Zoonomia/II.III.I.I

CLASS III.

DISEASES OF VOLITION.

ORDO I.

Increased Volition.

GENUS I.

Increased Actions of the Muscles.

We now step forward to consider the diseases of volition, that superior faculty of the sensorium, which gives us the power of reason, and by its facility of action distinguishes mankind from brute animals; which has effected all that is great in the world, and superimposed the works of art on the situations of nature.

Pain is introduced into the system either by excess or defect of the action of the part. (Sect. IV. 5.) Both which circumstances seem to originate from the accumulation of sensorial power in the affected organ. Thus when the skin is exposed to great cold, the activity of the cutaneous vessels is diminished, and in consequence an accumulation of sensorial power obtains in them, because they are usually excited into incessant motion by the stimulus of heat, as explained in Sect. XII. 5. 2. Contrarywise, when the vessels of the skin are exposed to great heat, an excess of sensorial power is also produced in them, which is derived thither by the increase of stimulus above what is natural.

This accounts for the relief which is received in all kinds of pain by any violent exertions of our muscles or organs of sense; which may thus be in part ascribed to the exhaustion of the sensorial power by such exertions. But this relief is in many cases so instantaneous, that it seems nevertheless probable, that it is also in part owing to the different manner of progression of the two sensorial powers of sensation and volition; one of them commencing at some extremity of the sensorium, and being propagated towards the central parts of it; and the other commencing in the central parts of the sensorium, and being propagated towards the extremities of it; as mentioned in Sect. XI. 2. 1.

These violent voluntary exertions of our muscles or ideas to relieve the sensation of pain constitute convulsions and madness; and are distinguished from the muscular actions owing to increased sensation, as in sneezing, or coughing, or parturition, or ejectio feminis, because they do not contribute to dislodge the cause, but only to prevent the sensation of it. In two cases of parturition, both of young women with their first child, I have seen general convulsions occur from excess of voluntary exertion, as above described, instead of the actions of particular muscles, which ought to have been excited by sensation for the exclusion of the fetus. They both became insensible, and died after some hours; from one of them the fetus was extracted in vain. I have heard also of general convulsions being excited instead of the actions of the musculi acceleratores in the ejectio feminis, which terminated fatally. See Class III. 1. 1. 7.

These violent exertions are most frequently excited in consequence of those pains, which originate from defect of the action of the part. See Sect. XXXIV. 1. and 2. The pains from excess and defect of the action of the part are distinguishable from each other by the former being attended with increase of heat in the pained part, or of the whole body; while the latter not only exist without increase of heat in the pained part, but are generally attended with coldness of the extremities of the body.

As soon as these violent actions of our muscular or sensual fibres for the purpose of relieving pain cease to be exerted, the pain recurs; whence the reciprocal contraction and relaxation of the muscles in convulsion, and the intervals of madness. Otherwise these violent exertions continue, till so great a part of the sensorial power is exhausted, that no more of it is excitable by the faculty of volition; and a temporary apoplexy succeeds, with snoring as in profound sleep; which so generally terminates epileptic fits.

When these voluntary exertions become so connected with certain disagreeable sensations, or with irritations, that the effort of the will cannot restrain them, they can no longer in common language be termed voluntary; but nevertheless belong to this class, as they are produced by excess of volition, and may still not improperly be called depraved voluntary actions. See Sect. XXXIV. 1. where many motions in common language termed involuntary are shewn to depend on excess of volition.

When these exertions from excess of volition, which in common language are termed involuntary motions, either of mind or body, are perpetually exerted in weak constitutions, the pulse becomes quick; which is occasioned by the too great expenditure of the sensorial power in these unceasing modes of activity. In the same manner as in very weak people in fevers, the pulse sometimes increases in frequency to 140 strokes in a minute, when the patients stand up or endeavour to walk; and subsides to 110, when they lie down again in their beds. Whence it appears, that when a very quick pulse accompanies convulsion or insanity, it simply indicates the weakness of the patient; that is, that the expenditure of sensorial power is too great for the supply of it. But if the strength of the patient is not previously exhausted, the exertions of the muscles are attended with temporary increase of circulation, the reciprocal swellings and elongations of their bellies push forwards the arterial blood, and promote the absorption of the venous blood; whence a temporary increase of secretion and of heat, and a stronger pulse.

SPECIES.

1. Jactitatio. Restlessness. There is one kind of restlessness attending fevers, which consists in a frequent change of posture to relieve the uneasiness of the pressure of one part of the body upon another, when the sensibility of the system, or of some parts of it, is increased by inflammation, as in the lumbago; which may sometimes be distinguished in its early stage by the incessant desire of the patient to turn himself in bed. But there is another restlessness, which approaches towards writhing or contortions of the body, which is a voluntary effort to relieve pain; and may be esteemed a slighter kind of convulsion, not totally unrestrainable by opposite or counteracting volitions.

M. M. A blister. Opium. Warm bath.

2. Tremor febrilis. Reciprocal convulsions of the subcutaneous muscles, originating from the pain of the sense of heat, owing to defect of its usual stimulus, and consequent accumulation of sensorial power in it. The actual deficiency of heat may exist in one part of the body, and the pain of cold be felt most vividly in some other part associated with it by sensitive sympathy. So a chillness down the back is first attended to in ague-fits, though the disease perhaps commences with the torpor and consequent coldness of some internal viscus. But in whatever part of the system the defect of heat exists, or the sensation of it, the convulsions of the subcutaneous muscles exerted to relieve it are very general; and, if the pain is still greater, a chattering of the teeth is added, the more suddenly to exhaust the sensorial power, and because the teeth are very sensible to cold.

These convulsive motions are nevertheless restrainable by violent voluntary counteraction; and as their intervals are owing to the pain of cold being for a time relieved by their exertion, they may be compared to laughter, except that there is no interval of pleasure preceding each moment of pain in this as in the latter.

M. M. See I. 2. 2. 1.

3. Clamor. Screaming from pain. The talkative animals, as dogs, and swine, and children, scream most, when they are in pain, and even from fear; as they have used this kind of exertion from their birth most frequently and most forcibly; and can therefore sooner exhaust the accumulation of sensorial power in the affected muscular or sensual organs by this mode of exertion; as described in Sect. XXXIV. 1. 3. This facility of relieving pain by screaming is the source of laughter, as explained below.

4. Risus. The pleasurable sensations, which occasion laughter, are perpetually passing into the bounds of pain; for pleasure and pain are often produced by different degrees of the same stimulus; as warmth, light, aromatic or volatile odours, become painful by their excess; and the tickling on the soles of the feet in children is a painful sensation at the very time it produces laughter. When the pleasurable ideas, which excite us to laugh, pass into pain, we use some exertion, as a scream, to relieve the pain, but soon stop it again, as we are unwilling to lose the pleasure; and thus we repeatedly begin to scream, and stop again alternately. So that in laughing there are three stages, first of pleasure, then pain, then an exertion to relieve that pain. See Sect. XXXIV. 1. 3.

Every one has been in a situation, where some ludicrous circumstance has excited him to laugh; and at the same time a sense of decorum has forbid the exertion of these interrupted screams; and then the pain has become so violent, as to occasion him to use some other great action, as biting his tongue, and pinching himself, in lieu of the reiterated screams which constitute laughter.

5. Convulsio. Convulsion. When the pains from defect or excess of motion are more distressing than those already described, and are not relievable by such partial exertions, as in screaming, or laughter, more general convulsions occur; which vary perhaps according to the situation of the pained part, or to some previous associations formed by the early habits of life. When these convulsive motions bend the body forwards, they are termed emprosthotonoi; when they bend it backward, they are termed opisthotonoi. They frequently succeed each other, but the opisthotonoi are generally more violent; as the muscles, which erect the body, and keep it erect, are naturally in more constant and more forcible action than their antagonists.

The causes of convulsion are very numerous, as from toothing in children, from worms or acidity in their bowels, from eruption of the distinct small-pox, and lastly, from breathing too long the air of an unventilated bed-room. Sir G. Baker, in the Transactions of the College, described this disease, and detected its cause; where many children in an orphan-house were crowded together in one chamber without a chimney, and were almost all of them affected with convulsion; in the hospital at Dublin, many died of convulsions before the real cause was understood. See Dr. Beddoes's Guide to Self-preservation. In a large family, which I attended, where many female servants slept in one room, which they had contrived to render inaccessible to every blast of air; I saw four who were thus seized with convulsions, and who were believed to have been affected by sympathy from the first who fell ill. They were removed into more airy apartments, but were some weeks before they all regained their perfect health.

Convulsion is distinguished from epilepsy, as the patient does not intirely lose all perception during the paroxysm. Which only shews, that a less exhaustion of sensorial power renders tolerable the pains which cause convulsion, than those which cause epilepsy. The hysteric convulsions are distinguished from those, owing to other causes, by the presence of the expectation of death, which precedes and succeeds them, and generally by a flow of pale urine; these convulsions do not constantly attend the hysteric disease, but are occasionally superinduced by the disagreeable sensation arising from the torpor or inversion of a part of the alimentary canal. Whence the convulsion of laughter is frequently sufficient to restrain these hysteric pains, which accounts for the fits of laughter frequently attendant on this disease.

M. M. To remove the peculiar pain which excites the convulsions. Venesection. An emetic. A cathartic with calomel. Warm-bath. Opium in large quantities, beginning with smaller ones. Mercurial frictions. Electricity. Cold-bath in the paroxysm; or cold aspersion. See Memoirs of Med. Society, Lon. V. 3. p. 147. a paper by Dr. Currie.

Convulsio debilis. The convulsions of dying animals, as of those which are bleeding to death in the slaughter-house, are an effort to relieve painful sensation, either of the wound which occasions their death, or of faintness from want of due distention of the blood-vessels. Similar to this in a less degree is the subsultus tendinum, or starting of the tendons, in fevers with debility; these actions of the muscles are too weak to move the limb, but the belly of the acting muscles is seen to swell, and the tendon to be stretched. These weak convulsions, as they are occasioned by the disagreeable sensation of faintness from inanition, are symptoms of great general debility, and thence frequently precede the general convulsions of the act of dying. See a case of convulsion of a muscle of the arm, and of the fore-arm, without moving the bones to which they were attached, Sect. XVII. 1. 8. See twitchings of the face, Class IV. 1. 3. 2.

6. Convulsio dolorifica. Raphania. Painful convulsion. In this disease the muscles of the arms and legs are exerted to relieve the pains left after the rheumatism in young and delicate people; it recurs once or twice a-day, and has been mistaken for the chorea, or St. Vitus's dance; but differs from it, as the undue motions in that disease only occur, when the patient endeavours to exert the natural ones; are not attended with pain; and cease, when he lies down without trying to move: the chorea, or dance of St. Vitus, is often introduced by the itch, this by the rheumatism.

It has also been improperly called nervous rheumatism; but is distinguished from rheumatism, as the pains recur by periods once or twice a day; whereas in the chronic rheumatism they only occur on moving the affected muscles. And by the warmth of a bed the pains of the chronic rheumatism are increased, as the muscles or membranes then become more sensible to the stimulus of the extraneous mucaginous material deposited under them. Whereas the pains of the raphania, or painful convulsion, commence with coldness of the part, or of the extremities. See Rheumatismus chronicus, Class I. 1. 3. 12.

The pains which accompany the contractions of the muscles in this disease, seem to arise from the too great violence of those contractions, as happens in the cramp of the calf of the leg; from which they differ in those being fixed, and these being reiterated contractions. Thus these convulsions are generally of the lower limbs, and recur at periodical times from some uneasy sensation from defect of action, like other periodic diseases; and the convulsions of the limbs relieve the original uneasy painful sensation, and then produce a greater pain from their own too vehement contractions. There is however another way of accounting for these pains, when they succeed the acute rheumatism; and that is by the coagulable lymph, which may be left still unabsorbed on the membranes; and which may be in too small quantity to affect them with pain in common muscular exertions, but may produce great pain, when the bellies of the muscles swell to a larger bulk in violent action.

M. M. Venesection. Calomel. Opium. Bark. One grain of calomel and one of opium for ten successive nights. A bandage spread with emplastrum de minio put tight on the affected part.

7. Epilepsia is originally induced, like other convulsions, by a voluntary exertion to relieve some pain. This pain is most frequently about the pit of the stomach, or termination of the bile-duct; and in some cases the torpor of the stomach, which probably occasioned the epileptic fits, remains afterwards, and produces a chronical anorexia; of which a case is related in Class II. 2. 2. 1. There are instances of its beginning in the heel, of which a case is published by Dr. Short, in the Med. Essays, Edinb. I once saw a child about ten years old, who frequently fell down in convulsions, as she was running about in play; on examination a wart was found on one ancle, which was ragged and inflamed; which was directed to be cut off, and the fits never recurred.

When epilepsy first commences, the patients are liable to utter one scream before they fall down; afterwards the convulsions so immediately follow the pain, which occasions them, that the patient does not recollect or seem sensible of the preceding pain. Thus in laughter, when it is not excessive, a person is not conscious of the pain, which so often recurs, and causes the successive screams or exertions of laughter, which give a temporary relief to it.

Epileptic fits frequently recur in sleep from the increase of sensibility at that time, explained in Sect. XVIII. 14. In two such cases, both of young women, one grain of opium given at night, and continued many months, had success; in one of them the opium was omitted twice at different times, and the fit recurred on both the nights. In the more violent case, described in Sect. XVIII. 15, opium had no effect.

Epileptic fits generally commence with setting the teeth, by which means the tongue is frequently wounded; and with rolling the eyeballs in every kind of direction; for the muscles which suspend the jaw, as well as those which move the eyes, are in perpetual motion during our waking hours; and yet continue subservient to volition; hence their more facile and forcible actions for the purpose of relieving pain by the exhaustion of sensorial power. See Section XXXIV. 1. 4.

Epileptic convulsions are not attended with the fear of death, as in the hysteric disease, and the urine is of a straw colour. However it must be noted, that the disagreeable sensations in hysteric diseases sometimes are the cause of true epileptic convulsions, of syncope, and of madness.

The pain, which occasions some fits of epilepsy, is felt for a time in a distant part of the system, as in a toe or heel; and is said by the patient gradually to ascend to the head, before the general convulsions commence. This ascending sensation has been called aura epileptica, and is said to have been prevented from affecting the head by a tight bandage round the limb. In this malady the pain, probably of some torpid membrane, or diseased tendon, is at first only so great as to induce slight spasms of the muscular fibres in its vicinity; which slight spasms cease on the numbness introduced by a tight bandage; when no bandage is applied, the pain gradually increases, till generally convulsions are exerted to relieve it. The course of a lymphatic, as when poisonous matter is absorbed; or of a nerve, as in the sciatica, may, by the sympathy existing between their extremities and origins, give an idea of the ascent of an aura or vapour.

In difficult parturition it sometimes happens, that general convulsions are excited to relieve the pain of labour, instead of the exertions of those muscles of the abdomen and diaphragm, which ought to forward the exclusion of the child. See Class III. 1. 1. That is, instead of the particular muscular actions, which ought to be excited by sensation to remove the offending cause, general convulsions are produced by the power of volition, which still the pain, as in common epilepsy, without removing the cause; and, as the parturition is not thus promoted, the convulsions continue, till the sensorial power is totally exhausted, that is, till death. In patients afflicted with epilepsy from other causes, I have seen the most violent convulsions recur frequently during pregnancy without miscarriage, as they did not tend to forward the exclusion of the fetus.

M. M. Venesection. A large dose of opium. Delivery.

The later in life epileptic fits are first experienced, the more dangerous they may be esteemed in general; as in these cases the cause has generally been acquired by the habits of the patient, or by the decay of some part, and is thus probably in an increasing state. Whereas in children the changes in the system, as they advance to puberty, sometimes removes the cause. So in toothing, fits of convulsion with stupor frequently occur, and cease when the tooth advances; but this is not to be expected in advanced life. Sir ——, about sixty years of age, had only three teeth left in his upper jaw, a canine tooth, and one on each side of it. He was seized with epileptic fits, with pain commencing in these teeth. He was urged to have them extracted, which he delayed too long, till the fits were become habitual, and then had them extracted in vain, and in a few months sunk under the disease.

Mr. F——, who had lived intemperately, and had been occasionally affected with the gout, was suddenly seized with epileptic fits; the convulsions were succeeded by apoplectic snoring; from which he was, in about 20 minutes, disturbed by fresh convulsions, and had continued in this situation above four-and-twenty hours. About eight ounces of blood were then taken from him; and after having observed, that the apoplectic's torpor continued about 20 minutes, I directed him to be forcibly raised up in bed, after he had thus lain about fifteen minutes, to gain an interval between the termination of the sleep, and the renovation of convulsion. In this interval he was induced to swallow forty drops of laudanum. Twenty more were given him in the same manner in about half an hour, both which evidently shortened the convulsion fits, and the consequent stupor; he then took thirty more drops, which for the present removed the fits. He became rather insane the next day, and after about three more days lost the insanity, and recovered his usual state of health.

The case mentioned in Sect. XXVII. 2. where the patient was left after epileptic fits with a suffusion of blood beneath the tunica adjunctiva of the eye, was in almost every respect similar to the preceding, and submitted to the same treatment. Both of them suffered frequent relapses, which were relieved by the same means, and at length perished, I believe, by the epileptic fits.

In those patients, who have not been subject to epilepsy before they have arrived to about forty years of age, and who have been intemperate in respect to spirituous potation, I have been induced to believe, that the fits were occasioned by the pain of a diseased liver; and this became more probable in one of the above subjects, who had used means to repel eruptions on the face; and thus by some stimulant application had prevented an inflammation taking place on the skin of the face instead of on some part of the liver. Secondly, as in these cases insanity had repeatedly occurred, which could not be traced from an hereditary source; there is reason to believe, that this as well as the epileptic convulsions were caused by spirituous potation; and that this therefore is the original source both of epilepsy and of insanity in those families, which are afflicted with them. This idea however brings some consolation with it; as it may be inferred, that in a few sober generations these diseases may be eradicated, which otherwise destroy the family.

M. M. Venesection. Opium. Bark. Steel. Arsenic. Opium one grain twice a day for years together. See the preceding article.

8. Epilepsia dolorifica. Painful epilepsy. In the common epilepsy the convulsions are immediately induced, as soon as the disagreeable sensation, which causes them, commences; but in this the pain continues long with cold extremities, gradually increasing for two or three hours, till at length convulsions or madness come on; which terminate the daily paroxysm, and cease themselves in a little time afterwards.

This disease sometimes originates from a pain about the lower edge of the liver, sometimes in the temple, and sometimes in the pudendum; it recurs daily for five or six weeks, and then ceases for several months. The pain is owing to defect of action, that is, to the accumulation of sensorial power in the part, which probably sympathizes with some other part, as explained in Sect. XXXV. 2. XII. 5. 3. and Class II. 1. 1. 11. and IV. 2. 2. 3.

It is the most painful malady that human nature is liable to!—See Sect. XXXIV. 1. 4.

Mrs. C—— was seized every day about the same hour with violent pain on the right side of her bowels about the situation of the lower edge of the liver, without fever, which increased for an hour or two, till it became totally intolerable. After violent screaming she fell into convulsions, which terminated sometimes in fainting, with or without stertor, as in common epilepsy; at other times a tempory insanity supervened; which continued about half an hour, and the fit ceased. These paroxysms had returned daily for two or three weeks, and were at length removed by large doses of opium, like the fits of reverie or somnambulation. About half an hour before the expected return of the fit three or four grains of opium were exhibited, and then tincture of opium was given in warm brandy and water about 20 or 30 drops every half hour, till the eyes became somewhat inflamed, and the nose began to itch, and by the sharp movements of the patient, or quick speech, an evident intoxication appeared; and then it generally happened that the pain ceased. But the effects of this large dose of opium was succeeded by perpetual sickness and efforts to vomit, with great general debility all the succeeding day.

The rationale of this temporary cure from the exhibition of opium and vinous spirit depends on the great expenditure of sensorial power in the increased actions of all the irritative motions, by the stimulus of such large quantities of opium and vinous spirit; together with the production of much sensation, and many movements of the organs of sense or ideas in consequence of that sensation; and lastly, even the motions of the arterial system become accelerated by this degree of intoxication, all which soon exhausted so much sensorial power as to relieve the pain; which would otherwise have caused convulsions or insanity, which are other means of expending sensorial power. The general debility on the succeeding day, and the particular debility of the stomach, attended in consequence with sickness and frequent efforts to vomit, were occasioned by the system having previously been so strongly stimulated, and those parts in particular on which the opium and wine more immediately acted. This sickness continued so many hours as to break the catenation of motions, which had daily reproduced the paroxysm; and thus it generally happened, that the whole disease ceased for some weeks or months from one great intoxication, a circumstance not easily to be explained on any other theory.

The excess or defect of motion in any part of the system occasions the production of pain in that part, as in Sect. XII. 1. 6. This defect or excess of fibrous action is generally induced by excess or defect of the stimulus of objects external to the moving organ. But there is another source of excessive fibrous action, and consequent pain, which is from excess of volition, which is liable to affect those muscles, that have weak antagonists; as those which support the under jaw, and close the mouth in biting, and those of the calf of the leg; which are thus liable to fixed or painful contractions, as in trismus, or locked jaw, and in the cramp of the calf of the leg; and perhaps in some colics, as in that of Japan: these pains, from contraction arising from excess of volition in the part from the want of the counteraction of antagonist muscles, may give occasional cause to epileptic fits, and may be relieved in the same way, either by exciting irritative and sensitive motions by the stimulus of opium and wine; or by convulsions or insanity, as described above, which are only different methods of exhausting the general quantity of sensorial power.

Considering the great resemblance between this kind of painful epilepsy and the colic of Japan, as described by Kemfer; and that that disease was said to be cured by acupuncture, or the prick of a needle; I directed some very thin steel needles to be made about three inches long, and of such a temper, that they would bend double rather than break; and wrapped wax thread over about half an inch of the blunt end for a handle. One of these needles, when the pain occurred, was pushed about an inch into the painful part, and the pain instantly ceased; but I was not certain, whether the fear of the patient, or the stimulus of the puncture, occasioned the cessation of pain; and as the paroxysm had continued some weeks, and was then declining, the experiment was not tried again. The disease is said to be very frequent in Japan, and its seat to be in the bowels, and that the acupuncture eliminates the air, which is supposed to distend the bowel. But though the aperture thus made is too small to admit of the eduction of air; yet as the stimulus of so small a puncture may either excite a torpid part into action, or cause a spasmodic one to cease to act; and lastly, as no injury could be likely to ensue from so small a perforation, I should be inclined at some future time to give this a fairer trial in similar circumstances.

Another thing worth trial at the commencement of this deplorable disease would be electricity, by passing strong shocks through the painful part; which, whether the pain was owing to the inaction of that part, or of some other membrane associated with it, might stimulate them into exertion; or into inactivity, if owing to fixed painful contraction.

And lastly, the cold bath, or aspersions with cold water on the affected part, according to the method of Dr. Currie in the Memoirs of a Med. Soc. London, V. iii. p. 147, might produce great effect at the commencement of the pain. Nevertheless opium duly administered, so as to precede the expected paroxysm, and in such doses, given by degrees, as to induce intoxication, is principally to be depended upon in this deplorable malady. To which should be added, that if venesection can be previously performed, even to but few ounces, the effect of the opium is much more certain; and still more so, if there be time to premise a brisk cathartic, or even an emetic. The effect of increased stimulus is so much greater after previous defect of stimulus; and this is still of greater advantage where the cause of the disease happens to consist in a material, which can be absorbed. See Art. IV. 2. 8.

M. M. Venesection. An emetic. A cathartic. Warm bath. Opium a grain every half hour. Wine. Spirit of wine. If the patient becomes intoxicated by the above means, the fit ceases, and violent vomitings and debility succeed on the subsequent day, and prevent a return. Blisters or sinapisms on the small of the leg, taken off when they give much pain, are of use in slighter convulsions. Acupuncture. Electricity. Aspersion with cold water on the painful part.

9. Somnambulismus. Sleep-walking is a part of reverie, or studium inane, described in Sect. XIX. In this malady the patients have only the general appearance of being asleep in respect to their inattention to the stimulus of external objects, but, like the epilepsies above described, it consists in voluntary exertions to relieve pain. The muscles are subservient to the will, as appears by the patient's walking about, and sometimes doing the common offices of life. The ideas of the mind also are obedient to the will, because their discourse is consistent, though they answer imaginary questions. The irritative ideas of external objects continue in this malady, because the patients do not run against the furniture of the room; and when they apply their volition to their organs of sense, they become sensible of the objects they attend to, but not otherwise, as general sensation is destroyed by the violence of their voluntary exertions. At the same time the sensations of pleasure in consequence of ideas excited by volition are vividly experienced, and other ideas seem to be excited by these pleasurable sensations, as appears in the case of Master A. Sect. XXXIV. 3. 1. where a history of a hunting scene was voluntarily recalled, with all the pleasurable ideas which attended it. In melancholy madness the patient is employed in voluntarily exciting one idea, with those which are connected with it by voluntary associations only, but not so violently as to exclude the stimuli of external objects. In reverie variety of ideas are occasionally excited by volition, and those which are connected with them either by sensitive or voluntary associations, and that so violently as to exclude the stimuli of external objects. These two situations of our sensual motions, or ideas, resemble convulsion and epilepsy; as in the former the stimulus of external objects is still perceived, but not in the latter. Whence this disease, so far from being connected with sleep, though it has by universal mistake acquired its name from it, arises from excess of volition, and not from a suspension of it; and though, like other kinds of epilepsy, it often attacks the patients in their sleep, yet those two, whom I saw, were more frequently seized with it while awake, the sleep-walking being a part of the reverie. See Sect. XIX. and XXXIV. 3. and Class II. 1. 7. 4. and III. 1. 2. 18.

M. M. Opium in large doses before the expected paroxysm.

10. Asthma convulsivum. The fits of convulsive asthma return at periods, and are attended with cold extremities, and so far resemble the access of an intermittent fever; but, as the lungs are not sensible to the pain of cold, a shivering does not succeed, but instead of it violent efforts of respiration; which have no tendency, as in the humoral asthma, to dislodge any offending material, but only to relieve the pain by exertion, like the shuddering in the beginning of ague-fits, as explained Class III. 1. 1. 2.

The insensibility of the lungs to cold is observable on going into frosty air from a warm room; the hands and face become painfully cold, but no such sensation is excited in the lungs; which is another argument in favour of the existence of a peculiar set of nerves for the purpose of perceiving the universal fluid matter of heat, in which all things are immersed. See Sect. XIV. 6. Yet are the lungs nevertheless very sensible to the deficiency of oxygen in the atmosphere, as all people experience, when they go into a room crowded with company and candles, and complain, that it is so close, they can scarcely breathe; and the same in some hot days in summer.

There are two diseases, which bear the name of asthma. The first is the torpor or inability of the minute vessels of the lungs, consisting of the terminations of the pulmonary and bronchial arteries and veins, and their attendant lymphatics; in this circumstance it resembles the difficulty of breathing, which attends cold bathing. If this continues long, a congestion of fluid in the air-cells succeeds, as the absorbent actions cease completely before the secerning ones; as explained in Class I. 1. 2. 3. And the coldness, which attends the inaction of these vessels, prevents the usual quantity of exhalation. Some fits cease before this congestion takes place, and in them no violent sweating nor any expuition of phlegm occurs. This is the humoral asthma, described at Class II. 1. 1. 7.

The second kind of asthma consists in the convulsive actions in consequence of the disagreeable sensations thus induced; which in some fits of asthma are very great, as appears in the violent efforts to raise the ribs, and to depress the diaphragm, by lifting the shoulders. These, so long as they contribute to remove the cause of the disease, are not properly convulsions, but exertions immediately caused by sensation; but in this kind of asthma they are only efforts to relieve pain, and are frequently preceded by other epileptic convulsions.

These two kinds of asthmas have so many resembling features, and are so frequently intermixed, that it often requires great attention to distinguish them; but as one of them is allied to anasarca, and the other to epilepsy, we shall acquire a clearer idea of them by comparing them with those disorders. A criterion of the humoral or hydropic asthma is, that it is relieved by copious sweats about the head and breast, which are to be ascribed to the sensitive exertions of the pulmonary vessels to relieve the pain occasioned by the anasarcous congestion in the air-cells; and which is effected by the increased absorption of the mucus, and its elimination by the retrograde action of those lymphatics of the skin, whose branches communicate with the pulmonary ones; and which partial sweats do not easily admit of any other explanation. See Class I. 3. 2. 8. Another criterion of it is, that it is generally attended with swelled legs, or other symptoms of anasarca. A criterion of the convulsive asthma may be had from the absence of these cold clammy sweats of the upper part of the body only, and from the patient having occasionally been subject to convulsions of the limbs, as in the common epilepsy.

It may thus frequently happen, that in the humoral asthma some exertions of the lungs may occur, which may not contribute to discharge the anasarcous lymph, but may be efforts simply to relieve pain; besides those efforts, which produce the increased absorption and elimination of it; and thus we have a bodily disease resembling in this circumstance the reverie, in which both sensitive and voluntary motions are at the same time, or in succession, excited for the purpose of relieving pain.

It may likewise sometimes happen, that the disagreeable sensation, occasioned by the congestion of lymph in the air-cells in the humoral or hydropic asthma, may induce voluntary convulsions of the respiratory organs only to relieve the pain, without any sensitive actions of the pulmonary absorbents to absorb and eliminate the congestion of serous fluid; and thus the same cause may occasionally induce either the humoral or convulsive asthma.

The humoral asthma has but one remote cause, which is the torpor of the pulmonary vessels, like that which occurs on going into the cold bath; or the want of absorption of the pulmonary lymphatics to take up the lymph effused into the air-cell. Whereas the convulsive asthma, like other convulsions, or epilepsies, may be occasioned by pain in almost any remote part of the system. But in some of the adult patients in this disease, as in many epilepsies, I have suspected the remote cause to be a pain of the liver, or of the biliary ducts.

The asthmas, which have been induced in consequence of the recess of eruptions, especially of the leprous kind, countenance this opinion. One lady I knew, who for many years laboured under an asthma, which ceased on her being afflicted with pain, swelling, and distortion of some of her large joints, which were esteemed gouty, but perhaps erroneously. And a young man, whom I saw yesterday, was seized with asthma on the retrocession, or ceasing of eruptions on his face.

The convulsive asthma, as well as the hydropic, are more liable to return in hot weather; which may be occasioned by the less quantity of oxygen existing in a given quantity of warm air, than of cold, which can be taken into the lungs at one inspiration. They are both most liable to occur after the first sleep, which is therefore a general criterion of asthma. The cause of this is explained in Sect. XVIII. 15. and applies to both of them, as our sensibility to internal uneasy sensation increases during sleep.

When children are gaining teeth, long before they appear, the pain of the gums often induces convulsions. This pain is relieved in some by sobbing and screaming; but in others a laborious respiration is exerted to relieve the pain; and this constitutes the true asthma convulsivum. In other children again general convulsions, or epileptic paroxysms, are induced for this purpose; which, like other epilepsies, become established by habit, and recur before the irritation has time to produce the painful sensation, which originally caused them.

The asthma convulsivum is also sometimes induced by worms, or by acidity in the stomachs of children, and by other painful sensations in adults; in whom it is generally called nervous asthma, and is often joined with other epileptic symptoms.

This asthma is distinguished from the peripneumony, and from the croup, by the presence of fever in the two latter. It is distinguished from the humoral asthma, as in that the patients are more liable to run to the cold air for relief, are more subject to cold extremities, and experience the returns of it more frequently after their first sleep. It is distinguished from the hydrops thoracis, as that has no intervals, and the patient sits constantly upright, and the breath is colder; and, where the pericardium is affected, the pulse is quick and unequal. See Hydrops Thoracis, I. 2. 3. 14.

M. M. Venesection once. A cathartic with calomel once. Opium. Assafœtida. Warm bath. If the cause can be detected, as in toothing or worms, it should be removed. As this species of asthma is so liable to recur during sleep, like epileptic fits, as mentioned in Section XVIII. 15. there was reason to believe, that the respiration of an atmosphere mixed with hydrogen, or any other innocuous air, which might dilute the oxygen, would be useful in preventing the paroxysms by decreasing the sensibility of the system. This, I am informed by Dr. Beddoes, has been used with decided success by Dr. Ferriar. See Class II. 1. 1. 7.

11. Asthma dolorificum. Angina pectoris. The painful asthma was first described by Dr. Heberden in the Transactions of the College; its principal symptoms consist in a pain about the middle of the sternum, or rather lower, on every increase of pulmonary or muscular exertion, as in walking faster than usual, or going quick up a hill, or even up stairs; with great difficulty of breathing, so as to occasion the patient instantly to stop. A pain in the arms about the insertion of the tendon of the pectoral muscle generally attends, and a desire of resting by hanging on a door or branch of a tree by the arms is sometimes observed. Which is explained in Class I. 2. 3. 14. and in Sect. XXIX. 5. 2.

These patients generally die suddenly; and on examining the thorax no certain cause, or seat, of the disease has been detected; some have supposed the valves of the arteries, or of the heart, were imperfect; and others that the accumulation of fat about this viscus or the lungs obstructed their due action; but other observations do not accord with these suppositions.

Mr. W——, an elderly gentleman, was seized with asthma during the hot part of last summer; he always waked from his first sleep with difficult respiration, and pain in the middle of his sternum, and after about an hour was enabled to sleep again. As this had returned for about a fortnight, it appeared to me to be an asthma complicated with the disease, which Dr. Heberden has called angina pectoris. It was treated by venesection, a cathartic, and then by a grain of opium given at going to bed, with ether and tincture of opium when the pain or asthma required, and lastly with the bark, but was several days before it was perfectly subdued.

This led me to conceive, that in this painful asthma the diaphragm, as well as the other muscles of respiration, was thrown into convulsive action, and that the fibres of this muscle not having proper antagonists, a painful fixed spasm of it, like that of the muscles in the calf of the leg in the cramp, might be the cause of death in the angina pectoris, which I have thence arranged under the name of painful asthma, and leave for further investigation.

From the history of the case of the late much lamented John Hunter, and from the appearances after death, the case seems to have been of this kind, complicated with vertigo and consequent affection of the stomach. The remote cause seems to have arisen from ossifications of the coronary arteries; and the immediate cause of his death from fixed spasm of the heart. Other histories and dissections are still required to put this matter out of doubt; as it is possible, that either a fixed spasm of the diaphragm, or of the heart, which are both furnished with but weak antagonists, may occasion sudden death; and these may constitute two distinct diseases.

Four patients I have now in my recollection, all of whom I believed to labour under the angina pectoris in a great degree; which have all recovered, and have continued well three or four years by the use, as I believe, of issues on the inside of each thigh; which were at first large enough to contain two pease each, and afterwards but one. They took besides some slight antimonial medicine for a while, and were reduced to half the quantity or strength of their usual potation of fermented liquor.

The use of femoral issues in angina pectoris was first recommended by Dr. Macbride, physician at Dublin, Med. Observ. & Enquir. Vol. VI. And I was further induced to make trial of them, not only because the means which I had before used were inadequate, but from the ill effect I once observed upon the lungs, which succeeded the cure of a small sore beneath the knee; and argued conversely, that issues in the lower limbs might assist a difficult respiration.

Mrs. L——, about fifty, had a small sore place about the size of half a pea on the inside of the leg a little below the knee. It had discharged a pellucid fluid, which she called a ley-water, daily for fourteen years, with a great deal of pain; on which account she applied to a surgeon, who, by means of bandage and a saturnine application, soon healed the sore, unheedful of the consequences. In less than two months after this I saw her with great difficulty of breathing, which with universal anasarca soon destroyed her.

The theory of the double effect of issues, as above related, one in relieving by their presence the asthma dolorificum, and the other in producing by its cure an anasarca of the lungs, is not easy to explain. Some similar effects from cutaneous eruptions and from blisters are mentioned in Class I. 1. 2. 9. In these cases it seems probable, that the pain occasioned by issues, and perhaps the absorption of a small quantity of aerated purulent matter, stimulate the whole system into greater energy of action, and thus prevent the torpor which is the beginning of so many diseases. In confirmation of this effect of pain on the system, I remember the case of a lady of an ingenious and active mind, who, for many of the latter years of her life, was perpetually subject to great pains of her head from decaying teeth. When all her teeth were gone, she became quite low spirited, and melancholy in the popular sense of that word, and after a year or two became universally dropsical and died.

M. M. Issues in the thighs. Five grains of rhubarb, and one sixth of a grain of emetic tartar every night for some months, with or without half a grain of opium. No stronger liquor than small beer, or wine diluted with twice its quantity of water. Since I wrote the above I have seen two cases of hydrops thoracis, attended with pain in the left arm, so as to be mistaken for asthma dolorificum, in which femoral issues, though applied early in the disease, had no effect.

12. Stridor dentium. The clattering of the teeth on going into cold water, or in the beginning of ague-fits, is an exertion along with the tremblings of the skin to relieve the pain of cold. The teeth and skin being more sensible to cold than the more internal parts, and more exposed to it, is the reason that the muscles, which serve them, are thrown into exertion from the pain of cold rather than those of respiration, as in screaming from more acute pain. Thus the poet,

Put but your toes into cold water, Your correspondent teeth will clatter.

In more acute pains the jaws are gnashed together with great vehemence, insomuch that sometimes the teeth are said to have been broken by the force. See Sect. XXXIV. 1. 3. In these cases something should be offered to the patient to bite, as a towel, otherwise they are liable to tear their own arms, or to bite their attendants, as I have witnessed in the painful epilepsy.

13. Tetanus trismus. Cramp. The tetanus consists of a fixed spasm of almost all the muscles of the body; but the trismus, or locked jaw, is the most frequent disease of this kind. It is generally believed to arise from sympathy with an injured tendon. In one case where it occurred in consequence of a broken ankle from a fall from a horse, it was preceded by evident hydrophobia. Amputation was advised, but not submitted to; two wounds were laid into one with scissors, but the patient died about the seventh day from the accident. In this case the wounded tendon, like the wounds from the bite of a mad dog, did not produce the hydrophobia, and then the locked jaw, till several days after the accident.

I twice witnessed the locked jaw from a pain beneath the sternum, about the part where it is complained of in painful asthma, or angina pectoris, in the same lady at some years distance of time. The last time it had continued two days, and she wrote her mind, or expressed herself by signs. On observing a broken tooth, which made a small aperture into her mouth, I rolled up five grains of opium like a worm about an inch long, and introducing it over the broken tooth, pushed it onward by means of a small crow-quill; as it dissolved I observed she swallowed her saliva, and in less than half an hour, she opened her mouth and conversed as usual.

Men are taught to be ashamed of screaming from pain in their early years; hence they are prone to exert the muscles of the jaws instead, which they have learnt to exert frequently and violently from their infancy; whence the locked jaw. This and the following spasm have no alternate relaxations, like the preceding ones; which is perhaps owing, first, to the weakness of their antagonist muscles, those which elevate the jaw being very strong for the purpose of biting and masticating hard substances, and for supporting the under jaw, with very weak antagonist muscles; and secondly, to their not giving sufficient relief even for a moment to the pain, or its preceding irritation, which excited them.

M. M. Opium in very large quantities. Mercurial ointment used extensively. Electricity. Cold bath. Dilate the wound, and fill it with lint moistened with spirit of turpentine; which inflames the wound, and cures or prevents the convulsions. See a case, Transact. of American Society, Vol. II. p. 227.

Wine in large quantities in one case was more successful than opium; it probably inflames more, which in this disease is desirable. Between two or three ounces of bark, and from a quart to three pints of wine a day, succeeded better than opium. Ib.

14. Tetanus dolorificus. Painful cramp. This kind of spasm most frequently attacks the calf of the leg, or muscles of the toes; it often precedes paroxysms of gout, and appears towards the end of violent diarrhœa, and from indigestion, or from acid diet. In these cases it seems to sympathize with the bowels, but is also frequently produced by the pain of external cold, and to the too great previous extension of the muscles, whence some people get the cramp in the extensor muscles of the toes after walking down hill, and of those of the calf of the leg after walking up a steep eminence. For the reason why these cramps commence in sleep, see Sect. XVIII. 15.

The muscle in this disease contracts itself to relieve some smaller pain, either from irritation or association, and then falls into great pain itself, from the too great action of its own fibres. Hence any muscle, by being too vehemently exerted, falls into cramp, as in swimming too forcibly in water, which is painfully cold; and a secondary pain is then induced by the too violent contraction of the muscle; though the pain, which was the cause of the contraction, ceases. Which accounts for the continuance of the contraction, and distinguishes this disease from other convulsions, which are relaxed and exerted alternately. Hence whatever may be the cause of the primary pain, which occasions the cramp of the calf of the leg, the secondary one is relievable by standing up, and thus by the weight of the body on the toes forcibly extending the contracted muscles. For the cause, which induces these muscles of the calf of the leg to fall into more violent contraction than other spasmodic muscles, proceeds from the weakness of their antagonist muscles; as they are generally extended again after action by the weight of the body on the balls of the toes. See the preceding article.

M. M. Rub the legs with camphor dissolved in oil, and let the patient wear stockings in bed. If a foot-board be put at the bed's feet, and the bed be so inclined, that he will rest a little with his toes against the foot-board, that pressure is said to prevent the undue contractions of the musculi gastrocnemii, which constitute the calf of the leg. In gouty patients, or where the bowels are affected with acidity, half a grain of opium, and six grains of rhubarb, and six of chalk, every night. Flesh-meat to supper. A little very weak warm spirit and water may be taken for present relief, when these cramps are very troublesome to weak or gouty patients.

15. Hydrophobia. Dread of water generally attending canine madness. I was witness to a case, where this disease preceded the locked jaw from a wound in the ankle, occasioned by a fall from a horse; as mentioned in the preceding article. It came on about the sixth day after the accident; when the patient attempted to swallow fluids, he became convulsed all over from the pain of this attempt, and spurted them out of his mouth with violence. It is also said to happen in some hysterical cases. Hence it seems rather the immediate consequence of a pained tendon, than of a contagious poison. And is so far analogous to tetanus, according with the opinions of Doctor Rusch and Doctor Percival.

In other respects, as it is produced by the saliva of an enraged animal instilled into a wound, it would seem analogous to the poison of venomous animals. And from the manner of its access so long after the bite, and of its termination in a short time, it would seem to resemble the progress of contagious fevers. See Sect. XXII. 3. 3.

If the patient was bitten in a part, which could be totally cut away, as a finger, even after the hydrophobia appears, it is probable it might cure it; as I suspect the cause still remains in the wounded tendon, and not in a diffused infection tainting the blood. Hence there are generally uneasy sensations, as cold or numbness, in the old cicatrix, before the hydrophobia commences. See a case in Medical Communications, Vol. II. p. 190.

If the diseased tendon could be inflamed without cutting it out, as by cupping, or caustic, or blister after cupping, and this in the old wound long since healed, after the hydrophobia commences, might prevent the spasms about the throat. As inflaming the teeth by the use of mercury is of use in some kinds of hemicrania. Put spirit of turpentine on the wound, wash it well. See Class I. 3. 1. 11. IV. 1. 2. 7.

M. M. Wine, musk, oil, internally. Opium, mercurial ointment, used extensively. Mercurial fumigation. Turpeth mineral. To salivate the patient as soon as possible. Exsection or a caustic on the scar, even after the appearance of hydrophobia. Put a tight bandage on the limb above the scar of the old wound to benumb the pained tendon, however long the wound may have been healed. Could a hollow catheter of elastic gum, caoutchouc, be introduced into the œsophagus by the mouth or nostril, and liquid nourishment be thus conveyed into the stomach? See Desault's Journal, Case I. where, in an ulcer of the mouth, such a catheter was introduced by the nostril, and kept in the œsophagus for a month, by which means the patient was nourished and preserved.

It is recommended by Dr. Bardsley to give oil internally by a similar method contrived by Mr. John Hunter. He covered a probang with the skin of a small eel, or the gut of a lamb or cat. It was tied up at one end above and below the sponge, and a slit made above the upper ligature; to the other end of the eel-skin or gut was fixed a bladder and pipe. The probang thus covered was introduced into the stomach, and the liquid food or medicine was put into the bladder and squeezed down through the eel-skin. Mem. of Society at Manchester. See Class I. 2. 3. 25.

Dr. Bardsley has endeavoured to prove, that dogs never experience the hydrophobia, or canine madness, without having been previously bitten or infected; and secondly, that the disease in this species of animal always shews itself in five or six weeks; and concludes from hence, that this dreadful malady might be annihilated by making all the dogs in Great Britain perform a kind of quarantine, by shutting them up for a certain number of weeks. Though the disease from the bite of the mad dog is perhaps more analogous to those from the wounds inflicted by venomous animals than to those from other contagious matter, yet these observations are well worthy further attention; which the author promises.