size of an asylum; and, in connection with this circumstance, we gladly quote it as the opinion of the English board, "that a gradual enlargement of asylum buildings, far beyond the limits of personal supervision or individual control, has removed the only safe guarantee against those temptations to the exercise of power by which the best attendants are corrupted, and to which the average of those now employed are especially liable" (Rep.' 24, p. 73).

And the Commissioners proceed to point out the necessity, on the part of the superior officers, for the greatest vigilance, and "of severity of supervision to the utmost possible degree," of attendants. For, as they observe, nothing is easier for a man in the position of an attendant, "with unrestricted and uncontrolled power over the habits and happiness of another, than to act cruelly without being cruel. He has but to neglect and be careless of his patient, which, if not conscious himself of a vigilant superior above him, it is more than probable he will be. He has but to use freely the powers in his hands to excuse or conceal his own idleness."

The Commissioners for Scotland follow in the same track and animadvert on the evils accruing to attendants by overgrown asylums. In every institution for the treatment of the insane the physician "has, in a great degree, to rely on the zeal, the attention, and the kindness of his attendants. Attendants, however, are frequently not trustworthy, and are occasionally even guilty of harshness and cruelty. Nor is this surprising. The life of an asylum attendant is one which presents few attractions, and its rewards are inconsiderable. Consequently there are frequent changes in almost every asylum staff. Many dislike the work, or their health suffers, and they leave after a short trial. Others are soon discharged for incapacity, inattention, drunkenness, insubordination, cruelty, or some similar cause." These changes, it is worth while to note, are more frequent in larger asylums, and in the Scottish establishments amount annually, on an average, to considerably more than a third of the staff. Another circumstance is that not only do they enter upon duties respecting which they are profoundly ignorant, but it is too frequently the case that no special care is taken to teach them. They are left to pick up for themselves what information they can, and this almost wholly from colleagues in the wards. Consequently, with a modicum of acquaintance with the rules propounded officially for their guidance, they become initiated also into the traditions and usages of fellow-attendants of older standing, and not a few of those, to say the least, of doubtful character and expediency. And such traditions and usages rank as mysteries of their office, and concur with the conditions of com

mon life and the sense of common interest to knit together attendants in a special craft, whose members owe to each other mutual support, forbearance, and secrecy.

Admitting the truth of the foregoing remarks, less mystery will be apparent both in the character of many of the accidents reported, and in the difficulties surrounding investigations into their cause and the detection of the parties involved in their

occurrence.

Both the English and the Scottish Commissioners, impressed with the responsible position of attendants, and with the sad history of neglect and cruelty in asylums, have sought to elevate the position of attendants and to provide against the hiring of inefficient and improper ones. They endeavour to attain these ends by holding out inducements to a better educated and higher class of applicants, and by instituting a system of registration, setting forth the grounds of discharge or dismissal. What they have done in this direction is narrated by the English Commissioners in their 24th Report, to which we would refer the

reader.

And here we must bring to a close this review of the contents of the reports under notice, not from lack of material, but from lack of space; for several important themes, and among them the state of the insane in workhouses, the extent of the use of mechanical restraint, and the success of the treatment of lunatics in cottage homes, would furnish ample matter for profitable discussion. J. T. ARLIDge.

VIII.-The Present State of Cardiac Diagnosis and

Therapeutics.1

ANDRAL, in editing the fourth edition of Laennec's Traité de l'Auscultation Médiate et des Maladies des Poumons et du Cœur,' in the year 1837, writes in a note, "In spite of many laborious researches, the history of the diseases of the heart is far from being yet finished; it still presents a great many doubts

11. A Practical Treatise on the Diagnosis, Pathology, and Treatment of Diseases of the Heart. By AUSTIN FLINT, M.D., Professor of the Principles and Practice of Medicine and of Clinical Medicine in the Bellevue Hospital Medical College, &c. Second Edition. pp. 550. Philadelphia, 1870.

2. Lectures on the Principles and Practice of Physic, delivered at King's College, London. By Sir THOMAS WATSON, Bart., M.D., F.R.S. Fifth Edition. 1871.

3. Oppolzer's Vorlesungen. Die Krankheiten des Herzens. pp. 111. Erlangen,

to be removed, and many gaps to be filled up, and the time is not yet arrived when the diagnosis of these diseases can be regarded as being so easy and certain as that of the diseases of the lungs. Still, the continual progress which has been made from the time of Lancisi to that of Laennec, and from the latter to that of M. Bouillaud, must inspire us with hope for the future." If to these remarks we add," and from the time of Bouillaud, Hope, and C. J. B. Williams to the present day," the remarks of Andral are still applicable, for it is quite true that the whole history of the diseases of the heart is even yet, in the year 1872, not completed, and that some of them are still enveloped in a certain amount of obscurity; that the relations existing between the rational and physical symptoms during life and the appearances found after death are not yet absolutely determined in all cases; and that very many problems of treatment yet remain to be solved. Still, much more has been done in all these directions than Andral, in the preface referred to, appears willing to admit, and it may be asserted with tolerable truth that the diagnosis of cardiac diseases is at least as easy and certain as that of the lungs, while in reference to therapeutics there can be no doubt that a very great advance has been effected, not only by the introduction of new or improved remedial measures, but by the omission of many old ones which are now proved to be mischievous.

Andral, while he attributes great merit to the labours of Bouillaud, does very little justice to the British investigators of cardiac diseases, especially the late Dr. Hope and Dr. C. J. B. Williams, although their researches were made before the period when Andral wrote the preface to Laennec's treatise. In fact, the elaborate and conclusive experiments made on the causes of the sounds of the heart by Drs. Hope and Williams, by the Dublin committee of 1835, and by the London committee of 1836, have thrown a complete flood of light upon the diagnosis of diseases of the organ, and have almost cast into the shade the brilliant investigations of Laennec himself, so far as cardiac auscultation is concerned. For the great French stethoscopist, while he explained very clearly the auscultatory phenomena of the rest of the chest, left the præcordial region in a great measure to the labours of subsequent explorers. Although, too, Laennec indicated the character of the sounds caused by the motions of the heart, he made no attempt to explain the mechanism by which they were produced; and while to him, moreover, is justly due the discovery of the abnormal cardiac sounds or murmurs (bruit de soufflet, bruit de rápe, &c.), he was unable to account for their occurrence except upon the supposition that they denoted a spasm of the heart. "It appears to me," he

says, in treating of this subject in his Treatise on Mediate Auscultation," that the positive and negative facts which I have just adduced all tend to prove that the bruit de soufflet is produced by a simple spasm, and does not indicate any lesion of the heart or arteries.' He was, however, very near to the discovery of the valvular origin of the murmurs when he states that "the bruit de soufflet exists pretty constantly in the heart of persons who are affected with narrowing of the orifices of this organ;" but he goes on somewhat erroneously to state that "it is also pretty frequently met with in persons affected with hypertrophy or dilatation; but it is found still more frequently, as well in the heart as in the arteries, of persons who have no lesion of these organs, and who are attacked by very different affections."

The progress made in our knowledge and practice in reference to cardiac diseases in the present day is still more strikingly displayed by the perusal of the single short chapter devoted by Laennec to the treatment of the organic affections of the heart. "Of all the organic affections of the heart," he writes, "simple hypertrophy or combined with dilatation appears to me the most susceptible of cure. By applying courageously and perseveringly to the treatment of hypertrophy the method advised by Valsalva and Albertini for aneurism of the arteries, we may promise to ourselves much more frequent and complete success, especially if we begin to employ it at a period when the disease has not yet produced serious general symptoms. The treatment ought to be pursued in an energetic manner, especially at first. We must begin, therefore, by bleeding the patient as copiously as he can bear without fainting, and the bleeding must be repeated every two, four, or eight days, at the latest, until the palpitations have ceased, and the heart no longer gives more than a moderate impulse under the stethoscope."

Laennec goes on to advise that the patient must reduce his diet by at least one half, and after about two months of bleeding and low diet, if he no longer suffers from palpitation, or presents a strong cardiac impulse, then the bleeding may be practised at more distant intervals, and the severity of the regimen may be in some measure relaxed. But he adds that the same measures must be resorted to, and with equal vigour, if the impulse of the heart should afterwards increase.

The influence of these doctrines and of those of Bouillaud, who carried out the system of sanguineous depletions to a still greater extent, especially in recent cardiac affections, was, no doubt, exceedingly injurious, and the success said to attend such treatment must rather be attributed to the enthusiastic and coloured statements of the practitioners of the period than to any actual relief afforded to the patient. But the inutility of

bleeding in the chronic organic diseases of the heart, and its questionable efficacy even in the acute ones, were among the therapeutical doctrines which made but tardy progress even in this country, and we have only to turn over the pages of some of our most distinguished writers to find abundant confirmation of this proposition.

Dr. Hope, whose classical Treatise on Diseases of the Heart' has been of invaluable service to the progress of cardiac pathology and diagnosis, very distinctly condemns the treatment recommended by Laennec, but he admits that he himself has invariably found the greatest benefit to be derived, in the early stages of hypertrophy of the heart, from sparing abstractions of blood at intervals of two or three weeks or more. His plan of treating hypertrophy of the heart consisted in the abstraction of blood to the amount of four, six, or eight ounces, every two, three, four, or six weeks, according to the age and strength of the patient, so as merely to keep down palpitation, dyspnoea, and strong impulse of the heart. But although this plan was recommended, and no doubt adopted, only about twenty years ago, it is now justly discarded, as not only useless but mischievous, for experience has shown that its tendency is to continue or to aggravate the very symptoms which it is intended to relieve, while the hypertrophy itself, so far from being a specific morbid condition, is rather to be regarded as a compensatory provision of nature to assist the walls of the heart. in carrying on the circulation in spite of the mechanical obstacles opposed to the due performance of that function.

But while Dr. Hope recommends the cautious abstraction of blood in hypertrophy of the heart, he is by no means sparing of this mode of depletion in the acute affections of that organ. In the treatment of acute pericarditis and endocarditis he advises that the antiphlogistic treatment, in as energetic a form as circumstances will allow, should be employed with the utmost promptitude. If the attack is recent, and the patient's strength will admit, he recommends that blood should, in the first place, be drawn freely from a large incision in the arm of the patient, in the erect position, so as to bring him to the verge of syncope. From five-and-twenty to forty leeches, according to the strength, should then be applied to the præcordial region as soon as the faintness from the venesection disappears and reaction com

mences.

Bouillaud, writing in 1835, announces as a happy discovery his method of bleeding copiously and frequently in pericarditis, and he declares that this kind of treatment has been so successful in his hands that recovery has become the rule and death the exception in such cases; while, according to his prede