1847]

Principles of Treating Insanity.

299

morbid anatomists, although indicated by the most unequivocal symptoms. Mr. Solly has added an interesting communication from Dr. Peacock, confirmatory of several of Dr. Bennett's researches, and from which we extract the following conclusions :

:

"1st. That in all cases where characteristic symptoms of softening of the brain are present during life, evidences will be found, on microscopic examination, of the extravasation of lymph into the cerebral substance under one or other of the several forms of the so-called exudation granules, corpuscles, or

masses:

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2ndly. That the appearance of portions of the brain softened after death, either artificially, by manipulation, or from post-mortem change, often, to the naked eye so closely resembles the genuine results of disease as to render it extremely difficult, if not impossible, for practised morbid anatomists to decide between them: and

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3rdly. And consequently that portions of brain, presenting every appearance of softening to the naked eye, but in which the microscope does not reveal the presence of some form of exudation, intermixed with the broken-up cerebral substance, cannot, in the present state of our knowledge, be regarded as having resulted from any diseased process during life." P. 388.

We are happy to find Mr. Solly advocating a principle for which we have always contended, namely, "that every decided deviation from the normal action of the brain is always found to correspond to some alteration of structure." The progress of minute observation, joined to a more just appreciation of the relations existing between the vital actions and the instruments by which they are produced, will doubtless explode the unphilosophical notion that such a thing as a pure functional disease can exist in any part of the body. Lest it should be supposed that this is a mere speculative question in which the practitioner has no concern, we would submit to our readers the following important observations, which coming from a scientific surgeon, who has enjoyed extensive opportunities at Hanwell and elsewhere, of inspecting the brains of lunatics, are deserving of the most serious attention.

"I have long felt convinced," remarks Mr. Solly, " that much of the obscurity which envelopes these diseases and those of other parts of the brain, might be removed by comparing them with diseases of the eye; viewing them through the light which the observation of this interesting class of affections affords us. I do not refer so much to acute disease as chronic, though both are useful as instructors. One great reason why these affections of the eye ought to guide us in our treatment and prognosis of inflammation, both chronic and acute in other organs, is the facility with which we can observe the action of remedies, medicines, topical applications, general stimulants, and diet, upon an organ so open to observation. I believe that every form of mental derangement is dependent on some change, though often very slight and temporary, of the vital condition of the hemispherical ganglion.

"I am convinced that the reason why physicians, to whom the treatment of the insane has been entrusted, believe in the existence of mental disease unattended with disease of the instrument which the mind employs in its communications with the world, is because the medicine, both constitutional and local, has so little controul over these diseases, and the great good to be derived from moral treatment. A knowledge of the treatment of diseases of the eye would teach them a different lesson. Let any man ignorant of the treatment of ophthalmic diseases attempt the cure of a case of strumous ophthalmia; he would, in all probability, seeing the red, inflamed conjunctiva, the pain suffered by the patient,

and the distress occasioned by the presence of light, employ all the most approved antiphlogistic measures. He would bleed from the arm, purge violently, and then possibly put his patient under the influence of mercury. What would be the consequence? Why, most assuredly the loss of the eye, total blindness. And the same sad results followed the treatment of insanity when it was considered to be an inflammation of the brain, except in very acute cases occurring in subjects with much constitutional power; injudicious treatment being attended in the one case with the loss of sight, in the other with the loss of intellect. But suppose a judicious surgeon, one bred in the school of Farre, Travers, Lawrence, and my late respected colleague, Frederic Tyrrell, called upon to treat this strumous inflammation of the eye. He would support his patient's general health with a tonic plan of treatment; he would improve the condition of the circulating fluid and the instruments which circulate it. He would endeavour to arrest local inflammation by small local blood-lettings, counter-irritants, and astringent lotions, by removing him from all those atmospheric influences and moral circumstances which would stimulate the organ. And thus he might ultimately succeed; but what care, what patience, and what confidence in the remedial agents employed, does it require on the part of the surgeon who treats these cases, to effect a cure!

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If, then, it is so difficult to subdue an inflammation in an organ, the actual condition of whose blood-vessels we can view, to which we can actually apply local remedies, and from which we can withdraw the injurious agents which have produced this inflammation, and exclude the natural stimulus of the organ, and see, in the whole course of our remedial measures, the progress or the failure of each particular plan of treatment, is it astonishing that men should have failed so much in the treatment of chronic and strumous inflammation of the arachnoid, pia mater, and hemispherical ganglion, when they have all these difficulties to contend with, and want many of the adjuncts?" P. 478.

We very much regret that our limits will not allow us to notice the valuable sections treating on apoplexy and convulsive affections; they are eminently of a practical character and merit the careful perusal of every surgeon and physician. For the same reason, we can only briefly refer to the interesting discussion of the author on the nature and treatment of that most intractable affection, epilepsy. As to the seat of the disease, Mr. Solly dissents from the doctrine of Dr. M. Hall, that it is the true spinal cord; being convinced that the brain and not the spinal cord, is primarily affected." With respect to the pathology of epilepsy, we have the following theory:

"The first morbid action is a sudden determination of blood to the brain, which expends itself, in the secretion of that nervous power which, in a state of health, is employed by the brain to convey volition to the muscles, and which power is, I have no doubt, identical with electricity. This excessive secretion is carried off by the motor nerves, like a discharge from an electric battery, and, from its quantity and excess, produces excessive action of the muscles. It is another illustration of a law that we had occasion to decide upon already, namely, that the first effect of arterial excitement in every secreting organ is to excite to an unnatural degree the natural function of the organ. We know that mental emotion will cause a sudden determination of blood to other organs, which, according to the nature of the part, will be followed or not by secretion.

"Blushing and erection of the penis are instances of sudden determination of blood to a particular part. And the lachrymal glands, salivary glands, testicles, prostate gland, gastric glands, and even the kidneys, often pour forth their secretions so abundantly and so suddenly that the formative fluid, the blood, must have circulated through their capillaries in greater quantity and with greater

1817]

Pathology of Epilepsy.

301

rapidity than when the glands were at rest, and their secretions suspended. I think that the periodic attacks of mania, with which many of the insane are afflicted, may be regarded in this light." P. 591.

In connexion with this point, the author thus explains his views as to the condition of the blood-vessels in congestion :

"The expression determination of blood to the head' is often made use of, but without any explanation of the manner in which this takes place. I doubt whether the profession generally have any distinct idea as to the exact condition of the vascular system which produces it. I would venture to offer the following theory, the first idea of which I certainly derived many years ago from that most truly philosophical work, the Elements of Physics, of Dr. Arnott. It applies not merely to the head, but everywhere else. The middle or muscular coat of the arteries in a state of health contracts with each systole of the ventricles just sufficiently to give a solidity to the wall of the pipe, so that the force of the contraction is not lost on a yielding surface. A much greater force is required to drive water through a leather hose than through a leaden tube. The middle coat contracts just sufficient to assimilate the artery physically and temporarily to the leaden tube. Arteries with permanently rigid walls, like leaden tubes, would have interfered by their rigidity with the motions of the limbs; and hence this beautiful contrivance. When this middle coat does not contract, or only contracts imperfectly, then the force of the heart dilates the tubes, and produces congestion. "I believe then, that determination of blood to the head arises simply from deficient contraction of the muscular coat of the capillaries of the brain, preceded by excitement of the heart's action." P. 592.

The reader will understand from these extracts, that the author regards the essential cause of epilepsy to be a congestion of the arteries and capillaries of the brain, the venous turgescence, which has been noticed by so many writers, being merely the result of the previous arterial accumulation. (p. 595.) In another part of the work, the resemblance of that troublesome affection commonly called 'catchings of the limbs' to epilepsy is pointed out; the cause is thus stated:

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"Worry in business, mental anxiety, and vexation of spirit, will sometimes bring on spasmodic action of the muscles, and paralysis. In some cases the anxiety and mental irritation induces disease in the hemispherical ganglion, seriously affecting the temper, but not affecting the intellect. Such cases are familiar to all practical men, but it is very difficult to explain their pathology. suppose that the disease or diseased action excites unnaturally the tubular neurine, which, commencing in this ganglion as the motor tract, conducts the will to the muscles; and the consequence of this excitement is an irregular supply of stimulus to the muscular system exhibited by the twitchings and spasms. This irregular action the mind can more or less control and arrest when awake; but as soon as sleep takes place, then the spasms commence. I suspect that epilepsy, is a form of this irregular innervation, only that in epilepsy the nervous or electric fluid accumulates in undue quantity, and passes off in a large quantity at once, like the discharge of an electric battery. In many cases of epilepsy, the discharge takes place in small quantities both before and after the complete fit. I have two patients under my care now who suffer seriously in this way: one, a single man, has always warning of the advent of the fit by twitchings of the right leg as soon as he drops off to sleep; the other, a married man, has these twitchings so constantly in bed, that his wife is often kept awake during a whole night. In the non-epileptic cases, though electric fluid is secreted in undue quantities, still it does not accumulate, so as to produce a complete convulsive fit, but is constantly oozing out." P. 444.

NEW SERIES, NO. XII.--VI.

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The fact here noticed that the twitchings usually come on as soon as the person falls asleep, is a strong corroboration of the theory, which attributes all convulsive actions to the true spinal system. We are acquainted with a family, several of the members of which are peculiarly subject to these "catchings," and in all they principally occur during sleep.

But to return from this digression. Mr. Solly subsequently adduces several arguments, to prove that the brain is in a state of congestion during the fit: thus he has always seen a flushing of the face previous to the convulsive paroxysm," previous, as he believes, to the discharge of the electric fluid in those epileptics who were full-blooded and plethoric;" then the amazing benefit he has seen from the sedative influence of digitalis, which medicine is most serviceable when it keeps down the pulse below the standard of health, is another corroboration of the views stated above. Dr. Conolly has also observed that epileptic patients are occasionally warned of the approach of the paroxysm by mental excitement, owing, as Mr. Solly infers, to increased arterial action. Other patients have, as a warning, a singing in the ears, arising it is thought from the dilated carotid vibrating in its osseous canal, like an enlarged artery going to an inflamed part. The evidence of morbid anatomy confirms the idea of this congested state of the blood-vessels, for "in all cases of fatal epilepsy, where there has been an autopsy, the vessels of the brain and membranes have been found enormously distended, and in some there has been extravasation."

"The Enanthe crocata, or hemlock water drop wort, when taken in any quantity, produces epileptic convulsions. I was present at the post-mortem examination of four convicts, who died at Woolwich from eating it. The progressive amount of sanguineous effusion on the brain was in proportion to the length of time they survived. The seizure was most striking and instructive.

"In all there was great congestion and some sanguineous effusion on the surface of the brain; in those that lived the longest, the quantity was in proportion to the length of time they survived the seizure. The first man died in about an hour, and the last in about two hours." P. 600.

Among the remote causes of epilepsy it is well to recollect that syphilitic irritation of the dura mater, a fact first pointed out to the author by Mr. Copeland, is to be enumerated.

As regards the treatment of these obstinate affections, Mr. Solly has found the oxide of silver and the continued use of digitalis most efficient as medicines; the latter being adapted to young and excitable subjects in whom it produces the best results, and the former to older patients, where the disease is more confirmed and the fits do not occur so frequently. In order to tranquillize the stomach when the digitalis is administered, creosote or hydrocyanic acid should be given; the digestive organs being generally in fault, will of course require attention. Notwithstanding the conviction the author entertains of the congested state of the cerebral vessels, he does not advocate blood-letting, either general or local.

"I never saw any good derived from blood-letting, and I have seen a great deal of harm from it. I bled freely in one or two cases some years ago, under the impression that the disease was inflammatory, when there was a decidedly plethoric state of the system and great congestion of the brain; but I am convinced it caused a repetition of the attacks. Even the application of leeches, either before the attack, at the time, or afterwards, only does harm." P. 615.

1847] Polli's Researches and Experiments on the Blood. 303

There are of course some exceptional cases where depletion may be beneficial; when, for example, there is hypertrophy of the left ventricle, a not unfrequent cause of epilepsy, a few leeches applied to the cardiac region, will be found useful, especially if combined with hydrocyanic acid, which is of great value in subduing irritability of the heart. Foville also recommends the periodical application of leeches to the arms, in plethoric individuals, with large heads, habitually injected with blood.

We must here conclude our notice of this admirable treatise; and, in doing so, we earnestly advise all our professional brethren to enrich their libraries with a work which bears the stamp of extensive observation and careful research; and which has in addition this peculiar advantage, that it combines, in a moderate compass, a scientific and practical account of the anatomy, physiology, and pathology of the brain.

RICERCHE ED ESPERIENZE SUL SANGUE UMANO. Del Dottore Gio. Polli. Serie I. II. III. ed. IV. (Annali Universali, Vol. 106, 109, 113, 121, ed. 122. 1843-47.)

Researches and Experiments upon the Human Blood. By Dr. Polli.

DR. POLLI having been much struck, during his studentship at Pavia several years since, with the perusal of the account of some of Hewson's Experiments upon the Blood, resolved entering himself upon a course of experimental inquiry respecting certain points needing illustration; and he has, from time to time, communicated to the Annali the valuable series of papers detailing their results and the therapeutical conclusions derivable from these, an analysis of which we now propose laying before our readers.

The First Series has for its title

RESEARCHES AND EXPERIMENTS UPON THE FORMATION OF THE BUFFY COAT OF THE BLOOD, AND ITS SYMPTOMATIC VALUE IN DISEASE.

After adverting to the contradictory accounts which were formerly furnished of the appearance of the blood in disease, and the rarity and uncertainty with which practitioners employed these as indications of treatment, he observes that the chemical physicians of our own times have effectually revived attention to the subject, and led to the belief that, at least as much information may be obtained from the inspection of the blood as from post-mortem examinations. He then continues :

"The true pathological anatomy of the blood is its analysis, since we can only divide the fluid by means of re-agents. But every hand is not able to wield such a scalpel as the re-agent. This requires a longer and more severe course of study than is necessary for the acquisition of anatomical knowledge. But, without pretending that every practitioner should know as well how to analyze

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