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pigment. The pulmonary expansion is deficient, but there is no bronchophony, or increased vocal fremitus. A systolic murmur may be heard at the mitral apex. Two years since, she coughed up half a drachm of blood every morning for a week, not at the catamenial period; but latterly only streaks. There is a slight murmur over the right jugular vein. And here I may incidentally remark that, according to my observation, the venous murmur occurs less frequently in consumptive patients than in those debilitated by other diseases ; and that, as a general rule, those cases of consumption in which it is observed are apt to proceed more favourably than others. This young woman had been an invalid for four years, suffering from gastrodynia, palpitation, and slight cough; and had been treated with valerian, steel, and a host of other nervine medicines including sumbul. In July, 1850, she came under the care of my friend Dr. Cotton, at which time she was affected with weak respiration, some dulness on percussion in the right side, and marked hysterical symptoms. In 1851 there was some dulness in the right suprascapular region. The hysterical symptoms are now less marked, but the dulness on percussion in the right side is undoubted. Phthisis has probably set in, but seems to be kept in check by the treatment.
In this case, as in that of Miss L., first narrated, the dulness on percussion, although during the last three months too well established, seemed at an early period observable, sometimes on the one side, sometimes on the other; and I cannot help suspecting that alternations of this sort may be induced by what I would venture to designate hysterical congestion. Irregular con
gestions of various parts and organs, I believe to be no unusual concomitant of hysteria, especially when amennorrhea is associated with it ; and I would propose the inquiry whether hypertrophy of the breasts and other parts, as occurring in hysterical subjects, may not have relation to conditions of this kind.
C. S., a patient at present under my care in Rose Ward, suffering from uterine irritation and extreme sensitiveness of the skin, was six weeks since affected with transient albuminuria, and recently with swelling of the calves of the legs, which did not pit on pressure, being of the kind to which the Germans apply the term anathymiasis, and so considerable as to lead her to attribute to it an increase of weight of some pounds, really due to the administration of cod-liver oil.
And here a question occurs, philosophically and practically of great interest; namely, how far hysterical congestion may be induced by certain directions of consciousness. We know that cramp may be renewed by direction of the attention to the part affected ; and that expectancy of other actions, or a morbid election of them may occasion their return. Does this line of inquiry suggest an explanation of the fact, that nervous conditions may assume the character of real disease ? On this tempting field of speculation I shall not further enter;* but briefly recapitulate the conclusions to which I am conducted, by the consideration of such cases as those which we have been investigating
* Interesting and philosophical observations, having reference to this subject, may be found in “A Treatise on the Nervous Diseases of Women,” by W. S. Laycock, M.D. London, 1840; and in an Essay “ On the Pathology and Treatment of Hysteria,” by R. Brudenell Carter. London, 1853.
CONCLUSIONS REGARDING HYSTERIA.
[ 1st. That, in patients not affected with tuberculosis, hysteria may induce many symptoms and even local signs, much resembling those of phthisis. • 2nd. That, when phthisis exists in hysterical subjects, some of its symptoms are often aggravated, to an extent disproportioned to the amount of organic change.
3rd. That, as phthisis advances, hysteria usually retreats, so that the presence of hysterical symptoms may encourage a hopeful prognosis, pretty much in proportion to their severity ; hysteria and phthisis, although not incompatible, being apparently uncongenial. To this rule, hysterical affection of the joints is perhaps an exception, for I have occasionally known hysterical hip complaint continue at advanced periods of consumption.
4th. That, when hysteria and phthisis are associated, the treatment serviceable for the one disorder tends also to relieve the other; excepting that exposure to the air, and other parts of a hardening treatment, are available to a greater extent in hysteria than in cases of established consumption.
Causes of consumption: 1. Hereditary tendency; influence of
this cause as modified by sex, &c. ; 2. Bad air ; 3. Dissipation; 4. Mental depression; effects of climate — Value of the respirator-Importance of muscular exercise-Mental causes of disease under our control.
THE attention which you have given to the consideration of the diagnosis and treatment of consumption, will not, I am sure, gentlemen, be withheld from a subject of perhaps paramount importance, affecting us personally as well as professionally,—namely, the causes of the disease.
I place before you a tabular view of the consumptive patients at present in my wards ; in order that you may compare their history in relation to this question of causes.
The first of the causes to which this tabular statement directs our attention, is hereditary influence. There is, perhaps, no disease respecting which this influence is better established ; and it peculiarly claims our attention in consequence of the power, which the existence of such a proneness implies, to perpetuate the effect of those primary causes which might otherwise prove temporary, and be restricted to the individual directly exposed to their agency. This influence may