/ £>- X STIMULANTS AND NARCOTICS STIMULANTS AND NARCOTICS, THEIR MUTUAL RELATIONS: WITH SPECIAL RESEARCHES ON THE ACTION OF ALCOHOL, .ETHER, AND CHLOROFORM ON THE VITAL ORGANISM. BY FRANCIS E. ANSTIE, M.D., M.R.C.P. Assistant Physician to Westminster Hospital, Lecturer on Materia Medica and Therapeutics to the School, and formerly Lecturer on Toxicology. PHILADELPHIA: LINDSAY AND BLAKISTON. 1865. !8fe5 pYlw a/0 , 5/36 Ol« . /^ HENRY B. ASH.VEAD, PRINTER. PREFACE. The purpose of this work is, of necessity, imperfectly rep- resented by its title-page. No sentence of moderate length would have expressed the whole scope of the inquiry; a few prefatory words are therefore particularly needed, in order that the reader may appreciate the objects aimed at. These objects are two—to destroy and to reconstruct; or rather to show, in some degree, how reconstruction may be possible in the future. The historical chapter on the origin of the doctrine of stimulus makes no attempt at an exhaustive treatment of its subject, my only aim being to prove clearly that the source of the Vitalistic notions on which our classification of reme- dies is based is to be found in certain metaphysical theories. The dynamical terms which many modern writers employ ought not to be permitted to deceive us; they are, in fact, X PREFACE. but the artificial clothing of a mode of research which is unconsciously but purely metaphysical, and, as such, ex- tremely unfitted for the purposes of the physiologist or the physician. It is the mixture of a phraseology based on this kind of speculation with a perfectly skeptical empiricism in practice, which has brought the science of therapeutics into the extraordinary state of confusion in which we see it at the present day. It is the profound conviction that a com- plete review of our principles of classification is necessary, if experimental inquiry is to bring us any advantage, which has induced me to write the first two hundred and forty pages of the present volume. The special researches which make up the latter part of the work are intended as the first of a series of pidces justifi- catives, which I hope to publish as evidence that the views promulgated in this book are not without solid foundation in observed fact. They by no means include all my re- searches on the properties of alcohol, chloroform, and aether, but only such of them as bear more directly on the questions treated in the other parts of the volume. If fault be found with their arrangement or the manner of their relation, it must be remembered that the difficulty was great of select- PREFACE. xi ing, from a large quantity of material which I had collected, such portions as would best illustrate my subject within the compass which a work like the present affords. For the special use of the word Hypnotism, which I have employed as signifying the production of natural sleep, and not in its modern and very inaccurate application to the phenomena of mesmerism, I think I need hardly make any apology. On another matter I must say a word. In one or two instances, owing to the progress of science during the writing of this volume, an author is quoted only partially in the early sheets, and more fully in the later ones (this was un- avoidably the case with regard to the opinions of Dr. Ead- cliffe). A glance, however, at the table of contents will enable the reader to follow with so much ease the general course of the work, that I believe no serious misapprehension will arise from it. One feature in the work is sufficiently important to justify my calling the reader's attention to it; namely, the presence, among the notes at the end of the volume, of two biblio- Xll PREFACE. graphical indexes, which may be of considerable use, I be- lieve, to any one who desires to follow up the line of thought developed in my book. To my numerous friends who have helped me, my warmest acknowledgments are due. To Dr. Reynolds the book may be said to owe its birth, since his kindness enabled me to solve the most serious preliminary difficulties as to its form and publication. To Dr. Radcliffe's writings I am indebted (in a degree which the pages of my book will testify) for materials of thought and experiment, and to his kindness for many additional hints, and one or two valuable cases. Dr. Buzzard, my colleague Mr. H. Power, Dr. Way, J. C. Whitehorne, Esq., and other valued friends, have wearied themselves in advising and in correcting ; and last, not least, I have to thank H. Chandler, Esq., of Pembroke College, Oxford, Dr. Meryon, and the Rev. H. Wace, for suggestions as to the sources of the necessary information, on many historical points, which were invaluable. For everything in the book, however, I am solely responsible. 16 Wimfole Street, Cavendish Square. March. 1864. TABLE OF CONTENTS. INTRODUCTION. Reasons for reinvestigating the subject of this work •» Plan to be followed . . . J PAGE 25-39 CHAPTER, I. HISTORY OF THE DOCTRINE OF STIMULUS AND ITS PHILOSOPHI- CAL ORIGIN IN THE VITAL THEORIES OF THE ANCIENTS. Plato ..... Aristotle ..... Hippocrates .... Democritus, Epicurus, and the Methodists The Pneumatists and Aretaeus The Stoics and Galen Nemesius .... The Arabians The Church in the Middle Ages The Revival of Platonism; Ficinus The Rosicrucians Paracelsus Van Helmont . Descartes .... Bacon .... Willis .... Glisson .... Boerhaave Stahl ..... . 41 42 . 43 43 . 43 44 . 45 45 . 45 46 . 46 47 47-50 50 . 50 51 . 51 52 . 52 XIV TABLE OF CONTENTS. PAQE Hoffmann ......... 53 Haller..........53 Winter .......... 54 Cullen..........54 James Gregory ......... 55 John Brown .......... 55 Darwin .......... 57 Vicq. d'Azyr . . . . . . . . .58 Rasori and the doctrine of Coutra-stimulus ..... 59 Broussais .......... 60 John Hunter ........ .62 ' Cellular" Physiology .. . . . . .64 "Cellular" Pathology—Virchow ...... 65 Dr. Hughes Bennett . . . . .66 Dr. Todd.........67 Mr. Lister .......... 67 MM. Bernard and B'rown-Sequard ...... 69 Dr Radcliffe ......... 70 Dr Radcliffe's views on Animal Electricity and Muscular Contraction (see also p. 229) ......... 70 Reaction from the doctrines of Broussais, under Laennec, &c. ... 71 Dr. Harley on the action of strychnia . . . . . .72 Unfortunate consequences of the literal interpretation of the vital theories of the ancients by their successors . . . . . .75 Modern writers- on Therapeutics, and their definitions of iStimulus, e.g. Pereira ........ .76 Wood ......... 77 Neligan ......... 78 Headland ......... 81 CHAPTER II. CRITICISM OF THE DOCTRINE OF STIMULUS. This doctrine assumes that— All mental excitement; All increased sensibility, and pain; All convulsive muscular action; All considerable increase of secretion; All increase, whether of force or frequency of the heart's action, Are caused by, and the proofs of, a stimulant action upon the organism . . 83 TABLE OF CONTENTS. XV i.—Mental excitement, however, is not a proof of stimulation. Analysis of the inebriation produced by alcohol . . . .85 opium .... 85 hashish . . . .86 Mental excitement rather implies cerebral paralysis ... 87 ii.—Increased sensibility and pain are no proofs of stimulation. Pain of neuralgia ........ 88-92 myalgia . . . . . . . .92 certain inflammations ...... 92—94 wounds . . . . . . . .94 receding alcoholism ...... 94 of mortification . . . . . . .94 Sir W. Hamilton's theory of Pleasure and Pain .... 94 Objections to theory that pains are ever 'the reflex of an overstimulated energy" ......... 95-97 Sir W. Hamilton's distinction between " perception proper " and "sensation proper" . . . . . . ... .97 iii.—Muscular convulsion does not prove antecedent stimulation . . .97 iv.—Increased secretion does not prove antecedent stimulation . . 98 Brown-Sequard, Bernard, Gairdner . . . . . .98 Author's case of unilateral flushing and sweating . . . 98-100 v.—Increased rapidity of circulation does not prove antecedent stimulation 101 vi.—Increased nutritive, or formative action, does not prove antecedent stim- ulation ........ 102-104 CHAPTER III. SUGGESTIONS FOR THE RECONSTRUCTION OF THE DOCTRINE OF STIMULUS. Figurative use of the word Stimulus to be retained .... 105 Necessity of realizing what we mean by " Life " .... 105 Dr. Inman on Vital Force ........ 106 Coleridge on Life ........ 107 Grove on Correlation of Forces ....... 108 Carpenter on Correlation of Vital and Physical Forces . . . 108 Dr. Radcliffe on Correlation of Vital and Physical Forces .. . . 109 Mr. Lewes on Vital Principle ....... 109 Life can only be properly defined as the "Individuation" of organized creatures 111 Genuine effects of stimulation ....... 112 XVI TABLE OF CONTENTS. i-acie i.—The relief of pain— Action of food, in neuralgia, in inflammatory pain (case) . . 113 opium on pains of catarrh, hunger (cases), inflammations 115-119 ammonia compared with that of opium . . . 119 alcohol in relieving pain (case) ..... 120 counter-irritants in pain ..... 121 food-tonics in relieving pain (case) . . . 121-123 ii.—Removal of muscular convulsion, &c, by stimulants. Action of chloroform in minute doses (case) .... 123 ammonia (cases, Dr. Reynolds and Author) . . . 125 alcohol (case) ....... 126 Observations of Dr. Radcliffe ...... 128 Action of food-tonics . . . . . . . .128 iii.—Reduction of unduly frequent circulation by stimulants . 129 iv.—Reduction of excessive secretion by stimulants .... 129 v.—Relief of general debility, or special fatigue of brain, muscles, digestive organs, &c. ......... 130 vi.—Removal of delirium, maniacal excitement, and coma, and production of natural sleep by means of stimulants— State of brain circulation during sleep, according to Mr. Durham . 131 Extreme anaemia favors delirium and coma, according to Todd . . 131 In sleep the brain naturally tends to recover from the disorganization produced by exertion . . . . . . .131 In delirium there is no such tendency, e.g. delirium tremens . . 132 Injurious influence of true narcotics in delirium .... 132 Delirium requires to be treated with stimulants, especially with food . 132 " Delirium ferox:" Dr. Murchison's opinion (case) .... 133 Production of natural sleep by food and other stimuli . . . 133 Objections to Mr. Durham's theory, as to the cause of certain forms of insomnia ........ 134 vii.—Support of the organism by stimulants in the absence of common articles of nutriment . . . . . . . .135 Objections to the ordinary explanation of this phenomenon . . 136 Food action of coca . . . . . . .136 tobacco ....... 137 alcohol ....... 138 opium ....... 139-111 viii.—Local increase of nutrition, caused by stimulants— By opium ......... 141 By strychnia ....... 142-143 The stimulant action of atmospheric oxygen shown to be an epitome of the above described "genuine effects" of medicinal stimulation . 143 Objections to the common arguments for a complete physiological distinc- tion between stimulants and foods. "Temporary" character of stimulant action . \.\(\ Stimulus is not followed by a " recoil," as usually stated . 147 Fallacious appearances which give plausibility to the common opinion . 117 TABLE OF CONTENTS. xvii PAGE Counter-irritation, when beneficial, not followed by any recoil . 148 Tobacco-smoking, when moderate, not followed by any recoil . . 148 Small doses of opium not followed by any recoil . . . 149 Foods are not all transformed in the body ..... 149 Proposals as to the use which shall in future be made of the word " stim- ulant," &c. ........ 150 CHAPTER IV. THE DEFINITION OF NARCOSIS. Origin of the word (Hippocrates, Erotian, Aristotle, Homer, Plato, Galen) . 152 Sir W. Hamilton's opinion as to the ancient sense of the word Narcosis; and objections to this opinion ....... 153 Proper distinction of the words "Nepenthes," "Anodyne," from "Narcotic" by the ancients, especially Galen ..... 154—157 Discussion of the distinction commonly made between " Narcotics" and "Seda- tives," and rejection of the same ..... 157-159 Hypnotism is no part of true narcosis ...... 159 Definition of narcosis proper ....... 160 General symptoms of narcosis ....... 161 Variations in the course which the symptoms of narcosis may take, illustrated by the action of opium in varying circumstances (experiments on animals, &c.).........162-167 Physiological significance of various symptoms of narcosis . . . 167 CHAPTER V. SYMPTOMS OF NARCOSIS. Mental phenomena. Inebriation . . . . . . . . .171 with alcohol . . . . . . 171 with chloroform . . . . . . .172 with hashish . . . . . . .173 Involuntary reminiscence— Produced by alcohol (case) . . . . .174 chloroform . . . . . .174 opium (De Quincey) .... 175 hashish (De Luca, O'Shaughnessy) . . . 175 xvm TABLE OF CONTENTS. PAGE Narcotic reminiscence compared with that which occurs during the delirium of fever, of epilepsy (Coleridge, Radcliffe) . . . . .176 Narcotic reminiscence, compared with the powerful memory, for certain sub- jects, of the mentally deficient (cases) . . . . .177 Involuntary fancy (hallucinations, illusions)— De Quincej', Von Bibra, Ac, »" Renewal of Life," a work which requires some notice here, because it contains, along with much which I cannot agree with, certain views of disease which point to a comparatively new and unworked field of therapeutical inquiry. The position which Dr. Chambers seeks to establish is this: " That disease is, in all cases, not a positive existence, but a negation; not a new excess of action, but a deficiency; not a manifestation of life, but partial death ; and there- fore that the business of the physician is, directly or indirectly, not to take away material, but to add; not to diminish function, but to give it play ; not to weaken life, but to renew life."* I have preserved the original ty- pography, in order to give all the emphasis to this doctrine which its author could desire. It happens that my own attention has for a long time past been directed to the alimentary character of numerous drugs, and to the fact that modern practice includes a constantly increasing selection of such remedies in its pharmacopoeia. Of the truly alimentary character of some medicines, such as cod-liver oil and iron, there is no longer any dispute, though there are differences of opinion as to the mode in which their food-action takes effect. But with regard to many other sub- stances, there is the greatest opposition of views, and especially * "The Renewal of Life." By Thomas K. Chambers, M.D., &c. Churchill, Lon- don ; Lindsay and Blakiston, Philadelphia. 34 STIMULANTS AND NARCOTICS. with respect to the whole class of narcotic-stimulant medi- cines, and of their congeners—tea, coffee, tobacco, and the like, which are in use as articles of every-day consumption. I cannot but think that a work professing to treat of such vast questions as those propounded by Dr. Chambers should have included something more serious on this subject than the short and rather superficial chapter on Alcohol at the end of the volume. It so happened, that owing to the circumstance of my being for several years (between 1855 and 1861) in the constant habit of administering chloroform, I became interested in the action of anaesthetic agents of various kinds, and made a great many experiments, both on animals and on the human subject, and I particularly investigated the action of small doses of these substances. Some of the results obtained in the latter way were so unexpected that they led me to extend my inquiries to various other narcotic agents, with particular reference to the influence of alterations of dosage; and the consequence has been that I have been led to propose a dif- ferent explanation of the medicinal effects of many narcotics in common use from that which is ordinarily stated. I wish to call the reader's attention to the remarks and to the clinical illustrations, which he will find in the section on Stimulation, on the production of sleep and the arrest of con- vulsive movements by medicinal doses of opium, chloroform, sulphuric aether, and other remedies which in common par- lance are called narcotics, and to the comparison instituted between the action of these substances, given in this way, with that of undoubted stimulants, such as ammonia, and with that of common foods. I feel that it is impossible for me to do full justice to this very important subject, but I should be only too glad to initiate further inquiry. It has surprised me very much to find that more notice has not been taken of this aspect of the question by authors who have written expressly on the Use and Abuse of Narcotics; espe- cially as the facts of the case, although in an isolated form INTRODUCTION. 35 have been noted by various writers, and only needed careful collation and comparison to suggest important inferences. Some of the remarks of Dr. John Brown (hereafter to be quoted) on this topic are pregnant with interest, although he unfortunately thought it necessary to incorporate them with a highly complex theory, which was destined to go the way of all such devices for explaining every difficulty in medicine, and converting it into a science of certainties. The profession, and the public generally, have a right to complain that the writers of systematic treatises on Thera- peutics have shown too great a disregard to certain broad and important facts as to the daily use of the so-called nar- cotics (which, in truth, are also stimulants) by persons in a state of ordinary health; and it is necessary to state these facts clearly, even at the risk of saying what is not new to the reader, because they have a direct bearing on the par- ticular views which will be put forward in the course of this work. The first of these is—that there is no nation, and that there are very few individuals, who do not make daily use of some substance to which the term Stimulant Narcotic may be applied in strictest accordance with what we know of the action of drugs. Von Bibra* puts the matter roughly, but strikingly: " Coffee-leaves are taken, in the form of infusion, by two millions of the world's inhabitants. " Paraguay tea is taken by ten millions. " Coca by as many. "Chicory, either pure or mixed with coffee, by forty millions. " Cacao, either as chocolate, or in some other form, by fifty millions. " Haschisch is eaten and smoked by 300 millions. " Opium by 400 millions. " Chinese tea is drunk by 500 millions. " Finally, all the known nations of the world are addicted * Von Bibra, " Narkotischen Genussmittel und der Mensch "—Preface. 36 STIMULANTS AND NARCOTICS. to the use of tobacco, chiefly in the form of smoke; otherwise, by snuffing or chewing." Professor Johnstone* completes the picture thus drawn, by an ingenious map, in which it is sufficiently shown that no considerable tract of the earth's surface is without some special indigenous narcotic plant, of which the natives freely avail themselves, not merely for medicinal purposes, but for every-day use. Nor is the use, in every-day life, of these substances an out- growth of modern corruption; on the contrary, it is conse- crated by whatever sanction immemorial custom can confer. There is absolutely no period of history, as there is absolutely no nation upon earth, in which we do not find evidence of this custom. Against these weighty statements there is nothing to be said; they are as free from any admixture of fallacy as they could possibly be. It is idle to urge that the subject of a carefully prepared experiment can be made to live in apparent health without the use of any of the substances vulgarly called Narcotics, if the practical fact be that nations cannot, and never have been able to, do without them. Under these circumstances it is the duty of the physiologist to inquire very seriously whether there is not some practical test by which we may distinguish the effect which is hurtful, from the effect which the instincts of men teach them to be- lieve is useful. But this task is of immense difficulty. It can only be approached, with the remotest chance of success, by means of a simultaneous use of the facts which are known, or can be discovered, as to the action of the narcotic-stimu- lants in disease, of those which the every-day experience of a large number of healthy consumers of narcotic-stimulants supplies, and of those which transpire when the victims of the abuse of these powerful physiological agents come under the care of the physician. I need hardly say that it is neces- sary entirely to exclude the special moral and religious aspects * " Chemistry of Common Life." INTRODUCTION. 37 of the question if we wish to arrive at a sound, scientific re- sult. What we desire is not a test of this kind—which in human hands is liable to be so much perverted—but some- thing positive, tangible, capable of physical demonstration. Such a test there must surely be, if we could only find it. It is inconsistent with our ideas of the order and design of the universe, that so important a matter as the discrimination between foods and poisons should be left to chance or instinct, without the possibility of certain knowledge. Our best hope of arriving at this knowledge lies in studying diligently the nature of those actions which we call stimulant, and of those which we call narcotic, respectively, in order that we may analyze that compound result which is observed to be pro- duced by the administration of those substances which are capable of producing both these effects. I venture to think that, notwithstanding the frequency with which we use both these terms, we seldom realize to ourselves what we mean by them. I think so for this reason—that we constantly hear people designate the same physiological actions interchange- ably by both these names; and that it is easy to trace, in the familiar .expressions we use in common conversation or ordi- nary clinical description, that, in fact, we do not recognize the distinction between them. In this way the greatest con- fusion arises, both in our physiological and our therapeutic notions; and the consequence is that we seldom realize fully, when prescribing one of those remedies which stand on the debatable ground, whether we intend to produce a stimulant or a narcotic effect. Another source of much obscurity in our ideas is the use of the word Sedative in its modern sense. The action of "Seda- tives" has been made to signify something different from the depressing part of the influence exerted on the nervous system by narcotic-stimulants; it has been supposed that sedatives act chiefly upon the sensitive nerves, and that therefore they are to be distinguished from all other depressors of nervous force. How unreal this distinction is, I shall hereafter en- 38 STIMULANTS AND NARCOTICS. deavor to show; meantime it has occasioned a great deal of trouble and anxiety to the student, who might otherwise have contented himself with using the word "stimulant" to express an agent which exalts nervous force, "narcotic" to signify one that depresses it, and narcotic-stimulant for one which produces both kinds of effect. The plan which will be adopted in the ensuing inquiries is as follows: The first section will be devoted to the consider- ation of various theories of stimulation which have been pro- posed, and I shall endeavor to give an explicit idea of the actions which ought to be included under that general name, illustrating my remarks by clinical and physiological obser- vations. The general features of sedative action will next be sketched, the common features which distinguish all varieties of this effect indicated, and the apparent contradictions as far as may be reconciled. The mode in which the two kinds of physiological effect are combined in the narcotic-stimulants will be then described; and a short chapter will be given to those substances which produce distinctly irritant poisonous effects, simultaneously with their narcotic effects. As it would be clearly impossible, on the mere score of space, if for no other reason, for me to dwell minutely on the individual members of such very large classes of medicines as the stimulants and the narcotics, I shall content myself, in the body of the work, with isolated examples taken from the action of the more prominent members of these groups. The latter portion of the volume will be taken up with a more extended series of observations on the three principal mem- bers of that group of narcotic-stimulants commonly known as the " Anaesthetics," viz., alcohol, chloroform, and ether. These substances have been chosen for detailed examination, as well from their great importance as from the fact that many features of their action upon the organism are already familiar to most readers. I feel that it is necessary for me to bespeak a very patient hearing. Some of the views which I shall have to bring for- ward are opposed to ideas which have become, by the influence INTRODUCTION. 39 of tradition, incorporated into the stock of things which are received as matters of course. I can only say that a con- siderable amount of experimental familiarity with the subjects of the present inquiry has convinced me that more is com- monly taken for granted than will stand the test of proof in regard to these matters; and that this is particularly to be noted, that the ordinary mode of reasoning on the effect of physiological agents is vicious, ab initio, because it retains, in many cases, the unmistakable impress of metaphysical speculation applied to things with which it has really no fit connection. My object will be fully attained if a more general interest be awakened in the profession, in the bearing on therapeutics which the facts of common life, apart from the circumstances of actual disease, assuredly have. It is no stigma on the reputation of those who have already handled the subjects which I am now to deal with, that their writings exhibit, as I think they do, a too limited view of the scope of medical inquiry. It was but yesterday that disease was uni- versally regarded as something entirely foreign to the vital organism, which came to it from without, resided in it for a time, and then departed, exorcised by the physician's art. To-day we are inclined to take a less exalted view of our functions, to confess ourselves to be but the humble assistants in those curative processes which Nature herself initiates, and very often carries through without our help, or even in spite of our ignorant interference. Together with such changed ideas there must come a revolution in our modes of therapeu- tical inquiry; and notably, a disposition to compare those instances of the beneficial action of drugs which are well au- thenticated, with similar effects produced by the unaided operation of natural causes. And it is surely lawful to hope that even partial success in this direction may prove more advantageous to the progress of our art than the most bril- liant reasoning which should presuppose the physician's power to effect radical alterations in the working of the vital agen- cies, whose operations we are only just beginning dimly and partially to understand. CHAPTER I. THE DOCTRINE OF STIMULUS.—HISTORY. The history of the doctrine of Stimulus may be said to be the history of medicine itself. At least we find traces or foreshadowings of this doctrine in the discussions which agi- tated the medical schools of every age, if we except that remote period of antiquity in which, as yet, no theory of vital action, of the nature of disease, or of the modus operandi of remedies had appeared, and medical inquiry was confined to an empirical search for substances possessed of curative prop- erties. It need hardly be said, however, that the modern ideas of stimulation are widely different from the form in which the process first figured itself to speculative minds. So marked is the difference, that one* of the few writers who have at- tempted to trace the history of the doctrine refuses to allow the existence of any distinct theory on the subject prior to the sixteenth century, near the commencement of which cer- tain authors spoke of the "irritation exercised by the humors on the solids." I believe this to be a partial and incorrect view. The truth seems to be, that the modern discussions on Stimulation, Irritation, Vital Excitation, and the like, are but a part of a much larger question, which has been debated in every age. " How is it that mind can enter into relation with matter, so that the two things, so utterly dissimilar, may react upon each other?" In the early speculations of great thinkers upon this endless topic, we may, perhaps, find the clew which we require. The great father of the medical art—Hippocrates—lived in * Broussais. De l'irritation et de la folie, p. 48. Paris, 1828. THE DOCTRINE OF STIMULUS.—HISTORY. 41 a time and country in which such questions excited a vivid interest. In him were united the sacred dignity of the Escu- lapian priest; the high philosophic culture of the age and of the nation which produced his contemporaries, Socrates, Plato, and Aristotle; and a power of accurate observation of natural phenomena unrivaled in his own or any other time. That such a man would leave the mark of his thought upon the medical science of many succeeding centuries was inevitable: nor was it less certain that the thoughts thus handed down would reflect the philosophic spirit of his age, and that the example of their great teacher would incline his successors to study medicine, not as a thing apart, but as one branch merely of a general philosophy. It is, therefore, a matter of great interest to ascertain what were the views of vital action which were held by the great philosophers of his day, and how far they were modified by him in consequence of his practical acquaintance with vital and morbid phenomena. The doctrine of Plato as to the relations of matter to intel- ligence in the human organism is expressed in the Timaeus.* He there represents the Supreme Deity as committing into the hands of the inferior gods the intelligent soul, in order to the creation of man. These deities construct for it a mortal body, and form within this a kind of mortal soul, possessed of passions and appetites. This mortal soul is placed within the trunk of the body, and is thus separated, by the whole length of the neck, from the head, wherein is lodged the immortal part, in order that the divine nature may not be sullied more than is necessary by contact with the baser. Further, the mortal soul is again divided into two parts, whereof the nobler, which partakes of courage and spirit, and loves strife, is situated within the cavity of the chest: being thus more immediately under the control of the reason, which resides in the head; while the appetitive part is located in the abdomen (chiefly in the liver). The heart is placed in a * Timseus, \ 69-70. Ed. Stallbaum. Etudes sur le Timee de Platon. Par T. H. Martin. Paris, 1841. Notes 139, 167, 186. 4 42 STIMULANTS AND NARCOTICS. kind of watch-house, and being connected with the members by means of the veins, it is able, when informed by the reason of any evil committed in the members (from any foreign cause, or any internal passion), to send through all its chan- nels the threatenings and exhortations of reason, and thus reduce the body to perfect obedience. The lungs are placed around the heart, in order that being soft, and bloodless* and spongy, they may cool the heart when it is inflamed with passion. The office of the nvev/ia, or breath, is to cool the blood; and the various obstructions and diversions of its course to which it is liable are the cause of many diseases. According to Aristotle, the vital principle of every living animal and plant resides in the germ.f He describes it as something which may be called heat; but which is not fire, but a spirit, which is of the nature of the sun and stars. For fire begets nothing, nor is anything composed by the dense,J the moist, or the dry; but the sun's heat, and the heat of animals (not only that which is in the germ, but also if there be any kind of excretion), this also has a vital principled He says that the soul contains the body, rather than the body the soul, a doctrine which, as Sir W. Hamilton|| re- marks, was the basis of the common dogma of the schools, that the soul is all in the whole body, and all in every of its parts. This residence of the soul in every part of the body may be the reason, according to Aristotle, why severed por- tions of some insects may continue to show signs of vitality, the *vxy itself being divisible. Of the functions of the brain as an organ of intellect, Aristotle knew nothing. He places the mortal soul in the heart, as did also Zeno, and the Stoics generally, at a later period.! Like Plato, he believed that * This part of the description is, of course, exactly the reverse of the truth. f De Generatione Animalium, lib. ii, cap. 3. De partibus Anim., lib. ii, cap. 2. I The reader will recognize the reference to the Pythagorean doctrine of the four elements, which was held by the great majority of ancient philosophers. g De Anima, lib. i, cap. 5. || Notes on Reid, p. 856, foot-note. f For an abstract of the Aristotelian doctrine, see Sprengel, Geschichte der Arznei- kunde, Th. i, p. 528-30. THE DOCTRINE OF STIMULUS.—HISTORY. 43 one chief office of the nvevfia, or breath, was to cool the blood, and that it acted in some way as an important instrument of mind in its operations on the body. The existence of a materialistic school of philosophy (as represented in Hippocrates' time by Democritus particularly) requires a word of notice here, in order that I may state that, so far as I can perceive, the Corpuscular theory had no real share in the foundation of a doctrine of vital irritation, either at this time or in its later development by the Epicurean philosophers, and by the methodic school of medicine founded by Asclepiades and Themison. From first to last, in the history of medicine, the Corpuscular doctrines, which were in total opposition to the Hippocratic, were more or less over- borne by the latter, which ultimately obtained a decided ascendancy, chiefly through the powerful advocacy of Galen. Such was the philosophic atmosphere in which Hippocrates lived; its influence is very conspicuous in his writings. He accepts the Pythagorean doctrine of the four elements (prob- ably in a far more literal sense than did Plato or Aristotle), and he erects upon it the theory of the four principal humors of the body. He recognizes the existence of an intermediate nature, the source of vital activities (™ hopfiuv—the impetum faciens of later writers) which is distinct from the immortal soul. He seems to identify the pneuma, or breath, with the very soul itself, at least such is the apparent meaning of a passage in his treatise on Epilepsy.* He recognizes a vis medicatrix natura, in virtue of which the organism reacts against hostile influences, and by means of the processes which we call disease, tends to cure its own disorders. In the first century of the Christian era, Athenaeus of Attila founded a system of pathology, in which great prominence was given to the influence of the pneuma, and the supporters of which were thence called Pneumatists. According to this school, the phenomenon of the pulse in arteries was due to * De Morbo Sacro, xvii. Ab. Kaau Boerhaave. " Impetum faciens." Lugdun. 1745. 44 STIMULANTS AND NARCOTICS. the alternate contraction and dilatation of those vessels during the passage of the pneuma. Aretaeus, who at the commence- ment of his career was a pneumatist, says that the pneuma passes from the heart to the arteries, and by these channels to the whole of the body. It was universally believed, at this time, that the arteries did not contain blood, but only some kind of spirit; an error for which Praxagoras seems to have been primarily responsible. The influence of Stoic teaching* caused the still more de- cided identification of the pneuma with the soul itself: as is very apparent in the account given by Galen (circ. a.d. 130) of the nature of the vital forces. He speaks of a natural force which resides in the liver, and is due to the influence of the Trvevfia (pvoinbv, a life-force which resides in the heart, and is nourished by the nvevna. %utik6v : and an animal-force (or soul- force), which resides in the brain, and is supplied by the nvevfia *vXik6v.-\ All these varieties of the pneuma are only modifications of the inspired air: the latter enters the brain by the nostrils (passing through the sieve-like plate of the aethmoid bone), it enters the heart with the blood which comes' from the lungs, and it enters the liver by means of anastomoses which connect the vessels going to that viscus with the arterial system. The learned author of an article^ in the Allgemeine Encyklopadie remarks, that we have in this doctrine of Galen, the germ of modern ideas as to the distinction between Vege- tative, Irritable, and Sensitive life. The influence of Galen was most powerful; it carried all before it, and for centuries was everywhere predominant in medical Europe. The decline of anatomical studies which followed his death, together with the influence of Alexandrian Neo-Platonism, tended to the production of many strange and * Chrysippus—quoted by Galen. De Plac. Hipp, et Plat, ii, p. 264; iii, p. 1-7; vi, p. 2-9. Diog. Laert. lib. vii, c. 1, sect. 84, g 167. Plutarch. Adv. Stoicos, cap. 46. De Prim. frig. c. 2. f Galen. De loc. affect, v. De usu part. lib. v. Art. et ven. diss. lib. vi, vii. De usu Respir. p. 163—1. J Gruber's Allgemeine Encyklopadie. Art. Galenus. THE DOCTRINE OF STIMULUS.—HISTORY. 45 fanciful developments of the pneumatic doctrine, as to which a very interesting chapter might be written had we unlimited time and space at our disposal.* We must not, however, pass without notice the doctrine of the celebrated Nemesius, Bishop of Emesa in Syria (circ. a.d. 360). In his treatise, "De Natura Hominis," we find it stated that the dilatation of the artery " draws with force the thinner parts of the blood from the next veins, the exhalation or vapor of which is made the aliment for the vital spirit."^ At the downfall of the Alexandrian school of medicine (641), caused by the taking of the city by the Saracens, and the destruction of the great library, Greek learning and Greek medicine might be thought to have received a death- blow : on the contrary, however, the Saracens soon turned to the Greek authors, and studied them with an almost slavish reverence. Galen was especially held in honor, and pneuma- tism seems to have been a universal creed among them. It is useless, however, to delay over this period of our history, for the Saracenic epoch is a blank as regards any real progress in physiology or pathology. But it was favorable to the prog- ress of pneumatism; and so, either directly or indirectly, was another great influence which waged war with the Saracenic power in Europe, and at last overthrew it—that of the Christian Church. Ecclesiastics by degrees acquired a great deal of influence on medical education, and at last monopolized it almost entirely; and it would seem that, whether Neo- Aristotelian or Neo-Platonist, they almost universally favored the belief in forces analogous to the pneuma. It need hardly be said that both Aristotelian and Platonic doctrines were extremely corrupted, owing to the wretched translations, at * The reader who may feel interested in this subject is recommended to study Vol. II of Cudworth's Intellectual System: Plotinus, Enneades (A French edition by M. Bouillot—Paris, 1857—has most valuable notes); Proclus Institutiones; John Philo- ponus in Aristot. De Anima (there is a good Latin translation, published at Venice, 1600), Preface; Etudes sur le Timge de Platon, par T. H. Martin. But the subject is endless, or rather, one might say, bottomless. f Nemesius, De Natura Hominis. Ed. Matthiae. 46 STIMULANTS AND NARCOTICS. third hand, which were the only ones existing, in Western Europe at least, and which were the guides even of such men as St. Thomas Aquinas, and his master Albertus Magnus. This corruption of the classic writers was doubtless partly responsible for the mystic and magical notions which vulgar- ized medical science, and tended to keep it in the hands of privileged quacks. At the time of the general revival of classical literature, which took place under the auspices of the Greek literati who crowded to the Medicean Courts in the fifteenth century, both Plato and Aristotle found restorers; and in Italy, Platon- ism was especially illustrated by Ficinus and by Picus Miran- dolus. The former of these had a powerful influence upon the Italian Schools of Medicine; and this influence was en- tirely in favor of pneumatism.* Ficinus held that all matter in itself is totally inactive, and that in order that any force may be communicated to it, there must be a nature placed above it. In the human animal, this seems to correspond to Plato's mortal soul: it is incorporeal according to Ficinus, and completely interpenetrates the matter of the body. It is upon this middle nature, and not upon the material body, that all impressions and images of external objects are received. It would be difficult, perhaps, to estimate correctly the effect which revived Platon ism had upon the progress of medical theories; but there can be little doubt that the abuse and corruption of this philosophy had much to do with the mysticism which tainted medical science for a long period, and of which Cardan, Cornelius Agrippa, Paracelsus and Van Helmont were prominent examples, and Rosicrucianism an incidental result. The great improvements in Anatomy which were effected by the labors of Sylvius, Fallopius, Fabricius, Harvey, and many others, were not given to the world till the latter half of the sixteenth century: indeed, Harvey's great discovery was not published till 1628. It is, * Vide Buhle. Vol. ii, Pneumatologie de Ficin. THE DOCTRINE OF STIMULUS.—HISTORY. 47 therefore, at an epoch peculiarly favorable to futile speculation upon the deep mysteries of vital action, that Paracelsus comes upon the stage—a true apostle of quackery, though doubtless a sincere enthusiast. He was an illiterate man; at least, he had no regular education, and though he traveled far and wide, and visited many universities, seems never to have acquired any accurate learning, and probably obtained his notions of philosophy by hearsay only. A strange jumble these notions were of Platonic, Aristotelian, and mystical doctrine. The central point of his physiological teaching, or, at least, that point which it most concerns us to notice, is the notion which he propounded of the Arch&us. This name he gave to an imaginary demon whom he supposed to reside in the stomach, and to govern the processes of nutrition, separating the useful from the poisonous part of the food, and distributing each to its proper destination. This theory will be considered presently, in connection with the doctrines of Van Helmont. Of Paracelsus himself we have no more to • say, than to allude to the important impulse which he gave to chemistry, and also to therapeutics, by his rash, blunder- ing, yet eminently suggestive, experiments, and to the great influence which he undoubtedly exercised on the course of medical thought for many years. Van Helmont was a follower of Paracelsus, and he adopted the notion of the Archaeus, which the latter had propounded, and made it the foundation of a host of fanciful speculations. He represented this Archaeus as an immaterial force, presiding over all bodily functions: and he subdivided it, giving to each member of the body its own peculiar vital spirit: he taught, moreover, that the consensus of all these vital spirits produced health, and their disagreement disease. The cen- tral Archaeus he placed, as did Paracelsus, in the stomach. The doctrine of a vital spirit, controlling all the functions of the body, and presiding over the generation of all the organs, was not a mere abstract idea with Van Helmont. He was an excellent chemist, and an industrious investigator 48 STIMULANTS AND NARCOTICS. in this branch of science: among other discoveries, he first established the existence of gaseous bodies, and he appears to identify the Archaeus itself with a gas. It was, of course, perfectly natural for one who was, doubtless, imbued with Platonic, as we know he was with mystical, learning, to at- tribute the highest importance to the discovery of a kind of impalpable matter which had so much the appearance of an intermediate nature between body and mind. Spiritualism runs fairly rampant in the works of this author, and it is sometimes extremely difficult to extract his real meaning from the mass of crude metaphors in which he en- velops it. But it is certain that he recognized vital spirits in all* forms of matter, and that he thus established, as did his philosophic teachers, a complete sympathy between the bodily organism of man, and every substance in the universe. He speaks of a celestial and enormontical virtue (the very phrase used by Hippocrates) which resides in every organism, and which depends for the regularity of its actions upon an external motor; such for instance, as the orderly movement of the celestial bodies, f And he distinctly recognizes the excitement of the vital spirits by different kinds of medicine, as by "the subductive virtue of cathartic or purgative, the somniferous faculty of hypnotic or dormitive medicaments, &c."X These influences he speaks of as "less noble and more corporeal (than certain others), yet abundantly satisfactory to those ends which, by the primitive destiny of their crea- tion, they regard." These words foreshadow the doctrine of appropriate stimuli. Van Helmont was an able and original thinker, and a per- fectly honest man; but the tone of his mental organization disposed him naturally to fanatical superstitions of all kinds. The services he rendered to chemistry were very great; but they are almost overweighed by the mischief which he did to * Helmont. Ortus Medicus, p. 43-44. f A Ternary of Paradoxes. Translated by Walter Charleton, 1650, pp. 33-4 + Ibid. p. 79. THE DOCTRINE OF STIMULUS.—HISTORY. 49 rational physiology and pathology, by the cloud of mysticism in which he enshrouded the philosophy of life and disease. The notion of man's sympathy with the universe, of which he is the microcosm, was elaborated into a multitude of subtle fancies about magnetic influences, and what not: which if any one feels interested in, he may study them in a tractate, "Of the Magnetic Cure of Wounds," which is to be found in the volume translated by Charleton. The most important aspect of Van Helmont's doctrines is that they form a turning-point, at which purely metaphysical notions of physiology may be seen to mix and blend with legitimate physical science. It might have been expected that this phenomenon would present itself, provided that Chemistry obtained a considerable start over Anatomy in the race of scientific development which was originated by the revival of letters; and thus it happened, quite naturally, that the lucky guesses of Paracelsus, and the far more genuine researches of his pupil, gave a new turn to biological inquiries. The notion of fermentation forms the physical element (small as it is) which enters into Van Helmont's theory of inflam- mation. The morbid cause having insinuated itself into a part of the body, the Archaeus (who, it must be remembered, was an actual personality, endowed with intelligence, and with the most lively emotions) became enraged, and sent into the parts a ferment which it had always at its disposal, which irritated the tissues, and called the blood into them, and thus became the proximate cause of inflammation. In another place, he says that an inflamed part is in the same state as an organ pricked to the quick by a thorn: "it is as if a sharp thorn wounded a nervous tissue."* The value of this dictum of Van Helmont, as an illustration of the history of the doctrine of Stimulus, is very great. The connection between the pricking of a thorn and the Greek word oriy/iig (a pricking or stabbing), from which our modern * Van Helmont. Principes de Medecine et de Physiologie. Preface Necessaire. Ort. Med. p. 320. 50 STIMULANTS AND NARCOTICS. word "stimulus" is certainly derived, is obvious. The idea of a distinct injury inflicted, corresponds well with the notion of the Archaeus, a being who would certainly resent such an injury, just as a passionate man might resent a blow. Both Broussais* and Vicq d'Azyrf regard the announcement of these opinions as the real origin of modern ideas as to vital irritability; and the latter expressly grounds his teaching on it. (1792.) The doctrine of vital spirits continued to prevail. In the first part of the seventeenth century we find Descartes and Bacon:}; each expressing it in his own way. Descartes held that the vital spirits were separated from the blood in the brain, and chiefly in the pineal gland (which he considered to be the center of the brain and the seat of the soul). They are material in their nature, but the matter which constitutes them is extremely subtle, and they are excessively mobile. The source of movements is the contraction of particular muscles, and the relaxation of their antagonist muscles, a greater afflux of vital spirits taking place to the former than to the latter. As to the movements of the vital spirits, they proceed from the great diversity of motions which the organs of the soul experience from the external agents which operate upon them, and from the inferior activity of the principles from which the vital spirits derive their origin. All parts of the body are capable of being moved by the objects of sense, and the vital spirits, without consciousness on the part of the animal. § Lord Bacon says|| that " the main differences between ani- mate and inanimate are two: the first is, that the spirit of things animate are all continued with themselves, and are all branched, in veins and secret canals, as blood is; and in living * L'irritation et la folie, p. 10. f Encyclop6die MSthodique, Art. Aiguillon. J See also Sir Thomas Browne, Common and Vulgar Errors, book iv, chap. 7. g Des Cartes, De passione Animae, i, p. 12. Epist., lib. ii, pp. 36, 38, Dioptr., p. 56. See also Buhle. Hist, de la Philosophie Moderne, vol. hi, p. 17, et seq. || Nat. Hist., Cent. vii. THE DOCTRINE OF STIMULUS.—HISTORY. 51 things the spirits have not only branches, but certain cells or seats where the principal spirits do reside, and whereunto the rest do resort: but the spirits of things inanimate are shut in and cut off by the tangible parts, and are pervious one to another, as air is in snow. The second main difference is, that the spirits of animate bodies are all in some degree more or less kindled and inflamed, and have a fine commixture of flame and an aerial substance. But inanimate bodies have their spirits no whit inflamed or kindled. And this differ- ence consists, not in the heat or coldness of spirits, for cloves and other spices......have exceeding hot spirits (hotter a great deal than oil, wax or tallow, &c), but not inflamed. When any of these weak and temperate bodies come to be inflamed, they gather a much greater heat than others have uninflamed, besides their light and heat." It is a curious circumstance that Bacon, though deriding Paracelsus and other "darksome authors," for reviving Pythagorean doc- trines, mentions, with apparent respect, the wildest stories of the "natural magic" school, so prevalent in his day. Helmontian doctrines,* more or less modified, seem to have carried the day in England during the seventeenth century, at least among the theorizers.f The names of Willis and of Glisson deserve some special notice. The former (the great illustrator of the nervous system), besides manufacturing a a new kind of "mortal soul," added something to the theory of vital irritation by suggesting that the blood was provided abundantly with saline principles, which might irritate any part into which it was effused. Glisson, an Oxford professor, and an excellent anatomist, spoke of irritability as a force of which perception and appetite are the factors. Perception precedes the movements which are the effect of irritability, and is converted into sensation as soon as it is perceived by the mind. Perception is inherent in the fibers, it renders * Charleton, the translator of Helmont's Paradoxes, was physician to Charles I. f It is obvious that the great Sydenham comes into quite a different category; there is little or no place for his name in the history of an abstruse doctrine like that of Stimulus. 52 STIMULANTS AND NARCOTICS. them irritable, it is the basis of natural motion, as distin- guished from sensitive motion, the result of a sensation. Irri- tability is divided into natural, animal, and vital,* and the humors participate in it, as well as the solids. Glisson believes in the existence of vital spirits, intermediate between the soul and the organs. Toward the end of the seventeenth century three distin- guished men arose, who were destined to exercise a powerful influence on the progress of the doctrine of vital irritation. Boerhaave at Halle, and Stahl and Hoffmann at Leyden, were the three leading teachers of their day. The patho- logical doctrines of Boerhaave had, on the whole, a decided tendency toward mechanical explanations of vital phenomena, as is shown in his theory of inflammation, the principal cause of which he places in the obstruction of the small vessels by the corpuscles of the blood; nevertheless, we recognize in his definition of "disease," as signifying "every condition of the human body which injures the natural, vital, or animal actions," distinct traces of the influence of Galen. Stahl was the founder of the theory of "Animism;" he represented the body as entirely under the domination of the immaterial soul, which alone perceived impressions, and which gave rise to bodily motions by acting on the tonicity^ of the fibers. Disease consists in the various irregularities in the govern- ment of the vital economy by the affections of the soul; of its proximate causes the most common is plethora, the great frequency of which affection is accounted for by the universal tendency of mankind to take too much food. Hence arise congestions of the blood-vessels in various parts; these con- gestions are due to the action of the soul, which excites tonic movements of the vessels, with a curative intention. In the case of the acute fevers these efforts of Nature are ineffectual to produce a cure; greater efforts are then put forth, and * Compare Galen's account of the three forces presided over by the irvtv^a. Supra, p. 44. | Stahl. De Motu Tonico, &c. THE DOCTRINE OF STIMULUS.—HISTORY. 53 shivering is produced, by exaltation of the tonic movements of the vessels; if even this be insufficient to produce an evac- uation of the blood from the parts, pus is generated, and this causes a definite resolution of the inflammation by withdraw- ing the sulphureous materials from the blood, which gives its redness and heat, &c. Passive congestions, on the other hand, arise from feebleness or spasm of the vessels. Haemor- rhages are means by which Nature often obtains a cure by evacuating the thickened humors. Hoffmann was educated in the ideas of Van Helmont, and the basis from which he starts is the assumption that matter is in itself totally inert. To account for vital movements, he invokes the aid of the monads of Leibnitz, which he makes as numerous as were the atoms of Democritus, and represents them as presiding over every molecule of matter. These monads preside over the development of all organisms, and have the power to alter them or to destroy them, so as to reproduce others, or the same in other forms. There are two kinds of movement in the solids of the human body, contrac- tion and dilatation; these are the cause of all motions of the fluids. The blood is charged with saline, sulphureous and aethereal matters; these are derived from a subtle matter, aether, which circulates in space, and penetrates the body through the lungs and the pores of the skin; it first falls upon the nervous system, and is elaborated in the brain, to vital spirits which are spread all over the body; the lymph of the nerve-sheaths being the vehicle in which it is carried. The aethereal matter, finding its way everywhere into the blood, gives it the power of irritating the solids, and communicating to them the movements of contraction and dilatation. The movements of the heart are thus accounted for; the impulse of the blood produces dilatation: the irritation of the muscular tissue by the sulphureous and saline constituents of the blood makes the heart contract again. The next great step was made by Haller, who declared that the muscular tissue was alone endowed with Irritability. 54 STIMULANTS AND NARCOTICS. Nervous tissues, and those abundantly supplied with nerves, are endowed with sensibility; other tissues are without either sensibility or irritability, and possess only a "dead force." Winter, and his followers, however, declared that irritability exists in all parts of the organism, arguing from the evidences of its presence in zoophytes and plants; and, moreover, they distinguished the agents which are capable of operating on it, so as to excite, to diminish, to waste or to extinguish it, by the name of Stimulants* From this time forward the use of the word "stimulus" is frequent, and the idea of stimulant action begins to assume a prominent place in all theories of life and disease. Cullen was a pupil of Hoffmann, and a great opponent of the humoral doctrines which had been in fashion ever since the days of Hippocrates. He carried to Edinburgh, and established in that school, a doctrine which may be said to be a kind of solidism, in which Hoffmann's notions were combined with the Hallerian doctrine of- irritability. Hoffmann had held a theory as to the existence of two opposite conditions, spasm and atony, which at first sight has some resemblance to the strictum and laxum of the Methodists, whose doctrine, how- ever, he would have rejected as based upon a materialistic philosophy. Both he and his pupil, Cullen, recognized the vis medicatrix naturae. According to Cullen, a state of spasm is produced in the commencement of all fevers; these diseases are uniformly preceded by debility, and the spasm is the result of a reaction brought about by the vis medicatrix. Inflammation is caused by irritation of the capillary vessels. Cullen speaks frequently of the action of stimulants, and of the irritation which is caused by them spreading by sym- pathy to parts of the body remote from that to which they may be applied. * Broussais seems to imply (De l'irritation et de la folie, p. 30) that the school of Winter were the first among pathologists to use the word "stimulant" in regard to vital actions. This may be the case, but at any rate the germ of the idea was in Van Helmont's doctrines. THE DOCTRINE OF STIMULUS.—HISTORY. 55 Dr. James Gregory, the author of the Conspectus Medicina, gave great prominence to the nervous system in the causation of disease, and discussed the subject of the action of stimu- lants with care and elaboration. He defined stimulants as agents which excite sensation in the sentient parts and motion in the muscular parts; the majority of them producing both these kinds of action. They operate upon the nervous sys- tem : primarily, upon that part of it to which they are ap- plied; and, secondarily, in proportion to the degree of their "diffusibility," upon the nervous system at large. The local result of stimulation is an increased impetus of blood toward the stimulated part, causing redness and heat, often swelling and pain, and sometimes real inflammation; secretion is ex- ceedingly increased or disturbed. Nor are the effects confined to the stimulated parts or to those contiguous to them, for frequently very remote parts which are connected with the former by sympathy, are excited to violent motions, and sometimes the whole body, participating quickly in the affec- tion of a particular locality, is very manifestly excited. In consequence of this, all parts acquire renewed alacrity, vigor, and mobility, and not unfrequently the mind itself exhibits a renewed cheerfulness. The effect of some stimulants is more, of some less, perma- nent ; but in all cases it is characterized by evanescence, nay, more, stimulation often terminates in its opposite, and the alacrity, mobility, and vigor of body, and the cheerfulness of mind, originally produced, quickly give place to positive de- pression. The stomach, being liberally supplied with nerves, is an excellent medium by which the influence of stimulants may be diffused over the whole body. The operation of stimulants upon the organism is strongest when the latter is feeble; in acute diseases, for instance, in which the body is weak and unusually irritated, these diseases, therefore, re- quire a treatment the reverse of stimulant.* A more important theory of stimulation than those of Cul- * Conspect. Medicinse, cap. 1166, et seq. 56 STIMULANTS AND NARCOTICS. len and Gregory was put forward by the celebrated JohE. Brown, the author of the so-called "Brunonian" system; which has a peculiar interest for us, inasmuch as it is sup- posed by those who have not studied Brown's views, that they were revived in the practice of the late Dr. Todd and others. A greater mistake than this could hardly be im- agined. Brown was a theorist pur sang, and his system was as cut and dried, and as remote from the rational empiricism which has distinguished the present medical generation, and that which immediately preceded it, as it could possibly be. Nevertheless it possessed some merits which were by no means insignificant. The fundamental idea of the Brunonian system was,* that animal life cannot be maintained for an instant without the perpetual operation of stimuli, and that all foods, and whatever tends to preserve life, are to be looked on as stimulant in their action. Every animal is born with a cer- tain definite amount of a faculty called Excitability; the operation of stimuli upon this faculty produces excitement, or stimulation, and proportionably exhausts the excitability. There is a certain juste milieu which represents perfect health, namely when the excitability and the excitement exist in equal amounts. If the former be in excess, diseases of de- bility (asthenic) are produced, if the latter, diseases of over- strength (sthenic) make their appearance. Debility is of two kinds: " direct," when it is the result of a deficiency of stimu- lation; "indirect," when it is produced by excessive stimu- lation unduly exhausting the excitability, as in the termination of sthenic diseases. Both direct and indirect debility are to be treated with stimulant remedies. It is only sthenic dis- eases, in their progress toward debility, that admit of a lowering treatment, and the number of such diseased con- ditions is very small, in Brown's classification, compared to those of an opposite character. Brown professed the greatest contempt for all systems of medicine which had preceded his own, yet it is obvious that * Works of Dr. John Brown,' 3 vols. London, 1804. THE DOCTRINE OF STIMULUS.—HISTORY. 57 he was less original than he assumed to be. His faculty of "excitability" is the Hallerian "irritability," but elevated into so distinct a form that, as is justly remarked by Brous- sais, it takes the rank of an ontological creation; in fact, it is as purely the work of fancy as was the Archaeus of Van Hel- mont. The characteristics of a personality may be traced in it distinctly. But there is one great merit which belongs to Brown, and deserves to be remembered, namely, his apprecia- tion of the fact that disease, in by far the greater number of cases, implies a debilitated condition of the organism. Darwin, the author of the "Zoonomia," propounded a doc- trine which, in its main features, closely corresponded with that of Brown. The following are the " laws of animal causa- tion," as set forth by Darwin:* "1. The fibers which con- stitute the muscles and the organs of sense possess a power of contraction. The circumstances attending the exertion of this power of contraction constitute the laws of animal motion, as the circumstances attending the exertion of the power of attraction constitute the laws of motion of inanimate matter. 2. The spirit of animation is the immediate cause of the con- traction of animal fibers; it resides in the brain and nerves, and is liable to general or partial diminution, or accumulation. 3. The stimulus of bodies external to the moving organ is the remote cause of the original contraction of animal fibers. 4. A certain quantity of stimulus produces irritation, which is an exertion of the spirit of animation, exciting the fibers into contraction. 5. A certain quantity of contraction of animal fibers, if it be perceived at all, produces pleasure; a greater or less quantity of contraction, if it be perceived at all, produces pain; these constitute sensation. 6. A certain quantity of sensation produces desire or aversion: these con- stitute volition. 7. All animal motions which have occurred at the same time, or in immediate succession, become so con- nected, that when one of them is reproduced, the other has a tendency to accompany or succeed it. When fibrous con- * Zoonomia, p. 30-1 5 58 STIMULANTS AND NARCOTICS. tractions succeed or accompany other fibrous contractions, the connection is termed association; when fibrous contrac- tions succeed sensorial motions, the connection is termed causation; when fibrous and sensorial motions reciprocally introduce each other, it is termed catenation of animal motions. All these connections are said to be produced by habit; that is, by frequent repetition." Darwin held that the continued application of a stimulus exhausts the " sensorial power or spirit of animation," which obviously corresponds with Brown's "excitability." Perhaps, on the whole, the former term is preferable to the latter, as being more explicit, yet not more ontological, than that of Brown. But the most decided proof that old influences were still at work, and that pathology had changed in little except in its terms, is to be found in the celebrated article, " Aiguillon," written by Vicq d'Azyr, in the "Encyclopedic M6thodique" (1787). The author expressly adopted the idea of the spina Helmontii, already alluded to, as the basis of his explanation of vital stimulation. It is true that he makes no reference to an Archaeus, and, indeed, expressly limits himself to the use of such expressions as, "tonic movement," "nervous de- turgescence," "muscular movement," &c, and that he refers all the phenomena of stimulation to the nervous system; nevertheless, it is impossible not to see that the metaphysical bias of Van Helmont has extended itself to his commentator. "I conclude," says Vicq d'Azyr, "that in the case where an inflammatory tumor has been produced by a thorn driven into (the spot which now forms) its center, the nerves excited by the presence of this stimulating cause, have reacted on the muscular fibers of the arteries; that an increased move- ment of these fibers is thus occasioned, and a more rapid cir- culation in the vessels; that consequently an increased quan- tity of the juices is carried to the part; that the juices are extravasated into the cellular tissue through the dilated ex- tremities of the small arteries; . . . that the blood, thus extravasated, cannot return in sufficient quantity by the THE DOCTRINE OF STIMULUS.—HISTORY. 59 veins, and that these phenomena are not at all more surpris- ing than the fact, that, on our pinching one of its nerves, a muscle will be thrown into convulsion, or that the same muscle will distend itself with blood, and contract, when the internal nervous action directed by volition brings to it a sort of stimulus, the momentary effect of which corresponds to what I have already described." The reader will doubtless observe, that this illustration, so far from affording any true explanation or confirmation of the theory of Vicq d'Azyr, is itself the expression of a mere hypothesis which has not been proved. That it should have been so confidently appealed to by this eminent author is a proof of the reluctance which was still felt to relinquish the metaphysical method of inquiry, and the ideas which, by its influence, had become consecrated. The doctrines of Brown, though counting many able sup- porters in this country, were by no means adopted with so general an enthusiasm here as in many parts of the Continent. It would be quite impossible to sketch, ever so briefly, the various foreign modifications of Brunonian doctrines; it must suffice to refer to the most notable, namely, to that which took its rise in the schools of Italy, and found its most characteristic expression in the teaching of Rasori. This physician was the inventor of the doctrine of "contra-stimulus," which is so im- portant, that we must examine its relation to the principles of Brown. The author of Brunonism had stated that there was, in truth, no such thing as direct sedative action; and that all the so-called sedative affections were produced by the use of a weaker stimulus than usual. Rasori, on the other hand, maintained the existence of a large class of physio- logical agents, which possessed the power of producing an effect on the animal fiber directly contrary to the effect of stimulants, and held that the operation of these agents would remove the symptoms caused by stimulation, and, if carried far enough, produce disorders which could only be remedied by the use of stimulants. He gave to this new class of remedies the title of "Contra-Stimulants;" and he assumed 60 STIMULANTS AND NARCOTICS. the existence of two opposed diatheses in disease—that of Stimulus, and that of Contra-stimulus, which required re- spectively to be treated by remedies of a lowering, and of a stimulant, character. Otherwise, the phenomena of stimu- lation were explained in much the same way by Rasori, as they had been by Brown; but the doctrine of contra-stimulus led the Italian physicians to a practice very different from that of Brown; for they regarded the large majority of dis- eases as resulting from the diathesis of stimulus, and declared that, as such, they must be treated on a depressing plan. Every student of therapeutics is familiar with the history of the introduction, by Rasori and Tommasini, of large depress- ing doses of antimony in the treatment of inflammations; a practice which may be considered typical of the contra-stimu- lant method. Against the doctrines of Brown, there arose, at the com- mencement of the present century, an opponent of no ordinary ability and energy—the celebrated Broussais; whose influence in his generation was unbounded, and whose so-called "physio- logical doctrine" rapidly acquired a great sway, the traces of which are visible enough even now. This author professed to be the champion of a most important principle. He an- nounced himself as the founder of a pathology which, for the first time in the history of pathologies, was based upon an enlarged and comprehensive acquaintance with anatomy. The splendid researches of Bichat, which had shed new light on physiology, by giving an intelligible account of the several tissues and organs of the body, and of their varied functions, had excited his enthusiasm, and there is no doubt that he might have become the founder of a true science of pathology. Such was not to be the case, however. Broussais did indeed render important services in opposing the exclusive nervous doctrines of Cullen and Brown, and in calling attention to local morbid affections. But he was an inveterate theorist, and so prejudiced in favor of an idea, that he could not observe correctly. He took the anatomical system of Bichat, and by THE DOCTRINE OF STIMULUS.—HISTORY. 61 the aid of a lively fancy, built upon it a system of diseases such as they ought to be, and as he therefore thought they were. The advance of pathological anatomy, particularly in the hands of the great Laennec, effectually disposed of many of his statements as to the morbid changes in disease. The basis of Broussais' doctrine was the assumption that all the animal tissues are endowed with a property called Irritability, a property which is called into play by the action of stimuli of various kinds, and by the operation of which all vital phenomena are produced. So far he is in accord with Brown; but the next step in his theory places him in direct opposition to the latter. For whereas the Brunonian system places all local manifestations of irritation in quite a subordi- nate position to the accompanying constitutional disturbance, with Broussais the first importance is always accorded to the local affection. To such an extent did the latter carry his views on this point, that he denied altogether the existence of " essential" fevers, and declared that all the diseases so called depended primarily upon an inflammation, simple or complicated, of the mucous membranes of the stomach or in- testines.* So, again, pulmonary consumption, which is now well known to be a general affection of the constitution, at- tended with the deposition of tubercles in the lungs, was to be ascribed, according to Broussais, entirely to an inflamma- tion of the mucous membrane of the windpipe and bronchi, spreading to the tissue of the lung. The doctrine of sympa- thy enabled him to account for the occurrence of inflammation in a part far distant to that originally affected, in consequence of irritation conveyed by the medium of the nervous system. Thus when in the course of rheumatism or gout, delirium or convulsions set in, it was at once assumed that the inflamma- tion had spread, or had migrated, to the brain. Almost every morbid phenomenon, with Broussais, was an indication of inflammation, and inflammation was only a high degree of the irritation or stimulation which, in its proper degree, was * Examen des Doct. Medicales, &c, vol. i, p. xxxiv. 62 STIMULANTS AND NARCOTICS. a necessary condition of life. But as it was impossible for a physician of his experience to overlook the fact, that many severe inflammations are accompanied with great general debility, he declared that the development of vital force, i.e. of irritation, might be unequal in the various parts of the organism; so that while the vitality of one viscus was greatly exalted, that of the body generally might be much below its normal standard. The cardinal point of Broussais' doctrine is, as I have already said, that irritation, by which he understands an ex- altation of vital force, is at the bottom of every morbid con- dition ; in addition to this, he believed that such irritation always results in the production of an increased flow of blood to the part. The progress of anatomical research has demon- strated the incorrectness of the observations on which the latter proposition was grounded, but the belief that irritation is the necessary starting-point of inflammation, and is itself a proof of exaltation of the vital force residing in the irritated part, or in the neighboring tissues, has survived to the present time, and is expressed in the "Cellular Pathology" of Professor Virchow. We shall return to this subject presently. It is impossible to think of John Hunter without reverence for his genius and his labors, but it is surely permissible to lament his peculiar bias of mind, or rather, perhaps, his want of early education, when we observe how he has dealt with the subject of stimulation. His language, when discussing this topic, is unsatisfactory.* It is evident that he believed in the existence of something which closely corresponds to the "mortal soul" of the ancients; and it would further appear that he inclined to divide this principle into two, the one presiding over the organic, the other over the sensitive func- tions; for he repeatedly speaks of the "living principle," and the "sensitive principle," and he ascribes to each of them a sort of intelligence, and power of choice. Nay, more, he even * Hunter's works (Palmer's edit.), vol. i, p. 268, &c. THE DOCTRINE OF STIMULUS.—HISTORY. 63 goes so far as to endow the body, quite independently of the action of the mind, with a sort of memory: for instance, he relates the case of a gentleman who had lost the power of being constitutionally affected by mercury, by long-continued use of that medicine, but who regained his former suscepti- bility to its influence after disusing it for some time; a circum- stance which Hunter accounts for by supposing that the tissues had lost the memory of the action of the drug. Hunter's view of the action of stimuli and irritants makes these agents really appeal, not to the tissues themselves, but to the half-incorporeal principle or principles which reside in them. The difference between a stimulus and irritant is this: the former appeals to and promotes the natural tendency or function of an organ ; the latter merely excites the vital or the sensitive principle to action, without increasing any nor- mal function of the irritated part. The excessive action of a stimulus, however, always becomes irritant. It is probable that the introduction of the vital principles was a measure which rather indicated Hunter's impatience of leaving things unexplained, than any conviction which we ought to receive with that very high degree of deference which is usually to be paid to anything, however difficult to understand, which that great man has recorded. There is one part of his teaching, as to the action of stimulants, how- ever, which throws valuable light on their true nature; that, namely, in which he separates them from irritants, by only attributing to them excitant action of such a kind as tends to promote some natural function or tendency. We shall have occasion, at a later period, to reflect on this idea, and we shall find that it contains, probably, the germ of the true defi- nition of stimuli. Nothing is more remarkable than the immense superiority of Hunter's labors to those of either Brown or Broussais. Each of them was greatly his superior in the logical faculty, and in everything which tends to utilize mental powers which are not of the very first class. But the spirit of his work was 64 STIMULANTS AND NARCOTICS. true, his power was first-rate, and he had pre-eminently that faculty of insight which Brown and Broussais only possessed in a far inferior degree. Whether or not his individual opinions on some isolated points were correct, is of little con- sequence to his true glory, which is—that he decided the fate of medicine, and laid the first stone of an edifice which has slowly grown up since, almost unnoticed among the crowd of ambitious but temporary structures which are destined to disappear and leave it standing alone. The science of medi- cine, thenceforth, was to be established on the study of life as it is in nature, not life as it should be according to the books; and the ultimate result of these studies may be more clearly surmised at present than they could in Hunter's days. One thing which will probably happen is the final interment of his "vital" and "sentient" principles in the tomb of their ancestors. The epoch which has succeeded Hunter, Cuvier, and Bichat, has been marked by a tendency to cultivate sedulously the minute anatomy of the tissues of the body. The old disputes between solidism and humoralism have not been forgotten, nor have they died out. But the natural consequence of the existence of improved means for the careful examination of the bodily structure has been a less exclusive attention to blood-vessels on the one hand, or to nerves on the other. The observations of Schleiden and Schwann as to the development of living organisms from cells, has given an immense impulse to this movement, and while the more special results of the change are to be traced in the existence of a great school of cellular pathologists, its influence has overflowed on all sides, and has pervaded, more or less, every school of physiology. To Professor Virchow, as the most prominent representative of the cellular pathologists, we naturally turn with interest for an exposition of the doctrine of stimulus as modified by the modern researches in which he has borne so distinguished a part. Contrary to what we should have expected, the views expressed by him correspond more nearly, perhaps, than THE DOCTRINE OF STIMULUS.—HISTORY. 65 those of any other physiologist of the day with the older doctrines. It need hardly be premised that the Cellular Pathology re- gards the minute elements of the tissues themselves, as the locus in quo of vital actions and of diseases.* " Every vital act," says Virchow, "presupposes an excitation, or, if you like, an irritation. The irritability of a part, therefore, ap- pears to us the criterion by which we judge whether it is alive or dead. . . . The different actions which can be provoked by the influence of any external agency are essentially of three kinds. . . . When, namely, a given action is called into play, we have to deal with a manifestation either of the function, the nutrition, or the formation of a part." As an example of the mode of action of stimuli, we may cite the case of in- flammation, which according to this author consists in an ex- citation of the nutritive and formative power of the inflamed part. In a note to the English edition of his work, furnished by himself, he illustrates this process in the following way: "Suppose three people were sitting quietly on a bench, and suddenly a stone came, and injured one of them, the others would be excited, not only by the appearance of the stone, but also by the injury done to their companion, to whose help they would feel bound to hasten. Here the stone would be the irritant, the injury the irritament,~\ the help an expres- sion of the irritation called forth in the by-standers." Upon this theory of stimulation it may be observed, that it belongs essentially to the same category with the vitalism which in earlier times was constantly invoked to solve all difficulties; and that it appears to be of very doubtful advantage at the present day, when we are constantly learning from the inves- tigation of physical laws to explain some action of our bodies which had previously been unintelligible. That it descends from Broussais, the professed enemy of metaphysical explana- * Cellular Pathology (translated by Dr. Chance), p. 287 et seq. f The German word used for the passive change in the tissues immediately in- jured. 66 STIMULANTS AND NARCOTICS. tions of corporeal processes, is not surprising, for vital irrita- tion, such as Broussais conceived it, was as much an artificial abstraction as were any of the vital principles, &c, which it was intended finally to displace. Professor Bennett, of Edinburgh, another representative man among recent pathologists, in the account which he gives of the early stage of the inflammatory process, speaks of it as originally caused by an irritation of the ultimate molecules of the part, in consequence of which their vital power of selection is destroyed, and that of their attraction is increased. The strong pulse, the fever, and the increased flow of blood in the neighborhood of inflamed parts, are the results and not the cause of inflammation, and show that the economy is actively at work repairing the injury. The original irritant is either an overstimulation of the part, or an irritation conveyed from a distance by the medium of the nervous system. A stimu- lant which, in a certain degree and manner of application, would assist the natural nutrition of a part, will, when ap- plied in excessive quantity, produce a destructive effect, in one sense, although the mere bulk of the part may be in- creased, and certain phenomena, by which the activity of an inflammation is commonly gauged, may make their appear- ance. The justice of the view which associates with inflam- mation a certain tumultuous and indiscriminately increased formative power of the tissues of the part, is borne out by the general result of modern microscopic research; of this fact examples may be cited from the investigations of Redfern* upon abnormal nutrition of the human articular cartilages, and of Strubef and His| upon the normal and pathological anatomy of the cornea, and from the observations of many other pathologists. But it is also most clearly established that the increased formative action is not a mere exaggera- tion of that which is proper to the healthy state, since its re- * Monthly Journal of Medical Science, 1849-50. f Die normale Bau der Cornea, Ac. Wiirzburg, 1851. J Beitrage zur norm. u. pathologisch. Histol. der Cornea. Basel, 1856. THE DOCTRINE OF STIMULUS.—HISTORY. 67 suits are of a low kind, that is to say, the formed matter is always imperfect. Professor Bennett's practical inference from the natural history of inflammation is, that the results of that affection can only be remedied by the natural action of ordinary cell-processes; and so far he appears to be justi- fied by undoubted facts. When, however, he speaks of the evils of "overstimulation "* in the treatment of inflammation, he seems to be relapsing, to a certain extent, into the vital- istic notion that it is a stimulant action which produces the inflammatory process. The practice which the late Dr. Todd made so conspicuous was based on opinions which closely resemble those of Pro- fessor Bennett; with this important difference, however, that he rejected altogether the vitalistic notion of overstimula- tion. Those substances which are pre-eminently known as stimulants (viz. the alcohols), he prescribed fearlessly in in- flammatory diseases, because he regarded them, in proper doses, as foods, and believed that the evils arising from an accidental excess in their medicinal use did not lie at all in the direction of increased inflammation. It cannot be denied that Dr. Todd's practice, so far as it was based on an accept- ance of the theory of Liebig (hereafter to be noticed), rested on an unsatisfactory foundation. Meanwhile, that theory served him, as an unsound hypothesis has often served a gen- uine inquirer for truth, as the means of making most import- ant inductions. The result of his practice was the conviction, in the minds of those who had most closely watched it by the bedside, as carried out by himself, that the idea that internal inflammations could be directly aggravated by the constitu- tional action of large doses of alcohol was completely errone- ous. The influence of his teaching was directly hostile to vitalism. The observations of Professor Lister must be considered as placing many of the phenomena of morbid irritation in an en- tirely new light. In his valuable paper on the early stages * Vide Lancet, August 16, 1862. 68 STIMULANTS AND NARCOTICS. of Inflammation,* this author demonstrates the following facts: 1. That the early stages of a local inflammation are characterized by a singular tendency of the corpuscles of the blood to adhere to each other, and in this way to produce a continually-increasing obstruction to the capillary circulation. 2. That this adhesive quality of the corpuscles does not ap- pear to be a vital property, since it is never developed in the body in a state of health, but can be artificially produced in blood which has been withdrawn from the body, by means which modify the chemical constitution of the fluid plasma of the blood. 3. That it always affects the white corpuscles more strongly than the red, the vital organization of which is higher than that of the former. 4. That the influence which causes this abnormal adhesiveness of the corpuscles is due to some change in the condition of the blood-vessels which contain them; and that this change is of such a nature as lowers the vitality of the tissues of these vessels. 5. That even the early stages of a local irritation are accompanied with depression of the vitality of the part: and that 6. The general conclusion seems warranted, that inflammation con- sists in the removal of the modifying influences of the living state, allowing the physical properties of the parts, hitherto restrained, to come into play. The seat of the changes thus described by Professor Lister is the web of capillary vessels. He shows that the dilated condition of the arteries leading to the part (the cause of the so-called "determination of blood") is a phenomenon apart, and merely incidental to the inflammatory process, instead of being its cause, as has often been supposed; that it depends, in fact, on nervous irritation transmitted from the part to the nervous centers, and reflected thence upon the arteries. These observations certainly afford the strongest argument against the notion that morbid irritation of a part, at any rate from local causes, implies an exaggeration of its normal vital action. All the facts observed seem, on the contrary, * Philosophical Transactions, 1858. THE DOCTRINE OF STIMULUS.—HISTORY. 69 to indicate that it is the depression of vital powers which produces those diseased actions, the most striking expression of which is seen in a severe acute inflammation. One thing is especially to be noted—that all really irritant action (i.e. which is capable, if prolonged, of causing inflammation) is of a radically distinct, if not opposite kind from whatever in- creases the proper functions of a part, whatever, in fact, makes it to be more alive. We have no right, for instance, to speak of the agglomeration of blood corpuscles which takes place when mustard is applied to a delicate web of nearly naked capillary vessels, as a higher degree, or as any degree, of the same action which is produced when we swallow minute quantities of mustard with our food. The next result of modern research which attracts our attention as bearing strongly on the idea of stimulus, is the discovery by Bernard and Brown-S6quard of the remarkable phenomena attending lesions of the sympathetic nervous sys- tem. These physiologists observed that the division of the sympathetic nerve in the neck was followed by an immediate elevation in the temperature of all that side of the face and head which corresponded to the injured nerve; the skin was red and hot, the arteries beat with increased force and full- ness ; there was augmented sensibility to pain; the eye and ear seemed oversensitive to light and sound, respectively; and the muscles were more easily excited to contraction than usual; the pupil, also, was strongly contracted. These phe- nomena, and certain others of less importance which accom- pany them, immediately disappear on the application of galvanism to that end of the cut nerve which is nearest the head. This remarkable discovery has naturally been followed up. In the first place it has been proved by M. Bernard that the arteries of the limbs are controlled in the same way as are those of the head and neck, and that their liberation from this control by section of their vaso-motor nerves is followed by similar phenomena to those observed in the latter situation. It has also been ascertained that paralysis of the sympathetic 70 STIMULANTS AND NARCOTICS. nerves which accompany the arteries going to secreting glands has a remarkable influence in increasing secretion, and that stimulation by galvanism of the paralyzed nerves temporarily arrests the increased flow. A most important innovation upon the old ideas of vital action has been recently advocated by Dr. Radcliffe. In the older systems of physiology, motion of every kind in the human body was assumed, as a matter of course, to be the result of a property especially belonging to living beings, and thus it came to pass that the amount of mobility, or rather of movement, manifested by an animal organ or organism was taken as the measure of its vital force. Dr. Radcliffe has pointed out, more forcibly than any other author, that we are not justified in placing so low a value as is implied in this view on the influence of the physical forces which pervade the universe in the production of the so-called "vital" motions. The most striking of all vital motions—those of the muscular system—may at least be strongly suspected to depend upon the physical properties of the tissue in which they are developed; and the true action of vital force would appear to be rather that of restraining muscular contraction than of exciting it. This theory is supported by numerous arguments, of which some are derived from the superficial, and others from the more recondite phenomena of muscular contraction. Thus, it is notorious that the most steady and persistent contraction which muscle can possibly exhibit is that which sets in after death, which does not occur till the last remnants of vitality have disappeared, and which, once having commenced, never relaxes till putrefaction releases the tissue from the ordinary laws of molecular attraction. It is well known that sudden haemorrhages, by which the brain is at once deprived of its accustomed supply of blood, are fre- quently accompanied or followed by severe involuntary con- vulsions of the muscles, over which the brain presides by the medium of the nerves. Further, although it is true that interruption of communication between brain and muscle, or THE DOCTRINE OF STIMULUS.—HISTORY. 71 spinal cord and muscle, destroys the power of voluntary con- traction, yet it is certain that the paralyzed muscle retains the power of contracting; for not only do involuntary con- tractions frequently take place, but, after a time, a permanent state of contraction nearly always sets in, which is closely analogous to the rigor mortis. These and very many other striking facts appear, even to common observation, to connect the phenomena of contraction more with the operation of physical than with that of vital laws. What then is this vital force which opposes contraction? Are we about to escape from the old vitalism only to plunge into a new abyss of metaphysical theory? There is no need for such a pro- ceeding, for there are physical forces which, although we dare not say that they are identical with the vital energy, at least are closely related to it, and, indeed, may be individu- ally shown to be present and active in the animal body. And with regard to one of these forces, electricity, the progress of research of late years has given us the most striking proofs of its importance in the vital processes. The presence of this agent in the body was first demonstrated so long ago as the days of Galvani, but it has been reserved for later observers, and especially for Du Bois-Reymond, Matteucci, and Chauveau, to develop the history of its action. In every fragment of the animal body there exist electrical currents, and the laws of action of all these currents are iden- tical, whatever their situation; the most notable development of them, however, takes place in muscle and in nerve, in both of which tissues the current may be traced as proceeding from the ends toward the sides, that is, from the transverse section to the sides. Numerous experiments tend to show that the muscular and nerve currents are always weakened during contractions which occur in life, and that they are altogether extinguished before the rigor mortis sets in. It appears highly probable that both living muscle and living nerve are composed of an infinite number of electro-motive molecules; that whatever disturbs the relations of the electro-motive 72 STIMULANTS AND NARCOTICS. molecules of a nerve will weaken its current; that the weak- ening of the nerve-current will give rise to extra currents of high tension in the nerve, and to induced currents in the neighborhood of the nerve, and consequently in the muscle to which it is distributed; and that these induced currents will so disturb the electro-motive molecules of the muscle, as temporarily to suspend its current, and thus allow the natural attraction of its molecules to come into play and cause con- traction. As regards the action of these substances which especially possess the power of provoking muscular contraction by their influence upon the nervous system, it is interesting to refer to the case of strychnia, the most typical of these drugs. The researches of Dr. Harley have rendered it ex- tremely probable that strychnia acts by preventing the oxy- genation of the blood, in which case it can hardly be supposed to communicate increased force to the nervous system. Rather it would appear probable that it reduces the muscles to a con- dition in which they obey the laws of inorganic matter. Dr. Radcliffe inclines to place the phenomena of pain on a level with those of involuntary muscular contraction, as re- gards their vital significance. Both these phenomena will be discussed hereafter, in their relations to the action of stimulants; at present we need only remark that, although the new opinions as to their causation are not as yet so estab- lished as to command universal assent, they are supported by a mass of evidence which calls loudly for a revision of the older ideas. One of the most noteworthy features of the state of medical opinion of late years, is the prevalence—which has been in- creasing ever since the downfall of Broussais' theories of dis- ease was accomplished by the efforts of the anatomical pathol- ogists—of free empirical inquiry as to the action of remedies upon the body. The old contest between dogmatists and empirics, which commenced in the days of Hippocrates and his successors, has been going on, more or less, ever since; but in these later times the empiric is a man of real knowl- THE DOCTRINE OF STIMULUS.—HISTORY. 73 edge, who does not neglect, as did his prototypes, the sciences of anatomy and physiology. The effect of the reaction against Broussais' doctrines has been a general tendency to specialize diseases, and to seek for remedies which may annihilate them at a blow, for antidotes, in short.* The result of this has, in one sense, been disastrous for therapeutics; for it has thrown that branch of science even more decidedly behind the physi- ology and pathology of the day than it would otherwise have been. That is to say, although individual discoveries which have been made are highly valuable, the therapeutic art has not been regenerated. As soon as a medicine has been proved to have curative powers in a certain number of cases, its modus operandi is somewhat carelessly assigned to someone of the recognized classes of medicinal action, instead of being made, as it should be, the point of departure for fresh experi- ments, which might help to test the accuracy of the classifi- cation itself, and of the physiological theories on which it depends. What do we know for instance, or what did we know till quite lately, of the real physiological action of strychnia, one of the most remarkable medicines which modern practice employs? We assumed that it was an irri- tant to the spinal cord, but this was merely in deference to preconceived ideas as to irritability, so far are modern em- pirics from throwing off the yoke of theory; and, in fact, the researches of Dr. Harley were the first scientific attempt to give an explanation of the matter. The main feature of in- terest to the empiric discoverer of a remedy, is, that it will cure such and such an affection, and he is apt to be careless about its physiological relations to the organism, or to accept a hasty explanation of them. And in this way it may happen that an erroneous physiological theory derives a fictitious support from its supposed applicability to the case of a par- ticular medicinal agent. That it is now high time for this incomplete method of inquiry to be exchanged for a better, there can, I think, be * Trousseau and Pidoux. Traite de Therapeutique. Introduction. 6 74 STIMULANTS AND NARCOTICS. little doubt. For what is the result of our investigation of the history of the doctrine of stimulus? Surely this—that it originated in hypotheses, most excellent and useful in their day and generation, which ancient philosophers adopted for the purpose of helping themselves some little way further toward the comprehension of things which it was impossible, in the nature of things, that they could fully understand. So prodigious was the force of mind in these great men, and so vividly could they portray that which they wished their im- mediate audience to see and understand, that the very wisdom and beauty of their words have proved, in one sense, a serious misfortune to mankind. For the large number of the com- mentators who followed the golden age of philosophy, seem to have been smitten with a double blindness; first, in not knowing what their great teachers actually said, and secondly, in being unable to perceive that they did not, in many cases, mean it literally at all, but only figuratively.* From this double process, first of mutilation and next of incrustation, it has come to pass that old ideas, professedly tentative, have assumed their place as fundamental truths in medical belief, and have lasted to this day. It seems to be unquestionably to this source that we owe our ideas of stimulation, excit- ability, irritability, &c, for all these words refer to the resi- dence in the tissues of the body in some essence which, although not exactly mind, possessed at least passions and emotions and volition, and to which stimulants and irritants appealed. If this be the case, there can be little doubt that it is now desirable, in presence of the facts of modern phys- iology, to make a tabula rasa, and to sweep such ideas altogether from the field. If, as seems indeed unavoidable; the words stimulate, excite, irritate, and their derivatives, are to be retained in use, we must at least seek for some new definitions and limitations of their meaning, for it is unphilo- sophical to speak as if we still believed that a demon or demons * The combination, or confusion, of Platonic, Aristotelian, and Galenic ideas iu Philoponus is a notable instance. THE DOCTRINE OF STIMULUS.—HISTORY. 75 resided in our stomach, our nerves, or our ultimate cells, whom we could propitiate with cordials, soothe with ano- dynes, excite with stimulants, or inflame into active wrath with irritants. It may appear to some, that to ignore the participation of spirit in every action of the living body, would be to give a materialistic turn to our ideas of life. Surely, however, the very contrary of this would take place. If we could ^hake ourselves free of the old hypotheses of vital action, we should be far better prepared to realize the true character of mind— changeless, eternal, unconfined to time or space—and we should hardly read such language as we occasionally see in medical works, language which would almost imply that in- tellect is a secretion from the brain. Many of us must have felt the great impropriety of such expressions as are con- stantly made use of in describing the action of the so-called inebriants; it is quite customary to speak of these agents as "stimulating the mental powers" in their first operation. Again, it is a common thing to read, in works on insanity, of measures calculated to "reduce the mental excitement." The influence of the constant use of such expressions must doubtless be injurious to the physician's judgment. The assumption that particular mental states can be induced or removed by the production of what we choose to consider analogous corporeal processes, is unfounded and mischievous. All that we can know is, that the material organism of the brain should be placed in that state of nutrition, &c, which represents material health, and that when this has been done, the best chance has been afforded for the mind to act rightly. Of the influence on the mind which particular variations from this state will produce, we know nothing accurately. If any one will analyze for himself the train of reasoning by which the treatment of acute mania by large doses of opium must have been arrived at, he will find it highly unsatisfactory. "Acute mania is a state of mental excitement and derange- ment, characterized by want of sleep. Opium is a medicine 7S STIMULANTS AND NARCOTICS. which is calculated to produce sleep, and to relieve pain, which is an excitement and derangement of the nervous force. Therefore opium, in the doses calculated to produce these effects, is the proper remedy for acute mania." Such is the kind of argument by which the routine practice of giving large doses of narcotics in acute mania has been supported, against the manifest testimony of experience, which is now, however, gaining a tardy victory. That improvement has been so long delayed is, doubtless, owing to the inveteracy with which we have clung to the doctrine of stimulus, which has been a sort of central point from which the mind could constantly launch out into new excursions into the domain of theoretical pathology. I have reserved to the last the consideration of the opinions of recent writers on Therapeutics, as to the action of stimu- lants, that we may be enabled fairly to judge how far this branch of medical science has kept pace with modern patho- logical research. I propose now to examine briefly the ac- counts given by the authors of several therapeutical text- books, which doubtless represent the general way of thinking, as to the action of stimulant medicines. Dr. Pereira* classes stimulants under the general head of Neurotic remedies (acting upon the nervous system), and under the special class of Ganglionics (acting upon the sympathetic nervous system). He adopts the definition of Dr. Billing—" A stimulant is that which, through the medium of the nervous system, increases the action of the heart and other organs, by calling forth the nervous influence, or by facilitating the extrication of it in them." The local action of stimulants is not necessarily accompanied with any change, either chemical or anatomical, although some of these agents do produce a chemical change in the parts with which they come in contact, but which is not an essential feature in stimu- lant action. Swallowed in moderate quantities, they convey a sense of warmth to the stomach, promote the contraction * Materia Medica, vol. i, p. 222, 4th edit. THE DOCTRINE OF STIMULUS.—HISTORY. 77 of the muscular coat of the stomach and the intestines, and thereby expel gaseous matters, and assist digestion; and in general they produce hyperaemia and increased secretion of the mucous follicles of the stomach and intestines. In larger quantities they excite thirst, and give rise to nausea or vomit- ing. The active principle of most, if not of all of them, be- comes absorbed; in many instances with great rapidity; and a large number of them are again rejected from the body, through the secretions, unaltered. In the blood they act as stimulants to the heart and blood-vessels, and in passing out of the system in the secretions they act as stimulants to the glands. They cause increased quickness of respiration, and increase the temperature of the surface; and they stimulate the brain and spinal cord to a more active performance of their functions by causing them to be more copiously supplied with blood. In this way stimulants, by causing an increased supply of blood to the various parts of the body, act physio- logically as functional exalters, or pathologically as exciters of a febrile state. Their medicinal uses are as follows: 1. As local acrid applications. 2. As stimulants to the gastro- intestinal canal. 3. As stimulants to the heart and vascular system. 4. As stimulants to the brain: to arouse the energies, and correct certain disorders, of the nervous system, particu- larly certain spasmodic affections. 5. As stimulants to the secreting organs, they may increase, or alter, or in some cases check, the secretions. Dr. G. B. Wood,* one of the authors of the "United States Dispensatory," describes stimulants as agents which exalt the forces of the system. "A property common to all stimu- lation is, that it is followed, in the ordinary state of the system, by a degree of depression bearing some proportion to the previous excitement. There may be conditions of tempo- rary prostration in which stimulants may put the system in the power of resuming its ordinary grade of action without subsequent depression, but these do not come within the * Treatise on Therapeutics and Pharmacology, p. 48. 78 STIMULANTS AND NARCOTICS. general rule. The depression is dependent upon the tempo- rary diminution of excitability resulting from excessive action. If the stimulant influence be continued, it follows, as a consequence of the diminished excitability, that a greater amount of the stimulant agent must be employed to produce the same effect, and the excitability is thus still further di- minished, until in the end the system entirely refuses to respond to the ordinary healthy excitement, and morbid and often fatal debility results. This is an evil against which it is necessary to be constantly on our guard in the use of stimu- lant measures. Another, scarcely less important, is the pro- duction of inflammation by the excessive or repeated excite- ment to which the stimulated organ is exposed." Dr. Wood divides the general stimulants (which affect the whole system) thus: the lowest grade of action he assigns to Astringents; a somewhat higher to Tonics; and the highest to the Diffusible Stimulants, which powerfully and rapidly affect all parts of the nervous system, those which minister to Animal, as well as those which minister to Organic, life. Dr. Neligan* defines stimulants, in general terms, as "agents which produce a sudden, but not permanent aug- mentation in the activity of the vital functions." He dis- agrees with the common opinion which ascribes their effects primarily to the nervous system, and believes, from the effects which are often observed to follow their use, that they are allied, in some respects, to tonics, differing from the latter in the greater transiency of their effects; for their stimulant operation, he says, is " almost invariably followed by a cor- responding depression of vital power." Their effects also are more manifestly perceived by the senses than are those of tonics. It will be observed that the three writers above quoted, though differing in some important respects, agree in ascribing to the action of stimulants an exaltation of a vital or of a nervous force which already exists somewhere in the organ- * Medicines, their Uses and Modes of Administration, 4th edit., p. 348 THE DOCTRINE OF STIMULUS.—HISTORY. 79 ism; and it may be added that they agree also in stating that the first stimulant action is followed by a recoil—a depression. There is a vagueness, however, in the terms in which this recoil is described which may well attract our attention. It is nowhere expressly stated by these authors, that as a rule the secondary depression is carried so far as to place the vital energies at a level below that at which they were when the stimulant was taken; yet unless we know whether this was meant, the mere fact that " subsequent depression" always occurs, is of little or no practical value; since the whole question of the restorative properties of stimulants is left in complete uncertainty. Let us take first the supposition that the depressive recoil is greater than the previous excitement, and try to work out the problem of the continuous " stimu- lation" so frequently had recourse to in fevers. A first dose of the stimulant having been given, and having produced the highest degree of exaltation of which it is capable—that is to say, having used up as much vital or nervous force as it can educe—depression sets in: in order to prevent the de- velopment of this state we repeat the stimulant medicine, thereby using up fresh vital force. Presently comes the recoil, which we again immediately arrest by a fresh dose, and so on for days, it may be for weeks, together. Now one thing is pretty clear, if stimulation means the calling forth, that is, the getting rid of, a certain quantity of a force already existing in the organism, either the accumulated stores of this force must be immense, or they must be simultaneously re- paired by that which can create force, or the vital power must after a very short time become completely exhausted, and the patient, whether cured of his fever or not, must be "improved off the face of the earth." The simple facts of the case, however, are these: A fever patient often lies for days taking an entirely insufficient quantity of common food to create new force in place of that so lavishly wasted by the stimulant medicine, possibly taking no such food at all. Yet at the end of a certain time, it may be many days, it is dis- 80 STIMULANTS AND NARCOTICS. covered that the necessity for the stimulant medicine has ceased or diminished, not by the patient's death, but by his having recovered his energy so far as to digest common food. Nor is it possible to get over this difficulty by supposing that the tissues have been consumed to such an extent that force has been generated at the expense of bodily bulk; for the patients are comparatively very slightly emaciated on con- valescence, if they have been treated in this way. Has there been great emaciation, so to speak, of the nervous system, though this has been invisible to our eyes? It does not appear so, for the patients recover intelligence, sensation, and voluntary movement, with great rapidity. In short, on the theory that stimulant action is followed by a more than equivalent recoil, we are entirely unable to explain these facts. But if we agree to say that stimulant action is, indeed, followed by a recoil, but that the latter is not greater, or not so great, as the original exaltation—the statement loses all importance, since this is exactly what happens after Hie digestion of a true food. It is scarcely possible that so obvious a difficulty has not been perceived by the many excellent authors who held the opinion which we are discussing. The way of escape, which they probably found for themselves, is indicated by the fact, that they believe (vide Dr. Wood loc. cit.) that a repeated excitement of an organ, or of the system, may cause inflamma- tion. This would seem to show, that they assume the ex- istence of a vital principle, which, when closely examined, differs, in no essential respect, from the Archaeus of earlier times. It is capable of being excited, soothed, or exhausted: it is prompt in action, and violent in its resentments; it is, in short, a "spirit of animation." One of the greatest difficulties which the ordinary theories of stimulus have to encounter is, the explanation of the action of the so-called Antispasmodics. These substances form a sub-class of stimulants in all works of Therapeutics with which I am acquainted: but, in truth, it would be difficult to THE DOCTRINE OF STIMULUS.—HISTORY. 81 name a single general stimulant which does not possess more or less antispasmodic power. But if nerve-force be the source of muscular contraction (of which spasm is only a variety), and if the constant action of stimuli is to increase nerve-force, how can we explain the fact of stimuli acting in this way ? Dr. Headland says that spasms are due to a fault in the nerv- ous polarity, commencing generally in the brain or nerve- centers, but does not explain how stimuli, which are supposed to increase, and even to create, nerve-force, can rectify this faulty polarity. Dr. Pereira says that the cerebro-spinal stimulants, and especially the Alcohols and iEthers, exalt the power of volition by their action on the brain, and enable the will to control involuntary muscular contractions. It is evi- dent, however, that such an explanation does not apply to the spasms which are the most frequent of all, those of the mus- cular coats of the intestines. How can the will be exalted so as to control a colic ? A striking instance of the confusion of ideas which prevails with regard to the action of stimuli is afforded by the usual descriptions of the operation of chloroform, when inhaled. The muscular spasms which not unfrequently occur shortly before the full effect of the anaesthetic is induced, are con- stantly spoken of as symptoms of "excitement." Hereafter it will fully be shown that such an idea is entirely erroneous; and reasons will be given for considering the symptom in question as something very different in its significance. It i3 the fact that, so far from being any evidence of excitement, muscular rigidity under chloroform is one of the regular symptoms of advanced chloroform-narcosis with many pa- tients. It is characteristic of the moment when communica- tion between the nervous centers and the muscles is about to be cut off entirely, owing to the temporary death of the nerves. If the inhalation be steadily pushed, this lingering influence will be quickly abolished; the muscles will be left to their own vital conditions, and perfect relaxation will result. This is the state which is required for the performance of a 82 STIMULANTS AND NARCOTICS. surgical operation. That the previous stage of rigidity does not occur in many persons at all is probably due, as will be seen hereafter, to differences of the muscular system in differ- ent individuals. It may be confidently affirmed, that a stronger instance than this of a phraseology which conveys an entirely decep- tive impression can hardly be imagined. Nor is this a barren error, the consequences of which are trivial; for, as it will be shown hereafter, this mode of regarding convulsive action produced by chloroform is productive of the most mischiev- ous results by the influence it has on the method of ad- ministration. But it is in the neglect of any precise observations on the effects of dosage in modifying stimulant action that the most serious errors have arisen, as I shall hope to show in my chapter of general conclusions. In the ensuing chapter, certain phenomena, which are usu- ally assumed to be conclusive proofs of a stimulant action on the organism, will be considered, with a view to test the pro- priety of such assumptions. CHAPTER II. THE DOCTRINE OF STIMULUS.—CRITICISM. We are now to consider certain phenomena which are ordi- narily assumed to furnish decided proof of the antecedent operation of a stimulus upon the organism, and to examine the justice of this assumption. The phenomena in question may be classified under six heads, according as they refer to the mind, to sensation, to muscular motion, to secretion, to circulation, or to nutrition. I. Every rapidly increased manifestation of mental activity from an external cause is ordinarily assumed to result from the action of a stimulus. II. All increased sensibility, and all pain, is referred to a similar cause. III. All convulsive muscular contractions are supposed to result from stimulation, and the more violent the contrac- tion, the more powerful the stimulus is supposed to have been. IV. All marked increase in secretion is assumed to be due to stimulation of the secreting gland, either direct or through the medium of the nervous system. V. Every increase, whether of the force, or the frequency, of the action of the heart, or arteries, is supposed to be the result of stimulation. VI. All increase of the nutritive or of the formative activity of a part of the body is supposed to be due to the action of a stimulus. I. Mental Phenomena.—In order that the following re- marks may not be misunderstood, it is necessary to observe, even at the risk of uttering a truism, that the only influence 84 STIMULANTS AND NARCOTICS. of physical agents upon the mind, of which we are cognizant, is that which they exercise indirectly, by changing the con- dition of the brain; making the latter more or less efficient as an instrument of the mind, or of some part of it. In this limited sense, whatever relieves the brain from fatigue, and gives a new capacity for mental exertion, may be called a mental stimulus. Further, it may be allowed that whatever increases the physiological perfection of the brain to a limit which, though not ordinarily reached, is still congeni- tally possible to that organ, is in the same sense to be looked on as a mental stimulant. The common idea of the cerebral stimulant, however, implies more than this. It implies that a physical agent may produce, at once, and without the intro- duction of improved cerebral nutrition, an exaltation of men- tal activity which would not be possible without the use of extraordinary means. One of the most obvious considerations which presents it- self in an inquiry of this kind is, that we ought not to assume any extraordinary agency to account for facts which are capable of explanation in a simpler way. Looking, therefore, to the great improbability, & priori, of a direct instantaneous increase of the mental powers from the action of a physical stimulus, we are led to ask whether the increase be not merely apparent, and owing to the removal of a pre-existing obstacle to development? There are strong grounds for supposing that this is the case with regard to the action of the "cere- bral stimulants." The faculties of the mind are not homoge- neous, nor such as are necessarily put in motion all at the same time, or by the same causes. On the contrary, nothing is more certain than that a natural opposition exists between the reason and the will on the one hand, and the emotions and the appetites on the other. We may not hastily assume, then, that activity of the former implies activity of the lat- ter, or vice versd; we must carefully examine the phenomena of the so-called cerebral excitement, with a view to discover what sort of mental activity is developed. Let us take the THE DOCTRINE OF STIMULUS.—CRITICISM. 85 case of Alcohol, Opium, and Hashish, respectively, these three substances being typical of the "inebriant" medicines. The early phenomena of alcoholic intoxication usually wear j an appearance at first sight much resembling excitement. But on analyzing the symptoms we are at no loss to perceive that it is the emotional and appetitive part of the mind which is in action, while the intellect, on the contrary, is directly enfeebled. There is no exception to this rule, that in propor- tion to the degree in which the lower and more animal nature obtrudes itself in the actions and words of a drunken person, the less of intellectual activity does he display. It is at least possible, then, that the violent outbreak of the passions is due, not to any stimulation of them, but to the removal of the check ordinarily imposed by reason and will. This possibility we shall find converted to something like certainty when we discuss the narcotic effects of alcohol. With regard to opium there is more difficulty in coming to a decision, because the mental phenomena which are caused by its use are less familiarly known. In the great majority of European constitutions, opium produces nothing resembling mental excitement; the effect on myself, for instance, of a large dose, is mere depression and misery. But with most Orientals, and with some Europeans whose constitutions or whose habits of life are peculiar, a condition is produced by the taking of a large but not fatal dose which is very remark- able, and very difficult to analyze. These persons are able, sometimes without any previous practice, to take large quan- tities of opium without suffering stupefaction; on the con- trary, they appear much exhilarated in spirits, and their minds work with much freedom; in some cases, muscular power and the disposition for exertion seem to be increased, but more frequently there is great indisposition to locomotion or hard work of any kind. These effects last for a period varying from eighteen to forty-eight hours; they are suc- ceeded, in some cases, by a heavy, semi-comatose sleep of long duration; in other instances no particular after-effects are noted. 86 STIMULANTS AND NARCOTICS. It is impossible, without far more precise data than are at present accessible, to determine the true meaning of these facts. Here, again, we are bound in the first instance to take the simplest explanation possible, and to see how far this can be applied to the phenomena in question. This may be found in the supposition that, in the absence of any ex- traordinary circumstances, the apparent exaltation of certain faculties should be ascribed rather to the removal of controll- ing influences, than to positive stimulation of the faculties themselves or of the physical machinery by which they work, It remains to be proved (and a rigorous proof ought to be required), that in circumstances of ordinary health and nutri- tion, large doses of opium (proportionably to the taker's idio- syncrasy) can cause general exaltation of the mental activity; indeed, the details of every such case with which I am ac- quainted, when closely scrutinized, have seemed to give evi- dence of a really poisonous and depressing influence operating upon some portion of the brain simultaneously with the ap- parent stimulation. Something of the nature of paralysis, though it might be partial, has always appeared to me to characterize the action of large doses of opium from the moment that they have completely entered the circulation, supposing the state of health and nutrition to be normal at the time, and the circumstances of climate, &c, such as we know them in this country. And it would seem reasonable to account for the apparent increase of intellectual force, and of emotion, on the supposition that other activities are sus- pended, and their interference removed. For that would be a violent and improbable theory which should suggest that one portion of the nervous system was excited, and another paralyzed, at the same time and by the same agent. The " exciting " influence of hashish (and other preparations of Indian hemp) appears to be exercised on the emotions and passions, and on the fancy. Great exhilaration of spirits, of an unreasoning character, is the chief feature in most cases; in some, the passions rage furiously; in others, the chief phe- THE DOCTRINE OF STIMULUS.—CRITICISM. 87 nomenon observed is the involuntary production of fantastic mental images, of which I shall have more to say under the head of Narcotism. After a careful comparison of the accounts given by Von Bibra, Moreau, De Lucca, and other writers, with those which I have received from various persons who have eaten hashish, either in this country or in the East, I am persuaded that the above effects ought not to be called stimulant at all; that they are, in fact, the results of a partial and highly peculiar kind of paralysis of the brain. The true stimulative action of Indian hemp is a very different thing, and is produced by doses far too small to "excite" the emo- tions or the fancy in the way which occurs in a regular hashish debauch. Such at least is my present belief, but I am even now carrying on fresh experiments to test the matter thor- oughly. The above considerations are surely such as should warn us not to use the phrase "mental stimulation" indiscrimi- nately, since they throw so much doubt on the exciting character of three substances which are usually cited as typical "stimuli of the mind." And an additional argument to the same purpose may be found in the fact that substances like ammonia, which are universally allowed to act as pure stimulants, are in no case chargeable with the production of any such phenomena as those which are supposed to indicate mental excitement, although they may restore consciousness where it has been temporarily lost owing to cerebral weakness. II. Phenomena of Sensation.—It is usually assumed in physiological discussion, that all pain, and all increased sen- sibility is an indication of exalted function of the sensory nerves, or of the sensory tract of the nervous centers, pro- duced by the operation of a stimulus. In order to examine so complex a phenomenon as pain with any chance of success, it is necessary first of all to direct our attention to its simpler varieties.* For many reasons, Neu- * For a remarkable anticipation of the views on the nature of pain which appear to be deducible from the most modern observations, I may refer the reader to the doc- trines of Plato and Aristotle, as set forth in Macmillan's Magazine (October, 1863). 88 STIMULANTS AND NARCOTICS. ralgia, limiting itself to the track of a single nerve, the course of which can be easily identified, is the most typical kind of pain which can be selected; and chiefly, because it "is at once distinct in character, and involves the minimum of organic change in the affected part. There can be little doubt that in such an affection as this, so far from stimulation being to blame, the whole circumstances point to lowered vitality as the antecedent cause. On this topic I am able, unfortunately, to speak with the authority of personal experience. I have been subject, ever since childhood, to severe attacks of neuralgia of the brow, entirely independent of digestive derangement, although liable, as this affection usually is, to be aggravated by any coincident stomach disorder. The pain always follows accu- rately the course of those branches of the fifth nerve which are distributed to the forehead, the internal angle of the eye, and the nose, more rarely extending also to the branches derived from the second division of the fifth nerve, and dis- tributed to the cheek, but always on the right side only. This kind of headache began to trouble me at about the age of four- teen, and for two or three years was of frequent occurrence; for many years past, however, it has been an infrequent visitor. One circumstance ought to be mentioned, although I cannot pretend to estimate its exact relation to the production of the neuralgic pain, viz., that about the time when the headaches first occurred with any severity, I began to suffer from an obstruction of the lachrymal duct on the same side. This obstruction has been ascertained to depend upon a tight stricture of the upper end of the nasal duct, close to the lachrymal sac, and is apparently caused by a tough fibrous cicatrix, probably the relic of some past ulceration. Treat- ment by the passing of metallic probes has been adopted from time to time, with great temporary relief, but the obstruction has always recurred, and, as a consequence of it, the discharge of tears from the gland is inconveniently profuse. The attacks of pain are invariably caused by fatigue of body or mind, and THE DOCTRINE OF STIMULUS.—CRITICISM. 89 are preceded and accompanied by pallor of the face, weak pulse, and a general sense of depression. The only remedies which are of the slightest value are sal-volatile, hot tea, and, occasionally, quinine in a full dose, or a glass of wine. Am- monia, and hot tea are the most frequently useful. In such a case as this there is little reason to think that the function of the painful nerves can be in excess. The general bodily energy is always at a low point when the attacks occur, and the nerves of the part are habitually in circumstances which must tend to lower their functional activity. The constant passive flow of tears from the gland, and the curious fact that the hair of the right eyebrow years ago became decidedly gray at a point exactly opposite the supra-orbital nerve, are so many indications of defective nerv- ous energy, and are corroborated by own sensations when free from pain, for I am conscious of defective power in the orbicularis muscle, and of a somewhat blunted common sen- sibility of the skin around the inner angle of the eye. Under these circumstances it is, that fatigue being superadded (espe- cially when accompanied with longer abstinence from food than usual), an attack of acute neuralgic pain supervenes. The conclusion appears inevitable, that the pain is here the direct consequence of a further depression of an already feeble vitality in the nerves. There is one other most effectual remedy besides those already spoken of, namely, the applica- tion of blistering fluid to the skin immediately over the pain- ful nerves; a remedy which, from its inconvenience, has been but seldom adopted. Now, the effect of this must certainly be to increase the supply of blood to the painful nerve, and, pro tanto, to heighten its vital energy. Dr. Radcliffe, in his lectures* delivered not long since at the Royal College of Physicians, has given a description of his own experience of facial tic-douloureux, which in every way coincides with what I have observed. "About thirteen * Lectures on Certain Disorders of the Brain and Nervous System, &c. See Lancet, February to July, 1863. 7 90 STIMULANTS AND NARCOTICS. or fourteen years ago," says Dr. Radcliffe, "I had an oppor- tunity of becoming acquainted, in my own person, with the history of facial neuralgia, or tic-douloureux. At that time I was anything but strong or well, and the pain, so long as it lasted, did not tend to improve my condition, for it took away my appetite, and kept me awake at night. For the first two or three days after the commencement of the attack, the painful part of the cheek would admit of pressure, and the face was pale and perspiring. I was dejected also, and troubled with frequent chills and shivers. On the third or fourth day the painful cheek would become swollen, hot, and tender; a state of general feverish reaction would be developed; and, contemporaneously with these changes, the true neuralgic pain would come to an end. I had abundant opportunity for knowing that this was the true order of the changes: first, neuralgia without local tenderness, swelling, and redness, and with frequent chills and shivers, and a decidedly depressed condition of the circulation; and afterward, local tenderness, redness, and swelling, and general feverish reaction, without chills and without neuralgia. I also find that my own ex- perience in this matter is the exact counterpart of the experi- ence of several patients who have come under my notice at different times." The neuralgia from which I have personally suffered has not occurred in so severe a form as this, nor have the attacks lasted so long (except on one occasion), but the course and termination of the symptoms closely resemble those which Dr. Radcliffe describes. I have particularly noticed the great tenderness which supervenes in the affected parts as soon as the neuralgic pain subsides. I suspect this depends on con- gestion of the parts. The history of neuralgia generally, as observed on the large scale in the out-patient room of a hospital, substantially con- firms the idea of the pathology of this complaint which is sug- gested by the experience recorded above. Neuralgic com- plaints among the poor and laborious classes are numerous, THE DOCTRINE OF STIMULUS.—CRITICISM. 91 and they present three varieties, speaking roughly: 1. Neu- ralgia of the head and face. 2. Neuralgia intercostalis. 3. Sciatica. The great majority of the patients who apply for relief from either of these maladies are anaemic, and in a fair sprinkling of cases the anaemia is obviously connected with ague-poisoning. The most speedy way of obtaining a tem- porary relief from the pain in all these cases is certainly the application of a local stimulant, more especially of some pow- erful volatile agent such as mustard, or, still better, chloro- form diluted with seven parts of some simple liniment. Still more effective, though, from its nature, slower in acting, is a blister. The more profoundly the general health has been affected, and especially the greater the degree of anaemia, the more necessary it becomes to join with the use of stimulants (both local, such as above mentioned, and general, such as the carbonate or muriate of ammonia, taken in five and ten grain doses respectively), a treatment directed to improving the quality of the blood. The great efficacy of quinine in aguish cases is easily accounted for; the few cases in which it succeeds which are not traceable in any way to the malari- ous poison, owe their cure, I strongly suspect, simply to the remarkable effect which quinine certainly has in improving the systemic circulation: an action of which I have seen many curious proofs, though it is by no means exerted equally in all subjects. For the general run of chronic non-malarious cases, the most successful plan is the use of food tonics to the blood and nervous system, such as cod-liver oil,* arsenic or steel (the first of these being incomparably the best), or a combination of some of them, joined with the use of local stimulation by means of frictions with dilute chloroform, and the manipulations of the scientific shampooer. And even among the better classes, whose diet, &c. is good, a modifica- tion of the same treatment is still far more often successful * Dr. Radcliffe reports favorably of the hypophosphite of soda in neuralgic cases, and believes that the phosphorus of this salt (which is but loosely combined) acts as a direct food to the nervous tissue. 92 STIMULANTS AND NARCOTICS. than any other. The subcutaneous injection of small doses of morphia is a plan which I have often adopted for the pur- pose of giving temporary relief to a patient who was obliged to go through his ordinary day of labor. I only use such a small dose (^ to £ grain) as to produce a general stimulant effect, without the least drowsiness. The next variety of pain is one of which we may be said to owe our knowledge to Dr. Inman. I refer to the complaint which that author has termed Myalgia. The pain in these cases is referred to the muscular structures, and is often pres- ent in its greatest severity in the tendinous ends of those structures. Of the existence of a malady with such charac- teristics there can be no doubt in the mind of a competent observer, whose attention has once been directed to the sub- ject; but the puzzle involved in the facts is great, seeing that the tendinous structures of the body are very slenderly, if at all, endowed with nerves, and even the muscular tissue would seem to be poorly gifted in this respect. Whatever the ex- planation may be—whether or not we are to believe that pain may originate in non-nervous parts, and be conveyed to the percipient brain by the nerves of the neighboring tissues or not—certain it is that myalgia is a most frequent com- plaint, and that it attacks only such muscles as have been overworked proportionably to their nutrition. Here again, the most speedy remedies are such as improve the circulation of the part without fatiguing it. But both in myalgia, and also in all forms of neuralgia, the most permanent relief is obtained by means which gradually increase the general nutrition—arsenic, steel, cod-liver oil, and the like; and, pre- eminently, by a highly nourishing diet. In the pains which accompany some varieties of inflamma- tion we meet with what at first sight seems a complete con- tradiction of that order of phenomena in the causation of pain which we have just been considering; namely, pain occurring in organs which, from the nature of the case, must contain, on the whole, more blood than usual. But the phenomena of THE DOCTRINE OF STIMULUS.—CRITICISM. 93 painful inflammations may be explained by dividing them into two classes. 1. Those in which pain occurs at the commence- ment and soon ceases, at any rate, for a time. 2. Those in which it persists. (1.) It has been pointed out by Dr. Rad- cliffe that this is the normal type of inflammation, and that the pain is to be referred to the preliminary stage of irritation, which is marked by coldness of skin, shivering, and general contraction of the blood-vessels; and there is little doubt that the nerves are in a condition of unusual feebleness, and of electric disturbance owing to that feebleness. But as soon as the second stage, or that of inflammation proper, accompanied at first with increased circulation, commences, spontaneous pain ceases, and only tenderness on pressure remains. (2.) But in certain cases pain persists after the congestive stage has commenced and the skin is hot and the pulse throbbing. These cases, however, are universally such as are distinguished by the fact that the tissues of the inflamed part are subjected either to compression, or to friction or stretching, both of which are only varieties of compression. The pain of sub- fascial suppuration, of pleurisy and peritonitis, and of gout, respectively, may serve as illustrations; and we cannot help being reminded of the tenderness to pressure which, in the ordinary course of inflammation, follows the cessation of spon- taneous pain. It appears highly probable that the continu- ance of the pain during the congestive stage is the result of the accidental presence of pressure, more especially as the pain is severest in those instances (e.g. serous inflammations) where constant friction is going on. Inflammation, however, is by no means, on the whole, an elevation of vital force; and though its first stage may be accompanied with increased activity of the circulation in the affected part, this does not continue to be the case; for the adhesiveness of the blood-corpuscles soon causes an obstruc- tion, and at last an absolute stagnation of the flow. And correspondently with this, we find that the pain, though in 94 STIMULANTS AND NARCOTICS. an altered shape, often does return at a later stage with great severity. It seems hardly necessary to say that pain produced by cutting or by bruising wounds is not due to stimulation; for in the one case the nerves of the part, and the tissues round them ,*are drained of blood, and in the other they are pressed on by the products of extravasation. Moreover, there is little doubt that cutting or bruising wounds diminish the normal electricity of the parts, another source of vital depression. Then as to the phenomena of the mortification of parts, it is well known that the pain is severest shortly before the nerves (usually the last structures to die) are about to become alto- gether dead. Again, in recovery from frost-bite, and from profound alcoholic intoxication, the nerves, during their struggle from temporary death, through low degrees of vitality, up to a state of healthy energy, are excessively painful. Sir William Hamilton held the opinion that* "pleasure is the result of certain harmonious relations, of certain agree- ments ; pain, on the contrary, the effect of certain inharmoni- ous relations, of certain disagreements. Pleasure is a reflex of the spontaneous and unimpeded exertion of a power of whose energy we are conscious; pain a reflex of the overstrained or repressed exertion' of such a power." The varieties of pain which have been already mentioned would appear to come under the latter head—"pains which are the reflex of im- peded energy." With regard to the supposed class of pains which are "the reflex of an overstimulated energy," I would submit that there is some confusion of ideas here. The pain produced is not contemporaneous with the excessive energy, but with the exhausted condition in which the organ remains after the energy has operated. The brain, for instance, which has been laboring beyond its strength, has really been con- suming its tissue faster than nutrition could repair it, until at last it came to have an imperfect energy, owing to the * Lectures on Metaphysics, vol. ii, p. 440. THE DOCTRINE OF STIMULUS.—CRITICISM. 95 want of material in itself; and the result is a condition of the nervous system which, as far as its outward symptoms go, closely resembles the irritative stage of an inflammatory dis- ease, such as I have endeavored to describe it, with pale, cold, shrunken skin, and a tendency to shiver; it is under such circumstances as these that the headache of an over- worked brain sets in. The muscles of the boy who is going through his first fencing-lesson have already been much ex- hausted before they got into that condition when the nerves would convey the impression of pain to the sensorium. The pain occurs during a state of disorganization, when it would certainly seem that the energy must be impeded. And this probability is increased on consideration of the fact that in certain exceptional cases, when nutrition can be proportion- ately increased to meet the excessive waste of tissue, the sense of fatigue, and the pain which naturally accompanies it, are not produced, or are produced only in a much less degree than they would otherwise be. An apparent instance of pain occurring as the reflex of an overstrained energy, is to be found in the painful fatigue which affects organs of special sense, such as the eye or ear, when they have strenuously been directed, for long periods of time, to the appreciation of particular objects. But the supposition is doubly inappropriate in this case. It is inap- propriate for the same reason as in the cases already alluded to, because the painful feeling is not the accompaniment of the energy, but of the exhaustion which succeeds it. And it is further inappropriate, because it is irreconcilable with what we know of the structure and functions of the organs of dis- tinctive sense. For these organs consist essentially of nervous expansions on the surface of the body, which passively receive certain impressions (for the reception of which they are specially fitted) of which the mind takes active apprehension. When by an exercise of volition we place the organ in the best position for receiving external impressions, and by the exercise of attention provide that the mind shall take note of 96 STIMULANTS AND NARCOTICS. these impressions, it will be found that the organ is capable of receiving a certain number of them, ior a certain time, without fatigue, that is, without physical injury. But beyond this limit it is impossible to go; the only result of any effort in this direction will be a confusion of all the impressions re- ceived, and a sense of painful fatigue which is obviously the reflex of impeded energy (using that word, energy, as Hamil- ton does, to express passive as well as active processes). The receptive capacity of an organ of distinctive sense must surely be proportioned strictly to the state of its nutrition, and hence we can understand how that capacity may be im- proved by anything (e.g. gentle and regular exercise) which may improve the nutrition of the organ. Such improvement, however, must be the work of time; meanwhile it appears to be a contradiction in terms to say that an organ, whose duty is passively to receive certain impressions, can be "stimu- lated," at any particular moment, to receive more of those impressions than its actual capacity is adapted for. With regard to cases in which strong emotion seems to intensify the acuteness of any sense to a preternatural degree, while at the same time a feeling of pain is produced, it may be re- marked that such cases arrange themselves under the head of special and exaggerated attention. I ought, perhaps, to apologize for venturing to quote the authority of a romance- writer on a question of scientific observation; but Sir Walter Scott was so accurate an observer of Nature (and of course so unprejudiced as to this matter) that I am tempted to cite his description of the sensations of Henry Morton when mo- mentarily expecting death at the hands of the fanatic Cove- nanters, in illustration of pain from exaggerated attention. "Hisdestined executioners, as he gazed around them, seemed to alter their forms and features, like specters in a feverish dream; their figures became larger, and their faces more dis- turbed ; and as an excited imagination predominated over the realities which his eyes received, he could have thought him- self surrounded rather by a band of demons than of human THE DOCTRINE OF STIMULUS.—CRITICISM. 97 beings; the walls seemed to drop blood, and the light tick of the clock thrilled on his ear with such loud, painful distinct- ness, as if each sound were the prick of a bodkin inflicted on the naked nerve of the organ." Here we have an admirable description of the overmastering influence which emotion may exercise upon the finer and more distinctive sensations. In such circumstances as are here hypothetically represented (and also, as Dr. Chambers justly remarks,* in the disturb- ance of the nervous system, which often happens in fevers and in mania), some overpowering influence rivets the atten- tion on certain objects, and correspondingly impairs the dis- criminative power of the organ of sense, so that false images of them are represented to the mind. To speak of such phe- nomena as proofs of a genuine hyperaesthesia (if by aicdjioie we imply anything discriminative) is entirely incorrect. Sir William Hamilton has indicated the source of fallacy which is latent in all such statements,! viz. the neglect of clear dis- tinction between perception proper and sensation proper. The former faculty takes cognizance of external objects in the way of accurate distinction; the latter merely appreciates the pleasurable or painful nature of the impression. The law of correlation between them is thus stated by Hamilton: " Sensation proper and perception proper must always co- exist; but so far from existing in equal degrees, their respec- tive amounts are in exactly inverse proportion to each other. The more receptive of pleasurable or painful impressions an organ may be, the less adapted is it to the purposes of dis- tinctive perception." In the section of the present volume which details my special researches on Anaesthetics some facts will be found which appear strongly to support this proposition. At present I can only state my general assent to its truth. III. Muscular Phenomena.—The propriety of ascribing excessive or irregular muscular contraction to the influence of stimuli, exalting the nerve-force, cannot be discussed at length here; and considering how fully the subject has been * Renewal of Life, p. 68. f Notes on Reid, p. 886. 98 STIMULANTS AND NARCOTICS. treated by Dr. Radcliffe in his work on Epilepsy, and in his recent lectures at the Royal College of Physicians, there is little necessity for me to go over the ground again. In the chapters on true Stimulation, and on the Phenomena of Nar- cosis, however, proof will be adduced that one of the most ordinary effects of stimuli is to check convulsive muscular movements; and, on the other hand, that such movements are part of the regular sequence of phenomena in the action of paralyzing doses of many narcotics, and are occasionally pro- duced by every true narcotic. Relying on the accumulated testimony here indicated, I must content myself now with the simple statement, that the occurrence of irregular or convul- sive muscular movements affords no proof whatever of any antecedent stimulant action on the organism. IV. Secretory Phenomena.—The assumption that increased secretion necessarily implies stimulation of the secretory glands, or of the nerves governing them, has been conclu- sively proved to be unfounded, by the researches of Bernard and Brown-Se'quard on the effects of section of the sympa- thetic nerve. This operation, when performed on the cervical trunk of the nerve, is followed by intense congestion of the vessels beyond the point of section, contraction of the pupil, and a copious secretion or flux from the several glands of the corresponding part, and similar results have been obtained from the section of the sympathetic branch going to the sub- maxillary gland. Dr. Gairdner and others have observed cases in which pressure on the sympathetic nerve at the root of the neck by tumors has occasioned flushing of the face and copious unilateral sweating. I am able to cite one remark- able case from my own practice, in which similar effects were, in all probability, produced by paralyzing pressure on the abdominal branches of the sympathetic. Case*—W. R., aet. five years and nine months. Was a healthy-looking child when born, but at three days old sud- * By one of those mishaps that one can never sufficiently regret, some carelessness in the taking of this case renders the account of the state of the pupil unreliable; and I have, therefore, omitted all notice of this point. THE DOCTRINE OF STIMULUS.—CRITICISM. 99 denly had a series of fits, of which it is impossible to obtain any accurate description; remained insensible for three days, and then recovered, with no sign of anything amiss except an inward squint of the left eye. He continued in good health until he was about three years old, when he began to experience a constantly-increasing "choking sensation" in the throat, and it was observed that the temperature of the left cheek was higher, and its color deeper, than that of the other side; moreover, the left side of the face was frequently covered with perspiration. After this had lasted a few days, he suddenly became insensible, and foamed slightly at the mouth; the left arm and leg became quite rigid, and were repeatedly jerked toward the median line. This condition lasted for about half an hour. Since that time about four more fits had occurred (the last about seventeen months pre- viously to my first seeing him); the same phenomena pre- ceded and accompanied all of them. In the intervals there had always remained a certain amount of weakness of the whole left side, and a considerable tendency to rigidity of the left arm and leg; the act of putting on the left boot often caused the leg to be spasmodically extended. Recently the bowels had become constipated, and, as always happened when this was the case, the choking sensation had reappeared, and a fit appeared to be imminent. The boy was brought to me at the Chelsea Dispensary, October 31, 1862. He was a well-grown and well-nourished child, with a rather pale com- plexion, a considerable internal squint of the left eye, and a dragging of the left leg as he walked. The left side of the face and head was slightly hotter than the right, and there was a very perceptible flush on the left cheek. On handling the muscles of the left arm and leg, it was observed that they had a marked tendency to tonic contraction. The tongue was red and clean in the median line, over a space of about one-eighth of an inch on the left side of it, and over the whole of the right half. The outer three-fourths or thereabouts of the left half of the tongue was covered with a thick creamy 100 STIMULANTS AND NARCOTICS. fur, through which numerous bright red papillae protruded. The bowels had not been opened for two or three days ; the patient complained of nausea and a choking feeling in the throat. A very mild aperient mixture was ordered to be taken three times a day. This relieved the bowels regularly, and in the course of the next fortnight the threatening symptoms had almost entirely disappeared. He now ventured to omit the medicine, but in three days' time was brought to me in a much worse condition than when I first saw him. No motion of the bowels had taken place for forty-eight hours ; the whole left side of the face and the left ear were flushed deep red; the surface was pungently hot, and bedewed with a co- pious sweat—the heat and sweating were found to extend over the whole left half of the head, and to cease abruptly at the median line. Before he could leave the room, after I had prescribed for him, he was seized with an epileptiform fit precisely similar to those which have been already described, and which lasted twenty minutes. On recovery, he seemed heavy and semi-comatose for an hour or two. On visiting him at the end of this time, he appeared much as usual, except that the unilateral flushing and perspiration and the feeling of choking were still present. A brisk purgative enema was now administered, and a large quantity of scyba- lous faeces were discharged: this was almost immediately fol- lowed by the entire disappearance of the unilateral heat and sweating and of the choking sensation. The boy recovered his ordinary appearance, and was desired to continue the mild aperient medicine, and also to take half an ounce of cod- liver oil per diem. From this time forward, the boy never had a bad symptom: he was retained under observation for two months, and then discharged quite well, except that he had still a slight weakness of voluntary power in the right arm and leg. The paralyzing distention of the bowels by faeces, which seems to have produced such serious effects in this remark- able case, is exactly the same agency as often produces violent THE DOCTRINE OF STIMULUS.—CRITICISM. 101 convulsive outbreaks in general paralytics.* There can be little doubt, I think, in the mind of any one who will im- partially examine the facts, that the condition of the nervous apparatus is one of paralysis, in the one case and in the other. Henceforward there can be no sort of propriety in assuming that the flushing and sweating so commonly produced by an overfull or an ill-digested meal is an active phenomenon, depending on stimulation: indeed, the entire phenomena of excessive and untimely secretions from glands must be con- sidered open to a possible interpretation, the reverse of that which represents them to be the effects of stimulant action. There is too much reason to believe that many medicines which are supposed to have specific effects in increasing the flow from particular glands do, in truth, only cause a passive flow of a fluid containing some of the normal elements of the secretion, in virtue of their paralyzing influence upon the nervous apparatus of secretion. Nevertheless, the name of "specific stimuli" has been unhesitatingly accorded to such medicines hitherto: a practice which is decidedly objection- able in view of the facts of modern physiology. V. Circulatory Phenomena.—Increased rapidity of the heart's action is one of the most common items of evidence appealed to as indicating the operation of a stimulant upon the organism. This subject involves considerable difficulties; for there is little doubt that a moderate increase of the heart's action beyond its normal rapidity often does prove to be of real advantage to the vigor of the faculties, for the time, and is followed by no depressive reaction whatever. On the other hand, no fact is now more familiar to practitioners than that the most purely debilitating influences are precisely those which most greatly increase the rapidity of the pulse. No exact line of demarkation can probably be laid down: but we are entitled to believe that an increase of a few beats per minute, when the strength of the heart's action is simultane- ously maintained or increased, is a healthy phenomenon, one * Vide Austin, " On General Paralysis." 102 STIMULANTS AND NARCOTICS. which is within the order of Nature, and so far entitled to be described as an effect of stimulation; but that, on the other hand, too great an increase of frequency always implies de- bility, more especially when coupled with diminution in force, or irregularity in rhythm. As for the violent throbbings which often attend local in- flammations, there is little reason for attributing them, as is often done, to the results of stimulation, or irritation. The advance of pathological inquiry is more and more rendering it probable that this phenomenon is of purely mechanical origin; being, in fact, due to the opposition with which the blood meets in its progress forward through the vessels of the inflamed part. VI. Lastly, we have to consider the propriety of indis- criminately applying the term Stimulation, as is commonly done, to all processes which result in increased nutritive, or formative action, in a part of the body. This question forms the very central point of the discussion as to the essential nature of inflammation. We have to con- sider whether such a change as that which is set up in a tissue, let us say, like cartilage, by drawing a thread through it (leaving it imbedded as a foreign body), deserves the name of stimulation. What are the changes produced by such a lesion, in such a tissue as cartilage? In the immediate neighborhood of the damaged part all the cells are enlarged, indicating a distinctly increased nutrition of them. If now we inquire what is the result of a higher degree of irritation, such as that which is present in the case of so-called "ulceration" of articular car- tilage, we find that a greatly increased proliferation of the cells is the characteristic feature of the process in parts which are strongly affected, the formative activity being indicated by the presence of mother-cells which are crowded with numerous contained cells, probably representing successive generations, or more often with nucleoli. And in the parts which actually border on the focus of irritation, we perceive THE DOCTRINE OF STIMULUS.—CRITICISM. 103 unmistakable evidence that the exuberant formative process is attended with contemporaneous degeneration. The infer- ence would seem plain that the agency which produces all this mischief is a debilitating, devitalizing one; and that all this ill-timed and hasty excess of nutrition and formation is but the result of a shock to the vital condition of the part, of which the highest expression is seen in the positive degrada- tion of the new-formed matter, in the most strongly affected localities, from the very moment of its generation. We are not justified in speaking of such a process as this (which is, in truth, a type of all inflammatory processes) as an effect of stimulation. So again with the remarkable phenomena which are so often produced by diseases which injure the vitality of nerves which are distributed in the neighborhood of epithelial sur- faces. It is by no means uncommon, in cases where the fifth nerve of one side is affected with severe neuralgia, and is obviously in a state of great depression, to find the tongue coated, on the side toward the diseased nerve, with exuber- ant epithelium, and to observe that the thickness of this covering varies in direct ratio with the severity of the pain and the intensity of the depression. In the curious case above quoted of epileptiform convulsions dependent on loaded bowels, the same effect appeared to be produced through the sympathetic nerve of the affected side. And in the different varieties of herpes, there is very strong reason to suspect that the cause of mischief.lies in the depressed vitality of nerves which supply the skin in which the inflammation occurs. In all these cases the phenomena are essentially the same in their nature and order of occurrence: first of all, depression, evidenced both by the general sensations and by the occur- rence of local pain; and then, when this depression has lasted a certain time, and reached a certain depth, a hasty and im- perfect, though multitudinous formation of cells and other elements of tissue, with a positive tendency to decay even in the very moment of their birth. 104 STIMULANTS AND NARCOTICS. Activity of reproduction is not to be taken as the standard of life, either in the organism or in any part of it. If, indeed, we knew that every action in organized beings, which to our eyes looks different from what the inorganic world can ex- hibit, was really a peculiar attribute of "life," it would then seem to follow that the excess even of so humble a process as that of the mere multiplication of cells and fibers was a proof of superabundant vitality. Far different, as it seems to me, is the lesson inculcated by the actual state of our knowledge of physical laws; a lesson which I shall do my best to give brief expression to hereafter. We have no right to make the assumption in question, nor to use the test which is based upon it. If excess of formative action be rejected as a criterion of vital stimulation, the same course must be adopted with regard to excessive nutrition. Doubtless, nutrition is a necessary condition of life; the functions of no organ can be performed unless its elementary tissues receive a certain amount of development, and maintain a certain standard of bulk amidst the changes to which they are subjected. But it is by no means logical to infer from this that the amount of vitality is proportionate to the bulk of tissue, whatever this may be. Nor is it reasonable, because life implies con- stant change, to assume that the amount of change is the gauge of life. And as nutrition can only minister either to mere bulk or mere rapidity of change (when it passes a certain necessary line), we are entitled to reject all excessive and useless nutrition from the list of phenomena which prove the fact of antecedent "stimulation." CHAPTER III. THE DOCTRINE OF STIMULUS.—SUGGESTIONS FOR ITS RECONSTRUCTION. Having now reviewed the history of the rise and progress of the doctrine of Stimulus, and having indicated some of the most striking points of discrepancy between the popular views on this subject and the teachings of modern physiology, we have to inquire whether some new and more rational inter- pretation cannot be found for a word which it would be highly inconvenient to dismiss from use. In the first place, it seems obvious that etymology should be respected in any new application of the word which we may resolve to make. We should not forget that Stimulus means a spur or goad. On the other hand, we must learn to think of the expression as figurative only; once having realized this, we shall be the less likely to apply it to physio- logical processes with which it has no connection. It has been already mentioned that John Hunter defined stimuli as agents which increase some natural action or tendency as opposed to irritants which produce actions which are alto- gether abnormal; and this, if we reflect on it, will appear to be the most reasonable application of the term. We must take our ideas of stimulation, not from the notion of a sharp thorn plunged suddenly into a sensitive tissue, but from that of a goad applied to the sluggish ox, whose sensibilities it wounds no further than is sufficient to remind him of work which he has to do, and can do very well if he likes to try. And even this is but a figurative and a very imperfect ac- count of therapeutical stimulation, for the latter not im- probably includes, as I shall endeavor to show, not merely 8 106 STIMULANTS AND NARCOTICS. the impulse to act, but a supply of the materials which are necessary for action. It is impossible for us to advance a single step toward a satisfactory explanation of the true office of material stimuli, until we have determined what it is to which we suppose these physiological agents to be applied; whether we are to consider them as operating upon physical objects, under the guidance of the laws of the material universe, or as operating upon something resident in the organized body, which is not exactly physical. Our first duty, therefore, must be to state as clearly as possible the meaning which is to be assigned to the word Life, as far as it relates to corporeal processes. In the opening chapter of the present section it was shown that there is a true historic continuity of vitalistic ideas, from the earliest quite down to the present time. In the present day, however (pneumatology having gone out of favor with metaphysicians), we hear little or nothing of Vital Spirits.* In conformity with the general tendency to give dynamical explanations of all physical processes, it has become the fashion to assume the existence of a "vital force," similar in its nature to heat, light, electricity, and other known physical forces, but peculiar to organized beings; and it is this vital force which is supposed to be generated, or educed, in some way which it is not very easy to understand, by the'action of stimuli. This view is very strenuously supported by Dr. Inman, who certainly has not dealt with the question carelessly, and who is a thoroughly original thinker. "The words vital force," says this author, f " signify the living principle which exists in every organized being. It is the power which en- ables the eye to see, which a camera obscura cannot do; which converts inanimate matter into combinations that the * The last systematic attempt to restore such existences to popular favor was, I be- lieve, the Bridgewater Treatise of Prout " On Chemistry, Meteorology, and the Func- tion of Digestion, considered with reference to Natural Theology." Vide p. 309, Bohn's edition. j- Foundation for a New Theory of Medicine, 2d edit. p. 13. Churchill. THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 107 chemist cannot imitate, which frames out of the same ma- terials various organs, each having a different function. . It is not simply the result of a fortuitous concourse of atoms, for they may be present, and no life be there. It is not nerve force, for that is dependent upon life, and a dead nerve is as powerless as a stone. It is not organization alone, for organs may be present, as in a corpse, where there is no life or vital force." ... It is "a force completely sui generis, but one which, being more or less allied to physical forces, has its phenomena more or less modified thereby." Dr. In- man supports this position by numerous arguments derived from the striking differences exhibited by members of the same organic family, whose structure, nevertheless, may be built up, apparently, of exactly the same physical elements, 'and subjected to exactly the same physical influences; from the extremely different effects of different organic matters when introduced in the system of a healthy individual (e.g. variolous and leprous serum); the fact being, that each kind of organic matter thus introduced has a vital principle of its own, which, and which only, it can transmit, &c. Without attempting to answer Dr. Inman's arguments in detail, I would call attention to a remarkable development of recent scientific thought, the first traces of which may be seen in the writings of the greatest thinker of the present century. Arguing against the artificial separation commonly made between physical and vital forces, Coleridge says:* " To a reflecting mind, indeed, the very fact that the powers peculiar to life in living animals include cohesion, elasticity, &c. or (in the words of a late publication) ' that living matter exhibits these physical properties,' would demonstrate that in the truth of things they are homogeneous, and- that both the classes are but degrees and different dignities of one and the same tendency. . . . The lower powers are assimilated, not merely employed, and assimilation presupposes the homo- geneous nature of the thing assimilated; else it is a miracle, * The Theory of Life, p. 42. Edited by Seth B. Watson, M.D. Ac. Churchill, 1845. 108 STIMULANTS AND NARCOTICS. only not the same as that of a creation, because it would imply that additional and equal miracle of annihilation. In short, all the impossibilities which the acutest of the reformed divines have detected in the hypothesis of transubstantiation would apply, totidem verbis et syllabis, to that of assimilation, if the objects and the agents were really heterogeneous. Un- less, therefore, a thing can exhibit properties which do not belong to it, the very admission that living matter exhibits physical properties includes the further admission that those physical or dead properties are themselves vital in essence, really distinct, but in appearance only different; or in abso- lute contrast with each other." The position maintained by Coleridge, that the so-called inorganic world is as truly, though in a lower way, informed with "life," as is the world of organized beings, was doubt-' less a startling one ; and it is a striking proof of the foresight and penetration of that great man, that our latest scientific inquiries appear to be tending toward a confirmation of his views. The remarkable researches of Mr. Grove* have established the fact " that the various imponderable agencies, or the affections of matter which constitute the main object of experimental physics, namely, light, heat, electricity, mag- netism, chemical affinity, and motion, are all correlative, or have reciprocal dependence. That neither, taken abstract- edly, can be said to be the proximate or essential cause of the others, but that either may, as a force, produce or be con- vertible into the others; thus heat may mediately or imme- diately produce electricity, electricity may produce heat, and so on of the rest." And Mr. Grove expresses his belief "that the same principles and mode of reasoning as have been adopied" in his essay "might be applied to the organic as well as to the inorganic world; and that muscular force, animal and vegetable heat, &c, might, and at some time will be, found to have definite correlations, "f Dr. Carpenter goes * Correlation of the Physical Forces, 4th edit. Longman, 1862. j- "On the Mutual Relations of the Vital and Physical Forces." Philosoph. Trans- actions, 1850. THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 109 a step further, and arrives at the conclusion, that not merely are the materials withdrawn from the inorganic world by vital agencies, given back to it again by the disintegration of the living structures of which they have formed a part, but all the forces which are in operation in producing the phe- nomena of life are in the first place derived from the inorganic universe, and are finally restored to it again. The arguments of Dr. Radcliffe,* which were referred to in the first chapter as affording a startling proof of the unsound basis on which the popular theory of stimulus rests, regard the subject of vital forces from a point of view which annihilates any fundamental distinction between them and the forces of inorganic nature, and assert a complete unity between living organisms and the rest of the universe, both as to form and as to force. It is impossible here to recapitulate the several arguments by which the authors above quoted support their conclusions; but the mere fact that such a chain of reasoning has been wrought out under the influence of modern physiological re- search, by men of such mark, is itself a weighty reason for suspecting that truth must at least lie somewhere in the directions to which their speculations tend. Under these circumstances, it would seem to need something more than the arguments, chiefly negative, which Dr. Inman so ingeni- ously propounds, to command our assent to the proposition that vital force is a principle completely sui generis; and the words of Mr. Lewesf appear to be justifiable. "A vital principle," says Mr. Lewes, "is incapable of proof. If it exist we cannot know it, and unless its existence can be proved, it is to us a mere phrase concealing our ignorance." We are not called upon to account for Life, but only, as far as may be, to explain it. "The former process," as Cole- ridge forcibly remarks, "would imply the statement of some- thing prior (if not in time, yet in the order of nature) to the thing accounted for, as the ground or cause of that thing. . . . * Proteus, or the Law of Nature. Churchill, 1850. Epilepsy and Convulsive Dis- eases. Churchill, 3d edit. 1861. Vital Motion. Churchill, 1851. f Physiology of Common Life. 110 STIMULANTS AND NARCOTICS. And to this, in the question of Life, we know no possible answer, but God. To account for a thing is to see into the principle of its possibility, and from that principle to evolve its being. Thus the mathematician demonstrates the truths of geometry by constructing them. . . . To explain a power, on the other hand, is (the power being assumed, not compre- hended. . . . ) to unfold or spread it out: ex implicito pla- num facere. In the present instance, such an explanation would consist in the reduction of the idea of life to its simplest and most comprehensive form or mode of action; that is, to some characteristic instinct or tendency, evident in all its manifestations, and involved in the idea itself." Or to speak in other terms, the explanation would be like that of an in- quirer, who, presuming to know nothing of the power that moves the machine which he is investigating, takes those parts which are presented to his view, seeks to reduce the various movements to as few and simple laws of motion as possible, and out of their separate and conjoint action pro- ceeds to explain and appropriate the structure and relative positions of the works. " In obedience to the canon, ' Prin- cipia non esse multiplicanda praeter summam necessitatem cui suffragamur non ideo qui causalem in mundo unitatem vel ratione vel experientia perspicimus, sed illam ipsam indaga- mus impulsu intellectus, quia tantumdem sibi in explicatione phaenomenorum profecisse videtur quantum ab eodem princi- pio ad plurima rationata descendere ipsi concessum est.' " I cannot imagine that there can be any satisfactory inves- tigation of the subject on which we are engaged, or of any similar one, apart from an observance of these canons of inquiry. It is enough for us to know, by evidence which is overwhelm- ing, and on authority which we cannot dispute, that there is one part of our nature, the immortal soul, which is altogether mysterious, and of the true laws of which mere human science can tell us very little. There is nothing for it, in this case, but to acknowledge the impotence of observation and reason; but surely we show little wisdom in gratuitously assuming THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. Ill the existence of a further insoluble mystery, in the shape of a vital principle. And when we go beyond this, and proceed to endow this mysterious and incomprehensible principle with properties which are the faint and ghostly reflection of the characteristics of physical forces with which we have some acquaintance, I cannot but think that we commit an error of the very gravest kind. Pathology and therapeutics have been surging backward and forward for many a long day, at this very point. So long as we persist in assuming that the effects of medication are mysterious to us, not because we have not toiled long enough at physical science to understand them, but because they are produced through the agency of forces which are neither wholly physical nor wholly spiritual, so long shall we be incapable of real progress. Let us therefore be content to "reduce the idea of Life to its simplest and most comprehensive form or mode of action; that is, to some characteristic instinct or tendency, evident in all its manifestations, and involved in the idea itself;" and we shall agree, I think, with Coleridge, that the only such tendency to which we can ultimately refer all the phe- nomena, is that of—Individuation, "the internal copula of bodies . . . the power which discloses itself from within as a principle of unity in the many." But if this be the utmost limit to which we can go in the way of definition, it is obvious that we have no right to assume that the increase of any one or more of the "many" forces concerned in the life of the body, is an exaltation of the "vitality" of the organism, or of the part wherein such increase of force is developed. The standard of life is a certain exact balance of various forces, developed with a certain constant relation to material tissue arranged in a definite manner; to say that we increase such life or "vitality" in one part of the organism by destroying this balance, is a contradiction in terms. And the standard of function in an organ is the accurate discharge of such an amount and kind of work as may help to maintain this healthy adjustment of power and of matter in the organism: 112 STIMULANTS AND NARCOTICS. to say, then, that an organ exhibits an increased activity merely because it is seen to be under the influence of extraor- dinary powers, and to present a new arrangement of matter, is incorrect. It follows that the use of the word " stimulus" to express the cause of excessive action of any kind in the body, is improper, and we may expect to find that when a remedy really does improve vital power it does so by restoring, in a natural manner, the natural condition of things. Let us accept the facts that we can gather for ourselves, and see whether this be not the real action of stimulants. Genuine Effects of Stimulation. When these are carefully separated from apparent but unreal instances of this kind of physiological action, such as were discussed in the preceding chapter, they are divisible into cases of— I. Relief of pain. II. Removal of muscular spasm, tremor, or convulsion. III. Reduction of undue frequency of the circulation. IV. Reduction of excessive secretion. V. Removal of general debility, or of special fatigue of muscles, brain, or digestive organs. VI. Removal of delirium, or maniacal excitement, and pro- duction of healthy sleep. VII. Support of the organism in the absence of ordinary food. VIII. Local increase of nutrition where this is deficient. The merit of perceiving that most of the above effects can be produced by stimulation better than in any other way, certainly belongs to Brown; and there is hardly any more striking instance, in medical history, of important observa- tions undeservedly neglected, than is afforded by the fate of the " Elements of Medicine." The theory contained in that work was, doubtless, justly condemned; but many of the facts recorded are of precious significance, and should have been THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 113 carefully remembered. I shall have frequent occasion to refer to them in the remarks which are now to follow. I. The power to relieve pain is a property which is com- monly supposed to be pre-eminently characteristic of sedative, depressing remedies; but nothing can be more unjust than such an idea. Such remedies will indeed relieve pain, but only by a process of poisoning, which puts life in more or less danger, and which will be described later as " True Narco- tism." The mode of treatment which, ninety-nine times out of a hundred, proves successful in removing pain in medical practice, is pure stimulation. As examples of the remedies which act in this way, we may mention— 1. Quickly digested and nutritious food. 2. Opium, in doses of one to two grains; or morphia, in doses of a quarter to half a grain. 3. Carbonate and muriate of ammonia, in doses of five and ten grains respectively. 4. Alcohol, in doses just too small to produce flushing of the face, or sweat- ing of the brow. 5. Chloroform, inhaled (in the proportion of about two per cent, to the bulk of atmospheric air) for a short time; or taken internally, in doses of a few drops. 6. Certain fetid gum-resins. 7. Many aromatic volatile oils. 8. The bitters, pure and aromatic. 9. " Counter-irritation," as it is called; stimulation, as it should be termed, through the adjacent skin with mustard, turpentine, &c, or with blis- ters. These are some of the more rapidly-acting remedies. At the very head of this list it wiR be seen that I have placed food. I do so because if food can be digested there is nothing which in so many cases relieves pain with satisfactory celerity, unless it be kept up by a mechanical cause. The action of all the other remedies in the list is a pale reflex of that of highly nutrient and easily-digested food. The same increased firmness, without hurry, of the pulse; the same re- newed cheerfulness, less of the sense of fatigue, feeling of grateful warmth throughout the body, in each case accom- pany the relief of pain, in a greater or less degree. Brown states, that the headache and pains in the joints which attend 114 STIMULANTS AND NARCOTICS. asthenic diseases (and asthenic diseases with Brown formed 97 per cent, of all maladies) are easily curable by stimulant plans of treatment (among which he includes the use of ordi- nary food). From personal experience, I can speak as to the effects of food in relieving the pains of two very different af- fections—the first of a neuralgic kind, and the second from intense cellular inflammation of the finger and hand owing to a dissection wound. And I have seen one patient suffering severe agony from peritonitis, who derived rapid relief from the careful and gradual injection of a pint of rich soup into the rectum. These statements will excite a certain amount of surprise, perhaps even of incredulity; for they are certainly in direct opposition to the teaching which most practitioners must have had impressed on their minds. That common food should ex- ercise a salutary influence both in neuralgic and in inflamma- tory pains is what we certainly were not taught, in our class-books, to believe or expect: but I submit that inveterate preposession on this head has prevented anything like a fair trial of the question. In inflammatory affections attended with acute pain, there is often another reason for not trying such a plan of treatment, viz.: the inability of the stomach to retain any considerable quantity of food. In such a case the plan of injection into the rectum might be tried, and with good prospect of success, because in most of these cases the sys- tem is suffering severely from a compelled abstinence from food. Case.—The case above referred to, of peritonitic pain relieved by the administration' of food, was that of a young girl, aged fourteen, in whom there was every reason to believe that a group of enlarged mesenteric glands, probably tuberculous, had suppurated; possibly some pus had suddenly been dis- charged into the peritoneal cavity; at any rate the excessively rapid and small pulse, the posture of the patient, the expres- sion of countenance, and the intense and persistent vomiting, which caused everything swallowed to be immediately re- THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 115 jected, left no doubt, when taken together with the character of the pain, of the general inflammatory affection of the peri- toneum. Leeches, turpentine stupes, and opium in large doses had been tried before I saw the case, but utterly in vain : the vomiting was worse than ever, the pain excruci- ating. I ascertained that decided, though temporary relief, had been obtained at one time after the use of a warm gruel enema, which however had produced no evacuation of faeces. Suspecting that the enema might have given relief by reason of part of it having been absorbed and having acted as nour- ishment, I ordered a pint of strong meat soup to be slowly thrown, in three successive portions, into the rectum. Within a quarter of an hour a most sensible relief of the pain was felt, and the expression of anxiety and distress in the countenance had almost disappeared : the amendment thus produced lasted for about three hours, when the pain again returned, though not with its original violence. A new injection of soup was followed by the same relief to the pain as previously: more- over, the pulse fell in about an hour's time to 104 (at the time of the first visit it was 124); the skin became much cooler and slightly moist; the tongue assumed a more healthy appearance, and the stomach so far lost its irritability as to bear the presence of small quantities of broth and wine, which were now ordered to be administered every two hours. In forty-eight hours from the time of the first injection, the pain had altogether disappeared. All action of the bowels was carefully prevented for several days, and the patient made a complete though tedious recovery. Of all stimulant medicines there is none which approaches more closely to food in its manner of relieving pain than opium administered in small doses. Brown indeed considered that this drug was far more potent as a stimulus than any other substance; but this is certainly a mistake, for nothing acts so rapidly as ordinary food in cases where it is suitable. It ought, moreover, to be clearly understood, that there are two ways in which opium may relieve pain, viz.: by its em- 116 STIMULANTS AND NARCOTICS. ployment as a stimulant, in small doses, and its use as a true narcotic, in larger quantities. It is with the former alone that we have to do at present. Dr. Inman has called atten- tion to this kind of action of opium, and has justly observed that it can only take place in consequence of the drug exert- ing a modifying influence on the organic condition of the af- fected part; in fact, that opium administered in this way averts a threatened destruction of tissue, and consequently relieves pain. This idea is perfectly consonant with the opin- ions as to the physiology of pain which were expressed in the preceding chapter. It must be allowed that opium is a drug which more than any other is liable to produce varying ef- fects, according to the idiosyncrasy of the patient to whom it is administered : nevertheless, the careful collation of a large number of observations on its action in small doses (relatively to the idiosyncrasy of the taker) has convinced me that in this sort of use of the drug we produce no narcotic or depress- ing effects whatever. My own personal experience on this point consists of two parts—observations on the action of one- grain and two-grain doses of opium, or an equivalent quan- tity of a salt of morphia, taken during a state of full health, and of the same taken for the relief of depressing catarrh of an influenzal type accompanied with severe pains in the limbs. One grain of opium, or one-fourth of a grain of mor- phia, taken by me when in a state of health, produces scarcely any appreciable effect, supposing that I am in a state of indif- ference as to food (i.e. with a stomach neither recently filled nor, on the contrary, pained with hunger). Administered at a time when I am decidedly hungry, it has a most remark- able influence in dispelling the desire for food, for which it substitutes a warm and comfortable feeling, not merely in the stomach but also in the whole body, which exactly resembles the pleasant sensation occasioned by a moderate meal of good food, and endures for about an hour or an hour and a half, and then quickly subsides, leaving no trace of depression ex- cept that caused by hunger. I have repeated this experiment THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 117 at least a dozen times, at intervals of several weeks; and always with the same result (except that on one or two occa- sions the influence of the drug had lasted longer). The medicine caused no particular inclination for sleep. The largest dose of opium which I have been able to take without producing greater effects than those mentioned is two grains, of morphia half a grain; any increase beyond this amount has invariably pro- duced some of those symptoms which will be described in the section on " Narcotism." The other way in which I have personally tested the effects of opium is as a remedy for influ- enza-like catarrh, of which I rarely escape one or two attacks every winter. These attacks are very sudden, and are at- tended with great depression, with very severe aching pains in the head, back, and limbs, and much febrile disturbance. For this sort of ailment opium, if taken early enough, is a perfect remedy. One-third of a grain of muriate of morphia is taken at bedtime: its influence begins to be felt, in from twenty minutes to half an hour, in the gradual disappearance of the sense of intense weakness, the relief of the pains, and that peculiar feeling of thorough and evenly distributed warmth of the whole body, which is so different from fever on the one hand, or chilliness on the other. Natural sleep at last supervenes, and the morning finds me ready to wake at the usual time, with a moist and clean tongue, a total absence of pains and of fever, and an excellent appetite; but little food, probably, having been taken on the previous day. The effects of an overdose of morphia, taken with the mistaken notion of making sure of a cure, will be described further on. That the pains of severe catarrh are removed by the above- mentioned doses of morphia acting in a stimulant manner, is, I think, proved, first by the fact that the same result can be obtained without the aid of this medicine, if the strong re- pugnance which I usually feel at these times to food and wine can be got over and a fair quantity of either be taken; and secondly, that there is never any, even the slightest, de- pressive collapse as an after-consequence. Out of forty patients 118 STIMULANTS AND NARCOTICS. in whom the same treatment was adopted for the relief of similar catarrhal pains, only six failed to experience consider- able relief: in all these six cases the opium disagreed more or less, causing sickness, constipation, and headache, and rather aggravating the patient's distress ; but all those by whom the peculiar feelings of relief which have been described were experienced were exempt from headache or after-depression of any sort. The use of opium for the relief of severe catarrh, is a very old and well-known treatment, and is satisfactorily justified by accurate clinical observation: but it is important that we should not forget that the effect we desire may be obtained, if at all, by small doses; small, that is to say, in proportion to the patient's idiosyncrasy and habits. The use of full narcotic doses is both needless, and, in most cases, injurious. The pain of inflammatory affections is remedied, so far as it can be directly remedied, by the stimulant action of opium, and the same moderate dose only is required to produce the effect: but this must be repeated more frequently than would be necessary in a more trifling affection, probably because the reparative power of the system is more deeply dis- ordered. Thus the dose of morphia which is sufficient in the average run of cases to relieve the pain of acute pleurisy is one-third of a grain; but it needs to be repeated about every third hour. Again, in peritonitis, if opium will relieve at all, it will relieve in a moderate dose, except in those cases where the patient cannot keep his muscles relaxed and quiet, or in which the peristaltic action of the bowels goes on. It is by paralyzing the movement of the intestines, or by para- lyzing the brain to the perception of pain, that larger doses sometimes appear to relieve when smaller ones have failed. It need hardly be remarked, that the pain which occurs in a distant organ sympathetically (to use a common phrase) with disorder of the digestive organs, is not to be relieved by opium in any shape: this is not because of any radical differ- ence in the pain itself from that of pure neuralgia (which THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 119 notoriously may be temporarily relieved by such a dose as a grain or two grains of opium), but because the opium in this case is not quietly digested, and consequently aggravates the mischief on which the pain depends. Such, briefly, is the action of opium in relieving pain, when it is used in judicious medicinal doses: let us now compare it with that of ammonia, in the forms of carbonate, sesquicar- bonate, and muriate. The carbonate forms the basis of that favorite remedy, sal volatile; but as there is alcohol in this preparation, it is perhaps better not to talk about the in- fluence of the ammonia as a thing to be distinctly known. The sesquicarbonate, however, dissolved in simple water, has an action which is obvious, and not to be mistaken. After making comparative experiments on myself with grain doses of opium, and five-grain doses of sesquicarbonate of ammonia, I am prepared to affirm that the action of the two substances (in these respective doses), in health, is as nearly identical in its general result as it is possible to imagine them to be, with the exception of differences in taste, and in the rapidity of diffusion. And from experiments, both on myself and others, it has become obvious to me that they are about equal in their power of relieving pain, and that, so far as can be judged from outward signs, they relieve it in the same way. Bating such slight differences as have been named, the de- scription above given of the way in which opium relieves pain in small doses may apply in so many words to the effects of sesquicarbonate of ammonia in the dose of from three to five grains. The muriate (sal ammoniac) is a medicine which I suspect is less generally used, and its powers less highly rated than they should be. In doses of from ten up to twenty grains (more than this is a needlessly, and I think perhaps mischievously, large dose), this drug has a pure and powerful stimulant action, which lasts for a considerable time, and among its other effects frequently relieves any pain, more especially of the neuralgic kind. I have known severe neu- ralgia, when not of long standing, removed permanently by 120 STIMULANTS AND NARCOTICS. a single dose. Both the carbonate and the muriate produce effects some of which last for several hours, although the more obvious disappear more quickly: the practical ad- vantage in using the muriate consists in the fact that a larger dose may be given without irritating the stomach. No depressive reaction follows the use of a moderate dose of either, salt. There is no adequate reason for separating the action of the carbonate and muriate of ammonia from that of opium administered in small doses, such as I have mentioned, so far as their effects on pain are concerned. Even in inflammatory affections, such as pleurisy, I am strongly inclined to believe that the salts of ammonia have a direct influence in reliev- ing pain. It is customary to ascribe to their diaphoretic action the diminution of pain which often follows their use in serous inflammations: but this notion is of the vaguest, and rests on no evidence that will bear examination; although the sweating may be, and probably is, beneficial to the patient. Why it is that for pain in general the carbonate and muriate are the more frequently serviceable remedies, while for the relief of the particular pain which accompanies serous in- flammations the citrate and acetate are more valuable, I am not prepared to say; but the fact does not depend on any difference in their diaphoretic power, if indeed any exist, which is doubtful. One of the most powerful remedies which can be used for the relief of pain is Alcohol. In cases of neuralgia there is sometimes no medicine whatever which will produce so great an effect in relieving the sufferings of the patient as a full stimulant dose of alcohol. There is no necessity to produce any of the narcotic or intoxicating effects: we may stop short of this point with distinct advantage: by carrying the treat- ment any further we not only expose the patient to the cer- tainty of the unpleasant depression which accompanies the recovery from alcoholic poisoning, but there is a considerable danger of the neuralgic pain recurring with as much violence THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 121 as ever during the period of that depression. An illustration of this was afforded by a case of severe facial tic which came under my care, and which will be referred to presently under the head of " Treatment with Food-medicines." The patient told me that occasionally, when the pain was more unbear- able than usual, he resorted to brandy-and-water for relief, and always obtained it, for the time. He told me also that a small dose (according to his habits when in health) was sufficient to relieve the pain in about half an hour from the time of taking it; but that sometimes, when the agony was especially acute, he had been tempted to hasten the relief by taking two or three glasses instead of one; under these cir- cumstances the pain ceased, but a heavy comatose sleep su- pervened, from which he awoke shivering and depressed and in such a state that the slightest puff of cold air, or even a sudden movement, would cause a new access of neuralgic pain. On the other hand, a moderate dose would usually completely relieve the pain, which might not recur for days. The treatment of pain by counter-irritation unquestion- ably produces its beneficial effects by stimulating the circu- lation of the painful part when this has been unnaturally depressed. If it were in our power to put the blister, or turpentine stupe, actually upon the seat of pain, we should so far destroy the vitality of the tissues that the pain would be aggravated. As it is, we apply our "counter-irritant" at such a distance from the painful part that we produce a healthy quickening of circulation in it, while very probably at the same time electric changes are effected in the nerves, which aid in the beneficial effect. If now we turn our consideration to the remedies which act more slowly, but more permanently, in relieving pain and the disposition to pain, we shall find that by far the greater number of these are such as any one must acknowledge to owe their efficacy to their power of promoting nutrition. Cod-liver oil and iron obviously act in this way; the latter by improving the quality of the blood, the former not only 9 122 STIMULANTS AND NARCOTICS. in this way, but also, in all probability, by specially nourish- ing the nervous tissue. Quinine seems to have a double influence, at once improving the quality of the blood, and strengthening the systemic circulation. We are entitled also to suspect strongly that iodine and the iodide of potassium act by directly improving the nutrition of the blood; for any one who has watched the gradual abolition of the syphilitic cachexy under the influence of these remedies, must reason strangely if he do not arrive at the conclusion that these remedies effect a cure precisely at that moment, and at no other, when they have built up again the disorganized struc- ture of the vital fluid. With regard to zinc, the testimony is very conflicting: and if we eliminate those cases in which valerianic acid has been used in combination with it, we shall find much difficulty in assuring ourselves that it is a true remedy for pain of any kind. There remain a host of remedies, the prolonged use of which has often proved useful, such as naphtha, aether, and alcohol, in repeated small doses, numerous volatile oils, and numerous vegetable substances containing such oils:—concerning all these remedies, it may be said that they prove useful in proportion as nutrition im- proves under their continued use, and no otherwise. The arguments for this view will be partially worked out in the special remarks on Anaesthetics, in the latter part of the present work. The effect of the persevering use of cod-liver oil in remov- ing neuralgic pains, is typical of the action of this whole group of remedies. The case above referred to, in which temporary relief was obtained by the use of alcohol, illus- trates this action of cod-liver oil very forcibly, and may be taken as an example of what I have now witnessed several times. The patient was a man aged sixty, who applied for relief at Westminster Hospital, suffering from severe tic, which affected the branches of the second and third division of the fifth nerve on the right side. He had been treated with almost every imaginable sedative, without deriving THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 123 more than the most trivial relief, and the disease was of eighteen months' standing. (January, 1862.) The face was haggard and worn, and there were frequent twitchings of the facial muscles on the affected side: the pulse was slow and rather weak, the appetite very poor, and the patient com- plained of great sleeplessness, which had latterly increased, owing to the increasing severity of the pain. The tongue presented a curious appearance, being strongly furred in its right lateral half, and comparatively clean as to the rest of its surface. The patient suffered much from cold hands and feet. Cod-liver oil was prescribed in increasing doses, till 5iss was taken daily, and this treatment was steadily per- sisted in for six months. At the end of about three weeks a great improvement was manifested, both as to general health, and also as to the pain; the patient also slept better: from this time forward, although there were many relapses, his tendency to improvement was progressive, and he was finally discharged cured, having been free from any attacks of the pain for five weeks. II. The removal of muscular tremor, spasm, and convul- sion, is one of the most striking effects which is produced by stimuli. According to the stock descriptions in treatises on therapeutics, they produce this effect by acting in this in- stance as "antispasmodics;" which is as much as to say that they relieve the symptoms by virtue of their ability to relieve them. In fact, upon the theory that all muscular movement is a result of stimulation or irritation, it was altogether inex- plicable that convulsive movements should be arrested by the action of stimuli: so a sort of tacit agreement seems to have been formed to call the agents which were found to have this effect by a name which concealed the fact that they were stimulants. Among stimulants which have the power to arrest convul- sive movements, the first rank must be given to chloroform, administered in small doses by inhalation. It is commonly supposed that chloroform arrests convulsions by inducing a 124 STIMULANTS AND NARCOTICS. narcotic state, but this idea arises from an imperfect acquaint- ance with the order of phenomena in the induction of anaes- thesia ; for, in fact, true narcosis from chloroform is a state highly favorable to the production of convulsive movements. It is the state of stimulation produced when only a small dose has been breathed which puts an end to convulsive mus- cular movements; to go beyond this point would be to risk their recurrence, as will be shown hereafter. A good illustration of the action of small doses of chloro- form in cutting short convulsive attacks, fell under my notice some years ago, in King's College Hospital. A woman of middle age, who was the subject of epileptic fits, which re- curred every day, and sometimes more than once a day, was treated by the administration of chloroform. At any recur- rence of the convulsion, fifty minims were placed in a Snow's inhaler, and the weak atmosphere of chloroform vapor thus formed was breathed by the patient; a very few inspirations were always sufficient to subdue the convulsions, and to restore the patient to complete consciousness. I repeatedly administered the same dose myself, and always with the same effect: and extensive experience in the production of anaes- thesia enables me to state confidently that no true narcosis could have been produced by so small an amount of chloro- form, as indeed was sufficiently demonstrated by the collected state of the patient's intellect as soon as the convulsions ceased. Since that time I have very frequently adopted the same course with epileptic patients, and always with the same result: chloroform being carefully administered in the way above described, the convulsion always ceases. The influence of this treatment upon the ultimate progress of the malady appears, however, to be very small; though on this point more evidence is required. The convulsions of teeth- ing may also be arrested in the same way; and on the whole, I am inclined to expect better ultimate results from this ap- plication of the stimulant powers of chloroform, though it is necessary to speak with great reserve. With regard to the THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 125 use of chloroform in tetanus, there is the same uncertainty as to lasting benefit; but there can be no doubt whatever that the muscular spasms may be resolved in most cases ; and I am satisfied that it is the administration of a small dose, such as is quite insufficient to produce narcosis, which is best suited to this purpose. Some experiments will hereafter be detailed, on the action of chloroform in relieving the artificial tonic spasm of strychnia-poisoning in animals. The action of small doses of chloroform in arresting con- vulsive movements, affords a good example of the operation of minute quantities of a substance, which in larger doses is an undoubted narcotic, or paralyzer. The operation of an undoubted stimulant, such as carbonate of ammonia, in a five- grain dose, produces smaller, but precisely similar, effects. We cannot administer remedies by the stomach during the progress of an epileptic convulsion; but in cases where the patient is in time to swallow a dose on the occurrence of threatening symptoms of a fit, the catastrophe is not unfre- quently warded off. Dr. Reynolds* notices the fact that the epileptic fit may sometimes be retarded by the use of am- monia : and I am able to refer to a number of instances in which this has proved to be the case. In one patient, a man aged forty-two, who had been the subject of epilepsy for about fourteen years, the fits were warded off many times suc- cessively ; so that at one period he absolutely passed a month entirely without fits; as he invariably took the dose of am- monia on the occurrence of premonitory symptoms. This man assured me, that the moment the sense of warmth induced by the ammonia spread over his system "so as to reach his finger- ends," all the unpleasant symptoms, including a spasmodic jerking of the right foot, vanished. After this long interval of repose, the fits began to return, f and the medicine was only occasionally effectual in preventing the occurrence of the fits. This patient afterward derived much benefit from * On Epilepsy. Churchill. f The patient's own vicious habits were partly responsible for this. 126 STIMULANTS AND NARCOTICS. the persevering use of cod-liver oil; but it was a hopeless case as to prospects of cure.* Intermediate between chloroform and ammonia, in the de- gree of its efficacy in arresting convulsive movements, is alcohol. I have notes of several cases of epilepsy, in which I was assured by the patients that they could sometimes ward off a fit completely by taking a tumblerful of hot brandy and water, or a glass of wine, as soon as any threatenings were perceived: and in two very severe cases under my care, alcohol has appeared to be absolutely the only remedy which was capable of mitigating the violence and duration of the parox- ysms (chloroform could not be tried): in one case ammonia had completely failed, in the other it produced only trivial effects. In one of these cases I had the opportunity of per- sonally observing the arrest of a fit, which was imminent, by a dose of brandy. I was conversing with the patient in his own house, when a curious expression of horror and bewilder- ment passed over his face, he began to stammer in his speech, and the head was jerked several times spasmodically toward the right shoulder. A hot glass of brandy and water was immediately administered, and the sufferer sat down quietly, the convulsive jerks ceased in a minute or two, and although the patient continued trembling and shaking for some time, there was no return of the threatening symptoms. The con- vulsions of teething in children form another class of diseases for which there is very considerable reason to believe that alcohol is one of the best remedies possible. Modern clinical observation has done much to discredit the views which were formerly held, not merely as to the sthenic character of the irritation which is present in these cases, but also as to the possibility of relieving it, either by general depletory meas- ures on the one hand, or by incision of the gums on the other. * While this goes through the press, a patient has come under my care, who has many times succeeded in averting a threatened fit by the inhalation of the vapor of liq. ammoniae. THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 127 On the latter point some observations of Mr. Clendon* are worthy of the most serious consideration; for that gentleman argues forcibly the improbability that the soft tissues, by their resistance to the emergence of the tooth, are the cause of the nervous irritation; and gives good reasons for the belief that the inadequate space for the teeth in the jaw itself, and the pressure on the dental branches of the nervus trigeminus which results from this crowding, is answerable for the mis- chief. If this be the case, the evil is unremovable except by time, and meanwhile the object would seem to be to prevent the continuance of the convulsions, which might fatally ex- haust the little patient's strength: and acting upon this idea, I have latterly given a trial to alcohol, in the treatment of these complaints. My experience is far too limited to enable me to speak with confidence; but in the three ^cases in which the plan has been tried by me, it has appeared to produce the best results; and at least I have little doubt that the con- vulsions may often be temporarily arrested by a dose of alcohol which is insufficient to produce any toxic effects. It need hardly be said that, supposing alcohol to be a suitable remedy at all, its rapidity of action is a strong recommenda- tion in cases of this kind: and the same remark applies to chloroform. A very curious variety, as it seems, of choreic convulsion, which is characterized by involuntary movements of a rota- tory or semi-rotatory character, has been treated by Dr. Radcliffe, in two remarkable cases, by repeated doses of alcohol, with very complete success, the movements being arrested when a full stimulant effect had been produced. It is needless to dwell upon the well-known effects of alcohol in relieving many kinds of muscular spasm: the most familiar instances, perhaps, are its beneficial influence upon colic, and upon spasmodic asthma; in both of which affections it often acts favorably: it is proper, however, to remark, that the use * On the Causes of the Evils of Infant Dentition. By J. E. Clendon, M.R.CS. London: T. Richards. 128 STIMULANTS AND NARCOTICS. of intoxicating doses is entirely unnecessary, and, I believe, indirectly very injurious, by the after-depression which it causes. I would venture also to express the opinion, that the very sensible relief which is often experienced in spas- modic asthma from the inhalation of the smoke of tobacco, and of stramonium, may be procured without carrying their action as far so' to produce a truly narcotic or paralyzing effect. This statement is made on the strength of observa- tions made on asthmatic patients under my own care, as well as from what I can gather by conversation with medical men much accustomed to the treatment of this disease: and I can- not but think that the fact that asthmatic fits so constantly occur either during the feebleness of the nervous centers, which accompanies the state of sleep, or else during some artificially induced condition of depression, favors this idea. With regard to that minor degree of involuntary muscular action which we are accustomed to speak of as tremor, it is scarcely necessary to say anything as to its amenability to the influence of alcoholic stimuli in many instances. Perhaps the most remarkable instance of this is the fact, that the very tremors which have been caused by narcotic doses of alcohol, are often relievable by means of small doses of the very same agent. If now we leave the subject of the more rapidly acting anti- convulsive remedies, and proceed to consider the measures which are calculated gradually to eradicate the convulsive tendency, it is impossible not to see, at a glance, that these remedies are all of them probably—the great majority cer- tainly—such as directly tend to improve nutrition. One by one the various sedative remedies appear to lose the 'confi- dence of the profession, that is to say, as far as regards their employment in sedative or depressing doses. Of the tonic medicines now adopted into more general use, by far the most effective is cod-liver oil: the experience of Dr. Radcliffe on this point is fully borne out by my own, as recorded in a paper read before the Western Medical and Surgical Society THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 129 of London.* In the decidedly anaemic cases, steel sometimes acts excellently, when the disease is within reach of any treat- ment at all. Quinine has proved equally effective in a smaller number of cases,f more particularly in such as are character- ized by some local numbness, either persistent or recurring in the form of an aura preceding the fits; and the bromides of potassium and ammonium have been proved to possess an extraordinary influence in reducing the number of fits, even in very bad cases. All these are probably to be looked upon as agents which tend to restore nutrition to a healthy state. III. Reduction of unduly frequent circulation. The most familiar instances which can be adduced of this result of stimulation, is the extraordinary influence exerted on the frequency of the pulse in febrile and inflammatory affections, by the administration of wine or spirit. So well known is this effect, that a certain degree of frequency of pulse, vary- ing somewhat according to the observed type of the disease, is very commonly taken as the best indication of the necessity of administering stimulants: and granting, even, with Dr. Stokes, the importance of testing the strength of the heart's action by the audibility of its sounds through the stethoscope, nevertheless, on the whole, the mere frequency of action is the safest guide; for it will be found, I believe, in the large majority of cases to follow pari passu the gravity of the other symptoms, and it is certain that mere apparent strength of the heart sounds can by no means be always depended upon as annulling the indications of a rapid circulation. Here again it is by no means desirable to drench the patient with a large dose; the object should be to administer small quanti- ties at short intervals. For to narcotize a fever patient, is a most serious and dangerous step; and the well-meant zeal of those who have desired to procure sleep, has often induced coma, from which the patient has only recovered to collapse and quickly sink. * Vide Med. Times and Gazette, 1862. f As an example of this, see a case published by the author in the Medical Times and Gazette, 1861. 130 STIMULANTS AND NARCOTICS. Upon the reduction (IV.) of excessive secretion, and the relief (V.) of general debility, or of special fatigue of the brain, the muscles, or the digestive organs, as examples of stimulant action, I need not dwell here, for they are familiar even to triviality: but I would venture, here again, to insist that effects of this sort, when produced by a so-called narcotic, are often falsely ascribed to its narcotic action, when they are really owing to the fact that so small a dose has been em- ployed as could only act as a stimulant. With respect to excessive secretion, I must be understood to mean merely excess in quantity of matter secreted, with the distinct understanding that I do not regard such a phenomenon as a proof of exalted natural function, but as an instance of mor- bid waste: upon this point I agree with the remarks of Dr. Chambers* and Dr. Inman.f VI. The removal of delirium, and of maniacal excitement, and the production of healthy sleep where it has been mor- bidly absent, is an effect of stimuli which, according to the older ideas of stimulus, would surely have been unreasonable and impossible : and yet it is really one of the most charac- teristic of effects which these agents are capable of producing. So far as regards mania, and the majority of cases of delirium, this fact has at length been reluctantly acknowledged; but the occurrence of healthy sleep is still tacitly assumed to imply, of necessity, a subsidence of the bodily vigor, and accordingly we still hear of the necessity of " calming excite- ment," "reducing nervous action," &c, before sleep can take place, in cases of febrile disturbance. Upon this very import- ant matter it will be necessary to dwell with some particu- larity. That the brain does become depressed, to a certain extent, during sleep, in so far as this may be judged from its being in a state of anozmia, or bloodlessness, as compared with its condition in waking moments, is rendered probable by the * Renewal of Life, p. 37. f Foundation for a New Theory, &c. THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 131 recent researches of Mr. Durham.* But it is certain that there is a more extreme degree of anaemia of the brain which is absolutely incompatible with sleep of a natural and healthy kind. It was fully established by Dr. Todd, in his admirable Lectures on Delirium and Coma,f that the anaemic state is highly favorable both to the production of delirium and also of coma: and the history of fevers, of alcoholic delirium, and of the delirium and coma of uraemic poisoning, abundantly prove that there is a natural opposition between the tendency to these two formidable affections and the inclination to natu- ral sleep. For the most part, that which will produce natural sleep will tend to check delirium and remove coma, and vice versa. It appears desirable to take as our starting-point the physiology of natural sleep, in order to explain the kind of stimulant action with which we are at present concerned. Natural sleep is that repose of the brain which, in a healthy state of the organism, and the absence of artificial hinderance, follows the performance of a certain amount of bodily labor, which has exhausted the nervous system to a certain extent. We may suppose, if we please (with Mr. Durham), that the results of the chemical changes in the nervous matter which necessarily accompany the action of the brain—the dtbris, so to speak—have impeded the continuance of the action by which they were produced, and that a state of comparative anaemia follows, during which the brain is allowed time to repair itself, as we know that it certainly does. Provided that this process of repair can go on properly, sleep is inter- rupted ; not that it is a uniform state, on the contrary, as Sir Henry Holland justly observes,! it is a "series of fluc- tuating conditions, of which no two moments, perhaps, are strictly alike;" the variations extending "from complete wakefulness to the most perfect sleep of which we have cog- * On the Physiology of Sleep. Guy's Hospital Reports, 1860. ■f- Lumleian Lectures; College of Physicians, 1850. Vide Med. Times, 1850. J Chapters on Mental Physiology, 2d Edit. p. 6. 132 STIMULANTS AND NARCOTICS. nizance from outward or from inward signs." It is a state which, as it seems to me, we may best express by supposing the mind to be in perfect vigor, but united to a corporeal instrument, whose efficiency is constantly fluctuating, in correspondence with the interstitial changes by which it is slowly being repaired, but with a steady progress on the whole toward recovery. In delirium, on the other hand, whether produced by disease or by narcotic poisoning (hereafter to be described), in insanity, and in coma, an impaired condition of the brain is present which is not in the course of spontaneous rectifica- tion : the very gravity of the import of these phenomena lies in this fact. In order that the organism may pass from one of these conditions to that of natural sleep, it requires to receive some aid either from common food or from some stim- ulant which has the power to act like food. A typical example of this action is to be found in the treatment for delirium tremens, which in one form or another has long been adopted. Formerly the custom was to rely upon alco- hol and opium: small stimulant doses of these agents not unfrequently cured the delirium and muscular tremors: if these failed, however, larger doses of the same remedies were tried: but rarely, I believe, with beneficial result. The narcotism thus induced was unnecessary, and not unfre- quently fatal; its depressing influence being excited, not gradually and by slow degrees, but suddenly and powerfully, depressing the heart's power in so rapid a manner as to cause collapse and death. At present a more rational plan is sub- stituted for this: the stimulant action of food is brought to bear upon the fatigued and anaemic brain, and the result, as I have myself witnessed, is the cessation of the delirium and the production of healthy sleep. Food is the stimulus, par excellence, for the brain which frequent narcotism has reduced to the state in which delirium occurs—as I need hardly say it is in the treatment of acute mania and for the wild vio- lence of patients who are suffering from general paralysis of THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 133 the insane. In all these cases the action of food may be supplemented or partially replaced by stimulant doses of alcohol, ammonia, &c, but true narcotics are injurious. It is asserted by some, however, that delirium varies greatly in character, and that it presents, in different cases, features which are diametrically opposed, and requires an equally varying treatment, in accordance with these distinc- tions. There is a great improbability, I think, at the very first sight, in this view: nevertheless, it has the support of such high authority that it cannot be lightly treated. It is perhaps hardly necessary to notice what was said by authors who belong to an epoch when medical opinion tended to ascribe every kind of delirium to the effects of inflammatory disease: but the maintenance by Dr. Murchison, in his most excellent work on "Fevers," of the existence of a delirium ferox, which is opposed in its characteristics to the ordinary type of the affection, was to me a considerable surprise. This delirium Dr. Murchison describes as characterized by flush- ing of the features, loud talking, and violence of demeanor, a bold expression of countenance, &c. These features may belong to delirium ferox, but they have certainly also be- longed to more than one severe case of delirium, in typhus, erysipelas, &c, which has fallen under my care, and which presented no exception to the ordinary rule which calls for the administration of support and stimulus. And here I would not only produce the evidence of my own personal experience; I appeal to those gentlemen who may have held clinical offices in King's College Hospital in Dr. Todd's time, whether such cases were not repeatedly observed, and as repeatedly treated with marked success by means of stim- ulants. For my own part, I may say with confidence, that the most typical case of delirium ferox which I ever saw was one in which slight delirium, occurring in the course of typhoid fever, had been accepted as a proof of encephalitis, and treated by leeching the temples, combined with starva- tion. The patient, who was young and muscular, was really 134 STIMULANTS AND NARCOTICS. rather an object of terror, so savage was the expression of countenance and so violent were the muscular efforts. Nev- ertheless, the yolks of half a dozen eggs, and half a dozen glasses of port wine, administered at intervals of an hour, vanquished the delirium completely. Nor did the results of ! this case surprise me, reflecting, as I did and had often done, on the incredible violence and muscular strength of many patients who are sinking into a state of general paralysis 'of the insane, and on their docility when treated with nutritious food. The production of natural sleep in cases of fatigue carried so far as to render it impossible for the tired brain to sink spontaneously into repose, is one of the most valuable proper- ties of stimuli. It is one of the commonest observations that severe and continuous labor, whether of body or of mind, will often produce a state of restlessness in which it is utterly im- possible to sleep. Under these circumstances a small dose of opium will sometimes calm the agitation of the nervous sys- tem, and induce sleep; but more frequently the same object will be better attained by means of a cup of green tea, a glass of wine, or spirit and water, or a basin of good soup, the last being the best remedy of all. Another well-known remedy, which occasionally proves useful, is the immersion of the feet in hot water. And Mr. Durham has ingeniously suggested that this is because the brain, which should be anaemic in sleep, is congested, and the application of heat to the extremities acts as a derivative. It is certain, however, that the congestion theory will not explain the phenomenon of restlessness in many varieties of fatigue, nor the strictly analogous "jactitations" which occur after severe haemor- rhages and in the course of peculiarly depressing fevers, and it is probable that the influence of hot foot-baths is merely that of removing a present sense of discomfort, and also of producing a mild stimulant impression upon the nervous sys- tem generally. When intense fatigue is accompanied with great coldness of the extremities, this remedy is often very THE DOCTRINE OF STIMULUS.—RECONSTRUCTION. 135 useful in the way above suggested. The principle of cure in all such cases is stimulation, whether there be greatly de- pressed circulation or not, and whether the feet are cold or warm ; and the best stimulant of all, where it can be digested, is meat soup, next to that of alcohol. Those who have not tried the practice extensively would be surprised at the pow- erful effect which can often be obtained in the state of wake- fulness accompanied by fidgeting movements, which is so apt to occur in fevers, by the use of food in sufficient quantity. The value of this remedy cannot be tested properly, in many cases, unless the food be administered per rectum, as a suffi- cient quantity can seldom be tolerated by the stomach; but it is precisely these cases which are most strikingly bene- fited—natural and refreshing sleep being frequently induced within a very short time. With regard to the action of alco- hol in such cases, it is to be noted that the quantity which can be taken without producing more than a gentle stimula- ting effect, is often greatly increased, so that the patient will take half-ounce doses of spirit, or glasses of port wine, in rapid succession, without showing the faintest sign of alcoholic narcotism, either at the time or afterward. Both food and alcohol are preferable, as stimulants, to opium in these cases; nevertheless, there are many fever-patients, and still more erysipelas-patients, who are greatly quieted by minute doses of opium quite insufficient to narcotize. In erysipelas, the simultaneous use of brandy and small doses of morphia often produces a series of short, sweet dozes, without the least tendency to coma. VII. The support of the organism in the absence of ordi- nary food, by stimulants, is one of the most remarkable phe- nomena which can be offered to the attention of the physiolo- gist. Since the majority of substances which are capable of acting in this way are also capable, in large doses and under some circumstances, of acting as true narcotics, it has been somewhat hastily assumed that the only manner in which alcohol, opium, &c. can act as food, is by means of their capacity 136 STIMULANTS AND NARCOTICS. for arresting vital changes and causing life to go on at a low degree of intensity. Concerning this hypothesis, it is only necessary here to re- mark—first, that no proof exists that the measure of vitality ought to be taken from the rapidity of tissue-change, although tissue-change is necessary to life; secondly, that it has never been proved that arrest of tissue-change does result, at any rate to an important extent, as the result of the daily use of small quantities of the ordinary stimulant ingesta; thirdly, that observations are entirely lacking as to the rapidity of tissue changes in the extraordinary instances in which life has been preserved in the absence of ordinary food, by the action of a stimulant, for a considerable period; but that, fourthly, the recorded instances are numerous in which the latter oc- currence has been noted, and in many of these vital energy would seem to have been maintained at a high point. The effects now ascertained, beyond doubt, to be produced by the regular consumption of moderate doses of the coca (the great Peruvian narcotic-stimulant) by the natives of the country where it grows, are quite unreconcilable with any reasonable idea of narcotic action, and are clearly to be as- cribed to the influence of a powerful stimulant. Von Tschudi,* Markham,f Poppig,^ Weddell,§ and many others, substan- tially concur in declaring that this wonderful drug, when taken in moderation by the South American Indians, or even by foreigners resident in the country, enables the taker to perform the most severe physical tasks upon an extremely small allowance of common food; and this without suffering any evil after-effects, such as invariably result from the use of any true narcotic which is not extremely volatile and eliminable. Von Tschudi, in particular, relates that an In- dian, sixty-two years of age, worked for him (at excavation) for five days and nights consecutively, without any ordinary * Von Tschudi. Travels in Peru, p. 451,