 -
- p 383-387
-
- I shall only notice one more instance. The
momentary shock and rigidity of the frame which
occurs as an effect of surprise or alarm when we
"jump," as we say, at an unexpected appearance,
is not without its pathological representatives.
The painful and violent shock which some persons
experience when first dropping off to sleep is
an occurrence of a similar kind, and if too
familiar to be considered morbid, it certainly
occupies the confines between health and
disease, like hiccup, sneezing, and so many
minor explosive nervous actions; and with some
persons at certain times it occurs so frequently
and occasions so much distress as to amount to a
positive malady; it exhibits, moreover, in the
time of its occurrence a further conformity to
the neurosal character. Sir H. Holland has
pointed out that a very similar affection may
occur by day a as distinct malady of the
epileptic class -" In another instance which
happened to me lately, where the remarkable
symptom at the time was that singular shock or
jar which patients themselves often compare to
an electric shock, and which in this case
occurred with frequency and violence in the
lower limbs, the attacks when most severe in
degree, came on almost exactly at equal
intervals of somewhat more than two minutes . .
. . The patient in this case described the
sensation as 'a sudden shot into the limbs,
seeming as suddenly to disperse itself into
innumerable sparks which penetrated into every
corner of them.' Most persons," continues Sir
Henry, "will probably recognise in this
description a frequent occurrence of ordinary
health, where a sudden shock or jar is felt to
spread in an instant through the whole body,
happening generally without obvious cause, yet
most frequently during the approaches of
sleep."
-
- There remains one other class of facts
connected with the history of neurosal disorders
to which we have not hitherto referred, but
which may be briefly noticed here, as forming an
additional link between those disorders and the
actions of the healthy nervous system which most
nearly resemble them. I refer to the influence
of Involuntary Imitation and Habit in
determining or reproducing the seizures.
-
- Recurring once more to those normal
convulsive actions which belong to the
respiratory system. We all know how
involuntarily and often unconsciously the act of
yawning, if once started, will go the
round of a whole circle of people who are not
very actively engaged, and the interest and
significance of the fact are only lost sight of
in its familiarity. It is much the sanie with
the act of coughing; it sometimes requires a
considerable effort to resist the impulse to
cough in sympathy with another, and its epidemic
propagation through a whole assembly of people
may often be noticed in our churches. The same
influence may be observed in connexion with the
sensations and movements of sickness; many
people are made sick by merely seeing others so,
and in susceptible persons this is not confined
to the sense of nausea, but may extend to the
convulsive actions of retching and vomiting.
Cullen says of himself, "I have often coughed
when another person has coughed; and I cannot
help vomiting when I see another person
straining and vomiting." Even the natural
appetite for food admits of being considerably
heightened by company, and the sight of others
eating.
-
- It should be observed however, and the fact
bears directly on our present inquiry and the
analogy of neurosal phenomena, that this
influence of imitation becomes much more
apparent when the persons concerned are in any
way predisposed to the actions in question; to
yawning, for example, by weariness, to
coughing by the prevalence of catarrh, and to
sickness by being at sea.
-
- Again, in the case of the emotions and their
outward expression we trace the operation of the
same principle. Every due knows how a laughing
face makes us laugh and a suffering one makes us
sad; how quickly women and children are moved to
tears by the sight of others crying. Let a
person unexpectedly find himself in merry
company, and he is instantly caught by the
prevailing humour and laughing with the rest
before he has any distinct idea of the cause of
merrimeni. A curious instance of this
involuntary imitation of laughter is quoted by
Percival from Wesley's Journal. "Part of Sunday
my brother and I then used to spend in walking
in the meadows and singing psalms. But one day,
just as we were beginning to sing, he burst out
into loud laughter. I asked him if he was
distracted, and began to be very angry, and
presently after to laugh as loud as he. Nor
could we possibly refrain, though we were ready
to tear ourselves in pieces, but we were forced
to go home without singing another line."
-
- The power which great actors and orators
possess of working on the feelings of their
audience lies in their ability successfully to
assume the outward expressions and gestures of
the deeper passions. We have instances too of
the propagation of violent emotions among large
bodies of people, and of the accumulated
intensity they may attain by sympathetic
imitation, in the outbreaks of fury, of panic,
and of admiration, to which mobs and armies are
liable.
-
- If now we turn our attention to pathological
cases, we shall have no difficulty in tracing
the same influence of imitation in the case of
various neurosal seizures which we have just
observed under circumstances of health. Thus it
is a well established fact, that persons have
been rendered epileptic by seeing others so
affected. In a case of epilepsy recorded by Mr.
Solly, to which reference has already been made,
a little girl became epileptic at the age of
seven, after seeing her nurse in an epileptic
fit. So Van Swieten observes:-" I have known a
great many rendered epileptic and who have
remained so for the rest of their lives, from
another person falling down in a fit before
them; and there are a great many such cases to
be met with among medical writers."* The same
influence is still more strikingly seen in
hysteria. "It has frequently happened in the
ROyal Infirmary here (Edinburgh)," writes Robert
Whytt, "that women have been seized with
hysteric fits from seeing others attacked with
them ;"t and this experience has been repeatedly
confirmed. Dr. Bright relates in his reports of
cases at Guy's Hospital that having occasion to
pass a probang for an hysterical patient, the
operation was followed by a convulsive paroxysm,
which was immediately repeated among several
patients in the same ward. Dr. Laycock bas given
an interesting account of the spread of
hysterical retching and vomiting with other
symptoms among four female patients in the wards
of the York Hospital, so as to give rise at
first to a suspicion of poisoning; and it would
be easy to refer to many more instances.
-
p 357-359
-
- 1f now we pursue the comparison which has
here been suggested a little further into
detail, with particular reference to some of the
problems our subject presents, we shall find
much to confirm the foregoing analogies, and we
shall be able to trace among the same
physiological actions the representatives of
many circumstances in the history of megrim and
other neuroses which are among the most singular
and anomalous we have to explain. The class of
facts which more particularly deserve our
attention are the following
-
- A. The assumption from time to time of a
distinctly morbid and neurosal type by the
natural actions of which we have spoken, in
consequence either of a great exaggeration of
character or frequency or spontaneity of
recurrence.
- B. A certain capacity of substitution or
mutual replacement among such physiological
actions under circumstances of health, reminding
one of that same kind of equivalency among
various neurosal seizures which we have been at
some pains to trace in the preceding chapter.
-
- C. The transition not unfrequently observed
between these normal modes of activity and
certain well-known forms of neurosal
seizure, so that the former become influential
exciting causes of the latter; as when a mental
emotion determines an epileptic fit, or the
latter aborts in one of laughter.
-
- D. The still more remarkable, and at first
sight paradoxical power these normal actions
possess, not only of exciting but occasionally
also of dispersing others of a pathological
kind, and the consequent possibility of
sometimes anticipating the occurrence of an
expected neurosal paroxysm by the artificial
induction of a vicarious physiological action of
an explosive character.
-
- E. The occasional determination of these
definite trains of normal action by other
influences or impressions besides those to which
they are especially affiliated in connexion with
their final purpose in the economy, and which
call to mind the varied character and operation
of the different exciting causes of neurosal
seizures.
-
- These several points I shall now endeavour
to illustrate by reference to as many instances
as occur to me; and I think it will thus appear
that we are dealing with a class of phenomena,
both healthy and morbid, which are united in
obedience to certain common laws, and mutually
illustrate one another; their consideration
moreover will suggest I think some useful
reflections on the theories of neurosal
phenomena already discussed, and will help to
correct or enlarge our views in this branch of
pathology.
-
- I shall again have recourse for a first
illustration to those minor explosive nervous
actions which are limited to the Respiratory
Apparatus, such as sneezing, yawning, and
hiccup. It is an observation which we owe to no
less an authority than Hippocrates that-"
Sneezing coming on in a person afflicted with
hiccup removes the hiccup-"
-
 -
- The engagement of a neighbouring nervous
circle in repeated acts of deglutition will have
the same effect; so will the development of any
sudden emotion; and so will the induction of
that painful state of nervous tension-the sense
of "want of breath." We are all familiar with
the nursery expedients for the cure of
hiccup-the charm of the "three drops," the
frightening it away by a sudden surprise or
other emotion, repeating the well-known rhymes
in one breath, which requires at the same time a
strong effort of articulation.
-
- Trifling as these illustrations may seem,
they bring before us in epitome the operation of
the principles I have just enunciated; nor
should we forget, as I have already pointed out,
that although hiccup and sneezing are ordinarily
trivial occurrences, referrible to some
transient local irritation, they are sometimes
presented to us under a very distressing form,
as distinct idiopathic neuroses. Some years
since I had under my care, at King's College
Hospital, a case of this kind: the patient was a
man past middle-age, and hiccup had occurred in
paroxysms of twelve hours' duration, about twice
a week for four years. Dr. Prichard relates the
history of a little girl of twelve, who for
nearly three years was subject to fits of
violent hiccup, attacking her during sleep by
night as well as by day, the paroxysms lasting
from ten minutes to an hour, and recurring three
or four times in the course of a day and night.
Sneezing and gaping occasionally set in towards
the close, and the paroxysms usually ended in
headache. There were no worms, but the child was
cured by turpentine. Dr. Prichard justly
observes of such cases "that we may look upon
them as imperfect attempts to produce epilepsy,
or as differing from general epilepsy in some,
perhaps, trivial modification."
-
p 405-409
-
- Malarial Megrim
- Hemicrania Intermittens," or "Brow Ague,"
was once very common in this country, but is now
seldom met with, at least in town. I have
already referred to the endemic prevalence of a
malady of this kind in the Migrafia of some
parts of Spain and other malarial countries.
Most of the writers on megrim have recognised
Marsh poison as one of the causes of the
disorder. Robert Whytt, besides the idiopathic,
gastric, catamenial, and arthritic varieties of
periodical headache, describes a fifth as
maintaining exactly regular periods and
evidently of an aguish character, and he
mentions having found opium of great value in
the treatment of a violent quotidian
hemicrania.* Tissot himself appears to have
suffered from the epidemic prevalence of a
migraine of this kind. "When thus epidemic," he
says, "it is symptomatic of intermittent fever,
as I have experienced in my own case, and as has
been observed by M. Schobeit in a case where the
affection returned very regularly at the same
hour every other night, and terminated by
sweating."
-
- Dr. Macculloch, who has left us by far the
best treatise on malarial disorders which we
have in our language, and has especially
directed his attention to the aguish origin of
many neuroses, describes periodical headache as
one of the commonest of the masked or irregular
forms of intermittent fever; and with regard to
the situation and character of such headaches,
he considers "Hemicrania as undoubtedly the most
important variety." In other instances the pain
may be of a still more circumscribed character
and take the form of "clavus hystericus," which
is but a variety of megrim; and many of the
cases commonly known as "nervous headache," and
the so-called "determinations of blood to the
head," he believes to have a similar origin. As
an acute affection, or "brow ague" strictly
speaking, such periodical headache may, he says,
present "any of the types of Intermittent; and
if I have not myself seen it under every form, I
have at least known it as a double quotidian, as
a single one, and as a tertian."t It is,
however, the more chronic forms which have the
greatest interest for us, assuming as they do
more nearly the character of idiopathic megrim
in respect to periodicity and the length of
intervals. "Where the intermittent has been of
long duration, it is more common for the
periodical headache which is united with it to
recur in a very irregular manner, as is true
generally of the disorder in all its modes, when
of such standing; and it is in these cases
especially, that its real nature is so commonly
mistaken, as it then wants those obvious
characters which alone would arrest the
attention of a superficial observer."
-
- With regard to the dependence of such
hemicrania on malaria, "It will be found," Dr.
Macculloch says, "that this disorder is most
common in situations of the unhealthy nature
formerly described, and that it is often
directly brought on by causes which produce
ordinary Intermittent. But what affords a much
stronger proof of its identity, is the fact that
it occurs frequently, perhaps most frequently,
in those who labour under chronic Intermittents
or Remittents, or have formerly suffered from
these disorders. Thus it may occupy the whole
period of one relapse, as the substitute of what
would otherwise have been a common one; as it is
even found to do, in frequent interchanges, and
through a long life, in those who possess that
inveterate habit of intermittent which may
almost fairly be esteemed incurable. Still more
remarkably, it is sometimes found to interchange
by paroxysms with the common intermittent; or
the ordinary fever of one day is replaced on
another by the headache. Thus I have seen the
headache and the ague fit occupy alternate days,
a modification which may be considered a double
tertian, and proceeding thus through a long
period."
-
- Respecting the nature of its relation to
ague, Dr. Macculloch holds that the difference
between the regular and irregular forms of
malarial disorder is merely a difference of
localization of the same essential morbid action
in different territories of the nervous system:
"The action of malaria is on the nervous system,
on the whole and on the parts; or affecting the
whole in a slender manner, it may exert its
chief influence on some peculiar nerve or
portion of a nerve. And till we know more of
their nature and of this action, we cannot
pronounce a negative, or say, that no cause but
malaria shall produce even a simple
intermittent." And again-" Everything tends to
show that if the diseases produced by malaria
are not purely, and all, mere affections of the
nervous system, the principal action of this
poison is on that system, and the greater
proportion of the disorders which are caused by
it, disorders of the nerves."
-
- Under this view of its affinities with ague,
some other nervous phenomena which often attend
the headache, or form a part of the same
paroxysm, become at once intelligible-" Such as
previous yawning, increased and sudden
secretion of urine, spasmodic and hysterical
affections, derangements of the mental
faculties, and, as I conjecture, vomiting." With
regard to this associated vomiting, he adds-" In
this particular disorder (headache) that act
generally occupies the same place in the
paroxysm which it does in the common
intermittent (terminal); and though I do not
doubt that there is a headache, terminating in
vomiting, of a different nature, and commonly
called 'bilious headache,' I have had no
difficulty in tracing many reputed cases of this
nature to the disorder which I am now
describing."* In an earlier part of the treatise
he had written of this sickness, thus :-" I have
already remarked that the ordinary paroxysm of
an Intermittent sometimes terminates in
vomiting, while nausea also occurs in them as in
Chronic Remittents; often very durable and
forming a very distressing addition to the other
symptoms. In the cases to which I would here
specially call attention, and which are the
chronic ones, the vomiting becomes the most
conspicuous symptom, or even the only one which
the patient may notice.
-
- . . . I must also remark that it is very
commonly preceded by a state of drowsiness of
which it is the termination. It is, in reality,
in all cases where it occurs, the real
termination of the paroxysm, as in well-marked
Intermittents.
-
- I need only add, that as far as I have seen,
the vomiting is very transitory; occurring
whether the stomach is full or empty, and when
past, leaving it without any derangement, or
rather being the immediate forerunner of the
interval of temporary health. And when its
period is arrived, the slightest cause, even a
glass of water, will bring it on instantly;
while it also comes on at times with so little
previous notice, that the patient has not even
time to leave his seat or change his position.
Thus have I seen it continue for three months;
being either removed only bt the cessation of
that particular relapse, or else becomig
exchanged for some other local symptom."
-
-
-
|
