I have seen various instances where patients have complained of this unusual depression, and inability to move: they have shown me prescriptions in which the stimulant or tonic plan was recommended, but instead of any alleviation the symptoms had become worse from their use. This hint was generally sufficient, for if the disease of predisposition had been asthenic, cordials and tonics ought to have relieved it: if, on inquiry, I found the exciting powers had acted too powerfully, I then, without hesitation, had recourse to the debilitating plan, and with the greatest certainty of success. Before I viewed diseases and their causes in this way, I must confess that I often felt great hesitation in practice; and judging merely from symptoms, which are frequently very fallacious, the operation of a remedy often disappointed me, and I could not pretend to predict the event with the certainty that I now can. This observation is of the greatest consequence in the cure both of predisposition and of disease. Though excitement regulates all the phenomena of life, yet the symptoms of diseases which either its excess or deficiency produces, do not of themselves lead to any proper judgment respecting it. On the contrary their fallacious appearance has proved the source of infinite error.
As excitement both depends on exciting powers and excitability, it is evident that when a middle degree of stimulus acts upon a middle degree of excitability, the most perfect effect will be produced. This point, could we ascertain it, might be called the point of health. For the sake of illustration, we may suppose that the greatest excitability of which the living body is capable is 80 degrees: this may be supposed to be the excitability possessed by the body at the commencement of its life, because no part has then been wasted or exhausted by the action of stimuli. Now, if we suppose a scale of excitability to be formed, and divided into 80 equal parts or degrees, the excitability will be wasted or exhausted in proportion to the application of stimuli, from the beginning to the end of the scale. One degree of exciting power applied takes off one degree of excitability, and every subsequent degree impairs the excitability in proportion to its degree of force. Thus a degree of stimulus or exciting power equal to 10 will reduce the excitability to 70, 20 to 60, 30 to 50, 40 to 40, 50 to 30, 60 to 20, 70 to 10, 80 to 0; and, on the contrary, the subtraction of stimulant power will allow the excitability to accumulate.
[DIAGRAM]
The range of good health is ranked from 30 to 50 degrees in the scale; for perfect health, which consists in the middle point only, or at 40 degrees, rarely occurs; in consequence of the variation of the stimuli to which man is continually exposed, such as meat and drink, heat, exercise, and the emotions of the mind, the excitement commonly fluctuates between 30 and 50 degrees, and yet no particular disturbance of the functions takes place. But when at these points, 30 or 50, predisposition commences, the slightest debilitating cause in the former case, and the slightest stimulating cause in the latter, brings on disease, in which the functions begin to be disturbed in various ways, and this disturbance is always in proportion to the hurting powers which have produced the disease, and the delicacy or importance of the part affected.
The effect produced on the excitability by any stimulus, must evidently be in a ratio compounded of the degree of excitability and the force of the stimulus. The same stimulus will produce greater contractions upon a fibre that is more irritable than upon one which possesses less irritability; and the irritability or excitability of the fibre being given, or remaining the same, the contraction will be in proportion to the strength of the stimulus. Hence it is evident, that the effect or excitement must be in a ratio compounded of the exciting powers and excitability.
Sthenic diathesis and disease is caused by the operation of different exciting powers, which produce too great a degree of excitement in the system: this at first increases all the functions, and, when increased, produces a disturbance and inordinate action of them, which is communicated to the whole body. In diseases of this kind there is often an appearance of debility, but this is extremely fallacious, and arises from the disturbed state of the different functions. Hence it is evidently of the utmost consequence to ascertain carefully whether this debility is real, or the effect of asthenic disease: or whether it is owing to the disturbance of the functions by over stimulating, and in this case fallacious; for should a sthenic disease be treated by stimulants and cordials, the effect would be an aggravation of all the symptoms, and a much higher degree of disease.
Asthenic diathesis and disease is brought on by the excitement of the system being diminished: and this may proceed either from a diminution of common stimulant powers, while the excitability is sufficiently abundant, or it may proceed from an exhausted excitability, while the stimulus is sufficiently abundant. The former is called direct, and the latter indirect debility. The exciting causes therefore of asthenic disease, first impair the functions, then occasion a disturbed or inordinate action of them, giving many of them a false appearance; some of them, for instance, appear to be increased, for in hysteria and epilepsy, which are both diseases of debility, the action of the muscles seems to be preternaturally increased; but this depends chiefly on the accumulated excitability, which gives such a degree of irritability to the system, that the smallest irritation, whether external, such as heat, exercise, &c. or internal, as emotions of the mind, excite a strong spasmodic action, which brings on the symptoms of epilepsy and hysteria. This inordinate action however soon exhausts the morbid excitability, and thus suspends itself, a sleep often follows, from which the patient wakes with only a general sense of languor and debility: but as the same cause still remains, the excitability of the body again becomes morbidly accumulated, and thus the slightest stimulus produces a recurrence of the fit, and the tendency to return will increase with its recurrence, so that at last the slightest imaginable cause will produce it, on account of the power of habit and association.
Gout likewise appears like a sthenic disease, and in inflammation takes place, which resembles pleurisy or peripneumony; but this symptom is fallacious, for it depends on debility, and is only to be cured by means, which in pleurisy and peripneumony, would produce death.
Hence it must be evident that those phenomena of diseases, which we call symptoms, are generally fallacious; but this may be owing to our imperfect knowledge of the animal economy, so that we are not able to explain or understand the manner in which they are produced: we ought however carefully to guard against being misled by them in practice. The great difficulty is to distinguish the nature of the disease, whether it is sthenic or asthenic, or whether it depends on too great excitement, or on debility; for this being once clearly ascertained, we proceed with certainty in our mode of treatment, instead of the random practice, which must be the consequence of not taking a proper view of the laws of life, and the causes of diseases.
The nature of the disease may be generally ascertained, by attending to the habits of the patient, and the manner in which he has lived, as well as to the state of the pulse; but in cases where these circumstances do not render it clear, it may be ascertained, beyond a doubt, by a trifling degree of stimulus, as, for instance, by any cordial, as a little wine or spirits. If the disease be of an inflammatory or sthenic kind, the symptoms will be aggravated, and the cordial will not produce its usual pleasant effects on the system; but on the contrary, if the nature of the disease be asthenic, then the usual pleasant effects of the cordial will be perceived, and the pain and other symptoms will be alleviated. This trial, which is soon made, and without danger, will determine our plan of cure, and we can then proceed with the most perfect certainty. Thus you will see that this view we have taken leads to a very different and much more rational plan of practice than is generally followed, in which the most judicious physicians confess that they have no clue to guide them; and complain that the science of medicine consists merely in a number of insulated facts, not connected by any theory: that they merely prescribe a remedy because they have seen it of use in an apparently similar state, but that they have no certainty of its producing a similar effect in the cases in which they prescribe it. This all depends on trusting to the fallacious appearance of symptoms, and not having taken a proper view of the laws of life, or the manner in which the exciting powers act on living bodies.
After these observations on the diagnosis, or the method of distinguishing the nature of diseases, I shall proceed to consider more particularly the nature of sthenic diseases, and the methods of curing them, which will occupy the remainder of our time this evening.
The powers or causes, which by their action produce inflammatory or sthenic diseases, are, first, heat, which is a very frequent cause, particularly when it succeeds cold; for the cold accumulates the excitability, and then renders the whole body, or a part, more liable to be affected by the heat afterwards applied. In this way is produced rheumatism, catarrh, or, as it is commonly called, a cold, and peripneumony. These complaints have been often attributed to cold, but I believe that there never was a well attested instance where cold alone, without being either followed by heat or some other stimulus, produced a real sthenic, or inflammatory disease. This is not merely a distinction, it is a circumstance of the utmost importance, because it influences the mode of practice to be pursued. Heat is one of the exciting or stimulant powers which support life, and one of the most powerful of these stimulants; but cold is only a diminution of it: how then can this produce a sthenic state, or a state of too high excitement? The blood is one of the exciting powers, which, by its continual circulation supports life; but surely if we abstracted a quantity of this fluid from the body, no person will be bold enough to say, that we by that means should produce an inflammatory disease. Cold renders the body more liable to be affected by heat, or any other stimulus applied, but does not of itself produce any stimulant or inflammatory effects.
To see more clearly the manner in which cold acts, let us inquire how it produces or contributes towards the production of catarrh. When we go into the cold air, at every respiration we take a quantity of it into the lungs, which brushes over the surface of the mucous membrane that lines the nostrils and trachea, and thus, robbing them of their heat, allows the excitability to accumulate. But we feel no fever, no sense of tightness or stuffing, nor any other symptom of catarrh, so long as we continue in the cold. If however we afterwards go into a warm room, and particularly near a fire, we receive by the act of respiration the warm air into those very parts which have been previously exposed to cold, and whose excitability is consequently accumulated. The first effect we perceive is a glow of the parts, which is by no means unpleasant, this however increases; and, in the course of half an hour or an hour, a sense of dryness and huskiness comes on, with a sensation of stuffing in the nostrils, and a tendency to a short dry cough: often likewise, if the exposure to cold has been considerable, and the heat afterwards applied great and sudden, we experience a shivering, and other symptoms of fever. These symptoms are all increased by taking into the stomach any liquid that is either of warm temperature or stimulating quality, or particularly both; we spend a restless night, and awake with all the symptoms of a catarrh, or cold, as it is improperly called. For it is evidently an inflammatory fever, and can be speedily cured by the debilitating plan, and particularly by keeping in a moderately cool place, where the temperature is equable, and not subject to alternations of heat and cold.
But how easily might this complaint have been avoided, were the person subject to it acquainted with its real nature, and the manner in which it is brought on. When we come out of a very cold atmosphere, we should not at first go into a room that has a fire in it; or, if this cannot be well avoided, we should keep for a considerable time at as great a distance from the fire as possible, that the accumulated excitability may be gradually exhausted by the moderate and gentle action of heat; and then we may bear the heat of the fire without any danger; but above all, we should refrain from taking warm or strong liquors while we are hot. In confirmation of this opinion, numerous instances might be brought, where catarrh was cured merely by exposure to cold.
When a part of the body only has been exposed to the action of cold, and the rest kept heated; if, for instance, a person in a warm room has been sitting so that a current of air, coming through a broken window, has fallen upon any part of the body, that part will soon be affected with an inflammation, or what is called a rheumatic affection. In this case, the excitability of the part exposed to the action of the cold, becomes accumulated, and the warm blood, rushing through it, from every other part of the body, excites an inflammation.
Thus catarrh and rheumatism are inflammatory complaints, or depend on too great a degree of excitement, and are to be cured by lowering the excitement, or diminishing the action of the exciting powers; by bleeding, purging, low diet, and particularly keeping in a moderately cool place; and these complaints will be as speedily and certainly cured by these methods, properly and judiciously persevered in, as a slight cut or wound will be healed by what surgeons call the first intention.
There are complaints which resemble these, but whose nature, however, is very different, and which require a very different mode of treatment. After a part has been long affected with rheumatic inflammation the excitability of the muscular fibres becomes so far exhausted, that a state of indirect debility takes place, and an inflammation, accompanied with pain and redness, which is very different from that I formerly described, as it depends upon a debilitated or relaxed state of the parts, instead of too great a degree of excitement. This instance shows strongly the fallacy of symptoms; but it may be readily distinguished from the inflammatory rheumatism, by attention to the effects of the exciting causes. The inflammatory rheumatism is aggravated by heat, hence it is more violent in bed than at any other time. The latter complaint, however, is greatly relieved by heat: the warm bath alleviates all the symptoms; so does a warm bed. It is evident that these diseases, though attended by the same symptoms, are as opposite, and require as different modes of treatment as an inflammation of the brain, and a dropsy. The inflammatory state has been called the acute rheumatism, and the other, the chronic rheumatism; I would, however, prefer the terms sthenic and asthenic rheumatism.
In the same manner, there is a catarrh, which is liable to afflict persons who have often been subject to an inflammatory cold, particularly persons advanced in years; and this depends on a state of indirect debility of the parts, the excitability of which has been exhausted by frequent and violent inflammatory affections. This complaint, which I would call asthenic catarrh, requires directly opposite treatment from the inflammatory or sthenic catarrh. The latter is aggravated by heat, but relieved by a cool temperature. Warm air is peculiarly grateful to those who are afflicted with the former, and if they go into a cool temperature, they are immediately seized with cough, and expectoration; for the disease being a disease of debility, the withdrawing the stimulus of heat, must increase it. The excitability of the parts is so far exhausted, that it requires a stimulus even more than natural to keep them in tone: hence persons labouring under asthenic catarrh, and some species of asthma, which are only varieties of this disease, find themselves best when exposed to a warm temperature, but on the heat being diminished, and consequently the parts relaxed, the cough and difficulty of breathing immediately come on.
Having examined the effect of heat, in producing inflammatory or sthenic disease, I now proceed to the consideration of the other powers. Of the articles of diet, the only food in danger of being too stimulant, is perhaps flesh or land animal food, used in too great quantity, particularly when seasoned, a preparation which adds much to its stimulant power. Spirituous and vinous liquors, let them be ever so weak or much diluted, stimulate more quickly, and more readily than seasoned food, and their stimulus is in proportion to the quantity of alcohol which they contain. These substances, when conjoined with rich food, must bring on a predisposition to sthenic disease, in almost any constitution, particularly in the young and healthy, and, in many instances, those diseases actually take place; or should this not be the case, should the person avoid, or escape the effects of inflammatory diseases, the excitability will be exhausted, and diseases of indirect debility, such as gout, apoplexy, indigestion, palsy, &c. will take place.
These stimulants are never necessary to a good constitution, and their effects will always, sooner or later, be experienced: for though a person with a good constitution may continue for years to indulge in the pleasures of the bottle, or the luxuries of the table, depend upon it that a continuance of them will sap the vigour of the strongest constitution that ever existed.
As nothing contributes more to the health of the body than moderate and frequently repeated exercise, which rouses the muscles to contraction, and promotes the circulation of the blood in the veins towards the heart: it thus produces excitement; but an excess of it will produce sthenic diathesis; and, if carried to great excess, it will produce a state of indirect debility, or exhausted excitability.
When any, or all of these exciting powers act too strongly on the body, the first effect they produce is a preternatural acuteness of all the senses; the motions, both voluntary and involuntary, are performed with vigour, and there is an acuteness of genius and intellectual power. In short, every part of the body seems in a state of complete vigour and strength; that this is the case with the heart and arteries, appears from the strong and firm pulse; in the stomach it is shown by the appetite; and, in the extreme parts, by the ruddy colour and complexion. In short, every appearance marks vigour of the body, and abundance of blood. Could the body be kept in this state, nothing could be more to be desired; this, however, is impossible; the excitement, though still within the bounds of health, has overstepped the point of good health, and is verging fast to predisposition to sthenic disease; so that, to secure a permanent state of health, it is always better to keep the excitement rather under the middle point, or 40 degrees, than above it. During the predisposition to sthenic disease, which is produced by the longer continued, or increased action of these powers, no symptoms of disease appear; but shortly after, disturbed sleep, depressed spirits, languor, a sense of fulness, heaviness, particularly after eating, show that this sthenic state cannot be further increased with impunity. The least increase of sthenic diathesis now brings on a disturbance of the functions, or actual disease; the commencement of which is generally a shivering, and a sense of cold; thirst and heat succeed; and then generally a pain in some part, either external or internal: costiveness generally attends this state, the urine is clear, and secreted in small quantity; memory and imagination become diminished, and there is generally less appetite for food.
In peripneumony, inflammatory sore throat, and acute rheumatism, there is an inflamed condition of the lungs, of the parts about the throat, or of the muscles of the extremities: this shows that the excitement here is greater than in other parts of the body; but it is still increased or too great in every part, only those parts which give the peculiar character to the disease are more affected than other parts of the body, by being more exposed to the exciting causes: thus, if a person be in perfect health, or a little below, he will not be easily affected by any of the exciting causes of sthenic disease, unless their application be very violent; he will go into a warm room out of the cold air, and feel no other effect than a pleasant glow: but if, by high living, or other means, he is brought near the point of predisposition to sthenic disease, then the slightest additional stimulus will bring it on, and if the throat has been exposed to the application of cold, and the person comes afterwards into a heated room, an inflammation of the parts about the throat, or an inflammatory sore throat, accompanied by a sthenic diathesis of the whole system, will be the consequence. This cannot be cured by merely diminishing the excitement of the part, while the excitement of the whole system remains: if we apply leeches to the throat in this state, to diminish the quantity of blood, we only debilitate the vessels, while fresh quantities of blood are poured into them from the too full vessels of the body; even if we could thus remove the sthenic diathesis of the part, we should go but a little way towards removing the inflammatory disease, which universally pervades the system.
The mode to be pursued therefore is, to take a quantity of blood from the body, by opening a vein; to keep the body cool, by remaining in a room where the temperature is at temperate, or a little below; by abstaining from animal food, and from spirituous or fermented liquors; and by the exhibition of purgatives, or at least of laxatives. Then leeches or blisters applied to the part affected will produce a good effect; and even stimulant applications to the inflamed part may be advantageous; for a topical inflammation, as we shall afterwards have occasion to see, depends on a debilitated state of the minute vessels of the part, while at the same time the action of the whole system is increased.
Besides the energy of the exciting hurtful powers, which I have mentioned, there is in the parts which undergo the inflammation, a greater sensibility, or an accumulated excitability; by which it happens that some are more affected than the rest. To this we may add, that whatsoever part may have been injured by inflammation, that part in every future sthenic attack is in more danger of being inflamed than the rest. Hence inflammatory sore throat, rheumatism, and some other complaints of the kind, when once they have supervened, are very apt to recur.
Among the sthenic or inflammatory diseases may be enumerated rheumatism, catarrh, cynanche, or sore throat, scarlet fever, inflammations of the brain, stomach, lungs, &c. &c.
Many of the contagious diseases, particularly small pox and measles, produce a sthenic state, and are to be cured, or their action moderated, by the debilitating plan which has been pointed out; and particularly by a moderate, constant, and equable diminution of temperature. Hence the violence of these diseases is greater when they attack a person already predisposed to sthenic diathesis, but much more mild when the excitement is rather under par.