURALGIA OF THE JOINTS. 279 ness 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 instances 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- 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 concentrated upon the painful joint, with the result of magnifying 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 exhibit- ing any real improvement. The tendency is for the limb to become weaker, and the joint more stiff. 280 DIAGNOSIS OF NEURALGIA OF TRE JOINTS. Diagnosis. — The diagnosis of nervous affections of joints is in not a few cases a very difficult task, especially in the early stages, and whenever there is any history of previous injury, however slight and unimportant. 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 as to the real condition of things; but it is generally advisable to make several examinations, 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 generally be observed that remedies which would relieve a real affec- tion of a joint will only increase the symptoms in a neurotic disorder. It has, for instance, been found that the applica- tion 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 generally 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 contraction of the knee-joint and other ailments, the knee jerked out immediately the patellar reflex was TREATMENT OF NEURALGIA OF THE JOINTS. 281 tested. A similar result was obtained in another case, the patient being a young woman, aged 26, who had been bed- ridden for four months. It must not be forgotten that in young subjects obstinate pain in the knee is 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 kiiids 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 carry out a few simple injunc- tions. The remedies to be prescribed are massage, care- fully conducted, douches of tepid water, active and passive movements, 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 electrodes should correspond with the size of these spots, against 282 TREATMENT OF NEURALGIA OF THE JOINTS. which they should be pressed, the strength of the current being gradually increased to the maximum that the patient can bear. Before withdrawing the electrodes 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 oftenSymptomatic — Associated with Cerebral Hyperemia, 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 Refrac- tive Apparatus of the Kye — Diagnosis of Headache — Treatment of the Hyperemic 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 likewise 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, implicating especially the frontal sinuses ; and, lastly, it is not unfrequent 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- 284 FOliJIS OF HEADACHE. proposed to consider those headaches which, not connected with acute local or general disorder, are due to a variety of causes not always very obvious, and comparatively insigni- ficant 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 ; sometimes it is felt principally at the vertex, as in women with uterine disorders. The character of the pain varies with the condition with which it is associated. Thus, when there is active hyperaemia, it is described as throbbing, 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 un- bearable. In idiopathic cases the pain is wont to occur periodically ; it is rarely continuous, 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 head- aches may be divided into classes, according as they are associated with vascular or nervous symptoms. The former may be either those of increased or of diniitiished blood- supply, and this first category may again be subdivided into FORMS OF HE AD A CHE. 285 those in which the hypersemia is active and those in which it is passive. In headache due to active hyperemia 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 lowering 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. This kind of headache is not unfre- quent in young persons of both sexes, 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 ; sleeplessness is always present, and its effect is to exaggerate all the symptoms. Vomiting and attacks resembling apoplexy with transient loss of speech sometimes occur, and the complaint at this stage proves very intractable. Headache, associated with passive hyperaeinia, is a common symptom of diseases in which the escape of blood 2S6 FORMS OF SEADACHE. from the veins of the skull is impeded. Hence it is frequently met with in diseases of the heart, and in cases in which cers'ical 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 treatment. 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 in the recumbent position. The sensation in the head is described as if the skull were forcibly compressed ; but sometimes the pain is felt especially in the forehead and vertex. There is likewise a 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. (See page 34.) These form a large class at the present day, and include brain-workers of all kinds, men of business, speculators, and others \\hose 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 FORMS OF HEADACHE. 287 ihis other symptoms of neurasthenia, as described in the chapter devoted to that subject, are always associated. In some cases there is more or less hyperaemia, 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 ; listless- ness 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 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 by the fact that the former is greatly relieved, or perhaps completely subsides, when vomiting takes place. Headaches of this class are often associated with 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 dis- orders. Rheumatic and gouty subjects are prone to suffer from Jieadache. 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 288 FORMS O F SEADACHE. either of migraine, which is very common, or of sharp explosions of lightning-like pains over the parietal bones, occurring in quick succession, 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 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 ligt/ors has been already mentioned, and in chronic cases results, in some degree at least, from the action of the poison upon the stomach and li\'er. A small dose of opmm 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-poisoning, 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 svphilis, deserves a brief notice, if only because its nature is apt to be overlooked, and the treatment correspondingly mis- directed. Pain in the head often accompanies an outbreak of secondary symptoms, and is wont to persist after the FOliMS OF HEADACHE. 289 fever has subsided and the eruption is fully out. The seat of the pain is usually 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 inflammation 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 are adopted. The attention of the profession was particularly directed to this form of headache some years ago by Mr. Brudenell Carter, who met with a case in which a wrong diagnosis had caused much w 290 DIAGNOSIS OF HUADACHF. 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 astig- matism being discovered on examination. Besides the attacks of headache, such patients often complain of giddi- ness, faintness, indigestion in various forms, languor, sleep- lessness, and debility, all of which symptoms are 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. Diagnosis. — The account just given of the various forms of headache will sufficiently indicate the great variety of conditions under which the affection may arise. Neuralgia affecting the head and migraine are to be distinguished from headache in general ; in the former the pain follows the course of certain nerves, branches of the fifth or the • See paper by Mr. T. H. Bickerton, on " Headache due to Errors of the Kcfraclivc Media of the Eye,'' Lancet, August 13, 1887. Sec also Dr. Stevens' work on " Functional Nervous Affections," p 35. DIAGNOSIS OF HEADACHE. 291 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 condi- tions with which it is associated. Attention should, there- fore, be paid to the head itself, the eyes and nose, the organs of circulation and digestion, 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 con- comitant disorder 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 and casts of the tubes. Care must be taken that the pain of acute glaucoma is not mistaken for headache ; the rapid decrease in visual power and the increased tension of the eyeball are the distinguishing characteristics of the former complaint. 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 aie discoverable in a large proportion of cases. 292 TREATMENT OF HE AD AC RE. Treatment. — Every case of headache requires to be made a separate study in order that the treatment may be pro- perly directed. In chronic cases with evidences of cerebral hyperaemia, 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 ; cold affusion may be practised, or an india rubber bag filled with iced water may be placed upon the head. Saline purgatives are usually indicated, and sometimes it is necessary to aid their effect by a preliminary dose of calomel or compound colocynth pill. Various mineral waters are suitable for these cases, and especially those of Carlsbad, Marienbad, Friedrichshall, Hunyadi Janos, and Rubinat 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 calm excitement, but their use should not be too long continued. Galvanism applied to the sympathetic nerve in the neck is sometimes 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 TBEATMENT OF HEADACHE. 293 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 appropriate combination. In opposite conditions of the system, viz., those connected with anaemia, tonics Sive indicated, and especially the various preparations of iron and quinine. Arsenic and strychnine are also sometimes suitable for these cases. Headaches occurring in cases of neurasthenia or result- ing from over-work, are often very difficult to treat. Rest is one main element in the treatment, and supplemented by change of air and scene will often do more good than medicines. Anaemia must be dealt with as above indicated. In some cases a combination of quinine with hydrobrofnic acid proves very serviceable. Bromide of potassium is useful to procure sleep, and morphine may be used hypoder- mically for the same purpose. Moderate exercise, plain nutritious diet, wath 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 lieadache, alkalies and warm applications are indicated, and a few doses of iodide of potassium 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. 294 TREATMENT OF HEADACHE. The treatment of headache due to sympathy with other organs is that of the original affection. When the symptoms are those of acute indigestion and are traceable to errors in diet, an emetic, such as mustard or ipecacuanha in warm water, is often the best remedy. The treatment of head- ache connected with errors of refraction is simply the use of the appropriate spectacles. In cases in which, after thorough investigation, the 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. Nervous headache, especially if associated with sleepless- ness, is often relieved by cannabis indica, taken night and morning, in doses of gr. \ of the extract, for some days or weeks. The valerianate of quinine is suitable for the headache of nervous hysterical women ; it may be given in combination with the cannabis. 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 belladonna, either separately or mixed, and to any of these a little chloroform liniment may be added with advantage. Pain in the forehead and temples may be relieved by the application of a pigment containing equal parts of chloral and camphor, or of chloral and menthol. CHAPTER XL HEMICRANIA.— MIGRAINE.— MEGRIM. Frequency of Hemicrania — Its Prominent Features — Premonitory Symptoms — Symptoms of the Attack — Phenomena indicative of Vaso-motor DiSTURiiANCE— Two Forms — Disorders of Vision — Periodicity of Migraine — Length of Paroxysms — Causes of Migraine — Sex, Age, Hereditary Tendency, Gouty Predisposition — Exciting Causes — Anxikty, Over-exertion, Impressions on Certain Nerves of Special Sense, Derangement of Stomach, Rela- tion 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 Neuralgia — Diagnosis — Prognosis — Treatment— A Course of Quinine — Aperients — The Iodides with the Alkaline Carbonates for Gouty Subjects — Strychnine, Arsenic, Oxide of Zinc, and Nitrate of Silver — Attention to Diet and Habits — Question with regard to Stimulant^, Sleep, and Exercise — Change of Air and Scene — Pre- cautionary Measures when a Paroxysm is Threatening — Rest, Darkness, and Warmth — Stimulants, Nux Vomica, Sodium Bicar- bonate — 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 Guarana — Galvanism. This form of headache is very common, and causes more suffering and incapacity for work than could well be imagined by those who have had no personal experience of the complaint. There are, moreover, many obscure points 296 SYMPTOMS OF MIGRAINE. connected with its pathogeny, and it is often very intract- able ; 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 modiHcations 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 alteration 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 uni- lateral there is some amount of uneasiness felt on the other side. Symptoms. — As a general rule attacks of migraine are preceded by ccrfaiii prodromal symptoms, the nature and duration of which vary in different cast's and in different attacks. For a period varying from half-an-hour to per- haps three or four hours before the jjain 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 SYMPTOMS OF MIGRAINE. 297 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 pain is felt on waking in the morning, as in a case which I attended in consultation with Sir W. Jenner ; sometimes the attacks occur in the evening, after a day of more or less uneasiness. The pain never comes on suddenly and with- out 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, 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 aggra- vated 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 indicative of vaso- motor disturbance , and occurring in two principal forms. In the first of these during the attack the painful side is 298 SYMPTOMS OF MIGRAINE. 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 fiow of thick saliva. After an interval, which varies much in different 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 symptoms which are liable to occur are palpitation of the heart with increased frequency of the pulse, sensation of heat over the body, vomiting, and secretion of limpid urine. The vomiting and retching are apt to be peculiarly distressing in young subjects; as age advances these symptoms generally become less prominent. At the close of some attacks diarrhoea occasionally sets in. I have recently been attending a lady, aged 24, whose attacks always thus terminate. 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. SYMPTOMS OF MIGliAINE. 299' In some few cases ophthalmoscopic 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 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 disorder, 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 certain 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 appearances. 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 300 SYMPTOMS OF Ml&RAINE. vision, coming on in paroxysms, with intervals in which the sight is comparatively unaffected. The spectral ap- pearances are less frequently noticed ; flashes of light are perhaps the most common. Some patients describe a kind of glimmering, 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 happen 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 commence at noon, or at any time afterwards, it generally reaches its acme before bed-time ; the patient then is apt to fall into a CA USES OF MIG1{AIN]£. 301 heavy sleep, from which he awakes, whether in the night or early morning, free from pain. There are, however, excep- tions to this rule, for in a small proportion of sufferers the attacks last for several clays, 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 impossible. Those who, under such circumstances, have to attend to the slightest duties are much to be pitied. Causes. — 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 sexj age, and hej-editary 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 pro- cess, and they are wont to cease after the menopause ; their severity and frequency are increased by menstrual irregularities. With regard to age, the attacks generally ap- pear before adult life is reached ; it has indeed been stated that they rarely, if 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 302 CAUSES OF MIGRAINE. 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 complaint. A decided liercditary tendency can often be shown to exist in cases of migraine, the occurrence of the complaint being traceable through several generations. It is more- over a fact of considerable interest that the complaint is apt to occur in children whose progenitors have suffered from other forms of nervous disorders, e.g., epilepsy, hysteria, neuralgia, and various mental derangements. When the hereditary predisposition to nervous affections is very strongly marked in one or both parents, it is some- times noticed that one child may suffer from migraine, while others are the subjects of epilepsy, hysteria, or neuralgia. K gouty family taint\s a predisposing cause of migraine. In my work on Gout* I have drawn attention to the frequent coincidence of nervous affections with the presence of the gouty diathesis. In some families 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 sometimes take the place of the latter. Dr. Liveiiig thinks that migraine, whatever form it may assume, is very frequently connected * " Gout ami its Relations to Distases of the Livir and Kidneys," 6th edit., p. 98. CA USES OF MIGRAINE. 303 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. More definite statements can be made with regard to the exciting causes of the attacks. Excitement, anxiety, worry, over-exertion, whether mental or bodily, will often cause an attack ; impressions on the nerves of special sense, whether caused by disagreeable odours, exposure of the eyes to strong light, 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 enjoyment which makes a decided impression on the nervous system. Derangement of the stomach is not unfrequently 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 cases, 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 pass off. This experience is 304 CA US J': .V O F HI I G R A 1 SE. 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. Attacks of migraine are some- times connected with insufficiency of various ocular muscles and errors of refraction. The condition of some patients as regards sleep is closely 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 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 head- ache ; in the latter, however, there are generally indica- tions of cerebral hypenemia, whereas there is every reason to suppose that an opposite condition prevails during sleep. The influences of menstrual disorders, both as predisposing and exciting causes, has been already noticed. PATHOGMNY OF 31IGB,AINE. 305 Pathogeny. — 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 circula- tion. Whatever the condition of the affected parts may be, it is, to say the least, highly improbable that it corres- ponds with that which lies at the bottom of facial neuralgia, which differs from migraine in so many respects. The spastic form of the disorder, viz., that 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 doubt- ful point, but it seems probable that the dura mater, the pia mater, 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 contractions whether of the striped muscular fibres, e.g., of the legs, or of the unstriped fibres of the bowels or uterus. This theory, X son PATHOGEN y OF MIGIiAiyE. 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 observed in the two opposite conditions of anaemia and hypersemia set up irritation of sensory nerves in any or all of the following parts — the skin, the pericranium, the cerebral membranes, and the sensory por- tions 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 extraor- dinary than the origination of epileptiform convulsions under equally diverse states of the vascular system. The other symptoms of migraine, e.g., the cutaneous hyperaes- thesia, 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 quan- tity 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 PATROaENY OF MIGRAINE. 307 disorder or irregularity of the circulation, but in a primary 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 accumulation and discharge of nerve-force. The immediate ante- cedent 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 disorder 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. ^ 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. * See Dr. Liveing's work on " Megrim, Sick Headache, and some Allied Disorders," p. 3^6, et seq. 308 DIAGNOSIS AND PROGNOSIS OF MIGRAINE. Diagnosis and Prognosis. — The d/agnosis 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 constitutional 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. 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 occurrence tends to restrain patients from various excesses to which so un- pleasant 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 circumstances and habits of life of the patient; under favourable surroundings, and with TREATMENT OF MIGRAINE. 3U9 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 affec- tion, owing in a great measure to the difficulty or impos- sibility 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 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 imme- diately after. 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 310 T]iEAT3IEyT OF MIGRAINE. had for many years been subject to almost weekly recur- rences. A course of cannabis indica (gr. \ of the extract twice daily for several weeks or months) is sometimes very beneficial, and is always worthy of a trial. 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 irregularities should receive careful attention. In cases of migraine with a gouty family history, I have witnessed much relief from a com- bination of the iodides with al/calinc carbonates and mix vomica. As a matter of course. In all cases of migraine the diet and general habits of the patient are points of much im- portance. The food should be nourishing, easily digestible, moderate in quantity, taken leisurely and at regular in- tervals. The evening meal should always be a light one. Tea and cofTee may be allowed, but always in moderation, and with regard to alcoholic drinks, excess must, of course, be prohibited, but small quantities of those preferred by the patient may be allowed if taken with meals. Sleep is another important consideration, 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 regulated by the patient's circumstances, always remembering that over-exertion is likely to be as mis- chievous as the opposite condition. The functions of the trjea tme n t of MIGRA INE. 3 1 1 skin must likewise be attended to. The eyes should always be examined, and errors of refraction should be relieved by suitable glasses. 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 water- ing-places, but the effect seems to be of a transitory character. 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 by 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 lo or 15 minims of the tincture with an ounce of water, and to sip the mixture slowly. In some persons the effect of this remedy, especially when combined with the measures just adverted to, is very satisfactory. Dr. E. L. Dana recom- mends menthol, gr. v-xv, in a wineglassful of hot water for 312 TREATMENT OF MIGRAINE. the purpose of cutting short an attack. A full dose of sodium bicarbonate acts well in most 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 recumbent position will often induce sleep, from which the patient awakes almost or altogether free from discomfort. Dr. Haig believes that certain forms of migraine are closely connected with a large excretion of uric acid, and that such excretion is diminished by large quantities of acid drinks and increased by alkalies. At the beginning of an attack, he therefore advises from 40 to 60 drops of dilute nitro-jnuriatic acid taken in two doses within an hour, or a glass of very strong lemonade. It must be admitted that the rationale of this treatment is somewhat obscure. A )i tip}')' in has lately been recommended for the relief of migraine. A single dose of from 10 to 15 grains will sometimes cut short an impending attack. I have wit- nessed 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. It is perhaps better to use small doses at iirst (gr. iii-v), and to repeat every half-hour, if necessary, until 20 or 30 grains have been taken ; even a few grains of antipyrin sometimes cause sickness and other unpleasant symptoms. TREATMENT OF MIGRAINE. 313 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. A more potent anodyne is a mixture of menthol and chloral, equal parts, or menthol and campho7' (3 : 2) ; this is applied on a brush to the supra-orbital region. 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 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 hypoder- 314 TREATMENT OF MIGRAINE. mically (eight to ten minims of the Pharmacopoeia injec- tion). Cannabis indica appears to benefit some patients ; from ten to fifteen minims of the tincture may be 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 hypodermic injection of morphine is another remedy of this class, but it is less efficacious than chloral, and is, moreover, quite unsuitable 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 ; the effervescing preparation is a very convenient form. 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 TREATMENT OF MIGRAINE. 315 must be used, one pole being placed on each mastoid pro- cess. If it be wished to galvanize the sympathetic 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 anu Liver — In Affections or 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— \ertigo of An.f.mia, Neuras- thenia, 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 epilepsy; in states of debility and anaemia; as an effect of various functional disorders of the nervous system, and of some chronic diseases of the heart. There are also toxic forms of vertigo, examples of which are seen in some cases of lilhaemia, and likewise as a result of alcohol, tobacco, and various other drugs. In a few rare cases in which giddiness is a prominent symptom, no other abnormal condition can be detected. I have recently treated a gentleman aged 35, FORMS OF VERTIGO. 317 in whom vertigo was the only symptom, while its cause remained obscure. The term vertigo implies a sense of defective equilibration, accompanied by a feeling of false impressions 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 revolv- ing 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 accom- panied by a feeling of nausea or even by vomiting, 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 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 age, 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 318 GASTRIC VERTIGO. attack of nausea and vertigo is the invariable result of eating certain articles of food, e.g., shell-fish and eggs. I have met 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, flushing of the face, buzzing or other noises in the ears, eructations, perhaps of an acid character, palpitation, 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, or partial blindness, flashes of light before the eyes, confusion of ideas, and great uneasiness. In some cases^ but not in all, the giddiness passes off, 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. When the vertigo is most marked some hours after eating, the symptoms are pro- bably due to the presence in the blood of the products of imperfect digestion. The attacks, whatever form they may GASTRIC VERTIGO. 319 assume, are very apt to recur, and in some patients a condition of giddiness becomes established, 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 at- tention 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 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 with a draught of lukewarm water. If the bowels be 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. Tincture of nux vomica is likely to be serviceable ; ni^v-x may be given before meals. When the liver appears 320 OCULAli VERTIGO. 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 confusion of vision, and these symptoms with the giddiness may become so severe that the patient fears to walk alone in the streets. When the affected eye is closed, the vertigo usually passes off. Loss of power of the internal recti muscles is another cause of vertigo, and this condition is not unfrequent in per- sons whose daily occupation 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 graduallv 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 hand, after rest, change of air, and 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 AURAL VERTIGO. 321 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 treatrnent of vertigo due to ocular causes consists in remedying the defect in the eyes, either by suitable glasses or by operation. Aural vertigo, to which much attention has been paid since its pathology was explained by Meniere in 1861, is generally regarded as due to irritation of the nerves of the semicircular canals. The vertigo is associated with auditory sensations of a severe character. The acute attacks may be 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 con- scious of a loud, buzzing, whistling, or cracking noise in one ear; the heart's action becomes irregular; the face is 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 con- sultation with Dr. Woakes. Neighbouring objects appear to oscillate or to revolve round the patient ; he reels or totters as though the ground were moving under his feet, Y 322 AUBAL VEJiTIGO. 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 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 hear- ing is commonly noticed after the first attack, when the latter has occurred without any premonitory symptoms. There is generally no evidence of disease of the external or middle ear ; but bone-conduction is found to be more or less impaired. In some patients the giddiness and -noises in the ears are almost habitual, becoming worse at intervals. In ordinary cases the giddiness and impairment 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 recently •seen a patient suffering from aural disease, in whom the noises continued for months and then stopped suddenly, and would 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 become complete, cessation of the attacks is the general AURAL VEliTIGO. 323 rule. Aural vertigo is liable to be mistaken for giddiness, the result of cerebral congestion. In this latter condition there are frequently intervals of decided loss of conscious- ness, 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 characteristic 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 condi- tion 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 peripheral organ, a brain-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 pro- ducing anaemia of certain parts of the brain. The vertigo, reeling, 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 324 AURAL TEliTIGO. 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. Dr. Buzzard {Lancet, Vol. i., 1890, p. 179) thinks that in a large number of cases, the auditory nerve is affected through its centre in the medulla and not at the periphery, and that vertigo, with auditory symptoms, is not always dependent upon a local affection of the labyrinth. He further suggests that " something like a nerve-storm of migraine sweeps through the medulla oblongata, and sets up in the auditory nerve a condition which would give rise to neuralgia in a nerve of common sensation." A gouty history is very common among the subjects of auditory vertigo, and it may be that the presence of some uric acid salt, or other product of disordered metabolism, irritates the medulla, and induces the attack of giddiness, vomiting, irregular action of the heart, etc. In the treatment of aural vertigo, the ear should be examined in the ho[)e 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, astringent 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 AURAL VERTIGO. 325 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. Dr. Buzzard recommends the salicy- late of sodium ; it promotes the elimination of uric acid and also acts on the nerve-centres in the medulla oblon- gata. 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 mas- toid process is likely to prove serviceable. Attention should be paid to any gastric derangement, for in the subjects of aural vertigo, disorder of the stomach is liable to provoke an attack. It must not be forgotten that when the deaf- ness becomes complete and permanent, the vertiginous 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 being counterbalanced 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 cavity and hence the greater or less * " On Post-Nasal Catarrh and Diseases of the Nose causing Deafness," p. 52. 326 VJEllTIGO AND DEBILITY. 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-labyrinthine fluid, which constitutes a predis- posing cause of vertigo. Now the subjects of chronic catarrh are particularly prone to attacks of vertigo, which attacks are frequently initiated in i\\& prinue vice." In various conditions of debility, as a}ixt)iia and neuras- thenia, more or less severe vertigo is a somewhat 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 conditions, 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 neuras- thenic 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 complaints 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 unsteadiness. There is no deafness, and noises in the ears are rarely complained of; VERTIGO AXD yEJiVOUS BISORBEES. 327 the vertigo is aggravated by 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 equilibrial 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 dizzi- ness, 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 giddi- ness. Epileptic vertigo is generally accompanied by impairment or loss of consciousness, and often by various motor phenomena and some of the other ordinary symptoms of the typical epileptic paroxysm. Dr. H. C. Wood states that attacks of vertigo of the mildest descrip- tion may be a symptom of or represent a paroxysm of incurable epilepsy. The vertiginous feelings in an attack of migraine are seldom severe, unless the patient happen to be travelling 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 after free vomitinor. There is neither deafness nor noise in 328 VERTIGO AND GOUT. the ear ; but various ocular symptoms of migraine are generally associated with the giddiness. The treatment of these forms of vertigo is, of course, that of the conditions with which they are associated. Vertigo is sometimes complained of by the subjects of chronic cardiac disease, and especially of fatty degeneration or of some other lesion accompanied by failing power. In these cases, sudden change of position may produce an attack. The vertigo of old age is generally due to disturb- ance of the circulation, and imperfect supply of blood to the brain, the result of atheromatous changes in the vessels. When once developed, the giddiness is apt to be very troublesome and persistent. Vertigo is somewhat frequent in ^outy 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 irregular or shooting pains, depression of spirits, irritability, headache, disturbed sleep, flatulence, and other signs of gastric disorder. It is probably due to the presence of lithic acid and otlier imperfectly oxidized sub- stances in the blood, and not unfrequently to the presence of undigested and irritating articles of food in the stomach and bowels. In some cases, gouty vertigo is associated with marked irregularity of the heart's action, leading to the belief that cardiac disease is the cause of the symptom. The treatment is that of gouty dyspepsia; the diet must VERTIGO AND GOUT. 329 be carefully regulated; excess of animal food and indi- gestible 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, y^sculap, Hunyadi Janos, or the Rubinat-Condal. When there are marked symptoms of gastric catarrh, such as fermentation and acid eructations, Carlsbad water is preferable. Should the function of the liver appear to be imperfectly per- formed, small doses of calomel or blue pill, either alone or in combination with colocynth or rhubarb, may 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. The salicylate of sodium has been already referred to. 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 pre- sumably 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 Fokms — Allied Disorders — Diagnosis — Treat- ment — Rest — Wolff's Method —Galvanism — Attention to General Health — Local Measures — Counter- irritation — Mechanical Ap- pliances. 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, previously accomplished with perfect ease, are rendered difficult or even impossible in consequence of cramp, tremor, paralysis or acute neuralgic pain, whereas other movements are performed by the same muscles without 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 involved are comparatively few in number. Writer's cramp occurs almost exclusively in persons whose avocations require them to write for many hours WRITER'S CRAMP. 331 daily. The majority of the sufferers are those who are compelled to write a good legible hand and overtax their muscles. Weakly subjects with a predisposition to nervous affections 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. Dr. Wood regards writer's cramp as a form of local neurasthenia, and states that it is frequently associated with brain-exhaustion- It sometimes appears as the herald of a general break- down ; in such cases the cramp is less marked, but there is loss of power and distress in the arm on attempting to write. 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 dis- ordered 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 years of laborious education to act in harmony with many others 332 SYMPTOMS OF WRITER'S CRAMP. for the accomplishing of a complicated and delicate 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. Moreover, if the left hand is used to supply the place of the right it is soon apt to become affected in a similar 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, inasmuch 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. Coarse movements can be made with comparative ease. In the most co7?tmon/orm 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 (jbvious that certain muscles, or groups of muscles, are spasmodically contracted. In some cases the thumb is drawn across the palm, and thus pressed against the pen ; in others the index linger 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 SY3IFT03IS OF WRITER'S CRAMP. 333. 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 spasmodically con- tracted. When the hand is affected^ as above described, writing becomes very difficult, 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 painful 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 per- formed without difficulty by the affected hand, and no discomfort is felt except 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. In some cases neuralgic pains on using the hand are the most prominent features of the complaint. 334 SY^IPTOJIS OF WINTER'S CRAMP. These forms of writer's cramp may be combined In various ways ; tremulous movements are often superadded 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 comfortably with a pencil than with a pen. A feeling of tiredness is common to all the patients, but it is especially marked in those who suffer from the spastic form of the disorder. 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 eczema, with severe tingling at the back of the forearm, has been noticed in some cases. The electrical excitability 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 TMEATMJSNT OF W-RITER'S CRAMP. 335 to become similarly affected. I have treated 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 occasionally wit- nessed in ballet-dancers and in girls working treadle sewing- machines. The diagnosis of writer's cramp is almost always easily made. It is only necessary to remember that 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 use of a substitute for whisky. The habit is said to be especially common in certain districts in the county of Derry (it is believed to have originated in Draperstown), and in the borders of the neighbouring counties of Antrim and Tyrone. A considerable impetus was given to the practice by the introduction of cheap ether, made from methylated spirit, and sold wholesale at an average price of a shilling a pound. Large quantities are sent from London to Belfast, whence the ether is distributed to grocers, druggists, and general dealers, and sold retail at the rate of a penny for two drachms. It is also hawked about by beggar-women, and exchanged for eggs and farm- produce. Archdeacon Hamilton, of Desert-Martin, Belfast, has informed me that abundant evidence of the growing popularity of ether as a dram has come under his observa- tion. The habit is very common among females, and the Archdeacon has seen examples even among school children. The statement has recently been made that ether- drinking has become quite common in certain districts of Norway. As in Ireland, the practice seems to have followed closely upon abstinence from alcoholic liquors, the sale of which is much restricted by law in Norway. The farmers are said to buy considerable quantities of ether, and to get drunk with it on festive occasions, as they formerly did with potato or barley brandy. It is also said to be used as a stimulant by many other persons, young and old, rich and poor, of both sexes. 380 ETHER-DltlNKINO. The usual quantity of ether taken at one time varies from one to two drachms, and the dose is often repeated four or five times in the twenty-four hours. It is generally preceded and followed by mouthfuls of water, but the habitue takes the ether alone. It is said that a dozen or more doses are sometimes taken in one evening. Effects are very rapidly produced and pass off very quickly, leaving behind little or no discomfort in the shape of nausea, headache, dry mouth, etc. ; hence intoxication can be indulged in several times a day. The prevalence of the evil can be gauged by the details given as to the quantities supplied by certain large firms. In two small villages there are two traders each selling over 500 gallons annually. In some places the atmosphere along the roads on market-days is simply impregnated with the fumes of ether, and the smell in the third-class carriages from women who have attended the markets is said to be " disgusting and abominable." Several inquests have been held in recent years on persons who have died from the effects of the drug. The immediate effects are similar to tliose produced by alcohol, but are much more rapidly developed; "the stages of excitement, mental confusion, loss of muscular power, and loss of consciousness follow each other so quickly that they cannot be clearly separated." When a large dose is taken, exhilaration quickly passes into stupor. The stage of excitement, though short, is often very marked ; after ETRER-DRINKING. 381 shouting, dancing, laughing, and violent gesticulations, resembling those of maniacs, the persons fall down, writhing and foaming at the mouth. Recovery soon takes place, but the accompanying depression causes a renewal of the dose, with a return of the excitement. The exhilaration is accompanied by a peculiar feeling of light- ness, and often by profuse salivation and flushing of the face, followed by pallor. Sometimes whisky and ether are taken together, and the condition produced is one of great violence. As to remote effects of ether, there is no evidence of the production of gross lesions akin to those due to alcohoL Chronic gastritis and dyspepsia would appear to be the ordinary consequences ; but when the habit has become confirmed observers have noticed " general debility, great nervous prostration, accompanied by tremors (especially of the neck and forearm), indigestion, irregular action of the heart, subacute gastritis, a peculiar white sallow com- plexion, and in some cases a peculiar livid cyanotic face." Other symptoms, such as muscular wasting, feeble circula- tion, and exaggerated reflexes, have also been noticed ; and the effects on the mind and character are not less marked. The victims are apt to fall into a kind of chronic hysterical condition, and to lose all self-respect; as in the case of nearly all who abuse narcotics, they will lie and even steal to procure their favourite stimulant. It is doubtful whether ether per se causes insanity, but it 382 IITHER.DRINKING. probably calls into action any tendency that exists thereto. It doubtless leads to crime through the violence and pugnacity which are the characteristic features of the first stage of intoxication. The habit probably shortens life by interfering with digestion and nutrition, and death some- times occurs suddenly from an overdose. Ether-drinkers are exposed to another danger, viz., that of setting them- selves on fire when lighting a pipe. TREATiMENT. — The only way of stopping so degrading and mischievous a practice as ether-drinking is to prevent any supply from being obtained, and this step was taken by the Government last winter, after consultation with the Royal College of Physicians of Ireland. An order was passed scheduling sulphuric ether as a poison ; it can now be dispensed only as such, and with the usual pre- cautions, by qualified chemists. It is much to be regretted that prevention was not adopted at an earlier period, and before the habit had become common. SECTION II. FUNCTIONAL DISORDERS OF THE ORGANS OF CIRCULATION. INTRODUCTORY CHAPTER. Peculiar Featuues of Functional Disorders of the Heart — Differ- ences Between Functional and Organic Affections — Symptoms of Functional Disorders, Movements or Sensations of the Organ Affected — Disturbances of Rhythm — Causes of Functional Dis- {jrder of the Heart — Predisposing Causes — Dr. Shapter's Classi- fication — Symptoms 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 Sympathetic Nerve^The Depressor Fibres of the Vagus — Summary of the Circumstances Affecting the Fre- quency OF the Heart's Action. Functional disorders of the heart are of frequent occur- rence, and, owing to the importance of the organ, they are often the source of much inconvenience, distress, and even danger. The symptoms to which they give rise are identical with some of those which result from organic affections, and they are apt to cause much anxiety and 384 FUNCTIONAL CABJJIAC DISORDERS. 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 func- tional disorder may supervene from time to time in cases in which organic disease exists, without anv necessary mutual dependence. A correct diagnosis is, therefore, of great importance, both for the satisfaction of the patient and for determining the treatment 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. 1. In purely functional cardiac disorders, the symptoms, whether serious or the reverse, are never constant for any length of time. In organic cases this constancy is the rule, though the severity of the symptoms necessarily varies very considerably from time to time. When, there- fore, the signs of cardiac disorder are always discover- able, the idea of a functional origin must be excluded. 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 albuminuria. As a matter of course, increased dulness on percussion, and. FUNCTIONAL C AUDI AC DLSORDERS. 385 murmurs of certain kinds, especially when persistent and not occurring in anaemic subjects, are indicative of struc- tural changes. 3 The effect of exercise sometimes serves to distin- o^uish 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, move- ment is very apt to induce and to aggravate palpitation, 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 discontinued. The symptoms of functional disorders of the heart appear as alterations either in the movements or the sensations of the organ. Derangement of movement \.2l^q.s 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 i&rxn palpita- tion. 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 func- C C 386 FUNCTIONAL CARDIAC DISORDERS. tional affection in which pain is a prominent feature, and this latter may be associated with decreased or increased action of the organ. In most of these functional disorders motor and sensory disturbances are variously combined. Disturbances of rhythm in the forms of intermissions and irregularity are not unfrequent symptoms of functional dis- orders. Intermission is mostly of functional origin ; irregu- larity is sometimes observed in dyspepsia, but is more often associated with mitral disease. With regard to their causation in general, it may be stated that functional dis- turbances of the heart's action may be caused by anything 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 pneu- mogastric nerves, and these, together with the muscular walls, require for their normal action an adequate supply of healthy blood. The working of the heart maybe indirectly disturbed by reflex nervous action, as in dyspepsia, intes- tinal 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 paljjitation or irregular action, accompanied, or not, by a bruit. Errors in diet, the immoderate use of FUNCTIONAL CARDIAC DISORDERS. 387 alcohol and of tobacco, over-exertion, and mental shock are amongst the most frequent exciting causes of func- tional 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 exhaustion of the nervous system, all forms of reflex irritation, venereal excesses, vain long- ings, purposeless occupations and amusements, protracted mental exercise, abstinence from adequate repose, etc. (2). Those conditions acting upon the general blood-supply of the body, and consequently affecting the special blood- supply of the heart, such as the turgid and plethoric states ■of gross feeders, depraved states caused by bad and deficient diet, and all forms of blood disorders, as anaemia, gout, scurvy, etc. To these may be added the special tempera- ment 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 faint- ness, with 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, * " Fanctional Disorders of the Heart." — " Qaaiii's Diet, of Medicine." 388 FUNCTIONAL CARDIAC DISORDERS. or too little out-door exercise ; and, especially when irre- gular action of the heart and praecordial pain are very marked, it is difficult to make the patient believe that he is not the victim of organic disease. When the heart's action is affected, and there is dimi- nished impulse with no sign of organic change, the sym- ptoms are evidenced by much depression and mental anxietv. Faintness is often experienced, and there may be flatulence or other symptoms of dyspepsia. In a case recently under my care, the patient, a gentleman 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 precordial 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 Ave minutes to two hours, and occurred at intervals of 10 to 20 days, and always were induced by smoking or sexual intercourse. A few years 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 mas- turbation. The symptoms in this case, though much less urgent, were none the less marked. The j)ractical 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 pre- scribing any special form of treatment. FUNCTIONAL CARDIAC DISORDERS. 389 Functional disturbances of the heart are frequently asso- ciated, as before mentioned, with bruits or murmurs. They are basic and always systolic, 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 anxious lives, not given to dietetic or venereal license. I see many cases in both sexes, and of all ages, who present these murmurs, which are wont to disappear more or less readily under treatment, leaving no morbid results whatever. 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 * ''Essentials of Medicine," 5th Ed., p. 253. 390 THE NERVES OF THE HEART. other organic disease. Careful investigation of these satis- fied me that the condition was one of vmsciilar exhaustion of the heart." The same author says, " Heart starvation is probabh' (in people who are underfed, overworked, or suffer- ing from worry) often overlooked or mistaken for fatty degeneration of the hearth My experience entirely coincides with the opinion expressed by Dr. Hartshorne ; I have seen many cases of the irritable 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 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 nutritious 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 ab- normity 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 experi- ment proves that the rhythmical movements depend upon THE NERVES OF THE HEART. 391 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, l^his phenomenon is best seen in the heart of a fish or turtle ; contractions go on for hours after removal, and even after they have ceased they may be re- 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 dependent upon the central nervous system for the continuance of its rhythmical move- ments. 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 automatic cardiac centres are connected with each other by nervous fibres. The dominating centre, according to Landois, lies in the auricles, and hence the regular pro- gressive movement usually starts from them. The auricular centres seem to be more excitable than those of the ventricle; 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 may be excited from its internal surface, and that very 392 THE SERVES OF THE HEART. 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 Hbres 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. According to some observers, the heart also contains certain ganglia which exercise an inhi- bitory 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 or 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 foramen, and a few days suffered to elapse, the nervous fibres supplied to the vagus in that position undergo degeneration at their peripheral ex- tremities, and are incapable of being excited ; it is then found that irritation of the vagus on that side has no effect THE NERVES OF THE HEART. 393 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 heart's action, after a few pulsa- tions, 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 heart's 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 heart's action is sometimes brought about not by in- creasing the pause between 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. Division of the pneumogastric nerve is followed by per- manent increase in the number of the heart's pulsations and simultaneous elevation of the blood pressure through- out the arterial system, and the amount of work done by the heart is, therefore, increased. The same result is wit- nessed when both spinal accessory nerves are removed from the base of the skull, and no further effect is produced 394 THE NERVES OF THE HEART. by subsequent division of the vagus. It is, 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 strength of action. In addition to being the channel for inhibitory influences, 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 mechani- cally 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 are those through whose instrumentality its action is accele- rated. These are centrifugal fibres, and when excited, they increase the number of pulsations by from 30 to 70 per cent., and thus act as the antagonists of the inhibitory nerves just described. Some pass, however, with these latter in the cervical portions oi both vagi, but a still larger supply is derived from the branchi-s of thi- first thoracic ganglion of the sympathetic, and these take their course to the h<.>art j)artly as independent fibres and partly in con- nection with branches of the vagus. The sympathetic in the nt.'ck sometimes gives off similar fibres. The larger THE NERVES OF THE HEART. 395 portion of these accelerating nerves pass downwards from the medulla oblongata through the cervical and dorsal spinal cord, and thence to the thoracic sympathetic, and finally ta the cardiac plexus. The course described by these nerves is therefore loop-shaped, the majority passing downwards in the spinal cord and upwards 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 which the action of the heart is accelerated, are not, as a general rule, in any 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 pneumogastrics 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 excitement increases the force as well as the frequency of the hearts contractions. There is yet, in some animals at least, a fourth set of nerves, by means of which the action of the heart is in- fluenced. These are the so-called depressor fibres of the vagus, and in rabbits are derived from the superior laryn- geal nerve and are sometimes increased by a second branch 596 THE NERVES OF THE HEART. 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 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 n(;rves of the skin and viscera, is peculiar to them, or whether it is derived from other sensory nerves which are associated with them. The following extract from Dr. Carpenter's " Principles of Human Physiology " gives a short summary of the circumstances affecting the frequency of the heart's action. THE NERVES OF THE HEART. 397 " The heart not only possesses an internal system of ganglia and nerves, by which its 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 in- fluenced — " A. By conditions affecting the intra-cardiac motor gayiglia which may be (i) excited and the frequency of the pulsations increased ; {a) by heat ; {b) by mechanical, chemical, and electrical excitation; [c] by increased blood- pressure, which is essentially a mechanical irritant ; [d) by various poisons ; or (2) depressed, and the pulsations lowered; {a) by cold; {b) by diminished blood-pressure; [c] by certain poisons, as chloral. " B. By conditions affecting the intra-cardiac inhibitory 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 accelerator ganglia leading to increased frequency of action. At present these cannot be satisfactorily distinguished from those affecting^ the intra-cardiac motor eanelia. 398 THE NERVES OF THE HEART. " D. By conditions affecting the cardiac inJiihitory coiii'es in the medulla oblongata, such 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. Thev 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 being dependent upon the preponderating influence of the cardiac motor or medullary inhibitory centres. Usually 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, Dhscription 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 Recurrencii — 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. 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 emotions of every-day life, and under such circumstances 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 alternate with the normal move- ments ; they may last for a few minutes or for some hours. The frequency with which they occur varies greatly ; in 400 SYMFT03IS O F PALPITATION. some cases scarcely a day passes without one or more ; in others there may be weeks or months between the attacks. Symptoms. — A severe attack of palpitation is often ushered in by peculiar sensations in the cardiac region. The patient experiences a feeling of indescribable discom- fort ; the heart appears to be beating irregularly and with difficulty, 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 super- added. The countenance is indicative of the feelings 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 giddiness 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 palpitation its action is found to be tumultuous, abnormally frequent, and perceptible over a large surface. If the attack last 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 some- times so faint that it may appear to be absent ; this change results from the insufficient quantity of blood contained in. SYMPTOMS OF PALPITATION. 401 the aorta and pulmonary artery ; it is more and more marked in proportion to the rapidity of the movements. Sometimes 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 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 always 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 inspirations. The difficulty is aggravated when the patient lies down, but D D 402 CAUSES OF PALPITATION. is relieved by raising the thorax, or by adopting a sitting posture. In severe attacivs 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 dis- figured ; the face is red and generally covered with per- spiration ; 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 gradually. After its disappearance the patients feel very anxious lest it should recur. Sudden subsidence of the attack is sometimes attended with vomiting, eructations, or free action of the bowels. It is worthy of note that there are some cases of palpita- tion 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 mani- fested. Careful examination may, however, detect some irregularity of the pulse during the attacks. Causes. — 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 pncumogastric 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 CAUSES OF PALPITATION. 403 be stated that in most cases of palpitation the condition is that of paralysis of the inhibitory nerve fibres of the heart, supplied by the pneumogastric, and less commonly one of irritation of the excito-motor nerves from the sympathetic. For clinical purposes it is convenient to 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 excitement •caused by joy, grief, shock, anxiety, and the like. The effect of the imagination in producing palpitation is some- times 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 ques- tion, 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 voluntarily 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. Thus it often occurs in connection with congestion, haemorrhage, 404 CAUSES OF PALPITATION. 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 nerves. In a case recorded by myself in the Archives of Laryn- gology, 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 bv 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-venti- lated 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 which palpitation and signs of 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 dinniT. In some persons certain articles of food, even when taken in moderation, are sufficient to induce an attack. In all these cases the pnrunKjgastric is the nerve through which the irritation is CAUSES OF PALPITATION. 405 propagated. Other causes of a reflex nature are constipa- tion, 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 palpi- tation have quite ceased since he has undergone a success- ful operation for the radical cure of piles. Disorders of the uterus and ovaries are especially liable to cause palpi- tation and other symptoms of hysteria, and attacks are sometimes 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 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 discomfort. The palpitation in gouty subjects is due in the first place to irritation, pro- pagated 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, 406 DIAGNOSIS OF PALPITATIOy. and anxiety. Other causes, such as debility, indigestion, and worms, are often present. In all cases the attacks are wont to come on spontaneously; sometimes, 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 occupation is relinquished. Among other causes of attacks may be mentioned intestinal disorders, menstrual irregularities, exposure to cold, or to heat, and the like. Some persons have an attack of palpitation if they lie on the left side. Diagnosis. — 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 during a severe attack of nervous palpita- tion. The murmur is, however, always systolic in character, and is never associated with signs of dilatation and hypertrophy. In chlorotic and anx-mic cases a permanent systolic murmur is often present, but the detection of the bruit de diable and the improvement which almost in- variably takes place under treatment will indicate the TRJEATMENT OF PALPITATION. 407 nature of the case. Pericarditis is often accompanied with severe attacks of palpitation, but the cause of the symptoms can hardly be mistaken. Prognosis. — This, 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 appro- priate treatment. In cases in which the cause cannot be removed more or less amelioration can almost always be promised, but the patients are apt to become very low- spirited and even hypochondriacal. However distressing the attacks may be, a fatal termination 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 existence of obstruction, but in a less numerous class of cases it is the result of increased cardiac action without increased resistance. Niemeyer's statement on this subject has been already referred to. " In many persons 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 principal 408 TREATMENT OF PALPITATION. 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, 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. Pressure 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 injection of morphme often has the effect of relieving palpitation, but its use requires caution. Other remedies 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 aiiiinonium will gener- ally allay the discomfort. In nervous, hysterical, and hypochondriacal subjects, relief will often be afforded by the nervine stimulants, as asafoetida and valerian, camphor, and preparations of ammonia and aether. Aromatics combined with antacids are sometimes useful, inasmuch as they help the expulsion 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 in combination with half the quantity of aromatic spirit of ammonia. TREATMENT OF PALPITATION. 409 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. ^ij of the hydrochlorate of apomorphine may be used instead. For attacks of palpitation in gouty subjects, emetics are not advisable unless there be ineffectual 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 ; moder- ate exercise in the open air and attention to the skin will tend to lessen the irritability of the nervous centres. Con- stipation, if present, must be dealt with by laxatives and mild purgatives. The latter will often relieve palpitation in plethoric subjects ; they may be followed by small doses •of tincture of aconite every two hours. With regard to medicines having a specific action on the heart, digitalis and the broviide of potassium are likely to be serviceable, either separately or in combination. The digitalis should be given in small doses {\\\ v-x of the tincture) three times -a day, and the effects carefully watched. The bromide of 410 TREATMENT OF PALPITATION. 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 eoino- 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 palpita- tion, 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 anemic subjects, the prepara- tions 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 a day, for five or six weeks, under careful medical observation. A few drops of spirit of camphor will often afford relief during the attacks. 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 considered. If there be uterine disorders, as evinced by irregular or suppressed menstruation, special TREA T3£ENT OF PA LP IT A TION. 41 1 treatment will be requisite. Hot foot-baths may be tried to restore 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 III. SYNCOPE— SWOONING— FAINTNESS. Syncopk, Dkfimtion asu Symptoms — Incomplete Attacks ou Faintness — Duration of Attacks — Causes, the Nervous System, the State OF THE Heart, the Condition of the Blood — Impressions on the Nerv us System — Dikkct Effects on the Heart — Mechanical Causes, Poisons — Svscopi-; Resulting from Loss or Deficiency of Blood — Mixed Casks — Duration of Attacks — Syncope Distin- guished from Epilepsy, Apoplexy, Shock, Concussion, and Poison- ing — Prolon(;ed 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 con- sciousness and of respiration, and usually attended by de- pression of the temperature of the body. It may be briefly described as inhibitory paralysis of the heart. The condi- tion 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, 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, SYMPTOMS OF SYNCOPE. 4ia 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 inspirations, the pulse becomes percep- tible, the colour slowly 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, giddiness, 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 diiratio7i of syncope varies ; in the slighter degrees the sensations may last for considerable periods, alternately diminishing and increasing in intensity until they com- pletely 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 condition, 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 414 CAUSJES OF SYNCOFi:. attacks, when connected with organic disease of the heart, may recur again and again until a fatal issue takes place. Causes. — 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 intelligence. In some cases the same effect is produced upon the heart by less severe impressions on the nervous system, such, for example, as result from certain oppressive 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 especially if likewise exhausted after exercise, has been known to produce fatal syncope. Persons differ greatly as regards tlunr liability to syncope. In nervous women attacks are somewhat common. Many of the heroines of the novels written in the last century were CAUSES OF SYNCOPE. 415 remarkable for their proneness to faint under the influence of surprise or excitement. Very sHght causes are some- times sufficient to induce attacks of syncope. Many 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 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 heart's 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 necessary to produce fainting is much less than 416 CAUSES OF Si'NCOPi:. 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 quantity necessary to produce an efTect. 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 organ. 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 c-auses above described co-operate in the production of the result. Thus in aiuemic subjects, the effect of shock or grief is aided by the weakened condition of the heart and the deficiency in the (juantity and (|uality of the blood. Also in cases in which there is organic cardiac disease, an attack of syncope may be easily induced by slight causes, and particularly by gastric distension. DIAGNOSIS OF SYNCOPE. 417 The duration of attacks of syncope has been already alluded to ; it may extend to some seconds or minutes, in rare cases the condition, with various modifications, con- tinues 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 heart 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. Diagnosis. — Attacks of syncope require to be distin- guished from other conditions attended by loss of con- sciousness, 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 consciousness is sudden in its onset, and is frequently accompanied by tonic spasm, succeeded by convulsive movements. The change in colour which the face under- goes from pallor to lividity is a distinguishing feature of epilepsy as compared with syncope. Apoplexy is some- times ushered in with an attack of syncope, the patient becoming faint and collapsed, with pale face, cold damp E E 418 DIAGNOSIS OF SYNCOFH. skin, frequent, feeble and irregular pulse, nausea, and vomiting. These symptoms are soon followed by insen- sibility 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 symptoms 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 inter- fered with, and may be almost completely preserved. In 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 continue 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 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 DIAGNOSIS OF SYNCOPE. 419 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 cofna 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 countenance 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 the rectum. 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. Prognosis. — This will, of course, mainly depend upon the cause of the symptoms ; it is generally favourable unless the syncope depend upon organic disease or profuse haemorrhage. The facility and rapidity with which treat- ment 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 420 TREATMENT OF SYNCOPE. 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 faint- ness, 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 be adopted ; but they are very liable to recur, either speedily or after a longer 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 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 posi- tion when he feels any of the premonitory symptoms. Threatened fainting may also be averted by causing the patient to sit down and lean forward as far as possible, so as to bring the head between the legs ; the blood then gravitates to the brain. In severe cases, as after excessive haemorrhage, it is necessary to maintain the horizontal posi- tion for some time, and to be very careful in rising from it. At the same time that this position is adopted all jjressure from tight articles of dress should be carefully removed from the neck, chest, and abdomen ; pure, fresh air should TBEATMENT OF SYNCOFE. 421 be freely admitted, for which purpose the windows and doors should be thrown open and persons should be pre- vented 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 stimulants should be given. A little spirit of ammonia, brandy, or eau de Cologne are those which are generally at hand. Sprink- ling cold water on the face is also useful, 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 swallow- ing ; sipping cold water acts as a powerful cardiac stimu- lant, 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 xther may be administered subcutaneously ; recourse may also be had to the inhalation of amyl nitrite (ni. ii-iii). 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 422 TREATMENT OF SYNCOPE. ipecacuanha. I have seen three cases, in elderly persons, of syncope from an overloaded stomach ; life was ap- parently 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 dose of compound spirit of aether with hot brandy-and-'water, and in cases of com- plete unconsciousness, these remedies may be administered by means of the stomach pump or in an enema. At the same time, hot fomentations with a little turpentine, or a mustard plaister, should be applied to the epigastrium. As a matter of course, in syncope the result of serious haemor- rhage the question of transfusion will have to be con- sidered. In all cases, after recovery from the attack, 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 nourishment have been taken to restore the nervous energy regulating the heart's action. In cases in which the attack has been due to distension of the stomach, the production of this condition must be pre- vented by appropriate diet and medicines. Food should be taken in small quantities, and articles likely to engender flatulence should be rigorously forbidden. 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 — Cases due to Alcohol — Prognosis and Treat- ment. The influence of the nervous system upon the movements of the heart accounts for the frequency with w^hich symptoms of cardiac disorder occur among the subjects of neurasthenia. Weakness of the heart's action and excessive excitability 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 sometimes grounds for suspecting that a slight degree of fatty degeneration may exist. It is impossible to do more than speculate as to the nature and seat of the nervous 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 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 424 SYMPTOMS OF CARDIAC NEURASTHENIA. 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 hypochon- driasis, profound melancholia, 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 infrequent pulse, weakness of the heart's impulse, and faintness of the sounds. In some of these cases the number of the pulsa- tions is as low as 40 in a minute ; after a meal it may rise to 50 or perhaps 60 if stimulants 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. A few years ago I had under my care a young man aged 27, without any sign of organic disease, but who after a day's hunting invariably suffered 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 symptoms. The heart may act normally for some hours, the patient continuing his occupa- CAUSES OF CARDIAC NEURASTHENIA. 425 tion and being either quite or comparatively free from any feeling of discomfort. At a certain time of the day, how- ever, perhaps towards evening, the symptoms 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 circum- stances ; 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 super- added to the weakness of the heart's action ; palpitation and pain are set up by very slight causes. Few of these patients can take a cup of coffee or tea without suffering for it. Causes. — It is very necessary in these cases of cardiac neurasthenia 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 of treatment the symptoms are always chronic, and may continue for some years. They are not dangerous to life, but should the 426 CAUSES OF CARDIAC NEURASTHENIA. 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. Cardiac neurasthenia, due to alcohol, requires to be more minutely described, for in many cases the symptoms are mainly due to the immoderate use of stimulants. Instances of this kind are often seen among hard-worked men, who profess to have no time for regular meals, and take wine or spirits-and-water to keep themselves refreshed and ready for business. In another class the stimulants are taken by way of preparation for oft-recurring emergencies. Sooner or later the want becomes more urgent in order to relieve the sensation of depression or sinking which the sufferer experiences. Other symptoms, e.g., faintness, lightness of the head, nausea, and giddiness are rapidly superadded, and the craving is thereby still further increased. Mental and bodily powers are diminished, and even the stimulant fails to produce the desired effect. The heart's action shows signs of marked disorder. It is irregular both in strength and rhythm ; the sphygmographic tracings are abortive ; "the irregularity of tension is such that it is impossible to fix on any one base line as the origin of the tracings or the foundation of the series of events" (Richardson). The temperature varies ; it is raised tem- porarily by a little alcohol, but when the latter is withheld, it may fall as low as four degrees beneath the standard. TEEAT3IENT OF CARDIAC NEURASTSENIA. 427 Sleep is always disturbed ; after perhaps an hour or two the heart's action seems to stop when there is a sudden start from sleep, followed by wakefulness until more alcohol is taken. Treatment. — This consists first and foremost in the avoidance of the causes (and of all excesses in particular), 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 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 farinaceous 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 discomfort. Toast is more suitable ; but some- times 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. In cases due to 428 TREATMENT OF CARDIAC NEURASTHENIA. excess in alcohol, if the patient will submit, it is well to try the effects of abstinence; but in the absence of this con- dition, 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 07ily with meals), may be allowed. There is much truth in Dr. Richardson's state- ment that the greater the sense of failure of the heart from alcoholic debility, the more urgent is the necessity for absolute abstinence from alcohol. Depression and gastric suffering may be comforted by the remedies described in a previous chapter (see page 366) ; hot milk and water, equal parts of each, will often relieve the feeling of sinking. Tobacco must be strictly forbidden. A proper amount of sleep is all-important, 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 seaside, or other suitable locality, and the adminis- tration of suitable tonics, as described in the chapter on neurasthenia, 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 Pneumo- gastuic, and the Sympathetic — Vaso-Motor Angina Pectoris — Diagnosis — Prognosis — Treatment, Relief of Attacks and During Intervals — Subcutaneous Injection of Morphine — Inhalations of Nitrite of Amvl — 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 alteration, the com- plaint must be included in the category of functional disorders of the heart. The affection is characterized by attacks of pain which begins in the cardiac region and extends along the course of various nerves. Alterations in the movements of the heart and in the force of its con- tractions are almost always associated with the pain. 430 SYMPTOMS OF AJS'GIXA PECTORIS. Symptoms. — 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 rouse him from a normal sleep of some hours. In the case of a married lady whom I attended, the attacks, three in number, came on just as the patient was falling asleep. In other cases they occur irregularly, and are, perhaps, traceable to such antecedents as exposure to cold, bodily or mental exertion, indigestion, and the like. They may last only for a few minutes, or may be prolonged for hours : in rare cases the sensations 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. Premonitory symptoms are seldom observed, but in some cases the attacks are preceded by vertigo, noises in the ears, ocular spectra, nausea, 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 jjricking, burning, boring character, as if a hot iron were being driven into the chest, or as if the heart were being torn out of it ; in oth(;r cases the sensation is one of pressure and constriction. A SYMPTOMS OF ANGINA PECTORIS. 431 sensation of impending dissolution is always superadded. The objective symptoms are always 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, and often intermittent. An opposite condition of the heart's 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 suffocation appears imminent. These symptoms are due to reflex action, resulting from the cardiac pain, for 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 suffer- ings 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 •confined 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, following the course and distribution of the ulnar nerve. The patients generally 432 SYMPTOMS OF ANGINA PECTORIS. 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 premonitory symptom, and not unfre- quently the part is the seat of severe cutaneous hyper- aesthesia. 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, 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 downwards to the legs. I have witnessed 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. Various forms of spasm are witnessed in many cases ; thus, swallowing is often difficult, while vomiting, difficulty of speaking, hiccough, and epileptiform convulsions are not unfrequent. Indications of vaso-niotor disorder are always present. The extremities are pale and marked with livid discolora- tions, wliilc their temperature is lower than normal. These phenomena are attril:)utable to s[)asm of the minute cutaneous vessels, and arc 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 tlu-y precede and cause the attacks of cardiac pain. Cases such as these have SYMPTOMS OF ANGINA PECTORIS. 433 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. 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 last 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 iL 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 take place. If organic lesions be present, their symptoms F F 434 CAUSES OF ANGINA PECTORIS. 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 hajmorrhage 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. Causes. — 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. He7'editary predisposition is sometimes traceable, as in Dr. Arnold's case; in other instances there is a family history of other nervous disorders. Rheumatism^ ^^iit, 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 well-to-do persons, leading sedentary lives, and disposed to obesity. It is much more frequent in cold than in warm climates. Angina is an occasional manifestation of hysteria. In endeavouring to trace the disorder to its cause, it is PATHOGENY OF ANGINA PECTORIS. 435 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 percent, 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 in- dulgence 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. Morbid Changes and Pathogeny. — In cases of symptomatic angina, the most common changes found after death are those which affect the organs of the circu- lation, such as atheromatous degeneration in the aorta and coronary arteries, aneurism of the aorta, and insufficiency of the aortic valves. Angina is a less frequent accompani- ment of mitral disease and fatty degeneration and of peri- cardial adhesions. 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 changes found in the heart and in the blood-vessels, it cannot be regarded as certain that these are the cause of the attacks, 43G PATROGUNY OF A2iGINA PECTOBIS. 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 change has been discovered in the organs of circu- lation. 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 trust- worthy 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 have been discovered in the cardiac ganglia themselves. These organs in one case, in which during life there were symp- toms of angina pectoris, were found to be in a state of hyperaemia with interstitial inflammation and increased growth of connective tissue ; some of the ganglia were des- troyed, and the interstitial tissue was infiltrated with calcareous matter. In another case, the mesenteric and praevertebral ganglia and the coeliac plexus were affected with carcinoma, tiie tliora.K being ht'althy. The physiological exj^lanation 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 chaj)ter (see page 390) that FATHOGUNT OF ANGINA PECTORIS. 437 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 sympathetic, 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 the sympathetic. It has been proved that the cardiac ganglia can be irritated or paralyzed by solutions of various substances 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 accelerated; 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 imagined that in atheromatous degeneration 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 438 PATHOGENY OF ANGINA PECTORIS. in the experiment of Goltz, of tapping the intestines. In cases of angina, provoked by indigestion, the irritation is propagated by the sympathetic nerves through the cervical spinal cord to the pneumogastric. The result is diminished frequency of the heart's action, amounting, perhaps, to temporary suspension, with impediments to intonation and to swallowing. The pain, which is likewise present, is due to 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 connections 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 otherwise, and an impediment to the free circulation of blood no longer exists. It has been sup- posed that congenital weakness of the cardiac nerve-centres exists in some cases, and that in others a weakened condi- tion may result from immoderate muscular or mental exercise. Attacks of angina have been observed for' the TIISATMEJSTT OF ANGINA PECTORIS. 439 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. Diagnosis. — This for the most part is easily made, the distinguishing feature being the severe paroxysmal pain in the cardiac region. The attacks can scarcely be mistaken for those of ordinary palpitation or of asthma, or hysteria. It is, of course, important 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 mistake as to the nature of the symptoms. It must be remembered that attacks resembling angina sometimes occur in hysterical women ; the past history of the patient and the presence of other symptoms will explain their real nature. Prognosis. — This 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 complaint, 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. Treatment. — The measures to be taken to relieve an attack, and of those best adapted to prevent recurrences are the main points for consideration. When a paroxysm of 440 TREATMENT OF ANGINA PECTORIS. angina is threatening, the patient should be placed in a quiet, 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 dis- tress, and cold applications to the praecordia are generally grateful to the patient. As a general rule in all cases of functional disorder of the heart, attended by palpitation and irregular action, it is of great importance that the physician should gain the confi- dence 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. i of morphijie 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 a-fher, the former of which has been known to cause epileptiform attacks, followed by severe collapse. Inhalations of the nitrite of a»iyl are often very efficacious, and they are especially suitable whenever 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 ^^\ v on a handkerchief, and allowing 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 TREATMENT OF ANGINA PECTORIS. 441 and silk. When used the glass capsule is broken, the liquid soaks the cotton wool and silk cover, and can be con- veniently inhaled. Dr. Murrell has recently recommended 7iitro-glycerine for the relief of, or to ward off attacks of angina pectoris. A I per cent, solution in rectified spirit is prepared, and of this 3 to 5 minims are given when an attack is impend- ing. In some cases it gives complete relief, and is thus a great boon to the sufferers, who acquire perfect confidence in being able to control the attacks. Nitro-glycerine, 111^ ii of a I per cent, solution, has been found to relieve attacks of angina following acute pericarditis. In four minutes it removed the feeling of suffocation and quieted the heart. The remedy may also be conveniently administered, combined with chocolate in the form of lozenges, each containing yi^ of a grain. Sti7nulants must be given if during an attack there be evidences of •cardiac exhaustion, such as a much weakened impulse, with scarcely audible heart-sounds and a very feeble pulse. Under such circumstances brandy should be given if the patient be able to swallow, and if not, some aether should be subcutaneously injected. At the same time the feet should be placed in hot water, and a mustard plaister applied to the left side of the chest. The application of liniment of belladonna and chloroform (equal parts), followed by a warm linseed poultice, will be found very •soothing. In vaso-motor angina pectoris the application of heat to the extremities is always useful. 442 TREATMENT OF ANGINA PECTORIS. In order to prevent recurrences of the attack the patient's habits and fnode of life must be carefully regulated. All excess in eating and drinking, and in the use of tobacco, is to be strictly prohibited ; it is, indeed, well to forbid tobacco altogether. The bowels should be kept regularly open ; the patient should take a fair amount of exercise in the open air, but always short of fatigue ; he should have a tepid sponge bath daily, and scrupulously avoid exposure to cold and mental excite- ment. Change of air often does good to these patients ; the seaside suits some ; others are benefited by a sojourn in elevated districts if sheltered from high winds. If organic disorders be present, these, of course, require appropriate treatment; anaemia must be combated by iron and (/ 2{ in ifie, and nutritious diet; nervous excitement by bromide of potassium and various tonics. If there be valvular, or other disease of the heart, with irregular action, digitalis is likely to be suitable. When there are evidences of fatty degeneration of the heart, a course of arsenic, with strychnine, may be tried. Arsoiic is also useful in cases in which the patients are much depressed. This remedy, and also phosphorus, given for a few weeks, would seem to have the power of preventing attacks. A case has been recorded in which the attacks were aggra- vated by the condition induced by a hot summer; other remedies had been tried without avail, when an immediate improvement followed the administration of Fowler's solu- TREATMENT OF ANGINA PECTORIS. 443 tion in doses of two-and-a-half minims three times a day. For gouty cases the treatment of the uric acid diathesis should be rigorously carried out. A course of bicarbonate of sodium, combined with ammonia and some bitter tonic, is certain to be useful. The diet and condition of the stomach will require careful attention. SECTION III. FUNCTIONAL DISORDERS OF THE RESPIRATORY ORGANS. INTRODUCTORY CHAPTER. Functional Disorders of Respiration — Nerves of Sensation or Motion Implicated — Disorders of theVoice — Hoarseness — Aphonia and its Causes — Laryngeal Growths, Catarrhal Swelling, Paralysis of THE Laryngeal Muscles, Hysieria, Anemia — Dysphonia Clericorum — Insufficient Stream of Air — Treatment of Hoarseness and Aphonia — Inhalations — Ton ics — Mineral Waters — Far ad ism — Anesthesia and Hypeu.t.sthesia of the Respiratory Nerves — Neuralgia of the Larynx — Treatment — Nervous Cough — Symptoms — Causes — Connection between Cough and Affections of the Ear — Treatment. Functional disorders of the respiratory organs are char- acterized by symptoms referable in the main either to the nerves of sensation or those of motion or to both at the same time. Moreover, in the larynx, disorders are apt to occur involving alterations in the voice, independently of inflammation or other organic change ; and it will be con- venient to consider these first. The condition of the voice known as hoarseness is most often caused by mucus upon the vocal cords ; it may be CAUSES OF APEONIA. 445 also due to swelling, roughness, and defective tension of these structures. If while speaking the cords suddenly come together, the speech is broken, owing to the forma- tion of nodal points (Landois). Hoarseness sometimes precedes complete loss of voice or aphonia ; but the latter may occur alone and come on either gradually or suddenly. Apho7iia is liable to occur when anything prevents or impedes the free vibrations of the vocal cords. A tumour on one or both of these structures is a cause of this char- acter, and the same effect may be produced by catarrhal swelling of the cords, and likewise by a similar condition of the false vocal cords and adjacent parts. The swollen mucous membrane impedes the vibrations by encroaching on the space in which these take place. Another cause of aphonia is paralysis or weakness of the laryngeal muscles. Examples of such paralysis, of a functional character, are seen in cases of hysteria. In such patients there is no considerable alteration in the mucous membrane, which is healthy and of normal colour, or at most but slightly congested. The hyperaemia, which is an occasional accessory, is due perhaps to the same causes as those which produce the aphonia, or is of a secondary char- acter. In not a few of these cases the vocal cords approxi- mate as in health. In another class of cases belonging to this category, the mucous membrane of the larynx is pale and anaemic, a 416 CAUSES OF AFHOSIA. condition which coincides with the aspect of the patients. The aphonia is due to imperfect approximation and insuffi- cient tension of the vocal cords. There are yet other patients who present this symptom, but are neither hysteri- cal nor anaemic, and the aphonia must be regarded as due to some perverted distribution of nerve-force. Such purely functional aphonia appears generally in girls and young women under thirty. In loss of voice occurring in the patients just referred to, the symptoms may come on suddenly, as a result of sudden and strong mental emotion, caused, for example, by joy, anger, or fright. In other cases its accession is gradual, depending upon general debility, as after long-continued and exhausting diseases. The aphonia in another class of cases is due to debility of the laryngeal muscles, as when these have been over- strained by excessive or protracted use in speaking or singing. The voice may be reduced to a whisper, or perfectly inaudible. In so-called dysplionia clericonim, chronic catarrh and swelling of the mucous membrane of the larynx are combined with loss or impairment of muscu- lar power, but the latter may exist alone. Under such circumstances, the patient can read or talk for half-an-hour or more, but then the voice becomes feeble, and less and less audible. There is a sensation of fatigue and pain in the larynx, but there is no decided change visible on examination, certainly none sufficient to account for the loss of voice. TREAT3IENT OF AFEONIA. 447 Another cause of aphonia is an insufficient stream of air ; " the vocal pipe feebly blown through refuses to speak." This condition is seen in cases of faintness and collapse from various causes, in emphysema, and in attacks of asthma. Intercostal neuralgia is another cause of this character ; the patient fears to use his chest in consequence of the pain ; and atrophy of these muscles leads to a similar result. It must not be forgotten that acute enlarge- ment of the tonsils may cause almost complete aphonia, owing to the insufficient amount of air which is allowed to pass upwards. The treatment of hoarseness and aphonia depends upon the cause of the affection. When catarrh is present, cold compresses to the throat, local astringents, and the inhala- tion of medicated vapours are likely to prove serviceable. One of the best local astringents is the chloride of zinc (gr. XXX to 5J glycerine), applied by means of a brush daily or every alternate day. Carbolic acid pigment of the same strength is useful when the mucous membrane is dry and shining (Mackenzie). The vapour of Scotch pine (Pinus sylvestris) forms a mild stimulant inhalation for slight laryngeal catarrh, and the vapours of creasote, juniper, and benzoin may be employed for the same pur- pose. These inhalations should be used twice or three times daily for about ten minutes at a temperature of 140°. Another useful remedy is powdered ou?}i eucalyptus gr. ^ with an equal quantity of powdered starch, applied by 448 TREAT3IENT OF APHONIA. means of an insufflator, and when the pharynx is affected, the same drug may also be used in the form of a lozenge. Iron, quinine, and other tonics, change of air, rest, and hygienic measures of all kinds are likely to be serviceable for cases of aphonia due to slight laryngeal catarrh. When the disorder has subsided, precautionary measures should always be taken in order to lessen the susceptibility of the part. A daily bath of tepid water, in which a little salt has been dissolved, followed by friction over the whole body ; flannel next the skin ; outdoor exercise adapted to the patient's state, and avoidance of over-heated rooms, constitute the principal measures of this character. The waters of Ems, Selters, and Obersalzbrunnen, and those of Aix-les Bains and Marlioz, are useful in many cases of chronic laryngeal catarrh. In functional aphonia, depending on inaction of the adductors on both sides and consequent non-approximation of the vocal cords on attempted phonation, the treatment consists in stimulating the mucous membrane of the larynx in various ways. Sir M. Mackenzie has known the voice to be restored by the use of a vapour impregnated with ammonia ; but he recommends as more efficacious inhala- tions of oil of calamus aromaticus and of creasote. Either 40 minims of the latter or five minims of the former are mixed with 20 grains of magnesium carbonate and one ounce of water, and used at a temperature of 140°. Other local remedies are stimulating or astringent solutions, such TR TLA TME NT OF A P HON I A . 449 as nitrate of silver (3J to 5J) or perchloride of iron (3!] to 5j), applied with a brush to the interior of the larynx, or introduced in the atomized form. All the above-mentioned remedies often fail ; on the other hand, Sir M. Mackenzie"^ states that endo-laj-yngeal faradism is almost always successful. The electric current should, however, not be applied until any hyperaemia of the mucous membrane has been got rid of. In using faradism to the larynx, one pole is passed within the glottis and placed on the vocal cords and the other applied externally by means of a necklet. The laryngeal rheophore is so constructed that the current does not pass until the metalled point or sponge is in contact with the vocal cords. It is kept in this position for a second or two, and then withdrawn, and the current may be applied five or six times at a sitting. A distinct laryngeal sound will generally be produced on the first application of endo-laryngeal faradism, and the voice will get stronger on each succeeding application. After it has been restored, faradism should be applied externally either daily or every other day for a week or two in order to keep up the effect, and the patient should be directed to count and read aloud several times daily so as to exercise the voice. In hysterical cases, the general treatment suitable for the neurosis should be put in force at the same time. These cases are often very obstinate, but they are almost * " Diseases of the Throat and Nose," Vol. i., p. 467. G G 450 LARYNGEAL HYPLEJESTHESIA. always cured at last, even when the aphonia has existed for several years. It remains to consider various conditions of ansesthesia, and of hyperesthesia of the respiratory nerves. The former is of very rare occurrence, except in connection with coma as a result of poisoning, and in certain cerebral diseases. Sir M. Mackenzie states that laryngeal anaes- thesia as a serious manifestation appears to be confined to cases of diphtheritic and bulbar paralysis. In affections of the former class, recovery takes place under ordinary tonic treatment; if the disorder become chronic the application of faradism as described in the previous paragraph is likely to prove successful. The opposite condition of hyperaesthesia may result from catarrh, from the irritation produced by a foreign body, from excessive use of the organ, and as a symptom of general nervous irritability. When associated with any of these conditions the hyperaesthesia is liable to be complicated by a troublesome dry cough of a spasmodic character, and in some cases, notably in hysterical subjects, a cough of this kind may exist without perver- sion of sensation. The symptoms of laryngeal hyperaesthesia are a feeling of more or less discomfort, such as dryness or rawness of the part, or even actual pain of a burning, pricking, or constric- tive character, and they are apt to be increased by coughing and swallowing, A\hile spasm of the muscles of the throat NEURALGIA OF TILE LARYNX. 451 and larynx is sometimes superadded. Some patients also complain of various perversions of sensation, e.g., of a feel- ing as though a foreign body were present in the larynx, whereas nothing can be detected after the most careful examination. Such a feeling is, of course, common in cases in which some offending body has been removed, and it is apt to last for some time. Cases of true neuralgia of the larynx have been placed on record by Drs. Handfield Jones, Graves, Mackenzie, and others, but the affection is very rare. In Dr. Graves' case"^ the patient, a young lady, was originally of vigorous con- stitution, but had suffered for some time from menstrual irregularity and hysteria. Antiphlogistic treatment of all kinds had been tried without avail ; the pain, though not violent, was almost constant, and was liable to occasional aggravation. The feeling was one of distress about the whole region of the larynx ; there was no external tender- ness, and the throat was healthy. The paroxysms were attended by a change of tone and weakness in the voice. It was curious that in this case the employment of tonics (iron, quinine, and arsenic) had the effect of rendering the attacks perfectly periodic. For laryngeal neuralgia. Sir M. Mackenzie recommends that the patient's general condition should, when necessary, be improved by such measures as change of air, sea-bathing, or a course of hydropathic treatment. If the malady appear * Graves' "Clinical Medicine," New Syd. Soc. Ed., Vol. i., p. 656. 452 LAIiYNGl^AL COUGH. to be of purely local origin, persistent pencilling of the laryngeal mucous membrane with chloroform and morphine would seem to be the best means of curing it. Should these fail to afford relief, Indian hemp and bromide of potassium may be tried either separately or combined. The same remedies would probably be serviceable in cases of perverted sensibility of the larynx. We occasionally meet both in children and in adults with a condition in which a troublesome cough is the only symptom. It is not accompanied by any catarrh of the air passages, or by any morbid sounds in the chest ; it appears to be a purely nervous affection, the result of some morbid condition of the respiratory nerves. The cough is almost always dry, unless a violent paroxysm give rise to the formation of a little mucus ; the attacks come on at irregular intervals and last for indelinite periods. Sometimes the coughing is almost incessant for days, being checked only by sleep ; in other cases it comes on mainly at night, and prevents the sufferer from getting any sleep. Its character varies ; the sound is sometimes hollow and loud, sometimes it resembles the barking of a dog. Sir M. Mackenzie records the case ot a }oung lady whose " cough was so loud and constant that lur friends were required by the pro- prietor of tlie hotel in which she was staying to have her removed, as she was a nuisance to all tin; other guests." In such cases nothing abnormal can be detected with the laryngoscope, nor docs the general health sufft'r. Trousseau, COUGH FROM IRRITATION OF THE EAR. 453 however, states that when the disorder is much prolonged it is apt to affect injuriously the general health, and especially when the cough is complicated with obstinate vomiting. A cough of this kind is not unfrequent in hysterical subjects, and the majority of the patients are young girls between 16 and 20 years of age. There is sometimes tenderness of the spine between the scapulae ; and in other cases the cough is the result of reflex irritation of the pharynx, sfo?nach, or intestines. Irritation of the stomach alone will not cause coughing; but it will do so if irritation of the larynx and trachea be already present, and in such cases the cough will be relieved by a dose of alkali. In some patients the cough would seem to be the result of gouty or rheumatic irritation. Certain morbid states of the ear are apt to be associated with a spasmodic cough, and this organ should never be neglected in cases in which the latter symptom occurs. Dr. C. Fox has published a case of a woman aged 50, who for eighteen months was troubled by laryngeal irritation and cough ; the throat and lungs were healthy and the larynx normal, but the patient was deaf in the right ear, in which a plug of wax and a small ulcer were found. The cough ceased after the removal of the wax. In another case the cough was associated with the presence of dead bone in the meatus. The irritation in these instances is conveyed by branches of the auriculo-temporal of the fifth to the vagus, the deep origin of which in the medulla oblongata is close 454 TREATMENT OF SPASMODIC COUGH. to that of the sensory root of the fifth nerve. The irritation is referred to the larynx because the medulla oblongata is wont to receive impressions through the vagus from that organ. Vomiting and cough sometimes arise from the state of the teeth; dentists know that irritation of the dental branches of the fifth nerve may give rise to cough. The treatment of these cases of spasmodic cough is apt to be difficult, but the complaint generallv yields to remedies. Atropine is one of the best of these; it should be given in doses of gr. -^^ combined with various tonics, such as iron, quinine, or nitric acid. Morphine may be substituted for the atropine, should the latter fail to relieve. The combination of chloral with bromide of ammonium would seem likely to prove useful in purely nervous cough. Valerianate of zinc and asafcetida may be tried for hysterical cases, while for rheumatic and gouty subjects alkalies and purgatives will generally be serviceable. When the cough appears to depend upon disorder of the stomach or bowels, the remedies must be directed to these parts. Purgatives are usually indicated, and hisvuith with hydrocyanic acid and henbane will probably lessen or cure the paroxysms of cough. In nervous and weakly subjects, change of air, travelling, and the use of chaly- beate waters will be found the best treatment. There is one other cause of spasmodic cough which must not be overlooked, namely, tapeworm. Dr. Graves records the TREATMENT OF SPASMODIC COUGH. 455 case of a young lady whose medical attendants (himself among the number) had exhausted their list of remedies, but without the least benefit to the patient ; the fits of coughing went on for several hours with extraordinary intensity ; the cough was dry, extremely loud, hollow, and repeated every five or six seconds, night and day. This patient was completely cured by an old woman, a servant in the family, who suggested a dose of turpen- tine and castor-oil for the relief of an attack of colic. The result was the passage of a mass of tapeworm and the immediate disappearance of every symptom of pulmonary irritation. Another functional disorder of the larynx and similar affections of the lungs will require special chapters for their consideration. All these disorders are characterized by muscular spasm ; in the one case affecting the larynx, and in the other the smaller bronchi, dyspnoea being the prominent symptom in both sets of cases. CHAPTER II. LARYNGISMUS STRIDULUS-LARVNGEAL ASTHMA. Laryngismls Stridulus — Natuuk and Causes — Age, Rickets and Scrofula, Heredity, Malnutrition — Exciting Causes of Attacks — Symptoms of a Paroxysm — Spasm of Larynx — Carpopedal Contrac- Tif)Ns, Eclampsia — Anatomical Changes— Theories as to Nature of Complaint — Sir AL Mackenzie's Views —DiA Antispasmodics — During the Intervals — Removal of Causes — Inhalation of Oxygen and of Con- densed Air — CiiANCiE of Air — Treatment of Gouty Cases— Purga- t i V i:s — A 1. K A L I L s — I ( ) I) I D li or Potassium — E i, ect r i cit y. The term asthma is apt to be somewhat vaguely applied to express attacks of difficulty of breathing in general, and patients suffering from chronic bronchitis, emphysema, or heart- disease are often regarded as asthmatic. The two disorders, however, bronchitis and asthma, are perfectly dis- tinct, and either may exist without the other. Bronchial asthma, which 1 am now about to discuss, consists of attacks of difficulty of breathing which depend upon the periodical recurrence of spasmodic contraction of the bronchial muscles. The pneumogastric is the nerve distributed to these struc- tures, and inasmuch as in cases of essential asthma, anatomical changes which would account for tlu^ attacks are not to be discovered, the disorder must, at least for CAUSES OF ASTHMA. 465 the present, be regarded as a neurosis of the nerve just mentioned. Causes. — Nothing of a very definite character can be stated with reference to the causes of asthma ; the com- plaint is more common in the well-to-do than in those differently situated ; males are more often affected than females, the proportion being two to one ; as age advances the numbers become more nearly equal. The majority of the sufferers are under 40 years of age, and children form a comparatively large contingent ; in many cases the first attack occurs during the first decade. Heredity plays a certain part in the causation of asthma, and it is not un- common to find several members of the family suffering from the complaint or from other forms of nervous disorder. With regard to constitutional conditions^ the disorder is said to be more frequent among the subjects of rickets, scrofula, anaemia, and those of a decidedly nervous tendency. Some forms of asthma are affected as regards prevalence by climate and season ; cold and damp weather produces bronchial catarrh, which in its turn may lead to a develop- ment of a symptomatic asthma. Change of weather and of locality has a different influence on different asthmatic subjects. Most of them are relieved by a 7noist air and a residence in low-lying places ; but peculiarities of an oppo- site kind are sometimes noticed. Many sufferers feel decidedly better in London than in country air. H H 466 CAUSES OF ASTHMA. Two forms of the complaint have to be considered, viz., the idiopathic or essential asthma, and that which is sympto?natic or of reflex origin. In the former of these no obvious cause can be demonstrated ; in the latter there are lesions of organs more or less distant, the irritation result- ing from which is propagated to the pneumogastric nerve, with spasm of the bronchial muscles as a result. The existence of such a connection is proved by those cases in which the attacks cease after the cure of the lesions by which they were excited. In rare cases, changes have been found in the nuclei of the vagus itself, and in other parts of the brain and cord, but the significance of such lesions is doubtful. Not a few cases, however, have been reported in which the nerve itself was compressed by various growths, such as enlarged lymphatic glands either in the neck or connected with the bronchi, or by an enlarged thymus gland. Enlargement of the bronchial glands is a frequent result of measles, scarlet fever, and whooping cough in children, and attacks of asthma are thus liable to be produced in these subjects. Swellings of a like character are somewhat frequent in scrofulous and rachitic cases. The mucous membrane of the nose ox of the )iaso-pJiarynx is the spot whence the irritation proceeds in another class of cases, and this condition of morbidl\- increased irritability may exist either with or without definite changes. In most persons, cough is excited by irritating the terminations of CAUSES OF ASTHMA. 467 the fifth nerve in the nasal mucous membrane, and there are many curious idiosyncrasies in respect of the irritability of this part. Thus in some persons a severe attack of bronchial asthma is brought on by inhaling powdered ipecacuanha ; and in others by the pollen of grasses, oats, and maize. Certain chemical irritants have a similar power in some cases ; thus chlorine gas and even perfumes and emanations of various kinds, such as the scents of violet, heliotrope, and peppermint are sufficient to provoke symptoms of asthma. Emanations from animals are said to produce the same effect in some persons. Such causes would be more likely to prove operative in persons with a tendency to the disorder, than where such a proclivity was absent. Attacks of asthma are not uncommon in cases of nasal polypus and other affections of the nose, the nasal nerves being in a condition of abnormal reflex irritability. About seven per cent, of all cases of asthma are said to be thus caused. The attacks subside after removal of the growths; but they sometimes recur with fresh development. Affec- tions of the inferior turbinate bone are especially liable to lead to these consequences, and chronic rhinitis of an atrophic character has been observed to be attended by symptoms of asthma. With regard to throat affections^ a granular condition of the pharynx and even enlarged tonsils have occasioned similar attacks. I have known two cases of asthma in children the subject of enlarged tonsils; 468 CAUSES OF ASTHMA. removal of the latter was followed by cessation of the asthmatic attacks. Bronchial asthma often complicates bronchitis ; but the disorder must be distinguished from the attacks of dyspnoea, so common in the latter complaint. Similar symptoms are likewise observed in many cases of heart disease. Disorders of the abdominal organs are potent causes of asthmatic attacks in those predisposed to them. Thus severe paroxysms are often occasioned by over- distension of the stomach whether by food or by the gaseous products of fermentation, and in some persons such a result is occasioned by the ingestion of certain articles of food even in moderation. Constipation and the presence of worms are other causes of this character. Asthma is sometimes connected with disorders of the uterus and ovaries, and hence attacks are not unfrequent in hysterical and nervous women. In some women, the symptoms come on during pregnancy and cease after delivery. Certain peculiarities are sometimes exhibited by hysterical subjects ; thus in the case of a girl aged twenty, with marked hysteria, attacks of asthma are apparently brought on by taking a cup or two of tea. Symptoms of asthma are sometimes associated with renal disorders ; in uraemia, the diffirulty of breathing is caused by the excessive amount of urea and other urinary constituents present in the blood. A similar causation, uric acid being the offending material, is seen in cases of -S Y3IF TOMS OF A S THMA . 469 gouty asthma. The connection between the bronchial disorder and the gouty diathesis is shown by the fact that the former either subsides or remits on the development of the articular inflammation. It is said that asthma is some- times associated with eczeyna ; in such cases the two affections have probably a common origin, both being symptoms of the uric acid diathesis. Lastly, symptoms of asthma are occasionally seen in cases of chronic poisoning by lead and mercury. Symptoms. — Difficulty of breathing constitutes the prin- cipal symptom of attacks of bronchial asthma, the ex- piratory movements being especially affected and the lungs remaining in a condition of acute over-inflation. The attacks occur either with or without premonitory symptoms. In the former case, the patient complains of general malaise, a feeling of pressure in the head, an uncontrollable , desire to yawn, eructations, vomiting, distension of the abdomen, or chilliness. In other cases there are signs of catarrh of the conjunctiva, and nasal mucous membrane, the bronchial tubes becoming gradually involved. Some patients know that an attack is impending, because they have exposed themselves to influences against which their experience has w^arned them. Paroxysms of asthma exhibit many peculiarities, and among these that of being most frequent in the early morning is one of the most marked. The patients are often aroused from their sleep with a feeling of suffocation, 470 SYMPTOMS OF ASTHMA. which rapidly becomes worse ; violent attempts are made to obtain air ; many patients get before an open window and expose themselves to a cool draught. At this stage whistling rhonchi are heard, and are sometimes so loud as to be audible throughout the house. The attack after lasting a variable time, during which the condition of the patient may have been most alarming, gradually sub- sides. The breathing becomes more free, cough with a muco-purulent expectoration sets in, the respiratory move- ments are less and less embarrassed, and yawning, eructa- tions, or vomiting are apt to take place. The skin during an attack feels cool to the touch, but the thermometer indicates some rise of temperature. The pulse is small, generally hard and frequent. The attacks vary in duration from a few minutes to several hours, and they may occur daily or even several times a day, or at longer or shorter intervals, which are sometimes regular. Certain of the symptoms require a more detailed exami- nation, and especially the respiratory acts. The alteration is mainly in the expiration, but the auxiliary muscles for inspiration are also called into play. The action of the expiratory muscles is very marked ; the recti abdominis and the transverse muscles are forcibly contracted during expiration. The time occupied by the two acts shows considerable alterations ; insi)iration is slower than usual, but the expiratory act is very much prolonged. It may be three times as long as that of inspiration ; the number of SYMPTOMS OF A STEM A. 471 respirations is, therefore, much reduced, and the pause between the two acts is altogether absent. The distended lung prevents the movements of the heart from being visible. The position and aspect of the patient are very charac- teristic. He sits up, supporting himself on his elbows, with his mouth open, his shoulders elevated, and his head thrown back ; his countenance betrays intense anxiety. The sterno-mastoid muscles project, like hard cords, from the sides of the neck. Indications of cyanosis soon show themselves ; the cervical veins form hard, blue cords, and the eyes appear to be starting from their sockets; some- times blood escapes beneath the conjunctiva. The face is covered with copious perspiration, and if the attack last for any length of time, the countenance becomes livid and pale, and there is more or less insensibility with delirium and muscular twitchings. The thorax on examination is found to be greatly expanded ; the percussion sound all over the chest is loud, deep, and tympanitic. In the lower regions of the thorax, especially behind and at the sides, there is a modification of the tympanitic note, described by Prof. Biermer,of Zurich, as the baitdbox note, from its resemblance to the sound given by such a box when struck ; it depends upon the increased tension of the alveolar tissue. On further examination the borders of the lungs are found to extend lower, and also further inwards towards the sternum 472 SYMPTOMS OF ASTHMA. than under normal circumstances, and they are little if at all affected by the respiratory acts. The upper margin of the liver is one or two intercostal spaces lower than natural, and the cardiac dulness is considerably reduced. These changes likewise remain unaffected by respiration, but when the attacks cease the lungs return to their normal positions, unless emphysema has been set up. The diaphragm is considerably depressed and moves but little during respiration. Its position is the result not of tonic spasm of its fibres, but of an increase in the amount of air in the lungs, an excessive inflation, so to speak, and this depends upon the spastic contraction of the bronchi. On auscultation during an attack the vesicular respiratory murmur is either altogether absent or else concealed by the sibilant or sonorous rhonchi. When the spasm is slight the sibilant rhonchi are almost equally loud in both acts ; in more marked spasm they are louder in expiration, but when the spasm has reached its height they are no longer audible, because the interchange of air has been reduced to a minimum, and the conditions are absent for the production of any respiratory murmur in the liner air-passages. For the most part we hear a short and weak whistle in inspira- tion, and a longer and stronger in expiration (I)iermer). As the attack passes off the sibilant rhonchi gradually cease and give place to mucous rales. While the attack is at its height the patients speak in a hoarse, low voice, and often with great difficulty, so that they prefer to make signs for PA THO GJENY OF ASTR3IA . 473 anything they require. The heart-sounds may be almost inaudible, owing to the manner in which the organ is covered up by the lungs. Expectoration is for the most part absent during the attack, but at its termination cough is apt to set in, and is accompanied by the expectoration of more or less greyish- white, tenacious and frothy matter, which is sometimes thick, like gelatine. Besides various flakes, threads, and little clots, the expectoration often contains twisted threads, greyish or yellowish in colour, and somewhat regular in form. Their length is from two to three centimetres, and sometimes more, and the largest is about a millimetre wide ; they are supposed to originate in the finest divisions of the bronchial tubes, and to be the results of exudation. Curious octahedral crystals, similar to those met with in the tissues of leukaemic subjects, are sometimes found in the expectoration. Their chemical composition is unknown, but they are not peculiar to asthma ; they have been found in cases of bronchial catarrh and phthisis. Oxalate of lime ■crystals also occur m the expectoration. Pathogeny. — Several explanations have been offered as to the manner in which a paroxysm of bronchial asthma is induced. The important point to be borne in mind is that nervous influences are not only present, but play the most considerable part in causing the attacks. The following would appear the most probable view : the smooth muscular fibres in the middle-sized and smaller 474 PATHOGENY OF ASTHMA. bronchi, to which the pneumogastric nerve is distributed, are thrown into a state of tonic contraction ; the inter- change of air is thus rendered not impossible, for then life would cease, but extremely diflficult. The powerful muscles of inspiration are able to overcome the increased resist- ance, but the expiratory muscles fail in this respect. Their action is hindered by the fact that the pressure in expiration acts not only from below upwards, but also in two other directions, viz., from the sides towards the middle line and from before backwards. Hence the minuter bronchi, together with the alveoli, are laterally compressed ; and inasmuch as both parts are under the same pressure, the escape of air from the one into the other can take place only as the result of pressure exercised from below upwards. The lateral pressure may, however, be so strong that the walls of the finer ramifications of the tubes, in which all traces of cartilage are wanting, are compressed so as to meet, and in such a case the resistance would be more than could be overcome by the abdominal pressure. If the interchange of air were reduced below a certain point, death would, of course, follow ; but here the self-regulatory power of the respiratory act comes into play, the accumula- tion of carbonic acid in the blood acts upon the vagus centres, the spasm of the bronchial muscles is relaxed, and expiratory acts are once more possible. In addition to the spasm, the fluxionary hypera^mia of the bronchial and alveolar vessels increases the obstacles to PATHOGENY OF ASTHMA. 475 the admission of air, and diminishes the extent of surface from which interchange of gases takes place. Such hyper- aemia may be inferred to exist from the fact that in some cases of asthma a watery fluid exudes from the nose and eyes, both which parts are obviously hyperaemic. This condition would still further impede the exchange of air as occurs in capillary bronchitis. It is also highly probable that when the finer air-tubes are much contracted the forcible inspiratory movements exercise an aspirating effect upon the contents of the alveolar vessels, and that thus cedema is set up. Even when the degree of spastic contraction is small, any swelling of the bronchial mucous membrane will suffice to induce the phenomena of asthma. With regard to the position of the diaphragm, it is due to the over-distension of the lungs, but the suggestion has been made that this muscle is thrown into a state of clonic spasm by reflex action transmitted by the vagus to the phrenic nerve. Such a condition cannot be regarded as that of tetanus ; it is much more probable that the muscle is for the time in the condition it occupies during inspira- tion, as a result, it may be, of irritation, and that during expiratory efforts only very little relaxation occurs. The bronchial spasm must be regarded as the predominating factor; its existence explains the alterations in the respiratory acts, the distension of the lungs, the occurrence of various kinds of rhonchi, and the position of the diaphragm. It may, however, be admitted that in some 476 DIAGI^'OSIS OF ASTH3IA. cases a certain degree of spasm of this muscle, and like- wise of fluxionary hyperaemia, contributes toward the development of the symptoms. Asthma rarely continues for any length of time without giving rise to organic affections of the lungs and heart. Emphysema is the most common sequela; as a result of the constant distension of the alveoli, their elasticity is lost, and they become permanently dilated. Rupture of their walls is also apt to take place, with the formation of large air-sacs as a result. Chronic catarrh of the tubes is a frequent accompaniment. With regard to the heart, the right ventricle is apt to become hypertrophied and dilated, in consequence of the obstruction during the attacks to the course of the blood through the lungs. Diagnosis. — The diagnosis of bronchial asthma is for the most part easily made ; there can be no doubt as to the nature of the complaint in typical cases. The sudden and paroxysmal character of the attacks ; their most frequent occurrence in the latter half of the night ; the expiratory dyspnoea, with the whistling and wheezing sounds that accompany it ; the signs of over-distension of the lung ; the catarrhal expectoration at the close of the attack, and the freedom from disorder during the intervals constitute a group of features not met with in any other complaint. Asthmatic attacks may, however, complicate various affec- tions of the heart and lungs, and in some affections of the nervous system attacks of difficulty of breathing are apt to occur. DIAGNOSIS OF ASTH3IA. 477 Dyspnoea frequently complicates bronchitis, but the attacks do not come on suddenly, and are usually referable to a distinct cause, such as an extension of the original disorder. Moreover, in bronchitis the state of the lungs in the intervals is sufficient to determine the nature of the case. The two conditions may, of course, co-exist ; either having preceded the other. Attacks of shortness of breath are common also in e77iphysema, but they do not come on suddenly and un- expectedly. On the other hand, they are noticed to be an exaggeration of the patient's ordinary condition, they can generally be induced by exertion, and they subside only in an incomplete manner. On examining the chest during the intervals, evidences of changes in the lung-structure will be easily discovered. Asthmatic patients often become emphysematous. Attacks of dyspnoea are common in patients suffering from diseases of the heart ; in these cases they are apt to be provoked by exertion and excitement. There are also the various murmurs and the condition of the patient between the paroxysms, to determine the diagnosis. Similar attacks occur in croup, and as the result of the presence of foreign bodies in the larynx or trachea, but in all these cases the difficulty of breathing will be con- nected with the inspiratory acts, and the lungs are incom- pletely filled. Expiration, on the other hand, in the absence of complications is performed quickly, and with comparative ease, and the chest resumes its normal form. 478 PROGNOSIS OF ASTHMA. Spasm of the diaphragm sometimes occurs in hysterical subjects, and the effects closely simulate an attack of asthma. The thorax remains for some seconds in the in- spiratory position ; the inspirations are short and spasmodic, like the movements in hiccough ; the epigastrium projects ; the heart is drawn downwards, and towards the median line, and the patient complains of pain in the region of the diaphragm. Another condition, simulating asthma, likewise occurs in hysterical subjects, \\z., paralysis of the posterior crico- arytenoid muscles. The difficulty is, however, connected with inspiration, the current of air causing the vocal cords to approximate, thus preventing its ingress. The dyspnoea in such cases is continuous rather than paroxysmal. It is possible that attacks of nightmare may be mistaken for asthma when the dyspnoea occurs only during sleep, and the physician has no opportunity of noticing the course of the symptoms, but has to depend upon the statements of the patient. When due to asthma, the dyspnoea increases after the patient wakes, whereas it soon ceases when con- sciousness is restored in cases of nightmare. PrOG.N'OSIS. — The prognosis of asthma in general is much more favourable than might be supposed from the severity of the symptoms. Death very rarely occurs during a paroxysm ; fur when the excess of carbonic acid in the blood reaches a certain degree, the spasm of the bronchial muscles gives place to a condition of paralysis. With TREATMENT OF ASTHMA. 479 regard to the cure of the complaint, this depends upon the condition to which the symptom is due ; if removable, the attacks may be expected to cease. Age is a consideration in the prognosis ; the younger the patient the greater the probability of recovery. In not a few cases the complaint continues throughout life, the results depending in great measure upon the circumstances and habits of the patient. With the development of complications the prognosis becomes more and more unfavourable. Treatment. — The treatment of asthma divides itself into a consideration of the measures to be adopted (i) during a paroxysm, and (2) during the intervals, in order to prevent recurrences. When a paroxysm is impending the patient's clothes should be freely loosened about the neck and chest, and cool, pure air admitted into the room. As a matter of course, all objects, the presence of which is likely to induce an attack, should be at once removed. Some patients find by experience that a cup of strong coffee, a cigar, or a few pieces of ice will afford much relief. In one case recorded by Trousseau benefit was obtained by lighting up the room with several lamps. With regard to medicines, certain of the narcotics yield very satisfactory results, and the most potent of them is chloral, which should be given in full doses, say 30 grains at once, or in half this quantity, to be repeated in half-an- hour. These large doses are much more efficacious than small ones. Instead of chloral we may have recourse to 480 TREA THE NT OF AS TSMA . hypodermic injections of morphine, gr. \-\, or the same drug may be given internally. Other narcotics have also been found efficacious — among them belladonna, cannabis indica, lobelia, and cocaine. Atropine is said to paralyze the constrictor fibres of the vagus which supply the bronchial muscles. Beneficial effects have been seen to follow the subcutaneous injection of cocaiiie. Very good results have been obtained from doses of 2 to 5 grains of nitrite of sodium given in water. The bronchial spasm is relieved in a few minutes and the effect is maintained for some hours, when, if necessary, the medicine may be repeated. The nitrite and nitroglycerine may be especially relied upon whenever there is high tension of the pulse. Antispasmodics may likewise be administered by inhala- tion, but they are seldom so efficacious as chloral. Chloro- form, amyl nitrite, sulphuric aether, ammonia, hydriodic aefclier, and oil of turpentine are used for inhalation pur- poses ; and other remedies similarly employed are arsenical cigarettes, the fumes of nitrate of potassium, stramonium cigars, the vapour of camphor, etc. Some patients are benefited by cigars composed of belladonna, stramonium, henbane, and opium, and by others to which nitre is added. The alcoholic extract oi grindelia robusta is likewise used in a similar manner, and it is sometimes given internally ; half- a-teaspoonful of the fluid extract is stated to have afforded almost instantaneous relief in several cases of asthma occurring in old persons. Whenever there are indications TREATMENT OF ASTHMA. 481 of a distended stomach in connection with the attack, an emetic should, of course, be administered ; sulphate of zinc or mustard will answer the purpose, but the subcutaneous injection of apomorphine gr. \ will prove more efficacious. In cardiac asthma, digitalis and caffeine may be given with advantage. Spartei7ie has also been recommended (gr. y^-;^) and it acts well in combination with iodide of potassium. In order to fulfil the second indication, viz., to prevent recurrences, a careful inquiry should be made into any possible causes of the complaint; and should such be dis- covered, whether in the abdomen or elsewhere, they should be properly dealt with. The nose especially should be carefully examined, and if there be any growth on the inferior turbinate bones, surgical treatment will probably cure the bronchial complaint. Dr. Woakes, in his work on " Nasal Polypus," has clearly explained the pathogeny of nasal asthma, and has cited several cases in which the attacks were obviously dependent on the presence of polypi and hypertrophy of the tissues covering the inferior and middle turbinate bones. He recommends the galvano-cautery and chromic acid. When bronchial catarrh is present this will require appropriate remedies, to which may be added the inhalation of condensed air. For some cases of this kind the inhalation of oxygen has been found serviceable. I have made trial of this remedy in several cases of asthma, and have had every reason to be satisfied with the results. An inhaler suitable for the administration of nitrous oxide I 1 482 TREATMENT OF ASTHMA. answers the purpose very well ; it should be used about an hour-and-a-half after a meal, and either in the morning or afternoon. Oxygen-water, as prepared by Messrs. Brin, is also serviceable in asthma. In using condensed air the patient is either placed in a pneumatic cabinet or a portable apparatus is used, by which the lungs alone are acted upon. It has been recommended that the patient should inspire compressed and expire into rarefied air, and apparatus have been constructed for fulfilling these purposes. For acute attacks of bronchitis, steam inhalatio7is containing benzoin or eucalyptus give most relief, and when the expectoration is decidedly purulent, terebene and the balsams may be prescribed. Change of air often proves most efficacious for asthmatic subjects. Dr. Hyde Salter remarks that residence in one locality will often radically and permanently cure asthma resisting all treatment in another locality. The localities most beneficial for the great majority of cases are large, populous, and smoky cities, the effect depending probably on the air. It is curious that the air which would be imagined to be the worst for the general health should be the best for asthma, though this is not always the case. When the patient's means are sufficient, a change of residence from time to time is often beneficial ; thus, during the summer, the seaside or any good country place may be chosen ; in the winter the south of France or the Italian coast, Madeira, or Egypt, may prove suitable. The TEjEATMENT of asthma. 483 condition of the bronchial tubes during the intervals will serve in some measure as a guide in selecting the locality. Exercise in the open air, and warm, tepid, or cold baths are all likely to be serviceable according to circumstances. For asthma occurring in gouty and dyspeptic subjects the regulation of the diet and mode of living is all- important. The meals must be small, and the food easily digestible. The patient should dine at two o'clock, and should take nothing but a light supper afterwards ; break- fast should be the chief meal, when meat, eggs, and cocoa may be taken in moderation. Stimulants should generally be avoided, save with meals ; a little good brandy or whisky, well-diluted, may then be allowed. Distension of the stomach is likely to prove very mischievous, and should be carefully guarded against. For plethoric subjects of this kind a course of treatment at Carlsbad, Marienbad, Kissingen, or Homburg, is likely to be serviceable. In all cases constipation must be prevented by laxatives or purga- tives. Whenever decided periodicity is a feature of the attacks quinine should be given in full doses. Yox anxmic subjects iron is, of course, indicated ; and whenever there are indications of nervous depression or irritability we may try the bromides, oxide of silver, or arsenic. This last is sometimes very efficacious, and is always worthy of a trial. In some forms of asthma, notably those for which no special cause can be discovered, iodide of potassium some- 4:84 TREATMENT OF ASTHMA. times prov^es very useful ; it should be given in doses of gr. v-x three times a day, and continued for several weeks. It may be advantageously combined with extract of stra- monium (gr. \-\) given until the pupil becomes dilated, when the dose should be diminished. A few drops of tincture of belladonna with each dose would not interfere with its efficacy, and would obviate the production of dis- agreeable symptoms. Chloral may also be given at the same time. It has likewise been recommended that the tincture of iodine should be applied to the sides of the neck. Electricity has, of course, been tried in cases of asthma, and the poles are recommended to be applied in various positions. Thus they can be placed one on each side of the thyroid cartilage, or the positive pole applied to the back of the neck, while the negative is placed between the larynx and the sterno-mastoid muscle. The faradic current has also been used, the electrodes being placed one on each side, either below the angle of the jaw or on a line with the thyroid cartilage. CHAPTER IV. H AY- ASTHM A- 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 Experiments — Symptoms — Affections of the Nose, Eyes, and Throat — Cough and Difficulty of Breathing — Appearances of THE Affected Parts — Diagnosis — Treatment, Prophylactic and Curative. It is doubtful whether, in the present state of our know- ledge, hay-asthma can fairly be classified among functional disorders. It is, however, very closely allied to them ; and although the theory of its origination from pollen has been placed on a very sure footing, it is by no means certain that the symptoms cannot be excited by other causes. The complaint, variously termed hay-asthma, hay-fever, summer catarrh, and June cold, is a catarrhal affection implicating the conjunctivae, mucous membrane of the nose and of the entire respiratory tract ; appearing in the early summer or autumn and attacking predisposed persons in the same manner and at the same time every year. Its symptoms resemble those of catarrhal influenza; the implicated mucous membranes being red, swollen, and 486 CAUSES OF HAY-ASTHMA. covered with increased secretion ; sneezing, fever, cough, and attacks similar to those of asthma make up the clinical features of the disorder. It is interesting to find that an English physician, Dr. Bostock, was the first to recognize and describe this com- plaint. He read a paper on a " Case of a Periodical Affec- tion of the Eyes and -Chest " before the Medico-Chirurgical Society in 1819, the description given being that of his own symptoms. Some years afterwards, he had collected nearly 30 additional instances, and he advanced the theory that heat was the real cause of the complaint, in opposition to the popular idea which attributed it to emanations from hay and flowers. Since the period specified the number of reported cases has enormously increased. It may be that the complaint, like many nervous disorders, is more common now than it was in former times; possibly, how- ever, increased accuracy of diagnosis may account for the difference in the number of cases. The disorder was not clearly recognized in Germany till 1859. Causes. — With regard to the causes of hay-asthma, there is still much diversity of opinion. Ordinary heat and exposure to the sun's rays, artificially heated air, as that of greenhouses, and the pollen of certain grasses have been credited with the causation of the complaint. Before examining the evidence in favour of the claims of any of these, it will be well to notice the persons who are especially prone to be attacked. Statistics show that hay- CA USES OF HA Y-A S THMA . 4S7 asthma is more prevalent among males than females ; that the majority of the patients are under 40 years of age, and that those whose pursuits involve mental toil are very much more susceptible than labourers of all kinds. A predispo- sition to attacks is often transmitted from one generation to another; a nervous temperament is said to characterize the majority of the patients. Some authorities state that decided swelling of the nasal mucous membrane, especially of that covering the inferior turbinate bones, is an antece- dent condition in many cases of hay-asthma. It is with regard to the exciting causes of the complaint that many different views have been and still are held. Dr. Bostock considered that excessive heat was the chief cause ; but it would appear that something else is necessary. Dryness of the atmosphere is one requisite ; moreover, in damp and cloudy weather the sufferers always feel relieved. The dust of hay has long been supposed to contain the exciting causes of the affection ; patients are attacked when the grass becomes quite ripe, and when haymaking is going on the cause becomes still more active. If per- sons, predisposed to attack, leave the country district, where they have suffered for many years previously, and spend the summer in a large city or by the seaside, they remain free from the symptoms. The pollen of the grasses contained in hay would appear to be the agents whereby the attacks are excited ; and a similar power is possessed by wheat, oats, and rye in bloom, and the pollen of many 488 SYMPTOMS OF HAY-ASTHMA. sweet-scented flowers. Emanations from animals are said to produce a similar effect on some persons. The pollen of ragweed (Ambrosia artemisiaefolia) is a potent cause of the autumnal variety of the complaint frequently seen in the United States. Dr. Blackley, of Manchester, has performed a great many experiments which show that the symptoms may be induced in certain individuals by applying a small quantity of the pollen of various plants to the mucous membrane of the nostrils. He also detected pollen grains in the air, and determined their amount at different altitudes, by attach- ing to kites glass-slides covered with a mixture of water, proof spirit, and glycerine. Fully 95 per cent, of the pollen belonged to the Graminaceae, and it appeared that the rise and progress of the complaint corresponded with the amount of pollen present in the atmosphere. The chain of evidence connecting hay-asthma with pollen would, therefore, seem to be complete ; but some other observers still believe that the complaint may be produced in another way, having noticed that in some persons strong light or sunshine fall- ing on the face will produce a paroxysm of sneezing, and that the other symptoms then follow in quick succession. Symptoms. — In many cases of hay-asthma the effects rapidly follow the operation of the cause. The first symptoms are often noticed soon after a walk through a hay-field ; but sometimes there are premonitory sym- ptoms, such as a feeling of malaise, loss of appetite and SYMPTOMS OF HAY-ASTHMA. 489 feverishness, and these may last for a few hours or even a day or two. The symptoms of the attack closely re- semble those of coryza ; there is a feeling of heat and irritatio7i in the nose, frequent sneezing, increased secre- tion from the nasal mucous membrane, and obstruction of the passages ; swelling of the membrane covering the inferior turbinate bones can often be discovered ; taste and smell are generally much impaired. The conjunctivae are likewise affected ; there is a sensation as if the eyes were full of dust, the lachrymal secretion is increased ; there is intolerance of light, hyperaemia, and perhaps oedema of the lids. The mucous membrane of the throat often participates ; it seems to be hot, dry, and rough, and there is much uneasiness or even diflficulty in swallowing ; in some cases the throat-affection is the first to appear. These symptoms may constitute the whole of the com- plaint ; but in many cases laryngeal and bronchial catarrh is superadded, and sometimes there is a considerable amount oi fever , pain in the forehead or back of the head, or a feeling of pressure and lowness of spirits. Itching of the skin is very common, the face, back and chest being mainly affected ; an eczematous eruption is sometimes present. Some patients are conscious of a feeling of cold in the nose, and especially at the tip of the organ, which is likewise cool to the touch. The symptoms occasionallv pass off after a few hours or in a day or two, but more frequently they continue for several weeks. Relapses are 490 S Y3IPT0MS OF HA T-A S THMA . common, especially if the patient remain in the neighbour- hood of hay-fields. Symptoms resembling asthma are frequently super- added, but they are not present in all cases ; they seem to result from extension of the laryngeal catarrh, There is at first a frequent and dry cough, associated with a sensation of tickling in the larynx, and the expectoration of a little transparent mucus. The severity of these symptoms is much influenced by the state of the atmosphere ; they are aggravated during hot and dry weather and considerably relieved after a rainfall. The cough is often spasmodic in character; the attacks occurring in paroxysms of consider- able duration and causing much distress to the patient. It is stated that small crystals, resembling those found in ordinary asthma, have been discovered in the expectora- tion. The nasal secretion, which is often very copious, contains vibriones and the pollen of grasses, either unchanged or swollen and flattened ; the granules sometimes exhibit spontaneous movements, and occasionally form small chains. With regard to the appearance of the affected parts, the mucous membrane of the nose, throat, and larynx is much swoIUmi, hyperc-emic, and covered with secretion. Recovery from the attacks is, of course, the general rule ; it is scarcely possible that death should ever be caused by them, except in the subjects of severe organic disease. Immunity from attacks is scarcely if ever attainable by those who TREATMENT OF HAY-ASTSMA. 491 have already suffered unless the patient takes up his abode in a large city. The diagnosis of the complaint can seldom be a matter of difficulty ; the local symptoms in the nostrils, eyes, and throat, and the attacks of sneezing, and of difficulty of breathing, are sufficient to indicate the nature of the case. Treatment. — The only way to avoid attacks is to remove to a locality, e.g., a large town or seaside place, in which the complaint is unknown. The patient must, of course, leave the country before the hay-season commences, and remain till harvest is gathered in. For persons who are obliged to stay in the country. Dr. Blackley recom- mends the use of a respirator moistened with a weak solution of carbolic acid, and at the same time the wearing of spectacles provided with closely-fitting gauze guards. Something may be done to diminish susceptibility to attacks by prescribing hygienic measures of various kinds, such as cold baths, liberal diet, with tonics and stimulants. When a patient has been exposed to the causes of attacks the nose should be syringed out with weak solutions of quinine or carbolic or salicylic acid, and the same remedies may be freely used during the continuance of the nasal catarrh. Dr. Illingworth strongly advocates a warm nasal douche containing the biniodide of mercury (i :20oo), and also the same solution used in the form of a spray at bed- time. One such application was sufficient to cure a very severe case. For the same purpose a powder has been recommended consisting of calomel and alum, of each 9 492 TREA TMENT OF HA Y-A S TEMA. parts, hydrochlorate of morphine, i part ; about a grain to be used three times daily as a snuff. Such remedies as arsenic, strychnine, camphor, and bromide of potassium are recommended for lessening the severity of the attacks, and small doses of morphine will usually aid in relieving the patient's distress. To allay the irritability Sir A. Clark recommends the local application of cocaine (a 5 to 15 per cent, solution) to the mucous membrane of the nose and back of the pharynx, on a camel-hair brush. To exhaust the irritability, he applies locally a mixture composed of glycerine of carbolic acid i oz., hydrochlorate of quinine, I drachm, and the two-thousandth part of perchloride of tnercury. The nostrils are first cleansed with a douche of warm water containing boro-glyceride (i oz. to the pint), a laryngeal brush is filled with the mixture and applied freely to the upper part and floor of the nasal cavities. The immediate effects are somewhat disagreeable ; but as a rule, a cure is effected by two or three applications, which may be made on alternate days or less frequently. This plan should be reserved for obstinate cases ; for others, milder applications are more suitable and equally efficacious. Inhalations of iodine and of menthol have proved successful in some patients. In cases in which the mucous membrane of the inferior turbinate bones is con- gested and hypertrophied it has been advised to remove the diseased tissue with the galvanic cautery, or by the application of glacial acetic acid. SECTION IV. FUNCTIONAL DISORDERS OF THE 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 Nitro- genous Materials — Bread as a Food — Influence of the Tannin of Tea on Salivary Digestion — Effects of Improper Food — Peculiarities in Certain Individuals — Effects of Nervous Ex- haustion — Spasm of the Stomach and Intestines — Spasm of the CEsophagus — Perversion of Gastric and Intestinal Secretion — Effects of Nervous Influence — Hepatic and Pancreatic Secretion — Effects ofNervous Influence on Intestinal Movements — Effects of Altekations in the Blood Supply — Enumeration of the Sym- ptoms of Functional Disorders of the Stomach and Intestines. Functional disorders of the organs of digestion offer a wide field for study. Those in which the stomach, intes- tines, and liver are respectively implicated form a large and important category, and will be considered in this section. In connection with the intestinal tract we meet with disorders of sensation, motion, and secretion ; functional affections of the liver are evidenced by per- 494 FUNCTIONAL DISORDERS OF DIGESTION. verted sensations, secretions, and metabolic processes. Disorder of sensation is exhibited in such complaints as gastralgia, enteralgia, and hepatalgia ; disorders of motion in colic, constipation, and diarrhoea ; while disorder of gastric and biliary secretion is shown in many forms of dyspepsia, which are also often accompanied by pain and disorder of movement in various parts of the intestinal tract. These functional affections differ in one important respect from those already considered, for they are often traceable to distinct causes, e.g., in the case of the stomach, to the ingestion of food improper in quality, or excessive in amount. Another marked peculiarity consists in the fact that the occurrence of one condition is often quickly followed by another ; thus indigestion is frequently asso- ciated with gastralgia, and both with constipation or diarrhoea, of which the indigestion is the primary cause. Disturbance of one function is speedily followed by dis- order of another, so close is the mutual interdependence of the various organs and processes. The causes and symptoms of the functional disorders of the alimentary tract will be minutely discussed in succeed- ing chapters ; but it seems advisable to make a few general remarks on these subjects before entering into particulars. With regard to causation, the influence of errors in diet is daily becoming more and more obvious, and nothing is more certain than that the majority of functional disorders of the stomach, liver, and intestines belong to the class of CAUSES OF DYSFEPSIA. 495 preventible diseases. If we take as an example any one of the forms of indigestion we shall almost invariably find that it is traceable to errors in diet, and that it can be relieved or cured only by dealing with its cause. The same holds good of those secondary results which con- stantly obtrude themselves in the form of hepatic derange- ments, gouty symptoms, urinary deposits, and the like. Among the well-to-do classes dyspepsia is by far the most common complaint, and its causes are seldom far to seek ; excess of nitrogenous food is the most potent of these. As direct consequences of such excess, the organs engaged in preparing and assimilating food in order that it may serve to nourish the body, become over-worked and eventually break down. Moreover, when too much nitrogenous food is taken some of it is eliminated without having undergone the necessary changes, and acts in- juriously upon the excretory organs, and especially upon the kidneys and skin. Albumin not unfrequently appears in the urine after habits of indulgence in excess of albuminous food ; some portion of the excess is, doubt- less, got rid of by this channel, but at the risk of setting up destructive changes in the kidneys. In my work on Gout I have endeavoured to show that defective assimila- tion may ultimately result in irritation and chronic inflam- mation of the kidney, and may, therefore, be regarded as one cause of Bright's disease. Cutaneous affections, notably eczema and acne, are additional consequences of 496 CAUSES OF DYSPEPSIA. malassimilation, and the general health of the patient sooner or later suffers, as shown by the occurrence of such symptoms as lassitude, incapacity for exertion, disturbed sleep, headache, and impairment of the mental faculties. If, as is often the case, a deficient amount of exercise be taken at the same time, the symptoms are more marked and more rapid in their onset. A deficient supply of nitrogenous materials is a far less common source of gastric and general disorder ; but severe suffering is occasionally traceable to this cause. Some patients, poor women especially, live mainly on bread and tea, and meat in any shape forms a very small part of their diet. Life can, of course, be supported on good wheaten bread, which (always provided that whole meai be used for its manufacture) contains all the elements necessary for nutrition, though not in the proper propor- tions, for to obtain the 300 grains of nitrogen required daily by the system, it would be necessary to eat at least three pounds of bread. This would involve the ingestion of nearly double the quantity of carbon required, and the bulk of the food would give rise to much inconvenience. In the patients referred to the amount of bread taken is much less than this, and as such persons almost invariably choose white bread, the quantity of nitrogen is altogether insufficient for the wants of the economy. There is, how- ever, another drawback connected with the diet referred to, viz., that tea is a powerful retarder of salivary digestion ; IMFHOPBR FOOD AS A CAUSE OF DISORDER. 497 it owes this property to the large proportion of tannin that it contains. Hence, a diet composed of tea and bread is a fertile cause of dyspepsia and gastralgia, for much of the starchy matter remains for some time in the stomach, and passes out of it in an undigested condition. Peptic digestion is retarded by malt liquors as well as by tea and coffee. The effects of improper food may be described in a few words. In this category are included substances, either naturally indigestible, or imperfectly prepared. Disorder of the digestive organs is often traceable to this cause. It is only necessary to mention unripe fruits, the rinds and seeds of fruits, and the stalks of leaves ; very few uncooked vegetables are thoroughly digested. The symptoms which matters of this kind induce are of common occurrence, and are generally recognized. Eating unripe fruit, or even ripe fruit in excess, is apt to be followed by colic and diarrhoea, and some persons are very susceptible in this respect. There are also many curious idiosyncrasies in reference to the effects of articles of food, some of which, harmless to most people, act as poisons upon a few individuals. Thus we find that some persons cannot eat eggs in any form without very severe suffering; others, again, are affected by shell-fish ; intense gastric irritation, conjunctivitis, or severe urticaria being the invariable penalties. The effect of cold drinks in retarding digestion has long been recognized, but the warnings of experience are apt to be K K 498 VARIOUS SYMPTOMS OF GASTRIC DISORDERS. neglected. Iced drinks, taken with or soon after meals, are powerful causes of indigestion. In order that the food should be thoroughly mixed with the secretions of the stomach, and converted into chyme, the movements of the organ must be perfectly carried on, and in various disordered conditions these movements are either exaggerated or impaired, or associated with various kinds of painful sensations. Among the causes which impair the activity of the movements, may be mentioned nervous exhaustion in general, and especially when due to excessive mental strain. Very decided symptoms, referable to gastric paralysis, are not unfrequently seen in persons who after a heavy meal, perhaps towards the close of the day, at once occupy themselves with severe mental work. The nervous energy necessary for digestion is diverted into other channels, and the processes in the stomach come to a standstill, or are very imperfectly performed. The con- ditions are similar in the case of persons who eat heartily when over-fatigued ; the food remains undigested owing to lack of nervous power. The same result sometimes follows violent and protracted bodily exercise soon after a full meal. In another class of cases the disorder takes the form of spasm, and this is often set up by the presence of articles of food ; the spasm is paroxysmal, and always accompanied by severe pain. It must not be forgotten that symptoms of a like character are sometimes connected with spinal SPASM OF THE (ESOPHAGUS. 499 disorders, and notably with locomotor ataxy. When the intestines are affected the condition is known as colic ; it may be due to articles of food, to lesions of the intestines, to lead poisoning, or to strangulated hernia. The last- named cause should never be forgotten in all cases of .abdominal pain, and especially in women, in whom a small femoral hernia may easily escape observation, and be almost painless though causing severe pain, perhaps in the um- bilicus or upper part of the abdomen. In connection with the subject of spasm of the stomach and intestines, it is worth while to refer briefly to a similar condition of the oesophagus. This is of rare occurrence, except in hysterical subjects ; it may easily be mistaken for gastric disorder, and for organic stricture of the oesophagus itself. The contraction takes place at or near the pharyn- geal end of the tube ; there is a sore spot or downright stoppage with return of food: in some cases swallowing is painful and performed irregularly. When spasm exists the regurgitation is almost immediate; the food is flung back and not retained for 40 or 50 seconds, as occurs in organic stricture of the oesophagus, and liquids generally are more resented than solids. The history also presents certain characteristics ; there is generally dyspepsia of a gouty character; the urine is abnormally acid, and the stomach and intestines are liable to tympanitic distension. Dr. Brinton, who has described several of these cases [Lancet, Vol. i., 1866), explains them as follows: the muscular con- 500 PERVERSION OF SECRETION. tractions of the intestinal tube are influenced by irritations extrinsic to itself. Acidity causes spasm of the muscular walls, and the end of the pharynx is especially liable to be affected, because the voluntary part of swallowing is there translated into an involuntary act. Perversion of secretion is another and very important factor in the production of functional disorders of the alimentary tract ; and when we reflect upon the number and variety of the secretions poured into the intestinal canal, the uses for which they are adapted, and the in- numerable kinds of food which are subjected to their action, we cannot but marvel at the comparative infre- quency of signs of irregular action. Secretion is well- known to be under the influence of the nervous system ; the salivary secretion is the most prominent instance of this character, and we may easily believe that the gastric, intestinal, and hepatic secretions are similarly influenced. We know that the state of the tongue and throat is often affected by nervous excitement ; that swallowing is some- times impossible, even in the absence of organic disease,, and there is every reason to suppose that the stomach may be subject to influences of this character. There is no nerve passing to the stomach, whose stimulation causes a flow of secretion, as the chorda t}-mpani does in the sub- maxillary gland ; but certain experiments point to the existence of local secretory centres in the stomach, and there is evidence to show that there is some connection INFLUENCE OF NERVES ON SECRETION. 501 between the central nervous system and the gastric glands. In a case of gastric fistula it was found that even the sight 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 contradictory. It has, however, been proved that the 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 influence upon the pancreatic secretion. The latter is excited by direct stimulation of the gland itself, and by 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 within its walls, between the longitudinal and circular muscular fibres. When this plexus is unaffected by any stimulus the move- ments of the intestines cease ; when food passes from the stomach into the bowels peristaltic contractions of a reflex 502 INFLUENCE OF NERVES ON INTESTINES. nature at once begin. The effect of the food is heightened by the condition of the blood-vessels ; when these latter are turgid with blood the irritability of the nervo-muscular apparatus is considerably increased, so that slight stimuli produce a comparatively 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. The continuous application of strong stimuli causes com- plete 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 painlul sensa- tions. The effects of alterations in the J)lood-supply have been incidentally alluded to in preceding paragraphs; but changes in the quality of the blood also play a certain part FUNCTIONAL DISORDERS OF DIGESTION. 503 in the causation of disorders of the abdominal 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 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. The symptoms of functional disorders of the stomach and intestines will be fully described and their significance pointed out in succeeding chapters. They may be briefly recapitulated and summarized 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 sen- sations, flatulence and eructation, nausea and vom.iting, constipation and diarrhoea. A numerous category of sym- ptoms are connected with other organs. The kidneys have been already alluded to. They are often the first to suffer, and cutaneous affections are frequently superadded. The action of the heart is generally interfered with ; palpitation and intermittency are common symptoms of dyspepsia. Even the lungs occasionally become affected ; dyspnoea and attacks of asthma are sometimes traceable to the state of the stomach. The nervous system especially suffers in 504 FU2sCTI0NAL LISOEDEltS OF DIGESTION. another class of cases, the symptoms exhibited being more marked in this portion of the organism than in the abdo- minal viscera themselves. Headache, vertigo, depression of spirits, irritability, incapacity for mental exertion, sleep- lessness, 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 fe^^ of these cases, the patients becoming thin, anaemic, and debilitated, and these symptoms are sometimes so pro- minent 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 indications 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 andIntestines — -Mechanical Actions and Chemical Changes Therein — Meaning of Term Dyspepsia — Relations with Catarrh — The Vascular Apparatus of the Stomach — Sjrong 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 froji the Stomach — Formation of Organic Acids — Increase of Salivary Secretion — Pyrosis— Constipation — Diarrhcea — The Urine and Skin — General Condition 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 Suitable — Fluids — Milk Diet — Theatment of Constipation — Laxatives — Aloes, Cascara, Salines — Stronger Purgatives — Hygienic Measures as Change op /\ir, Exercise, Baths, Medicines such as Acids, Alkalies, Bismuth, and Charcoal — Treat- ment OF Irritative Dyspepsia — Arsenic, Ipecacuanha — Question of Health-Resorts. The stomach and the Intestinal canal have a double task to perform. They have to act meclianically upon the materials Avhich are introduced into them, and they are the seat of not a few clieinical processes, set up by the secre- tions of glands which form an important part of their 506 DEFINITION OF DYSPEPSIA. structure, or whose excretory ducts open into their cavities. The chemical changes are intimately connected with the mechanical action of the parts concerned, 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. Pathological disorder of the move- ments of the intestines is, therefore, generally associated with disorder of digestion, and when the chemical pro- cesses 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 confined to one spot only when the irritation is comparatively slight. Dis- orders of the stomach and bowels are, therefore, frequently associated ; it rarely happens that the one is affected with- out 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 affect the surface, or at least the mucous membrane, principally. No such sharp line of demarcation can, how- ever, 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. DYSFUFSIA AND GASTRIC CATARRH. 507 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 in- flammation. A similar result may follow^ the operation of a very different but less common cause. When the stomach contains food, mental excitement may check the secretion of gastric juice and the movements of the organ, and may thus produce catarrh. Individual peculiarities, dependent upon a variety of circumstances, tend to in- crease 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 be the case with corresponding portions of the cutaneous integument. As contributing to the production of functional disorder, 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 ^jos causj^s of dyspi:fsia. hours or days. The terms " weak " and " strong" applied to stomachs may not be very scientific, but they serve to express differences which undoubtedly exist. It is easy to explain the frequent 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 the intestine, and are not rendered innocuous by the various secretions which there become blended with them, they will- at all events cause irritation, and possibly inflammation of the bowels. Irregularities and disorders of digestion 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. Causes. — The causes of indigestion may be grouped under the following heads : — I. I^^ood 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 fashionable tastes be gratified, other considerations arc 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 CAUSES OF BYiSFEPSIA. SOQ- very beneficial in a large majority of cases. There is still, however, much that is faulty ; too much authority is still left to the palate, with little consideration for the powers of the stomach. 2. Improper intervals betiveen meals. — Two faults may be included in this category, the one being much moie common than the other. Indigestion is sometimes caused by eating too frequently ; the stomach is never allowed to be at rest and is never free from peptones ; 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. I nsufficient division and preparation of the food while in the month.— 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 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 food is swallowed, but not eaten. Immoderate eaters often sin against themselves in the manner just described; some 510 CA USi:S OF D YSPEPSIA . of them, indeed, never seem to use the muscles of mastica- tion. Persons with defective teeth unwittingly offend in a similar manner. There is another source of mischief con- nected 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 dri)ikiiig of a large quantity of fluid at a loiv temperature is a potent cause of indigestion. Too much stress cannot be laid upon this fact; persons are very apt, especially during hot weather, to take immoderate quantities of iced liuids during meals. The symptoms, in some cases, quickly follow the cause ; the cold applied to the lining membrane of the stomach converts its hj^Deraemic 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 fuids, especially when these are taken upon an empty stomach. — The operation of this cause is universally recognized ; the worst use to which stimulants can be put is to take them between meals ; they irritate the stomach, set up hypcr^emia 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 altera- tions. Besides causing local changes, alcohol, after acting CAUSES OF DYSPEPSIA. 511 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 positio7is of the body and tightly fitting clothes may contribute to the causation of dyspepsia by interfering with the movements of the stomach and bowels. Tight lacing among women comes under this head, and among the lower classes, the stooping 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, however, obstructed if the activity of other portions of the body simultaneously claim an increased supply of that fluid. Thus it is that active mental or bodily exertion immediately 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 512 CAUSES OF DYSPEPSIA. the circulation. There is, however, some difference in opinion with regard to the desirabiHty 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 mis- chievous, and should always be forbidden : the interval between a late meal and bedtime should be devoted to recreation and amusement. 9. Nervous excitement is another cause of indigestion. It is well known that during such a condition the want of food is scarcely felt, and that when a meal is taken dis- comfort 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 oppor- tunity occurs, one form of discomfort is speedily exchanged for another. 10. The last cause of indigestion which requires notice is that which is connected with diseases of 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 insufficiently supplied with blood, and also to the disturbances in the nervous system. S YMF TOMS OF DYSFFFSIA. 513 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, 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 connective 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. Symptoms. — 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 forms 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 L L 514 SYMPT03IS OF DYSPEPSIA. bile. If the matters vomited have been but a short time in the stomach, the other symptoms will soon pass off ; dis- order of the intestines will either be very 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 discomfort may remain beyond a transient feeling of exhaustion. When, however, severe irritation has been set up the suffering may be pro- portionately 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 may be 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 head- ache ; food 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 pc^riod, sometimes for several hours, and they may subside from time to time, and again recur. SYMPTOMS OF DYSPEPSIA. 515 Chronic forms of indigestion are much more common than the acute type ; they make up, indeed, no small pro- portion 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 the 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 discovery 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, but retching and vomiting are 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, and, unless much pain be likewise present, are often unheeded. A careful person will notice that the symptoms are liable to be provoked by sundry articles of food, and 516 SYMPTOMS OF DYSPEPSIA. will abstain from them, or take them only in great modera- tion. It is only a select few, however, who can exercise such restraint, more especially if the food to be avoided be 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 condi- tion 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 these symptoms are aggravated by con- stipation, which so often accompanies dyspepsia, and in not a few cases a condition of melancholia or hypochon- driasis 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 whatev'er is taken has to be forced down, and these attempts are followed by a feeling of weight and pain, which may amount to car- dialsria. A burning sensation at the back of the throat, attended by retching, eructations of acriti matters, vomit- ing, 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 SYMPTOMS OF DYSPEPSIA. 517 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 some- what 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 decomposition of albuminous substances can be detected in some cases, and among these sulphuretted hydrogen is the most common ; it may become absorbed and cause symptoms of poisoning. The symptoms of mental depression, so common in cases of dyspepsia, are doubtless attributable to absorption of the products of putrefactive decomposition ; 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 con- version of albumen into peptone is therefore limited. The 518 FYHOSIS AS A SYMPT03I OF DYSPEPSIA. 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 inordinate secretion of mucus and the less frequent and active movements of the stomach, ^vhich retard absorption, 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. 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 \omiting, 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 cram]) 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 symptom, states that the " gush of saliva is something tremendous, often greater than incessant swallowing efforts can dispose of, and the surplus flows out abundantly from the mouth. . . . \ paroxysm of this kind only occurs SFMJPTOMS OF DYSPEPSIA. 519 during the presence of surplus acid in the stomach." In gastric catarrh occurring in drunkards, the quantity of saUva 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 energy of the peristaltic action. The food remains for lengthened period? in the large intestine, and loses much of its watery con- stituents. The attacks of diarrhoea are the consequence of catarrh of the colon, 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 dis- tension of the intestines, or possibly to the accumulation of the products of retrogressive metamorphosis. The circula- tion of the blood through the abdominal organs is more or less retarded ; the sensitiveness 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- 520 SYMPTOMS OF DYSPEPSIA. 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 are not unfrequent. In cases of gouty dyspepsia the urine is often scanty and high-coloured, and contains a minute quantity of albumen, the presence of which is due to de- rangement of the functions of the liver and consequent defective metamorphosis of nutritive materials. Disorders of the skin are also common in cases of dyspepsia, and take the form of acne, eczema, erythema, or urticaria. In gouty cases eczema is frequently present. The influence of indigestion upon \.\\q general condition of the patient is often very marked. The principal agents concerned in producing the effects are the products of de- composition set free in the intestines, but other causes are often at work. The effects, for example, of anaemia are frequently traceable, and besides these the results of irrita- tion of the vagus and sympathetic nerves which supply the stomach and intestines are seen in the psychical disorders so common in dyspepsia. Among these may be mentioned that inactive condition of the brain which shows itself in sluggishness of the flow of ideas, and difliculty in forming conclusions and following them out, and this may well depend upon a deficient supply of blood to the nerve- centres, or iij)on alterations in the composition of that fluid. The rapid variations in tin- mmtal state of the patient may be thus accounted for. More or less pronounced sleepless- SYMPTOMS OF DYSPEPSIA. 521 ness is a very mcomon accompaniment of indigestion, and is due either to distension of the stomach or to the presence of imperfectly assimilated matters in the blood, or possibly to both causes. The last set of symptoms requiring to be noticed in any detail are those which refer to the organs of circidation. The action of the heart is often much modified in cases of dyspepsia. As a general rule the pulse is less frequent than natural, but this condition is often rudely interrupted by attacks of palpitation, attended by a feeling of distress and violent pain shooting down into the left arm. The symptoms may be so severe as closely to resemble angina pectoris, attacks of which are, as is well known, often provoked by the condition of the stomach. Vertigo from gastric causes is another troublesome symptom in not a few dyspeptic patients. The symptom has been fully dis- cussed in a preceding chapter : it is only necessary to say here that it is often associated with disorder of the heart's action and cerebral anaemia. The sensation in these cases is generally described as though surrounding objects were in motion around the patient, or as though the ground were coming up to meet him. This form of vertigo is very common, but it must never be forgotten that some auditory lesion may exist, and that the state of the stomach may serve only to excite an attack. The special condition known as nervous dyspepsia will be discussed in a separate chapter, as it presents several DIAGNOSIS OF DYSPEPSIA. features which distinguish it from the more ordinary forms of the complaint. The course and duration of the symptoms of indigestion depend for tlie most part on their causation and se\ erity. In acute forms the symptoms rapidly subside under proper treatment, and may not recur if suitable rules for living be enjoined and obeyed. On the other hand, some chronic forms of dyspepsia constitute the most tedious and obstinate complaints which the physician has to treat ; but very much depends upon the individuality of the patient, the circumstances by which he is surrounded, and his willingness and power to act upon medical advice. Diagnosis. — The diagnosis that dyspepsia exists is an easy task ; but the difficulty is to determine whether the symptoms are purely functional, or whether they depend upon some organic lesion. A catarrhal state of the gastric mucous membrane is rarely absent in severe cases, and is evidenced by the quantity of mucus which is discharged from time to time by vomiting. With regard to serious lesions affecting the stomach, the physician has to think especially of malignant disease and of ulceration. In the former, a tumour will be sooner or later perceptible in the neighl)ourhood of the pylorus, and the matters vomited will at some time or other contain blood. The absence of free hydrochloric acid from the gastric juice is indicative of cancer. If no tumour be discoverable, such other symptoms as cachexia, swelling of the supracla\icular TREATMENT OF DYSPEPSIA. ' 523 lymphatic glands on the left side, and the age of the patient will point towards malignant disease. In cases of gastric ulcer, the patients are usually anaemic or chlorotic ; the pain is often very violent and referred to one spot, and it is almost certain to be induced by taking food. Haemor- rhage is also a common symptom, the blood at times appearing suddenly and in considerable quantities. In some of these patients, the blood passes away mainly by the bowels. Prognosis. — The prognosis in cases of dyspepsia depends, of course, upon the diagnosis. It is favourable in acute cases provided that no organic disease can be detected. In chronic cases we must take into considera- tion the general condition of the patient, the severity of the symptoms, and the other points referred to as influenc- ing the course and duration of the complaint. In old people in whom there is reason to suspect atrophy of the mucous membrane of the stomach, the prognosis cannot be otherwise than unfavourable. Treatment. — The treatment of acute attacks of dys- pepsia is easy and simple ; the irritated organ must be placed at rest. For this purpose food of all kinds should be interdicted until the symptoms have completely sub- sided ; a little water or soda-water maybe sipped from time to time, the patient keeping perfectly quiet, and in the recumbent position. A mustard plaister applied to the epigastrium will not only relieve pain, but will have a 524 TREATMENT OF DYSPEPSIA. soothing effect upon the irritated organ. If there be in- effectual attempts at vomiting, it will be well to administer an emetic, and this treatment is especially suitable for cases in which the attack is obviously due to some marked error in diet. A scruple of ipecacuanha in half a tumbler of tepid water, or a teaspoonful of mustard similarly adminis- tered, will be found suitable for these cases ; and tepid water alone is sufficient for some patients. If the efforts at vomiting continue after the stomach has been emptied, we may allow the patient to suck ice, or administer a little effervescing water containing live or six minims of solution of morphine ; the mustard plaister is especially suitable for such symptoms. If there be excessive secretion of gastric juice, and the eructation of a highly acid fluid, half-a-teaspoonful of sodium bicarbonate dissolved in a little water will afford relief. Should diarrhoea set in, it is well not to attempt to check it unless it persist after the bowels have been thoroughly emptied of faeces; in that case we may give a few drops of laudanum with chalk mixture and aromatics. Warmth to the abdomen is generally grateful and can be supplied by means of poultices, or an india-rubber bag. If there be constipation, a mild but efficacious laxative should be given after the gastric symptoms have subsided; fro'm gr. L to gr. ij of calomel, followed by a little solution of magnesia, ma)- jjrove sufficient, and a draught, containing rhubarb, magnesia, and soda, may be used to produce a ATTENTION TO DIET. 525 more decided effect. After the symptoms have passed off, a warm bath, followed by rest in bed, will help to remove any feelings of discomfort. The patient must be very cautious in returning to ordinary diet ; light and easily digestible articles should be taken in moderation, and excesses of all kinds should be avoided. The patient should likewise beware of exposure to cold and damp. In the treatment of chronic indigestion the condition of the stomach must, of course, occupy the first place in the consideration, but the functions of the body generally must on no account be neglected. Each case has to be studied separately, and even though it may prove impossible to discover the primary cause of the symptoms, yet it will generally be feasible after careful examination to detect errors in diet and living which help to perpetuate the disorder. Bearing in mind the causes noticed in preced- ing paragraphs, and after making himself acquainted with the symptoms, the physician should inquire as to the food, the time for meals, the manner in which these are taken, the fluids used, and the other points already referred to. It often happens that something faulty can be detected referable to all these headings, and it is, therefore, desirable to lay down rules for the patient's guidance both as to the quality and quantity of the food. To quote what I have elsewhere said on this subject, " I have, for some time past, been in the habit of supplying my patients with printed diet rules. I keep at hand a set of forms on which the hours 526 TREAT2IE2\T OF DYSPEPSIA. for meals and the articles that may betaken, and those that must be avoided are clearly specified. As a matter of course modifications by way of addition or subtraction are sometimes required, and spaces are therefore left for additions. I attach the greatest importance to these diet rules; a patient is far more likely to obey instructions con- tained in a printed form than verbal directions, however empliatically expressed." Before considering the question of diet, the physician should always inquire into the state of the teeth, and this precaution is especially necessary in treating middle-aged and elderly patients. Defective teeth are a fertile cause of indigestion, the remedy for which, under such circumstances, is to be found in the skill of the dentist. Having attended to this particular, we must next prescribe the diet, and it is often necessary to remind the patient that it is a bad habit to take only one good meal per diem, and little or no nourishment at the other meals. On the other hand, the daily amount of food should be divided into three ap- proximately equal portions, and taken at intervals of four or five hours. The last meal should be eaten two or three hours before bed-time. The work thrown upon the stomach is thus fairly distributed; the organ is never over- burdened, and it has its periods of rest. When small quantities of food are frequently taken the stomach is constantly being excited to increased activity, and is never quite emptied ; fatigue of its muscular coat and exhaustion ATTENTION TO DIET. 527 of the nervous energy which presides over secretion must sooner or later occur. Moreover, as already mentioned, the presence of peptones in the stomach checks the ■digestion of any food that may be taken. In regulating the diet for chronic cases we get but little aid from the experience of the patients, for they have often forgotten what the sensation of perfect digestion really amounts to. The object to be compassed is to restore this sensation, and we endeavour to do this by supplying food in sufficient quantity to nourish the system, while it makes as slight a call as possible upon the powers of the stomach, and does not by its tastefulness invite to excess. With regard to the articles of diet from which a selec- tion must be made, mutton, beef, game, chicken, fish, and eggs make up the list of animal substances ; green vegetables, stale bread, and a small quantity of butter may generally be allowed. The mutton and beef should never be overdone ; the eggs, too, should be lightly cooked ; the other articles are dressed in the usual way. They are all easy of digestion and are not likely to set up acid fermenta- tion in the stomach. The patients should always be warned against the ill effects of rapid eating. Fluids should be taken sparingly at meal-times, and for most dyspeptics two or three glasses of sound claret with some alkaline effervescing water will be found suitable. If the patient prefer it, an ounce of good brandy or zvhisky, well diluted, may replace the claret. For manv patients hot 528 TREATMENT OF DYSFEFSIA. water (with or without a little sugar) may be mixed with the claret with advantage ; iced drinks are to be scrupulously avoided. The stomach should never be dis- tended ; many dyspeptics should on this account avoid soup ; others may take a few spoonfuls with advantage. Pastry of all kinds must, of course, he forbiddeti ; milk puddings are generally allowable. Most dyspeptic patients have to be very careful in the use of bread ; for some, indeed, it is better to prescribe toast and plain biscuits. Whenever there is much flatulence, all kinds of starchy food, e.g., bread, potatoes, rice, etc., must be avoided ; and when bread is asjain allowed it should have been baked at least twenty-four hours previously. Aerated bread is better than the ordinary kind, W'hich is too often sour and indigestible. For the morning meal, cocoa made from the nibs is preferable to either tea or coffee ; the latter, indeed, must be forbidden to most dyspeptic patients. Tea may sometimes be allowed, but it must be taken in strict moderation and with plenty of milk. The highly astringent Indian teas are not advisable for these patients. In dyspeptic patients who are at the same time the subjects of ana'iiiia, the loss of appetite which is often noticeable is sometimes due to the fatigue which the act of eating produces ; and under such lircumstances after a few mouthfuls the patient is disinclined to make any further attempts. The difficulty should be overcome by ad- ministering Jliiid or scmi-Jliiid iiiii riineiit, which makes TREATMENT OF DYSPEPSIA. 529 little demands upon the muscles of mastication. Milk thickened with amylaceous materials and peptonized milk are very suitable for these patients, and in extreme cases peptonized nutrient enemata or suppositories may be used. With regard to a milk-diet in general, we know that this fluid contains everything that is necessary for nutrition, and that life can be maintained for almost indefinite periods upon it alone. But in order that the necessary quantity of nutriment should be introduced, a large volume of milk, perhaps six or seven pints, must be supplied. In an ordinary stomach, however, there is a great risk of undue distension if so large a quantity be taken, and this con- dition cannot but impede the movements of the organ. Moreover, the casein is apt to form hard lumps, for the solution of which much time may be required. These large quantities of milk are therefore badly borne by many patients, and some modifications are rendered necessary. Three or four pints may be tolerated without difficulty ; but the amount of nutrmient therein contained is insufficient for the daily wants, and some addition is requisite. Several slices of well-toasted bread, or a corresponding number of biscuits, may be soaked in the milk, and such diet may be persevered with for several days, often with great advantage to the patient, provided, of course, that he is kept at rest at the same time. The transition to a more nutritious diet should be very gradually made; some pep- tonized food, either Savory and Moore's or Benger's, may M iM 630 REMEDIES FOE COySTIFATIOS. first be tried, and these can be followed, if the patient likes them, by lightly boiled eggs. After a few days sweetbread and boiled fowl may be allowed, and these may be replaced by boiled or roast mutton, roast fowl, and roast beef. The directions given in preceding paragraphs with regard to the meal-times and the avoidance of rapidity should, of course, be carefully attended to. The cure of dyspepsia is not to be regarded as complete until the patient has regained the sensations which a healthy stomach experiences after food is taken. When this stage has been reached, and provided that the patient is capable of exercising a due amount of self-control, he may be allowed some latitude in the choice of viands. If any difficulties recur he should at once go back for a day or two to his former restricted diet. The condition of the bowels always requires attention, and when constipation is present, means must be adopted for its relief. Laxatives are often required, but these should be given with the view of restoring the natural action of the bowels. This process should be further encouraged by a visit to the closet at a regular hour daily, even if there be no desire to defaecate. Drastic purgatives are always to be avoided; their use would only exaggerate the evils they are intended to remove. The extract of aloes is one of the best remedies for the cases under consideration, and it may be advantageously combined with belladonna, quinine, and henbane, or with the dried sulphate of iron in lieu of the TEE A TMENT OF I) YSPEP SI A . 53 1 quinine. The following prescription will be found useful in many cases : — R Extract. Aloes Socot. gr. j-jss ; Quininse Sulphat. gr. j (vel Ferri Sulphat. Exsiccat. gr. ^, vel Extract Nuc. Vomicae, gr. \) ; Extract. Belladonnae gr. ^ ; Extract. Hyoscyami gr. j ; misce, fiat pil j. This pill may be taken daily, or as required, before or after the midday meal, or at bedtime, and when regularity of the bowels is attained the aloes should be diminished in quantity. For some patients cascara sagrada acts satisfactorily. It is best given in the form of the liquid extract, of which nixv-xxv may be taken night and morning, the dose being regulated according to circumstances. Messrs. Squire have introduced a palatable and convenient elixir of cascara, of which the dose is a tablespoonful. Messrs. Parke, Davis and Co.'s cascara cordial (dose »i|.xv-5j ;) is also a satisfactory preparation. Saline purgatives are suitable for some cases of dyspepsia, and especially for gouty subjects of full habit. The salts may be very conveniently administered in some one or other of the natural mineral waters, a host of which are at our disposal. The most efficacious are those of Carlsbad, Marienbad, Hunyadi Janos^ Friedrichshall, and a newly introduced Spanish water, the Rubinat-Condal. The best way to take any of these is to mix from 4 to 6 ozs. with an equal quantity of hot water, and this is to be drunk on rising, or while dressing. The quantity should be sufficient to move the bowels once or twice after breakfast, but un- due purgation is to be avoided. In some cases it is found 532 CRASGE OF AIR A^D SCENi:. that saline purgatives cause a great deal of depression, and for these they are not suitable. Whenever a more decided purgative action is required we may have recourse to the rhubarb draught with soda and magnesia, to the compound liquorice poivder, or to colocyntli and Jienbane pills. For debilitated subjects small doses of aloes are usually the most appropriate ; and some effervescing preparation of magnesium will often answer the purpose, but this drug should not be administered continuously for any length of time. The improvement of the general health is an all-impor- tant object in the treatment of dyspepsia, and change of air under proper regulations will often do more good than any other measure. In prescribing this change the habits and tastes of the patient must, to some extent at least, be con- sulted. The town-dweller will, probably, be benefited by a change into fresh country air, or to the seaside, while a change of an opposite character will sometimes assist a patient depressed by the; tranquillity and dulncss of a country life. In some of these cases the benefit is due really to the change of en^•ironnu■nt, and not to the hygienic qualities of the place. New scenes, agreeable society^ recreation, rest, or at least freedom from toil and ordinary avocations, assist very decidedly in the restoration of shattered nerves and broken health, which are both causes and consequences of gastric disorders. Exercise is another subject requiring careful attention ; it must be adapted to. TREATMENT OF DYSPEPSIA. 53:5 the powers and tastes of the patient. Walking, driving, and horse-exercise are all likely to be useful ; in any case fatigue must be avoided, and rest should be enjoined after meals. It is also well to prescribe half-an-hour's rest be- fore meals, especially for weakly subjects. The Swedish system (Dr. Ling's) of medical gymnastics, massage, or the Zander system of exercise by mechanical means will be serviceable in appropriate cases. Many muscles are thus brought into play without undue fatigue. When the strength has improved a sojourn for some weeks in a mountainous district will tend to restore the patient to perfect health. Attention to ih.Q functions of the skin and the itse of tepid baths will assist the cure. A wet compress applied over the stomach and liver often has a good effect, and particu- larly in cases attended by pain and discomfort. Abdominal compression by means of an elastic bandage will relieve some forms of dyspepsia. With regard to medicines for cases of dyspepsia they are sometimes indispensable, but they should be regarded for the most part only as adjuvants to more rational measures. To improve the condition of the stomach, and to supply a constituent of the gastric juice, often deficient in these cases, hydi'ochloric, or niiro-hydrochloric acidrmy be given with advantage. The following combination will be found to suit many patients : — R Acid. Nitro-hydrochloric. Dil. ii|.x-xv; Tinct. Nucis Vom. ii^v-x ; Tinct. Hyoscyami ii^x-xv; Infus. Lupuli vel Calumbae, vel Chirettae 5J — to be taken 534 ALKALIES FOR ACIDITY. three times a day, half-an-hour before meals. It may be continued for several weeks ; after each dose the mouth should be washed out with water containing a little sodium carbonate. When constipation is present and flatulence is also troublesome I find a pill, composed as follows, to be most useful : — R Podophylli Res. gr. -i ; Creasoti ^^\ ^ ; Ext. Col. Co. ; Pil. Rhei Co. ; Ext. Hyoscyami aa gr. iss. — to be taken at bedtime as required. Whenever there is excessive formation of acid in the stomach, a process which is usually the result of fermen- tation, and is attended with much pain, mi alkali, the sodium bicarbonate, is preferable to the hydrochloric acid. It should be given in quantity sufficient to neutralize the acid ; and even if the reaction of the stomach be rendered alkaline, this condition will be of short duration, inasmuch as the bicarbonate excites the secretion of gastric juice. Distension of the stomach is by all means to be avoided, for it will add to the patient's discomfort, and probably provoke retching or vomiting. The salt should be given slowly and in small quantities at a time ; a teaspoonful should be dissolved in about half a tumblerful of water not too cold, and mouthfuls of this should be taken at intervals of several minutes. An indication for the employment of the soda is increased secretion of saliva, and a feeling of rawness or burning in the throat. The alkalies should not be given too frequently, but should be reserved for acute attacks ; the administration of hydrochloric acid, as above MEMEBJES FOR FLATULENCE. 535 directed, will prove more efficacious for relieving the chronic state of acidity so frequent in dyspeptic cases. It is almost invariably serviceable in cases of oxaluria, in which the eructations often consist of much sulphuretted hydrogen. Y ox gouty dyspepsia this acid is often useful com- bined with niij-iv of acid, hydrocyanic, dil. and a vegetable bitter, and taken before food. The acid is also efficacious when given before a meal, for cases of pyrosis in which the fluid that rises has an acid reaction ; if this symptom occur after meals the alkalies are indicated. For acid dyspepsia Sir W. Roberts recommends lozenges^ and especially gum lozenges. When these are taken salivation is promoted, the blood itself is made the source of the alkali, and the excessive acidity of the stomach is neutral- ized by the passage downwards of the alkaline saliva. A very effective antacid lozenge is one containing i\ grains of carbonate of magnesium, 4 grains of carbonate of calcium, and i grain of sodium chloride. The bismuth lozenges of the pharmacopoeia fulfil a similar indication ; they should be taken not sooner than an hour after meals. For some cases of dyspepsia in which the prominent symptoms are pain at the pit of the stomach extending to the back, and the development of flatus^ a preparation of bismuth, with a little mix vo^nica will often prove valuable. The bismuth appears to be especially efficacious when the pain is of a cramp-like character and comes on in paroxysms. Dr. Leared has recommended the purified 536 TREATMENT OF DYSPEPSIA. oxide of majigancse as a more potent remedy for this class of cases. The dose is from three to ten grains made into pills with syrup, and taken three times a day. For dyspepsia with foul eructations vegetable charcoal is often a good remedy, and the author just quoted recommends that it should be given hermetically sealed in gelatine capsules. In this country charcoal is occasionally pre- scribed in mixtures, and in the form of biscuits or lozenges. The two latter must, of course, be thoroughly mixed with saliva before being swallowed, and charcoal taken in this way cannot be of much efficacy as an absorbent of gases. Dr. I^eared's capsules contain more than ten grains of charcoal made from vegetable ivory, and of these three or four should be taken at a time. Papain in doses of 2 to 8 grains sometimes relieves acid fermentation in the stomach accompanied by pain and eructations. It may be given in lozenges, or dissolved in glycerine slightly acidulated with hydrochloric acid. Crcasote is also a valuable remedy for the relief of flatulence and pain occurring after food. It may be given in doses of one minim made into a pill with a little myrrh. The siilplw-carbolate of sodium is another remedy of this class. The dose is lo or 15 grains taken in water either before or after meals according lo circum- stances. In many cases of flatulent (lys])e{)sia I often see great benefit from a lozenge prej)ared for me by Messrs. Squire, and containing suhiiitratc of hisniulli and salpJio- carbolafe of sodium. One or two of these should be taken TREATMENT OF DYSPEPSIA. 537 either one hour before or two hours after a meal. For -dyspepsia marked by hepatic derangement I find salicin and sodium salicylate often useful. As a purgative in these cases a pill containing podophyllin, euonymin, and pil. col. et hyoscyam. will generally be found suit- able. For so-called irritative dyspepsia^ when pain comes on after food is taken and diarrhoea is apt to be set up, arsenic is often a very useful remedy. In these cases the tongue is furred and its papillae red and prominent, ■especially at the tip, and vomiting of food soon after taking it is a frequent symptom. The arsenic should be given in doses of two or three minims shortly before meals. Ipecacuanha is useful in some forms of dyspepsia. It may be added to the purgatives with a view of increasing the secretion of mucus in the intestinal canal. One grain given each morning is said by Ringer to relieve constipa- tion depending on great torpor of the intestines and the ■dyspepsia therewith associated, which is ''characterized by depression of spirits, some flatulence, coldness of the extremities, and by the food lying on the stomach like a heavy weight." Pepsin in doses of two to five grains, taken with meals, is often useful in these cases, and Benger's liquor pepticus I find to be an excellent preparation. As an adjuvant to all the remedies just mentioned quinine is useful in most cases of indigestion, and especially when the acute symptoms have subsided. Nux vomica is also a very 538 SEALTH-BESORTS FOE DYSPEPSIA. valuable remedy, and may be advantageously combined with most other medicines suitable for dyspeptic patients. In cases of dilatation of the stomach, which is a not un- frequent consequence of a long-continued dyspepsia, much improvement may sometimes be produced by regularly washing out the organ with warm water. In the case of a lady, aged 38, brought to me by a medical man some time ago, this plan, carried out three or four times at weekly in- tervals, was attended with excellent results. It only remains to notice the methods of treatment carried out at the various health-resorts where the water and climate are suitable for dyspeptic cases. Much good is often obtained by a sojourn of four or six weeks at some one or other of these places. The water, the diet, the change of air and scene, the regular exercise, and the daily routine all combine to produce the desired effect, and patients who in their own houses are often somewhat re- fractory generally submit without a murmur even to severe restrictions and regulations at a foreign watering-place. The choice of the health-resort always requires considera- tion. Gouty cases may be sent with advantage to Carlsbad, Marienbad, or Vichy ; more delicate patients may go to Kissingen and afterwards to Schwalbach, while such places as Wiesbaden, Baden-Baden, and Homburg will suit mild cases of dyspepsia presenting no very special indication. It must never be forgotten that in this country we have many excellent health-resorts suitable for cases of dyspepsia. It TREATMIINT OF DYSPEPSIA. 539 is only necessary to mention Buxton, Bath, Cheltenham, Harrogate, and Woodhall Spa. Properly selected and with good sanitary surroundings, almost any country place may be utilized as a health-resort. As regards seaside health-resorts, no country in Europe presents so many or such a variety as our own. CHAPTER III. NERVOUS DYSPEPSIA AND PERVERTED APPETITE. Causes of Nervous Dvsprpsia^Symptoms — Gastric and Nervous Troubles — Diagnosis — Treatment — Diet and Regimen — Exercise — Drugs, Quinine, Arsenic, and Belladonna — The Weir Mitchell Treatment as for Neurasthenia — Perversion of Appetite — Appetite Abnoioially Increased — Symptoms and Causes — Treat- ment — Diminution and Loss of Appetite or Anorexia — Case and Treatment — Depraved Appetite- Symptoms and 1'reatment. In the preceding chapter on Indigestion in general, reference was made to a form of the complaint to which the epithet "nervous" may be suitably a])plied, inasmuch as the symptoms make themselves felt for the most part in the nervous system. As a matter of course the symptoms in question may be associated with various lesions of the stomach, such as catarrh, ulcer, or malignant disease, and it is only when these can be excluded that we are justified in regarding the attacks as of neurotic origin. Causes. — Nervous dyspepsia is more common in men than in women, and it occurs for the most part among those dwellers in towns or cities, upon whose nervous energies demands are constantly being made ; such patients are usually between 30 and 40 years of age. SYMPTOMS OF NERVOUS DYSFJSFSIA. 541 The symptoms in many cases are associated with those of other neurotic complaints, such as neurasthenia, hypo- chondriasis, and hysteria. Prolonged mental strain^ deficiency of sleep, and sedentary habits are common causes of nervous indigestion. In other cases the symptoms are associated with those of anaemia, and are thus some- times witnessed in the subjects of chlorosis and tubercu- losis, and as the result of excesses, sexual and otherwise. In other cases the symptoms are the consequence of immoderate use of alcohol and tobacco ; malarial poison- ing, also, is able to cause symptoms of nervous dyspepsia. As of reflex origin, these latter are sometimes noticed in cases of disorders of the uterus, ovaries, kidneys, and intestines. Symptoms. — Nervous dyspepsia is distinguished from other forms of the complaint by the fact that there are na appreciable alterations in the mechanical and chemical pro- cesses of digestion, but that the preparation of the food for its absorption is accompanied by local troubles, and by nervous symptoms of a general character having their starting-point in the stomach, and propagated by reflex actions. The symptoms for the most part come on after the principal meal, but not until several hours have elapsed ; they are not due to errors or excesses of any kind in connection with food then taken. On the contrary^ the patient may have been careful as regards both quality and quantity, yet at the time specified he is conscious of an 542 SYMPTOMS OF NFRVOUS DYSPEPSIA. unpleasant sensation of fulness, distension, and pressure in the epigastrium. Sometimes there is more or less decided pain, which is relieved by pressure ; eructation of odourless gaseous matters is a frequent symptom ; burning sensations in the throat are less common, but there is sometimes nausea, and an inclination to vomit. The patient feels thirsty, but has no appetite ; the tongue may be normal, but an unpleasant taste in the mouth is a common symptom. Some patients complain of fulness and con- striction in the oesophagus, and of a feeling more or less resembling the globus hystericus. Constipation is generally present, haemorrhoids are frequently developed and various uncomfortable sensations are experienced in the intestines. The nervous symptoms are, however, the most trouble- some to the patient ; he complains of a feeling of beating in the head, coupled with that of rushing of blood to the part, of confusion of thought, noises in the ears, spots or sparks before the eyes, headache, and giddiness. The spirits are depressed, sleep is disturbed and unrefreshing ; some patients are much troubled with drowsiness and languor, and constant yawning, especially after eating. Palpitation of the heart, intercostal neuralgia and attacks resembling asthma are not uncommon in these patients. If vomiting take place, nothing abnormal is discoverable in the ejected matters ; on the contrary, there are evidences that digestion has been well performed. The complaint must, therefore, be attributed to undue sensitiveness of the TREA TIIENT OF NJER VO US D YSPJEFSIA . 543 nerves of the stomach. The patient's condition is apt to be seriously influenced by these attacks ; he becomes pale, and loses flesh and strength. Symptoms of hypochon- driasis or of melancholia are apt to supervene. Diagnosis. — The diagnosis of nervous dyspepsia is sometimes difficult ; the important question for determina- tion is whether any organic lesion of the stomach is the cause of the symptoms. This latter question may usually be settled in the negative if the symptoms disappear and the digestion be quite normally performed from time to time. Such a change for the better is apt to be observed when the patient takes his food with cheerful companions ; under such circumstances the symptoms not unfrequently disappear. The prognosis in cases of nervous dyspepsia must be regulated by the nature and duration of the symptoms. Treatment. — The treatinent of this affection consists, first, in attention to diet and hygiene ; and, secondly, in the administration of certain drugs. The diet requires careful study, inasmuch as these patients differ considerably in their powers of digestion. One preliminary point must be borne in mind, viz., that a definite period of rest should be allowed between exercise and a meal, and also after the latter has been taken. To sit down to dinner when tired, or to exercise mind or body while digestion is in progress, will nullify all attempts at relieving the symptoms. As to the diet itself, it should be of a nutritious, easily digestible 644 TREATMENT OF NERVOUS LYSPEPSIA. character, and the food should be well masticated and eaten slowly. Stimulants in moderation are likely to do good, but much fluid should not be taken during eating ; some hot claret and water will be found to suit most cases. When the stomach is very irritable and the nervous symptoms likewise prominent, a diet composed exclusively of milk will often do good after other forms of treatment have been tried in vain. Every endeavour should be made to secure a fair amount of sleep at night ; the exercise taken should be proportioned to the strength, and always short of fatigue ; a change of air to the seaside or to a mountainous district is generally desirable for these patients. With regard to drugs, the most useful are quinine, mix vomica , and arsenic ; if there be much pain belladonna will probably be serviceable. The arsenic should, of course, be given after meals ; the bowels should be kept open by means of mild laxatives, such as cascara, an elixir of which, prepared by Messrs. Squire, will be found to be quite palatable, the disagreeable flavour of the drug being completeh' masked. Mild hydropathic remedies, and especially the application of wet compresses to the epigastrium will sometimes afford relief. If, as often happens, there be decided evidences of neurasthenia, the best course to pursue will be to place the patient under the Weir Mitchell system of treatment, for a description of which the reader is referred to )). 79. In connection with nervous dyspepsia, some reference must be made to certain alterations or perversions of EXCESSIVE APPETITE. 545 appetite presumably due to nervous disorder. Such per- version occurs in three principal forms : in the first, the desire for food is abnormally increased ; in the second, it is very much diminished, or altogether lost ; while in the third, the appetite is directed towards unusual objects. All these conditions may be quite independent of organic disorder in the stomach ; their causes are those of gastric neuroses in general, and they are most frequently seen in the subjects of hysteria, neurasthenia, and hypochondriasis. I. In the first form above mentioned, the appetite is excessive or voracious ; there may be only a slight increase or a constant and well-nigh insatiable craving for food. In extreme cases the amount consumed has reached 20, 30, and even 60 pounds weight in a day. When food is with- held there is a feeling of uneasiness and even faintness, with an indescribable sense of sinking in the stomach, and of a void that must be filled. Such patients are usually thin and emaciated, inasmuch as the food either passes through the bowels without being digested, or the greater portion of it is vomited. In other instances the patients become enormously fat. I have seen two cases of neurotic dyspepsia in mentally over-worked men, in whom the appetite was enormous, and constant craving and uneasi- ness were complained of when food was withheld ; these patients were thin almost to emaciation. With regard to the cause of this condition we know that hunger, though always referable to the stomach, may be N N 546 HXCESSiri: APn£TITE. produced by impressions sent to the brain from various parts of the body, and it would therefore appear that a voracious appetite may depend either upon an abnormal condition of the stomach, or upon th(; general state of the nutrition. Excessive ap])etite referable to the latter cause is seen in persons after long fasting, and in convalescents from acute diseases, as well as in those suffering from dis- orders accompanied by excessive waste of tissue, as con- sumption and diabetes. Disordered innervation of the stomach itself may arise from causes affecting the nervous system in general, as in hysteria, and the same effect is sometimes due to reflex action, as in cases of worms in the bowels. In some instances the condition has been attri- buted to preternatural capacity of the organ, and to enlargement of the pyloric orifice, whereby the food is allowed to pass into the duodenum before digestion is completed. In another class of cases the excessive appetite is due to habits of indulgence, while in others the condition is referable to the existence of some cerebral lesion. With regard to ireatmcnt, any attempt to cure an established habit of over-eating must be gradually made. Medicines should be given to relieve any catarrhal condi- tion that may be present, whether of the stomach or intes- tines. Compression of the abdomen by a tight band has been recommended as a palliative. When the complaint depends upon any morbid state of the system the remedies must be directed towards the cure of the primary disease. LOSS OF APPETITE. 547 In cases of downright gluttony we may give with advantage small doses of tartar emetic, just sufficient to nauseate the patient. In dealing with convalescents we must prescribe the quantity and quality of food to be taken, and point out the great danger attendant upon excess. This caution is especially necessary in cases of typhoid fever and dysentery. II. An opposite condition, loss of appetite, or anorexia, accompanies almost all kinds of disorders of the stomach, and these in their turn are frequent concomitants of febrile and other affections. Loss of appetite is a common result ■of exhausting diseases. In acute gastritis the patient has no desire whatever for food, and in the chronic forms the appetite is generally much diminished, or, at least, very irregular. In ulcer of the stomach there may be no loss of appetite, but the patient fears to eat owing to the pain that is produced. In malignant disease the appetite varies, but it tends to fail as time goes on, and the secreting structure of the stomach is destroyed. Anorexia is a common sym- ptom in some hysterical subjects, and is often very difficult to treat, as it is usually impossible to accept the statements of the patient with regard to the amount of food really taken. Reference has been made to this subject in a pre- vious chapter (see p. 143). A typical case of this character bas been placed on record by Sir William Gull [Lancet, March 17th, 1888). The patient, a girl, aged 14, was healthy and well until the beginning of 1887, when, with- out apparent cause, she began to evince a repugnance to 548 DEFRA VEI) APPETITE. food, and soon after refused to take any whatever, except a small quantity of tea or coffee. As a matter of course, in a few weeks she became extremely emaciated, weighing- only 4 stone ylbs., her height being 5ft. 4in. She was placed under the care of a hospital nurse, who was ordered to administer light food every few hours. In six weeks the patient had much improved, and she progressed steadily toward recovery. There was a curious feature in this as in other cases, viz., the persistent desire to be on the move,, though the emaciation was so great and the nutritive func- tions so much reduced. In 1885 I met with a case of pro- found emaciation from loss of appetite in a young lady„ aged 17, who presented most of the symptoms described by Sir W. Gull ; she rapidly improved under enforced feed- ing. In some cases, which come under the heading of nervous anorexia, the distaste for food is due to the pain consequent on eating. Cases of nervous anorexia must be treated according to circumstances: in hysterical cases a nurse is always re- quired, and tin- exhibition of a little firmness will generally prove sufficient. For other patients change of air, tonics^ especiallv (/iiinine and ini\ vo)nica, and stimulants in moderation will tend to effect a cure. In the anorexia which often follows exhausting diseases, tincture of cnniiahis indicn (iii^v-x) tak(Mi half an hour before food, often acts- satisfactorily. III. Examples of depraved appetite are most often afforded by hysterical and chk)rotic subjects, and there is DIE PR AVE D APPETITE. 549 scarcely any object, which can be swallowed, which the patients will not endeavour to introduce into the stomach. Pregnant women sometimes exhibit remarkable symptoms of this kind. Indigestible substances, such as slate pencil, chalk, clay, paper, and even offensive and disgusting materials are thus taken. Such practices are sometimes indulged in from time to time ; occasionally they become habitual, and chronic gastritis and general disorder are thus induced. The practice may depend upon some form of gastric irritation, upon deranged innervation of the stomach, or upon cerebral disorder. When chalk is swallowed it is possible that undue acidity of the stomach has created a desire for alkalies, and the swallowing of rough hard substances may have for its object the relief of feelings of sinking. In treating such cases the general state of the system requires special attention. Any existing gastric disorder should be relieved by antacids, tonics, and anodynes according to circumstances. The diet should be carefully regulated, and every attempt made to improve the mental condition of the patient, and to restore the appetite to a normal state. CHAPTER IV. GASTRALGIA— GASTRODYXIA— CAHDIALGIA. Pain in the Siomach as a Definitk Complaint — Causes — Conditions UNDER WHICH IT OCC U RS— G ASTRALGI A IN GoUTY SUBJECTS — In LoCO- MOTOit Ataxy — Of Rufi.ex Origin — Due to Renal Disease — Symptoms — Duration and Exciting Causes of Paroxysms — Spas- modic FoRji of GasTkalgia — Diagnosis, from Intercostal Neu- ralgia, Myalgia, Colic, Peritonitis, Gallstones, etc., and from Gastric Disordeus, as Ulcer, Cancer, and Catarrh — Prognosis AND Tiu'Atment — Laxatives — Quinine — Arsenic — Alkalies — Ipecacuanha — Morphine, Strychnine, Chloral, Electricity — Treatment of Gouty Cases. Pain in the stomach is a symptom of many organic diseases of this portion of the alimentary canal, and especially of cancer and ulcer. It also occurs in several forms of dyspepsia ; but in another class of cases it appears to be a pure neurosis and independent both of anatomical change and of disordered functions of the stomach. It would then seem to be a neuralgia of the sensory nerves of the organ, and is probably due to per- verted nutrition of these structures. The stomach is by far the most frequent seat of abdominal neuralgia (Allbutt). Gastralgia is more frequent in women than in men, and the majority of the sufferers are between iifteen and forty- CAUSES OF GASTRALGIA. 551 five years of age. It tends to die out in middle life, and is less often attended with vomiting as age increases. In this respect it resembles migraine, with which it is often associated. It is rare in young children, but not uncommon in elderly women. Causes. — Pain in the stomach of purely nervous origin is a common symptom in chlorosis, and in conditions of debility and malnutrition in general ; it is thus often observed in persons convalescing from acute diseases, and in the subjects of nervous exhaustion from depressing emotions, anxiety, etc. It is also common in certain affections of the system in general, both of an infectious and of a non-infectious character. Thus in gouty subjects an attack of gastralgia sometimes precedes the articular inflammation, or occurs instead thereof. In a third class of cases the gastric pain follows the subsidence of the articular symptoms, and especially when these latter have been cut short by cold applications to the affected part. The gas- tralgia is then apt to be violent, and is a symptom of grave import.* Pain in the stomach is sometimes, but far less often, experienced in the course of chronic rheumatism ; it is not of uncommon occurrence in connection with malarious fevers. In such cases it comes on at regular intervals with the other symptoms, which may be of a less marked character, but as also the pain, are cured or pre- * For a detailed account of the symptoms of this form of gastralgia, see the Author's work on " Gout and its Relations to Diseases of the Liver and Kid- neys." 6th Edit., Chapter V. 552 CAUSES OF GASTRALGIA. vented by antiperiodics. Dr. Austin Flint has recorded a case in which gastralgia took the place of the cold stage of malarious fever, and was followed by the hot and sweating stages. Severe pain in the stomach is a frequent symptom in hvsteria and hypochondria, and is apt to be associated with other neuralgic troubles. It is also a symptom of grave lesions of the nervous system, such as spinal sclerosis, myelitis, and softening of the brain. It is a peculiar feature of locomotor ataxy, in which the attacks sometimes assume great intensity, and are attended by vomiting, faint- ness, and disturbed action of the heart. These symptoms are wont to recur from time to time, and closely resemble those of acute gouty disorder of the stomach. Dr. Buzzard, indeed, suggests that many cases of so-called " gout in the stomach" would be found, if examined by the light of our present knowledge, to be examples of tabes dorsalis, with gastric crises. It must be remembered that severe gastric attacks are sometimes witnessed in persons who, although examples of tabes dorsalis, " show at the time no sign of inco-ordination of movement." Attacks of gastralgia are not unfrequcntly of reflex origin, being induced by affections of various abdominal organs. Instances of such causation are often met with in women suffering from uterine or ovarian disorders ; the pain generally comes on at the menstrual periods and subsides with the discharge. Pregnant women, too, some- SYMPTOMS OF GASTRALGIA. 553 times suffer from gastralgia, and less frequently the pain is associated with affections of the kidneys, liver, pancreas, spleen, and intestines. Gastralgia is often associated with asthma, and sometimes one member of a family suffers from the former and others from the latter complaint. In not a few cases of gastralgia no obvious cause is ■discoverable. A history of sexual and alcoholic excesses can sometimes be ascertained, and occasionally there is evidence of disordered renal secretion. The urine should always be examined; the gastric disorder may be the first indication of mischief. The lungs, too, should not be passed over, for gastralgia is sometimes severe in the earliest stage of pulmonary phthisis. Symptoms. — An attack of gastralgia may come on suddenly and without warning, or may be preceded by such premonitory symptoms as a feeling of distension in the stomach, nausea and eructations, vomiting, depression of spirits, etc. The pain, once set in, soon becomes extremely severe, and is described by the patients as boring, burning, pricking, smarting, or cramp-like ; it is felt principally in the cardiac and epigastric regions, but is apt to extend to the back and up between the scapulae and to the umbilical and hypochondriac regions. Sometimes the attacks resemble those of angina ; the pain shoots down the left arm, and the pulse falls to forty or even thirty beats per minute. I have seen several patients of both sexes in whom the gastralgia was attended by pains 554 SY3IPT03IS OF GASTRALGIA. shooting down the left arm and up into the left shoulder joint. The patients find that firm pressure will relieve the pain, and accordingly apply their hands to the epigastrium and over the heart, or press the abdomen against some firm substance ; others feel better when lying on the back, and others, again, when sitting in a chair with the body bent forwards as much as possible. The deep-seated pain may be accompanied by superficial hypersesthesia. When the pain is at its height the feeling of prostration becomes intense ; the face is pale and the skin cold ; the pulse is small and irregular, and either more or less frequent than natural ; perspiration breaks out on the face, neck, and hands; sometimes there are muscular twitchings, amount- ing, it may be, to convulsions. Dyspnoea and cough are not unfrequent, especially in hysterical subjects. The termination of the attack is often preceded by fluid eructa- tions, yawning and vomiting, and ineffectual attempts and retching may remain for some time after the pain has subsided. On examining the patient during the continuance of the pain the abdomen is generally found to be drawn in ; its walls are hard and firm, and the pulsations of the aorta are freely visible. In other instances the abdomen is distended and the stomach is felt as a globular swelling at the upper part ; occasionally spasmodic movements of the stomac-h and bowels may be observed. Constij)ation is often present, and the colon can sometimes be detected on SYMPTOMS OF GASTllALGIA. 555 percussion. The urine is for the most part scanty and high-coloured, except in hysterical subjects, in whom, after the subsidence of the attack, abundant discharge of watery urine is a frequent symptom. A temporary condition of albuminuria, with hyaline casts, and lasting for a few days, has been noticed in some cases. The appearance is due to the diminution of blood-pressure in the renal artery, which is caused by the pain. Paroxysms of gastralgia vary much as regards their duration : sometimes the attacks are over in a few minutes, and, on the other hand, they may last for hours, with remissions and exacerbations. There is a corresponding difference as regards recurrences : daily attacks of greater or less severity are sometimes experienced, in other cases long intervals occur between the attacks. When the latter are associated with malarial influence, they are wont to occur at uniform intervals and at the same hour of the day. In women they are apt to become prominent shortly before and during the menstrual periods. In some attacks no obvious exciting cause is discoverable; in others there has been undue mental or bodily exertion. Sometimes the attacks are attributable to prolonged abstinence from food, and are relieved by eating, to recur when the stomach is again empty ; not a few of these patients are from time to time conscious of feelings of intense hunger, while some of them exhibit signs of perversion of appetite and desire indigestible and extraordinary articles of food. In some 556 DIAGNOSIS OF GASTRALGIA. patients the attacks are the result of taking particular articles, such as hot tea ; and the suffering after food may be so great as to lead to complete abstinence for many hours. Other neuralgic affections sometimes alternate with gas- tralgia, and of these migraine and intercostal neuralgia are the most common. Attacks of gastralgia, of which the prominent features are spasmodic pain and contraction of the walls of the stomach, have been regarded as constituting a separate neurosis ; but there is no just reason for regarding them otherwise than as a variety of the type already described. The symptoms are especially apt to be excited by indi- gestible or irritating articles of food or drink, such as cold water in excess, ices, etc., and gastric pain of this character is not uncommon in gouty subjects, and in some persons, as a result of severe mental emotion. The pain is described as intense, of a twisting, constrictive, griping kind, coming on suddenly and most marked near the pylorus ; it may, however, extend across the epigastrium and even up the oesophagus. In severe cases the patients seek relief by lying on the abdomen, or rolling about. The symptoms of collapse, as described in a former paragraph, become very marked, and may actually end in death, as a result of failure of the heart's action. Diagnosis. — The diagnosis of gastralgia is often a task of some difficulty. The points to be determined are, first, that the pain is really situated in the stomach, and secondly DIAGNOSIS OF GASTllALGIA. 557 that it is not due to organic lesions of that viscus. The ailments other than gastric, for which it may be mistaken, are : intercostal neuralgia; myalgia of the abdominal muscles ; colic ; circumscribed peritonitis ; pain due to the passage of gall-stones, and pain radiated from neighbouring organs. In intercostal ?ieuralgia the pain can be traced along one or more intercostal spaces as far back as the vertebral column ; tender spots are generally discoverable, and there is an absence of gastric symptoms other than the pain. In myalgia of the abdominal muscles, the pain is of a more continuous and less paroxysmal character ; it is increased by pressure and movement ; it changes its seat from time to time, and is relieved when the patient lies on his back so as to relax the abdominal muscles. In colic the pain is not confined to one spot, but moves from place to place, and is accompanied by flatulent distension of the abdomen. In circumscribed peritonitis^ the affected part is excessively tender on pressure ; the pain is continuous rather than paroxysmal, and is attended with febrile symptoms. The history of the case will also guide the diagnosis. In cases of gall-stone colic, the pain is especially felt over the gall- bladder, at the outer border of the right rectus abdominis muscle, close to the margin of the thorax, its onset is frequently attended by rigors and vomiting; there are often signs of jaundice, and the gall-stones may be afterwards found in the stools. With regard to affections of other organs, in renal colic, in pericarditis, and in pleurisy, there 558 FliOGNOSIS OF GASTRALGIA. may be more or less epigastric pain, but its true source will be discovered on careful examination and by observation of other symptoms. Having determined that the stomach is the seat of the pain, the next point for investigation is whether any anatomical changes exist that would account for the suffer- ing, or whether the latter is purely of nervous origin. Pain is a prominent symptom of gastric ulcer, but is then much aggravated by taking food and is not relieved but increased by pressure ; it is, moreover, often associated with vomiting of blood. The pain is of a dull, gnawing character, localized in the middle of the epigastrium. In cancer the pain is not so spasmodic and so severe as in some attacks of gastralgia ; vomiting is a prominent symptom, and the ejected matters contain a much diminished proportion of hydrochloric acid. Other points to be considered are : the age of the patient ; the presence of cancerous cachexia ; the rapid course of the symptoms ; the presence of a tumour in the epigas- trium, and sometimes of enlarged glands above the left clavicle. InJIamiiiatorv affeciions of the stomach are excluded by the absence of thirst, tenderness, and fever, and by the intermittent character of the pain. Prognosis. — The prognosis of gastralgia is favourable as regards life, but the complaint is often a very obstinate one. When dependent on an obvious and removable cause, the prospect of cure is much more favourable. In mild cases the attacks do ncjt much influence the general TREAT3IENT OF GASTEALOIA. 559 condition of the patient; but a more serious result is witnessed when the attacks are severe and frequent, and the patient's appetite is much disturbed. This, however, is a somewhat rare consequence, as compared with the results of chronic gastric catarrh in which the digestive functions may be much disordered and the patient may lose flesh and strength. Treatment. — There are two principal objects to be ful- filled : the causes of the suffering should be inquired into and dealt with as far as possible, and means must be adopted for relieving the patient during the attacks. . Rest is an important item in the treatment, and when coupled with warmth and comfort will often do much towards effecting a cure. Conditions of debility will require tonic treatment of all kinds, and particularly the preparations of iron. In most cases of gastralgia, laxatives adapted to the circumstances of the case will be found beneficial. When there is a history of exposure to malarious influences, qimiine is, of course, indicated, and if it fail to relieve, arsenic may be given in doses of ii\^iij-v of the Liquor Arsenicalis three times a day after meals. The same drug is often very serviceable in ordinary cases. If ovarian or uterine dis- order be present, appropriate treatment will generally cure the gastralgia. For attacks occurring in gouty subjects, we must in the intervals have recourse to alJzalies and pur- gatives, and above all things regulate the diet in every 560 TREATMENT OF GASTRALGIA. particular. In cases of gastralgia, attended by nausea and vomiting, ipecacuanha is sometimes a useful remedy. My friend Dr. Gordon thus treated a case of this character, the patient being a young lady, aged 20. The pain and vomit- ing had lasted for a month, and were relieved in two days by drop doses of ipecacuanha wine, taken every half-hour, until twenty drops were taken. To relieve the pain during the paroxysms, warm fomen- tations may be applied over the stomach and gr ^-\ of morphine mav be injected hypodermically. For symptoms of faintness or collapse we may give a few drops of aether or ammoniated tincture of valerian on a lump of sugar. The late Dr. Anstie recommended the hypodermic injection of stryc/uiine gr. y^ro to relieve the pain. There is, he says, " no such remedy for gastralgia as this." Chloral hydrate, belladonna, and bisnuith may be tried if these fail, and dilute hydrocyanic acid (ntiij-vi) may be added to any of these remedies. Cocaine (gr. \-\) and codcina (gr. \-^ are useful in purely nervous cases. Some German autho- rities recommend ivashing out the stomach with warm water holding carbonic acid in solution. Others assert that electricity is always serviceablr in gastralgia, and that failure under the use of this remedy indicates some organic lesion. If the constant current be used, the positive pole is placed oxer the painful s])ot, while tlie negative is applied to the axilla or to i\u- vertcliral column. The rheophores should remain in position for from live to ten minutes, and TREATMENT OF GASTIiALGIA. 561 a somewhat strong current is necessary. The faradic current has been found useful in some cases, and is most conveniently applied by placing both poles over the epigas- trium. It has also been recommended that while one elec- trode is kept in this position, the other should be passed through an elastic tube into the stomach, previously filled with warm water. For attacks of gastralgia occurring in gouty subjects, morphi7ie must be avoided, but there is no objection to the subcutaneous use of atropine. At the same time warm fomentations must be assiduously applied, and if the pain prove obstinate, we may have recourse to sinapisms, or to friction with chloroform liniment. The legs should also be placed in hot mustard and water. It must be remembered that the attacks in these subjects are often associated with undue acidity in the stomach, and it is therefore desirable to give lo or 15 grains of bicarbonate of sodiinn at short intervals. After the attack has subsided a purgative will generally be desirable, and the treatment and regimen adapted to the uric acid diathesis should be carefully prescribed. Change of air will almost certainly do good, and gouty cases of this complaint, like most others, will be benefited by warmth, rest, comforts, and freedom from anxietv and worries. o o CHAPTER V. NERVOUS VOMITING AND ERUCTATIONS. Phenomena of Vomitinp — Nervous Vomiting — Ri^flex Causes — Mental Impuessions — Organic Nervous Lesions — Peripheral Irritations — Disorders of the Abdominal Organs — Disorders of THE Sexual Organs— Toxic Causes — Symptoms of Nervous Vomit- ing — Diagnosis and Prognosis — Treatment, Causal and Sym- ptomatic—Ice, Anodynes, Cocaine, Bromide of Potassium, etc. — Nervous Eructations — Symptoms— Sources of the Gas — Case of Nervous Eructations — Treatment. Vomiting is a common symptom of many affections of the stomach, the act, as a matter of course, being accomplished through the instrumentality of the nervous system. A lesion in the gastric tissues or the contents of the stomach cause irritation of the nerves ; this is conveyed to the vomiting centre in the medulla oblongata, and thence to the diaphragm and to certain abdominal muscles, and to the stomach itself, the cardiac orifice of which is opened by the longitudinal muscular iibres. These results are often witnessed after improper food and excess in alcoholic drinks. Causes. — Vomiting due to gastric causes is easily in- telligible ; but the process is a symptom of many affections of other parts of the body, the stomach itself being quite CA USES OF NER VO US VOMITING. 563 free from disease. Thus nervous vomiting often occurs as a consequence of direct irritation of the vomiting centre, which is closely associated with the centre for respiration, as is shown by the facts that the latter is excited by emetics, that their action is usually preceded by increased respira- tory movement, and that nausea may be overcome by rapid and deep respirations. Direct irritation of the vomiting centre may be caused by injuries to the head, tumours, hasmorrhage, etc. Nervous vomiting is, however, more often due to reflex causes, such as disorders of the brain .and spinal cord. For the effect to be produced, it is by no means necessary that such disorder should be of an organic kind. In many persons, violent mental excitement and impressions made upon the nerves of special sense, whether by disagreeable odours, tastes or sights, and in some even the remembrance of such things, are apt to provoke nausea .and vomiting. I have met with several persons in whom these symptoms were liable to occur as results of mental •excitement. With regard to organic lesions of the central nervous system, it is sufficient to mention meningeal affec- tions of all kinds, inflammation, tumours, haemorrhage, etc. In cerebral tumours, vomiting is a very common and obstinate symptom ; it is also frequently associated with functional disorders as hemicrania and vertigo, and with .such general neuroses as hysteria and neurasthenia. In .affections of the spinal cord violent and obstinate vomiting is most often seen in connection with tabes, the so-called 564 CAUSES OF NEliVOUS VOMITING. "gastric crises'' being a peculiar feature of this disease. Vomiting is far less common in myelitis, sclerosis, and other affections of the spinal cord. Peripheral irritation of the most varied kind is a common cause of nervous vomiting, and some individuals are very susceptible in this respect. Nausea and vomiting are excited in some persons by irritating the external auditory meatus ; in others, by tickling the feet or the axillae. It is. a very common experience for vomiting to be induced by tickling the fauces or the base of the tongue, and this knowledge is often turned to practical use. Tumours and other affections of the nasal mucous membrane, and bron- chial disorders, e.g., asthma and whooping cough, not unfrequently cause vomiting, and the same symptom is. often troublesome in cases of heart-disease. Disorders of the abdominal organs often induce paroxysms of nervous vomiting. Irritation of the gall-ducts or of the peKis of the kidney or ureters, caused by the passage of calculi, almost invariably causes vomiting; and the same result often follows contusions of the abdomen. The irritation may likewise proceed from the mucous coat of the intestines, as in cases of worms and foreign bodies. X'^omiting is also a constant s\m])t()m of intestinal strangula- tion, and it is not unfrequcnt in peritonitis, even when the serous membrane covering the stomach is not implicated. Disorders of the sexual organs are frequent causes of vomiting. Thus the symptom is wont to occur in connec^ SYMPTOMS OF NERVOUS VOMITING. 565 tion with various forms of dysmenorrhoea, with malpositions of the uterus and parametritis ; in some women the normal discharge of the uterine functions, as during menstruation, is attended with nausea and vomiting, and the occurrence of the same symptoms during pregnancy is a matter of common experience. In male patients, injuries to the testicle, epididymitis, and orchitis are often attended by nausea and vomiting. In another series of cases the symptom is due to toxic causes, examples of which are to be found in uraemia, jaundice, and in the early stages of some infectious fevers. The effect of several medicines in producing vomiting is well known, and the symptom is one of the drawbacks which occasionally attends the administration of other drugs, notably the preparations of opium, in some patients. The vomiting of drunkards belongs to this category. There are, of course, no anatomical changes to be found in the stomach in cases of purely nervous origin ; but in some cases lesions have been discovered in the nuclei of the vagus after death. Symptoms. — The symptoms of nervous vomiting present certain peculiarities. They are easily induced by causes acting upon the nervous system, and are not necessarily connected with the taking of food. Sometimes they occur when the stomach is empty; pregnant women, as is well known, are most often troubled in the early morning. The matters ejected are but little changed, and signs of 566 SYMPTOMS OF NJERVOUS VOMITIXG. fermentation are seldom discoverable. The attacks of nervous vomiting last for variable periods, and do not terminate when the stomach is empty ; with the cessation of the symptoms the discomfort is at an end, but after violent attacks there may be some amount of collapse with pallor and coldness of skin and clammy perspiration. Certain varieties in the symptoms have been described. Thus, in some cases the cardiac orifice is principally affected, and vomiting soon follows the takmg of food. In other cases the pylorus is the seat of the trouble, and food is retained in the stomach for some hours after being taken. The general health of these patients not un frequently remains unchanged : they may look fairly well, and not lose weight. An opposite condition of things is, however, sometimes witnessed, the patients losing flesh and strength, and eventually falling a prey to tubercle. The appetite varies, the patients generally complain of thirst. No particular changes are discoverable in the abdomen ; only after violent attacks is there pain and tenderness in the epigastrium. In hysterical sul:)jects the urine is often scanty before an attack, and is freely discharged after- wards ; urea has been discovered in the matters vomited by these patients As a matter of course, in all cases of nervous vomiting depending on a definite lesion, the symptoms of the latter will become prominent from time to time. TREATMENT OF NERVOUS V03IITING. 567 Diagnosis. — This may be very difficult, and especially when no obvious cause can be detected. Vomiting may, however, be assigned to nervous causes rather than to any organic gastric mischief when the appetite is good, the tongue clean, the general appearance that ot fair health, and especially when evidences of disordered gastric digestion and of objective lesions are not discovered after careful examination. There is, however, one point on which too much stress can scarcely be laid, viz., the possibility that the symptom may be due to cerebral tumour or incipient Bright's disease. The ophthalmoscope should be used, and if a choked disc be discovered there will be little doubt as to the cause of the symptom, while the detection of albumen in the urine will yield a clue of great importance. All the organs of the body should be examined as carefully as possible. The prognosis, of course, depends upon the cause of the symptom. Treatment. — In treating a case of nervous vomiting, the discovery of the cause is all-important, and if it can be dealt with satisfactorily the symptom may be expected to cease. Means may, however, be required to check the vomiting, and of these the administration of ice and of various anodynes is the most efficacious. The patient should be kept quiet in bed and should be allowed to suck small pieces of ice, and a little brandy or cham- pagne may be at the same time administered. The morphine is best used hypodermically (about gr. ^), and 568 NERVOUS ERUCTATIONS. if it be known to disagree, a dose of chloral hydrate internally may be substituted for it. Cocaine would be likely to relieve this kind of vomiting; it should be administered in doses of gr. \-\ and repeated according to circumstances. Hysterical patients will probably be relieved by a few drops of aether, or by the ammoniated tincture of valerian in doses of nixv-xxx on a lump of sugar. Bromide of potassium is sometimes serviceable; it may be combined with a little chloral. If collapse supervene as the result of an attack, aether may be injected subcutaneously, or beef-tea and brandy given as an enema. During the intervals between the attacks a course of bismuth with bicarbonate of sodium and Jiydrocyanic acid, in infusion of quassia or calumba, will tend to prevent recurrences. The patient should, of course, be careful as to diet ; distension of the stomach should be avoided and the food should be of an easily digestible, nourishing character. Whenever flatulence is a prominent symptom, starchy articles of food must be forbidden. A little stimulant should be taken with meals, old whisky or brandy being the most suitable, and either of these may be advantageously diluted with seltzer or other alkaline effervescing water. For the vomiting of pregnancy oxalate of cerium in doses of gr. j-ij is often serviceable. NrCRVOUS EkL'CIATIONS. — In connection with nervous vomiting, the- occurrence of frequent eructations due pre- sumably to nervous causes requires a brief notice. Such NERVOUS ERUCTATIONS. 569 eructations are not unfrequent in the subjects of hysteria, neurasthenia, and hypochondriasis, and there are generally more or less marked indications of other nervous dis- order, but sometimes the eructations are so frequent and troublesome as to constitute the principal cause of the patient's suffering. There is some risk lest they should be attributed to the presence of organic disease in the stomach, some forms of which are accompanied by eructations as a symptom. In cases belonging to the category under discussion, the patient is worried by frequent eructations of odourless, tasteless gas ; the attacks come on spontaneously, but they are very liable to be induced by any form of excitement. In some patients slight pressure over the abdomen or on the spine is sufficient to cause eructations, and these under any circumstances may go on for some minutes or even for hours, with short intervals between them. A day or two may pass during which the patient is comparatively free, and these are followed by hours or days of almost con- tinuous discomfort. The eructations are seldom attended by any decided pain, but sometimes a feeling of constric- tion is mentioned ; the stomach may appear to be dis- tended, but this is by no means always the case even when the eructations are very troublesome. As to the source of the enormous quantities of gas which are discharged, possibly much of it is simply air that has been swallowed ; the fermentation of food might account for some, and it is 570 NERVOUS ERUCTATIONS. not improbable that gases may be secreted by the stomach, or at all events escape from the vessels in their atonic con- dition. Analyses have, however, shown that the gas con- sists mostly of atmospheric air. A case presenting many of the features just described has been recently reported to me by a medical friend. The patient, a gentleman aged 76, tall and thin, and of decidedly nervous temperament, had for many years been engaged in active religious controversy, which had left its mark upon him. He had a worn, tired look, was subject to fits of depression and of irritation, and although highlv intelligent, was unable to take much interest in anything. Even reading excited him, and time hung heavily on his hands. He had a fair amount of bodily strength, and in ordinarv w'eather could take sufficient exercise. For some two or three years before he came under my friend's care he had been troubled with frequent gaseous eructations,, not connected with the presence of food in the stomach, but always made worse by the least excitement. The attacks would sometimes go on for hours, and at night especially they were apt to be very troublesome, prevent- ing sleep and causing great irritation. The appetite was good and the diet had always been carefully attended to; the bowels acted regularly ; the urine was pale, normal in quantity, of somewhat low specific gravity, but contained neither albumen nor sugar. The tongue was clean and rather large and ilabby ; the stomach was sometimes dis- TREATMENT OF NERVOUS ERUCTATIONS. 571 tended, though never very prominent. After repeated examinations by my friend, aided by a distinguished London physician, nothing abnormal was discoverable in the abdomen or elsewhere. Various medicines and local applications gave only temporary relief ; the patient grew thinner and more miserable, and finally went to another part of the country, where he died shortly afterwards. Treatment. — The treatment of such a case as that above described is difficult and unsatisfactory. The patient was provided with a set of artificial teeth, which soon became quite comfortable to him. Some relief was obtained from nux vomica and small doses of rhubarb, and from mustard plaisters over the stomach. Small doses of creasote and of carbolic acid were tried, combined with morphine and myrrh, and at first the discharge of gas was appreciably lessened, but the improvement was not per- manent. Quinine, too, had a good effect for a time. Faradisni was tried, one pole being placed over each extremity of the stomach, but little or no benefit resulted. The diet received the most careful attention ; but the dis- comfort appeared to be unconnected with the food. CHAPTER VI. ENTERALGIA— COLIC— NEURALGIA MESEN'I ERICA. Colic, Definition and Causes — Irritating Articles of Food — Gaseous Distension 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 — Dia(;nosis — Prognosis — Other Forms of Coi.ic — Neuralgia of the Bowels — Nervous DiARRHUiA — Treatment — Aromatics and Stimulants — Warmth L(;cally — Opiates — Ipecac- uanha — Purgatives — Enemata — Morphine Hypodermically — Treatment of Gouty and Rheumatic Cases — Treatment of Neu- ralgia (JF THE Bowels — Anodynes, Tonics, Improvement of General Health, etc. Colic may be defined as pain in the intestines, unattended by obvious anatomical changes in any of the structures of the bowels. It may, therefore, be regarded as a purely nervous disorder, sometimes excited by the intestinal contents, or by changes which they have undergone, but sometimes occurring as an independent neurosis. In cases belonging to this latter category, cither central or peri- pheral reflex irritation may be presumed to exist. With regard to the intestinal contents, faecal accumula- tion is one of the most common and potent causes of colic. Such accumulation acts for the most part as a mechanical irritant upon the mucous membrane ; the increasing hard- CAUSES OF ENTJERALGIA. 573 ness of the faeces adds to the effect of their volume, by which the bowel is abnormally distended. Less common causes of this nature are foreign bodies of various kinds, e.g., masses of round worms or of tape-worms, gall-stones, and various substances, swallowed either by accident or in- tention. Severe attacks of colic are often caused by articles of food of an irritating nature, or having acquired such properties after having been swallowed. Imperfectly fer- mented liquor of all kinds, unripe fruit, sour milk, semi- decomposed fish or meat are well-known causes of this character. I have seen many cases of colic due to irritating ingesta and faecal accumulation, and two instances in which the attacks were due to tapeworms. Even normal articles of food may act as irritants, when taken in excessive quantities ; the gastric and intestinal secretions are in- sufficient for their due preparation and digestion, and more or less decomposition is the result. In another class of cases, the attacks are induced by the physical peculiarities of the articles taken ; the effect upon many persons of cold drinks and ices may be quoted as an example, and other attacks are connected with personal idiosyncrasy. Thus in some subjects colic is apt to be induced by eating certain shell-fibh, pork, fruits and vegetables of various kinds, all of which other persons take with complete impunity. A very common form of colic is that which is due to gaseous distension of the abdomen, a frequent result of the fermentation of food. This form is very often seen in 574 CAUSES OF EyTEltALGIA. children, farinaceous food being especially liable to undergo fermentative changes. The abuse of drastic purgative medicines is another cause ; instances of this character are common among poor people. Cases of colic due to the influence of lead and copper form a distinct class ; the manner in which these poisons produce their effects is very uncertain. As a neurosis, in the strict sense of the term, colic is a somewhat common complaint among the subjects of hysteria, hypochondriasis, and neurasthenia, and it likewise occurs in connection with some organic disorders of the nervous system. Thus the gastric crises of locomotor ataxy are sometimes accompanied by like symptoms refer- able to the intesiines. Such enteric crises may, however, occur independently ; they take the form of sudden attacks of diarrhoea, with or without pain, and they may continue for several days. As examples of colic due to reflex action may be mentioned the intestinal pain and diarrhoea which sometimes accompanies disorders of the liver, kidneys, uterus, and ovaries. Both the gouty and the rheumatic diatheses occasionally contribute towards the production of an attack of colic. In gouty cases the symptom may precede the articular inflam- mation and subside on its development, or may replace it, little or no pain being felt in the joint. In colic connected with gout and rheumatism, there is often tenderness on pressure, and sometimes fever. Pain in the intestines of a SY3IFT0MS OF JENTERALGIA. bib neuralgic character and coming on at regular intervals, has been occasionally observed in cases of malarious fever. The only other important cause of colic which requires notice is exposure to cold and wet. Cases of this kind are some- W'hat frequent; contraction of the cutaneous vessels may be supposed to be followed by dilatation of the intestinal capillaries. Cold applied directly to the abdomen may produce an immediate effect on the muscular coat of the intestines. Symptoms. — The principal symptom in colic is the pain which comes on suddenly without premonitory warnings, and is felt especially in and about the umbilicus, whence it extends to the region of the caecum, ascending and transverse colon ; but it often radiates to the loins, and downwards towards the thighs. The severest pain is sometimes confined to one spot; in other cases the pain changes its place and is then often accompanied by rumbling noises in the intestines, portions of which create protrusions from the abdominal wall. As a general rule the pain is at first slight, and gradually increases in intensity, but in some cases it is very severe from the first. Like other kinds of pain, the sensation is variously described by different patients ; thus, it is sometimes said to be cutting, pricking, pinching, boring, or as though the bowel were being stretched or torn. The violence of the pain may be such that persons with considerable command over themselves are completely overcome by it, and are unable to check 576 SYMPTOMS OF ENTERALGIA. their cries and groans. As objective symptoms, the skin becomes cool and covered with perspiration ; the face is pale, the pulse is generally slow and hard. The attacks vary considerably as regards duration and liability to recurrence ; sometimes the pain ceases after a few minutes, and does not return ; in other cases the attacks recur again and again during several hours, and the patient is never entirely free from pain during that time. The positions assumed by patients suffering from colic are often characteristic ; the sufferer lies " doubled up," as it is termed, with the knees brought close to the abdomen, or he presses his hands against the painful part and some- times he tries to get ease by adopting a prone position. On examining the abdomen, it is either hard and retracted, or prominent, tympanitic and distended. In a thin patient, the distended loops of intestine are often plainly visible, and the irregular peristaltic movements can be easily traced. Rumbling sounds — borborygmi — are often asso- ciated with the Uiovements. As a general rule, the pain is relie\ed by firm pressure over the abdomen, and the patient's experience teaches him to try this plan. In some cases, however, there is decifled t(;nderness of the abdomen, and pressure causes so much jKiin as to excitt- a suspicion of peritonitis. Symptoms due to reflex action are fr((iu('ntly experienced in other organs ; thus, attacks of colic are liable to be attended witii nausea and vomiting, hiccough, dyspnoea, DIAGNOSIS OF ENTERALGIA. 577 palpitation of the heart, precordial oppression, strangury, tenesmus, etc. In male subjects the testicles are often drawn up, and the levator ani is spasmodically contracted. Painful cramps in the legs, fainting, and other symptoms of collapse, muscular twitchings, and even convulsions have been noticed in some patients. In most cases, after lasting for a variable time, attacks of colic suddenly pass off, perhaps after vomiting, eructations, discharge of flatus or diarrhoea. Complete recovery is the rule, but death has been known to occur, as a result of rupture of the intestines from excessive gaseous disten- sion ; and in another case the fatal issue was due to con- vulsions. Diagnosis. — The diagnosis of colic is for the most part easily made after careful investigation. The important point to determine is whether the symptoms are due to some organic lesion, inflammatory or otherwise, or whether this possibility can be excluded. Colic in hysterical subjects may be so severe as to v&s&vn\Ae peritonitis, but it differs essentially from the latter in being unattended by fever, or, as a general rule, by tenderness, either on gentle or firm pressure. Moreover, in peritonitis, the symptoms are continuous, and tend to become worse. It must, of course, be remembered that colicky pains are apt to occur in many intestinal affections, and especially in dysentery, and in connection with catarrhal, tuberculous and carcinomatous ulceration. It would scarcely be possible, however, to P P FEO GNOSIS OF ENTERALGIA. mistake the symptoms of these diseases for an attack of colic, and the same remark applies to stra?tgulated hernia, which cannot be overlooked on proper examination. Rheiiiiiatisvi of the abdominal muscles may be mistaken for colic, but in the former the pain shifts its place, is apt to become chronic, and exhibits no decided exacerbations and remissions. The abdomen is tender to the touch, the pain is not deep-seated, but superficial, and can be excited by friction. In lumbo-abdominal neuralgia /o//^/i' douloureux can generally be detected towards the vertebral column. Hysterical subjects are liable to colic, and likewise to neuralgic pains in the abdominal muscles and skin, of a shifting character, and generally relieved by friction with anodyne liniments. As a matter of course, when a diagnosis of colic has been arrived at, the nature of the attack has yet to be determined, and for this purpose it would be necessary to take into consideration the various points discussed in the aetiology. The possibility of lead being the cause of colic must never be forgotten ; the gums should always be examined for any traces of a blue line. I have seen several cases of intractable colic due to lead speedily relieved after discovery of the cause, which had not been previously suspected. Prognosis. — This dcjjends upon the cause of the symptom ; in the great majority of cases the complaint yields readily to suitable treatment. When the pain is dependent upon obstruction in the bowels and persists in PROGNOSIS OF ENTERALGIA. 579 spite of remedies, the prognosis must be more guarded. Unless, however, the obstacle be insuperable, as in cases of malignant disease of the bowel, recovery may be expected to take place. Neglected attacks of colic may pass into actual inflammation, either of the peritoneal or of the mucous coat of the bowel. Before proceeding to discuss the treatment, it will be well to refer to certain modifications sometimes noticeable in the symptoms of these painful affections of the bowels. Cases are met with from time to time in which the spasmodic element is either wanting altogether, or else very slightly marked, though the pain is very severe indeed. There is no inflammation and no attendant vascular excite- ment, and the pain, though paroxysmal, is more steady for some time than in spasmodic colic. The paroxysms are wont to occur without obvious cause, though they are sometimes excited by the passage of food ; some amount of tenderness often remains after their subsidence. These attacks, to which the term " neuralgia of the bowel "' would appear to be applicable, are due to various causes, such as general debility, a rheumatic or gouty diathesis, spinal dis- order, or some aft'ection of the sympathetic ganglia. Dr. Clifford Allbutt thinks tliat gout and the strife of public life are potent factors in the production of enteralgia; he has given details of several cases in his lectures on "Visceral Neuroses ; " my own experience coincides with this author's views. After severe attacks, the collapse and prostration 580 TREATMENT OF ENTEEALGIA. are often very serious ; periodicity is sometimes noticeable ; and in some cases the enteralgia takes the place of another neurosis, e.g., migraine. There is no marked constipation, flatulence or disordered alvine secretions, and the com- plaint is associated with various conditions of the general health. Disordered innervation of the intestinal tract may pro- duce disturbances not only of sensation, but also of motion and secretion, and according as the motor activity is lessened or excited, symptoms either of nervous constipa- tion or of nervous diarrhoea will be liable to occur. In many persons, attacks of the latter complaint are liable tO' be induced by anxiety or grief; in others, the subjects of idiosyncrasies, such attacks set in immediately after certain articles of food have been taken, and are to be explained by attributing them to increased peristaltic action, the result of nerve-irritation. The intestines often participate in disordered action of the stomach ; and symptoms refer- able to both these parts are frequent in cases of hysteria, hypochondriasis, and neurasthenia, and in women suffering from ovarian and uterine disorders. In the treatment of these nervous gastric and intestinal troubles it is of great importance to bear in mind the condition which underlies all the manifestations. Treatment. — The cause of the attack is the first point to be attended to ; relief of the pain and evacuation of the bowels are the main indications. For simple spasmodic TREATMENT OF ENTEEALGIA. 5Sl colic, due to flatulence or exposure to cold, and of no great severity, relief may often be obtained by the exhibition of aromatics and stimulants, such as tincture of ginger, spirits of peppermint, compound tincture of lavender or cardamoms diluted with hot water. To any of these a few drops of laudanum or half a drachm of compound tincture of camphor may be added to relieve pain, or tincture of chloroform and morphine rn,x may be given for the same purpose. At the same time warm applications, e.g., tur- pentine stupes, to the abdomen, and placing the feet in warm water will aid in procuring relief. In hysterical cases some tincture of asafoetida or valerian may be combined with the aromatics. Severe pain must be checked by in- creased doses of opiates, and if symptoms of collapse set in, sether and other stimulants may be freely given. When the attack of colic is obviously due to acrid and irritating ingesta, antispasmodics and opiates must be with- held until the source of the evil has been got rid of. If the attack commence soon after eating, it will be well to administer an emetic, and ipecacuanha will be the most suitable, inasmuch as it often produces free action of the bowels. When the stomach has been evacuated, five grains of calomel or a draught containing rhubarb, soda, and aromatic spirit of ammonia may be given if the bowels have not been sufficiently relieved. To hasten the action of the cathartics, and as substitutes for them when the transverse colon is the principal seat of pain, purgative 682 TBEATMEJSIT OF ENTEEALGIA. enemata are of the greatest service. Warm water, injected slowly with an O'Beirne's tube, may prove sufficient, but if not, a turpentine enema may be employed. In hysterical cases, and especially if there be much flatulence, a warm water enema containing a drachm of asafcetida will be pre- ferable. If convulsions occur, chlorofovjn inhalation (not pushed to complete anaesthesia) will check the movements, and likewise subdue the intestinal spasm. For the relief of the latter, and especially in dealing with children, a warm bath will prove very efficient. In all these cases of colic, after the pain and spasm have subsided and the bowels have been thoroughly evacuated, the patient should be kept quiet and warm for some time. A wet compress, kept over the abdomen for some hours, will prove very grateful, and will prevent a return of the pain. The diet should be carefully regulated ; food of a light and easily digestible nature should be prescribed, and everything likely to engender flatulence must be rigorously interdicted. If necessary the bowels must be kept open by mild laxatives, and aromatics, with bitter tonics, may be given to prevent recurrences. If the colic be suspected to be due to the presence of worms, or other foreign bodies, the treatment is obvious. For tapeworm, the oil of inale fern or the oil of turpentine should be given in suitable doses. When the attack is due to irritating articles of food, and has come on some hours after they have been taken, or to distension, the result of TREATMENT OF JEJSTEEALGIA. 583 fermentation, we may give such purgatives as above described, or a dose of castor oil if tolerated by the stomach; and in any of these cases if the pain be very severe, we may at the same time endeavour to subdue it by administering opium in some form. The hypodermic injectiofi of morphine gr. \ will be found very suitable, and its effects, as regards both pain and spasm, will be increased by adding gr. J^ of atropine. Laudanum may also be added to the castor oil and to the rhubarb draught. When the attack is due to the abuse of purgative medicines, opium is especially indicated, and it may be advantageously com- bined with chalk and aromatics. In attacks of colic of gouty or rheumatic origin it is generally desirable to evacuate the bowels, and for this purpose the draught containing rhubarb, soda, magnesia, and tincture of cardamoms will be found most serviceable. Local external remedies, and the use of the warm or hot baths, are desirable adjuvants. In gouty subjects, if the attack be due to metastasis, revulsion to the extremities is indicated, for which purpose hot and stimulating foot-baths, with sinapisms to the feet and ankles may be employed. After the acute pain has subsided, a draught containing tinct. colchici, liquor morphinae hydroch. aa nixv, may be given every four hours for a day or two, in order to diminish irritation. Under similar circumstances, in rheumatic cases, bromide of potassium with alkalies and some bitter tonic 584 TREATMENT OF ENTERALGIA. should be administered, the diet in all these cases being very carefully attended to. In that form of colic which is attributable to neuralgia of the bowels, purgatives and other remedies of a lowering character are seldom indicated ; on the other hand, anodynes and tonics constitute the best remedies for the symptoms. Morphine may be administered subcutaneously in com- bination with atropine ; and if the former drug be ill borne, atropi7ie alone or the extracts of belladonna, coniuni, or hyoscyamiis may be given separately or in combination, and pushed so far as to produce a decided elTect. Pre- parations of iron, especially the carbonate, are likely to prove serviceable, and if there be any evidence of perio- dicity, quinine should be administered in combination with hydrobromic acid. The diet requires careful attention ; it should be of a nutritious character and abundant in quantity. In extreme cases, the Weir Mitchell system of treatment should be tried, or at least the patient should be kept in bed for two or three weeks ; warmth is always beneficial. Change of air, rest, freedom from worry, and cheerful society will tend to cure the complaint, and to prevent recurrences. When pain in the stomach is associated with the abdominal symptoms, small doses of arsenic taken after meals will be found very efficacious. The treatment of nervous diarrhoea, due to disordered motor activity, will be discussed in a subsequent chapter. CHAPTER VII. CONSTIPATION. IPrevalence of Constipation — Causes, Age, Sex, Occupation, Want of Exercise, Neglect — Too Little Fluid in Diet — Normal Action of Bowels — Contents of F^ces — Defecation — Consequences of Con- stipation — Chlorosis — Other Causes of Constipation and Dis- orders with which Associated — Surgical Causes — Habitual Con- stipation, Influence of Drastic Purgatives — Insufficiency and Improper Quality of Food — Diagnosis — Treatment of Constipation — Of Occasional Attacks— Castor Oil, Salines, Rhubarb, Calomel and Senna — Enemata — Faradism — Treatment of Chronic Constipa- tion — Attention to Habits — Necessity of Daily Visit to the Clc)set — 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 PODOPHVLLIN, IrIDIN, EuONY'MlN, AND LePTANDRIN NiTRO-M UR I ATIC Acid — Belladonna — Enemata, their Drawbacks — Other Remedies — ■ Caution as to Use of Laxatives — Massage. Of the functional disorders of daily life, few are more common than constipation. It affects persons of all ages and both sexes, though women, and especially married women who have borne children, are particularly liable to 1)6 troubled. It is a common ailment of scrofulous, rachitic, and syphilitic children, and also of infants brought up by hand. It likewise constitutes one of the difficulties con- nected with advanced age. Examples of the complaint are 586 CAUSES OF CONSTIPATIOIf. to be found in every class, but certain occupations and habits specially favour its development. Thus the effect of lead in the production of constipation is well known, and we find that persons who lead sedentary lives, e.g., tailors, shoemakers, seamstresses, lawyers, and intellectual workers in general, form a large contingent of cases. On the other hand, labourers are seldom affected, for bodily exercise stimulates peristaltic action, increases respiration and circulation, and improves the quality of the blood, while the action of the diaphragm and abdominal muscles on the intestines produces an effect similar to that of massage. Constipation is frequently experienced by those who lead luxurious and slothful lives, who eat, drink, and smoke too much, who are irregular at their meals and indulge in various enervating habits. The complaint is also common among persons in many respects quite the opposite to those just described. Men actively employed in business, having apparently more to do than time will permit, often hurrying over their breakfasts to catch a train, are very apt to neglect the calls of nature. Women, too, frequently suffer from similar neglect, and in their cast; another important factor often comes into play, viz., an insufficient amount of fluid in their diet. Water forms the principal constituent of the body, and the integrity of its various parts is closely connected with the amount of fluid contained therein. When an insufficient (juantity of water is taken the excreta CAUSES OF CONSTIPATION. ?87 become inspissated and hard, and pass through the bowels with difficulty. As a result of their retention the sensitive- ness of the rectal walls becomes deadened ; the sigmoid flexure and the colon are abnormally distended, the muscular coat of the bowel is weakened, and the peristaltic power considerably reduced, and in this way a condition of chronic constipation is slowly but surely established. For perfect health, as a general rule, it is necessary that the bowels should be relieved once in 24 hours. Owing to a variety of causes, some persons have an action of the bowels once in two or three days, or even at a longer interval, and yet enjoy good health; while others, again, are not comfortable unless the bowels act twice or three times a day. There are infinite differences with regard to frequency of action ; Dr. Habershon relates the case of a woman, 60 years of age, who from her youth up had had a passage only every six or eight days, and yet was always healthy. Variations are due to individual peculiarities and conditions, such as temperament, quantity and quality of the food ; the rapidity and com- pleteness of the digestive processes, whereby there is a smaller or larger residue ; the activity or otherwise of the skin and the normal average peristaltic power of the intestine. That a daily action of the bowels is most conducive to health is not only borne out by experience generally, but is also confirmed by the teachings of physiology. The con- 688 CONTENTS OF FJECES. tents of the large intestine are made up of the remains of food that has resisted the digestive processes in the passage from the stomach to the colon. These differ in consistence, colour, and odour, and in chemical and micro- scopical appearances from the contents of the small intes- tine. The average quantity in 24 hours is about 4^ozs., 73 per cent, of which is water. The odour is due to decom- position of the residue of the food ; the colour to the bile pigment, the absence of which leaves the faeces light or clay-coloured, while their consistence is the result of the constant absorption of the liquid portions. About 10 per cent, of the solid residue consists of undigested matters, and the remainder of faecal substances. The undigested matters examined under the microscope are seen to be composed of animal and vegetable structures that have not been acted upon by the digestive fluids ; the faecal substances are made up of disintegrated intestinal epithelium, mucus, and the solid remains of the secretions, none of which serve to nourish the body. As the faeces are moved along the large intestine by its peristaltic power, they become more solid and acid in reaction ; fermentation is often set up and is accompanied by the development of several gases. Owing to the absorption which takes place in the colon, the faeces gradually become more solid, till the sigmoid flexure is reached. Here they rest upon the bladder and sacrum, but do not press upon the sphincter ani. When the column of faeces descends RESULTS OF CONSTIPATION. 589 into the rectum, peristaltic action is excited in its walls, so that the mass is pressed against the sphincter ; the lumbar centre which controls this muscle is now inhibited, the abdominal and accessory muscles come into play, the sphincter is relaxed, and the rectum is unloaded. The maximum irritation of the rectal walls occurs, as a rule, once in 24 hours ; and when the habit has become regularly established, the desire to defaecate at a certain hour is quite independent of the will. When we consider the mechanism of defaecation, the composition of the faeces, the effects of pressure upon the rectal and intestinal walls, and the local, as well as the general symptoms that are aroused by the retention of faeces, we must be convinced that it is of the greatest importance for the health of the body that the act should be regularly and thoroughly accomplished. Apart altogether from the local disturbances that are set up by retained faeces, there is risk of a kind of blood- poisoning from the absorption by the colon of portions of the fermenting and decomposing mass. The results, as- often witnessed, are paleness and loss of flesh, a dull and unhealthy complexion, and offensive exhalations from the skin and lungs ; dulness and depression of spirits, irrita- bility, drowsiness, vertigo, headache, palpitation, furred tongue, pains in the loins, gastric derangement, and various biliary and urinary disorders. Conditions of hypochondriasis and melancholia are often traceable to- constipation. ,-,90 CAUSES OF CONSTIPATION- A recent writer in the Lancet (Nov. 26, 1887) regards chlorosis as a consequence of auto-infection, a true poison- ing, from the retention of faecal matters in the intestine. The affection is generally preceded and accompanied by constipation : sometimes the poisoning takes place rapidly, putrid decomposition being promptly followed by absorp- tion from the intestine. Febrile symptoms are another result of auto-infection. It may be doubted whether constipation is the sole cause of chlorosis, but it is pro- bably an important factor in the production of the com- plaint. There is often constipation, of a temporary kind, in acute and wasting diseases, such as acute rheumatism, phthisis, and various fevers. Under such circumstances the condi- tion is due mainly to the dryness of the intestinal contents (inasmuch as more water escapes through the skin and lungs), to the diminution in their amount, and likewise to the change of habits necessitated by the disorder. Consti- pation is common in puerperal women, owing to the pressure of the uterus on the intestines, to the relaxation of the abdo- minal walls, and the withdrawal of fluid, resulting from the secretion of milk. The constipation that so often accom- panies jaundice may be due to the absence of bile, which excites peristaltic action, or to the accumulation of that secre- tion in the blood, whereby the intestinal movements arc hindered, as is also tiie action of the heart. Constipation is always present in acute hydrocephalus, and is due to the CAUSES OF CONSTIPATION. 591 irritation of the inhibitory nerves. The same condition likewise prevails in acute peritonitis, and is due to the extension of the inflammation to the muscular coat of the bowels. The walls become infiltrated with serum, and thus their tonicity and peristaltic power are much impaired. It is not my object, however, in the present chapter to consider all the forms of constipation, acute and chronic, which are met with by the physician in daily practice, or to discuss minutely all the various causes that may produce the complaint. I propose rather to confine my remarks to the more common forms of habitual constipation due to deficient propulsive power of the intestines, and not dependent upon mechanical obstruction in these organs or in the surrounding tissues. Causes belonging to the categories last mentioned must, however, be referred to in connection with diagnosis, and though little more than their enumeration can be attempted, yet in order to arrive at a correct estimate of the nature of the disorder in any given case, they must be carefully borne in mind in the examina- tion of the patient. In general terms it may be stated that anything that retards or prevents the passage of the faeces through and out of the intestines will be a cause of constipation. Ob- struction, slowly developed, may be due to pressure on the rectum by an ovarian or uterine tumour ; to displacements of the uterus ; enlarged prostate ; polypoid growths in the rectum or colon ; cancerous or other stricture of the rectum, 592 SURGICAL CAUSES OF CONSTIPATION. or Other portions of the intestines. Dysentery and syphilis- are the most common causes of the latter character : their effects are slowly produced, and the condition always tends from bad to worse. Constipation is also caused by internal strangulation and. by bands formed in peritonitis. Internal obstruction may be caused by one portion of intestine entering another (invagination) or passing into one of the foramina con- nected with the abdomen ; by twisting of the mesentery, or of this structure and a portion of intestine about a loop of the latter; and finally by rotation of the intestine upon its own axis. As a result of chronic diarrhoea, the lower end of the small intestine sometimes enters the colon, and prolapse of portions of the latter into the rectum is not uncommon as a result of severe and chronic dysentery. There are certain surgical disorders which produce constipation and require a brief notice. Chief among these is fissure or painful ulcer of the rectum ; in this complaint defaecation is accompanied and followed by very severe pain. A similar condition is sometimes noticed in connec- tion with haemorrhoids, the mucous membrane covering them becoming ulcerated and exquisitely sore. In both these cases constipation is largely due to the efforts of the patient to restrain the bowels from acting ; the retained faeces increase the ulceration and prevent healing. In elderly persons degeneration of the muscular tissue,, especially of the rectum, sometimes induces constipation,. CAUSES OF CONSTIPATION. 593 and in male subjects enlargement of the prostate may impede defaecation and lead to the same result. After injuries of various kinds requiring confinement to bed, constipation is a common trouble, but unless other condi- tions be present it generally subsides. After injuries to the head and spine, and in many chronic nervous affections, the bowels are apt to become much confined, and the original disorder is thereby considerably aggravated. Having thus glanced at some of the structural causes that may give rise to constipation, I shall now discuss more particularly those cases of habitual disorder of this kind so often occurring in practice, and generally to be ascribed to sluggish peristaltic action of the bowel. Besides the causes already mentioned there are several others which must not be passed over. The peristaltic action of the bowel may be temporarily enfeebled by over-action and simple fatigue, induced by severe diarrhoea or the action of medicines ; and it may be permanently weakened by repeated drastic purgatives. Many sufferers from habitual constipation aggravate their disorder by the frequent use of these medicines, and the effect of this practice is that a con- stantly increasing degree of irritation, obtained either by increasing the dose or by employing still more powerful drugs, is required to induce the peristaltic action of the bowels. The habitual use of pills, "liver-regulators" and so-called "vegetable aperients," in great demand by maid-servants, as well as that of the purgative QQ 09-4 CAUSES OF CONSTIPATION. mineral waters among the upper classes, is a fertile source of constipation. In the course of time the reflex activity of the bowel, whose natural stimulus is the intestinal contents, is never brought into play except by artificial aid. Besides increasing the constipation, the habitual use of purgatives leads to chronic catarrh of the mucous membrane, tumefaction and hypertrophy of the muscular coat, diminished excitability, tonicity and reflex contractile power, distension of the bowels and various displacements, proctitis and follicular ulceration in the colon. Chronic peritonitis, with the formation of fibrous bands, is another consequence of constipation and of attempts to relieve it by injudicious methods. I have recently seen a case in a young lady in whom constipation was aggravated, if not induced, by tight lacing. Pressure on the ascending and descending colon as a result of the constriction and faecal accumulation had set up ulceration about the appendix caeci, and this was followed by perfora- tion and localized peritonitis. Another cause of constipation is obstruction of the portal circulation, either directly, as in cirrhosis, or by a tumour ; or as a result of heart-disease interrupting the return of blood through the vena cava, and causing venous congestion and chronic intestinal catarrh. Insufficiency of food is another cause of constipation, and cases of this kind are often seen among women whose food is inadequate in quantity to excite the peristaltic action of DIAGNOSIS OF CONSTIPATION. 595 the bowels. The nature of the food is not without influ- ence ; if it consist mainly of farinaceous articles, such as bread, potatoes, rice, and pastry, and especially if these be washed down by draughts of tea, constipation is very apt to be induced. Some kinds of tea are especially mis- chievous in these respects, owing to the large proportion of tannin they contain. The influence of this constituent upon salivary digestion has been already alluded to (see p. 497)- Diagnosis. — This can never be difficult if a proper examination be made. Individual peculiarities with regard to the action of the bowels must, of course, be borne in mind; and it must never be forgotten that very decided constipation may exist, notwithstanding regular evacuations, but insufficient in quantity. It not unfrequently happens that a portion of the fasces which ought to be discharged at each evacuation is retained, and accumulation thus takes place, eventually becoming very considerable. Under such circumstances faeces may be discharged from the rectum, and when they are accompanied by much mucus, the result of irritation, the patient may fancy that he is suffering from diarrhoea. A careful examination of the abdomen and rectum will reveal the true state of things. A tumour will often be detected in some part of the colon and the rectum will be found full of faeces. It must be remembered that obstinate constipation is a symptom of many affections of the brain and spinal cord ; 596 TREATMENT OF CONSTIPATION. of diseases of the liver, heart, and lungs ; of mechanical impediments to the passage of faeces ; and of disorders attended with copious elimination of water by the skin or kidneys. Treatment. — This may be considered under two heads : [. The means of dealing with occasional attacks, and 2. The course to be adopted for cases in which the condition is habitual. For occasional attacks we may have recourse to purgatives or laxatives, proportionate in their activity to the circumstances of the case ; and it is always well to give mild remedies at first. Of these, castor-oil is one of the best, and its nauseous taste, its only drawback, should be disguised by the addition of oil of almonds, or other flavouring material. Saline purgatives, of which the sul- phates of sodium and magnesium and the phosphate of sodium may be taken as the type, are suitable for those cases in which constipation is accompanied by febrile movement, and for gouty and plethoric subjects. The alkaline carbonates may be added with advantage, and if it be desired to produce a more decided effect the salts may be dissolved in infusion of scn7ia, qualified by the addition of aroviatics. A draught containing rhubarb, soda, magnesia^ and aromatics is an old-fashioned remedy for constipation ; it is suitable for cases in which the condition is temporary and due to an <'rror in diet. The more active purgatives, such :&.% jalap, colocyntli, scainjno)iy, and gamboge, diVe. seldom rccjuired for the cases undcT considera- TREATMENT OF OCCASIONAL CONSTIPATION. 597 tion. The pil. colocynth. et hyoscyami is, however, a good combination, and suitable for occasional use. If it be wished to act decidedly on the liver, in cases in which torpidity of that organ is associated with the constipation, 3 or 4 grains of calomel or blue pill should be given, and followed in a few hours' time by the salts and senna draught. All these remedies are suitable only for occasional use ; they are not adapted for habitual constipation. In the cases under discussion, should the purgative prove ineffectual, or should its use be unadvisable by reason of the irritability of the stomach, the employ- ment of enemata becomes indispensable. The safest and most efficient substance for this purpose is simple warm water injected into the bowel in large quantities, and repeated so as gradually to soften and wash away the faecal matter. It may be necessary to aid the contractile power of the sphincter by twisting a towel round the tube of the enema-syringe, and pressing it against the perinaeum. It is sometimes advantageous, and indeed necessary, to introduce the water directly into the colon through a suit- able tube passed high up into the bow^el. If warm w^ater fail to produce any effect, recourse may be had to enemata containing turpentine, sulphate of magnesium, or aloes. In cases of impaction of faeces in the rectum, the employ- ment of a scoop or similar instrument becomes necessary in order to break up the solid mass. By way of aiding the effect of injections, we may have recourse to friction over 59S TREATMENT OF CHRONIC CONSTIPATION. the abdomen and loins, or allow a stream of cold water to fall upon their surface. The application of cloths wetted with cold water sometimes proves effectual, and if all these measures fail, faradism should be tried. For this purpose, the rectum having been emptied, one pole constructed for the purpose is introduced within the bowel, while the other is moved gently over the abdomen, especially over the position of the colon from right to left. The application should be continued for ten or fifteen minutes ; the results are sometimes very satisfactory. T/ie c/ironic for77is of constipation require treatment differing in many respects from that just laid down. In the first place, attention must be paid to the removal of the cause, which will often be discoverable on inquiry. The patient should be instructed to endeavour to acquire the habit of regular evacuations by daily visits to the closet ; but straining should be avoided as likely to cause prolapsus ani and ha3morrhoids. When opposite conditions have apparently contributed to produce the constipation, regular habits of life, moderate exercise, and relaxation from intense mental toil, with change of air and scene, often prove valuable auxiliaries to the measures about to be dis- cussed. Cold or tepid baths, according to the state of the patient, should never be omitted ; they often aid greatly in restoring tone to the bowels. The regulation of the diet is all-important, and in some cases will prove sufficient to induce a proper action of the SYQIENIC MEASURES. 599 bowels. The food should be sufficient in quantity, taken at regular intervals, and of a digestible character, contain- ing a due amount of vegetables and fruits. Certain articles of diet possess laxative properties, and these are generally- suitable unless they irritate the stomach. One of the best of these is bread made from " whole meal ; " only the silicious envelope is removed from the wheat, the whole grain being then ground into moderately fine flour. Some patients can eat with advantage the so-called "brown bread," which contains a considerable quantity of bran", very coarsely ground. Either kind should be taken when- ever bread is eaten ; except among ignorant persons, the prejudice in favour of white bread is soon got over. Porridge may also be recommended for the same purpose ; some persons find that it acts admirably as a regulator of the bowels. When the stomach is free from irritation, fresh and dried fruits are often very serviceable in cases of constipation ; patients find out for themselves that they are often free from discomfort when ripe fruits are pro- curable. The most suitable of these are gooseberries, currants, and strawberries, ripe pears and apples ; the latter should generally be cooked. In winter, and when other fruits are not procurable, orangeSj figs, and prunes may be used instead. Ringer recommends an orange or two to be taken before breakfast as a pleasant and often effectual way of overcoming habitual constipation. Among various articles of diet which have a beneficial effect in 600 TREATMENT OF CHRONIC CONSTIPATION. these cases may be mentioned honey, treacle, buttermilk, and bacon. Milk should be rather sparingly used by these patients, and especially by children who are subject to constipation. With regard to fluids, care should be taken that the daily quantity is not too small ; tea should be avoided on account of the tannin it contains, but coffee is less harmful ; in some cases, indeed, it appears to exhibit laxative properties. Water constitutes the best drink, and should be taken freely with meals ; some patients find that a glass of cold water taken while dressing has a good effect. Stimulants should be avoided as much as possible ; if their use has become a necessity a little sound bitter beer, or a glass or two of hock may be allowed ; claret should be avoided, as it is more or less astringent in its action. In most of the cases of constipation that come under the notice of the physician, laxative medicines of some kind are indispensable. The patients have usually had recourse to first one and then another aperient drug; indeed, the number of those advertised is a measure of the extent to which the disorder prevails. It is neces- sary to emphasize one point in starting, viz., the injury which these persons inflict upon themselves by taking doses of strong purgatives. Relief may be gained for the time, but at the cost of aggravating the original disorder. The restoration of the natural action of the bowels is the indication to be fulfilled. VSJE OF LAXATIVES. 601 In the choice of laxatives the physician has to determine whether salines or drugs belonging to the vegetable king- dom are likely to prove the more suitable, and perhaps for the majority of cases remedies belonging to the latter class will best answer the purpose. In dealing with a case of habitual constipation complicated probably with dyspepsia, we may, after regulating the diet and mode of life as far as practicable, prescribe aloes in some such combination as the following: — R. Extract. Aloes Socot. gr. j-iss; Extract. Belladonnae gr. ^ ; Quininae Sulphat. gr. j ; Extract Hyos- ■cyam. gr. j ft. pil. j. A dozen of these pills should be given to the patient with the instructions that he should take one daily before dinner, and after a few days try whether one every other day will answer the requirements. Purging is, of course, to be avoided, and if improvement result it will be well gradually to diminish the dose. For some patients the sulphate of iron, or the extract of nux vomica, may be substituted for the quinine, but the com- bination as given above will be found a very useful one. Another drug, the cascara sagrada, is of great value in many of these cases, and, like aloes, it possesses tonic as well as aperient properties. It is best administered in the form of the liquid extract of the pharmacopoeia, the dose being ti|xv-xx twice or three times a day, and gradually diminished as soon as a satisfactory effect results. Various palatable preparations of the drug are to be found at the •chemists, and of these Messrs. Squire^s " elixir " and Parke, 602 TREATilENT OF CHRONIC CONSTIPATION. Davis and Co.'s " cordial " can be safely recommended. A " laxative tincture," containing equal parts of liquid extract of cascara sagrada, aromatic spirit of ammonia, spirit of chloroform, tincture of belladonna and tincture of nux vomica is a good preparation for use in habitual constipa- tion. The dose is from 20 to 60 minims twice daily. Some patients find by experience that castor-oil relieves habitual constipation, and that the dose may be gradually lessened until a teaspoonful proves sufficient. Sen7ia is another purgative often employed, and it may be con- veniently administered in the form of the compound liquorice powder of the pharmacopoeia. The bulk and sweet taste of this powder are somewhat objectionable ; but the latter drawback may be obviated, while the efficacy of the mixture is decidedly increased, by adding gr. x-xv of the acid tartrate of potassium to each dose. A fluid extract of senna pods is a very convenient preparation. These possess the laxative properties of the leaves, but are comparatively free from griping constituents and a nauseous taste. The extract is taken without disgust by children. Senna may also be given in the form of confection, to which a similar preparation of sulphur and black pepper may be added with advantage, especially for patients with a tendency to haemorrhoids. Rhubarb is not suitable for chronic constipation. Its employment tends to perpetuate the condition, and the same remark applies to the stronger purgatives, such as colocynth, jalap, and scammony. SALINU PURGATIVES. 603 The effects of the laxatives just mentioned can often be reinforced by bitter tonics, and a course of such medicines as quassia, gentian, calumba, or cascarilla, with alkalies or acids according to circumstances, will in many cases prove advantageous. The nux vomica is perhaps the most valu- able remedy of this class, and often suffices to relieve habitual constipation. For this purpose iT\^viii-x of the tincture should be taken every morning. It is especially indicated whenever there is pronounced atony of the bowels, and much gastric or intestinal flatulence. For these latter cases gr. \ of the extract will advantageously replace the quinine in the pills mentioned in a preceding paragraph, and when the intestinal secretions are deficient, gr. \ of ipecacuanha may be added to each pill. In plethoric subjects, and whenever there are evidences of functional derangement of the liver, saline aperients are generally indicated. These act promptly, and besides re- moving the contents of the bowels, they cause a decided drain from the intestinal vessels, and relieve congestion of the portal system. It would appear that they prevent the absorption of the intestinal secretions which would other- wise be taken up by the veins and lymphatics. The salts best adapted for the purpose are the sulphates of sodium and magnesium^ the. phosphate of sodiuin and the tartarated soda. These may be given in the ordinary manner, but a very convenient way of exhibiting them is in the form of someone or other of such mineral waters ■3^.% Friedrichshall, <304 TREATMENT OF CERONIC CONSTIPATION. Piillna, Kissingen, ^sculap, or Hunyadi Janos. The Rubinat-Condal, a Spanish mineral water, contains a large percentage of sodium sulphate, and a small proportion of magnesium ; it is free from the bitter taste so objection- able in many of these waters, and does not depress the system. The dose of any of these varies according to circumstances; from two to six fluid ounces may be re- quired. It is generally advisable to add an equal quantity of hot water; and the medicine should be taken about half-an-hour before breakfast. The quantity should be so regulated as to produce one, or at most two evacuations, without griping or discomfort. It is often advantageous to combine tonics with salines ; thus the sulphate of quinine with a little sulphuric acid may be added to the sulphates of magnesium and sodium. When the constipation is associated with symptoms of gastric catarrh, fermentation and acidity, Carlsbad water is preferable. The principal salts contained in the Sprudel spring are the sulphate, carbonate, and chloride of sodium. These salts may be obtained in the dry state, and when dissolved in water are very efficacious. About a teaspoonful should be added to half- a-pint of boiling water, and when the solution has cooled down to 120°, two or three ounces should be taken every five minutes. The salts may be thus taken every morning or every other morning according to circumstances, and LAXATIVE MEDICINES. 605 the dose may be increased, if necessary, or one of the aloes pills may be taken before dinner. In cases of constipation dependent upon, or associated with functional disorder of the liver, certain vegetable drugs may be used with advantage, the chief among them hoing pod op hylli7i, iridin, euo7tymin, and leptandrm. All these rank as cholagogues and aperients. The resin of podophyllum in doses of gr. \-\ maybe conveniently com- bined with aloes, capsicum, and belladonna in the form of a pill ; the dose of iridin is from one to five grains, and of euonymin about the same quantity; leptandrin is given in doses of two grains. The three last-named drugs are less irritating to the intestines than podophyllum. As a tonic for the cases under, discussion, the most suitable is the nitro-muriatic acid, with the tinctures of mix vomica and hyoscyamiis in infusion of chiretta. .For habitual constipation in general. Trousseau recom- mends belladonna in doses of gr. i-i of the extract either night or morning, increased if required, and diminished or discontinued when the constipation is removed. It should be tried for a fortnight or three weeks. Dr. Nunneley,. cited by Ringer, " finds this treatment useful in all forms of constipation, especially when coexisting with dyspepsia, characterized by a thinly-furred tongue, with prominent red papillae at the tip, epigastric tenderness, pain after food^ and often more or less headache." 606 TREATMENT OF CHRONIC CONSTIPATION. Many persons employ enemata as substitutes for cathartics by the mouth, administering them daily or every other day. The practice is liable to several objections ; if used warm, enemata are apt to cause a torpid condition of the intestines ; moreover, they apply to one part of the bowels the irrita- tion which laxatives spread more or less over the whole tract, and they do not empty the upper part of the canal. Their frequent use also washes away the mucus intended to lubricate the surface of the bowel. In cases in which there is a tendency to haemorrhoids or prolapsus ani, it is well to inject two or three ounces of cold water after the bowels have been moved. For constipation in infants a small piece of soap used as a suppository often proves efficacious ; and for some adults, glycc7'ine injected into the rectum affords a simple means of relieving constipation. A tea- spoonful is used for each injection, and the bowels generally act in 15 or 20 minutes. The same remedy is prepared in the form of suppositories, which can be easily inserted. Among other remedies for the relief of chronic con- stipation it is only necessary to mention faradism both general and internal, already referred to; tepid or cold douches ; frictions to the abdomen, with coarse flannel, or the flesh brush. Some persons iind that smoking after break- fast produces the desired effect. One caution must be borne in mind with reference to laxative medicines. They are to be regarded only as adjuvants to more rational methods ; the dose should be no larger than absolutely MASSAGE FOR CONSTIPATION. 607 necessary, and the drugs should be discontinued when they are no longer absolutely required. Dr. Murrell states that massage is one of the most powerful therapeutic agents at our command for the relief of constipation. Petrissage of the abdomen is the best method : this consists in picking up a portion of the muscles with both hands or the fingers of one hand, and subjecting it to firm pressure, rolling it at the same time between the fingers and the subjacent tissues. The manipulations are to be made in the directions of the three portions of the colon, and should be associated with different varieties of tapotement, " the flat open hand, the hand partially closed so as to form an air-cushion, and the margins of the hands being employed according to circumstances. . . . Massage probably acts in three ways : (i) by increasing the intestinal and other secretions ; (2) by stimulating the peristaltic action of the intestines; (3) by mechanically pressing the accumulated faeces towards the rectum." The manipula- tions should be practised for about 20 minutes twice daily, and continued during three or four weeks. A natural action of the bowels may take place after the first manipu- lations ; but is more often deferred until several have been practised. CHAPTER VIII. DIARRHCEA. DiARRHCEA, Conditions for its Production — Causes, Food, Cold, Mental Excitement, Summer Diarrhcea — Diarrhcea Accompanying Intes- tinal Lesions and Various Morbid Conditions — Persons most Subject to Attacks — Anatomical Appearances — Symptoms in Adults — Influence on General Condition — Severe Attacks — Diagnosis — Treatment, Question as to Arresting Discharges — Sometimes Desirable to Facilitate them — Castor Oil, Sulphate OF Sodium, Rhubarb, and Calomel — For Checking Diarrhcea^ Opium, Aromatics and Astringents, Camphor, Warmth, Stimulants — Chronic Diarriiq;a — Diet and Regimen— Rest — Diarrhcea in Children — Causes of Frequency — Disorders of Digestion — Com- plications — Treatment, Cautions as to Use of Opiates — Warm Baths, Stimulants, Flannel to Surface— Dirt — Enemata of Warm Water — Calomel — Cautions as to Excessive Feeding — Chronic Diarrhcea — Diet, Flannel and Warmth — Grey Powder, Vegetable Astringents, Chalk, Bismuth, Peuchloride of Mercury, Arsenic, Iron. Diarrhcea, owing to its frequency, occupies a prominent place among the functional disorders of the abdomen ; 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 conditions are necessary for the production of diarrhoea: (i) increased peristaltic action, CAUSES OF DIAERHCEA. 609 (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. Causes. — The following are the principal causes of diarrhoea : — I. The passage of substances from the stomach into the intestines, capable of accelerating the peristaltic move- ments of the latter, either with or without the production 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 suffi- cient to produce free action of the bowels. Under patho- logical conditions, 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 the starting-point ; but it often happens that both parts are 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 R R 610 CAUSES OF niARRHCEA. category may be placed many articles of food ; fluids, especially water, and laxative medicines of a non-irritating kind. 2. 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 especially if damp be combined with the cold. In such cases it is generally said that the alimentary canal is a locus minoris resis- tentix. It may be that the diarrhoea is the result of transudation into the intestines, taking place as a con- sequence of paralysis of the vaso-motor nerves. Cold often acts very energetically after previous exposure to heat, and especially when the body is perspiring 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 affected at the same time, as shown by eructations and vomiting. 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 CA USE S OF DIAR 11 E(EA . 611 proper treatment it may quickly subside, and such is the general rule in subjects otherwise healthy. It may, how- ever, 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 accom- panies catarrhal inflammation of the colon, and is apt to become very marked as the complaint continues. The intestinal lesions and various conditions often accom- panied by diarrhoea are as follows : — 1. Ulceration occurring in the course of specific infec- tious disorders, such as typhoid fever, dysentery, and intestinal tuberculosis. 2. Disordered movement of the blood in the intestines, such as results from obstruction to the flow in the vena portae. This condition exists in those diseases of the liver Avhich produce compression of the capillary system of the organ, and in cases in which the intestines are agglutinated together as a consequence of chronic peritonitis. Cono-es- 612 CAUSES OF DIARRHCEA. tion 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 degeneration, of which diarrhoea is a marked symptom. Once set up, it is apt to be almost uncontrollable, and con- tinues until death. Besides the infectious disorders above mentioned which are localized in the bowels, and are always attended by diarrhoea, there are other infectious complaints which are often similarly accompanied. Thus, various septic pro- cesses, such as occur in puerperal fever and disorders of a different character, viz., scarlet fever and uraemia, are not unfrcquently 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, extravasations of blood in the mucous and sub- mucous coats, and even ulcers as a result of necrosis. In MORTALITF FROM DIARRHCEA. 613 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 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 patients, once set up, is apt to be violent and obstinate. Deaths from diarrhoea are about i per i,ooo of the popu- lation ; the prevalence of the complaint is always favoured by hot summers, and the mortality from it in London becomes high when the mean weekly temperature rises to 63°. The connection between a high mean temperature and extent of prevalence of summer diarrhoea is not apparently a direct causal one. In all probability it is rather the putrefactive changes in connection with milk, water, dustbins, etc., which cause the disease. A deficient rainfall commonly occurs in the years in which diarrhoea is above the average, going along with the excessive tempera- ture of the air (Newsholme). The anatomical changes in cases of diarrhoea can be dis- posed 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 614 SYMPTOMS OF DIARRH(EA. 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. Symptoms. — In describing the symptoms and treatment of diarrhoea it is well to make a distinction between the complaint 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. Rumbling sounds are caused in the abdomen, which becomes some- what 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 dis- charged with the more solid faeces, and the stool is often frothy. After the motion the abdominal pain and uneasi- ness 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 SYMPTOMS OF DIARRECEA. 615 straining 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 disturbance then subsiding and stools of natural consistence making their appearance. Diarrhceal discharges are sometimes unattended by pain, but as a general rule they are preceded by the sensations above described. Sometimes painful and painless dis- charges alternate in the same patient. The presence or absence of pain is no indication of the special form of dis- order 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 616 DIAGNOSIS OF DIARRS(EA. 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. After very frequent stools and copious discharges result- ing 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 cramps in the legs, muscular twitchings, suppression of urine, and diminution of temperature. In children general convulsions are sometimes caused by diarrhoea ; adults often become listless and apathetic. Alter serious attacks, recovery is a tedious process ; and in aged and weakly sub- jects 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 pro- gress while the abdominal symptoms are liable to variations. Diarrhoea much aggravates the effects of other exhausting diseases. Diagnosis and Treatment. — The former 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 TREATMENT OF DIARRRCEA. 617 guided 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 must not, however, be given to weakly sub- jects, nor to cases in which the discharges have been very profuse and fluid in character. Rhubarb is another excel- lent remedy for these cases ; the dose is about gr. x, and it may be advantageously combined with soda, magnesia, and carminatives. When the stomach is in an irritable condition, and would reject either castor oil or rhubarb, a full dose of calomel 618 TREATMENT OF DIARRH(EA. (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 diarrhoea, 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 con- veniently 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. Cretae Aromat., will be found efficacious. In so-called "summer diarrhoea" it is well to combine some bitter astringent with the oj)ium, and tincture of cinchona is very suitable for this ])urpose. The same combination (using tinct. opii, niiij-v) may 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, gallic acid, acetate of lead, dilute sulphuric acid, chalk, and TRJEATMUNT OF DIARRECEA. 619 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 given in combination with opium, inasmuch as its alkaloids are thereby rendered almost insoluble. If opium be contraindicated for any reason, the vegetable astringents may be substituted and given either with or without chalk. A new remedy, coto bark in the form of a tincture, Is useful for catarrhal diarrhoea. For summer diarrhoea, and for cases in which the symptoms continue after expulsion of the exciting irritant, spirits of camphor, in doses of four or five drops every ten minutes till the symptoms abate, is often very efficacious, and a little brandy may be added with advantage. The same drug is also useful in diarrhoea the result of exposure to cold. Another remedy, of great use in summer diarrhoea, is the cannabis indica. Ten minims of the tincture may be given with an equal quantity of spirit of chloroform and one drachm of tincture of kino with peppermint water. The cannabis may also be given every two or three hours with morphine and aromatic spirit of ammonia and spirit of chloroform. Besides the remedies above mentioned, rest in bed and warm applications to the abdomen will do much to check diarrhoea and to relieve pain and tenderness, and should never be omitted. A warm bath once or twice daily is very grateful to the patient, and is especially serviceable when 620 DIARRBCEA IN CHILDMEN. the attack has been due to cold ; it should be followed by a warm bed. The diet in acute attacks should be restricted to small quantities of bread and milk, arrowroot or sago, taken lukewarm. If stimulants are necessary, a little warm brandy and water, or claret and water, may be administered. During convalescence, the greatest care is necessary with regard to diet ; the rules laid down in the chapter on Dyspepsia must be put in force. In dealing with cases of chronic diarrhoea, the habits of life and diet of the patient require minute attention. Every attempt should be made to discover the cause of the complaint, and any errors which tend to perpetuate it. The dietetic rules applicable to dyspepsia, subject to such modifications as may be required, should be clearly pre- scribed ; as a general rule such articles of diet should be chosen as are of a nutritious character, but leave a small amount of faecal residue. Warm clothing with flannel next the skin should always be worn, and an extra piece of thin flannel or of silk round the abdomen is generally to be recommended. In severe cases, and during exacerbations the patient should be kept in bed, but under more favour- able circumstances suitable exercise should not be neg- lected. Diarrhoea dependent on hepatic derangement will be described in the last chapter of this work. It now remains to consider the subject of diarrhoea in connection with children among whom the complaint is DIARRECEA IN CHILDREN. 621 extremely prevalent. The younger the child, the greater the liability to disorder of the digestive organs, and the attacks usually involve the entire intestinal tract, and are accompanied with diarrhoea. The normal physiological conditions are very favourable to the development of disorders of digestion in children ; the organs charged with providing the necessary secretions are insuiSciently de- veloped in early life, and it is only by slow degrees that they become equal to the tasks laid upon them. Moreover, the child cannot at first distinguish between the sensations of hunger and thirst, and for some time is unable to express its wants otherwise than by crying. While still at the breast its food is such as to satisfy both hunger and thirst, but the case is very different after weaning. A child conscious of thirst is only too apt to get such food as relieves hunger ; the alimentary canal is overloaded with materials in greater quantity than can be dealt with by the secretions : decomposition of the food follows, with gastric and intestinal irritation or inflammation as an inevitable consequence. The influences of disorders of digestion upon young children are only too clearly manifest ; their slight power of resistance to injurious influences is exhibited by the mortality. Fatal diarrhoea is pre-eminently an infantile disease, and one of the chief causes of excessive mortality in large towns. Eighty-eight per cent, of all fatal cases occur in children under five, and sixty-two per cent, among ■622 TEEATMEyT OF DIARliH(EA IX CHILD SEN. •children in their first year. The greatest mortality is in the second three months of life and is probably due to the greater prevalence of feeding by hand. "^ The symptoms of these complaints are liable to be complicated by certain others which are never seen in older and stronger subjects, and are obviously due to the small power of resistance pos- sessed by the child's tissues. Among the more serious of these secondary phenomena are the formation of abscesses and the spread of suppuration with the development of much unhealthy pus : haemorrhages into the skin and mucous membranes, sloughing in the mouth and other parts, destructive inflammation of the eyes, etc. It not unfre- quently happens that the violence of the attack itself produces fatal collapse, and epidemics of this character are very liable to occur in crowded cities during hot weather. Even milder forms of diarrhoea, if continued for any length of time, may produce serious emaciation with a fatal result. The child's organism suffers from the withdrawal of nutritive materials much more rapidly and seriously than the system of the adult; on the other hand, owing to its greater powers of assimilation, a child under favourable circumstances often makes a very speedy recovery. Treatment. — The treatment of diarrhoea in children is the more difficult inasmuch zs opium is a dangerous 7'einedy in very young subjects who are particularly sensitive to its * Dr, Newsholmc's " Elements of Vital Statistics," j). 189. TREATMENT OF DIARRRCEA IN CHILDREN. 623 action. Many a child has been sent out of the world by a dose or two of " soothing syrup" or some such nostrum of which opium is the active constituent. The drug is, how- ever, often indispensable, and it may be given to very young children provided that due care be taken. For a child under six months the maximum dose is half a drop of laudanum repeated in three hours if necessary. Between six and twelve months, one drop is the dose, and for every year a drop may be added, six or seven being regarded as the maximum. In violent attacks all food should be withheld for five or six hours ; a few drops of claret or a drop or two of brandy may be given every quarter of an hour, and the child should be placed in a warm bath and kept there for ten or fifteen minutes, while friction is applied to the surface. The warmth often acts admirably by relieving the venous congestion in the abdomen. It may be applied in another way, viz., by enveloping the body in folds of linen rung out of hot water, and covered with india-rubber sheeting over which flannel is rolled : this plan may also be adopted as a supplement to the bath. The child is then placed in a warmed bed, and if its lower extremities be cold they should be wrapped in flannel. After four hours have elapsed, the bath may be repeated, and a longer interval may be allowed if there are signs of increased power of the circulation, such as moisture appearing about the skin of the face. After a period varying from six to twelve hours, supposing the patient to be an infant, 624 TREATMENT OF DIARRH(EA IN CHILDREN. attempts may be made to administer the mother's milk ; but if this be not tolerated, the wine should be given every ten or fifteen minutes. For the treatment of attacks in children brought up by hand, a wet nurse is generally indispensable. When there are indications of tenesmus, it is well to administer an enema of warm water with a little salt dissolved in it. Great gentleness should be used in injecting the fluid which serves to wash away irritating matters from the bowels. Should the tenesmus continue, a little viiicilage of starch containing a drop or two of laudanum should be injected. Small doses of calomel (gr. Jt,) every three or four hours are often useful in sub- acute cases ; the mercurial acts as a local disinfectant. One caution is necessary in dealing with infants suffering or recovering from diarrhoea, viz., to prevent them from dis- tending their stomachs with the breast-milk ; the child is thirsty, but its powers of digestion are in abeyance and any excess of food becomes decomposed and acts as a poison. Intervals of from four to six hours between suckling should be allowed ; the number and condition of the evacuations are the best guide for regulating the frequency of feeding. In dealing with cJironic diai-rha'a in children, the regula- tion of the diet is the main point to be attended to. If the child be yet unweaned, proper intervals, say of three or four hours, should be suffered to elapse between suckling, and especially if the mother or nurse has much milk. TREATMENT OF DIARRRCEA IN CHILDREN. 625 When artificial food is given, it should be well diluted'; thus cows' milk should be mixed with twice its volume of water, boiled and allowed to cool down, before being administered. The child's bottle and the articles in which the food is kept must be scrupulously cleansed, and plenty of fresh air is very necessary for these cases. Flannel should be worn next the skin and the feet should be kept warm. For older children rice-flour, arrowroot, or baked flour may be added to the milk with advantage, and milk and lime-water is sometimes useful. When the stools are offensive as well as frequent a little grey powder, with rhubarb and carbonate of sodium, is a good remedy. Sour- smelling frequent stools will require chalk, or bis7nuth in doses of one or two grains. The vegetable astringents are useful to check frequency ; a drop or two of laudanum will heighten their action. For very slimy stools, especially if mixed with blood and accompanied by pain and strain- ing, the perchloride of mercury in doses of gr. -^ every two or three hours will be found very efficacious ; a little Dover's powder may also be given at bedtime. When the stools contain lumps of half-digested food the liquor arsenicalis, in doses of one or two drops, should be given before each meal. The tincture of cannabis indica, given before food, often acts well in these cases. During conval- escence from diarrhoea, a course of the liquor ferri perni- trat. will often prove very serviceable. S S CHAPTER IX. CORPULENCE.— OBESITY. Meaning of the Tkrm — Causes — Manner of Production —Anatomical Appearances — Symptoms — Two Kinds of Corpulence — Diagnosis AND Prognosis — Treatment — General Principles — Methods sug- gested BY Banting, Ebstein, and Oertet,. CORPULEN'CE is a term used to denote excessive accumula- tion of fat in the subcutaneous connective tissue, and in various portions of the body in which it is normally present, e.g., in the mediastinum, the epicardium, the omentum, the mesentery, the capsule of the kidney, etc. The beginning of corpulence cannot be definitely determined, for the normal passes very gradually into the abnormal ; but cases of the latter character can generally be distinguished with- out much difficulty. Corpulence is very frequently met with, and often causes great trouble and danger to life. Among other incon- veniences are the increase of size and wcisfht, the breath- lessness, the loss of activity, the accumulation of fat about the heart, and the frequent development of intertrigo between folds of skin. Hippocrates observed that corpu- lent persons were seldom long-lived. CAUSES OF COEPULENCi:. 627 Causes. — These may be described as predisposing and direct, and the two classes are often combined. Among the former comes heredity, which is traceable in nearly 50 percent, of all cases. Next comes age ; the condition is most common in infancy and after 40. Childhood and manhood are more often exempt. Women are more liable to be affected than men ; in the former, corpulence is most fre- quent after 50 ; in the latter, cases begin to be common ten years earlier. Quiet and sedentary habits, often the result of enforced inaction, are favourable to the development of ■obesity, and to these may be added racial peculiarities and the influence of moist and warm climates. As a general rule, all these causes are capable of being rendered in- operative by certain precautions : but they may be power- fully reinforced by errors in diet, which are often the direct and sole cause of corpulence. The food may be either too abundant or unsuitable in its composition^ and these errors are not unfrequently combined. It is neces- sary to remember that the fat of the tissues originates principally from the albuminous substances taken as food ; these are broken up into nitrogenous and non-nitrogenous compounds, and the latter go to form fat. It is very doubtful whether the fat taken as food is directly converted into a similar tissue of the body ; at any rate, the fat formed in this way is very much less than that yielded by albuminous bodies. Recent researches have proved Liebig's conclusions on this subject to be erroneous ; fat 628 CAUSES OF COEPULJENCE. does not originate from carbo-hydrates, unless taken in excessive quantities. The fat formed from the albuminous constituents of food is destined to be consumed by progressive oxidation, and converted into carbonic acid and water. When albuminous materials are supplied in excess, and fat-formation is too large, oxidation may be insufficient to disintegrate the fat so that it is deposited in the tissues in abnormal amounts. As a general rule, this condition is more rare than that in which excessive fat-formation is due to diet unsuitable in composition, i.e., containing improper proportions of albumen and carbo-hydrates. When both are in excess the mischief thus arises; the carbo-hydrates are more readily oxidised, the albuminous substances escape, and the fat is unconsumed and deposited in the tissues. The effects of addiction to the pleasures of the table are thus easily explained ; albuminates are present in excess, puddings and sweets supply the carbo-hydrates, and alcoholic drinks check metamorphosis. Corjiulence is often produced by alterations in habits ; common experience teaches that the quantity and quality of food should be adapted to the consumption which is required by circumstances. A strong, active man com- pelled to lead a sedentary life, but not reducing the food- supply, runs great risk of becoming corpulent; the forma- tion of fat continues, and the oxidation-processes fail to keep pace with it. In like manner, infants at the breast ANATOMICAL APPEARANCES OF CORPULENCE. 629 readily become very fat, they are mainly at rest, and their food is rich in carbo-hydrates. Diminished oxidation of fat may be the condition existing in hereditary corpulence; such persons are often characterized by a phlegmatic temperament, flabby muscles, and other conditions asso- ciated with diminished oxidation. It must not be forgotten that loss of blood may be asso- ciated with corpulence, and may, indeed, be a direct cause thereof. Diminished oxidation is the link connecting the two conditions. Some amount of obesity is sometimes present in various states of anaemia, e.g., in chlorosis, in progressive pernicious anaemia, scrofula, Addison's disease, and in the first stage of cancer. It is occasionally witnessed during convalescence from severe diseases ; as typhoid, and after recovery from scarlatinal nephritis. Corpulence is sometimes associated with disorders of the sexual organs and functions ; thus chastity is a decided cause, and the subjects of imperfect development of the sexual organs often become fat. The effects of castration are well known ; amenorrhoea and sterility in women tend to pro- duce a similar condition. Cases of congenital corpulence have been reported from time to time ; in one case a still- born child weighed over 17 pounds, and measured more than 24 inches. Anatomical Appearances. — These require a brief description. The most striking feature is the enormous development of the subcutaneous fat, especially over the 630 ANATOMICAL APPEABANCES OF COliPTILEXCE. abdomen ; the muscles are often pale, and of a brownish or light yellow colour. The intermuscular connective tissue contains excess of fat ; the fibres are atrophied from pressure, and many are in a state of partial fatty degenera- tion. There is much fat in the medullary tissue of the bones, and in the mediastinal cellular tissue and around the heart. The latter organ often shows signs of degeneration of its muscular fibres and hypertrophy of the left ventricle ; atheroma of the great vessels is also common, and the blood-serum frequently presents a milky appearance, due to drops of fat, which form an emulsion. The quantity of the blood is not increased in proportion to the amount of fat deposited, whereby the weight of the body is absolutely increased ; corpulent persons have relatively less blood than ordinary individuals. In the abdomen, the omentum and the appendices epiploic^s are seen to be composed of large masses of fat ; there is much fat round the kidneys, and fat-globules in the cells of the tubuli uriniferi ; the liver is enlarged and fatty ; the diaphragm is forced up- wards so that the lungs are compressed and their volume more or less reduced. The impeded action of the heart is due to the mechanical obstacle caused by the fat and the embarrassed respiration. At each systole the heart must expend a certain amount of force in order to set in motion the fatty envelope and the deposits, or to compress them. Descent of the diaphragm is impeded by the fat surround- ing the intestines, and by the increased resistance offered by the walls of the abdomen. SYMPTOMS OF CORPULENCi:. 631 Symptoms. — These, in most cases, are gradually deve- loped ; but sometimes very rapidly, i.e., in a few weeks. Increase of size and weight is the most tangible symptom, the alterations being most decided wherever fatty tissue is normally most developed, and therefore in the chin, breasts, neck, shoulders, extensor side of extremities, dorsum of hands and feet, abdominal and gluteal regions. The shape of the body becomes much altered : roundness takes the place of angularity, the cheeks hang down, the chin is drawn inwards, owing to the development of folds beneath it. The features lose their normal expression, and become relaxed and flabby: the neck seems shortened, the head is sessile upon the thorax. The chest and abdomen are pro- minent, the latter sometimes hangs down over the upper part of the thighs. The navel is sometimes depressed, sometimes prominent ; the genital organs are often hidden in masses of fat; varicocele is not uncommon in the male subject, and haemorrhoids are often developed. The gluteal region becomes very prominent, and a layer of fat is some- times developed on the backs of the hands. When the condition is thus advanced, the power of walking is much diminished ; the patient waddles, with his legs far apart and the head and upper part of the body thrown back; rising from a chair is effected very slowly, and any decided muscular action is followed by copious perspira- tion. The inactivity tends still further to aggravate the condition ; and the weight and circumference of various parts of the body are often enormously increased. Over 632 SYMPTOMS OF CORPULENCE. 700 pounds has been reached in one case, and even greater weights have been reported. The specific gravity is of course diminished. According to the colour of the skin, two kinds of corpu- lence have been distinguished, viz., the plethoric and the anaemic. In the former the face is red and congested, and the patients complain of rushing of blood to the head, giddiness, and noises in the ears; the subjects of the latter are pale and sickly looking. In both classes the skin is generally smooth and delicate ; there is a marked tendency to eruptions, e.g., eczema and intertrigo, the latter below the breasts and about the navel and buttocks. Acne rosacea and vulgaris are also common. There is decided increase of perspiration and secretion from the sebaceous glands, and unless great cleanliness be observed the secre- tions are apt to accumulate and become offensive. The temperament is generally phlegmatic ; there is loss of energy and of power of endurance, and disinclination for bodily and mental exertion ; lethargy and somnolence are often noticed. The pulse is apt to be very frequent, and at times arhythmic ; breathing is more or less difficult, owing to embarrassed action of the heart and lungs, and deficiency of haemoglobin in the blood. CEdema and vari- cose veins are not uncommon. On examining the thorax, the percussion note is found to be less resonant than usual, and there is marked dulncss over the sternum, owing to accumulation of fat in the mediastinum ; there are often SYMPTOMS OF CORPULENCE. r.33 signs of catarrh of the air-passages. The cardiac dulness extends over an increased area ; the impulse is external to its natural position ; the sounds are weak ; sometimes there are systolic murmurs, and, if there be hypertrophy of the left ventricle, the second aortic sound will be accen- tuated. In the abdomen, fatty liver may be suspected ; but is not readily diagnosed, owing to the thick layer of fat. The urine often deposits sediments of uric acid and its salts, and sometimes oxalate of lime ; sugar is occasionally present, and may be unimportant or serious. Corpulent women often suffer from disorders of menstruation, and from uterine catarrh and displacements. Gastric and in- testinal catarrhs are somewhat frequent symptoms ; con- stipation is sometimes very troublesome. Corpulency diminishes the power of resisting injurious influences, and increases the tendency to prostration. This effect is very obvious in all febrile complaints, which are especially dangerous in corpulent persons. It is very difficult to reduce the temperature by baths, and death is apt to occur from cardiac paralysis. Corpulent persons are also severely affected by loss of blood. Another source of danger is the predisposition which corpulence engenders to various diseases. Among these may be mentioned — gout, urinary calculi, diabetes, carbuncle, functional dis- orders of the heart, and cerebral haemorrhage as a result of arterial sclerosis. 634 TREATMENT OF CORPULENCE. Diagnosis and Prognosis. — The diagnosis is for the most part easily made ; the patient's appearance is suffi- ciently indicative of his condition. The prognosis varies with the degree of obesity, the nature of any existing com- plications, and the patient's power of will in reference to necessary treatment. If he be incapable of making any alteration in his manner of living, the condition is certain to become aggravated. Treatment. — Spontaneous improvement takes place in some forms of obesity ; thus young and fat infants become thinner as soon as they are able to use their limbs, and are fed upon a diet less rich in carbo-hydrates than that to which they have been accustomed. In another class of cases, viz., those in which the obesity is connected with anaemia, it is prone to subside />a7'i passn with im- provement in the general condition. In most cases, however, decided steps are necessary in order to bring about an improvement ; the majority are due to errors in diet, though other causes not unfrequently co-operate. The general rules may be thus briefly summarised : All articles of diet should be uniformly reduced, the patient and his food should be weighed from week to week, and if there be no diminution in bodily weight, a further reduction should be made in the food. It is not advisable to limit the amount of fat and carbo- hydrates alone, inasmuch as fat is formed from proteids; the consumption of fluids of all kinds should be lessened. TEJEATMENT OF CORPULENCE. 635- Muscular activity should be developed by taking plenty of exercise, and the mind should also be kept employed. The evolution of heat should be promoted by cold baths and frictions to the skin ; the patient should be lightly clad, and not too warm at night. If necessary, the bowels should be kept open by simple laxatives ; acid fruits are likely to be beneficial. Allusion must be made to certain systems, the efficacy of vi'hich has been more or less clearly demonstrated in the treatment of obesity. The first of these is the plan known as Banting's. The details with reference to the diet are as follows : Breakfast, four or five ounces of beef, mutton, kidneys, broiled fish, bacon, or cold meat of any kind except pork, one ounce of dry toast, or a little biscuit, a large cup of tea without milk or sugar. For dinner, five or six ounces of any fish except salmon, any meat except pork, any vegetable except potato, one ounce of dry toast, fruit out of a pudding, any kind of poultry or game, and two or three glasses of good claret, sherry, or Madeira ; champagne, port, or beer forbidden. For tea, two or three ounces of fruit, a rusk or two, and a cup of tea without milk or sugar. For supper, three or four ounces of meat or fish, similar to dinner, with a glass or two of claret. Breakfast between 8 and 9 ; dinner between i and 2 ; tea between 5 and 6 ; and supper at g. By this method, Mr. Banting reduced his weight in little more than a year by 46 pounds, and his waist measurement by 12A- inches. 636 TREATMENT OF CORPULENCE. It will be seen that in this plan albuminous materials are freely supplied, but fats and carbo-hydrates in very limited amount, so as to promote the oxidation of the fat of the body. The object may be attained, but the plan cannot be persevered with for long periods ; the common results being gastro-intestinal catarrh, palpitation of the heart, giddiness, attacks of syncope, loss of sleep, and other nervous troubles. Signs of mental disorder have appeared in some patients thus treated; others have become con- sumptive. Ill effects may, however, to a great extent be prevented by gradually reducing the quantity of fat and carbo-hydrates, and then allowing a slight increase. Another plan, of an opposite character, and suggested by Prof. Ebstein, consists in supplying a relatively large quantity of fat ; this method is in accordance with Hippo- crates' plan for dealing with similar cases. It is well known that fatty food diminishes the appetite for both solids and fluids, so that both are taken in less quantities. To be of any use, this method must be persevered with for a very long time; for otherwise, on relinquishing it, the former condition will soon return. The details of Ebstein's method are as follows : Three meals are taken daily : (i) Breakfast, consisting of a large cup of black tea, 50 grammes of bread or toast with plenty of butter; in summer this is taken from 6 to 6.30, in winter at 7.30 a.m. (2) The midday meal, 2 to 2.30, soup (often with marrow), 120 to 180 grammes of baked or boiled fish, of a fatty kind, and TEEATMENT OF CORPULENCE. 637 with melted butter, plenty of vegetables especially of the leguminous kind, and cabbage but no potatoes ; salad or fruit without sugar. For dessert, fresh fruit, with two or three glasses of thin white wine. Soon after dinner, a large cup of black tea without milk or sugar. (3) The evening meal, from 7.30 to 8 o'clock ; in winter, regularly, in summer, occasionally, a large cup of black tea, without milk or sugar ; one Qgg, fat bacon or ham, smoked or fresh fish, 30 grammes of white bread with plenty of butter, occasionally some cheese or fresh fruit. As a general rule, corpulent patients should take relatively plenty of fat, in the form of fat meat, good butter, fat sauces, fat ham and fish, etc. ; they should, how- ever, avoid carbo-hydrates as much as possible, and there- fore the following articles : potatoes, flour, cakes, sugar, milk, beer, champagne, etc. Ebstein's plan comprehends the details as to clothing, exercise, baths, etc., as mentioned in a preceding para- graph. Anaemic subjects should take iron, and in summer may use with advantage Kissingen, Homburg, or Marienbad waters. In many cases it has been shown that the employment of Ebstein's method has produced rapid diminution of the bodily weight, and a decided feeling of invigoration, so that the patients willingly abstained from many things which they had previously counted among the pleasures of life. Some patients, however, cannot take the fat, attempts 638 TREATMENT OF CORPULENCE. to persevere destroy all appetite, and the method has to be relinquished. In other cases, the result is to render the stomach very sensitive, so that the smallest quantities of solid food cause vomiting and diarrhoea. A very curious result has been noticed in a few cases, viz., the appearance of round hard subcutaneous tumours, about the size of a plum, and consisting of lipomatous growths with much connective tissue. A method, recently proposed by Dr. Oertel, differs from those already described. The proportion of fatty articles is very much reduced, and to a greater extent than that of the carbo-hydrates. Much stress is laid upon diminishing the supply of fluids ; and the withdrawal of liquid from the body is sought to be effected by active exercise, e.g., mountain climbing, baths of various kinds, and the use of pilocarpine subcutaneously. Fluids of all kinds are abstained from as much as possible ; liquids are not allowed until an hour or more has elapsed after a meal. The details with regard to food arc as follows: Mornins: and afternoon a small cup of coffee with milk and sugar, and 50 grammes of bread with butter are allowed at the earliest meal. At midday, 200 grammes of beef, 50 grammes of green salad, 100 grammes of fresh fruit, but no soup. Evening meal, 2 eggs, 150 grammes of meat, some caviare and white wine. At a later period, when the corpulence has become less, and any circulatory disorders have sub- sided, the patient is allowed to have at the midday meal TEUATMJSNT OF COliPULENCJE. 639 100 grammes of fish, and an equal weight of flour, and still later 200 grammes of white wine. Bread and cheese are also allowed at the evening meal. The quantity of liquid is likewise increased, if there be no circulatory disorders. Exercise is a very important feature in this method. It is taken under medical precautions, first on level ground and then on gradually increasing gradients. The cardiac muscle is thus strengthened and exercised. Experience teaches that no general rules can be laid down applicable to every case. Corpulence should be cured by removing the causes to which it is due. When this object has been effected, subsidiary measures of all kinds should be put in force. For mild cases, a course at Marienbad or Carlsbad is likely to prove efficacious, and massage, properly directed, is sometimes of great value. CHAPTER X. FUNCTIONAL DISORDERS OF THE LIVER. Functions of Liveu — Secretion of Bile, Formation of Glycogen and Metabolic Processes — Functional Disorders — Hepatalgia — Cir- culatory Disorder — Hyper*:mia, Causes and Symptoms — Treat- ment — Biliousness 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 — Lith.-emia as a Result of Functional Hepatic Disorder — Symptoms, Causes, and Treatment — Albuminuria in these Cases — Its Causes, Import, and Treatment — Cutaneous Affections in LlTHff:MIA AND their TREATMENT. The liver discharges at least three functions, one of which is perfectly obvious, while the other two are less apparent, but not less real. In the first place the gland secretes bile, which, formed by its cells, passes into the bile-ducts and thence into the duodenum. (2). The hepatic cells also form glycogen, which does not escape by the ducts, but in a diffusible form passes into the blood-vessels, and leaves the liver by the hepatic veins. (3). The liver is largely con- cerned in the destruction of albuminous matters derived from the blood and tissues, and in the formation of urea HEPATALGIA. 641 and uric acid. The organ is one of the chief places in which red blood-corpuscles become disintegrated; the haemo-globin is the source of bile-pigments, and the blood of the hepatic vein contains fewer red corpuscles than the blood of the vena portae (Landois). In the present chapter I propose to consider disorders of the liver, of a functional character, and appearing in the form of perversions of the nervous, circulatory, secretory, and metabolic processes. I. Nervous disorder of the liver. Pain of a neuralgic character is the only recognized affection of the liver coming under this head. Pains are felt in the right hypochondrium and epigastrium, and are not connected with any appreci- able change in the volume or position of the liver. They occur in paroxysms; are sometimes of a dull character, sometimes acute and lancinating ; and they vary extremely as regards their duration and times of recurrence. They may come on daily, or at longer regular or irregular intervals ; they may last only a few minutes, or may con- tinue to be troublesome for days or weeks. They are pro- bably connected with a gouty or rheumatic habit, and especially with the former, in the development of which functional hepatic disorder plays a very important part. They are distinguishable from the pain attendant upon inflammation of the liver by their fugitive character and by the absence of all other signs of that affection, and notably by the absence of tenderness on pressure. Firm pressure, T T 642 FUNCTIONAL DISORDERS OF THE LIVER. indeed, will rather relieve the pain of hepatalgia. There is neither febrile disturbance nor jaundice; but there may be constipation and some loss of appetite, and the attacks are usually attended with much depression of spirits. The treatment of hepatalgia consists in the administra- tion of purgatives and alkalies ; a few doses of blue pill at bedtime, followed in the morning by a teaspoonful or more of Carlsbad salts dissolved in six ounces of hot water will generally prove eflficacious. If there be decided gouty manifestations a little extract of colchicuni may be added to the blue pill. Iodide of potassium will probably relieve the pain in rheumatic subjects, and quinine should be given during the intervals. II. Circulatory disorder of the liver. Hyperaemia of the liver is a common condition, and occurs under various circumstances. The fluxionary form is set up during the digestion of food, some of the constituents of which are absorbed by the radicles of the portal vein and conveyed to the liver. The physiological process may pass into that of disease, and fail to subside when an excessive amount of nourishment is habitually taken, especially when at the same time little or no bodily exercise is practised. The condition is, therefore, very common among those who eat and drink to excess and lead idle or sedentary lives. It is also liable to be provoked by the ingestion of stimulating condiments and by the use of spirituous liquors. As a chronic morbid condition, passive congestion of the liver is HYPERJEMIA OF TRF LIVER. 643 a frequent accompaniment of circulatory and respiratory disorders, of tumours in the mediastinum compressing the inferior vena cava, and of disorders of the hepatic veins. Chronic hyperaemia of the liver is often the result of malarial poisoning, and the organ is frequently congested in cases of typhus and typhoid fevers, and as a con- sequence of prolonged exposure to tropical heat. Attacks of congestion of the liver also not unfrequently result from chills, especially after the body has been over-heated. The symptoms of hyperaemia of the liver vary accord- ing to the causation and the state of fulness of the vessels. There is generally a feeling of weight, tension, or oppres- sion in the right hypochondrium, diminution or loss of appetite, furred tongue, nausea, either constipation or some amount of diarrhoea, perhaps a bitter taste in the mouth, and a yellowish tinge of the eyes, skin, and urine. None of these symptoms are constant, but whenever they exist signs of mental disturbance are often superadded. The patient is apt to be low-spirited, languid, or drowsy ; things in general seem to be going wrong, the feeling of despondency may perhaps amount to melancholia, or the symptoms may be those of hypochondriasis. Sometimes there is shortness of breath, and the patient from time to time takes deep inspirations, so as to relieve the conges- tion by pressure on the diaphragm. In some cases there is severe pain, shooting to the back of the right shoulder, and down the right arm. Some patients find that lying on 614 TREATME]S'T OF RYPER^3IIA. either side causes severe pain. On examining the hypo- chondrium the volume of the liver is found to be more or less increased, and there is considerable tenderness on pressure. In some instances the symptoms are quickly developed, and as quickly disappear; but in others, and especially when the causes remain in operation, they assume a chronic character. Haemorrhoids are not un- frequent accompaniments of hyperaemia of the liver. Some- times the condition is relieved by an attack of diarrhoea or by a discharge of blood from the rectum. The treatment of hyperaemia of the liver depends upon the causation. If due to excessive indulgence in food and stimulants, the latter should be entirely interdicted and the diet considerably reduced, animal food being either with- drawn for a time or allowed in very small quantities. Exercise should be likewise enjoined, and warm baths will relieve the condition of the liver. Sn line purgatives w'xih alkalies are generally suitable, and a little blue pill may be given occasionally at bedtime. Cold compresses may be applied with benefit to the region of the liver, and in obstinate cases superficial blistering is likely to be of great service. When the symptoms become chronic we may have recourse to 7iitro-nniriatic acid and mix vomica, pay- ing due attention to the diet, exercise, and state of the skin, and keeping the bowels regular by means of aloes or cascara. Exposure to cold should be avoided by these patients, and when the symptoms have passed off it is well A BILIOUS ATTACK. 645 to recommend the wearing of a silk or flannel belt over the hepatic region. Such prophylactic measures for pre- venting recurrences as exercise and proper abstinence should never be neglected. For hepatic congestion due to malaria quinine and nitro-miiriatic acid are the best remedies. The treatment of cases due to organic disease must, of course, be guided by the nature of the latter. Before discussinpf in detail the various disorders of the secretory function of the liver, it seems desirable to say a few words upon the condition known as "biliousness," and its acme, a " bilious attack." There are perhaps few words more freely or more indefinitely used by the public at large for describing ailments than these two expressions. " Biliousness " generally signifies a form or state of indi- gestion, attended by a bitter or otherwise nasty taste in the mouth and perhaps nausea. A "bilious attack " implies a more or less severe explosion of gastric derangement with headache and vomiting. Biliousness is in truth often due to torpor of the liver resulting in lessened or vitiated secretion of bile, and the symptoms will be described under those headings. A " bilious attack " is generally the result of gastric and duodenal catarrh caused by errors in diet, frequent in- dulgence in rich and highly seasoned dishes, and alcoholic stimulants. In some persons one such repast is followed by a "bilious attack," the symptoms of which may ensue at once, or not until several hours have elapsed. Perhaps 646 A BILIOUS ATTACK. the patient goes to bed soon after a meal of the above character, passes a restless or feverish night, and is altogether unrefreshed when morning comes. He is con- scious of a disagreeable taste in the mouth, and the tongue is foul and coated. Thirst is troublesome, and is but slightly relieved by fluids. Black spots float before the eyes ; eructations, with an odour resembling that of a rotten Ggg, cause the patient much annoyance. There is more or less headache, felt chiefly in the forehead and increased by moving, and especially by stooping. Nausea is succeeded by retching and vomiting, the ejected matters consisting of undigested articles of food, much frothy and foul-smelling fluid and finally bile. The efforts at retching are apt to continue long after the stomach has been emptied, but they subside after a variable interval ; the headache also passes off, and except, perhaps, for some amount of depression the patient feels much as usual. Some persons get quite accustomed to these attacks, and instead of striving to prevent them, they regard a blue pill and a black draught as the appropriate antidote. They confess themselves to be bilious, and attribute their attacks to ill behaviour on the part of the liver. As a matter of fact, the stomach is the offended organ ; there is no hindrance to the flow of bile and no disorder of the liver other than that of a temporary character due to the errors in diet. It is, however, very difficult to persuade patients that such is the actual state of the case; "biliousness" seems a far BILIOUS DISORDER. 647 easier explanation, and is the more welcome inasmuch as scores ot " antibilious " remedies are easily procurable. In thus referring to a bilious attack, it is necessary to remember that, according to one theory, migraine, instead of being essentially a nervous malady, is the result of "bilious" disorder. This idea is supported by the fact that vomiting and sometimes the ejection of biliary matters are apt to occur during an attack of migraine. The causes of the latter affection have been fully described in a pre- vious chapter, and while it is true that an error in diet is sometimes the exciting cause of an attack, it is quite certain that migraine has no necessary causal connection with the state of the stomach. In not a few cases there are no signs of gastric disorder ; in others the latter super- vene some hours perhaps after the first symptoms in the head, and are the result of the nervous disorder. Again, when the attacks occur at regular intervals, and a paroxysm is nearly due, it maybe sometimes brought on by an error in diet, whereas the same error repeated a day or two afterwards is followed by no such effect. The differences between migraine and an ordinary bilious attack due to improper food are so marked that no observant person can fail to distinguish between the two conditions. With regard to the symptoms of disorders of the secre- tory functions of the liver a minute account will be given in succeeding paragraphs, but there is one test for these dis- orders lately insisted on by Dr. S. Fenwick, and which may 648 FUNCTIONAL DISORDER OF THE LIVER. here be mentioned. He believes that the sulphocyanide of potassium " in the saliva is increased in quantity whenever an unusual demand is made upon the nutritive organs by the necessities of the system, and these organs are capable of answering to the call ; but that on the contrary the amount of the salt is diminished whenever the nutritive organs are unable to meet its requirements." The pre- sence of the sulphocyanide in the saliva depends upon a decomposition of the biliary salts, and inasmuch as chronic congestion of the liver lessens its functional activity, the salt is always below the normal amount when this con- dition exists. Dr. Fenwick's researches show that any circumstance preventing the digestion or absorption of the food is accompanied by a diminution in the amount of the salivary salt, and that the quantity of this latter can be accepted as a measure of the activity of the liver, duode- num, and salivary glands, but mainly of the first alone. For the methods of testing the saliva the reader is referred to Dr. Fenwick's essay.* III. Disorder of the secretory function of the liver. The secretion of the liver is liable to three forms of dis- order ; it may be excessive, dejicieiit, or vitiated in quality. In all these cases, other symptoms, or., diarrhoea, jaundice, or constipation, are liable to result, but evidences of the hepatic disorder of secretion, as shown by -the state of * "The Saliva as a 'I'cst for Functional Disorders of tlie Liver," by Samuel Fenwick, M.D. 1887. JEXCESSIVE SECRETION OF BILE. 649 the alvine evacuations, may be for some time the only manifestation. (i.) Excessive secretion of bile is a common symptom in hot climates ; it may also be caused by undue use of stimulants, alcoholic and otherwise, and by gastric and intestinal irritation. In hot climates the liver seems to act vicariously for the lungs in carrying off excess of carbona- ceous matter. The exaltation of function under such circumstances is not of long duration, and is generally con- fined to the earlier years of residence. Afterwards an opposite condition is apt to set in, and a deficiency of the biliary secretion becomes evident. Much, however, depends upon the habits of life of the individual, and especially upon the diet and the amount of exercise taken. The symptoins of excessive secretion are more or less pain and tenderness in the right hypochondrium, loss of appetite, nausea, and perhaps vomiting, but especially diarrhoea, with a deep bilious colour of the evacuations. The latter are sometimes green from the action of acid in the bowels, are generally rather frequent, and attended with abdominal pain and a burning sensation in the rectum; more or less fever is generally present, and the patient likewise complains of headache and thirst. The treatinent in the early stage consists in the removal of the cause, rest, cool drinks, and a low diet. Before diarrhoea has set in we may administer a mild laxative, such as sulphate of sodium with an alkali, or a little 650 DIMINISHED SECRETION OF BILE. rhubarb and magnesia. If diarrhoea has already occurred it may be allowed to continue unless it become excessive, in which case a pill containing a quarter of a grain of calomel, with one-eighth of a grain of opium, may be given every hour or two, up to eight doses if necessary. If the purging should continue and the evacuations become pale a few doses of chalk mixture with catechu and aromatics will serve to check it. (2.) Diminished secretion of bile is a common occur- rence, and sometimes the function seems to be for a time altogether in abeyance. Such a condition may result from excessive stimulation, followed by torpor and exhaustion of the organ. It may also depend upon an insufficient quantity in the blood of the materials out of which bile is produced. Other causes are direct or indirect sedative agents, such as insufficient food, mental anxiety, want of exercise, various anaemic conditions, and the diversion of nervous energy to other organs. The state of the liver is shown by the colour of the evacuations, which gradually become lighter and lighter, until at last they resemble clay, or are almost white. Constipation is generally present, but in some cases diarrhcra is the prevailing condition, the evacuations being usually opaque and sometimes almost milky. The dis- charges are probably the result of congestion of the intes- tinal mucous membrane, consequent upon obstructed circu- lation within the liver ; the congestion is relieved by the escape of fluid from the distended vessels. Suppression of DIMINISHED SECRETION OF BILE. 651 bile and the attendant diarrhoea are usually accompanied by abdominal pain or uneasiness, with gastric derangement, furred tongue, a foul taste in the mouth, and depression of spirits. Jaundice is not uncommon, especially in cases in which there is duodenal catarrh. The treatment of inactivity of the secretory function of the liver is often attended with difficulties, and in chronic cases the complaint is apt to prove obstinate. The diet requires careful attention ; it should be easily digestible and non-stimulating. Rich dishes, fat, and pastry of all sorts must be interdicted ; a little claret, hock, or whisky may generally be allowed with meals ; they should be well diluted by some alkaline effervescing water. The patient should be kept warm, wear flannel next the skin, and avoid chills ; warm compresses and warm or tepid baths are likely to be serviceable. With regard to medicines, if constipa- tion be present this should be corrected by means of mild laxatives, such as small doses of aloes with a little ipecac- uanha Siwd mix vomica ; the various saline purgative waters are also suitable. For cases in which the condition is the result of over-stimulation, as in persons returned from the tropics, a course of nitro-miiriatic acid with taraxacum, mix vomica and a little henbane often yields most satis- factory results ; the medicine should be continued for a month or six weeks, all other precautions being observed at the same time. The same remedy is often suitable for other cases ; if it fail we may have recourse to one or more 652 VITIATED SECRETIO]S OF BILE. of the lately introduced hepatic stimulants, \\z.,podophyllin, iridin, euonymin, and leptandrin. The first of these should be given in small doses, gr. yjj's' "ig^t and morning ; i^ constipation exist, it may be combined with aloes. Iridin is another hepatic stimulant ; it is said to be more reliable than podophyllin when a slight cholagogue is wanted for a lengthened period ; the dose is gr. j-ij night and morning. Eitonymin and leptandrin possess like properties, and may be given in the same doses. All these drugs are more or less aperient in their action. Other less used remedies of the same character are hydrastin, juglandin, and sangui- narin. Mercury is said to diminish the secretion of bile, and yet cases are not rare in which small doses of this drug seem to produce an opposite effect. Certainly in children with clay-coloured, loose, offensive stools a small dose of grey powder often repeated, or minute doses of the perchloride will yield very excellent results, checking the diarrhoea and restoring the colour to the stools. The same remedy does good in adults presenting the symptoms of rapidly- developed suppression of bile, as a result of excitement or after exposure to cold ; half-a-grain of grey powder every three hours will often restore the secretion. (3). Vitiated secretion of bile. This condition, unless very marked, is less easily detected than either increase or deficiency of the secretion. In extreme cases the colour of the bile is much altered, varying between a deep bottle- VITIATED SECRETION OF BILE. 653 green and jet black. When vomited in this condition it is very acrid and bitter to the taste ; when it passes off through the bowels it causes diarrhoea and severe colicky pains and burning sensations in the rectum. Similar disorder of a less severe character gives rise to irregular action of the bowels, with stools of various colours and foetid odour ; nausea, especially in the mornings, unpleasant taste in the mouth, and a yellowish fur about the tongue ; high-coloured urine, with perhaps vesical irritation ; and a yellowish tinge in the eyes and skin. The appetite is generally impaired ; there is headache, general languor of body and mind, per- haps irritability and depression of spirits, and disturbed sleep. Pains in the back and loins, uneasiness under the shoulder-blades, fulness and pain in the right hypochon- drium, particularly on taking a full inspiration, are often complained of. Symptoms such as those above described are of common occurrence in tropical climates and during hot weather in this country. They are generally caused by exposure to the heat of the sun, indulgence in alcoholic liquors, and rich and stimulating diet. If diarrhoea occur the symptoms will probably soon pass off, but repeated attacks, especially in hot climates, pave the way for serious derangement of the liver. The treatment of cases of vitiated biliary secretion depends upon the cause of the symptom. If it be due to heat, the patient should be kept quiet and as cool as 65-4 DISORDERS OF METABOLISM. possible. A mild purgative, such as rhubarb, with soda and magnesia, will generally be serviceable, and effervescing salines may be afterwards prescribed. If there be irrita- bility of the stomach, with nausea and vomiting, an emetic dose of ipecacuanJia will constitute the best treatment. The same remedy will be suitable for cases due to errors in diet, and after the vomiting has ceased four or five grains of calomel may be given to clear out the bowels. To pre- vent recurrences, temperance and non-stimulating diet, rest, and avoidance of exposure to heat are the main points to be attended to. When the symptoms have become chronic, after attention to the diet, we may prescribe with advantage the nitro-muriatic acid or podophylliu or some other hepatic alterative, as iridin, etc., and warm baths. Moderate exercise is always serviceable, and horse-exercise is often the best form. Uneasy sensations about the liver will be relieved by compresses, dry-cupping, or blisters. IV. Disorders of the metabolic processes of which the liver is the seat still remain to be described, and it is some- what remarkable that the views now held as to the pro- cesses in question were entertained, though, of course, somewhat crudely, in very early times, and were subse- quently forgotten or neglected. Only within the last few decades has proper recognition been accorded to one most important function of the liver, viz., the conversion of albuminous matters derived from the food and tissues and the formation of urea and uric acid. Disorders of this DISORDERS OF METABOLISM. 655 function I propose now to consider, and in doing so I cannot fail to allude to the writings of the late Dr. Murchison,^ to whom the profession was much indebted for a clear exposition of our knowledge on this subject and the inferences to be drawn therefrom. His observations show that the liver is largely concerned in the formation of urea and uric acid. For evidence in support of this view the reader is referred to my work on Gout and particularly to the chapter dealing with the causes of the complaint. It is, however, necessary to allude to the main points and facts brought forward as evidence. In acute yellow atrophy of the liver, the secreting tissue is destroyed to a greater or less extent. The organ may be reduced to half or even one-third its normal bulk ; all traces of lobules and vessels are almost or completely obliterated. A very important symptom is connected with the urine, which may be normal in quantity and acid, but contains a much reduced amount of urea, the place of which appears to be taken by leucin and tyrosin. Again, Dr. Parkes has shown that in cases of hepatitis and hepatic abscess, with excessive suppuration, the urea is lessened in a degree proportionate to the extent to which the secreting structure is destroyed by the abscess. When the liver is not suppurating, but actively congested and enlarged, the amount of urea and uric acid seems to be increased. In chronic congestion and in the various forms of cirrhosis, in * "Functional Derangements of the Liver/' 2nd edition, 1879. 6o6 LITR^MIA. simple jaundice, and in cases of obstruction from gall- stones, there is a considerable diminution in the quantity of urea. The interpretation of these pathological facts is sup- ported by some experiments recently made by Dr. Noel Paton on the relationship of the formation of urea and uric acid to the secretion of bile. He has shown that stimulation of the flow of bile by means of drugs is accompanied by an increased production of urea, and not merely by an increased elimination. When the transformation of albuminous matters is imperfectly performed, the condition known as lithxinia is a frequent consequence. The ordinary cause of such imperfect transformation is an excess of supply, combined as it often is with deficient action of the assimilating organs. An occasional deposit of urates in the urine is a common result of errors in diet, and over-indulgence at the table, and is of no serious import. If, however, such a deposit be constantly or even frequently noticed, it ought to attract attention, for it indicates that oxidation is less perfect than it ought to be, and that functional disorder is becoming chronic. Persons are only too apt to think that the kidneys are " out of order," but as a matter of fact it is not these organs, but the liver, which is generally at fault, and the distinction as influencing the treatment is, of course, very important. When a condition of lith.-emia has become developed, SYMPTOMS OF LITSMMIA. 657 certain symptoms, perhaps occasionally noticed before, are apt to become prominent. There is more or less dyspepsia, as shown by flatulence, distension, feelings of uneasiness or even severe pain in the stomach and duodenum. The right hypochondrium is tender on pres- sure, and the patient is conscious of a feeling of weight and tension. Nausea and acid eructations are common symptoms, and there is often a bitter taste in the mouth ; the tongue is furred, large, and indented at the edges, the bowels are irregular and generally constipated, and the skin has sometimes a slightly jaundiced tinge. Palpitation of the heart and shortness of breath, aggravated by exer- tion, are often complained of, and a short dry cough, attended with excessive secretion of viscid mucus in the fauces and at the back of the nose, is sometimes very troublesome. Haemorrhoids in various stages are not un- frequent, and indicate congestion of the liver. As might be expected, symptoms of derangement of the nervous system are almost invariably superadded to those above described, and in different patients take the forms of irritability, depression, restlessness, lassitude, drowsiness after meals, headache, and inability for mental exertion. Sleep is broken and unrefreshing, and often disturbed by dreams ; noises in the ears, dimness of sight, and vertigo are sometimes very troublesome and alarming. Such patients are apt to become hypochondriacal, feeling as they do more or less discomfort in every part of the body, WW 658 CAUSES OF LITEMMIA. Aching pains in the back and limbs, attacks of migraine and of facial and other forms of neuralgia tend still further to depress the patient. As time goes on decided symptoms of gout are wont to be experienced ; the small joints are painful and tender, the eyes are hot and irritable, and sensations of burning and tingling in the hands and feet cause much annoyance. It not unfrequently happens that after many of the symptoms above described have existed for some time, an acute attack of gout supervenes, and the patient becomes relieved from his general troubles. But before such a culmination takes place the patient notices that the symptoms are liable to frequent exacerbations, and that they are always aggravated by errors in diet and excess in alcohol, or even by indulgence in a glass or two of champagne or beer. There are two other symptoms of common occurrence among these patients ; the first of these is the appearance of a small quantity of albumen in the urine, while the second is an eruption of eczema. Further allusion will be made to these symptoms in subsequent paragraphs. Tht causes oi lithaemia require a brief notice; they are for the most part connected with errors in diet. Hereditary tendency is also a potent factor in their development, and its influence is often reinforced by the patient's habits. Excess in albuminous food is, moreover, frequently accom- panied by deficiency of exercise, and the disproportion be- tween the absorbed albuminates and the absorbed oxygen TREATMENT OF LITR2E1S1IA. 659 must result in imperfect oxidation and its consequences, notably the retention in the system of refuse materials and irritation of the eliminating organs. The nature and digestibility of the food are important elements in the con- sideration. Malt liquors of all kinds and the stronger and imperfectly fermented wines play a conspicuous part in the causation of lithaemia, and their effects are often superadded to those of improper food. The acidity so often complained of is the result partly of the fermentation of the food, and partly of increased secretion of gastric juice. The sugars and starches are apt to undergo lactic fermentation in the stomach, the gastric mucus acting as a ferment. The albuminous and fatty substances are subject to butyric fermentation, and other acids, such as the acetic, succinic, etc., are often developed. The treatment of lithaemia may be described in a few words. The causes must be avoided ; the diet must be reduced and suitably modified ; and a due amount of exercise must be taken. The patient should be provided with diet- rules, as described in previous pages, and every attempt should be made to restore the normal functions of the liver. Purgatives -3^x0. generally indicated, and of these the salines are the most suitable. They may be conveniently ad- ministered in the form of such mineral waters as Friedrich- shall, Hunyadi Janos, or Rubinat-Condal, and when much acidity and fermentation exist the Carlsbad water or salts are preferable. The various hepatic alteratives, alluded to 660 ALBUMINURIA WITH LITII2EMIA. in previous paragraphs, will often be suitable for these cases, and when the urine contains much free acid, a course of alkalies is generally indicated. The state of the skin always requires attention ; tepid or warm baths are always beneficial. For young and plethoric subjects an occasional Turkish bath will improve the condition of the skin and promote its eliminative action. A course of treatment at such places as Bath, Buxton, Harrogate, Teplitz, or Vichy, will almost always benefit chronic cases. Disorder of the metabolic function of the liver may result not only in lithsemia, but likewise in a form of albuminuria, which has attracted much notice during the last few years. I have observed this symptom in many cases, the patients being for the most part men in middle life, of active literary habits, but somewhat free livers. They exhibit the ordinary symptoms of lithaemia and gouty dyspepsia, but no severe attacks of articular inflammation. The albumen generally occurs in very minute quantities ; but it may vary from one-tenth to three percent. No casts are discoverable, and the albumen disappears in the course of a few weeks under the use of appropriate diet and treatment. Albuminuria is often a very grave symptom, as it generally indicates organic mischief in the kidneys ; but in the cases now alluded to I believe that it is due to defective metabolism of nutritive materials by the liver. There is abundant evidence forthcoming to show that ALBUMINURIA WITH LITSJEMIA. 661 albumen is often temporarily present in the urine under a great variety of circumstances, e.g., after excessive con- sumption of albuminous food, which is imperfectly assimilated ; exposure to cold and wet ; during pregnancy; after hard mental toil, and nervous excitement ; as the result of a gouty inheritance, and in a smaller number of cases, as a result of privations and unhealthy surroundings. It is, doubtless, the " albuminuria of digestion " which is present in the cases now before us ; some of the albuminous constituents of the food not being converted into urea, and passing out of the system in an unchanged state. In addition to the suspicion likely to be excited, this excretion of albumen, if of frequent occurrence, is very liable to cause irritation of the kidneys. In his treatise on albuminuria, Dr. Senator points out that when egg-albumen, as such, finds its way into the blood, it is excreted by the kidneys ; " but frequently this is not all that happens, for more albumen is excreted than is introduced ; as a matter of course, not more egg-albumen, but a form which pos- sesses the properties of the ordinary albuminous substances of the serum (serum-albumin and globulin)." Doubtless the same result follows the frequent passage through the kidneys of other albuminous matters imperfectly metamor- phosed, and hence it is that functional disorder of tlie liver may give rise to organic renal disease. The treatment of albuminuria, occurring under the con- 662 TREATMENT OF LITHMMIA. ditions above described, is practically the same as that of lithaemia ; the diet especially will demand very careful attention. Milk diet is especially indicated; it causes the albumen to diminish or even to disappear in a few days. If there be evidences of renal congestion, such as pain in the loins, frequent micturition and highly concentrated urine, in addition to saline purgatives and alkalies, we should prescribe warm baths, warm fomentations, or mustard plaisters to the loins, and besides these remedies I can strongly recommend dry cupping over the loins, repeated from time to time if necessary. The albumen rapidly diminishes under this treatment, but its presence must never be disregarded, for if neglected it may cause serious lesions of the kidney. The eczema, which is often a troublesome symptom in connection with lithsemia, would appear to be due to the accumulation in the blood of certain excrementitious materials, of which uric acid is the one most easily demonstrable. When the quantity of these products existing in the blood is greater than can be removed by the kidneys, the work is thrown upon other organs, and especially upon the skin, and the result in many cases is an outbreak of eczema or psoriasis. For the treatynent of these cutaneous affections con- stitutional remedies are always required, and those which stimulate the hepatic functions are generally serviceable. The diet will demand very careful attention, ?\.nd purgatives, TREATMENT OF LITK2EMIA. 663 alkalies, and tonics must be given according to circum- stances. Warm baths are generally serviceable, and arsenic or antimony may be tried for obstinate cases. The itching is best relieved by an ointment of boric acid, but it must always be remembered that relief is often temporary, and that the complaint is very apt to recur. INDEX. A. Albuminuria, due to functional disorder of the liver, 660 ; treatment of, 661. Alcoholism, 359; consequences of, 360; course of, 363; neuritis in, 361 ; statistics of, 364; treatment of, 365. Anaemia, associated with corpulence, 629. Angina pectoris, 429; cardiac pain in, 430; causes of, 434 J diagnosis of, 439; lesions accompanying, 435; pathogeny o^j 435 j prognosis of, 439; radiation of pain in, 431; respiratory symptoms in, 431 ; symptoms of, 430; treatment of, 439 ; vasomotor disorder in, 432. Anorexia, nervous, 547. Aphonia, 445 ; causes of, 445 ; treatment of, 447. Appetite, excessive, 545; loss of, 547; perversions of, 544; vitiated, 548. Articular neuralgia (see Neuralgia of the joints), 276. Asthma, 464 ; causes of, 465 ; diagnosis of, 476 ; essential, 466 ; laryngeal (see Laryngismus Stridulus) ; pathogeny of, 473 ; prognosis of, 478; sequelae of, 476; symptoms of, 469 ; treat- ment of, 479. B. Banting, method of treating corpulence, 635. Bile, diminished secretion of, 650; excessive secretion of, 649; vitiated secretion of, 652. Bilious attacks and Biliousness, 645. Bowels, neuralgia of the, 579; normal action of the, 587. 666 INDEX. c. Causes of functional nervous disorders, ii. Charcoal as a remedy for flatulence, 536. Chloral-habit, the, 375 ; symptoms and results of, 376 ; treatment of, 378. Chlorosis in connection with constipation, 590. Chorea as an example of the neuroses, 7 ; causes of, 200 ; con- nected with rheumatism, 202; definition of, 198; depending on ocular disorders, 201 ; diagnosis of, 211; embolic theory of, 203 ; geographical distribution of, 199 ; heart disease in, 203 ; nature of, 203 ; prognosis of, 210 ; symptoms of, 206 ; treatment of, 211. Circulation, functional disorders of organs of, 382. Colic, see Enteralgia, 572. Constipation, 585 ; causes of, 586; consequences of, 589 ; diag- nosis of, 595; hepatic alteratives for, 605; laxatives suitable for, 600 ; massage in the treatment of, 607 ; saline aperients for, 603 ; surgical causes of, 592 ; treatment of, 596 ; use of enemata for, 606. Corpulence, 626; anatomical appearances of, 629; causes of, 627; consequences of, 633 ; diagnosis and prognosis of, 634 ; symptoms of, 631 ; treatment of, 634. Cough, laryngeal, 452. D. Diarrhoea, 608 ; causes of, 609; diagnosis of, 616 ; in connection with infectious disorders, 612; in connection with intestinal lesions, 611 ; symptoms of, 614 ; treatment of, 616. Diarrhoea, chronic, treatment of, 618 ; in children, 620 ; treatment of, 622. Digestion, functional disorders of organs of, 493. Dyspepsia, 505 ; acute, 513 ; and gastric catarrh, 506; causes of, 508 ; chronic, symptoms of, 515 ; constipation, as a symptom of, 519; course and duration of, 522; diagnosis of, 522; prognosis of, 522 ; pyrosis, as a symptom of, 518; results of, 520 ; symptoms of, 513 ; treatment of, 523 ; urine, condition of, in, 519. INDEX. 667 E. Ebstein, method of treating corpulence, 636. Eczema due to functional disorder of the liver, 662. Enemata, for relief of constipation, 606. Enteralgia, 572 ; causes of, 572; diagnosis of, 577 ; prognosis of, 578; symptoms of, 575; treatment of, 580. Epilepsy, as an example of the neuroses, 6; causes of, 165 ; course of, 184; definition of, 164; diagnosis of, 185 ; exciting causes of, 170; geographical distribution of, 165 ; irregular forms of, 180; Jacksonian, 183; mental disorder in, 184; milder forms of, 179; morbid anatomy and pathology of, 171; ocular defects as a cause of, 170 ; prognosis of, 187 ; symptoms of, 176 ; treatment of, 188 ; of paroxysms, 196. Epileptic aura, 177. Epileptic state, artificial production of, 168. Epileptoid states, 181. Ether-drinking in Ireland, 378; effects of, 380 ; measures to check, 382. Facial neuralgia (see Tic Douloureux, 239.) Facial paralysis, 339; causes of, 340; degrees of, 344; diagnosis of, 345 ; loss of taste in, 342 ; prognosis of, 346 ; symptoms of, 341 ; treatment of, 347. Food, improper, as a cause of disorder, 495. Functional disorders, causes of, 11; characters of, 20 ; description of, I ; nature of, 3 ; of the liver, 640 ; of the nervous system, 22 ; of the organs of circulation, 382 ; of digestion, 493 ; of respiration, 444. G. Gastralgia, 550; causes of, 551 ; diagnosis of, 556; prognosis of, 558 ; spasmodic form of, 556 ; symptoms of, 553 ; treatment of, 559- Gastric disorders due to food, 495. Gout as a cause of functional nervous disorders, 18 ; as a result of functional disorder of liver, 658. 668 . INDEX. H. Hay-asthma, 485 ; causes of, 486 ; diagnosis of, 491 ; experiments in connection with, 488 ; symptoms of, 488 ; treatment of, 491. Headache, 282 ; anaemic, 286; as a symptom, 282; causes of, 282; character of pain in, 284 ; diagnosis of, 290; due to optical disorders, 289 ; in cerebral hypersemia, 284 ; in gastric disorder, 287 ; in gout and rheumatism, 287 ; in hysteria, 288 ; in neurasthenia, 286 ; in syphilis, 288 ; treatment of, 292. (See also Migraine). Heart, functional disorders of the, 382 ; causes of, 386 ; character- istics of, 387 ; murmurs in, 389; symptoms of, 385. Heart, movements of, how regulated, 391. Heart, nervous supply of, 390. Heart, palpitation of the, 399 ; causes of, 402 ; diagnosis of, 406 ; nervous causes of, 403 ; prognosis of, 407 ; symptoms of, 400 ; toxic causes of, 405 ; treatment of, 407. Hemicrania (see Migraine, 295.) Hoarseness, causes of, 444 ; treatment of, 447. Hypnotism in the treatment of chorea, 214 ; of hysteria, 161 ; of sleeplessness, 118. Hypochondriasis, 349 ; causes of, 350; course of, 354 ; diagnosis of, 355 ; forms of, 349 ; prognosis of, 354 ; symptoms of, 351 ; treatment of, 356. Hysteria, 121 ; causes of, 123 ; course of, 146; contraction of joints in, 137 ; definition of, 121 ; diagnosis of, 148 ; disorders of circulation in, 144; disorders of digestion in, 142; disorders of respiration in, 144; disorders of secretion in, 145; dis- orders of sensation in, 138 ; disorders of uterus as causes of, 124 ; duration of, 146 ; exciting causes of attack, 126 ; geo- graphical distribution of, 122 ; hy[)notism in the treatment of, 161 ; mental j)erversion in, 127; paralysis in, 135 ; paroxysms of, 130; prognosis of, 147; results of, 146; symptoms of, 126 ; treatment of, 151 ; treatment of paroxysms, 157 ; Weir Mitchell system of treatment, 163. Hystero-epilepsy, 133 ; diagnosis of from epilepsy, 148. INDHX. 669 Intercostal neuralgia, 253; causes of, 253; diagnosis of, 257; eruptions connected with, 256; points douloureux in, 255; radiation of pain in, 255; symptoms of, 254; treatment of, 259. Irritable breast, or mastodynia, 258 ; diagnosis of, 259; treatment of, 261. L. Laryngeal cough, 452. Laryngismus stridulus, 456 ; causes of, 456; diagnosis of, 460 ; nature of, 459 ; prognosis of, 461 ; symptoms of, 457; treat- ment of, 461. Larynx, application of faradism to, 449 ; hypersesthesia of, 450 ; neuralgia of, 451, Liver, circulatory disorders of, 642; functional disorders of, 640; hyperasmia of, 642 ; metabolism in, 640; disorders of, 654; secretory disorders of, 648 (see also Bile). Lithsemia, causes of, 658 ; due to functional disorder of liver, 656 ; treatment of, 659. M. Metallo-therapeutics in hysteria, 159. Migraine, 295 ; and gout, 302 ; causes of, 301 ; diagnosis of, 308 ; exciting causes of, 303; forms of, 297; ocular disorders in, 299; pathogeny of, 305; prodromal symptoms of, 296; prognosis of, 308 ; symptoms of, 296 ; treatment of, 309 ; vaso-motor disorder in, 297. Morphine habit, the (see Opium, 369). N. Nerve prostration, 22 ; causes of, 24; diagnosis of, 52; disorders of circulation in, 45 ; disorders of digestion in, 47; disorders of respiration in, 46 ; duration of symptoms of, 53 ; electricity for, 75 ; mental disorder in, 30; morbid dread in, 37; motor disorder in, 42; prognosis of, 56; sensory disorder in, 33; sleeplessness in, 40; symptoms of, 30; treatment of, 58; 670 INDEX. varieties of, 30 ; vaso-motor disorder in, 43 ; Weir Mitchell treatment of, 79. Nervous dyspepsia, 540; causes of, 540; diagnosis of, 543; prognosis of, 543 ; symptoms of, 541 ; treatment of, 543. Nervous eructations, 568; treatment of, 571. Nervous vomiting, 562 ; causes of, 562 ; diagnosis of, 567 ; sym- ptoms of, 565 ; treatment of, 567. Neuralgia, 215 ; causes of, 220; characteristics of, 217 ; diagnosis of, 230 ; electricity in treatment of, 235 ; eruptions connected with, 228; points douloureux in, 225 ; radiation of pain in, 224 ; surgical measures for, 227 ; symptoms of, 221 ; treat- ment of, 231 ; various forms of, 239 ; vaso-motor disorder in, 227 (see also Intercostal Neuralgia, Sciatica, and Tic Douloureux). Neuralgia of the joints, 276 ; causes of, 276 ; diagnosis of, 280 ; symptoms of, 277 ; treatment of, 281. Neurasthenia (see Nerve Prostration and Spinal Neurasthenia). Neurasthenia of the heart, 423 ; causes of, 425 ; prognosis of, 425 ; symptoms of, 423 ; treatment of, 427. O. Obesity (see Corpulence). Ocular defects as causes of functional nervous disorders, 19. Oertel, method of treating corpulence, 638. CEsophagus, spasm of the, 499. Opium habit, the, 369; forms of, 370; prognosis in, 373 ; treat- ment of, 374. R. Respiratory organs, functional disorders of the, 444. S, Saliva, the, as a test for functional disorders of the liver, 648. Sciatica, 261 ; causes of, 262 ; course of, 267; diagnosis of, 268 ; electricity in treatment of, 272; points douloureux in, 265; prognosis in, 269; symptoms of, 263; treatment of, 269; vaso-moior and trophic symptoms in, 266, INBJEX. 671 Secretion, gastric and intestinal, perversion of, 500. Secretory functions of liver, disorders of, 648. ■Sleeplessness, causes of, 105; electricity for, 117 ; in gouty sub- jects, 109; hypnotism for, 118; remedies for, no; treat- ment of, 109. •Spinal irritation, causes of, 93 ; compared with spinal neurasthenia, 96; diagnosis of, 97; symptoms of, 94; treatment of, 100. Spinal neurasthenia, causes and symptoms of, 91 ; diagnosis of, 97 ; treatment of, 98. Syncope, 412; causes of, 414; duration of, 413 ; diagnosis of, 417; prognosis of, 419; symptoms of, 412; treatment of, 420. T. Tannin, effects of, on salivary digestion, 497. 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