No.201.] LONDON, SATURDAY, JULY 7.

LECTURES

ON THE

Diseases of the Nervous System.BY

DR. CLUTTERBUCK.

LECTURE XVII.

]Tysteiia, or the Hysteric Disease.THis disease received its appellation from

the uterus (ufr7pn) being supposed to be theseat of the disease. The reason of this, pro-bably, was its occurring very frequently infemales at a certain period of life, and undercircumstances when this organ is in its mostactive and excitable state. A more satis-

factory pathology, however, may, I think,be given, although we may admit that theuterus, and the feelings connected with it,are among the most frequent occasional causesof the disease.

It is difficult to define hysteria in the com-pass of a few words, or even sentences ; forit is subject to much diversity of characterat different times. We must give its his-tory, therefore, somewhat in detail. Hys-teria, then, may be said to be, a convulsiveaffection of various muscles, both voluntaryand involuntary ; in this respect it bears astriking resemblance to epilepsy; but thepatient generally retains a consciousness ofwhat is passing around, which is not com-monly the case in epilepsy. Like epilepsy,too, it recurs by paroxysms, though in ge-neral with less regularity. In hysteria, manyof the involuntary muscles are spasmodicallyor convulsively affected, as well as the vu-luntary. Thus, palpitation of the heart takesplace very frequently to a very distressingdegree. The alimentary canal, more espe-cially, is affected in this way. Hence the

passage of flatus from one part of the canalto another, and which, by an inverted mo-tion of the canal, being carried upwards tillit arrives at the oesophagus, is apt to be

retained there ; and, by making pressureupon the wind-pipe, produces a sense ofstrangling or suffocation, (globus hystericus.)By compressing the blood vessels in theneck, likewise, it tends to impede and dis-turb the circulation in the brain, and thusto derange its functions.The mind is often greatly agitated, or even

slightly deranged, the patient laughing orcrying violently, without cause. Instead ofconvulsions, there is sometimes stitpor, orinsensibility. Frequently, a large quantityof limpid urine is discharged immediatelybefore the fit.

With as much variety, there is more irre-gularity in the returns and paroxysms ofhysteria, than in those of epilepsy ; and yetthe more severe attacks of hysteria have, attimes, so complete a resemblance to thoseof epilepsy, as hardly, or indeed not at all,to be distinguished from it, except by ob-serving the slighter paroxysms, which havethe ordinary characters of hysteria.

H yste7’Ía occurs most frequently in femalesfrom the age of puberty, to 30 or even 40years of age ; especially the unmarried, andthose who have not borne children. Itoccurs most frequently in women of ple-thoric habits, and who manifest great sensi-bility as well as irritability; and wheremenstruation is suppressed or irregular;but often, also, where it is profuse. Thedisease, however, occasionally takes placein spare and weakly females. Sometimes itoccurs in males, but commonly in such asdisplay something of the feminine character.

It used formerly to be thought that hypo.chondriasis in males, was the same diseaseas hysteria in females ; but there is no foun-dation for such an opinion. The sympfomsof the two diseases, the causes producingthem, and the habit and other circumstancesin which they occur, are altogether diffe-rent. Hypochondriasis belongs rather to theclass of mental than corpOl’eaZ affections, andis, in fact, a variety of insanity, with whichit will hereafter be considered.The exciting or occasional cause of a hysteric

paroxysm, is not always perceptible. In

general, it is brought on by mental emo-tion, as terror or surprise, or by uterineexcitement.

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7V,atiti-e nf Hysteria.-The analogy between Ihysteria and epilepsy, is apparent on compar- Iing together the leading characters of thetwo affections. In both the sensorial func-tions are constantly more or less disturbed,though unequally so. The brain, therefore,(the organ executing those functions) is to

Ibe considered as the primary seat of the Idisease in both. The immediate cause ofthe paroxysm, probably, is a partial andtemporary arterial excitement of this organ,as I endeavoured to show you was the casein epilepsy. Dr. Cullen ascribes it to a

turgescence of blood in the vessels of theuterus, or in other parts of the genital sys-tem ; but such turgescence, supposing it toexist, is only a remote or occasional cause ofthat excitement in the vascular action of thebrain, which is the immediate cause of theparoxysm, both in epilepsy and hysteria.Hence it is brought on, in both cases, by avariety of circumstances that have a decidedinfluence on the brain.

It is true that the alimentary canal has itsmovements greatly disordered, in most casesof hysteria; and the usual course of reason-ing upon the subject is, that thefiatus, risingupwards, affects the brain. But the ques-tion here is, which organ is primarily affect-ed, the brain or the alimentary canal? I Ithink the brain is so, because there are

various proofs of this organ suffering in

hysteria, in the disordered state of all itsfunctions ; while it cannot be doubted, thatan affection of the brain is quite adequateto explain the disordered state of the ali-

mentary canal. Besides, this disordered stateof the alimentary canal (the globus hystericus),is not always present in hysteria; nor is iteasy to understand, how such a state ofthese passages, though present, should giverise to so peculiar and varied a train of

symptoms, as take place in this disease.

Flatulency to a very great degree often oc-curs, without the symptome of hysteria, andwithout perceptibly disturbing the senso-

rial functiores, which are always much dis-turbed in this disease. When to this you addthe fact, that the paroxysm is brought onby many causes that are wholly indepen-dent of the alimentary canal, but which evi-dently influence the brain, and that in adirect way ; such as mental emotions—youwill find reason, I think, to conclude, thatthere is no more ground for accusing thealimentary cartal, as the part primarily affect-ed in hysteria, than there was formerly to

accuse the uterus, the ascent of which wasconsidered as the immediate cause of thesymptoms. My conclusion then, in regardto the order in which the phenomena pre-sent themselves, is this : that an excitedstate of the uterus is a vezy frequent causeof that disturbance in the sensorial jimctions,(and consequently in the organ performing i

those functions, the brain), which consti-tutes the disease—2dly, That the alimentarycanal is less frequently disordered, and whenit is so, it is in a secondary way only, aris-

ing out of the previous disturbed state ofthe brain—3dly, That causes which act morecertainly and directly upon the brain, are

the general exciting causes of the disease.Upon these grounds, therefore, it may be

safely maintained, that the brain, or rathera part of it, is the primary and essentialseat of hysteria. What particular part of theorgan suffers, can only be inferred from thesymptoms, or particular functions observedto be disturbed. This inference, however,we are not yet competent to draw, owing tothe imperfect state of the physiology of thebrain.

In regard to the actual condition of thebrain, or what has been called the proximatecause, this is in a great degree conjectural;for we have not the advantage of inspectionto determine the point, hysteria, in itself,rarely if ever terminating fatally. Thereseems no reason, however, to suppose theexistence of any alteration of structure inthe brain ; for such an idea would hardlybe consistent with the mild and fleeting cha-racter of the disease, and the long and per-fect intervals that the patients enjoy. Wemust resort, therefore, to some temporarycause, in order to account for the parox.ysms of hysteria, and which, there seems

great reason to suppose, is a state of vascu.lar (of course, arterial) excitement in thebrain. This must appear probable from aconsideration of both the symptoms and causes,as above described ; while it appears fullysufficient to explain the phenomena. Thestate of excitement in the vessels of thebrain, which I have supposed to be the im.mediate cause of the paroxysm, both in

epilepsy and hysteria, does not necessarilyamount to actual inflammation, though pro.bably it is a near approach to it, and mightbe easily converted into it. Upon this

theory, of arterial excitement in the brainbeing the proximate or immediate cause ofthe paroxysm in those diseases, it is notdifficult to understand their occasional ter.

mination both in apoplexy and palsy, as Istated to you was sometimes the case.

Prognosis.—The prognosis in hysteria is fa-vourable upon the whole, the disease gene-rally terminating in health, and that spoiita-neously, when the exciting and predisposingcauses are removed, or cease to act. Occa

sionally, however, it degenerates into per-feet epilepsy. I have seen it also terminatein apoplexy that proved fatal.Of the treatment of hyste2,ia.-According to

the theoretical principles now laid down, andwhich ought always (supposing them to be

true) to be your guide as far as possible, is

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practice, the indications to be aimed at areas follows :-

1. To reduce that state of vascular ex-citement, which I suppose to be the imme-diate or exciting cause of the paroxysm.

2. To lessen the disposition to the re-currence of sueh a state of excitement, andthereby to prevent future attacks of the

malady.These objects are very distinct, and the

means of accomplishing tiiem different: theydiffer also in importance. And as the ob-servations to be made on the subject, applyto other periodical diseases, it may be worthyour while to attend to them more par-ticularly.

It is of no great moment, generally speak-ing, to reduce by artificial means (providedwe possessed them) a state of vascular ex-citement that so soon subsides of itself, aswe know to be the case here. It wouldhardly be worth while to weaken the systemby bloodletting, for example, unless it shouldappear that the further advantage would begamed, of lessening the predisposition tothe disease ; which, however, does not seemto be the case, unless where change ofstructure is suspected to have taken placein the brain ; but this is certainly not thecase in general in hysteria, though it is verycommon, I believe, in epilepsy, and servesto keep up the disposition to the disease,and so determines the recurrence of the

paroxysms. The only ground, therefore,upon which bloodletting in the fit can be

justified, is the apprehension that, in theviolence of arterial action that is takingplace, rupture or serous effusion may ensue,so as to induce apoplexy or palsy. This, inrobust and plethoric subjects, is no un-reasonable ground of apprehension, andtherefore warrants the abstraction of blood :

especially if the disease is recent. In othercases, such an evacuation is unnecessary,and had better, in general, be avoided. A

little time and quiet will, in general, sufficefor the subsidence of the paroxysm. Cold ’,might perhaps be usefully applied to the Ihead, as a means of diminishing arterialaction within the skull ; or the same resultmight be obtained with greater safety andcertainty, by exciting the vascular action ofremote parts, and thus determining a greaterflow of blcod in a different direction fromthe brain ; as bv purgatives, frictions, or othermeans. General stimulants, and those of thekind termed diffusible, that is, which exert aquick aud universal effect over the wholebody, may be properly enough employed inweak and delicate subjects. The 1’olatilealk(iii is well adapted to such a purpose, espe-cially where the external circulation is feeblycarried on, and the extremities are cold in

consequence ; for the ammonia tends, in sucha case, to equalize the circulation, while it

is free from the objection that applies for-cibly to narcotics in general, and particularly

to alcohol and cether, of inciting peculiarly- or specifically, as it were, the arterial action

of the brain. Opium is in general highlyobjectionable, upon the same grounds. Thisi medicine is very apt to deceive us by chang-ing the character, without really diminish.

ing the violence of the disease. It may puta stop to the convulsive movements, while itr aggravates the local mischief in the brain ;an effect that I have often observed it toproduce, when used for the purpose of

allaying subsiiltus tendinum in the advancedstage of fever : it has accomplished its pur-pose in this respect, but the ’disease con-tinues nevertheless to advance, and often

ends fatally, in spite of this partial relief ofsymptoms.

. The second object to be aimed at in thetreatment of hysteria, according to the prin-ciples above suggested, is of a preventivenature, and consists in endeavouring to

lessen the predisposition to the disease. Thispredisposition probably consists in too greatexcitability of the general system, but more

especially that of the brain, the local seat ofthe disease. Our means of accomplishingthis object, however, are imperfect and un-certain. Medicine has very little power ofthis kind. Astringents, (or tonics, as they arecommonly called, though without much pre-cision of language,) cold buthing, continuedexercise, with the avoidance of all excess andindulgence, and an attention to the variousexciting causes so as to remove them as far aspossible, embrace all that we have really inour power.

Practically speaking, the treatment of hy·steria is sufficiently simple, and for the mostpart successful, provided the causes, occa-sional as well as predisposing, can be averted,little else than the avoidance of those causes

being required. We often fail, however, tocure, because the circumstances inducingthe disease are not sufficiently under ourcontrol: time then generally accomplishesthe purpose. If menstruation should be de-fective, means must be used to promote thisevacuation. If the habit of body is plethoric,and the general vascular action strong, ab-stinence and evacuations of different kindsmust be resorted to ; and the mind, as far asthis is concerned, should be regulated ac-cording to the circumstances. The generalsensibility and irritability of the system mayin some degree be diminished, by continuedexercise in a cool and open atmosphere ;much sleep should be avoided, both as in-jurious in itself, by accumulating as it werethe excitability of the brain, and by favour-ing a determination of blood to the organby the horizontal posture being too longcontinued. Cold bl1thing is often useful.Tonic medicines, as they are called, that is,

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bitters and astilingents, produce an effectnearly of the same kind.The paroxysm itself may often be both

prevented and shortened, by counter-irrita-time of almost any kind : as by producingvomiting or purging; by the cold affusion ; bystimulant or t’etid odours, as those of burninganimal matter of any kind; or by ammoniaor asafietirta and the like, taken into the sto-mach. Counter-irritatiora may be appliedalso, as a preventive means, and that throughthe medium of the mind; as by reproach orridicule. The influence of the mind overthis disease, was strikingly shown duringthe French revolution, when hysteria, as

well as other nervous disorders that werebefore prevalent, nearly ceased, we are told,altogether; and the same thing was re-

marked during the rebellion in Scotland.In both cases, diseases of a fanciful nature,or at least, which owed their origin to in-dulgence and luxury, in a great measuredisappeared ; though they were replaced byothers of a really dangerous character, (theresult of terror principally,) and which oftenproved fatal ; such as mania, and apoplexy.

Of Chorea Sancti Viti, or St. Vitus’s Dance.

It is hardly worth while to trouble youwith an account of the origin of the ridicu-lous name given to this disease. The affec-tion now known however, under this deno-mination, is probably not the same as thatwhich was first so called ; the term seems tohave been originally applied to a sect offanatics, who, some centuries ago, in certainparts of Germany, manifested their religiouszeal, by contortions of body and grimace ofcountenance ; not unlike the sect of jumpers,that is still to be met with in some remote

parts of our own country.Chorea,—the disease we are now to con-

sider-is marked by involuntary and irre-

gular movements of the limbs, chiefly ob-served when any voluntary motion is at-

tempted, which is then very imperfectlyaccomplished, and often in a ridiculous man-ner. In sleep the involuntary movementscease. One side is generally observed to bemore affected than the other, often indeed

exclusively so ; in which respect chorea bearsa strong resemblance to hemiplegia, intowhich it sometimes degenerates.

In most cases the mind betrays a con-siderable degree of imbecility, amount-

ing almost to fatuity. The disease comeson gradually, and for the most part withoutany obvious exciting cause. It usually con-tinues for several months, though the du-ration is uncertain and unequal. In mostcases it terminates favourably, but slowly.Sometimes, however, it ends in perfecthemiplegia, as I have just stated. The pupilsof the eyes are generally more or less di-

lated, and often irregularly so, as in hydro-cephadus.

Chorea takes place commonly between theages of eight or nine, and fourteen or six-

teen ; though I have seen it in children offour years of age, and in one instance in a

woman far advanced in life. It occurs more

frequently in females than in males; and inthose of delicate, rather than those of robustt habits. Occasionally, however, it is meti with in those of ordinary strength, and whor are in the possession of good general healtb.r In many cases, there are both pain in the head, and a febrile state of body.

The theory, or, as it is now the fashionto speak, the pathology of chi)i-ea, is not

more difficult than that of either epilepsy orpalsy; like which, it is to be considered asa brain affection, and upon the same grounds,namely, that the constant and essential cha-racters of the disease consist merely in adisordered state of the functions of the brain,the sensorial functions, as we term them. Itis an affection of the voluntary muscles, andoften of the mental functions likewise; sen.sation being little, if at all disturbed. Thesecircumstances go to prove, that the diseaseis a local one, and not a general affection ofthe whole system, as has been commonlysupposed, nor even of the whole brain. Thepartial disturbance of some of the sensorial

functions, while others escape, shows thelimited extent of the disease in the brain.The notion, therefore, so prevalent, of thedisease being founded in general debility ofsystem, cannot be sustained.The precise nature of the disease in the

part affected, can only be inferred from ge.neral principles, and the peculiar symptomsthat present themselves. In many cases,indeed we may say in most, there is no paiain the head complained of; nor is there ingeneral pyrexia, or a febrile state of body, tobe observed ; so that there is nothing to

show decisively the existence of inflamma-tion. Nevertheless, I am inclined to refer

the disease to partial and slow inflammationof the brain, and that for different reasons.In the first place., various as are the clarac-ters of brain affections altogether, the actualI diseases of this organ, as far as we have any! real knowledge of them, are few and simple.)In fact, they seem to be all referrible to

disordered vascular action, (and that for themost part of an inflammatory kind,) and the. consequences of this : the more acute dis-eases of this organ, consisting in active in-t flammation, such as phrenitis, hydrocephalus,- and fever ; while the chronic ones are theresult of slow inflammation, and the changest which this induces ; such as extravasation of. blood, accumulation of serous fluid, thickeningt of membranes, and all the other alterationss of structure which inflammation is capable- of producing. And in this way are erpoptaies,

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palsies, epilepsy, hysteria, chorea, and mentaldisorders, to be explained, the differencebetween them arising from the particularseat and extent of the disease in the brain,rather than from any real difference in itsintrinsic nature. The periodical character,or the tendency to recur by paroxysms, inmany of these diseases, is to be ascribed tothe varying states of arterial action, and thenumerous causes that are capable of dis-turbing it.Another reason for believing that chorea

is founded in partial inflammation of thebrain, is that, in many instances, the signsupon which we are accustomed to rely, as

indicating the existence of inflammation, areactually present; such as continued and

throbbing pain in the head, with a febrilestate of system; to which may be added itsoccasional degeneracy into confirmed para-lvsis, a disease which is in most cases demon-strably dependant upon disorganization ofthe brain, and of course, originating in in-flammation.Now I should not have thought it neces-

sary to enter into speculations of this kind,regarding the intrinsic nature of chorea, hadthey not an important bearing upon prac-tice. It has been a prevailing notion, espe-cially of late years, that chorett was a diseaseof debility, and required a tonic, and even astimulant mode of treatment. If this prac-tice is followed indiscriminately, it willoften do positive harm, as well as fail inattaining its object, as I have many timesexperienced. Yet, on many occasions, sucha treatment is the best and most useful thatcan be devised. On the other hand, youare not to imagine, as some do, that becausethe disease originates in inflammation of thebrain, of limited extent and violence, thatbloodletting is necessarily called for. The

propriety of this as a remedy, depends notmerely upon the existence of inflammation,but upon the degree and duration of thedisease, and the habit and other circum-stances of the patient; as in all other casesof inflammation, wherever seated. Choreais sometimes found in liabits of considerablestrength, and accompanied with much painin the head, and a considerable degree ofpyreria. When such is the case, bloodlettingto a moderate extent, is highly useful, as Iknow by many trials. In several instances,occurring in the practice of this Dispensary,I have caused the patient to be bled, at

intervals of a few days, ten or a dozentimes; and even oftener, where the cir-cumstances were such as I have described ;and always the effect has corresponded withour wishes, and a cure been ultimatelyeffected, without the aid of any other activeremedy. Now, in such cases it is reason-able to believe, that a tonic and stimulant

plan of cure would have been hurtful. But

l you will find that in a majority of cases of, persons afflicted in this way, the patient isof a feeble habit of body, with soft and re-laxed solids, weak pulse, and cold extre-

; mities, the result of imperfect circulation.In such, tonics, and even stimulants, are un-doubtedly useful, and chiefly to be relied, upon. But, even in weak habits, the vas-cular action of the brain is sometimes somuch excited, as to call for a moderateabstraction of blood ; by local means in pre-

; ference, as by the application of leeches orcupping. This is not at all inconsistent; with the use of tonic remedies, which of; themselves, and without the aid of previousbloodletting, would probably have failed to dogood. The practice of Sydenham, whichwas that of alternate bleeding and purging,; is probably adapted to the greater number

of cases, and agrees perfectly well with thetheory I have proposed; while, at the sameFtime, I can state from experience, that withthe exceptions mentioned, it will be found

eminently successful. Some, of late, haverecommended purging alone, as the only re-

medy required for the cure of this disease :but this is too exclusive. I may observe to. you, in conclusion, that whatever mode of

practice is adopted, several months often

elapse before a cure is effected ; whichleads to a suspicion, that the terminationmay be in reality spontaneous, in manycases where we ascribe it to the remedieswe have employed.

ZOOLOGICAL SOCIETY.

13th JUNE, 1827.

Mr. BrtooxFS’s last lecture excited evenmore attention if possible than either ofthe preceding. It was chiefly on the ana-tomy and physiology of the heart and lungsof the ostrich and vertebrated animals.The assembly was numerous, and inter.

spersed with many individuals of distinc-tion.Mr. Brookes began his discourse by a

reference to a part of his last lecture, leftunfinished, on volitant mammalia ; for ex-

ample, by showing a superb specimen ofthe petaurus macrourus, the largest of theflying quadrupeds, and the aorobatapygmoea,the smallest, and subsequently he expatiatedon the fore arm of some of the mammalia ;for instance, in the internal condyle of thegenerality of the carnivora, and in manyother quadrupeds, there is a hole for the pas-sage and protection of the brachial artery:he also pointed out the very singular and