147
COMMENTS ON CONTEMPORARY JOURNALS. Tetany. That form of neurosis designated by the term tetany, presents many features to lend it interest in the eyes of physicians; not the least perhaps being the comparative rarity of. its occurIts exact nature is still matter of discussion, and any rence. well-recorded instances possess a value to make them deserving of careful consideration. Probably the most likely explanation of the affection is that which refers it to the class of spinal irritations, but the distinctive phenomena that characterise the attacks sufficiently serve to give it an individuality of its own. Dr. Hirschfelder communicates some particulars of the disease " Pacific Medical and Surgical in the February number of the on observations of a case which had come founded Journal,"
The patient was a man of care in private practice. temperament, who had nevertheless enjoyed good health until February 1880, when he fell with an elevator, sliding down a trap a distance of three stories, and lacerating the palms and fingers of both hands, but especially of the left side. No unusual symptoms occurred during the next five days, except slight convulsive movement at night, to which no attention was paid ; a severe convulsion, however, set in on the evening of the fifth day, and being regarded as tetanus was treated with bromide. Morphia subcutaneously only made Two matters worse; chloral finally checked the condition. weeks later a second attack was again met with chloral, and a depressed nervous state persisted after it. Another severe convulsion occurred shortly before Christmas, chloral again conquering it; but a decayed tooth having been blamed for the mischief, it was extracted. Fresh attacks, apparently causeless, has continued on in June 1881, since when patient came
under his nervous
and excitable. Dr. Hirschfelder describes the obvious appearances as follows:? " You see, gentlemen, the patient before you looks to be in the best of health, and no one would suspect him to be a victim of the disease present. I press upon the radial nerve and you in the palmar muscles supplied. I see contraction occurring nerve?the muscles on the ulnar side draw up. ulnar the squeeze I press upon the axillary nerves rather forcibly and you see the the head turns back, opisthopatient stiffens, the arms draw up, At the tonos and a well-marked tetaniform convulsion ensue. nervous
L
2
148
COMMENTS ON CONTEMPORARY JOURNALS.
time the face reddens, and you hear a short, hacking I cease to press and instantly you see the attack passes over and the patient seems as well as before. I stick him with a pin here upon the arm, and you see the same convulsive I press upon the facial nerve, and the muscles movement. supplied by it twitch. Pressure on the scalp produces no contractions. Our patient is quite a sceptic, and thinks that a perhaps by powerful exertion of his will he might possibly prevent the attack coming on; but you see now, when firmly determined not to permit the convulsion, he is unable to do so when the axillary nerves are pressed, and the contractions occur as heretofore. He has, however, made a discovery never before noted in a case of tetany, that if he causes his muscles to become powerfully contracted, as when firmly holding a stick in both hands, the convulsive movements do not occur upon irritation." This observation of the patient may not be without some practical result, and may be borne in mind by any who may in the future meet with similar cases. That tetany is distinct from tetanus is shown by the frequency of its attendant phenomena. Painful contractions are present in both forms, but the order in which the parts of the body are attacked is remarkably different. In tetany, the contractions are centripetal, not, as in tetanus, centrifugal, the extremities being first attacked, then the trunk or head; and in less severe forms the seizure is confined to the limbs. The peculiar form assumed by the contracted hand also is apparently a constant sign of tetany, this being like the folding up in a conical form followed by the obstetrician when about to explore the vagina. Dr. Kadcliff'e, in Eeynolds's " " system," questions whether a sufficient case is made out in describing tetany as a definite disorder, and whether it is not rather a form of spinal irritation, complicated with some graver same
cough;
spinal disease?spinal meningitis, myelitis, spinal congestion? varying proportions," and he arrives at an affirmative conclusion also from the presence in such cases of tingling and numbness, with prolonged contraction, this being at any rate a not unfrequent symptom in single spinal irritation. Hyperoemia, moreover, has been mostly noticed in the upper portion of the cord in those rare cases when post-morten examination of persons dying from tetany have been made. Dr. Hirschfelder has the following in relation to causation of the disease :? Tetany may be produced by a large number of causes. It frequently occurs in epidemiform groups, and seems to be most frequent during the winter months. It occurs most frequently In many cases a connection in children and during lactation. exists between the tetany and intestinal irritation. Psychic in
"
alterations
seem
to stand in causal relation to it.
A number of
COMMENTS ON CONTEMPORARY JOURNALS.
149
have been observed immediately following extirpation In one sucli case the formation of a small abscess occurred, and the tetany persisted until the abscess was opened, when it permanently disappeared. In our case the tetany occurred after a trauma, but whether it was produced by the injury or the fright is very difficult to determine." cases
of
goitres.
Hypnotism. Of late the subject of hypnotism has attracted a good deal of attention both at home and abroad, several interesting communications respecting it being found in the various home and foreign journals. Dr. Beard, of New York, whose demonstrations of the hypnotic state last summer in London were so unfavourably criticised, has been diligently pursuing further studies, and has published several papers in reply to criticism, and in explanation of his position.
The "Alienist and Neurologist "for January contains an article from his pen on " Current Delusions in relation to Hypnotism," Dr. Beard admits to which attention may properly be drawn. that the silly delusions formerly popularly held on hypnotism
are becoming rarer and rarer, but he contends that even yet there remain among the best special workers a number of other delusions that are attended with results almost as serious, and that until these are finally and utterly dissipated, the phenomena of trance, its real nature, and the practical scientific details of the condition, will never be accurately appreciated. Trance is defined as " the concentration of nervous force in some one direction, with corresponding suspension of nervous force in other directions." It may further be natural or artificial; the former
arising from natural causes, and separable, like insanity, into cataleptic, somnambulistic, emotional, intellectual, &c.. the latter form of trance, artificial, is hypnotism. All alike, however, are to be explained by> the concentration theory; and Dr. Beard deplores the error committed by specialists in assuming that any
radical distinctions divide the natural varieties of trance from He says: "Writers the artificial or hypnotic description. speak of the artificial variety as something different from the natural state, just as they would speak of different varieties of insanity as something distinct from general insanity. Insanity may be artificially produced in various ways, just as trance can If we make a man drunk with, be produced artificially. alcohol, we produce a case of artificial, the symptoms of which resemble many cases of natural, insanity ; if we put a man out of his head by fright, we may also in some cases produce a case of artificial insanity, and it is the same in principle as the
150
COMMENTS ON CONTEMPORARY JOURNALS.
natural varieties of insanity. An attack of drunkenness, then, is to insanity what an attack of hypnotism is to trance" On the surface this argument is specious and imposing; but it is in veality a veritable surface induction. It cannot be maintained jn careful examination, for the premises on which the conclusion depends are not stable quantities. Reasonable objection may be taken to the likeness drawn between the cerebral excitement of a drunken man and the structural changes productive of insanity in even its simplest forms. It is perhaps a point in favour of Dr. Beard's view, that we are, too often alas ! unable to recognise the lesions or the molecular disturbances which generate a condition of mental unsoundness; but it is a fatal objection, nevertheless, that there is a specific quality in the latter which widely removes it from the merely drunken state. Nor does it help to reconcile the disparities to admit that continuous indulgence in alcoholic poisons will induce actual madness, for this is then consequent, not on momentary changes, but on a general condition of disturbance which results from constant operation of disturbing forces of an exactly similar kind. Intoxication of the most decided character may, and often does result, at the first employment of alcohol in immoderate amounts; but no stretch of imagination could conceive any similarity between a drunken schoolboy and the maudlin toper whose whole mental faculties are weakened and ruined by long-continued abuse of excitants. To justify Dr. Beard's conclusion, however, this should be more than possible; it is an essential element of proof of the identity of conditions he insists on. The second delusion complained of is, " that it is necessary for the operator to do anything, or cause the subjects to do anything, in order to produce this artificial trance, this so-called hypnotism." Dr. Beard comments on the incredulity expressed by European experts when his experiments were performed in this country, and on the fact, especially, that the subject of them entered and emerged from the trance state " without anything being done either by himself or anybody else." Tbe force of this illustration, however, is lost, when it is remembered that the subject had already been trained into a condition of excitability by long excitation of the emotions by the " method of expectation"; and when once the task of educating such a person to the reception of and obedience to impressions has been accomplished, it is not difficult to comprehend how response may be made to them, even when operator and operated-on are far removed from each other. Dr. Beard would seem to have been guilty in this respect of forgetting the necessary connection between cause and effect; and because the action performed does not immediately precede the phenomena
COMMENTS ON CONTEMPORARY JOURNALS.
151
exhibited, that therefore no relation exists between the two factors. We may even admit the bona fides of the experiments on this understanding; but none the less they display direct causal relations that at once dispose of the theory that nothing is done either by operator or subject. Here, too, maybe considered the third complaint uttered?that, namely, it is improperly assumed that persons who are entranced artificially are necessarily liable to the natural varieties of trance, and also that they are liable to be injured thereby in mind or body." On this point Dr. Beard very decidedly expresses an opinion contrary to that generally accepted here, and, it must be added, by those also on the continent of Europe, who have specially investigated the phenomena of trance, notably, Heidenhain. Dr. Beard thus "
"
"
expresses himself:? " There is common belief that good subjects for these experiments are those who are, or have been, epileptic, anaemic, hysterical, or insane. This belief, which is mostly an erroneous one, prevails all over Europe and in this country also, except much time and thought to invesProf. Preyer, of Jena, who is working successfully in this department, on witnessing
among those who have tigation of this subject.
given
faithfully and the experiments, repeatedly urged me to desist, or to be more moderate lest the subject should be injured. Trance produced by acting on the emotion of expectation is a purely psychological, not a physical state, and lias not necessarily any relation to physical health, whether good or bad. The Jumpers of Maine are strong and long-lived. I have experimented with persons of different ages, of both sexes, white and black, old and young, and the majority, though not all of the very best subjects for the average of experiments, and for the most interesting experiments, are of firm or medium health, and it is on this class that for scientific purposes, I prefer to experiment. Nervous, feeble, hysterical women, who are made subjects of these experiments, and become frightened or alarmed in regard to them, may become temporarily and, possibly, in rare cases, permanently injured thereby. The possibility of this, on theoretical grounds, I will allow, but I must say, that in my own personal experience extending over many years, in which I have made many thousands of experiments on hundreds of different individuals, I have never known of one being permanently injured thereby; a few temporary disturbances, lasting over a few hours or days, have been the only unpleasant results I have witnessed, and these due almost always to the inexperience of the experimenter. This is the position which the psychological science of the future is to take on this subject." At the present time confident assertions to this effect are
152
COMMENTS ON CONTEMPORARY JOURNALS.
scarcely justifiable; it must be for further inquirers to decide the question at issue. Of the genuineness of the phenomena of artificial trance, Dr. Beard says we have as much proof as of any of those of insanity, and even better proofs than can be obtained of insanity where simulation is suspected. He admits, however, that long series of experiments may be needed to ensure certain proof, and that " no person, however skilful in this department, or however large his experience may be, can tell from witnessing a number of experiments whether they are genuine or not." This of course disposes of the objections raised against his own experiments here last summer, and it likewise effectually precludes any but specialists, who particularly confine themselves to the study of hypnotism from judging of the value of exhibited results. Consequently, therefore, the vast majority of medical men are declared incompetent to test the reality of trance phenomena, and are at the mercy of every pretender who chooses to pose before them as a hypnotic individual. This necessary deduction from Dr. Beard's statements may be agreeable to him, and the few who think with him, to accept. We must dissent from them in toto, and while admitting that the phenomena referred to present many features of interest, when they are not the outcome of intentional fraud, but that they are one and all open to discussion and explanation both clinically and
psychologically.
Dr. Beard's paper, as we have said, is worthy of attention because its author is so completely identified with the subject of it: but that it does anything more than put into words objections against dogmatic and unsatisfactory explanations of an ill-understood mental condition, without any attempt to clear up the mysterious relations between the mental and bodily state of persons in trance, cannot be said with any truth; as further discussing the problems the essay is useful, as helping to enlighten our ignorance of them it does not possess a very high value. The Opium Habit. The opium question has been subject to discussion in nearly all the medical journals within the past few months; and a considerable number of books and pamphlets have likewise been issued in connection with it. Opinion, however, is by no means unanimous in respect to the injury that is done by excessive indulgence in opium-smoking; even so competent a " That the judge as Sir Risdon Bennet is content to say :* *
Preface to Medical Testimonies to the Trade.
Suppression of the Opium
Effect of Opium-Smoking?Society for
COMMENTS ON CONTEMPORARY JOURNALS.
of
153
whether smoked or eaten, as of alcohol with health and comfort is perfectly true ; but it is not the less true that opium is a dangerous poison, and not the less pernicious because, when taken habitually, its action is very insidious." This opinion is undoubtedly at variance with that of the majority who have essayed to ventilate the question; and in the pamphlet whence the quotation is extracted, few venture to make the concession yielded by the ex-president of the Royal College of Physicians. Dr. Edward C. Mann, in a paper on the Nature and Treatment of the Opium Habit, contributed to the " New York Medical Journal," believes " the habitual use of opium seems to produce a peculiar type of moral insanity, leaving the intellectual centres of the brain untouched. The patient's views of right and wrong are perverted, and, while he may go on with his routine duties, either in public or in private life, he often manifests an utter disregard of truthfulness, honesty and sincerity, and after a time shows a seeming inability to exert his will in any other direction or for any other purpose than the gratification of his morbid appetite. The use of opium tends to sterility and impotence, and to the extinction of the reproductive propensities. Hearing and vision are not unfrequently affected, and insomnia is very common. Tremors and an unsteady, ill-balanced gait are generally observed in all welldeveloped cases. Opium rather suspends the operations of the mind than causes disease, for it does not seem to act directly on cerebral structure. If it did insanity would be the result, and I have never met with a case of mental disease that I could trace to indulgence in opium or morphine, and I had many cases of this nature under These views, especially my care." those relating to the effects on the mind of the opium habits, will cause surprise to a good many who are accustomed to look upon the abuse of the drug as a fruitful cause of insanity. Certain it is, that when Dr. Mann succeeds in establishing his theory on a perfectly sound basis, we shall be compelled to expunge from future asylum reports one of the most prolific socalled origins of mental disease. In the last published report of the Pennsylvania Asylum, opium accounts for 33 cases of insanity, and it is very frequently cited in this connection in American official tables. That the masses in China and elsewhere, to whom indulgence in the use of the drug is habitual, are degraded in mind as well as physically demoralised, that their mental faculties are diseased rather than suspended, has been again and again insisted upon; but, notwithstanding, the number of those who hold less pessimist views on the ill effects of opiumsmoking are both numerous and competent to express them. moderate or
use
opium,
tobacco, may be compatible
154
COMMENTS ON CONTEMPORARY JOURNALS.
In marked contrast to Dr. Mann's gloomy forecast, " The other side of the Opium Question," by W. J. Moore, L.K.C.P., &c., Deputy Surgeon-General H.M. Forces, and Hon. Surgeon to the Viceroy, distinctly denies the evil effects attributed to " opium. Mr. Moore emphatically protests against preventing a comparatively few Chinamen, abuse of an the from suffering agent which many more Chinamen find to be a source of enjoyment, of comfort, a necessity and even a blessing." He further continues: " I do not advocate the use of opium. Were it possible I should rejoice to see a law against the immoderate use of opium in force throughout the world. But of the two I would prefer to see the immoderate use of spirits abolished, as the greater of two evils. The moderate use of opium, and the moderate use of spirits (as sanctioned by all law?human and Divine?except Mohammedan law), I hold to be legitimate; also under innumerable circumstances, beneficial to mankind, both in health and in sickness." The aim of this remarkable pamphlet is to refute what its author regards as the artificial nature of the anti-opium agitation. He certainly succeeds in putting the matter in a light very different from that in which it is usually regarded. One more quotation may be made from it (p. 91): "Very recently a publication has been issued from the ' Chinese Imperial Maritime Customs.' It is calculated the that there in are round numbers 1,000,000 by compiler smokers of opium. The population of China is spoken of as
amounting to more than 400,000,000, and may be fairly estimated as something above 300,000,000. Estimating the population at these figures, and the opium-smokers at 1,000,000, the result is that three in every 1,000 smoke, that is, opium is used by probably less than one-tldrd of one per cent, of the population; a sufficiently lame and impotent conclusion to the statements which have been unblushingly made that opium is rapidly destroying the Chinese nation." Old Standing Lesion
of tiie
Insulae Lobule.
" Archives de Neurologie " conarticle contributed by Drs. Bourneville and important Bonnaire, on a case of extremely rare character, in which an oldstanding lesion of the convolution known as the Island of Reil had resulted in entire destruction of all the cligitations of the lobule, neighbouring convolutions remaining almost unaffected by the changes set up. The patient, a man 54 years old, a carpenter, came under the care of Dr. Bourneville at Bicetre in 18(58. The nature of the disease from which his parents had died could not be ascertained. He had two sisters without
The current number of the
tains
an
COMMENTS ON CONTEMPORARY JOURNALS.
155
family; no history of epilepsy or lunacy was recorded of any member of patient's own family. Patient was married when 34 years of age, was addicted to excessive smoking, but not to drinking. Eighteen months after his wedding he was suddenly seized with left hemiplegia, and six years subsequently he became subject to epileptic attacks. In the interval he gained a livelihood by opening carriage-doors in the streets, and at this time, too, became addicted to drink. The frequency with which the epileptiform seizures recurred compelled renunciation of all attempts at work, and that the patient should seek permanent hospital shelter. .Two daughters, one aged 22, the other 17, and both enjoying good health, are the fruits of the marriage. The condition of the patient, and the treatment adopted from September 1880 to the end of July 1881, when death occurred, are detailed in the paper, and careful post-mortem notes are appended. While in hospital, for a period of four years memory and conversational power were both retained, but afterwards recollection was entirely lost, and the patient paid no
surroundings. At the same time as the mental physical weakness increased, but, apart from the paresis consequent on the first injury, the patient exhibited other symptoms of cerebral lesion than were comprised in no intermittent attacks of headache. The number of epileptic fits recorded, however, is very considerable: thus in 1871, 35; 1872, 43; 1873, 17 ; 1874, 48; 1875, 51; 1876, 46 ; 1877, 85; 1878, 112 ; 1879, 111; 1880, 454; 1881 (seven months), 49. At the autopsy the following notes as to the condition of the brain were made. Its weight was 1,160 grammes, surface slightly pale, arteries and nerves at the base healthy. The right mammillary tubercle a third smaller than the left, and of normal colour. The right cerebral peduncle was markedly atrophised, flattened and smaller then the left, and the right anterior pyramid was represented by a mere flattened band of greyish tint,, on the same level as the corresponding olivary body. The right half of the pons, or isthmus of the encephalon, was considerably less in size than the left, and on section, the cerebral peduncle was very much smaller on the same side of the brain. Corpora quadrigemina, normal. On being weighed the right hemisphere was found lighter than the left by 140 grammes, and was shorter. The cerebrum weighed 970 grammes altogether. Cerebellum healthy, the two hemispheres being of equal volume. The left cerebral hemisphere presented little to notice; but when the right was examined, a considerable depression was at once seen on a level with the insular lobule and the sphenoidal lobe. The pia mater was everywhere easily detached, except on certain points where it was attention to his
faculties
were
lost
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COMMETNS OX CONTEMPORARY JOURNALS.
thickened and brown, reddish or slightly ochreous in hue. The superficial depression was filled by a collection of cerebro-spinal fluid, and on raising the pia mater, the hemisphere presented as a flat surface. There was discovered a region of atrophy which involved the whole posterior part of the third frontal convolution, the rest of this convolution not having suffered ; the inferior portion of the frontal and parietal ascending convolutions ; and the entirety of the island (Reil), of which no trace of the digitations were observable. The first temporo-sphenoidal and posterior part of the second convolution exhibited similar changes. The parenchyma in the region of the insular lobule was replaced by a reddish-coloured gelatinous substance, but the neighbouring convolutions were atrophied without alteration of colour. The corpus striatum was represented by two small nodules about the size of a bean ; the thalamus, diminished two-thirds of its volume, was distorted also in form. The wall of the ventricle was thinned, its capacity sensibly increased. Taken altogether, the right hemisphere was shorter, thicker, and shallower than the right. The authors consider that during the efforts made at some time by their patient while defecating, a clot may have lodged in the middle cerebral artery near its origin. This conclusion was strengthened by the fact that the tract supplied by the
to ihe third frontal convolution was found to be anaemic The most remarkable features of the whole case was perhaps the absence of aphasia in presence of lesion of the posterior parts of the right third frontal convolution, when considered in relation to the theory which localises the faculty of speech in the corre-
artery
sponding left convolution. Also it is deeply interesting to note the effects produced on the brain as consequent to an injury persisting for 36 years. One other important fact in connection with the case should be added; that, namely, a perforating ulcer of the left foot existed for some time before the death of the patient. The appearance of this
on a
member condemned to relative functional inaction,
consequently independently of conditions generally assumed as determining such ulcers, is regarded by the authors as indicating its trophic nature, and that it had therefore a central origin. and
An Interesting Case. Dr. Geo. L. Peabody communicated an interesting case of caries of the alvearium and abscess of the brain, resulting from a non-penetrating gunshot wound, to the New York Pathological Society in January last" The patient, a German labourer,
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157
1881.
The bullet, which was lying in removed at the Chambers Street Hospital soon after the shooting. The wound was found to be non-penetrating, and the patient was treated as a dispensary He suffered a little from headache, and case, every other day. about the middle of June he vomited several times, and his headache increased. On June 18th he was sent to the New York Hospital. On admission, he complained of severe headache ; he was drowsy, and unwilling to talk, but was easily aroused, and answered questions slowly and intelligently. His pulse was full and strong, his temperature was 97.4? F. There He gradually grew more and was no paralysis at any time. more stupid, became comatose, and died two days after admission. " The aivearium exhibited the effect of the bullet-wound above the right superciliary ridge. In that situation a button of bone, about half an inch in diameter, had been almost completely detached from the outer table of the skull, being united to it by a narrow isthmus of bone, about one-eighth of an inch wide. On the inner table the separation was less complete, extending only over about half its circumference. The bone in the neighbourhood of this button was porous, the process of caries having distinctly invaded both tables of the skull. The inner surface of the frontal bone exhibited several small osteophytes, not in any way connected with the injury. " The brain showed more extensive injury. The dura mater, pia mater, and brain surface beneath the site of the injury were firmly adherent; so that on gently separating the former from the brain, a small fragment of grey matter came with it from the second frontal convolution. This was followed by the oozing of pus from the opening. The brain was then hardened, was
shot
on
May 28,
contact with the
and
hone,
was
being subsequently opened,
disclosed
an
abscess-cavity,
which was ovoidal in shape. It had an antero-posterior long diameter of one and one-half inch, and a vertical short diameter of one and one-eighth inch. It was lined by a thick pyogenic membrane, so called. It comes within three-fourths of an inch of the upper surface of the frontal lobe, and within about the same distance of the base, invading the grev matter only to a slight extent in the second frontal convolution. It was separated from the corpus striatum by about one-fourth of an inch." Unfortunately, Dr. Peabody could not speak definitely as to the flattening of the convolutions ; he believed it was only local. Dr. E. 0. Seguin, President of the Society, commenting on the case, described a recent post-mortem examination of a brain, in which he discovered that a tumour situate under the ascending convolution, near the medjan line, had produced local flattening on immediately adjacent convolutions, while the
COMMENTS ON CONTEMPORARY JOURNALS.
158
first frontal and
posterior part of the second and third convoluperfectly natural, and there was only a slight flattening across the median line. On clinical grounds, lie did
tions
were
not believe in transmission of pressure in all
he knew of
directions, but
post-mortem demonstrations in point. Dr. Seguin quotes also another example in illustration of the subject no
under discussion. In this, an orbital abscess led to necrosis of the orbital plate of the frontal bone, the dura mater covering which within was diseased, as well as the arachnoid and grey matter of the brain, an abscess forming in the frontal lobe of the latter. The patient had no paralysis, no lesion of
theoptic until
a
nerves,
no
convulsions,
short time before
Cheyne-Stokes respiration,
and not any very severe pain There was slow pulse,
death. and
gradually increasing
coma.
The whole of the white centre of the frontal globe, except a portion near the convexity of the hemisphere, was destroyed close to the island of Reil and the head of the nucleus candatus. The mass of white substance connecting the posterior part of the third frontal convolution and the anterior gyri of the island of Reil, with the internal capsule, were uninjured.On the question of trephining in such cases, Dr. Seguin expressed an opinion that the operation would have been justifiable, seeing the diagnosis of abscess was unequivocal. The cases are both of very decided interest from many points of view, and deserve to be attentively considered in all their details. The extracts given above are taken from the New York Medical Record
COMMENTS ON CONTEMPORARY JOURNALS. Tetany. That form of neurosis designated by the term tetany, presents many features to lend it interest in the eyes of physicians; not the least perhaps being the comparative rarity of. its occurIts exact nature is still matter of discussion, and any rence. well-recorded instances possess a value to make them deserving of careful consideration. Probably the most likely explanation of the affection is that which refers it to the class of spinal irritations, but the distinctive phenomena that characterise the attacks sufficiently serve to give it an individuality of its own. Dr. Hirschfelder communicates some particulars of the disease " Pacific Medical and Surgical in the February number of the on observations of a case which had come founded Journal,"
The patient was a man of care in private practice. temperament, who had nevertheless enjoyed good health until February 1880, when he fell with an elevator, sliding down a trap a distance of three stories, and lacerating the palms and fingers of both hands, but especially of the left side. No unusual symptoms occurred during the next five days, except slight convulsive movement at night, to which no attention was paid ; a severe convulsion, however, set in on the evening of the fifth day, and being regarded as tetanus was treated with bromide. Morphia subcutaneously only made Two matters worse; chloral finally checked the condition. weeks later a second attack was again met with chloral, and a depressed nervous state persisted after it. Another severe convulsion occurred shortly before Christmas, chloral again conquering it; but a decayed tooth having been blamed for the mischief, it was extracted. Fresh attacks, apparently causeless, has continued on in June 1881, since when patient came
under his nervous
and excitable. Dr. Hirschfelder describes the obvious appearances as follows:? " You see, gentlemen, the patient before you looks to be in the best of health, and no one would suspect him to be a victim of the disease present. I press upon the radial nerve and you in the palmar muscles supplied. I see contraction occurring nerve?the muscles on the ulnar side draw up. ulnar the squeeze I press upon the axillary nerves rather forcibly and you see the the head turns back, opisthopatient stiffens, the arms draw up, At the tonos and a well-marked tetaniform convulsion ensue. nervous
L
2
148
COMMENTS ON CONTEMPORARY JOURNALS.
time the face reddens, and you hear a short, hacking I cease to press and instantly you see the attack passes over and the patient seems as well as before. I stick him with a pin here upon the arm, and you see the same convulsive I press upon the facial nerve, and the muscles movement. supplied by it twitch. Pressure on the scalp produces no contractions. Our patient is quite a sceptic, and thinks that a perhaps by powerful exertion of his will he might possibly prevent the attack coming on; but you see now, when firmly determined not to permit the convulsion, he is unable to do so when the axillary nerves are pressed, and the contractions occur as heretofore. He has, however, made a discovery never before noted in a case of tetany, that if he causes his muscles to become powerfully contracted, as when firmly holding a stick in both hands, the convulsive movements do not occur upon irritation." This observation of the patient may not be without some practical result, and may be borne in mind by any who may in the future meet with similar cases. That tetany is distinct from tetanus is shown by the frequency of its attendant phenomena. Painful contractions are present in both forms, but the order in which the parts of the body are attacked is remarkably different. In tetany, the contractions are centripetal, not, as in tetanus, centrifugal, the extremities being first attacked, then the trunk or head; and in less severe forms the seizure is confined to the limbs. The peculiar form assumed by the contracted hand also is apparently a constant sign of tetany, this being like the folding up in a conical form followed by the obstetrician when about to explore the vagina. Dr. Kadcliff'e, in Eeynolds's " " system," questions whether a sufficient case is made out in describing tetany as a definite disorder, and whether it is not rather a form of spinal irritation, complicated with some graver same
cough;
spinal disease?spinal meningitis, myelitis, spinal congestion? varying proportions," and he arrives at an affirmative conclusion also from the presence in such cases of tingling and numbness, with prolonged contraction, this being at any rate a not unfrequent symptom in single spinal irritation. Hyperoemia, moreover, has been mostly noticed in the upper portion of the cord in those rare cases when post-morten examination of persons dying from tetany have been made. Dr. Hirschfelder has the following in relation to causation of the disease :? Tetany may be produced by a large number of causes. It frequently occurs in epidemiform groups, and seems to be most frequent during the winter months. It occurs most frequently In many cases a connection in children and during lactation. exists between the tetany and intestinal irritation. Psychic in
"
alterations
seem
to stand in causal relation to it.
A number of
COMMENTS ON CONTEMPORARY JOURNALS.
149
have been observed immediately following extirpation In one sucli case the formation of a small abscess occurred, and the tetany persisted until the abscess was opened, when it permanently disappeared. In our case the tetany occurred after a trauma, but whether it was produced by the injury or the fright is very difficult to determine." cases
of
goitres.
Hypnotism. Of late the subject of hypnotism has attracted a good deal of attention both at home and abroad, several interesting communications respecting it being found in the various home and foreign journals. Dr. Beard, of New York, whose demonstrations of the hypnotic state last summer in London were so unfavourably criticised, has been diligently pursuing further studies, and has published several papers in reply to criticism, and in explanation of his position.
The "Alienist and Neurologist "for January contains an article from his pen on " Current Delusions in relation to Hypnotism," Dr. Beard admits to which attention may properly be drawn. that the silly delusions formerly popularly held on hypnotism
are becoming rarer and rarer, but he contends that even yet there remain among the best special workers a number of other delusions that are attended with results almost as serious, and that until these are finally and utterly dissipated, the phenomena of trance, its real nature, and the practical scientific details of the condition, will never be accurately appreciated. Trance is defined as " the concentration of nervous force in some one direction, with corresponding suspension of nervous force in other directions." It may further be natural or artificial; the former
arising from natural causes, and separable, like insanity, into cataleptic, somnambulistic, emotional, intellectual, &c.. the latter form of trance, artificial, is hypnotism. All alike, however, are to be explained by> the concentration theory; and Dr. Beard deplores the error committed by specialists in assuming that any
radical distinctions divide the natural varieties of trance from He says: "Writers the artificial or hypnotic description. speak of the artificial variety as something different from the natural state, just as they would speak of different varieties of insanity as something distinct from general insanity. Insanity may be artificially produced in various ways, just as trance can If we make a man drunk with, be produced artificially. alcohol, we produce a case of artificial, the symptoms of which resemble many cases of natural, insanity ; if we put a man out of his head by fright, we may also in some cases produce a case of artificial insanity, and it is the same in principle as the
150
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natural varieties of insanity. An attack of drunkenness, then, is to insanity what an attack of hypnotism is to trance" On the surface this argument is specious and imposing; but it is in veality a veritable surface induction. It cannot be maintained jn careful examination, for the premises on which the conclusion depends are not stable quantities. Reasonable objection may be taken to the likeness drawn between the cerebral excitement of a drunken man and the structural changes productive of insanity in even its simplest forms. It is perhaps a point in favour of Dr. Beard's view, that we are, too often alas ! unable to recognise the lesions or the molecular disturbances which generate a condition of mental unsoundness; but it is a fatal objection, nevertheless, that there is a specific quality in the latter which widely removes it from the merely drunken state. Nor does it help to reconcile the disparities to admit that continuous indulgence in alcoholic poisons will induce actual madness, for this is then consequent, not on momentary changes, but on a general condition of disturbance which results from constant operation of disturbing forces of an exactly similar kind. Intoxication of the most decided character may, and often does result, at the first employment of alcohol in immoderate amounts; but no stretch of imagination could conceive any similarity between a drunken schoolboy and the maudlin toper whose whole mental faculties are weakened and ruined by long-continued abuse of excitants. To justify Dr. Beard's conclusion, however, this should be more than possible; it is an essential element of proof of the identity of conditions he insists on. The second delusion complained of is, " that it is necessary for the operator to do anything, or cause the subjects to do anything, in order to produce this artificial trance, this so-called hypnotism." Dr. Beard comments on the incredulity expressed by European experts when his experiments were performed in this country, and on the fact, especially, that the subject of them entered and emerged from the trance state " without anything being done either by himself or anybody else." Tbe force of this illustration, however, is lost, when it is remembered that the subject had already been trained into a condition of excitability by long excitation of the emotions by the " method of expectation"; and when once the task of educating such a person to the reception of and obedience to impressions has been accomplished, it is not difficult to comprehend how response may be made to them, even when operator and operated-on are far removed from each other. Dr. Beard would seem to have been guilty in this respect of forgetting the necessary connection between cause and effect; and because the action performed does not immediately precede the phenomena
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exhibited, that therefore no relation exists between the two factors. We may even admit the bona fides of the experiments on this understanding; but none the less they display direct causal relations that at once dispose of the theory that nothing is done either by operator or subject. Here, too, maybe considered the third complaint uttered?that, namely, it is improperly assumed that persons who are entranced artificially are necessarily liable to the natural varieties of trance, and also that they are liable to be injured thereby in mind or body." On this point Dr. Beard very decidedly expresses an opinion contrary to that generally accepted here, and, it must be added, by those also on the continent of Europe, who have specially investigated the phenomena of trance, notably, Heidenhain. Dr. Beard thus "
"
"
expresses himself:? " There is common belief that good subjects for these experiments are those who are, or have been, epileptic, anaemic, hysterical, or insane. This belief, which is mostly an erroneous one, prevails all over Europe and in this country also, except much time and thought to invesProf. Preyer, of Jena, who is working successfully in this department, on witnessing
among those who have tigation of this subject.
given
faithfully and the experiments, repeatedly urged me to desist, or to be more moderate lest the subject should be injured. Trance produced by acting on the emotion of expectation is a purely psychological, not a physical state, and lias not necessarily any relation to physical health, whether good or bad. The Jumpers of Maine are strong and long-lived. I have experimented with persons of different ages, of both sexes, white and black, old and young, and the majority, though not all of the very best subjects for the average of experiments, and for the most interesting experiments, are of firm or medium health, and it is on this class that for scientific purposes, I prefer to experiment. Nervous, feeble, hysterical women, who are made subjects of these experiments, and become frightened or alarmed in regard to them, may become temporarily and, possibly, in rare cases, permanently injured thereby. The possibility of this, on theoretical grounds, I will allow, but I must say, that in my own personal experience extending over many years, in which I have made many thousands of experiments on hundreds of different individuals, I have never known of one being permanently injured thereby; a few temporary disturbances, lasting over a few hours or days, have been the only unpleasant results I have witnessed, and these due almost always to the inexperience of the experimenter. This is the position which the psychological science of the future is to take on this subject." At the present time confident assertions to this effect are
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scarcely justifiable; it must be for further inquirers to decide the question at issue. Of the genuineness of the phenomena of artificial trance, Dr. Beard says we have as much proof as of any of those of insanity, and even better proofs than can be obtained of insanity where simulation is suspected. He admits, however, that long series of experiments may be needed to ensure certain proof, and that " no person, however skilful in this department, or however large his experience may be, can tell from witnessing a number of experiments whether they are genuine or not." This of course disposes of the objections raised against his own experiments here last summer, and it likewise effectually precludes any but specialists, who particularly confine themselves to the study of hypnotism from judging of the value of exhibited results. Consequently, therefore, the vast majority of medical men are declared incompetent to test the reality of trance phenomena, and are at the mercy of every pretender who chooses to pose before them as a hypnotic individual. This necessary deduction from Dr. Beard's statements may be agreeable to him, and the few who think with him, to accept. We must dissent from them in toto, and while admitting that the phenomena referred to present many features of interest, when they are not the outcome of intentional fraud, but that they are one and all open to discussion and explanation both clinically and
psychologically.
Dr. Beard's paper, as we have said, is worthy of attention because its author is so completely identified with the subject of it: but that it does anything more than put into words objections against dogmatic and unsatisfactory explanations of an ill-understood mental condition, without any attempt to clear up the mysterious relations between the mental and bodily state of persons in trance, cannot be said with any truth; as further discussing the problems the essay is useful, as helping to enlighten our ignorance of them it does not possess a very high value. The Opium Habit. The opium question has been subject to discussion in nearly all the medical journals within the past few months; and a considerable number of books and pamphlets have likewise been issued in connection with it. Opinion, however, is by no means unanimous in respect to the injury that is done by excessive indulgence in opium-smoking; even so competent a " That the judge as Sir Risdon Bennet is content to say :* *
Preface to Medical Testimonies to the Trade.
Suppression of the Opium
Effect of Opium-Smoking?Society for
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of
153
whether smoked or eaten, as of alcohol with health and comfort is perfectly true ; but it is not the less true that opium is a dangerous poison, and not the less pernicious because, when taken habitually, its action is very insidious." This opinion is undoubtedly at variance with that of the majority who have essayed to ventilate the question; and in the pamphlet whence the quotation is extracted, few venture to make the concession yielded by the ex-president of the Royal College of Physicians. Dr. Edward C. Mann, in a paper on the Nature and Treatment of the Opium Habit, contributed to the " New York Medical Journal," believes " the habitual use of opium seems to produce a peculiar type of moral insanity, leaving the intellectual centres of the brain untouched. The patient's views of right and wrong are perverted, and, while he may go on with his routine duties, either in public or in private life, he often manifests an utter disregard of truthfulness, honesty and sincerity, and after a time shows a seeming inability to exert his will in any other direction or for any other purpose than the gratification of his morbid appetite. The use of opium tends to sterility and impotence, and to the extinction of the reproductive propensities. Hearing and vision are not unfrequently affected, and insomnia is very common. Tremors and an unsteady, ill-balanced gait are generally observed in all welldeveloped cases. Opium rather suspends the operations of the mind than causes disease, for it does not seem to act directly on cerebral structure. If it did insanity would be the result, and I have never met with a case of mental disease that I could trace to indulgence in opium or morphine, and I had many cases of this nature under These views, especially my care." those relating to the effects on the mind of the opium habits, will cause surprise to a good many who are accustomed to look upon the abuse of the drug as a fruitful cause of insanity. Certain it is, that when Dr. Mann succeeds in establishing his theory on a perfectly sound basis, we shall be compelled to expunge from future asylum reports one of the most prolific socalled origins of mental disease. In the last published report of the Pennsylvania Asylum, opium accounts for 33 cases of insanity, and it is very frequently cited in this connection in American official tables. That the masses in China and elsewhere, to whom indulgence in the use of the drug is habitual, are degraded in mind as well as physically demoralised, that their mental faculties are diseased rather than suspended, has been again and again insisted upon; but, notwithstanding, the number of those who hold less pessimist views on the ill effects of opiumsmoking are both numerous and competent to express them. moderate or
use
opium,
tobacco, may be compatible
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COMMENTS ON CONTEMPORARY JOURNALS.
In marked contrast to Dr. Mann's gloomy forecast, " The other side of the Opium Question," by W. J. Moore, L.K.C.P., &c., Deputy Surgeon-General H.M. Forces, and Hon. Surgeon to the Viceroy, distinctly denies the evil effects attributed to " opium. Mr. Moore emphatically protests against preventing a comparatively few Chinamen, abuse of an the from suffering agent which many more Chinamen find to be a source of enjoyment, of comfort, a necessity and even a blessing." He further continues: " I do not advocate the use of opium. Were it possible I should rejoice to see a law against the immoderate use of opium in force throughout the world. But of the two I would prefer to see the immoderate use of spirits abolished, as the greater of two evils. The moderate use of opium, and the moderate use of spirits (as sanctioned by all law?human and Divine?except Mohammedan law), I hold to be legitimate; also under innumerable circumstances, beneficial to mankind, both in health and in sickness." The aim of this remarkable pamphlet is to refute what its author regards as the artificial nature of the anti-opium agitation. He certainly succeeds in putting the matter in a light very different from that in which it is usually regarded. One more quotation may be made from it (p. 91): "Very recently a publication has been issued from the ' Chinese Imperial Maritime Customs.' It is calculated the that there in are round numbers 1,000,000 by compiler smokers of opium. The population of China is spoken of as
amounting to more than 400,000,000, and may be fairly estimated as something above 300,000,000. Estimating the population at these figures, and the opium-smokers at 1,000,000, the result is that three in every 1,000 smoke, that is, opium is used by probably less than one-tldrd of one per cent, of the population; a sufficiently lame and impotent conclusion to the statements which have been unblushingly made that opium is rapidly destroying the Chinese nation." Old Standing Lesion
of tiie
Insulae Lobule.
" Archives de Neurologie " conarticle contributed by Drs. Bourneville and important Bonnaire, on a case of extremely rare character, in which an oldstanding lesion of the convolution known as the Island of Reil had resulted in entire destruction of all the cligitations of the lobule, neighbouring convolutions remaining almost unaffected by the changes set up. The patient, a man 54 years old, a carpenter, came under the care of Dr. Bourneville at Bicetre in 18(58. The nature of the disease from which his parents had died could not be ascertained. He had two sisters without
The current number of the
tains
an
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155
family; no history of epilepsy or lunacy was recorded of any member of patient's own family. Patient was married when 34 years of age, was addicted to excessive smoking, but not to drinking. Eighteen months after his wedding he was suddenly seized with left hemiplegia, and six years subsequently he became subject to epileptic attacks. In the interval he gained a livelihood by opening carriage-doors in the streets, and at this time, too, became addicted to drink. The frequency with which the epileptiform seizures recurred compelled renunciation of all attempts at work, and that the patient should seek permanent hospital shelter. .Two daughters, one aged 22, the other 17, and both enjoying good health, are the fruits of the marriage. The condition of the patient, and the treatment adopted from September 1880 to the end of July 1881, when death occurred, are detailed in the paper, and careful post-mortem notes are appended. While in hospital, for a period of four years memory and conversational power were both retained, but afterwards recollection was entirely lost, and the patient paid no
surroundings. At the same time as the mental physical weakness increased, but, apart from the paresis consequent on the first injury, the patient exhibited other symptoms of cerebral lesion than were comprised in no intermittent attacks of headache. The number of epileptic fits recorded, however, is very considerable: thus in 1871, 35; 1872, 43; 1873, 17 ; 1874, 48; 1875, 51; 1876, 46 ; 1877, 85; 1878, 112 ; 1879, 111; 1880, 454; 1881 (seven months), 49. At the autopsy the following notes as to the condition of the brain were made. Its weight was 1,160 grammes, surface slightly pale, arteries and nerves at the base healthy. The right mammillary tubercle a third smaller than the left, and of normal colour. The right cerebral peduncle was markedly atrophised, flattened and smaller then the left, and the right anterior pyramid was represented by a mere flattened band of greyish tint,, on the same level as the corresponding olivary body. The right half of the pons, or isthmus of the encephalon, was considerably less in size than the left, and on section, the cerebral peduncle was very much smaller on the same side of the brain. Corpora quadrigemina, normal. On being weighed the right hemisphere was found lighter than the left by 140 grammes, and was shorter. The cerebrum weighed 970 grammes altogether. Cerebellum healthy, the two hemispheres being of equal volume. The left cerebral hemisphere presented little to notice; but when the right was examined, a considerable depression was at once seen on a level with the insular lobule and the sphenoidal lobe. The pia mater was everywhere easily detached, except on certain points where it was attention to his
faculties
were
lost
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thickened and brown, reddish or slightly ochreous in hue. The superficial depression was filled by a collection of cerebro-spinal fluid, and on raising the pia mater, the hemisphere presented as a flat surface. There was discovered a region of atrophy which involved the whole posterior part of the third frontal convolution, the rest of this convolution not having suffered ; the inferior portion of the frontal and parietal ascending convolutions ; and the entirety of the island (Reil), of which no trace of the digitations were observable. The first temporo-sphenoidal and posterior part of the second convolution exhibited similar changes. The parenchyma in the region of the insular lobule was replaced by a reddish-coloured gelatinous substance, but the neighbouring convolutions were atrophied without alteration of colour. The corpus striatum was represented by two small nodules about the size of a bean ; the thalamus, diminished two-thirds of its volume, was distorted also in form. The wall of the ventricle was thinned, its capacity sensibly increased. Taken altogether, the right hemisphere was shorter, thicker, and shallower than the right. The authors consider that during the efforts made at some time by their patient while defecating, a clot may have lodged in the middle cerebral artery near its origin. This conclusion was strengthened by the fact that the tract supplied by the
to ihe third frontal convolution was found to be anaemic The most remarkable features of the whole case was perhaps the absence of aphasia in presence of lesion of the posterior parts of the right third frontal convolution, when considered in relation to the theory which localises the faculty of speech in the corre-
artery
sponding left convolution. Also it is deeply interesting to note the effects produced on the brain as consequent to an injury persisting for 36 years. One other important fact in connection with the case should be added; that, namely, a perforating ulcer of the left foot existed for some time before the death of the patient. The appearance of this
on a
member condemned to relative functional inaction,
consequently independently of conditions generally assumed as determining such ulcers, is regarded by the authors as indicating its trophic nature, and that it had therefore a central origin. and
An Interesting Case. Dr. Geo. L. Peabody communicated an interesting case of caries of the alvearium and abscess of the brain, resulting from a non-penetrating gunshot wound, to the New York Pathological Society in January last" The patient, a German labourer,
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1881.
The bullet, which was lying in removed at the Chambers Street Hospital soon after the shooting. The wound was found to be non-penetrating, and the patient was treated as a dispensary He suffered a little from headache, and case, every other day. about the middle of June he vomited several times, and his headache increased. On June 18th he was sent to the New York Hospital. On admission, he complained of severe headache ; he was drowsy, and unwilling to talk, but was easily aroused, and answered questions slowly and intelligently. His pulse was full and strong, his temperature was 97.4? F. There He gradually grew more and was no paralysis at any time. more stupid, became comatose, and died two days after admission. " The aivearium exhibited the effect of the bullet-wound above the right superciliary ridge. In that situation a button of bone, about half an inch in diameter, had been almost completely detached from the outer table of the skull, being united to it by a narrow isthmus of bone, about one-eighth of an inch wide. On the inner table the separation was less complete, extending only over about half its circumference. The bone in the neighbourhood of this button was porous, the process of caries having distinctly invaded both tables of the skull. The inner surface of the frontal bone exhibited several small osteophytes, not in any way connected with the injury. " The brain showed more extensive injury. The dura mater, pia mater, and brain surface beneath the site of the injury were firmly adherent; so that on gently separating the former from the brain, a small fragment of grey matter came with it from the second frontal convolution. This was followed by the oozing of pus from the opening. The brain was then hardened, was
shot
on
May 28,
contact with the
and
hone,
was
being subsequently opened,
disclosed
an
abscess-cavity,
which was ovoidal in shape. It had an antero-posterior long diameter of one and one-half inch, and a vertical short diameter of one and one-eighth inch. It was lined by a thick pyogenic membrane, so called. It comes within three-fourths of an inch of the upper surface of the frontal lobe, and within about the same distance of the base, invading the grev matter only to a slight extent in the second frontal convolution. It was separated from the corpus striatum by about one-fourth of an inch." Unfortunately, Dr. Peabody could not speak definitely as to the flattening of the convolutions ; he believed it was only local. Dr. E. 0. Seguin, President of the Society, commenting on the case, described a recent post-mortem examination of a brain, in which he discovered that a tumour situate under the ascending convolution, near the medjan line, had produced local flattening on immediately adjacent convolutions, while the
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first frontal and
posterior part of the second and third convoluperfectly natural, and there was only a slight flattening across the median line. On clinical grounds, lie did
tions
were
not believe in transmission of pressure in all
he knew of
directions, but
post-mortem demonstrations in point. Dr. Seguin quotes also another example in illustration of the subject no
under discussion. In this, an orbital abscess led to necrosis of the orbital plate of the frontal bone, the dura mater covering which within was diseased, as well as the arachnoid and grey matter of the brain, an abscess forming in the frontal lobe of the latter. The patient had no paralysis, no lesion of
theoptic until
a
nerves,
no
convulsions,
short time before
Cheyne-Stokes respiration,
and not any very severe pain There was slow pulse,
death. and
gradually increasing
coma.
The whole of the white centre of the frontal globe, except a portion near the convexity of the hemisphere, was destroyed close to the island of Reil and the head of the nucleus candatus. The mass of white substance connecting the posterior part of the third frontal convolution and the anterior gyri of the island of Reil, with the internal capsule, were uninjured.On the question of trephining in such cases, Dr. Seguin expressed an opinion that the operation would have been justifiable, seeing the diagnosis of abscess was unequivocal. The cases are both of very decided interest from many points of view, and deserve to be attentively considered in all their details. The extracts given above are taken from the New York Medical Record
