cases also of peculiar morbid irritability of the stomach, which are best relieved by a few drops of laudanum, sometimes combined with an alkali taken immediately before food. But it must be owned that the general course of treatment in all these disorders is vague and inconsistent; and that no divisions or descriptions have yet been adopted, determinate enough to define the proper direction of practice, or to supersede the particular judgment in each case. While seeing, however, in this and other examples, how far medicine is from being an exact science, we may recognise the ample scope it affords for sagacity and watchful observation, and the eminent value of these qualities in every part of practice. The external application of opium is not sufficiently brought into use, nor is there a due appreciation of all that may be attained in this way. That certain of its specific effects are conveyed through the skin to other parts of the body is unquestionable from experiment; though the action, so produced, is less strongly marked than that of belladonna and some other narcotics. These effects are distinctly augmented by removing the skin; so as to bring it into more direct action on the nerves of the part, if topical causes are concerned; or within reach of readier absorption, if more diffused effect be sought for.* In many cases of painful affection of * The experiments of Sir B. Brodie (Phil. Trans. for 1811), and the more recent researches of Müller, show that both these agencies of opium must be admitted, but render it certain that the action of absorption into the blood is much the most important in kind and degree. All modern inquiry tends to show the facility and extraordinary speed with which substances may enter into the circulation by means of imbibition, not before known to exist. Even since the remarks in this chapter were written, the Endermic method of treatment, as it is called, has acquired a remarkable extension and increase of repute; justified on the whole by present experiment, and sanctioning the hope of much future benefit from this modification in the use of remedies. particular nerves, I have found great benefit from a strong opiate ointment on a blistered surface; or a little of the muriate of morphia sprinkled over it. In the more complex case of gastrodynia, so trying to the skill of the practitioner, though the cause cannot thus be obviated, yet much relief to suffering may often be given by similar means applied to the epigastrium, or other more especial seat of pain. I have found no remedy more beneficial in those irritable forms of local psoriasis, which are so distressing from their obstinacy, than the application of poultices, prepared with a small proportion of a solution of opium, and continued until the state of the skin is thoroughly changed. In many nervous and spasmodic affections, as in some forms of asthma, when we have reason to suppose that the medulla spinalis is the chief source of disorder, the same remedies may be applied along the course of the spine; and often with singular good, when all methods of depletion or counter-irritation have proved utterly unavailing. If opium might be supposed capable of good in hydrophobia, after the many fruitless trials of it, this is the manner of use most likely to succeed. And the general method of practice is one which I feel assured, on experience, may beneficially be carried much further than we have hitherto pursued it. Resources of this kind ought ever indeed to be present to the mind of the practitioner. If insufficient for cure, they yet are adjuncts of great value to other more active means of treatment. But often the relief they afford is more speedy than that from internal remedies; and, what can never be too highly appreciated in medicine, with much less ambiguity of result. Cases indeed are related of serious mischief from opium applied externally to wounds, or excoriated surfaces; but the instances are rare, and probably to be qualified by facts regarding the peculiar temperament of those so affected.* The more common cause of failure in this remedy is its insufficient use; either from the proportion of opium being too small, or from the careless manner of application common to this with other external remedies. It is more difficult to secure constancy in the patient when the means are thus simple and obvious, than when hidden under the formulæ fitted for internal use. * I have seen one or two remarkable instances of the noxious effect of belladonna, thus applied, upon the sensorium. In one of these, delirium, continued for more than thirty hours, was the consequence of dressing a blistered surface, by mistake, with belladonna ointment. 433 CHAP. XXVI. ON SLEEP. Ir concerns not less the physician than the metaphysical inquirer, to learn all the conditions of this remarkable function of life, and the causes by which they are modified. Remarkable it may fitly be called; for what more singular than that nearly a third part of existence should be passed in a state thus far separate from the external world! - a state in which consciousness and sense of identity are scarcely maintained; where memory and reason are equally disturbed; and yet, with all this, where the fancy works variously and boldly, creating images and impressions which are carried forwards into waking life, and blend themselves deeply and strongly with every part of our mental existence.* It is the familiarity with this great function of our nature which prevents our feeling how vast is the mystery it involves; how closely linked with all the phenomena of mental derangement, whencesoever produced; and, yet further, how singularly shadowing forth to our conception the greater and more lasting changes the mind may undergo without loss of its individuality. I am not sure that the subject, in its medical relations, has even yet received all the notice it deserves. Much * "Half our days we pass in the shadow of the earth, and the brother of death extracteth a third part of our lives," says Sir Thomas Browne; a writer whose genius and eloquence give him a high place in English literature, as well as in that of the profession to which he belonged. F F knowledge indeed has been gained of late, by looking more closely into the physical connexions of sleep with other actions of the body; and particularly with those functions of the nervous system to which it is most intimately allied. But there is still scope for a few remarks; having reference partly to the physiology of sleep, partly to its connexion with the various forms and treatment of disease. - It is singular that in a state thus familiar, and filling so large a portion of the term of life, it should yet be difficult to distinguish that which is the most perfect condition of sleep the furthest removed from the waking state. No certain proof can be had of this from our own recollections, nor from the feelings on awakening. Both depend more or less on the dream or other condition immediately antecedent or even on the manner in which we are aroused from it. The best proofs, though ambiguous, are derived from the observation of those around. That may be presumed generally the soundest sleep, in which there is most complete tranquillity of the bodily organs commonly dependent on the will. Sensation, the other great function of the brain involved, furnishes evidence to the same point in the varying effect of stimuli applied to the senses when thus closed. And this test might perhaps be the most certain, were it not that we have cause to believe the different senses to be unequally under this state, even at the same moment of time: and further, that there is ambiguity from the passage of sleep into coma, through gradations which cannot be defined by any limits we are competent to draw. * Evidence by ready tests as to the soundness of sleep is often of value in practice; both in reference to the point last *Aristotle, towards the end of his Book, IIɛpi Evvжviv, has some curious remarks on the subject, well illustrated by examples. All his writings on this and other collateral topics deserve much more intimate perusal than is given to them at the present day. |