T~oraeic Aneurism and Dementia. 323

in the day time being usually dry; and according to Traube's researches, the critical evacuations in typhus fever, and among them perspiration, are always preceded by a considerable fall in the pulse. In many other cases depression of the heart's action is a well-known cause of perspiration--for example, those attending the syneopal state, which the inexperienced smoker falls into, the sweating which attends sea sickness, extreme purgation, the exhibition of tartarized antimony, and the effects of terror. The remedies which prove serviceable in the majority of cases of excessive general sweating are such as tend to remove depression of the heart's action and act as tonics on the vaso-motor nerves. The difference in gravity of import between local and general sweatings appears to be very great, because, although a partial sweating may excite more alarm and closer attention from the greater rarity of its occurrence, yet it does not appear that it is in most eases indicative of by any means as serious nervous disturbance as are the general sweatings.

.ART. XIV. - -Thoracie Aneurism and Dementia. By WILLIAM MOORE, M.D., Dub. Univ.; Fellow and Examiner in the " Practice of Medicine," King and Queen's College of Physicians; Physician to Mercer's Hospital; Physician-in-Ordinary to Sir P. Dun's Hospital; Lecturer on " Practice of ~r and on Clinical Medicine, &c.

THORACm .A~EURIS~ may be said to be relatively a rare disease. Now, among the cases of this affection which I have had an" opportunity of observing for some years, I have seen dementia a prominent symptom in three of them. This phenomenon struck me as remarkable, and therefore I thought a detail of these three instances might not prove devoid of interest, as going to show that mental diseases are more intimately associated with general pathological changes than some time ago they were believed to be, and that they may depend on comparatively remote, and frequently very obscure, exciting causes, the diagnosis of which must materially affect our prognosis and treatment.

CASE L--Mania, with General Incoherence; Aneurism of Trans- verse Portion of the T/wraeie Aorta.

Philip S., aged forty-seven, was admitted into Mcrcer's Hospital on the 1st of May, 1863. He had been a labourer for the past few years. About four years before his admission he was seized with a

v 2

824 Thoracic Aneurism and Dvmentia.

hard, dry cough, difficulty of breathing, and pain in the fight side; and about this date he spat some black blood, which reappeared from time to time. He complained of pain down the right arm after using it, the pain about the articulation of the humerus being very severe. For about a year previous to his admission he suffered from difficulty in swallowing, and his voice was subdued and hoarse. On making him take a deep inspiration the expansion of the chest was not equable, the right scapula being more movable than the left. There was absence of" respiration over this side, except under the scapula, where a faint respiratory murmur was audible ; respiration was audible over the right side. The heart's action was irregular; the pulse in the right wrist stronger than that in the left. The veins over the top of the chest generally were unduly prominent; there was contraction of both pupils, especially of the right. I made the diagnosis of thoracic aneurism mainly from the character o f the hemoptysis and the absence of respiration in the left lung, coupled with dysphagia. About a mouth after leaving hospital this patient was admitted into the Richmond Lunatic Asylum, where he died the day after his admission.

Dr, Banks was kind enough to show me the pathological condl- tions, which consisted of an aneurism, slightly pyriform in shape, which engaged the posterior portion of the ascending angle and transverse portion of the aortic arch; the heart was fatty, its valves intact; the brain was not examined. Now, whilst this patient was under my observation, his manner at times was so excitable and unsteady as to induce me to inquire carefully into his antecedents, when i learned he had been an inmate of a lunatic asylum some years previously, and afterwards was admitted into the Richmond Lunatic Asylum, as Dr. Lalor has told me, labouring under " mania, with delusions and general incoherence."

From the situation of the aneurism in this case, it might be reasonable to infer that the carotid supply was interfered with, and, in addition, that reflected nervous irritation may have played an important part in the production of the psychological phenomena present; but as the brain was not examined I am not disposed 1/o indulge in these hypotheses, but to confine myself to what we did find, viz., an intra-thoracic aneurism, associated with dementia.

C.~sE I I --l_)i~culty of Speech; Imperfection of Mental Powers ; Loss of Memory ; Paralysis of Motion and Sensation.

P ~rrI:[O LOG Y--Zarge 1'horacic Aneurism, with left Carotid Artery

By DR. W. Mooa•. 325

imperviouslY'ore its origin to its bifurcation ; atrophy of left hemisphere of the Brain.--Andrew F., aged forty-four, hy trade a shoemaker, was admitted into Mereer's Hospital suffering from neuralgic pains over the top of the sternum, from a troublesome cough and dysphagia. He complained of tightness of the skin of the left half of the face, of tingling sensations of the same half, and, at times, of intense heat of both ears. There was ptosis of the left eyelid and drooping of the left angle of the mouth. The left pupil was more contracted than the right, and a herpetic eruption covered the left half of the upper lip and chin, and other patches of herpes were present over the top of the chest and shoulders. The superficial veins over the upper part of the chest were remarkable, and a prominent tumour extended from the right clavicular articulation across tile sternum for more than an inch under the left clavicle, over which tumour a second centre of pulsation could be felt. The left radial pulse was indistinct, and the respiration was especially feeble over the left lung. In the month of May previous to admission he had an attack of eplstaxis, which gave him relief, and in October and November it returned, at the end of which the semi-ptosis of the left lid, the deformity of the mouth, the herpetic eruption, ringing laryngeal cough, partial aphonia, and visible tumour, were present; but the contraction of the pupil, the tightness of the muscles of the face, with increased heat of ears, had disappeared to a great extent.

On the 16th of March, 1864, this patient was admitted into the Whitworth Hospital under the care of Dr. Banks, four days pre. vious to which he was seized with severe~ headache and giddiness, his articulation having become so imperfect that he could scarcely be understood. On admission there was still some difficulty of articulation, and his mental powers were evidently v~ry imperfect ; his memory was quite gone. On being asked his age he stated that he was twenty.four, his }eal age being forty-five or forty-six. There was some slight paralys~s of the right side of the body and also of the right side of the face ; however, he was able to walk into hospital, hut on the second or third day after admission he completely lost all motion of the right side, and there was manifest anesthesia of the same.

On examining his chest a turnout was found, small in size, but of extreme hardness; it was prominent and occupied the upper part of the sternum, and extended to the right sterno.elavleular artieula-

Proceedings of Pathological Society, u ii., Part III.

326 T]wraclc Aneurism and Dementla~

tion. From the 16th March till 23rd May, when he left the hospital, Dr. Banks tells us that, so far as the tumour was concerned, there was no change, but the paralytic symptoms gradually disappeared; he recovered the motion of the right aide, and his memory returned.

It would be needless to follow the various phases this case presented till it proved fatal, which occurrence took place on the 28th March, 1864, when a post mortem examination revealed the following pathological changes : ~ A spherical-shaped tumour was found to spring from the upper part of the transverse portion of the aorta; it measured sixteen inches in circumference. Neither the ascending or descending aorta seemed to be altered in their calibre. The turnout separated the vessels at each side which arise from the aortic arch to a great extent, The trachea was completely flattened and arched so as, over the most projecting part of the tumour, to havo become convex posteriorly. There was so much pressure exercised on the trachea that it was strange the patient did not suffer more and earlier from dyspnea. The recurrent laryngeal pneumogastric and phreni~ nerves did not seem to have been pressed upon materially, and the heart was small and healthy, with the exception of some calcareous deposit about the semi-lunar valves, which did not seem to have interfered with their functions,

On examining the cranial cavity the arachnoid was slightly thickened and opaque, and a slight amount of sub-araehnoid effusion was found ; but what was particularly interesting, the left hemisphere of the brain was smaller than the right, and a small depression or cicatrix existed on its surface on the inner and anterior part of the anterior lobe. Small atheromatous deposits could be seen on both internal carotids, and the left carotid was impervious from its origin in the aneurism to its bifurcation.

Here was a case of thoracic aneurism, in which difficulty of articulation, imperfection of mental powers, with total loss of memory, and paralysis of motion and sensation were associated with an impervious condition of the left carotid artery from its origin ~o its bifurcation, and an atrophic condition of the left hemisphere of the brain. Now" Greisinger tells us that an important lesion, and one which is frequently met with in the insane, is atrophy of the brain, sometimes of the convolutions, sometimes of the entire cerebral mass; and, in many instances, insanity is a symptom of a cerebral disease, of which we do not yet know the minute anatomical

�9 Sydenham'Society~ 1867.

By DR. W. MOORE. 827

changes of the first stage, but which, at a later period, leads to atrophy of the brain; whilst changes of nutrition, and disorder of the circulation within the cranium appear to play an important part in the ori#n of insanity.

Wi th respect to the symptoms produced by unilateral atrophy of the brain. ~ Schroeder Van Der Kolk tells us they manifest them- selves partly in the more or less defective exercise of the mental powers. That in atrophy of the one-half of the cerebrum, the psychical powers should be blunted or paralysed might be, perhaps, assumed, as generally true, and, in fact, such atrophy is most usually met with in adults,

Hence when embolism of the cerebral vessels or obstruction of the carotids or their tributaries, with consequent diminished nutri- tion of the brain occur, we may expect giddiness, loss of conscious- ness, loss of speech, loss of memory, and disorders of the intellect generally, with lesions of motion and sensation, as the above case exemplified; these phenomena were still further well shown in the following case of thoracic aneurism, which, through the kindness of Dr. Jennings, I had frequent opportunities of observing during the past six months, and to whom I am indebted for the following history.

CASE III.--Complete Tempora~ T I~sensibility-- Dementia - - .Delirium--Fugitive Paralysis.

P.~HOLOGY.--Enormous Tlwraeic Aneurism--Empty Ca~otidsm General Atrophy of the Brain. Matthew E , aged forty-four, of stout and muscular build, was admitted into the South Dublin Union on the 29th June, 1867. He seemed in perfect health, and retired to bed on the night of the 1st July without having made the slightest complaint; he was found on the following morning in a state of complete insensibility. When seen by Dr. Jennings, about 11 a.m., he was lying on his back, silent and motionless, with closed eyelids and compressed tips, the temperature of his body being perfectly natural, and his respiration tranquil and free from the slightest strider. When his eyelids were separated the pupils were natural in size, but completely unaffected by the admission of light.

This state of tranquil immobility, however, was reported by the attendants to have been occasionally interrupted, since his admission into hospital, by attacks of vomiting and restlessness, his struggles

�9 " A t r o p h y of the Left ttemisphere of Brain."--Sydenham Socie~y~ 1861.

328 Thoracic Aneurism and Dementia.

being restrained with much difficulty. The heart's a~tion over the entire precord~um was found to be rapid, the pulses at both wrists strletly similar in character, and visible pulsations were present in the carotid, subclavian, and humeral arteries.

A eonlcal tumour, several inches in height, and having a base of considerable extent, with double heaving impulse, was seen situated over the upper part of the sternum, whilst a second centre of pulsation, though much more faint and limited, was observed below the left nipple, In neither of these situations could any bruit be detected.

When loudly addressed by name he languidly opened his eyes, but made no attempt at reply; however, when shaken somewhat roughly by one of the byestanders, he raised his head from the pillow. On the following morning the insensibility was found to be much less profound; he seemed semi-conscious, but still incapable of giving intelligible replies. When the cup was held to his lips he drank freely, and his respiration was tranquil and unembarrassed. The throbbing in the tumour was not by any means so distinct as on the day previous. The expansion, percussion, and respiration of both sides, posteriorly, were normal.

On the morning of the 5th July, Dr. Jennings found the right arm completely paralysed; when roused by being shaken or loudly called by name, he would start as if from sleep, stating his age, name, trade, as the case might be. One or other of these replies he invariably gave to whatever question was addressed to him.

The paralysis of the right arm, was said by his daughter, who happened to be present, to have attacked him for the first time about four months previously, when he had been carried home insensible, and to have disappeared after the lapse of three days. She further stated that the growth of the tumour, which first appeared ten years ago, was occasionally attended with paroxysms of pain, which lasted for hours, and which were so agonizing as to well-nigh deprive him of his reason.

The statement as to the fugitive nature of the paralysis was veri. fled on the present occasion, as on the following morning it had completely disappeared, although all the other symptoms continued unchanged for several days.

On the 14th Ju ly a marked improvement was observed in his manner; having been dull and heavy, he now became lively and vivacious, when spoken to; he replied promptly, although his answers had no connexion with the question asked. He was

By DR. W. MOORE. 3"29

extremely restless and required to be confined. He remained much in this state for a month, his intelligence gradually coming about, till at length he drew Dr. Jenning's attention to the eyes of the patient in the next bed, which he remarked were " very sore," such being the ease. During the months of September and October no very unusual symptoms were present; on the 2nd November the left arm was found to be paralysed; however, after few days he recovered the use of it.

All this time the tumour was increasing, and early in December he had again become dull and idiotic. On the 10th of this month he was suddenly seized with furious delirium, after the partial sub- sidence of which, he complained of great pain in the aneurism, which he guarded with both hands; when the violence completely disappeared, which it did after the lapse of a few days, he became more rational then he had been since his admission into hospital.

On the 16th February l~st, Dr. Jennings first observed a difference in the radial pulses, the left being rapid and indistinct. On this day he was convulsed, and the tumour was beginning to discolour and slough; at one point there was very slight oozing, which was soon checked by the application of sesqui-chloride of iron ; from this day he continued more or less insensible till the 26th February, when he died from apparent astheuia.

Dr. Jennlngs, in making the post mortem examination, was assisted by Dr. Purser. On removing the calvarium the brain was seen not nearly to fill the membranes, which in several places lay in folds over it ; in fact, it was generally atrophied.

A considerable quantity of fluid was found in the sub.araehnoid spaces, as also in the ventricles. The arachnoid membrane was thickened, pulpy, and gelatinous, The upper and outer part of both hemispher0s were of a dirty yellowish eolour, and the convolu. tions small and depressed. I t would be difficult to define the actual condition of the brain substance; it might be termed " brittle " in consistence.

No emboli were found in any of the vessels, but thg carotids and the larger arteries of the brain werr well nigh empty, and large eoagula occupied both pulmonary arteries. The heart was in a state of fatty degeneration, all its cavities were enlarged, the valves seemed intact. On slitting open the aorta from behind, the aneur- ism was seen to spring from the front of the ascending portion of the arch, immediately above the semi-lunar valves; the aperture of communication with the vessel being circular in outline and three

330 On the Management of Sleeplessness in the

inches in .diameter, and its circumference thickened, rounded and prominent. The sac was filled partly by eoagula of blood, and partly by masses of fibrin. The coats of the aorta were occupied generally by atheromatous and seml-osseous depositions.

In this case we had an unusually large thoracic aneurism and chronic arteritis combining to diminish the calibre of the cerebral vessels; in fact, giving rise to an empty condition of the carotids with consequent atrophy of the brain, the dementia and paralysis pointing to disorganization as well of the grey substance as of tile ganglionic centres,

My object in adducing these cases is to show that "mental diseases," so called, may be entailed by comparatively remote physi- cal conditions, and hence arises the importance of taking the widest range in approaching the consideration of these affections. W e are familiar with mental phenomena termed ~' reflex," when they are found to co-exist with uterine, genito-urinary or other abdominal irritations, but the changes which these causes bring about in the nutrition of the brain are difficult to define, l~ow, whilst our knowledge of psychology as yet is not so far advanced as to enable us to specify in all cases from certain symptoms, certain pathological changes, still if in a case of dementia we can detect a latent aneurism or intra.thoracie tumour whleh, from its situation, it is to be pre- sumed, would eaus6 obstruction of the cerebral supply and conse- quent atrophy of the brain, it is needless to add, how materially such a discovery would affect the prognosis and treatment of such a case; experience having shown us that dementia attendant on a chronic atrophic condition of the brain is of most unfavourable prognosis, whilst insanity in more a~ute and subaeute forms, where no such positive evidence of persistent diminished nutrition of the brain is present, may he regarded as relatively hopeful and capable of c u r e .

ART, XV . - -On the Management of Sleeplessness in the Acute Affec- tions of Children. By HENRY K~N~EDr, A,B., M.B. ; one of the Physicians of the Cork-street Hospital, and attached to Sir P. Dun's Hospital.

I~r the following remarks, which I promise will be very brief, I would make some observations on the raving and sleeplessness so often attendant on the acute diseases of children. I am induced