1846.] Treatment of Apoplexy. 45 periments, very considerable. In deciding upon the propriety and extent of bloodletting, Dr. Burrows lays the greater stress upon the importance of the indications derivable from cardiac auscultation. Without this, the condition of the pulse will be found in many cases to be very perplexing. If no disease of the heart can be discovered, or if this consist in simple hypertrophy, depletion may be carried as far as the cerebral symptoms demand. "But, suppose the examination of the heart discloses the existence of valvular disease to the extent of obstructing the circulation through its cavities, here the pulse will be a most deceptive guide as to the propriety or impropriety of abstracting blood. If the mitral valve be principally implicated, and allow of regurgitation from the left ventricle, the small and irregular pulse so commonly observed with that lesion, would probably dissuade from the free abstraction of blood which the cerebral symptoms might require. If, in another case, the aortic valves be found diseased to the extent of not only obstructing the onward current of blood, but also of allowing regurgitation into the ventricles during its diastole, there will propably be associated with this lesion considerable hypertrophy of the left ventricle. Here will be observed a full and vibrating or thrilling pulse, but a pulse of increased action without real power, and hence a deceptive pulse; and one which, if it be regarded without reference to the struc tural changes of the heart, would invite to a more copious abstraction of blood than was called for by the general symptoms. In each of these last-mentioned cases greater relief to the symptoms will be obtained by a free local abstraction of blood from the vicinity of the heart (either by cupping from beneath the left mamma, or between the left scapula and spine) than by a much larger depletion by venesection." P. 142. Auscultation would also dissuade us from large depletion, notwithstanding a hard and full pulse, if by it we detected serious valvular disease or ossific deposits. In other cases we may find dilatation of the cavities of the heart and extensive emphysema of the lungs, and be deterred from aggravating by large depletion the condition of the heart which has induced the cerebral congestion, notwithstanding that great congestion and dyspnoea may be present. "I should suggest the employment of cuppingglasses to the nape of the neck, or between the scapula, with the internal administration of stimulant diuretics, diffusible stimulants, and the application of rubefacients to the sternum." 2. The treatment during the Stage of Cerebral Excitement supervening soon after the seizure. The pain in the head, flushing of face, knitting of brow, &c., together with the more active condition of the circulation, which supervene after recovering from the depletion, &c., employed during the attack, are symptomatic of inflammation commencing around the effused clot, and are generally markedly relieved by local depletion, application of cold, purgatives, spare diet, and quietude. When the heat of scalp has subsided, a blister to the occiput relieves the oppressive headache; and if the patient be not very aged or much exhausted, small doses of mercury, short of inducing ptyalism, are useful. Together with the above symptoms, or after they have disappeared, the patient may be subjected to a spasmodic and distressing neuralgic condition of the palsied limbs. The author has tried numerous local remedies for these severe pains, but with little success. When symptoms of remaining cerebral irritation have continued, he has found slight local depletion from the head and evaporating lotions to the limbs the most useful proceeding, and where symptoms of cerebral irritation have been absent, leeches applied to the limb itself have proved serviceable. 3. Treatment of Paralysis following Apoplexy.—When patients have suffered only a slight attack, or have been quickly relieved by prompt treatment, they sometimes incautiously are allowed to put themselves too fast forwards (although still suffering from the palsy,) as regards getting up, mental occupation, diet, &c. In this way, they endanger the produc tion of a fresh extravasation, before the first one is encysted, and the softened brain has recovered its consistency and excitement or inflammation, and consequent disorganization of the cerebral substance may too be induced. Some cases illustrative of the ill effects of such imprudence and incautiousness are related. When sufficient time has been allowed for the restoration of the cerebral substance to its normal condition, we may proceed to endeavour, by means of counter-irritants, to excite the suspended functions of the nerves of the palsied limbs. These are sometimes useful, and always sure to employ the attention of the patient. Dr. Burrows thinks little of the utility of electricity, and still less of that of strychnia, which indeed sometimes changes the wearing pains of the limbs into acute suffering. Regular fric. tions and well-devised exercises of the limbs are useful. Functional Disturbance of the Brain, induced by Diseases of the Heart.— Not only may cardiac disease give rise to the serious and fatal lesions of the brain now adverted to, but to various other symptoms indicative of disturbed cranial circulation. "Recurring attacks of vertigo, headaches, rushing of the blood to the head, epistaxis, somnolency, nervous irritation, and even insanity, may often be traced to the operation of cardiac disease, which has not attracted the notice of the patient or his medical attendant." Dr. Burrows relates several cases of epistaxis dependent upon the disturbed state of the circulation consequent on heart-disease. The congestion of the cerebral vessels so induced may, in one case (or at different periods of the history of the same case,) give rise to an epistaxis, and in another to an internal hæmorrhage. "If the foregoing observations be correct, they impart an additional significance to the occurrence of epistaxis, which is often regarded as an isolated and unimportant symptom. This hæmorrhage may, I believe, often be considered as strictly pathognomic of an obstructed circulation through the heart, as hæmoptysis is symptomatic of tuberculated lungs, or intestinal hæmorrhage of an indurated liver." Dr. Latham first called the author's attention to another class of cases manifesting various cerebral symptoms the chief of which is headache, and in whom the original cause of the symptoms is hypertrophy of the heart without valvular disease. These persons have usually been spirit-drinkers; they are liable to profuse hæmorrhages, and ultimately become the subjects of general dropsy. Their faces are usually pallid, and their pulse peculiarly hard and incompressible. Corvisart has forcibly alluded to the aggravated forms of disturbance of the mental and other cerebral functions which attend aggravated diseases of the heart, plunging the patient into despair, and sometimes leading him to suicide. 1846.] AFFECTION OF THE BRAIN IN PERICARDITIS. 47 Affections of the Brain and Spinal Cord dependent upon Acute Diseases of the Heart.-The observations hitherto made apply only to the chronic structural changes of the heart; but acute diseases of this organ may also give rise to symptoms so indicative of severe affections of the nervous centres, that the primary cardiac affection may be entirely overlooked even by experienced observers. Several of such cases have been published from time to time, but Dr. Burrows is the first who has assembled any number of them (sixteen) together, and endeavoured to connect them by a satisfactory explanation in extension of the principles already laid down. They consist of examples of rheumatic or idiopathic pericarditis or carditis in which the symptoms were those of inflammation of the brain, delirium, myelitis, insanity, coma, chorea, or tetanus. In respect to this last order of morbid manifestations, Dr. Burrows observes that it behoves us, in idiopathic trismus and tetanus, the pathology of which is so obscure and the treatment so unsuccessful, to carefully examine for this source of eccentric irritation. "It is a melancholy reflection, but I fear a just one, that numbers have perished from these supposed diseases of the spinal cord, when in truth the morbid action has been in the heart, although that has not been detected." Dr. Bright has already (Med. Chir. Trans., vol. 22) signalized the frequent occurrence of chorea as a result of rheumatic pericarditis. Dr. From the detail of these cases it is evident that "the most formidable diseases of the brain and spinal cord may arise from irritation of the nerves of the heart, without any structural change in the nervous centres them. selves." Some have supposed that they only occur in connection with rheumatism and its consequent pericarditis; but of the 16 cases here detailed, no rheumatic affection existed in seven. In two or three the pericarditis was idiopathic, and in the others came on in the course of various chronic diseases. Dr. Burrows, without denying the possibility of metastasis to the encephalon, states that, in no one of the 11 fatal cases enumerated was any trace of disease of the brain or its membranes discernible; and in four fatal cases recorded by Dr. Watson, an accumulation of serum beneath the membrane was the only morbid symptom discovered. Bright, remarking that in the cases of chorea induced by pericarditis, inflammatory action was found on the exterior of the pericardium, as well as on the pleura, infers that the phrenic nerve distributed over these parts is the medium of communicating the irritation to the spinal cord. M. Bouillaud likewise has observed that the nervous disturbance in pericarditis especially occurs when this affection is complicated with diaphragmatic pleurisy. Such cases are, however, not necessarily attended with nervous excitement; while Dr. Burrows has observed a few intances of pericarditis unconnected with pleurisy, in which such existed. Dr. Hope refers the peculiar expression of features attendant upon bad cases of pericarditis to the propagation of the irritation through the pneumogastric nerves to the spine, and its reflection hence to the face through the portio dura. Dr. Watson explains the nervous disorders in these cases simply by the disturbed state of the cerebral circulation induced through the embarrassment of the heart's action by the inflammation of its tissues. "In collecting and collating the foregoing examples of endocarditis and pericarditis, my object has been to draw attention more closely to a class of cases, the real nature of which is so likely to be overlooked; and to enforce the neces sity of an early examination of the heart by means of auscultation, in all obscure and intractable affections of the brain and spinal cord. The advantages of such an examination are rendered very conspicuous by a comparison of the relative mortality of the cases where the cardiac disease was detected, and of those where it was not suspected during life. Of the 16 recorded cases, 11 proved fatal, and only 5 recovered. In 4 of the successful cases the diagnosis of cardiac disease was satisfactory, and only suspected in the 5th. In only 2 of the 11 fatal cases was an affection of the heart detected during life, in 1 it was suspected, and in the remaining 8 cases there was no suspicion of acute disease of the heart until it was revealed by examination after death. "I shall conclude this section with some observations upon the treatment of these cases. It appears that only 5 of the 16 terminated favourably. In 4 the cardiac disease was detected at an early stage, and remedies employed to control the exciting cause of the nervous symptoms. These remedies were the abstraction of blood by venesection, and by cupping from the region of the heart, the application of blisters over the cardiac region, and the free administration of mercury combined with opium, so as to produce mercurial affection of the mouth. In two other cases the disease of the heart was indeed detected during the life of the patient, but nevertheless it ended fatally. It will be instructive to inquire into the cause of the want of success in the treatment of these two. In the one, although a slight affection of the heart was discovered on the day of the patient's admission, still it was not until two days afterwards, and only 24 hours before the boy's death, that the physical signs indicated the existence of pericarditis, and it was only from that period that the active remedies above described were employed to subdue the cardiac inflammation; but they proved ineffectual. Upon the other occasion the pericarditis was only discovered the day before the patient's death, when his system was already exhausted by general dropsy of some weeks' duration, and by five days' continuance of the peculiar urgent nervous symptoms which sometimes indicate the presence of active cardiac inflammation. The want of success in the treatment of these two cases is sufficiently accounted for by the late period at which the cardiac disease was detected." P. 214. The very complete analysis we have presented of the contents of this work supersedes any lengthened statement of the value we attach to these. Our readers are in a condition to judge for themselves, and we much mistake if they do not pronounce their verdict in favour of the author. That he has ably expounded an important physiological principle, and exhibited a too neglected pathological condition is plain enough, and the only difference we have with him is one of degree. Like most observers whose attention has been directed to some particular subject, he perhaps extends the application of his doctrines to a larger proportion of cases than a farther investigation will warrant. When too we observe so many instances of heart-disease, the subjects of which manifest no cerebral symptoms whatever, we feel the necessity of caution lest we sometimes mistake a mere coincidence for cause and effect: and we believe that apoplexy is more frequently dependent upon a local diseased condition of the blood-vessels or cerebral pulp than the author seems willing to admit. However, there can be no doubt the connexion of the lesions is in many cases such as he represents it; this forms an important fact always to be borne in mind in the management of such, although the frequency of its occurrence may not be as yet determinable. We can, however, scarcely allow that the attention of well-informed practitioners has not of late been considerably directed to the production of head symptoms by heart-disease, as this has now been an established doctrine for some time past in our medical schools. 1846.] ON INSANITY. 49 I. DE LA FOLIE, CONSIDÉRÉE SOUS LE POINT DE VUE PATHOLOGIQUE, PHILOSOPHIQUE, &C., &c. Par L. F. Calmeil, D. M. P. Paris, 1845. On Insanity, considered in a Pathological, Philosophical, Historical, and Judicial point of view, from the Revival of Learning in Europe until the Nineteenth Century. By L. F. Calmeil, Physician of Charenton. Two Vols. 8vo. pp. 1050. Paris, 1845. II. AN ACT (8 & 9 Vic., c. 100) FOR THE REGULATION OF THE III. OBSERVATIONS AND ESSAYS ON THE STATISTICS OF INSANITY. October, 1845. V. A LETTER TO LORD ASHLEY, M. P. By W. B. Costello, M.D. 1846. VI. CLINICAL LECTURES ON THE PRINCIPAL FORMS OF INSANITY. By John Conolly, M.D. (Publishing in the Lancet.) VII. ANNUAL REPORT OF THE MANAGERS OF THE NEW YORK STATE LUNATIC ASYLUM. By Amariah Brigham, M. D. 1845. THE above publications treat of the past, present, and future condition of the Insane, upon each of which points we are desirous of offering a few remarks. It would be surprising indeed, if, amid the now generally prevalent disposition to search out for the causes and means of relieving the social, moral, and physical evils which afflict the unfortunate, the cause of the Lunatic, the most helpless of all sufferers, were forgotten. That happily this is not the case the labours and devotion of so many highlygifted individuals throughout Europe and America, the progressive melioration of his condition, the warm sympathy with which the public has watched the various attempts at accomplishing this, and the readiness with which our Government and Legislature have so recent'y accorded most extensive means for future improvements, combine to prove. The history of the management of the insane presents but a humiliating picture of human intelligence and progress. It does not seem that any provision for even their safe-keeping existed prior to the Reformation, and long after the establishment of "Bedlam," indeed to comparatively modern times, the more harmless were allowed to roam about, objects of the jest, contumely, and cruel treatment of the thoughtless and ignorant; while such as manifested dispositions for violence or insubordination, were subNo. 105. 4 |