Nervous Diseases and Insanity. 153

ABSTRACTS FROM CURRENT MEDICAL

LITERATURE.

NERVOUS DISEASES AND INSANITY.

By Dr. R. S. STEWART.

A Case of Hysteria Simulating the Symptom of Weber. By Charcot (Archives de Neurologie, May, 1801).?This is the case of a young -woman of 18, who presented herself at the Salp^triere suffering from right hemiplegia and left ptosis, a combination of symptoms which would point to an organic lesion of the lower and inner part of the cerebral peduncle, and which has not hitherto been observed in hysteria. The onset of the hemi-

plegia, four years previous to the time of observation, was gradual and without appreciable cause, and it was succeeded one year afterward by exquisite hyperesthesia localised in the right side of the body, and especially in the neighbourhood of the joints. At the end of a few days these arthralgias improved, and gave place to hemianesthesia and complete right hemiplegia, which confined the patient to bed for ten months. The paralysis gradually and spontaneously disappeared in the course of a year. The ptosis had developed gradually without any known cause two years previous to the onset of the paralysis, and had persisted without any notable modification. Not-

withstanding the apparent gravity of the co-existence of ocular symptoms of one side, with motor troubles of the opposite limbs, M. Charcot expresses his conviction that the condition is one of hysteria, and predicts a complete cure.

The dropping of the lid of the affected eye is held to be due not to paralysis, but to spasm, even though some of the usual symptoms of this latter condition were absent, such as vibration of the lid and resistance on attempts being made to open it, pronounced wrinkling from contracture and spontaneous tremors increased by voluntary attempts to open the eye. The signs present in this case indicative of spasm were a relative lowering of the eyebrow of the affected side, not disappearing on wrinkling the brow, and accentuated during attempts to open the eye widely, more pronounced wrinkling of the brow on the healthy side, the presence above the dropped lid and towards its nasal end of two or three vertical corrugations, one of which very distinctly limits a small rounded depression. The result of these various contractions is to

give to the physiognomy a sad and disappointed air.

Use and Abuse of Hyoscine.?By Weatherley (Journal of Mental Science, July, 1891).?In a paper read at the last quarterly meeting of the Medico-Psychological Association, this writer expresses the strong conviction that this drug is most deserving of a permanent place among the recently introduced hypnotics. Its use, however, requires watchful care in cases of weak heart or general feeble circulation, and in these conditions he

recommends its combination with aromatic spirit of ammonia. Mental

excitement, especially motor, if not hysterical, is greatly controlled by it, but it often fails in the excitement of tabes. Its effect on temper and irritability is usually very marked. In small or moderate doses it induces a

condition closely resembling sleep, but in larger doses (7V gr.) it often

produces deep sleep. Its proper use, in the writer's opinion, is as a mental alterative in cases characterised by a quarrelsome, resentful, abusive, arrogant, and domineering disposition. In hysterical cases with hallucina- tions, it is very unsuitable, but in delirium tremens, disseminated sclerosis, and chronic alcoholism, its use has been attended with success. Given

154 Abstracts from Current Medical Literature.

hypodermically, it will act surely and rapidly in subduing delirious and maniacal excitement ; but its indiscriminate use as a powerful and sudden hypnotic is, the writer thinks, an abuse.

In the discussion which followed, Percy Smith remarked that hyoscine in his experience, unlike hyoscyamine, \vas unattended with serious effects.

Savage described the case of a female patient who was extremely maniacal, and in whom a single dose of gr. induced a sleep from which she never roused. He recommends it in cases of folio, circulaire and recurrent mania. In Law Wade's experience, its effect is purely temporary, and he deprecates entirely the hypodermic use of the drug.

Some Unusual Cases of General Paralysis. By Fox (Journal of Mental Science, July, 1891).?Four cases of this disease presenting peculiarities are here described. The first was characterised by well-marked remission and disappearance of nearly all the typical features of the disease ; the second, by the rapid appearance of pathognomic paralytic symptoms, both physical and mental, directly after an injury to the head ; the third, by the supervention of the disease upon tabes dorsalis, which had existed for some time previously ; and the fourth, by the occurrence of melancholic delusions and the rapid development of bedsores. As regards treatment, the writer remarks that in active mania opiates fail,

and prolonged warm baths, free purgation and digitalis in large doses are to be recommended. He has utterly failed to find anything like a specific, and he is doubtful that benefit is to be obtained from physostigma. Tonics?such as iron, arsenic, and quinine?are beneficial, and for epileptiform seizures there is no remedy equal to the combination of chloral and bromide. In cases in which there has been preceding syphilis, the use of mercury and iodide has been unattended with benefit. The concluding remarks are, that the occurrence of considerable periods of

remission, and the prolongation of the disease, albeit exceptional, to 20 or 30 years, should indicate the possibility of cure in early cases of general paralysis; that paralytic symptoms may follow immediately on a blow, suggesting cause and effect; that the most desperate physical condition need not necessarily prove fatal; that tabes dorsalis predisposes to general paralysis ; that it may be impossible to recognise in the early stage the melancholic type of the disease ; that this variety is characterised by a tendency to gangrene, and runs a rapid course ; and that it is uncertain what conditions predispose to or determine its occurrence.

Post-Eclamptic Mania. By Alexander (Journal of Mental Science, July, 1891).?A primipara, aged 17, during the last three months of pregnancy had complained of headaches, pains in the loins, vomiting, and oedema of hands, feet, and face. Convulsions set in after the confinement, and she was admitted to the Edinburgh Maternity Hospital three and a half hours after- wards in a comatose state. The urine was found to be albuminous and to

contain casts and blood. Bleeding, active purgation, vapour bath, cupping over the kidneys, chloral by the rectum, chloroform during the fits, and pilocarpine were ordered, and she had in all eight fits after admission. Deep coma succeeded the eclampsia, and this was in turn replaced by furious mania, which disappeared on the succeeding day. Recovery followed after a short period of drowsiness and stupidity. Causes predisposing to the maniacal outburst were to be found in the childish and emotional disposition of the patient and the existence of distinct neurotic heredity.

Accumulation of Cocoa-nut Fibre in the Stomach: Death from Intestinal Obstruction. By R. S. Stewart, M.I)., D.r.H.Camb. {Journal of Mental Science, July, 1891).?I. A. H., aged 12, was admitted into the Glamorgan County Asylum on 6th November, 1888. When 7 months old he had convulsions, and these recurred till he was two years of age, and then disappeared. At the age of 7 he had one other tit. He is said to have been

Nervous Diseases and Insanity. 155

able to speak w hen two years old, but not since then. Ultimately he became so troublesome and defective in his habits as to be unmanageable at home, and he was removed to the asylum.

His mental condition was one of idiocy, with much restlessness. He was

noisy and dirty, and was much given to picking up rubbish and pulling door- mats to pieces.

Until the commencement of the fatal illness, which occurred on 4th Sep- tember, 1890, his bodily condition was uniformly good, and there was no hint whatever of any disturbance of the digestive system. He took food well, and was not at any time troubled with sickness, vomiting, or constipation. On

the last mentioned date he became listless and apathetic, lost his appetite, and began to be sick. Next day he vomited the little milk he took, and

appeared to be in some pain, as he now and then put his hand over his

abdomen as if suffering there. On that day there was one natural motion. There was no apparent enlargement of the abdomen, and little tenderness on manipulation, but a hard inelastic tumour could be detected in the epigastrium over the site of the stomach. One dose of 5 grs. of grey powder was administered, but was shortly after rejected, and an enema brought away only a small piece of faices. The vomiting and complete inaction of the bowels continued, the temperature rose to 100J F., and death occurred on 11th

September, seven days from the onset of the illness. On post-mortem examination, made twenty-three hours after death, the

brain was found to be much hypertrophied, its weight being 57 oz., or 11 oz. over the average ; the heart was normal, and the lungs and solid organs of the abdomen presented nothing noteworthy beyond slight congestion. A small

quantity of brownish serum was present in the pelvic portion of the peritoneal sac, but nowhere was there any fibrinous exudation. About the junction of the lower and middle third of the small intestine an obstructive mass could be

felt, and the stomach was occupied by a firm unyielding mass. The peritoneal lining of the small gut above the seat of obstruction was inflamed. The

stomach on removal weighed 25^ oz., and, when emptied, 7 oz. Its contents, "weighing 18i oz., consisted of three separate solid masses, each about the size and shape of the closed fist, and several smaller masses wedged in between the larger. These were composed almost entirely of cocoa-nut fibre, with a few strands of dried grass, soaked in a pea-soup like and only slightly stercor- aceous fluid. On section of two of the pieces no lamination could be observed ; the fibres assumed a dense felted arrangement. The gastric mucous membrane was only slightly congested ; and in the neighbourhood of the pylorus, where the muscular coat was much hypertrophied, it was strikingly rugose. The

obstruction in the ileum was found to be a mass of similar composition to those described. It assumed a banana-like shape, and the sharp ends of the loose fibres were projected downwards and outwards into the wall of the gut in a manner that seriously prevented its downward passage. The intestine above the obstruction contained slightly feculent fluid, but not in any great amount, and the mucous membrane presented a swollen and inflamed appear- ance. Below the obstruction the intestine was empty, with the exception of a small mass of feces in the caput csecum coli. The Peyer's patches, below the obstruction as well as above it, presented distinct alteration from the normal. Above they were much congested, and below they had a swollen and roughened appearance. The total weight of the fibre masses after drying was only oz.

Collections of indigestible substances are occasionally found in the stomach of cattle, horses, and goats ; and here, as a rule, they form round a nucleus, and present a greater or less degree of lamination. Youatt, in a book on the diseases of cattle, published in 1834, records instances in which the nucleus took the form of such varied articles as scissors, a handkerchief, an old shoe, the lash and part of the handle of a whip, a waistcoat, a buckskin glove, a shell, and pieces of straw, stone or iron (verily il tie feint point disputer des goUts). Sometimes, as in the case here recorded, there is no distinct central nucleus, and these masses are usually composed of hair irregularly matted

1 56 Abstracts from Current Medical Literature.

together. Occasionally the concretion contains a large quantity of mineral matter, and forms a calculus capable of taking on a high polish, and sometimes these, forming as they do in the intestine of the horse, give rise to fatal obstruction.

Treves, in his work on intestinal obstruction, classifies foreign bodies

occurring in the stomach and intestines .into (1) rounded or regularly shaped bodies capable of passing readily, (2) sharp pointed bodies, and (3) indigestible materials of small size which are apt to accumulate and form large masses, such as husks of oats, vegetable fibres, grape skins, hair, wool, and yarn, the latter swallowed by habit by dressmakers and others, or intentionally by lunatics and hysterical persons. The case here recorded M ould belong to the third class, and it further affords an illustration of a remark which he makes to the effect that these bodies may remain for years in the stomach or intestine without causing any mischief, but that when so lodged they may almost at any time induce changes leading to a fatal result. From inquiries made subsequently to the patient's death it appears that, even before his admission, he had been addicted to eating, among other things, cocoa-nut fibre, and that during the first twelve months of his residence in the asylum he had picked two doormats to pieces, but subsequently to that he entirely gave up the habit. There is every reason, therefore, to believe that the masses found in the stomach had been present for some considerable time, and that there was on the part of the stomach an entire toleration of their presence. The practi- cally unaltered condition of the gastric mucous membrane found on post-mortem examination would point in the same direction, and the fatal result is to be attributed not to the presence of these masses in the stomach, but to the extrusion?an accident liable to occur at any moment?of the small mass into the intestine and consequent obstruction.

Many of the reported cases have occurred in lunatics and hysterical persons. In one case recorded by Dr. Quain, and cited in Treve's work, the obstructive mass of cocoa-nut fibre weighed 4 lb. Another is described by Dr. M'Dowall (Journal of Mental Science, January, 1882), where the colon contained a mass composed of pieces of wood, wire, stocking, ticking, and leaves. Dr. Campbell records (Journal of Mental Science, July, 1886), an instance where the stomach contained a mass of matted hair, pieces of blanket, and a hank of twine, one end of which had become unwound and extended into the intestine for 2 feet, and in the case of an idiot patient of the Earlswood Asylum, described by Dr. Cobbold in the same journal (April, 1866), death resulted from persistent vomiting induced by the presence in the stomach of a collection of human hair, cocoa-nut fibre, horse hair, and leaves, weighing lb. Habershon

{Diseases of the Abdomen, third edition, p. 253), cites the case of a sailor who had repeatedly swallowed clasp knives. The stomach contained several knives and parts of others ; one was found fixed transversely in the rectum, and one blade had perforated the colon. In Walshe's book, The Horse, an account is given of a young lady who died in consequence of the accumulation in her stomach of hair which she had swallowed. Since writing the above an instance has been related to me where several recently hatched chicks died in consequence of the accumulation in the gizzard of the fibres from moss litter which they had picked up from the floor of their coop.