in the asylum. It is a mockery to tell attendants, who are not sure of their places for a day, that they are to devote themselves entirely to the patients, and to be themselves patterns of forbearance. Yet the want of devotedness on their parts is a want of that for which there is no substitute, and the want of forbearance in the attendants will lead to the worst consequences. So strictly connected is the proper government of an asylum with the welfare, and even with the safety of the patients. Unjust officers, or unjust rulers, make attendants indifferent or cruel, and indifferent or cruel attendants make the patients wretched." (pp.113-14.) The last chapter considers the Religious Services of an Asylum— Schools-Government-Treatment of Officers-Qualifications and duties of the Superintendent.

The following beautiful passage shows at once the author's opinions as to the good and evil of religious observances in relation to insanity.

"The institution of religious services in asylums has created new and peculiar duties for the officers; and although I can readily conceive the apprehension with which the medical superintendents of some asylums regard this subject, and know how unjust it generally would be to ascribe such apprehensions to indifference, I am quite satisfied, that with reasonable caution in the exercise of his peculiar duties, a chaplain may become a valuable officer in asylums for the insane. It is unfortunately true, that no cause of mania, melancholia, and imbecility is more common than a gloomy religion, which excludes the idea of God's mercy so carefully, and brings forward God's judgments so prominently, as to alarm, and depress, and enfeeble many enthusiastic and weak persons who are exposed to its doctrines. Among persons of education, and particularly among women, I believe that nearly one half of the cases of derangement of mind arise from this perversion of religion alone. Exciting meetings, enthusiastic exhortations, false reports of wild missions, foolish biographies of sickly and delirious children, incoherent tracts, and books of unfruitful controversy, constitute all the intellectual exercises of these sincere and misguided persons. All elegant literature, and almost all science is kept from them, as demoralizing or tending to unbelief. All cheerful avenues of thought are forbidden to them. A restless, meddling, dictatorial spirit, much opposed to real charity, assumes the guise and name of benevolence and religious zeal. By degrees, the mind-so ill-exercised, so ill-governed, so excited-becomes weakened, and then the mask falls to the ground. Spiritual and worldly pride, idle prophesyings, convictions of eternal wrath, fierce denunciations of neighbours, or parents, or children, or relatives, and too often despair and attempts at self-destruction, declare that madness has supervened. Knowing all this, by daily observation, I feel as strongly physician can do, the danger of misapplying religious attentions; but I still believe that many insane persons are capable of deriving much satisfaction from being permitted to attend the services of their church; and that a good and prudent clergyman may become a useful auxiliary to a physician, by correcting fanatical delusions, moderating spiritual conceit, vindicating God from the unjust views of his creatures, and reviving every hope that is permitted to the imperfect and the penitent." (pp. 123-24.)

With the following extracts relating to the duties and qualifications of the medical superintendent of an asylum, we must take our leave of this fascinating volume. Our readers may probably be able to find a local habitation and a name for such offices and such an officer.

Duties and qualifications of a superintendent. "It is to him that the whole house must at all times look for the principles by which everything done in it is to be regulated. His supposed or his known wishes should be present to the mind of every officer and every attendant in every variety of accident, and his character of mind and heart ever in their view. Indifference on his part must lead to

negligence on the part of those who execute his commands; severity exhibited by him must lead to brutality on the part of the attendants. His steady discouragement of negligence, his known abhorrence of cruelty, and his real and deep sympathy with his patients, may be reflected from every humane heart in the asylum.

"His duty comprehends a wide and careful survey of everything that can favorably or unfavorably affect the health of the mind or the body. He has to regulate the habits, the character, the very life of his patients. He must be their physician, their director, and their friend. The whole house, every great and every trifling arrangement, the disposition of every officer and servant, should be in perpetual conformity to his views; so that one uniform idea may animate all to whom his orders are intrusted, and the result be one uniform plan. Nothing should be done without his sanction. The manners and language of all who are employed in the asylum should but reflect his; for everything done and everything said in an asylum is remedial or hurtful; and not an order should be given, or a word spoken, except in accordance with the spirit of the director of the whole establishment. By such a system alone can it ever be proved to what extent the cure or the improvement of the insane is practicable.

"That he should be a person naturally benevolent is indispensable; and it is extremely desirable that he should possess an almost inexhaustible patience. The qualities to which, of old, much importance was attached-a commanding stature, a stern manner, a fierce look, a loud voice-have become either unnecessary, or positive disqualifications. Threats or reproofs, seconded by these attributes, may terrify the patients, but they loosen the bonds of affection, and generate feelings which will burst forth into expression in the next paroxysm, or revengeful designs, which will wait their time. Even remonstrances, to be successful, must be calm and carefully timed, being, as they are, addressed to the afflicted rather than the faulty. If sickness lays open all the delusions of life, madness often shows all human weaknesses magnified, and they must be viewed with never-failing charity, at no time forgetful that the dispositions so exhibited are impaired and deformed by insanity." (pp. 140-1.)

Results and rewards of good management. "If the whole of the system which I have imperfectly endeavoured to sketch be steadily persevered in, -no anger-no severity-no revenge-no deception-no disregard ever shown to the insane,-the resident superintendent will no longer find himself living among the habitually furious, or the incurably gloomy, or the constantly discontented. Calmness will come; hope will revive; satisfaction will prevail. Some unmanageable tempers, some violent or sullen patients, there must always be; but much of the violence, much of the ill-humour, almost all the disposition to meditate mischievous or fatal revenge, or self-destruction, will disappear. Some of the worst habits that beset the poor lunatic will also be got the better of; cleanliness and decency will be maintained or restored; and despair itself will sometimes be found to give place to cheerfulness or secure tranquillity. I could walk through such an asylum as I have described, and point out illustrations of every word in every ward.

"Resolved, therefore, to make his asylum a place where everything is regulated with one humane view, and where humanity, if anywhere on earth, shall reign supreme, the resident medical director must be prepared to make a sacrifice of some of the ordinary comforts and conventionalities of life. His duties are peculiar, and apart from common occupations. His society, even, must chiefly consist of his patients; his ambition must solely rest on doing good to them; his happiness on promoting theirs.

None but those who live among the insane can fully know the pleasures which arise from imparting trifling satisfactions to impaired minds; none else can appreciate the reward of seeing reason returning to a mind long deprived of it; none else can fully know the value of diffusing comfort, and all the blessings of orderly life, among those who would either perish without care, or each of whom would, if out of the asylum, be tormented or a tormentor. Constant

intercourse and constant kindness can alone obtain their entire confidence; and this confidence is the very keystone of all successful management.

"Thus living, and thus occupied, the director will learn to love his people, with all their infirmities, which are their afflictions. The asylum is his world. The patients are his friends; humble, but not without even delicate consideration for others; wayward, but not malignant, except when cruelty exasperates them; capricious, but not ungrateful; distrustful, but to be won by candour and truth; disturbed and grievously afflicted, but not dead to some of the best and purest affections. He will almost regard his patients as his children; their cares and their joys will become his; and humanly speaking, his whole heart will be given to them." (pp. 143-4.)

ART. XI.

Die Krankheiten des Zwerchfells des Menschen. Von C. W. MEHLISS, M.D., &c.-Eisleben, 1845.

The Diseases of the Diaphragm in Man. By C. W. MEHLISS, M.D., &c.— Eisleben, 1845. 8vo, pp. 212.

We

THE diagnosis of disease of the diaphragm is attended with so much difficulty and uncertainty, that every attempt made in an earnest and philosophical spirit practically to advance our knowledge of the subject, or even to collect and arrange the scattered and fragmentary information afforded by medical literature, is deserving of praise. We ought, indeed, to consider ourselves the more beholden to Dr. Mehliss, that this task, which he has undertaken and fulfilled with great industry, and, upon the whole, with much good sense, is not altogether a very grateful one. were really not a little curious, at first, to ascertain how it could be possible to fill 212 pages with a subject of apparently so little promise. Still, as we proceeded, our interest, we confess, soon became sufficiently excited to carry us very pleasantly to the conclusion of the treatise. It contains little, perhaps not any, information altogether new, but it has brought the scattered rays into such a focus as to render them, in some degree, available for practical purposes. It reteaches us a lesson which the progress and bent of anatomical pathology in the present day had almost made us forget; namely, that the diaphragm, far from being a mere blank leaf between two all-important classes of organs, is a muscle whose mere functional derangement may seriously, if not irreparably damage both the one and the other; in fine, that its condition ought always to be carefully investigated and duly weighed in our estimate both of thoracic and of abdominal disease.

The work commences with an elaborate account both of the anatomy and physiology of the diaphragm, in which, however, there is little that requires comment, or that is not to be found, in a condensed shape, in every good hand-book of anatomy. From this portion, therefore, we shall merely quote as useful the observation of Krause,* "that the highest convexity of the diaphragm, in the adult, is on a level with the upper margin of the middle portion of the seventh rib, or with the cartilage of the fifth; but that on the right side, it rises from half an inch to an inch higher than on the left."

*

Since the publication of Dr. Mehliss's work-in short, quite recentlya most valuable and interesting paper has been read at the Medico-Chirurgical Society, on the physiology of respiration, wherein it is shown by the author, Mr. Hutchinson, contrary to the generally received opinion, that, whilst ordinary, involuntary respiration is performed chiefly, if not solely, through the instrumentality of the diaphragm, this organ remains nearly quiescent during a profound respiration. Of the truth of this the reader may convince himself by experiment. He will find that every ordinary act of inspiration is accompanied by a relaxation of the abdominal muscles, denoted by a protrusion of the abdomen; every ordinary act of expiration by their contraction. Now it is to be remembered that, in breathing, the action of the abdominal muscles is inverse or antagonistic with that of the diaphragm. In the above movements the intercostal and other respiratory muscles participate only very slightly, so that a large proportion of the lungs does not become inflated. On the other hand, all the intercostal and other auxiliary muscles of respiration are engaged during a profound, or it might be more correct to say, a full inspiration, whilst the abdominal muscles are tightly braced up, the hypochondria drawn inward, and the diaphragm, if anything, slightly relaxed. Indeed, so long as the diaphragm is under contraction, it would seem to be impossible for the upper portion of the thorax to expand. We must, however, add to Mr. Hutchinson's statement, that after full expansion of the upper portion of the chest, and consequently inflation of the peripheral portions of the lungs have been effected, the diaphragm may, by a voluntary act, be still made to contract, by which means no inconsiderable amount of air may yet be inhaled. This double act of inspiration is, however, obviously a forced one, and not very frequently performed.

To remind the reader that both surfaces of the diaphragm have a serous investment would be needless, except, perhaps, for the purpose of remarking incidentally what is sometimes lost sight of, namely, that the base of the pericardium is firmly attached to the central tendinous portion of the diaphragm, by means both of cellular tissue and of fibrous bands, which close connexion, of course, tends very materially to promote a reciprocal reaction between the heart and diaphragm, both in health and in disease.

The position of the diaphragm, the importance and variety of its functions, the sensitive character of the momentous organs and parts by which it is compassed, or traversed, render it apparent how seriously disease of this muscle must impair the general health, but serve at the same time to explain both the obscure and the dependent nature of most of its ailments. The multiplicity of its sympathies, resulting not alone from juxtaposition, but also from the numerous excito-motory influences to which it is subject†, has gained for it a reputation for an extraordinary amount of inherent muscular irritability. No other muscle of the human body is so greatly under the influence of reflex action as this. Respiration, laughter, sobbing, coughing and sneezing, and again vomiting and defecation, are severally enacted by the whole or parts of the diaphragm sympathising

• Since published in the Medico-Chirurgical Transactions.

+ The phrenic nerves are often derived from the anterior branches of the second to the sixth cervical nerves-always from the third and fourth-and are at their origin often connected with the cervical ganglia of the great sympathetic, with the pneumo-gastric nerve, and with the descending branch of the hypoglossus. Besides this, the diaphragm receives emissaries from the solar plexus.

indirectly; that is, through the medium of the nervous centres, with remote nerves directly stimulated. These are, for the most part, involuntary acts; for, although the muscle is to nearly an equal extent under the control of the will, this power is here more frequently exercised in arresting or subduing, than in promoting its action. Ordinary respiration would, however, appear to be the only function in which the diaphragm is singly active. In all its other functions it is associated with other muscles, and that not in consequence of any direct nervous consensus between them. All are here evidently set in motion directly from the sensorium, and not all simultaneously, but in the exact sequence in which they derive their nerves from the cerebro-spinal centres. Thus, in laughter, the muscles of the face receive the impulse first; and if the latter be slight, exclusively. Where the impulse is greater, the laryngeal,-then the pectoral muscles, next the diaphragm,-and lastly, where the impulse is violent, the abdominal muscles severally, or all, become engaged.

Disease of the diaphragm. If we except the heart, no muscle of the human body is probably more often morbidly affected than the diaphragm. The variety of its affections is, however, not commensurate with their frequency, the great majority ranging between the extremes of spasm and paralysis. Of these two, spasm is by far the more common, the number and extent of its nervous sympathies causing the organ to participate very readily in spasm affecting other parts, whilst these identical relations at the same time prevent its entire innervation from becoming easily suspended. Thus, in general, convulsions of whatever kind, the diaphragm is always in a high degree implicated, whereas, in general states of paralysis, its activity is, for the most part, little impaired. The other affections of the diaphragm are nearly all due or subordinate to, or at any rate inseparable from, the diseases of adjacent parts. Upon the whole, thoracic disease is more readily communicated to the diaphragm than abdominal; the latter has, however, a much greater tendency to excite in it convulsive action.

The symptoms generally indicative of diaphragmatic ailment are divisible into those of anomalous sensation and those of anomalous motion. The former consist in a characteristic sense of tightness or constriction at the lower part of the thorax (which is also felt sympathetically, from organic disease of the cervical portion of the spinal marrow); and, secondly, in pain, which, in partial disease of the diaphragm, is referred to the affected locality, in general disease of the organ, to behind the inferior portion of the sternum, and from thence across to the spine. This pain is never, as some writers affirm, very intense, and differs in no particular from muscular pain elsewhere.

Anomalous motions of the diaphragm. These are tremulous, spasmodic, or convulsive. The preternatural sensations they produce have a singular effect upon the imaginations of patients, who often fancy that some living animal has taken up its abode in their interior;-notions which may possibly have given rise to the fables recounted from time to time of serpents being extracted from the stomachs of men. The vibratory movements of a tremulous diaphragm are not unfrequently perceptible to the

eye.

The secondary symptoms of diseased diaphragm consist in disturbance of those functions which are carried on through its instrumentality or aid.