TREATISE, &c. A ____ '__ TREATISE 4^'-M THE NATURE AND CURE OF THOSE DISEASES, EITHER ACUTE OR CHRONIC, WHICH PRECEDE CHANGE OF STRUCTURE; WITH A VIEW TO THE PRESERVATION OF HEALTH, AND, PARTICULARLY, THE PREVENTION OF ORGANIC DISEASES. A. P. W. PHILIP, M.D. F.R.S L.&E. &c. Notes an?* SipiJCtttrfccs, J. H. MILLER, M.D. Professor of the Institutes and Practice of M«diefn«/,ii)the Washington Medical College of Baltimore. —^TTR BALTIMORE: PUBLISHED BY EDWARD J. COALE, AND COALE & CO. WASHINGTON CITY. 1831. v'vfr ? District of Maryland, lo w'U: BE IT REMi:.\Il)ERED, That on this eighth day of January, in the fifty-fifth year of the Independence of the United States of America, Edward J. Coale, of the said District, hath deposited in this ofiice the title of a book, the right whereof he claims as proprietor, in the words following, to wit: "A Treatise on the Nature and Cure of those Diseases, either Acute or Chronic, which precede Change of Structure; with a view to the Preservation of Health, and particularly, the Prevention of Organic Diseases. By A. P. W. Philip, M.D. F.R.S. L. & E. &c. With Notes and Appen- dices, by J. H. Miller, M.D. l'rofessor of the Institutes and Practice of Medicine, in the Washing- ton Medical College of Baltimore." In conformity to the act of the Congress of the United States, entitled "An act for the encour. agement of learning, by securing the copies of maps, charts and books, to the authors and proprit- tors of such copies, during the times therein mentioned;" and also to the act, entitled '"An act supplementary to an act, entitled 'An act lor the encouragement ol learning, by securing the copies of maps, charts and books, to the authors and proprietors of such copies during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints/' PHILIP MOORE, Clerk of the District of Maryland. J. D. TOY, PRINTER. THE EDITOR'S PREFACE. Much as may be deprecated, the necessity under which American writers are compelled to resort to the aid of foreigners to insure them a reception or notice, even by their own countrymen, the desire of communi- cating some observations and inductions that are pecu- liar, has forced a reluctant consent to the practice of ap- pending our ideas to the works of another. The sense of degradation inseparably connected with the conscious- ness of dependency, is in a great measure obviated in the present instance by the choice of an usher; for what brow, however haughtily independent, need be suffused with the blush of shame, upon an introduction to the world under the auspices of Wilson Philip? Few have made themselves a brighter or more extended reputation, and none possesses a mantle under whose voluminous folds, a novice can better hope to hide his defects. The innovations in the principles of medicine to which I lay claim, are the results of experiments, observations and reflections, begun more than twenty years ago, and continued up till the present time. Whilst yet a young student of anatomy, unsatisfied by the demonstrations of the nerves by my venerated preceptor, and their de- scriptions given by the best writers of that period, and particularly what they denominated the great sympathe- vi PREFACE. tic; 1 thought I saw ample space for farther explora- tion. Consequently, the experiments then conducting by Le Gallois, of which Dr. Wistar was regularly ad- vertised, and with which I was by him kindly favored, excited me to engage in their reiteration and extension. This desire was soon gratified by an opportunity of en- gaging in the necessary experiments with my late la- mented friend Dr. Dorsey, adjunct professor of surgery, and Dr. Cughler, demonstrator of anatomy in the Uni- versity of Pennsylvania. Phenomena observed, at that time, in the living movements of the animals, subjected to our operations, and which were inexplicable upon the accredited physiology of that day, acted as continual in- citements to the ascertainment of their causes, connex- ions and other relations. Circumstances occasionally transpiring under observation in private practice, kept alive the spirit of investigation, and prompted to farther experiments, until I became satisfied that I had obtain- ed a clue to direct me through the labyrinth. With this impression I seized the first opportunity to commu- nicate my opinions to others, which I have now done publicly for four years, to small classes of students of medicine. I never would have aspired to become a teacher of medicine, had I not believed that I had some- thing new and valuable to communicate. In this I may be mistaken; therefore, to divest myself of all doubts, I submit a few chalk-lines of my system to public inspec- tion and correction In the researches which have conducted to the con- clusions, very summarily presented in this work, little advantages from foreign sources were enjoyed, because they were principally conducted during a residence in PREFACE. vii the country, where few opportunities existed of learn- ing what improvements were making elsewhere; and formed in the intervals of an extensive and laborious prac- tice, which left little time for reading. Lest, therefore, it may be surmised, that suggestions or more substantial assistance may have been obtained from other quarters, and that I may have greatly profited by the labors of Philip, Hewson, Home, Rrodie, Bell, Bichat, Majendie, Flourens, Rolando, Teideman, Gmellin, Lobstein, &c. I can only assert that the utmost I stand indebted, is for corroboration of my previous conceptions, which, asse- veration, if necessary, could be proved by the order of time, and substantiated by other testimony. But I trust that my views being so entirely different from those of all others, in their most marked features, will shield me from the imputation of dependency upon any extrinsic aid. My rationale of the circulation, I trust, stands without other claimant in any degree. Some remarks of Majen- die and others may seem subversive of my theory, but if room had been afforded, all my positions would have been corroborated to the entire discomfit of the most hardy scepticism. The imperfections, and they are doubtless many, of my contributions, can plead in apology, that they were undertaken at the solicitation of the publisher, com- menced at the instant, and framed in the brief spaces intervening between daily lectures and repeated calls of practice. They are all extemporaneous preparations or hastily culled excerptae from manuscript lecture-notes, made whilst the work was in the press, and forced "to march in double quick time'- to keep in advance of the printer. Viii PREFACE. The object in obtruding these crudities upon the world is simply and honestly this: I was hesitating the publica- tion of a larger work, but fearful of its reception and success, thought it better to dispatch a small dove to as- certain whether a foot-hold could be found upon the public mind, that would warrant the liberation of the other inhabitants of the ark of my brain. If this little messenger shall be crushed by the jarring elements of public opinion, chilled by the cold breath of disap- probation, or famished by neglect, its hapless fate will be taken as a salutary warning; but, if on the contrary, its novel plumage shall excite curiosity, to see what other monsters may have been its companions, I may perhaps be induced to expose the whole menagerie. The editor's notes are marked numerically. Baltimore, January 4, 1831. PREFACE. The following Treatise is written on the same plan as my Treatise on Indigestion. I do not offer it to the members of our profession as a regular treatise on the subject, or as comprehending all its parts; but merely as the result of my own experience, not during a few months or years, but nearly half a life-time: and, I be^- lieve, a physician, who has been long engaged in prac- tice, cannot better promote the objects of his profession, than by simply relating, with accuracy, the facts he has himself observed, and the reflections they have sug- gested. I refer to few of the works of others, because I have made use of none in the composition of this Treatise. In my earlier publications, it was my view to give the sum of our knowledge of the subjects to which they relate; and few, as appears from those publications, have more extensively consulted, or with more care and deference considered, the opinions of others. In my late publications, my objects have been to state my own observations, and the inferences to which they have led me; and, as many parts of the present Trea- tise relate to the subjects of these publications, the va- rious papers which the Royal Society have done me the honour to publish, a Treatise on the Vital Functions, 2 X PREFACE. and that on Indigestion, it was necessary either to re- peat what I had already published, and swell this volume to too great a size, or frequently refer to them. This will explain my frequent reference to them, and, I hope, be my apology with the reader. One of the papers in the Philosophical Transactions, for reasons which I shall state, I shall republish in the present Treatise. I shall indulge in no speculative doctrines, but wholly confine myself to facts which came under my own view, and the necessary inferences from them. I shall avoid the narration of cases which, however useful and proper under other circumstances, would occupy too much space in a Treatise like the present; and shall only, occasionally and shortly, state certain circumstances of individual cases, when they happen particularly to illustrate what I have occasion to say. As the chief objects of the following Treatise are, to call the attention to, and correct the first beginnings of disease, its purposes would be very imperfectly answer- ed were it not made intelligible to the general reader; I shall, therefore, as far as I can, without much circum- locution, avoid the use of technical language. In the introduction to the third edition of my Treatise on the Vital Functions, which may rather be considered as belonging to general science than exclusively to medi- cine, I gave such a view of the functions of the animal body as would enable the general reader to understand all that is said in it, and, consequently, in the present Treatise. I have endeavoured, however, to render the practical, that is the second part of this Treatise intelli- PREFACE. ' xi gible to those who do not possess even that knowledge of our frame. It happens, in the course of life, as happens more quickly in that of tedious diseases, which are not them- selves of a fatal nature, that the wear of the constitution begins to be felt most in some particular organ. I never knew any one die of old age; some disease almost always destroys us before we arrive at the period at which this would take place. The great art of preserv- ing health and prolonging life, therefore, is to observe what organ is most inclined to fail, watch the state of that organ, and correct its first deviations. The objects of the present Treatise are, to point out the means of detecting and correcting this tendency and its conse- quences. CONTENTS Editor's Preface ------ v Preface ....... jx Introduction - - - - - - - 17 PART I. Of the Jfature and Symptoms of those Derangements which precede Change of Structure - - - - - 19 CHAP. I. Of the general Derangement of the Vital Functions - - 20 CHAP. II. Of the Powers of the Nervous and Vascular Systems, and the Re- lation they bear to each other ----- 37 CHAP. III. Of some of the more acute Diseases of the Brain - - 67 CHAP. IV. Of the Chronic Affections which indicate a Tendency to Organic Disease of the Brain ------ 84 CHAP. V. Of the Appearances on Dissection in Organic Diseases of the Brain 95 CHAP. VI. Of the Morbid Affections which precede Change of Structure in the Heart - ......100 CHAP. VIL Of the Morbid Affections which precede Change of Structure in the Lungs - - - - - - - - 111 CHAP. VIII. Of Organic Disease of the Stomach - - - - 122 xiv CONTENTS. CHAP. IX. Of the Morbid Affections which precede Change of Structure in the Liver 125 CHAP. X. Of the Morbid Affections which precede Change of Structure in the other Abdominal Viscera - - - - 14G PART II. Of the Means of correcting the States which precede Organic Disease and counteracting their Effects - - - - 154 CHAP. I. Of the Treatment of Plethora - - - 155 CHAP. II. Of the Principles of Treatment in acute Diseases which tend to counteract their Tendency to be followed by Chronic Derange- ment ._-._-. 164 CHAP. III. Of the Treatment of the Functional Derangement of the Brain, which precedes Change of Structure - - - 175 CHAP IV. Of the Treatment of the Functional Derangement of the Heart, which precedes Change of Structure - - - - 196 CHAP. V. Of the Treatment of the Functional Derangement of the Lungs, which precedes Change of Structure - 208 CHAP. VI. Of the Treatment of the Functional Derangement of the Liver which precedes Change of Structure - - - - 219 CHAP. VII. Of the Treatment of the Functional Derangements of the other Ab- dominal Viscera, which precede Change of Structure - 234 CHAP. VIII. Of the Treatment of Organic Disease - - - 244 CONTENTS. XV APPENDICES. Premise -.-.... 273 APPENDIX I. Physiological Researches, deduced from Original views in Anatomy 275 APPENDIX II. Path ological Inductions - - - - 309 APPENDIX III. Therapeutical Suggestions - 326 A TREATISE, &c. The objects of the present Treatise are to be attain- ed by directing the attention to those slight beginnings of the more serious diseases, which, in the business of life, are often overlooked, or confounded with states really trivial; by tracing the steps by which they assume a formidable appearance, and pointing out the means of arresting their progress. Disordered structure is preceded by disordered function, and great disorder of function is often for a long time preceded by slighter degrees of it; and we almost always find, that when the more severe affection occurs, its obstinacy is propor- tioned to the length of time it has been preceded by the slighter symptoms, by which the part is weakened before the disease is established, and in the same de- gree the tendency to change of structure increased. 1 shall, in the first place, consider the causes and ef- fects of a general derangement of the functions of life, and shortly inquire into the nature of these functions, and their mutual dependence on each other. We shall thus be prepared for considering the more complicated cases, in which the disorder, affecting particular organs, through them produces its effects on the general system. In considering the progress of the more insidious cases, 3 is INTRODUCTION. it will be requisite to lay before the reader the general nature and effects of the confirmed diseases of the part; for without having the attention directed to them, it is impossible to perceive the tendency of the slight begin- nings which often lead to them. We shall next review the means of preserving the general health and correcting the first approaches to failure in it, and those which counteract the tendency of acute, to lay the foundation of chronic diseases. The means necessary where disease of some vital organ is established will then be considered; and the work will conclude with such observations respecting the treatment, as the author's experience has suggested, when the continuance of the disease has affected the structure of the part. The subject thus naturally divides itself into two parts; the nature and symptoms of those states which precede organic disease, and the means of preventing their appearance and counteracting their effects/1) (1) In the present work of our author, he has taken new ground, and laid his location warrant upon that intervening and nearly unoccupied region between Hygieineand Practice. Systematic writers generally have confined their "Art of Preserving Health" to didactic precepts for the avoidance of the causes of disease, and their practical rules are mostly predicated upon full formed disease as existing upon change of structure. All that large space between the first morbid impression, disturbing the functional action of an organ, the influence of this perversion upon others, from organ to ortran, or system to system, till some one becomes involved in structural lesion has engaged so little attention, that the student may look in vain to his library for the features and characters of disease in its "forming state,'' as it has not inaptly been denominated, or what perhaps we might with propriety call its curable condition; because, although recovery is not impossible after chancre of structure, the chances are diminished in proportion to the importance^ the organ, and even in the most fortunate instances there remains a debility and consequent liability to a recurrence; whereas it maybe affirmed that anv disease is under the control of remedies whilst it is confined to functional derangement. At no period has it been more important to direct or reclaim attention to these states of disease, than at present, whilst the rage for morbid anatomy stethoscopy, &c. is turning the medical mind to the exclusive consideration PART I. OF THE NATURE AND SYMPTOMS OF THOSE DERANGE- MENTS WHICH PRECEDE CHANGE OF STRUCTURE. In this part, I shall, in the first place, make some observations on the general derangement of the vital functions, the nature of the powers on which they de- pend, and the relation these powers bear to each other. We shall thus be prepared for its proper subject, the nature and symptoms of those derangements which pre cede change of structure/2) of altered structures. The direct tendency of these fashionable pursuits is to the overthrow of all useful pathology. They may instruct us when a disease is incurable, and show the amount of disorganization productive of death, but they fail to impart a knowledge of the several steps in the pro- gress of disease from its inception to its fatal termination. They cannot even instruct us how far change of structure may progress without inevita- bly fatal consequences, much less can they inform us of the means of avoid- ing the dire catastrophe. These necrological observations, or "meditations on death," make baneful impressions upon the tyro in medicine, by associat- ing post-mortem appearances with every stage of the disease, and prompt him to prescribe for conditions of parts which have not yet occurred. As much injury may be thus done by injudicious anticipation, as by the most blameable neglect. We are not inimical to autopsia cadaverum, ausculta- tion or any other means of benefiting our science, however little or remotely, but we do deprecate that neglect of the earlier stages of disease, which per- mits it to gain ascendency and becomj formidable, for the honour of a fiercer conflict and more doubtful success. It is much better to be able to obviate or remove numerous cases of commencing disease, than occasionally to pro nounce an astonishing prognostic, or perform a "wonderful cure." (2) The editor's peculiar views of the principal vital functions are suc- cinctly stated in Appendix, No. 1; and as he differs essentially from the author in many points, it would perhaps be well if the reader would turn to them at this time, to enable him to understand the occasional comments upon the text, in our foot-notes. CHAP. I. Of the general Derangement of the Vital Functions. The most superficial study of the animal frame is sufficient to demonstrate the power of habit in all its complicated functions. There is no man of so little observation as not to perceive its effect on the mental functions; and by those who love extremes, even all difference of character has been ascribed to the influ- ence of education. With respect both to mind and body, much depends on original conformation, and hardly less on the circumstances in which we have been placed. Many mix in society under chronic affections, which, had they all at once established themselves, would for a time have unfitted them for the active duties of life; but, stealing on by degrees, they produce a gra- dual accommodation both of the feelings and the func- tions, and the first cause of alarm is often the impres- sion which the changed appearance of the invalid makes on those who have not been in the frequent habit of seeing him. I have so frequently witnessed serious diseases thus imperceptibly established, and the surprise of the patient at finding the difficulty of correcting what he had conceived so little wrong, that I believe, in the present state of medicine, no attempt can be more im- portant than an inquiry into the causes which produce and the means which tend to obviate, such deviations from health. They are sometimes the consequence of a general or partial derangement left by more acute attacks, and sometimes arise from imperceptible beginnings. DERANGEMENT OF THE VITAL FUNCTIONS. 21 In the first instance, the patient gradually becomes accustomed to the feelings of the derangement; in the latter, it is often long before they attract any serious attention. They may be classed under the three following heads:—general debility accompanied by a state of in- anition, the consequence of a general failure of power in the various processes by which our food is converted and properly distributed; general debility accompanied by a state of plethora, from a failure in the power of those organs which throw off from the system what is no longer necessary, and soon becomes injurious to it; and, lastly, a greater or less failure of function in some particular organ essential to life. The first of these states, existing as a permanent dis- ease, I believe to be extremely rare: as a temporary state of the system, we see it existing in a greater or less degree after all acute diseases. Suffering and ab- stinence have impaired the powers of the system, as well as the quantity of the circulating fluids, and a cer- tain time necessarily elapses before the due supply of nourishment is again established; but it rarely happens, unless the state of inanition be extreme or local disease of some kind has taken place, that the powers of assimi- lation do not gradually regain their usual vigour—each accession of strength being the means of acquiring more. In some instances of acute disease, the constitution receives such a shock, that, for some time after it, and as far as we can see, without the existence of any local affection, due nourishment is not supplied, and the pa- tient does not regain, and sometimes still continues to lose, strength: but this state seldom lasts; he either be- gins to rally, or local disease of some kind shows itself. There are few constitutions so well balanced, that some part is not more prone to disease than others, and the 22 OF THE GENERAL DERANGEMENT general debility being most felt in the weakest part, lo- cal disease is sooner or later established. Genera] debility accompanied by plethora, on the contrary, is one of the most common as well as insidi- ous forms of permanent chronic disease. I regard it as a state of general disease, because it affects equally every part of the system; although, in considering its causes, it will appear that in most cases, it is in the first instance, a disease of the excreting organs. As might a priori be supposed of general states of disease, they often arise by such imperceptible devia- tions from health, that it is very difficult to say where the one terminates and the other begins. The animal body is fruitful in resources, and it so accommodates itself to slight deviations from the most perfect health, that it is only where the change proceeds to a certain degree that it can be said to deviate from it. No doubt, there is a certain state of the appetite and a certain quantity of nourishment which constitutes the most perfect health; yet we see one man eating twice as much as another, and both apparently in good health and equally well nourished. If one individual is led by the nature of his constitution to eat more than others, by a freer action of his excreting organs the nourishment is more quickly carried off; but this state stands in op- position to that in which a devotion to the pleasures of the table induces us to exceed the natural appetite. For this, nature makes not the same provision, and the debility it induces, we shall find, by impairing the ac- tion of the excreting organs, adds to the evil of the un- necessary supply. Contrary to what we should at first view suppose it is in those who have naturally the smallest appetites that states of plethora are most apt to arise. Except as far as we are influenced by a wish to gratify the palate our desire for food is proportioned to the demand for OF THE VITAL FUNCTIONS. 23 it. In those constitutions where the excreting organs —and particularly the skin, which is the most exten- sive—are in a state of greatest activity, the greatest supply is required, and any morbid accumulation least apt to arise. In those whose excreting organs are lan- guid, a less supply is necessary, and an accumulation more apt to take place. Those who naturally eat little, for the same reason, are generally also fatter than those who eat a great deal. Both extremes incline to disease. Where the appe- tite is small, with a tendency to fatten on the little that is taken, the habit is apt to become languid, bloated, and lethargic, from not throwing off what the constitu- tion no longer requires. Those whose excreting organs are much more vigorous than usual, are worn out by the activity of their own systems, by the morbific acti- vity of both the excreting and assimilating organs. A striking instance of this state occurred in a French prisoner in this country about 1790, and was noticed in the journals of that time, and attested by Dr. Cochrane, the physician to the prisoners. He required the allow- ance of five or six men. The allowance of four, which he had, was far from satisfying him. He was thin and sallow, and the superfluous nourishment ran off by pro- fuse night sweats. This state we have few means of influencing, and it fortunately happens that it rarely exists in such a degree as to deserve the name of dis- ease. For the most part those whose excreting organs are most active, and whose appetites are consequently best, enjoy the most vigorous health; but they are also subject to the most sudden and severe attacks of disease; for, as we may easily suppose, where the supply of nourish- ment is most rapid, any impediment to its due distribu- tion and to the corresponding discharges from the sys- tem must be most felt. 24 OF THE GENERAL DERANGEMENT In every part, even the hardest bone and the teeth themselves, a constant change is going on. New par- ticles are constantly being deposited, and those which have performed their function and are no longer fitted for it, removed; and every deviation from this necessa- ry process tends to disease. The symptoms by which the opposite states of inani- tion and plethora are characterised, differ less than at first view we should suppose; both are states of debility. The state of vigour is that in which the quantity of cir- culating fluids is in due proportion to the powers of the system. If they fall short of this proportion, the func- tions languish; if they exceed it, they are oppressed. I have already had occasion to observe, that a state of simple inanition, that is, a state of inanition indepen- dent of any local affection, rarely, if ever, continues long, except when due nourishment is withheld. The assimilating processes either recover their vigour, or local disease ensues. It will be necessary to consider at greater length the state of simple plethora, the parent of many diseases, which often arises from imperceptible beginnings, and the existence of which is often detect- ed with some difficulty. I do not now speak of too great determination of blood to particular parts, which falls under the next di- vision of the subject; but of that state of the system where the organs of waste become gradually more or less debilitated without a corresponding affection of the organs of supply, and the functions are oppressed by more blood than they require; the evil of which is in- creased by the blood itself, under such circumstances always in some degree deviating from the healthy state. All parts of the blood are not with equal ease sup- plied, nor with equal ease discharged from the system. The former of these positions is well illustrated by com- paring the effects of blood-letting with those of purga- OF THE VITAL FUNCTIONS. 25 tives. We recover from the effects of many times the quantity, discharged by the latter means, in half the time required in the case of blood-letting; because, by the one, it is chiefly the watery part of the blood that is drained off; by the other, along with this, the more essential parts also/3) The immediate effects of the former are less felt, be- cause while it lessens the quantity of blood, it leaves what remains richer. Its permanent effects are less felt, because the watery part of the blood is most easily and soonest replaced. This part is also that which is most easily discharged by the excretories. It often happens, in cases of ex- treme debility, that it runs off by the skin, bowels, or other excretories, apparently without effort; a conse- quence of mere relaxation of the excreting vessels. We must suppose, then, that one consequence of a debility chiefly affecting them, will be that the watery parts thrown off by them will be in too large a propor- tion: thus it is, that in plethora the blood is always too rich. The circulating and secreting systems are not only languid in consequence of being oppressed with more blood than in due proportion to their powers; but also from the blood itself being too rich, and this rich- ness not proceeding from too great a supply of the par- ticles fit for the purposes of life, but of too great a pro- (3) The restoration of a humoral pathology, modified by and adapted to the present improved state of the physical sciences, as countenanced by our author, and many others of the most conspicuous medical philosophers of the age, must soon have a transforming influence upon our science and illumine many of its darkest passages. The indiscriminate rejection of the fluids from all participation in the causation of disease, since the predominancy of solidism, by abstracting observation from their known varying conditions, lias left us poorer in facts than could be desired, yet a sufficient number are well known and established, to confirm the assumption that the changes the fluids of animal bodies undergo, both in quantity and quality, not only mark the ravages of disease, but enter largely into its causes. This subject will be found briefly discussed in Appendix No. II. 4 26 OF THE GENERAL DERANGEMENT portion remaining of those which have become unfit for them.C4) Those in the least acquainted with the animal econo- my must see how apt this state of the system must be to derange the function of any particular organs, which, from other causes, may happen to be disposed to dis- ease. We are here to attend to the effects it produces, where the power of the various organs happens to be so well balanced that no one feels it more than the rest. The chief indications of a plethoric state of the sys- tem are a languor and sluggishness both of mind and body, and often a distressing sense of debility even in slight exertions. Those parts of the body where the vessels are most superficial, the cheeks, eyes, &c, of- ten become redder than usual; and flushings, often fol- lowed by some degree of perspiration, are not unusual. But a state of plethora may exist without these latter indications; for it seems sometimes to happen that, with- (4) We have not been able to catch the exact shade of signification, given by our author to the term plethora. If he means that superabundance of fluids created by repletion in contradistinction with their deficiency in inan- ition, as may be inferred from a preceding paragraph, then his position "that in plethora the blood is always too rich," may be correct; but if it is that fulness of the vessels, arising "from a failure in the power of those organs which throw off" from the system what is no longer necessary, and soon be- comes injurious to it," we know not how the epithet "too rich" can be ap- plied to fluids confessedly superabounding in the effete matters of every part of the general system, and which must stand in a relation to pure blood simi lar to that which the earthy matter of an ore bears to its metal. It is certainly an important point in practice to determine the amount and kind of plethora. The former can be pretty accurately measured by the pulse and other diagnostic means; the latter requires a more elaborate scru- tiny. The older writers distinguished the kinds into sanguinous and serous. As a general division, this might remain, provided we could assign to each its actual possession of the products of the too great activity or torpor of the several secreting and excreting organs, and thus estimate the excess or defect of the usual components of the blood. This subject demands farther investigation. Some hints are ventured in the appendices, which it is hoped will stimulate to farther research. We are the more solicitous upon this subject from the conviction, that the changes in the amount and properties of the fluids are in turn effects and causes of most form:; of disease. OF THK VITAL FUNCTIONS. 27 out any deiermination of blood to a particular organ, the more internal vessels become loaded, while those of the surface appear no more charged with blood than usual: and the opposite of this state sometimes exists; the external vessels being more charged than those of internal parts, and a red and turgid countenance, which suggests the idea of threatened apoplexy, will continue for many years; and that, where the causes of plethora continue to be applied without symptoms of internal disease, and seems even to be a means of prevention— the external vessels affording a receptacle for the su- perabundant blood, and thus tending to prevent morbid distention of those more internals5) It seems at first view surprising, that the state of the external may not always be regarded as an indication of that of the more internal vessels—all parts of the circu- lating system freely communicating. In a mere system of inanimate tubes, it would indeed be difficult to ac- count for it; but we must recollect that the animal body is not governed by mechanical laws alone. It is of the utmost consequence, in explaining the phenomena of disease, to keep in view the relation which the organs of the vital functions bear to each other. This part of the subject I shall soon have occa- sion to consider at some length, for, without a know- ledge of it, it is impossible to understand the rise or progress of any deviation from the healthy state. 1 shall here confine myself to such observations as the nature of the present subject requires. (5) Excessive determinations of blood to particular parts, partial plethora or congestion, are facts of more frequent occurrence, than of ensy solution. The rationale attempted in the appendices, it is hoped will be satisfactory, and at. the same time practically useful. Until the practitioner can deter- mine the precise^ causes of these irregular distributions of the fluids, his pre- scriptions must have the character of experiments, and it is high time such suspicions sliould be removed from our plans of treatment in diseases of most ordinary occurrence. 28 OF THE GENERAL DI-RA\fiEMENT Although the power of the heart and blood-vessels, we shall find, is independent of the nervous system, it is throughout the whole frame capable of being influ- enced by it.* By it the animal body is formed into a whole, every part of which is under the influence of the central parts of that system, where all its powers, if we except merely the power of conveying its influence, reside; and the causes of deviations from the healthy state often so affect this system, that their influence is felt most in certain parts; and, consequently, the ves- sels of those parts are most affected. Now when the causes of plethora produce too great fulness of the vessels, it is evident that if the action of any particular set, from some peculiarity in the excit- ing causes, or in the habit of the patient, be more de- bilitated than the rest, these will become more distend- ed, and, by their preternatural distention, tend to re- lieve the others. Thus, the morbid distentions sometimes take place chiefly in the external, and sometimes in the internal vessels. When we consider local affections, we shall find that, even with respect to particular parts of the body, this fact is clearly demonstrated. Nay, we have sufficient proof that a weakness of particular sets of vessels is often the sole cause of the partial plethora which attends it; for although the quantity of blood, on the whole, may be no greater or even much less than it ought to be, if any set of vessels be debilitated, they will yield most to the general force of circulation, and thus receive more blood than their due proportion. In most cases, however, in which the external ves- sels are preternaturally and habitually distended, we find symptoms demonstrating the same tendency, in the * See a paper which the Royal Society did me the honour to publish in the Philosophical Transactions of 1815, and my Treatise on the Vital Func- tions. OF THE VTTAL FUNCTIONS. 29 internal vessels; but we often see this tendency, as it were, limited, and the individual protected against its more alarming effects, by the ease with which the ex- ternal vessels yield. Whether this state of the exter- nal indicates a similar state of the internal vessels, or tends to counteract it, and in what degree it has this effect, can only be determined by watching the tenden- cy to the symptoms of internal plethora. Although, then, a plethoric state of the system is gen- erally indicated by the appearance of the individual, this is not universally the case; but freedom and acti- vity in the functions of the nervous and circulating sys- tems always assure us that their organs are not oppress- ed by a superfluous quantity of blood. If, on the other hand, the individual be languid, and incapable of ordi- nary exertions, we may suspect this to be the case; which may, with certainty, be determined by a consid- eration of the two following circumstances:— In the first place, the freedom of the patient from local disease, which is to be ascertained by questioning him respecting the state of the various functions, and, as far as we can, examining the seat of the organs of such as may appear more particularly affected; for cer- tain local affections, in consequence of the sympathy of the various organs, are often as much characterised by symptoms of general indisposition, as by those referred to the seat of the disease: in the second place, such causes having preceded as tend to produce plethora, the suppression of accustomed discharges, a fuller diet, or less active mode of life, whatever, in short, tends either to increase the supply of nourishment, or to im- pair the vigour of the excreting organs. When such causes, then, have preceded a state of languor and debility, and no set of functions are very particularly disordered, we may be assured the patient labours under -enernl plethora, and that he can only be 30 OF THE GENERAL DERANGEMENT relieved by lessening the ingesta or increasing the acti- vity of the excreting organs, according to the cause which has produced the morbid state. It is not uncommon to confound a full and plump habit of body with plethora; they are, however, very differ- ent states; plethora may exist in the sparest habit. We often find in such habits periodical discharges of blood, and much inconvenience from the ceasing of the accustomed discharge; and in the fattest people we sometimes observe that general vigour and free play of all the functions, which prove the quantity of the cir- culating fluids to be in due proportion to the powers of the system. There is, therefore, no necessary connection between the tendency to a great secretion of fat and a morbidly distended state of the vessels. Yet the tendency to plethora is certainly greatest in habits inclined to fatten, because in them the excreting organs are generally most languid; and when in such habits plethora does occur, and the patient, mistaking the feeling of weak- ness for a proof that more nourishment is required, pampers the taste, and thus induces the stomach to re- ceive more food than the natural appetite calls for, he not unfrequently, as I have witnessed, falls into a state of obstinate disease; and, if he persevere, necessarily counteracts every means of relief: he is receiving a superabundance of nourishment, while he is incapable of distributing the due proportion. These observations apply, more or less, to people of all habits; for, however spare the habit may be, if the proportion of blood be too great, the same evils ensue although it is in the full and gross habit that they are soonest felt, and in the greatest degree; such habits being least able to resist the cause, and least fitted for the exertions which tend to counteract it. OF THE VITAL FUNCTIONS. 31 A plethoric state is also confounded with the inflam- matory tendency. In this instance, also, although the two states are not necessarily connected, they often con- cur; the cause of which will appear from a very short consideration of their nature.(G) Inflammation arises from the minute vessels of the in- flamed part becoming, from the operation of causes par- ticularly affecting them, too weak to afford due resis- tance to the general force of the circulation. They thus become preternaturally distended, which still farther im- pairs their power, and retards the passage of the blood through them; inconsequence of which the vessels which immediately precede them in the course of circulation, and if the inflammation be very extensive, or affect a vital part, of the whole circulating system, are excited to in- creased action, the final cause of which appears to be to support the circulation in the debilitated part.* Now it is evident, that if the whole sanguiferous sys- tem be morbidly distended, a slighter cause will debili- tate the vessel of any particular part, and this experi- ence proves to be the case: but we should be led also to infer, and the inference is also supported by experi- ence, that in plethoric habits the inflammatory symp- toms would seldom run so high as in more vigorous states of the body, because the languid circulation is less calculated to occasion a great degree of morbid distention in the debilitated vessels. The symptoms, therefore, of the local distentions, (6) It is not for the sake of contrariety, or to moot a point with the profes- sion, that we have given in Appendix No. II. a rationale of inflammation en- tirely opposite from that in the text, and which generally prevails, but because we believe it quadrates with the "universality of the facts," or phenomena presented in every variety of inflammatory action, and also because it is the natural inference from our previous postulates in physiology and pathology. Nor is it a useless distinction, without a real difference. * The Introduction to my Treatise on Symptomatic Fevers. 32 OF THE GENERAL DERANGEMENT heat, pain, and swelling, are less considerable; and, for the same reason, the constitutional symptoms, the strong and hard pulse, with general heat and other marks of excitement, are in the same proportion less. The in- flammation on these accounts is more insidious; that is, more apt to run into some of its unfavourable termina- tions, without the usual warnings. The plethoric are also unfavourable subjects of in- flammation for another reason. We have seen that ple- thora generally arises less from an excess of nourishment than from deficient power in the excretory system, and that, in general, the plethoric receive a less supply of nourishment than those whose excretories are more ac- tive. Thus it is, that although their blood is almost always, for reasons that have been explained, too rich, containing too small a proportion of the watery parts, they bear blood-letting ill. As they are receiving but a small supply of nourish- ment, they ill afford to lose the richer part of the blood. Thus, in them, blood-letting soon produces too watery a state of that fluid. It is quite common, as I have wit- nessed a hundred times in those whose excretories have been long debilitated, for the blood, however rich at first, after a few blood-lettings to become watery, the coagu- lum, in the first instance too large, now forming but a small part of the whole. Besides, the richness of their blood, depending not on an unusual supply of the more nutritious parts, but on a defective excretion of those become unfit for the purposes of life, is generally from the first of a loose consistence; and from this cause, also, as well as the previous general debility of the functions, the strength fails more rapidly than usual under the effects of blood- letting; a consequence still farther increased by the fol- lowing circumstances. OF THE VITAL FUNCTIONS. 33 In healthy habits, although the immediate effects of blood-letting is to lessen the quantity of blood, its ten- dency, by the general check it gives to the action of the various excreting organs, is to increase it. Thus butch- ers bleed animals to fatten them. But in plethoric habits the excretories are already debilitated, and little of this secondary effect of blood-letting is to be expect- ed; and, as far as it does take place, adds to the un- healthy state of the blood, which has already exceeded the limit to which it may be loaded, in consequence of the defective action of the excretories, without materi- ally interfering with health. There is another affection so far allied to inflamma- tion that they often imperceptibly run into each other, to which plethora disposes in a much greater degree. This has been called congestion, a term, however, which has not been used in a very definite sense. When the morbid distention is in the minute vessels, termed in medical language the capillaries, inflammation is the consequence. When the distention is in the larger ves- sels of the part affected, to which case I shall confine the term congestion, the disease is of a very different nature. We have then neither the heat, nor pain, nor fever which attends inflammation, nor even, to the same de- gree, the loss of function in the organ affected; for if the capillaries, on whose action the various functions immediately depend, retain their vigour, the function of the part will go on more or less perfectly, as long as the debilitated trunks can afford them any supply of blood, the circulation in the capillaries depending little, if at all, on that of the heart and large vessels, except for the supply of blood.* * By the aid of the microscope the capillaries may be seen carrying on the blood for hours, not only after death, but after ligatures have been thrown around the large vessels attached to the heart in the newly dead animal, 5 34 OF THE GENERAL DERANGEMENT The congestion of the larger vessels of vital organs may be regarded as the disease peculiarly connected with a plethoric state of the system, and a source of a great part of the danger which attends its continuance. In fact, it is the plethora of a part: it is only the gene- ral plethora increased in some particular part. In the generally distended and, consequently debilitated state of the circulating system, its larger vessels have, by some cause operating on it, for the effect of which their previous debility particularly prepares them, been more weakened, and, therefore, become more distended than the rest. It is evident that inflammation and congestion may readily run into each other, as in practice we constant- ly find to be the case. When the debility of the capil- laries spreads to the larger vessels the inflammatory symptoms abate, because the force impelling the blood into the former is lessened; and in like manner, when in congestion the debility of the larger vessels spreads to the capillaries, those of inflammation, more or less languid in proportion as the larger vessels have been more or less debilitated, show themselves.C8) This tendency to loss of power in the capillaries or the larger vessels, of particular parts, however, is only one of the ways in which a plethoric state of the system disposes to local diseases. By influencing the sources and this organ removed. See my treatise on the Vital Functions, 2d ed. Exp. 63.(7) (7) This fact is inexplicable by, and indeed refutes, the doctrine which makes the heart the sole impulsive agent of the circulation, but adds another strong argument in favour of the theory advanced in Appendix No. I. (8) May not inflammation and congestion coexist in the same organ? May not congestion occur in the vessels, supplying the blood for the func- tional action of an organ, whilst there is inflammation in those of its nutri- tion, and vice versa? Not aware that these questions were ever before started, we shall give them some consideration when we arrive at the chaD ters treating of the diseases of the several organs. OF THE VITAL FUNCTIONS. 35 of nervous power, it influences the state of the various organs whose functions more or less depend on that power. It appears to be chiefly in this way that ple- thora tends to its own cure. The various functions by which the nourishment we receive is digested and duly distributed, if we except merely that function by which the blood is moved in its vessels, depend on the powers of the nervous system. Thus, when the powers of that system are impeded, these functions languish, and among them those of the stomach, by which the first change in the food is effected, and the appetite, which depends on the presence of a healthy gastric juice, fails. The patient is thus warned to lessen the usual supply of food; and if he be left to obey the dictates of nature, the evil is in a greater or less degree corrected. As this happens he finds himself less languid and oppressed, and, consequently, better fitted for exercise, which, by promoting the action of the excreting organs, tends to throw off that part of the circulating fluids, which having become unfit for the purposes of life, adds, by its quality as well as bulk, to the oppressed state of the circulation. Even those who are least in the habit of considering such subjects will perceive, from what has been said, that the state of the sanguiferous must in many ways be influenced by that of the nervous system, and vice versa; so that it is impossible for us to proceed in our inquiries respecting the nature of even the most sim- ple deviations from health, and, consequently, in our endeavours to determine rational means of correcting them, without ascertaining the relations those systems bear to each other. All the functions of the animal body depend upon the due co-operation of the two great systems of the nerves and blood vessels; and no deviation from health can 36 DERANGEMENT OF THE VITAL FUNCTIONS. take place without an error in one or both of them, the importance of the disease depending upon the nature and extent of that error. It is here necessary, there- fore, to inquire into the nature of that co-operation, and the part which belongs to each of these systems in the various functions of life.(9) (9) Evident as it must appear, that without knowing the connexion sub- sisting between these grand fundamental systems of the animal economy, the mode of their relationship and the laws by which their reciprocal actions are governed, the utmost acquaintance which can possibly be attained of the functions of any of the subordinate organs, must be very imperfect and amount to little more than plausible conjecture. Conscious of this radical defect, in the obscurity that invelopes the first laws of life, the present age has characterized itself by the most indefatigable industry to discover by experiment and observations the bonds of alliance between the blood vessels and nerves. In this research we too have joined our feeble efforts, the re- sults of which are offered for consideration in the Appendices. CHAP. II. Of the Powers of the Nervous and Vascular Systems and the Relation they bear to each other. (I0) Physicians soon perceived the importance of ascer- taining the nature of the powers of the nervous and vas- cular systems, and the relation which subsists between them. The older physicians imagined that the whole powers of the system reside in the former; and Haller was the first who attempted to prove that the heart possesses a power depending on its own mechanism, and showed that it is capable of its function after all connection with the brain has been destroyed. His opponents, however, refused to admit his conclu- sion, alleging that, although in his experiments the heart was prevented from receiving more nervous in- fluence, it was not deprived of that which it had already received, either constituting an essential part of its fibres, or existing in nervous filaments too small to be removed, and on which, they maintained, the temporary power of the heart, after its separation from the brain, depends. They referred, also, to the influence of the passions, which they considered as proving the dominion of the brain over the heart; and asked, without receiving any satisfactory reply, Of what use are the nerves of the heart, if its power is not derived from the nervous system? (10) The reader is respectfully desired to collate the anatomy and physi- ology of the nervous systems, in Appendix No. I. with this chapter, by which, it is hoped, he will see that many of the difficulties pointed out by the author tend to confirm the positions of the editor, and the editor's theory explains away the difficulties of the author. 38 POWERS OF THE NERVOUS Notwithstanding these objections, such was the im- pression made by the experiments of Haller, who had the great merit of being the first who introduced the inductive mode into medical reasonings, that his opinion was very generally received, and he and his followers maintained that the power of the heart was not only in- dependent of the brain, but incapable of being directly influenced by it; and, in proof of this, stated the fact, that the heart cannot, after death, like the muscles of a limb, be excited through the medium of its nerves. Thus it became a general opinion that the brain is incapable of immediately influencing the heart and blood vessels, and to the present hour this opinion has no small share both in determining our views of disease, and regulating our plans of treatment. The subject seemed involved in so much confusion and uncertainty, that in 1815 I commenced a set of ex- periments, for the purpose of ascertaining the nature of the powers of the nervous and sanguiferous systems, and the relation which they bear to each other, and a large portion of the time I could spare from the more active duties of the profession, has ever since that pe- riod been devoted to the investigation. The different results were laid before the Royal So- ciety, and published in the Philosophical Transactions, while the inquiry was going on; and in those of last year the Society did me the honour to publish a con- nected view of all the inferences at which I had arrived, some of which are more fully stated in an Inquiry into the Laws of the Vital Functions, the third edition of which was published in 1826. I cannot give a more concise view of these inferences and the facts on which they are founded, than by here republishing this paper, for which I have obtained the permission of the President and Council of the Society. It is satisfactory to me, and will give confidence to the AND VASCULAR SYSTEMS. 39 reader, to state, that although many of my experiments have been repeated by the physiologists both of this country and the Continent, they have not in any in- stance been found inaccurate. The nerves may be divided into two classes: those which proceed directly from the brain and spinal mar- row to the parts to which they convey the influence of these organs; and those which enter such ganglions as receive nerves proceeding from different parts of the brain and spinal marrow, whether these nerves have or have not protuberances belonging to themselves which have also been termed ganglions, but which receive only the different fibres that belong to the particular nerve to which they are attached, and, from the circum- stances in which they are placed, must have a different, or at least a more confined relation to other parts of the nervous system. To the former, therefore, I shall, for the sake of distinction, and to avoid circumlocution, confine the term ganglion. I beg leave to lay before the reader the following ex- tract from lectures delivered by Mr. Brodie before the College of Surgeons, and which have not yet been pub- lished, in which this accurate anatomist and physiolo- gist has given the sum of our knowledge respecting the structure of the ganglions. "Those bodies which are found in certain nerves which appear to be formed by an enlargement of the nervous substance, and which are denominated ganglia, are of a complicated structure. Into ganglia the nervous fibres may be traced, and from these ganglia the nervous fibres again emerge. Scarpa has paid much attention to the fabric of the ganglia, and he gives the following history of it. He says, that the fasciculi of nervous filaments which enter a ganglion are separated and divided from each other, and that they are combined anew. A nervous fasciculus enter- ing a ganglion divides into smaller fasciculi. These 40 POWERS OF THE NERVOUS divide again, and cross and intersect each other at va- rious angles. Then the divided fasciculi become again united, and as at first they divided into smaller and smaller fibres, so when they begin to unite they form gradually larger and larger bundles. At last the nerve which entered a ganglion emerges from it, with its fibres collected into one or more fasciculi. Sometimes several nerves enter a ganglion, in which case they are all blended together, forming a complicated net-work, in which it is impossible to determine what belongs to one nerve and what belongs to another nerve. Every fasci- culus or filament which enters a ganglion passes through it. There is no appearance of any one terminating in it." "If we unravel the texture of a ganglion, we find that each nervous fibre retains its own peculiar neuri- lema; but besides this, the spaces left between the in- tersection of the fibres are filled up with a peculiar soft substance, of a greyish or yellowish colour. With the nature of this substance we are unacquainted. Some have considered it as corresponding to the cineritious substance of the brain and spinal marrow; but Scarpa is disposed to regard it as a soft cellular substance, filled with a greyish and mucilaginous matter in ema- ciated subjects, and with a yellowish oily matter in those that are fat." Such, then, is the structure of the ganglions as far as it is known; and as, for the reason just mentioned, I shall confine the term to those ganglions which receive nerves proceeding from different parts of the nervous system; the term ganglionic nerve I shall confine to those nerves which either enter or proceed from such ganglions, without adverting to their having or not hav- ing protuberances resembling ganglions belonging to themselves; although it is probable that a more perfect knowledge of the nervous system will point out this cir- AND vascular systems. 41 cumstance as a proper basis for a subdivision. It is necessary to keep this explanation in view, because neither the term ganglion nor gaglionic nerve has been employed with much precision. Physiology has been greatly indebted to Mr. Bell, for his important discovery of the different properties of the two sets of nerves which unite in forming each of the spinal nerves. It appears from his experiments, which have been confirmed by those of Majendie, that the one set are nerves of sensation, the other of motion; a circumstance which explains many of the phenomena of disease, which have suggested the pro- bability of these functions being exercised by different nerves bound up in the same envelope. Dr. Parry, in his treatise on the pulse, for example, relates a case where feeling alone was lost in one arm, and voluntary power alone in the other. But these are not the only, nor indeed the most important functions of the spinal nerves. All of them contribute to the formation of the ganglionic system, on which the life of the animal, as will appear from many facts I am about to state, imme- diately depends. It is evident from what has been said, that the gang- lions and plexuses resemble each other in their nature; and as the nerves which terminate in them come from all the most distant parts of the nervous system, some from the brain, and some from the lower extremity, and all intermediate'parts of the spinal marrow, we can- not help supposing that there is some design in thus uniting nerves which arise from so many different parts of these organs. One of the most striking differences between the ganglionic nerves, and those proceeding directly from the brain and spinal marrow, is that even independently of the ganglions and plexuses, the former every where more freely anastomose, if I may borrow a term from the sanguiferous system; while the latter pro- . 6 42 POWERS OF THE NERVOUS ceed in a more direct course, being less connected with each other in their progress, to the parts on which they bestow sensation and voluntary power; still further de- monstrating the care with which nature blends the power of the ganglionic nerves. What purpose is served by this perpetual intertwin- ing of these nerves? It is impossible for a moment to conceive that it is without an object. This question is most likely to be answered, by inquiring into the nature and functions of the parts supplied by this class of nerves; those parts are the vital organs, the thoracic and abdominal viscera, and the vessels even, as we shall find by expe- riment, where the parts are too minute to be made the subject of dissection, to their smallest ramifications. It would appear from this arrangement, that, although to other parts the influence of only one part of the brain or spinal marrow is sent, the vital organs receive that of every part of them, and this inference has been con- firmed by numerous experiments, too simple to admit of our being deceived, which I made many years ago, and the results of which were laid before the Royal Society, and published in the Philosophical Transac- tions of 1815, and which are more fully detailed in my treatise on the Vital Functions. From them it appears, that although the muscles of voluntarily motion obey a stimulus applied to no part of the brain and spinal mar- row but that from which their nerves take their origin, the heart is influenced by stimuli applied to every part of these organs, from the very uppermost surface of the brain and cerebellum to the lowest portion of the spinal marrow. The same was found to be the case with the blood-vessels to their minutest ramifications. Even the , extremities of the arteries and veins, where they unite to complete the circulation, it was found by the aid of the microscope, could be influenced, nay even deprived and vascular systems. 43 of power, by agents whose operation was confined either to the brain or spinal marrow. In some animals even of warm blood, as appears from experiments related in my treatise on the Vital Func- tions, the motion of the blood in the capillaries may be observed for an hour or even two hours after death, provided neither great and sudden injury to the nerv- ous system, nor great loss of blood be occasioned by the mode of death; that is, long after the heart has ceased to beat. The continued action of the capillaries ap- pears, from what is said in that treatise, to be the cause of the large arteries being found empty some hours af- ter death. It has also been shown by experiments detailed in the same treatise, an account of some of which has ap- peared in the Philosophical Transactions, that the sto- mach and lungs are in like manner under the influence of both the brain and spinal marrow. The partial connection with the nervous system of the organs supplied by the cerebral and spinal nerves, and the universal connection with that system of those supplied by the ganglionic nerves, explain many of the phenomena, both of health and disease. Why are the affections of the stomach and other vital organs felt in- stantly through every part of the frame, while the effects of those of a muscle of voluntary motion, or even an organ of sense, although often a part of greater sensi- bility, is confined to the injured part? If the eye or ear, or the muscle of a limb, be so deranged by a sudden blow, for example, as instantly to destroy its power, sight, hearing, or the voluntary power of the part is lost, and there the evil ends, unless inflammation ensues; but a blow on the stomach, which instantly destroys its power, at the same moment destroys that of every other part. It is not difficult to answer the question, since the state of the stomach, from the cause just pointed 41 POWERS OF THE NERVOUS out, may influence every part of the nervous system; and it appears from experiments which the Society did me the honour to publish many years ago, some of which were repeated by Mr. Cliff, that a powerful and sudden affection of the nervous system is capable of immediately destroying the circulation in every part of the animal, by instantly depriving both the heart and blood-vessels of their power. Here the question naturally arises,—for what purpose are the vital organs thus connected with every part of the brain and spinal marrow? This question is answered by experiments detailed in my treatise on the Vital Functions, an account of some of which appeared in the Philosophical Transactions of 1822. From them it was found that the power of se- creting surfaces is deranged by abstracting from them any considerable part of the influence either of the brain or spinal marrow; and as the function of secretion is ef- fected by the action of the nerves on the blood, as ap- pears from facts detailed in the paper just referred to, and another which the Royal Society did me the hon- our to publish last year, it is evident that the presence of nervous power in a secreting organ would be useless, were not the blood on which it operates also supplied, and disordered if it were not supplied in due propor- tion; and, consequently, its supply varied as the supply of nervous power varies. We thus see not only why secreting surfaces are placed under the influence of every part of the nervous system, but also why it is necessary that the sanguifer- ous system should be under the control of the same laws which regulate the supply of nervous power. It appears, then, that by means of the system of ganglionic nerves, the influence of every part of the brain and spinal marrow is bestowed on secreting sur- faces, and on those organs by which the supply of their and vascular systems. 45" fluids is regulated, and that this influence is necessary to their functions. But it is not the secreting power alone that is thus placed under the influence of every part of the brain and spinal marrow; for it is a necessary inference from experiments related in a paper which the Society did me the honour to publish in 1828, that the whole of those processes on which the healthy structure of the part depends are under the same influence. It appears from the facts stated in this paper, that by depriving the lungs of a considerable portion of their nervous power, without in any other way influencing them, the assimilating processes were so disordered, that the most serious organic disease was established in them, even in the space of a few hours. The influence, therefore, of the whole brain and spi- nal marrow is thus united by nerves from various parts of these organs entering ganglions and plexuses, from which are sent to the vital organs nerves proved by direct experiment to convey the influence of every part of them; and this combined influence of the brain and spinal marrow is employed in forming the various secreted fluids, and supporting the other processes on which the due structure of every part depends; and I have, in a treatise entitled "'On Indigestion," pointed out how extensively the phenomena and treatment of all diseases are influenced by this cause. Such, then, is the relation which subsists between the nervous system and the other vital organs I have had occasion to mention; but there is another relation of that system which must be considered before the nature of its functions can be clearly understood. The nervous system, in the usual acceptation of the term, is very ill defined, and functions of the most dis- similar nature are classed together under the general denomination of nervous. Those of sensation and 46 POWERS OF THE NERVOUS volition, for example, are classed with the excitement of a muscle and the formation of a secreted fluid. It seems highly improbable that results so different should arise from the same or similar causes. On the most cursory view of the subject, we cannot help supposing that the nervous system, according to the common ac- ceptation of the term, includes more than one principle of action. We have every reason to believe, that the sensorial is a power wholly distinct from that strictly called ner- vous; and all doubt seems to be removed by the cir- cumstance, that although the organs of both belong to the nervous system, it is evident they are not the same organs, because the sensorial power resides chief- ly in the brain, while the nervous power, properly so called, resides equally in the brain and spinal marrow; the latter of which organs is capable of its functions independently of the former, as appears from many of the experiments of Le Gallois, which have been confirmed by several of my own. It occurred to me, on reviewing the whole of these circumstances, that as we can destroy the nervous, without at all impairing the muscular power, it might be possible to remove the sensorial power without im- mediately destroying that more strictly called nervous. I made many experiments, which are detailed in my treatise on the Vital Functions, for the purpose of de- termining this point; from which it appears that in all modes of death, except the most sudden, (arising from a violent and sudden impression made on the nervous system, by which the whole of the functions are instan- taneously destroyed,) the sensorial functions are the first which cease, all the other powers of the system remaining more or less perfect, and any imperfection which appears in them not directly depending on the loss of the sensorial power. and vascular systems. 47 Of the sensorial functions, sensation and volition are the only ones which we are called upon to consider here, because they alone have any share in maintaining ani- mal life. That these functions are essential to the maintenance of life in all the more perfect animals will, I think, appear from what I am about to lay before the reader. The following may be regarded as the nervous func- tions properly so called. The excitement of the mus- cles of voluntary motion, by which, through the inter- vention of the nervous system, they in their usual func- tions are subjected to the sensorial power; the occasional excitement of the muscles of involuntary motion, by which, under certain circumstances, the sensorial power is also capable of impressing them through the nerves, particularly when under the influence of the pas- sions; the act of causing an evolution of caloric from the blood, by which the due temperature of the animal body is maintained; the act of forming from the blood the various secreted fluids, and of maintaining the other assimilating processes by which the healthy structure of every part of the body is preserved. The first of these functions is universally acknow- ledged to be a function of the nervous power, properly so called; but there has been much difference of opinion respecting the way in which it operates. I have alrea- dy had occasion to make some observations on this sub- ject. Haller,* we have seen, was the first who taught that the muscular power belongs to the muscle itself, to which the nervous power bears no relation but that of a stimulus, and that the heart is incapable of being directly influenced through the nervous system; and endeavoured to support those opinions by experiment; his opponents, however, objecting to them, for reasons which I have had occasion to state. * Element. Physiolog. 48 POWERS OF THE NERVOUS It appeared to me that the question, whether the mus- cular fibre derives its power from the nervous system, could only be determined by some experiment capable of directly ascertaining whether the excitability of mus- cles is maintained by the influence they receive from the nerves, or impaired as by other stimuli. On trial, the latter was found to be the case. Muscles whose nerves had been divided sustained the action of the same stimulus longer than those whose nerves were entire, and which, consequently, were exposed to the action both of the nervous power applied by the will of the animal, and the artificial stimulus.* The power of the muscle, therefore, is independent of the nervous power, and is affected by it in the same way as by other stimuli. The experiments by which all the other functions just mentioned, with the exception of the maintenance of animal temperature, have been ascertained to be functions of the nervous power, I laid before the Royal Society, which has done me the honour to publish them. From these experiments it appears, that the functions in question were always destroyed by depriving their organs of the influence of the nervous system. That the maintenance of animal temperature is a function of the nervous system, properly so called, appears from a variety of facts generally known; the temperature either of a part or of the whole body being lessened by any cause that impairs the action of particular nerves in the former instance, or of the whole nervous system in the latter. The question then is, Is the nervous system ca- pable of all these functions after the sensorial power is withdrawn? At the moment of what we call death, the sensorial functions cease—the animal no longer feels or wills. * My Treatise on the Vital Functions, third edition, Exper. 34, 35. AND VASCULAR SYSTEMS. 49 Whether the nervous functions, properly so called, still continue, can only be determined by experiment. That the nerves when stimulated are still capable of exciting the muscles of voluntary motion, is a fact generally ad- mitted; and that they are still capable of exciting the action of the muscles of involuntary motion, appears from many experiments related in the second paper which I had the honour to present to the Royal Society and which was published in the Philosophical Transac- tions of 1815. That the nervous system is capable of causing the evolution of caloric, which supports animal temperature after the sensorial power is withdrawn, ap- pears from many experiments related in my treatise on the Vital Functions; and that the nervous power, under the same circumstances, is still capable of forming the secreted fluids, and supporting the other processes by which the structure of every part is maintained, is shown by very frequently repeated experiments on the newly dead animal, related in the same treatise. From these experiments it appears, that some secretion of gastric juice takes place after what we call death, and that some derangement of structure in the lungs may be produced by dividing the eighth pair of nerves imme- diately after death; a proof, that the processes on which the structure of the part depends continue for some time after the sensorial power can no longer influence them. We may thus trace the existence of the whole of the nervous functions, properly so called, after the removal of the sensorial power. The former, therefore, have no immediate dependence on the latter; but in the entire animal we know that the nervous, in many of its func- tions always, and occasionally in all of them, is subject- ed to the sensorial power. These powers, therefore, bear the same relation to each other that the nervous 7 50 POWERS OF THE NERVOUS and muscular powers do—the muscular existing inde- pendently of the nervous, but being influenced by it. It was this independence of the functions properly called nervous on those of the sensorial power, and the analogy which subsists between the former and chemi- cal processes, which suggested that the agent on which the nervous functions immediately depend, instead of being peculiar'to the living animal, may only be an agent employed by those powers which are so, in the same way as any other constituent part which the living animal possesses in common with inanimate nature; and it ap- peared to me that the accuracy of this suggestion would be placed beyond a doubt, if the nervous power could be proved to be capable of its function after it had been made to pass through any other conductor than the nerves; for it will be admitted that the powers peculiar to the living animal can only operate, and, as far as we see, can only exist, in the organs to which they belong: the brain cannot perform the office of a muscle, nor a muscle that of the brain. If, then, the nervous power can be made to pass through any substance but that of the nervous system in which it resides, it evidently has an existence inde- pendent of the mechanism of that system, and therefore is not peculiar to it. This, after many vain attempts, I succeeded in effecting. It appears from experiments, an account of which the Royal Society did me the ho- nour to publish in 1822, and which have been repeated with the same result by M. Brechet and other physiol- ogists at Paris, that the nervous power is capable of its functions after it has been made to pass through other conductors than the nerves. It would seem, therefore, that however generally the nervous power has been ranked with those powers more strictly called vital, it is only an agent employ- ed by them. This view of the subject seemed to me AND VASCULAR SYSTEMS. 51 to point out the possibility of finding some of those powers which operate in inanimate nature capable of the functions of the nervous power, properly so called, if brought to operate under the same circumstances; and on trial it was found, as appears from experiments published in the Philosophical Transactions of 1822 and 1828, and repeated with the same result by Dr. Abel,* M. Brechetf and others, that galvanism may be substi- tuted for the nervous power, not only in the more sim- ple but in the more complicated functions of that power. It not only appears that galvanism is capable of excit- ing the muscles, but of causing an evolution of caloric from arterial blood,| of forming the secreted fluids from the blood, and supporting all those functions on which the structure of the body depends. How far do the whole of those facts, whether relating to the nature or functions of the nervous power, go in proving its iden- tity with galvanism? On reviewing what has been said of the relations of the sensorial, nervous, and muscular powers, the ques- tion naturally arises—If both the nervous and muscu- lar powers are thus independent of the sensorial pow- er, and capable of their functions after it is withdrawn, why do the more perfect animals for so short a time survive the loss of the sensorial functions? The cause is, that on the removal of the sensorial power, respira- tion ceases; because this function partakes of all the three powers, the sensorial, nervous, and muscular. * The London Medical and Physical Journal for May, 1820, vol. xliii. p. 385. f De l'lnfluence du Systeme Nerveux sur la Digestion Stomacale; par MM. Brechet, D. M. P., chef de Travaux Anatomiques de la Faculte de Medecine de Paris, etc.; H. Milne Edwards, D.M.P.; et Vavasseur, D.M.P. (Memoire lu a la Societe Philomatique la 2 Aout, 1823.) Extrait des Archives Ginirales de Jiltdccine, Aout 18-2:3. \ My Treatise on the Vital Functions, third edition, Exper. 80, 81, 82, 83, 84, 85, 86. 52 POWERS OF THE NERVOUS It has been customary to speak of the muscles of re- spiration as at least in part muscles of involuntary mo- tion. What is meant by a muscle of voluntary motion? It is a muscle whose action under all ordinary circum- stances we can excite, interrupt, retard, and accelerate at pleasure; but it is not a muscle whose action we can at all times control. There is no such muscle; because, the impression on the sensorium, tending to call any par- ticular set of muscles into action, may be so powerful, that we are unable to control it. Who can prevent the action of the muscles of the arm when fire is suddenly applied to the fingers? Neither do we mean by the term muscle of voluntary motion, one which we cannot call into action during sleep. \^ our posture during sleep becomes uncomfortable, we call the muscles, both of the trunk and limbs, into action for the purpose of changing it. The uneasiness caused by the continuance of the same posture sufficiently rouses the sleeper to make him will a change of posture, without rendering him at all more sensible to other impressions of a slight- er nature, and his sleep continues. What muscles, then, are more under command than those of respiration? We can on all usual occasions interrupt, renew, retard, or accelerate their action at pleasure; and if we cannot interrupt it for as long a time as that of the muscles of a limb, this depends on no peculiarity in the action of these muscles, but on the nature of the office they are called on to perform; and if we excite them in sleep for the removal of an unea- sy sensation, and cannot control them under a sense of suffocation, that is, in a state of greater suffering than we can voluntarily bear, all this is no more than applies to every other muscle of voluntary motion: but from the nature of our constitutiom, we must breathe many times every minute, and we need not turn ourselves more than once in many hours,—a difference depending AND VASCULAR SYSTEMS. 53 on circumstances which have nothing to do with the nature of the muscles we employ in either of these acts. If we find the breathing going on in apoplexy after all voluntary motion of the limbs has ceased, it is because the sensation exists which calls on the patient to inflate his lungs, while there is none which calls for the action of the limbs. In the slighter states of apoplexy, if the limbs be much irritated, the muscles which move them will also be called into action; and in the severer states, if the patient breathes, when no irritation of the limbs can excite him to move them, it is that the want of wholesome air in the lungs, after a certain interval, pro- duces a more powerful impression than any other means we can employ. People have voluntarily held the hand in the fire, but no man ever voluntarily abstained from breathing till the lungs were injured. When at length no irritation, however violent, can impress the sensorium, the breathing ceases and death ensues. The mode of death sufficiently illustrates what is here said. We find the intervals of breathing becoming longer before it ceases. As the insensibility increases, a greater want of fresh air is necessary to excite the patient to inspire, till at length the total privation of fresh air no longer producing any sensation, can no longer excite this effort. The muscles of respiration, then, it would appear, are as perfectly muscles of voluntary motion as those of the limbs, and are never excited but by an act of the sen- sorium. When there is no feeling to induce us to breathe, the breathing ceases. That on ordinary occasions we are unconscious of this feeling, in the common acceptation of the term, (that is, that it makes no lasting impression on the mind, for this is necessary to what we mean by consciousness,) unless the attention is particularly directed to itj, is no 54 POWERS OF THE NERVOUS proof that it has not existed. When we direct our attention to the act of breathing, especially if we breathe more slowly than usual, we can distinctly per- ceive the sensation which induces us to inspire, and that it is a voluntary act which relieves it. The same observations respecting consciousness apply to all the more trivial habitual acts of the sensorium. In playing on an instrument, we cannot tell which finger last struck the chord; in walking, we cannot tell which leg we last moved;—yet all such acts are strictly acts of volition: when we attend to them, we can regulate them as we please; but, in proportion as they are habitual we attend to them the less, and therefore least of all to the act of respiration. To the consciousness of having experienced any feel- ing, it is evident that its strength, or some other circum- stance attending it, must be such as to impress it on the memory. We are every hour performing many acts of volition which are too trivial to be remembered, and consequently, at the time we are questioned, we have no conciousness of their having existed. The proper feeling excites the act required, but the feeling is too habitual to command the attention. It may be difficult for a person not accustomed to re- flect on such subjects, to believe, that every time his leg is moved in walking he performs a distinct act of voli- tion; but he will be convinced of this, if he observes the motions of those whose power of volition is impair- ed by disease. He will find the patient hesitate which leg to move at every step, and at length his attempts to move the limbs produce a confused and irregular ac- tion, incapable of carrying him forward. The act of expanding the chest is an act of volition; it is an act, in ordinary breathing, rendered extremely easy by the gentleness of the motion required, and the continual habit which renders it familiar, and is excited AND VASCULAR SYSTEMS. 55 by a sensation proportionably slight; but which is as es- sential to it as stronger sensations are to more powerful acts of volition. Thus it is, that on the removal of the sensorial power respiration ceases. It may be here said, perhaps, that we have no in- stance of a muscle of voluntary motion continuing to act at short intervals during life: but, besides that this is begging the question, it is to be recollected that the action of the muscles in ordinary respiration is very slight, and performed at considerable intervals: for it is only during inspiration that the muscles act; they are quiescent during expiration, which in our usual breath- ing is performed by the elasticity of the cartilages and the weight of the parts concerned. There is perhaps no muscle of the body which could not without fatigue maintain a similar action, were there a cause capable of exciting it. In certain diseases we find both more powerful and more frequent actions of the muscles of volition continued for years, during the whole of our waking hours, without any complaint of fatigue. When the change in the blood, effected by respira- tion, no longer takes place, most of the pulmonary ves- sels lose their proper stimulus, red blood; and feel more directly, perhaps, the debilitating influence of black blood;—their function therefore begins to fail. In pro- portion as this happens, the blood accumulates in the lungs. The right side of the heart consequently expe- riences an increased difficulty in emptying itself, and the due supply of blood to the left side fails. By the operation of these causes, both sides of the heart soon lose their power after respiration ceases. The arteries, under such circumstances, it is evident, cannot long supply fluids proper for the purposes of assimilation. The nervous and muscular solids, therefore, deviate from the state necessary for the functions of life, which at length cease in every part. 56 POWERS OF THE NERVOUS The foregoing appears to be the order in which the functions always, with the exception of their instanta- neous destruction as above mentioned, cease in death; whether it be occasioned by injury of the sanguiferous or nervous system, or both. Such, then, appears to be the nature of respiration. The first act is the impression made on the sensorium, the sensation excited by the want of fresh air in the lungs. We are enabled to supply it, and thus remove the uneasiness, by exciting certain muscles subjected to the will. Through nerves which are fitted to this pur- pose, we apply a stimulus to certain muscles which perform the act required. Thus, respiration is the combined act of the sensorial, nervous, and muscular powers. It is as effectually destroyed by a failure of the sensation which makes us will to inspire, as by that of the nervous or muscular > power by which the will effects its object. With this view of the subject before us, and I can see no other which the facts admit of, it will be proper to examine the nature of respira- tion more in detail. I have already had occasion to observe, that the ef- fort made in ordinary breathing is very slight. It is chiefly performed by the diaphragm, by the contraction of which the cavity of the chest being slightly enlarged perpendicularly, the pressure of the atmosphere readily causes the air cells to be distended with air; but if any obstacles occur tending to prevent the passage of the air to the cells, a greater effort is required, and other muscles are called into action. It seems almost unne- cessary to observe, that the sensation which induces us to make this greater effort, must, as the object is still the same, operate in the same way. The more powerful sensation, indeed, and the trouble the effort gives us by calling our attention to it, enables us at once to perceive that it is an effort of the same kind with any other vo- AND VASCULAR SYSTEMS. 57 luntary effort by which we endeavour to relieve our- selves from a painful feeling, and, like any other power- ful voluntary effort long continued, produces the feel- ings, of fatigue. Would any privation of air induce the struggle that we see in severe difficulty of breathing, if no sensation were excited by it? This sensation is ex- cited in the sensorium through the nerves of the lungs, and all that follows is evidently the consequences of it. The effort consists in two things: drawing the air into the chest with greater force, that is, expanding the chest more forcibly that the air may enter it with a greater degree of atmospheric pressure, and thus any obstacle to its entrance be overcome; and doing all wre can to enlarge the passage by which the air enters. The action of the muscles by which these objects are effected has been ascribed to a particular sympathy supposed to exist between certain nerves. But if the eighth pair of nerves which supplies the lungs originate near the nerves of the diaphragm, and certain muscles of the face, by which the nostrils are expanded, this cannot be said of the nerves of many other muscles, equally called into action in severe dyspnoea, the muscles of the loins, &c; and if we could, by what is called sympathy of nerves, explain the phenomena in question, it is not to be overlooked that the same sympathy must exist with respect to the abdominal as thoracic viscera, for the same nerves supply both. We must, therefore, look for another principle to account for the relation which subsists between such acts and peculiar states of the lungs. The principle is at hand. The sensation which induces us to inspire, forms a necessary link in the chain of causes; for every contraction excited in the muscles is evidently calculated to relieve this sensation, in one of the two ways just pointed out: it either tends to expand the chest, or enlarge the passage of the air. It is impos- 8 58 POWERS OF THE NERVOUS sible in such a case to overlook the act of the senso- rium which is sufficient to account for the phenomena without any particular sympathy of nerves, which, on the other hand, I have just had occasion to point out is insufficient for this purpose. The muscles employed in extreme dyspnoea are not confined to a particular set. They are the whole muscles of the trunk, and sometimes many of the limbs also—muscles which have nothing in common, except that they are all muscles of voluntary motion, and bear the same relation to the nervous and sensorial systems which all other muscles of voluntary motion do. Actions of the muscles of the face, indeed, are equally associated with sensations referred to the ab- domen and the limbs, and arising from causes ope- rating in them. Who can have a placid countenance while in agony from the operation of any cause, to whatever part applied? It appears from a great variety of experiments to which I have referred, that organs supplied with ganglionic nerves are subjected to the influence not of any one, but of every part of the brain and spinal marrow. No inference, therefore, can be drawn re- specting the sympathies of any ganglionic nerve, as the term is here used; that is, a nerve that either enters or proceeds from ganglions, according to the sense in which I use the term, from any particular distribution of nerves, or from the part where any particular nerve which contributes to the power of the ganglionic sys- tem originates. Vital organs are equally connected with every part of the brain and spinal marrow; and if we must not look for those partial sympathies with respect to their other functions, there is still less room it is evident, to look for them in those functions where the sensorial power is concerned. AND VASCULAR SYSTEMS. 59 The sensorium evidently residing and operating at the source of nervous power, there receives the va- rious impressions conveyed by the nerves, and there influences those nerves which convey its dictates. I shall beg leave to close this part of the subject with a short recapitulation of the principal points which ap- pear to be ascertained by the experiments which have been referred to. The nerves are divided into two classes, whose func- tions essentially differ: those proceeding directly from the brain and spinal marrow, which, in the one direc- tion, convey the influence of the part of those organs from which they have their origin, and are the sole means of exciting the muscles of voluntary motion, and in the other, impressions which influence the sensorium; and the ganglionic nerves, which, while they also con- vey impressions to the sensorium and occasionally ex- cite the muscles of involuntary motion, usually excited by stimuli peculiar to themselves, have for their principal function one of greater importance, and which requires the combined influence of the whole brain and spinal marrow, that of supporting the various processes of secretion and assimilation, and are, consequently, in the strictest sense a vital organ. Although the nervous power, therefore, stands only in the relation of a stimulus to the muscular fibre, whether of voluntary or involuntary motion, in no de- gree contributing to its power, which depends on its own mechanism; it is essential to the existence of the secreting and assimilating powers, which are immedi- ately destroyed by withdrawing its influence. Such is the relation which the nervous system bears to what may be termed the circumference of the animal body, in contradistinction to the sensorium, which may be justly regarded as its centre, to which that system bears a relation of equal importance; for it is the means of 60 POWERS OF THE NERVOUS connecting the organs of the sensorium with all other parts. In its power, this system is independent of the sensorium; for we have seen it capable of all its func- tions after the sensorial power is withdrawn; but in all of them it is influenced by it, constantly in some, occasionally in others: it therefore bears the same rela- tion to the sensorial organs which the muscles bear to it. As the muscular is independent of the nervous power, so is the nervous of the sensorial power. As the nervous influence all the muscular functions—those of the muscles of voluntary motion constantly, those of the muscles of involuntary motion occasionally—so the sensorial influence all the nervous functions, those of the cerebral and spinal nerves constantly, those of the ganglionic nerves occasionally. Thus all the functions of the nervous and muscular systems, by which we are connected with the world that surrounds us, are constantly subjected to the sensorial power, and in such a. manner that they are also subjected to the will; while the functions on which our life depends, with the exception of respira- tion, are only occasionally so, and under circumstances in which the will has no control. With this exception, the latter are all functions of the nervous and muscular powers alone. The sensorial power being necessary to respiration, the nervous and muscular powers never long survive the loss of that power. The nervous power which connects all the other powers of the animal body, effects so many changes in it, and has so large a share in connecting it with the world around it, cannot, strictly speaking, be regarded as one of the vital powers of that body, but as an agent employed by those powers; because it has been proved by direct experiment that it is capable of exist- ing independently of the mechanism of the part in which i resides, and, therefore, is not peculiar to that AND VASCULAR SYSTEMS. 61 mechanism; and by the same means that all its func- tions may be performed by galvanism, made to operate in the same circumstances in which the nervous power operates. The experiments referred to in the foregoing paper, suggested the use of galvanism in those diseases which arise either from a partial or general failure of the nervous power; and the success which has attend- ed its employment has afforded another proof of its capability of the functions of that power. The dis- eases in which it has been chiefly employed are habi- tual asthma, the various forms of indigestion, affections of the spinal marrow, and general nervous debility. An account of its affects in the first of these diseases was laid before the Society, and published in the Phi- losophical Transactions of 1817. An account of its effects in the others is published in the third edition of my Treatise on the Vital Functions. On revewing the positions which appear to be established by the foregoing statements, and compar- ing them with what I have had occasion to say of the necessary deviation from the healthy state of the blood when the excretory organs are debilitated, we readily perceive that the effect of the state of blood, which thence ensues, by its influence on the brain, must tend further to debilitate the excretory as well as all the other assimilating functions. What is here said is well illustrated by the effects of the depressing passions. On these principles we are at no loss to see why, under them, the appetite fails, from a defective or vitiated gastric juice; why bilious derangements, and all their chain of consequences, in the bowels and other parts of the system, ensue; and why, if the influence of the offending cause be long continued, organic disease itself should be established. And when we consider that the blood is still further 62 POWERS OF THE NERVOUS vitiated by a morbid state of the secretions, and thus the source of the nervous power, also, still further influenced, we readily account for the gradual decay of all the powers of the system. A greater or less degree of the same train of conse- quences, observed from the continued influence of the depressing passions, must arise from morbid states of the blood arising from other causes, or any other cause tending to injure the source of nervous power. No single function of importance can be deranged, without producing more or less of the same effect. Through the medium of the nervous system it is felt in every part of our frame, and we readily perceive why the permanent derangement of any one part tends to derange every other. It is in a great measure, in this way that organic disease so constantly produces the haggard counte- nance, and the emaciated or bloated form, which almost always, be where it may, announce its existence to the experienced eye of the physician, before the patient answers one of his questions. He feels no difficulty in distinguishing, from the mere appearance of the patient, such a case, from that of emaciation or debility, however great, the result of acute disease, which has left the frame exhausted, but its structure entire. In the present state of medical science, it would be of little use to pause for the sake of considering the advantages that would result from a correct knowledge of the chemical changes which here take place in the various fluids, and, consequently, solids of the body. The laborious and important investigations of Dr. Prout, and the success which, in the department to which his attention has been chiefly directed has crowned his labours, afford some reason to hope that this knowledge may one day be attained; that we may AND VASCULAR SYSTEMS. 63 be able to trace the chemical changes, which, by the relation of the vital powers ol the system to each other, are constantly propagated from the suffering part to the whole, till life is extinguished by a process similar in its nature to that which takes place after death, although modified by those powers, of which, as of all other principles, we know nothing but the properties. The aids that such a knowledge would give us are incal- culable, but the labour which must precede its attain- ment is no less so. In the mean time we are to make the best use we can of the knowledge we already pos- sess. The reader will also easily understand, from what has been said of the general states of disease, with the consideration of which this treatise commences,— namely, those in which the circulating fluids are either in too great or two small proportion to the powers of the system,—how these states dispose particular parts to disease, and thus, as it were, prepare them for the effects of a morbid state of the nervous system; their liability to be affected depending, in some degree, on the nature of their structure, function, and relation to other organs; and, still more, on the particular constitu- tion of the patient, and the circumstances in which he is placed, as will more fully appear in considering the affections of the different organs. These affections are of two kinds: those which de- range the function only, and those in which the struc- ture of the part also is implicated. Disease of function always precedes that of structure, with the exception, we shall find, of certain cases where, from the gradual manner in which the latter takes place, the obscure nature of the function of the part, or some less evident cause, disease of structure is established, without hav- ing betrayed itself by any symptom. 64 POWERS OF THE NERVOUS Did not constant experience assure us of the facts, we might, from the circumstances which have been stated, infer that all important and long-continued deviations from the healthy state of the functions tend to change of structure; and that when this takes place in any vital organ, a general decay of the powers of life is inevitable, if its healthy structure cannot be restored. It is surprising, however, in well balanced systems— that is, systems in which the vigour of the different organs are so justly proportioned that there is in no one a greater tendency to disease than in the rest, and where no one is particularly exposed to the operation of the offending causes—how long states both of great debility and great general irritation may exist without the structure of any particular organ yielding; and, conse- quently, for how great a length of time even severe suffering may continue without destroying life. This I had occasion to point out and comment upon at con? siderable length in my Treatise on Indigestion. It is the giving way of some particular organ which precipi- tates the fatal event, and in how many ways it has this tendency the intelligent reader will easily perceive from what has been said of the mutual dependence of the vital powers. Few diseases afford a source of greater irritation than severe indigestion. Every part of the system feels it; and if there lurk in the constitution a tendency to any particular disease, consumption, asthma, paraly- tic affection, gout, &,c, it seldom fails to show itself; so that there is hardly a morbid tendency which if long continued, it may not be the means of calling into action; yet where there is no such tendency, we see the strength reduced by it to the last stage, without the supervention of any train of local symptoms. AND VASCULAR SYSTEMS. 65 Under such circumstances, a change of great impor- tance sometimes takes place, indicating, we shall find, a meterial change in the nature of the disease. The stomach itself, to a certain degree, regains its power, and a state of general debility is substituted for that of severe indigestion. It is not very uncommon to hear the patient declaring, that nothing surprises him so much as to find that now, when he is unfitted for all the active duties, both his appetite and digestion are better than when he could mix with the world, and do, in most respects, as others do. This change deserves mature consideration, not only as tending to a failure of the whole powers of the system, but as throwing light both on the nature and treatment of a state of disease, which has hitherto obtained too little attention. It has been confounded with others of little comparative importance; and we are surprised to see all the powers decaying without our being able to assign any adequate cause for the change that is evidently going on, till at length a train of symptoms supervenes that are no longer equivocal, under which the patient sinks; both friends and physi- cian declaring that, although they had long considered him in a delicate and nervous state of health, they had no apprehension of such a termination. But the bet- ter to prepare us for considering the nature of such cases, it will be necessary to consider that of some other morbid affections, to which they are immediately allied. In the preceding parts of this treatise I have endea- voured to point out the nature and relation of the general functions of the animal body, and the manner in which a failure in any one necessarily affects the rest. As functional disease always precedes disease of structure, before the latter is established we may per- 9 66 NERVOUS AND VASCULAR SYSTEMS. ceive a train of symptoms pointing out the seat it is about to occupy. In the prevention of organic disease, therefore, these are the symptoms to which the atten- tion must be directed; and here the task of the phy- sician is not always an easy one. He has often to con- tend with an obstinate and insidious, and not unfre- quently an obscure disease. I shall consider the tendency to organic disease in the different vital organs in the order of their impor- tance; and, in the first instance, therefore, direct the reader's attention to the brain. Its influence in the animal body, we have seen, is more extensive than that of any other organ, and consequently more extensive- ly concerned in its diseases. We shall, in the first place, take a rapid view of such of the more acute diseases of the brain, as will better prepare us to consider those affections which belong to the proper subject of this treatise, in which from deceitful, and sometimes almost imperceptible' beginnings, the most formidable diseases are often established. CHAP. III. Of some of the more acute Diseases of the Brain. The acute diseases which threaten the structure of the brain appear with such symptoms that their ten- dency cannot be mistaken;—namely, the more common forms assumed by inflammation and congestion of that organ, which in proportion as the minute vessels are the seat of the preternatural distention, produce fever and furious delirium; in proportion as it is confined to the larger vessels, low muttering delirium, coma, and apoplexy; and those acute affections in which the cause of injury is rather in the substance of the brain than its vessels, which often asume the form of nervous apoplexy, epilepsy, or mania, in various degrees and modifications^11) It is surprising how long epileptic paroxysms, which may be considered the most severe functional disease to which the brain is subject, may continue to recur, at long intervals, without materially affecting its structure, especially where a mental cause has had a considerable share in their production. If they recur at short inter- vals,* structural disease generally takes place rapidly; (11) May there not be a diversity of function amongst "the minute ves- sels" of the brain, which, when thrown into morbid action, will diversify the aspect of disease? Do not a portion of these vessels supply nourishment to the substance of the organs, whilst others furnish the material from which the sensorial power is elaborated? The effects, then, of their un- natural action must be essentially different; the former alone are capable of what is ordinarily termed inflammation, seeing their ofiice is to separate from the blood the palpable matter of nutrition; whereas, a similarly elevated action of the latter will only yield an increased amount of sensorial or cere- bral power. gg ACUTE DISEASES and an uninterrupted succession of such fits, in various diseases often announces their fatal termination. It is not to be overlooked, as might be inferred from the general principles afforded by the' experiments which have been referred to, and as proved by constant experience, that all diseases of long continuance, of whatever part, tend to produce organic disease of the brain. As the brain is not only the organ of perception, but the source of nervous power, and as the vital organs in every part of the system are influenced by, and capa- ble of influencing, it, (12) it is easy to understand why long-continued suffering of any kind may have this tendency. Hence it is, that insensibility and epileptic paroxysms, in many diseases of long continuance, are so often the forerunners of death, even when the prin- cipal seat of the disease has been in a distant part. It is not uncommon to find organic derangement in the brain in tedious cases of pulmonary consumption, and other forms of atrophy, and, in short, in organic dis- ease of slow progress in any vital organ. Of the operation of many of the causes of disease of the brain we have no knowledge: it would, therefore, be only a waste of time to attempt to trace the steps by which their effects are produced. In other instan- ces their operation is less obscure, and the treatment of the diseases which result from them is greatly aided by tracing, as far as our knowledge of the animal economy permits, the manner in which they influence the state of this organ; the effects which, through it, they pro- duce on other parts of the system; and the manner in (12) Entertaining other ideas of the source of nervous power, and be- lieving that of the brain to be a secondary production, we considerably limit its influence over other vital organs; consequently sliould give solutions of many morbid phenomena very different from those of the text; but we shall obtrude them as rarely and concisely as possible. OF THE BRAIN. 69 which the brain is again affected by the state of those parts. Such is the nature of the animal body, that the effects of any cause of disease are never confined to the organ on which they make their impression; and their injurious effects on other parts seldom fail to re-act on that organ, and thus both to increase and modify its derangement. This, as we might, a priori) suppose, is particularly the case with respect to the brain, without whose aid, even the minutest of that almost infinite variety of functions which are necessary to the growth, maintenance, and protection of the animal body, cannot exist; and which is the immediate organ of the mental powers, no less varied, and hardly less influencing, and being influenced by, the state of the more vital powers of that body. The occasional causes of diseases of the brain may be divided into those which morbibly excite, and those which morbidly depress, its powers. I shall take a view of the necessary effects of each of these sets of causes, as far as we can trace them.—When the brain is exposed to a highly exciting cause, from the imme- diate influence of this organ on the heart and blood- vessels, they also are excited to increased action. If the cause be of a transitory nature, and not excessive, little other sensible effect ensues. As its influence subsides, the functions of the brain and sanguiferous system re- turn to their usual state. When it is excessive, though of short duration, other consequences sometimes ensue. The blood is conveyed to the head by vessels subject, of course, to the same affections as those of other parts of the body. When the sanguiferous system, therefore, is preter- naturally excited, they partake of this increased excite- ment; and by this cause, combined with the increas- ed action of the heart, a greater than usual quantity of blood is sent to the head: but as the blood is return- 1 70 ACUTE DISEASES ed from the brain by membranous canals which cannot partake of this excitement, a tendency to accumulation of blood in the head takes place; which is much increased, if the occasional cause has been of such a nature as at the same time to excite the muscles of voluntary motion; whose action, by pressing irregularly on the veins, in consequence of the valvular structure of these vessels, greatly increases the rapidity of the circulation. An increased accumulation of blood in the brain, within certain limits, for the time increases its energy; and both the valvular structure of the veins in the limbs, and the inexcitable nature of the canals just mentioned, appear to have for their object, that the vigour of the brain should be temporarily increased under strong exercise, and the influence of certain passions in proportion to the increased demand for it. This temporary increase of excitement in the nervous and sanguiferous systems is succeeded by a propor- tional depression in the powers of both. It sometimes happens, during the state of excitement and consequent turgescence of the vessels of the brain, that one of these gives way; and, blood being effused on the surface or in the internal parts of the brain, this organ is so compressed as to become suddenly incapa- ble of its functions, and one of the most fatal forms of apoplexy ensues. When, without rupture of the vessels, the brain is so compressed by their morbid distention as to become incapable of its functions, an apoplectic state in like manner ensues; but which after the cause of the ex- citement is removed, if the constitution be otherwise sound, disappears spontaneously. I knew an elderly gentleman, stout, and of a full habit, who laboured under hooping-cough, and every return of cough left him in a state of insensibility on the floor. He, how- OF THE BRAIN. 71 ever, passed through the disease without any serious accident, and enjoyed his usual health after it. When such distention of the vessels arises from more permanent causes, or the vessels of the brain have been previously debilitated, the result is more serious, and constitutes one of the most frequent forms of apoplexy; the recovery from which depends on the vessels, when being relieved from the superfluous quantity of blood, recovering and maintaining their vigour, and consequently their healthy diameter. But it is not unusual, when a plethoric state of the head has been habitual for some time previous to the apo- plectic attack, and the vessels consequently have been debilitated, for the patient several times to revive on abstraction of blood; but constantly to relapse into the same state, as the vessels again allow themselves to become morbidly distended, till, the powers of the constitution being exhausted, death closes the scene. The following observations must be kept in view, in judging of many of the diseased states of the brain:— It seldom happens that great excitement of the brain, without other concurrent causes, produces the apoplexy here described: for however much the circulation be excited by the excitement of this organ, and however much the vessels of the head may in consequence be distended, the increased excitement of the brain sup- ports its functions under the increased pressure, and thus enables it to resist what, at other times, would have oppressed its powers. Here the risk is from the rupture of a vessel. On the other hand, when causes have occurred to debilitate the brain, its functions sink under a degree of pressure that would, under other cir- cumstances, be little felt. This often appears to be a principal cause of apoplexy after a full meal in the habitual glutton, which, by oppressing the stomach, 72 ACUTE DISEASES debilitated by former excesses, debilitates for the time the brain itself, as well as its vessels. We find that liability to apoplexy, under such circumstances, is not proportioned merely to the degree to which the stomach is distended, and consequently presses on the descend- ing vessels; but to this, and the indigestible nature of its contents/13) There is something at first view very inexplicable in the phenomena of apoplexy, such as it sometimes ap- pears in those who have long been exposed to causes which tend to debilitate the vessels of the brain. Dis- section has not only shown that sanguinous apoplexy, which is generally attended with a flushed countenance and strong beating of the temporial arteries, sometimes occurs when, both from the paleness of the countenance and the previous symptoms, as well as the nervous and exhausted habit of the patient, we should have expect- to find the blood in the brain rather below than above the due quantity. But that the state of the vessels of this organ, under such circumstances, is often that of morbid distention, even when the countenance, on the attack of the apoplexy, becomes much paler than before, and the beating of the temporial arteries hardly perceptible, dissection after death has evinced. Nay, such cases will be relieved by blood-letting, and the cautious use of it is indispensable. When we consider the communications which exist between the vessels of the brain and those of the ex- ternal parts of the head, and that both are supplied by the same trunks, great fulness of the former appears in- compatible with a shrunk and comparatively empty state of the latter; yet no physician has practised long, without seeing proofs of the existence of the state here (13) Or, rather, that the concentration of power in the digestive apara- tus, by withholding from the already enfeebled brain its customary supply, permits it to fall into-complete inaction. OF THE BRAIN. 73 described. I have seen, in an exhausted constitution, the face become suddenly pale and all power lost, the patient falling down insensible, and the countenance continuing to increase in paleness till it assumed a ca- daverous hue; and yet this patient has been immediate- ly restored to the use of his faculties, the paleness of his countenance at the same time abating, by the loss of blood; and there is every reason to believe would have died without it. The brain, as appears from all that has been said, is one of those parts which are most apt to sympathise with others.O4) In attacks of indigestion, for example, its powers are not unfrequently so enfeebled that all its functions are impaired. This debility extends to, and indeed seems sometimes to exist chiefly in, its vessels. We know, from the evidence of dissection, that in such cases they suffer themselves, and that often very sud- denly, to be morbidly distended by the force of the circulation, and thus to receive a greater than usual share of the blood sent to the head; the external vessels consequently receiving a smaller quantity: hence the paleness of countenance, on the attack of this species of apoplexy, and the increasing paleness, as the blood accumulates in the internal vessels, owing to their in- creasing debility. (14) Nothing so effectually stamps the characteristic of uncertainty upon our science as the familiar introduction of those metaphysical abstractions, or terms which signify any thing, every thing, or nothing; and which are used like post-notes as a convenient currency, because they can be filled with any denomination at the option of the drawer. Of this class is the word sympathy, a kind of Asmodeus of every science,—a short hand mode of expression sometimes carelessly adopted by the really intellectual,—and more frequently the resort or scape-goat, for the ignorant. Devices of this kind may be invaluable supporters of pretensions, but grievous obstacles in the way of honest inquiry. Men, such as our author, possessing inherent strength sufficient to sustain themselves in every instance, ought to spurn all such adventitious aid. 10 74 ACUTE DISEASES Such is the nature of the different forms of sangui- neous apoplexy. The danger, where there is no rup- ture of vessel, is proportioned to the degree of determi- nation of blood to the head, the degree in which the vessels yield to the pressure, and the ease with which the functions of the brain are oppressed; all of which may be different under different circumstances, although the occasional cause of the disease be the same. This species of apoplexy, when unaccompanied by that we are about to consider, never proves instantly fatal; because pressure of the brain never instantly de- stroys the powers of circulation, or so wholly destroys the sensibility as instantly to put a stop to respira- tion,—the only causes of instantaneous death in apo- plexy.* I found that the brain can bear a greater de- gree of uniform pressure than can be applied to it by any distention of its vessels, without at all directly affecting the action of the heart.f In sanguineous apoplexy, the only change which takes place in the action of the heart is the effect of the impeded respiration. The respiration becoming slower in proportion as the insensibility increases, for a reason above explained, the passage of the blood through the lungs is impeded; in consequence of which the action of the heart becomes proportionably slower and more laborious. Hence the slow and oppressed but strong pulse which characterises apoplexy from compression— the powers of circulation still retaining their vigour, but having a greater than usual obstacle to overcome; and hence the cause of death, we have seen, when the insensibility becomes such that no want of fresh air in the lungs can excite the patient to inflate them. In proportion as this state approaches, the whole of the secreting and assimilating powers, from the oppres- * Inquiry into the Laws of the Vital Functions. f Ibid. OF THE BRAIN. 75 sed state of the brain, become deranged; and, even were it possible that the circulation under such circum- stances could go on, would be incapable of the functions oflife.O*) The most suddenly fatal form of the disease we are considering, has justly obtained the name of nervous apoplexy, and seems to arise from a sudden derange- ment of the finer mechanism of the brain itself; some- times leaving no trace to be discovered by dissection.(16) In some of the experiments above referred to, suddenly crushing the brain by the blow of a hammer was found to occasion instant and universal death; not only the functions of the brain being destroyed by such a cause, but through it the muscular system so impressed as in- stantly to destroy its power, and, in consequence, the action of the heart and vessels. The effect is similar to that of death by lightning, which so completely des- troys the muscular power, that the muscles do not even stiffen after death. It seems to be a law of nature which has no excep- tion, that all stimulants applied in excess act as direct sedatives. There is no stimulant of the muscles so powerful as electricity; but its extreme application does not, as some writers have maintained, exhaust the power by excessive excitement, but at once destroys it, (15) On the contrary, we believe that if respiration and circulation could be maintained, the general functions of animal life, especially the secreting and assimilating powers, would go on, if the brain were even destroyed. The only direct agency the brain exerts in maintaining life, is through its instrumentality in respiration. (16) Nervous apoplexy is caused by the abstraction of the power com- municated by the inferior system of nerves. When this occurs suddenly, the specific operations of the brain instantly cease and the effects are the same of those consequent upon blows or lightning, noticed in the subsequent part of the paragraph. An attempt to explain the peculiarity of the ap- pearances presented in death upon these causes, will be found in the Appendices. 76 ACUTE DISEASES without previous excitement. This is true, whether we regard the nervous or vascular system. Thus, when a draught of spirit of wine has been swallowed, the effect has not been intoxication followed by apo- plexy, but instant death. The same observation applies to mental stimulants. None is more powerful ,than joy; yet excessive joy has produced instant death, without previous excitement. Thus, in all cases of apoplexy from compression, the powers sink gradually together; while, in the most acute form of nervous apoplexy, they are together in- stantly destroyed: in the former case, by the gradual failure of respiration; in the latter, by the instant de- rangement of the mechanism of the brain. Such are the effects on the brain and other parts of those agents which are termed stimulants, because, ap- plied within certain limits, they excite both the brain and muscular fibre. Of those which have been termed sedative, it may be observed, that as stimulants in excess produce the sedative effect, there is no sedative which will not, if applied in a smaller degree, act as a stimu- lant. Thus, tobacco, which is one of the most power- ful sedatives we possess, is well known, in very small quantity, to have the stimulant effect. The same is true of opium, digitalis, cold, grief, and all other seda- tives.<17) Their sedative effect, when applied in larger quantity, differs from that of the excessive application of stimu- lants in being less instantaneous, and, consequently more limited in its effect. It is proved by many expe- riments, an account of which was published in the Phi- losophical Transactions of 1815, and more fully in my In- quiry into the Laws of the Vital Functions, that no a°-ent of whatever power, can, through the nervous system^ (17) See Appendix No. HI. OF THE BRAIN. 77 destroy .the power of the muscles, however much it may for the time impair their action, unless its opera- tion be instantaneous. The effect of sedatives acting on the brain is that of impairing the action of the heart and blood-vessels:* the risk is now, not from the effect on the brain of over-dis- tention of its vessels, but from the joint effect of the se- dative on that organ, and the diminished supply of blood, from the enfeebled state of the circulation so les- sening its powers that it becomes incapable of its func- tions: and as, in the former case, the indication is to re- lieve it from the pressure of too much blood, it is now our object to support its powers under the joint effect of the sedative and diminished supply of that fluid, both by stimulating the brain, and more directly exciting the heart and blood-vessels; and when blood-letting, which is too indiscriminately had recourse to in cases of in- sensibility, has been employed here, immediate death has been the consequence/18) Thus nervous apoplexy is either the effect of a sud- den and excessive application of stimulants, which often produces instant death, and always threatens it; or of the slower operation of sedatives,—namely, of those * Inquiry into the Laws of Vital Functions. Exp. 29. et seq. (18) We are happy to have the concurrence of our author's high au- thority in reprehension of the indiscriminate practice of blood-letting in apoplexy, and also in other sudden and alarming cases of disease. Innume- rable patients have thus been precluded the possibility of a readjustment of their deranged functions, and their feeble streams of life have flowed out through the orifice formed by the unwary operator. Every case of disease demands the nicest scrutiny and the formation of a most deliberate judg- ment, before resort is had to a step so decisive as the abstraction of blood. In concussion of the brain, before the system has rallied after the sudden arrestation of its movements, the lancet cuts off the very means of resuming action. The same may bo affirmed of most instances of syncope, hysteric, hypochondriac and other nervous sinkings. Humanity might shudder at the profusion of blood shed by this empyrical practice, and question whether the lancet in unskilful hands has not been equally destructive of human life, with the weapons of the not more reckless soldier. 78 ACUTE DISEASES causes which debilitate the action of the brain, and, through it, that of the vascular system. We have a striking instance of the effects of the for- mer cause in what surgeons call concussion of the brain; that is, of a blow on the head which so shakes the brain as to endanger the immediate failure of the powers of life. It has just been observed that, in the experiments above referred to, a blow, which instantly and wholly deranged the mechanism of the brain, was found at the same moment to deprive the heart and blood-vessels of their power. A case of concussion is, in its first stage, only a less degree of the same state. It will place all that has been said in a clearer point of view, cursorily to enumerate the effects of such an impression made on the nervous system as suddenly les- sens the power of the heart and vessels. They will be found very accurately to correspond with the best ac- counts given by surgeons of concussion of the brain,* —a disease whose nature has been considered obscure; nor is it possible to understand it without being aware of the immediate influence of the brain on the heart and blood-vessels. When the brain is by any cause powerfully and sud- denly impressed, but not sufficiently so wholly'to des- troy its mechanism, it debilitates, without destroying, the various functions: the sensibility is impaired the heart acts more frequently and feebly, and, for the most part irregularly; and the circulating system suffers a similar loss of power in every part of the body. The sphincters of the rectum and bladder do not merely cease to be excited by any voluntary effort, as in sangui- neous apoplexy, but have the power, on which the de- gree of contraction constituting their state of rest de- *See the third Part of Mr. Abernethy's Surgical and Physiological Essays, and other works on concussion of the brain. OF THE BRAIN. 79 pends, more or less impaired, so that the contents- of these cavities often escape. This state is succeeded by some improvement in the symptoms. The heart and blood-vessels in some degree recover from the shock they received. The former begins to beat with less frequency, and with more force and regularity, and the latter to convey the blood with greater velocity, and in a more uniform stream. In proportion as this change takes place, the various functions, as I have very frequently observed in animals, improve, a greater degree of sensibility returning. If the offending cause has been comparatively slight, the symptoms continue to improve;(19) if severe, the heart soon begins again to beat more languidly, and with it all the functions gradually fail. This second failure is always final. If the injury done to the nervous system be of such a nature as particularly to debilitate the capillary vessels of the injured part, during that interval in which the vigour of the circulation is in some degree restored, the vessels of this part yield to the force of the blood, and the symptoms of inflammation are thus added to those more immediately arising from the injury. The reader will perceive, from the foregoing view of the subject, that the nervous is a much more complicat- ed disease than the sanguineous apoplexy. In the lat- ter, although the powers of the nervous system are im- paired, those of the sanguiferous system are in the com- mencement of the disease entire, and only become af- fected through the failure of respiration and the assimi- lating processes. In nervous apoplexy, not only the powers of circulation suffer directly from the injury (19) This revival often runs on to the higher grades of reaction. In such occurrences, the interdict against blood-letting is repealed, and on the contrary, it is recommended as one of the most efficient means of averting the second and final failure. 80 ACUTE DISEASKS done to the nervous system, thus producing a combina- tion of diseased states of both systems, but the debility of the heart and blood-vessels has a secondary effect on the nervous system itself. The action of the brain and spinal marrow fail from defective circulation, and a state of these organs, analogous to that which takes place in fainting, is superadded to that produced by the cause of the disease. Hence the immediate danger in this form of apoplexy. From the whole that has been said of the more acute diseases of the brain, we may clearly perceive the gene- ral laws which regulate them; and although those of slower progress appear with less marked symptoms, we may still observe the same tendencies in them. They are still such as lead to derangement of its mechanism, or morbid distention of its vessels. All such affections of the brain as are capable of de- ranging its functions, particularly of producing a con- stant derangement, however slight, in the secreting and assimilating powers throughout the system, may, if long continued, produce disorganization of this organ. The brain itself suffers as much from the failure of these powers as other organs, and is at the same time the part on which the offending cause operates. The reader will now perceive the nature of that state of general debility which I have already had occasion to mention as supervening on long-continued indiges- tion, and which has not only acquired an existence in- dependent of the disease which produced it,* but whose presence even relieves that disease. In my Treatise on Indigestion, I entered, at consi- derable length, into the nature of that species of con- sumption which arises from disorder of the digestive *It seems to be a general law of the animal economy, that if a secondary disease is kept up for a certain length of time, it will continue, although the disease that produced it be removed. OF THE BRAIN. 81 organs. I had occasion to point out that, as indigestion from the influence of the stomach and other digestive organs on the brain, and, through it, on every part of the system, keeps the whole habit on the fret, if any part, from peculiarity of constitution, or any other cause, is more liable to disease than the rest, that part is apt to suffer; and, unless the cause of irritation can be re- moved, the functional disease, thus excited, runs on to change of structure. The lungs, under such circumstances, it appeared, are particularly apt to suffer; as, in them functional disease is easily changed into disease of structure. Thus pulmonary consumption is frequently the effect of neglected stomach and bilious complaints.(2°) It was also observed, that the establishment of desease in the lungs generally relieves the indigestion that caus- ed it. The patient, for the most part, both eats and di- gests better than in the earlier stages of his complaint; and the tenderness, on pressure, in the region of the stomach and liver, abate. Now, the case before us is of the same nature: but the general irritation to which the system has been so long exposed has produced disease of the brain, instead of the lungs; and, instead of the local symptoms which indicate the presence of the latter, we have symptoms of general indisposition, because the functions of the organ now affected equally influence every part of the system. It is not, however, on this account, the less a local affection. It relieves the original affection from which it sprung, in the same way as the supervention of other local affections do; and, we know from expe- rience, if not arrested in its progress, will, like them^ terminate in deranged structure of the part affected; not (20) In proportion to the interchange of good offices between organs in health, is their power of mutual contamination in disease. 11 82 ACUTE DISEASES so quickly, indeed, as in the lungs, because the brain is less liable to such a change. The reader will easily understand, from what has been said of the more severe affections of the brain, that the disorder which we are here considering is, in the first instance, of the brain itself, not of its vessels. The long-continued irritation which precedes the esta- blishment of disease in it, acts on the principle of a sedative, of slow but pernicious operation. But when the powers of the brain are weakened by any cause, and whatever length of time may be required to pro- duce the effect, its vessels, in consequence of the directC21) influence of the brain on the vascular system, and that influence being always most felt in the seat of the irritation, by degrees, however slowly, partake of the debility; and I have known, on dissection after death, in such cases, the vessels preternaturally dis- tended, and the membranes thickened; in short, the same appearances presented as if the diseased action had originated in the vessels themselves; and, till the vessels begin to partake of the disease,—till symptoms of increased determination of blood to the head, and obstructed circulation in the brain show themselves,— it often happens that little alarm is excited. The symptoms differ but little from those of what are called nervous complaints; which, for the most part, arising from causes of little danger, seldom command much attention. Here a question of great consequence presents itself,— By what means shall we distinguish these cases in their early stage,—the only stage in which, in general, our endeavours can be successful? For the reader will easily perceive, from what has been said, that when the distention of the vessels proceeds from such a cause, the state of the habit must be ill calculated to bear (21) We would read indirect. OF THE BRAIN. 83 well the means of unloading them; and that, if they are, to a certain degree, unloaded, they will readily again yield to the force of the circulation: and such I have found, in actual practice, to be the results. How shall we know when the nervous symptoms may be safely disregarded, and when they indicate a disease which, if its progress cannot be checked, must lead to the worst consequences? This diagnosis will form the subject of the following chapter. In the preceding observations respecting the more acute diseases of the brain, I have spoken only of those which affect this organ generally. When the causes of disease act partially on it, the parts of the system which correspond to the parts chiefly injured are those necessarily most affected; and thus the symp- toms become more complicated. In epilepsy, for example, those parts which excite the muscles of voluntary motion particularly suffer; in palsy, those parts which correspond to particular sets of this class of muscles, are affected in a different way, &c. Here there is infinite variety; and although we may observe the same principles influencing all the diseases of the brain, and a constant tendency of its local diseases to run into the more general affections we have been considering, neither dissection nor expe- riment gives us the same assistance in the former cases; and the nature of many of them is, and probably will remain, involved in obscurity.* This is less to be regretted, because, in proportion as the diseases of the brain depend on local affections of that organ, our plans of treatment become less effectual; and, in its mere local affections, palliative modes of treatment, founded on the principles just laid down, are all that can be attempted. *See the chapter on the morbid appearances discovered by dissection. CHAP. IV. Of the Chronic Affections which indicate a tendency to Organic disease of the Brain. The brain, properly so called, while it conspires, we have seen, with the spinal marrow in maintaining the secreting and assimilating processes, and occasionally influencing the powers of circulation, is at once the seat of the sensorial functions, and the source of the powers on which they depend. These functions, it appears, from what has been said, except as far as relates to respiration, have no direct influence in the preservation of life, and may, therefore, be greatly deranged without endangering it;(22) but they are so intimately connected with all the vital powers, that the mental are constantly influencing, and being influenced by, the more vital functions; and hence one of the greatest difficulties the physician has to contend with in the disease which forms the subject of this chapter. The symptoms arising from affections of the nervous system, although severe, may be of a nature which produces little serious disturbance in the functions of life, and, without appearing more formidable, nay, while to a superficial view they appear less so, may be the indications of an undermining process, which, if it cannot be arrested, will leave the brain incapable of (22) The brain and spinal marrow, according to our positions, have no direct agency "in maintaining the secreting and assimilating processes," this duty belonging exclusively to the inferior system: and their "direct in- fluence in the preservation of life," is limited to volition in respiration and locomotion; and beyond these, their control is effectuated indirectly. ORGANIC DISEASE OF THE BRAIN. 85 all its functions. It is the business of the physician to distinguish these cases; without which he can neither know when a regular plan of treatment becomes indispensable, nor the nature of the means he should employ. No class of diseases is so common as those called nervous.(23) We are accustomed to see them continue for years without material injury to the constitution, and are too ready to infer that they are of a trivial nature; and to believe that, if the patient's mind can be made easy, little is to be apprehended from them; and in many cases this conclusion is correct. In my Treatise on Indigestion, I have endeavoured to point out the nature and most common sources of such affections, and endeavoured to ascertain the best means of relieving them; for, however free from dan- ger they usually may be, they constitute one of the most distressing of all our maladies; when in excess, unfit the patient for every active duty; often when there is a tendency to disease in other vital organs, by the general irritation they occasion, call it into activity; and, it cannot be denied, sometimes, though rarely, pass into the affection we are now to consider, which in all its stages, bears so great a resemblance to them. (23) Nor is there any less understood. Whilst the functions of the nerves were confounded, and no distinction was known between those of sensation, voluntary and involuntary motion, the medical mind must have entertained very indistinct ideas of the nature of the several forms of dis- ease! attributable to them. This may have been the chief reason why all those diseases have been considered trivial; for the pride of our nature will not permit importance to be attached to subjects of which we are ignorant. How many miserable wretches have been condemned to protracted suffer ing, by the unfounded judgment which pronounces their diseases imaginary! There are no more grievous or real evils, than those unhesitatingly set down as fancied ills. Wo trust there is, or soon will be, a physiology of the nervous systems so correct as to enable us to classify the facts of their pathology, point directly to their causes and seats, and establish indications of treatment that will re- move the opprobrium yet adhering to this part of our science. 86 ORGANIC DISEASE In both the symptoms consist in depression of mind, occasional derangement of more or fewer of the func- tions of perception and volition, and more or less deviation from the healthy action in different secreting organs, particularly in those of digestion. The appe- tite is defective or variable, and the patient troubled with a train of dyspeptic symptoms. How, then, are we to distinguish from a crowd of such cases those where a tendency to organic diseases of the brain lurks?(24) To accomplish this difficult but important diagnosis, we must call to our aid the whole circumstances of the case, the habit of the patient, the nature both of the predisposing and exciting causes, the general course of the symptoms, the changes produced by the con- tinuance of the disease, particularly the patient's com- plection and general appearance, and even the expres- sion of his countenance. I shall make such observa- tions as a pretty extensive and long experience has furnished on each of these heads, in the order in which they are here arranged. If the habit of the patient be irritable, and the body as well as mind alive to slight impressions, particularly if the patient be of the female sex, and the symptoms incline to hysteria, and, although neither of these be the case, if what are called bilious and stomach com- plaints have preceded the nervous symptoms, we have (24) This inquiry may be facilitated and the author's very valuable ob- servations will also be better appreciated, by tracing symptoms as they oc- cur, to their appropriate system of nerves. If they are such as arise from impaired perception or volition, they unquestionably belong to the brain and its nerves: if, however, they flow from.functional lesion of any of the secretin* or assimilating organs, then they as certainly pertain to the primary or au" tomatic system, and whatever elevation, depression or other variation of the operations of mind may accompany visceral affections, may be deemed se- condary or symptomatic. Change of secretion may in time operate altera- tion not only of the functions but also of the structure of the brain, and thus render what was at first only symptomatic, real organic affection OF THE BRAIN. 87 reason to believe that they are the mere effect of ner- vous irritation, and that the protracted suffering of the patient is, probably, all that is to be apprehended from their continuance. When, on the contrary, they appear in a more phlegmatic and composed habit, with compa- ratively little derangement of the stomach and bowels, there is more cause for apprehension. With respect to the predisposing causes, when obsti- nate nervous symptoms supervene some time after the ceasing of accustomed discharges, the healing of old wounds, the drying up of issues, long-continued sup- pression of menstrual discharge, a general failure of vigour in the excretories, from an active being succeed- ed, especially if suddenly, by an inactive life, a very spare by a very full diet, or any other cause of ple- thora, there is more reason to fear their tendency than when they have not been preceded by any cause of this kind. Among the chief predisposing causes of organic dis- ease, both in the brain and elsewhere, are to be rank- ed scrofulous and other bad habits of body; that, for example, produced by the excessive use of fermented liquors. Obstinate states of debility, from whatever cause, having preceded the establishment of nervous symptoms, are unfavourable. We may regard the un- favourable tendency of all diseases as inversely as the patient's strength. With the failure of strength, that tendency in the system to counteract diseases, without which all our efforts would be useless, also fails; and this fact affords one of the most important maxims in practice. With respect to the occasional causes,—if, as we have just had occasion to observe, we find a sufficient derangement of the alimentary canal and the organs connected with it to account for the nervous symptoms, we need, in general, look no farther; and, in almost 88 ORGANIC DISEASE every such instance, we shall find them disappear when the healthy state of the abdominal functions is restored. We have also reason to believe the nervous symptoms to be of no formidable nature, if they have arisen from slight and occasional causes, if they super- vene soon after the application of these causes, and are easily renewed by a recurrence of them; and this, however severe the symptoms may be; for the severi- ty of nervous symptoms depends morea frequently on peculiarity of habit, than on the nature of the cause which produces them. When, on the contrary, the occasional cuse has been of a more serious and permanent nature,—when it has continued to operate for some time before the nervous symptoms show themselves,—we may, if other circum- stances conspire to the same view, regard them in a more serious light. I have found no cause of nervous affections more apt to produce disease of a formidable nature, than the depressing passions, especially if their origin be such as is liable to continual renewal; for this produces a more injurious effect than a settled grief, which time, if it, cannot remove, seldom fails to soften. When obstinate nervous symptoms succeed severe blows, or other accidents, tending to injure the brain, or they have been preceded by long continued and severe suf- fering from diseases of other parts, there is reason to fear a tendency to organic disease of the brain. A great deal may be inferred from a careful observa- tion of the nature of the symptoms and the general course they take. When they are variable, relieved by slight means, and renewed by trivial causes, we form a better prognostic than when they are less variable. When the mind, in particular, is affected in a sudden and variable manner, they are less to be feared than when it labours under a settled depression, even although OF THE BRAIN. 89 the mental affection in the former case may occasionally be more severe. It is also unfavourable that the symptoms should chiefly affect particular parts of the head; although this does not, as I have witnessed in many cases, afford an inference much to be depended on. It is not very un- common, even where there is little tendency to organic disease, for more or less debility and numbness to affect chiefly one side of the body: I have seen it do so for months together, without serious consequences. This, however, is never to be regarded as a trivial symptom. I have known these symptoms leave one side of the body and affect the other, and yet the patient die of organic disease of the brain; but, for a considerable time before death, they were confined to the same side, better and worse at different times, and never, till to- wards the termination of the disease, such as to deprive him of the power of walking, with little seeming impe- diment. A general tendency to derangement in the secreting system, without any one organ being much more affect- ed than the rest, especially if this be pretty uniformly the case, and the symptoms be not readily relieved by the usual means, is unfavourable; and the less they are complicated with mental affections, with the exception of depression of spirits, and the more uniform this de- pression is, they are the more to be feared. When there is a tendency to organic disease of the brain, even when the patient makes no particular complaint, which can be referred to any of the vital organs, it will often be found that the heart is more irritable than usual, more easily excited by slight causes; that the lungs have not, especially on exercise, the free play of health, that the stomach is easily disordered, and the state of the bowels languid and variable. 12 90 ORGANIC DISEASE In such cases there is always some degree of tight- ness of pulse to be perceived, if the artery be very slightly pressed in the way explained in my Treatise on Indigestion; and this symptom is less variable than in the second stage of indigestion, when little tendency to organic disease has supervened. The pulse is frequent- ly, particularly towards evening, inclined to be a little more frequent than usual. It also sometimes intermits, or is otherwise irregular. There is often some tendency to increased heat, espe- cially in the hands and feet, particularly towards even- ing and in the night, and this although in general the feet are cold. In other instances they are uniformly so; and in some, the temperature of the whole body is evi- dently reduced, and the patient complains of a constant tendency to chilliness. These symptoms only assist the diagnosis, when compared with the general course of the disease, being all such as are frequently observed in other nervous affections; but here their course is more uniform; for, like all the other symptoms of nervous complaints, the more they are variable the less is to be apprehended from them. We may, in a great degree, judge of the tendency to Organic affection of the brain by the changes induced by the disease. When nervous affections continue for a considerable time, without much change in the gene- ral appearance and plumpness of the patient, when the mind is occasionally alert and capable of its usual exer- tion, we may be assured that they indicate little tenden- cy of this kind. When, on the contrary, he becomes more or less, however slowly, emaciated, and the face assumes a sal- low hue; when the spirits become more and more de- pressed, and the mental energy subdued; we may fear this tendency. OF THE BRAIN. 91 The expression of the countenance, also, to a person accustomed to see those labouring under organic disease, or a strong tendency to it, greatly assists the prognosis, although it is difficult to express in what the peculiari- ty consists. There is an appearance of anxiety, the consequence of a constant though ill-defined cause of uneasiness, which, combined with the sallowness of colour, produces an expression of countenance that es- pecially, after the organic disease is established, can hardly be misunderstood by the experienced physician; something wholly different from what is observed in the most severe nervous affections, when no immediate ten- dency to organic disease prevails. It appears, from what has been said, that no doubt can remain of the tendency to organic disease of the brain, if it be found that the patient had laboured under long-continued and severe indigestion; and that while the general disease has increased, the digestive organs have, in some degree, recovered their tone; from which, however, as in bilious consumption, the patient derives no other advantage than that of being less troubled with the oppression and other symptoms, referred to the di- gestive organs. From all that has been said of the circumstances which indicate a disposition to organic disease of the brain, in what is called nervous complaints, we infer that this termination is most to be feared in scrofulous and debilitated habits, when there is not such derange- ment in the digestive or any other set of organs as accounts for the severity of the nervous symptoms, and the patient is not of a variable and hysterical dis- position; when the occasional causes have been of a serious and permanent nature, and the nervous symp- toms have not shown themselves for some time after their application; when the symptoms, both of mind and body, are less variable than is usual in nervous 92 ORGANIC DISEASE complaints, and the latter, particularly, apt to affect the same parts of the body; when there is constantly a more or less general tendency to derangement in the secreting system; when the heart is more irritable, and the lungs less free, the nervous symptoms do not yield so readily as usual, the sensations less various, and the depression of spirits more uniform, the tight pulse and tendency to increased heat, or, on the other hand, the sense of chilliness and debility, more constant; when the constitution seems more affected than usual by the continuance of the disease, the strength and flesh, on the whole, wasting; and, particularly, where the coun- tenance assumes a sallow colour and an habitually irrita- ble and anxious expression;—when these, or several of these circumstances, are well marked in what are called nervous complaints, I have been assured, by repeated observations, that they are not to be safely disregarded. Such is the best diagnosis which my experience af- fords of an alarming, and, by no means, a very uncom- mon disease, in which the structure of the brain is threatened; while, to a careless observer, the patient seems to labour under symptoms in no respect dif- ferent from those which every day's experience tells us, however distressing to the sufferer, are seldom attended with danger. I have dwelt the longer on the diagnosis we have been considering, because all long- continued and, particularly, all organic diseases of vital parts, as appears from all I have had occasion to say relating to this part of the subject, and from all the evidence afforded by dissection, tends to chronic dis- eases of the brain, the diagnosis of which I have been endeavouring to point out; and their phenomena cannot be understood, without keeping this tendency in view. Such cases, if they cannot be arrested, terminate fatally, by gradually exhausting the strength; or the organic affection of the brain produces a similar affec- OF THE BRAIN. 93 tion elsewhere, and the patient sinks under more than one disease. The lungs are the most frequent seat of this secondary disease. After being reduced to a state of great debility, he begins to cough, to which he had no previous disposition, and the worst symptoms of pulmonary consumption rapidly show themselves. Thus and from similar sympathies, it is that, in prac- tice, diseases often do not appear in the distinct form in which they are laid down in systematic works; and a physician will frequently find himself at a loss at the bed-side of the patient, if he is unacquainted with those laws of the constitution, in consequence of which diseases are prone to run into each other; one not only giving rise to another, but each, according to circum- stances, relieving, aggravating, rendering more obsti- nate, or otherwise modifying the other.(25) The strong- er the sympathies with other parts of the system in the original seat of the complaint, the more its affections are apt to run into such complicated diseases. With respect to affections which originate in, and are confined to, the spinal marrow, from its having less direct effect on the mental functions, from the influence of this organ on the muscular system being more defined, and our being better assisted by the local symptoms, we can generally form a better judgment (25) That disease of one organ will excite disease of another, or that there is a power of mutual contamination amongst the several organs, is a neces- sary inference from their relationship; this, however, is not uniform, but is proportionate to the importance of the organ in the general economy. For the reason that the brain is a dependant upon the other organs, it can not exert as much morbid influence over them as they over it. Thus disease of the brain may exist for a long period before it involves other organs in dis- ease of fatal tendency. Disease of the stomach, liver, and most of the other important, yet inferior structures, will jeopardize life in a much shorter time than an equal amount of disease of the brain. Hence, disease of the brain which is secondary and arising from previous visceral affection is more dan- gerous to life than many of its primary forms. Thus mania often continues for years without impairing the general health. 94 ORGANIC DISEASE OF THE BRAIN. respecting the state of its affections, than those of the brain, properly so called. The tenderness and other local symptoms in the course of the spine, with the particular muscles affected, generally point out the chief seat of the disease; the degree in which the functions of the lungs and alimentary canal are impair- ed, and the extent of the injury sustained.* From the local nature of such cases they belong rather to the department of the surgeon than physician. * Inquiry into the Laws of the Vital Functions. CHAP. V. Of the Appearances on Dissection in Organic Disease of the Brain. We should, at first view, expect that much advan- tage would be derived, in the treatment of those dis- eases which lead to organic derangement of the brain, from the appearances afforded on dissection. In this expectation, however, we have hitherto, in general, been disappointed. Many have attempted to connect particular appearances in the brain with particular trains of symptoms; but, if we except inflammation and its more evident effects, with little or no success. When the symptoms have been similar, very dif- ferent morbid states of the brain have been found on dissection; and it has often happened, when the symp- toms have been very different, that similar morbid appearances have presented themselves: and further to perplex our endeavours, we know on the one hand, that the finer mechanism of the brain may be so changed as to unfit it for the purposes of life, without any trace being left that can be discovered by dissec- tion; and, on the other, that certain parts of the brain may be disorganised, and even removed, without pro- ducing any symptoms to indicate the change. Nature has been bountiful to us in many ways; and, as we have two eyes and two ears, we have reason to believe, from many observations, that some of the organs of the brain, also, are double; and that we may, with- out material injury, be deprived of the use of par- ticular parts of it, especially of those on which the 96 ORGANIC DISEASE sensorial functions seem to depend, provided the cause which deprives us of it be not one that, at the same time, affects the brain more generally. Thus tumors and coagula have remained in certain parts of the brain, not only without any material impe- diment to the functions of life, but without betraying themselves by any marked symptoms. Those parts of the brain, which, in combination with the spinal marrow, support the secreting and other assimilating processes, are the most vital; and nature, with her usual providence, has placed them in the position of greatest security, at the base of the brain, where they are involved in the deepest seated parts.C26) Had they "occupied any of the more expos- ed parts of this organ, life would have been held on a very precarious tenure. Those who are in the habit of killing rabbits and other small animals know that a very slight blow, skilfully directed to that part where the head and neck join, immediately proves fatal. We occasionally find in the brain all the different ap- pearances produced by inflammatory action elsewhere,— suppuration; gangrene; softening and hardening, ge- neral or partial, of its substance; ulceration; adhesion; thickening of membranes; effusions, &,c, and we also find various other morbid appearances; bony projections pressing on different parts of it; morbid growths, of dif- ferent kinds and in various situations; calculi, &c. But, as I have already had occasion to observe, if we except inflammation and some of its consequences, no particular trains of symptoms have been so associated with these morbid appearances as with any degree of certainty to enable us to distinguish them. (26) If the views entertained in Appendix, No. I. are correct there are no parts of the brain or spinal marrow concerned in supporting "the secret- ing and other assimilating processes, and only so much of this system as is tributary to respiration can be accounted" vital. OF THE BRAIN. 97 Even in the consequences of inflammatory action of the brain, and in points most generally admitted, much uncertainty exists in our inferences from the symptoms. It has been generally supposed that the disease termed water of the head, in children, proves fatal by the effu- sion which relieves the inflammatory state; and that the insensibility and squinting are the indications of the effusion having taken place; yet it appears, from the dissections recorded by Quin and others, that death, preceded by these and all the other symptoms peculiar to this disease, sometimes takes place where no fluid has been effused; and we have abundant proof that in other cases a similar effusion of fluid into the same parts of the brain may occur without producing such symptoms; so that it would appear, that, even in this disease, death is rather the consequence of some pecu- liar state of the brain, than of any thing we can detect by dissection. On the whole, then, trusting little to dissection for the nature and treatment of organic disease of the brain, we must direct our study to the symptoms which indi- cate their approach, and the means which experience has proved most effectual in arresting their progress. From the nature of the brain, and the situation it occupies, much of the difficulty of connecting its morbid states with particular trains of symptoms may be under- stood, and, indeed, might have been foreseen. Its structure necessarily partakes of the extreme deli- cacy of its functions; and derangements which wholly elude our senses are probably the immediate causes of most of its diseases. Its functions are so various and complicated, that the disordered structure, we perceive, must, from circumstances too minute to be detected, sometimes influence them in one way, and sometimes in another. It is sometimes, no doubt, rather the conse- quence than the cause of the derangement; and may be 13 98 ORGANIC DISEASE attended with symptoms very different in their nature and degree, according to the nature and situation of that derangement, although to our eye the morbid appearance may be the same. Something, too, must be ascribed to the brain being enclosed in a bony and unyielding case; in consequence of which, an enlargement or pressure on any one part must necessarily be felt through the whole; and the peculiar symptoms produced may vary according to a thousand circumstances which we cannot estimate, even when the morbid change, as far as we can see, is the same, and confined to the same part; and how various might we find them when the same cause affects differ- ent parts, even if we had the means of ascertaining that the cause is really the same! The nature of the brain is wholly different from that of any other organ which is limited to its own particu- lar function, from the derangement of which we judge of its state. The brain, on the other hand, if we ex- cept the circulation, is equally essential to all the func- tions of both mind and body, and the circumstances which determine the derangement to any particular set of its functions, must often be such as wholly to elude the senses. Its states of general inflammation and congestion necessarily affect all its functions. Of their effects, therefore, we are enabled to judge, as if the brain, like other organs, had but one function. But with regard to those causes which influence it partially, we may venture to predict, that the symptoms will never with any degree of accuracy, be associated with the morbid appearances presented on dissection. Even partial inflammation of the brain in different cases, not only produces different but opposite trains of symptoms. In one, we find it indicated by furious delirium and a strong bounding pulse; in another, the OF THE BRAIN. 99 pulse is small and fluttering, and the strength so sub- dued that actual fainting is not very unusual, and the delirium is low and muttering. Nothing more strikingly shows the difficulty of asso- ciating the morbid appearances of the brain with the symptoms than the fact, that it is only necessary that the same cause of injury, even acting on the same part, should make its impression more or less suddenly, in order that it shall, in the one case, excite to morbid activity the whole circulating system, or so reduce its powers that it is hardly capable of its function.* ♦Inquiry into the Laws of the Vital Functions, Exper. 19. et seq. CHAP. VI. Of the Morbid Affections which precede Change of Structure in the Heart. Of the vital organs the next in importance to the brain is the heart. These organs are strikingly con- trasted, both in their structure and their functions. In structure, the brain is the most complicated, the heart the most simple, of all the vital organs. So numerous are the functions of the former, that it is difficult to assign their limits. The heart has but one function, that of impelling the blood; a function, however, on which every other depends. A necessary consequence of the simplicity of its structure and its function is, that its diseases, also, are simple. They may be divided into two classes,—those which weaken the power with which it propels the blood, and those which impede the passage of the blood through it. The former, the diseases of the substance of the heart itself; the latter, of its orifices and its valves. In such a treatise as the present, whose objects are to detect the first beginnings of organic disease, and point out the means of obviating them, it would be of little advantage to dwell on the simple organic diseases of the heart; because they betray themselves by no symptoms till they have made such progress that we have no means of arresting them: and the same obser- vation applies to the organic diseases of the aorta, and other large vessels attached to the heart. CHANGE OF STRUCTURE, &,C. 101 But, although we have no warning of the approach of simple organic disease of the heart, and therefore can lay down no rules for its prevention, as organic disease is sometimes the effect of other diseases of this organ, which may both be detected and relieved, these diseases are the proper subjects of such a treatise. The heart, like other organs, is liable both to chronic and acute inflammation, and their various consequences. Like other organs, also, it is liable to disordered func- tion from other causes; and here, as in other instances, long-continued derangement of function leads to de- rangement of structure. We shall, in the first place, cansider the inflammatory affections of the heart. Both in the case of acute and chronic inflammation, it is difficult to distinguish the affection of the heart from the corresponding affection of the lungs, with which, indeed, it is frequently complicated; the cause of which readily appears, when we consider the relative position and intimate connection of the functions of these organs. We distinguish the seat of internal inflammations by two sets of symptoms,—those of the pain or uneasiness caused by the inflammation, and those which arise from the impeded function of the part. When, for example, we find the patient labouring under fever of a particu- lar description, with severe pain in the region of the stomach, and constant efforts to vomit, we know that the stomach is inflamed. When, in like manner, we find him labouring under fever of a particular descrip- tion, with pain or other uneasiness of the chest, and oppressed breathing, we know that some part of the viscera of the thorax is inflamed; but whether it be the heart or the lungs, these symptoms afford no certain means of ascertaining.* * This question is considered at length in my Treatise on Symptomatic Fevers, under the heads of Pneumonia and Carditis. 102 CHANGE OF STRUCTURE As the lungs fill the whole of the thorax, except the part occupied by the heart and vessels, the position of the pain or other uneasiness gives us little assistance, although, when they are fixed in that part of the thorax where the heart lies nearly surrounded by the lungs, this circumstance aids those I am about to men- tion in determining the seat of the disease. The difficulty of breathing affords still less assistance. This symptom in inflammation of the lungs arises from the enlargement of the part it occupies, and the uneasi- ness which attends the motion of all inflamed parts. Inflammation, we have seen, consists in a greater than natural distention of the minute vessels; hence the swelling of the inflamed part. Thus, the substance of the lungs, being enlarged, encroaches on the numerous minute cavities destined for the reception of the air, which is therefore admitted wTith greater difficulty and in less quantity; and, the lungs being in constant mo- tion, the patient feels a certain degree of uneasiness, and a greater difficulty in this necessary motion than in health. To the latter cause alone we must ascribe the difficulty of breathing when the investing membranes of the lungs only are inflamed; yet so similar are the sen- sations excited by these causes, that it is impossible for the patient to distinguish them, and we consequently have no means of distinguishing inflammation of the lungs from that of their membranes.* What prospect, then, is there of our being able, from the state of the breathing, to distinguish inflammation of the heart from that of the lungs; for both the causes *This point also is fully considered in my Treatise on Symptomatic Fevers, under the head of Pneumonia. It was once generally supposed, and is stiU supposed by many, that inflammation of the substance of the lungs is characterised either by the absence of pain, or such as is obtuse; of the membrane, by acute pain; but dissections have amply proved that this distinction rests on hypothesis, not fact. IN THE HEART. 103 which operate in the latter are present also in the former disease? As the heart, at every beat, both throws the blood into, and receives it from, the lungs, any impediment to its motions must impede the func- tion of the lungs as much as an impediment to the motion of the lungs themselves; and, as every impedi- ment to the transmission of the blood through the heart necessarily causes more or less accumulation of blood in the veins of the lungs, it has a similar tendency with distention of the minute vessels to lessen the spaces allotted to the air; and when, as explained above, this distention happens to extend to the minute vessels, which is not uncommon, actual inflammation of the lungs is established: hence it is, that, when the inflam- mation originates in the heart, we so frequently find that of the lungs also. In the more chronic forms of the disease, when time has been given for the change to take place, this is almost universally found to be the case. By the seat of the uneasiness, and the difficulty of breathing, therefore, we are hardly at all assisted in distinguishing inflammation of the heart and lungs, and the nature of the fever is the same in both: but there is another set of functions involved, whose state rather better, though still very imperfectly, aids us. We should, at first view, suppose that the difficulty would be easily surmounted, when we consider that in inflammation of the heart we must perceive, in other ways than by the difficulty of breathing, the impeded functions of this organ; and this, to a certain degree, is the case. Here the pulse is more apt to be irregular and fluttering than in simple inflammation of the lungs, and the action of the heart is occasionally so much im- peded as to produce a tendency to, or acutual, fainting. But the last is not a frequent symptom, nor is the irregular and fluttering pulse a constant one; and in 104 CHANGE OF STRUCTURE simple inflammation of the lungs, from the intimate connection of their function with that of the heart, as well as from the fever which attends all internal inflam- mations, the pulse is always greatly disordered. We have, however, still another means of distinction. The heart being the more important organ, its derang- ed function produces symptoms of still greater severity, in proportion to the degree of derangement, than in the case of the lungs; but still, different degrees of the same symptoms, especially as it is chiefly by them that we judge of the degree of the offending cause, afford but a fallacious diagnostic. The circumstance which most assists us, in this otherwise difficult diagnosis, is one, of which, at first view, it appears difficult to account for, the cause of which I shall afterwards consider,—that inflammation of the heart is often preceded by severe rheumatic pains of the limbs. If inflammatory symptoms of the chest supervene on such pains, whatever be their par- ticular nature or degree, we have reason to believe that the heart is inflamed. This diagnostic, however, does not, in all cases exist.(27) With respect to the symptoms of the disease itself, the conclusion from the whole is, that, when they are unusually severe>> and most interfere with the function of the heart, and particularly when we observe a ten- dency to fainting, we have most reason to believe that the heart is inflamed; but none of these symptoms afford a certain diagnostic, except rheumatic pains of the limbs have preceded the attack. (27) We attended a boy who after a paroxysm of anger, complained of excruciating pain in the right thigh, which he attributed to a blow inflicted by another boy in a quarrel. There was no appearance of injury of the part: he had very high fever, with excessive arterial action, which resisted the most energetic antiphlogistic remedies; delirium supervened, then coma and death. Post-mortem examination exhibited no traces of disease any where, except ulceration of the right ventricle and a small abscess or pus- tule on the left auricle of the heart IN THE HEART. 105 It fortunately happens, however, that the want of a diagnosis that will in all cases apply is the less felt that the practice is of the same nature in both cases. All we can do, when the diagnostic is insufficient, is to proportion the treatment to the severity of the symp- toms, keeping in view that the more the symptoms incline to inflammation of the heart, the practice should be the more active in proportion to their severity; because, independently of the peculiar terminations of inflammation, organic disease is more apt to arise from common inflammation of the heart than of the lungs. We often see the latter inflamed again and again, and the organ still left in a sound state; but this is less frequently the case with the heart, the cause of which depends partly on the different nature, situation, and functions of these organs, and probably on the differ- ence of their sympathy with other parts; for the ten- dencies of disease can never be understood without taking into account the changes effected through the nervous system. There are other ways in which the function of the heart is disturbed, of which the lungs only partake by the corresponding derangement of function, when the motion of the blood through the heart is impeded, which does not always happen in the cases I now speak of. The heart is subject to irregular, sometimes de- bilitated, and sometimes increased, action, without any inflammatory tendency. This disease is known by the name of palpitation, and it varies from an action so enfeebled, that the motion of the heart can hardly be perceived when the hand is laid on the side, to such a degree of violence, that the heart seems inclined to leap from its place. Its action is more apt to be irregular when its power is lessened than when it is increased. 11 106 CHANGE OF STRUCTURK Palpitation sometimes arises from the state of the heart itself; but it is more frequently a symptom of dis- ease in other parts. What gives it its greatest impor- tance is, that it often attends organic disease of this organ. Even when the cause exists in the heart itself, however, it more frequently arises from morbid irritabili- ty than any other source. From these circumstances the reader will perceive that it must, in many cases, be an object of great im- portance to ascertain the cause which produces it; and, from whatever cause it arises, it is always of conse- quence to prevent its becoming habitual, both because it is one of those diseases which is rendered extremely obstinate by continuance, even when it has neither pro- ceeded from nor caused any degree of organic dis- ease; and because, as in other organs, a long-continued disease of function seldom fails at length to affect the structure. The questions, then, of most importance here, are, by what means shall we ascertain-the seat of the irritation which keeps up this irregular action of the heart? and, if it be in the heart itself, how shall we determine whether organic disease of that organ has any share in producing it? The former question is answered by a careful exam- ination of the patient, with a view to ascertain whether a sufficient cause of irritation exists in any other part of the system to account for the irregular action of the heart. Although great irritation of any of the vital organs may, through the nervous system, influence the action of the heart, no irritation of a distant part is so apt to have this effect as that of the digestive organs; and of these, the stomach most sympathises with it. If we find, therefore, that the patient is a sufferer from indigestion, and particularly from acidity and fla- tulence of the stomach, without the symptoms I am IN THE HEART. 107 about to mention, as characterising organic disease of the heart, there is little reason to doubt that the palpi- tation depends on this cause. When, on the contrary, we find that the function of no other vital organ is materially disordered, we must regard the irregularity of the heart as depending on a cause existing in itself. It either arises from unusual irritability of its fibres, or from some change of struc- ture having taken place in it. If from the former cause, it will be variable, excited occasionally by slight causes, sometimes not by the more powerful ones, and as much by causes affecting the mind as body; if from the latter, mental causes will have less influence, nor will it be so much influenced by the state of distant parts, but much more uniformly by those bodily causes which increase the rapidity of the circu- lation, and particularly by strong exercise; while, in the case of mere irritability, even this cause at times, and in some cases always, except under the paroxysm of pal- pitation, may be borne without inconvenience. If going up stairs or up hill constantly, and nearly as much at one time as another, disorders the action of the heart, and causes a sense of oppression, and particular- ly if it produces a sensation which obliges the patient suddenly to stand still, especially with pain or other un- easiness referred to one or both arms, we may suspect the existence of organic disease of the heart; and if this continue to be the case for a considerable length of time, especially if the countenance assume the sallow- ness and anxiety which is so characteristic of organic disease, there can be little doubt that such, to a greater or less degree, is the case, particularly when no con- siderable derangement of the digestive organs attends these symptoms: for even these 1 have known arise from a great degree of disorder in those organs, especially when the tenderness and distention of the regions of the 108 CHANGE OF STRUCTURE pylorus and duodenum were considerable, and wholly yield to the means which restored the vigour; and that after they had lasted for many years, during which the patient had in vain been treated for organic disease of the heart. In dyspeptic patients, especially in old dyspeptics, it is not at all uncommon, when the stomach is more dis- ordered than usual, for exercise to bring on a sense of great oppression, with beating of the heart, that must be regarded as a slighter degree of the preceding symp- toms, which have obtained the name of angina pectoris, from the distressing feelings referred to the chest. I have seen many cases of severe palpitation and oc- casional failure of power in the heart, which had been treated as organic disease of that organ, but without that uniform distress on strong exercise, the best diag- nostic of its organic affections, which proved merely sympathetic cases, rendered obstinate by a neglect of the cause which had produced them, and yielded on the removal of that cause. There is often both in the functional and structural disease of the heart more or less permanent irregularity of pulse. This symptom, therefore, but little assists the diagnosis, except that in the case of organic disease it is generally more uniform. It is not difficult to understand why a permanent cause, either impeding the action of the heart or the passage of the blood through it, and all its organic dis- eases are such as must have one of those effects, should produce the symptoms of angina pectoris. In the ear- lier, and sometimes even in the more advanced, stages, while the patient is still, or under only gentle exercise he is easy. The heart is still capable, under these cir- cumstances, of transmitting the quantity of blood re- turned to it; but when, by stronger exercise, as run- ning or going up hill, a quantity of blood is thrown upon IN THE HEART. 109 it which it cannot transmit, feelings of the most painful nature necessarily ensue. The patient describes them, not as the feelings of suf- focation, although they interfere with the breathing, but as those of extreme oppression and anxiety, which per- suade him that, if the effort which causes them were continued, he should die: and he is not deceived in this persuasion; for if the blood continues to be returned to the heart faster than it can be transmitted, its powers must necessarily be overcome. Hence it is that, as the disease increases, the patient often dies suddenly, under some slight exertion increas- ing the velocity of the circulation; for his feelings soon teach him to avoid all powerful ones: or, when the disease has arrived at that point that the heart can no longer transmit the quantity of blood necessary to maintain the circulation in a state of rest, its motion sud- denly ceases, and he expires, although afrest. It appears, from all that has been said, that the only states with which we are acquainted, which dispose to oaganic disease of the heart, if we except a state of habitual plethora, which tends to derange all the vital organs, are inflammation and too irritable a state of its fibres, arising either from a fault in the heart itself, or supported by a cause of irritation in some other organ, affecting it through the medium of its nerves. We have seen, in the experiments above referred to, that independent of the brain as the power of the.heart is, it is wholly subjected to its influence; that although for a certain time it is capable of its perfect function after the brain has ceased to exist, yet, while the brain and its nerves are entire, it is placed so completely under the influence of the nervous system, that through it its power may even be instantly destroyed. This arises from the direct operation of the brain on the mus- cular fibre: but the heart, it further appears from those 1 110 CHANGE OF STRUCTURE IN THE HEART. experiments, is also, in common with all other parts, subjected to the power of the brain, through the as- similating processes on which the healthy structure every where depends. We have seen that, when the influence of the brain was withdrawn from the lungs, the most formidable organic disease was established in them in the space of a few hours. Thus it is that long-continued nervous irritation— that is, deranged or defective nervous power—is so fre- quent a cause of disordered structure; and it seems to be chiefly in this way that our frame at length decays. The due mechanism of every part depending on the healthy action of the nervous system, decays in propor- tion as its vigour is impaired. This observation applies to no organ more remarkably than to the heart and large vessels. As old age advances, an evident change takes place in them, even where nothing occurs which de- serves the name of disease; they acquire too great a de- gree of firmness, and often in some parts a bony hardness. When the change is slow, the other vital organs, at the same time, and for the same reason, gradually losing their power, little inconvenience is experienced, except that of increasing weakness. CHAP. VII. Of the Morbid Affections which precede Change of Structure in the Lungs. Of all the vital organs, the lungs are most liable to change of structure. It has been supposed that in the lungs, as in the heart, this change will sometimes arrive at a stage which defies our means, before it pro- duces any symptom by which its presence may be detected. Tubercles, it has been supposed, may thus be formed. If this ever happen, which I greatly doubt, it must be very rarely; because I have found that, in the most consumptive habits, the first symptoms can generally be checked, and perfect health re-established. Nor can I subscribe to the opinion, that the predis- posed are born with the seeds of tubercles in the lungs, and that no other can become victims of this disease. It may be induced in those, who apparendy are least disposed to pulmonary disease, by the frequent repetition of powerful causes; and in such cases, its consequences in the lungs are of precisely the same nature—the lungs after death presenting, in all re- spects, the same appearances as in those in whom the predisposition is strongest. We may, therefore, very confidently assume—and at all events they are the safest assumptions—that dis- ease of the lungs never exists without betraying itself by evident disorder of their function, and that, at the commencement of the symptoms, the lungs contain neither tubercles nor their seeds. And the opposite 112 CHANGE OF STRUCTURE assumptions are so gratuitous, that, as far as I know, not even an attempt has been made to adduce a direct proof of either. Tubercles, 1 believe, are always the consequence of some occasional cause, and, in the first threatenings of the disease, may generally be prevent- ed, however strong the disposition may be, by correct- ing the symptoms which precede them.C28) These are a cough, which, in the first instance, rather deserves the name of a tendency to cough, some- times both very slight and unfrequent; and a less free state of the breathing, under strong exercise, than is consistent with a perfectly healthy state of the lungs: for the very first beginnings are not to be disregarded. It unfortunately happens, however, that they are so slight as often to escape attention; and, Avhen they are observed, are almost always regarded as too trivial for serious treatment; and yet, in those who are most pre- disposed to disease of the lungs, slight as they are, it is often only by a great deal of care that their progress can be arrested. (28) Idiopathic diseases of the lungs are not of more frequent occurrence or more difficult of treatment [than those of other structures. Wounds of the luDgs, cceteris paribus, heal as kindly and inflammation yields as readily as in most other organs. Even cases of seemingly confirmed consumption have been known to recover rapidly, after the voidance of extraneous matters which had caused the irritative abscess and other symptoms, and the structure has resumed a condition adequate to the performance of its natural offices. Diseases forced upon the lungs by the faulty action of other organs are those that are truly formidable. Pulmonary consumption is rarely if ever a pri- mary disease of the lungs. Some one or more of the other important organs will be found to have first failed in the performance of their regular duties. Cessation of action on the part of any of the larger secreting glands, or in- discriminate absorption by the lactials, by retaining or introducing into the circulation, matters of injurious quality and tendency, must impede the func- tions of the lungs, induce general debility, and extend the evil until there will remain in no part sufficient power for readjustment. In the earlier stages, by carefully tracing back the train of morbid consequences to the first defaulter, we shall have Uttle difficulty in estabUshing indications of successful treatment. IN THE LUXGS. 113 The patient is accustomed to see hundreds affected in the same way, who get well without trouble, and he sees no reason why he should not do the same; nay, he has probably again and again experienced the same thing in himself; but he is not aware that every time the symptoms recur, such is the power of habit, they become more obstinate, and the lungs less able to resist them; and he is, at length, surprised to find that his cough does not go off as usual. When a person, in whom the predisposition to pul- monary disease exists, makes this observation, his state is already doubtful; his cough will prove more or less tedious, and it is impossible to say whether the struc- ture of his lungs will bear its continuance. For the strongly predisposed there is no safety but in watching the very first approach of the disease, and regarding even the slight symptoms just mentioned as a serious ailment. If the habit of frequent coughs is formed, there is but one step between them and immediate danger. It is in this way that the young so often fall a sacri- fice to pulmonary consumption, where there is no peculiar weakness of the vital organs but in the lungs. But the lungs, like other organs, also suffer by sym- pathy with other parts; which will not surprise the reader, w^Jien he reflects on the facts which have been laid before him. We still find the digestive organs those whose affec- tions are most apt to produce sympathetic disease; but while the heart sympathises most with the stomach, it is with' the liver that the sympathy of the lungs is strongest. Hence it is that the affections of the stomach only tend to produce pulmonary disease in proportion as they have produced disorder in this organ. But such is this propensity, when disorder of the liver has taken place,—that is, in what are called bilious com- 15 114 CHANGE OF STRUCTURE plaints,—that, I believe, we shall not err in saying, that thev lay the foundation of more than half the cases of pulmonary consumption which occur in this country. I have, in my Treatise on Indigestion, considered this species of the disease at length, which I have termed dyspeptic phthisis, and shall not, therefore, enter parti- cularly on it here. Nothing is more common than to see bilious complaints continue, even at the time of life most disposed to consumption, without producing this disease; we are, therefore, assured that it is chiefly in the predisposed that they are apt to have this effect. But, besides that it is difficult to ascertain where the slighter degrees of predisposition exist, there is another morbid effect of long continued disorder of the liver, which determines its affections to influence the lungs in all habits. Inflammation of the liver, whether acute or chronic, is in all habits attended by cough, and, therefore, by nervous irritation of the lungs; and obstinate bilious af- fections, in inflammatory habits, are always apt to pro- duce a degree of chronic inflammation of the liver. Its left lobe, in particular, is apt to become full and tender to the touch; and this state of it seldom continues long without producing cough. If the function of the liver continues to be disordered, the inflammatory state is renewed, with its attendant cough, on every slight occasion; and in this way I have, in very many instances, seen, pulmonary disease estab- lished, in those apparently least predisposed to it. In the predisposed, the continual recurrence of the state I am here describing, never fails to terminate in it. This species of consumption is nearly allied to another disease, which here demands very serious attention; be- cause there are few more common, and none more in- sidious. I mean, an affection of the lungs, which is most apt to appear at more advanced periods of life than IN THE LUNGS. 115 that most subject to pulmonary consumption; and which is often overlooked, till it has more or less undermined the powers of the constitution. It is not at all uncommon to hear people in, and after, middle life,—especially those whose digestion has been for a long time disordered, although, perhaps, not to such a degree as to prevent their enjoying very good health, and who still possess their usual vigour,—saying, that they never feel themselves comfortable in the morn- ing, till they have what they call "cleared their lungs," that is, till they have hawked or coughed up something. If what they bring up be examined, it is found to be a colourless, thick mucus; sometimes blackish, as if mix- ed with a small portion of soot. This blackish appear- ance has been supposed to depend on particles drawn in with the breath. It seems, however, to arise from a process going on in the lungs; for it only shows itself in mild states of disease. As the more serious symp- toms arise, it always disappears; and it appears quite as readily in the clearest air of the country as in the closest parts of large towns. When such patients have gone through this process, they are in as good spirits, and as fit for business, and, apparently in as good health, as those who have no occasion for such clearing of the lungs; and it cannot be denied that this will often go on for years, apparently without making any injurious im- pression on the health. They, however, labour under a chronic disease, which slight causes may call into a state of activity; and this never happens without more or less risk. Let the cause which disturbs the health be what it may, its effects will fall chiefly on the parts concerned in producing the symptoms I have described; and it assails them when their powers have been more or less, according to its severity, weakened by the previous affection, and are, 116 CHANGE OF STRUCTURE consequently, in the same proportion less able to resist the attack. When the patient escapes such sudden attacks, his disorder, however slow its progress, never remains altogether stationary. In the course of years, and generally sooner, if the causes which produced it con- tinue to be applied, the necessity for this morning clearing of the lungs becomes more urgent, although, when the change is very gradual, the patient is seldom sensible of it. It begins to be attended with what he calls a huskiness, and at length a little to affect the breathing till the chest is thoroughly cleared, which is done with rather more difficulty than it used to be. What is expectorated, if it has had the blackish hue, loses it. It begins to appear less clear, and at length streaks of a yellowish colour may be distinguished in it. If the disease is not checked, the proportion of this opake yellowish part increases, till it forms the princi- pal part of what is expectorated. While this change goes on, the patient begins to be troubled with his hawking, coughing, and huskiness at other times than the morning, and to feel himself not quite equal to his usual exertions. He is now, for the most part, more or less troubled with these symptoms after each meal, particularly after dinner, and when he uses more exercise than usual. With these symptoms, he begins to be occasionally feverish, especially in the evenings, and the pulse soon becomes permanently quicker, as it has for some time been tighter than in health. He begins, also, to lose his colour and his flesh, and along with them his usual spirits; and his friends begin to think him, to use their expression, in a bad way: but he himself is almost always the last to arrive at this opinion. I have even known physicians, under such circumstances, placed IN THE LUNGS. 117 beyond all hope of recovery, before they regarded themselves as seriously ill. The state I have been describing generally ends in one of three ways: pulmonary consumption, modified by the languid nature of the previous disease, and the advanced age of the patient; dropsy of the chest; or that of the abdomen. That the reader may understand the nature of this disease, it will be necessary to direct his attention to the following circumstances. I have already had occa- sion to observe, that it is allied to dyspeptic phthisis,— that species of consumption in which the disorder spreads from the liver to the lungs. It is in those who have been subject to indigestion that the disease we are considering is apt to show itself; and here, as in dys- peptic phthisis, it is chiefly in proportion as the indi- gestion affects the function of the liver that the lungs are affected by it. Some degree of morbid acidity and flatulence of stomach, and some occasional derangement in the biliary secretion, are so common, that, by many, they are hardly regarded as deserving the name of disease: yet even these slight affections, if long continued, often produce a corresponding affection of the lungs, which, like themselves, is seldom considered of sufficient im- portance to attract much attention; but, however mild the symptoms may be, the state of the patient, when more than one vital organ is affected,, is essentially dif- ferent from that in which the disease is confined to one. However slight, it is a case of complicated disease; and, from the sympathy established between all parts of the body through the nervous system, the affection of each tends to increase both the symptoms and obsti- nacy of the other; and it adds not a little to the evil that, from the nature of such cases, the organs affected 1 118 CHANGE OF STRUCTURE must necessarily be those which greatly sympathise with each other. The effect of every cold, cause of fatigue, &c. fall chiefly on the debilitated parts, and thus, also, the evil accumulates. Of all the causes of injury, in such cases, the most pernicious is the excessive use of fermented liquors, and particularly if they have been distilled, which pro- duces a change in their effects, which no dilution with water, or addition of lemon-juice, sugar, &c, can after- wards counteract. We see the excessive use of wine, ale, &c. produce a plethoric state of the habit: it becomes full and bloated, and consequently liable to the diseases which arise from overloaded vessels; while spirit-drinkers are pale and emaciated, and subject to the diseases which arise from more direct injury of the nervous system; they become feeble, unsteady, and paralytic. If the drunkard dies neither from diseases of pletho- ric nor nervous exhaustion, he falls a sacrifice to the disease we are considering, and his life is terminated by a slowly wasting consumption of the lungs, or the effusion of water into the chest or belly, or both, or in some cases by a combination of all of these diseases; his tendency to which is easily explained, when we consider that it is on the liver, whose sympathy with the lungs is so strong, and through which the blood of the abdominal viscera must return in its passage to the heart, that the cause of the disease chiefly makes its impression. Pulmonary consumption, and the disease we have just been considering, are the most common causes of organic disease of the lungs; but, as in all other organs, long-continued derangement of function, from what- ever cause, will sooner or later have this effect. The lungs are subject to severe nervous affections, particularly the spasmodic, and what, for want of a IN THE LUXGS. 119 more appropriate name, I have called habitual asthma, which is distinguished from the former by the difficulty of breathing, never wholly leaving the patient. It is also more importantly distinguished from spasmodic asthma, by its being more apt, when severe and long- continued, to produce organic disease of the lungs; which arises, I believe, from its depending on a failure of nervous power,—every cause which lessens the ner- vous power of this organ, inducing it; while the spas- modic asthma appears, properly speaking, not to be a disease of the lungs themselves, but of the parts at the upper extremity of the windpipe, in which the con- traction of the passage ot the air, by spasm of its muscles, produces the violent struggling for breath which attends its paroxysms.(29> I have found it impossible, by depriving the lungs of their nervous power, or by any other cause operat- ing on them, to produce the symptoms of spasmodic asthma which are immediately produced by a cause lessening the passage through the upper part of the windpipe. The nature and treatment of habitual asthma are fully considered in my Treatise on Indiges- tion, and also in a paper published in the Philosophi- cal Transactions of 1817. Like other organs, the lungs are subject to the more common forms of inflammation. In a Treatise on Symptomatic Fevers, I have entered fully into the dif- ferent species of inflammation of the lungs, and their consequences; and in the two works just mentioned, therefore, have considered the effects on the lungs of (29) May not the pathology of these two forms of asthma, and some other vices of respiration, receive some elucidation from the consideration, that the nerves which excite the functional action of the lungs derive their origin from the automatic system, whilst those of the muscles of the thorax con- cerned in the contraction and expansion of the chest in inspiration and ex- piration, arise from the brain and spinal marrow? 120 CHANGE OF STRUCTURE the great sources of organic disease,—disordered cir- culation, and disordered nervous power. Although in the cases just mentioned, the one or the other is the immediate cause of the. disease, disorder of neither exists long without producing more or less of that of the other. The disease, however, still con- tinues to be characterised by the cause from which it first arises. Thus, in inflammation, the lungs are dis- organised by suppuration and gangrene; in derange- ment of the nervous power, by thickening of their membranes, or consolidation of their substance.!30) In the former case, the first morbid change is debili- ty and consequent distention of the capillary vessels of the part; but its destructive effects cannot ensue with- out the action of the nervous power being modified or destroyed. In the latter, the original disease is in the nervous, that is, assimilating power; but the diseased structure cannot be established without a correspond- ing change in the capillary vessels of the part. I have, in a paper published in the Philosophical Transactions of 1828, pointed out the effects of mere nervous derangement on the lungs, where the cause had no direct operation on the powers of circulation. But neither in the lungs nor other organs is the imme- diate cause of disease always so simple. Its occasional causes often at the same time derange both the circu- lating and nervous powers of the part: hence, it is not difficult to conceive how varied the result in different cases must be, according to the degree and the manner in which, from peculiarity of constitution, or the nature of the occasional cause, each of these powers is affected. (30) The diversity of morbid products in an organ must materially de- pend upon the vessels and nerves by which they are formed, whether they belong to those furnishing its nutrition, or those conveying the blood to un- dergo its functional operation. IN THE LUNGS. 121 I have had occasion, in my Treatise on Indigestion, to point out that, in some cases, after the disease has spread to the liver, it produces a difficulty of breathing which has all the characters of a nervous affection, and which sometimes remains after both the stomach and liver have regained their functions, and then generally resists all that can be done by medicine. It is from time to time relieved by antispasmodic medicines; but when it has remained after the disease which has pro- duced it, I have never seen it cured, except by galvan- ism, which always relieves, and frequently wholly removes it;—a circumstance which, from what I have laid before the reader respecting the nervous power, sufficiently explains the nature of this affection. In some instances I have known it, whether pro- duced in this way or existing as an original disease, (for it occasionally arises from other causes,) continue, without increasing, for many years. In other instances it gradually increases, and at length unfits the patient for all active duties. I have known many of the lower ranks, especially those who were addicted to the free use of fermented liquors, obliged to abandon their oc- cupations, although not particularly laborious, from this cause, after all the usual means had been tried in vain; and had the satisfaction of seeing them resumed, in consequence of the use of galvanism. This, of course, can only happen when the structure of the lungs is entire, or nearly so. We have reason to believe that, in every case, as we know happens in some, as I shall have occasion to point out more par- ticularly, the slighter degrees of organic derangement are corrected by any means which tend powerfully to restore the due function of the part. 16 CHAP. VIII. Of Organic Disease of the Stomach. Of all the vital organs, the stomach is least prone to organic disease. It seems almost to form an exception to the general law, that long-continued derangement of function terminates in disease of structure: for we see people labouring under a certain degree of indigestion for the greater part of life, and even the more severe forms of it, without apparently any tendency to organic disease of this organ; and that even when the irritation of the stomach has been such as, through the interven- tion of the nervous system, to derange the structure of distant parts; and, on the other hand, when organic diseases of the stomach do take place, it is not particu- larly in those who have been troubled with symptoms of indigestion. Nor are we acquainted with any other symptoms which indicate their approach, if we except the usual consequences of inflammation. So that I may say of this organ, as was said of the heart, that, in such a treatise as the present, whose object is to point out the first beginnings of organic diseases with a view to their prevention, it would be of little advantage to dwell on those of the stomach. We have no means of ascertain- ing the tendency to them; and, before they have made such progress as to denote their presence, their cure is beyond our art.(31) (31) There is .a disorder of this viscus which does sometimes induce or- ganic derangement, or if it did not, from the amount and kind of suffering it inflicts, would entitle it to especial consideration—it is the siek-headache. ORGANIC DISEASE OF THE STOMACH. 123 The first part of this observation applies also to or- ganic affections throughout the whole course of the bowels; and the last to all, except those of the rectum, which is within the reach of the surgeon, to whose care its organic affections must be committed. I have seen death occasioned by the .contraction of a part of the small intestines, the contracted part, for the length of a couple of inches, not exceeding the size of a crow- quill,—a disease that must have been in a state of progress for a gieat length of time; yet there was at no period any symptoms which could suggest either the tendency to, or even the existence of, such a change. There is no part of the stomach which is not subject, however rarely, to disease of structure, thickening and induration of its coats, ulceration, &c. The thicken- ing is often very great. The most frequent seat of or- ganic disease is the pylorus; and, next to it, the great end of the stomach, where the change of the food is chiefly effected.* But although indigestion is rarely, if ever, the sole cause in organic disease of the stomach, it is a fruitful source of it in other parts of the system. I have just had occasion to make'some observations on the manner in wrhich it produces, through the medium of the liver, organic disease of the lungs, which often happens while the structure of the liver itself remains unaffected. But the organs whose sympathy with the stomach itself is strongest, and, consequently, whose functions its dis- orders are most apt directly to affect, are' that just From too much personal experience and not a little professional observation, we are satisfied, that it in a great measure depends upon spasmodic con- striction of the pylorus, and that it does occasionally produce thickening and even scirrhus of the lower aperture of the stomach. Although it possesses some symptoms in common with indigestion or dyspepsia, it is a specifically distinct form of disease. The present, however, is not a fit opportunity for such discussion as it merits. * Treatise on the Vital Functions. 124 ORGANIC DISEASE OF THE STOMACH. mentioned, the liver, and the brain and heart; and, in speaking of the two last organs, I have had occasion to point out the manner in which disorder of the stomach affects them. From the extreme sensibility of the stomach, and the various causes of irritation to which it is exposed, there is hardly any part of the body that is not liable to be affected through it; and it gives peculiar power to all its sympathies, that the brain, through the medium of which all sympathetic affections take place, peculiar- ly sympathises with it. Thus it is, that by indigestion the whole system is kept on the fret, if I may use this expression; and if any part is more liable to disease, of whatever nature, than the rest, it is apt to show itself. I have taken much pains, in my Treatise on Indiges- tion, to illustrate this general and powerful'influence of disorder of the stomach, by which it often becomes the exciting cause of many of our most formidable dis- eases; and in those cases where the power of other organs is so well balanced as to resist its effects, it sometimes, we have just seen, produces general and permanent disorder of the brain itself, which, if it can- not be arrested, ends in structural disease of that organ. The reader must have remarked, from many facts I have had occasion to mention, that organic disease is always most apt to occur when the disorder of function which precedes it has become permanent. The most severe disorder of function which recurs at intervals, is less apt to' have this effect than one comparatively slight but continued—one of the chief causes of the insidious nature of organic disease. The resumption of the natural function always tends to counteract the effect of the previous functional derangement. CHAP. IX. Of the Morbid Affections which precede Change of Structure in the Liver. The liver, on two accounts, particularly deserves at- . tention in such a treatise as the present.^) Of all the vital organs, next to the lungs, it is the most frequent subject of organic disease; and it is the only one, the organic affections of which, we are assured, even when considerably advanced, sometimes admit of cure. This organ also, from its office being that of preparing a fluid necessary to the due conversion of our food, from its peculiar sympathy both with the brain and stomach, its great size, the nature of the circula- tion in it, and the importance of the organs from which it receives its blood, is intimately connected with most of the great changes of the system; and there are few local diseases of importance of which it does not more or less partake. Although more liable than the stomach to organic disease, like it, it is capable of bearing long- continued derangement of function without injury to its structure. Except in the earliest stage, derangement of (32) From the complication of the structure, the variety of operations it performs and the nature of the materials subjected to its elaboration, the liver is obnoxious to more'of the causes of disease than any other organ in the body, and consequently demands more discrimination between its several diseases, than, it is to be regretted, has generally been made. • In aU organs that perform several offices, agents which may promote action in one may suppress it in another; consequently when diseased, unless it is accurately determined which function is impaired, any active article of medicine stands an even chance to do harm as good; and hence the evils continually arising from the empirical practice of exhibiting calomel and other mercurials in- discriminately whenever the liver is susprcted of error. 126 CHANGE OF STRUCTURE its function almost uniformly attends that of the stomach; yet, in this country at least, indigestion, however severe and long-continued, seldom produces disorganization of the liver; except in drunkards and those who have suf- fered from the effects of sultry climates. I have already had occasion to point out sufficient proofs of the powerful sympathy which exists between the liver and stomach. The sympathy of the former with the brain is no less striking. One of the best proofs of which is, the effect of the passions on the liver, par- ticularly the depressing passions, which often instantly derange its function, and seldom fail, if long-continued, to affect its structure. It is not at all uncommon for blows on the head to pro- duce inflammation of the liver; an effect they rarely, if ever, produce in any other of the abdominal or thoracic viscera: and on the other hand, while, in the most severe inflammation- of the heart, lungs, stomach, or bowels, the mental functions remain clear to the last, delirium attends that of the liver. In its sympathy with the stomach, however, we find the most frequent cause of its diseases, and the stomach very generally suffers when the. offending cause makes its first impression on the liver. The former of these positions is well illustrated by the effect of stomach com- plaints in the adult: the latter, by the bilous complaints of children; for,-in them, particularly in those who are not beyond the age of infancy, disease of the digestive organs, contrary to what takes place in the adult, gene- rally commences in the liver. When the disordered function of the stomach spreads to the liver, either the secretion of bile begins to fail, or its properties are altered; an inactive bile, or bile of irritating qualities, being secreted. The bile, also, seems often to be vitiated by stagnating in the gall-tubes of the liver; for it is not uncommon to find a deficiency of IN THE LIVER. 127 bile in the bowels evinced by the pale colour of their contents, while the liver may be felt preternaturally dis- tended: and when, by proper medicine, it is roused to a more vigorous action, the bile is discharged of a dark, and sometimes almost of a black colour, often occasion- ing great irritation in its passage through the bowels; while the tumefaction of the liver is found to subside. We have, in the state of a certain part of the bowels, a measure, as far as. I have been able to judge, that rarely fails of the degree of habitual derangement of the biliary secretion, which I know of no other means of estimating. The fulness of the right side of the body, so common an attendant on indigestion, especially when it extends pretty far down, even when combined with tenderness on pressure, does not usually arise from any enlarge- ment of the liver, but appears, from the various cir- cumstances I shall have occasion to mention, to be chiefly the consequence of a distended state of that bowel into which the stomach first pours its contents, from its imperfectly carrying them on, in consequence' of the liver supplying a bile less active in its properties, and, therefore, less capable of exciting it. That the fulness I am here speaking of arises from a distended state of some part of the intestines, ap- pears from our always being able, at early periods of the disease, to remove it for the time, by thoroughly emptying the bowels. This could not happen if it proceeded from any other cause, with the exception of a gorged state of the liver; and it is not difficult to distinguish, by the hand, the distended intestine from the fulness produced by the gorged liver: the former is less firm and defined, and the swelling extends lower down. The latter proceeds more immediately from under the edge of the ribs, and its outline may be dis- tinctly traced. 1 128 CHANGE OF STRUCTURE As there may be some difference of opinion, how- ever respecting the part of the intestines where the accumulation which I refer to the first intestine takes place, I shall here state my reasons for believing it to be in that intestine. At first view, it might seem easy to ascertain the point by inspection after death; but, the mere affection of the alimentary canal itself, such as usually attends disordered liver, never proves fatal; and in other affec- tions, whether induced by the irritated state of that canal, or accidentally combined with it, death is gene- rally preceded by long-continued abstinence, during which, under all circumstances, this accumulation is generally lessened or removed. We are, therefore, left to ascertain its seat from the symptoms of the disease, the nature, position, and office of the different parts of the canal, and the effects of the means employed. These, if carefully consider- ed, will, I think, leave little room for doubt. The first intestine lies exactly in the seat of the ful- ness, the distinctive character of which 1 am endea- vouring to describe, and, where the fulness is greatest, forms a kind of pouch; for, having descended to this place, it rises to a higher part of the abdomen, and, from its form and structure, as well as position, it would seem the intention of nature that its contents should for some time be detained. This seems also pointed out by its office; for the food is there mixed with the bile and pancreatic juice. It is not only wider, but more dilatable than other parts of the small intestines, so that it has even obtained the appellation of a second stomach. The other parts in the same region are other parts of the small intestines, in which there is no position or other circumstances particularly calculated to detain their contents, nor any particular function to be per- IN THE LIVER. 129 formed; and the ascending part of the large intestine, whose contents, when delayed, cause a fulness which is firmer, more circumscribed, and lies more to the right side of the abdomen than that we are considering. But the circumstance, which, compared with what has just been said, seems to leave no room to doubt that the first intestine is the seat of the accumulation in question, is, that I have almost constantly observed that the more severe nervous symptoms which attend bilious complaints are, in the same patient, proportion- ed to the degree of this accumulation, and generally disappear on its removal. Now, it is well known that the sympathy of the alimentary canal with other parts of the system increases as we approach the stomach in either direction. The system sympathises more with the affection of the gullet than the mouth, more with the affection of the first intestine than with more distant parts of the small intestines, and more with these than with any part of the large intestines. The colon may sometimes be felt loaded with its contents almost in a hardened state, with much less general derangement that often arises from such a fulness of the region I am speaking of as can be only perceived by an attentive examina- tion. What is here said is well illustrated by the difference of the fever, and other symptoms, excited by inflammatory affections of the small and large intes- tines. While the region of the pylorus is almost always tender in severe and long-continued bilious complaints, that of the first intestine is only occasionally so; but the latter, even when unaccompanied by tenderness on pressure, often feels more full; and pressure, particu- larly sudden pressure, upon it, almost always occasions a greater sense of oppression, and affects the state of the breathing more, than similar pressure on the cor- 17 130 CHANGE OF STRUCTURE responding part of the left side. The patient will almost always tell you that the left side feels more free than the right, and that there is something in the latter which gives him a sense of obstruction, and if it be attempted to press the fingers under the ribs in the two sides,'a sensible difference will be perceived in the ease with which this can be done. It is natural to suppose that, as the liver lies on the right side, these differences may be ascribed to it, even when it is free from enlargement. On this account I have, both alone and with other physicians, examined in this way healthy people, without the slightest differ: ence between the sides being detected. In a healthy subject the liver lies wholly under the ribs, and on both sides lower than the ribs; we press on nothing but the soft bowels; and when the fingers are pushed up under the ribs, the liver, if not enlarg- ed, lies too much out of reach, and yields too easily, to admit of our perceiving it through the integuments of the abdomen. I am the more particular here, because I find that even medical men have sometimes been deceived in these respects; they can, however, readily satisfy themselves by an examination of the heal- thy subject, which some have done in my presence, and had the candour to allow that they had not sufficiently adverted to the circumstances just mentioned. The truth is, the mind has not been particularly directed to the subject we are considering, and it has not, there- fore, obtained the attention it will be found to deserve. If it be ascertained that no enlargement of the liver has taken place, which is easily done, any diffuse ful- ness of the region in question always appears to be the effect of the accumulation I speak of; and when there is, at the same time, enlargement of the liver, it can easily be distinguished from distention of the intestine in the way just pointed out. IN THE LIVER. 131 I have of late years regarded the degree of this distention as the best measure of that in which the function of the liver is deranged in chronic cases, and it has seldom deceived me. The enlargement of the liver itself is by no means a correct measure of its derangement, for it is remarkable that even considerable enlargement of the liver sometimes seems little to inter- fere with its function: the patient's sufferings are pro- portioned to the irritability of his nerves as well as the degree of his complaint, and the degree of ten- derness to the degree of inflammatory tendency; but the difficulty with wrhich the first intestine empties itself, very accurately tells us the degree in which the properties of the bile, and, consequently, the powers of the liver are impaired. As soon as an inactive bile begins to be secreted, in the same proportion the action of this intestine begins to languish; and bilious patients, often for months, or even years, suffer an accumulation there of what ought to be carried forward. Not that the same contents remain—for a continual passage is, of course, necessary to life—but the intestine never empties itself thorough- ly, a great portion of its contents is retained beyond the due time, and only evacuated in proportion as a fresh supply from the stomach supports the accumula- tion; and thus an enlargement, evident to the eye as well as the hand, often takes place, and the patients them- selves, particularly women, from the nature of their dress, not unfrequently perceive the body sensibly, and often to a considerable degree, enlarged. Children, on whose livers I have had occasion to ob- serve the causes of disease often directly operate, are still more inclined to this accumulation than adults, most of their complaints being connected with the state of the digestive organs. Of those who are out of health, with the exception of such as labour under contagious 132 CHANGE OF STRUCTURE diseases,—and they are by no means always excepted,— not one in twenty will be found free from more or less of it, and their restoration to health is never perma- nent till the due action of the first intestine is restored. When this intestine is habitually loaded, no ordinary aperient will relieve it: it passes through it, leaving the greater part of its contents behind. In the more re- cent cases, whether in children or adults, it may gene- rally be emptied by a brisk dose of calomel; but if the case has been of any standing, the accumulation soon forms again, and is only to be permanently removed, and the patient restored to health, by such means as produce a bile of healthy properties. When this is accomplished by the means I shall soon have occasion to point out, the intestine, without any effect of the remedy which the patient can perceive, empties itself regularly, and the symptoms which had so long harassed him disappear; one among many other proofs, that the load on the delicate nerves of the first intestine is the chief source of these symptoms, which I have enumerated at length in my Treatise on Indi- gestion. I have already had occasion to observe, that they often continue for a great length of time without pro- ducing organic disease of the liver. This, however, is not universally the case. In unfavourable habits, and especially in those who indulge in the use of fermented liquor, and particularly distilled spirits, even although not to the excess of the drunkard, the structure of the liver often at length becomes diseased; and even where the patient had never been exposed to the effects of a sultry climate, nor-been guilty of excess, I have seen it as proved by dissection wholly destroyed. When organic disease of the liver has commenced, and enlargement (its common but not constant attend- ant,—for it is sometimes even lessened in size) has IN THE LIVER. 133 taken place, it requires some attention to distinguish it from the occasional distention to which it is subject, when its function only is disordered. Both generally, in the first instance, chiefly affect the left lobe, although, for the most part, some degree of general enlarge- ment of the organ attends. The most unequivocal means of distinction in these cases is afforded by the effects of a mercurial aperient, which, in the latter case, never fails more or less to re- duce the distended liver, while it makes little sensible impression in the former. The sensation given to the hand, however, in the two cases, is very different. In both, the liver, and particularly the left lobe, descends below the ribs, and may be distinctly felt; but in the case of disordered function it is neither so hard, nor is its edge so well defined, as in that of the organic dis- ease, and the attendant symptoms confirm the diagnos- tic thus obtained. They may not, in the latter, be more severe, but they are more obstinate, and the patient's countenance soon begins to acquire that peculiar hue and expression which is given by all organic disease of vital organs. The flesh is more inclined to waste, and the whole ap- pearance and manner is that of more serious indisposi- tion. The pulse is generally small, contracted, and more or less increased in frequency; there is often, also, more tendency to increased heat, particularly to occa- sional burning of the hands or feet, which, especially the latter, at other times are cold. All affections of the liver produce depression of spirits; hence the name melancholy. In its organic affection this symptom is generally more uniform; its secretion is also more uniformly deranged, although, as I have just had occasion to observe, it is not very uncommon to find the colour of the bile natural, even when the liver is both enlarged and indurated;—one 134 CHANGE OF STRUCTURE amono- many proofs that, by the colour alone, we judge very imperfectly of the state of this fluid. From the enlarged, and, consequently, heavy liver pressing on other organs, the patient often experiences considerable difficulty in lying on the left side, although this symptom is not so uniform as, from reasoning, we might expect, and is probably influenced by the degree in which its ligaments are relaxed. When he lies on the right side, the enlarged liver, resting only on the ribs and muscles, generally gives less uneasiness. As the disease advances he usually finds lying on the back the only easy posture; and in the most advanced cases, the easiest position is on the back, inclining a little to the right side with the shoulders considerably raised. The symptoms, in the progress of the disease, vary according to the liability to disease in the particular constitution in those organs with which the liver chiefly sympathises, particularly the brain and lungs. In some cases the patient becomes more or less lethargic, the mind at times wandering; and long continued irritation of the liver occasionally gives rise to some of those states which dispose to the different forms of apoplexy which we have been considering. Either by debilitat- ing the vessels of the brain it gives a tendency to their morbid distention, or by its effect on the brain itself weakens its powers, and disposes to their failure from slight causes. The headaches of bilious subjects every one has witnessed. They are, for the most part, felt chiefly in the forehead. They are of various descriptions; dull and heavy, or acute and lancinating, and not unfre- quently occupy other parts of the head, the crown, the sides, or the back part. In the same patient they generally return to the same part, and often excite the idea that there must be some fixed disease of the brain in the situation they IN THE LIVER. 135 occupy; but the pain is not constant, and although any uniformity in such symptoms is never favourable, this has very rarely, in my practice, proved to be the case. Some peculiar nervous sympathy, little inclined to pro- duce organic disease, serves in bilious subjects to de- termine the particular seat of the headache. One of the most common and fatal effects on the head of disordered liver, is what is called internal water of the head, which is apt to appear under thir- teen years of age, and is most frequent in infants. In this disease, as in many of the other diseases of chil- dren, we see the illustration of a principle which has an extensive influence on the phenomena of disease. As we advance in life, the nervous system becomes less movable, if I may use the expression, it becomes both less easily affected by causes of irritation, and less capable of producing violent effects on other parts of the system. In early infancy we find irritation of the stomach and bowels, or of the gums in teething, sud- denly producing general convulsions; and this irritated state of the nervous system giving rise to fatal obstruc- tions and their various consequences, effects which, at later periods, we either never see from such causes of irritation, or see only after a continuance of many years. Of this nature is internal water of the head, the con- sequence of languid inflammation of the brain, which is rare after the period just mentioned; for if this disease in children is not the consequence of injury of the head itself from blows; &c. it is almost always the effect of disordered liver; and I can without hesitation say, from a pretty extensive experience, that it is only on this principle that its treatment is generally successful; not that the means of relieving the disorder of the liver are themselves sufficient, because secondary affections, when once established, require a plan of treatment directed to the part they occupy; but if the original 136 CHANGE OF STRUCTURE disease be neglected, no plan of this kind alone, ex- cept in the most favourable cases, will prove successful. By such plans the injury done to the brain may be more or less counteracted; but, in general, if the origi- nal cause be allowed to remain, there will be a con- stant recurrence of the symptoms of the secondary dis- ease. In other cases, the state of the liver influences the lungs more than the brain. The patient is oppressed with difficulty of breathing and cough, at first generally dry and irritating, afterwards producing an expectora- tion of phlegm and mucus, which at length becomes purulent, and the disease of the lungs I have already had occasion to describe, is established. In some instances, along with these symptoms, or without their ever becoming so well marked, the diffi- culty of breathing increases, particularly in the lying position, any degree of which at length becomes oppres- sive; and as the disease advances, the patient is obliged to sit up, and sometimes to have his feet on the ground, so that at length, much as his strength is reduced, he is obliged to exchange his bed for a chair, and even in this posture cannot recline on the back of the chair, but leans on something placed before him, in order to bring himself into that position wThich is most favourable to the impeded expansion of the lungs. While these symptoms are increasing, his feet and legs swell, the swelling gradually rising higher, and being much aggravated by the erect posture. In such circumstances the skin of the legs often inflames, and a discharge of water takes place from them, which gives a degree of temporary relief to. the general symptoms, but is often attended with great uneasiness from the state of the legs themselves, which frequently ulcerate, and sometimes even become gangrenous. IN THE LIVER. 137 The action of the kidneys has all along been failing. The water is now very small in quantity, high coloured and turbid, generally depositing a copious sediment; and if medicine fails to increase it, which, when the dis- ease has arrived at this state, generally sooner or later happens, the patient sinks under his complicated evils. Such is the course of dropsy of the chest from diseased liver, of all species of dropsy, in its early stages, most easily relieved by medicine, if it super- venes before any considerable affection of the liver be established; but in its termination the most uniformly fatal. Although I have seen patients survive the first collection of water in the chest even for several years, and appear for a certain time to be restored to health, I have never seen one instance, from whatever cause it arose, in which this disease was permanently cured. When it arises in the way I am here describing, the length of the interval, and the degree of health which the patient enjoys, depend on the degree to which the affection of the liver can be relieved; but from what I have seen, I have little doubt that if, after the diseased liver has produced effusion in the chest, it could be wholly restored to the healthy^tate, this effusion would still continue to recur. The vessels of the part, having once been brought into the state which causes it, seem never to recover permanent vigour. There is another dropsical affection of the chest, however, which I have often seen confounded with that we are considering, from which perfect recovery is by no means unusual,—I mean what is called an anasarcous state of the lungs. When water is effused into the cellular texture under the skin, it is sometimes effused also into that of the lungs. This is distinguish- ed from dropsy of the chest, properly so called, by being evidently an attendant on the general dropsical state of the habit, which precedes and produces it. IS 138 CHANGE OF STRUCTURE There also the water is usually scanty and high coloured, and the patient is much oppressed by the horizontal posture; but it is in a different way. The inability to lie down is seldom so great, and the sense of oppression is not so immediately felt on assuming the horizontal posture, but gets worse by its continu- ance, and the patient soon finds it necessary to assume one more erect, but is seldom obliged permanently to exchange his bed for a chair,—one of the most painful effects of disease, and which fortunately, in such cases as that we are considering, the powers of our constitu- tion never permit to be of very long continuance. We have seen that the irritation of disordered liver, also, sometimes produces the nervous affections of the lungs; that temporary oppression of breathing to which dyspeptics are liable, and which is often experienced from oppressed stomach in various degrees of severity and duration, from a slight and transitory feeling to the permanent establishment of what I have termed habit- ual asthma. Even the spasmodic asthma, if it is not sometimes caused, is always aggravated, by disorder of the liver. Of all these affections of the lungs, it may be observ- ed that, with few exceptions, each has a greater or less tendency to induce the others; so that each is often ac- companied by some degree of the others. The inflam- matory states are apt to cause some degree of the nervous affection, so that while the disease advances uniformly, the breathing shall be better and worse at different times; and the severe nervous affections never continue long without exciting some degree of the in- flammatory tendency, with its accompanying symptoms, tight pulse, tendency to increased heat, &,c. The disease of the lungs which appears least mixed with other affections of this organ, is dropsy of the chest, properly so called; the magnitude of this disease IN THE LIVER. 139 seeming, as it were, to prevent the approach of any other, although even here we can often trace a degree of nervous difficulty of breathing occasionally aggra- vating the symptoms; and on examining the lungs after death, we often find traces of inflammation even when the effusion has not proceeded from that cause, which is not unusual. The effects of deranged liver in the other abdominal viscera are often no less serious than in the head and chest. In my Treatise on Indigestion, I have had occasion to enumerate the slighter abdominal affections proceeding from it, particularly the effects of the viti- ated bile on the whole tract of the alimentary canal. Whether it ever gives rise to organic disease in any part of that canal, it is not easy to judge. This is certainly not a frequent effect of indigestion; for in what are called bilious cases, we find patients labouring under irritation of the bowels, occasionally extreme, for many years, without the occurrence of organic disease of any part of them. The bowels par- take of the disposition of the stomach in being little liable to such disease. In the large bowels this dispo- sition is greatest. Of this subject I shall soon have oc- casion to speak more particularly. It is not uncommon, however, for the mucous mem- brane which lines the surface, to acquire a morbid sen- sibility throughout the whole canal; and this state sometimes continues for many years notwithstanding all that can be done to relieve it, causing great tender- ness on pressure, and often much distention and pain of the abdomen, occasionally attended with a consider- able degree of fever. Such affections are more apt to attend disordered function, than diseased structure of the liver. How far habitual irritation from the disordered secre- tion of the liver disposes to stricture of the rectum, it 140 CHANGE OF STRUCTURE is difficult to say; but we are assured it has no great degree of this tendency. It is not uncommon to find stricture of the rectum attended with disordered action of the liver; but in all the cases of this kind which have occurred to me, the stricture was evidently the original disease, the derangement of the digestive organs de- pending on it, and abating in proportion as the stric- ture was relieved by local means. There can be no doubt respecting the deranged state of the liver disposing to piles, which are by no means an uncommon accompaniment of it. A diseas- ed state of the liver doubly disposes to them by the direct irritation caused by the passage of the vitiated bile, and by the obstructed liver offering an impedi- ment to the free return of the blood from the bowels, which is most felt in the most depending part of them. In the latter way highly obstructed liver not un- frequently produces a more serious disease,—effusion into the cavity of the abdomen, and thus dropsy of the belly is often established, which sometimes yields to the means that relieve the obstructed liver, affording an additional proof of its origin. It is not uncommon for obstructed liver to be attend- ed with similar obstruction in the other abdominal vis- cera. In the same subjects we sometimes find the pan- creas, and more frequently the spleen, more or less disorganised. When this happens, however, it seems to be the result of a common cause, not the effect of the obstructed liver, which we often find existing in all its degrees, without any consequence of this kind. I have known glandular disease of the abdomen so universal, that when the water in dropsy of the belly was drawn off, and the flaccid skin allowed to fall on the diseased viscera, the whole abdomen felt to the hand like a cluster of grapes, from the induration of the mesenteric and other glands. It is not uncommon, IN THE LIVER. 141 indeed, to see this general tendency to glandular ob- struction pervading the whole habit; and from what has been said of the influence of the nervous power in the assimilating processes, and the immediate effect of its failure in producing diseased structure,* we can feel no hesitation respecting the seat of the derangement which gives rise to this tendency. Among the effects of disordered liver, the disposi- tion it gives to rheumatic pains of the trunk and limbs is too prominent and common to be overlooked. Of this nature are those irregular and flying pains so fre- quent in indigestion after the liver has partaken of the debilitated state of the stomach; and hence it is that rheumatic pains are so apt to become obstinate in bilious subjects, when produced by their usual occa- sional cause,—taking cold, and that in such habits cold is so apt to have this effect. I have already had occasion to point out the great sym- pathy which exists between the stomach and the heart. When the former is much disordered, and at the same time there exists in the habit a highly inflammatory tendency, this sympathy often directs it to the heart. Most of the attacks of inflammation of this organ which I have seen, have been in those who had long laboured under great irritation of stomach; and as we always find this accompanied with a disordered state of the liver, which, whenever the inflammatory tendency is great, is apt to give rise to rheumatic pains of the limbs, these frequently precede inflammation of the heart, which, according to one of the most general laws of disease, that the supervention of any one tends to relieve that first established, relieves the rheumatic pains. Thus it is that when such pains have preceded inflammatory affections of the chest, we may be assur- ed that the inflammation has attacked the heart. * Philosophical Transactions of 1829. 142 CHANGE OF STRUCTURE Such are the most prominent and formidable effects of organic disease of the liver, or of that state of this organ which leads to it. Without keeping them in view, we cannot understand the nature and tendency of those slighter affections, which are more properly the subject of the present treatise. These comprehend the various symptoms of indigestion, and particularly those termed bilious, from their depending more or less on a disordered state of the bile. They are detail- ed at length in my Treatise on Indigestion, in which I have been at great pains to point out the changes that take place in the progress of that disease, and the steps by which it becomes complicated, and sometimes lays the foundation of the diseases we have been considering. The object which chiefly demands attention here is, to ascertain the circumstances which determine what is called stomach complaints to assume the form of those more serious diseases. The most important observation which can be made on the subject of their prevention is, that as we occa- sionally, however rarely, find the symptoms of com- mon indigestion assume a more formidable appearance, when we can refer the change to no cause but peculi- arity of constitution, which does not betray itself by any indication; those who aim at absolute security from such effects can only obtain it by correcting the slighter symptoms, which, both from this cause, and the suffer- ing the indigestion itself occasions, is always worth doing, even at the expense of a good deal of trouble. The great secret of preserving health is to obviate the first beginnings of disease; and however feeble our art may often be, in more serious affections, with the aid of the patient, it is almost always equal to this task; when these beginnings betray themselves before serious injury is done, which always happens in the case before us. IN THE LIVER. 143 With respect to the more evident causes which de- termine the unfavourable course of indigestion, I have already had occasion to mention the two which are most so,—the effects of sultry climates, and the free use of intoxicating liquors. A scrofulous and debili- tated habit, from whatever cause, as in all similar cases, disposes to the more formidable symptoms. It is re- markable, however, and seems at first view unaccount- able, that when formidable symptoms have appeared, while a debilitated state is always unfavourable, a scro- fulous habit often adds to the favourable prognostic. This seems to arise from two causes: that as scrofulous habits more readily fall into serious diseases, in them they often arise from slighter causes; and that those of a scrofulous habit generally bear a very tonic plan of treatment better than the more vigorous. It is not un- common to see them for years subject to the recurrence of symptoms which, in people of stronger constitutions, would soon prove fatal. With respect to the circumstances which, in the symptoms themselves, of the milder forms of indiges- tion indicate a more than usually unfavourable tendency, according to my observation, they may be arranged under three heads:—a greater than usual uniformity in the general course of the symptoms, a determination of them to particular parts, and a greater than usual in- flammatory tendency. From the nature of the early and most simple forms of indigestion the symptoms are necessarily variable. They depend altogether on the state of the nervous system, and are influenced by a thousand circumstan- ces of diet, feeling and situation. Any thing more indigestible than usual, or, for other reasons, offensive to the nerves of the stomach, will, for the time, occasion considerable, and sometimes severe, distress; and, in a few hours, when the offending cause 144 CHANGE OF STRUCTURE has passed from the stomach, the patient will again be at ease. Any sudden affection of mind, especially of a painful nature, will occasion flatulence and acidity; but this effect, like the former, is transitory. A similar observation applies to low and close, or exposed and bleak, situations; great noise and bustle, or extreme seclusion and want of variety; and the tendency of the disease is less to be inferred from the degree of the effects of these causes, than from their permanent or transitory nature, and from the freedom or embarrass- ment of the patient's feelings in the intervals. If we see him very uniformly restless and dispirited, although to no great degree, we may expect an obsti- nate disease; and the unfavourable prognosis is strength- ened if the local symptoms show a tendency chiefly to affect some particular part. If every slight cause of irritation is felt chiefly in the head, for example, or in the lungs or the lower bowels, it is necessary to watch the effect of such attacks; and the less other parts suffer, the more attention the case requires, even although the symptoms be slighter than where the dis- ease is more variable. But whether variable or not, their general nature is of great consequence, in forming our opinion: the more they are merely nervous symptoms, they are the more favourable; the more the circulation is implicated, the less so; and with respect to the sanguiferous as the nervous system, the variable symptoms, although more severe, are less to be feared than those which are more uniform, although slighter. Occasional attacks of fever and fits of palpitation, which leave the patient in a state differing but little from that of health, are slighter symptoms, than a tight pulse and parched skin which have become habitual. All the consequences of indigestion I have just had occasion to remark, commence with states of simple IN THE LIVER. 145 nervous irritation, and none of them ever pass into serious disease without having previously produced a more or less inflammatory state; that is, without more or less affecting the circulation, both of the general habit and of the part chiefly affected. We can always, if the pulse be examined in the way I have pointed out in my Treatise on Indigestion, perceive it more or less contracted, and if the part chiefly affected can be felt, it will always be found more or less tender on pressure; that is, indicating more or less of an inflammatory ten- dency; and it is this state of the circulating system and of the part on which the disease is inclined to fix, that gives steadiness to the symptoms. While they continue to be the indications of mere nervous irritation, however severe, they must, from their nature, be transitory; however strong the impres- sion they make, they cannot produce permanent dis- order in any part while they leave the circulation healthy. The circulating is neither liable to be so easily in- jured, nor so readily restored as the nervous system. As soon as it begins to be implicated, it gives some de- gree of its own character to the disease; and through all its stages the state of the circulation continues to be the chief cause which influences its important changes: and we find, when a tendency to change of structure has taken place, its progress is always proportioned to the degree in which the inflammatory symptoms, both general and local, prevail; and, on these principles, we shall find, the only plan of treatment which at all con- trols this tendency is founded. Thus, all the important tendencies in the cases we have been considering, depend on the direct influence of the nervous on the sanguiferous system, on the fact that continued nervous irritation always tends to pro- duce inflammatory action. 19 CHAP. X. Of the Morbid Affections which precede Change of Structure in the other Abdominal Viscera. There is, for the most part, the same obscurity re- specting the origin of organic disease of the pancreas and spleen which exists respecting that of the stomach; and, from our ignorance of the function of the spleen, and our not being able to judge of the state of that of the pancreas, even when organic disease is established, it is not easy to detect its presence, unless the organs become so indurated and enlarged as to be felt exter- nally, which is difficult with respect to the pancreas, from the deep seat of this organ. As organic disease of both, especially of the spleen, is often combined with that of the liver, we must sup- pose that it is more or less liable to be produced by the same causes, whether directly or through the me- dium of the diseased liver; and some fevers, particular- ly those of sultry climates, which are generally attend- ed with great derangement of the liver, are so apt to leave induration and enlargement of the spleen, that, in some places, this disease has obtained the name of ague cake.(33) (33) Conscious that any attempt to give importance to the spleen and its functions, will be met by the ridicule of the illiberal and contentedly igno- rant of the profession, we are willing to brave petty opposition from such quarters, in the hope of advancing something which may improve the science and benefit the world; or if we shall be equally unsuccessful where all others have failed, we shall be consoled with the reflection, that we adventured into a region which had been abandoned in despair. But we are confident our efforts will not be altogether vain; for even in the worst contingency, CHANGE OF STRUCTURE, &.C. 147 Of the intestines the colon is most subject to organic disease; but, as I have already had occasion to observe, we are unacquainted with the circumstances which dis- pose to it. It is sometimes difficult to distinguish in- duration of that part of the colon which lies near the stomach, from a similar affection of the stomach itself, the situation of the induration and the feeling given to the hand being nearly the same in both: nor is it easy to distinguish some of the less important affections of these organs. The best means of distinguishing them are, that the digestive process in affections of the colon is better performed, in proportion to the severity of the local symptoms, the state of the bile being less disordered, and the patient not experiencing the increase of un- easiness which often comes on after meals, for a con- siderable time after eating; and often perceiving more or less pain, or some other uneasiness, in the region of the stomach a short time before the bowels are moved, and more or less relief soon after their action. The general health also suffers less in proportion to the severity of the symptoms, than when the stomach is affected. These observations, however, apply chiefly to the slighter affections of that part of the colon which lies near the stomach, or the early stages of its more severe diseases. In their more advanced stages, the stomach and other digestive organs, either by actual participa- we shall perhaps awaken interest to the subject, and our errors may indi- rectly promote the advancement of others in the way to truth. When the physiology of the spleen, in the Appendix, shall have acquired further confirmation and currency, its pathology will command more atten- tion, and the science will be enriched with valuable facts of repeated occur- rence, which now pass unnoticed; enough are already upon record, if properly collated, to establish our theory and elucidate the nature of its own diseases; and also those of other organs depending upon it for their means of functional operation. 148 CHANGE OF STRUCTURE tion of the disease, or by sympathy, suffer so much, that the diagnosis becomes much more difficult. As the disease, however, after induration has taken place, while it increases in severity, generally, at the same time, becomes more extensive, its seat may often be ascertained by tracing it to a considerable distance by the hand, in the course of the colon. The pain of the left side, in what are called bilious complaints, in many cases evidently arises from a de- bilitated action of this bowel, where it descends on that side, and where it may sometimes be felt loaded with its contents, and is immediately relieved by their dis- charge. We have reason to believe, however, that this is not its most common cause, and that it is gene- rally to be classed with the mere sympathetic pains of indigestion, and has its seat in the muscles of the side. Feculent accumulations are particularly apt to form in the ascending portion of the colon, where they may be felt in the right side near to, but rather more distant from, the centre of the body, than the region of the first bowel. As I have already had occasion to ob- serve, in speaking of the distention of that intestine, the impression they make on the hand is firmer, better de- fined, and less in extent, than that made by its disten- tion. I have known this state of the colon, for the mo- ment, mistaken for disease of other parts; but the effects of bringing the bowels into a freer state soon points out its real nature. A permanent thickening and induration of this part of the colon gives to the hand so much of the same kind of feeling, and its situation is so nearly the same, that it may be mistaken for the kidney, removed from its usual place in consequence of relaxation of its liga- ments, which sometimes happens; and I have known men of great experience give these very different opinions respecting the same case. The attendant cir- IN THE ABDOMINAL VISCERA. 149 cumstances, however, for the most part, enable us to distinguish its real nature, the affection of the colon being generally attended with more or less uneasiness and functional derangement, and the displacement of the kidney with little or none. With regard to the nature of the affections of the colon, which sometimes supervene in indigestion, the most usual appears to be merely a degree of languor causing delay in the passage of its contents, and pro- ducing the symptoms just mentioned, the consequence of the bile and other secretions being less adapted to support its action. When its contents are longer de- layed than usual, they become hardened, and irritate the surface of the intestine, sometimes causing tender- ness on pressure, as well as a feeling of hardness in the part. The colon, like the stomach, it appears from what I have just had occasion to say, is subject to thickening and induration of its coats. Where the disease had existed long, I have known it found, on dissection, in- • durated through almost its whole extent. Whether constipation, or any of the other attendants on indiges- tion, ever give rise to such affections of this bowel, without the co-operation of other causes, may be doubted, the former being extremely common, and the latter very rare. I have known organic affection of the colon become evident after obstinate fits of consti- pation; but whether these act as a cause, or are only among the first symptoms, it is difficult to determine. When a tendency to such affections exists, frequent constipation can hardly fail to increase it, and may be the means of calling it into action. It is not very unusual for preternatural growths to form in different parts of the abdomen; and it is often very difficult to ascertain how far and in what manner they are connected with the viscera. I have repeatedly ^ 150 CHANGE OF STRUCTURE known tumours of this kind remain for years without materially affecting the health, when they were of an indolent nature, and happened not to press unfavour- ably on the surrounding parts, although in such cases the patient's countenance seldom has a healthy colour. I once saw death occasioned by a tumour of this kind, about an inch and a half in diameter, pressing on the gall ducts. By stopping the passage of the bile, it had caused them to be distended to many times their natural size. The patient had no other disease, and the symptoms had only been such as are termed bilious, complicated with obstinate jaundice. It appeared from the colour of the skin that the bile was of a healthy quality; I had, therefore, concluded, that the disease arose from something obstructing the ducts, although the pain was not such as could be ascribed to the ob- struction of a gall stone. Fever, at length, necessarily supervened, and proved fatal. In another case, where there had long been returns of excruciating pains, re- ferred to the lower belly, a large tumour was found in the mesentery of the nature of fungus haematodes. Such cases are rare, but of course admit of infinite variety, and must make us cautious in giving an opinion unless the circumstances be such as leave no room for doubt. There is often much difficulty in determining the presence of organic affections of the mesenteric glands, respecting which some mistaken opinions have been prevalent. It has been customary, particularly in chil- dren, who are most subject to mesenteric obstruction, wherever the patient wastes without any apparent cause, to consider the passage of the nourishment from the intestines to the blood obstructed by disease of those glands; but I have found opinions given on this principle often very ill supported by the subsequent inspection of the body. From the position of the IN THE ABDOMINAL VISCERA. 151 mesentery and the small size of its glands, they may be considerably enlarged without our being able to feel them through the integuments of the abdomen; and, unless this can be done, we are left to judge of their state by the nature and general course of the symp- toms. According to my experience, the mere wasting of the body, notwithstanding the reception of nourish- ment, without other marked symptoms, frequently arises from failure of power in the nervous system; and what has been laid before the reader respecting the functions of that system leaves him at no loss to under- stand why this failure should be attended with such a result. But when, with wasting of the body, we find the liver and other larger abdominal glands enlarged and indurated, we often find, on dissection, that the mesen- teric glands are in a greater or less degree affected in the same way, particularly if at the same time there is a greater than usual protuberance of the central parts of the belly, and a greater than usual feeling of firm- ness given to the hand by those parts. When a gene- ral wasting of the body occurs in scrofulous subjects, particularly in children with scrofulous enlargements of the glands in the neck and other external parts, we also have reason to ascribe the wasting to an obstruc- tion of these glands. They may be, and sometimes are, affected, when we can discover nothing wrong from manual examination of the abdomen or other parts; but in this case we have no means of ascertaining that it is so, and many reasons for suspecting that a debilitated state of the nervous functions is the real cause of the wasting. Debility of these functions, indeed, as the reader is prepared to believe from the facts that have been laid before him, appears often to be the cause of a general tendency 152 CHANGE OF STRUCTURE to glandular indurations; and we may be assured that such is its origin if the debility has lasted for some time before this tendency appears. It has been supposed by some respecting obstruction of the mesenteric glands as respecting tubercles of the lungs, that it is an incurable disease; but I believe there are few physicians, who have been much engaged in practice, who have not seen instances of its perfect cure, when its existence had been unequivocally proved by these glands having acquired such a size as to be dis- tinctly felt through the integuments. In a case I have already had occasion to mention, where, after some gallons of water had been drawn off, the whole flaccid and emaciated abdomen felt like a cluster of grapes, the event was favourable, and the patient, who was at the time about thirteen years of age, became one of the stoutest and healthiest young men I have known. This is an extreme case, and the event such as we cannot always look for; but I have seen many cases of the same kind, particularly in still earlier childhood, where the result was equally favourable. It is by no means very uncommon to see young children reduced to the last degree of emaciation, with yellow, shrivelled, and parched skins hanging loose on them, and counte- nances, from their wrinkles and a constant expression of anxiety, assuming the character of the most advanc- ed age, with general tendency to glandular obstruction both of the surface and abdomen, restored to health and vigour by a long-continued gentle alterative course of medicine. But I have almost always observed that, in the cases in which it is about to be successful, its good effects soon begin to appear. If some weeks pass without evident amendment, the case will probably prove fatal, especially if a tendency to affection of the lungs has appeared, although even to this observation I have re- IN THE ABDOMINAL VISCERA. 153 peatedly seen exceptions. As far as I am able to judge, the most common cause of failure is a languid action of the absorbents preventing the absorption of the medicines; for, when they failed to do good, they have generally appeared, particularly in children, to have little effect of any kind. Organic disease of the uterus is by no means unfre- quent. Of this disease there are so many means of judging, that it is hardly possible to be deceived re- specting either its existence or its nature. I have seen it implicated in the general tendency to organic dis- ease, which, from the debilitated state of the nervous functions, sometimes supervenes in the second stage of indigestion, where it has been severe and long pro- tracted. Of the functional derangement of the uterus which, amongst its other evils, disposes to organic dis- ease of this organ, I shall have occasion to speak par- ticularly on more than one occasion in the following part of this treatise; but it is nOt^my intention to enter farther on its diseases than their connection with those of the general system or other organs leads me, be- cause there is a class of medical men, many of them of great science and talents, whose attention is more par- ticularly directed to them. Nor shall I enter on the organic diseases of the urinary organs, and the symptoms which particularly indicate a tendency to them, although their importance, especially in the latter part of life, may well secure for them our most considerate attention, because Dr. Prout has, in the present state of our knowledge, left nothing for others to do on this subject; and has thrown a de- gree of light upon it, for which neither the members of our profession nor society at large can too strongly express their obligation. To his works I refer the reader. 20 PART II. OF THE MEANS OF CORRECTING THE STATES WHICH PRECEDE ORGANIC DISEASE AND COUNTERACTING THEIR EFFECTS. It appears, from all that has been laid before the reader, that organic disease is always preceded by per- manent disorder of function, and permanent disorder of function by that which is occasional. The subject of the present part of the treatise, therefore, divides itself into three heads:—the means of preventing occasional being changed into permanent disorder of function; those of preventing permanent disorder of function pro- ducing change of structure; and, when change of structure has taken place, the means of correcting it or retarding its progress. We have also seen that when the quantity of the circulating fluids is too great in proportion to the powers of the system, and the properties of the blood, as necessarily happens as well from the causes which produce this state as from its continuance, vitiated, a general tendency to derangement of function is the consequence, and, therefore, that a state of plethora may be regarded as a predisposing cause of chronic functional derangement in particular organs. Acute disease is a still more fruitful source of such derangement. I shall, therefore, before entering on the treatment of the functional derangement of particular organs, make some observations on the means of correcting a plethoric state of the habit, and on the principles of OF THE TREATMENT OF PLETHORA. 155 treatment in acute disease, which tend to prevent the establishment of chronic derangement. We shall then consider the treatment of chronic derangements of particular organs, whether occasional or permanent, in the same order in which their symptoms have been considered; and the treatise will conclude with some observations on the means to be employed when or- ganic disease is actually established in whatever part. CHAP. I. Of the Treatment of Plethora. From what was said of the states of inanition and plethora, it appeared that the former is either the consequence of other diseases or of a privation of due nourishment, and seldom continues long after its causes are removed. It is unnecessary, therefore, to say much of its treatment. If the privation of nourishment has been great, its increase must be gradual, lest the weak- ened powers of the system be overcome by a greater supply than they can digest and distribute. When the state of inanition has been the effect of previous dis- ease, the powers of the system should be supported by such means as shall not tend to a renewal of that dis- ease, till the constitution has regained its usual powers. The state of plethora, we found, is both more obsti- nate and more apt to produce other diseases; its treat- ment, therefore, requires more attention. We here enjoy two great advantages constantly aimed at, but seldom to the same degree obtained,—those of both seeing clearly the nature and tendency of the disease, and the manner in which our remedies operate. The causes of the disease have either afforded too great a supply of the materials from which the blood is 156 OF THE TREATMENT formed, or too much lessened the customary discharges, whether natural or artificial; for such is the power of habit, that the failure of the latter, if they have con- tinued for a certain length of time, is not only as cer- tainly felt as that of the former, but, from their acting more partially, often produces worse effects; for we still find, that the more general the disease is, the less is to be apprehended from it. It is when the whole power of the offending cause is centred in some organ essential to life, that its effects are both most rapid and most fatal. We have found in all the preceding observations on the nature and causes of disease, that the risk is gene- rally proportioned to the determination of the symptoms to particular parts. Even in fever, which is the only acute disease affecting equally every part of the system, although dissection assures us that it sometimes proves fatal by its general effects alone, the danger is usually proportioned to its tendency to affect particular organs. Such are the principles on which the treatment of plethora must be founded. Our objects are to restore the due proportion between the quantity of the circulat- ing fluids and the powers of the system, and while this is being done to give the temporary support which the oppressed powers of the system demand, and particu- larly to prevent failure in any organ of life, which, from a fault in the constitution or some peculiarity in the oc- casional causes, most feels the general derangement. It would appear, at first view, that, as the disease consists in the quantity of blood being greater than in due proportion to the powers of the system, blood-let- ting would be the appropriate remedy, and from it the patient generally experiences immediate relief. But in diseases of continuance we must look rather to the permanent than immediate effects of our plans of treat- OF PLETHORA. 157 ment; and I have already had occasion to explain why they have here been found to add to the evil. The effects of the causes of plethora are considerably modified by the state of the patient at the time they are applied. For the same reason that blood-letting at stated periods tends to produce plethora, all other causes lessening the action of the excreting organs are unfavourable. One of the most powerful is a state of inanition. When the quantity of the circulating fluids is in too small proportion, the action of these organs is necessarily lessened. Hence, one reason of the causes of plethora being so powerful in producing disease, if they are applied after a defective supply of nourish- ment, or any other cause too much reducing the quan- tity of the circulating fluids. As might a priori be supposed from the nature of the circulation in the liver, that of its function and its extensive sympathies, a plethoric state of the system is generally much felt in this organ, and in women, par- ticularly from fifteen to five and twenty, in the uterine vessels, by which the system is relieved from its natural periodical tendency to plethora. The functions of the liver and uterus, therefore, particularly demand atten- tion here. The liver is not merely (as some have supposed) an excreting organ, nor is the only office of the bile that of regulating the action of the bowels: its presence appears to be necessary to the due conversion of the food. Mr. Brodie* has shown that, when it is prevented from en- tering the bowels, the fluid which results from the ope- ration of the secreted fluids of the digestive organs on the food, and is absorbed from the intestines for the purposes of nourishment, is never duly formed, and cannot, therefore, possess the nutritive qualities neces- sary to maintain a healthy state of the functions. * The fourteenth volume of the Journal of Science, &c. 158 OF THE TREATMENT The foregoing circumstances point out the impor- tance of derangement of the liver, of the effects of which I shall soon have occasion to speak more parti- cularly. But the state of the more extensive excreting sur- faces, the skin and the bowels, most immediately in- fluence the state of the blood. Diaphoretics, of which antimonials are the best, and purgatives may be used with great freedom, and are generally well borne, and it is proper, especially when the biliary secretion is much disordered, occasionally to employ a mercurial purgative, a few grains of calomel given at bedtime and carried off by an active aperient on the following morning. When the uterine secretion fails the purga- tive should be such as acts particularly on the lower bowels, which, from their vicinity, greatly sympathise with the uterus. It generally happens that the same means which ex- cite the bowels also excite the kidneys. Such, indeed, is the sympathy of the various excreting organs, that the excitement of any one tends to that of all the others. These, as well as other, means must be proportioned to the degree of the disease and the state of the patient; and when the first beginnings are watched they seldom require to be carried far, but, even in the most recent case, must be continued for some time, and only gra- dually and in proportion as the tendency to the disease admits of, laid aside. The effect of medicine in the excitement of the se- creting surfaces is greatly aided by due exercise in the open air, to which the patient is often much disinclined, and there is no mode of excercise equal to walking. It is that for which nature designed us, and is the only one which equally excites the functions, because it OF PLETHORA. 159 equally supports the circulation in every part of the system. Riding, driving, and sailing, from their enabling, the patient to be longer in exercise and the open air than walking alone admits of, and their effects on particular parts of the system, are good additions; but they must never be allowed to come in place of walking, which should only be limited by the ability of the patient: all approach to fatigue, however,—that is, to such a state as is not almost immediately relieved by rest,—is in- jurious. Here, and in all other functional disease, the most valuable principle is not to wait till the derangement has become permanent. We have seen that perma- nent derangement of function is always preceded by such as is occasional. In the case before us the patient has occasional fits of languor and depression before the disease is established. It is then that our practice is easily and quickly successful, and the patient is both well able to bear the remedies and to assist us by his own exertions. The object is, by a proper treatment in the intervals, to prevent the recurrence of the symp- toms, by which much suffering and wear of the con- stitution are prevented, to say nothing of the risk of other evils. In the regulation of the diet there is often great trouble: the feeling of weakness prompts the patient to eat unnecessarily, which doubly injures him, by tend- ing still to increase the quantity of the circulating fluids, already beyond his powers, and oppress the digestive organs, which, in plethoric states of the system, are always more or less debilitated, and whose oppression, in consequence of their extensive sympathies, adds to all the evils. If the patient will not submit to the ne- cessary abstinence, the less nutritious articles of food 160 OF THE TREATMENT may be chosen; but it unfortunately happens that they are for the most part least digestible. Fermented liquors of all kinds are particularly inju- rious in states of plethora, and the feelings of debility often urge the patient to too free a use of them: they should only be allowed in such proportion as his pre- vious habits render unavoidable. It is often of great use, when the strength and the state of the stomach bear it well, to abstain from animal food for two days in the week, especially when a tendency to feverish- ness, that is, to some increase of heat in the evenings, particularly in the hands and feet, has supervened. We have seen that plethora and the inflammatory tendency, although very different states, are from their nature allied. It is this circumstance which renders the choice of medicines for the purpose of supporting the strength a point of considerable difficulty. The effects of the more purely stimulant are transitory, and what are called tonics are generally found too inflam- matory. Even the patient's feelings are usually such as prevents their continued use, and in some cases, where the inflammatory tendency is more prevalent than usual, actual refrigerants, particularly the effer- vescing saline draught and nitrate of potash given in a considerable portion of water with a little mucilage, are both grateful and beneficial; but the debilitated state of the functions generally limits their use, and they are only proper as far as the inflammatory symptoms tend more to debilitate than the means which relieve them. Of stimulants, I have found ammonia the best. The transitory nature of its effects is more than compensat- ed by the freedom with which it may be repeated, and its having no tendency to increase the plethora, which is the case with all spirituous medicines, although the state of the stomach often renders their use in a very limited degree proper. OF PLETHORA. 161 It may be observed, however, of ammonia, as of all other stimulants, that its use must be confined within the limits at which it produces a sensible increase of temperature; and there are some constitutions so sen- sible to every thing having this tendency, that such medicines are almost wholly precluded. The treatment of plethora, then, where it arises from its mogt frequent cause, a gradual failure of power in the excreting vessels, and is unaccompanied by local determinations, may be comprised in a few words; and, from whatever cause it arises, as this state of those ves- sels always attends it, the same principles are applica- ble in all other cases. We must excite the debilitated excreting surfaces, proportion the nourishment receiv- ed to the diminished discharges of the system, and support the strength under the effects of the disease and restricted diet, by such means as shall neither in- crease the plethora nor the inflammatory tendency that always, in a greater or less degree, attends it. When the failure of the excreting vessels is the con- sequence of a more inactive life or fuller diet than usual, the attention must be particularly directed to the parts of the treatment which most directly tend to ob- viate these causes. But great and sudden changes should never be attempted. To them, the debilitated state of the functions is ill suited. The change must be gradual, and the state of the strength always care- fully considered. Obstruction of the uterine secretion is a frequent cause of plethora in young women, and of many of its evils; to some of which, from the sympathies of the uterus, it particularly disposes. The states of health thus induced are easily understood from what has been said of plethora, and the sympathies of the vital organs. 21 162 OF THE TREATMENT In this case, the great object is to restore the regular return of the uterine secretion. I have already had occasion to refer to the kind of purgatives most bene- ficial; which, at the same time that they tend to correct the plethoric habit, tend^ by their local operation, more directly to relieve the obstruction. All the means of determining the blood to the lower parts of the body, immersing the legs in hot water, the warm hip-bath, &lc. at proper times, are often beneficial; but the most effectual are medicines of a tonic nature, which appear to act by giving vigour to the extreme vessels. Combinations of iron and aromatics, of which myrrh is one of the best, are the most powerful; but where a general inflammatory tendency, or a tendency to par- ticular affection of any vital organ has supervened, the use of such medicines requires caution; if they do not soon produce the desired effect, they may aggravate the evil. They should only be continued when, by cooling medicines and proper local means, such tenden- cies can be corrected. Whatever other means are employed, they must be combined with more or less of the proper treatment of plethora, according to the degree in which its symp- toms prevail; and in many cases these means are suffi- cient without the tonic. Whether tonics have been employed or not, I would, particularly in the case be- fore us, urge the necessity of the early use of such means as correct the determination of the symptoms to particular organs. That to the brain and lungs in uterine obstruction is the most frequent. The former, if not corrected, soon becomes obstinate; and the latter, if there be any predisposition to pulmonary affection, runs immediately into danger. It appears, from all that has been said, that of the various effects of pletho- ra, the determination to particular organs is that which most calls for decisive measures. It is the commence- OF PLETHORA. 163 ment of almost all its more serious consequences. Their proper treatment will appear from what I am about to say of that of the derangements of the differ- ent vital organs. The plethora which arises from the failure of the uterine secretion at the time of life at which it natural- ly ceases, must be treated as a case of simple plethora, without any of the means which determine to the uterus. The bad effects of this change often arise from too sedentary habits. In the plethora which follows the drying up of old sores or issues, the disappearance of long-continued eruptions, &c, if other means do not soon succeed, an artificial discharge is the appropriate remedy. CHAP. II. On the Principles of Treatment in Acute Diseases which tend to counteract their Tendency to be followed by Chronic Derangement. The objects of the present treatise,—the prevention and cure of those chronic derangements which lead to change of structure,—are to be obtained, on the one hand, by calling the attention to the first beginnings of disease; those slight symptoms, which, in the midst of diseases apparently of greater consequence, are over- looked till they produce effects which often at once force themselves on the attention, and assure us that no attention can then avail: and, on the other, by so regulating the treatment in the more acute attacks of disease as shall, as much as possible, obviate their ten- dency to produce permanent debility of some vital part. The more quickly acute diseases can be relieved, and with the less loss of strength, the less likely they are to lay the foundation of chronic derangements. The point of greatest importance in their treatment, therefore, and it is also that of greatest difficulty, is, in the first instance, to judge of the extent of the means required to relieve them; that we may neither unneces- sarily reduce the strength, nor, by the feebleness of the means employed, allow the diseased state to be unnecessarily protracted. The most decided treatment is the best; but, in pro- portion to its power, must be the caution which deter- mines upon and regulates it. We must be influenced by carefully considering the following circumstances:— PRINCIPLES OF TREATMENT, &C. 165 The nature and severity of the symptoms, the strength and habit of the patient, his former diseases, particu- larly the course of former attacks of the same disease or similar ones if such have occurred; we must inquire whether the disease has arisen from one or more causes, and what the nature of its cause or causes is; observe whether one or more parts are affected; con- sider the nature of the. part or parts affected; observe whether, in the course of the disease, any new deter- minations to particular parts show themselves; and, lastly, what are the effects of the means employed. With respect to the nature and severity of the symp- toms: the greater the degree of the fever, and, where the disease is of a local nature, the more the functions of the part are deranged, the more immediately neces- sary to life the organ chiefly affected is and the more powerful and general its sympathies, the more vigorous our treatment should be. The more suddenly, too, that the symptoms have assumed a formidable aspect, it should be the more vigorous, because, by the rapidi- ty as well as the degree of the disease, we judge both of the power of the cause, and of the course the symp- toms will probably take. Much depends on the constitution, habits, and pre- vious diseases of the patient, and not less on the nature of the causes which have produced the present attack. Those of a firm fibre bear all debilitating measures better than those of a more relaxed habit, who, besides, disinclined to powerful exertions either of mind or body, generally lead an indolent life. It is remarkable that, in proportion as either the mind or body is incapable of exercise, it feels the want of it less. In painful diseases, which generally pre- clude exercise, the suffering of the invalid supplies its place: we often see those labouring under such diseases maintain a state of general health that would be quite 166 PRINCIPLES OF TREATMENT incompatible with the life they lead, were they free from suffering: and even when the only suffering is in- ability, inactivity does not produce the same effect as in more vigorous states of body. This is still more remarkably the case with respect to the mind: the in- activity of an inactive mind never injures the health. The more, of course, the powers of the constitution have been broken by excess of any kind, the less the patient is capable of bearing debilitating measures. The same may be said of his distance, either way, from the most vigorous period of life. Infancy and age are both unfavourable. The previous state of health, however, even more than the habit and age, influence the effect of our measures in acute diseases. I have already had occa- sion to point out the circumstances which make the plethoric bear blood-letting ill, and the reader will per- ceive that some of the observations made upon this subject are applicable to other debilitating measures. The general failure of power which always attends plethora, is a bad preparation for either acute disease or the.means of relieving it. The same observation applies to all chronic diseases, which impair the strength, or acute attacks, after which the patient has not had sufficient time to recover it. There is this difference, however, between these states,—while in the latter the debility is apparent, and we can form a pretty correct estimate of what the pa- tient can bear, nothing is more difficult than to make this estimate in the former. He often appears to be enjoying tolerable health and vigour, yet sinks rapidly under acute disease, and the plans of treatment suited to it. The power of some vital organ has been impair- ed, and although it is still capable of its function under ordinary circumstances, and while the vigour of other vital parts is nearly entire, it severely feels the strain IN ACUTE DISEASES. 167 of any additional call upon its powers; and the failure of one vital organ necessarily leads to that of all the rest.(34) It is thus that those who have long laboured under chronic disease bear powerful measures ill, and often sink rapidly under acute attacks; and, not unfrequently, when the chronic disease has been of an obscure na- ture, in a way that even the medical attendant is not prepared for. On the contrary, previous attacks of acute disease, especially of the same nature as that present or affecting the same parts, if the patient in the intervals has enjoyed good health, with perfect recovery of strength and spirits, is in favour of vigorous mea- sures, because we then have reason to believe that the constitution is sound, and that there is a great proba- bility of the present disease proving both severe and obstinate. With regard to the cause of -the disease, the more simple and sudden it has been, the better in general the patient bears the means of relief. When different causes have conspired, especially if some of them have been of a chronic nature, for some time affecting certain (34) These remarks on the condition produced by the supervention of acute disease upon chronic organic derangement, are of inestimable value, and cannot be kept too constantly before the mind of the practitioner. There is perhaps no point in practice more essential than to determine the complicated existence of acute and chronic affections: because if the case is simply acute, we unhesitatingly adopt the most prompt and energetic mea- sures; but if, on the contrary, there should lurk under the acute symptoms an occult structural lesion, we should hesitate, feel our way, and proceed with the utmost caution, lest we overstrain the enfeebled organ and bring out into overt disease, disabilities which might have remained harmless. The young and unwary, solicitous to achieve a rapid conquest over disease, in their ardour to compass their designs by a coup de main, forget that there may be other enemies in ambuscade, or that there may be mines ready to explode at every instant, hurry on at every risk, and inevitably precipi- tate ruin and destruction. We must never lay as heavy hands upon the acute diseases of valetudinarians, as we are compelled to inflict upon the same amount and form in those of previously unimpaired constitution. 1 168 PRINCIPLES OF TREATMENT organs and constantly renewing in them some degree of temporary derangement, the effect is similar to that of the previous establishment of chronic disease; and different causes making their impressian on different parts of the constitution, the debilitated parts, in conse- quence of the sympathy which exists between them, tend to aggravate and render more obstinate the affec- tion of each other. If, for example, a person of healthy constitution and regular life, in consequence of taking cold, is seized with inflammation of the lungs, we take blood from him freely, he bears the remedy well, and his disease is soon subdued. But if he has had frequent bilious attacks from occasional intemperance, the depressing passions, or any other cause, the effect of the cold is modified by these causes. Such a predisposition is given to derangement of the liver that the cold, along with the inflammation of the lungs, occasions more or less of an inflammatory state of that organ also, and we find the course of the disease considerably altered. The patient neither bears the bleeding so well, nor does it produce the same quick and decided effects in relieving the lungs. The inflammatory state of the liver, although less severe^ will prove more obstinate than that of the lungs. It will show a greater tenden-j cy to run into a chronic state, and till it is relieved, the inflammation of the lungs, however for the time sub- dued, will have a constant disposition to return; and, in most instances, will not finally be subdued till, by the combination of alterative medicines with the evacu- ating plan, we have restored the liver. Thus the inflammatory state of the lungs is not only more pro- tracted, but it is altered in its nature by its association with that of the liver. It assumes a more chronic ten- dency, and on both accounts is more apt to run into disease of structure. Many other instances of the same IN ACUTE DISEASES. 169 kind, familiar to those who have been long conversant with disease, might be adduced. When the disease arises from more than one cause, but all affecting the same organ alone, although we have not the morbid sympathy to contend with, we have another evil which produces similar effects. In the preceding case, if the effects of the cold had been wholly confined to the liver, weakened by the operation of the previous causes, we should have had a disease that would neither bear the remedies so well, nor yield to them so readily, as if it had been the effect of the cold alone. It would then have found both the organ itself, and the general constitution, better able to resist it. The more the cause or causes of the disease, like its symptoms, partake of a chronic nature, the less able the patient is to bear active treatment, and, it fortunate- ly happens, the less in general he requires it. The symptoms necessarily partake of the nature of the cause, and the same is true of the treatment suited to them. The nature of the part affected is also to be consi- dered. To return to the same illustration, the languid nature of the circulation in the liver, and its greater tendency to chronic disease, render a less active treat- ment proper in inflammation of this organ than in that of the lungs: here we can do more by local, and, there- fore, ought to do less by general, blood-letting. When local can be substituted for general blood-letting, we gain, because less than half the loss of blood answers the purpose. It appears from what I have said of these remedies, that general blood-letting is the appropriate remedy in the early, and local in the advanced stages,—not that any general rule can be laid down—we must be guided by circumstances. The peculiar effect of the former is 22 170 PRINCIPLES OF TREATMENT to reduce the force with which the blood is thrown into the debilitated vessels in inflammation, still further tending to distend them; of the latter, directly to re- lieve the vessels from the load that distends them. The continuance of the disease and the remedies of its early periods, always, more or less, subdue the general force of the circulation; and, as the disease ad- vances, the debilitated vessels, partaking of the general state, become less and less capable of expelling the superfluous blood; for blood-letting is vain, if the relief thus given does not enable the vessels of the inflamed part in a greater or less degree to expel the load that oppresses them. The effects of general blood-letting are more quickly apparent, and, consequently, more gratifying to the physician; for, while its immediate effect is often very great, and its whole effect is generally felt in a few hours, the immediate effect of local blood-letting, although also felt at the time, is rarely felt to the same degree, and its full effect cannot be judged of sooner than about twenty-four hours. Whether it be from this cause, or to save the patient trouble, I should feel no hesitation in saying, from all I have seen of the treatment of disease, that general blood-letting is em- ployed too much, and local blood-letting too little, in acute diseases. It is certainly of consequence to save trouble to the patient, but, especially in protracted cases, of much greater to save his strength. I have seen fatal organic diseases supervene after internal in- flammations, wholly removed by general blood-letting; when the latter part of the treatment would, in every respect, have been more beneficially conducted, had the blood-letting been chiefly local. I am also persuaded that the combination of general and local blood-letting should be more frequent than it is. They answer different purposes, and eminently IN ACUTE DISEASES. 171 assist each other. It is a bad rule to have recourse to the latter only when the former fails, or the patient is no longer able to bear it. Thus much of the good effects of both is often lost. We must carefully observe whether a new determi- nation to any particular part shows itself in the course of the disease, that measures may be immediately adopted to check it. Determinations to particular or- gans I shall have occasion to consider in the following chapters, and shall only observe here, that they are particularly apt to supervene in acute disease; both the excited state of the circulation and the causes of irrita- tion existing in the chief seat of the disease, if it be of a local nature, by its sympathy with other parts, give a strong predisposition to them; and when they occur under such circumstances, they are always of an in- flammatory nature, and greatly influence the course of the original disease. As in all other cases, they acquire force by continuance; and it is of great consequence, in the treatment of acute diseases, to watch the first ten- dency to them. The last of the circumstances which were mentioned as of importance in determining our practice, is the effects of the means already employed: and those who know little of the imperfections of our art can have no idea of its importance. With all the skill and experi- ence of the best physician, and all the information he can obtain, it is seldom that he can say exactly what the effects of his remedy will be. When the effects are actually seen, he is either confirmed in his first opinion, or enabled to form a more correct one. They at once inform him of the degree in which the disease is obstinate; that in which the patient can bear the means of cure, and that in which the means are suited to the case: and they have the pre-eminent advantage 172 PRINCIPLES OF TREATMENT over all his other means of judging, that they are the only ones which cannot deceive him. The effects of the means employed, therefore, must be carefully watched: and, if we are making a greater impression on the strength than on the disease, we are either pursuing an erroneous plan, or the patient has not sufficient strength to carry him through his com- plaint. If not even temporary relief be obtained, the means employed are not suited to the case; if we ob- tain temporary relief from our measures, we shall succeed better by a less powerful application of them. In the treatment, whether of acute or chronic dis- ease, nothing is to be guarded against with more care than a great reduction of the strength. With the strength the healing powers of the constitution fail, on which depend the success of all our means; and it is only the alternative of a probably fatal termination which should induce us to risk a great reduction of them. We must never forget that the part to which our remedies are directed, is a part of the whole, and that its state will be as much influenced by the general state of the constitution, as by the effects of our reme- dies. This maxim is weA illustrated by the course of inflammation under different circumstances. White the constitution is vigorous, blood-letting,— especially if the inflammation be seated in an organ essential to life, in which case the powers of the con- stitution always make the greatest effort to relieve it,— generally has an immediate effect. Before the arm is bound up, and even while the blood is flowing, the symptoms often abate, and sometimes for the time disappear. In proportion as they continue to recur, the relief becomes less immediate, and the vessels of the inflam- ed part regain the healthy diameter with more difficul- ty. We at length find it necessary, in order to enable IN ACUTE DISEASES. 173 them to contract, to unload those vessels in particular, by local blood-letting; for, although we do not actually, by this means, except in external inflammation, unload the vessels of the part, we unload those in their neigh- bourhood; and, by the sympathy of all neighbouring parts, the internal partake of the contracted state of the external vessels. If still the disease recurs, this sympathy begins to fail with the other powers of the constitution, and local blood-letting, in the same pro- portion, fails to influence the seat of the disease. In such cases, blistering, and other rubefacients, which stimulate the vessels of the surface, and, through them, the more internal ones, again assist us; and, in protracted cases, we often succeed by such means, when local blood-letting has, in a great degree, lost its power. But as we ought not to defer local till general blood-letting begins to fail, so blistering ought not to be deferred till local blood-letting begins to lose its effect. When these means, properly supported by medicine, fail, our remedies are at an end, and the exhausted patient is necessarily left to his fate. Whether he has had a good or bad chance of recovery,—whether the most has been made of his constitutional powers, depends on the judgment with which our means have been employed, the care with which his strength has been saved without allowing too great a recurrence of the symptoms, and the judgment which has adapted the means to the perpetually changing state both of the patient and the disease. On the principle on which blisters are employed, a severer practice has sometimes been adopted, where other means had failed, and, it is said, occasionally with success; that of producing a sudden and exten- sive vesication of the surface by the application of scalding water. The suffering it causes is necessarily 174 PRINCIPLES OF TREATMENT, &C. extreme; and it is not likely that it will ever be em- ployed often enough to enable us to judge of its value and the circumstances which should regulate its appli- cation. Although we cannot with respect to all our remedies trace the steps so distinctly as in the case of blood- letting, in all instances the healing powers equally sink with the strength. If we thus duly consider the whole of the circum- stances of the case, adopt no debilitating measures which they do not render necessary, choose the least debilitating means, and, by a proper combination render our plans as speedily effectual as the state of the patient admits of, watching, and, as far as we can, counteracting any tendency to local determinations, we have only to support the patient's powers by all the means compatible with the nature of his disease, to give him the best chance of a favourable issue. No more can be done to prevent acute laying the founda- tion of chronic disease. CHAP. III. Of the Treatment of the Functional Derangement of the Brain which precedes Change of Structure. We have just seen that a disposition to organic dis- ease may arise in two ways; that it may either be the consequence of the more acute forms of disease, or of causes operating more slowly, and imperceptibly under- mining the power of the vital organs. In our endea- vours to prevent organic disease of the brain, the prin- ciples laid down in the preceding chapter are applicable to its more acute attacks: we are now to consider those on which the treatment must be founded, when its structure is threatened more insidiously, the preceding symptoms bearing the character of what are called nervous complaints, the diagnosis and serious tendency of which I have endeavoured to point out. The brain, it has appeared, is capable of influencing, and being influenced by, every other part. A general failure of the various functions, therefore, although ex- isting in a slight degree in each part, and consequently ' producing little derangement in any one, may indicate considerable derangement in the brain, which feels the whole; and to this the obstinacy and insidious nature of certain affections tending to derange the structure of this organ, may, in a great measure, be ascribed. They betray themselves by no very marked derange- ment of any of the functions, but each derangement tends to confirm the effects of the others. 176 TREATMENT OF FUNCTIONAL The reader has also seen that, as the derangement is formidable rather from its extent than from the degree in which any one part suffers, there is little room for powerful measures; and, as it is habitual, little chance of advantage from any which cannot be em- ployed for a considerable length of time. The diseas- ed state, being an habitual one, requires an habitual remedy. In the cure of all diseases, the object is to restore the healthy functions of the parts concerned: it is only in proportion as this is effected that the disease is reliev- ed. Now, the functions that are disturbed in the present case are, on the one hand, the functions of life, the assimilating and secreting functions throughout the whole system; and, on the other hand, the no less vari- ed functions by which we are connected with the world around us. If the appetite is not impaired, which is frequently the case, the digestion and assimilation of the food, and the due purging of the circulating fluids, are never perfect; the patient becomes languid, and sallow, and gradually, however slowly, loses his flesh, or becomes bloated, according as the organs of supply, or those of waste, are most debilitated. In either case, our object is to excite both to the due performance of their func- tions, and all the means which tend to this effect tend also to restore the due functions of the brain, from the failure of which the disorder arises, and through which alone the favourable change can be effected. The objects are, to soften the skin, which is gene- rally dry, sometimes parched; or brace it, if relaxed, which is more rarely the case, but is equally a symp- tom of impaired vigour; to restore the healthy action of the thoracic and abdominal viscera; for an attentive observer in all such cases will perceive more or less tendency to derangement in their functions; and to DERANGEMENT OF THE ERAIN. 177 soothe the feelings, divert the attention, and, within certain limits, to excite the mental energies,—for the voluntary powers are impaired, and the mind anxious, unsteady, and incapable of its usual exertions. Such, we have seen, are the symptoms of disordered function of the brain, which, as in the case of all other instan- ces of disordered function long continued, is apt to terminate in disordered structure. Cases of this kind, it appeared, have been confound- ed with mere nervous complaints, which they so much resemble, but which, proceeding from the derangement of other parts only affect the brain secondarily and in a more variable manner, and on both these accounts are less apt to lead to change of structure; the risk of which is always better measured by the uniformity than the severity of the symptoms. Every remission gained is a step towards a cure; for it is the perma- nency of the fault which leads to evil. From the case before us having been confounded with what is called nervous complaints, no appropriate treatment has been attempted in it; and thus it is that it so frequently ends in a fatal disease. I could adduce many cases of this kind, in which the means I am about to point out have succeeded in restoring the patient to permanent health, when all others employed for years had failed; and when there was every reason to believe that organic disease of the brain must other- wise have ensued. The first object in the treatment of all diseases is to remove the occasional causes, and prevent their re-ap- plication. It is here necessary, therefore, as much as possible, to divert the mind of the patient from his sufferings. The most powerful means are change of scene, and such occupations as amuse without fatiguing the mind; the conversation of friends, which inspires hope, without treating too lightly the patient's suffer- 23 178 TREATMENT OF FUNCTIONAL ings, which always irritates, I have known of great use.(35) Such means, however, if trusted to alone, as I have often witnessed, will fail, except in the most favourable cases, and where they can be employed to their great- est extent. This can only be done by foreign travel- ling, which from the power both of novelty and variety, is best calculated to counteract the effects of former impressions. It should be continued for a great length of time, with all the requisites for rendering it amus- ing, and preventing harassment and fatigue: but much will depend on the disposition of the patient; for such causes act differently on different minds. If it have no tendency to soothe and amuse, it will fail; and, if the thousand little and unavoidable inconveniences of such a course produce discomfort and irritation, do harm. The great objects in the prevention of organic dis- ease are to restore and support the natural functions of the part. Any means which produce cheerfulness will do more or less good. If the morbid state of mind is not relieved, that is, if one, and that no unimportant set of the functions of the brain, are not brought more or less into a more natural state, no good will arise; if they are led further from it, nothing but evil. Similar observations may be made on every thing else relating to the feelings, which, in a disease of the organ of feel- ing, must always form an essential part of the treat- ment. But powerful as such means may be in certain instances, we should have little hope of frequent suc- cess, if we were not possessed of others both more powerful and more under command. It appears, from all that has been said, that the vari- ous digestive and assimilating processes, which are al- (35) Are not moral remedies most pertinent in the convalescent state, or after visceral derangement has bean removed or palliated by physical means, whether the case has originated from moral or physical causes? DERANGEMENT OF THE BRAIN. 179 ways in such cases the most important, because they are the most constant of the nervous functions, and therefore best indicate and most influence the state of the brain, are the results of changes going on in the extreme parts of the nervous and sanguiferous systems. It is in the capillary vessels and sentient extremities of the nerves, that all the great changes of our frame take place; it is there the vessels so distribute the blood as to expose it to the operation of the nervous power, and, consequently, it is there where this power effects all the chemical changes on which life depends; for these changes no less deserve that name, that the chemistry of the living animal is modified by its vital powers. In attempting to relieve the disease before us by me- dicines, then, we are not to look for such as powerfully affect any particular part, but gently affect the whole. And as the animal body cannot exist under an affection at once both general and powerful, it is not with a violent, but extended, deviation from health that we have to contend, and which, from the sympathy of the various parts, is obstinate in proportion as it is ex- tended. We possess two medicines, in large doses, capable of the most powerful effects on individual parts when given with a view to affect them; and in small doses, of the most gentle and universal operation when given with a view to affect the whole,—mercury and anti- mony. By these medicines, properly administered, we can, without any sensible effect, excite all the secreting surfaces, and often in the case before us, if it is not ren- dered obstinate either by the great length of time it has continued, or from its depending on a local cause over which we have no power, gradually restore the healthy state of the system, and, consequently, that of the functions of the brain, when all other means which our art affords have failed. I say this with confidence, 180 TREATMENT OF FUNCTIONAL because I have repeatedly seen them successful under such circumstances. Many circumstances must be attended to in their em- ployment, and other medicines occasionally had recourse to; for, although no other can be substituted for them, there are many which occasionally aid their effects. The first observation I shall make, because it is of greatest importance and most general application, is, that the quantities employed must be small, and so frequently administered as to keep the system constant- ly under their operation, observations still more appli- cable to mercury than to antimony, the latter, in very minute doses, appearing to have little effect. Those that have never seen their effects would smile at such doses as the eighth part of a grain of blue pill equal to the eightieth part of a grain of calomel; for, from all I have observed of the effect of these prepara- tions, it appears to me that, whether we use them as an alterative or as a purgative, one grain of calomel is equal in power to ten of blue pill; I say, such doses may excite a smile, but it is in those who are unac- quainted with both the nature of the disease and the effects of the medicine. I have had the satisfaction to see many, who supposed them wholly inert, change their opinion after having made a fair trial of them. They have this, at least, to recommend them, which is no small advantage, that they can do no harm.C36) (36) The last sentence of this paragraph must certainly be construed ironically; for the writer is too sound a philosopher to commit a solecism so glaring as the literal acceptation would imply. He must have intended a sneer at the nostrum venders, and expectant practitioners, whose highest boast is, that "if they do no good, they will do no harm," when the converse of the proposition only can be true, that if they are incapable of doing harm, they can never, in any contingency, do good. Medicinal agents must pro- duce some effect, which effect must consist in a change of action in some part of the system, and every change must be for better or worse. We ad- mit no neutrals; every agent must act for or against us. DERANGEMENT OF THE BRAIN. 181 Let such objectors recollect, that our view in the case before us is to restore the functions of the brain in a disease which is formidable, not from the degree in which any of them are deranged, but from their being all deranged, and constantly so. If any one particular set become more deranged than the rest, which we have seen in protracted cases is apt to happen, a more vigor- ous treatment, adapted to the greater derangement, must be resorted to, as far as the strength can bear it; but vigorous means, where no great degree of derange- ment exists, is the surest means of inducing it. The disease is mild in its symptoms, but constant and steady in its progress. The plan of treatment, which is opposed to it, must have the same characters. After the more severe states have commenced, our means must be proportioned to them, however little hope of relief may remain. In considering the mode of conducting such a course, I shall first point out those effects of the plan itself which oppose its beneficial operation, and then the causes, arising from the nature of the disease, which have the same tendency; for even this plan is not always free from inconveniences, and sometimes such as are not easily removed. On the other hand, the patient frequently ex- periences so great a degree of relief, even from its im- mediate effects, that, in many instances, it has been dif- ficult to prevent his employing it both more constantly Nor will his expressions admit of a qualified signification, conveying an idea that these minute doses are less liable to produce salivation, for all ex- perience proves the fact, which he impliedly concedes a few pages in ad- vance, that small repeated doses are more apt to stimulate the salivary or- gans than larger portions, which pass off rapidly by the bowels. Regarding the comparative merits of the blue pill and other mercurials in many nervous affections tending to mania, we are happy to add our expe- rience to the same scale; yet there are cases, and especially those compli- cated with torpor of the portal circulation, in which we would give a decided preference to calomel, alone or in combination. 182 TREATMENT OF FUNCTIONAL and more freely than I judged proper. Circumstances which are alone sufficient to prove that it is not nugatory. It sometimes happens that mercurial medicines, even in the smallest doses, irritate the bowels; and such is the injurious effect of this irritation, that, unless it can be allayed, the alterative, at whatever expense, must be abandoned, for the disease will bear no serious cause of continued irritation; and, in the use of opiates, we are greatly restricted; it is only in the smallest doses that they are admissible. The henbane is the best in the case before us; but, like the rest, is often not sufficiently powerful in any dose that is not injurious. If neither this nor any other opiate, in very small doses, will an- swer the purpose, we have no resource but still lessen- ing the dose of the alterative, and increasing the interval at which it is given; and if this plan will not leave such a dose as is still capable of making some impression on the disease, the medicine must be laid aside; and then, as far as I know, we have little more than antimonials and palliatives to trust to. The various means which relieve the more common nervous symptoms, although they have a certain effect, afford only very imperfect and temporary relief/37) (37) Doubtless there are cases of disease of the brain in which opium is interdicted, and others in which it must be cautiously administered, yet there are some where the restrictions may with propriety be repealed. By quieting some irritations of the brain, it becomes a most essential agent. In combination with calomel to restrain catharsis, it at the same time allays the morbid irritability of the nerves of motion, softens down the angry pas- sions and excites the intellectual operations into lively and agreeable play, and thus restores a temporary equilibrium favourable to the resumption of healthy action. The calomel, in these instances, is not liable to bring on salivation, and it operates a modifying power over the opium; combined in proper proportion their joint effect is very different from that of either singly exhibited. The narcotics all act upon the nervous systems, but on different parts and in different modes. Some increase the functions on one set, whilst they paralyse those of other nerves. We may thus paralyse the nerves of motion, whilst we increase the power of those of sensation, and vice versa. Some DERANGEMENT OF THE BRAIN. I S3 I have mentioned the eighth part of a grain of blue pill, taken three times a day, as a dose often attended with very sensible good effects. I believe, in many con- stitutions, even smaller and less frequent doses may be of service. The largest quantity I ever give, with a view merely to its alterative effect, is half a grain of blue pill, three times a day, in chronic, and four times in acute dis- eases, and this only when the derangement particularly affects the liver. Under certain circumstances, and par- ticularly, as frequently happens, when acute diseases are attended with, and, in some degree, supported by, a dis- ordered state of the liver, I have found such an addition to the usual means, render them both more certainly and more quickly effectual. We sometimes, but not always, derive advantage, in irritation of the bowels from the alterative, by changing the blue pill for the hydrargyrum cum creta. This pre- paration is, 1 think, of about one half the strength of the blue pill; but it is by no means so effectual an alterative, whatever be the dose, being more apt to oppress the digestive organs. In the plan I am speaking of, the gums are never allowed to become affected. There is no occasion for so considerable an effect of the altera- tive; and any thing like salivation must always do harm, where all causes of irritation are particularly injurious. Many will be surprised, considering the smallness of the dose, to learn that it is necessary to guard against are confined in their influence to the cerebral, others to the automatic,. whilst others may extend to both systems. The latter class is not numerous. Most articles are circumscribed in their spheres, being generally limited not only to one system, but to parts of that system, and whilst they excite one' part, reduce the energies of other parts. There is, therefore, no general or universal stimulus; for what is a stimulus to one part of the system is a se- dative to another. Hence, then, opiates or narcotics may be employed to abstract morbid action from one part and transfer it to another which re- quires to be roused. 184 TREATMENT OF FUNCTIONAL such an effect; but it is more apt to take place than would easily be believed, by judging in this way; and some constitutions are susceptible of the effect of mer- cury to a degree that seems, at first view, incredible. I shall mention the two most remarkable cases I have met with, one illustrating each of these observations. I was requested to see a lady, whose apothecary informed me, that although her case was bilious, and other means had failed, he had been obliged to abstain from mercurial medicines, in consequence of only half a grain of blue pill, and that after she had been for some time recovered from the effects of former doses, having occasioned sali- vation. Finding that her mouth, at the time I saw her, had been well for some weeks, I advised him to repeat the mercurial, but still to lessen the dose. She took a quarter of a grain of blue pill on going to bed, and the next day was in a state of salivation. A lady came from a great distance to London, for the purpose, she said, of being salivated, which she had been told would cure her. For this purpose, she had taken in vain, in the country, very large quantities of mercury, much beyond the largest usually given in this climate. I saw no occa- sion for salivation, but directed for her, with other means, half a grain of blue pill three times a day. Her case did not require frequent visits; and, not being then so well acquainted with the effects of the plan, I thought, as the mouth had resisted such doses, no precautions respect- ing it were necessary; when, at one of my visits, after she had taken the mercurial for about a fortnight, I found her in a state of salivation. She soon left London, well; and I learned from her sister, who, two years after, was under my care, that she remained so. The rule I follow, is to direct a patient, when he feels the least uneasiness in eating a crust of bread, to dis- continue the pills for one or two days, which is gene- rally sufficient to remove it, or for whatever time is DERANGEMENT OF THE BRAIN. 185 necessary for this purpose; and I never have any trouble from this cause, except where, as in the case just men- tioned, the peculiar habit of the patient absolutely for- bids the use of the medicine, which is extremely rare: in most people, indeed, such a course may be continued for an unlimited time, without any effect of this kind. The cause of its sometimes producing a greater effect on the gums than where larger doses are given, is, I believe, that in certain constitutions the larger doses so excite some of the excretories, that they are immediately thrown off; and these organs relapsing into a state of in- activity, little impression is made upon the disease. It is to the general steady and gentle impression that the frequently-repeated small doses make, thus throughout the system supporting an excitement similar to the healthy action, that they owe an efficacy which sur- prises those who have not been accustomed to see their effects; and which, being supported for a certain length of time, is confirmed by habit, and at length goes on without the aid of the medicine. But I find it always a necessary precaution to lay aside the medicine gradu- ally; if it be done too suddenly, the inactivity of the sur- faces is apt to return. When the patient observes this precaution, and also recurs to the means for a few days when the symptoms show a tendency to return, the health is at length permanently established; and this hap- pens the sooner the more cautious he is to avoid the causes of return. The chief circumstances in the disease itself which oppose the beneficial operation of the alterative, are a great degree of general debility, induced by its continu- ance; the inflammatory tendency arising from the same cause; and the determination of the symptoms to par- ticular organs. As, of the two medicines which I have mentioned, mercury is by far the most effectual, and produces its 24 186 TREATMENT OF FUNCTIONAL effects in the smallest doses, experience has led me to trust more to it than to antimony. I shall point out the circumstances in which I have found it beneficial to call in the aid of the latter. Both because we have seen, that when the powers of the system are greatly debilitated the healing power fails with the rest, and because the operation of the remedy being that of exciting all the secreting surfaces, and, consequently, increasing the discharges from the system, it is often necessary at the same time to use medicines of a tonic nature; but a tight pulse and other inflammatory symptoms and determinations to particu- lar parts, generally much limit their employment. This is the most formidable difficulty we have to contend with; which always, as might be supposed, cceteris paribus, exists in the greatest degree in the most protracted cases. There are two different plans which tend to obviate it, one or other of which gene- rally succeeds; either that the tonics employed should be of that kind whose effects are transitory, and so fre- quently repeated as to compensate for this property, or that the more permanent tonics should be given for short intervals, according as the case admits of, for the most powerful can generally be borne for a few days; and this exhibition of them, from time to time, is often sufficient. When the tightness of the pulse begins to increase, and a tendency to increased heat, with the sense of oppression which attends it, to be experienced, the tonic must be discontinued, and resumed when these symptoms disappear. Peculiarity of constitution, and, perhaps, particular states of the disease, which it is difficult to detect, but whose effects soon become ap- parent, determines which of these plans we should pursue: we must watch their effects, and act according- DERANGEMENT OF THE BRAIN. 187 ly; but there are few instances in which the continued effects of a powerful tonic can be borne. I have already had occasion to observe, that of the tonics of more transitory effect, I have here found ammonia and its preparations the best; and it may be aided by the lighter bitters and less heating aromatics. In those cases where the general temperature is per- manently reduced, large doses of ammonia are particu- larly valuable. It is equally grateful to the stomach and the nerves; and, except as far as its continued use may tend to too alkalesceal a state of the system, little is to be apprehended from it. Of the more permanent tonics, iron and the bark are the best. Of the preparations of the latter, I have found the sulphate of quinine uniformly the best; in many cases, indeed, its guarded use is attended with the best effects, particularly where the debility is great, with little tendency to increased heat. Of the former, either the carbonate or the liquor ferri ammoniati of the London College are the best preparations in the case before us; but, in some instances, not only the more powerful, but even the most transitory tonics, cannot, in any dose, be taken without a tendency to heat and oppressive restlessness. When this is the case, nothing could be more injurious than their con- tinuance. An increase of the inflammatory, that is of the worst, tendency of the disease would be the con- sequence. In almost all cases where the tendency to increased heat is considerable, particularly if accompanied with pain of the head, the combination of an antimonial pre- paration with the alterative dose of the mercurial is beneficial. The tartrate of antimony has appeared to be the best preparation; but it must not be given in such doses as interfere with the appetite. If the stomach does not bear this preparation well, the sul- 188 TREATMENT OF FUNCTIONAL phuret of antimony is preferable. In all our plans, the chronic nature of the case must be kept in view; no means can be of service without being long continued; and, therefore, none which tend sensibly to reduce the strength. In most cases, I have experienced great advantage from combining the alterative with quieting medicine of some kind, except where there has been much ten- dency to pains of the head, or drowsiness; the latter 01 which rarely, the former rather more frequently at- tends. The henbane is generally found the best; I have given it in the dose of from one to two grains ol the extract with each alterative dose. When there is pain and tightness of the head, even without increased heat, which sometimes attend such cases, considerable advantage is often derived from combining with the other means the tartrate of antimo- ny, and occasionally increasing it till some degree of nausea is produced. In the occasional attacks of extreme nervous irrita- tion, the soothing effect of a combination of tartrate of antimony and henbane, given in the dose of two or three grains of the latter, and as much of the former as the stomach can bear without nausea, which is generally from the eighth to the fourth part of a grain, in the liquid form if its most immediate effect is required, will sometimes, for its effect is not equally beneficial in all cases, surprise those who have not seen it. I have often seen states of the greatest agitation allayed by it, sometimes in a few minutes, generally within half an hour after it is taken, which had wholly resisted all other means; and, if this effect does not take place within half an hour, the dose may be repeated till a degree of nausea comes on, which favours its compos- ing effect. In this way I have known composure ob- tained even in maniacal cases; but here, the dose of the DERANGEMENT OF THE BRAIN. 189 tartrate required to produce nausea is often that of several grains, and nausea is generally necessary to produce composure. In some cases, when the tonic is found to increase the tendency to heat and oppression, instead of laying it aside, it often happens that some of its good effects may still be obtained, and this tendency corrected, by combining it with cooling medicines. I have not, in general, found this plan to succeed well with the more powerful tonics; but with those whose effect is more transitory, it is so generally successful, that it is only where the sensibility to stimulants of every description is unusually great, that I have found it necessary wholly to lay them aside. I enter more fully into the particulars of the case be- fore us, because many of the principles of its treatment are applicable to a great variety of other cases. In all, the functions of the brain are concerned; and there are few chronic, and not many acute, cases, in which it is not necessary to regulate some part of the treatment by the same rules. Of cooling medicines, the saline draught is the most grateful, but the nitrate of potash the most effectual. Many of the observations I had occasion to make on the use of this medicine, in my Treatise on Indigestion, are applicable here. In the case before us, however, it is less frequently required, because the inflammatory tendency is neither so common nor considerable as in protracted cases of indigestion; and, from the greater uniformity and obstinacy of the symptoms, the debili- tating effect of all saline medicines more frequently precludes their employment. Sarsaparilla, though mild in its operation, has often a considerable effect in exciting the vessels of the sur- face. 1 have known it necessary to lay it aside in consequence of its constantly causing a considerable 190 TREATMENT OF FUNCTIONAL degree of sensible perspiration. It is often of great use in such cases as that we are considering. The infusion in lime-water, or in distilled water, to which the liquor potassae has been added in the proportion of half a drachm to twelve ounces of the water, is by far its best preparation. By this means all its virtues are extract- ed, without the heavy mucilage extracted from it in the preparation of the decoction. In short, the principle of the treatment here being to support the action of the extreme vessels, and restore the vigour of the nerves, too much or too little general excitement is injurious. We must assist the constitu- tion to maintain that moderate degree which alone is consistent with health, and recollect that we have no other means of restoring the brain, but that of regulat- ing the functions of the whole system; for, with the exception of the circulation, all are the functions of that organ. With regard to the effects of local measures, directed to the brain itself, the result of my experience is, that unless a determination of blood to this organ has taken place, which is known by symptoms with which every practitioner is well acquainted, they are less beneficial than in any other local disease; and, although I was not prepared to find this to be the case so much as it is, when we reflect that the state of the brain is as much influenced by as it influences every other part, it is a result for which we might be prepared. The only local means which has appeared to me to be at all effectual, is the shower-bath,—cold, when the tempera- ture, either of the head or the system in general, is in- creased; and tepid, the temperature being regulated by the feelings of the patient, when this is not the case. Blisters and issues in the neighbourhood of the head, I have found in general of little use, although the former I think occasionally does good if it does not excite DERANGEMENT OF THE BRAIN. 191 much irritation, which is always injurious. To the ob- servations I am now making, there is one exception.!38) From what has been said of the nature of plethora, the reader will readily perceive that it may frequently arise in the case we are considering. Peculiarity of constitution or other circumstances, may determine the debility of the excreting organs to be greater than that of those of supply; and if the patient is unable to take the necessary exercise,, and bear the necessary reduc- tion of diet, an artificial drain may often be of service; but I believe it is better to place it where it is least troublesome, than to make any considerable sacrifice of ease for the purpose of placing it near the head. I need hardly say, that in such an affection of the brain all irregularities are particularly injurious; they are all debilitating causes of the most pernicious kind, acting immediately on the seat of the disease; and those kinds of irregularities, in particular, which chief- ly affect the nerves, are one of the most fruitful sources of the disease, and, I have found, produce it in its most obstinate form. The obstinacy of the disease depends much on the nature of the occasional cause. When originating from a local weakness in other parts of the system, its obstinacy, if it has not made great progress, depends (88) Most cheerfully do we subscribe to the author's commendation of antimonials, and could have accompanied him several steps farther, as we have often experienced the most satisfactory results from both their inter- nal and external administration. We are at a loss to account for the omis- sion of the tartar emetic ointment or plaister, than which we know few greater or more useful discoveries in modern medicine. In the treatment of maniacs we can persuade or deceive them into the use of antimonials, when they cannot be made to submit to any other plan. Whatever injurious effects may arise from the irritation of blisters or issues, we have never witnessed any such from antimonial vessication in mania, notwithstanding the pain they inflict is more intolerable. The pain, perhaps, is a necessary counter irritation, and may be of more utility than the serous or purulent discharge. 1 192 TREATMENT OF FUNCTIONAL much on that of the original disease. It is, of course, impossible permanently to relieve any disease, if the cause continues to be applied. In the case of indigestion, we have seen the local weakness is relieved by the establishment of the more serious disease; but this is not the case in all instances, some of which seem to be confirmed by the great nervous debility which attends the affection of the brain, and in such cases I have seen the whole powers, both of mind and body, gradually sink together, no means that could be employed making any impression on the disease. According to my experience, the most favourable case is that which commences with indigestion. I have never seen a case decidedly of this nature, that is, where the indigestion was its only cause, that did not yield to proper treatment continued for a sufficient length of time; and I have seen some, where slighter degrees of debility elsewhere had contributed with the state of the stomach to induce the disease of the brain, almost as perfectly removed. If we except cases in which the whole powers of the brain are impaired by excessive intemperance, there are none so obstinate as those which gradually come on without derangement elsewhere, or any other evident cause, many of such cases depending on local diseases of the brain, which we have few means of influencing. But even here the due regulation of all the functions, that is, the means that tend most to maintain the healthy functions of the brain, often give great relief, and, I believe, always retard the progress of the disease. The great cause of organic disease is deranged func- tion, its great cure the establishment of the healthy one, and when this cannot be perfectly and permanently DERANGEMENT OF THE BRAIN. 193 effected, the more it is effected the more the evil is relieved and its progress retarded. I have already had occasion to observe, that I had seen states of general nervous debility, which had resisted every other means, relieved by galvanism. Those cases, had they continued, would have ended in that permanent derangement of the brain we are considering. Although it be admitted that the nervous power is galvanism under the control of the vital powers of the constitution,—and I do not see, when the facts are considered and compared, how we can avoid this con- clusion,—we must allow that the effects of our clumsy modes of applying it, must be very different from those of its application by the vital powers of the system itself. In general nervous debility I have made its applica- tion in no other way than by passing it, in the course of the eighth pair of nerves, through the lungs and stomach; but, in promoting the functions of these organs, I have always found it most effectual when most directly applied to them; and, no doubt, it would be more effectual in the general disease, if it could be directly applied to all parts of the system, for in such a case all suffer; it would not be difficult to make its ap- plication much more general than has hitherto been done. From our modes of applying it, and our not having sufficient experience to regulate the power required with any degree of precision, it is apt to excite an in- flammatory state of the parts, to which it is applied, as an excess of oxygen does in the lungs, and this requires the more attention because the irritation, caused by the disordered function, has the same tendency. It must be corrected by the means adapted to the states of chronic inflammation. 25 194 TREATMENT OF FUNCTIONAL I never saw any unpleasant consequences from the inflammatory tendency excited by galvanism, and such effects as arose have always been easily relieved, which will be readily accounted for when it is considered that, although, from its mode of application, it excites this tendency, it, at the same time, improves the function of the part. It is probable that it will be very difficult wholly to remove this objection, because we have reason to believe that, as we cannot apply it so well as nature herself applies it, we must use it in greater power to compensate for the defect in its application. Such, then, are the principles of treatment in that permanent functional disorder of the brain, which leads to organic disease of this organ, without betraying itself by symptoms, on a superficial view, calculated to excite alarm. We must as much as possible, prevent all additional causes of irritation, particularly those chiefly affecting the nervous system; and endeavour, artificially, to support the various functions of the brain, both with a view to the immediate effects, and that the diseased state of the different organs of life may not react on the brain, thus confirming and increasing its morbid affection. Whatever tends to restore the healthy state of any of the functions, either of mind or body, tends, more or less, to correct the morbid action of the brain. For a certain time, to preserve the whole in this state, or in one approaching to it, seems all that is necessary to the cure; the healing powers of the con- stitution will do the rest. While such a plan as I have described is pursued, we occasionally find temporary relief from all those means usually beneficial in the more common nervous affec- tions; but no permanent advantage is to be expected from any of them. In every stage of the disease, all tendencies to local determination must be carefully watched, and particu- DERANGEMENT OF THE BRAIN. 195 larly the symptoms of determination of blood to the head itself, and obviated by the usual means as speedily as possible. The means of obviating determination to the other vital organs, will appear from what I am about to say in the following chapters. Besides the local means of blood-letting, blistering, &c, determination of blood to the head is powerfully counteracted by the shower- bath, of which I shall presently have occasion to speak more particularly, and by a free action of the liver and bowels, by which the fluids are determined downwards; and, as appears from what I had occasion to say of the nature of nervous and sanguineous apoplexy, and the manner in which a disposition to these diseases is given by deranged states of the digestive organs, by all the other means which tend to promote the regularity of their function, and particularly that of the liver. Their derangement, we have seen, tends equally to debilitate the brain itself and its vessels, thus confirming its func- tional derangement, tending to produce a plethoric state of its vessels, and, in both ways, disposing to organic disease of this organ. If the disease of the brain does not produce disor- ganization of some other vital organ, its fatal termina- tion is an apoplectic state, often preceded or accom- panied by epileptic paroxysms; and, on dissection, we occasionally find all the usual appearances observed in apoplectic cases, and many of those of the more chronic derangements of this organ,—effusion, thicken- ing of the membranes, &c; and it is not uncommon, as I have witnessed, and, as might be expected from what has been said, to find after death, when caused by the disease of the brain we had been considering, organic derangements existing at the same time in various other parts of the body. CHAP. IV. Of the Treatment of the Functional Derangement of the Heart, which precedes Change of Structure. It appears, from what was said of the organic dis- eases of the heart, that they are generally established without being preceded by any functional derangement of this organ which can be detected; and that which we can detect, and which produces a tendency to change of structure, in proportion to its severity, and still more its permanence, arises either from a morbid irritability of the heart itself, or irritation of its nerves, from a morbid state of those organs, with which it sympathises. As far as it depends on the latter cause, it can only be relieved by the means that relieve the disease which produces it. For these, I must refer the reader to the preceding and following chapters. Here, therefore, we have only to consider the treatment of morbid irritability of the heart itself; and, in this case, the risk depends on the degree in which the heart is affected, compared with the state of the general system. After all severe attacks of acute disease, or strong and injurious impressions on the mind, the patient is left in a weak and irritable state; every cause of either mental or bodily disturbance increases the action of the heart, both in power and rapidity: but, in proportion as the general health improves, this morbid irritability of the heart subsides, and requires no particular attention; and, although the palpitation arises from very slight causes, or even, as sometimes happens, from no evident cause, but is readily allayed by those medicines which soothe TREATMENT OF FUNCTIONAL, &C. 197 the nerves, we have still reason to believe it to be of little importance, and that, as the strength is restored, it will subside. When, however, the usual means have little effect in allaying it, and it does not improve in the same propor- tion as the general health, we have reason to believe that the patient will, for some time, remain subject to its returns; which, if they continue to be severe and fre- quent, may lay the foundation of organic disease of this organ; but we have no reason to infer the existence of such disease, till the characteristic symptoms above point- ed out show themselves. In the majority of cases, when the morbid irritability of the heart is thus obstinate, it will be found, on in- quiry, to depend on morbid affections elsewhere, par- ticularly in the digestive organs, which should be very carefully examined; if not, our means of relief are very limited; they consist in those of allaying the palpitation when it occurs, and strengthening the general habit. The former is to be done by rest and nervous medi- cines, of which I have found ether, asafcetida, and cas- tor the best, and a combination of such medicines gene- rally answers better than any of them singly; and both the medicine and combination, which answers best are different in different cases; for the means which succeed in mere nervous diseases are as variable as their symp- toms. These means have no other tendency to prevent the recurrence of the palpitation than arises from lessen- ing the severity and duration of the attacks. Every thing having these effects tends, of course, to prevent the increase of the morbid habit, the great source of ob- stinacy in nervous affections. With regard to the means of strengthening the gene- ral habit, the chief things to be attended to are, that we shall neither overcome the remaining strength by the 198 TREATMENT OF FUNCTIONAL power of the remedy, nor call into action any lurking morbid tendency. The more transitory tonics, called stimulants from their effects being immediate, are to be used for the pur- pose of present relief, if the state of the strength re- quires it. I know of none superior to the compound spirit of ammonia or lavender, the essential oil of which possesses a peculiarly cordial property, in camphor mix- ture; this or any similar medicine may be used: but it is always proper to guard the patient against the abuse of such means, to which the relief they afford often leads. In the present instance, it is advantageous to add to the cordial some of the nervous medicines just mentioned, which tend to prevent as well as relieve the palpitation. But, our chief reliance in states of general debility is on the more permanent tonics, a proper regimen, baths, and what is called change of air. I shall make a few obser- vations on each of these means. The most powerful tonics we possess are the bark and iron, whose good effects are often aided by the former medicines, which both increase their invigorat- ing effects and render them more grateful to the stomach; but the more the patient's state permits us to trust to the permanent and the less to the transitory tonic the better. The former does not produce that sudden excitement which is so apt to be followed, and, when considerable, always is followed by corresponding debility of the parts concerned; to which the habitual drunkard owes all his morbid tendencies. The permanent tonic, on the other hand, has its inconveniences; the most im- portant of which is its tendency to produce an inflam- matory state of the habit; which, as appears from what has been said, is that most apt to call into activity any morbid tendency. It is only, we have seen, in propor- DERANGEMENT OF THE HEART. 199 tion as nervous derangement is accompanied by this state, that it ever does permanent mischief. In the use of the permanent tonic, therefore, the at- tention must be directed to this effect, which always makes its continued use injurious where the continu- ance of the nervous derangement has already excited the same tendency. In the second stage of indigestion, for example, medicines of this description can seldom be long borne. Nothing is more common than to hear those labouring under this stage of indigestion express a horror for the effects of tonics, which they often ex- perience from the proper change of treatment not being made at the time the inflammatory tendency super- venes. If such a cause- oppose the use of the tonic, the pa- tient will soon begin to complain of oppression and a greater tendency to increased heat. When these con- sequences show themselves in any considerable degree, the tonic is doing harm, not good; it is combining with the nervous derangement to induce an inflammatory tendency, and thus is contributing to the implication of the sanguiferous system, on which we have seen all the more serious effects of nervous derangement de- pend; and, if its use be continued, this tendency will probably show itself in inflammatory action in some of the vital organs, more or less chronic according to the constitution of the patient, whose feelings, luckily, if the observation of the physician does not, generally prevent this going far. When neither this obstacle nor oppression of the stomach oppose the continued use of the tonic, we have no other means of restoring the strength so effec- tual. Its operation appears to be chiefly on the nervous system, through which it invigorates the whole frame; for its effect is often, to a certain degree, perceived as soon as it is received into the stomach: and, with re- 200 TREATMENT OF FUNCTIONAL spect to many tonics, it is doubtful if they are ever taken into the circulating system, their chief effects being evidently produced through the nerves of the stomach and bowels. We are assured that this is the case with respect to the bark. When, in agues, the interval of the par- oxysms is long, as in the tertian and quartan, the most successful plan is, not to give the bark at regular inter- vals throughout the whole of the intermission, but in large doses, at short intervals, for such a time before the return of the fever as shall allow of a sufficiently large quantity being in the stomach and bowels at the time of its recurrence; and we find army physicians, who are so conversant with agues and constitutions able to bear the medicine in its most effectual shape, declaring that, in this way, they have cured cases by a few ounces of bark, which would have required many times the quantity had its exhibition been distributed throughout the whole of the intermission. Besides, we know that such fevers are cured with nearly the same certainty when the bark is discharged by di- arrhoea, almost as soon as it is taken; provided it-be taken often enough, and in such doses that the stomach and bowels may be sufficiently exposed to its effects. One of the greatest objections which have existed to the bark, its tendency to oppress the stomach, is now removed by its admirable preparation, the sulphate of quinine. How far this preparation possesses the whole of the properties of the bark in substance, which none of its other preparations do, it may be difficult to say; but it possesses them in a most concentrated form in so eminent a degree that, in all ordinary cases, it answers the purposes of the bark, and we have few medicines less offensive to the stomach. In the most essential respect the effects of iron are similar to those of the bark. It is a powerful tonic, DERANGEMENT OF THE HEART. 201 only perhaps inferior to the bark; and to compensate for this inferiority, it is more generally applicable, both because its tendency to produce the inflammatory state is less, and it is less oppressive to the digestive organs than even the sulphate of quinine. The difference in the effects of these medicines does not, however, wholly consist either in these circum- stances or in the degree of tonic power they possess: each has effects peculiar to itself. Iron has compara- tively little power in the cure of ague, and there are cases where it is eminently useful, in which bark would be injurious. The carbonate and ammoniated tincture of iron here also appear to me to be its best preparation; and the occasional or continued use of them may often be had recourse to for the purpose of increasing the tonic effect of our plans of treatment, when the bark cannot be employed; although the tendency of the former to produce an inflammatory state of the habit, and, con- sequently, of the part chiefly affected, also require to be watched with care. A free state of the bowels is one of the best means of obviating this tendency under the use of either; and many cases of chronic debility, particularly where the digestive organs are chiefly concerned, will yield to these or similar medicines combined with the free use of purgatives. This plan, however, has sometimes been employed too indiscriminately, and continued too long. The patient feels that the oppressive effects of the tonics are relieved by the purgative, and the debili- tating effects of the latter by the tonic, which often re- conciles him to the plan, although, on the whole, little progress is made; and even when, notwithstanding the temporary relief in the first instance, the cause of the disease has been gradually increasing. 26 1 202 TREATMENT OF FUNCTIONAL A great variety of other medicines have more or less the properties of bark and iron. Almost all the bitters possess a tonic power, columbo and gentian a good deal, quassia and camomile less, and hops, perhaps, the least of all. The latter are often a good addition to other means, when the inflammatory tendency is too great to admit of the former. To the stomach they are generally more or less grateful, and assist in en- abling it to bear other medicines.(39) It is remarkable, however, that some stomachs can- not bear bitters even in the smallest quantity. The late celebrated Dr. Gregory had this peculiarity to such a degree, that, in consequence of accidentally eat- ing the seed of an apple, he had a fit of palpitation which lasted several days. Such a degree of this pe- culiarity as wholly precludes the use of bitters is by no means uncommon. The various aromatics, also, have more or less of a tonic quality, and, even more than bitters, tend to re- concile the stomach to less grateful medicines. Cam- phor, which has a slightly anodyne power, is most generally useful, and ginger, perhaps, is less heating in proportion to its stimulating quality than any other; but it is not very uncommon to meet with chronic cases in which the inflammatory tendency is so great, that all medicines which possess any stimulating power, how- ever transitory, produce increased heat and its attend- ants. Yet, even in these cases, the patient often bears animal food pretty well, at proper times of the day, although he seldom bears wine. Sometimes it is ne- cessary to abstain from animal food for two or three days in the week, and, in a few instances, the morbid irritability requires a wholly farinaceous diet. (39) Colombo and gentian may be improved in efficacy by a combination with iome of the condiments, and especially the cubebs. DERANGEMENT OF THE HEART. 203 I need not say that it is of great consequence, in re- lieving irritable and debilitated states of the habit, to regulate with care every circumstance respecting diet and exercise; to render the former, at once nutritious, easy of digestion, and suitable to the peculiarities of the patient's state; and the latter, such as supports the functions without irritation or fatigue. In my Treatise on Indigestion I have endeavoured to point out the principles by which these objects are to be attained, and shall, in the present treatise, have occasion to recur to them. Whatever can be done by diet and exercise is better done than by medicine, and there are few things that strain the constitution more than any indulgence re- specting diet, the effects of which require to be con- tinually corrected by medicine. The cold bath, when the patient's state is suited to it, is one of the best tonics. Like others it has an in- flammatory tendency, but not in the same degree with bark or iron, although, from the occasional suddenness of its effects it is often less safe. It is also apt to over- power the strength in cases of debility, and must be employed with some caution, except in those who have been accustomed to it. To the tepid bath there is neither of these objections. It is in general both invigorating and refreshing, par- ticularly when sea-water is used, and, although not a powerful remedy, assists other means. About 94° is the temperature that suits most patients, but it must never be too low to be agreeable to the feelings, and I have known some who required it as high as 100°. The shower bath is often the most effectual, espe- cially, as I have already had occasion to observe, where there is a determination to the head. The effects of the tepid shower bath are essentially different from those of the general tepid bath, as strikingly appears in 1 204 TREATMENT OF FUNCTIONAL their effects in fevers, in which the effusion of tepid, allays the heat almost as much as that of cold water, while from the tepid general bath little effect of this kind is observed. Water, more or less tepid, should always, in the first instance, be employed in the use of the shower bath, except where the instantaneous effect of the cold is particularly required. I have known severe effects from the cold shower bath in those unaccustomed to it, and this precaution is the more necessary the more the patient is debilitated. There is little advantage from medicating the water of baths, except from the stimulant effect on the skin, and for this purpose salt is the best addition. I have seen considerable advantage in states of debility from washing the whole surface with salt or vinegar and water, followed by general friction, for ten or fifteen minutes. When the skin is peculiarly languid the vapour bath often gives temporary relief; but, from the trials I have seen, its effects appear to be transitory. With respect to what is called change of air, there can be little doubt of its favourable effects in almost all cases of debility. There has been much difference of opinion respecting the cause to which the benefit de- rived from change of place is to be ascribed: we have reason to believe it arises from various circumstances, but, in general, least of all from mere change of air. It is evident that the air is effectually changed by the wind, and far more rapidly than it can be by any change of place. Yet it is only when the temperature or degree of moisture is changed by the wind that we can perceive it produce any change in the health; if we except that a certain degree of wind is useful by preventing absolute stillness of the air, which always becomes oppressive when long continued, and that in- DERANGEMENT OF THE HEART. 205 dependently of any impregnation, for it is felt by those who inhabit single houses in the country as well as by the inhabitants of towns. A free circulation of air is particularly grateful to the feelings, and, from this circumstance alone, we might infer, favourable to health. The truth is, the air is essentially the same in all places. It has been found, by correct experiment, that, in the closest parts of London, and on the Malvern hills, it possesses the same proportion of the principle which supports animal life, and is itself, indeed, in all respects the same; but it is capable of being variously impregnated. The sense of smell at once informs those from the country, that the air of large towns is less unmixed than that which they have been accustomed to breathe. All impregnation of this kind we should at first view suppose must be more or less injurious, and to a certain degree it may be so; but we have reason to believe, I think, that it is much less so than the occasional greater dampness and consequent chilliness of the air of large towns, and the usual greater stillness of the air in them from confinement by the buildings. It was found by Dr. Hutton, that when portions of warm and cold air both charged with moisture are mix- ed, the mean temperature produced will not hold the same quantity of water in solution; in consequence of which, a precipitation taking place, the air becomes damp. Thus it is that the air of large towns is generally more damp than that of the country, from its being of a higher temperature in consequence of the number of fires, and constantly mixing with the colder air from the country. If we except moisture, the chief impregnation of the air of large towns of this country seems to be from smoke, which does not appear to be particularly unwholesome. It has, on the contrary, indeed, been supposed to pre- 206 TREATMENT OF FUNCTIONAL serve from disease, and has often been employed with this view. The other effluvia of our towns are in too small quantity to produce much impregnation of the ex- ternal air. It has just been remarked, that the change of air by the wind, seems only to affect the health by the motion of the air it occasions, and by its influencing its temper- ature and degree of moisture. I am inclined to think that it is, except under very peculiar circumstances, merely in these ways, which are, doubtless, in many cases, very important, that change of place, as far as air is concerned, usually affects us.(40) Some have been inclined to doubt whether the air is ever so changed as to affect the health, independently of the presence of contagion, and the changes of its tem- perature and degree of moisture; but there are some well-ascertained facts which it is difficult to explain on any other supposition. We (see contagious diseases, par- ticularly the plague, appearing and declining in different parts of a country, perhaps hundreds of miles distant from each other, at the same time, and without any evi- dent cause, which it would be difficult to account for by any of the known properties of contagion. I have had occasion to consider this subject at some length in a Treatise on simple and irruptive Fevers.* There are other things, however, in change of place capable of essentially influencing health, of which, 1 be- lieve, the most powerful is the excitement given by the change itself. How often do we find continual change necessary; the new place being no better than the old, as soon as the novelty is worn away. To the mere ex- (40) May not the decomposition of atmospheric air in the lungs be fa- voured or opposed by certain conditions of density, temperature, moisture, electricity, &c. and thus those conditions become either salutiferous or noxious causes? What influence may the electric state, whether negative or positive, exert in this respect? * Page 158, et. seq. fourth edition. DERANGEMENT OF THE HEART. 207 ercise of body occasioned by the travelling, or to which a new situation .naturally excites, much must often be ascribed; but we must look to the variety, and to the occupation and cheerfulness of mind occasioned by the change, for its chief effects. The feelings of sickness, on the one hand, like all other feelings, are soon associated with every thing around us; and, on the other, the mind, if not forcibly abstract- ed, fixes intensely on any object which, for a long time, chiefly occupies it. In long-continued sickness we want something to break that association, and something to abstract the attention from the feelings of our disease. What can so powerfully produce these effects as a total change of place? The poor, in some parts of this coun- try, who cannot afford to send their children to a dis- tance in the decline of hooping-cough, in which change of place is so powerful a remedy, confine them daily, for a certain time, close to the machinery of a mill; and this often answers the purpose as well. Those who ascribe to fancy all the diseases which may be cured by change, know little of the nature of disease, or the laws of the animal economy. Can the hooping-cough be ascribed to fancy, or eruptions and sores of the surface, pains and stiffness of the joints, and a thousand other ailments, which are often cured by change alone? The diseases which attend on those of the digestive organs, for example, however various, are all influenced by the state of the mind, which is nearly as much the subject of external circumstances as the body. It is almost unnecessary to add, that while the ten- dency to palpitation continues, every thing which tends to produce it should be carefully avoided. By a com- bination of the general and local means which have been laid before the reader, selected according to the circumstances of the case, the returns of palpitation 208 TREATMENT OF FUNCTIONAL will generally be prevented, if they neither arise from any degree of organic disease nor the diseases of other parts. If they are not wholly prevented, they will be both mitigated and rendered less frequent, and thus their injurious tendency more or less counteracted. When they can be rendered unfrequent, little, in gene- ral, is to be apprehended from them. CHAP. V. Of the Treatment of the Functional Derangement of the Lungs, which precedes Change of Structure. Pulmonary consumption is the most important or- ganic derangement of the lungs. For my opinions re- specting the nature and treatment of its various forms, I refer the reader to my Treatises on symptomatic Fevers and Indigestion. I am here to consider the treatment of those insidious beginnings, which may rather be re- garded as indicating a tendency to this disease, than forming a part of it. I have said that even a tendency to cough, and that not frequent, and more than usual hurry of breathing on exercise, are symptoms requiring serious attention in those highly predisposed to pulmonary consumption. Of this truth it is difficult to convince those unacquaint- ed with the nature of the disease. The existence of bilious complaints, in any of their various forms, is not less a serious affection in such habits. In them it is not safe to wait till the bilious affection has produced a cough. The general irritation kept up by this com- plaint disposes to any disease to which the constitution is liable; and in the present instance, that to which it is liable is one of fatal tendency, and often, even at an derangement of the lungs. 209 early period, of difficult management. I have already had occasion to observe, that one half of the cases of pulmonary consumption of this country, originates in bilious complaints. Common bilious complaints and such slight affections of the lungs as those just mentioned, can almost always be removed, particularly in the commencement, for every day they continue adds to the difficulty; but the greatest difficulty is to direct the attention to them, and to convince the patient of their importance. In con- sidering the importance of obviating them, the contagi- ous nature of pulmonary consumption is not to be over- looked: it is not one life alone that is endangered. Pulmonary consumption is not contagious in the same sense that fever is so; but in the last stage, it may certainly be communicated to the predisposed. Hence it is, that even when the disease has disappeared for a long time in families who have been subject to it, when it returns, it often sweeps off many in succession; and hence the husband or wife of the first sufferer, though of different families, often falls a sacrifice to it. When the slight pulmonary symptoms I have men- tioned appear in an individual of a consumptive fami- ly, particularly if from fifteen to thirty-five years of age, the first thing to be determined is, whether he labours under any bilious complaint. When it is ascer- tained that this is not the case, the whole attention should be directed to correct this first deviation from the healthy state of the lungs. Strong exercise, and all causes of taking cold should be carefully avoided; the bowels should be kept rather free; the diet should be so regulated, as in no degree to oppress the stomach; the patient should be much in the open air, under such exercise as does not in the least degree hurry the breathing or occasion fatigue; and three times a-day, at least, he should take such a •27 1 210 treatment of functional dose of quieting medicine,—a combination of extract of poppies and digitalis I have found the best,—as allays the tendency to cough, care being taken to ob- viate any constipating effect it may have. In short, the principle is to bring the patient into the best pos- sible state of health, to allay the irritation which excites the tendency to cough, and to avoid all those circum- stances which tend to increase it; and the less the symptoms yield to these measures, the more assidious we should be in their application. If they do not soon succeed, blistering the chest is a necessary addition to them. When the tendency to cough is not immediately removed, the blister may for some time be kept open, or a succession of small blisters may be applied to different parts of the chest; and if there be any pain in the chest, and especially if the pulse be in any degree tight, which often happens even at this early period, if the first blister does not succeed, the application of the second should be pre- ceded by that of a few leeches.Ui) (41) We unquestionably expose ourselves to the imputation of presump- tion in questioning the propriety of a practice rendered common by the sanc- tion of much and high authority; yet, nevertheless, we unhesitatingly raise our hands against blistering the breast in any stage of pulmonary consump- tion, and especially in those conditions of the system threatening this formi- dable disease. When the lungs have become debilitated from any cause, we only farther embarrass their action by voluntarily restricting the movements of res- piration, to avoid the pain and irritation consequent upon motion of a vessi- cated surface. Nay, more, the muscles under a blister seem to be deprived of the power of contraction, and to breathe at all, demands an effort. Blisters invite disease to their seats, either by stimulating to new action, or on the principle that pars dolens trabit; and, as is well known, any part previously debilitated is in a condition not to resist, but to become the convenient loca- tion and rendezvous of whatever train of morbid actions may be forming in the system. We blister either to deplete or stimulate. Can a blister over the thorax de- plete directly from the lungs? Anatomy, experience, common sense say no. Can they stimulate them directly? Every thing gives the same response. Then derangment of the lungs. 211 The patient must not pause to compare the trouble of the treatment with the mildness of the symptoms. The mildness of the first symptoms is one of their great- est evils. He may be assured that the necessity of the means is proportioned to the trouble required to relieve him; and that the present trouble will probably save ten times as much afterwards,—with this additional differ- ence, that he is now at a distance from danger, and will then be on the brink of it, from which no trouble may be able to preserve him. I am no advocate for unnecessarily minute attention to health. Many evils attend it. A pampered con- stitution is like a pampered child, ill able to contend with the unavoidable occurrences of life; for the more we are nursed, the more delicate we become, and too much care, as well as too little, may spoil a good con- stitution: but of two evils we must choose the least, and why blister? To draw off morbid excitement from an important organ to a less essential structure: if so, then why not transfer to a part which has no direct concern in the transactions of the diseased organ? If proximity is desirable, then choose any part which does not immediately interfere with respiration: and if it must be near the thorax, why not pre- fer the spine, where it will have little influence upon the motions of the chest? If pulmonary consumption is, as we have already asserted, mostly a secon- dary disease, induced by the previous mal-performance of some other organ, then blisters over the chest will only tend to transfer the disease from the original seat to its new location sooner than it would have happened in the ordinary progress: but if they must be applied, would it not be better to place them over the organ of primary disease, by which we confine its ac- tion, or restore a new, and perhaps healthy function to the original defaulter, and thus diminish disease and prevent affection of the lungs altogether? The lungs ought always to be let alone, or at most our aim should be to remove every obstruction to their free play, and our agents directed point- edly to the restoration of natural functions to the organs of primary affec- tion. Were sufficient attention bestowed upon the beginnings of disease which usually determine *o the lungs, they could for the most part be readily re- moved, and consumption would be of rare occurrence. But if we persist in tampering with the operations of the lungs in every slight affection, we must expect to contribute largely to the item, already greatly too large in our bills of mortality. 212 TREATMENT OF FUNCTIONAL too little care is a more pernicious folly than too much. A late well known writer, a widower of a consumptive family, had but one child, a daughter, who engrossed his whole attention: he said he would give her a strong constitution by habituating her to a hardy life, but she died of consumption before she was twenty years of age. It is as easy to change the sex, as to change the constitution; but much may be done to prevent morbid tendencies from being called into action. I have little doubt that this young lady, with more judicious man- agement, might have still been alive. When the disposition to cough is just beginning, or has nearly disappeared, a good deal may be done by the voluntary efforts of the patient to stop it. The effort of coughing is very easy, and we naturally yield to the sensation that excites and is relieved by it. I have known a tendency to a slight habitual cough, which had continued for some months, checked by the efforts of the patient, without medicine. It had been sup- ported by habit alone; but the habit which supported the cough supported also the increased secretion from the lungs which excited it, and which, had it continued, might, on some trivial occasion, have assumed a worse character. A young lady, many of whose sisters had died of consumption, had, for some months, laboured under fever and purulent expectoration, with a con- siderable degree of emaciation. She, however, recov- ered, except that a slight occasional cough still continu- ed. She was very anxious to go into the country, and I told her, that as soon as she and her family agreed that she had not coughed for three days, she should go. This happened in about ten days, although the slight cough had continued for several weeks. Medicine has often comparatively little power in removing the last remains of disease. The constitu- tion is habituated to them, and being no longer in DERANGEMENT OF THE LUNGS. 213 immediate danger, makes little effort to subdue them. This young lady remained well; but had the habitual cough continued, it would probably, on the first slight occasion, have assumed a more serious form. If the first beginnings resist the foregoing means, which, I believe, will rarely be the case when they are resorted to sufficiently early, and applied with suffi- cient perseverance, however perfect the patient's gene- ral health may still appear to be, his danger is very great. If these means cannot check the disease on its first appearance, there can be no sanguine hopes of better success afterwards; for, in pulmonary consump- tion, originating in the lungs themselves, we have only the same care and the same means to look to, varied as the symptoms vary, with the exception of those neces- sary for combatting particular symptoms, which, from their nature, are only palliative. As to the effects of the thousand nostrums recommended in such cases, it has never once occured to me to see them of any avail. When the disease has not originated in the lungs, which I have had occasion to observe is very frequent- ly the case, if proper means be employed, success in the earliest period may almost be regarded as certain. I have seen few cases of this kind, in which, even although the symptoms had become a little troublesome, provided they had not lasted above ten days or a fort- night, a proper treatment was not successful. There are but two other organs whose affections strongly dispose to disease of the lungs—the liver, and uterus. When obstruction has taken place in the latter in young women, the state of the lungs should be care- fully watched, and the obstruction as quickly as possible removed. If they are of a consumptive family, they are in danger every day of its continuance; and the more, because, if cough arises, it often materially interferes with some part of the most effectual means of restoring 214 TREATMENT OF FUNCTIONAL the uterine secretion, which I have already had occa- sion to consider, for its failure is a fruitful source of dis- ease. I shall only, therefore, observe here, that any means which increase the inflammatory tendency must, in the case before us, be cautiously employed, and their effects carefully watched. A disordered state of the liver much more frequently lays the foundation of pulmonary consumption. In a work just referred to, I have very fully considered the nature and treatment of the species of the disease which originates in this way, and shall here, therefore, confine myself to the proper treatment in its first threatenings. In the present treatise I have pointed out the different ways in which the lungs gradually become implicated in affections of the liver, both in the early and later pe- riods of life. As it is in vain to attempt the removal of an effect, while the cause still continues to operate, we are here, in addition to the several means just pointed out, which are all still as necessary as when the affection of the lungs is the original disease, particularly to direct our attention to the state of the liver. The several means of ascertaining the state of its secretion, and particularly the most certain and unequivocal one, the degree in which the first intestine is distended,—for it rarely hap- pens that the disordered state of the liver affects the lungs till it has lasted long enough to produce more or less of this distention,—must be attended to, and the careful observer will soon find, that in such cases he only effectually relieves the pulmonary symptoms, in proportion as he relieves it. In considering the treatment in disordered states of the liver, I shall have occasion to enter particularly into the means of correcting their early stages, and shall only make a few observations here particularly applica- ble to the case before us. As few things in this case are DERANGEMENT OF THE LUNGS. 215 of greater consequence than to save the patient's strength, it fortunately happens that the gentlest means are also the most effectual for correcting the disorders of this organ in their earlier stages. When the distention of the first intestine is evident, an occasional dose of calomel is necessary; and in the most favourable cases, repeating it once in ten days or a fortnight is sometimes sufficient to restore the due ac- tion of the liver, and, consequently, the free state, of this intestine; but if this is not sufficient, a less debilitat- ing course than the frequent repetition of the calomel must be pursued. The relief it affords often leads the patient to an em- ployment of it: that I have, in many cases, seen injurious, both by its debilitating effects and by the loss of time which the temporary relief it gives frequently leads to; for, except in the most favourable cases^ the relief is transitory; and as the preternatural excitement it occa- sions for the time, is as much a disordered action of the liver as that it is given to relieve, both the disease and the remedy tend to injure the lungs. It is quite common to hear the patient say he always coughs more while the calomel is operating, although he is relieved after it. If the temporary cause of irritation be of rare occur- rence, it is of little importance; but, when frequently re- peated, whatever the effects of the calomel may be on the liver, the impression it makes on the lungs is inju- rious. The great object here, as in all similar cases, is to excite and maintain the natural action of the organ. A morbidly-increased action, were it continued, would be even worse than a habitually defective one, because it is attended both with greater irritation and greater loss of strength. I have already had occasion to make some observa- tions on the means of supporting the healthy action of the debilitated vital organs in general, and shall soon 216 TREATMENT OF FUNCTIONAL have occasion to consider those which are applicable to the liver in particular; and shall, therefore, close my observations on this part of the subject, by observing, that there is no case in which a careful and steady, as well as early, application of our remedies is more essen- tial, than in that we are considering. Such are the means to be employed for the preven- tion of pulmonary consumption, properly so called; that is, that disease which proves fatal by the production and suppuration of tubercles, which appear to be of a nature similar to that of the glandular swellings that appear externally in scrofulous habits: and it is by no means uncommon to see, in the same family, some fall- ing a sacrifice to pulmonary disease, and others affect- ed with such swellings,—the establishment of the ex- ternal disease appearing, on a principle familiar to physicians, to save the internal parts; although, as I have had occasion to observe, such is the proneness of the lungs to this species of organic disease, that, when its causes are powerful and repeatedly applied, we have reason to believe there is no constitution in which it may not appear. There is another affection of the lungs nearly allied to, and often complicated with it, and from which it is often difficult to distinguish it,-—ulceration of the wind- pipe and its branches. Were I to trust to my own ob- servation, I should say that this disease rarely, if ever, appears as an original affection. In all the cases of it I have seen, it has arisen from a disordered state of the liver; although, according to a law of the animal economy, which we have more than once had occasion to consider, the primary affection often disappears after the secondary disease is established. However free from disordered liver the patient has been at the time I have seen him, 1 have always found, from the history DERANGEMENT OF THE LUNGS. 217 of the case, that he had, in the first instance, laboured more or less under symptoms of biliary derangement. The first effect of diseased liver on the lungs, seems always to be some irritation of the surface of the wind- pipe and its branches; and the species of consumption which thence arises, instead of generally beginning with a dry cough, as is usually the case in original dis- ease of the lungs; a little mucus proceeding from an increase, in consequence of nervous irritation, of the mucus which is secreted by all internal surfaces for the purpose of defending them, here, often from the first, attends the cough. As the disease advances, we have found, this mucus begins to be mixed with a fluid of purulent appearance, and, at length, it chiefly consists of this fluid. The experiments of Sir Everard Home have shown how readily nervous irritation of secreting surfaces produces purulent matter. In most instances, if the disease is allowed to pro- ceed, the continued irritation of the windpipe and its branches, from their close sympathy with the other parts of the lungs, produces the derangement which causes tubercles. But in some cases instead of taking this course, it produces ulceration of the surface of the air tubes; and I believe the chief circumstances which determinate to this course, rather than the production of tubercles, are there being little tendency in the con- stitution to the latter disease, for it is generally in those who have little of this tendency that we find bronchial ulceration; and the cause of irritation being from some peculiar sympathy which it is impossible for us to ex- plain, in certain comparatively rare cases, (for such cases are rare compared with tubercular consumption, even when the original disease has been in the liver,) being more confined to the windpipe and its larger branches. It is, of course, in the minute extremities 2S 218 TREATMENT OF FUNCTIONAL, &.C. of the air-tubes that the connection between these tubes and other parts of the lungs is most intimate. The treatment of the two cases differs but little, and the means of prevention in no respect whatever. Such are the means—few, simple, and of easy appli- cation, which never strain the constitution, and to which there is no possible objection, but that they re- quire a little care and trouble at a time when it is not easy to convince the patient that either is necessary; by which the lives of thousands might be yearly saved in this country, and, for the most part, at a time of life when they are only entering on its busy scenes, and the feelings of their friends are most deeply interested in them.(42) (42) Pulmonary consumption may nearly always be prevented, and will rarely ever be cured. It is consequent upon neglected or ill treated dis- eases of other organs, and the fault may be divided between the patients, their friends and the family physicians. The latter are entitled to the largest share of blame, upon account of their ignorant or inattentive performance of official duties. They are still more culpable in a too early abandonment of remedies suitable |for eradicating the primary disorder, and concentrat- ing attention to the lungs, whenever cough, pain in the breast, or irregu- larity of respiration may supervene upon other forms of disease. How many slight catarrhal, bilious and other affections of easy cure, have been converted into confirmed consumptions by blisters on the breast, expecto- rants, cough mixtures, and other equally empirical practices! Humanity shudders at the contemplation. CHAP. VI. Of the Treatment of the Functional Derangement of the Liver which precedes Change of Structure. I have already had occasion to observe, that we have no means of detecting a tendency to organic dis- ease of the stomach. On this subject, therefore, there is nothing to be said, but that, as in all other cases, the more perfect its function is, and the less it is exposed to causes of irritation, we have reason to believe, the less it is liable to change of structure. I knew a gen- tleman, who was always remarked for his gluttonous appetite, who died of organic disease of the stomach, at the age of nearly sixty. The unusual appetite, which had existed during his whole life, cannot here be re- garded as a consequence of any degree of the disease, which, had it been so, must have shown itself earlier: yet it is difficult to suppose that the two circumstances were not connected. I knew another, still more remarkable for his extraordinary appetite, who died of organic disease of the bowels. There is no organ to which the observation just made, respecting the stomach, applies less than to the liver. Its organic diseases, at least, in this country, are generally preceded by a long-continued derangement of function, which makes itself apparent by all the usual symptoms which attend the more obstinate cases of indigestion. A long-continued deranged state of the liver, we have seen, is the parent of many of our most serious disorders; and the nature of those diseases readily explains to us that of the slighter affections of 220 TREATMENT OF FUNCTIONAL this organ. They point out the parts with which the liver chiefly sympathises, and explain the nature of the symptoms which accompany its slighter affections, in which the distant part is influenced, but not diseased, by the state of this organ. We need not be surprised, for example, that the slighter affections of the liver should be attended with occasional headache, cough, and oppressed breathing, when we see the continuance of its more severe or obstinate derangement is capable of at length produc- ing apoplexy and pulmonary consumption. They also afford the strongest argument for endeavouring 1o cor- rect the first beginnings of its derangements. The most temporary fit of disordered stomach, if at all severe, is often attended with a corresponding dis- order of the liver. It is generally excited to pour out a greater quantity of bile, which, by its effect on the bowels, carries off the offending cause, and, if the patient has not been subject to frequent attacks of the same kind, with the cause its effects disappear; but, when such attacks become frequent, the function of the stomach begins to be more permanently affected; the patient begins to be daily troubled with flatulence and acidity, and more or less oppression after eating, and this state never continues long without the biliary secretion becoming habitually more or less vitiated and irregular. These symptoms, however, occasion no serious effects, and the patient finds he can prevent their being very troublesome by a little more than usual attention to diet; and if, by these means, he can keep himself tolerably easy, he thinks no more about his complaint till the increasing weakness of the digestive organs calls his attention to it by the recurrence of some new incon- venience; and the most common cause of his attention being more seriously arrested, is finding, from some DERANGEMENT OF THE LIVER. 221 degree of debility of the limbs, and his not being able with ease to fix his attention, that he is less capable of his usual occupations. He now finds it necessary to remedy the evil, and is generally surprised to learn that he can only be relieved by a good deal of trouble and considerable sacrifices. If the evil day be put off, and still only palliative mea- sures pursued, the next warning is generally of a kind which must be attended to; and then, for the most part, he has some danger, as well as trouble, to encounter. These results, however, are not certain, or, at least, are often very distant; for, in many instances, slight disorder of the digestive organs will continue to recur for years, without material increase: but they are sufficiently, and more than sufficiently common, to make it well worth while to attend to the beginnings of the evil: and there is an important fact which I have more than once seen strikingly exemplified, and wish to impress on the reader's attention. The debility of the parts concerned, and, conse- quently, the obstinacy of the derangement, appears often to be proportioned rather to the length of time the symptoms have continued than to their severity; and when the debility has by the operation of some accidental cause, been extended, by the sympathies of the liver, to an organ more inclined to organic derange- ment, it has been found impossible to relieve the original, in time to prevent the fatal effects of the se- condary disease; and the patient has sunk with a ra- pidity that seemed surprising, when the whole of the circumstances and the general laws of our frame were not taken into account. There is but one means of security against the fore- going consequences—correcting the first beginnings of the disease, which may generally be done with certain- 222 TREATMENT OF FUNCTIONAL ty and slight sacrifices; but, however slight, seldom very quickly. In the most favourable cases, a strict attention to diet and exercise alone is sufficient; but the patient will be disappointed if he expects, either that the effect will be immediate, or that, if he soon returns to his usual mode of living after the symptoms are removed, it will be permanent. He must not only live by rule till his symptoms disappear, but he must depart from the means which have relieved him very cautiously, and only as far as this can be done without any tendency to their recurrence. It seldom happens that those whose digestive pow- ers have once been seriously impaired can enjoy the same security as people who have always been well; but the longer they can preserve themselves from a re- turn of the complaint, the more nearly they approach to that state. When a stricter attention to diet, exercise, and a regular state of the. bowels fail, it is necessary to assist these means by some stomachic medicines: a combina- tion of bitters and aromatics gives greater tone to the stomach, and if no degree of permanent disorder of the liver be established, generally succeeds, with the aid of the former means, either alone or with the assistance of some of the preparations of iron. If, on the other hand, some permanent debility of the liver has supervened, the means which only influence the liver through the stomach will generally fail, with- out the aid of some mercurial alterative; for, although it is not uncommon to employ mercurial medicines in all cases of indigestion, we have reason to believe that, while the permanent debility is confined to the stomach, they are of little use, and, if freely employed, injurious. That the liver is more or less permanently disorder- ed will be known by a greater degree of depression of DERANGEMENT OF THE LIVER. 223 spirits, and the bowels being seldom in their natural state; not merely languid,—for this is often the case in the earliest stage of indigestion, the languor of the stomach spreading to them,—but variable and irritated, their contents not having the usual appearance, and aperients operating in an uncertain and unsatisfactory manner; for one of the functions of the bile being that of maintaining a due excitement of the bowels, when it is vitiated by an imperfect action of the organ which prepares it, this function is necessarily affected in vari- ous ways corresponding to its state. The occasional use of the mercurial, then, becomes necessary; and the form I have found most convenient is three or four grains of blue pill, given every second night at bed-time, and carried off next morning by a slight aperient of a saline nature, if saline medicines in other respects suit the patient; for about this time some tendency to increased temperature and tightness of the pulse generally begins to show itself, and the cooling effects of the saline medicine is beneficial. A full dose is not necessary or proper: the bowels should be excited freely once or twice; and it is generally ad- visable to allow them to remain quiet on the interme- diate day, to which the greater than usual excitement generally, though not always, inclines them. It is sometimes sufficient merely to combine with the alterative an aperient pill, although this is a less effectual plan, both because the alterative is too much hurried in its passage through the canal effectually to do its office, and the bowels are seldom so thoroughly moved without the risk of doing too much. If saline medicines disagree with the bowels, which is not un- common, the morning aperient may be of any nature which the patient has found to agree with him. . By these means, unless the absorbents are more active than usual, little or none of the mercurial is re- 224 TREATMENT OF FUNCTIONAL ceived into the system, its temporary operation on the liver being often sufficient to restore the due action of this organ. The stomachic medicines are thus aided, and if the patient is cautious respecting regimen, nothing more in general is required; but the use of the alterative must never suddenly be laid aside, but only in proportion as this can be done without a return of the symptoms. The proper plan is to continue its use for ten days or a fortnight after the symptoms have disappeared, and then gradually to increase the interval at which it is taken; and in a few weeks, if no tendency to return appear, it may be laid aside. If, on the contrary, on lessening its frequency a tendency to return is perceiv- ed, it must be used, with the same frequency as at first, a little longer; and a time will come, which is different in different cases, when it can be lessened, and at length laid aside, with impunity. It is also necessary, for some time after recovery, to watch any tendency to a recurrence of the disease, and check it by having immediate recourse to the same treatment, which for the most part, is then only neces- sary for a few days. By these means a tendency to the disease gradually subsides, and permanent health is restored. After the disease has been allowed to become habit- ual, and any degree of permanent derangement of the liver is established, no less tedious plan than that just detailed will restore to permanent health; and if they are not aided by a correct regimen, the means will lose their power before the disease is eradicated. All the effects of medicine are impaired by habit, the first im- pression being the most effectual. When this happens, there is no alternative but a more effectual plan; and, in this case, I have always found it better to have re- course to the frequently repeated minute doses, than DERANGEMENT OF THE LIVER. • 225 greatly to increase the occasional mercurial: but the nature of the present Treatise does not admit of my entering on the various plans necessary in the more advanced stages of the disease, and which are consider- ed at length in my Treatise on Indigestion. I shall only observe, that when the plan we have been considering admits of any occasional increase of accumulation^ in the first intestine, or distention in the gall tubes of the liver, which will generally be indicat- ed by the patient complaining of a greater degree of op- pression, an occasional more active mercurial dose is beneficial; but if its frequent repetition becomes neces- sary, it is proper to have recourse to the more effectual plan, which will prove both more speedy and less debil- itating. The peculiarity in the effect of medicines in certain habits is not unfrequently experienced with respect to the different preparations of mercury, some of which I have already had occasion to mention. In some, the smallest dose of blue pill occasions nausea: I have almost always found in such cases that the stomach bears calomel well; the half or third part of a grain of this preparation may then be substituted for the three or four grains of blue pill, but it is more apt to irritate the bowels; and from this cause, and probably its passing more quickly along the alimentary canal, does not an- swer the purpose of an alterative so well. The tendency of mercurials to oppress the stomach, I have generally found in the opposite proportion to their activity. Blue pill is lighter than the hydrargy- rum cum creta, and calomel than blue pill; and the muriate of mercury, which can only be given in ex- tremely small doses, will often agree with the stomach, when all other mercurial preparations oppress it. The blue pill, however, in small doses, rarely has any effect of this kind; and is, on the whole, when well 29 226 • TREATMENT OF FUNCTIONAL prepared, the most convenient as well as effectual alte- rative. It is more effectual than the hydrargyrum cum creta, without being much more inclined to irritate the bowels, and it has much less of this tendency than the more active preparations. It is necessary for some time after the removal of the disease, that the means of preventing its recurrence should always be at hand, till the habit of health is es- tablished; but as I have already had occasion to observe, after it is once subdued, if the first recurrence be watch- ed, a very temporary use of the means is almost always sufficient. It seems to be from this, amongst other rea- sons, that indigestion is seldom permanently cured by the use of mineral waters, although often for the time greatly relieved. A due attention to diet is, at all periods of the dis- ease, indispensable. The following are the principles on which it should be regulated. Meat, provided the skin and much fat be avoided, and stale bread, are both the most easy of digestion, and the most nutritious articles of diet, although to certain stomachs bread is oppressive. That, in general, is the lightest which is best risen and soonest becomes dry. Mutton is the lightest meat, and the oily and mucilaginous meats the least so. Fish is both more difficult of digestion, and less nutritious. At the period of the disease we are speaking of, un- less there be some particular reason to forbid it, there is no objection to animal food twice in the day, but it should not be taken later than three o'clock. The sto- mach generally requires about six hours to digest an ordinary meal. This time, therefore, if the feelings of the patient will allow him to fast so long, should be al- lowed after each meal; some degree of hunger is a whole- some stimulus to the stomach, but a long continuance of it is injurious. DERANGEMENT OF THE LIVER. 227 If the food is not taken with relish, it is never well digested; and if one meal be taken before the digestion of the former is completed, the stomach soon becomes oppressed. Mastication is the first process of digestion, and when the food is not well divided and well mixed with the saliva, its other processes are never well per- formed by a weak stomach. Proper mastication has the additional advantage of putting the food slowly on the stomach. The appetite continues while there is any disengaged gastric juice in the stomach, and the powers of this juice being weak- ened in indigestion, it requires a longer time to combine with the food; if the dyspeptic, therefore, eat as fast as those in health, some part of this juice remains disen- gaged, till, from the consequent continuance of the ap- petite, the patient has put more on his stomach than it can digest. In weak stomachs, indeed, the gastric juice often does not flow freely till the stomach is stimulated by the food. Hence, it is common with them for the appetite to in- crease while they eat; and if the irritating remains of a former ill-digested meal continue on the stomach, the irritation it causes often excites a sensation which being confounded with the feelings of hunger increases it, and makes the patient think he never has had enough, and thus the evil is still increased. For all these reasons the dyspeptic should be careful to masticate his food well, and put it slowly on the sto- mach; for the same reasons he must take care not to eat too much. Different constitutions, we have seen, re- quire very different quantities of food. I have found it the best rule for the patient to leave off with such an appe- tite that about one-third more could be taken with plea- sure; and although the appetite is not satisfied at the moment, in ten minutes or a quarter of an hour it will 228 TREATMENT OF FUNCTIONAL be so; that is, when time is given for the whole of the gastric juice to combine with the food. This rule, for reasons just given, may sometimes de- ceive; but its errors may be very effectually corrected by the patient's observing whether any sense of oppres- sion succeeds the meal, which will not fail to ensue if the food remains undigested. Nothing in the diet of the dyspeptic is of greater con- sequence than making it simple. When we eat of a va- riety of dishes every new dish excites a fresh appetite, and it is impossible for us to judge when such a quan- tity as the stomach can digest is taken; and thus injury would arise, although all the articles were of equally easy digestion. Thus, although no general rule can be laid down, each patient may ascertain the quantity which suits his own stomach, a point of essential consequence; because any part of the food remaining undigested, is nothing less than a constant application of the cause of the dis- ease, which must necessarily baffle the means of cure. All hard animal substances are of difficult digestion; and all oily, stringy, and membranous substances whe- ther animal or vegetable; the fat of bacon, toasted like bread before the fire, that the flame may not render it empyreumatic, in some patients, being the only excep- tion I know. All fruits and fresh vegetables, and whatever else is inclined to ferment; all the fermented liquors of this country, for example, with the exception of distilled spirits, which are in another way the most pernicious of all, are usually oppressive to a weak stomach. Of vege- tables a mealy potato is the best, and peas, beans, and cabbage, the worst. Of fermented liquors, foreign wine is the only one which, in moderate quantity, appears to be innocent. Different kinds agree best with different stomachs. When DERANGEMENT OF THE LIVER. 229 French wines agree well with the stomach, they are the best, particularly claret; but the Spanish wines more generally suit a weak stomach: and whenever these cannot be used, and the habits of the patient render some fermented liquor necessary, a little distilled spirits may be substituted, and then the less the quantity, and the more diluted, the state of the stomach and gene- ral health admit of, the better. A liquid diet, whatever be the nature of the liquid, is unfavourable to digestion in a weak stomach. The gastric juice of such a stomach, already too feeble, will not bear much dilution. The contents of the stomach, however, may be too dry for their necessary motions; of this we have no measure but the thirst, and the comparative quantity of liquid which the patient takes: but liquids are often rapidly absorbed from the stomach; and in the thirst, as in the appetite of the dyspeptic, there is often a fallacy, and for a similar reason. The best rule is for the patient to drink when thirsty, but not copious draughts, a few mouthfuls will often quench the thirst. With the exception of a moderate use of wine, his drink should be water. It may be mixed with the wine, or taken alone, as he pleases. If the wine is taken undiluted, it should be taken after, not during dinner, as at this time it is an additional excitement to overload the stomach. A moderate quantity of wine seems to be innocent to those whose stomachs and con- stitutions agree with it: they who take it enjoy as good health and live as long as others. Peculiarities of constitution occasionally interfere with every rule; as far as these exist, the patient must be allowed to judge for himself. The object in view is a diet that is light and easy of digestion; and if he is in earnest, he will very soon, with the assistance of the foregoing observations, find out that which suits him. 230 TREATMENT OF FUNCTIONAL It appears from what has been said, that, in general, three meals in the day is the best number, the last always being a light one. After the irritations of the day, even the healthy are less fitted for irritating food, and the delicate are much hurt by it. Some, of quick- er digestion than usual, or more debilitated and conse- quently less fitted to receive the necessary quantity, or abstain the proper time, require four meals. It is of great consequence to observe regularity in meals. All the functions of the system are best per- formed at stated periods. A thousand circumstances prove that such is the nature of our constitutions. The importance of regularity is equally remarkable in the regulation of exercise and sleep. The early part of the day is the proper time for all the more powerful exertions of both mind and body. Towards night the various impressions of the day have pro- duced their effects, and the languor which succeeds all kinds of excitement is sensibly felt by the invalid. Repose is then more necessary, and exertion of every kind more apt to be injurious. In health, there is often some increased excitement of pulse in the evening. In the invalid it frequently amounts to a degree of feverishness, and is only effec- tually relieved by the most perfect repose, healthy sleep. Those are mistaken who imagine the period of the day allotted to exercise and to sleep immaterial, provided the proper length of time be spent in both; there is a diurnal revolution in the animal which cor- responds to that of the natural world. We are active and vigorous in the fresh air and rising dews of the morning, and more or less worn and relax- ed in the vapid air and falling dews of the evening. The healthy do not sensibly feel each deviation, but there is a sensible difference even in the appearance of those who habitually keep good or bad hours, although DERANGEMENT OF THE LIVER. 231 the latter may spend more time both in exercise and sleep. The languor of the evening in the invalid is not wholly the consequence of the exertions of the day. The evening air has always been found unfavourable to him, and in some countries it is very sensibly so to the most healthy. The peculiar quality of the morn- ing air is given by the contact of the cold and moist surfaces of the night; of the evening air, by that of the dry and heated surfaces of the day. Every one has felt the refreshing effects of a sudden shower after a sultry day. The evening and morning air is always, more or less, the air before and after the shower. The luxurious neither experience the freshness of the morning air, nor the calmness of the evening repose which nature dictates. Thus, as in all other in- stances, if we deviate from her laws, we only lose on the one hand as we gain on the other; and I believe, if the balance could be fairly struck, it would always be found in favour of her votaries. It requires much reflection to see all the consequences of any deviation from them. One effect produces another, and the tone of both mind and body are influenced by many cir- cumstances which, viewed barely in their immediate effects, appear of litttle moment. In the more obstinate diseases we must watch care- fully the state of those organs with which the seat of the present disease sympathises. In the present in- stance, the state of the head and lungs must be con- stantly kept in view, and that of the lower bowels often demands particular attention. They are little subject to organic disease; but the habitual irritation of their extensive and highly sensi- ble surface, in combination with the irritation of the original disease, preys on the constitution. I have seen in an old bilious case, in which there had for 232 TREATMENT OF FUNCTIONAL many years been an unusual degree of irritation in them, the patient, on taking cold, notwithstanding an advanced period of life and her family not being con- sumptive, fall into rapid pulmonary consumption; and her friends with surprise saw her sink in a few weeks under a disease to which they had never supposed her liable. She had been subject to what is called a bilious cough, but it was only temporary, and evidently arose from disordered stomach. By it, however, the lungs were prepared to suffer, and the long continued irrita- tion of the whole system had impaired the vigour of all its organs. Such a case is full of instruction to the reflecting physician, and gives us many lessons in the prevention of organic disease. Habitual disease is like the drop- ping of water on the stone; every drop does something, although its effect cannot be perceived. This, in the animal system, is what crime is in the moral; its effects extend in a thousand ramifications, and neither its limits nor its tendencies can be calculated. The func- tions both of mind and body are influenced; and who can number their functions, or trace all the effects of the changes in any one? The animal system is a whole; one part cannot be disturbed without more or less influencing every other. In the case just mentioned, the friends of the invalid could make no estimate of the causes which had every where gradually weakened the powers of life, and, from the peculiar sympathies of the constitution, the lungs in particular; they could only wonder that a per- son, none of whose friends had been consumptive, who in their opinion had never shown any tendency of the kind, should die of a more rapid decline than is usual in the most predisposed: and yet, with the proper clue, the effect appears only the consequence of the most common laws of our frame. DERANGEMENT OF THE LIVER. 233 Almost all the unexpected occurrences of disease may be traced to the sympathies which are constantly operating,—which, as I have already had occasion to observe, have obtained too little attention; and which, the more refinement increases our sensibilities, operate with the greater force. In proportion as the vigour of each part is entire, it is independent of others; in proportion as it is enfee- bled, it falls under their influence. If the hardy savage produces morbid distention of the stomach by an ex- cessive meal, he neither complains of headache nor is harassed by cough. With more time the stomach can do its own work, without disturbing its neighbours, and they are too much at ease to be easily disturbed. But when a thousand anxieties and irritations, with which he is unacquainted, have given to every nerve what may almost be called a morbid sensibility, depending on the same law by which the gums, naturally of little feeling, become morbidly sensible from the long irrita- tion of a carious tooth, each part feels the state of every other, and a door is opened to a thousand ailments. The complicated feelings of civilized life, while they sharpen the mind, enfeeble the body; as in the plea- sures of the luxurious, if we gain in one way we lose in another. 30 CHAP. VII. Of the Treatment of the Functional Derangements of the other Abdominal Viscera which precede Change of Structure. The bowels, we have seen, are little liable to organic disease; but, from the case mentioned towards the end of the last chapter, and many similar ones might be adduced, we have reason to believe that great and long- continued functional derangement in them may contribute to the establishment of organic disease in other parts. Its tendency to produce this effect, however, in propor- tion to the more confined sympathies of the bowels, is less than that of similar derangement* of the stomach and liver. I have already had occasion to observe, that in proportion as the seat of disease of the alimentary canal from the mouth downwards is distant in either direction from the stomach, its sympathies with other parts are the less powerful. But I have met with few chronic cases more obstinate or distressing than that morbid irritabili- ty of the bowels which is sometimes the effect of long-continued indigestion, but which in a great mea- sure, depends on a peculiar tendency in the bowels themselves; because, neither in its frequency nor its degree is it proportioned to the severity of the indi- gestion: and I have known it established when the patient had been so little troubled with derangement of the stomach, liver, and first intestine,—the organs whose affections constitute what more properly de- serves the name of indigestion,—that there was reason TREATMENT OF FUNCTIONAL, &C 235 to believe that they only suffered secondarily, the origi- nal cause being in the bowels themselves. The first symptoms are only such irregularity and occasional pains as often arise from indigestion in its various degrees; and as the symptoms are most felt when the principal digestive organs are deranged by any temporary cause, they are naturally ascribed to this derangement; to which, in all irritable states of the bowels, these organs are of course more subject than in health. By degrees, such affections of the bowels return more frequently and prove more obstinate, and begin to be accompanied by and leave behind them more or less general tenderness, on pressure, in the abdomen; for the most part, chiefly felt in the central parts below the navel, accompanied with a greater or less degree of fulness, and sometimes an oppressive distention. The action of the bowels is irritating, imperfect, and- unsatisfactory; the evacuations often watery and mucous. When the solid contents come away, they are fre- quently enveloped in mucus; and sometimes mucus, often more or less mixed with blood, is discharged in distinct masses, with great pain and irritation, and fol- lowed with a distressing bearing down, and a feeling that the bowels had only imperfectly emptied them- selves. The discharge of mucus is the effect of a morbidly copious secretion of that fluid which is poured out by all internal surfaces for the purpose of defending them against the irritation of their contents; and is always increased by causes of irritation, whether the conse- quence of the contents being more irritating, or the surface becoming more sensible to the ordinary degree of irritation. We see an instance of the latter when the membrane of the nose becomes too sensible from the effects of 236 TREATMENT OF FUNCTIONAL cold; and the air, constantly passing through it, ex- cites a morbidly increased secretion from its surface;— of the former, when the presence of stone in the bladder has the same effect on the surface of this organ. It often happens, when the bowels are thus irritated, that they contract upon and confine their more solid contents, while the watery part escaping causes the liquid evacuations so common in such cases. The retained faeces harden, and still add to the irritation; and when little liquid remains in the bowels, the mucus alone passes, and often appears unmixed, and in great quantity, and not unfrequently, the irritation occasioning some abrasion of the surface, it is streaked with blood. Attacks of this kind increase in frequency, till at length the patient is hardly ever free from some degree of them. The general constitution begins to suffer. The small contracted pulse of more or less increased frequency, which attends the attacks, becomes habitual, and at length constant; and I have known the patient, for months, and even years, with little intermission, confined to bed; and, even where no other disease had been induced, brought to a state of extreme suffering and debility, although this disease, which at length pro- duces an inflammatory state of the inner surface of the bowels, I believe chiefly the small bowels, rarely proves fatal, except by inducing others. The affection I am here describing is only a greater degree of the state which all who have suffered from severe indigestion occasionally, in a greater or less de- gree, experience. The effect for the time is nearly the same, whether the symptoms arise from the con- tents of the bowels being very irritating, or the bowels themselves having become too irritable. But the great difference in the two states is, that, like their causes, the one is of a transitory, the other of a permanent nature. DERANGEMENT OF THE VISCERA. 237 The indications of the cure are to soothe the irritated surface of the bowels as much as possible, to preserve the healthy state of their contents by all the means which tend to improve the abdominal secretions and otherwise secure and promote a healthy digestion, and to relieve the inflammatory tendency of the surface of the bowels, which their constant irritation supports, and which equally aggravates the symptoms and all their unfavourable tendencies. The diet should be in all respects such as best agrees with the dyspeptic, except as far as it is influenced by the inflammatory tendency in the bowels. On this ac- count it is often necessary to abstain from animal food, and use a mucilaginous diet; but the latter being of dif- ficult digestion, if used too freely, will, by deranging the bile and other abdominal secretions, rather increase than relieve the irritation. The same observation applies to mucilaginous medi- cines, which, properly administered, are generally soothing to the patient's feelings, and more perma- nently beneficial. The decoction of marsh-mallows, with a very small addition of gum-arabic, has appeared to me the best. It should be used on the day it is made. Much gum is both oppressive to the stomach, and binding in the bowels, and on both accounts inju- rious, our object being to relax the bowels excited to morbid contraction by the increased irritation. Oatmeal gruel, in such quantity as does not oppress the stomach, sweetened with soft sugar, is one of the best articles of this description. All preparations of this kind answer the double purpose of food and medi- cine. There is a popular one whose good effects I have witnessed:—balls of flour and water baked in an pven, grated and boiled in water; it forms a very soft fluid, and, I believe, is lighter than gruel. 238 TREATMENT OF FUNCTIONAL It must never be forgotten, that every thing of this kind will irritate if it oppresses the stomach. It ac- quires irritating properties by fermentation, and irri- tates still more by deranging the secretions. The reader will readily perceive, that all the means of pre- serving and restoring their healthy state, must be of great importance in a disease of this nature. Opiates would be invaluable in such cases, did they not in so eminent a degree possess the two properties so hurtful in them,—that of deranging the digestive organs, and constipating the bowels. I have found a few drops of laudanum and of wine of ipecacuanha in the decoction of marsh-mallows, rendered still softer by the addition of a small quantity of gum, or in some other mucilaginous mixture, beyond all comparison the best opiate in such cases. Such small doses of opium often have little tendency, either to derange the digestive organs, or constipate the bowels. The more ipecacuanha that is used, the medicine is generally the less binding—the more opium, the more soothing; and the ipecacuanha tends to prevent the bad effects of the opiate on the stomach, liver, and first intestine, as well as by relaxing the skin to relax the bowels also. The smallest doses only are proper, from three to five drops of laudanum, and from three to ten of wine of ipecacuanha: when much of the latter is used, it tends to increase the irritation. These doses may be repeated every two or three hours, and the one or the other ingredient increased or diminished according to circumstances. The more common dysenteric affections of the bowels may often be relieved more quickly than by any other means I know, by the judicious management of this mixture, mild aperients, and such means as relieve the inflammatory tendency. DERANGEMENT OF THE VISCERA. 239 It unfortunately happens that the most powerful means of improving the abdominal secretions, mercuri- als, are particularly offensive in this disease; and, in- deed, as we have seen in considering the treatment of bilious complaints, are often the means of bringing on its temporary attacks: and lessening the dose, so far from answering the purpose of preventing its bad effects, seems, particularly if frequently repeated, to add to them; for the smaller dose passing more slowly, the bowels are longer exposed to its irritation. In general, where there is great deficiency or de- rangement of bile, it answers better to give a larger dose at longer intervals, allowing it to rest for some time in the stomach and first intestine, and carrying it quickly through the bowels by an active aperient taken six or eight hours after it. Calomel is particularly irritating in these cases. Five or six grains of blue pill, according to my experi- ence, generally answer better than any other prepara- tion. Here, however, as in many similar instances, much often depends on peculiarity of constitution. It is desirable to make the mercurial effectual, that it may be repeated as seldom as possible. An observation I have had occasion to make, that the affection of the bowels in such cases often appears to be the original disease, and, consequently, that the derangement of the biliary secretion will often be increased by any cause which materially increases that irritation, must not be forgotten. When the abdomen becomes very tender, nothing so certainly gives relief as local blood-letting. In the earlier stages of the disease it often removes the ten- derness, and by relieving the inflammatory state, re- lieves the morbid irritability of the bowels, and thus allows them to relax; in consequence of which their contents are passed, and the tumefaction subsides. 240 TREAT3IENT OF FUNCTIONAL Leeches should either be applied to the most tender part of the abdomen, or near the anus; by the latter, blood is drawn from vessels in immediate communica- tion with those of the intestines. I have seen a very small discharge of blood from piles give immediate re- lief in such cases. It is surprising how very small a loss of blood will give immediate relief when the tension of the distend- ed vessels is great, the vessels instantly contracting on the slightest diminution of the distending power: this, of course, can only happen in recent cases. I once saw a man labouring under complete apoplexy, sit up in bed, and look about on those who stood by him, before two tea-spoonsful of blood had flowed from the temple. The distention of the vessels constantly re- turned, and latterly the greatest loss of blood that was warranted failed to restore any degree of sensibility. It always happens in the more obstinate cases of the disease before us, that the relief given by the local blood-letting is less and less perfect and immediate; and blisters generally cause a great deal of irritation externally, the inflammation of the blistered part impeding, and being increased by every motion of the body, while it is often impossible, from the pain, for the patient to lie still. In this way the inflammation caused by the blister being aggravated, sometimes spreads to the muscles, and every motion of the body produces torture. A lotion, composed of three or four grains of the super- acetate of lead and a tea-spoonful of laudanum, in four ounces of water made lukewarm, and applied to the part by a piece of surgeon's lint dipped in it and spread over the blistered surface, I have never known fail to give almost immediate relief, however much inflamed the surface was, provided it was applied before the inflammation spread to the muscles. DERANGEMENT OF THE VISCERA. 241 In such cases, the warm bath often allays the irrita- tion of the bowels; and I have known considerable relief obtained from a large warm poultice applied over the abdomen, or the injection into the bowels of warm bland fluids. In some cases, all means of relief are but temporary; and the patient, exhausted by pain and fever, is only able to leave his bed after weeks and even months of suffering, and that sometimes only for a short interval. If it appear, from the manner in which the symp- toms make their attack, the nature of its causes, and the history of the case, that ^the affection of the bowels is the original disease, the most assiduous appli- cation of the proper means in the commencement is often necessary to prevent its degenerating into such a state as I have described.(43) Repeated colds are then its most frequent cause, all risk of which must be guarded against; the diet ren- dered as bland as the state of the digestive organs will admit of, even the total abstinence from animal food is often proper; and a horizontal posture, which always (43) We do not presume to proffer our experience in opposition to that of our author, but we have been accustomed to pursue a more energetic practice in such affections of the bowels, and have never had cause for re- pentance. We have used the bland mucilaginous articles as palliatives only or in the convalescent state, and relied for remediate agency upon large and repeated doses of calomel, the spirits of turpentine, balsam copaiba, rhubarb, sulphate of alumine, Colombo and cubebs, aud other of the heroic agents, according to circumstances. We have not found that large doses of calomel increase, but allay irritation; and when we give it in smaller doses only, do we combine it with ipecacuanha, or add opium to avoid increased , irritation. There may exist reason for the prevailing dread of irritation and inflam- mation of the mucous coat of the alimentary tube, in Europe, which is un- known on this side of the Atlantic; for in this country we have been gene rally taught, that the most effectual plan for subduing those morbid condi- tions, is to create a new action or counter-irritation, by means of agent? sufficiently potent. 31 1 242 TREATMENT OF FUNCTIONAL tends greatly to relieve irritation of the bowels, as far as is consistent with due exercise, enjoined. Such cases, it may readily be supposed, sometimes terminate in confirmed dysentery, or even ulceration of the bowels. These consequences, however, according to my experience, are less apt to ensue than the symp- toms might lead us to expect. When, as in most cases, such affections of the bowels are merely the consequence of derangement of the principal digestive organs, they are generally of a more temporary nature, and can only be effectually prevented by restoring the healthy state of those organs. I have already had occasion to observe, that the chief seat of the foregoing disease is generally in the small bowels. The same means, varied in degree ac- cording to the degree of the symptoms, are proper when it is chiefly seated in the large bowels, which may be ascertained by the seat of the chief pain and tenderness on pressure, and the greater mildness of the general, compared with the local, symptoms. Bland injections, and leeching in the neighbourhood of the anus, are then generally most serviceable. The great bowels, we have seen, are more disposed to organic disease than other parts of the alimenta- ry canal; a circumstance which, though of rare occur- rence, and probably for the most part arising from other causes than those which produce the affection we have been considering, or at least from other causes in combination with these, must never be forgotten in the treatment of their diseases. Of the tendency to organic disease of the spleen and pancreas, for reasons already given, little can be said here. It is impossible to apply a remedy, when we have no means of detecting the disease: we are even wholly unacquainted with any of the circum- DERANGEMENT OF THE VISCERA. 243 stances which dispose to disease of the pancreas, with the exception of the general tendency to organic dis- ease given by affections of the nervous system. Organic disease of the spleen, we have seen, is apt to arise from certain acute diseases, and, perhaps, occa- sionally from all severe affections of the liver; and must be prevented, in the former instance, by the means which prevent acute laying the foundation of chronic diseases; and in the latter, by the various means of re- storing the liver. We have no means of ascertaining a tendency to organic disease of the mesenteric glands, except a gene- ral tendency to glandular obstruction, which can only be relieved by the means which restore the due func- tions of the nervous system, which have been detail- ed. Of the affections of the uterus, which chiefly de- mand attention in such a treatise as the present, I have had occasion to speak in the chapters on the treatment of plethora and pulmonary diseases. CHAP. VIII. Of the Treatment of Organic Disease. So generally fatal is change of structure in a vital organ, that, for the most part, the patient's fate is re- garded as decided as soon as it can be clearly ascertain- ed that this has taken place. In some instances, how- ever, the prognosis is less decided; and in many we can alleviate the symptoms and check the progress of the disease, when we can do little or nothing to repair the mischief already done. It appears, from all that has been said, and the con- clusion is confirmed by all our experience respecting the treatment of organic diseases, that as deranged function is generally the cause of change of structure, the great means of correcting it is, as far as we can, to restore the natural function of the part. Those organic diseases, therefore, are the most cer- tainly fatal which, in the first instance affecting only minute parts of the organ, make considerable progress without sensibly disturbing its function. And of those which more early betray themselves by functional de- rangement, the degree in which they are curable is always proportioned to the power of our means in cor- recting that derangement. It also appears that the tendency to organic disease is generally proportioned to the inflammatory tendency of the habit, and particularly of the part chiefly affect- ed. Active inflammation runs immediately into change of structure; and languid inflammation, though slower in its effects, leads as certainly to the same result. OF THE TREATMENT OF ORGANIC DISEASE. 245 All the great changes of the animal body, we have seen, take place in the extreme parts of the nervous and sanguiferous systems, because it is there alone that their powers co-operate. It is, therefore, in the means which influence the extreme parts of those systems alone, that we can find any aid in either preventing or correcting change of structure. Those directed to other parts of the system are more or less effectual in proportion as they influence them; and the conclusions, to which we are thus led, all our experience of disease of structure amply confirms. Such are the principles on which the treatment of organic disease is founded. I shall take a rapid view of the means of relief we possess in the organic dis- eases of the different vital organs: and it is mortifying to observe how scanty, and, in the great majority of cases, ineffectual, they are. It is very difficult to say how far the means of cor- recting functional derangement is capable of correcting the first beginnings of organic disease of any vital or- gan, because it is impossible for us to ascertain their existence at so early a period: but there are many rea- sons which would lead us to suppose that they fre- quently have this effect. We see cases, even where organic disease would be of the most fatal nature, in which we know, if left to their own course, it would soon ensue, yield to such means; and that in some cases they restore the healthy structure after its de- rangement, and that to a great degree, has been ascer- tained. In the obscurity of the commencement of organic disease, the power of the healthy function in preserv- ing the healthy structure, and the diminution of the power of our means in proportion to the continuance of the disease, we find the strongest motives for watching 246 OF THE TREATMENT and correcting the first beginnings of functional de- rangement. The moment at which the change from functional to organic disease takes place, which generally decides the patient's fate, we cannot tell: but we well know that, in most cases, such is the effect of the continuance of the former; and that, the longer it continues, it not merely approaches the nearer to this change, but that the difficulty of preventing it rapidly increases in the more advanced stages. The ship, when first caught in the whirlpool, a gentle breeze may save; but the strongest must fail as it approaches the centre, and may accelerate its destruction. There is a period in disease when powerful medicines do nothing but harm; they cannot repair the evils done, and only add their own irritations to the sum. The early stages of organic affections of the brain are involved in peculiar obscurity: partly from the com- plexity of its structure, and the vast variety of its func- tions, and partly from its being enclosed in a bony case, which prevents all attempts at manual examination: and it would only be a waste of time to say any thing of the treatment of organic disease of this organ after it has become apparent, except that we must endeavour to check its progress by all the means of preserving the general health, particularly those which obviate the in- flammatory tendency without increasing the debility, and, as much as the circumstances of the case admit of, afford repose; for all powerful action of a diseased organ increases the mischief. These means have been fully considered in speaking of the functional derange- ment of the brain. Many of the foregoing observations apply, in nearly the same degree, to the organic diseases of the heart. Notwithstanding the simplicity both of the structure and function of this organ, they are nearly as little OF ORGANIC DISEASE. 247 under control as those of the brain. The chief differ- ence is, that seeing here more clearly, both, the nature of the disease, and the manner in which the means of temporary relief operate, we are better able to adapt them to the circumstances of the disease, and the par- ticular case under treatment. Our practice, therefore, is more determinate, and, as far as our aim goes, that of obtaining temporary relief, more successful. It is also more successful, because the means are more under command. The heart has but one function,—that of propelling the blood. To this alone, therefore, and the general state of the health, our views are directed. Experi- ence has told us that neither active nor alterative means can remove the disease, nor even sensibly retard its progress; the treatment, therefore, is confined within very narrow limits. A mild diet of the most easy digestion; a regular state of the bowels; being much in the open air, under such exercise as does not aggravate the symptoms; such means as lessen, as much as is consistent with the general state of health, the labour the debilitated heart has to perform, and those which occasionally assist its action, comprehend the whole. When it is considered that the stomach peculiarly sympathises with the heart, the importance of a diet of easy digestion, in all diseases of the latter organ, will be readily admitted. But here, although it is our ob- ject to make the diet easy of digestion, it is neither proper to make it very stimulating or very nutritious. Animal food, although the most easy of digestion, produces more blood, and that of a more stimulating quality, than a diet composed of vegetable substances: hence a difficulty we sometimes have to contend with. A diet even in part composed of animal food, often too 248 OF THE TREATMENT much increases the labour of the heart; and a wholly vegetable diet is apt to oppress the stomach. Those vegetable substances must be chosen which are least apt to have this effect,—stale bread, rice, &c, and the quantity proportioned to the powers of the stomach; and in the early stages a little animal food is often proper. But the digestion, in many cases, is little further weakened than as it partakes of the gene- ral debility; for affections of the heart, probably from its being an organ of less sensibility, less influence the stomach, than those of the latter influence it. The kind and quantity of the food must be regulated by the degree in which the power of the heart is im- paired, and the state of the general habit affected. The object is to supply as small a quantity of blood as will duly support the functions of life; that the mass of blood to be moved may, in some degree, be propor- tioned to the weakened powers of the organ which has the greatest share in impelling it. For the same reason, all other causes which increase the rapidity of its motions must be avoided, still, how- ever, with due attention to the state of the general health. In the early stages, walking in the open air at such a pace as in no degree disturbs the heart, is proper; but as its inability increases, active must be changed for passive exercise, first that of horseback, and, when this begins to be too great an effort, that of a carriage .or a boat. If the patient is not carried off suddenly, from some cause of excitement occasioning a greater return of blood to the heart than can be trans- mitted, he becomes incapable of all kinds of exercise, and, at length, even of the erect position. All causes of irritation, although in a less degree than exercise, tend to quicken the circulation; and both on this account, and by their more direct effect on the heart, are injurious. OF ORGANIC DISEASE. 249 The bowels should be kept moderately free; the temperature such as suits the patient's feelings. A free circulation of air he finds particularly grateful; for every thing which interferes with the free action of the lungs necessarily impedes that of the heart. All causes of mental excitement also should, as much as possible, be avoided, particularly all excitement of the passions: that of sudden anger has here not unfre- quently been the immediate cause of death. With respect to medicines, the nature of the case at once informs us that little is to be expected from them. Where the debility is so great, stimulants and tonics are naturally suggested; and did we not understand the nature of the disease, all its symptoms would often be aggravated, as so often happens in other cases, the nature of which is more obscure, by constant attempts habitually to increase the force of the circulation; yet even here the temporary use of stimulants is often proper. In a disease where every motion threatens to over- power the action of the heart, a tendency to fainting is necessarily a frequent occurrence; and, from the im- mediate sympathy between the stomach and heart, stimulant medicines often for the time relieve it, be- cause the heart feels their effect more than it is felt by the other powers of circulation, so that the momentary increase of its vigour is greater than of the quantity of blood returned to it. Such medicines ought to be, like the causes of the affection they relieve, of the transitory kind. Ammonia and the essential oils are the best; and, in the fits of palpitation, what are called nervous medicines, because they tend to allay nervous irritation, of which I have already had occasion to speak, and digitalis, often give temporary relief. Digitalis operates in part by its sedative power on the heart itself; but it also gives relief, in the case be- 32 250 OF THE TREATMENT fore us, by at once, through the nervous system, lessening the power of the vessels in every part of the body, and thus lessening, for the time, the quantity of blood returned to the heart. In this way, its habitual use often enables the patient to use rather a fuller diet. It has an effect similar to that of rendering the diet less stimulating: it renders both the heart and vessels less sensible to the stimulus. The dose must be re- gulated by its effects. When to the foregoing means we add such medi- cines as are necessary to ^correct acidity,—for which pur- pose the carbonate of soda or liquor potassce will gene- rally be found the best,—and other causes of irritation in the stomach, with an occasional mercurial when the action of the liver is disordered,—and here calomel is generally better than the less active preparations of mercury,—we have nearly completed the scanty cata- logue of medicines suited to organic disease of the heart.(44) If the use of any other be beneficial, it is of those which insensibly promote the action of the skin; which, by causing a freer perspiration, more thoroughly purge the circulating fluids of those parts which have become useless and irritating, and thus often conduce to more comfortable feelings, and a more composed state of the whole system, as well as to prevent a superabundance of those fluids. The medicines which seem here best suited to those purposes, are the acetate of ammonia and the milder antimonial preparations, particularly the sulphuret. Unless the immediate effect of such medicines be grateful to the patient, the advantage de- rived from them will hardly compensate for the risk of (44) Blood-letting ought to obtain a place in this enumeration, as the best means of lightening the labour of the heart when oppressed by ple- thora. OF ORGANIC DISEASE. 251 their oppressing the stomach, and the trouble of taking them, when every effort is a trouble. When we are assured that organic disease is estab- lished in the lungs, the case is nearly as hopeless; for it has generally made great advances before we are assured of its existence. This may appear surprising respecting an organ with the diseases of which we are so familiar: but in the earlier periods, we have no means of judging, except by the state of the breathing, cough, and expectorated fluid, all of which present nearly the same appearances when the air-tubes are irritated by the presence of unsuppurated or closed tubercles, or by causes external to the lungs. Nor are we assisted either by sounding the chest, by gently striking different parts of it, or the use of a lately invented instrument: for, although either of these means readily point out where and to what ex- tent the lungs are obstructed, neither will tell us whether the obstruction arises from tubercles or other change oi structure, or thick and viscid fluids clogging the air- tubes and cells.(45) The best diagnostics of the establishment of organic disease of the lungs belong to the advanced stages, and are derived from the appearance of the expecto- rated fluid and the state of the fever. When the regular exacerbations and morning sweats of hectic fever su- pervene on the increasing pulmonary symptoms, we (45) The Stethoscope has no doubt been greatly overrated, yet it does often communicate intelligence of mournful events. It is still very dubi- ous whether its discovery will prove a greater benefit or curse. It requires more acuteness of perception than many possess, and a longer training than most will undergo, to enable them to form correct diagnoses from its application. Hence' mistakes of the most mischievous tendency may be made; unfavourable prognostics may be pVonounced and patients consigned to hopeless phthisis, from the presence of a little viscid mucus in the bron- chial tubes or some other slight accident of those organs, or perhaps, from an error in the s ii«o of the explorer. 252 OF THE TREATMENT may be assured that organic disease of the lungs is far advanced; and we may make the same inference from states of the expectorated fluid which I shall soon have occasion to describe. But we know that organic disease of the lungs may exist to a great degree before it can be detected in either of these ways, and sometimes without betraying itself by any other symptom than cough and more or less difficulty of breathing, and, in certain rare instan- ces, it has existed even without cough. The following are the most remarkable cases I have met with, illus- trating these observations. A man in the lower ranks of life, between thirty and forty years of age, of robust make, and very fat, but of an unhealthy appearance, complained of consider- able difficulty of breathing, and a troublesome cough, increased by exercise, by which he expectorated nothing but a little phlegm and mucus. He had no other complaint: his pulse was of the proper frequency, and the temperature natural. It was found impossible effectually to relieve either the cough or difficulty of breathing, the latter of which gradually increased till he died of suffocation, no marked symptoms but the consequences of a gradually increasing difficulty of breathing having supervened. He continued to eat his victuals, and suffered no sensible loss of flesh. The surgeon who examined the body after death, and who was much accustomed to make such examina- tions, said he had never, in any other instance, seen so great a collection of fat about the heart: yet this man's lungs were found wholly converted into clusters of small tubercles, many of which contained purulent matter, but all closed, no matter being found in the air- tubes or cells. This case strongly countenances the opinion that closed abscess of the lungs does not pro- duce hectic fever. OF ORGANIC DISEASE. 253 A gentleman rather more advanced in life, who had led the irregular life of an officer in the time of war, and suffered much from a wound in the leg which ren- dered amputation necessary, laboured under all the usual symptoms of diseased heart. Water of the chest gradually supervened and proved fatal. During the whole course of the disease he was free from cough, yet the lungs were found extremely disorganised. They contained no tubercles, but were, in many parts, converted into a substance like liver. The heart was much enlarged, and both this organ and the lungs showed many marks of chronic inflammation. Such cases are chiefly useful by preventing our plac- ing too great reliance even on the circumstances which least frequently deceive us. We have here the lungs converted into a cluster of suppurated tubercles, without either fever or emaciation; and the structure of the same organ extensively diseased in another way, and affected with chronic inflammation, which doubtless had caused the change of structure, without cough. The more the symptoms incline to those of tuber- cular consumption, and the less to those of an inflam- matory state of the windpipe and its branches, we have the more reason to believe that change of struc- ture has taken place. The following appear to me the best means of distinguishing these cases:— The more florid and clear the complexion of the patient is, the less he is troubled with what is called bilious complaints; and the less these have preceded his present complaint, the less variable the symptoms are, and the less they are influenced by the state of the stomach: the less the spirits are depressed, and the more confidence the patient has in his recovery, the more we have reason to believe that the disease has originated in the lungs. 254 OF THE TREATMENT We have reason to make the same inference when the expectorated fluid is rather suddenly increased in quantity, and at the same time assumes more of the purulent character, especially if the purulent matter appear in small distinct masses; if it be occasionally mixed with blood, and particulurly if the blood be much mixed with it, and still more if they be now and then so perfectly mixed together, as to present the ap- pearance of a thick creamy mass of a reddish hue, the masses of matter at the same time increasing in size,— if the difficulty of breathing has been uniformly increas- ing, and has been uniformly increased by exercise, and not remarkably so by meals,—if it is little changed by the recumbent posture, and the patient complains little of a sense of tightness about the stomach,—if the cough is little inclined to come on in fits, and is rather fre- quent than severe, and, like the breathing, not much influenced by meals, but easily induced by exercise, and often by speaking,—if he has a fixed pain or other un- easiness,—constantly referred to one particular part of the chest, particularly in the front or sides, and most felt when he attempts to make a deep inspiration,—if, from sounding the chest, the obstruction of the lungs does not appear to be chiefly in the lower part of the right lobe, and if the hectic fever be completely form- ed, the morning perspirations being most profuse about the chest and head, and the emaciation rapid. When, on the contrary, the patient is sallow, and has been long troubled with bilious complaints, and still continues to be so,—when there is tenderness and fulness in the region of the lower orifice of the stomach and first intestine,—when the cough and difficulty of breathing are variable, and the former particularly dis- tressing in fits of various duration from a few minutes to a few hours, these symptoms being less influenced by exercise, and more by meals and a recumbent pos- OF ORGANIC DISEASE. 255 ture, the patient complaining of a sense of tightness across the pit of the stomach, and his spirits being de- pressed; when the expectoration comes on early and is copious, when the purulent matter in the expectorated fluid appears in streaks rather than masses, when- the blood, if any, is little mixed with the other parts of this fluid, when there is no fixed pain in any part of the chest, or the pain is in the back part of it, particularly about the shoulders, and less affected by a deep inspi- ration, when, on sounding the chest, the greatest de- gree of obstruction appears to be in the lower part of the right lobe of the lungs, when the fever does not assume the regular form of hectic, there being no morn- ing perspirations, or such only as are irregular, and the emaciation is slow, there is reason to believe that the affection of the lungs is secondary, and has arisen from disorder of the liver: the chance of recovery, in the earlier stages, being much better, and depending, in a great degree, on the proper treatment of the biliary complaint. As this species of pulmonary consumption advances, however, it more and more assumes the form of that in which the affection of the lungs is the original disease; and, in the last stage it hardly in any respect differs from it except that the hectic is seldom so perfectly formed. At this period, however, the most distinguishing mark of hectic—the morning perspiration—is, even in the original disease of the lungs, less uniform than at the height of the disease. The fatal termination, in both cases, is now equally certain; and the appearances on dissection are, for the most part, the same, except that, in biliary consump- tion, we generally find the right lobe of the lungs most affected, and some traces either of disease of the liver, or of its having existed; for we have seen that when 256 OF THE TREATMENT disease of the lungs is established, that of the liver ge- nerally disappears. In these cases, the structure of the liver is rarely disordered: for, as I have already had occasion to re- mark, affections of this organ often cause organic disease of the lungs, when its own affection is only functional; and when traces of disease in it are disco- vered by dissection, they are generally only those of chronic inflammatory action; and so slight a degree of disordered function of the liver is often capable of affecting the lungs of the predisposed, that it is com- mon, in biliary consumption, to find no trace of disease in this organ. There is little reason to believe, when tubercles have come at all into an active state, particularly when they have suppurated and begun to discharge their matter into the air-tubes and cells, that the due structure of the lungs is ever restored; and it must remain doubtful if, even in their incipient state and when they are least inclined to inflame, they are ever resolved; although there are strong reasons, both from analogy and the course the disease occasionally takes, to believe that this is the case. I have mentioned sufficient reasons for believing that their nature is allied to external glandular swellings, which we often see, after remaining for a longer or shorter time in an indolent state, wholly disappear; and we sometimes see recovery from cases of pulmonary consumption where we have every reason to believe, from the nature of the symptoms, as well as the course of the disease, tubercles, in their more indolent state, had existed. It is also in favour of this opinion, that we know that indurated states of the liver and me- senteric glands,—affections allied in their nature to tubercles,—sometimes admit of cure. OF ORGANIC DISEASE. 257 If this happen at all in the case of tubercles, it must be more frequent in the symptomatic than origi- nal affection of the lungs; because, in the former, we have it more in our power to relieve them, from the cause which produced and supports the disease, and we sometimes see recovery in a stage that precludes hope in the latter. I have already had occasion to point out the treat- ment of the earliest stage of both species of pulmonary consumption, in the chapters on the treatment of the early stages of functional derangement of the lungs and liver. When the state of the lungs depends on that of the liver, the two plans of treatment must of course be combined; and the presence of the pulmonary dis- ease only influences the treatment of the biliary affec- tion, by rendering it still more necessary, by every means in our power, to save the strength. For my opinions respecting the various means to be employed in the more advanced stages of both species of the disease, I have already had occasion to refer to a Trea- tise on Indigestion, and the fourth edition of that on Symptomatic Fevers. Of the treatment of organic disease of the stomach there is little to be said. As in the case of organic disease of the heart, we have no reason to believe that we possess any means of cure, or even of arresting its progress; nor have we any means of retarding it but those which tend to retard the progress of all organic diseases; the means of preserving the general health, and particularly counteracting the inflammatory ten- dency, both in the general system and the part affect- ed, by a cooling regimen and medicines, and as far as the patient's state will admit, local blood-let- ting and other discharges from the neighbourhood of the stomach, when it becomes tender on pressure, and 33 258 OF THE TREATMENT the removal of all causes of irritation, particularly those making their impression directly on the part affected. The treatment of organic disease of the liver de- serves more attention; because we are not destitute of means capable of influencing, and even sometimes wholly removing it. I have often had occasion to call the reader's attention to the facts, that long-continued derangement of func- tion is the most fruitful cause of organic disease, and restoring the healthy function the only means of cure; and the greater success we experience in the treatment of organic disease of the liver than in that of the or- gans we have been considering, appears to depend on our possessing a medicine of peculiar power in restor- ing its function. The effect of a brisk mercurial aperient in restoring, for the time, the function of the liver, is familiar to every one; and we have seen the effect of frequently repeated small doses, continued for a sufficient length of time, even where its failure has become habitual. We are now to consider the proper employment of this medicine when organic disease is established in it, which, in a large proportion of cases, defies all its powers, and in the most favourable, requires its long- continued and assiduous employment. The employment of mercury in the case before us, as far as we can see, is less influenced by the nature of the organic derangement of this organ, than the effects it has produced in other parts. Of the first of these subjects our knowledge is extremely defective. We know, from dissection, that the liver is subject to vari- ous kinds of organic derangement; but as we can sel- dom distinguish them except by dissection, this know- ledge is of little use in practice: nor do we know to what particular organic affection of the liver mercury is most applicable, except that the more generally the OF ORGANIC DISEASE. 259 organ is affected—that is, the less the disease is of a local nature—the more readily, for the most part, it yields. We know that when the liver is enlarged and indu- rated, we can sometimes reduce and soften it by means of this medicine; and the principal questions to be de- termined in its use are, the circumstances of the dis- ease under which it is likely to prove most bene- ficial, the most beneficial manner of using it, and the doses requisite to produce the desired effect. As we have seen that the disposition to organic dis- ease is proportioned to the degree in which the ves- sels of the part are affected, that is, in proportion to the degree in which the irritation caused by the de- rangement of its nerves has deranged the circulation in the part; that this derangement is always of an in- flammatory nature, and that all causes of inflammatory action, whether of the part itself, or of the general system, promote the establishment of organic disease; we find, after its establishment, that all such causes tend to confirm it, and promote its progress, and con- sequently to oppose the operation of the means of cure. On the other hand, organic disease of vital organs is, for the most part, accompanied by a debilitated state of the general habit, which, by weakening the healing powers of the constitution, never fails to increase its obstinacy. In order, therefore, to bring the habit into the state most favourable to the removal of organic disease, and, consequently for the operation of the remedy, we must, at the same time that we lessen the inflammatory ten- dency, do all which the circumstances of the case ad- mit of to support the strength. These indications, in a great degree, oppose each other, and our practice must lean to that side where the symptoms are most urgent. 260 OF THE TREATMENT Our great resource is a combination of general with local means, to support by the former the general powers of the nervous and sanguiferous systems; and by the latter to lessen, as much as we can, the determination to the part affected, the consequence of the greater debility of its vessels, by which we relieve both the inflammatory tendency of the part, and that of the general habit which depends upon it. It fortunately happens, in the case before us, that the liver is so situated as to be readily made a subject of manual examination. If it be very tender on pressure; and the pulse much contracted, striking the finger when lightly touched like a wire, (for we are not here to look for the pulse of active inflammation, which is ge- nerally both strong and hard,) we may be assured that the mercurial will be less useful till these symptoms are mitigated, and will hardly fail, if freely administered, to increase them. It is therefore necessary, under such circumstan- ces, that it should be given cautiously: for even un- der these it should be given. It is one of the great- est advantages of the minute and frequently-repeated doses, to which I have been gradually led by the effects of this medicine, that they do not occasion that excite- ment of the general system which we observe from larger doses; and, by tending imperceptibly to restore the functions of the debilitated part, and thus remove a principal source of the irritation which attends the dis- ease, and exciting all the secreting surfaces, they often eventually prove the most effectual means of removing the inflammatory tendency. However little ground is gained by each dose we keep it, and thus the good ef- fects accumulate. When larger and more distant doses are employed, the effect of one is more or less lost before the next is given; and thus often little pro- OF ORGANIC DISEASE. 261 gress is made, or perhaps, notwithstanding the tempo- rary relief, the disease, on the whole, is increasing. But, although the small doses are little inclined to increase the inflammatory tendency, from the gentle- ness of the impression they make, they necessarily op- erate slowly; and, while the inflammatory state is con- siderable, their benefit is less felt. Local blood-letting, therefore, is essential to speedy relief, wherever there is much tenderness on pressure of the liver; and where, from its having been frequently repeated, or an unusual languor in the vessels of the part affected, it has not its proper effect, which is often the case when the disease has been of long standing, it must be aided by blisters, applied over the part; while, if the general excitement of the system goes the length of producing any degree of general increased heat, this must be allayed by small and repeated doses of the nitrate of pot- ash and henbane. The latter adds to the cooling effect of the nitrate, by allaying nervous irritation; and, in chronic cases, is often of great importance, by enabling us to lessen the dose of the saline medicines, all of which are more or less debilitating. In urgent cases, the blister should follow the local blood-letting as soon as the general excitement is suffi- ciently allayed to render its application proper. It fortunately happens, in the languid inflammation of chronic cases, that it is seldom necessary to reduce the diet more than the diminution of the appetite re- duces it. When the patient is inclined to eat meat, if it does not produce any sensible increase of tempera- ture, it is always right that he should have it; and even when it has a little of this effect, if small doses of the saline medicine easily allay it, it is often better that it should be continued, than that the strength should be reduced by too low a diet. 262 OF THE TREATMENT In this point, we must, of course, be guided by cir- cumstances. If the excitement produced by the meat be such as either materially to increase the local symp- toms, or to be followed by greater depression than the change to a diet wholly farinaceous would occasion, it must be abandoned. Similar observations apply to wine, the use of which must be regulated by the patient's habits and its effects; but, as the state of the appetite does not here limit us, and the feelings of debility naturally incline to a free use of stimulants, harm is often done by it, and particu- larly in the case before us, from the peculiar effect of fermented liquors on the liver. When neither the tenderness of the part affected, nor the tightness of pulse and tendency to increased heat, is great, and the patient's habits temperate, it ge- nerally answers best to allow him his usual quantity of wine. The debility, in such cases, is often one of the most pressing evils; and the maxim with respect to all strengthening measures, in such cases, is to employ them as far as the state of the patient admits of; and with respect to debilitating measures, no further than is required. The circumstance which, next to the inflammatory tendency and the state of the strength, most influences our means of treatment, and particularly the use of the mercurial, is the nature of the consequences which the obstructed liver has produced. I have just had occasion to observe, that the minute and frequently re- peated doses are necessarily slow in their effects. By them no sudden effect is attempted. They act by slow- ly and imperceptibly altering the habit, and thus often produce results which cannot be obtained by other means; but they are not calculated to produce the sud- den effect required in urgent cases: the impression they make is not sufficiently powerful to be speedy. OF ORGANIC DISEASE. 263 Before I turn the reader's attention to those cases, I shall concisely lay before him the particulars of one case treated by the small doses, that he may the better understand the effects of such doses, at once the most effectual and safest mode of employing the mercurial in all cases to which it is applicable. An officer, between thirty and forty years of age, returned from India in a state of great debility. His countenance was sallow, and at once informed the ex- perienced eye that he laboured under organic disease. His liver was much enlarged and indurated; he was subject to severe inflammatory attacks, which increased his debility, and frequently brought him into immediate danger; and the whole of his state was such as is sup- posed rarely to admit of a perfect restoration to health. The temporary attacks were relieved by local blood- letting, and such means as allayed the pain and quick- ly restored a freer secretion of bile; and, in the inter- vals, he was desired to take half a grain of a blue-pill, and a grain of extract of henbane, three times a day, with such medicines as allayed the tendency to fever. The most nutritious diet, of easy digestion, which his state admitted of was enjoined; and he was desired to be as much as he could in the open air without any de- gree of fatigue, or the risk of taking cold; and as his strength improved, to make walking his principal exer- cise. In a short time he experienced a sensible improve- ment in his health; the severity of the occasional attacks abated, and, in the space of some months, ceased to return. He could now move about with more ease, although the enlargement of the liver was still consid- erable; and, after being made acquainted with the cir- cumstances necessary to be attended to, he was not prevented from going to the country, and the Conti- nent, to which his affairs called him. His recovery 264 OF THE TREATMENT gradually advancing, he repeatedly thought himself well enough, according to the directions I had given him, to permit the alterative to be discontinued; but was constantly obliged to return to its use. I saw him, from time to time, without finding any reason to change his plan of treatment; assuring him that the time would come when the means might be laid aside, without a return of the disease, and that it only required the habit of health to be longer main- tained by the medicines, in order to render it perma- nent without their aid: for hardly any enlargement of the liver could now be perceived; and, at each interval, the improvement, both of his looks and strength, was apparent. 1 still advised him, from time to time, to try how far the alterative could be laid aside, but to return to it as soon as he perceived the least threaten- ing of his symptoms. At the end of more than two years from the time he had begun to use the alterative, during which he was uniformly recovering his strength and healthy appear- ance, he found my prediction verified. He no longer required the use of medicine: all enlargement of the liver had disappeared; and he had, in all respects, re- gained both the feelings and appearance of health. He returned to the service, but not to India; and, although several years have now elapsed, he has ex- perienced no return of his disease. I have related the circumstances of this case at greater length, because they tend to illustrate several positions of the foregoing treatise, as well as the effect of the alterative. It is only where organic disease has actually taken place, that so long and constant an em- ployment of the alterative is necessary. In the preceding case, the more severe attacks were of such a nature as yielded quickly to active treatment: but organic disease of the liver sometimes produces OF ORGANIC DISEASE. 265 such as are of a more obstinate nature, when the only alternative is a continuance of the most active means of treatment, or a certainly fatal termination; and then it is always in some degree doubtful, whether the disease or the treatment most strains the constitution. I have already had occasion to speak of its effects on the brain and lung6. One of the most formidable is dropsy of the belly; ?nd, as this effect in adults seldom takes place except in those who have been exposed to the frequent effects of highly debilitating causes, the patient is generally a bad subject for active treatment. Even here, the state of the symptoms is often such as makes it necessary to commence the treatment with abstraction of blood from the region of the liver; for in the more acute, as in the more chronic cases, all our plans will be baffled, if any considerable inflammatory tendency is allowed to continue. In both, it equally opposes the effect of the alterative; but, I believe there is hardly any case of this kind in which bleeding from the arm is proper. The general force of tho circula- tion is, for the most part, sufficiently reduced: it is the local effect on the disease of the liver that is required, and which is here the best means of relieving any general excitement that may attend, wholly arising, as it does, from the state of that organ. To