The causes, symptoms and treatment of hysterical, hypochondriacal, epileptic and other nervous affections

Front matter

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JAMES J. WARING MEMORIAL BOOK FUND

Preface

In the following pages, the author has endeavoured to set forth, briefly, the causes, symptoms, and treatment of Eccentric Nervous Affections ; that is to say, of such complaints as originate in causes extraneous to the nervous centres, and are totally unconnected with any organic lesion of those parts.

In the first place is described the intimate connexion which exists between the nervous and circulating systems, as well as their mutual dependence the one upon the other. The processes of assimilation, both primary and secondary, are adverted to, in order to point out the manner in which the blood is formed, and from it the a 2

Vlll PREFACE.

various tissues of the body, and how, consequently, any derangement of these processes must affect the whole constitution. Secondly, the difference between centric and eccentric nervous affections is pointed out, and some experiments are related in order to show the difference between reflex action and the motions of irritability. Subsequently to this, the various eccentric nervous affections themselves are described ; first, those which depend, for the most part, upon an improper quality of the blood ; secondly, those which are of a more doubtful nature, and may depend either upon this last-mentioned cause, or upon direct irritation of the nervous system ; thirdly, those which arise from a shock or direct irritation of the nervous system, and are not necessarily connected with any abnormal condition of the blood ; and lastly, those which are produced by the introduction of some poison into the current of the circulation.

In all these cases, the causes both predisposing and exciting, have (as far as was in the author's power) been sought out and described, in order that a rational plan of treatment might be adopted,

PREFACE. IX for, without a perfect knowledge of the cause of a complaint, all treatment must be empirical.

The subject is illustrated with cases, which, it will be observed, have, with one exception, occurred in the public practice of a large hospital. The author has preferred giving such cases, because they have not only come under his own observation, but also under that of many others, who are, therefore, capable of bearing testimony as to their accuracy, if they should happen to fall under their notice.

Welbeck Street,

Cavendish Square.

Chapter I

Intimate connexion between the nervous and circulating systems — General description of the circulating system — Heart — Arteries — Veins — Capillaries — General description of the circulation — Action of the heart — Pulmonic and systemic circulation — Analysis of the blood — Properties of the blood during circulation, and after it is drawn from the body — Analysis of ha?matosine — Peculiarities of the red globules ; their importance in respiration and in the production of animal heat ; changes occurring in them during the conversion of arterial into venous blood, and vice versd — Assimilation, primary and secondary — General description of the nervous system — Membranes — Grey and white matter; their separate functions — Nerves — Sympathetic system ; its ganglia and nerves — Mode of communication between the sympathetic and spinal nerves — Reflex action — Mutual dependence of the nervous and circulating systems, the one upon the other p. 1

Chapter II

Nervous affections divided into centric and eccentric — Difference between the two — Cases — Centric affections may be either cerebral or spinal, and dependent either upon organic lesion of the nervous centres, or upon some temporary cause — Eccentric nervous affections, their nature and causes — Effect of mental

Xll CONTENTS.

emotion — Case — Poisons may be received from extraneous sources, or generated in the system itself ; both affect the nervous system secondarily — Cases — Experiments illustrating the difference between reflex action and the motions of irritability . p. 34

CHAPTER in.

Hysteria — Its symptoms — Difference between plethora and ansemia — Their effect upon the nervous system — Causes of hysteria both predisposing and exciting — Effect of hysteria upon the mind — Chorea — Difference between it and hysteria — Symptoms — Exciting causes twofold : local irritation and mental emotion — Case — Causes, both predisposing and exciting — True seat of chorea — Hypochondriasis, its symptoms — Causes, both predisposing and exciting — Prognosis of hysteria, chorea, and hypochondriasis — Treatment of hysteria, constitutional and local — Cases — Necessity of moral treatment — Treatment of chorea — Case — Treatment of hypochondriasis, constitutional and mora] . p. 05

Chapter IV

Epilepsy — Its symptoms — Causes, either centric or eccentric, as well as predisposing and exciting — Case — Complications attending epilepsy — Case — Seat of epilepsy — Prognosis — Treatment — Catalepsy and ecstasy, their symptoms and causes — Prognosis and treatment ... p. 112

Chapter V

State of collapes dependent upon shock of nervous system — Causes — Symptoms vary in degree according to the severity of the shock — It may terminate in healthy reaction, or be gradually or suddenly fatal — Treatment — Over-stimulation followed by excessive reaction — Delirium traumaticum, its symptoms and treatment — Case — Tetanus, divided into acute or traumatic, and chronic or

CONTENTS. XU1

idiopathic — Acute tetanus ; symptoms — Chronic tetanus ; symptoms not essentially different from acute form — Causes of tetanus — Tetanus infantium vel neonatorum — Causes — Prognosis — Post-mortem appearances — Treatment . . p. 140

Chapter VI

Nervous affections may depend upon a poisoned state of the circulation — Delirium tremens — Its symptoms when fully developed — Premonitory signs — Case — Difference between delirium tremens and phrenitis — Prognosis — Case — Appearauces after death — Symptoms of inebriation, ordinary and occasional effect — Causes of delirium tremens — Alcohol not absolutely essential for its production — Treatment — Hydrophobia — Case — Symptoms in the dog — Cause of the complaint — Necessity of prophylactic measures before the appearance of any symptoms .... p. 163

THE

CAUSES, SYMPTOMS, AND TREATMENT

ECCENTRIC NERVOUS AFFECTIONS.

Chapter I

Intimate connexion between the nervous and circulating systems — General description of the circulating system — Heart — Arteries — Veins — Capillaries — General description of tbe circulation — Action of the heart — Pulmonic and systemic circulation — Analysis of the blood — Properties of the blood during circulation, and after it is drawn from the body — Analysis of hsenmtosine — Peculiarities of the red globules; their importance in respiration and in the production of animal heat ; changes occurring in them during the conversion of arterial into venous blood, and vice versd — Assimilation, primary and secondary — General description of the nervous system — Membranes — Grey and white matter; tlieir separate functions — Nerves — Sympathetic system ; its ganglia and nerves — Mode of communication between the sympathetic and spinal nerves — Reflex action — Mutual dependence of the nervous and circulating systems, the one upon the other.

The connexion between the nervous and the circulating system is so intimate, that it is impossible for the one to be affected without the other suffering nearly at the same moment; of this we have almost daily examples, as for instance in concussion of the brain ; the cerebrum is here first

B affected by the blow, the heart's action is then immediately diminished in power, and syncope is the result; the same effect is produced by a blow on the pit of the stomach, from concussion of the solar plexus: and from either of these causes, if severe enough, the shock may be so great to the nervous system, that the heart is unable to regain its power from want of nervous influence, and the syncope is consequently fatal. These are striking illustrations, which cannot fail to attract the notice of the most casual observer ; but it is not to such as these that I wish to allude so particularly at present, as to that connexion which exists between those parts of either system, the most remote from their great centres. Previously, however, to doing this, it will be necessary to give a brief description of each system, more especially adverting to those points by which the present subject may be illustrated.

The circulating system consists of a propelling organ, the heart, and two sets of vessels, viz., the arteries, to convey the nutrient fluid, and the veins, to return that fluid after it has served its purpose. The heart is the great central organ of circulation, and is situated in the centre of the chest, between the two lungs ; its shape is conical, and its size variable, according to the sex, being a little larger in the male than the female. It is contained in a fibro-serous sac, called the pericardium, the external fibrous coat of which is con-

ECCENTRIC NERVOUS AFFECTIONS. o

nected superiorly with the coats of the large vessels entering and arising from the heart, and invests them for a short space; inferiorly, it is organically attached to the central tendon of the diaphragm, so that it cannot be separated; this is lined by a serous membrane, which covers the whole of its internal surface, passes with it on to the commencement of the great vessels, and is thence reflected over the external surface of the heart itself, forming a closed sac, the cavity of which is moistened by halitus, and after death, in the normal state, contains from one to two drachms of fluid. The heart itself is placed transversely across the chest, the base directed upwards and backwards towards the right side, the apex downwards and forwards towards the left side, where it may be felt at each pulsation, between the fifth and sixth ribs, just below the nipple. Internally the organ consists of four cavities, two auricles, and two ventricles, one auricle superiorly and one ventricle inferiorly on the right side, separated from the same on the left side by means of a vertical plane, the septum cordis. Superiorly, there is a right and left auricle, which are separated by a transverse plane, the tendo-cordis, from a right and left ventricle inferiorly. This tendo-cordis is pierced by an opening on each side to allow the passage of the blood from the auricles into the ventricles, both of which openings are guarded by b 2

4 CATJ8E9, SYMPTOMS, AND TREATMENT OF

valves, to prevent regurgitation. The heart consists of three coats ; an external serous coat, which is derived from the pericardium, a middle muscular, and an internal serous. This latter is continuous, on the right side, with the lining membrane of the veins, on the left with that of the arteries, and forms various reduplications which, with the additional interposition of fibrous tissue placed between their folds, constitute the valves.

Opening into the right auricle, superiorly and posteriorly, is found the vena cava superior, separated by a slight projection, the tuberculum Loweri, from the vena cava inferior, situated inferiorly and posteriorly. In the septum, between the auricles, exists a relict of foetal life, the fossa ovalis, surrounded by the annulus; the Eustachian valve extends from this, to the vena cava inferior, and serves, in the foetus, to direct the blood from that vein to the foramen, which then exists in the place of the fossa, thus enabling it to pass to the left auricle. Below the Eustachian valve is placed the opening of the coronary vein, in addition to which are numerous small openings, termed foramina Thebesii, which return the blood directly from the substance of the organ ; and lastly, there is the auriculo-ventricular opening, with its three tricuspid valves. The cavity of the right ventricle is exceedingly irregular, and has opening into it on the left side the pulmonary artery, protected by three semilunar valves. Arising from the sides, and continuous with the muscular fibres of the ventricle, are the columnse carneae, which terminate in the cordae tendineae — tendinous bands attached to the edges of the tricuspid valves, which they pull down when the ventricle contracts, and thus prevent regurgitation into the auricle. The left auricle has opening into it posteriorly the four pulmonary veins ; it has also the foramina Thebesii in its parietes, and in the septum the valve which closes the foramen ovale. The left ventricle is much thicker and stronger than the right, but its cavity is smaller and less irregular; the aorta opens from it on the right side, protected by three semilunar valves; it has also columnse carneae and cardae tendineas attached to the mitral valve, which they pull down, and thus close the auriculo-ventricular opening.

There are two sets of vessels, the arteries and the veins, the lining membrane of each being continuous with that of the heart, the arteries with that of the left side, the veins with that of the right. Arteries originate in large trunks, which divide and subdivide, by degrees, into minute ramifications, whereas veins commence in small radicles, gradually coalescing to form larger trunks; arteries convey the blood from the heart to the lungs and the system, veins return it from the lungs and the system to the heart.

Between the ultimate ramifications of the arteries and the commencing radicles of the veins we find the capillaries, an exceedingly minute set of vessels, in which, nevertheless, some of the most important functions of the animal economy are performed. The arteries terminate in, and the veins commence from them ; but the arteries pass so insensibly into veins, that these vessels can scarcely be considered as a distinct set, though generally described as such ; they, however, possess this peculiarity, that they maintain the same size throughout, and, consequently, the circulation in them is equable ; they anastomose freely in every part of the body. Secretion, excretion, and assimilation take place in them, and in them animal heat is evolved; in the systemic set, the arterial blood becomes changed into venous, whereas, in the pulmonic, the venous blood is regenerated, and again converted into arterial.

The circulation, in the normal state, is conducted in the following manner: the two ventricles contract simultaneously, and at the same time that the two auricles dilate, and vice versa. When the contraction of the ventricles takes place, the cordae tendineae are put on the stretch, and the tricuspid and mitral valves pulled down over the auriculo-ventricular openings, the venous blood in the right ventricle is propelled through the pulmonary artery to the lungs, and in the capillaries here situated the necessary changes take place by endosmosis and exosmosis ; the carbonic acid is exhaled through their coats, and passes off in expiration, the blood, at the same time receiving its supply of oxygen from the inspired air, is thus rendered fit for distribution to the system ; it now passes through the ramifications of the pulmonary veins to their four main trunks, by which it is returned, as arterial blood, to the left auricle. This portion of the heart, then, i. e., the right ventricle and left auricle, may be termed the pulmonic portion, being entirely connected with the pulmonary circulation, whereas the general circulation of the system is conducted by the left ventricle and right auricle, which may, therefore, be called the systemic portion. The arterialized blood, then, dilates the left auricle at the same time that the ventricle below is contracting ; having done this, the auricle contracts, and causes it to pass through the auriculo-ventricular opening into the left ventricle, which it dilates, the same process going on simultaneously in the right side; the left ventricle again contracts, and sends the arterial blood along the aorta, and thence, by means of the various arterial ramifications, to the system at large ; here, having served its purpose, it becomes, in the systemic capillaries, converted into venous blood, passes through the numerous veins to the superior and inferior venae cava?, by which it is conveyed to the right auricle ; having dilated this cavity, it in its turn contracts, and propels the blood into the right ventricle, from whence it is passed to the luno-s, to be again regenerated, as before described.

From this brief view, we see that the pulmonic circulation is carried on simultaneously and in equal ratio with the systemic ; the two ventricles contract together, the right propelling the venous blood to the lungs, the left the arterial blood to the system ; at the same time that this is happening, the two auricles dilate, the right to receive the venous blood from the system, the left the regenerated arterial blood from the lungs; they, in their turn, contract together, while the ventricles dilate, and thus the equilibrium of the circulation is maintained.

Having thus briefly described the process of circulation, the next thing to be considered is the nature of the circulating fluid itself. The following is the analysis of blood, according to Lecanu :

Water

Fibrine

Albumen

Colouring matter (globules)

Fatty crystallizable matter

Oily matter

Extractive matter soluble in water and alcohol

Albumen combined with soda

Chloride of Sodium \

Chloride of Potassium

Carbonates .

Phosphates ( of Potass and Soda

Sulphates }

Carbonates of Lime and Magnesia

Phosphates of Lime, Magnesia and Iron

Peroxide of Iron

Loss

.. 780-14.')

... 65-090

... 133-000

2-430

1-310

1-790

1-205

8-370

2-100 2-400

100-000

The blood, while circulating in the living body, is divided into two parts — a fluid portion, termed the liquor sanguinis, and a solid portion, consisting of the corpuscles. When drawn from the body, and allowed to stand for a certain time, it separates itself spontaneously into a solid portion, the clot or crassamentum, and a liquid part, the serum. The liquor sanguinis differs from the serum by containing fibrine in solution, which, on the removal of the blood from the body, contracts, and in so doing entangles the globules, by which means it separates them, together with itself, from the serum, and constitutes the clot. The red globules contain an animal principle, termed haematosine, which possesses, as one of its ingredients, an oxide of iron, which is a substance peculiar to itself, and not found elsewhere in the animal system. Haematosine cannot be entirely isolated and separated from the albumen which exists in the colouring matter, and, therefore, a perfectly correct analysis cannot be obtained : the following is one according to Mulder :

Carbon 6C4

Hydrogen

Nitrogen

Oxygen...

Iron

5-30 10-50 1105

According to Liebig, the globules themselves take no share in the process of nutrition, though b3 they play an important part in the process of respiration, as well as in the production of animal heat. They contain an oxydized compound of iron, which may be proved by obtaining oxide of iron from the dried clot, on carefully adding sulphuric acid ; or the same result may be obtained on digesting the dried and pulverized clot with dilute hydrochloric acid, while peroxide of iron is produced by the addition of excess of chlorine to the solution thus obtained.

Now, compounds of protoxide of iron take up oxygen from other oxydized compounds, while oxygen is given up with the greatest facility by compounds of the peroxide. Hydrated peroxide of iron, in contact with organic matters destitute of sulphur, is converted into carbonate of the protoxide. Carbonate of the protoxide of iron, in contact with water and oxygen, is decomposed : the carbonic acid is given off, oxygen is absorbed, and it is converted into the hydrated peroxide, which may again be converted into a compound of the protoxide.

Iron

Atoms.

... 1 ... ... 1 ...

Eq. Wt.

... 28 ...

... 8 ...

Per cent.

... 77-8 222

Protoxide of Iron ...

... 30 ...

... 1000

Iron

... 1 ...

... 1* ...

... 28 ... ... 12' ...

... 70 ... 30

Peroxide of Iron ...

... 1 ...

... 40 ...

... 100

Atoms Eq. Wt. Per cent.

Protoxide of Iron 1 30 02

Carbonic Acid 1 22 38

Protocarbonate, or Car-"i

bonate of the Proton- [ 1 08 100

ide of Iron

Carbon 1 27-27

Carbonic Acid 1 22 100-00

The globules, then, of the arterial blood contain a compound of iron saturated with oxygen, which they lose in their passage through the capillaries. The compound, rich in oxygen, passes, by the loss of oxygen, into one far less charged with that element. One of the products of oxydation formed in this process is carbonic acid. The compound of iron in the venous blood possesses the property of combining with carbonic acid, and the globules of the arterial blood, after losing a portion of their oxygen, will also combine with that gas if they meet with it. On reaching the lungs, they again take up the oxygen they have lost, and again acquire the power of giving off that gas. The globules of the arterial blood, in their passage through the capillaries, afford oxygen to certain constituents of the body, they then, having lost their oxygen, combine with carbonic acid, and produce venous blood ; on reaching the lungs, the compound of iron existing in the venous blood recovers its oxygen, the carbonic acid is separated by this absorption of oxygen and expired.

Whenever a rare body becomes condensed, a diminution of capacity takes place, and heat is evolved ; but, on the other hand, when a dense body becomes more rare, there is an increased capacity for heat, which is therefore absorbed, and becomes latent. The venous blood, on reaching the lungs, gives off its carbonic acid, and absorbs an equal volume of oxygen, by which means the blood is arterialized. The arterial blood is lighter, and contains more heat than the venous, because it contains a light gas, oxygen, instead of the denser one, carbonic acid. This arterial blood, having passed to the capillaries, loses its oxygen, absorbs carbonic acid, and becomes venous, animal heat at the same time being evolved. We see, then, that the globules of the blood, though they take no share in the process of nutrition, nevertheless perform several most important functions ; by their instrumentality, that most essential element, oxygen, is absorbed from the atmosphere, and conveyed to the capillaries, there to play its allimportant part in the animal economy ; by their means (having yielded up their oxygen), carbonic acid is absorbed, conveyed to the lungs, and there exhaled, thus disposing of the effete principles of the body produced by the oxydation of its various tissues, during which process of oxydation animal heat is evolved.

The processes of assimilation are so intimately connected with the circulation, and will have so often to be referred to hereafter, that it will be as well to allude to them in this place ; they have been divided by Prout into two classes, the primary and the secondary. The primary includes the whole process of digestion up to sanguification, or the conversion of the chyle into blood ; the, secondary includes all those stages which take place subsequently to this, the formation of the various tissues from the blood, and their final dissolution and removal from the system.

All alimentary substances may be divided into four classes — viz., aqueous, albuminous, oleaginous, and saccharine. Water performs a most important part in the animal economy, being essential to both processes of assimilation. It is necessary, for the process of digestion, that all alimentary substances should, in the first instance, be reduced to a liquid state — this is accomplished by their combination with water in the stomach, and is said to be brought about by the agency of the gastric juice. The water, having thus become combined with the alimentary substances — or rather with that part of them destined to serve the purpose of nutrition — is then, by degrees, removed, as the chyle passes through the lacteals, and approaches more nearly in its properties to those of the blood.

The albuminous aliments are principally deprived from the animal kingdom, and are all of them azotized substances — that is, they possess nitrogen as one of the elements entering into their composition.

The oleaginous alimentary bodies are sometimes solid as fat, or liquid as oil, and are insoluble previously to their entering into combination with the alkali of the bile.

The saccharine elements are principally derived from the vegetable kingdom, in contradistinction to the albuminous, and are, as well as the oleaginous, non-azotized substances, not possessing nitrogen as one of their elements.

The food, having been converted into chyme in the stomach, by the action of the gastric juice, passes through the pyloric orifice into the duodenum, as a grey pulp, with an acid reaction. In the duodenum, the chyme meets with the bile and the pancreatic juice, and is converted into an excrementitious and a nutritious portion, which latter is termed chyle. The soda contained in the bile neutralizes the acid of the chyme, and gives it an alkaline reaction, at the same time saponifying, and thus rendering soluble, the oily principles of the food ; the biliary resin is set free, and acts as a stimulus to the muscular coat of the intestines. The nitrogenous principles of the bile,picromel, &c, according to Prout, impart animalization to those particles of the food which are capable of it, but deficient in nitrogen, and thus convert them into incipient albumen. The chyle thus formed appears on the surface of the mass, and is absorbed by the lacteals ; it is thence conveyed between the layers of the mesentery, and passes through the vasa inferentia to the mesenteric glands, from which it is carried away by the vasa efferentia to the receptaculum chyli, on the body of the second lumbar vertebra. Having arrived at the receptaculum chyli, it receives the lymph from the lower extremities, then passes along the thoracic duct, and at the junction of the internal jugular, with the subclavian vein on the left side, it enters the circulation — the two currents from the subclavian and jugular veins ensuring its mixture with the blood. It now passes to the right side of the heart, and is sent from thence with the venous blood to the lungs ; here it meets with atmospheric air, and undergoes its final change, becoming inseparably mixed with the circulating fluid.

The chyle is a white-coloured, alkaline fluid, when first taken up by the lacteals, and contains albumen in an incipient state, which does not, like the albumen of the blood, coagulate spontaneously, but will do so on the application of heat. There are several important points in which the chyle differs from the blood ; when first formed, it does not coagulate spontaneously, possesses no fibrine, has no coloured corpuscles, and the albumen which it contains is in an incipient state. These are its qualities until it arrives at the mesenteric glands ; after passing these, it contains some fibrine, coagu-

16 CAL'SES, SYMPTOMS, AND TREATMENT OF

lates spontaneously, though imperfectly, and assumes a pinkish colour. Animalization of the chyle occurs then at three different stages — firstly, through the intervention of the nitrogenized principles of the bile, albumen is formed ; secondly, fibrine is added in the mesenteric glands ; and thirdly, nitrogen is absorbed from the atmospheric air in the lungs.

The secondary assimilation is divided into the formative and destructive ; the former includes all those steps by which the principles of the blood are converted into the various tissues and secretions ; the latter includes those processes by which the tissues thus formed become extinct, and converted either into new principles, for ulterior purposes, or into disorganized substances, which are eventually removed from the system.

The principal secondary assimilating processes of the formative kind consist of gratification, or the conversion of a portion of the albumen contained in the blood into the solid gelatinous tissues ; albumification, or the conversion of another portion of albumen of the blood into the solid albuminous tissues; and fibrification, or the conversion of the fibrine of the blood into solid muscular fibre. These changes take place in the capillaries simultaneously with the conversion of the arterial into venous blood ; and during the conversion of albumen into gelatine, carbonic acid is given off, to be absorbed, as before described, by the corpuscles of the blood, which have yielded up their oxygen.

This process of gelatification, though serving, as well as the two others, for the nutrition of the body, is concomitant and intimately connected with the evolution of animal heat, and the conversion of arterial into venous blood. Again, referring to that law by which the transition of a light into a denser body causes an evolution of heat, we may suppose that the solidification of these fluid principles of the blood is also a source of animal heat, and though the changes in the blood corpuscles perform a great, if not the most important part, still it must be borne in mind that the two processes are so intimately connected together, that the one cannot be carried on without the other.

The formation of bone, horn, hair, &c, is principally connected with gelatification, while the various fluid secretions, as the saliva, the gastric juice, semen, &c, are derived from the albuminous and oleaginous principles.

Examples of the secondary assimilating process of the destructive kind may be taken in urea and lactic acid, formed from the effete parts of the gelatinous tissues, as well as lithic acid, formed from the albuminous principles.

With regard to the changes which the oleaginous matters undergo, there is a difference of opinion between Prout and Liebig; the former says — "That the oleaginous principles may be converted into most, if not all the matters necessary for the existence of animal bodies, seems to be proved by the well-known fact, that the life of an animal may be prolonged by the appropriation of the oleaginous and other matters contained within its own body." Again, in speaking of the secondary assimilating process of the destructive kind, he says — " Of the ulterior changes of the oleaginous principles, we know still less, perhaps, than of either of the other staminal principles. The large proportion of oleaginous matter which enters into the composition of the nervous mass, shows the important part which oleaginous matters perform in the animal economy ; and the disappearance of fat during the process of hybernation, and under many other circumstances, indicates that this principle is most extensively appropriated during the secondary destructive assimilating process."