« السابقةمتابعة »
and has chiefly embarrassed all practitioners. The most general precept on this subject is liable to exceptions; but, collecting what on the whole is safest and most expedient, it must be one which forbids bleeding as an ordinary practice in the disorder. The adynamic type throughout in the greater number of cases; the singular disproportion in all between the seeming severity of the inflammatory symptoms and their real slightness or nullity; the actual failure of bleeding in mitigating the violent and painful cough which seems most expressly to require it; and the frequent success of remedies precisely the reverse of this;—all show a specialty in the disease, to which we must refer, more or less directly, in every question of practice. Whatever the cause or precise seat of irritation, it is certain that it has rarely the characters of true membranous inflammation. In truth, the same reasons which prevent or limit bleeding in hooping-cough apply no less to the peculiar cough and irritation of the influenza. We have rarely any authority for it in the state of the pulse; which neither in strength nor frequency bears relation to these seemingly inflammatory symptoms. While the difficult or painful respiration, which often suggests the remedy, furnishes evidence against its fitness, by becoming frequently more laborious than before;-the effect of larger accumulation in the bronchial cells, and of diminished power.
These are all points of great interest in practice. It is less needful indeed to enforce them now, as the repeated experience in several epidemics, speedily following each other, has given general knowledge and warning on the subject. It is certain, however, that much injury resulted from the error, before this experience was obtained; and especially in the treatment of those of infirm habit, or who were advanced in years.
Exceptions there undoubtedly are to the principle just laid
down. In some habits, prone to inflammation, the first reaction of the disorder may pass into what is really this state, and require blood-letting for relief. There are other instances where the congestion on the lungs is such in degree as to demand the same remedy. And I believe on my own experience that these latter instances are more frequent than the former, and carry with them more distinct justification of the means employed. It is hardly necessary to add that, when used, it should be as early in the disorder as possible; with a cautious regard to age, and with close observation of the effects on the pulse, cough, and respiration. When there is much doubt existing, blisters may expediently be tried first; and especially where the cough is the symptom most urgent in the case. The epigastrium I believe to be generally the best place for their application.
The conditions which thus render bleeding for the most part improper, go further, in sanctioning to a certain extent the treatment which has for its express purpose to excite or sustain the vital powers. And accordingly cases are not infrequent where stimulants give immediate relief to symptoms which, on first aspect, and interpreting them by other diseases, would seem to require very different treatment. Here happily, as I have before observed, the pulse is generally a more faithful guide; and there are few cases where, if fairly consulted, and in immediate sequel to the means employed, it may not be relied upon for direction. If wine or other cordials give it force and steadiness, without adding to its frequency, and without exciting fresh cough, the inference may safely be drawn as to the treatment of the disorder in its future progress.
But watchfulness as to these tests is always needful, to guard against exceptions to the general rule, and excess in the methods so suggested. Stimulants may be used earlier,
or to greater extent, than it is fit they should be; and morbid actions brought on which would not otherwise have existed. It is well indeed to repeat here regarding the treatment of influenza, that the majority of cases require rather the forbearance of the physician than any strenuous use of active remedies, upon whatever principles adopted. Still it is important that these principles should be fixed as far as possible, and made capable of ready application to the more urgent, though rarer, cases which come before us.
The only other remark I have to offer regards the use of bark, or the sulphate of quina, in the influenza. Its value here is unquestionable; derived not simply from its quality as a tonic, but further, and more especially, from its specific power in various intermittent affections. Any inference that might be drawn as to its use, from the tendency in the disorder to these intermittent actions, is fully justified by the actual effects. It relieves them, when fully established, almost as speedily and certainly as the attacks of a common ague; and this whatever the part of the body so affected. This remarkable power over one of the conditions of the disease gives so far a specific character to the remedy, that it may rightly be adopted in prevention of a state which it is capable of curing. It is not easy, however, to define an exact time at which its use should be begun. This must vary in different temperaments, and in different degrees of the disorder. Occasionally the irritable state of the membranes of the alimentary canal creates a hindrance requiring either precaution or delay. But it is an inference from the reasons already stated, that bark may be given safely and beneficially in many cases where there is still hard cough, with pain, oppression, and restlessness;— and experience confirms this conclusion. A soft feeble pulse, and moist skin, often concur with these symptoms, and furnish additional
authority for the practice. If the cough itself, as frequently happens, tends to intermittent character, the security of the remedy becomes greater, and its effects more speedy.
It may seem that I have drawn upon my notes at too great length, regarding a disease not very frequently occurring, and the suggestions as to the treatment of which are rather negative than positive in kind. To this it may be replied, that we are wholly ignorant when, or how often, the epidemic may recur;-that the long lapses of time without appearance of it are quite as extraordinary as its frequent return of late years; that the lesson of forbearance in some points of practice is as valuable as that of activity in others; -and that the best chance of reaching further knowledge on the subject is to define exactly the limits of that we now possess. Any excuse that may still be wanting for the length of these remarks must be found in the singular character and history of the epidemic, and in its relation to other diseases; points to which I have already sufficiently adverted, and which render the topic a very interesting one to the medical inquirer.
ON DREAMING, INSANITY, INTOXICATION, ETC.
DREAMING insanity in its many forms-intoxication from wine or narcotics—and the phenomena arising from cerebral disease, are the four great mines of mental discovery still open to us; if indeed any thing of the nature of discovery remains, on a subject which has occupied and exhausted the labours of thinking men in all ages. These several states, singly and in their connexion with each other, unfold facts, and illustrate relations, which seemingly could have been known to us from no other source. By the curtailment or suspension of certain functions, by the excess of others, and by the altered balance and connexion of all, a sort of analysis is obtained of the nature of mind, which its waking and healthy acts cannot equally afford, either to individual consciousness or the observation of others.
The following remarks refer chiefly to the states of dreaming, intoxication, delirium, and insanity; the conditions which arise from obvious disease, though they illustrate the others in many most important points, being in some respects better considered apart.
The relations and resemblances of these several states are well deserving of note, even in their most general aspect. A dream put into action (as in fact it is, under certain conditions of somnambulism) might make madness in one or other of its most frequent forms; and, conversely, insanity may often with fitness be called a waking and active dream.