PATHOLOGY AND PRACTICE OP MEDICINE.
On the Neck as a Medical Region ; in Syncopal Seizures ; &>'c.
By Marshall Hall, M. D.,F. R. S., &c.
(Concluded.)
I trust the time will arrive when a minute knowledge of anatomy
and physiology will be esteemed to be as essential to the physician as
to the surgeon, and that this view of the subject will prevail, not in the
profession only, but in the public. Then, and not till then, will the
hydra-headed monster, quackery, become extinct. And yet it does
not appear to be exacting too much to require, that he who undertakes
to repair a complicated machine should first become acquainted with its
structure and springs of action, and the nature of its varied derange-
ments. '
A useful work might be written on Medical Anatomy and Physio-
logy. I have ventured to offer specimens of such a work, in treating
of the Neck as a medical region, and arriere circulation. In the
present paper I propose to add another topic to those already mentioned,
in noticing briefly the effect of conditions within the cranium and spinal
canal in inducing shock of the medulla oblongata, and of this on the
heart and stomach.
It will be observed, that all kinds of seizure to which I have ad-
verted, are spinal in their origin—emotion and causes of reflex action
acting variously on this centre of the nervous system—whatever their
forms, and whether these be cerebral or spinal, or, as I now proceed to
describe them, cardiac or stomachic.
For the seizure is not always one affecting the intellect, or the muscu-
lar system ; sometimes on the contrary, there are pallor and faintishness,
if not actual syncope, and nausea, if not vomiting.
This form of seizure—I purposely avoid the term epilepsy—arises
from the same causes as the others to which I have adverted. They
•belong to a Class of affections, which, however various and varied
in other respects, combine the symptoms of faintness or sickishness.
A fall, or blow on the head ; an apoplectic seizure ; hydrencephalus ;
loss of blood ; disgust, fear, and other forms of emotion, and sea-sick-
ness, are of this kind.
A fall or blow on the head may be regarded as likely to be more or
less serious in its ulterior effects, according as it is or is not followed by
pallor and sickness. The apoplectic seizure is frequently marked by
pallor and vomiting; a frequent, sometimes the only, symptom of
incipient hydrencephalus, is vomiting. Every one knows the effect of
certain emotions in blanching the cheeks, and inducing nausea; the
effects of loss of blood and of posture during bloodletting or hae-
morrhage ; the phenomena of sea-sickness : in all these cases it is
probable that the medulla oblongata is the precise part of the nervous
centres specially affected. It is on this part that the blow, or contre-
coup in the case of accident, that certain emotions, that the diminished
pressure of the column of spinal blood in bloodletting in the erect posi-
tion, and that the varied pressure of that column on the sea, have their
chief influence.
I have suggested the anatomy of the veins and muscles of the neck
as an important subject of inquiry to the physician. I would now
suggest a careful examination of the veins within the spinal canal and
cranium, as presenting another topic in medical anatomy of great
interest. Again, I would express my hope, that medicine, like surgery
will one day be based on the sciences of anatomy and physiology,
to the exclusion of ignorance and empiricism together. It was written
on the portal of the school of Plato ; OuStt?	ttot-ra. Is it
too much to ask of the legislature to enact that no one ignorant of
anatomy and physiology shall prescribe or administer medicine, and
cause the words	A'J’YSIOAOrOS fidito to be inscribed over our
Medical Colleges ? Anatomy, physiology, diagnosis, pathology, (that
is, living pathology,) therapeutics, (or the modus operandi of medi-
cine),—such are the steps to be taken by the scientific physician in his
visits to his patients. In the absence of any part of this knowledge,
he may descend to what is termed experience or experiment. He must
descend low, indeed, if he would place himself on a level with public
expectation and opinion. Men in general have no higher ideas of
medicine than those of a remedy, or of a collection of remedies, for a
disease or diseases. Of pathology and of therapeutics, of the nature
of morbid actions, and of the actions of remedies, and so of the Science
and rational treatment of disease, no adequate idea exists in the public
mind. But I proceed with my subject.
We do not find the most violent voluntary efforts to affect the brain.
No delirium or loss of consciousness attends or follows them. There
must be something more in convulsive actions than in mere voluntary
efforts, however violent, to produce these effects. What is the nature of
this additional impulse ? I imagine that the crushing influence of con-
vulsive action not only compresses the veins, but extends even to the
arteries ; and that the violence of action is thus applied in its unmiti-
gated form to the intermediate capillary vessels ! On the face, espe-
cially in the eyelids and adjacent portions of integument, we observe
minute ecchymoses, as the result of the epileptic convulsion, for instance ;
how much more may it be supposed that the delicate tissues of the
cerebrum and medulla suffer. We no longer wonder that delirium, or
oblivion or unconsciousness, either momentary or more persistent—that
a paroxysm of mania, a continued state of coma, that paralysis, or
general convulsion should be the occasional result, the intermediate
vessels being either gorged and distended with blood, or even ruptured,
with its effusion—cerebral or medullary ecchymosis, or haemorrhagy !
/The only other circumstances in which I have seen the minute
ecchymoses round the eye, to which I have adverted, are, parturition
and violent retching and vomiting. The former actually induces, occa-
sionally, a fit of apoplexy, or of mania. That the latter does not do so
is astonishing, and owing perhaps to the simultaneous feebleness of the
action of the heart, and emptied condition of the stomach, with the
yielding of the closed glottis, and expiration.
The violent cough of pertussis sometimes issues in convulsion.
But the difference between the effects of all these violent efforts, and
the condition induced by the simultaneous compression of the veins
and arteries of the neck, upwards, will be obvious on the least reflection.
It is usual to observe in intense blushing, not only the face, but even
the neck and bosom, involved in the suffusion. The course of the
blood, not only of the external jugular, but of the external mammary
vein, is arrested, the subclavian being compressed by spasm of the
subclavius.
In violent and general convulsion, the whole surface of the body, the
hands and the feet, became affected with lividity—an effect induced by
closure of the larynx and violent expiratory efforts, with the continued
and violent contraction of the muscles of the limbs on the deeply seated
veins.
Disease of the heart induces similar effects on the arriere circulation
more slowly, with congestion, or with effusion of blood or serum, in
the lungs, liver, kidney, and in the haemorrhoidal veins, as well as those
of the head, neck, and extremities.
A contracted condition of the right side of the heart, especially such
as would distend the vessels and induce swelling of the neck, would,
I imagine, arrest the coronary circulation, and prove as it does probably,
in too many instances, the cause of sudden death.
I may here remark that a painful paroxysmal spasm sometimes affects
the muscles of the upper part of the thorax. I have seen two cases of
this kind. I have not seen it described in any medical work.
There is something quite special, both in regard to the cause and form
of seizures, and to the susceptibility to their return.
Infantile convulsions, arising, as they do, from causes peculiar to this
age, do not present the protrusion of the tongue and its compression by
the closure of the maxilice, so usual in the adult; nor do they leave the
patient subject to epileptic seizures in after life, so frequently as we
might have expected.
A similar remark may be made in regard to puerperal convulsions;
the epileptic patient is not specially liable to puerperal convulsions, nor
do these leave the patient specially liable to epileptic seizures.
In epileptic patients in general, the cause and the form are usually the
same in the same individual, and the susceptibility is a susceptibility to
the same kind of seizure.
An unwholesome meal is frequently the common cause of the epilep-
tic seizure in the same, patient. In one patient there were regularly
epileptic seizures at each catamenial period for more than ten years.
No other excitant seemed to have any influence in inducing the
paroxysms, the first of which occurred on the very first appearance of
the catamenia. The rest occurred at each period only. The patient
married at the age of eighteen, and was never pregnant.
The form of the malady is also usually similar in its return in the
same patient; for instance, it is always cerebral, or always spinal, and,
in the same case, similar in form.
I formerly objected to the use of the term epilepsy altogether, on
account of the formidable meaning of this term, as generally used.
For, in fact, the term designates two kinds of malady—one the most
formidable and incurable with which we meet in practice—the other,
by no means incurable. The term epilepsy, if not discarded, may be
applied more extensively than is usually done to designate certain cases of
sickness and syncope, greatly allied to the less formidable epilepsy ;
and in this manner the force of the term may be diminished. “ Sick-
headache,” sickness, faintishness, vertigo, clammy perspiration, sickness
the effect of disgust, are not dissimilar from the milder epilepsy—the
“ petit mat" of the French writers. The effect on the susceptible
medulla oblongata of a swing, of sea-sickness, belong to the same class of
morbid affections, and deserve the designation of pixpa ertito^ia far
more than that physiological act to which it had been applied, whilst the
state of sleep may be viewed as a^xpaartort^ia, induced by such a tonic
action in the muscles of the neck, as, in the orbicularis, closes the eyelid.
There are seizures of a character altogether peculiar, and which
combine, in the same patient, pallor, or pale lividity, faintness or actual
syncope, sickishness or actual vomiting, sometimes with a clammy per-
spiration ; or one or two of these symptoms may occur without the
rest.
It is worthy of remark that the emotions, whilst each produces its
own peculiar effect through the spinal and ganglionic systems, have their
analogues, as it were, amongst the seizures of which the nervous system
is the seat. Thus anger causes the countenance to flush or to turn pale,
in various cases, and sometimes issues in apoplexy, epilepsy or syncope.
Seizures, as I would use the term, induce precisely similar effects in
different cases or circumstances. Even a fall or blow on the head, and
the apoplectic seizure, is apt to be attended or followed by pallor and
by vomiting, by which symptoms, indeed, its degree of severity is indi-
cated.
The most minute inquiries ought to be made, in every case of sudden
seizure, as to the appearance of the countenance. Pallor, and syncope,
and sickness, probably depend on shock to the medulla oblongata.
They become diagnostic, both of the seat and of the severity of the
affection.
Another form of seizure is that of delirium. This may last an hour,
several hours, or longer; it may even be protracted into a paroxysm of
mania.
Previous to the delirium, which lasted in one case from three o’clock
in the morning until six, pallor of the countenance followed by flushing
was observed. After this paroxysm had passed off, the mind was
observed to be enfeebled,
It was a cardiac or syncopal seizure followed by cerebral excitement.
The condition of the medulla oblongata has a special influence,
through the medium of the pneumogastric nerve, on that of the heart.
Even in the batrachian, it is almost impossible to retain the circula-
tion, after having destroyed or removed the medulla oblongata. In order
to accomplish this in the frog, the brain must be removed first ; then,
after an interval of several hours, the lower part of the spinal marrow ;
and lastly, after another similar interval, the medulla oblongata. Even
in this manner, it is only under favourable circumstances that the capil-
lary circulation remains good.
We need not wonder that, in the higher orders of animals, and espe-
cially in the human subject, any affection of the medulla oblongata in-
duces peculiar effects on the heart, and indeed, through the medium of
the same nerve, on the stomach, or that these effects should be vari-
ously combined with others manifested in the class of spasmodic disea-
ses. Sickness, for example, is sometimes joined with head affection,
receiving then the designation of “ sick-headach ; sometimes with epi-
leptoid seizures, sometimes with attacks of syncope.
The circulation within the medulla oblongata cannot become inordinate
without affection of the heart.
Besides the sensations and spasmodic actions about the neck, I have
repeatedly heard patients describe similar conditions extending across or
around the upper part of the thorax, a state of things which might be
mistaken for angina pectoris.
Every symptom attending or constituting sea-sickness points to the
medulla oblongata as the part of the nervous system chiefly or prima-
rily affected.
The respiration becomes impaired, a condition which is arrested by
drawing a deep sigh. The secretions of the stomach are deranged,
and there are acidity and heartburn, and the eructation of flatus. Next
the heart becomes feeble in its action, and the countenance turns pallid,
or pale and livid.
Then there is a diffused heat of the face and surface; all coverings
are thrown off; a clammy perspiration and actual vomiting ensue.
Acid fluid, mucus, bile, are rejected in their turn, and at the last
the attacks consist of painful contractions of the diaphragm or
hiccup, which sometimes continue for several minutes after the sick
ness is over, pointing distinctly, I imagine to the medulla oblongata,
as the central nervous organ chiefly affected, as, indeed, it is in every
kind of vomiting.
Meantime the cerebrum is unaffected ; the intellect is clear ; the
lower part of the spinalmarrow—the lower medulla oblongata—is also
unaffected ; the sphincters perform their office.
Sea-sickness resembles that form of epilepsy which I have noticed as
combining nausea and headache, except that there is no affection of the
cerebrum ; and it partakes, in some measure, of the nature of syncope.
The influence of posture points to irregular circulation in the
medulla oblongata, induced by the motion of the vessel, as the cause of
the series of phenomena in this painful affection.
There is a view of this subject which I approach with great diffi-
dence. A seizure—perhaps a hidden seizure—may take place, and
leave a monomaniacal propensity or ruling idea !
Under the influence of this propensity, Crime may be committed 1
Of such a case the Law, hitherto, equally with Medicine, has taken no
cognizance. The crime may be suicidal or homicidal, infanticidal, or
sexual, or perhaps directed against truth, honour, or property I
How fearful the consequences of such a state of tilings might be, I
need not say; but certainly every means should be employed to detect
such a hidden seizure in such a case, and especially the temples should
be examined, for ecchymosis ; the tongue, for a bitten wound ; the
pillow, for marks of foaming at the mouth ; and the linen, for the
stains left by some evacuation, whilst the patients should be carefully in-
terrogated, to detect the slightest incoherence or aberration of ideas, or
confusion or defect of memory.
Under all circumstances of sudden crime, the possibility of the occur-
rence of a seizure should be present to the mind ; how much more, if
the patient have been epileptic, or if the case be puerperal!
I have already remarked upon the treatment of this Class of diseases.
The principles which should guide us are—
1.	To avoid all emotion, or mental effort, or excitement.
2.	To preserve the stomach and intestines free from load or oppres-
sion.
3.	To act on all the secretions, especially those of the liver, the
kidney, the skin.
4.	To combine abundance of walking exercise with early hours ;
frictions, with ablutions of the general surface, warmth and dryness of
the feet, &c.
It is astonishing to see how much has been effected in many cases
apparently the most untoward, by a just combination of, and perse-
verance in, these remedies.
I beg once more to apologize for the style of these papers. I have
not had leisure for composition. They are intended merely io suggest
material for thought and reflection.—London Lancet.